Sniff nasal inspiratory pressure in patients with moderate-to-severe chronic obstructive pulmonary disease: learning effect and short-term between-session repeatability.

BACKGROUND: Sniff nasal inspiratory pressure (SNIP) is a non-invasive measure of inspiratory muscle function often used as an outcome measure in clinical studies. An initial period of familiarisation with the test is recommended to minimise the learning effect. The repeatability of SNIP in patients with chronic obstructive pulmonary disease (COPD) is currently unknown. OBJECTIVES: The aim of this study was to assess the between-session repeatability of SNIP over a 3-week period in moderate-to-severe COPD patients and compare it with that of maximal inspiratory (PI max) and expiratory pressure (PE max). METHODS: Twenty-one patients (13 males) with a mean forced expiratory volume in 1 s (FEV1) of 38% of predicted (SD: 15) and FEV1/forced vital capacity of 34.3% (SD: 10.4) performed SNIP and PI max and PE max manoeuvres on 3 different sessions (S1, S2 and S3) 3-7 days apart. SNIP was performed at functional residual capacity (FRC), and PI max was performed at FRC and at residual volume (RV) to explore volume-dependent differences in the learning effect between sessions and PE max from total lung capacity. RESULTS: The intra-class correlation coefficient (ICC) for SNIP was the highest of the three measures: S1-S3 ICC (95% CI) SNIP: 0.96 (0.88-0.94); PI max at FRC 0.82 (0.63-0.92); PI max at RV: 0.89 (0.78-0.95), and PE max: 0.96 (0.92-0.98), and had the lowest mean change between sessions [mean S2 - S1: 2.1(p = 0.4) and S3 - S2: -0.3 (p = 0.9)]. CONCLUSIONS: SNIP is repeatable over a period of 3 weeks in medically stable, moderate-to-severe COPD patients. In our study, 2 sessions were adequate to learn how to perform the test.

Trends over time in prescribing by English primary care nurses: a secondary analysis of a national prescription database.

BACKGROUND: A growing number of countries legislate for nurses to have medication prescribing authority although it is a contested issue. The UK is one of these countries, giving authority to nurses with additional qualifications since 1992 and incrementally widened the scope of nurse prescribing, most recently in 2006. The policy intention for primary care was to improve efficiency in service delivery through flexibility between medical and nursing roles. The extent to which this has occurred is uncertain. This study investigated nurses prescribing activities, over time, in English primary care settings. METHODS: A secondary data analysis of a national primary care prescription database 2006-2010 and National Health Service workforce database 2010 was undertaken. RESULTS: The numbers of nurses issuing more than one prescription annually in primary care rose from 13,391 in 2006 to 15,841 in 2010. This represented forty three percent of those with prescribing qualifications and authorisation from their employers. The number of items prescribed by nurses rose from 1.1% to 1.5% of total items prescribed in primary care. The greatest volume of items prescribed by independent nurse prescribers was in the category of penicillins, followed by dressings. However, the category where independent nurse prescribers contributed the largest proportion of all primary care prescriptions was emergency contraception (9.1%). In contrast, community practitioner nurse prescribers' greatest volume and contribution was in the category of gel and colloid dressings (27%), medicated stockings (14.5%) and incontinence appliances (4.2%). There were slightly higher rates of nurse prescribing in areas with higher levels of socio-economic deprivation and fewer physicians per capita, but the correlations were weak and warrant further investigation. CONCLUSIONS: The percentage of prescriptions written by nurses in primary care in England is very small in comparison to physicians. Our findings suggest that nurse prescribing is used where it is seen to have relative advantage by all stakeholders, in particular when it supports efficiency in nursing practice and also health promotion activities by nurses in general practice. It is in these areas that there appears to be flexibility in the prescribing role between nurses and general practitioners.

First diagnosis and management of incontinence in older people with and without dementia in primary care: a cohort study using The Health Improvement Network primary care database.

BACKGROUND: Dementia is one of the most disabling and burdensome diseases. Incontinence in people with dementia is distressing, adds to carer burden, and influences decisions to relocate people to care homes. Successful and safe management of incontinence in people with dementia presents additional challenges. The aim of this study was to investigate the rates of first diagnosis in primary care of urinary and faecal incontinence among people aged 60-89 with dementia, and the use of medication or indwelling catheters for urinary incontinence. METHODS AND FINDINGS: We extracted data on 54,816 people aged 60-89 with dementia and an age-gender stratified sample of 205,795 people without dementia from 2001 to 2010 from The Health Improvement Network (THIN), a United Kingdom primary care database. THIN includes data on patients and primary care consultations but does not identify care home residents. Rate ratios were adjusted for age, sex, and co-morbidity using multilevel Poisson regression. The rates of first diagnosis per 1,000 person-years at risk (95% confidence interval) for urinary incontinence in the dementia cohort, among men and women, respectively, were 42.3 (40.9-43.8) and 33.5 (32.6-34.5). In the non-dementia cohort, the rates were 19.8 (19.4-20.3) and 18.6 (18.2-18.9). The rates of first diagnosis for faecal incontinence in the dementia cohort were 11.1 (10.4-11.9) and 10.1 (9.6-10.6). In the non-dementia cohort, the rates were 3.1 (2.9-3.3) and 3.6 (3.5-3.8). The adjusted rate ratio for first diagnosis of urinary incontinence was 3.2 (2.7-3.7) in men and 2.7 (2.3-3.2) in women, and for faecal incontinence was 6.0 (5.1-7.0) in men and 4.5 (3.8-5.2) in women. The adjusted rate ratio for pharmacological treatment of urinary incontinence was 2.2 (1.4-3.7) for both genders, and for indwelling urinary catheters was 1.6 (1.3-1.9) in men and 2.3 (1.9-2.8) in women. CONCLUSIONS: Compared with those without a dementia diagnosis, those with a dementia diagnosis have approximately three times the rate of diagnosis of urinary incontinence, and more than four times the rate of faecal incontinence, in UK primary care. The clinical management of urinary incontinence in people with dementia with medication and particularly the increased use of catheters is concerning and requires further investigation. Please see later in the article for the Editors' Summary.

Predictors of two forms of attrition in a longitudinal health study involving ageing participants: an analysis based on the Whitehall II study.

BACKGROUND: Longitudinal studies are crucial providers of information about the needs of an ageing population, but their external validity is affected if partipants drop out. Previous research has identified older age, impaired cognitive function, lower educational level, living alone, fewer social activities, and lower socio-economic status as predictors of attrition. METHODS: This project examined attrition in participants of the Whitehall II study aged between 51-71 years, using data from questionnaires participants have completed biennially since 1985 when the study began. We examine the possibility of two distinct forms of attrition--non-response and formally requesting to withdraw--and whether they have different predictors. Potential predictors were age, gender, marital status, occupational grade, retirement, home ownership, presence of longstanding illness, SF-36 quality of life scores, social participation and educational level comparing participants and those who had withdrawn from the study. RESULTS: The two forms of attrition share many predictors and are associated but remain distinct. Being older, male, having a lower job grade, not being a home owner, not having a long standing illness, having higher levels of education, and not having retired, were all associated with a greater probability of non-response; being married was associated with higher probability in women and lower in men. Being older, male, having a lower job grade, not being a home owner, having lower SF-36 scores, taking part in fewer social activities, and not having a long standing illness, were all associated with greater probability of withdrawal. CONCLUSIONS: The results suggest a strong gender effect on both routes not previously considered in analyses of attrition. Investigators of longitudinal studies should take measures to retain older participants and lower level socio-economic participants, who are more likely to cease participating. Recognition should be given to the tendency for people with health problems to be more diligent participants in studies with a medical screening aspect, and for those with lower socio-economic status (including home ownership), quality of life and social participation, to be more likely to request withdrawal. Without taking these features into account, bias and loss of power could affect statistical analyses.

Challenges in comparing the quality of life of older people between ethnic groups, and the implications for national well-being indicators: a secondary analysis of two cross-sectional surveys.

BACKGROUND: The current international interest in well-being indicators among governmental agencies means that many quality of life scales are potential components of such national indicator sets. Measuring well-being in minority groups is complex and challenging. Scales are available that have been validated in specific parts of the population, such as older people. However, validation among combinations of minority groups, such as older adults of ethnic minority backgrounds, is lacking. FINDINGS: We pooled data from two surveys of older adults in Great Britain: one conducted among White British people, and one among four ethnic minority groups. Quality of life was measured by the Older People's Quality of Life (OPQOL); Control, Autonomy, Self-realisation, Pleasure (CASP-19); and World Health Organization Quality of Life scale for older people (WHOQOL-OLD). We found differences, some significant, between groups in terms of self-reported importance of various aspects of quality of life. A regression model of each total quality of life scale revealed greater unexplained variability in the White British group than the others. Principal components analysis within each ethnic group's data showed considerable differences in the correlation structures. CONCLUSIONS: There are differences between ethnic groups that are consistent across the three scales and are not explained by a battery of predictor variables. If scales such as these are used to compare quality of life between ethnic groups, or equivalently between geographical regions, the different results in each group are liable to bias any comparison which could lead to inequitable policy decisions.

Growth, Body Composition, and Lung Function in Prepubertal Children with Cystic Fibrosis Diagnosed by Newborn Screening.

BACKGROUND: Children with cystic fibrosis (CF) are at risk of altered body composition (BC). Newborn screening (NBS) may lead to improved BC outcomes. We investigated BC and its relationship with lung function in prepubertal children diagnosed with CF by NBS. Secondary aims explored predictors of fat-free mass (FFM) and lung function. METHODS: Thirty-seven screened (non-meconium ileus) children with CF (20 boys) born 2007-2012 had a dual-energy x-ray absorptiometry scan at 5-8 years to determine whole-body (WB) and appendicular BC. Anthropometry was performed and routine spirometry recorded. Results were converted to z-scores, height-adjusted (fat mass index [FMI] and FFM index [FFMI]) and compared with population mean values. Predictors of forced expiratory volume in 1 second (FEV1 ) were assessed using linear regression. RESULTS: Height, body mass index (BMI), and FEV1 were within normal limits, however, weight and BC were significantly low compared with reference data (weight, P = .03; WB FMI, P = .001; WB FFMI, P = .009). Gender differences were detected, with lower appendicular BC in boys and lower weight, BMI, and BC in girls. The association between FEV1 and WB FFMI (r = 0.38; P = .02) was stronger than with BMI (r = 0.29; P = .08). WB FFMI was the only significant predictor of FEV1 in a multivariable model (95% CI, 0.11-0.99; P = .016). CONCLUSION: In this NBS CF population, gender differences in growth and BC were apparent despite preserved lung function. These results support BC assessment in prepubertal children, particularly girls, with an opportunity to direct interventions to optimize FFM.

Staffing levels and patient dependence in English stroke units.

Little research has been performed to determine how a stroke unit should be staffed and what the links are between patient dependency and staffing. For this study, 140 stroke units were randomly selected--35 from each of the four quartiles of performance in the National Sentinel Audit of Stroke. A questionnaire was sent to each of the units to collect data on patient numbers and dependency, staffing numbers and therapy, and nursing contact times on a single weekday. The response rate was 66% (92 sites) and information on 1,398 patients was provided. The median number of beds was 18 (interquartile range 12-24). Staffing levels per 10 beds were a median of 10.9 nurses, 1.7 physiotherapists, 1.3 occupational therapists and 0.4 speech and language therapists. Of the patients, 74% received physiotherapy, 46% occupational therapy and 25% speech and language therapy during the day with median contact times being 170 minutes for nursing, 40 minutes for physiotherapy, 45 minutes for occupational therapy and 30 minutes for speech therapy. There was a weak correlation between patient dependency and contact time with nurses and therapists. Stroke patients in England receive relatively little rehabilitation from therapists and there is a wide variation in the amount of nursing time each patient receives.

The uptake of Bayesian methods in biomedical meta-analyses: A scoping review (2005-2016).

AIM: Bayesian statistical methods can allow for more complete and accurate incorporation of evidence in meta-analyses. However, these methods remain under-utilized. METHODS: A scoping review was conducted to examine the proportion of biomedical meta-analyses that used Bayesian methods in the period 2005-2016. The review also examined the reproducibility of the work, the cited sources, the reasons for it, its success or failure, the type of model and prior distributions, and whether a mixture of Bayesian and frequentist methods were employed. RESULTS: We found that 1% of meta-analyses are Bayesian and that the reporting and conduct of these were often poor. Data were published in 41% of analyses, and programs to run the analysis in 18%. Network meta-analysis was the most common reason and became increasingly popular in recent years. In the majority of papers, models and distributions were either not reported or explained in such brief and ambiguous terms as to be uninformative. CONCLUSIONS: More use needs to be made of Bayesian meta-analysis, and reporting needs to be improved. Greater awareness of these methods and access to training in them is essential.

Capturing complexity in clinician case-mix: classification system development using GP and physician associate data.

BACKGROUND: There are limited case-mix classification systems for primary care settings which are applicable when considering the optimal clinical skill mix to provide services. AIM: To develop a case-mix classification system (CMCS) and test its impact on analyses of patient outcomes by clinician type, using example data from physician associates' (PAs) and GPs' consultations with same-day appointment patients. DESIGN & SETTING: Secondary analysis of controlled observational data from six general practices employing PAs and six matched practices not employing PAs in England. METHOD: Routinely-collected patient consultation records (PA n = 932, GP n = 1154) were used to design the CMCS (combining problem codes, disease register data, and free text); to describe the case-mix; and to assess impact of statistical adjustment for the CMCS on comparison of outcomes of consultations with PAs and with GPs. RESULTS: A CMCS was developed by extending a system that only classified 18.6% (213/1147) of the presenting problems in this study's data. The CMCS differentiated the presenting patient's level of need or complexity as: acute, chronic, minor problem or symptom, prevention, or process of care, applied hierarchically. Combination of patient and consultation-level measures resulted in a higher classification of acuity and complexity for 639 (30.6%) of patient cases in this sample than if using consultation level alone. The CMCS was a key adjustment in modelling the study's main outcome measure, that is rate of repeat consultation. CONCLUSION: This CMCS assisted in classifying the differences in case-mix between professions, thereby allowing fairer assessment of the potential for role substitution and task shifting in primary care, but it requires further validation.

Exercise facilities for neurologically disabled populations - Perceptions from the fitness industry.

BACKGROUND: People with neurological disabilities (pwND) face many barriers to undertaking physical activity. One option for exercise alongside formal physiotherapy is local fitness facilities but accessibility is often found wanting and gyms are seen as unwelcoming to pwND. OBJECTIVE: The objective of this exploratory study was to investigate the perceptions of fitness facility managers with respect to exercise for pwND in a gym environment. The aim was to identify potential barriers to provision by the fitness industry for pwND. METHODS: The participants included those who were in a position to influence provision at a policy level and those working at management level within fitness providers. A mixed methods approach was used: a quantitative questionnaire and 4 qualitative interviews. Descriptive and correlational analysis, thematic content analysis and concurrent triangulation analysis was undertaken. RESULTS: Specially trained staff is perceived to be necessary to make fitness facilities accessible for pwND. CONCLUSIONS: Ensuring the provision of specially trained staff to support pwND to exercise in gyms may be the main barrier to provision for this population. Investigation into the standard training of fitness professionals combining the expertise of neurological physiotherapists with that of fitness professionals to meet the needs of pwND would be advantageous.

Evaluation of the effectiveness of a home-based inspiratory muscle training programme in patients with chronic obstructive pulmonary disease using multiple inspiratory muscle tests.

PURPOSE: To evaluate the effectiveness of a home-based inspiratory muscle training (IMT) programme using multiple inspiratory muscle tests. METHOD: Sixty-eight patients (37 M) with moderate to severe chronic obstructive pulmonary disease (COPD) (Mean [SD], FEV1 36.1 [13.6]% pred.; FEV1/FVC 35.7 [11.2]%) were randomised into an experimental or control group and trained with a threshold loading device at intensity >30% maximum inspiratory pressure (PImax) or <15% PImax, respectively, for 7 weeks. Thirty-nine patients (23 M) completed the study. The following measures were assessed pre- and post-IMT: PImax, sniff inspiratory nasal pressure (SNIP), diaphragm contractility (Pdi,tw), incremental shuttle walk test (ISWT), respiratory muscle endurance (RME), chronic respiratory disease questionnaire (CRDQ), the hospital anxiety and depression scale (HADS) and the SF-36. Between-group changes were assessed using one-way analysis of variance (ANOVA). RESULTS: PImax and perception of well-being improved significantly post-IMT [p = 0.04 and <0.05 in four domains, respectively]. This was not reflected in SNIP [p = 0.7], Pdi,tw [p = 0.8], RME [p = 0.9] or ISWT [p = 0.5]. CONCLUSIONS: A seven-week, community-based IMT programme, with realistic use of health-care resources, improves PImax and perception of well-being but a different design may be required for improvement in other measures. Multiple tests provide a more comprehensive evaluation of changes in muscle function post-IMT. IMPLICATIONS FOR REHABILITATION: A seven-week, home-based inspiratory muscle training programme improves maximal inspiratory pressure and perception of well-being in patients with moderate to severe COPD but not sniff nasal inspiratory pressure or diaphragm contractility, respiratory muscle endurance and exercise capacity. Multiple tests are recommended for a more comprehensive assessment of changes in muscle function following inspiratory muscle training programmes. Therapists need to explore different community-based inspiratory muscle training regimes for COPD patients and identify the optimal exercise protocol that is likely to lead to improvements in diaphragm contractility and exercise capacity.

Physician associates and GPs in primary care: a comparison.

BACKGROUND: Physician associates [PAs] (also known as physician assistants) are new to the NHS and there is little evidence concerning their contribution in general practice. AIM: This study aimed to compare outcomes and costs of same-day requested consultations by PAs with those of GPs. DESIGN AND SETTING: An observational study of 2086 patient records presenting at same-day appointments in 12 general practices in England. METHOD: PA consultations were compared with those of GPs. Primary outcome was re-consultation within 14 days for the same or linked problem. Secondary outcomes were processes of care. RESULTS: There were no significant differences in the rates of re-consultation (rate ratio 1.24, 95% confidence interval [CI] = 0.86 to 1.79, P = 0.25). There were no differences in rates of diagnostic tests ordered (1.08, 95% CI = 0.89 to 1.30, P = 0.44), referrals (0.95, 95% CI = 0.63 to 1.43, P = 0.80), prescriptions issued (1.16, 95% CI = 0.87 to 1.53, P = 0.31), or patient satisfaction (1.00, 95% CI = 0.42 to 2.36, P = 0.99). Records of initial consultations of 79.2% (n = 145) of PAs and 48.3% (n = 99) of GPs were judged appropriate by independent GPs (P<0.001). The adjusted average PA consultation was 5.8 minutes longer than the GP consultation (95% CI = 2.46 to 7.1; P<0.001); cost per consultation was GBP £6.22, (US$ 10.15) lower (95% CI = -7.61 to -2.46, P<0.001). CONCLUSION: The processes and outcomes of PA and GP consultations for same-day appointment patients are similar at a lower consultation cost. PAs offer a potentially acceptable and efficient addition to the general practice workforce.

Graduates from dual qualification courses, registered nurse and health visitor: a career history study.

BACKGROUND: Educationalists and managers internationally are challenged to find ways of preparing, recruiting early in their careers, and retaining nurses into public health roles in primary care. Public health nursing qualifications are post-initial nurse registration in the United Kingdom as in some other countries. In the mid twentieth century there were a number of innovative programmes of dual qualification: registered nurse and health visitor (the United Kingdom term for public health nurse). OBJECTIVE: To investigate the career histories of graduates from courses integrating both nursing and health visitor qualifications. DESIGN: An observational, survey study. SETTING: The United Kingdom. PARTICIPANTS: A purposive sample of graduates from integrated registered nurse and health visitor programmes, 1959-1995, from one University. METHODS: Self completed, anonymous, survey sent to graduates, with contact details known to the University and through snowballing techniques, in 2011. FINDINGS: Forty five women (56%), graduates in all four decades, returned the survey. A significant majority (82%) had taken up health visitor posts on completing the course. Over their careers, 42% of all jobs held were as health visitors. Only four never worked in a post that required a health visiting qualification. Most had undertaken paid work throughout their careers that focused on aspects of public health, often linked to child, maternal and/or family wellbeing. Many held teaching/lecturing and management posts at some point in their career. Those holding management posts were more likely to report leaving them as a result of organisational re-structuring or redundancy than those in non-management posts. CONCLUSIONS: Courses that prepare students to be both nurses and health visitors result in a majority of graduates who take up posts as health visitors on qualification and subsequently. Nurse education planners may find this evidence of value in determining ways of providing a future workforce for public health nursing.

Value of information in the osteoarthritis setting: cost effectiveness of COX-2 selective inhibitors, traditional NSAIDs and proton pump inhibitors.

BACKGROUND: Recent National Institute for Health and Clinical Excellence (NICE) guidance recommended that when traditional NSAIDs or cyclo-oxygenase (COX)-2 selective inhibitors are used by people with osteoarthritis (OA), they should be prescribed along with a proton pump inhibitor (PPI). However, specific recommendations about the type of NSAID or COX-2 could not be made due to high levels of uncertainty in the economic evaluation. OBJECTIVE: To investigate the value of obtaining further evidence to inform the economic evaluation of NSAIDs, COX-2s and PPIs for people with OA. METHODS: An economic evaluation with an expected value of perfect information (EVPI) analysis was conducted, using a Markov model with data identified from a systematic review. The base-case model used adverse event data from the three largest randomized trials of COX-2 inhibitors, and we repeated the analysis using observational adverse event data. The model was run for a hypothetical population of people with OA, and subgroup analyses were conducted for people with raised gastrointestinal (GI) and cardiovascular (CV) risk. The EVPI was based upon the OA population in England - approximately 2.8 million people. Of these, 50% were assumed to use NSAIDs or COX-2 selective inhibitors for 3 months per year and 56% of these were assumed to be patients with raised GI and CV risk. RESULTS: The value of further information for this decision problem was very high. Population-level EVPI was £85.1 million in the low-risk group and £179.5 million in the high-risk group (2007-8 values). Expected value of partial perfect information (EVPPI) analysis showed that the groups of parameters for which further evidence was likely to be of most value were CV adverse event risks and all adverse event rates associated with the specific drugs celecoxib and ibuprofen. The value of perfect information remained high even when observational adverse event data were used. CONCLUSIONS: There is a very high value associated with obtaining further information on uncertain parameters for the economic evaluation of NSAIDs, COX-2 selective inhibitors and PPIs for people with OA. Obtaining further randomized or observational information on CV risks is likely to be particularly cost effective.

Cost effectiveness of COX 2 selective inhibitors and traditional NSAIDs alone or in combination with a proton pump inhibitor for people with osteoarthritis.

OBJECTIVES: To investigate the cost effectiveness of cyclo-oxygenase-2 (COX 2) selective inhibitors and traditional non-steroidal anti-inflammatory drugs (NSAIDs), and the addition of proton pump inhibitors to these treatments, for people with osteoarthritis. DESIGN: An economic evaluation using a Markov model and data from a systematic review was conducted. Estimates of cardiovascular and gastrointestinal adverse events were based on data from three large randomised controlled trials, and observational data were used for sensitivity analyses. Efficacy benefits from treatment were estimated from a meta-analysis of trials reporting total Western Ontario and McMaster Universities (WOMAC) osteoarthritis index score. Other model inputs were obtained from the relevant literature. The model was run for a hypothetical population of people with osteoarthritis. Subgroup analyses were conducted for people at high risk of gastrointestinal or cardiovascular adverse events. Comparators Licensed COX 2 selective inhibitors (celecoxib and etoricoxib) and traditional NSAIDs (diclofenac, ibuprofen, and naproxen) for which suitable data were available were compared. Paracetamol was also included, as was the possibility of adding a proton pump inhibitor (omeprazole) to each treatment. MAIN OUTCOME MEASURES: The main outcome measure was cost effectiveness, which was based on quality adjusted life years gained. Quality adjusted life year scores were calculated from pooled estimates of efficacy and major adverse events (that is, dyspepsia; symptomatic ulcer; complicated gastrointestinal perforation, ulcer, or bleed; myocardial infarction; stroke; and heart failure). RESULTS: Addition of a proton pump inhibitor to both COX 2 selective inhibitors and traditional NSAIDs was highly cost effective for all patient groups considered (incremental cost effectiveness ratio less than pound1000 (euro1175, $1650)). This finding was robust across a wide range of effectiveness estimates if the cheapest proton pump inhibitor was used. In our base case analysis, adding a proton pump inhibitor to a COX 2 selective inhibitor (used at the lowest licensed dose) was a cost effective option, even for patients at low risk of gastrointestinal adverse events (incremental cost effectiveness ratio approximately pound10 000). Uncertainties around relative adverse event rates meant relative cost effectiveness for individual COX 2 selective inhibitors and traditional NSAIDs was difficult to determine. CONCLUSIONS: Prescribing a proton pump inhibitor for people with osteoarthritis who are taking a traditional NSAID or COX 2 selective inhibitor is cost effective. The cost effectiveness analysis was sensitive to adverse event data and the specific choice of COX 2 selective inhibitor or NSAID agent should, therefore, take into account individual cardiovascular and gastrointestinal risks.

False negative biliary scintigraphy in gangrenous cholecystitis.

Gangrenous cholecystitis is a serious complication of acute cholecystitis and is associated with increased morbidity and mortality rates. We report a case in which the diagnosis was suggested by ultrasound, but cholecystectomy delayed due to atypical clinical presentation and a false negative radionuclide biliary scan.

Using prescribing indicators to measure the quality of prescribing to elderly medical in-patients.

OBJECTIVES: to evaluate the performance of hospitals using eight indicators designed to assess prescribing practice in medical in-patients aged > or =65 years. DESIGN: local coalition teams were invited to collect cross-sectional prescribing and clinical data on 100 consecutive medical in-patients aged > or =65 years during a specific week in April 1999. SETTING: 102 hospitals across England. PARTICIPANTS: all NHS Trust hospitals in Wales and England were invited to participate in the study. MAIN OUTCOME MEASURES: the performance and inter-hospital variation of hospitals in eight indicators of prescribing. Also, the age-related appropriate use of anti-thrombotic stroke prophylaxis in atrial fibrillation, of aspirin in angina and of benzodiazepines. RESULTS: data were collected on 9,979 patients prescribed 70,458 medications. The number of hospitals achieving the prescribing goal for the indicators varied between 0 and 70. Frequency of administration instructions with 'as required' prescriptions were documented on 60% (10,403/17,258) of occasions. Generic (or acceptable proprietary) names were used for 84% (58,953/70,458) medications, 50% (4,870/9,778) of patients had documentation of allergy status on the drug chart and 23% (1,380/6,060) of patients had the potential risk of exceeding the maximum recommended dosage (4 g/24 h) of paracetamol. Long-acting hypoglycaemic drugs were prescribed to 50 patients. Anti-thrombotic stroke prophylaxis in atrial fibrillation were used appropriately for 53% (805/1,518) of patients, aspirin was used appropriately in angina for 90% (952/1,052) of patients and benzodiazepines were used appropriately for 49% (824/1,689) of patients. For the latter three indicators, the appropriate use of medications declined from 60% to 44%, 95% to 85% and 53% to 44% in patients aged >/=85 years compared with those aged 65-74 years. CONCLUSIONS: prescribing indicators were effective in evaluating the performance of 102 hospitals on prescribing practice to medical in-patients aged >/=65 years. Prescribing to elderly medical in-patients is sub-optimal but targets were achieved by some hospitals. This should inspire those hospitals not achieving high standards to improve their performance. The higher level of inappropriate prescribing with increasing age is unacceptable.