Volume of procedures and outcome of treatment

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Development and use of methods to estimate chronic disease prevalence in small populations

Introduction National data on the prevalence of chronic diseases on general practice registers is now available. The aim of this PhD was to develop and validate epidemiological models for the expected prevalence of chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), stroke, hypertension, overall cardiovascular disease (CVD) and high CVD risk at general practice and small area level, and to explore the extent of undiagnosed disease, factors associated with it, and its impact on population health. Methods Multinomial logistic regression models were fitted to pooled Health Survey for England data to derive odds ratios for disease risk factors. These were applied to general practice and small area level population data, split by age, sex, ethnicity, deprivation, rurality and smoking status, to estimate expected disease prevalence at these levels. Validation was carried out using external data, including population-based epidemiological research and case-finding initiatives. Practice-level undiagnosed disease prevalence i.e. expected minus registered disease prevalence, and hospital admission rates for these conditions, were evaluated as outcome indicators of the quality and supply of primary health care services, using ordinary least squares (OLS) regression, geographically-weighted regression (GWR), and other spatial analytic methods. Results Risk factors, odds of disease and expected prevalence were consistent with external data sources. Spatial analysis showed strong evidence of spatial non-stationarity of undiagnosed disease prevalence, with high levels of undiagnosed disease in London and other conurbations, and associations with low supply of primary health care services. Higher hospital admission rates were associated with population deprivation, poorer quality and supply of primary health care services and poorer access to them, and for COPD, with higher levels of undiagnosed disease. Conclusion The epidemiologic prevalence models have been implemented in national data sources such as NHS Comparators, the Association of Public Health Observatories website, and a number of national reports. Early experience suggests that they are useful for guiding case-finding at practice level and improving and regulating the quality of primary health care. Comparisons with external data, in particular prevalence of disease detected by general practices, suggest that model predictions are valid. Practice-level spatial analyses of undiagnosed disease prevalence and hospital admission rates failed to demonstrate superiority of GWR over OLS methods. Disease modellers should be encouraged to collaborate more effectively, and to validate and compare modelling methods using an agreed framework. National leadership is needed to further develop and implement disease models. It is likely that prevalence models will prove to be most useful for identifying undiagnosed diseases with a slow and insidious onset, such as COPD, diabetes and hypertension

Ethnic inequalities in the treatment and outcome of diabetes in three English Primary Care Trusts

BACKGROUND:Although the prevalence of diabetes is three to five times higher in UK South Asians than Whites, there are no reports of the extent of ethnicity recording in routine general practice, and few population-based published studies of the association between ethnicity and quality of diabetes care and outcomes. We aimed to determine the association between ethnicity and healthcare factors in an English population.METHODS:Data was obtained in 2002 on all 21,343 diabetic patients registered in 99% of all computerised general practitioner (GP) practices in three NW London Primary Care Trusts (PCTs), covering a total registered population of 720,000. Previously practices had been provided with training, data entry support and feedback. Treatment and outcome measures included drug treatment and blood pressure (BP), total cholesterol and haemoglobin A1c (HbA1c) levels.RESULTS:Seventy per cent of diabetic patients had a valid ethnicity code. In the relatively older White population, we expected a smaller proportion with a normal BP, but BP differences between the groups were small and suggested poorer control in non-White ethnic groups. There were also significant differences between ethnic groups in the proportions of insulin-treated patients, with a smaller proportion of South Asians - 4.7% compared to 7.1% of Whites - receiving insulin, although the proportion with a satisfactory HbA1c was smaller- 25.6% compared to 37.9%.CONCLUSION:Recording the ethnicity of existing primary care patients is feasible, beginning with patients with established diseases such as diabetes. We have shown that the lower proportion of South Asian patients with good diabetes control, and who are receiving insulin, is at least partly due to poorer standards of care in South Asians, although biological and cultural factors could also contribute. This study highlights the need to capture ethnicity data in clinical trials and in routine care, to specifically investigate the reasons for these ethnic differences, and to consider more intensive management of diabetes and education about the disease in South Asian patient

Access to primary care and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data

BACKGROUND: The UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes. OBJECTIVE: To determine whether primary care access is associated with the route of emergency admission-via a GP versus via an A and E department. METHODS: Retrospective analysis of national administrative data from English hospitals for 2011-2012. Adults admitted in an emergency (unscheduled) for ≥1 night via a GP or an A and E department formed the study population. The measure of primary care access-the percentage of patients able to get a general practice appointment on their last attempt-was derived from a large, nationally representative patient survey. Multilevel logistic regression was used to estimate associations, adjusting for patient and admission characteristics. RESULTS: The analysis included 2 322 112 emergency admissions (81.9% via an A and E department). With a 5 unit increase in the percentage of patients able to get a general practice appointment on their last attempt, the adjusted odds of GP admission (vs A and E admission) was estimated to increase by 15% (OR 1.15, 95% CI 1.12 to 1.17). The probability of GP admission if ≥95% of appointment attempts were successful in each general practice was estimated to be 19.6%. This probability reduced to 13.6% when <80% of appointment attempts were successful. This equates to 139 673 fewer GP admissions (456 232 vs 316 559) assuming no change in the total number of admissions. Associations were consistent in direction across geographical regions of England. CONCLUSIONS: Among hospital inpatients admitted as an emergency, patients registered to more accessible general practices were more likely to have been admitted via a GP (vs an A and E department). This furthers evidence suggesting that access to general practice is related to use of emergency hospital services in England. The relative merits of the two admission routes remain unclear

Practice size, caseload, deprivation and quality of care of patients with coronary heart disease, hypertension and stroke in primary care: national cross-sectional study

<p>Abstract</p> <p>Background</p> <p>Reports of higher quality care by higher-volume secondary care providers have fuelled a shift of services from smaller provider units to larger hospitals and units. In the United Kingdom, most patients are managed in primary care. Hence if larger practices provide better quality of care; this would have important implications for the future organization of primary care services. We examined the association between quality of primary care for cardiovascular disease achieved by general practices in England and Scotland by general practice caseload, practice size and area based deprivation measures, using data from the New General Practitioner (GP) Contract.</p> <p>Methods</p> <p>We analyzed data from 8,970 general practices with a total registered population of 55,522,778 patients in England and Scotland. We measured practice performance against 26 cardiovascular disease (coronary heart disease, left ventricular disease, and stroke) Quality and Outcomes Framework (QOF) indicators for patients on cardiovascular disease registers and linked this with data on practice characteristics and census data.</p> <p>Results</p> <p>Despite wide variations in practice list sizes and deprivation, the prevalence of was remarkably consistent, (coronary heart disease, left ventricular dysfunction, hypertension and cerebrovascular disease was 3.7%; 0.45%; 11.4% and 1.5% respectively). Achievement in quality of care for cardiovascular disease, as measured by QOF, was consistently high regardless of caseload or size with a few notable exceptions: practices with larger list sizes, higher cardiovascular disease caseloads and those in affluent areas had higher achievement of indicators requiring referral for further investigation. For example, small practices achieved lower scores 71.4% than large practices 88.6% (P < 0.0001) for referral for exercise testing and specialist assessment of patients with newly diagnosed angina.</p> <p>Conclusion</p> <p>The volume-outcome relationship found in hospital settings is not seen between practices in the UK in management of cardiovascular disorders in primary care. Further work is warranted to explain apparently poorer quality achievement in some aspects of cardiovascular management relating to initial diagnosis and management among practices in deprived areas, smaller practices and those with a smaller caseload.</p

Evaluation of complex integrated care programmes: the approach in North West London

Background: Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect. Study design: We present a mixed methods evaluation methodology. It includes a quantitative approach measuring changes in service utilization, costs, clinical outcomes and quality of care using routine primary and secondary data sources. It also contains a qualitative component, involving observations, interviews and focus groups with patients and professionals, to understand participant experiences and to understand the pilot within the national policy context. Theory and discussion: This study considers the complexity of evaluating a large, multi-organisational intervention in a changing healthcare economy. We locate the evaluation within the theory of evaluation of complex interventions. We present the specific challenges faced by evaluating an intervention of this sort, and the responses made to mitigate against them. Conclusions: We hope this broad, dynamic and responsive evaluation will allow us to clarify the contribution of the pilot, and provide a potential model for evaluation of other similar interventions. Because of the priority given to the integrated agenda by governments internationally, the need to develop and improve strong evaluation methodologies remains strikingly important

Development of a questionnaire to evaluate patients’ awareness of cardiovascular disease risk in England’s National Health Service Health Check preventive cardiovascular programme

Background The National Health Service (NHS) Health Check is a CVD risk assessment and management programme in England aiming to increase CVD risk awareness among people at increased risk of CVD. There is no tool to assess the effectiveness of the programme in communicating CVD risk to patients. Aims The aim of this paper was to develop a questionnaire examining patients’ CVD risk awareness for use in health service research evaluations of the NHS Health Check programme. Methods We developed an 85 item questionnaire to determine patients’ views of their risk of CVD. The questionnaire was based on a review of the relevant literature. After review by an expert panel and focus group discussion, 22 items were dropped and 2 new items were added. The resulting 65 item questionnaire with satisfactory content validity (content validity indices >=0.80) and face validity was tested on 110 NHS Health Check attendees in primary care in a cross sectional study between May 21 and July 28, 2014. Results Following analyses of data, we reduced the questionnaire from 65 to 26 items. The 26 item questionnaire constitutes 4 scales: Knowledge of CVD Risk and Prevention, Perceived Risk of Heart Attack/Stroke, Perceived Benefits and Intention to Change Behaviour and Healthy Eating Intentions. Perceived Risk (Cronbach’s α = 0.85) and Perceived Benefits and Intention to Change Behaviour (Cronbach’s α = 0.82) have satisfactory reliability (Cronbach’s α >=0.70). Healthy Eating Intentions (Cronbach’s α = 0.56) is below minimum threshold for reliability but acceptable for a three item scale. Conclusions The resulting questionnaire, with satisfactory reliability and validity, may be used in assessing patients’ awareness of CVD risk among NHS Health Check attendees