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Funston G, Moullet M, Mounce L, Lyratzopoulos G, Walter FM, Zhou Y. Pre-diagnostic prescription patterns in bladder and renal cancer: a longitudinal linked data study. Br J Gen Pract 2023; 74:BJGP.2023.0122. [PMID: 38164573 PMCID: PMC10764107 DOI: 10.3399/bjgp.2023.0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/14/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Understanding pre-diagnostic prescribing activity could reveal windows during which more timely cancer investigation and detection may occur. AIM To examine prescription patterns for common urological clinical features prior to renal and bladder cancer diagnoses. DESIGN AND SETTING A retrospective cohort study was performed using electronic primary care and cancer registry data on patients with bladder and renal cancer, who received their diagnosis between April 2012 and December 2015 in England. METHOD Primary care prescriptions up to 2 years pre- diagnosis were analysed for five groups of clinical features (irritative urological symptoms, obstructive symptoms, urinary tract infections [UTIs], genital infections, and atrophic vaginitis). Poisson regressions estimating the inflection point from which the rate of prescriptions increased from baseline were used to identify the start of diagnostic windows during which cancer could be detected. RESULTS A total of 48 094 prescriptions for 5322 patients were analysed. Inflection points for an increase in UTI prescriptions were identified 9 months pre- diagnosis for renal (95% confidence interval [CI] = 5.3 to 12.7) and bladder (95% CI = 7.4 to 10.6) cancers. For bladder cancer, the change in UTI antibiotic prescription rates occurred 4 months earlier in females (11 months pre- diagnosis, 95% CI = 9.7 to 12.3) than in males (7 months pre-diagnosis, 95% CI = 5.4 to 8.6). For other clinical features, no inflection points were identified and, as such, no diagnostic windows could be defined. CONCLUSION Prescription rates for UTIs increased 9 months before bladder and renal cancer diagnoses, indicating that there is potential to expedite diagnosis of these cancers in patients presenting with features of UTI. The greatest opportunity for more timely diagnosis may be in females with bladder cancer, who experienced the earliest increase in UTI prescription rate.
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Affiliation(s)
- Garth Funston
- Department of Public Health and Primary Care, University of Cambridge, Cambridge; Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Marie Moullet
- Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Luke Mounce
- University of Exeter Medical School, University of Exeter, Exeter
| | | | - Fiona M Walter
- Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Yin Zhou
- Department of Public Health and Primary Care, University of Cambridge, Cambridge; Wolfson Institute of Population Health, Queen Mary University of London, London
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Hamilton W, Mounce L, Abel GA, Dean SG, Campbell JL, Warren FC, Spencer A, Medina-Lara A, Pitt M, Shephard E, Shakespeare M, Fletcher E, Mercer A, Calitri R. Protocol for a pragmatic cluster randomised controlled trial assessing the clinical effectiveness and cost-effectiveness of Electronic RIsk-assessment for CAncer for patients in general practice (ERICA). BMJ Open 2023; 13:e065232. [PMID: 36940950 PMCID: PMC10030284 DOI: 10.1136/bmjopen-2022-065232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION The UK has worse cancer outcomes than most comparable countries, with a large contribution attributed to diagnostic delay. Electronic risk assessment tools (eRATs) have been developed to identify primary care patients with a ≥2% risk of cancer using features recorded in the electronic record. METHODS AND ANALYSIS This is a pragmatic cluster randomised controlled trial in English primary care. Individual general practices will be randomised in a 1:1 ratio to intervention (provision of eRATs for six common cancer sites) or to usual care. The primary outcome is cancer stage at diagnosis, dichotomised to stage 1 or 2 (early) or stage 3 or 4 (advanced) for these six cancers, assessed from National Cancer Registry data. Secondary outcomes include stage at diagnosis for a further six cancers without eRATs, use of urgent referral cancer pathways, total practice cancer diagnoses, routes to cancer diagnosis and 30-day and 1-year cancer survival. Economic and process evaluations will be performed along with service delivery modelling. The primary analysis explores the proportion of patients with early-stage cancer at diagnosis. The sample size calculation used an OR of 0.8 for a cancer being diagnosed at an advanced stage in the intervention arm compared with the control arm, equating to an absolute reduction of 4.8% as an incidence-weighted figure across the six cancers. This requires 530 practices overall, with the intervention active from April 2022 for 2 years. ETHICS AND DISSEMINATION The trial has approval from London City and East Research Ethics Committee, reference number 19/LO/0615; protocol version 5.0, 9 May 2022. It is sponsored by the University of Exeter. Dissemination will be by journal publication, conferences, use of appropriate social media and direct sharing with cancer policymakers. TRIAL REGISTRATION NUMBER ISRCTN22560297.
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Affiliation(s)
- Willie Hamilton
- Primary Care Diagnostics, University of Exeter, EXETER, GB, UK
| | - Luke Mounce
- Institute of Health Research, University of Exeter, Exeter, UK
| | - Gary A Abel
- University of Exeter Medical School (Primary Care), University of Exeter, Exeter, Essex, UK
| | | | | | - Fiona C Warren
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Anne Spencer
- Health Economics, University of Exeter Medical School, Exeter, UK
| | | | - Martin Pitt
- University of Exeter: Medical School, University of Exeter, Exeter, Essex, UK
| | | | | | - Emily Fletcher
- Primary Care Research Group, University of Exeter Medical School, Exeter, Devon, UK
| | - Adrian Mercer
- Primary Care, University of Exeter Medical School, Exeter, UK
| | - Raff Calitri
- Primary Care, University of Exeter Medical School, Exeter, UK
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Zhou Y, Walter FM, Mounce L, Abel GA, Singh H, Hamilton W, Stewart GD, Lyratzopoulos G. Identifying opportunities for timely diagnosis of bladder and renal cancer via abnormal blood tests: a longitudinal linked data study. Br J Gen Pract 2022; 72:e19-e25. [PMID: 34903517 PMCID: PMC8714503 DOI: 10.3399/bjgp.2021.0282] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/14/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Understanding pre-diagnostic test use could reveal diagnostic windows where more timely evaluation for cancer may be indicated. AIM To examine pre-diagnostic patterns of results of abnormal blood tests in patients with bladder and renal cancer. DESIGN AND SETTING A retrospective cohort study using primary care and cancer registry data on patients with bladder and renal cancer who were diagnosed between April 2012 and December 2015 in England. METHOD The rates of patients with a first abnormal result in the year before cancer diagnosis, for 'generic' (full blood count components, inflammatory markers, and calcium) and 'organ-specific' blood tests (creatinine and liver function test components) that may lead to subsequent detection of incidental cancers, were examined. Poisson regression was used to detect the month during which the cohort's rate of each abnormal test started to increase from baseline. The proportion of patients with a test found in the first half of the diagnostic window was examined, as these 'early' tests might represent opportunities where further evaluation could be initiated. RESULTS Data from 4533 patients with bladder and renal cancer were analysed. The monthly rate of patients with a first abnormal test increased towards the time of cancer diagnosis. Abnormalities of both generic (for example, high inflammatory markers) and organ-specific tests (for example, high creatinine) started to increase from 6-8 months pre-diagnosis, with 25%-40% of these patients having an abnormal test in the 'early half' of the diagnostic window. CONCLUSION Population-level signals of bladder and renal cancer can be observed in abnormalities in commonly performed primary care blood tests up to 8 months before diagnosis, indicating the potential for earlier diagnosis in some patients.
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Affiliation(s)
- Yin Zhou
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fiona M Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK; professor of primary care cancer research, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Luke Mounce
- University of Exeter Medical School, Exeter, UK
| | - Gary A Abel
- University of Exeter Medical School, Exeter, UK
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, US; Baylor College of Medicine, Houston, TX, US
| | | | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
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Hatton N, Bhartia B, Aslam R, Bradley S, Darby M, Hamilton W, Hurst E, Kennedy M, Mounce L, Neil R, Shinkins B, Callister M. P62.09 A Prospective Cohort Evaluation of the Sensitivity and Specificity of the Chest X-Ray for the Detection of Lung Cancer in Symptomatic Adults. J Thorac Oncol 2021. [DOI: 10.1016/j.jtho.2021.08.654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Strain WD, Elyas S, Wedge N, Mounce L, Henley W, James M, Shore AC. Evaluation of microalbuminuria as a prognostic indicator after a TIA or minor stroke in an outpatient setting: the prognostic role of microalbuminuria in TIA evolution (ProMOTE) study. BMJ Open 2021; 11:e043253. [PMID: 34489262 PMCID: PMC8422314 DOI: 10.1136/bmjopen-2020-043253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Transient ischaemic attacks (TIA) and minor strokes are important risk factors for further vascular events. We explored the role of albumin creatinine ratio (ACR) in improving risk prediction after a first event. SETTING Rapid access stroke clinics in the UK. PARTICIPANTS 2202 patients attending with TIA or minor stroke diagnosed by the attending stroke physician, able to provide a urine sample to evaluate ACR using a near-patient testing device. PRIMARY AND SECONDARY OUTCOMES Primary outcome was major adverse cardiac events (MACE: recurrent stroke, myocardial infarction or cardiovascular death) at 90 days. The key secondary outcome was to determine whether urinary ACR could contribute to a risk prediction tool for use in a clinic setting. RESULTS 151 MACE occurred in 144 participants within 90 days. Participants with MACE had higher ACR than those without. A composite score awarding a point each for age >80 years, previous stroke/TIA and presence of microalbuminuria identified those at low risk and high risk. 90% of patients were at low risk (scoring 0 or 1). Their 90-day risk of MACE was 5.7%. Of the remaining 'high-risk' population (scoring 2 or 3) 12.4% experienced MACE over 90 days (p<0.001 compared with the low-risk population). The need for acute admission in the first 7 days was twofold elevated in the high-risk group compared with the low-risk group (3.23% vs 1.43%; p=0.05). These findings were validated in an independent historic sample. CONCLUSION A risk score comprising age, previous stroke/TIA and microalbuminuria predicts future MACE while identifying those at low risk of a recurrent event. This tool shows promise in the risk stratification of patients to avoid the admission of low-risk patients.
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Affiliation(s)
- W David Strain
- Diabetes and Vascular Research Centre, University of Exeter, Exeter, Devon, UK
- Academic Department of Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, Devon, UK
| | - Salim Elyas
- Diabetes and Vascular Research Centre, University of Exeter, Exeter, Devon, UK
- Academic Department of Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Nicola Wedge
- Academic Department of Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, Devon, UK
| | - Luke Mounce
- Institute of Health Research, University of Exeter Medical School, Exeter, Devon, UK
| | - William Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, Devon, UK
| | - Martin James
- Academic Department of Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Angela C Shore
- Diabetes and Vascular Research Centre, University of Exeter, Exeter, Devon, UK
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, Devon, UK
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Carney MH, Price S, Shephard E, Mounce L, Quiroga M, Hamilton W. Abstract A25: Effect of pre-existing conditions on bladder cancer diagnosis: A cohort study using electronic primary care records. Clin Cancer Res 2020. [DOI: 10.1158/1557-3265.bladder19-a25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Existing comorbid diseases may delay the diagnosis of bladder cancer. This study tested two hypotheses. First, there is an association between existing comorbidity burden and advanced-stage cancer, where the conditions compete for clinical attention and cancer symptoms are overlooked. Second, there is an association between the presence of comorbid conditions that mimic the patient's first possible symptom of cancer and advanced-stage cancer, through symptom misattribution.
Methods: This population-based, observational study was set in The Clinical Practice Research Datalink (CPRD; a dataset of UK primary care medical records) with linkage to Public Health England National Cancer Registration and Analysis Service data. We studied adults (≥40 years) with an incident bladder cancer diagnosis (ICD10 code C67) between 01/01/2000 and 12/31/2015. CPRD records made in the year before cancer diagnosis were searched for codes indicating attendance for bladder cancer symptoms (hematuria, dysuria, and abdominal mass). CPRD records made in the 2 years before the earliest cancer symptom were searched for diagnostic codes for common comorbid conditions (e.g., diabetes and cardiovascular diseases) and for conditions sharing symptoms with bladder cancer (urinary tract infection, sexually transmitted disease, kidney disease, tuberculosis, sickle cell disease, nephrolithiasis, prostatitis, menorrhagia, endometriosis, benign prostatic hyperplasia, uterine fibroids, aortic aneurysm, and retention). The data were analyzed using logistic regression. The outcome variable was stage of bladder cancer diagnosis: advanced (3 or 4) vs. early (1 or 2). Explanatory variables included count of pre-existing comorbid conditions, and an “alternative-explanations” variable indicating when a patient's comorbid condition could explain their first possible bladder cancer symptom. The model adjusted for age, sex, and deprivation.
Results: The analysis included 1,469 (76.4% male) patients, of whom 270 (18.4%) had advanced-stage cancer. 1,178/1,469 (80.2%) patients (73.6% male) had 1 or more comorbid conditions. 616/1,469 (41.9%) patients (64.8% male) had alternative explanations for the first possible symptom of cancer. Women were more likely than men to be diagnosed with advanced-stage cancer (odds ratio 1.62; 95% confidence interval 1.20 to 2.18; p=0.001). Alternative explanations for the first possible symptom of bladder cancer were strongly associated with advanced-stage diagnosis similarly in men and women (1.69, 1.20 to 2.39, p=0.003). Count of conditions was not associated with stage at diagnosis (p=0.64).
Conclusion: Existing comorbid diseases that mimic the presentation of bladder cancer are associated with advanced stage at diagnosis. Women are more likely than men to be diagnosed with advanced-stage cancer, but the effect is not driven by alternative explanations.
Note: This abstract was not presented at the conference.
Citation Format: Madeline H. Carney, Sarah Price, Elizabeth Shephard, Luke Mounce, Myra Quiroga, Willie Hamilton. Effect of pre-existing conditions on bladder cancer diagnosis: A cohort study using electronic primary care records [abstract]. In: Proceedings of the AACR Special Conference on Bladder Cancer: Transforming the Field; 2019 May 18-21; Denver, CO. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(15_Suppl):Abstract nr A25.
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Affiliation(s)
| | - Sarah Price
- 2University of Exeter, Exeter, United Kingdom
| | | | - Luke Mounce
- 2University of Exeter, Exeter, United Kingdom
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Rodgers LR, Dennis JM, Shields BM, Mounce L, Fisher I, Hattersley AT, Henley WE. Prior event rate ratio adjustment produced estimates consistent with randomized trial: a diabetes case study. J Clin Epidemiol 2020; 122:78-86. [PMID: 32194148 PMCID: PMC7262589 DOI: 10.1016/j.jclinepi.2020.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/06/2020] [Accepted: 03/12/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Electronic health records (EHR) provide a valuable resource for assessing drug side-effects, but treatments are not randomly allocated in routine care creating the potential for bias. We conduct a case study using the Prior Event Rate Ratio (PERR) Pairwise method to reduce unmeasured confounding bias in side-effect estimates for two second-line therapies for type 2 diabetes, thiazolidinediones, and sulfonylureas. STUDY DESIGN AND SETTINGS Primary care data were extracted from the Clinical Practice Research Datalink (n = 41,871). We utilized outcomes from the period when patients took first-line metformin to adjust for unmeasured confounding. Estimates for known side-effects and a negative control outcome were compared with the A Diabetes Outcome Progression Trial (ADOPT) trial (n = 2,545). RESULTS When on metformin, patients later prescribed thiazolidinediones had greater risks of edema, HR 95% CI 1.38 (1.13, 1.68) and gastrointestinal side-effects (GI) 1.47 (1.28, 1.68), suggesting the presence of unmeasured confounding. Conventional Cox regression overestimated the risk of edema on thiazolidinediones and identified a false association with GI. The PERR Pairwise estimates were consistent with ADOPT: 1.43 (1.10, 1.83) vs. 1.39 (1.04, 1.86), respectively, for edema, and 0.91 (0.79, 1.05) vs. 0.94 (0.80, 1.10) for GI. CONCLUSION The PERR Pairwise approach offers potential for enhancing postmarketing surveillance of side-effects from EHRs but requires careful consideration of assumptions.
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Affiliation(s)
- Lauren R Rodgers
- Institute of Health Research, University of Exeter Medical School, Exeter, UK.
| | - John M Dennis
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Beverley M Shields
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK
| | - Luke Mounce
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | | | - Andrew T Hattersley
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - William E Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
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Affiliation(s)
- Jessica Watson
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
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Affiliation(s)
- Jessica Watson
- Centre for Academic Primary Care, Canynge Hall, Bristol BS8 2PS, UK
| | | | - Sarah Bailey
- College House, University of Exeter, St Luke's Campus, Exeter, UK
| | - Luke Mounce
- College House, University of Exeter, St Luke's Campus, Exeter, UK
| | - Willie Hamilton
- College House, University of Exeter, St Luke's Campus, Exeter, UK
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Burt J, Campbell J, Abel G, Aboulghate A, Ahmed F, Asprey A, Barry H, Beckwith J, Benson J, Boiko O, Bower P, Calitri R, Carter M, Davey A, Elliott MN, Elmore N, Farrington C, Haque HW, Henley W, Lattimer V, Llanwarne N, Lloyd C, Lyratzopoulos G, Maramba I, Mounce L, Newbould J, Paddison C, Parker R, Richards S, Roberts M, Setodji C, Silverman J, Warren F, Wilson E, Wright C, Roland M. Improving patient experience in primary care: a multimethod programme of research on the measurement and improvement of patient experience. Programme Grants Appl Res 2017. [DOI: 10.3310/pgfar05090] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BackgroundThere has been an increased focus towards improving quality of care within the NHS in the last 15 years; as part of this, there has been an emphasis on the importance of patient feedback within policy, through National Service Frameworks and the Quality and Outcomes Framework. The development and administration of large-scale national patient surveys to gather representative data on patient experience, such as the national GP Patient Survey in primary care, has been one such initiative. However, it remains unclear how the survey is used by patients and what impact the data may have on practice.ObjectivesOur research aimed to gain insight into how different patients use surveys to record experiences of general practice; how primary care staff respond to feedback; and how to engage primary care staff in responding to feedback.MethodsWe used methods including quantitative survey analyses, focus groups, interviews, an exploratory trial and an experimental vignette study.Results(1)Understanding patient experience data. Patients readily criticised their care when reviewing consultations on video, although they were reluctant to be critical when completing questionnaires. When trained raters judged communication during a consultation to be poor, a substantial proportion of patients rated the doctor as ‘good’ or ‘very good’. Absolute scores on questionnaire surveys should be treated with caution; they may present an overoptimistic view of general practitioner (GP) care. However, relative rankings to identify GPs who are better or poorer at communicating may be acceptable, as long as statistically reliable figures are obtained. Most patients have a particular GP whom they prefer to see; however, up to 40% of people who have such a preference are unable regularly to see the doctor of their choice. Users of out-of-hours care reported worse experiences when the service was run by a commercial provider than when it was run by a not-for profit or NHS provider. (2)Understanding patient experience in minority ethnic groups. Asian respondents to the GP Patient Survey tend to be registered with practices with generally low scores, explaining about half of the difference in the poorer reported experiences of South Asian patients than white British patients. We found no evidence that South Asian patients used response scales differently. When viewing the same consultation in an experimental vignette study, South Asian respondents gave higher scores than white British respondents. This suggests that the low scores given by South Asian respondents in patient experience surveys reflect care that is genuinely worse than that experienced by their white British counterparts. We also found that service users of mixed or Asian ethnicity reported lower scores than white respondents when rating out-of-hours services. (3)Using patient experience data. We found that measuring GP–patient communication at practice level masks variation between how good individual doctors are within a practice. In general practices and in out-of-hours centres, staff were sceptical about the value of patient surveys and their ability to support service reconfiguration and quality improvement. In both settings, surveys were deemed necessary but not sufficient. Staff expressed a preference for free-text comments, as these provided more tangible, actionable data. An exploratory trial of real-time feedback (RTF) found that only 2.5% of consulting patients left feedback using touch screens in the waiting room, although more did so when reminded by staff. The representativeness of responding patients remains to be evaluated. Staff were broadly positive about using RTF, and practices valued the ability to include their own questions. Staff benefited from having a facilitated session and protected time to discuss patient feedback.ConclusionsOur findings demonstrate the importance of patient experience feedback as a means of informing NHS care, and confirm that surveys are a valuable resource for monitoring national trends in quality of care. However, surveys may be insufficient in themselves to fully capture patient feedback, and in practice GPs rarely used the results of surveys for quality improvement. The impact of patient surveys appears to be limited and effort should be invested in making the results of surveys more meaningful to practice staff. There were several limitations of this programme of research. Practice recruitment for our in-hours studies took place in two broad geographical areas, which may not be fully representative of practices nationally. Our focus was on patient experience in primary care; secondary care settings may face different challenges in implementing quality improvement initiatives driven by patient feedback. Recommendations for future research include consideration of alternative feedback methods to better support patients to identify poor care; investigation into the factors driving poorer experiences of communication in South Asian patient groups; further investigation of how best to deliver patient feedback to clinicians to engage them and to foster quality improvement; and further research to support the development and implementation of interventions aiming to improve care when deficiencies in patient experience of care are identified.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Jenni Burt
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | - Gary Abel
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
- University of Exeter Medical School, Exeter, UK
| | - Ahmed Aboulghate
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Faraz Ahmed
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | | | - Julia Beckwith
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - John Benson
- Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Olga Boiko
- University of Exeter Medical School, Exeter, UK
| | - Pete Bower
- National Institute for Health Research (NIHR) School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | | | - Mary Carter
- University of Exeter Medical School, Exeter, UK
| | | | | | - Natasha Elmore
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Conor Farrington
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Hena Wali Haque
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | - Val Lattimer
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Nadia Llanwarne
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Cathy Lloyd
- Faculty of Health & Social Care, The Open University, Milton Keynes, UK
| | - Georgios Lyratzopoulos
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | - Luke Mounce
- University of Exeter Medical School, Exeter, UK
| | - Jenny Newbould
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Charlotte Paddison
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Richard Parker
- Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | | | | | | | | | - Ed Wilson
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | - Martin Roland
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
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Davey AF, Roberts MJ, Mounce L, Maramba I, Campbell JL. Test-retest stability of patient experience items derived from the national GP patient survey. Springerplus 2016; 5:1755. [PMID: 27795898 PMCID: PMC5055510 DOI: 10.1186/s40064-016-3377-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/23/2016] [Indexed: 11/24/2022]
Abstract
Purpose The validity and reliability of various items on the GP Patient Survey (GPPS) survey have been reported, however stability of patient responses over time has not been tested. The purpose of this study was to determine the test–retest reliability of the core items from the GPPS. Methods Patients who had recently consulted participating GPs in five general practices across the South West England were sent a postal questionnaire comprising of 54 items concerning their experience of their consultation and the care they received from the GP practice. Patients returning the questionnaire within 3 weeks of mail-out were sent a second identical (retest) questionnaire. Stability of responses was assessed by raw agreement rates and Cohen’s kappa (for categorical response items) and intraclass correlation coefficients and means (for ordinal response items). Results 348 of 597 Patients returned a retest questionnaire (58.3 % response rate). In comparison to the test phase, patients responding to the retest phase were older and more likely to have white British ethnicity. Raw agreement rates for the 33 categorical items ranged from 66 to 100 % (mean 88 %) while the kappa coefficients ranged from 0.00 to 1.00 (mean 0.53). Intraclass correlation coefficients for the 21 ordinal items averaged 0.67 (range 0.44–0.77). Conclusions Formal testing of items from the national GP patient survey examining patient experience in primary care highlighted their acceptable temporal stability several weeks following a GP consultation.
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Affiliation(s)
- Antoinette F Davey
- Primary Care Research Group, University of Exeter Medical School, St Lukes Campus, Exeter, EX1 2LU UK
| | - Martin J Roberts
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Luke Mounce
- Primary Care Research Group, University of Exeter Medical School, St Lukes Campus, Exeter, EX1 2LU UK
| | - Inocencio Maramba
- NIHR CLAHRC South West Peninsula (PenCLAHRC), Plymouth University Peninsula Schools of Medicine and Dentistry, Room N10, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon PL6 8BX UK
| | - John L Campbell
- Primary Care Research Group, University of Exeter Medical School, St Lukes Campus, Exeter, EX1 2LU UK
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Wright C, Davey A, Elmore N, Carter M, Mounce L, Wilson E, Burt J, Roland M, Campbell J. Patients' use and views of real-time feedback technology in general practice. Health Expect 2016; 20:419-433. [PMID: 27124589 PMCID: PMC5433544 DOI: 10.1111/hex.12469] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2016] [Indexed: 11/26/2022] Open
Abstract
Background There is growing interest in real‐time feedback (RTF), which involves collecting and summarizing information about patient experience at the point of care with the aim of informing service improvement. Objective To investigate the feasibility and acceptability of RTF in UK general practice. Design Exploratory randomized trial. Setting/Participants Ten general practices in south‐west England and Cambridgeshire. All patients attending surgeries were eligible to provide RTF. Intervention Touch screens were installed in waiting areas for 12 weeks with practice staff responsible for encouraging patients to provide RTF. All practices received fortnightly feedback summaries. Four teams attended a facilitated reflection session. Outcomes RTF ‘response rates’ among consulting patients were estimated, and the representativeness of touch screen users were assessed. The frequency of staff–patient interactions about RTF (direct observation) and patient views of RTF (exit survey) were summarized. Associated costs were collated. Results About 2.5% consulting patients provided RTF (range 0.7–8.0% across practices), representing a mean of 194 responses per practice. Patients aged above 65 were under‐represented among touch screen users. Receptionists rarely encouraged RTF but, when this did occur, 60% patients participated. Patients were largely positive about RTF but identified some barriers. Costs per practice for the twelve‐week period ranged from £1125 (unfacilitated team‐level feedback) to £1887 (facilitated team ± practitioner‐level feedback). The main cost was the provision of touch screens. Conclusions Response rates for RTF were lower than those of other survey modes, although the numbers of patients providing feedback to each practice were comparable to those achieved in the English national GP patient survey. More patients might engage with RTF if the opportunity were consistently highlighted to them.
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Affiliation(s)
- Christine Wright
- Primary Care Research Group, University of Exeter Medical School, Exeter, Devon, UK
| | - Antoinette Davey
- Primary Care Research Group, University of Exeter Medical School, Exeter, Devon, UK
| | - Natasha Elmore
- The Primary Care Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Mary Carter
- Primary Care Research Group, University of Exeter Medical School, Exeter, Devon, UK
| | - Luke Mounce
- Primary Care Research Group, University of Exeter Medical School, Exeter, Devon, UK
| | - Ed Wilson
- The Primary Care Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Jenni Burt
- The Primary Care Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Martin Roland
- The Primary Care Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - John Campbell
- Primary Care Research Group, University of Exeter Medical School, Exeter, Devon, UK
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Tonks J, Williams WH, Mounce L, Harris D, Frampton I, Yates P, Slater A. 'Trails B or not Trails B?' Is attention-switching a useful outcome measure? Brain Inj 2011; 25:958-64. [PMID: 21745176 DOI: 10.3109/02699052.2011.589792] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE Difficulties with attention contribute to behavioural and cognitive problems during childhood and may reflect subtle deficits in executive functioning (EF). Attention problems in early childhood have also been found to predict higher levels of anxiety and depression symptoms at 10 years old. It has also been reported that attention problems during childhood may be differentially related to later-emerging distinct EF difficulties. Many of these findings, however, rely on teacher-ratings of attention difficulties. METHODS AND PROCEDURES This study administered neuropsychological tests of attention-switching and EF to 67 healthy children aged 9-15 years of age. It additionally measured socio-emotional behavioural functioning. MAIN OUTCOMES AND RESULTS A critical phase of improvement was found at 10 years of age. Correlations were found between attention-switching skills and EF. Attention-switching skills were also correlated with socio-emotional functioning. CONCLUSIONS Attention-switching skills have some interdependence with EF, but in paediatric assessment such skills are easier to routinely assess than many of the currently available tests of EF. It is suggested that attention-switching ability may prove to be a useful predictor of EF performance in understanding long-term outcome after a neurological event such as traumatic brain injury.
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Affiliation(s)
- James Tonks
- School of Psychology, University of Exeter , Exeter, Devon , UK.
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Bastani B, Mounce L. Lack of allergic reaction to Ferrlecit in a patient with a history of severe pruritic reaction with INFeD. Nephron Clin Pract 2001; 89:237-8. [PMID: 11549911 DOI: 10.1159/000046076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Savage EP, Keefe TJ, Wheeler HW, Mounce L, Helwic L, Applehans F, Goes E, Goes T, Mihlan G, Rench J, Taylor DK. Household pesticide usage in the United States. Arch Environ Health 1981; 36:304-9. [PMID: 7316568 DOI: 10.1080/00039896.1981.10667642] [Citation(s) in RCA: 39] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
A total of 10,000 U.S. households in 25 standard metropolitan statistical areas and 25 counties were included in the United States. More than 8,200 households granted an interview. Nine of every ten households in the United States used some types of pesticide in their house, garden, or yard. Households in the southeastern United States used the most pesticides. Although more than 500 different pesticide formulations were used by the sampled households, 15 pesticides accounted for 65.5% of all pesticides reported in this study. Thirteen of these 15 pesticides were insecticides, one was a herbicide, and one was a rodenticide.
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Savage EP, Bagby JR, Mounce L, Williams LP, Cholas PH, Cholas G. Pesticide poisonings in rural Colorado. Rocky Mt Med J 1971; 68:29-33. [PMID: 5575488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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