Gary McLean

Deprivation and quality of primary care services: evidence for persistence of the inverse care law from the UK Quality and Outcomes Framework

Objective: To examine whether the quality of primary care measured by the 2004 contract varies with socioeconomic deprivation. Design: Retrospective analysis of publicly available data, comparing quality indicators used for payment that allow exclusion of patients (payment quality) and indicators based on the care delivered to all patients (delivered quality). Setting and participants: 1024 general practices in Scotland. Main outcome measures: Regression coefficients summarising the relationships between deprivation and payment and delivered quality. Results: Little systematic association is found between payment quality and deprivation but, for 17 of the 33 indicators examined, delivered quality falls with increasing deprivation. Absolute differences in delivered quality are small for most simpler process measures, such as recording of smoking status or blood pressure. Greater inequalities are seen for more complex process measures such as diagnostic procedures, some intermediate outcome measures such as glycaemic control in diabetes and measures of treatment such as influenza immunisation. Conclusions: The exclusions system succeeds in not penalising practices financially for the characteristics of the population they serve, but does not reward the additional work required in deprived areas and contributes to a continuation of the inverse care law. The contract data collected prevent examination of most complex process or treatment measures and this analysis is likely to underestimate the extent of continuing inequalities in care. Broader lessons cannot be drawn on the effect on inequalities of this new set of incentives until changes are made to the way contract data are collected and analysed.

Schizophrenia is associated with excess multiple physical-health comorbidities but low levels of recorded cardiovascular disease in primary care: cross-sectional study

Objective To assess the nature and extent of physical-health comorbidities in people with schizophrenia and related psychoses compared with controls. Design Cross-sectional study. Setting 314 primary care practices in Scotland. Participants 9677 people with a primary care record of schizophrenia or a related psychosis and 1 414 701 controls. Main outcome measures Primary care records of 32 common chronic physical-health conditions and combinations of one, two and three or more physical-health comorbidities adjusted for age, gender and deprivation status. Results Compared with controls, people with schizophrenia were significantly more likely to have one physical-health comorbidity (OR 1.21, 95% CI 1.16 to 1.27), two physical-health comorbidities (OR 1.37, 95% CI 1.29 to 1.44) and three or more physical-health comorbidities (OR 1.19, 95% CI 1.12 to 1.27). Rates were highest for viral hepatitis (OR 3.98, 95% CI 2.81 to 5.64), constipation (OR 3.24, 95% CI 3.00 to 4.49) and Parkinsons disease (OR 3.07, 95% CI 2.42 to 3.88) but people with schizophrenia had lower recorded rates of cardiovascular disease, including atrial fibrillation (OR 0.62, 95% CI 0.51 to 0.73), hypertension (OR 0.71, 95% CI 0.67 to 0.76), coronary heart disease (OR 0.75, 95% CI 0.61 to 0.71) and peripheral vascular disease (OR 0.83, 95% CI 0.71 to 0.97). Conclusions People with schizophrenia have a wide range of comorbid and multiple physical-health conditions but are less likely than people without schizophrenia to have a primary care record of cardiovascular disease. This suggests a systematic under-recognition and undertreatment of cardiovascular disease in people with schizophrenia, which might contribute to substantial premature mortality observed within this patient group.

Determinants of primary medical care quality measured under the new UK contract: cross sectional study

Abstract Objective To identify factors associated with the quality of primary medical care incentivised under the new UK general medical services contract. Design Cross sectional study. Setting NHS Ayrshire and Arran area, Scotland. Participants 60 general practices. Main outcome measures Quality scores reflecting the total points achieved on the 10 clinical domains and holistic care. Univariate and multivariate regression analyses were used to relate quality scores to measures of population characteristics, urban-rural location, general practitioner characteristics, clinical team size and composition, practice characteristics, and income from other sources. Results Deprivation was associated with higher scores. Quality scores increased with the size of the clinical team. Practices with higher income from other sources had lower quality scores. Practices that were accredited, had training status, or contained younger general practitioners had higher quality scores, but these effects were explained by other associated factors. 53% of the variation in quality scores was explained by a multivariate model, which included measures of deprivation, clinical team size and composition, and financial incentives. Conclusions Population characteristics showed little association with the quality of primary medical care incentivised under the UK general medical services contract. Larger clinical teams delivered higher quality clinical care, but the nurse-doctor composition of the clinical team did not influence quality. Practices that were more likely to respond to financial incentives because of previous behaviour or lower income from other sources recorded higher quality. If generalisable, the results suggest that initiatives to improve primary medical care quality should focus on the structure and resourcing of providers.

Multimorbidity in bipolar disorder and undertreatment of cardiovascular disease: a cross sectional study

BackgroundIndividuals with serious mental disorders experience poor physical health, especially increased rates of cardiometabolic morbidity and premature morbidity. Recent evidence suggests that individuals with schizophrenia have numerous comorbid physical conditions that may be under-recorded and undertreated, but to date very few studies have explored this issue for bipolar disorder.MethodsWe conducted a cross-sectional analysis of a dataset of 1,751,841 registered patients within 314 primary care practices in Scotland, UK. Bipolar disorder was identified using Read Codes recorded within electronic medical records. Data on 32 common chronic physical conditions were also assessed. Potential prescribing inequalities were evaluated by analysing prescribing data for coronary heart disease (CHD) and hypertension.ResultsCompared to controls, individuals with bipolar disorder were significantly less likely to have no recorded physical conditions (OR 0.59, 95% CI 0.54 to 0.63) and significantly more likely to have one physical condition (OR 1.27, 95% CI 1.16 to 1.39), two physical conditions (OR 1.45, 95% CI 1.30 to 1.62) and three or more physical conditions (OR 1.44, 95% CI 1.30 to 1.64). People with bipolar disorder also had higher rates of thyroid disorders, chronic kidney disease, chronic pain, chronic obstructive airways disease and diabetes but, surprisingly, lower recorded rates of hypertension and atrial fibrillation. People with bipolar disorder and comorbid CHD or hypertension were significantly more likely to be prescribed no antihypertensive or cholesterol-lowering medications compared to controls, and bipolar individuals with CHD or hypertension were significantly less likely to be on two or more antihypertensive agents.ConclusionsIndividuals with bipolar disorder are similar to individuals with schizophrenia in having a wide range of comorbid and multiple physical health conditions. They are also less likely than controls to have a primary-care record of cardiovascular conditions such as hypertension and atrial fibrillation. Those with a recorded diagnosis of CHD or hypertension were less likely to be treated with cardiovascular medications and were treated less intensively. This study highlights the high physical healthcare needs of people with bipolar disorder, and provides evidence for a systematic under-recognition and undertreatment of cardiovascular disease in this group.

The influence of socioeconomic deprivation on multimorbidity at different ages: a cross-sectional study

Background Multimorbidity occurs at a younger age in individuals in areas of high socioeconomic deprivation but little is known about the ‘typology’ of multimorbidity in different age groups and its association with socioeconomic status. Aim To characterise multimorbidity type and most common conditions in a large nationally representative primary care dataset in terms of age and deprivation. Design and setting Cross-sectional analysis of 1 272 685 adults in Scotland. Method Multimorbidity type of participants (physical-only, mental-only, mixed physical, and mental) and most common conditions were analysed according to age and deprivation. Results Multimorbidity increased with age, ranging from 8.1% in those aged 25–34 to 76.1% for those aged ≥75 years. Physical-only (56% of all multimorbidity) was the most common type of multimorbidity in those aged ≥55 years, and did not vary substantially with deprivation. Mental-only was uncommon (4% of all multimorbidity), whereas mixed physical and mental (40% of all multimorbidity) was the most common type of multimorbidity in those aged <55 years and was two- to threefold more common in the most deprived compared with the least deprived in most age groups. Ten conditions (seven physical and three mental) accounted for the top five most common conditions in people with multimorbidity in all age groups. Depression and pain featured in the top five conditions across all age groups. Deprivation was associated with a higher prevalence of depression, drugs misuse, anxiety, dyspepsia, pain, coronary heart disease, and diabetes in multimorbid patients at different ages. Conclusion Mixed physical and mental multimorbidity is common across the life-span and is exacerbated by deprivation from early adulthood onwards.

Depression and multimorbidity: a cross-sectional study of 1,751,841 patients in primary care.

BACKGROUND Depression is common in many chronic physical health disorders, but the nature and extent of physical health comorbidities in depression, particularly within large population-based samples of patients, and how these comorbidities relate to factors such as age, sex, and social deprivation, are unknown. We aimed to assess the nature and extent of multiple physical health comorbidities in primary care patients with depression within a large and representative Scottish dataset. METHOD This study was a cross-sectional secondary data analysis of 314 primary care practices in Scotland (from the Primary Care Clinical Informatics Unit at the University of Aberdeen, Scotland, March 31, 2007), including 143,943 people with depression and 1,280,435 controls. The outcomes assessed were 32 common chronic physical health conditions, adjusted for age, sex, and social deprivation. Depression was defined as a Read code for depression recorded within last year and/or 4 or more antidepressant prescriptions (excluding low-dose tricyclic antidepressants) within the last year. RESULTS Individuals in primary care with depression were more likely than individuals without depression to have every one of the 32 comorbid physical conditions we assessed, even after adjusting for age, sex, and deprivation. The depression group was also significantly more likely to have multiple levels of comorbidity, including 2 physical health conditions (OR = 1.55; 95% CI, 1.53-1.58), 3 physical health conditions (OR = 1.84; 95% CI, 1.81-1.87), 4 physical health conditions (OR = 2.06; 95% CI, 2.01-2.11; P < .001), and 5 or more physical health conditions (OR = 2.65; 95% CI, 2.59-2.71; P < .001). CONCLUSION Depression in primary care is associated with a very wide range of physical health comorbidities and considerable medical burden. The nature and extent of this multimorbidity and the important association with social deprivation have not been previously described within a large and representative dataset of routine primary care data. Our findings have important implications for the integrated management of depression and physical health problems in the United Kingdom and throughout the world.

Visual impairment is associated with physical and mental comorbidities in older adults: a cross-sectional study

BackgroundVisual impairment is common in older people and the presence of additional health conditions can compromise health and rehabilitation outcomes. A small number of studies have suggested that comorbities are common in visual impairment; however, those studies have relied on self-report and have assessed a relatively limited number of comorbid conditions.MethodsWe conducted a cross-sectional analysis of a dataset of 291,169 registered patients (65-years-old and over) within 314 primary care practices in Scotland, UK. Visual impairment was identified using Read Code ever recorded for blindness and/or low vision (within electronic medical records). Prevalence, odds ratios (from prevalence rates standardised by stratifying individuals by age groups (65 to 69 years; 70 to 74; 75 to 79; 80 to 84; and 85 and over), gender and deprivation quintiles) and 95% confidence intervals (95% CI) of 37 individual chronic physical/mental health conditions and total number of conditions were calculated and compared for those with visual impairment to those without.ResultsTwenty seven of the 29 physical health conditions and all eight mental health conditions were significantly more likely to be recorded for individuals with visual impairment compared to individuals without visual impairment, after standardising for age, gender and social deprivation. Individuals with visual impairment were also significantly more likely to have more comorbidities (for example, five or more conditions (odds ratio (OR) 2.05 95% CI 1.94 to 2.18)).ConclusionsPatients aged 65 years and older with visual impairment have a broad range of physical and mental health comorbidities compared to those of the same age without visual impairment, and are more likely to have multiple comorbidities. This has important implications for clinical practice and for the future design of integrated services to meet the complex needs of patients with visual impairment, for example, embedding depression and hearing screening within eye care services.

Differences in the quality of primary medical care for CVD and diabetes across the NHS: evidence from the quality and outcomes framework

BackgroundHealth policy in the UK has rapidly diverged since devolution in 1999. However, there is relatively little comparative data available to examine the impact of this natural experiment in the four UK countries. The Quality and Outcomes Framework of the 2004 General Medical Services Contract provides a new and potentially rich source of comparable clinical quality data through which we compare quality of primary medical care for coronary heart disease (CHD), stroke, hypertension and diabetes across the four UK countries.MethodsA cross-sectional analysis was undertaken involving 10,064 general practices in England, Scotland, Wales and Northern Ireland. The main outcome measures were prevalence rates for CHD, stroke, hypertension and diabetes. Achievement on 14 simple process, 3 complex process, 9 intermediate outcome and 5 treatment indicators for the four clinical areas.ResultsPrevalence varies by up to 28% between the four UK countries, which is not reflected in resource distribution between countries, and penalises practices in the high prevalence countries (Wales and Scotland). Differences in simple process measures across countries are small. Larger differences are found for complex process, intermediate outcome and treatment measures, most notably for Wales, which has consistently lower quality of care. Scotland has generally higher quality than England and Northern Ireland is most consistently the highest quality.ConclusionPreviously identified weaknesses in Wales related to waiting times appear to reflect a more general quality problem within NHS Wales. Identifying explanations for the observed differences is limited by the lack of comparable data on practice resources and organisation. Maximising the value of cross-jurisdictional comparisons of the ongoing natural experiment of health policy divergence within the UK requires more detailed examination of resource and organisational differences.

Comorbidity and polypharmacy in people with dementia: insights from a large, population-based cross-sectional analysis of primary care data

Background The care of older people with dementia is often complicated by physical comorbidity and polypharmacy, but the extent and patterns of these have not been well described. This paper reports analysis of these factors within a large, cross-sectional primary care data set. Methods Data were extracted for 291,169 people aged 65 years or older registered with 314 general practices in the UK, of whom 10,258 had an electronically recorded dementia diagnosis. Differences in the number and type of 32 physical conditions and the number of repeat prescriptions in those with and without dementia were examined. Age–gender standardised rates were used to calculate odds ratios (ORs) of physical comorbidity and polypharmacy. Results People with dementia, after controlling for age and sex, had on average more physical conditions than controls (mean number of conditions 2.9 versus 2.4; P < 0.001) and were on more repeat medication (mean number of repeats 5.4 versus 4.2; P < 0.001). Those with dementia were more likely to have 5 or more physical conditions (age–sex standardised OR [sOR] 1.42, 95% confidence interval (CI) 1.35–1.50; P < 0.001) and were also more likely to be on 5 or more (sOR 1.46; 95% CI 1.40–1.52; P < 0.001) or 10 or more repeat prescriptions (sOR 2.01; 95% CI 1.90–2.12; P < 0.001). Conclusions People with dementia have a higher burden of comorbid physical disease and polypharmacy than those without dementia, even after accounting for age and sex differences. Such complex needs require an integrated response from general health professionals and multidisciplinary dementia specialists.

Differences in the quality of primary medical care services by remoteness from urban settlements

Objective: To examine if the quality of primary medical care varies with remoteness from urban settlements. Design: Cross-sectional analysis of publicly available data of 18 process and intermediate outcome measures for people with coronary heart disease (CHD), diabetes and stroke. Setting and participants: Populations registered with 912 general practices in Scotland grouped into three categories by level of remoteness from urban settlements: not remote, remote and very remote. Main outcome measures: Mean percentages achieving quality indicators and interquartile range scores. Results: Remote and very remote practices were more likely to have characteristics associated with low Quality and Outcomes Framework (QOF) total points score (smaller, higher capitation income, dispensing practice, and had lower statin prescribing despite higher prevalence of cardiovascular disease and diabetes). However, in contrast with previous research, there was little evidence that quality of care was lower in more remote areas for the 18 process and intermediate outcome measures examined. The exception was significantly lower cholesterol measurement and control in people with CHD, diabetes and stroke attending very remote practices (p<0.01) and β-blocker prescription in CHD (p = 0.01). Conclusions: Under QOF, there are few differences in the quality of care delivered to patients in practices with different degrees of remoteness. The differences in achievement for cholesterol were consistent with lower rates of statin prescribing relative to disease burden in very remote practices. No differences were found for complex process measures such as retinopathy screening, implying that differences under QOF are more likely to be due to slower adoption of evidence-based practice than access problems. Examining this will require analysis of individual patient data.