Building on "The concept of prevention: a good idea gone astray?".

BACKGROUND: In the article by Starfield and colleagues, it was suggested that the concept of prevention has gone astray. This article aims to extend their ideas. METHODS: Our methods are to take the Starfield et al article and argue that it is possible and useful to see prevention in a wider context, going beyond prevention in healthcare and viewing prevention as a social good. RESULTS: This wider view results in some questioning of the nature of the benefits of prevention. At the same time, it suggests that the values of informed citizens might be more often elicited to help establish the principles underpinning the concept of prevention. CONCLUSION: There is a need for further debate involving various disciplines to examine the concept of prevention in greater depth.

Ectopic eruption of first permanent molars: presenting features and associations.

AIM: To investigate presenting features of ectopically erupting first permanent molars and associations with other dental anomalies. STUDY DESIGN: Prospective convenience study. METHODS: 28 panoral radiographs were collected, over a 24-month period, of 7-11 year-old children with radiographic evidence of ectopic eruption of first permanent molars who presented to a Dental Teaching Hospital in the North of England. A further 20 radiographs were collected of matched patients with no evidence of ectopic molar eruption. All radiographs were analysed under standard conditions to record the distribution and type of ectopic eruption (if present). In addition, the presence of the following dental anomalies was noted: cleft lip and/or palate; supernumerary teeth; hypodontia, and infraocclusion of primary molars. Chi-squared analysis was performed to determine any significant differences in the frequency of these dental anomalies between ectopic molar and control groups. RESULTS: For patients with ectopic molar eruption, the majority demonstrated ectopic eruption of either one or two first permanent molars (32% and 57% of subjects respectively). There were a similar proportion of 'jumps' and 'holds'. 92% of these were maxillary teeth and there was equal left and right distribution. Interestingly, a positive record of ectopic eruption was only documented in the dental records of 35.7% of these subjects. Children with ectopic eruption were significantly more likely to have at least one additional dental anomaly than was the case for the control group (60.7% versus 25%). Notably, primary molar infraocclusion and cleft lip/palate were significantly more frequent in the ectopic group. CONCLUSIONS: This study, the first in a British population, has identified a significant association between ectopic eruption of first permanent molars and other dental anomalies. A multifactorial aetiology is thus supported and clinicians should be alert to the co-existence of ectopic eruption and other dental anomalies.

The dental health and preventative habits of cardiac patients attending the Royal Hospital for Sick Children Glasgow.

AIM: To assess the dental health and preventive practices of child patients with congenital heart disease treated at the Royal Hospital for Sick Children, Glasgow. STUDY DESIGN: A retrospective study using an audit data collection sheet. METHODS: Data collected for 370 paediatric cardiac patients between January 2002 and December 2003 was analysed to obtain an insight into these patients' tooth brushing methods, use of fluoride (F), dental attendance and past dental treatment. An oral examination assessed the patient's caries experience. RESULTS: There were 195 subjects aged between 1 and 5 years, 105 were 6 - 11 years and 70 were 12 -16 years of whom 291 (78%) children were registered for dental care. Of these children 331 (90%) maintained that they brushed their teeth regularly with F- toothpaste. Experience of dental treatment revealed that 132 (36%) children had undergone previous dental treatment. Oral examination showed that out of 370 patients, 236 (64%) had no active caries. The dental health of the cardiac subjects was poor compared with that of Scottish primary school children (5 year-olds) and the 12 year-olds but compared favourably with the 14-year old group. STATISTICS: The relationship between caries activity and frequency of toothbrushing was significant (p<0.01). The relationship between caries activity and attendance for dental care was not significant. CONCLUSION: Children with cardiac problems should be identified in early infancy through liaison with medical colleagues and the family offered all the preventive advice and regular dental care necessary to prevent dental disease.

Factors related to recovery after mild traumatic brain injury.

PRIMARY OBJECTIVES: To study the variables that relate to outcome after mild traumatic brain injury (TBI). METHODS AND PROCEDURES: Sixty-seven adults with disappointing recoveries after mild TBI most occurring in a compensation or litigation context were studied with regard to pre-injury, neuro-trauma, physical, emotional and cognitive variables on outcome. Validity of physical, emotional and cognitive symptoms was controlled for. MAIN OUTCOMES AND RESULTS: Except for prior psychological traumatization, neither pre-injury, neuro-trauma or cognitive variables were related to outcome. Variables most consistently related to outcome were depression, pain and symptom invalidity on measures of response bias. These factors accounted for the majority of variance in outcome. CONCLUSIONS: In cases of poor recovery after mild TBI where compensation or litigation may be a factor, most of the variance in recovery seems to be explained by depression, pain and symptom invalidity, rather than by the injury variables themselves.

Involving the general public in priority setting: experiences from Australia.

The discussion over whether community preferences have a legitimate role to play in priority setting has been highly polarised. Skeptics warn of the risk of establishing a 'dictatorship of the uninformed', while advocates proclaim the legitimacy of the participatory process. The one group who appears not to be consulted in this debate is the citizens themselves. In this study, a convenience sample of 373 citizens attending two medical clinics in central Sydney were surveyed about whether the general public has a legitimate role to play in informing priority setting in health care. Respondents were presented with three different levels of priority setting: across health care programmes, across medical procedures, and at a global level. To assist respondents in understanding the choices and trade-offs involved, they were given information about current levels of funding and the cost-effectiveness of each alternative. Respondents were asked whether they felt the preferences of the general public should be used to inform priority setting at each level. Of particular interest was the question of whether their willingness to use public preferences depended on the level of priority setting. Respondents were also asked about who else's preferences should be used to inform priority setting at each level. The results suggest that the public overwhelmingly want their preferences to inform priority-setting decisions in health care. This was seen to be particularly important in informing decisions about how to prioritise across broad health care programmes and about the criteria to be used to allocate funds across different population groups. In contrast, the preferences of medical professionals and health service managers were rated most highly in relation to the prioritisation of different treatments and medical procedures. In most cases, however, respondents did not advocate the use of one particular group's preferences. Even when the preferences of the general public were considered most important, it was felt that any decision-making process needed to be informed by the preferences of a range of groups. The preferences of politicians were viewed as least important to processes of priority setting in health care.

The association between mild traumatic brain injury and psychiatric conditions.

The majority of patients with mild traumatic brain injury (TBI) recover fairly quickly and are usually restored to their previous level of functioning. However, a significant minority have prolonged, complicated, or incomplete recoveries and have outcomes disproportionately worse than would have been predicted by the objective facts of the injury. This failure to recover as expected was the focus of this study. The participants were 80 adults with actual or suspected mild TBI who were referred to an outpatient mild TBI clinic. Most were characterized by problematic recoveries. The results indicated that those individuals who only had brain injuries made good recoveries, but that those with psychiatric comorbidity did not (chi(2) = 19.65, p = 0.0002). Most of the new psychiatric conditions responsible for poor recovery consisted of depression, anxiety disorders or conversion disorder. Dissociative phenomena appeared common after mild TBI and scores on the Dissociative Experiences Scale predicted brain injury outcome with 77% accuracy.

Agenda-setting in health reform: the role of community.

This paper presents a number of issues surrounding the setting of agendas for health care reform. We argue the need for increased community involvement, as well as the necessity to wrest health-care decision-making from health care professionals, or at least to ensure that such decision-making is informed by community values. We attempt to answer a few questions: who sets the health reform agenda and who should set it, how is the agenda set and why is this critical, when and where is the agenda set, and how should the agenda be set in the future?

Judging goodness must come before judging quality--but what is the good of health care?

The paper argues first that until it is known what the good of health care is there cannot be a judgement about what is better, and second that until it is known what is better there cannot be a judgement about what is quality. It is further suggested that in judging good and better with respect to health care as a social institution, there is no-one better placed to do this than the community. Too little is currently known about what communities want from their health services. Some suggestions as to how this situation might be improved in both principle and practice are discussed and the notion of 'communitarian claims' linked to conjoint analysis posited as a useful way forward. Such an approach will allow the development of a set of community-based principles--what is called a 'communitarian constitution'--on which to base the direction and objectives of health care.

The use of conjoint analysis to elicit community preferences in public health research: a case study of hospital services in South Australia.

AIMS: To demonstrate the use of conjoint analysis (CA) in public health research through a survey of the South Australian community about aspects of their public hospital services. METHODS: A series of focus groups determined the most important attributes in choice of hospital services. These were built into a CA survey, using the discrete choice approach. The survey was posted to a representative sample of 700 South Australians. Theoretical validity, internal consistency and non-response bias were all investigated. RESULTS: Some 231 individuals returned the questionnaire. The attribute, 'improvement in complication rates' was positively associated with choice of hospital. Three attributes were found to be negatively associated with such choice: 'waiting times for casualty', 'waiting times for elective surgery' and, anomalously, 'parking and transport facilities'. 'Travel time' and the cost attribute, 'Medicare levy' were not statistically significant. Trade-offs between the significant attributes were estimated, as were satisfaction or utility scores for different ways of providing hospital services. Results concerning internal consistency and internal validity were encouraging, but some potential for non-response bias was detected. CONCLUSION: A high premium is placed on the quality of hospital care and members of the community are prepared to choose between hospitals largely on the basis of outcomes and length of waiting times for elective surgery and in casualty. IMPLICATIONS: CA can yield potentially policy-relevant information about community preferences for health services.

The emperor's quality clothes: for goodness' sake, let's take the strain off the word quality!

Quality is a much used word in health care. It clearly has positive connotations. Yet there is less than clarity in the literature as to what it means. This article suggests that quality has to have something to do with 'goodness' and indeed 'betterment'. It then argues that it follows that quality cannot be defined before we have sorted out 'good' and 'better'. The author appeals for these terms to be defined.

Vertical equity in health care resource allocation.

This paper introduces this mini-series on vertical equity in health care. It reflects on the fact that by and large equity policies in health care have failed and that there is a need for positive discrimination to promote equity better in future. This positive discrimination is examined under the heading of 'vertical equity'. The paper considers Varian's notion of 'envy' as a basis for equity in health care but concludes that this is not a helpful route to go down. Better it would seem to pursue the idea from Sen of 'freedoms' and 'communitarian claims' (as raised previously by this author). While it is argued that procedural justice is to be preferred in the longer run as a basis for equity there are gains in adopting a short run goal of promoting distributive justice. Some preliminary evidence is presented on the weighting of health gains to reflect such vertical equity concerns.

Primary health care records: an integrated approach.

The extended primary health care team is expected to achieve the government's vision of an integrated service for patients. Key to this vision is an integrated record-keeping system, integrating GP and community nursing functions.