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

Variations in statin prescribing for primary cardiovascular disease prevention: cross-sectional analysis

Background Statins are an important intervention for primary and secondary cardiovascular disease (CVD) prevention. We aimed to establish the variation in primary preventive treatment for CVD with statins in the English population. Methods Cross sectional analyses of 6155 English primary care practices with 40,017,963 patients in 2006/7. Linear regression was used to model prescribing rates of statins for primary CVD prevention as a function of IMD (index of multiple deprivation) quintile, proportion of population from an ethnic minority, and age over 65 years. Defined Daily Doses (DDD) were used to calculate the numbers of patients receiving a statin. Statin prescriptions were allocated to primary and secondary prevention based on the prevalence of CVD and stroke. Results We estimated that 10.5% (s.d.3.7%) of the registered population were dispensed a statin for any indication and that 6.3% (s.d. 3.0%) received a statin for primary CVD prevention. The regression model explained 21.2% of the variation in estimates of prescribing for primary prevention. Practices with higher prevalence of hypertension (β co-efficient 0.299 p <0.001) and diabetes (β co-efficient 0.566 p < 0.001) prescribed more statins for primary prevention. Practices with higher levels of ethnicity (β co-efficient-0.026 p <0.001), greater deprivation (β co-efficient −0.152 p < 0.001) older patients (β co-efficient −0.032 p 0.002), larger lists (β co-efficient −0.085, p < 0.001) and were more rural (β co-efficient −0.121, p0.026) prescribed fewer statins. In a small proportion of practices (0.5%) estimated prescribing rates for statins were so low that insufficient prescriptions were issued to meet the predicted secondary prevention requirements of their registered population. Conclusions Absolute estimated prescribing rates for primary prevention of CVD were 6.3% of the population. There was evidence of social inequalities in statin prescribing for primary prevention. These findings support the recent introduction of a financial incentive for primary prevention of CVD in England

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

Unequal socioeconomic distribution of the primary care workforce : whole-population small area longitudinal study

OBJECTIVE: To measure changes in socioeconomic inequality in the distribution of family physicians (general practitioners (GPs)) relative to need in England from 2004/2005 to 2013/2014. DESIGN: Whole-population small area longitudinal data linkage study. SETTING: England from 2004/2005 to 2013/2014. PARTICIPANTS: 32 482 lower layer super output areas (neighbourhoods of 1500 people on average). MAIN OUTCOME MEASURES: Slope index of inequality (SII) between the most and least deprived small areas in annual full-time equivalent GPs (FTE GPs) per 100 000 need adjusted population. RESULTS: In 2004/2005, inequality in primary care supply as measured by the SII in FTE GPs was 4.2 (95% CI 3.1 to 5.3) GPs per 100 000. By 2013/2014, this SII had fallen to -0.7 (95% CI -2.5 to 1.1) GPs per 100 000. The number of FTE GPs per 100 000 serving the most deprived fifth of small areas increased over this period from 54.0 to 60.5, while increasing from 57.2 to 59.9 in the least deprived fifth, so that by the end of the study period there were more GPs per 100 000 need adjusted population in the most deprived areas than in the least deprived. The increase in GP supply in the most deprived fifth of neighbourhoods was larger in areas that received targeted investment for establishing new practices under the 'Equitable Access to Primary Medical Care'. CONCLUSIONS: There was a substantial reduction in socioeconomic inequality in family physician supply associated with national policy. This policy may not have completely eliminated socioeconomic inequality in family physician supply since existing need adjustment formulae do not fully capture the additional burden of multimorbidity in deprived neighbourhoods. The small area approach introduced in this study can be used routinely to monitor socioeconomic inequality of access to primary care and to indicate workforce shortages in particular neighbourhoods. http://creativecommons.org/licenses/by/4.0

Are patients in heart failure trials representative of primary care populations? A systematic review.

BACKGROUND: Guidelines recommend drug treatment for patients with heart failure with a reduced ejection fraction (HFrEF), however the evidence for benefit in patients with mild disease, such as most in primary care, is uncertain. Importantly, drugs commonly used in heart failure account for one in seven of emergency admissions for adverse drug reactions. AIM: To determine to what extent patients included in studies of heart failure treatment with beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and aldosterone antagonists were representative of a typical primary care population with HFrEF in England. DESIGN & SETTING: Systematic review of randomised controlled trials (RCTs) of drug treatment in patients with HFrEF. METHOD: MEDLINE, MEDLINE In-Process, EMBASE, and CENTRAL were searched from inception to March 2015. The characteristics of the patient's New York Heart Association (NYHA) classification were compared with a primary care reference population with HFrEF. RESULTS: Of the 30 studies included, two had incomplete data. None had a close match (defined as ≤10% deviation from reference study) for NYHA class I disease; 5/28 were a close match for NYHA class II; 5/28 for NYHA class III; and 18/28 for NYHA class IV. In general, pre-existing cardiovascular conditions, risk factors, and comorbidities were representative of the reference population. CONCLUSION: Patients recruited to studies typically had more severe heart failure than the reference primary care population. When evidence from sicker patients is generalised to less sick people, there is increased uncertainty about benefit and also a risk of harm from overtreatment. More evidence is needed on the effectiveness of treatment of heart failure in asymptomatic patients with NYHA class I

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