Shared decision-making in back pain consultations: an illusion or reality?

PURPOSE: Amid a political agenda for patient-centred healthcare, shared decision-making is reported to substantially improve patient experience, adherence to treatment and health outcomes. However, observational studies have shown that shared decision-making is rarely implemented in practice. The purpose of this study was to measure the prevalence of shared decision-making in clinical encounters involving physiotherapists and patients with back pain. METHOD: Eighty outpatient encounters (comprising 40 h of data) were observed audio-recorded, transcribed verbatim and analysed using the 12-item OPTION scale. The higher the score, the greater is the shared decision-making competency of the clinicians. RESULTS: The mean OPTION score was 24.0% (range 10.4-43.8%). CONCLUSION: Shared decision-making was under-developed in the observed back pain consultations. Clinicians' strong desire to treat acted as a barrier to shared decision-making and further work should focus on when and how it can be implemented.

The clinical effectiveness of static resting splints in early rheumatoid arthritis: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of static resting splints in early RA. METHODS: A multicentre, randomized, trial was conducted. Patients (n = 120) received either static resting splints [positioned with the wrist in neutral, MCP joint (MCPJ) and IP joint (IPJ) in a maximum of 60 degrees and 30 degrees of flexion, respectively] plus standardized occupational therapy or standardized occupational therapy alone. Change in grip strength (Ns), structural impairment (MCPJ ulnar deviation), applied dexterity (Button Board), self-report hand ability [Michigan Hand Outcomes Questionnaire (MHQ)], hand pain and morning hand stiffness were assessed at 0 and 12 months. RESULTS: Data for 56 (97%) splinted and 60 (97%) control group patients were analysed. Splint wear adherence was moderate; 24.5% 'never wore' the splints. The adjusted mean difference between groups for handgrip was -14.2 Ns (P = 0.342; 95% CI -43.7, 5.4); MCPJ ulnar deviation -1.1 degrees (P = 0.657; 95% CI = -6.2, 3.9); dexterity 0.1 s (P = 0.975; 95% CI = -6.6, 6.8) and self-report ability -3.0 on the MHQ score (P = 0.426; 95% CI -10.5, 4.5). Pain scores were unchanged in either group (P = 0.15). The occurrence of morning hand stiffness was reduced in a small group of splinted patients (P = 0.021), but the duration shortened in control patients (P = 0.010). CONCLUSIONS: There was no significant difference between the two interventions on grip strength, deformity, hand function and pain. The data favoured the control group and this study suggests that resting splints should not be used as a routine treatment of patients with early RA.

Recording of vital signs in a district general hospital emergency department.

AIM: To examine and explore factors that may influence the recording of vital signs in adult patients within the initial 15 min and again within 60 min of arrival in the "resuscitation" and "major" areas of the emergency department (ED). METHODS: A retrospective analysis of recording of vital signs was performed on 400 consecutive sets of notes from adult patients presenting to the "major" or "resuscitation" areas of a district general hospital ED. The effect of staffing levels, triage category and attendances on the recording of vital signs was examined using logistic regression. The main outcome measures were the proportion of patients with all vital signs recorded within 15 min of arrival, the proportion of patients with all vital signs repeated within 60 min of arrival and the outcomes of logistic regression analysis. RESULTS: Only 223/387 patients (58%) had all vital signs recorded within 15 min of arrival and only 29/387 (7%) had all vital signs repeated at 60 min. There was a significant relationship between the failure to record vital signs and lower triage categories. There was no evidence that staffing levels or number of attendances predicted the recording of vital signs within 15 min of arrival. CONCLUSION: Recording of vital signs was poor and unrelated to staffing levels or numbers of patients attending the ED. Failure to record patients' vital signs undermines strategies to detect and manage ill patients.

An evaluation of the costs, effectiveness and quality of renal replacement therapy provision in renal satellite units in England and Wales.

OBJECTIVES: To survey of the structure, processes and organisation of renal satellite units (RSUs) in England and Wales (Phase 1), and to compare the effectiveness, acceptability, accessibility and economic impact of chronic haemodialysis performed in RSUs compared to main renal units (MRUs) (Phase 2). DATA SOURCES: Phase 1: all renal satellite units in England and Wales. Phase 2: haemodialysis patients in a representative sample (based on geography, site, private--public ownership, medical input) of 12 RSUs and their MRUs. REVIEW METHODS: Phase 1 consisted of a questionnaire survey. Semi-structured interviews were held in a representative sample of 24 RSUs with the senior clinician, senior nurse and manager. Phase 2 consisted of a cross-sectional comparison of patients in these RSUs and patients in the parent MRUs deemed suitable for satellite care by senior staff. Clinical information was obtained from medical notes and unit computer systems. Generic and disease specific health-related quality of life (HRQoL) measures were used. Co-morbidity was assessed by the Wright/Khan Index, the Lister/Chandna score, the Modified Charlson Index, and the Karnofsky Performance Score. Statistical analyses compared RSU versus MRU patients and took account of the paired and clustered nature of the data. RESULTS: In Phase 1, responses were received from 74/80 (93%) of RSUs; 2600 patients were being treated in these RSUs. The interviews were generally positive about the impact of RSUs in terms of improved accessibility and a better environment for chronic haemodialysis (HD) patients, and in expanding renal replacement therapy patients (RRT) capacity. In Phase 2, some 82% of eligible patients took part, 394 patients in the 12 RSUs and 342 in the parent MRUs. The response rate was similar in both groups. There were no significant differences in clinical processes of care. Most clinical outcomes were similar, especially after pooled analysis, although a few parameters were statistically significantly different -- notably the proportion achieving Renal Association Standards for adequacy of dialysis as measured by the urea reduction ratio (URR) was higher in the RSU patients. Patient-specific quality of life did not differ except on the patient satisfaction questions from the KDQOL, which were scored higher by the RSU sample. Strength of preference for health status on and off dialysis was very similar between the groups, as were EQ-5D utilities. Major adverse events were not common in the RSU patients, although there were many hypotensive episodes on HD, a proportion of which affected the duration of the HD session. Of the costs measured, the only difference that was statistically significant was for District Nurse visits. Of particular note was that despite the MRU group having a higher proportion of patients hospitalised, this did not translate into a statistically significant budgetary impact in terms of the total cost per patient of hospitalisations or mean cost per patient per hospitalisation. CONCLUSIONS: This study has shown that RSUs are an effective alternative to MRU HD for a wide spectrum of patients. They improve geographic access for more dispersed areas and reduce patients' travel time, and are generally more acceptable to patients on several criteria. There does not seem to be an adverse impact of care in the RSUs although comparative long-term prospective data are lacking. The evidence suggests that satellite development could be successfully expanded; not all MRUs have any satellites and many have only a few. No single RSU model can be recommended but key factors would include local geography, the likely catchment population and the type of patients to be treated. There is a need for more basic budgetary information linking activity and expenditure to be available and more transparent, to perform at least an insightful top-down costing of the two care settings. Other areas suggested for further research include: a comparison of adverse events occurring in MRUs and RSUs with longer duration and larger numbers to identify more severe events, along with the more research into the scope for preventing such events, and a study into the patients deemed ineligible for satellite care. International comparisons of satellite care would also be useful.

Aberrant diagnoses by individual surgical pathologists.

Methods of auditing the performance of histopathologists, such as external and internal quality assurance, clinicopathological conferences, and "double-reporting" of microscopic slides, show significant diagnostic errors in at least 1.2% of reports. Although some of these are in well-recognized areas of difficulty, such as melanoma or lymphoma, most errors are in common biopsy specimens. We have developed a method that compares diagnostic patterns of individual histopathologists. This aims to identify specific diagnoses that a pathologist makes more or less frequently than other colleagues and enables the individual to reflect on his or her own histologic expertise in reporting on specific biopsy results. The bottom line diagnoses of transurethral resection of prostate specimens; rectal, gastric, and bladder biopsy samples; and endometrial curettages were analyzed retrospectively. Analyses were performed on diagnoses made by at least 15 pathologists on each specimen type and expressed as a standardized ratio (SR) with 95% confidence intervals (CI). An SR of 1.0 indicated a pattern of diagnosis matching the combined pattern of other colleagues. An SR <1.0 indicated relative "underdiagnosis" and an SR >1.0 indicated relative "overdiagnosis." Diagnostic rates of individual pathologists whose CIs did not straddle the value of 1.0 were considered aberrant, although not necessarily incorrect. The 47 of 226 (20.8%) aberrant SRs included four pathologists' diagnoses of prostatic carcinoma, three each of endometrial, rectal, and bladder carcinoma, and one of gastric malignancy. This method, which could easily be automated and used regionally or nationally, should provide pathologists with a profile of their diagnostic patterns in comparison with their peers.

Laboratory markers predict bone loss in Crohn's disease: relationship to blood mononuclear cell function and nutritional status.

BACKGROUND: Crohn's disease is associated with reduced bone density. The power of simple markers of systemic inflammation to identify higher rates of bone loss, in Crohn's disease, is uncertain. This relationship and the role of circulating (peripheral blood) mononuclear cells were investigated in a case-control study. METHODS: Urinary deoxypyridinoline/creatinine and serum osteocalcin concentrations were compared in male and premenopausal females with "active" Crohn's disease (C-reactive protein > or = 10 and/or erythrocyte sedimentation rate > or = 20) (n = 22) and controls with "quiescent" Crohn's disease (C-reactive protein < 10 and erythrocyte sedimentation rate < 20) (n = 21). No patients were receiving corticosteroid therapy. Production of tumour necrosis factor-alpha, interferon-gamma and prostaglandin E(2) by peripheral blood mononuclear cells were measured. RESULTS: Active Crohn's disease was associated with a higher deoxypyridinoline/creatinine (P = 0.02) and deoxypyridinoline/creatinine:osteocalcin ratio (P =0.01) compared with quiescent Crohn's disease, but similar osteocalcin (P = 0.24). These were not explained by vitamin D status, dietary intake or nutritional status. However, production of interferon-gamma by concanavalin A-stimulated peripheral blood mononuclear cells was lower in active Crohn's disease (P = 0.02) and correlated negatively with the deoxypyridinoline/creatinine:osteocalcin ratio (r = -0.40, P = 0.004). CONCLUSION: In Crohn's disease, raised C-reactive protein and erythrocyte sedimentation rate may indicate higher rates of bone loss and, if persistent, the need to assess bone mass even where disease symptoms are mild. This may be partly explained by altered production of interferon-gamma by peripheral blood mononuclear cells.

Essential fatty acid status in paediatric Crohn's disease: relationship with disease activity and nutritional status.

BACKGROUND: Active paediatric Crohn's disease is associated with nutritional deficiencies and altered nutrient intake. The availability of essential fatty acids (linoleic and alpha-linolenic acids) or their derivatives (arachidonic and eicosapentaenoic acids) may alter in plasma and cell membrane phospholipid in protein-energy malnutrition in children and in Crohn's disease in adults. AIM: To investigate the relationship of fatty acid phospholipid profiles with disease activity and nutritional status in paediatric Crohn's disease. METHODS: The fatty acid (proportionate) composition of plasma and erythrocyte phosphatidylcholine was determined in 30 patients (10.3-17.0 years) stratified into active and quiescent Crohn's disease (paediatric Crohn's disease activity index) and high and low body mass (body mass index centile). RESULTS: In plasma phosphatidylcholine, active disease activity was associated with a lower level of alpha-linolenic acid compared with that in quiescent disease (P < 0.05). A body mass index below the 50th centile was associated with active Crohn's disease, low linoleic and alpha-linolenic acids and high arachidonic acid (P < 0.05) in plasma phosphatidylcholine, and low alpha-linolenic acid in erythrocyte phosphatidylcholine. These findings could not be explained through differences in habitual dietary fat intake. CONCLUSION: In paediatric Crohn's disease, a low body mass index centile and high disease activity are associated with altered profiles of essential fatty acids and their derivatives, which may reflect altered metabolic demand.

Inequalities in survival from colorectal cancer: a comparison of the impact of deprivation, treatment, and host factors on observed and cause specific survival.

OBJECTIVE: To investigate whether socioeconomic deprivation is associated with cause specific and all cause survival for colorectal cancer and to what extent this is independent of significant prognostic factors. DESIGN: Prospective cohort. SETTING: The former Wessex Health Region, South West England. PARTICIPANTS: All patients resident in Wessex registered with a diagnosis of colorectal cancer over three years (n=5176). Survival analysis was carried out on those patients with compete data for all factors and a positive survival time (n=4419). OUTCOMES: Death from colorectal cancer and all cause over five year follow up from initial diagnosis. MAIN RESULTS: Deprivation was significantly associated with survival for both outcomes in univariate analysis; the unadjusted hazard ratio for dying from colorectal cancer (most deprived compared with most affluent) was 1.12 (95% CI 1.00 to 1.25) and for all cause was 1.18 (1.07 to 1.30). Significant prognostic factors for both outcomes were age, specialisation of surgeon, Dukes's stage, and emergency compared with elective surgery. Comorbidity and gender were only associated with all cause survival. After adjustment for prognostic factors, the effect of deprivation on both cause specific and all cause mortality was reduced, and it was non-significant for colorectal cancer. However, the most deprived group had consistently worse survival than the most affluent. CONCLUSIONS: Factors associated with survival with colorectal cancer depend on the outcome measure. Socioeconomic deprivation is adversely associated with survival in patients with colorectal cancer. This is strongest for non-colorectal cancer death, partly reflecting higher comorbidity, but it is there for colorectal cancer though not statistically significant. Conclusive evidence of the inequalities by socioeconomic status and underlying reasons needs to come from studies using individual based measures of socioeconomic status and more detail on treatment and host related factors.

Clinical outcome and bromodeoxyuridine derived proliferation indices in 100 colonic and rectal carcinomas.

AIM: In vivo labelling of human colonic and rectal tumours with bromodeoxyuridine (BrdUrd) and analysis by flow cytometry (FCM) allows the labelling index (LI), S phase duration (Ts) and the potential doubling time (Tpot) of the tumour to be estimated in vivo. METHODS: The data for a series of 100 tumour specimens from 97 patients with colonic and rectal carcinoma was reported in 1991, and correlated with Dukes' classification and histological differentiation. RESULTS: This study reports the eventual outcome of the 97 patients after 12 years. There were no significant associations between proliferation data of the index tumours and patient outcome. No adverse events were identified which could be attributed to the use of the halogenated pyrimidine label in vivo. CONCLUSION: Dynamic cell proliferation indices provide detailed information on the cell kinetics of colorectal tumours but these do not correlate with clinical prognostic markers or outcome.

The flow cytometric analysis of total p53 protein content and proliferation indices in colorectal cancer, in relation to clinical outcome.

This study was undertaken to assess the value of flow cytometric measurements of total p53 protein content and proliferation indices derived from in vivo halogenated pyrimidine labelling. Two series of colorectal cancer specimens were studied for which clinical outcome data were recorded. A series of 84 archival, ethanol-fixed, bromodeoxyuridine (BrdUrd) labelled colorectal tumours were analysed by flow cytometry for their total and cell cycle phase p53 protein content using the pAb1801 monoclonal antibody. A second series of 33 freshly obtained tumours was used for assay evaluation and for comparison with the archival material. In the archival series (n=84), the median p53-pAb1801 LI was 81.9% (range: 11.1-99.8%). In only three tumours could significant amounts of p53 protein not be detected. The median phase specific p53-pAb1801 LI in G0/G1 was 71.6%, in S was 95.5%, and in G2/M was 98.5%. In the series of fresh tumours (n=33), the median p53-pAb1801 labelling index (LI) was 94.6% (range: 17.9-99.9%). Only two tumours failed to express significant amounts of p53 protein. There was no significant difference in the generally high levels of p53 protein content between the fresh and archival series. Life-table analysis of the patients in the archival series failed to demonstrate a statistical difference in life expectancy in relation to Dukes' stage when tumours were stratified by the median total p53 labelling index. In this study, p53 content and proliferative indices measured by flow cytometry do not have independent predictive value over Dukes' grading in determining the outcome of colorectal cancer. Flow cytometry is confirmed as a practical tool for multi-parametric and cell cycle analysis of oncoprotein expression in human tumour biopsies.

Clinical outcome and bromodeoxyuridine-derived proliferation indices in 75 invasive breast carcinomas.

INTRODUCTION: In vivo labelling of human breast tumours with bromodeoxyuridine (BrdUrd) and analysis by flow cytometry (FCM) allows the labelling index (LI), S phase duration (t(s)) and the potential doubling time (t(pot)) of the tumour to be estimated. METHODS: The data for a series of tumour specimens from 75 patients with invasive breast carcinoma were reported in 1991, correlated with their lymph-node status, tumour size and grade. RESULTS AND CONCLUSIONS: This study reports the follow-up data over 10 years in respect of time to recurrence and death from the disease. There were no significant correlations between proliferation data and outcome measures. No adverse events were identified which could be attributed to the use of the halogenated pyrimidine label in vivo.

The Poole Diabetes Study: how many cases of Type 2 diabetes are diagnosed each year during normal health care in a defined community?

UNLABELLED: We have investigated the incidence of newly diagnosed Type 2 diabetes in the Poole area and extrapolated it to the rest of the UK. METHODS: this prospective observational study used a surveillance programme in primary and secondary care. We identified all cases of newly diagnosed Type 2 diabetes mellitus occurring from 1st May 1996 to 30th June 1998 through the normal health care process without any active screening in 186889 people registered with 24 primary care practices in the Poole area. RESULTS: the 1996 prevalence of diagnosed Type 2 diabetes in this population was 1.59 (95% CI 1.53-1.65%)%. During the first 24 months of the study, 706 new cases of Type 2 diabetes mellitus, 382 men and 324 women, were identified. The crude annual incidence of newly diagnosed Type 2 diabetes, thus was 1.93/1000 (95% CI 1.73-2.13%) and age/sex adjusted incidence was 1.67/1000 (95% CI 1.49-1.84%). The age-adjusted incidence was higher in men, 1.86/1000 (95% CI 1.60-2.13), than in women, 1.48/1000 (95% CI 1.25-1.71%), relative risk 1.26 (95% CI 0.997-1.527%), but this difference did not reach statistical significance. Mean HbA1c at diagnosis was 10.8 (S.D. 2.9%)%. Men were younger at diagnosis than women (mean age, 62.9 vs. 65.9%, P<0.01). CONCLUSION: in UK, prior to the change in the WHO diagnostic criteria for diabetes, we estimate that over 98000 new cases of Type 2 diabetes were diagnosed each year.

The significance of involved tumour bed biopsy following wide local excision of breast cancer.

AIM: Following wide local excision of breast cancer approximately 25% of patients have residual disease in the tumour bed. The aim of this study was to determine whether positive bed biopsy correlated with either local recurrence or overall survival. METHOD: Following wide excision bed biopsies were taken at four separate sites from the tumour bed. Histopathological assessment of the bed biopsies was made and compared to features within the primary tumour. Patients were followed-up over a median period of 6.17 years and local recurrence and survival data documented. RESULTS: Two hundred and sixty-eight patients were included in the study and 63 had positive bed biopsies. In all, 85 patients had a recurrence of breast cancer and 69 died. Kaplan-Meier plots showed no evidence of a difference in survival between bed biopsy positive and negative patients. Bed biopsy positive patients were at greater risk of local recurrence. CONCLUSIONS: These findings suggest that positive bed biopsy is associated with an increase in local recurrence rates but has no effect on overall survival following wide excision of breast cancer.

Lung function measurement in general practice: a comparison of the Escort spirometer with the Micromed turbine spirometer and the mini-Wright peak flow meter.

It is important that new types of spirometer for widespread clinical use are pragmatically evaluated in primary care. This study compared measurements taken by a new portable Fleisch pneumotachograph spirometer (known as the Escort) with those of the commonly used mini-Wright peak flow meter and the Micromed Pocket turbine spirometer. A pragmatic study was conducted in two phases during routine surgeries at Aldermoor Health Centre, Southampton. Phase I compared the new spirometer with the mini-Wright peak flow meter and Phase 2 compared the new spirometer and the turbine spirometer. One hundred patients aged 5-88 years (56 patients with a history of chronic respiratory complaints and 44 patients without) entered Phase 1, and 100 patients aged 6-82 years (62 patients with a history of chronic respiratory complaints and 38 patients without) entered Phase 2. Each patient contributed only once to each phase, but some entered both phases on separate occasions. Ninety-five percent limits of agreement (mean +/- SD) were wide for all comparisons. Graphical plots revealed trends towards higher Escort values as mean values rose compared with both mini-Wright and turbine readings for peak expiratory flow rate and forced expiratory volume in one second. Possible over-reading of peak expiratory flow rate with the mini-Wright meter at low mean values was also seen. Readings taken with these different types of meter cannot be interchanged with confidence in clinical practice. The clinical significance of the theoretically more accurate measures of lung function produced with the new meter, and indeed of spirometry itself, needs further investigation.

A bibliography of the statistical analysis of vaginal bleeding patterns.

An annotated bibliography of 123 references and review papers on graphical description and statistical analysis of vaginal bleeding patterns is presented.

Proactive, nurse-run asthma care in general practice reduces asthma morbidity: scientific fact or medical assumption?

Nurse-run asthma care in general practice in the United Kingdom has become extremely common, particularly since the introduction of the 1990 contract for general practitioners, but there have been few controlled trials of the clinical effectiveness of this approach to asthma care. A study attempted to compare the outcome of asthma care over three years in two similar practices when one practice provided proactive, nurse-run care and the second continued with a traditional (reactive) approach, and to examine the process of care when such changes were introduced. Despite the investment of considerable resources, statistically significant differences could not be shown between the two practices using a comprehensive variety of outcome measures. This could be interpreted as meaning that nurse-run asthma care may be ineffective, but the negative outcome is much more likely to reflect difficulties in the manner in which the intervention practice sought to develop its service and in the research process. There were extensive methodological problems leading to a potential type 2 error. A randomized controlled trial of nurse-run asthma care would now be difficult to conduct, and so it may be necessary to accept nurse-run asthma care without definitive proof of its clinical effectiveness.

Audit of the effect of a nurse run asthma clinic on workload and patient morbidity in a general practice.

The aim of this study was to assess the effect of a nurse run asthma clinic on practice workload and the morbidity of patients in a four partner general practice. One hundred and fifteen asthmatic patients were studied and comparisons were made between the 12 months prior to the introduction of the clinic and the first 12 months after the clinic started. Morbidity was measured in terms of: the number of courses of oral steroids, the number of emergency salbutamol nebulizations, and the number of days lost from work or school. The number of consultations with the general practitioners were recorded. The repeat prescribing register was also monitored throughout the study to examine the effect of the clinic on prescribing in the practice. Consultations with general practitioners fell from a total of 818 to 414 during the study period (P less than 0.001). This was offset by 496 consultations with the nurse in the first 12 months of the clinic. As a result of attending the nurse clinic significant reductions (P less than 0.01) were found in the patients' requirements for courses of oral steroids, acute nebulizations and days lost from work or school. The results for the 46 children were similar to those for the 69 adults, confirming that the asthma clinic was effective for all ages. The clinic coincided with an increase in the number of patients receiving regular bronchodilator therapy and prophylactic medication. Eighty per cent of patients had their medication modified as a result of attending the clinic. The cost of prescribing remained remarkably stable.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison between primary care physiotherapy education/advice clinics and traditional hospital based physiotherapy treatment: a randomized trial.

BACKGROUND: Studies have shown that patients prefer to received physiotherapy services in the primary care setting, but none has made direct comparisons between hospital and primary care based physiotherapy. AIM: This pragmatic randomized trial set out to compare general-practice-based physiotherapy education and advice clinics with traditional physiotherapy treatment in an acute hospital setting. METHOD: The study involved 130 patients referred to physiotherapy services by 43 general practitioners over a one-year period. Patients were included in the study if they were at work, independent in all activities of daily living and would have routinely been referred to the hospital physiotherapy department for treatment. Patients were randomly allocated to one of two intervention groups: general practice education/advice, or treatment and education/advice at the local hospital. Patients completed a questionnaire prior to their first physiotherapy appointment and again 6 weeks later. RESULTS: A disappointing number of patients failed to attend either the first or subsequent appointments. The post-intervention scores revealed improvements in patients' problems, with the advice group exhibiting a slightly better outcome than the hospital group, as measured by the Nottingham health profile, the anxiety component of the hospital anxiety and depression rating scale, pain and problem size visual analogue scales, and measures of patient satisfaction. Advice group patients also had less attendances than the hospital treatment group. The general practitioners surveyed commented favourably on the advice clinics. CONCLUSIONS: The findings of this study justify the concept of general-practice-based physiotherapy education and advice clinics.

To what extent are the needs of severely disabled people met by community rehabilitation services? A follow-up study.

PURPOSE: To evaluate which needs of disabled people would be met over a one year follow-up period and to examine which factors would be predictive of identifying those people who had more needs met from those who had fewer needs met. METHOD: A follow-up study of a cohort of community dwelling disabled people (aged 16-65) from two NHS Health Districts in Southern England with contrasting patterns of rehabilitation provision, who had participated in a cross-sectional interview study one year previously which had assessed their met and unmet needs. The Southampton Needs Assessment Questionnaire was used to examine needs. Disability was evaluated with the OPCS Disability and Severity Scales and perceived health status with the SF-36. RESULTS: Participation rate at follow-up was 92 %. Of the 300 baseline unmet needs reported by 69 of the 77 participants 33% had been met at follow-up. People whose disability had increased more and/or whose mental health status had improved more had greater percentages of their baseline needs met. There was a non-significant trend for smaller percentages of baseline needs to be met in Basingstoke than in Southampton. CONCLUSIONS: At ground level, disabled people's views were taken into account, to some extent, in the provision of rehabilitation services. This input should be made at a higher level, in the overall shaping of services.

Met and unmet needs reported by severely disabled people in southern England.

PURPOSE: To examine the met and unmet needs for rehabilitation of disabled people living in the community in Southern England. METHOD: A cross sectional interview study of people with a primary physical disability, aged 1665. Disabled people were randomly selected from two existing disability registers, which comprised disabled people who had been identified by community rehabilitation services as being in need of regular surveillance by formal assessment of their care needs. A new semi-structured needs assessment questionnaire was developed and validated for the study (the Southampton Needs Assessment Questionnaire, SNAQ). Level of disability was examined with the OPCS Disability and Severity Scales. RESULTS: Ninety three disabled people participated. Their median (IQR) OPCS score was 8 (6-10). Participants reported a median (IQR) of three unmet needs (2-7). The most prevalent unmet needs were for adaptations, equipment, physiotherapy and wheelchairs, rather than unmet needs for intellectual and social fulfilment. CONCLUSIONS: Disabled people who were already in touch with community rehabilitation services continued to express unmet needs for further services. Meeting the more basic needs relating to people's housing, equipment, physiotherapy and wheelchairs may enable them to be more independent and fulfilled in other areas of their lives.