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Predicting major adverse cardiovascular events for secondary prevention: protocol for a systematic review and meta-analysis of risk prediction models.
Introduction Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally. With advances in early diagnosis and treatment of CVD and increasing life expectancy, more people are surviving initial CVD events. However, models for stratifying disease severity risk in patients with established CVD for effective secondary prevention strategies are inadequate. Multivariable prognostic models to stratify CVD risk may allow personalised treatment interventions. This review aims to systematically review the existing multivariable prognostic models for the recurrence of CVD or major adverse cardiovascular events in adults with established CVD diagnosis. Methods and analysis Bibliographic databases (Ovid MEDLINE, EMBASE, PsycINFO and Web of Science) will be searched, from database inception to April 2020, using terms relating to the clinical area and prognosis. A hand search of the reference lists of included studies will also be done to identify additional published studies. No restrictions on language of publications will be applied. Eligible studies present multivariable models (derived or validated) of adults (aged 16 years and over) with an established diagnosis of CVD, reporting at least one of the components of the primary outcome of major adverse cardiovascular events (defined as either coronary heart disease, stroke, peripheral artery disease, heart failure or CVD-related mortality). Reviewing will be done by two reviewers independently using the pre-defined criteria. Data will be extracted for included full-text articles. Risk of bias will be assessed using the Prediction model study Risk Of Bias ASsessment Tool (PROBAST). Prognostic models will be summarised narratively. If a model is tested in multiple validation studies, the predictive performance will be summarised using a random-effects meta-analysis model to account for any between-study heterogeneity. Ethics and dissemination Ethics approval is not required. The results of this study will be submitted to relevant conferences for presentation and a peer-reviewed journal for publication.
Self-management interventions to reduce healthcare use and improve quality of life among patients with asthma: systematic review and network meta-analysis
Objective: To compare the different self-management models (multidisciplinary case management, regularly supported self-management, and minimally supported self-management) and self-monitoring models against usual care and education to determine which are most effective at reducing healthcare use and improving quality of life in asthma. Design: Systematic review and network meta-analysis. Data sources: Medline, the Cochrane Library, CINAHL, EconLit, Embase, Health Economics Evaluations Database, NHS Economic Evaluation Database, PsycINFO, and ClinicalTrials.gov from January 2000 to April 2019. Review methods: Randomised controlled trials involving the different self-management models for asthma were included. The primary outcomes were healthcare use (hospital admission or emergency visit) and quality of life. Summary standardised mean differences (SMDs) and 95% credible intervals were estimated using bayesian network meta-analysis with random effects. Heterogeneity and publication bias were assessed. Results: From 1178 citations, 105 trials comprising 27 767 participants were included. In terms of healthcare use, both multidisciplinary case management (SMD –0.18, 95% credible interval −0.32 to −0.05) and regularly supported self-management (–0.30, −0.46 to −0.15) were significantly better than usual care. For quality of life, only regularly supported self-management (SMD 0.54, 0.11 to 0.96) showed a statistically significant benefit compared with usual care. For trials including adolescents/children (age 5-18 years), only regularly supported self-management showed statistically significant benefits (healthcare use: SMD –0.21, −0.40 to −0.03; quality of life: 0.23, 0.03 to 0.48). Multidisciplinary case management (SMD –0.32, −0.50 to −0.16) and regularly supported self-management (–0.32, −0.53 to −0.11) were most effective at reducing healthcare use in patients with symptoms of severe asthma at baseline. Conclusions: This network meta-analysis indicates that regularly supported self-management reduces the use of healthcare resources and improves quality of life across all levels of asthma severity. Future healthcare investments should provide support that offer reviews totalling at least two hours to establish self-management skills, reserving multidisciplinary case management for patients with complex disease.
Associations of the systolic and diastolic components of orthostatic hypotension with markers of cardiovascular risk in older men: A cross‐sectional analysis from The British Regional Heart Study
The mechanisms underlying the association between orthostatic hypotension (OH) and cardiovascular disease are unclear. We investigated whether OH is associated with circulating cardiovascular risk markers. This was a cross‐sectional analysis of 3857 older, community‐dwelling men. “Consensus OH” was defined as a sitting‐to‐standing decrease in systolic blood pressure ≥20 mm Hg and/or diastolic blood pressure ≥10 mm Hg that occurred within three minutes of standing. Multiple generalized linear regression and logistic models were used to examine the association between cardiovascular risk markers and OH. Consensus OH was present in 20.2%, consisting of isolated systolic OH in 12.6%, isolated diastolic OH in 4.6%, and combined systolic and diastolic OH in 3.0%. Concentration of von Willebrand factor, a marker of endothelial dysfunction, was positively associated with isolated systolic OH (OR 1.35, 95% CI 1.05‐1.73) and combined systolic and diastolic OH (OR 2.27, 95% CI 1.35‐3.83); high circulating phosphate concentration, which may reflect vascular calcification, was associated with isolated diastolic OH (OR 1.53, 95% CI 1.04‐2.25) and combined systolic and diastolic OH (OR 2.12, 95% CI 1.31‐3.44), high‐sensitivity troponin T, a marker of myocardial injury, was positively associated with isolated diastolic OH (OR 1.69, 95% CI 1.07‐2.65) and N‐terminal pro‐brain natriuretic peptide, a marker of cardiac stress, was positively associated with combined systolic and diastolic OH (OR 2.14, 95% CI 1.14‐4.03). In conclusion, OH is associated with some cardiovascular risk markers implicated in endothelial dysfunction, vascular calcification, myocardial injury, and cardiac stress. Clinicians should consider assessing cardiovascular risk in patients with OH.
Relational continuity and patients’ perception of GP trust and respect: a qualitative study
Background: Despite the benefits of relational continuity of care, particularly for patients with multimorbidity, the traditional model of continuity is changing. Revisiting what patients with ongoing problems want from relational continuity could encourage initiatives to achieve these within a modern healthcare system. Aim: To examine the attributes of GPs that patients with long-term conditions value most, and which attributes patients believe are facilitated by relational continuity. Design and setting: Qualitative study in UK general practice. Method: A thematic analysis was carried out, based on secondary analysis of interviews with 25 patients with long-term conditions that were originally conducted to inform a patient-reported outcome measure for primary care. Results: Patients with long-term conditions wanted their GPs to be clinically competent, to examine, listen to, care for, and take time with them, irrespective of whether they have seen them before. They believed that relational continuity facilitates a GP knowing their history, giving consistent advice, taking responsibility and action, and trusting and respecting them. Patients acknowledged practical difficulties and safety issues in achieving the first three of these without relational continuity. However, patients felt that GPs should trust and respect them even when continuity was not possible. Conclusion: Policy initiatives promoting continuity with a GP or healthcare team should continue. Many patients see continuity as a safety issue. When patients experience relationship discontinuity, they often feel that they are not taken seriously or believed by their GP. GPs should therefore consistently seek to visibly demonstrate trust in their patients, particularly when they have not seen them before.
Longitudinal clusters of pain and stiffness in polymyalgia rheumatica: 2-year results from the PMR Cohort Study
Objectives: To investigate potential subgroups of primary care–diagnosed patients with PMR based on self-reported pain and stiffness severity over time. Methods: A total of 652 people with an incident PMR diagnosis were recruited from English general practices and completed a baseline postal questionnaire. They were followed up with a further six questionnaires over a 2 year period. A total of 446 people completed the 2 year follow-up. Pain and stiffness were reported on a 0–10 numerical rating scale. Latent class growth analysis was used to estimate the joint trajectories of pain and stiffness over time. A combination of statistical and clinical considerations was used to choose the number of clusters. Characteristics of the classes were described. Results: Five clusters were identified. One cluster represented the profile of ‘classical’ PMR symptoms and one represented sustained symptoms that may not be PMR. The other three clusters displayed a partial recovery, a recovery followed by worsening and a slow, but sustained recovery. Those displaying classical PMR symptoms were in better overall health at diagnosis than the other groups. Conclusion: PMR is a heterogeneous condition, with a number of phenotypes. The spectrum of presentation, as well as varying responses to treatment, may be related to underlying health status at diagnosis. Future research should seek to stratify patients at diagnosis to identify those likely to have a poor recovery and in need of an alternative treatment pathway. Clinicians should be aware of the different experiences of patients and monitor symptoms closely, even where there is initial improvement.
Should zinc be used for COVID-19 prophylaxis or treatment? A rapid review [version 1; peer review: awaiting peer review]
Background: There have been intensive efforts worldwide to establish effective treatments for coronavirus disease 2019 (COVID-19), with recent interest in the use of zinc as a potential therapeutic agent. The aim of this rapid review was therefore to critically appraise and evaluate the evidence for using zinc as prophylaxis and/or treatment for COVID-19. Methods: We conducted electronic searches on 20th and 21st May 2020 of PubMed, TRIP, EPPI COVID Living Map, MedRxiv, Google Scholar and Google. All searches were updated on 11th July 2020 to check for new relevant studies. We included in vivo studies assessing the safety and effectiveness of zinc, alone or combined with other interventions, as treatment or prophylaxis for COVID-19. Studies assessing the activity of zinc against SARS-CoV-2 in vitro were also included. Results: We identified one observational study with a high risk of bias that was suitable for inclusion. The study authors found that treatment with a combination of zinc, azithromycin and hydroxychloroquine in patients hospitalised with COVID-19 resulted in increased odds of being discharged home (adjusted odds ratio (OR) 1.53; 95% CI 1.12 to 2.09; p = 0.008) and reduced odds of death or being transferred to a hospice (adjusted OR 0.559; 95% CI 0.385 to 0.811; p = 0.002), compared with treatment with hydroxychloroquine and azithromycin. Conclusions: We identified extremely limited evidence from a study with methodological problems of an association between improvement in certain outcomes when COVID-19 patients are treated with a combination of zinc, hydroxychloroquine and azithromycin, compared with treatment with hydroxychloroquine and azithromycin. The results of randomised clinical trials in this area should provide robust evidence of the effectiveness of zinc as treatment/prophylaxis for COVID-19.
Identifying and managing care for children with autism spectrum disorders in general practice: A systematic review and narrative synthesis
Many healthcare systems are organised such that General Practitioners (GPs) often have a key role in identifying autism spectrum disorders (hereafter collectively referred to as autism) in children. In this review, we explored what GPs know about autism and the factors that influence their ability to identify and manage care for their patients with autism in practice. We conducted a systematic narrative review using eight electronic databases. These included Embase and MEDLINE via Ovid, Web of Knowledge, PsycINFO via Ebscohost, PubMed, Scopus, ProQuest Dissertations and Thesis, and Applied Social Sciences Index and Abstracts (ASSIA) via ProQuest. Our search yielded 2,743 citations. Primary research studies were included, and we did not impose any geographical, language or date restrictions. We identified 17 studies that met our inclusion criteria. Studies included in the review were conducted between 2003 and 2019. We thematically synthesised the material and identified the following themes: the prototypical image of a child with autism; experience, sources of information, and managing care; barriers to identification; strategies to aid in identification; and characteristics that facilitate expertise . Together, the findings from this review present a mixed picture of GP knowledge and experiences in identifying autism and managing care for children with the condition. At one end of the continuum, there were GPs who had not heard of autism or endorsed outmoded aetiological theories. Others, however, demonstrated a sound knowledge of the conditions but had limited confidence in their ability to identify the condition. Many GPs and researchers alike called for more training and this might be effective. However, framing the problem as one of a lack of training risks silences the array of organisational factors that impact on a GP's ability to provide care for these patients.
Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis
The risks of harms from opioids increase substantially at high doses, and high-dose prescribing has increased in primary care. However, little is known about what leads to high-dose prescribing, and studies exploring this have not been synthesized. We, therefore, systematically synthesized factors associated with the prescribing of high-dose opioids in primary care. Methods: We conducted a systematic review of observational studies in high-income countries that used patient-level primary care data and explored any factor(s) in people for whom opioids were prescribed, stratified by oral morphine equivalents (OME). We defined high doses as ≥ 90 OME mg/day. We searched MEDLINE, Embase, Web of Science, reference lists, forward citations, and conference proceedings from database inception to 5 April 2019. Two investigators independently screened studies, extracted data, and appraised the quality of included studies using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. We pooled data on factors using random effects meta-analyses and reported relative risks (RR) or mean differences with 95% confidence intervals (CI) where appropriate. We also performed a number needed to harm (NNTH) calculation on factors when applicable. Results: We included six studies with a total of 4,248,119 participants taking opioids, of whom 3.64% (n = 154,749) were taking high doses. The majority of included studies (n = 4) were conducted in the USA, one in Australia and one in the UK. The largest study (n = 4,046,275) was from the USA. Included studies were graded as having fair to good quality evidence. The co-prescription of benzodiazepines (RR 3.27, 95% CI 1.32 to 8.13, I2 = 99.9%), depression (RR 1.38, 95% CI 1.27 to 1.51, I2 = 0%), emergency department visits (RR 1.53, 95% CI 1.46 to 1.61, I2 = 0%, NNTH 15, 95% CI 12 to 20), unemployment (RR 1.44, 95% CI 1.27 to 1.63, I2 = 0%), and male gender (RR 1.21, 95% CI 1.14 to 1.28, I2 = 78.6%) were significantly associated with the prescribing of high-dose opioids in primary care. Conclusions: High doses of opioids are associated with greater risks of harms. Associated factors such as the co-prescription of benzodiazepines and depression identify priority areas that should be considered when selecting, identifying, and managing people taking high-dose opioids in primary care. Coordinated strategies and services that promote the safe prescribing of opioids are needed.
Research priorities in advanced heart failure: James Lind alliance priority setting partnership
Objective: To determine research priorities in advanced heart failure (HF) for patients, carers and healthcare professionals. Methods: Priority setting partnership using the systematic James Lind Alliance method for ranking and setting research priorities. An initial open survey of patients, carers and healthcare professionals identified respondents’ questions, which were categorised to produce a list of summary research questions; questions already answered in existing literature were removed. In a second survey of patients, carers and healthcare professionals, respondents ranked the summary research questions in order of priority. The top 25 unanswered research priorities were then considered at a face-to-face workshop using nominal group technique to agree on a ‘top 10’. Results: 192 respondents submitted 489 responses each containing one or more research uncertainty. Out-of-scope questions (35) were removed, and collating the responses produced 80 summary questions. Questions already answered in the literature (15) were removed. In the second survey, 65 questions were ranked by 128 respondents. The top 10 priorities were developed at a consensus meeting of stakeholders and included a focus on quality of life, psychological support, the impact on carers, role of the charity sector and managing prognostic uncertainty. Ranked priorities by physicians and patients were remarkably divergent. Conclusions: Engaging stakeholders in setting research priorities led to a novel set of research questions that might not have otherwise been considered. These priorities can be used by researchers and funders to direct future research towards the areas which matter most to people living with advanced HF.
Editorial: Context, context, context: how has covid-19 changed implementation globally and how can we ‘lock in’ learning?
In our recent editorial [1] 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’ [2]) 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.
Anticipatory prescribing in community end-of-life care in the UK and Ireland during the COVID-19 pandemic: online survey
Background: Anticipatory prescribing (AP) of injectable medications in advance of clinical need is established practice in community end-of-life care. Changes to prescribing guidelines and practice have been reported during the COVID-19 pandemic. Aims and objectives: To investigate UK and Ireland clinicians’ experiences concerning changes in AP during the COVID-19 pandemic and their recommendations for change. Methods: Online survey of participants at previous AP national workshops, members of the Association for Palliative Medicine of Great Britain and Ireland and other professional organisations, with snowball sampling. Results: Two hundred and sixty-one replies were received between 9 and 19 April 2020 from clinicians in community, hospice and hospital settings across all areas of the UK and Ireland. Changes to AP local guidance and practice were reported: route of administration (47%), drugs prescribed (38%), total quantities prescribed (35%), doses and ranges (29%). Concerns over shortages of nurses and doctors to administer subcutaneous injections led 37% to consider drug administration by family or social caregivers, often by buccal, sublingual and transdermal routes. Clinical contact and patient assessment were more often remote via telephone or video (63%). Recommendations for regulatory changes to permit drug repurposing and easier community access were made. Conclusions: The challenges of the COVID-19 pandemic for UK community palliative care has stimulated rapid innovation in AP. The extent to which these are implemented and their clinical efficacy need further examination.
Arriving or departing: Primary Care Annual Scientific Meeting
From 3–5 July we attended the Society of Academic Primary Care (SAPC)’s annual scientific meeting (ASM), held at the University of Exeter. SAPC aims to advance primary care through education and research, and their stated goal is ‘to promote understanding of primary care - what it is and why it matters, and why academic primary care is an essential component of strong primary care’. This year’s conference theme was ‘Primary Care: Arriving? Or Departing?’ We are all aware of the challenges facing primary care, with changing socio-demographic population profiles, increased demand, decreased funding and challenges recruiting and retaining a dynamic, motivated workforce. As such, high-quality research is needed to provide evidence to address these challenges and shape the future of primary care. The conference programme reflected this issue, covering a range of research informing the design and delivery of high-quality clinical care as well as addressing organisational and behavioural aspects of primary care service development and delivery. The conference was opened in style by Ukrainian-born international opera singer Irtna Ilnytska, administration assistant at the University of Exeter and graduate of the Academy of Music, Milan; a reminder of how the UK benefits from the diverse talents of international workers. The conference included 128 oral presentations, specialist interest group meetings (https://sapc.ac.uk/special-interest-groups) and workshops, allowing attendees to personalise a programme most relevant for them.
Impact of emergency hospital admissions on patterns of primary care prescribing: a retrospective cohort analysis of electronic records in England
Background: Little is known about the impact of hospitalisation on prescribing in UK clinical practice. Aim: To investigate whether an emergency hospital admission drives increases in polypharmacy and potentially inappropriate prescriptions (PIPs). Design and setting: A retrospective cohort analysis set in primary and secondary care in England. Method: Changes in number of prescriptions and PIPs following an emergency hospital admission in 2014 (at admission and 4 weeks post-discharge), and 6 months post-discharge were calculated among 37 761 adult patients. Regression models were used to investigate changes in prescribing following an admission. Results: Emergency attendees surviving 6 months (N = 32 657) had a mean of 4.4 (standard deviation [SD] = 4.6) prescriptions before admission, and a mean of 4.7 (SD = 4.7; P<0.001) 4 weeks after discharge. Small increases (<0.5) in the number of prescriptions at 4 weeks were observed across most hospital specialties, except for surgery (−0.02; SD = 0.65) and cardiology (2.1; SD = 2.6). The amount of PIPs increased after hospitalisation; 4.0% of patients had ≥1 PIP immediately before pre-admission, increasing to 8.0% 4 weeks post-discharge. Across hospital specialties, increases in the proportion of patients with a PIP ranged from 2.1% in obstetrics and gynaecology to 8.0% in cardiology. Patients were, on average, prescribed fewer medicines at 6 months compared with 4 weeks post-discharge (mean = 4.1; SD = 4.6; P<0.001). PIPs decreased to 5.4% (n = 1751) of patients. Conclusion: Perceptions that hospitalisation is a consistent factor driving rises in polypharmacy are unfounded. Increases in prescribing post-hospitalisation reflect appropriate clinical response to acute illness, whereas decreases are more likely in patients who are multimorbid, reflecting a focus on deprescribing and medicines optimisation in these individuals. Increases in PIPs remain a concern.
Delegating home visits in general practice: a realist review on the impact on GP workload and patient care
Background UK general practice is being shaped by new ways of working. Traditional GP tasks are being delegated to other staff with the intention of reducing GPs’ workload and hospital admissions, and improving patients’ access to care. One such task is patient-requested home visits. However, it is unclear what impact delegated home visits may have, who might benefit, and under what circumstances. Aim To explore how the process of delegating home visits works, for whom, and in what contexts. Design and setting A review of secondary data on home visit delegation processes in UK primary care settings. Method A realist approach was taken to reviewing data, which aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes. A range of data has been used including news items, grey literature, and academic articles. Results Data were synthesised from 70 documents. GPs may believe that delegating home visits is a risky option unless they have trust and experience with the wider multidisciplinary team. Internal systems such as technological infrastructure might help or hinder the delegation process. Healthcare professionals carrying out delegated home visits might benefit from being integrated into general practice but may feel that their clinical autonomy is limited by the delegation process. Patients report short-term satisfaction when visited by a healthcare professional other than a GP. The impact this has on long-term health outcomes and cost is less clear. Conclusion The delegation of home visits may require a shift in patient expectation about who undertakes care. Professional expectations may also require a shift, having implications for the balance of staffing between primary and secondary care, and the training of healthcare professionals.
Antimicrobial resistance associations with national primary care antibiotic stewardship policy: Primary care-based, multilevel analytic study
Background: Recent UK antibiotic stewardship policies have resulted in significant changes in primary care dispensing, but whether this has impacted antimicrobial resistance is unknown. Aim: To evaluate associations between changes in primary care dispensing and antimicrobial resistance in community-acquired urinary Escherichia coli infections. Methods: Multilevel logistic regression modelling investigating relationships between primary care practice level antibiotic dispensing for approximately 1.5 million patients in South West England and resistance in 152,704 community-acquired urinary E. coli between 2013 and 2016. Relationships presented for within and subsequent quarter drug-bug pairs, adjusted for patient age, deprivation, and rurality. Results: In line with national trends, overall antibiotic dispensing per 1000 registered patients fell 11%. Amoxicillin fell 14%, cefalexin 20%, ciprofloxacin 24%, co-amoxiclav 49% and trimethoprim 8%. Nitrofurantoin increased 7%. Antibiotic reductions were associated with reduced within quarter same-antibiotic resistance to: amoxicillin, ciprofloxacin and trimethoprim. Subsequent quarter reduced resistance was observed for trimethoprim and amoxicillin. Antibiotic dispensing reductions were associated with increased within and subsequent quarter resistance to cefalexin and co-amoxiclav. Increased nitrofurantoin dispensing was associated with reduced within and subsequent quarter trimethoprim resistance without affecting nitrofurantoin resistance. Conclusions: This evaluation of a national primary care stewardship policy on antimicrobial resistance in the community suggests both hoped-for benefits and unexpected harms. Some increase in resistance to cefalexin and co-amoxiclav could result from residual confounding. Randomised controlled trials are urgently required to investigate causality.
Contribution of paramedics in primary and urgent care: a systematic review
Background: Within the UK, there are now opportunities for paramedics to work across a variety of healthcare settings away from their traditional ambulance service employer, with many opting to move into primary care. Aim: To provide an overview of the types of clinical roles paramedics are undertaking in primary and urgent care settings within the UK. Design and setting: A systematic review. Method: Searches were conducted of MEDLINE, CINAHL, Embase, the National Institute for Health and Care Excellence, the Journal of Paramedic Practice, and the Cochrane Database from January 2004 to March 2019 for papers detailing the role, scope of practice, clinician and patient satisfaction, and costs of paramedics in primary and urgent care settings. Free-text keywords and subject headings focused on two key concepts: paramedic and general practice/primary care. Results: In total, 6765 references were screened by title and/or abstract. After full-text review, 24 studies were included. Key findings focused on the description of the clinical role, the clinical work environment, the contribution of paramedics to the primary care workforce, the clinical activities they undertook, patient satisfaction, and education and training for paramedics moving from the ambulance service into primary care. Conclusion: Current published research identifies that the role of the paramedic working in primary and urgent care is being advocated and implemented across the UK; however, there is insufficient detail regarding the clinical contribution of paramedics in these clinical settings. More research needs to be done to determine how, why, and in what context paramedics are now working in primary and urgent care, and what their overall contribution is to the primary care workforce.
Development and validation of the DIabetes Severity SCOre (DISSCO) in 139 626 individuals with type 2 diabetes: a retrospective cohort study
Objective: Clinically applicable diabetes severity measures are lacking, with no previous studies comparing their predictive value with glycated hemoglobin (HbA1c). We developed and validated a type 2 diabetes severity score (the DIabetes Severity SCOre, DISSCO) and evaluated its association with risks of hospitalization and mortality, assessing its additional risk information to sociodemographic factors and HbA1c. Research design and methods: We used UK primary and secondary care data for 139 626 individuals with type 2 diabetes between 2007 and 2017, aged ≥35 years, and registered in general practices in England. The study cohort was randomly divided into a training cohort (n=111 748, 80%) to develop the severity tool and a validation cohort (n=27 878). We developed baseline and longitudinal severity scores using 34 diabetes-related domains. Cox regression models (adjusted for age, gender, ethnicity, deprivation, and HbA1c) were used for primary (all-cause mortality) and secondary (hospitalization due to any cause, diabetes, hypoglycemia, or cardiovascular disease or procedures) outcomes. Likelihood ratio (LR) tests were fitted to assess the significance of adding DISSCO to the sociodemographics and HbA1c models. Results: A total of 139 626 patients registered in 400 general practices, aged 63±12 years were included, 45% of whom were women, 83% were White, and 18% were from deprived areas. The mean baseline severity score was 1.3±2.0. Overall, 27 362 (20%) people died and 99 951 (72%) had ≥1 hospitalization. In the training cohort, a one-unit increase in baseline DISSCO was associated with higher hazard of mortality (HR: 1.14, 95% CI 1.13 to 1.15, area under the receiver operating characteristics curve (AUROC)=0.76) and cardiovascular hospitalization (HR: 1.45, 95% CI 1.43 to 1.46, AUROC=0.73). The LR tests showed that adding DISSCO to sociodemographic variables significantly improved the predictive value of survival models, outperforming the added value of HbA1c for all outcomes. Findings were consistent in the validation cohort. Conclusions: Higher levels of DISSCO are associated with higher risks for hospital admissions and mortality. The new severity score had higher predictive value than the proxy used in clinical practice, HbA1c. This reproducible algorithm can help practitioners stratify clinical care of patients with type 2 diabetes.
Exploring how health behaviours are supported and changed in people with severe mental illness: A qualitative study of a cardiovascular risk reducing intervention in Primary Care in England
Objectives: This study explored how health behaviours were supported and changed in people with severe mental illness by primary health care professionals trained in delivering behaviour change techniques (BCTs) within a cardiovascular disease risk reducing intervention. Design: Secondary qualitative analysis of 30 staff and patient interviews. Methods: We mapped coded data to the BCT Taxonomy (version 1) to identify BCT application. Thematic analysis was conducted to explore the barriers and facilitators of supporting and changing health behaviours. Themes were then interpreted using the Capability, Opportunity, Motivation, and Behaviour model to gain greater explanation behind the processes. Results: Twenty BCTs were identified. Staff and patients perceived that health behaviours were commonly affected by both automatic and reflective motivation, sometimes in turn affected by psychological capability, social, and physical opportunity. Staff and patients suggested that motivation was enhanced by both patient and staff ability to observe health benefits, in some cases patients’ health knowledge, mental health status, and social support networks. It was suggested that engaging in/sustaining healthy behaviours was influenced by physical opportunities to engrain behaviours into routine. Conclusions: According to staff and patients, health behaviour change in this population was driven by complex processes. It was suggested that capability, opportunity, and motivation were in some cases enhanced by BCTs, but variable. Behaviour change may be optimized by individualized behavioural assessments, identifying drivers of behaviour and applying a range of BCTs may help to target individual needs. Patient peer‐led approaches, techniques to encourage awareness of visible success, and normalizing health behaviours may increase behaviour change.
Patient and public involvement in general practice research
Patient and public involvement (PPI) in research has become expected practice by funders and Research Ethics Committees (RECs).1–3 Working with public contributors from the outset in designing and undertaking patient-related research aims to ensure that the focus is relevant to, and grounded in, their lived experiences.4 Despite sustained UK research policy advocating the importance of PPI,3 public contributions are often absent or minimal in reports of primary care research.5 In this patient perspectives edition of the BJGP, only two papers report on public contributions to the design and execution of the research.6,7 When PPI input is described, research reports are rarely specific about the input of public contributors along the way; how their concerns, reviews, suggestions, and objections have actually shaped or changed the course of the research.1,4,8 PPI work often remains a ‘black box’. This editorial makes the case that meaningful PPI makes a positive contribution, but the nature and content of PPI work need to be transparent and appropriate. PPI collaboration in research is time consuming and more problematic for both public contributors and researchers than best-practice guidelines suggest.4,9 The reasons why general practice research is not designed and undertaken with public contributors are numerous, including insufficient resources and a desire to avoid complicating a project.2,8 We draw on our experience as three researchers and one PPI group member to highlight some of the key challenges and practicalities involved.
Administration of end-of-life drugs by family caregivers during covid-19 pandemic
Doctors, nurses, and family caregivers worldwide are facing tough decisions concerning the supply and administration of medications to manage symptoms when patients are dying from covid-19 or other conditions in the community or care homes. Proposed changes in practice aimed at ensuring adequate end-of-life symptom control need careful consideration alongside appropriate training and support. Editorial Updated UK advice, including NICE rapid guidance on managing covid-19 symptoms in the community, reiterates the importance of prescribing medications in advance of need for pain, nausea and vomiting, agitation, and respiratory secretions.These drugs may be administered if needed by visiting doctors or nurses, as is already well established in some countries. However, this practice is being overhauled radically in response to the pandemic.
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To mark Mental Health Awareness Week 2025, the NIHR School for Primary Care Research (SPCR) is highlighting some projects that demonstrate the power of community in supporting mental health and wellbeing.
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The Primary Care Academic CollaboraTive (PACT) has published its Summary & Impact Report 2019–2024, highlighting five years of collaborative research achievements supported by the NIHR School for Primary Care Research (SPCR).