Medical Centre

Primary care is a major component of England’s National Health Service , providing around 300 million consultations per year with GPs in England. In addition to providing healthcare to their patients, GPs are also charged with coordination and gatekeeping of access to services provided by secondary care, tertiary care and other allied healthcare providers; a responsibility that will become more important now that GPs will be undertaking the commissioning of health care. This new responsibility for GPs provides an opportunity to re-model care delivery to maximize outcomes, cost efficiency and patient access by focusing on diseases that are most amenable to management in primary care. In a paper published in the Journal of the Royal Society of Medicine , Daniel Gibbons and Colleagues review the evidence on what conditions are most sensitive to management in primary care – commonly referred to as primary care sensitive conditions (PCSCs) or ambulatory care sensitive conditions. Such de...

In a systematic review published in JRSM Short Reports , Josip Car and colleagues collated and critically evaluate the available scientific evidence on the negative health system effects of global health initiatives in developing countries. They identified 24 studies commenting on adverse effects on health systems arising from Global Fund investments. Sixteen were quantitative studies, six were qualitative and two used both quantitative and qualitative methods, but none explicitly stated that the studies were originally designed to capture or to assess health system effects (positive or negative). Only anecdotal evidence or authors’ perceptions/interpretations of circumstances could be extracted from the included studies. Dr Car and colleagues concluded that that much of the currently available evidence generated between 2002 and 2009 on global health initiatives potential negative health system effects is not of the quality expected or needed to best serve the academic or broader c...

In a paper published in the journal JRSM Short Reports , Layla Alhyas and colleagues examined the quality of type 2 diabetes mellitus (T2DM) care in Al-Ain, a diabetes centre located in a tertiary care hospital, in the United Arab Emirates (UAE). They carried out a a retrospective cohort study from 2008 to 2010. 382 Emirates patients with T2DM were included in the analysis. Overall in 2010, proportions of people with T2DM reaching the following targets were: glycated haemoglobin (HbA1c) 41%, low-density lipoprotein (LDL) 72%, systolic and diastolic blood pressure (SBP/DBP) 47% and 73%, respectively. There was a significant improvement from 2008 to 2010 in HbA1c, LDL, and SBP control. Alhyas and colleagues concluded that there had been encouraging progress in diabetes care in Al-Ain, UAE as reflected by the overall improvement in key intermediate outcome measures, exemplified by the increase in the percentage if patients reaching the target for these indicators from ...

During the past decade, national governments and international agencies have strengthened the implementation of prevention of mother-to-child HIV transmission (PMTCT) programmes. However, many women still do not access these services. In 2010, there were 390,000 new HIV infections in children, 90% of which were infected through vertical transmission.  The fear of violence or abandonment by male partners, cultural gender rules and disparate decision making power for women are among the main reasons that women do not access PMTCT services. Hence, interventions should focus on promoting gender equality and improving male awareness and engagement in their families’ health in order to improve uptake of PMTCT services. In a systematic review published in the Cochrane Library ,  Serena Brusamento and colleagues assessed the effectiveness of male involvement interventions on women’s uptake of PMTCT services in developing countries. They concluded that we need more studies assessing d...

Patients are increasingly using the Internet to rate their physicians. In a study published in the Journal of Medical Internet Research , Felix Greaves and colleagues examined the usage of NHS Choices, a government website that encourages patients to rate the quality of family practices in England, and associations between web-based patient ratings and conventional measures of patient experience and clinical quality in primary care. Greaves and colleagues obtained all ratings of family practices posted on NHS Choices between October 2009 and December 2010. They then examined associations between patient ratings and family practice and population characteristics. Associations between ratings and survey measures of patient experience and clinical outcomes were also examined. They reported that 61% of the 8089 family practices in England were rated, and 69% of ratings would recommend their family practice. Practices serving younger, less deprived, and more densely populated areas we...

The number of children admitted to hospital in England for acute throat infections increased by 76 per cent between 1999 and 2010, according to new research published by Elizabeth Koshy and colleagues in the journal Archives of Disease in Childhood . The article was covered by a number of media outlets, including the BBC . Acute throat infection (ATI), which includes acute tonsillitis and acute pharyngitis, is one of the most common reasons for consulting a GP. The majority of ATIs are self-limiting and can be managed at home or by the GP, but a small proportion may require hospital admission. This study investigated admission rates for children up to age 17 with ATI alongside trends in tonsillectomy rates, between 1999 and 2010.  The study was motivated by concerns that the decline in tonsillectomy rates in recent years has led to an increase in hospital admissions for tonsillitis of increased severity. It also investigated whether performing fewer tonsillectomies is associat...

Targeted screening for cardiovascular disease (CVD) can be carried out using existing data from patient medical records. However, electronic medical records often contain missing data for which values must be estimated to produce risk scores. In a paper published in the journal Informatics in Primary Care , Andrew Dalton and colleagues compared two methods of substituting missing risk factor data: multiple imputation and the use of default National Health Survey values. They used patient-level data from patients in 70 general practices in Ealing, London and substituted missing risk factor data using the two methods. They reported that using multiple imputation, mean CVD risk scores were similar to those using default national survey values, a simple method of imputation. There were fewer patients designated as high risk (>20%) using multiple imputation, although differences were again small (10.3% compared with 11.7%; 3.0% compared with 3.4% in women). Agreement in high-risk clas...

Linkage between routinely collected hospital birth and other records offers the potential for epidemiological and public health research by developing population-level birth cohorts with lifelong follow-up. In a paper published in the Journal of Public Health , Jo Murray and colleagues from Imperial College London examined the range and completeness of birth information recorded in Hospital Episode Statistics (HES) and tested an approach for minimizing the effect of hospital-level variations by selecting hospitals with high completeness of recording (≥90%) for key fields. The authors reported that the proportion of missing data in key birth record fields such as gestational age and birth weight has been decreasing annually (from 46.2 and 43.9% in 2005/06 to 18.1 and 16.9% in 2009/10, respectively). There was however a wide variation in the completeness of recording between hospitals. The authors concluded that the completeness of recording of hospital birth information varies greatly ...

Health systems throughout the world face many challenges, including the rising prevalence of chronic diseases such as diabetes; a rise in unhealthy behaviours and risk factors for poor health outcomes, such as physical inactivity, calorie-rich diets and obesity; increasing difficulty in maintaining expenditure on health services and funding new, high-cost treatments; maintaining the population’s access to healthcare while at the same time curtailing this growth in healthcare spending; and determining the most appropriate balance between primary care and specialist services. A new series of health policy reviews in the JRSM will report on these issues and how health systems are aiming to address key health policy challenges. Traditionally, research and debate in these areas has been very nation-specific, with relatively few attempts to carry out cross-national studies. However, if many of the challenges faced by healthcare systems are similar, then it is likely that countries can dr...

Immediate access to patients' complete health records via electronic databases could improve healthcare and facilitate health research. However, the possible benefits of a national electronic health records (EHR) system must be balanced against public concerns about data security and personal privacy. Successful development of EHRs requires better understanding of the views of the public and those most affected by EHRs: users of the National Health Service. In an article published recently in BMC Medical Informatics & Decision Making , Serena Luchenski and colleagues from Imperial College London describe a protocol for a study that aims to explore the correlation between personal healthcare experience (including number of healthcare contacts and number and type of longer term conditions) and views relating to development of EHR for healthcare, health services planning and policy and health research. A multi-site cross-sectional self-complete questionnaire designed for use ...

The Joint Committee on Vaccination and Immunisation (JCVI) advises the Secretary of State for Health and Welsh Ministers on vaccination and immunisation policies. As an academic primary care physician , I am a strong supporter of evidence-based immunisation schemes and also believe - as far as is practical - in open policy-making in which evidence that government bodies use to make their decisions is made public. In a letter published in the British Medical Journal , I commented on the use by the JCVI of unpublished data and refusal of the JCVI to make public all the evidence it uses. The Chair of the  JCVI, Andy Hall, states that the Joint Committee on Vaccination and Immunisation (JCVI) does not make public all the evidence it uses for its decisions because this would lead to scientists refusing to send their work to the committee before it was published in a peer reviewed journal. However, he does not supply any evidence supply evidence that academics would refuse ...

Clinical guidelines recommend maintaining blood pressure levels to below 130/80 mm Hg in high risk patients, including people with diabetes. In a paper published in the British Medical Journal , Eszter Vamos and colleagues from Imperial College London examined the effect of systolic and diastolic blood pressure achieved in the first year of treatment on all cause mortality in patients newly diagnosed with type 2 diabetes, with and without established cardiovascular disease. They carried out a retrospective cohort study using data from the United Kingdom General Practice Research Database on 126 092 adults with a new diagnosis of type 2 diabetes, between 1990 and 2005. Before diagnosis, 12 379 (9.8%) patients had established cardiovascular disease (myocardial infarction or stroke). During a median follow-up of 3.5 years, they recorded 25 495 (20.2%) deaths. In people with cardiovascular disease, tight control of systolic (less than 130 mm Hg) and diastolic (less than 80 mm Hg) bloo...

The worldwide increase in the prevalence of Type 2 Diabetes Mellitus (T2DM) has been particularly marked in the states of the Cooperation Council for the Arab States of the Gulf (GCC). In a systematic review published in PLoS One , Layla Alhyas and colleagues from Imperial College London examined studies that had aimed to measure the prevalence of T2DM in this region. They identified 27 for review. Six studies were published in the 1980s, 13 in the 1990s, 8 in the 2000s. Eleven studies were of Saudi populations, 3 Kuwaiti, 2 Bahraini, 6 Emirati, 4 Omani and 1 Qatari. Sample sizes ranged from 336 to 600132. All were cross-sectional studies. Subgroup analysis by country indicated that the estimated prevalence of T2DM between GCC countries are comparable. The lowest estimated prevalence was found in KSA 4.01%; followed by Oman 4.5%. Bahrain had the highest estimated prevalence of T2DM among GCC countries at 5.17%. The estimated prevalence rates between Qatar, UAE and Kuwait were clo...

Copper intrauterine devices (copper-IUDs) are safer, more effective and cheaper than hormonal contraceptive methods and are the most widely used reversible contraception in the world. However, they are underused in developed countries. In an article published recently In Contraception , Myat Arrowsmith and colleagues from Imperial College London reviewed randomized controlled trials and controlled before-and-after studies to determine the effectiveness of interventions for improving uptake of copper-IUDs. Nine studies representing 7960 women met our inclusion criteria, including seven randomized controlled trials and two controlled before-and-after studies. Meta-analysis from three studies showed contraceptive provision by community workers doubled uptake of IUD, and studies on antenatal contraceptive counselling showed similar increases. One study reported major increases in IUD uptake with postnatal couple contraceptive counselling; a study on postnatal home visits and two studie...

In an article published recently in the journal Psychology, Health & Medicine , Michelle Van Velthoven and colleagues from Imperial College London reviewed the scope, effectiveness, acceptability and feasibility of the use of mobile phone messaging for HIV infection prevention, treatment and care.  They reported that the use of mobile phone messaging had been evaluated for HIV prevention, appointment reminders, HIV testing reminders, medication adherence and for communication between health workers. They also reported that of three randomized controlled trials assessing the use of short message service (SMS) to improve medication adherence, two showed positive results. Other interventional studies did not generally provide significant results. They concluded that there was limited evidence on the effectiveness of mobile phone messaging for HIV care and that this area of medical practice would benefit from additional high-quality studies.

Financial incentives may help improve the delivery of smoking cessation interventions in primary care. However, UK have generally not examined the impact of financial incentives on disparities in the delivery of smoking cessation interventions. In a paper published recently in the Journal of Public Health , Fiona Hamilton and colleagues examined associations between disease group [cardiovascular disease (CVD), respiratory disease, depression or none of these diseases], ethnicity and smoking outcomes following the introduction of the Quality and Outcomes Framework in 2004. They found that significantly, more CVD patients had smoking status ascertained compared with those with respiratory disease (89% versus 72%), but both groups received similar levels of cessation advice (93% and 89%). Patients with depression or none of the diseases were less likely to have smoking status ascertained (60% for both groups) or to receive advice (80 and 75%). Smoking preval...

Medical technology has developed rapidly in recent in recent decades and there is now real potential to apply these technological developments to improve the quality, safety and efficiency of healthcare worldwide. In a report published in the leading medical journal, The Lancet , Peter Howitt and colleagues from Imperial College London examine how medical technology should best be used to improve health in low- and middle-income countries. The report concludes that in many cases, medical technology — almost exclusively developed in rich countries— is not appropriate for use in poorer nations . Although medical technology is making a substantial contribution to global health, there is much more that it could do if developed and applied correctly for low and middle income countries.

The increasing burden of chronic diseases, such as chronic obstructive pulmonary disease (COPD), is placing increasing strains on countries with developing health systems. In an article published in the Primary Care Respiratory Journal , Ailsa McKay and colleagues carried out a systematic review of studies investigating the prevalence of COPD in India. The authors did not identify any studies from which they could draw a rigorous estimate of the prevalence of COPD. Reliable standard estimates of chronic bronchitis were only available for rural populations. They identified four studies that gave estimated prevalences of between 6.5% and 7.7%. Smoking status was an important predictor of COPD prevalence. Residential environs, age, and domestic smoke exposure are also important, but investigation of their effect was limited by study heterogeneity. Ailsa McKay and colleagues concluded that although limited by the number and heterogeneity of studies and their unsuitability for meta-ana...

Cancer survival in the United Kingdom is poorer than in many other European countries. For many patients with cancer, their diagnosis is first made when they are admitted to hospital as an emergency with complications of cancer. Hence, studying patients in whom cancer is diagnosed in this sway may provide information that can be used to improve the detection of cancer by the NHS. In a paper published recently in the British Journal of Cancer , Alex Bottle and colleagues from the Department of Primary Care & Public Health at Imperial College London examined patient and general practice characteristics associated with emergency (unplanned) first hospital admissions for cancer in England. They reported that there were around 640,000 patients with a first-time admission for cancer, of which around 140,000 were unplanned, coming from 7957 GP practices. The unplanned proportion ranged from 14% (patients aged 15–44 years) to 45% (patients aged 85 years and older), with a large variat...

End-stage renal disease (ESRD) is an irreversible decline in kidney function, when renal replacement therapy (RRT) is needed for survival. The countries of the Gulf Cooperation Council (GCC), which consist of Saudi Arabia, the United Arab Emirates, Kuwait, Qatar, Bahrain, and Oman have an increasing burden of non-communicable diseases, including ESRD. In a paper published recently in JRSM Short Reports , Amal Hassanien and colleagues reviewed the epidemiological studies of ESRD in the countries of the GCC. The studies included in this review showed that the incidence of ESRD has increased while the prevalence and mortality rate of ESRD in the GCC has not been well reported. The leading primary cause of ESRD is diabetes and the most common co-morbid conditions are Hypertension and Hepatitis C Virus infection. The most common causes of death were cardiovascular disease and sepsis. The study highlighted that the lack of national renal registries data is a critical issue in the coun...