Duncan Edwards

Medication Taking in Coronary Artery Disease: A Systematic Review and Qualitative Synthesis

PURPOSE Despite the compelling evidence supporting cardiovascular medications in the secondary prevention of coronary artery disease, many patients discontinue treatment. In this synthesis, we sought to understand from a patient perspective the factors that promote medication persistence. METHODS We systematically searched 7 databases (MEDLINE, Embase, PsycINFO, SCOPUS, CINAHL, ASSIA, and SSCI) for published qualitative research about the medication-taking experiences of patients with coronary artery disease and their partners. Articles were assessed for quality using a modified CASP (Critical Appraisal Skills Programme) checklist. Synthesis was undertaken using well-established meta-ethnographic approaches. RESULTS We included 17 articles in the final synthesis from the United Kingdom (6), Europe (5), United States (4), China (1), and Australia (1), with a total sample size of 391 patients. Analyses suggested that some patients hold fatalistic beliefs about their disease, whereas others believe they have been cured by interventions; both can lead to failure to take medication. Patients who adapt to being a “heart patient” are positive about medication taking. Some individuals dislike taking tablets generally and are wary of long-term effects. Relationships with prescribing clinicians are of critical importance for patients, with inaccessibility and insensitive terminology negatively affecting patients’ perceptions about treatments. CONCLUSIONS Strategies to promote higher persistence of secondary prevention medications in patients with coronary artery disease need to recognize the key role of the prescribing clinician. Providing medication-specific information at the time of initiating therapy, improving the transition between secondary and primary care, and explaining the risk of disease recurrence may all help to modify patient attitudes toward drugs to prevent further cardiovascular disease.

Varying uses of the ABCD2 scoring system in primary and secondary care: A qualitative study

Objectives To explore the usage of the ABCD2 risk stratification score by general practitioners (GPs) and hospital staff during the referral of patients with suspected transient ischaemic attack (TIA) or minor stroke. Design Qualitative study using semistructured interviews. Setting Nine general practices and two hospital sites in England (Birmingham and Cambridge). Participants Nine GPs and nine hospital staff (two consultants, four nurses, two ultrasonographers and one administrator). Results In both sites, clinicians used a referral proforma based around the ABCD2 scoring system for a range of purposes including self-education, to assist emphasising urgency to the patient, as a referral pathway facilitator and as a diagnostic tool. Negative views of its role included potential medicolegal threats, that it was a barrier to appropriate care, and led to misdiagnoses. Despite having differing uses by different clinicians, the ABCD2 proforma was the central means of interprofessional communication in TIA referrals across both sites. Conclusions Understanding how prediction rules are used in practice is key to determining their impact on processes of care and clinical outcomes. In practice, GPs and their colleagues use the ABCD2 score in subtly different ways and it functions as a ‘boundary object’ by both accommodating these multiple purposes, yet still successfully aiding communication between them.

Association of comorbidity and health service usage among patients with dementia in the UK: a population-based study

Background The majority of people with dementia have other long-term diseases, the presence of which may affect the progression and management of dementia. This study aimed to identify subgroups with higher healthcare needs, by analysing how primary care consultations, number of prescriptions and hospital admissions by people with dementia varies with having additional long-term diseases (comorbidity). Methods A retrospective cohort study based on health data from the Clinical Practice Research Datalink (CPRD) was conducted. Incident cases of dementia diagnosed in the year starting 1/3/2008 were selected and followed for up to 5 years. The number of comorbidities was obtained from a set of 34 chronic health conditions. Service usage (primary care consultations, hospitalisations and prescriptions) and time-to-death were determined during follow-up. Multilevel negative binomial regression and Cox regression, adjusted for age and gender, were used to model differences in service usage and death between differing numbers of comorbidities. Results Data from 4999 people (14 866 person-years of follow-up) were analysed. Overall, 91.7% of people had 1 or more additional comorbidities. Compared with those with 2 or 3 comorbidities, people with ≥6 comorbidities had higher rates of primary care consultations (rate ratio (RR) 1.31, 95% CI 1.25 to 1.36), prescriptions (RR 1.68, 95% CI 1.57 to 1.81), and hospitalisation (RR 1.62, 95% CI 1.44 to 1.83), and higher risk of death (HR 1.56, 95% CI 1.37 to 1.78). Discussion In the UK, people with dementia with higher numbers of comorbidities die earlier and have considerably higher health service usage in terms of primary care consultations, hospital admissions and prescribing. This study provides strong evidence that comorbidity is a key factor that should be considered when allocating resources and planning care for people with dementia.

Stroke Prevention in Atrial Fibrillation Putting the Guidelines into Practice

Atrial fibrillation confers a 5-fold increase in risk of stroke. A number of drugs aimed at reducing this risk have been tested in randomized controlled trials. These include antiplatelet agents (singly and in combination); anticoagulants, including vitamin K antagonists and direct thrombin inhibitors; and anticoagulants with antiplatelet agents. Guidelines recommend that the choice of therapy should be determined by an assessment of underlying risk of stroke, with antiplatelet agents being indicated for people at low risk of stroke and anticoagulants for those at higher risk. The treatment decision is complicated by considerations of haemorrhage risk, with factors that increase risk of stroke also associated with increased risk of haemorrhage. Evidence from recent studies confirms that patients at high risk of stroke should be treated with anticoagulants, including elderly patients, provided that good international normalized ratio (INR) control can be maintained. Newer agents may enable a higher proportion of patients at high risk of stroke to be treated with anticoagulants than is currently the case. Decision making about people at moderate risk of stroke is less clear cut, and a choice of either an antiplatelet agent or an anticoagulant can be justified. For people at low risk of stroke, anticoagulation is not indicated.

RApid Primary care Initiation of Drug treatment for Transient Ischaemic Attack (RAPID−TIA): study protocol for a pilot randomised controlled trial

BackgroundPeople who have a transient ischaemic attack (TIA) or minor stroke are at high risk of a recurrent stroke, particularly in the first week after the event. Early initiation of secondary prevention drugs is associated with an 80% reduction in risk of stroke recurrence. This raises the question as to whether these drugs should be given before being seen by a specialist – that is, in primary care or in the emergency department. The aims of the RAPID-TIA pilot trial are to determine the feasibility of a randomised controlled trial, to analyse cost effectiveness and to ask: Should general practitioners and emergency doctors (primary care physicians) initiate secondary preventative measures in addition to aspirin in people they see with suspected TIA or minor stroke at the time of referral to a specialist?Methods/DesignThis is a pilot randomised controlled trial with a sub-study of accuracy of primary care physician diagnosis of TIA. In the pilot trial, we aim to recruit 100 patients from 30 general practices (including out-of-hours general practice centres) and 1 emergency department whom the primary care physician diagnoses with TIA or minor stroke and randomly assign them to usual care (that is, initiation of aspirin and referral to a TIA clinic) or usual care plus additional early initiation of secondary prevention drugs (a blood-pressure lowering protocol, simvastatin 40 mg and dipyridamole 200 mg m/r bd). The primary outcome of the main study will be the number of strokes at 90 days. The diagnostic accuracy sub-study will include these 100 patients and an additional 70 patients in whom the primary care physician thinks the diagnosis of TIA is possible, rather than probable. For the pilot trial, we will report recruitment rate, follow-up rate, a preliminary estimate of the primary event rate and occurrence of any adverse events. For the diagnostic study, we will calculate sensitivity and specificity of primary care physician diagnosis using the final TIA clinic diagnosis as the reference standard.DiscussionThis pilot study will be used to estimate key parameters that are needed to design the main study and to estimate the accuracy of primary care diagnosis of TIA. The planned follow-on trial will have important implications for the initial management of people with suspected TIA.Trial registrationISRCTN62019087

The epidemiology of multimorbidity in primary care: a retrospective cohort study

Background Multimorbidity places a substantial burden on patients and the healthcare system, but few contemporary epidemiological data are available. Aim To describe the epidemiology of multimorbidity in adults in England, and quantify associations between multimorbidity and health service utilisation. Design and setting Retrospective cohort study, undertaken in England. Method The study used a random sample of 403 985 adult patients (aged ≥18 years), who were registered with a general practice on 1 January 2012 and included in the Clinical Practice Research Datalink. Multimorbidity was defined as having two or more of 36 long-term conditions recorded in patients’ medical records, and associations between multimorbidity and health service utilisation (GP consultations, prescriptions, and hospitalisations) over 4 years were quantified. Results In total, 27.2% of the patients involved in the study had multimorbidity. The most prevalent conditions were hypertension (18.2%), depression or anxiety (10.3%), and chronic pain (10.1%). The prevalence of multimorbidity was higher in females than males (30.0% versus 24.4% respectively) and among those with lower socioeconomic status (30.0% in the quintile with the greatest levels of deprivation versus 25.8% in that with the lowest). Physical–mental comorbidity constituted a much greater proportion of overall morbidity in both younger patients (18–44 years) and those patients with a lower socioeconomic status. Multimorbidity was strongly associated with health service utilisation. Patients with multimorbidity accounted for 52.9% of GP consultations, 78.7% of prescriptions, and 56.1% of hospital admissions. Conclusion Multimorbidity is common, socially patterned, and associated with increased health service utilisation. These findings support the need to improve the quality and efficiency of health services providing care to patients with multimorbidity at both practice and national level.

Should we screen for atrial fibrillation

No country has yet established a national screening programme (NSP) for atrial fibrillation (AF), including the UK. However, there is an increasing body of evidence suggesting screening may be beneficial, prompting recommendations from prominent expert bodies to screen for AF.1 Despite these data, the UK National Screening Committee (NSC) has not recommended systematic population screening. The review in 2014 concluded ‘… it is not clear that those identified as at risk through screening would benefit from early diagnosis’.2 The NSC also identified a need to improve clinical management and standardise the treatment services currently available to those with diagnosed AF. The British Cardiovascular Society issued a subsequent statement in response to the decision questioning the interpretation of the evidence and suggesting that it would be in the public interest to reconsider their decision.3 A further review by the UK NSC is scheduled for 2017/2018. AF is the most common cardiac arrhythmia, present in around 1% of the population and 5% of those aged ≥65 years.4 Approximately 1 million people are …

Spatial distribution of clinical computer systems in primary care in England in 2016 and implications for primary care electronic medical record databases: a cross-sectional population study.

Objectives UK primary care databases (PCDs) are used by researchers worldwide to inform clinical practice. These databases have been primarily tied to single clinical computer systems, but little is known about the adoption of these systems by primary care practices or their geographical representativeness. We explore the spatial distribution of clinical computing systems and discuss the implications for the longevity and regional representativeness of these resources. Design Cross-sectional study. Setting English primary care clinical computer systems. Participants 7526 general practices in August 2016. Methods Spatial mapping of family practices in England in 2016 by clinical computer system at two geographical levels, the lower Clinical Commissioning Group (CCG, 209 units) and the higher National Health Service regions (14 units). Data for practices included numbers of doctors, nurses and patients, and area deprivation. Results Of 7526 practices, Egton Medical Information Systems (EMIS) was used in 4199 (56%), SystmOne in 2552 (34%) and Vision in 636 (9%). Great regional variability was observed for all systems, with EMIS having a stronger presence in the West of England, London and the South; SystmOne in the East and some regions in the South; and Vision in London, the South, Greater Manchester and Birmingham. Conclusions PCDs based on single clinical computer systems are geographically clustered in England. For example, Clinical Practice Research Datalink and The Health Improvement Network, the most popular primary care databases in terms of research outputs, are based on the Vision clinical computer system, used by <10% of practices and heavily concentrated in three major conurbations and the South. Researchers need to be aware of the analytical challenges posed by clustering, and barriers to accessing alternative PCDs need to be removed.

The Tip of the Iceberg: Finding Patients with Heart Failure with Preserved Ejection Fraction in Primary Care

This paper presents independent research funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR).

The tip of the iceberg: finding patients with heart failure with preserved ejection fraction in primary care. An observational study

Background Heart failure with preserved ejection fraction (HFpEF) is under-identified in primary care. Aim The aim of this study was to determine what information is available in patients’ primary care practice records that would identify patients with HFpEF. Design & setting Record review in two practices in east of England. Method Practices completed a case report form on each patient on the heart failure register and sent anonymised echocardiography reports on patients with an ejection fraction (EF) >50%. Reports were reviewed and data analysed using SPSS (version 25). Results One hundred and forty-eight patients on the heart failure registers with mean age 77 +12 years were reviewed. Fifty-three patients (36%) had possible HFpEF based on available information. These patients were older and multimorbid, with a high prevalence of overweight and obesity. Confirmation of diagnosis was not possible as recommended HFpEF diagnostic information (natriuretic peptides, echocardiogram parameters of structural heart disease and diastolic function) was widely inconsistent or absent in these patients. Conclusion Without correct identification of HFpEF, patient management may be suboptimal or inappropriate, and lack the needed focus on comorbidities and lifestyle that can improve patient outcomes. This study describes in detail the characteristics of many of the patients who probably have HFpEF in a real-world sample, and the improvements and diagnostic information required to better identify them. Identifying more than the tip of the iceberg that is the HFpEF population will allow the improvement of the quality of their management, the prevention of ineffective health care, and the recruitment of patients into research.