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Measuring the complexity of general practice consultations: development and validation of a complexity measure
Background: The complexity of general practice consultations may be increasing and vary in different settings. Testing these hypotheses requires a measure of complexity. Aim: To develop a valid measure of general practice consultation complexity applicable to routine medical records. Design: Delphi study to select potential indicators of complexity followed by cross-sectional study to develop and validate a complexity measure. Setting: English general practices. Method: An online Delphi study over two rounds involved 32 general practitioners to identify potential indicators of consultation complexity. The cross-sectional study used an age-sex stratified random sample of 173,130 patients and 725,616 general practice face-to-face consultations from 2013/14 in the Clinical Practice Research Datalink. We explored independent relationships between each indicator and consultation duration using mixed effects regression models, and revalidated findings using data from 2017/18. We assessed the proportion of complex consultations in different age-sex groups. Results: After two rounds, the Delphi panel endorsed 34 of 45 possible complexity indicators. In the cross-sectional study, after excluding factors because of low prevalence or confounding, 17 indicators were retained. Defining complexity as the presence of any of these factors, 308,370 consultations (42.5%) were complex. Mean duration of complex consultations was 10.49 minutes, compared to 9.64 minutes for non-complex consultations. The proportion of complex consultations was similar in men and women but increased with age. Conclusion: Our consultation complexity measure has face and construct validity. It may be useful for research, management and policy, informing decisions about the range of resources needed in different practices.
Context, context, context: how has covid-19 changed implementation globally and how can we ‘lock in’ learning?
In our recent editorial  we discussed the importance of knowledge mobilization (KM; defined as ‘a proactive process that involves efforts to transform practice through the circulation of knowledge within and across practice domains’ ) to the implementation of best practice to drive up the quality of care for patients. We acknowledged the role and importance of recognizing real-world context, providing examples of individual, organizational and national contextual factors that influence KM. Since the publication of that editorial, the context of healthcare both nationally and internationally has changed substantially. The covid-19 pandemic has, and will continue to have, a significant impact on KM and the design and delivery of healthcare services. The commonly cited conclusion in KM is that ‘context is everything’, and we would like to add to this discussion and build upon our previous editorial in light of the covid-19 situation. This piece explores the impact of covid-19 on KM, in the context of musculoskeletal services, and the ways in which organizations can ‘lock in’ learning, after arguably the biggest challenge that healthcare services have ever experienced.
It is estimated that 85% of healthcare research is ‘wasted’, avoidably, due to inadequacies in research design, conduct and dissemination . Such inadequacies in implementing healthcare research lead to health, economic and opportunity costs. A major review investigating the use of healthcare research identified two ‘gaps’ in research translation, the first being between bench and bedside and the second relating to ‘implementing … products and approaches into clinical practice’ . So, whilst we know there is a problem in this area, what can the growing field of research into implementation do to help healthcare professionals, patients and carers improve outcomes and quality of care?
Timing of GP end-of-life recognition in people aged ≥75 years: retrospective cohort study using data from primary healthcare records in England
Background: High-quality, personalised palliative care should be available to all, but timely recognition of end of life may be a barrier to end-of-life care for older people. Aim: To investigate the timing of end-of-life recognition, palliative registration, and the recording of end-of-life preferences in primary care for people aged ≥75 years. Design and setting: Retrospective cohort study using national primary care record data, covering 34% of GP practices in England. Method: ResearchOne data from electronic healthcare records (EHRs) of people aged ≥75 years who died in England between 1 January 2015 and 1 January 2016 were examined. Clinical codes relating to end-of-life recognition, palliative registration, and end-of-life preferences were extracted, and the number of months that elapsed between the code being entered and death taking place were calculated. The timing for each outcome and proportion of relevant EHRs were reported. Results: Death was recorded for a total of 13 149 people in ResearchOne data during the 1-year study window. Of those, 6303 (47.9%) records contained codes suggesting end of life had been recognised at a point in time prior to the month of death. Recognition occurred ≥12 months before death in 2248 (17.1%) records. In total, 1659 (12.6%) people were on the palliative care register and 457 (3.5%) were on the register for ≥12 months before death; 2987 (22.7%) records had a code for the patient’s preferred place of care, and 1713 (13.0%) had a code for the preferred place of death. Where preferences for place of death were recorded, a care, nursing, or residential home (n = 813, 47.5%) and the individual’s home (n = 752, 43.9%) were the most common. Conclusion: End-of-life recognition in primary care appears to occur near to death and for only a minority of people aged ≥75 years. The findings suggest that older people’s deaths may not be anticipated by health professionals, compromising equitable access to palliative care.
Objectives: To investigate whether patterns of National Early Warning Scores (NEWS/NEWS2) in care homes during the COVID pandemic correspond with area-level COVID-19 death registrations from care homes. Study design: Longitudinal ecological study. Setting: 460 Care home units using the same software package to collect data on residents, from 46 local authority areas in England. Participants: 6,464 care home residents with at least one NEWS recording. Exposure measure: 29,656 anonymised person-level NEWS from 29/12/2019 to 20/05/2020 with component physiological measures: systolic blood pressure, respiratory rate, pulse rate, temperature, and oxygen saturation. Baseline values for each measure calculated using 80th and 20th centile scores before March 2020. Outcome measure: Time series comparison with Office for National Statistics (ONS) weekly reported registered deaths of care home residents where COVID-19 was the underlying cause of death, and all other deaths (excluding COVID-19) up to 10/05/2020. Results: Deaths due to COVID-19 were registered from 23/03/2020 in the study geographical areas. Between 23/03/2020 and 10/05/2020, there were 5,753 deaths (1,532 involving COVID-19 and 4,221 other causes). The proportion of above-baseline NEWS increased from 16/03/2020 and closely followed the rise and fall in COVID-19 deaths over the study period. The proportion of above-baseline oxygen saturation, respiratory rate and temperature measurements also increased approximately two weeks before peaks in care home deaths in corresponding geographical areas. Conclusions: NEWS may make a useful contribution to disease surveillance in care homes during the COVID-19 pandemic. Oxygen saturation, respiratory rate and temperature could be prioritised as they appear to signal rise in mortality almost as well as total NEWS. This study reinforces the need to collate data from care homes, to monitor and protect residents’ health. Further work using individual level outcome data is needed to evaluate the role of NEWS in the early detection of resident illness.
Background Patient and public involvement (PPI) can help with steering and shaping research prioritisation and execution. However, some groups of people may not be encouraged to take part and their voices may be seldom listened to in the production of research. This is important to consider because they may have poorer healthcare experiences. We tried using art as a vehicle for including individuals not necessarily invited to be part of research priority setting. Methods We contacted existing groups and organisations to reach people not routinely supported to be part of PPI. We targeted individuals: a) with dementia, b) with a mental and physical health condition, c) of South Asian heritage. We ran a workshop with each group at which individuals shared their experiences of healthcare. A young amateur artist also attended, who produced a piece of artwork afterwards that reflected the research priorities raised. We held a Twitter chat to discuss these pieces of art and the processes involved in their generation. Results From each workshop, we produced a list of research priorities. These included: a) improving coordination of care for people with dementia, b) information needs and anxiety/guilt around accessing care for people with physical and mental health conditions, c) supporting discussion of women’s health issues in South Asian communities. These priorities were reflected in three pieces of art, which can be viewed online. Feedback from those at workshops suggested that the artwork helped them to feel that their voice had been heard and triggered their interest in how research is developed. Those involved in the Twitter chat commented that art was one means through which researchers could connect with a range of groups in a PPI context when preparing and producing a study. Conclusions We found the medium of art to be an effective way of including a range of people in research prioritisation setting. This approach could be useful for future PPI, building on what we have learnt from the project described in this paper.
Using evidence-based infographics to increase parents’ understanding about antibiotic use and antibiotic resistance: a proof-of-concept study
Background: Communities need to see antibiotic stewardship campaigns as relevant to enhance understanding of antibiotic use and influence health-seeking behaviour. Yet, campaigns have often not sought input from the public in their development. Objectives: To co-produce evidenced-based infographics (EBIs) about antibiotics for common childhood infections and to evaluate their effectiveness at increasing parents’ understanding of antibiotic use. Methods: A mixed-methods study with three phases. Phase 1 identified and summarized evidence of antibiotic use for three childhood infections (sore throat, acute cough and otitis media). In phase 2, we co-designed a series of prototype EBIs with parents and a graphic design team (focus groups). Thematic analysis was used to analyse data. Phase 3 assessed the effect of EBIs on parents’ understanding of antibiotic use for the three infections using a national online survey in the UK. Results: We iteratively co-produced 10 prototype EBIs. Parents found the evidence displayed in the EBIs novel and relevant to their families. Parents did not favour EBIs that were too medically focused. Parents preferred one health message per EBI. We included eight EBIs in a national survey of parents (n = 998). EBIs improved knowledge by more than a third across the board (34%, IQR 20%–46%, P < 0.001). Respondents confirmed that EBIs were novel and potentially useful, corroborating our focus groups findings. Conclusions: Co-designed EBIs have the potential to succinctly change parents’ perceptions about antibiotics for acute respiratory tract infections in children. Further research should test EBIs in real-world settings to assess their reach as a potential public-facing intervention.
Providing person-centred end-of-life care at home and in care homes during the COVID-19 pandemic has been challenging. These challenges extend beyond the interpersonal communication barriers created by wearing personal protective equipment (PPE) for infection control. Visors and facemasks make it harder to hear soft voice tones or read facial expressions, which are key tools in empathetic communication. Traditional models of care, based on predominantly face-to-face multidisciplinary clinical consultations, have been radically overhauled in the UK and other countries worse affected by the pandemic (Antunes et al, 2020; Costantini et al, 2020). The unprecedented rapid adoption of technology, including video and telehealth consultations, alongside virtual ward rounds and online team meetings, reduces infection risks and may have the advantage of enabling faster access to clinical advice (Powell et al, 2020). However, concerns that health professional home visits would reduce has led to an increased focus on care provision by family members, including, potentially, the administration of end-of-life care medications (Antunes et al, 2020; Johnson et al, 2020). The pandemic has imposed massive stress on care resources, and the changes in healthcare service delivery after COVID-19 look set to be substantial (Antunes et al, 2020; Kasaraneni, 2020). New models of care delivery have also created opportunities for nurses supporting people in community settings to develop their role and skills.
Parents and carers’ experiences of seeking health information and support online for long-term physical childhood conditions: a systematic review and thematic synthesis of qualitative research
Objective: To systematically review and synthesise qualitative research exploring parents/carers’ experiences of seeking online information and support for long-term physical childhood conditions. Design: Systematic review and thematic synthesis of qualitative research. Data sources: Medline, CINAHL, Embase, PsycINFO and the International Bibliography of the Social Sciences were searched from inception to September 2019. We used thematic synthesis to analyse findings. Eligibility criteria: Primary research papers presenting qualitative data collection and analysis, focusing on parents/carers’ experiences of seeking health information and support from online resources for long-term physical childhood health conditions. No language restrictions were placed. Results: 23 studies from seven countries met inclusion criteria and were included in the synthesis. Included studies presented data collected through interviews/focus groups with 559 parents/carers; free-text surveys and essays with 26 parents/carers and 2407 messages from online support groups. Parents/carers developed a variety of strategies to obtain information and support online, based on personal preferences, appraisal of trustworthiness, perceived needs and previous experiences online. Many parents sought the benefits of online information and support, which included reassurance and validation from online communities, and feeling they had greater knowledge about their children’s conditions. Some concerns and perceived risks were discussed, which often stemmed from prior unsatisfactory experiences of seeking information and support online, consultations with health professionals and seeing distressing stories online. Conclusion: Most parents/carers were successful in obtaining information and support online. Many continued to share experiences with other parents/carers online. The need for information was particularly apparent early after diagnosis of the condition, whereas the need for peer support continued. The potential concerns and perceived risks with information and support online were especially apparent among parents/carers of children with life-limiting long-term conditions. Findings may be useful for health professionals to facilitate discussions regarding use of online resources, and researchers designing online health resources for parents/carers.
Parents and GPs’ understandings and beliefs about food allergy testing in children with eczema: qualitative interview study within the Trial of Eczema allergy Screening Tests (TEST) feasibility trial
Aim: To explore parent and general practitioner (GP) understanding and beliefs about food allergy testing for children with eczema. Design and setting: Qualitative interview study in UK primary care within the Trial of Eczema allergy Screening Tests feasibility trial. Participants: Semi-structured interviews with parents of children with eczema taking part in the feasibility study and GPs at practices hosting the study. Results: 21 parents and 11 GPs were interviewed. Parents discussed a range of potential causes for eczema, including a role for food allergy. They believed allergy testing to be beneficial as it could potentially identify a cure or help reduce symptoms and they found negative tests reassuring, suggesting to them that no dietary changes were needed. GPs reported limited experience and uncertainty regarding food allergy in children with eczema. While some GPs believed referral for allergy testing could be appropriate, most were unclear about its utility. They thought it should be reserved for children with severe eczema or complex problems but wanted more information to advise parents and help guide decision making. Conclusions: Parents’ motivations for allergy testing are driven by the desire to improve their child’s condition and exclude food allergy as a possible cause of symptoms. GPs are uncertain about the role of allergy testing and want more information about its usefulness to support parents and help inform decision making.
Association of socioeconomic deprivation with opioid prescribing in primary care in England: a spatial analysis
Background: The increasing trends in opioid prescribing and opioid-related deaths in England are concerning. A greater understanding of the association of deprivation with opioid prescribing is needed to guide policy responses and interventions. Methods: The 2018/2019 English national primary care prescribing data were analysed spatially. Prescribing of opioids in general practice was quantified by defined daily doses (DDD) and attributed to 32 844 lower layer super output areas (LSOAs), the geographical units representing ~1500 people. Linear regression was used to model the effect of socioeconomic deprivation (quintiles) on opioid prescribing while accounting for population demographics and the prevalence of specific health conditions. Adjusted DDD estimates were compared at each deprivation level within higher organisational areas (Clinical Commissioning Groups, CCGs). Results: In total, 624 411 164 DDDs of opioids were prescribed. LSOA-level prescribing varied between 1.7 and 121.04 DDD/1000 population/day. Prescribing in the most deprived areas in the North of England was 1.2 times higher than the national average for areas with similar deprivation levels and 3.3 times higher than the most deprived areas in London. Prescribing in the most deprived areas was on average 9.70 DDD/1000 people/day (95% CI 9.41 to 10.00) higher than the least deprived areas. Deprivation-driven disparities varied between individual CCGs. In the most unequal CCG, prescribing in the most deprived areas was twice that in the least deprived areas. Conclusion: Opioid prescribing varied substantially across England and deprivation was strongly associated with prescribing. This paper provides evidence for guiding policy interventions and allocation of resources to areas with the highest levels of opioid prescribing.
Treatment interventions to maintain abstinence from alcohol in primary care: systematic review and network meta-analysis
Objective: To determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care. Design: Systematic review and network meta-analysis. Data sources: Medline, Embase, PsycINFO, Cochrane CENTRAL, ClinicalTrials.gov, and the World Health Organization’s International Clinical Trials Registry Platform. Study selection: Randomised controlled trials comparing two or more interventions that could be used in primary care. The population was patients with alcohol dependency diagnosed by standardised clinical tools and who became detoxified within four weeks. Data extraction: Outcomes of interest were continuous abstinence from alcohol (effectiveness) and all cause dropouts (as a proxy for acceptability) at least 12 weeks after start of intervention. Results: 64 trials (43 interventions) were included. The median probability of abstinence across placebo arms was 25%. Compared with placebo, the only intervention associated with increased probability of abstinence and moderate certainty evidence was acamprosate (odds ratio 1.86, 95% confidence interval 1.49 to 2.33, corresponding to an absolute probability of 38%). Of the 62 included trials that reported all cause dropouts, interventions associated with a reduced number of dropouts compared with placebo (probability 50%) and moderate certainty of evidence were acamprosate (0.73, 0.62 to 0.86; 42%), naltrexone (0.70, 0.50 to 0.98; 41%), and acamprosate-naltrexone (0.30, 0.13 to 0.67; 17%). Acamprosate was the only intervention associated with moderate confidence in the evidence of effectiveness and acceptability up to 12 months. It is uncertain whether other interventions can help maintain abstinence and reduce dropouts because of low confidence in the evidence. Conclusions: Evidence is lacking for benefit from interventions that could be implemented in primary care settings for alcohol abstinence, other than for acamprosate. More evidence from high quality randomised controlled trials is needed, as are strategies using combined interventions (combinations of drug interventions or drug and psychosocial interventions) to improve treatment of alcohol dependency in primary care.
Postnatal checks and primary care consultations in the year following childbirth: an observational cohort study of 309573 women in the UK, 2006–2016
Objective: To describe women’s uptake of postnatal checks and primary care consultations in the year following childbirth. Design: Observational cohort study using electronic health records. Setting: UK primary care. Participants: Women aged 16–49 years who had given birth to a single live infant recorded in The Health Improvement Network (THIN) primary care database in 2006–2016. Main outcome measures: Postnatal checks and direct consultations in the year following childbirth. Results: We examined 1 427 710 consultations in 309 573 women who gave birth to 241 662 children in 2006–2016. Of these women, 78.7% (243 516) had a consultation at the time of the postnatal check, but only 56.2% (174 061) had a structured postnatal check documented. Teenage women (aged 16–19 years) were 12% less likely to have a postnatal check compared with those aged 30–35 years (incidence rate ratio (IRR) 0.88, 95%CI 0.85 to 0.91) and those living in the most deprived versus least deprived areas were 10% less likely (IRR 0.90, 95%CI 0.88 to 0.92). Women consulted on average 4.8 times per woman per year and 293 049 women (94.7%) had at least one direct consultation in the year after childbirth. Consultation rates were higher for those with a caesarean delivery (7.7 per woman per year, 95%CI 7.7 to 7.8). Consultation rates peaked during weeks 5–10 following birth (11.8 consultations/100 women) coinciding with the postnatal check. Conclusions: Two in 10 women did not have a consultation at the time of the postnatal check and four in 10 women have no record of receiving a structured postnatal check within the first 10 weeks after giving birth. Teenagers and those from the most deprived areas are among the least likely to have a check. We estimate up to 350 400 women per year in the UK may be missing these opportunities for timely health promotion and to have important health needs identified following childbirth
The role of digital health interventions as a resource for people with type 2 diabetes to develop self-care expertise, adapt to identity changes and influence how they are viewed by others: a qualitative study
Abstract Pre-Print Background: A diagnosis of type 2 diabetes (T2D) results in widespread changes to a person’s life and can be experienced as an assault on their sense of self. The resources available to an individual influences how they adapt to their diabetic identity and subsequently engage in self-care. Digital interventions can be viewed as a resource people can draw on to adapt to the diagnosis. However, there is an indication that people from disadvantaged groups find digital health technologies more challenging to access and use, which may increase health inequalities. Objective: To gain insights into how and why people with T2D use digital self-care technology and how experiences vary between individuals and social groups. Methods: A purposive sample of people who had used a digital intervention to help them self-care for their T2D. Semi-structured interviews were conducted and data were analysed thematically. Results: A diverse sample of 21 participants were interviewed. Participants used digital interventions to help them understand and feel more in control of their bodies. They used digital tools to project positive identities, and as a defence against the stigmatised diabetic identity. Some participants used technology to increase their sense of power in their interaction with clinicians, while others used technology to demonstrate their ‘good’ness. These benefits were not equally distributed. There was some indication that those who could afford to, purchased more expensive equipment. Privately purchased blood glucose monitors were more discrete than those provided on the NHS so were preferred by those who wanted to keep their condition hidden. Some attributed their success at keeping their diabetes under control to the purchase of more sophisticated and more expensive equipment. Conclusions: The technology people with T2D have access to shapes the way they are able to understand and control their bodies and support preferred social identities.
Relation between opioid consumption and inclusion of opioids in 137 national essential medicines lists
Introduction: Opioids are deemed essential medicines by the World Health Organization (WHO). However, many countries have inadequate access to them. Whether including opioids in national essential medicines lists (EMLs) influences national opioid consumption has not been evaluated. Methods: We conducted a cross-sectional study to determine whether the listing of opioids in national EMLs was associated with consumption. We quantified the numbers and types of all opioids included in 137 national EMLs, for comparison with opioids in the WHO’s Model List of Essential Medicines. Using the International Narcotics Control Board (INCB) consumption statistics for 2015–2017, we assessed the relation between annual mean opioid consumption (mg/person) and the numbers of opioids included in EMLs, controlling for region, population, healthcare expenditure, life expectancy, gross domestic product, human development and corruption. Results: Five opioids were included in the 20th edition of the WHO’s Model List of Essential Medicines: codeine, fentanyl, loperamide, methadone and morphine. On average, countries’ lists included significantly (p<0.05) more opioids than the WHO’s Model List. However, there were wide variations in the numbers (median 6 opioids; IQR: 5–9) and types (n=33) of opioids included in national EMLs. Morphine (95%), fentanyl (83%) and codeine (69%) were the most commonly included opioids. Most national EMLs were out of date (median publication date: 2011, IQR: 2009–2013). After adjusting for country characteristics, there was no relation between mean opioid consumption and the number of opioids in EMLs. Conclusions: Including opioids in national EMLs was not associated with consumption. National EMLs should be regularly updated to reflect the availability of opioids and the populations’ needs for managing pain.
Understanding the management of heart failure with preserved ejection fraction: a qualitative multiperspective study
Background About half of all people with heart failure have heart failure with preserved ejection fraction (HFpEF), in which the heart is stiff. This type of heart failure is more common in older people with a history of hypertension, obesity, and diabetes mellitus. Patients with HFpEF are often managed in primary care, sometimes in collaboration with specialists. Knowledge about how best to manage this growing population is limited, and there is a pressing need to improve care for these patients. Aim To explore clinicians’ and patients’/carers’ perspectives and experiences about the management of HFpEF to inform the development of an improved model of care. Design and setting: A multiperspective qualitative study involving primary and secondary care settings across the east of England, Greater Manchester, and the West Midlands. Method: Semi-structured interviews and focus groups were conducted. Transcribed data were analysed using framework analysis and informed by the normalisation process theory (NPT). Results: In total, 50 patients, nine carers/relatives, and 73 clinicians were recruited. Difficulties with diagnosis, unclear illness perceptions, and management disparity were identified as important factors that may influence management of HFpEF. The NPT construct of coherence reflected what participants expressed about the need to improve the identification, understanding, and awareness of this condition in order to improve care. Conclusion: There is a pressing need to raise the public and clinical profile of HFpEF, develop a clear set of accepted practices concerning its management, and ensure that systems of care are accessible and attuned to the needs of patients with this condition.
Use of hormone replacement therapy and risk of breast cancer: nested case-control studies using the QResearch and CPRD databases
Objective: To assess the risks of breast cancer associated with different types and durations of hormone replacement therapy (HRT). Design: Two nested case-control studies. Setting: UK general practices contributing to QResearch or Clinical Practice Research Datalink (CPRD), linked to hospital, mortality, social deprivation, and cancer registry (QResearch only) data. Participants: 98 611 women aged 50-79 with a primary diagnosis of breast cancer between 1998 and 2018, matched by age, general practice, and index date to 457 498 female controls. Main outcome measures: Breast cancer diagnosis from general practice, mortality, hospital, or cancer registry records. Odds ratios for HRT types, adjusted for personal characteristics, smoking status, alcohol consumption, comorbidities, family history, and other prescribed drugs. Separate results from QResearch or CPRD were combined. Results: Overall, 33 703 (34%) women with a diagnosis of breast cancer and 134 391 (31%) controls had used HRT prior to one year before the index date. Compared with never use, in recent users (<5 years) with long term use (≥5 years), oestrogen only therapy and combined oestrogen and progestogen therapy were both associated with increased risks of breast cancer (adjusted odds ratio 1.15 (95% confidence interval 1.09 to 1.21) and 1.79 (1.73 to 1.85), respectively). For combined progestogens, the increased risk was highest for norethisterone (1.88, 1.79 to 1.99) and lowest for dydrogesterone (1.24, 1.03 to 1.48). Past long term use of oestrogen only therapy and past short term (<5 years) use of oestrogen-progestogen were not associated with increased risk. The risk associated with past long term oestrogen-progestogen use, however, remained increased (1.16, 1.11 to 1.21). In recent oestrogen only users, between three (in younger women) and eight (in older women) extra cases per 10 000 women years would be expected, and in oestrogen-progestogen users between nine and 36 extra cases per 10 000 women years. For past oestrogen-progestogen users, the results would suggest between two and eight extra cases per 10 000 women years. Conclusion: This study has produced new generalisable estimates of the increased risks of breast cancer associated with use of different hormone replacement preparations in the UK. The levels of risks varied between types of HRT, with higher risks for combined treatments and for longer duration of use.
Performance and clinical utility of supervised machine-learning approaches in detecting familial hypercholesterolaemia in primary care
Familial hypercholesterolaemia (FH) is a common inherited disorder, causing lifelong elevated low-density lipoprotein cholesterol (LDL-C). Most individuals with FH remain undiagnosed, precluding opportunities to prevent premature heart disease and death. Some machine-learning approaches improve detection of FH in electronic health records, though clinical impact is under-explored. We assessed performance of an array of machine-learning approaches for enhancing detection of FH, and their clinical utility, within a large primary care population. A retrospective cohort study was done using routine primary care clinical records of 4,027,775 individuals from the United Kingdom with total cholesterol measured from 1 January 1999 to 25 June 2019. Predictive accuracy of five common machine-learning algorithms (logistic regression, random forest, gradient boosting machines, neural networks and ensemble learning) were assessed for detecting FH. Predictive accuracy was assessed by area under the receiver operating curves (AUC) and expected vs observed calibration slope; with clinical utility assessed by expected case-review workload and likelihood ratios. There were 7928 incident diagnoses of FH. In addition to known clinical features of FH (raised total cholesterol or LDL-C and family history of premature coronary heart disease), machine-learning (ML) algorithms identified features such as raised triglycerides which reduced the likelihood of FH. Apart from logistic regression (AUC, 0.81), all four other ML approaches had similarly high predictive accuracy (AUC > 0.89). Calibration slope ranged from 0.997 for gradient boosting machines to 1.857 for logistic regression. Among those screened, high probability cases requiring clinical review varied from 0.73% using ensemble learning to 10.16% using deep learning, but with positive predictive values of 15.5% and 2.8% respectively. Ensemble learning exhibited a dominant positive likelihood ratio (45.5) compared to all other ML models (7.0–14.4). Machine-learning models show similar high accuracy in detecting FH, offering opportunities to increase diagnosis. However, the clinical case-finding workload required for yield of cases will differ substantially between models.
Managing older people’s perceptions of alcohol-related risk: a qualitative exploration in Northern English primary care
Background: Risk of harm from drinking increases with age as alcohol affects health conditions and medications that are common in later life. Different types of information and experiences affect older people’s perceptions of alcohol’s effects, which must be navigated when supporting healthier decisions on alcohol consumption. Aim: To explore how older people understand the effects of alcohol on their health; and how these perspectives are navigated in supportive discussions in primary care to promote healthier alcohol use. Design and setting: A qualitative study consisting of semi-structured interviews and focus groups with older, non-dependent drinkers and primary care practitioners in Northern England. Method: A total of 24 older adults aged ≥65 years and 35 primary care practitioners participated in interviews and focus groups. Data were analysed thematically, applying principles of constant comparison. Results: Older adults were motivated to make changes to their alcohol use when they experienced symptoms, and if they felt that limiting consumption would enable them to maintain their quality of life. The results of alcohol-related screening were useful in providing insights into potential effects for individuals. Primary care practitioners motivated older people to make healthier decisions by highlighting individual risks of drinking, and potential gains of limiting intake. Conclusion: Later life is a time when older people may be open to making changes to their alcohol use, particularly when suggested by practitioners. Older people can struggle to recognise potential risks or perceive little gain in acting on perceived risks. Such perceptions may be challenging to navigate in supportive discussions.
Cross-sectional questionnaire study to gather the teaching preferences and expectations of UK undergraduate medical students for culinary medicine learning
Aim :To determine undergraduate medical students’ teaching preferences and expectations for Culinary Medicine (CM) learning with a view to informing development of a CM course at a UK medical school. Setting: A single, urban UK medical school. Participants: 180 undergraduate medical students. Study design: A cross-sectional questionnaire study collecting quantitative and qualitative (free-text) data. Methods and outcome measures: An online questionnaire consisting of 16 questions of various styles (Likert-type, multiple choice and free-text). Quantitative analysis of multiple choice and Likert-type scale questions was conducted. Qualitative thematic analysis was used to analyse the free-text responses and identify themes. Results: Three core themes related to students’ understanding of CM were identified: (1) ‘CM Learning’: students’ perceived relevance of CM knowledge, perceived relevance of CM to healthcare and their expectations for teaching; (2) ‘The Relationship between Food and Health’: links between diet, social factors and health; and (3) ‘Evidence-based Medicine’: students’ perceptions about scientific principles underlying CM. Quantitative analysis revealed that, although 83% of students felt that learning CM is important for their future clinical practice, 56% felt unable to take a dietary history. 73% of students were dissatisfied with the quality, and 78% were dissatisfied with the quantity, of existing medical school teaching understood to be relevant to CM. Topics that students would like to be taught on a CM course included weight management and portion control. Students felt that problem-based style learning would be the most appropriate method for delivering CM teaching. Conclusions: This study revealed that medical students felt their dietary counsulting skills could be improved with further clinically relevant teaching in the undergraduate medical curriculum. Students’ preferences for CM learning have been taken into consideration in the development of a CM course for fifth-year undergraduate students at a UK medical school, which is delivered during their General Practice placement.