Primary medical care continuity and patient mortality: a systematic review.

BACKGROUND: A 2018 review into continuity of care with doctors in primary and secondary care concluded that mortality rates are lower with higher continuity of care. AIM: This association was studied further to elucidate its strength and how causative mechanisms may work, specifically in the field of primary medical care. DESIGN AND SETTING: Systematic review of studies published in English or French from database and source inception to July 2019. METHOD: Original empirical quantitative studies of any design were included, from MEDLINE, Embase, PsycINFO, OpenGrey, and the library catalogue of the New York Academy of Medicine for unpublished studies. Selected studies included patients who were seen wholly or mostly in primary care settings, and quantifiable measures of continuity and mortality. RESULTS: Thirteen quantitative studies were identified that included either cross-sectional or retrospective cohorts with variable periods of follow-up. Twelve of these measured the effect on all-cause mortality; a statistically significant protective effect of greater care continuity was found in nine, absent in two, and in one effects ranged from increased to decreased mortality depending on the continuity measure. The remaining study found a protective association for coronary heart disease mortality. Improved clinical responsibility, physician knowledge, and patient trust were suggested as causative mechanisms, although these were not investigated. CONCLUSION: This review adds reduced mortality to the demonstrated benefits of there being better continuity in primary care for patients. Some patients may benefit more than others. Further studies should seek to elucidate mechanisms and those patients who are likely to benefit most. Despite mounting evidence of its broad benefit to patients, relationship continuity in primary care is in decline - decisive action is required from policymakers and practitioners to counter this.

A Self-Management Programme of Activity Coping and Education - SPACE for COPD(C) - in primary care: The protocol for a pragmatic trial.

INTRODUCTION: National guidance for chronic obstructive pulmonary disease (COPD) suggests that self-management support be provided for patients. Our institution has developed a standardised, manual-based, supported self-management programme: Self-Management Programme of Activity Coping and Education (SPACE for COPD(C)). SPACE was previously piloted on a 1-2-1 basis, delivered by researchers, to individuals with COPD. Discussions with stakeholders highlighted considerable interest in delivering the SPACE for COPD(C) intervention as a group-based self-management programme facilitated by healthcare professionals (HCPs) in primary care settings. The study aims are to explore the feasibility, acceptability and efficacy for the intervention to be delivered and supported by HCPs and to examine whether group-based delivery of SPACE for COPD(C), with sustained support, improves patient outcomes following the SPACE for COPD(C) intervention. METHODS AND ANALYSIS: A prospective, multi-site, single-blinded randomised controlled trial (RCT) will be conducted, with follow-up at 6 and 9 months. Participants will be randomly assigned to either the control group (usual care) or intervention group (a six-session, group-based SPACE for COPD(C)self-management programme delivered over 5 months). The primary outcome is change in COPD assessment test at 6 months.A discussion session will be conducted with HCPs who deliver the intervention to discuss and gain insight into any potential facilitators/barriers to implementing the intervention in practice. Furthermore, we will conduct semi-structured focus groups with intervention participants to understand feasibility and acceptability. All qualitative data will be analysed thematically. ETHICS AND DISSEMINATION: The project has received a favourable opinion from South Hampshire B Research Ethics Committee, REC reference: 14/SC/1169 and full R&D approval from the University Hospitals of Leicester NHS Trust: 152408.Study results will be disseminated through appropriate peer-reviewed journals, national and international respiratory/physiotherapy conferences, via the Collaboration and Leadership in Applied Health Research and Care and through social media. TRIAL REGISTRATION: ISRCTN17942821; pre-results.

Population health needs as predictors of variations in NHS practice payments: a cross-sectional study of English general practices in 2013-2014 and 2014-2015.

BACKGROUND: NHS general practice payments in England include pay for performance elements and a weighted component designed to compensate for workload, but without measures of specific deprivation or ethnic groups. AIM: To determine whether population factors related to health needs predicted variations in NHS payments to individual general practices in England. DESIGN AND SETTING: Cross-sectional study of all practices in England, in financial years 2013-2014 and 2014-2015. METHOD: Descriptive statistics, univariable analyses (examining correlations between payment and predictors), and multivariable analyses (undertaking multivariable linear regressions for each year, with logarithms of payments as the dependent variables, and with population, practice, and performance factors as independent variables) were undertaken. RESULTS: Several population variables predicted variations in adjusted total payments, but inconsistently. Higher payments were associated with increases in deprivation, patients of older age, African Caribbean ethnic group, and asthma prevalence. Lower payments were associated with an increase in smoking prevalence. Long-term health conditions, South Asian ethnic group, and diabetes prevalence were not predictive. The adjusted R2 values were 0.359 (2013-2014) and 0.374 (2014-2015). A slightly different set of variables predicted variations in the payment component designed to compensate for workload. Lower payments were associated with increases in deprivation, patients of older age, and diabetes prevalence. Smoking prevalence was not predictive. There was a geographical differential. CONCLUSION: Population factors related to health needs were, overall, poor predictors of variations in adjusted total practice payments and in the payment component designed to compensate for workload. Revising the weighting formula and extending weighting to other payment components might better support practices to address these needs.

Population characteristics, mechanisms of primary care and premature mortality in England: a cross-sectional study.

OBJECTIVES: Health systems with strong primary care tend to have better population outcomes, but in many countries demand for care is growing. We sought to identify mechanisms of primary care that influence premature mortality. DESIGN: We developed a conceptual model of the mechanisms by which primary care influences premature mortality, and undertook a cross-sectional study in which population and primary care variables reflecting the model were used to explain variations in mortality of those aged under 75 years. The premature standardised mortality ratios (SMRs) for each practice, available from the Department of Health, had been calculated from numbers of deaths in the 5 years from 2006 to 2010. A regression model was undertaken with explanatory variables for the year 2009/2010, and repeated to check stability using data for 2008/2009 and 2010/2011. SETTING: All general practices in England were eligible for inclusion and, of the total of 8290, complete data were available for 7858. RESULTS: Population variables, particularly deprivation, were the most powerful predictors of premature mortality, but the mechanisms of primary care depicted in our model also affected mortality. The number of GPs/1000 population and detection of hypertension were negatively associated with mortality. In less deprived practices, continuity of care was also negatively associated with mortality. CONCLUSIONS: Greater supply of primary care is associated with lower premature mortality even in a health system that has strong primary care (England). Health systems need to sustain the capacity of primary care to deliver effective care, and should assist primary care providers in identifying and meeting the needs of socioeconomically deprived groups.

Estimating smoking prevalence in general practice using data from the Quality and Outcomes Framework (QOF).

OBJECTIVES: To determine to what extent underlying data published as part of Quality and Outcomes Framework (QOF) can be used to estimate smoking prevalence within practice populations and local areas and to explore the usefulness of these estimates. DESIGN: Cross-sectional, observational study of QOF smoking data. Smoking prevalence in general practice populations and among patients with chronic conditions was estimated by simple manipulation of QOF indicator data. Agreement between estimates from the integrated household survey (IHS) and aggregated QOF-based estimates was calculated. The impact of including smoking estimates in negative binomial regression models of counts of premature coronary heart disease (CHD) deaths was assessed. SETTING: Primary care in the East Midlands. PARTICIPANTS: All general practices in the area of study were eligible for inclusion (230). 14 practices were excluded due to incomplete QOF data for the period of study (2006/2007-2012/2013). One practice was excluded as it served a restricted practice list. MEASUREMENTS: Estimates of smoking prevalence in general practice populations and among patients with chronic conditions. RESULTS: Median smoking prevalence in the practice populations for 2012/2013 was 19.2% (range 5.8-43.0%). There was good agreement (mean difference: 0.39%; 95% limits of agreement (-3.77, 4.55)) between IHS estimates for local authority districts and aggregated QOF register estimates. Smoking prevalence estimates in those with chronic conditions were lower than for the general population (mean difference -3.05%), but strongly correlated (Rp=0.74, p<0.0001). An important positive association between premature CHD mortality and smoking prevalence was shown when smoking prevalence was added to other population and service characteristics. CONCLUSIONS: Published QOF data allow useful estimation of smoking prevalence within practice populations and in those with chronic conditions; the latter estimates may sometimes be useful in place of the former. It may also provide useful estimates of smoking prevalence in local areas by aggregating practice based data.

An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomised controlled trial.

OBJECTIVE: To investigate whether an early rehabilitation intervention initiated during acute admission for exacerbations of chronic respiratory disease reduces the risk of readmission over 12 months and ameliorates the negative effects of the episode on physical performance and health status. DESIGN: Prospective, randomised controlled trial. SETTING: An acute cardiorespiratory unit in a teaching hospital and an acute medical unit in an affiliated teaching district general hospital, United Kingdom. PARTICIPANTS: 389 patients aged between 45 and 93 who within 48 hours of admission to hospital with an exacerbation of chronic respiratory disease were randomised to an early rehabilitation intervention (n=196) or to usual care (n=193). MAIN OUTCOME MEASURES: The primary outcome was readmission rate at 12 months. Secondary outcomes included number of hospital days, mortality, physical performance, and health status. The primary analysis was by intention to treat, with prespecified per protocol analysis as a secondary outcome. INTERVENTIONS: Participants in the early rehabilitation group received a six week intervention, started within 48 hours of admission. The intervention comprised prescribed, progressive aerobic, resistance, and neuromuscular electrical stimulation training. Patients also received a self management and education package. RESULTS: Of the 389 participants, 320 (82%) had a primary diagnosis of chronic obstructive pulmonary disease. 233 (60%) were readmitted at least once in the following year (62% in the intervention group and 58% in the control group). No significant difference between groups was found (hazard ratio 1.1, 95% confidence interval 0.86 to 1.43, P=0.4). An increase in mortality was seen in the intervention group at one year (odds ratio 1.74, 95% confidence interval 1.05 to 2.88, P=0.03). Significant recovery in physical performance and health status was seen after discharge in both groups, with no significant difference between groups at one year. CONCLUSION: Early rehabilitation during hospital admission for chronic respiratory disease did not reduce the risk of subsequent readmission or enhance recovery of physical function following the event over 12 months. Mortality at 12 months was higher in the intervention group. The results suggest that beyond current standard physiotherapy practice, progressive exercise rehabilitation should not be started during the early stages of the acute illness.Trial registration Current Controlled Trials ISRCTN05557928.

Modelling factors in primary care quality improvement: a cross-sectional study of premature CHD mortality.

OBJECTIVES: To identify features of primary care quality improvement associated with improved health outcomes using premature coronary heart disease (CHD) mortality as an example, and to determine impacts of different modelling approaches. DESIGN: Cross-sectional study of mortality rates in 229 general practices. SETTING: General practices from three East Midlands primary care trusts. PARTICIPANTS: Patients registered to the practices above between April 2006 and March 2009. MAIN OUTCOME MEASURES: Numbers of CHD deaths in those aged under 75 (premature mortality) and at all ages in each practice. RESULTS: Population characteristics and markers of quality of primary care were associated with variations in premature CHD mortality. Increasing levels of deprivation, percentages of practice populations on practice diabetes registers, white, over 65 and male were all associated with increasing levels of premature CHD mortality. Control of serum cholesterol levels in those with CHD and the percentage of patients recalling access to their preferred general practitioner were both associated with decreased levels of premature CHD mortality. Similar results were found for all-age mortality. A combined measure of quality of primary care for CHD comprising 12 quality outcomes framework indicators was associated with decreases in both all-age and premature CHD mortality. The selected models suggest that practices in less deprived areas may have up to 20% lower premature CHD mortality than those with median deprivation and that improvement in the CHD care quality from 83% (lower quartile) to 86% (median) could reduce premature CHD mortality by 3.6%. Different modelling approaches yielded qualitatively similar results. CONCLUSIONS: High-quality primary care, including aspects of access to and continuity of care, detection and management, appears to be associated with reducing CHD mortality. The impact on premature CHD mortality is greater than on all-age CHD mortality. Determining the most useful measures of quality of primary care needs further consideration.

Are there enough GPs in England to detect hypertension and maintain access? A cross-sectional study.

BACKGROUND: Fewer patients are recorded by practices as having hypertension than are identified in systematic population surveys. However, as more patients are recorded on practice hypertension registers, mortality from coronary heart disease and stroke declines. AIM: To determine whether the number of GPs per 1000 practice population is associated with the number of patients recorded by practices as having hypertension, and whether patients' reports of being able to get an appointment with a GP are associated with the number of GPs and the number of patients recorded as having hypertension. DESIGN AND SETTING: Cross-sectional study of available data for all general practices in England for 2008 to 2009. METHOD: A model was developed to describe the hypothesised relationships between population (deprivation, ethnicity, age, poor health) and practice characteristics (list size, number of GPs per 1000 patients, management of hypertension) and the number of patients with hypertension and patient-reported ability to get an appointment fairly quickly. Two regression analyses were undertaken. RESULTS: Practices recorded only 13.3% of patients as having hypertension. Deprivation, age, poor health, white ethnicity, hypertension management, and the number of GPs per 1000 patients predicted the number of patients recorded with hypertension. Being able to get an appointment fairly quickly was associated with the number of patients recorded with hypertension, age, deprivation, practice list size, and the number of GPs per 1000 patients. CONCLUSION: In order to improve detection of hypertension as part of a strategy to lower mortality from coronary heart disease, the capacity of practices to detect hypertension while maintaining access needs to be improved. Increasing the supply of GPs may be necessary, as well as improvements in efficiency.

Chronic disease detection and access: does access improve detection, or does detection make access more difficult?

BACKGROUND: The recorded detection of chronic disease by practices is generally lower than the prevalence predicted by population surveys. AIM: To determine whether patient-reported access to general practice predicts the recorded detection rates of chronic diseases in that setting. DESIGN AND SETTING: A cross-sectional study involving 146 general practices in Leicestershire and Rutland, England. METHOD: The numbers of patients recorded as having chronic disease (coronary heart disease, chronic obstructive pulmonary disease, hypertension, diabetes) were obtained from Quality and Outcomes Framework (QOF) practice disease registers for 2008-2009. Characteristics of practice populations (deprivation, age, sex, ethnicity, proportion reporting poor health, practice turnover, list size) and practice performance (achievement of QOF disease indicators, patient experience of being able to consult a doctor within 2 working days and book an appointment >2 days in advance) were included in regression models. RESULTS: Patient characteristics (deprivation, age, poor health) and practice characteristics (list size, turnover, QOF achievement) were associated with recorded detection of more than one of the chronic diseases. Practices in which patients were more likely to report being able to book appointments had reduced recording rates of chronic disease. Being able to consult a doctor within 2 days was not associated with levels of recorded chronic disease. CONCLUSION: Practices with high levels of deprivation and older patients have increased rates of recorded chronic disease. As the number of patients recorded with chronic disease increased, the capacity of practices to meet patients' requests for appointments in advance declined. The capacity of some practices to detect and manage chronic disease may need improving.

Characteristics of general practices associated with numbers of elective admissions.

BACKGROUND: In England both emergency (unplanned) and non-emergency (elective) hospital admissions have been increasing. Some elective admissions are potentially avoidable. AIM: to identify the characteristics of general practices and patients associated with elective admissions. METHODS: A cross-sectional study, in Leicestershire, England, was conducted using admission data (2006-07 and 2007-08). Practice characteristics (list size, distance from principal hospital, quality and outcomes framework score and general practitioner (GP) patient access survey data) and patient characteristics (age, ethnicity and deprivation and gender) were used as predictors of elective hospital admissions in a negative binomial regression model. RESULTS: Practices with a higher proportion of patients aged 65 years or greater and of white ethnicity had higher rates of elective hospital admissions. Practices with more male patients and with more patients reporting being able to consult a particular GP had fewer elective hospital admissions. For 2007-08 practices with a larger list size were associated with higher elective hospital admissions. Quality and outcomes framework performance did not predict admission numbers. CONCLUSIONS: As for unplanned admissions, elective admissions increase as being able to consult a particular GP declines. Interventions to improve continuity should be investigated. Practices face major problems in managing the increased need for planned care as the population ages.

Limited impact on patient experience of access of a pay for performance scheme in England in the first year.

BACKGROUND: Improvement of access to general practice is a priority in England. In 2006/07 an annual national survey of patient experience of access was introduced, with financial incentives to practices based on the findings of the survey among their own patients. OBJECTIVES: To describe changes in patient experience of access over the first two years of the survey and incentive scheme, and identify respondent and practice characteristics associated with patient experience of access. DESIGN AND METHODS: The study included 222 general practices in the east of England, which had completed the access survey in 2006/07 and 2007/08. We compared proportions of patients reporting satisfaction with different aspects of access in each year. In explanatory regression models, we investigated the associations between improvement of reported access and respondent and practice characteristics. RESULTS: There were some small improvements in reported access between the two surveys, although satisfaction with opening hours declined marginally. The explanatory analysis showed that larger practices, a higher proportion of respondents from ethnic minority groups, and higher deprivation were associated with patient reports of worse access. These variables and practice response rates did not explain the amount of change between the two years. CONCLUSIONS: The launch of the incentive scheme was not followed by convincing improvements in patient experience of access. Practices with deprived populations or with a high proportion of ethnic minority survey respondents are perceived as offering worse access, were not more likely to achieve improvements, and additional support should be considered to help these practices.

Early graft function defined by area under the curve serum creatinine 7 days post-transplant in a series of live donor kidney transplantation.

BACKGROUND: There is a degree of variability in early graft function that is often not highlighted in live kidney donor transplantation. We used the calculation of area under the curve of serum creatinine (AUC Cr) in the first 7 d post-transplant to assess early graft function and examine the influence on longer term outcome. METHODS: A total of 188 live donor renal transplants performed between 1998 and 2007 were analyzed. AUC Cr was calculated over the first 7 d post-transplant and 12 mo serum creatinine levels recorded. Donor and recipient demographics were recorded, and univariable and multivariable analyses were used to determine influencing factors. The sensitivity and specificity of AUC Cr for the detection of reduced serum creatinine at 12 mo (cut-off 130 µmol/L) were assessed by the receiver operating characteristic (ROC) curve. RESULTS: There was a significant variation in levels of AUC Cr over the first 7 d post-transplant (range, 692-5765 µmol/L.d). The ROC curve had a relatively low predictive value for the AUC Cr calculation (AUC=0.735). However, multivariable analysis showed that higher levels of AUC Cr were associated with higher serum creatinine levels at 12 mo (slope 0.012; P=0.0005). The need for dialysis, lower kidney weight, and higher recipient weight were significant independent predictors of a higher serum creatinine at 12 mo. CONCLUSION: The calculation of AUC serum creatinine 7 d post-transplant highlighted the significant variation in early graft function following live donor transplantation and was associated with creatinine levels at 12 mo. This calculation may be used as a simple prognostic marker to highlight poorer graft outcome.

Association of features of primary health care with coronary heart disease mortality.

CONTEXT: The goal of US health care reform is to extend access. In England, with a universal access health system, coronary heart disease (CHD) mortality rates have decreased by more than two-fifths in the last decade, but variations in rates between local populations persist. OBJECTIVE: To identify which features of populations and primary health care explain variations in CHD mortality rates between the 152 primary care trust populations in England. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study in England of all 152 primary care trusts (total registered population, 54.3 million in 2008) using a hierarchical regression model with age-standardized CHD mortality rate as the dependent variable, and population characteristics (index of multiple deprivation, smoking, ethnicity, and registers of individuals with diabetes) and service characteristics (level of provision of primary care services, levels of detected hypertension, pay for performance data) as candidate explanatory variables. MAIN OUTCOME MEASURES: Age-standardized CHD mortality rates in 2006, 2007, and 2008. RESULTS: The mean age-standardized CHD mortality rates per 100,000 European Standard Population were 97.9 (95% confidence interval [CI], 94.9-100.9) in 2006, 93.5 (95% CI, 90.4-96.5) in 2007, and 88.4 (95% CI, 85.7-91.1) in 2008. In all 3 years, 4 population characteristics were significantly positively associated with CHD mortality (index of multiple deprivation, smoking, white ethnicity, and registers of individuals with diabetes), and 1 service characteristic (levels of detected hypertension) was significantly negatively associated with CHD mortality (adjusted r(2) = 0.66 in 2006, adjusted r(2) = 0.68 in 2007, and adjusted r(2) = 0.67 in 2008). Other service characteristics did not contribute significantly to the model. CONCLUSION: In England, variations in CHD mortality are predominantly explained by population characteristics; however, greater detection of hypertension is associated with lower CHD mortality.

Do the Quality and Outcomes Framework patient experience indicators reward practices that offer improved access?

BACKGROUND: The Quality and Outcomes Framework (QOF) includes indicators for patient experience, but there has been little research on whether the indicators identify practices that deliver good patient access. AIM: To determine whether practices that achieved high QOF patient experience points in 2005/2006 or 2006/2007 also delivered good patient access. DESIGN OF STUDY: Use of publicly available data to investigate two hypotheses: practices with more positive access survey findings in 2006/2007 will be more likely to have achieved maximum QOF patient experience points in the same year; and practices with maximum QOF patient experience points in 2005/2006 will have higher access survey findings in 2006/2007. SETTING: Two-hundred and twenty-four East Midlands general practices. METHOD: For hypothesis one, binary logistic regression was used, with achievement of maximum QOF points as the dependent variable, and access survey findings, responder variables, and practice variables as independent variables. For hypothesis two, general linear models were used, with access survey findings as the independent variables, and achievement of maximum QOF points and the responder and practice variables as dependent variables. RESULTS: The findings did not support the first hypothesis. For the second hypothesis, achievement of maximum QOF points was only significantly associated with patient satisfaction with opening hours (positive correlation). QOF points were not associated with any other aspect of access. CONCLUSION: The QOF patient experience indicators do not reward practices that offer good patient access. A standard patient survey with financial incentive may be more effective in identifying and rewarding practices that offer better access, including opportunity to book appointments with a particular doctor.