• 【彻底根治性膀胱切除术在英国膀胱癌的中心化,距“改善预后指南”已经十年了:超级中心化的情况。】 复制标题 收藏 收藏
    DOI:10.1111/bju.13929 复制DOI
    作者列表:Afshar M,Goodfellow H,Jackson-Spence F,Evison F,Parkin J,Bryan RT,Parsons H,James ND,Patel P
    BACKGROUND & AIMS: OBJECTIVE:To analyse the impact of centralisation of radical cystectomy (RC) provision for bladder cancer in England, on postoperative mortality, length of stay (LoS), complications and re-intervention rates, from implementation of centralisation from 2003 until 2014. In 2002, UK policymakers introduced the 'Improving Outcomes Guidance' (IOG) for urological cancers after a global cancer surgery commission identified substantial shortcomings in provision of care of RCs. One key recommendation was centralisation of RCs to high-output centres. No study has yet robustly analysed the changes since the introduction of the IOG, to assess a national healthcare system that has mature data on such institutional transformation. PATIENTS AND METHODS:RCs performed for bladder cancer in England between 2003/2004 and 2013/2014 were analysed from Hospital Episode Statistics (HES) data. Outcomes including 30-day, 90-day, and 1-year all-cause postoperative mortality; median LoS; complication and re-intervention rates, were calculated. Multivariable statistical analysis was undertaken to describe the relationship between each surgeon and the providers' annual case volume and mortality. RESULTS:In all, 15 292 RCs were identified. The percentage of RCs performed in discordance with the IOG guidelines reduced from 65% to 12.4%, corresponding with an improvement in 30-day mortality from 2.7% to 1.5% (P = 0.024). Procedures adhering to the IOG guidelines had better 30-day mortality (2.1% vs 2.9%; P = 0.003) than those that did not, and better 1-year mortality (21.5% vs 25.6%; P < 0.001), LoS (14 vs 16 days; P < 0.001), and re- intervention rates (30.0% vs 33.6%; P < 0.001). Each single extra surgery per centre reduced the odds of death at 30 days by 1.5% (odds ratio [OR] 0.985, 95% confidence interval [CI] 0.977-0.992) and 1% at 1 year (OR 0.990, 95% CI 0.988-0.993), and significantly reduced rates of re-intervention. CONCLUSION:Centralisation has been implemented across England since the publication of the IOG guidelines in 2002. The improved outcomes shown, including that a single extra procedure per year per centre can significantly reduce mortality and re-intervention, may serve to offer healthcare planners an evidence base to propose new guidance for further optimisation of surgical provision, and hope for other healthcare systems that such widespread institutional change is achievable and positive.
    背景与目标: 目的:分析从2003年至2014年实施中央集权化对英国膀胱癌的根治性膀胱切除术(RC)的集中化对术后死亡率,住院时间(LoS),并发症和再干预率的影响。2002年,英国的一项政策制定者在全球癌症外科委员会发现了在提供RC护理方面存在的重大缺陷后,针对泌尿系统癌症引入了“改善结果指南”(IOG)。一项重要建议是将区域合作中心集中到高产出中心。自从引入IOG以来,还没有研究有力地分析这些变化,以评估拥有有关此类机构转型的成熟数据的国家医疗保健系统。
    病人与方法:根据《医院病情统计》(HES)数据分析了2003/2004年至2013/2014年在英格兰进行的膀胱癌RCs。结果包括30天,90天和1年的全因术后死亡率;中位数视距;计算并发症发生率和再干预率。进行多变量统计分析以描述每个外科医生与提供者的年度病例数量和死亡率之间的关系。
    结果:总共鉴定出15 292个RC。与IOG指南不符的RC的百分比从65%降低到12.4%,对应的30天死亡率从2.7%降低到1.5%(P = 0.024)。遵循IOG指南的程序的LoS较好,其30天死亡率(2.1%比2.9%; P = 0.003)和没有更好的1年死亡率(21.5%比25.6%; P <0.001),LoS(14) vs 16天; P <0.001)和再干预率(30.0%vs 33.6%; P <0.001)。每个中心的每一次额外手术都会使30天时的死亡几率降低1.5%(赔率[OR] 0.985,95%置信区间[CI] 0.977-0.992)和1%时1%(OR 0.990,95%CI 0.988) -0.993),并显着降低了再次干预率。
    结论:自从2002年IOG指南发布以来,英格兰就开始实行集中化措施。结果有所改善,包括每个中心每年增加一次额外程序可以显着降低死亡率和再次干预,这可能为医疗保健计划者提供证据以此为基础,为进一步优化外科手术提供新的指导,并希望其他医疗保健系统能够实现这种广泛的机构变革,并带来积极的影响。
  • 【成年患者接受NHS慢性疲劳综合症(CFS / ME)专业服务的经验:在英国进行的定性研究。】 复制标题 收藏 收藏
    DOI:10.1186/s12913-017-2337-6 复制DOI
    作者列表:Broughton J,Harris S,Beasant L,Crawley E,Collin SM
    BACKGROUND & AIMS: BACKGROUND:Few studies have explored patients' experiences of treatment for CFS/ME. This study aims to fill this gap by capturing the perspective of patients who have been treated by NHS specialist CFS/ME services in England. METHODS:Semi-structured interviews were conducted during the period June-September 2014 with 16 adults who were completing treatment at one of three outpatient NHS specialist CFS/ME services. Interviews were analysed thematically using constant comparison techniques, with particular attention paid to contrasting views. RESULTS:Three themes were identified: 'Journey to specialist services'; 'Things that help or hinder treatment'; and 'Support systems'. Within these themes nine sub-themes were identified. A wide range of factors was evident in forming participants' experiences, including personal characteristics such as perseverance and optimism, and service factors such as flexibility and positive, supportive relationships with clinicians. Participants described how specialist services played a unique role, which was related to the contested nature of the condition. Many participants had experienced a lack of validation and medical and social support before attending a specialist service. Patients' experiences of life before referral, and the concerns that they expressed about being discharged, highlighted the hardship and obstacles which people living with CFS/ME continue to experience in our society. CONCLUSIONS:The experiences of CFS/ME patients in our study showed that NHS specialist CFS/ME services played a vital role in patients' journeys towards an improved quality of life. This improvement came about through a process which included validation of patients' experiences, acceptance of change, practical advice and support, and therapeutic outcomes.
    背景与目标: 背景:很少有研究探讨患者对CFS / ME的治疗经验。这项研究旨在通过捕获英国NHS专家CFS / ME服务所治疗患者的观点来填补这一空白。
    方法:在2014年6月至9月期间,对三名门诊NHS专家CFS / ME服务之一中完成治疗的16名成年人进行了半结构式访谈。访谈采用恒定比较技术进行主题分析,尤其要注意对比观点。
    结果:确定了三个主题:“专业服务之旅”; “有助于或阻碍治疗的事情”;和“支持系统”。在这些主题中,确定了9个子主题。形成参与者体验的因素很明显,包括毅力和乐观情绪等个人特征,以及灵活性和与临床医生之间的积极支持关系等服务因素。参与者描述了专家服务如何发挥独特作用,这与疾病的争议性质有关。许多参与者在参加专科服务之前经历了缺乏验证以及医疗和社会支持的经历。患者转诊前的生活经历以及他们对出院的担忧,凸显了CFS / ME患者在我们社会中继续经历的艰辛和障碍。
    结论:本研究中CFS / ME患者的经验表明,NHS专家CFS / ME服务在患者改善生活质量的旅程中起着至关重要的作用。这种改善是通过一个过程来实现的,该过程包括验证患者的经历,接受变更,实用的建议和支持以及治疗效果。
  • 【“试图在盒子上没有照片的情况下进行拼图”:了解在对英格兰老年人进行单次评估的情况下医疗整合的挑战。】 复制标题 收藏 收藏
    DOI:10.5334/ijic.186 复制DOI
    作者列表:Wilson R,Baines S,Cornford J,Martin M
    BACKGROUND & AIMS: INTRODUCTION:Demographic ageing is one of the major challenges for governments in developed countries because older people are the main users of health and social care services. More joined-up, partnership approaches supported by information and communications technologies (ICTs) have become key to managing these demands. This article discusses recent developments towards integrated care in the context of one of the arenas in which integration is being attempted, the Single Assessment Process (SAP) to support the care for older people in England. It draws upon accounts of local SAP implementations in order to assess and reflect upon some of the successes and limitations of service integration enabled by ICTs. DESCRIPTION OF CARE PRACTICE:At the Department of Health in England, policy and strategy are directed at the integration of services through a 'whole systems' approach, with services that are interdependent upon one another and organised around the person that uses them. The Single Assessment Processes (SAP) is an instance of inter-organisational and cross-sectoral sharing of information intended to improve communication and coordination amongst professions and agencies and so support more integrated care. The aim of SAP is to ensure that older people receive appropriate, effective and timely responses to their health and social care needs and that professionals do not duplicate each others efforts. This article examines examples from two programmes of work within the context of SAP in England: one with the direction coming from local government social services, the other where the momentum is coming from the National Health Service (NHS). CONCLUSION AND DISCUSSION:Both examples show that the policy and practice of ICT-supported integration continues to represent a significant challenge. Although the notion of integrated care underpinned by ICT-enabled information sharing is persuasive, it has limitations in practice. The notion of an 'open systems' approach is proposed as an alternative way of improving communication and coordination across the domains of health and social care.
    背景与目标: 简介:人口老龄化是发达国家政府面临的主要挑战之一,因为老年人是卫生和社会护理服务的主要使用者。在信息和通信技术(ICT)的支持下,更多的联合伙伴关系方法已成为管理这些需求的关键。本文讨论了尝试整合的领域之一,即单一评估流程(SAP)以支持英格兰老年人护理的最新发展。它利用本地SAP实施的帐户来评估和反思ICT带来的服务集成的一些成功和局限性。
    护理实践说明:在英格兰卫生部,政策和策略旨在通过“整体系统”方法来整合服务,服务相互依赖并围绕使用它们的人进行组织。单一评估流程(SAP)是组织间和跨部门共享信息的一个实例,旨在改善专业和机构之间的沟通和协调,从而支持更全面的护理。 SAP的目的是确保老年人能够对其健康和社会护理需求做出适当,有效和及时的回应,并且确保专业人员之间不会相互重复。本文研究了SAP在英格兰范围内的两个工作计划的示例:一个计划的方向来自地方政府的社会服务,另一个计划的动力来自国家卫生服务(NHS)。
    结论和讨论:两个例子都表明,信息通信技术支持的一体化的政策和做法继续构成重大挑战。尽管以信息通信技术促成的信息共享为基础的综合保健的概念具有说服力,但在实践中仍存在局限性。提出了“开放系统”方法的概念,作为改善跨卫生和社会护理领域沟通与协调的另一种方法。
  • 【由初级保健领导的调试:将过去的经验教训应用到英格兰临床调试小组的早期发展中。】 复制标题 收藏 收藏
    DOI:10.3399/bjgp13X671597 复制DOI
    作者列表:Checkland K,Coleman A,McDermott I,Segar J,Miller R,Petsoulas C,Wallace A,Harrison S,Peckham S
    BACKGROUND & AIMS: BACKGROUND:The current reorganisation of the English NHS is one of the most comprehensive ever seen. This study reports early evidence from the development of clinical commissioning groups (CCGs), a key element in the new structures. AIM:To explore the development of CCGs in the context of what is known from previous studies of GP involvement in commissioning. DESIGN AND SETTING:Case study analysis from sites chosen to provide maximum variety across a number of dimensions, from September 2011 to June 2012. METHOD:A case study analysis was conducted using eight detailed qualitative case studies supplemented by descriptive information from web surveys at two points in time. Data collection involved observation of a variety of meetings, and interviews with key participants. RESULTS:Previous research shows that clinical involvement in commissioning is most effective when GPs feel able to act autonomously. Complicated internal structures, alongside developing external accountability relationships mean that CCGs' freedom to act may be subject to considerable constraint. Effective GP engagement is also important in determining outcomes of clinical commissioning, and there are a number of outstanding issues for CCGs, including: who feels 'ownership' of the CCG; how internal communication is conceptualised and realised; and the role and remit of locality groups. Previous incarnations of GP-led commissioning have tended to focus on local and primary care services. CCGs are keen to act to improve quality in their constituent practices, using approaches that many developed under practice-based commissioning. Constrained managerial support and the need to maintain GP engagement may have an impact. CONCLUSION:CCGs are new organisations, faced with significant new responsibilities. This study provides early evidence of issues that CCGs and those responsible for CCG development may wish to address.
    背景与目标: 背景:目前对英语NHS的重组是有史以来最全面的重组之一。这项研究报告了来自临床调试小组(CCG)发展的早期证据,CCG是新结构中的关键要素。
    目的:在先前有关GP参与调试的研究中得知的背景下,探索CCG的发展。
    设计与设置:从2011年9月至2012年6月,对在各个维度上提供最大多样性的站点进行案例研究分析。
    方法:使用八个详细的定性案例研究进行案例分析,并在两个时间点从网络调查中获得描述性信息。数据收集涉及对各种会议的观察以及对主要参与者的采访。
    结果:先前的研究表明,当GP能够自主行动时,临床参与调试是最有效的。复杂的内部结构以及不断发展的外部问责关系意味着CCG的行动自由可能受到相当大的限制。有效的全科医生参与对于确定临床调试的结果也很重要,对于CCG而言,存在许多悬而未决的问题,包括:谁感觉到CCG的“所有权”;内部沟通如何被概念化和实现;以及地方团体的作用和职权范围。以前由GP领导的投身方式倾向于集中在本地和初级保健服务上。 CCG热衷于采取行动,使用许多基于实践的委托开发的方法来提高其组成实践的质量。有限的管理支持和维持GP参与的需求可能会产生影响。
    结论:CCG是新的组织,面临着重大的新职责。这项研究提供了CCG和CCG开发负责人可能希望解决的问题的早期证据。
  • 【一项针对英格兰年轻人的心理健康服务转型对患者获取,资源利用和健康的影响:一项准实验研究。】 复制标题 收藏 收藏
    DOI:10.1136/bmjopen-2019-034067 复制DOI
    作者列表:Rocks S,Fazel M,Tsiachristas A
    BACKGROUND & AIMS: OBJECTIVE:To evaluate the impact of child and adolescent mental health services (CAMHS) transformation in South East England on patient access, resource utilisation and health outcomes. DESIGN:In an observational study, we use difference-in-differences analysis with propensity score matching to analyse routinely collected patient level data. SETTING:Three CAMHS services in South East England. PARTICIPANTS:All patients attending CAMHS between April 2012 and December 2018, with more than 57 000 spells of care included. MAIN OUTCOME MEASURES:The rate and volume of people accessing CAMHS; waiting times to the first contact and waiting times between the first and second contact; and health outcomes, including the Strengths and Difficulties Questionnaire (SDQ) and the Revised Child Anxiety and Depression Scale (RCADS). RESULTS:The intervention led to 20% (incidence rate ratio: 1.20; 95% CI: 1.15 to 1.24) more new patients starting per month. There was mixed evidence on waiting times for the first contact. The intervention led to 10% (incidence rate ratio: 1.10; 95% CI: 1.02 to 1.18) higher waiting time for the second contact. The number of contacts per spell (OR: 1.08; 95% CI: 0.94 to 1.25) and the rereferral rate (OR: 1.06; 95% CI: 0.96 to 1.17) were not significantly different. During the post intervention period, patients in the intervention group scored on average 3.3 (95% CI: -5.0 to -1.6) points lower on the RCADS and 1.0 (95% CI: -1.8 to -0.3) points lower on the SDQ compared with the control group after adjusting for the baseline score. CONCLUSIONS:Overall, there are signs that transformation can help CAMHS achieve the objectives of greater access and improved health outcomes, but trade-offs exist among different performance metrics, particularly between access and waiting times. Commissioners and providers should be conscious of any trade-offs when undertaking service redesign and transformation.
    背景与目标: 目的:评估英格兰东南部的儿童和青少年心理健康服务(CAMHS)转型对患者获取,资源利用和健康结果的影响。
    设计:在一项观察性研究中,我们使用差异评分分析和倾向得分匹配来分析常规收集的患者水平数据。
    地点:英格兰东南部的三项CAMHS服务。
    参加者:2012年4月至2018年12月期间参加CAMHS的所有患者,包括超过5.7万例护理。
    主要观察指标:访问CAMHS的人数和数量;第一联系人的等待时间以及第一联系人和第二联系人之间的等待时间;和健康结果,包括优势和困难问卷(SDQ)和修订后的儿童焦虑和抑郁量表(RCADS)。
    结果:干预导致每月开始增加新患者20%(发生率:1.20; 95%1.CI:1.15至1.24)。关于首次联系的等待时间,有各种各样的证据。干预导致第二次接触的等待时间增加10%(发生率:1.10; 95%CI:1.02至1.18)。每个咒语的接触次数(OR:1.08; 95%CI:0.94至1.25)和引荐率(OR:1.06; 95%CI:0.96至1.17)没有显着差异。在干预后的期间,干预组的患者在RCADS上平均得分低3.3分(95%CI:-5.0至-1.6),在SDQ上平均得分低1.0(95%CI:-1.8至-0.3)得分。调整基线得分后,再与对照组进行比较。
    结论:总的来说,有迹象表明,转型可以帮助CAMHS实现更多获取和改善健康结果的目标,但是在不同的绩效指标之间存在权衡,特别是在获取和等待时间之间。专员和提供者在进行服务重新设计和转换时应意识到任何权衡取舍。
  • 【在英格兰农村地区实施当地空气质量管理方面取得的进展。】 复制标题 收藏 收藏
    DOI:10.1006/jema.2000.0391 复制DOI
    作者列表:Ing C,Beattie C,Longhurst J
    BACKGROUND & AIMS: :Air quality in the UK, although vastly improved from the smogs of the 1950s, now faces a new set of challenges from a variety of sources and pollutants. Poor air quality has long been associated with urban areas, but it is becoming clear that many rural locations also have locations likely to exceed the UK Air Quality Strategy-objectives: This paper will examine the extent to which rural authorities have been engaged in the local air-quality management (LAQM) process, a new regime by which air quality control is being accomplished in the UK. Results are presented from a questionnaire survey of environmental health officers of 100 rural authorities undertaken in January 1999. The paper investigates both the technical aspects of the LAQM process as well as the management approaches. The current progress of rural authorities, and some of the problems they face, are discussed particularly in comparison with urban areas. It is concluded that some rural authorities with air pollution problems stemming either from within or outwith their borough, may face significant challenges from the LAQM review and assessment process, particularly where air pollution responsibilities have only relatively recently been addressed. Rural authorities seem to be embracing these new responsibilities enthusiastically, but it is almost inevitable that they will be trailing behind urban authorities who have several decades of experience and joint working to draw upon.
    背景与目标: :尽管1950年代的烟雾大大改善了英国的空气质量,但如今它面临着来自各种来源和污染物的一系列新挑战。长期以来,空气质量差一直与城市地区有关,但是越来越明显的是,许多农村地区的位置也可能超过英国《空气质量战略》的目标:本文将研究农村当局在当地开展活动的程度。空气质量管理(LAQM)流程,这是英国正在实施的一种新的空气质量控制制度。结果来自于1999年1月对100个农村当局的环境卫生官员进行的问卷调查。该文件同时调查了LAQM流程的技术方面和管理方法。特别是与城市地区相比,讨论了农村当局的当前进展以及他们面临的一些问题。结论是,一些农村当局因其行政区内部或外部产生的空气污染问题可能会面临来自LAQM审查和评估过程的重大挑战,特别是在空气污染责任只是在最近才得到解决的地方。农村当局似乎热情地承担着这些新的责任,但是,它们将不可避免地落后于拥有数十年经验和共同工作经验的城市当局。
  • 【英格兰初级保健质量与冠心病住院治疗之间的关联:国家横断面研究。】 复制标题 收藏 收藏
    DOI:10.1007/s11606-007-0390-2 复制DOI
    作者列表:Bottle A,Gnani S,Saxena S,Aylin P,Mainous AG 3rd,Majeed A
    BACKGROUND & AIMS: BACKGROUND:A new pay-for-performance scheme for primary care physicians was introduced in England in 2004 as part of an initiative to link the quality of primary care with physician pay. OBJECTIVE:To investigate the association between the quality of primary care and rates of hospital admissions for coronary heart disease. DESIGN:Ecological cross-sectional study using data from the Quality and Outcomes Framework for family practice, hospital admissions, and census data. PARTICIPANTS:All 303 primary care trusts in England, covering approximately 50 million people. MEASUREMENTS:Rates of elective and unplanned hospital admissions for coronary heart disease and rates of coronary angioplasty and coronary artery bypass grafting were regressed against quality-of-care measures from the Quality and Outcomes Framework, area socioeconomic scores, and disease prevalence. RESULTS:Correlations between prevalence, area socioeconomic scores, and admission rates were generally weak. The strongest relations were seen between area socioeconomic scores and elective and unplanned hospital admissions and revascularization procedures among the age group 45-74 years. Among those aged 75 years and over, the only positive association observed was between area socioeconomic scores and unplanned hospital admissions. CONCLUSIONS:The lack of an association between quality scores and admission rates suggests that improving the quality of primary care may not reduce demands on the hospital sector and that other factors are much better predictors of hospitalization for coronary heart disease.
    背景与目标: 摘要背景:2004年在英格兰引入了一种新的针对基层医疗医生的绩效工资计划,该计划是将基层医疗质量与医生薪酬联系起来的一项举措。
    目的:探讨基层医疗质量与冠心病住院率之间的关系。
    设计:采用横断面质量和结果框架中的数据进行生态横断面研究,以获取家庭执业,住院人数和人口普查数据。
    参与者:英格兰所有303个初级保健信托基金,覆盖约5000万人。
    测量:根据“质量和结果框架”,区域社会经济得分和疾病患病率,对护理质量指标进行回归分析,得出针对冠心病的选择性和计划外入院率,冠状动脉成形术和冠状动脉搭桥术的发生率。
    结果:患病率,地区社会经济得分和入学率之间的相关性通常较弱。在45-74岁年龄段中,地区社会经济得分与选择性和计划外的入院和血运重建程序之间的关系最密切。在75岁及以上的人群中,观察到的唯一正相关是地区社会经济得分与计划外的住院人数之间的关系。
    结论:质量得分与入院率之间缺乏关联,表明改善初级保健质量可能不会减少对医院部门的需求,而其他因素则更能预测冠心病住院率。
  • 【疼痛和功能在全膝关节置换术后确定患者满意度中的作用。英格兰和威尔士国家联合登记处的数据。】 复制标题 收藏 收藏
    DOI:10.1302/0301-620X.89B7.19091 复制DOI
    作者列表:Baker PN,van der Meulen JH,Lewsey J,Gregg PJ,National Joint Registry for England and Wales.
    BACKGROUND & AIMS: :A postal questionnaire was sent to 10,000 patients more than one year after their total knee replacement (TKR). They were assessed using the Oxford knee score and were asked whether they were satisfied, unsure or unsatisfied with their TKR. The response rate was 87.4% (8231 of 9417 eligible questionnaires) and a total of 81.8% (6625 of 8095) of patients were satisfied. Multivariable regression modelling showed that patients with higher scores relating to the pain and function elements of the Oxford knee score had a lower level of satisfaction (p < 0.001), and that ongoing pain was a stronger predictor of this. Female gender and a primary diagnosis of osteoarthritis were found to be predictors of lower levels of patient satisfaction. Differences in the rate of satisfaction were also observed in relation to age, the American Society of Anesthesiologists grade and the type of prosthesis. This study has provided data on the Oxford knee score and the expected levels of satisfaction at one year after TKR. The results should act as a benchmark of practice in the United Kingdom and provide a baseline for peer comparison between institutions.
    背景与目标: :在他们的全膝关节置换术(TKR)一年多后,向10,000名患者发送了邮政问卷。使用牛津膝关节评分对他们进行评估,并询问他们是否对TKR感到满意,不确定或不满意。回应率为87.4%(9417份合格问卷中的8231份),总计81.8%(8095的6625份)患者满意。多变量回归模型显示,与牛津膝盖评分的疼痛和功能要素相关的评分较高的患者满意度较低(p <0.001),而持续疼痛是对此的更强预测指标。发现女性和骨关节炎的初步诊断是患者满意度降低的预测因素。满意度的差异还与年龄,美国麻醉医师学会等级和假体类型有关。这项研究提供了有关牛津膝关节评分和TKR一年后预期满意度的数据。结果应作为英国实践的基准,并为机构之间的同行比较提供基准。
  • 【在英格兰早期盎格鲁撒克逊时代是否有必要采取种族隔离般的社会结构?】 复制标题 收藏 收藏
    DOI:10.1098/rspb.2008.0352 复制DOI
    作者列表:Pattison JE
    BACKGROUND & AIMS: :It has recently been argued that there was an apartheid-like social structure operating in Early Anglo-Saxon England. This was proposed in order to explain the relatively high degree of similarity between Germanic-speaking areas of northwest Europe and England. Opinions vary as to whether there was a substantial Germanic invasion or only a relatively small number arrived in Britain during this period. Contrary to the assumption of limited intermarriage made in the apartheid simulation, there is evidence that significant mixing of the British and Germanic peoples occurred, and that the early law codes, such as that of King Ine of Wessex, could have deliberately encouraged such mixing. More importantly, the simulation did not take into account any northwest European immigration that arrived both before and after the Early Anglo-Saxon period. In view of the uncertainty of the places of origin of the various Germanic peoples, and their numbers and dates of arrival, the present study adopts an alternative approach to estimate the percentage of indigenous Britons in the current British population. It was found unnecessary to introduce any special social structure among the diverse Anglo-Saxon people in order to account for the estimates of northwest European intrusion into the British population.
    背景与目标: :最近有人争辩说,英格兰早期盎格鲁-撒克逊人有一个类似种族隔离的社会结构。提出这一点是为了解释西北欧洲日耳曼语地区与英格兰之间相对较高的相似度。关于在此期间是否发生了大规模的日耳曼式入侵或仅少量入侵英国的观点不一。与种族隔离模拟中对通婚的限制相反,有证据表明英国人和日耳曼人发生了重大的混合,而且早期的法律法规,例如韦塞克斯国王伊内国王的法规,可能会故意鼓励这种混合。更重要的是,模拟没有考虑到盎格鲁-撒克逊早期之前和之后到达的任何西北欧洲移民。鉴于各种日耳曼人民的原籍地及其数量和到达日期尚不确定,因此本研究采用另一种方法来估计当前英国人口中土著英国人的比例。人们发现没有必要在盎格鲁-撒克逊人中引入任何特殊的社会结构,以解释西北欧洲入侵英国人口的估计。
  • 【使用多层层次回归模型,研究组织结构对英格兰所有急诊医院急诊就诊单元中患者体验得分的影响程度。】 复制标题 收藏 收藏
    DOI:10.1136/bmjopen-2016-012133 复制DOI
    作者列表:Sullivan P,Bell D
    BACKGROUND & AIMS: OBJECTIVES:Previous studies found that hospital and specialty have limited influence on patient experience scores, and patient level factors are more important. This could be due to heterogeneity of experience delivery across subunits within organisations. We aimed to determine whether organisation level factors have greater impact if scores for the same subspecialty microsystem are analysed in each hospital. SETTING:Acute medical admission units in all NHS Acute Trusts in England. PARTICIPANTS:We analysed patient experience data from the English Adult Inpatient Survey which is administered to 850 patients annually in each acute NHS Trusts in England. We selected all 8753 patients who returned the survey and who were emergency medical admissions and stayed in their admission unit for 1-2 nights, so as to isolate the experience delivered during the acute admission process. PRIMARY AND SECONDARY OUTCOME MEASURES:We used multilevel logistic regression to determine the apportioned influence of host organisation and of organisation level factors (size and teaching status), and patient level factors (demographics, presence of long-term conditions and disabilities). We selected 'being treated with respect and dignity' and 'pain control' as primary outcome parameters. Other Picker Domain question scores were analysed as secondary parameters. RESULTS:The proportion of overall variance attributable at organisational level was small; 0.5% (NS) for respect and dignity, 0.4% (NS) for pain control. Long-standing conditions and consequent disabilities were associated with low scores. Other item scores also showed that most influence was from patient level factors. CONCLUSIONS:When a single microsystem, the acute medical admission process, is isolated, variance in experience scores is mainly explainable by patient level factors with limited organisational level influence. This has implications for the use of generic patient experience surveys for comparison between Trusts and should prompt further research to explore if more discriminant surveys can be developed.
    背景与目标: 目的:先前的研究发现,医院和专科医院对患者经验得分的影响有限,患者水平因素更为重要。这可能是由于组织内各个子部门之间经验交付的异质性。我们旨在确定,如果在每家医院中分析相同的亚专业微系统的分数,组织水平因素是否会产生更大的影响。
    地点:英格兰所有NHS急性信托基金中的急性医疗收治单位。
    参与者:我们分析了来自英国成人住院调查的患者经验数据,该数据每年在英格兰的每个急性NHS信托基金中对850名患者进行管理。我们选择了所有返回调查的8753名患者,这些患者均为急诊入院,并在其入院病房中停留了1-2个晚上,以隔离急性入院过程中提供的经验。
    主要和次要指标:我们使用多级逻辑回归分析确定宿主组织和组织水平因素(规模和教学状况)以及患者水平因素(人口统计学,长期病情和残疾)的分配影响。我们选择“受到尊重和尊严对待”和“疼痛控制”作为主要结局指标。将其他Picker Domain问题分数作为次要参数进行分析。
    结果:在组织层面,总体差异的比例很小;尊重和尊严为0.5%(NS),控制疼痛为0.4%(NS)。长期的状况和随之而来的残疾与低分相关。其他项目得分也表明,影响最大的是患者水平因素。
    结论:当一个单独的系统(即急性医疗入院流程)被隔离时,经验得分的差异主要可以由受组织水平影响有限的患者水平因素来解释。这对于使用通用的患者经验调查来在Trust之间进行比较具有影响,并且应该促使进行进一步的研究以探索是否可以开发出更多的有区别的调查。
  • 【新英格兰稀有植物的生物地理学和衰落:历史证据和当代监测。】 复制标题 收藏 收藏
    DOI:10.1890/1051-0761(2006)016[1327:badorp]2.0.co;2 复制DOI
    作者列表:Farnsworth EJ,Ogurcak DE
    BACKGROUND & AIMS: :Detecting range shifts and contractions is critical for determining the conservation priority of rare and declining taxa. However, data on rare species occurrences frequently lack precise information on locations and habitats and may present a biased picture of biogeographic distributions and presumed habitat preferences. Herbarium or museum specimen data, which otherwise could be useful proxies for detecting temporal trends and spatial patterns in species distributions, pose particular challenges. Using data from herbaria and Natural Heritage Programs on numbers of occurrences within individual municipalities (towns, cities, or townships), we quantified temporal changes in the estimated distributions of 110 rare plant species in the six New England (USA) states. We used the partial Solow equation and a nonparametric test to estimate the probability of observing multiple absences (gaps in the collection record) if a given population was actually still extant. Bayes' Theorem was used to estimate the probability that occurrences were misclassified as extinct. Using the probabilities obtained from these three methods, we eliminated taxa with high probabilities of pseudo-absence (that would yield an inaccurate profile of species distributions), narrowing the set for final analysis to 71 taxa. We then expressed occurrences as centroids of town polygons and estimated current and historical range areas (extents of occurrence as defined by alpha-hulls inscribing occurrences), mean distances between occurrences, and latitudinal and longitudinal range boundaries. Using a geographic information system, we modeled first, second, and third circular standard deviational polygons around the mean center of the historical range. Examining the distribution of current occurrences within each standard deviational polygon, we asked whether ranges were collapsing to a center, expanding, fragmenting, or contracting to a margin of the former range. Extant ranges of the species were, on average, almost 67% smaller than their historical ranges, and distances among occurrences decreased. Five New England hotspots were observed to contain >35% of rare plant populations. Extant occurrences were more frequently marginalized at the periphery of the historical range than would be expected by chance. Coarse-grained data on current and historical occurrences can be used to examine large suites of species to prioritize taxa and sites for conservation.
    背景与目标: :检测范围的变化和收缩对于确定稀有和下降的类群的保护优先级至关重要。但是,关于稀有物种发生的数据通常缺乏有关位置和栖息地的精确信息,并且可能会呈现出生物地理分布和假定的栖息地偏好的偏见。植物标本室或博物馆的标本数据,否则可能是检测物种分布的时间趋势和空间格局的有用代理,这带来了特殊的挑战。使用来自草本植物和自然遗产计划的数据,了解各个城市(城镇,城市或乡镇)内的发生次数,我们量化了六个新英格兰(美国)州110种稀有植物物种的估计分布的时间变化。如果给定人口实际上仍然存在,我们使用偏Solow方程和非参数检验来估计观察到多个缺勤(收集记录中存在缺口)的可能性。贝叶斯定理用于估计发生错误归类为灭绝的可能性。使用从这三种方法获得的概率,我们消除了伪伪概率很高的分类单元(这将导致物种分布的轮廓不准确),从而将最终分析的范围缩小到71个分类单元。然后,我们将事件表示为城镇多边形的质心,并估计当前和历史范围区域(事件发生的程度,由包含事件的alpha壳定义),事件之间的平均距离以及纬度和纵向范围边界。使用地理信息系统,我们围绕历史范围的平均中心对第一,第二和第三圆形标准偏差多边形进行了建模。检查每个标准偏差多边形中当前事件的分布,我们询问范围是否塌陷到中心,正在扩展,碎片化或收缩到前一个范围的边缘。该物种的现存范围平均比其历史范围小了近67%,并且出现次数之间的距离减小了。观察到五个新英格兰热点的稀有植物种群超过35%。在历史范围的外围,现存的事件比被偶然预期的更经常地被边缘化。可以使用有关当前和历史事件的粗粒度数据来检查大型物种,从而优先考虑分类单元和保护地点。
  • 【应对污名和歧视:来自英国精神卫生服务使用者的证据。】 复制标题 收藏 收藏
    DOI:10.1017/S204579601700021X 复制DOI
    作者列表:Isaksson A,Corker E,Cotney J,Hamilton S,Pinfold V,Rose D,Rüsch N,Henderson C,Thornicroft G,Evans-Lacko S
    BACKGROUND & AIMS: AIMS:Mental health stigma and discrimination are significant problems. Common coping orientations include: concealing mental health problems, challenging others and educating others. We describe the use of common stigma coping orientations and explain variations within a sample of English mental health service users. METHODS:Cross-sectional survey data were collected as part of the Viewpoint survey of mental health service users' experiences of discrimination (n = 3005). Linear regression analyses were carried out to identify factors associated with the three stigma coping orientations. RESULTS:The most common coping orientation was to conceal mental health problems (73%), which was strongly associated with anticipated discrimination. Only 51% ever challenged others because of discriminating behaviour, this being related to experienced discrimination, but also to higher confidence to tackle stigma. CONCLUSIONS:Although stigma coping orientations vary by context, individuals often choose to conceal problems, which is associated with greater anticipated and experienced discrimination and less confidence to challenge stigma. The direction of this association requires further investigation.
    背景与目标: 目的:心理健康的污名和歧视是重大问题。常见的应对方向包括:隐藏心理健康问题,挑战他人并教育他人。我们描述了常见的耻辱应对方式的使用,并解释了英国精神卫生服务用户样本中的变化。
    方法:收集横断面调查数据作为对精神卫生服务使用者歧视经历的观点调查的一部分(n = 3005)。进行了线性回归分析,以确定与三个柱头应对方向相关的因素。
    结果:最常见的应对方法是隐瞒心理健康问题(73%),这与预期的歧视密切相关。只有51%的人曾因为歧视行为而挑战过其他人,这既与经历的歧视有关,也与解决污名的更高信心有关。
    结论:尽管耻辱应对的方向因环境而异,但个人经常选择隐瞒问题,这与更大的预期和经历的歧视以及挑战耻辱的信心不足有关。该协会的方向需要进一步调查。
  • 【一项对英格兰和威尔士囚犯自杀危险因素的国家病例对照研究[已更正]。】 复制标题 收藏 收藏
    DOI:10.1007/s00127-012-0632-4 复制DOI
    作者列表:Humber N,Webb R,Piper M,Appleby L,Shaw J
    BACKGROUND & AIMS: PURPOSE:To examine risk factors for suicide among prisoners in a national population. METHODS:The Ministry of Justice identified all suicides occurring in prisons in England and Wales between 2005 and 2008. Two hundred and twenty suicides were matched to 220 living controls on age, gender, date of reception into prison and establishment type. Relative risks for clinical, custodial, service-response and socio-demographic characteristics were estimated using conditional logistic regression models. RESULTS:Having a history of violence and several indicators of past or current psychiatric illness were strong predictors at univariate level. Prisoners who died by suicide were over nine times more likely than controls to have been identified and managed as being at-risk of self-harm/suicide during the prison term. Multivariate analysis identified five mutually independent predictors: previous psychiatric service contact, history of self-harm, single cell occupation, remand status, and non-white ethnicity. CONCLUSIONS:Suicide risk is elevated among certain types of prisoners, and targeted suicide prevention strategies should be developed for the monitoring, care and support of the high-risk groups that we identified. Further research is needed to determine the causal mechanisms that explain why some prisoners have a higher suicide risk than their peers.
    背景与目标: 目的:研究全国人口中囚犯自杀的危险因素。
    方法:司法部确定了2005年至2008年在英格兰和威尔士监狱中发生的所有自杀事件。将220例自杀与220名生活控制相匹配,包括年龄,性别,入狱日期和机构类型。使用条件逻辑回归模型估算了临床,保管,服务响应和社会人口统计学特征的相对风险。
    结果:具有暴力病史和过去或现在的精神疾病的几个指标是单因素水平的有力预测指标。在监狱任期内,被自杀死亡的囚犯被识别和管理为有自残/自杀风险的可能性是对照组的九倍以上。多变量分析确定了五个相互独立的预测因素:以前的精神病服务联系,自我伤害史,单细胞职业,还押状况和非白人种族。
    结论:在某些类型的囚犯中自杀风险较高,因此应制定有针对性的自杀预防策略,以监测,护理和支持我们确定的高危人群。需要做进一步的研究以确定导致某些囚犯自杀风险高于同龄人的原因的成因机制。
  • 【[在英格兰对全国性自体血清滴眼液进行集中服务的经验]。】 复制标题 收藏 收藏
    DOI:10.1007/s00347-008-1753-8 复制DOI
    作者列表:Maclennan S,Hartwig D,Geerling G
    BACKGROUND & AIMS: :The majority of patients with dry eye syndromes respond to conventional treatment aimed at optimising the ocular surface environment. There are some, however, who do not respond adequately to conventional lubricants. The first description of the use of autologous serum as a nutrient tears substitute was published more than 20 years ago. In 1997, NHS Blood and Transplant (NHSBT) developed a reliable and reproducible method for the production of eyedrops derived from autologous serum according to GMP Guidelines. The current cost of a batch of eyedrops (i. e. the product from one donation episode) is approximately 1300 GBP - this covers costs of collection, processing, testing and distribution. One "batch" of eyedrops will last for approximately 5 months if a bottle a day is used. A 6 month shelf life is put on the product and patients keep them in their domestic freezer.
    背景与目标: :大多数患有干眼症的患者对旨在优化眼表环境的常规治疗有反应。但是,有些人对常规润滑剂的反应不充分。使用自体血清作为营养眼泪替代品的第一个描述已发表于20多年前。 1997年,NHS血液与移植(NHSBT)根据GMP指南开发了一种可靠且可重现的方法,用于生产自体血清衍生的滴眼剂。一批眼药水(即一次捐赠的产品)的当前成本约为1300英镑-这包括了收集,加工,测试和分发的成本。如果每天使用一瓶,一滴眼药水将持续约5个月。该产品的保质期为6个月,患者将其保存在家用冰箱中。
  • 【在英格兰,十分之九的日光浴浴床发出的紫外线辐射水平超过了当前的安全限制。】 复制标题 收藏 收藏
    DOI:10.1111/bjd.12181 复制DOI
    作者列表:Tierney P,Ferguson J,Ibbotson S,Dawe R,Eadie E,Moseley H
    BACKGROUND & AIMS: BACKGROUND:Exposure to ultraviolet (UV) radiation from sunlight is recognized as the principal cause of skin cancer. Moreover, sunbeds have been classified as carcinogenic by the International Agency for Research on Cancer. Despite this, there is a shortage of objective data on UV exposure levels in sunbeds in England. OBJECTIVES:We set out to measure UV emission levels in sunbeds at sites around England, and to compare these levels with both current standards and natural sunlight. METHODS:Between October 2010 and February 2011, UV spectra were measured on site from a total of 402 artificial tanning units in England. Measurement instrumentation was calibrated, traceable to the National Physical Laboratory. Compliance with the relevant British and European standard was determined, and a skin-cancer weighting factor was used to compare the carcinogenic potential of sunbeds with that of sunlight. RESULTS:For compliance with the European standard, erythemal-effective irradiance should not exceed 0·3 W m(-2). The values that we measured ranged between 0·10 and 1·32 W m(-2) with a mean of 0·56 ± 0·21 W m(-2) . Only 10% of sunbeds surveyed were within the recommended limit. Application of the skin-cancer weighting factor produced values that varied from 0·17 to 2·52 W m(-2) with a mean of 0·99 ± 0·41 W m(-2). The comparable value for Mediterranean noon day sun was 0·43 W m . CONCLUSIONS:Nine out of 10 sunbeds surveyed throughout England emitted levels of UV radiation that exceed the maximum levels contained within the European standard. Moreover, the skin cancer risk for comparable times of exposure was up to six times higher than that for Mediterranean sunlight. This situation is unacceptable and stricter control measures must be put in place.
    背景与目标: 背景:暴露于阳光下的紫外线(UV)被认为是皮肤癌的主要原因。此外,日光浴床被国际癌症研究机构归类为致癌物质。尽管如此,英格兰缺乏关于日光浴床紫外线暴露水平的客观数据。
    目的:我们着手测量英格兰周围地区日光浴床的紫外线辐射水平,并将这些水平与当前标准和自然阳光进行比较。
    方法:2010年10月至2011年2月,在英格兰现场测量了总共402个人工晒黑装置的紫外线光谱。测量仪器经过校准,可追溯到国家物理实验室。确定是否符合相关的英国和欧洲标准,并使用皮肤癌加权因子比较日光浴床和日光浴的致癌潜力。
    结果:为了符合欧洲标准,红斑有效辐照度不应超过0·3 W m(-2)。我们测量的值在0·10和1·32 W m(-2)之间,平均值为0·56±0·21 W m(-2)。被调查的日光浴浴床中只有10%在建议的限制范围内。皮肤癌加权因子的应用产生的值从0·17到2·52 W m(-2)不等,平均值为0·99±0·41 W m(-2)。地中海正午太阳的可比值是0·43 W m。
    结论:在整个英格兰进行调查的10个日光浴床中,有9个日光浴床的紫外线辐射水平超过了欧洲标准所规定的最大水平。此外,可比暴露时间的皮肤癌风险比地中海阳光高六倍。这种情况是不可接受的,必须采取更严格的控制措施。

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