The cost of diabetic foot ulcers and amputations to the National Health Service in England.

AIM: To estimate the healthcare costs of diabetic foot disease in England. METHODS: Patient-level data sets at a national and local level, and evidence from clinical studies, were used to estimate the annual cost of health care for foot ulceration and amputation in people with diabetes in England in 2014-2015. RESULTS: The cost of health care for ulceration and amputation in diabetes in 2014-2015 is estimated at between £837 million and £962 million; 0.8% to 0.9% of the National Health Service (NHS) budget for England. More than 90% of expenditure was related to ulceration, and 60% was for care in community, outpatient and primary settings. For inpatients, multiple regression analysis suggested that ulceration was associated with a length of stay 8.04 days longer (95% confidence interval 7.65 to 8.42) than that for diabetes admissions without ulceration. CONCLUSIONS: Diabetic foot care accounts for a substantial proportion of healthcare expenditure in England, more than the combined cost of breast, prostate and lung cancers. Much of this expenditure arises through prolonged and severe ulceration. If the NHS were to reduce the prevalence of diabetic foot ulcers in England by one-third, the gross annual saving would be more than £250 million. Diabetic foot ulceration is a large and growing problem globally, and it is likely that there is potential to improve outcomes and reduce expenditure in many countries.

Filling the out of season gaps for lamb and hogget production: Diet and genetic influence on carcass yield, carcass composition and retail value of meat.

This study investigated the use of camelina forage and meal supplementation to a finishing diet on carcass traits, composition and retail value of lamb and hoggets. The metabolisable energy and crude protein concentrations of all 3 diets were 10-11 MJ/kg DM and 14-15% CP. Thirty maternal Composite wether lambs (28-38 kg) and 30 Merino wether hoggets (37-43 kg) were used in a 3 × 2 factorial experiment. Animals were slaughtered after 10 weeks of feeding with carcasses classified as 'Heavy lamb' or 'Heavy hogget' (>22 kg carcass weight). Carcass traits, composition, meat mineral concentrations and retail colour were measured. Camelina diets increased liveweight (P < 0.02) and carcass weight (P < 0.002) for both sheep types. Carcass weight (P < 0.005) and dressing % (P < 0.01) were lower for Merino hoggets than Composite lambs. Mineral concentration and retail colour stability of fresh meat were unaffected by diet, with 72 h retail colour considered acceptable for consumers.

Cost of diabetic foot disease to the National Health Service in England.

AIM: To estimate the annual cost of diabetic foot care in a universal healthcare system. METHODS: National datasets and economic modelling were used to estimate the cost of diabetic foot disease to the National Health Service in England in 2010-2011. The cost of hospital admissions specific to foot disease or amputation was estimated from Hospital Episode Statistics and national tariffs. Multivariate regression analysis was used to estimate the impact of foot disease on length of stay in admissions that were not specific to foot disease or amputation. Costs in other areas were estimated from published studies and data from individual hospitals. RESULTS: The cost of diabetic foot care in 2010-2011 is estimated at £580 m, almost 0.6% of National Health Service expenditure in England. We estimate that more than half this sum (£307 m) was spent on care for ulceration in primary and community settings. Of hospital admissions with recorded diabetes, 8.8% included ulcer care or amputation. Regression analysis suggests that foot disease was associated with a 2.51-fold (95% CI 2.43-2.59) increase in length of stay.The cost of inpatient ulcer care is estimated at £219 m, and that of amputation care at £55 m. CONCLUSIONS: The cost of diabetic foot disease is substantial. Ignorance of the cost of current care may hinder commissioning of effective services for prevention and management in both community and secondary care.

Supermarket own brand foods: lower in energy cost but similar in nutritional quality to their market brand alternatives.

BACKGROUND: The present study aimed to compare the nutritional quality (NQ) and energy costs (EC) (£ MJ(-1) ) of own brand (OB) versus market brand (MB) foods in 2010 and 2012. METHODS: A list of processed foods (n = 32) was identified based on the most frequently consumed foods in the UK. Total fat, saturated fat, sugars, salt and energy density (ED) (kJ g(-1) ) in 2010 and 2012 were compared for six OB and one MB version of each food using a NQ scoring method based on the Food Standards Agency's Traffic Light System (TLS). Additional information (fruit, vegetable and nut content; protein; fibre and sodium) was recorded in 2012, and NQ was assessed using the Food Standards Agency's nutrient profiling model (NPM). The EC of the food baskets (FB) was compared in 2010 and 2012. RESULTS: There were no differences in overall NQ between OB and MB FB in 2010 (TLS, P = 0.978) or 2012 (TLS, P = 0.840; NPM, P = 0.696). However, the MB FB was highest in EC in 2010 and 2012 (both P < 0.001). There was an inverse relationship between the ED and EC of the MB foods in 2010 (r = -0.484; P = 0.005) and 2012 (r = -0.452; P = 0.009). CONCLUSIONS: The MB FB was higher in EC than the OB FB in 2010 and 2012 but not superior in overall NQ based on both the TLS and NPM.

The P15 - a multinational assessment battery for collecting data on health indicators relevant to adults with intellectual disabilities.

BACKGROUND: Health disparities between adults with intellectual disabilities (ID) and the general population have been well documented but, to date, no dedicated assessment battery for measuring health disparity has been available. This paper reports on the development and testing of a multinational assessment battery for collecting data on a range of health indicators relevant to adults with ID. METHODS: An assessment battery (the P15) was developed following piloting, and administered to samples of adults with ID, in 14 EU countries. Samples were neither random, nor representative of the countries from which they were drawn. However, within the local health administration areas selected in each country, efforts were made to ensure samples were broadly representative of the typical living circumstances, ages and ability levels of the administrative population of adults with ID. The total sample comprised 1269 adults with ID, of whom 49% were female. The mean age was 41 years (range 19 to 90). RESULTS: Overall, feasibility, internal consistency and face validity of the P15 was acceptable. CONCLUSIONS: With some refinement the P15 could be useful for collecting data on health indicators known to be particularly important for adults with ID. It is useable in a range of countries and has the potential to highlight health inequity for adults with ID at a national or local level. Larger scale epidemiological studies are needed to exploit the potential of the P15 to address health inequity in this group.

A general practice-based prevalence study of epilepsy among adults with intellectual disabilities and of its association with psychiatric disorder, behaviour disturbance and carer stress.

BACKGROUND: Although the elevated occurrence of epilepsy in people with intellectual disabilities (ID) is well recognized, the nature of seizures and their association with psychopathology and carer strain are less clearly understood. The aims were to determine the prevalence and features of epilepsy in a community-based population of adults with ID, and to explore whether the presence of epilepsy was associated with greater psychopathology or carer strain. METHODS: Data were collected on the age, gender, place of residence, adaptive and challenging behaviour, social abilities and psychiatric status of 318 adults from 40 general practices, together with the degree of malaise and strain of family carers. For participants with epilepsy, a nurse collected information on seizures, investigations, treatment and carer concerns by interview. Association between epilepsy and psychiatric morbidity, challenging behaviour and caregiver malaise or strain, was explored by comparing those with epilepsy with a comparison group matched on adaptive behaviour. RESULTS: Fifty-eight participants (18%) had epilepsy: 26% were seizure free, but 34% had extremely poorly controlled seizures. Earlier onset and seizure frequency were associated with adaptive behaviour. Carer concerns were related to seizure frequency and a history of injury. There were no significant differences in psychopathology, carer malaise or caregiver strain between the matched epilepsy and non-epilepsy groups. CONCLUSIONS: This study supports the high occurrence and chronicity of epilepsy among people with ID. While psychopathology and carer strain is common within this population, underlying disability-related factors appear to be more important than the presence of epilepsy per se.

Developing health indicators for people with intellectual disabilities. The method of the Pomona project.

AIM: Recently, attention has focused on the health inequalities experienced by people with intellectual disabilities (ID) when compared with the general population. To inform policies aimed at equalizing health opportunities, comparable evidence is needed about the aspects of their health that may be amenable to intervention. METHOD: Applying the framework of the European Community Health Indicators (ECHI) for the general population, the Pomona group developed a set of health indicators reflecting aspects of the health of people with ID: socio-demographic data, health status, health determinants and health systems. RESULTS: This paper documents the procedures that partners carried out in 13 European countries. The process comprised a search for evidence in published literature; consultation with advocates, family members and health professionals; and analyses of national and international databases. Indicators were selected if they were appraised as important, useful, measurable and if resulting data would enable comparisons between the health of people with ID and that of the general population. CONCLUSION: The thus developed indicator set that is aligned with ECHI will permit investigators to compare key aspects of health of people with ID with those of people in the general population within Europe. The final set of 18 indicators will be applied in the Pomona 2 project (2005-08) to gather information about the health of samples of adults in 14 participating European countries.

A hospital-level analysis of the work environment and workforce health indicators for registered nurses in Ontario's acute-care hospitals.

The purpose of this study was to explore the relationship between hospital-level indicators of the work environment and aggregated indicators of health and well-being amongst registered nurses working in acute-care hospitals in Ontario, Canada. This ecological analysis used data from a self-reported survey instrument randomly allocated to nurses using a stratified sampling approach. Multivariable linear regression models were used to examine hospital-level associations for burnout, musculoskeletal pain, self-rated general health, and absence due to illness. The unit of analysis was the hospital (n = 160), with individual nurse responses (n = 6,609) aggregated within hospitals. After controlling for basic differences in nurse workforces, including mean age and education, higher (better) work-environment scores were found to be generally associated with higher health-indicator scores, while a larger proportion of full-time than part-time nurses was found to be associated with lower (poorer) health scores. This study may provide direction for policy-makers in coping with the recruitment and retention of nursing staff in light of the current nursing shortage.

Early postnatal growth of low birthweight infants in the WIC program.

Patterns of early postnatal growth were analyzed among low birthweight infants enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Infants were divided into four groups according to their neonatal status: (1) term, normal birthweight (NBW); (2) term, low birthweight (LBW); (3) moderately preterm LBW; and (4) very preterm LBW. Comparison of mean weight and length z-scores indicated that term NBW and very preterm LBW infants were at or near the national reference averages at 8, 12, and 18 months. Term LBW and moderately preterm infants were lighter and shorter than the other two study groups at each visit. Term LBW and moderately preterm infants displayed evidence of catch-up growth during the study period. Catch-up growth was defined as a decrease in the percentage of infants below the 10th percentile for weight. The effect of neonatal body proportions on postnatal growth was investigated in term LBW infants. The infants were divided into two groups based on their ponderal index (PI) at birth (low PI and proportionate PI). Comparison of weight and length z-scores indicated that both groups of term LBW infants improved in z-scores between birth and the first visit (approximately 8 months). However, infants with evidence of asymmetric intrauterine growth restriction (low PI) continued to improve in weight and length z-scores, whereas those with symmetric growth restriction (proportionate PI) remained lighter and shorter.

How do they manage? Disabled elderly persons in the community who are not receiving Medicaid long-term care services.

OBJECTIVE: To expand our understanding of how low-income functionally impaired elderly persons are able to remain in the community. DATA SOURCES AND STUDY SETTING: In-person and telephone interviews with 25 elderly individuals who applied for but did not enroll in Connecticut's Home Care Program for Elders (CHCPE). All met the state's nursing home level-of-care criteria. STUDY, DESIGN: In-depth discussions with a small, purposefully selected sample of functionally impaired elderly persons in the community. PRINCIPLE FINDINGS: Many sample members with very high levels of impairment and multiple chronic health conditions remained in the community without CHCPE services because of Medicare home health services combined with extensive levels of informal care. Some sample members, particularly those with more limited informal care networks, did not receive the level of care that they needed. Virtually all were at high risk for medical complications, hospitalizations for acute illnesses, falls, and further loss of functioning. Further, in many cases, informal care networks were overextended, stressed and vulnerable to break down. All but a few of those we interviewed were not receiving services through the waiver program for financial reasons. Most met Medicaid's income criteria but had assets that exceeded Medicaid's $2,000 limit. Several were not participating due to concerns about estate recovery. CONCLUSIONS: Additional formal help is needed to avoid eventual nursing home placement for many sample members. This could be achieved by expanding the availability of case management services and/or relaxing program financial requirements. Further, efforts to reduce Medicare home health expenditures must recognize the heightened vulnerability of many beneficiaries for potentially costly adverse outcomes.

Work force diversity. Implications for occupational health nursing.

1. Increasing work force diversity is reflected in the Healthy People 2010 goal to eliminate health disparities. 2. At the organization level, a framework of cultural competence defines the developmental process toward cultural proficiency. 3. Strategies are suggested for organizations and nurses to engage in cultural competence.

Auditing research studies.

BACKGROUND: Recognizing the increasing attention being given to reports of misconduct, fraud, and unethical behavior in biomedical research, it appears timely for nurse researchers to engage in an organized method of peer review. OBJECTIVES: To describe an auditing process for funded research grants, the guidelines used to conduct the research audit, and the results to date. METHODS: The audit encompassed National Institutes of Health (NIH)-funded projects and their respective research teams, 12 faculty auditors using an audit worksheet developed by the Center for Nursing Research. RESULTS: Overall, auditing of research grants was viewed positively by both investigators and faculty auditors. Minor problems were identified that could be corrected. Only one grant required a second review. CONCLUSIONS: Specific guidelines are proposed for future audits that include level of funding and timing of audits.

Fathers and child neglect.

OBJECTIVE: To examine the association between father involvement and child neglect. DESIGN: Cohort study. SETTING: Participants were recruited from an inner-city pediatric primary care clinic and a clinic for children at risk for human immunodeficiency virus infection in a teaching hospital. PARTICIPANTS: Mothers and fathers or father figures, and 244 five-year olds participating in a longitudinal study. MAIN OUTCOME MEASURES: Child neglect measured via home observation, a videotaped mother-child interaction, and child protective services reports. RESULTS: A father or father figure was identified for 72% of the children. Rates of neglect ranged between 11% and 30%. Father absence alone was not associated with neglect. However, in families with an identified and interviewed father, a longer duration of involvement (P<.01), a greater sense of parenting efficacy (P<.01), more involvement with household tasks (P<.05), and less involvement with child care (P<.05) were associated with less neglect. The overall model explained 26.5% of the variance in neglect. CONCLUSIONS: There is substantial involvement of fathers in a subset of this high-risk sample, although more than a quarter of the children lacked a father or father figure. The mere presence of a father did not significantly influence the neglect of the children; rather, the nature of his involvement did. Fathers who felt more effective as parents were less likely to have neglected their children. A greater sense of efficacy may reflect parenting skills and be important in enhancing the contribution of fathers to their children's well-being. Pediatric health care providers can play a valuable role in enhancing the involvement and skills of fathers.

Applying the health promotion model to development of a worksite intervention.

INTRODUCTION: Consistent use of hearing protection devices (HPDs) decreases noise-induced hearing loss, however, many workers do not use them consistently. Past research has supported the need to use a conceptual framework to understand behaviors and guide intervention programs; however, few reports have specified a process to translate a conceptual model into an intervention. PURPOSE: The strongest predictors from the Health Promotion Model were used to design a training program to increase HPD use among construction workers. SUBJECTS/SETTING: Carpenters (n = 118), operating engineers (n = 109), and plumber/pipefitters (n = 129) in the Midwest were recruited to participate in the study. DESIGN: Written questionnaires including scales measuring the components of the Health Promotion Model were completed in classroom settings at worker trade group meetings. MEASURES: All items from scales predicting HPD use were reviewed to determine the basis for the content of a program to promote the use of HPDs. Three selection criteria were developed: (1) correlation with use of hearing protection (at least .20), (2) amenability to change, and (3) room for improvement (mean score not at ceiling). RESULTS: Linear regression and Pearson's correlation were used to assess the components of the model as predictors of HPD use. Five predictors had statistically significant regression coefficients: perceived noise exposure, self-efficacy, value of use, barriers to use, and modeling of use of hearing protection. Using items meeting the selection criteria, a 20-minute videotape with written handouts was developed as the core of an intervention. A clearly defined practice session was also incorporated in the training intervention. CONCLUSION: Determining salient factors for worker populations and specific protective equipment prior to designing an intervention is essential. These predictors provided the basis for a training program that addressed the specific needs of construction workers. Results of tests of the effectiveness of the program will be available in the near future.

The impact of family transition on the development of delinquency in adolescent boys: a 9-year longitudinal study.

The purpose of this study was to examine prospectively the impact of family transition on deviant development in a sample of 427 French-Canadian boys participating in a longitudinal study from kindergarten onwards. During the course of the study some boys experienced family transition. We grouped the boys by developmental period and number of marital transitions they experienced: divorced between ages 6 and 11; divorced between ages 12 to 15; remarried between ages 6 and 11; and remarried between ages 12 and 15. From ages 11 to 15 we assessed boys' delinquency and their family processes (parental supervision, punishment, and communication) annually. The results suggest that boys who experienced remarriage between ages 12 and 15 are at greater risk for delinquency. In particular, they showed evidence of comparatively more theft and fighting at earlier ages than their peers from families that had remained intact. At similar points in development, they perceived less expressive parent-child relationships. Finally, these boys also perceived less monitoring by their parents, both overall and at different points in adolescence.

Attitudes of general practitioners towards health care for people with intellectual disability and the factors underlying these attitudes.

An intellectual disability attitude questionnaire was used to explore the attitudes of general practitioners (GPs) towards primary health care, organizing health promotion and the role of specialist services for people with intellectual disability. The results of this questionnaire from GPs in Gwent (Wales) and GPs in west Gloucestershire (England) were compared. The GPs in both areas responded similarly and tended to agree that they were responsible for the medical care of people with intellectual disability in the community. They also tended to feel that the move from hospitals to the community of people with intellectual disability would greatly increase their workload. The GPs in both areas were generally against a responsibility on their part for health promotion and health screening initiatives for people with intellectual disability. However, GPs in west Gloucestershire felt more strongly against these issues. Further analysis of the data revealed factors which influenced the response of GPs to the questionnaire, including their position regarding health promotion and screening, and their view of the role of specialist health services. The GPs generally felt that community learning disability teams provided useful support, and there is clearly scope for team members to liaise more closely with GP practices and to provide helpful information to GPs about intellectual disability and the specialist health services available. Professionals seeking to work collaboratively with GPs should be sensitive to their workload pressures and to their attitudes towards health promotion initiatives and health screening.

A randomized control trial of an opportunistic health screening tool in primary care for people with intellectual disability.

People with intellectual disability have an increased variety of health care problems compared with the general population. The transition of care for such people from institutions into the community places them in a primary care system already facing increasing demands for their services. There is a consensus that health screening is at its most useful in identifying functional disabilities. Therefore, an intervention which helps the general practitioner (GP) towards opportunistically checking those areas of health most often deficient in people with intellectual disability would appear of considerable benefit (especially if information directing the GP towards appropriate secondary care services is also provided). The present study was designed to evaluate the impact of such an intervention.

Disruptiveness, friends' characteristics, and delinquency in early adolescence: a test of two competing models of development.

This study tested 2 competing models of friends' influence on the development of delinquency in disruptive boys. In so doing, we examined whether highly disruptive, moderately disruptive, moderately conforming, and highly conforming boys' delinquency increased or decreased depending on their friends' characteristics. A sample of 868 boys was classified into the 4 groups according to teacher ratings at ages 11 and 12. Each group was then subdivided by mutual friends' peer-rated aggressiveness-disturbance at the same ages: aggressive-disturbing friends, average friends, nonaggressive-nondisturbing friends, and no friends. Subgroups were next compared on self-reported delinquency at age 13 while controlling for average self-reported delinquency and socioeconomic variables at ages 11 and 12. Results indicate that moderately disruptive boys with aggressive-disturbing friends were more delinquent at age 13 than other subgroups of moderately disruptive boys. Highly disruptive and conforming boys, however, were unaffected by their friends' characteristics. We conclude that the results partially support each theoretical model, suggesting that both individual characteristics and deviant peer association might play causal roles.

Telephone interviews: a cost-effective way to select faculty.

The telephone interviewing process was a very positive experience for the interviewers. It gave us the opportunity to collaborate together to determine how best to represent our own peers and find future peers. With minimal expense, it expedited the process of filling our positions. The efficiency and thoroughness of the interview process allowed us to fill the positions by holding only three on-campus interviews which were shorter (less than one day in length in one case) and within budgetary allotments.