Ethnic differences in early onset multimorbidity and associations with health service use, long-term prescribing, years of life lost, and mortality: A cross-sectional study using clustering in the UK Clinical Practice Research Datalink.

BACKGROUND: The population prevalence of multimorbidity (the existence of at least 2 or more long-term conditions [LTCs] in an individual) is increasing among young adults, particularly in minority ethnic groups and individuals living in socioeconomically deprived areas. In this study, we applied a data-driven approach to identify clusters of individuals who had an early onset multimorbidity in an ethnically and socioeconomically diverse population. We identified associations between clusters and a range of health outcomes. METHODS AND FINDINGS: Using linked primary and secondary care data from the Clinical Practice Research Datalink GOLD (CPRD GOLD), we conducted a cross-sectional study of 837,869 individuals with early onset multimorbidity (aged between 16 and 39 years old when the second LTC was recorded) registered with an English general practice between 2010 and 2020. The study population included 777,906 people of White ethnicity (93%), 33,915 people of South Asian ethnicity (4%), and 26,048 people of Black African/Caribbean ethnicity (3%). A total of 204 LTCs were considered. Latent class analysis stratified by ethnicity identified 4 clusters of multimorbidity in White groups and 3 clusters in South Asian and Black groups. We found that early onset multimorbidity was more common among South Asian (59%, 33,915) and Black (56% 26,048) groups compared to the White population (42%, 777,906). Latent class analysis revealed physical and mental health conditions that were common across all ethnic groups (i.e., hypertension, depression, and painful conditions). However, each ethnic group also presented exclusive LTCs and different sociodemographic profiles: In White groups, the cluster with the highest rates/odds of the outcomes was predominantly male (54%, 44,150) and more socioeconomically deprived than the cluster with the lowest rates/odds of the outcomes. On the other hand, South Asian and Black groups were more socioeconomically deprived than White groups, with a consistent deprivation gradient across all multimorbidity clusters. At the end of the study, 4% (34,922) of the White early onset multimorbidity population had died compared to 2% of the South Asian and Black early onset multimorbidity populations (535 and 570, respectively); however, the latter groups died younger and lost more years of life. The 3 ethnic groups each displayed a cluster of individuals with increased rates of primary care consultations, hospitalisations, long-term prescribing, and odds of mortality. Study limitations include the exclusion of individuals with missing ethnicity information, the age of diagnosis not reflecting the actual age of onset, and the exclusion of people from Mixed, Chinese, and other ethnic groups due to insufficient power to investigate associations between multimorbidity and health-related outcomes in these groups. CONCLUSIONS: These findings emphasise the need to identify, prevent, and manage multimorbidity early in the life course. Our work provides additional insights into the excess burden of early onset multimorbidity in those from socioeconomically deprived and diverse groups who are disproportionately and more severely affected by multimorbidity and highlights the need to ensure healthcare improvements are equitable.

How do primary care doctors in England and Wales code and manage people with chronic kidney disease? Results from the National Chronic Kidney Disease Audit.

Background: In the UK, primary care records are electronic and require doctors to ascribe disease codes to direct care plans and facilitate safe prescribing. We investigated factors associated with coding of chronic kidney disease (CKD) in patients with reduced kidney function and the impact this has on patient management. Methods: We identified patients meeting biochemical criteria for CKD (two estimated glomerular filtration rates <60 mL/min/1.73 m2 taken >90 days apart) from 1039 general practitioner (GP) practices in a UK audit. Clustered logistic regression was used to identify factors associated with coding for CKD and improvement in coding as a result of the audit process. We investigated the relationship between coding and five interventions recommended for CKD: achieving blood pressure targets, proteinuria testing, statin prescription and flu and pneumococcal vaccination. Results: Of 256 000 patients with biochemical CKD, 30% did not have a GP CKD code. Males, older patients, those with more severe CKD, diabetes or hypertension or those prescribed statins were more likely to have a CKD code. Among those with continued biochemical CKD following audit, these same characteristics increased the odds of improved coding. Patients without any kidney diagnosis were less likely to receive optimal care than those coded for CKD [e.g. odds ratio for meeting blood pressure target 0.78 (95% confidence interval 0.76-0.79)]. Conclusion: Older age, male sex, diabetes and hypertension are associated with coding for those with biochemical CKD. CKD coding is associated with receiving key primary care interventions recommended for CKD. Increased efforts to incentivize CKD coding may improve outcomes for CKD patients.

Accounting for overdispersion when determining primary care outliers for the identification of chronic kidney disease: learning from the National Chronic Kidney Disease Audit.

Background: Early diagnosis of chronic kidney disease (CKD) facilitates best management in primary care. Testing coverage of those at risk and translation into subsequent diagnostic coding will impact on observed CKD prevalence. Using initial data from 915 general practitioner (GP) practices taking part in a UK national audit, we seek to apply appropriate methods to identify outlying practices in terms of CKD stages 3-5 prevalence and diagnostic coding. Methods: We estimate expected numbers of CKD stages 3-5 cases in each practice, adjusted for key practice characteristics, and further inflate the control limits to account for overdispersion related to unobserved factors (including unobserved risk factors for CKD, and between-practice differences in coding and testing). Results: GP practice prevalence of coded CKD stages 3-5 ranges from 0.04 to 7.8%. Practices differ considerably in coding of CKD in individuals where CKD is indicated following testing (ranging from 0 to 97% of those with and glomerular filtration rate <60 mL/min/1.73 m 2 ). After adjusting for risk factors and overdispersion, the number of 'extreme' practices is reduced from 29 to 2.6% for the low-coded CKD prevalence outcome, from 21 to 1% for high-uncoded CKD stage and from 22 to 2.4% for low total (coded and uncoded) CKD prevalence. Thirty-one practices are identified as outliers for at least one of these outcomes. These can then be categorized into practices needing to address testing, coding or data storage/transfer issues. Conclusions: GP practice prevalence of coded CKD shows wide variation. Accounting for overdispersion is crucial in providing useful information about outlying practices for CKD prevalence.

The impact of a social prescribing service on patients in primary care: a mixed methods evaluation.

BACKGROUND: Social prescribing is targeted at isolated and lonely patients. Practitioners and patients jointly develop bespoke well-being plans to promote social integration and or social reactivation. Our aim was to investigate: whether a social prescribing service could be implemented in a general practice (GP) setting and to evaluate its effect on well-being and primary care resource use. METHODS: We used a mixed method evaluation approach using patient surveys with matched control groups and a qualitative interview study. The study was conducted in a mixed socio-economic, multi-ethnic, inner city London borough with socially isolated patients who frequently visited their GP. The intervention was implemented by 'social prescribing coordinators'. Outcomes of interest were psychological and social well-being and health care resource use. RESULTS: At 8 months follow-up there were no differences between patients referred to social prescribing and the controls for general health, depression, anxiety and 'positive and active engagement in life'. Social prescribing patients had high GP consultation rates, which fell in the year following referral. The qualitative study indicated that most patients had a positive experience with social prescribing but the service was not utilised to its full extent. CONCLUSION: Changes in general health and well-being following referral were very limited and comprehensive implementation was difficult to optimise. Although GP consultation rates fell, these may have reflected regression to the mean rather than changes related to the intervention. Whether social prescribing can contribute to the health of a nation for social and psychological wellbeing is still to be determined.

Unmasking quality: exploring meanings of health by doing art.

BACKGROUND: Quality in healthcare has many potential meanings and interpretations. The case has been made for conceptualisations of quality that place more emphasis on describing quality and less on measuring it through structured, vertically oriented metrics. Through discussion of an interdisciplinary community arts project we explore and challenge the dominant reductionist meanings of quality in healthcare. DISCUSSION: The model for structured participatory arts workshops such as ours is 'art as conversation'. In creating textile art works, women involved in the sewing workshops engaged at a personal level, developing confidence through sharing ideas, experiences and humour. Group discussions built on the self-assurance gained from doing craft work together and talking in a relaxed way with a common purpose, exploring the health themes which were the focus of the art. For example, working on a textile about vitamin D created a framework which stimulated the emergence of a common discourse about different cultural practices around 'going out in the sun'. These conversations have value as 'bridging work', between the culture of medicine, with its current emphasis on lifestyle change to prevent illness, and patients' life worlds. Such bridges allow for innovation and flexibility to reflect local public health needs and community concerns. They also enable us to view care from a horizontally oriented perspective, so that the interface in which social worlds and the biomedical model meet and interpenetrate is made visible. Through this interdisciplinary art project involving academics, health professionals and the local community we have become more sensitised to conceptualising one aspect of health care quality as ensuring a 'space for the story' in health care encounters. This space gives precedence to the patient narratives, but acknowledges the importance of enabling clinicians to have time to share stories about care.

Characteristics of patients with asthma overprescribed short-acting beta-agonist (SABA) reliever inhalers stratified by blood eosinophil count in North East London: a cross-sectional observational study.

BACKGROUND: Overprescription of short-acting beta-agonist (SABA) inhalers and blood eosinophil count have strong associations with exacerbation risk in asthma. However, in the authors' recent publication only a minority of patients overprescribed SABA (≥6 inhalers in 12 months) were eosinophilic (≥0.3 x 109 cells/l). AIM: To compare the characteristics of eosinophilic and non-eosinophilic patients with asthma overprescribed SABA inhalers, and identify latent classes using clinical variables available in primary care. DESIGN & SETTING: Cross-sectional analysis of patients with asthma in North East London, England, using primary care electronic health record data. METHOD: Unadjusted and adjusted multi-variate regression models and latent class analysis. RESULTS: Eosinophilia was significantly less likely in female patients (P = 0.004), those with multiple mental health comorbidities (P<0.001), and those with SABA on repeat prescription (P<0.001). Latent class analysis identified the following three classes of patients overprescribed SABA: class 1, which represents classical uncontrolled asthma (oral steroids required for exacerbations, step 2-3 asthma medications, high probability of being eosinophilic); class 2, which represents mild asthma (low exacerbation frequency, low asthma medication step, low probability of being eosinophilic); and class 3, which represents difficult asthma (high exacerbation frequency despite high-strength preventer inhalers, low probability of being eosinophilic). The mild asthma class was the largest. CONCLUSION: Many patients being overprescribed SABA were non-eosinophilic with a low exacerbation frequency, suggesting disproportionately high SABA prescription compared with other asthma control markers. Potential reasons for high SABA prescription in these patients included repeat prescription (being dispensed but not taken) and use of SABA for non-asthma breathlessness (for example, breathing pattern disorders with anxiety). Further research is needed into management of SABA overuse in patients without other markers of uncontrolled asthma.

Characterisation of type 2 diabetes subgroups and their association with ethnicity and clinical outcomes: a UK real-world data study using the East London Database.

BACKGROUND: Subgroups of type 2 diabetes (T2DM) have been well characterised in experimental studies. It is unclear, however, whether the same approaches can be used to characterise T2DM subgroups in UK primary care populations and their associations with clinical outcomes. AIM: To derive T2DM subgroups using primary care data from a multi-ethnic population, evaluate associations with glycaemic control, treatment initiation, and vascular outcomes, and to understand how these vary by ethnicity. DESIGN AND SETTING: An observational cohort study in the East London Primary Care Database from 2008 to 2018. METHOD: Latent-class analysis using age, sex, glycated haemoglobin, and body mass index at diagnosis was used to derive T2DM subgroups in white, South Asian, and black groups. Time to treatment initiation and vascular outcomes were estimated using multivariable Cox-proportional hazards regression. RESULTS: In total, 31 931 adults with T2DM were included: 47% South Asian (n = 14 884), 26% white (n = 8154), 20% black (n = 6423). Two previously described subgroups were replicated, 'mild age-related diabetes' (MARD) and 'mild obesity-related diabetes' (MOD), and a third was characterised 'severe hyperglycaemic diabetes' (SHD). Compared with MARD, SHD had the poorest long-term glycaemic control, fastest initiation of antidiabetic treatment (hazard ratio [HR] 2.02, 95% confidence interval [CI] = 1.76 to 2.32), and highest risk of microvascular complications (HR 1.38, 95% CI = 1.28 to 1.49). MOD had the highest risk of macrovascular complications (HR 1.50, 95% CI = 1.23 to 1.82). Subgroup differences in treatment initiation were most pronounced for the white group, and vascular complications for the black group. CONCLUSION: Clinically useful T2DM subgroups, identified at diagnosis, can be generated in routine real-world multi-ethnic populations, and may offer a pragmatic means to develop stratified primary care pathways and improve healthcare resource allocation.

Measuring continuity of care in general practice: a comparison of two methods using routinely collected data.

BACKGROUND: Despite well-documented clinical benefits of longitudinal doctor-patient continuity in primary care, continuity rates have declined. Assessment by practices or health commissioners is rarely undertaken. AIM: Using the Usual Provider of Care (UPC) score this study set out to measure continuity across 126 practices in the mobile, multi-ethnic population of East London, comparing these scores with the General Practice Patient Survey (GPPS) responses to questions on GP continuity. DESIGN AND SETTING: A retrospective, cross-sectional study in all 126 practices in three East London boroughs. METHOD: The study population included patients who consulted three or more times between January 2017 and December 2018. Anonymised demographic and consultation data from the electronic health record were linked to results from Question 10 ('seeing the doctor you prefer') of the 2019 GPPS. RESULTS: The mean UPC score for all 126 practices was 0.52 (range 0.32 to 0.93). There was a strong correlation between practice UPC scores measured in the 2 years to December 2018 and responses to the 2019 GPPS Question 10, Pearson's r correlation coefficient, 0.62. Smaller practices had higher scores. Multilevel analysis showed higher continuity for patients ≥65 years compared with children and younger adults (ß coefficient 0.082, 95% confidence interval = 0.080 to 0.084) and for females compared with males. CONCLUSION: It is possible to measure continuity across all practices in a local health economy. Regular review of practice continuity rates can be used to support efforts to increase continuity within practice teams. In turn this is likely to have a positive effect on clinical outcomes and on satisfaction for both patients and doctors.

Reducing short-acting beta-agonist overprescribing in asthma: lessons from a quality-improvement prescribing project in East London.

BACKGROUND: Excess prescription and use of short-acting beta-agonist (SABA) inhalers is associated with poor asthma control and increased risk of hospital admission. AIM: To quantify the prevalence and identify the predictors of SABA overprescribing. DESIGN AND SETTING: A cross-sectional study using anonymised clinical and prescribing data from the primary care records in three contiguous East London boroughs. METHOD: Primary care medical record data for patients aged 5-80 years, with 'active' asthma were extracted in February 2020. Explanatory variables included demography, asthma management, comorbidities, and prescriptions for asthma medications. RESULTS: In the study population of 30 694 people with asthma, >25% (1995/7980), were prescribed ≥6 SABA inhalers in the previous year. A 10-fold variation between practices (<6% to 60%) was observed in the proportion of patients on ≥6 SABA inhalers/year. By converting both SABAs and inhaled corticosteroids (ICSs) to standard units the accuracy of comparisons was improved across different preparations. In total, >25% of those taking ≥6 SABAs/year were underusing ICSs, this rose to >80% (18 170/22 713), for those prescribed <6 SABAs/year. Prescription modality was a strong predictor of SABA overprescribing, with repeat dispensing strongly linked to SABA overprescribing (odds ratio 6.52, 95% confidence interval = 4.64 to 9.41). Increasing severity of asthma and multimorbidity were also independent predictors of SABA overprescribing. CONCLUSION: In this multi-ethnic population a fifth of practices demonstrate an overprescribing rate of <20% a year. Based on previous data, supporting practices to enable the SABA ≥12 group to reduce to 4-12 a year could potentially save up to 70% of asthma admissions a year within that group.

Association between practice coding of chronic kidney disease (CKD) in primary care and subsequent hospitalisations and death: a cohort analysis using national audit data.

OBJECTIVE: To examine the association between practice percentage coding of chronic kidney disease (CKD) in primary care with risk of subsequent hospitalisations and death. DESIGN: Retrospective cohort study using linked electronic healthcare records. SETTING: 637 general practitioner (GP) practices in England. PARTICIPANTS: 167 208 patients with CKD stages 3-5 identified by 2 measures of estimated glomerular filtration rate <60 mL/min/1.73 m2, separated by at least 90 days, excluding those with coded initiation of renal replacement therapy. MAIN OUTCOME MEASURES: Hospitalisations with cardiovascular (CV) events, heart failure (HF), acute kidney injury (AKI) and all-cause mortality RESULTS: Participants were followed for (median) 3.8 years for hospital outcomes and 4.3 years for deaths. Rates of hospitalisations with CV events and HF were lower in practices with higher percentage CKD coding. Trends of a small reduction in AKI but no substantial change in rate of deaths were also observed as CKD coding increased. Compared with patients in the median performing practice (74% coded), patients in practices coding 55% of CKD cases had a higher rate of CV hospitalisations (HR 1.061 (95% CI 1.015 to 1.109)) and HF hospitalisations (HR 1.097 (95% CI 1.013 to 1.187)) and patients in practices coding 88% of CKD cases had a reduced rate of CV hospitalisations (HR 0.957 (95% CI 0.920 to 0.996)) and HF hospitalisations (HR 0.918 (95% CI 0.855 to 0.985)). We estimate that 9.0% of CV hospitalisations and 16.0% of HF hospitalisations could be prevented by improving practice CKD coding from 55% to 88%. Prescription of antihypertensives was the most dominant predictor of a reduction in hospitalisation rates for patients with CKD, followed by albuminuria testing and use of statins. CONCLUSIONS: Higher levels of CKD coding by GP practices were associated with lower rates of CV and HF events, which may be driven by increased use of antihypertensives and regular albuminuria testing, although residual confounding cannot be ruled out.

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

BACKGROUND: The effect of ethnicity on the prevalence and management of hypertension and associated chronic kidney (CKD) disease in the UK is unknown. METHODS: We 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. RESULTS: The 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. CONCLUSIONS: Significant 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.

Prescribing in general practice for people with coronary heart disease; equity by age, sex, ethnic group and deprivation.

OBJECTIVE: Differences in drug prescribing for coronary heart disease have previously been identified by age, sex and ethnic group. Set in the UK, our study utilises routinely collected data from 98 general practices serving a socially diverse population in inner East London, to examine differences in prescribing rates among patients aged 35 years and over with coronary heart disease. DESIGN: 10,933 patients aged 35 years or more, with recorded coronary heart disease, from 98 practices in two Primary Care Trusts (PCT) in East London during 2009/2010 were included for this cross-sectional study. Multivariable logistic regression was used to assess the odds of prescribing for recommended coronary heart disease drugs by age, sex, ethnicity, social deprivation, co-morbidity and recorded reasons for not prescribing. RESULTS: Women are prescribed fewer recommended coronary heart disease drugs than men; Black African/Caribbean patients are prescribed fewer lipid modifying drugs and other cardiovascular drugs than White patients. Patients over age 84 are prescribed fewer lipid modifying drugs and beta blockers than patients aged 45-54. South Asian patients had the highest levels of prescribing and higher prevalence of coronary heart disease and diabetes co-morbidity. No difference in prescribing rates by social deprivation was found. DISCUSSION: Overall levels of prescribing are high but small differences between sex and ethnic groups remain and prescribing may be inequitable for women, for Black/African Caribbeans and at older ages. These differences were not explained by recorded intolerance, contraindications or declining treatment.

Reducing missed appointments in general practice: evaluation of a quality improvement programme in East London.

BACKGROUND: Missed appointments are common in primary care, contributing to reduced clinical capacity. NHS England has estimated that there are 7.2 million missed general practice appointments annually, at a cost of £216 million. Reducing these numbers is important for an efficient primary care sector. AIM: To evaluate the impact of a system-wide quality improvement (QI) programme on the rates of missed GP appointments, and to identify effective practice interventions. DESIGN AND SETTING: Practices within a clinical commissioning group (CCG) in East London, with an ethnically diverse and socially deprived population. METHOD: Study practices engaged in a generic QI programme, which included sharing data on appointment systems and Did Not Attend (DNA) rates. Fourteen out of 25 practices implemented DNA reduction projects, supported by practice-based coaching. Appointment data were collected from practice electronic health records. Evaluation included comparisons of DNA rates pre- and post-intervention using interrupted times series analysis. RESULTS: In total, 25 out of 32 practices engaged with the programme. The mean DNA rate at baseline was 7% (range 2-12%); 2 years later the generic intervention DNA rates were 5.2%. This equates to a reduction of 4030 missed appointments. The most effective practice intervention was to reduce the forward booking time to 1 day. The practice that made this change reduced its mean DNA rate from 7.8% to 3.9%. CONCLUSION: Forward booking time in days is the best predictor of practice DNA rates. Sharing appointment data produced a significant reduction in missed appointments, and behaviour change interventions with patients had a modest additional impact; in contrast, introducing structural change to the appointment system effectively reduced DNA rates. To reduce non-attendance, it appears that the appointment system needs to change, not the patient.

Feasibility of evaluation of the natural history of kidney disease in the general population using electronic healthcare records.

BACKGROUND: Knowledge about the nature of long-term changes in kidney function in the general population is sparse. We aim to identify whether primary care electronic healthcare records capture sufficient information to study the natural history of kidney disease. METHODS: The National Chronic Kidney Disease Audit database covers ∼14% of the population of England and Wales. Availability of repeat serum creatinine tests was evaluated by risk factors for chronic kidney disease (CKD) and individual changes over time in estimated glomerular filtration rate (eGFR) were estimated using linear regression. Sensitivity of estimation to method of evaluation of eGFR compared laboratory-reported eGFR and recalculated eGFR (using laboratory-reported creatinine), to uncover any impact of historical creatinine calibration issues on slope estimation. RESULTS: Twenty-five per cent of all adults, 92% of diabetics and 96% of those with confirmed CKD had at least three creatinine tests, spanning a median of 5.7 years, 6.2 years and 6.1 years, respectively. Median changes in laboratory-reported eGFR (mL/min/1.73 m2/year) were -1.32 (CKD) and -0.60 (diabetes). Median changes in recalculated eGFR were -0.98 (CKD) and -0.11 (diabetes), underestimating decline. Magnitude of underestimation (and between-patient variation in magnitude) decreased with deteriorating eGFR. For CKD Stages 3, 4 and 5 (at latest eGFR), median slopes were -1.27, -2.49 and -3.87 for laboratory-reported eGFR and -0.89, -2.26 and -3.75 for recalculated eGFR. CONCLUSIONS: Evaluation of long-term changes in renal function will be possible in those at greatest risk if methods are identified to overcome creatinine calibration problems. Bias will be reduced by focussing on patients with confirmed CKD.

Inequalities in glycemic management in people living with type 2 diabetes mellitus and severe mental illnesses: cohort study from the UK over 10 years.

INTRODUCTION: Using data from a a primary care pay-for-performance scheme targeting quality indicators, the objective of this study was to assess if people living with type 2 diabetes mellitus (T2DM) and severe mental illnesses (SMI) experienced poorer glycemic management compared with people living with T2DM alone, and if observed differences varied by race/ethnicity, deprivation, gender, or exclusion from the scheme. RESEARCH DESIGN AND METHODS: Primary care data from a cohort of 56 770 people with T2DM, including 2272 people with T2DM and SMI, from London (UK), diagnosed between January 17, 2008 and January 16, 2018, were used. Adjusted mean glycated hemoglobin (HbA1c) and HbA1c differences were assessed using multilevel regression models. RESULTS: Compared with people with T2DM only, people with T2DM/SMI were more likely to be of an ethnic minority background, excluded from the pay-for-performance scheme and residing in more deprived areas. Across the sample, mean HbA1c was lower in those with T2DM and SMI (mean HbA1c: 58 mmol/mol; 95% CI 57 to 59), compared with people with T2DM only (mean HbA1c: 59 mmol/mol; 95% CI 59 to 60). However, HbA1c levels were greater in Bangladeshi, Indian, Pakistani, and Chinese people compared with the White British reference in the T2DM/SMI group. People with T2DM/SMI who had been excluded from the pay-for-performance scheme, had HbA1c levels which were +7 mmol/mol (95% CI 2 to 11) greater than those with T2DM/SMI not excluded. Irrespective of SMI status, increasing deprivation and male gender were associated with increased HbA1c levels. CONCLUSIONS: Despite a pay-for-performance scheme to improve quality standards, inequalities in glycemic management in people with T2DM and SMI persist in those excluded from the scheme and by gender, ethnicity, and area-level deprivation.

Reducing the use of inhaled corticosteroids in mild-moderate COPD: an observational study in east London.

Inhaled corticosteroids (ICS) are often prescribed for worsening breathlessness, exacerbation frequency or lung function in chronic obstructive pulmonary disease (COPD). In mild-moderate disease and infrequent exacerbations, treatment risks may outweigh benefits and ICS may be withdrawn safely under supervision. A systematic ICS deprescribing programme for patients with mild-moderate COPD was introduced in an east London Clinical Commissioning Group (CCG) in April 2017. Primary care patient record analysis found that prescribing fell from 34.9% (n = 701) in the 18 months pre-intervention to 26.9% (n = 538) by the second year of implementation, decreasing 0.84% per quarter post intervention (p = 0.006, linear regression). The relative decrease was greater than the comparison CCG (23.0% vs. 9.9%). Only South Asian ethnicity was associated with increased cessation (odds ratio 1.48, confidence interval (CI) 1.09-2.01), p = 0.013, logistic regression). Patient outcome data were not collected. A primary care-led programme comprising local education, financial incentivisation and consultant support led to a significant decrease in ICS prescribing.

Prevalence of suspected COVID-19 infection in patients from ethnic minority populations: a cross-sectional study in primary care.

BACKGROUND: The first wave of the London COVID-19 epidemic peaked in April 2020. Attention initially focused on severe presentations, intensive care capacity, and the timely supply of equipment. While general practice has seen a rapid uptake of technology to allow for virtual consultations, little is known about the pattern of suspected COVID-19 presentations in primary care. AIM: To quantify the prevalence and time course of clinically suspected COVID-19 presenting to general practices, to report the risk of suspected COVID-19 by ethnic group, and to identify whether differences by ethnicity can be explained by clinical data in the GP record. DESIGN AND SETTING: Cross-sectional study using anonymised data from the primary care records of approximately 1.2 million adults registered with 157 practices in four adjacent east London clinical commissioning groups. The study population includes 55% of people from ethnic minorities and is in the top decile of social deprivation in England. METHOD: Suspected COVID-19 cases were identified clinically and recorded using SNOMED codes. Explanatory variables included age, sex, self-reported ethnicity, and measures of social deprivation. Clinical factors included data on 16 long-term conditions, body mass index, and smoking status. RESULTS: GPs recorded 8985 suspected COVID-19 cases between 10 February and 30 April 2020.Univariate analysis showed a two-fold increase in the odds of suspected COVID-19 for South Asian and black adults compared with white adults. In a fully adjusted analysis that included clinical factors, South Asian patients had nearly twice the odds of suspected infection (odds ratio [OR] = 1.93, 95% confidence interval [CI] = 1.83 to 2.04). The OR for black patients was 1.47 (95% CI = 1.38 to 1.57). CONCLUSION: Using data from GP records, black and South Asian ethnicity remain as predictors of suspected COVID-19, with levels of risk similar to hospital admission reports. Further understanding of these differences requires social and occupational data.

Obesity Predicts Liver Function Testing and Abnormal Liver Results.

OBJECTIVE: Abnormal liver function tests in children and young people (CYP) predict a greater burden of liver disease in adulthood, especially in the context of obesity. This study aimed to determine whether obesity and metabolic risk factors predict liver function testing and abnormal liver test results in CYP. METHODS: This was a retrospective cross-sectional population study using electronic health care records from 257,746 CYP aged 10 to 25 years who were registered with 170 contiguous general practices in London, UK. Demographic and clinical data were extracted, including serum alanine aminotransferase (ALT) tests between 2015 and 2017. BMI category thresholds were adjusted according to age group and ethnicity. RESULTS: Fourteen percent of CYP had ALT measured, of whom 5.4% had abnormal results; 36.3% had BMI indicating overweight or obesity. Nonalcoholic fatty liver disease was the most common liver diagnosis. Multivariate analyses demonstrated that overweight or obesity was an independent predictor of ALT testing in young people (ages 18-25) but not in children (ages 10-17) and of abnormal test results in all CYP, irrespective of ALT threshold. CONCLUSIONS: Overweight and obesity are predictors of liver testing (not in children) and abnormal test results, irrespective of ALT threshold. Given the rising prevalence of metabolic dysfunction, a coordinated strategy is needed for liver testing and interpreting results in this young population.

Perspectives on the Phase 0 clinical trial of microdose administration of ABY-029 for fluorescence guided surgery: Stability testing.

ABY-029, an anti-epidermal growth factor receptor (EGFR) Affibody molecule labeled with IRDye 800CW, has been used in three Phase 0 microdosing clinical trials for fluorescence guided surgery. In May of 2019, the clinical trials were put on hold because the ABY-029 produced under Good Manufacturing Practices (GMP) for human administration had come to the end of term in which the drug product was known to be stable. Stability testing was halted due to limitations in supply of a suitable reference standard and a required test product being discontinued from commercial sale. In order to complete the remaining patients in the three clinical trials, new stability tests were developed and the GMP batch of ABY-029 drug product tested under the new protocols. The GMP batch of ABY-029 passed all stability tests under the new protocols and the Federal Drug Administration (FDA) has given permission to complete the remaining patients with stability testing of ABY-029 performed for each patient. The tests developed and used to test ABY-029 drug product stability are described here.

Hospital data may be more accurate than census data in estimating the ethnic composition of general practice populations.

BACKGROUND: Equity of service provision by age, ethnicity and sex is a key aim of Government policy in the UK. The prevalence, natural history and management of common chronic conditions, such as diabetes and hypertension, vary between ethnic groups. Developing and monitoring responsive local services requires accurate measures of ethnicity and language needs. Hence establishing the ethnic composition of GP populations is important. OBJECTIVE: To compare three methods of estimating the ethnic composition of GP registered populations in three east London primary care trusts (PCTs). DESIGN: Self-reported ethnicity, routinely collected at practice level (and considered the 'gold standard'), was compared with two indirect methods of attributing ethnicity. The indirect method currently used in the UK assigns ethnicity to GP populations based on geographical postcode attribution from the national census. A proposed alternative indirect method uses the ethnic breakdown of hospital admission data from practice lists to attribute ethnicity to the whole practice population. Comparisons were made between practice self-report recording and these two indirect methods. Bland-Altman plots were used to assess the agreement between methods of measurement. RESULTS: Data from 103 practices, covering 70% of the GP registered population, was used. The hospital admission method showed better agreement with practice self-report data than the census attributed method. For white populations Bland-Altman plots showed a mean difference of 1.4% (95% CI-14.9 to 17.7) between hospital admission and practice data, and a mean difference of 12.5% (95% CI-6.2 to 31.1) between census attributed and practice data. Differences were also found for south Asian and black populations. CONCLUSION: Practice ethnicity measured using hospital attendance data is in closer agreement with practice recording of self-reported ethnicity than the census attribution method. Census attribution may provide misleading information on the ethnic composition of practice populations. We recommend that healthcare commissioners change to this method of measurement when practice self-report data is not available.