Found 10864 matches for
Real-world prevalence of the inclusion criteria for the LEADER trial: Data from a national general practice network
© 2019 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd. Aims: To explore the prevalence and describe the clinical characteristics of people with type 2 diabetes with a similar cardiovascular (CV) profile to that of the LEADER trial participants in a primary care setting in England. Materials and methods: In this cross-sectional analysis, using the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, we identified people with type 2 diabetes meeting the LEADER inclusion criteria. We identified people's CV risk factors using computerized medical records. Additionally, we assessed the prescription pattern of glucagon-like peptide-1 receptor agonists (GLP-1RAs) in this cohort. Results: Of 1 275 461 adults, we identified 84 394 with type 2 diabetes, of whom 14 000 (16.6%) met the LEADER inclusion criteria for established or high-risk CV disease (RCGP RSC-CVD group). The LEADER cohort was younger than the RCGP RSC-CVD group (64.2 vs 73.2 years), had higher mean glycated haemoglobin (71.6 vs 67.1 mmol/mol) and blood pressure (BP) values (systolic BP: 135.9 vs 132.9 mmHg; diastolic BP: 77.2 vs 72.7 mmHg), and a higher mean body mass index (32.5 vs 30.9 kg/m 2 ). In the RCGP RSC-CVD group, only 1215 people (8.7%) had ever been prescribed a GLP-1RA and 760 (5.4%) had ever received liraglutide. Conclusions: In a cohort of English general practice patients, one in six people with type 2 diabetes met the LEADER inclusion criteria, and less than one in 10 of these received liraglutide, a drug which has demonstrated CV benefits amongst others. There is scope to improve the outlook in people with type 2 diabetes and high CV risk through evidence-based use of specific GLP-1RAs.
Variation in the diagnosis and control of hypertension is not explained by conventional variables: Cross-sectional database study in English general practice
© 2019 Coyle et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Hypertension is a major cause of preventable disability and death globally and affects more than one in four adults in England. Unwarranted variation is variation in access, quality, outcome or value which is unexplained by differences in the condition or patient characteristics and which reduces quality and efficiency. Distinguishing unwarranted from variation due to clinical, organisational or patient factors can be challenging. We carried out this study to explore inter-practice variation in the diagnosis and management of hypertension in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, a large, representative surveillance database. Methods and finding We carried out a cross-sectional study using primary care data extracted from the electronic health records of 1,271,419 adults registered at RCGP RSC general practices on 31 st December 2016. Logistic regression was used to indirectly standardise practice-level hypertension prevalence and control against the RCGP RSC population, adjusted for age, gender, ethnicity, deprivation, co-morbidity, NHS region and practice size. Inter-practice variation was demonstrated using funnel plots with 95% and 99.8% control limits. The prevalence of detected hypertension was 18.4% (95% CI 18.4–18.5), n = 234,165. Uncontrolled hypertension was present in 146,553 of 196,052 individuals, 25.2% (25.1–25.4), in whom blood pressure had been recorded in the previous year. Hypertension management varied markedly between practices with a three-fold difference in prevalence, 13.5–38.4%, and a four-fold difference in the proportion of uncontrolled hypertension, 11.8–47.9%. Despite adjustment for sociodemographic and practice characteristics funnel plots demonstrated marked over-dispersion. Conclusions Substantial variation in the prevalence of diagnosed hypertension and the management of hypertension was only partially explained by characteristics captured within a routine dataset. The over-dispersion suggests variation is not fully explained by these factors and that context, behaviour and processes of care delivery may contribute to variation. Routine data sources in isolation to not provide sufficient contextual data to diagnose the causes of variation.
The association between serum sodium concentration, hypertension and primary cardiovascular events: a retrospective cohort study
© 2018, Springer Nature Limited. The mechanisms underlying the adverse cardiovascular effects of increased salt intake are incompletely understood, but parallel increases in serum sodium concentration may be of importance. The aim of this retrospective cohort study was to investigate the relationship between serum sodium, hypertension and incident cardiovascular disease (CVD). Routinely collected primary care data from the Royal College of General Practitioners Research and Surveillance Centre were analysed. A total of 231,545 individuals with a measurement of serum sodium concentration at baseline were included. Exclusion criteria were: age < 40 years; abnormal serum sodium; diabetes mellitus; prior CVD event; stage 5 chronic kidney disease; and liver cirrhosis. The primary outcome was incident CVD (myocardial infarction, acute coronary syndrome, coronary revascularisation, stroke, transient ischaemic attack or new heart failure diagnosis) over 5 years. There was a ‘J-shaped’ relationship between serum sodium concentration and primary cardiovascular events that was independent of established risk factors, medications and other serum electrolytes. The lowest cardiovascular risk was found with a serum sodium between 141 and 143 mmol/l. Higher serum sodium was associated with increased risk in hypertensive individuals, whereas lower concentrations were associated with increased risk in all individuals. Therefore, alterations in serum sodium concentration may be a useful indicator of CVD risk. Higher serum sodium could have a direct effect on the vasculature, particularly in hypertensive individuals. Lower serum sodium may be a reflection of complex volume and neuroendocrine changes.
Trends in end digit preference for blood pressure and associations with cardiovascular outcomes in Canadian and UK primary care: A retrospective observational study
© Author(s) (or their employer(s)) 2019. Objectives To study systematic errors in recording blood pressure (BP) as measured by end digit preference (EDP); to determine associations between EDP, uptake of Automated Office BP (AOBP) machines and cardiovascular outcomes. Design Retrospective observational study using routinely collected electronic medical record data from 2006 to 2015 and a survey on year of AOBP acquisition in Toronto, Canada in 2017. Setting Primary care practices in Canada and the UK. Participants Adults aged 18 years or more. Main outcome measures Mean rates of EDP and change in rates. Rates of EDP following acquisition of an AOBP machine. Associations between site EDP levels and mean BP. Associations between site EDP levels and frequency of cardiovascular outcomes. Results 707 227 patients in Canada and 1 558 471 patients in the UK were included. From 2006 to 2015, the mean rate of BP readings with both systolic and diastolic pressure ending in zero decreased from 26.6% to 15.4% in Canada and from 24.2% to 17.3% in the UK. Systolic BP readings ending in zero decreased from 41.8% to 32.5% in the 3 years following the purchase of an AOBP machine. Sites with high EDP had a mean systolic BP of 2.0 mm Hg in Canada, and 1.7 mm Hg in the UK, lower than sites with no or low EDP. Patients in sites with high levels of EDP had a higher frequency of stroke (standardised morbidity ratio (SMR) 1.15, 95% CI 1.12 to 1.17), myocardial infarction (SMR 1.16, 95% CI 1.14 to 1.19) and angina (SMR 1.25, 95% CI 1.22 to 1.28) than patients in sites with no or low EDP. Conclusions Acquisition of an AOBP machine was associated with a decrease in EDP levels. Sites with higher rates of EDP had lower mean BPs and a higher frequency of adverse cardiovascular outcomes. The routine use of manual office-based BP measurement should be reconsidered.
Determinants of inter-practice variation in childhood asthma and respiratory infections: Cross-sectional study of a national sentinel network
© Author(s) (or their employer(s)) 2019. Objectives Respiratory infections are associated with acute exacerbations of asthma and accompanying morbidity and mortality. In this study we explore inter-practice variations in respiratory infections in children with asthma and study the effect of practice-level factors on these variations. Design Cross-sectional study. Setting We analysed data from 164 general practices in the Royal College of General PractitionersResearch and Surveillance Centresentinel network in England. Participants Children 5-12 years. Interventions None. In this observational study, we used regression analysis to explore the impact of practice-level determinants on the number of respiratory infections in children with asthma. Primary and secondary outcome measures We describe the distribution of childhood asthma and the determinants of upper/lower respiratory tract infections in these children. Results 83.5% (137/164) practices were in urban locations; the mean number of general practitioners per practice was 7; and the mean duration since qualification 19.7 years. We found almost 10-fold difference in the rate of asthma (1.5-11.8 per 100 children) and 50-fold variation in respiratory infection rates between practices. Larger practices with larger lists of asthmatic children had greater rates of respiratory infections among these children. Conclusion We showed that structural/environmental variables are consistent predictors of a range of respiratory infections among children with asthma. However, contradictory results between measures of practice clinical care show that a purely structural explanation for variability in respiratory infections is limited. Further research is needed to understand how the practice factors influence individual risk behaviours relevant to respiratory infections.
What is the contribution of physician associates in hospital care in England? A mixed methods, multiple case study
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. Objectives To investigate the deployment of physician associates (PAs); the factors supporting and inhibiting their employment and their contribution and impact on patients' experience and outcomes and the organisation of services. Design Mixed methods within a case study design, using interviews, observations, work diaries and documentary analysis. Setting Six acute care hospitals in three regions of England in 2016-2017. Participants 43 PAs, 77 other health professionals, 28 managers, 28 patients and relatives. Results A key influencing factor supporting the employment of PAs in all settings was a shortage of doctors. PAs were found to be acceptable, appropriate and safe members of the medical/surgical teams by the majority of doctors, managers and nurses. They were mainly deployed to undertake inpatient ward work in the medical/surgical team during core weekday hours. They were reported to positively contribute to: continuity within their medical/surgical team, patient experience and flow, inducting new junior doctors, supporting the medical/surgical teams' workload, which released doctors for more complex patients and their training. The lack of regulation and attendant lack of authority to prescribe was seen as a problem in many but not all specialties. The contribution of PAs to productivity and patient outcomes was not quantifiable separately from other members of the team and wider service organisation. Patients and relatives described PAs positively but most did not understand who and what a PA was, often mistaking them for doctors. Conclusions This study offers new insights concerning the deployment and contribution of PAs in medical and surgical specialties in English hospitals. PAs provided a flexible addition to the secondary care workforce without drawing from existing professions. Their utility in the hospital setting is unlikely to be completely realised without the appropriate level of regulation and authority to prescribe medicines and order ionising radiation within their scope of practice.
© 2019 Bentham Science Publishers. Background and Objective: Obesity is an important contributor to the risk of both asthma and Type 2 Diabetes (T2DM). However, it has been suggested that T2DM and asthma are also independently associated. The aim of this systematic review was to synthesize the evidence for an independent relationship between T2DM and asthma. Methods: MEDLINE and EMBASE were searched for studies reporting the relationship between asthma and T2DM in adults. Given a potential bidirectional relationship, articles relating to T2DM as a risk factor for asthma, and asthma as a risk factor for T2DM were examined separately. Results: Eight studies were identified for inclusion in the review (n=2,934,399 participants). Four studies examined incident diabetes in those with asthma. The pooled (random effects model) adjusted hazard ratio for incident T2DM in asthma was 1.37 (95%CI 1.12-1.69; p <0.001) after controlling for BMI. Four studies reported prevalence or incidence rates of asthma in people with T2DM; higher rates of asthma in those with T2DM were reported in all four studies. Meta-analysis of results was not possible due to methodological heterogeneity. The quality of included studies was good, but due to small numbers, publication bias cannot be excluded. Conclusion: The published literature suggests a bidirectional independent relationship between T2DM and asthma, although we cannot exclude publication bias.
© 2019 The European Federation for Medical Informatics (EFMI) and IOS Press. The analysis of primary care data plays an important role in understanding health at an individual and population level. Currently the utilization of computerized medical records is low due to the complexities, heterogeneities and veracity associated with these data. We present a deep learning methodology that clusters 11,000 records in an unsupervised manner identifying non-linear patterns in the data. This provides a useful tool for visualization as well as identify features driving the formation of clusters. Further analysis reveal the features that differentiate sub-groups that can aid clinical decision making. Our results uncover subsets that contain the highest proportion of missing data, specifically Episode type, as well as the sources that provide the most complete data.
Common Data Models (CDMs) to Enhance International Big Data Analytics: A Diabetes Use Case to Compare Three CDMs
© 2018 The authors and IOS Press. Common data models (CDM) have enabled the simultaneous analysis of disparate and large data sources. A literature review identified three relevant CDMs: The Observational Medical Outcomes Partnership (OMOP) was the most cited; next the Sentinel; and then the Patient Centered Outcomes Research Institute (PCORI). We tested these three CDMs with fifteen pre-defined criteria for a diabetes cohort study use case, assessing the benefit (good diabetes control), risk (hypoglycaemia) and cost effectiveness of recently licenced medications. We found all three CDMs have a useful role in planning collaborative research and enhance analysis of data cross jurisdiction. However, the number of pre-defined criteria achieved by these three CDMs varied. OMOP met 14/15, Sentinel 13/15, and PCORI 10/15. None met the privacy level we specified, and most of the other gaps were clinical and cost outcome related data.
© 2018 The authors and IOS Press. Ontologies are an important big-data analytics tool. Historically code lists were created by domain experts and mapped between different coding systems. Ontologies allow us to develop better representations of clinical concepts, data and facilitate better data extracts from routine clinical data. It also makes the process of case identification and key outcome measures transparent. We describe a process we have operationalised in our research. We use ontologies to resolve the semantics of complex health care data. The use of the method is demonstrated through a pregnancy case identification method. Pregnancy data are recorded in different coding systems and stored in different general practice systems; and pregnancy has its own complexities in that not all pregnancies proceed to term, they have different lengths and involve multiple providers of health care.
Time to mandate systems that promote collaborative working with computerised medical record systems, at a time of general practitioner shortage
Copyright © 2018 The Author(s). Whilst the computerisation of primary care has had many advantages, it is also associated with a time of altering GP workloads. It is plausible that better collaborative working could have a positive effect on sustaining the existing workforce, as well as introducing efficiency into our current ways of working. Enhancing collaborative working might help reduce the isolation of clinicians working alone with their computer systems, as well as enable much more remote part-time working. However, our preference would be in a way that enhances continuity of care, albeit at the natural size of that community. It might even stop some doctors hating their computers. 6 Sophisticated collaborative working has long been a feature of medical practice, and new collaborative working methods that in enabled remote working may have a role in both addressing the workforce crisis in primary care.
An instrument to identify computerised primary care research networks, genetic and disease registries prepared to conduct linked research: TRANSFoRm International Research Readiness (TIRRE) survey
Copyright © 2018 The Author(s). Purpose The Translational Research and Patients safety in Europe (TRANSFoRm) project aims to integrate primary care with clinical research whilst improving patient safety. The TRANSFoRm International Research Readiness survey (TIRRE) aims to demonstrate data use through two linked data studies and by identifying clinical data repositories and genetic databases or disease registries prepared to participate in linked research. Method The TIRRE survey collects data at micro-, meso- and macro-levels of granularity; to fulfil data, study specific, business, geographical and readiness requirements of potential data providers for the TRANSFoRm demonstration studies. We used descriptive statistics to differentiate between demonstration-study compliant and non-compliant repositories. We only included surveys with >70% of questions answered in our final analysis, reporting the odds ratio (OR) of positive responses associated with a demonstration-study compliant data provider. Results We contacted 531 organisations within the Eurpean Union (EU). Two declined to supply information; 56 made a valid response and a further 26 made a partial response. Of the 56 valid responses, 29 were databases of primary care data, 12 were genetic databases and 15 were cancer registries. The demonstration compliant primary care sites made 2098 positive responses compared with 268 in non-use-case compliant data sources [OR: 4.59, 95% confidence interval (CI): 3.93–5.35, p < 0.008]; for genetic databases: 380:44 (OR: 6.13, 95% CI: 4.25–8.85, p < 0.008) and cancer registries: 553:44 (OR: 5.87, 95% CI: 4.13–8.34, p < 0.008). Conclusions TIRRE comprehensively assesses the preparedness of data repositories to participate in specific research projects. Multiple contacts about hypothetical participation in research identified few potential sites.
Copyright © 2018 The Author(s). Lawrence Weed proposed we develop computerised, problem-oriented medical records that guide and teach. The Bawa-Garba case outcomes might have been different if care had been supported by computerised medical record (CMR) systems. CMR systems can reduce prescribing errors and could be developed to flag gaps in supervision. However, CMR systems are not a panacea and need to be fit for purpose. Our informatics perspective on this case is to call for widespread use of CMR systems – designed to guide and protect.
Uptake of a dashboard designed to give realtime feedback to a sentinel network about key data required for influenza vaccine effectiveness studies
© 2018 European Federation for Medical Informatics (EFMI) and IOS Press. Dashboards are technologies that bringing together a range of data sources for observational or analytical purposes. We have created a customised dashboard that includes all the key data elements required for monitoring flu vaccine effectiveness (FVE). This delivers a unique dashboard for each primary care provider (general practice) providing data to the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), one of the oldest European surveillance systems. These FVE studies use a test negative case control (TNCC) design. TNCC requires knowledge of practice denominator; vaccine exposure, and results of influenza virology swabs carried out to identify in an influenza-like-illness (ILI), a clinical diagnosis, really is influenza. The dashboard displays the denominator uploaded each week into the surveillance system, compared with the nationally known practice size (providing face-validity for the denominator); it identifies those exposed to the vaccine (by age group and risk category) and virology specimens taken and missed opportunities for surveillance (again by category). All sentinel practices can access in near real time (4 working days in areas) their rates of vaccine exposure and swabs conducted. Initial feedback is positive; 80% (32/40) practices responded positively.
Automated differentiation of incident and prevalent cases in primary care computerised medical records (CMR)
© 2018 European Federation for Medical Informatics (EFMI) and IOS Press. Identifying incident (first or new) episodes of illness is critical in sentinel networks to inform about the seasonal onset of diseases and to give early warning of epidemics, as well as differentiating change in health service utilization from change in pattern of disease. The most reliable way of differentiating incident from prevalent cases is through the clinician assigning episode type to the patient's computerized medical record (CMR). However, episode type assignment is often made inconsistently. The objective of this collaborative study between the Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC), University of Surrey and the National Physical Laboratory (NPL) is to develop a methodology to reconstruct missing or miscoded episode types. The data, gathered from the RCGP RSC network of over 230 practices, are analyzed and poor episode typing reconstructed by disease type. The methodology is tested in practices with good episode type data quality. This method could be used to improve prediction of epidemics, and to improve the quality of historical rates retrospectively.
Profiling databases to facilitate comparison of child health systems across Europe using standardised quality markers
© 2018 European Federation for Medical Informatics (EFMI) and IOS Press. Models of child primary health care vary across Europe. There are three categories, primary care paediatricians, general practitioner based, or mixed. This paper describes the metadata schema used in the profiling process of candidate data sources for appraisal for the Models of Child Health Appraised (MOCHA) project using the MOCHA International Research Opportunity Instrument (MIROI). The ten clinical indicators included: asthma, antibiotic stewardship, immunisation, rickets, diarrhea, epilepsy, depression, ADHD, enuresis and care of women during pregnancy. Our metadata allows us to identify data within included data sources concerning any of the 10 clinical indicators identified for comparative analysis within the MOCHA project. From the 30 countries we found a minimum of 5 and a maximum of 36 different databases for each indicator.
Ischaemic stroke, haemorrhage, and mortality in older patients with chronic kidney disease newly started on anticoagulation for atrial fibrillation: A population based study from UK primary care
© Published by the BMJ Publishing Group Limited. Objective To assess the association between anticoagulation, ischaemic stroke, gastrointestinal and cerebral haemorrhage, and all cause mortality in older people with atrial fibrillation and chronic kidney disease. Design Propensity matched, population based, retrospective cohort analysis from January 2006 through December 2016. Setting The Royal College of General Practitioners Research and Surveillance Centre database population of almost 2.73 million patients from 110 general practices across England and Wales. Participants Patients aged 65 years and over with a new diagnosis of atrial fibrillation and estimated glomerular filtration rate (eGFR) of <50 mL/min/1.73m 2, calculated using the chronic kidney disease epidemiology collaboration creatinine equation. Patients with a previous diagnosis of atrial fibrillation or receiving anticoagulation in the preceding 120 days were excluded, as were patients requiring dialysis and recipients of renal transplants. Intervention Receipt of an anticoagulant prescription within 60 days of atrial fibrillation diagnosis. Main outcome measures Ischaemic stroke, cerebral or gastrointestinal haemorrhage, and all cause mortality. Results 6977 patients with chronic kidney disease and newly diagnosed atrial fibrillation were identified, of whom 2434 were on anticoagulants within 60 days of diagnosis and 4543 were not. 2434 pairs were matched using propensity scores by exposure to anticoagulant or none and followed for a median of 506 days. The crude rates for ischaemic stroke and haemorrhage were 4.6 and 1.2 after taking anticoagulants and 1.5 and 0.4 in patients who were not taking anticoagulant per 100 person years, respectively. The hazard ratios for ischaemic stroke, haemorrhage, and all cause mortality for those on anticoagulants were 2.60 (95% confidence interval 2.00 to 3.38), 2.42 (1.44 to 4.05), and 0.82 (0.74 to 0.91) compared with those who received no anticoagulation. Conclusion Giving anticoagulants to older people with concomitant atrial fibrillation and chronic kidney disease was associated with an increased rate of ischaemic stroke and haemorrhage but a paradoxical lowered rate of all cause mortality. Careful consideration should be given before starting anticoagulants in older people with chronic kidney disease who develop atrial fibrillation. There remains an urgent need for adequately powered randomised trials in this population to explore these findings and to provide clarity on correct clinical management.