The study aimed to conduct a process evaluation for a cluster randomised trial of a computer-delivered, point-of-care intervention to reduce antibiotic prescribing in primary care. The study aimed to evaluate both the intervention and implementation of the trial.
The intervention comprised a set of electronic educational and decision support tools that were remotely installed and activated during consultations with patients with acute respiratory infections over a 12 month intervention period. A mixed method evaluation was conducted with 103 general practitioners (GPs) who participated in the trial. Semi-structured telephone interviews were conducted with 20 GPs who had been in the intervention group of the trial and 4 members of the implementation staff. Questionnaires, consisting of both intervention evaluation and theory-based measures, were self-administered to 83 GPs (56 control group and 27 intervention group).
Interviews suggested that a key factor influencing GPs’ use of the intervention appeared to be their awareness of the implementation of the system into their practice. GPs who were aware of the implementation of the intervention reported feeling confident in using it if they chose to and understood the purpose of the intervention screens. However, GPs who were unaware that the intervention would be appearing often reported feeling confused when they saw the messages appear on the screen and not fully understanding what they were for or how they could be used. Intervention evaluation questionnaires indicated that GPs were satisfied with the usability of the prompts, and theory-based measures revealed that intervention group GPs reported higher levels of self-efficacy in managing RTI patients according to recommended guidelines compared to GPs in the control group.
Remote installation of a computer-delivered intervention for use at the point-of-care was feasible and acceptable. Additional measures to promote awareness of the intervention may be required to promote health care professionals’ utilisation of the intervention and these might sometimes compromise the pragmatic intention of a trial.
ISRCTN47558792 (registered on 17 March 2010).
Cluster trial; Pragmatic trial; Point of care; Antibiotic utilisation; Primary care; Implementation science
Overutilisation of antibiotics may contribute to the emergence of antimicrobial drug resistance, a growing international concern. This study aimed to analyse the performance of UK general practices with respect to antibiotic prescribing for respiratory tract infections (RTIs) among young and middle-aged adults.
Data are reported for 568 UK general practices contributing to the Clinical Practice Research Datalink.
Participants were adults aged 18–59 years. Consultations were identified for acute upper RTIs including colds, cough, otitis-media, rhino-sinusitis and sore throat.
Primary and secondary outcome measures
For each consultation, we identified whether an antibiotic was prescribed. The proportion of RTI consultations with antibiotics prescribed was estimated.
There were 568 general practices analysed. The median general practice prescribed antibiotics at 54% of RTI consultations. At the highest prescribing 10% of practices, antibiotics were prescribed at 69% of RTI consultations. At the lowest prescribing 10% of practices, antibiotics were prescribed at 39% RTI consultations. The median practice prescribed antibiotics at 38% of consultations for ‘colds and upper RTIs’, 48% for ‘cough and bronchitis’, 60% for ‘sore throat’, 60% for ‘otitis-media’ and 91% for ‘rhino-sinusitis’. The highest prescribing 10% of practices issued antibiotic prescriptions at 72% of consultations for ‘colds’, 67% for ‘cough’, 78% for ‘sore throat’, 90% for ‘otitis-media’ and 100% for ‘rhino-sinusitis’.
Most UK general practices prescribe antibiotics to young and middle-aged adults with respiratory infections at rates that are considerably in excess of what is clinically justified. This will fuel antibiotic resistance.
Statins are an important intervention for primary and secondary cardiovascular disease (CVD) prevention. We aimed to establish the variation in primary preventive treatment for CVD with statins in the English population.
Cross sectional analyses of 6155 English primary care practices with 40,017,963 patients in 2006/7. Linear regression was used to model prescribing rates of statins for primary CVD prevention as a function of IMD (index of multiple deprivation) quintile, proportion of population from an ethnic minority, and age over 65 years. Defined Daily Doses (DDD) were used to calculate the numbers of patients receiving a statin. Statin prescriptions were allocated to primary and secondary prevention based on the prevalence of CVD and stroke.
We estimated that 10.5% (s.d.3.7%) of the registered population were dispensed a statin for any indication and that 6.3% (s.d. 3.0%) received a statin for primary CVD prevention. The regression model explained 21.2% of the variation in estimates of prescribing for primary prevention. Practices with higher prevalence of hypertension (β co-efficient 0.299 p <0.001) and diabetes (β co-efficient 0.566 p < 0.001) prescribed more statins for primary prevention. Practices with higher levels of ethnicity (β co-efficient-0.026 p <0.001), greater deprivation (β co-efficient −0.152 p < 0.001) older patients (β co-efficient −0.032 p 0.002), larger lists (β co-efficient −0.085, p < 0.001) and were more rural (β co-efficient −0.121, p0.026) prescribed fewer statins. In a small proportion of practices (0.5%) estimated prescribing rates for statins were so low that insufficient prescriptions were issued to meet the predicted secondary prevention requirements of their registered population.
Absolute estimated prescribing rates for primary prevention of CVD were 6.3% of the population. There was evidence of social inequalities in statin prescribing for primary prevention. These findings support the recent introduction of a financial incentive for primary prevention of CVD in England.
Electronic supplementary material
The online version of this article (doi:10.1186/1472-6963-14-414) contains supplementary material, which is available to authorized users.
Hydroxymethylglutaryl-CoA reductase inhibitors; Primary health care; Cardiovascular diseases
Serious mental illness (SMI) is associated with elevated mortality compared to the general population; the majority of this excess is attributable to co-occurring common physical health conditions. There may be variation within the SMI group in the distribution of physical co/multi-morbidity. This study aims to a) compare the pattern of physical co- and multi-morbidity between patients with and without SMI within a South London primary care population; and, b) to explore socio-demographic and health risk factors associated with excess physical morbidity among the SMI group.
Data were obtained from Lambeth DataNet, a database of electronic patient records derived from general practices in the London borough of Lambeth. The pattern of 12 co-morbid common physical conditions was compared by SMI status. Multivariate ordinal and logistic regression analyses were conducted to assess the strength of association between each condition and SMI status; adjustments were made for potentially confounding socio-demographic characteristics and for potentially mediating health risk factors.
While SMI patients were more frequently recorded with all 12 physical conditions than non-SMI patients, the pattern of co-/multi-morbidity was similar between the two groups. Adjustment for socio-demographic characteristics – in particular age and, to a lesser extent ethnicity, considerably reduced effect sizes and accounted for some of the associations, though several conditions remained strongly associated with SMI status. Evidence for mediation by health risk factors, in particular BMI, was supported.
SMI patients are at an elevated risk of a range of physical health conditions than non-SMI patients but they do not appear to experience a different pattern of co-/multimorbidity among those conditions considered. Socio-demographic differences between the two groups account for some of the excess in morbidity and known health risk factors are likely to mediate the association. Further work to examine a wider range of conditions and health risk factors would help determine the extent of excess mortality attributable to these factors.
Serious mental illness; Mental health; Physical health; Comorbidity; Multimorbidity
Health policy in the UK is increasingly focused on the measurement of
outcomes rather than structures and processes of health care.
To develop a measure of the effectiveness of primary care in terms of
population health outcomes.
Design and setting
A cross-sectional study of general practices in England.
Twenty clinical quality of care indicators for which there was evidence of
mortality reduction were identified from the national Quality and Outcomes
Framework (QOF) pay-for-performance scheme. The number of lives saved by
8136 English practices (97.97% of all practices) in 2009/2010 was
estimated, based on their performance on these measures, and a public health
impact measure, the PHI score, was constructed. Multilevel regression models
were used to identify practice and population predictors of PHI scores.
The mean estimated PHI score was 258.9 (standard deviation
[SD] = 73.3) lives saved per 100 000 registered
patients, per annum. This represents 75.7% of the maximum potential
PHI score of 340.9 (SD = 91.8). PHI and QOF scores were weakly
correlated (Pearson r = 0.28). The most powerful predictors of PHI
score were the prevalence of the relevant clinical conditions
(β = 0.77) and the proportion of
patients aged ≥65 years (β = 0.22).
General practices that were less successful at achieving their maximum
potential PHI score were those with a lower prevalence of relevant
conditions (β = 0.29), larger list sizes
(β = −0.16), greater area
deprivation (β = −0.15), and a
larger proportion of patients aged ≥65 years
(β = −0.13).
The PHI score is a potential alternative metric of practice performance,
measuring the estimated mortality reduction in the registered population.
Rewards under the QOF pay-for-performance scheme are not closely aligned to
the public health impact of practices.
health outcomes; population mortality reduction; primary health care
Involving patients in treatment is becoming increasingly popular in mental health [Sales & Alves: Personalized evaluation of psychological treatments: A review of tools and research designs, submitted]. However, in substance misuse treatment settings, the patient perspective about treatment tends to be overlooked. This has been cited as a key priority by Orford et al. [Addiction, 103: 875-885, 2008] who included patient feedback about treatment as one of ten areas requiring an urgent paradigm shift in addiction research and practice.
This project will apply an innovative method to involve substance misuse patients in psychological therapies, by asking them to suggest topics to evaluate their treatment. These topics suggested by patients can be written as a list of personalised items, so-called as patient-generated outcome measures (PGOM). Despite its patient-friendly features, PGOM’s have never been used in this population, which is what this project aims to overcome.
This project is part of an International Exchange Platform on Personalising Addiction Treatment. Data will be collected in two phases (pre-post study and focus groups with patients) to explore the following:
1). How reliable and sensitive to change are PGOM’s and standardised measures in substance misuse treatment?
2). Do PGOM’s add relevant information to standardised measures?
3). What are the views of substance misuse patients about personalised outcome assessment?
4). Development of guidelines on using PGOM’s in this population
This research will potentially demonstrate the diversity of personal problems among patients seeking substance misuse treatment, suggesting the relevance of PGOM as a method to personalise outcome measurement and, ultimately, guiding treatment provision. It is expected that, as in previous studies, PGOM’s will be perceived as helpful and patient-friendly tools, where patients may express their own concerns in a semi-structured setting. Similarly to other populations, we also expect PGOM’s to be reliable, valid and sensitive to clinical changes in substance misuse treatment, as well as more content informative than their standardised counterparts. If these results are achieved, we might hypothesize that PGOM’s are a potentially valid supplement to traditional standardised scales, by providing a closer insight to what motivates patients to participate in substance misuse treatment programmes.
Patient involvement; Personalised outcome measurement; Patient perspective; Patient-generated outcome measures; Individualized outcome measures; Substance misuse treatment
There is conflicting evidence as to whether achievement of cholesterol targets at the population level is dependent on the choice and cost of statin.
To investigate the practice-level relationship between cholesterol quality indicators in patients with heart disease, stroke, and diabetes and prescribing of low-cost statins.
Design and setting
Correlations and linear regression modelling of retrospective cross-sectional practice-level data with potential explanatory variables in 7909 (96.4%) general practices in England in 2008–2009.
Quality indicator data were obtained from the Information Centre and prescribing data from the NHS Business Authority. A ‘cholesterol quality indicator’ score was constructed by dividing the numbers of patients achieving the target for cholesterol control of ≤5 mmol/l in stroke, diabetes, and heart disease by the numbers on each register. A ‘low-cost statin’ ratio score was constructed by dividing the numbers of defined daily doses of simvastatin and pravastatin by the total numbers of defined daily doses of statins.
Simvastatin accounted for 83.3% (standard deviation [SD] = 15.7%) of low-cost statins prescribed and atorvastatin accounted for 85.7% (SD = 14.8%) of high-cost statins prescribed. The mean cholesterol score was 73.7% (SD = 6.0%). Practices using a higher proportion of the low-cost statins were less successful in achieving cholesterol targets. An increase of 10% in the prescribing of low-cost statins was associated with a decrease of 0.46% in the cholesterol quality indicator score (95% confidence interval = –0.54% to –0.38%, P<0.001).
Greater use of low-cost statins was associated with a small reduction in cholesterol control.
costs and cost analysis; hydroxymethylglutaryl-CoA reductase inhibitors; primary health care
NICE guidelines are the accepted standard for determining the management of hypertension in UK primary care.
To explore adherence and non-adherence to NICE hypertension guidelines, the extent to which this influences blood pressure control, and the role of ethnicity.
Design and setting
A cross-sectional study was conducted based on primary care data from Lambeth DataNet, a database of primary care records in one inner-city London borough.
NICE guidelines were used to determine adherence to recommended treatment options for four groups of patients with hypertension: aged <55 years on monotherapy; aged ≥55 years on monotherapy; any age on dual therapy; any age and with comorbid diabetes. Blood pressure control was determined for each treatment category and ethnic group. The study controlled for age, sex, social deprivation, and clustering within general practices.
A total of 32 183 patients were identified with a current diagnosis of hypertension. Ethnic coding was available for 28 320 (88.0%). Overall, 13 546 patients with ethnicity coding could be allocated to one of the four clinical categories of hypertension; 44% of these patients received non-guideline-adherent treatment; ethnicity was not a significant determinant. Mean arterial pressure did not differ significantly between those receiving ‘correct’ or ‘incorrect’ hypotensive therapy.
Evidence-based guidelines for the management of hypertension were not followed in a relatively large proportion of patients included in this study. Nevertheless, no evidence was found that failure to follow treatment recommendations resulted in poorer blood pressure control. Further work is needed to determine the reasons for non-implementation of guideline recommendations in primary care.
ethnicity; guidelines; hypertension; primary care
The purpose of this research is to develop and evaluate methods for conducting pragmatic cluster randomized trials in a primary care electronic database. The proposal describes one application, in a less frequent chronic condition of public health importance, secondary prevention of stroke. A related protocol in antibiotic prescribing was reported previously.
The study aims to implement a cluster randomized trial (CRT) using the electronic patient records of the General Practice Research Database (GPRD) as a sampling frame and data source. The specific objective of the trial is to evaluate the effectiveness of a computer-delivered intervention at enhancing the delivery of stroke secondary prevention in primary care. GPRD family practices will be allocated to the intervention or usual care. The intervention promotes the use of electronic prompts to support adherence with the recommendations of the UK Intercollegiate Stroke Working Party and NICE guidelines for the secondary prevention of stroke in primary care. Primary outcome measure will be the difference in systolic blood pressure between intervention and control trial arms at 12-month follow-up. Secondary outcomes will be differences in serum cholesterol, prescribing of antihypertensive drugs, statins, and antiplatelet therapy. The intervention will continue for 12 months. Information on the utilization of the decision-support tools will also be analyzed.
The CRT will investigate the effectiveness of using a computer-delivered intervention to reduce the risk of stroke recurrence following a first stroke event. The study will provide methodological guidance on the implementation of CRTs in electronic databases in primary care.
Current Controlled Trials ISRCTN35701810
Clinical trials; Cluster analysis; Electronic health records; Feasibility studies; Stroke; Secondary prevention
Community studies reveal people with coronary heart disease (CHD) are twice as likely to be depressed as the general population and that this co-morbidity negatively affects the course and outcome of both conditions. There is evidence for the efficacy of collaborative care and case management for depression treatment, and whilst NICE guidelines recommend these approaches only where depression has not responded to psychological, pharmacological, or combined treatments, these care approaches may be particularly relevant to the needs of people with CHD and depression in the earlier stages of stepped care in primary care settings.
This pilot randomised controlled trial will evaluate whether a simple intervention involving a personalised care plan, elements of case management and regular telephone review is a feasible and acceptable intervention that leads to better mental and physical health outcomes for these patients. The comparator group will be usual general practitioner (GP) care.
81 participants have been recruited from CHD registers of 15 South London general practices. Eligible participants have probable major depression identified by a score of ≥8 on the Hospital Anxiety and Depression Scale depression subscale (HADS-D) together with symptomatic CHD identified using the Modified Rose Angina Questionnaire.
Consenting participants are randomly allocated to usual care or the personalised care intervention which involves a comprehensive assessment of each participant’s physical and mental health needs which are documented in a care plan, followed by regular telephone reviews by the case manager over a 6-month period. At each review, the intervention participant’s mood, function and identified problems are reviewed and the case manager uses evidence based behaviour change techniques to facilitate achievement of goals specified by the patient with the aim of increasing the patient’s self efficacy to solve their problems.
Depressive symptoms measured by HADS score will be collected at baseline and 1, 6- and 12 months post randomisation. Other outcomes include CHD symptoms, quality of life, wellbeing and health service utilisation.
This practical and patient-focused intervention is potentially an effective and accessible approach to the health and social care needs of people with depression and CHD in primary care.
Child and adolescent mental health problems are common in primary healthcare settings. However, few parents of children with mental health problems express concerns about these problems during consultations. Based on parental views, we aimed to create quality of care measures for child and adolescent mental health in primary care and develop consensus about the importance of these quality standards within primary care.
Quality Standards were developed using an iterative approach involving four phases: 1) 34 parents with concerns about their child’s emotional health or behaviour were recruited from a range of community settings including primary care practices to participate in focus group discussions, followed by validation groups or interviews. 2) Preliminary Quality Standards were generated that fully represented the parents’ experiences and were refined following feedback from an expert parent nominal group. 3) 55 experts, including parents and representatives from voluntary organisations, across five panels participated in a modified two-stage Delphi study to develop consensus on the importance of the Quality Standards. The panels comprised general practitioners, other community-based professionals, child and adolescent psychiatrists, other child and adolescent mental health professionals and public health and policy specialists. 4) The final set of Quality Standards was piloted with 52 parents in primary care.
In the Delphi process, all five panels agreed that 10 of 31 Quality Standards were important. Although four panels rated 25–27 statements as important, the general practitioner panel rated 12 as important. The final 10 Quality Standards reflected healthcare domains involving access, confidentiality for young people, practitioner knowledge, communication, continuity of care, and referral to other services. Parents in primary care agreed that all 10 statements were important.
It is feasible to develop a set of Quality Standards to assess mental healthcare provision for children and adolescents seen within primary healthcare services. Primary care practitioners should be aware of parental perspectives about quality of care as these may influence help-seeking behaviours.
Epilepsy is an important cause of amenable mortality but risk factors for death in epilepsy are not well understood.
To evaluate trends in epilepsy mortality in a large population and identify risk factors for death in epilepsy.
Design and setting
Nested case–control study in the UK, using data from the General Practice Research Database (GPRD) from 1993 to 2007.
Participants were included if they had ever been diagnosed with epilepsy and prescribed anticonvulsant drugs. Trends in all-cause mortality in persons with epilepsy in the GPRD were compared with death registrations with epilepsy as the underlying cause. A nested case–control study was implemented to compare participants with epilepsy who died with those who did not die.
The prevalence of epilepsy increased from 9 per 1000 in 1993 to 12 per 1000 in 2007, and epilepsy deaths also increased in this period. In a nested case–control study, mortality was associated with: recorded alcohol problems (odds ratio [OR] 2.96, 95% confidence interval [CI] = 2.25 to 3.89, P<0.001); having collected the last anticonvulsant prescription 90–182 days previously (OR 1.83, CI = 1.66 to 2.03, P<0.001); having an injury in the previous year (OR 1.41, 95% CI = 1.30 to 1.53, P<0.001), and having been treated for depression (OR 1.39, 95% CI = 1.28 to 1.50, P<0.001). In data available from 2004 onwards, being recorded seizure free in the previous 12 months was associated with lower mortality (OR 0.78, 95% CI = 0.71 to 0.86, P<0.001).
Mortality with epilepsy appears to be increasing. Patients who have alcohol problems, do not collect repeat prescriptions for anticonvulsant drugs, have recent injuries, or have been treated for depression may be at increased risk of death; patients who remain seizure free over 12 months are at a lower risk.
cohort study; epilepsy mortality; epilepsy prevalence; nested case-control study; primary care
High blood pressure is the single most important risk factor worldwide for the development of cardiovascular disease, and has been shown to affect some ethnic minority groups disproportionately.
To explore ethnic inequalities in blood pressure monitoring and control.
Data from Lambeth DataNet was used, based on case records from GP practices in one inner-city London borough. Blood pressure monitoring and control was compared using Quality and Outcomes Framework (QOF) targets for patients with: diabetes, coronary heart disease, stroke, hypertension, and chronic kidney disease. The study controlled for age, sex, social deprivation, and clustering within GP practices.
A total of 16 613 patients met the study criteria, with 5962 categorised as black/black British. Blood pressure monitoring was similar across ethnic groups and as good, if not better, for black patients compared to white. However, marked ethnic inequalities in blood pressure control were found, with black patients significantly less likely to achieve QOF targets than their white counterparts (odds ratio [OR] 0.73; 95% confidence interval [CI] = 0.64 to 0.82). Further inequalities were revealed in blood pressure control within disease groups and ethnic subgroups. In particular, blood pressure control was poor in African patients with diabetes (OR 0.63; 95% CI = 0.50 to 0.79) and Caribbean patients with coronary heart disease (OR 0.53; 95% CI = 0.37 to 0.77) when compared with white patients.
While black patients with chronic conditions are equally likely to have their blood pressure monitored, their blood pressure control is consistently poorer than that of their white counterparts. This may have important implications for cardiovascular risk management in black patients.
ethnicity/race; inequalities; health care; hypertension
Psychological outcome measures are evolving into measures that depict progress over time. Interval measurement during therapy has not previously been reported for a patient-generated measure in primary care. We aimed to determine the sensitivity to change throughout therapy, using ‘PSYCHLOPS’ (Psychological Outcome Profiles), and to determine if new problems appearing during therapy diminish overall improvement.
Responses to PSYCHLOPS, pre-, during- and post-therapy were compared. Setting: patients offered brief cognitive behaviour therapy in primary care in Poland.
238 patients completed the pre-therapy questionnaire, 194 (81.5%) the during-therapy questionnaire and 142 the post-therapy questionnaire (59.7%). For those completing all three questionnaires (n = 135), improvement in total scores produced an overall Effect Size of 3.1 (2.7 to 3.4). We estimated change using three methods for dealing with missing values. Single and multiple imputation did not significantly change the Effect Size; ‘Last Value Carried Forward’, the most conservative method, produced an overall Effect Size of 2.3 (1.9 to 2.6). New problems during therapy were reported by 81 patients (60.0%): new problem and original problem scores were of similar magnitude and change scores were not significantly different when compared to patients who did not report new problems.
A large proportion of outcome data is lost when outcome measures depend upon completed end of therapy questionnaires. The use of a during-therapy measure increases data capture. Missing data still produce difficulties in interpreting overall effect sizes for change. We found no evidence that new problems appearing during therapy hampered overall recovery.
Background and Objectives
Asthma and depression are common health problems in primary care. Evidence of a relationship between asthma and depression is conflicting. Objectives: to determine 1. The incidence rate and incidence rate ratio of depression in primary care patients with asthma compared to those without asthma, and 2. The standardized mortality ratio of depressed compared to non-depressed patients with asthma.
A historical cohort and nested case control study using data derived from the United Kingdom General Practice Research Database. Participants: 11,275 incident cases of asthma recorded between 1/1/95 and 31/12/96 age, sex and practice matched with non-cases from the database (ratio 1∶1) and followed up through the database for 10 years. 1,660 cases were matched by date of asthma diagnosis with 1,660 controls. Main outcome measures: number of cases diagnosed with depression, the number of deaths over the study period.
The rate of depression in patients with asthma was 22.4/1,000 person years and without asthma 13.8 /1,000 person years. The incident rate ratio (adjusted for age, sex, practice, diabetes, cardiovascular disease, cerebrovascular disease, smoking) was 1.59 (95% CI 1.48–1.71). The increased rate of depression was not associated with asthma severity or oral corticosteroid use. It was associated with the number of consultations (odds ratio per visit 1.09; 95% CI 1.07–1.11). The age and sex adjusted standardized mortality ratio for depressed patients with asthma was 1.87 (95% CI: 1.54–2.27).
Asthma is associated with depression. This was not related to asthma severity or oral corticosteroid use but was related to service use. This suggests that a diagnosis of depression is related to health seeking behavior in patients with asthma. There is an increased mortality rate in depressed patients with asthma. The cause of this needs further exploration. Consideration should be given to case-finding for depression in this population.
Coronary heart disease and depression are both common health problems and by 2020 will be the two leading causes of disability worldwide. Depression has been found to be more common in patients with coronary heart disease but the nature of this relationship is uncertain. In the United Kingdom general practitioners are now being remunerated for case-finding for depression in patients with coronary heart disease, however it is unclear how general practitioners should manage these patients. We aim to explore the relationship between coronary heart disease and depression in a primary care population and to develop an intervention for patients with coronary heart disease and depression.
This programme of research will consist of 4 inter-related studies. A 4 year prospective cohort study of primary care patients with coronary heart disease will be conducted to explore the relationship between coronary heart disease and depression. Within this, a nested case-control biological study will investigate genetic and blood-biomarkers as predictors of depression in this sample. Two qualitative studies, one of patients' perspectives of treatments for coronary heart disease and co-morbid depression and one of primary care professionals' views on the management of patients with coronary heart disease and depression will inform the development of an intervention for this patient group. A feasibility study for a randomised controlled trial will then be conducted.
This study will provide information on the relationship between coronary heart disease and depression that will allow health services to determine the efficiency of case-finding for depression in this patient group. The results of the cohort study will also provide information on risk factors for depression. The study will provide evidence on the efficacy and feasibility of a joint patient and professional led intervention and data necessary to plan a definitive randomised controlled trial of the intervention.
The purpose of this research is to develop and evaluate methods for conducting cluster randomised trials in a primary care database that contains electronic patient records for large numbers of family practices. Cluster randomised trials are trials in which the units allocated represent groups of individuals, in this case family practices and their registered patients. Cluster randomised trials often suffer from the limitation that they include too few clusters, leading to problems of insufficient power and only imprecise estimation of the intraclass correlation coefficient, a key design parameter. This difficulty might be overcome by utilising databases that already hold electronic patient records for large numbers of practices. The protocol describes one application: a study of antibiotic prescribing for acute respiratory infection; a second protocol outlines an intervention in a less frequent chronic condition of public health importance, stroke.
The objective of the study is to implement a cluster randomised trial to test the effectiveness of an electronic record-based intervention at achieving a reduction in antibiotic prescribing at consultations for respiratory illness in patients aged 18 and 59 years old in intervention family practices as compared with controls. Family practices will be recruited from the practices that presently contribute data to the UK General Practice Research Database (GPRD). Following randomisation, electronic prompts will be installed remotely at intervention practices to promote adherence with evidence-based standards of medical practice. The intervention was developed through qualitative research at non-intervention practices. Data for outcome assessment will be obtained from anonymised electronic patient records that are routinely collected into GPRD. This protocol outlines the proposed study designs, data sources, sample size requirements, analysis methods and dissemination plans. Ethical issues are also discussed.
Results from this study will provide methodological evidence concerning the use of electronic patient records and databases for implementing cluster randomised trials in primary care. The study will also provide substantive findings in respect of electronic record-based interventions to reduce antibiotic prescribing in primary care.
Current Controlled Trials ISRCTN 47558792.
Referrals for psychological treatment have been problematic for many years. Even though GPs have attempted to limit access into the small psychological treatment services, long waiting lists have developed which have deterred referrals and deferred psychological care. GPs have understandably been frustrated. In addition, the consultation rate for psychological problems is low when compared with the rate of identified mental health problems in population surveys. Possible reasons include patients' failure to recognise the problem as psychological and thus not consulting one's GP, and/or the problem not being detected by the GP. While a self-referral system may be seen as a way of trying to allow non-consulters to receive treatment, this has been viewed with some scepticism since it may allow the ‘worried well’ to access already limited services. However, a study has shown that those self-referring to advertised psychological workshops had high levels of psychological morbidity and also were more representative of the population, in terms of ethnicity, than GP referrals. The government has set up the Increasing Access to Psychological Therapies (IAPT) programme to address some of the service shortfalls by expanding the provision of psychological therapists. Notably, the IAPT programme is allowing self-referrals such that any member of the public can access the service directly, bypassing general practice. Although not available at all the sites, this represents a radical shift from the present system in which access to talking therapy is generally only available through direct referral by the GP. The implications of this new development are discussed.
access; psychological therapy; self-referral
This study aimed to inform the design of a pragmatic trial of stroke prevention in primary care by evaluating data recorded in electronic patient records (EPRs) as potential outcome measures. The study also evaluated achievement of recommended standards of care; variation between family practices; and changes in risk factor values from before to after stroke.
Data from the UK General Practice Research Database (GPRD) were analysed for 22,730 participants with an index first stroke between 2003 and 2006 from 414 family practices. For each subject, the EPR was evaluated for the 12 months before and after stroke. Measures relevant to stroke secondary prevention were analysed including blood pressure (BP), cholesterol, smoking, alcohol use, body mass index (BMI), atrial fibrillation, utilisation of antihypertensive, antiplatelet and cholesterol lowering drugs. Intraclass correlation coefficients (ICC) were estimated by family practice. Random effects models were fitted to evaluate changes in risk factor values over time.
In the 12 months following stroke, BP was recorded for 90%, cholesterol for 70% and body mass index (BMI) for 47%. ICCs by family practice ranged from 0.02 for BP and BMI to 0.05 for LDL and HDL cholesterol. For subjects with records available both before and after stroke, the mean reductions from before to after stroke were: mean systolic BP, 6.02 mm Hg; diastolic BP, 2.78 mm Hg; total cholesterol, 0.60 mmol/l; BMI, 0.34 Kg/m2. There was an absolute reduction in smokers of 5% and heavy drinkers of 4%. The proportion of stroke patients within the recommended guidelines varied from less than a third (29%) for systolic BP, just over half for BMI (54%), and over 90% (92%) on alcohol consumption.
Electronic patient records have potential for evaluation of outcomes in pragmatic trials of stroke secondary prevention. Stroke prevention interventions in primary care remain suboptimal but important reductions in vascular risk factor values were observed following stroke. Better recording of lifestyle factors in the GPRD has the potential to expand the scope of the GPRD for health care research and practice.
In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a ‘pay for performance’ scheme.
To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF.
Design of the study
Cross-sectional analysis of routine data.
English general practice in 2005/2006.
QOF data from 7456 general practices were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per full-time equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it.
A high level of nurse staffing (fewer patients per full-time equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary heart disease, diabetes, and hypertension, P = 0.004 to P<0.001) and in 4/10 clinical outcome indicators (diabetes: glycosylated haemoglobin [HbA1C] ≤7.4%, HbA1C ≤10% and total cholesterol ≤193 mg/dl; and stroke: total cholesterol ≤5 mmol/L, P = 0.0057 to P<0.001).
Practices that employ more nurses perform better in a number of clinical domains measured by the QOF. This improved performance includes better intermediate clinical outcomes, suggesting real patient benefit may be associated with using nurses to deliver care to meet QOF targets.
cross-sectional studies; family practice; health care; incentive; nursing staff; personnel staffing and scheduling; physician incentive plans; quality indicators; quality of health care; reimbursement
Non-adherence to clinical guidelines has been identified as a consistent finding in general practice. The purpose of this study was to develop theory-informed, computer-delivered interventions to promote the implementation of guidelines in general practice. Specifically, our aim was to develop computer-delivered prompts to promote guideline adherence for antibiotic prescribing in respiratory tract infections (RTIs), and adherence to recommendations for secondary stroke prevention.
A qualitative design was used involving 33 face-to-face interviews with general practitioners (GPs). The prompts used in the interventions were initially developed using aspects of social cognitive theory, drawing on nationally recommended standards for clinical content. The prompts were then presented to GPs during interviews, and iteratively modified and refined based on interview feedback. Inductive thematic analysis was employed to identify responses to the prompts and factors involved in the decision to use them.
GPs reported being more likely to use the prompts if they were perceived as offering support and choice, but less likely to use them if they were perceived as being a method of enforcement. Attitudes towards using the prompts were also related to anticipated patient outcomes, individual prescriber differences, accessibility and presentation of prompts and acceptability of guidelines. Comments on the prompts were largely positive after modifying them based on participant feedback.
Acceptability and satisfaction with computer-delivered prompts to follow guidelines may be increased by working with practitioners to ensure that the prompts will be perceived as valuable tools that can support GPs' practice.
Substantial variation in antibiotic prescribing rates between general practices persists, but remains unexplained at national level.
To establish the degree of variation in antibiotic prescribing between practices in England and identify the characteristics of practices that prescribe higher volumes of antibiotics.
Design of study
8057 general practices in England.
A dataset was constructed containing data on standardised antibiotic prescribing volumes, practice characteristics, patient morbidity, ethnicity, social deprivation, and Quality and Outcomes Framework achievement (2004–2005). Data were analysed using multiple regression modelling.
There was a twofold difference in standardised antibiotic prescribing volumes between practices in the 10th and 90th centiles of the sample (0.48 versus 0.95 antibiotic prescriptions per antibiotic STAR-PU [Specific Therapeutic group Age-sex weightings-Related Prescribing Unit]). A regression model containing nine variables explained 17.2% of the variance in antibiotic prescribing. Practice location in the north of England was the strongest predictor of high antibiotic prescribing. Practices serving populations with greater morbidity and a higher proportion of white patients prescribed more antibiotics, as did practices with shorter appointments, non-training practices, and practices with higher proportions of GPs who were male, >45 years of age, and qualified outside the UK.
Practice and practice population characteristics explained about one-sixth of the variation in antibiotic prescribing nationally. Consultation-level and qualitative studies are needed to help further explain these findings and improve our understanding of this variation.
antibiotics; prescriptions; primary care
Wide variations in anxiolytic and hypnotic prescribing by GPs in England have been described, but are largely unexplained.
To examine the relationships between the volume of anxiolytics and hypnotics prescribed by GPs and their practice characteristics, population demography, and performance indicators.
Design of study
All general practices in England.
A dataset was constructed for 8469 (98.8%) general practices including: standardised prescribing volume data for anxiolytics and hypnotics (average daily quantities per 1000 STAR-PUs [Specific Therapeutic group Age-sex weightings Related Prescribing Units]), practice descriptors, Index of Multiple Deprivation 2004, ethnicity data (2001 UK Census), and Quality and Outcomes Framework (QOF) data.
The standardised volume of anxiolytics and hypnotics prescribed varied eightfold between practices on the 5th and 95th centiles. A regression model was constructed which explained 20.5% of the variation. Higher prescribing practices were located in more deprived areas (standardised β 0.31), but also in areas with a lower proportion of ethnic minorities (black or black British = −0.22; Asian or Asian British = −0.12). Higher volumes were also prescribed by practices with lower QOF scores (‘Clinical Care’ domain = −0.12; ‘Organisational’ domain = −0.08). Other significant but weaker predictors were: lower proportions of female GPs, higher recorded prevalence of serious mental illness and non-training status. The proportion of GPs trained outside UK was not a predictor.
Demographic factors were more powerful determinants of prescribing than characteristics of the practice itself. Nevertheless, the findings provide some support for the notion that high prescribing practices were less well developed, in that their QOF scores were lower and they were less likely to be training practices.
anxiolytics; general practice; hypnotics; prescribing