Telehealth and primary care: a special collection from BJGP Open

In this BJGP Open special issue, we explore how increased reliance on telehealth has changed clinical practice. Telehealth, defined as the provision of healthcare remotely through telecommunications technology, has been integrated into health services with varying degrees of success in the past. The COVID-19 pandemic has accelerated this process, with telehealth presenting a solution to care delivery during national lockdowns and social distancing requirements. There has been vast amounts of research examining what has worked, potential improvements, and what should be retained in the post-pandemic world. This collection of articles adds to the discourse and considers telehealth in three broad areas: access to services, quality of care, and conducting consultations

Effect on cardiovascular disease risk factors of interventions to alter consultations between practitioners and patients with type 2 diabetes: A systematic review and meta-analysis of trials in primary care

$\textbf{Objective:}$ To examine the effect on cardiovascular (CVD) risk factors of interventions to alter consultations between practitioners and patients with type 2 diabetes. $\textbf{Search Strategy:}$ Electronic and manual citation searching to identify relevant randomized controlled trials (RCTs). $\textbf{Inclusion Criteria:}$ RCTs that compared usual care to interventions to alter consultations between practitioners and patients. The population was adults aged over 18 years with type 2 diabetes. Trials were set in primary care. $\textbf{Data extraction and synthesis:}$ We recorded if explicit theory-based interventions were used, how consultations were measured to determine whether interventions had an effect on these and calculated weighted mean differences for CVD risk factors including glycated haemoglobin (HbA$_{1c}$), systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), LDL cholesterol (LDL-C) and HDL cholesterol (HDL-C). $\textbf{Results:}$ We included seven RCTs with a total of 2277 patients with type 2 diabetes. A range of measures of the consultation was reported, and underlying theory to explain intervention processes was generally undeveloped and poorly applied. There were no overall effects on CVD risk factors; however, trials were heterogeneous. Subgroup analysis suggested some benefit among studies in which interventions demonstrated impact on consultations; statistically significant reductions in HbA$_{1c}$ levels (weighted mean difference, −0.53%; 95% CI: [−0.77, −0.28]; $P$<.0001; $I^{2}$ =46%). $\textbf{Conclusions:}$ Evidence of effect on CVD risk factors from interventions to alter consultations between practitioners and patients with type 2 diabetes was heterogeneous and inconclusive. This could be explained by variable impact of interventions on consultations. More research is required that includes robust measures of the consultations and better development of theory to elucidate mechanisms.HDM was an Academic Clinical Fellow, Andrew Cooper is funded by the University of Cambridge MRC Epidemiology Unit (grant code: MC_UU_12015/4), SJG is an NIHR Senior Investigator. The primary care unit is a member of the National Institute for Health Research (NIHR) School for Primary Care Research and supported by NIHR Research funds. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health

Clustering populations by health and social care with multiple long-term conditions: a cohort study - the English Longitudinal Study of Ageing (ELSA)

Background The integration of health and social care services is a potential solution for improving care, despite monetary constraints and increasing demand. How two or more multiple long-term conditions (MLTC) cluster, interact and associate with socioeconomic factors, and affect access to unscheduled primary healthcare services is understudied. Aim To cluster an MLTC population by health and social care, examine clusters, and quantify associations with health outcomes. Method A retrospective cohort study was conducted using the ELSA database (2002 to 2019) on 19802 participants aged ≥50 years. Ten major health conditions, and social care need, including difficulty in activities of daily living (ADL) and mobility, for example, were used to cluster MLTC by latent class modelling. Multivariate logistic regression models were used to establish further association. Results The mean age of the participants at baseline (wave 2) was about 66 years and 55% of participants were female, with more than 60% developing MLTC in their lifetime (waves 2 to 9). Of the five distinct latent clusters, cluster 5 was the most significant cluster composed of lung diseases, stroke, dementia, and high ADL and mobility difficulty scores. The majority of the participants were aged 70–79 years, female, and married. The odds of having a longer nursing home stay were 8.97 (95% confidence interval = 4.36 to 18.45), and death was 10% higher in this cluster compared to the highest probability cluster 4 in the maximally adjusted regression model. Conclusion This study identified MLTC clusters by social care need with the highest primary care demand. Targeting clinical practice to prevent MLTC progression for these groups may lessen future pressures on primary care demand

Socioeconomic inequalities in the risk of infection with SARS-CoV-2 Delta and Omicron variants in United Kingdom, 2020-22

Objective: It is unknown whether SARS-CoV-2 exposure risks vary by socioeconomic deprivation within and across occupation sectors. We explored the risk of testing positive for Delta or Omicron variants, the predominantly dominant SARS-CoV-2 variants during our study period, within certain occupation sectors and deprivation groups in the UK. Methods and Analysis: We used the COVID-19 Infection Survey (CIS) to examine the risk of testing positive with SARS-CoV-2 across area-level deprivation and occupation sectors. We divided our cohort into Delta (02.07.2020–19.12.2021) and Omicron (20.12.2021–31.01.2022) cohorts as they were the predominantly dominant variants during our study period. Multivariable Poisson regression models were used to estimate adjusted incidence rate ratio (IRR) after adjusting for age, sex, ethnicity, comorbid conditions, urban/rural home address, household size, healthcare/client-facing job categories and calendar time. Results: There were 329,356 participants in the Delta cohort and 246,061 in the Omicron cohort. The crude incidence rate for Delta and Omicron cases were higher in the most deprived decile (Delta: 4.33 per 1000 person months; 95% CI: 4.09, 4.58; Omicron: 76.67; 71.60, 82.11) than in the least deprived decile (3.18; 3.05, 3.31; and 54.52; 51.93, 57.24, respectively); the corresponding adjusted IRRs were 1.37 (95% CI: 1.29, 1.47) and 1.34 (1.24, 1.46) during the Delta and Omicron period, respectively. The adjusted IRR for testing positive in the most deprived compared with the least deprived decile in the Delta cohort were 1.59 (1.25, 2.02) and 1.50 (1.19, 1.87) in healthcare and manufacturing or construction occupation sectors, respectively. Corresponding values in the Omicron cohort were 1.50 (1.15, 1.95) and 1.43 (1.09, 1.86) in healthcare and teaching and education sectors. The associations for the other employment sectors were not statistically significant or not tested due to small numbers. Conclusion: The risk of testing positive for SARS-CoV-2 in the Delta and Omicron cohorts was higher in the most deprived compared with the least deprived decile in healthcare, manufacturing or construction, and teaching and education sectors

Behaviour change, weight loss and remission of Type 2 diabetes: a community-based prospective cohort study

Aim: To quantify the association between behaviour change and weight loss after diagnosis of Type 2 diabetes, and the likelihood of remission of diabetes at 5-year follow-up. Method: We conducted a prospective cohort study in 867 people with newly diagnosed diabetes aged 40–69 years from the ADDITION-Cambridge trial. Participants were identified via stepwise screening between 2002 and 2006, and underwent assessment of weight change, physical activity (EPAQ2 questionnaire), diet (plasma vitamin C and self-report), and alcohol consumption (self-report) at baseline and 1 year after diagnosis. Remission was examined at 5 years after diabetes diagnosis via HbA1c level. We constructed log binomial regression models to quantify the association between change in behaviour and weight over both the first year after diagnosis and the subsequent 1–5 years, as well as remission at 5-year follow-up. Results: Diabetes remission was achieved in 257 participants (30%) at 5-year follow-up. Compared with people who maintained the same weight, those who achieved ≥ 10% weight loss in the first year after diagnosis had a significantly higher likelihood of remission [risk ratio 1.77 (95% CI 1.32 to 2.38;

Patient-centred care, health behaviours and cardiovascular risk factor levels in people with recently diagnosed type 2 diabetes: 5-year follow-up of the ADDITION-Plus trial cohort.

OBJECTIVE: To examine the association between the experience of patient-centred care (PCC), health behaviours and cardiovascular disease (CVD) risk factor levels among people with type 2 diabetes. DESIGN: Population-based prospective cohort study. SETTING: 34 general practices in East Anglia, UK, delivering organised diabetes care. PARTICIPANTS: 478 patients recently diagnosed with type 2 diabetes aged between 40 and 69 years enrolled in the ADDITION-Plus trial. MAIN OUTCOME MEASURES: Self-reported and objectively measured health behaviours (diet, physical activity, smoking status), CVD risk factor levels (blood pressure, lipid levels, glycated haemoglobin, body mass index, waist circumference) and modelled 10-year CVD risk. RESULTS: Better experiences of PCC early in the course of living with diabetes were not associated with meaningful differences in self-reported physical activity levels including total activity energy expenditure (β-coefficient: 0.080 MET h/day (95% CI 0.017 to 0.143; p=0.01)), moderate-to-vigorous physical activity (β-coefficient: 5.328 min/day (95% CI 0.796 to 9.859; p=0.01)) and reduced sedentary time (β-coefficient: -1.633 min/day (95% CI -2.897 to -0.368; p=0.01)). PCC was not associated with clinically meaningful differences in levels of high-density lipoprotein cholesterol (β-coefficient: 0.002 mmol/L (95% CI 0.001 to 0.004; p=0.03)), systolic blood pressure (β-coefficient: -0.561 mm Hg (95% CI -0.653 to -0.468; p=0.01)) or diastolic blood pressure (β-coefficient: -0.565 mm Hg (95% CI -0.654 to -0.476; p=0.01)). Over an extended follow-up of 5 years, we observed no clear evidence that PCC was associated with self-reported, clinical or biochemical outcomes, except for waist circumference (β-coefficient: 0.085 cm (95% CI 0.015 to 0.155; p=0.02)). CONCLUSIONS: We found little evidence that experience of PCC early in the course of diabetes was associated with clinically important changes in health-related behaviours or CVD risk factors. TRIAL REGISTRATION NUMBER: ISRCTN99175498; Post-results.The trial is supported by the Medical Research Council (grant reference no: G0001164 ), the Wellcome Trust (grant reference no: G061895 ),Diabetes UK and National Health Service R&D support funding . SJG is a member of the National Institute for Health Research (NIHR) School for Primary Care Research. The General Practice and Primary Care Research Unit was supported by NIHR Research funds. ATP is supported by the NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London. The views expressed in this publication are those of the authors and not necessarily those of the Department of Health.This is the final version of the article. It was first available from BMJ via http://dx.doi.org/10.1136/bmjopen-2015-00893

Social care need in multimorbidity

No abstract available