General Medical Services Research Articles

Do VIP medical services damage efficiency? New evidence of medical institutions' total factor productivity using Chinese panel data.

This study examines the causal impact of very important person (VIP) medical services on hospital total factor productivity in Deyang, a prefectural-level city in western China, spanning the years 2015-2020. This aims to offer empirical evidence and policy recommendations for the implementation of VIP practices in the medical field. A secondary unbalanced panel dataset of 416 observations was collected from the annual reports of the Health Commission and 92 eligible medical institutions were included. This study utilized a two-stage strategy. First, the Global Malmquist index was used to calculate the total factor productivity and its decomposition terms for hospitals from 2015 to 2020. In the second stage, two-way fixed effects models and Tobit models were used to identify the relationship between VIP medical services and hospital efficiency; instrumental variables were used to solve potential endogeneity problems in the model. The results showed that VIP medical services had a significantly negative impact on medical institutions' efficiency. The technological advances and pure technical efficiency related to VIP medical care may help explain these negative impacts, which were heterogeneous across groups divided by the nature of the hospital and the outside environment. It is imperative to prioritize the standardized provision of VIP medical services for medical institutions, optimize management and service process, enhance the training of clinical and scientific research capabilities of medical personnel, and scientifically allocate resources for both VIP and general medical services. This will help mitigate health inequality while improving the overall quality of medical services.

Primary care transformation in Scotland: a qualitative evaluation of the views of patients.

The new Scottish GP contract introduced in April 2018 aims to improve quality of care through expansion of the multidisciplinary team (MDT) to enable GPs to spend more time as expert medical generalists with patients with complex needs. To explore patients' views on the changes in general practice in Scotland since the inception of the new contract. Qualitative study with 30 patients (10 living in urban deprived areas, 10 living in urban affluent/mixed urban areas, and 10 living in remote and rural areas). In-depth semi-structured interviews with thematic analysis. Patients were generally unaware of the new GP contract, attributing recent changes in general practice to the COVID-19 pandemic. Ongoing concerns included access to GP consultations (especially face-to-face ones), short consultation length with GPs, and damage to continuity of care and the GP-patient relationship. Most patients spoke positively about consultations with MDT staff but still wanted to see a known GP for health concerns that they considered potentially serious. These issues were especially concerning for patients with multiple complex problems, particularly those from deprived areas. Following the introduction of the new Scottish GP contract, patients in this study's sample were accepting of first contact care from the MDT but still wanted continuity of care and longer face-to-face consultations with GPs. These findings suggest that the expert generalist role of the GP is not being adequately supported by the new contract, especially in deprived areas, though further quantitative research is required to confirm this.

Assessment of population satisfaction with medical care in conflict conditions.

In the context of health care reform, the primary task is to ensure the delivery of high-quality medical services and good end results in the performance of individual physicians, structural units, and general medical services. The healthcare sector is one of the most socially significant spheres of functioning in every country. The problem of conflicts presents special social importance in this field, as a result of the rather close relationship between doctor and patient. The main objective of this study was to determine patients' satisfaction with the quality of healthcare at the primary level. The survey was conducted using an electronic questionnaire. The sample consisted of 1,146 residents of Chernivtsi and the Chernivtsi region, aged 18-56 and older. Almost half of the respondents (42.5%) offered a neutral overall rating of the quality of medical services at the primary care level. Only 25.5% gave a positive valuation of the quality of health care services they received, while 32% gave a negative evaluation. Patients' actions, opinions, and ideas shape and complement industry policies and the way they are implemented. In this context, if a dialogue is established among the main actors in the healthcare system, improvements in the system can be achieved, which will lead to better health and quality of life for people in the future.

P128: The Valladolid Multicentre Study: Delirium characteristics in patients attended in seven liaison psychiatry services in Spain.

Introduction and objective:Delirium is an acute and fluctuating disorder characterized by a disturbance in attention and cognition that is commonly observed in hospitalized older adults; being present in up to 23% of patients admitted to a general medical service and as many as 85% of patients in the intensive care unit. Delirium causes complications such as increased morbidity, persistent functional decline, mortality, increased frailty and increased length of hospital stay. Nonetheless, it is often underdiagnosed, especially when it occurs in its hypoactive form. The objective of this study is to describe characteristics and factors associated with the presence of delirium in patients ≥65 years treated by the liaison psychiatric units in seven general hospitals.Methods:This is an observational, cross-sectional, multicentre study. We obtained data from a sample of 165 patients (≥65 years) admitted to seven general hospitals in Spain referred from different departments to each liaison psychiatry unit. Data was collected for a month and a half period. Psychiatric evaluations were performed while the patients were on wards.Results:We obtained a sample of 165 patients (78 women, 88 men) with a mean age of 76,03 years old (42.10% <75 years, 57,83% ≥ 75 years). Most of them were married and they lived accompanied (67,27%). Delirium was diagnosed in 20% of the consultations. A multivariate analysis was developed with the presence of delirium as the independent variable. The nature of the underlying pathology, the presence of a previous mental disorder, functionality using the Barthel and Lawton Brody Indexes and the prescribed pharmacological treatments were used as dependent variables. Cohen’s kappa statistics were used to estimate the agreement between delirium diagnose made by psychiatrists and the diagnoses considered by the referring doctors. Low agreement was found for the presence of delirium (Kappa= 0,2341). We also explored the relationship between the presence of delirium and the mean length of stay, as well as the discharge destination of these patients.Conclusions:There are still many difficulties in the diagnosis and treatment of patients with delirium. Better knowledge of the factors associated with its appearance would improve the management of these patients.

UTI Friday: The Review of Antibiotic Prophylaxis for Recurrent Urinary Tract Infection (rUTI) in Primary Care

Abstract Introduction There is an established link between antibiotic use and the emergence of resistant organisms. Current NICE guidelines [NG15, NG112] state that patients on antibiotic prophylaxis for rUTI should be reviewed within 6 months and consideration given to discontinue the antibiotic. Self-care measures should be promoted instead. Aim This project aims to assess current practice in relation to rUTI management in Primary Care and identify opportunities for improved antimicrobial stewardship. Methods An audit was developed to review rUTI management and it was used in three GP practices (patient population 35,134) within the Bridgend Locality of Cwm Taf Morgannwg University Health Board. A search for all repeat prescriptions issued between 1st July 2017 and 30th June 2018, for any strength of antibiotic, was run and 179 patients were identified as being on antibiotic prophylaxis for rUTI. The results of the audit were fed back to the practice and a co-designed action plan agreed to review the identified patients. The outcome of this activity was the proof of concept for national roll-out and lead to the audit being included in a ‘basket’ of Quality Improvement Projects as part of the Welsh General Medical Services (GMS) 2019/20 contract, remaining until 2022 due to the COVID pandemic. Ethical approval not required. Results Primary care initiated prophylaxis accounted for 69% of the total number of patients identified (n=123). Of those taking prophylaxis for >6 months (n=160), 24% had a prophylactic review within the previous 6 months as per NICE guidance. Patients taking prophylaxis for >3 years accounted for 39% of the total (n=70). Whilst taking antibiotic prophylaxis, 98 patients (54.7%) had at least one documented acute UTI in the previous 12 months. For an acute UTI, 35 patients (19.6%) were prescribed the same antibiotic as they were taking prophylactically. When an MSU showed resistance to the prophylactic antibiotic, prophylaxis was changed 17.5% of the time, n = 57. Therefore 82.5% were continued on a potentially ineffective antibiotic. Results from the Welsh GMS contract for the Bridgend Locality (patient population 152,041) identified 431 patients on antibiotic prophylaxis for rUTI. Of these, 334 (77.5%) were reviewed and of those reviewed 171 (51%) were stopped (confirmed on re-audit after 6 months). This equates to a 40% locality reduction in antibiotic prophylaxis for rUTI, which is estimated to be in the region of 2,223 fewer antibiotic prescriptions per year. Discussion/Conclusion Initial results suggest that there can be marked improvement in antibiotic use for rUTI management. Through a multi-disciplinary approach, this project has demonstrated how pharmacists can support GPs in the review and management of patients with rUTI. The impact of this in terms of antimicrobial resistance is not yet known but, with increased guideline awareness/compliance, a positive step has been made towards improving rUTI management and meeting the antimicrobial stewardship targets set by the UK Antimicrobial Resistance National Action Plan 2019-2024. In order to tackle high rates of antibiotic prescribing in primary care, innovative approaches to quality improvement and prescriber feedback will be essential and should be further developed.

Patients' experiences of GP consultations following the introduction of the new GP contract in Scotland: a cross-sectional survey.

The new Scottish GP contract commenced in April 2018 with a stated aim of mitigating health inequalities. To determine the health characteristics and experiences of patients consulting GPs in deprived urban (DU), affluent urban (AU), and remote and rural (RR) areas of Scotland. In 2022, a postal survey of a random sample of adult patients from 12 practices who had consulted a GP within the previous 30 days was undertaken. Patient characteristics and consultation experiences in the three areas (DU, AU, RR) were evaluated using validated measures including the Consultation and Relational Empathy (CARE) Measure and Patient Enablement Instrument (PEI). In total, 1053 responses were received. In DU areas, multimorbidity was more common (78% versus 58% AU versus 68% RR, P<0.01), complex presentations (where the consultation addressed both psychosocial and physical problems) were more likely (16% versus 10% AU versus 11% RR, P<0.05), and more consultations were conducted by telephone (42% versus 31% AU versus 31% RR, P<0.01). Patients in DU areas reported lower satisfaction (82% DU completely, very, or fairly satisfied versus 90% AU versus 86% RR, P<0.01), lower perceived GP empathy (mean CARE score 38.9 versus 42.1 AU versus 40.1 RR, P<0.05), lower enablement (mean PEI score 2.6 versus 3.2 AU versus 2.8 RR, P<0.01), and less symptom improvement (P<0.01) than those in AU or RR areas. Face-to-face consultations were associated with significantly higher satisfaction, enablement, and perceived GP empathy than telephone consultations in RR areas (all P<0.05). Four years after the start of the new GP contract in Scotland, patients' experiences of GP consultations suggest that the inverse care law persists.

Prescribing differences among older adults with differing health cover and socioeconomic status: a cohort study

IntroductionAs health reforms move Ireland from a mixed public-private system toward universal healthcare, it is important to understand variations in prescribing practice for patients with differing health cover and socioeconomic status. This study aims to determine how prescribing patterns for patients aged ≥ 65 years in primary care in Ireland differ between patients with public and private health cover.MethodsThis was an observational study using anonymised data collected as part of a larger study from 44 general practices in Ireland (2011–2018). Data were extracted from electronic records relating to demographics and prescribing for patients aged ≥ 65 years. The cohort was divided between those with public health cover (via the General Medical Services (GMS) scheme) and those without. Standardised rates of prescribing were calculated for pre-specified drug classes. We also analysed the number of medications, polypharmacy, and trends over time between groups, using multilevel linear regression adjusting for age and sex, and hospitalisations.ResultsOverall, 42,456 individuals were included (56% female). Most were covered by the GMS scheme (62%, n = 26,490). The rate of prescribing in all drug classes was higher for GMS patients compared to non-GMS patients, with the greatest difference in benzodiazepine anxiolytics. The mean number of unique medications prescribed to GMS patients was 10.9 (SD 5.9), and 8.1 (SD 5.8) for non-GMS patients. The number of unique medications prescribed to both GMS and non-GMS cohorts increased over time. The increase was steeper in the GMS group where the mean number of medications prescribed increased by 0.67 medications/year. The rate of increase was 0.13 (95%CI 0.13, 0.14) medications/year lower for non-GMS patients, a statistically significant difference.ConclusionOur study found a significantly larger number of medications were prescribed to patients with public health cover, compared to those without. Increasing medication burden and polypharmacy among older adults may be accelerated for those of lower socioeconomic status. These findings may inform planning for moves towards universal health care, and this would provide an opportunity to evaluate the effect of expanding entitlement on prescribing and medications use.

Analysis of health inequities in transfers of admitted patients from an academic emergency department to partner community hospital

BackgroundMany academic medical centers (AMC) transfer patients who require admission but not tertiary care to partner community hospitals from their emergency departments (ED). These transfers alleviate ED boarding but may worsen existing healthcare disparities. We assessed whether disparities exist in the transfer of patients from one AMC ED to a community hospital General Medical Service. MethodsWe performed a retrospective cohort study on all patients screened for transfer between April 1 and December 31, 2021. During the screening process, the treating ED physician determines whether the patient meets standardized clinical criteria and a patient coordinator requests patient consent. We collected patient demographics data from the electronic health record and performed logistic regression at each stage of the transfer process to analyze how individual characteristics impact the odds of proceeding with transfer. Results5558 patients were screened and 596 (11%) ultimately transferred. 1999 (36%) patients were Black or Hispanic, 698 (12%) had a preferred language other than English, and 956 (17%) were on Medicaid or uninsured. A greater proportion of Black and Hispanic patients were deemed eligible for interhospital transfer compared to White patients and a greater proportion of Hispanic patients completed transfer to the community hospital (p < 0.017 after Bonferroni correction). After accounting for other demographic variables, patients older than 50 (OR 1.21, 95% CI 1.04–1.40), with a preferred language other than English (OR 1.27, 95% CI 1.00–1.62), and from a priority neighborhood (OR 1.38, 95% CI 1.18–1.61) were more likely to be eligible for transfer, while patients who were male (OR 1.50, 95% CI 1.10–2.05) and younger than 50 (OR 1.85, 95% CI 1.20–2.78) were more likely to consent to transfer (p < 0.05). ConclusionHealth disparities exist in the screening process for our interfacility transfer program. Further investigation into why these disparities exist and mitigation strategies should be undertaken.

Is Scotland's new GP contract addressing the inverse care law?

Scotland, like many countries around the world, has wide health inequalities resulting, in part, from the longstanding 'inverse care law', in which a mismatch between patient needs and provision of care in general practice in deprived areas results in poorer care and worse patient outcomes compared with affluent areas. In early 2018, Scotland embarked on a new GP contract, a stated aim of which was to reduce healthcare inequalities. National data on avoidable mortality showed a 4.8 (2019) and 4.9 (2021)-fold higher rate in the most deprived compared with the most affluent decile of the population. However, the distribution of whole-time equivalent (WTE) general practice clinicians per 10,000 patients, including GPs, and practice-employed practice nurses and other allied healthcare professionals, showed the opposite trend in both 2019 and 2022, with fewer WTE clinicians of all types in GP practices in deprived areas compared with affluent areas. These findings suggest that radical change is needed to reverse the inverse care law in Scotland.

Health inequalities, multimorbidity and primary care in Scotland

Scotland has an ageing population and the widest health inequalities in Western Europe. Multiple health conditions develop ∼10-15 years earlier in deprived areas than in affluent areas. General practice is central to the effective and safe management of such complex multiple health conditions, but the inverse care law has permeated deprived communities ('Deep End' general practices) for the past 50 years. A new, radical, Scottish GP contract was introduced in April 2018, which has a vision to improve quality of care through cluster working and expansion of the multidisciplinary team (MDT), enabling GPs to deliver 'expert generalism' to patients with complex needs. It states a specific intention to address health inequalities and also to support the integration of health and social care. Here, we discuss recent evidence for whether the ambition of the new GP contract, to reduce health inequalities, is being achieved.

Trends in acute hospital smoking prevalence and support of campus ban in Dublin, Ireland (1997-2018)

Abstract Background St Vincent's University Hospital (SVUH), a major hospital in Dublin, Ireland pioneered a hospital smoke-free campus policy in 2009; pre/post this intervention it conducted periodic surveys of patients, staff &amp; visitors for smoking prevalence and policy attitudes. As rates of smoking decline nationally in Ireland, it is important to monitor trends for at-risk groups, including lower socioeconomic status (SES). Methods Repeat questionnaires were administered by census surveys of inpatients, quota or random sub-sample surveys of staff, and quota surveys with outpatients and visitors between 1997 and 2018. As a proxy for social deprivation, the rate of inpatients eligible by income for the state-funded General Medical Services (GMS) card was assessed. Chi square test for trend and SPSS v.27 were used for analysis. Results Support for and awareness of the campus smoking ban increased steadily; post ban agreement varied by smoking status (64.7% smokers, 89.7% ex-smokers; 92.5% non-smokers, p = 0.002). Smoking rates declined in all groups but significantly in outpatients (19.5% vs. 10%; p &amp;lt; 0.01), visitors (27.4% vs 9.5%; p &amp;lt; 0.0001) and staff (30.0% vs 10.8%; p &amp;lt; 0.0001). Rates of inpatient GMS entitlement was high at 54.2% average, compared with national rates of approximately 30% in 2021. Rates of smoking were non-significantly higher in GMS entitled inpatients (33.2% vs 26.8%; p = 0.09) across all survey periods. Conclusions While hospital smoking prevalence has decreased and campus ban support persists, the campus is not immune to challenges in keeping it smoke-free. There are many socioeconomically deprived patients who smoke; this in part may reflect a private hospital on the same campus where affluent smokers are more likely to attend. Recent national initiatives for free nicotine replacement therapy and targeted smoking cessation courses in deprived areas work to address inequalities. We are not aware of similar studies in a hospital population over 25 years. Key messages • Periodic hospital smoking surveys show trends in prevalence which mirror the falling national trends in Ireland. • Socioeconomic differences persist in smoking rates among hospital patients.

Eligibility rates and representativeness of the General Medical Services scheme population in Ireland 2016-2021: A methodological report

Background In Ireland, the means tested General Medical Services (GMS) scheme provides access to a range of healthcare services at no or low cost to approximately one third of the population. Individuals eligible for the GMS scheme are often a focus of research, as a population that account for a large proportion of healthcare services use. The aim of this study is to describe the eligibility rates and representativeness of the GMS scheme population over time, with respect to age group, sex, and geographical area in Ireland. Methods Population data was obtained from the Central Statistics Office (CSO), using 2016 Census figures and projected population figures for 2017-2021. GMS eligibility figures for 2016-2021 were obtained from the HSE Primary Care Reimbursement Service (PCRS). GMS eligibility rates and relative rates of eligibility were calculated for 2016-2021 by age group and sex. Additionally, 2016 eligibility rates were calculated by geographical area. Results The crude eligibility rate decreased from 36.4% in 2016 to 31.2% in 2020, with a slight increase to 31.6% in 2021. In the 75+ years age group, 78.2% of the total population were eligible for the GMS scheme in 2021. The age group with the lowest rate of eligible individuals was the 25–34 age group, with 19.5% eligible in 2021. The eligibility rate was higher among females compared to males throughout the study period. The highest eligibility rate was seen in Donegal, with a crude rate of 52.8%. Dublin had the lowest rate, with a crude rate of 29.3%. Conclusions GMS eligibility varies greatly depending on age, sex, and geographical area, and decreased between 2016 and 2021. This study uses the most up-to-date data available to provide age group, sex and area-based figures for GMS eligibility which may inform planning and conduct of research focusing on GMS-eligible individuals.

Evidence from a Smoking Management Service in a University Teaching Hospital in Dublin, Ireland monitored by repeat surveys, 1997–2022

St Vincent’s University Hospital (SVUH) has a comprehensive smoking management programme and since 1997 has conducted periodic surveys of inpatients, outpatients, staff and visitors to establish prevalence of smoking and associated attitudes towards the hospital’s smoke-free campus policy pioneered in 2009. We report trends and describe also the online community stop smoking course (SSC) developed more recently in response to COVID-19. A questionnaire examining attitudes and smoking status was administered by census surveys of inpatients, quota or random sub-sample surveys of staff, and quota surveys with outpatients and visitors in the time period of 1997–2018. Chi square test for trend was used. Smoking rates declined in all groups but significantly so in outpatients (19.5% vs. 10%; p < 0.01), visitors (27.4% vs. 9.5%; p < 0.0001) and staff (30.0% vs. 10.8%; p < 0.0001). Use of E-Cigarettes was low in all cohorts. Rates of smoking were borderline higher in inpatients eligible by income for state-funded General Medical Services (33.2% vs 26.8%, p = 0.099). Support for and awareness of the ban increased over time. Demographic and quit data was compared between participants of in-person or online SSC. The online courses were successful with a maintenance of quit rates (End of Course: 54.7% vs. 55.0%, 1 Month: 50.4% vs. 54.0%, 3 Month: 19.8% vs. 22.5%). While the hospital community’s smoking prevalence has decreased over time and attitudes to the smoking ban have been increasingly positive, the campus is not without difficulties in keeping it smoke-free. We continue to advocate for hospital staff support in enacting this flagship initiative.

Analysis of the trend in the morbidity of the population of the Russian Federation considering the factors affecting the availability of general medical services

Introduction. The morbidity is one of the key indicators used to assess the level of public health and demonstrating the level of accessibility of medical care to the population and the effectiveness of primary health care. &#x0D; The aim was to analyze the trend in the morbidity of the population in the Russian Federation, considering factors affecting the availability of general medical services, in the context of the subjects of the Russian Federation. &#x0D; Material and methods. The study based on information from the federal static observation form No. 12 “Information on the number of diseases registered in patients living in the service area of a medical organization” for 2018–2021. &#x0D; Results. In the Russian Federation from 2018 to 2021, general morbidity increased by 2.6%, while newly identified morbidity increased by 9.4%. The Ivanovo region had the largest rate of rise in general morbidity (24.9%), Stavropol Krai — the highest newly identified morbidity (34.7%). When assessing the influence of various factors on the level of morbidity using the method of stable regression, the level of provision of the population with doctors was revealed to have the greatest influence, which is confirmed by the presence of a strong direct dependence.&#x0D; Limitations. The data from the federal static observation form No. 12 “Information on the number of diseases registered in patients living in the service area of a medical mamnagement” for 2018–2021 for 85 subjects of the Russian Federation were examined to determine the morbidity of the population of the Russian Federation that is able-bodied and over the working age.&#x0D; Conclusion. The morbidity rate in the Russian Federation during the period under review tends to increase. It is an integral indicator of the availability of medical care and the detection of diseases, which influenced by a variety of factors, including the availability of primary care doctors, the strength of the medical managemorganization, the degree of hospitalization, the average number of visits to doctors.

Enhancement of Tuberculosis Detection and Prevention in HIV-Infected Patients

Tuberculosis incidence and HIV infection incidence in the regions of the Russian Federation are declining, but the proportion of HIV positive people among the entire cohort of tuberculosis patients is clearly growing.The objective: to determine causes for increasing proportion of HIV infected people among tuberculosis patients and to provide additional recommendations for enhancement of tuberculosis detection in HIV infected patients. as well as prevention of its transmission.Subjects and Methods. The cohort of new tuberculosis patients with concurrent HIV infection (TB/HIV coinfection) in the Russian Federation region with a high prevalence of HIV infection was studied based personal medical records of patients for the first 6 months of 2022 (682 cases totally).Results. The cohort of patients with TB/HIV co-infection belonged to socially vulnerable population. Among them, the parenteral route of HIV infection transmission still prevails, while in the whole country, among new HIV patients, the sexual (heterosexual) route of transmission already prevails. The majority of patients with TB/HIV co-infection, who had been infected with HIV for more than 5 years by the time tuberculosis was detected, were not registered with the Center for AIDS Prevention and Control and accordingly received no antiretroviral therapy. In most cases, HIV-infected patients sought medical care in general medical services when they developed symptoms of tuberculosis, however they referred for help when the disease was advanced. When assessing effectiveness of tuberculosis treatment, the specific parameters of tuberculosis course in HIV-infected patients with compromised immunity have not been taken into account.

Primary care transformation in Scotland: a qualitative study of GPs' and multidisciplinary team members' views.

The Scottish Government's vision to transform primary care includes expansion of the primary care multidisciplinary team (MDT), formalised in the new GP contract in April 2018. To explore practitioners' views on the expansion of MDT working in Scotland. Qualitative study with GPs and a range of MDT staff working in three different population settings in Scotland. In-depth semi-structured interviews were carried out by telephone with 8 GPs and 19 MDT staff between May and June 2022. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted to identify commonalities and divergences in the interviews. Internal challenges facing MDT staff included adapting to the fast pace of primary care, building new relationships, training and professional development needs, line management issues, and monitoring and evaluation of performance. External challenges included the ongoing effects of the COVID-19 pandemic, lack of time, difficulties with hybrid working, and low staff morale. Most GPs reported that expansion of their roles as expert medical specialists had not yet happened because their workload had not decreased (and in many cases had increased). In deprived areas, insufficient resources to deal with the high numbers of patients with complex multimorbidity remained a key issue. Interviewees in remote and rural settings felt the new contract did not take into account the unique challenges of providing primary care services in such areas, and recruitment and accommodation were cited as particular problems. Although there has been substantial expansion of the primary care MDT, which most GPs welcome, many challenges to effective implementation remain that must be addressed if transformation of primary care in Scotland is to become a reality.

Excess mortality among adults with mental disorders treated in psychiatric and general medical settings: A population-based cohort study using municipal medical claims data in Japan

ObjectivesTo estimate the excess mortality associated with serious mental illnesses (schizophrenia and bipolar disorder) and common mental disorders (depression and anxiety) at the population level. MethodsWe conducted a population-based, retrospective cohort study in Tsukuba, Japan. Individuals aged 20–74 years and insured for at least 12 months by the National Health Insurance or Late Elders’ Health Insurance as of April 2015 were included (n = 41,618, 29% of the city’s population aged 20–74 years). Individuals with mental disorders (International Classification of Diseases-10 code: F00-F99) were identified in psychiatric and general medical services using medical claims during the 12-month baseline period and classified into mutually exclusive diagnostic subgroups. Their age/sex-adjusted all-cause mortality rate ratios (aMRRs) were estimated and compared to those of individuals without mental disorders. ResultsAltogether, 12.0% of participants had mental disorders (general medical service: 7.2% vs. psychiatric service: 4.8%). Common mental disorders were the most prevalent (8.1%). During the median 48 months of observation, 225 deaths were observed in people with mental disorders. The aMRR was 1.98 (95%CI: 1.70–2.29) for all mental disorders, with a higher rate ratio in psychiatric service than in general medical service users (aMRR: 2.64 [2.12–3.29] vs. 1.70 [1.42–2.04]), 3.57 (2.71–4.70) for serious mental illness, with a higher rate ratio in psychiatric inpatient service than in outpatient service users (aMRR: 5.74 [3.76–8.78] vs. 2.84 [2.00–4.04]), and 1.53 (1.27–1.84) for common mental disorders. ConclusionSerious and common mental disorders in psychiatric and general health services are associated with increased mortality in Japan.

P16 UTI Friday: a review of antibiotic prophylaxis in the management of recurrent UTI in primary care

Abstract Background An appropriate and evidence-based strategy for treating patients with recurrent urinary tract infection (rUTI) is to use low-dose antibiotics as prophylaxis. All antibiotics used for rUTI prophylaxis are associated with problems of resistance and adverse effects. Antimicrobial resistance (AMR) refers to a natural phenomenon in which micro-organisms become resistant to antibiotics that were originally effective in killing them. There is an established link between antibiotic use and the emergence of resistant organisms. Current NICE guidelines (NG15, NG112) state that patients on antibiotic prophylaxis for rUTI should have a clinical review within 6 months to assess success from the prophylactic regimen. At this review, consideration should be given to discontinuing the antibiotic and the promotion of self-care measures in its place. This project aims to assess current practice in relation to rUTI management in primary care and identify opportunities for improved antimicrobial stewardship. Methods An audit was developed to review rUTI management, and it was used in three GP practices (patient population 35 134) within the Bridgend Locality of Cwm Taf Morgannwg University Health Board. If regular antibiotic prophylaxis is required, nitrofurantoin 50 mg/100 mg nocte or trimethoprim 100 mg nocte should be considered first line, unless associated with resistance, allergy or co-morbidities. Cefalexin 125 mg nocte is the second choice. A search for all repeat prescriptions issued for any strength of these drugs, from 1 July 2017 to 30 June 2018, was run in the GP practice systems, and 179 patients were identified as being on antibiotic prophylaxis for rUTI (∼0.5% of the practice populations). The results of the audit were fed back to the practice, and a co-designed action plan agreed to review the identified patients. The outcome of this activity was the proof of concept for national roll-out and lead to the audit being included in a ‘basket’ of Quality Improvement Projects as part of the Welsh General Medical Services (GMS) 2019/20 contract. Due to the COVID pandemic, it remained live until September 2022. Results Primary care–initiated prophylaxis accounted for 69% of the total number of patients identified (n = 123). Of those taking prophylaxis for &amp;gt;6 months (n = 160), 24% had a prophylactic review within the previous 6 months as per NICE guidance. Patients taking prophylaxis for &amp;gt;3 years accounted for 39% of the total (n = 70). Whilst taking antibiotic prophylaxis, 98 patients (54.7%) had at least one documented acute UTI in the previous 12 months. For an acute UTI, 35 patients (19.6%) were prescribed the same antibiotic as they were taking prophylactically. When an MSU showed resistance to the prophylactic antibiotic, prophylaxis was changed 17.5% of the time, n = 57. Therefore, 82.5% were continued on a potentially ineffective antibiotic. Results from the Welsh GMS contract for the Bridgend locality (patient population 152 041) identified 431 patients on antibiotic prophylaxis for rUTI. Of these, 334 (77.5%) were reviewed, and of those reviewed, 171 (51%) were stopped (confirmed on re-audit after 6 months). This equates to a 40% locality reduction in antibiotic prophylaxis for rUTI, which is estimated to be in the region of 2223 fewer antibiotic prescriptions per year. Conclusions Initial results from the UTI Friday audit suggest that there can be marked improvement in antibiotic use for rUTI management. Through a multi-disciplinary approach, this project has demonstrated how pharmacists can support GPs in the review and management of patients with rUTI. Using audit feedback, co-designed action plans have been implemented. The impact of this on resistance seen in urinary isolates is not yet known but, with increased guideline awareness/compliance, a positive step has been made towards improving rUTI management and meeting the antimicrobial stewardship targets set by the UK Antimicrobial Resistance National Action Plan 2019–2024. In order to tackle high rates of antibiotic prescribing in primary care, innovative approaches to quality improvement and prescriber feedback will be essential and should be further developed.

Items from emergency medicine as part of recommendations for nurses’ decision-making to involve general practitioner vs. emergency medical services in emergencies of nursing home residents—results from the project NOVELLE

Items from emergency medicine as part of recommendations for nurses’ decision-making to involve general practitioner vs. emergency medical services in emergencies of nursing home residents—results from the project NOVELLE

Development and applicability of a risk assessment tool for hospital-acquired mobility impairment in ambulatory older adults.

Mobility loss is common in hospitalized older adults, and resources to prevent mobility impairment are finite. Our goal was to use routinely collected data to develop a risk assessment tool that identifies individuals at risk of losing the ability to walk during hospitalization on the first hospital day. Second, we determined if the tool could inform the use of mobility-preserving interventions. We included patients admitted to a general medical service, aged ≥65 years, who walked occasionally or frequently on admission (Braden Scale Activity subset > = 3). Patients were considered to have a new mobility impairment if, at discharge, their ability to walk was severely limited or nonexistent or they were confined to bed (Braden Scale Activity subset <3). We used predictors available on the first hospital day to develop (2017-18 cohort) and validate (2019 cohort) a risk assessment tool. We determined the association between predicted risk and therapy use in the validation cohort to highlight the model's clinical utility. 5542 patients were included (median age 76 years, 48% women); 7.6% were discharged unable to walk. The model included 5 predictors: age, medication administrations, Glasgow Coma Scale verbal score, serum albumin, and urinary catheter presence. In the validation cohort, the model discriminated well (c-statistic 0.75) and was strongly associated with hospital-acquired mobility impairment (lowest decile 1%, highest decile 25%). In the validation cohort, therapy consultation ordering increased linearly with predicted risk; however, observed mobility impairment increased exponentially. The tool assesses the risk of mobility impairment in all ambulatory hospitalized older adults on the first hospital day. Further, it identifies at-risk older adults who may benefit from mobility interventions.