Sally Hull

The effect of ethnicity on the prevalence of diabetes and associated chronic kidney disease

BACKGROUND The effect of ethnicity on the prevalence of diabetes mellitus (DM) and associated chronic kidney disease (CKD) is unknown. AIM To establish the impact of ethnicity on the prevalence and severity of diabetes mellitus and associated CKD. DESIGN Cross-sectional study of 34 359 adult diabetic patients in three primary care trusts in the UK. METHODS Read coded data from general practice computers was used to analyse the relationship between ethnicity, DM and CKD. RESULTS The prevalence of DM was 3.5% for Whites, 11% for South Asians and 8% for Black groups. The prevalence of CKD (stages 3-5) among diabetics was 18%. CKD stage 3 was more prevalent in Whites compared to South Asians--OR 0.79 (95% CI: 0.71-0.87) and Blacks--OR 0.49 (95% CI: 0.43-0.57). Among all CKD patients severity (CKD stages 4, 5) was associated with Black (OR 1.39, 95% CI: 1.06-1.81) and South Asian (OR 1.54, 95% CI: 1.26-1.88) ethnicity compared to Whites. Less than 50% of diabetics with CKD met the target blood pressure (BP) of 130/80 mmHg. The prevalence of a blood pressure > 150/90 mmHg in diabetics with CKD was South Asian 15.6%, White 13.9%, Black 21.8% (P < 0.001). Proteinuria was present in 8.6% of all diabetic patients. However, this increased to 18.6% in patients with CKD, and was more frequent in Black (22.6%) and South Asian (21%) patients compared to White patients (14.1%) (P < 0.001). CONCLUSION Significant disparities exist between the major ethnic groups in both disease prevalence and management. Future studies examining the management of CKD need to take variation by ethnicity into account.

Patient safety and estimation of renal function in patients prescribed new oral anticoagulants for stroke prevention in atrial fibrillation: a cross-sectional study

Objective In clinical trials of dabigatran and rivaroxaban for stroke prevention in atrial fibrillation (AF), drug eligibility and dosing were determined using the Cockcroft-Gault equation to estimate creatine clearance as a measure of renal function. This cross-sectional study aimed to compare whether using estimated glomerular filtration rate (eGFR) by the widely available and widely used Modified Diet in Renal Disease (MDRD) equation would alter prescribing or dosing of the renally excreted new oral anticoagulants. Participants Of 4712 patients with known AF within a general practitioner-registered population of 930 079 in east London, data were available enabling renal function to be calculated by both Cockcroft-Gault and MDRD methods in 4120 (87.4%). Results Of 4120 patients, 2706 were <80 years and 1414 were ≥80 years of age. Among those ≥80 years, 14.9% were ineligible for dabigatran according to Cockcroft-Gault equation but would have been judged eligible applying MDRD method. For those <80 years, 0.8% would have been incorrectly judged eligible for dabigatran and 5.3% would have received too high a dose. For rivaroxaban, 0.3% would have been incorrectly judged eligible for treatment and 13.5% would have received too high a dose. Conclusions Were the MDRD-derived eGFR to be used instead of Cockcroft-Gault in prescribing these new agents, many elderly patients with AF would either incorrectly become eligible for them or would receive too high a dose. Safety has not been established using the MDRD equation, a concern since the risk of major bleeding would be increased in patients with unsuspected renal impairment. Given the potentially widespread use of these agents, particularly in primary care, regulatory authorities and drug companies should alert UK doctors of the need to use the Cockcroft-Gault formula to calculate eligibility for and dosing of the new oral anticoagulants in elderly patients with AF and not rely on the MDRD-derived eGFR.

Factors Influencing the Attendance Rate at Accident and Emergency Departments in East London: The Contributions of Practice Organization, Population Characteristics and Distance

Objectives: To examine the contribution of general practice organisation, population characteristics and distance to practice attendance rates at four local accident and emergency departments. Design: Practice-based study examining variations in accident and emergency department attendance rates in 105 practices, using routine data from the Family Health Services Authority (FHSA), the District Health Authority and the 1991 Census. Setting: East London and the City Health Authority, covering practices based in the inner city boroughs of Hackney, Tower Hamlets and Newham, and the City of London. Main outcome measure: Practice-based, age-standardized, adult attendance rates at accident and emergency departments in the year to 31 March 1994. Results: Annual age-standardized practice accident and emergency department attendance rates ranged from 10.3 to 29.4 per 100 population. The mean practice attendance rate was 17.6 per 100 (95% CI 16.8–18.4). No significant relationship was found between attendance rates and practice characteristics (number and sex of general practitioner (GP) principals, presence of practice manager or nurse, computerization and training status). There were strong positive relationships between attendance rates and households not owner-occupied (R = 0.55, P < 0.001) and pensioners living alone (R = 0.55, P < 0.001). There were negative correlations with Asian ethnicity (R = −0.31, P = 0.002) and residents lacking amenities (R = −0.26, P = 0.007). The distance to the nearest accident and emergency department also correlated negatively with attendance (R = −0.27, P = 0.006). A backwards multiple regression model showed that 48% of the variation in attendance rates could be accounted for by six factors: Percentage of households not owner occupied, percentage living in households without a car, percentage living in households lacking amenities, percentage of pensioners living alone, percentage of Asian ethnicity, and percentage living in households with a head born in the New Commonwealth and Pakistan. Optimal subsets regression identified a number of alternative models with similar explanatory value. Conclusions: Social deprivation is strongly linked with attendance rates at accident and emergency departments in East London. In contrast, the organizational characteristics of general practices appear to have no bearing on the rates. Both purchasers and providers need to take account of these findings when planning accident and emergency provision.

Cardiovascular multimorbidity: the effect of ethnicity on prevalence and risk factor management

BACKGROUND Multimorbidity is common in primary care populations. Within cardiovascular disease, important differences in disease prevalence and risk factor management by ethnicity are recognised. AIM To examine the population burden of cardiovascular multimorbidity and the management of modifiable risk factors by ethnicity. DESIGN AND SETTING Cross-sectional study of general practices (148/151) in the east London primary care trusts of Tower Hamlets, City and Hackney, and Newham, with a total population size of 843 720. METHOD Using MIQUEST, patient data were extracted from five cardiovascular registers. Logistic regression analysis was used to examine the risk of being multimorbid by ethnic group, and the control of risk factors by ethnicity and burden of cardiovascular multimorbidity. RESULTS The crude prevalence of cardiovascular multimorbidity among patients with at least one cardiovascular condition was 34%. People of non-white ethnicity are more likely to be multimorbid than groups of white ethnicity, with adjusted odds ratios of 2.04 (95% confidence interval [CI] = 1.94 to 2.15) for South Asians and 1.23 (95% CI = 1.18 to 1.29) for groups of black ethnicity. Achievement of targets for blood pressure, cholesterol, and glycated haemoglobin (HbA(1c)) was higher for patients who were multimorbid than unimorbid. For cholesterol and blood pressure, South Asian patients achieved better control than those of white and black ethnicity. For HbA(1c) levels, patients of white ethnicity had an advantage over other groups as the morbidity burden increased. CONCLUSION The burden of multiple disease varies by ethnicity. Risk factor management improves with increasing levels of cardiovascular multimorbidity, but clinically important differences by ethnicity remain and contribute to health inequalities.

Ethnic and social disparity in glycaemic control in type 2 diabetes; cohort study in general practice 2004-9.

Objective To determine whether ethnic group differences in glycated haemoglobin (HbA1c) changed over a 5-year period in people on medication for type 2 diabetes. Design Open cohort in 2004–9. Setting Electronic records of 100 of the 101 general practices in two inner London boroughs. Participants People aged 35 to 74 years on medication for type 2 diabetes. Main outcome measures Mean HbA1c and proportion with HbA1c controlled to ≤7.5%. Results In this cohort of 24,111 people, 22% were White, 58% South Asian and 17% Black African/Caribbean. From 2004 to 2009 mean HbA1c improved from 8.2% to 7.8% for White, from 8.5% to 8.0% for Black African/Caribbean and from 8.5% to 8.0% for South Asian people. The proportion with HbA1c controlled to 7.5% or less, increased from 44% to 56% in White, 38% to 53% in Black African/Caribbean and 34% to 48% in South Asian people. Ethnic group and social deprivation were independently associated with HbA1c. South Asian and Black African/Caribbean people were treated more intensively than White people. Conclusion HbA1c control improved for all ethnic groups between 2004–9. However, South Asian and Black African/Caribbean people had persistently worse control despite more intensive treatment and significantly more improvement than White people. Higher social deprivation was independently associated with worse control.

Improving MMR vaccination rates: herd immunity is a realistic goal

Problem As measles is a highly infectious disease, the United Kingdom recommendation is for at least 95% of children to receive a first vaccination with the measles, mumps, and rubella (MMR) vaccine before age 2 years and a booster before age 5 years to achieve herd immunity and prevent outbreaks. Reported vaccination rates for England have improved since a low level in 2003-4. Coverage for London is consistently lower than for England, however, and concerns have been expressed that there could be an epidemic of measles in the capital. Design Observational time series study. Setting London Borough of Tower Hamlets. Key measurements for improvement Uptake rates for childhood vaccinations. The key target was to reach 95% coverage for the first MMR vaccine before age 2 years. Strategies for change Financial support for the development of geographically based networks of general practices. Commissioning of care packages, incentivising delivery of high quality integrated care with network level vaccination targets of 95%. Innovative use of information technology to enable robust call and recall processes, active follow-up of defaulters, and increased knowledge about the demography of the children most difficult to reach. Effects of change The development of networks of practices facilitated collaborative working among primary care clinicians and other stakeholders; peer review of achievements; and an element of healthy competition. Uptake improved for all childhood vaccinations, and to herd immunity levels for most. Uptake of the first MMR vaccine before age 2 years rose from 80% in September 2009 to 94% in March 2011. Lessons learnt Achieving herd immunity for childhood vaccinations is an achievable target in an ethnically mixed, socially deprived inner city borough. The ability to identify characteristics of the difficult to reach groups, including significant differences in uptake across different ethnicities, will allow targeted interventions that may further improve overall coverage.

Ethnicity and stroke risk in patients with atrial fibrillation

Objective To examine the prevalence of atrial fibrillation (AF) and stroke risk by ethnic group in south and east London; to compare classification with CHA2DS2VASc and CHADS2; to examine the appropriateness of anticoagulant treatment and historic trends in prescribing by gender, age, and ethnicity. Design Cross-sectional study. Setting Routine general practice records from south and east London. Patients Patients aged 18 years or over with AF. Main outcome measures Risk of stroke by CHA2DS2VASc and CHADS2 score, and prescription of anticoagulant. Results In 2011, we identified 6292 patients with AF, with an age adjusted prevalence of 0.63% (1.2% white, 0.4% black African/Caribbean and 0.2% South Asian). 93% of the AF population were at high risk of stroke with a CHA2DS2VASc score ≥1, of whom 54% were on warfarin. South Asian patients were at higher stroke risk than white patients (OR 1.67, 95% CI 1.02 to 2.73). Warfarin under-prescribing in people over 80 years of age persisted without improvement throughout 2008–2011. There were no clear differences in warfarin use by ethnic group. Conclusions Despite a reduced prevalence of AF among South Asian patients, their risk of stroke is higher than for white patients or black African/Caribbean patients in association with diabetes, cardiovascular disease, and hypertension. Under-prescription of anticoagulation persists in all ethnic groups, a deficit most pronounced in the elderly. Use of the CHA2DS2VASc score would enhance optimal management in primary care.

The relationship of ethnicity to the prevalence and management of hypertension and associated chronic kidney disease.

BackgroundThe effect of ethnicity on the prevalence and management of hypertension and associated chronic kidney (CKD) disease in the UK is unknown.MethodsWe performed a cross sectional study of 49,203 adults with hypertension to establish the prevalence and management of hypertension and associated CKD by ethnicity. Routinely collected data from general practice hypertension registers in 148 practices in London between 1/1/07 and 31/3/08 were analysed.ResultsThe crude prevalence of hypertension was 9.5%, and by ethnicity was 8.2% for White, 11.3% for South Asian and 11.1% for Black groups. The prevalence of CKD stages 3-5 among those with hypertension was 22%. Stage 3 CKD was less prevalent in South Asian groups (OR 0.77, 95% CI 0.67 - 0.88) compared to Whites (reference population) with Black groups having similar rates to Whites. The prevalence of severe CKD (stages 4-5) was higher in the South Asian group (OR 1.53, 95% CI 1.17 - 2.0) compared to Whites, but did not differ between Black and White groups. In the whole hypertension cohort, achievement of target blood pressure (< 140/90 mmHg) was better in South Asian (OR 1.43, 95% CI 1.28 - 1.60) and worse in Black groups (OR 0.79, 95% CI 0.74 - 0.84) compared to White patients. Hypertensive medication was prescribed unequally among ethnic groups for any degree of blood pressure control.ConclusionsSignificant variations exist in the prevalence of hypertension and associated CKD and its management between the major ethnic groups. Among those with CKD less than 50% were treated to a target BP of ≤ 130/80 mmHg. Rates of ACE-I/ARB prescribing for those with CKD were less than optimal, with the lowest rates (58.5%) among Black groups.

Progression of chronic kidney disease in a multi-ethnic community cohort of patients with diabetes mellitus.

Ethnicity is a risk factor for the prevalence of severe chronic kidney disease among patients with diabetes. We studied the effect of ethnicity on progression of chronic kidney disease in people with diabetes managed in community settings.

Improving outcomes for patients with type 2 diabetes using general practice networks: a quality improvement project in east London

Background Structured diabetes care can improve outcomes and reduce risk of complications, but improving care in a deprived, ethnically diverse area can prove challenging. This report evaluates a system change to enhance diabetes care delivery in a primary care setting. Methods All 35 practices in one inner London Primary Care Trust were geographically grouped into eight networks of four to five practices, each supported by a network manager, clerical staff and an educational budget. A multidisciplinary team developed a ‘care package’ for type 2 diabetes management, with financial incentives based on network achievement of targets. Monthly electronic performance dashboards enabled networks to track and improve performance. Network multidisciplinary team meetings including the diabetic specialist team supported case management and education. Key measures for improvement included the number of diabetes care plans completed, proportion of patients attending for digital retinal screen and proportions of patients achieving a number of biomedical indices (blood pressure, cholesterol, glycated haemoglobin). Results Between 2009 and 2012, completed care plans rose from 10% to 88%. The proportion of patients attending for digital retinal screen rose from 72% to 82.8%. The proportion of patients achieving a combination of blood pressure ≤140/80 mm Hg and cholesterol ≤4 mmol/L rose from 35.3% to 46.1%. Mean glycated haemoglobin dropped from 7.80% to 7.66% (62–60 mmol/mol). Conclusions Investment of financial, organisational and education resources into primary care practice networks can achieve clinically important improvements in diabetes care in deprived, ethnically diverse communities. This success is predicated on collaborative working between practices, purposively designed high-quality information on network performance and engagement between primary and secondary care clinicians.