Improving the mix of institutional and community care for older people with dementia: an application of the balance of care approach in eight European countries.

OBJECTIVES: To examine whether the mix of community and institutional long-term care (ILTC) for people with dementia (PwD) in Europe could be improved; assess the economic consequences of providing alternative services for particular groups of ILTC entrants and explore the transnational application of the 'Balance of Care' (BoC) approach. METHOD: A BoC study was undertaken in Estonia, Finland, France, Germany, the Netherlands, Spain, Sweden, and the UK as part of the RightTimePlaceCare project. Drawing on information about 2014 PwD on the margins of ILTC admission, this strategic planning framework identified people whose needs could be met in more than one setting, and compared the relative costs of the possible alternatives. RESULTS: The findings suggest a noteworthy minority of ILTC entrants could be more appropriately supported in the community if enhanced services were available. This would not necessarily require innovative services, but more standard care (including personal and day care), assuming quality was ensured. Potential cost savings were identified in all countries, but community care was not always cheaper than ILTC and the ability to release resources varied between nations. CONCLUSIONS: This is believed to be the first transnational application of the BoC approach, and demonstrates its potential to provide a consistent approach to planning across different health and social care systems. Better comparative information is needed on the number of ILTC entrants with dementia, unit costs and outcomes. Nevertheless, the findings offer important evidence on the appropriateness of current provision, and the opportunity to learn from different countries' experience.

Telemedicine in dermatology: a randomised controlled trial.

OBJECTIVES: To compare the clinical equivalence, patient and clinician opinion of store-and-forward (SF) teledermatology with conventional face-to-face consultation in setting a management plan for new, adult outpatient referrals. To assess the equivalence of digital photography and dermoscopy with conventional face-to-face consultation in the management of suspected cases of malignant melanoma or squamous cell carcinoma. DESIGN: For the SF teledermatology aspect of the study, a prospective randomised controlled trial was carried out. SETTING: Eight general practices and a hospital dermatology department in Sheffield, England. PARTICIPANTS: For the SF teledermatology part of the study, adults (aged 16 years and over) requiring a new (not seen by a hospital dermatologist within the past year) consultant opinion. For the digital photography element of the study, adults (aged 16 years and over) requiring a consultant opinion due to suspicion of malignant melanoma or squamous cell carcinoma. INTERVENTIONS: Patients in the telemedicine intervention group were referred to the consultant, and managed as far as possible using one or more digital still images and a structured, electronic referral and reply. The control group was managed by conventional hospital outpatient consultation. Patients referred to the 2-week wait clinic were invited to have a series of digital photographs, with and without dermoscopy, immediately before their face-to-face consultation. A second consultant viewed these and outlined a diagnosis and management plan which was compared with the actual management. Both were compared with the definitive diagnosis (either the final clinical or histological diagnosis, where undertaken). MAIN OUTCOME MEASURE: The concordance between the consultant who had managed the case and an independent consultant who gave a second face-to-face opinion. RESULTS: A total of 208 patients were recruited. There was also a greater loss of control cases (26%) than intervention cases (17%). A statistically significant difference in ages between the two groups completing the study (mean age of intervention group 43.6 years, control group 49.7 years, p = 0.039) indicates that this may have introduced a bias between the two groups. A further possible source of bias is the delay (mean difference of 54 days, p = 0.0001) between the SF opinion and the second opinion in the SF group, whereas control patients usually received their second opinion on the same day as their outpatient appointment. In 55% (51/92) of telemedicine cases and 78% (57/73) of control cases, the diagnosis concurred, with the second opinion. In 55% (51/92) of telemedicine cases and 84% (61/73) of control cases, the management plan concurred with the second opinion. Of the 92 telemedicine cases, 53 were judged also to require a face-to-face consultation, mainly to establish a diagnosis and treatment plan. With the digital photography for suspected skin cancer aspect of the study, it was found that an unexpectedly high proportion (33%, 85/256) of referrals proved to have a malignancy or a severely dysplastic lesion, with almost 22% having a malignant melanoma or squamous cell carcinoma, possibly reflecting the rise in incidence of skin cancers reported elsewhere. When both standard and dermoscopic images were employed, diagnostic concordance was modest (68%). The approach was highly sensitive (98%, 95% CI: 92 to 99%), at the expense of specificity (43%, 95% CI: 36 to 51%). Overall, 30% of cases would not have needed to be seen face-to-face, though two squamous cell carcinomas would have been missed (a number-needed-to-harm of 153). If the highest level of clinician confidence had been applied, no cancers would have been missed, but only 20% of patients would have avoided an outpatient appointment. CONCLUSIONS: In view of the difficulties in recruitment and the potential biases introduced by selective loss of patients and the delay in obtaining a valid second opinion in the study group, no valid conclusions can be drawn regarding the clinical performance of this model of SF telemedicine. With regard to digital photography in suspected skin cancer, it is unlikely that this approach can dramatically reduce the need for conventional clinical consultations, whilst still maintaining clinical safety. Additional research on the assessment of diagnostic and management agreement between clinicians would be valuable in this and other fields of research.

Hitting the target: the equitable distribution of health visitors across caseloads.

BACKGROUND: Health visitors in the United Kingdom work mainly with pre-school children and their mothers. Their distribution across the population is largely historical, highly variable and relates poorly to indicators of population need. METHODS: A range of largely routine data sources were used to describe the nature, variation and statistical determinants of the workload of individual health visitors in Sheffield, England, in 1996-1997. Regression models were tested relating measures of need and deprivation to the total number of client contacts. RESULTS: Caseloads were smaller in the most deprived areas, with wide variation. Most (93 per cent) contacts were with mothers and young children. Health visitors visited the clients designated as highest priority on average 4.7 times more often than routine clients. The main reasons for high priority ratings were child protection concerns, maternal mental health problems, child development and health concerns, and first-time mothers in the postnatal period. Half of all client contacts were with low-priority families for routine child health surveillance or were client initiated. Models based on the number of children under five and any one of a range of measures of social deprivation account for 57-59 per cent of variation in workload and could be used to allocate resources more equitably. CONCLUSIONS: Although most health visitors apparently subscribe to the principle of targeting, the extent varies widely. Constraints on targeting are routine child health surveillance reviews, and client demands. More equitable allocation of health visitors and more explicit targeting policies might increase the effectiveness of the health visiting service.

General practitioners' perceptions of store-and-forward teledermatology.

We studied the views of 26 general practitioners (GPs) towards store-and-forward tele-dermatology before its introduction into their practices. A postal questionnaire was developed using Likert-type questions with respondents able to explain their answers in free text. Questions related to the GPs' knowledge, perceptions and expectations of tele-dermatology, as well as their attitudes towards being part of a research trial. Most of the GPs had limited prior knowledge of tele-dermatology. They perceived its role to relate to quicker access to specialist opinions, decreased referrals, increased convenience for patients, diagnosis, and education and teaching. There was an overwhelming view that any system needed to be quick, easy to use, efficient and reliable. Concerns were expressed about being part of the clinical trial, using new technology and an increased workload. The future of tele-dermatology was thought to depend on the clinical adequacy of the system.

Levels of satisfaction of 'low-risk' mothers with their current health visiting service.

AIMS AND OBJECTIVES: To assess the expressed levels of satisfaction of 'low-risk' mothers with the current health visiting service. Setting Sheffield, England, Autumn 1997. METHODOLOGY: Self-completion, postal questionnaire (initial postcard reminder followed by a second letter and questionnaire) to a sample of 403 mothers assessed as 'low priority' by their health visitor. Questions largely related to maternal opinion of the adequacy of the health visiting service delivered during the first 9-12 months. The local research ethics committee approved the study. RESULTS: A corrected response rate of 75% with little evidence of significant bias. A high proportion (86%) of women stated that they were either 'fairly' or 'very' satisfied with the service they had received from their health visitor with regard to their baby. A lower proportion (72%) was equally satisfied with the service they had received in respect of their own health. Despite an average number of approximately 10 contacts in relation to infant health with the health visitor during the first year of life, some 6% of women wanted more frequent contacts, particularly in the first few weeks. Study limitations The questionnaire was designed specifically for the study and validation was limited. The study population comprised a selected, 'low-risk' group. CONCLUSIONS: The number of reported contacts with the health visitor seemed to greatly exceed those indicated by a basic child health surveillance programme. The overall level of maternal satisfaction is high, though a minority of women would like more support. Dissatisfaction was expressed with the lack of an appointment system for clinics, poor punctuality in home visits, and inappropriate or inadequate advice.

Errors in postcode to enumeration district mapping and their effect on small area analyses of health data.

BACKGROUND: Health research often seeks to associate individuals to their socio-economic circumstances by linking an individual's postcode to their Census enumeration district (ED). As part of a study into health visitor resource allocation the objective here is to quantify the errors that arise in attaching ED level deprivation scores to records and counts of records by ED when records are matched to EDs via their postcodes rather than their exact address. METHODS: The result of routine matching of postcodes to EDs was compared with the more accurate method of matching addresses to EDs. Townsend scores were then attributed to records according to the two different methods and the results compared. A sample of 4013 births registered in Sheffield in 1996 was used. RESULTS: The comparative work showed that the mismatching of individual addresses arising from matching postcodes to EDs was 16.4 per cent. (The 95 per cent confidence interval is 15.1-17.7 per cent.) Over one-third of mismatched records (about 6 per cent of the total records) were found to have Townsend scores greater than +/- 2 compared with the score obtained through the more accurate process of address matching. CONCLUSIONS: The evidence of the study is that it is important to recognize there are errors inherent in matching individual addresses to EDs via the address postcode. For problems involving resource allocation and for research into relationships between health outcomes or service uptake and deprivation it may be necessary to seek to quantify the level of error introduced through using postcode to ED matching.

Standard generalized mark-up language: should it have a role in clinical records?

Standard generalized mark-up language (SGML) could have a role as one of the information management tools available to system developers and users because it has unique features that can help solve some of the current problems in clinical informatics. SGML allows the logical structure of multimedia documents to be described in a way that is independent of the hardware or software platform. This offers considerable advantages for purchasers of systems because it gives an opportunity to develop records that can be readily authored and read by a variety of systems, offering a route to effective communication of electronic clinical information.

Local confidential inquiry into avoidable factors in deaths from stroke and hypertensive disease.

OBJECTIVE: To audit avoidable deaths from stroke and hypertensive disease. DESIGN: Details of care before death were obtained from general practitioners and other doctors, anonymised, and assessed by two experts against agreed minimum standards of good practice for detecting and managing hypertension. SETTING: Health authority with population of 250,000. SUBJECTS: All patients under 75 years who died of stroke, hypertensive disease, or hypertension related causes during November 1990 to October 1991. MAIN OUTCOME MEASURES: Presence of important avoidable factors and departures from minimum standards of good practice. RESULTS: Adequate information was obtained for 88% (123/139) of eligible cases. Agreement between the assessors was mostly satisfactory. 29% (36/123, 95% confidence interval 21% to 37%) of all cases and 44% (36/81, 34% to 55%) of those with definite hypertension had avoidable factors that may have contributed to death. These were most commonly failures of follow up and continuing smoking. Assessment against standards of minimum good practice showed that care was inadequate but not necessarily deemed to have contributed to death, in a large proportion of patients with definite hypertension. Common shortcomings were inadequate follow up, clinical investigation, and recording of smoking and other relevant risk behaviours. CONCLUSIONS: This method of audit can identify shortcomings in care of patients dying of hypertension related disease.

Case finding in elderly people: validation of a postal questionnaire.

A continuing concern of primary care is to produce economical methods of case finding among elderly patients to reduce unmet need in practice populations. This paper reports the use of a postal questionnaire to identify high dependency groups and the use of statistical methods to produce a formula which weights the relative importance of different items in identifying patients with a high level of dependency. It appears possible to identify such high dependency cases reliably at the cost of assessing between one half and two thirds of the population aged 75 years and over.

Management of myocardial infarction in the elderly: admission and outcome on a coronary care unit.

A data base of 1,511 patients admitted to a single Coronary Care Unit was analysed to examine the potential impact of thrombolytic therapy in elderly patients with myocardial infarction. Age was confirmed as a highly significant prognostic factor, and cost utility analysis showed that the cost of thrombolytic therapy with streptokinase in the elderly was lower per quality adjusted life year than in younger patients. However, median delay time of admission from onset of symptoms was significantly greater in this age-group, suggesting a need for a greater awareness of the benefits of thrombolytic therapy in elderly people.