Suchergebnisse

Introduction Health research using routinely collected National Health Service (NHS) data derived from electronic health records (EHRs) and health service information systems has been growing in both importance and quantity. Wide population coverage and detailed patient-level information allow this data to be applied to a variety of research questions. However, the sensitivity, complexity and scale of such data also hamper researchers from fully exploiting this potential. Objective Here, we establish the current challenges preventing researchers from making optimal use of the data sets at their disposal, on both the legislative and practical levels, and give recommendations as to how these challenges can be overcome. Method A number of projects has recently been launched in the UK to address poor research datamanagement practices. Rapid Organisation of Healthcare Research Data (ROHRD) at Imperial College, London produced a useful prototype that provides local researchers with a one-stop index of available data sets together with relevant metadata. Findings Increased transparency of data sets' availability and their provenance leads to better utilisation and facilitates compliance with regulatory requirements. Discussion Research data resulting from NHS data is often not utilised fully, or is handled in a haphazard manner that prevents full auditability of the research. Furthermore, lack of informatics and data management skills in research teams act as a barrier to implementing more advanced practices, such as provenance capture and detailed, regularly updated, data management strategies. Only by a concerted effort at the levels of research organisations, funding bodies and publishers, can we achieve full transparency and reproducibility of the research.

Introduction Health research using routinely collected National Health Service (NHS) data derived from electronic health records (EHRs) and health service information systems has been growing in both importance and quantity. Wide population coverage and detailed patient-level information allow this data to be applied to a variety of research questions. However, the sensitivity, complexity and scale of such data also hamper researchers from fully exploiting this potential.Objective Here, we establish the current challenges preventing researchers from making optimal use of the data sets at their disposal, on both the legislative and practical levels, and give recommendations as to how these challenges can be overcome.Method A number of projects has recently been launched in the UK to address poor research data management practices. Rapid Organisation of Healthcare Research Data (ROHRD) at Imperial College, London produced a useful prototype that provides local researchers with a one-stop index of available data sets together with relevant metadata.Findings Increased transparency of data sets' availability and their provenance leads to better utilisation and facilitates compliance with regulatory requirements.Discussion Research data resulting from NHS data is often not utilised fully, or is handled in a haphazard manner that prevents full auditability of the research. Furthermore, lack of informatics and data management skills in research teams act as a barrier to implementing more advanced practices, such as provenance capture and detailed, regularly updated, data management strategies. Only by a concerted effort at the levels of research organisations, funding bodies and publishers, can we achieve full transparency and reproducibility of the research.

BACKGROUND: The UK government plans to extend the opening hours of general practices in England. The 'extended hours access scheme' pays practices for providing appointments outside core times (08:00 to 18.30, Monday to Friday) for at least 30 min per 1000 registered patients each week. OBJECTIVE: To determine the association between extended hours access scheme participation and patient experience. METHODS: Retrospective analysis of a national cross-sectional survey completed by questionnaire (General Practice Patient Survey 2013-2014); 903 357 survey respondents aged ≥18 years old and registered to 8005 general practices formed the study population. Outcome measures were satisfaction with opening hours, experience of making an appointment and overall experience (on five-level interval scales from 0 to 100). Mean differences between scheme participation groups were estimated using multilevel random-effects regression, propensity score matching and instrumental variable analysis. RESULTS: Most patients were very (37.2%) or fairly satisfied (42.7%) with the opening hours of their general practices; results were similar for experience of making an appointment and overall experience. Most general practices participated in the extended hours access scheme (73.9%). Mean differences in outcome measures between scheme participants and non-participants were positive but small across estimation methods (mean differences ≤1.79). For example, scheme participation was associated with a 1.25 (95% CI 0.96 to 1.55) increase in satisfaction with opening hours using multilevel regression; this association was slightly greater when patients could not take time off work to see a general practitioner (2.08, 95% CI 1.53 to 2.63). CONCLUSIONS: Participation in the extended hours access scheme has a limited association with three patient experience measures. This questions expected impacts of current plans to extend opening hours on patient experience.

BACKGROUND: The UK Government has introduced several national policies to improve access to primary care. We examined associations between patient experience of general practice and rates of visits to accident and emergency (A&E) departments and emergency hospital admissions in England. METHODS: The study included 8124 general practices between 2011-2012 and 2013-2014. Outcome measures were annual rates of A&E visits and emergency admissions by general practice population, according to administrative hospital records. Explanatory variables included three patient experience measures from the General Practice Patient Survey: practice-level means of experience of making an appointment, satisfaction with opening hours and overall experience (on 0-100 scales). The main analysis used random-effects Poisson regression for cross-sectional time series. Five sensitivity analyses examined changes in model specification. RESULTS: Mean practice-level rates of A&E visits and emergency admissions increased from 2011-2012 to 2013-2014 (310.3-324.4 and 98.8-102.9 per 1000 patients). Each patient experience measure decreased; for example, mean satisfaction with opening hours was 79.4 in 2011-2012 and 76.6 in 2013-2014. In the adjusted regression analysis, an SD increase in experience of making appointments (equal to 9 points) predicted decreases of 1.8% (95% CI -2.4% to -1.2%) in A&E visit rates and 1.4% (95% CI -1.9% to -0.9%) in admission rates. This equalled 301 174 fewer A&E visits and 74 610 fewer admissions nationally per year. Satisfaction with opening hours and overall experience were not consistently associated with either outcome measure across the main and sensitivity analyses. CONCLUSIONS: Associations between patient experience of general practice and use of emergency hospital services were small or inconsistent. In England, realistic short-term improvements in patient experience of general practice may only have modest effects on A&E visits and emergency admissions.

BACKGROUND: The UK government aims to improve the accessibility of general practices in England, particularly by extending opening hours in the evenings and at weekends. It is unclear how important these factors are to patients' overall experiences of general practice. AIM: To examine associations between overall experience of general practice and patient experience of making appointments and satisfaction with opening hours. DESIGN AND SETTING: Analysis of repeated cross-sectional data from the General Practice Patient Surveys conducted from 2011-2012 until 2013-2014. These covered 8289 general practice surgeries in England. METHOD: Data from a national survey conducted three times over consecutive years were analysed. The outcome measure was overall experience, rated on a five-level interval scale. Associations were estimated as standardised regression coefficients, adjusted for responder characteristics and clustering within practices using multilevel linear regression. RESULTS: In total, there were 2 912 535 responders from all practices in England (n = 8289). Experience of making appointments (β 0.24, 95% confidence interval [CI] = 0.24 to 0.25) and satisfaction with opening hours (β 0.15, 95% CI = 0.15 to 0.16) were modestly associated with overall experience. Overall experience was most strongly associated with GP interpersonal quality of care (β 0.34, 95% CI = 0.34 to 0.35) and receptionist helpfulness was positively associated with overall experience (β 0.16, 95% CI = 0.16 to 0.17). Other patient experience measures had minimal associations (β≤0.06). Models explained ≥90% of variation in overall experience between practices. CONCLUSION: Patient experience of making appointments and satisfaction with opening hours were only modestly associated with overall experience. Policymakers in England should not assume that recent policies to improve access will result in large improvements in patients' overall experience of general practice.

BACKGROUND: The UK government aims to improve the accessibility of general practices in England, particularly by extending opening hours in the evenings and at weekends. It is unclear how important these factors are to patients' overall experiences of general practice. AIM: To examine associations between overall experience of general practice and patient experience of making appointments and satisfaction with opening hours. DESIGN AND SETTING: Analysis of repeated cross-sectional data from the General Practice Patient Surveys conducted from 2011–2012 until 2013–2014. These covered 8289 general practice surgeries in England. METHOD: Data from a national survey conducted three times over consecutive years were analysed. The outcome measure was overall experience, rated on a five-level interval scale. Associations were estimated as standardised regression coefficients, adjusted for responder characteristics and clustering within practices using multilevel linear regression. RESULTS: In total, there were 2 912 535 responders from all practices in England (n = 8289). Experience of making appointments (β 0.24, 95% confidence interval [CI] = 0.24 to 0.25) and satisfaction with opening hours (β 0.15, 95% CI = 0.15 to 0.16) were modestly associated with overall experience. Overall experience was most strongly associated with GP interpersonal quality of care (β 0.34, 95% CI = 0.34 to 0.35) and receptionist helpfulness was positively associated with overall experience (β 0.16, 95% CI = 0.16 to 0.17). Other patient experience measures had minimal associations (β≤0.06). Models explained ≥90% of variation in overall experience between practices. CONCLUSION: Patient experience of making appointments and satisfaction with opening hours were only modestly associated with overall experience. Policymakers in England should not assume that recent policies to improve access will result in large improvements in patients' overall experience of general practice.

Taiwan adopted a national health insurance system in 1995. It is a government administered insurance-based national healthcare system. Although, like the UK, Taiwan has a single payer system for healthcare, there are several differences between the two systems. The characteristics of the Taiwanese system include good accessibility, comprehensive population coverage, short waiting times, relatively low costs and a national health insurance databank for planning, monitoring and evaluating health services. The weaknesses include variable quality of care, a weak gatekeeper role and increasing financial pressures.

In the UK, there are policy and regulatory concerns regarding the governance of care homes and healthcare provision within these homes. From a public health perspective, these issues can pose significant challenges to the provision of safe and quality medication use services to care home residents. The objective of this paper is to highlight an important and neglected issue for the growing population of institutionalized older adults. We reviewed relevant literature for the years 2000 to present and identified recent efforts undertaken to improve medication safety standards in UK care homes. We consider the limitations and reasons for the National Health Service's restricted role and lack of leadership in providing medical services for this institutionalized population. The efforts taken by the Department of Health and other healthcare authorities targeting medication safety in care homes are also highlighted. In order to improve the quality of healthcare, specifically in areas related to medication safety and quality use of medicines, interventions need to be taken by the national government and similarly by local authorities and NHS commissioners.

BACKGROUND: The risk of iatrogenic harm from the use and misuse of prescription drugs such as gabapentin, pregabalin, and oxycodone is substantial. In recent years, deaths associated with these drugs in England have increased. AIM: To characterise general practice prescribing trends for gabapentin, pregabalin, and oxycodone — termed dependence forming medicines (DFM) — in England and describe potential drivers of unwarranted variation (that is, very high prescribing). DESIGN & SETTING: This study is a retrospective secondary analysis of open source, publicly available government data from various sources pertaining to primary care demographics and prescriptions. METHOD: This study used 5 consecutive years (April 2013–March 2018) of aggregate data to investigate longitudinal trends of prescribing and variation in prescribing trends at practice and clinical commissioning group (CCG) level. RESULTS: Annual prescriptions of gabapentin, pregabalin, and oxycodone increased each year over the period. Variation in prescribing trends was associated with GP practice deprivation quintile, where the most deprived GP practices prescribed 313% (P<0.001) and 238% (P<0.001) greater volumes of gabapentin and pregabalin per person respectively, than practices in the least deprived quintile. The highest prescribing CCGs of each of these drugs were predominantly in northern and eastern regions of England. CONCLUSION: Substantial increases in gabapentin, pregabalin, and oxycodone prescriptions are concerning and will increase iatrogenic harm from drug-related morbidity and mortality. More research is needed to understand the large variation in prescribing between general practices, and to develop and implement interventions to reduce unwarranted variation and increase the appropriateness of prescribing of these drugs.

Objective To examine associations between the contract and ownership type of general practices and patient experience in England. Design Multilevel linear regression analysis of a national cross-sectional patient survey (General Practice Patient Survey). Setting All general practices in England in 2013-2014 ( n = 8017). Participants 903,357 survey respondents aged 18 years or over and registered with a general practice for six months or more (34.3% of 2,631,209 questionnaires sent). Main outcome measures Patient reports of experience across five measures: frequency of consulting a preferred doctor; ability to get a convenient appointment; rating of doctor communication skills; ease of contacting the practice by telephone; and overall experience (measured on four- or five-level interval scales from 0 to 100). Models adjusted for demographic and socioeconomic characteristics of respondents and general practice populations and a random intercept for each general practice. Results Most practices had a centrally negotiated contract with the UK government ('General Medical Services' 54.6%; 4337/7949). Few practices were limited companies with locally negotiated 'Alternative Provider Medical Services' contracts (1.2%; 98/7949); these practices provided worse overall experiences than General Medical Services practices (adjusted mean difference -3.04, 95% CI -4.15 to -1.94). Associations were consistent in direction across outcomes and largest in magnitude for frequency of consulting a preferred doctor (-12.78, 95% CI -15.17 to -10.39). Results were similar for practices owned by large organisations (defined as having ≥20 practices) which were uncommon (2.2%; 176/7949). Conclusions Patients registered to general practices owned by limited companies, including large organisations, reported worse experiences of their care than other patients in 2013-2014.

BackgroundThe UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes.ObjectiveTo determine whether primary care access is associated with the route of emergency admission-via a GP versus via an A and E department.MethodsRetrospective analysis of national administrative data from English hospitals for 2011-2012. Adults admitted in an emergency (unscheduled) for ≥1 night via a GP or an A and E department formed the study population. The measure of primary care access-the percentage of patients able to get a general practice appointment on their last attempt-was derived from a large, nationally representative patient survey. Multilevel logistic regression was used to estimate associations, adjusting for patient and admission characteristics.ResultsThe analysis included 2 322 112 emergency admissions (81.9% via an A and E department). With a 5 unit increase in the percentage of patients able to get a general practice appointment on their last attempt, the adjusted odds of GP admission (vs A and E admission) was estimated to increase by 15% (OR 1.15, 95% CI 1.12 to 1.17). The probability of GP admission if ≥95% of appointment attempts were successful in each general practice was estimated to be 19.6%. This probability reduced to 13.6% when <80% of appointment attempts were successful. This equates to 139 673 fewer GP admissions (456 232 vs 316 559) assuming no change in the total number of admissions. Associations were consistent in direction across geographical regions of England.ConclusionsAmong hospital inpatients admitted as an emergency, patients registered to more accessible general practices were more likely to have been admitted via a GP (vs an A and E department). This furthers evidence suggesting that access to general practice is related to use of emergency hospital services in England. The relative merits of the two admission routes remain unclear.

BACKGROUND: The UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes. OBJECTIVE: To determine whether primary care access is associated with the route of emergency admission-via a GP versus via an A and E department. METHODS: Retrospective analysis of national administrative data from English hospitals for 2011-2012. Adults admitted in an emergency (unscheduled) for ≥1 night via a GP or an A and E department formed the study population. The measure of primary care access-the percentage of patients able to get a general practice appointment on their last attempt-was derived from a large, nationally representative patient survey. Multilevel logistic regression was used to estimate associations, adjusting for patient and admission characteristics. RESULTS: The analysis included 2 322 112 emergency admissions (81.9% via an A and E department). With a 5 unit increase in the percentage of patients able to get a general practice appointment on their last attempt, the adjusted odds of GP admission (vs A and E admission) was estimated to increase by 15% (OR 1.15, 95% CI 1.12 to 1.17). The probability of GP admission if ≥95% of appointment attempts were successful in each general practice was estimated to be 19.6%. This probability reduced to 13.6% when <80% of appointment attempts were successful. This equates to 139 673 fewer GP admissions (456 232 vs 316 559) assuming no change in the total number of admissions. Associations were consistent in direction across geographical regions of England. CONCLUSIONS: Among hospital inpatients admitted as an emergency, patients registered to more accessible general practices were more likely to have been admitted via a GP (vs an A and E department). This furthers evidence suggesting that access to general practice is related to use of emergency hospital services in England. The relative merits of the two admission routes remain unclear.

Background: Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect.Study design: We present a mixed methods evaluation methodology. It includes a quantitative approach measuring changes in service utilization, costs, clinical outcomes and quality of care using routine primary and secondary data sources. It also contains a qualitative component, involving observations, interviews and focus groups with patients and professionals, to understand participant experiences and to understand the pilot within the national policy context.Theory and discussion: This study considers the complexity of evaluating a large, multi-organisational intervention in a changing healthcare economy. We locate the evaluation within the theory of evaluation of complex interventions. We present the specific challenges faced by evaluating an intervention of this sort, and the responses made to mitigate against them.Conclusions: We hope this broad, dynamic and responsive evaluation will allow us to clarify the contribution of the pilot, and provide a potential model for evaluation of other similar interventions. Because of the priority given to the integrated agenda by governments internationally, the need to develop and improve strong evaluation methodologies remains strikingly important

Background: Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect. Study design: We present a mixed methods evaluation methodology. It includes a quantitative approach measuring changes in service utilization, costs, clinical outcomes and quality of care using routine primary and secondary data sources. It also contains a qualitative component, involving observations, interviews and focus groups with patients and professionals, to understand participant experiences and to understand the pilot within the national policy context. Theory and discussion: This study considers the complexity of evaluating a large, multi-organisational intervention in a changing healthcare economy. We locate the evaluation within the theory of evaluation of complex interventions. We present the specific challenges faced by evaluating an intervention of this sort, and the responses made to mitigate against them. Conclusions: We hope this broad, dynamic and responsive evaluation will allow us to clarify the contribution of the pilot, and provide a potential model for evaluation of other similar interventions. Because of the priority given to the integrated agenda by governments internationally, the need to develop and improve strong evaluation methodologies remains strikingly important. ; The evaluation of the NWL ICP is funded by the Imperial College Healthcare Charity.

Introduction: Early evidence confirms lower COVID-19 vaccine uptake in established ethnic minority populations, yet there has been little focus on understanding vaccine hesitancy and barriers to vaccination in migrants. Growing populations of precarious migrants (including undocumented migrants, asylum seekers and refugees) in the UK and Europe are considered to be under-immunised groups and may be excluded from health systems, yet little is known about their views on COVID-19 vaccines specifically, which are essential to identify key solutions and action points to strengthen vaccine roll-out. Methods: We did an in-depth semi-structured qualitative interview study of recently arrived migrants (foreign-born, >18 years old; <10 years in the UK) to the UK with precarious immigration status between September 2020 and March 2021, seeking their input into strategies to strengthen COVID-19 vaccine delivery and uptake. We used the 'Three Cs' model (confidence, complacency and convenience) to explore COVID-19 vaccine hesitancy, barriers and access. Data were analysed using a thematic framework approach. Data collection continued until data saturation was reached, and no novel concepts were arising. The study was approved by the University of London ethics committee (REC 2020.00630). Results: We approached 20 migrant support groups nationwide, recruiting 32 migrants (mean age 37.1 years; 21 [66%] female; mean time in the UK 5.6 years [SD 3.7 years]), including refugees (n = 3), asylum seekers (n = 19), undocumented migrants (n = 8) and migrants with limited leave to remain (n = 2) from 15 different countries (5 WHO regions). 23 (72%) of 32 migrants reported being hesitant about accepting a COVID-19 vaccine and two (6%) would definitely not accept a vaccine. Participants communicated concerns over vaccine content, side-effects, lack of accessible information in an appropriate language, lack of trust in the health system and low perceived need. A range of barriers to accessing the COVID-19 vaccine were reported and concerns expressed that their communities would be excluded from or de-prioritised in the roll-out. Undocumented migrants described fears over being charged and facing immigration checks if they present for a vaccine. Participants (n = 10) interviewed after recent government announcements that COVID-19 vaccines can be accessed without facing immigration checks remained unaware of this. Participants stated that convenience of access would be a key factor in their decision around whether to accept a vaccine and proposed alternative access points to primary care services (for example, walk-in centres in trusted places such as foodbanks, community centres and charities), alongside promoting registration with primary care for all, and working closely with communities to produce accessible information on COVID-19 vaccination. Conclusions: Precarious migrants may be hesitant about accepting a COVID-19 vaccine and face multiple and unique barriers to access, requiring simple but innovative solutions to ensure equitable access and uptake. Vaccine hesitancy and low awareness around entitlement and relevant access points could be easily addressed with clear, accessible, and tailored information campaigns, co-produced and delivered by trusted sources within marginalised migrant communities. These findings have immediate relevance to the COVID-19 vaccination initiatives in the UK and in other European and high-income countries with diverse migrant populations. Funding: NIHR.