Correlation between prescribing quality and pharmaceutical costs in English primary care: national cross-sectional analysis

Background Both pharmaceutical costs and quality-indicator performance vary substantially between general practices, but little is known about the relationship between prescribing costs and quality Aim To measure the association between prescribing quality and pharmaceutical costs among English general practices Design and setting Cross-sectional observational study using data from the Quality and Outcomes Framework and the Prescribing Analysis and Cost database from all 8409 general practices in England in 2005-2006 Method Correlation between practice achievement of 26 prescribing quality indicators in eight prescribing areas and related pharmaceutical costs was examined. Results There was no significant association between the overall achievement of quality indicators and related pharmaceutical costs (P= 0.399). Mean achievement of quality indicators across all eight prescribing areas was 79.0% (standard deviation 4.4%). There were small positive correlations in five prescribing areas: influenza vaccination, beta blockers, angiotensin converting enzyme inhibitors, lipid lowering, and antiplatelet treatment (all

Do the incentive payments in the new NHS contract for primary care reflect likely population health gains?

The new contract for primary care in the UK offers fee-for-service payments for a wide range of activities in a quality outcomes framework, with payments designed to reflect likely workload. This study aims to explore the link between these financial incentives and the likely population health gains. The study examines a subset of eight preventive interventions covering 38 of the 81 clinical indicators in the quality framework. The maximum payment for each service was calculated and compared with the likely population health gain in terms of lives saved per 100,000 population based on evidence from McColl et al. (1998). Maximum payments for the eight interventions examined make up 57% of the sum total maximum payment for all clinical interventions in the quality outcomes framework. There appears to be no relationship between pay and health gain across these eight interventions. Two of the eight interventions (warfarin in atrial fibrillation and statins in primary prevention) receive no incentive. Payments in the new contract do not reflect likely population health gain. There is a danger that clinical activity may be skewed towards high-workload activities that are only marginally effective, to the detriment of more cost effective activities. If improving population health is the primary goal of the NHS, then fee-for-service incentives should be designed to reflect likely health gain rather than likely workload.health policy, incentive payments, primary care, quality, UK

Medical morbidities in people following hip and knee arthroplasty: data from the Osteoarthritis Initiative

Background: Total hip (THA) and knee (TKA) arthroplasty are common orthopaedic procedures most frequently for older people. Whilst it is known that this older population frequently present with medical morbidities, no studies have previously documented the prevalence of such morbidities in people who have undergone THA or TKA. The purpose of this study was to determine the prevalence and what factors are in association with the presentation of medical morbidities in these populations. Methods: Data from the Osteoarthritis Initiative, a population-based observational study, was assessed. In total 419 people who had undergone a THA or TKA were assessed to determine the prevalence of recorded morbidities within 12 months post-arthroplasty. All medical morbidities were then assessed using univariate and then multivariate logistic regression analysis to identify factors influencing the presentation of specific morbidities at 12 months following THA or TKA. Results: The most common medical morbidities included: osteoporosis (16%), mild to moderate depression (8%), cancer (8%), diabetes (6%), history of stroke or TIA (6%) and asthma (5%). The medical morbidities demonstrated are similar between those who undergo THA and TKA. Only gender and ethnic origin were identified as statistically significant predictors of medical morbidities in these populations. Gender was a predictor of history of heart failure, whilst ethnic origin significantly predicted depression. Conclusions: People who undergo THA or TKA may present with a variety of medical morbidities. Accordingly consideration should be made on how to encourage the adoption and maintenance of physical activity and healthy lifestyle choices for this population

Does practice analysis agree with the ambulatory care sensitive conditions list of avoidable unplanned admissions: cross-sectional study in the East of England.

Objectives: To use Significant Event Audits (SEA) in primary care to determine which of a sample of emergency (unplanned) admissions were potentially avoidable; and compare to the NHS list of ambulatory care sensitive conditions (ACSCs). Design: Analysis of unplanned medical admissions randomly identified in secondary care. Setting: Primary Care in the East of England. Participants: 20 general practice teams trained to use SEA on unplanned admissions to identify potentially preventable factors. Interventions: SEA of admissions. Main outcome measures: Level of agreement between those admissions identified as potentially preventable by SEA and the NHS ACSC list. Results: 132 (26%) of randomly selected patients with unplanned admissions gave consent and an SEA was performed by their primary practice team. 130 SEA reports had sufficient data for our analysis. Practices concluded that 17 (13%) of admissions were potentially preventable. The NHS ACSC list identified 36 admissions (28%) as potentially preventable. There was a low level of agreement between the practices and the NHS list as to which admissions were preventable (Kappa = 0.253). The ACSC list consisted mainly of respiratory admissions whereas the practice list identified a wider range of cases and identified context-specific factors as important. Conclusions: There was disagreement between the NHS list and practice conclusions of potentially avoidable admissions. The SEAs suggest that the pathway into unplanned admission may be less dependent on the condition than on context-specific factors, and the assumption that unplanned admissions for ACSC conditions are reasonable indicators of performance for primary care may not be valid

The dynamics of quality: a national panel study of evidence-based standards

This is the final version of the article. Available from NIHR Health Technology Assessment Programme via the DOI in this record.Background Shortfalls in the receipt of recommended health care have been previously reported in England, leading to preventable poor health. Objectives To assess changes over 6 years in the receipt of effective health-care interventions for people aged 50 years or over in England with cardiovascular disease, depression, diabetes or osteoarthritis; to identify how quality varied with participant characteristics; and to compare the distribution of illness burden in the population with the distributions of diagnosis and treatment. Setting and participants Information on health-care quality indicators and participant characteristics was collected using face-to-face structured interviews and nurse visits in participants’ homes by the English Longitudinal Study of Ageing in 2004–5, 2006–7, 2008–9 and 2010–11. A total of 16,773 participants aged 50 years or older were interviewed at least once and 5114 were interviewed in all four waves; 5404 reported diagnosis of one or more of four conditions in 2010–11. Main outcome measures Percentage of indicated health care received by eligible participants for 19 quality indicators: seven for cardiovascular disease, three for depression, five for diabetes and four for osteoarthritis, and condition-level quality indicator achievement, including achievement of a bundle of three diabetes indicators. Analysis Changes in quality indicator achievement over time and variations in quality with participant characteristics were tested with Pearson’s chi-squared test and logistic regression models. The size of inequality between the hypothetically wealthiest and poorest participants, for illness burden, diagnosis and treatment, was estimated using slope indices of wealth inequality. Results Achievement of indicators for cardiovascular disease was 82.7% [95% confidence interval (CI) 79.9% to 85.5%] in 2004–5 and 84.2% (95% CI 82.1% to 86.2%) in 2010–11, for depression 63.3% (95% CI 57.6% to 69.0%) and 59.8% (95% CI 52.4% to 64.3%), for diabetes 76.0% (95% CI 74.1% to 77.8%) and 76.5% (95% CI 74.8% to 78.1%), and for osteoarthritis 31.2% (95% CI 28.5% to 33.8%) and 35.6% (95% CI 34.2% to 37.1%). Achievement of the diabetes care bundle was 67.8% (95% CI 64.5% to 70.9%) in 2010–11. Variations in quality by participant characteristics were generally small. Diabetes indicator achievement was worse in participants with cognitive impairment [odds ratio (OR) 0.5, 95% CI 0.4 to 0.7] and better in those living alone (OR 1.7, 95% CI 1.3 to 2.0). Hypertension care was better for those aged over 74 years (vs. 50–64 years) (OR 3.2, 95% CI 2.0 to 5.3). Osteoarthritis care was better for those with severe (vs. mild) pain (OR 1.8, 95% CI 1.4 to 2.2), limiting illness (OR 1.8, 95% CI 1.5 to 2.1), and obesity (OR 1.6, 95% CI 1.2 to 2.0). Previous non-achievement of the diabetes care bundle was the biggest predictor of non-achievement 2 years later (OR 3.3, 95% CI 2.2 to 4.7). Poorer participants were always more likely than wealthier participants to have illness burden (statistically significant OR 3.9 to 16.0), but not always more likely to be diagnosed or receive treatment (0.2 to 5.3). Conclusions Shortfalls in quality of care for these four conditions have persisted over 6 years, with only half of the level of indicated health care achieved for osteoarthritis, compared with the other three conditions. Quality for osteoarthritis improved slightly over time but remains poor. The relatively high prevalence of specific illness burden in poorer participants was not matched by an equally high prevalence of diagnosis or treatment, suggesting that barriers to equity may exist at the stage at diagnosis. Further research is needed into the association between quality and health system characteristics at the level of clinicians, general practices or hospitals, and regions. Linkage to routinely collected data could provide information on health service characteristics at the individual patient level.Funding for this study was provided by the Health Services and Delivery Research programme of the National Institute for Health Research

Protocol for a feasibility randomised controlled trial of Screening and Enhanced Risk management for Vascular Event-related Decline in Memory (SERVED Memory)

INTRODUCTION: Stroke is a leading cause of death and disability. The development of dementia after stroke is common. Vascular risk factors (VRF) which contribute to stroke risk can also contribute to cognitive decline, especially in vascular dementia (VaD). There is no established treatment for VaD, therefore strategies for prevention could have major health resource implications. This study was designed to assess whether patients with early cognitive decline after stroke/transient ischaemic attack (TIA) can be easily identified and whether target-driven VRF management can prevent progression to dementia.  OBJECTIVES: The primary objective is to establish the feasibility of recruitment and retention of patients with early cognitive decline to a randomised controlled trial of enhanced VRF management. Secondary objectives include: (a) to determine the potential clinical benefit of the intervention; (b) to estimate the sample size for a future definitive multicentre randomised controlled trial; (c) to inform a future economic evaluation; (d) to explore the link between VRF control and the incidence of cognitive impairment on longitudinal follow-up in a UK population after stroke/TIA with current routine management.  METHODS: 100 patients with cognitive decline poststroke/TIA will be recruited from stroke services at the Norfolk and Norwich University Hospital. After collection of baseline data, they will be randomised to intervention (3 monthly follow-up with enhanced management) or control (treatment as usual by the general practitioner). At 12 months outcomes (repeat cognitive testing, VRF assessment) will be assessed. A further 100 patients without cognitive decline will be recruited to a parallel observational group from the same site. At 12 months they will have repeat cognitive testing.  ETHICS AND DISSEMINATION: Ethical approval has been granted in England. Dissemination is planned via publication in peer-reviewed medical journals and presentation at relevant conferences.  TRIAL REGISTRATION NUMBER: 42688361; Pre-results

Tongue-tie and breastfeeding: Identifying problems in the diagnostic and treatment journey

Background Tongue-tie is a common condition that often adversely affects breastfeeding. There is research that suggests that frenulotomy can improve breastfeeding but there is also evidence of lack of professional knowledge on tongue-tie. Methods This was a qualitative interview study with GPs, midwives, health visitors and nine mothers to explore facilitators and barriers to receiving a diagnosis of and treatment for tongue-tie. Findings Mothers told a common story of having to push for support, experiencing diagnostic and treatment delays and suffering ongoing distress, which threatened their ability to establish breastfeeding. Mothers also described feeling vulnerable in the neonatal period, and witnessing a variation in professional knowledge about tongue-tie. Conclusions Variable professional knowledge, conflicting advice, and a delayed diagnosis can lead to a difficult patient pathway. Assessment for tongue-tie should be considered when approaching infants with feeding difficulties. Frenulotomy should also be considered and services made available where findings suggest the cause is structural and breastfeeding support has not helped. </jats:sec