Reducing short-acting beta-agonist overprescribing in asthma: lessons from a quality-improvement prescribing project in East London.

BACKGROUND: Excess prescription and use of short-acting beta-agonist (SABA) inhalers is associated with poor asthma control and increased risk of hospital admission. AIM: To quantify the prevalence and identify the predictors of SABA overprescribing. DESIGN AND SETTING: A cross-sectional study using anonymised clinical and prescribing data from the primary care records in three contiguous East London boroughs. METHOD: Primary care medical record data for patients aged 5-80 years, with 'active' asthma were extracted in February 2020. Explanatory variables included demography, asthma management, comorbidities, and prescriptions for asthma medications. RESULTS: In the study population of 30 694 people with asthma, >25% (1995/7980), were prescribed ≥6 SABA inhalers in the previous year. A 10-fold variation between practices (<6% to 60%) was observed in the proportion of patients on ≥6 SABA inhalers/year. By converting both SABAs and inhaled corticosteroids (ICSs) to standard units the accuracy of comparisons was improved across different preparations. In total, >25% of those taking ≥6 SABAs/year were underusing ICSs, this rose to >80% (18 170/22 713), for those prescribed <6 SABAs/year. Prescription modality was a strong predictor of SABA overprescribing, with repeat dispensing strongly linked to SABA overprescribing (odds ratio 6.52, 95% confidence interval = 4.64 to 9.41). Increasing severity of asthma and multimorbidity were also independent predictors of SABA overprescribing. CONCLUSION: In this multi-ethnic population a fifth of practices demonstrate an overprescribing rate of <20% a year. Based on previous data, supporting practices to enable the SABA ≥12 group to reduce to 4-12 a year could potentially save up to 70% of asthma admissions a year within that group.

Measuring continuity of care in general practice: a comparison of two methods using routinely collected data.

BACKGROUND: Despite well-documented clinical benefits of longitudinal doctor-patient continuity in primary care, continuity rates have declined. Assessment by practices or health commissioners is rarely undertaken. AIM: Using the Usual Provider of Care (UPC) score this study set out to measure continuity across 126 practices in the mobile, multi-ethnic population of East London, comparing these scores with the General Practice Patient Survey (GPPS) responses to questions on GP continuity. DESIGN AND SETTING: A retrospective, cross-sectional study in all 126 practices in three East London boroughs. METHOD: The study population included patients who consulted three or more times between January 2017 and December 2018. Anonymised demographic and consultation data from the electronic health record were linked to results from Question 10 ('seeing the doctor you prefer') of the 2019 GPPS. RESULTS: The mean UPC score for all 126 practices was 0.52 (range 0.32 to 0.93). There was a strong correlation between practice UPC scores measured in the 2 years to December 2018 and responses to the 2019 GPPS Question 10, Pearson's r correlation coefficient, 0.62. Smaller practices had higher scores. Multilevel analysis showed higher continuity for patients ≥65 years compared with children and younger adults (ß coefficient 0.082, 95% confidence interval = 0.080 to 0.084) and for females compared with males. CONCLUSION: It is possible to measure continuity across all practices in a local health economy. Regular review of practice continuity rates can be used to support efforts to increase continuity within practice teams. In turn this is likely to have a positive effect on clinical outcomes and on satisfaction for both patients and doctors.

Characterisation of type 2 diabetes subgroups and their association with ethnicity and clinical outcomes: a UK real-world data study using the East London Database.

BACKGROUND: Subgroups of type 2 diabetes (T2DM) have been well characterised in experimental studies. It is unclear, however, whether the same approaches can be used to characterise T2DM subgroups in UK primary care populations and their associations with clinical outcomes. AIM: To derive T2DM subgroups using primary care data from a multi-ethnic population, evaluate associations with glycaemic control, treatment initiation, and vascular outcomes, and to understand how these vary by ethnicity. DESIGN AND SETTING: An observational cohort study in the East London Primary Care Database from 2008 to 2018. METHOD: Latent-class analysis using age, sex, glycated haemoglobin, and body mass index at diagnosis was used to derive T2DM subgroups in white, South Asian, and black groups. Time to treatment initiation and vascular outcomes were estimated using multivariable Cox-proportional hazards regression. RESULTS: In total, 31 931 adults with T2DM were included: 47% South Asian (n = 14 884), 26% white (n = 8154), 20% black (n = 6423). Two previously described subgroups were replicated, 'mild age-related diabetes' (MARD) and 'mild obesity-related diabetes' (MOD), and a third was characterised 'severe hyperglycaemic diabetes' (SHD). Compared with MARD, SHD had the poorest long-term glycaemic control, fastest initiation of antidiabetic treatment (hazard ratio [HR] 2.02, 95% confidence interval [CI] = 1.76 to 2.32), and highest risk of microvascular complications (HR 1.38, 95% CI = 1.28 to 1.49). MOD had the highest risk of macrovascular complications (HR 1.50, 95% CI = 1.23 to 1.82). Subgroup differences in treatment initiation were most pronounced for the white group, and vascular complications for the black group. CONCLUSION: Clinically useful T2DM subgroups, identified at diagnosis, can be generated in routine real-world multi-ethnic populations, and may offer a pragmatic means to develop stratified primary care pathways and improve healthcare resource allocation.

Prevalence of suspected COVID-19 infection in patients from ethnic minority populations: a cross-sectional study in primary care.

BACKGROUND: The first wave of the London COVID-19 epidemic peaked in April 2020. Attention initially focused on severe presentations, intensive care capacity, and the timely supply of equipment. While general practice has seen a rapid uptake of technology to allow for virtual consultations, little is known about the pattern of suspected COVID-19 presentations in primary care. AIM: To quantify the prevalence and time course of clinically suspected COVID-19 presenting to general practices, to report the risk of suspected COVID-19 by ethnic group, and to identify whether differences by ethnicity can be explained by clinical data in the GP record. DESIGN AND SETTING: Cross-sectional study using anonymised data from the primary care records of approximately 1.2 million adults registered with 157 practices in four adjacent east London clinical commissioning groups. The study population includes 55% of people from ethnic minorities and is in the top decile of social deprivation in England. METHOD: Suspected COVID-19 cases were identified clinically and recorded using SNOMED codes. Explanatory variables included age, sex, self-reported ethnicity, and measures of social deprivation. Clinical factors included data on 16 long-term conditions, body mass index, and smoking status. RESULTS: GPs recorded 8985 suspected COVID-19 cases between 10 February and 30 April 2020.Univariate analysis showed a two-fold increase in the odds of suspected COVID-19 for South Asian and black adults compared with white adults. In a fully adjusted analysis that included clinical factors, South Asian patients had nearly twice the odds of suspected infection (odds ratio [OR] = 1.93, 95% confidence interval [CI] = 1.83 to 2.04). The OR for black patients was 1.47 (95% CI = 1.38 to 1.57). CONCLUSION: Using data from GP records, black and South Asian ethnicity remain as predictors of suspected COVID-19, with levels of risk similar to hospital admission reports. Further understanding of these differences requires social and occupational data.

Reducing the use of inhaled corticosteroids in mild-moderate COPD: an observational study in east London.

Inhaled corticosteroids (ICS) are often prescribed for worsening breathlessness, exacerbation frequency or lung function in chronic obstructive pulmonary disease (COPD). In mild-moderate disease and infrequent exacerbations, treatment risks may outweigh benefits and ICS may be withdrawn safely under supervision. A systematic ICS deprescribing programme for patients with mild-moderate COPD was introduced in an east London Clinical Commissioning Group (CCG) in April 2017. Primary care patient record analysis found that prescribing fell from 34.9% (n = 701) in the 18 months pre-intervention to 26.9% (n = 538) by the second year of implementation, decreasing 0.84% per quarter post intervention (p = 0.006, linear regression). The relative decrease was greater than the comparison CCG (23.0% vs. 9.9%). Only South Asian ethnicity was associated with increased cessation (odds ratio 1.48, confidence interval (CI) 1.09-2.01), p = 0.013, logistic regression). Patient outcome data were not collected. A primary care-led programme comprising local education, financial incentivisation and consultant support led to a significant decrease in ICS prescribing.

Improving coding and primary care management for patients with chronic kidney disease: an observational controlled study in East London.

BACKGROUND: The UK national chronic kidney disease (CKD) audit in primary care shows diagnostic coding in the electronic health record for CKD averages 70%, with wide practice variation. Coding is associated with improvements to risk factor management; CKD cases coded in primary care have lower rates of unplanned hospital admission. AIM: To increase diagnostic coding of CKD (stages 3-5) and primary care management, including blood pressure to target and prescription of statins to reduce cardiovascular disease risk. DESIGN AND SETTING: Controlled, cross-sectional study in four East London clinical commissioning groups (CCGs). METHOD: Interventions to improve coding formed part of a larger system change to the delivery of renal services in both primary and secondary care in East London. Quarterly anonymised data on CKD coding, blood pressure values, and statin prescriptions were extracted from practice computer systems for 1-year pre- and post-initiation of the intervention. RESULTS: Three intervention CCGs showed significant coding improvement over a 1 year period following the intervention (regression for post-intervention trend P<0.001). The CCG with highest coding rates increased from 76-90% of CKD cases coded; the lowest coding CCG increased from 52-81%. The comparison CCG showed no change in coding rates. Combined data from all practices in the intervention CCGs showed a significant increase in the proportion of cases with blood pressure achieving target levels (difference in proportion P<0.001) over the 2-year study period. Differences in statin prescribing were not significant. CONCLUSION: Clinically important improvements to coding and management of CKD in primary care can be achieved by quality improvement interventions that use shared data to track and monitor change supported by practice-based facilitation. Alignment of clinical and CCG priorities and the provision of clinical targets, financial incentives, and educational resource were additional important elements of the intervention.

Does the ethnic density effect extend to obesity? A cross-sectional study of 415 166 adults in east London.

OBJECTIVES: To examine the prevalence of obesity by ethnic group and to examine the association between ethnic density and obesity prevalence. DESIGN AND SETTING: Cross-sectional study utilising electronic primary care records of 128 practices in a multiethnic population of east London. PARTICIPANTS: Electronic primary care records of 415 166 adults with a body mass index recorded in the previous 3 years. OUTCOME MEASURES: (1) Odds of obesity for different ethnic groups compared with white British. (2) Prevalence of obesity associated with each 10% increase in own-group ethnic density, by ethnic group. RESULTS: Using multilevel logistic regression models, we find that compared with white British/Irish males, the odds of obesity were significantly higher among black ethnic groups and significantly lower among Asian and white other groups. Among females, all ethnic groups except Chinese and white other were at increased odds of obesity compared with white British/Irish. There was no association between increasing ethnic density and obesity prevalence, except among black Africans and Indian females. A 10% increase in black ethnic density was associated with a 15% increase in odds of obesity among black African males (95% CI 1.07 to 1.24) and 18% among black African females (95% CI 1.08 to 1.30). Among Indian females, a 10% increase in Indian ethnic density was associated with a 7% decrease in odds of obesity (95% CI 0.88 to 0.99). CONCLUSION: Wider environmental factors play a greater role in determining obesity than the ethnic composition of the area for most ethnic groups. Further research is needed to understand the mechanism through which increasing ethnic density is associated with increased odds of obesity among black Africans and decreased odds of obesity among Indian females.

Using the electronic health record to build a culture of practice safety: evaluating the implementation of trigger tools in one general practice.

BACKGROUND: Identifying patients at risk of harm in general practice is challenging for busy clinicians. In UK primary care, trigger tools and case note reviews are mainly used to identify rates of harm in sample populations. AIM: This study explores how adaptions to existing trigger tool methodology can identify patient safety events and engage clinicians in ongoing reflective work around safety. DESIGN AND SETTING: Mixed-method quantitative and narrative evaluation using thematic analysis in a single East London training practice. METHOD: The project team developed and tested five trigger searches, supported by Excel worksheets to guide the case review process. Project evaluation included summary statistics of completed worksheets and a qualitative review focused on ease of use, barriers to implementation, and perception of value to clinicians. RESULTS: Trigger searches identified 204 patients for GP review. Overall, 117 (57%) of cases were reviewed and 62 (53%) of these cases had patient safety events identified. These were usually incidents of omission, including failure to monitor or review. Key themes from interviews with practice members included the fact that GPs' work is generally reactive and GPs welcomed an approach that identified patients who were 'under the radar' of safety. All GPs expressed concern that the tool might identify too many patients at risk of harm, placing further demands on their time. CONCLUSION: Electronic trigger tools can identify patients for review in domains of clinical risk for primary care. The high yield of safety events engaged clinicians and provided validation of the need for routine safety checks.

Ethnic differences in the progression of chronic kidney disease and risk of death in a UK diabetic population: an observational cohort study.

OBJECTIVE: To determine ethnic differences in the progression of chronic kidney disease (CKD) and risk of end-stage renal failure (ESRF) and death in adults with type 2 diabetes mellitus (T2DM), and to identify predictors of rapid renal decline. DESIGN: Observational community-based cohort study undertaken from 2006 to 2016 with nested case-control study. SETTING: 135 inner London primary care practices contributing to the east London Database. PARTICIPANTS: General practice-registered adults aged 25-85 years with established T2DM and CKD at baseline. OUTCOMES: The annual rate of renal decline was compared between white, south Asian and black groups, and stratified by proteinuria and raised blood pressure (BP) at baseline. Predictors of rapid renal decline were identified in a nested case-control study. Cox proportional hazards regression was used to determine ethnic differences in the risk of ESRF and death. RESULTS: Age-sex adjusted annual decline was greatest in the Bangladeshi population. There was stepwise increase in the rate of decline when stratifying the cohort by baseline proteinuria and BP control, with south Asian groups being most sensitive to the combined effect of proteinuria and raised BP after accounting for key confounders.The odds of rapid renal decline were increased for individuals of Bangladeshi, African and Caribbean ethnicity, those with hypertension, proteinuria, cardiovascular disease and with increasing duration of diabetes. Rapid progression was more frequent in younger age groups. Risk of developing ESRF was highest in the black group compared with the white group (HR 1.88, 95% CI 1.11 to 3.19). Risk of death from any cause was 29% lower in the south Asian group compared with the white group (HR 0.71, 95% CI 0.56 to 0.91). CONCLUSIONS: Proteinuria and hypertension trigger accelerated estimated glomerular filtration rate decline differentially by ethnicity. Active monitoring of younger adults, who have greater odds of rapid progression and the most to gain from interventions, is essential.

Population and patient factors affecting emergency department attendance in London: retrospective cohort analysis of linked primary and secondary care records.

BACKGROUND: Population factors, including social deprivation and morbidity, predict the use of emergency departments (EDs). AIM: To link patient-level primary and secondary care data to determine whether the association between deprivation and ED attendance is explained by multimorbidity and other clinical factors in the GP record. DESIGN AND SETTING: Retrospective cohort study based in East London. METHOD: Primary care demographic, consultation, diagnostic, and clinical data were linked with ED attendance data. GP Patient Survey (GPPS) access questions were linked to practices. RESULTS: Adjusted multilevel analysis for adults showed a progressive rise in ED attendance with increasing numbers of long-term conditions (LTCs). Comparing two LTCs with no conditions, the odds ratio (OR) is 1.28 (95% confidence interval [CI] = 1.25 to 1.31); comparing four or more conditions with no conditions, the OR is 2.55 (95% CI = 2.44 to 2.66). Increasing annual GP consultations predicted ED attendance: comparing zero with more than two consultations, the OR is 2.44 (95% CI = 2.40 to 2.48). Smoking (OR 1.30, 95% CI = 1.28 to 1.32), being housebound (OR 2.01, 95% CI = 1.86 to 2.18), and age also predicted attendance. Patient-reported access scores from the GPPS were not a significant predictor. For children, younger age, male sex, white ethnicity, and higher GP consultation rates predicted attendance. CONCLUSION: Using patient-level data rather than practice-level data, the authors demonstrate that the burden of multimorbidity is the strongest clinical predictor of ED attendance, which is independently associated with social deprivation. Low use of the GP surgery is associated with low attendance at ED. Unlike other studies, the authors found that adult patient experience of GP access, reported at practice level, did not predict use.

How do primary care doctors in England and Wales code and manage people with chronic kidney disease? Results from the National Chronic Kidney Disease Audit.

Background: In the UK, primary care records are electronic and require doctors to ascribe disease codes to direct care plans and facilitate safe prescribing. We investigated factors associated with coding of chronic kidney disease (CKD) in patients with reduced kidney function and the impact this has on patient management. Methods: We identified patients meeting biochemical criteria for CKD (two estimated glomerular filtration rates <60 mL/min/1.73 m2 taken >90 days apart) from 1039 general practitioner (GP) practices in a UK audit. Clustered logistic regression was used to identify factors associated with coding for CKD and improvement in coding as a result of the audit process. We investigated the relationship between coding and five interventions recommended for CKD: achieving blood pressure targets, proteinuria testing, statin prescription and flu and pneumococcal vaccination. Results: Of 256 000 patients with biochemical CKD, 30% did not have a GP CKD code. Males, older patients, those with more severe CKD, diabetes or hypertension or those prescribed statins were more likely to have a CKD code. Among those with continued biochemical CKD following audit, these same characteristics increased the odds of improved coding. Patients without any kidney diagnosis were less likely to receive optimal care than those coded for CKD [e.g. odds ratio for meeting blood pressure target 0.78 (95% confidence interval 0.76-0.79)]. Conclusion: Older age, male sex, diabetes and hypertension are associated with coding for those with biochemical CKD. CKD coding is associated with receiving key primary care interventions recommended for CKD. Increased efforts to incentivize CKD coding may improve outcomes for CKD patients.

Accounting for overdispersion when determining primary care outliers for the identification of chronic kidney disease: learning from the National Chronic Kidney Disease Audit.

Background: Early diagnosis of chronic kidney disease (CKD) facilitates best management in primary care. Testing coverage of those at risk and translation into subsequent diagnostic coding will impact on observed CKD prevalence. Using initial data from 915 general practitioner (GP) practices taking part in a UK national audit, we seek to apply appropriate methods to identify outlying practices in terms of CKD stages 3-5 prevalence and diagnostic coding. Methods: We estimate expected numbers of CKD stages 3-5 cases in each practice, adjusted for key practice characteristics, and further inflate the control limits to account for overdispersion related to unobserved factors (including unobserved risk factors for CKD, and between-practice differences in coding and testing). Results: GP practice prevalence of coded CKD stages 3-5 ranges from 0.04 to 7.8%. Practices differ considerably in coding of CKD in individuals where CKD is indicated following testing (ranging from 0 to 97% of those with and glomerular filtration rate <60 mL/min/1.73 m 2 ). After adjusting for risk factors and overdispersion, the number of 'extreme' practices is reduced from 29 to 2.6% for the low-coded CKD prevalence outcome, from 21 to 1% for high-uncoded CKD stage and from 22 to 2.4% for low total (coded and uncoded) CKD prevalence. Thirty-one practices are identified as outliers for at least one of these outcomes. These can then be categorized into practices needing to address testing, coding or data storage/transfer issues. Conclusions: GP practice prevalence of coded CKD shows wide variation. Accounting for overdispersion is crucial in providing useful information about outlying practices for CKD prevalence.

Asthma prescribing, ethnicity and risk of hospital admission: an analysis of 35,864 linked primary and secondary care records in East London.

Inappropriate prescribing in primary care was implicated in nearly half of asthma deaths reviewed in the UK's recent National Review of Asthma Deaths. Using anonymised EMIS-Web data for 139 ethnically diverse general practices (total population 942,511) extracted from the North and East London Commissioning Support Unit, which holds hospital Secondary Uses Services (SUS)-linked data, we examined the prevalence of over-prescribing of short-acting ß2-agonist inhalers (SABA), under-prescribing of inhaled corticosteroid (ICS) inhalers and solo prescribing of long-acting ß2-agonists (LABA) to assess the risk of hospitalisation for people with asthma for 1 year ending August 2015. In a total asthma population of 35,864, multivariate analyses in adults showed that the risk of admission increased with greater prescription of SABA inhalers above a baseline of 1-3 (4-12 SABA: odds ratio (OR) 1.71; 95% confidence interval (CI) 1.20-2.46, ⩾13 SABA: OR 3.22; 95% CI 2.04-5.07) with increasing British Thoracic Society step (Step 3: OR 2.90; 95% CI 1.79-4.69, Step 4/5: OR 9.42; 95% CI 5.27-16.84), and among Black (OR 2.30; 95% CI 1.64-3.23) and south Asian adult populations (OR 1.83; 95% CI 1.36-2.47). Results in children were similar, but risk of hospitalisation was not related to ethnic group. There is a progressive risk of hospital admission associated with the prescription of more than three SABA inhalers a year. Adults (but not children) from Black and South Asian groups are at an increased risk of admission. Further work is needed to target care for these at-risk groups.

Patient safety and estimation of renal function in patients prescribed new oral anticoagulants for stroke prevention in atrial fibrillation: a cross-sectional study.

OBJECTIVE: In clinical trials of dabigatran and rivaroxaban for stroke prevention in atrial fibrillation (AF), drug eligibility and dosing were determined using the Cockcroft-Gault equation to estimate creatine clearance as a measure of renal function. This cross-sectional study aimed to compare whether using estimated glomerular filtration rate (eGFR) by the widely available and widely used Modified Diet in Renal Disease (MDRD) equation would alter prescribing or dosing of the renally excreted new oral anticoagulants. PARTICIPANTS: Of 4712 patients with known AF within a general practitioner-registered population of 930 079 in east London, data were available enabling renal function to be calculated by both Cockcroft-Gault and MDRD methods in 4120 (87.4%). RESULTS: Of 4120 patients, 2706 were <80 years and 1414 were ≥80 years of age. Among those ≥80 years, 14.9% were ineligible for dabigatran according to Cockcroft-Gault equation but would have been judged eligible applying MDRD method. For those <80 years, 0.8% would have been incorrectly judged eligible for dabigatran and 5.3% would have received too high a dose. For rivaroxaban, 0.3% would have been incorrectly judged eligible for treatment and 13.5% would have received too high a dose. CONCLUSIONS: Were the MDRD-derived eGFR to be used instead of Cockcroft-Gault in prescribing these new agents, many elderly patients with AF would either incorrectly become eligible for them or would receive too high a dose. Safety has not been established using the MDRD equation, a concern since the risk of major bleeding would be increased in patients with unsuspected renal impairment. Given the potentially widespread use of these agents, particularly in primary care, regulatory authorities and drug companies should alert UK doctors of the need to use the Cockcroft-Gault formula to calculate eligibility for and dosing of the new oral anticoagulants in elderly patients with AF and not rely on the MDRD-derived eGFR.

Ethnic differences in primary care management of diabetes and cardiovascular disease in people with serious mental illness.

BACKGROUND: Patients with serious mental illness (SMI) have high rates of cardiovascular disease (CVD). In contrast to widespread perception, their access to effective chronic disease management is as high as for the general population. However, previous studies have not included analysis by ethnicity. AIM: To identify differences in CVD and diabetes management, by ethnicity, among people with SMI. DESIGN AND SETTING: Three inner east London primary care trusts with an ethnically diverse and socially deprived population. Data were obtained from 147 of 151 general practices. METHOD: Coded demographic and clinical data were obtained from GP electronic health records using EMIS Web. The sample used was the GP registered population on diabetes or CVD registers (52,620); of these, 1223 also had SMI. RESULTS: The population prevalence of CVD and diabetes is 7.2%; this rises to 18% among those with SMI. People with SMI and CVD or diabetes were found to be as likely to achieve clinical targets as those without SMI. Blood pressure control was significantly better in people with SMI; however, they were more likely to smoke and have a body mass index above 30 kg/m(2). Ethnic differences in care were identified, with south Asian individuals achieving better cholesterol control and black African or Caribbean groups achieving poorer blood pressure control. CONCLUSION: Risk factor management for those with SMI shows better control of blood pressure and glycosylated haemoglobin than the general population. However, smoking and obesity rates remain high and should be the target of public health programmes. Ethnic differences in management mirror those in the general population. Ethnic monitoring for vulnerable groups provides evidence to support schemes to reduce health inequalities.