Utz J. Pape

Associations between internet-based patient ratings and conventional surveys of patient experience in the English NHS: an observational study

Objective Unsolicited web-based comments by patients regarding their healthcare are increasing, but controversial. The relationship between such online patient reports and conventional measures of patient experience (obtained via survey) is not known. The authors examined hospital level associations between web-based patient ratings on the National Health Service (NHS) Choices website, introduced in England during 2008, and paper-based survey measures of patient experience. The authors also aimed to compare these two methods of measuring patient experience. Design The authors performed a cross-sectional observational study of all (n=146) acute general NHS hospital trusts in England using data from 9997 patient web-based ratings posted on the NHS Choices website during 2009/2010. Hospital trust level indicators of patient experience from a paper-based survey (five measures) were compared with web-based patient ratings using Spearmans rank correlation coefficient. The authors compared the strength of associations among clinical outcomes, patient experience survey results and NHS Choices ratings. Results Web-based ratings of patient experience were associated with ratings derived from a national paper-based patient survey (Spearman ρ=0.31–0.49, p<0.001 for all). Associations with clinical outcomes were at least as strong for online ratings as for traditional survey measures of patient experience. Conclusions Unsolicited web-based patient ratings of their care, though potentially prone to many biases, are correlated with survey measures of patient experience. They may be useful tools for patients when choosing healthcare providers and for clinicians to improve the quality of their services.

Association of systolic and diastolic blood pressure and all cause mortality in people with newly diagnosed type 2 diabetes: retrospective cohort study

Objective To examine the effect of systolic and diastolic blood pressure achieved in the first year of treatment on all cause mortality in patients newly diagnosed with type 2 diabetes, with and without established cardiovascular disease. Design Retrospective cohort study. Setting United Kingdom General Practice Research Database, between 1990 and 2005. Participants 126 092 adult patients (age ≥18 years) with a new diagnosis of type 2 diabetes who had been registered with participating practices for at least 12 months. Main outcome measure All cause mortality. Results Before diagnosis, 12 379 (9.8%) patients had established cardiovascular disease (myocardial infarction or stroke). During a median follow-up of 3.5 years, we recorded 25 495 (20.2%) deaths. In people with cardiovascular disease, tight control of systolic (<130 mm Hg) and diastolic (<80 mm Hg) blood pressure was not associated with improved survival, after adjustment for baseline characteristics (age at diagnosis, sex, practice level clustering, deprivation score, body mass index, smoking, HbA1c and cholesterol levels, and blood pressure). Low blood pressure was also associated with an increased risk of all cause mortality. Compared with patients who received usual control of systolic blood pressure (130-139 mm Hg), the hazard ratio of all cause mortality was 2.79 (95% confidence interval 1.74 to 4.48, P<0.001) for systolic blood pressure at 110 mm Hg. Compared with patients who received usual control of diastolic blood pressure (80-84 mm Hg), the hazard ratios were 1.32 (1.02 to 1.78, P=0.04) and 1.89 (1.40 to 2.56, P<0.001) for diastolic blood pressures at 70-74 mm Hg and lower than 70 mm Hg, respectively. Similar associations were found in people without cardiovascular disease. Subgroup analyses of people diagnosed with hypertension and who received treatment for hypertension confirmed initial findings. Conclusion Blood pressure below 130/80 mm Hg was not associated with reduced risk of all cause mortality in patients with newly diagnosed diabetes, with or without known cardiovascular disease. Low blood pressure, particularly below 110/75 mm Hg, was associated with an increased risk for poor outcomes.

Impacts of a national strategy to reduce population salt intake in England: serial cross sectional study.

Background The UK introduced an ambitious national strategy to reduce population levels of salt intake in 2003. The aim of this study was to evaluate the impact of this strategy on salt intake in England, including potential effects on health inequalities. Methods Secondary analysis of data from the Health Survey for England. Our main outcome measure was trends in estimated daily salt intake from 2003–2007, as measured by spot urine. Secondary outcome measures were knowledge of government guidance and voluntary use of salt in food preparation over this time period. Results There were significant reductions in salt intake between 2003 and 2007 (−0.175grams per day per year, p<0.001). Intake decreased uniformly across all other groups but remained significantly higher in younger persons, men, ethnic minorities and lower social class groups and those without hypertension in 2007. Awareness of government guidance on salt use was lowest in those groups with the highest intake (semi-skilled manual v professional; 64.9% v 71.0% AOR 0.76 95% CI 0.58–0.99). Self reported use of salt added at the table reduced significantly during the study period (56.5% to 40.2% p<0.001). Respondents from ethnic minority groups remained significantly more likely to add salt during cooking (white 42.8%, black 74.1%, south Asian 88.3%) and those from lower social class groups (unskilled manual 46.6%, professional 35.2%) were more likely to add salt at the table. Conclusions The introduction a national salt reduction strategy was associated with uniform but modest reductions in salt intake in England, although it is not clear precisely which aspects of the strategy contributed to this. Knowledge of government guidance was lower and voluntary salt use and total salt intake was higher among occupational and ethnic groups at greatest risk of cardiovascular disease.

Patients’ Ratings of Family Physician Practices on the Internet: Usage and Associations With Conventional Measures of Quality in the English National Health Service

Background Patients are increasingly rating their family physicians on the Internet in the same way as they might rate a hotel on TripAdvisor or a seller on eBay, despite physicians’ concerns about this process. Objective This study aims to examine the usage of NHS Choices, a government website that encourages patients to rate the quality of family practices in England, and associations between web-based patient ratings and conventional measures of patient experience and clinical quality in primary care. Methods We obtained all (16,952) ratings of family practices posted on NHS Choices between October 2009 and December 2010. We examined associations between patient ratings and family practice and population characteristics. Associations between ratings and survey measures of patient experience and clinical outcomes were examined. Results 61% of the 8089 family practices in England were rated, and 69% of ratings would recommend their family practice. Practices serving younger, less deprived, and more densely populated areas were more likely to be rated. There were moderate associations with survey measures of patient experience (Spearman ρ 0.37−0.48, P<.001 for all 5 variables), but only weak associations with measures of clinical process and outcome (Spearman ρ less than ±0.18, P<.001 for 6 of 7 variables). Conclusion The frequency of patients rating their family physicians on the Internet is variable in England, but the ratings are generally positive and are moderately associated with other measures of patient experience and weakly associated with clinical quality. Although potentially flawed, patient ratings on the Internet may provide an opportunity for organizational learning and, as it becomes more common, another lens to look at the quality of primary care.

The Uptake of Integrated Perinatal Prevention of Mother-to-Child HIV Transmission Programs in Low- and Middle-Income Countries: A Systematic Review

Background The objective of this review was to assess the uptake of WHO recommended integrated perinatal prevention of mother-to-child transmission (PMTCT) of HIV interventions in low- and middle-income countries. Methods and Findings We searched 21 databases for observational studies presenting uptake of integrated PMTCT programs in low- and middle-income countries. Forty-one studies on programs implemented between 1997 and 2006, met inclusion criteria. The proportion of women attending antenatal care who were counseled and who were tested was high; 96% (range 30–100%) and 81% (range 26–100%), respectively. However, the overall median proportion of HIV positive women provided with antiretroviral prophylaxis in antenatal care and attending labor ward was 55% (range 22–99%) and 60% (range 19–100%), respectively. The proportion of women with unknown HIV status, tested for HIV at labor ward was 70%. Overall, 79% (range 44–100%) of infants were tested for HIV and 11% (range 3–18%) of them were HIV positive. We designed two PMTCT cascades using studies with outcomes for all perinatal PMTCT interventions which showed that an estimated 22% of all HIV positive women attending antenatal care and 11% of all HIV positive women delivering at labor ward were not notified about their HIV status and did not participate in PMTCT program. Only 17% of HIV positive antenatal care attendees and their infants are known to have taken antiretroviral prophylaxis. Conclusion The existing evidence provides information only about the initial PMTCT programs which were based on the old WHO PMTCT guidelines. The uptake of counseling and HIV testing among pregnant women attending antenatal care was high, but their retention in PMTCT programs was low. The majority of women in the included studies did not receive ARV prophylaxis in antenatal care; nor did they attend labor ward. More studies evaluating the uptake in current PMTCT programs are urgently needed.

Association of practice size and pay-for-performance incentives with the quality of diabetes management in primary care.

Background: Not enough is known about the association between practice size and clinical outcomes in primary care. We examined this association between 1997 and 2005, in addition to the impact of the Quality and Outcomes Framework, a pay-for-performance incentive scheme introduced in the United Kingdom in 2004, on diabetes management. Methods: We conducted a retrospective open-cohort study using data from the General Practice Research Database. We enrolled 422 general practices providing care for 154 945 patients with diabetes. Our primary outcome measures were the achievement of national treatment targets for blood pressure, glycated hemoglobin (HbA1c) levels and total cholesterol. Results: We saw improvements in the recording of process of care measures, prescribing and achieving intermediate outcomes in all practice sizes during the study period. We saw improvement in reaching national targets after the introduction of the Quality and Outcomes Framework. These improvements significantly exceeded the underlying trends in all practice sizes for achieving targets for cholesterol level and blood pressure, but not for HbA1c level. In 1997 and 2005, there were no significant differences between the smallest and largest practices in achieving targets for blood pressure (1997 odds ratio [OR] 0.98, 95% confidence interval [CI] 0.82 to 1.16; 2005 OR 0.92, 95% CI 0.80 to 1.06 in 2005), cholesterol level (1997 OR 0.94, 95% CI 0.76 to 1.16; 2005 OR 1.1, 95% CI 0.97 to 1.40) and glycated hemoglobin level (1997 OR 0.79, 95% CI 0.55 to 1.14; 2005 OR 1.05, 95% CI 0.93 to 1.19). Interpretation: We found no evidence that size of practice is associated with the quality of diabetes management in primary care. Pay-for-performance programs appear to benefit both large and small practices to a similar extent.

Rural, urban and migrant differences in non-communicable disease risk-factors in middle income countries : a cross-sectional study of WHO-SAGE data

Background Understanding how urbanisation and rural-urban migration influence risk-factors for non-communicable disease (NCD) is crucial for developing effective preventative strategies globally. This study compares NCD risk-factor prevalence in urban, rural and migrant populations in China, Ghana, India, Mexico, Russia and South Africa. Methods Study participants were 39,436 adults within the WHO Study on global AGEing and adult health (SAGE), surveyed 2007–2010. Risk ratios (RR) for each risk-factor were calculated using logistic regression in country-specific and all country pooled analyses, adjusted for age, sex and survey design. Fully adjusted models included income quintile, marital status and education. Results Regular alcohol consumption was lower in migrant and urban groups than in rural groups (pooled RR and 95%CI: 0.47 (0.31–0.68); 0.58, (0.46–0.72), respectively). Occupational physical activity was lower (0.86 (0.72–0.98); 0.76 (0.65–0.85)) while active travel and recreational physical activity were higher (pooled RRs for urban groups; 1.05 (1.00–1.09), 2.36 (1.95–2.83), respectively; for migrant groups: 1.07 (1.0 -1.12), 1.71 (1.11–2.53), respectively). Overweight, raised waist circumference and diagnosed diabetes were higher in urban groups (1.19 (1.04–1.35), 1.24 (1.07–1.42), 1.69 (1.15–2.47), respectively). Exceptions to these trends exist: obesity indicators were higher in rural Russia; active travel was lower in urban groups in Ghana and India; and in South Africa, urban groups had the highest alcohol consumption. Conclusion Migrants and urban dwellers had similar NCD risk-factor profiles. These were not consistently worse than those seen in rural dwellers. The variable impact of urbanisation on NCD risk must be considered in the design and evaluation of strategies to reduce the growing burden of NCDs globally.

Effectiveness of the influenza vaccine in preventing admission to hospital and death in people with type 2 diabetes

Background: The health burden caused by seasonal influenza is substantial. We sought to examine the effectiveness of influenza vaccination against admission to hospital for acute cardiovascular and respiratory conditions and all-cause death in people with type 2 diabetes. Methods: We conducted a retrospective cohort study using primary and secondary care data from the Clinical Practice Research Datalink in England, over a 7-year period between 2003/04 and 2009/10. We enrolled 124 503 adults with type 2 diabetes. Outcome measures included admission to hospital for acute myocardial infarction (MI), stroke, heart failure or pneumonia/influenza, and death. We fitted Poisson regression models for influenza and off-season periods to estimate incidence rate ratios (IRR) for cohorts who had and had not received the vaccine. We used estimates for the summer, when influenza activity is low, to adjust for residual confounding. Results: Study participants contributed to 623 591 person-years of observation during the 7-year study period. Vaccine recipients were older and had more comorbid conditions compared with nonrecipients. After we adjusted for covariates and residual confounding, vaccination was associated with significantly lower admission rates for stroke (IRR 0.70, 95% confidence interval [CI] 0.53–0.91), heart failure (IRR 0.78, 95% CI 0.65–0.92) and pneumonia or influenza (IRR 0.85, 95% CI 0.74–0.99), as well as all-cause death (IRR 0.76, 95% CI 0.65–0.83), and a nonsignificant change for acute MI (IRR 0.81, 95% CI 0.62–1.04) during the influenza seasons. Interpretation: In this cohort of patients with type 2 diabetes, influenza vaccination was associated with reductions in rates of admission to hospital for specific cardiovascular events. Efforts should be focused on improvements in vaccine uptake in this important target group as part of comprehensive secondary prevention.

Disentangling secular trends and policy impacts in health studies: use of interrupted time series analysis:

Although randomized control trials (RCTs) are the ‘gold standard’ to evaluate treatment effects in health care, they are frequently not practical, ethical or politically acceptable in the evaluation of many health system or public health interventions. A good examplewhere a health system intervention has undergone evaluation using an RCT design is the universal health insurance scheme, Seguro Popular, in Mexico. However, this is a rare exception mainly due to the academic background of the Mexican Health Minister, Julio Frenk, who introduced the scheme. More frequently, randomization is not feasible or practical, particularly when interventions target whole or large subgroups of populations. Because of political considerations, policy makers often want to implement changes quickly and refuse to wait several years to determine a new intervention’s effects. Further, they may be reluctant to be seen to withhold an intervention from a particular community, as was the case with the SureStart programme, which aimed to improve health and educational outcomes in young children in the UK. RCTs may also be unethical where clear evidence of benefit has been demonstrated from observational studies, as was the case with cervical cancer screening. Additionally, lack of funding often poses a hurdle to formal evaluation through an RCT, as RCTs can be very costly to carry out. In the absence of an RCT, evaluations often use quasi-experimental designs such as a pre-post study design with measurements before and after the intervention period. Figure 1, panel A shows an introductory example with an outcome measure subject to a secular time trend and an intervention without any impact. The standard approach to detect a significant impact would apply a t-test to compare the means of the preintervention phase with the post-intervention data. However, a t-test does not consider time but simply separates the data into two groups. In the example in panel A of Figure 1, the t-test would obtain a significant p-value although the difference is not due to the intervention but rather captures the secular time trend. In settings with a secular trend, a t-test (or another statistical test) is prone to false positives, as illustrated in the example, and false negatives in case of a negative secular trend. An interrupted time series (ITS) in contrast, adjusts for secular time trends and should be used instead. Panel B of Figure 1 contains a new data set with an intervention affecting the outcome. An ITS is a segmental linear regression model; preintervention and post-intervention are each modeled as a linear regression. Based on an ITS, a secular trend can therefore be captured in the regression line as shown in panel B of Figure 1. An ITS compares the intercept and slope of the regression line before the intervention with the intercept and slope after intervention. A one-time baseline effect of the intervention without influencing the secular trend can be detected as an intercept change. If the intervention changed the secular trend, there will also be a significant difference in the slope between the two periods. Later, we will see that an ITS also comprises more flexible models. Instead of using an ITS design, many studies use preand post-intervention groups without modeling the secular time trend. Examples include evaluations of major interventions DECLARATIONS

Impact of 'stretch' targets for cardiovascular disease management within a local pay-for-performance programme.

Pay-for-performance programs are often aimed to improve the management of chronic diseases. We evaluate the impact of a local pay for performance programme (QOF+), which rewarded financially more ambitious quality targets (‘stretch targets’) than those used nationally in the Quality and Outcomes Framework (QOF). We focus on targets for intermediate outcomes in patients with cardiovascular disease and diabetes. A difference-in-difference approach is used to compare practice level achievements before and after the introduction of the local pay for performance program. In addition, we analysed patient-level data on exception reporting and intermediate outcomes utilizing an interrupted time series analysis. The local pay for performance program led to significantly higher target achievements (hypertension: p-value <0.001, coronary heart disease: p-values <0.001, diabetes: p-values <0.061, stroke: p-values <0.003). However, the increase was driven by higher rates of exception reporting (hypertension: p-value <0.001, coronary heart disease: p-values <0.03, diabetes: p-values <0.05) in patients with all conditions except for stroke. Exception reporting allows practitioners to exclude patients from target calculations if certain criteria are met, e.g. informed dissent of the patient for treatment. There were no statistically significant improvements in mean blood pressure, cholesterol or HbA1c levels. Thus, achievement of higher payment thresholds in the local pay for performance scheme was mainly attributed to increased exception reporting by practices with no discernable improvements in overall clinical quality. Hence, active monitoring of exception reporting should be considered when setting more ambitious quality targets. More generally, the study suggests a trade-off between additional incentive for better care and monitoring costs.