Christopher Millett

Social Epidemiology of Hypertension in Middle-Income Countries Determinants of Prevalence, Diagnosis, Treatment, and Control in the WHO SAGE Study

Large-scale hypertension screening campaigns have been recommended for middle-income countries. We sought to identify sociodemographic predictors of hypertension prevalence, diagnosis, treatment, and control among middle-income countries. We analyzed data from 47 443 adults in all 6 middle-income countries (China, Ghana, India, Mexico, Russia, and South Africa) sampled in nationally representative household assessments from 2007 to 2010 as part of the World Health Organization Study on Global Aging and Adult Health. We estimated regression models accounting for age, sex, urban/rural location, nutrition, and obesity, as well as hypothesized covariates of healthcare access, such as income and insurance. Hypertension prevalence varied from 23% (India) to 52% (Russia), with between 30% (Russia) and 83% (Ghana) of hypertensives undiagnosed before the survey and between 35% (Russia) and 87% (Ghana) untreated. Although the risk of hypertension significantly increased with age (odds ratio, 4.6; 95% confidence interval, 3.0–7.1; among aged, 60–79 versus <40 years), the risk of being undiagnosed or untreated fell significantly with age. Obesity was a significant correlate to hypertension (odds ratio, 3.7; 95% confidence interval, 2.1–6.8 for obese versus normal weight), and was prevalent even among the lowest income quintile (13% obesity). Insurance status and income also emerged as significant correlates to diagnosis and treatment probability, respectively. More than 90% of hypertension cases were uncontrolled, with men having 3 times the odds as women of being uncontrolled. Overall, the social epidemiology of hypertension in middle-income countries seems to be correlated to increasing obesity prevalence, and hypertension control rates are particularly low for adult men across distinct cultures.Large-scale hypertension screening campaigns have been recommended for middle-income countries. We sought to identify sociodemographic predictors of hypertension prevalence, diagnosis, treatment, and control among middle-income countries. We analyzed data from 47 443 adults in all 6 middle-income countries (China, Ghana, India, Mexico, Russia, and South Africa) sampled in nationally representative household assessments from 2007 to 2010 as part of the World Health Organization Study on Global Aging and Adult Health. We estimated regression models accounting for age, sex, urban/rural location, nutrition, and obesity, as well as hypothesized covariates of healthcare access, such as income and insurance. Hypertension prevalence varied from 23% (India) to 52% (Russia), with between 30% (Russia) and 83% (Ghana) of hypertensives undiagnosed before the survey and between 35% (Russia) and 87% (Ghana) untreated. Although the risk of hypertension significantly increased with age (odds ratio, 4.6; 95% confidence interval, 3.0–7.1; among aged, 60–79 versus <40 years), the risk of being undiagnosed or untreated fell significantly with age. Obesity was a significant correlate to hypertension (odds ratio, 3.7; 95% confidence interval, 2.1–6.8 for obese versus normal weight), and was prevalent even among the lowest income quintile (13% obesity). Insurance status and income also emerged as significant correlates to diagnosis and treatment probability, respectively. More than 90% of hypertension cases were uncontrolled, with men having 3 times the odds as women of being uncontrolled. Overall, the social epidemiology of hypertension in middle-income countries seems to be correlated to increasing obesity prevalence, and hypertension control rates are particularly low for adult men across distinct cultures. # Novelty and Significance {#article-title-31}

Harnessing the cloud of patient experience: using social media to detect poor quality healthcare

Recent years have seen increasing interest in patient-centred care and calls to focus on improving the patient experience. At the same time, a growing number of patients are using the internet to describe their experiences of healthcare. We believe the increasing availability of patients’ accounts of their care on blogs, social networks, Twitter and hospital review sites presents an intriguing opportunity to advance the patient-centred care agenda and provide novel quality of care data. We describe this concept as a ‘cloud of patient experience’. In this commentary, we outline the ways in which the collection and aggregation of patients’ descriptions of their experiences on the internet could be used to detect poor clinical care. Over time, such an approach could also identify excellence and allow it to be built on. We suggest using the techniques of natural language processing and sentiment analysis to transform unstructured descriptions of patient experience on the internet into usable measures of healthcare performance. We consider the various sources of information that could be used, the limitations of the approach and discuss whether these new techniques could detect poor performance before conventional measures of healthcare quality.

Ethnic disparities in diabetes management and pay-for-performance in the UK: the Wandsworth Prospective Diabetes Study.

Background Pay-for-performance rewards health-care providers by paying them more if they succeed in meeting performance targets. A new contract for general practitioners in the United Kingdom represents the most radical shift towards pay-for-performance seen in any health-care system. The contract provides an important opportunity to address disparities in chronic disease management between ethnic and socioeconomic groups. We examined disparities in management of people with diabetes and intermediate clinical outcomes within a multiethnic population in primary care before and after the introduction of the new contract in April 2004. Methods and Findings We conducted a population-based longitudinal survey, using electronic general practice records, in an ethnically diverse part of southwest London. Outcome measures were prescribing levels and achievement of national treatment targets (HbA1c ≤ 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol ≤ 5 mmol/l or 193 mg/dl). The proportion of patients reaching treatment targets for HbA1c, BP, and total cholesterol increased significantly after the implementation of the new contract. The extents of these increases were broadly uniform across ethnic groups, with the exception of the black Caribbean patient group, which had a significantly lower improvement in HbA1c (adjusted odds ratio [AOR] 0.75, 95% confidence interval [CI] 0.57–0.97) and BP control (AOR 0.65, 95% CI 0.53–0.81) relative to the white British patient group. Variations in prescribing and achievement of treatment targets between ethnic groups present in 2003 were not attenuated in 2005. Conclusions Pay-for-performance incentives have not addressed disparities in the management and control of diabetes between ethnic groups. Quality improvement initiatives must place greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes.

Changes in the Incidence of Lower Extremity Amputations in Individuals With and Without Diabetes in England Between 2004 and 2008

OBJECTIVE To describe recent trends in the incidence of nontraumatic amputations among individuals with and without diabetes and estimate the relative risk of amputations among individuals with diabetes in England. RESEARCH DESIGN AND METHODS We identified all patients aged >16 years who underwent any nontraumatic amputation in England between 2004 and 2008 using national hospital activity data from all National Health Service hospitals. Age- and sex-specific incidence rates were calculated using the total diabetes population in England every year. To test for time trend, we fitted Poisson regression models. RESULTS The absolute number of diabetes-related amputations increased by 14.7%, and the incidence decreased by 9.1%, from 27.5 to 25.0 per 10,000 people with diabetes, during the study period (P > 0.2 for both). The incidence of minor and major amputations did not significantly change (15.7–14.9 and 11.8–10.2 per 10,000 people with diabetes; P = 0.66 and P = 0.29, respectively). Poisson regression analysis showed no statistically significant change in diabetes-related amputation incidence over time (0.98 decrease per year [95% CI 0.93–1.02]; P = 0.12). Nondiabetes-related amputation incidence decreased from 13.6 to 11.9 per 100,000 people without diabetes (0.97 decrease by year [0.93–1.00]; P = 0.059). The relative risk of an individual with diabetes undergoing a lower extremity amputation was 20.3 in 2004 and 21.2 in 2008, compared with that of individuals without diabetes. CONCLUSIONS This national study suggests that the overall population burden of amputations increased in people with diabetes at a time when the number and incidence of amputations decreased in the aging nondiabetic population.

Quality of diabetes care in the UK: comparison of published quality-of-care reports with results of the Quality and Outcomes Framework for Diabetes.

Aims  To conduct a systematic review of published observational studies of quality of diabetes care in primary care in the UK and to compare the results with the quality of care data from the Quality and Outcomes Framework (QOF) of the new General Practice Contract in the UK.

Uptake of the NHS Health Checks programme in a deprived, culturally diverse setting: cross-sectional study

BACKGROUND The UK is embarking on a national cardiovascular risk assessment programme called NHS Health Checks; in order to be effective, high and equitable uptake is paramount. METHODS A cross-sectional study, using data extracted from electronic medical records of persons aged 35-74 years estimated to be at a high risk of developing cardiovascular disease, to examine the uptake of the Health Checks using logistic regression and statin prescribing. RESULTS A total of 44.8% of high risk patients invited for a Health Check attended. Uptake was lower among younger men but higher among patients from south Asian (AOR = 1.71 [1.29-2.27] compared with white) or mixed ethnic backgrounds (AOR = 2.42 [1.50-3.89]), and patients registered with smaller practices (AOR = 2.53 [1.09-5.84] <3000 patients compared with 3000-5999). The percentage of patients confirmed to be at high risk of CVD prescribed a statin increased from 24.7 to 44.8%. CONCLUSIONS Uptake of cardiovascular risk assessment and prescribing of statins in high risk patients was considerably lower than projected in the first year of NHS Health Checks programme. Targeting efforts to increase uptake and adherence to interventions in high risk populations and reinvesting resources into population wide strategies to reduce obesity, smoking and salt intake may prove more cost-effective in reducing the burden of cardiovascular disease in the UK.

Impact of pay for performance on inequalities in health care: systematic review

Objectives: To assess the impact of pay for performance programmes on inequalities in the quality of health care in relation to age, sex, ethnicity and socioeconomic status. Methods: Systematic search and appraisal of experimental or observational studies that assessed quantitatively the impact of a monetary incentive on health care inequalities. We searched published articles in English identified in the MEDLINE, EMBASE, PsycINFO and Cochrane databases. Results: Twenty-two studies were identified, 20 of which were conducted in the United Kingdom and examined the impact of the Quality and Outcomes Framework. Sixteen studies used practice level data rather than patient level data. Socioeconomic status was the most frequently examined inequality; age, sex and ethnic inequalities were less frequently assessed. There was some weak evidence that the use of financial incentives reduced inequalities in chronic disease management between socioeconomic groups. Inequalities in chronic disease management between age, sex and ethnic groups persisted after the use of such incentives. Conclusions: Inequalities in chronic disease management have largely persisted after the introduction of the Quality and Outcome Framework. Pay for performance programmes should be designed to reduce inequalities as well as improve the overall quality of care.

Impact of a pay-for-performance incentive on support for smoking cessation and on smoking prevalence among people with diabetes

Background: Many people with diabetes continue to smoke despite being at high risk of cardiovascular disease. We examined the impact of a pay-for-performance incentive in the United Kingdom introduced in 2004 as part of the new general practitioner contract to improve support for smoking cessation and to reduce the prevalence of smoking among people with chronic diseases such as diabetes. Methods: We performed a population-based longitudinal study of the recorded delivery of cessation advice and the prevalence of smoking using electronic records of patients with diabetes obtained from participating general practices. The survey was carried out in an ethnically diverse part of southwest London before (June–October 2003) and after (November 2005–January 2006) the introduction of a pay-for-performance incentive. Results: Significantly more patients with diabetes had their smoking status ever recorded in 2005 than in 2003 (98.8% v. 90.0%, p <0.001). The proportion of patients with documented smoking cessation advice also increased significantly over this period, from 48.0% to 83.5% (p < 0.001). The prevalence of smoking decreased significantly from 20.0% to 16.2% (p < 0.001). The reduction over the study period was lower among women (adjusted odds ratio 0.71, 95% confidence interval 0.53–0.95) but was not significantly different in the most and least affluent groups. In 2005, smoking rates continued to differ significantly with age (10.6%–25.1%), sex (women, 11.5%; men, 20.6%) and ethnic background (4.9%–24.9%). Interpretation: The introduction of a pay-for-performance incentive in the United Kingdom increased the provision of support for smoking cessation and was associated with a reduction in smoking prevalence among patients with diabetes in primary health care settings. Health care planners in other countries may wish to consider introducing similar incentive schemes for primary care physicians.

Hospital Admissions for Childhood Asthma After Smoke-Free Legislation in England

OBJECTIVE: To assess whether the implementation of English smoke-free legislation in July 2007 was associated with a reduction in hospital admissions for childhood asthma. METHODS: Interrupted time series study using Hospital Episodes Statistics data from April 2002 to November 2010. Sample consisted of all children (aged ≤14 years) having an emergency hospital admission with a principle diagnosis of asthma. RESULTS: Before the implementation of the legislation, the admission rate for childhood asthma was increasing by 2.2% per year (adjusted rate ratio 1.02; 95% confidence interval [CI]: 1.02–1.03). After implementation of the legislation, there was a significant immediate change in the admission rate of −8.9% (adjusted rate ratio 0.91; 95% CI: 0.89–0.93) and change in time trend of −3.4% per year (adjusted rate ratio 0.97; 95% CI: 0.96–0.98). This change was equivalent to 6802 fewer hospital admissions in the first 3 years after implementation. There were similar reductions in asthma admission rates among children from different age, gender, and socioeconomic status groups and among those residing in urban and rural locations. CONCLUSIONS: These findings confirm those from a small number of previous studies suggesting that the well-documented population health benefits of comprehensive smoke-free legislation appear to extend to reducing hospital admissions for childhood asthma.

A method of identifying and correcting miscoding, misclassification and misdiagnosis in diabetes: a pilot and validation study of routinely collected data

Diabet. Med. 27, 203–209 (2010)