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Mukherjee M, Okusi C, Jamie G, Byford R, Ferreira F, Fletcher M, de Lusignan S, Sheikh A. Deploying an asthma dashboard to support quality improvement across a nationally representative sentinel network of 7.6 million people in England. NPJ Prim Care Respir Med 2024; 34:18. [PMID: 38951547 PMCID: PMC11217285 DOI: 10.1038/s41533-024-00377-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/21/2024] [Indexed: 07/03/2024] Open
Abstract
Every year, there are ~100,000 hospital admissions for asthma in the UK, many of which are potentially preventable. Evidence suggests that carefully conceptualised and implemented audit and feedback (A&F) cycles have the potential to improve clinical outcomes for those with chronic conditions. We wanted to investigate the technical feasibility of developing a near-real time asthma dashboard to support A&F interventions for asthma management in primary care. We extracted cross-sectional data on asthma from 756 participating GP practices in the Oxford-Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) database in England comprising 7.6 million registered people. Summary indicators for a GP practice were compared to all participating RCGP RSC practices using practice-level data, for the week 6-12th-Mar-2023. A weekly, automated asthma dashboard with features that can support electronic-A&F cycles that compared key asthma indicators for a GP practice to RCGP RSC could be created ( https://tinyurl.com/3ydtrt85 ): 12-weeks-incidence 0.4% vs 0.4%, annual prevalence 6.1% vs 6.7%, inhaled relievers to preventer 1.2 vs 1.1, self-management plan given 83.4% vs 60.8%, annual reviews 36.8% vs 57.3%, prednisolone prescriptions 2.0% vs 3.2%, influenza vaccination 56.6% vs 55.5%, pneumococcal vaccination ever (aged ≥65 years) 90.2% vs 84.1% and current smokers 14.9% vs 14.8%. Across the RCGP RSC, the rate of hospitalisations was 0.024%; comparative data had to be suppressed for the study practice because of small numbers. We have successfully created an automated near real-time asthma dashboard that can be used to support A&F initiatives to improve asthma care and outcomes in primary care.
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Grants
- This work is carried out with the support of BREATHE - The Health Data Research Hub for Respiratory Health [MC_PC_19004] in partnership with Oxford-RCGP Clinical Informatics Digital Hub (ORCHID), a trusted research environment. BREATHE is funded through the UK Research and Innovation Industrial Strategy Challenge Fund and delivered through Health Data Research UK. Health Data Research UK is funded by UK Research and Innovation, the Medical Research Council, the British Heart Foundation, Cancer Research UK, the National Institute for Health and Care Research, the Economic and Social Research Council, the Engineering and Physical Sciences Research Council, Health and Care Research Wales, Health and Social Care Research and Development Division (Public Health Agency, Northern Ireland), Chief Scientist Office of the Scottish Government Health and Social Care Directorates. This work was also funded by The Health Data Research UK, reference EDIN1 and Asthma + Lung UK, reference AUK-AC-2018-01.
- No Relevant Funding
- Health Data Research UK, grant number EDIN1
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Affiliation(s)
- Mome Mukherjee
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK.
- HDR UK BREATHE Respiratory Data Hub, Usher Institute, The University of Edinburgh, Edinburgh, UK.
- HDR UK Better Care, Usher Institute, The University of Edinburgh, Edinburgh, UK.
| | - Cecilia Okusi
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gavin Jamie
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rachel Byford
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Filipa Ferreira
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Monica Fletcher
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
- HDR UK BREATHE Respiratory Data Hub, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Simon de Lusignan
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), London, UK
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
- HDR UK BREATHE Respiratory Data Hub, Usher Institute, The University of Edinburgh, Edinburgh, UK
- HDR UK Better Care, Usher Institute, The University of Edinburgh, Edinburgh, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Heider AK, Mang H. Effects of Non-monetary Incentives in Physician Groups-A Systematic Review. Am J Health Behav 2023; 47:458-470. [PMID: 37596755 DOI: 10.5993/ajhb.47.3.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Objectives: Healthcare expenditures in western countries have been rising for many years. This leads many countries to develop and test new reimbursement systems. A systematic review about monetary incentives in group settings indicated that a sole focus on monetary aspects does not necessarily result in better care at lower costs. Hence, this systematic review aims to describe the effects of non- monetary incentives in physician groups. Methods: We searched the databases MEDLINE (PubMed), The Cochrane Library, CINAHL, PsycINFO, EconLit, and ISI Web of Science. Grey literature search, reference lists, and authors' personal collection provided additional sources. Results: Overall, we included 36 studies. We identified 4 categories of interventions related to non-monetary incentives. In particular, the category of decision support achieved promising results. However, design features vary among different decision support systems. To enable effective design, we provide an overview of the features applied by the studies included. Conclusions: Not every type of non-monetary incentive has a positive impact on quality of care in physician group settings. Thus, creating awareness among decision-makers regarding this matter and extending research on this topic can contribute to preventing implementation of ineffective incentives, and consequently, allocate resources towards tools that add value.
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Affiliation(s)
- Ann-Kathrin Heider
- Faculty of Medicine, Friedrich-Alexander-Universität, Erlangen-Nürnberg, Germany
| | - Harald Mang
- Master Program Medical Process Management, Universitätsklinikum Erlangen, Germany
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De Simoni A, Hajmohammadi H, Pfeffer P, Cole J, Griffiths C, Hull SA. Reducing short-acting beta-agonist overprescribing in asthma: lessons from a quality-improvement prescribing project in East London. Br J Gen Pract 2022; 72:BJGP.2021.0725. [PMID: 35995577 PMCID: PMC9423045 DOI: 10.3399/bjgp.2021.0725] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/25/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Excess prescription and use of short-acting beta-agonist (SABA) inhalers is associated with poor asthma control and increased risk of hospital admission. AIM To quantify the prevalence and identify the predictors of SABA overprescribing. DESIGN AND SETTING A cross-sectional study using anonymised clinical and prescribing data from the primary care records in three contiguous East London boroughs. METHOD Primary care medical record data for patients aged 5-80 years, with 'active' asthma were extracted in February 2020. Explanatory variables included demography, asthma management, comorbidities, and prescriptions for asthma medications. RESULTS In the study population of 30 694 people with asthma, >25% (1995/7980), were prescribed ≥6 SABA inhalers in the previous year. A 10-fold variation between practices (<6% to 60%) was observed in the proportion of patients on ≥6 SABA inhalers/year. By converting both SABAs and inhaled corticosteroids (ICSs) to standard units the accuracy of comparisons was improved across different preparations. In total, >25% of those taking ≥6 SABAs/year were underusing ICSs, this rose to >80% (18 170/22 713), for those prescribed <6 SABAs/year. Prescription modality was a strong predictor of SABA overprescribing, with repeat dispensing strongly linked to SABA overprescribing (odds ratio 6.52, 95% confidence interval = 4.64 to 9.41). Increasing severity of asthma and multimorbidity were also independent predictors of SABA overprescribing. CONCLUSION In this multi-ethnic population a fifth of practices demonstrate an overprescribing rate of <20% a year. Based on previous data, supporting practices to enable the SABA ≥12 group to reduce to 4-12 a year could potentially save up to 70% of asthma admissions a year within that group.
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Affiliation(s)
- Anna De Simoni
- Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Hajar Hajmohammadi
- Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Paul Pfeffer
- Wolfson Institute of Population Health, Queen Mary University of London, London and Department of Respiratory Medicine, Barts Health NHS Trust, London
| | - Jim Cole
- Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Chris Griffiths
- Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Sally A Hull
- Wolfson Institute of Population Health, Queen Mary University of London, London
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Alsallakh MA, Rodgers SE, Lyons RA, Sheikh A, Davies GA. Association of socioeconomic deprivation with asthma care, outcomes, and deaths in Wales: A 5-year national linked primary and secondary care cohort study. PLoS Med 2021; 18:e1003497. [PMID: 33577558 PMCID: PMC7880491 DOI: 10.1371/journal.pmed.1003497] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 01/15/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Socioeconomic deprivation is known to be associated with worse outcomes in asthma, but there is a lack of population-based evidence of its impact across all stages of patient care. We investigated the association of socioeconomic deprivation with asthma-related care and outcomes across primary and secondary care and with asthma-related death in Wales. METHODS AND FINDINGS We constructed a national cohort, identified from 76% (2.4 million) of the Welsh population, of continuously treated asthma patients between 2013 and 2017 using anonymised, person-level, linked, routinely collected primary and secondary care data in the Secure Anonymised Information Linkage (SAIL) Databank. We investigated the association between asthma-related health service utilisation, prescribing, and deaths with the 2011 Welsh Index of Multiple Deprivation (WIMD) and its domains. We studied 106,926 patients (534,630 person-years), 56.3% were female, with mean age of 47.5 years (SD = 20.3). Compared to the least deprived patients, the most deprived patients had slightly fewer total asthma-related primary care consultations per patient (incidence rate ratio [IRR] = 0.98, 95% CI 0.97-0.99, p-value < 0.001), slightly fewer routine asthma reviews (IRR = 0.98, 0.97-0.99, p-value < 0.001), lower controller-to-total asthma medication ratios (AMRs; 0.50 versus 0.56, p-value < 0.001), more asthma-related accident and emergency (A&E) attendances (IRR = 1.27, 1.10-1.46, p-value = 0.001), more asthma emergency admissions (IRR = 1.56, 1.39-1.76, p-value < 0.001), longer asthma-related hospital stay (IRR = 1.64, 1.39-1.94, p-value < 0.001), and were at higher risk of asthma-related death (risk ratio of deaths with any mention of asthma 1.56, 1.18-2.07, p-value = 0.002). Study limitations include the deprivation index being area based and the potential for residual confounders and mediators. CONCLUSIONS In this study, we observed that the most deprived asthma patients in Wales had different prescribing patterns, more A&E attendances, more emergency hospital admissions, and substantially higher risk of death. Interventions specifically designed to improve treatment and outcomes for these disadvantaged groups are urgently needed.
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Affiliation(s)
- Mohammad A. Alsallakh
- Swansea University Medical School, Swansea, United Kingdom
- Health Data Research UK, Swansea and Edinburgh, United Kingdom
- Asthma UK Centre for Applied Research, Edinburgh, United Kingdom
| | - Sarah E. Rodgers
- Department of Public Health and Policy, University of Liverpool, Liverpool, United Kingdom
| | - Ronan A. Lyons
- Swansea University Medical School, Swansea, United Kingdom
- Health Data Research UK, Swansea and Edinburgh, United Kingdom
| | - Aziz Sheikh
- Health Data Research UK, Swansea and Edinburgh, United Kingdom
- Asthma UK Centre for Applied Research, Edinburgh, United Kingdom
- Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Gwyneth A. Davies
- Swansea University Medical School, Swansea, United Kingdom
- Asthma UK Centre for Applied Research, Edinburgh, United Kingdom
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Shlomi D, Oberman B, Katz I. Short-acting bronchodilators purchase as a marker for asthma control. J Asthma 2020; 59:206-212. [PMID: 33125311 DOI: 10.1080/02770903.2020.1837157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Administrative data has been used to quantify the amount of medication use in order to identify at-risk asthma patients. In our previous study we used short-acting beta-agonists (SABA) inhalers as a marker for asthma control. METHODS We further analyzed patient data from the SABA inhalers study in which asthma control was classified by GINA guidelines, physician assessment and the patients overall estimation. We identified all short-acting bronchodilator purchases (SABA and anticholinergic inhalers and solutions) in the year prior to administering the questionnaire relating to asthma control, and compared inhaled and systemic steroid use. RESULTS Of 241 asthma patients, 83 completed questionnaires. Using the GINA guidelines criteria, 26 were symptom controlled, 46 were partially controlled and 11 were uncontrolled. Using patients' overall impression of their asthma control, mean annual short-acting bronchodilator purchases were significantly higher in the partially controlled and uncontrolled patients (10 and 8.9 respectively) than in the controlled patients (2, p = 0.005). Most asthma patients purchase less than half of the controller medications prescribed to them. CONCLUSION When using administrative data, 3 or more -of all types of short-acting bronchodilator purchases in one year should alert the physician to evaluate asthma control and purchase alerts should notify both physicians and patients when controller consumption is low.
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Affiliation(s)
- Dekel Shlomi
- Adelson School of Medicine, Ariel University, Ariel, Israel.,Pulmonary Clinic, Clalit Health Services, Dan- Petah-Tiqwa District, Israel
| | - Bernice Oberman
- The Biostatistics & Biomathematics Unit, The Gertner Institute for Epidemiology and Health Policy Research, Ramat-Gan, Israel
| | - Irit Katz
- Department of Neurological Rehabilitation, Sheba Medical Center, Ramat-Gan, Israel
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Amin S, Soliman M, McIvor A, Cave A, Cabrera C. Usage Patterns of Short-Acting β 2-Agonists and Inhaled Corticosteroids in Asthma: A Targeted Literature Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2556-2564.e8. [PMID: 32244024 DOI: 10.1016/j.jaip.2020.03.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/26/2020] [Accepted: 03/05/2020] [Indexed: 01/14/2023]
Abstract
Despite the availability of effective asthma treatments, some patients are poorly controlled because of overreliance on short-acting β2-agonists (SABAs) and underuse of inhaled corticosteroids (ICSs). To identify patient characteristics and outcomes associated with SABA overreliance and ICS underuse, we conducted a targeted literature review of the quantitative evidence on asthma medication use. Articles evaluating SABA and/or ICS use in patients with asthma (aged ≥12 years), published between January 2012 and March 2018, were identified using MEDLINE and EMBASE. We observed that studies classified SABA usage as "overuse," "high use," "excess use," "extreme overuse," "suboptimal use," and "inappropriate use." Multiple thresholds were used to define overuse of SABA (≥3 to ≥12 canisters/y). SABA overreliance was prevalent, with approximately 20% of adults using 3 or more canisters per year (≥12 inhalations/wk). Similarly, inappropriate ICS use, classified as "suboptimal," "high use," "underuse," and "unlicensed use," was defined by varying thresholds. Specific patient populations, such as older adults, smokers, and patients with low income, were more susceptible to SABA overreliance and ICS underuse. Overreliance on SABAs was associated with increased risk of severe exacerbations, asthma-related hospitalizations, emergency department visits, and asthma-related costs. These findings emphasize the prevalence and related burden of SABA overreliance at the potential expense of appropriate ICS use.
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Affiliation(s)
| | - Mena Soliman
- BioPharmaceuticals Medical, AstraZeneca, Mississauga, ON, Canada
| | - Andrew McIvor
- Firestone Institute for Respiratory Health, St Joseph's Healthcare and McMaster University, Hamilton, ON, Canada
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Chen J, Kaye L, Tuffli M, Barrett MA, Jones-Ford S, Shenouda T, Gondalia R, Henderson K, Combs V, Van Sickle D, Stempel DA. Passive Monitoring of Short-Acting Beta-Agonist Use via Digital Platform in Patients With Chronic Obstructive Pulmonary Disease: Quality Improvement Retrospective Analysis. JMIR Form Res 2019; 3:e13286. [PMID: 31647471 PMCID: PMC7010108 DOI: 10.2196/13286] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 07/26/2019] [Accepted: 08/19/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Digital health programs assist patients with chronic obstructive pulmonary disease (COPD) to better manage their disease. Technological and adoption barriers have been perceived as a limitation. OBJECTIVE The aim of the research was to evaluate a digital quality improvement pilot in Medicare-eligible patients with COPD. METHODS COPD patients were enrolled in a digital platform to help manage their medications and symptoms as part of their routine clinical care. Patients were provided with electronic medication monitors (EMMs) to monitor short-acting beta-agonist (SABA) use passively and a smartphone app to track use trends and receive feedback. Providers also had access to data collected via a secure website and were sent email notifications if a patient had a significant change in their prescribed inhaler use. Providers then determined if follow-up was needed. Change in SABA use and feasibility outcomes were evaluated at 3, 6, and 12 months. RESULTS A total of 190 patients enrolled in the pilot. At 3, 6, and 12 months, patients recorded significant reductions in daily and nighttime SABA use and increases in SABA-free days (all P<.001). Patient engagement, as measured by the ratio of daily active use to monthly active use, was >90% at both 6 and 12 months. Retention at 6 months was 81% (154/190). Providers were sent on average two email notifications per patient during the 12-month program. CONCLUSIONS A digital health program integrated as part of standard clinical practice was feasible and had low provider burden. The pilot demonstrated significant reduction in SABA use and increased SABA-free days among Medicare-eligible COPD patients. Further, patients readily adopted the digital platform and demonstrated strong engagement and retention rates at 6 and 12 months.
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Affiliation(s)
| | - Leanne Kaye
- Propeller Health, San Francisco, CA, United States
| | | | | | | | - Tina Shenouda
- JenCare Senior Medical Center, Louisville, KY, United States
| | | | | | - Veronica Combs
- Content Strategy Solutions, Louisville, KY, United States
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"Tossing a coin:" defining the excessive use of short-acting beta 2-agonists in asthma-the views of general practitioners and asthma experts in primary and secondary care. NPJ Prim Care Respir Med 2018; 28:26. [PMID: 30022059 PMCID: PMC6052065 DOI: 10.1038/s41533-018-0096-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 11/11/2022] Open
Abstract
The National Review of Asthma Deaths (NRAD) identified high prescribing of short–acting beta2-agonists (SABAs) as a key factor in over 40% of deaths. We interviewed asthma experts from both a hospital background (n = 5) and a primary care background (n = 8), and general practitioners delivering asthma care (n = 8), to identify how SABA use is defined and perceived. We identified disparity in how acceptable SABA use is defined, ranging from 0.5 (100 doses/year) to 12 SABA inhalers (2400 doses/year), and complacency in the perception that over-use did not represent a marker for risk of asthma death. Despite current evidence, these findings suggest clinicians of various backgrounds are complacent about excessive SABA use.
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