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Showing posts from 2013

Opening hours of general practices in England

A letter published in the BMJ discusses the question: should general practices open for longer?’  The recent proposal for GPs in England to see patients from 8 am to 8 pm, seven days a week [2] tells us little about how much longer the hours in which GPs provide consultations would become. We therefore analysed data, obtained from NHS Choices [3] on 1st October 2013, on the ‘surgery’ (as opposed to ‘reception’) opening hours for 8,973 general practices in England.

Surgery opening hours currently total 341,857 hours per week; the median value is 40 hours per week. The median for opening hours outside of core hours (8 am to 6.30 pm, Monday to Friday) is 1.25 per week.

If the Government’s proposal was implemented nationally in each general practice, surgery opening hours would total 753,732 hours per week (a 120% increase). Each practice would provide consultations during 84 opening hours (a 110% increase over the current median), and 31.5 hours outside of core times (as defined above; …

Multidisciplinary integration in the context of integrated care

In the context of integrated care, Multidisciplinary Group meetings involve participants from diverse professional groups and organisations and are potential vehicles to advance efficiency improvements within the local health economy. We developed a novel method to characterise the communication within Multidisciplinary Group meetings measuring the extent to which participants integrate and whether this integration leads to improved working. The findings of the study were published in the International Journal of Integrated Care.

We purposively selected four Multidisciplinary Group meetings and conducted a content analysis of audio-recorded and transcribed Case Discussions. Two coders independently coded utterances according to their ‘integrative intensity’ which was defined against three a-priori independent domains - the Level (i.e. Individual, Collective and Systems); the Valence (Problem, Information and Solution); the Focus (Concrete and Abstract). Inter- and intra-rater reliabi…

No need for GPs to be over-awed by the members of the Shelford Group

The 10 NHS Trusts that are members of the Shelford Group see themselves as members of an elite group. But the members of this elite can be dealt with by general practitioners (GPs) and clinical commissioning groups. Here are my tips on how GPs and CCGs can do this.

1. Form your own consortia. General practices can work in federations and networks to share resources and expertise. CCGs can come together in joint commissioning activities. Working in larger groupings - whether it is of general practices or CCGs - will give you more bargaining power and greater consolidation of expertise to challenge the members of the Shelford Group.

2. Become skilled in using the language of evidence-based medicine, healthcare evaluation and data-driven healthcare in your dealings with the managers of the Shelford Group NHS Trusts. You will soon discover that many NHS managers are poorly trained in these essential components of modern healthcare delivery and in using NHS data to evaluate the performanc…

Diabetes in the Middle-East and North Africa: An update for 2013 for the IDF Diabetes Atlas

An article in the journal Diabetes Research and Clinical Practice looks at the current state and future predictions of diabetes in the Middle-East and North Africa. In recent decades, the prevalence of diabetes has risen dramatically in many countries of the International Diabetes Federation's (IDF) Middle-East and North Africa (MENA) Region. This increase has been driven by a range of factors that include rapid economic development and urbanisation; changes in lifestyle that have led to reduced levels of physical activity, increased intake of refined carbohydrates, and a rise in obesity. These changes have resulted in the countries of MENA Region now having among the highest rates of diabetes prevalence in the world. The current prevalence of diabetes in adults in the Region is estimated to be around 9.2%. Of the 34 million people affected by diabetes, nearly 17 million were undiagnosed and therefore at considerable risk of diabetes complications and poor health outcomes. Enhanc…

Obesity paradox in people newly diagnosed with type 2 diabetes

Recent studies have raised the issue of ‘obesity paradox’ in patients with type 2 diabetes mellitus (T2DM). Sanjoy Paul and colleagues evaluated the cardiovascular and mortality risks associated with normal and overweight patients compared to obese at diagnosis of diabetes, separately for patients with and without cardiovascular disease (CVD) before diagnosis. The study was published in the journal Diabetes, Obesity and Metabolism.

They carried out a retrospective study with two study cohorts with/without prior CVD with complete measures of body mass index (BMI) at diagnosis of T2DM from UK General Practice Research Database. Primary outcomes were long-term risks of cardiovascular events (CVEs) and all-cause mortality in patients with normal weight, overweight and obesity at diagnosis.

They reported that mortality rates per 1000 person-years in normal weight, overweight and obese patients among patients without prior CVD were 13.1, 8.6 and 6.0, respectively, during 5 years of median …

Increasing the use of statins in people at low cardiovascular risk is difficult

Although statins reduce cardiovascular events even in people at low risk,[1] population benefits from their more widespread use will occur only if a sufficiently high proportion of people at lower cardiovascular risk (whether based on a formal risk assessment or on age alone) are prescribed statins.[2] Some of these issues were discussed in a commentary published in the BMJ.

Early evidence from the NHS Health Check programme suggests that it will be difficult to achieve high statin uptake in people at low cardiovascular risk. NHS Health Check is a population-wide primary prevention programme that was established in England by the Department of Health in 2009.[3] The programme represents a major investment in the prevention and early detection of cardiovascular disease.

In early results from the programme, prescription of statins in people at high cardiovascular risk (≥20%) increased from around 25% to only 45%.[4] The prescription of statins is likely to be substantially lower than 4…

Deprivation, risk of emergency readmission and inpatient mortality in people with sickle cell disease

Sickle cell disease (SCD) is a frequent cause of emergency readmissions. In a paper published in the Journal of Public Health, Ghida Aljuburi and colleages examined trends in SCD emergency readmissions and inpatient mortality in England in relation to socio-economic status.

Data from Hospital Episode Statistics were extracted for all SCD patients admitted in 2005/06. The financial year 2005/06 was taken as the index year for analysis. We calculated readmission rates and inpatient mortality for patients admitted with a primary or secondary diagnosis of sickle cell anaemia with crisis and without crisis in the index year during the subsequent 5 years (2006/07–2010/11). Charlson Score was used to measure comorbidity. Using Cox proportional hazards models, we also examined the relationship between patient characteristics and both emergency readmissions and inpatient mortality.

In 2005/06, there were 7679 SCD index admissions. Over the subsequent 5-year period, patients living in the most…

Ethnicity and prediction of cardiovascular disease

Risk prediction is one of the key strategies for the prevention of cardiovascular disease (CVD). Two of the main CVD risk calculators in use in the United Kingdom are QRISK2 and Framingham. In a paper published in Heart, the SABRE Study Group evaluated the performance of the QRISK2 and Framingham scores as predictors of CVD outcomes over 10 years of follow-up in European, South Asian, and African Caribbean men and women in a UK population based cohort in West London. The sample was obtained by randomly selecting from local general practices. Follow-up data were available for 87% of traced participants, comprising 1866 white Europeans, 1377 South Asians, and 578 African Caribbeans.

The outcome measures included in the study were myocardial infarction, coronary revascularisation, angina, transient ischaemic attack or stroke reported by participant, primary care or hospital records or death certificate. During follow-up, 387 CVD events occurred in men (14%) and 78 in women (8%). Both QRI…

Unscheduled care in the UK and USA

In a publication in the Annals of Internal Medicine, Thomas Cowling and colleagues describe how discussion of acute unscheduled care in the United States resembles the debate on the same topic in England, where the National Health Service is conducting a comprehensive review of unscheduled care services.

In England, general practices staffed by primary care physicians and hospital emergency departments (EDs) form the 2 “silos of acute care delivery”. Approximately 9% of patients who try but are unable to obtain a convenient appointment at their general practice office subsequently visit an emergency department. Consequently, recent national policies have attempted to improve access to general practice, using financial incentives to reduce demand for acute unscheduled care at emergency departments.

A potential unintended consequence of expanding alternative care settings is that the “question of where patients with acute care needs should go for unscheduled care” becomes more confusin…

Life expectancy at birth and at age 65 in England and Wales

Life expectancy at birth has been used as a measure of the health status of the population of England and Wales since the mid-nineteenth century. Recently published statistics from the UK Office for National Statistics show that the long-standing North-South divide in distribution of life expectancy across England continues, with people in the North of England generally living shorter lives than those living in the south.

Life Expectancy at Birth
Male life expectancy at birth was highest in East Dorset (82.9 years) and lowest in Blackpool (74.0 years). For females, life expectancy at birth was highest in Purbeck at 86.6 years and lowest in Manchester at 79.5 years. Life expectancy at birth increased across England and Wales by 1.3 years for males and 1.0 year for females between 2006–08 and 2010–12. This is part of a long-standing trend of improving life-expectancy, which is leading to a gradual increase in the average age of the population of England and Wales, and the elderly forming…

Cancer has replaced cardiovascular disease as the commonest cause of avoidable mortality

A recent analysis of causes of potentially avoidable deaths in England and Wales by the Mortality Team at the Office for National Statistics (ONS) showed that cardiovascular diseases were the largest cause of avoidable deaths between 2001 and 2006. In 2007, cancers became the leading cause of avoidable deaths and have remained so since then.

This change in ranking has occurred because deaths from cardiovascular diseases have been falling for many years. Deaths from cancer in contrast have been falling much more slowly than deaths from cardiovascular disease and cancer has therefore now become the commonest cause of avoidable deaths. The rapid decline in age-standardised death rates from cardiovascular diseases have been driven by a range of factors. These include medical (e.g. statins) and surgical treatments (e.g. angioplasty); and changes in lifestyle (such as a reduction in the prevalence of smoking).

The findings of this very useful analysis by the ONS illustrate the need to maint…

mHealth project in Zhao County, rural China

In a paper published in the Journal of Global Health, Michelle van Velthoven and colleagues describe a a collaboration between researchers in China and the UK that aimed to explore the use of mHealth in China. This is the first paper in a series of papers on a large mHealth project part of this collaboration. This paper includes the aims and objectives of the mHealth project, our field site, and the detailed methods of two studies. This large mHealth project is part of a collaboration between researchers in China and the UK. The mixed methods study evaluating factors that influence sample size calculations could help future studies with estimating reliable sample sizes. The cross–over study comparing face–to–face and text message survey data collection could help future studies with developing their mHealth tools.

Simon Stevens appointed as the Chief Executive of the NHS in England

Simon Stevens has been appointed as the new Chief Executive of the NHS in England and will start in his post in April 2014. Stevens is the Executive Vice President of UnitedHealth Group and President for Global Health. He has been based in the USA in recent years. He has formerly worked as a NHS manager in England and as an adviser to Tony Blair when he as Prime Minister. Professor Malcolm Grant, Chairman of NHS England, said that Mr Stevens was the best man for the job because he could bring experience from many different models of healthcare delivery. His appointment has brought a mixed reaction in England. Many people view his appointment as NHS Chief Executive as a positive step, viewing him as someone who will bring innovative ideas and ways of working. Others are more wary and are concerned he may push further marketization and models of healthcare delivery derived from the USA.

Sophie Coronini-Cronberg invited to join Royal College of Ophthalmologists Working Group

Following the publication of her paper, "Evaluation of clinical threshold policies for cataract surgery among English commissioners", in the Journal of Health Services Research and Policy, Sophie Coronini-Cronberg (Honorary Clinical Research Fellow in the Department of Primary Care & Public Health at Imperial College London) has been invited by the Royal College of Ophthalmologists to join its working group responsible for developing cataract surgery commissioning guidance. The work is due to be completed by the end of this year.

Health policies should incorporate public health priorities

In a letter published in the British Medical Journal (BMJ), Michale Soljak, Chris Millett and I discuss the call by Krogsbøll to abandon the NHS Health Check Programme.As members of one of the research teams evaluating the national programme, we challenge their view that a randomised controlled trial (RCT) of the current programme should be the sole arbiter on which to base national health policy decisions. As noted in comments on the Cochrane review, the dearth of RCTs of screening for cardiovascular (CVD) risk since 1999 is unfortunate, but there were many RCTs of individual screening components over this period that have been used in subsequent NICE guidance.

There are other reasons why Krogsbøll et al’s views should be challenged. Firstly, RCTs are expensive and time-consuming, and as a result, a lack of evidence from RCTs may deprive millions of people of potential benefits from interventions.  RCTs should therefore be complemented where possible by well-validated modelling stud…

Arguments in Favour of a Salaried GP Service

The independent contractor model has been at the core of general practice in the UK since the NHS was first established and this model has many strengths. For example it has allowed the development of a s strong primary care sector that has allowed the NHS to operate efficiently - NHS general practices have typically used between 8-10% of the total NHS budget and dealt with up to 90% of all patient contacts with the NHS. However, in recent years, general practices have come under increasing pressure through a combination of rising workload, increased complexity of care, and a reduction in the resources allocated to primary care.

Many general practitioners now find themselves struggling to cope with their day to day workloads. This makes it difficult for patients to gain timely access to their general practices and in turn increases pressure on other parts of the NHS, such as Emergency Departments. We are also now seeing a divide developing in the profession between salaried GPs and G…

Text messages can help prevent type 2 diabetes

Text messages that encourage the recipient to eat healthily and exercise can help prevent type 2 diabetes in people at high risk, a study has found. Researchers from Imperial College London and the India Diabetes Research Foundation recruited 537 men in South-East India with impaired glucose tolerance, a condition that commonly precedes type 2 diabetes. Half received frequent text messages reminding them to eat healthily and be physically active, while the other half had standard care from their doctor.

After an average of 20 months’ follow-up, 18 per cent of the text message group developed type 2 diabetes, compared with 27 per cent of the control group. The findings were published in the journal Lancet Diabetes and Endocrinology. The messages included practical tips for healthy eating and reminders about the importance of exercise. They were also tailored to the individual’s behaviour. Those with the most unhealthy lifestyles were given information about the benefits of good habits…

Arguments in Favour of an Independent Contractor Model of General Practice

I have written an article on why GPs should consider giving up their independent contractor status and become NHS employees, which was published in Pulse. In this blog post, I will make the opposing argument and will list reasons why we should retain the current independent contractor model of general practice. This will be helpful for those GPs who are against the proposal that we should become NHS employees but who are unable to put together a coherent or logical counter-argument. If anyone has further arguments in favour of the independent contractor model, please let me know and I will add them to the list.

1- The independent contractor model is very efficient. For between 8-10% of NHS spending, general practices deal with up to 90% of patient contacts in the NHS.

2- Because GPs are not NHS employees, they have more freedom to act as patient advocates and to speak up about deficiencies in the NHS.

3- The independent contractor model gives GPs a stake in their practices and encour…

Low rate of adverse events recorded in English primary care

A study by Dr Carmen Tsang and colleagues at Imperial College London has found a low incidence of patient safety incidents recorded in general practice. The research, which was published by the British Journal of General Practice, measured the extent of patient safety incidents recorded in 74 763 patients at 457 English general practices between 1999 and 2008, and the patient characteristics associated with these adverse events.

Older patients, those with more comorbid diseases or who had more previous emergency admissions to hospital were at greater risk of complications of care. Dr Carmen Tsang, lead author of the paper, says “Our finding of a low incidence of patient harm in general practice supports previously published studies. To better understand these adverse events, we must also examine the healthcare interactions from which they originate, and consider how to reduce the incidents that are potentially preventable”.

Outcomes following adverse events, including emergency admis…

Improving Access to Psychological Therapies and antidepressant prescribing rates in England

Antidepressant prescribing rates in England have been increasing since the 1970s. The impact of the Improving Access to Psychological Therapies (IAPT) initiative on antidepressant prescribing rates is unknown. In a paper published in the British Journal of General Practice, Vaishnavee Sreeharan and colleagues from Imperial College London investigated the impact of the establishment of IAPT services on antidepressant prescribing rates in primary care trusts (PCTs) in England.  They used a longitudinal time-series analysis, using PCT-level data from 2008 to 2011. They reported that antidepressant prescribing rates in England increased by 10% per year during the study period. The implementation of IAPT services had no significant effect on antidepressant prescribing. They concluded that the introduction of a large-scale initiative to increase provision of psychological therapies has not curbed the long-term increased prescribing of antidepressants in England. You can read commentaries o…

Fairer Funding Model Needed for UK General Practice

In an article published in the Journal of the Royal Society of Medicine, I discuss some of the current challenges facing general practitioners in the UK, such as rising workload, increasingly complex patients, and reductions in budgets. In the article, I also discuss options for tackling these challenges. These include a fairer funding model for general practice that links patients needs and practices' workloads more closely to funding. Other options discussed in the article include the creation of practice federations or 'super partnerships' and the transfer of GPs from their current independent contractor status to becoming NHS employees on similar terms to other senior doctors working for the NHS. Many GPs (including my own colleagues in South London) are struggling to manage their workload with their current practice budgets; and this could have serious implications for patients, the public and the NHS. We do therefore need a serious debate about the future of primary…

Patient and Public Views on Electronic Health Records and Their Uses

The development and implementation of electronic health records (EHRs) remains an international challenge. Better understanding of patient and public attitudes and the factors that influence overall levels of support toward EHRs is needed to inform policy. In a paper published in the Journal of Medical of Medical Internet Research, Serena Luchenski and colleagues reported the findings of a study that explored patient and public attitudes toward integrated EHRs used simultaneously for health care provision, planning and policy, and health research.

They carried out a cross-sectional questionnaire survey administered to patients and members of the public who were recruited from a stratified cluster random sample of 8 outpatient clinics of a major teaching hospital and 8 general practices in London . 5331 patients and members of the public responded to the survey, with 2857 providing complete data for the analysis presented here. There were moderately high levels of support for integrat…

The provision and impact of online patient access to their electronic health records (EHR) and transactional services

A paper published in the journal Informatics in Primary Care describes the protocol for a systematic review of the provision and impact of online patient access to their electronic health records (EHR) and transactional services on the quality and safety of health care. The review aims to assess the factors that may affect the provision of online patient access to their EHR and transactional services, and the impact of such access on the quality and safety of health care. Developers have piloted improvements in communication, changed patterns of practice and patient empowerment from online access to electronic health records. International studies of online services, such as prescription ordering, online appointment booking and secure communications with primary care, show good uptake of email consultations, accessing test results and booking appointments; when technologies and business process are in place. Online access and transactional services are due to be rolled out across Eng…

Cancer diagnosed by emergency admission in England

Patients diagnosed with cancer by the emergency route often have more advanced diseases and poorer outcomes. Rates of cancer diagnosed through unplanned admissions vary within and between countries, suggesting potential inconsistencies in the quality of care. To reduce diagnoses by this route and improve patient outcomes, high risk patient groups must be identified. In a paper published in BMC Health Services Research, Carmen Tsang and colleagues report the results of a cross-sectional observational study that determined the incidence of first-ever diagnoses of cancer by emergency (unplanned) admission and identified patient-level risk factors for these diagnoses in England.

Data for 74,763 randomly selected patients at 457 general practices between 1999 and 2008 were obtained from the General Practice Research Database (GPRD), including integrated Hospital Episode Statistics (HES) data and Office for National Statistics (ONS) mortality data. The proportion of first-ever diagnoses by…

Managing routinely collected NHS data for research

Health research using routinely collected National Health Service (NHS) data derived from electronic health records (EHRs) and health service information systems has been growing in both importance and quantity. Wide population coverage and detailed patient-level information allow this data to be applied to a variety of research questions.

The sensitivity, complexity and scale of such data also hamper researchers from fully exploiting this potential. In an article published in the journal Informatics in Primary Care, Vasa Curcin and colleagues examine the current challenges preventing researchers from making optimal use of the data sets at their disposal, on both the legislative and practical levels, and give recommendations as to how these challenges can be overcome.

Several projects have recently been launched in the UK to address poor research data-management practices. Rapid Organisation of Healthcare Research Data (ROHRD) at Imperial College, London produced a useful prototype t…

Primary care and population factors associated with NHS Health Check coverage

High and equitable coverage of systematic cardiovascular disease (CVD) prevention programmes, such as the NHS Health Check programme in England, is essential if they are to effectively reduce the population CVD burden. In a paper published in the Journal of Public Health, Macide Artac report the findings of a cross-sectional study using data from 151 English primary care trusts (PCTs) on NHS Health Check coverage during 2011–12. They examined the associations between programme coverage and primary care and population factors, including patient demographics, primary care workforce and cardiovascular health need.

Artac and colleagues reported that the median coverage of NHS Health Checks was 8.2%, with wide PCT-level variation (range = 0–29.8%). Coverage was significantly higher in PCTs in the most deprived areas compared with the least deprived, after adjusting for covariates. Significant negative associations between coverage and a higher proportion of PCT population aged 40–74 years…

Admission rates for heart failure in England 2004–2011

Heart failure is an important clinical problem. Expert consensus has defined heart failure as a primary care-sensitive condition for which the risk of unplanned admissions may be reduced by high quality primary care, but there is little supporting evidence. In a paper published in the European Journal of Heart Failure, Rachel Brettell and colleagues analysed time trends in Heart failure admission rates in England and risk and protective factors for admission.

They used Hospital Episodes Statistics to produce indirectly standardized HF admission counts by general practice for 2004–2011. Clustered negative binomial regression analysis produced admission risk ratios and assessed the significance of potential explanatory covariates. These included population factors (deprivation; HF, coronary heart disease, and smoking prevalence), primary care resourcing [access; general practitioner (GP) supply], and primary care quality (‘Quality and Outcomes Framework’ indicator.) There were 327,756 …

A mixed methods evaluation of the Integrated Care Pilot in North-West London

The North-West London Integrated Care Pilot (ICP), originally launched for one year in July 2011 and later extended for a further year, is a large-scale change programme involving two hospitals, two mental health providers, three community health care service providers, five municipal providers of social care, two non-governmental organisations and (by April 2012) 103 general practitioners. Its aims are to improve health outcomes and reduce unnecessary admissions to hospital by pro-actively managing people living with diabetes and/or those aged 75+ through creating better access to more integrated care outside hospital and by enabling effective working of professionals across organisations.  In a paper published in the International Journal of Integrated Care, researchers from Imperial College London and the Nuffield Trust describe the results of the evaluation of the first year of the programme. The evaluation was funded by the Imperial College Healthcare NHS Trust Charity and the N…

Use of emergency departments

The use of emergency departments is a prominent policy issue in both England and the USA. In a letter published in JAMA, Thomas Cowling and I compare the use of emergency departments in the two countries. The annual number of hospital ED visits in England increased from 15.4 million in 2007-2008 to 18.4 million in 2011-2012.1 The patient was given advice only or did not receive treatment in approximately 48% of these ED visits, and no investigations were performed in approximately 40% of ED visits.

Patterns of healthcare use among adolescents attending an urban general practitioner-led urgent care centre

Adolescence is a time of increasing health and peak fitness, as well as increasing health risks. In the UK, primary care is free at the point of access, yet, adolescents aged 10-19 years are the lowest users of primary care services, and disproportionately high users of emergency services. The effect of new general practitioner (GP)-led urgent care centres in meeting the needs of adolescents are unknown. In a paper published in the Emergency Medicine Journal, Shamini Gnani and colleagues examined the demographics and attendance pattern among adolescents at two new co-located GP-led urgent care centres at Hammersmith and Charing Cross Hospitals, London. They also compared attendance rates with those observed in routine general practice and emergency departments.

They reported that adolescents formed 6.5% of total urgent care attendances. 13.2% were recorded as not being registered with a GP. Commonest reasons for attendance were musculoskeletal conditions and injuries (30.2%), respira…

Computerised decision support systems for healthcare professionals

Computerised decision support systems are designed to support clinicians in making decisions and thereby enhance the quality and safety of care. In a systematic review published in Informatics in Primary Care, Kathrin Cresswell and her co-authors describe the results of an interpretative review of the empirical evidence on computerised decision support systems, their contexts of use, and summarise evidence on the effectiveness of these tools and insights into how these can be successfully implemented and adopted.

Cresswell and collagues concluded that whilst the potential of clinical decision support systems in improving, in particular, practitioner performance is considerable, such technology may also introduce new risks resulting not only from technical challenges (such as data inaccuracies) but also from disruption of clinical workflows. Moving forward, there is a need for system development, procurement and implementation to be characterised by a user 'pull' and then tail…

One year evaluation of a cardiovascular disease risk assessment program

In a study published in the journal Preventive Medicine, Macide Artac and colleagues assessed whether the National Health Service (NHS) Health Check, a systematic cardiovascular disease (CVD) risk assessment and management program, was associated with reduction in CVD risk in attendees after one year. They used data on patients aged 40–74 years, with high estimated CVD risk, who were registered with general practices in a deprived, culturally diverse setting in England. They included 4748 patients at baseline (July 2008–November 2009), with 3712 at follow-up (December 2009–March 2011). They used a pre–post study design to assess changes in global CVD risk, individual CVD risk factors and statin prescription in patients with a complete and partial Health Check.

There were significant reductions in mean CVD risk score (28.2% to 26.2%), diastolic blood pressure, total cholesterol levels and lipid ratios after one year in patients with a complete Health Check. Statin prescription increas…

Evaluation of a general practitioner-led urgent care centre

Demand for urgent care in England continues to rise with increasing numbers of attendances at emergency departments, and the associated growth in unplanned hospital admissions and healthcare costs. With NHS budgets under severe pressure, using emergency services appropriately will be important in an era of financial austerity in healthcare.

Estimates of patients attending with conditions deemed non-urgent or inappropriate for accident and emergency services vary widely, from 6 to 80%. Previous research suggests that general practitioners (GPs) working in emergency departments can reduce referral rates, diagnostic testing, the proportion of patients who become emergency hospital admissions, and inappropriate attendances. However, little of this previous research is recent (much of it was published nearly 20 years ago) and new models of care for GPs working in and alongside emergency departments have now been developed, which remain to be evaluated.

In a paper published in JRSM Short Re…

Rise in children treated for obesity-related conditions

In a paper published in the journal PLoS One, Dr Jessica Jones Neilsen and colleagues from the Department of Primary Care & Public Health at Imperial College London reported that the number of children admitted to hospital for problems related to obesity in England and Wales quadrupled between 2000 and 2009. Nearly three quarters of these admissions were to deal with problems complicated by obesity such as asthma, breathing difficulties during sleep, and complications of pregnancy, rather than obesity itself being the primary reason. Although some of the increase is likely to be due to improved case ascertainment, conditions associated with obesity in children and young people are imposing greater challenges for health care providers in English hospitals.

The authors concluded that most inpatient care is directed at dealing with associated conditions rather than primary assessment and management of obesity itself. With levels of admissions for obesity-related diagnoses rising, th…

Fewer A&E visits where access to GPs is better

Patients with more timely access to general practitioner (GP) appointments make fewer visits to accident and emergency departments, suggests a study published in the journal PLoS One. The findings of the article reinforce the need for more investment in GP services. People living in more affluent areas areas also had lower rates of use of A & E. Improving access to GPs by employing more GPs in deprived, urban areas and giving primary care teams more resources could help improve access to health services, improve quality of care and reduce pressures on other parts of the NHS.

Lead author Thomas Cowling, from the School of Public Health at Imperial College London, said: “This is the first national evidence of an association between access to GP appointments and rates of A&E attendances in England. Policy makers should consider this relationship when designing plans to reduce the use of A&E departments. A new era of service commissioning, led by GPs, has just started in the …

Health research in the Eastern Mediterranean Region

Countries across the Eastern Mediterranean Region face unprecedented health challenges, and are buffeted by demographic change, a dual disease burden, rising health costs, and the effects of ongoing conflict and population movements – exacerbated in the near-term by instability arising from recent political upheaval in the Middle East. However, health agencies in the region are not well positioned to respond to these challenges because of a dearth of good quality health research.

An article published in the Journal of the Royal Society of Medicine by Professor Salman Rawaf and colleagues presents an assessment of the current state of health research systems across the Eastern Mediterranean based on publicly available literature and data sources. The review finds that – while there have been important improvements in productivity in the Region since the early 1990s – overall research performance is poor with critical deficits in system stewardship, research training and human resource…

Ethnic group differences in cardiovascular risk assessment scores

There are marked inequalities in cardiovascular disease (CVD) incidence and outcomes between ethnic groups. CVD risk scores are increasingly used in preventive medicine and should aim to accurately reflect differences between ethnic groups. Ethnicity, as an independent risk factor for CVD, can be accounted for in CVD risk scores primarily using two methods, either directly incorporating it as a risk factor in the algorithm or through a post hoc adjustment of risk. In a study published in the journal Ethnicity & Health, Andrew Dalton and colleagues compared these two methods in terms of their prediction of CVD across ethnic groups using representative national data from England.

They carried out a cross-sectional study using data from the Health Survey for England. We measured ethnic group differences in risk estimation between the QRISK2, which includes ethnicity and Joint British Societies 2 (JBS2) algorithm, which uses post hoc risk adjustment factor for South Asian men. They r…

Evaluation of the Inner North West London Integrated Care Pilot

Researchers from Imperial College London and the Nuffield Trust have published the findings from an evaluation of the first year of a project designed to deliver more integrated care to patients in North West London. The Inner North West London Integrated Care Pilot is a large-scale programme focused on developing new models of care planning and coordination for people with diabetes and those who are over 75 years of age. The pilot is being implemented at a time of major reform of the NHS in England, and has been the subject of significant attention among policy makers and commissioners wanting to encourage new models of integrated care.

The benchmarks set in this first evaluation report provide a sound basis for the pilot to assess its progress against, particularly in relation to activity, cost, and health outcomes. The pilot was evaluated by Imperial College London and the Nuffield Trust between September 2011 and July 2012, with funding from the Imperial College Healthcare Charit…

Improving telephone consultation skills in clinicians

The ability to consult by telephone is now an integral part of any modern patient-centred healthcare system and the British Medical Association (BMA) has provided guidance for general practitioners (Consulting in the modern world, which was published in 2001). The BMA concludes that "telephone consultations when correctly conducted can be considered to be safe and acceptable practice". In a protocol for a Cochrane Review, Rumant Grewal and colleagues explain how they will identify and measure the effectiveness of interventions that aim to improve the clinician telephone consultation skills of clinicians. Grewal and colleagues believe that their review will provide evidence about the most effective interventions for improving telephone consultation skills and thereby improve both quality of care and patients' experiences of their health care.

Care for People with Type 2 Diabetes in the UAE

The United Arab Emirates has one of the the highest prevalences of diabetes in the world. Improving the care of people with Type  2 diabetes is therefore a priority for its health system. In a paper published in JRSM Short Reports, Layla Alhyas and colleagues aimed to identify facilitators of and barriers to healthcare professionals' motivation in a specialist diabetes centre. A qualitative research approach was employed using semi-structured interviews to assess perceptions and attitudes regarding healthcare professionals' motivation in providing good quality diabetes care. The participants included specialist physicians, dieticians, podiatrists, health educators and nurses.

Important facilitators and barriers related to patient, professional, organization and cultural factors were identified. Barriers that related to heavy workload, disjointed care, lack of patient compliance and awareness, and cultural beliefs and attitudes about diabetes were common. Key facilitators incl…

Rotavirus Vaccination for Babies

Over the course of 2013-14, a new national vaccination programme for Rotavirus will be introduced for babies. The vaccine (Rotarix) will be given to babies at two months of age, followed by a second dose at three months of age. Rotavirus is a virus that causes gastroenteritis, leading to diarrhoea and vomiting, in particular in infants and young children. Almost all children have had a Rotavirus infection by the time they are 5 years old, with the maximum risk of infection occurring at around one year of age. Many children with Rotavirus infection will be managed by their parents without needing medical treatment but around 130,000 children will see their general practitioner each year because of Rotavirus infection and around 12,700 children will be admitted to hospital. The new vaccination programme should substantially reduce both the number of children infected with Rotavirus and the number of children admitted to hospital each year. Early studies suggest that the vaccine is safe…

Multidisciplinary Group Performance in an Integrated Care Pilot

Multidisciplinary Group Meetings (MDGs) are seen as key facilitators of integration, moving from individual to multi-disciplinary decision-making, and from a focus on individual patients to a focus on patient groups. In an article published in the International Journal of Integrated Care, Matthew Harris and colleagues describe the development of a method for coding MDG transcripts to identify whether they are or are not vehicles for delivering the anticipated efficiency improvements across various providers and apply it to a test case in the North West London Integrated Care Pilot.

Harris and colleagues defined ‘integrating’ as the process within the MDG meeting that enables or promotes an improved collaboration, improved understanding, and improved awareness of self and others within the local healthcare economy such that efficiency improvements could be identified and action taken. Utterances within the MDGs are coded according to three distinct domains grounded in concepts from co…

Use of interrupted time series analysis in biomedical research

Although randomized control trials (RCTs) are the ‘gold standard’ to evaluate treatment effects in health care, they are frequently not practical, ethical or politically acceptable in the evaluation of many health system or public health interventions. In the absence of an RCT, evaluations often use quasi-experimental designs such as a pre-post study design with measurements before and after the intervention period, such as interupted time series (ITS). An ITS compares the intercept and slope of the regression line before the intervention with the intercept and slope after intervention. A one-time baseline effect of the intervention without influencing the secular trend can be detected as an intercept change. If the intervention changed the secular trend, there will also be a significant difference in the slope between the two periods. Use of ITS in biomedical research is described in more detail in an article published by Utz Pape and colleagues in the Journal of the Royal Society o…

Uptake of the NHS Health Check programme in an urban setting

The NHS Health Check programme aims to improve prevention, early diagnosis and management of cardiovascular disease (CVD) in England. High and equitable uptake is essential for the programme to effectively reduce the CVD burden. In a study published in the journal Family Practice and reported on by Pulse, Macide Artac and colleagues assessed the impact of a local financial incentive scheme on uptake and statin prescribing in the first 2 years of the programme. They carried out a cross-sectional study using data from electronic medical records of general practices in Hammersmith and Fulham, London on all patients aged 40–74 years. They assessed uptake of complete Health Check, exclusion of patients from the programme (exception reporting) and statin prescriptions in patients confirmed with high CVD risk.

They reported that Health Check uptake was 32.7% in Year 1 and 20.0% in Year 2. Older patients had higher uptake of Health Check than younger (65- to 74-year-old patients: The percent…