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Email communication between patients and healthcare professionals

Although email is now a very commonly-used method of communication, its use in health care is not yet routine. Email has been used for communication of clinical information between patients and healthcare professionals, but the effects of using email in this way are not known. In a recent review published by the Cochrane Collaboration, Helen Atherton and colleagues assessed the use of email for two-way clinical communication between patients and healthcare professionals. Atherton and colleagues concluded that the evidence was limited it was not possible to adequately assess the effect of email for clinical communication between patients professionals. They advised that future research should take into account the changing nature of technology when designing and conducting future studies and barriers to trial development and implementation should also be tackled. Potential outcomes of interest for future research include clinical effectiveness, cost-effectiveness and use of health ser…

Guardian article on cuts to primary care budgets

A recent article in the Guardian newspaper by Juliette Jowit discusses the potential impact on patient care on cuts to primary care budgets. The article quotes from my experience as a general practitioner in Lambeth.

"People will start to go to A&E: that costs a lot more and puts a strain on hospitals," he said. "And there's evidence from a number of studies that the better access to GPs is, the better you get in terms of low rates of inpatient admissions for things like strokes [and] lung infections. You end up with poorer health, more cases of hospital care and higher costs."

I also discussed these issues in a recent article in the British Journal of General Practice.

Differences in BP control using NICE guidelines and QOF targets

High blood pressure is the main risk factor for cardiovascular disease. As cardiovascular risk is directly associated with blood pressure levels, the aim of interventions is to lower blood pressure. This aim results in a definition of the control of blood pressure which is currently understood as an achievement of specific blood pressure levels or targets. These targets have been established in different guidelines based on the consensus views of experts. In a study published in JRSM Short Reports, Lena Barrera and colleagues compared differences in the classification of hypertensive controlled patients between the quality indicator established in QOF guidance and the clinical target recommended in NICE guidelines using data from general practices in London.

They found that 80% of patients were classified as controlled by the QOF target and 1% by the NICE target. 93% and 14% of practices had more than 70% of patients classified as controlled using the QOF and NICE targets respectivel…

Primary care in England: an era of austerity

General practitioners (GPs) in England are currently facing perhaps their most challenging financial circumstances since the NHS was founded in 1948. In an editorial published in the British Journal of General Practice, I discuss these the very difficult financial environment that general practitioners find themselves in. GPs will find themselves caught between the priorities of clinical commissioning groups (CCGs) and the NHS Commissioning Board; with CCGs requiring ever greater efficiencies in the use of secondary care services; and the NHS Commissioning Board demanding more ‘value for money’ from general practice contracts.

A strong primary care sector has allowed the NHS to make efficient use of resources, through the gatekeeping role that GPs have in controlling access to specialist services, and through the wide range of medical, social, and psychological problems that GPs and their teams manage through a mix of person-based and population-centred care. The impact of cuts in pr…

Obstructive sleep apnoea, obesity and snoring

Obstructive sleep apnoea (OSA) affects between 2-3% of the population of the UK.  Interestin OSA has increased because of its association with hypertension, type 2 diabetes mellitus and coronary artery disease, and adverse health outcomes. In an article published in the Primary Care Respiratory Journal, Ravi Parekh and colleagues discuss the association of OSA with obesity and snoring.

Defining primary care sensitive conditions

Primary care is a major component of England’s National Health Service , providing around 300 million consultations per year with GPs in England. In addition to providing healthcare to their patients, GPs are also charged with coordination and gatekeeping of access to services provided by secondary care, tertiary care and other allied healthcare providers; a responsibility that will become more important now that GPs will be undertaking the commissioning of health care.

This new responsibility for GPs provides an opportunity to re-model care delivery to maximize outcomes, cost efficiency and patient access by focusing on diseases that are most amenable to management in primary care. In a paper published in the Journal of the Royal Society of Medicine, Daniel Gibbons and Colleagues review the evidence on what conditions are most sensitive to management in primary care – commonly referred to as primary care sensitive conditions (PCSCs) or ambulatory care sensitive conditions. Such defi…

Negative health system effects of Global Fund's investments

In a systematic review published in JRSM Short Reports, Josip Car and colleagues collated and critically evaluate the available scientific evidence on the negative health system effects of global health initiatives in developing countries. They identified 24 studies commenting on adverse effects on health systems arising from Global Fund investments. Sixteen were quantitative studies, six were qualitative and two used both quantitative and qualitative methods, but none explicitly stated that the studies were originally designed to capture or to assess health system effects (positive or negative).

Only anecdotal evidence or authors’ perceptions/interpretations of circumstances could be extracted from the included studies. Dr Car and colleagues concluded that that much of the currently available evidence generated between 2002 and 2009 on global health initiatives potential negative health system effects is not of the quality expected or needed to best serve the academic or broader com…

Care for patients with type 2 diabetes in the UAE

In a paper published in the journal JRSM Short Reports, Layla Alhyas and colleagues examined the quality of type 2 diabetes mellitus (T2DM) care in Al-Ain, a diabetes centre located in a tertiary care hospital, in the United Arab Emirates (UAE). They carried out a a retrospective cohort study from 2008 to 2010.

382 Emirates patients with T2DM were included in the analysis. Overall in 2010, proportions of people with T2DM reaching the following targets were: glycated haemoglobin (HbA1c) 41%, low-density lipoprotein (LDL) 72%, systolic and diastolic blood pressure (SBP/DBP) 47% and 73%, respectively. There was a significant improvement from 2008 to 2010 in HbA1c, LDL, and SBP control.

Alhyas and colleagues concluded that there had been encouraging progress in diabetes care in Al-Ain, UAE as reflected by the overall improvement in key intermediate outcome measures, exemplified by the increase in the percentage if patients reaching the target for these indicators from 2008 to 2010. There…

Male involvement for increasing the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) programmes

During the past decade, national governments and international agencies have strengthened the implementation of prevention of mother-to-child HIV transmission (PMTCT) programmes. However, many women still do not access these services. In 2010, there were 390,000 new HIV infections in children, 90% of which were infected through vertical transmission.  The fear of violence or abandonment by male partners, cultural gender rules and disparate decision making power for women are among the main reasons that women do not access PMTCT services. Hence, interventions should focus on promoting gender equality and improving male awareness and engagement in their families’ health in order to improve uptake of PMTCT services. In a systematic review published in the Cochrane Library,  Serena Brusamento and colleagues assessed the effectiveness of male involvement interventions on women’s uptake of PMTCT services in developing countries. They concluded that we need more studies assessing different …

Patients’ Ratings of Family Physician Practices on the Internet

Patients are increasingly using the Internet to rate their physicians. In a study published in the Journal of Medical Internet Research, Felix Greaves and colleagues examined the usage of NHS Choices, a government website that encourages patients to rate the quality of family practices in England, and associations between web-based patient ratings and conventional measures of patient experience and clinical quality in primary care.

Greaves and colleagues obtained all ratings of family practices posted on NHS Choices between October 2009 and December 2010. They then examined associations between patient ratings and family practice and population characteristics. Associations between ratings and survey measures of patient experience and clinical outcomes were also examined.

They reported that 61% of the 8089 family practices in England were rated, and 69% of ratings would recommend their family practice. Practices serving younger, less deprived, and more densely populated areas were mor…

Increase in number of children admitted to hospital for acute throat infections

The number of children admitted to hospital in England for acute throat infections increased by 76 per cent between 1999 and 2010, according to new research published by Elizabeth Koshy and colleagues in the journal Archives of Disease in Childhood. The article was covered by a number of media outlets, including the BBC.

Acute throat infection (ATI), which includes acute tonsillitis and acute pharyngitis, is one of the most common reasons for consulting a GP. The majority of ATIs are self-limiting and can be managed at home or by the GP, but a small proportion may require hospital admission.

This study investigated admission rates for children up to age 17 with ATI alongside trends in tonsillectomy rates, between 1999 and 2010.  The study was motivated by concerns that the decline in tonsillectomy rates in recent years has led to an increase in hospital admissions for tonsillitis of increased severity. It also investigated whether performing fewer tonsillectomies is associated with h…

Comparison of cardiovascular risk scores using two methods of substituting missing risk factor data

Targeted screening for cardiovascular disease (CVD) can be carried out using existing data from patient medical records. However, electronic medical records often contain missing data for which values must be estimated to produce risk scores. In a paper published in the journal Informatics in Primary Care, Andrew Dalton and colleagues compared two methods of substituting missing risk factor data: multiple imputation and the use of default National Health Survey values. They used patient-level data from patients in 70 general practices in Ealing, London and substituted missing risk factor data using the two methods.

They reported that using multiple imputation, mean CVD risk scores were similar to those using default national survey values, a simple method of imputation. There were fewer patients designated as high risk (>20%) using multiple imputation, although differences were again small (10.3% compared with 11.7%; 3.0% compared with 3.4% in women). Agreement in high-risk classi…

Using hospital records for creating birth cohorts

Linkage between routinely collected hospital birth and other records offers the potential for epidemiological and public health research by developing population-level birth cohorts with lifelong follow-up. In a paper published in the Journal of Public Health, Jo Murray and colleagues from Imperial College London examined the range and completeness of birth information recorded in Hospital Episode Statistics (HES) and tested an approach for minimizing the effect of hospital-level variations by selecting hospitals with high completeness of recording (≥90%) for key fields. The authors reported that the proportion of missing data in key birth record fields such as gestational age and birth weight has been decreasing annually (from 46.2 and 43.9% in 2005/06 to 18.1 and 16.9% in 2009/10, respectively). There was however a wide variation in the completeness of recording between hospitals. The authors concluded that the completeness of recording of hospital birth information varies greatly …

Health policy reviews in the JRSM

Health systems throughout the world face many challenges, including the rising prevalence of chronic diseases such as diabetes; a rise in unhealthy behaviours and risk factors for poor health outcomes, such as physical inactivity, calorie-rich diets and obesity; increasing difficulty in maintaining expenditure on health services and funding new, high-cost treatments; maintaining the population’s access to healthcare while at the same time curtailing this growth in healthcare spending; and determining the most appropriate balance between primary care and specialist services.

A new series of health policy reviews in the JRSM will report on these issues and how health systems are aiming to address key health policy challenges. Traditionally, research and debate in these areas has been very nation-specific, with relatively few attempts to carry out cross-national studies. However, if many of the challenges faced by healthcare systems are similar, then it is likely that countries can draw…

Patient and public perceptions of use of electronic health records for research

Immediate access to patients' complete health records via electronic databases could improve healthcare and facilitate health research. However, the possible benefits of a national electronic health records (EHR) system must be balanced against public concerns about data security and personal privacy. Successful development of EHRs requires better understanding of the views of the public and those most affected by EHRs: users of the National Health Service.

In an article published recently in BMC Medical Informatics & Decision Making, Serena Luchenski and colleagues from Imperial College London describe a protocol for a study that aims to explore the correlation between personal healthcare experience (including number of healthcare contacts and number and type of longer term conditions) and views relating to development of EHR for healthcare, health services planning and policy and health research.

A multi-site cross-sectional self-complete questionnaire designed for use in w…

Joint Committee on Vaccination and Immunisation

The Joint Committee on Vaccination and Immunisation (JCVI) advises the Secretary of State for Health and Welsh Ministers on vaccination and immunisation policies. As an academic primary care physician, I am a strong supporter of evidence-based immunisation schemes and also believe - as far as is practical - in open policy-making in which evidence that government bodies use to make their decisions is made public. In a letter published in the British Medical Journal , I commented on the use by the JCVI of unpublished data and refusal of the JCVI to make public all the evidence it uses.

The Chair of the  JCVI, Andy Hall, states that the Joint Committee on Vaccination and Immunisation (JCVI) does not make public all the evidence it uses for its decisions because this would lead to scientists refusing to send their work to the committee before it was published in a peer reviewed journal. However, he does not supply any evidence supply evidence that academics would refuse to supply unpubli…

Blood pressure and mortality in people with newly diagnosed type 2 diabetes

Clinical guidelines recommend maintaining blood pressure levels to below 130/80 mm Hg in high risk patients, including people with diabetes. In a paper published in the British Medical Journal, Eszter Vamos and colleagues from Imperial College London examined the effect of systolic and diastolic blood pressure achieved in the first year of treatment on all cause mortality in patients newly diagnosed with type 2 diabetes, with and without established cardiovascular disease. They carried out a retrospective cohort study using data from the United Kingdom General Practice Research Database on 126 092 adults with a new diagnosis of type 2 diabetes, between 1990 and 2005.

Before diagnosis, 12 379 (9.8%) patients had established cardiovascular disease (myocardial infarction or stroke). During a median follow-up of 3.5 years, they recorded 25 495 (20.2%) deaths. In people with cardiovascular disease, tight control of systolic (less than 130 mm Hg) and diastolic (less than 80 mm Hg) blood pre…

Type 2 Diabetes in the Gulf Cooperation Council States

The worldwide increase in the prevalence of Type 2 Diabetes Mellitus (T2DM) has been particularly marked in the states of the Cooperation Council for the Arab States of the Gulf (GCC). In a systematic review published in PLoS One, Layla Alhyas and colleagues from Imperial College London examined studies that had aimed to measure the prevalence of T2DM in this region. They identified 27 for review. Six studies were published in the 1980s, 13 in the 1990s, 8 in the 2000s. Eleven studies were of Saudi populations, 3 Kuwaiti, 2 Bahraini, 6 Emirati, 4 Omani and 1 Qatari. Sample sizes ranged from 336 to 600132. All were cross-sectional studies.

Subgroup analysis by country indicated that the estimated prevalence of T2DM between GCC countries are comparable. The lowest estimated prevalence was found in KSA 4.01%; followed by Oman 4.5%. Bahrain had the highest estimated prevalence of T2DM among GCC countries at 5.17%. The estimated prevalence rates between Qatar, UAE and Kuwait were close (5…

Interventions for increasing uptake of copper intrauterine devices

Copper intrauterine devices (copper-IUDs) are safer, more effective and cheaper than hormonal contraceptive methods and are the most widely used reversible contraception in the world. However, they are underused in developed countries. In an article published recently In Contraception, Myat Arrowsmith and colleagues from Imperial College London reviewed randomized controlled trials and controlled before-and-after studies to determine the effectiveness of interventions for improving uptake of copper-IUDs.

Nine studies representing 7960 women met our inclusion criteria, including seven randomized controlled trials and two controlled before-and-after studies. Meta-analysis from three studies showed contraceptive provision by community workers doubled uptake of IUD, and studies on antenatal contraceptive counselling showed similar increases. One study reported major increases in IUD uptake with postnatal couple contraceptive counselling; a study on postnatal home visits and two studies o…

Mobile phone messaging for HIV & AIDS care

In an article published recently in the journal Psychology, Health & Medicine, Michelle Van Velthoven and colleagues from Imperial College London reviewed the scope, effectiveness, acceptability and feasibility of the use of mobile phone messaging for HIV infection prevention, treatment and care.  They reported that the use of mobile phone messaging had been evaluated for HIV prevention, appointment reminders, HIV testing reminders, medication adherence and for communication between health workers. They also reported that of three randomized controlled trials assessing the use of short message service (SMS) to improve medication adherence, two showed positive results. Other interventional studies did not generally provide significant results. They concluded that there was limited evidence on the effectiveness of mobile phone messaging for HIV care and that this area of medical practice would benefit from additional high-quality studies.

Financial incentives and ethnic disparities in smoking cessation interventions

Financial incentives may help improve the delivery of smoking cessation interventions in primary care. However, UK have generally not examined the impact of financial incentives on disparities in the delivery of smoking cessation interventions. In a paper published recently in the Journal of Public Health, Fiona Hamilton and colleagues examined associations between disease group [cardiovascular disease (CVD), respiratory disease, depression or none of these diseases], ethnicity and smoking outcomes following the introduction of the Quality and Outcomes Framework in 2004. They found that significantly, more CVD patients had smoking status ascertained compared with those with respiratory disease (89% versus 72%), but both groups received similar levels of cessation advice (93% and 89%). Patients with depression or none of the diseases were less likely to have smoking status ascertained (60% for both groups) or to receive advice (80 and 75%). Smoking prevalence was high, especially for …

Technologies for global health

Medical technology has developed rapidly in recent in recent decades and there is now real potential to apply these technological developments to improve the quality, safety and efficiency of healthcare worldwide. In a report published in the leading medical journal, The Lancet, Peter Howitt and colleagues from Imperial College London examine how medical technology should best be used to improve health in low- and middle-income countries. The report concludes that in many cases, medical technology — almost exclusively developed in rich countries— is not appropriate for use in poorer nations. Although medical technology is making a substantial contribution to global health, there is much more that it could do if developed and applied correctly for low and middle income countries.

COPD in India

The increasing burden of chronic diseases, such as chronic obstructive pulmonary disease (COPD), is placing increasing strains on countries with developing health systems. In an article published in the Primary Care Respiratory Journal, Ailsa McKay and colleagues carried out a systematic review of studies investigating the prevalence of COPD in India.

The authors did not identify any studies from which they could draw a rigorous estimate of the prevalence of COPD. Reliable standard estimates of chronic bronchitis were only available for rural populations. They identified four studies that gave estimated prevalences of between 6.5% and 7.7%. Smoking status was an important predictor of COPD prevalence. Residential environs, age, and domestic smoke exposure are also important, but investigation of their effect was limited by study heterogeneity.

Ailsa McKay and colleagues concluded that although limited by the number and heterogeneity of studies and their unsuitability for meta-analysis…

Unplanned first-time admissions for cancer

Cancer survival in the United Kingdom is poorer than in many other European countries. For many patients with cancer, their diagnosis is first made when they are admitted to hospital as an emergency with complications of cancer. Hence, studying patients in whom cancer is diagnosed in this sway may provide information that can be used to improve the detection of cancer by the NHS. In a paper published recently in the British Journal of Cancer, Alex Bottle and colleagues from the Department of Primary Care & Public Health at Imperial College London examined patient and general practice characteristics associated with emergency (unplanned) first hospital admissions for cancer in England.

They reported that there were around 640,000 patients with a first-time admission for cancer, of which around 140,000 were unplanned, coming from 7957 GP practices. The unplanned proportion ranged from 14% (patients aged 15–44 years) to 45% (patients aged 85 years and older), with a large variation …

Epidemiology of end-stage renal disease in the countries of the Gulf Cooperation Council

End-stage renal disease (ESRD) is an irreversible decline in kidney function, when renal replacement therapy (RRT) is needed for survival. The countries of the Gulf Cooperation Council (GCC), which consist of Saudi Arabia, the United Arab Emirates, Kuwait, Qatar, Bahrain, and Oman have an increasing burden of non-communicable diseases, including ESRD.

In a paper published recently in JRSM Short Reports, Amal Hassanien and colleagues reviewed the epidemiological studies of ESRD in the countries of the GCC. The studies included in this review showed that the incidence of ESRD has increased while the prevalence and mortality rate of ESRD in the GCC has not been well reported. The leading primary cause of ESRD is diabetes and the most common co-morbid conditions are Hypertension and Hepatitis C Virus infection. The most common causes of death were cardiovascular disease and sepsis.

The study highlighted that the lack of national renal registries data is a critical issue in the countries …

Emergency admissions from sickle cell crisis in Brent

Sickle cell disease (SCD) is a common genetic disorder, largely affecting Black and ethnic minorities (BME) groups. The prevalence in England has increased significantly in recent decades, particularly in urban areas. The increase in the number of people with SCD in England  and the associated burden on the health of patients with SCD  have led to gaining increased attention from the NHS.

In article published in JRSM Short Reports, Stuart Green and colleagues examined admissions from SCD in people living in the London Borough of Brent. The looked at admission between January 2008 and July 2010 by length of stay (average and <2 days versus ≥2 days), age group and registered GP practice of the patient. They reported that 36% of sickle cell disease admission spells resulted in a length of stay of less than two days. Seventy four percent of total bed days are associated with patients with more than one admission during the period of analysis, i.e. multiple admissions.  The figure shows…

The North West London Integrated Care Pilot

The North West London Integrated Care Pilot (ICP) was launched in June 2011. The ICP includes around 100 general practices, 2 acute care trusts, 5 primary care trusts, 2 mental health care trusts, 3 community health trusts, 5 local authorities, and 2 voluntary sector organizations (Age UK and Diabetes UK). The programme aims  to improve the care for older people and people with diabetes in the 550, 000 people living in the area covered by the pilot.

The key objectives of the ICP are discussed in article published in the Journal of Ambulatory Care Management by Matthew Harris and colleagues. These objectives include:

Early identification of at-risk diabetic or elderly peopleRisk stratification using simple assessment scales (combined predictive model)Proactive care planning and delivery by community teamMultidisciplinary teams led by a general practitioner or consultant Improved information flows and system redesignImproved systems and processes to share patient notes and care plans ac…

Computer-assisted history-taking systems in health care

Medical history taking lies at the centre of clinical diagnosis and decision-making. Computer-assisted history-taking systems (CAHTS) are tools that aids clinicians in gathering data from patients to inform a diagnosis or treatment plan. Even though CAHTS have been available for nearly three decades, these remain underused in routine clinical practice. In a paper published in the journal Informatics in Primary Care, Yannis Pappas and colleagues reviewed the previous research on CAHTS.

The review reported that CAHTS can save professionals' time, improve delivery of care to those with special needs and also facilitate the collection of information, especially potentially sensitive information (e.g. sexual history, alcohol consumption). The use of CAHTS, however, also has disadvantages that hinder the process of history taking and may pose risks to patients. CAHTS are also limited in detecting non-verbal communication, may pose irrelevant questions and frustrate the users with techn…

Primary Care in Europe: Entering the Age of Austerity

Many European countries have well-developed health systems that offer universal access to health services and which have a strong primary care sector. Primary care physicians are the point of first contact with the health care system in such countries, providing open access to all patients, and dealing with most of the problems patients present with. Strong primary care sectors have allowed health systems in Europe to make efficient use of health care resources, for example, through the gatekeeping role of primary care physicians. However, as the financial crisis in Europe continues to progress, it is now starting to affect health and social services. In Ireland, for example, this has led to a reduction in the number of hospital beds and in recruitment to unfilled posts in the health service. In Italy, additional user charges have been imposed on patients. The potential impact of this new era of financial austerity were discussed in an article I published in the Journal of Ambulatory…

Effect of Pay-for-Performance on Ethnic Disparities in Diabetes Outcomes

The United Kingdom's Quality and Outcomes Framework (QOF) is a pay-for-performance program that rewards family practitioners in the United Kingdom for the achievement of quality standards. The impact of such quality improvement strategies on disparities in health care is unclear. In an article published in the journal Annals of Family Medicine, Riyadh Alshamsan and colleagues carried out an interrupted time series analysis to examine the impact of QOF on ethnic disparities in diabetes outcomes, using data from the electronic medical records diabetes patients registered with 29 family practices in South West London. The main outcome measures examined were mean haemoglobin A1c (HbA1c), total cholesterol, and blood pressure.

They found that the introduction of QOF was associated with initial accelerated improvements in systolic blood pressure in white and black patients, but these improvements were sustained only in black patients . Initial improvements in diastolic blood pressure i…

Hospital admissions for sickle cell disease in England

Sickle cell disease (SCD) is a rising cause of mortality and morbidity in England and consequently an important policy issue for the National Health Service. In an article published recently in the Journal of Public Health, Ghida Aljuburi and colleagues examined SCD admission rates in England using data from the Hospital Episode Statistics database. They reported that the admission rate for SCD per 100 000 people in England has risen from 21.2 in 2001/02 to 33.5 in 2009/10, a rise of over 50%. London accounted for around 75% of all SCD admissions in England. Nearly 60% of patients admitted with SCD were discharged within 24 hours. The authors concluded that because over half of all patients admitted with SCD were discharged within 24 hours, some of these admissions could be prevented through better ambulatory care of patients with sickle cell disease.

In a letter also published in the Journal of Public Health in response to some comments from Radoslav Latinovic and Allison Streetly, …

Improving Uptake of Prevention of Mother-to-Child HIV Transmission Programs

The United Nations General Assembly Special Session in 2001 set a goal to reduce the proportion of HIV infected infants by 50% by 2010. Achieving this target would require that around 80% of pregnant women and their children need to receive essential HIV prevention, treatment and care. In an article published in the open access journal PLoS One, Lorainne Tudor Car and colleagues from Imperial College London carried out a systematic review to assess the effect of integrated perinatal prevention of mother-to-child transmission of HIV interventions (PMTCT) in low and middle-income countries. Five studies met their inclusion criteria. After reviewing these studies, they found limited, non-generalizable evidence to support the effectiveness of integrated PMTCT programs. None of the included studies evaluated integration of the whole PMTCT program. Further, the uptake of integrated PMTCT interventions was mostly low, and did not reach the 80% target set by  United Nations General Assembly …

Internet-based patient ratings of patient experience in the NHS

Comments made on Internet sites by patients about their experience of the NHS care they have received are increasing. In an article published in BMJ Safety & Quality, Felix Greaves and colleagues examined the association between such online patient reports and conventional measures of patient experience. They compared hospital level associations between web-based patient ratings on the National Health Service (NHS) Choices website and more conventional measures of patient experience.

They did this by carrying out a study of all acute general NHS hospital trusts in England using information from  patient ratings on the NHS Choices website. Greaves and colleagues reported that web-based ratings of patients' experience of NHS hospital care were associated with ratings derived from a more conventional patient survey.

They concluded that web-based ratings that patient made about their care, despite being prone to many biases, are correlated with survey measures of patient experien…

Primary care factors associated with cervical screening coverage in England

An article published recently in the Journal of Public Health by Dr Ji Bang and colleagues reported wide variations in cervical screening uptake, both across primary care trusts (PCTs) and also at general practice level. Rates were lowest in general practices with high proportions of women who are young, non-white, and deprived. The study showed that the proportion of female patients aged 25-49 years, the percentage of black and ethnic minority patients, and the Index of Multiple Deprivation score were all associated with significantly lower rates of cervical screening in both PCTs and individual practices. In contrast, the percentage of female patients aged 50–64 years was associated with higher uptake of cervical screening.

Dr Ji Bang suggested that “a multifaceted approach is needed that includes patients, physicians, individual practices and policy makers,” if cervical screening uptake is to be improved. She also stated that “Performance indicators, such as cervical screening cov…

Women develop type 2 diabetes at a higher body mass index than men

An article published in Diabetologia by Sanjoy Paul and colleagues examined the age–BMI relationship at the time of diagnosis of type 2 diabetes using data on 84,633 patients in the UK who were diagnosed with diabetes between January 1990 and April 2007. They observed that women develop type 2 diabetes at a higher body mass index than men. They also reported a significant difference in the inverse relationships between age and BMI for men and women and marked differences in the average BMI levels for men and women at younger ages, which decreased with increasing age.

General Practice at a Glance

A new textbook of general practice - General Practice at a Glance - from academics in the Department of Primary Care & Public Health at Imperial College London will be published in October 2012. The authors include Dr Paul Booton, Dr Carol Cooper, Dr Graham Easton & Margaret Harper. The book provides an illustrated introduction to the full range of important primary care presentations. It also includes sample questions to ask during history taking and examination, as well as and featuring ‘red flags’ to highlight symptoms or signs that must not be overlooked. The textbook is ideal for medical students undertaking their general practice attachment and also for other medical practitioners working in primary care.

Smoking Cessation in Taiwan

Evidence that smoking restrictions and raising cigarette taxes affect smokers' behaviour is limited. In a paper published in the Asia-Pacific Journal of Public Health, Tai-Yin Wu and colleagues carried out a study of 200 people in Taipei City, Taiwan to evaluate the association between knowledge of smoking legislation and seeking help in smoking cessation. They compared smokers who sought assistance in clinics/classes and smokers who did not. Both banning smoking and increasing prices had positive effects on smokers' behavior, but the effect size of the latter was larger. Better knowledge of the regulations was associated with greater efforts at smoking cessation. Tai-Yin Wu and colleagues concluded that increased knowledge of smoking regulations is associated with seeking help for smoking.

Identifying patients with neuropathic pain using electronic patient records

Chronic neuropathic pain is challenging to treat and a condition for which further research is needed. Primary care records may allow more appropriate patients to be recruited for clinical studies. In an article by Camille Gajria and colleagues published in the journal Informatics in Primary Care, the authors examined whether electronic primary care records could be used to identify patients with neuropathic pain. The study used data from around 100,000 patients in the London Borough of Brent.  The prevalence of diagnoses associated with chronic neuropathic pain was around 13 per 1000, with the elderly, women and white patients experiencing the greatest burden of disease. The study confirmed that electronic patient records can be used to identify patients with chronic neuropathic pain; and that to make full use of data from these records, standardisation of clinical coding and consensus on diagnostic criteria are needed.

Unintended consequences of quality measurement

Although pay-for-performance programs and public reporting of the performance of health care providers - such as general practices in the UK - have become integral components of strategies to improve the quality of health care, measurement and reporting of the quality of healthcare can also have unintended consequences. In a recent article published in the Annals of Internal Medicine, I discuss 'exception reporting', a method whereby patients who will not benefit from an intervention (such as those who are terminally ill) are excluded from quality measurement and not treated inappropriately.

Exception reporting rates in the UK Quality & Outcomes Framework vary widely among general practices that take part in the scheme. When Dalton et al examined exception reporting rates among people with diabetes from 23 general practices in London, they found that patients who were exception-reported by their physicians were significantly less likely to achieve treatment targets for ha…

Integrated care for diabetes—a Singapore approach

An article in the International Journal of Integrated Care by Su Qian Yeo and colleagues discusses the integrated care approach to managing diabetes in Singapore. The number of individuals with diabetes worldwide has increased from about 153 million in 1980 to about 347 million in 2008, due in part to population growth, ageing, urbanisation, and a rising prevalence of risk factors for type 2 diabetes such as obesity and physical inactivity. This rise in prevalence causes considerable burden on health systems and national economies.This has made developing new models of diabetes care a priority for many health systems.

The Singapore General Hospital (SGH) Delivering on Target (DOT) Programme was launched in 2005 to site clinically stable diabetic patients from the hospital to general practitioners (GPs). The Chronic Disease Management Office (CDMO) was established and a fully customised DOT information technology (IT) system was developed. Three initiatives were implemented: (i) subsi…

Measurement of cardiovascular risk factors before NHS Health Checks

Cardiovascular disease (CVD) remains the leading cause of death in the UK. Reducing the burden of CVD requires both primary and secondary prevention strategies. While there have been some primary prevention strategies in the UK over the past decade, there has been far greater focus on secondary prevention strategies targeting high risk individuals. The National Health Service (NHS) Health Check, a national primary prevention programme for vascular disease, aims to improve the prevention and early diagnosis of CVD.

In an article published recently in the medical journal JRSM Short Reports, Macide Artac and Colleagues from the Department of Primary Care & Public Health at Imperial College London  assessed measurement and level of CVD risk factors (blood pressure, cholesterol, body mass index (BMI), blood glucose and smoking status) before implementation of NHS Health Checks in general practices in the London Borough of Hammersmith & Fulham.

They found a high rate of recording o…

Reducing readmissions to hospital.

Reducing readmission of patients to hospital after their initial discharge is a priority for many health systems because of the considerable public health impact and financial cost of these readmissions. For example, in England, there are around 535 000 readmissions annually in patients aged 16 years or older. About 11.2% of hospital admissions result in readmission, and there is a wide variation between both general practices and primary care trusts. I discuss the experience of England in this area in a publication in the Annals of Internal Medicine. A number of initiatives have aimed to reduce hospital readmissions in England but their success has generally been limited. The most recent initiative - the success of which remains to be assessed - is to give general practitioners more control of NHS budgets. Giving physicians collective responsibility for health service budgets in their locality in an attempt to improve the efficiency of a health system  is a radical step and one that…

Web-Based Patient Ratings

Patients in many countries are now using the Internet to rate the how they feel about their experience of the health care they receive. In an article published in Archives of Internal Medicine, Felix Greaves and colleagues examined the associations between patient ratings on the NHS Choices website and other, more standard measures of the quality of services provided by NHS hospitals in England. They found an association between atients’ ratings of hospitals on the NHS Choices website and some more standard measures of clinical quality,  such as mortality and infection rates. They concluded that that the information provided by NHS Choices could be an important development in the measurement of the quality of hospital care. The article was featured by a number of media outlets, including the Guardian, Daily Telegraph, Daily Mail, and Pulse.

Computer-assisted history taking for diabetes

Two recent Cochrane reviews examine the role of computer-assisted history taking in people with diabetes. In the first review, Igor Wei and colleagues examine the role of computer-assisted history taking for dietary histories.  They found that computer-assisted diet history taking was potentially as accurate as the conventional oral-and-written method and may potentially allow doctors to spend more time with their patients. However, the research on this topic was limited and they concluded  that more primary research is required in this area.

In the second review, Yannis Pappas and colleagues examined the role of computer-assisted for identifying people with identifying people with a family history of of type 2 diabetes. Pappas and colleagues found no randomised controlled trials that investigated this area. They concluded that more primary research is required in this area to allow an informed decision to be made by physicians, patients and policymakers.

Although information technol…

Patient safety measures in primary care

In a paper published in JRSM Short Reports, Carmen Tsang and colleagues from the Department of Primary Care & Public Health at Imperial College London interviewed a sample of NHS general practitioners to determine what they felt were the  main patient safety issues and priorities for improvement in general practice. The study provided a snapshot of general practitioners' views on patient safety concerns, uses of routinely collected data to measure adverse events and existing methods for monitoring incidents of patient harm in primary care. Medication-related issues were  identified a major cause for concern. Issues such as communication and training were also identified as important factors in ensuring patient safety in primary care. Further investigation of the patient safety topics identified by Tsang and colleagues will help develop methods to improve the involvement of general practitioners and other health professionals in schemes to improve patient safety in primary care…

Hospital Admissions for Major Cardiovascular Events and Procedures Among People With and Without Diabetes

Although recent years have seen reduction in mortality and other events associated with coronary heart disease, we don't know if people with and without diabetes have benefited equally. In a paper published recently in Diabetes Care, Eszter Vamos and colleagues from the Department of Primary Care & Public Health at Imperial College London compared recent trends in hospital admission rates for angina, acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) among people with and without diabetes in England.

The found that in people with diabetes, admission rates for angina, AMI, and CABG decreased significantly by 5% , 5%, and 3% per year, respectively. Admission rates for stroke did not significantly change but increased for PCI in people with diabetes. People with and without diabetes experienced similar proportional changes for all outcomes, with no significant differences in trends between these groups. Ho…

After-hours primary care

The provision of after-hours primary care in the USA was discussed in a number of articles and letters published recently in the Annals of Internal Medicine. In a response to the articles. I discussed the relevance to the USA of England's experience in providing after-hours primary care. Many of the innovations recommended by by the authors of one of the articles in the Annals of Internal Medicine for the provision of after-hours primary care in the U.S. health care system are already present in England's NHS. These innovations are aimed at improving the care of people with emergencies and reducing pressures on emergency departments.

For example, all residents of England have access to free after-hours primary care services from the NHS, either provided by their own primary care physician or by their local primary care trust. Despite the wide availability of primary care services and a readily accessible 24-hour helpline, patient attendance at emergency departments, urgent ca…

End-digit preference in blood pressure recording

End-digit preference (EDP) leads to clinicians recording specific end-digits (such as zero or five) more often than is expected by chance when measuring blood pressure. This can lead to inaccuracies in the monitoring of blood pressure and the effects of anti-hypertensive treatment. In a paper published recently in the International Journal of Clinical Practice, Alsanjari and colleagues examined trends in EDP over a 10 year period. They reported a decline in both blood pressure levels and EDP over the study period but also reported that around a quarter to a third of patients still have their BP recorded with a zero end digit. The authors conclude that blood pressure should be recorded using automated blood pressure monitoring devices to help to overcome the problem of EDP.