Cancer recording and mortality in the General Practice Research Database and linked cancer registries.

PURPOSE: Large electronic datasets are increasingly being used to evaluate healthcare delivery. The aim of this study was to compare information held by cancer registries with that of the General Practice Research Database (GPRD). METHODS: A convenience sample of 101 020 patients aged 40+ years drawn from GPRD formed the primary data source. This cohort was derived from a larger sample originally established for a cohort study of diabetes. GPRD records were linked with those from cancer registries in the National Cancer Data Repository (NCDR). Concordance between the two datasets was then evaluated. For cases recorded only on one dataset, validation was sought from other datasets (Hospital Episode Statistics and death registration) and by detailed analysis of a subset of GPRD records. RESULTS: A total of 5797 cancers (excluding non-melanomatous skin cancer) were recorded on GPRD. Of these cases, 4830 were also recorded on NCDR (concordance rate of 83.3%). Of the 976 cases recorded on GPRD but not on NCDR, 528 were present also in the hospital records or death certificates. Of the 341 cases recorded on NCDR but not on GPRD, 307 were recorded in these other two datasets. Rates of concordance varied by cancer type. Cancer registries recorded larger numbers of patients with lung, colorectal, and pancreatic cancers, whereas GPRD recorded more haematological cancers and melanomas. As expected, GPRD recorded significantly more non-melanomatous skin cancer. Concordance decreased with increasing age. CONCLUSION: Although concordance levels were reasonably high, the findings from this study can be used to direct efforts for better recording in both datasets

Integrated out-of-hours care arrangements in England: observational study of progress towards single call access via NHS Direct and impact on the wider health system

Objectives: To assess the extent of service integration achieved within general practice cooperatives and NHS Direct sites participating in the Department of Health’s national “Exemplar Programme” for single call access to out-of-hours care via NHS Direct. To assess the impact of integrated out-of-hours care arrangements upon general practice cooperatives and the wider health system (use of emergency departments, 999 ambulance services, and minor injuries units). Design: Observational before and after study of demand, activity, and trends in the use of other health services. Setting: Thirty four English general practice cooperatives with NHS Direct partners (“exemplars”) of which four acted as “case exemplars”. Also 10 control cooperatives for comparison. Main Outcome Measures: Extent of integration achieved (defined as the proportion of hours and the proportion of general practice patients covered by integrated arrangements), patterns of general practice cooperative demand and activity and trends in use of the wider health system in the first year. Results: Of 31 distinct exemplars 21 (68%) integrated all out-of-hours call management by March 2004. Nine (29%) established single call access for all patients. In the only case exemplar where direct comparison was possible, cooperative nurse telephone triage before integration completed a higher proportion of calls with telephone advice than did NHS Direct afterwards (39% v 30%; p<0.0001). The proportion of calls completed by NHS Direct telephone advice at other sites was lower. There is evidence for transfer of demand from case exemplars to 999 ambulance services. A downturn in overall demand for care seen in two case exemplars was also seen in control sites. Conclusion: The new model of out-of-hours care was implemented in a variety of settings across England by new partnerships between general practice cooperatives and NHS Direct. Single call access was not widely implemented and most patients needed to make at least two telephone calls to contact the service. In the first year, integration may have produced some reduction in total demand, but this may have been accompanied by shifts from one part of the local health system to another. NHS Direct demonstrated capability in handling calls but may not currently have sufficient capacity to support national implementation

Nongovernmental organizations and health delivery in sub-Saharan Africa

This paper attempts to present the distinctive characteristics - both positive and negative - of nongovernmental organizations (NGOs) as institutions for providing health care. It reviews the historical role of NGOs as vital contributors to health care delivery in Africa and looks at how the current environment has brought NGOs to the fore. It analyzes the implications of the trend among donors to channel resources to developing countries through NGOs and discusses various policy options governments have employed in relation to NGOs. Finally, it raises some unanswered questions about environments conducive to NGO activity and contributing to roles that NGOs can be encouraged to fulfill without sacrificing their very strength in the development process.Agricultural Knowledge&Information Systems,Health Monitoring&Evaluation,Health Systems Development&Reform,Housing&Human Habitats,Regional Rural Development

The Cancer Transition in Japan since 1951

The overall trend of cancer mortality in Japan has been decreasing since the 1960s (age-standardized death rates for ages 30-69), though trends differ enormously among various forms of the disease. Cancer mortality was heavily influenced by Japanese postwar economic recovery, which led to improved living conditions and better control of infectious agents known to cause some common forms of cancer (stomach, cervical). However, Japanese wealth and development have also been associated with risky personal behaviors (smoking, drinking) and other conditions, leading to increases in cancers with no known or else very weak links to infection. This shift away from infectious and toward non-infectious causes of prevalent forms of cancers is called the "cancer transition," by analogy to Omran's "epidemiologic transition." We suggest that the cancer transition described here in the case of Japan must be a part of efforts to revise and update the epidemiologic transition, which should incorporate new knowledge about the role of infection in chronic disease morbidity and mortality.cancer, cancer transition, epidemiologic transition, health, health and development, infectious diseases, Japan, mortality, non-infectious disease

Marijuana and Youth

This paper contains the first estimates of the price sensitivity of the prevalence of youth marijuana use. Survey data on marijuana use by high school seniors from the Monitoring the Future Project are combined with data on marijuana prices and potency from the Drug Enforcement Administration Office of Intelligence or Intelligence Division. Our estimates of the price elasticity of annual marijuana participation range from 0.06 to 0.47, while those for thirty day participation range from 0.002 to 0.69. These estimates clearly imply that changes in the real, quality adjusted price of marijuana contributed significantly to the trends in youth marijuana use between 1982 and 1998, particularly during the contraction in use from 1982 to 1992. Similarly, changes in youth perceptions of the harms associated with regular marijuana use had a substantial impact on both the contraction in use during the 1982 though 1992 period and the subsequent expansion in use after 1992. These findings underscore the usefulness of considering price in addition to more traditional determinants in any analysis of marijuana consumption decisions made by youths.

Comparative effectiveness of antiepileptic drugs in juvenile myoclonic epilepsy

Objective: To study the effectiveness and tolerability of antiepileptic drugs (AEDs) commonly used in juvenile myoclonic epilepsy (JME). Methods: People with JME were identified from a large database of individuals with epilepsy, which includes detailed retrospective information on AED use. We assessed secular changes in AED use and calculated rates of response (12-month seizure freedom) and adverse drug reactions (ADRs) for the five most common AEDs. Retention was modeled with a Cox proportional hazards model. We compared valproate use between males and females. Results: We included 305 people with 688 AED trials of valproate, lamotrigine, levetiracetam, carbamazepine, and topiramate. Valproate and carbamazepine were most often prescribed as the first AED. The response rate to valproate was highest among the five AEDs (42.7%), and significantly higher than response rates for lamotrigine, carbamazepine, and topiramate; the difference to the response rate to levetiracetam (37.1%) was not significant. The rates of ADRs were highest for topiramate (45.5%) and valproate (37.5%). Commonest ADRs included weight change, lethargy, and tremor. In the Cox proportional hazards model, later start year (1.10 [1.08-1.13], P&nbsp;&lt;&nbsp;0.001) and female sex (1.41 [1.07-1.85], P&nbsp;=&nbsp;0.02) were associated with shorter trial duration. Valproate was associated with the longest treatment duration; trials with carbamazepine and topiramate were significantly shorter (HR [CI]: 3.29 [2.15-5.02], P&nbsp;&lt;&nbsp;0.001 and 1.93 [1.31-2.86], P&nbsp;&lt;&nbsp;0.001). The relative frequency of valproate trials shows a decreasing trend since 2003 while there is an increasing trend for levetiracetam. Fewer females than males received valproate (76.2% vs 92.6%, P&nbsp;=&nbsp;0.001). Significance: In people with JME, valproate is an effective AED; levetiracetam emerged as an alternative. Valproate is now contraindicated in women of childbearing potential without special precautions. With appropriate selection and safeguards in place, valproate should remain available as a therapy, including as an alternative for women of childbearing potential whose seizures are resistant to other treatments