A comparison of the yield and relative cost of active tuberculosis case-finding algorithms in Zimbabwe

Setting

Ten districts and three cities in Zimbabwe.

Objective

To compare the yield and relative cost of identifying a case of tuberculosis (TB) using the three WHO-recommended algorithms (WHO2b, symptom inquiry only; WHO2d, chest X-ray [CXR] after a positive symptom inquiry; WHO3b, CXR only) and the Zimbabwe active case finding (ZimACF) algorithm (symptom inquiry plus CXR) to everyone.

Design

Cross-sectional study using data from the ZimACF project.

Results

A total of 38 574 people were screened from April to December 2017; 488 (1.3%) were diagnosed with TB using the ZimACF algorithm. Fewer TB cases would have been diagnosed with the WHO-recommended algorithms. This ranged from 7% fewer (34 cases) with WHO3b, 18% fewer (88 cases) with WHO2b and 25% fewer (122 cases) with WHO2d. The need for CXR ranged from 36% (WHO2d) to 100% (WHO3b). The need for bacteriological confirmation ranged from 7% (WHO2d) to 40% (ZimACF). The relative cost per case of TB diagnosed ranged from US$180 with WHO3b to US$565 for the ZimACF algorithm.

Conclusion

The ZimACF algorithm had the highest case yield, but at a much higher cost per case than the WHO algorithms. It is possible to switch to algorithm WHO3b, but the trade-off between cost and yield needs to be reviewed by the Zimbabwean National TB Programme.

United Kingdom Diabetic Retinopathy Electronic Medical Record (UK DR EMR) Users Group: report 4, real-world data on the impact of deprivation on the presentation of diabetic eye disease at hospital services

AIM

To assess the impact of deprivation on diabetic retinopathy presentation and related treatment interventions, as observed within the UK hospital eye service.

METHODS

This is a multicentre, national diabetic retinopathy database study with anonymised data extraction across 22 centres from an electronic medical record system. The following were the inclusion criteria: all patients with diabetes and a recorded, structured diabetic retinopathy grade. The minimum data set included, for baseline, age and Index of Multiple Deprivation, based on residential postcode; and for all time points, visual acuity, ETDRS grading of retinopathy and maculopathy, and interventions (laser, intravitreal therapies and surgery). The main  outcome measures were (1) visual acuity and binocular visual state, and (2) presence of sight-threatening complications and need for early treatment.

RESULTS

79 775 patients met the inclusion criteria. Deprivation was associated with later presentation in patients with diabetic eye disease: the OR of being sight-impaired at entry into the hospital eye service (defined as 6/18 to better than 3/60 in the better seeing eye) was 1.29 (95% CI 1.20 to 1.39) for the most deprived decile vs 0.77 (95% CI 0.70 to 0.86) for the least deprived decile; the OR for being severely sight-impaired (3/60 or worse in the better seeing eye) was 1.17 (95% CI 0.90 to 1.55) for the most deprived decile vs 0.88 (95% CI 0.61 to 1.27) for the least deprived decile (reference=fifth decile in all cases). There is also variation in sight-threatening complications at presentation and treatment undertaken: the least deprived deciles had lower chance of having a tractional retinal detachment (OR=0.48 and 0.58 for deciles 9 and 10, 95% CI 0.24 to 0.90 and 0.29 to 1.09, respectively); in terms of accessing treatment, the rate of having a vitrectomy was lowest in the most deprived cohort (OR=0.34, 95% CI 0.19 to 0.58).

CONCLUSIONS

This large real-world study suggests that first presentation at a hospital eye clinic with visual loss or sight-threatening diabetic eye disease is associated with deprivation. These initial hospital visits represent the first opportunities to receive treatment and to formally engage with support services. Such patients are more likely to be sight-impaired or severely sight-impaired at presentation, and may need additional resources to engage with the hospital eye services over complex treatment schedules.

Did school characteristics affect the uptake of meningococcal quadrivalent vaccine in Greater Manchester, United Kingdom?

OBJECTIVES

The objective of this study was to assess if school characteristics were associated with the uptake of the meningococcal ACWY (MenACWY) vaccine in Greater Manchester in 2017/18.

STUDY DESIGN

This is an ecological cross-sectional study.

METHODS

We analysed data on all 129 schools in seven local authorities in Greater Manchester from the Department for Education and from local child health information systems to determine whether school characteristics, including school type and Ofsted effectiveness score, were associated with vaccine uptake. Schools with no eligible pupils were excluded. We undertook single-variable and multivariable analysis and considered key interactions.

RESULTS

The overall uptake rate was 80.7%, with a median uptake per school of 80.6% (interquartile range, 69.0%-87.4%). Lower vaccination rates were associated with lower overall effectiveness scores (odds ratio [OR]: 3.54, 95% confidence interval [CI]: 3.00-4.19) and lower numbers of pupils eligible for vaccination (OR: 1.39, 95% CI: 1.28-1.51). Schools with a lower percentage of pupils for whom English is a second language and high deprivation were associated with lower uptake (OR: 1.58, 95% CI: 1.41-1.78). In addition, community schools (the schools with the most local authority oversight) had lower vaccination rates than other categories of schools.

CONCLUSIONS

In this study, uptake rates of the MenACWY vaccine were associated with all five school characteristics considered. Effectiveness scores for schools had the largest association with vaccine uptake, with poorer schools having lower uptake. These characteristics should be used by vaccination providers to prioritise their interventions to increase immunisation rates.

Tuberculosis-diabetes screening: how well are we doing? A mixed-methods study from North India

Setting

Public health care facilities in Sonipat District, Haryana State, India.

Objectives

To assess 1) the proportion of tuberculosis (TB) patients screened for diabetes mellitus (DM) and vice versa, 2) factors associated with screening, and 3) the enablers, barriers and solutions related to screening.

Design

A mixed-methods study with quantitative (cohort study involving record reviews of patients registered between November 2016 and April 2017) and qualitative (interviews of patients, health care providers [HCPs] and key district-level staff) components.

Results

Screening for TB among DM patients was not implemented, despite documents indicating that it had been. Of 562 TB patients, only 137 (24%) were screened for DM. TB patients registered at tertiary and secondary health centres were more likely to be screened than primary health centres. Low patient awareness, poor knowledge of guidelines among HCPs, lack of staff and inadequate training were barriers to screening. Enablers were the positive attitude of HCPs and programme staff. The key solutions suggested were to improve awareness of HCPs and patients regarding the need for screening, training of HCPs and wider availability of DM testing facilities.

Conclusion

The implementation of bidirectional screening was poor. Adequate staffing, regular training, continuous laboratory supplies for DM diagnosis and widespread publicity should be ensured.

Renewing Felsenstein's phylogenetic bootstrap in the era of big data

Felsenstein's application of the bootstrap method to evolutionary trees is one of the most cited scientific papers of all time. The bootstrap method, which is based on resampling and replications, is used extensively to assess the robustness of phylogenetic inferences. However, increasing numbers of sequences are now available for a wide variety of species, and phylogenies based on hundreds or thousands of taxa are becoming routine. With phylogenies of this size Felsenstein's bootstrap tends to yield very low supports, especially on deep branches. Here we propose a new version of the phylogenetic bootstrap in which the presence of inferred branches in replications is measured using a gradual 'transfer' distance rather than the binary presence or absence index used in Felsenstein's original version. The resulting supports are higher and do not induce falsely supported branches. The application of our method to large mammal, HIV and simulated datasets reveals their phylogenetic signals, whereas Felsenstein's bootstrap fails to do so.

The United Kingdom Diabetic Retinopathy Electronic Medical Record Users Group: Report 3: Baseline Retinopathy and Clinical Features Predict Progression of Diabetic Retinopathy

PURPOSE

To determine the time and risk factors for developing proliferative diabetic retinopathy (PDR) and vitreous hemorrhage (VH).

DESIGN

Multicenter, national cohort study.

METHODS

Anonymized data of 50 254 patient eyes with diabetes mellitus at 19 UK hospital eye services were extracted at the initial and follow-up visits between 2007 and 2014. Time to progression of PDR and VH were calculated with Cox regression after stratifying by baseline diabetic retinopathy (DR) severity and adjusting for age, sex, race, and starting visual acuity.

RESULTS

Progression to PDR in 5 years differed by baseline DR: no DR (2.2%), mild (13.0%), moderate (27.2%), severe nonproliferative diabetic retinopathy (NPDR) (45.5%). Similarly, 5-year progression to VH varied by baseline DR: no DR (1.1%), mild (2.9%), moderate (7.3%), severe NPDR (9.8%). Compared with no DR, the patient eyes that presented with mild, moderate, and severe NPDR were 6.71, 14.80, and 28.19 times more likely to develop PDR, respectively. In comparison to no DR, the eyes with mild, moderate, and severe NPDR were 2.56, 5.60, and 7.29 times more likely to develop VH, respectively. In severe NPDR, the eyes with intraretinal microvascular abnormalities (IRMA) had a significantly increased hazard ratio (HR) of developing PDR (HR 1.77, 95% confidence interval [CI] 1.25-2.49, P = .0013) compared with those with venous beading, whereas those with 4-quadrant dot-blot hemorrhages (4Q DBH) had 3.84 higher HR of developing VH (95% CI 1.39-10.62, P = .0095).

CONCLUSIONS

Baseline severities and features of initial DR are prognostic for PDR development. IRMA increases risk of PDR whereas 4Q DBH increases risk of VH.

Influence of Ebola on tuberculosis case finding and treatment outcomes in Liberia

Setting: National Leprosy and Tuberculosis (TB) Control Programme, Liberia. Objectives: To assess TB case finding, including human immunodeficiency virus (HIV) associated interventions and treatment outcomes, before (January 2013-March 2014), during (April 2014-June 2015) and after (July-December 2015) the Ebola virus disease outbreak. Design: A cross-sectional study and retrospective cohort analysis of outcomes. Results: The mean quarterly numbers of individuals with presumptive TB and the proportion diagnosed as smear-positive were: pre-Ebola (n = 7032, 12%), Ebola (n = 6147, 10%) and post-Ebola (n = 6795, 8%). For all forms of TB, stratified by category and age group, there was a non-significant decrease in the number of cases from the pre-Ebola to the Ebola and post-Ebola periods. There were significant decreases in numbers of cases with smear-positive pulmonary TB (PTB) from the pre-Ebola period (n = 855), to the Ebola (n = 640, P < 0.001) and post-Ebola (n = 568, P < 0.001) periods. The proportions of patients tested for HIV, found to be HIV-positive and started on antiretroviral therapy decreased as follows: pre-Ebola (respectively 72%, 15% and 34%), Ebola (69%, 14% and 30%) and post-Ebola (68%, 12% and 26%). Treatment success rates among TB patients were: 80% pre-Ebola, 69% Ebola (P < 0.001) and 73% post-Ebola (P < 0.001). Loss to follow-up was the main contributing adverse outcome. Conclusion: The principal negative effects of Ebola were the significant decreases in diagnoses of smear-positive PTB, the declines in HIV testing and antiretroviral therapy uptake and poor treatment success. Ways to prevent these adverse effects from recurring in the event of another Ebola outbreak need to be found.

Knockdown and recovery of malaria diagnosis and treatment in Liberia during and after the 2014 Ebola outbreak

Setting: The malaria-endemic country of Liberia, before, during and after the 2014 Ebola outbreak. Objective: To describe the consequences of the Ebola outbreak on Liberia's National Malaria Programme and its post-Ebola recovery. Design: A retrospective cross-sectional study using routine countrywide programme data. Results: Malaria caseloads decreased by 47% during the Ebola outbreak and by 11% after, compared to the pre-Ebola period. In those counties most affected by Ebola, a caseload reduction of >20% was sustained for 12 consecutive months, while this lasted for only 4 consecutive months in the counties least affected by Ebola. Linear regression of monthly proportions of confirmed malaria cases-as a proxy indicator of programme performance-over the pre- and post-Ebola periods indicated that the malaria programme could require 26 months after the end of the acute phase of the Ebola outbreak to recover to pre-Ebola levels. Conclusions: The differential persistence of reduced caseloads in the least- and most-affected counties, all of which experienced similar emergency measures, suggest that factors other than Ebola-related security measures played a key role in the programme's reduced performance. Clear guidance on when to abandon the emergency measures after an outbreak may be needed to ensure faster recovery of malaria programme performance.

The UK Diabetic Retinopathy Electronic Medical Record (UK DR EMR) Users Group, Report 2: real-world data for the impact of cataract surgery on diabetic macular oedema

AIM

To assess the rate of 'treatment-requiring diabetic macular oedema (DMO)' in eyes for the two  years before and after cataract surgery.

METHODS

Multicentre national diabetic retinopathy (DR) database study with anonymised data extraction across 19 centres from an electronic medical record system.

INCLUSION CRITERIA

eyes undergoing cataract surgery in patients with diabetes with no history of DMO prior to study start. The minimum dataset included: age, visual acuity (all time-points), injection episodes, timing of cataract surgery and ETDRS grading of retinopathy and maculopathy.

MAIN OUTCOME MEASURE

rate of developing first episode of treatment-requiring DMO in relation to timing of cataract surgery in the same eye.

RESULTS

4850 eyes met the inclusion criteria. The rate of developing treatment-requiring DMO in this cohort was 2.9% in the year prior to surgery versus 5.3% in the year after surgery (p<0.01). The risk of 'treatment-requiring DMO' increased sharply after surgery, peaking in the 3-6 months' period (annualised rates of 5.2%, 6.8%, 5.6% and 4.0% for the 0-3, 3-6, 6-9 and 9-12 months' post-operative time periods respectively). Risk was associated with pre-operative grade of retinopathy: risk of DMO in the first year post-operatively being 1.0% (no DR pre-operatively), 5.4% (mild non-proliferative diabetic retinopathy; NPDR), 10.0% (moderate NPDR), 13.1% (severe NPDR) and 4.9% (PDR) (p<0.01).

CONCLUSIONS

This large real-world study demonstrates that the rate of developing treatment-requiring DMO increases sharply in the year after cataract surgery for all grades of retinopathy, peaking in the 3-6 months' postoperative period. Patients with moderate and severe NPDR are at particularly high risk.

Zero suicide southwest UK initiative – Steps to mitigate suicide risk in local populations using quality improvement methodology and a whole life approach

Background

Only 25% of people who die by suicide see mental health services. Suicide is not just a health issue. Its causation and consequences lie within all of society. Many erroneously believe that suicide is inevitable and not preventable, because its causation is too complex. Underlying associations with suicide are largely social. There are programmes in the USA, which have combined interventions to reduce suicides. The 2014 UK suicide rate per 100,000 was 10.8 but 11.1 in South West (SW) England (pop: 5 million). A whole system approach is necessary. Zero Suicides SW is a project to address this.

Aim

(1) To develop a regional strategy to reduce and prevent suicide. (2) To make whole populations suicide risk aware. (3) Reduce regional suicide rates.

Method

A collaborative involving national and local 60 organisations including charities and voluntary sector was formed. Five collaborative meetings used narratives of suicide survivors, national experts led themed workshops, etc. to come up with a regional strategy. Quality Improvement (QI) Methodology was used to develop and examine the success of all projects.

Outputs

Initiatives such as using local radio stations for mental health promotion, collaboration via a poster campaign with local breweries and pubs to make men more self-aware of risk, suicide risk counselling for relatives/carers of patients admitted to psychiatric care, improving scrutiny to access to medication for recently discharged psychiatric patients have developed from the project. The QI model demonstrated how localised changes at person and organisation level could combine and have a powerful role in suicide prevention.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The United Kingdom Diabetic Retinopathy Electronic Medical Record Users Group, Report 1: baseline characteristics and visual acuity outcomes in eyes treated with intravitreal injections of ranibizumab for diabetic macular oedema

AIMS

To describe baseline characteristics and visual outcome for eyes treated with ranibizumab for diabetic macular oedema (DMO) from a multicentre database.

METHODS

Structured clinical data were anonymised and extracted from an electronic medical record from 19 participating UK centres: age at first injection, ETDRS visual acuity (VA), number of injections, ETDRS diabetic retinopathy (DR) and maculopathy grade at baseline and visits. The main outcomes were change in mean VA from baseline, number of injections and clinic visits and characteristics affecting VA change and DR grade.

RESULTS

Data from 12 989 clinic visits was collated from baseline and follow-up for 3103 eyes. Mean age at first treatment was 66 years. Mean VA (letters) for eyes followed at least 2 years was 51.1 (SD=19.3) at baseline, 54.2 (SD: 18.6) and 52.5 (SD: 19.4) at 1 and 2 years, respectively. Mean visual gain was five letters. The proportion of eyes with VA of 72 letters or better was 25% (baseline) and 33% (1 year) for treatment naïve eyes. Eyes followed for at least 6 months received a mean of 3.3 injections over a mean of 6.9 outpatient visits in 1 year.

CONCLUSIONS

In a large cohort of eyes with DMO treated with ranibizumab injections in the UK, 33% of patients achieved better than or equal to 6/12 in the treated eye at 12 months compared with 25% at baseline. The mean visual gain was five letters. Eyes with excellent VA at baseline maintain good vision at 18 months.

Flying After Conducting an Aircraft Excessive Cabin Leakage Test

INTRODUCTION

Aviation medical specialists should be aware that commercial airline aircraft engineers may undertake a 'dive equivalent' operation while conducting maintenance activities on the ground. We present a worked example of an occupational risk assessment to determine a minimum safe preflight surface interval (PFSI) for an engineer before flying home to base after conducting an Excessive Cabin Leakage Test (ECLT) on an unserviceable aircraft overseas.

METHOD

We use published dive tables to determine the minimum safe PFSI.

RESULTS

The estimated maximum depth acquired during the procedure varies between 10 and 20 fsw and the typical estimated bottom time varies between 26 and 53 min for the aircraft types operated by the airline. Published dive tables suggest that no minimum PFSI is required for such a dive profile.

DISCUSSION

Diving tables suggest that no minimum PFSI is required for the typical ECLT dive profile within the airline; however, having conducted a risk assessment, which considered peak altitude exposure during commercial flight, the worst-case scenario test dive profile, the variability of interindividual inert gas retention, and our existing policy among other occupational groups within the airline, we advised that, in the absence of a bespoke assessment of the particular circumstances on the day, the minimum PFSI after conducting ECLT should be 24 h. Houston S, Wilkinson E. Flying after conducting an aircraft excessive cabin leakage test. Aerosp Med Hum Perform. 2016; 87(9):816-820.

Development and evaluation of a secondary reference panel for BCR-ABL1 quantification on the International Scale

Molecular monitoring of chronic myeloid leukemia patients using robust BCR-ABL1 tests standardized to the International Scale (IS) is key to proper disease management, especially when treatment cessation is considered. Most laboratories currently use a time-consuming sample exchange process with reference laboratories for IS calibration. A World Health Organization (WHO) BCR-ABL1 reference panel was developed (MR¹–MR⁴), but access to the material is limited. In this study, we describe the development of the first cell-based secondary reference panel that is traceable to and faithfully replicates the WHO panel, with an additional MR^4.5 level. The secondary panel was calibrated to IS using digital PCR with ABL1, BCR and GUSB as reference genes and evaluated by 44 laboratories worldwide. Interestingly, we found that >40% of BCR-ABL1 assays showed signs of inadequate optimization such as poor linearity and suboptimal PCR efficiency. Nonetheless, when optimized sample inputs were used, >60% demonstrated satisfactory IS accuracy, precision and/or MR^4.5 sensitivity, and 58% obtained IS conversion factors from the secondary reference concordant with their current values. Correlation analysis indicated no significant alterations in %BCR-ABL1 results caused by different assay configurations. More assays achieved good precision and/or sensitivity than IS accuracy, indicating the need for better IS calibration mechanisms.

The contribution of primary prevention medication and dietary change in coronary mortality reduction in England between 2000 and 2007: a modelling study

OBJECTIVE

To analyse the falls in coronary heart disease (CHD) mortality in England between 2000 and 2007 and quantify the relative contributions from preventive medications and population-wide changes in blood pressure (BP) and cholesterol levels, particularly by exploring socioeconomic inequalities.

DESIGN

A modelling study.

SETTING

Sources of data included controlled trials and meta-analyses, national surveys and official statistics.

PARTICIPANTS

English population aged 25+ in 2000-2007.

MAIN OUTCOME MEASURES

Number of deaths prevented or postponed (DPPs) in 2007 by socioeconomic status. We used the IMPACTSEC model which applies the relative risk reduction quantified in previous randomised controlled trials and meta-analyses to partition the mortality reduction among specific treatments and risk factor changes.

RESULTS

Between 2000 and 2007, approximately 20 400 DPPs were attributable to reductions in BP and cholesterol in the English population. The substantial decline in BP was responsible for approximately 13 000 DPPs. Approximately 1800 DPPs came from medications and some 11 200 DPPs from population-wide changes. Reduction in population BP prevented almost twofold more deaths in the most deprived quintile compared with the most affluent. Reduction in cholesterol resulted in approximately 7400 DPPs; approximately 5300 DPPs were attributable to statin use and approximately 2100 DPPs to population-wide changes. Statins prevented almost 50% more deaths in the most affluent quintile compared with the most deprived. Conversely, population-wide changes in cholesterol prevented threefold more deaths in the most deprived quintile compared with the most affluent.

CONCLUSIONS

Population-wide secular changes in systolic blood pressure (SBP) and cholesterol levels helped to substantially reduce CHD mortality and the associated socioeconomic disparities. Mortality reductions were, in absolute terms, greatest in the most deprived quintiles, mainly reflecting their bigger initial burden of disease. Statins for high-risk individuals also made an important contribution but maintained socioeconomic inequalities. Our results strengthen the case for greater emphasis on preventive approaches, particularly population-based policies to reduce SBP and cholesterol.

A certified plasmid reference material for the standardisation of BCR-ABL1 mRNA quantification by real-time quantitative PCR

Serial quantification of BCR–ABL1 mRNA is an important therapeutic indicator in chronic myeloid leukaemia, but there is a substantial variation in results reported by different laboratories. To improve comparability, an internationally accepted plasmid certified reference material (CRM) was developed according to ISO Guide 34:2009. Fragments of BCR–ABL1 (e14a2 mRNA fusion), BCR and GUSB transcripts were amplified and cloned into pUC18 to yield plasmid pIRMM0099. Six different linearised plasmid solutions were produced with the following copy number concentrations, assigned by digital PCR, and expanded uncertainties: 1.08±0.13 × 10⁶, 1.08±0.11 × 10⁵, 1.03±0.10 × 10⁴, 1.02±0.09 × 10³, 1.04±0.10 × 10² and 10.0±1.5 copies/μl. The certification of the material for the number of specific DNA fragments per plasmid, copy number concentration of the plasmid solutions and the assessment of inter-unit heterogeneity and stability were performed according to ISO Guide 35:2006. Two suitability studies performed by 63 BCR–ABL1 testing laboratories demonstrated that this set of 6 plasmid CRMs can help to standardise a number of measured transcripts of e14a2 BCR–ABL1 and three control genes (ABL1, BCR and GUSB). The set of six plasmid CRMs is distributed worldwide by the Institute for Reference Materials and Measurements (Belgium) and its authorised distributors (https://ec.europa.eu/jrc/en/reference-materials/catalogue/; CRM code ERM-AD623a-f).

Netmums: a phase II randomized controlled trial of a guided Internet behavioural activation treatment for postpartum depression

BACKGROUND

Despite the high prevalence of postnatal depression (PND), few women seek help. Internet interventions may overcome many of the barriers to PND treatment use. We report a phase II evaluation of a 12-session, modular, guided Internet behavioural activation (BA) treatment modified to address postnatal-specific concerns [Netmums Helping With Depression (NetmumsHWD)].

METHOD

To assess feasibility, we measured recruitment and attrition to the trial and examined telephone session support and treatment adherence. We investigated sociodemographic and psychological predictors of treatment adherence. Effectiveness outcomes were estimated with the Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder-7, Work and Social Adjustment Scale, Postnatal Bonding Questionnaire, and Social Provisions Scale.

RESULTS

A total of 249 women were recruited via a UK parenting site, Netmums.com. A total of 83 women meeting DSM-IV criteria for major depressive disorder were randomized to NetmumsHWD (n = 41) or treatment-as-usual (TAU; n = 42). Of the 83 women, 71 (86%) completed the EPDS at post-treatment, and 71% (59/83) at the 6-month follow-up. Women completed an average of eight out of 12 telephone support sessions and five out of 12 modules. Working women and those with less support completed fewer modules. There was a large effect size favouring women who received NetmumsHWD on depression, work and social impairment, and anxiety scores at post-treatment compared with women in the TAU group, and a large effect size on depression at 6 months post-treatment. There were small effect sizes for postnatal bonding and perceived social support.

CONCLUSIONS

A supported, modular, Internet BA programme can be feasibly delivered to postpartum women, offering promise to improve depression, anxiety and functioning.

An examination of concordance and cultural competency in the diabetes care pathway: South Asians living in the United Kingdom

The Care Pathway project used a multilevel and multimethod approach to explore access to the care pathway for diabetic renal disease. Taking what was known about the outcomes of ethnic minority patients with diabetic renal disease; the study sought to explore and further understand how and why South Asian patients’ experiences may be different from the majority of population in relation to access. Through improved understanding of any observed inequalities, the study aimed to inform the development of culturally competent diabetes services. The design incorporated audits of patient indicators for diabetes and renal health at key points in the pathway: Diagnosis of diabetes and referral to specialist renal services in two years- 2004 and 2007, and qualitative individual interviews with patients and providers identified through the 2007 samples. This article describes the care provider perspective of access to diabetes care from a thematic analysis of 14 semistructured interviews conducted with professionals, at three study sites, with different roles in the diabetes pathway. National policy level initiatives to improve quality have been mirrored by quality improvements at the local practice level. These achievements, however, have been unable to address all aspects of care that service providers identified as important in facilitating access to all patient groups. Concordance emerged as a key process in improving access to care within the pathway system, and barriers to this exist at different levels and are greater for South Asian patients compared to White patients. A conceptual model of concordance as a process through which access to quality diabetes care is achieved and its relation to cultural competency is put forward. The effort required to achieve access and concordance among South Asian patients is inversely related to cultural competency at policy and practice levels. These processes are underpinned by communication.

Concordance facilitates access in diabetes care--service provider perspectives of service improvement and cultural competency

AIMS

Inequalities between different ethnic groups in diabetes care and outcomes are well documented in the UK. This research sought to explore and understand how national and local policy interventions impacted upon access and the development of culturally competent diabetes services from the care provider perspective.

METHODS

This paper describes the care provider perspective of access to diabetes care in ethnically mixed populations from a thematic analysis of 14 semi-structured interviews conducted with professionals, at three study sites, with different roles in the diabetes care pathway.

RESULTS

National policy level initiatives to improve quality have led to quality improvements at a practical level. These achievements, however, have been unable to address all aspects of care that service providers identified as important in facilitating access for all patient groups. Concordance emerged as a key process in improving access to care within local systems and barriers to this exist at different levels and are greater for some groups of patients compared with others.

CONCLUSIONS

Concordance is a key concept that underpins access and cultural competency in diabetes service improvement. A focus on concordance at different levels within local systems may improve access to quality diabetes care for ethnic minority groups.