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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Varying uses of the ABCD2 scoring system in primary and secondary care: A qualitative study
Objectives: To explore the usage of the ABCD2 risk stratification score by general practitioners (GPs) and hospital staff during the referral of patients with suspected transient ischaemic attack (TIA) or minor stroke. Design: Qualitative study using semistructured interviews. Setting: Nine general practices and two hospital sites in England (Birmingham and Cambridge). Participants: Nine GPs and nine hospital staff (two consultants, four nurses, two ultrasonographers and one administrator). Results: In both sites, clinicians used a referral proforma based around the ABCD2 scoring system for a range of purposes including self-education, to assist emphasising urgency to the patient, as a referral pathway facilitator and as a diagnostic tool. Negative views of its role included potential medicolegal threats, that it was a barrier to appropriate care, and led to misdiagnoses. Despite having differing uses by different clinicians, the ABCD2 proforma was the central means of interprofessional communication in TIA referrals across both sites. Conclusions: Understanding how prediction rules are used in practice is key to determining their impact on processes of care and clinical outcomes. In practice, GPs and their colleagues use the ABCD2 score in subtly different ways and it functions as a 'boundary object' by both accommodating these multiple purposes, yet still successfully aiding communication between them.
Self-monitoring of blood pressure in hypertension: A UK primary care survey
This study aimed to determine the prevalence of Self-Monitoring Blood Pressure amongst people with hypertension using a cross-sectional survey. Of the 955 who replied (53), 293 (31) reported that they self-monitored blood pressure. Nearly 60 (198/331) self-monitored at least monthly. Diabetic patients monitoring their blood glucose were five times more likely than those not monitoring to monitor their blood pressure. Self-monitoring is less common in the UK than internationally, but is practiced by enough people to warrant greater integration into clinical practice. © 2012 S. Baral-Grant et al.
Routine intrauterine device checks: Are they advisable?
Background: Patients using the intrauterine contraceptive device (IUD) were previously advised to undergo routine checks; in 2004, the National Institute for Health and Clinical Excellence stated the practice was unnecessary. This study was conducted to examine the evidence for this advice. Methods: A retrospective examination of case records of patients of Whitehall Medical Practice, Rugby, UK who had used an IUD for a minimum of 2 years was performed. Data were extracted concerning demographic details, types of IUD used, dates of their use and of any checks, defaults from checks and side effects. Kaplan-Meier survival analysis was performed to compare outcomes in frequent and infrequent attenders, and in frequent and infrequent defaulters from checks. Results: The study population comprised 272 individuals using a total of 423 devices. Frequent check attenders showed adverse events earlier, or at no signifi cant time difference, to infrequent attenders. Conclusions: Considering patients who use an IUD for a minimum of 2 years, this study found no evidence of harm occurring in those who attended infrequently compared to frequent attenders. If these data from a single practice are generalisable, after an initial check following insertion, women can be asked to attend as needed and only be recalled for smears and at the end of the life of the IUD.
The effect of seeking consent on the representativeness of patient cohorts: Iron-deficiency anaemia and colorectal cancer
Aim The study aimed to establish the level of selection bias that may occur should individual patient consent be sought, by comparing characteristics of consenters and nonconsenters to a request for access to medical records within a cohort of patients diagnosed with iron-deficiency anaemia (IDA). Method A cohort study and cross-sectional survey was carried out of consent preferences that compared the sociodemographic characteristics of patients providing or not providing consent for access to their records, the consent rates by participant subgroup and the predictors of consent/nonconsent. Results Of 599 patients mailed requesting consent for access to their medical records, 425 (71.0%) responses were received. Of the valid responses, explicit consent was granted by 371 (62.7%) respondents, with 47 (7.9%) refusals. The characteristics of consenters and nonconsenters differed with regard to age, gender and deprivation quartile. Nonconsent was associated with younger age (40-60years vs 60+years; bivariate OR=2.84; 95% CI=2.01-4.02), female gender (OR=1.62; 95% CI=1.13-2.34) and being socioeconomically deprived (OR=1.61; 95% CI=1.15-2.26). Conclusion The current research governance framework demonstrates a conflict between protecting the rights of the individual and the development of a sound research base to improve the delivery of healthcare services for society as a whole. If epidemiological research includes data only from individuals who have given consent for access to their records, the resulting selection bias may have consequences for the scientific validity and generalizability of research findings, and ultimately the quality of patient care. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.
Does self-monitoring reduce blood pressure? Meta-analysis with meta-regression of randomized controlled trials
Introduction. Self-monitoring of blood pressure (BP) is an increasingly common part of hypertension management. The objectives of this systematic review were to evaluate the systolic and diastolic BP reduction, and achievement of target BP, associated with self-monitoring. Methods. MEDLINE, Embase, Cochrane database of systematic reviews, database of abstracts of clinical effectiveness, the health technology assessment database, the NHS economic evaluation database, and the TRIP database were searched for studies where the intervention included self-monitoring of BP and the outcome was change in office/ambulatory BP or proportion with controlled BP. Two reviewers independently extracted data. Meta-analysis using a random effects model was combined with meta-regression to investigate heterogeneity in effect sizes. Results. A total of 25 eligible randomized controlled trials (RCTs) (27 comparisons) were identified. Office systolic BP (20 RCTs, 21 comparisons, 5,898 patients) and diastolic BP (23 RCTs, 25 comparisons, 6,038 patients) were significantly reduced in those who self-monitored compared to usual care (weighted mean difference (WMD) systolic-3.82 mmHg (95% confidence interval-5.61 to-2.03), diastolic-1.45 mmHg (-1.95 to-0.94)). Self-monitoring increased the chance of meeting office BP targets (12 RCTs, 13 comparisons, 2,260 patients, relative risk 1.09 (1.02 to 1.16)). There was significant heterogeneity between studies for all three comparisons, which could be partially accounted for by the use of additional co-interventions. Conclusion. Self-monitoring reduces blood pressure by a small but significant amount. Meta-regression could only account for part of the observed heterogeneity. © 2010 Informa UK Ltd.
Seated bilateral leg exercise effects on hemiparetic lower extremity function in chronic stroke
Background. Bilateral arm training with rhythmic auditory cueing (BATRAC) improves hemiparetic upper extremity (UE) function in stroke. It is unknown whether a similar exercise for the hemiparetic lower extremity (LE) is effective. Objective. The authors sought to test whether the BATRAC strategy would transfer to the legs by improving LE motor function following ten 30-minute sessions of bilateral leg training with rhythmic auditory cueing (BLETRAC). Methods. Twenty-four chronic stroke participants, recruited from the community, were randomized to either the BLETRAC or the BATRAC intervention. Assessments were performed before (week 0) and after (week 6) training as well as 3 months later (week 18). Change in the Fugl-Meyer LE and UE subscales served as primary outcomes. Timed 10-m walk, movement parameters during treadmill walking, and a repetitive aiming task for both feet and hands were the secondary outcomes. Results. Following an intention-to-treat approach, data from 21 subjects were analyzed. After training, improvements in the Fugl-Meyer LE and UE subscales tended to be better for the corresponding intervention group. The BLETRAC group also showed increases in step length during treadmill walking and performance in the repetitive foot and hand aiming tasks. No differences between the intervention groups were found at follow-up. Conclusions. This exploratory trial demonstrates that transfer of the BATRAC approach to the legs is feasible. Transient improvements of limb motor function in chronic stroke participants were induced by targeted exercise (BATRAC for the UE and BLETRAC for the LE). It may be that further periods of training would increase and maintain effects.
Evaluation of a cardiovascular disease opportunistic risk assessment pilot ('Heart MOT' service) in community pharmacies
Background Cardiovascular risk-based screening is proposed as a key intervention to reduce premature cardiovascular disease (CVD) in the UK and internationally. This study evaluated a targeted cardiovascular (CVD) assessment pilot in 23 community pharmacies in Birmingham, UK. Methods The CVD risk assessment service used near-patient testing and the Framingham risk equations administered by pharmacists to screen clients aged 40-70 without known CVD. Outcomes assessed included volume of activity, uptake by deprivation and ethnicity and onwards referral. Results Complete data were available for 1130 of 1141 clients; 679 (60%) male, 218 (19%) smokers and 124 (11%) had a family history of CVD. Overall, 792 (70%) of clients were referred to their general practice: 201 (18%) at CVD risk of 20% or more, remainder with individual risk factor(s). Greater representation from Black (7.4%) and Asian (24.8%) communities and from average and less deprived quintiles than the affluent and most deprived was observed. Conclusions Community pharmacies can provide a CVD risk assessment service in a UK urban setting that can attract males and provide access for deprived communities and Black and Asian communities. A pharmacy service can support GP practices in identifying and managing the workload of around 30% of clients.
Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study.
OBJECTIVES: To examine the management of diabetes between 2001 and 2007 in the United Kingdom and to assess whether changes in the quality of care reflect existing temporal trends or are a direct result of the implementation of the quality and outcomes framework. DESIGN: Retrospective cohort study. SETTING: 147 general practices (annual list size over 1 million) across the UK. Patients People with type 1 or type 2 diabetes. MAIN OUTCOME MEASURES: Annual prevalence of diabetes and attainment of process and clinical outcomes over the three years before and the three years after the introduction of the quality and outcomes framework. RESULTS: Significant improvements in process and intermediate outcome measures were observed during the six year period, with consecutive annual improvements observed before the introduction of incentives. However, the current diagnostic case definition for the quality and outcomes framework does not capture up to two thirds of people with type 1 diabetes and a third of people with type 2 diabetes. After the introduction of the quality and outcomes framework, existing trends of improvement in glycaemic control, cholesterol levels, and blood pressure were attenuated, particularly in people with diabetes who did not meet the case definition of the quality and outcomes framework. The introduction of the quality and outcomes framework did not lead to improvement in the management of patients with type 1 diabetes, nor to a reduction in the number of patients with type 2 diabetes who had HbA(1c) levels greater than 10%. Introduction of the quality and outcomes framework may have increased the number of patients with type 2 diabetes with HbA(1c) levels of
Effect of the quality and outcomes framework on diabetes care in the United Kingdom: Retrospective cohort study
Objectives: To examine the management of diabetes between 2001 and 2007 in the United Kingdom and to assess whether changes in the quality of care reflect existing temporal trends or are a direct result of the implementation of the quality and outcomes framework. Design: Retrospective cohort study. Setting: 147 general practices (annual list size over 1 million) across the UK. Patients: People with type 1 or type 2 diabetes. Main outcome measures: Annual prevalence of diabetes and attainment of process and clinical outcomes over the three years before and the three years after the introduction of the quality and outcomes framework. Results: Significant improvements in process and intermediate outcome measures were observed during the six year period, with consecutive annual improvements observed before the introduction of incentives. However, the current diagnostic case definition for the quality and outcomes framework does not capture up to two thirds of people with type 1 diabetes and a third of people with type 2 diabetes. After the introduction of the quality and outcomes framework, existing trends of improvement in glycaemic control, cholesterol levels, and blood pressure were attenuated, particularly in people with diabetes who did not meet the case definition of the quality and outcomes framework. The introduction of the quality and outcomes framework did not lead to improvement in the management of patients with type 1 diabetes, nor to a reduction in the number of patients with type 2 diabetes who had HbA1c levels greater than 10%. Introduction of the quality and outcomes framework may have increased the number of patients with type 2 diabetes with HbA1c levels of ¡Ü7.5%; odds ratio 1.05 (95% confidence interval 1.01 to 1.09; P=0.02). Conclusions: The management of people with diabetes has improved since the late 1990s, but the impact of the quality and outcomes framework on care is not straightforward; upper thresholds may need to be removed or targets made more challenging if people are to benefit. Many patients in whom care may be suboptimal may not be captured in the quality and outcomes framework assessment.
Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study.
ObjectivesTo examine the management of diabetes between 2001 and 2007 in the United Kingdom and to assess whether changes in the quality of care reflect existing temporal trends or are a direct result of the implementation of the quality and outcomes framework.DesignRetrospective cohort study.Setting147 general practices (annual list size over 1 million) across the UK. Patients People with type 1 or type 2 diabetes.Main outcome measuresAnnual prevalence of diabetes and attainment of process and clinical outcomes over the three years before and the three years after the introduction of the quality and outcomes framework.ResultsSignificant improvements in process and intermediate outcome measures were observed during the six year period, with consecutive annual improvements observed before the introduction of incentives. However, the current diagnostic case definition for the quality and outcomes framework does not capture up to two thirds of people with type 1 diabetes and a third of people with type 2 diabetes. After the introduction of the quality and outcomes framework, existing trends of improvement in glycaemic control, cholesterol levels, and blood pressure were attenuated, particularly in people with diabetes who did not meet the case definition of the quality and outcomes framework. The introduction of the quality and outcomes framework did not lead to improvement in the management of patients with type 1 diabetes, nor to a reduction in the number of patients with type 2 diabetes who had HbA(1c) levels greater than 10%. Introduction of the quality and outcomes framework may have increased the number of patients with type 2 diabetes with HbA(1c) levels of ConclusionsThe management of people with diabetes has improved since the late 1990s, but the impact of the quality and outcomes framework on care is not straightforward; upper thresholds may need to be removed or targets made more challenging if people are to benefit. Many patients in whom care may be suboptimal may not be captured in the quality and outcomes framework assessment.