Evaluation of an innovative approach to the Director of Public Health's annual report.

BACKGROUND: The aim of this study was to evaluate the process of an innovative 'presentation with discussion' approach to the Director of Public Health's (DPH) annual report for North Derbyshire Health Authority. STUDY DESIGN: Mixed methods-survey and interviews. METHODS: Survey methods were used to obtain qualitative and quantitative data. Key stakeholders were sent a postal questionnaire, individuals attending presentations could respond via a printed slip or letter, structured group discussions following presentations were recorded manually, and presenters and producers were interviewed. RESULTS: Thirty-five of 41 (85.4%) key stakeholders returned questionnaires, 18 people responded individually, discussions following 26/30 (86.7%) presentations were documented, and all eight presenters and 11 producers were interviewed. The general response was extremely positive with 25 of 35 (71%) key stakeholders, 100% of presenters and 80% of producers preferring the new format to the previous year's report. People felt that it conveyed the public health message effectively, and appreciated the opportunity to contribute to the recommendations for improving health in North Derbyshire. Many were concerned that the circulation should be wide, and key stakeholders were keen to have a printed reference document to support their work. Presenters enjoyed the process although tailoring the presentations to unfamiliar audiences proved difficult. The production team found the process more efficient and focused, although direct production costs were increased. Presenters and producers were concerned that the process for implementing recommendations for action was not fully considered. CONCLUSIONS: Most people preferred this innovative approach to the traditional annual report, and it is therefore recommended that this format should be used for future DPH annual reports. Key stakeholders still require a reference document, and presenters' briefing notes could be adapted for this purpose. Circulation of the report should be wide, and further consideration of how participants' recommendations for action are implemented is needed.

The impact of a general practice co-operative on accident and emergency services, patient satisfaction and GP satisfaction.

BACKGROUND: The advent of general practice co-operatives represented a fundamental change in the delivery and organization of out-of-hours services. Concerns have been voiced that co-operatives might impact adversely on workload in accident and emergency (A&E) departments. OBJECTIVE: The purpose of this study was to assess the impact of establishing a general practice co-operative on use of A&E services, patient satisfaction and GP satisfaction. METHODS: A controlled before and after study of a GP co-operative in Sheffield, UK was carried out. A postal questionnaire was sent to 26 911 people, 13 442 before and 13 469 after the opening of the co-operative, to determine service use, in particular A&E attendance, in the previous 4 weeks. Patient satisfaction was assessed through structured interviews with 653 patients. GP satisfaction was assessed using a postal survey of all 98 Sheffield practices 2 years after the opening of the co-operative. RESULTS: There was no change in the use of A&E services, odds ratio = 1.08 (95% confidence interval 0.60-1.94). There was no change in patient satisfaction overall, mean difference 0.02 (-0.32 to 0.36). Sixty-seven per cent of doctors in member practices were much more satisfied with out-of-hours duty compared with 10% in non-member practices (P < 0.001). CONCLUSIONS: General practice co-operatives have been successful in achieving their policy objectives, improving GP morale without jeopardizing patient satisfaction or impacting adversely on A&E services.

Cost effectiveness of HMG-CoA reductase inhibitor (statin) treatment related to the risk of coronary heart disease and cost of drug treatment.

OBJECTIVES: To estimate the cost effectiveness of statin treatment in preventing coronary heart disease (CHD) and to examine the effect of the CHD risk level targeted and the cost of statins on the cost effectiveness of treatment. DESIGN: Cohort life table method using data from outcome trials. MAIN OUTCOME MEASURES: The cost per life year gained for lifelong statin treatment at annual CHD event risks of 4.5% (secondary prevention) and 3.0%, 2.0%, and 1.5% (all primary prevention), with the cost of statins varied from pound 100 to pound 800 per year. RESULTS: The costs per life year gained according to annual CHD event risk were: for 4.5%, pound 5100; 3.0%, pound 8200; 2.0%, pound 10 700; and 1.5%, pound 12 500. Reducing the cost of statins increases cost effectiveness, and narrows the difference in cost effectiveness across the range of CHD event risks. CONCLUSIONS: At current prices statin treatment for secondary prevention, and for primary prevention at a CHD event risk 3.0% per year, is as cost effective as many treatments in wide use. Primary prevention at lower CHD event risks (< 3.0% per year) is less cost effective and unlikely to be affordable at current prices and levels of health service funding. As the cost of statins falls, primary prevention at lower risk levels becomes more cost effective. However, the large volume of treatment needed will remain a major problem.

Lipid-lowering for prevention of coronary heart disease: what policy now?

1. Recent outcome trials suggest that lipid-lowering with 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors is justifiable on risk-benefit grounds in subjects with serum cholesterol > 5.5 mmol/l who have coronary heart disease, other forms of atherosclerotic vascular disease, or who are free of vascular disease but have a risk of major coronary events > or = 1.5% per year. Choice of an appropriate treatment policy will require (i) knowledge of the proportion of the population who will need treatment for secondary prevention, and (ii) targeting of treatment for primary prevention at a specified absolute risk of coronary heart disease events. Selection of an appropriate coronary heart disease risk for primary prevention requires consideration of the number needed to be treated to prevent one coronary heart disease event, the proportion of the population requiring treatment, the cost-effectiveness of treatment and the total cost of treatment. 2. In a random stratified sample of subjects aged 35-69 years from the Health Survey for England 1993 we first examined the prevalence of subjects with cardiovascular disease and serum cholesterol > 5.5 mmol/l who may be candidates for secondary prevention. In those free of cardiovascular disease we then examined the prevalence of subjects with serum cholesterol > 5.5 mmol/l who had three different levels of coronary heart disease risk: coronary heart disease event rates of 4.5% per year, 3.0% per year and 1.5% per year. These subjects may be candidates for primary prevention depending on the treatment policy selected. 3. For secondary prevention, 4.8% (95% confidence interval 4.3-5.3) of the U.K. population aged 35-69 years might be candidates for 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor treatment, comprising 2.4% (2.0 to 2.7) with a history of myocardial infarction, 1.9% (1.6 to 2.2) with angina and 0.5% (0.3-0.7) with a history of stroke--all with total cholesterol > 5.5 mmol/l. The prevalence of these diagnoses with total cholesterol > 5.5 mmol/l increased with age, from 1.5% at age 35-39 years to 16.2% at age 65-69 years in men, and from 0.2% at age 35-39 years to 10.0% at age 65-69 years in women. Approximately 13 people would need treatment for 5 years to prevent one coronary event, at a cost of 36,000 pounds per event prevented. The number needing treatment for secondary prevention would increase substantially if treatment was extended to patients above 70 years of age or to those with serum cholesterol < or = 5.5 mmol/l. 4. Primary prevention aimed at a coronary event risk of 4.5% per year would lead to treatment of only 0.3% (0.2-0.4) of those aged 35-69 years, and those treated would be predominantly older men with additional risk factors for coronary heart disease. The number needed to be treated and cost per coronary event prevented would be similar to those for secondary prevention. 5. Primary prevention targeted at subjects with a coronary event rate of 3.0% per year would entail treating 3.4% (3.0-3.9) of all those aged 35-69 years. At this level of risk, 20 people would need treatment for 5 years to prevent one coronary event, at a cost of 55,000 pounds per event prevented. 6. Primary prevention aimed at a coronary event rate of 1.5% per year would entail treating 19.6% (18.7-20.6) of all subjects aged 35-69 years, and about 80% of men aged 60-69 years for primary or secondary prevention. At this level of risk, 40 people would need treatment for 5 years to prevent one event, at a cost of 111,000 pounds per event saved. 7. Guidelines for 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor treatment should take into account the considerable workload and financial resources needed to implement secondary prevention of coronary heart disease, the accepted first priority. For primary prevention they need to consider the number needed to be treated to prevent one event, the number of subjects needing treatment, the cost-effectiveness of treatment and

Pharmacokinetics of FCE 22101 in man following different modes of administration.

Twelve healthy volunteers received single iv doses of either 500 and 1000 mg or 750 and 1500 mg of the sodium salt of FCE 22101; in addition, five of the volunteers received a further dose of 2000 mg. In the second part of the study, 11 of the volunteers received 1000 mg doses of FCE 22101 in a four-way randomized fashion by iv bolus (1000 mg, with and without probenecid), im injection (1000 mg plus lignocaine) and a continuous infusion (280 mg/h) to steady state. All doses were well tolerated by the volunteers with no serious side effects and no significant haematological or biochemical changes following drug administration. Plasma and urine concentrations of FCE 22101, and in the cross-over study also its open ring metabolites P1 and P2, were determined by HPLC. Good linearity was observed between the peak plasma levels or AUC and the dose given. Plasma concentrations were fitted to a two-compartment model and the mean pharmacokinetic parameters determined after iv bolus were: Cmax 117 mg/l, T1/2 beta 36 min, Vss 181, AUC 2179 mg/min/l with urinary recoveries of FCE 22101 37%, P1 36% and P2 6%. With probenecid the values were Cmax 116 mg/l, T1/2 beta 47 min, Vss 141, AUC 4540 mg/min/l and urinary recoveries of FCE 22101 20%, P1 40% and P2 7%. Following im injection the mean values were Cmax 15 mg/l, Tmax 30 min, T1/2abs 14 min, T1/2 beta 61 min, AUC 2117 mg/min/l and urinary recoveries of FCE 22101 33%, P1 37% and P2 6%. At steady state during continuous infusion, mean values were Css 12.7 mg/l, Vss 131 and T1/2 beta after steady state was 22 min. Although urinary recoveries varied widely between volunteers there was a tendency towards consistency of recovery within individual volunteers. We conclude that FCE 22101 is a well tolerated penem with pharmacokinetic properties broadly similar to those of other penem and carbapenem antibiotics.