Do primary care quality improvement frameworks consider equity?

BACKGROUND: Quality improvement (QI) is used by healthcare organisations internationally to improve care. Unless QI explicitly addresses equity, projects that aim to improve care may exacerbate health and care inequalities for disadvantaged groups. There are several QI frameworks used in primary care, but we do not know the extent to which they consider equity. This work aimed to investigate whether primary care QI frameworks consider equity. METHODS: We conducted a search of MEDLINE, EMBASE and key websites to compile a list of the QI frameworks used in primary care. This list was refined by an expert panel. Guidance documents for each of the QI frameworks were identified from national websites or QI organisations. We undertook a document analysis of the guidance using NVivo. RESULTS: We analysed 15 guidance documents. We identified the following themes: (1) there was a limited discussion of equity or targeted QI for disadvantaged groups in the documents, (2) there were indirect considerations of inequalities via patient involvement or targeting QI to patient demographics and (3) there was a greater focus on efficiency than equity in the documents. CONCLUSION: There is limited consideration of equity in QI frameworks used in primary care. Where equity is discussed, it is implicit and open to interpretation. This research demonstrates a need for frameworks to be revised with an explicit equity focus to ensure the distribution of benefits from QI is equitable.

Does workforce explain the relationship between funding and patient experience? A mediation analysis of primary care data in England.

OBJECTIVES: To determine whether general practitioner (GP) workforce contributes to the link between practice funding and patient experience. Specifically, to determine whether increased practice funding is associated with better patient experience, and to what degree an increase in workforce accounts for this relationship. SETTING: Primary care practice level analysis of workforce, funding and patient experience of all NHS practices in England. PRIMARY AND SECONDARY OUTCOME MEASURES: The link between NHS-provided funding to general practice (payments per patient) and patient experience, as per the General Practice Patient Survey, was evaluated. Subsequently, mediation analysis, adjusted for covariates, was used to scrutinise the extent to which GP workforce accounts for this relationship (measured as the number of GPs per 10 000 patients). PARTICIPANTS: We included all general practices in England for which there was relevant data for each primary variable. Atypical practices were excluded, such as those with a patient list size of 0 or where the workforce variable was recorded as being more than 3 SD from the mean. After exclusion, 6139 practices were included in the final analysis. RESULTS: We found that workforce (GPs per 10 000 population) significantly (p<0.001) acts as a mediator in the effect of practice funding on overall patient experience even after adjusting for rurality, sex and age, and deprivation. On average, the mediated effect constitutes 30% of the total effect of practice funding on patient experience. CONCLUSIONS: The increase in the number of doctors in primary care in England appears to be a mechanism through which augmented practice funding could positively impact patient experience. Policy initiatives targeting improved patient experience should prioritise considerations related to workforce and practice funding.

What impact do self-referral and direct access pathways for patients have on health inequalities?

BACKGROUND: There is increasing interest in self-referral and direct access as alternatives pathways to care to improve patient access to specialist services. The impact of these pathways on health inequalities is unknown. OBJECTIVES: The purpose of this systematic review is to explore the impact of self-referral and direct access pathways on inequalities in health care use. DESIGN: Three databases (Ovid Medline, Embase, Web of Science) and grey literature were systematically searched for articles from January 2000 to February 2023, reporting on self-referral and direct access pathways to care. Title and abstracts were screened against eligibility criteria to identify studies that evaluated the impact on health inequalities. Data were extracted from eligible studies after full text review and a quality assessment was performed using the ROBINS-I tool. RESULTS: The search strategy identified 2948 articles. Nineteen records were included, covering seven countries and six healthcare services. The impact of self-referral and direct access on inequalities was mixed, suggesting that the relationship is dependent on patient and system factors. Typically self-referral pathways and direct access pathways tend to widen health inequalities. White, younger, educated women from less deprived backgrounds are more likely to self-refer, exacerbating existing health inequalities. CONCLUSIONS: Self-referral pathways risk widening health inequalities. Further research is required to understand the context-dependent mechanisms by which this can occur, explore ways to mitigate this and even narrow health inequalities, as well as understand the impact on the wider healthcare system.

Systematic review of the effectiveness of the health inequalities strategy in England between 1999 and 2010.

OBJECTIVES: The purpose of this systematic review is to explore the effectiveness of the National Health Inequality Strategy, which was conducted in England between 1999 and 2010. DESIGN: Three databases (Ovid Medline, Embase and PsycINFO) and grey literature were searched for articles published that reported on changes in inequalities in health outcomes in England over the implementation period. Articles published between January 1999 and November 2021 were included. Title and abstracts were screened according to an eligibility criteria. Data were extracted from eligible studies, and risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions tool. RESULTS: The search strategy identified 10 311 unique studies, which were screened. 42 were reviewed in full text and 11 were included in the final review. Six studies contained data on inequalities of life expectancy or mortality, four on disease-specific mortality, three on infant mortality and three on morbidities. Early government reports suggested that inequalities in life expectancy and infant mortality had increased. However, later publications using more accurate data and more appropriate measures found that absolute and relative inequalities had decreased throughout the strategy period for both measures. Three of four studies found a narrowing of inequalities in all-cause mortality. Absolute inequalities in mortality due to cancer and cardiovascular disease decreased, but relative inequalities increased. There was a lack of change, or widening of inequalities in mental health, self-reported health, health-related quality of life and long-term conditions. CONCLUSIONS: With respect to its aims, the strategy was broadly successful. Policymakers should take courage that progress on health inequalities is achievable with long-term, multiagency, cross-government action. TRIAL REGISTRATION NUMBER: This study was registered in PROSPERO (CRD42021285770).

How and why do financial incentives contribute to helping people stop smoking? A realist review protocol.

INTRODUCTION: Smoking is harmful to human health and programmes to help people stop smoking are key public health efforts that improve individual and population health outcomes. Research shows that financial incentives improve the success of stop smoking programmes. However, a better understanding of how they work is needed to better inform policy and to support building capability for implementation.The aims of this study: (1) To review the international literature to understand: How, why, in what circumstances and for whom financial incentives improve the success of stop smoking interventions among general population groups and among pregnant women. (2) To provide recommendations for how to best use financial incentives in efforts to promote smoking cessation. METHODS AND ANALYSIS: A realist review of published international literature will be undertaken to understand how, why, for whom and in which circumstances financial incentives contribute to success in stopping smoking for general population groups and among pregnant women. Systematic searches were undertaken on 16 February 2022 of five academic databases: MEDLINE (ovid), Embase.com, CIHAHL, Scopus and PsycINFO. Iterative searching using citation tracking and of grey literature will be undertaken as needed. Using Pawson and Tilley's iterative realist review approach, data collected will be screened, selected, coded, analysed and synthesised into a set of explanatory theoretical findings. ETHICS AND DISSEMINATION: Ethical approval is not required for this review as data sources to be included are previously published. The study will provide important findings for policy-makers and health system leaders to guide the development of stop smoking services which use incentives, for example, as part of the Health Service Executive's Tobacco Free Programme in Ireland. Understanding how contextual factors impact implementation and programmatic success is key to developing a more effective public health approach to stop smoking. Our dissemination strategy will be developed with our stakeholders. PROSPERO REGISTRATION NUMBER: CRD42022298941.

Health equity audits: a systematic review of the effectiveness.

OBJECTIVES: The purpose of this systematic review is to explore whether health equity audits (HEAs) are effective in improving the equity of service provision and reducing health inequalities. DESIGN: Three databases (Ovid Medline, Embase, Web of Science) and grey literature (Opengrey, Google Scholar) were systematically searched for articles published after 2000, reporting on the effectiveness of HEA. Title and abstracts were screened according to an eligibility criteria to identify studies which included a full audit cycle (eg, initial equity analysis, service changes and review). Data were extracted from studies meeting the eligibility criteria after full text review and risk of bias assessed using the ROBINS-I tool. RESULTS: The search strategy identified 596 articles. Fifteen records were reviewed in full text and three records were included in final review. An additional HEA report was identified through contact with an author. Three different HEAs were included from one peer-reviewed journal article, two published reports and one unpublished report (n=4 records on n=3 HEAs). This included 102 851 participants and over 148 practices/pharmacies (information was not recorded for all records). One study reviewed health equity impacts of HEA implementation in key indicators for coronary heart disease, type 2 diabetes and chronic obstructive pulmonary disease. Two HEAs explored Stop Smoking Services on programme access and equity. All reported some degree of reduction in health inequalities compared with prior HEA implementation. However, impact of HEA implementation compared with other concurrent programmes and initiatives was unclear. All included studies were judged to have moderate to serious risk of bias. CONCLUSIONS: There is an urgent need to identify effective interventions to address health inequalities. While HEAs are recommended, we only identified limited weak evidence to support their use. More evidence is needed to explore whether HEA implementation can reduce inequalities and which factors are influencing effectiveness. TRIAL REGISTRATION NUMBER: The study was registered prior to its conduction in PROSPERO (CRD 42020218642).

Reducing health inequalities through general practice: protocol for a realist review (EQUALISE).

INTRODUCTION: Healthcare organisations recognise the moral imperative to address inequalities in health outcomes but often lack an understanding of which types of interventions are likely to reduce them. This realist review will examine the existing evidence on the types of interventions or aspects of routine care in general practice that are likely to decrease or increase health inequalities (ie, inequality-generating interventions) across cardiovascular disease, cancer, diabetes and chronic obstructive pulmonary disease. METHODS AND ANALYSIS: Our realist review will follow Pawson's five iterative stages. We will start by developing an initial programme theory based on existing theories and discussions with stakeholders. To navigate the large volume of literature, we will access the primary studies through the identification of published systematic reviews of interventions delivered in general practice across the four key conditions. We will examine the primary studies included within each systematic review to identify those reporting on inequalities across PROGRESS-Plus categories. We will collect data on a range of clinical outcomes including prevention, diagnosis, follow-up and treatment. The data will be synthesised using a realist logic of analysis. The findings will be a description and explanation of the general practice interventions which are likely to increase or decrease inequalities across the major conditions. ETHICS AND DISSEMINATION: Ethics approval is not required because this study does not include any primary research. The findings will be integrated into a series of guiding principles and a toolkit for healthcare organisations to reduce health inequalities. Findings will be disseminated through peer-reviewed publications, conference presentations and user-friendly summaries. PROSPERO REGISTRATION NUMBER: CRD42020217871.

Current treatments in diabetic macular oedema: systematic review and meta-analysis.

OBJECTIVES: The aim of this systematic review is to appraise the evidence for the use of anti-VEGF drugs and steroids in diabetic macular oedema (DMO) as assessed by change in best corrected visual acuity (BCVA), central macular thickness and adverse events DATA SOURCE: MEDLINE, EMBASE, Web of Science with Conference Proceedings and the Cochrane Library (inception to July 2012). Certain conference abstracts and drug regulatory web sites were also searched. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS: Randomised controlled trials were used to assess clinical effectiveness and observational trials were used for safety. Trials which assessed triamcinolone, dexamethasone, fluocinolone, bevacizumab, ranibizumab, pegaptanib or aflibercept in patients with DMO were included. STUDY APPRAISAL AND SYNTHESIS METHODS: Risk of bias was assessed using the Cochrane risk of bias tool. Study results are narratively described and, where appropriate, data were pooled using random effects meta-analysis. RESULTS: Anti-VEGF drugs are effective compared to both laser and placebo and seem to be more effective than steroids in improving BCVA. They have been shown to be safe in the short term but require frequent injections. Studies assessing steroids (triamcinolone, dexamethasone and fluocinolone) have reported mixed results when compared with laser or placebo. Steroids have been associated with increased incidence of cataracts and intraocular pressure rise but require fewer injections, especially when steroid implants are used. LIMITATIONS: The quality of included studies varied considerably. Five of 14 meta-analyses had moderate or high statistical heterogeneity. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: The anti-VEGFs ranibizumab and bevacizumab have consistently shown good clinical effectiveness without major unwanted side effects. Steroid results have been mixed and are usually associated with cataract formation and  intraocular pressure increase. Despite the current wider spectrum of treatments for DMO, only a small proportion of patients recover good vision (≥20/40), and thus the search for new therapies needs to continue.