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1.  Cervical and breast cancer screening uptake among women with serious mental illness: a data linkage study 
BMC Cancer  2016;16:819.
Background
Breast and cancer screening uptake has been found to be lower among women with serious mental illness (SMI). This study aims to corroborate these findings in the UK and to identify variation in screening uptake by illness/treatment factors, and primary care consultation frequency.
Methods
Linked population-based primary and secondary care data from the London borough of Lambeth (UK) were used to compare breast and cervical screening receipt among linked eligible SMI patients (n = 625 and n = 1393), to those without SMI known only to primary care (n = 106,554 and n = 25,385) using logistic regression models adjusted first for socio-demographic factors and second, additionally for primary care consultation frequency.
Results
Eligible SMI patients were less likely to have received breast (adjusted odds ratio (OR) 0.69, 95 % confidence interval (CI), 0.57 - 0.84, p < 0.001) or cervical screening (adjusted OR 0.72, CI: 0.60 - 0.85, p < 0.001). Schizophrenia diagnosis, depot injectable antipsychotic prescription, and illness severity and risk were associated with the lowest odds of uptake of breast (adjusted ORs 0.46 to 0.59, all p < 0.001) and cervical screening (adjusted ORs 0.48 - 0.65, all p < 0.001). Adjustments for consultation frequency further reduced effect sizes for all subgroups of SMI patient, in particular for cervical screening.
Conclusions
Women with SMI are less likely to receive breast and cervical cancer screening than comparable women without SMI. Higher primary care consultation rates among SMI patients is likely a mediating factor between SMI status and uptake, particularly for cervical screening - a service organised in primary care. To tackle health disparities linked to SMI, efforts at increasing screening uptake are key and should be targeted at women with other markers of illness severity or risk, beyond SMI status alone.
doi:10.1186/s12885-016-2842-8
PMCID: PMC5073417  PMID: 27769213
Cancer screening; Breast cancer; Cervical cancer; Mammography; Psychoses; Serious mental illness; Data linkage
2.  Socioeconomic deprivation and accident and emergency attendances: cross-sectional analysis of general practices in England 
The British Journal of General Practice  2015;65(639):e649-e654.
Background
Demand for England’s accident and emergency (A&E) services is increasing and is particularly concentrated in areas of high deprivation. The extent to which primary care services, relative to population characteristics, can impact on A&E is not fully understood.
Aim
To conduct a detailed analysis to identify population and primary care characteristics associated with A&E attendance rates, particularly those that may be amenable to change by primary care services.
Design and setting
This study used a cross-sectional population-based design. The setting was general practices in England, in the year 2011–2012.
Method
Multivariate linear regression analysis was used to create a model to explain the variability in practice A&E attendance rates. Predictor variables included population demographics, practice characteristics, and measures of patient experiences of primary care.
Results
The strongest predictor of general practice A&E attendance rates was social deprivation: the Index of Multiple Deprivation (IMD-2010) (β = 0.3. B = 1.4 [95% CI =1.3 to 1.6]), followed by population morbidity (GPPS responders reporting a long-standing health condition) (β = 0.2, B = 231.5 [95% CI = 202.1 to 260.8]), and knowledge of how to contact an out-of-hours GP (GPPS question 36) (β = −0.2, B = −128.7 [95% CI =149.3 to −108.2]). Other significant predictors included the practice list size (β = −0.1, B = −0.002 [95% CI = −0.003 to −0.002]) and the proportion of patients aged 0–4 years (β = 0.1, B = 547.3 [95% CI = 418.6 to 676.0]). The final model explained 34.4% of the variation in A&E attendance rates, mostly due to factors that could not be modified by primary care services.
Conclusion
Demographic characteristics were the strongest predictors of A&E attendance rates. Primary care variables that may be amenable to change only made a small contribution to higher A&E attendance rates.
doi:10.3399/bjgp15X686893
PMCID: PMC4582877  PMID: 26412841
accident and emergency department; general practice; primary health care; socioeconomic factors
3.  Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: a cluster randomised trial using electronic health records—REDUCE Trial study original protocol 
BMJ Open  2016;6(8):e010892.
Introduction
Respiratory tract infections (RTIs) account for about 60% of antibiotics prescribed in primary care. This study aims to test the effectiveness, in a cluster randomised controlled trial, of electronically delivered, multicomponent interventions to reduce unnecessary antibiotic prescribing when patients consult for RTIs in primary care. The research will specifically evaluate the effectiveness of feeding back electronic health records (EHRs) data to general practices.
Methods and analysis
2-arm cluster randomised trial using the EHRs of the Clinical Practice Research Datalink (CPRD). General practices in England, Scotland, Wales and Northern Ireland are being recruited and the general population of all ages represents the target population. Control trial arm practices will continue with usual care. Practices in the intervention arm will receive complex multicomponent interventions, delivered remotely to information systems, including (1) feedback of each practice's antibiotic prescribing through monthly antibiotic prescribing reports estimated from CPRD data; (2) delivery of educational and decision support tools; (3) a webinar to explain and promote effective usage of the intervention. The intervention will continue for 12 months. Outcomes will be evaluated from CPRD EHRs. The primary outcome will be the number of antibiotic prescriptions for RTIs per 1000 patient years. Secondary outcomes will be: the RTI consultation rate; the proportion of consultations for RTI with an antibiotic prescribed; subgroups of age; different categories of RTI and quartiles of intervention usage. There will be more than 80% power to detect an absolute reduction in antibiotic prescription for RTI of 12 per 1000 registered patient years. Total healthcare usage will be estimated from CPRD data and compared between trial arms.
Ethics and dissemination
Trial protocol was approved by the National Research Ethics Service Committee (14/LO/1730). The pragmatic design of the trial will enable subsequent translation of effective interventions at scale in order to achieve population impact.
Trial registration number
ISRCTN95232781; Pre-results.
doi:10.1136/bmjopen-2015-010892
PMCID: PMC4985802  PMID: 27491663
Drug Resistance; Anti-Bacterial Agents; Respiratory Tract Infections; Electronic Health Records; Primary Health Care; Random Allocation
4.  Financial incentives and professionalism: another fine mess 
doi:10.3399/bjgp15X686005
PMCID: PMC4513716  PMID: 26212824
5.  “It is not just about the alcohol”: service users’ views about individualised and standardised clinical assessment in a therapeutic community for alcohol dependence 
Background
The involvement of service users in health care provision in general, and specifically in substance use disorder treatment, is of growing importance. This paper explores the views of patients in a therapeutic community for alcohol dependence about clinical assessment, including general aspects about the evaluation process, and the specific characteristics of four measures: two individualised and two standardised.
Methods
A focus group was conducted and data were analysed using a framework synthesis approach.
Results
Service users welcomed the experience of clinical assessment, particularly when conducted by therapists. The duration of the evaluation process was seen as satisfactory and most of its contents were regarded as relevant for their population. Regarding the evaluation measures, patients diverged in their preferences for delivery formats (self-report vs. interview). Service users enjoyed the freedom given by individualised measures to discuss topics of their own choosing. However, they felt that part of the standardised questions were difficult to answer, inadequate (e.g. quantification of health status in 0–20 points) and sensitive (e.g. suicide-related issues), particularly for pre-treatment assessments.
Conclusions
Patients perceived clinical assessment as helpful for their therapeutic journey, including the opportunity to reflect about their problems, either related or unrelated to alcohol use. Our study suggests that patients prefer to have evaluation protocols administered by therapists, and that measures should ideally be flexible in their formats to accommodate for patient preferences and needs during the evaluation.
doi:10.1186/s13011-016-0070-5
PMCID: PMC4949765  PMID: 27430578
User involvement; Clinical assessment; Personalised assessment; Evaluation measures; Patient views; Individualised measures; Qualitative research
6.  Prostate-specific antigen testing in inner London general practices: are those at higher risk most likely to get tested? 
BMJ Open  2016;6(7):e011356.
Objectives
To investigate the association between factors influencing prostate-specific antigen (PSA) testing prevalence including prostate cancer risk factors (age, ethnicity, obesity) and non-risk factors (social deprivation and comorbidity).
Setting
A cross-sectional database of 136 inner London general practices from 1 August 2009 to 31 July 2014.
Participants
Men aged ≥40 years without prostate cancer were included (n=150 481).
Primary outcome
Logistic regression analyses were used to estimate the association between PSA testing and age, ethnicity, social deprivation, body mass index (BMI) and comorbidity while adjusting for age, benign prostatic hypertrophy, prostatitis and tamsulosin or finasteride use.
Results
PSA testing prevalence was 8.2% (2013–2014), and the mean age was 54 years (SD 11). PSA testing was positively associated with age (OR 70–74 years compared to 40–44 years: 7.34 (95% CI 6.82 to 7.90)), ethnicity (black) (OR compared to white: 1.78 (95% CI 1.71 to 1.85)), increasing BMI and cardiovascular comorbidity. Testing was negatively associated with Chinese ethnicity and with increasing social deprivation.
Conclusions
PSA testing among black patients was higher compared to that among white patients, which differs from lower testing rates seen in previous studies. PSA testing was positively associated with prostate cancer risk factors and non-risk factors. Association with non-risk factors may increase the risk of unnecessary invasive diagnostic procedures.
doi:10.1136/bmjopen-2016-011356
PMCID: PMC4947776  PMID: 27406644
Prostate-specific antigen; testing prevalence; general practice; prostate cancer; ethnicity; comorbidity
7.  Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records 
The BMJ  2016;354:i3410.
Objective To determine whether the incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome is higher in general practices that prescribe fewer antibiotics for self limiting respiratory tract infections (RTIs).
Design Cohort study.
Setting 610 UK general practices from the UK Clinical Practice Research Datalink.
Participants Registered patients with 45.5 million person years of follow-up from 2005 to 2014.
Exposures Standardised proportion of RTI consultations with antibiotics prescribed for each general practice, and rate of antibiotic prescriptions for RTIs per 1000 registered patients.
Main outcome measures Incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome, adjusting for age group, sex, region, deprivation fifth, RTI consultation rate, and general practice.
Results From 2005 to 2014 the proportion of RTI consultations with antibiotics prescribed decreased from 53.9% to 50.5% in men and from 54.5% to 51.5% in women. From 2005 to 2014, new episodes of meningitis, mastoiditis, and peritonsillar abscess decreased annually by 5.3%, 4.6%, and 1.0%, respectively, whereas new episodes of pneumonia increased by 0.4%. Age and sex standardised incidences for pneumonia and peritonsillar abscess were higher for practices in the lowest fourth of antibiotic prescribing compared with the highest fourth. The adjusted relative risk increases for a 10% reduction in antibiotic prescribing were 12.8% (95% confidence interval 7.8% to 17.5%, P<0.001) for pneumonia and 9.9% (5.6% to 14.0%, P<0.001) for peritonsillar abscess. If a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then it might observe 1.1 (95% confidence interval 0.6 to 1.5) more cases of pneumonia each year and 0.9 (0.5 to 1.3) more cases of peritonsillar abscess each decade. Mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome were similar in frequency at low prescribing and high prescribing practices.
Conclusions General practices that adopt a policy to reduce antibiotic prescribing for RTIs might expect a slight increase in the incidence of treatable pneumonia and peritonsillar abscess. No increase is likely in mastoiditis, empyema, bacterial meningitis, intracranial abscess, or Lemierre’s syndrome. Even a substantial reduction in antibiotic prescribing was predicted to be associated with only a small increase in numbers of cases observed overall, but caution might be required in subgroups at higher risk of pneumonia.
doi:10.1136/bmj.i3410
PMCID: PMC4933936  PMID: 27378578
8.  Cardiovascular disease treatment among patients with severe mental illness: a data linkage study between primary and secondary care 
The British Journal of General Practice  2016;66(647):e374-e381.
Background
Suboptimal treatment of cardiovascular diseases (CVD) among patients with severe mental illness (SMI) may contribute to physical health disparities.
Aim
To identify SMI characteristics associated with meeting CVD treatment and prevention guidelines.
Design and setting
Population-based electronic health record database linkage between primary care and the sole provider of secondary mental health care services in south east London, UK.
Method
Cardiovascular disease prevalence, risk factor recording, and Quality and Outcomes Framework (QOF) clinical target achievement were compared among 4056 primary care patients with SMI whose records were linked to secondary healthcare records and 270 669 patients without SMI who were not known to secondary care psychiatric services, using multivariate logistic regression modelling. Data available from secondary care records were then used to identify SMI characteristics associated with QOF clinical target achievement.
Results
Patients with SMI and with coronary heart disease and heart failure experienced reduced prescribing of beta blockers and angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (ACEI/ARB). A diagnosis of schizophrenia, being identified with any indicator of risk or illness severity, and being prescribed with depot injectable antipsychotic medication was associated with the lowest likelihood of prescribing.
Conclusion
Linking primary and secondary care data allows the identification of patients with SMI most at risk of undertreatment for physical health problems.
doi:10.3399/bjgp16X685189
PMCID: PMC4871302  PMID: 27114210
cardiovascular diseases; data linkage; health inequalities; primary health care; psychoses
9.  The relationship between prior antimicrobial prescription and meningitis: a case–control study 
The British Journal of General Practice  2016;66(645):e228-e233.
Background
Recent research into the role of the human microbiome in maintaining health has identified the potentially harmful impact of antimicrobials.
Aim
The association with bacterial and viral meningitis following antimicrobial prescription during the previous year was investigated to determine whether antimicrobials have a deleterious effect on the nasopharyngeal microbiome.
Design and setting
A case-control study (1:4 cases to controls) was conducted examining the rate of previous antimicrobial exposure in cases of meningitis and in a matched control group. Data from a UK primary care clinical database were analysed using conditional logistic regression.
Results
A total of 7346 cases of meningitis were identified, 3307 (45%) viral, 1812 (25%) bacterial, and 2227 (30%) unspecified. The risks of viral (adjusted odds ratio [AOR] 2.45; 95% confidence interval [CI] = 2.24 to 2.68) or bacterial (AOR 1.98; 95% CI = 1.71 to 2.30) meningitis were both increased following antimicrobial prescription in the preceding year. Patients who received ≥4 antimicrobial prescriptions in the preceding year were at significantly increased risk of all types of meningitis (AOR 2.85; 95% CI = 2.44 to 3.34), bacterial meningitis (AOR 3.06; 95% CI = 2.26 to 4.15) and viral meningitis (AOR 3.23; 95% CI = 2.55 to 4.08) compared to their matched controls.
Conclusion
There was an increased risk of meningitis following antimicrobial prescription in the previous year. It is possible that this increase was due to an effect of antimicrobials on the microbiome or reflected an increased general susceptibility to infections in these patients.
doi:10.3399/bjgp16X684313
PMCID: PMC4809705  PMID: 26965030
antimicrobial agents; case-control studies; meningitis; microbiome; primary care
11.  Challenges of the Pandemic Response in Primary Care during Pre-Vaccination Period: A Qualitative Study 
Background
During the 2009/A/H1N1 pandemic, the main burden of the patient management fell on primary care physicians (PCPs), and they were the principal implementers of pandemic policies. Broad involvement of PCPs in the pandemic response offered an excellent opportunity to investigate the challenges that they encountered.
Objective
To examine challenges faced by PCPs as they implemented pandemic policies in Australia, Israel and England before the 2009/A/H1N1 pandemic vaccine became available.
Methods
This is a qualitative descriptive study that employed in-depth semi-structured interviews with 65 PCPs from Australia, Israel and England. The data were analysed thematically to provide a detailed account of the themes.
Results
Challenges in three fields of the pandemic response were identified. (i) Consultation of patients was challenged by the high flow of patients, sick and worried-well, the necessity to provide personalised information about the disease during consultations, and unfamiliar antiviral treatment. (ii) Performance of public health responsibilities was complicated in regards to patient segregation and introduction of personal protection measures. (iii) Communication with the health authorities was inefficient, with no established route to provide feedback about the pandemic policies.
Conclusions
The experience of the 2009/A/H1N1 pandemic highlighted the centrality of primary care in the pandemic response. Despite intensive pre-pandemic planning, numerous barriers for implementation of the pandemic policies in primary care were identified. Investigation of three different approaches for involvement of PCPs in the pandemic management showed that none of these approaches worked smoothly.
doi:10.1186/s13584-015-0028-5
PMCID: PMC4606524  PMID: 26473026
Primary Health Care; Pandemics; Disease outbreaks; Public Health; Qualitative research; Health politics; General practice; Influenza; H1N1; Preparedness
12.  Nursing consultations and control of diabetes in general practice: a retrospective observational study 
The British Journal of General Practice  2015;65(639):e642-e648.
Background
Diabetes affects around 3.6 million people in the UK. Previous research found that general practices employing more nurses delivered better diabetes care, but did not include data on individual patient characteristics or consultations received.
Aim
To examine whether the proportion of consultations with patients with diabetes provided by nurses in GP practices is associated with control of diabetes measured by levels of glycated haemoglobin (HbA1c).
Design and setting
A retrospective observational study using consultation records from 319 649 patients with diabetes from 471 UK general practices from 2002 to 2011.
Method
Hierarchical multilevel models to examine associations between proportion of consultations undertaken by nurses and attaining HbA1c targets over time, controlling for case-mix and practice level factors.
Results
The proportion of consultations with nurses has increased by 20% since 2002 but patients with diabetes made fewer consultations per year in 2011 compared with 2002 (11.6 versus 16.0). Glycaemic control has improved and was more uniformly achieved in 2011 than 2002. Practices in which nurses provide a higher proportion of consultations perform no differently to those where nurse input is lower (lowest versus highest nurse contact tertile odds ratio [OR] [confidence interval {95% CI}]: HbA1c ≤53 mmol/mol (7%) 2002, 1.04 [95% CI = 0.87 to 1.25] and 2011, 0.95 [95% CI = 0.87 to 1.03]; HbA1c ≤86 mmol/mol (10%) 2002, 0.97 [95% CI = 0.73 to 1.29] and 2011, 0.95 [95% CI = 0.86 to 1.04]).
Conclusion
Practices that primarily use GPs to deliver diabetes care could release significant resources with no adverse effect by switching their services towards nurse-led care.
doi:10.3399/bjgp15X686881
PMCID: PMC4582876  PMID: 26412840
diabetes mellitus; general practice; health workforce; nurses; nursing staff; primary health care
13.  Alcohol use, socioeconomic deprivation and ethnicity in older people 
BMJ Open  2015;5(8):e007525.
Objectives
This study explores the relationship between alcohol consumption, health, ethnicity and socioeconomic deprivation.
Participants
27 991 people aged 65 and over from an inner-city population, using a primary care database.
Primary and Secondary Outcome Measures
Primary outcome measures were alcohol use and misuse (>21 units per week for men and >14 for units per week women).
Results
Older people of black and minority ethnic (BME) origin from four distinct ethnic groups comprised 29% of the sample. A total of 9248 older drinkers were identified, of whom 1980 (21.4%) drank above safe limits. Compared with older drinkers, older unsafe drinkers contained a higher proportion of males, white and Irish ethnic groups and a lower proportion of Caribbean, African and Asian groups. For older drinkers, the strongest independent predictors of higher alcohol consumption were younger age, male gender and Irish ethnicity. Independent predictors of lower alcohol consumption were Asian, black Caribbean and black African ethnicity. Socioeconomic deprivation and comorbidity were not significant predictors of alcohol consumption in older drinkers. For older unsafe drinkers, the strongest predictor variables were younger age, male gender and Irish ethnicity; comorbidity was not a significant predictor. Lower socioeconomic deprivation was a significant predictor of unsafe consumption whereas African, Caribbean and Asian ethnicity were not.
Conclusions
Although under-reporting in high-alcohol consumption groups and poor health in older people who have stopped or controlled their drinking may have limited the interpretation of our results, we suggest that closer attention is paid to ‘young older’ male drinkers, as well as to older drinkers born outside the UK and those with lower levels of socioeconomic deprivation who are drinking above safe limits.
doi:10.1136/bmjopen-2014-007525
PMCID: PMC4550718  PMID: 26303334
MENTAL HEALTH; PUBLIC HEALTH; PRIMARY CARE
14.  Hypertension: a cross-sectional study of the role of multimorbidity in blood pressure control 
BMC Family Practice  2015;16:98.
Background
Hypertension is the most prevalent cardiovascular long-term condition in the UK and is associated with a high rate of multimorbidity (MM). Multimorbidity increases with age, ethnicity and social deprivation. Previous studies have yielded conflicting findings about the relationship between MM and blood pressure (BP) control. Our aim was to investigate the relationship between multimorbidity and systolic blood pressure (SBP) in patients with hypertension.
Methods
A cross-sectional analysis of anonymised primary care data was performed for a total of 299,180 adult patients of whom 31,676 (10.6 %) had a diagnosis of hypertension. We compared mean SBP in patients with hypertension alone and those with one or more co-morbidities and analysed the effect of type of comorbidity on SBP. We constructed a regression model to identify the determinants of SBP control.
Results
The strongest predictor of mean SBP was the number of comorbidities, β −0.13 (p < 0.05). Other predictors included Afro-Caribbean ethnicity, β 0.05 (p < 0.05), South Asian ethnicity, β −0.03 (p < 0.05), age, β 0.05 (p < 0.05), male gender, β 0.05 (p < 0.05) and number of hypotensive drugs β 0.06 (p < 0.05). SBP was lower by a mean of 2.03 mmHg (−2.22, −1.85) for each additional comorbidity and was lower in MM regardless of the type of morbidity.
Conclusion
Hypertensive patients with MM had lower SBP than those with hypertension alone; the greater the number of MM, the lower the SBP. We found no evidence that BP control was related to BP targets, medication category or specific co-morbidity. Further research is needed to determine whether consultation rate, “white-coat hypertension” or medication adherence influence BP control in MM.
doi:10.1186/s12875-015-0313-y
PMCID: PMC4528716  PMID: 26248616
15.  Using a patient-generated mental-health measure ‘PSYCHLOPS’ to explore problems in patients with coronary heart disease 
The British Journal of General Practice  2014;64(623):e354-e363.
Background
Patients with coronary heart disease (CHD) who are depressed have an increased risk of further cardiac events and higher mortality.
Aim
To use a patient generated instrument (PSYCHLOPS) to define categories of concerns in patients with CHD. To define the psychometric characteristics of patients in each category.
Design and setting
Cross-sectional study set in general practices in south London.
Method
Of 3325 patients on the CHD registers in 15 general practices, 655 completed six baseline psychometric and functional instruments: PSYCHLOPS, HADS-Depression, HADS-Anxiety, Clinical Interview Schedule – Revised, SF12-Mental and SF12-Physical. Content analysis was used to categorise patients based on their main problem, as elicited by PSYCHLOPS. Mean psychometric scores were adjusted for confounding by age, sex, deprivation and ethnicity and calculated for each response category.
Results
Response categories were: physical problems, both non-cardiac (23.2%) and cardiac (6.0%); social problems: relationship/family (18.2%), money (7.5%), work (3.1%); functional (9.8%); psychological (6.9%); miscellaneous (7.3%); ‘no problem’ (18.2%). The highest psychological distress scores were found in ‘physical, cardiac’ and ‘psychological’ categories. The ‘no problem’ category had significantly lower psychological distress and higher functional capacity than other categories.
Conclusions
PSYCHLOPS enabled the identification of subtypes of CHD patients, based on a classification of self-reported problems. A high proportion of CHD patients report social problems. Psychological distress was highest in those reporting cardiac or psychological symptoms. Services should be aligned to the reported needs of patients.
doi:10.3399/bjgp14X680137
PMCID: PMC4032018  PMID: 24868073
primary care; coronary heart disease; functional capacity measures; mental health outcome measures; patient-generated outcome measures
16.  Comparing the effectiveness of an enhanced MOtiVational intErviewing InTervention (MOVE IT) with usual care for reducing cardiovascular risk in high risk subjects: study protocol for a randomised controlled trial 
Trials  2015;16:112.
Background
Interventions targeting multiple risk factors for cardiovascular disease (CVD), including poor diet and physical inactivity, are more effective than interventions targeting a single risk factor. A motivational interviewing (MI) intervention can provide modest dietary improvements and physical activity increases, while adding cognitive behaviour therapy (CBT) skills may enhance the effects of MI. We designed a randomised controlled trial (RCT) to examine whether specific behaviour change techniques integrating MI and CBT result in favourable changes in weight and physical activity in those at high risk of CVD. A group and individual intervention will be compared to usual care. A group intervention offers potential benefits from social support and may be more cost effective.
Methods/Design
Individuals aged between 40 and 74 years in 11 South London Clinical Commissioning Groups who are at high risk of developing CVD (≥20%) in the next 10 years will be recruited. A sample of 1,704 participants will be randomised to receive the enhanced MI intervention, delivered by trained healthy lifestyle facilitators (HLFs), in group or individual formats, in 10 sessions (plus an introductory session) over one year, or usual care. Randomisation will be conducted by King’s College London Clinical Trials Unit and researchers collecting outcome data will be blinded to treatment allocation. At 12-month and 24-month follow-up assessments, primary outcomes will be change in weight and physical activity (average steps per day). Secondary outcomes include changes in low-density lipoprotein cholesterol and CVD risk score. Incidence of CVD events since baseline will be recorded. A process evaluation will be conducted to evaluate factors which impact on delivery, adherence and outcome. An economic evaluation will estimate relative cost-effectiveness of each type of intervention delivery.
Discussion
This RCT assesses the effectiveness of a healthy lifestyle intervention for people at high risk of CVD. Benefits of the study include the ethnic and socioeconomic diversity of the study population and that, via social support within the group setting and long-term follow-up period, the intervention offers the potential to support maintenance of a healthy lifestyle.
Trial registration
This trial is registered with the ISRCTN registry (identifier: ISRCTN84864870, registered 15 May 2012).
doi:10.1186/s13063-015-0593-5
PMCID: PMC4399238  PMID: 25886569
Cardiovascular disease; Physical activity; Diet; Accelerometer; Motivational interviewing; CBT; Primary care; Health trainers
17.  Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study 
Objectives To quantify the relationship between a national primary care pay-for-performance programme, the UK’s Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework.
Design Longitudinal spatial study, at the level of the “lower layer super output area” (LSOA).
Setting 32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012.
Participants 8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care.
Intervention National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators.
Main outcome measures All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality.
Results All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality.
Conclusions Higher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.
doi:10.1136/bmj.h904
PMCID: PMC4353289  PMID: 25733592
18.  Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study 
The BMJ  2015;350:h904.
Objectives To quantify the relationship between a national primary care pay-for-performance programme, the UK’s Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework.
Design Longitudinal spatial study, at the level of the “lower layer super output area” (LSOA).
Setting 32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012.
Participants 8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care.
Intervention National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators.
Main outcome measures All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality.
Results All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality.
Conclusions Higher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.
doi:10.1136/bmj.h904
PMCID: PMC4353289  PMID: 25733592
19.  Patient experience and the role of postgraduate GP training: a cross-sectional analysis of national Patient Survey data in England 
The British Journal of General Practice  2014;64(620):e168-e177.
Background
Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care.
Aim
The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care.
Design and setting
Retrospective cross-sectional study in general practices in England.
Method
Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections. Outcome measures: multilevel regression models adjusted for clustering.
Results
GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the ‘doctor care’ (n = 6) and ‘overall satisfaction’ (n = 2) domains but not to any of the ‘nurse care’ or ‘out-of-hours’ domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients.
Conclusion
Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as ‘listening’ or ‘care and concern’.
doi:10.3399/bjgp14X677545
PMCID: PMC3933833  PMID: 24567656
medical education; primary health care; quality indicators
20.  Process evaluation of a point-of-care cluster randomised trial using a computer-delivered intervention to reduce antibiotic prescribing in primary care 
Background
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.
Methods
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).
Results
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.
Conclusions
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.
Trial registration
ISRCTN47558792 (registered on 17 March 2010).
doi:10.1186/s12913-014-0594-1
PMCID: PMC4260184  PMID: 25700144
Cluster trial; Pragmatic trial; Point of care; Antibiotic utilisation; Primary care; Implementation science
21.  Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices 
BMJ Open  2014;4(10):e006245.
Objectives
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.
Setting
Data are reported for 568 UK general practices contributing to the Clinical Practice Research Datalink.
Participants
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.
Results
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’.
Conclusions
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.
doi:10.1136/bmjopen-2014-006245
PMCID: PMC4212213  PMID: 25348424
PUBLIC HEALTH
22.  Variations in statin prescribing for primary cardiovascular disease prevention: cross-sectional analysis 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1472-6963-14-414
PMCID: PMC4263070  PMID: 25240604
Hydroxymethylglutaryl-CoA reductase inhibitors; Primary health care; Cardiovascular diseases
23.  Patterns of physical co-/multi-morbidity among patients with serious mental illness: a London borough-based cross-sectional study 
BMC Family Practice  2014;15:117.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1471-2296-15-117
PMCID: PMC4062514  PMID: 24919453
Serious mental illness; Mental health; Physical health; Comorbidity; Multimorbidity
24.  Capturing general practice quality: a new paradigm? 
doi:10.3399/bjgp13X668041
PMCID: PMC3662424  PMID: 23735379
25.  The Public Health Impact score: a new measure of public health effectiveness for general practices in England 
The British Journal of General Practice  2013;63(609):e291-e299.
Background
Health policy in the UK is increasingly focused on the measurement of outcomes rather than structures and processes of health care.
Aim
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.
Method
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.
Results
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).
Conclusion
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.
doi:10.3399/bjgp13X665260
PMCID: PMC3609477  PMID: 23540486
health outcomes; population mortality reduction; primary health care

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