Undiagnosed diabetes in the over-60s: performance of the Association of Public Health Observatories (APHO) Diabetes Prevalence Model in a general practice.

AIM: The Association of Public Health Observatories (APHO) Diabetes Prevalence Model has been interpreted to suggest that a substantial number of people with diabetes are 'missed'. An affluent suburb of Newcastle upon Tyne has a low known diabetes prevalence. We aimed to determine the true prevalence of diabetes in the practice population aged over 60 years and compare our prevalence estimate with that of the Association of Public Health Observatories Diabetes Prevalence Model (18.0%; uncertainty limit 10.7-27.7%). At baseline, the known prevalence of diabetes in this group was 7.4%. METHODS: All individuals aged 60 years and over registered with one general practice in Newcastle-upon-Tyne, not known to have diabetes (n = 1375), were invited for a standard oral glucose tolerance test and measurement of HbA(1c). Standard World Health Organization cut points for fasting and post-challenge glucose on oral glucose tolerance test or HbA(1c) ≥ 48 mmol/mol (6.5%) were used to identify diabetes. RESULTS: Five hundred and eighty-four individuals (42.5%) attended for screening. Using oral glucose tolerance test criteria, 4.5% were identified with undiagnosed diabetes. Using HbA(1c), 3.1% had undiagnosed diabetes. The estimated prevalence of total diabetes for the practice population aged 60 years and older is 11.8 (10.5-13.2%) and 10.3 (9.3-11.6) for oral glucose tolerance test and HbA(1c) criteria, respectively. CONCLUSIONS: The prevalence of diabetes in those aged 60 years and older registered with this practice is lower than the point estimate of the Association of Public Health Observatories Diabetes Prevalence Model, but within its uncertainty limits. Application of the Association of Public Health Observatories model must take into account its uncertainty limits.

Diabetes in care homes: current care standards and residents' experience.

AIMS: The Diabetes UK good clinical practice guidelines for care home residents were revised in 2010. In this study, we examined current care against these standards and sought the views of residents on their diabetes. METHODS: Mixed methods (qualitative and quantitative), including interviews with residents, carers and staff, participant record reviews and focus group discussions were used to gather data in care homes in Newcastle upon Tyne. RESULTS: Thirty-one residents from seven care homes participated. Eighty-seven per cent of residents had probable dementia (based on abbreviated mental test score or clock-drawing test). Weight, body mass index and blood pressure were satisfactorily monitored. Glucose monitoring took place in all residents who received insulin, but was monitored unnecessarily in those with diet-controlled diabetes (63%). The majority of residents (90%) had seen a chiropodist and had received eye screening (> 80%) recently. Only one of the care homes had staff that had diabetes training. Residents reported little knowledge of diabetes management. However, when asked what they knew about diabetes, comments included 'It's a common thing... like cancer'; '[I would have liked a] plain language explanation of diabetes' and 'They told me they could control it by diet, and then it was tablets, then insulin. They didn't explain why.' CONCLUSIONS: In Newcastle upon Tyne care homes there is good care provided but also evidence of inadequacies. Despite high levels of dementia, many patients have strong and valid opinions about their disease and the care they receive. Despite the challenges, we believe that residents must be included in discussions about service development.

Traumatic brain injury and quality of life: initial Australian validation of the QOLIBRI.

The Quality of Life after Brain Injury (QOLIBRI) is a new international instrument for assessing quality of life after traumatic brain injury (TBI). We report first use and validation. Patients previously admitted with TBI to the Royal Melbourne Hospital, Melbourne, Australia, were randomly sampled (n=66, 61% response rate) and administered the QOLIBRI. Fifty-five re-completed it at 2-week follow-up. QOLIBRI scales (with two exceptions) met standard criteria for internal consistency, homogeneity and test-re-test reliability. Correlations with the Assessment of Quality of Life, Short Form-36 version 2 and the Satisfaction with Life Scale were moderate. The QOLIBRI was sensitive to the Glasgow Outcome Scale - Extended scores, Hospital Anxiety and Depression scale, and measures of social isolation (Friendship Scale). There was evidence that further refinement may improve the QOLIBRI. The QOLIBRI should be considered as an outcome measure by clinicians and researchers conducting treatment trials, rehabilitation studies or epidemiological surveys into the treatment or sequelae of trauma.

Trends in prevalence and outcomes of pregnancy in women with pre-existing type I and type II diabetes.

OBJECTIVE: To describe recent trends in prevalence, outcomes and indicators of care for women with pre-existing type I or type II diabetes. DESIGN: Regional population-based survey. SETTING: All maternity units in the North of England. POPULATION: A total of 1258 pregnancies in women with pre-existing diabetes delivered between 1996 and 2004. METHODS: Data from the Northern Diabetic Pregnancy Survey. Outcome of pregnancy cross-validated with the Northern Congenital Abnormality Survey and the Northern Perinatal Mortality Survey. MAIN OUTCOME MEASURES: Perinatal mortality, congenital anomaly and total adverse perinatal outcome (perinatal mortality and live births with congenital anomaly). RESULTS: The prevalence of pregestational diabetes increased from 3.1 per 1000 births in 1996-98 to 4.7 per 1000 in 2002-04 (test for linear trend, P < 0.0001), driven mainly by a sharp increase in type II diabetes. Perinatal mortality declined from 48 per 1000 births in 1996-98 to 23 per 1000 in 2002-04 (P = 0.064). There was a significant reduction in total adverse perinatal outcome rate (P = 0.0194) from 142 per 1000 in 1996-98 to 86 per 1000 in 2002-04. There were substantial improvements in indicators of care before and during pregnancy and in glycaemic control throughout pregnancy, but indicators of preconceptual care, such as use of folic acid, remained disappointing. CONCLUSION: We observed improvements in pregnancy care and outcomes for women with diabetes in a region with an established audit and feedback cycle. There remains considerable scope for further improvement, particularly in periconceptual glycaemic control. The rising prevalence of type II diabetes presents a challenge to further improvement.

Laparoscopic versus open Burch colposuspension: a randomised controlled trial.

OBJECTIVE: To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. DESIGN: Randomised surgical trial with single blinding. SETTING: Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. POPULATION: Two hundred women with urodynamic stress incontinence (USI). METHODS: The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. MAIN OUTCOME MEASURES: Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. RESULTS: There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P< 0.0001) but was associated with less blood loss (P = 0.03), less pain (P = 0.02), and quicker return to normal activities (P = 0.01). CONCLUSION: LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes. To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. Randomised surgical trial with single blinding. Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. Two hundred women with urodynamic stress incontinence (USI). The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P < 0.0001) but was associated with less blood loss (P= 0.03), less pain (P= 0.02), and quicker return to normal activities (P= 0.01). LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes.

Metformin use and diabetic pregnancy-has its time come?

The prevalence of Type 2 diabetes in women of childbearing age continues to grow as the incidence of Type 2 diabetes increases. Recent evidence shows that treatment of gestational diabetes ensures the best possible outcome for pregnancy complicated by gestational diabetes. Metformin is a logical treatment in these circumstances but there has always been concern about its safety for the fetus, particularly as it crosses the placenta and it may increase the risk of teratogenesis. Although evidence is accumulating that metformin is useful and has a role in polycystic ovary syndrome, a condition of insulin resistance, it is not yet accepted as treatment for Type 2 diabetes in pregnancy and gestational diabetes. Observational data supports the use of metformin in Type 2 diabetes in pregnancy and its role in gestational diabetes is currently under investigation. Metformin may become an important treatment for women with either gestational or Type 2 diabetes in pregnancy and indeed may have additional important benefits for women, including reducing insulin resistance, body weight and long-term risk of diabetes. There is a need for a randomized controlled trial in women with Type 2 diabetes in pregnancy with long-term follow-up of both mothers and children. Until then the best advice remains that optimized glycaemic control prior to conception and during pregnancy is the most important intervention for best possible pregnancy outcome.

Transdermal posterior tibial nerve laser therapy is not effective in women with interstitial cystitis.

PURPOSE: Interstitial cystitis (IC) is a debilitating condition which causes irritative bladder symptoms, pain and a decrease in health status. The pathophysiology is poorly understood so therapeutic options are diverse. Percutaneous posterior tibial nerve stimulation is an effective treatment and pulsed transdermal laser stimulation is an established technique for pain management. We evaluated the efficacy of transdermal laser stimulation of the posterior tibial nerve for patients with IC. MATERIALS AND METHODS: Women meeting the National Institutes of Health National Institute for Diabetes and Digestive and Kidney Diseases criteria for IC were prospectively recruited and randomized to treatment (29) or placebo (27) cohorts in a double-blind trial. At home the patient performed laser therapy daily for 30 seconds over the SP6 acupuncture point for 12 weeks. Measures at baseline and at 84-day followup included the 7-day voiding diary, the Interstitial Cystitis Problem Index, Interstitial Cystitis Symptom Index and RAND 36-Item Health Survey questionnaires. RESULTS: There were no significant differences between the treatment and control cohorts on any of the measures. However, there was a significant decrease between baseline and 12-week followup in the amount voided, symptom problems and severity, and on all 8 SF-36 scales. There was no significant effect of fluid intake. CONCLUSIONS: This study demonstrated no difference between the active and sham device. However, it is interesting that treatment and control cohorts experienced similar improvements, suggesting that the control cohort improvements may have been due to participants' belief that they were receiving active treatment from the stimulator. These findings provide support for investigating placebo effects in randomized trials.

Cardiovascular malformations in infants of diabetic mothers.

OBJECTIVE: To compare the prevalence at live birth and the spectrum of cardiovascular malformations in infants born to diabetic mothers with pre-existing diabetes with that in infants of non-diabetic mothers. DESIGN: Prospective study of all live births in the resident population of one health region, with recording of details of the outcome of all pregnancies of women with pre-existing diabetes and of all live born babies with cardiovascular malformations. RESULTS: In the six years 1995-2000 there were 192 618 live births in the study population. Cardiovascular malformations were confirmed in 22 of 609 (3.6%) babies with diabetic mothers and in 1417 of 192 009 (0.74%) babies with non-diabetic mothers. The odds ratio for a cardiovascular malformation with maternal diabetes was 5.0 (95% confidence interval 3.3 to 7.8). Combination of these results with previous reports and comparison with the spectrum of cardiovascular malformations in infants of non-diabetic mothers shows a greater than threefold excess of transposition of the great arteries, truncus arteriosus, and tricuspid atresia. CONCLUSIONS: Pre-existing maternal diabetes is associated with a fivefold increase in risk of cardiovascular malformations. Transposition of the great arteries, truncus arteriosus, and tricuspid atresia are overrepresented to produce a substantial excess of these malformations.

Maternity services for women with diabetes in the UK.

Diabetic pregnancy is high risk in those regions within the UK that have reported on such an outcome. There is a paucity of information about diabetic pregnancy outcome in the rest of the UK but it seems appropriate to assume that poor outcome is widespread. Previously reports have highlighted problems with the delivery of preconception care and the lack of agreement about the screening and diagnosis of gestational diabetes. The provision of maternity services for women with diabetes in the UK is reviewed. Service development is traced from the 1980s to more recent surveys from Scotland and the former Northern region of England. Service provision has improved over the years in those regions that have agreed and audited standards for provision of care. There is a lack of information about current services within the UK but this will be partly addressed by the forthcoming survey of organization of services co-ordinated by the Confidential Enquiry into Stillbirths and deaths in Infancy (CESDI), which will survey England, Wales and Northern Ireland. In Scotland the Scottish Intercollegiate Guidelines 'Management of diabetes in pregnancy' has been implemented and audited. A similar guideline of agreed standards of care is needed for the rest of the UK.

A comparison of the Assessment of Quality of Life (AQoL) with four other generic utility instruments.

As part of the validation of the Assessment of Quality of Life (AQoL) instrument comparisons were made between five multiattribute utility (MAU) instruments, each purporting to measure health-related quality of life (HRQoL). These were the AQoL, the Canadian Health Utilities Index (HUI) 3, the Finnish 15D, the EQ-5D (formerly the EuroQoL) and the SF6D (derived from the SF-36). The paper compares absolute utility scores, instrument sensitivity, and incremental differences in measured utility between different instruments predicted by different individuals. The AQoL predicted utilities are similar to those from the HUI3 and EQ-5D. By contrast the 15D and SF6D predict systematically higher utilities, and the differences between individuals are significantly smaller. There is some evidence that the AQoL has greater sensitivity to health states than other instruments. It is concluded that at present no single MAU instrument can claim to be the 'gold standard', and that researchers should select an instrument sensitive to the health states they are investigating. Caution should be exercised in treating any of the instrument scores as representing a trade-off between length of life and HRQoL.

The role of economic evaluation in mental health care.

OBJECTIVE: A consequence of the integration of psychiatry into acute and public health medicine is that psychiatrists are being asked to evaluate their services. There is pressure on mental health-care systems because it is recognized that funds should be directed where they can provide the best health outcomes, and also because there are resource constraints which limit our capacity to meet all demands for health care. This pressure can be responded to by evaluation which demonstrates the effectiveness and efficiency of psychiatric treatment. This paper seeks to remind psychiatrists of the fundamental principles of economic evaluation in the hope that these will enable psychiatrists to understand the methods used in evaluation and to work comfortably with evaluators. METHOD: The paper reviews the basic principles behind economic evaluation, illustrating these with reference to case studies. It describes: (i) the cost of the burden of illness and treatment, and how these costs are measured; (ii) the measurement of treatment outcomes, both as changes in health status and as resources saved; and (iii) the various types of economic evaluation, including cost-minimization, cost-effectiveness, cost-utility and cost-benefit analysis. RESULTS: The advice in the paper provides psychiatrists with the necessary background to work closely with evaluators. A checklist of the critical questions to be addressed is provided as a guide for those undertaking economic evaluations. CONCLUSIONS: If psychiatrists are willing to learn the basic principles of economic evaluation and to apply these, they can respond to the challenges of evaluation.

Quality management and the Emergency Services Enhancement Program.

Since the introduction of the Emergency Services Enhancement Program (ESEP) in Victoria in 1995, improvements have been demonstrated in the indicators relating to Emergency waiting times, ambulance bypass rates and inpatient bed access block. This study focuses on staff perceptions of changes in these indicators, factors perceived to influence performance improvements and the extent to which ESEP is perceived to have contributed to overall patient care. A questionnaire was directed at four focus groups within each of the hospitals participating in ESEP. These were Chief Executive Officers, Emergency Department Directors and Nurse Unit Managers, bed coordinators and personnel from the Emergency Department floor. A total of 101 staff responded. Emergency Department staff were generally accurate in their perceptions of performance changes. The most important factors effecting the changes were perceived to be changes in staff profile, management of patient flow through the department, changes in administrative policies and changes in work practices. Staff perceived that patient care has improved by 10% since 1995 and that ESEP has contributed 8% of this improvement. Staff have perceived improvements in ESEP performance indicators consistent with actual changes. The possible mechanisms by which these changes have occurred are presented and discussed. Factor analysis indicated that changes perceived to be most likely to result in improvements were: changes in staff profile (seniority), managing the flow of patients through emergency departments, changing administrative policies, changes in work practices and changes in staff numbers. Improvements in patient care were considered partly due to ESEP. In addition, ESEP has raised awareness of quality management issues.

Health-related quality-of-life outcomes from adult cochlear implantation: a cross-sectional survey.

PURPOSE: The purpose of this study was to examine the extent to which cochlear implants and related rehabilitation improve health-related quality-of-life (HRQoL) and social participation for deafened adults and their partners. METHOD: A cross-sectional survey was used to examine HRQoL and social participation experiences of 202 deafened adults (148 with implants and 54 without) and 136 partners associated with cochlear implant clinics in Australia and New Zealand. Respondents completed a mailed survey consisting of the Assessment of Quality of Life instrument (a utility instrument), the Participation Scale and questions concerning their socioeconomic status. Both univariate and multivariate analyses were performed. RESULTS: Controlling for socioeconomic factors, people with cochlear implants reported improved HRQoL and social participation when compared with non-implantees. Implantees reported a relative gain in health utility of 50%, and a relative improvement in social participation of 31%. Such differences were not reported by partners, although patient and partner HRQoL were weakly correlated. CONCLUSION: The results of this cross-sectional study suggest that cochlear implantation contributes significantly to improvements for deafened adults in everyday communication settings and makes a major contribution to their HRQoL. Nonetheless, when compared with population-based studies, this population continues to report considerably reduced quality of life. Partners also report significantly reduced quality of life when compared to population norms.

Measuring the value of program outcomes: a review of multiattribute utility measures.

Selection of a multiattribute utility instrument for economic evaluation is complex due to competition between developers and inflated claims for instrument properties. This review presents multiattribute utility theoretical requirements and assesses leading multiattribute utility instruments against these. Instruments reviewed are: the QWB, HUI3, 15D, EQ5D, AQoL and SF6D. The key finding is that no current instrument satisfies all the requirements for multiattribute utility measurement. We recommend that users should choose instruments most relevant to their circumstances and that studies should include two instruments. Rigorous sensitivity analyses should be conducted and both results reported. Subject to these caveats, preference should be given to instruments best meeting multiattribute utility theoretical requirements, viz., the AQoL or HUI3. However, we recognise that other instruments may perform as well, or even better, under certain circumstances.

Pay for performance: what trustees should be applauding.

The responsibilities of the board's compensation committee go beyond just determining annual pay. The committee must develop a plan that outlines organizational goals and identifies the CEO's accountabilities. Then trustees can fulfill their fiduciary and stewardship roles by providing continuous feedback to their CEO.

The Assessment of Quality of Life (AQoL) instrument: a psychometric measure of health-related quality of life.

This paper describes constructing the Assessment of Quality of Life (AQoL) instrument; designed to measure health-related quality of life (HRQoL), and to be the descriptive system for a multi-attribute utility instrument. Unlike previous utility instruments' descriptive systems, the AQoL's has been developed using state-of-the-art psychometric procedures. The result is a descriptive system which emphasizes five different facets of HRQoL and which can claim to have construct validity. Based on the WHO's definition of health a model of HRQoL was developed. Items were written by focus groups of doctors and the researchers. These were administered to a construction sample, comprising hospital patients, and community members chosen at random. Final construction was through an iterative process of factor and reliability analyses. The AQoL measures 5 dimensions: illness, independent living, social relationships, physical senses and psychological wellbeing. Each has three items. Exploratory factor analysis showed the dimensions were orthogonal, and each was unidimensional. Internal consistency was alpha = 0.81. Structural equation modeling explored its internal structure; the comparative fit index was 0.90. These preliminary results indicate the AQoL has the prerequisite qualities for a psychometric HRQoL instrument for evaluation; replication with a larger sample is needed to verify these findings. Scaling it for economic evaluation using utilities is being undertaken. Respondents have indicated the AQoL is easy to understand and is quickly completed. Its initial properties suggest it may be widely applicable.