Adherence to guidelines in management of symptoms suggestive of heart failure in primary care.

OBJECTIVE: Clinical guidelines on heart failure (HF) suggest timings for investigation and referral in primary care. We calculated the time for patients to achieve key elements in the recommended pathway to diagnosis of HF. METHODS: In this observational study, we used linked primary and secondary care data (Clinical Practice Research Datalink, a database of anonymised electronic records from UK general practices) between 2010 and 2013. Records were examined for presenting symptoms (breathlessness, fatigue, ankle swelling) and key elements of the National Institute for Health and Care Excellence-recommended pathway to diagnosis (serum natriuretic peptide (NP) test, echocardiography, specialist referral). RESULTS: 42 403 patients were diagnosed with HF, of whom 16 597 presented in primary care with suggestive symptoms. 6464 (39%) had recorded NP or echocardiography, and 6043 (36%) specialist referral. Median time from recorded symptom(s) to investigation (NP or echocardiography) was 292 days (IQR 34-844) and to referral 236 days (IQR 42-721). Median time from symptom(s) to diagnosis was 972 days (IQR 337-1468) and to treatment with HF-relevant medication 803 days (IQR 230-1364). Factors significantly affecting timing of referral, treatment and diagnosis included patients' sex (p=0.001), age (p<0.001), deprivation score (p=0.001), comorbidities (p<0.001) and presenting symptom type (p<0.001). CONCLUSIONS: Median times to investigation or referral of patients presenting in primary care with symptoms suggestive of HF considerably exceeded recommendations. There is a need to support clinicians in the diagnosis of HF in primary care, with improved access to investigation and specialist assessment to support timely management.

Real-world presentation with heart failure in primary care: do patients selected to follow diagnostic and management guidelines have better outcomes?

Objective: To describe associations between initial management of people presenting with heart failure (HF) symptoms in primary care, including compliance with the recommendations of the National Institute for Health and Care Excellence (NICE), and subsequent unplanned hospitalisation for HF and death. Methods: This is a retrospective cohort study using data from general practices submitting records to the Clinical Practice Research Datalink. The cohort comprised patients diagnosed with HF during 2010-2013 and presenting to their general practitioners with breathlessness, fatigue or ankle swelling. Results: 13 897 patients were included in the study. Within the first 6 months, only 7% had completed the NICE-recommended pathway; another 18.6% had followed part of it (B-type natriuretic peptide testing and/or echocardiography, or specialist referral). Significant differences in hazards were seen in unadjusted analysis in favour of full or partial completion of the NICE-recommended pathway. Covariate adjustment attenuated the relations with death much more than those for HF admission. Compared with patients placed on the NICE pathway, treatment with HF medications had an HR of 1.16 (95% CI 1.05 to 1.28, p=0.003) for HF admission and 1.03 (95% CI 0.90 to 1.17, p= 0.674) for death. Patients who partially followed the NICE pathway had similar hazards to those who completed it. Patients on no pathway had the highest hazard for HF admission at 1.30 (95% 1.18 to 1.43, p<0.001) but similar hazard for death. Conclusions: Patients not put on at least some elements of the NICE-recommended pathway had significantly higher risk of HF admission but non-significant higher risk of death than other patients had.

Outcome of elective withdrawal of anti-tumour necrosis factor-α therapy in patients with Crohn's disease in established remission.

BACKGROUND AND AIMS: Outcomes of cessation of anti-TNF therapy for Crohn's disease (CD) in clinical and/or endoscopic remission in routine clinical practice is uncertain. This study aimed to evaluate clinical outcomes and factors associated with relapse in CD patients following formal disease assessment and elective anti-TNF withdrawal. METHODS: Prospective observational study of CD patients in whom anti-TNF therapy was stopped electively after ≥12months and follow-up of ≥6months. Investigations at assessment prior to cessation included ≥1 of clinical assessment, endoscopic and/or imaging. Relapse was defined as recurrent symptoms of CD requiring medical or surgical therapy. RESULTS: Eighty-six patients received anti-TNF for a median duration of 23 (12-80) months for severe active luminal (70%), fistulating perianal (25.5%) and other fistulating disease (4.5%). Relapse rates at 90,180 and 365days were 4.7%, 18.6% and 36%, respectively. If anti-TNF dose escalation occurred 6months prior to withdrawal, 88% (7/8) relapsed. Based on multivariate analysis, risk factors for relapse include ileocolonic disease at diagnosis and previous anti-TNF therapy. An elevated faecal calprotectin (FC) is likely to predict relapse (p=0.02), with a PPV of 66.7% at >50µg/g. Of 36 patients who relapsed, 31 were retreated with anti-TNF, with an overall recapture rate of 93%. CONCLUSION: Relapse rates at 1year following elective withdrawal of anti-TNF are 36%, with high retreatment response rate. Predictors of relapse include ileocolonic involvement, previous anti-TNF therapy and raised FC. Endoscopic/radiologic assessment prior to cessation of therapy does not appear to predict those at lower risk of relapse.

Integrated care for diabetes-a Singapore approach.

BACKGROUND: The prevalence of diabetes mellitus is 12.7% in Singapore. Managing people with diabetes in the community may be needed to reduce unnecessary utilisation of expensive specialist resources and to reduce hospital waiting times for patients with complications. CARE PRACTICE: The Singapore General Hospital (SGH) Delivering on Target (DOT) Programme was launched in 2005 to right-site clinically stable diabetic patients from the hospital to private DOT GPs. The Chronic Disease Management Office (CDMO) was established and a fully customised DOT information technology (IT) system was developed. Three initiatives were implemented: (i) Subsidised drug delivery programme, (ii) Diagnostic tests incentive programme, and (iii) Allied healthcare incentive programme. DISCUSSION: Right-siting was enabled through patient incentives that eased the burden of out-of-pocket expenditure. Right Siting Officers (RSOs) maintained a general oversight of the patient pathway. The integrated system supported shared care follow-up by enabling DOT GPs to share updates on the patients' health status with the referring specialists. CONCLUSION: A coherent process across all healthcare providers similar to the SGH DOT Programme may facilitate efforts to shift the care for people with diabetes to the community and to provide integrated care. Successful integration may require incentives for institutional partners and patients.

Evaluation of restenosis and extent of coronary artery disease in patients with previous percutaneous coronary interventions by dobutamine stress real-time myocardial contrast perfusion imaging.

OBJECTIVES: To assess the accuracy of real-time myocardial contrast perfusion imaging (MCPI) for the diagnosis of restenosis and extent of coronary artery disease (CAD) in patients with previous percutaneous coronary intervention (PCI). METHODS: 56 patients were studied 1.9 (SD 1.4) years after PCI. They underwent MCPI with commercially available ultrasound contrast agents (Optison or Definity) at rest and at peak dobutamine-atropine stress. Coronary angiography was performed within one month. Significant CAD was defined as >or= 50% stenosis in >or= 1 major epicardial coronary artery. Significant restenosis was defined as >or= 50% stenosis in a coronary segment with previous intervention. RESULTS: Reversible perfusion abnormalities were detected in 40 of 43 patients with significant CAD and in 4 of 13 patients without (overall sensitivity 93%, 95% CI 85% to 99%; specificity 69%, 95% CI 44% to 94%; and accuracy 88%, 95% CI 79% to 96%). Significant restenosis in >or= 1 coronary artery with previous PCI was detected in 38 (68%) patients. Reversible perfusion abnormalities were present in 35 of them (sensitivity 92%, 95% CI 84% to 99%). Reversible perfusion abnormalities were detected in >or= 2 vascular distributions in 20 of 28 patients with multivessel CAD and in 3 of 28 patients without (sensitivity 71%, 95% CI 55% to 88%; specificity 89%, 95% CI 78% to 99%; and accuracy 80%, 95% CI 70% to 91%). Restenosis was detected in 41 coronary arteries. Sensitivity of MCPI for regional diagnosis of restenosis was 73% (95% CI 60% to 87%), specificity was 75% (95% CI 60% to 90%), and accuracy was 74% (95% CI 64% to 84%). CONCLUSION: Dobutamine stress MCPI is a useful technique for the evaluation of restenosis and extent of CAD after PCI.

Deprivation payments to general practitioners: limitations of census data.

The census data from which deprivation payments have been calculated since June 1995 suffer from limitations including underenumeration; under counting of homeless people and refugees, and artefactual errors because of the way in which the 1991 census data were tabulated. These limitations reduced the fairness of the changes that many practices experienced in their deprivation payments. The validity of the current system of deprivation payments would be improved if these limitations were borne in mind when allocating payments to practices and if enumeration districts were used as the basis of payments rather than electoral wards.

Home visiting by general practitioners in England and Wales.

OBJECTIVE: To use data from the fourth national survey of morbidity in general practice to investigate the association between home visiting rates and patients' characteristics. DESIGN: Survey of diagnostic data on all home visits by general practitioners. SETTING: 60 general practices in England and Wales. SUBJECTS: 502 493 patients visited at home between September 1991 and August 1992. MAIN OUTCOME MEASURES: Home visiting rates per 1000 patient years and home visiting ratios standardised for age and sex. RESULTS: 10.1% (139 801/1 378 510) of contacts with general practitioners took place in patients' homes. The average annual home visiting rate was 299/1000 patient years. Rates showed a J shaped relation with age and were lowest in people aged 16-24 years (103/1000) and highest in people aged > or = 85 years (3009/1000). 1.3% of patients were visited five or more times and received 39% of visits. Age and sex standardised home visiting ratios increased from 69 (95% confidence interval 68 to 70) in social class I to 129 (128 to 130) in social class V. The commonest diagnostic group was diseases of the respiratory system. In older age groups, diseases of the circulatory system was also a common diagnostic group. Standardised home visiting ratios for the 60 practices in the study varied nearly eightfold, from 28 to 218 (interquartile range 67 to 126). CONCLUSIONS: Home visits remain an important component of general practitioners' workload. As well as the strong associations between home visiting rates and patient characteristics, there were also large differences between practices in home visiting rates. A small number of patients received a disproportionately high number of home visits. Further investigation of patients with high home visiting rates may help to explain the large differences in workload between general practices and help in allocation of resources to practices.

Age and sex differences in the management of ischaemic heart disease.

OBJECTIVE: To investigate age and sex differences in the utilisation of hospital services for ischaemic heart disease. DESIGN: Analysis of routine mortality data and hospital activity data. SETTING: South West Thames Regional Health Authority. SUBJECTS: Residents of the South West Thames Regional Health Authority who in 1991 either died from ischaemic heart disease or were admitted to an NHS hospital in England and Wales with a main diagnosis of ischaemic heart disease. MAIN OUTCOME MEASURES: Ratio of consultant episodes to deaths from ischaemic heart disease (as a proxy measure of the utilisation of hospital care), and the percentages of consultant episodes in which further investigation (angiography or catheterisation) or revascularisation treatment (coronary artery bypass grafting or angioplasty) were carried out. RESULTS: The ratio of episodes to deaths was similar in men and women (odds ratio for men vs. women 0.96, 95% confidence intervals 0.90 to 1.03). The percentage of episodes in which further investigation was carried out was higher in men than women (odds ratio for men vs. women 1.46, 95% confidence intervals 1.25 to 1.70) as was the percentage of episodes in which revascularisation treatment was carried out (odds ratio for men vs. women 1.46, 95% confidence intervals 1.20 to 1.77). The ratio of episodes to deaths, the percentage of episodes in which further investigation was carried out, and the percentage of episodes in which revascularisation treatment was carried out all declined with age (all p values < 0.001). CONCLUSIONS: Women with ischaemic heart disease are as likely as men to be admitted to hospital, but after admission are less likely to undergo further investigation and revascularisation treatment. Elderly patients with ischaemic heart disease are less likely than younger patients to be admitted to hospital; after admission, they are also less likely to undergo further investigation and revascularisation treatment. Further research is needed to determine whether these age and sex differences in the use of hospital services are clinically justified.

Annual night visiting rates in 129 general practices in one family health services authority: association with patient and general practice characteristics.

BACKGROUND: Rates of night visiting by general practitioners have increased steadily over the last 30 years and vary widely between general practices. AIM: An ecological study was carried out to examine night visiting rates by general practices in one family health services authority, and to determine the extent to which differences in night visiting rates between practices could be explained by patient and practice characteristics. METHOD: The study examined the variation in annual night visiting rates, based on night visit fees claimed between April 1993 and March 1994, among 129 general practices in Merton, Sutton and Wandsworth Family Health Services Authority, London. RESULTS: Practices' annual night visiting rates varied from three per 1000 to 75 per 1000 patients. The percentages of the practice population aged under five years and aged five to 14 years were both positively correlated with night visiting rates (r = 0.38 and r = 0.35, respectively), as were variables associated with social deprivation such as the estimated percentage of the practice population living in one-parent households (r = 0.24) and in households where the head of household was classified as unskilled (r = 0.20). The percentage of the practice population reporting chronic illness was also positively associated with night visiting rates (r = 0.26). The percentages of the practice population aged 35 to 44 years and 45 to 54 years were both negatively associated with night visiting rates (r = -0.34 and r = -0.31, respectively) as was the estimated list inflation for a practice (r = -0.31). There was no significant correlation between night visiting rates and the distance of the main practice surgery from the nearest hospital accident and emergency department. There was also no association between night visiting rates and permission to use a deputizing service. In a stepwise multiple regression model, the multiple correlation coefficient was 0.56 with four factors (percentage of the practice population aged under five years, percentage aged 35-44 years, percentage who were chronically ill and estimated list inflation) explaining 32% of the variation in night visiting rates. CONCLUSION: Only about one third of the variation in night visiting rates between practices could be explained by patient and practice variables derived from routine data. Population-based research using data collected on individual patients and practices is required to improve current understanding of the patient and practice characteristics that influence the demand for night visits and of why night visiting rates vary so widely between practices.

Using data from the 1991 census.

The 1991 census for England and Wales provides a substantial amount of data on demography, ethnicity, housing tenure, employment status, and other social factors for geographical areas ranging in size from enumeration districts upwards. Many in the health service and in the academic community are making use of the data in the 1991 census. However, users of census data need to be aware of the problems and limitations of these data, which include the format of the data, data modification and suppression, sampling error, and underenumeration. An important innovation of the 1991 census was that the census form included a question on the postcode of respondents; this allowed the Office of Population Censuses and Surveys to produce a postcode-enumeration district look up table which overcomes many of the problems previously encountered in trying to assign postcodes to enumeration districts. The new look up table also includes the grid reference of postcodes, and this will improve the geographical referencing of census data.

Do general practitioners influence the uptake of breast cancer screening?

OBJECTIVES: To investigate the relative importance of patient and general practice characteristics in explaining variations between practices in the uptake of breast cancer screening. DESIGN: Ecological study examining variations in breast cancer screening rates among 131 general practices using routine data. SETTING: Merton, Sutton, and Wandsworth Family Health Services Authority, which covers parts of inner and outer London. MAIN OUTCOME MEASURE: Percentage of eligible women aged 50-64 who attended for mammography during the first round of screening for breast cancer (1991-1994). RESULTS: Of the 43,063 women eligible for breast cancer screening, 25,826 (60%) attended for a mammogram. Breast cancer screening rates in individual practices varied from 12.5% to 84.5%. The estimated percentage list inflation for the practices was the variable most highly correlated with screening rates (r = -0.69). There were also strong negative correlations between screening rates and variables associated with social deprivation, such as the estimated percentage of the practice population living in households without a car (r = -0.61), and with variables that measured the ethnic make-up of practice populations, such as the estimated percentage of people in non-white ethnic groups (r = -0.60). Screening rates were significantly higher in practices with a computer than in those without (59.5% v 53.9%, difference 5.6%, 95% confidence interval 1.1 to 10.2%). There was no significant difference in screening rates between practices with and without a female partner; with and without a practice nurse; and with and without a practice manager. In a forward stepwise multiple regression model that explained 58% of the variation in breast cancer screening rates, four factors were significant independent predictors (at P = 0.05) of screening rates: list inflation and people living in households without a car were both negative predictors of screening rates, and chronic illness and the number of partners in a practice were both positive predictors of screening rates. The practice with the highest screening rate (84.5%) contacted all women invited for screening to encourage them to attend for their mammogram and achieved a rate 38% higher than predicted from the regression model. Breast cancer screening rates were on average lower than cervical cancer screening rates (mean difference 14.5%, standard deviation 12.0%) and were less strongly associated with practice characteristics. CONCLUSIONS: The strong negative correlation between breast cancer screening rates and list inflation shows the importance of accurate age-sex registers in achieving high breast cancer screening rates. Breast cancer screening units, family health services authorities, and general practitioners need to collaborate to improve the accuracy of the age-sex registers used to generate invitations for breast cancer screening. The success of the practice with the highest screening rate suggests that practices can influence the uptake of breast cancer screening among their patients. Giving general practitioners a greater role in breast cancer screening, either by offering them financial incentives or by giving them clerical support to check prior notification lists and contact nonattenders, may also help to increase breast cancer screening rates.

Equity in the NHS. Monitoring and promoting equity in primary and secondary care.

Although need is often assumed to be the most important factor in determining the use of health services, there are many inequities in the provision and use of NHS services in both primary and secondary care. For example, existing data from district child health information services have been combined with census data for small areas to show wide variations in immunisation rates between affluent and deprived areas. Purchasers of health care are already responsible for assessing health needs and evaluating services, and the process of monitoring equity is a logical extension of these activities. Routine data sources used to collect activity data in both primary and secondary care can be used to assess needs for care and monitor how well these needs are met. Purchasers and providers should collaborate to improve the usefulness of these routine data and to develop a framework for monitoring and promoting equity more systematically.

Using patient and general practice characteristics to explain variations in cervical smear uptake rates.

OBJECTIVES: To produce practice and patient variables for general practices from census and family health services authority data, and to determine the importance of these variables in explaining variation in cervical smear uptake rates between practices. DESIGN: Population based study examining variations in cervical smear uptake rates among 126 general practices using routine data. SETTING: Merton, Sutton, and Wandsworth Family Health Services Authority, which covers parts of inner and outer London. MAIN OUTCOME MEASURE: Percentage of women aged 25-64 years registered with a general practitioner who had undergone a cervical smear test during the five and a half years preceding 31 March 1992. RESULTS: Cervical smear uptake rates varied from 16.5% to 94.1%. The estimated percentage of practice population from ethnic minority groups correlated negatively with uptake rates (r = -0.42), as did variables associated with social deprivation such as overcrowding (r = -0.42), not owning a car (r = -0.41), and unemployment (r = -0.40). Percentage of practice population under 5 years of age correlated positively with uptake rate (r = 0.42). Rates were higher in practices with a female partner than in those without (66.6% v 49.1%; difference 17.5% (95% confidence interval 10.5% to 24.5%)), and in computerised than in non-computerised practices (64.5% v 50.5%; 14.0% (6.4% to 21.6%)). Rates were higher in larger practices. In a stepwise multiple regression model that explained 52% of variation, five factors were significant predictors of uptake rates: presence of a female partner; children under 5; overcrowding; number of women aged 35-44 as percentage of all women aged 25-64; change of address in past year. CONCLUSIONS: Over half of variation in cervical smear uptake rates can be explained by patient and practice variables derived from census and family health services authority data; these variables may have a role in explaining variations in performance of general practices and in producing adjusted measures of practice performance. Practices with a female partner had substantially higher uptake rates.