Medical students' attitudes towards and views of general practice careers in Singapore: a cross-sectional survey and qualitative analysis.

BACKGROUND: Like many other countries, Singapore needs to support its ageing population by attracting more doctors into general practice (GP) and family medicine (FM). To achieve this requires a better understanding of what attracts or deters medical students. We conducted a cross-sectional survey among medical students in Singapore. METHODS: An online survey was distributed to students from all three medical schools to understand their likelihood of choosing primary care careers, what they valued in their careers, their attitude towards different aspects of general practice and family medicine relative to other medical fields, and the positive and negative perceptions of primary care held by themselves, their lecturers, and clinical mentors. They were able to elaborate the negativity encountered in the open-ended questions. Quantitative data was analyzed with descriptive statistics, principal component analysis, and linear regression; qualitative data was analyzed thematically. RESULTS: The survey was completed by 391 students. Slightly over half indicated a likelihood of choosing a career in primary care. For their own careers, the students valued job satisfaction and career development opportunities the most. They perceived careers in primary care as being most likely to offer reasonable hours and close patient relationships, but least likely to offer career advancement potential relative to other medical fields. Their likelihood of choosing primary care careers was significantly predicted by what they value in their own career and their attitudes toward GP/FM relative to other medical fields, but not by the perceptions of GP/FM by others. Free-text responses illustrated how students encounter derogatory comments about GP/FM: the work being "mundane and repetitive", the careers non-competitive, and the doctors poor in clinical competence. CONCLUSION: While the shortage of primary care doctors is a global issue, our findings highlight the value of situating inquiries in localized contexts. Medical curriculum should emphasize the critical role of primary care in the healthcare system and primary care doctors should be given due recognition to build a strong and motivated primary care workforce to serve the future healthcare needs of the population.

Melatonin and health: an umbrella review of health outcomes and biological mechanisms of action.

BACKGROUND: Our aims were to evaluate critically the evidence from systematic reviews as well as narrative reviews of the effects of melatonin (MLT) on health and to identify the potential mechanisms of action involved. METHODS: An umbrella review of the evidence across systematic reviews and narrative reviews of endogenous and exogenous (supplementation) MLT was undertaken. The Oxman checklist for assessing the methodological quality of the included systematic reviews was utilised. The following databases were searched: MEDLINE, EMBASE, Web of Science, CENTRAL, PsycINFO and CINAHL. In addition, reference lists were screened. We included reviews of the effects of MLT on any type of health-related outcome measure. RESULTS: Altogether, 195 reviews met the inclusion criteria. Most were of low methodological quality (mean -4.5, standard deviation 6.7). Of those, 164 did not pool the data and were synthesised narratively (qualitatively) whereas the remaining 31 used meta-analytic techniques and were synthesised quantitatively. Seven meta-analyses were significant with P values less than 0.001 under the random-effects model. These pertained to sleep latency, pre-operative anxiety, prevention of agitation and risk of breast cancer. CONCLUSIONS: There is an abundance of reviews evaluating the effects of exogenous and endogenous MLT on health. In general, MLT has been shown to be associated with a wide variety of health outcomes in clinically and methodologically heterogeneous populations. Many reviews stressed the need for more high-quality randomised clinical trials to reduce the existing uncertainties.

Clinical relevance of smartphone apps for diabetes management: A global overview.

BACKGROUND: We assessed the number, proportion, and clinical relevance of diabetes self-management apps in major languages spoken by 10 countries with the highest number of people with diabetes. METHODS: China, India, USA, Brazil, Russian Federation, Mexico, Indonesia, Egypt, Japan, and Pakistan were identified as the 10 countries with the largest number of people with diabetes based on the latest NCD-RisC survey. Android and iOS apps in the 10 national languages were extracted with a search strategy. App titles and descriptions were systematically screened by trained reviewers, including apps specific for diabetes self-management and excluding apps for health care providers, general well-being, health and product promotion, and traditional cure. Eighteen apps in the above languages were then downloaded based on availability and popularity and assessed for clinical relevance to diabetes self-management with reference to current clinical guidelines. RESULTS: The diabetes-related search terms identified 3374 Android and 4477 iOS apps, where 1019 Android and 1303 iOS apps were screened as being relevant for diabetes self-management. Chinese and English language apps constitute above 80% of the diabetes apps, have more downloads, and more comprehensive clinically relevant functions compared with other languages. None of the apps assessed met all criteria for information provision and app functionalities nor provided information cited from accredited sources. CONCLUSIONS: Our study showed that apps could play an important role in complementing multifaceted diabetes care, but should preferably be regulated, context specific, and more tailored to users' needs with clear guidance for patients and clinicians about the choices.

Correction to: Associations between post-operative rehabilitation of hip fracture and outcomes: national database analysis.

Following publication of the original article [1], the author reported an error in the Title. The original article has been corrected.

Associations between post-operative rehabilitation of hip fracture and outcomes: national database analysis (90 characters).

BACKGROUND: Rehabilitation programmes are used to improve hip fracture outcomes. There is little published trial clinical trial or population-based data on the effects of the type or provider of rehabilitation treatments on hip fracture outcomes. We evaluated the associations of rehabilitation interventions with post-operative hip fracture outcomes. METHODS: Cross-sectional (2013-2015) analysis of data from the English National Hip Fracture Database (NHFD) from all 191 English hospitals treating hip fractures. Of 62,844 NHFD patients, we included 17,708 patients with rehabilitation treatment and 30-day mobility data, and 34,142 patients with rehabilitation treatment and discharge destination data. The intervention was early mobilisation rehabilitation treatments delivered by a physiotherapist (PT, physical therapist in North America) or other clinical staff as identifiable in NHFD. We used ordinal logistic and propensity scoring regression models to adjust for confounding variables including age, sex, pre-fracture mobility, operative delay, and cognitive function and peri-operative risk scores. RESULTS: In both the adjusted multivariate and propensity-weighted analyses, mobilisation on the day or the day following surgery is associated with better mobility function 30 days after discharge. However patients mobilised by a PT did not have better mobility compared to mobilisation by other professionals. Patients who received a PT assessment were not protected from poorer mobility 30 days after discharge, compared with those who did not receive an assessment. The discharge destination outcome is also better in mobilised than unmobilised patients, whether done by a PT or another health professional, and the difference persists, slightly attenuated, after propensity weighting. CONCLUSIONS: In addition to the type of health professional initiating mobilisation, data on rehabilitation treatment activity and post-operative gait speed is needed to determine optimum rehabilitation dosage and functional outcome. After adjustment patients mobilised by non-PTs did as well as patients mobilised by PTs, suggesting that PTs' current roles in very early rehabilitation should be reconsidered, with a view to redeploying them to more specialised later rehabilitation activity.

Are cardiovascular disease risk assessment and management programmes cost effective? A systematic review of the evidence.

The World Health Organization recommends that countries implement population-wide cardiovascular disease (CVD) risk assessment and management programmes. The aim of this study was to conduct a systematic review to evaluate whether this recommendation is supported by cost-effectiveness evidence. Published economic evaluations were identified via electronic medical and social science databases (including Medline, Web of Science, and the NHS Economic Evaluation Database) from inception to March 2016. Study quality was evaluated using a modified version of the Consolidated Health Economic Evaluation Reporting Standards. Fourteen economic evaluations were included: five studies based on randomised controlled trials, seven studies based on observational studies and two studies using hypothetical modelling synthesizing secondary data. Trial based studies measured CVD risk factor changes over 1 to 3years, with modelled projections of longer term events. Programmes were either not, or only, cost-effective under non-verified assumptions such as sustained risk factor changes. Most observational and hypothetical studies suggested programmes were likely to be cost-effective; however, study deigns are subject to bias and subsequent empirical evidence has contradicted key assumptions. No studies assessed impacts on inequalities. In conclusion, recommendations for population-wide risk assessment and management programmes lack a robust, real world, evidence basis. Given implementation is resource intensive there is a need for robust economic evaluation, ideally conducted alongside trials, to assess cost effectiveness. Further, the efficiency and equity impact of different delivery models should be investigated, and also the combination of targeted screening with whole population interventions recognising that there multiple approaches to prevention.

Evaluation of community provision of a preventive cardiovascular programme - the National Health Service Health Check in reaching the under-served groups by primary care in England: cross sectional observational study.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of premature mortality and a major contributor of health inequalities in England. Compared to more affluent and white counterparts, deprived people and ethnic minorities tend to die younger due to preventable CVD associated with lifestyle. In addition, deprived, ethnic minorities and younger people are less likely to be served by CVD prevention services. This study assessed the effectiveness of community-based outreach providers in delivering England's National Health Services (NHS) Health Check programme, a CVD preventive programme to under-served groups. METHODS: Between January 2008 and October 2013, community outreach providers delivered a preventive CVD programme to 50,573 individuals, in their local communities, in a single consultation without prescheduled appointments. Community outreach providers operated on evenings and weekends as well as during regular business hours in venues accessible to the general public. After exclusion criteria, we analysed and compared socio-demographic data of 43,177 Health Check attendees with the general population across 38 local authorities (LAs). We assessed variation between local authorities in terms of age, sex, deprivation and ethnicity structures using two sample t-tests and within local authority variation in terms of ethnicity and deprivation using Chi squared tests and two sample t-tests respectively. RESULTS: Using Index of Multiple Deprivation, the mean deprivation score of the population reached by community outreach providers was 6.01 higher (p < 0.05) than the general population. Screened populations in 29 of 38 LAs were significantly more deprived (p < 0.05). No statistically significant difference among ethnic minority groups was observed between LAs. Nonetheless some LAs - namely Leicester, Thurrock, Sutton, South Tyneside, Portsmouth and Gateshead were very successful in recruiting ethnic minority groups. The mean proportion of men screened was 11.39% lower (p < 0.001) and mean proportion of 40-49 and 50-59 year olds was 9.98% and 3.58% higher (p < 0.0001 and p < 0.01 respectively) than the general population across 38 LAs. CONCLUSIONS: Community-based outreach providers effectively reach under-served groups by delivering preventive CVD services to younger, more deprived populations, and a representative proportion of ethnic minority groups. If the programme is successful in motivating the under-served groups to improve lifestyle, it may reduce health inequalities therein.

Impact of the National Health Service Health Check on cardiovascular disease risk: a difference-in-differences matching analysis.

BACKGROUND: The National Health Service Health Check program in England is the largest cardiovascular risk assessment and management program in the world. We assessed the effect of this program on modelled risk of cardiovascular disease, individual risk factors for cardiovascular disease, prescribing of relevant medications and diagnosis of vascular disease. METHODS: We obtained retrospective electronic medical records for a randomly selected sample of 138 788 patients aged 40-74 years registered with 462 English general practices participating in the Clinical Practice Research Datalink between 2009 and 2013. We used a quasi-experimental design of difference-indifferences matching analysis to compare changes in outcomes between Health Check attendees and nonattendees, with a median follow-up time of 2 years. RESULTS: Overall, 21.4% of the eligible population attended a Health Check. After matching (n = 29 672 in each group), attendees had a significant absolute reduction in modelled risk for cardiovascular disease (-0.21%, 95% confidence interval [CI] -0.24% to -0.19%) and individual risk factors: systolic blood pressure (-2.51 mm Hg, 95% CI -2.77 to -2.25 mm Hg), diastolic blood pressure (-1.46 mm Hg, 95% CI -1.62 to -1.29 mm Hg), body mass index (-0.27, 95% CI -0.34 to -0.20) and total cholesterol (-0.15 mmol/L, 95% CI -0.18 to -0.13 mmol/L). Statins were prescribed for 39.9% of attendees who were at high risk for cardiovascular disease. The program resulted in significantly more diagnoses of selected vascular diseases among attendees, with the largest increases for hypertension (2.99%) and type 2 diabetes mellitus (1.31%). INTERPRETATION: The National Health Service Health Check program had statistically significant but clinically modest impacts on modelled risk for cardiovascular disease and individual risk factors, although diagnosis of vascular disease increased. Overall program performance was substantially below national and international targets, which highlights the need for careful planning, monitoring and evaluation of similar initiatives internationally.

COPD Multidisciplinary Team Meetings in the United Kingdom: Health Care Professionals' Perceptions of Aims and Structure.

Over the last 10 years, community and hospital-based multidisciplinary teams (MDTs) have been set up for the management of patients with chronic obstructive pulmonary disease (COPD) in the UK. Meetings of the MDTs have become a regular occurrence, mostly on healthcare professionals' own initiatives. There are no standardized methods to conduct an MDT meeting, and although cancer MDT meetings are widely implemented, the value and purpose of COPD MDT meetings are less clear. Therefore, the aim of this study was to conduct a cross-sectional descriptive online survey to explore COPD MDT members' perceptions of the purpose and usefulness of MDT meetings, and to identify suggestions or requirements to improve the meetings. In total, we received 68 responses from 10 MDTs; six teams (n = 36 members) were located in London and four (n = 32 members) outside. Analysis of the replies by two independent researchers found that MDT meetings aim to optimise management and improve pathways for respiratory patients by improving communication between providers across settings and disciplines. Education of the MDT members also occurs with the aim of safer practice. Discussed patients are characterised by (multiple) co-morbidities, frequent exacerbations and admissions, social and mental health problems, unclear diagnosis and suboptimal responses to interventions. Members reported participating in a COPD MDT as very useful (74%) or useful (20%). Meetings could be improved by ensuring attendance through requirement in job plans, by clear documentation and sharing of derived plans with a wider audience including general practitioners and patients.

Coverage of a national cardiovascular risk assessment and management programme (NHS Health Check): Retrospective database study.

OBJECTIVE: To determine coverage of NHS Health Check, a national cardiovascular risk assessment programme in England, in the first four years after implementation, and to examine prevalence of high cardiovascular disease (CVD) risk and uptake of statins in high risk patients. METHOD: Study sample was 95,571 patients in England aged 40-74years continuously registered with 509 practices in the Clinical Practice Research Datalink between April 2009 and March 2013. Multilevel logistic regression models were used to assess predictors of Health Check attendance; elevated CVD risk factors and statin prescribing among attendees. RESULTS: Programme coverage was 21.4% over four years, with large variations between practices (0%-72.7%) and regions (9.4%-30.7%). Coverage was higher in older patients (adjusted odds ratio 2.88, 95% confidence interval 2.49-3.31 for patients 70-74years) and in patients with a family history of premature coronary heart disease (2.37, 2.22-2.53), but lower in Black Africans (0.75, 0.61-0.92) and Chinese (0.68, 0.47-0.96) compared with White British. Coverage was similar in patients living in deprived and affluent areas. Prevalence of high CVD risk (QRISK2≥20%) among attendees was 4.6%. One third (33.6%) of attendees at high risk were prescribed a statin after Health Checks. CONCLUSIONS: Coverage of the programme and statin prescribing in high risk individuals was low. Coverage was similar in deprived and affluent groups but lower in some ethnic minority groups, possibly widening inequalities. These findings raise a question about whether recommendations by WHO to develop CVD risk assessment programmes internationally will deliver anticipated health benefits.

Comorbidity of dementia: a cross-sectional study of primary care older patients.

BACKGROUND: The epidemiologic study of comorbidities of an index health problem represents a methodological challenge. This study cross-sectionally describes and analyzes the comorbidities associated with dementia in older patients and reviews the existing similarities and differences between identified comorbid diseases using the statistical methods most frequently applied in current research. METHODS: Cross-sectional study of 72,815 patients over 64 seen in 19 Spanish primary care centers during 2008. Chronic diseases were extracted from electronic health records and grouped into Expanded Diagnostic Clusters®. Three different statistical methods were applied (i.e., analysis of prevalence data, multiple regression and factor analysis), stratifying by sex. RESULTS: The two most frequent comorbidities both for men and women with dementia were hypertension and diabetes. Yet, logistic regression and factor analysis demonstrated that the comorbidities significantly associated with dementia were Parkinson's disease, congestive heart failure, cerebrovascular disease, anemia, cardiac arrhythmia, chronic skin ulcers, osteoporosis, thyroid disease, retinal disorders, prostatic hypertrophy, insomnia and anxiety and neurosis. CONCLUSIONS: The analysis of the comorbidities associated with an index disease (e.g., dementia) must not be exclusively based on prevalence rates, but rather on methodologies that allow the discovery of non-random associations between diseases. A deep and reliable knowledge about how different diseases are grouped and associated around an index disease such as dementia may orient future longitudinal studies aimed at unraveling causal associations.

Ethnic group differences in cardiovascular risk assessment scores: national cross-sectional study.

OBJECTIVES: There are marked inequalities in cardiovascular disease (CVD) incidence and outcomes between ethnic groups. CVD risk scores are increasingly used in preventive medicine and should aim to accurately reflect differences between ethnic groups. Ethnicity, as an independent risk factor for CVD, can be accounted for in CVD risk scores primarily using two methods, either directly incorporating it as a risk factor in the algorithm or through a post hoc adjustment of risk. We aim to compare these two methods in terms of their prediction of CVD across ethnic groups using representative national data from England. DESIGN: A cross-sectional study using data from the Health Survey for England. We measured ethnic group differences in risk estimation between the QRISK2, which includes ethnicity and Joint British Societies 2 (JBS2) algorithm, which uses post hoc risk adjustment factor for South Asian men. RESULTS: The QRISK2 score produces lower median estimates of CVD risk than JBS2 overall (6.6% [lower quartile-upper quartile (LQ-UQ)=4.0-18.6] compared with 9.3% [LQ-UQ=2.3-16.9]). Differences in median risk scores are significantly greater in South Asian men (7.5% [LQ-UQ=3.6-12.5]) compared with White men (3.0% [LQ-UQ=0.7-5.9]). Using QRISK2, 19.1% [95% confidence interval (CI)=16.2-22.0] fewer South Asian men are designated at high risk compared with 8.8% (95% CI=5.9-7.8) fewer in White men. Across all ethnic groups, women had a lower median QRISK2 score (0.72 [LQ-UQ=- 0.6 to 2.13]), although relatively more (2.0% [95% CI=1.4-2.6]) were at high risk than with JBS2. CONCLUSIONS: Ethnicity is an important CVD risk factor. Current scoring tools used in the UK produce significantly different estimates of CVD risk within ethnic groups, particularly in South Asian men. Work to accurately estimate CVD risk in ethnic minority groups is important if CVD prevention programmes are to address health inequalities.

Breathlessness and skeletal muscle weakness in patients undergoing lung health screening in primary care.

Earlier diagnosis of COPD is a major public health challenge as symptoms may be attributed to the normal consequences of aging. The optimum strategy for identifying patients with COPD remains to be determined. People aged 35 and over (n = 1896) on a GP practice register were randomised to either invitation or an opportunistic lung health check which included spirometry, quadriceps strength and MRC dyspnoea score. Then, 101 participants subsequently completed the General Practice Physical Activity Questionnaire. A total of 335 attended over a 15-week period; 156 were in the invitation group and 179 from the opportunist group. In 25 persons, spirometry was unsatisfactory or contraindicated. Spirometry was normal in 204(65.8%) and restrictive in 36(11.6%). 70(22.6%) had airflow obstruction, corresponding to Global Initiative for Chronic Lung Disease (GOLD) stages I-IV in 18(5.8%), 35(11.3%), 14(4.5%) and 3(1.0%), respectively. The opportunist group were significantly more likely to have airflow obstruction 30.1% vs 14.3% (p = 0.001). Breathlessness was reported commonly (40.5%) and quadriceps strength correlated significantly with MRC dyspnoea score independent of age, sex, pack-years smoked, fat-free mass and FEV(1) percent predicted. This relationship was also present in the subgroup of healthy participants (n = 143). 51.5% of participants screened were classified as "inactive" and this group were weaker and more breathless than those who were more active. Airflow obstruction was more common in those screened opportunistically. Breathlessness and inactivity are common in patients taking part in spirometry screening. Breathlessness is significantly associated with leg strength independent of spirometry and should be amenable to interventions to increase physical activity.

Finding the missing millions - the impact of a locally enhanced service for COPD on current and projected rates of diagnosis: a population-based prevalence study using interrupted time series analysis.

BACKGROUND: Many patients with chronic obstructive pulmonary disease (COPD) are not identified until their condition is relatively advanced and there is a considerable gap between the modelled and diagnosed prevalence of the disease. We have previously shown that, in the first year after the introduction of a locally enhanced service (LES) for COPD in 2008, there was a significant step-up in the diagnosed prevalence. AIMS: To investigate whether this initial increase in prevalence was sustained, and the impact of this increase on future projected rates of COPD diagnosis. METHODS: Using data from 2005-2011, we compared the prevalence of diagnosed COPD in the LES Primary Care Trust (LES-PCT) before and after it was introduced. Data were compared with a neighbouring PCT, the London Strategic Health Authority, and England. The true prevalence of COPD was estimated based on data from the Health Survey for England. Trends were extrapolated to estimate the proportion of patients that would be diagnosed in 2017. RESULTS: The introduction of the LES was associated with a significant acceleration in the annual increase in diagnosed COPD (p<0.0001). By 2011 the prevalence was 1.17% in the LES-PCT compared with a predicted value of 0.91% (95% CI 0.86% to 0.95%) based on the pre-LES trend. There was no change in the rate of increase in COPD prevalence for the neighbouring PCT or for London as a whole. The LES-PCT would be expected to diagnose 55.6% of COPD patients by 2017 compared with only 27.3% without the LES, and only 33.3% would be diagnosed in the neighbouring PCT. CONCLUSIONS: These data suggest that, with appropriate incentives, it is possible to achieve a sustained improvement in COPD case-finding in primary care and that such policies need to be implemented systematically.

Primary care factors associated with cervical screening coverage in England.

BACKGROUND: The National Health Service Cervical Screening Programme was established to decrease the incidence and mortality of cervical cancer in England. METHODS: To identify socioeconomic and general practice factors associated with cervical screening coverage in England, a national cross-sectional study was conducted using data on 26 497 476 female patients registered with 7970 practices in 152 English primary care trusts (PCTs). The 2008-09 data on cervical screening coverage rates from the quality and outcomes framework (QOF) database were used with data on QOF indicators, staffing levels and socioeconomic status. RESULTS: The mean cervical screening coverage rate was 78.5% at the PCT level and 83.5% at the practice level. At both levels, cervical screening coverage was significantly negatively associated with the index of multiple deprivation score, percentage of female patients aged 25-49 years and percentage of ethnic minority patients. Also, at the practice level, the percentage of female patients aged 50-64 years, overall QOF score and records and information score were significantly positively associated with cervical screening coverage. CONCLUSIONS: Cervical screening coverage was significantly lower in PCTs and practices serving higher percentages of younger-aged women, non-Caucasian individuals and those living in socioeconomic deprivation. It is therefore important to adopt strategies to improve cervical screening coverage in these groups.

Socio-economic differences in the health-related quality of life impact of cardiovascular conditions.

BACKGROUND: Those responsible for planning and commissioning health services require a method of assessing the benefits and costs of interventions. Quality-adjusted life years, based on health-related quality of life (HRQoL) estimates, can be used as part of this commissioning process. The purpose of this study was to generate nationally representative HRQoL estimates for cardiovascular disease (heart attack, angina and stroke) and predisposing conditions (diabetes, hypertension and obesity) and assess differential impacts by socio-economic position using data from the Health Survey for England. METHODS: Regression modelling was used to estimate the relationship of EQ-5D index scores with each condition independently and differentially by socio-economic position. RESULTS: Of the cardiovascular conditions/risk factors considered, having doctor-diagnosed stroke, heart attack or angina were each associated with the greatest decreases in EQ-5D. With the exception of heart attack, the reduction in EQ-5D associated with the condition/risk factor was greater for those occupying lower socio-economic positions, statistically significantly so for obesity, hypertension and diabetes. CONCLUSION: The estimates calculated provide nationally representative baseline data for England, which can be used for modelling the impact of interventions on HRQoL. They illustrate the importance of socio-economic circumstances for the association between a given condition/risk factor and HRQoL.

Managing and exploiting routinely collected NHS data for research.

INTRODUCTION: Health research using routinely collected National Health Service (NHS) data derived from electronic health records (EHRs) and health service information systems has been growing in both importance and quantity. Wide population coverage and detailed patient-level information allow this data to be applied to a variety of research questions. However, the sensitivity, complexity and scale of such data also hamper researchers from fully exploiting this potential. OBJECTIVE: Here, we establish the current challenges preventing researchers from making optimal use of the data sets at their disposal, on both the legislative and practical levels, and give recommendations as to how these challenges can be overcome. METHOD: A number of projects has recently been launched in the UK to address poor research data-management practices. Rapid Organisation of Healthcare Research Data (ROHRD) at Imperial College, London produced a useful prototype that provides local researchers with a one-stop index of available data sets together with relevant metadata. FINDINGS: Increased transparency of data sets' availability and their provenance leads to better utilisation and facilitates compliance with regulatory requirements. DISCUSSION: Research data resulting from NHS data is often not utilised fully, or is handled in a haphazard manner that prevents full auditability of the research. Furthermore, lack of informatics and data management skills in research teams act as a barrier to implementing more advanced practices, such as provenance capture and detailed, regularly updated, data management strategies. Only by a concerted effort at the levels of research organisations, funding bodies and publishers, can we achieve full transparency and reproducibility of the research.

General practitioners' views on retaining Singapore's primary care doctors: a cross-sectional survey and qualitative analysis.

BACKGROUND: To support its ageing population and the increasing need for chronic care in the community, Singapore needs to boost the number of doctors in its primary care workforce. To better understand how to improve doctor retention and build a more robust primary care system, we conducted a cross-sectional survey with doctors in general practice and family medicine to explore their career satisfaction, their career plans, factors related to their plans to leave, and their view on retaining GPs in primary care. METHODS: An anonymous online survey was distributed to general practitioners working in the public and private sectors. The survey contained questions on career satisfaction, career plans in the next 5 years, and factors important for retaining doctors in primary care. In addition, there were open-ended questions for respondents to elaborate on retention initiatives and other factors that may improve engagement among primary care doctors. Quantitative data was analyzed with descriptive statistics, principal component analysis, χ2 tests, t-tests, and Pearson's correlations; qualitative data was analyzed thematically. RESULTS: The survey was attempted by 355 general practitioners and completed in full by 303. The respondents were most satisfied with rapport with patients and their current professional role; they were least satisfied with the amount of paperwork and the status of general practice in society. In terms of their career plans in the next 5 years, 49/341 (14.4%) of the respondents plan to leave general practice permanently, 43/341 (12.6%) plan to take a career break, and 175/341 (51.3%) plan to reduce their clinical hours. Higher remuneration, recognizing general practice and family medicine as a medical specialty, and reducing the litigious pressures on medical practice were rated as the most important factors for retaining primary care. Free-text responses also revealed a growing dissatisfaction with the Third-Party Administrators that manage insurance arrangements. CONCLUSION: While the proportion of doctors who intend to leave is smaller than that reported in overseas studies, our findings highlight an urgent need for targeted interventions to engage and retain primary care doctors. Increasing recognition and support for general practitioners and their professional practice may contribute to strengthening community care for the ageing population.

Association of population and primary healthcare factors with hospital admission rates for chronic obstructive pulmonary disease in England: national cross-sectional study.

BACKGROUND: Hospital admission rates for chronic obstructive pulmonary disease (COPD) are known to be strongly associated with population factors. Primary care services may also affect admission rates, but there is little direct supporting evidence. OBJECTIVES: To determine associations between population characteristics, diagnosed and undiagnosed COPD prevalence, primary healthcare factors, and COPD admission rates primary care trust (PCT) and general practice levels in England. DESIGN, SETTING, AND PARTICIPANTS: National cross-sectional study (53,676,051 patients in 8,064 practices in 152 English PCTs), combining data on hospital admissions, populations, primary healthcare staffing, clinical practice quality and access, and prevalence. Main outcome measures Directly and indirectly standardised hospital admission rates for COPD, for PCT and practice populations. RESULTS: Mean annual COPD admission rates per 100,000 population varied from 124.7 to 646.5 for PCTs and 0.0 to 2175.2 for practices. Admissions were strongly associated with population deprivation at both levels. In a practice-level multivariate Poisson regression, registered and undiagnosed COPD prevalence, smoking prevalence and deprivation were risk factors for admission (p < 0.001), while healthcare factors- influenza immunisation, patient-reported access to consultations within two days, and primary care staffing, were protective (p < 0.05). CONCLUSION: Associations of COPD admission rates with deprivation, primary healthcare access and supply highlight the need for adequate services in deprived areas. An association between admission rates and undiagnosed COPD prevalence suggests that case-finding strategies should be evaluated. Of the COPD clinical quality indicators, only influenza immunisation was associated with reduced admission rates. Patients' experience of access to primary care may also be clinically important.