Risk prediction of advanced colorectal neoplasia among diabetic patients: A derivation and validation study.

Background and Aim: Colorectal cancer (CRC) is the third most common cancer in the world. This study devises and validates a clinical scoring system for risk prediction of advanced colorectal neoplasia (ACN) to guide colonoscopy evaluation among diabetic patients. Methods: We identified 55 964 diabetic patients who received colonoscopies from a large database in a Chinese population (2008-2018). We recruited a derivation cohort based on random sampling. The risk factors of CRC evaluated by univariate analysis were examined for ACN, defined as advanced adenoma, CRC, or any combination thereof using binary logistic regression analysis. We used the adjusted odds ratios (aORs) for independent risk factors to devise a risk score, ranging from 0 to 6: 0-4 "average risk" (AR) and 5-6 "high risk" (HR). The other subjects acted as an independent validation cohort. Results: The prevalence of ACN in both the derivation and validation cohorts was 2.0%. Using the scoring system constructed, 78.5% and 21.5% of patients in the validation cohort were classified as AR and HR, respectively. The prevalence of ACN in the AR and HR groups was 1.5% and 4.1%, respectively. Individuals in the HR group had a 2.78-fold increased prevalence of ACN than the AR group. The concordance (c-) statistics was 0.70, implying a good discriminatory capability of the risk score to stratify high-risk individuals who should consider colonoscopy. Conclusion: The clinical risk scoring system based on age, gender, smoking, presence of hypertension, and use of aspirin is useful for ACN risk prediction among diabetic patients.

A mixed-methods evaluation of patients' views on primary care multi-disciplinary teams in Scotland.

BACKGROUND: Expanding primary care multi-disciplinary teams (MDTs) was a key component of the 2018 Scottish GP contract, with over 4,700 MDT staff appointed since then. AIM: To explore patients' views on primary care MDT expansion in Scotland. DESIGN AND METHODS: (1) Survey of patients recently consulting a GP in deprived-urban, affluent-urban and remote/rural areas, assessing awareness of five MDT roles and attitudes towards receptionist signposting; (2) 30 individual interviews exploring MDT-care experiences. RESULTS: Of 1,053 survey respondents, most were unaware of the option of MDT rather than GP consultations for three out of five roles (69% unaware of link worker appointments; 68% mental health nurse; 58% pharmacist). Reception signposting was less popular in deprived-urban areas (34% unhappy vs 29% in remote/rural vs 21% affluent-urban; P<0.001), and in patients with multimorbidity (31% unhappy vs 24% in non-multimorbid; P<0.05).Two-thirds of interviewees had multimorbidity and almost all reported positive MDT-care experiences. However, MDT-care was generally seen as a supplement rather than a substitute for GP care. Around half of patients expressed concerns about reception signposting. These patients were more likely to also express concerns about GP access in general. Both of these concerns were more common in deprived-urban areas than in remote/rural or affluent-urban areas. CONCLUSION: MDT-care has expanded in Scotland with limited patient awareness. Although patients understand its potential value, many patients are unhappy with reception signposting to first-contact MDT care, especially those in deprived-urban areas living with multimorbidity. This represents a barrier to the aims of the new GP contract.

Community Engagement in Vaccination Promotion: Systematic Review and Meta-Analysis.

BACKGROUND: Community engagement plays a vital role in global immunization strategies, offering the potential to overcome vaccination hesitancy and enhance vaccination confidence. Although there is significant backing for community engagement in health promotion, the evidence supporting its effectiveness in vaccination promotion is fragmented and of uncertain quality. OBJECTIVE: This review aims to systematically examine the effectiveness of different contents and extent of community engagement for promoting vaccination rates. METHODS: This study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A comprehensive and exhaustive literature search was performed in 4 English databases (PubMed, Embase, Web of Science, and Cochrane Library) and 2 Chinese databases (CNKI and Wan Fang) to identify all possible articles. Original research articles applying an experimental study design that investigated the effectiveness of community engagement in vaccination promotion were eligible for inclusion. Two reviewers independently performed the literature search, study selection, quality assessment, and data extraction. Discrepancies were resolved through discussion, with the arbitration of a third reviewer where necessary. RESULTS: A total of 20 articles out of 11,404 records from 2006 to 2021 were retrieved. The studies used various designs: 12 applied single-group pre-post study designs, 5 were cluster randomized controlled trials (RCTs), and 3 were non-RCTs. These studies targeted multiple vaccines, with 8 focusing on children's immunization, 8 on human papillomavirus vaccine, 3 on hepatitis B virus vaccine, and 1 on COVID-19 vaccine. The meta-analysis revealed significant increases in vaccination rates both in pre-post comparison (rate difference [RD] 0.34, 95% CI 0.21-0.47, I2=99.9%, P<.001) and between-group comparison (RD 0.18, 95% CI 0.07-0.29, I2=98.4%, P<.001). The meta-analysis revealed that participant recruitment had the largest effect size (RD 0.51, 95% CI 0.36-0.67, I2=99.9%, P<.001), followed by intervention development (RD 0.36, 95% CI 0.23-0.50, I2=100.0%, P<.001), intervention implementation (RD 0.35, 95% CI 0.22-0.47, I2=99.8%, P<.001), and data collection (RD 0.34, 95% CI 0.19-0.50, I2=99.8%, P<.001). The meta-analysis indicated that high community engagement extent yielded the largest effect size (RD 0.49, 95% CI 0.17-0.82, I2=100.0%, P<.001), followed by moderate community engagement extent (RD 0.45, 95% CI 0.33-0.58, I2=99.6%, P<.001) and low community engagement extent (RD 0.15, 95% CI 0.05-0.25, I2=99.2%, P<.001). The meta-analysis revealed that "health service support" demonstrated the largest effect sizes (RD 0.45, 95% CI 0.25-0.65, I2=99.9%, P<.001), followed by "health education and discussion" (RD 0.39, 95% CI 0.20-0.58, I2=99.7%, P<.001), "follow-up and reminder" (RD 0.33, 95% CI 0.23-0.42, I2=99.3%, P<.001), and "social marketing campaigns and community mobilization" (RD 0.24, 95% CI 0.06-0.41, I2=99.9%, P<.001). CONCLUSIONS: The results of this meta-analysis supported the effectiveness of community engagement in vaccination promotion with variations in terms of engagement contents and extent. Community engagement required a "fit-for-purpose" approach rather than a "one-size-fits-all" approach to maximize the effectiveness of vaccine promotion. TRIAL REGISTRATION: PROSPERO CRD42022339081; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=339081.

Primary care transformation in Scotland: a qualitative evaluation of the views of patients.

BACKGROUND: The new Scottish GP contract introduced in April 2018 aims to improve quality of care through expansion of the multidisciplinary team (MDT) to enable GPs to spend more time as expert medical generalists with patients with complex needs. AIM: To explore patients' views on the changes in general practice in Scotland since the inception of the new contract. DESIGN AND SETTING: Qualitative study with 30 patients (10 living in urban deprived areas, 10 living in urban affluent/mixed urban areas, and 10 living in remote and rural areas). METHOD: In-depth semi-structured interviews with thematic analysis. RESULTS: Patients were generally unaware of the new GP contract, attributing recent changes in general practice to the COVID-19 pandemic. Ongoing concerns included access to GP consultations (especially face-to-face ones), short consultation length with GPs, and damage to continuity of care and the GP-patient relationship. Most patients spoke positively about consultations with MDT staff but still wanted to see a known GP for health concerns that they considered potentially serious. These issues were especially concerning for patients with multiple complex problems, particularly those from deprived areas. CONCLUSION: Following the introduction of the new Scottish GP contract, patients in this study's sample were accepting of first contact care from the MDT but still wanted continuity of care and longer face-to-face consultations with GPs. These findings suggest that the expert generalist role of the GP is not being adequately supported by the new contract, especially in deprived areas, though further quantitative research is required to confirm this.

Patients' experiences of GP consultations following the introduction of the new GP contract in Scotland: a cross-sectional survey.

BACKGROUND: The new Scottish GP contract commenced in April 2018 with a stated aim of mitigating health inequalities. AIM: To determine the health characteristics and experiences of patients consulting GPs in deprived urban (DU), affluent urban (AU), and remote and rural (RR) areas of Scotland. DESIGN AND SETTING: In 2022, a postal survey of a random sample of adult patients from 12 practices who had consulted a GP within the previous 30 days was undertaken. METHOD: Patient characteristics and consultation experiences in the three areas (DU, AU, RR) were evaluated using validated measures including the Consultation and Relational Empathy (CARE) Measure and Patient Enablement Instrument (PEI). RESULTS: In total, 1053 responses were received. In DU areas, multimorbidity was more common (78% versus 58% AU versus 68% RR, P<0.01), complex presentations (where the consultation addressed both psychosocial and physical problems) were more likely (16% versus 10% AU versus 11% RR, P<0.05), and more consultations were conducted by telephone (42% versus 31% AU versus 31% RR, P<0.01). Patients in DU areas reported lower satisfaction (82% DU completely, very, or fairly satisfied versus 90% AU versus 86% RR, P<0.01), lower perceived GP empathy (mean CARE score 38.9 versus 42.1 AU versus 40.1 RR, P<0.05), lower enablement (mean PEI score 2.6 versus 3.2 AU versus 2.8 RR, P<0.01), and less symptom improvement (P<0.01) than those in AU or RR areas. Face-to-face consultations were associated with significantly higher satisfaction, enablement, and perceived GP empathy than telephone consultations in RR areas (all P<0.05). CONCLUSION: Four years after the start of the new GP contract in Scotland, patients' experiences of GP consultations suggest that the inverse care law persists.

Primary care transformation in Scotland: a qualitative study of GPs' and multidisciplinary team members' views.

BACKGROUND: The Scottish Government's vision to transform primary care includes expansion of the primary care multidisciplinary team (MDT), formalised in the new GP contract in April 2018. AIM: To explore practitioners' views on the expansion of MDT working in Scotland. DESIGN AND SETTING: Qualitative study with GPs and a range of MDT staff working in three different population settings in Scotland. METHOD: In-depth semi-structured interviews were carried out by telephone with 8 GPs and 19 MDT staff between May and June 2022. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted to identify commonalities and divergences in the interviews. RESULTS: Internal challenges facing MDT staff included adapting to the fast pace of primary care, building new relationships, training and professional development needs, line management issues, and monitoring and evaluation of performance. External challenges included the ongoing effects of the COVID-19 pandemic, lack of time, difficulties with hybrid working, and low staff morale. Most GPs reported that expansion of their roles as expert medical specialists had not yet happened because their workload had not decreased (and in many cases had increased). In deprived areas, insufficient resources to deal with the high numbers of patients with complex multimorbidity remained a key issue. Interviewees in remote and rural settings felt the new contract did not take into account the unique challenges of providing primary care services in such areas, and recruitment and accommodation were cited as particular problems. CONCLUSION: Although there has been substantial expansion of the primary care MDT, which most GPs welcome, many challenges to effective implementation remain that must be addressed if transformation of primary care in Scotland is to become a reality.

Challenges in implementing GP clusters in Scotland: a qualitative study comparing the views of senior primary care stakeholders in 2016 with those in 2021.

BACKGROUND: Formation of GP clusters began in Scotland in April 2016 as part of a new Scottish GP contract. They aim to improve the care quality for local populations (intrinsic role) and the integration of health and social care (extrinsic role). AIM: To compare predicted challenges of cluster implementation in 2016 with reported challenges in 2021. DESIGN & SETTING: Qualitative study of senior national stakeholders in primary care in Scotland. METHOD: Qualitative analysis of semi-structured interviews with 12 senior primary care national stakeholders in 2016 (n = 6) and 2021 (n = 6). RESULTS: Predicted challenges in 2016 included balancing intrinsic and extrinsic roles, providing sufficient support, maintaining motivation and direction, and avoiding variation between clusters. Progress of clusters in 2021 was perceived as suboptimal and was reported to vary significantly across the country, reflecting differences in local infrastructure. Practical facilitation (data, administrative support, training, project improvement support, and funded time) and strategic guidance from the Scottish Government was felt to be lacking. GP engagement with clusters was felt to be hindered by the significant time and workforce pressures facing primary care. These barriers were considered as collectively contributing to cluster lead 'burnout' and loss of momentum, exacerbated by inadequate opportunities for shared learning between clusters across Scotland. Such barriers preceded, but were perpetuated by, the impact of the COVID-19 pandemic. CONCLUSION: Apart from the COVID-19 pandemic, many of the challenges reported by stakeholders in 2021 were predicted in 2016. Accelerating progress in cluster working will require renewed investment and support applied consistently across the country.

Evaluating primary care transformation: synthesis of findings from UK pilot project reviews.

BACKGROUND: Pilot 'new models' of primary care have been funded across the UK since 2015, through various national transformation funds. Reflections and syntheses of evaluation findings provide an additional layer of insight into 'what works' in transforming primary care. AIM: To identify good practice in policy design, implementation, and evaluation for primary care transformation. DESIGN & SETTING: A thematic analysis of existing pilot evaluations in England, Wales, and Scotland. METHOD: Ten studies presenting evaluations of three national pilot studies - the Vanguard programme in England, the Pacesetter programme in Wales, and the National Evaluation of New Models of Primary Care in Scotland - were thematically analysed, and findings synthesised in order to identify lessons learnt and good practice. RESULTS: Common themes emerged across studies in all three countries at project and policy level, which can support or inhibit new models of care. At project level, these included the following: working with all stakeholders, including communities and front-line staff; providing the time, space, and support necessary for the project to succeed; agreeing on clear objectives from the outset; and support for data collection, evaluation, and shared learning. At policy level, more fundamental challenges related to the parameters for pilot projects, in particular, the typically short-term nature of funding, with an expectation of results within 2-3 years. Changing expectations about outcome measures or project guidance part-way through project implementation was also identified as a key challenge. CONCLUSION: Primary care transformation requires coproduction and a rich, contextual understanding of local needs and complexities. However, a mismatch between policy objectives (care redesign to better meet patient needs) and policy parameters (short timeframes) is often a significant challenge to success.

Primary care transformation in Scotland: qualitative evaluation of the views of national senior stakeholders and cluster quality leads.

BACKGROUND: Primary care transformation in Scotland aims to improve population health, reduce health inequalities, and reduce GP workload. Two key strategies (formalised in April 2018 in the new Scottish GP contract [Scottish General Medical Services contract], although started in early 2016) are the expansion of the multidisciplinary team (MDT) and GP cluster working. AIM: To explore progress in the implementation of the GP contract in Scotland in terms of the MDT and cluster working. DESIGN AND SETTING: Qualitative study with key national primary care stakeholders (PCSs) (n = 6) and cluster quality leads (CQLs) in clusters serving urban high deprivation areas (n = 4), urban mixed areas (n = 4), and remote and rural areas (n = 4). METHOD: Semi-structured interviews with thematic analysis. RESULTS: There was general support for the initial aims of the new GP contract but all interviewees felt that progress on both MDT expansion and cluster working was slow, even before the pandemic. None of the CQLs (and few PCSs) felt that GP workload had reduced significantly, nor that the care of patients with complex needs had improved. Lack of time and poorly developed relationships were key barriers, as was a lack of relevant primary care data, and additional support (including guidance, administration, training, and protected time). CONCLUSION: Key PCSs and CQLs in different areas of Scotland report limited progress in primary care transformation, only partly related to the pandemic. There is a need for better workforce planning and support if the new GP contract is to succeed in transforming primary care in Scotland.

The cost-effectiveness of starting 23-valent pneumococcal polysaccharide vaccine and influenza vaccination at 50 vs. 65 years: A comparative modelling study.

OBJECTIVES: Pneumococcal infection is a leading cause of morbidity and mortality. We aimed to evaluate the cost-effectiveness of 23-valent polysaccharide vaccine (PPV23) together with influenza vaccination or pneumococcal vaccination alone in adults starting from 50 years vs. 65 years in Hong Kong. METHODS: A hypothetical population of 100,000 older adults was included in a Markov model with age ranging from 50 to 85 years to calculate the cost and quality-adjusted life-years (QALYs) gained for vaccination strategies, including: (1) annual influenza vaccine and PPV23 at 50 and 65 years; (2) annual influenza vaccine and PPV23 at 65 years (similar with the current vaccination programme); (3) PPV23 at 50 and 65 years; (4) PPV23 at 65 years; and (5) no vaccination. We evaluated the incremental cost-effectiveness ratio (ICER) and used Monte Carlo simulation for probabilistic sensitivity analysis. The cost-effectiveness threshold was extracted from previous literature. RESULTS: In comparison with no vaccination, all strategies were cost-effective with ICERs less than the threshold (US$24,302 per QALY gained). When compared with no vaccination, strategies 1-4 saved US$ 49.5, US$ 94.9, US$ 584.3, and US$ 1114.2 to gain one QALY respectively. In comparison with strategy 2, strategy 1 spent US$ 195.3 to gain one QALY, whilst strategies 3 and 4 showed less effectiveness with increased costs. CONCLUSIONS: All vaccination strategies were cost-effective, among which the strategy of PPV23 at 50/65 years with annual influenza vaccine was cost-effective even in comparison with current vaccination programme. These findings could help inform the design and implementation of vaccination strategies.

Evaluation of anti-smoking television advertising on tobacco control among urban community population in Chongqing, China.

BACKGROUND: China is the largest producer and consumer of tobacco in the world. Considering the constantly growing urban proportion, persuasive tobacco control measures are important in urban communities. Television, as one of the most pervasive mass media, can be used for this purpose. METHODS: The anti-smoking advertisement was carried out in five different time slots per day from 15 May to 15 June in 2011 across 12 channels of Chongqing TV. A cross-sectional study was conducted in the main municipal areas of Chongqing. A questionnaire was administered in late June to 1,342 native residents aged 18-45, who were selected via street intercept survey. RESULTS: Respondents who recognized the advertisement (32.77 %) were more likely to know or believe that smoking cigarettes caused impotence than those who did not recognize the advertisement (26.11 %). According to 25.5 % of smokers, the anti-smoking TV advertising made them consider quitting smoking. However, females (51.7 %) were less likely to be affected by the advertisement to stop and think about quitting smoking compared to males (65.6 %) (OR = 0.517, 95 % CI [0.281-0.950]). In addition, respondents aged 26-35 years (67.4 %) were more likely to try to persuade others to quit smoking than those aged 18-25 years (36.3 %) (OR = 0.457, 95 % CI [0.215-0.974]). Furthermore, non-smokers (87.4 %) were more likely to find the advertisement relevant than smokers (74.8 %) (OR = 2.34, 95 % CI [1.19-4.61]). CONCLUSIONS: This study showed that this advertisement did not show significant differences on smoking-related knowledge and attitude between non-smokers who had seen the ad and those who had not. Thus, this form may not be the right tool to facilitate change in non-smokers. The ad should instead be focused on the smoking population. Gender, smoking status, and age influenced the effect of anti-smoking TV advertising on the general population in China.

Factors associated with adoption of the electronic health record system among primary care physicians.

BACKGROUND: A territory-wide Internet-based electronic patient record allows better patient care in different sectors. The engagement of private physicians is one of the major facilitators for implementation, but there is limited information about the current adoption level of electronic medical record (eMR) among private primary care physicians. OBJECTIVE: This survey measured the adoption level, enabling factors, and hindering factors of eMR, among private physicians in Hong Kong. It also evaluated the key functions and the popularity of electronic systems and vendors used by these private practitioners. METHODS: A central registry consisting of 4324 private practitioners was set up. Invitations for self-administered surveys and the completed questionnaires were sent and returned via fax, email, postal mail, and on-site clinic visits. Current users and non-users of eMR system were compared according to their demographic and practice characteristics. Student's t tests and chi-square tests were used for continuous and categorical variables, respectively. RESULTS: A total of 524 completed surveys (response rate 524/4405 11.90%) were collected. The proportion of using eMR in private clinics was 79.6% (417/524). When compared with non-users, the eMR users were younger (users: 48.4 years SD 10.6 years vs non-users: 61.7 years SD 10.2 years, P<.001); more were female physicians (users: 80/417, 19.2% vs non-users: 14/107, 13.1%, P=.013); possessed less clinical experience (with more than20 years of practice: users: 261/417, 62.6% vs non-user: 93/107, 86.9%, P<.001); fewer worked under a Health Maintenance Organization (users: 347/417, 83.2% vs non-users: 97/107, 90.7%, P<.001) and more worked with practice partners (users: 126/417, 30.2% vs non-users: 4/107, 3.7%, P<.001). Efficiency (379/417, 90.9%) and reduction of medical errors (229/417, 54.9%) were the major enabling factors, while patient-unfriendliness (58/107, 54.2%) and limited consultation time (54/107, 50.5%) were the most commonly reported hindering factors. The key functions of computer software among eMR users consisted of electronic patient registration system (376/417, 90.2%), drug dispensing system (328/417, 78.7%) and electronic drug labels (296/417, 71.0%). SoftLink Clinic Solution was the most popular vendor (160/417, 38.4%). CONCLUSIONS: These findings identified several physician groups who should be targeted for more assistance on eMR installation and its adoption. Future studies should address the barriers of using Internet-based eMR to enhance its adoption.

Predictors of switching from beta-blockers to other anti-hypertensive drugs: a review of records of 19,177 Chinese patients seen in public primary care clinics in the New Territory East, Hong Kong.

BACKGROUND: Beta-blocker drugs are commonly used in family practice and studies showed that they were the most popularly prescribed medications among all antihypertensive agents. This study aimed to identify the factors associated with medication switching from a beta-blocker to another antihypertensive drug among Chinese patients. METHODS: We used a validated database which consisted of the demographic and clinical information of all Chinese patients prescribed a beta-blocker from any public, family practice clinics between 01 Jan 2004 to 30 June 2007 in one large Territory of Hong Kong. The proportion of patients switched from beta-blockers to another antihypertensive agent 180 days within their first prescription was studied, and the factors associated with medication switching were evaluated by using multivariate regression analyses. RESULTS: From 19,177 eligible subjects with a mean age of 59.1 years, 763 (4.0%) were switched from their beta-blockers within 180 days of commencing therapy. A binary logistic regression model used medication switching as the outcome variable and controlled for age, gender, socioeconomic status, clinic setting (general out-patient clinics, family medicine specialist clinic or staff clinics), district of residence, visit type (new vs. follow-up attendance), the number of concomitant co-morbidities, and the calendar year of prescription. It was found that older patients (age 50-59 years: adjusted odds ratio [AOR] 1.38, 95% C.I. 1.12-1.70; p = 0.002; age 60-69 years: AOR 1.63 95% C.I. 1.30-2.04, p < 0.001; age ≥ 70 years: AOR 1.82, 95% C.I. 1.46-2.26, p < 0.001; referent age < 50 years) and new visitors (AOR 0.57, 95% C.I. 0.48-0.68, p < 0.001) were more likely to have their medication switched. CONCLUSIONS: Closer monitoring of the medication taking behavior among the older patients and the new clinic visitors prescribed a beta-blocker is warranted. Future studies should evaluate the reasons of drug switching.