UK Primary Health Care Research Articles

Incident dementia risk among patients with type 2 diabetes receiving metformin versus alternative oral glucose-lowering therapy: an observational cohort study using UK primary healthcare records

Introduction4.2 million individuals in the UK have type 2 diabetes, a known risk factor for dementia and mild cognitive impairment (MCI). Diabetes treatment may modify this association, but existing evidence...

Multi-infection screening for migrant patients in UK primary care: Challenges and opportunities

BackgroundMigrants in Europe face a disproportionate burden of undiagnosed infection, including tuberculosis, blood-borne viruses, and parasitic infections and many belong to an under-immunised group. The European Centre for Disease Control (ECDC) has called for innovative strategies to deliver integrated multi-disease screening to migrants within primary care, yet this is poorly implemented in the UK. We did an in-depth qualitative study to understand current practice, barriers and solutions to infectious disease screening in primary care, and to seek feedback on a collaboratively developed digitalised integrated clinical decision-making tool called Health Catch UP!, which supports multi-infection screening for migrant patients. MethodsTwo-phase qualitative study of UK primary healthcare professionals, in-depth semi-structured telephone-interviews were conducted. In Phase A, we conducted interviews with clinical staff (general practitioners (GPs), nurses, health-care-assistants (HCAs)); these informed data collection and analysis for phase B (administrative staff). Data were analysed iteratively, using thematic analysis. ResultsIn phase A, 48 clinicians were recruited (25 GPs, 15 nurses, seven HCAs, one pharmacist) and 16 administrative staff (11 Practice-Managers, five receptionists) in phase B. Respondents were positive about primary care's ability to effectively deliver infectious disease screening. However, we found current infectious disease screening lacks a standardised approach and many practices have no system for screening meaning migrant patients are not always receiving evidence-based care (i.e., NICE/ECDC/UKHSA screening guidelines). Barriers to screening were reported at patient, staff, and system-levels. Respondents reported poor implementation of existing screening initiatives (e.g., regional latent TB screening) citing overly complex pathways that required extensive administrative/clinical time and lacked financial/expert support. Solutions included patient/staff infectious disease champions, targeted training and specialist support, simplified care pathways for screening and management of positive results, and financial incentivisation. Participants responded positively to Health Catch-UP!, stating it would systematically integrate data and support clinical decision-making, increase knowledge, reduce missed screening opportunities, and normalisation of primary care-based infectious disease screening for migrants. ConclusionsOur results suggest that implementation of infectious disease screening in migrant populations is not comprehensively done in UK primary care. Primary health care professionals support the concept of innovative digital tools like Health Catch-UP! and that they could significantly improve disease detection and effective implementation of screening guidance but that they require robust testing and resourcing.

Where are all the veterans? A mixed methods assessment of a systematic strategy to increase veteran registration in UK primary healthcare practices

ObjectivesTo identify effective initiatives to increase veteran registration in UK primary healthcare (PHC) practices.DesignA structured and systematic strategy was designed to improve the number of military veterans correctly coded within...

Prevalence and treatment patterns of adult atopic dermatitis in the UK Clinical Practice Research Datalink.

The prevalence of active atopic dermatitis (AD) in adults in the UK according to disease severity shows variability. This study evaluated disease prevalence and treatment patterns among the adult UK population with AD. Data were obtained from the Clinical Practice Research Datalink (CPRD) database. Adults with active AD were identified by an AD-related prescription or general practitioner visit within the same calendar year. Prevalence was defined as the number of patients with active AD on 1 January of each year as a percentage of the number of adults in the CPRD population on that date. Moderate-to-severe disease was classified as either referral to a specialist or prescription(s) for topical calcineurin inhibitors, phototherapy, or systemic treatment. Patient characteristics and treatment and referral patterns were analysed for patients with active AD in 2019. The overall prevalence of AD was stable at 2.4% per year during the period 2015-2019. In 2019, mean patient age (± standard deviation) was 52.6±21.0years, 58.2% of patients were female and mean disease duration was 9.4±5.9years. The most prescribed treatment was topical corticosteroids, in 78.5% of patients. 36.7% of patients with moderate-to-severe AD were prescribed systemic agents and 59.8% (vs. 32.3% of patients with mild AD) were referred to any secondary care or specialist treatment. The prevalence of active AD in the adult UK population was stable over the 5-year period (2015-2019) and was comparable to estimates from similar studies based on UK primary healthcare records.

The normative grounds for NICE decision-making: a narrative cross-disciplinary review of empirical studies.

The National Institute for Health and Care Excellence (NICE) is the UK's primary health care priority-setter, responsible for advising the National Health Service on its adoption of health technologies. The normative basis for NICE's advice has long been the subject of public and academic interest, but the existing literature does not include any comprehensive summary of the factors observed to have substantively shaped NICE's recommendations. The current review addresses this gap by bringing together 29 studies that have explored NICE decision-making from different disciplinary perspectives, using a range of quantitative and qualitative methods. It finds that although cost-effectiveness has historically played a central role in NICE decision-making, 10 other factors (uncertainty, budget impact, clinical need, innovation, rarity, age, cause of disease, wider societal impacts, stakeholder influence and process factors) are also demonstrably influential and interact with one another in ways that are not well understood. The review also highlights an over-representation in the literature of appraisals conducted prior to 2009, according to methods that have since been superseded. It suggests that this may present a misleading view of the importance of allocative efficiency to NICE's current approach and illustrates the need for further up-to-date research into the normative grounds for NICE's decisions.

Design issues of a pan European Smart Cross Border "dream like" e-Gov Primary Health Care Medical Service

The European Commission of the European Union has provided Member States with the appropriate regulation and systems for the development of services facilitating cross border transactions. So far there has been little progress in putting such services to full practice. This may be justified where such systems involve the processing of confidential and personal data. Nevertheless, the proposed by the European Commission systems guarantee (as far as recent developments in network and cloud securities can do it) efficient validation of data, through authentication procedures. Cross border systems are essential in supporting one of the key principles of the EU that of free movement. Recent research and the relevant literature has witnessed the proposal and development of a few cross border systems focusing on health, social services, the environment, and life sciences. In this paper, design issues of such a cross border authentication service, linking public or/and private primary health units, are presented. The system in support of this service will offer a standard conceptual design model to interested European Member States. To evaluate the potential of such a system and its practical appeal, Greece's and the UK's primary health care services are examined. They are used as a case study of a conceptual design model applied in building up a pan European smart cross border primary health service to the benefit of citizens of any European countries being on mobility.

Predicting Future Health Risk in COPD: Differential Impact of Disease-Specific and Multi-Morbidity-Based Risk Stratification.

ObjectiveMulti-morbidity contributes to mortality and hospitalisation in COPD, but it is uncertain how this interacts with disease severity in risk prediction. We compared contributions of multi-morbidity and disease severity factors in modelling future health risk using UK primary care healthcare data.MethodsHealth records from 103,955 patients with COPD identified from the Clinical Practice Research Datalink were analysed. We compared area under the curve (AUC) statistics for logistic regression (LR) models incorporating disease indices with models incorporating categorised comorbidities. We also compared these models with performance of The John Hopkins Adjusted Clinical Groups® System (ACG) risk prediction algorithm.ResultsLR models predicting all-cause mortality outperformed models predicting hospitalisation. Mortality was best predicted by disease severity (AUC & 95% CI: 0.816 (0.805–0.827)) and prediction was enhanced only marginally by the addition of multi-morbidity indices (AUC & 95% CI: 0.829 (0.818–0.839)). The model combining disease severity and multi-morbidity indices was a better predictor of hospitalisation (AUC & 95% CI: 0.679 (0.672–0.686)). ACG-derived LR models outperformed conventional regression models for hospitalisation (AUC & 95% CI: 0.697 (0.690–0.704)) but not for mortality (AUC & 95% CI: 0.816 (0.805–0.827)).ConclusionStratification of future health risk in COPD can be undertaken using clinical and demographic data recorded in primary care, but the impact of disease severity and multi-morbidity varies depending on the choice of health outcome. A more comprehensive risk modelling algorithm such as ACG offers enhanced prediction for hospitalisation by incorporating a wider range of coded diagnoses.

Exorcising the positivist ghost in the priority-setting machine: NICE and the demise of the 'social value judgement'.

The National Institute for Health and Care Excellence (NICE), the UK's primary health care priority-setting body, has traditionally described its decisions as being informed by 'social value judgements' about how resources should be allocated across society. This paper traces the intellectual history of this term and suggests that, in NICE's adoption of the idea of the 'social value judgement', we are hearing the echoes of welfare economics at a particular stage of its development, when logical positivism provided the basis for thinking about public policy choice. As such, it is argued that the term offers an overly simplistic conceptualisation of NICE's normative approach and contributes to a situation in which NICE finds itself without the necessary language fully and accurately to articulate its basis for decision-making. It is suggested that the notion of practical public reasoning, based on reflection about coherent principles of action, might provide a better characterisation of the enterprise in which NICE is, or hopes to be, engaged.

Atopic eczema in adulthood and mortality: UK population–based cohort study, 1998-2016

BackgroundAtopic eczema affects up to 10% of adults and is becoming more common globally. Few studies have assessed whether atopic eczema increases the risk of death.ObjectiveWe aimed to determine whether adults with atopic eczema were at increased risk of death overall and by specific causes and to assess whether the risk varied by atopic eczema severity and activity.MethodsThe study was a population-based matched cohort study using UK primary care electronic health care records from the Clinical Practice Research Datalink with linked hospitalization data from Hospital Episode Statistics and mortality data from the Office for National Statistics from 1998 to 2016.ResultsA total of 526,736 patients with atopic eczema were matched to 2,567,872 individuals without atopic eczema. The median age at entry was 41.8 years, and the median follow-up time was 4.5 years. There was limited evidence of increased hazard for all-cause mortality in those with atopic eczema (hazard ratio = 1.04; 99% CI = 1.03-1.06), but there were somewhat stronger associations (8%-14% increased hazard) for deaths due to infectious, digestive, and genitourinary causes. Differences on the absolute scale were modest owing to low overall mortality rates. Mortality risk increased markedly with eczema severity and activity. For example, patients with severe atopic eczema had a 62% increased hazard (hazard ratio = 1.62; 99% CI = 1.54-1.71) for mortality compared with those without eczema, with the strongest associations for infectious, respiratory, and genitourinary causes.ConclusionThe increased hazards for all-cause and cause-specific mortality were largely restricted to those with the most severe or predominantly active atopic eczema. Understanding the reasons for these increased hazards for mortality is an urgent priority.

What items should be included in an early warning score for remote assessment of suspected COVID-19? qualitative and Delphi study

BackgroundTo develop items for an early warning score (RECAP: REmote COVID-19 Assessment in Primary Care) for patients with suspected COVID-19 who need escalation to next level of care.MethodsThe study was...

Cohort profile: Oxford Pain, Activity and Lifestyle (OPAL) Study, a prospective cohort study of older adults in England

PurposeThe ‘Oxford Pain, Activity and Lifestyle’ (OPAL) Cohort is a longitudinal, prospective cohort study of adults, aged 65 years and older, living in the community which is investigating the determinants...

Estratégias que viabilizam o acesso aos serviços de Atenção Primária à Saúde no Reino Unido

Este artigo apresenta algumas características organizativas e operacionais da Atenção Primária à Saúde (APS) inglesa. Seu objetivo é evidenciar pontos relevantes no funcionamento das clínicas da APS que facilitam o equilíbrio dinâmico entre o atendimento à demanda espontânea e as ações programáticas em saúde. Ele tem como base um estudo etnográfico, realizado no Reino Unido no período de 2013/14, no qual se analisou o modelo de pagamento por desempenho no país. Os tópicos abordados incluem: (a) composição das equipes da APS inglesa; (b) organograma funcional de uma clínica de APS; (c) consulta de 10 minutos dos médicos de família e horário de funcionamento da clínica; (d) recepção; (e) equipe de enfermagem; e (f) sistema de tecnologia da informação. Cada um desses itens possui referências para as quais é possível explorar websites e tutoriais de modo a compreender melhor alguns aspectos das clínicas da APS inglesa. O Reino Unido profissionalizou o acesso dos pacientes aos serviços da APS. Isto ocorreu por meio de um contingente maior de pessoal administrativo, menor proporção população/médico de família, maior autonomia da equipe de enfermagem e um robusto sistema de tecnologia da informação. No Brasil, a Estratégia Saúde da Família (ESF) necessita percorrer caminho semelhante a fim de aprimorar a qualidade da APS no país.

Inhaled corticosteroids, blood eosinophils, and FEV1 decline in patients with COPD in a large UK primary health care setting.

Background: Inhaled corticosteroid (ICS)-containing medications slow rate of decline of FEV1. Blood eosinophil (EOS) levels are associated with the degree of exacerbation reduction with ICS.Purpose: We investigated whether FEV1 decline differs between patients with and without ICS, stratified by blood EOS level.Patients and methods: The UK Clinical Practice Research Datalink (primary care records) and Hospital Episode Statistics (hospital records) were used to identify COPD patients aged 35 years or older, who were current or ex-smokers with ≥2 FEV1 measurements ≥6 months apart. Prevalent ICS use and the nearest EOS count to start of follow-up were identified. Patients were classified at baseline as higher stratum EOS (≥150 cell/µL) on ICS; higher stratum EOS not on ICS; lower stratum EOS (<150 cells/µL) on ICS; and lower stratum EOS not on ICS. In addition, an incident ICS cohort was used to investigate the rate of FEV1 change by EOS and incident ICS use. Mixed-effects linear regression was used to compare rates of FEV1 change in mL/year.Results: A total of 26,675 COPD patients met our inclusion criteria (median age 69, 46% female). The median duration of follow up was 4.2 years. The rate of FEV1 change in prevalent ICS users was slower than non-ICS users (−12.6 mL/year vs −21.1 mL/year; P =0.001). The rate of FEV1 change was not significantly different when stratified by EOS level. The rate of FEV1 change in incident ICS users increased (+4.2 mL/year) vs −21.2 mL/year loss in non-ICS users; P<0.001. In patients with high EOS, incident ICS patients showed an increase in FEV1 (+12 mL/year) compared to non-ICS users whose FEV1 decreased (−20.8 mL/year); P<0.001. No statistical difference was seen in low EOS patients. Incident ICS use is associated with an improvement in FEV1 change, however, over time this association is lost.Conclusion: Regardless of blood EOS level, prevalent ICS use is associated with slower rates of FEV1 decline in COPD.

The Future of Health Care: Protocol for Measuring the Potential of Task Automation Grounded in the National Health Service Primary Care System.

BackgroundRecent advances in technology have reopened an old debate on which sectors will be most affected by automation. This debate is ill served by the current lack of detailed data on the exact capabilities of new machines and how they are influencing work. Although recent debates about the future of jobs have focused on whether they are at risk of automation, our research focuses on a more fine-grained and transparent method to model task automation and specifically focus on the domain of primary health care.ObjectiveThis protocol describes a new wave of intelligent automation, focusing on the specific pressures faced by primary care within the National Health Service (NHS) in England. These pressures include staff shortages, increased service demand, and reduced budgets. A critical part of the problem we propose to address is a formal framework for measuring automation, which is lacking in the literature. The health care domain offers a further challenge in measuring automation because of a general lack of detailed, health care–specific occupation and task observational data to provide good insights on this misunderstood topic.MethodsThis project utilizes a multimethod research design comprising two phases: a qualitative observational phase and a quantitative data analysis phase; each phase addresses one of the two project aims. Our first aim is to address the lack of task data by collecting high-quality, detailed task-specific data from UK primary health care practices. This phase employs ethnography, observation, interviews, document collection, and focus groups. The second aim is to propose a formal machine learning approach for probabilistic inference of task- and occupation-level automation to gain valuable insights. Sensitivity analysis is then used to present the occupational attributes that increase/decrease automatability most, which is vital for establishing effective training and staffing policy.ResultsOur detailed fieldwork includes observing and documenting 16 unique occupations and performing over 130 tasks across six primary care centers. Preliminary results on the current state of automation and the potential for further automation in primary care are discussed. Our initial findings are that tasks are often shared amongst staff and can include convoluted workflows that often vary between practices. The single most used technology in primary health care is the desktop computer. In addition, we have conducted a large-scale survey of over 156 machine learning and robotics experts to assess what tasks are susceptible to automation, given the state-of-the-art technology available today. Further results and detailed analysis will be published toward the end of the project in early 2019.ConclusionsWe believe our analysis will identify many tasks currently performed manually within primary care that can be automated using currently available technology. Given the proper implementation of such automating technologies, we expect considerable staff resources to be saved, alleviating some pressures on the NHS primary care staff.International Registered Report Identifier (IRRID)DERR1-10.2196/11232

Cross-cultural adaptation of the medical engagement scale into Danish general practice setting

Introduction: The need to involve doctors in healthcare leadership has long been recognized by clinical staff and policymakers. A Medical Engagement Scale has been designed in England to evaluate levels of medical engagement in leadership and management.Objective: The aim of this study was to translate and adapt the scale and to test the translated version for comprehension and suitability in Danish general practice setting.Design and method: The process involved forward translation, backward translation, and field tests. The field tests included cognitive debriefing interviews. In all 30 general practitioners and 5 non-general practitioners participated in the process of translation. After using the scale among 1652 general practitioners statistical analysis was carried out to test internal consistency.Setting: The study was carried out in general practice in Denmark.Results: Several changes made during the process in order to achieve a Danish version that is acceptable, understandable and still capable of measuring medical engagement comparable of the original English version. Analysis of scale internal consistency using Cronbach’s alpha revealed acceptable reliability for all three meta-scales, which ranged from 0.69 to 0.81. The overall tool achieved a Cronbach’s alpha of 0.89.Conclusion: The Danish version of the Medical Engagement Scale is a valid and reliable tool that is acceptable and relevant for general practice in Denmark.Key pointsThis study describes the cross-cultural adaptation of the Medical Engagement Scale from a UK primary healthcare setting to a Danish primary healthcare setting.The process produced a relevant and acceptable questionnaire measuring medical engagement.Internal consistency revealed acceptable reliabilityThe translation of the scale provides the possibility to use this scale for practical and academic purposes.

Failure demand: a concept evaluation in UK primary care.

The purpose of this paper is to assess failure demand as a lean concept that assists in waste analysis during quality improvement activity. The authors assess whether the concept's limited use is a missed opportunity to help us understand improvement priorities, given that a UK Government requirement for public service managers to report failure demand has been removed. The authors look at the literature across the public sector and then apply the failure demand concept to the UK's primary healthcare system. The UK National Health Service (NHS) demand data are analysed and the impact on patient care is elicited from patient interviews. The study highlighted the concept's value, showing how primary care systems often generate failure demand partly owing to existing demand and capacity management practices. This demand is deflected to other systems, such as the accident and emergency department, with a considerable detrimental impact on patient experience. More research is needed to fully understand how best to exploit the failure demand concept within wider healthcare as there are many potential barriers to its appropriate and successful application. The authors highlight three practical barriers to using failure demand: first, demand within the healthcare system is poorly understood; second, systems improvement understanding is limited; and third, need to apply the concept for improvement and not just for reporting purposes. The authors provide an objective and independent insight into failure demand that has not previously been seen in the academic literature, specifically in relation to primary healthcare.

Observational safety study of specific outcomes after trivalent cell culture seasonal influenza vaccination (Optaflu® ) among adults in THIN database of electronic UK primary healthcare records.

To investigate the safety of trivalent seasonal influenza vaccine (TIVc) (Optaflu® ), the first cell culture seasonal trivalent influenza vaccine available in Europe. Codes and unstructured text in adult electronic healthcare records (The Health Improvement Network) were searched for a TIVc brand name or batch number and possible outcomes within a 3month pre- to 6month post-TIVc exposure study period (2012-2015). The outcomes were severe allergic reactions, Bell's palsy, convulsions, demyelination, paresthesia, noninfectious encephalitis, neuritis (optic and brachial), vasculitis, inflammatory bowel disease, and thrombocytopenia. Risk periods were defined based on biologically plausible time frame postvaccination when an outcome caused by the vaccine might be expected to occur. Possible outcomes were adjudicated against outcome specific case definitions and a date of onset assigned by using electronic and other medical records. Observed (risk period) to expected (outside risk and preexposure periods) rate ratios, postexposure incidence, and plots of time from exposure to outcome were reported. Sixteen of 1011 events from 4578 exposures fulfilled a primary case definition and had a date of onset during the study period. Three were in observed time. The observed-to-expected rate ratios were (3.3, 95% CI 0.3, 31.7) for convulsions and (1.5, 95% CI 0.2, 14.9) for thrombocytopenia with 1 outcome each in observed time. There was 1 incident inflammatory bowel disease in observed, but none in expected, time. The small sample size restricts interpretation; however, no hypothesis of an increased risk of a study outcome was generated. Adjudication of events against case definitions to reduce misclassification of onset and outcomes allowed use of precise risk periods. KEY POINTS This observational study did not generate a hypothesis of an association between the first cell-culture seasonal influenza vaccination available in the European Union and any of the study outcomes (severe allergic reactions, Bell's palsy, convulsions, demyelination, paresthesia, noninfectious encephalitis, neuritis [optic and brachial], vasculitis, inflammatory bowel disease [IBD], and thrombocytopenia). The small sample size limits interpretation of the results. The review of each possible outcome identified from electronic healthcare records against case definitions was included to minimize misclassification of time and outcomes and allow the use of precise risk-periods in an observed-to-expected within cohort analysis. Plots of time from exposure to outcome were included to assess the risk windows.

Benefits, harms and evidence - reflections from UK primary healthcare.

In this paper I examine the relationship between benefits, harms and evidence-based medicine in the context of British primary healthcare. First, I will examine: ‘What is a benefit and what is a harm?’ Second, what should we know about where the balance of risk and benefit appear to lie? Third, what should we do with this knowledge, particularly in the context of the biopsychosocial gaze of primary care? I conclude that even perfect knowledge about benefits and harms requires to be translated in the context of the individual patient: it also requires to be interpreted according to what that persons’ wishes are.Why this matters to meBy reiterating again and again how biases are stacked in favour of recommending treatments and interventions well beyond their rational evidence, my hope is that more honest medicine will result in less but higher value medicine. Stopping doing things that don’t work, or work rarely, or come with an unacceptable burden of side effects or appointments should make room for the pleasure of practicing medicine.Key message(s) •Even perfect knowledge about benefits and harms requires to be translated in the context of the individual patient: it also requires to be interpreted according to what that persons’ wishes are.•In the real, messy frontline world of general practice, we will always have uncertainty about where the balance of risk and benefit might lie.

PS-08-015 Screening for hypogonadism in UK primary healthcare: How to do this effectively

PS-08-015 Screening for hypogonadism in UK primary healthcare: How to do this effectively

Comparison of microbiological diagnosis of urinary tract infection in young children by routine health service laboratories and a research laboratory: Diagnostic cohort study

ObjectivesTo compare the validity of diagnosis of urinary tract infection (UTI) through urine culture between samples processed in routine health service laboratories and those processed in a research laboratory.Population and methodsWe conducted a prospective diagnostic cohort study in 4808 acutely ill children aged <5 years attending UK primary health care. UTI, defined as pure/predominant growth ≥105 CFU/mL of a uropathogen (the reference standard), was diagnosed at routine health service laboratories and a central research laboratory by culture of urine samples. We calculated areas under the receiver-operator curve (AUC) for UTI predicted by pre-specified symptoms, signs and dipstick test results (the “index test”), separately according to whether samples were obtained by clean catch or nappy (diaper) pads.Results251 (5.2%) and 88 (1.8%) children were classified as UTI positive by health service and research laboratories respectively. Agreement between laboratories was moderate (kappa = 0.36; 95% confidence interval [CI] 0.29, 0.43), and better for clean catch (0.54; 0.45, 0.63) than nappy pad samples (0.20; 0.12, 0.28). In clean catch samples, the AUC was lower for health service laboratories (AUC = 0.75; 95% CI 0.69, 0.80) than the research laboratory (0.86; 0.79, 0.92). Values of AUC were lower in nappy pad samples (0.65 [0.61, 0.70] and 0.79 [0.70, 0.88] for health service and research laboratory positivity, respectively) than clean catch samples.ConclusionsThe agreement of microbiological diagnosis of UTI comparing routine health service laboratories with a research laboratory was moderate for clean catch samples and poor for nappy pad samples and reliability is lower for nappy pad than for clean catch samples. Positive results from the research laboratory appear more likely to reflect real UTIs than those from routine health service laboratories, many of which (particularly from nappy pad samples) could be due to contamination. Health service laboratories should consider adopting procedures used in the research laboratory for paediatric urine samples. Primary care clinicians should try to obtain clean catch samples, even in very young children.