Report into a discordant result at D16S539 between SGM Plus® and PowerPlex® ESI 16 kits in a criminal case sample and implications for the UK National DNA Database upgrade.

Upon re-testing of a DNA extract as part of a defence examination, a discordant result was observed at D16S539. Further STR testing and DNA sequencing of the sample identified the cause as a primer binding site mutation which was shown to be a previously unreported SNP. The testing results obtained in this case are considered in light of the current ongoing Multiplex Upgrade Project in the UK and the likely increase in discordant results that may be observed once different next generation kits are introduced.

Y chromosome STR haplotype data for an Irish population.

Y chromosome haplotype data was collected for 155 Irish males residing in the Republic of Ireland. Eleven short tandem repeat (STR) markers: DYS19, DYS385, DYS389I, DYS389II, DYS390, DYS391, DYS392, DYS393, DYS437, DYS438 and DYS439 were analysed and the allele and haplotype frequencies calculated. This Irish data is presented here and was found to be less diverse when compared with the neighbouring UK population.

A study of mutation rates and the characterisation of intermediate, null and duplicated alleles for 13 Y chromosome STRs.

Previously reported Y chromosome STR haplotype databases for three UK population groups, plus additionally analysed samples, have been scrutinised for the presence of non-standard (intermediate, null and duplicated) alleles. These alleles have been characterised by sequencing, some showing changes in the repeat structure, and the frequencies reported. Mutation rates for each of the 13 STRs have been calculated when analysis of father-son pairs has been possible. An example illustrating the use of non-standard alleles in a large family tree is outlined.

Y chromosome STR haplotypes in three UK populations.

Eleven Y chromosome short tandem repeat markers: DYS19, DYS385, DYS389I, DYS389II, DYS390, DYS391, DYS392, DYS393, DYS437, DYS438 and DYS439, have been typed in the three main UK population groups: Caucasians, Afro-Caribbeans and South Asians. Existing PCR reactions were adapted to incorporate DYS437, DYS438 and DYS439. The observed 11 loci haplotypes and the individual allele frequencies for each locus are presented. Distinct differences for most markers were observed between the population groups studied.

The consequences of under-use of coronary revascularization; results of a cohort study in Northern Italy.

AIM: To assess whether under-use of coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) affects patient outcome. PATIENTS AND METHODS: A prospective observational study was performed following up a cohort of patients, candidates for a revascularization procedure (either CABG or PTCA) after an index angiogram. A total of 1258 patients, candidates -- according to explicit criteria -- for either CABG or PTCA entered the study enrolled by 16 hospitals located in a Northern Italian region (Lombardia). Information on demographic and clinical characteristics, type of care received (i.e. CABG or PTCA performed Yes/No) and vital status was obtained from revascularization laboratories, patients' hospital medical records and local census offices of the town of patients' residence. The main outcome measure was total unadjusted and adjusted mortality at a minimum follow-up of 9 months after the index cardiac angiogram. RESULTS: Patients who received CABG or PTCA (n=863) had lower mortality than those who did not (n=350) (4.8% vs 10.6%, P=0.001). This held true after adjustment for relevant risk factors between the two groups such as extent of coronary artery disease, clinical symptoms, and cardiac surgical risk index (adjusted odds ratio=0.48; 95% confidence intervals=0.30--0.77) and after performing a survival analysis (adjusted hazard ratio=0.31; 95% confidence intervals=0.19--0.50). CONCLUSIONS: Failure to perform a revascularization procedure when it was indicated led, in this study, to a significantly increased mortality showing that under-use of effective procedures may represent a significant quality of care problem even in areas where health care systems are well developed. Although the study was not specifically designed to identify determinants of under-use (i.e. reduced capacity leading to waiting lists, physicians' competence or patients' refusal to undergo a recommended procedure) our data suggest that limited capacity could have been the most important reason. Our findings also provide further evidence of the validity of the RAND method to assess the impact of under-use of coronary revascularization procedures.

Comparison of an enhanced versus a written feedback model on the management of Medicare inpatients with venous thrombosis.

BACKGROUND: A multistate randomized study conducted under the Health Care Financing Administration's (HCFA's) Health Care Quality Improvement Program (HCQIP) offered the opportunity to compare the effect of a written feedback intervention (WFI) with that of an enhanced feedback intervention (EFI) on improving the anticoagulant management of Medicare beneficiaries who present to the hospital with venous thromboembolic disease. METHODS: Twenty-nine hospitals in five states were randomly assigned to receive written hospital-specific feedback (WFI) of feedback enhanced by the participation of a trained physician, quality improvement tools, and an Anticoagulant Management of Venous Thrombosis (AMVT) project liaison (EFI). Differences in the performance of five quality indicators between baseline and remeasurement were assessed. Quality managers were interviewed to determine perceptions of project implementation. RESULTS: No significant differences in the change from baseline to remeasurement were found between the two intervention groups. Significant improvement in one indicator and significant decline in two indicators were found for one or both groups. Yet 59% of all quality managers perceived the AMVT project as being successful to very successful, and more EFI quality managers perceived success than did WFI managers (71% versus 40%). In the majority of EFI hospitals, physician liaisons played an important role in project implementation. CONCLUSION: Study results indicated that the addition of a physician liaison, quality improvement tools, and a project liaison did not provide incremental value to hospital-specific feedback for improving quality of care. Future studies with larger sample sizes, lengthier follow-up periods, and interventions that include more of the elements shown to affect practice behavior change are needed to identify an optimal feedback model for use by external quality management organizations.

Household income losses associated with ischaemic heart disease for US employees.

OBJECTIVE: To estimate the cost of lost work days due to ischaemic heart disease (IHD), and the cost of this reduced productivity using reduction in household income. DESIGN AND SETTING: Using 2 years of nationally representative observational data, this study examined the effect on household income of IHD. This effect was estimated after accounting for unemployment, days lost to illness and other effects of illness on the income of workers aged 18 to 64 years. MAIN OUTCOME MEASURES AND RESULTS: Previous measures of indirect costs of disease have typically not included the loss in productivity due to suboptimal work performance. Among workers in this age group, IHD was associated with a reduction of $US3013 in annual household income; this reduction was independent of occupational class, age, size of household and educational level. Such a reduction may be because of reduced on-the-job performance, employer perception of this, or unrelated lifestyle choices. It represents an estimated $US6.05 billion annual loss in productivity in 1992 dollars (or $US6.45 billion in 1996 dollars). CONCLUSIONS: Estimates of the indirect costs of chronic disease that do not account fully for the lost income of employees may significantly underestimate the benefits to employers and society of treatment and prevention.

Variations among hospitals in the quality of care for heart failure.

CONTEXT: Determining variations in quality of care among hospitals can help direct attention to poorly performing institutions. PRACTICE PATTERN EXAMINED: The proportion of patients with congestive heart failure meeting various quality criteria in 69 hospitals. HOSPITAL SELECTION: The hospitals were voluntary participants in a quality improvement program in five states (Colorado, Connecticut, Georgia, Oklahoma, and Virginia). PATIENT SELECTION: All patients with congestive heart failure discharged from the participating hospitals during a 15-month period in 1995 to 1996 (or, for hospitals with more than 50 eligible patients, a random sample of 50 patients). The total sample consisted of 2077 patients. DATA SOURCE: Documentation in the hospital medical record of left ventricular function, discharge medications, and discharge instructions. RESULTS: Left ventricular function was determined in 72% of patients (range across hospitals, 18% to 97%). Among patients with left ventricular systolic dysfunction, 79% were prescribed an angiotensin-converting enzyme inhibitor (range, 54% to 94%). Only 23% of the patients prescribed angiotensin-converting enzyme inhibitors received the target dose (range, 0% to 60%). Sixty-four percent of patients were counseled about the importance of a low-sodium diet at discharge (range, 25% to 97%), but only 8% were counseled about daily weight monitoring (range, 0% to 30%). CONCLUSION: Our results show substantial hospital-to-hospital variation in the quality of care for patients with heart failure.

Purchasing oncology services. Kerr L. White Institute/American Cancer Society Task Force on Purchasing Oncology Services.

BACKGROUND: A multidisciplinary panel representing various stakeholders in the health care delivery and oncology services marketplace was convened to develop specific criteria for healthcare purchasers to consider when evaluating the structures and processes of health plans. These rank ordered criteria also can be used by oncologic service providers and health plan designers as a yardstick for the services they offer. METHODS: A multidisciplinary 31-member Task Force was assembled by the Kerr L. White Institute and the American Cancer Society in March 1997. Task Force members were selected for their ability to offer expert insight as purchasers, suppliers, policymakers, consumers, or stakeholders in the health care marketplace. A preference-weighted majority voting rule was used to identify the three most important recommendations of the 10 that were generated through a modified Delphi technique. To test the practicality of the top three recommendations, leaders of large managed care organizations (MCOs) were surveyed; the results of this survey then were compared with the results of the Task Force survey. RESULTS: The three most important recommendations from the Task Force were that health plans provide access to: 1) comprehensive cancer care, 2) preventive and screening services, and 3) second opinions and treatment options supported by scientific evidence. The difference between the responses of the Task Force and the MCOs was that MCOs placed the highest importance on evidence-based decision-making, with their next three rankings coinciding with those identified by the Task Force. CONCLUSIONS: The value of these summary recommendations will be realized through their use by both purchasers and suppliers to influence the structure and content of the delivery of oncologic services.

Surgery for small asymptomatic abdominal aortic aneurysms.

BACKGROUND: An aneurysm is an abnormal ballooning of an artery. One site in which this occurs is in the abdominal aorta, which is the major artery running through the abdomen. Some abdominal aortic aneurysms (AAA) present as an emergency and require surgery; others remain asymptomatic. Treatment of asymptomatic aneurysms depends on a number of factors, one of which is size. The risk of rupture increases with aneurysm size. Large asymptomatic aneurysms (>6 cm diameter) are operated on; small aneurysms (<4 cm diameter) have regular ultrasound to monitor growth. OBJECTIVES: The objective of this review was to compare the mortality, quality of life and cost effectiveness of early surgical repair with routine ultrasound surveillance in patients with an AAA of between 4-6 cm diameter. SEARCH STRATEGY: Trials were identified through searching the Cochrane Peripheral Vascular Diseases Group trials register and the reference lists of relevant articles. The reviewers also contacted investigators in the field and hand searched recent conference proceedings. SELECTION CRITERIA: Randomised controlled trials in which men and women with asymptomatic AAA of diameter 4-6 cm were randomly allocated to early surgery, or ultrasound surveillance at least once every 12 months. Outcome measures had to include mortality, quality of life or financial costs. DATA COLLECTION AND ANALYSIS: Data were abstracted by one reviewer and checked by others. Due to the small number of trials at present no tests of heterogeneity or sensitivity analyses were performed. MAIN RESULTS: Only one trial, the UK Small Aneurysm Trial, fulfilled the criteria for inclusion. This trial found no differences in mortality between the early surgery and surveillance groups at two, four and six years following randomisation (six years Peto OR 1.01 [95% CI 0.77-1.31]). Mean health service costs were higher in the surgery than the surveillance group, difference 1,064 pounds per patient [95% CI 796-1332]. Quality of life remained similar in the two groups but early surgery patients thought they were healthier and had less pain one year after randomisation. There were not enough patients in the trial to allow analysis of subgroups by, for example, age or aneurysm size. REVIEWER'S CONCLUSIONS: The results from the one trial to date indicate that patients with asymptomatic AAA of 4-5.5 cm should normally have regular ultrasound surveillance accompanied by surgical intervention for aneurysms which grow rapidly (>1 cm per year) or reach 5.5 cm. The results are awaited of a major trial in progress in the USA.

Racial variation in treatment for transient ischemic attacks: impact of participation by neurologists.

OBJECTIVE: This study evaluates the role of neurologists in explaining African American-white differences in the use of diagnostic and therapeutic services for cerebrovascular disease. DATA SOURCES/STUDY SETTING: Medicare inpatient hospital records were used to identify a random 20 percent sample of patients age 65 and over hospitalized with a principal diagnosis of TIA between January 1, 1991 and November 30, 1991 (n = 17,437). STUDY DESIGN: Medicare administrative data were used to identify five outcome measures: noninvasive cerebrovascular tests, cerebral angiography, carotid endarterectomy, anticoagulant therapy (as proxied by outpatient prothrombin time tests), and the specialty of the attending physician (neurologist versus other specialist). DATA COLLECTION/EXTRACTION METHODS: All Medicare claims were extracted for a 30-day period beginning with the date of admission. PRINCIPAL FINDINGS: Even after adjusting for patient demographics, comorbidity, ability to pay, and provider characteristics, African American patients were significantly less likely to receive noninvasive cerebrovascular testing, cerebral angiography, or carotid endarterectomy, compared with white patients, and to have a neurologist as their attending physician. At the same time, patients treated by neurologists were more likely to undergo diagnostic testing and less likely to undergo carotid endarterectomy. CONCLUSIONS: The findings suggest that African American patients with TIA may have less access to services for cerebrovascular disease and that at least some of this may be attributed to less access to neurologists. More research is needed on how patients at risk for stroke are referred to specialists.

The quality of care for Medicare patients with peptic ulcer disease.

OBJECTIVE: The aim of this study was to examine quality of care for hospitalized Medicare beneficiaries with peptic ulcer disease. METHODS: Collaborating with five Peer Review Organizations, we used 1995 Medicare claim files to select samples of inpatients with a principal diagnosis of peptic ulcer disease. Quality of care indicators developed by content experts included percentages for ulcer patients tested for Helicobacter pylori (H. pylori); biopsied patients who received tissue tests; H. pylori-positive patients who received appropriate therapy; and ulcer patients screened for preadmission nonsteroidal anti-inflammatory drug (NSAID) use and counseled about risks. RESULTS: Of 2,644 patients eligible for medical record review, 56% were tested for H. pylori, and 73% of those testing positive were treated appropriately; 84% of patients with endoscopic biopsies received a tissue test for H. pylori; 74% of patients were screened for preadmission NSAID use, 24% had documented counseling of NSAID use, and only 2% had documented counseling on the ulcer risk of NSAID use. Statistically significant regional variation occurred in four of six quality indicators. Outpatient records were reviewed for 529 patients to document prior outpatient H. pylori in this population; only 2% (n = 12) were tested for H. pylori in the year before admission. CONCLUSIONS: Opportunities exist to improve quality of care by testing for and treating H. pylori in hospitalized Medicare beneficiaries with peptic ulcer disease and to improve screening for NSAIDs and counseling on ulcer risks.

Red blood cell transfusions for elective hip and knee arthroplasty: opportunity to improve quality of care and documentation.

OBJECTIVES: To assess current practice for red blood cell transfusion relative to the American College of Physicians guideline for red blood cell transfusion; to determine comparative rates and relative appropriateness of autologous versus allogeneic blood use; and, to assess cost implications of current transfusion practices. DESIGN: Computerized quality-of-care algorithm applied retrospectively to medical-record and blood-bank data. SETTING: Twenty-six hospitals in Colorado, Connecticut, Georgia, Oklahoma, and Virginia. PATIENTS: Medicare beneficiaries (2,137) who were hospitalized in 1993 for two elective surgical procedures: total hip arthroplasty and total knee arthroplasty. Of the 1,195 patients who received a preoperative or postoperative transfusion, 728 were excluded from the analysis because the hospital medical record did not contain the clinical documentation necessary to apply the American College of Physicians guideline to each unit transfused. The remaining 467 patients comprised the sample. RESULTS: For 467 patients who underwent these two procedures and received a total of 651 units of preoperative or postoperative blood, there were 256 excess units transfused. Two hundred four of these units were autologous, and 52 were allogeneic. These excess units accounted for $48,200 of the total $121,000 direct cost of transfused units. CONCLUSIONS: These findings demonstrate that current medical records lack the documentation necessary to evaluate transfusion practice for the majority of Medicare beneficiaries undergoing elective hip and knee arthroplasty. The direct costs of preoperative and postoperative blood transfusion for these two procedures could be reduced by nearly 40% through adherence to the American College of Physicians guideline. The majority of this cost saving would be realized through reduction in unnecessary collection and use of autologous blood.

Relation between mode of pacing and long-term survival in the very elderly.

OBJECTIVES: This study analyzes the relationship between pacing mode and long-term survival in a large group of very elderly patients (> or = 80 years old). BACKGROUND: The relationship between pacing mode and long-term survival is not clear. Because the number of very elderly who are candidates for pacing is increasing, issues related to pacemaker (PM) use in the elderly have important clinical and economic implications. METHODS: We retrospectively reviewed 432 patients (mean age, 84.5+/-3.9 years) who received their initial PM (ventricular in 310 and dual chamber in 122) between 1980 and 1992. Follow-up was complete (3.5+/-2.6 years). Observed survival was estimated by the Kaplan-Meier method. Age- and gender-matched cohorts from the Minnesota population were used for expected survival. Log-rank test and Cox regression hazard model were used for univariate and multivariate analyses. RESULTS: Patients with ventricular PMs appeared to have poor overall survival compared with those with dual-chamber PMs. Observed survival after PM implantation in high grade atrioventricular block (AVB) patients was significantly worse than expected survival of the age- and gender-matched population (p < 0.0001), whereas observed survival of patients with sinus node dysfunction was not significantly different from expected survival of the matched population (p = 0.413). By univariate analysis, ventricular pacing in patients with AVB appeared to be associated with poor survival compared with dual-chamber pacing (hazard ratio [HR] 2.08; 95% confidence interval [CI] 1.33 to 3.33). After multivariate analysis, this difference was no longer significant (HR 1.41; 95% CI 0.88 to 2.27). Independent predictors of all-cause mortality were number of comorbid illnesses, New York Heart Association functional class, left ventricular depression and older age at implant. Pacing mode was not an independent predictor of overall survival. Older age at implantation, diabetes mellitus, dementia, history of paroxysmal atrial fibrillation and earlier year of implantation were independent predictors of ventricular pacemaker selection. CONCLUSIONS: After PM implantation, long-term survival among very elderly patients was not affected by pacing mode after correction of baseline differences. Selection bias was present in pacing mode in the very elderly, with ventricular pacing selected for sicker and older patients, perhaps partly explaining the apparent "beneficial impact on survival" observed with dual-chamber pacing.

Child sexual abuse prevention programs in Texas public elementary schools.

This survey determined if selected Texas public school districts provided an established child sexual abuse prevention program for elementary schools. The survey examined the type of program being implemented, training available for faculty and staff type of evaluation used, involvement of local agencies, and type of funding sources. Survey data were obtained from a nonrandomized sample of 89 largest public school districts in Texas, all recording an average daily attendance over 5,000. Fifty-eight of the 89 districts addressed child sexual abuse as a formal prevention program or as an awareness program. Training for child sexual abuse prevention program presenters was offered in 89% of districts. Consistent, effective evaluation was minimal. Funding for prevention programs was limited or unknown. Results confirmed the need for consistent, effective child sexual abuse prevention programs in elementary schools.

Expert panel assessment of appropriateness of abdominal aortic aneurysm surgery: global judgement versus probability estimation.

OBJECTIVE: To compare an expert panel's global assessment of appropriateness of elective surgery for abdominal aortic aneurysms (AAA) with their assessment of the effect of surgery on the probability of 5-year mortality. METHODS: Nine expert panel members rated the appropriateness of 120 scenarios for elective AAA repair on a nine-point scale, and also estimated the 5-year probability of AAA-related death and of non-AAA related death among 30-day survivors of AAA surgery and among patients with unoperated AAA. These probabilities were used to determine differences in 5-year probability of mortality of surgery vs. no surgery for each scenario. Three categories of appropriateness were defined based on these differences: inappropriate (< 0%), equivocal (0-5%), and appropriate (> 5%). RESULTS: The distribution of scenarios was inappropriate (39%), equivocal (12%), and appropriate (49%) based on probability estimates and inappropriate (43%), equivocal (22%), and appropriate (36%) based on global assessment. There was poor agreement between the two methods, with a Kappa coefficient = 0.28 (95% CI: 0.23 to 0.32). Although a higher proportion of scenarios were rated as appropriate using probability estimation rather than global judgment, the level of agreement among members of the panel was similar, Kappa coefficient = 0.07 (95% CI: -0.07 to 0.72). CONCLUSIONS: Experts disagree about the appropriate indications for elective surgery for AAA. Explicit estimates used in a decision analysis may provide a better assessment of appropriate indications than the global judgment of experts. Global assessment of the appropriateness of AAA surgery based on panel members' review of research evidence for increased survival appears to include implicitly their valuation of outcomes.