Medical Centre

An article published recently in Pulse by Michael Soljak and I examined the use of patient reported outcome measures. Patient-reported outcome measures (PROMs) estimate the effectiveness of healthcare delivered to patients as perceived by the patients themselves. The recent Government White Paper, ‘Equity and excellence: Liberating the NHS',2 envisages an increase in the scope and coverage of PROMs in future, starting from April 2011. For providers, PROMs will provide important data for quality improvement, in the form of comparative, casemix-adjusted pre- to post-operative changes in scores. They will also have a role in commissioning. For example, PROMs might be used to identify procedures with little benefit, or subgroups of patients who do not benefit greatly from surgery. This could allow more effective targeting of resources to improve health gain.

Type 2 diabetes mellitus is increasing worldwide. Recent growth has been particularly dramatic in the states of The Co-operation Council for the Arab States of the Gulf (GCC), and these and other developing economies are at particular risk. In a systematic review published recently in PLoS One , Layla Alhyas and colleagues review the quality of control of type 2 diabetes in the GCC, and the nature and efficacy of interventions. They found the the quality of diabetes management to be sub-optimal. Assessment of the efficacy of interventions was difficult due to poor quality studies and a lack of data, but the findings of the review suggested that there was considerable scope to improve the quality of diabetes care in this region.

In an article published recently in the Canadian Association Medical Journal , Eszter Vamos and colleagues from Imperial College examined the association between size of general practice and the quality of diabetes management in England between 1997 and 2005. They found improvements in the recording of process of care measures, prescribing and achieving intermediate diabetes outcomes in all practice sizes during the study period. They concluded that size of practice was not strongly associated with the quality of diabetes management in primary care; and that pay for performance programmes appear to benefit both large and small practices to a similar extent.

A systematic review published recently by Layla Alhyas and colleagues in JRSM Short Reports examined the prevalence of risk factors for diabetes and its major complications in the Co-operation Council of the Arab States of the Gulf (GCC) region. They reported high prevalences of risk factors such as obesity, hyperglycaemia, hypertension and abnormal blood lipids. Enhanced management of these risk factors will be essential if escalation of diabetes-related problems is to be averted as industrialization, urbanization and changing population demographics continue in the countries in the Gulf region.

A recent paper by Jo Murray and colleagues published in JRSM Short Reports examined the impact of patients' use of the NHS Choices website on primary care consultations in England and Wales. They found that NHS Choices did alter healthcare-seeking behaviour, attitudes and knowledge among its users. Using NHS Choices appeared to result in reduced demand for primary care consultations among young, healthy users in particular. The authors concluded that the use of online medical services should be explored further.

In the UK, quality standards for chronic kidney disease (CKD) are set out in a National Service Framework and in pay-for-performance indicators. As CKD is largely asymptomatic in its early stages, it is therefore generally detected following routine renal function testing. In a paper published recently in Family Practice , Simon de Lusignan and colleagues examined which groups of patients were most likely to have renal function testing in primary care. The found that testing rates were highest in people with diabetes, and slightly higher in women than men. The results will help in the planning of the new NHS Health Check programme.

Many doctors will already be familiar with Google Scholar. Google have recently launched a new linked service, Google Scholar Citations, which provides a web-based tool for academics to monitor citations to their articles. Academics can check who is citing their publications, view citations over time and examine citation metrics. Academics can also make their profile public so that other people can view their citation metrics. The service was launched with a small number of users and I was fortunate enough to be selected as one of the early users. You can view my Google Scholar Citations page to see the data available. Amongst the metrics that can be viewed are the total number of citations and the h-index, along with a chart showing the number of citations per year. Detailed citation counts are also available for individual papers. Many universities already have updateable publication pages for their academics (as an example, see my Imperial College London Publications page). Google...

Ninety per cent of HIV infections in children under the age of 15 are caused by mother-to-child transmission of HIV during pregnancy, delivery and breastfeeding. In high-income countries introduction of prevention of mother-to-child HIV transmission (PMTCT) programmes substantially reduce the rate of transmission of HIV from mothers to infants. In a recent systematic review published in the Cochrane Database of Systematic Reviews , Lorraine Car and Colleagues examined the effectiveness of integrated PMTCT programmes compared to non-integrated and partially integrated care. They found very little evidence of evidence on this area and suggested that additional research is needed to allow clinicians and policy makers to make a definitive conclusion about the effectiveness of integration of PMTCT interventions with other health services.

In a letter published recently in the Lancet , Helen Atherton and I argue for a more pragmatic  approach to the use of social networking in healthcare. For example, we should be using current evidence on how social  networking might be used to improve communication with patients. This could involve considering the use of social networking in terms of wider clinical behaviour. Concerns about the eff ect of new  technology on the doctor–patient  relationship were probably being  expressed when telephones were first  introduced more than 100 years ago. Rather than viewing new technology as a threat, we should use the opportunities it offers to improve the efficiency and effectiveness of health systems and to improve people’s knowledge of their health and illnesses.

Access to health information allows people to take a more active role in their health care by making them more informed about their health and the management of their illnesses. The internet is an increasingly popular way for people to obtain this kind of health information, but there are many barriers that prevent people making full use of such information. In particular, people may lack the motivation or the skills to use the internet. In a recent systematic review published in the Cochrane Database of Systematic Reviews , Josip Car and colleagues examined whether teaching people to find, evaluate or use online health information (online health literacy) improves those skills and improves their health. They found only two studies met the inclusion criteria for the review. They concluded that there is limited evidence on which to draw conclusions about the effect of these interventions and that further high-quality research on this topic was necessary.

Electronic health databases that contain data obtained from health records generated by routine clinical practice are widely in biomedical research. Because of the large number of patients in such databases and long patient follow-up, these databases have unique characteristics that are very valuable for academic researchers. An article published recently in PLoS One describes the use of the United Kingdom's General Practice Research Database (GPRD). The authors identified 749 studies published between 1995 and 2009 based on the GPRD. The studies included authors from 22 countries published in 193 journals across 58 study fields The findings of the study illustrate how valuable the data collected in UK primary care by primary care teams is for research and public health.

Over 30 million people in the United Kingdom now use the Internet every day, and around 12 million people use mobile phones to access the Internet. Can the NHS start to make effective use of this rapid development in information technology to improve communication between professionals and patients, and patients’ experience of their healthcare? This question is discussed by Helen Atherton and I in an article published in the Journal of the Royal Society of Medicine . We also give some examples of how clinicians and managers can begin to incorporate online technologies into their day-to-day practice. Online technologies and the ‘information revolution’ are changing the delivery of health services in the NHS and health systems in many other countries. Clinicians and managers need to act to take advantage of these developments now or risk being left behind, as their patients become increasingly familiar with the use of online and mobile communication technologies. This will in turn lead t...

NHS Health Checks, a cardiovascular risk assessment programme for all adults aged 40–74 years in England, was introduced in 2009. The programme aims to both decrease the incidence of cardiovascular disease (CVD), and reduce socio-economic and ethnic inequalities in cardiovascular health. The programme involves systematic screening, measurement of CVD risk factors, the generation of global risk estimates, risk communication and lifestyle counselling. In a study published in the Journal of Public Health , Andrew Dalton and colleagues examine the uptake of the programme in Ealing, London. They found that uptake of the programme and subsequent prescribing of statins in high risk patients was lower than predicted in the first year of the NHS Health Checks programme. Efforts to increase the uptake of the programme, particularly amongst patients more likely to have undiagnosed CVD or uncontrolled CVD risk factors, is needed. 

In an article published recently in the Student BMJ , Ms Zineb Mehbali, a UROP student in the Department of Primary Care & Public Health discusses the use of medical students as interpreters. This is a role that is often taken on informally by students and for which they may not be full trained or comfortable with doing. Medical schools should consider regulating this area more closely to avoid undue pressure being placed on students.

Dr Utz Pape , a statistician in the Department of Primary Care & Public Health , recently co-authored an article in Nature. For a synopsis of the article, see Utz's blog . 

Despite financial incentives to encourage general practices to register new cases, there is still under-diagnosis of cardiovascular disease (CVD) in England. In a paper published recently in BMC Cardiovascular Disorders , Michael Soljak colleagues compared the modelled (expected) and diagnosed (observed) prevalence of three cardiovascular conditions- coronary heart disease (CHD), hypertension and stroke- at local level, their geographical variation, and population and healthcare predictors which might influence diagnosis. They found that  9,682,176 patients were on practice CHD, stroke and transient ischaemic attack, and hypertension registers. There was wide spatial variation in observed: expected prevalence ratios for all three diseases, with less than five per cent of expected cases diagnosed in some areas. They concluded that despite access to universal, free primary healthcare, there may be substantial under-diagnosis of CVD across England.

The British Medical Association prides itself on its supposed commitment to tackling societal inequalities, particularly inequalities in health. One of the key drivers of health inequalities is income inequalities. In a letter published in the BMJ by one of the BMA's staff, the BMA claimed that it pays all its staff well above the minimum wage. However, it did not state what staff whose services were contracted out - such as catering staff - were paid. What the BMA representative seemed to be saying in her letter was that the BMA had subcontracted the employment of workers who are most likely to receive the minimum wage to external companies and had no idea (and perhaps doesn't care?) what they are paid. In a follow on letter also published in the BMJ , I asked for further clarification from the BMA on this point. Nearly three months after publication of my letter, there has been no further response from the BMA. Does the BMA really care about inequalities - or ...

In an article published in the BMJ , Dr Adrian Raby - a Senior Teaching Fellow in the Department of Primary Care & Public Health at Imperial College London - and one of his patients discuss how they dealt with his patient's alcoholism. Health problems caused by excessive alcohol intake are increasing in society. The article highlights the importance of clinicians in all fields of medicine being able to detect problem levels of drinking in their patient and wither intervening to aim to limit the harms associated with excessive alcohol intake or referring patients to specialist services or to voluntary groups such as Alcoholics Anonymous. One of the respondents to the article also highlighted the need for doctors to act as good role models for their patients.

The Introduction of the Quality and Outcome Framework (QOF) in 2004 was a major change in how family practitioners are paid in the United Kingdom. The scheme rewards family practitioners for the achievement of predetermined targets. Diabetes is one of the most important components of QOF and accounts for approximately 15 percent of the QOF clinical domain points (650 points are available in the clinical domain out of he total 1,000 points). Currently half of the points available for diabetes care are directed towards the achievement of intermediate outcome targets such as the control of blood pressure, cholesterol and HbA1c. Although financial incentives have gained momentum in recent years and are seen as a way to improve quality of care, many commentators raised their concerns regarding the potential negative consequences of using pay for performance to improve the quality of care, such as its impact on care delivered to patients from ethnic minority groups and how this may contrib...

Public reporting of physician and provider performance has become a key component of strategies to improve the quality of health care. Public reporting of performance is also increasingly being linked to provider pay through pay for performance programmes. Many pay for performance schemes permit physicians to exclude selected patients from performance indicators. For example, the Quality and Outcomes Framework (QOF), a major pay for performance scheme introduced into UK primary care in 2004, permits general practitioners to ‘exception report’ patients using set criteria. The criteria include circumstances where a treatment is not clinically appropriate, e.g. achieving tight blood glucose control in a diabetes patient with terminal cancer, or where a patient refuses to attend a review after three clinic invitations. In a paper published recently in the Journal Diabetic Medicine , Andrew Dalton and colleagues examined associations between patient and practice characteristics and exclus...