Emergency hospital admissions for the elderly: insights from the Devon Predictive Model.

BACKGROUND: In the UK, people aged 85 and over are the fastest growing population group and are predicted to double in number by 2030. Emergency hospital admissions are also rising. METHODS: All emergency admissions for the registered population in Devon to all English hospitals were analysed by age, and admission rates per thousand registered were calculated. The Devon Predictive Model (DPM) was built, using local data, to predict emergency admissions in the following 12 months. This model was compared with the Combined Predictive Model over five risk categories. RESULTS: The registered Devon population on 31 March 2011 was 761 652 with 65 892 emergency admissions in 2010/2011. The DPM had 89 variables including several local factors which strengthened the model. Three of the four most powerful predictors were age 85-89, 90-94 and 95 and over. The positive predictive value for the DPM was better than the CPM's in all five risk categories. Half (49.6%) of all emergency admissions were from those aged 65 or over. Admissions rose progressively and significantly in each successive elderly age band. At age 85 and over there were 420 emergency admissions per thousand registered. CONCLUSIONS: Age, especially 85 and over, has been undervalued as a risk factor for emergency hospital admissions.

The cost of diagnosing Type 2 diabetes mellitus by clinical opportunistic screening in general practice.

AIMS: Type 2 diabetes is associated with serious complications and shortens life. Its prevalence is increasing rapidly worldwide and no cure is available. One logical response is to diagnose the condition as early as possible. Clinical opportunistic screening is one mechanism for making the diagnosis before symptoms are reported. This paper reports the cost of using this technique in UK general practice. METHODS: In one UK general practice, the electronic medical records were searched to determine the number of blood glucose and oral glucose tolerance tests undertaken for non-pregnant adults without known diabetes over three consecutive years. The laboratory, staff and administrative costs associated with these screening tests were calculated. The records of all patients newly diagnosed with Type 2 diabetes during the same period were reviewed to identify diagnoses made by clinical opportunistic screening. Total costs were divided by the number of diagnoses to determine a cost per diagnosis detected by opportunistic screening. RESULTS: During the study period, 5720 screening tests were conducted for 2763 patients. Over the 3 years, 86 patients were diagnosed with Type 2 diabetes, 54 (63%) via screening (yield 2.0%; number needed to screen 51.2). The screening costs totalled £ 20,372. The average cost per new screen-detected diagnosis was £ 377. CONCLUSIONS: Almost two-thirds of new cases of Type 2 diabetes can be detected before symptoms are reported, at reasonable cost by opportunistic screening in general practice, without the use of extra resources. As an affordable alternative to population screening, clinical opportunistic screening merits further consideration.

Home-based versus hospital-based rehabilitation after myocardial infarction: A randomized trial with preference arms--Cornwall Heart Attack Rehabilitation Management Study (CHARMS).

BACKGROUND: Participation in cardiac rehabilitation after acute myocardial infarction is sub-optimal. Offering home-based rehabilitation may improve uptake. We report the first randomized study of cardiac rehabilitation to include patient preference. AIM: To compare the clinical effectiveness of a home-based rehabilitation with hospital-based rehabilitation after myocardial infarction and to determine whether patient choice affects clinical outcomes. DESIGN: Pragmatic randomized controlled trial with patient preference arms. SETTING: Rural South West England. METHODS: Patients admitted with uncomplicated myocardial infarction were offered hospital-based rehabilitation classes over 8-10 weeks or a self-help package of six weeks' duration (the Heart Manual) supported by a nurse. Primary outcomes at 9 months were mean depression and anxiety scores on the Hospital Anxiety Depression scale, quality of life after myocardial infarction (MacNew) score and serum total cholesterol. RESULTS: Of the 230 patients who agreed to participate, 104 (45%) consented to randomization and 126 (55%) chose their rehabilitation programme. Nine month follow-up data were available for 84/104 (81%) randomized and 100/126 (79%) preference patients. At follow-up no difference was seen in the change in mean depression scores between the randomized home and hospital-based groups (mean difference: 0; 95% confidence interval, -1.12 to 1.12) nor mean anxiety score (-0.07; -1.42 to 1.28), mean global MacNew score (0.14; -0.35 to 0.62) and mean total cholesterol levels (-0.18; -0.62 to 0.27). Neither were there any significant differences in outcomes between the preference groups. CONCLUSIONS: Home-based cardiac rehabilitation with the Heart Manual was as effective as hospital-based rehabilitation for patients after myocardial infarction. Choosing a rehabilitation programme did not significantly affect clinical outcomes.

Home-based cardiac rehabilitation versus hospital-based rehabilitation: a cost effectiveness analysis.

BACKGROUND: Home-based cardiac rehabilitation offers an alternative to traditional, hospital-based cardiac rehabilitation. AIM: To compare the cost effectiveness of home-based cardiac rehabilitation and hospital-based cardiac rehabilitation. METHODS: 104 patients with an uncomplicated acute myocardial infarction and without major comorbidity were randomized to receive home-based rehabilitation (n=60) i.e. nurse facilitated, self-help package of 6 weeks' duration (the Heart Manual) or hospital-based rehabilitation for 8-10 weeks (n=44). Complete economic data were available in 80 patients (48 who received home-based rehabilitation and 32 who received hospital-based rehabilitation). Healthcare costs, patient costs, and quality of life (EQ-5D4.13) were assessed over the 9 months of the study. RESULTS: The cost of running the home-based rehabilitation programme was slightly lower than that of the hospital-based programme (mean (95% confidence interval) difference - 30 pounds sterling (- 45 pounds sterling to - 12 pounds sterling) [-44 euro, -67 euro to -18 euro] per patient. The cost difference was largely the result of reduced personnel costs. Over the 9 months of the study, no significant difference was seen between the two groups in overall healthcare costs (78 pounds sterling, - 1102 pounds sterling to 1191 pounds sterling [-115 euro, -1631 euro to -1763 euro] per patient) or quality adjusted life-years (-0.06 (-0.15 to 0.02)). The lack of significant difference between home-based rehabilitation and hospital-based rehabilitation did not alter when different costs and different methods of analysis were used. CONCLUSIONS: The health gain and total healthcare costs of the present hospital-based and home-based cardiac rehabilitation programmes for patients after myocardial infarction appear to be similar. These initial results require affirmation by further economic evaluations of cardiac rehabilitation in different settings.

Teenagers' use of emergency contraception in a general practice.

British teenagers who become pregnant commonly express ignorance about emergency contraception. A case-note survey was conducted in a general practice serving about 14,200 people in a Devon market town. Of the 373 registered girls aged 15-19 years, 59 (16%) had consulted for emergency contraception, 19 of them more than once. The oral method (Yuzpe regimen) was prescribed eighty times and 2 girls became pregnant. 4 of the 59 girls who used emergency contraception had subsequent unwanted pregnancies. A consultation for emergency contraception presents an opportunity to discuss more reliable and acceptable methods of contraception.

Like mother, like daughter: a general practice study of maternal influences on teenage pregnancy.

This study confirmed the hypothesis that pregnant teenagers in the 1990s are more likely to have a mother who had a teenage pregnancy than non-pregnant teenagers. It also found that the daughters of teenage mothers are more likely to continue their own pregnancies.

PIP: General practice records were studied to identify differences between pregnant and nonpregnant teenagers in relation to their mothers' experiences. 37 females aged 13-19 years registered with the Honiton Group Practice who had had at least one pregnancy by January 1, 1996, were studied in detail. An equal number of nonpregnant controls also participated in the study. For 31 of the 37 girls in the study group and 34 of the 37 in the control group it was possible to establish whether their mother had had a teenage pregnancy. Half of the pregnant teenagers had a mother who had also had a teenage conception compared with 25% of the girls in the control group. These findings therefore confirm the hypothesis that pregnant teenagers in the 1990s are more likely to have a mother who had a teenage pregnancy than nonpregnant teens. The study also found that the daughters of teenage mothers are more likely to continue their own pregnancies.

The Exeter Diabetic Project: an acceptable district-wide education programme for general practitioners.

The Health District is a logical administrative unit for planning health services, and therefore the feasibility of delivering education for general practitioners across one such area was studied. By providing a suitable educational programme at convenient locations, it was possible to involve 89% out of 180 principals in General Practice in the Exeter Health District. Two-thirds of these general practitioners attended educational sessions away from the District Postgraduate Centre. In a questionnaire answered by 81% of the involved general practitioners, 98% acknowledged responsibility for managing their diabetic patients, but 76% admitted to inadequate skills in retinal assessment. In a follow-up postal questionnaire answered by 64% of general practitioners involved in the project, 74% found that they learnt from the retinopathy screening clinic and 100% found the sessions on eye disease helpful. The education programme was designed to link with a District-wide retinopathy screening initiative.

Continuity counts.

Group practice in Australia developed more quickly than it did in the UK and although our system of primary care differs, some problems are shared, especially criticism from patients about lack of continuity of care. Dr Pereira Gray, eminent British general practitioner, discusses his ideas about meeting this criticism. Doctors working in group practice would do well to examine their own practices from this point of view.