Showing papers by "Mark Ashworth published in 2021"

Impact of multimorbidity on healthcare costs and utilisation: a systematic review of the UK literature

Abstract: Background Managing multimorbidity is complex for both patients and healthcare systems. Patients with multimorbidity often use a variety of primary and secondary care services. Country-specific research exploring the healthcare utilisation and cost consequences of multimorbidity may inform future interventions and payment schemes in the UK. Aim To assess the relationship between multimorbidity, healthcare costs, and healthcare utilisation; and to determine how this relationship varies by disease combinations and healthcare components. Design and setting A systematic review. Method This systematic review followed the bidirectional citation searching to completion method. MEDLINE and grey literature were searched for UK studies since 2004. An iterative review of references and citations was completed. Authors from all articles selected were contacted and asked to check for completeness of UK evidence. The National Institutes of Health National Heart, Lung, and Blood Institute quality assessment tool was used to assess risk of bias. Data were extracted, findings synthesised, and study heterogeneity assessed; meta-analysis was conducted when possible. Results Seventeen studies were identified: seven predicting healthcare costs and 10 healthcare utilisation. Multimorbidity was found to be associated with increased total costs, hospital costs, care transition costs, primary care use, dental care use, emergency department use, and hospitalisations. Several studies demonstrated the high cost of depression and of hospitalisation associated with multimorbidity. Conclusion In the UK, multimorbidity increases healthcare utilisation and costs of primary, secondary, and dental care. Future research is needed to examine whether integrated care schemes offer efficiencies in healthcare provision for multimorbidity.

Association between antibiotics and gut microbiome dysbiosis in children: systematic review and meta-analysis.

Abstract: Antibiotics in childhood have been linked with diseases including asthma, juvenile arthritis, type 1 diabetes, Crohn’s disease and mental illness. The underlying mechanisms are thought related to d...

Identifying longitudinal clusters of multimorbidity in an urban setting: A population-based cross-sectional study

Abstract: Background Globally, there is increasing research on clusters of multimorbidity, but few studies have investigated multimorbidity in urban contexts characterised by a young, multi-ethnic, deprived populations. This study identified clusters of associative multimorbidity in an urban setting. Methods This is a population-based retrospective cross-sectional study using electronic health records of all adults aged 18 years and over, registered between April 2005 to May 2020 in general practices in one inner London borough. Multiple correspondence analysis and cluster analysis was used to identify groups of multimorbidity from 32 long-term conditions (LTCs). Results The population included 41 general practices with 826,936 patients registered between 2005 and 2020, with mean age 40 (SD15·6) years. The prevalence of multimorbidity was 21% (n = 174,881), with the median number of conditions being three and increasing with age. Analysis identified five consistent LTC clusters: 1) anxiety and depression (Ratio of within- to between- sum of squares (WSS/BSS Interpretation Mental health problems, pain, and at-risk behaviours leading to cardiovascular diseases are the important clusters identified in this young, urban population. Funding Impact on Urban Health, United Kingdom.

Cancer detection via primary care urgent referral and association with practice characteristics: a retrospective cross-sectional study in England from 2009/2010 to 2018/2019.

Abstract: Background: There is substantial variation in use of urgent suspected cancer referral (two week wait/2WW) between practices. Aim: To examine change in use of 2WW referrals in England over ten years (2009/10 to 2018/19) and practice and population factors associated with cancer detection. Design and Setting: Retrospective cross-sectional study of English general practices and their 2WW referral and cancer waiting times (CWT) detection data (all cancers other than non melanoma skin cancers) 2009/10 to 2018/19. Methods: Descriptive statistics of changes over ten years in 2WW referral data. Yearly linear regression models to determine the association between cancer detection rates and quintiles of practice and population characteristics. Predicted cancer detection rates were calculated and the difference between lowest (Q1) to highest (Q5) quintiles. Results: Over the ten years studied there were 14.89m 2WW referrals (2.2m 2018/19), 2.68m new cancer diagnoses of which 1.26m were detected following 2WW. The detection rate increased from 41% to 52%. In 2018/19 an additional 66,172 cancers were detected via 2WW compared to 2009/10. Higher cancer detection via 2WW referrals was associated with larger practices and those with younger GPs. From 2016/17 onwards more deprived practice populations were associated with decreased cancer detection. Conclusions: From 2009/10 to 2018/19 2WW referrals increased on average by 10% year on year. Higher cancer detection was found in larger practices, with relatively younger GPs and more recently, less deprived populations. COVID-19 has led to significant impacts on 2WW referral activity and the impact on patient outcomes will need to be studied.

Adapting the definition of multimorbidity – development of a locality-based consensus for selecting included Long Term Conditions

Abstract: Defining multimorbidity has proved elusive in spite of attempts to standardise definitions. For national studies, a broad definition is required to capture national diversity. For locally based studies, the definition may need to reflect demographic and morbidity patterns. We aimed to define multimorbidity for an inner city, multi-ethnic, deprived, young age community typical of many large cities. We used a scoping literature review to identify the international literature, standards and guidelines on Long Term Condition (LTC) definitions for inclusion in our multimorbidity definition. Consensus was categorised into high, medium or low consensus, depending on the number of literature sources citing each LTC. Findings were presented to a workshop consisting of local health service stakeholders who were asked to select LTCs for inclusion in a second stage review. In the second stage, each LTC was tested against seven evaluation domains: prevalence, impact, preventability, treatment burden, progression to multiple LTCs, impact on younger people, data quality. These domains were used to create 12 target criteria. LTC rankings according to consensus group and target criteria scores were presented to a second workshop for a final decision about LTC inclusion. The literature review identified 18 literature sources citing 86 LTCs: 11 were excluded because they were LTC clusters. The remainder were allocated into consensus groupings: 13 LTCs were ‘high consensus’ (cited by ≥ 11 sources); 15 were ‘medium consensus’ (cited by 5–10 sources); 47 were ‘low consensus’ (cited by < 5 sources). The first workshop excluded 31 LTCs. The remaining 44 LTCs consisted of: 13 high consensus LTCs, all with high target score (score 6–12); 15 medium consensus LTCs, 11 with high target scores; 16 low consensus LTCs, 6 with high target scores. The final workshop selected the 12 high consensus conditions, 12 medium consensus LTCs (10 with high target scores) and 8 low consensus LTCs (3 with high target scores), producing a final selection of 32 LTCs. Redefining multimorbidity for an urban context ensures local relevance but may diminish national generalisability. We describe a detailed LTC selection process which should be generalisable to other contexts, both local and national.

Prevalence and predictors of potentially inappropriate prescribing in middle-aged adults: a repeated cross-sectional study.

Abstract: Background Potentially inappropriate prescribing (PIP) is common in older adults and known to be associated with polypharmacy and multimorbidity. Less is known about the prevalence and causes of PIP in middle-aged adults. Aim To determine the prevalence and predictors of PIP in middle-aged adults. Design and setting A repeated cross-sectional study was conducted using primary care data in London. Method PIP was defined using the PRescribing Optimally in Middle-aged People’s Treatments (PROMPT) criteria. Prescribing and demographic data were extracted from Lambeth DataNet (LDN), a pseudonymised database of all patients registered at general practices in Lambeth, for those aged 45–64 years prescribed ≥1 medicines in each year from 2014–2019 (n = 46 633–52 582). Prevalence and trends over 6 years were investigated, including the association of PIP with polypharmacy, multimorbidity, deprivation, sex, and age. Results The prevalence of PIP decreased from 20% in 2014 to 18% in 2019. The most prevalent PROMPT criteria in 2019 were the use of ≥2 drugs from the same pharmacological class (7.6%), use of non-steroidal anti-inflammatory drugs for >3 months (7.1%) and use of proton pump inhibitors above recommended maintenance dosages for >8 weeks (3.1%). Over the study period, the prevalence of multimorbidity increased (47–52%) and polypharmacy remained stable (27%). Polypharmacy, multimorbidity, deprivation, and age were independently associated with PIP. Sex was the only variable not associated with PIP. Conclusion Almost one-fifth of middle-aged adults prescribed medicines are exposed to PIP, as defined by the PROMPT criteria. This is likely to be linked with exposure to avoidable adverse drug events. The PROMPT criteria may provide a useful aid in interventions to optimise prescribing.

Impact of primary care funding on patient satisfaction: a retrospective longitudinal study of English general practice, 2013-2016.

Abstract: Background Providing high-quality clinical care and good patient experience are priorities for most healthcare systems. Aim To understand the relationship between general practice funding and patient-reported experience. Design and setting Retrospective longitudinal study of English general practice-level data for the financial years 2013–2014 to 2016–2017. Method Data for all general practices in England from the General and Personal Medical Services database were linked to patient experience data from the GP Patient Survey (GPPS). Panel data multivariate regression was used to estimate the impact of general practice funding (current or lagged 1 year) per patient on GPPS-reported patient experience of access, continuity of care, professionalism, and overall satisfaction. Confounding was controlled for by practice, demographic, and GPPS responder characteristics, and for year effects. Results Inflation-adjusted mean total annual funding per patient was £133.66 (standard deviation [SD] = £39.46). In all models, higher funding was associated with better patient experience. In the model with lagged funding and practice fixed effects (model 6), a 1 SD increase in funding was associated with increases in scores in the domains of access (1.18%; 95% confidence interval [CI] = 0.89 to 1.47), continuity (0.86%; 95% CI = 0.19 to 1.52), professionalism of GP (0.47%; 95% CI = 0.22 to 0.71), professionalism of nurse (0.51%; 95% CI = 0.24 to 0.77), professionalism of receptionist (0.51%; 95% CI = 0.24 to 0.78), and in overall satisfaction (0.88%; 95% CI = 0.52 to 1.24). Conclusion Better-funded general practices were more likely to have higher reported patient experience ratings across a wide range of domains.

Spatio-temporal associations of air pollutant concentrations, GP respiratory consultations and respiratory inhaler prescriptions: a 5-year study of primary care in the borough of Lambeth, South London

Abstract: Although the associations of outdoor air pollution exposure with mortality and hospital admissions are well established, few previous studies have reported on primary care clinical and prescribing data. We assessed the associations of short and long-term pollutant exposures with General Practitioner respiratory consultations and inhaler prescriptions. Daily primary care data, for 2009–2013, were obtained from Lambeth DataNet (LDN), an anonymised dataset containing coded data from all patients (1.2 million) registered at general practices in Lambeth, an inner-city south London borough. Counts of respiratory consultations and inhaler prescriptions by day and Lower Super Output Area (LSOA) of residence were constructed. We developed models for predicting daily PM2.5, PM10, NO2 and O3 per LSOA. We used spatio-temporal mixed effects zero inflated negative binomial models to investigate the simultaneous short- and long-term effects of exposure to pollutants on the number of events. The mean concentrations of NO2, PM10, PM2.5 and O3 over the study period were 50.7, 21.2, 15.6, and 49.9 μg/m3 respectively, with all pollutants except NO2 having much larger temporal rather than spatial variability. Following short-term exposure increases to PM10, NO2 and PM2.5 the number of consultations and inhaler prescriptions were found to increase, especially for PM10 exposure in children which was associated with increases in daily respiratory consultations of 3.4% and inhaler prescriptions of 0.8%, per PM10 interquartile range (IQR) increase. Associations further increased after adjustment for weekly average exposures, rising to 6.1 and 1.2%, respectively, for weekly average PM10 exposure. In contrast, a short-term increase in O3 exposure was associated with decreased number of respiratory consultations. No association was found between long-term exposures to PM10, PM2.5 and NO2 and number of respiratory consultations. Long-term exposure to NO2 was associated with an increase (8%) in preventer inhaler prescriptions only. We found increases in the daily number of GP respiratory consultations and inhaler prescriptions following short-term increases in exposure to NO2, PM10 and PM2.5. These associations are more pronounced in children and persist for at least a week. The association with long term exposure to NO2 and preventer inhaler prescriptions indicates likely increased chronic respiratory morbidity.

Development and validation of the Maudsley Modified Patient Health Questionnaire (MM-PHQ-9).

Abstract: Background The Patient Health Questionnaire-9 (PHQ-9) is a widely used measure of depression in primary care. It was, however, originally designed as a diagnostic screening tool, and not for measuring change in response to antidepressant treatment. Although the Quick Inventory of Depressive Symptomology (QIDS-SR-16) has been extensively validated for outcome measurement, it is poorly adopted in UK primary care, and, although free for clinicians, has licensing restrictions for healthcare organisation use. Aims We aimed to develop a modified version of the PHQ-9, the Maudsley Modified PHQ-9 (MM-PHQ-9), for tracking symptom changes in primary care. We tested the measure's validity, reliability and factor structure. Method A sample of 121 participants was recruited across three studies, and comprised 78 participants with major depressive disorder and 43 controls. MM-PHQ-9 scores were compared with the QIDS-SR-16 and Clinical Global Impressions improvement scale, for concurrent validity. Internal consistency of the scale was assessed, and principal component analysis was conducted to determine the items’ factor structure. Results The MM-PHQ-9 demonstrated good concurrent validity with the QIDS-SR-16, and excellent internal consistency. Sensitivity to change over a 14-week period was d = 0.41 compared with d = 0.61 on the QIDS-SR-16. Concurrent validity between the paper and mobile app versions of the MM-PHQ-9 was r = 0.67. Conclusions These results indicate that the MM-PHQ-9 is a valid and reliable measure of depressive symptoms in paper and mobile app format, although further validation is required. The measure was sensitive to change, demonstrating suitability for use in routine outcome assessment.

Epilepsy and mortality: a retrospective cohort analysis with a nested case-control study identifying causes and risk factors from primary care and linkage-derived data.

Abstract: Objectives People with epilepsy (PWE) have a higher mortality rate than the general population. Epilepsy-related deaths have increased despite all-cause mortality decreasing in the general population pre-COVID-19. We hypothesised that clinical and lifestyle factors may identify people more at risk. Design We used a retrospective cohort study to explore cause of death and a nested case-control study to identify risk factors. Setting We explored factors associated with mortality using primary care population data from 1 April 2004 to 31 March 2014. Data were obtained from the Clinical Practice Research Datalink which compiles anonymised patient data from primary care in the UK. Cause of death data was supplemented from the Office of National Statistics when available. Participants The analysis included 70 431 PWE, with 11 241 registered deaths. Results The number of deaths within the database increased by 69% between the first and last year of the study. Epilepsy was considered as a contributing cause in approximately 45% of deaths of PWE under 35. Factors associated with increased risk of death included attendance at emergency departments and/or emergency admissions (OR 3.48, 95% CI 3.19 to 3.80), antiepileptic drug (AED) polytherapy (2 AEDs: OR 1.60, 95% CI 1.51 to 1.71; 3 AEDs: OR 2.06, 95% CI 1.86 to 2.29; 4+AEDs: OR 2.62, 95% CI 2.23 to 3.08), status epilepticus (OR 2.78, 95% CI 1.64 to 4.71), depression (OR 1.67, 95% CI 1.57 to 1.76) and injuries (OR 1.54, 95% CI 1.43 to 1.67). No seizures in the prior year (OR 0.52, 95% CI 0.41 to 0.65). Conclusion Our results add to existing evidence that deaths in epilepsy are increasing. Future studies could focus on identifying PWE at high risk and addressing them with clinical interventions or better self-management. Identifying specific risk factors for younger people should be a priority as epilepsy may be a factor in close to half of deaths of PWE under 35 years of age.

What gets recorded, counts: dementia recording in primary care compared with a specialist database.

Abstract: Background databases of electronic health records are powerful tools for dementia research, but data can be influenced by incomplete recording. We examined whether people with dementia recorded in a specialist database (from a mental health and dementia care service) differ from those recorded in primary care. Methods a retrospective cohort study of the population covered by Lambeth DataNet (primary care electronic records) between 2007 and 2019. Documentation of dementia diagnosis in primary care coded data and linked records in a specialist database (Clinical Records Interactive Search) were compared. Results 3,859 people had dementia documented in primary care codes and 4,266 in the specialist database, with 2,886/5,239 (55%) documented in both sources. Overall, 55% were labelled as having Alzheimer's dementia and 29% were prescribed dementia medication, but these proportions were significantly higher in those documented in both sources. The cohort identified from the specialist database were less likely to live in a care home (prevalence ratio 0.73, 95% confidence interval 0.63-0.85), have multimorbidity (0.87, 0.77-0.98) or consult frequently (0.91, 0.88-0.95) than those identified through primary care codes, although mortality did not differ (0.98, 0.91-1.06). Discussion there is under-recording of dementia diagnoses in both primary care and specialist databases. This has implications for clinical care and for generalizability of research. Our results suggest that using a mental health database may under-represent those patients who have more frailty, reflecting differential referral to mental health services, and demonstrating how the patient pathways are an important consideration when undertaking database studies.

Identifying multimorbidity clusters with the highest primary care use: 15 years of evidence from a multi-ethnic metropolitan population.

Abstract: Background People with multimorbidity have complex healthcare needs. Some co-occurring diseases interact with each other to a larger extent than others and may have a different impact on primary care use. Aim To assess the association between multimorbidity clusters and primary care consultations over time. Design and setting A retrospective longitudinal (panel) study design was used. Data comprised electronic primary care health records of 826 166 patients registered at GP practices in an ethnically diverse, urban setting in London between 2005 and 2020. Method Primary care consultation rates were modelled using generalised estimating equations. Key controls included the total number of long-term conditions, five multimorbidity clusters, and their interaction effects, ethnic group, and polypharmacy (proxy for disease severity). Models were also calibrated by consultation type and ethnic group. Results Individuals with multimorbidity used two to three times more primary care services than those without multimorbidity (incidence rate ratio 2.30, 95% confidence interval = 2.29 to 2.32). Patients in the alcohol dependence, substance dependence, and HIV cluster (Dependence+) had the highest rate of increase in primary care consultations as additional long-term conditions accumulated, followed by the mental health cluster (anxiety and depression). Differences by ethnic group were observed, with the largest impact in the chronic liver disease and viral hepatitis cluster for individuals of Black or Asian ethnicity. Conclusion This study identified multimorbidity clusters with the highest primary care demand over time as additional long-term conditions developed, differentiating by consultation type and ethnicity. Targeting clinical practice to prevent multimorbidity progression for these groups may lessen future pressures on primary care demand by improving health outcomes.

The validity of the International Physical Activity Questionnaire (IPAQ) for adults with progressive muscle diseases.

Abstract: Purpose Measuring the physical activity of adults with progressive muscle diseases is important to inform clinical practice, for activity recommendations and for outcomes meaningful to participants in clinical trials. Despite its wide use, the measurement properties of the International Physical Activity Questionnaire (IPAQ) have not been established in a muscle disease population. Materials and methods The sample of 103 adults with progressive muscle diseases included independently mobile participants and wheelchair users. Their home-based activity measured by the IPAQ was compared to simultaneous weeks of accelerometer activity data collected remotely in a longitudinal, measure evaluation study. Validity, reliability, and responsiveness were evaluated for the IPAQ alone, and for the IPAQ used in conjunction with a smart activity monitor. Results The IPAQ did not demonstrate satisfactory criterion validity, reliability or responsiveness and it systematically overestimated moderate and vigorous physical activity time by 161 minutes per week. Measurement properties of the IPAQ were improved when it was used in combination with a smart activity monitor. Conclusions The IPAQ did not have satisfactory measurement properties compared to accelerometry in adults with progressive muscle disease. Combining self-report and objective activity measures might improve the accuracy of physical activity assessment in this and other comparable populations.Implications for RehabilitationPhysical activity is a meaningful health outcome for adults with progressive muscle diseases, for whom precise activity quantification is important because of the potential for activity-related disease exacerbation.The International Physical Activity Questionnaire (IPAQ) had unsatisfactory measurement properties compared to accelerometry; however, these were improved by adjunctive smart activity monitoring.Objective or combined physical activity measurement is recommended over self-report alone for clinical assessment of physical activity as part of rehabilitation and self-management programmes.

Safety of reducing antibiotic prescribing in primary care: a mixed-methods study

Abstract: Background The threat of antimicrobial resistance has led to intensified efforts to reduce antibiotic utilisation, but serious bacterial infections are increasing in frequency. Objectives To estimate the risks of serious bacterial infections in association with lower antibiotic prescribing and understand stakeholder views with respect to safe antibiotic reduction. Design Mixed-methods research was undertaken, including a qualitative interview study of patient and prescriber views that informed a cohort study and a decision-analytic model, using primary care electronic health records. These three work packages were used to design an application (app) for primary care prescribers. Data sources The Clinical Practice Research Datalink. Setting This took place in UK general practices. Participants A total of 706 general practices with 66.2 million person-years of follow-up from 2002 to 2017 and antibiotic utilisation evaluated for 671,830 registered patients. The qualitative study included 31 patients and 30 health-care professionals from primary care. Main outcome measures Sepsis and localised bacterial infections. Results Patients were concerned about antimicrobial resistance and the side effects, as well as the benefits, of antibiotic treatment. Prescribers viewed the onset of sepsis as the most concerning potential outcome of reduced antibiotic prescribing. More than 40% of antibiotic prescriptions in primary care had no coded indication recorded across both Vision® and EMIS® practice systems. Antibiotic prescribing rates varied widely between general practices, but there was no evidence that serious bacterial infections were less frequent at higher prescribing practices (adjusted rate ratio for 20% increase in prescribing 1.03, 95% confidence interval 1.00 to 1.06; p = 0.074). The probability of sepsis was lower if an antibiotic was prescribed at an infection consultation, and the number of antibiotic prescriptions required to prevent one episode of sepsis (i.e. the number needed to treat) decreased with age. For those aged 0–4 years, the number needed to treat was 29,773 (95% uncertainty interval 18,458 to 71,091) in boys and 27,014 (95% uncertainty interval 16,739 to 65,709) in girls. For those aged > 85 years, the number needed to treat was 262 (95% uncertainty interval 236 to 293) in men and 385 (95% uncertainty interval 352 to 421) in women. Frailty was associated with a greater risk of sepsis and a smaller number needed to treat. For severely frail patients aged 55–64 years, the number needed to treat was 247 (95% uncertainty interval 156 to 459) for men and 343 (95% uncertainty interval 234 to 556) for women. At all ages, the probability of sepsis was greatest for urinary tract infection, followed by skin infection and respiratory tract infection. The numbers needed to treat were generally smaller for the period 2014–17, when sepsis was diagnosed more frequently. The results are available using an app that we developed to provide primary care prescribers with stratified risk estimates during infection consultations. Limitations Analyses were based on non-randomised comparisons. Infection episodes and antibiotic prescribing are poorly documented in primary care. Conclusions Antibiotic treatment is generally associated with lower risks, but the most serious bacterial infections remain infrequent even without antibiotic treatment. This research identifies risk strata in which antibiotic prescribing can be more safely reduced. Future work The software developed from this research may be further developed and investigated for antimicrobial stewardship effect. 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. 9. See the NIHR Journals Library website for further project information.

Validity of Fitbit activity monitoring for adults with progressive muscle diseases.

Abstract: Purpose Measuring physical activity informs activity recommendations in clinical practice and provides outcomes in clinical trials that are meaningful to patients. Activity assessment in muscle disease is challenging and there is insufficient evidence to support any single activity measure; however, multi-modal activity measurement might have potential. Materials and methods This two-part study included 20 and 95 adults with progressive muscle diseases with mobility ranging from independent to assisted, including wheelchair users. Their activity was measured using a multi-sensor Fitbit activity monitor, for which criterion validity and acceptability were tested in study 1 and validity, reliability, and responsiveness were tested in the longitudinal, home-based study 2. Results Study 1: Fitbit was acceptable and had strong criterion validity (rho/kappa ≥0.90), although up to 15% measurement error. Study 2: Fitbit had satisfactory concurrent and construct validity, reliability, and responsiveness. However, Fitbit active minutes registered 75 min more activity per week than gold standard moderate and vigorous physical activity (MVPA) time. Conclusions Fitbit had satisfactory measurement properties for monitoring physical activity in adults with progressive muscle diseases. However, Fitbit should not be considered an exact step counter, heart rate monitor or calorimeter and Fitbit active minutes are not synonymous with MVPA time.Implications for rehabilitationPeople with progressive muscle diseases mobilise independently, with walking aids and with wheelchairs; physical activity measurement can be challenging in this population.Multisensor smart activity monitoring by Fitbit had satisfactory validity, reliability, responsiveness, and acceptability for the estimation of physical activity in adults with progressive muscle diseases.Fitbit active minutes are not synonymous with moderate and vigorous physical activity (MVPA) time measured using a research grade accelerometer.

Inequalities in glycemic management in people living with type 2 diabetes mellitus and severe mental illnesses: cohort study from the UK over 10 years.

Abstract: Introduction Using data from a a primary care pay-for-performance scheme targeting quality indicators, the objective of this study was to assess if people living with type 2 diabetes mellitus (T2DM) and severe mental illnesses (SMI) experienced poorer glycemic management compared with people living with T2DM alone, and if observed differences varied by race/ethnicity, deprivation, gender, or exclusion from the scheme. Research design and methods Primary care data from a cohort of 56 770 people with T2DM, including 2272 people with T2DM and SMI, from London (UK), diagnosed between January 17, 2008 and January 16, 2018, were used. Adjusted mean glycated hemoglobin (HbA1c) and HbA1c differences were assessed using multilevel regression models. Results Compared with people with T2DM only, people with T2DM/SMI were more likely to be of an ethnic minority background, excluded from the pay-for-performance scheme and residing in more deprived areas. Across the sample, mean HbA1c was lower in those with T2DM and SMI (mean HbA1c: 58 mmol/mol; 95% CI 57 to 59), compared with people with T2DM only (mean HbA1c: 59 mmol/mol; 95% CI 59 to 60). However, HbA1c levels were greater in Bangladeshi, Indian, Pakistani, and Chinese people compared with the White British reference in the T2DM/SMI group. People with T2DM/SMI who had been excluded from the pay-for-performance scheme, had HbA1c levels which were +7 mmol/mol (95% CI 2 to 11) greater than those with T2DM/SMI not excluded. Irrespective of SMI status, increasing deprivation and male gender were associated with increased HbA1c levels. Conclusions Despite a pay-for-performance scheme to improve quality standards, inequalities in glycemic management in people with T2DM and SMI persist in those excluded from the scheme and by gender, ethnicity, and area-level deprivation.

Primary care funding entrenches health inequalities: time for a rethink.

Abstract: Fifty years since the term was first used to describe the mismatch between healthcare provision and healthcare need,1 the inverse care law is alive and well. Coined by Julian Tudor Hart, a GP in a coal-mining community in south Wales, the term was a clever pun on the inverse square law. And it has stuck ever since. Although primary care in 2021 has changed beyond recognition since 1971, one factor remains largely unchanged and it is a factor that perpetuates disparity. The funding of primary care is still largely based on capitation payments together with the more recent addition of target-based pay-for-performance rewards. Equality of practice funding in areas of high and low social deprivation, so-called ‘flat funding’, simply widens healthcare inequality in the presence of unequal healthcare needs.2 Marmot has advocated the principle of ‘proportionate universalism’, whereby universal healthcare provision is supplemented by targeted approaches related to the level of social need.3 But surely current primary care funding already invests in deprived communities? Capitation funding, accounting for the majority of funding, is not linked with social deprivation, although it is linked to measures of community ill health.4 The Carr-Hill …

The psychometric properties of PSYCHLOPS, an individualized patient-reported outcome measure of personal distress.

Abstract: OBJECTIVE Few studies report the psychometric properties of individualized patient-reported outcome measures (I-PROMs) combining traditional analysis and Item Response Theory (IRT). METHODS Pre- and posttreatment PSYCHLOPS data derived from six clinical samples (n = 939) were analyzed for validity, reliability, and responsiveness; caseness cutoffs and reliable change index were calculated. Exploratory and confirmatory factor analyses were used to determine whether items represented a unidimensional construct; IRT examined item properties of this construct. RESULTS Values for internal consistency, construct validity, convergent and discriminant validity, and structural validity were satisfactory. Responsiveness was high: Cohen's d, 1.48. Caseness cutoff and reliable clinical change scores were 6.41 and 4.63, respectively. IRT analysis confirmed that item scores possess strong properties in assessing the underlying trait measured by PSYCHLOPS. CONCLUSION PSYCHLOPS met the criteria for norm-referenced measurement of patient psychological distress. PSYCHLOPS functioned as a measure of a single latent trait, which we describe as "personal distress."

COVID-19 lockdown impact on the physical activity of adults with progressive muscle diseases

Abstract: Introduction This short article summarises findings about reduced physical activity of adults with progressive muscle disease as a result of COVID-19 lockdown. Methods As part of an ongoing longitudinal cohort study, we prospectively and objectively measured physical activity using accelerometry at baseline in 2019 and follow-up in 2020. A subset of 85 participants incidentally had follow-up data collected during the first UK COVID-19 lockdown from 23 March to 4 July 2020. Thus, for this cohort we had activity data from before and during the COVID-19 pandemic and we were able to prospectively and accurately quantify the changes in their physical activity. Results Our data highlighted reduced overall activity intensity and reduced light activity time in particular. Conclusions From our findings, we can infer specific evidence-based recommendations about how to redress inactivity secondary to COVID-19 restrictions for adults with progressive muscle diseases. These recommendations are likely to be generalisable to other groups who are vulnerable to functional decline secondary to prolonged inactivity.

Hypertension and cardiovascular risk factor management in a multi-ethnic cohort of adults with CKD: a cross sectional study in general practice

Abstract: Hypertension, especially if poorly controlled, is a key determinant of chronic kidney disease (CKD) development and progression to end stage renal disease (ESRD). To assess hypertension and risk factor management, and determinants of systolic blood pressure control in individuals with CKD and hypertension. Cross-sectional survey using primary care electronic health records from 47/49 general practice clinics in South London. Known effective interventions, management of hypertension and cardiovascular disease (CVD) risk in patients with CKD Stages 3–5 were investigated. Multivariable logistic regression analysis examined the association of demographic factors, comorbidities, deprivation, and CKD coding, with systolic blood pressure control status as outcome. Individuals with diabetes were excluded. Adults with CKD Stages 3–5 and hypertension represented 4131/286,162 (1.4%) of the total population; 1984 (48%) of these individuals had undiagnosed CKD without a recorded CKD clinical code. Hypertension was undiagnosed in 25% of the total Lambeth population, and in patients with CKD without diagnosed hypertension, 23.0% had systolic blood pressure > 140 mmHg compared with 39.8% hypertensives, p < 0.001. Multivariable logistic regression revealed that factors associated with improved systolic blood pressure control in CKD included diastolic blood pressure control, serious mental illness, history of cardiovascular co-morbidities, CKD diagnostic coding, and age < 60 years. African ethnicity and obesity were associated with poorer systolic blood pressure control. We found both underdiagnosed CKD and underdiagnosed hypertension in patients with CKD. The poor systolic blood pressure control in older age groups ≥ 60 years and in Black African or obese individuals is clinically important as these groups are at increased risk of mortality for cardiovascular diseases.

Evaluation of NHS Practitioner Health: capturing mental health outcomes using five instruments.

Abstract: Background NHS Practitioner Health is the England wide programme providing mental health and addiction healthcare to doctors and dentists. Outcomes are assessed using five measures. Aims To contribute to a service evaluation of NHS Practitioner Health. To determine responsiveness to change and compare outcome measures. Method Measures were completed at baseline and 6 months: Generalized Anxiety Disorder Assessment (GAD-7), Perceived Stress Scale (PSS), Patient Health Questionaire-9 (PHQ-9), Warwick-Edinburgh Mental Wellbeing scale (WEMWBS), Psychological Outcome Profiles (PSYCHLOPS). Responsiveness to change was determined using effect size with improvement threshold ≥0.80. Instruments were compared using Bland–Altman plots. Results Our sample, n = 402; with 14 (3.5%) excluded for missing data; final sample, n = 388. All measures showed strong mean effect sizes: PSYCHLOPS 1.86 (95%CI 1.73–1.99), 75.8% ≥0.80; PSS 1.48 (1.34–1.62), 64.4% ≥0.80; WEMWBS 1.24 (1.13–1.35), 58.2% ≥0.80; GAD-7 1.07 (0.96–1.18), 52.8% ≥0.80; PHQ-9 0.86 (0.76–0.96), 52.8% ≥0.80. Findings were largely unchanged after stratification by diagnosis, presenting problem or therapy type. Fifty (12.9%) participants did not reach the threshold for improvement on any instrument. Bland–Altman plots indicated generally strong agreement between measures; combining PSYCHLOPS with WEMWBS maximised capture of improvement with only 3.6% of patients lying outside limits of agreement; GAD-7 was most likely to duplicate recovery scores of other measures. Conclusions Patients attending the NHS Practitioner Health service demonstrated high levels of improvement in mental health scores. The patient-generated instrument produced higher change scores than standardised instruments. Combining PSYCHLOPS and WEMWBS captured 96% of patients with above threshold improvement; GAD-7 added little to overall recovery measurement.

The provision of additional services in primary care: a cross-sectional study of incentivised additional services, social deprivation, and ethnic group.

Abstract: Background Primary care in England is contracted to provide essential services. Many practices also provide additional services, termed ‘directed enhanced services’ (DES), for extra income. The optional nature of DES may result in inequitable service delivery. Aim To determine the range of DES activity and equity of service provision. Design & setting A cross-sectional analysis of data from general practices in England took place from 2018–2019. Method DES were defined in terms of activity level and measured as total DES funding per registered patient. Linear regression modelling was used to explore the relationship between DES activity, practice, and population characteristics. Results Data were available for 6873 practices providing up to 10 DES in the initial sample. Due to negative funding amounts and a list size of ≤750 registered patients, 24 practices were excluded. Of the final sample (n = 6849), highest DES provision was for influenza and pneumococcal immunisation (99.9%), pertussis immunisation (97.9%), rotavirus and shingles immunisation (99.9%), meningitis immunisation (99.7%), and childhood immunisation (99.6%); lowest provision was for extended hours access (72.4%), violent patient services (2.0%), and out-of-area urgent care (1.3%). Mean DES funding was £6.25 per patient. In deprived areas, DES funding was £0.35 lower (95% confidence interval [CI] = £0.60 to £0.10) per patient (most versus least deprived quintiles); ethnic group-related differences were not significant. DES funding was higher in practices with more GPs or practice nurses per patient. In deprived communities, there was less immunisation activity (including influenza, pneumococcal, meningitis, childhood, and rotavirus and shingles immunisation) and provision of extended hours access; however, learning disability checks provision was greater in these communities. Conclusion DES provision is lower in deprived areas (notably for immunisations and some aspects of access) but higher in better staffed practices. Voluntary quality schemes may contribute to widening health inequalities.

Health condition at first fit note and number of fit notes: a longitudinal study of primary care records in south London.

Abstract: Objectives The fit note replaced the sick note in the UK in 2010, with the aim of improving support for patients requiring sickness absence, yet there has been very little research into fit note use. This study aims to describe number of fit notes by condition, to improve our understanding of patterns of fit note use in primary care. Previous fit note research has relied on extracting diagnoses directly from fit notes, rather than extracting information from clinical records. In this paper, we extract information from clinical records to explore demographic factors and conditions associated with number of fit notes issued. Design This is a longitudinal study of clinical data. We analysed individual-level anonymised data from general practitioner consultations, including demographic information and condition recorded at first fit note. The latter encompassed diagnoses, individual symptoms and psychosocial issues. Setting A database called Lambeth DataNet, containing electronic clinical records on 326 415 adults (ages 16–60) from all 45 general practices within the London Borough of Lambeth from 1 January 2014 to 30 April 2017. Participants Our analytical sample contained 40 698 people with a condition recorded at first fit note. Primary outcome measure Predicted number of fit notes in the period January 2014–April 2017 Results Of all studied diagnostic groups, mental illness had the highest predicted number of fit notes (n=3.3; 95% CI: 3.1 to 3.4) after controlling for demographic factors and long-term conditions. The highest predicted number of fit notes for any condition subgroup was among patients presenting for drug and/or alcohol misuse (n=4.5; 95% CI: 4.1 to 4.8). Conclusions For the first time, we show drug and/or alcohol misuse at first fit note are associated with the highest number of fit notes. Research is needed to understand the trajectories of individuals at highest risk of long-term sickness absence, in particular, people presenting with drug and/or alcohol misuse.

Access to mental healthcare in the year after first fit note: a longitudinal study of linked clinical records

Abstract: Objectives Sickness absence is strongly associated with poor mental health, and mental disorders often go untreated. In this population-based cohort study, we identified people receiving fit notes from their general practitioner (GP) and determined access to mental health treatment stratified by health complaint and demographic variables. Design Longitudinal study of health records. Setting Primary care and secondary mental health care in the borough of Lambeth, South London. Forty-five GP practices in Lambeth and the local secondary mental healthcare trust. Participants The analytical sample included 293 933 working age adults (16-60 years) registered at a Lambeth GP practice between 1 January 2014 and 30 April 2016. Primary and secondary outcome measures Three indicators of mental healthcare in the year after first fit note were antidepressant prescription, contact with Improving Access to Psychological Therapy (IAPT) services and contact with secondary mental health services. Results 75% of people with an identified mental health condition at first fit note had an indicator of mental healthcare in the following year. Black Caribbean and Black African groups presenting with mental disorders were less likely to have a mental healthcare indicator compared with White British groups. Conclusions The majority of those with an identified mental health need receive some treatment in the year following a fit note; however, our results suggest Black African and Black Caribbean groups with an identified mental healthcare need have less complete access compared to the White British group.

IT Evaluation of Foundation Healthcare Group Vanguard Project

Abstract: The aim of the Foundation Healthcare Group (FHG) Vanguard model was to develop a sustainable local hospital model between two National Health Service (NHS) Trusts (a London Teaching Hospital Trust and a District General Hospital Trust) that makes best use of scarce resources and can be replicated across the NHS, UK. The aim of this study was to evaluate the provision, use and implementation of the IT infrastructure; based on qualitative interviews and focused mainly on the perspectives of the IT staff and the clinicians' perspectives. In total 24 interview transcripts, along with 'Acute Care Collaboration' questionnaire responses, were analysed using a thematic framework for IT infrastructure, sharing themes across the vascular, paediatric and cardiovascular strands of the FHG programme. Findings indicated that Skype for Business had been an innovative and helpful development widely available to be used between the two Trusts. Clinicians initially reported lack of IT support and infrastructure expected at the outset for a national Vanguard project, but later appreciated that remote access to most clinical applications between the two Trusts became operational. The Local Care Record (LCR), an IT project was perceived to have been delivered successfully in South London. Shared technology reduced patient travelling time by providing locally based shared care. Spreading and scaling-up innovations from the Vanguard sites was the aspiration and challenge for system leaders.