1,601 research outputs found
A randomised controlled trial to measure the effect of chest pain unit care upon anxiety, depression, and health-related quality of life [ISRCTN85078221]
Background
The chest pain unit (CPU) has been developed to provide a rapid and accurate diagnostic assessment for patients attending hospital with acute, undifferentiated chest pain. We aimed to measure the effect of CPU assessment upon psychological symptoms and health-related quality of life.
Methods
We undertook a single-centre, cluster-randomised controlled trial. Days (N = 442) were randomised in equal numbers to CPU or routine care. Patients with acute chest pain, undiagnosed by clinical assessment, ECG and chest radiograph, were recruited and followed up with self-completed questionnaires (SF-36 and HADS) at two days and one month after hospital attendance.
Results
Patients receiving CPU assessment had significantly higher scores on the physical functioning (difference 5.1 points; 95% CI 1.1 to 9.0), vitality (4.6; 1.3 to 8.0), and general health (5.7; 2.3 to 9.2) dimensions of the SF-36 at two days, and significantly higher scores on all except the emotional role dimension at one month. They also had significantly lower depression scores on the HADS depression scale at two days (0.93; 0.34 to 1.51) and one month (1.0; 0.36 to 1.66). However, initially lower anxiety scores at two days (0.89; 0.21 to 1.56) were not maintained at one month (0.48; -0.26 to 1.23). CPU assessment was associated with reduced prevalence (OR 0.71; 95% CI 0.52 to 0.97) and severity (6.5 mm on 100 m visual analogue scale; 95% CI 2.2 to 10.8) of chest pain at one month, but no significant difference in the proportion of patients taking time off work (OR 0.82; 95% CI 0.54 to 1.04).
Conclusion
CPU assessment is associated with improvements in nearly all dimensions of quality of life and with reduced symptoms of depression
What to do about poor clinical performance in clinical trials
The performance of individual clinicians is being monitored as never before. Su Mason and colleagues discuss the implications of this for clinical trials and recommend what should happen if during a trial the performance of one clinician or one centre is identified as being particularly poor. Tom Treasure, a surgeon, wants the monitoring to be done fairly and to take account of the complexities of clinical practice; and Heather Goodare, a patient, wants to be told when things go wrong.
The Department of Health in England has issued guidelines for research governance stating that healthcare organisations remain responsible for the quality of all aspects of patients' care whether or not some aspects of the care are part of a research study.1 We discuss how this obligation can be met in multicentre trials, given that data on the performance of clinicians are held by the trial management team, not by the host organisation
Systematic investigation of the fallback accretion powered model for hydrogen-poor superluminous supernovae
The energy liberated by fallback accretion has been suggested as a possible
engine to power hydrogen-poor superluminous supernovae. We systematically
investigate this model using the Bayesian light-curve fitting code MOSFiT
(Modular Open Source Fitter for Transients), fitting the light curves of 37
hydrogen-poor superluminous supernovae assuming a fallback accretion central
engine. We find that this model can yield good fits to their light curves, with
a fit quality that rivals the popular magnetar engine models. Examining our
derived parameters for the fallback model, we find the total energy
requirements from the accretion disk are estimated to be 0.002 - 0.7 Msun c^2.
If we adopt a typical conversion efficiency ~ 1e-3, the required mass to
accrete is thus 2 - 700 Msun. Many superluminous supernovae, therefore, require
an unrealistic accretion mass, and so only a fraction of these events could be
powered by fallback accretion unless the true efficiency is much greater than
our fiducial value. The superluminous supernovae that require the smallest
amounts of fallback mass still remain to be the fallback accretion powered
supernova candidates, but they are difficult to be distinguished solely by
their light curve properties.Comment: 12 pages, 8 figures, 3 tables, accepted by The Astrophysical Journa
General practitioners' reasons for removing patients from their lists: postal survey in England and Wales
The removal of patients from doctors' lists causes conĀ
siderable public and political concern, with speculation
that patients are removed for inappropriate, including
financial, reasons. In 1999 the House of Commons
Select Committee on Public Administration noted that
little evidence was available on either the frequency of,
or the reasons for, removal of patients. National statistics do not distinguish between patients removed after
moving out of a practice area and those removed for
other reasons. Two postal surveys have reported why
general practitioners might, in general, remove
patients, and one small study has described the
reasons doctors give for particular removals. We
therefore determined the current scale of, and doctors'
reasons for, removal of patients from their lists in EngĀ
land and Wales
Evaluation of NHS Direct āāreferralāā to community pharmacists
OBJECTIVES: To evaluate a pilot scheme of referrals from a nurse-led telephone helpline (NHS
Direct) to community pharmacists.
METHODS: A multi-method approach, including analysis of routine data from NHS Direct, postal
surveys of NHS Direct callers, analysis of anonymised transcripts of calls, a postal survey of callers
referred to pharmacists, and face-to-face interviews with NHS Direct nurses.
SETTING: Essex, Barking and Havering.
KEY FINDINGS: During the first three months of the pilot scheme, 6% (1,995/31,674) of NHS Direct
calls triaged by nurses were logged as referred to pharmacists. This built on an existing foundation of
informal referral to pharmacists of 4%. There was no measurable change in callersā views of the
helpfulness of advice, enablement, or caller satisfaction associated with the scheme. Conditions sent
to pharmacists included skin rash, cough, sore throat, stomach pain, and vomiting and/or diarrhoea.
86% (54/63) of callers referred to pharmacists during the scheme felt the referral was very or quite
appropriate and 75% (48/64) attempted to contact a pharmacist. In general, those who did so found
the experience a positive one: 65% (31/48) spoke to the pharmacist, and 80% (28/35) of people
expressing an opinion were satisfied with the advice offered, but the lack of privacy in the pharmacy
was of some concern. Although routine data indicated high usage of the scheme, nurse referral of
callers to pharmacists declined over time. Their initial enthusiasm diminished due to concerns about
the appropriateness of guidelines, their lack of understanding of the rationale behind some referrals,
and the lack of feedback about the appropriateness of their referrals.
CONCLUSIONS: The evaluation of the pilot scheme has generated a range of recommendations for
the wider national roll-out of the scheme, including revision of the guidelines and review of NHS
Direct nurse training for referral to pharmacy. NHS Direct and pharmacists should consider how to
strengthen the system of pharmacist feedback to NHS Direct
Exploring the effect of changes to service provision on the use of unscheduled care in England: population surveys
Background
Unscheduled care is defined here as when someone seeks treatment or advice for a health problem without arranging to do so more than a day in advance. Recent health policy initiatives in England have focused on introducing new services such as NHS Direct and walk in centres into the unscheduled care system. This study used population surveys to explore the effect of these new services on the use of traditional providers of unscheduled care, and to improve understanding of help seeking behaviour within the system of unscheduled care.
Methods
Cross-sectional population postal surveys were undertaken annually over the five year period 1998 to 2002 in two geographical areas in England. Each year questionnaires were sent to 5000 members of the general population in each area.
Results
The response rate was 69% (33,602/48,883). Over the five year period 16% (5223/33602) 95%CI (15.9 to 16.1) of respondents had an unscheduled episode in the previous four weeks and this remained stable over time (p = 0.170). There was an increased use of telephone help lines over the five years, reflecting the change in service provision (p = 0.008). However, there was no change in use of traditional services over this time period. Respondents were most likely to seek help from general practitioners (GPs), family and friends, and pharmacists, used by 9.0%, 7.2% and 6.3% respectively of the 5815 respondents in 2002. Most episodes involved contact with a single service only: 7.0% (2363/33,602) of the population had one contact and 2% (662/33602) had three or more contacts per episode. GPs were the most frequent point of first contact with services.
Conclusion
Introducing new services to the provision of unscheduled care did not affect the use of traditional services. A large majority of the population continued to turn to their GP for unscheduled health care
Impact of NHS Direct on demand for immediate care: observational study
OBJECTIVES: To quantify the impact of NHS Direct on
the use of accident and emergency, ambulance, and
general practitioner cooperative services.
DESIGN: Observational study of trends in use of NHS
Direct and other immediate care services over 24
months spanning introduction of NHS Direct.
Setting Three areas in England in first wave of
introduction of NHS Direct, and six nearby general
practitioner cooperatives as controls.
SUBJECTS: All contacts with these immediate care
services.
MAIN OUTCOME MEASURES: Changes in trends in use
after introduction of NHS Direct.
Results NHS Direct received about 68 500 calls from
a population of 1.3 million in its first year of
operation, of which 72% were out of hours and 22%
about a child aged under 5 years. Changes in trends
in use of accident and emergency departments and
ambulance services after introduction of NHS Direct
were small and nonĀsignificant. Changes in trends in
use of general practitioner cooperatives were also
small but significant, from an increase of 2.0% a
month before introduction of NHS Direct to - 0.8%
afterwards (relative change - 2.9% (95% confidence
interval - 4.2% to - 1.5%)). This reduction in trend
was significant both for calls handled by telephone
advice alone and for those resulting in direct contact
with a doctor. In contrast, the six control cooperatives
showed no evidence of change in trend; an increase of
0.8% a month before NHS Direct and 0.9% after
(relative change 0.1% ( - 0.9% to 1.1%)).
CONCLUSION: In its first year NHS Direct did not reduce
the pressure on NHS immediate care services,
although it may have restrained increasing demand
on one important partāgeneral practitioners' out of
hours services
Impact of NHS Direct on other services: the characteristics and origins of its nurses
OBJECTIVE:: To characterise the NHS Direct nurse workforce and estimate the impact of NHS Direct on the staffing of other NHS nursing specialties.
METHOD: A postal survey of NHS Direct nurses in all 17 NHS Direct call centres operating in June 2000.
RESULTS: The response rate was 74% (682 of 920). In the three months immediately before joining NHS Direct, 20% (134 of 682, 95% confidence intervals 17% to 23%) of respondents had not been working in the NHS. Of the 540 who came from NHS nursing posts, one fifth had come from an accident and emergency department or minor injury unit (110 of 540), and one in seven from practice nursing (75 of 540). One in ten (65 of 681) nurses said that previous illness, injury, or disability had been an important reason for deciding to join NHS Direct. Sixty two per cent (404 of 649) of nurses felt their job satisfaction and work environment had improved since joining NHS Direct.
CONCLUSION: The NHS Direct nurse workforce currently constitutes a small proportion (about 0.5%) of all qualified nurses in the NHS, although it recruits relatively experienced and well qualified nurses more heavily from some specialties, such as accident and emergency nursing, than others. However, its overall impact on staffing in any one specialty is likely to be small. NHS Direct has succeeded in providing employment for some nurses who might otherwise be unable to continue in nursing because of disability
NHS Direct: consistency of triage outcomes
OBJECTIVES: To examine the consistency of triage outcomes by nurses using four types of computerised
decision support software in NHS Direct.
METHODS: 119 scenarios were constructed based on calls to ambulance services that had been
assigned the lowest priority category by the emergency medical dispatch systems in use. These
scenarios were presented to nurses working in four NHS Direct call centres using different computerised
decision support software, including the NHS Clinical Assessment System.
RESULTS: The overall level of agreement between the nurses using the four systems was āfairā rather than
āmoderateā or āgoodā (k=0.375, 95% CI: 0.34 to 0.41). For example, the proportion of calls triaged
to accident and emergency departments varied from 22% (26 of 119) to 44% (53 of 119). Between
21% (25 of 119) and 31% (37 of 119) of these low priority ambulance calls were triaged back to the
999 ambulance service. No system had both high sensitivity and specificity for referral to accident and
emergency services.
CONCLUSIONS: There were large differences in outcome between nurses using different software systems
to triage the same calls. If the variation is primarily attributable to the software then standardising on a
single system will obviously eliminate this. As the calls were originally made to ambulance services and
given the lowest priority, this study also suggests that if, in the future, ambulance services pass such
calls to NHS Direct then at least a fifth of these may be passed back unless greater sensitivity in the
selection of calls can be achieved
The calibration of WET-sensor for volumetric water content and pore water electrical conductivity in different horticultural substrates
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