Medical Centre

Although recent years have seen reduction in mortality and other events associated with coronary heart disease, we don't know if people with and without diabetes have benefited equally. In a paper published recently in Diabetes Care , Eszter Vamos and colleagues from the Department of Primary Care & Public Health at Imperial College London compared recent trends in hospital admission rates for angina, acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) among people with and without diabetes in England. The found that in people with diabetes, admission rates for angina, AMI, and CABG decreased significantly by 5% , 5%, and 3% per year, respectively. Admission rates for stroke did not significantly change but increased for PCI in people with diabetes. People with and without diabetes experienced similar proportional changes for all outcomes, with no significant differences in trends between these groups....

The provision of after-hours primary care in the USA was discussed in a number of articles and letters published recently in the Annals of Internal Medicine . In a response to the articles. I discussed the relevance to the USA of England's experience in providing after-hours primary care. Many of the innovations recommended by by the authors of one of the articles in the Annals of Internal Medicine for the provision of after-hours primary care in the U.S. health care system are already present in England's NHS. These innovations are aimed at improving the care of people with emergencies and reducing pressures on emergency departments. For example, all residents of England have access to free after-hours primary care services from the NHS, either provided by their own primary care physician or by their local primary care trust. Despite the wide availability of primary care services and a readily accessible 24-hour helpline, patient attendance at emergenc...

End-digit preference (EDP) leads to clinicians recording specific end-digits (such as zero or five) more often than is expected by chance when measuring blood pressure. This can lead to inaccuracies in the monitoring of blood pressure and the effects of anti-hypertensive treatment. In a paper published recently in the International Journal of Clinical Practice , Alsanjari and colleagues examined trends in EDP over a 10 year period. They reported a decline in both blood pressure levels and EDP over the study period but also reported that around a quarter to a third of patients still have their BP recorded with a zero end digit. The authors conclude that blood pressure should be recorded using automated blood pressure monitoring devices to help to overcome the problem of EDP.

There is uncertainty about the best size for the primary care organisations responsible for commissioning health services in England. This includes the concern that small commissioning units are more exposed to financial risk, due to their smaller populations. Smaller commissioning units may also not have sufficient expertise or the required ‘market power’ to be able to negotiate effectively with health care providers to achieve good-value contracts. Alternatively, smaller organisations may have better local engagement and responsiveness for clinicians and patients. In a study publishedin the British Journal of General Practice , Felix Greaves and colleagues from the Department of Primary Care & Public Health at Imperial College London investigated whether there is a relationship between the size of commissioning organisations and how well they perform on a range of performance measures. This included a comparison of primary care trust (PCT) size against 36 indicators of co...

The Quality and Outcomes Framework (QOF), a pay for performance programme, was introduced into United Kingdom (UK) primary care as part of a new General Practitioner (GP) contract in April 2004. Before the introduction of QOF, most British family doctors were earning a large proportion of their income from capitation payments. This system rewarded family doctors for having a large list of registered patients rather than for the quality of care that they provided. There is limited definitive information about the impact of the QOF on level disparities in health care. In a study published in the journal PLoS One , John Lee and colleagues from Imperial College London investigated the following research questions: has QOF resulted in a step change in the quality of care for coronary heart disease, stroke and hypertension in white, black and south Asian patients? Has QOF reduced disparities in the quality of care for these conditions between these ethnic groups? Did general practices wi...

Hospital admission rates for stroke are strongly associated with population factors. The supply and quality of primary care services may also affect admission rates, but there is little previous research on this association. In a paper published recently in the British Journal of General Practice , Michael Soljak and colleagues from the Department of Primary Care & Public Health at Imperial College London investigated whether the hospital admission rate for stroke is reduced by effective primary and secondary prevention in primary care. This was a national cross-sectional study in an English population (52 763 586 patients registered with 7969 general practices in 152 primary care trusts). They found that mean annual stroke admission rates per 100 000 population varied from zero to 476.5 at practice level. In a practice-level multivariable Poisson regression, observed stroke prevalence, deprivation, and smoking prevalence were all risk factors for hospital admission. Protectiv...

Financial incentives are seen as one approach to encourage more systematic use of smoking cessation interventions by healthcare professionals. In a study published in the journal Tobacco Control , Dr Fiona Hamilton and colleagues from the Department of Primary Care & Public Health at Imperial College London carried out a systematic review to examine the evidence to support financial incentives for health professionals as a method for improving smoking cessation activities.They found 8 studies examined smoking cessation activities alone and 10 that studies that examined the UK's Quality and Outcomes Framework, which contains quality measures for chronic disease management including smoking recording and smoking cessation activities. Five non-Quality and Outcomes Framework studies examined the effects of financial incentives on individual doctors and three examined effects on groups of healthcare professionals based in clinics and general practices. Most studies showed imp...

Google Scholar Citations Open To All - Google Scholar Blog I've been using Google Scholar Citations since it was launched earlier this year and have found it a very useful tool for tracking citations of my work. The service was launched with a limited number of users but has now been opened up. I'll be encouraging my colleagues in the Department of Primary Care & Public Health at Imperial College London to sign up for Google Scholar Citations. You can find out how to do this on the Google Scholar Blog .

The National Health Service (NHS) Health Check Programme aims to identify and manage patients in England aged 40-74 years with a 10-year cardiovascular disease (CVD) risk score over 20%. In an article published in the European Journal of Cardiovascular Prevention & Rehabilitation . Andrew Dalton and colleagues from the Department of Primary Care & Public Health at Imperial College London assessed the prevalence of high CVD risk in the English population, using the two CVD risk scores and the 20% cut off mandated in national policy, and the prevalence of risk factors within this population. They found that of those eligible for an NHS Health Check, 10.5% (2,012,000) had a risk score greater than 20% using the QRISK2 risk score; 22.0% (4,267,000) using Joint British Societies' (JBS2) score. To reduce risk in those at high CVD risk, we estimate the total costs of the Programme to be £176 million using QRISK2 or £378 million using JBS2. They concluded that a large number of ...

In a  recent article in the New Perspectives Part II Section of  the SGIM Forum , the newsletter of the US Society of General Internal Medicine, I discuss the NHS Health Checks Programme. The burden of cardiovascular disease, type 2 diabetes and kidney disease will increase, both in developed countries with ageing populations, and in developing and middle income countries that are undergoing economic and demographic transitions. These diseases all share risk factors that include smoking, hypertension, obesity, physical inactivity, and impaired glycemic status. Integrated approaches to their prevention, early identification and effective management could therefore have major public health and economic benefits, and help limit the impact of the predicted future rise in non-communicable diseases. For example, even very modest reductions in population risk factor prevalence could prove to be highly effective in reducing the impact of these diseases. Despite downward secul...

Childhood vaccines are among the most successful and cost-effective public health interventions available. Within England, vaccination coverage is lowest in deprived, urban areas with mobile populations, such as London. Barriers to immunisation can stem from parental concerns about risks, inadequate knowledge and provision by providers, and generalized system barriers involving the organization of the health system and access to services. In an article published recently in JRSM Short Reports , Nia Willaims and colleagues from the Department of Primary Care & Public Health at Imperial College London carried out a systematic literature review aimed at providing GPs with up-to-date, evidence-based guidelines on how to improve uptake rates of primary immunisations for children registered under their care. Forty-six studies were included for analysis, published between 1980 and 2009. A number of interventions were found to increase vaccination rates in children. These inclu...

Errors in journal articles are common. Most journals now have policies to correct errors in research articles. However, errors in other types of articles often remain uncorrected. I've listed below a few statements in BMJ articles that are either wrong or that are highly unlikely to be true but which remain uncorrected. The BMJ is probably no worse in this respect than other medical journals, but as a member of the BMA, I receive a weekly copy of the print edition and therefore spend more time reading it than other medical journals. This means that I am more likely to pick up errors in the BMJ than in other journals. The reported incidence [of polycystic ovary syndrome] varies between 3% and 15% of women of reproductive age. http://www.bmj.com/content/343/bmj.d6407.full An annual incidence of 15% would imply that after 10 years, a women of childbearing age would have around an 80% risk of developing PCOS. Even the 3% incidence figure would mean that a women of childbearing a...

On an average weekday in England, there are over1 million consultations with general practitioners. The limited data on errors and patient harm in primary care obstructs the development of strategies to improve patient safety. In an article published recently in Family Practice , Carmen Tsang and colleagues reported the results of a systematic review to determine the types of adverse events that are routinely recorded in primary care. They found that there is limited use of routinely collected data to measure adverse events in primary care despite large volumes of data generated in the electronic patient records now used by most general practitioners in the UK. 

Patient safety measures can be derived from routinely collected hospital data. Carmen Tsang and Colleagues from the Department of Primary Care & Public Health at Imperial College recently carried out a review of such measures, the results of which were published in the American Journal of Medical Quality . They found that many studies were frequently conducted in the United States between using Agency for Healthcare Research and Quality patient safety indicators. They concluded that these indicators need further development, refinement and validation. Patient safety indicators that can be used  in ambulatory care settings were also needed. 

A recent commentary published in the Lancet by Allyson Pollock and colleagues concluded that there is no evidence that competition for patients in the NHS saves lives or improves quality of care, Improvements in area such as survival following acute myocardial infarction are likely to be due to the development of cardiac networks that encourage collaboration between hospitals and the wider provision of services such as percutaneous coronary interventions (PCI). The article was widely quoted in the media, including in the Independent and Pulse . 

A newly published Cochrane systematic review by Nik Tuah and Colleagues reported that there is currently limited evidence that the transtheoretical model stages of change (TTM SOC) method is effective in producing weight loss. The transtheoretical model describes a step-by-step way in which people move from unhealthy behaviours to healthy ones. The five stages of change that the model anticipates are pre-contemplation, contemplation, preparation, action and maintenance. The BBC reported on the study and noted that behavioural change to promote weight loss was very difficult to achieve.

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.