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Mellanen E, Kauppila T, Kautiainen H, Lehto M, Rahkonen O, Pitkälä K, Laine MK. Use of primary health care services and mortality in older patients with type 2 diabetes with or without comorbidities. Scand J Prim Health Care 2023; 41:392-399. [PMID: 37706640 PMCID: PMC11001330 DOI: 10.1080/02813432.2023.2255062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/30/2023] [Indexed: 09/15/2023] Open
Abstract
OBJECTIVE This study aimed to examine primary health care (PHC) service utilization and mortality in older patients with type 2 diabetes (T2D) with or without comorbidities. DESIGN AND SETTING A cohort study in PHC in the city of Vantaa, Finland. Follow-up period was set between the years 2011 and 2018. SUBJECTS PHC patients aged 60 years or more with a T2D were included. MAIN OUTCOME MEASURES Service utilization was defined as the number of face-to-face appointments and telephone contacts between a patient and general practitioner (GP) or nurse. The presence of comorbidities was defined using the Charlson Comorbidity Index (CCI). Mortality was assessed using hazard ratio (HR) and standardized mortality ratio (SMR). RESULTS In total, 11,020 patients were included and followed for 71,596 person years. Mean age of the women and men in the beginning of follow-up were 71 and 69 years, respectively. The patients in the study cohort had a mean of eight appointments per person year to the GPs or nurses. Patients with T2D with comorbidities had more appointments than patients with T2D without comorbidities (incidence rate ratio (IRR) 1.44 [95% CI 1.39-1.49]). Increase in the number of all appointments reduced mortality in patients with T2D with and without comorbidities. Between patients with T2D with comorbidities and patients with T2D without comorbidities, the age and sex adjusted HR for death was 1.50 (95% CI 1.39-1.62). The SMR was higher in patients with T2D with comorbidities (1.83 [95% CI 1.74-1.92]) than in patients with T2D without comorbidities (0.91 [95% CI 0.86-0.96]). CONCLUSIONS In older patients with T2D, the presence of comorbidities was associated with increased use of PHC services and increased mortality. Increase in the number of appointments was associated with reduced mortality in patients with T2D with or without comorbidities.Key PointsIn older patients with T2D, it has not been studied whether and to what extend multimorbidity affects use of PHC services and mortality.The presence of comorbidities according to the Charlson Comorbidity Index (CCI) was associated with increased use of PHC services.The number of appointments to GPs or nurses was associated with reduced mortality in patients with T2D with or without comorbidities according to the CCI.
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Affiliation(s)
- E. Mellanen
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - T. Kauppila
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H. Kautiainen
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Centre, Helsinki, Finland
- Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland
| | - M. Lehto
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- City of Vantaa, Vantaa, Finland
| | - O. Rahkonen
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - K. Pitkälä
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M. K. Laine
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Centre, Helsinki, Finland
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Crane M, Joly L, Daly BJ, Gage H, Manthorpe J, Cetrano G, Ford C, Williams P. Integration, effectiveness and costs of different models of primary health care provision for people who are homeless: an evaluation study. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-217. [PMID: 37839804 DOI: 10.3310/wxuw5103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Background There is a high prevalence of health problems among single people who are homeless. Specialist primary health care services for this population have been developed in several locations across England; however, there have been very few evaluations of these services. Objectives This study evaluated the work of different models of primary health care provision in England to determine their effectiveness in engaging people who are homeless in health care and in providing continuity of care for long-term conditions. It concerned single people (not families or couples with dependent children) staying in hostels, other temporary accommodation or on the streets. The influence on outcomes of contextual factors and mechanisms (service delivery factors), including integration with other services, were examined. Data from medical records were collated on participants' use of health care and social care services over 12 months, and costs were calculated. Design and setting The evaluation involved four existing Health Service Models: (1) health centres primarily for people who are homeless (Dedicated Centres), (2) Mobile Teams providing health care in hostels and day centres, (3) Specialist GPs providing some services exclusively for patients who are homeless and (4) Usual Care GPs providing no special services for people who are homeless (as a comparison). Two Case Study Sites were recruited for each of the specialist models, and four for the Usual Care GP model. Participants People who had been homeless during the previous 12 months were recruited as 'case study participants'; they were interviewed at baseline and at 4 and 8 months, and information was collected about their circumstances and their health and service use in the preceding 4 months. Overall, 363 participants were recruited; medical records were obtained for 349 participants. Interviews were conducted with 65 Case Study Site staff and sessional workers, and 81 service providers and stakeholders. Results The primary outcome was the extent of health screening for body mass index, mental health, alcohol use, tuberculosis, smoking and hepatitis A among participants, and evidence of an intervention if a problem was identified. There were no overall differences in screening between the models apart from Mobile Teams, which scored considerably lower. Dedicated Centres and Specialist GPs were more successful in providing continuity of care for participants with depression and alcohol and drug problems. Service use and costs were significantly higher for Dedicated Centre participants and lower for Usual Care GP participants. Participants and staff welcomed flexible and tailored approaches to care, and related services being available in the same building. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services. Limitations There were difficulties recruiting mainstream general practices for the Usual Care GP model. Medical records could not be accessed for 14 participants of this model. Conclusions Participant characteristics, contextual factors and mechanisms were influential in determining outcomes. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were relatively favourable. They had dedicated staff for patients who were homeless, 'drop-in' services, on-site mental health and substance misuse services, and worked closely with hospitals and homelessness sector services. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (HSDR 13/156/03) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Maureen Crane
- National Institute for Health and Care Research Health and Social Care Workforce Research Unit, King's College London, London, UK
| | - Louise Joly
- National Institute for Health and Care Research Health and Social Care Workforce Research Unit, King's College London, London, UK
| | - Blánaid Jm Daly
- Special Care Dentistry, Division of Population and Patient Health, King's College London, London, UK
| | - Heather Gage
- Surrey Health Economics Centre, Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Jill Manthorpe
- National Institute for Health and Care Research Health and Social Care Workforce Research Unit, King's College London, London, UK
| | - Gaia Cetrano
- National Institute for Health and Care Research Health and Social Care Workforce Research Unit, King's College London, London, UK
| | | | - Peter Williams
- Department of Mathematics, University of Surrey, Guildford, UK
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Davies J, Cooper RE, Moncrieff J, Montagu L, Rae T, Parhi M. The costs incurred by the NHS in England due to the unnecessary prescribing of dependency-forming medications. Addict Behav 2022; 125:107143. [PMID: 34674906 DOI: 10.1016/j.addbeh.2021.107143] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/04/2021] [Accepted: 10/07/2021] [Indexed: 01/20/2023]
Abstract
This cross-sectional study estimates the costs incurred by the National Health Service (NHS) in England as a consequence of the unnecessary prescribing (i.e. non-indicated or dispensable) of dependency-forming medicines (antidepressants, opioids, gabapentinoids, benzodiazepines, Z-drugs). It assesses prescribing in primary care from April 2015-March 2018. Analyses were based upon the following data sets: the number of adults continuously prescribed dependency forming medications and the duration of prescriptions (obtained from Public Health England); the Net Ingredient Cost (NIC) and the dispensing costs for each medicine (obtained from the NHS Business Service Authority [NHSBSA]). Consultation costs were calculated based on guideline recommendations and the number of consultations evidenced in prior research for long-term medication monitoring. Across opioids, gabapentinoids, benzodiazepines, Z-drugs the total estimated unnecessary cost over three years (April 2015-March 2018) was £1,367,661,104 to £1,555,234,627. For antidepressants the total estimated unnecessary cost for one year was £37,321,783 to £45,765,504. The data indicate that the NHS in England may incur a significant estimated mean annual loss of £455,887,035 to £518,411,542 for opioids, gabapentinoids, benzodiazepines, Z-drugs and an estimated annual loss of £37,321,783 to £45,765,504 for antidepressants. Combined, this gives an estimated annual loss of £493,208,818 to £564,177,046 as a result of non-indicated or dispensable prescribing of dependency-forming medicines. Estimates are conservative and figures could be higher.
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Affiliation(s)
- J Davies
- University of Roehampton, Department of Life Sciences, UK; All -Party Parliamentary Group for Prescribed Drug Dependence (secretariat), Westminster, UK.
| | - R E Cooper
- University of Greenwich, Faculty of Education, Health and Human Sciences, SE10 9LS, UK
| | - J Moncrieff
- Research & Development Department, Goodmayes Hospital, North East London NHS Foundation Trust, Essex IG3 8XJ, UK; Division of Psychiatry, University College London, Gower Street, London WC1E 6BS, UK
| | - L Montagu
- All -Party Parliamentary Group for Prescribed Drug Dependence (secretariat), Westminster, UK
| | - T Rae
- University of Roehampton, Department of Life Sciences, UK
| | - M Parhi
- Roehampton Business School, University of Roehampton, SW15 5PU, UK
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Hodgson S, Morgan-Harrisskitt J, Hounkpatin H, Stuart B, Dambha-Miller H. Primary care service utilisation and outcomes in type 2 diabetes: a longitudinal cohort analysis. BMJ Open 2022; 12:e054654. [PMID: 35105641 PMCID: PMC8808402 DOI: 10.1136/bmjopen-2021-054654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To describe primary care utilisation patterns among adults with type 2 diabetes and to quantify the association between utilisation and long-term health outcomes. DESIGN Retrospective cohort study. SETTING 168 primary care practices in Southern England within the Electronic Care and Health Information Analytics database between 2013 and 2020. PARTICIPANTS 110 240 adults with Quality and Outcomes Framework read code of type 2 diabetes diagnosis; age greater than 18 years; linked and continuous records available from April 2013 until April 2020 (or death). PRIMARY AND SECONDARY OUTCOME MEASURES: (1) Rates of service utilisation (total number of primary care contacts per quarter) across the study period; (2) participant characteristics associated with higher and lower rates of service utilisation; and (3) associations between service utilisation and (A) cardiovascular disease (CVD events) and (B) all-cause mortality. RESULTS Mean (SD) number of primary care attendances per quarter in the cohort of 110 240 went from 2.49 (2.01) in 2013 to 2.78 (2.06) in 2020. Patients in the highest usage tertile were more likely to be female, older, more frail, white, from the least deprived quintile and to have five or more comorbidities. In adjusted models, higher rates of service utilisation (per consultation) were associated with higher rates of CVD events (OR 1.0058; 95% CI 1.0053 to 1.0062; p<0.001) and mortality (OR 1.0057; 95% CI 1.0051 to 1.0064; p<0.001). CONCLUSIONS People with type 2 diabetes are using primary care services more frequently, but increased volume of clinical care does not correlate with better outcomes, although this finding may be driven by more unwell patients contacting services more frequently. Further research on the nature and content of contacts is required to understand how to tailor services to deliver effective care to those at greatest risk of complications.
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Affiliation(s)
- Sam Hodgson
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | | | - Hilda Hounkpatin
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Beth Stuart
- Primary Care Research Centre, University of Southampton, Southampton, UK
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Gens-Barberà M, Hernández-Vidal N, Vidal-Esteve E, Mengíbar-García Y, Hospital-Guardiola I, Oya-Girona EM, Bejarano-Romero F, Castro-Muniain C, Satué-Gracia EM, Rey-Reñones C, Martín-Luján FM. Analysis of Patient Safety Incidents in Primary Care Reported in an Electronic Registry Application. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8941. [PMID: 34501530 PMCID: PMC8430626 DOI: 10.3390/ijerph18178941] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES (1) To describe the epidemiology of patient safety (PS) incidents registered in an electronic notification system in primary care (PC) health centres; (2) to define a risk map; and (3) to identify the critical areas where intervention is needed. DESIGN Descriptive analytical study of incidents reported from 1 January to 31 December 2018, on the TPSC Cloud™ platform (The Patient Safety Company) accessible from the corporate website (Intranet) of the regional public health service. SETTING 24 Catalan Institute of Health PC health centres of the Tarragona region (Spain). PARTICIPANTS Professionals from the PC health centres and a Patient Safety Functional Unit. MEASUREMENTS Data obtained from records voluntarily submitted to an electronic, standardised and anonymised form. Data recorded: healthcare unit, notifier, type of incident, risk matrix, causal and contributing factors, preventability, level of resolution and improvement actions. RESULTS A total of 1544 reports were reviewed and 1129 PS incidents were analysed: 25.0% of incidents did not reach the patient; 66.5% reached the patient without causing harm, and 8.5% caused adverse events. Nurses provided half of the reports (48.5%), while doctors reported more adverse events (70.8%; p < 0.01). Of the 96 adverse events, 46.9% only required observation, 34.4% caused temporary damage that required treatment, 13.5% required (or prolonged) hospitalization, and 5.2% caused severe permanent damage and/or a situation close to death. Notably, 99.2% were considered preventable. The main critical areas were: communication (27.8%), clinical-administrative management (25.1%), care delivery (23.5%) and medicines (18.4%); few incidents were related to diagnosis (3.6%). CONCLUSIONS PS incident notification applications are adequate for reporting incidents and adverse events associated with healthcare. Approximately 75% and 10% of incidents reach the patient and cause some damage, respectively, and most cases are considered preventable. Adequate and strengthened risk management of critical areas is required to improve PS.
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Affiliation(s)
- Montserrat Gens-Barberà
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain; (N.H.-V.); (E.V.-E.); (Y.M.-G.); (I.H.-G.); (E.M.O.-G.); (F.B.-R.); (C.C.-M.)
| | - Núria Hernández-Vidal
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain; (N.H.-V.); (E.V.-E.); (Y.M.-G.); (I.H.-G.); (E.M.O.-G.); (F.B.-R.); (C.C.-M.)
| | - Elisa Vidal-Esteve
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain; (N.H.-V.); (E.V.-E.); (Y.M.-G.); (I.H.-G.); (E.M.O.-G.); (F.B.-R.); (C.C.-M.)
| | - Yolanda Mengíbar-García
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain; (N.H.-V.); (E.V.-E.); (Y.M.-G.); (I.H.-G.); (E.M.O.-G.); (F.B.-R.); (C.C.-M.)
| | - Immaculada Hospital-Guardiola
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain; (N.H.-V.); (E.V.-E.); (Y.M.-G.); (I.H.-G.); (E.M.O.-G.); (F.B.-R.); (C.C.-M.)
- Primary Health-Care Centre, Institut Català de la Salut, 43005 Tarragona, Spain
| | - Eva M. Oya-Girona
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain; (N.H.-V.); (E.V.-E.); (Y.M.-G.); (I.H.-G.); (E.M.O.-G.); (F.B.-R.); (C.C.-M.)
- Primary Health-Care Centre, Institut Català de la Salut, 43005 Tarragona, Spain
| | - Ferran Bejarano-Romero
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain; (N.H.-V.); (E.V.-E.); (Y.M.-G.); (I.H.-G.); (E.M.O.-G.); (F.B.-R.); (C.C.-M.)
- Pharmacy Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain
| | - Carles Castro-Muniain
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain; (N.H.-V.); (E.V.-E.); (Y.M.-G.); (I.H.-G.); (E.M.O.-G.); (F.B.-R.); (C.C.-M.)
| | - Eva M. Satué-Gracia
- Research Support Unit Tarragona-Reus, Institut Universitari D’investigació en L’atenció Primària Jordi Gol, (IDIAP Jordi Gol), Institut Català de la Salut, 43202 Reus, Spain; (E.M.S.-G.); (C.R.-R.); (F.M.M.-L.)
| | - Cristina Rey-Reñones
- Research Support Unit Tarragona-Reus, Institut Universitari D’investigació en L’atenció Primària Jordi Gol, (IDIAP Jordi Gol), Institut Català de la Salut, 43202 Reus, Spain; (E.M.S.-G.); (C.R.-R.); (F.M.M.-L.)
- Faculty of Medicine and Health Sciences, Universitat Rovira i Virgili, 43201 Reus, Spain
| | - Francisco M. Martín-Luján
- Research Support Unit Tarragona-Reus, Institut Universitari D’investigació en L’atenció Primària Jordi Gol, (IDIAP Jordi Gol), Institut Català de la Salut, 43202 Reus, Spain; (E.M.S.-G.); (C.R.-R.); (F.M.M.-L.)
- Faculty of Medicine and Health Sciences, Universitat Rovira i Virgili, 43201 Reus, Spain
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Ogden SJ, Huxtable R, Ives J. Protocol for a scoping review to understand what is known about how GPs make decisions with, for and on behalf of patients who lack capacity. BMJ Open 2020; 10:e038032. [PMID: 33082190 PMCID: PMC7577062 DOI: 10.1136/bmjopen-2020-038032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION General Practitioners (GPs) and allied healthcare professionals working in primary care are regularly required to make decisions with, for and on behalf of patients who lack capacity. In England and Wales, these decisions are made for incapacitated adult patients under the Mental Capacity Act 2005, which primarily requires that decisions are made in the patient's 'best interests'. Regarding children, decisions are also made in their best interests but are done so under the Children Act 1989, which places paramount importance on the welfare of the child. Decisions for children are usually made by parents, but a GP may become involved if he or she feels a parent is not acting in the best interests of the child. Internationally, including elsewhere in the UK, different approaches are taken. We hypothesise that, despite the legislation and professional guidelines, there are many different approaches taken by GPs and allied healthcare professionals in England and Wales when making these complex decisions with, for and on behalf of patients who lack capacity. To better understand what is known about how these decisions are made, we plan to undertake a scoping review and directed content analysis of the literature. While the majority of decisions made in primary care are made by GPs, for completeness, this review will include all allied healthcare professionals working in primary care. METHODS AND ANALYSIS To ensure a wide breadth of literature is captured, a scoping review will be undertaken as described by Arksey and O'Malley (2005). A five-stage approach will be taken when conducting this review: (1) identifying the research question; (2) identifying relevant papers; (3) study selection; (4) data extraction and (5) summarising and synthesis. The final stage will include a directed content analysis of the data to help establish the cross-cutting themes. ETHICS AND DISSEMINATION The scoping review will be disseminated through conferences and peer-reviewed publications. This scoping review is the first (mapping) phase in a proposed larger study to explore how GPs make decisions with, for and on behalf of those who lack capacity. Qualitative research with GPs, patients and their families will follow, before all the results are synthesised using an 'empirical bioethics' methodology.
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Affiliation(s)
- Simon Jack Ogden
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Richard Huxtable
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jonathan Ives
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
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