This doctoral statement links previously published original research and places this in the context of the wider literature. Analysis of a national database identified over 200,000 patient falls, including 1,000 fractures, reported from hospitals in England and Wales during 2005/06, leading to excess morbidity, mortality, healthcare costs, litigation, distress and anxiety. Mean falls rates for acute hospitals were 4.8 falls per 1,000 occupied bed days, falls were most likely to be reported as occurring between 10:00 and 12:00, and in relation to bed occupancy, patients aged over 85 years and males were at greatest risk. Although the only such study on a national scale, its findings were congruent with earlier smaller studies. A cluster randomised trial of multifactorial interventions carried out in acute and rehabilitation wards for older people identified a significant reduction in rate of falls between intervention and control groups (incident rate ratio 0.59 95% CI 0.49-0.70). The use of a ward-based multidisciplinary approach and several components of the intervention were found in review of other successful trials of hospital falls prevention. A systematic review identified that both routine bedrail use and unselective bedrail elimination appear to increase the risk of falls and injury, and that direct injury from bedrails, including fatal entrapment, is primarily related to outdated equipment design, and poor fitting and maintenance. The dominant orthodoxy in the literature that bedrails are harmful and unacceptable appears to have become detached from the empirical evidence and patients’ views. A multi-hospital overnight survey of bedrail use found 25.7% of patients had full bedrails raised, with immobility the most significant factor associated with bedrail use on logistic regression (OR 62.5 95% CI 27.4-142.8). These findings were disseminated through publications for the National Patient Safety Agency and through additional journal publications, and influenced policy in UK hospitals and internationally.

This study was designed to assess why children become fearful of dentistry and what role relative analgesia (RA) plays in reducing a child's fear. The dental literature indicated that dental anxiety could be divided into three major factors: medical/dental, individual and environmental. The psychological literature provided a model of anxiety based upon a conjunction of cognitive and behavioural theories. The subjects were aged between 6 and 18 years, and comprised of 65 experimental subjects (selected from referrals for anxiety and/or noncooperation) and 42 control subjects (matched for age and gender with the experimental group). All subjects were taken from one dentist's case list and were seen by the same dentist. Data were collected in three stages, firstly, from a pre-treatment questionnaire/interview based on the work of Williams et al. (1985) together with the Corah Dental Anxiety Scale (DAS) to measure parent's dental anxiety and the Child Manifest Anxiety Scale (CMAS) to assess children's general anxiety levels. Secondly, video data of children undergoing dental treatment were collected for analysis using the Venham Anxiety Scale, Melamed Child Behaviour Profile and Weinstein Dentist Behaviour Profile. Thirdly, further data were collected after treatment from parents and dentist. This information related to treatment given, measures of how anxious and cooperative the child had been and whether the child had had a GA or RA. The major conclusions reached by this study were, firstly, that dental anxiety is a specific fear (phobia) of potential injury with a postulated temperamental factor, relating to vigilance and pain expectation. Secondly, a short checklist was developed to aid dentists in assessing children at initial examination for potential dental anxiety. Thirdly, no relation between dental fear and the use of RA could be found. Fourthly, dentist behaviour changes in both beneficial and nonbeneficial ways with respect to rising child anxiety levels.

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No description available.

Background: Approximately 30,000 women are diagnosed with breast cancer in England and Wales each year. There are differences in incidence and survival rates for women from differing socioeconomic backgrounds. Affluent women have a higher incidence ofbreast cancer, however, survival is lower in deprived women. Since research has generally linked these two findings, it was hypothesised that these results would also be found in a small area in the North West ofEngland. Aims and Objectives: In light of previous research findings, the purpose of this study was to: examine inequality in incidence, mortality and survival of breast cancer in the 1990's for the localities of Halton and Warrington; identify the factors that influence the incidence, mortality and survival of breast cancer in affluent and deprived areas; and, investigate the differences in women's breast cancer journeys throughout the locality of Halton and Warrington PCTs. Methods: The study was divided into two parts, the first part being an epidemiological small area analysis which studied incidence, mortality and survival from breast cancer in Warrington and Halton in the North West of England over a twelve year period. The second part ofthe study involved the interviewing of eighty women in order to gain a more indepth knowledge of their breast cancer journey and chart the process by which they reached the point ofdiagnosis and treatments. Results: The first part of the study revealed, the lowest incidence of breast cancer was found in the affluent women throughout the 1990's. In keeping with the literature, large increases were seen in the five year survival rates for North Cheshire in the 1990's. The screening results indicated that the screening uptake was higher in the affluent women, although during the 1990's the gap narrowed. Grade of cancer at diagnosis rather than deprivation accounted for variation in survival. The second part of the study revealed, there were delays from symptom recognition to diagnosis and diagnosis to treatment, however, the main reason for the delay in the process was attributable to the respondent rather than health system factors. This study did not find delay differences between deprivation groups. A key element in the delay in seeking health care was that of past experiences. The main difference between the affluent and deprived respondents was a lack of knowledge of breast cancer in the deprived group. Both parts of the study found no evidence of women from deprived areas presenting with more advanced cancer, which can impact on mortality and survival rates. Conclusion: This study found that grade was more important than deprivation when assessing variation in survival. Delay in seeking health care with symptoms of breast cancer did not vary by deprivation groups. Deprivation was not consistently associated with less favourable help seeking behaviours or outcomes.

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The aim of this programme of work was to explore the effects of EPRs on hospital pharmacy personnel. A multiple case study approach was used, with research carried out at four acute NHS hospital Trusts in England, at varying stages of developing and implementing their EPR systems. Within the Trusts studied, a mixture of paper and electronic prescribing systems were in use. Paper-based prescribing systems were found to be well developed to support communication and coordination of medicines supply and clinical pharmacy activities. The electronic prescribing systems supported these activities to varying degrees. This 'fit' with working practices was an important factor in whether a system had been accepted by personnel, and highlighted the importance of a good understanding of work practices in successful system design. In the paper and electronic prescribing systems, pharmacists were able to modify prescribed therapies, usually to optimise patient care and safety. Here, both systems fitted with the aspirations of the profession for an expanding clinical role, influence on prescribing, and a contribution to enhanced patient safety in the use of medicines. If EPR systems are seen to contain a representation of the activities of healthcare professionals, then they go some way to formalise pharmacists' role in this particular activity. They may also be a tool to prompt further debate as to the roles of professional groups in hospital prescribing processes in the future. Important safety issues for EPR systems were highlighted; the potential for EPRs to both reduce certain types of error, and allow or facilitate the occurrence of others was identified in the systems studied.

The papers on which this thesis is based are the result of original research work undertaken in collaboration with healthcare researchers in the South West Peninsula. Modern healthcare research involves large scale multidisciplinary projects and the Statistician's role In these projects, from concept through design and execution to the production of published papers, is crucial. Funding bodies, and in particular the Medical Research Council (MRC), expect a Statistician to be part of the project team and the statistical input and expertise included plays a key role in determining whether or not projects are funded and are subsequently successful. The selection of papers concentrates on work in the specialty of Neurology, which forms the major part of the thesis, a trial of a complementary therapy in General Practice, work in Primary Dental Care and work in the Anaesthetics and Histopathology departments in Plymouth. Some of the papers are the outcomes resulting from NHS researchers approaching the candidate for statistical advice and assistance to support their clinical work In the South West Peninsula. Funding in 1997 enabled a small group of Statisticians In Plymouth to set up a Statistical Support Service for researchers in health care across the South West Peninsula. Clinical researchers have taken the opportunity to consult a statistician with regard to the design, execution, analysis and reporting of their research work over the past eight years and, whilst many consultations progress the researcher's work but are not major undertakings, a sizeable proportion have developed into significant contributions to the body of knowledge In the clinical specialty. The paper reporting the results of. Phase I of a trial on the use of Cannabinoids in Multiple Sclerosis (CAMS) has become a major reference work In Neurology and also specialties where pain relief is important, such as cancer. This was a high profile project partly as a result of the nature of the treatment and partly because of the type of patients involved. Anecdotal reporting often suggests alternative therapy to treating physicians but many of these remain untested and. in the evidence-based and cost conscious world, are increasingly coming under scrutiny using a scientific approach. The nature of this particular treatment necessitated extreme caution at every stage of the trial and the candidate was part of the Thai Management Group from inception to completion. This submission also includes a paper reporting the Phase II results and a further paper on chemical markers relating to the treatment. With the emphasis on prevention in Health Care, more research is emanating from researchers in Primary Care and this is represented here by the results of a trial on the use of the common stinging nettle to treat arthritic pain in the thumb, and by work on anxiety in Dental Clinics. The remaining papers look at applications in radiology and histopathology, the laboratory based research on which clinical decisions so often depend but which frequently fails to grab the headline news. These papers represent just some of the output from my part in the developing role of the Medical Statistics group in the clinical research of the South West Peninsula.

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No description available.