Effects of ethnic density on the risk of compulsory psychiatric admission for individuals attending secondary care mental health services: evidence from a large-scale study in England.

BACKGROUND: Black, Asian and minority ethnicity groups may experience better health outcomes when living in areas of high own-group ethnic density - the so-called 'ethnic density' hypothesis. We tested this hypothesis for the treatment outcome of compulsory admission. METHODS: Data from the 2010-2011 Mental Health Minimum Dataset (N = 1 053 617) was linked to the 2011 Census and 2010 Index of Multiple Deprivation. Own-group ethnic density was calculated by dividing the number of residents per ethnic group for each lower layer super output area (LSOA) in the Census by the LSOA total population. Multilevel modelling estimated the effect of own-group ethnic density on the risk of compulsory admission by ethnic group (White British, White other, Black, Asian and mixed), accounting for patient characteristics (age and gender), area-level deprivation and population density. RESULTS: Asian and White British patients experienced a reduced risk of compulsory admission when living in the areas of high own-group ethnic density [odds ratios (OR) 0.97, 95% credible interval (CI) 0.95-0.99 and 0.94, 95% CI 0.93-0.95, respectively], whereas White minority patients were at increased risk when living in neighbourhoods of higher own-group ethnic concentration (OR 1.18, 95% CI 1.11-1.26). Higher levels of own-group ethnic density were associated with an increased risk of compulsory admission for mixed-ethnicity patients, but only when deprivation and population density were excluded from the model. Neighbourhood-level concentration of own-group ethnicity for Black patients did not influence the risk of compulsory admission. CONCLUSIONS: We found only minimal support for the ethnic density hypothesis for the treatment outcome of compulsory admission to under the Mental Health Act.

Association of socioeconomic deprivation with asthma care, outcomes, and deaths in Wales: A 5-year national linked primary and secondary care cohort study.

BACKGROUND: Socioeconomic deprivation is known to be associated with worse outcomes in asthma, but there is a lack of population-based evidence of its impact across all stages of patient care. We investigated the association of socioeconomic deprivation with asthma-related care and outcomes across primary and secondary care and with asthma-related death in Wales. METHODS AND FINDINGS: We constructed a national cohort, identified from 76% (2.4 million) of the Welsh population, of continuously treated asthma patients between 2013 and 2017 using anonymised, person-level, linked, routinely collected primary and secondary care data in the Secure Anonymised Information Linkage (SAIL) Databank. We investigated the association between asthma-related health service utilisation, prescribing, and deaths with the 2011 Welsh Index of Multiple Deprivation (WIMD) and its domains. We studied 106,926 patients (534,630 person-years), 56.3% were female, with mean age of 47.5 years (SD = 20.3). Compared to the least deprived patients, the most deprived patients had slightly fewer total asthma-related primary care consultations per patient (incidence rate ratio [IRR] = 0.98, 95% CI 0.97-0.99, p-value < 0.001), slightly fewer routine asthma reviews (IRR = 0.98, 0.97-0.99, p-value < 0.001), lower controller-to-total asthma medication ratios (AMRs; 0.50 versus 0.56, p-value < 0.001), more asthma-related accident and emergency (A&E) attendances (IRR = 1.27, 1.10-1.46, p-value = 0.001), more asthma emergency admissions (IRR = 1.56, 1.39-1.76, p-value < 0.001), longer asthma-related hospital stay (IRR = 1.64, 1.39-1.94, p-value < 0.001), and were at higher risk of asthma-related death (risk ratio of deaths with any mention of asthma 1.56, 1.18-2.07, p-value = 0.002). Study limitations include the deprivation index being area based and the potential for residual confounders and mediators. CONCLUSIONS: In this study, we observed that the most deprived asthma patients in Wales had different prescribing patterns, more A&E attendances, more emergency hospital admissions, and substantially higher risk of death. Interventions specifically designed to improve treatment and outcomes for these disadvantaged groups are urgently needed.

Trajectory of excess healthcare consultations, medication use, and work disability in newly diagnosed knee osteoarthritis: a matched longitudinal register-based study.

PURPOSE: To estimate the excess healthcare use and work disability attributable to knee osteoarthritis (OA) in the first 5 years following diagnosis. METHODS: Among individual aged 40-80 years who resided in Skåne on 31st December 2008, we identified those with a main diagnosis of knee OA during 2009-2014 and no previous diagnosis of any OA from 1998 (n = 16,888). We created a comparison cohort matched (1:1) by sex, age, and municipality from individuals with no OA diagnosis (at any site) during 1998-2016. We compared healthcare use and net disability days for 60 months following diagnosis between the two groups. We applied a survival-adjusted regression technique controlling for sociodemographic characteristics as well as pre-diagnosis outcome and comorbidity. RESULTS: The estimated 5-year incremental effects of knee OA per-patient were 16.8 (95% CI: 15.8, 17.7) healthcare consultations, 0.7 (0.4, 1.1) inpatient days, 420 (372, 490) defined daily dose of prescribed medications, and 21.8 (15.2, 30.0) net disability days. Primary care consultations constituted about 73% of the excess healthcare consultations. Most of these incremental effects occurred in the first year after diagnosis. Better survival in the knee OA group accounted for 0.7 (95% CI: 0.5, 0.8) and 1.4 (0.7, 2.6) of the excess healthcare consultations and net disability days, respectively. Both estimated total and incremental resources use were generally greater for women than men with knee OA. CONCLUSION: Knee OA was associated with considerable excess healthcare use and work disability independent of pre-diagnosis resources use, comorbidity, and sociodemographic characteristics.

Secondary care specialist visits made by children and young people prescribed antidepressants in primary care: a descriptive study using the QResearch database.

BACKGROUND: Antidepressants may be used to manage a number of conditions in children and young people including depression, anxiety, and obsessive-compulsive disorder. UK guidelines for the treatment of depression in children and young people recommend that antidepressants should only be initiated following assessment and diagnosis by a child and adolescent psychiatrist. The aim of this study was to summarise visits to mental health specialists and indications recorded around the time of antidepressant initiation in children and young people in UK primary care. METHODS: The study used linked English primary care electronic health records and Hospital Episode Statistics secondary care data. The study included 5-17-year-olds first prescribed antidepressants between January 2006 and December 2017. Records of visits to paediatric or psychiatric specialists and potential indications (from a pre-specified list) were extracted. Events were counted if recorded less than 12 months before or 6 months after the first antidepressant prescription. Results were stratified by first antidepressant type (all, selective serotonin reuptake inhibitors (SSRIs), tricyclic and related antidepressants) and by age group (5-11 years, 12-17 years). RESULTS: In total, 33,031 5-17-year-olds were included. Of these, 12,149 (37%) had a record of visiting a paediatrician or a psychiatric specialist in the specified time window. The majority of recorded visits (7154, 22%) were to paediatricians. Of those prescribed SSRIs, 5463/22,130 (25%) had a record of visiting a child and adolescent psychiatrist. Overall, 17,972 (54%) patients had a record of at least one of the pre-specified indications. Depression was the most frequently recorded indication (12,501, 38%), followed by anxiety (4155, 13%). CONCLUSIONS: The results suggest many children and young people are being prescribed antidepressants without the recommended involvement of a relevant specialist. These findings may justify both greater training for GPs in child and adolescent mental health and greater access to specialist care and non-pharmacological treatments. Further research is needed to explore factors that influence how and why GPs prescribe antidepressants to children and young people and the real-world practice barriers to adherence to clinical guidelines.

Effect of the dr. Bart application on healthcare use and clinical outcomes in people with osteoarthritis of the knee and/or hip in the Netherlands; a randomized controlled trial.

OBJECTIVE: To evaluate the short-term effects of use of the dr. Bart app, compared to usual care, on the number of secondary health care consultations and clinical outcomes in people with knee/hip OA in the Netherlands. METHOD: A randomized controlled design involving participants ≥50 years with self-reported knee and/or hip OA recruited from the community. The number of secondary health care consultations (primary outcome) and secondary outcomes were assessed at baseline, 3 and 6 months via online questionnaires. Data were analyzed using longitudinal mixed models, corrected for baseline values. Due to the design of this study, blinding of participants and researchers was not possible. RESULTS: In total, 427 eligible participants were allocated to either the dr. Bart group (n = 214) or usual care (n = 213). We found no difference between groups in the number of secondary (i.e., orthopaedic surgeon, rheumatologist, or physician assistant) health care consultations (incidence rate ratio (IRR) 1.20 (95% CI: 0.67; 2.19)). We found positive treatment effects of the dr. Bart app on symptoms (2.6 (95% CI: 0.4; 4.9)), pain (3.5 (95% CI: 0.9; 6.0)), and activities of daily living (2.9 (95% CI: 0.2; 5.6)) on a 0-100 scale, higher score indicating less complaints, but not in any other secondary outcome. CONCLUSION: The dr. Bart app did not change the number of secondary health care consultations compared to usual care. However, we found small positive effects (not clinically relevant) on pain, symptoms, and activities of daily living in people with knee/hip OA. TRIAL REGISTRATION: Dutch Trial Register (Trial Number NTR6693/NL6505) (https://www.trialregister.nl/trial/6505).

Prevalence and management of diabetic neuropathy in secondary care in Qatar.

AIMS: Diabetic neuropathy (DN) is a "Cinderella" complication, particularly in the Middle East. A high prevalence of undiagnosed DN and those at risk of diabetic foot ulceration (DFU) is a major concern. We have determined the prevalence of DN and its risk factors, DFU, and those at risk of DFU in patients with type 2 diabetes mellitus (T2DM) in secondary care in Qatar. MATERIALS AND METHODS: Adults with T2DM were randomly selected from the two National Diabetes Centers in Qatar. DN was defined by the presence of neuropathic symptoms and a vibration perception threshold (VPT) ≥ 15 V. Participants with a VPT ≥ 25 V were categorized as high risk for DFU. Painful DN was defined by a DN4 score ≥4. Logistic regression analysis was used to identify predictors of DN. RESULTS: In 1082 adults with T2DM (age 54 ± 11 years, duration of diabetes 10.0 ± 7.7 years, 60.6% males), the prevalence of DN was 23.0% (95% CI, 20.5%-25.5%) of whom 33.7% (95% CI, 27.9%-39.6%) were at high risk of DFU, and 6.3% had DFU; 82.0% of the patients with DN were previously undiagnosed. The prevalence of DN increased with age and duration of diabetes and was associated with poor glycaemic control (HbA1c ≥ 9%) AOR = 2.1 (95% CI, 1.3-3.2), hyperlipidaemia AOR = 2.7 (95% CI, 1.5-5.0), and hypertension AOR = 2.0 (95% CI, 1.2-3.4). CONCLUSIONS: Despite DN affecting 23% of adults with T2DM, 82% had not been previously diagnosed with one-third at high risk for DFU. This argues for annual screening and identification of patients with DN. Furthermore, we identify hyperglycaemia, hyperlipidaemia, and hypertension as predictors of DN.

Respiratory tract infection-related healthcare utilisation in children with Down's syndrome.

PURPOSE: Children with Down's syndrome (DS) are prone to respiratory tract infections (RTIs) due to anatomical variation, immune system immaturity and comorbidities. However, evidence on RTI-related healthcare utilisation, especially in primary care, is incomplete. In this retrospective cohort study, we use routinely collected primary and secondary care data to quantify RTI-related healthcare utilisation in children with DS and matched controls without DS. METHODS: Retrospective cohort study of 992 children with DS and 4874 matched controls attending English general practices and hospitals as identified in Clinical disease research using LInked Bespoke studies and Electronic health Records (CALIBER) from 1997 to 2010. Poisson regression was used to calculate consultation, hospitalisation and prescription rates, and rate ratios. Wald test was used to compare risk of admission following consultation. The Wilcoxon rank-sum test was used to compare length of stay by RTI type and time-to-hospitalisation. RESULTS: RTI-related healthcare utilisation is significantly higher in children with DS than in controls in terms of GP consultations (adjusted RR 1.73; 95% CI 1.62-1.84), hospitalisations (adjusted RR 5.70; 95% CI 4.82-6.73), and antibiotic prescribing (adjusted RR 2.34; 95% CI 2.19-2.49). Two percent of children with DS presenting for an RTI-related GP consultation were subsequently admitted for an RTI-related hospitalisation, compared to 0.7% in controls. CONCLUSIONS: Children with DS have higher rates of GP consultations, hospitalisations and antibiotic prescribing compared to controls. This poses a significant burden on families. Further research is recommended to characterise healthcare behaviours and clinical decision-making, to optimise care for this at risk group.

Incidence of injuries in Norway: linking primary and secondary care data.

Aims: Most studies of injury incidence underestimate the total burden of injury, as they do not include injuries treated in primary care. The aim of this study was to measure the total incidence of medically treated injuries in Norway. We further investigated the epidemiology of injuries treated in primary and secondary care. Methods: We collected individual-level data on injury diagnoses from the Norwegian Patient Registry and the national registry dataset for reimbursement of primary care providers for the period 2009-2014, and estimated the annual incidence of patients registered with an injury diagnosis in either or both of these registries. We also converted ICD-10 codes in secondary care into ICPC-2 codes to compare the types of injuries treated in primary and secondary care. Results: The annual incidence of medically treated injuries in Norway was 125 patients per 1000 inhabitants. Fifty-five per cent of injured patients received treatment exclusively in primary care. We observed stable time trends over the six-year period. Incidence rates were higher in primary care for the youngest children and in middle adulthood, but were higher in secondary care for older people. Overall, injury incidence was higher for men, but women became more injury prone with age. We only observed this gender reversal in secondary care. With the exception of fractures, all injury types were predominantly treated in primary care. Conclusions: A substantial proportion of injured patients in Norway are treated exclusively in primary care. The demographic profile of these patients differs from those treated in secondary care.

Can cluster analyses of linked healthcare data identify unique population segments in a general practice-registered population?

BACKGROUND: Population segmentation is useful for understanding the health needs of populations. Expert-driven segmentation is a traditional approach which involves subjective decisions on how to segment data, with no agreed best practice. The limitations of this approach are theoretically overcome by more data-driven approaches such as utilisation-based cluster analysis. Previous explorations of using utilisation-based cluster analysis for segmentation have demonstrated feasibility but were limited in potential usefulness for local service planning. This study explores the potential for practical application of using utilisation-based cluster analyses to segment a local General Practice-registered population in the South Wales Valleys. METHODS: Primary and secondary care datasets were linked to create a database of 79,607 patients including socio-demographic variables, morbidities, care utilisation, cost and risk factor information. We undertook utilisation-based cluster analysis, using k-means methodology to group the population into segments with distinct healthcare utilisation patterns based on seven utilisation variables: elective inpatient admissions, non-elective inpatient admissions, outpatient first & follow-up attendances, Emergency Department visits, GP practice visits and prescriptions. We analysed segments post-hoc to understand their morbidity, risk and demographic profiles. RESULTS: Ten population segments were identified which had distinct profiles of healthcare use, morbidity, demographic characteristics and risk attributes. Although half of the study population were in segments characterised as 'low need' populations, there was heterogeneity in this group with respect to variables relevant to service planning - e.g. settings in which care was mostly consumed. Significant and complex healthcare need was a feature across age groups and was driven more by deprivation and behavioural risk factors than by age and functional limitation. CONCLUSIONS: This analysis shows that utilisation-based cluster analysis of linked primary and secondary healthcare use data for a local GP-registered population can segment the population into distinct groups with unique health and care needs, providing useful intelligence to inform local population health service planning and care delivery. This segmentation approach can offer a detailed understanding of the health and care priorities of population groups, potentially supporting the integration of health and care, reducing fragmentation of healthcare and reducing healthcare costs in the population.

Reorganising dermatology care: predictors of the substitution of secondary care with primary care.

BACKGROUND: The substitution of healthcare is a way to control rising healthcare costs. The Primary Care Plus (PC+) intervention of the Dutch 'Blue Care' pioneer site aims to achieve this feat by facilitating consultations with medical specialists in the primary care setting. One of the specialties involved is dermatology. This study explores referral decisions following dermatology care in PC+ and the influence of predictive patient and consultation characteristics on this decision. METHODS: This retrospective study used clinical data of patients who received dermatology care in PC+ between January 2015 and March 2017. The referral decision following PC+, (i.e., referral back to the general practitioner (GP) or referral to outpatient hospital care) was the primary outcome. Stepwise logistic regression modelling was used to describe variations in the referral decisions following PC+, with patient age and gender, number of PC+ consultations, patient diagnosis and treatment specialist as the predicting factors. RESULTS: A total of 2952 patients visited PC+ for dermatology care. Of those patients with a registered referral, 80.2% (N = 2254) were referred back to the GP, and 19.8% (N = 558) were referred to outpatient hospital care. In the multivariable model, only the treating specialist and patient's diagnosis independently influenced the referral decisions following PC+. CONCLUSION: The aim of PC+ is to reduce the number of referrals to outpatient hospital care. According to the results, the treating specialist and patient diagnosis influence referral decisions. Therefore, the results of this study can be used to discuss and improve specialist and patient profiles for PC+ to further optimise the effectiveness of the initiative.

The quality of e-fit notes issued in secondary care.

BACKGROUND: Few data are available on the pattern of use of fit notes issued in secondary care settings. AIMS: To evaluate the pattern and quality of e-fit notes issued in an NHS Trust. METHODS: Anonymized data on patients admitted to Guy's and St Thomas' NHS Foundation Trust (London, UK) who had an e-fit note issued from 1 January to 31 August 2017 were analysed using descriptive statistical methods. Thematic analysis was used to group the free-text comments into distinct categories and themes. RESULTS: A total of 815 fit notes were issued during the study period. A total of 659 (81%) fit notes advised that patients were 'not fit' for work, whilst 156 (19%) advised that they 'may be fit' for work. The specialty with the highest proportion of patients assessed as may be fit was plastic surgery 46/104 (44%), whilst the lowest was ear, nose and throat surgery 0/57 (0%). The majority 151/156 (97%) of fit notes which advised that patients may be fit for work used the tick-box sections on the fit note to recommend work modifications. Of the free-text comments in section 4 of the 'may be fit' e-fit notes issued, 91/114 (80%) were related to the functional ability of patients. CONCLUSIONS: Our study suggests that doctors in secondary care are more willing to use the 'may be fit' option on the fit note than primary care practitioners. Most fit notes, which advised that a patient may be fit for work, suggested workplace modifications.

Healthcare utilization and management of actinic keratosis in primary and secondary care: a complementary database analysis.

BACKGROUND: The high prevalence of actinic keratosis (AK) requires the optimal use of healthcare resources. OBJECTIVES: To gain insight in to the healthcare utilization of people with AK in a population-based cohort, and the management of AK in a primary and secondary care setting. METHODS: A retrospective cohort study using three complementary data sources was conducted to describe the use of care, diagnosis, treatment and follow-up of patients with AK in the Netherlands. Data sources consisted of a population-based cohort study (Rotterdam Study), routine general practitioner (GP) records (Integrated Primary Care Information) and nationwide claims data (DRG Information System). RESULTS: In the population-based cohort (Rotterdam Study), 69% (918 of 1322) of participants diagnosed with AK during a skin-screening visit had no previous AK-related visit in their GP record. This proportion was 50% for participants with extensive AK (i.e. ≥ 10 AKs; n = 270). Cryotherapy was the most used AK treatment by both GPs (78%) and dermatologists (41-56%). Topical agents were the second most used treatment by dermatologists (13-21%) but were rarely applied in primary care (2%). During the first AK-related GP visit, 31% (171 of 554) were referred to a dermatologist, and the likelihood of being referred was comparable between low- and high-risk patients, which is inconsistent with the Dutch general practitioner guidelines for 'suspicious skin lesions' from 2017. Annually, 40 000 new claims representing 13% of all dermatology claims were labelled as cutaneous premalignancy. Extensive follow-up rates (56%) in secondary care were registered, while only 18% received a claim for a subsequent cutaneous malignancy in 5 years. CONCLUSIONS: AK management seems to diverge from guidelines in both primary and secondary care. Underutilization of field treatments, inappropriate treatments and high referral rates without proper risk stratification in primary care, combined with extensive follow-up in secondary care result in the inefficient use of healthcare resources and overburdening in secondary care. Efforts directed to better risk differentiation and guideline adherence may prove useful in increasing the efficiency in AK management. What's already known about this topic? The prevalence of actinic keratosis (AK) is high and, in particular, multiple AKs are a strong skin cancer predictor. The high prevalence of AK requires optimal use of healthcare resources. Nevertheless, (population based) AK healthcare utilization and management data are very rare. What does this study add? Although AK-related care already consumes substantial resources, about 70% of the AK population has never received care. Primary care AK management demonstrated underutilization of topical therapies and high referral rates without proper risk stratification, while in secondary care the extensive follow-up schedules were applied. This inefficient use of healthcare resources highlights the need for better harmonization and risk stratification to increase the efficiency of AK care.

Maternal smoking during pregnancy and offspring utilisation of health care services: A population-based cohort study.

BACKGROUND: Maternal smoking during pregnancy (MSDP) has been associated with a wide range of adverse effects on offspring health, such as low birthweight, behavioural disorders, and asthma. The number of women that smoke during pregnancy in Denmark is still high, making it relevant to study the long-term health outcomes in offspring exposed to maternal smoking in utero. OBJECTIVE: We investigated whether exposure to MSDP is associated with more frequent use of health care services during the first 10 years of life. METHODS: This population-based cohort study included participants enrolled in the Danish National Birth Cohort between 1996 and 2003. Data on MSDP were obtained from two telephone interviews during pregnancy and one interview after pregnancy. The primary outcome was contacts to the health care system. From Danish national registries, we obtained information on number and type of contacts to the general practitioner (GP), and information on the specific types of services provided. Further, we obtained information on hospital admissions, and redemption of prescribed medicine. We fitted negative binomial regression models and Cox proportional hazards regression models to estimate associations. All analyses were adjusted for socio-economic status, birth year, and various maternal factors. RESULTS: We studied 83,905 liveborn singletons and found that offspring exposed to maternal smoking in utero had more contacts to the GP in the first 10 years of life with an incidence rate ratio of 1.05, 95% confidence interval [CI] 1.04, 1.06. A higher rate of admission to hospital in 9 out of 20 categories was found, as was a higher rate of being prescribed psychoanaleptics (hazard ratio [HR] 1.41, 95% CI 1.25, 1.60), drugs for obstructive pulmonary disease (HR 1.14, 95% CI 1.14, 1.20), and antibiotics (HR 1.03, 95% CI 1.01, 1.05). CONCLUSIONS: We found that offspring exposed to MSDP had a higher use of health care services than unexposed offspring.

Clinical management of nausea and vomiting in pregnancy and hyperemesis gravidarum across primary and secondary care: a population-based study.

OBJECTIVES: To assess how nausea and vomiting in pregnancy (NVP) and hyperemesis gravidarum (HG) are managed and treated across primary and secondary care. DESIGN: Population-based pregnancy cohort. SETTING: Medical records (CPRD-GOLD) from England. POPULATION: 417 028 pregnancies during 1998-2014. METHODS: Proportions of pregnancies with recorded NVP/HG diagnoses, primary care treatment, and hospital admissions were calculated. Multinomial logistic regression was employed to estimate adjusted relative risk ratios (aRRRs) with 99% confidence intervals (CIs) for the association between NVP/HG management paths and maternal characteristics. MAIN OUTCOME MEASURES: NVP/HG diagnoses, treatments, and hospital admissions. RESULTS: Overall prevalence of clinically recorded NVP/HG was 9.1%: 2.1% had hospital admissions, 3.4% were treated with antiemetics in primary care only, and 3.6% had only recorded diagnoses. Hospital admissions and antiemetic prescribing increased continuously during 1998-2013 (trend P < 0.001). Younger age, deprivation, Black/Asian/mixed ethnicity, and multiple pregnancy were associated with NVP/HG generally across all levels, but associations were strongest for hospital admissions. Most comorbidities had patterns of association with NVP/HG levels. Among women with NVP/HG who had no hospital admissions, 49% were prescribed antiemetics, mainly from first-line treatment (21% prochlorperazine, 15% promethazine, 13% cyclizine) and metoclopramide (10%). Of those admitted, 38% had prior antiemetic prescriptions (34% first-line, 9% second-line, 1% third-line treatment). CONCLUSION: Previous focus on hospital admissions has greatly underestimated the NVP/HG burden. Although primary care prescribing has increased, most women admitted to hospital have no antiemetics prescribed before this. An urgent call is made to assess whether admissions could be prevented with better primary care recognition and timely treatment. TWEETABLE ABSTRACT: The NVP/HG burden is increasing over time and management optimisation should be high priority to help reduce hospital admissions.

The interplay of context factors in hypnotic and sedative prescription in primary and secondary care-a qualitative study.

PURPOSE: Non-medical or contextual factors strongly influence physicians' prescribing behavior and may explain why drugs, such as benzodiazepines and Z-drugs, are still frequently prescribed in spite of well-known adverse effects. This study aimed to explore which contextual factors influence the prescription of hypnotics and sedatives and to compare their role in primary and secondary care. METHODS: Understanding medical practices as games with specific rules and strategies and performed in a largely habitual, not fully conscious manner, we asked a maximum variation sample of 12 hospital doctors and 12 general practitioners (GPs) about their use of hypnotics and sedatives. The interviews were analyzed by qualitative content analysis. RESULTS: Hospital doctors' and GPs' use of hypnotics and sedatives was influenced by a variety of contextual factors, such as the demand of different patient groups, aims of management, time resources, or the role of nurses and peers. Negotiating patient demands, complying with administrative regulations, and finding acceptable solutions for patients were the main challenges, which characterized the game of drug use in primary care. Maintaining the workflow in the hospital and finding a way to satisfy both nurses and patients were the main challenges in secondary care. CONCLUSIONS: Even if doctors try to act rationally, they cannot escape the interplay of contextual factors such as handling patient needs, complying with administrative regulations, and managing time resources. Doctors should balance these factors as if they were challenges in a complex game and reflect upon their own practices.

Complications after discharge and delays in adjuvant chemotherapy following colonic resection: a cohort study of linked primary and secondary care data.

AIM: By understanding the reasons for delays in adjuvant chemotherapy (AC) after colonic resection, there is the potential to improve patient outcome. The aim of this study is to determine the extent and impact of complications after hospital discharge on delays to AC. METHOD: The study cohort included patients from Hospital Episode Statistics (HES) who had a colorectal cancer resection; linkage to primary care data was provided by the Clinical Practice Research Datalink (CPRD). Complications during the index hospital stay (from HES) and after discharge (from CPRD) were compared. The risk of late AC treatment (8 weeks or later) following a complication, stoma at the index procedure or emergency admission was described after accounting for age and Charlson score. A Cox hazards model determined the association of these factors with overall survival (OS). RESULTS: A total of 1266 patients underwent AC following colon cancer resection, of whom 598 (47.2%) received treatment within 8 weeks. Patients receiving late AC had a significantly higher proportion of re-operations (7.0% vs 3.3% P < 0.005) and wound infections (5.5% vs 3.7% P = 0.042), with 96% of the latter only being noted in CPRD. In multivariate analysis, the risk of AC delay significantly increased following a complication (OR 1.53, 95% CI 1.16-2.03, P = 0.003) or a stoma at the index operation. AC delay was associated with worse OS [hazard ratio (HR) 1.44, 95% CI 1.16-1.79, P = 0.001], as was an emergency admission (HR 1.59, 95% CI 1.21-1.98, P < 0.0005). However, the presence of a complication did not independently reduce OS (HR 1.15, 95%CI 0.89-1.48, P = 0.295). CONCLUSION: The true extent and impact of complications following colonic resection is underestimated when only secondary care data are used.

Correspondence between primary and secondary care about patients with cancer: a Delphi consensus study.

INTRODUCTION: To provide optimal care for patients with cancer, timely and efficient communication between healthcare providers is essential. In this study, we aimed to achieve consensus regarding the desired content of communication between general practitioners (GPs) and oncology specialists before and during the initial treatment of cancer. METHODS: In a two-round Delphi procedure, three expert panels reviewed items recommended for inclusion on referral and specialist letters. RESULTS: The three panels comprised 39 GPs (42%), 42 oncology specialists (41%) (i.e. oncologists, radiotherapists, urologists and surgeons) and 18 patients or patient representatives (69%). Final agreement was by consensus, with 12 and 35 items included in the GP referral and the specialist letters, respectively. The key requirements of GP referral letters were that they should be limited to medical facts, a short summary of symptoms and abnormal findings, and the reason for referral. There was a similar requirement for letters from specialists to include these same medical facts, but detailed information was also required about the diagnosis, treatment options and chosen treatment. After two rounds, the overall content validity index (CVI) for both letters was 71%, indicating that a third round was not necessary. DISCUSSION: This is the first study to differentiate between essential and redundant information in GP referral and specialist letters, and the findings could be used to improve communication between primary and secondary care.

Associations between untreated depression and secondary health care utilization in patients with hypertension and/or diabetes.

PURPOSE: We determined the prevalence of untreated depression in patients with hypertension (HT) and/or diabetes (DM) and estimated the extra health care use and expenditures associated with this comorbidity in a rural Hungarian adult population. We also assessed the potential workload of systematic screening for depression in this patient group. METHODS: General health check database from a primary care programme containing survey data of 2027 patients with HT and/or DM was linked to the outpatient secondary care use database of National Institute of Health Insurance Fund Management. Depression was ascertained by Beck Depression Inventory score and antidepressant drug use. The association between untreated depression and secondary healthcare utilization indicated by number of visits and expenses was evaluated by multiple logistic regression analysis controlled for socioeconomic/lifestyle factors and comorbidity. The age-, sex- and education-specific observations were used to estimate the screening workload for an average general medical practice. RESULTS: The frequency of untreated depression was 27.08%. The untreated severe depression (7.45%) was associated with increased number of visits (OR 1.60, 95% CI 1.11-2.31) and related expenses (OR 2.20, 95% CI 1.50-3.22) in a socioeconomic status-independent manner. To identify untreated depression cases among patients with HT and/or DM, an average GP has to screen 42 subjects a month. CONCLUSION: It seems to be reasonable and feasible to screen for depression in patients with HT and/or DM in the primary care, in order to detect cases without treatment (which may be associated with increase of secondary care visits and expenditures) and to initiate the adequate treatment of them.

Secondary care usage and characteristics of hospital inpatients referred to a UK homeless health team: a retrospective service evaluation.

BACKGROUND: UK "Pathway" teams offer specialist hospital care coordination for people experiencing homelessness. Emergency healthcare use is high among homeless people, yet "homelessness" is not routinely coded in National Health Service (NHS) data. Pathway team records provide an opportunity to assess patterns in admissions and outcomes for inpatients identified as homeless. METHODS: Retrospective analysis of patients referred to "Pathway" homelessness teams in seven UK hospitals to explore the patterns of hospital admission, morbidity, secondary healthcare utilisation and housing status. Each patient was individually identified as experiencing homelessness. Within a six-month period, demographic data, reason for admission, morbidity, mortality and secondary care hospital usage 120-days before and 120-days after the index admission was collected. RESULTS: A total of 1009 patients were referred, resulting in 1135 admissions. Most admissions had an acute physical health need (94.9%). Co-morbid mental illness and/or substance misuse was common (55.7%). Reasons for admission included mental and behavioral disorders (overdose, alcohol withdrawal or depression, 28.3%), external causes of morbidity and mortality (assault or trauma, 18.7%), and injury, poisoning and external causes (head injury, falls and fractures, 12.4%). Unplanned Emergency Department attendances reduced after index admission and unplanned hospital admissions increased slightly. Planned admissions doubled and total bed days increased. Housing status was maintained or improved for over 60% of inpatients upon discharge. Within 12 months of index admission, 50 patients (5%) died, 15 deaths (30%) occurred during the index admission. CONCLUSIONS: Disengagement with health services is common among homeless people. Many deaths are due to treatable medical conditions (heart disease, pneumonia, cancer). Observed increases in planned admissions suggests intervention from Pathway teams facilitates necessary investigations and treatment for homeless people. Equity, parity of care, and value should be inbuilt interventions for inclusion health groups and evaluations need to move beyond simply seeking cost reductions.

The burden of cancer on primary and secondary health care services before and after cancer diagnosis in New South Wales, Australia.

BACKGROUND: Primary and secondary healthcare service usage is assessed in the year before and following a cancer diagnosis, in cancer cases versus matched non-cancer controls in New South Wales (NSW), Australia over 2006-2012, for all invasive cancers collectively and for selected common sites: breast, prostate, colorectal and lung, and melanoma. METHODS: The 45 and Up cohort (n ≈267,000) was linked to NSW Cancer Register (NSWCR), Emergency Department Data Collection (EDDC) and Medical Benefits Schedule (MBS) data using probabilistic record linkage. First-ever malignant cancers diagnosed after enrolment in the 45 and Up study comprised the study cases. Where possible, five controls were randomly selected per case from the 45 and Up cohort, matched by sex and year of birth. Controls comprised those with no cancer recorded on the NSWCR. For each month in the year preceding and following the cancer diagnosis, general practitioner, specialist and specified hospital ED service use was compared between cases and controls using proportions, means, and odds ratios derived from conditional logistic regression. RESULTS: Compared to controls, cases of all cancers combined had a significantly higher likelihood of GP and specialist consultation in the year leading up to diagnosis. This was most pronounced in the 3-4 months leading up diagnosis for all cancers, similarly for lung cancer (GPs and specialists) and melanoma (GPs), and colorectal cancer (specialists). Likelihood of a GP consultation remained significantly higher in cases than controls in the 12 months following diagnosis. During most of the year preceding cancer diagnosis, the likelihood of specified ED presentations was also significantly higher in cases than controls for all cancers, and most pronounced in the 2-3 months before diagnosis. Excepting melanoma, the likelihood of specified ED presentations remained significantly elevated for most of the year following diagnosis for all cancers combined and for the selected cancers. CONCLUSIONS: People with cancer experience a higher use of primary and secondary healthcare services in the year preceding and following diagnosis, with GPs continuing to play a significant role post diagnosis. The higher likelihood of pre-diagnosis GP consultations among cancer cases requires further investigation, including whether signals might be derived to alert GPs to possibilities for earlier cancer detection.