Elizabeth Cecil

Access to Primary Care and Visits to Emergency Departments in England: A Cross-Sectional, Population-Based Study

Background The number of visits to hospital emergency departments (EDs) in England has increased by 20% since 2007-08, placing unsustainable pressure on the National Health Service (NHS). Some patients attend EDs because they are unable to access primary care services. This study examined the association between access to primary care and ED visits in England. Methods A cross-sectional, population-based analysis of patients registered with 7,856 general practices in England was conducted, for the time period April 2010 to March 2011. The outcome measure was the number of self-referred discharged ED visits by the registered population of a general practice. The predictor variables were measures of patient-reported access to general practice services; these were entered into a negative binomial regression model with variables to control for the characteristics of patient populations, supply of general practitioners and travel times to health services. Main Result and Conclusion General practices providing more timely access to primary care had fewer self-referred discharged ED visits per registered patient (for the most accessible quintile of practices, RR = 0.898; P<0.001). Policy makers should consider improving timely access to primary care when developing plans to reduce ED utilisation.

Does higher quality primary health care reduce stroke admissions? a national cross-sectional study

BACKGROUND Hospital admission rates for stroke are strongly associated with population factors. The supply and quality of primary care services may also affect admission rates, but there is little previous research. AIM To determine if the hospital admission rate for stroke is reduced by effective primary and secondary prevention in primary care. DESIGN AND SETTING National cross-sectional study in an English population (52,763,586 patients registered with 7969 general practices in 152 primary care trusts). METHOD A combination of data on hospital admissions for 2006-2009, primary healthcare staffing, practice clinical quality and access indicators, census sources, and prevalence estimates was used. The main outcome measure was indirectly standardised hospital admission rates for stroke, for each practice population. RESULTS Mean (3 years) annual stroke admission rates per 100,000 population varied from zero to 476.5 at practice level. In a practice-level multivariable Poisson regression, observed stroke prevalence, deprivation, smoking prevalence, and GPs/100,000 population were all risk factors for hospital admission. Protective healthcare factors included the percentage of stroke or transient ischaemic attack patients whose last measured total cholesterol was ≤5 mmol/l (P<0.001), and ability to book an appointment with a GP (P<0.003). All effect sizes were relatively small. CONCLUSION Associations of stroke admission rates with deprivation and smoking highlight the need for smoking-cessation services. Of the stroke and hypertension clinical quality indicators examined, only reaching a total cholesterol target was associated with reduced admission rates. Patient experience of access to primary care may also be clinically important. In countries with well-developed primary healthcare systems, the potential to reduce hospital admissions by further improving the clinical quality of primary healthcare may be limited.

Reducing heart failure admission rates in England 2004-2011 are not related to changes in primary care quality: National observational study

Heart failure (HF) is an important clinical problem. Expert consensus has defined HF as a primary care‐sensitive condition for which the risk of unplanned admissions may be reduced by high quality primary care, but there is little supporting evidence. We analysed time trends in HF admission rates in England and risk and protective factors for admission.

Primary Care Access, Emergency Department Visits, and Unplanned Short Hospitalizations in the UK

BACKGROUND AND OBJECTIVE: Demand for unplanned hospital services is rising, and children are frequent users, especially where access to primary care is poor. In England, universal health care coverage entitles parents to see a general practitioner (GP) for first-contact care. However, access to GP appointments is variable, and few patients can see their own regular GP out of hours (OOH). The goal of this study explored the association between access to GPs , emergency department (ED) visits and short hospitalizations (<2 days) in children in England. METHODS: ED visit and short hospitalization rates were investigated in 9.5 million children aged <15 years registered with English family practices between April 2011 and March 2012 by using administrative hospital data. Six access categories ranked all practices according to patients’ reported ability to schedule GP appointments; from national GP Patient Survey data. GP consulting hours were 8:00 am to 6:30 pm on weekdays. RESULTS: There were 3 074 616 ED visits (56% OOH) and 470 752 short hospitalizations over the 12 months studied. Children registered with practices in the highest access group compared with the lowest were 9% less likely to visit an ED (adjusted rate ratio: 0.91 [95% confidence interval: 0.89–93]), particularly OOH compared with consulting hours (10% vs 7%). Children in the highest access groups were equally likely to be admitted for a short stay. CONCLUSIONS: Increasing GP accessibility might alleviate the burden of ED visits from children, particularly during peak times OOH. Short hospitalizations may be more sensitive to other aspects of health systems.

The impact of timing and duration of thiopurine treatment on colectomy in ulcerative colitis: a national population-based study of incident cases between 1989--2009

The role of thiopurines in altering the risk of colectomy in ulcerative colitis (UC) remains unclear.

Impact of UK Primary Care Policy Reforms on Short-Stay Unplanned Hospital Admissions for Children With Primary Care–Sensitive Conditions

PURPOSE We aimed to assess the impact of UK primary care policy reforms implemented in April 2004 on potentially avoidable unplanned short-stay hospital admissions for children with primary care–sensitive conditions. METHODS We conducted an interrupted time series analysis of hospital admissions for all children aged younger than 15 years in England between April 2000 and March 2012 using data from National Health Service public hospitals in England. The main outcomes were annual short-stay (<2-day) unplanned hospital admission rates for primary care–sensitive infectious and chronic conditions. RESULTS There were 7.8 million unplanned admissions over the study period. More than one-half (4,144,729 of 7,831,633) were short-stay admissions for potentially avoidable infectious and chronic conditions. The primary care policy reforms of April 2004 were associated with an 8% increase in short-stay admission rates for chronic conditions, equivalent to 8,500 additional admissions, above the 3% annual increasing trend. Policy reforms were not associated with an increase in short-stay admission rates for infectious illness, which were increasing by 5% annually before April 2004. The proportion of primary care–referred admissions was falling before the reforms, and there were further sharp reductions in 2004. CONCLUSIONS The introduction of primary care policy reforms coincided with an increase in short-stay admission rates for children with primary care–sensitive chronic conditions, and with more children being admitted through emergency departments. Short-stay admission rates for primary care–sensitive infectious illness increased more steadily and could be related to lowered thresholds for hospital admission.

Impact of early thiopurines on surgery in 2770 children and young people diagnosed with inflammatory bowel disease: A national population-based study

The role of early thiopurine treatment in inflammatory bowel disease (IBD) is unproven.

Does higher quality of primary healthcare reduce hospital admissions for diabetes complications? A national observational study

To determine if hospital admission rates for diabetes complications (acute complications, chronic complications, no complications and hypoglycaemia) were associated with primary care diabetes management.

Impact of Timing and Duration of Thiopurine Treatment on First Perianal Surgery in Crohn's Disease: UK Population-based Study (1995–2009)

Background:The impact of thiopurine (TP) use on perianal surgery is uncertain. Our aim was to determine trends in perianal surgery and the impact of timing and duration of TPs on the risk of first perianal surgery. Methods:We identified a population-based cohort of incident cases of Crohns disease between 1995 and 2009. We used Kaplan–Meier analysis to determine trends in TP usage and first perianal surgery by era of diagnosis: era 1 (1995–2002) and era 2 (2003–2009). We quantified the impact of duration and timing of TPs on the risk of perianal surgery using a Cox regression model. Results:We identified a cohort of 5235 incident cases of Crohns disease. The 5-year cumulative probability of first perianal surgery decreased from 2.7% to 1.7% between era 1 and era 2, respectively (P = 0.03). TP use for greater than 18 months was associated with a 40% risk reduction for first perianal surgery (hazard ratio: 0.60, 95% confidence interval: 0.39–0.95) and 49% if TPs were used for 2 years or more (hazard ratio: 0.51, 95% confidence interval: 0.32–0.99). There was no demonstrable additional benefit from early TP use within the first year after diagnosis (hazard ratio: 0.85, 95% confidence interval: 0.52–1.40, P = 0.53). Conclusions:Over the past 15 years, TP use has increased by 50%, whereas perianal surgery rates have decreased by 37% among UK population with Crohns disease. Sustained use for 18 months was associated with a reduced risk of perianal surgery by almost a half in the first 5 years after diagnosis.

Steroid dependency and trends in prescribing for inflammatory bowel disease - a 20-year national population-based study.

It is unclear whether adherence to prescribing standards has been achieved in inflammatory bowel disease (IBD).