Lesley Jones

A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-86. 1. Methodology, demography and incident cases of first-ever stroke.

A prospective study of acute cerebrovascular disease in a community of about 105,000 people is reported. The study protocol combined rapid clinical assessment of patients with accurate diagnosis of the pathological type of stroke by CT or necropsy, whether or not they were admitted to hospital. The study population was defined as those people who were registered with one of 50 collaborating general practitioners (GPs). Referrals to the study were primarily from the GPs though, to ensure complete case ascertainment, hospital casualty and admission registers, death certificates and special data from the Oxford Record Linkage Study were also scrutinized. Six hundred and seventy five cases of clinically definite first-ever in a lifetime stroke were registered in four years yielding a crude annual incidence of 1.60/1,000 or 2.00/1,000 when adjusted to the 1981 population of England and Wales. The age and sex specific incidence rates for first stroke showed a steep rise with age for both sexes. The odds of a male sustaining a first stroke were 26% greater than those of a female. Ninety one per cent of patients were examined in a median time of four days after the event by a study neurologist and 88% had cerebral CT or necropsy.

Effectiveness of health checks conducted by nurses in primary care: Results of the OXCHECK study after one year

Abstract Objective : To assess the effectiveness of health checks by nurses in reducing risk factors for cardiovascular disease in patients from general practice. Design : Randomised controlled trial. Setting : Five urban general practices in Bedfordshire. Subjects : 2136 patients receiving an initial health check in 1989-91 and scheduled to be re-examined one year later in 1990-2 (intervention group); 3988 patients receiving an initial health check in 1990-2 (control group). All patients were aged 35-64 years at recruitment in 1989. Main outcome measures : Serum total cholesterol concentration, blood pressure, body mass index, confirmed smoking cessation. Results : Mean serum total cholesterol was 2.3% lower in the intervention group than in the controls (difference 0.14 mmol/l (95% confidence interval 0.08 to 0.20)); the difference was greater in women (3.2%, P<0.0001) than men (1.0%, P=0.18). There was no significant difference in smoking prevalence, quit rates, or body mass index. Systolic and diastolic blood pressure were 2.5% and 2.4% lower respectively in the intervention group. The proportion of patients with diastolic blood pressure >=100 mm Hg was 2.6% (55/2131) in the intervention group and 3.4% (137/3987) in the controls (difference 0.9% (0.0 to 1.7); the proportion with total cholesterol concentration >=8 mmol/l 4.8% (100/2068) and 7.6% (295/3905) (difference 2.7% (1.5 to 4.0)); and that with body mass index >=30 12.4% (264/2125) and 14.0% (559/3984) (difference 1.6% (-0.2 to 3.4)). Conclusion : General health checks by nurses are ineffective in helping smokers to stop smoking, but they help patients to modify their diet and total cholesterol concentration. The public health importance of this dietary change depends on whether it is sustained.

A randomized controlled trial of cervical cerclage in women at high risk of spontaneous preterm delivery

Summary. The effect of cervical suture on pregnancy outcome was studied in 194 women with a high risk (approximately 30%) of having a late abortion or a preterm delivery. The women were randomly allocated either to have a cervical suture inserted (n=96) or to be managed without a suture (n=98). There was no evidence that cervical cerclage either prolonged gestation or improved survival. Patients allocated to receive cerclage spent significantly longer in hospital, even when the period of admission for insertion was excluded. The patients in the cerclage group were more likely to receive tocolytic drugs, and more of them experienced puerperal pyrexia, although these differences between the groups were not statistically significant.

Atrial fibrillation and stroke: prevalence in different types of stroke and influence on early and long term prognosis (Oxfordshire community stroke project)

OBJECTIVE--To determine in patients with first ever stroke whether atrial fibrillation influences clinical features, the need to perform computed tomography, and prognosis. DESIGN--Observational cohort study with maximum follow up of 6.5 years. SETTING--Primary care, based on 10 general practices in urban and rural Oxfordshire. SUBJECTS--Consecutive series of 675 patients with first ever stroke registered in the Oxfordshire community stroke project. MAIN OUTCOME MEASURES--Prevalence of atrial fibrillation by type of stroke; effect of atrial fibrillation on case fatality rate and risk of recurrent stroke, vascular death, and death from all causes. RESULTS--Prevalence of atrial fibrillation was 17% (95% confidence interval 14% to 20%) for all stroke types (115/675), 18% (15% to 21%) for cerebral infarction (97/545), 11% (4% to 11%) for primary intercerebral haemorrhage (7/66), and 0% (0 to 11%) for subarachnoid haemorrhage (0/33). For patients with cerebral infarction the 30 day case fatality rate was significantly higher with atrial fibrillation (23%) than with sinus rhythm (8%); the risk of early recurrent stroke (within 30 days) was 1% with atrial fibrillation and 4% with sinus rhythm. In patients who survived at least 30 days the average annual risk of recurrent stroke was 8.2% (5.9% to 10.9%) with sinus rhythm and 11% (6.0% to 17.3%) with atrial fibrillation. CONCLUSIONS--After a first stroke atrial fibrillation was not associated with a definite excess risk of recurrent stroke, either within 30 days or within the first few years. Survivors with and without atrial fibrillation had a clinically important absolute risk of further serious vascular events.

Regional variations in the use of common surgical procedures: Within and between England and Wales, Canada and the United States of America

Abstract The regional variations in age/sex standardized rates of common surgical operations in three countries are examined. Large differences between these countries are noted and possible explanations are examined. In England and Wales the extent to which particular surgical rates are related to indices of medical supply by Regional Health Authority are examined in detail. Overall hospital sector funding, relative to norms of medical “need”, are seen to be strongly positively related to many operation rates indicating a dependence on supply factors. The role of manpower levels in explaining utilization rates is examined in some detail to compare with empirical observations made in North America. Generally in a National Health Service context numbers of surgeons or general practitioners are not as strongly related as in the United States. Finally these observations are examined in the context of previous work particularly on the role and nature of supply or induced demand.

Health checks in general practice: another example of inverse care?

OBJECTIVE--To assess attendance at and the characteristics of patients attending health checks for cardiovascular disease offered in a general practice over a period of five years (1984-9). DESIGN--Medical record audit and postal questionnaire survey. SETTING--One general practice in Oxfordshire with a socially diverse population. PARTICIPANTS--1101 Men and 1110 women aged 35-64 registered with the practice. MAIN OUTCOME MEASURES--Age, sex, marital state, social class, smoking habits, alcohol consumption, and diet. RESULTS--Of the 2211 men and women in the target age group (35-64) in 1989, 1458 (65.9%) had been offered screening and 963 (43.6%) had attended for a health check. Attenders were more likely to be women, aged greater than or equal to 45, married, non-smokers, and of higher social class than patients who did not respond to the invitation. The relative likelihood of non-attendance was 1.24 for smokers, 1.20 for the overweight, 1.16 for heavy drinkers, and 1.28 for those with a less healthy diet, even after adjustment for age, sex, marital state, and social class. CONCLUSIONS--After five years of offering health checks, opportunistically (to men) and in the context of cervical smear tests (to women), less than half of the eligible patients had attended. The likelihood of acceptance of an invitation to attend was inversely related to the patients cardiovascular risk for all factors measured except age. A coherent strategy to reduce cardiovascular disease depends on more careful targeting of scarce health service resources and more emphasis on public health measures (such as dietary regulation and tobacco taxation). Doctors should be careful not to absolve the government of its public health obligations by substituting unproved preventive interventions aimed at the individual patient.

Costs and cost effectiveness of health checks conducted by nurses in primary care: the Oxcheck study.

Abstract Objective: To measure the costs and cost effectiveness of the Oxcheck cardiovascular risk factor screening and intervention programme. Design: Cost effectiveness analysis of a randomised controlled trial using clinical and economc data taken from the trial. Setting: Five general practices in Luton and Dunstable, England. Subjects: 2205 patients who attended a health check in 1989-90 and were scheduled for re-examination in 1992-3 (intervention group); 1916 patients who attended their initial health check in 1992-3 (control group). Participants were men and women aged 35-64years. Intervention: Health check conducted by nurse, with health education and follow up according to degree of risk. Main outcome measures: Cost of health check programme; cost per 1 % reduction in coronary risk. Results: Health check and follow up cost £29.27 per patient. Estimated programme cost per 1% reduction in coronary risk per participant was between £1.46 and £2.25; it was nearly twice as much for men as women. Conclusions: The cost to the practice of implementing Oxcheck-style health checks in an average sized practice of 7500 patients would be £47 000, a proportion of which could be paid for through staff pay reimbursements and Band Three health promotion target payments. This study highlights the considerable difficulties faced when calculating the costs and benefits of a health promotion programme. Economic evaluations should be integrated into the protocols of randomised controlled trials to enable judgments to be made on the relative cost effectiveness of different prevention strategies. Key messages Research was undertaken to estimate the cost of the health checks and relate the cost to changes in the relative risk of cardiovascular disease The immediate cost of implementing Oxcheck-style health checks in an average sized practice of 7500 patients would be £47 000, which is comparable with the immediate cost of a cervical screening programme The actual costs to the practice would be substantially reduced by staff pay reimbursements and health promotion target payments Further research is required to estimate the wider costs of health checks resulting from the additional use of health care services

Dietary questions as determinants of mortality: the OXCHECK experience.

OBJECTIVE To determine whether responses to simple dietary questions are associated with specific causes of death. DESIGN Self-reported frequency intakes of various classes of foods and data on confounding factors were collected at the baseline survey. Death notifications up to 31 December 1997 were ascertained from the Office for National Statistics. Relative risk (RR) of death and 95% confidence intervals (CI) associated with baseline dietary factors were calculated by Cox regression. SETTING Prospective follow-up study based on five UK general practices. SUBJECTS Data were used from 11,090 men and women aged 35-64 years (81% of the eligible patient population) who responded to a postal questionnaire in 1989. RESULTS After 9 years of follow-up, 598 deaths were recorded, 514 of these among the 10,522 subjects with no previous history of angina. All-cause mortality was positively associated with age, smoking and low social class, as expected. Among the dietary variables, all-cause mortality was significantly reduced in participants who reported relatively high consumption of vegetables, puddings, cakes, biscuits and sweets, fresh or frozen red meat (but not processed meat), among those who reported using polyunsaturated spreads and among moderate alcohol drinkers. These associations were broadly similar for deaths from ischaemic heart disease (IHD), cancer and all other causes combined, and were not greatly attenuated by adjusting for potential confounding factors including social class. CONCLUSIONS Responses to simple questions about nutrition were associated with mortality. These findings must be interpreted with caution since residual confounding by dietary and lifestyle factors may underlie the associations.

Use of computerised general practice data for population surveillance: comparative study of influenza data

OBJECTIVE--To assess the potential for using routine computerised general practice data for surveillance of illness. DESIGN--Comparison of the incidence of influenza during the 1989 epidemic derived from a computerised database with that derived from the Royal College of General Practitionerss weekly returns service--a well established predominantly manual surveillance system. SETTING--433 general practices throughout the United Kingdom that used a commercial computer system linked to a central databank. MAIN OUTCOME MEASURE--Incidence of influenza. RESULTS--The slope of the influenza epidemic curve was essentially the same whether derived from the routine computerised data or royal colleges weekly returns service data, and the computerised data were geographically consistent. Throughout the study period, however, the computer derived incidence was between one third and one quarter of that derived from the royal colleges system (which is served by practitioners trained in surveillance methods). The peak weekly rates were 164 cases per 100,000 for the computerised system and 583 cases per 100,000 for the royal colleges surveillance system. CONCLUSIONS--The apparent underreporting in the routine computerised data probably reflects lack of motivation and experience in disease surveillance and haphazard computer entry (particularly of consultations that took place outside of the surgery and consultations that did not result in a prescription), along with overestimation of the population under surveillance. Nevertheless, routine computerised surveillance allows rapid data collection from a large number of practices over a wide geographical area and would greatly augment existing methods.

The "Help Your Patient Stop" initiative. Evaluation of smoking prevalence and dissemination of WHO/UICC guidelines in UK general practice.

The World Health Organisation and the International Agency against Cancer in 1988 published joint guidelines on smoking cessation for primary health care teams. A booklet entitled Help Your Patient Stop was produced in the United Kingdom as a model for the international dissemination of these guidelines. This booklet was sent to UK general practitioners by post; about 4 weeks later, a random sample of 5000 were asked to complete a postal questionnaire about the booklet and their smoking habits. The response rate was 75%. About half (50.5%) remembered receiving the booklet, 27.7% had read it, and only 8.8% could write down any of the three essential activities in smoking cessation which the booklet was intended to promote and which were printed in bold letters on the inside back cover. Although the booklet itself might be an adequate model for other countries, unless dissemination and marketing of the information it contains can be improved, its achievement will be limited. However, the survey did have one optimistic feature: only 13.5% of general practitioners reported that they smoke; and only a third of those who gave full details of their smoking habit smoke cigarettes.