Kambiz Boomla

Using nurses for preventive activities with computer assisted follow up: a randomised controlled trial.

OBJECTIVE--To assess whether an organised programme of prevention including the use of a health promotion nurse noticeably improved recording and follow up of cardiovascular risk factors and cervical smears in a general practice that had access to computerised cell and recall. DESIGN--Randomised controlled trial. SETTING--General practice in inner London. PATIENTS--All 3206 men and women aged 30-64 registered with the practice. INTERVENTION--The intervention group had their risk factors ascertained and followed up by the health promotion nurse and the general practitioner, whereas those in the control group were managed by the general practitioner alone. END POINT--Recording and follow up of blood pressure and cervical smears after three years. Recording of smoking, family history of ischaemic heart disease, and serum cholesterol concentrations were also examined. MEASUREMENTS and MAIN RESULTS--When the trial was stopped after two years the measurements of blood pressure in the preceding five years were 93% (1511/1620) v 73% (1160/1586) (95% confidence interval for difference 17.5 to 22.7%) for intervention and control groups respectively. For patients with hypertension the figures were 97% (104/107) v 69% (80/116) (18.2 to 38.2%). For women the proportion who had had a cervical smear in the preceding three years were 76% (606/799) v 49% (392/806) (22.5 to 31.9%). Recording of smoking, family history of ischaemic heart disease, and serum cholesterol concentrations was also higher in the intervention group compared with the control group. CONCLUSION--An organised programme, which includes a nurse with specific responsibility for adult prevention, is likely to make an important contribution to recording of risk factors and follow up of those patients with known risks.

Estimating cardiovascular risk for primary prevention: outstanding questions for primary care

Editorial by Jackson The recent joint British recommendations on the prevention of coronary heart disease, 1 the British Hypertension Society guidelines for the management of hypertension, 2 and comparable recommendations from the United States3 all conclude that the decision to start drug treatment in people at high risk but without cardiovascular disease should be based on their risk of coronary heart disease as estimated by the Framingham risk equations. We review some implications of their use in primary care. #### Summary points Prediction of coronary risk on the basis of multiple risk factors is more accurate than with any single factor alone People with a 30% or greater risk of a coronary heart disease event in 10 years should be considered for treatment with aspirin, antihypertensives, and statins Risk assessment for coronary heart disease should be routinely added to the existing screening programme for smoking and raised blood pressure The measurement of serum lipid concentrations in all adults is not necessary for the identification of people at high risk A national programme is required to support the identification and treatment of the 10% of the population who have coronary risks of 30% or more For 50 years the Framingham heart study has documented blood pressure, smoking, lipid concentrations, and other characteristics of 5300 white men and women, together with their causes of death and disease.4 These data have been used to predict death or major vascular events. It is important to be clear which outcome is being predicted and over what period. Expressed as risks at one, five, or 10 years the predicted outcomes include fatal and non-fatal coronary heart disease, 5 stroke, 6 and total cardiovascular disease including congestive cardiac failure and peripheral vascular disease.7 8 The risk of a coronary heart disease event in 10 years (myocardial infarction …

Promotion of rapid testing for HIV in primary care (RHIVA2): a cluster-randomised controlled trial.

BACKGROUND Many people with HIV are undiagnosed. Early diagnosis saves lives and reduces onward transmission. We assessed whether an education programme promoting rapid HIV testing in general practice would lead to increased and earlier HIV diagnosis. METHODS In this cluster randomised controlled trial in Hackney (London, UK), general practices were randomly assigned (1:1) to offer either opt-out rapid HIV testing to newly registering adults or continue usual care. All practices were invited to take part. Practices were randomised by an independent clinical trials unit statistician with a minimisation program, maintaining allocation concealment. Neither patients nor investigators were masked to treatment allocation. The primary outcome was CD4 count at diagnosis. Secondary outcomes were rate of diagnosis, proportion with CD4 count less than 350 cells per μL, and proportion with CD4 count less than 200 cells per μL. This study is registered with ClinicalTrials.gov, number ISRCTN63473710. FINDINGS 40 of 45 (89%) general practices agreed to participate: 20 were assigned to the intervention group (44 971 newly registered adult patients) and 20 to the control group (38 464 newly registered adult patients), between April 19, 2010, and Aug 31, 2012. Intervention practices diagnosed 32 people with HIV versus 14 in control practices. Mean CD4 count at diagnosis was 356 cells per μL (SD 254) intervention practices versus 270 (SD 257) in control practices (adjusted difference of square root CD4 count 3·1, 95% CI -1·2 to 7·4; p=0·16);); in a pre-planned sensitivity analysis excluding patients diagnosed via antenatal care, the difference was 6·4 (95% CI, 1·2 to 11·6; p=0·017). Rate of HIV diagnosis was 0·30 (95% CI 0·11 to 0·85) per 10 000 patients per year in intervention practices versus 0·07 (0·02 to 0·20) in control practices (adjusted ratio of geometric means 4·51, 95% CI 1·27 to 16·05; p=0·021). 55% of patients in intervention practices versus 73% in control practices had CD4 count less than 350 cells per μL (risk ratio 0·75, 95% CI 0·53 to 1·07). 28% versus 46% had CD4 count less than 200 cells per μL (0·60, 0·32 to 1·13). All patients diagnosed by rapid testing were successfully transferred into specialist care. No adverse events occurred. INTERPRETATION Promotion of opt-out rapid testing in general practice led to increased rate of diagnosis, and might increase early detection, of HIV. We therefore recommend implementation of HIV screening in general practices in areas with high HIV prevalence. FUNDING UK Department of Health, NHS City and Hackney.

The NHS Health Check programme: implementation in east London 2009-2011

Objectives To describe implementation and results from the National Health Service (NHS) Health Check programme. Design Three-year observational open cohort study: 2009–2011. Participants People of age 40–74 years eligible for an NHS Health Check. Setting 139/143 general practices in three east London primary care trusts (PCTs) serving an ethnically diverse and socially disadvantaged population. Method Implementation was supported with education, IT support and performance reports. Tower Hamlets PCT additionally used managed practice networks and prior-stratification to call people at higher cardiovascular (CVD) risk first. Main outcomes measures Attendance, proportion of high-risk population on statins and comorbidities identified. Results Coverage 2009, 2010, 2011 was 33.9% (31 878/10 805), 60.6% (30 757/18 652) and 73.4% (21 194/28 890), respectively. Older people were more likely to attend than younger people. Attendance was similar across deprivation quintiles and was in accordance with population distributions of black African/Caribbean, South Asian and White ethnic groups. 1 in 10 attendees were at high-CVD risk (20% or more 10-year risk). In the two PCTs stratifying risk, 14.3% and 9.4% of attendees were at high-CVD risk compared to 8.6% in the PCT using an unselected invitation strategy. Statin prescription to people at high-CVD risk was higher in Tower Hamlets 48.9%, than in City and Hackney 23.1% or Newham 20.2%. In the 6 months following an NHS Health Check, 1349 new cases of hypertension, 638 new cases of diabetes and 89 new cases of chronic kidney disease (CKD) were diagnosed. This represents 1 new case of hypertension per 38 Checks, 1 new case of diabetes per 80 Checks and 1 new case of CKD per 568 Checks. Conclusions Implementation of the NHS Health Check programme in these localities demonstrates limited success. Coverage and treatment of those at high-CVD risk could be improved. Targeting invitations to people at high-CVD risk and managed practice networks in Tower Hamlets improved performance.

Prescribing in general practice for people with coronary heart disease; equity by age, sex, ethnic group and deprivation.

Objective. Differences in drug prescribing for coronary heart disease have previously been identified by age, sex and ethnic group. Set in the UK, our study utilises routinely collected data from 98 general practices serving a socially diverse population in inner East London, to examine differences in prescribing rates among patients aged 35 years and over with coronary heart disease. Design. 10,933 patients aged 35 years or more, with recorded coronary heart disease, from 98 practices in two Primary Care Trusts (PCT) in East London during 2009/2010 were included for this cross-sectional study. Multivariable logistic regression was used to assess the odds of prescribing for recommended coronary heart disease drugs by age, sex, ethnicity, social deprivation, co-morbidity and recorded reasons for not prescribing. Results. Women are prescribed fewer recommended coronary heart disease drugs than men; Black African/Caribbean patients are prescribed fewer lipid modifying drugs and other cardiovascular drugs than White patients. Patients over age 84 are prescribed fewer lipid modifying drugs and beta blockers than patients aged 45–54. South Asian patients had the highest levels of prescribing and higher prevalence of coronary heart disease and diabetes co-morbidity. No difference in prescribing rates by social deprivation was found. Discussion. Overall levels of prescribing are high but small differences between sex and ethnic groups remain and prescribing may be inequitable for women, for Black/African Caribbeans and at older ages. These differences were not explained by recorded intolerance, contraindications or declining treatment.

GP funding formula masks major inequalities for practices in deprived areas

Appleby reminds us that general practice funding has fallen to 8% of total NHS spending.1 But his analysis masks the important point that differing population needs greatly affect practice workload. The 2004 Carr-Hill funding formula had the laudable aim of allocating funds to reflect the workload requirements of each practice population. Reliable data on the workload implications of social deprivation were unavailable, and the resulting formula did not redress the health burden of inequality, as shown …

Recording ethnicity in primary care: assessing the methods and impact

### The importance of ethnicity recording in the UK The reduction of ethnic health inequalities has been a priority for government health policy in the UK since the introduction of the Race Relations (Amendment) Act in 2000.1 This Act places a duty on all public bodies to consider the race-equality implications in all of the policies that shape their operations. The UK is one of the few European countries that officially recognises the need for ethnicity data to support service-monitoring purposes and places no restrictions on the collection of such data; this is in contrast to France and Germany, for example, where restrictions on collecting such data do exist.2 For general practice this means developing robust counts of ethnicity at practice level and using the data to monitor access and service utilisation. This is particularly important in urban areas, which tend to be most ethnically diverse and where population mobility is greatest. At the local level, one of the primary purposes of collecting ethnic-category data about patients is to establish whether services are meeting the needs of different ethnic groups in the community and to assist future planning of service provision. In addition, reductions in the disparity in health service utilisation and outcomes by different ethnic groups can be used as a key service quality marker in any health system.3 To date, ethnicity recording at the general practice level in the UK has been low.2,4 To bolster data quality and recording levels in primary care, the NHS has introduced financially incentivised targets for ethnicity recording in general practice through the Quality and Outcomes Framework (QOF); however, this is limited to new registrations.5 ### Defining and categorising ethnicity The legal definition of ‘ethnic group’, as adopted by the House of Lords, states that a long, shared history and common cultural tradition are essential characteristics. In addition, a common …

Ethnicity and the diagnosis gap in liver disease: a population-based study

Background Liver disease is a major cause of morbidity and mortality worldwide. Large numbers of liver function tests (LFTs) are performed in primary care, with abnormal liver biochemistry a common finding. Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver injury. Metabolic syndrome, common in people from South Asia, is an important risk factor for NAFLD. Aim It is hypothesised that a large gap exists between numbers of patients with abnormal LFTs and those with recorded liver diagnoses, and that NAFLD is more common among adults of South Asian ethnic groups. Design and setting A cross-sectional study of 690 683 adults in coterminous general practices in a region with high ethnic diversity. Method Data were extracted on LFTs, liver disease, and process of care measures from computerised primary care medical records. Results LFTs were performed on 218 032 patients, of whom 31 627 had elevated serum transaminases. The prevalence of abnormal LFTs was highest among individuals of Bangladeshi ethnicity. Of the patients with abnormal LFTs, 88.4% did not have a coded liver diagnosis. NAFLD was the most frequently recorded liver disease and was most common among Bangladeshi patients. In a multivariate analysis, independent risk factors for NAFLD included Bangladeshi ethnicity, diabetes, raised BMI, hypertension, and hypercholesterolaemia. Conclusion Abnormal LFTs are common in the population, but are underinvestigated and often remain undiagnosed. Bangladeshi ethnicity is an important independent risk factor for NAFLD.

Improving cardiovascular disease using managed networks in general practice: an observational study in inner London

BACKGROUND System redesign is described in one primary care trust (PCT)/clinical commissioning group (CCG) resulting in improved cardiovascular disease (CVD) management. AIM To evaluate CVD managed practice networks in one entire local health economy using practice networks, compared with PCTs in London, England, and local PCTs. DESIGN AND SETTING Observational study of 34 general practices in Tower Hamlets, a socially disadvantaged inner-London borough. METHOD In 2009, all 34 practices were allocated to eight geographical networks of four to five practices, each serving 30 000-50 000 patients. Each network had a network manager, administrative support, and an educational budget to deliver financially-incentivised attainment targets in four care packages of which CVD comprised one. RESULTS In 2009/11, Tower Hamlets increased total statin prescribing (ADQ-STAR PU) by 17.9% compared with 5.5% in England (P<0.001). Key CVD indicators improved faster in Tower Hamlets than in England, London, or local PCTs, and in 2012/13, Tower Hamlets ranked top in the national Quality and Outcomes Framework for blood pressure and cholesterol control in coronary heart disease (CHD) and diabetes, top five for stroke and top in London for all these measures. Male mortality from CHD was fourth highest in England in 2008 and reduced more than any other PCT in the next 3 years; reducing by 43% compared with an average fall of 25% for the top 10 PCTs in 2008 ranked by mortality. CONCLUSION Managed geographical practice networks delivered a step-change in key CVD performance indicators in comparison with England, London, or similar PCT/CCGs.

Improving anticoagulation in atrial fibrillation: observational study in three primary care trusts

BACKGROUND Atrial fibrillation (AF) is a cause of stroke, and undertreatment with anticoagulants is a persistent issue despite their effectiveness. AIM To increase the proportion of people with AF treated appropriately using anticoagulants, and reduce inappropriate antiplatelet therapy. DESIGN OF STUDY Cross-sectional analysis. SETTING Electronic patient health records on 4604 patients with AF obtained from general practices in three inner London primary care trusts between April 2011 and 2013. METHOD The Anticoagulant Programme East London (APEL) sought to achieve its aims through an intervention with three components: altering professional beliefs using new clinical guidance and related education; facilitating change using computer software to support clinical decisions and patient review optimising anticoagulation; motivating change through evaluative feedback showing individual practice performance relative to peers. RESULTS From April 2011 to April 2013, the proportion of people with CHA2DS2-VASc ≥1 on anticoagulants increased from 52.6% to 59.8% (trend difference P<0.001). The proportion of people with CHA2DS2-VASc ≥1 on aspirin declined from 37.7% to 30.3% (trend difference P<0.001). Comparing the 2 years before the intervention with the 2 years after, numbers of new people on the AF register almost doubled from 108 to 204. CONCLUSIONS The APEL programme supports improvement in clinical managing AF by a combined programme of education around agreed guidance, computer aids to facilitate decision-making and patient review and feedback of locally identifiable results. If replicated nationally over 3 years, such a programme could result in approximately 1600 fewer strokes every year.