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This study examines the costs of running a method of systematic care for diabetic patients in one general practice--the monthly 'diabetic day'. Doctor, nurse, chiropodist, dietitian, clerical officer, building and stationery costs were included in the evaluation. The study took place in an inner city practice of seven partners based in a health centre. The cost per year of running the diabetic days was 1854.53 pounds to the practice and 4465.69 pounds to the National Health Service (1989 prices). The cost to the practice included family health services authority reimbursements and excluded the cost of the chiropodist and dietitian. The cost per attendance was 38.17 pounds to the NHS and 15.85 pounds to the practice while the cost per patient per year was 58.00 pounds to the NHS and 24.08 pounds to the practice. The practice suffered a net loss after taking into account health promotion clinic payments received from the family health services authority. The cost to the NHS of each attendance at the practice was considerably greater than estimates of the cost of attendance at the outpatients department of a local trust hospital. However, it is argued that general practice has an essential role in the improvement of diabetic surveillance, and that an adequate remuneration package could transform the care of many patients with diabetes.
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PMID:Systematic care of diabetic patients in one general practice: how much does it cost? 145 72

All doctors, and most of their patients, are familiar with the consequences of stroke. In 1985 more than 70,000 men and women over the age of 65 died after a stroke and only one third of the survivors of stroke made a good recovery. It is thus a major source of chronic disability, placing a very heavy burden on patients' relatives and friends and consuming a great deal of NHS resources. The purpose of this Report is to set out guidelines for the clinical, radiological and pathological assessment of stroke, to suggest how to care for and rehabilitate patients who have suffered a stroke, and to evaluate and recommend measures for its prevention. The Report emphasises the need to use standard terms for the clinical description and classification of stroke, and the assessment of degrees of disability. It traces its changing epidemiology in the UK and in other countries and assesses the significance of putative risk factors such as hypertension, smoking, obesity, alcohol, diabetes, serum cholesterol, oral contraceptives and ischaemic heart disease. It sets out the indications for admitting patients to hospital and how they should be investigated, including the value of CT scanning at different intervals after the stroke has occurred. The Report describes the organisational aspects of the care of stroke patients during the acute phase, in the early recovery phase and in the longer term rehabilitation.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Stroke. Towards better management. Summary and recommendations of a report of the Royal College of Physicians. 230 9

The objective was to describe, by means of a retrospective study of three years' routine District information (financial years 1991/92 to 1993/94), the in- and out-patient activity for patients with diabetes, and compare this with the non-diabetic population. The clinical resource usage by patients with diabetes relative to those without was estimated by (a) their relative probability of admission by specialty, (b) attendance rates at out-patient clinics, (c) primary diagnosis, and (d) operations and procedures. The setting was a District Health Authority with a population of 408 000. All in-patient and out-patient records were reclassified as attributable to a patient with or without diabetes by cross-referral to routine records of patients with identified diabetes from separate hospital databases. The main outcome measures were: (a) relative frequency, and crude and age-specific relative probability of admission by specialty, ICD9 primary diagnosis, and OPCS4 primary operation and procedure, and (b) out-patient attendance rates by specialty. Patients with diabetes were responsible for 5.5% of admissions and 6.4% of out-patient attendances. However, because of increased length of stay, patients with diabetes occupy 9.4% of bed days. The relative risk of admission for diabetes related complications was: coronary heart disease 11.8 (95% CI = 11.4-12.3), cerebrovascular disease 11.8 (10.8-12.8), neuropathy and peripheral vascular disease 15.6 (13.6-17.9), eye complications 10.4 (9.3-11.7), and renal disease 14.7 (12.6-17.3). Recognised diabetes related vascular (9.3-11.7), and renal disease 14.7 (12.6-17.3). Recognised diabetes related vascular complications accounted for at least 23% of admissions of patients with diabetes. The relative risk of admission for diagnoses and procedures not known to be related to diabetes were similar for non-diabetic and diabetic patients. The pattern of out-patient activity mirrored that of the relative probability of admission. It is concluded that previous estimates of the proportion of NHS resources used for the treatment of patients with diabetes had been significantly underestimated. Patients with diabetes were found to occupy 1 in 10 non-obstetric, non-psychiatric beds. Many of these admissions were for diagnoses and procedures that are known to be related to diabetes.
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PMID:Patterns of in and out-patient activity for diabetes: a district survey. 868 50

Coronary artery disease (CAD) has a strong genetic component, but is also greatly influenced by environmental factors such as diet and smoking, and disorders such as diabetes mellitus and hypertension. This interaction makes prediction of CAD risk generally difficult. However, in familial hypercholesterolaemia (FH), risk of early CAD is considerably increased by the mutation of a single gene, and genetic testing may be appropriate. We summarize current knowledge concerning DNA-based tests in the identification and management of FH, and propose specific recommendations for genetic testing and further research. The major value of DNA tests for FH is in genetic tracing programs to identify and treat affected individuals. DNA testing is appropriate for: (a) diagnosis of FH when physical signs or family history are equivocal or absent (important given the increased risk of CAD associated with FH compared to other hypercholesterolaemias); (b) detection of a mutation causing FH in immediate family members (particularly children) where there is a family history of premature CAD. A positive DNA-based test for a mutation is especially useful in children, in whom plasma lipid levels may not be diagnostic. Current clinical practice is to test relatives for raised cholesterol. Testing for mutation carriers in distant relatives, although feasible, is not currently recommended. Research projects should now be started to address two issues: (i) whether genetic tests for FH better predict clinical outcome than does measurement of plasma lipid levels; (ii) whether genetic testing for FH confers overall benefit both to the patient and their relatives, and to the NHS. Answers to these questions will guide the subsequent development and implementation of genetic tests for CAD risk in general, if and when the considerably more complex genetic causes of CAD are identified.
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PMID:Genetic testing for familial hypercholesterolaemia: practical and ethical issues. 909 94

The inappropriate use of self monitoring of glucose is wasteful of NHS resources and can cause psychological harm. Although a few patients find that self monitoring enables them to understand and take control of their diabetes, many people with diabetes are performing inaccurate or unnecessary tests. There is no convincing evidence that self monitoring improves glycaemic control, nor that blood testing is necessarily better than urine testing. It may be appropriate for some patients not to monitor their own glucose but to rely instead on regular laboratory estimations of glycaemic control. Glucose self monitoring should be performed only when it serves an identified purpose. It is widely assumed that glucose self monitoring, preferably of blood glucose concentrations, is desirable or even essential for everyone with diabetes. It is common for patients who have previously tested their urine, or have done no glucose monitoring at home, to be taught to measure their blood glucose when they are admitted to hospital. In the community too, patients are often encouraged to monitor their blood glucose, and newly diagnosed patients of all ages are usually taught to measure their blood glucose concentrations. Self monitoring can sometimes be useful, but evidence is mounting that its indiscriminate use is of questionable value. In 1995, Pounds 42.6 million was spent on home monitoring of glucose in the United Kingdom (Intercontinental Medical Statistics, personal communication). Is this enormous cost justified? Is blood testing necessarily better than urine testing? Is glucose self monitoring always necessary, or is it sometimes a waste of time and money? Are recommendations for self monitoring based on sound evidence?
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PMID:Self monitoring of glucose by people with diabetes: evidence based practice. 925 56

We have established a records linkage between 'Diabeta' (the computerized clinical records system in the Diabetes Unit of St Thomas' Hospital) and the National Health Services Central Register (NHSCR) of the United Kingdom. Over 7000 diabetic patient records have been collected since 1973. Demographic data on all diabetic patients were retrieved and submitted to the NHSCR via a floppy disk. A matching system (automatic or manual) was used by the NHSCR to identify deceased patients and the most recent demographic data was provided on patients alive. This linkage resulted in an update of 91% of records in Diabeta. The findings of the update included: (1) 86% of diabetic patient's death had not been notified to the hospital and were not recorded on Diabeta. Mortality can now be assessed accurately as an outcome measure in our diabetic population. (2) Provision of the NHS number to Diabeta, as before it was not available on many patients seen in the hospital. The NHS number is a key patient identifier which can be used to exchange information within the NHS-wide network. (3) Diabetes was recorded as a cause of death in only 36% of death certificates. Analyses of death certificates alone must thus give poor information about mortality in diabetes. (4) Geographical location of patients on the database was updated, enabling tracing of patients for long-term studies and analyses of movement.
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PMID:Linking a hospital diabetes database and the National Health Service Central Register: a way to establish accurate mortality and movement data. 937 82

There is increasing recognition of the importance of primary care research in relation to diabetes. Doing research in general practice is in many ways different from the hospital setting. This article considers some of the potential barriers to doing valid and reliable research in general practice. It is written for both novice researchers and researchers new to the general practice setting. Careful initial definition of the research question is crucial, especially as the clinical material may be less well defined in general practice and patients' problems need addressing on many levels (physical, psychological, social, cultural). Searching the literature for general practice-based studies is not straightforward. If your study involves more than one geographical site you may have to obtain ethical approval from multiple research ethical committees, and it is prudent to discuss your research with the Local Medical Committee. Practical advice is given on working with practices: improving response rates from questionnaires; recruiting and retaining practices; 'getting hold' of the GPs; particular difficulties related to novice or experienced practices; ensuring uniformity of methodology; and the importance of ancillary staff. Contentious issues such as money should be discussed at the outset. Many areas of the country now have General Practice Research Networks, and many of these now have NHS R&D support funding. Training in research methodology can be accessed through the Association of University Departments of General Practice or Royal College of General Practitioners or local departments of general practice. A list of useful contacts is given.
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PMID:Doing research in general practice: advice for the uninitiated. 982 65

Erectile dysfunction, which is common among men with diabetes, leads to significant reduction in quality of life, and as with other complications of diabetes deserves to be treated on the NHS. This article explores the problem of erectile dysfunction and diabetes and the role of sildenafil, which is likely to be the first choice treatment of patients presenting with erectile dysfunction.
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PMID:Erectile dysfunction in patients with diabetes. 1062 89

The principle of a Third Way is to balance the autonomous needs of the individual with the need for community. Elevating Arts into a pivotal role across the spectrum of healthcare may provide a third way. Ill health is not isolated from society. A holistic approach sees health as successful adaptation to environment; Unemployment, social exclusion and bereavement become as much health concerns as diabetes. The health perspective should widen from the narrow scientific to a broader humanistic approach: changing professional medical education; introducing arts in healthcare settings and understanding the community impact of participation in the arts. Harnessing disparate perspectives present a challenge. Professional medical education should change to bridge the gap between science and society. Evidence suggests that the healthcare settings that support and reflect the perspectives offered by Dance, Music, Literature, Museums and Galleries lead to health gain and are in the long term cost-effective. Over the last decade a number of studies and grassroots projects have demonstrated the therapeutic value of arts in treating and preventing illness, yet there is a need to fully exploit this potential; health planners should provide leadership and support. The potential for arts to inform and facilitate individual expression is enourmous and should be further explored. A third way for health requires fundamental reassessment: what is health? What is a health centre: Arts should provide a third way to a dynamic engagement between the NHS and its constituents.
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PMID:Arts, health and wellbeing: a third way for health? 1062 13

Diabetes Mellitus is approaching pandemic proportions across the globe. It is a disproportionately expensive condition, accounting for 5-9% of annual NHS expenditure. Family practices often play a huge role in the care of diabetic patients. Many GPs elect to play a larger role in diabetes care, but the increasing burden on the multidisciplinary secondary care team means that some of the burden has to fall to family practitioners. In order to provide a high standard of care, the practitioner requires access to continuing education regarding diabetes care. The value of patient education is undisputed. In light of this situation a computer-aided learning (CAL) system is being developed for the education of both patients and practitioners concerning diabetes and its care. The proposed system takes a two pronged approach, being aimed at both patient and practitioner. This interactive system employs multimedia technology to teach practical skills and promote and consolidate theoretical understanding. It is hoped this system will improve patient self-care, and in the long-term reduce the incidence of diabetic complications and their associated costs.
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PMID:Computer-aided learning for the education of patients and family practice professionals in the personal care of diabetes. 1083 6


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