Underdiagnosis of dementia in primary care: variations in the observed prevalence and comparisons to the expected prevalence.

OBJECTIVES: Dementia is a major and growing health problem. Diagnosis is an important step in the access to care, but many dementia patients remain undiagnosed. This study investigated the magnitude and variation in the difference between 'observed' and 'estimated' prevalence of dementia in general practices. We also explored practice characteristics associated with observed prevalence rates. METHOD: Six Primary Care Trusts (PCTs) provided data on all general practices (N = 351) in their area in terms of number of doctors, patient list size, number of patients over 65 years of age, socio-economic deprivation status of practices and number of patients on dementia registers. RESULTS: The average observed prevalence overall of dementia amongst patients 65 years and over was 3.0% [95CI 2.8, 3.2]. The observed prevalence was 54.5% [95CI 49.2, 58.9] lower than the prevalence observed in the epidemiological studies in the UK. For an average size general practice (list size of 5269 patients) approximately 27 [95CI 22, 32] patients with dementia may remain undiagnosed. Statistically significant differences in prevalence rates were found between the different PCTs (Wald chi-square = 103.8 p < 0.001). The observed prevalence of dementia was significantly lower among practices run by one GP compared to multiple GPs (p = 0.003), and in more affluent areas (p < 0.001). CONCLUSION: Just under a half of the expected numbers of patients with dementia are recognised in GP dementia registers. The underdiagnosis of dementia varies with practice characteristics, socio-economic deprivation and between PCTs, which has implications for the local implementation of the National Dementia Strategy.

Changes in patient experiences of primary care during health service reforms in England between 2003 and 2007.

PURPOSE: Major primary care reforms have been introduced in recent years in the United Kingdom, including financial incentives to improve clinical quality and provide more rapid access to care. Little is known about the impact of these changes on patient experience. We examine patient reports of quality of care between 2003 and 2007, including random samples of patients on practice lists and patients with long-term conditions. METHODS: We conducted a cross-sectional design study of family practices in which questionnaires were sent to serial samples of patients in 42 representative general practices in England. Questionnaires sent to samples of patients with chronic disease (asthma, angina, and diabetes) and random samples of adult patients (excluding patients who reported any long-term condition) in 2003, 2005, and 2007 addressed issues of access, communication, continuity of care, coordination, nursing care, and overall satisfaction. RESULTS: There were no significant changes in quality of care reported by either group of patients between 2003 and 2007 for communication, nursing care, coordination, and overall satisfaction. Some aspects of access improved significantly for patients with chronic disease, but not for the random samples of patients. Patients in both samples reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care. Most scores were significantly higher for the chronic illness samples than for the random samples of patients in 2003, even after adjusting for age. CONCLUSIONS: There was a modest improvement in access to care for patients with chronic illness, but all patients now find it somewhat harder to obtain continuity of care. This outcome may be related to the incentives to provide rapid appointments or to the increased number of specialized clinics in primary care. The possibility of unintended effects needs to be considered when introducing pay for performance schemes.

Under-provision of medical care for vascular diseases for people with dementia in primary care: a cross-sectional review.

BACKGROUND: Vascular diseases contribute to the causation and progression of clinical dementia. AIM: To evaluate the quality of medical care for vascular diseases provided to people with dementia, the patient and practice characteristics that influence quality, and to compare care with that provided to those without dementia. DESIGN AND SETTING: Observational, cross-sectional review of primary care records of people with dementia from 52 general practices from five primary care trusts in the UK, and comparison with publicly available summary data on patients without dementia. METHOD: A total of 700 patients with ≥1 diagnosed vascular disease or risk factor were identified from dementia registers. Quality of care was measured on 30 indicators from the UK Quality and Outcomes Framework (QOF) for hypertension, coronary heart disease, stroke, diabetes mellitus, atrial fibrillation, heart failure, and smoking. Overall quality of vascular care was calculated for each patient with dementia. RESULT: Level of care received by people with dementia was significantly lower compared with those without dementia for 22 of 30 (73%) indicators; most notably for measurement processes such as peripheral pulses check and neuropathy testing for diabetes, and cholesterol measures for stroke. Among people with dementia, women, those in care homes, and those with fewer comorbid physical conditions and medications were associated with lower scores for overall quality of vascular care. CONCLUSION: The quality of medical care provided to people with dementia with regard to vascular diseases is not concordant with quality, as defined by the QOF. Research is needed to improve access to high-quality care.

Quality of care provided to people with dementia: utilisation and quality of the annual dementia review in general practice.

BACKGROUND: Primary care services are often the main healthcare service for people with dementia; as such, good-quality care at this level is important. AIM: To measure the quality of care provided to people with dementia in general practice using routinely collected data, and to explore associated patient and practice factors. DESIGN AND SETTING: Observational, cross-sectional review of medical records from general practices (n = 52) in five primary care trusts. METHOD: A total of 994 people with dementia were identified from dementia registers. An unweighted quality-of-care score was constructed using information collected in the annual dementia review, together with pharmacological management of cognitive and non-cognitive symptoms. Multilevel modelling was carried out to identify factors associated with quality-of-care scores. RESULTS: In total, 599 out of 745 (80%) patients with dementia had received an annual dementia review; however, a social care review or discussion with carers was evident in just 305 (51%) and 367 (61%) of those 599 cases, respectively. Despite high prevalence of vascular disease, over a quarter (n = 259, 26%) of all patients with dementia were prescribed antipsychotics; only 57% (n = 148) of these had undergone medication review in the previous 6 months. Those with vascular dementia who were registered with single-handed practices received poorer quality of care than those registered with practices that had more than one GP. CONCLUSION: Although the number of people with dementia with a record of an annual dementia review is high, the quality of these reviews is suboptimal. The quality score developed in this study could be used as one source of data to identify weaknesses in practice activity that need to be corrected, and so would be of value to commissioners and regulators, as well as practices themselves.