Asthma in the intensive care unit: A review of patient characteristics and outcomes.

Background: Most asthma-related deaths occur in low- and middle-income countries, and South Africa (SA) is ranked fifth in global asthma mortality. Little is known about the characteristics and outcome of asthma patients requiring intensive care unit (ICU) admission in SA. Objectives: To identify and characterise patients with acute severe asthma admitted to the respiratory ICU at Groote Schuur Hospital, Cape Town, SA, in order to evaluate outcomes and identify predictors of poor outcomes in those admitted. Methods: We performed a retrospective descriptive study of patients with severe asthma admitted to the respiratory ICU at Groote Schuur Hospital between 1 January 2014 and 31 December 2019. Results: One hundred and three patients (110 admission episodes) were identified with an acute asthma exacerbation requiring ICU admission; all were mechanically ventilated. There was a female preponderance (53.6%; n=59/110), with a median (range) age overall of 33 (13 - 84) years. Of all admissions, 40 (36.4%) were current tobacco smokers and 16 (14.5%) patients with a history of substance abuse. Two thirds (60.0%; n=66/110) of the patients were using an inhaled corticosteroid (ICS). No predictors of mortality were evident in multivariate modelling, although those who died were older, and had higher Acute Physiology and Chronic Health Evaluation (APACHE II) scores and longer duration of admission. Only 59 of the surviving 96 individual patients (61.5%) attended a specialist pulmonology clinic after discharge. Conclusion: Among patients admitted to the respiratory ICU at Groote Schuur Hospital for asthma exacerbations, there was a high prevalence of smokers and poor coverage with inhaled ICSs. Although mortality was low compared with general ICU mortality, more needs to be done to prevent acute severe asthma exacerbations. Study synopsis: What the study adds. Intensive care unit (ICU) admission represents the most severe form of exacerbation of asthma. South Africa (SA) has a very high rate of asthma deaths, and this study demonstrates that admission to an ICU with a very severe asthma exacerbation frequently results in a good outcome. However, many of the patients admitted to the ICU were not adequately treated with background asthma medications prior to their admission. Implications of the findings. Death from asthma should be avoidable, and admission to an ICU is not associated with high mortality. Patients are therefore likely to be dying at home or out of hospital. Better education and access to medication and early access to health services rather than improved in-hospital care would potentially alter SA's high asthma mortality.

Exploring overcrowding trends in an inner city emergence department in the UK before and during COVID-19 epidemic.

BACKGROUND: The COVID-19 pandemic and the associated lockdowns have caused significant disruptions across society, including changes in the number of emergency department (ED) visits. This study aims to investigate the impact of three pre-COVID-19 interventions and of the COVID-19 UK-epidemic and the first UK national lockdown on overcrowding within University College London Hospital Emergency Department (UCLH ED). The three interventions: target the influx of patients at ED (A), reduce the pressure on in-patients' beds (B) and improve ED processes to improve the flow of patents out from ED (C). METHODS: We collected overcrowding metrics (daily attendances, the proportion of people leaving within 4 h of arrival (four-hours target) and the reduction in overall waiting time) during 01/04/2017-31/05/2020. We then performed three different analyses, considering three different timeframes. The first analysis used data 01/04/2017-31/12-2019 to calculate changes over a period of 6 months before and after the start of interventions A-C. The second and third analyses focused on evaluating the impact of the COVID-19 epidemic, comparing the first 10 months in 2020 and 2019, and of the first national lockdown (23/03/2020-31/05/2020). RESULTS: Pre-COVID-19 all interventions led to small reductions in waiting time (17%, p < 0.001 for A and C; an 9%, p = 0.322 for B) but also to a small decrease in the number of patients leaving within 4 h of arrival (6.6,7.4,6.2% respectively A-C,p < 0.001). In presence of the COVID-19 pandemic, attendance and waiting time were reduced (40% and 8%; p < 0.001), and the number of people leaving within 4 h of arrival was increased (6%,p < 0.001). During the first lockdown, there was 65% reduction in attendance, 22% reduction in waiting time and 8% increase in number of people leaving within 4 h of arrival (p < 0.001). Crucially, when the lockdown was lifted, there was an increase (6.5%,p < 0.001) in the percentage of people leaving within 4 h, together with a larger (12.5%,p < 0.001) decrease in waiting time. This occurred despite the increase of 49.6%(p < 0.001) in attendance after lockdown ended. CONCLUSIONS: The mixed results pre-COVID-19 (significant improvements in waiting time with some interventions but not improvement in the four-hours target), may be due to indirect impacts of these interventions, where increasing pressure on one part of the ED system affected other parts. This underlines the need for multifaceted interventions and a system-wide approach to improve the pathway of flow through the ED system is necessary. During 2020 and in presence of the COVID-19 epidemic, a shift in public behaviour with anxiety over attending hospitals and higher use of virtual consultations, led to notable drop in UCLH ED attendance and consequential curbing of overcrowding. Importantly, once the lockdown was lifted, although there was an increase in arrivals at UCLH ED, overcrowding metrics were reduced. Thus, the combination of shifted public behaviour and the restructuring changes during COVID-19 epidemic, maybe be able to curb future ED overcrowding, but longer timeframe analysis is required to confirm this.

Systematic review of the influence of socioeconomic deprivation on mortality after colorectal surgery.

BACKGROUND: Socioeconomic deprivation is a potentially important factor influencing surgical outcomes. This systematic review aimed to summarize the evidence for any association between socioeconomic group and mortality after colorectal surgery, and to report the definitions of deprivation used and the approaches taken to adjust for co-morbidity in this patient population. METHODS: MEDLINE, Embase, the Cochrane Library and Web of Science were searched for studies up to November 2016 on adult patients undergoing major colorectal surgery, which reported on mortality according to socioeconomic group. Risk of bias and study quality were assessed by extracting data relating to study size, and variations in inclusion and exclusion criteria. Quality was assessed using a modification of a previously described assessment tool. RESULTS: The literature search identified 59 studies published between 1993 and 2016, reporting on 2 698 403 patients from eight countries. Overall findings showed evidence for higher mortality in more deprived socioeconomic groups, both in the perioperative period and in the longer term. Studies differed in how they defined socioeconomic groups, but the most common approach was to use one of a selection of multifactorial indices based on small geographical areas. There was no consistent approach to adjusting for co-morbidity but, where this was considered, the Charlson Co-morbidity Index was most frequently used. CONCLUSION: This systematic review suggests that socioeconomic deprivation influences mortality after colorectal surgery.

HIV-positive patients in the intensive care unit: A retrospective audit.

BACKGROUND: The indications for and outcomes of intensive care unit (ICU) admission of HIV-positive patients in resource-poor settings such as sub-Saharan Africa are unknown. OBJECTIVE: To identify indications for ICU admission and determine factors associated with high ICU and hospital mortality in HIV-positive patients. METHODS: We reviewed case records of HIV-positive patients admitted to the medical and surgical ICUs at Groote Schuur Hospital, Cape Town, South Africa, from 1 January 2012 to 31 December 2012. RESULTS: Seventy-seven HIV-positive patients were admitted to an ICU, of whom two were aged <18 years and were excluded from the final analysis. HIV infection was newly diagnosed in 37.3% of the patients admitted during the study period. HIV-positive patients had a median CD4 count of 232.5 (interquartile range 59 - 459) cells/µL. Respiratory illness, mainly community-acquired pneumonia, accounted for 30.7% of ICU admissions. ICU and hospital mortality rates were 25.3% and 34.7%, respectively. Predictors of ICU mortality included an Acute Physiology and Chronic Health Evaluation ΙΙ (APACHE II) score >13 (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.1 - 1.7; p=0.015), receipt of renal replacement therapy (RRT) (OR 2.2, 95% CI 1.2 - 4.1; p=0.018) and receipt of inotropes (OR 2.3, 95% CI 1.6 - 3.4; p<0.001). Predictors of hospital mortality were severe sepsis on admission (OR 2.8, 95% CI 0.9 - 9.1; p=0.07), receipt of RRT (OR 1.9, 95% CI 1.0 - 3.6; p=0.056) and receipt of inotropic support (OR 2.0, 95% CI 1.4 - 3.2; p<0.001). Use of highly active antiretroviral therapy (HAART), CD4 count, detectable HIV viral load and diagnosis at ICU admission did not predict ICU or hospital mortality. CONCLUSIONS: Respiratory illnesses remain the main indication for ICU in HIV-positive patients. HIV infection is often diagnosed late, with patients presenting with life-threatening illnesses. Severity of illness as indicated by a high APACHE ΙΙ score, multiple organ dysfunction requiring inotropic support and RRT, rather than receipt of HAART, CD4 count and diagnosis at ICU admission, are predictors of ICU and hospital mortality.

HIV-positive patients in the intensive care unit: A retrospective audit

Background. The indications for and outcomes of intensive care unit (ICU) admission of HIV-positive patients in resource-poor settings such as sub-Saharan Africa are unknown.Objective. To identify indications for ICU admission and determine factors associated with high ICU and hospital mortality in HIV-positive patients.Methods. We reviewed case records of HIV-positive patients admitted to the medical and surgical ICUs at Groote Schuur Hospital, Cape Town, South Africa, from 1 January 2012 to 31 December 2012.Results. Seventy-seven HIV-positive patients were admitted to an ICU, of whom two were aged <18 years and were excluded from the final analysis. HIV infection was newly diagnosed in 37.3% of the patients admitted during the study period. HIV-positive patients had a median CD4 count of 232.5 (interquartile range 59 - 459) cells/µL. Respiratory illness, mainly community-acquired pneumonia, accounted for 30.7% of ICU admissions. ICU and hospital mortality rates were 25.3% and 34.7%, respectively. Predictors of ICU mortality included an Acute Physiology and Chronic Health Evaluation ΙΙ (APACHE II) score >13 (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.1 - 1.7; p=0.015), receipt of renal replacement therapy (RRT) (OR 2.2, 95% CI 1.2 - 4.1; p=0.018) and receipt of inotropes (OR 2.3, 95% CI 1.6 - 3.4; p<0.001). Predictors of hospital mortality were severe sepsis on admission (OR 2.8, 95% CI 0.9 - 9.1; p=0.07), receipt of RRT (OR 1.9, 95% CI 1.0 - 3.6; p=0.056) and receipt of inotropic support (OR 2.0, 95% CI 1.4 - 3.2; p<0.001). Use of highly active antiretroviral therapy (HAART), CD4 count, detectable HIV viral load and diagnosis at ICU admission did not predict ICU or hospital mortality.Conclusions. Respiratory illnesses remain the main indication for ICU in HIV-positive patients. HIV infection is often diagnosed late, with patients presenting with life-threatening illnesses. Severity of illness as indicated by a high APACHE ΙΙ score, multiple organ dysfunction requiring inotropic support and RRT, rather than receipt of HAART, CD4 count and diagnosis at ICU admission, are predictors of ICU and hospital mortality

Inequalities in cancer screening participation: examining differences in perceived benefits and barriers.

OBJECTIVE: Inequalities exist in colorectal cancer (CRC) screening uptake, with people from lower socioeconomic status backgrounds less likely to participate. Identifying the facilitators and barriers to screening uptake is important to addressing screening disparities. We pooled data from 2 trials to examine educational differences in psychological constructs related to guaiac fecal occult blood testing. METHODS: Patients (n = 8576) registered at 7 general practices in England, within 15 years of the eligible age range for screening (45-59.5 years), were invited to complete a questionnaire. Measures included perceived barriers (emotional and practical) and benefits of screening, screening intentions, and participant characteristics including education. RESULTS: After data pooling, 2181 responses were included. People with high school education or no formal education reported higher emotional and practical barriers and were less likely to definitely intend to participate in screening, compared with university graduates in analyses controlling for study arm and participant characteristics. The belief that one would worry more about CRC after screening and concerns about tempting fate were strongly negatively associated with education. In a model including education and participant characteristics, respondents with low emotional barriers, low practical barriers, and high perceived benefits were more likely to definitely intend to take part in screening. CONCLUSIONS: In this analysis of adults approaching the CRC screening age, there was a consistent effect of education on perceived barriers toward guaiac fecal occult blood testing, which could affect screening decision making. Interventions should target specific barriers to reduce educational disparities in screening uptake and avoid exacerbating inequalities in CRC mortality.

Reasons for non-uptake and subsequent participation in the NHS Bowel Cancer Screening Programme: a qualitative study.

BACKGROUND: Screening for bowel cancer using the guaiac faecal occult blood test offered by the NHS Bowel Cancer Screening Programme (BCSP) is taken up by 54% of the eligible population. Uptake ranges from 35% in the most to 61% in the least deprived areas. This study explores reasons for non-uptake of bowel cancer screening, and examines reasons for subsequent uptake among participants who had initially not taken part in screening. METHODS: Focus groups with a socio-economically diverse sample of participants were used to explore participants' experience of invitation to and non-uptake of bowel cancer screening. RESULTS: Participants described sampling faeces and storing faecal samples as broaching a cultural taboo, and causing shame. Completion of the test kit within the home rather than a formal health setting was considered unsettling and reduced perceived importance. Not knowing screening results was reported to be preferable to the implications of a positive screening result. Feeling well was associated with low perceived relevance of screening. Talking about bowel cancer screening with family and peers emerged as the key to subsequent participation in screening. CONCLUSIONS: Initiatives to normalise discussion about bowel cancer screening, to link the BCSP to general practice, and to simplify the test itself may lead to increased uptake across all social groups.

Determinants of dynamic hyperinflation during metronome-paced tachypnea in COPD and normal subjects.

In COPD, dynamic hyperinflation (DH) occurs during exercise and during metronome-paced tachypnea (MPT). We investigated the relationship of DH with breathing pattern and ventilation (V˙E) in COPD and normal subjects (NS). In 35 subjects with moderate COPD and 17 younger healthy volunteers we measured inspiratory capacity (IC), breathing frequency (fR), expiratory time (TE), ventilation (V˙E) and end-tidal carbon dioxide tension (PETCO2) at baseline and after 30s of MPT at 40breaths/min with metronome-defined I:E ratios of 1:1 and 1:2. A reduction in IC (ΔIC) was taken to indicate DH. In COPD subjects, DH correlated with TE but not with V˙E or PETCO2, and was best predicted by total lung capacity. NS also showed DH (although less than in COPD), which correlated with PETCO2 but not with fR, TE or V˙E. We conclude that MPT evokes DH in both NS and patients with COPD. TE is the most important determinant of DH during MPT in patients with COPD.

Socioeconomic variation in uptake of colonoscopy following a positive faecal occult blood test result: a retrospective analysis of the NHS Bowel Cancer Screening Programme.

BACKGROUND: Bowel cancer is a serious health burden and its early diagnosis improves survival. The Bowel Cancer Screening Programme (BCSP) in England screens with the Faecal Occult Blood test (FOBt), followed by colonoscopy for individuals with a positive test result. Socioeconomic inequalities have been demonstrated for FOBt uptake, but it is not known whether they persist at the next stage of the screening pathway. The aim of this study was to assess the association between colonoscopy uptake and area socioeconomic deprivation, controlling for individual age and sex, and area ethnic diversity, population density, poor self-assessed health, and region. METHODS: Logistic regression analysis of colonoscopy uptake using BCSP data for England between 2006 and 2009 for 24 180 adults aged between 60 and 69 years. RESULTS: Overall colonoscopy uptake was 88.4%. Statistically significant variation in uptake is found between quintiles of area deprivation (ranging from 86.4 to 89.5%), as well as age and sex groups (87.9-89.1%), quintiles of poor self-assessed health (87.5-89.5%), non-white ethnicity (84.6-90.6%) and population density (87.9-89.3%), and geographical regions (86.4-90%). CONCLUSION: Colonoscopy uptake is high. The variation in uptake by socioeconomic deprivation is small, as is variation by subgroups of age and sex, poor self-assessed health, ethnic diversity, population density, and region.

Indications for fenestrated endovascular aneurysm repair.

BACKGROUND: Endovascular technology has advanced rapidly in the development of fenestrated endovascular aneurysm repair (FEVAR). Current evidence for endovascular aneurysm repair is limited to infra-renal aortic aneurysms. With increased costs and complexity of FEVAR, its current role is unclear. A national multicentre, cross-disciplinary consensus model was developed to propose indications for FEVAR. METHODS: All UK FEVAR centres and a wide selection of high-volume aneurysm treatment centres were invited to participate. The RAND appropriateness methodology was used. Five key steps were undertaken: meta-analysis of current literature; survey of current UK practice; nominal group establishment and definition of key clinical attributes; round 1--online survey of case vignettes; and round 2--nominal group consensus meeting. RESULTS: More than 90 per cent of UK FEVAR centres participated. Literature review showed heterogeneous case series with no clear indications for use of FEVAR. Survey of current practice showed wide variations in aneurysm management. Consensus agreement on the role of FEVAR was achieved in 68·8 per cent of cases. Consensus for FEVAR was agreed in areas of moderate risk from open repair and need for suprarenal clamping, but it was less likely to be indicated in patients aged 85 years or more with 5·5-6-cm aneurysms, or short-necked infrarenal aortic aneurysms. CONCLUSION: These data record areas of agreement and define the grey area of equipoise. Consequently, guidelines and recommendations can be developed on the indications for FEVAR to inform clinicians, commissioners and health economists.

Strategy for power calculation for interactions: application to a trial of interventions to improve uptake of bowel cancer screening.

Poorer postcodes within 5 regions in England have a lower response to bowel-cancer screening invitations than do richer postcodes. An extension of the sample-size formula for two proportions is used to determine that needed to detect an increase in response rate that varies by deprivation quintile. The proportions plugged into the formula are weighted averages based on the relationship between response and deprivation; the response rate is adjusted to be constant across deprivation quintiles. From a baseline period between October 2006 and January 2009, detection of an absolute or relative increase of at least 1,2,3,4 and 5% in response rate is required for the richest to poorest quintiles respectively because the interventions were chosen as those most likely to have an effect in the lower socioeconomic groups. A computer simulation experiment shows that the approach is more conservative than a likelihood-ratio calculation, and it appears sensible when compared with repeated application of a two-sample calculation at each quintile.

Guideline for the management of chronic obstructive pulmonary disease--2011 update.

OBJECTIVE: To revise the South African Guideline for the Management of Chronic Obstructive Pulmonary Disease (COPD) based on emerging research that has informed updated recommendations. KEY POINTS: (1) Smoking is the major cause of COPD, but exposure to biomass fuels and tuberculosis are important additional factors. (2) Spirometry is essential for the diagnosis and staging of COPD. (3) COPD is either undiagnosed or diagnosed too late, so limiting the benefit of therapeutic interventions; performing spirometry in at-risk individuals will help to establish an early diagnosis. (4) Oral corticosteroids are no longer recommended for maintenance treatment of COPD. (5) A therapeutic trial of oral corticosteroids to distinguish corticosteroid responders from non-responders is no longer recommended. (6) Primary and secondary prevention are the most cost-effective strategies in COPD. Smoking cessation as well as avoidance of other forms of pollution can prevent disease in susceptible individuals and ameliorate progression. Bronchodilators are the mainstay of pharmacotherapy, relieving dyspnoea and improving quality of life. (7) Inhaled corticosteroids are recommended in patients with frequent exacerbations and have a synergistic effect with bronchodilators in improving lung function, quality of life and exacerbation frequency. (8) Acute exacerbations of COPD significantly affect morbidity, health care units and mortality. (9) Antibiotics are only indicated for purulent exacerbations of chronic bronchitis. (10) COPD patients should be encouraged to engage in an active lifestyle and participate in rehabilitation programmes. OPTIONS: Treatment recommendations are based on the following: annual updates of the Global Obstructive Lung Disease (GOLD), initiative, that provide an evidence-based comprehensive review of management; independent evaluation of the level of evidence in support of some of the new treatment trends; and consideration of factors that influence COPD management in South Africa, including lung co-morbidity and drug availability and cost. OUTCOME: Holistic management utilising pharmacological and nonpharmacological options are put in perspective. EVIDENCE: Working groups of clinicians and clinical researchers following detailed literature review, particularly of studies performed in South Africa, and the GOLD guidelines. BENEFITS, HARMS AND COSTS. The guideline pays particular attention to cost-effectiveness in South Africa, and promotes the initial use of less costly options. It promotes smoking cessation and selection of treatment based on objective evidence of benefit. It also rejects a nihilistic or punitive approach, even in those who are unable to break the smoking addiction. RECOMMENDATIONS: These include primary and secondary prevention; early diagnosis, staging of severity, use of bronchodilators and other forms of treatment, rehabilitation, and treatment of complications. Advice is provided on the management of acute exacerbations and the approach to air travel, prescribing long-term oxygen and lung surgery including lung volume reduction surgery. VALIDATION: The COPD Working Group comprised experienced pulmonologists representing all university departments in South Africa and some from private practice, and general practitioners. Most contributed to the development of the previous version of the South African guideline. GUIDELINE SPONSOR: The meeting of the Working Group of the South African Thoracic Society was sponsored by an unrestricted educational grant from Boehringer Ingelheim and Glaxo-Smith-Kline.

Why do patients with systemic lupus erythematosus take or fail to take their prescribed medications? A qualitative study in a UK cohort.

OBJECTIVE: It has been suggested that low adherence may contribute to poor clinical outcomes in patients with SLE. In this study, we explored the reasons why patients with lupus did or did not take their medications as prescribed. METHODS: Questionnaires including a 10-cm visual analogue scale (VAS) to assess self-reported adherence to prescribed medications were distributed to 315 patients with SLE. The responses were used to select a purposive sample of subjects who participated in interviews to discuss why they did or did not take their medications. RESULTS: Of the 315 patients, 220 (70%) completed the questionnaire. Thirty-three patients were interviewed. Themes explaining why patients took their medications regularly included: the fear of worsening disease, the belief that there was no effective therapeutic alternative to their prescribed medications, lack of knowledge about SLE to allow confidence in changing medications and feelings of moral obligation or responsibility to others. Themes explaining why patients did not take their medications regularly included: the belief that lupus could and should be controlled using alternative methods, the belief that long-term use of drugs was not necessary, the fear of drug adverse effects, practical difficulties in obtaining medications, and poor communication between patients and doctors. CONCLUSION: The patients' reasons for taking or not taking their medications largely related to previous experiences with the disease and/or drugs. However, improvements in communication between doctors and patients may promote better adherence in patients with SLE.

Running along parallel lines: how political reality impedes the evaluation of public health interventions. A case study of exercise referral schemes in England.

Political decisions about the way that public health initiatives are implemented have a significant impact on the ability to evaluate their effectiveness. However, the influence of the political imperative has been little explored. This case study of key research, policy and practice events concerning one initiative, exercise referral schemes (ERSs), demonstrates that these schemes were encouraged to expand by the Department of Health (DH) before DH-funded evaluations had reported their findings and with little reference to National Institute for Health and Clinical Excellence (NICE) recommendations. Policy evolved in parallel rather than in conjunction with the development of evidence, and experimental evaluations in England are now unlikely. This is due to the comprehensive coverage of schemes, widespread assumptions of effectiveness, likely difficulties in obtaining research funding, indirect adverse consequences of dismantling schemes and lack of appropriate process and outcome data. Embedding a commitment to robust evaluation prior to universal adoption of new initiatives has been shown to be feasible by policy-makers in the international setting. This is required to prevent the establishment of public health interventions that do not work and may cause harm or widen health inequalities.

Factors influencing adherence to medications in a group of patients with systemic lupus erythematosus in Jamaica.

The objective of this study was to examine the factors influencing adherence to medications in a group of patients with systemic lupus erythematosus (SLE) in Jamaica. A qualitative study was designed using a screening questionnaire and semi-structured interviews. The study was conducted in the rheumatology clinic at the University Hospital of the West Indies, Kingston, Jamaica. 75 patients with SLE including 20 interviewees, who had SLE for at least 1 year participated in the study. The main outcome measures were: (i) level of self-reported adherence in a sample of the clinic attendees and (ii) interviewees explanations of the reasons for taking or not taking drugs as prescribed by their physician. 56% of the 75 study participants reported taking their medications more than 85% of the time. High cost and poor availability of medications were the main reasons for poor adherence, but some patients chose not to take their medications because of side effects, perceived mild severity of their disease and/or a preference to take drugs only when symptomatic. Patients used herbal medicines to counteract side effects of Western medicines, to 'purge the blood' and to manage lupus symptoms when they had no medications. Religious beliefs were used as a coping strategy. Traditional use of herbal medicines is common particularly in patients from rural Jamaica, and may explain the observed use of herbal medicines in those who have emigrated to developed countries. Socio-economic constraints and poor drug availability are particularly important influences on poor adherence in Jamaican patients with SLE. Religious beliefs and use of herbal remedies do not seem to affect adherence adversely but are used when drugs cannot be obtained.

An experimental study of determinants of the extent of disagreement within clinical guideline development groups.

OBJECTIVE: To assess the effect of design features and clinical and social cues on the extent of disagreement among participants in a formal consensus development process. METHODS: Factorial design involving 16 groups consisting of 135 general practitioners (GPs) and 42 mental health professionals from England. The groups rated the appropriateness of four mental health interventions for three conditions (chronic back pain, irritable bowel syndrome, and chronic fatigue syndrome) in the context of various clinical and social cues. The groups differed in three design features: provision of a systematic literature review (versus not provided), group composition (mixed versus GP only), and assumptions about the healthcare resources available (realistic versus idealistic). Disagreement was measured using the mean absolute deviation from a group's median rating for a scenario. RESULTS: None of the design features significantly affected the extent of disagreement within groups (all p>0.3). Disagreement did differ between treatments (closer consensus for cognitive behavioural therapy and behavioural therapy than for brief psychodynamic intervention therapy and antidepressants) and cues (closer consensus for depressed patients and patients willing to try any treatment). CONCLUSION: In terms of the extent of disagreement in the groups in this study, formal consensus development was a robust technique in that the results were not dependent on the way it was conducted.

Gender differences in the management and outcome of patients with acute coronary artery disease.

STUDY OBJECTIVE: s: To compare the clinical management and health outcomes of men and women after admission with acute coronary syndromes, after adjusting for disease severity, sociodemographic, and cardiac risk factors. DESIGN: Prospective national survey of acute cardiac admissions followed up by mailed patient questionnaire two to three years after initial admission. SETTING: Random sample of 94 district general hospitals in the UK. PATIENTS: 1064 patients under 70 years old recruited between April 1995 and November 1996. MAIN RESULTS: Of the 1064 patients recruited, 126 (11.8%) died before follow up. Of the 938 survivors, 719 (76.7%) completed a follow up questionnaire. There were no gender differences in the use of cardiac investigations during the index admission or follow up period. However, male patients with hypertension were more likely to undergo rehabilitation compared with female hypertensive patients (OR 2.01, 95% CI 0.85 to 4.72). Men were also more likely to undergo coronary artery bypass grafting (CABG) than women (OR 1.90, 95%CI 1.21 to 3.00), but there was no gender difference in the use of revascularisation overall (p=0.14). An indirect indication that the gender differences in CABG were not attributable to bias was provided by the lack of gender differences in health outcomes, which implies that patients received the care they needed. CONCLUSIONS: Despite the extensive international literature referring to a gender bias in favour of men with coronary heart disease, this national survey found no gender differences in the use of investigations or in revascularisation overall. However, the criteria used for selecting percutaneous transluminal coronary angioplasty compared with CABG requires further investigation as does the use of rehabilitation. It is unclear whether the clinical decisions to provide these procedures are made solely on the basis of clinical need.