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1.  Systemic chemokine levels, coronary heart disease, and ischemic stroke events 
Neurology  2011;77(12):1165-1173.
Objectives:
To quantify the association between systemic levels of the chemokine regulated on activation normal T-cell expressed and secreted (RANTES/CCL5), interferon-γ-inducible protein-10 (IP-10/CXCL10), monocyte chemoattractant protein-1 (MCP-1/CCL2), and eotaxin-1 (CCL11) with future coronary heart disease (CHD) and ischemic stroke events and to assess their usefulness for CHD and ischemic stroke risk prediction in the PRIME Study.
Methods:
After 10 years of follow-up of 9,771 men, 2 nested case-control studies were built including 621 first CHD events and 1,242 matched controls and 95 first ischemic stroke events and 190 matched controls. Standardized hazard ratios (HRs) for each log-transformed chemokine were estimated by conditional logistic regression.
Results:
None of the 4 chemokines were independent predictors of CHD, either with respect to stable angina or to acute coronary syndrome. Conversely, RANTES (HR = 1.70; 95% confidence interval [CI] 1.05–2.74), IP-10 (HR = 1.53; 95% CI 1.06–2.20), and eotaxin-1 (HR = 1.59; 95% CI 1.02–2.46), but not MCP-1 (HR = 0.99; 95% CI 0.68–1.46), were associated with ischemic stroke independently of traditional cardiovascular risk factors, hs-CRP, and fibrinogen. When the first 3 chemokines were included in the same multivariate model, RANTES and IP-10 remained predictive of ischemic stroke. Their addition to a traditional risk factor model predicting ischemic stroke substantially improved the C-statistic from 0.6756 to 0.7425 (p = 0.004).
Conclusions:
In asymptomatic men, higher systemic levels of RANTES and IP-10 are independent predictors of ischemic stroke but not of CHD events. RANTES and IP-10 may improve the accuracy of ischemic stroke risk prediction over traditional risk factors.
doi:10.1212/WNL.0b013e31822dc7c8
PMCID: PMC3174064  PMID: 21849651
2.  Offering a prognosis in lung cancer: when is a team of experts an expert team? 
The outlook for patients with lung cancer is poor, so an accurate estimation of prognosis will underpin treatment decisions and allow patients to make personal plans for the future. However, evidence suggests that there is a variation between doctors in their predictions of outcomes and also they tend to be overoptimistic. Two main questions are addressed in this study: whether multidisciplinary team discussion changes prognostic accuracy of individual clinicians; and whether team discussion improves the accuracy of the team's aggregated prediction. A real‐time study of 50 newly diagnosed patients discussed by a regional lung cancer team was undertaken. A case proforma informed the completion of a pre‐discussion questionnaire by each team member, seeking prognostic predictions at specific time points. This was repeated after team discussion. Medical notes were reviewed at 6 months to establish actual survival status. Group discussion did not significantly change the accuracy of survival predictions for any one clinician, but the team as a whole performed better after case discussion. Predictions which the clinicians were more confident about were found to be no more accurate than those where they were less confident. There is a wide variation in the range and accuracy of prognostic predictions made by individual clinicians, with no consistent improvement after team discussion. As such predictions are integral to decision making, further research on decision‐making processes of clinical teams is required.
doi:10.1136/jech.2005.044917
PMCID: PMC2652939  PMID: 17372290
3.  Demographic and temporal trends in out of hospital sudden cardiac death in Belfast 
Heart  2005;92(3):311-315.
Objective
To determine the epidemiology of out of hospital sudden cardiac death (OHSCD) in Belfast from 1 August 2003 to 31 July 2004.
Design
Prospective examination of out of hospital cardiac arrests by using the Utstein style and necropsy reports. World Health Organization criteria were applied to determine the number of sudden cardiac deaths.
Results
Of 300 OHSCDs, 197 (66%) in men, mean age (SD) 68 (14) years, 234 (78%) occurred at home. The emergency medical services (EMS) attended 279 (93%). Rhythm on EMS arrival was ventricular fibrillation (VF) in 75 (27%). The call to response interval (CRI) was mean (SD) 8 (3) minutes. Among patients attended by the EMS, 9.7% were resuscitated and 7.2% survived to leave hospital alive. The CRI for survivors was mean (SD) 5 (2) minutes and for non‐survivors, 8 (3) minutes (p < 0.001). Ninety one (30%) OHSCDs were witnessed; of these 91 patients 48 (53%) had VF on EMS arrival. The survival rate for witnessed VF arrests was 20 of 48 (41.7%): all 20 survivors had VF as the presenting rhythm and CRI ⩽ 7 minutes. The European age standardised incidence for OHSCD was 122/100 000 (95% confidence interval 111 to 133) for men and 41/100 000 (95% confidence interval 36 to 46) for women.
Conclusion
Despite a 37% reduction in heart attack mortality in Ireland over the past 20 years, the incidence of OHSCD in Belfast has not fallen. In this study, 78% of OHSCDs occurred at home.
doi:10.1136/hrt.2004.059857
PMCID: PMC1860807  PMID: 15939727
sudden cardiac death; ventricular fibrillation
4.  Late referral for assessment of renal failure 
It has been recommended that adult patients with a serum creatinine above 150 µmol/l should be referred to a nephrologist for specialist assessment. This study ascertained all patients in Northern Ireland with creatinine above this concentration in 2001 (n = 19 286 ) to see if this triggered referral within the subsequent year. After exclusion of those who were already known to a nephrologist and those who had acute renal failure, it was found that younger patients and diabetic patients were more likely to be referred. There was no difference in referral rates between male and female patients. However, only 6.5% of all non-diabetic subjects and 19% of diabetic patients were referred within 12 months after a first increased serum creatinine test.
doi:10.1136/jech.2004.026658
PMCID: PMC1733077  PMID: 15831687
6.  The changing scope of colorectal cancer 
Gut  2002;50(5):741.
PMCID: PMC1773213  PMID: 11950829
colorectal cancer; screening; flexible sigmoidoscopy; endoscopy
7.  Flexible sigmoidoscopy and the changing distribution of colorectal cancer: implications for screening 
Gut  2001;48(4):522-525.
BACKGROUND AND AIMS—There has been a significant proximal shift in the distribution of colorectal cancer (CRC) in Northern Ireland over recent decades. The aim of this study was to investigate the potential implications of this proximal shift in CRC distribution on the efficacy of flexible sigmoidoscopy (FS) as a screening tool.
PATIENTS AND METHODS—The site distribution of 5153 CRCs was available from the Northern Ireland Colorectal Cancer Register for the period 1990-1997. Similar data on 1241 CRCs between 1976 and 1978 were available from a previous study. Data on the site reached by FS were obtained from a prospectively collected endoscopy database at one of Northern Ireland's main teaching hospitals for the period 1993-1998.
RESULTS—There was a significant proximal shift in CRC distribution between the two periods (23.5% proximal to the splenic flexure between 1976 and 1978 v 36.7% between 1990 and 1997; p<0.001). The descending colon was visualised during 74.4% of FS examinations. By combining the observed extent of FS examination with CRC site distribution, it was calculated that FS could have visualised 68.8% of CRCs between 1976 and 1978 but only 56.0% between 1990 and 1997. Extrapolating these data to a Northern Ireland screening programme involving FS and faecal occult blood testing suggests that significantly more CRCs could have been detected between 1976 and 1978 than between 1990 and 1997 (51.7% v 48.2%, respectively; p=0.03).
CONCLUSIONS—This study confirms the previously documented left to right shift in CRC distribution in Northern Ireland and demonstrates that if this shift continues, FS will become less successful as a screening tool than is currently predicted.


Keywords: colorectal cancer; screening; flexible sigmoidoscopy; endoscopy
doi:10.1136/gut.48.4.522
PMCID: PMC1728246  PMID: 11247897
8.  Polymorphisms of the P-selectin gene and risk of myocardial infarction in men and women in the ECTIM extension study 
Heart  2000;84(5):548-552.
BACKGROUND AND OBJECTIVE—Studies in animal models and humans implicate cell adhesion molecules in atherogenesis but their role in mediating the risk of myocardial infarction is unclear. The ECTIM (étude cas-temoin de l'infarctus myocarde) extension study was established to determine whether a previously implicated polymorphism of the P-selectin gene was associated with myocardial infarction risk in men and women in Belfast and Glasgow.
PATIENTS AND STUDY SETTING—696 cases with a recent myocardial infarction and 561 age matched controls (both male and female) were recruited into a case-control study in MONICA project areas of Belfast and Glasgow.
METHODS—Demographic and lifestyle information was collected by interview administered questionnaire, and each subject was examined and provided a blood sample for DNA extraction. The polymerase chain reaction (PCR) was used to amplify regions encompassing the P-selectin Thr→Pro (A/C) polymorphism at position 715. Genotype odds ratios for myocardial infarction were estimated by logistic regression adjusted for population, age, and sex.
RESULTS—There was no significant association between conventional risk factors (such as hypercholesterolaemia, increased body mass index, or raised blood pressure) and either the rare or the common Pro715 allele of the P-selectin gene in controls. Overall, comparing Pro715/Pro715 and Pro715/Thr715 with Thr715/Thr715, with adjustment for centre, age, and sex, the odds ratio was 0.78 (95% confidence interval 0.60 to 1.00) (p = 0.054), indicating a "protective" effect of the less common Pro715 allele. There was no significant heterogeneity in odds ratios between men and women either in this sample or when combined with the original ECTIM subjects.
CONCLUSIONS—In a large population based study in two regions of the UK, we have been able to corroborate the earlier ECTIM findings of a lower frequency of the Thr/Pro715 polymorphism in subjects with myocardial infarction. An apparently "protective effect" of similar magnitude also seems to apply to women.


Keywords: P-selectin; cell adhesion molecules; atherogenesis
doi:10.1136/heart.84.5.548
PMCID: PMC1729474  PMID: 11040019
9.  Prioritising the cardiac surgery waiting list: the angina patient's perspective. 
Heart  1997;77(4):330-332.
OBJECTIVE: To determine patients' views on how clinical and demographic factors should affect priorities for cardiac revascularisation. DESIGN: A descriptive survey of patients' views conducted immediately after angiography and treatment counselling. SUBJECTS: 136 patients who were awaiting coronary angioplasty in either of the two regional cardiology centres in Northern Ireland. RESULTS: About half the subjects (52%) felt that certain social factors such as having dependent relatives should be taken into account when deciding priority for surgery. A sizeable minority felt that younger subjects and non-smokers (40% and 44%, respectively) should be accorded higher priority, with older subjects and smokers being more likely to hold such views. CONCLUSIONS: While there is little evidence that demographic and lifestyle factors affect the relative efficacy of surgery, the challenge remains to devise a prioritisation guideline that can properly reflect societal values and the evidence base.
PMCID: PMC484726  PMID: 9155611
10.  Influence of hospital and clinician workload on survival from colorectal cancer: cohort study 
BMJ : British Medical Journal  1999;318(7195):1381-1386.
Objective
To determine whether clinician or hospital caseload affects mortality from colorectal cancer.
Design
Cohort study of cases ascertained between 1990 and 1994 by a region-wide colorectal cancer register.
Outcome measures
Mortality within a median follow up period of 54 months after diagnosis.
Results
Of the 3217 new patients registered over the period, 1512 (48%) died before 31 December 1996. Strong predictors of survival both in a logistic regression (fixed follow up) and in a Cox's proportional hazards model (variable follow up) were Duke's stage, the degree of tumour differentiation, whether the liver was deemed clear of cancer by the surgeon at operation, and the type of intervention (elective or emergency and curative or palliative intent). In a multilevel model, surgeon’s caseload had no significant effect on mortality at 2 years. Hospital workload, however, had a significant impact on survival. The odds ratio for death within 2 years for cases managed in a hospital with a caseload of between 33 and 46 cases per year, 47 and 54 cases per year, and ⩾55 cases per year (compared to one with ≤23 cases per year) were respectively 1.48 (95% confidence interval 1.03 to 2.13), 1.52 (1.08 to 2.13), and 1.18 (0.83 to 1.68).
Conclusions
There was no detectable caseload effect for surgeons managing colorectal cancer, but survival of patients treated in hospitals with caseloads above 33 cases per year was slightly worse than for those treated in hospitals with fewer caseloads. Imprecise measurement of clinician specific “events rates” and the lack of routinely collected case mix data present major challenges for clinical audit and governance in the years ahead.
Key messagesVarious benefits have been described for multidisciplinary cancer care, but the precise relation between a surgeon's or hospital's caseload and the outcome for the patient is not knownAny investigation of a caseload effect at the hospital or practitioner level has to simultaneously account for each factor and adjust adequately for case mixSurgeon had no significant effect on caseload, but patients treated in hospitals with low caseloads (<33 cases per year) had a slightly better survival at 2 years than those treated in hospitals with a higher caseloadDefining surgical expertise in terms of volume of activity may be a misdirected and imprecise yardstick for the quality of cancer care; other aspects of the organisation of services may be far more important
PMCID: PMC27880  PMID: 10334746
12.  Risks and benefits of coronary angioplasty: the patients perspective: a preliminary study. 
Quality in Health Care  1997;6(3):131-139.
OBJECTIVES: To describe what cardiac patients in Northern Ireland understand to be the benefits of coronary angioplasty and assess the extent to which they have been able to make informed choices about their treatment. DESIGN: An interview based questionnaire survey completed after the patients had undergone coronary angiography, within hours of treatment counselling. SUBJECTS: 150 patients consecutively recruited from two regional cardiology centres in Belfast, Northern Ireland. MAIN OUTCOME MEASURES: The perceived complication rate and the perceived gain in life expectancy from coronary angioplasty. RESULTS: Although most subjects had asked the consultant questions, 70% (n = 104) thought that they contributed negligibly or not at all to the treatment decision. Although 75% (n = 112) recalled discussing the complication rate from the procedure, only 27% accurately estimated this rate (as between 0.5 and 1.5%). Eighty eight per cent (n = 131) thought that their mortality risks would be substantially or greatly reduced by having the procedure. The patients anticipated a gain in life expectancy of some 10 years (median) and this was significantly in excess of the potential gain in life expectancy which dietary prudence to lower blood cholesterol, not smoking, and taking more exercise might produce (median 5 years respectively; P < 0.0001, Wilcoxon matched pairs signed rank test). CONCLUSIONS: Patients vastly overrate the capacity of angioplasty to control their disease: angioplasty is seen as more effective than risk factor modification.
PMCID: PMC1055474  PMID: 10173770
13.  Socioeconomic circumstances and the risk of bowel cancer in Northern Ireland. 
OBJECTIVE: To describe the variation in the incidence of colorectal cancer across Northern Ireland and relate it to factors associated with community deprivation. DESIGN: This was a cross sectional descriptive study. SETTING: Incidence data were obtained from a population based register for the period 1990-91. Small areas were characterised by their "affluence", or lack of it, by deriving a Townsend deprivation score for each electoral ward, using information from the 1991 census. PARTICIPANTS, MAIN OUTCOME MEASURES, AND STATISTICAL METHODS: The age standardised incidence was calculated for all colorectal cancer cases diagnosed histologically in 1990-91. Electoral wards were grouped into quintiles of the population after ranking of their Townsend scores and the association with incidence was studied using Poisson regression. RESULTS: The age standardised colorectal cancer incidence ranged from 22.5 (for quintile 1) to 29.9/100,000 (quintile 5) for men but the trend for women was less regular and rates were 18.4, 23.8, 27.3, 26.5, and 23.9/100,000 for quintiles 1-5 respectively (that is, from the most "affluent" to the most "deprived" fifths of the population). After adjusting for age and sex in Poisson regression, there was a significant association between the total colorectal cancer incidence and levels of community deprivation. The rate ratio for the most deprived quintile of the population (compared with the least) was 1.28 (95% CI 1.06,1.53). The effect was stronger for rectal cancer than for colonic cancer. There was no association between community deprivation and the cancer stage at diagnosis. CONCLUSIONS: In this population, the colorectal cancer incidence is associated with the level of material deprivation. The disease stages at the time of diagnosis in patients from more deprived areas seem to be comparable with those of patients from affluent areas. As others have shown, associations such as these are not explicable entirely on the basis of the distribution of known risk factors. Further research is needed to determine plausible mechanisms for the association.
PMCID: PMC1060381  PMID: 9039383
14.  Patients' prerogatives and perceptions of benefit. 
BMJ : British Medical Journal  1996;312(7036):958-960.
Patients today demand more information about their treatment. Doctors, however, seem reluctant to cast aside ingrained habits of paternalism, believing they can best interpret therapeutic choices for their patients. Whether doctors can be more objective and effective than patients in interpreting the "probabilities" of medical evidence is open to question. On the other hand, the exercise of choice by patients may itself have a bearing on the probabilities of outcome. Involving patients more in making therapeutic choices is justified if doctors can present options in an unbiased and effective manner and if the process improves the outcome of the care delivered.
PMCID: PMC2350793  PMID: 8616314
15.  Natural history of reflux oesophagitis: a 10 year follow up of its effect on patient symptomatology and quality of life. 
Gut  1996;38(4):481-486.
BACKGROUND--Although oesophagitis is the most common diagnosis made at upper gastrointestinal endoscopy, data on the longterm outcome of affected patients are sparse. AIMS--This study assessed the level of reflux symptoms, quality of life, drug consumption, and complications in patients at least 10 years after diagnosis of oesophagitis at one centre. PATIENTS--One hundred and fifty two patients with typical reflux symptoms and a first time diagnosis by endoscopy of grade I-III oesophagitis between 1981 and 1984, were followed up using a postal questionnaire and telephone interview. RESULTS--Eighteen of 152 patients had died, 33 failed to respond, and 101 replied (mean follow up 11 years, range 121-160 months). Over 70% of patients still had heartburn at least daily (32%) or weekly (19%) or required daily acid suppression treatment (20%). Two patients (2%) had developed oesophageal strictures and one had Barrett's oesophagus. Two of eight quality of life scores (physical function and social function) measured by the Short Form-36 were significantly lower than Northern Ireland population scores. CONCLUSION--Nearly three quarters of patients previously diagnosed as having oesophagitis still had significant morbidity related to gastro-oesophageal reflux disease more than 10 years after diagnosis. Some quality of life scores were significantly lower than those of the general population.
PMCID: PMC1383100  PMID: 8707073
16.  Predictors for waiting time for coronary angioplasty in a high risk population. 
Quality in Health Care  1995;4(4):244-249.
Objective--To describe the clinical and non-clinical factors which influence the waiting time from initial angiography to angioplasty. Design--Follow up of a random sample of 106 patients undergoing their first coronary angiography for whom a decision to revascularise by percutaneous transluminal angioplasty was made in 1991. The period between the date of angiography and the date of angioplasty and various clinical characteristics of patients were retrieved from medical notes in mid 1993. Patients were sampled from those investigated in the two Northern Ireland catheterisation laboratories in Belfast, which provide services for the whole of the province (population 1.5 million). Main measures--The dependent variable was the period between initial angiography and angioplasty, and the independent variables included age, sex, distance from cardiac catheterisation centre, referral source, characteristics of the clinical history, severity of angina, and anatomical extent of disease. Cox's proportional hazards analysis was used to derive a relative hazard, expressing the relative chances of revascularisation occurring at any time during follow up. Results--Of the 106 patients studied, 93 had had percutaneous transluminal angioplasty at follow up. The most important predictors of waiting time were the presence of severe angina (relative hazards 3.1(95 % confidence interval (95% CI) 1.4-6.8) and 2.7(1.2-6.2) for Canadian Cardiovascular grades III and IV v angina grade I angina), a recent history of myocardial infarction (relative hazard, 2.5(1.3-4.8), and whether or not the patient was economically active (relative hazard 0.6(0.4-1.0) for economically inactive v active patients). Although there was also an association with the relative deprivation of the area of residence of the patient it had no clear linear trend. Conclusions--Although waiting time for percutaneous transluminal angioplasty was predictably related to the patient's clinical presentation, demographic factors may also be important in determining access to intervention. These factors clearly merit further study; ultimately, the evaluation of equity in a waiting time distribution may more properly be a societal rather than a clinical judgment.
PMCID: PMC1055334  PMID: 10156393
17.  Are the economically active more deserving? 
British Heart Journal  1995;73(4):385-389.
OBJECTIVE--To investigate the possibility of an association between the duration of medical treatment before coronary angiography and demographic and non-clinical factors. DESIGN--A systematic review of a random sample of 500 patients undergoing their first angiographic assessment. SUBJECTS--500 cases were selected randomly from patients investigated in 1991 at the two catheterisation centres in Northern Ireland. MAIN OUTCOME MEASURES--The duration of medical management before angiography. RESULTS--346 had elective and 154 urgent catheterisation. The duration of medical management was adjusted for both case mix (age at onset, body mass index, angina grade, history of myocardial infarction, history of hypertension, diabetes or hyperlipidaemia, treatment intensity) and other demographic variables (sex, smoking status, an indicator of "deprivation", and distance of the patient's area of residence from the hospital). After this adjustment the mean duration of medical management before angiography was twice as long for economically inactive patients as for those who were economically active. In a multiple regression, the relevant beta coefficient was 0.44 (95% confidence interval 0.33 to 0.58, P < 0.0001). CONCLUSIONS--These results suggest that, in making discretionary decisions about when to refer patients with angina for revascularisation assessment, doctors may be influenced by non-clinical factors unrelated to disease severity.
PMCID: PMC483836  PMID: 7756076
18.  Expanding access to coronary artery bypass surgery: who stands to gain? 
British Heart Journal  1995;73(2):129-133.
OBJECTIVE--To determine the perceptions of general practitioners (GPs) about the benefits of coronary artery bypass surgery, in terms of gains in life expectancy, for different groups of patients. DESIGN--A questionnaire survey of all GPs in Northern Ireland. SETTING--A survey conducted collaboratively by the departments of public health medicine in each of the four health boards in the province, serving a total population of 1.5 million. MAIN OUTCOME MEASURES--The median and mean gain in life expectancy perceived by groups of doctors for smoking and non-smoking male and female 55 year old patients. The percentage of 50 year old and 70 year old non-smoking patients considered likely to have their lives extended with bypass surgery. Differences were assessed using the Mann-Whitney U test for unpaired samples and the Wilcoxon signed rank tests for paired. RESULTS--541 GPs replied (response rate 56%). The median (and mean) perceived gain in life expectancy after cardiac surgery for non-smoking 55 year old subjects was 120 (104) months for men and 120 (112) months for women (z = 6.42; P < 0.0001; Wilcoxon signed rank test). For male and female smokers of the same age, the perceived gains were 48 (47) and 60 (52) months respectively (z = 6.72; P < 0.0001; Wilcoxon signed ranks test), both figures being significantly different than for non-smokers. The median (and mean) percentage of patients that the doctors considered would have their lives extended by bypass surgery was 70 (64) of every 100 "young" patients and 40 (42) of every 100 "old" patients, (z = 16.2; P < 0.0001). CONCLUSIONS--These results point to a significant overestimation of the benefits of coronary artery bypass surgery by GPs in Northern Ireland and to a need to develop guidelines for referral.
PMCID: PMC483778  PMID: 7696021
19.  The role of the general practitioner hospital in inpatient care. 
The Ulster Medical Journal  1994;63(2):176-184.
The rationale of the general practitioner hospital continues to be questioned. A study of the services and case-mix of two of the four remaining general practitioner hospitals in Northern Ireland was undertaken to determine whether the nature and cost of inpatient care in these hospitals was comparable to the available alternatives. The case-notes of all non-maternity admissions (n = 509) were reviewed. The two hospitals provide acute medical care for a wide range of patients. The majority of patients appeared to require hospitalisation. It is likely that the beds at the two hospitals were mainly a substitute for district general hospital care. The general practitioner hospitals were estimated to be less costly than alternative forms of care, although it was doubtful whether they fulfilled all the structural criteria of quality generally regarded as important for hospitals of this type.
PMCID: PMC2448755  PMID: 8650831
20.  Is choice of general practitioner important for patients having coronary artery investigations? 
Quality in Health Care  1994;3(1):17-22.
OBJECTIVE--To determine whether particular sociodemographic characteristics of patients with stable angina affected their general practitioners' (GPs') decisions to refer them for revascularisation assessment. DESIGN--Postal questionnaire survey. SETTING--Collaborative survey by the departments of public health medicine in each of the four health boards in Northern Ireland, serving a total population of 1.5 million. SUBJECTS--All (962) GPs. MAIN MEASURES--The relation between GPs' referral decisions and patients' age, sex, employment status, home circumstances, smoking habits, and obesity. RESULTS--541 GPs replied (response rate 56%). Most were "neutral" towards a patient's sex (428, 79%), weight (331, 61%), smoking habit (302, 56%), employment status (431, 80%), and home circumstances (408, 75%) in making decisions about referral. In assigning priority for surgery most were neutral towards the patient's sex (459, 85%), employment status (378, 70%), and home circumstances (295, 55%). However, most GPs (518, 95%) said that younger patients were more likely to be referred, and a significant minority were less likely to refer patients who smoked (202, 37%) and obese patients (175, 32%) and more likely to refer employed patients (97, 18%) and those with dependents (117, 22%) (compared with patients with otherwise comparable clinical characteristics); these views paralleled the priority which GPs assigned these groups. The stated likelihood of referral of young patients was independent of the GPs' belief in ability to benefit from revascularisation, but propensity to refer and perception of benefit were significantly associated for all other patient characteristics. CONCLUSION--GPs' weighting of certain characteristics in reaching decisions about referral for angiography is not uniform and may contribute to unequal access to revascularisation services for certain patient groups.
PMCID: PMC1055177  PMID: 10136255
21.  Reliability of reported family history of myocardial infarction. 
BMJ : British Medical Journal  1993;307(6918):1528-1530.
OBJECTIVE--To assess the reliability of reported family histories of myocardial infarction. DESIGN--A case-control study in which reported histories of first degree relatives were validated from death certificates, general practitioners' records, and hospital notes. SETTING--Participants enrolled in the Belfast centre of the World Health Organisation's study monitoring trends and determinants in cardiovascular disease (MONICA). SUBJECTS--200 men who survived myocardial infarction and 200 age matched controls drawn randomly from the population. MAIN OUTCOME MEASURES--The sensitivity, specificity, positive predictive value, and proportion of overall agreement with validated records of reported family histories of myocardial infarction in first degree relatives; odds ratios for myocardial infarction, given at least one reported relative or at least one verified relative being affected. RESULTS--349 of the 400 probands provided detailed family histories, reporting on 2812 first degree relatives. The overall sensitivity, specificity, and positive predictive value of reported histories were 67.3%, 96.5%, and 70.5% for cases and 68.5%, 97.7%, and 73.8% for controls. The kappa coefficients were modest: 0.65 for cases and 0.68 for controls. The odds ratios for myocardial infarction, given at least one affected relative, were not substantially inflated by recall bias. Some recall bias was evident for the probands' reports of their siblings' histories of myocardial infarction, the odds ratio for a reported history being 1.67 (95% confidence interval 1.09 to 2.57) and for the validated history 1.54 (1.01 to 2.37). CONCLUSIONS--Although the relative risk of disease is correctly estimated, the predictive accuracy of a casual family history of myocardial infarction may limit the effectiveness of targeted screening programmes. They may, however, complement other strategies based on genetic testing.
PMCID: PMC1679560  PMID: 8274922
22.  Access to coronary catheterisation: fair shares for all? 
BMJ : British Medical Journal  1993;307(6915):1305-1307.
OBJECTIVE--To determine the effects of patient's sex and area's material deprivation on utilisation rates of coronary catheterisation and angiography in the investigation of ischaemic heart disease. DESIGN--Retrospective analysis of routinely collected hospital statistics. SETTING--Acute hospitals throughout Northern Ireland. SUBJECTS--24,179 episodes of patients discharged from hospital with a primary diagnosis of ischaemic heart disease and 1270 episodes relating to patients with an underlying diagnosis of ischaemic heart disease who had either coronary catheterisation or angiography. MAIN OUTCOME MEASURES--Age standardised admission rates for heart disease and age standardised utilisation rates for catheterisation or angiography, or both, for 566 electoral wards ranked by Townsend "deprivation" scores. RESULTS--Catheterisation-angiography rates in men were over fivefold those of women, ranging from 85.5/100,000 v 16/100,000 in patients from "well off" areas to 123/100,000 v 22/100,000 for patients from deprived areas. After admission rates for heart disease were controlled for, the overall rate ratio for women was 0.48 (95% confidence interval 0.38 to 0.60). After differential admission rates for heart disease and other potential clinical confounders were controlled for, the investigation rates of patients from the least and most "deprived" areas were not significantly different (rate ratio 1.04 (0.87 to 1.25)). CONCLUSION--Although investigation rates were significantly lower in women than in men, further clinical data would be required before labelling this underutilisation as evidence of bias. There was no significant difference in invasive investigation rates for heart disease in areas of varying deprivation or affluence.
PMCID: PMC1679460  PMID: 8257883
23.  Referrals for coronary angiography in a high risk population. 
Quality in Health Care  1993;2(2):87-90.
OBJECTIVES--To examine variations in referral for coronary angiography within Northern Ireland and relate these to local death rates from coronary artery disease (ICD rubrics 410-414). DESIGN--A descriptive retrospective analysis of aggregate hospital activity data for 1979-88 and corresponding mortality rates in the local population. SETTING--Two regional referral hospitals and 26 local district council areas. PATIENTS--5173 patients aged 35-74 years with an underlying diagnosis of ischaemic heart disease, whose records contained complete information on their age, sex, and home address. MAIN MEASURES--Age-standardised angiography rates and corresponding standardised death rates derived from the registrar general's reports. RESULTS--Among the 26 constituent district council areas there was significant heterogeneity in the angiography rates, ranging from 62 to 335/100,000 in men and from 7 to 62/100,000 in women (likelihood ratio statistic 856 and 359 respectively). There was no significant association between these angiography rates and the local death rates from ischaemic heart disease. CONCLUSION--The results suggest a non-uniform threshold for referral for angiography. IMPLICATIONS--Clinicians need to examine the appropriate indications for referral for invasive investigation.
PMCID: PMC1055090  PMID: 10131638
24.  Evaluating the breast screening programme: the need for surgical audit. 
It is to be anticipated that a reduction in population mortality attributable to mammographic screening would be heralded by an increasing proportion of breast cancer cases diagnosed at earlier stages and by an improvement in case fatality. Few cancer registers routinely produce incidence or survival data by stage at diagnosis and thus improvement in these will be the harder to assess. By thorough casenote review and follow up, this study has determined the usual presentation and survival of breast cancer in Northern Ireland in 1986 before the introduction of screening. Overall, 85% of cases were Manchester stage I or II, figures which accord with other British studies. Five-year survival ranged from 77.8% for stage I (95% confidence limits 71.7%, 82.7%) to 35.7% for stage IV (95% confidence limits 13.0%, 59.4%). Forty-three per cent of cases treated in non-teaching hospitals could not be pathologically staged, more than twice the figure for teaching hospitals (Chi-squared = 15.7, df = 1, P < 0.001). Since many tumours not detected by screening will be treated outside teaching centres, this difference will reduce the statistical power to detect the true shift in stage distribution and improvement in survival from screening. Comprehensive surgical audit would help to resolve the inadequacies in existing data collection and improve the ability to evaluate the outcome of the screening programme.
PMCID: PMC1293854  PMID: 8433312

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