Association of iron overload based quantitative T2* MRI technique and carotid intima-media thickness in patients with beta-thalassemia: A cross-sectional study

Background

Heart failure (HF) is a major cause of hospitalization and death in the aging population around the world. Home care utilization is associated with improved survival for the patients with HF, and varies by ethno-culture. The purpose of this study was to investigate the difference in hospital readmission rate and mortality between Asian and other Canadian HF patients.

Methods

HF patients were identified using hospital discharge abstracts from March 31, 2000 to April 1, 2006 in Calgary Health Region. Readmission and one-year mortality for HF were determined by linking hospital discharge and vital statistics data. Stratified by home care services use, readmission and mortality rates were compared between the Asians and other Canadians while controlling for age, sex, comorbidities, and household income.

Results

Of 26,171 HF patients discharged from hospital, 56.6% of Asians and 58.0% of other Canadians used home care services [adjusted odds ratio (OR) for Asian: 0.84, 95% confidence interval (CI): 0.74-0.89]. The hospital readmission rate was similar between Asians and other Canadians regardless of home care services use. Mortality was similar between those who used home care services (adjusted OR for Asian: 0.96, 95% CI: 0.81-1.13). For patients who did not use home care services, Asians had significantly lower mortality than other Canadians (adjusted OR for Asian: 0.76, 95% CI: 0.60-0.86).

Conclusion

Mortality was similar between Asian and other Canadian patients when home care services were utilized. However, among those without home care, Asian patients had a significantly lower mortality than other Canadian patients.     

Are elderly people living alone an at risk group?

OBJECTIVE--To test the hypothesis that elderly people living alone are an at risk group with a high level of morbidity that makes high demands on health and social services. DESIGN--Secondary analysis of data from a community survey of 239 people aged 75 and over, identified from general practitioners'' age-sex registers. SETTING--Nine practices in the London boroughs of Brent and Islington. MAIN OUTCOME MEASURES--Scores on the mini-mental state examination; stated satisfaction with life; assessment of mobility; numbers of diagnoses of major physical problems; numbers of prescribed drugs taken; urinary incontinence; alcohol consumption; contacts with general practitioners and hospital outpatient and inpatient services; contact with community health and social services. RESULTS--There were significantly more women among those living alone (93/120 (78%) v 63/119 (53%); p < 0.0005) and the median age of elderly people living alone was higher (81 v 80; p < 0.04). Those living alone and those living with others showed no significant differences in measures of cognitive impairment, numbers of major physical diagnoses, impaired mobility, or use of general practitioner or hospital services. Stated satisfaction with life was somewhat higher in those living alone. Elderly people living alone were significantly more likely to have contact with chiropody, home help, and meals on wheels services and less likely to have someone they could contact in an emergency or at night. Living alone increased the likelihood of contact with one or more community health professionals (district nurses, health visitors, or chiropodists) considered as a group and also increased the likelihood of contact with social services as a whole. There was a tendency for more of those living alone than those living with others to have home visits from their general practitioners, but there were no significant differences in contact with hospital services between the two groups. CONCLUSIONS--Elderly people living alone do not have an excess of morbidity compared with those living with others and do not seem to be an at risk group requiring specifically targeted assessments. More help is needed to provide elderly people living alone with a point of contact in case of emergency.     

The elderly mentally ill--whose responsibility?

The elderly mentally ill make considerable demands on health and social services. To evaluate the need for these services a one-day census of all people aged 65 and over was carried out in an area containing 220 000 people (40 000 over 65). Data were obtained on the nursing needs and psychiatric state of the 2162 elderly people in hospital or local authority residential homes for the elderly, or living at home receiving care from the community nursing service. One-third were classified as having psychiatric problems, more than half of them being outside hospital. Residential homes and community nurses play a significant part in caring for the elderly mentally ill, and an integrated but flexible manpower policy is important.     

Supporting elderly dependent people at home.

OBJECTIVE--To clarify the relation between the dependency of elderly people and the assistance they receive from others by using a detailed but simple measure of dependency. DESIGN--Secondary analysis of data from a survey of people aged 70 and over. SETTING--Two general practices in south Wales. SUBJECTS--1280 people aged 70 and over. MAIN OUTCOME MEASURES--Dependency on others to perform essential functions; detailed data on who assists with those functions. RESULTS--Increasing dependency was associated with increased use of more than one member of the family or friends and an increase in the provision of statutory services. CONCLUSION--The complexity of the relation between dependency and those who care for dependent people has previously been underestimated. The presence of providers of statutory services at the household of elderly dependent people suggests that these services can be developed further to help those caring for elderly people at home.     

Vitamin D status in different subgroups of British Asians.

To assess the effect of religious dietary practices and social customs on the vitamin D status of Asian immigrants, we kept records of the dietary intake and time spent out of doors of 81 Ugandan Asian men, women, and girls (9-19 years old). Sera were analysed for 25-hydroxycholecalciferol (25-OHD3), and 28% of the subjects were found to have levels below the lower limit of normal. The (vegetarian) Hindus had the lowest dietary intakes, least time out of doors, and lowest serum 25-OHD3. The Goan (Roman Catholic) Asians, despite more pigmentation, had 25-OHD3 levels similar to those found among indigenous British people and had the most satisfactory vitamin D intakes. Among Asians, whose exposure to sunlight may be limited, dietary vitamin D becomes the major determinant of serum 25-OHD3.     

Medical and social factors influencing admission to residential care.

The increasing number of people aged over 75 in Britain makes heavy demands on health and social services. To obtain accurate information for rational allocation of resources to domiciliary and residential services a group of 98 housebound women over 75 were compared with a group of 99 women of the same age in residential care. They had a similar range of physical disorders with the exception that deafness was more common among women in residential care. A much higher proportion in residential care were demented. Though in many respects women in residential care had less physical incapacity, a higher proportion needed help at times of crisis. Important social factors were that women at home were more likely to be living with others, and that the principal helper was more likely to be a husband or relative than a neighbour. Both groups received the same amount of support from home helps and community nurses. Any reduction in the number of residential care places for elderly women whose relatives are not available or are unable to cope would require the establishment of an effective community psychogeriatric service and a system for providing appropriate subjects with 24 hour care and supervision.     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program''s first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.     

Effects of preventive home visits to elderly people.

OBJECTIVES--To assess the effect of preventive home visits by public health nurses on the state of health of and use of services by elderly people living at home. DESIGN--Randomised controlled trial. SETTING--General population of elderly people in one of the southern regions of the Netherlands. SUBJECTS--580 subjects aged between 75 and 84 years randomly allocated to intervention (292) or control (288) group. INTERVENTIONS--Four visits a year over three years in intervention group. Control group received no home visits. MAIN OUTCOME MEASURES--Self rated health, functional state, well being, loneliness, aspects of the mental state (depressive complaints, memory disturbances), and mortality. Use of services and costs. RESULTS--Visits had no effect on the health of the subjects. In the group visited no higher scores were seen on health related measures, fewer died (42 (14%) v 50 (17%)), and community care increased slightly. In the control group more were referred to outpatient clinics (166 (66%) v 132 (55%)), and they had a 40% increased risk of admission (incidence rate ratio 1.4; 90% confidence interval 1.2 to 1.6). No differences were found in long term institutional care, and overall expenditure per person in the intervention group exceeded that in the control group by 4%. Additional analyses showed that visits were effective for subjects who initially rated their health as poor. CONCLUSIONS--Preventive home visits are not beneficial for the general population of elderly people living at home but might be effective when restricted to subjects with poor health.     

Community care for the elderly 1976-84.

The aging of the elderly population is of crucial importance as people who are over 80 make far greater use of health and social services than any other age group. Government guidelines on the provision of services, which are generally related to the whole population aged 65 and over, fail to take account of this change in the age structure of the elderly population and are no longer appropriate. Recent trends in the provision of domiciliary services, day care, specialist housing for the elderly, and residential care have been related to changes in the number of potential consumers. Ironically, despite the government''s stated commitment to "community care," the chief growth area has been private institutional care. The number of day care places and sheltered housing units has also increased in real terms, but the provision of domiciliary services, such as home help and health visitor visits to the elderly, has either fallen behind or barely matched the increase in the number of very old people. If community care is to be made a reality and if the present inadequate levels of service are to be maintained, let alone improved, then additional resources, greater cooperation among agencies, and a more imaginative approach to the development and delivery of services are urgently needed.     

Cut‐points for Waist Circumference in Europids and South Asians

There is little strong evidence that currently recommended higher waist circumference cut‐points for Europids compared with South Asians are associated with similar risk for type 2 diabetes. This study was designed to provide such evidence. Longitudinal studies over 5 years were conducted among 5,515 Europid and 2,214 ethnically South Asian participants. Age‐standardized diabetes incidence at different levels of waist circumference and incidence difference relative to a reference value were calculated. The Youden Index was used to determine waist circumference cut‐points. At currently recommended cut‐points, estimated annual diabetes incidence for a 50‐year‐old Europid was <0.6% for both sexes, and for a 50‐year‐old South Asian, 5.8% for men and 2.1% for women. Annual diabetes incidence of 1% was observed for a 50 year old at a waist circumference 35–40 cm greater in Europid compared to South Asian men and women. Incidence difference between recommended cut‐points and a reference value (80 cm in men, 70 cm in women) was 0.3 and 4.4% per year for Europid and South Asian men, and 0.2 and 0.8% per year for Europid and South Asian women, respectively. Waist circumference cut‐points chosen using the Youden Index were shown to be dependent on obesity levels in the population. The much higher observed risk of diabetes in South Asians compared to Europids at the respective recommended waist circumference cut‐points suggests that differences between them should be greater. Approaches that use the Youden Index to select waist circumference cut‐points are inappropriate and should not be used for this purpose.     

Home accidents in older people: role of primary health care team.

OBJECTIVES--To determine the incidence and nature of unreported and reported home accidents in older people and to investigate associated environmental factors. DESIGN--Postal questionnaire requesting information on home accidents in the preceding month. SETTING--Inner London general practice. SUBJECTS--All registered patients aged over 65 years (n = 1662), of whom 120 were inappropriately registered and 1293 responded. MAIN OUTCOME MEASURE--Circumstances and consequences of accidents in the home. RESULTS--108 accidents were recorded in 100 patients, giving a home accident rate of 84/1000 patients, equivalent to an annual rate of 1002/1000. 73 accidents were falls, and 83 were unreported. Of the 25 reported accidents, 19 were reported to general practice and six to accident and emergency departments (5.6% of all events). Rates of home accidents increased with age and were higher in women than men (79/819 upsilon 29/474; chi 2 = 4.5, df = 1, p less than 0.05). CONCLUSIONS--The incidence of home accidents in people aged over 65 years was high but few events were reported to medical services. General practice provided the main contact for patients who reported home accidents, and primary care workers have important opportunities for advising elderly patients on home accident prevention. Improved publicity on home safety targeted at older people and their carers would support the primary health care team in this role.     

Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris

Objectives To determine whether coronary angiography for suspected stable angina pectoris is underused in older patients, women, south Asian patients, and those from socioeconomically deprived areas, and, if it is, whether this is associated with higher coronary event rates.Design Multicentre cohort with five year follow-up.Setting Six ambulatory care clinics in England.Participants 1375 consecutive patients in whom coronary angiography was individually rated as appropriate with the Rand consensus method.Main outcome measures Receipt of angiography (420 procedures); coronary mortality and acute coronary syndrome events.Results In a multivariable analysis, angiography was less likely to be performed in patients aged over 64 compared with those aged under 50 (hazard ratio 0.60, 95% confidence interval 0.38 to 0.96), women compared with men (0.42, 0.35 to 0.50), south Asians compared with white people (0.48, 0.34 to 0.67), and patients in the most deprived fifth compared with the other four fifths (0.66, 0.40 to 1.08). Not undergoing angiography when it was deemed appropriate was associated with higher rates of coronary event.Conclusions At an early stage after presentation with suspected angina, coronary angiography is underused in older people, women, south Asians, and people from deprived areas. Not receiving appropriate angiography was associated with a higher risk of coronary events in all groups. Interventions based on clinical guidance that supports individualised management decisions might improve access and outcomes.     

Private rest homes in the care of the elderly.

Sixteen private rest homes were visited to assess their facilities and the types of disability of the residents. Apart from one home, which was a hotel for the elderly, all the homes provided care for physically and mentally frail elderly people over the long term. Although care was good the trends in the use of the homes are worrying, and stricter regulations are required to ensure appropriate levels of care. Greater support is also required from district nursing services.     

Prevalence of urinary incontinence.

The prevalence of urinary incontinence was investigated by determining the number of incontinent patients under the care of various health and social service agencies in two London boroughs and by a postal survey of the 22 430 people aged 5 years and over on the practice lists of 12 general practitioners in different parts of the country. The prevalence of incontinence known to the health and social service agencies was 0.2% in women and 0.1% in men aged 15-64 and 2.5% in women and 1.3% in men aged 65 and over. The postal survey, to which 89% of the people whose correct address was known replied, showed a prevalence of urinary incontinence of 8.5% in women and 1.6% in men aged 15-64 and 11.6% in women and 6.9% in men aged 65 and over. Nulliparous women had a lower prevalence than those who had had one, two, or three babies, but within the parity range of one to three there were no differences in prevalence. The prevalence was appreciably increased in women who had had four or more babies. Incontinence was moderate or severe in a fifth of those who reported it in the postal survey, of whom less than a third were receiving health or social services for the condition. Incontinence is a common symptom, and many unrecognised cases appear to exist. There may be considerable scope for improving its management.     

Abuse of elderly people by their carers.

OBJECTIVE--To assess the prevalence of abuse of elderly people by their carers and the characteristics of abusers and the abused. DESIGN--Information on abuse and risk factors was collected over six months from carers and patients. Risk factors were identified in the abused group and compared with those in a non-abused control group. SETTING--Carers were interviewed at home; patients were examined in the wards of Putney and Barnes geriatric hospitals, London. SUBJECTS--All patients referred from any source for respite care to the geriatric services over a six month period and their carers. MAIN OUTCOME MEASURES--Amount of physical and verbal abuse or neglect. Quantification of risk factors and correlation with the presence or absence of abuse. RESULTS--45% Of carers openly admitted to some form of abuse. Few patients admitted abuse. The most significant risk factor for physical abuse was alcohol consumption by the carer (p less than 0.001). Other significant risk factors were a poor pre-morbid relationship and previous abuse over many years. Abuse was often reciprocated and was associated with social dysfunction in many patients. Service delivery, respite care, and level of mental and physical disability were not significantly associated with abuse. CONCLUSION--The high level of abuse found in elderly patients in respite care was particularly associated with alcohol abuse and long term relationships of poor quality, which are difficult to change. Even with increased provision of services, care in the community may not be the best solution for these people.     

Population need for renal replacement therapy in Thames regions: ethnic dimension.

OBJECTIVES--To determine the use of renal replacement therapy by ethnic origin and to ascertain the variation in provision of such therapy and to relate this to the distribution of ethnic minority populations. DESIGN--Analysis of retrospective and cross sectional data from 19 renal units. SETTING--All four Thames regional health authorities. SUBJECTS--Patients resident in the Thames regions who were accepted as new patients for renal replacement therapy during 1991 and 1992 and the patients who were already undergoing such treatment between December 1992 and April 1993. MAIN OUTCOME MEASURES--Rates of acceptance for and prevalence of renal replacement therapy among white, black, and Asian people. RESULTS--The average annual acceptance rates per million in 1991-2 were 61 for white people, 175 for black people, and 178 for Asians, and the prevalences per million were 351, 918, and 957 respectively. The relative risks increased with age. A threefold increase in the acceptance rate occurred in people aged under 55 in both the black and Asian populations, suggesting that the higher rates are probably not due to factors related to access alone. Treatment rates varied considerably among districts, reflecting both the distribution of ethnic minority populations and access to services. CONCLUSION--Black and Asian people receive and have a greater need for renal replacement therapy, and the need will increase as these populations age. These findings have important implications for the provision of renal services in districts with a high proportion of ethnic minorities and for the management of diabetes mellitus and hypertension, two important causes of end stage renal failure in these populations.     

Old people's homes: the relatives' view.

On 1 April new arrangements came into force for arranging and funding residential care for elderly people in Britain. From now on those who seem to need full time care will be assessed first by care managers employed by local authority social services departments. This may lead to admission to an old people''s home or a nursing home. Local authorities have been told to consult both users and carers about such decisions. But what about relatives who have not actually been giving care directly? The Relatives Association was set up last year as a voluntary organisation for the relatives and friends of older people living in residential homes. Below, its vice president, Mavis Nicholson, a journalist and broadcaster whose mother died of Alzheimer''s disease in a residential home last year, gives her personal view of being such a relative. And Dorothy White, the association''s founder, explains what the future may hold for elderly residents and their relatives.     

Randomised trial of impact of model of integrated care and case management for older people living in the community

Objective: To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community. Design: Randomised study with 1 year follow up. Setting: Town in northern Italy (Rovereto). Subjects: 200 older people already receiving conventional community care services. Intervention: Random allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care. Main outcome measures: Admission to an institution, use and costs of health services, variations in functional status. Results: Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls (hazard ratio 0.69; 95% confidence interval 0.53 to 0.91). Health services were used to the same extent, but control subjects received more frequent home visits by general practitioners. In the intervention group the estimated financial savings were in the order of £1125 ($1800) per year of follow up. The intervention group had improved physical function (activities of daily living score improved by 5.1% v 13.0% loss in controls; P<0.001). Decline of cognitive status (measured by the short portable mental status questionnaire) was also reduced (3.8% v 9.4%; P<0.05). Conclusion: Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community.

Key messages

• Responsibility for management of care of elderly people living in the community is poorly defined
• Integration of medical and social services together with care management programmes would improve such care in the community
• In a comparison of this option with a traditional and fragmented model of community care the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced costs

     

Understanding users' perspectives of barriers to maternal health care use in Maharashtra, India.

This paper uses data collected using in-depth, semi-structured interviews to examine utilization of maternal health care services among two rural and urban populations of Pune and Mumbai in Maharashtra, India. The study aims to identify key social, economic and cultural factors influencing women's decisions to use maternal health care and the places used for child delivery, whilst considering the accessibility of facilities available in the local area. Socioeconomic status was not found to be a barrier to service use when women perceived the benefits of the service to outweigh the cost, and when the service was within reasonable distance of the respondent's place of residence. A large number of women perceived private services to be superior to those provided by the government, although cost often meant they were unable to use them. The provision of services did not ensure that women used them; they had to first perceive them to be beneficial to their health and that of their unborn child. Respondents identified the poor quality of services offered at government institutions to be a motivating factor for delivering at home. Thus further investigation is needed into the quality of services provided by government facilities in the area. A number of respondents who had received antenatal care went on to deliver in the home environment without a trained birth attendant. Further research is needed to establish the types of care provided during an antenatal consultation to establish the feasibility of using these visits to encourage women, particularly those with high-risk pregnancies, to be linked to a trained attendant for delivery.     

Estimated burden of diabetes mellitus in Manitoba according to health insurance claims: a pilot study.

OBJECTIVE: To estimate the burden of diabetes mellitus in Manitoba from 1980 to 1984. DESIGN: Review of the Manitoba Health Services Commission (MHSC) database. The validity of the MHSC data was established through two substudies: one involved self-reports from a survey of elderly Manitobans, and the other involved people with confirmed diabetes enrolled in the provincial diabetes education program. SUBJECTS: Sample of 100,000 people stratified by age, sex and MHSC health region: 50,000 were aged 25 to 64 years, and 50,000 were aged 65 or more. All MHSC claims containing the ICD-9-CM code for diabetes mellitus or gestational diabetes were identified. MAIN RESULTS: Of the sample 7627 people were found to have a diagnosis of diabetes, the annual prevalence being 0.8% among those 25 to 44 years of age, 3.5% among those 45 to 64 and 7.6% among those 65 or older. The annual incidence rate among those over 25 years of age was 7.8 per 1000. Of the 4556 pregnant women 25 to 44 years old 85 (1.9%) had diabetes; 23 were believed to have gestational diabetes. CONCLUSIONS: The incidence and prevalence rates were similar to those determined on the basis of self-reports in Canadian and US national surveys. The use of an administrative database such as that of the MHSC will provide key information for planning health services for diabetic patients and will permit the monitoring of long-term trends in the incidence and prevalence of the disease.