Inequities in hypertension management: observational cross-sectional study in North East London using electronic health records.

BACKGROUND: Hypertension is a key modifiable risk factor for cardiovascular disease - the leading cause of death in the UK. Good blood pressure (BP) control reduces mortality. However, health inequities may lead to variability in hypertension monitoring and control. AIM: To investigate health inequities related to ethnicity, sex, age, and socioeconomic status in the monitoring, treatment, and control of BP in a large cohort of adult patients with hypertension. DESIGN AND SETTING: A cross-sectional cohort study of adults with hypertension registered with general practices in North East London on 1 April 2019. METHOD: Multivariable logistic regression was used to estimate associations of demographics and treatment intensity for the following hypertension management indicators: a) BP recording in past 12 months; b) BP on age- adjusted target; and c) BP on age-adjusted target and BP recorded in past 12 months. RESULTS: In total, 156 296 adults were included. The Black ethnicity group was less likely to have controlled BP than the White ethnicity group (odds ratio [OR] 0.87, 95% [confidence interval] CI = 0.84 to 0.91). The Asian ethnicity group was more likely to have controlled BP (OR 1.28, 95% CI = 1.23 to 1.32). Ethnicity differences in control could not be explained by the likelihood of having a recent BP recording, nor by treatment intensity differences. Older adults (aged ≥50 years) were more likely to have controlled hypertension than younger patients. CONCLUSION: Individuals of Black ethnicity and younger people are less likely to have controlled hypertension and may warrant targeted interventions. Possible explanations for these findings are presented but further research is needed about reasons for ethnic differences.

Unravelling the potential of social prescribing in individual-level type 2 diabetes prevention: a mixed-methods realist evaluation.

BACKGROUND: Social prescribing (SP) usually involves linking patients in primary care with services provided by the voluntary and community sector. Preliminary evidence suggests that SP may offer a means of connecting patients with community-based health promotion activities, potentially contributing to the prevention of long-term conditions, such as type 2 diabetes (T2D). METHODS: Using mixed-methods realist evaluation, we explored the possible contribution of SP to individual-level prevention of T2D in a multi-ethnic, socio-economically deprived population in London, UK. We made comparisons with an existing prevention programme (NHS Diabetes Prevention Programme (NDPP)) where relevant and possible. Anonymised primary care electronic health record data of 447,360 people 18+ with an active GP registration between December 2016 and February 2022 were analysed using quantitative methods. Qualitative data (interviews with 11 primary care clinicians, 11 social prescribers, 13 community organisations and 8 SP users at high risk of T2D; 36 hours of ethnographic observations of SP and NDPP sessions; and relevant documents) were analysed thematically. Data were integrated using visual means and realist methods. RESULTS: People at high risk of T2D were four times more likely to be referred into SP than the eligible general population (RR 4.31 (95% CI 4.17-4.46)), with adjustment for socio-demographic variables resulting in attenuation (RR 1.33 (95% CI 1.27-1.39)). More people at risk of T2D were referred to SP than to NDPP, which could be explained by the broad referral criteria for SP and highly supportive (proactive, welcoming) environments. Holistic and sustained SP allowed acknowledgement of patients' wider socio-economic constraints and provision of long-term personalised care. The fact that SP was embedded within the local community and primary care infrastructure facilitated the timely exchange of information and cross-referrals across providers, resulting in enhanced service responsiveness. CONCLUSIONS: Our study suggests that SP may offer an opportunity for individual-level T2D prevention to shift away from standardised, targeted and short-term strategies to approaches that are increasingly personalised, inclusive and long-term. Primary care-based SP seems most ideally placed to deliver such approaches where practitioners, providers and commissioners work collectively to achieve holistic, accessible, sustained and integrated services.

Implementation of a quality improvement programme using the Active Patient Link call and recall system to improve timeliness and equity of childhood vaccinations: protocol for a mixed-methods evaluation.

INTRODUCTION: Call and recall systems provide actionable intelligence to improve equity and timeliness of childhood vaccinations, which have been disrupted during the COVID-19 pandemic. We will evaluate the effectiveness, fidelity and sustainability of a data-enabled quality improvement programme delivered in primary care using an Active Patient Link Immunisation (APL-Imms) call and recall system to improve timeliness and equity of uptake in a multiethnic disadvantaged urban population. We will use qualitative methods to evaluate programme delivery, focusing on uptake and use, implementation barriers and service improvements for clinical and non-clinical primary care staff, its fidelity and sustainability. METHODS AND ANALYSIS: This is a mixed-methods observational study in 284 general practices in north east London (NEL). The target population will be preschool-aged children eligible to receive diphtheria, tetanus and pertussis (DTaP) or measles, mumps and rubella (MMR) vaccinations and registered with an NEL general practice. The intervention comprises an in-practice call and recall tool, facilitation and training, and financial incentives. The quantitative evaluation will include interrupted time Series analyses and Slope Index of Inequality. The primary outcomes will be the proportion of children receiving at least one dose of a DTaP-containing or MMR vaccination defined, respectively, as administered between age 6 weeks and 6 months or between 12 and 18 months of age. The qualitative evaluation will involve a 'Think Aloud' method and semistructured interviews of stakeholders to assess impact, fidelity and sustainability of the APL-Imms tool, and fidelity of the implementation by facilitators. ETHICS AND DISSEMINATION: The research team has been granted permission from data controllers in participating practices to use deidentified data for audit purposes. As findings will be specific to the local context, research ethics approval is not required. Results will be disseminated in a peer-reviewed journal and to stakeholders, including parents, health providers and commissioners.

Impact of the COVID-19 pandemic on timeliness and equity of measles, mumps and rubella vaccinations in North East London: a longitudinal study using electronic health records.

OBJECTIVES: To quantify the effect of the COVID-19 pandemic on the timeliness of, and geographical and sociodemographic inequalities in, receipt of first measles, mumps and rubella (MMR) vaccination. DESIGN: Longitudinal study using primary care electronic health records. SETTING: 285 general practices in North East London. PARTICIPANTS: Children born between 23 August 2017 and 22 September 2018 (pre-pandemic cohort) or between 23 March 2019 and 1 May 2020 (pandemic cohort). MAIN OUTCOME MEASURE: Receipt of timely MMR vaccination between 12 and 18 months of age. METHODS: We used logistic regression to estimate the ORs (95% CIs) of receipt of a timely vaccination adjusting for sex, deprivation, ethnic background and Clinical Commissioning Group. We plotted choropleth maps of the proportion receiving timely vaccinations. RESULTS: Timely MMR receipt fell by 4.0% (95% CI: 3.4% to 4.6%) from 79.2% (78.8% to 79.6%) to 75.2% (74.7% to 75.7%) in the pre-pandemic (n=33 226; 51.3% boys) and pandemic (n=32 446; 51.4%) cohorts, respectively. After adjustment, timely vaccination was less likely in the pandemic cohort (0.79; 0.76 to 0.82), children from black (0.70; 0.65 to 0.76), mixed/other (0.77; 0.72 to 0.82) or with missing (0.77; 0.74 to 0.81) ethnic background, and more likely in girls (1.07; 1.03 to 1.11) and those from South Asian backgrounds (1.39; 1.30 to 1.48). Children living in the least deprived areas were more likely to receive a timely MMR (2.09; 1.78 to 2.46) but there was no interaction between cohorts and deprivation (Wald statistic: 3.44; p=0.49). The proportion of neighbourhoods where less than 60% of children received timely vaccination increased from 7.5% to 12.7% during the pandemic. CONCLUSIONS: The COVID-19 pandemic was associated with a significant fall in timely MMR receipt and increased geographical clustering of measles susceptibility in an area of historically low and inequitable MMR coverage. Immediate action is needed to avert measles outbreaks and support primary care to deliver timely and equitable vaccinations.

Valproate use in women aged 15-44 years: an observational study in general practice.

BACKGROUND: Valproate is a known teratogen. In April 2018, the Medicines and Healthcare products Regulatory Agency (MHRA) restricted its use in women and banned use in pregnancy, except for epilepsy with no other effective treatment. To date, there is limited information on valproate prescribing within primary care. AIM: To characterise valproate prescribing to women of childbearing age, recorded advice or GP prescribed contraception, and recorded pregnancies. DESIGN & SETTING: A cross-sectional study of patients from all 141 general practices across three clinical commissioning groups (CCGs) in East London. METHOD: Women aged 15-44 years prescribed valproate between 1 October 2017 and 1 January 2020 were included. Exclusion criteria were early menopause, sterilisation procedures, or hysterectomy. Pseudonymised data on valproate indication, pregnancy, pre-conception, and contraception advice were retrospectively extracted from general practice consultation data. Data were analysed by quarter using univariate statistics. RESULTS: Of the total 1 042 463 registered patients, 344 women aged 15-44 years were prescribed valproate during the study period; 14 were excluded. There were 10 pregnancies during possible valproate exposure; one was terminated. During the study period, the number of women prescribed valproate significantly decreased (P = 0.003). The pregnancy rate decreased from 9.9/1000 on valproate before the MHRA April 2018 warning, to an average of 2.8/1000 afterwards. Recorded pre-conception and contraception advice increased by 79%, from 24% to 43%, of women prescribed valproate. CONCLUSION: With continued pregnancies in women aged 15-44 years prescribed valproate, patient education and foetal outcomes remain ongoing concerns. Further improvements are needed to ensure women make informed reproductive choices and safeguard future pregnancies from valproate exposure.

Gaps in antihypertensive and statin treatments and benefits of optimisation: a modelling study in a 1 million ethnically diverse urban population in UK.

OBJECTIVES: To characterise gaps in antihypertensive treatment in people with hypertension and statin treatment in people with cardiovascular diseases (CVD) in a large urban population and quantify the health and economic impacts of their optimisation. DESIGN: A cross-sectional population study and a long-term CVD decision model. SETTING: Primary care, UK. PARTICIPANTS: All adults with diagnosed hypertension or CVD in a population of about 1 million people, served by 123 primary care practices in London, UK in 2019. INTERVENTIONS: Following UK clinical guidelines, all adults with diagnosed hypertension were categorised into optimal, suboptimal and untreated groups with respect to their antihypertensive treatment, and all adults with diagnosed CVD were categorised in the same manner with respect to their statin treatment. OUTCOMES: Proportion of patients suboptimally treated or untreated. Projected cardiovascular events avoided, years and quality-adjusted life years (QALYs) gained and healthcare costs saved with optimised treatments. RESULTS: 21 954 of the 91 828 adults with hypertension (24%; mean age 59 years; 49% women) and 9062 of the 23 723 adults with CVD (38%; mean age 69 years; 43% women) were not optimally treated with antihypertensive or statin treatment, respectively. Per 1000 additional patients optimised over 5 years, hypertension treatment is projected to prevent 25 (95% CI 16 to 32) major vascular events (MVEs) and 7 (3 to 10) vascular deaths, statin treatment, 28 (22 to 33) MVEs and 6 (4 to 7) vascular deaths. Over their lifespan, a patient with uncontrolled hypertension aged 60-69 years is projected to gain 0.64 (95% CI 0.36 to 0.87) QALYs with optimised hypertension treatment, and a similarly aged patient with previous CVD not optimally treated with statin is projected to gain 0.3 (0.24 to 0.37) QALYs with optimised statin treatment. In both cases, the hospital cost savings minus extra medication costs were about £1100 per person over remaining lifespan. CONCLUSIONS: Optimising cardiovascular treatments can cost-effectively reduce cardiovascular risk and improve life expectancy.

Opportunistic pulse checks in primary care to improve recognition of atrial fibrillation: a retrospective analysis of electronic patient records.

BACKGROUND: Atrial fibrillation (AF) is an important and modifiable risk factor for stroke. Earlier identification may reduce stroke-related morbidity and mortality. Trial evidence shows that opportunistic pulse regularity checks in individuals aged ≥65 years increases detection of AF. However, this is not currently recommended by the National Screening Programme or implemented by most clinical commissioning groups (CCGs). AIM: To evaluate the impact of a systematic programme to promote pulse regularity checks, the programme's uptake in general practice, and the prevalence of AF. DESIGN AND SETTING: Retrospective analysis of electronic primary care patient records in three east London CCGs (City and Hackney, Newham, and Tower Hamlets) over 10 years. METHOD: Rates of pulse regularity checks and prevalence of AF in individuals aged ≥65 years were compared from the pre-intervention period, 2007-2011, to the post-intervention period, 2012-2017. RESULTS: Across the three CCGs, rates of pulse regularity checks increased from a mean of 7.3% pre-intervention to 66.4% post-intervention, achieving 93.1% (n = 58 722) in the final year. Age-standardised prevalence of AF in individuals aged ≥65 years increased significantly from a pre-intervention mean of 61.4/1000 to a post-intervention mean of 64.5/1000. There was a significant increase in a post-intervention trend to a final-year mean of 67.3/1000: an improvement of 9.6% (5.9/1000) with 790 additional new cases identified. CONCLUSION: Organisational alignment, standardised data entry, peer-performance dashboards, and financial incentives rapidly and generally increased opportunistic screening with pulse regularity checks. This was associated with a significant increase in detection and prevalence of AF and is of public health importance.

NHS Health Check comorbidity and management: an observational matched study in primary care.

BACKGROUND: The NHS Health Check programme completed its first 5 years in 2014, identifying those at highest risk of cardiovascular disease and new comorbidities, and offering behavioural change support and treatment. AIM: To describe the coverage and impact of this programme on cardiovascular risk management and identification of new comorbidities. DESIGN AND SETTING: Observational 5-year study from April 2009 to March 2014, in 139 of 143 general practices in three clinical commissioning groups (CCGs) in east London. METHOD: A matched analysis compared comorbidity in NHS Health Check attendees and non-attendees. RESULTS: A total of 252 259 adults aged 40-74 years were eligible for an NHS Health Check and, of these, 85 122 attended in 5 years. Attendance increased from 7.3% (10 900/149 867) in 2009 to 17.0% (18 459/108 525) in 2013 to 2014, representing increasing coverage from 36.4% to 85.0%. Attendance was higher in the more deprived quintiles and among South Asians. Statins were prescribed to 11.5% of attendees and 8.2% of non-attendees. In a matched analysis, newly-diagnosed comorbidity was more likely in attendees than non-attendees, with odds ratios for new diabetes 1.30 (95% confidence interval [CI] = 1.21 to 1.39), hypertension 1.50 (95% CI = 1.43 to 1.57), and chronic kidney disease 1.83 (95% CI = 1.52 to 2.21). CONCLUSION: The NHS Health Check programme provision in these CCGs was equitable, with recent coverage of 85%. Statins were 40% more likely to be prescribed to attendees than non-attendees, providing estimated absolute benefits of public health importance. More new cases of diabetes, hypertension, and chronic kidney disease were identified among attendees than a matched group of non-attendees.

The NHS Health Check in England: an evaluation of the first 4 years.

OBJECTIVES: To describe implementation of a new national preventive programme to reduce cardiovascular morbidity. DESIGN: Observational study over 4 years (April 2009--March 2013). SETTING: 655 general practices across England from the QResearch database. PARTICIPANTS: Eligible adults aged 40-74 years including attendees at a National Health Service (NHS) Health Check. INTERVENTION: NHS Health Check: routine structured cardiovascular check with support for behavioural change and in those at highest risk, treatment of risk factors and newly identified comorbidity. RESULTS: Of 1.68 million people eligible for an NHS Health Check, 214 295 attended in the period 2009-12. Attendance quadrupled as the programme progressed; 5.8% in 2010 to 30.1% in 2012. Attendance was relatively higher among older people, of whom 19.6% of those eligible at age 60-74 years attended and 9.0% at age 40-59 years. Attendance by population groups at higher cardiovascular disease (CVD) risk, such as the more socially disadvantaged 14.9%, was higher than that of the more affluent 12.3%. Among attendees 7844 new cases of hypertension (38/1000 Checks), 1934 new cases of type 2 diabetes (9/1000 Checks) and 807 new cases of chronic kidney disease (4/1000 Checks) were identified. Of the 27,624 people found to be at high CVD risk (20% or more 10-year risk) when attending an NHS Health Check, 19.3% (5325) were newly prescribed statins and 8.8% (2438) were newly prescribed antihypertensive therapy. CONCLUSIONS: NHS Health Check coverage was lower than expected but showed year-on-year improvement. Newly identified comorbidities were an important feature of the NHS Health Checks. Statin treatment at national scale for 1 in 5 attendees at highest CVD risk is likely to have contributed to important reductions in their CVD events.

Statin prescribing for primary prevention of cardiovascular disease: a cross-sectional, observational study.

BACKGROUND: The updated (2014) National Institute for Health and Care Excellence (NICE) guideline lowered the recommended threshold for statin prescription from 20% to 10% 10-year cardiovascular disease (CVD) risk. AIM: To determine the characteristics of patients prescribed statins for primary prevention according to their CVD risk. DESIGN AND SETTING: Cross-sectional study in primary care settings in the three east London CCGs (Newham, City and Hackney, and Tower Hamlets). METHOD: Data were extracted from electronic health records of 930 000 patients registered with 137 of 141 general practices for a year ending 1 April 2014. RESULTS: Of 341 099 patients aged 30-74 years, excluding those with CVD or diabetes, 22 393 were prescribed statins and had a 10-year CVD risk recorded. Of these, 9828 (43.9%) had a CVD risk ≥20%, 7121 (31.8%) had a CVD risk of 10-19%, and 5444 (24.3%) had a CVD risk <10%. Statins were prescribed to 9828/19 755 (49.7%) of those at ≥20% CVD risk, to 7121/37 111 (19.2%) of those with CVD risk 10-19%, and to 5444/146 676 (3.7%) of those with CVD risk <10%. Statin prescription below the 20% CVD risk threshold targeted individuals in the 10-19% risk band in association with hypertension, high serum cholesterol, positive family history, older age, and south Asian ethnicity. CONCLUSION: This study confirms continuing undertreatment of patients at highest CVD risk (≥20%). GPs prescribed statins to only one-fifth of those in the 10-19% risk band usually in association with known major risk factors. Only 3.7% of individuals below 10% were prescribed statins.

Reduction in self-monitoring of blood glucose in type 2 diabetes: an observational controlled study in east London.

BACKGROUND: Self-monitoring of blood glucose (SMBG) confers no benefit for many people with type 2 diabetes not being treated with insulin. It accounts for 21% of diabetes prescribing costs. AIM: To improve care quality at reduced cost for type 2 diabetes by reducing unnecessary SMBG. DESIGN AND SETTING: Non-randomised, observational controlled study in two intervention clinical commissioning groups (CCGs) and one control CCG in east London. METHOD: In total, 19,602 people with type 2 diabetes not being treated with insulin were recruited from two intervention CCGs; 16,033 were recruited from a control CCG. The intervention (from 2010 to 2013) comprised implementation of a locally developed guideline, including IT support and peer feedback of performance. Data on practice prescribing SMBG testing strips were gathered using GP electronic health records. Information on costs were obtained via the ePACT electronic database. RESULTS: Over 4 years, in all non-insulin type 2 diabetes treatment groups, use of SMBG was reduced in the two intervention CCGs from 42.8% to 16.5%, and in the control CCG from 56.4% to 47.2%. In people on metformin alone or no treatment, intervention CCGs reduced SMBG use from 29.6% to 6.0%, and in the control CCG use dropped from 47.1% to 38.7% (P<0.001). From 2009 to 2012 the total cost of all SMBG prescribing (type 1 and type 2 diabetes, including users of insulin) was reduced by 4.9% (£62,476) in the two intervention CCGs and increased in the control CCG by 5.0% (£42,607); in England, the total cost increased by 13.5% (£19.4 million). In total, 20% (3865 of 19 602) fewer patients used SMBG in the intervention CCGs. CONCLUSION: This low-cost programme demonstrated a major reduction in unnecessary prescribing of SMBG, along with cost savings. If replicated nationally, this would avoid unnecessary testing in 340 000 people and prescribing costs that total £21.8 million.

The NHS Health Check programme: implementation in east London 2009-2011.

OBJECTIVES: To describe implementation and results from the National Health Service (NHS) Health Check programme. DESIGN: Three-year observational open cohort study: 2009-2011. PARTICIPANTS: People of age 40-74 years eligible for an NHS Health Check. SETTING: 139/143 general practices in three east London primary care trusts (PCTs) serving an ethnically diverse and socially disadvantaged population. METHOD: Implementation was supported with education, IT support and performance reports. Tower Hamlets PCT additionally used managed practice networks and prior-stratification to call people at higher cardiovascular (CVD) risk first. MAIN OUTCOMES MEASURES: Attendance, proportion of high-risk population on statins and comorbidities identified. RESULTS: Coverage 2009, 2010, 2011 was 33.9% (31,878/10,805), 60.6% (30,757/18,652) and 73.4% (21,194/28,890), respectively. Older people were more likely to attend than younger people. Attendance was similar across deprivation quintiles and was in accordance with population distributions of black African/Caribbean, South Asian and White ethnic groups. 1 in 10 attendees were at high-CVD risk (20% or more 10-year risk). In the two PCTs stratifying risk, 14.3% and 9.4% of attendees were at high-CVD risk compared to 8.6% in the PCT using an unselected invitation strategy. Statin prescription to people at high-CVD risk was higher in Tower Hamlets 48.9%, than in City and Hackney 23.1% or Newham 20.2%. In the 6 months following an NHS Health Check, 1349 new cases of hypertension, 638 new cases of diabetes and 89 new cases of chronic kidney disease (CKD) were diagnosed. This represents 1 new case of hypertension per 38 Checks, 1 new case of diabetes per 80 Checks and 1 new case of CKD per 568 Checks. CONCLUSIONS: Implementation of the NHS Health Check programme in these localities demonstrates limited success. Coverage and treatment of those at high-CVD risk could be improved. Targeting invitations to people at high-CVD risk and managed practice networks in Tower Hamlets improved performance.

Improving anticoagulation in atrial fibrillation: observational study in three primary care trusts.

BACKGROUND: Atrial fibrillation (AF) is a cause of stroke, and undertreatment with anticoagulants is a persistent issue despite their effectiveness. AIM: To increase the proportion of people with AF treated appropriately using anticoagulants, and reduce inappropriate antiplatelet therapy. DESIGN OF STUDY: Cross-sectional analysis. SETTING: Electronic patient health records on 4604 patients with AF obtained from general practices in three inner London primary care trusts between April 2011 and 2013. METHOD: The Anticoagulant Programme East London (APEL) sought to achieve its aims through an intervention with three components: altering professional beliefs using new clinical guidance and related education; facilitating change using computer software to support clinical decisions and patient review optimising anticoagulation; motivating change through evaluative feedback showing individual practice performance relative to peers. RESULTS: From April 2011 to April 2013, the proportion of people with CHA2DS2-VASc ≥1 on anticoagulants increased from 52.6% to 59.8% (trend difference P<0.001). The proportion of people with CHA2DS2-VASc ≥1 on aspirin declined from 37.7% to 30.3% (trend difference P<0.001). Comparing the 2 years before the intervention with the 2 years after, numbers of new people on the AF register almost doubled from 108 to 204. CONCLUSIONS: The APEL programme supports improvement in clinical managing AF by a combined programme of education around agreed guidance, computer aids to facilitate decision-making and patient review and feedback of locally identifiable results. If replicated nationally over 3 years, such a programme could result in approximately 1600 fewer strokes every year.