Economic evaluation of a publicly funded hepatitis A travel vaccination program in Ontario, Canada.

BACKGROUND: Hepatitis A virus (HAV) causes acute liver infection and is spread through the fecal-oral route. Travel to countries in HAV-endemic regions (e.g., Asia and Latin America) is a well-described risk factor for infection. Currently, Ontario publicly funds hepatitis A vaccination for some populations at high risk of HAV infection but not for all travellers to endemic countries. The objective of this study was to determine the cost-effectiveness of expanding publicly funded HAV vaccination to people planning travel to HAV-endemic regions, from the Ontario healthcare payer perspective. METHODS: We conducted a cost-utility analysis comparing an expanded high-risk publicly-funded hepatitis A vaccination program including funded vaccine for travellers to endemic regions to the current high risk program in Ontario. A Markov state transition model was developed, including six possible health states. Model parameters were informed through targeted literature searches and included hepatitis A disease probabilities, utilities associated with health states, health system expenditures, and vaccine costs. Future costs and health outcomes were discounted at 1.5%. Primary outcomes included cost, incremental cost-effectiveness ratio (ICER) and quality adjusted life years (QALYs) over a lifetime time horizon. We conducted one-way, two-way, and probabilistic sensitivity analysis. RESULTS: The expanded high risk HAV vaccine program provided few incremental health gains in the travel population (mean 0.000037 QALYs/person), at an incremental cost of $124.31. The ICER of the expanded program compared to status quo is $3,391,504/QALY gained. The conclusion of the model was robust to changes in key parameters across reasonable ranges. CONCLUSIONS: The expanded vaccination program substantially exceeds commonly accepted cost-effectiveness thresholds. Further research concerning possible cost-effective implementation of high-risk travel hepatitis A vaccination should focus on a more integrated understanding of the risk of acquiring hepatitis A during travel to endemic regions (e.g., purpose, length of stay).

Theory analysis of the Dental Hygiene Human Needs Conceptual Model.

PURPOSE: Theories provide a structural knowing about concept relationships, practice intricacies, and intuitions and thus shape the distinct body of the profession. Capturing ways of knowing and being is essential to any professions' practice, education and research. This process defines the phenomenon of the profession - its existence or experience. Theory evaluation is a systematic criterion-based assessment of a specific theory. This study presents a theory analysis of the Dental Hygiene Human Needs Conceptual Model (DH HNCM). METHODS: Using the Walker and Avant Theory Analysis, a seven-step process, the DH HNCM, was analysed and evaluated for its meaningfulness and contribution to dental hygiene. The steps include the following: (i) investigate the origins; (ii) examine relationships of the theory's concepts; (iii) assess the logic of the theory's structure; (iv) consider the usefulness to practice; (v) judge the generalizability; (vi) evaluate the parsimony; and (vii) appraise the testability of the theory. FINDINGS: Human needs theory in nursing and Maslow's Hierarchy of Need Theory prompted this theory's development. The DH HNCM depicts four concepts based on the paradigm concepts of the profession: client, health/oral health, environment and dental hygiene actions, and includes validated eleven human needs that evolved overtime to eight. It is logical, simplistic, allows scientific predictions and testing, and provides a unique lens for the dental hygiene practitioner. With this model, dental hygienists have entered practice, knowing they enable clients to meet their human needs. CONCLUSION: For the DH HNCM, theory analysis affirmed that the model is reasonable and insightful and adds to the dental hygiene professions' epistemology and ontology.

Are housing tenure and car access still associated with health? A repeat cross-sectional study of UK adults over a 13-year period.

BACKGROUND: It is usually assumed that housing tenure and car access are associated with health simply because they are acting as markers for social class or income and wealth. However, previous studies conducted in the late 1990s found that these household assets were associated with health independently of social class and income. Here, we set out to examine if this is still the case. METHODS: We use data from our 2010 postal survey of a random sample of adults (n=2092) in 8 local authority areas in the West of Scotland. Self-reported health measures included limiting longstanding illness (LLSI), general health over the last year and the Hospital Anxiety and Depression Scale. RESULTS: We found a statistically significant relationship between housing tenure and all 4 health measures, regardless of the inclusion of social class or income as controls. Compared with owner occupiers, social renters were more likely to report ill-health (controlling for social class-LLSI OR: 3.24, general health OR: 2.82, anxiety η2: 0.031, depression η2: 0.048, controlling for income-LLSI OR: 3.28, general health OR: 2.82, anxiety η2: 0.033, depression η2: 0.057) (p<0.001 for all models). Car ownership was independently associated with depression and anxiety, with non-owners at higher risk of both (controlling for income-anxiety η2: 0.010, depression η2: 0.023, controlling for social class-anxiety η2: 0.013, depression η2: 0.033) (p<0.001 for all models). CONCLUSIONS: Our results show that housing tenure and car ownership are still associated with health, after taking known correlates (age, sex, social class, income) into account. Further research is required to unpack some of the features of these household assets such as the quality of the dwelling and access to and use of different forms of transport to determine what health benefits or disbenefits they may be associated with in different contexts.

Young people's exposure to point-of-sale tobacco products and promotions.

OBJECTIVES: Point of sale (POS) displays are one of the most important forms of tobacco marketing still permitted in many countries. Reliable methods for measuring exposure to such displays are needed in order to assess their potential impact, particularly on smoking attitudes and uptake among young people. In this study we use a novel method for evaluating POS exposure based on young people's use of retail outlets and recall of tobacco displays and observational data on the characteristics of displays. STUDY DESIGN: Observational audit of retail outlets (n = 96) and school-based pupil survey (n = 1482) in four Scottish communities reflecting different levels of social deprivation and urbanisation, conducted in 2013 before legislation to remove POS displays was implemented in supermarkets. METHODS: Measures were taken of: visibility and placement of tobacco displays; internal and external advertising; display unit size, branding and design; visibility of pack warnings; proximity of tobacco products to products of potential interest to children and young people; pupils' self-reported frequency of visiting retail outlets; and pupils' recall of tobacco displays. Variation in POS exposure across social and demographic groups was assessed. RESULTS: Displays were highly visible within outlets and, in over half the stores, from the public footway outside. Tobacco products were displayed in close proximity to products of interest to children (e.g. confectionery, in 70% of stores). Eighty percent of pupils recalled seeing tobacco displays, with those from deprived areas more likely to recall displays in small shops. When confectioners, tobacconists and newsagents (CTNs) and grocery/convenience stores (two of the outlet types most often visited by young people) were examined separately, average tobacco display unit sizes were significantly larger in those outlets in more deprived areas. CONCLUSIONS: POS displays remain a key vector in most countries for advertising tobacco products, and it is important to develop robust measures of exposure. The data reported in this paper provide a baseline measure for evaluating the efficacy of legislation prohibiting such displays.

Effective count rates for PET scanners with reduced and extended axial field of view.

We investigated the relationship between noise equivalent count (NEC) and axial field of view (AFOV) for PET scanners with AFOVs ranging from one-half to twice those of current clinical scanners. PET scanners with longer or shorter AFOVs could fulfill different clinical needs depending on exam volumes and site economics. Using previously validated Monte Carlo simulations, we modeled true, scattered and random coincidence counting rates for a PET ring diameter of 88 cm with 2, 4, 6, and 8 rings of detector blocks (AFOV 7.8, 15.5, 23.3, and 31.0 cm). Fully 3D acquisition mode was compared to full collimation (2D) and partial collimation (2.5D) modes. Counting rates were estimated for a 200 cm long version of the 20 cm diameter NEMA count-rate phantom and for an anthropomorphic object based on a patient scan. We estimated the live-time characteristics of the scanner from measured count-rate data and applied that estimate to the simulated results to obtain NEC as a function of object activity. We found NEC increased as a quadratic function of AFOV for 3D mode, and linearly in 2D mode. Partial collimation provided the highest overall NEC on the 2-block system and fully 3D mode provided the highest NEC on the 8-block system for clinically relevant activities. On the 4-, and 6-block systems 3D mode NEC was highest up to ∼300 MBq in the anthropomorphic phantom, above which 3D NEC dropped rapidly, and 2.5D NEC was highest. Projected total scan time to achieve NEC-density that matches current clinical practice in a typical oncology exam averaged 9, 15, 24, and 61 min for the 8-, 6-, 4-, and 2-block ring systems, when using optimal collimation. Increasing the AFOV should provide a greater than proportional increase in NEC, potentially benefiting patient throughput-to-cost ratio. Conversely, by using appropriate collimation, a two-ring (7.8 cm AFOV) system could acquire whole-body scans achieving NEC-density levels comparable to current standards within long, but feasible, scan times.

Measured count-rate performance of the Discovery STE PET/CT scanner in 2D, 3D and partial collimation acquisition modes.

We measured count rates and scatter fraction on the Discovery STE PET/CT scanner in conventional 2D and 3D acquisition modes, and in a partial collimation mode between 2D and 3D. As part of the evaluation of using partial collimation, we estimated global count rates using a scanner model that combined computer simulations with an empirical live-time function. Our measurements followed the NEMA NU2 count rate and scatter-fraction protocol to obtain true, scattered and random coincidence events, from which noise equivalent count (NEC) rates were calculated. The effect of patient size was considered by using 27 cm and 35 cm diameter phantoms, in addition to the standard 20 cm diameter cylindrical count-rate phantom. Using the scanner model, we evaluated two partial collimation cases: removing half of the septa (2.5D) and removing two-thirds of the septa (2.7D). Based on predictions of the model, a 2.7D collimator was constructed. Count rates and scatter fractions were then measured in 2D, 2.7D and 3D. The scanner model predicted relative NEC variation with activity, as confirmed by measurements. The measured 2.7D NEC was equal or greater than 3D NEC for all activity levels in the 27 cm and 35 cm phantoms. In the 20 cm phantom, 3D NEC was somewhat higher ( approximately 15%) than 2.7D NEC at 100 MBq. For all higher activity concentrations, 2.7D NEC was greater and peaked 26% above the 3D peak NEC. The peak NEC in 2.7D mode occurred at approximately 425 MBq, and was 26-50% greater than the peak 3D NEC, depending on object size. NEC in 2D was considerably lower, except at relatively high activity concentrations. Partial collimation shows promise for improved noise equivalent count rates in clinical imaging without altering other detector parameters.

Pain assessment tools: children's nurses' views.

The persistence of inadequate treatment of pain in children could be due to lack of knowledge and nurses' failure to assess and manage pain effectively. It is recognized that effective pain assessment leads to more satisfied children and families. This study explored children's nurses' views on the use of pain assessment tools in a tertiary referral centre. Almost two-thirds of nurses did not have a preference for a pain assessment tool, but nearly three-quarters of nurses surveyed agreed that the introduction of pain assessment tools would improve documentation. When nurses were asked how much time they needed for education on these tools, 83 percent wanted only two hours, although almost half stated lack of knowledge or education as the main obstacle to use of a pain assessment tool. The inconsistencies in these replies could reflect the conflicting demands between the nurses' need to increase their knowledge of pain assessment while managing a heavy workload.

Use of accelerometers as an ergonomic assessment method for arm acceleration-a large-scale field trial.

Ergonomists need easy-to-use, quantitative job evaluation methods to assess risk factors for upper extremity work-related musculoskeletal disorders in field-based epidemiology studies. One device that may provide an objective measure of exposure to arm acceleration is a wrist-worn accelerometer or activity monitor. A field trial was conducted to evaluate the performance of a single-axis accelerometer using an industrial population (n=158) known to have diverse upper limb motion characteristics. The second phase of the field trial involved an examination of the relationship between more traditional observation-based ergonomic exposure measures and the monitor output among a group of assembly-line production employees (n=48) performing work tasks with highly stereotypic upper limb motion patterns. As expected, the linear acceleration data obtained from the activity monitor showed statistically significant differences between three occupational groups known observationally to have different upper limb motion requirements. Among the assembly-line production employees who performed different short-cycle assembly work tasks, statistically significant differences were also observed. Several observation-based ergonomic exposure measures were found to explain differences in the acceleration measure among the production employees who performed different jobs: hand and arm motion speed, use of the hand as a hammer, and, negatively, resisting forearm rotation from the torque of a power tool. The activity monitors were found to be easy to use and non-intrusive, and to be able to distinguish arm acceleration among groups with diverse upper limb motion characteristics as well as between different assembly job tasks where arm monitors were performed repeatedly at a fixed rate.

High resolution ultrasound assessment of the carotid artery: its relevance in postmenopausal women and the effects of tibolone on carotid artery ultrastructure.

OBJECTIVES: Hormone replacement therapy protects from cardiovascular disease at the menopause in part by reduction of menopausal pro-atherogenic serum lipid changes. Tibolone has beneficial effects on lipids, although serum high density lipoprotein levels decrease. This study aimed primarily to establish the effects of long-term administration of tibolone on a new surrogate marker for cardiovascular disease risk, the measurement of carotid artery intima-media thickness (CIMT) using high-resolution ultrasound. METHODS: Measurement of CIMT and assessment of carotid atherosclerotic plaques were undertaken in 31 women on tibolone and 30 voluntary controls from an ongoing open-label study of tibolone. RESULTS: The two groups were comparable, except for mean age and prevalence of current smokers. Repeatability of CIMT measurements was acceptable (CV, 10.0%). CIMT was significantly thicker in those with atherosclerotic plaques and increased systolic blood pressure. Prevalence of plaques was raised in those who had ever smoked, and those with elevated systolic blood pressure. There was no influence of tibolone on CIMT, whether plaques were present or not. CONCLUSIONS: This reliable technique demonstrates associations between CIMT and established risk factors. CIMT was significantly thicker in those with existing plaques. We did not demonstrate an effect of long-term tibolone use on either CIMT or prevalence of plaques.

A randomized controlled trial of the cost-effectiveness of a district co-ordinating service for terminally ill cancer patients.

The objective of this paper is to compare the cost effectiveness of a co-ordination service with standard services for terminally ill cancer patients with a prognosis of less than one year. We designed a randomized controlled trial, with patients randomized by the general practice with which they were registered. Co-ordination group patients received the assistance of two nurse coordinators whose role was to ensure that patients had access to appropriate services. The setting was in a South London health authority. Complete service use and outcome data were collected on 167 patients, 86 in the co-ordination group, and 81 in the control group. Our results, as previously reported, show that no differences in outcomes were detected between the co-ordination and control groups; the mean total costs incurred by the co-ordination group were significantly less than those of the control group. The co-ordinated group used significantly fewer inpatient days (mean 24 versus 40 inpatient days; t = 2.4, p = 0.002) and nurse home visits (mean 14.5 versus 37.5 visits; t = 0.3, p = 0.01). Mean cost per co-ordinated patient was almost half that of the control group patients 4774 pounds versus 8034 pounds, t = 2.8, p = 0.006). Although the unit cost data were relatively crude, these cost reductions were insensitive to a wide range of unit costs. These differences persisted when, in order to control for any putative differences in severity between the two groups, the analysis was restricted to patients who had died by the end of the study. The ratio of potential cost savings to the cost of co-ordination service was between 4:1 and 8:1. In conclusion, the co-ordination service for cancer patients who were terminally ill with a prognosis of less than one year was more cost effective than standard services, due to achieving the same outcomes at lower service use, particularly inpatient days in acute hospital. Assuming that the observed effects are real, improved co-ordination of palliative care offers the potential for considerable savings. Further research is needed to explore this issue.

Early prediction of chronic disability after occupational low back injury.

STUDY DESIGN: An inception cohort design was used to study a consecutive sample of back-injured workers. OBJECTIVE: To refine and to test the Vermont Disability Prediction Questionnaire's ability to indicate an individual's relative risk for chronic disability after occupational low back injury. SUMMARY OF BACKGROUND DATA: Although most back-injured workers return to work quickly, the minority who do not account for the majority of associated costs and health care. Early identification of workers at high risk for disability would facilitate intervention strategies. METHODS: During the study recruitment period, people aged 18-60 years reporting occupational low back injury to the Vermont Department of Labor and Industry within 11 days of onset were eligible. A Vermont Disability Prediction Questionnaire was mailed to the 442 subjects who could be contacted and who gave informed consent. One hundred sixty-three of the 166 subjects who completed and returned the questionnaire within 15 days of initial injury were telephoned 3 months later to determine work status. Those who returned the questionnaire were compared with those who would not consent or did not return the questionnaire in time according to age, sex, residence, wages, work hours per week, and length of employment. Employment status (inability to work because of low back pain) was evaluated by telephone interview 3 months after initial injury. RESULTS: The follow-up interviewer was blinded to the Vermont Disability Prediction Questionnaire scores. of the 163 subjects, 16 (10%) were not working because of low back pain. Using a simple dichotomous scoring system for 11 questionnaire items, a cut-off score of 0.48 identified 3-month postinjury work status, with 0.94 sensitivity and 0.84 specificity. CONCLUSIONS: The Vermont Disability Prediction Questionnaire is a brief, easily administered and scored tool for identifying back-injured workers at relative risk for chronic disability. Such early identification should increase the efficiency of disability prevention strategies by directing them toward people who need them most. The accuracy of the questionnaire needs to be tested in a variety of different clinical and socioeconomic settings.

Educational assessment of general practice experience for psychiatric trainees.

Eighteen psychiatric trainees spent 6 months each as general practice trainees. The educational impact of the experience was assessed by a self-assessment questionnaire, a semi-structured interview and a videotaped interview with a psychiatric patient. Each assessment was conducted at a baseline and after 12 months. A control group of 14 trainees was recruited from the same rotation. On the self-assessment questionnaire, the study registrars rated their abilities to solve general medical problems significantly improved compared to controls. They had also acquired greater understanding of the limitation of their knowledge and their legal responsibilities towards their patients. The semi-structured interview failed to distinguish between the two groups. Videotapes for rating at baseline and follow-up were available for only 17 of the trainees. Assessment of the tapes used the Maguire Scale and the Interview Behaviour Scale. Neither scale demonstrated any intervention effect. The interviews were all characterized by a preponderance of 'closed psychological' and 'checking-out' questions. It appears that psychiatric trainees' interviewing styles had not been influenced by the experience. This study suggests that psychiatric trainees gain greater confidence in their role as a doctor and greater understanding of the scope and nature of general practice by such an attachment. It is unclear whether or not supplementary interviewing skills had been acquired which were not utilized in the taped interview, which conforms very much to traditional psychiatric examination behaviour. Trainees were reassured that they had increased their knowledge without losing any of their specific professional skills.

A new approach to the measurement of quality of life. The Patient-Generated Index.

Quality of life has been defined as "the extent to which our hopes and ambitions are matched by experience." To improve a patient's quality of life through medical care would be to "narrow the gap between a patient's hopes and expectations and what actually happens." Using the above definition as a conceptual basis, we produced a self-administered, Patient-Generated Index (PGI) of quality of life. The PGI was completed by 359 patients presenting with low back pain. The validity of the measure was assessed by correlating patients' PGI scores with a well-validated health profile, the Short-Form 36-item Health Survey (SF-36), and with their scores on a clinical back pain questionnaire. Stepwise multiple regression was then used to model the relationship between the PGI score and the SF-36. Patients' PGI scores showed a high correlation with SF-36 scales measuring pain, social functioning, and role limitations attributable to physical problems, and with the clinical questionnaire. Together with whether a person was retired or not, these health variables were able to explain 25% of the variance in PGI scores. Patient generated index scores were significantly lower in patients referred to hospital compared with those managed solely in general practice and tended to reflect the general practitioner's assessment of symptom severity. We conclude that it is possible to construct a questionnaire that quantifies the effect of a medical condition on patients' quality of life in a way that has meaning and relevance in the context of their daily lives. The PGI has considerable potential for routine use in a wide range of clinical conditions for which the measurement of outcome has hitherto proved very difficult.

Towards measurement of outcome for patients with varicose veins.

OBJECTIVE: To develop a valid and reliable outcome measure for patients with varicose veins. DESIGN: Postal questionnaire survey of patients with varicose veins. SETTING: Surgical outpatient departments and training general practices in Grampian region. SUBJECTS: 373 patients, 287 of whom had just been referred to hospital for their varicose veins and 86 who had just consulted a general practitioner for this condition and, for comparison, a random sample of 900 members of the general population. MAIN MEASURES: Content validity, internal consistency, and criterion validity. RESULTS: 281(76%) patients (mean age 45.8; 76% female) and 542(60%) of the general population (mean age 47.9; 54% female) responded. The questionnaire had good internal consistency as measured by item-total correlations. Factor analysis identified four important health factors: pain and dysfunction, cosmetic appearance, extent of varicosity and complications. The validity of the questionnaire was demonstrated by a high correlation with the SF-36 health profile, which is a general measure of patients' health. The perceived health of patients with varicose veins, as measured by the SF-36, was significantly lower than that of the sample of the general population adjusted for age and a lower proportion of women. CONCLUSION: A clinically derived questionnaire can provide a valid and reliable tool to assess the perceived health of patients with varicose veins. IMPLICATIONS: The questionnaire may be used to justify surgical treatment of varicose veins.

The relationship between severe asthma and social class.

Asthma is one of the few diseases which has been reported to be common in the higher social classes. In order to assess the relationship between severe asthma and social class we analysed a national study of disabled adults undertaken by the Office of Population Censuses and Surveys (OPCS). The study estimated that there were 5.8 million people over 16 years with some degree of disability living in private households in England and Wales. Thirteen percent of disabilities were due to respiratory disease: 6% chronic bronchitis and emphysema, 3% asthma and allergy, and 4% other respiratory diseases. Among 10,000 individuals interviewed, 338 disabled adults reported asthma as a contributing cause of their disability. Of 291 cases with social class recorded, 41 (14%) were in social classes 1 and 2, 128 (44%) in social class 3, and 122 (42%) in social classes 4 and 5. An estimate of the relationship between social class and adult asthma in the general population was derived by calculating a morbidity ratio for the different social classes. The morbidity ratio for all social classes combined equals 100: for social classes 1 and 2 it was 63 (95% confidence intervals 48, 91); 93 (95% confidence intervals 77, 109) for social class 3; and 131 (95% confidence intervals 108, 153) for social classes 4 and 5. Adults in social classes 4 and 5 were approximately twice as likely to have severe asthma as those in social classes 1 and 2. This could be as a result of differences in the prevalence or treatment of asthma among the social classes.

Marital status: association with social and economic circumstances, psychological state and outcomes of pregnancy.

We examined the association of marital status with economic, social and psychological factors and with the outcomes of pregnancy (defined as onset of labour, type of delivery, live and still births and birthweight). The study population was 1431 white women consecutively booking for antenatal care. Birth registrations were inspected. Of 278 women who were unmarried during pregnancy, 61 per cent were cohabiting, 26 per cent were living with adults other than the father and 13 per cent were living alone. Compared with the married women, unmarried women overall were, on average, younger, less educated, of lower social class, in poorer economic circumstances, more dependent on state support and less satisfied with their living arrangements. Irrespective of age and social class, they were less likely to have planned the pregnancy, more likely to smoke and drink, to book later for antenatal care and to miss more appointments. In general, unmarried women were more likely to have some indication of depression and to experience more serious life events during the pregnancy. Controlling for age and social class, the categories 'married', 'cohabiting' and 'on their own' showed significant trends from best to worst. Those living with adults other than the father showed intermediate results. There were no significant effects of marital status, controlled for age and social class, and associated social, economic and psychological circumstances on outcomes of pregnancy. Forty-one per cent of births to women on their own, 35 per cent to women living with other adults and 11 per cent to women cohabiting during pregnancy were registered by only one parent.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: The authors examined the association of marital status with economic, social, and psychological factors and with the outcomes of pregnancy (defined as onset of labor, type of delivery, live and stillbirths, and birthweight). The study population comprised 1431 white women who were consecutively booked for antenatal care. Birth registrations were inspected. Of 278 women who were unmarried during pregnancy, 61% were cohabiting, 26% were living with adults other than the father, and 13% were living alone. Compared with the married women, unmarried women overall were, on the average, younger, less educated, of lower social class, in poorer economic circumstances, more dependent on state support, and were less satisfied with their living arrangements. Regardless of age and social class, they were less likely to have planned the pregnancy, were more likely to smoke and drink, to book later for antenatal care, and to miss more appointments. In general, unmarried women were more likely to have some indication of depression and to experience more serious life events during the pregnancy. Controlling for age and social class, the categories "married", "cohabiting", and "on their own" showed significant trends from best to worst. Those living with other adults other than the father showed intermediate results. There were no significant effects of marital status controlled for age and social class, and associated social, economic, and psychological circumstances on pregnancy outcomes. 41% of births to women on their own, 35% to women living with other adults, and 11% to women cohabiting during pregnancy were registered by only 1 parent. It is possible that a continuation of the poor quality of life observed among unmarried women during pregnancy could affect the later wellbeing of their children.

Effects of reduction of acute hospital services on district nursing services: implications for quality assurance.

Two questions of importance to those concerned with maintaining standards and increasing the efficiency of Community Nursing are: (1) does reducing hospital provision alter the number of patients referred for Community Nursing or the type of care provided; (2) are Community Nursing Services directed towards those who most require them? A base-line study was carried out in the first quarter of 1988, before the closure of one of two general hospitals in an inner London Health Authority and was replicated in the same quarter of 1989, after all acute inpatient services had been transferred to the other hospital. Comparison of patients discharged before and after closure showed no significant differences in patients' age, sex, proportion living alone, length of stay in hospital, readmissions or deaths within one month of discharge. There was some decline in general nursing care. Total discharges declined by 20% while the number of referrals remained the same, indicating that proportionately more patients were discharged with a referral. Comparing referred and unreferred patients showed that Community Nursing Services were already being directed towards those most in need both before and after hospital closure. Results suggest that Community Nursing helps to maintain patients in the community.