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In the wake of COVID-19 exposing vulnerabilities in pandemic preparedness globally, Nigeria is taking proactive measures to fortify its health security resilience through the Nigeria Centre for Disease Control (NCDC). This piece, written by a current student provides an in-depth look at the innovative strategies and tailored approaches NCDC is implementing to address vulnerabilities.
Overseas general practitioners (GPs) and opioid prescriptions in England.
The substantial recent rise in opioid prescription rates, along with increasing evidence of misuse and associated morbidity and mortality, raises serious concerns about the appropri- ateness of these drugs for pain management. This study investigates prescription behaviour differences across opioid drug categories between UK-trained and overseas-trained GPs. Us- ing panel data covering all English practices from 2018 to 2021, we find a strong association between practices with more overseas GPs and opioid prescription patterns. Regional dif- ferences emerge, with GPs from North America prescribing more opioids and those from Africa and Asia prescribing less, relative to the UK-trained counterparts. Heterogeneous cultural norms, different training environments, and varying epidemiological patterns might explain these different prescribing behaviours. Comprehensive cross-country assessments of GP competencies could identify areas for targeted training, helping to align the practices of foreign-trained GPs with UK standards while supporting the attraction of global talent.
The importance of experience: insights into optimal home-blood pressure monitoring regimens from the TASMINH4 Trial
Objectives: This study investigates how prior home blood pressure monitoring (HBPM) experience affects blood pressure variability and evaluates if reduced HBPM regimens could be recommended for experienced patients. Methods: This posthoc analysis of the TASMINH4 trial included self-monitored blood pressure (BP) data from 225 patients. The standard deviation of systolic BP recordings was calculated for each patient-week to assess how BP variability changes with HBPM duration. A subgroup of 84 patients, who submitted at least 1 reading a day for 7days at months 1, 3, and 6, was analysed to assess the impact of reduced HBPM regimens on BP estimates. Results: Day 1 readings were significantly higher than day 2–7 in the first 3months of HBPM: 1.1 (95% CI 1.8, 0.4) day 1 vs. day 2. This effect diminished after 6months: 1.0 (95% CI -0.8, 2.8) day 1 vs. 2. Long term monitoring significantly reduced intra-week BP variability, with the standard deviation of systolic BP recordings within each patient-week significantly reduced after 6months. After 6months of HBPM, the inclusion of day 1 readings or use of an abbreviated monitoring regimen had a reduced impact on estimates of mean systolic and diastolic blood pressure. Conclusions: Long-term HBPM reduces intra-week BP variability, making day 1 readings insignificantly raised after 6months of HBPM. This provides rationale for different HBPM recommendations: longer regimes, excluding day one readings, for diagnosis and short-term monitoring; and abbreviated regimes including day 1 for longer term monitoring in those with HBPM experience.
Use of integrated services in antenatal care: A case study of Mabvuku Polyclinic, Zimbabwe
Background: The integration of diagnostic services presents a critical opportunity to improve health outcomes in low- and middle-income countries (LMICs), potentially averting up to 1 million premature deaths annually. Antenatal care provides a critical platform for diagnosing multiple diseases in an integrated manner. Aim: This study explored the experiences of healthcare providers and pregnant women using integrated diagnostic services at a primary care facility in Zimbabwe. Setting: A qualitative case study was conducted at Mabvuku Polyclinic in Harare, Zimbabwe. Methods: Using purposive sampling, 14 healthcare workers and 22 pregnant women participated in interviews. Observations and semi-structured interviews were recorded, transcribed and analysed using NVivo software. Thematic analysis was applied to identify key themes related to access, patient-provider interactions and systemic barriers. Results: According to the interviewees’ reports, challenges such as limited resources, medical equipment and staff hinder efforts to integrate diagnostic services. The women strongly preferred integrated diagnosis, even if it meant enduring long waiting times, and valued the convenience of receiving all necessary services in a single visit. The study highlighted the hidden socio-economic barriers to ‘free’ healthcare and underscored the importance of addressing systemic inefficiencies. Conclusion: The insights gained from this study are transferable and contribute to the understanding of integrated diagnostic services in maternal healthcare contexts. Contribution: They offer practical recommendations for improving service delivery and health outcomes in similar settings.
Disparities in the care and direct-acting oral anticoagulant (DOAC) management in atrial fibrillation (AF) and chronic kidney disease (CKD) in English primary care between 2018 and 2022: primary care sentinel network database study.
BACKGROUND: In England, most prescribing of direct-acting oral anticoagulants (DOACs) for patients with chronic kidney disease (CKD) and atrial fibrillation (AF) takes place in primary care. The 2024 European Society of Cardiology guidelines introduced the AF-CARE ((C) comorbidities and risk factors; (A) avoid stroke and thromboembolism by appropriate prescription of oral anticoagulants; (R) rate and rhythm control; (E) evaluation and reassessment should be individualised for every patient, with a dynamic approach) framework to address this. OBJECTIVE: To describe any health disparities in CKD and AF, including anticoagulation management and correct dosing of DOACs. METHODS: Using English primary care sentinel network data from 2018 to 2022, demographics of AF and CKD including anticoagulation and appropriate DOAC dosing according to creatinine clearance and other factors were assessed. The study also examined disparities in CKD and AF in relation to socioeconomic status and ethnicity. We defined socioeconomic status by Index of Multiple Deprivation (IMD), a weighted composite index combining information from the domains of deprivation including income. RESULTS: Of 10 513 950 people registered with general practices in the sentinel network, 2.9% (n=304 678) were aged ≥18 years with a diagnosis of AF. The prevalence of CKD in AF was 26.0% (n=79 210) and 63.3% of people eligible for anticoagulation were prescribed a DOAC. Among the 54 897 people with AF and CKD 3 or 4, greater likelihood of DOAC prescribing was associated with higher socioeconomic status. Socioeconomic disparities in anticoagulation increased through the 5 years. No association was identified between ethnicity and likelihood of being anticoagulated.In terms of correct dosing, there was no association with socioeconomic status. Overdosing was more frequent than underdosing. Incorrect dosing was associated with male sex (OR 0.80 (95% CI 0.74, 0.86)), dementia (OR 0.94 (0.83, 1.07)) and frailty (OR 0.42 (0.37, 0.48)). CONCLUSIONS: People in the most deprived IMD quintile were least likely to be anticoagulated. Incorrect DOAC dosing was associated with male sex, increasing frailty and dementia. Socioeconomic and health disparities are apparent in anticoagulation prescribing and should be addressed in line with the AF-CARE framework.
Menopause care for diverse communities: a qualitative study of GP clinician experiences
Background In the UK, there is increasing public awareness of menopause. However, there remain inequalities in its treatment, with lower hormone replacement therapy (HRT) prescribing in socially-deprived areas. Little is known about how health care professionals (HCPs) view and understand this. Aim To explore barriers and facilitators to the provision of menopause care in diverse communities through qualitative interviews with primary healthcare professionals involved in delivering care. Method We purposively sampled 15 HCPs working in patient-facing roles in areas of high deprivation in England (Midlands). 11 individual interviews and 1 focus group were conducted and subject to team-based iterative thematic analysis. Results Three key themes emerged; the context of contemporary primary care, delivering menopause care, and limitations of the current approach to menopause care. HCPs reported experiencing increasing awareness of menopause and request for HRT by women. Cultural and ethnic differences were perceived as impacting on whether women seek menopause care and/or HRT from their GP. HCPs believe women have high expectations of HRT and that discussions around expectations were important. HCPs emphasised the difficulty of remaining up-to-date on menopause care, limited ability to refer to specialists and the impact of patient requests for testosterone. Conclusion HCPs believe that differences in levels of menopause care across diverse populations experiencing health inequalities reflect differing demands from communities and a lack of time and funding to provide targeted community-based education on menopause and its treatment. Future work should include culturally sensitive and targeted health education for patients and HCPs.
Patient characteristics associated with clinically coded long COVID: an OpenSAFELY study using electronic health records.
BACKGROUND: Clinically coded long COVID cases in electronic health records are incomplete, despite reports of rising cases of long COVID. AIM: To determine patient characteristics associated with clinically coded long COVID. DESIGN & SETTING: With the approval of NHS England, we conducted a cohort study using electronic health records within the OpenSAFELY-TPP platform in England, to study patient characteristics associated with clinically coded long COVID from 29 January 2020 to 31 March 2022. METHOD: We summarised the distribution of characteristics for people with clinically coded long COVID. We estimated age-sex adjusted hazard ratios and fully adjusted hazard ratios for coded long COVID. Patient characteristics included demographic factors, and health behavioural and clinical factors. RESULTS: Among 17 986 419 adults, 36 886 (0.21%) were clinically coded with long COVID. Patient characteristics associated with coded long COVID included female sex, younger age (under 60 years), obesity, living in less deprived areas, ever smoking, greater consultation frequency, and history of diagnosed asthma, mental health conditions, pre-pandemic post-viral fatigue, or psoriasis. These associations were attenuated following two-doses of COVID-19 vaccines compared to before vaccination. Differences in the predictors of coded long COVID between the pre-vaccination and post-vaccination cohorts may reflect the different patient characteristics in these two cohorts rather than the vaccination status. Incidence of coded long COVID was higher in those with hospitalised COVID than with those non-hospitalised COVID-19. CONCLUSIONS: We identified variation in coded long COVID by patient characteristic. Results should be interpreted with caution as long COVID was likely under-recorded in electronic health records.
Risk of bias in routine mental health outcome data: the case of Health of the Nation Outcome Scales
BackgroundRoutine outcome data in secondary mental health services have significant potential for service planning, evaluation and research. Expanding the collection and use of these data is an ongoing priority in the National Health Service (NHS), but inconsistent use threatens their validity and utility. If recording is more likely among certain patient groups or at specific stages of treatment, measured outcomes may be biased and unreliable.ObjectiveThe objective is to assess the scale, determinants and implications of incomplete routine outcome measurement in a secondary mental health provider, using the example of the widely collected Health of the Nation Outcome Scores (HoNOS).MethodsA retrospective cohort study was conducted using routine HoNOS assessments and episodes of care for patients receiving secondary mental healthcare from an NHS Trust in Southeast England between 2016 and 2022 (n=30 341). Associations among demographic, clinical and service factors, and rates and timings of HoNOS assessments were explored with logistic regressions. Relationships between total HoNOS scores and related mental health outcomes (costs, relapse and improvement between assessments) were estimated after adjusting for the likelihood of assessment.Findings66% of patients (n=22 288) had a recorded HoNOS assessment. Of the distinct episodes of care for these patients (n=65 439), 43% (n=28 170) were linked to any assessment, 25% (n=16 131) were linked to an initial baseline assessment, while 4.7% (n=3 094) were linked to multiple HoNOS assessments, allowing for evaluation of clinical progress. Likelihood and timing of assessment were significantly associated with a range of factors, including service type, diagnosis, ethnicity, age and gender. After adjusting for observed factors determining the likelihood of assessment, the strength of association between HoNOS scores and overall costs was significantly reduced.ConclusionMost of the activity observed in this study cannot be evaluated with HoNOS. HoNOS assessments are highly unlikely to be missing at random. Without approaches to correct for substantial gaps in routine outcome data, evaluations based on these may be systematically biased, limiting their usefulness for service-level decision-making.Clinical implicationsRoutine outcome collection must increase significantly to successfully implement proposed strategies for outcome assessment in community mental healthcare without inconsistent records undermining the use of resulting data.
Preferences for multi-cancer tests (MCTs) in primary care: discrete choice experiments of general practitioners and the general public in England.
BACKGROUND: Multi-Cancer tests (MCTs) hold potential to detect cancer across multiple sites and some predict the origin of the cancer signal. Understanding stakeholder preferences for MCTs could help to develop appealing MCTs, encouraging their adoption. METHODS: Discrete Choice Experiments (DCEs) conducted online in England. RESULTS: GPs (n = 251) and the general public (n = 1005) preferred MCTs that maximised negative predictive value, positive predictive value, and could test for a larger number of cancer sites. A reduction of the NPV of 4.0% was balanced by a 12.5% increase in the PPV for people and a 32.5% increase in PPV for GPs. People from ethnic minority backgrounds placed less importance on whether MCTs can detect multiple cancers. People with more knowledge and experience of cancer placed substantial importance on the MCT being able to detect cancer at an early stage. Both GPs and members of the public preferred the MCT reported in the SYMPLIFY study to FIT, PSA, and CA125, and preferred the SYMPLIFY MCT to 91% (GPs) and 95% (people) of 2048 simulated MCTs. CONCLUSIONS: These findings provide a basis for designing clinical implementation strategies for MCTs, according to their performance characteristics.
A Cluster Randomized Controlled Trial of Social Workers in Schools (SWIS) in England
Purpose: “Social Workers in Schools” (SWIS) is a school-based intervention aiming to reduce the need for children to receive child protection services in England. This article reports the findings of a randomized controlled trial (RCT) designed to evaluate SWIS. Method: The study was a two-arm pragmatic cluster RCT with an embedded process and economic evaluation. The intervention physically located social workers within schools. The primary outcome was the rate of child protection inquiries and secondary outcomes included care entry and educational outcomes. Results: 278,858 students in 268 schools were randomized to the intervention (136 schools) or control arm (132 schools). We found no statistically significant effects on primary or secondary outcomes. SWIS was implemented well and positively perceived. Discussion: SWIS appears ineffective in reducing the need for statutory services. The study demonstrates it is possible to conduct a large-scale school-based social work RCT. The study was registered at https://www.isrctn.com/, ref: ISRCTN90922032.
Nurse-delivered sleep restriction therapy in primary care for adults with insomnia disorder: a mixed-methods process evaluation
Background Sleep restriction therapy (SRT) is a behavioural therapy for insomnia. Aim To conduct a process evaluation of a randomised controlled trial comparing SRT delivered by primary care nurses plus a sleep hygiene booklet with the sleep hygiene booklet only for adults with insomnia disorder. Design and setting A mixed-methods process evaluation in a general practice setting. Method Semi-structured interviews were conducted in a purposive sample of patients receiving SRT, the practice nurses who delivered the therapy, and also GPs or practice managers at the participating practices. Qualitative data were explored using framework analysis, and integrated with nurse comments and quantitative data, including baseline Insomnia Severity Index score and serial sleep efficiency outcomes to investigate the relationships between these. Results In total, 16 patients, 13 nurses, six practice managers, and one GP were interviewed. Patients had no previous experience of behavioural therapy, needed flexible appointment times, and preferred face-to-face consultations; nurses felt prepared to deliver SRT, accommodating patient concerns, tailoring therapy, and negotiating sleep timings despite treatment complexity and delays between training and intervention delivery. How the intervention produced change was explored, including patient and nurse interactions and patient responses to SRT. Difficulties maintaining SRT, negative attitudes towards treatment, and low self-efficacy were highlighted. Contextual factors, including freeing GP time, time constraints, and conflicting priorities for nurses, with suggestions for alternative delivery options, were raised. Participants who found SRT a positive process showed improvements in sleep efficiency, whereas those who struggled did not. Conclusion SRT was successfully delivered by practice nurses and was generally well received by patients, despite some difficulties delivering and applying the intervention in practice.
Sleep regularity index as a novel indicator of sleep disturbance in stroke survivors: a secondary data analysis
Sleep disturbance is common but often overlooked after stroke. Regular sleep is increasingly recognised as important for overall health, yet little is known about how sleep regularity changes after stroke. This study examined differences in the Sleep Regularity Index (SRI) between stroke survivors and healthy controls using actigraphy data from an existing dataset (~ 1 week per participant). Data were analysed for 162 stroke survivors (mean age 61 ± 14 years, 5 ± 5 years post-stroke, 89 males) and 60 controls (mean age 57 ± 17 years, 32 males). Stroke survivors had significantly lower SRI scores than controls (p = 0.001), indicating less regular sleep. In the stroke group, higher SRI correlated with longer total sleep time (p = 0.003) and better self-reported sleep quality (p = 0.001) but not with other sleep metrics. Lower SRI was associated with worse depressive symptoms (p = 0.006) and lower quality of life (p = 0.001) but not with disability (p = 0.886) or time since stroke (p = 0.646). These findings suggest that sleep regularity is disrupted post-stroke and may influence well-being. Future research should explore interventions to improve sleep regularity and related health outcomes in stroke survivors.