Sarah Purdy

Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study

BACKGROUND In developed countries, primary health care increasingly involves the care of patients with multiple chronic conditions, referred to as multimorbidity. AIM To describe the epidemiology of multimorbidity and relationships between multimorbidity and primary care consultation rates and continuity of care. DESIGN OF STUDY Retrospective cohort study. SETTING Random sample of 99 997 people aged 18 years or over registered with 182 general practices in England contributing data to the General Practice Research Database. METHOD Multimorbidity was defined using two approaches: people with multiple chronic conditions included in the Quality and Outcomes Framework, and people identified using the Johns Hopkins University Adjusted Clinical Groups (ACG®) Case-Mix System. The determinants of multimorbidity (age, sex, area deprivation) and relationships with consultation rate and continuity of care were examined using regression models. RESULTS Sixteen per cent of patients had more than one chronic condition included in the Quality and Outcomes Framework, but these people accounted for 32% of all consultations. Using the wider ACG list of conditions, 58% of people had multimorbidity and they accounted for 78% of consultations. Multimorbidity was strongly related to age and deprivation. People with multimorbidity had higher consultation rates and less continuity of care compared with people without multimorbidity. CONCLUSION Multimorbidity is common in the population and most consultations in primary care involve people with multimorbidity. These people are less likely to receive continuity of care, although they may be more likely to gain from it.

Which features of primary care affect unscheduled secondary care use? A systematic review

Objectives To conduct a systematic review to identify studies that describe factors and interventions at primary care practice level that impact on levels of utilisation of unscheduled secondary care. Setting Observational studies at primary care practice level. Participants Studies included people of any age of either sex living in Organisation for Economic Co-operation and Development (OECD) countries with any health condition. Primary and secondary outcome measures The primary outcome measure was unscheduled secondary care as measured by emergency department attendance and emergency hospital admissions. Results 48 papers were identified describing potential influencing features on emergency department visits (n=24 studies) and emergency admissions (n=22 studies). Patient factors associated with both outcomes were increased age, reduced socioeconomic status, lower educational attainment, chronic disease and multimorbidity. Features of primary care affecting unscheduled secondary care were more complex. Being able to see the same healthcare professional reduced unscheduled secondary care. Generally, better access was associated with reduced unscheduled care in the USA. Proximity to healthcare provision influenced patterns of use. Evidence relating to quality of care was limited and mixed. Conclusions The majority of research was from different healthcare systems and limited in the extent to which it can inform policy. However, there is evidence that continuity of care is associated with reduced emergency department attendance and emergency hospital admissions.

Pharmacist-led interventions to reduce unplanned admissions for older people: a systematic review and meta-analysis of randomised controlled trials

PURPOSE medication problems are thought to cause between 10 and 30% of all hospital admissions in older people. This systematic review aimed to evaluate the effectiveness of interventions led by hospital or community pharmacists in reducing unplanned hospital admissions for older people. METHODS eighteen databases were searched with a customised search strategy. Relevant websites and reference lists of included trials were checked. Randomised controlled trials were included that evaluated pharmacist-led interventions compared with usual care, with unplanned admissions or readmissions as an outcome. Two authors independently extracted data and assessed methodological quality. RESULTS twenty-seven randomised controlled trials (RCTs) were identified; seven trials were excluded. The 20 included trials comprised 16 for older people and 4 for older people with heart failure. Interventions led by hospital pharmacists (seven trials) or community pharmacists (nine trials) did not reduce unplanned admissions in the older population (risk ratios 0.97 95% CI: 0.88, 1.07; 1.07 95% CI: 0.96, 1.20). Three trials in older people with heart failure showed that interventions delivered by a hospital pharmacist reduced the relative risk of admissions. However, these trials were heterogeneous in intensity and duration of follow-up. One trial had a high risk of bias. CONCLUSIONS evidence from three randomised controlled trials suggests that interventions led by hospital pharmacists reduce unplanned hospital admissions in older patients with heart failure, although these trials were heterogeneous. Data from 16 trials do not support the concept that interventions led by hospital or community pharmacists for the general older population reduces unplanned admissions.

The content of general practice consultations: cross-sectional study based on video recordings.

BACKGROUND Demographic and policy changes appear to be increasing the complexity of consultations in general practice. AIM To describe the number and types of problems discussed in general practice consultations, differences between problems raised by patients or doctors, and between problems discussed and recorded in medical records. DESIGN AND SETTING Cross-sectional study based on video recordings of consultations in 22 general practices in Bristol and North Somerset. METHOD Consultations were examined between 30 representative GPs and adults making a pre-booked day-time appointment. The main outcome measures were number and types of problems and issues discussed; who raised each problem/issue; consultation duration; whether problems were recorded and coded. RESULTS Of 318 eligible patients, 229 (72.0%) participated. On average, 2.5 (95% CI = 2.3 to 2.6) problems were discussed in each consultation, with 41% of consultations involving at least three problems. Seventy-two per cent (165/229) of consultations included problems in multiple disease areas. Mean consultation duration was 11.9 minutes (95% CI = 11.2 to 12.6). Most problems discussed were raised by patients, but 43% (99/229) of consultations included problems raised by doctors. Consultation duration increased by 2 minutes per additional problem. Of 562 problems discussed, 81% (n = 455) were recorded in notes, but only 37% (n = 206) were Read Coded. CONCLUSION Consultations in general practice are complex encounters, dealing with multiple problems across a wide range of disease areas in a short time. Additional problems are dealt with very briefly. GPs, like patients, bring an agenda to consultations. There is systematic bias in the types of problems coded in electronic medical records databases.

Specialist clinics for reducing emergency admissions in patients with heart failure: a systematic review and meta-analysis of randomised controlled trials

Unplanned admissions for heart failure are common and some are considered preventable. Objective Undertake a systematic literature review and meta-analysis to evaluate the effectiveness of specialist clinics in reducing unplanned hospital admissions in people with heart failure. Data sources 18 databases were searched from inception to June 2010. Relevant websites and reference lists of included studies were checked for additional publications. Study selection Randomised controlled trials in Organisation for Economic Co-operation and Development countries that evaluated the effectiveness of specialist clinic interventions for heart failure compared with usual care, where unplanned heart failure admissions or readmissions were an outcome. Data extraction Data were extracted by one reviewer and checked by a second reviewer. Results 10 of 17 randomised controlled trials met the inclusion criteria. Specialist clinics showed a reduction in unplanned admissions at 12 months (pooled risk ratio (RR) for five studies 0.51 (95% CI 0.33 to 0.76); absolute risk reduction 16 per 100 (95% CI 12 to 20)). Studies with initial frequent (weekly/fortnightly) appointments reducing in frequency over the study duration demonstrated a 58% RR reduction in unplanned admissions (pooled RR for three studies 0.42 (95% CI 0.27 to 0.65); absolute risk reduction 14 per 100 (95% CI 7 to 20)). Clinics conducted on a monthly or 3 monthly basis throughout or tailored to the individual patients did not show an effect. Conclusions Specialist clinics for patients with heart failure can reduce the risk of unplanned admissions; these were most effective when there was a high intensity of clinic appointments close to the time of discharge which then reduced over the follow-up period.

Is case management effective in reducing the risk of unplanned hospital admissions for older people? A systematic review and meta-analysis

BACKGROUND Case management is a collaborative practice involving coordination of care by a range of health professionals, both within the community and at the interface of primary and secondary care. It has been promoted as a way of reducing unplanned admissions in older people. OBJECTIVE The objective was to systematically review evidence from randomized controlled trials regarding the effectiveness of case management in reducing the risk of unplanned hospital admissions in older people. METHODS Eighteen databases were searched from inception to June 2010. Relevant websites were searched with key words and reference lists of included studies checked. A risk-of-bias tool was used to assess included studies and data extraction performed using customized tables. The primary outcome of interest was enumeration of unplanned hospital admission or readmissions. RESULTS Eleven trials of case management in the older population were included. Risk of bias was generally low. Six were trials of hospital-initiated case management. Three were suitable for meta-analysis, of which two showed a reduction in unplanned admissions. Overall, there was no statistically significant reduction in unplanned admissions [relative rate: 0.71 (95% confidence interval, CI: 0.49 to 1.03)]. Three trials reported reduced length of stay. Five trials were of community-initiated case management. None showed a reduction in unplanned admissions. Three were suitable for meta-analysis [mean difference in unplanned admissions: 0.05 (95% CI: -0.04 to 0.15)]. CONCLUSIONS The identified trials included a range of case management interventions. Nine of the 11 trials showed no reduction of unplanned hospital admissions with case management compared with the same with usual care.

Implications of comorbidity for primary care costs in the UK: a retrospective observational study

BACKGROUND Comorbidity is increasingly common in primary care. The cost implications for patient care and budgetary management are unclear. AIM To investigate whether caring for patients with specific disease combinations increases or decreases primary care costs compared with treating separate patients with one condition each. DESIGN Retrospective observational study using data on 86 100 patients in the General Practice Research Database. METHOD Annual primary care cost was estimated for each patient including consultations, medication, and investigations. Patients with comorbidity were defined as those with a current diagnosis of more than one chronic condition in the Quality and Outcomes Framework. Multiple regression modelling was used to identify, for three age groups, disease combinations that increase (cost-increasing) or decrease (cost-limiting) cost compared with treating each condition separately. RESULTS Twenty per cent of patients had at least two chronic conditions. All conditions were found to be both cost-increasing and cost-limiting when co-occurring with other conditions except dementia, which is only cost-limiting. Depression is the most important cost-increasing condition when co-occurring with a range of conditions. Hypertension is cost-limiting, particularly when co-occurring with other cardiovascular conditions. CONCLUSION Three categories of comorbidity emerge, those that are: cost-increasing, mainly due to a combination of depression with physical comorbidity; cost-limiting because treatment for the conditions overlap; and cost-limiting for no apparent reason but possibly because of inadequate care. These results can contribute to efficient and effective management of chronic conditions in primary care.

Emergency respiratory admissions: influence of practice, population and hospital factors.

Objective To determine the influence of population, hospital and general practice characteristics on practice admission rates for asthma and chronic obstructive pulmonary disease (COPD) in England. Methods Cross sectional study using Hospital Episode Statistics (HES), routine population data and primary care data. Admissions for all general practices in England during 2005-06, adjusted for age and sex composition of practice population. Univariable analysis of population, practice and hospital care provision variables, including prevalence and quality data. Significant factors included in multiple regression Poisson model. Results Admissions from 8169 practices were included. Risk of admission for each condition increased with deprivation, prevalence and smoking. Admission rates were higher in urban than rural practices. Hospital bed availability and distance to the nearest emergency department were also significantly associated with risk of admission. The associations with practice factors including practice size and quality markers varied across conditions. Conclusions Practice population, geographic and hospital supply factors are consistently associated with asthma and COPD admissions. Higher smoking rates among such patients in a practice are associated with higher admission rates. There is little evidence from this study that other modifiable general practice factors are important in influencing admission rates.

Reducing hospital admissions

Guidance should be evidence based and take a holistic view of patient care

Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process

Background Telephone calls for emergency ambulances are rising annually, increasing the pressure on ambulance resources for clinical problems that could often be appropriately managed in primary care. Objective To explore and understand patient and carer decision making around calling an ambulance for primary care-appropriate health problems. Methods Semistructured interviews were conducted with patients and carers who had called an ambulance for a primary care-appropriate problem. Participants were identified using a purposive sampling method by a non-participating research clinician attending ‘999’ ambulance calls. A thematic analysis of interview transcripts was undertaken. Results A superordinate theme, patient and carer anxiety in urgent-care decision making, and four subthemes were explored: perceptions of ambulance-based urgent care; contrasting perceptions of community-based urgent care; influence of previous urgent care experiences in decision making; and interpersonal factors in lay assessment and management of medical risk and subsequent decision making. Conclusions Many calls are based on fundamental misconceptions about the types of treatment other urgent-care avenues can provide, which may be amenable to educational intervention. This is particularly relevant for patients with chronic conditions with frequent exacerbations. Callers who have care responsibilities often default to the most immediate response available, with decision making driven by a lower tolerance of perceived risk. There may be a greater role for more detailed triage in these cases, and closer working between ambulance responses and urgent primary care, as a perceived or actual distance between these two service sectors may be influencing patient decision making on urgent care.