The GP's role in promoting winter wellness

Evaluation of winter pressures on general practice in Manchester: a cross-sectional analysis of nine GP practices

Background

The Nuffield Trust’s report on NHS winter pressures highlights a lack of data for primary care, with a consequential focus on secondary care. An increase in data is required on the scale of the winter demand on primary care, so the need for investment in this area can be clearly seen.

Aim

To quantify seasonal variation in workload in primary and secondary care.

Design & setting

Analysis of data for nine GP practices in Greater Manchester with a patient population of 75 421.

Method

Descriptive and comparative analyses were performed for winter and summer periods in 2018–2019. Data were obtained from the North of England Clinical Support Unit (NECSU) via the Rapid Actionable Insight Driving Reform (RAIDR) toolkit, and EMIS Enterprise clinical audit tools.

Results

Accident and emergency (A&E) attendances increased by 4% (P = 0.035) during winter with no difference in the number of hospital admissions (P = 0.668). The number of problems (defined as separate diagnoses or causes for a GP consultation, for example, chest infection or medication request) seen in general practice increased by 61% (P<0.001) in winter compared to summer, as did the number of GP consultations, which was also 61% (P<0.001). Respiratory diagnoses saw the greatest seasonal variation accounting for 10% in winter compared with 4% in summer (P<0.001). Self-referral accounted for 66% of all A&E attendance and increased by 16% in winter. GP referral accounted for 7% in winter and 6% in summer (P = 0.002).

Conclusion

General practice observed a greater seasonal increase in presenting patients compared with secondary care. Any winter pressures strategy should target both respiratory illness and patients who self-refer to A&E. Transferring 50% of self-referrals in Manchester to GP appointments would achieve a £2.3 million cost saving. Increasing provision in primary care requires funding and increased appointments, but more importantly improved patient opportunities to easily access timely advice and assistance.

Significant spike in excess mortality in England in winter 2014/15 - influenza the likely culprit

Significant increases in excess all-cause mortality, particularly in the elderly, were observed during the winter of 2014/15 in England. With influenza A(H3N2) the dominant circulating influenza A subtype, this paper determines the contribution of influenza to this excess controlling for weather. A standardised multivariable Poisson regression model was employed with weekly all-cause deaths the dependent variable for the period 2008-2015. Adjusting for extreme temperature, a total of 26 542 (95% CI 25 301-27 804) deaths in 65+ and 1942 (95% CI 1834-2052) in 15-64-year-olds were associated with influenza from week 40, 2014 to week 20, 2015. This is compatible with the circulation of influenza A(H3N2). It is the largest estimated number of influenza-related deaths in England since prior to 2008/09. The findings highlight the potential health impact of influenza and the important role of the annual influenza vaccination programme that is required to protect the population including the elderly, who are vulnerable to a severe outcome.

Incidence of Lower Respiratory Tract Infections and Atopic Conditions in Boys and Young Male Adults: Royal College of General Practitioners Research and Surveillance Centre Annual Report 2015-2016

Background

The Royal College of General Practitioners Research and Surveillance Centre comprises more than 150 general practices, with a combined population of more than 1.5 million, contributing to UK and European public health surveillance and research.

Objective

The aim of this paper was to report gender differences in the presentation of infectious and respiratory conditions in children and young adults.

Methods

Disease incidence data were used to test the hypothesis that boys up to puberty present more with lower respiratory tract infection (LRTI) and asthma. Incidence rates were reported for infectious conditions in children and young adults by gender. We controlled for ethnicity, deprivation, and consultation rates. We report odds ratios (OR) with 95% CI, P values, and probability of presenting.

Results

Boys presented more with LRTI, largely due to acute bronchitis. The OR of males consulting was greater across the youngest 3 age bands (OR 1.59, 95% CI 1.35-1.87; OR 1.13, 95% CI 1.05-1.21; OR 1.20, 95% CI 1.09-1.32). Allergic rhinitis and asthma had a higher OR of presenting in boys aged 5 to 14 years (OR 1.52, 95% CI 1.37-1.68; OR 1.31, 95% CI 1.17-1.48). Upper respiratory tract infection (URTI) and urinary tract infection (UTI) had lower odds of presenting in boys, especially those older than 15 years. The probability of presenting showed different patterns for LRTI, URTI, and atopic conditions.

Conclusions

Boys younger than 15 years have greater odds of presenting with LRTI and atopic conditions, whereas girls may present more with URTI and UTI. These differences may provide insights into disease mechanisms and for health service planning.

Use of primary care data to predict those most vulnerable to cold weather: a case-crossover analysis

Background

The National Institute for Health and Care Excellence (NICE) recommends that GPs use routinely available data to identify patients most at risk of death and ill health from living in cold homes.

Aim

To investigate whether sociodemographic characteristics, clinical factors, and house energy efficiency characteristics could predict cold-related mortality.

Design and setting

A case-crossover analysis was conducted on 34 777 patients aged ≥65 years from the Clinical Practice Research Datalink who died between April 2012 and March 2014. The average temperature of date of death and 3 days previously were calculated from Met Office data. The average 3-day temperature for the 28th day before/after date of death were calculated, and comparisons were made between these temperatures and those experienced around the date of death.

Method

Conditional logistic regression was applied to estimate the odds ratio (OR) of death associated with temperature and interactions between temperature and sociodemographic characteristics, clinical factors, and house energy efficiency characteristics, expressed as relative odds ratios (RORs).

Results

Lower 3-day temperature was associated with higher risk of death (OR 1.011 per 1°C fall; 95% CI = 1.007 to 1.015; P<0.001). No modifying effects were observed for sociodemographic characteristics, clinical factors, and house energy efficiency characteristics. Analysis of winter deaths for causes typically associated with excess winter mortality (N = 7710) showed some evidence of a weaker effect of lower 3-day temperature for females (ROR 0.980 per 1°C, 95% CI = 0.959 to 1.002, P = 0.082), and a stronger effect for patients living in northern England (ROR 1.040 per 1°C, 95% CI = 1.013 to 1.066, P = 0.002).

Conclusion

It is unlikely that GPs can identify older patients at highest risk of cold-related death using routinely available data, and NICE may need to refine its guidance.