Mark Ashworth

Effect of social deprivation on blood pressure monitoring and control in England: a survey of data from the quality and outcomes framework

Objective To determine levels of blood pressure monitoring and control in primary care and to determine the effect of social deprivation on these levels. Design Retrospective longitudinal survey, 2005 to 2007. Setting General practices in England. Participants Data obtained from 8515 practices (99.3% of all practices) in year 1, 8264 (98.3%) in year 2, and 8192 (97.8%) in year 3. Main outcome measures Blood pressure indicators and chronic disease prevalence estimates contained within the UK quality and outcomes framework; social deprivation scores for each practice, ethnicity data obtained from the 2001 national census; general practice characteristics. Results In 2005, 82.3% of adults (n=52.8m) had an up to date blood pressure recording; by 2007, this proportion had risen to 88.3% (n=53.2m). Initially, there was a 1.7% gap between mean blood pressure recording levels in practices located in the least deprived fifth of communities compared with the most deprived fifth, but, three years later, this gap had narrowed to 0.2%. Achievement of target blood pressure levels in 2005 for practices located in the least deprived communities ranged from 71.0% (95% CI 70.4% to 71.6%) for diabetes to 85.1% (84.7% to 85.6%) for coronary heart disease; practices in the most deprived communities achieved 68.9% (68.4% to 69.5%) and 81.8 % (81.3% to 82.3%) respectively. Three years later, target achievement in the least deprived practices had risen to 78.6% (78.1% to 79.1%) and 89.4% (89.1% to 89.7%) respectively. Target achievement in the most deprived practices rose similarly, to 79.2% (78.8% to 79.6%) and 88.4% (88.2% to 88.7%) respectively. Similar changes were observed for the achievement of blood pressure targets in hypertension, cerebrovascular disease, and chronic kidney disease. Conclusions Since the reporting of performance indicators for primary care and the incorporation of pay for performance in 2004, blood pressure monitoring and control have improved substantially. Improvements in achievement have been accompanied by the near disappearance of the achievement gap between least and most deprived areas.

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.

Achievement of metabolic targets for diabetes by English primary care practices under a new system of incentives

Objective  To analyse achievement of metabolic targets by English general practices following the introduction of a new system of incentives.

Selective decrease in consultations and antibiotic prescribing for acute respiratory tract infections in UK primary care up to 2006.

Background The aim of this study was to estimate trends in primary care consultations and antibiotic prescribing for acute respiratory tract infections (RTIs) in the UK from 1997 to 2006. Methods Data were analysed for 100 000 subjects registered with 78 family practices in the UK General Practice Research Database; the numbers of consultations for RTI and associated antibiotic prescriptions were enumerated. Results The consultation rate for RTI declined in females from 442.2 per 1000 registered patients in 1997 to 330.9 in 2006, and in males from 318.5 to 249.0. The rate of consultations for colds, rhinitis and upper respiratory tract infection (URTI) declined by 4.2 (95% CI 2.3–6.1) per 1000 per year in females and by 3.6 (2.3–4.8) in males. The rate of antibiotic prescribing for RTI was higher in females and declined by 8.5 (2.0–15.1) per 1000 in females and 6.7 (2.7–10.8) in males. For colds, rhinitis and URTI, the proportion of consultations with antibiotics was prescribed declined by 1.7% per year in females and 1.8% in males. Conclusions Decreasing frequency of consultation and antibiotic prescription for colds, rhinitis and ‘URTI’ continues to drive a reduction in the rate of antibiotic utilization for RTIs.

Trends in antiepileptic drug utilisation in UK primary care 1993-2008: Cohort study using the General Practice Research Database.

PURPOSE To describe changes in utilisation of antiepileptic drugs (AED) by people with epilepsy in the United Kingdom during 1993-2008. METHODS Cohort study of 63,586 participants with epilepsy and prescribed AEDs from 434 UK family practices. Prescriptions for different AEDs and AED combinations were evaluated by calendar year, gender and age group. RESULTS Total follow-up was 361,207 person-years, with 282,080 person-years treated with AEDs and 79,126 person-years untreated. AED monotherapy accounted for 72.6% of treated person years of follow-up. Carbamazepine and valproates were among the most commonly used medications throughout 1993-2008. Phenytoin accounted for 39.5% of treated person-years in 1993 declining to 18.3% by 2008. Use of barbiturates declined from 14.3% in 1993 to 6.0% in 2008. In contrast between 1993 and 2008 there were substantial increases in the use of lamotrigine (2.0% to 17.0%) and to a lesser extent levetiracetam (0% to 8.6%). Newer AEDs were more frequently prescribed to younger participants, especially women aged 15-44 years, while older adults were more likely to be prescribed longer established AEDs. In 1993, 201 different AED combinations were prescribed, increasing to 500 different combinations in 2008. Combinations of sodium valproate and carbamazepine were frequent throughout, while sodium valproate and lamotrigine was frequent in 2008. CONCLUSIONS Utilisation of newer AEDs in UK primary care has increased between 1993 and 2008 with increasing use of diverse combinations of AEDs. The data quantify exposure to AEDs relevant to planning analytical pharmaco-epidemiological studies, as well as providing information to inform prescribing policies.

Parental help-seeking in primary care for child and adolescent mental health concerns: qualitative study

BACKGROUND Child and adolescent mental health problems are common in primary care. However, few parents of children with mental health problems express concerns about these problems during consultations. AIMS To explore the factors influencing parental help-seeking for children with emotional or behavioural difficulties. METHOD Focus group discussions with 34 parents from non-specialist community settings who had concerns about their childs mental health. All groups were followed by validation groups or semi-structured interviews. RESULTS Most children had clinically significant mental health symptoms or associated impairment in function. Appointment systems were a key barrier, as many parents felt that short appointments did not allow sufficient time to address their childs difficulties. Continuity of care and trusting relationships with general practitioners (GPs) who validated their concerns were perceived to facilitate help-seeking. Parents valued GPs who showed an interest in their child and family situation. Barriers to seeking help included embarrassment, stigma of mental health problems, and concerns about being labelled or receiving a diagnosis. Some parents were concerned about being judged a poor parent and their child being removed from the family should they seek help. CONCLUSIONS Primary healthcare is a key resource for children and young people with emotional and behavioural difficulties and their families. Primary care services should be able to provide ready access to health professionals with an interest in children and families and appointments of sufficient length so that parents feel able to discuss their mental health concerns.

Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices

Objectives Overutilisation of antibiotics may contribute to the emergence of antimicrobial drug resistance, a growing international concern. This study aimed to analyse the performance of UK general practices with respect to antibiotic prescribing for respiratory tract infections (RTIs) among young and middle-aged adults. Setting Data are reported for 568 UK general practices contributing to the Clinical Practice Research Datalink. Participants Participants were adults aged 18–59 years. Consultations were identified for acute upper RTIs including colds, cough, otitis-media, rhino-sinusitis and sore throat. Primary and secondary outcome measures For each consultation, we identified whether an antibiotic was prescribed. The proportion of RTI consultations with antibiotics prescribed was estimated. Results There were 568 general practices analysed. The median general practice prescribed antibiotics at 54% of RTI consultations. At the highest prescribing 10% of practices, antibiotics were prescribed at 69% of RTI consultations. At the lowest prescribing 10% of practices, antibiotics were prescribed at 39% RTI consultations. The median practice prescribed antibiotics at 38% of consultations for ‘colds and upper RTIs’, 48% for ‘cough and bronchitis’, 60% for ‘sore throat’, 60% for ‘otitis-media’ and 91% for ‘rhino-sinusitis’. The highest prescribing 10% of practices issued antibiotic prescriptions at 72% of consultations for ‘colds’, 67% for ‘cough’, 78% for ‘sore throat’, 90% for ‘otitis-media’ and 100% for ‘rhino-sinusitis’. Conclusions Most UK general practices prescribe antibiotics to young and middle-aged adults with respiratory infections at rates that are considerably in excess of what is clinically justified. This will fuel antibiotic resistance.

Epilepsy mortality and risk factors for death in epilepsy: a population-based study

BACKGROUND Epilepsy is an important cause of amenable mortality but risk factors for death in epilepsy are not well understood. AIM To evaluate trends in epilepsy mortality in a large population and identify risk factors for death in epilepsy. DESIGN AND SETTING Nested case-control study in the UK, using data from the General Practice Research Database (GPRD) from 1993 to 2007. METHOD Participants were included if they had ever been diagnosed with epilepsy and prescribed anticonvulsant drugs. Trends in all-cause mortality in persons with epilepsy in the GPRD were compared with death registrations with epilepsy as the underlying cause. A nested case-control study was implemented to compare participants with epilepsy who died with those who did not die. RESULTS The prevalence of epilepsy increased from 9 per 1000 in 1993 to 12 per 1000 in 2007, and epilepsy deaths also increased in this period. In a nested case-control study, mortality was associated with: recorded alcohol problems (odds ratio [OR] 2.96, 95% confidence interval [CI] = 2.25 to 3.89, P<0.001); having collected the last anticonvulsant prescription 90-182 days previously (OR 1.83, CI = 1.66 to 2.03, P<0.001); having an injury in the previous year (OR 1.41, 95% CI = 1.30 to 1.53, P<0.001), and having been treated for depression (OR 1.39, 95% CI = 1.28 to 1.50, P<0.001). In data available from 2004 onwards, being recorded seizure free in the previous 12 months was associated with lower mortality (OR 0.78, 95% CI = 0.71 to 0.86, P<0.001). CONCLUSION Mortality with epilepsy appears to be increasing. Patients who have alcohol problems, do not collect repeat prescriptions for anticonvulsant drugs, have recent injuries, or have been treated for depression may be at increased risk of death; patients who remain seizure free over 12 months are at a lower risk.

Population Intermediate Outcomes of Diabetes Under Pay-for-Performance Incentives in England From 2004 to 2008

OBJECTIVE—To evaluate diabetes outcomes under a national “pay-for-performance” program. RESEARCH DESIGN AND METHODS—Data were analyzed for 98% of all English family practices. For each practice, the proportion of diabetic subjects with A1C ≤7.5%, blood pressure ≤145/85 mmHg, and cholesterol ≤5 mmol/l was determined. Practices achieving less than the 25th centile for the A1C target for 2006–2007 were classified as low performing. RESULTS—The proportion achieving the A1C target at the median practice increased from 59.1% (interquartile range [IQR] 51.7–65.9) in 2004–2005 to 66.7% (IQR 60.6–72.7) in 2007–2008, blood pressure from 70.9% in 2004–2005 to 80.2% in 2007–2008, and cholesterol from 72.6% in 2004–2005 to 83.6% in 2007–2008. In 2004–2005, 57% of practices were low performing (range by region 42.4–69.9). In 2007–2008, 26% of practices were low performing (range 11.6–37.5). CONCLUSIONS—Introduction of pay-for-performance may be one factor contributing to increasing achievement of targets and reducing problems of low performance.

Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study

Objectives To quantify the relationship between a national primary care pay-for-performance programme, the UK’s Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework. Design Longitudinal spatial study, at the level of the “lower layer super output area” (LSOA). Setting 32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012. Participants 8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care. Intervention National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators. Main outcome measures All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality. Results All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality. Conclusions Higher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.