National Health Service Scotland Research Articles

CURL Extensions – Weaving a Unique Property Reference Number into Address Histories in the Scottish Community Health Index

The Community Health Index (CHI) is the patient registration system for the National Health Service (NHS) in Scotland, covering the entire population. CHI has long been used as a population Indexing Spine to facilitate health-based data linkage for both operational and research purposes in Scotland. Changes in patient’s residential address since 2000 have been captured in a CHI Address History File. Addresses in CHI are recorded in unstructured free-text format, so property-based analyses and linkage is problematic. In August 2020, 90% of CHI addresses for currently registered patients, and people who had died that year, were seeded with a Unique Property Reference Number (UPRN). This product, called CHI-UPRN Residential Linkage (CURL), enabled NHS Scotland to harness important information on the patient population (5.8 million) and their place of residence, facilitating several data products related to COVID-19. The current project is extending CURL to UPRN-seed the 31 million address histories of everyone registered with a family doctor in Scotland since January 2000. The project, due for completion in Summer 2024, will look at alternative address-matching algorithms with the aim of achieving a 95% UPRN-match rate across the longitudinal CURL file. Quality assurance exercises help us to understand the precision and sensitivity of matching across time and geography. Analysis of how the longitudinal file is constructed across the person and property-level indices permits a deeper understanding of the capabilities and limitations of the CURL product when used to deliver innovative analyses or modelling that link people and places over time.

Exploring the perceptions and experiences of community rehabilitation for Long COVID from the perspectives of Scottish general practitioners’ and people living with Long COVID: a qualitative study

ObjectivesTo explore the experience of accessing Long COVID community rehabilitation from the perspectives of people with Long COVID and general practitioners (GPs).DesignQualitative descriptive study employing one-to-one semistructured virtual interviews analysed...

Community antibiotic prescribing in patients with COVID-19 across three pandemic waves: a population-based study in Scotland, UK

ObjectivesThis study aims to examine community antibiotic prescribing across a complete geographical area for people with a positive COVID-19 test across three pandemic waves, and to examine health and demographic...

Real-world experience of nintedanib for progressive fibrosing interstitial lung disease in the UK.

Nintedanib slows progression of lung function decline in patients with progressive fibrosing (PF) interstitial lung disease (ILD) and was recommended for this indication within the United Kingdom (UK) National Health Service in Scotland in June 2021 and in England, Wales and Northern Ireland in November 2021. To date, there has been no national evaluation of the use of nintedanib for PF-ILD in a real-world setting. 26 UK centres were invited to take part in a national service evaluation between 17 November 2021 and 30 September 2022. Summary data regarding underlying diagnosis, pulmonary function tests, diagnostic criteria, radiological appearance, concurrent immunosuppressive therapy and drug tolerability were collected via electronic survey. 24 UK prescribing centres responded to the service evaluation invitation. Between 17 November 2021 and 30 September 2022, 1120 patients received a multidisciplinary team recommendation to commence nintedanib for PF-ILD. The most common underlying diagnoses were hypersensitivity pneumonitis (298 out of 1120, 26.6%), connective tissue disease associated ILD (197 out of 1120, 17.6%), rheumatoid arthritis associated ILD (180 out of 1120, 16.0%), idiopathic nonspecific interstitial pneumonia (125 out of 1120, 11.1%) and unclassifiable ILD (100 out of 1120, 8.9%). Of these, 54.4% (609 out of 1120) were receiving concomitant corticosteroids, 355 (31.7%) out of 1120 were receiving concomitant mycophenolate mofetil and 340 (30.3%) out of 1120 were receiving another immunosuppressive/modulatory therapy. Radiological progression of ILD combined with worsening respiratory symptoms was the most common reason for the diagnosis of PF-ILD. We have demonstrated the use of nintedanib for the treatment of PF-ILD across a broad range of underlying conditions. Nintedanib is frequently co-prescribed alongside immunosuppressive and immunomodulatory therapy. The use of nintedanib for the treatment of PF-ILD has demonstrated acceptable tolerability in a real-world setting.

Investigating Scottish Long COVID community rehabilitation service models from the perspectives of people living with Long COVID and healthcare professionals: a qualitative descriptive study

ObjectivesThis study aimed to explore the perceptions and experiences of barriers and facilitators to accessing Long COVID community rehabilitation.DesignWe used a qualitative descriptive design over two rounds of data collection...

Use of machine learning to predict mortality in patients with type 2 diabetes mellitus, according to socioeconomic status

Abstract Introduction Patients with Type 2 diabetes mellitus (T2DM) are at increased risk of developing cardiovascular disease (CVD) that adversely affects prognosis. Socioeconomic deprivation may be associated with lifestyle choices that contribute to adverse outcomes. The influence of social deprivation on the prognosis of T2DM is rarely investigated in large cohorts. Therefore, we assessed the associations between socioeconomic status and survival in patients with T2DM by applying conventional statistical methods and state-of-the-art, machine learning (ML) models. Methods We obtained routinely collected, linked administrative data for individuals with T2DM aged >50 years from the National Health Service (NHS) Scotland, including demographic data, laboratory measurements, prescriptions, death records and primary and secondary care diagnostic codes. We developed a random survival forest model for predicting all-cause mortality, overall and for each quintile of socioeconomic status using the Scottish Index of Multiple Deprivation (SIMD), which is based on postcodes that reflect a combination of income, employment, local crime rates, education, housing and health. We used Cox proportional hazards models to investigate the risk between the most and least deprived quintiles. Subsequently, we applied Shapely Additive Explanations (SHAP), a state-of-the-art ML interpretability method, to identify key prognostic factors that influence the survival probability prediction score for each sub-group. Results 30,495 people had a newly recorded diagnosis of T2DM between 2009-2019, of whom 4,300 died within 10 years. Table 1 shows the c-index (global assessment of model discrimination) and time-brier score (measure of calibration for time-dependent probability prediction) for the whole cohort and for each SIMD quintile: use of loop diuretics, older age, lower serum concentrations of albumin and alanine transaminase (ALT) and estimated glomerular function rate (eGFR) were strong predictors of death for all quintiles. Prevalence of chronic obstructive pulmonary disease (COPD) was strongly associated with mortality for the most deprived quintile (Q1, whilst strokes were strongly associated with mortality for the most affluent (Q5). A history of heart failure, in addition to use of loop diuretics, predicted a higher risk, in 3 of the 5 quintiles. Overall Q1 had a 36% higher mortality than Q5 (HR: adjusted for age and sex 1.36 [95% CI 1.24 – 1.50 (<0.005)]). Conclusion Greater socioeconomic deprivation is associated with a worse prognosis in patients with T2DM. Results of commonly measured blood tests, allied to readily available patient characteristics (including heart failure and use of loop diuretics) predict mortality risks across all deprivation groups for people with T2DM.Table:Predictors of Mortality in T2DM

HEalth And Dementia outcomes following Traumatic Brain Injury (HEAD-TBI): protocol for a retrospective cohort study

BackgroundIt is estimated that by 2050 the global incidence of dementia will have exceeded 152 million. At present, there are no effective therapies for dementia, with a focus in research...

Evaluation of an Innovative Colon Capsule Endoscopy Service in Scotland From the Perspective of Patients: Mixed Methods Study.

Colonoscopy is the gold standard for lower gastrointestinal diagnostics. The procedure is invasive, and its demand is high, resulting in long waiting times. Colon capsule endoscopy (CCE) is a procedure that uses a video capsule to investigate the colon, meaning that it can be carried out in a person's own home. This type of "hospital-at-home" service could potentially reduce costs and waiting times, and increase patient satisfaction. Little is currently understood, however, about how CCE is actually experienced and accepted by patients. The aim of this study was to capture and report patient experiences of the CCE technology (the capsule and associated belt and recorder) and of the new clinical pathway for the CCE service being rolled out as part of routine service in Scotland. This was a mixed methods service evaluation of patient experiences of a real-world, deployed, managed service for CCE in Scotland. Two hundred and nine patients provided feedback via a survey about their experiences of the CCE service. Eighteen of these patients took part in a further telephone interview to capture more in-depth lived experiences to understand the barriers and opportunities for the further adoption and scaling up of the CCE service in a way that supports the patient experience and journey. Patients overall perceived the CCE service to be of significant value (eg, mentioning reduced travel times, reduced waiting times, and freedom to complete the procedure at home as perceived benefits). Our findings also highlighted the importance of clear and accessible information (eg, what to expect and how to undertake the bowel preparation) and the need for managing expectations of patients (eg, being clear about when results will be received and what happens if a further colonoscopy is required). The findings led to recommendations for future implementations of managed CCE services in National Health Service (NHS) Scotland that could also apply more widely (United Kingdom and beyond) and at a greater scale (with more patients in more contexts). These include promoting CCE with, for, and among clinical teams to ensure adoption and success; capturing and understanding reasons why patients do and do not opt for CCE; providing clear information in a variety of appropriate ways to patients (eg, around the importance of bowel preparation instructions); improving the bowel preparation (this is not specific to CCE alone); providing flexible options for issuing and returning the kit (eg, dropping off at a pharmacy); and embedding formative evaluation within the service itself (eg, capturing patient-reported experiences via surveys in the information pack when the equipment is returned).

Leadership identity construction in a hybrid medical context: ‘Claimed’ but not ‘granted’

In the United Kingdom National Health Service (NHS), the growing number of hybrid clinical leaders has given rise to professional practice and identity struggles. Co-construction theories of leadership point to a need for leaders to engage in significant ‘identity work’ to construct themselves as leaders and to make legitimate claims for a leadership identity to potential followers. Our research aimed to contribute to the leader-follower literature by examining how medical leaders deal with professional identity struggles and changes to traditional work identities. We draw on data from a study of senior hospital doctors (consultant-level doctors from a variety of medical specialties in Health Boards in NHS Scotland). Our findings suggest that most senior hospital doctors in our study struggle to grant leadership identities to their medical leaders who claim such leadership identities, although they seek to see more doctors engaging in leadership. This article contributes to extant research on the influence of medical leadership roles on leader-follower identity construction.

Diagnosis, treatment, and outcome of patients with oesophagogastric cancer during the COVID-19 pandemic: national study.

The national response to COVID-19 has had a significant impact on cancer services. This study investigated the effect of national lockdown on diagnosis, management, and outcomes of patients with oesophagogastric cancers in Scotland. This retrospective cohort study included consecutive new patients presenting to regional oesophagogastric cancer multidisciplinary teams in National Health Service Scotland between October 2019 and September 2020. The study interval was divided into before and after lockdown, based on the first UK national lockdown. Electronic health records were reviewed and results compared. Some 958 patients with biopsy-proven oesophagogastric cancer in 3 cancer networks were included: 506 (52.8 per cent) before and 452 (47.2 per cent) after lockdown. Median age was 72 (range 25-95) years and 630 patients (65.7 per cent) were men. There were 693 oesophageal (72.3 per cent) and 265 gastric (27.7 per cent) cancers. Median time to gastroscopy was 15 (range 0-337) days before versus 19 (0-261) days after lockdown (P < 0.001). Patients were more likely to present as an emergency after lockdown (8.5 per cent before versus 12.4 per cent after lockdown; P = 0.005), had poorer Eastern Cooperative Oncology group performance status, were more symptomatic, and presented with a higher stage of disease (stage IV: 49.8 per cent before versus 58.8 per cent after lockdown; P = 0.04). There was a shift to treatment with non-curative intent (64.6 per cent before versus 77.4 per cent after lockdown; P < 0.001). Median overall survival was 9.9 (95 per cent c.i. 8.7 to 11.4) months before and 6.9 (5.9 to 8.3) months after lockdown (HR 1.26, 95 per cent c.i. 1.09 to 1.46; P = 0.002). This national study has highlighted the adverse impact of COVID-19 on oesophagogastric cancer outcomes in Scotland. Patients presented with more advanced disease and a shift towards treatment with non-curative intent was observed, with a subsequent negative impact on overall survival.

HPR37 Comparing Reimbursement of New Drugs During the COVID-19 Pandemic in Ireland and Scotland

Following the onset of the COVID-19 pandemic, the Scottish Medicines Consortium (SMC) suspended monthly meetings from April to August 2020, to support the National Health Service (NHS) Scotland in maintaining essential work. Following the return of meetings, a fast-track process was introduced to expedite reimbursement for certain medicines. Conversely, the Irish health technology assessment (HTA) agency, the National Centre for Pharmacoeconomics (NCPE), continued to assess new reimbursement applications throughout this period, using the two-stage process of a rapid review (RR), followed by full HTA for some medicines. This research explores how these different approaches impacted reimbursement submissions and recommendations during this time. A database was developed using published data (from 01/03/2020 to 01/03/2022) on the NCPE, SMC and Irish Health Service Executive (HSE) websites, including; • Breakdown of submissions received • Assessment outcomes • Breakdown of reimbursement recommendations Data was extracted into Excel® and analysed using summary and descriptive statistics. SMC advice for 169 medicines were identified (n=89 full submissions; n=36 abbreviated submissions; n=28 non-submissions; n=13 resubmissions; n=3 ultra-orphan assessments). Positive reimbursement recommendations were made for 136 of these medicines (n=68 accepted for use, n=58 accepted for restricted use, n=7 accepted on interim basis, n=3 available under ultra-orphan assessment), with 48 recommendations made using the fast-track process. Contrastingly, the NCPE published 148 RR outcomes and 61 HTA outcomes, with 70 reimbursement recommendations published by the HSE (n=38 positive recommendations, n=11 restricted reimbursement, n=21 reimbursement not recommended). While a similar number of submissions were assessed by the Irish and Scottish HTA agencies during the COViD-19 period, there was a significantly higher number of positive reimbursement recommendations from the SMC, which may be explained by the SMC fast-track process. This research further explores the reimbursement recommendations for each category of submission and compares the reimbursement timelines for each jurisdiction.

How are declarations of interest working? A cross-sectional study in declarations of interest in healthcare practice in Scotland and England in 2020/2021

ObjectiveTo understand arrangements for healthcare organisations’ declarations of staff interest in Scotland and England in the context of current recommendations.DesignCross-sectional study of a random selection of National Health Service (NHS)...

Population-wide cohort study of statin use for the secondary cardiovascular disease prevention in Scotland in 2009–2017

ObjectiveTo estimate the extent of suboptimal statin use for the secondary prevention of atherosclerotic cardiovascular disease (ASCVD) at different stages of the treatment pathway and identify patient groups at risk...

Commercial business and partnership aspects of general practice: the learning needs of First5 general practitioners in NHS Scotland–a qualitative study

ObjectivesTo identify the learning needs of recently qualified general practitioners (GPs) (First5) in National Health Service (NHS) Scotland concerning GP partnership and the commercial business aspects of general practice. It...

What patient assessment skills do pharmacist independent prescribers require to prescribe immunomodulators in myeloma?

To gain consensus on the patient assessment skills required by pharmacist independent prescribers prescribing immunomodulators in myeloma across National Health Service Scotland. This was a two-phase study which used nominal group technique to gain local consensus followed by a two-round eDelphi questionnaire to gain national consensus across all cancer networks. This project was conducted across the three cancer networks within NHS Scotland: South East Scotland Cancer Network; West of Scotland Cancer Network and North Cancer Alliance. Participants were invited from each cancer network (South East Scotland Cancer Network, West of Scotland Cancer Network and North Cancer Alliance) and included haematology consultants, haematology specialist registrars, haematology advanced nurse practitioners and haematology pharmacists. There were five participants in the nominal group technique. Twenty-two out of 31 patient assessment skills gained local consensus, seven patient assessment skills did not gain consensus and two patient assessment skills were deemed irrelevant. There were 12 and 14 participants in round one and two of the eDelphi questionnaire, respectively. Twenty-nine patient assessment skills were included in the first-round questionnaire and 21 gained consensus. The remaining eight patient assessment skills were included in round two where seven did not achieve consensus and one achieved disagreement consensus. This research outlines 21 patient assessment skills required for pharmacist independent prescribers to prescribe immunomodulators for myeloma patients according to haematology specialists in Scotland. Discussion on patient assessment skills without consensus showed that the pharmacist independent prescribers would have a shared responsibility with the consultant. This work should inform the development of a competency framework to allow training of pharmacist independent prescribers in Scotland. Some patient assessment skills could be transferrable for pharmacist independent prescribers prescribing systemic anti-cancer therapy for other haematological malignancies.

Impact on emergency and elective hospital-based care in Scotland over the first 12 months of the pandemic: interrupted time-series analysis of national lockdowns.

COVID-19 has resulted in the greatest disruption to National Health Service (NHS) care in its over 70-year history. Building on our previous work, we assessed the ongoing impact of pandemic-related disruption on provision of emergency and elective hospital-based care across Scotland over the first year of the pandemic. We undertook interrupted time-series analyses to evaluate the impact of ongoing pandemic-related disruption on hospital NHS care provision at national level and across demographics and clinical specialties spanning the period 29 March 2020-28 March 2021. Scotland, UK. Patients receiving hospital care from NHS Scotland. We used the percentage change of accident and emergency attendances, and emergency and planned hospital admissions during the pandemic compared to the average admission rate for equivalent weeks in 2018-2019. As restrictions were gradually lifted in Scotland after the first lockdown, hospital-based admissions increased approaching pre-pandemic levels. Subsequent tightening of restrictions in September 2020 were associated with a change in slope of relative weekly admissions rate: -1.98% (-2.38, -1.58) in accident and emergency attendance, -1.36% (-1.68, -1.04) in emergency admissions and -2.31% (-2.95, -1.66) in planned admissions. A similar pattern was seen across sex, socioeconomic status and most age groups, except children (0-14 years) where accident and emergency attendance, and emergency admissions were persistently low over the study period. We found substantial disruption to urgent and planned inpatient healthcare provision in hospitals across NHS Scotland. There is the need for urgent policy responses to address continuing unmet health needs and to ensure resilience in the context of future pandemics.

Socioeconomic inequality, waiting time initiatives and austerity in Scotland: an interrupted time series analysis of elective hip and knee replacements and arthroscopies.

National Health Service (NHS) waiting times have long been a political priority in Scotland. In 2002, the Scottish government launched a programme of investment and reform to reduce waiting times. The effect on waiting time inequality is unknown as is the impact of subsequent austerity measures. An interrupted time series analysis between the most and least socioeconomically deprived population quintiles since the introduction of waiting time initiative 1 July 2002 and austerity measures 1 April 2010. All NHS-funded elective primary hip replacement, primary knee replacement and arthroscopy patient data in Scotland from 1 April 1997 to 31 March 2019. NHS Scotland funded patients treated in Scotland. Trends and changes in mean waiting time. There were 135,176, 122,883 and 173,976 NHS funded hip replacement, knee replacement and arthroscopy patients, respectively, in Scotland between 1 April 1997 and 31 March 2019. From 1 July 2002 to 31 March 2010, waiting time inequality between the most and least deprived patients fell and increased thereafter. For hip replacements before 1 July 2002, waiting time inequality increased 1.07 days per quarter; this changed at 1 July 2002 with significant slope change of -2.32 (-3.53, -1.12) days resulting in a decreasing rate of inequality of -1.26 days per quarter. On 1 April 2010 the slope changed significantly by 1.84 (0.90, 2.78) days restoring increasing inequality at 0.58 days per quarter. Knee replacements and arthroscopies had similar results. The waiting time initiative in Scotland is associated with a reduction in waiting time inequality benefiting the most socioeconomically deprived patients. Austerity measures may be reversing these gains.

Unscheduled care pathways in patients with myocardial infarction in Scotland

ObjectiveTreatment of acute myocardial infarction (MI) requires rapid transfer of people with chest pain to hospital, however, unscheduled care pathways vary in their directness (the minimal number of contacts to...

Remote neuropsychological assessment: Acceptability and feasibility of direct-to-home teleneuropsychology methodology during the COVID-19 pandemic

Objective To determine the acceptability and feasibility of telephone and video-conference calls to complete cognitive assessments during the COVID-19 pandemic. Method In rapid response to the pandemic, evidence-based adaptations were made to routine face-to-face (FTF) practice, delivering teleneuropsychology (TNP) within a National Health Service (NHS) Scotland neuropsychology service. Caldicott guardian approval was obtained to complete a six month study (April to October 2020) from the early stages of the first United Kingdom (UK) lockdown. Assessments were completed with patients in their own homes (direct-to-home) via remote connections. Neuropsychology clinicians, service-users and referring agents were approached for structured feedback and qualitative comment. Results Data was captured for 212 referrals assessed by seven clinical psychologists; with responses from 70 (33%) service-users and 14 (58%) referring agents. 94% of referrals were assessed remotely and discharged. TNP reduced defaulted appointment discharge rates. Gender, socioeconomic deprivation and age did not affect access to information technology (IT) equipment. Clinicians agreed that remote assessment allowed them to complete initial interview (96%) and formulate (77%) cases appropriately. Service-users agreed they were comfortable with equipment (84%), the process was straightforward (74%), and would recommend TNP to others (68%). Referring agents were satisfied with the service provided (100%). Limitations included evidence-based remote test availability, technical issues and home distractions. Conclusions Study findings evidence the acceptability and efficiency of TNP; increasing service accessibility, while reducing infection risk, defaulted appointments and travel. The results advocate for a post-pandemic mixed model of service delivery encompassing both FTF and TNP approaches.

Evaluating Diuretics in Normal Care (EVIDENCE): a feasibility report of a pilot cluster randomised trial of prescribing policy in primary care to compare the effectiveness of thiazide-type diuretics in hypertension

BackgroundObtaining evidence on comparative effectiveness and safety of widely prescribed drugs in a timely and cost-effective way is a major challenge for healthcare systems. Here, we describe the feasibility of the Evaluating Diuretics in Normal Care (EVIDENCE) study that compares a thiazide and thiazide-like diuretics for hypertension as an exemplar of a more general framework for efficient generation of such evidence. In 2011, the UK NICE hypertension guideline included a recommendation that thiazide-like diuretics (such as indapamide) be used in preference to thiazide diuretics (such as bendroflumethiazide) for hypertension. There is sparse evidence backing this recommendation, and bendroflumethiazide remains widely used in the UK.MethodsPatients prescribed indapamide or bendroflumethiazide regularly for hypertension were identified in participating general practices. Allocation of a prescribing policy favouring one of these drugs was then randomly applied to the practice and, where required to comply with the policy, repeat prescriptions switched by pharmacy staff. Patients were informed of the potential switch by letter and given the opportunity to opt out. Practice adherence to the randomised policy was assessed by measuring the amount of policy drug prescribed as a proportion of total combined indapamide and bendroflumethiazide. Routinely collected hospitalisation and death data in the NHS will be used to compare cardiovascular event rates between the two policies.ResultsThis pilot recruited 30 primary care practices in five Scottish National Health Service (NHS) Boards. Fifteen practices were randomised to indapamide (2682 patients) and 15 to bendroflumethiazide (3437 patients), a study population of 6119 patients. Prior to randomisation, bendroflumethiazide was prescribed to 78% of patients prescribed either of these drugs. Only 1.6% of patients opted out of the proposed medication switch.ConclusionThe pilot and subsequent recruitment confirms the methodology is scalable within NHS Scotland for a fully powered larger study; currently, 102 GP practices (> 12,700 patients) are participating in this study. It has the potential to efficiently produce externally valid comparative effectiveness data with minimal disruption to practice staff or patients. Streamlining this pragmatic trial approach has demonstrated the feasibility of a random prescribing policy design framework that can be adapted to other therapeutic areas.Trial registrationISRCTN Registry, ISRCTN46635087. Registered on 11 August 2017