The role of the Quality and Outcomes Framework in the care of long-term conditions: a systematic review

Quality indicators for schizophrenia care: A scoping review

Measuring quality of care is a critical first step towards improving the healthcare contributing to persistent poor outcomes experienced by many people living with schizophrenia. This scoping review aims to identify and characterize indicators for measuring the quality of care for people living with schizophrenia. We searched 6 academic databases, 4 grey literature databases, and 23 organization websites for documents containing quality indicators developed for or applied in a population with schizophrenia-spectrum disorders. We identified 119 unique documents, yielding 390 distinct quality indicators. Most measures were process indicators (68 %; n = 267) commonly reflecting safety (30 %; n = 118) and effectiveness (35 %; n = 136) domains of quality of care. Quality indicators included measures of primarily mental healthcare (77 %; n = 299), as well as physical healthcare (23 %; n = 91). Indicators reflected aspects of care related to service delivery, pharmacotherapy, assessments, resources and policies, psychological interventions, social and other interventions. Indicator development was notable for a lack of well-described validation and selection processes. Gaps in indicator availability for comorbid substance use, reproductive health, and healthcare equity were also identified. Results reflect a growing recognition of the importance of quality measurement in this population but highlight the need for prioritization of indicators to guide future quality measurement and improvement.

Understanding access to general practice through the lens of candidacy: a critical review of the literature

BACKGROUND

Dominant conceptualisations of access to health care are limited, framed in terms of speed and supply. The Candidacy Framework offers a more comprehensive approach, identifying diverse influences on how access is accomplished.

AIM

To characterise how the Candidacy Framework can explain access to general practice - an increasingly fraught area of public debate and policy.

DESIGN AND SETTING

Qualitative review guided by the principles of critical interpretive synthesis.

METHOD

We conducted a literature review using an author-led approach, involving iterative analytically guided searches. Articles were eligible for inclusion if they related to the context of general practice, without geographical or time limitations. Key themes relating to access to general practice were extracted and synthesised using the Candidacy Framework.

RESULTS

A total of 229 articles were included in the final synthesis. The seven features identified in the original Candidacy Framework are highly salient to general practice. Using the lens of candidacy demonstrates that access to general practice is subject to multiple influences that are highly dynamic, contingent, and subject to constant negotiation. These influences are socioeconomically and institutionally patterned, creating risks to access for some groups. This analysis enables understanding of the barriers to access that may exist, even though general practice in the UK is free at the point of care, but also demonstrates that a Candidacy Framework specific to this setting is needed.

CONCLUSION

The Candidacy Framework has considerable value as a way of understanding access to general practice, offering new insights for policy and practice. The original framework would benefit from further customisation for the distinctive setting of general practice.

Gender and contemporary risk of adverse events in atrial fibrillation

BACKGROUND AND AIMS

The role of gender in decision-making for oral anticoagulation in patients with atrial fibrillation (AF) remains controversial.

METHODS

The population cohort study used electronic healthcare records of 16 587 749 patients from UK primary care (2005-2020). Primary (composite of all-cause mortality, ischaemic stroke, or arterial thromboembolism) and secondary outcomes were analysed using Cox hazard ratios (HR), adjusted for age, socioeconomic status, and comorbidities.

RESULTS

78 852 patients were included with AF, aged 40-75 years, no prior stroke, and no prescription of oral anticoagulants. 28 590 (36.3%) were women, and 50 262 (63.7%) men. Median age was 65.7 years (interquartile range 58.5-70.9), with women being older and having other differences in comorbidities. During a total follow-up of 431 086 patient-years, women had a lower adjusted primary outcome rate with HR 0.89 vs. men (95% confidence interval [CI] 0.87-0.92; P < .001) and HR 0.87 after censoring for oral anticoagulation (95% CI 0.83-0.91; P < .001). This was driven by lower mortality in women (HR 0.86, 95% CI 0.83-0.89; P < .001). No difference was identified between women and men for the secondary outcomes of ischaemic stroke or arterial thromboembolism (adjusted HR 1.00, 95% CI 0.94-1.07; P = .87), any stroke or any thromboembolism (adjusted HR 1.02, 95% CI 0.96-1.07; P = .58), and incident vascular dementia (adjusted HR 1.13, 95% CI 0.97-1.32; P = .11). Clinical risk scores were only modest predictors of outcomes, with CHA2DS2-VA (ignoring gender) superior to CHA2DS2-VASc for primary outcomes in this population (receiver operating characteristic curve area 0.651 vs. 0.639; P < .001) and no interaction with gender (P = .45).

CONCLUSIONS

Removal of gender from clinical risk scoring could simplify the approach to which patients with AF should be offered oral anticoagulation.

Thromboembolic events and vascular dementia in patients with atrial fibrillation and low apparent stroke risk

The prevention of thromboembolism in atrial fibrillation (AF) is typically restricted to patients with specific risk factors and ignores outcomes such as vascular dementia. This population-based cohort study used electronic healthcare records from 5,199,994 primary care patients (UK; 2005-2020). A total of 290,525 (5.6%) had a diagnosis of AF and were aged 40-75 years, of which 36,340 had no history of stroke, a low perceived risk of stroke based on clinical risk factors and no oral anticoagulant prescription. Matching was performed for age, sex and region to 117,298 controls without AF. During 5 years median follow-up (831,005 person-years), incident stroke occurred in 3.8% with AF versus 1.5% control (adjusted hazard ratio (HR) 2.06, 95% confidence interval (CI) 1.91-2.21; P < 0.001), arterial thromboembolism 0.3% versus 0.1% (HR 2.39, 95% CI 1.83-3.11; P < 0.001), and all-cause mortality 8.9% versus 5.0% (HR 1.44, 95% CI 1.38-1.50; P < 0.001). AF was associated with all-cause dementia (HR 1.17, 95% CI 1.04-1.32; P = 0.010), driven by vascular dementia (HR 1.68, 95% CI 1.33-2.12; P < 0.001) rather than Alzheimer's disease (HR 0.85, 95% CI 0.70-1.03; P = 0.09). Death and thromboembolic outcomes, including vascular dementia, are substantially increased in patients with AF despite a lack of conventional stroke risk factors.

[Tabacco harm reduction: the need for a paradigm shift in German tobacco control policy]

The consumption of tobacco continues to be the greatest preventable health risk in Germany. Every year, more than 127,000 people die prematurely as a result of using tobacco - one in five new cases of cancer is a consequence of smoking. Germany's current tobacco control policy, consisting of advertising bans, the promotion of smoke-free environments, and an abstinence-only paradigm, are only able to initiate slow change. Other countries have shown how the number of smokers can be reduced and deaths prevented by integrating harm reduction as a complementary measure and providing a much more active support for people who want to quit. This article first presents the current situation and current measures in Germany. Then recommendations for changes to the current tobacco control policy in Germany are derived from a look at the United Kingdom, which is considered a pioneer throughout Europe with its tobacco control policy, as well as a summary of the current state of research.

Prevalence of cardiovascular drug-related adverse drug reactions consultations in UK primary care: A cross-sectional study

BACKGROUND

Adverse drug reactions (ADRs) represent a significant barrier to achieve optimal treatment outcomes. Cardiovascular drugs, including antihypertensive drugs, lipid-lowering drugs, and antithrombotic drugs, are among the most prescribed medications in the primary care setting.

OBJECTIVES

To estimate the prevalence of cardiovascular drug-related ADRs consultations in United Kingdom (UK) primary care and identify risk factors of these ADRs.

METHODS

This was a cross-sectional study of cardiovascular drug users between 2000-2019 using UK IQVIA Medical Research Data. ADRs consultations were identified using database screening method employing standardised designated codes. The overall and annual age-standardised prevalence was estimated using direct standardisation method using 2019 mid-year UK population. Risk factors of ADRs consultations were estimated using logistic regression model stratified by therapeutic areas.

RESULTS

The standardised prevalence of consultations related to cardiovascular drugs ADRs was 10.60 (95% CI. 10.46, 10.75) per 1000 patients. Patients aged 70-79 years had the highest occurrence of ADRs consultations. The most frequently drug classes implicated in the ADRs consultations were statins (n = 9,993 events, 27.09%), beta-blockers (n = 8,538 events, 23.15%), ACEIs/ARBs (n = 8,345 events, 22.62%), and aspirin (n = 6,482 events, 17.57%). Risk factors of ADRs consultations were previous history of cardiovascular diseases, e.g., myocardial infarction and stroke; advanced age, comorbidities; diabetes and dyslipidaemia; and polypharmacy.

CONCLUSIONS

The burden of cardiovascular drug-related ADRs consultations in primary care was considerable. Statins, beta-blockers, ACEIs/ARBs, and aspirin were the most frequently implicated drug classes. Closer clinical monitoring should be performed for patients affected by the ADRs to mitigate the risk of suboptimal treatment outcomes.

Deploying an asthma dashboard to support quality improvement across a nationally representative sentinel network of 7.6 million people in England

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.

Does shortage of GPs matter? A cross-sectional study of practice population life expectancy

BACKGROUND

There are not enough GPs in England. Access to general practice and continuity of care are declining.

AIM

To investigate whether practice characteristics are associated with life expectancy of practice populations.

DESIGN AND SETTING

A cross-sectional ecological study of patient life expectancy from 2015-2019.

METHOD

Selection of independent variables was based on conceptual frameworks describing general practice's influence on outcomes. Sixteen non-correlated variables were entered into multivariable weighted regression models: population characteristics (Index of Multiple Deprivation, region, % White ethnicity, and % on diabetes register); practice organisation (total NHS payments to practices expressed as payment per registered patient, full-time equivalent fully qualified GPs, GP registrars, advanced nurse practitioners, other nurses, and receptionists per 1000 patients); access (% seen on the same day); clinical performance (% aged ≥45 years with blood pressure checked, % with chronic obstructive pulmonary disease vaccinated against flu, % with diabetes in glycaemic control, and % with coronary heart disease on antiplatelet therapy); and the therapeutic relationship (% continuity).

RESULTS

Deprivation was strongly negatively associated with life expectancy. Regions outside London and White ethnicity were associated with lower life expectancy. Higher payment per patient, full-time equivalent fully qualified GPs per 1000 patients, continuity, % with chronic obstructive pulmonary disease having the flu vaccination, and % with diabetes with glycaemic control were associated with higher life expectancy; the % being seen on the same day was associated with higher life expectancy in males only. The variable aged ≥45 years with blood pressure checked was a negative predictor in females.

CONCLUSION

The number of GPs, continuity of care, and access in England are declining, and it is worrying that these features of general practice were positively associated with life expectancy.

Relationships between the Structural Characteristics of General Medical Practices and the Socioeconomic Status of Patients with Diabetes-Related Performance Indicators in Primary Care

The implementation of monitoring for general medical practice (GMP) can contribute to improving the quality of diabetes mellitus (DM) care. Our study aimed to describe the associations of DM care performance indicators with the structural characteristics of GMPs and the socioeconomic status (SES) of patients. Using data from 2018 covering the whole country, GMP-specific indicators standardized by patient age, sex, and eligibility for exemption certificates were computed for adults. Linear regression models were applied to evaluate the relationships between GMP-specific parameters (list size, residence type, geographical location, general practitioner (GP) vacancy and their age) and patient SES (education, employment, proportion of Roma adults, housing density) and DM care indicators. Patients received 58.64% of the required medical interventions. A lower level of education (hemoglobin A1c test: β = -0.108; ophthalmic examination: β = -0.100; serum creatinine test: β = -0.103; and serum lipid status test: β = -0.108) and large GMP size (hemoglobin A1c test: β = -0.068; ophthalmological examination β = -0.031; serum creatinine measurement β = -0.053; influenza immunization β = -0.040; and serum lipid status test β = -0.068) were associated with poor indicators. A GP age older than 65 years was associated with lower indicators (hemoglobin A1c test: β = -0.082; serum creatinine measurement: β = -0.086; serum lipid status test: β = -0.082; and influenza immunization: β = -0.032). Overall, the GMP-level DM care indicators were significantly influenced by GMP characteristics and patient SES. Therefore, proper diabetes care monitoring for the personal achievements of GPs should involve the application of adjusted performance indicators.

Impact of reimbursement systems on patient care - a systematic review of systematic reviews

BACKGROUND

There is not yet sufficient scientific evidence to answer the question of the extent to which different reimbursement systems influence patient care and treatment quality. Due to the asymmetry of information between physicians, health insurers and patients, market-based mechanisms are necessary to ensure the best possible patient care. The aim of this study is to investigate how reimbursement systems influence multiple areas of patient care in form of structure, process and outcome indicators.

METHODS

For this purpose, a systematic literature review of systematic reviews is conducted in the databases PubMed, Web of Science and the Cochrane Library. The reimbursement systems of salary, bundled payment, fee-for-service and value-based reimbursement are examined. Patient care is divided according to the three dimensions of structure, process, and outcome and evaluated in eight subcategories.

RESULTS

A total of 34 reviews of 971 underlying primary studies are included in this article. International studies identified the greatest effects in categories resource utilization and quality/health outcomes. Pay-for-performance and bundled payments were the most commonly studied models. Among the systems examined, fee-for-service and value-based reimbursement systems have the most positive impact on patient care.

CONCLUSION

Patient care can be influenced by the choice of reimbursement system. The factors for successful implementation need to be further explored in future research.

Effect of timeframes to define long term conditions and sociodemographic factors on prevalence of multimorbidity using disease code frequency in primary care electronic health records: retrospective study

Objective

To determine the extent to which the choice of timeframe used to define a long term condition affects the prevalence of multimorbidity and whether this varies with sociodemographic factors.

Design

Retrospective study of disease code frequency in primary care electronic health records.

Data sources

Routinely collected, general practice, electronic health record data from the Clinical Practice Research Datalink Aurum were used.

Main outcome measures

Adults (≥18 years) in England who were registered in the database on 1 January 2020 were included. Multimorbidity was defined as the presence of two or more conditions from a set of 212 long term conditions. Multimorbidity prevalence was compared using five definitions. Any disease code recorded in the electronic health records for 212 conditions was used as the reference definition. Additionally, alternative definitions for 41 conditions requiring multiple codes (where a single disease code could indicate an acute condition) or a single code for the remaining 171 conditions were as follows: two codes at least three months apart; two codes at least 12 months apart; three codes within any 12 month period; and any code in the past 12 months. Mixed effects regression was used to calculate the expected change in multimorbidity status and number of long term conditions according to each definition and associations with patient age, gender, ethnic group, and socioeconomic deprivation.

Results

9 718 573 people were included in the study, of whom 7 183 662 (73.9%) met the definition of multimorbidity where a single code was sufficient to define a long term condition. Variation was substantial in the prevalence according to timeframe used, ranging from 41.4% (n=4 023 023) for three codes in any 12 month period, to 55.2% (n=5 366 285) for two codes at least three months apart. Younger people (eg, 50-75% probability for 18-29 years v 1-10% for ≥80 years), people of some minority ethnic groups (eg, people in the Other ethnic group had higher probability than the South Asian ethnic group), and people living in areas of lower socioeconomic deprivation were more likely to be re-classified as not multimorbid when using definitions requiring multiple codes.

Conclusions

Choice of timeframe to define long term conditions has a substantial effect on the prevalence of multimorbidity in this nationally representative sample. Different timeframes affect prevalence for some people more than others, highlighting the need to consider the impact of bias in the choice of method when defining multimorbidity.

Temporal trends in admissions for atrial fibrillation and severe bleeding in England: an 18-year longitudinal analysis

Objective. Temporal trends in admissions for atrial fibrillation (AF) and severe bleeding associated with AF vary worldwide. We aimed to explore their temporal trends in England and their relation to the introduction of DOACs in 2014 in the UK. Design. This longitudinal ecological study utilised aggregated data that was extracted from the Hospital Episode Statistics database, which captured annual admissions for AF and severe bleeding associated with AF between 2001 and 2018. Trends in admissions over the study period and across age groups, gender and regions in England were assessed. Results. In total, there were 11,292,177 admissions for AF and 324,851 admissions for severe bleeding associated with AF. There was a steady rise in admissions for AF from 2001 to 2017 (204,808 to 1,109,295; p for trend<.001). A similar trend was observed for severe bleeding (4940 to 30,169; p for trend <.001), but the increase dropped slightly between 2013 and 2014 and continued thereafter. Conclusions. There was a rise in admissions for AF and severe bleeding in England between 2001 and 2018. There is little evidence that the slight drop in admissions for severe bleeding between 2013 and 2014 may have been caused by the introduction of DOACs in 2014. Contributors to these trends need urgent exploration.

Challenges in reaching patients with severe mental illness for trials in general practice-a convergent mixed methods study based on the SOFIA pilot trial

BACKGROUND

Patients with severe mental illness (SMI) die prematurely due to undetected and inadequate treatment of somatic illnesses. The SOFIA pilot study was initiated to mend this gap in health inequity. However, reaching patients with SMI for intervention research has previously proven difficult. This study aimed to investigate the recruitment of patients with SMI for the SOFIA pilot study in 2021.

METHODS

We used a mixed-method convergent design. The qualitative material comprised 20 interviews with general practitioners (GPs) and staff, during patient recruitment. The quantitative data consisted of process data on baseline characteristics, GPs reported reasons for excluding a patient, reported reasons for patients declining participation, and registered data from a Danish population of patients with SMI. We used thematic analysis in the qualitative analysis and descriptive statistics for the quantitative analysis. Pillar integration was used for integrating the material.

RESULTS

Our findings show that selection bias occurred in the pilot study. We describe four main themes based on the integrated analysis that highlights selection issues: (1) poor data quality and inconsistency in defining severity definitions troubled identification and verification, (2) protecting the patient and maintaining practice efficiency, (3) being familiar with the patient was important for a successful recruitment, and (4) in hindsight, the GPs questioned whether the target population was reached.

CONCLUSIONS

In the light of theories of professions and street-level bureaucracy, we find that the main drivers of the patient selection bias occurring in the SOFIA pilot study were that 1) GPs and staff mended eligibility criteria to protect certain patients and/or to minimize workload and maintain efficiency in the practice 2) the data from the GP record systems and the digital assessment tool to assist recruitment was not optimal. Interventions targeting this patient group should carefully consider the recruitment strategy with a particular focus on professionals' discretionary practices and information technology pitfalls.

TRIAL REGISTRATION

The pilot trial protocol was registered on the 5th of November 2020. The registration number is NCT04618250 .

Identifying potential biases in code sequences in primary care electronic healthcare records: a retrospective cohort study of the determinants of code frequency

OBJECTIVES

To determine whether the frequency of diagnostic codes for long-term conditions (LTCs) in primary care electronic healthcare records (EHRs) is associated with (1) disease coding incentives, (2) General Practice (GP), (3) patient sociodemographic characteristics and (4) calendar year of diagnosis.

DESIGN

Retrospective cohort study.

SETTING

GPs in England from 2015 to 2022 contributing to the Clinical Practice Research Datalink Aurum dataset.

PARTICIPANTS

All patients registered to a GP with at least one incident LTC diagnosed between 1 January 2015 and 31 December 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

The number of diagnostic codes for an LTC in (1) the first and (2) the second year following diagnosis, stratified by inclusion in the Quality and Outcomes Framework (QOF) financial incentive programme.

RESULTS

3 113 724 patients were included, with 7 723 365 incident LTCs. Conditions included in QOF had higher rates of annual coding than conditions not included in QOF (1.03 vs 0.32 per year, p<0.0001). There was significant variation in code frequency by GP which was not explained by patient sociodemographics. We found significant associations with patient sociodemographics, with a trend towards higher coding rates in people living in areas of higher deprivation for both QOF and non-QOF conditions. Code frequency was lower for conditions with follow-up time in 2020, associated with the onset of the COVID-19 pandemic.

CONCLUSIONS

The frequency of diagnostic codes for newly diagnosed LTCs is influenced by factors including patient sociodemographics, disease inclusion in QOF, GP practice and the impact of the COVID-19 pandemic. Natural language processing or other methods using temporally ordered code sequences should account for these factors to minimise potential bias.

Dementia prevention and the GP's role: a qualitative interview study

BACKGROUND

GPs play an increasingly important role in proactively preventing dementia. Dementia in 40% of patients could be prevented or delayed by targeting 12 modifiable risk factors throughout life. However, little is known about how GPs perceive their role in dementia prevention and the associated barriers.

AIM

To explore the role of GPs in dementia prevention.

DESIGN AND SETTING

Qualitative study among UK GPs.

METHOD

Semi-structured online interviews were conducted with 11 UK GPs exploring their views regarding their role in dementia prevention. Data were analysed using thematic analysis.

RESULTS

GPs reported that they never explicitly discuss dementia risk with patients, even when patients are presenting with risk factors, but acknowledge that dementia prevention should be part of their role. They advocate for adopting a whole team approach to primary care preventive practice, using long-term condition/medication reviews or NHS health checks as a platform to enable dementia risk communication targeting already at-risk individuals. Barriers included a lack of time and an absence of knowledge and education about the modifiable dementia risk factors, as well as a reluctance to use 'dementia' as a term within the appointment for fear of causing health anxiety. 'Brain health' was perceived as offering a more encouraging discursive tool for primary care practitioners, supporting communication and behaviour change.

CONCLUSION

There needs to be a whole-systems shift towards prioritising brain health and supporting primary care professionals in their preventive role. Education is key to underpinning this role in dementia prevention.

Cardiovascular Disease in Saudi Arabia: Facts and the Way Forward

Cardiovascular diseases (CVDs) remain a major health concern globally. While some risk factors for CVDs are non-modifiable, other determinants like obesity, hypertension, type-2 diabetes and dyslipidemia can be mitigated by a wide plethora of measures to control CVD morbidity and mortality. Those determinants have been on the rise in Saudi Arabia, exacerbated by sedentary lifestyle. The Saudi Vision 2030 aims to reduce CVD clinical and economic burden and to scale up vitality and longevity; in a new era of comprehensive healthcare. From a health economics standpoint, CVDs entail a burden on healthcare systems directly through expenditure and indirectly through years living with the disease, low productivity, premature morbidity and mortality. This manuscript reviews current CV health and unmet needs in Saudi Arabia, discusses G20 countries' initiatives on primary prevention: public health measures, awareness programs; and proposes national registries and digital solutions to facilitate population-specific research, improve CV surveillance and alleviate CVD burden in Saudi Arabia.

Gone Too Soon: priorities for action to prevent premature mortality associated with mental illness and mental distress

Globally, too many people die prematurely from suicide and the physical comorbidities associated with mental illness and mental distress. The purpose of this Review is to mobilise the translation of evidence into prioritised actions that reduce this inequity. The mental health research charity, MQ Mental Health Research, convened an international panel that used roadmapping methods and review evidence to identify key factors, mechanisms, and solutions for premature mortality across the social-ecological system. We identified 12 key overarching risk factors and mechanisms, with more commonalities than differences across the suicide and physical comorbidities domains. We also identified 18 actionable solutions across three organising principles: the integration of mental and physical health care; the prioritisation of prevention while strengthening treatment; and the optimisation of intervention synergies across social-ecological levels and the intervention cycle. These solutions included accessible, integrated high-quality primary care; early life, workplace, and community-based interventions co-designed by the people they should serve; decriminalisation of suicide and restriction of access to lethal means; stigma reduction; reduction of income, gender, and racial inequality; and increased investment. The time to act is now, to rebuild health-care systems, leverage changes in funding landscapes, and address the effects of stigma, discrimination, marginalisation, gender violence, and victimisation.

Impact of prevention in primary care on costs in primary and secondary care for people with serious mental illness

A largely unexplored part of the financial incentive for physicians to participate in preventive care is the degree to which they are the residual claimant from any resulting cost savings. We examine the impact of two preventive activities for people with serious mental illness (care plans and annual reviews of physical health) by English primary care practices on costs in these practices and in secondary care. Using panel two-part models to analyze patient-level data linked across primary and secondary care, we find that these preventive activities in the previous year are associated with cost reductions in the current quarter both in primary and secondary care. We estimate that there are large beneficial externalities for which the primary care physician is not the residual claimant: the cost savings in secondary care are 4.7 times larger than the cost savings in primary care. These activities are incentivized in the English National Health Service but the total financial incentives for primary care physicians to participate were considerably smaller than the total cost savings produced. This suggests that changes to the design of incentives to increase the marginal reward for conducting these preventive activities among patients with serious mental illness could have further increased welfare.

Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China

BACKGROUND

Quality measurements in primary healthcare (PHC) have become an essential component for improving diabetes outcomes in many high-income countries. However, little is known about their implementation within the Chinese health-system context and how they are perceived by patients, physicians, and policy-makers. We examined stakeholders' perceptions of quality and performance measurements for primary diabetes care in Shanghai, China, and analyzed facilitators and barriers to implementation.

METHODS

In-depth interviews with 26 key stakeholders were conducted from 2018 to 2019. Participants were sampled from two hospitals, four community healthcare centers (CHCs), and four institutes involved in regulating CHCs. The Consolidated Framework for Implementation Research (CFIR) guided data analysis.

RESULTS

Existing quality measurements were uniformly implemented via a top-down process, with daily monitoring of family doctors' work and pay-for-performance incentives. Barriers included excluding frontline clinicians from indicator planning, a lack of transparent reporting, and a rigid organizational culture with limited bottom-up feedback. Findings under the CFIR construct "organizational incentives" suggested that current pay-for-performance incentives function as a "double-edged sword," increasing family doctors' motivation to excel while creating pressures to "game the system" among some physicians. When considering the CFIR construct "reflecting and evaluating," policy-makers perceived the online evaluation application - which provides daily reports on family doctors' work - to be an essential tool for improving quality; however, this information was not visible to patients. Findings included under the "network and communication" construct showed that specialists support the work of family doctors by providing training and patient consultations in CHCs.

CONCLUSION

The quality of healthcare could be considerably enhanced by involving patients and physicians in decisions on quality measurement. Strengthening hospital-community partnerships can improve the quality of primary care in hospital-centric systems. The case of Shanghai provides compelling policy lessons for other health systems faced with the challenge of improving PHC.

Comparing antibiotic prescribing between clinicians in UK primary care: an analysis in a cohort study of eight different measures of antibiotic prescribing

BACKGROUND

There is a need to reduce antimicrobial uses in humans. Previous studies have found variations in antibiotic (AB) prescribing between practices in primary care. This study assessed variability of AB prescribing between clinicians.

METHODS

Clinical Practice Research Datalink, which collects electronic health records in primary care, was used to select anonymised clinicians providing 500+ consultations during 2012-2017. Eight measures of AB prescribing were assessed, such as overall and incidental AB prescribing, repeat AB courses and extent of risk-based prescribing. Poisson regression models with random effect for clinicians were fitted.

RESULTS

6111 clinicians from 466 general practices were included. Considerable variability between individual clinicians was found for most AB measures. For example, the rate of AB prescribing varied between 77.4 and 350.3 per 1000 consultations; percentage of repeat AB courses within 30 days ranged from 13.1% to 34.3%; predicted patient risk of hospital admission for infection-related complications in those prescribed AB ranged from 0.03% to 0.32% (5th and 95th percentiles). The adjusted relative rate between clinicians in rates of AB prescribing was 5.23. Weak correlation coefficients (<0.5) were found between most AB measures. There was considerable variability in case mix seen by clinicians. The largest potential impact to reduce AB prescribing could be around encouraging risk-based prescribing and addressing repeat issues of ABs. Reduction of repeat AB courses to prescribing habit of median clinician would save 21 813 AB prescriptions per 1000 clinicians per year.

CONCLUSIONS

The wide variation seen in all measures of AB prescribing and weak correlation between them suggests that a single AB measure, such as prescribing rate, is not sufficient to underpin the optimisation of AB prescribing.

Early Outcome Trends of Unicompartmental Knee Arthroplasty in Patients With Morbid Obesity: A Potential for Outpatient Surgery

BACKGROUND

Elevated body mass index (BMI) was previously considered a contraindication to unicompartmental knee arthroplasty (UKA). This study sought to determine if outcomes following UKA in patients with elevated BMI have improved over the years. We hypothesized that operative times and length of stay (LOS) following UKA would significantly decrease, while discharge to home rates would increase across all BMI cohorts, especially those with a BMI > 40.

METHODS

Using the National Surgical Quality Improvement Program registry, surgical cases categorized using the Current Procedural Terminology code 27446 for UKA with a recorded height and weight were included. Three BMI cohorts were created: BMI I (BMI < 30), BMI II (30 ≤ BMI ≤ 40), and BMI III (BMI > 40). Each BMI group was subclassified temporally by year of operation: Years A (2006-2009), Years B (2010-2014), and Years C (2015-2019).

RESULTS

A total of 14,114 patients were included. For BMI III, both operative time (P < .001) and LOS (P < .001) significantly decreased over the Years cohorts. Discharge home rates increased from 88.3% to 94.4% in BMI III (P = .001). All BMI cohorts saw similar changes in discharge patterns, 30-day readmissions, and reoperations within 30 days in recent years.

CONCLUSION

This study found that operative times and LOS have decreased significantly in patients with morbid obesity over the past 14 years, while more patients are being discharged home without being readmitted or reoperated on in the first month. As surgeons continue to improve their operative and reconstructive techniques, this study suggests that patients with elevated BMI should be considered candidates to undergo UKA procedures in ambulatory surgery centers or in hospitals with a rapid recovery unit.

Understanding factors influencing uptake and sustainable use of the PINCER intervention at scale: A qualitative evaluation using Normalisation Process Theory

Introduction

Medication errors are an important cause of morbidity and mortality. The pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) has demonstrated improvements in primary care medication safety, and whilst now the subject of national roll-out its optimal and sustainable use across health contexts has not been fully explored. As part of a qualitative evaluation we aimed to identify factors influencing successful adoption, embedding and sustainable use of PINCER across primary care settings in England, UK.

Methods

Semi-structured face-to-face or telephone interviews, including follow-up interviews and an online survey were conducted with professionals knowledgeable of PINCER. Interview recruitment targeted four early adopter regions; the survey was distributed nationally. Initial data analysis was inductive, followed by analysis using a coding framework. A deductive matrix approach was taken to map the framework to the Normalisation Process Theory (NPT). Themes were then identified.

Results

Fifty participants were interviewed, 18 participated in a follow-up interview. Eighty-one general practices and three Clinical Commissioning Groups completed the survey. Four themes were identified and interpreted within the relevant NPT construct: Awareness & Perceptions (Coherence), Receptivity to PINCER (Cognitive Participation), Engagement [Collective Action] and Reflections & Adaptations (Reflexive Monitoring). Variability was identified in how PINCER awareness was raised and how staff worked to operationalise the intervention. Facilitators for use included stakeholder investment, favourable evidence, inclusion in policy, incentives, fit with individual and organisational goals and positive experiences. Barriers included lack of understanding, capacity concerns, operational difficulties and the impact of COVID-19. System changes such as adding alerts on clinical systems were indicative of embedding and continued use.

Conclusions

The NPT helped understand motives behind engagement and the barriers and facilitators towards sustainable use. Optimising troubleshooting support and encouraging establishments to adopt an inclusive approach to intervention adoption and utilisation could help accelerate uptake and help establish ongoing sustainable use.

The effect of a pay-for-performance program on health-related quality of life for patients with hepatitis in Taiwan

Purpose

Chronic viral hepatitis is a major global public health problem. The guidelines suggest the long-term performance of regular ongoing liver examinations to monitor liver inflammation and screen for hepatocellular carcinoma. However, the effects of regular liver examinations on health-related quality of life (HRQoL) have not been adequately evaluated. Therefore, this study evaluated the effects of regular ongoing examinations on the quality of life of patients with hepatitis.

Methods

A cross-sectional study was conducted from October to December 2016 in four hospitals in northern Taiwan. A hepatitis pay-for-performance (P4P) program was launched in 2010 to ensure that hepatitis patients have regular ongoing liver examinations. The study group consisted of patients who joined and stayed in the program for more than one year. The study assessed HRQoL utilizing the five-level version of the EuroQol-5 Dimension (EQ-5D-5L) and the EuroQoL visual analog scale (EQ-VAS). The responses for the EQ-5D-5L in hepatitis patients were transformed into the EQ-5D index according to the Taiwanese population’s value set. Sociodemographic and clinical characteristics were collected by questionnaire, and descriptive statistics were presented. A two-part model and generalized linear model with a Poisson distribution and a log link function, respectively, were used to examine the associations of the EQ-5D index and EQ-VAS score with participation in the hepatitis P4P program. We applied propensity score weighting with inverse probability weighting to control for selection bias.

Results

In all, 508 patients (aged 57.6 ± 11.6 years; 60.8% male) were enrolled in this study. The mean (standard deviation, SD) reported EQ-5D index and EQ-VAS scores were 0.93 (0.12) and 75.1 (13.8), and the median (interquartile range, IQR) values were 1 (0.108) and 80 (15), respectively. The study group had a moderately significantly higher EQ-VAS score (mean ratio = 1.029, P < 0.001). However, the differences in the EQ-5D index scores between the study and control groups were not significant.

Conclusion

Patients with hepatitis partially benefited from receiving hepatitis P4P in Taiwan, which featured regular ongoing liver examinations, in that their EQ-VAS scores were enhanced but not their EQ-5D index scores.

Prescribing costs of hypoglycaemic agents and associations with metabolic control in Wales; a national analysis of primary care data

AIMS

There has been a dramatic increase in hypoglycaemic agent expenditure. We assessed the variability in prescribing costs at the practice level and the relationship between expenditure and the proportion of patients achieving target glycaemic control.

METHODS

We utilized national prescribing data from 406 general practices in Wales. This was compared against glycaemic control (percentage of patients achieving a HbA1c level < 59 mmol/mol in the preceding 12 months). Analyses were adjusted for the number of patients with diabetes in each general practice and the Welsh Index of Multiple Deprivation.

RESULTS

There was considerable heterogeneity in hypoglycaemic agent spend per patient with diabetes, Median = £289 (IQR 247-343) range £31.1-£1713. Higher total expenditure was not associated with improved glycaemic control B_(std)  = -0.01 (95%CI -0.01, 0.002) p = 0.13. High-spend practices spent more on SGLT2 inhibitors (16 vs. 9% p < 0.001) and GLP-1 agonists (13 vs. 11% p < 0.001) and less on insulin (34 vs. 42% p < 0.001), biguanides (9 vs. 11% p = 0.001) and sulphonylureas (2 vs. 3% p < 0.001) than low spend practices. There were no differences in the pattern of drug prescribing between high spend practices with better glycaemic control (mean 68% of patients HbA1c <59 mmol/mol) and those with less good metabolic control (mean 58% of patients HbA1c <59 mmol/mol).

CONCLUSIONS

Spend on hypoglycaemic agents is highly variable between practices and increased expenditure per patient is not associated with better glycaemic control. Whilst newer, more expensive agents have additional benefits, in individuals where these advantages are more marginal widespread use of these agents has important cost implications.

Evaluation of the introduction of QOF quality improvement modules in English general practice: early findings from a rapid, qualitative exploration of implementation

Background

A 2018 review of the English primary care pay-for-performance scheme, the Quality and Outcomes Framework, suggested that it should evolve to better support holistic, patient-centred care and leadership for quality improvement (QI). From 2019, as part of the vision of change, financially incentivised QI cycles (initially in prescribing safety and end-of-life care), were introduced into the scheme.

Objectives

To conduct a rapid evaluation of general practice staff attitudes, experiences and plans in relation to the implementation of the first two QI modules. This study was commissioned by NHS England and will inform development of the QI programme.

Methods

Semistructured telephone interviews were conducted with 25 practice managers from a range of practices across England. Interviews were audio recorded with consent and transcribed verbatim. Anonymised data were reflexively thematically analysed using the framework method of analysis to identify common themes across the interviews.

Results

Participants reported broadly favourable views of incentivised QI, suggesting the prescribing safety module was easier to implement than the end-of-life module. Additional staff time needed and challenges of reviewing activities with other practices were reported as concerns. Some highlighted that local flexibility and influence on subject matter may improve the effectiveness of QI. Several questioned the choices of topic, recognising greater need and potential for improving quality of care in other clinical areas.

Conclusion

Practices supported the idea of financial incentivisation of QI, however, it will be important to ensure that focus on QI cycles in specific clinical areas does not have unintended effects. A key issue will be keeping up momentum with the introduction of new modules each year which are time consuming to carry out for time poor General Practitioners (GPs)/practices.

What factors influence differential uptake of NHS Health Checks, diabetes and hypertension reviews among women in ethnically diverse South London? Cross-sectional analysis of 63,000 primary care records

BACKGROUND

Uptake of health checks among women has not been examined in relation to patient and General Practitioner (GP) practice level factors. We investigated patient and practice level factors associated with differential uptake of health checks.

METHODS

Primary care records from 44 practices in Lambeth for women aged 40-74 years old (N = 62,967) from 2000-2018 were analysed using multi-level logistic regression models. An odds ratio (OR) >1 indicates increased occurrence of no health check.

FINDINGS

The mean age (IQR) of the included female sample (aged 40-74 years) was 52.9 years (45.0-59.0). Adjusted for patient-level factors (age, ethnicity, English as first language, overweight/obesity, smoking, attendance to GP practices, and co-morbidity), the odds of non-uptake of health checks were higher for Other White (OR 1.24, 95% confidence interval 1.17-1.33), and Other ethnicity (1.20, 1.07-1.35) vs. White British. It was also higher for 50-69 year olds (1.55, 1.47-1.62), 70-74 year olds (1.60, 1.49-1.72) vs. 40-49 year olds. These ORs did not change on adjustments for practice level factors (proportion of patients living in deprived areas, proportion of patients with ≥1 chronic condition, ≥3 emergency diabetes admissions annually, GP density/1000 patients, quality outcome framework score of ≥ 95%, and patient satisfaction scores of ≥80%). Non-uptake was lower for Black Caribbeans, Bangladeshis, overweight/obese patients, frequent practice attenders and comorbid patients.

INTERPRETATION

Differential uptake in health checks remained after adjustment for patient and practice level factors. Better measures of social determinants of health and of practice context are needed.

FUNDING

NIHR Research for Patient Benefit Programme (NIHR202769).

Australian general practitioner perceptions to sharing clinical data for secondary use: a mixed method approach

OBJECTIVE

The potential for data collected in general practice to be linked and used to address health system challenges of maintaining quality care, accessibility and safety, including pandemic support, has led to an increased interest in public acceptability of data sharing, however practitioners have rarely been asked to share their opinions on the topic. This paper attempts to gain an understanding of general practitioner's perceptions on sharing routinely collected data for the purposes of healthcare planning and research. It also compares findings with data sharing perceptions in an international context.  MATERIALS AND METHODS: A mixed methods approach combining an initial online survey followed by face-to-face interviews (before and during COVID-19), designed to identify the barriers and facilitators to sharing data, were conducted on a cross sectional convenience sample of general practitioners across Western Australia (WA).

RESULTS

Eighty online surveys and ten face-to-face interviews with general practitioners were conducted from November 2020 - May 2021. Although respondents overwhelmingly identified the importance of population health research, their willingness to participate in data sharing programs was determined by a perception of trust associated with the organisation collecting and analysing shared data; a clearly defined purpose and process of collected data; including a governance structure providing confidence in the data sharing initiative simultaneously enabling a process of data sovereignty and autonomy.

DISCUSSION

Results indicate strong agreement around the importance of sharing patient's medical data for population and health research and planning. Concerns pertaining to lack of trust, governance and secondary use of data continue to be a setback to data sharing with implications for primary care business models being raised.

CONCLUSION

To further increase general practitioner's confidence in sharing their clinical data, efforts should be directed towards implementing a robust data governance structure with an emphasis on transparency and representative stakeholder inclusion as well as identifying the role of government and government funded organisations, as well as building trust with the entities collecting and analysing the data.

The prevalence of comorbidity in rheumatoid arthritis: a systematic review and meta-analysis

This systematic review and meta-analysis estimates the prevalence of common comorbid health disorders in adults with rheumatoid arthritis (RA). A multi-database search strategy was undertaken. Screening, data extraction and quality assessment were carried out by two independent reviewers. A meta-analysis and meta-regression were used to generate a pooled prevalence estimate and identify relevant moderators. After study selection, 33 studies (74633 participants) were included in the meta-analysis. Some 31 studies were judged to be of low risk of bias, and two studies were judged to be at moderate risk of bias. The three most common comorbidities in RA were anxiety disorders (62.1%, 95% Cl: 43.6%; 80.6%), hypertension (37.7%, 95% Cl: 29.2%; 46.2%) and depression (32.1%, 95% Cl: 21.6%; 42.7%). There was substantial statistically significant heterogeneity for all comorbidities (I2 ≥77%). Meta-regression identified that the covariate of mean age (unit increase) had a statistically significant effect on the prevalence of hypertension (+2.3%, 95% Cl: 0.4%; 4.2%), depression (-0.5%, 95% Cl: -0.6%; -0.4%) and cancer (0.5%, 95% Cl: 0.2%; 0.8%) in adults with RA. A country's income was identified to have a statistically significant effect on the prevalence of depression, with low-to moderate-income countries having 40% (95% Cl: 14.0%; 66.6%) higher prevalence than high-income countries. No studies consider health inequalities. It is concluded that comorbidities are prevalent among people with RA, particularly those associated with mental health and circulatory conditions. Provision of health services should reflect the importance of such multimorbidity and the consequences for quality and length of life.

Clustering of comorbidities and associated outcomes in people with osteoarthritis - A UK Clinical Practice Research Datalink study

OBJECTIVE

To examine the clusters of chronic conditions present in people with osteoarthritis and the associated risk factors and health outcomes.

METHODS

Clinical Practice Research Datalink (CPRD) GOLD was used to identify people diagnosed with incident osteoarthritis (n = 221,807) between 1997 and 2017 and age (±2 years), gender, and practice matched controls (no osteoarthritis, n = 221,807) from UK primary care. Clustering of people was examined for 49 conditions using latent class analysis. The associations between cluster membership and covariates were quantified by odds ratios (OR) using multinomial logistic regression. General practice (GP) consultations, hospitalisations, and all-cause mortality rates were compared across the clusters identified at the time of first diagnosis of osteoarthritis (index date).

RESULTS

In both groups, conditions largely grouped around five clusters: relatively healthy; cardiovascular (CV), musculoskeletal-mental health (MSK-MH), CV-musculoskeletal (CV-MSK) and metabolic (MB). In the osteoarthritis group, compared to the relatively healthy cluster, strong associations were seen for 1) age with all clusters; 2) women with the MB cluster (OR 5.55: 5.14-5.99); 3) obesity with the CV-MSK (OR 2.11: 2.03-2.20) and CV clusters (OR 2.03: 1.97-2.09). The CV-MSK cluster in the osteoarthritis group had the highest number of GP consultations and hospitalisations, and the mortality risk was 2.45 (2.33-2.58) times higher compared to the relatively healthy cluster.

CONCLUSIONS

Of the five identified clusters, CV-MSK, CV, and MSK-MH are more common in OA and CV-MSK cluster had higher health utilisation. Further research is warranted to better understand the mechanistic pathways and clinical implications.

Framework for identification and measurement of spillover effects in policy implementation: intended non-intended targeted non-targeted spillovers (INTENTS)

BACKGROUND

There is increasing awareness among researchers and policymakers of the potential for healthcare interventions to have consequences beyond those initially intended. These unintended consequences or "spillover effects" result from the complex features of healthcare organisation and delivery and can either increase or decrease overall effectiveness. Their potential influence has important consequences for the design and evaluation of implementation strategies and for decision-making. However, consideration of spillovers remains partial and unsystematic. We develop a comprehensive framework for the identification and measurement of spillover effects resulting from changes to the way in which healthcare services are organised and delivered.

METHODS

We conducted a scoping review to map the existing literature on spillover effects in health and healthcare interventions and used the findings of this review to develop a comprehensive framework to identify and measure spillover effects.

RESULTS

The scoping review identified a wide range of different spillover effects, either experienced by agents not intentionally targeted by an intervention or representing unintended effects for targeted agents. Our scoping review revealed that spillover effects tend to be discussed in papers only when they are found to be statistically significant or might account for unexpected findings, rather than as a pre-specified feature of evaluation studies. This hinders the ability to assess all potential implications of a given policy or intervention. We propose a taxonomy of spillover effects, classified based on the outcome and the unit experiencing the effect: within-unit, between-unit, and diagonal spillover effects. We then present the INTENTS framework: Intended Non-intended TargEted Non-Targeted Spillovers. The INTENTS framework considers the units and outcomes which may be affected by an intervention and the mechanisms by which spillover effects are generated.

CONCLUSIONS

The INTENTS framework provides a structured guide for researchers and policymakers when considering the potential effects that implementation strategies may generate, and the steps to take when designing and evaluating such interventions. Application of the INTENTS framework will enable spillover effects to be addressed appropriately in future evaluations and decision-making, ensuring that the full range of costs and benefits of interventions are correctly identified.

The Effect of Financial Incentives on Quality Measures in the Treatment of Diabetes Mellitus: a Randomized Controlled Trial

BACKGROUND

Financial incentives are often used to improve quality of care in chronic care patients. However, the evidence concerning the effect of financial incentives is still inconclusive.

OBJECTIVE

To test the effect of financial incentives on quality measures (QMs) in the treatment of patients with diabetes mellitus in primary care. We incentivized a clinical QM and a process QM to test the effect of financial incentives on different types of QMs and to investigate the spill-over effect on non-incentivized QMs.

DESIGN/PARTICIPANTS

Parallel cluster randomized controlled trial based on electronic medical records database involving Swiss general practitioners (GPs). Practices were randomly allocated.

INTERVENTION

All participants received a bimonthly feedback report. The intervention group additionally received potential financial incentives on GP level depending on their performance.

MAIN MEASURES

Between-group differences in proportions of patients fulfilling incentivized QM (process QM of annual HbA1c measurement and clinical QM of blood pressure level below 140/95 mmHg) after 12 months.

KEY RESULTS

Seventy-one GPs (median age 52 years, 72% male) from 43 different practices and subsequently 3838 patients with diabetes mellitus (median age 70 years, 57% male) were included. Proportions of patients with annual HbA1c measurements remained unchanged (intervention group decreased from 79.0 to 78.3%, control group from 81.5 to 81.0%, OR 1.09, 95% CI 0.90-1.32, p = 0.39). Proportions of patients with blood pressure below 140/95 improved from 49.9 to 52.5% in the intervention group and decreased from 51.2 to 49.0% in the control group (OR 1.16, 95% CI 0.99-1.36, p = 0.06). Proportions of non-incentivized process QMs increased significantly in the intervention group.

CONCLUSION

GP level financial incentives did not result in more frequent HbA1c measurements or in improved blood pressure control. Interestingly, we could confirm a spill-over effect on non-incentivized process QMs. Yet, the mechanism of spill-over effects of financial incentives is largely unclear.

TRIAL REGISTRATION

ISRCTN13305645.

Primary care service utilisation and outcomes in type 2 diabetes: a longitudinal cohort analysis

OBJECTIVES

To describe primary care utilisation patterns among adults with type 2 diabetes and to quantify the association between utilisation and long-term health outcomes.

DESIGN

Retrospective cohort study.

SETTING

168 primary care practices in Southern England within the Electronic Care and Health Information Analytics database between 2013 and 2020.

PARTICIPANTS

110 240 adults with Quality and Outcomes Framework read code of type 2 diabetes diagnosis; age greater than 18 years; linked and continuous records available from April 2013 until April 2020 (or death). PRIMARY AND SECONDARY OUTCOME MEASURES: (1) Rates of service utilisation (total number of primary care contacts per quarter) across the study period; (2) participant characteristics associated with higher and lower rates of service utilisation; and (3) associations between service utilisation and (A) cardiovascular disease (CVD events) and (B) all-cause mortality.

RESULTS

Mean (SD) number of primary care attendances per quarter in the cohort of 110 240 went from 2.49 (2.01) in 2013 to 2.78 (2.06) in 2020. Patients in the highest usage tertile were more likely to be female, older, more frail, white, from the least deprived quintile and to have five or more comorbidities. In adjusted models, higher rates of service utilisation (per consultation) were associated with higher rates of CVD events (OR 1.0058; 95% CI 1.0053 to 1.0062; p<0.001) and mortality (OR 1.0057; 95% CI 1.0051 to 1.0064; p<0.001).

CONCLUSIONS

People with type 2 diabetes are using primary care services more frequently, but increased volume of clinical care does not correlate with better outcomes, although this finding may be driven by more unwell patients contacting services more frequently. Further research on the nature and content of contacts is required to understand how to tailor services to deliver effective care to those at greatest risk of complications.

The DynAIRx Project Protocol: Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity

Background

Structured Medication Reviews (SMRs) are intended to help deliver the NHS Long Term Plan for medicines optimisation in people living with multiple long-term conditions and polypharmacy. It is challenging to gather the information needed for these reviews due to poor integration of health records across providers and there is little guidance on how to identify those patients most urgently requiring review.

Objective

To extract information from scattered clinical records on how health and medications change over time, apply interpretable artificial intelligence (AI) approaches to predict risks of poor outcomes and overlay this information on care records to inform SMRs. We will pilot this approach in primary care prescribing audit and feedback systems, and co-design future medicines optimisation decision support systems.

Design

DynAIRx will target potentially problematic polypharmacy in three key multimorbidity groups, namely, people with (a) mental and physical health problems, (b) four or more long-term conditions taking ten or more drugs and (c) older age and frailty. Structured clinical data will be drawn from integrated care records (general practice, hospital, and social care) covering an ∼11m population supplemented with Natural Language Processing (NLP) of unstructured clinical text. AI systems will be trained to identify patterns of conditions, medications, tests, and clinical contacts preceding adverse events in order to identify individuals who might benefit most from an SMR.

Discussion

By implementing and evaluating an AI-augmented visualisation of care records in an existing prescribing audit and feedback system we will create a learning system for medicines optimisation, co-designed throughout with end-users and patients.

Atopic Eczema-Associated Fracture Risk and Oral Corticosteroids: A Population-Based Cohort Study

BACKGROUND

Evidence suggests adults with atopic eczema have increased fracture risk. However, it is unclear whether oral corticosteroids explain the association.

OBJECTIVE

To assess to what extent oral corticosteroids mediate the relationship between atopic eczema and fractures.

METHODS

We conducted a cohort study using English primary care (Clinical Practice Research Datalink) and hospital admissions (Hospital Episode Statistics) records (1998-2016) including adults (18 years old and older) with atopic eczema matched (age, sex, and general practice) with up to 5 adults without atopic eczema. We used Cox regression to estimate hazard ratios (HRs) for specific major osteoporotic fractures (hip, spine, pelvis, or wrist) and for any-site fracture comparing individuals with atopic eczema with those without, adjusting for 6 different definitions of time-updated oral corticosteroid use (ever any prescription, ever high-dose, and recent, cumulative, current, or peak dose).

RESULTS

We identified 526,808 individuals with atopic eczema and 2,569,030 without. We saw evidence of an association between atopic eczema and major osteoporotic fractures (eg, spine HR 1.15, 99% CI 1.08-1.22; hip HR 1.11, 99% CI 1.08-1.15) that remained after additionally adjusting for oral corticosteroids (eg, cumulative corticosteroid dose: spine HR 1.09, 99% CI 1.03-1.16; hip HR 1.09, 99% CI 1.06-1.12). Fracture rates were higher in people with severe atopic eczema than in people without even after adjusting for oral corticosteroids (eg, spine HR [99% CI]: confounder-adjusted 2.31 [1.91-2.81]; additionally adjusted for cumulative dose 1.71 [1.40-2.09]).

CONCLUSIONS

Our findings suggest that little of the association between atopic eczema and major osteoporotic fractures is explained by oral corticosteroid use.

Managing asthma in primary healthcare

Asthma brings considerable challenges for family doctors because of its variety of shapes, different levels of severity, a wide age range, and the fact that in the last decades clinicians are able to offer much better treatment options with a better level of disease control and a higher quality of life. The objectives of the current review article are to provide an up-to-date review by primary care respiratory leaders from different countries of the most significant challenges regarding asthma diagnosis and management, the importance of team work and the problems in recognizing and dealing with difficult-to-manage and severe asthma in primary care. The article provides a short review of the main challenges faced by family physicians and other primary health care professionals in supporting their patients in the management of asthma, such as asthma diagnosis, promoting access to spirometry, the importance of a multiprofessional team for the management of asthma, how to organize an asthma review, the promotion of patient autonomy and shared decision-making, improving the use of inhalers, the importance of the personalized asthma action plan, dealing with difficult-to-manage and severe asthma in primary care and choosing when, where and how to refer patients with severe asthma. The article also discusses the development of an integrated approach to asthma care in the community and the promotion of Asthma Right Care.

A Summary of Current Findings on Quality of Life Domains and a Proposal for Their Inclusion in Clinical Interventions

Whilst the assessment of quality of life (QoL) and well-being has burgeoned in the past 50 years, there still remains relatively little research into its treatment in psychology, in spite of the launching of such approaches as positive psychology to widen the ambit of interventions to promote well-being. We posit that there are a number of outstanding QoL areas that could be integrated into standard therapeutic procedures, and that this would this result in an increase in well-being as a therapeutic outcome. To investigate this an exploratory search of the literature was undertaken of associations between improvements in a life domain and increased well-being or QoL. Ten domains (relationships, work, money, health, and leisure, mindfulness, self-esteem, resolution of past life events, mental style and life management skills) were identified. In view of the substantial evidence of the cumulative impact of these domains upon well-being, it is proposed that conducting a unidimensional clinical intervention that focuses only on the presenting issue is not sufficient. Implications and possible therapeutic pathways are discussed and it is recommended that practitioners include such QoL domains in their assessment, case formulation, and intervention planning.

Increase in Epinephrine Administration for Food-Induced Anaphylaxis in Pediatric Emergency Departments from 2007 to 2015

BACKGROUND

Epinephrine is underused in the treatment of anaphylaxis, despite being the first-line treatment, which reflects the challenges in diagnosing anaphylaxis and understanding the appropriate therapy.

OBJECTIVE

To describe trends in epinephrine administration for patients visiting the pediatric emergency department (ED) with food-induced anaphylaxis (FIA) from 2007 to 2015.

METHODS

This retrospective cohort study included children 0 to 17 years of age with FIA from 46 children's hospitals in the United States between 2007 and 2015. Multivariable regression was used to identify factors associated with epinephrine administration.

RESULTS

A total of 15,318 cases of FIA cases were seen in the pediatric EDs from 2007 to 2015. Among these ED visits, 7,600 (49.6%) had at least 1 dose of epinephrine administered in the ED. Administration of epinephrine for anaphylaxis in the pediatric ED increased by 4% each year (odds ratio [OR] 1.04; 95% CI 1.03-1.05; P < .001). Sensitivity analysis by census region demonstrated that hospitals in the Northeast and the West were associated with an increase in epinephrine administration per year (Northeast OR 1.18, 95% CI 1.13-1.22, P < .001; West OR 1.14, 95% CI 1.10-1.18, P < .001).

CONCLUSIONS

Epinephrine administration for FIA in the pediatric ED has increased over time, reflecting the need for continued advocacy for the optimal management of FIA. Further research is warranted to identify optimal strategies for proper recognition and early administration of epinephrine for anaphylaxis.

Promoting physical activity and physical function in people with long-term conditions in primary care: the Function First realist synthesis with co-design

Background

As people age and accumulate long-term conditions, their physical activity and physical function declines, resulting in disability and loss of independence. Primary care is well placed to empower individuals and communities to reduce this decline; however, the best approach is uncertain.

Objectives

To develop a programme theory to explain the mechanisms through which interventions improve physical activity and physical function in people with long-term conditions in different primary care contexts, and to co-design a prototype intervention.

Data sources

Systematic literature searches of relevant databases with forwards and backwards citation tracking, grey literature searches and further purposive searches were conducted. Qualitative data were collected through workshops and interviews.

Design

Realist evidence synthesis and co-design for primary care service innovation.

Setting

Primary care in Wales and England.

Participants

Stakeholders included people with long-term conditions, primary care professionals, people working in relevant community roles and researchers.

Methods

The realist evidence synthesis combined evidence from varied sources of literature with the views, experiences and ideas of stakeholders. The resulting context, mechanism and outcome statements informed three co-design workshops and a knowledge mobilisation workshop for primary care service innovation.

Results

Five context, mechanism and outcome statements were developed. (1) Improving physical activity and function is not prioritised in primary care (context). If the practice team culture is aligned to the elements of physical literacy (mechanism), then physical activity promotion will become routine and embedded in usual care (outcome). (2) Physical activity promotion is inconsistent and unco-ordinated (context). If specific resources are allocated to physical activity promotion (in combination with a supportive practice culture) (mechanism), then this will improve opportunities to change behaviour (outcome). (3) People with long-term conditions have varying levels of physical function and physical activity, varying attitudes to physical activity and differing access to local resources that enable physical activity (context). If physical activity promotion is adapted to individual needs, preferences and local resources (mechanism), then this will facilitate a sustained improvement in physical activity (outcome). (4) Many primary care practice staff lack the knowledge and confidence to promote physical activity (context). If staff develop an improved sense of capability through education and training (mechanism), then they will increase their engagement with physical activity promotion (outcome). (5) If a programme is credible with patients and professionals (context), then trust and confidence in the programme will develop (mechanism) and more patients and professionals will engage with the programme (outcome). A prototype multicomponent intervention was developed. This consisted of resources to nurture a culture of physical literacy, materials to develop the role of a credible professional who can promote physical activity using a directory of local opportunities and resources to assist with individual behaviour change.

Limitations

Realist synthesis and co-design is about what works in which contexts, so these resources and practice implications will need to be modified for different primary care contexts.

Conclusions

We developed a programme theory to explain how physical activity could be promoted in primary care in people with long-term conditions, which informed a prototype intervention.

Future work

A future research programme could further develop the prototype multicomponent intervention and assess its acceptability in practice alongside existing schemes before it is tested in a feasibility study to inform a future randomised controlled trial.

Study registration

This study is registered as PROSPERO CRD42018103027.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 16. See the NIHR Journals Library website for further project information.

Using electronic health records to develop and validate a machine-learning tool to predict type 2 diabetes outcomes: a study protocol

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a major cause of blindness, kidney failure, myocardial infarction, stroke and lower limb amputation. We are still unable, however, to accurately predict or identify which patients are at a higher risk of deterioration. Most risk stratification tools do not account for novel factors such as sociodemographic determinants, self-management ability or access to healthcare. Additionally, most tools are based in clinical trials, with limited external generalisability.

OBJECTIVE

The aim of this work is to design and validate a machine learning-based tool to identify patients with T2DM at high risk of clinical deterioration, based on a comprehensive set of patient-level characteristics retrieved from a population health linked dataset.

SAMPLE AND DESIGN

Retrospective cohort study of patients with diagnosis of T2DM on 1 January 2015, with a 5-year follow-up. Anonymised electronic healthcare records from the Whole System Integrated Care (WSIC) database will be used.

PRELIMINARY OUTCOMES

Outcome variables of clinical deterioration will include retinopathy, chronic renal disease, myocardial infarction, stroke, peripheral arterial disease or death. Predictor variables will include sociodemographic and geographic data, patients' ability to self-manage disease, clinical and metabolic parameters and healthcare service usage. Prognostic models will be defined using multidependence Bayesian networks. The derivation cohort, comprising 80% of the patients, will be used to define the prognostic models. Model parameters will be internally validated by comparing the area under the receiver operating characteristic curve in the derivation cohort with those calculated from a leave-one-out and a 10 times twofold cross-validation.

ETHICS AND DISSEMINATION

The study has received approvals from the Information Governance Committee at the WSIC. Results will be made available to people with T2DM, their caregivers, the funders, diabetes care societies and other researchers.

Evaluating the Effectiveness of a Local Primary Care Incentive Scheme: A Difference-in-Differences Study

National financial incentive schemes for improving the quality of primary care have come under criticism in the United Kingdom, leading to calls for localized alternatives. This study investigated whether a local general practice incentive-based quality improvement scheme launched in 2011 in a city in the North West of England was associated with a reduction in all-cause emergency hospital admissions. Difference-in-differences analysis was used to compare the change in emergency admission rates in the intervention city, to the change in a matched comparison population. Emergency admissions rates fell by 19 per 1,000 people in the years following the intervention (95% confidence interval [17, 21]) in the intervention city, relative to the comparison population. This effect was greater among more disadvantaged populations, narrowing socioeconomic inequalities in emergency admissions. The findings suggest that similar approaches could be an effective component of strategies to reduce unplanned hospital admissions elsewhere.

Barriers and facilitators to the adoption of electronic clinical decision support systems: a qualitative interview study with UK general practitioners

Background

Well-established electronic data capture in UK general practice means that algorithms, developed on patient data, can be used for automated clinical decision support systems (CDSSs). These can predict patient risk, help with prescribing safety, improve diagnosis and prompt clinicians to record extra data. However, there is persistent evidence of low uptake of CDSSs in the clinic. We interviewed UK General Practitioners (GPs) to understand what features of CDSSs, and the contexts of their use, facilitate or present barriers to their use.

Methods

We interviewed 11 practicing GPs in London and South England using a semi-structured interview schedule and discussed a hypothetical CDSS that could detect early signs of dementia. We applied thematic analysis to the anonymised interview transcripts.

Results

We identified three overarching themes: trust in individual CDSSs; usability of individual CDSSs; and usability of CDSSs in the broader practice context, to which nine subthemes contributed. Trust was affected by CDSS provenance, perceived threat to autonomy and clear management guidance. Usability was influenced by sensitivity to the patient context, CDSS flexibility, ease of control, and non-intrusiveness. CDSSs were more likely to be used by GPs if they did not contribute to alert proliferation and subsequent fatigue, or if GPs were provided with training in their use.

Conclusions

Building on these findings we make a number of recommendations for CDSS developers to consider when bringing a new CDSS into GP patient records systems. These include co-producing CDSS with GPs to improve fit within clinic workflow and wider practice systems, ensuring a high level of accuracy and a clear clinical pathway, and providing CDSS training for practice staff. These recommendations may reduce the proliferation of unhelpful alerts that can result in important decision-support being ignored.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01557-z.

Quality improvement in chronic care by self-audit, benchmarking and networking in general practices in South Tyrol, Italy: results from an interventional study

BACKGROUND

Systematic strategies promoting quality of care in general practice are yet under-represented in several European countries.

OBJECTIVE

This interventional study assessed whether a combined intervention (self-audit, benchmarking, quality circles) improved quality of care in Salzburg, Austria and South Tyrol, Italy. The present publication reports the Italian results.

METHODS

We developed quality indicators for general practice in a consensus process based on pre-existing quality programmes. The indicators addressed diagnosis and treatment regarding eight common chronic conditions. A quality score comprising 91 indicators was calculated (0-5 points per indicator depending on fulfilment, maximum 455 points). We collected anonymous data from the electronic health records of the participating physicians in 2012, 2013 and 2014. Wilcoxon signed-rank tests were used for pre-post analysis.

RESULTS

Thirty-six GPs participated in the study. The median quality score increased significantly from 177.0 points at baseline to 272.0 points at the second follow-up (P = 0.000). Improvements concerned process and intermediate outcome indicators particularly between baseline and the first follow-up.

CONCLUSION

Performance was relatively low at baseline and improved considerably, mainly in the first study period. The intervention investigated in this study can serve as a model for future quality programmes. A customized electronic health record for the implementation of this intervention as well as standardized and consistent documentation by GPs is a prerequisite. Use of a limited set of quality indicators (QIs) and regular QI modification is probably advisable to increase the benefits. Long-term prospective studies should investigate the impact of QI-based interventions on end-result outcomes.

Rates and estimated cost of primary care consultations in people diagnosed with type 2 diabetes and comorbidities: A retrospective analysis of 8.9 million consultations

AIMS

To determine whether telephone and face-to-face primary care consultation rates, costs, and temporal trends during 2000 to 2018 differed by the number of comorbidities in people with type 2 diabetes (T2DM).

METHODS

A total of 120 409 adults with newly diagnosed T2DM between 2000 and 2018 were classified by the number of prevalent and incident comorbidities. Data on face-to-face and telephone primary care consultations with a nurse or physician were obtained. Crude and sex- and age-adjusted annual consultation rates and associated costs were calculated based on the number of comorbidities at the time of consultation.

RESULTS

The crude rate of face-to-face primary care consultations for patients without comorbidities was 10.3 (95% confidence interval [CI] 10.3-10.4) per person-year, 12.7 (95% CI 12.7-12.7) for patients with one comorbidity, 15.1 (95% CI 15.1-15.2) for those with two comorbidities, and 18.7 (95% CI 18.7-18.8) for those with three or more comorbidities. The mean annual inflation-adjusted cost for face-to-face consultations was £412.70 per patient without comorbidities, £516.80 for one comorbidity, £620.75 for two comorbidities, and £778.83 for three or more comorbidities. The age- and sex-adjusted face-to-face consultation rate changed by an average of -3.3% (95% CI -4.4 to -2.3) per year from 2000 to 2018 for patients without comorbidities, -2.7% (95% CI -4.0 to -1.3) for those with one comorbidity, -2.2% (95% CI -3.3 to -1.2) for those with two comorbidities, and -4.3% (95% CI -8.7 to +0.3) for those with three or more comorbidities.

CONCLUSIONS

Although consultation rates for all patients decreased from 2000 to 2018, there was a significant disparity between the rate for patients with and without comorbidities. Patients with T2DM and comorbidities may require different models of service delivery.

Associations between attainment of incentivised primary care indicators and emergency hospital admissions among type 2 diabetes patients: a population-based historical cohort study

OBJECTIVES

England has invested considerably in diabetes care over recent years through programmes such as the Quality and Outcomes Framework and National Diabetes Audit. However, associations between specific programme indicators and key clinical endpoints, such as emergency hospital admissions, remain unclear. We aimed to examine whether attainment of Quality and Outcomes Framework and National Diabetes Audit primary care diabetes indicators is associated with diabetes-related, cardiovascular, and all-cause emergency hospital admissions.

DESIGN

Historical cohort study.

SETTING

A total of 330 English primary care practices, 2010-2017, using UK Clinical Practice Research Datalink.

PARTICIPANTS

A total of 84,441 adults with type 2 diabetes.

MAIN OUTCOME MEASURES

The primary outcome was emergency hospital admission for any cause. Secondary outcomes were (1) diabetes-related and (2) cardiovascular-related emergency admission.

RESULTS

There were 130,709 all-cause emergency admissions, 115,425 diabetes-related admissions and 105,191 cardiovascular admissions, corresponding to unplanned admission rates of 402, 355 and 323 per 1000 patient-years, respectively. All-cause hospital admission rates were lower among those who met HbA1c and cholesterol indicators (incidence rate ratio = 0.91; 95% CI 0.89-0.92; p < 0.001 and 0.87; 95% CI 0.86-0.89; p < 0.001), respectively), with similar findings for diabetes and cardiovascular admissions. Patients who achieved the Quality and Outcomes Framework blood pressure target had lower cardiovascular admission rates (incidence rate ratio = 0.98; 95% CI 0.96-0.99; p = 0.001). Strong associations were found between completing 7-9 (vs. either 4-6 or 0-3) National Diabetes Audit processes and lower rates of all admission outcomes (p-values < 0.001), and meeting all nine National Diabetes Audit processes had significant associations with reductions in all types of emergency admissions by 22% to 26%. Meeting the HbA1c or cholesterol Quality and Outcomes Framework indicators, or completing 7-9 National Diabetes Audit processes, was also associated with longer time-to-unplanned all-cause, diabetes and cardiovascular admissions.

CONCLUSIONS

Attaining Quality and Outcomes Framework-defined diabetes intermediate outcome thresholds, and comprehensive completion of care processes, may translate into considerable reductions in emergency hospital admissions. Out-of-hospital diabetes care optimisation is needed to improve implementation of core interventions and reduce unplanned admissions.

From policy to patient: Using a socio-ecological framework to explore the factors influencing safe practice in UK primary care

BACKGROUND

The recent and rapid changes in the model of primary care delivery have led to an increased focus on patient safety in what is one of the most diverse and complex healthcare settings. However, previous initiatives have failed to deliver the expected improvements, leading to calls for a better understanding of how a range of personal and contextual factors influence the decisions and behaviours of individual care providers.

METHODS

The socio-ecological framework, successfully used in public health settings to interpret the complex influences on individual behaviours, enabled a post-hoc deductive analysis of a series of semi-structured interviews conducted with clinical staff and senior managers at a range of practices across five geographically diverse regions in England to explore their perspectives on the factors that influence safe practice.

RESULTS

The five levels of the socio-ecological framework successfully helped unpick the myriad influences on safe primary care practice, including, at the Individual level, assumptions of responsibility and previous experience; at the Interpersonal, equitable communication in support of a team ethos; at the Organisational, the physical infrastructure, size and complexity of the practice; at the Community, the health profile and literacy of patients; and at the Policy, meeting the demands of competing local and national governing bodies.

CONCLUSIONS

Coherent, realistic and achievable goals are needed for improving patient safety in primary care addressing personal, organisational and environmental factors. Such goals and the tools and interventions designed to meet them must therefore be sympathetic to the demands on resources and the characteristics of patients, staff, and their organisations. Using the framework to interpret our findings provided much needed insight into the impact of these varying influences, and highlights the importance of recognising and communicating the relationship between specific contextual factors and the ability of individual providers to provide safe primary care.

Associations between attainment of incentivised primary care diabetes indicators and mortality in an English cohort

AIMS

To describe associations between incentivised primary care clinical and process indicators and mortality, among patients with type 2 diabetes in England.

METHODS

A historical 2010-2017 cohort (n = 84,441 adults) was derived from the UK CPRD. Exposures included English Quality and Outcomes Framework glycated haemoglobin (HbA1c; 7.5%, 59 mmol/mol), blood pressure (140/80 mmHg), and cholesterol (5 mmol/L) indicator attainment; and number of National Diabetes Audit care processes completed, in 2010-11. The primary outcome was all-cause mortality.

RESULTS

Over median 3.9 (SD 2.0) years follow-up, 10,711 deaths occurred. Adjusted hazard ratios (aHR) indicated 12% (95% CI 8-16%; p < 0.0001) and 16% (11-20%; p < 0.0001) lower mortality rates among those who attained the HbA1c and cholesterol indicators, respectively. Rates were also lower among those who completed 7-9 vs. 0-3 or 4-6 care processes (aHRs 0.76 (0.71-0.82), p < 0.0001 and 0.61 (0.53-0.71), p < 0.0001, respectively), but did not obviously vary by blood pressure indicator attainment (aHR 1.04, 1.00-1.08; p = 0.0811).

CONCLUSIONS

Cholesterol, HbA1c and comprehensive process indicator attainment, was associated with enhanced survival. Review of community-based care provision could help reduce the gap between indicator standards and current outcomes, and in turn enhance life expectancy.