General Practice Level Research Articles

Parents' and guardians' views and experiences of accessing routine childhood vaccinations during the coronavirus (COVID-19) pandemic: A mixed methods study in England.

To explore parents' and guardians' views and experiences of accessing National Health Service (NHS) general practices for routine childhood vaccinations during the coronavirus (COVID-19) pandemic in England. Mixed methods approach involving an online cross-sectional survey (conducted between 19th April and 11th May 2020) and semi-structured telephone interviews (conducted between 27th April and 27th May 2020). 1252 parents and guardians (aged 16+ years) who reported living in England with a child aged 18 months or under completed the survey. Nineteen survey respondents took part in follow-up interviews. The majority of survey respondents (85.7%) considered it important for their children to receive routine vaccinations on schedule during the COVID-19 pandemic; however, several barriers to vaccination were identified. These included a lack of clarity around whether vaccination services were operating as usual, particularly amongst respondents from lower income households and those self-reporting as Black, Asian, Chinese, Mixed or Other ethnicity; difficulties in organising vaccination appointments; and fears around contracting COVID-19 while attending general practice. Concerns about catching COVID-19 while accessing general practice were weighed against concerns about children acquiring a vaccine-preventable disease if they did not receive scheduled routine childhood vaccinations. Many parents and guardians felt their child's risk of acquiring a vaccine-preventable disease was low as the implementation of stringent physical distancing measures (from March 23rd 2020) meant they were not mixing with others. To promote routine childhood vaccination uptake during the current COVID-19 outbreak, further waves of COVID-19 infection, and future pandemics, prompt and sustained national and general practice level communication is needed to raise awareness of vaccination service continuation and the importance of timely vaccination, and invitation-reminder systems for vaccination need to be maintained. To allay concerns about the safety of accessing general practice, practices should communicate the measures being implemented to prevent COVID-19 transmission.

Self-Declared Roma Ethnicity and Health Insurance Expenditures: A Nationwide Cross-Sectional Investigation at the General Medical Practice Level in Hungary.

: IntroductionThe inevitable rising costs of health care and the accompanying risk of increasing inequalities raise concerns. In order to make tailored policies and interventions that can reduce this risk, it is necessary to investigate whether vulnerable groups (such as Roma, the largest ethnic minority in Europe) are being left out of access to medical advances. Objectives: The study aimed to describe the association between general medical practice (GMP) level of average per capita expenditure of the National Health Insurance Fund (NHIF), and the proportion of Roma people receiving GMP in Hungary, controlled for other socioeconomic and structural factors. Methods: A cross-sectional study that included all GMPs providing care for adults in Hungary (N = 4818) was conducted for the period 2012–2016. GMP specific data on health expenditures and structural indicators (GMP list size, providing care for adults only or children also, type and geographical location of settlement, age of GP, vacancy) for secondary analysis were obtained from the NHIF. Data for the socioeconomic variables were from the last census. Age and sex standardized specific socioeconomic status indicators (standardized relative education, srEDU; standardized relative employment, srEMP; relative housing density, rHD; relative Roma proportion based on self-reported data, rRP) and average per capita health expenditure (standardized relative health expenditure, srEXP) were computed. Multivariate linear regression model was applied to evaluate the relationship of socioeconomic and structural indicators with srEXP. Results: The srEDU had significant positive (b = 0.199, 95% CI: 0.128; 0.271) and the srEMP had significant negative (b = −0.282, 95% CI: −0.359; −0.204) effect on srEXP. GP age > 65 (b = −0.026, 95% CI: −0.036; −0.016), list size <800 (b = −0.043, 95% CI: −0.066; −0.020) and 800–1200 (b = −0.018, 95% CI: −0.031; −0.004]), had significant negative association with srEXP, and GMP providing adults only (b = 0.016, 95% CI: 0.001;0.032) had a positive effect. There was also significant expenditure variability across counties. However, rRP proved not to be a significant influencing factor (b = 0.002, 95% CI: −0.001; 0.005). Conclusion: As was expected, lower education, employment, and small practice size were associated with lower NHIF expenditures in Hungary, while the share of self-reported Roma did not significantly affect health expenditures according to our GMP level study. These findings do not suggest the necessity for Roma specific indicators elaborating health policy to control for the risk of widening inequalities imposed by rising health expenses.

Natural Experiments that Allow to Study Potential Drugs in Coronavirus Disease 2019 (COVID-19) from the General Practice Level

Abstract It is proposed to take advantage of the "natural experiments" in the prescription of drugs that have been reported as potentially useful for the treatment of COVID-19. Many of these are used in their licensed indications for a wide variety of health problems. Thus, the exposure to these drugs and the results of the disease (duration of symptoms, severity, hospitalization, viral load, etc.) could be studied. Therefore, patients treated with: 1) Azithromycin and doxycline (for various infections); 2) Alpha1 antagonists (for hypertension or benign prostatic hypertrophy); 3) Tocilizumab (in the treatment of various types of arthritis; 4) Statins (for dyslipidemia); 5) Selective serotonin reuptake inhibitors (fluoxetine, citalopram, sertraline, paroxetine, fluvoxamine, etc.) for depression/anxiety; 6) Antipsychotics; 7) Progesterone; 8) Vitamin D or calcifediol (25OHD); 9) Vitamin C; 10) Colchicine (for rheumatological and cardiac conditions); 11) ACE inhibitors (ACE-I) and AT1-A; 12) Ivermectin (as treatment and control of various tropical diseases; 13) Beta-blockers such as propranolol, nebivolol, carvedilol, atenolol, etc. (for heart problems and high blood pressure); and 14) Antihistamines such as clemastine and cloperastine (for coughs of various causes), they could be tested immediately. These researches could have a retrospective character (of computerized medical records at the level of general medicine), to find patterns, trends and associations both in small and selected samples, as well as in large data sets.

Links between the amount of antipsychotic medication prescribed per population at general practice level, local demographic factors and medication selection

BackgroundAntipsychotic medications are the first-line pharmacological intervention for severe mental illnesses (SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia.Our aim was to examine the factors relating to antipsychotic prescribing in general practices across England and how cost changes in recent years have impacted on antipsychotic prescribing.MethodsThe study examined over time the prescribing volume and prices paid for antipsychotic medication by agent in primary care.Monthly prescribing in primary care was consolidated over 5 years (2013–2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice.The defined Daily Dose (DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults.ResultsWe included 5750 general practices with practice population > 3000 and with > 30 people on their SMI register. In 2018/19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care.In 2017/18 there was a sharp increase in overall prices and they had not reduced to expected levels by the end of the 2018/19 evaluation year. There was a gradual increase in antipsychotic prescribing over 2013–2019 which was not perturbed by the increase in drug price in 2017/18.The strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density (urban), and comorbidities e.g. chronic obstructive pulmonary disease (COPD). Higher % younger and % older populations, northerliness and non-white (Black and Minority Ethnic(BAME)) ethnicity were all independently associated with less antipsychotic prescribing.Higher DDD/general practice population was linked with higher proportion(%) injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol depot. Less DDD/population was linked with general practices using higher % risperidone and higher spending/dose of antipsychotic.ConclusionsThe levels of antipsychotic prescribing at general practice level are driven by social factors/comorbidities. We found a link between depot prescriptions with higher antipsychotic DDD and risperidone prescriptions with lower antipsychotic DDD. It is important that all prescribers are aware of these drivers / links.

Effectiveness and cost-effectiveness of the Assessment of Burden of Chronic Conditions (ABCC) tool in patients with COPD, asthma, diabetes mellitus type 2 and heart failure: protocol for a pragmatic clustered quasi-experimental study

IntroductionThe number of people that have one or multiple condition(s) with a chronic course is rising, which consequently challenges healthcare systems. Healthcare geared to long-term care should focus on patient-centredness,...

Factors associated with variation in emergency diagnoses of cancer at general practice level in England.

Cancer patients diagnosed following an emergency presentation have poorer outcomes. We explore whether practice characteristics are associated with differences in the proportion of emergency presentations. Univariable and multivariable logistic regression models were fitted to investigate the relationships between 2017-18 emergency cancer presentations at practice level in England and access and continuity in primary care, trust in healthcare professionals, 2-week-wait (2WW) referrals, quality and outcomes framework (QOF) achievements and socio-demographic factors (age, gender and deprivation). Our analysis using comprehensive nationwide data found that the following practice level factors have significant associations with a lower proportion of emergency diagnosis of cancer: increased trust and confidence in the practice healthcare professionals; higher 2WW referral and conversion rate; higher total practice QOF score and higher satisfaction with appointment times or higher proportion able to see preferred GP. Our results also show that practices in more deprived areas are significantly associated with a higher proportion of emergency diagnoses of cancer. Regional cancer networks should focus their efforts in increasing both the quantity and appropriateness of 2WW referrals from primary care. In addition, primary care clinicians should be supported to undertake high quality consultations, thus building trust with patients and ensuring continuity of care.

Patient-reported outcomes after 10-year follow-up of intensive, multifactorial treatment in individuals with screen-detected type 2 diabetes: the ADDITION-Europe trial.

To present the longer-term impact of multifactorial treatment of type 2 diabetes on self-reported health status, diabetes-specific quality of life, and diabetes treatment satisfaction at 10-year follow up of the ADDITION-Europe trial. The ADDITION-Europe trial enrolled 3057 individuals with screen-detected type 2 diabetes from four centres [Denmark, the UK (Cambridge and Leicester) and the Netherlands], between 2001 and 2006. Participants were randomized at general practice level to intensive treatment or to routine care . The trial ended in 2009 and a 10-year follow-up was performed at the end of 2014. We measured self-reported health status (36-item Short-Form Health Survey and EQ-5D), diabetes-specific quality of life (Audit of Diabetes-Dependent Quality of Life questionnaire), and diabetes treatment satisfaction (Diabetes Treatment Satisfaction Questionnaire) at different time points during the study period. A mixed-effects model was applied to estimate the effect of intensive treatment (intention-to-treat analyses) on patient-reported outcome measures for each centre. Centre-specific estimates were pooled using a fixed effects meta-analysis. There was no difference in patient-reported outcome measures between the routine care and intensive treatment arms in this 10-year follow-up study [EQ-5D: -0.01 (95% CI -0.03, 0.01); Physical Composite Score (36-item Short-Form Health Survey): -0.27 (95% CI -1.11, 0.57), Audit of Diabetes-Dependent Quality of Life questionnaire: -0.01 (95% CI -0.11, 0.10); and Diabetes Treatment Satisfaction Questionnaire: -0.20 (95% CI -0.70, 0.29)]. Intensive, multifactorial treatment of individuals with screen-detected type 2 diabetes did not affect self-reported health status, diabetes-specific quality of life, or diabetes treatment satisfaction at 10-year follow-up compared to routine care.

The treatment rate of erectile dysfunction (ED) in younger men with type 2 diabetes is up to four times higher than the equivalent non-diabetes population.

Erectile dysfunction (ED) is common in older age and in diabetes mellitus (DM). Phosphodiesterase type 5-inhibitors (PDE5-is) are the first-line for ED. We investigated how the type of diabetes and age of males affect the PDE5-i use in the primary care setting. From 2018 to 2019, the general practice level quantity of all PDE5-i agents was taken from the general practice (GP) Prescribing Dataset in England. The variation in outcomes across practices was examined across one year, and for the same practice against the previous year. We included 5761 larger practices supporting 25.8 million men of whom 4.2 million ≥65years old. Of these, 1.4 million had T2DM, with 0.8 million of these >65. About 137000 people had T1DM. About 28.8 million tablets of PDE5-i were prescribed within the 12months (2018-2019) period in 3.7 million prescriptions (7.7 tablets/prescription), at total costs of £15.8 million (£0.55/tablet). The NHS ED limit of one tablet/user/wk suggests that 540000 males are being prescribed a PDE5-i at a cost of £29/y each. With approximately 30000 GPs practising, this is equivalent to one GP providing 2.5 prescriptions/wk to overall 18 males. There was a 3x variation between the highest decile of practices (2.6tablets/male/y) and lowest decile (0.96tablets/male/y). The statistical model captured 14% of this variation and showed that T1DM males were the largest users, while men age <65 with T2DM were being prescribed four times as much as non-DM. Those T2DM >65 were prescribed 80% of the non-DM amount. There is a wide variation in the use of PDE5-is. With only 14% variance capture, other factors including wide variation in patient awareness, prescribing rules of local health providers, and recognition of the importance of male sexual health by GP prescribers might have a significant impact.

Providing patients with direct access to musculoskeletal physiotherapy: the impact on general practice musculoskeletal workload and resource use. The STEMS-2 study

ObjectivesThis study examined the real-world impact of patient direct access to NHS physiotherapy (self-referral) on (a) general practice consultations for musculoskeletal (MSK) conditions and (b) specified clinical management for patients with MSK conditions. Design and settingNatural experiment in four general practices and the associated physiotherapy service. MethodsAnonymised routinely collected data were obtained. MSK coded GP consultations, recorded fit notes, MSK-related prescription medication, X-rays and MRI requests, and referrals to secondary care for patients consulting with MSK conditions were identified and trends described across a 6-year period (June 2011 to June 2017). Joinpoint regression analysis was used to identify any significant changes in GP MSK consultation trends before and after the introduction of self-referral to physiotherapy. Physiotherapy service data examined access methods used by patients (GP referred, GP recommended self-referral, true self-referral) and the number of physiotherapy sessions. ResultsDirect access resulted in inconsistent impact on general practices. In one arm of the experiment a significant increase in GP consultations was observed and in one arm was stable. Exploratory examination of clinical management showed only requests for X-rays (arm 1) and possibly requests for MRI (arm 2) changed over time. Physiotherapy service referrals showed a low uptake of true self-referral (10% and 6%) in each arm respectively. ConclusionThis is the first study to examine the real-world impact of patient direct access to physiotherapy at general practice level. We found no consistent impact of patient direct access on GP MSK workload. Impact on some clinical management was observed but not consistently in the direction suggested by previous studies.

Antidepressant Prescribing in England: Patterns and Costs.

The number of prescriptions for antidepressants (ADs) in England and Wales has almost doubled in the past decade. The objective of this article is to describe the current prescribing rates of different antidepressants by general practice (GP) practice. We collated the prescribing behavior in each GP practice in the year April 1, 2017, to March 31, 2018. The monthly GP practice prescribing data reports for medication prescribing for each British National Formulary code and practice, as well as the prescriptions, quantity, and costs were examined in relation to prescribing practice. The data showed that 2.1 billion doses of antidepressant were prescribed to a total population of 52 million people. That equates to 11% of individuals taking ≥ 1 antidepressants on any day. Selective serotonin reuptake inhibitors (SSRIs) were the most prescribed class of ADs, with sertraline the most prescribed SSRI. The other most prescribed ADs were citalopram, fluoxetine, and mirtazapine. Some older agents, such as trimipramine and doxepin, are prescribed at a very high tariff. Broadly, the findings are in keeping with National Institute for Health and Care Excellence guidance in that the bulk of prescriptions were for SSRIs. Regular audit of patient treatment at a general practice level will ensure appropriate targeted use of licensed medications as supported by the evidence base.

Clustering of continuous and binary outcomes at the general practice level in individually randomised studies in primary care - a review of 10\u2009years of primary care trials

BackgroundIn randomised controlled trials, the assumption of independence of individual observations is fundamental to the design, analysis and interpretation of studies. However, in individually randomised trials in primary care, this assumption may be violated because patients are naturally clustered within primary care practices. Ignoring clustering may lead to a loss of power or, in some cases, type I error.MethodsClustering can be quantified by intra-cluster correlation (ICC), a measure of the similarity between individuals within a cluster with respect to a particular outcome. We reviewed 17 trials undertaken by the Department of Primary Care at the University of Southampton over the last ten years. We calculated the ICC for the primary and secondary outcomes in each trial at the practice level and determined whether ignoring practice-level clustering still gave valid inferences. Where multiple studies collected the same outcome measure, the median ICC was calculated for that outcome.ResultsThe median intra-cluster correlation (ICC) for all outcomes was 0.016, with interquartile range 0.00–0.03.The median ICC for symptom severity was 0.02 (interquartile range (IQR) 0.01 to 0.07) and for reconsultation with new or worsening symptoms was 0.01 (IQR 0.00, 0.07). For HADS anxiety the ICC was 0.04 (IQR 0.02, 0.05) and for HADS depression was 0.02 (IQR 0.00, 0.05). The median ICC for EQ. 5D-3 L was 0.01 (IQR 0.01, 0.04).ConclusionsThere is evidence of clustering in individually randomised trials primary care. The non-zero ICC suggests that, depending on study design, clustering may not be ignorable. It is important that this is fully considered at the study design phase.

The effect of assessing genetic risk of prostate cancer on the use of PSA tests in primary care: A cluster randomized controlled trial.

BackgroundAssessing genetic lifetime risk for prostate cancer has been proposed as a means of risk stratification to identify those for whom prostate-specific antigen (PSA) testing is likely to be most valuable. This project aimed to test the effect of introducing a genetic test for lifetime risk of prostate cancer in general practice on future PSA testing.Methods and findingsWe performed a cluster randomized controlled trial with randomization at the level of general practices (73 in each of two arms) in the Central Region (Region Midtjylland) of Denmark. In intervention practices, men were offered a genetic test (based on genotyping of 33 risk-associated single nucleotide polymorphisms) in addition to the standard PSA test that informed them about lifetime genetic risk of prostate cancer and distinguished between “normal” and “high” risk. The primary outcome was the proportion of men having a repeated PSA test within 2 years. A multilevel logistic regression model was used to test the association.After applying the exclusion criteria, 3,558 men were recruited in intervention practices, with 1,235 (34.7%) receiving the genetic test, and 4,242 men were recruited in control practices. Men with high genetic risk had a higher propensity for repeated PSA testing within 2 years than men with normal genetic risk (odds ratio [OR] = 8.94, p < 0.01). The study was conducted in routine practice and had some selection bias, which is evidenced by the relatively large proportion of younger and higher income participants taking the genetic test.ConclusionsProviding general practitioners (GPs) with access to a genetic test to assess lifetime risk of prostate cancer did not reduce the overall number of future PSA tests. However, among men who had a genetic test, knowledge of genetic risk significantly influenced future PSA testing.Trial registrationThis study is registered with ClinicalTrials.gov, number NCT01739062.

THE FUTURE OF BIOFEEDBACK: Four Important Questions from Biofeedback Pioneer Lilian Rosenbaum

THE FUTURE OF BIOFEEDBACK: Four Important Questions from Biofeedback Pioneer Lilian Rosenbaum

Integration of nurses in general practice: A thematic synthesis of the perspectives of general practitioners, practice nurses and patients living with chronic illness.

To explore the views of general practitioners, practice nurses and patients on interprofessional collaboration in general practice and to understand to what extent the nurse-doctor relationship meets their needs and expectations. To address future challenges of primary health care, there is a need for integrated interprofessional collaboration care systems with a patient-centred focus. Worldwide, there is an integration of nurses in general practice. However, in a transitioning Belgian context little is known about the perspectives of three key stakeholder groups. The results of four qualitative descriptive primary studies were triangulated and a secondary analysis resulted in a thematic synthesis within a pragmatic research paradigm. Primary data were collected through individual, semi-structured interviews with 7 general practitioners, 19 practice nurses and 21 patients living with chronic illness in 26 primary care centres with different nurse integration levels. We conducted a secondary analysis for the thematic synthesis of the different stakeholders' perspectives. This study was reported in accordance with the COREQ checklist. Four overarching themes were found as follows: vision and mission at general practice level, patient-centred care, practice nurse role development and interprofessional collaboration. Interprofessional collaboration within general practice ensures better response to patient needs. Evolution of the practice nurse role to autonomous decision-making can be facilitated by clear vision and mission, team communication, complementarity of responsibilities and trust-based professional relationships. The key for patient-centred care in a well-organised practice is a clear vision and mission and well-defined task description for interprofessional collaboration. General practice is urging for systematic guidance for the sustainable integration of a practice nurse. Our study highlights opportunities and challenges to nurse integration in general practice from key stakeholders' perspectives, which can inform other transitioning contexts.

Personalized, Web-Based, Guided Self-Help for Patients With Medically Unexplained Symptoms in Primary Care: Protocol for a Randomized Controlled Trial.

BackgroundMedically unexplained symptoms (MUS) constitute a major health problem because of their high prevalence, the suffering and disability they cause, and the associated medical costs. Web-based interventions may provide an accessible and convenient tool for managing MUS. We developed a personalized, Web-based, guided self-help intervention for MUS in primary care (Grip self-help) and would compare its effectiveness with that of usual care.ObjectiveThis paper aims to describe the rationale, objectives, and design of a pragmatic randomized controlled trial (RCT) assessing the effectiveness of Grip self-help.MethodsFor a pragmatic multicenter RCT, 165 adult patients with mild to moderate MUS will be recruited through general practices in the Netherlands. Randomization will be performed at general practice level. Over the course of several months, patients in the intervention group will receive a personalized set of Web-based self-help exercises, targeting the unhelpful cognitions, emotions, behaviors, and social factors that are relevant to them. The intervention is guided by a general practice mental health worker. The control group will receive care-as-usual. Primary outcome is physical health-related quality of life (RAND-36 or 36-item general health survey, physical component score). Secondary outcomes include severity of physical and psychological symptoms, mental health–related quality of life, cost-effectiveness, and acceptability. Assessments will take place at baseline, end of treatment, and at 16-, 26-, and 52-week follow-ups.ResultsRecruitment started in December 2018, and enrolment is ongoing. The first results are expected to be submitted for publication in December 2021.ConclusionsTo our knowledge, this is the first study to combine the concepts of electronic health, self-help, and personalized medicine in the treatment of MUS. By improving the quality of life and reducing symptoms of patients with MUS, Grip self-help has the potential to reduce costs and conserve scarce health care resources.Trial RegistrationDutch Trial Register NTR7390; https://www.trialregister.nl/trial/7390.International Registered Report Identifier (IRRID)PRR1-10.2196/13738

Analysis of English general practice level data linking medication levels, service activity and demography to levels of glycaemic control being achieved in type 2 diabetes to improve clinical practice and patient outcomes

ObjectiveEvaluate relative clinical effectiveness of treatment options for type 2 diabetes mellitus (T2DM) using a statistical model of real-world evidence within UK general practitioner practices (GPP), to quantify the opportunities...

General practice (GP) level analysis shows that patients’ own perceptions of support within primary care as reported in the GP patient survey (GPPS) are as important as medication and services in improving glycaemic control

BackgroundThe way that GP practices organize their services impacts as much on glycaemia in type 2 diabetes as does prescribing. AimOur aim was to evaluate the link between patients’ own perception of support within primary care and the % patients at each GP practice at target glycaemic control (TGC) and at high glycaemic risk (HGR). Design and SettingUtilisation of National Diabetes Audit (NDA) available data combined with the General practitioner patient survey (GPPS). MethodThe NDA 2016_17 published data on numbers of type 2 patients, levels of local diabetes services and the target glycaemic control (TGC) % and high glycaemic risk (HGR) % achieved. The GPPS 2017 published % “No” responses from long term condition (LTC) patients to the question “In the last 6 months, had you enough support from local services or organisations to help manage LTCs?”. Multivariate regression was used on the set of indicators capturing patients’ demographics and services provided. Results6498 practices were included (with more than 2.5 million T2DM patients) and median values with band limits that included 95% practices for % “No” response to the question above was 12% (2%–30%), for TGC 67% (54%–78%) and for HGR 6% (2%–13%). The model accounted for 25% TGC variance and 26% HGR variance.The standardised β values shown as (TGC/HGR) (+=more people; −=less people) for older age (+0.24/−0.25), sulphonylurea use (−0.21/+0.14), greater social disadvantage (−0.09/+0.21), GPPS Support %No (−0.08/+0.12), %Completion 8 checks (+0.09/−0.12) and metformin use (+0.11/−0.05). ConclusionThe relation between the person with diabetes and clinician in primary care is shown to be quantitatively potentially as important in influencing glycaemic outcome as the services provided and medication prescribed. We suggest that all of us in who work in the health care system can bear this in mind in our everyday work.

Impact of abolishing prescription fees in Scotland on hospital admissions and prescribed medicines: an interrupted time series evaluation

ObjectivesTo identify whether the abolition of prescription fees in Scotland resulted in: (1) Increase in the number (cost to NHS) of medicines prescribed for which there had been a fee...

A web-based self-management programme for people with type 2 diabetes: the HeLP-Diabetes research programme including RCT

A web-based self-management programme for people with type 2 diabetes: the HeLP-Diabetes research programme including RCT

Sodium-glucose co-transporter-2 inhibitors, the latest residents on the block: Impact on glycaemic control at a general practice level in England.

To determine, using published general practice-level data, how differences in Type 2 diabetes mellitus (T2DM) prescribing patterns relate to glycaemic target achievement levels. Multiple linear regression modelling was used to link practice characteristics and defined daily dose (DDD) of different classes of medication in 2015/2016 and changes between that year and the year 2014/2015 in medication to proportion of patients achieving target glycaemic control (glycated haemoglobin A1c [HbA1c] ≤58 mmol/mol [7.5%]) and proportion of patients at high glycaemic risk (HbA1c >86 mmol/mol [10.0%]) for practices in the National Diabetes Audit with >100 people with T2DM on their register. Overall, HbA1c outcomes were not different between the years studied. Although, in percentage terms, most practices increased their use of sodium-glucose co-transporter-2 (SGLT2) inhibitors (96%), dipeptidyl peptidase-4 (DPP-4) inhibitors (76%) and glucagon-like peptide 1 (GLP-1) analogues (53%), there was wide variation in the use of older and newer therapies. For example, 12% of practices used >200% of the national average for some newer agents. In cross-sectional analysis, greater prescribing of metformin and analogue insulin were associated with a higher proportion of patients achieving HbA1c ≤58 mmol/mol; the use of SGLT2 inhibitors and metformin was associated with a reduced proportion of patients with HbA1c >86 mol/mol; otherwise associations for sulphonylureas, GLP-1 analogues, SGLT2 inhibitors and DPP-4 inhibitors were neutral or negative. In year-on-year analysis there was ongoing deterioration in glycaemic control, which was offset to some extent by increased use of SGLT2 inhibitors and GLP-1 analogues, which were associated with a greater proportion of patients achieving HbA1c levels ≤58 mmol/mol and a smaller proportion of patients with HbA1c levels >86 mmol/mol. SGLT2 inhibitor prescribing was associated with significantly greater improvements than those found for GLP-1 analogues. Greater use of newer agents was associated with improvement in glycaemic outcomes but was not sufficient to compensate for the prevailing decline. This may reflect wide variability in the prescribing of newer agents. We found that SGLT inhibitors may be superior to other oral agents in relation to HbA1c outcome. Serious consideration should be given to their use.