Medical Centre

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 prototy...

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 year...

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 Failur e, 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 we...

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 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.

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%), respi...

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 ta...

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 inc...

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 Shor...

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 diagnos...

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 ...

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 resour...

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. ...

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 Char...

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. 

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 in...

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 vacci...

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 ...

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 of...

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 ...