Are referrals to hospital from out-of-hours primary care associated with National Early Warning Scores?

Background: The National Early Warning Scores (NEWS) is used in various healthcare settings to augment clinical decision making, and there is growing interest in its application in primary care. This research aimed to determine the distribution of NEWS among patients in UK out-of-hours (OOH) general practice and explore the relationship between NEWS and referral of patients to hospital. Methods: A historical cohort study using routinely collected data from the Birmingham Out-of-hours general practice Research Database. This includes patients who attended a large out-of-hours general practice provider in the West Midlands, UK, between July 2013 and July 2018. All adults who were seen face to face who had a full set of physiological observations recorded were included. NEWS was calculated post hoc, and subsequent hospital referral was the outcome of interest. Results: A NEWS was calculated for 74 914 consultations. 46.9% of patients had a NEWS of 0, while 30.6% had a NEWS of 1. Patients were referred to hospital in 8.5% of all encounters. Only 6.9% (95% CI 6.3% to 7.5%) of the 6878 patients referred to hospital had a NEWS of ≥5. Of the 1509 patients with a NEWS ≥5, 68.6% (95%CI 66.2% to 70.9%) were not referred to hospital. When considering how NEWS was related to hospital referral, the area under the receiver operating characteristic (AUROC) for patients seen in their own home was 0.731 (95%CI 0.681 to 0.787). For patient seen in treatment centres, the AUROC was 0.589 (95% CI 0.582 to 0.596). Conclusions: Patients seen in out-of-hours general practice have low physiological acuity. Those referred to hospital have a slightly higher NEWS overall. NEWS is poorly associated with hospital referral, although the association is stronger for patients seen in at home compared with patients seen in treatment centres. Implementing NEWS-based referral from OOH general practice is likely to increase hospital admissions.</p

Statin initiations and QRISK2 scoring in UK general practice:a THIN database study

BackgroundStatin prescribing should be based on cardiovascular disease (CVD) risk, but evidence suggests overtreatment of low-risk groups and undertreatment of high-risk groups.AimTo investigate the relationship between CVD risk scoring in primary care and initiation of statins for the primary prevention of CVD, and the effect of changes to the National Institute for Health and Care Excellence (NICE) guidance in 2014.Design and settingHistorical cohort study using UK electronic primary care records.MethodA cohort was created of statin-naïve patients without CVD between 1 January 2000 and 31 December 2015. CVD risk scores (calculated using QRISK2 available from 2012) and statin initiations were identified. Rates of CVD risk score recording were calculated and relationships between CVD risk category (low-, intermediate-, and high-risk: &lt;10%, 10–19.9%, and ≥20% 10-year CVD risk) and statin initiation were analysed.ResultsA total of 1.4 million patients were identified from 248 practices. Of these, 151 788 had a recorded CVD risk score since 2012 (10.67%) and 217 860 were initiated on a statin (15.31%). Among patients initiated on a statin after 2012, 27.1% had a documented QRISK2 score: 2.7% of low-risk, 13.8% of intermediate-risk, and 35.0% of high-risk patients were initiated on statins. Statin initiation rates halved from a peak in 2006. After the 2014 NICE guidelines, statin initiation rates declined in high-risk patients but increased in intermediate-risk patients.ConclusionMost patients initiated on statins had no QRISK2 score recorded. Most patients at high risk of CVD were not initiated on statins. One in six statin initiations were to low-risk patients indicating significant overtreatment. Initiations of statins in intermediate-risk patients rose after NICE guidelines were updated in 2014.</jats:sec

Cohort study investigating the relationship between cholesterol, cardiovascular risk score and the prescribing of statins in UK primary care: study protocol

INTRODUCTION: Risk scoring is an integral part of the prevention of cardiovascular disease (CVD) and should form the basis for the decision to offer medication to reduce cholesterol (statins). However, there is a suggestion in the literature that many patients are still initiated on statins based on raised cholesterol rather than a raised CVD risk. It is important, therefore, to investigate the role that lipid levels and CVD risks have in the decision to prescribe. This research will establish how cholesterol levels and CVD risk independently influence the prescribing of statins for the primary prevention of CVD in primary care. METHODS AND ANALYSIS: The Health Improvement Network (THIN) is a database of coded primary care electronic patient records from over 500 UK general practices. From this resource, a historical cohort will be created of patients without a diagnosis of CVD, not currently receiving a prescription for statins and who had a lipid profile measured. A post hoc QRISK2 score will be calculated for these patients and they will be followed up for 60 days to establish whether they were subsequently prescribed a statin. Primary analysis will consist of predictive modelling using multivariate logistic regression with potential predictors including cholesterol level, calculated QRISK2 score, sociodemographic characteristic and comorbidities. Descriptive statistics will be used to identify trends in prescribing and further secondary analysis will explore what other factors may have influenced the prescribing of statins and the degree of interprescriber variability. ETHICS AND DISSEMINATION: The THIN Data Collection Scheme was approved by the South-East Multicentre Research Ethics Committee in 2003. Individual studies using THIN require Scientific Review Committee approval. The original protocol for this study and a subsequent amendment have been approved (16THIN009A1). The results will be published in a peer review journal and presented at national and international conferences

Clinical and demographic characteristics associated with suboptimal primary stroke and transient ischemic attack prevention: retrospective analysis

Background and Purpose— Primary prevention of stroke and transient ischemic attack (TIA) is important to reduce the burden of these conditions; however, prescribing of prevention drugs is suboptimal. We aimed to identify individual clinical and demographic characteristics associated with potential missed opportunities for prevention therapy with lipid-lowering, anticoagulant, or antihypertensive drugs before stroke/TIA. Methods— We analyzed anonymized electronic primary care records from a UK primary care database that covers 561 family practices. Patients with first-ever stroke/TIA, ≥18 years, with diagnosis between January 1, 2009, and December 31, 2013, were included. Missed opportunities for prevention were defined as people with clinical indications for lipid-lowering, anticoagulant, or antihypertensive drugs but not prescribed these drugs before their stroke/TIA. Mixed-effect logistic regression models evaluated the relationship between missed opportunities and individual clinical/demographic characteristics. Results— The inclusion criteria were met by 29 043 people with stroke/TIA. Patients with coronary heart disease, chronic kidney disease, peripheral arterial disease, or diabetes mellitus were at less risk of a missed opportunity for prescription of lipid-lowering and antihypertensive drugs. However, patients with a 10-year cardiovascular disease risk ≥20% but without these diagnoses had increased risk of having a missed opportunity for prescription of lipid-lowering drugs or antihypertensive drugs. Women were less likely to be prescribed anticoagulants but more likely to be prescribed antihypertensive drugs. The elderly (≥85 years of age) were less likely to be prescribed all 3 prevention drugs, compared with people aged 75 to 79 years. Conclusions— Knowing the patient characteristics predictive of missed opportunities for stroke prevention may help primary care identify and appropriately manage these patients. Improving the management of these groups may reduce their risk and potentially prevent large number of future strokes and TIAs in the population. </jats:sec

Nursery sickness policies and their influence on prescribing for conjunctivitis: audit and questionnaire survey

BACKGROUND: Acute infective conjunctivitis is common among preschool children. Public Health England (PHE) recommends that children with conjunctivitis do not need to be excluded from child care, but childcare providers are required to determine their own sickness policies and prior research suggests that children are often excluded until they are treated or have recovered. How the content of these policies impacts on prescribing decisions has not been quantified. AIM: To assess the content of childcare providers’ sickness policies and determine the impact they have on clinicians’ prescribing. DESIGN AND SETTING: An audit of childcare providers’ sickness policies and a questionnaire among primary care clinicians. METHOD: Sickness policies from childcare providers across the UK were compared with PHE guidance. Clinicians completed a questionnaire on the impact that childcare provider policies have on their decision to prescribe antibiotics to preschool children with conjunctivitis. RESULTS: Of 164 policies examined, 86.7% excluded children with conjunctivitis and 49.4% of policies specified a requirement for antibiotics. Two-hundred clinicians completed questionnaires and 42.6% replied that they had been influenced by childcare policies when deciding whether to prescribe antibiotics in this scenario. Furthermore, 15.4% admitted that childcare policies had been the only reason they prescribed antibiotics. CONCLUSION: Most of the childcare providers’ sickness policies contain requirements that are inconsistent with PHE guidance. The requirements of childcare sickness policies are likely to be resulting in unnecessary primary care consultations and thousands of prescriptions for antibiotics with little demonstrable clinical or public health benefit