Lindsay Groom

Randomised controlled trial of an occupational therapy intervention to increase outdoor mobility after stroke

Abstract Objective To evaluate an occupational therapy intervention to improve outdoor mobility after stroke. Design Randomised controlled trial. Setting General practice registers, social services departments, a primary care rehabilitation service, and a geriatric day hospital. Participants 168 community dwelling people with a clinical diagnosis of stroke in previous 36 months: 86 were allocated to the intervention group and 82 to the control group. Interventions Leaflets describing local transport services for disabled people (control group) and leaflets with assessment and up to seven intervention sessions by an occupational therapist (intervention group). Main outcome measures Responses to postal questionnaires at four and 10 months: primary outcome measure was response to whether participant got out of the house as much as he or she would like, and secondary outcome measures were response to how many journeys outdoors had been made in the past month and scores on the Nottingham extended activities of daily living scale, Nottingham leisure questionnaire, and general health questionnaire. Results Participants in the treatment group were more likely to get out of the house as often as they wanted at both four months (relative risk 1.72, 95% confidence interval 1.25 to 2.37) and 10 months (1.74, 1.24 to 2.44). The treatment group reported more journeys outdoors in the month before assessment at both four months (median 37 in intervention group, 14 in control group: P < 0.01) and 10 months (median 42 in intervention group, 14 in control group: P < 0.01). At four months the mobility scores on the Nottingham extended activities of daily living scale were significantly higher in the intervention group, but there were no significant differences in the other secondary outcomes. No significant differences were observed in these measures at 10 months. Conclusion A targeted occupational therapy intervention at home increases outdoor mobility in people after stroke.

Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey.

Abstract Objectives: To investigate the relation between out of hours activity of general practice and accident and emergency services with deprivation and distance from accident and emergency department. Design: Six month longitudinal study. Setting: Six general practices and the sole accident and emergency department in Nottingham. Subjects: 4745 out of hours contacts generated by 45 182 patients from 23 electoral wards registered with six practices. Main outcome measures: Rates of out of hours contacts for general practice and accident and emergency services calculated by electoral ward; Jarman and Townsend deprivation scores and distance from accident and emergency department of electoral wards. Results: Distances of wards from accident and emergency department ranged from 0.8 to 9 km, and Jarman deprivation scores ranged from −23.4 to 51.8. Out of hours contacts varied by ward from 110 to 350 events/1000 patients/year, and 58% of this variation was explained by the Jarman score. General practice and accident and emergency rates were positively correlated (Pearson coefficient 0.50, P=0.015). Proximity to accident and emergency department was not significantly associated with increased activity when deprivation was included in regression analysis. One practice had substantially higher out of hours activity (B coefficient 124 (95% confidence interval 67 to 181)) even when deprivation was included in regression analysis. Conclusions: A disproportionate amount of out of hours workload fell on deprived inner city practices. High general practice and high accident and emergency activity occurred in the same areas rather than one service substituting for the other. Key messages We studied the out of hours activity of six general practices and the local accident and emergency department in Nottingham for six months There were wide variations between electoral wards in both general practice and accident and emergency events Deprivation scores explained more than half of the variation, with out of hours activity being highest in deprived inner city areas Highly deprived areas close to the accident and emergency department generated high levels of work for both general practice and accident and emergency services, with no evidence of one service substituting for the other

Age and proximity to death as predictors of GP care costs: results from a study of nursing home patients

This paper reports the results of a study of GP costs associated with a group of nursing home patients who died at various stages during a 12-month period. The relationship between costs per month of care, patient age and proximity to death, where sex and diagnosis are controlled for are reported. A comparison of care costs for patients in their last year of life and those who survived the course of the study is also made. The study found that those in their last year of life were significantly more expensive to care for than those who survived the duration of the study, but that there was no statistically significant difference in age. In multivariate regression analyses, it was also found that among those who died during the study care costs were unrelated to age, but significantly related to proximity to death. The study supports the contention of others (Zweifel P, Felder S, Meiers M. Ageing of population and health care expenditure: a red herring? Health Econ 1999; 8: 485-496) that health care costs are more directly related to proximity to death than age.

Inequalities in hospital admission rates for unintentional poisoning in young children

Objective: To determine the relationship between deprivation and hospital admission rates for unintentional poisoning, by poisoning agent in children aged 0–4 years. Design: Cross sectional study of routinely collected hospital admissions data. Setting: East Midlands, UK. Participants: 1469 admissions due to unintentional poisoning over two years. Main outcome measure: Hospital admission rates for unintentional poisoning. Incidence rate ratios (IRRs) comparing hospital admission rates for poisoning in the most and least deprived electoral wards. Results: Children in the most deprived wards had admission rates for medicinal poisoning that were 2–3 times higher than those in the least deprived wards (IRR 2.49, 95% CI 1.87 to 3.30). Admission rates for non-medicinal poisoning were about twice as high in the most compared to the least deprived wards (IRR 1.77, 95% CI 1.19 to 2.64). Deprivation gradients were particularly steep for benzodiazepines (IRR 5.63, 95% CI 1.72 to 18.40), antidepressants (IRR 4.58, 95% CI 1.80 to 11.66), cough and cold remedies (IRR 3.93, 95% CI 1.67 to 9.24), and organic solvents (IRR 3.69, 95% CI 1.83 to 7.44). Conclusions: There are steep deprivation gradients for admissions to hospital for childhood poisoning, with particularly steep gradients for some psychotropic medicines. Interventions to reduce these inequalities should be directed towards areas of greater deprivation.

Risk Watch: cluster randomised controlled trial evaluating an injury prevention program.

Objective: to evaluate the effectiveness of a school-based injury prevention program. Design: Cluster randomised controlled trial. Setting: 20 primary schools in Nottingham, UK. Participants: 459 children aged 7 to 10 years. Intervention: The “Risk Watch” program delivered by teachers, aimed at improving bike and pedestrian, falls, poisoning and fire and burns safety. Main outcome measures: Safety knowledge, observed safety skills and self-reported safety behaviour. Results: At follow-up, intervention group children correctly answered more fire and burn prevention knowledge questions than control group children (difference between means 7.0% (95% CI 1.5% to12.6%)). Children in intervention group schools were more likely to know the correct actions to take if clothes catch fire and the correct way to wear a cycle helmet (difference between school means 35.3% (95% CI 22.7% to 47.9%) and 6.3% (95% CI 1.4% to 11.1%) respectively). They were also more likely to know the correct actions to take in a house fire and on finding tablets (OR 2.80 (95% CI 1.08 to 7.22) and OR 3.50 (95% CI 1.18 to 10.38) respectively) and correctly demonstrated more safety skills than control group children (difference between means 11.9% (95% CI 1.4% to 22.5%)). There was little evidence to suggest the first year of the program impacted on self-reported safety behaviours. Conclusions: The Risk Watch program delivered by teachers in primary schools increased some aspects of children’s safety knowledge and skills and primary schools should consider delivering this program. Longer term, larger scale evaluations are required to examine retention of knowledge and skills and impact on safety behaviours and child injury rates.

The UK Burden of Injury Study – a protocol. [National Research Register number: M0044160889]

BackgroundGlobally and nationally large numbers of people are injured each year, yet there is little information on the impact of these injuries on peoples lives, on society and on health and social care services. Measurement of the burden of injuries is needed at a global, national and regional level to be able to inform injured people of the likely duration of impairment; to guide policy makers in investing in preventative measures; to facilitate the evaluation and cost effectiveness of interventions and to contribute to international efforts to more accurately assess the global burden of injuries.Methods/DesignA prospective, longitudinal multi-centre study of 1333 injured individuals, atttending Emergency Departments or admitted to hospital in four UK areas: Swansea, Surrey, Bristol and Nottingham. Specified quotas of patients with defined injuries covering the whole spectrum will be recruited. Participants (or a proxy) will complete a baseline questionnaire regarding their injury and pre-injury quality of life. Follow up occurs at 1, 4, and 12 months post injury or until return to normal function within 12 months, with measures of health service utilisation, impairment, disability, and health related quality of life. National estimates of the burden of injuries will be calculated by extrapolation from the sample population to national and regional computerised hospital in-patient, emergency department and mortality data.DiscussionThis study will provide more detailed data on the national burden of injuries than has previously been available in any country and will contribute to international collaborative efforts to more accurately assess the global burden of injuries. The results will be used to advise policy makers on prioritisation of preventive measures, support the evaluation of interventions, and provide guidance on the likely impact and degree of impairment and disability following specific injuries.

Randomised controlled trial of thermostatic mixer valves in reducing bath hot tap water temperature in families with young children in social housing

Objectives To assess the effectiveness of thermostatic mixing valves (TMVs) in reducing bath hot tap water temperature, assess acceptability of TMVs to families and impact on bath time safety practices. Design Pragmatic parallel arm randomised controlled trial. Setting A social housing organisation in Glasgow, Scotland, UK. Participants 124 families with at least one child under 5 years. Intervention A TMV fitted by a qualified plumber and educational leaflets before and at the time of TMV fitting. Main outcome measures Bath hot tap water temperature at 3-month and 12-month post-intervention or randomisation, acceptability, problems with TMVs and bath time safety practices. Results Intervention arm families had a significantly lower bath hot water temperature at 3-month and 12-month follow-up than families in the control arm (3 months: intervention arm median 45.0°C, control arm median 56.0°C, difference between medians, −11.0, 95% CI −14.3 to −7.7); 12 months: intervention arm median 46.0°C, control arm median 55.0°C, difference between medians −9.0, 95% CI −11.8 to −6.2) They were significantly more likely to be happy or very happy with their bath hot water temperature (RR 1.43, 95% CI 1.05 to 1.93), significantly less likely to report the temperature as being too hot (RR 0.33, 95% CI 0.16 to 0.68) and significantly less likely to report checking the temperature of every bath (RR 0.84, 95% CI 0.73 to 0.97). Seven (15%) intervention arm families reported problems with their TMV. Conclusions TMVs and accompanying educational leaflets are effective at reducing bath hot tap water temperatures in the short and longer term and are acceptable to families. Housing providers should consider fitting TMVs in their properties and legislators should consider mandating their use in refurbishments as well as in new builds.

Is there a role for computerized decision support for drug dosing in general practice? A questionnaire survey

Objective: To determine: (i) whether general practitioners have difficulty with drug dosing; (ii) what information sources they currently use to help them with drug dosing; (iii) their views on the potential value of decision support software for drug dosing.

The impact of nursing home patients on prescribing costs in general practice.

Objectives: To compare the costs of prescribing for older people in nursing homes with older people living at home and to compare patterns of prescribing between these two groups.

Recruiting participants for injury studies in emergency departments

Emergency departments have the potential to maximize recruitment efficiency and minimize recruiting costs For many studies, especially those requiring incident injury cases, emergency departments are the most suitable location for recruiting participants.1 Although the total number of injury attendances is greater in outpatient or primary care settings than in emergency departments,2 geographical spread and the mixture of incident and prevalent cases make recruiting participants from these sites less feasible, more time consuming and more costly. Emergency departments, on the other hand, will see the largest number and spectrum of injury cases, usually presenting very shortly after injury in a single healthcare setting. This has the potential to maximize recruitment efficiency and minimize recruiting costs. Recruiting in emergency departments also provides opportunities to study the aetiology and epidemiology of injuries before recall of events diminishes with time and to enroll participants for studying short- and long-term consequences of injury. They are the only setting in which complete ascertainment of incident cases of specific injuries may be possible—for example, virtually all patients with long bone fractures will attend an emergency department, fewer will attend primary care and a proportion will be admitted to hospital, but this will vary between hospitals depending on a range of factors including clinician preference for management options, bed availability, social circumstances.3,4 Recruiting cases from emergency departments therefore, has the potential to minimize the selection bias inherent in recruiting such cases from other sites. Inspite of the potential for recruiting injured patients to studies within emergency departments, there are characteristics of the clinical setting and of injured patients which may make recruitment difficult. Emergency departments are often busy and crowded places, and the demand for emergency care continues to increase.5 Many emergency departments experience shortfalls in medical staffing and difficulties in recruiting and …