Charles R Gillis, David J Hole
Abstract
Objective - To compare survival outcome for patients with breast cancer cared for by specialist and non-specialist surgeons in a geographically defined area.
Design - Retrospective study of all female patients aged under 75 years in the area treated between 1980 and June 1988 (before breast screening began). Patients were identified from the cancer registry and from pathology records of all hospitals in the area. Specialist surgeons were identified by one author. All other surgeons caring for patients from the area were considered non-specialists.
Setting - A geographically defined population in urban west of Scotland.
Subjects - 3786 patients with histologically verified breast cancer operated on between 1 January 1980 and 30 June 1988 and followed to 31 December 1993.
Main outcome measures - Five and 10 year survival rates for specialists and non-specialists; relative hazard ratios derived from Cox's proportional hazards model adjusted for prognostic factors - age, socioeconomic status, tumour size, and nodal involvement.
Results - The five year survival rate was 9% higher and the 10 year survival 8% higher for patients cared for by specialist surgeons. A reduction in risk of dying of 16% (95% confidence interval 6% to 25%) was found after adjustment for age, tumour size, socioeconomic status, and nodal involvement. The benefit of specialist care was apparent for all age groups, for small and large tumours, and for tumours that did and did not affect the nodes and was consistent across all socioeconomic categories.
Conclusions - Survival differences of the magnitude demonstrated have implications for the provision of services for the treatment of women with breast cancer. There is a need to improve equity in the treatment of breast cancer.
West of Scotland Cancer Surveillance Unit Ruchill Hospital Glasgow G20 9NB Charles R Gillis director David J Hole principal epidemiologist
Correspondence to: Dr Gillis.
Prevention of respiratory complications after abdominal surgery: a randomised clinical trial
John C Hall, Richard A Tarala, Jeff Tapper, Jane L Hall
Abstract
Objective - To evaluate the prevention of respiratory complications after abdominal surgery by a comparison of a global policy of incentive spirometry with a regimen consisting of deep breathing exercises for low risk patients and incentive spirometry plus physiotherapy for high risk patients.
Design - Stratified randomised trial.
Setting - General surgical service of an urban teaching hospital.
Patients - 456 patients undergoing abdominal surgery. Patients less than 60 years of age with an American Society of Anesthesia classification of 1 were considered to be at low risk.
Outcome measures - Respiratory complications were defined as clinical features consistent with collapse or consolidation, a temperature above 38°C, plus either confirmatory chest radiology or positive results on sputum microbiology. We also recorded the time that staff devoted to prophylactic respiratory therapy.
Results - There was good baseline equivalence between the groups. The incidence of respiratory complications was 15% (35/231) for patients in the incentive spirometry group and 12% (28/225) for patients in the mixed therapy group (P equals 0.40; 95% confidence interval -3.6% to 9 0%). It required similar amounts of staff time to provide incentive spirometry and deep breathing exercises for low risk patients. The inclusion of physiotherapy for high risk patients, however, resulted in the utilisation of an extra 30 minutes of staff time per patient.
Conclusions - When the use of resources is taken into account, the most efficient regimen of prophylaxis against respiratory complications after abdominal surgery is deep breathing exercises for low risk patients and incentive spirometry for high risk patients.
University Department of Surgery Royal Perth Hospital Perth WA 6000 Australia John C Hall associate professor of surgery Richard A Tarala head of respiratory medicine Jeff Tapper deputy superintendent of physiotherapy Jane L Hall researchnurse
Correspondence to: Professor Hall.
Depression and other psychiatric morbidity in carers of elderly people
Gill Livingston, Monica Manela, Cornelius Katona
Abstract
Objective - To describe the mental health of a community sample of carers of elderly people with dementia, depression, or physical disability and to compare that with the mental health of other adults living in the household and of those living alone.
Design - Assessment of psychiatric morbidity and physical disability with standardised questionnaire in randomly selected enumeration districts; subjects were interviewed at home.
Setting - London Borough of Islington.
Subjects - 700 people aged at least 65 and other coresidents.
Main outcome measure - Depression measured with standardised interview.
Results - The prevalence of depression was not significantly higher in carers overall (15%) than in coresidents (11%). Being a woman carer was a significant predictor of psychiatric illness. Depression was more common in the carers of people with a psychiatric disorder than in coresidents (24% v 11%, P less than 0.05) and in those living alone (19%). Depression was most common (47%) in women carers of people with dementia.
Conclusion - The increase in psychiatric morbidity reported in carers of people with psychiatric disorders may reflect the lack of a confiding relation ship.
Department of Psychiatry University College London Medical School London W1N 8AA Gill Livingston senior lecturer in psychiatry Monica Manela research assistant Cornelius Katona professor of psychiatry of the elderly
Correspondence to: Dr Livingston.
Fetal growth and cardiovascular risk factors in Jamaican schoolchildren
Terrence E Forrester, Rainford J Wilks, Franklyn I Bennett, Donald Simeon, Clive Osmond, Mureen Allen, Andrene P Chung, Paul Scott
Abstract
Objective - To determine relation between schoolchildren's blood pressure, glycated haemoglobin level, and cholesterol concentration and their anthropometry, socioeconomic status, and birth measurements.
Design - Retrospective cohort study.
Setting - 27 schools closest to University Hospital of the West Indies, Kingston, Jamaica.
Subjects - 2,337 children aged 6-16 years who were born at university hospital were recruited, and their birth records were recovered: 1,610 had suitable records, 659 had records including birth length, and 610 of these were prepubertal.
Main outcome measures - Blood pressure, glycated haemoglobin level, serum cholesterol concentration, anthropometry at birth, current anthropometry, and socioeconomic status.
Results - Multiple regression analysis showed that children's systolic blood pressure was inversely related to their birth weight (P less than 0.0001) and directly related to their current weight. Glycated haemoglobin level was higher in children with thicker triceps skinfolds (P less than 0.001) and who had been shorter at birth (P equals 0.003). Serum cholesterol concentration was inversely related to current height (P equals 0.001) and to length at birth (P equals 0.09) and was directly related to triceps skinfold thickness and higher socioeconomic status (P less than 0.001).
Conclusions - Blood pressure in childhood was inversely related to birth weight and directly to current weight. Glycaemic control and serum cholesterol were related to short length at birth, height deficit in childhood, and childhood obesity.
Tropical Metabolism Research Unit University of the West Indies Mona Kingston 7 Jamaica Terrence E Forrester director Rainford J Wilks lecturer Franklyn I Bennett senior lecturer Donald Simeon lecturer Mureen Allen research fellow Andrene P Chung research fellow Paul Scott research fellow
Medical Research Council Environmental Epidemiology Unit University of Southampton Southampton General Hospital Southampton S09 4XY Clive Osmond statistician
Correspondence to: Dr Forrester.
Alternatives to hospital care: what are they and who should decide?
Joanna Coast, Abby Inglis, Stephen Frankel
Abstract
Objective - To examine potential for alternatives to care in hospitals for acute admissions, and to compare the decisions about these alternatives made by clinicians with different backgrounds.
Design - Standardised tool was used to identify patients who could potentially be treated in an alternative form of care. Information about such patients was assessed by three panels of clinicians: general practitioners without experience of general practitioner beds, general practitioners with experience of general practitioner beds, and consultants.
Setting - One hospital for acute admissions in a rural area of the South and West region of England.
Subjects - Of 620 patients admitted to specialties of general medicine and care of the elderly, details of 112 were assessed by panels.
Main outcome measures - Proportion of hospitalised patients who could have received alternative care and identification of most appropriate alternative form of care.
Results - Both general practitioner panels estimated that between 51 and 89 of the hospitalised patients could have received alternative care (equivalent to 8-14% of all admissions). Consultants estimated that between 25 and 55 patients could have had alternative care (5.5-9% of all admissions). General practitioner bed and urgent outpatient appointment were the main alternatives chosen by all three panels.
Conclusion - About 10% of admissions to general hospital might be suitable for alternative forms of care. Doctors with different backgrounds made similar overall assessments of most appropriate forms of care.
Department of Social Medicine University of Bristol Bristol BS8 2PR Joanna Coast lecturer in health economics Abby Inglis research associate Stephen Frankel professor of epidemiology and public health medicine
Correspondence to: Ms Coast.