Associations between general practice characteristics with use of urgent referrals for suspected cancer and endoscopies: a cross-sectional ecological study.

BACKGROUND: Large variation in measures of diagnostic activity has been described previously between English general practices, but related predictors remain understudied. OBJECTIVE: To examine associations between general practice population and characteristics, with the use of urgent referrals for suspected cancer, and use of endoscopy. METHODS: Cross-sectional observational study of English general practices. We examined practice-level use (/1000 patients/year) of urgent referrals for suspected cancer, gastroscopy, flexible sigmoidoscopy and colonoscopy. We used mixed-effects Poisson regression to examine associations with the sociodemographic profile of practice populations and other practice attributes, including the average age, sex and country of qualification of practice doctors. RESULTS: The sociodemographic characteristics of registered patients explained much of the between-practice variance in use of urgent referrals (32%) and endoscopic investigations (18-25%), all being higher in practices with older and more socioeconomically deprived patients. Practice-level attributes explained a substantial amount of between-practice variance in urgent referral (19%) but little of the variance in endoscopy (3%-4%). Adjusted urgent referral rates were higher in training practices and those with younger GPs. Practices with mean doctor ages of 41 and 57 years (at the 10th/90th centiles of the national distribution) would have urgent referral rates of 24.1 and 19.1/1000 registered patients, P < 0.001. CONCLUSION: Most between-practice variation in use of urgent referrals and endoscopies seems to reflect health need. Some practice characteristics, such as the mean age of GPs, are associated with appreciable variation in use of urgent referrals, though these associations do not seem strong enough to justify targeted interventions.

Drivers of overall satisfaction with primary care: evidence from the English General Practice Patient Survey.

BACKGROUND/OBJECTIVES: To determine which aspects of primary care matter most to patients, we aim to identify those aspects of patient experience that show the strongest relationship with overall satisfaction and examine the extent to which these relationships vary by socio-demographic and health characteristics. DESIGN/SETTING: Data from the 2009/10 English General Practice Patient Survey including 2,169,718 respondents registered with 8362 primary care practices. MEASURES/ANALYSES: Linear mixed-effects regression models (fixed effects adjusting for age, gender, ethnicity, deprivation, self-reported health, self-reported mental health condition and random practice effect) predicting overall satisfaction from six items covering four domains of care: access, helpfulness of receptionists, doctor communication and nurse communication. Additional models using interactions tested whether associations between patient experience and satisfaction varied by socio-demographic group. RESULTS: Doctor communication showed the strongest relationship with overall satisfaction (standardized coefficient 0.48, 95% CI = 0.48, 0.48), followed by the helpfulness of reception staff (standardized coefficient 0.22, 95% CI = 0.22, 0.22). Among six measures of patient experience, obtaining appointments in advance showed the weakest relationship with overall satisfaction (standardized coefficient 0.06, 95% CI = 0.05, 0.06). Interactions showed statistically significant but small variation in the importance of drivers across different patient groups. CONCLUSIONS: For all patient groups, communication with the doctor is the most important driver of overall satisfaction with primary care in England, along with the helpfulness of receptionists. In contrast, and despite being a policy priority for government, measures of access, including the ability to obtain appointments, were poorly related to overall satisfaction.

Informal carers' health-related quality of life and patient experience in primary care: evidence from 195,364 carers in England responding to a national survey.

BACKGROUND: We aim to describe the health-related quality of life of informal carers and their experiences of primary care. METHODS: Responses from the 2011-12 English General Practice Patient Survey, including 195,364 informal carers, were analysed using mixed effect logistic regressions controlling for age, gender, ethnicity and social deprivation to describe carer health-related quality of life (mobility, self-care, usual activities, pain, and anxiety/depression, measured using EQ-5D) and primary care experience (access, continuity and communication). RESULTS: Informal carers reported poorer health-related quality of life than non-carers of similar age, gender, ethnicity and social deprivation. Increasing caring commitment was associated with worse EQ-5D scores, with carers of 50+ hours a week scoring 0.05 points lower than non-carers (95 % CI 0.05 to 0.04), equivalent to 18 fewer days of full health annually. Considering each domain of EQ-5D separately, carers of 50+ hours/week were more likely to report pain OR = 1.53 (1.50-1.57), p < 0.0001, and anxiety/depression OR = 1.69 (1.66-1.73), p < 0.0001, than non-carers. Younger carers scored lower on EQ-5D than non-carer peers but the converse was true among over-85s. In the most deprived areas carers reported the equivalent of 37 fewer days of full health annually than carers in the most affluent areas. On average, carers reported poorer patient experiences in all areas of primary care than non-carers (odds ratios 0.84-0.97), with this difference being most marked in the domain of access. CONCLUSIONS: Informal carers experience a double disadvantage of poorer health-related quality of life and poorer patient experience in primary care. We find no evidence for health benefits of caregiving. We recommend physicians identify and treat carer health problems, including pain and anxiety/depression, particularly among young, deprived and high time-commitment carers. Improving patient experience for carers, including access to primary care, should be a priority.

Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care.

AIMS: Prescribing multiple medications is associated with various adverse outcomes, and polypharmacy is commonly considered suggestive of poor prescribing. Polypharmacy might thus be associated with unplanned hospitalization. We sought to test this assumption. METHODS: Scottish primary care data for 180 815 adults with long-term clinical conditions and numbers of regular medications were linked to national hospital admissions data for the following year. Using logistic regression (age, gender and deprivation adjusted), we modelled the association of prescribing with unplanned admission for patients with different numbers of long-term conditions. RESULTS: Admissions were more common in patients on multiple medications, but admission risk varied with the number of conditions. For patients with one condition, the odds ratio for unplanned admission for four to six medications was 1.25 (95% confidence interval 1.11-1.42) vs. one to three medications, and 3.42 (95% confidence interval 2.72-4.28) for ≥10 medications vs. one to three medications. However, this effect was greatly reduced for patients with multiple conditions; amongst patients with six or more conditions, those on four to six medications were no more likely to have unplanned admissions than those taking one to three medications (odds ratio 1.00; 95% confidence interval 0.88-1.14), and those taking ≥10 medications had a modestly increased risk of admission (odds ratio 1.50; 95% confidence interval 1.31-1.71). CONCLUSIONS: Unplanned hospitalization is strongly associated with the number of regular medications. However, the effect is reduced in patients with multiple conditions, in whom only the most extreme levels of polypharmacy are associated with increased admissions. Assumptions that polypharmacy is always hazardous and represents poor care should be tempered by clinical assessment of the conditions for which those drugs are being prescribed.

Experiences of care among Medicare beneficiaries with ESRD: Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results.

BACKGROUND: Patients with end-stage renal disease (ESRD) have special health needs; little is known about their care experiences. STUDY DESIGN: Secondary analysis of 2009-2010 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) data, using representative random samples of Medicare beneficiaries. Description of Medicare beneficiaries with ESRD and investigation of differences in patient experiences by sociodemographic characteristics and coverage type. SETTING & PARTICIPANTS: Data were collected from 823,564 Medicare beneficiaries (3,794 with ESRD) as part of the Medicare CAHPS survey, administered by mail with telephone follow-up of nonrespondents. PREDICTOR: ESRD status, age, education, self-reported general and mental health status, race/ethnicity, sex, Medicare coverage type, state of residence, and other demographic measures. OUTCOMES: 6 composite measures of patient experience in 4 care domains (access to care, physician communication, customer service, and access to prescription drugs and drug information) and 4 ratings (overall care, personal physician, specialist physician, and prescription drug plan). RESULTS: Patients with ESRD reported better care experiences than non-ESRD beneficiaries for 7 of 10 measures (P < 0.05) after adjustment for patient characteristics, geography, and coverage type, although to only a small extent (adjusted mean difference, <3 points [scale, 0-100]). Black patients with ESRD and less educated patients were more likely than other patients with ESRD to report poor experiences. LIMITATIONS: Inability to distinguish patient experiences of care for different treatment modalities. CONCLUSIONS: On average, beneficiaries with ESRD report patient experiences that are at least as positive as non-ESRD beneficiaries. However, black and less educated patients with ESRD reported worse experiences than other ESRD patients. Stratified reporting of patient experience by race/ethnicity or education in patients with ESRD can be used to monitor this disparity. Physician choice and confidence and trust in physicians may be particularly important for patients with ESRD.

The accuracy of diagnostic coding for acute kidney injury in England - a single centre study.

BACKGROUND: Acute kidney injury (AKI) is an independent risk factor for mortality and is responsible for a significant burden of healthcare expenditure, so accurate measurement of its incidence is important. Administrative coding data has been used for assessing AKI incidence, and shows an increasing proportion of hospital bed days attributable to AKI. However, the accuracy of coding for AKI and changes in coding over time have not been studied in England. METHODS: We studied a random sample of admissions from 2005 and 2010 where ICD-10 code N17 (acute renal failure) was recorded in the administrative coding data at one acute NHS Foundation Trust in England. Using the medical notes and computerised records we examined the demographic and clinical details of these admissions. RESULTS: Against a 6.3% (95% CI 4.8-7.9%) increase in all non-elective admissions, we found a 64% increase in acute renal failure admissions (95% CI 41%-92%, p < 0.001) in 2010 compared to 2005. Median age was 78 years (IQR 72-87), 11-25% had a relevant pre-admission co-morbidity and 64% (55-73%) were taking drugs known to be associated with AKI. Over both years, 95% (91-99%) of cases examined met the Kidney Disease: Improving Global Outcomes criteria for AKI. CONCLUSIONS: Patients with hospital admissions where AKI has been coded are elderly with multiple co-morbidities. Our results demonstrate a high positive predictive value of coding data for a clinical diagnosis of AKI, with no suggestion of marked changes in coding of AKI between 2005 and 2010.

Changes in patient experiences of primary care during health service reforms in England between 2003 and 2007.

PURPOSE: Major primary care reforms have been introduced in recent years in the United Kingdom, including financial incentives to improve clinical quality and provide more rapid access to care. Little is known about the impact of these changes on patient experience. We examine patient reports of quality of care between 2003 and 2007, including random samples of patients on practice lists and patients with long-term conditions. METHODS: We conducted a cross-sectional design study of family practices in which questionnaires were sent to serial samples of patients in 42 representative general practices in England. Questionnaires sent to samples of patients with chronic disease (asthma, angina, and diabetes) and random samples of adult patients (excluding patients who reported any long-term condition) in 2003, 2005, and 2007 addressed issues of access, communication, continuity of care, coordination, nursing care, and overall satisfaction. RESULTS: There were no significant changes in quality of care reported by either group of patients between 2003 and 2007 for communication, nursing care, coordination, and overall satisfaction. Some aspects of access improved significantly for patients with chronic disease, but not for the random samples of patients. Patients in both samples reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care. Most scores were significantly higher for the chronic illness samples than for the random samples of patients in 2003, even after adjusting for age. CONCLUSIONS: There was a modest improvement in access to care for patients with chronic illness, but all patients now find it somewhat harder to obtain continuity of care. This outcome may be related to the incentives to provide rapid appointments or to the increased number of specialized clinics in primary care. The possibility of unintended effects needs to be considered when introducing pay for performance schemes.

A comparison of chronic illness care quality in US and UK family medicine practices prior to pay-for-performance initiatives.

BACKGROUND: The Quality and Outcomes Framework (QOF) has contributed to modest improvements in chronic illness care in the UK. US policymakers have proposed similar pay-for-performance (P4P) approaches to improve care. Since previous studies have not compared chronic illness care quality in US and UK primary care practices prior to the QOF, the relative preparedness of practices to respond to P4P incentives is unknown. OBJECTIVE: To compare US and UK practices on P4P measures prior to program implementation. METHODS: We analysed medical record data collected before QOF implementation from randomly selected patients with diabetes or coronary artery disease (CAD) in 42 UK and 55 US family medicine practices. We compared care processes and intermediate outcomes using hierarchical logistic regression. RESULTS: While we found gaps in chronic illness care quality across both samples, variation was lower in UK practices. UK patients were more likely to receive recommended care processes for diabetes [odds ratio (OR), 8.94; 95% confidence interval (CI), 4.26-18.74] and CAD (OR, 9.18; 95% CI, 5.22-16.17) but less likely to achieve intermediate diabetes outcome targets (OR, 0.50; 95% CI, 0.39-0.64). CONCLUSIONS: Following National Health Service (NHS) investment in primary care preparedness, but prior to the QOF, UK practices provided more standardized care but did not achieve better intermediate outcomes than a sample of typical US practices. US policymakers should focus on reducing variation in care documentation to ensure the effectiveness of P4P efforts while the NHS should focus on moving from process documentation to better patient outcomes.

General practitioner attitudes to the care of people with epilepsy: an examination of clustering within practices and prediction of patient-rated quality of care.

BACKGROUND: There is wide variation in the quality of care provided by primary care practices to individuals with chronic illnesses. Individual doctor attitudes and interest have been demonstrated to influence patient outcomes in some instances. Given the trend towards larger practices and part-time working, continuity of care is likely to fall and thus practice-based rather than individual general practitioner attributes and attitudes are likely to become increasingly important. The aim in this paper was to examine the extent to which individual general practitioner (G.P.) attitudes to the care of people with epilepsy cluster within practices and predict patient-rated quality of care. METHODS: The sample consisted of 1255 people with active epilepsy (a recent seizure or on anti-convulsant medication for epilepsy) and 199 GPs from 82 general practices. Measures of GP attitudes (a 17-item GP attitudes questionnaire) and patient-rated quality of epilepsy care were obtained. 1210 individuals completed initial questionnaires and 975 patients filled in final questionnaires one year later. Responses were achieved from 64 practices (83% of total) and 115 GPs (60% of total). RESULTS: 2 main factors were found to underlie GP attitudes to the care of people with epilepsy and these demonstrated clustering within practices "epilepsy viewed as a primary care responsibility" (Eigenvalue 3.98, intra-class correlation coefficient (ICC) 0.40), and "medication skills"(Eigenvalue 2.74, ICC 0.35). GP-rated scores on "epilepsy care being a primary care responsibility" were a significant predictor of patient-rated quality of GP care (p = 0.031). Other contributory factors were seizure frequency (p = 0.044), and patient-rated "shared decision making" (p = 0.022). CONCLUSION: Specific general practitioner attitudes to the care of people with epilepsy cluster within practices and are significantly associated with patient-rated quality of epilepsy care. It is important to take these findings into consideration when planning primary care interventions to ensure people with epilepsy receive the benefits of available medical and surgical expertise.