Increasing the uptake of cervical screening at cornerstone medical practice

BackgroundNationally, cervical screening uptake is suboptimal, even though research shows that the programme is highly effective at preventing cervical cancer.Local problemCornerstone is a small practice located in Salford in the North West of England. Historically, screening uptake here has been lower than average. There were 656 eligible women on our practice list and 177 of them were unscreened at the start of the project. The largest group of non-white British or Irish people on our list (13) spoke Polish as their first language.MethodsWe used quality improvement methods: the model for improvement, a driver diagram and Plan, Do, Study, Act cycles. Specifically, we targeted 177 women who were previously non-responders, as well as keeping up the regular screening service. We managed to contact 120 women during the project.InterventionsWe tested different methods of inviting women to attend cervical screening: telephone calls, text messages and letters. Later, a video link was also included in the text invitation. Information leaflets about the tests were added to letters. The letter was also translated into Polish.ResultsUptake improved and the aim was reached. Telephone calls from the nurse increased uptake but took time away from other work, so was not a sustainable change for our practice. A letter stating evidence basis for the test, and a letter translated into Polish showed limited improvement. Sending letters with information leaflets and text messages with video links achieved similar response rates with no statistical significance when we analysed the data. Offering extended hours and flexible appointment times showed very positive results.ConclusionsThe text message with a video attached was adopted as an effective method for targeting persistent non-responders.The project in its second year is being scaled up across the Primary Care Network.

Liothyronine and Levothyroxine Prescribing in England: A Comprehensive Survey and Evaluation

Introduction: The approach to thyroid hormone replacement varies across centres but the extent and determinants of variation is unclear. We evaluated geographical variation in levothyroxine (LT4) and liothyronine (LT3) prescribing across General Practices in England and analysed the relationship of prescribing patterns to clinical and socioeconomic factors. Methods: Data was downloaded from the NHS monthly General Practice Prescribing Data in England for the period 2011-2020. Results Overall, 0.5% of levothyroxine treated patients continue to receive liothyronine. All Clinical Commission Groups (CCGs) in England continue to have at least one liothyronine prescribing practice and 48.5% of English general practices prescribed liothyronine in 2019-20. Factors strongly influencing more levothyroxine prescribing (model accounted for 62% of variance) were the CCG to which the practice belonged and the proportion of people with diabetes registered on the practice list plus antidepressant prescribing, with socioeconomic disadvantage associated with less levothyroxine prescribing. For liothyronine prescribing (model accounted for 17% of variance), factors that were associated with increased levels of liothyronine prescribing were antidepressant prescribing and % of type 2 diabetes mellitus individuals achieving HbA1c control of 58mmol/mol or less. Factors that were associated with reduced levels of liothyronine prescribing included smoking and higher obesity rates. Conclusion: In spite of strenuous attempts to limit prescribing of liothyronine in general practice a significant number of patients continue to receive this therapy, although there is significant geographical variation in the prescribing of this as for levothyroxine, with specific general practice and CCG related factors influencing prescribing of both levothyroxine and liothyronine.

Associations between socioeconomic deprivation and pharmaceutical prescribing in primary care in England

BackgroundSocioeconomic deprivation is associated with health inequality. Previous studies have described associations between primary care prescribing rates and deprivation for individual drugs or drug classes. We explore the correlation between socioeconomic deprivation and the rate of prescribing of individual pharmaceutical drugs, and drug classes, in primary care in England, to identify prescribing inequalities that would require further investigation.MethodsIn this cross-sectional study, national primary care prescribing data, by primary care practice, were retrieved for the calendar year 2019 in England. Socioeconomic deprivation was quantified using the Index of Multiple Deprivation (IMD) score. Correlations were calculated using Spearman’s rank correlation coefficient (ρ), adjusting for practice list size and demographics, with a Bonferroni-corrected p value threshold of 5×10–5.ResultsWe included 1.05 billion prescription items dispensed from 6896 England practices. 142/206 (69%) drug classes and 505/774 (65%) drugs were significantly correlated with IMD score (p<5×10−5). Of the 774 included drugs, 31 (4%) were moderately positively associated with IMD score (ρ>0.4). Only one was moderately negatively correlated with IMD score (ρ<−0.4), suggesting higher prescribing rates in more affluent areas. The drug classes most strongly associated with IMD score included opioid and non-opioid analgesics, antipsychotics and reflux medications. Drug classes most strongly associated with affluence included epinephrine, combined oral contraceptives and hormone replacement therapy.ConclusionWe identify novel associations of prescribing with deprivation. Further work is required to identify the underlying reasons for these associations so that appropriate interventions can be formulated to address drivers of inequality.

Socioeconomic status and HRT prescribing: a study of practice-level data in England

BackgroundConcerns have been raised that women from deprived backgrounds are less likely to be receiving hormone replacement therapy (HRT) treatment and its benefits, although evidence in support of this is lacking.AimTo investigate general practice HRT prescription trends and their association with markers of socioeconomic deprivation.Design and settingCross-sectional study of primary care prescribing data in England in 2018.MethodPractice-level prescribing rate was defined as the number of items of HRT prescribed per 1000 registered female patients aged ≥40 years. The association between Index of Multiple Deprivation (IMD) score and HRT prescribing rate was tested using multivariate Poisson regression, adjusting for practice proportions of obesity, smoking, hypertension, diabetes, coronary heart disease and cerebrovascular disease, and practice list size.ResultsThe overall prescribing rate of HRT was 29% lower in practices from the most deprived quintile compared with the most affluent (incidence rate ratio [IRR] = 0.71; 95% confidence interval [CI] = 0.68 to 0.73). After adjusting for all cardiovascular disease outcomes and risk factors, the prescribing rate in the most deprived quintile was still 18% lower than in the least deprived quintile (adjusted IRR = 0.82; 95% CI = 0.77 to 0.86). In more deprived practices, there was a significantly higher tendency to prescribe oral HRT than transdermal preparations (P<0.001).ConclusionThis study highlights inequalities associated with HRT prescription. This may reflect a large unmet need in terms of menopause care in areas of deprivation. Further research is needed to identify the factors from patient and GP perspectives that may explain this.

Is there an association between socioeconomic status of General Practice population and postgraduate training practice accreditation? A cross-sectional analysis of Scottish General Practices

Background Practice population socioeconomic status is associated with practice postgraduate training accreditation. General Practitioner recruitment to socioeconomically deprived areas is challenging, exposure during training may encourage recruitment. Objectives To determine the association of practice population socioeconomic deprivation score and training status, and if this has changed over time. Methods Cross-sectional study looking at socioeconomic deprivation and training status for all General Practices in Scotland (n = 982). Data from Information Services Division, from 2015, were combined with the Scottish Index of Multiple Deprivation to calculate weighted socioeconomic deprivation scores for every practice in Scotland. Scottish training body database identified training practices (n = 330). Mean deprivation score for training and non-training practices was calculated. Logistic regression was used to quantify the odds ratio of training status based on deprivation score, adjusted for practice list size, and compared with a similar 2009 analysis. Results Socioeconomic deprivation score is associated with training status, but is not significant when adjusted for practice list size [OR (adjusted) 0.87, 95% CI: 0.74–1.04]. In contrast, in 2009, adjusted deprivation score remained significant. Mean deprivation score in training and non-training practices remained similar at both time points [2015: 2.98 (SD 0.88) versus 3.17 (SD 0.81); 2009: 2.95 versus 3.19), with a more deprived mean score in non-training practices. Conclusions General practices in affluent areas remain more likely to train, although this association appears to be related to larger practice list sizes rather than socioeconomic factors. To ensure a variety of training environments training bodies should target, and support, smaller practices working in more socioeconomically deprived areas.

Mergers of primary care organizations: a systematic review of the literature

Background Mergers as large-scale collaborations in primary care organizations have become a commonplace in developed countries to offer economies of scale and more efficient delivery of care to population. The aim of this systematic review is to summarize the scientific evidence on the relationship between the increase in the size of organizations providing primary care services and their performance. Methods The PICO model was adopted and three electronic databases (Medline, Scopus, ISI Web of Knowledge) were searched using appropriate keywords. Screening by title and abstract and data extraction were performed by two independent investigators. Articles, written in English, evaluating the performance after increasing the size of an organization were included. Selected articles were assessed for quality and risk of bias using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Process and outcome quality indicators were used for evaluation. Results From a total of 1337, 12 studies met the inclusion criteria and 103 indicators were identified: 59.2% did not show any variation, 33.9% improved significantly after the merger, 6.9% worsened after the merger. In particular, diabetes care did not show any statistically significant variation in 40.0 % of the indicators, while 10.0 % showed an improvement and 10.0% a worsening in clinical outcomes. A significant negative association was found between practice list size and reported non-urgent or urgent doctors’ availability (P &lt; 0.05, both). The process of merging also created perceptions of takeover and had a negative effect on staff. Conclusions The effects of mergers are conflicting and there is little evidence that the performance is associated with the size of the structures involved. Assessment on the impact of primary care mergers should to be related to the population needs and the context where these processes are carried out. Key messages Merging processes may lead to contrasting results. To assess periodically and systematically the impact of mergers in a continuous quality improvement cycle.

Do doctors in dispensing practices with a financial conflict of interest prescribe more expensive drugs? A cross-sectional analysis of English primary care prescribing data

ObjectivesApproximately one in eight practices in primary care in England are ‘dispensing practices’ with an in-house dispensary providing medication directly to patients. These practices can generate additional income by negotiating lower prices on higher cost drugs, while being reimbursed at a standard rate. They, therefore, have a potential financial conflict of interest around prescribing choices. We aimed to determine whether dispensing practices are more likely to prescribe high-cost options for four commonly prescribed classes of drug where there is no evidence of superiority for high-cost options.DesignA list was generated of drugs with high acquisition costs that were no more clinically effective than those with the lowest acquisition costs, for all four classes of drug examined. Data were obtained prescribing of statins, proton pump inhibitors (PPIs), angiotensin receptor blockers (ARBs) and ACE inhibitors (ACEis). Logistic regression was used to calculate ORs for prescribing high-cost options in dispensing practices, adjusting for Index of Multiple Deprivation score, practice list size and the number of doctors at each practice.SettingEnglish primary care.ParticipantsAll general practices in England.Main outcome measuresMean cost per dose was calculated separately for dispensing and non-dispensing practices. Dispensing practices can vary in the number of patients they dispense to; we, therefore, additionally compared practices with no dispensing patients, low, medium and high proportions of dispensing patients. Total cost savings were modelled by applying the mean cost per dose from non-dispensing practices to the number of doses prescribed in dispensing practices.ResultsDispensing practices were more likely to prescribe high-cost drugs across all classes: statins adjusted OR 1.51 (95% CI 1.49 to 1.53, p<0.0001), PPIs OR 1.11 (95% CI 1.09 to 1.13, p<0.0001), ACEi OR 2.58 (95% CI 2.46 to 2.70, p<0.0001), ARB OR 5.11 (95% CI 5.02 to 5.20, p<0.0001). Mean cost per dose in pence was higher in dispensing practices (statins 7.44 vs 6.27, PPIs 5.57 vs 5.46, ACEi 4.30 vs 4.24, ARB 11.09 vs 8.19). For all drug classes, the more dispensing patients a practice had, the more likely it was to issue a prescription for a high-cost option. Total cost savings in England available from all four classes are £628 875 per month or £7 546 502 per year.ConclusionsDoctors in dispensing practices are more likely to prescribe higher cost drugs. This is the largest study ever conducted on dispensing practices, and the first contemporary research suggesting some UK doctors respond to a financial conflict of interest in treatment decisions. The reimbursement system for dispensing practices may generate unintended consequences. Robust routine audit of practices prescribing higher volumes of unnecessarily expensive drugs may help reduce costs.

Development of a modified open set sentence test for assessment of speech perception skills in Hindi preschool children

Introduction: Clinical assessment of speech perception skills is very important for several reasons. However, it is routinely assessed in older children and adults but not in very young children mainly due to lack of appropriate tools, especially in Indian languages. Considering the limitations of closed-set and open-set tests for young children modified open set test would be appropriate. Aim: To develop a modified open set sentence test in Hindi based on the Mr. Potato Head Test framework using appropriate toy and sentence material and employ the developed test to assess children with normal hearing in the age range of 18 to 48 months. Method: Two sentence lists with ten sentences each and one practice list with five sentences were developed. The test was recorded in a professional studio by a sound engineer and sentences were calibrated using the Bruel & Kjaer-Type-2250 sound level meter (SLM) so that the test could be administered via speakers using a laptop. The test was administered in a quiet room, directly through a laptop connected to speakers on 200 Hindi speaking children with normal motor and speech developmental milestones and bilateral pass result on OAE screening. Results and discussion: There was a significant difference in the scores between the 5 age groups of children with normal hearing. There was an increase in scores as age increased, thus indicating improved performance with increasing age. There was also no significant difference in the performance on List 1 and List 2 for all age groups indicating that the two lists were equivalent. Item reliability was also observed to be high. Conclusion: The developed Modified Open Set Sentence Test can be successfully used to assess speech perception skills in young children with normal hearing. This test has a potential to be a useful clinical tool when used as a part of a test battery and also play a role in monitoring the progress of an intervention program.

An observational study assessing high dose opioid prescribing and associated adrenal insufficiency

BackgroundLong-term opioid use is known to affect endocrine function, with case reports indicating an association with adrenal insufficiency.AimThis study aims to investigate long-term, high-dose opioid use (≥80mg morphine or equivalent per day) at a Suffolk (UK) General Practice and its effect on adrenal function.MethodFrom a practice list of 18,300, retrospective data was collected for patients prescribed high-dose opioids for non-cancer pain for at least three months on current repeat prescription. Patient demographics and prescribing information were collected using SystmOne. Cortisol levels in the high-dose opioid patients, and short synacthen testing if indicated, were performed.ResultsThe 35 identified patients (0.2% of practice list) were predominantly female (77%) ≥70 years old (37%), and taking opioids prescribed for osteoarthritis or back pain (77%). 6% were prescribed >280mg morphine or equivalent per day, with one patient prescribed 705 mg. Routine evaluation for development of adrenal suppression and subsequent management was poor. 31% (11 of 35) had developed symptoms potentially indicative of adrenal insufficiency. One of these patients was among the 21% (7 of 35) with suppressed serum cortisol. Adrenal insufficiency secondary to opioids was confirmed in one patient using short synacthen testing. There was no statistical difference in either opioid dose or months of use for those with or without early morning cortisol suppression.ConclusionThe investigation highlights both the considerable use of high-dose opioids for non-malignant pain and their apparent association with adrenal suppression, demonstrating the need for formal guidelines to aid recognition and diagnosis.