Enabling factors and barriers for the use of health impact assessment in decision-making processes.

OBJECTIVE: To identify key stakeholders' views of factors that may enable or limit the use of health impact assessment (HIA) in the decision-making processes within their organizations. METHODS: In-depth interviews were carried out with 14 key informants from local and regional stakeholder organizations. SETTING: North East of England, 2005. RESULTS: Three emergent themes were identified: leadership in HIA; integration of HIA with existing organizational structures; and joint working between key stakeholder organizations. CONCLUSIONS: With the exception of a 'leadership vacuum' that had not been described previously, the present findings on factors that enable or limit the use of HIA in decision making by organizations in the region are consistent with those reported previously in the literature. In the absence of a nationally defined regulatory and organizational framework for HIA practice, key stakeholders' views on factors that promote or hinder the use of HIA in the decision-making process of their organizations may be pivotal in advancing HIA practice in the region.

Use of surgery to aid weight reduction-experience of two regions of Northern England: a database study.

OBJECTIVE: To determine the usage of surgery in the management of obesity. DESIGN: Analysis of routine statistics. DATA SOURCES: Hospital Episode Statistics extract held by Public Health Observatories. GEOGRAPHICAL AREAS: Two Government Office Regions in England with a population of 7.6 million. TIME PERIOD: Data analysed in the study covered the 6 y 1996/1997-2001/2002. RESULTS: The availability and uptake of surgery for obesity in the two regions was hugely variable. The overall utilisation of the procedures examined (OPCS operation codes: G30.1, G30.2, G32.10, G61.00) was 5.6 per million per annum, but ranged by Primary Care Trust from zero (the case in eight of the 50 PCTs in the two regions) to 24.0 operations per million per year. The rates of access to this surgery differed over six-fold between the two regions (1.4 operations per year per million population to 7.9 operations per year per million population). The PCTs with the highest rates of surgery, were those closest to the large providers of service. CONCLUSIONS: Access to this intervention is highly variable. Primary Care Trusts in England and service providers need to ensure that there is appropriate access to this effective procedure in carefully selected cases. The surgical expertise required for these operations could be concentrated in fewer centres.

Impact of small variations of ischemia time after polyclonal antithymocyte globulins in a nonhuman primate model of ischemia-reperfusion injury.

Ischemia-reperfusion injury leads to increased leukocyte adherence enhancing acute cellular rejection, causing microvascular dysfunction and tissue damage. The length of the ischemic time is important in clinical transplantation. Polyclonal antithymocyte globulins (pATGs) induce T-cell depletion and functional impairment of nondepleted lymphocytes. In this study cynomolgus monkeys were used to evaluate the impact of three different pATGs on the microcirculation, on leukocyte behavior and infiltration, as well as on tissue damage after two different periods of ischemia (60 and 150 minutes). pATGs were administered 30 minutes before ex vivo reperfusion. Using intravital fluorescence microscopy, the postreperfusion microcirculation was visualized in vivo. Morphologic analyses were performed on biopsies obtained after the experiments. Significant differences were observed between the two periods of ischemia in both the ATG-treated and control groups. Minimizing ischemia time, even in short intervals, improves the outcome of ischemia-reperfusion injury by reducing leukocyte adherence to the antigen-presenting endothelial cells, improving the microcirculation, and reducing tissue damage.

Implementation and evaluation of local-level priority setting for stroke.

We aimed to develop and evaluate a prioritisation process to combine the evidence base with stakeholder involvement within a stroke programme for a Health Improvement Programme (HImP). Implementation involved: formation of a district stroke group (DSG); review of the evidence; survey of DSG members; survey of other key professionals; consensus within the DSG; consultation with local users of the service. Evaluation was through semi-structured interviews and documentary analysis. The process was accepted as appropriate and valuable by the majority of participants, and a district HImP implementation group allocated pound sterling 100 000 for stroke development as a result of this process. However, some felt that stroke itself had been an imposed, rather than an agreed, local priority. The priority setting process was not clear to all participants and change of personnel, particularly in the NHS trusts, led to some perceived lack of ownership. Professionals from secondary care participated, but later criticised the process when they felt that the priorities in the HImP could limit their ability to access money for other service developments. The user consultation days occurred too late to influence the 1999/2002 HImP. We have shown that it is possible to develop an approach that is broadly accepted by stakeholders and balance the evidence base with local ownership. The participation of stakeholders, clarity of procedures, local ownership and awareness of local politics are important in effective priority setting. The model developed will be of value in other settings.

Graveyard gleanings: socio-economic, geographical and gender inequalities in health at Tynemouth, UK, 1833-1853.

BACKGROUND: Inequalities in the health of different sections of populations are well recognized but were difficult to demonstrate before death registration was introduced in 1837. In the early years of civil registration, geographical and sex differences in mortality were clearly recognized, as were occupational hazards, but socio-economic differences were barely explored in the Annual Reports of the Registrar General. Tynemouth General Cemetery (TGC) was established in 1833 as a private cemetery with unusually detailed records. METHODS: A total of 2610 records from 1833 to 1853 were analysed. Variables used included sex, dates of death and burial, age at death, depth of burial, cause of death, place of residence and occupation. As no denominator population is available, median age at death has been used for comparisons. RESULTS: Depth of burial relates well to a hierarchy of specific occupations and so is used as a marker for socio-economic status. The median age for the burials was 12 years. People of higher socio-economic status survived longer. The people of North Shields, and especially the males, died younger than those from surrounding areas. Males outnumbered females in most age groups. CONCLUSION: Socio-economic, geographical and gender inequalities in mortality are clearly demonstrable in the early nineteenth century, without the use of registration data.

Teaching public health to medical students in the United Kingdom--are the General Medical Council's recommendations being implemented?

BACKGROUND: Despite frequent calls to improve undergraduate medical public health teaching, little is known about whether curricula have changed. We report a survey of undergraduate public health teaching in UK medical schools in 1996. The survey aimed to assess whether the General Medical Council's 1993 recommendations to strengthen undergraduate medical education in public health have been implemented. METHODS: We asked heads of academic departments of public health at all 26 UK medical schools to complete a questionnaire and provide supporting documentation for each undergraduate public health course or module. We compared results from the 1996 survey with those from a similar survey in 1992. RESULTS: Twenty-one out of 26 (81 per cent) medical schools responded. All responding medical schools included public health teaching within their curriculum. The median number of public health courses per medical school was unchanged since 1992. A wide variety of topics were taught. Core public health subjects were taught at most schools, though over a quarter of medical schools did not cover some core topics. Between 1992 and 1996 the proportion of time devoted to teaching by lectures decreased, whereas the following all increased: teaching by small group methods; the proportion of courses using methods of assessment encouraging active learning; and the contribution of public health courses to the final degree assessment. CONCLUSION: The findings suggest that many of the General Medical Council's recommendations for improving the delivery of undergraduate education are being addressed by public health teaching in UK medical schools. However, addressing the gaps in undergraduate public health teaching revealed in this survey is a continuing challenge for academic public health departments. Medical schools should review the content of their undergraduate public health teaching to ensure that tomorrow's doctors are adequately equipped with public health knowledge and skills.

Models of commissioning health services in the British National Health Service: a literature review.

The commissioning of health services is an under-researched area and yet it is critical to the way services meet health needs and to the quality of care. Recent emphasis in the United Kingdom and elsewhere has been on a 'primary care led National Health Service', particularly on locality commissioning through primary care groups. However, there are other models of commissioning using 'programmes of care' (focused on diseases or patient groups rather than geography) which may offer greater benefits. There is little research comparing the benefits and costs of these models, and most are not even clearly enough described to be replicated. There will always be a political dimension to models of commissioning, dependent, for example, on the balance of power in the decision-making process. None the less, a broader knowledge of possible models and a willingness to evaluate rigorously are needed if commissioning of health services is to result in better patient care.

Oral contraception and eye disease: findings in two large cohort studies.

PIP: The relationship between oral contraceptive (OC) use and eye disease was investigated through abstraction of salient data from the two large British cohort studies of the effects of OCs: the Royal College of General Practitioners' (RCGP) OC Study and the Oxford-Family Planning Association (FPA) Contraception Study. Together, these studies have accumulated over 850,000 person-years of observation since 1968 involving 63,000 women. The conditions considered in the analysis were conjunctivitis, keratitis, iritis, lacrimal disease, strabismus, cataract, glaucoma, retinal detachment, and retinal vascular lesions. The only eye disease for which there was consistent evidence of a notable increase in risk in OC users was retinal vascular lesions. The relative risk of retinal vascular lesions in OC users compared to never users was 2.0 (95% confidence interval (CI), 1.0-3.8) in the RCGP data set and 2.4 (95% CI, 0.4-9.2) in the Oxford-FPA Study. This increased risk was not concentrated in any one diagnostic category (e.g., retinal vascular occlusion, retinal vein thrombosis, retinal hemorrhage).^ieng

Improving the coverage of neonatal BCG vaccination.

BACKGROUND: It is recommended that neonates at higher risk of contracting tuberculosis (such as in certain ethnic groups) should be vaccinated with BCG as soon as possible after birth. In Milton Keynes, during the late 1980s, there was anecdotal evidence to suggest that many higher-risk cases were not receiving BCG vaccination. The objectives of the study were to audit the neonatal BCG vaccination programme and to develop a system for improving and monitoring coverage. METHOD: Two main sources of data were used: the obstetric computer, which gave the denominator of women considered to be in a higher-risk group, and the community child health computer, which gave the numerator of BCG vaccinations given. A case note audit was used to check the quality of these data. A computer-generated reminder was used to make sure that the antenatal assessment of risk was known about immediately after delivery. RESULTS: Estimated vaccine coverage rose from about 20 per cent (1988-1990) to 78 per cent by 1993. The audit suggested that about 8 per cent of vaccinations were not being recorded and 9 per cent were given unnecessarily. In addition, about 2 per cent were picked up postnatally and 1 per cent were missed completely. CONCLUSION: Improved coverage and adequate monitoring can be achieved using the two computerized systems. This methods has applications to other conditions where antenatal assessment can predict risk for a neonate, such as Hepatitis B or sickle cell disease.

The Oxford Laser Prostate Trial: economic issues surrounding contact laser prostatectomy.

OBJECTIVE: To compare the economic implications of transurethral resection of the prostate (TURP) and contact-laser vaporization of the prostate (with the SLT system) using data obtained from a randomized controlled trial. METHODS: All aspects of management before, during and after surgery on 102 patients, followed up for 3 months, were costed and analysed. Based on the data from the trial, the mean costs were calculated. A sensitivity analysis was then performed to examine the effect of changes in some of the relevant variables. The mean difference in cost between laser treatment and TURP was plotted against the cost of laser consumables, assuming a 5% re-operation rate for both operations at 5 years and a 5% discount rate. A range of laser re-operation rates was compared with the mean difference in costs, assuming a hospital stay of one night and two district-nurse visits. Other assumptions on discounts and re-operation rates, based on collected data, were also tested. RESULTS: TURP will remain more economical until the cost of laser consumables is reduced to 20% of the current list price, or a hospital stay of one night is introduced. CONCLUSIONS: The costs of contact-laser vaporization of the prostate are likely to exceed the costs of TURP unless laser treatment is accompanied by a more active approach to post-operative management, including a hospital stay of one night and, if necessary, the removal of the patient's catheter at home by a district nurse.

The Oxford Laser Prostate Trial: sensitivity to change of three measures of outcome.

OBJECTIVES: To evaluate the sensitivity to change of outcome measures in a double-blind randomized controlled trial of transurethral resection of the prostate (TURP) and contact laser prostatectomy. METHODS: A total of 152 patients were randomized to TURP or contact laser prostatectomy using the Surgical Laser Technology (SLT) system. Preoperative data were obtained using a self-administered questionnaire containing the American Urological Association (AUA-7) symptom score, the bothersome score (benign prostatic hyperplasia impact index), and the Short Form-36 health status questionnaire (SF-36). Follow-up was at 1 and 3 months. Effect size scores were calculated to indicate the extent of change from baseline to follow-up. RESULTS: Data were available on 148 patients: 72 received laser therapy and 76 received TURP. Mean change in AUA-7 score at 3 months was 7.3 in the laser arm, compared with 11.9 in the TURP arm (P < 0.05). Furthermore, substantial change was detected in both groups on the bothersome score. However, very few significant differences in SF-36 dimension scores from baseline to 3 months were detected. CONCLUSIONS: The SF-36 at both baseline and follow-up indicated a similar level of health status as that reported in the general population. Subsequently, the measure did not improve on any dimensions. Our data support the claim of some researchers that shorter disease-specific indices are vital to the evaluation of treatment regimens in clinical trials, especially when the general health of the patients is similar to that of the population.

An audit of environmental health calls to a department of public health medicine.

PURPOSE: To audit telephone calls concerning general issues in communicable disease control and environmental health to a department of public health medicine. SETTING: A department of public health medicine in a district with a population of 190,000 during 1993. METHOD: A retrospective audit of forms designed to record all calls concerning environmental health and communicable disease control. The intervention was a change in design of forms and education of doctors dealing with the calls. A re-audit was done after these changes had been implemented. RESULTS: The number of recorded calls increased from 1.75 (1992) to 3.29 (mid-1993) per week. Signing of forms increased from 61% to 83% and dating from 6% to 72%. All forms filled in by registrars or senior registrars were reviewed by the Consultant in Communicable Disease Control (CCDC). Very few calls were considered to be inappropriate. DISCUSSION: The increase in the number of calls was probably artefactual owing to better recording as a result of the audit. Improved recording will help in future training and audit, and be a medico-legal safeguard.

Primary hyperparathyroidism presenting as unilateral visual loss.

A 58 year old woman presented with unilateral visual loss due to ischaemic optic neuropathy. Investigations revealed severe hypercalcaemia due to hyperparathyroidism. Excision of a large parathyroid adenoma restored normocalcaemia. Visual acuity was unchanged. There was no evidence of any condition known to be associated with ischaemic optic neuropathy, or of any abnormal clotting tendency. The association between primary hyperparathyroidism and ischaemic optic neuropathy may be causal and related to vascular damage mediated by hypercalcaemia.

Thrombolysis for acute myocardial infarction in a district general hospital.

We report our experience in establishing thrombolysis as a routine part of the management of patients with acute myocardial infarction in our hospital; with particular reference to the effectiveness of the policy, safety and delays in administration.