North Western Regional Health Authority Research Articles

Social determinants of GHQ score by postal survey.

To develop interventions to reduce the morbidity associated with depression and anxiety, more information is needed about the social and demographic determinants of these disorders and the relative contributions of different potential predictors. Using stratified sampling from the Family Health Services Authority (FHSA) register, postal surveys were sent to 61,000 adults across the North Western Regional Health Authority. Psychological morbidity was assessed using the 12-item General Health Questionnaire (GHQ). Nine potential predictors of morbidity were rated, including socio-demographic details and the presence of longstanding limiting physical illness and of a confidante. Logistic regression analyses were used to consider each of the nine potential predictors separately and in combination. A total of 38,014 questionnaires were returned (63 per cent). After adjustment for all other variables the strongest predictors of a high GHQ score were the absence of a confidante (odds ratio (OR) 3.64), longstanding limiting physical illness (OR 2.93), unemployment (OR 1.91), being a student (OR 1.78), being female (OR 1.64), single parenthood (OR 1.55) and living alone (OR 1.32). GHQ scores were highest in the 18-34 age range. Ethnicity exerted no significant effect after adjustment for other variables. In keeping with other research the data suggest that sociodemographic factors are strong predictors of depression and anxiety. The most vulnerable population groups are those with longstanding limiting physical illness and no-one to talk to. This should help in identifying high-risk individuals and informing preventive strategies.

Validation of the University of Manchester Drug Misuse Database.

OBJECTIVE: The study was conducted to assess the validity and quality of data held by one of the UK regional drug misuse databases (DMD). DESIGN: The research was multi-centred and...

Objective assessment of spatial vision using the visual evoked potential

Early assessment of the visual function is very important, as many congenital and acquired visual anomalies may lead to permanent visual loss, if not detected and effectively treated within the critical period of visual system development. Any tests employed to assess vision in infants should be objective and give a valid result quickly.The visual evoked potential (VEP) does not require active responses from the patient. It is recorded in relation to a time‐locked stimulus, typically a grating that reverses in phase (pattern reversal VEPs). Reversal VEPs have been used to estimate visual acuity. A more complete psychophysical description of the visual function is obtained with the contrast sensitivity function (CSF) which determines visibility not only of the finest detail, but also of a wide range of spatial frequencies. However, the VEP amplitude versus spatial frequency function does not accurately reflect the normal CSF when reversing gratings are employed. Reduced VEP responses are obtained in the middle spatial frequency range where stimulus visibility is highest.Here we show that 16 Hz on‐off modulation of a grating elicits a VEP versus spatial frequency plot which is similar to the CSF in a group of normal adults. When compared with reversal modulation, the test was more predictive of spatial vision defects in a group of amblyopes, thus demonstrating its clinical utility. We have shown that the same technique can be used to monitor age‐related changes in spatial vision in a group of infants whose ages ranged from 5 weeks to 14 months. The test promises to be a useful clinical tool in paediatric ophthalmology.Supported by a grant from the North Western Regional Health Authority.

Towards quality control in cancer chemotherapy.

A survey of all hospital pharmacies in the former North Western Regional Health Authority has revealed that hospital personnel continue to prepare cytotoxic drugs in suboptimal conditions, despite the widespread introduction of pharmacy cytotoxic reconstitution services. Other concerns include the lack of formal training for medical staff in the administration of these agents and the frequent absence of written procedures for dealing with extravasation and chemotherapy errors.

Is the three year breast screening interval too long? Occurrence of interval cancers in NHS breast screening programme's north western region.

To report the detection rate of interval cancers in women screened by the NHS breast screening programme. Detection of interval cancers by computer linkage of records held by the screening centres in the North Western Regional Health Authority with breast cancer registrations at the regional cancer registry. North Western Regional Health Authority. 137,421 women screened between 1 March 1988 and 31 March 1992 who had a negative screening result. 297 invasive interval cancers were detected. The rate of detection of interval cancers expressed as a proportion of the underlying incidence was 31% in the first 12 months after screening, 52% between 12 and 24 months, and 82% between 24 and 36 months. The incidence of interval cancers in the third year after breast screening approaches that which would have been expected in the absence of screening and suggests that the three year interval between screens is too long.

Patterns and temporal trends in the incidence of malignant disease in children: II. Solid tumours of childhood

Incidence patterns and trends, in children, of individual types of non-reticulo-endothelial solid tumours and of all cancers combined (including leukaemia and lymphoma) were analysed. The study included 3360 cases diagnosed in residents under 15 years of age of the North Western Regional Health Authority area of England during 1954–1988. Log-linear modelling identified significant increases of juvenile astrocytoma (average quinquennial increase 15%) in males, of medulloblastoma (19%) and neuroblastoma (17%) in females, and of non-skin epithelial tumours (18%) overall, and a significant decrease of unspecified malignant neoplasms around 1974 by approximately 80%. The χ 2 trend test identified significant increases in gonadal germ cell tumours and skin cancers, and borderline significant increases in craniopharyngioma and hepatoblastoma. The incidence of all cancers combined increased significantly in those aged under 1 year (8%), 1–4 years (5%) and 10–14 years (8%). Age-sex patterns were similar to those in other Caucasian populations. Studies of incidence trends can provide the basis for investigations of the aetiology of childhood cancers.

Patterns and temporal trends in the incidence of malignant disease in children: I. Leukaemia and lymphoma

Patterns and trends in incidence of leukaemia and lymphoma in children aged under 15 years and resident in the North Western Regional Health Authority area of England at diagnosis, over the 35-year time period 1954–1988, were analysed. The study included 1407 cases registered with the Manchester Children's Tumour Registry, 100% of which had a histologically or cytologically verified diagnosis. Log-linear modelling identified significant linear increases in acute lymphocytic leukaemia (ALL) (average quinquennial increase 4%) and Hodgkin's disease (HD) (10%), but not in acute non-lymphocytic leukaemia nor non-Hodgkin's lymphoma. Additionally, the χ 2 test for trend identified a significant increase in the incidence of chronic myeloid leukaemia. The possibility that the increases seen in ALL and HD are linked to increases in prevalence of unknown infectious agents is discussed.

Cancer in young people in the north of England, 1968-85: analysis by census wards.

To determine whether the seeming excess of childhood leukaemia and lymphoma identified in Seascale, Cumbria, UK, remains unusual when put into a wider context. Analysis of cancer incidence by geographical area. The north of England including the Northern and North Western Regional Health Authority regions and the Southport and South Sefton districts of the Mersey Regional Health Authority. Altogether 6686 cases of malignant disease in people under 25 years old. Cases of cancer diagnosed before their 25th birthday between January 1968 and December 1985 identified from three regional cancer registries were allocated to a census ward on the basis of 'usual place of residence'. Population data were derived from the 1971 and 1981 censuses, and the cancer incidence was calculated for each ward. Of the 6686 cases, there were 1035 cases of acute lymphoblastic leukaemia and 361 of non-Hodgkins lymphoma. Wards were ranked by cancer incidence and Poisson probability, using different population bases. Seascale ward is the most highly ranked ward for acute lymphoblastic leukaemia for the time periods 1968-85 or 1968-76. It is not the most highly ranked for non-Hodgkins lymphoma. However, combining acute lymphoblastic leukaemia and non-Hodgkins lymphoma incidence gives an even more extreme position for Seascale. The most extreme Poisson probability for any of the analyses was that for brain tumours in the electoral ward of Ashton St Michael, Tameside (p = 0.000009). The incidence of acute lymphoblastic leukaemia and non-Hodgkins lymphoma in the Seascale ward remains high when put into a wider context. For other cancers there are wards with even more extreme Poisson probability values.

Improving Health and Social Care in Mental Illness Services: A Survey of Health Service Managers in One Region of the UK

National directives in the UK aim to enhance community provision for mentally ill people. One of these initiatives, the Care Programme Approach (CPA) requires health and social services to develop a needs‐led approach; care plans for discharged patients; co‐ordinated “packages” of health and social care and information systems. A survey conducted in the North Western Regional Health Authority area confirms many of the findings of recent work and raises other issues for health and social services managers. These include the need to: recognize and alter bad clinical‐organizational practices; develop assessment and priority rating systems which combine health and social care variables; implement relevant and accessible information systems; and develop adequate, standardized outcome measures for mental health services.

Quality of life measures in health care. III: Resource allocation.

BMJ 1992;305:1205-9 In our two previous papers we discussed the use of measures of health related quality of life in clinical trials and in describing the health of populations.12 We now turn to the difficult issue of using quality of life measures for allocating limited resources among com? peting health care programmes. We concentrate on the quality adjusted life year (QALYs) since this approach has received most attention. QALYs use an index combining changes in survival and quality of life of patients (and possibly others) to assess benefit brought about by the funded programme. For each programme this benefit can be divided by its economic cost and the resulting ratio used to help allocate resources. QALYs can be used to choose between alternative programmes for treating the same patients or, more controversially, to choose among programmes targeted at different groups. The underlying philosophy is that rationing of resources is inevitable and so it is best that it is explicit and accountable.3 To ration effectively some measures of output from health care must be established. However, it is important to distinguish between such general issues, with which most may agree, and the actual techniques used in published studies, which have been greatly criticised. For example, Williams describes a method to assess current life expectancy and quality of life in which quality of life is assigned a value q on a 0 to 1 scale, 1 representing perfect health and 0 representing death.4 Each future year is then counted as worth q, with the possibility of discounting the value of future years in a similar manner to that used for future costs. The total QALYs for the group are estimated with and without the intervention, and the difference between the two estimates is a single composite measure of the marginal output of the programme. Williams emphasised the possible role of QALY analysis in the marginal allocation of additional resources, and North Western Regional Health Authority made an early unsuccessful attempt at allocating its discretionary specialties revenue reserve fund to its district health authorities.5 However, dis? trict health authorities are now considering such schemes6 at a more basic level, and in at least one case serious attempts are being made at implementation.7 In this article we focus on British applications, although the most extreme example of a QALY type analysis is that attempted in Oregon.8 Here 714 condition treat? ment pairs were placed in rank order and Oregon proposed to fund them from the Medicaid budget according to those ranks; the future of this project is now, however, in doubt. The QALY analyses arouse strong opinions. Critics have questioned the assumptions underlying the pro? cedure, doubted the quality of the data for calcula? tions, raised ethical objections concerning equity, and questioned whose values were relevant and whether it is reasonable to compare different numbers of different groups of people by a single index.914 Supporters of the QALY approach have said that current examples of QALY analysis are not definitive, that the method is still in development, and that it is intended only as an aid to decision making rather than a strict recipe.1517 The lack of an alternative procedure has also been emphasised.16 To clarify the arguments below we identify the stages necessary to introduce a QALY system for resource allocation. We discuss whether progress from stage to stage is technically feasible or ethically desir? able, and conclude with some recommendations for the appropriate future role of QALY type analyses.

The influence of increased age and age matching on graft survival after first cadaveric renal transplantation.

We examined the influence of donor and recipient age as well as close donor and recipient age matching by analysis of the actuarial survival of 397 consecutive first cadaveric renal transplants carried out in the years 1987 to 1990. Graft failure was defined as return to dialysis, transplant nephrectomy, or death of the recipient from any cause. Overall 1-, 2-, and 3-year actuarial graft survival was 87, 84, and 79%. No effect on graft survival in adult patients was seen of advanced age of either donor or recipient. The source of the donor whether from within or outside the North Western Regional Health Authority did not influence outcome whatever the donor age. Results from patients in whom the donor was within 5 years of the recipient's age were no different from those obtained when the age difference was greater than 5 years. These data do not support the hypothesis that close age matching influences graft survival. Age matching need not be used as a recipient selection criterion. As neither recipient nor donor age influenced early graft survival, consideration should be given to increasing the average age of both donors and recipients.

A Continuous Development Approach to Training Health Service Personnel Specialists

Competency analysis for training and development remains controversial and varied in both interpretation and application. Research for the North Western Regional Health Authority has led to the development of a self‐assessment method, using a job‐composite model as part of a continuous development approach to the training of personnel specialists.

The use of QALYs in health service planning

There has been substantial interest in recent years, among research workers and in health service management, in the potential use of quality-adjusted life years (QALYs) as an aid to decision-making about the development of services and use of resources in health services (Gudex, 1986; Drummond, 1986). In 1986 the North Western Regional Health Authority (RHA) initiated the first large-scale attempt to use QALYs as a practical aid to planning in the National Health Service. This paper draws on the experience of the North Western RHA in examining some methodological and practical issues relating to the future of QALYs as an aid to decision-making in the Health Service.

A review of occupational exposure in the North-Western Region.

The Ionizing Radiations Regulations 1985 require employers to monitor all classified persons and to demonstrate that all non-classified persons who work in controlled areas do not exceed three-tenths (i.e. the classification level) of any relevant annual dose limit. A review of occupational doses was undertaken to ascertain whether any person needed to be designated as a classified person and to demonstrate compliance with the Regulation regarding non-classified staff working in controlled areas. The occupational-dose data for 1986 were compared with data for 1981 to identify any areas where changes in workload, equipment or techniques had led to increases in whole-body or organ doses. The results demonstrate that the level of whole-body occupational dose received by the vast majority of NHS employees in the North-Western Regional Health Authority is, as expected, extremely low. However, two specific areas were identified where occupational doses are relatively high and need to be carefully monitored. The review has also led to a number of operational changes being implemented by the Approved Dosimetry Service.

Drug Innovation, Cost‐effectiveness and Management: The Case of Erythropoietin

Advances in recombinant drug technology will impose pressure for swift action by decision‐makers who may be required to operate on the basis of very limited information. This paper is the by‐product of a recently initiated North Western Regional Health Authority interim procedure designed to give swift consideration to innovations, to provide additional information for decision‐makers and to permit both clinicians and decision‐makers to combine in ensuring that greater rationality is applied to the introduction of drug innovations than might otherwise be the case. It is envisaged that this procedure will be of equal value in other areas where new medicines may have major revenue consequences.

Economic evaluation of six scenarios for the treatment of stones in the kidney and ureter by surgery or extra-corporeal shock wave lithotripsy

Health policy makers in the U.K. have had to respond to the advent of a new, high technology, method of treating stones. In order to assist the definition of an appropriate policy this evaluative study of the new technique was undertaken. The economic benefits of extracorporeal shock wave lithotripsy (ESWL) were compared with those of conventional open surgery for the treatment of upper urinary tract stones considering 6 possible ‘scenarios’, or intuitively plausible combinations of prices and levels of diffusion. It was concluded that second generation ESWL machines operated and financed at designated ‘stone centers’ by coalitions of health regions for a supra-regional population of about 12–15 million would be the most cost efficient option. Use of the currently available Dornier machine on the same supra-regional basis would be the, somewhat more expensive, second best option. These results, along with a range of supplementary documentation, were presented to both the national Department of Health and Social Security, and to the North Western Regional Health Authority. The NWRHA in turn presented its case to a supra-regional committee. The most cost-effective solution was adopted by this supra-regional committee.

Prediction of resources needed to achieve the national target for treatment of renal failure.

A model of the treatment of end stage renal failure has been primed with observed survival statistics and used to predict the steady state that will be achieved when the present annual target of at least 40 new patients per million population is in equilibrium with the death rate. The number of patients expected to receive each type of dialysis or a transplant is given per million of population. The personnel and facilities required to care for these patients and the costs of each programme were derived using analyses of workloads and costs in the North Western Regional Health Authority. The study has documented the considerable need for "back up" beds for patients on dialysis who require temporary care as inpatients. The cost effectiveness of transplantation has been demonstrated; at steady state it is calculated that each successful graft saves the service pounds 30,000. Implementation of the minister's minimum target requires a build up to some three times the resources currently allocated, with parallel increases in numbers of medical, nursing, and other essential staff.

Immunization against whooping cough in Salford: A spatial analysis

The decline in pertussis (whooping cough) immunization in the 1970s is related to public concern about the safety of the vaccine. The debates about its safety and effectiveness and the impact of vaccination on notifications are reviewed. A study is made of spatial variations in vaccine uptake within the metropolitan district of Salford, Greater Manchester, using data available at ward level. Salford as a whole has one of the lowest rates of uptake in the North Western Regional Health Authority, which itself has the lowest uptake in the country. Variations from ward to ward are noted and an attempt is made to account for these using Poisson regression. Both the number of children being immunized against pertussis and the number receiving diphtheria and tetanus vaccine (but foregoing the pertussis component) are used as dependent variables. Of the explanatory variables social class proves a useful predictor. However, the analysis is an ecological one and further work is called for at the scale of individual clinics in order to investigate health worker and parental attitudes and the accessibility constraints felt by those responsible for bringing children to clinics.

A survey of the use of Withington Hospital Medical Library*

Library use by the staff and students of a large teaching hospital was investigated by means of two questionnaire‐based surveys. The first survey aimed to identify the users and non‐users of the library, in order to assess to what extent the library fulfilled its role as a multidisciplinary library serving the information needs of all categories of hospital staff and students. In the second survey the use of library facilities was analysed with a view to establishing priorities for the future development of services. Although the library is popular with the majority of its users it became apparent during the investigation that the library could not hope to satisfy the growing information need of its users without the back‐up of an official regional library network in the North Western Regional Health Authority.