Type 2 diabetes mellitus in people with severe mental illness: inequalities by ethnicity and age. Cross-sectional analysis of 588 408 records from the UK.

AIMS: To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age. METHODS: We conducted a cross-sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes. RESULTS: Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18-34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35-54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti-psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness. CONCLUSIONS: The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti-psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account.

Effects of intrauterine retention and postmortem interval on body weight following intrauterine death: implications for assessment of fetal growth restriction at autopsy.

OBJECTIVE: According to the classification system used, 15-60% of stillbirths remain unexplained, despite undergoing recommended autopsy examination, with variable attribution of fetal growth restriction (FGR) as a cause of death. Distinguishing small-for-gestational age (SGA) from pathological FGR is a challenge at postmortem examination. This study uses data from a large, well-characterized series of intrauterine death autopsies to investigate the effects of secondary changes such as fetal maceration, intrauterine retention and postmortem interval on body weight. METHODS: Autopsy findings from intrauterine death investigations (2005-2013 inclusive, from Great Ormond Street Hospital and St George's Hospital, London) were collated into a research database. Growth charts published by the World Health Organization were used to determine normal expected weight centiles for fetuses born ≥ 24 weeks' gestation, and the effects of intrauterine retention (maceration) and postmortem interval were calculated. RESULTS: There were 1064 intrauterine deaths, including 533 stillbirths ≥ 24 weeks' gestation with a recorded birth weight. Of these, 192 (36%) had an unadjusted birth weight below the 10th centile and were defined as SGA. The majority (86%) of stillborn SGA fetuses demonstrated some degree of maceration, indicating a significant period of intrauterine retention after death. A significantly greater proportion of macerated fetuses were present in the SGA population compared with the non-SGA population (P = 0.01). There was a significant relationship between increasing intrauterine retention interval and both more severe maceration and reduction in birth weight (P < 0.0001 for both), with an average artifactual reduction in birth weight of around -0.8 SD of expected weight. There was an average 12% reduction in fetal weight between delivery and autopsy and, as postmortem interval increased, fetal weight loss increased (P = 0.0001). CONCLUSION: Based on birth weight alone, 36% of stillbirths are classified as SGA. However, fetuses lose weight in utero with increasing intrauterine retention and continue to lose weight between delivery and autopsy, resulting in erroneous overestimation of FGR. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Cardiovascular risk assessment and treatment in chronic inflammatory disorders in primary care.

OBJECTIVE: To compare differences in cardiovascular (CV) risk factors assessment and management among patients with rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) with that of matched controls. METHODS: A matched cohort study was conducted using primary care electronic health records for one London borough. All patients diagnosed with RA or IBD, and matched controls registered with local general practices on 12th of January 2014 were identified. The study compared assessment and treatment of CV risk factors (blood pressure, body mass index, cholesterol and smoking) in the year before, the year after, and 5 years after RA and IBD diagnosis. RESULTS: A total of 1121 patients with RA and 1875 patients with IBD were identified and matched with 4282 and, respectively, 7803 controls. Patients with RA were 25% (incidence rate ratio, 1.25, 95% CI 1.12 to 1.35) more likely to have a CV risk factor measured compared with matched controls. The difference declined to 8% (1.08, 1.04 to 1.14) over 5 years of follow-up. The corresponding figures for IBD were 26% (1.26, 1.16 to 1.38) and 10% (1.10, 1.05 to 1.15). Patients with RA showed higher antihypertensive prescription rates during 5 years of follow-up (OR, 1.37, 95% CI 1.14 to 1.65) and patients with IBD showed higher statin prescription rates in the year preceding diagnosis (2.30, 1.20 to 4.42). Incomplete CV risk assessment meant that QRISK scores could be calculated for less than a fifth (17%) and clinical recording of CV disease (CVD) risk scores among patients with RA and IBD was 11% and 6%, respectively. CONCLUSIONS: The assessment and treatment of vascular risk in patients with RA and IBD in primary care is suboptimal, particularly with reference to CVD risk score calculation.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study.

PURPOSE: People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK. METHODS: E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers. RESULTS: In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)). CONCLUSIONS: There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.

Outreach and Support in South London (OASIS). Outcomes of non-attenders to a service for people at high risk of psychosis: the case for a more assertive approach to assessment.

BACKGROUND: International agreement dictates that clients must be help-seeking before any assessment or intervention can be implemented by an 'at-risk service'. Little is known about individuals who decline input. This study aimed to define the size of the unengaged population of an 'at-risk service', to compare this group to those who did engage in terms of sociodemographic and clinical features and to assess the clinical outcomes of those who did not engage with the service. METHOD: Groups were compared using data collected routinely as part of the service's clinical protocol. Data on service use and psychopathology since referral to Outreach and Support in South London (OASIS) were collected indirectly from clients' general practitioners (GPs) and by screening electronic patient notes held by the local Mental Health Trust. RESULTS: Over one-fifth (n=91, 21.2%) of those referred did not attend or engage with the service. Approximately half of this group subsequently received a diagnosis of mental illness. A diagnosis of psychosis was given to 22.6%. Nearly 70% presented to other mental health services. There were no demographic differences, except that those who engaged with the service were more likely to be employed. CONCLUSIONS: Over one-fifth of those referred to services for people at high risk of psychosis do not attend or engage. However, many of this group require mental health care, and a substantial proportion has, or will later develop, psychosis. A more assertive approach to assessing individuals who are at high risk of psychosis but fail to engage may be indicated.

Social deprivation and statin prescribing: a cross-sectional analysis using data from the new UK general practitioner 'Quality and Outcomes Framework'.

We aimed to study the relationship between the prescribing of lipid-lowering medication, social deprivation and other general practice characteristics. We conducted a cross-sectional survey of all general practices in England, 2004-05. For each practice, the following variables were obtained: standardized cost and volume data for lipid-lowering medication, descriptors of general practices, Index of Multiple Deprivation, 2004, ethnicity data from the 2001 Census and Quality and Outcomes Framework data. A regression model was constructed which explained 34.5% of the variation in statin prescribing by general practitioners. The most powerful predictors were higher social deprivation, higher prevalence of coronary heart disease and achievement of cholesterol targets for diabetics. Negative regression coefficients were demonstrated for the proportion of elderly patients in the practice and, to a lesser extent, for the proportion of south Asian and Afro-Caribbean patients. In conclusion, contrary to previous local studies, we found that statin prescribing was higher in more deprived communities, even after adjustment for increased disease prevalence and practice variables associated with deprivation. Statin prescribing was also independently associated with success at achieving cholesterol targets in established disease (secondary prevention). However, our findings suggest under-prescribing of statins to the elderly and possibly also to ethnic minorities.

The relationship between income and performance indicators in general practice: a cross-sectional study.

OBJECTIVE: To explore the relationship between the income of general practitioners (GPs) and the performance characteristics of their practices. DESIGN: Cross-sectional survey. SETTING: All practices (n = 166) in an inner city health authority, two years before the introduction of the new GP contract in April 2004 were studied. MAIN OUTCOME MEASURES: True income per GP was unavailable to us. Instead, the proxy measure - superannuable pay - was calculated (gross eligible income per GP minus the national average sum for GP expenses). Practice staff funding figures were also obtained. These two financial indicators were compared with practice characteristics and performance indicators. RESULTS: Data were available from 151 out of 166 practices. Based on regression analysis, larger list sizes and higher practice staff budgets predicted 31% of the variation in GP income (standardized beta = 0.66, P < 0.001; beta = 0.19, P = 0.02; respectively). Higher staff budgets were independently associated with better cervical smear and two-year-old vaccination rates (standardized beta = 0.24, P < 0.01; beta = 0.18, P = 0.03; respectively). No association was demonstrated between performance indicators and income. CONCLUSION: Under the previous contract, GPs were able to maximize their income by taking on more patients, whereas achievement of performance targets had very little impact on overall income. The opportunity costs of pursuing higher-quality care might have outweighed the modest financial rewards attached to performance targets. Provided rewards for good-quality care are sufficiently high, the new GP contract is likely to tip the balance in favour of generating earnings by improving the quality of clinical care. To deliver this care, as measured by available performance indicators, our findings imply that a greater investment in practice staff will be needed.

Community pharmacy treatment of minor ailments in refugees.

OBJECTIVE: To evaluate a scheme offering pharmacy referrals for minor ailments in a refugee community. To determine if minor ailments could be managed by pharmacists offering over-the-counter (OTC) medication, free of charge, to refugees exempt from prescription charges. DESIGN: Refugees presenting with minor illnesses were offered a voucher. This voucher could be taken to the pharmacist, who, after a consultation, could exchange the voucher for appropriate OTC medication. SETTING: A refugee community in south London. OUTCOME MEASURES: The presenting minor ailment and corresponding medication as recorded by the pharmacist. RESULTS: A total of 200 vouchers were distributed to 184 refugees over a 5-month period resulting in the dispensing of 264 items. The five most frequent minor ailments were: upper respiratory tract infections (37%), headache (14%), musculo-skeletal pains (7%), allergy including hay fever (6%), indigestion (6%). The five most frequently dispensed items were: paracetamol (28%), sudafed (16%), ibuprofen (11%), aspirin (10%) and simple linctus (8%). Only two clients were referred directly to the GP and two advised to attend if symptoms persisted. CONCLUSIONS: Minor ailment schemes elsewhere have demonstrated the potential to divert about one-third of patients with minor illnesses out of general practice and to care in the pharmacy. Such a scheme is being widely adopted in Scotland this year. Our results are the first to demonstrate the feasibility and acceptability of such a scheme in the refugee community.

Prescribing indicators and their use by primary care groups to influence prescribing.

OBJECTIVE: To examine the prescribing incentive schemes used by primary care groups (PCGs); to determine the prescribing indicators used under these schemes; and to assess whether the schemes were seeking to improve the quality of prescribing as well as controlling prescribing costs. DESIGN: Cross-sectional survey. SETTING: A total of 145 PCGs in the London and South-East NHS regions. PARTICIPANTS: Prescribing advisers in each PCG. METHODS: Descriptions of the prescribing indicators monitored by each PCG were obtained from a questionnaire survey of PCGs at the end of the 1999-2000 financial year. Financial information on prescribing and details about the implementation of prescribing incentive schemes for this period became available 6 months later and were obtained by a further questionnaire, follow-up telephone and E-mail surveys. OUTCOME MEASURES: Prescribing indicators, prescribing budgets and spend. RESULTS: One hundred and twenty-one out of 145 (83%) PCGs replied to the questionnaires about prescribing indicators and 129 out of 145 (89%) replied with details about their prescribing costs. The most frequently monitored prescribing indicator was generic prescribing, used by 106 out of 121 (88%) PCGs. The most frequently used clinical areas for prescribing indicators were antibiotics (76% of PCGs), gastro-intestinal prescribing (68%), non-steroidal anti-inflammatories (37%) and cardiovascular prescribing (32%). Seventy-six (63%) schemes also used non-prescribing analysis & cost (PACT) based data for their incentive schemes such as information from prescribing audits and reviews of repeat prescribing protocols. Only 33 (23%) had reached agreement with their practices enabling all prescribing indicator information to be disseminated on a named basis to allow practices to examine each others' prescribing data. CONCLUSIONS: Prescribing incentive schemes usually include targets for improvements in prescribing quality as well as cost. PACT-based data were used for cost control and quality improvement but non-PACT data were almost entirely used to promote prescribing quality improvements. The validity of non-PACT data was questioned as was the choice of some indicators that appeared to have been selected without full consideration of current expert opinion. Further work is needed on which indicators are most likely to act as catalysts to prescribing change.

The effects on GP prescribing of joining a commissioning group.

BACKGROUND: It is not known to what extent general practitioners (GP) can change their prescribing upon joining a commissioning group and what features of a commissioning group may promote prescribing change. The opportunity to study potential prescribing change arose with the formation of a limited number of Primary Care Commissioning Groups (PCCGs), a precursor of Primary Care Groups (PCGs) and Primary Care Trusts (PCTs). METHODS: This was a controlled study of general practice prescribing costs. All practices (n=24) within one inner city PCCG were compared with matched controls that were not part of a PCCG. Cross sectional survey data was collected from the PCCG practices to determine possible reasons for prescribing change. RESULTS: The total annual prescribing cost rose by 4.0% in the PCCG practices and by 6.9% in controls (P=0.01). Significant cost containment was found for gastrointestinal prescribing (P=0.03), attributable to differences in the cost of proton pump inhibitors (PPIs) which fell by 0.7% in the PCCG but rose by 7.3% in controls (P=0.03). Total relative savings in the PCCG practices amounted to around pound 220,000. General practitioners making the greater savings in PPI costs within the PCCG, were more likely to report being influenced by information from the prescribing adviser. CONCLUSION: General practice prescribing costs were contained to a greater degree in practices participating in the PCCG. The differences in gastrointestinal prescribing were most marked for PPIs which were specifically targeted by the prescribing adviser. The GPs themselves attributed their own prescribing change to information provided by the prescribing adviser. Other factors operating within the PCCG may also have influenced prescribing such as a more locally based management system, different financial incentives and a greater degree of co-operative working amongst GPs.

When questionnaire response rates do matter: a survey of general practitioners and their views of NHS changes.

This paper investigates whether general practitioners (GPs) who do not participate in questionnaire surveys (non-responders) hold different views on participation in primary care reorganisation than their more compliant colleagues. A survey of 72 GPs' involvement in a pilot primary care prescribing group elicited an initial response of 74%. Non-responders were then approached personally and persuaded to complete the questionnaire. Comparison of the responders and the non-responders showed that the latter did differ significantly from the responders in many of their views. This difference needs to be considered whenever the results of surveys are used to guide policy-making in the more corporate model of primary care that is now emerging.

Motivating general practitioners to change their prescribing: the incentive of working together.

OBJECTIVE: To determine the extent to which GPs were motivated to change their prescribing upon joining a Primary Care Commissioning Group (PCCG) and how effective certain interventions planned by the PCCG might be as a means to change prescribing. To define the characteristics of GPs less motivated to change their prescribing. DESIGN: A cross-sectional survey of participating general practitioners linked with current prescribing information derived from PACT data. SETTING: General practice covering a geographical locality within inner-city south London. SUBJECTS: All 72 general practitioners who had joined a GP Commissioning Group. MAIN OUTCOME MEASURES: questionnaire responses. RESULTS: 93% of GPs entering the GP Commissioning Group expected their prescribing to change but none expected substantial change. There was no difference between fundholders, singlehanders nor training practices in their expectation of change. GPs in practices with the lowest quality prescribing, as measured by a quality index, were least likely to expect change (Spearman's r = 0.25, P = 0.04). Those in practices with higher prescribing costs were not more likely to expect their prescribing to change, whereas expensive prescribers who were unaware of their practices' prescribing costs were associated with a reduced expectation of prescribing change (P = 0.05). Educational interventions were thought to be the most effective means by which prescribing could be changed, whereas formularies and financial factors were perceived as weaker influences. CONCLUSION: Acceptance of a cash-limited prescribing budget by GPs is accompanied by the expectation of personal prescribing change. The motivation to change prescribing may be related to a strongly developed collectivist perspective amongst GPs who are prepared to consider the prescribing implications for their fellow GPs. It is ironic that those with the least expectation of change should have the lowest quality prescribing, or be unaware of their high cost prescribing. Engendering greater commitment to the professional group may be one way of changing their prescribing.

Measuring case mix and severity of illness in Canada: case mix groups versus refined diagnosis related groups.

This study compares the effectiveness of Case Mix Groups (CMG*) groups and Refined Diagnosis Related Groups (RDRG) in reducing Canadian length of stay (LOS) variability. The effectiveness of the two case mix grouping methodologies was assessed with a common data base, 282,459 abstracts with ICD-9 CM diagnosis codes reported to the Hospital Medical Records Institute (HMRI) from January to March 1989. Death, signouts, transfers to or from acute care institutions and cases with an outlier LOS ("atypical" cases) were excluded from the analysis. HMRI utilization management reports to acute care hospitals use a data base defined in this way. On the basis of the variance reduction statistic (R2) from ordinary least squares regression analysis, CMG groups were found to be slightly more effective than RDRGs in reducing LOS variability. R2 statistics were 45.7 and 43.8 for CMG groups and RDRGs, respectively. Within subgroups of cases, CMG groups were found to be markedly more effective with the newborn/neonate group and to a lesser extent with non-surgical cases. The severity of illness categories within RDRGs did not, over all "typical" cases in the data base, yield more homogeneous groups of cases than CMG groups, which have half the number of categories. The value of tailoring severity measurement to Canadian medical practice and Canadian diagnosis coding is highlighted.