Medical Centre

There is increasing recognition on the importance of measuring outcomes in health care. One method of doing this is through the use of Patient Reported Outcome Measures (PROMs). These are indicators that measure quality from the patient perspective. A recent letter published in the British Medical Journal discussed the role of PROMs in promoting equity of access to elective health care. Preoperative measurement of PROMS, which is now routine for some NHS-funded procedures, can provide information about perceived needs and how this varies across referred populations by deprivation score or other socio-demographic factors. We already know that for some interventions, including hip replacement, postoperative improvement is strongly associated with preoperative PROM disease severity. This is demonstrated by data from the English hip replacement audit in the figure above. Using PROMs as part of an intervention threshold in elective surgery could improve both equity and efficiency, and thei...

Diabetic foot lesions remain a considerable cause of ill-health and a leading cause of hospitalization in people with diabetes. Unfortunately, despite intensive self-care and NHS treatment, many people with diabetes will eventually reach the stage when they need an amputation. Undergoing an amputation has a major social and psychological impact on patients, as well as considerable financial costs for health systems. In a recent study published in the journal Diabetes Care , Eszter Vamos and colleagues examined time trends in rates of amputation in people with diabetes aged over 16 years between 2004 and 2008 using national hospital activity from data from all NHS hospitals in England. They found an increase in the number of people with diabetes undergoing amputations. This was largely due to the increased prevalence (i.e. increased number of patients) with diabetes.  The findings illustrate the need to continue to improve the quality of care of people with diabetes to reduce the ri...

National Health Service Health Checks is a population-wide primary prevention programme for cardiovascular disease in England. The Department of Health began to implement the programme nationally in April 2009. The programme is delivered locally by primary health care teams and involves offering a ‘health check’ to all persons aged 40–74 years without diagnosed cardiovascular disease or diabetes. The health check includes measurement of body mass index (BMI), blood pressure, smoking status and lipid levels. A recent paper published in the journal Family Practice examined the current level of risk factor recording in one part of London and how this varied with patient characteristics. The study also sought to quantify the likely workload for primary care teams in England of the new Health Checks programme. The study found that the recording of smoking status and blood pressure was very high in the electronic medical records of people without existing cardiovascular disease o...

Obesity is a major public health issue because of its increasing prevalence and impact on health. For example, as well as its impact on conditions such as high blood pressure and coronary heart disease, obesity is now also an important risk factor for cancer and liver dieases. The management of overweight and obesity has therefore been a government priority for many years. However, overweight and obesity management at a local level has often been ineffective. Although there is a need to examine obesity strategies and policies for local populations, there is currently no readily available framework for evaluating local obesity strategies. Researchers at Imperial College, led by Nik Tuah, therefore developed a framework, the Imperial College Obesity Strategy Assessment Framework (IC-OSAF) , for examining the content of local obesity strategies. The IC-OSAF was developed by adapting two previous policy analysis frameworks (Bardach’s Eightfold Path Framework and Collins’ Health Policy An...

A study by Elaine Burns and colleagues published in the BMJ  describes the large increase in NHS laparoscopic bariatric surgery operations observed in recent years, with an increase from 238 operations in 2000 to 2543 in 2007. Recent years have also seen large increases in NHS prescribing and spending on drugs for obesity. For example, a study published in the Journal of Public Health Medicine reported that between 1998 and 2005, Orlistat prescriptions in England rose 36-fold from 17,880 to 646,700 and their total cost increased by over 35-fold to £27 million. Sibutramine prescriptions rose from 53,393 in 2001 to around 227,000 in 2005, a 4-fold increase, at a cost of £11 million in 2005.Despite this increased spending on medical and surgical NHS interventions, rates of obesity continue to increase inexorably and around 25% of adults in England are now considered to be obese, with a BMI of 30 or greater.The failure of medical treatments for obesity is further illustrated by t...

A recent World Health Organization (WHO) Working Group that I chaired examined the potential of information technology to improve patient safety. The report from the working group was published in the journal Quality & Safety in Healthcare . Previous research has identified as significant issues the substantial variations in the quality and safety of healthcare that patients receive; and the considerable risks of iatrogenic harm to patients. These failings contribute to the high rates of potentially avoidable morbidity and mortality; and to the rising levels of healthcare expenditure seen in many health systems. There have been substantial developments in information technology in recent decades and there is now real potential to apply these technological developments to improve the provision of healthcare. One area of international interest is the use of eHealth applications to address patient safety and quality issues. There is, however, a large gap between the theoretical and ...

Independent sector treatment centres (ISTCs) were established by the previous government to increase the capacity for elective surgical procedures. The new centres were expensive and there are concerns about the value for money they provide. An article from York University published in the August issue of the Journal of the Royal Society of Medicine concluded that NHS hospitals were treating more complex patients than independent treatment centres. The article provides new information on private sector treatment centres that will help inform the policy of the coalition government. The article highlights the need for much tighter regulation of all units providing NHS services to ensure that they deliver high quality care, provide value for money, and meet minimum standards for data collection. Other key findings from the article are that private sector treatment centres manage only a very small proportion of NHS-funded elective workload; their clinical coding is much poorer than that...

New forms of communication have much to offer, and can help to improve the relationship between doctors and patients, as well as making patients more informed about their health and illness. In my own medical practice, we now offer online access to medical records and patients are starting to use this, particularly for ordering prescriptions and booking appointments. But there can also a downside to new technology, as shown by the recent incident of "bleachgate", which illustrates some of the problems that can arise from the use of these newer methods of communication, such as social networking. In this episode, a 15 year old boy from South Wales, Rhys Morgan , showing remarkable maturity and ability for some one so young, pointed out the problems that could be caused by a putative remedy for Crohn's disease that was being publicised on an online forum for people with Crohn's. Rather than being commended for his actions in exposing a dangerous treatment that could hav...

A recent systematic review by Riyadh Alshamsan and colleagues assessed the impact of pay for performance programmes, in particular the Quality & Outcomes Framework in the UK, on inequalities in the quality of health care. There was some evidence that the use of financial incentives reduced inequalities in chronic disease management between socio-economic groups. However, inequalities in chronic disease management between age, sex and ethnic groups persisted after the use of pay for performance incentives. They concluded that inequalities in chronic disease management have often persisted after the introduction of pay for performance programmes such as the Quality and Outcome Framework in the UK. The findings of the paper reinforce the need for pay for performance programmes to be designed to reduce inequalities as well as improve the overall quality of care.

The Summer 2010 NIHR CLAHRC for Northwest London Collaborative Learning and Delivery Event was held at Imperial College on July 1.  The day was attended by over 160 delegates. The focus for the day was patient safety, with an international comparative perspective. We were fortunate in having a number of external speakers at the event, including a delegation of senior academics and clinicians from Taiwan. The implementation of patient engagement and the quality and safety of the patient journey are key points of importance for the CLAHRC, this was reflected throughout the day in various keynote plenaries, workshops and support sessions. Featured plenary sessions from a range of keynote speakers included: Prof Derek Bell, Programme Director, NIHR CLAHRC for Northwest London; Prof Ken Kuo, Director, Division of Health Policy Research and Development, National Health Research Institutes, Taiwan; Dr Gill Hicks, MBE, Founder, M.A.D. for Peace; and Prof Pe...

The UK health care system provides universal coverage; hence, equitable health improvement across ethnic groups should be more easily attainable than in fragmented health systems. However, previous studies have shown ethnic health inequalities in cardiovascular disease prevalence, health outcomes and access to interventions and treatment in the UK. In a recent paper published in Family Practice , Joanna Murray and colleagues examined whether policy changes over the past decade in the primary care management of coronary heart disease ( CHD ), have resulted in improved and more equitable risk factor control among patients. The study was carried out in Wandsworth in South-West London. They found that over a 10-year period from 1998 to 2007, mean blood pressure among patients with CHD decreased from 140/80 to 133/74 mm Hg, while their mean cholesterol was reduced from 5.2 to 4.3 mmol /l. Reductions in these risk factors occurred among both males and females and across all ethnic groups...

Diagnosed prevalence and morbidity data underestimate the total burden of chronic obstructive pulmonary disease (COPD) because the disease is usually not diagnosed until it is clinically apparent, and there is considerable variation in reported prevalence. Michael Soljak and colleagues have developed a multivariate model to estimate the expected prevalence of COPD in England, based on the data from the Health Survey for England, which can then used to produce local prevalence estimates. The results of this work were published in the Journal of Public Health . This COPD prevalence model is now available on the APHO Website and contains estimates of prevalence for general practices in England. The model is now being used a tool for COPD case finding.

A recent study in Quality & Safety in Healthcare by Paul Aylin and colleagues examined death rates in patients admitted as emergencies to NHS hospitals in England. This is the largest study published on weekend mortality and highlights an area of concern in relation to the delivery of acute services. Several studies have shown higher mortality for patients admitted as emergencies at weekends compared with emergency admissions on week days. Using routinely collected hospital administrative data, they examined in-hospital deaths for all emergency inpatient admissions to all public acute hospitals in England for 2005/2006. Odds of death were calculated for admissions at the weekend compared to admissions during the week, adjusted for age, sex, socioeconomic deprivation, comorbidity and diagnosis. The overall adjusted odds of death for all emergency admissions was 10% higher in those patients admitted at the weekend compared with patients admitted during a weekday The stud...

An adverse drug reaction (ADR) is an undesirable effect of a drug beyond its anticipated therapeutic effects occurring during clinical use, and is one of the major causes of iatrogenic disease. ADRs cause significant morbidity and mortality and increase the length of hospital stays. The economic burden of ADRs on the British NHS is also high, accounting for considerable extra NHS costs. A recent study by Dr Tai-Yin Wu and colleagues published in the Journal of the Royal Society of Medicine examined hospital admissions associated with ADRs in all NHS English hospitals in the past 10 years, using the Hospital Episode Statistics database. Between 1999 and 2008, there were 557,978 ADR-associated admissions, representing 0.9% of total hospital admissions. Over this period the annual number of ADRs increased by 76.8% (from 42,453 to 75,076), and in-hospital mortality rate increased by 10% (from 4.3% to 4.7%). In 2008, there were 6,830,067 emergency admissions of which 75,076 (1.1%) were d...

A recent article by Helen Atherton , Christopher Huckvale and Josip Car in the Journal of Telemedicine and Telecare discussed the use of email in healthcare . The use of email as a method of transferring information between clinicians and patients is increasing. For example, email is now commonly used for the management of appointments and to provide test results. The widespread availability and use of email by the public creates opportunities for people to participate more actively in their own health care. One common use of email to support this is its use by primary care physicians to provide patients with additional information about disease prevention and health promotion, and thus reinforce the messages given during the consultation. The article confirmed that the use of email in healthcare developing rapidly, but also found that the evidence base to support the use of email is not well established, and that better research was needed if we are to maximise the benefits of th...

A recent article in the journal Primary Health Care Research & Development  By Edgar Samarasundera and colleagues discusses the use of socio-demographic data sources for monitoring local health profiles and for use in the geographical planning of primary health care in England. The article updates an older paper published in the BMJ in 1995. There is an increasing range of resources available for geographical analyses in health. The 2001 census introduced important changes to what routine data are available, as will the 2011 census. These changes have been paralleled by developments in the availability of socio-demographic indicators and the increasing popularity of geographic information systems. Health data can now be combined with those from socio-demographic more efficiently to produce value-added datasets. Recent and planned developments in the availability of both socio-demographic datasets in tandem with parallel developments in spatial technologies have provid...

A scientific workflow  is a method in computer science for formulating abstract descriptions of analytical processes. This allows automation and reuse of many of the tasks in analysing large, complex data sets. A recent article in the journal Statistical Methods in Medical Research discussed the use of these scientific workflows for the analysis of data from large primary care databases . Routinely collected primary care data in electronic repositories are a promising source of data for audits, quality improvement, health service planning, epidemiological studies and research. However, a number of challenges have been noted about working with these data sets. In the paper, we discuss these issues and describe how we used scientific workflows to analyse data from one large primary care database (GPRD). Some of the steps in the analysis of data from the GPRD our shown in the figure below.

In a recent BMJ editorial , Nicholas Moore and Bernard Begaud outline initiatives to improve pharmacovigilance in Europe. Such initiatives are essential to improving the safety of healthcare because current approaches to detection of serious adverse drug reactions (ADRs) have major limitations. Serious adverse drug reactions are often too rare to be detected in early clinical trials, and may not be detected through post-marketing surveillance for many years. This delay in identifying adverse drug reactions leaves clinicians unaware about the potential risks of the drugs they are prescribing, puts patients at risk of iatrogenic harm, and increases both healthcare costs and the costs of drug development. The development of databases derived from electronic patient records and hospital administration systems could help to improve the detection of adverse drug reactions. In England, these databases include the General Practice Research Database (GPRD), The Health Improvement Network (THI...

I am sometimes asked where a list of my academic publications can be found? Details of my publications can be found on my Imperial College Publications Page . This is updated automatically - at regular intervals, a search of the PubMed and other bibliographic databases is carried out and any publications with an author matching my details are flagged for me to decide whether they are included on the page. The advantage of using this page to view my list of publications - rather than a PubMed search - is that there are other authors with similar details to me. Hence, a PubMed search will include publications from other authors and not just those which are mine.

The incorrect classification, diagnosis and coding of the type of diabetes can affect the quality of health care that people with diabetes receive. A study published recently in the journal Diabetic Medicine examined the accuracy of diagnostic data on diabetes. The study found that errors in the coding and classification of diabetes were common. The study included some useful algorithms to help doctors identify which patients may not have their diabetes recorded correctly.