bluuebunny/crossref_metadata_2025_split huggingface dataset:
OP96 Survey of use and Application of test Accuracy Measures for Decision Making in Primary Care
Authors: Davenport CF , Hyde CJ 
Published: September 2012

BackgroundIncrease in test use over recent decades has occurred despite disappointing results from test accuracy evaluations. Difficulties with understanding and application of test accuracy information are purported to be important contributors to this observed evidence ‘gap’. Empirical research to date is based on the premise that formal probability revision is a necessary pre-requisite for informed diagnostic decison making and is characterised by self selected samples with recent experience or expertise in test evaluation. The survey aims were to describe how clinicians apply existing test accuracy metrics for diagnostic decision making.MethodsAn incentivised, electronic survey was used. Informed application of test accuracy information was evaluated by asking respondents to indicate their management decision following presentation of nine different representations of the same test accuracy information to a common hypothetical scenario. Quantitative and qualitative synthesis was employed based on closed and open responses to management decisions.ResultsA total of 204 General Practitioners (response rate 95%) did not appear to be self-selected on the basis of academic position, involvement in policy or experience in test evaluation. Sensitivity and specificity, the annotated 2x2 diagnostic table and predictive values were reported to be familiar metrics by the most respondents. Likelihood ratios the DOR and AUC were familiar to less than 1/3 of respondents. Application of test accuracy metrics resulted in marked variation in responses to both positive and negative test results although greater inconsistency and management uncertainty was observed following presentation of a negative test result. Formal probability revision was not a feature of the diagnostic decision making process. Test errors (false negatives and false positives) were prominent as part of the translational pathway from quantitative summary estimates of test accuracy to management decisions. Summary measures that separate the two dimensions of test accuracy in the absence of prevalence information (for example sensitivity and specificity) appeared to result in a misplaced emphasis on one or other of false positive or false negative test errors. Presenting test accuracy data using the 2x2 diagnostic table or a pictograph attenuated this effect.ConclusionChoice of test accuracy metric appears to have a profound effect on diagnostic decision making. Understanding, contextual factors and motivational biases are likely to be contributing factors to the observed variability. It is unclear to what extent any advantage of test accuracy metric for informed decision making is based on familiarity as opposed to their intuitive nature. Simultaneous illustration of both dimensions of test accuracy in order to facilitate informed diagnostic decision making requires further exploration.
PL02 Breastfeeding and Social Mobility: Neurological Development or Stress Mechanisms?
Authors: Sacker A , Kelly Y , Bartley M , Iacovou M 
Published: September 2012

BackgroundBreastfeeding has been associated with higher cognitive scores, better test results and fewer socio-emotional problems in childhood. These outcomes in turn predict social mobility. This study examines the effect of breastfeeding on inter-generational social mobility and the role of two biologically plausible mechanisms: via improved neurological development due to the long-chain polyunsaturated fatty acids in breast milk and via hypothalamic-pituitary-adrenal (HPA) axis functioning due to growth hormones in breast milk.MethodsWe use data from two birth cohorts (the 1958 National Child Development Study and the 1970 British Birth Cohort) to examine breastfeeding’s relationship with social mobility. Social class at 10/11 years was based on father’s class. Both class of origin and own social class in adulthood (age 33/34) were measured by the Registrar General’s social class (RGSC). Neurological development was assessed using cognitive tests and assessments of fine motor function. HPA functioning was assessed using socio-emotional behaviour scales and a physical symptoms of stress score.ResultsRates of breastfeeding were higher in the 1958 cohort than the 1970 cohort (43% vs. 21% breastfed 1+ months). Breastfeeding was more socially patterned by 1970, with advantaged mothers being more likely to breastfeed. A propensity score approach matched breastfed and non-breastfed children on a large number of characteristics before estimating the effect of breastfeeding on social mobility. We modelled the odds of upward and downward social mobility conditional on being breastfed for 1 month or more and social class of origin. Results show that breastfeeding increased the odds of upward mobility (1958 cohort: OR 1.25 95% CI 1.13, 1.37; 1970 cohort: OR 1.14 95% CI 1.00, 1.31), and reduced the odds of downward mobility (1958 cohort: OR 0.81 95% CI 0.74, 0.90; 1970 cohort OR 0.79 95% CI 0.69, 0.91). Controlling for the measures of neurological development and stress functioning attenuated the effect of breastfeeding to marginal or non significance. Gender differences in these findings will be discussed.ConclusionBreastfeeding promotes upward social mobility and protects against downward mobility. The effects appear to operate through enhanced neurological development and more effective stress processes.
PL03 Socio-Economic Inequalities in Lung Cancer Treatment: A Systematic Review and Meta-Analysis
Authors: Forrest LF , Adams JM , Wareham H , Rubin G , White M 
Published: September 2012

BackgroundIntervention-generated inequalities in health result from the way that health interventions are organised and delivered. There is some evidence that socio-economic inequalities in care may occur for some common cancers and treatment inequalities may contribute to socio-economic differences in survival. Although the incidence and outcome of lung cancer varies with socio-economic status (SES), it is not known whether socio-economic inequalities in treatment occur. We conducted a systematic review and meta-analysis of existing research on socio-economic inequalities in receipt of treatment for lung cancer.MethodsSystematic methods were used to identify relevant studies, assess study eligibility for inclusion and evaluate study quality. Cohort studies of adults with a primary diagnosis of lung cancer, published in peer-reviewed English language journals up to 2011, were examined. All studies reporting rates of receipt of any treatment for lung cancer according to a measure of SES were included in the review. Studies that reported odds ratios for receipt of treatment, adjusted for at least age and sex, were included in the meta-analysis. Subgroup analyses by healthcare system (universal healthcare system or insurance-based system), histology and stage were conducted.ResultsFrom the initial 1345 studies identified, 46 studies were included in the review and 29 in the meta-analysis.Socio-economic inequalities in receipt of lung cancer treatment were observed. Low SES was associated with a reduced likelihood of receiving any treatment (OR=0.79, CI (0.74 to 0.84) p<0.001), surgery (OR=0.71 (CI 0.65 to 0.77), p<0.001) and chemotherapy (OR=0.81 (CI 0.73 to 0.91), p<0.001), but not radiotherapy (OR=0.95 (CI 0.84 to 1.07), p=0.41), for lung cancer. The association was found in both insurance-based and universal healthcare systems and remained when stage and histology were taken into account for receipt of surgery.ConclusionThis systematic review and meta-analysis found that lung cancer patients living in more socio-economically deprived circumstances were less likely to receive any type of treatment, surgery and chemotherapy. These inequalities cannot be accounted for by socio-economic differences in stage at presentation or by type of healthcare system. Further investigation is required into the patient, clinician and system factors that may contribute to socio-economic inequalities in receipt of lung cancer care and how these inequalities may impact on survival, and also into how to reduce such inequalities.
PS10 The Appropriateness of, and Compliance with, Telephone Triage Decisions
Authors: Blank L , Coster J , Cathain A , Knowles E , Tosh J , Turner J , Nicholl J 
Published: September 2012

BackgroundTelephone triage plays an important role in managing demand for healthcare. In recent years there has been an increasing use of telephone triage in managing demand for unscheduled health care for general health problems. Policy makers, service providers and service evaluators are interested in the appropriateness of triage decisions in the context of offering an effective and safe service. In 2009 the Department of Health in England announced the establishment of a small number of pilot sites to test a new telephone triage service called ‘NHS 111’. The service offers telephone triage to members of the general population calling about urgent but non-emergency health problems. Calls are triaged by trained non-clinical call advisors and directed to a range of services such as an emergency department, or a general practitioner.MethodsAs part of an evaluation of these pilots, in order to provide context for understanding the findings, a rapid evidence assessment was undertaken of the appropriateness of, and compliance with, telephone triage to synthesise the evidence on the percentage of telephone triage decisions assessed as appropriate and the percentage which callers complied with. The aim of this paper is to report on a systematic review of the literature on appropriateness of, and compliance with, telephone triage decisions. The study focused on telephone triage services directing patients to an appropriate health care provider. The principles of rapid evidence assessment were followed.ResultsWe identified 54 relevant papers; 26 papers reported appropriateness of triage decision, 26 papers reported compliance with triage decision and 2 papers reported both. Nurses triaged calls in most of the studies (n=49). Triage decisions rated as appropriate varied between 44% and 98% (median 75); compliance ranged from 56% to 98% (median 77%). Variation could not be explained by type of service or method of assessing appropriateness. However, inconsistent definitions of appropriateness may explain some variation. Triage decisions to contact primary care (median 66%, range 25%-91%) may have lower compliance than decisions to contact emergency services (median 75%, range 29%-100%) or self care (median 77%, range 26%-100%).ConclusionTelephone triage services can offer appropriate decisions, and decisions that callers comply with. However the association between the appropriateness of a decision and subsequent compliance requires further investigation and further consideration needs to be given to the minority of calls which are inappropriately managed. We suggest that a definition of appropriateness incorporating both accuracy and adequacy of triage decision should be encouraged.
PS11 Does Contact with a Podiatrist Prevent The Occurrence of a Lower Extremity Amputation in people with Diabetes? A Systematic Review and Meta-Analysis
Authors: Buckley CM , Kearney PM , Perry IJ , Bradley CP 
Published: September 2012

BackgroundDiabetes is associated with a significant risk of LEA (lower extremity amputation). LEA rates vary between communities, 46–9,600 per 105people with diabetes, for many reasons. The effects of clinical and socio-demographic risk factors on the occurrence of a LEA have been well documented in people with diabetes. However, the effect of patient contact with a podiatrist on the prevention of LEA in people with diabetes is less well explored. The objective of this study was to determine if contact with a podiatrist prevents the occurrence of lower extremity amputation in people with diabetes.MethodsWe conducted a systematic review of available published literature on the effect of contact with a podiatrist on the prevention of lower extremity amputation in people with diabetes. Eligible studies were identified through searches of PUBMED, CINAHL, EMBASE (Excerpta Medica), and Cochrane databases. Reference lists of all relevant papers were reviewed for additional eligible articles. Randomised and non-randomised studies of the effect of contact with a podiatrist on risk of LEAs in people with diabetes (type 1 or 2) were included. Two reviewers independently assessed titles, abstracts, and full articles to identify eligible studies. Meta-analysis was performed separately for randomised and non-randomised studies.ResultsFour hundred and ninety-nine titles were retrieved from searches of electronic databases. Duplicates (138) were removed and 361 titles/abstracts were reviewed. Nineteen papers were considered for review after initial screening of titles and abstracts. Three further studies were identified as potentially eligible from reference checking. After reviewing the full text articles, 6 studies met the inclusion criteria. The identified studies were heterogeneous in design (2 RCTs and 4 cohort studies) and included people with diabetes at both low and high risk of amputation. In a meta-analysis of available data from RCTs, the pooled RR of LEA was 1.4 (95% CI 0.2–9.3). The pooled RR from available cohort studies suggested a protective effect of podiatry but the estimate was unreliable, RR of 0.7 (95% CI 0.09–5.68).ConclusionThere is very limited data available on the effect of contact with a podiatrist on risk of LEA in people with diabetes. Further research in this area is warranted. An adequately powered RCT with a reasonably homogenous population regarding risk profiles would be the ideal way to answer this question if possible. A systematic review looking at the effect of podiatry as part of a multidisciplinary foot team on the risk of LEA in people with diabetes would also be prudent.
PS13 Equity of access to Health Care and Treatment of Non-Communicable Diseases in Scotland and Hong Kong
Authors: Elwell-Sutton TM , Schooling CM 
Published: September 2012

BackgroundProviding equitable access to health care is a goal for most health systems. The long-term and costly nature of treating non-communicable diseases may present particular challenges for equity of access (equal treatment for equal need), though few previous studies have considered this. This study compares equity of access to health care in Scotland and Hong Kong, with a particular focus on treatment for non-communicable diseases (NCDs). Since Scotland’s health care is largely tax-funded, while Hong Kong has a mixed medical economy (shared between public and private sectors) we expected to see greater equity of access to health care in Scotland, particularly for treatment of NCDs.MethodsIn two large, population-representative household surveys - the Scottish Health Survey (2008–9) and Hong Kong’s Thematic Household Survey (2010) - we assessed associations between health care utilisation (GP consultations, specialist consultations, admissions to hospital, and utilisation specifically for NCDs) and socioeconomic position (income, occupation and education) using multi-variable logistic regression. We also controlled for ‘need for health care’ (age, sex, self-rated health and chronic conditions).ResultsAfter controlling for need, in Scotland: utilisation of GP consultations and GP consultations for cardiovascular disease (CVD) were not associated with any measure of SEP; utilisation of specialist care, however, was positively associated with income (OR 1.27 for highest versus lowest income quintile, 95% CI 1.08 – 1.50), though this was attenuated by additionally adjusting for education, and the association was even stronger for specialist CVD consultations (OR 1.68, 95% CI 1.12 – 2.54); and hospital admissions were negatively associated with income (OR 0.73, 95% CI 0.57 – 0.94). In Hong Kong, utilisation of all types of health care was positively associated with income and occupation, except for care for chronic conditions; most associations were attenuated after additionally controlling for health insurance cover.ConclusionTaking utilisation rates as a proxy for access to health care, our results suggest that in Scotland, access to primary care is highly equitable, but that people on low incomes or with poor education may have restricted access to specialist treatment, especially for CVD. This could be due to GP referrals giving preference to higher SEP patients. Surprisingly, we found that, whilst access to care in Hong Kong was generally better for people with high SEP, treatment of chronic conditions was more equitable than in Scotland, showing that fully tax-funded health systems do not necessarily provide more equitable access to all forms of care than systems of mixed funding.
PS15 Policy Actions to Reduce Dietary Salt Intake: Price, Product, Place or Promotion? A Review of the Evidence
Authors: Orton LC , Bromley H , Hawkes C , Taylor-Robinson DC , Moonan M , O’Flaherty M , Lloyd-Williams F , Rayner M , Capewell S 
Published: September 2012

BackgroundA range of policies aim to reduce salt intake; however, their relative effects remain unclear. We undertook a narrative synthesis of existing evidence to determine the most promising approaches.MethodsWe searched for systematic reviews, then empirical and modelling studies of salt reduction policies in six electronic databases. Reference lists of retrieved articles were screened and key informants were asked to identify further reviews and empirical/modelling studies. Items were assessed for inclusion and data were extracted into predesigned forms. Results were categorised using a modified version of the marketing four P’s framework: Price, Product, Place and Promotion.ResultsPrice: A US sodium excise tax may reduce sodium intake (by 6%), systolic blood pressure (by 0.9mmHg), stroke (by 10%) and myocardial infarction (by 5%) over the lifetime of those aged 40 – 85 years.(One modelling study)Product:Voluntary US salt limits might achieve lifetime reductions in sodium intake (-9.5%), blood pressure (-1.25mmHg), myocardial infarction (-5%) and stroke (-10%). In Australia, mandatory salt limits could reduce cardiovascular disease (by 18%) but only by 1% with voluntary intervention.(Two modelling studies)Promotion:Intensive advice, support and encouragement to restrict dietary sodium intake led to significant long term reductions in urinary sodium excretion, systolic blood pressure (-1.1mmHg) and disease burden (-0.5%.) Interventions involving advertising/marketing/labelling have only been evaluated within multi-component interventions.(One systematic review.)Place:Place-based interventions (targeting schools, workplaces and community settings) have only been evaluated within multi-component interventions.Multi-component interventions:The UK FSA product and promotion-based initiatives reduced salt intake by approximately 10%. Two modelling studies estimate that similar interventions in low- and middle-income countries might achieve a 15% reduction in salt consumption, globally averting perhaps 1 million deaths and 21 million disability-adjusted life years annually. Modelling estimates from Norway suggest that combining taxes and subsidies with product and price interventions might reduce daily salt intake by 6g. Survey data reveal that in Finland between 1979 – 2002, a comprehensive and mandatory nutrition intervention (using regulations targeting price, product, place and promotion) reduced urinary sodium excretion from 13 to 10 g/day in men and from 10.5 to 7.5g/day in women.(Two empirical studies and three modelling studies)ConclusionThere is patchy evidence on the effectiveness of policy actions to reduce dietary salt intake. Dietary advice can achieve modest benefits. Modelling suggests taxes and reformulation may be effective (particularly when mandatory). Empirical and modelling studies indicate multi-component interventions could be particularly powerful.
PS18 Analysis of Emergency 30-Day Readmissions in England Using Routine Hospital Data 2004-2010. Is there Scope for Reduction?
Authors: Clarke A , Blunt I , Bardsley M 
Published: September 2012

BackgroundA number of health systems including the NHS have recently introduced arrangements to deny payment if a patient is readmitted to hospital as an emergency soon after a period of care. These approaches assume that emergency admissions are a reflection of poor quality of care and of errors or failure in the original care episode. Our objectives were to assess the extent and types of readmission within 30 days and possible causes and scope for reduction.MethodsRetrospective analysis of 83 million routinely-collected national hospital episode statistics (HES) records covering NHS hospitals in England for a 6 year period (2004–10). Records were linked at the individual level using an annonymised person level identifier. Numbers of 30-day readmissions were calculated. We categorised readmissions using pre-defined discharge-admission diagnostic pairs, overall admission patterns and the “Bridges to Health” patient group categories.ResultsThere were 7,166,304 emergency 30-day readmissions over a six year period equivalent to 8.7% of all hospital discharges. Readmissions were grouped into six categories:Potentially preventable (probable or possible suboptimal care during index admission): 1,988,967 (27.8%);Approach to care (anticipated but unpredictable hospital care): 1,503,282 (21.0%);Preference of patients or staff in admission or discharge timing: 56,514 (0.8%);Artefact in data collection: 139,508(2%);Accident or Coincidence: 1,473,583 (20.6%);No obvious cause: 2,107,339 (29.4%)ConclusionVery large numbers of emergency readmissions fell into potentially preventable categories and to categories amenable to immediate reduction by hospitals. Denial of payment for emergency readmission has the potential to improve quality of care by improving data systems and reducing error. Action to address the majority of emergency readmissions requires assessment of care delivery across health and social care providers for those with complex, chronic or terminal conditions. In conclusion, new systems of denial of payment will be dangerous if they invoke perverse incentives which reduce access to necessary hospital care for patients.