Medical Centre

Computer-assisted history taking for diabetes

2012-02-11T06:32:00.002Z

Two recent Cochrane reviews examine the role of computer-assisted history taking in people with diabetes. In the first review, Igor Wei and colleagues examine the role of computer-assisted history taking for dietary histories. They found that computer-assisted diet history taking was potentially as accurate as the conventional oral-and-written method and may potentially allow doctors to spend more time with their patients. However, the research on this topic was limited and they concluded that more primary research is required in this area.

In the second review, Yannis Pappas and colleagues examined the role of computer-assisted for identifying people with identifying people with a family history of of type 2 diabetes. Pappas and colleagues found no randomised controlled trials that investigated this area. They concluded that more primary research is required in this area to allow an informed decision to be made by physicians, patients and policymakers.

Although information technology potentially has a great role in improving the care of people with long-term illnesses such as diabetes, the full potential has not yet been realised and better evidence from high-quality studies is still needed.

Patient safety measures in primary care

2012-02-04T13:11:00.003Z

In a paper published in JRSM Short Reports, Carmen Tsang and colleagues from the Department of Primary Care & Public Health at Imperial College London interviewed a sample of NHS general practitioners to determine what they felt were the main patient safety issues and priorities for improvement in general practice. The study provided a snapshot of general practitioners' views on patient safety concerns, uses of routinely collected data to measure adverse events and existing methods for monitoring incidents of patient harm in primary care. Medication-related issues were identified a major cause for concern. Issues such as communication and training were also identified as important factors in ensuring patient safety in primary care. Further investigation of the patient safety topics identified by Tsang and colleagues will help develop methods to improve the involvement of general practitioners and other health professionals in schemes to improve patient safety in primary care.

Hospital Admissions for Major Cardiovascular Events and Procedures Among People With and Without Diabetes

2012-01-22T16:33:00.001Z

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. However, diabetes was associated with around a 3.5- to 5-fold risk of CVD events. Vamos and colleagues concluded that there were similar changes in admissions for CVD in people with and without diabetes.

After-hours primary care

2012-01-07T12:03:00.004Z

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 emergency departments, urgent care centres, and minor injury units in England continues to rise with a 35% increase from 15.3 million first attendances from 2003-2004 to 20.7 million in 2010-2011). The lesson from England for countries with more fragmented and less widely available after-hours primary care services is that a health system can strive hard to improve access to after-hours primary care, but this by itself may not be enough to curtail the demands placed on emergency departments.

End-digit preference in blood pressure recording

2012-01-02T10:45:00.001Z

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.

Primary care organisation size and quality of commissioning

2011-12-26T04:47:00.002Z

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 published recently in 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 commissioning performance, including measures of clinical and preventative effectiveness, patient centredness, access, cost, financial ability, and engagement.

They found that 14 of the 36 indicators had an association with size of the PCT and with 10 indicators, there was increasing quality with larger size. However, when population factors including deprivation, ethnicity, rurality, and age were included in the analysis, there was no relationship between size and performance for any measure. Greaves and colleagues concluded that there was little evidence to suggest that there is an optimum size for PCT performance and that the variations in PCT performance were explained by the characteristics of the populations they served. These findings suggest that configuration of clinical commissioning groups should aim to producing organisations that can function effectively across their key responsibilities, rather than being based on the size of their population alone.

Impact of Pay for Performance on Disparities in Stroke, Hypertension, and Coronary Heart Disease Management

2011-12-18T16:10:00.001Z

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 with different baseline performance respond differently to this programme?

The findings of this study suggest that the implementation of QOF resulted in significant short term improvements in blood pressure control. The magnitude of benefit varied between ethnic groups with a statistically significant short term reduction in systolic BP in white and black but not in south Asian patients with hypertension. Disparities in risk factor control were attenuated only on few measures and largely remained intact at the end of the study period.

The authors concluded that the QOF should set more challenging but achievable targets for general practitioners. Specific targets aimed at reducing ethnic disparities in health care may also be needed.

Figure: Trends in mean total cholesterol in patients with CHD and stroke.

Does higher quality primary health care reduce stroke admissions?

2011-12-11T18:54:00.001Z

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. Protective healthcare factors included the percentage of stroke or transient ischaemic attack patients whose last measured total cholesterol was ≤5 mmol/l, and ability to book an appointment with a GP.

They concluded that the associations of stroke admission rates with deprivation and smoking highlight the need for effective smoking-cessation services. Patient experience of access to primary care may also be clinically important. In countries with well-developed primary healthcare systems, the potential to reduce hospital admissions by further improving the clinical quality of primary healthcare may be limited unless more rigorous quality improvement measures than those currently being used are implemented.

Smoking cessation activities: How effective are financial incentives for healthcare professionals?

2011-12-03T12:25:00.001Z

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 improvements in recording smoking status and smoking cessation advice. Five studies examined the impact of financial incentives on quit rates and longer-term abstinence and these showed mixed results.They concluded that financial incentives improve recording of smoking status, and increase the provision of cessation advice and referrals to stop smoking services. however, the evidence that financial incentives lead to reductions in smoking rates is more limited.

Google Scholar Citations Open To All - Google Scholar Blog

2011-11-23T11:50:00.000Z

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.

Cardiovascular disease risk in people eligible for NHS Health Checks

2011-11-12T06:57:00.007Z

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 high-risk patients will be identified by the NHS Health Check programme. The NHS must consider whether extra costs for the programme if JBS2 is used are justified.

Reducing the risk of cardiovascular disease, diabetes and kidney disease

2011-11-09T06:22:00.000Z

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 secular trends, as in other developed countries, cardiovascular disease remains the largest single cause of mortality in England, accounting for around 34% of deaths annually. Cardiovascular disease also contributes significantly to health disparities, with risk factors, prevalence of established disease, adverse health outcomes and premature highest in people from lower socio-economic and ethnic minority groups. In an attempt to address the high burden resulting these diseases, NHS Health Checks, a population wide primary prevention program, was established by the Department of Health for England in 2009. The program is a major investment in “upstream” health promotion and disease prevention activities; and evidence of a serious attempt by England's National Health Service to improve public health and to contain health service spending on treating potentially preventable diseases.

Primary care strategies to improve childhood immunisation uptake in developed countries

2011-11-06T07:42:00.000Z

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 included parental reminders; and educational programmes and feedback of data on vaccination rates to providers. Williams and colleagues concluded that General practitioners are uniquely positioned to influence parental decisions on childhood vaccination.

How should medical journals respond to errors?

2011-11-01T07:18:00.000Z

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 age would have around a 26% risk of developing PCOS after 10 years. What the author is probably referring to is 'prevalence', which is an entirely different concept to incidence.

Study finds hepatitis C infections more prevalent than previously thought. http://www.bmj.com/content/341/bmj.c4598.full

This news item reported a small pilot study that had a high degree of selection bias in the people who were tested for hepatitis C, thus leading to a much higher rate of hepatitis C than reported in the larger surveys carried out by the Health Protection Agency.

In any one year one in four people in the United Kingdom have their thyroid function checked. http://www.bmj.com/content/338/bmj.b725.full.

Two references were given to support this statement. One contained no data on the frequency of thyroid function testing; the other reported that around 10 million thyroid function tests are carried out annually but did not report the source of this statistic. Even if we accept this statistic as accurate, this equates to about one test per six people in the UK, not one per four, assuming that the tests are independent (i.e. each test is carried out on only one patient), which won't be the case. Some people will have multiple tests and hence the actual proportion of the population undergoing thyroid function testing annually will be less than one in six, and very different the authors' quoted figure of one in four.

In 2004 a 1000 point plan called the quality and outcomes framework (QOF) was introduced. http://www.bmj.com/content/341/bmj.c7336.full

In fact, the QOF contained 1050 points when it was introduced in 2004; the number of points was not reduced to 1000 until 2006.

This is just a small selection of errors that I have noticed in the BMJ. As a 'journal of record', should the BMJ not be leading the way in ensuring that any facts it reports are accurate and any mistakes are corrected promptly?

Routinely recorded patient safety events in primary care

2011-10-26T05:11:00.000+01:00

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 Based on Routinely Collected Hospital Data

2011-10-19T05:53:00.000+01:00

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.

Cooperation is the way to improve NHS services

2011-10-13T06:11:00.000+01:00

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.

Evidence Lacking for Frequently Used Weight-Loss Method

2011-10-08T05:01:00.002+01:00

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.

Patient-reported outcome measures

2011-09-28T08:33:00.000+01:00

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.

Quality of Type 2 Diabetes Management in the States of The Co-Operation Council for the Arab States of the Gulf

2011-09-20T22:20:00.000+01:00

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.

Association of practice size and pay-for-performance incentives

2011-09-13T22:37:00.000+01:00

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 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.

Risk factors for adverse outcomes in diabetes in the Gulf

2011-09-06T22:58:00.000+01:00

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.

Use of the NHS Choices website for primary care consultations

2011-08-30T19:08:00.000+01:00

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.

Disparities in testing for renal function in UK primary care

2011-08-23T20:24:00.000+01:00

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.

Google Scholar Citations

2011-08-16T06:41:00.000+01:00

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 Scholar citations expands on the information available on these types of web pages and will be a very useful tool for academics.

Prevention of mother-to-child HIV transmission programmes

2011-08-10T19:28:00.000+01:00

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.

Social networking and health

2011-08-03T05:58:00.000+01:00

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.

Interventions for enhancing patients' online health literacy

2011-07-27T08:07:00.000+01:00

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.

Bibliometric Analysis of Studies Using the GPRD

2011-07-20T05:28:00.000+01:00

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.

An information revolution: time for the NHS to step up to the challenge

2011-07-12T17:39:00.000+01:00

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 to the NHS is seen as a technologically backwards health system that has failed to take advantage of this information revolution.

Uptake of the NHS Health Checks programme

2011-06-14T17:22:00.000+01:00

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.

Using medical students as interpreters

2011-06-01T06:21:00.000+01:00

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.

Article in Nature

2011-05-25T06:06:00.000+01:00

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.

Under-diagnosis of cardiovascular disease in England

2011-05-11T06:22:00.000+01:00

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.

Does the BMA really care about inequalities?

2011-05-04T20:45:00.000+01:00

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 are its comments on inequalities just a smokescreen to divert attention to what many people think is its primary purpose, negotiating pay deals for doctors?

A doctor's perspective on alcoholism

2011-04-28T10:48:00.000+01:00

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.

Ethnic Differences in Diabetes Management in Patients With and Without Comorbid Medical Conditions

2011-03-09T06:04:00.000Z

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 contribute to ethnic inequalities.

In a paper published recently in the journal Diabetes Care, Riyadh Alshamsan and colleagues examined ethnic disparities in diabetes management among patients with and without comorbid medical conditions after a period of sustained investment in quality improvement in the UK. They found that the presence of ≥2 cardiovascular comorbidities was associated with similar blood pressure control among white and South Asian patients when compared with whites without comorbidity but with worse blood pressure control among black patients. They concluded that despite major reforms to improve quality, disparities in blood pressure management have persisted in the UK, particularly among patients with cardiovascular comorbidities. Consequently, policy makers and clinicians should consider the potential impacts of quality initiatives on groups at high risk of clinical complications and adverse outcomes.

Exclusion of patients from pay-for-performance programmes may widen health inequalities

2011-03-02T05:52:00.000Z

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 exclusions from quality indicators for diabetes using data from the first three years of the Quality and Outcomes Framework. They carried out three cross-sectional analyses using data from the electronic medical records of all patients with diabetes registered in 23 general practices in Brent, North West London between 2004/2005 and 2006/2007. They found that excluded patients were less likely to achieve treatment targets for HbA1c, blood pressure and cholesterol control. Black and South Asian patients were more likely to be excluded from the HbA1c indicator than White patients. Patients diagnosed with diabetes duration of > 10 years, those patients with co-morbidities and older patients were also more likely to be excluded. Larger practices also excluded more patients from the HbA1c indicator. More deprived practices consistently excluded more patients from all indicators.

The findings of the study suggest that patients excluded from pay-for-performance programmes may be less likely to achieve treatment goals and disproportionately come from disadvantaged groups. One key implication of these findings is that allowing physicians to exclude patients from pay-for-performance programmes may worsen health inequalities.

New blog on Doc2Doc

2011-02-23T06:58:00.000Z

I now also have a blog on the BMJ Group's Doc2Doc site. The doc2doc site is an networking community for healthcare professionals.

Devolving national pay for performance programmes

2011-02-16T05:31:00.000Z

Primary health care services are important in establishing an effective, efficient, and equitable health system and in improving population health. This has led governments in many countries to increase their investment in primary care and introduce initiatives to improve quality, such as pay for performance. In the United Kingdom, this includes the Quality & Outcomes Framework (QOF), a national pay for performance programme. There is interest in devolving some aspects of national pay for performance programmes to local primary care organisations, to give greater flexibility and the ability to focus on local priorities. In a recent BMJ paper, Christopher Millett and colleagues discuss one such local programme, QOF+, which was implemented in NHS Hammersmith & Fulham.

The review of the scheme in NHS Hammersmith & Fulham suggests that local pay for performance incentive schemes may allow for opportunities to improve quality, encourage innovation, and tackle local public health priorities. An integrated incentive scheme such as QOF+ could also replace the plethora of disparate incentive schemes currently in place in primary care organisations However, there are also disadvantages of such schemes. They can require considerable investment in both time and money, and their widespread adoption is unlikely without the government devolving part of the national QOF budget to primary care organisations for local priorities, expediting plans to develop a national menu of quality indicators for local use, and having an information technology infrastructure that allows for the monitoring and evaluation of such schemes.

Hence, there are advantages and disadvantages to such local incentive schemes and their wider roll-out and implementation would need careful monitoring.

Improving prescribing for people living in care homes

2011-02-09T07:36:00.000Z

Prescribing for older people is complex and can lead to inappropriate prescribing, as well as side effects from prescribed medication. With a growing number of older people in the population, strategies to improve prescribing in this group are needed. Older people living in care homes are particularly at risk from polypharmacy and inappropriate prescribing. In a recent article published in the journal Age and Ageing, Malar Loganathan and colleagues reviewed the effects of interventions to optimise prescribing for people living in care homes.

Four interventional strategies were identified from previously published research: staff education, multi-disciplinary team (MDT) meetings, pharmacist medication reviews and computerised clinical decision support systems (CDSSs). Complex educational programmes that focused on improving patients' behavioural management and drug prescribing were the most studied area, with six of eight studies highlighting an improvement in prescribing. Mixed results were found for pharmacist interventions. CDSSs were evaluated in two studies, with one showing a significant improvement in appropriate drug orders. Two of three studies examining MDT meetings found an overall improvement in appropriate prescribing.

The results were mixed and there was no one interventional strategy that has proved to be effective. Nevertheless, education including academic detailing seems to show most promise. A multi-faceted approach and clearer policy guidelines are likely to be required to improve prescribing for patients in care homes. With the number of people living in care homes in the UK expected to continue to increase, research on how to improve the safety, quality and appropriateness of prescribing in this group will be important area for future work.

The Impact of eHealth on the Quality and Safety of Health Care

2011-02-02T05:43:00.000Z

Many health systems are investing heavily in IT-based systems that aim to improve the quality and safety of health care. For example, England has invested at least £12.8 billion in a National Programme for Information Technology (NPfIT) for the National Health Service, and the Obama administration in the United States (US) has similarly committed to a US$38 billion eHealth investment in health care. Examples of such investment include electronic health records (EHRs), picture archiving and communication systems (PACS), electronic prescribing (ePrescribing) and associated computerised provider (or physician) order entry systems (CPOE), and computerised decision support systems (CDSSs).

Policy makers hope that this investment will help address the problems of variable quality and safety in health care delivery. However, the scientific basis of such claims—remains to be established. A recent systematic review by Ashly Black and colleagues published in the journal PLoS Medicine aimed to investigate this question.The study found that there is a large gap between the proposed and demonstrated benefits of eHealth technologies. Moreover, there was a lack of methodologically sound research on the risks of implementing these technologies and their cost-effectiveness was yet to be demonstrated. Because of this, future eHealth technologies should be evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle.

End of MRC GPRD Access Scheme

2011-01-26T06:43:00.001Z

For the past few years, the MRC has funded access to GPRD data for UK researchers. This has been very helpful in increasing expertise in the use of GPRD amongst UK researchers and boosting the number of academic papers that use the database. This scheme has now ended and the effects this might have on research were discussed in a recent BMJ news article. The UK has one of the highest uses of electronic patient records in primary care, and these records have been a great resource for biomedical researchers.

Before the licence scheme was implemented the main users of the database were based in the United States, Spain, and Switzerland but that after it was set up this was no longer the case. Although the MRC will continue to fund access to the data via its research grants schemes, the process for applying for access to the database will be much lengthier and because applying for the council’s grants is highly competitive it is likely that most grant applications will be unsuccessful. Hence, it is very likely that we will see a reduction in UK based research using the GPRD once current projects using data obtained under the old scheme end. In other areas of the NHS and public health, there are datasets that can be obtained at relatively low cost (or sometimes no cost). These include hospital episode statistics, mortality statistics, and cancer registrations.

We need a similar easy and cheap access to anonymised primary care records for research. The UK has a strong primary healthcare delivery system and a very high use of electronic patient records in this setting. We should therefore be leading the world in the secondary uses of data obtained from primary care.

Awareness of stroke symptoms and risk factors amongst stroke patients

2011-01-19T05:25:00.000Z

Effective treatments exist for the acute management and prevention of stroke, but their uptake depends upon public awareness of stroke symptoms and risk factors. A recent study by Julia Slark and colleagues published in the Journal of Stroke and Cerebrovascular Disease assessed both types of knowledge amongst patients who had suffered a stroke and who were therefore at high-risk of suffering another stroke. The study found that knowledge was poor amongst many patients in this group. This is concerning as they are at high risk of stroke and other cardiovascular diseases.The findings suggest that more effective methods are needed about educating stroke patients about their risk factors; and how they can reduce their risk of a subsequent stroke, as well as recognising the symptoms of a new stroke should one occur.

Dr Curran & Partners now on Facebook

2011-01-12T07:18:00.000Z

The general practice where I work, Dr Curran and Partners, now has its own Facebook page. The page has some basic information about the practice that complements the information on the practice's website. With over 500 million Facebook users worldwide, the social networking site has become an important method for healthcare organisations to link with their patients.

Recording of adverse events in English general practice

2011-01-05T07:06:00.000Z

An study published in the journal Informatics in Primary Care examined the recording of adverse events in English general practice. Although the majority of patient contact within the UK's National Health Service (NHS) occurs in primary care, relatively little is known about the safety of care in this setting compared to the safety of hospital care. This study aimed to identify the rate and types of adverse events that might be recorded in primary care through routinely collected data. Records from the calendar year 2007 were available for 69 682 registered patients from 25 practices, consisting of 680 866 consultations. A number of adverse events could be detected through terms contained in certain chapters of the Read code system. These events include injuries due to surgical and medical care (0.72 cases of per 1000 consultations) and adverse drug reactions (1.26 reactions per 1000 consultations). The findings suggested that there is scope to develop more accurate and reliable means of safety surveillance in general practice using data obtained from electronic patient records.

MENA Diabetes Forum

2010-12-20T08:20:00.001Z

I recently attended the Middle East and North Africa (MENA) Diabetes Forum, which was held in Dubai in December 2010. The countries in the MENA region have amongst the world's highest prevalence of diabetes, driven by rapid changes in income, lifestyle, diet and physical activity. The forum covered a range of issues, from prevention, early diagnosis, and effective treatment. There were also sessions in which policies from other countries, such as the UK, USA and Italy, were discussed so that these policies from other health systems could be examined to see what lessons they might offer the countries of the MENA region. Amongst the speaker were Professor Tawfik Khoja, Professor Jean-Claude Mbanya, Professor Salman Rawaf, Professor Ala Alwan and former US President William (Bill) Clinton. I spoke about the UK experience of implementing screening programmes for diabetes and the UK pay for performance framework that encourages primary care physicians to provide high-quality care to people with long-term illnesses such as diabetes. You can view articles on diabetes management and on its risk factors in the Gulf in the journals PLoS One and JRSM Short Reports.

Hospital admission rates for chronic obstructive pulmonary disease

2010-12-15T06:24:00.000Z

A recent paper in the journal Thorax by Amaia Calderón-Larrañaga annd colleagues examined the association between hospital admissions for chronic obstructive pulmonary diseases (COPD) and population and primary health care factors. Hospital admission rates for COPD are known to be strongly associated with population factors. Primary care services may also affect admission rates, but there is little direct supporting evidence. The study examined admission rates in 8,064 general practices in 152 English PCTs. Admission rates for COPD were strongly associated with population deprivation and smoking prevalence, whereas healthcare factors such as influenza immunisation, patient-reported access to consultations within two days, and primary care staffing, were protective.

Suicide survey in a London borough

2010-12-08T09:04:00.000Z

About one million people worldwide die each year from suicide. Hence, strategies to reduce deaths from suicide are a key public health priority in many countries. A recent study by Dennis Ougrin and colleagues published in the Journal of Public Health aimed to collate relevant data from local and national sources, which will demonstrate the incidence of death from suicide and undetermined injury in the London Borough of Brent. The study also aimed to determine the characteristics of the subjects dying of suicide and undetermined injury in the locality and to identify what structures and processes are in place for recognizing, monitoring and sharing information about suicide between primary care, secondary care and public health.

The authors identified all deaths by suicides and open verdicts in the residents of Brent between February 2005 and February 2008. Health records of the identified subjects were analysed by two researchers. The annual rate of suicide in the study period was 6.8 per 100 000 inhabitants. Of the 54 cases of suicide in the , 45% had a psychiatric diagnosis and 18% were in current contact with mental health services. Hanging was the most frequent mode of suicide. Only 25% had seen their general practitioner within a month of suicide.

The study showed that a suicide survey is a feasible method of monitoring suicide, sharing data between key stakeholders and learning from the trends uncovered. The role for primary care in suicide prevention seems important but may be limited by an unexpectedly large proportion of the subjects not being in contact with primary care. In addition, the majority of the last primary care consultations were not for mental health problems This emphasizes the importance of wider societal initiative to improve suicide rates in addition to NHS interventions (e.g. reducing access to methods of suicide; and better employment, education and housing).

Blood pressure monitoring and control by cardiovascular disease status in UK primary care

2010-12-01T06:09:00.000Z

Cardiovascular diseases remain the main cause of morbidity and mortality in the UK. Strategies to reduce the burden of cardiovascular disease UK, such as the Quality & Outcomes Framework for general practitioners, have often emphasized improved management of high-risk individuals, rather than more population-based approaches to prevention. A recent study published in the Journal of Public Health Medicine by Anthony Laverty and colleagues from Imperial College London examined blood pressure monitoring and control among patients with and without cardiovascular disease in general practices in Wandsworth, London between 1998 and 2007. Logistic regression was used to assess associations among age, gender, ethnicity, deprivation and blood pressure control.

Laverty and colleagues found that the percentage of patients with elevated blood pressure (>140/90 mm Hg) decreased at a significantly slower rate in patients without cardiovascular disease (from 31.0 to 25.3%) compared with those with cardiovascular (from 56.8 to 36.0%). Mean systolic blood pressure decreased from 146.1 to 136.4 mm Hg in patients with cardiovascular disease and from 133.7 to 130.1 in patients without cardiovascular disease. Mean diastolic blood pressure decreased from 84.2 to 78.4 mm Hg in patients with cardiovascular disease; and from 80.5 to 79.0 in patients without cardiovascular disease. They also found that inequalities in blood pressure control decreased among age, ethnic and deprivation groups.

Laverty and colleagues concluded that measurement and control of blood pressure among those people with cardiovascular disease has improved much more rapidly compared with those without cardiovascular disease. This may have been a result of the guidance and incentives given to general practitioners to improve blood pressure control in people with cardiovascular disease.

QOF Plus Programme wins London Award

2010-11-24T06:30:00.003Z

Congratulations to Dr Josip Car and his team at NHS Hammersmith & Fulham for their work on the QOF Plus programme, which won the Award for Primary Care and Community Based Integration at the 2010 London Health and Social Care Awards. QOF Plus was developed jointly by the eHealth Unit at the Department of Primary Care and Public Health at Imperial and NHS Hammersmith and Fulham.

QOF Plus adopts a multi-modal approach based on:

Strong clinical leadership and shared ownership through clinical engagement and stakeholder panels
Targeted training and support
Innovative funding, financial and other incentives
Rigorous concurrent evaluation which feeds into constant self-improvement of the programme
Competitive motivation using dedicated software analysis tools to allow regular performance review, benchmarking and prediction of end-of-year performance
Patient-level management tools to assist practices in identifying those patients that may be missing out on particular interventions
Support for opportunistic management through the introduction of software that flags up outstanding tasks whenever a patient record is opened

Statistical Genetics

2010-11-17T06:03:00.000Z

Statistical genetics is a rapidly developing field that is producing models and methods for the analysis and interpretation of genetic data. Recent advances in new biotechnologies are generating detailed maps of genetic data are leading to potentially major developments in our understanding of the genetic basis of health and disease. An example of research in this area is a paper published recently by one of our statisticians, Dr Utz Pape, in the journal Nature. In the paper, Dr Pape and his colleagues investigated the link between an genetically-linked enzyme defect and myeloid cancers.

An Overview of the Health System in Taiwan

2010-11-10T06:31:00.000Z

An article published recently in the London Journal of Primary Care examined recent changes in the health system in Taiwan. Taiwan adopted a national health insurance system in 1995. Hence, both the British and the Taiwanese health systems are single-payment systems that offer universal coverage. However, the method of funding is different as the UK system is tax based, and the Taiwan system us other insurance-premium based. Now in its second decade, the National Health Insurance scheme in Taiwan continues to achieve high satisfaction rates among the Taiwanese people. Based on public opinion polls held by the Bureau of NHI, the overall satisfaction rate has consistently been over 70%.11 The next major challenge for the Taiwanese government is to improve quality of care while keeping national healthcare expenditure under control, and dealing with the rising number of older people in the Taiwanese population.

Supporting the development of GP Consortia in Northwest London

2010-11-03T08:25:00.000Z

The National Institute for Health Research Collaboration for Leadership for Applied Health Research and Care (CLAHRC) for Northwest London recently held a networking event to explore potential links between the NW London CLAHRC and GP Consortia in London. Amongst the speakers were myself; David Stout, Director of the Primary Care Trust Network, NHS Confederation; Dr Alan Cohen, Director of Primary Care, West London Mental Health Trust; Professor Derek Bell, Director, NIHR CLAHRC for Northwest London; and Ganesh Sathyamoorthy, Head of Operations and Delivery, NIHR CLAHRC for Northwest London. My talk at this meeting was on what role public health specialists could play in the new GP consortia. There are a number of areas in which public health specialists could support the new GP consortia, including needs assessment, planning health services, implementing preventive health care programmes, and evaluation of new programmes.

Implications of White Paper for General Practitioners

2010-10-27T05:56:00.001+01:00

In the period since the establishment of the new coalition government, we have seen radical changes proposed for the NHS in England. These are laid out in the new White Paper, Equity and Excellence: Liberating the NHS. These changes will have major implications for GPs and will lead to a period of major organisational change in the NHS in England. This is turn may lead to some general practices having less time to support non-core activities such as teaching and research.

GP contracts
The Government plans to abolish the current General Medical Services (GMS) and Personal Medical Services (PMS) contracts and bring in a new single contract for all general practitioners (GPs) in England. This new contract will include responsibility for commissioning health services. The White Paper also discusses linking GPs’ pay more closely to health outcomes (but it is currently unclear how this will be achieved in practice). The White Paper states that the Government ‘seeks over time to establish a single contractual and funding model to promote quality improvement, deliver fairness for all practices, support free patient choice and remove unnecessary barriers to new provision’. The new contract remains to be negotiated with the British Medical Association’s General Practice Committee (GPC) and hence the detailed content of the contract is yet to be agreed.

GPs to take on responsibility for commissioning
When the changes proposed in the White Paper are implemented, GPs will take on responsibility for commissioning the great majority of NHS services. Linked to this process will be an attempt to reduce management costs by abolishing SHAs (2012) and PCTs (2013). Under the new arrangements consortiums of GP practices will hold budgets to commission health services. At present, it is unclear how the other non-commissioning roles of PCTs will be carried out (e.g. research governance).

All general practices will have to join a consortium by the autumn of 2012; and from April 2013 will be funded directly by the new NHS Commissioning Board. GP consortiums will be able to employ staff to help them carry out their day to day administrative and management functions. Not all GPs will have to be actively involved in all aspects of commissioning, but every practice will need to take on basic commissioning responsibilities, such assessing the cost of specialist referrals. Each member practice is expected to work within the same financial framework.

Incentives for GP commissioning consortiums
Although the Secretary of State for Health (Andrew Lansley) has promised ‘powerful incentives’ for GPs to take on commissioning, it is likely that these financial incentives will have to come out of existing resources (unlike for example with the implementation of GP fundholding, when additional resources were made available to participating practices). A proportion of GP practice income will be linked to commissioning, with GPs able to earn a ‘quality premium’ if their consortium hits targets for clinical outcomes and financial performance set by the NHS board. This means that consortiums will have to look closely at the use of resources by their general practices (particularly prescribing costs, referrals to specialists and unplanned admissions). It is also possible that general practices could lose a proportion of their existing income (through failing to achieve the targets to receive the ‘quality premium’ payment) if their consortium overspends. This will create strong pressure on GPs to stay within their allocated budgets.

Management of general practices
The new National NHS Commissioning Board will be responsible for managing GP consortiums. The board will also hold general practice contracts, but may devolve the task of monitoring practice performance to local consortiums. This proposal has been resisted by some consortiums that do not want to take on this policing role. Andrew Lansley has said there will be ‘no bail out’ for GP consortiums, which he expects to take on the financial risk of commissioning. Risk will not, however, be shared with individual practices, who will not be penalised financially in the event of an overspend, other than through the loss of their quality premium. The NHS Commissioning Board will have the power to intervene if consortiums are at significant risk of failure, to impose measures to limit any overspend (such as reducing referral and admission activity), and in extreme circumstances to sanction temporary payments to keep consortiums solvent. Consortiums that overspend consistently are likely to be forced to undergo remedial action and may ultimately be stripped of their commissioning responsibilities. The number and size of GP consortiums remains to be determined.

Conclusions
The changes in the White Paper will lead to major changes in the way in which GPs work and in the management of their practices. In my department, we will be working to evaluate the impact of these changes on general practices, health outcomes and public health.

Trends in admission rates and in-hospital mortality for hip fractures in England

2010-10-20T05:18:00.000+01:00

The incidence of hip fractures is an index of the overall burden of osteoporosis in a society. Hip fractures are a major cause of morbidity, mortality and hospital admissions amongst older people. A study published recently in the Journal of Public Health Medicine by Tai-Yin Wu and colleagues examined trends in hip fracture admissions and mortality in England. They found that between 1998 and 2009, there was little change in age-standardized hip fracture rates (102.0 to 101.8 fractures per 100,000 person-years), but age-standardized in-hospital mortality decreased by 17%, from 127 to 106 deaths per 1,000 hip fracture admissions. Most hip fractures and deaths occurred in women and older people. A socioeconomic gradient was present for mortality, with a 26% difference in mortality in 2008 (94 to 118 deaths per 1,000) between the most affluent and most deprived areas in England. As the number of older people in the population rises, hips fractures will continue to be an important public health issue, emphasising the need for the effective prevention of osteoporosis, and rapid, high-quality treatment of patients once they are admitted to hospital.

Impact of Pay-for-Performance on Disparities in Diabetes Management in UK Primary Care

2010-10-13T05:00:00.000+01:00

Health systems like the UK's NHS aim to provide high-quality care for all groups of patients. Consequently, it is important to examine the impact of new initiatives in the delivery of health care on health disparities. A recent study by Fiona Hamilton and colleagues published in the Journal of Ambulatory Care Management examined the impact of a major pay-for-performance initiative introduced into UK primary care in 2004 on disparities in diabetes management. The study used data from the UK General Practice Research Database, which is widely used for epidemiological and health services research. The authors found that existing disparities in risk factor management (HbA1c, blood pressure, cholesterol) narrowed between men and women. Younger patients (under 45 years of age) with diabetes appear to have benefited less from Pay for Performance incentives than older patients, resulting in some widening of existing age group disparities. Patients living in affluent and deprived areas appeared to have derived a similar level of benefit from pay for performance. They concluded that a realignment of financial incentives may be required to further reduce health disparities. This could include a greater focus on outcome-based targets, such as HbA1c control and larger incentives for GPs working in more deprived areas.

2011 SAPC London Regional Meeting

2010-10-06T06:02:00.001+01:00

The SAPC’s annual meeting of academic departments of general practice and primary care from London and the South East is a longstanding fixture in the academic calendar. The 2011 Meeting will be held from February 4-6 at Madingley Hall, Cambridge. The meeting is organised by the departments of primary care in the five main London medical schools. The 2011 meeting is being organised by the Department of Primary Care & Public Health at Imperial College London. For the 2011, our guest speakers include Dr Fiona Godlee (Editor of the BMJ), Professor Jan De Maeseneer (Professor of Family Medicine at the University of Ghent in Belgium); and Dr Roger Kneebone from the Department of Surgery & Cancer at Imperial College London. The meeting offers a good opportunity to present any research, development or teaching work that you have carried out in primary care. See the 2011 Meeting Website for further details.

Patient Reported Outcome Measures (PROMs)

2010-09-29T06:10:00.000+01:00

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 their use in this role should be explored further.

Amputations in people with diabetes

2010-09-22T06:01:00.000+01:00

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 risk of important adverse complications such as amputation, in addition to public health programmes to prevent or delay the onset of diabetes.

Implementation of the NHS Health Checks programme

2010-09-15T08:12:00.001+01:00

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 or diabetes. The recording of BMI and cholesterol was considerably lower. Ethnicity recording was highly variable and was very low in some practices.

The authors concluded that the workload implications of the NHS Health Checks programme for general practices in England are substantial. Further research will evaluate the uptake of the programme amongst people invited to determine if the expected benefits of the programme will be realised.

The Imperial College Obesity Strategy Assessment Framework (IC-OSAF)

2010-09-08T06:52:00.000+01:00

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 Analysis Framework). These were used these with information from national guidelines to develop an obesity strategy analysis framework. The framewrok was then piloted to evaluate the obesity strategy for one London primary care trust (PCT). The framework was applied successfully and helped identify limitations and omissions in the PCT obesity management strategy. The IC-OSAF is a practical, easy-to-use tool for the analysis of local obesity management strategies. The framework can help identify gaps and limitations in strategies to help reduce variations in obesity management between PCTs. Its use should therefor be considered by other PCTs and GP commissioning groups to assess the completeness of their obesity strategies.

Laparoscopic bariatric surgery in England

2010-08-29T16:50:00.000+01:00

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 the subsequent withdrawal of Rimonabant and Sibutramine because of concerns about their safety. Although medical and surgical treatments have an important role in the management of obesity, particularly in some high risk groups, the key to tackling obesity lies in wider societal approaches, involving joint working between the NHS, local and national government, and the private sector.

Using information technology to improve patient safety

2010-08-23T08:11:00.000+01:00

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 empirically demonstrated benefits of current eHealth applications. While these applications typically have the technical capability to help professionals in the delivery of healthcare, inadequate attention to the socio-technical dimensions of their use (such as user involvement in their development and in training in their use) can result in new risks to patients. Given the current lack of evidence on quality and safety improvements and on the costs & benefits associated with the introduction of eHealth applications, there should be a focus on implementing more mature technologies; it is also important that eHealth applications should be evaluated against a comprehensive and rigorous set of measures, ideally at all stages of their application life cycle.

A key step in using information technology is through introducing the use of electronic patient record systems; these systems lie at the heart of many eHealth technologies, such as electronic prescribing and computerised test ordering, as well as providing data for the identification of potential threats to patient safety. However, the introduction of electronic patient records can bring its own threats to patient safety, particularly in the early stages, when healthcare providers could be using electronic and paper-based records in parallel. One consequence of this dual usage is that the data held in electronic patient record systems can be inaccurate or incomplete, with the potential to compromise patient safety because key data items (e.g., drug allergies or important comorbidities) might not be recorded. Other key steps are to ensure the full engagement of clinicians and other professionals, and to provide adequate training to allow them to use eHealth solutions appropriately. It is also important that methods for effective data interchange between IT systems are in place if the full benefits are to be realised, and to limit the workload and errors that can arise from duplicate and unnecessary data entry.

Independent sector treatment centres unlikely to be providing value for money

2010-08-19T19:20:00.000+01:00

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 of NHS hospitals; and they tend to treat people with less complex health needs. Private sector providers were generally given much better financial terms than NHS providers. The rationale for this was never very clear as, in a free market, we would expect all providers to compete on equal terms. Furthermore, because workload in private sector treatment centres is only a small fraction of that in NHS units, this suggests that the private sector providers will have very limited impact on areas such as access to treatment and waiting times.

It is also very disturbing that 36% of patients in private sector units were allocated to an uncoded Healthcare Resource Group (HRG), compared to just 1% in NHS units. These data are important to hospitals and ISTCs, as they provide essential information for clinical management and audit. For example, the data are commonly used to monitor mortality and readmission rates. They are also used extensively in national level analyses, for example, to monitor patient safety (e.g. see http://www.ncbi.nlm.nih.gov/pubmed/20110288). If the data are not of high quality with accurate coding, this limits their usefulness considerably and could have a major impact on public health.

The authors highlight that the private sector units are not operating at the capacity that was planned for them. In some areas, this has led to pressure on GPs to refer more patients to them instead of to NHS units. This seems to go against the government's desire to offer patients a choice in where they are referred for specialist treatment. For example, see http://bit.ly/9XcpCG. The key conclusion from this article is that ISTCs should be made to compete on a level playing field with NHS hospitals. If they are not able to match NHS hospitals on price and quality, then, where possible, their contracts should be terminated.

Social networking: Not always beneficial for patients

2010-08-15T14:04:00.003+01:00

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 have harmed patients, he ended up being banned from the group. To learn more about this episode, take a look at Rhys' video blog about the affair.

Impact of pay for performance on inequalities in health care

2010-07-31T07:26:00.002+01:00

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.

CLAHRC Collaborative Learning and Delivery (CLD) Event

2010-07-16T04:38:00.000+01:00

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 Peter Chang, Dean, Professor and Director, Taipei Medical University & Hospitals. Further information and copies of presentations are available on the CLAHRC CLD page.

Reductions in risk factors for secondary prevention of coronary heart disease

2010-07-09T17:47:00.000+01:00

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. The findings from this study illustrate how a national health care system with universal coverage can significantly improve care for all ethnic groups in a major long-term illness, such as CHD. This is in contrast to more fragmented health care systems such as in the USA, where ethnic disparities remain more marked than in the UK. Further reducing inequalities in chronic disease management should remain a priority for primary care in the UK.

COPD Prevalence Model for England

2010-07-03T15:46:00.001+01:00

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.

Mortality in patients admitted as emergencies during weekends

2010-06-25T17:37:00.000+01:00

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 study was widely reported in the media, including in the Guardian, Telegraph, and Nursing Times.

Trends in hospital admissions for adverse drug reactions in England

2010-06-19T07:25:00.002+01:00

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 drug-related. Systemic agents were most commonly implicated (19.2%), followed by analgesics (13.3%) and cardiovascular drugs (12.9%).There has been a near two-fold increase in nephropathy and cardiovascular consequences secondary to drugs and a 6.8% fall in mental and behavioural disorders due to drugs.

The study confirmed that ADRs have a major impact on public health, with the number of ADR admissions due to ADRs increasing at a greater rate than the increase in total hospital admissions. In-hospital mortality due to ADR admissions also increased during the study period. These findings should prompt policymakers to implement further measures to reduce ADR incidence and their associated in-hospital mortality, and develop educational interventions to improve the recording of ADRs by clinicians.

Using email to support health promotion in healthcare

2010-05-29T22:50:00.001+01:00

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 this technology.

Geographical planning of primary care in England

2010-05-16T17:39:00.000+01:00

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 provided a flexible, potent geographical methodology for primary health care research and development. The current consultation process for the 2011 census provides those involved with primary health care research and development an opportunity to influence future developments.

Scientific workflows for primary care database studies

2010-05-08T07:17:00.003+01:00

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.

Improving pharmacovigilance using routinely collected data

2010-05-04T16:55:00.006+01:00

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 (THIN) and QResearch, all of which are derived from electronic primary care records; and the Hospital Episode Statistics (HES) database, which is derived from hospital patient administration systems and hospital discharge records.

To illustrate this potential, we used one primary care database (THIN) to investigate the association of myopathy and myalgia with the use of statins. Using a case-crossover design (in which each patient acts as their own control and side-effects are examined in the period while a patient is on a drug compared when they are not), it may have been possible to detect the association with statins as early as 1996 (see the figure below, which shows the relative risk of myopathy & myalgia by year in 16,591 patients using statins or fibrates from 1991–2005). A longer exposure period then allows more precise quantification of the size of the effect with narrowing of confidence intervals. The full results of this study can be viewed in an article published in the medical journal PLoS One.

For adverse drug reactions that result in hospital admission, Hospital Episode Statistics, which cover all inpatient and day case activity in England, offer a method for identifying these admissions. For example, between 1998–2005, the total number of hospital episodes for all diagnoses increased by 14% but the total number of hospital episodes associated with adverse drug reactions increased by 45%.[4] The increase in admissions associated with adverse drug reactions may have due to a number of factors: improving record keeping from increased awareness, a general increase in adverse drug reactions against a background of an increasingly elderly population, the introduction of new drugs, and poly-pharmacotherapy because of increased pressure to prescribe medication for long-term illnesses such as diabetes, heart disease and hypertension. More detailed coding, and better use of HES data and of similar systems elsewhere in Europe, could considerably improve our surveillance of ADRs, as well as allowing the evaluation of interventions to improve the safety of prescribing. These issues and the full results of this study are discussed in an article published in BMC Clinical Pharmacology.

Health systems throughout Europe are investing substantially in information and communication technologies, such as the National Programme for Information Technology in England's NHS. One consequence of this investment could be substantially improved methods of pharmacovigilance, allowing pan-European studies building on the many national studies we have seen to date. For example, the EU-ADR project aims to use data from several European countries to develop improved methods of pharmacovigilance. Coverage of larger populations than allowed by single country and single database studies also increases study power with the potential benefit of earlier and more effective detection of adverse drug reactions.

Source: Improving pharmacovigilance: Use of routinely collected data. BMJ 2010;340:c2403.

Imperial College Publications Page

2010-05-02T11:48:00.002+01:00

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.

Accuracy of coding of diabetes

2010-04-24T13:30:00.002+01:00

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.

Research Assistant - TRANSFORM Project

2010-04-20T12:15:00.000+01:00

An opportunity has arisen for either a Research Assistant or Research Associate to join an international/cross-discipline team creating a rapid learning healthcare system to improve patient safety and volume of clinical research in Europe. This is an exciting opportunity for an individual with a keen interest in data mining and/or data provenance who is looking to gain experience in medical informatics. The aim of the research is to design and develop an extensible provenance framework to be integrated into the decision support and data mining engines to ensure auditability and accountability. This position will be responsible for investigating existing provenance models and their applicability to data mining tasks and contributing to the development of novel data mining models for translational data. See the Imperial College Recruitment Page for further details.

Public Financing of Health in Developing Countries

2010-04-09T16:40:00.001+01:00

I attended a conference today hosted jointly by the Imperial College’s Institute for Global Health and the Lancet which discussed public financing of health in developing countries. The centre-piece of the conference was a presentation by Professor Christopher Murray of the paper published by him and his colleagues in the Lancet. The main conclusion of Professor Murray’s study was that development assistance for health from donor countries can lead to a reduction in direct government spending on health in developing countries. In contrast, when development assistance for health was given to non-governmental organisations, this effect was not present. The study was a very impressive achievement, particularly given the limitations of the data that Professor Murray’s team had to use. The study raises some important questions for both donor countries and recipients of development assistance for health.

Has pay for performance improved the management of diabetes in the UK?

2010-04-07T09:38:00.003+01:00

A recent article in Primary Care Diabetes examines the question of whether pay for performance has improved the management of diabetes in the United Kingdom. Over the past decade, the UK government has introduced a number of major policy initiatives to improve the quality of health care. One such initiative was the introduction of the Quality and Outcomes Framework (QOF), a pay for performance programme for general practices launched in April 2004. The QOF aimed to improve the primary care management of common chronic conditions including diabetes. The introduction of QOF has been associated with improvements in the quality indicators for diabetes care included in the framework. However, it is difficult to disentangle the impact of QOF from other quality initiatives as few studies have adjusted for underlying trends in quality. QOF may also have reduced inequalities in diabetes care between affluent and deprived areas. Less is known about the impact of QOF on aspects of diabetes care not included in the framework, including self-management and continuity of care.

London RDS Session at the Reynolds Building

2010-03-20T18:59:00.002Z

The London Research Design Services will be holding a drop-in session at the Reynolds Building on Thursday March 25 2010. RDS London provides guidance and support to clinicians and academics preparing grant applications to he NIHR. The drop-in sessions are open to all, whether you just want to find out more about the service or would like to discuss a proposal with one of RDS London’s experts. There will be a number of RDS advisers available on the day that will be able to offer you advice on all aspects of your proposal.

Lecture at the University of Tokyo

2010-03-14T08:54:00.004Z

Last week, I attended a seminar at the University of Tokyo, organised by the Todai Policy Alternatives Research Institute. I spoke about the secondary uses of data from electronic patient records in the UK (the primary use is defined as their role in providing direct clinical care). Also speaking at the conference were John Halamka from Harvard and Nikolaus Forgo from Hanover, as well as speakers from the University of Tokyo, such as Professor Morita, Professor Akiyama, and Professor Sakata. Amongst the audience of 250 were representatives from clinical medicine, academia, government and health service management. I was very impressed by the expertise and commitment to this area of work in Japan. You can view a summary of the proceedings in Japanese.

Impact of universal health coverage in the UK on health disparities

2010-01-30T11:59:00.003Z

There is currently an ongoing debate in the USA about whether the US government should expand health coverage to include some groups that have limited access to health care. In the UK, we have had universal health coverage since 1948, when the NHS was introduced. The US health system has some stark disparities between ethnic groups. A recent article from Imperial College published in the Journal of Public Health examined change in the quality of care for people with diabetes over a 10 year period from 1997-2006. We found that although Although ethnic disparities persist in diabetes management, these are starting to be addressed, particularly in the South Asian group. It appears therefore that all ethnic groups have benefited from recent quality improvement initiatives in the UK.

Moving forward on the use of EPRs for research

2010-01-23T18:08:00.003Z

A recent article in Informatics in Primary Care discussed how we can build on a Wellcome Trust report on the use of electronic patient records (EPRs) from general practice for research. The UK could significantly enhance its health research capability by making effective use of data from electronic patient records for secondary research. The Wellcome Trust report provides useful guidance to researchers and clinicians on why secondary research using data from electronic records in primary care is important. Combined with advances in NHS Information Technology systems, particularly the Research Capability Programme, and financial support from the NIHR, we need to make this potential a reality and ensure that the UK remains a world leader in primary care informatics.

Visit by Delegation from Singapore

2010-01-17T16:07:00.003Z

The department hosted a visit this week by a delegation from Singapore, with help from the Lillie Road Surgery. The visit was to discuss collaboration between Singapore and Imperial College in the areas of undergraduate education and research.

The burden of alcohol related disease

2010-01-02T19:38:00.002Z

A recent report from the NHS Confederation and the Royal College of Physicians examines the growing cost to the NHS of treating people with alcohol-related diseases. The report was also covered by the BBC News. One of the important complications of excessive alcohol intake is liver disease.

In a paper published in 2008 in the journal Alcohol and Alcoholism, along with colleagues from St.Georges Hospital and the Office for National Statistics, I examined trends in hospital admissions and mortality in England from chronic liver disease. Hospital admission rates for chronic liver disease increased by 71% in males and 43% in females between 1989 to 2003. This increase was largely due to alcoholic liver disease, admission rates for which more than doubled between 1989/1990 and 2002/2003. Mortality rates for chronic liver disease more than doubled between 1979 and 2005 with two thirds of these deaths attributable to alcohol-related liver disease in 2005. The highest rate of alcoholic liver disease mortality was in the 45-64 age group, and the largest percentage increase between 1979 and 2005 occurred in the 25-34 age group.

Our study confirmed that hospital admissions and mortality in England from chronic liver disease are increasing. The underlying reasons are complex, but alcohol-induced liver disease makes a major contribution. There are clear social and health implications if the trend continues and addressing alcohol-related liver disease is a public health priority.

Primary Care in the Republic of Macedonia

2009-12-30T09:17:00.004Z

Earlier this year, the Department of Primary Care & Public Health at Imperial College hosted a visit from a delegation from the Ministry of Health in the Republic of Macedonia. During the visit, academics in the department discussed the primary healthcare system in the Republic of Macedonia and ways in which the Department of Primary Care & Public Health could support both undergraduate and postgraduate training in primary care. The Republic of Macedonia faces major challenges in improving its health system and the development of high-quality primary care services is seen as a key step in achieving improved access to healthcare.

Amputations in People with Diabetes

2009-12-29T09:44:00.002Z

A recent article in the journal Diabetes Research and Clinical Practice examined trends in lower extremity amputations in people with and without diabetes in England during the period 1996-2005. The study, which was reported on the BBC News Website, found that although overall numbers of amputations fell, the number occurring in people with type 2 diabetes increased. This may be because the prevalence of type 2 diabetes increased over this period and because surgeons are intervening earlier to prevent more serious damage to the feet and legs of people with type 2 diabetes.

Research Design Services London

2009-12-20T07:29:00.002Z

Research Design Service (RDS) London is part of the NIHR and provides help to those preparing research proposals for submission to the NIHR for applied health or social care research. With centres based at King's College London, Imperial College London, Queen Mary and University College London, it is focused on supporting applications for funding from NHS researchers and those working in partnership with the NHS. Priority is given to those applying for NIHR Research for Patient Benefit (RfPB) and Programme Grant funding. Advice is provided free of charge and is available through use of online resource and consultations with experts.

Diabetes Research Network

2009-12-12T12:31:00.003Z

One of my professional roles is acting as Associate Director (Primary Care) for the Diabetes Research Network. Diabetes is one of the most common chronic diseases that primary care professionals treat, affecting nearly 4% of the population of England. A key aim for Diabetes Research Network will be to encourage general practitioners, practice nurses and other primary care professionals to take part in its activities and to help recruit patients for clinical trials and other studies. A recent article in the journal Primary Care Diabetes discusses how primary health care professionals and the Diabetes Research Network can work together.

Metformin preferred as first line treatment for type 2 diabetes

2009-12-05T06:34:00.002Z

A study from Imperial College, LSHTM and the University of Leicester published online in the BMJ this week compared the safety of drugs used for the treatment of type 2 diabetes. The findings of the study confirm that Metformin remains the first choice drug for the treatment of type 2 diabetes. Patients taking sulphonylureas were more likely to suffer from heart attacks and heart failure or to die, compared to people taking Metformin. Doctors should therefore consider Metformin as their first choice when treating people with type 2 diabetes, as recommended by national guidelines from NICE. The study was reported by a number of media outlets, including the Guardian, Telegraph and NHS Choices.

MPH Session on Primary Care Data

2009-11-29T15:15:00.002Z

I gave a seminar on electronic primary care records last week on the Imperial College MPH programme, as part of the module on health information. The seminar covered the uses of data from primary care records to support public health, epidemiological, health services and clinical research. As more general practitioners use electronic primary care records, the scope for secondary uses of the data derived from them will increase. Further information is available from two of my publications on primary care data, published by the Eastern Region Public Health Observatory and in Health Statistics Quarterly.

NHS Choices

2009-11-18T18:39:00.002Z

NHS Choices is a service that aims to give patients and the public information about their health and healthcare. The service is intended to help patients and the public make decisions choices about their health, from lifestyle factors such as smoking, drinking and exercise, through to the practical aspects of finding and using NHS services in England. My practice now has a page on NHS choices, which we have now updated. In coming months, we will be aiming to make more use of the facilities available via NHS Choices to support our patients.

Should the QOF focus on outcome targets?

2009-11-15T17:42:00.002Z

The Quality & Outcomes Framework (QOF) is now well established in primary care. With control of the framework now lying with the National Institute for Health & Clinical Excellence (NICE), we can expect a greater focus on the clinical effectiveness and cost effectiveness of quality indicators. In the early years of the QOF, a large proportion of target payments were awarded for achieving process measures, such as measuring blood pressure or HbA1c. Achievement of such process measures is now very high, with little room for improvement in many practices and limited potential for further health gain.

By contrast, control of key risk factors, such as blood pressure in people with hypertension, or HBA1c in people with diabetes, could still be improved considerably. But changing patients' behaviour or optimising their management to achieve such improvements is difficult and imposes a considerable workload on primary care. So it is logical to consider increasing the financial incentives for achieving better management of such intermediate clinical outcome measures. It is also appropriate to raise the thresholds for achievement of quality targets to ensure practices that provide the very best care are rewarded appropriately for their work.

At the same time as improving the management of patients with established diseases such as diabetes, hypertension and stroke, we also need to reward practices that are effective in preventing disease and delaying the onset of complications once a disease such as diabetes or hypertension is present. The UK is faced with major public health challenges in areas such as obesity, smoking, alcohol and sexual health. Some GPs may argue improvements in such areas are outside the scope of primary care and lie with wider societal interventions. But this underestimates the ingenuity of primary care teams.

There are practices that have implemented innovative schemes in targeting public health, with support from their primary care organisations. An example is the QOF Plus scheme in Hammersmith and Fulham PCT, which has incentivised reductions in smoking and alcohol misuse, and areas such as cardiovascular disease prevention. An example of such an indicator might be the proportion of patients with newly identified impaired fasting glycaemia or impaired glucose tolerance who progress to normoglycaemia after entering a disease prevention programme. Practices that can implement effective interventions to improve management in these areas will have a direct impact on the health of their patients, and should be rewarded.

Outcome-based quality targets, whether for clinical indicators or public health indicators, are more difficult to achieve in some sections of the population. GPs working in inner-city areas may feel they have to work much harder and invest more practice resources to perform well on outcome-based quality targets. This is true - but we can address this by ensuring that, where appropriate, payments for achieving quality targets reflect the population GPs serve, to ensure those working with vulnerable populations are rewarded sufficiently for providing high-quality care and starting to address health inequalities.

We are right to be proud of the NHS. We all want it to provide high-quality care. Despite our best intentions, a considerable gap remains between best achievable practice and the quality of care actually being provided. Focusing the QOF on clinical outcomes will help address this quality gap by rewarding practices that ensure our patients receive the care they need to maintain their health, prevent the onset of disease and optimise their management when patients do develop a chronic disease.

Source: Pulse August 5th 2009

WHO Meeting on Technology and Patient Safety

2009-11-14T17:03:00.002Z

Information technology has great potential to improve the quality and safety of healthcare. However, this potential has not yet been fully realised and considerable work remains to be done in this field. Earlier this year, the World Health Organization held a meeting on technology and patient safety. I chaired one of the four working groups, which were comprised of members from across the world. My working group has now completed its report, which is currently undergoing peer review.

IEF Saharawi Refugee Event

2009-11-13T07:19:00.002Z

The International Educational Fund held a successful event to raise funds for their project to aid Saharawi refugee children living in Algeria. Amongst the speakers at the event were myself, Professor Alan Fenwick, Professor Sir Roy Anderson, Professor Sir Magdi Yacoub, Professor Yahia Zoubir and Ms Danielle Smith. Pictured above are Sir Roy Anderson, Alan Fenwick, Suha Bachir (the current chair of the IEF) and myself along with some of the other executive members of the IEF. Congratulations to the IEF for all the hard work they put in to make this event successful.

Academic Clinical Fellow Posts in Public Health

2009-11-03T16:25:00.002Z

Three Academic Clinical Fellow Posts in Public Health linked to Imperial College are currently being advertised. For further details of the application process, please see the London Deanery website. The job description is also available on the London Deanery Website. The deadline for applications is December 4th 2009. The posts offer the opportunity to undertake public health training with an academic focus and dedicated time for research. Please note, these posts are only open to medically qualified candidates with full GMC registration.

IEF Project Launch Event

2009-11-01T06:32:00.003Z

The IEF will launch a project for Saharawi refugees on November 11th 2009. Th IEF will provide computers for local schools working alongside a blind school, helping them receive specialist equipment, You can purchase tickets to attend at the IEF's Sahara Project Just Giving page.

Congratulations to Adeel Iqbal and the IEF

2009-10-26T09:21:00.000Z

Former chairman and founder of the International Education Fund, Adeel Iqbal, received Imperial College's prestigious 'Student Award for Outstanding Achievement'. Adeel and his dedicated team invested much energy and enthusiasm into developing an organisation which brings together the talents of enthusiastic students to bring about positive academic changes in third world countries. Amongst Adeel's major achievement has been partnering with a school for blind children in Kashmir. The IEF is growing rapidly and is now under the leadership of fifth year medical student Suha Bachir who is launching a project to help refugee children in the Western Sahara, Africa. This project is to be launched on the 11th November 2009 at Imperial College Business School.