Patient safety in English general practice : the role of routinely collected data in detecting adverse events

The use of routinely collected, or administrative, data for measuring and monitoring patient safety in primary care is a relatively new phenomenon. With increasing availability of data from different sources and care settings, their application for adverse event surveillance needs evaluation. In this thesis, I demonstrated that data routinely collected from primary care and secondary care can be applied for internal monitoring of adverse events at the general practice-level in England, but these data currently have limited use for safety benchmarking in primary care. To support this statement, multiple approaches were adopted. In the first part of the thesis, the nature and scope of patient safety issues in general practice were defined by evidence from a literature review and informal consultations with general practitioners (GPs). Secondly, using these two methods, measures of adverse events based on routinely collected healthcare data were identified. Thirdly, clinical consensus guided the selection of three candidate patient safety indicators for investigation; the safety issues explored in this thesis were recorded incidents with designated adverse event diagnostic codes and complications associated with two common diseases, emergency admissions for diabetic hyperglycaemic emergencies (diabetic ketoacidosis, DKA and hyperglycaemic hyperosmolar state, HHS) and cancer. In the second part of the thesis, the contributions of routinely collected data to new knowledge about potentially preventable adverse events in England were considered. Data from a primary care trust (NHS Brent), national primary care data (from the General Practice Research Database, GPRD) and secondary care data (Hospital Episode Statistics, HES) were used to explore the epidemiology of, and patient characteristics associated with, coded adverse events and emergency admissions for diabetic hyperglycaemic emergencies and cancer. Low rates of adverse events were found, with variation by individual patient factors. Finally, recommendations were made on extending the uses of routinely collected data for patient safety monitoring in general practice

Electronic medical records in paediatric ophthalmology: a study of potential users and uses to inform design

Electronic medical records are at the core of an advancing movement toward information-driven healthcare. By enhancing abilities to capture, store, and analyse vast amounts of health data, the routine use of electronic medical records is advocated as a means to improve the efficiency and quality of care provision, advance population health, empower patients, and reduce healthcare costs. However, the delivery of any benefits is threatened by a failure to understand the unique care environments of different clinical specialties, and to appropriately customise system design. This has prompted a move to the user-centred design process of health information technology. Paediatric ophthalmology is a unique field that faces particular challenges in electronic medical record adoption. As with other ophthalmic specialties, the heavy use of imaging and diagrammatic documentation is difficult to replicate electronically. As is the flexibility required to meet the demands incurred by the varying ages, developmental stages, and visual needs of each patient, reflecting a unique interface between the ophthalmic and paediatric requirements. The consideration of such requirements is essential throughout the user-centred design of effective health information technology systems. However, paucity in the evidence base surrounding electronic medical record design methodologies and system usage hinders technological development and application within paediatric ophthalmology. This research was centred on a user-centred design process, to provide an understanding of the users of electronic medical records in paediatric ophthalmology, and their requirements. Taking a mixed methods approach, this research initially explored the landscape of medical record use – gathering user- centred requirements – and concluded with the development and testing of three prototype data collection forms, for specific use cases within paediatric ophthalmology. Overall, this work articulates the specific challenges and requirements in this area, and provides the foundation for future design and adoption strategies of electronic medical record systems within paediatric ophthalmology

Interventions to increase attendance for diabetic retinopathy screening

BACKGROUND: Despite evidence supporting the effectiveness of diabetic retinopathy screening (DRS) in reducing the risk of sight loss, attendance for screening is consistently below recommended levels.OBJECTIVES: The primary objective of the review was to assess the effectiveness of quality improvement (QI) interventions that seek to increase attendance for DRS in people with type 1 and type 2 diabetes.Secondary objectives were:To use validated taxonomies of QI intervention strategies and behaviour change techniques (BCTs) to code the description of interventions in the included studies and determine whether interventions that include particular QI strategies or component BCTs are more effective in increasing screening attendance;To explore heterogeneity in effect size within and between studies to identify potential explanatory factors for variability in effect size;To explore differential effects in subgroups to provide information on how equity of screening attendance could be improved;To critically appraise and summarise current evidence on the resource use, costs and cost effectiveness.SEARCH METHODS: We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, Web of Science, ProQuest Family Health, OpenGrey, the ISRCTN, ClinicalTrials.gov, and the WHO ICTRP to identify randomised controlled trials (RCTs) that were designed to improve attendance for DRS or were evaluating general quality improvement (QI) strategies for diabetes care and reported the effect of the intervention on DRS attendance. We searched the resources on 13 February 2017. We did not use any date or language restrictions in the searches.SELECTION CRITERIA: We included RCTs that compared any QI intervention to usual care or a more intensive (stepped) intervention versus a less intensive intervention.DATA COLLECTION AND ANALYSIS: We coded the QI strategy using a modification of the taxonomy developed by Cochrane Effective Practice and Organisation of Care (EPOC) and BCTs using the BCT Taxonomy version 1 (BCTTv1). We used Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital (PROGRESS) elements to describe the characteristics of participants in the included studies that could have an impact on equity of access to health services.Two review authors independently extracted data. One review author entered the data into Review Manager 5 and a second review author checked them. Two review authors independently assessed risks of bias in the included studies and extracted data. We rated certainty of evidence using GRADE.MAIN RESULTS: We included 66 RCTs conducted predominantly (62%) in the USA. Overall we judged the trials to be at low or unclear risk of bias. QI strategies were multifaceted and targeted patients, healthcare professionals or healthcare systems. Fifty-six studies (329,164 participants) compared intervention versus usual care (median duration of follow-up 12 months). Overall, DRS attendance increased by 12% (risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14; low-certainty evidence) compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted (RD 0.17, 95% CI 0.11 to 0.22) and general QI interventions (RD 0.12, 95% CI 0.09 to 0.15) were effective, particularly where baseline DRS attendance was low. All BCT combinations were associated with significant improvements, particularly in those with poor attendance. We found higher effect estimates in subgroup analyses for the BCTs 'goal setting (outcome)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients, and 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting healthcare professionals.Ten studies (23,715 participants) compared a more intensive (stepped) intervention versus a less intensive intervention. In these studies DRS attendance increased by 5% (RD 0.05, 95% CI 0.02 to 0.09; moderate-certainty evidence).Fourteen studies reporting any QI intervention compared to usual care included economic outcomes. However, only five of these were full economic evaluations. Overall, we found that there is insufficient evidence to draw robust conclusions about the relative cost effectiveness of the interventions compared to each other or against usual care.With the exception of gender and ethnicity, the characteristics of participants were poorly described in terms of PROGRESS elements. Seventeen studies (25.8%) were conducted in disadvantaged populations. No studies were carried out in low- or middle-income countries.AUTHORS' CONCLUSIONS: The results of this review provide evidence that QI interventions targeting patients, healthcare professionals or the healthcare system are associated with meaningful improvements in DRS attendance compared to usual care. There was no statistically significant difference between interventions specifically aimed at DRS and those which were part of a general QI strategy for improving diabetes care. This is a significant finding, due to the additional benefits of general QI interventions in terms of improving glycaemic control, vascular risk management and screening for other microvascular complications. It is likely that further (but smaller) improvements in DRS attendance can also be achieved by increasing the intensity of a particular QI component or adding further components.</p

Outcomes of the metabolically healthy obese

Introduction: Obesity is a worldwide epidemic, Metabolic Healthy Obesity (MHO) is a vital subcohort of obesity that needs to be further investigated and epidemiologically defined. This has not received the clinical and public health attention it deserves and would help in targeting lifestyle and interventions (surgery) to those best suited. Methods: This thesis utilised long term primary care follow up using the Clinical Practice Research Datalink (CPRD) to quantify prevalence, investigate transition, investigate all-cause mortality in the sub-cohort and study intervention outcomes in the United Kingdom. Results: Total number of 414,522 patients were extracted, of which 231,399 (55.8%) had a body mass index (BMI) recorded. This thesis utilised 180,560 patients after exclusions. The prevalence of MHO in the UK population was 128,191/180,560 (71.0%), of which 71,485/128,191 (55.8%) remained healthy (p=<0.01) with a mean follow-up of 68.2 months. There was a 3.7% mortality rate in the MHO vs the metabolically unhealthy cohort 7.1% with an increased risk of mortality associated with a high BMI, late age at diagnosis and male gender. Frequency of bariatric surgery was generally was performed more in the metabolically healthy than unhealthy, 2.2% vs 1.9%. On Cox regression analysis, bariatric surgery remained a nonsignificant independent factor of survival within both the metabolically healthy and unhealthy obese. Conclusion: The implication of this study is that a diagnosis of obesity as an independent factor for immediate determination of impending complications. It is imperative that the body mass index of an obese patient is laid side by side with their metabolic rate indices. On the grounds of conclusions from this thesis, further studies into the pathophysiology of metabolically unhealthy obesity are necessary, with a close reference to the presence or absence of comorbidity.Open Acces

Quality of care in incident type 2 diabetes and initial presentation of vascular complications: Prospective cohort study using linked electronic health records from CALIBER research platform

Background. Numbers of new cases of type 2 diabetes (T2D) are increasing rapidly. Early and continuing intervention after T2D presentation is crucial for best possible outcomes, ensuring that the existing high burden of T2D will not be aggravated. Identification of patterns of continuous care and predictors for meeting key targets for T2D management can improve quality of care. Glycaemic control is particularly important for primary prevention of vascular complications but its relationship with contemporary cardiovascular diseases (CVDs) has been less explored. More importantly, long-term glycaemic control can be assessed from routine monitoring, potentially providing new insight into T2D management to prevent vascular complications. Linked electronic health records are invaluable data resources for investigating these issues. Objective. To examine the quality of care in an incident T2D cohort through assessment of temporal trends of care, predictors of glycaemic, blood pressure and lipid control, and associations of short-term and long-term glycaemic control with chronic vascular complications. Methods. The data source for studies in this thesis was CALIBER which links electronic health records from primary care, hospitalisation, myocardial infarction and mortality registries. Patients newly diagnosed with T2D between 1998 and 2010 were followed-up until a censoring administrative date or initial occurrence of vascular complications. Trends in receipt of care and attainment of glycaemic, blood pressure and total cholesterol targets were examined. Predictors for meeting the targets were explored using multinomial logistic regressions. Association of early glycaemic control with a range of specific cardiovascular complications were investigated using Cox regressions. A longitudinal metric for glycaemic control was developed by quantifying time spent at target during follow-up and was tested for its association with cardiovascular and microvascular outcomes using mixed logistic regressions. Results. A total of 52,379 incident T2D patients were identified with a median follow-up of over 4 years. Positive trends were observed for blood pressure and total cholesterol control, but not for glycaemic control, whilst attainment of HbA1c and blood pressure targets over time consistently fell short. Older age at diagnosis was an important predictor for meeting the key targets. In 36,149 patients free from prior CVD, early glycaemic and blood pressure control was associated with lower risk for heart failure and peripheral arterial disease, whereas cholesterol control with myocardial infarction and transient ischaemic attack. Shorter duration at glycaemic target was associated with higher risk of major adverse cardiovascular events, cardiovascular death and diabetic retinopathy. Conclusions. This thesis highlights missed opportunities and inequality in T2D care. Both short-term and long-term glycaemic control are important for reducing risk of vascular complications. Limitations and implications of the findings for clinical practice and research were discussed

Artificial intelligence in healthcare delivery: Prospects and pitfalls

This review provides a comprehensive examination of the integration of Artificial Intelligence (AI) into healthcare, focusing on its transformative implications and challenges. Utilising a systematic search strategy across electronic databases such as PubMed, Scopus, Embase, and ScienceDirect, relevant peer-reviewed articles published in English between January 2010 till date were identified. Findings reveal AI's significant impact on healthcare delivery, including its role in enhancing diagnostic precision, enabling treatment personalisation, facilitating predictive analytics, automating tasks, and driving robotics. AI algorithms demonstrate high accuracy in analysing medical images for disease diagnosis and enable the creation of tailored treatment plans based on patient data analysis. Predictive analytics identify high-risk patients for proactive interventions, while AI-powered tools streamline workflows, improving efficiency and patient experience. Additionally, AI-driven robotics automate tasks and enhance care delivery, particularly in rehabilitation and surgery. However, challenges such as data quality, interpretability, bias, and regulatory frameworks must be addressed for responsible AI implementation. Recommendations emphasise the need for robust ethical and legal frameworks, human-AI collaboration, safety validation, education, and comprehensive regulation to ensure the ethical and effective integration of AI in healthcare. This review provides valuable insights into AI's transformative potential in healthcare while advocating for responsible implementation to ensure patient safety and efficacy

Telemedicine

Telemedicine is a rapidly evolving field as new technologies are implemented for example for the development of wireless sensors, quality data transmission. Using the Internet applications such as counseling, clinical consultation support and home care monitoring and management are more and more realized, which improves access to high level medical care in underserved areas. The 23 chapters of this book present manifold examples of telemedicine treating both theoretical and practical foundations and application scenarios

An evaluation of the impact of a data driven, individualised, diabetes specific, structured information delivered by mail to people with diabetes : the WICKED (Wolverhampton Interface Care-Knowledge Empowered Diabetes) Project

Background Does promoting patient activation improve outcomes? We tested the hypothesis that provision of structured and personalised information can activate patients, promote selfcare, and improve outcomes. Methods We recruited all eligible people with diabetes in Wolverhampton CCG (n= 14,559), randomizing them into two groups. The active group was mailed their “My diabetes, My information, My plan” report at baseline, 3 and 6 months; the control group received standard care for first 3 months, then a single mailing. We compared a Failed Process Score (FPS = completion of nine processes; zero = full attainment) and HbA1c. A patient feedback survey was sent to 1000 randomly selected patients from the active cohort to assess the qualitative impact of this individualised report. Results At three months, the FPS score (1.25 ± 1.87 vs. 1.35 ± 1.97, P < 0.01) and the change in FPS score (0.48 ± 1.55 vs. 0.42 ± 1.49, P < 0.02) were significantly better in the active group. At 12 months FPS score between group differences just failed overall significance (F=3.459, p=0.06). However, in those with lower baseline activation (FPS of ≥2), FPS was significantly better (F=4.369, p=0.037, 3 month (p<0.01), 12 month (p=0.01)) in the multi mailed and their likelihood of achieving the good attainment category (12 month FPS ≤1) with mailing was 1.15 (95% CI 1.02 – 1.29, p=0.022). Considering baseline HbA1c% categories as ≤7.5, 7.6-8.4 and ≥8.5, and adjusting for variables in univariate analysis (r2=0.39, p<0.001; age p<0.001, gender (ns), ethnicity (ns), IMD score (ns), type of diabetes (ns)), the impact of being mailed multiple times was significant (F= 6.2, p=0.013).In the patient feedback survey, patients found this report useful (89%), a source of knowledge (78%) and confidence (74%) and it helped them in understanding their diabetes (78%). Conclusion The provision of structured and individualized information to people with diabetes can positively influence the level of patient activation, promote better engagement and open the potential to improve other crucial diabetes outcomes

Effectiveness of sitagliptin vs sulphonylureas for managing type 2 diabetes mellitus in clinical practice

One challenging prescribing decision in type 2 diabetes mellitus (T2DM) is when clinicians must choose between sitagliptin and sulphonylureas as add-on to metformin based on effectiveness. Evidence on effectiveness of sitagliptin versus sulphonylureas as add-on to metformin was therefore systematically searched and revealed no study evaluating “real-world” comparative effectiveness of these treatments, particularly in older, more comorbid individuals. To address this gap, The Health Improvement Network, UK primary care database was used to extract a cohort of 26,844 individuals with T2DM prescribed these treatments and four cohort studies were undertaken to evaluate their comparative effectiveness. The first two studies demonstrated no difference in HbA1c reduction, approximately 12 months after initiating either treatment as add-on to metformin, however a significant comparative weight reduction with sitagliptin in those aged 18-75 (-2.26kg 95%CI -2.48 to -2.04) and ≥75 (-1.31kg 95%CI -1.96 to -0.66) was found. Two further studies revealed individuals prescribed sitagliptin were 11% more likely to record an undesirable HbA1c >58mmol/mol (Hazard Ratio 1.11 95%CI 1.06-1.16), however nearly twice as likely to record an anti-diabetic treatment change (HR 1.98 95%CI 1.86-2.10) compared to sulphonylurea initiators. This analysis on treatment change also highlighted an underlying inertia in both groups, as 66.4% of those prescribed sitagliptin and 83.7% prescribed sulphonylureas had no treatment change introduced despite recording a HbA1c >58 mmol/mol. This thesis provides “real-world” evidence that both sitagliptin and sulphonylureas are equally effective in lowering HbA1c and achieving glycaemic targets in a population that includes individuals aged ≥75 and with significant comorbidity. Sitagliptin is preferable for weight reduction. There is however, a substantial inertia in changing treatment when targets are not met, which is greater among sulphonylurea initiators. There remains a need to eliminate barriers preventing clinicians changing treatment when these two add-on medications prove inadequate, and further evaluate their longer-term comparative effectiveness