Care pathways in older patients seen in a multidisciplinary same day emergency care (SDEC) unit

BACKGROUND

Same day emergency care (SDEC) services are being advocated in the UK for frail, older patients in whom hospitalisation may be associated with harm but there are few data on the 'ambulatory pathway'. We therefore determined the patient pathways pre- and post-first assessment in a SDEC unit focussed on older people.

METHODS

In consecutive patients, we prospectively recorded follow-up SDEC service reviews (face-to-face, telephone, Hospital-at-Home domiciliary visits), outpatient referrals (e.g. to specialist clinics, imaging, and community/voluntary/social services), and hospital admissions <30 days. In the first 67 patients, we also recorded healthcare interactions (except GP attendances) in the 180 days pre- and post-first assessment.

RESULTS

Among 533 patients (mean/SD age = 75.0/17.5 years, 246, 46% deemed frail) assessed in an SDEC unit, 210 were admitted within 30 days (152 immediately). In the 381(71%) remaining initially ambulatory, there were 587 SDEC follow-up reviews and 747 other outpatient referrals (mean = 3.5 per patient) with only 34 (9%) patients being discharged with no further follow-up. In the subset (n = 67), the number of 'healthcare days' was greater in the 180 days post- versus pre-SDEC assessment (mean/SD = 26/27 versus 13/22 days, P = 0.003) even after excluding hospital admission days, with greater healthcare days in frail versus non-frail patients.

DISCUSSION AND CONCLUSION

SDEC assessment in older, frail patients was associated with a 2-fold increase in frequency of healthcare interactions with complex care pathways involving multiple services. Our findings have implications for the development of admission-avoidance models including cost-effectiveness and optimal delivery of the multi-dimensional aspects of acute geriatric care in the ambulatory setting.

Evaluation of a Simple Low-cost Intervention to Empower People with CKD to Reduce Their Dietary Salt Intake: OxCKD1, a Multicenter Randomized Controlled Trial

Key Points

A randomized controlled trial demonstrates that a simple and cheap 1-month intervention empowers people with CKD to lower their dietary salt intake. The effect of the intervention persisted after the intervention finished.

Background

To evaluate the efficacy of a simple low-cost intervention to empower people with CKD to reduce their dietary salt intake.

Methods

A randomized controlled trial in primary and secondary care comparing the OxSalt care bundle intervention versus standard care for 1 month. Participants were people with CKD and an eGFR >20 ml/min per 1.73 m2 and were recruited from primary and secondary care. The primary outcome was a reduction in dietary salt intake, as assessed by 24-hour urinary sodium excretion, after 1 month of the intervention.

Results

Two hundred and one participants were recruited. Dietary salt intake, as assessed from 24-hour urine sodium excretion, fell by 1.9 (±2.9) g/d in the intervention group compared with 0.4 (±2.7) g/d in the control group (P < 0.001). Salt intake was still reduced to a lesser extent over the following year in the intervention group.

Conclusions

A short, low-cost, easily delivered intervention empowers people with CKD to reduce their dietary salt intake.

Trial registration

ClinicalTrials.gov NCT01552317 .

National Early Warning Scores Following Emergency Hospital Transfer: Implications for Care Home Residents

OBJECTIVE

Care home residents have high rates of hospital admission. The UK National Early Warning Score (NEWS2) standardizes the secondary care response to acute illness. However, the ability of NEWS2 to predict adverse health outcomes specifically for care home residents is unknown. This study explored the relationship between NEWS2 on admission to hospital and resident outcome 7 days later.

DESIGN

Repeated cross-sectional study.

SETTING AND PARTICIPANTS

Data on UK care home residents admitted to 160 hospitals in two 24-hour periods (2019 and 2020).

METHOD

Chi-squared and Kruskal-Wallis tests, and multinomial regression were used to explore the association between low (score ≤2), intermediate (3-4), high (5-6), and critically high (≥7) NEWS2 on admission and each of the following: discharge on day of admission, admission and discharge within 7 days, prolonged hospital admission (>7 days), and death.

RESULTS

From 665 resident admissions across 160 hospital sites, NEWS2 was low for 54%, intermediate for 18%, high for 13%, and critically high for 16%. The 7-day outcome was 10% same-day discharge, 47% admitted and subsequently discharged, 34% remained inpatients, and 8% died. There is a significant association between NEWS2 and these outcomes (P < .001). Compared with those with low NEWS2, residents with high and critically high NEWS2 had 3.6 and 9.5 times increased risk of prolonged hospitalization [relative risk ratio (RRR) 3.56; 95% CI 1.02-12.37; RRR 9.47; CI 2.20-40.67], respectively. The risk of death was approximately 14 times higher for residents with high NEWS2 (RRR 13.62; CI 3.17-58.49) and 54 times higher (RRR 53.50; CI 11.03-259.54) for critically high NEWS2.

CONCLUSION AND IMPLICATIONS

Higher NEWS2 measurements on admission are associated with an increased risk of hospitalization up to 7 days duration, prolonged admission, and mortality for care home residents. NEWS2 may have a role as an adjunct to acute care decision making for hospitalized residents.

Statistical models for the deterioration of kidney function in a primary care population: A retrospective database analysis

Background: Evidence for kidney function monitoring intervals in primary care is weak, and based mainly on expert opinion. In the absence of trials of monitoring strategies, an approach combining a model for the natural history of kidney function over time combined with a cost-effectiveness analysis offers the most feasible approach for comparing the effects of monitoring under a variety of policies. This study aimed to create a model for kidney disease progression using routinely collected measures of kidney function.

Methods: This is an open cohort study of patients aged ≥18 years, registered at 643 UK general practices contributing to the Clinical Practice Research Datalink between 1 April 2005 and 31 March 2014. At study entry, no patients were kidney transplant donors or recipients, pregnant or on dialysis. Hidden Markov models for estimated glomerular filtration rate (eGFR) stage progression were fitted to four patient cohorts defined by baseline albuminuria stage; adjusted for sex, history of heart failure, cancer, hypertension and diabetes, annually updated for age.

Results: Of 1,973,068 patients, 1,921,949 had no recorded urine albumin at baseline, 37,947 had normoalbuminuria (<3mg/mmol), 10,248 had microalbuminuria (3–30mg/mmol), and 2,924 had macroalbuminuria (>30mg/mmol). Estimated annual transition probabilities were 0.75–1.3%, 1.5–2.5%, 3.4–5.4% and 3.1–11.9% for each cohort, respectively. Misclassification of eGFR stage was estimated to occur in 12.1% (95%CI: 11.9–12.2%) to 14.7% (95%CI: 14.1–15.3%) of tests. Male gender, cancer, heart failure and age were independently associated with declining renal function, whereas the impact of raised blood pressure and glucose on renal function was entirely predicted by albuminuria.

Conclusions: True kidney function deteriorates slowly over time, declining more sharply with elevated urine albumin, increasing age, heart failure, cancer and male gender. Consecutive eGFR measurements should be interpreted with caution as observed improvement or deterioration may be due to misclassification.

Analysis of the relationship between sex and prescriptions for guideline-recommended therapy in peripheral arterial disease, in relation to 1-year all-cause mortality: a primary care cohort study

OBJECTIVES

To explore population patterns of sex-based incidence and prevalence of peripheral arterial disease (PAD), guideline-directed best medical therapy prescriptions and its relationship with all-cause mortality at 1 year.

DESIGN

A retrospective cohort study.

SETTING

Anonymised electronic primary care from 787 practices in the UK, or approximately 6.2% of the UK population.

PARTICIPANTS

All registered patients over 40 with a documented diagnosis of peripheral arterial disease.

OUTCOME MEASURE

Population incidence and prevalence of PAD by sex. Patterns of guideline-directed therapy, and correlation with all-cause mortality at 1 year (defined as death due to any outcome) in patients with and without an existing diagnosis of cardiovascular disease. Covariates included Charlson comorbidity, sex, age, body mass index, Townsend score of deprivation, smoking status, diabetes, hypertension, statin and antiplatelet prescription.

RESULTS

Sequential cross-sectional studies from 2010 to 2017 found annual PAD prevalence (12.7-14.3 vs 25.6 per 1000 in men) and incidence were lower in women (11.6-12.4 vs 22.7-26.8 per 10 000 person years in men). Cox proportional hazards models created for PAD patients with and without cardiovascular disease over one full year analysed 25 121 men and 13 480 women, finding that following adjustment for age, women were still less likely to be on a statin (OR 0.69; 95% CI 0.66 to 0.72; p<0.001) or antiplatelet (OR: 0.87; 95% CI 0.83 to 0.90; p<0.001). Once fully adjusted for guideline recommended medical therapy, all-cause mortality was similar between women and men (adjusted HR (aHR) 0.95, 95% CI 0.87 to 1.03, p=0.198 for all patients, aHR 1.01, 95% CI 0.88 to 1.16, p=0.860 for those with cardiovascular disease).

CONCLUSIONS

Women with a new diagnosis of PAD were not prescribed guideline-directed therapy at the same rate as men. However once adjusted for factors including age, all-cause mortality in men and women was similar.

Long-term monitoring in primary care for chronic kidney disease and chronic heart failure: a multi-method research programme

Background

Long-term monitoring is important in chronic condition management. Despite considerable costs of monitoring, there is no or poor evidence on how, what and when to monitor. The aim of this study was to improve understanding, methods, evidence base and practice of clinical monitoring in primary care, focusing on two areas: chronic kidney disease and chronic heart failure.

Objectives

The research questions were as follows: does the choice of test affect better care while being affordable to the NHS? Can the number of tests used to manage individuals with early-stage kidney disease, and hence the costs, be reduced? Is it possible to monitor heart failure using a simple blood test? Can this be done using a rapid test in a general practitioner consultation? Would changes in the management of these conditions be acceptable to patients and carers?

Design

Various study designs were employed, including cohort, feasibility study, Clinical Practice Research Datalink analysis, seven systematic reviews, two qualitative studies, one cost-effectiveness analysis and one cost recommendation.

Setting

This study was set in UK primary care.

Data sources

Data were collected from study participants and sourced from UK general practice and hospital electronic health records, and worldwide literature.

Participants

The participants were NHS patients (Clinical Practice Research Datalink: 4.5 million patients), chronic kidney disease and chronic heart failure patients managed in primary care (including 750 participants in the cohort study) and primary care health professionals.

Interventions

The interventions were monitoring with blood and urine tests (for chronic kidney disease) and monitoring with blood tests and weight measurement (for chronic heart failure).

Main outcome measures

The main outcomes were the frequency, accuracy, utility, acceptability, costs and cost-effectiveness of monitoring.

Results

Chronic kidney disease: serum creatinine testing has increased steadily since 1997, with most results being normal (83% in 2013). Increases in tests of creatinine and proteinuria correspond to their introduction as indicators in the Quality and Outcomes Framework. The Chronic Kidney Disease Epidemiology Collaboration equation had 2.7% greater accuracy (95% confidence interval 1.6% to 3.8%) than the Modification of Diet in Renal Disease equation for estimating glomerular filtration rate. Estimated annual transition rates to the next chronic kidney disease stage are ≈ 2% for people with normal urine albumin, 3–5% for people with microalbuminuria (3–30 mg/mmol) and 3–12% for people with macroalbuminuria (> 30 mg/mmol). Variability in estimated glomerular filtration rate-creatinine leads to misclassification of chronic kidney disease stage in 12–15% of tests in primary care. Glycaemic-control and lipid-modifying drugs are associated with a 6% (95% confidence interval 2% to 10%) and 4% (95% confidence interval 0% to 8%) improvement in renal function, respectively. Neither estimated glomerular filtration rate-creatinine nor estimated glomerular filtration rate-Cystatin C have utility in predicting rate of kidney function change. Patients viewed phrases such as ‘kidney damage’ or ‘kidney failure’ as frightening, and the term ‘chronic’ was misinterpreted as serious. Diagnosis of asymptomatic conditions (chronic kidney disease) was difficult to understand, and primary care professionals often did not use ‘chronic kidney disease’ when managing patients at early stages. General practitioners relied on Clinical Commissioning Group or Quality and Outcomes Framework alerts rather than National Institute for Health and Care Excellence guidance for information. Cost-effectiveness modelling did not demonstrate a tangible benefit of monitoring kidney function to guide preventative treatments, except for individuals with an estimated glomerular filtration rate of 60–90 ml/minute/1.73 m2, aged < 70 years and without cardiovascular disease, where monitoring every 3–4 years to guide cardiovascular prevention may be cost-effective. Chronic heart failure: natriuretic peptide-guided treatment could reduce all-cause mortality by 13% and heart failure admission by 20%. Implementing natriuretic peptide-guided treatment is likely to require predefined protocols, stringent natriuretic peptide targets, relative targets and being located in a specialist heart failure setting. Remote monitoring can reduce all-cause mortality and heart failure hospitalisation, and could improve quality of life. Diagnostic accuracy of point-of-care N-terminal prohormone of B-type natriuretic peptide (sensitivity, 0.99; specificity, 0.60) was better than point-of-care B-type natriuretic peptide (sensitivity, 0.95; specificity, 0.57). Within-person variation estimates for B-type natriuretic peptide and weight were as follows: coefficient of variation, 46% and coefficient of variation, 1.2%, respectively. Point-of-care N-terminal prohormone of B-type natriuretic peptide within-person variability over 12 months was 881 pg/ml (95% confidence interval 380 to 1382 pg/ml), whereas between-person variability was 1972 pg/ml (95% confidence interval 1525 to 2791 pg/ml). For individuals, monitoring provided reassurance; future changes, such as increased testing, would be acceptable. Point-of-care testing in general practice surgeries was perceived positively, reducing waiting time and anxiety. Community heart failure nurses had greater knowledge of National Institute for Health and Care Excellence guidance than general practitioners and practice nurses. Health-care professionals believed that the cost of natriuretic peptide tests in routine monitoring would outweigh potential benefits. The review of cost-effectiveness studies suggests that natriuretic peptide-guided treatment is cost-effective in specialist settings, but with no evidence for its value in primary care settings.

Limitations

No randomised controlled trial evidence was generated. The pathways to the benefit of monitoring chronic kidney disease were unclear.

Conclusions

It is difficult to ascribe quantifiable benefits to monitoring chronic kidney disease, because monitoring is unlikely to change treatment, especially in chronic kidney disease stages G3 and G4. New approaches to monitoring chronic heart failure, such as point-of-care natriuretic peptide tests in general practice, show promise if high within-test variability can be overcome.

Future work

The following future work is recommended: improve general practitioner–patient communication of early-stage renal function decline, and identify strategies to reduce the variability of natriuretic peptide.

Study registration

This study is registered as PROSPERO CRD42015017501, CRD42019134922 and CRD42016046902.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 10. See the NIHR Journals Library website for further project information.

'You see the empty bed which means it's either a transplant or a death': a qualitative study exploring the impact of death in the haemodialysis community

OBJECTIVE

To explore the impact of the death of a patient in the haemodialysis unit on fellow patients.

METHODS

We interviewed patients on dialysis in a tertiary dialysis centre using semistructured interviews. We purposively sampled patients who had experienced the death of a fellow patient. After interviews were transcribed, they were thematically analysed by independent members of the research team using inductive analysis. Input from the team during analysis ensured the rigour and quality of the findings.

RESULTS

10 participants completed the interviews (6 females and 4 males with an age range of 42-88 years). The four core themes that emerged from the interviews included: (1) patients' relationship to haemodialysis, (2) how patients define the haemodialysis community, (3) patients' views on death and bereavement and (4) patients' expectations around death in the dialysis community. Patients noticed avoidance behaviour by staff in relation to discussing death in the unit and would prefer a culture of open acknowledgement.

CONCLUSION

Staff acknowledgement of death is of central importance to patients on haemodialysis who feel that the staff are part of their community. This should guide the development of appropriate bereavement support services and a framework that promotes the provision of guidance for staff and patients in this unique clinical setting. However, the authors acknowledge the homogenous sample recruited in a single setting may limit the transferability of the study. Further work is needed to understand diverse patient and nurse experiences and perceptions when sharing the knowledge of a patient's death and how they react to loss.

Protocol for a scoping review exploring the use of patient-reported outcomes in adult social care

INTRODUCTION

Patient-reported outcomes (PROs) are measures of a person's own views of their health, functioning and quality of life. They are typically assessed using validated, self-completed questionnaires known as patient-reported outcome measures (PROMs). PROMs are used in healthcare settings to support care planning, clinical decision-making, patient-practitioner communication and quality improvement. PROMs have a potential role in the delivery of social care where people often have multiple and complex long-term health conditions. However, the use of PROMs in this context is currently unclear. The objective of this scoping review is to explore the evidence relating to the use of PROMs in adult social care.

METHODS AND ANALYSES

The electronic databases Medline (Ovid), PsychInfo (Ovid), ASSIA (ProQuest), Social Care Online (SCIE), Web of Science and EMBASE (Ovid) were searched on 29 September 2020 to identify eligible studies and other publically available documents published since 2010. A grey literature search and hand searching of citations and reference lists of the included studies will also be undertaken. No restrictions on study design or language of publication will be applied. Screening and data extraction will be completed independently by two reviewers. Quality appraisal of the included documents will use the Critical Appraisal Skills Programme and AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) checklists. A customised data charting table will be used for data extraction, with analysis of qualitative data using the framework method. The review findings will be presented as tables and in a narrative summary.

ETHICS AND DISSEMINATION

Ethical review is not required as scoping reviews are a form of secondary data analysis that synthesise data from publically available sources. Review findings will be shared with service users and other relevant stakeholders and disseminated through a peer-reviewed publication and conference presentations. This protocol is registered on the Open Science Framework (www.osf.io).

Urgent assessment and ongoing care for infection in community-dwelling older people: a qualitative study of patient experience

OBJECTIVES

To explore the experience of infection from the perspective of community-dwelling older people, including access and preferences for place of care.

DESIGN

Qualitative interview study, carried out between March 2017 and August 2018.

SETTING

Ambulatory care units in Oxfordshire, UK.

PARTICIPANTS

Adults >70 years with a clinical diagnosis of infection.

METHODS

Semistructured interviews based on a flexible topic guide. Participants were given the option to be interviewed with their caregiver. Thematic analysis was facilitated by NVivo V.11.

RESULTS

Participants described encountering several barriers when accessing an urgent healthcare assessment which were hard to negotiate when they felt unwell. They valued home comforts and independence if they received care for their infection at home, though were worried about burdening their family. Most talked about hospital admission being a necessity in the context of more severe illness. Perceived advantages included monitoring, availability of treatments and investigations. However, some recognised that admission put them at risk of a hospital-acquired infection. Ambulatory care was felt to be convenient if local, but daily transport was challenging.

CONCLUSIONS

Providers may need to think about protocols and targeted advice that could improve access for older people to urgent healthcare when they feel unwell. General practitioners making decisions about place of care may need to better communicate risks associated with the available options and think about balancing convenience with facilities for care.

Factors associated with admission to bed-based care: observational prospective cohort study in a multidisciplinary same day emergency care unit (SDEC)

BACKGROUND

The development of ambulatory emergency care services, now called 'Same Day Emergency Care' (SDEC) has been advocated to provide sustainable high quality healthcare in an ageing population. However, there are few data on SDEC and the factors associated with successful ambulatory care in frail older people. We therefore undertook a prospective observational study to determine i) the clinical characteristics and frailty burden of a cohort in an SDEC designed around the needs of older patients and ii) the factors associated with hospital admission within 30-days after initial assessment.

METHODS

The study setting was the multidisciplinary Abingdon Emergency Medical Unit (EMU) located in a community hospital and led by a senior interface physician (geriatrician or general practitioner). Consecutive patients from August-December 2015 were assessed using a structured paper proforma including cognitive/delirium screen, comorbidities, functional, social, and nutritional status. Physiologic parameters were recorded. Illness severity was quantified using the Systemic Inflammatory Response Syndrome (SIRS> 1). Factors associated with hospitalization within 30-days were determined using multivariable logistic regression.

RESULTS

Among 533 patients (median (IQR) age = 81 (68-87), 315 (59%) female), 453 (86%) were living at home but 283 (54%) required some form of care and 299 (56%) had Barthel< 20. Falls, urinary incontinence and dementia affected 81/189 (43%), 50 (26%) and 40 (21%) of those aged > 85 years." Severe illness was present in 148 (28%) with broadly similar rates across age groups. Overall, 210 (39%) patients had a hospital admission within 30-days with higher rates in older patients: 96 (87%) of < 65 years remained on an ambulatory pathway versus only 91 (48%) of ≥ 85 years (p < 0.0001). Factors independently associated with hospital admission were severe illness (SIRS/point, OR = 1.46,95% CI = 1.15-1.87, p = 0.002) and markers of frailty: delirium (OR = 11.28,3.07-41.44, p < 0.0001), increased care needs (OR = 3.08,1.55-6.12, p = 0.001), transport requirement (OR = 1.92,1.13-3.27), and poor nutrition (OR = 1.13-3.79, p = 0.02).

CONCLUSIONS

Even in an SDEC with a multidisciplinary approach, rates of hospital admission in those with severe illness and frailty were high. Further studies are required to understand the key components of hospital bed-based care that need to be replicated by models delivering acute frailty care closer to home, and the feasibility, cost-effectiveness and patient/carer acceptability of such models.

Antibiotic prescribing for the older adult: beliefs and practices in primary care

BACKGROUND

Older adults suffer high morbidity and mortality following serious infections, and hospital admissions with these conditions are increasingly common. Antibiotic prescribing in the older adult population, especially in long-term care facilities, has been argued to be inappropriately high. In order to develop the evidence base and provide support to GPs in achieving antimicrobial stewardship in older adults it is important to understand their attitudes and beliefs toward antibiotic prescribing in this population.

OBJECTIVES

To understand the attitudes and beliefs held by GPs regarding antibiotic prescribing in older adults.

METHODS

Semi-structured qualitative interviews were conducted with 28 GPs working in the UK. Data analysis followed a modified framework approach.

RESULTS

GPs described antibiotic prescribing in older adults as differing from prescribing in other age groups in a number of ways, including prescribing broad-spectrum, longer and earlier antibiotics in this population. There were also rationales for situations where antibiotics were prescribed despite there being no clear diagnosis of infection. Trials of antibiotics were used both as diagnostic aids and in an attempt to avoid admission. The risks of antibiotics were understood, but in some cases restrictions on antibiotic use were thought to hamper optimal management of infection in this age group.

CONCLUSIONS

Diagnosing serious infections in older adults is challenging and antibiotic prescribing practices reflect this challenge, but also reflect an absence of clear guidance or evidence. Research that can fill the gaps in the evidence base is required in order to support GPs with their critical antimicrobial stewardship role in this population.

What are physiotherapists and occupational therapists doing in services that replace acute hospital admission? A systematic review

BACKGROUND

Alternatives to acute hospital admission are required to accommodate the increasing pressures on health services. Since physiotherapists and occupational therapists are integral to inpatient teams, they may also be integral to admission replacement services, and thus their roles in these services merit investigation.

AIMS

Primarily to determine the presence and roles of physiotherapists and occupational therapists in services replacing acute hospital admission. The secondary outcome is to determine the impact of therapists in such services.

METHODS

Five electronic databases were searched, with keywords related to therapy, discharge, and admission replacement. Inclusion criteria were that studies explicitly described at least one therapist role within a service replacing acute hospital admissions. Two authors independently reviewed all potentially eligible studies. Two reviewers independently assessed data extracted from included studies into a standardized data extraction form.

RESULTS

Fifteen studies (3 Hospital at Home, 12 Early Supported Discharge) were included. Both clinical (eg, exercise prescription) and non-clinical (eg, organization and study outcome assessments) therapist roles were described in different admission substitution services. Some roles were only reported among teams, not individually ascribed to therapists.

CONCLUSIONS

The roles of therapists in services that replace hospital admission are rarely described in detail, with wide variation in reported roles, including across service types and patient populations. This review could not determine the impact of individual therapists on patient or service-level outcomes. Future studies need to more clearly define therapist roles and impact.

Ambulatory emergency oncology: A key tenet of future emergency oncology care

Ambulatory emergency oncology The challenges of emergency oncology alongside its increasing financial burden have led to an interest in developing optimal care models for meeting patients' needs. Ambulatory care is recognised as a key tenet in ensuring the safety and sustainability of acute care services. Increased access to ambulatory care has successfully reduced ED utilisation and improved clinical outcomes in high-risk non-oncological populations. Individualised management of acute cancer presentations is a key challenge for emergency oncology services so that it can mirror routine cancer care. There are an increasing number of acute cancer presentations, such as low-risk febrile neutropenia and incidental pulmonary embolism, that can be risk assessed for care in an emergency ambulatory setting. Modelling of ambulatory emergency oncology services will be dependent on local service deliveries and pathways, but are key for providing high quality, personalised and sustainable emergency oncology care. These services will also be at the forefront of much needed emergency oncology to define the optimal management of ambulatory-sensitive presentations.

Effects of antihypertensives, lipid-modifying drugs, glycaemic control drugs and sodium bicarbonate on the progression of stages 3 and 4 chronic kidney disease in adults: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effects of drug interventions that may modify the progression of chronic kidney disease (CKD) in adults with CKD stages 3 and 4.

DESIGN

Systematic review and meta-analysis.

METHODS

Searching MEDLINE, EMBASE, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, International Clinical Trials Registry Platform, Health Technology Assessment, Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index and Clinical Trials Register, from March 1999 to July 2018, we identified randomised controlled trials (RCTs) of drugs for hypertension, lipid modification, glycaemic control and sodium bicarbonate, compared with placebo, no drug or a drug from another class, in ≥40 adults with CKD stages 3 and/or 4, with at least 2 years of follow-up and reporting renal function (primary outcome), proteinuria, adverse events, maintenance dialysis, transplantation, cardiovascular events, cardiovascular mortality or all-cause mortality. Two reviewers independently screened citations and extracted data. For continuous outcomes, we used the ratio of means (ROM) at the end of the trial in random-effects meta-analyses. We assessed methodological quality with the Cochrane Risk of Bias Tool and confidence in the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

RESULTS

We included 35 RCTs and over 51 000 patients. Data were limited, and heterogeneity varied. Final renal function (estimated glomerular filtration rate) was 6% higher in those taking glycaemic control drugs (ROM 1.06, 95% CI 1.02 to 1.10, I²=0%, low GRADE confidence) and 4% higher in those taking lipid-modifying drugs (ROM 1.04, 95% CI 1.00 to 1.08, I²=88%, very low GRADE confidence). For RCTs of antihypertensive drugs, there were no significant differences in renal function. Treatment with lipid-modifying drugs led to a 36% reduction in cardiovascular disease and 26% reduction in all-cause mortality.

CONCLUSIONS

Glycaemic control and lipid-modifying drugs may slow the progression of CKD, but we found no pooled evidence of benefit nor harm from antihypertensive drugs. However, given the data limitations, further research is needed to confirm these findings.

PROSPERO REGISTRATION NUMBER

CRD42015017501.

Statistical models for the deterioration of kidney function in a primary care population: A retrospective database analysis

Background: Evidence for kidney function monitoring intervals in primary care is weak, and based mainly on expert opinion. In the absence of trials of monitoring strategies, an approach combining a model for the natural history of kidney function over time combined with a cost-effectiveness analysis offers the most feasible approach for comparing the effects of monitoring under a variety of policies. This study aimed to create a model for kidney disease progression using routinely collected measures of kidney function. Methods: This is an open cohort study of patients aged ≥18 years, registered at 643 UK general practices contributing to the Clinical Practice Research Datalink between 1 April 2005 and 31 March 2014. At study entry, no patients were kidney transplant donors or recipients, pregnant or on dialysis. Hidden Markov models for estimated glomerular filtration rate (eGFR) stage progression were fitted to four patient cohorts defined by baseline albuminuria stage; adjusted for sex, history of heart failure, cancer, hypertension and diabetes, annually updated for age. Results: Of 1,973,068 patients, 1,921,949 had no recorded urine albumin at baseline, 37,947 had normoalbuminuria (<3mg/mmol), 10,248 had microalbuminuria (3–30mg/mmol), and 2,924 had macroalbuminuria (>30mg/mmol). Estimated annual transition probabilities were 0.75–1.3%, 1.5–2.5%, 3.4–5.4% and 3.1–11.9% for each cohort, respectively. Misclassification of eGFR stage was estimated to occur in 12.1% (95%CI: 11.9–12.2%) to 14.7% (95%CI: 14.1–15.3%) of tests. Male gender, cancer, heart failure and age were independently associated with declining renal function, whereas the impact of raised blood pressure and glucose on renal function was entirely predicted by albuminuria. Conclusions: True kidney function deteriorates slowly over time, declining more sharply with elevated urine albumin, increasing age, heart failure, cancer and male gender. Consecutive eGFR measurements should be interpreted with caution as observed improvement or deterioration may be due to misclassification.

Challenges and strategies for general practitioners diagnosing serious infections in older adults: a UK qualitative interview study

BACKGROUND

Serious infections in older people are associated with unplanned hospital admissions and high mortality. Recognising the presence of a serious infection and making an accurate diagnosis are important challenges for General Practice. This study aimed to explore the issues UK GPs face when diagnosing serious infections in older patients.

METHODS

Qualitative study using semi-structured interviews. 28 GPs from 27 practices were purposively sampled from across the UK to achieve maximum variation in terms of GP role, experience and practice population. Interviews began by asking participants to describe recent or memorable cases where they had assessed older patients with suspected serious infections. Additional questions from the topic guide were used to explore the challenges further. Interview transcripts were coded and analysed using a modified framework approach.

RESULTS

Diagnosing serious infection in older adults was perceived to be challenging by participating GPs and the diagnosis was often uncertain. Contributing factors included patient complexity, atypical presentations, as well as a lack of knowledge of patients due to a loss in continuity. Diagnostic challenges were present at each stage of the patient assessment. Scoring systems were mainly used as communication tools. Investigations were sometimes used to resolve diagnostic uncertainty, but availability and speed of result limited their practical use. Clear safety-net plans shared with patients and their families helped GPs manage ongoing uncertainty.

CONCLUSIONS

Diagnostic challenges are present throughout the assessment of an older adult with a serious infection in primary care. Supporting GPs to provide continuity of care may improve the recognition and developing point of care testing for use in community settings may reduce diagnostic uncertainty.

SAMBA18 Report - A National Audit of Acute Medical Care in the UK

SAMBA18 took place on Thursday 28th June 2018 with follow up data at 7 days. Acute medical teams from 127 Acute Medical Units (AMUs) across the UK collected data relating to operational performance, clinical quality indicators and standards from NHS Improvement. Data was collected from 6114 patients.

Reduced kidney function at presentation in unselected acute emergency medical admissions: incidence, outcome and associated factors

We sought to assess the impact of renal impairment on acute medical admissions and to identify potential contributory factors to admissions involving renal impairment at presentation. In a prospective cohort study, 29.5% of all acute medical emergency admissions had an eGFR <60ml/min/1.73m2 at presentation. Of these, 19.9% had definite chronic kidney disease and 8.4% had definite acute kidney injury. Detailed analysis of a random subset of patients with an eGFR <60ml/min/1.73m2 at presentation demonstrated that the major reasons for admission included falls, dehydration and fluid overload. 46% were on diuretics and 53% were on an ACEI or ARB or both. Gastrointestinal disturbance and recent medication changes were common and diuretic use persisted even with diarrhoea or vomiting.

Sepsis recognition tools in acute ambulatory care: associations with process of care and clinical outcomes in a service evaluation of an Emergency Multidisciplinary Unit in Oxfordshire

OBJECTIVE

To assess the performance of currently available sepsis recognition tools in patients referred to a community-based acute ambulatory care unit.

DESIGN

Service evaluation of consecutive patients over a 4-month period.

SETTING

Community-based acute ambulatory care unit.

DATA COLLECTION AND OUTCOME MEASURES

Observations, blood results and outcome data were analysed from patients with a suspected infection. Clinical features at first assessment were used to populate sepsis recognition tools including: systemic inflammatory response syndrome (SIRS) criteria, National Early Warning Score (NEWS), quick Sequential Organ Failure Assessment (qSOFA) and National Institute for Health and Care Excellence (NICE) criteria. Scores were assessed against the clinical need for escalated care (use of intravenous antibiotics, fluids, ongoing ambulatory care or hospital treatment) and poor clinical outcome (all-cause mortality and readmission at 30 days after index assessment).

RESULTS

Of 533 patients (median age 81 years), 316 had suspected infection with 120 patients requiring care escalated beyond simple community care. SIRS had the highest positive predictive value (50.9%, 95% CI 41.6% to 60.3%) and negative predictive value (68.9%, 95% CI 62.6% to 75.3%) for the need for escalated care. Both NEWS and SIRS were better at predicting the need for escalated care than qSOFA and NICE criteria in patients with suspected infection (all P<0.001). While new-onset confusion predicted the need for escalated care for infection in patients ≥85 years old (n=114), 23.7% of patients ≥85 years had new-onset confusion without evidence for infection.

CONCLUSIONS

Acute ambulatory care clinicians should use caution in applying the new NICE endorsed criteria for determining the need for intravenous therapy and hospital-based location of care. NICE criteria have poorer performance when compared against NEWS and SIRS and new-onset confusion was prevalent in patients aged ≥85 years without infection.

What is the evidence base for ambulatory care for acute medical illness?

Acute ambulatory care is a critical component of the emergency care pathway with national policy support and a dedicated NHS Improvement network. The evidence base for treating acute medical illness outside hospital is a diverse mix of randomised and observational studies with varying inclusion criteria, prognostic stratification, interventions and healthcare setting which limits synthesis of all available evidence and translation to the UK context. There is little consensus on the level of risk for home-based treatment for acute medical illness. Selection tools for referral to acute ambulatory care have been developed but there is limited evidence for their use. There are still research questions concerning optimal staffing, referral mechanisms, point of care diagnostic portfolio and tools for shared decision making.

Management of transient ischemic attacks diagnosed by early-career general practitioners: A cross-sectional study

Background Transient ischemic attack incurs a risk of recurrent stroke that can be dramatically reduced by urgent guideline-recommended management at the point of first medical contact. Aims This study describes the prevalence and associations of new transient ischemic attack presentations to general practice registrars and the management undertaken. Methods A cross-sectional analysis of the Registrar Clinical Encounters in Training cohort study. General practice registrars from five Australian states (urban to very remote practices) collected data on 60 consecutive patient encounters during each of their three six-month training terms. The proportion of problems managed being new transient ischemic attacks and proportion of transient ischemic attacks with guideline-recommended management were calculated. Univariate and multivariable logistic regression established associations of patient, registrar, and practice factors with a problem being a new transient ischemic attack. Results A total 1331 general practice registrars contributed data (response rate 95.8%). Of the 250,625 problems, there were 65 new transient ischemic attacks diagnosed (0.03% [95% confidence interval: 0.02-0.03%]). General practice registrars were more likely to seek help, generate learning goals, and spend more time for a new transient ischemic attack compared to other problems. Compliance with management guidelines was modest: 15.4% ordered brain and arterial imaging, 36.9% prescribed antiplatelet medication, and 3.1% prescribed antihypertensive medication. Conclusions Transient ischemic attack is a very infrequent presentation for general practice registrars, giving little clinical opportunity to reinforce training program education regarding guideline-recommended management. General practice registrars found transient ischemic attacks challenging and management was not ideal. Since most transient ischemic attacks first present to general practice and urgent management is essential, an enhanced model of care utilizing rapid access to specialist transient ischemic attack support and follow-up could improve guideline compliance.

Who breaches the four-hour emergency department wait time target? A retrospective analysis of 374,000 emergency department attendances between 2008 and 2013 at a type 1 emergency department in England

Background

The four-hour target is a key hospital emergency department performance indicator in England and one that drives the physical and organisational design of the ED. Some studies have identified time of presentation as a key factor affecting waiting times. Few studies have investigated other determinants of breaching the four-hour target. Therefore, our objective was to describe patterns of emergency department breaches of the four-hour wait time target and identify patients at highest risk of breaching.

Methods

This was a retrospective cohort study of a large type 1 Emergency department at an NHS teaching hospital in Oxford, England. We analysed anonymised individual level patient data for 378,873 emergency department attendances, representing all attendances between April 2008 and April 2013. We examined patient characteristics and emergency department presentation circumstances associated with the highest likelihood of breaching the four-hour wait time target.

Results

We used 374,459 complete cases for analysis. In total, 8.3% of all patients breached the four-hour wait time target. The main determinants of patients breaching the four-hour wait time target were hour of arrival to the ED, day of the week, patient age, ED referral source, and the types of investigations patients receive (p < 0.01 for all associations). Patients most likely to breach the four-hour target were older, presented at night, presented on Monday, received multiple types of investigation in the emergency department, and were not self-referred (p < 0.01 for all associations). Patients attending from October to February had a higher odds of breaching compared to those attending from March to September (OR 1.63, 95% CI 1.59 to 1.66).

Conclusions

There are a number of independent patient and circumstantial factors associated with the probability of breaching the four-hour ED wait time target including patient age, ED referral source, the types of investigations patients receive, as well as the hour, day, and month of arrival to the ED. Efforts to reduce the number of breaches could explore late-evening/overnight staffing, access to diagnostic tests, rapid discharge facilities, and early assessment and input on diagnostic and management strategies from a senior practitioner.

Systematic Review and Metaanalysis Comparing the Bias and Accuracy of the Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration Equations in Community-Based Populations

BACKGROUND

The majority of patients with chronic kidney disease are diagnosed and monitored in primary care. Glomerular filtration rate (GFR) is a key marker of renal function, but direct measurement is invasive; in routine practice, equations are used for estimated GFR (eGFR) from serum creatinine. We systematically assessed bias and accuracy of commonly used eGFR equations in populations relevant to primary care.

CONTENT

MEDLINE, EMBASE, and the Cochrane Library were searched for studies comparing measured GFR (mGFR) with eGFR in adult populations comparable to primary care and reporting both the Modification of Diet in Renal Disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations based on standardized creatinine measurements. We pooled data on mean bias (difference between eGFR and mGFR) and on mean accuracy (proportion of eGFR within 30% of mGFR) using a random-effects inverse-variance weighted metaanalysis. We included 48 studies of 26875 patients that reported data on bias and/or accuracy. Metaanalysis of within-study comparisons in which both formulae were tested on the same patient cohorts using isotope dilution-mass spectrometry-traceable creatinine showed a lower mean bias in eGFR using CKD-EPI of 2.2 mL/min/1.73 m² (95% CI, 1.1-3.2; 30 studies; I² = 74.4%) and a higher mean accuracy of CKD-EPI of 2.7% (1.6-3.8; 47 studies; I² = 55.5%). Metaregression showed that in both equations bias and accuracy favored the CKD-EPI equation at higher mGFR values.

SUMMARY

Both equations underestimated mGFR, but CKD-EPI gave more accurate estimates of GFR.

Managing transient ischaemic attacks in Australia: a qualitative study

BACKGROUND

Stroke risk after transient ischaemic attack (TIA) is highest in the first few days. It is greatly reduced by commencing commonly used medications. Current Australian guidelines recommend that all TIAs be managed urgently by secondary-care specialists (mandatory for high-risk TIAs). The majority of TIAs present to general practice which creates a dilemma when specialist care is not readily accessible. There is a lack of evidence relating to the determinants of general practitioners' (GPs) actions in this situation.

OBJECTIVE

To explore GP management of TIA presentations.

METHODS

A qualitative study using semi-structured interviews of a maximum variation sample of senior and trainee GPs from New South Wales, Australia. Data collection and thematic analysis were concurrent and iterative, employing constant comparison, co-coding, participant transcript review, reflexivity and continued until thematic saturation was achieved.

RESULTS

Management of TIA was heterogeneous and depended upon the GP's engagement with the individual case. The level of engagement was predicated on the GP's predisposition toward managing transient neurological presentations generally, the clinical phenotype of the presentation and logistical or health system factors. Management was categorised as triage, guided collaboration, consultative collaboration and independent management. Collaboration with secondary care increased the GP's capability to diagnose and manage future TIAs.

CONCLUSION

Heterogeneity of TIA management equates with variation from guideline recommendations. However, Australian guidelines may not be practicable due to variability in access to secondary-care specialists. Future models of care should consider systems approaches such as telemedicine to promote collaboration and assist GPs to comply with guidelines.

Clinical Characteristics of Pertussis-Associated Cough in Adults and Children: A Diagnostic Systematic Review and Meta-Analysis

BACKGROUND

Pertussis (whooping cough) is a highly infective cause of cough that causes significant morbidity and mortality. Existing case definitions include paroxysmal cough, whooping, and posttussive vomiting, but diagnosis can be difficult. We determined the diagnostic accuracy of clinical characteristics of pertussis-associated cough.

METHODS

We systematically searched CINAHL, Embase, Medline, and SCI-EXPANDED/CPCI-S up to June 2016. Eligible studies compared clinical characteristics in those positive and negative for Bordetella pertussis infection, confirmed by laboratory investigations. Two authors independently completed screening, data extraction, and quality and bias assessments. For each characteristic, RevMan was used to produce descriptive forest plots. The bivariate meta-analysis method was used to generate pooled estimates of sensitivity and specificity.

RESULTS

Of 1,969 identified papers, 53 were included. Forty-one clinical characteristics were assessed for diagnostic accuracy. In adult patients, paroxysmal cough and absence of fever have a high sensitivity (93.2% [CI, 83.2-97.4] and 81.8% [CI, 72.2-88.7], respectively) and low specificity (20.6% [CI, 14.7-28.1] and 18.8% [CI, 8.1-37.9]), whereas posttussive vomiting and whooping have low sensitivity (32.5% [CI, 24.5-41.6] and 29.8% [CI, 8.0-45.2]) and high specificity (77.7% [CI, 73.1-81.7] and 79.5% [CI, 69.4-86.9]). Posttussive vomiting in children is moderately sensitive (60.0% [CI, 40.3-77.0]) and specific (66.0% [CI, 52.5-77.3]).

CONCLUSIONS

In adult patients, the presence of whooping or posttussive vomiting should rule in a possible diagnosis of pertussis, whereas the lack of a paroxysmal cough or the presence of fever should rule it out. In children, posttussive vomiting is much less helpful as a clinical diagnostic test.

Embedding new technologies in practice - a normalization process theory study of point of care testing

Background

Many point of care diagnostic technologies are available which produce results within minutes, and offer the opportunity to deliver acute care out of hospital settings. Increasing access to diagnostics at the point of care could increase the volume and scope of acute ambulatory care. Yet these technologies are not routinely used in many settings. We aimed to explore how point of care testing is used in a setting where it has become ‘normalized’ (embedded in everyday practice), in order to inform future adoption and implementation in other settings. We used normalization process theory to guide our case study approach.

Methods

We used a single case study design, choosing a community based ambulatory care unit where point of care testing is used routinely. A focused ethnographic approach was taken, including non-participant observation of all activities related to point of care testing, and semi-structured interviews, with all clinical staff involved in point of care testing at the unit. Data were analysed thematically, guided by normalization process theory.

Results

Fourteen days of observation and six interviews were completed. Staff had a shared understanding of the purpose, value and benefits of point of care testing, believing it to be integral to the running of the unit. They organised themselves as a team to ensure that point of care testing worked effectively; and one key individual led a change in practice to ensure more consistency and trust in procedures. Staff assessed point of care testing as worthwhile for the unit, their patients, and themselves in terms of job satisfaction and knowledge. Potential barriers to adoption of point of care testing were evident (including lack of trust in the accuracy of some results compared to laboratory testing; and lack of ease of use of some aspects of the equipment); but these did not prevent point of care testing from becoming embedded, because the importance and value attributed to it were so strong.

Conclusions

This case study offers insights into successful adoption of new diagnostic technologies into every day practice. Such analyses may be critical to realising their potential to change processes of care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1834-3) contains supplementary material, which is available to authorized users.

Global Prevalence of Chronic Kidney Disease - A Systematic Review and Meta-Analysis

Chronic kidney disease (CKD) is a global health burden with a high economic cost to health systems and is an independent risk factor for cardiovascular disease (CVD). All stages of CKD are associated with increased risks of cardiovascular morbidity, premature mortality, and/or decreased quality of life. CKD is usually asymptomatic until later stages and accurate prevalence data are lacking. Thus we sought to determine the prevalence of CKD globally, by stage, geographical location, gender and age. A systematic review and meta-analysis of observational studies estimating CKD prevalence in general populations was conducted through literature searches in 8 databases. We assessed pooled data using a random effects model. Of 5,842 potential articles, 100 studies of diverse quality were included, comprising 6,908,440 patients. Global mean(95%CI) CKD prevalence of 5 stages 13·4%(11·7-15·1%), and stages 3-5 was 10·6%(9·2-12·2%). Weighting by study quality did not affect prevalence estimates. CKD prevalence by stage was Stage-1 (eGFR>90+ACR>30): 3·5% (2·8-4·2%); Stage-2 (eGFR 60-89+ACR>30): 3·9% (2·7-5·3%); Stage-3 (eGFR 30-59): 7·6% (6·4-8·9%); Stage-4 = (eGFR 29-15): 0·4% (0·3-0·5%); and Stage-5 (eGFR<15): 0·1% (0·1-0·1%). CKD has a high global prevalence with a consistent estimated global CKD prevalence of between 11 to 13% with the majority stage 3. Future research should evaluate intervention strategies deliverable at scale to delay the progression of CKD and improve CVD outcomes.

What is the relationship between renal function and visit-to-visit blood pressure variability in primary care? Retrospective cohort study from routinely collected healthcare data

OBJECTIVE

To determine the relationship between renal function and visit-to-visit blood pressure (BP) variability in a cohort of primary care patients.

DESIGN

Retrospective cohort study from routinely collected healthcare data.

SETTING

Primary care in Nijmegen, the Netherlands, from 2007 to 2012.

PARTICIPANTS

19 175 patients who had a measure of renal function, and 7 separate visits with BP readings in the primary care record.

OUTCOME MEASURES

Visit-to-visit variability in systolic BP, calculated from the first 7 office measurements, including SD, successive variation, absolute real variation and metrics of variability shown to be independent of mean. Multiple linear regression was used to analyse the influence of estimated glomerular filtration rate (eGFR) on BP variability measures with adjustment for age, sex, diabetes, mean BP, proteinuria, cardiovascular disease, time interval between measures and antihypertensive use.

RESULTS

In the patient cohort, 57% were women, mean (SD) age was 65.5 (12.3) years, mean (SD) eGFR was 75.6 (18.0) mL/min/1.73m(2) and SD systolic BP 148.3 (21.4) mm Hg. All BP variability measures were negatively correlated with eGFR and positively correlated with age. However, multiple linear regressions demonstrated consistent, small magnitude negative relationships between eGFR and all measures of BP variability adjusting for confounding variables.

CONCLUSIONS

Worsening renal function is associated with small increases in measures of visit-to-visit BP variability after adjustment for confounding factors. This is seen across the spectrum of renal function in the population, and provides a mechanism whereby chronic kidney disease may raise the risk of cardiovascular events.

Increase in antibiotic prescriptions in out-of-hours primary care in contrast to in-hours primary care prescriptions: service evaluation in a population of 600 000 patients

OBJECTIVES

The objective of this study was to describe the frequency and nature of antibiotic prescriptions issued by a primary care out-of-hours (OOH) service and compare time trends in prescriptions between OOH and in-hours primary care.

METHODS

We performed a retrospective audit of 496 931 patient contacts with the Oxfordshire OOH primary care service. Comparison of time trends in antibiotic prescriptions from OOH primary care and in-hours primary care for the same population was made using multiple linear regression models fitted to the monthly data for OOH prescriptions, OOH contacts and in-hours prescriptions between September 2010 and August 2014.

RESULTS

Compared with the overall population contacting the OOH service, younger age, female sex and patients who were less deprived were independently correlated with an increased chance of a contact resulting in prescription of antibiotics. The majority of antibiotics were prescribed to patients contacting the service at weekends. Despite a reduction in patient contacts with the OOH service [an estimated decrease of 486.5 monthly contacts each year (95% CI -676.3 to -296.8), 5.0% of the average monthly contacts], antibiotic prescriptions from this service rose during the study period [increase of 37.1 monthly prescriptions each year (95% CI 10.6-63.7), 2.5% of the average monthly prescriptions]. A matching increase was not seen for in-hours antibiotic prescriptions; the difference between the year trends was significant (Z test, P = 0.002).

CONCLUSIONS

We have demonstrated trends in prescribing that could represent a partial displacement of antibiotic prescribing from in-hours to OOH primary care. The possibility that the trends we describe are evident nationally should be explored.

Chronic renal disease is not chronic kidney disease: implications for use of the QRISK and Joint British Societies risk scores

BACKGROUND

Chronic kidney disease (CKD) is a major risk factor for cardiovascular disease (CVD) and European guidelines advocate assessment of CVD risk. QRISK and JBS3 risk calculators do not use the consensus definition of CKD stages 3-5 but instead use a definition referring to renal pathologies and CKD stages 4 and 5. Consequently, there is potential for doctors to misclassify their patients when using these risk calculators.

OBJECTIVES

To quantify the number of people who may be affected by such misclassifications.

METHODS

Database analysis using the Clinical Practice Research Datalink (CPRD).We identified 2512053 adults aged 25-84 without prior history of CVD on 1st January 2014. We identified those with 'chronic renal disease' and/or CKD by searching medical event history data.

RESULTS

The study population was 48.7% male with mean age of 50.2 years. A total of 80718 had diagnostic READ codes for CKD stages 3, 4 or 5. Of these, 6585 individuals (8.2%) were classified as having 'chronic renal disease' according to the updated QRISK 2014, up from 3365 according to QRISK 2013. Whilst the updated QRISK definition of 'chronic renal disease' in total identified 62% more people than previously and had improved sensitivity for CKD stages 3 to 5, sensitivity remained poor (8.16%; 95% CI: 7.97-8.35%).

CONCLUSION

Misuse of risk scores by general practitioners could result in clinically important differences in risk estimates. Users of risk scores should recognize the potential for error and developers should aim to label risk factors more clearly.

"Sometimes we can't fix things": a qualitative study of health care professionals' perceptions of end of life care for patients with heart failure

BACKGROUND

Although heart failure has a worse prognosis than some cancers, patients often have restricted access to well-developed end of life (EoL) models of care. Studies show that patients with advanced heart failure may have a poor understanding of their condition and its outcome and, therefore, miss opportunities to discuss their wishes for EoL care and preferred place of death. We aimed to explore the perceptions and experiences of health care professionals (HCPs) working with patients with heart failure around EoL care.

METHODS

A qualitative in-depth interview study nested in a wider ethnographic study of unplanned admissions in patients with heart failure (HoldFAST). We interviewed 24 HCPs across primary, secondary and community care in three locations in England, UK - the Midlands, South Central and South West.

RESULTS

The study revealed three issues impacting on EoL care for heart failure patients. Firstly, HCPs discussed approaches to communicating with patients about death and highlighted the challenges involved. HCPs would like to have conversations with patients and families about death and dying but are aware that patient preferences are not easy to predict. Secondly, professionals acknowledged difficulties recognising when patients have reached the end of their life. Lack of communication between patients and professionals can result in situations where inappropriate treatment takes place at the end of patients' lives. Thirdly, HCPs discussed the struggle to find alternatives to hospital admission for patients at the end of their life. Patients may be hospitalised because of a lack of planning which would enable them to die at home, if they so wished.

CONCLUSIONS

The HCPs regarded opportunities for patients with heart failure to have ongoing discussions about their EoL care with clinicians they know as essential. These key professionals can help co-ordinate care and support in the terminal phase of the condition. Links between heart failure teams and specialist palliative care services appear to benefit patients, and further sharing of expertise between teams is recommended. Further research is needed to develop prognostic models to indicate when a transition to palliation is required and to evaluate specialist palliative care services where heart failure patients are included.

GPs' adherence to guidelines for structured assessments of stroke survivors in the community and care homes

BACKGROUND

Clinical practice guidelines recommend that stroke survivors' needs be assessed at regular intervals after stroke. The extent to which GPs comply with national guidance particularly for patients in care homes who have greatest clinical complexity is unknown.

OBJECTIVES

This study aimed to establish the current clinical practice in the UK of needs assessment by GPs for stroke survivors after hospital discharge for acute stroke.

METHODS

Cross-sectional online survey of current practice of GPs, using the national doctors.net network.

RESULTS

The survey was completed by 300 GPs who had on average been working for 14 years. The structured assessment of stroke survivors' needs was not offered by 31% of GPs, with no significant difference for level of provision in community or care home settings. The outputs of reviews were added to patients' notes by 89% of GPs and used to change management by 57%. Only half the GPs reported integrating the information obtained into care plans and only a quarter of GPs had a protocol for follow-up of identified needs. Analysis of free-text comments indicated that patients in some care homes may receive more regular and structured reviews.

CONCLUSIONS

This survey suggests that at least one-third of GPs provide no formal review of the needs of stroke patients and that in only a minority are identified needs addressed in a structured way. Standardization is required for what is included in reviews and how needs are being identified and met.

Managing patients with heart failure: a qualitative study of multidisciplinary teams with specialist heart failure nurses

PURPOSE

The purpose of this study was to explore the perceptions and experiences of health care clinicians working in multidisciplinary teams that include specialist heart failure nurses when caring for the management of heart failure patients.

METHODS

We used a qualitative in-depth interview study nested in a broader ethnographic study of unplanned admissions in heart failure patients (HoldFAST). We interviewed 24 clinicians across primary, secondary, and community care in 3 locations in the Midlands, South Central, and South West of England.

RESULTS

Within a framework of the role and contribution of the heart failure specialist nurse, our study identified 2 thematic areas that the clinicians agreed still represent particular challenges when working with heart failure patients. The first was communication with patients, in particular explaining the diagnosis and helping patients to understand the condition. The participants recognized that such communication was most effective when they had a long-term relationship with patients and families and that the specialist nurse played an important part in achieving this relationship. The second was communication within the team. Multidisciplinary input was especially needed because of the complexity of many patients and issues around medications, and the participants believed the specialist nurse may facilitate team communication.

CONCLUSIONS

The study highlights the role of specialist heart failure nurses in delivering education tailored to patients and facilitating better liaison among all clinicians, particularly when dealing with the management of comorbidities and drug regimens. The way in which specialist nurses were able to be caseworkers for their patients was perceived as a method of ensuring coordination and continuity of care.

Automated Risk Assessment for Stroke in Atrial Fibrillation (AURAS-AF)--an automated software system to promote anticoagulation and reduce stroke risk: study protocol for a cluster randomised controlled trial

Background

Patients with atrial fibrillation (AF) are at significantly increased risk of stroke. Oral anticoagulants (OACs) substantially reduce this risk, with gains seen across the spectrum of baseline risk. Despite the benefit to patients, OAC prescribing remains suboptimal in the United Kingdom (UK). We will investigate whether an automated software system, operating within primary care electronic medical records, can improve the management of AF by identifying patients eligible for OAC therapy and increasing uptake of this treatment.

Methods/Design

We will conduct a cluster randomised controlled trial, involving general practices using the Egton Medical Information Systems (EMIS) Web clinical system. We will randomise practices to use an electronic software tool or to continue with usual care. The tool will a) produce (and continually refresh) a list of patients with AF who are eligible for OAC therapy - practices will invite these patients to discuss therapy at the start of the trial - and b) generate electronic screen reminders in the medical records of those eligible, appearing throughout the trial. The software will run for 6 months in 23 intervention practices. A total of 23 control practices will manage their AF register in line with the usual care offered. The primary outcome is change in proportion of eligible patients with AF who have been prescribed OAC therapy after six months. Secondary outcomes are incidence of stroke, transient ischaemic attack, other major thromboembolism, major haemorrhage and reports of inappropriate OAC prescribing in the data collection sample - those deemed eligible for OACs. We will conduct a process evaluation in parallel with the randomised trial. We will use qualitative methods to examine patient and practitioner views of the intervention and its impact on primary care practice, including its time implications.

Discussion

AURAS-AF will investigate whether a simple intervention, using electronic primary care records, can improve OAC uptake in a high risk group for stroke. Given previous concerns about safety, especially surrounding inappropriate prescribing, we will also examine whether electronic reminders safely impact care in this clinical area.

Trial registration

http://ISRCTN 55722437

Validation of a TIA Recognition Tool in Primary and Secondary Care: Implications for Generalizability

Background

In spite of public education campaigns, patients with transient ischemic attack still present to primary care where accurate recognition of transient ischemic attack is essential so that specialist referral can be expedited to reduce stroke risk. The complex task of diagnosing transient ischemic attack is challenging in time-limited settings in primary care yet the potential for a transient ischemic attack recognition tool to improve diagnosis has not been determined.

Aims

We set out to examine the potential utility in primary care of the only existing transient ischemic attack recognition tool.

Methods

All primary care referrals with suspected transient ischemic attack from a total population of 91 000 people were analyzed over a four-year period from 2002 to 2006. Clinical and research records from the transient ischemic attack clinic and consultation notes and referral letters from primary care physicians were used to populate the Dawson recognition score.

Results

Of 513 referrals, 209 (47%) had a clinic confirmed diagnosis of transient ischemic attack. Agreement between primary care assessments and specialist assessments was greater for speech disturbance (kappa 0·68) than for unilateral facial weakness (0·58) and unilateral limb weakness (0·51). The Dawson score had greater accuracy in diagnosing all transient ischemic attack in specialist assessments than in primary care assessments (c statistics 0·80 vs. 0·70, P < 0·0001) and performed particularly poorly in primary care for detecting posterior circulation territory transient ischemic attack with a c statistic (95% confidence interval) of 0·52 (0·43–0·61).

Conclusion

The Dawson transient ischemic attack recognition score is less accurate in primary care than in its derivation setting of specialist care. Improving the recognition of transient ischemic attack by providers of first contact health care requires derivation of rules in the clinical setting in which they are to be used.

Philosophy of science and the diagnostic process

This is an overview of the principles that underpin philosophy of science and how they may provide a framework for the diagnostic process. Although philosophy dates back to antiquity, it is only more recently that philosophers have begun to enunciate the scientific method. Since Aristotle formulated deduction, other modes of reasoning including induction, inference to best explanation, falsificationism, theory-laden observations and Bayesian inference have emerged. Thus, rather than representing a single overriding dogma, the scientific method is a toolkit of ideas and principles of reasoning. Here we demonstrate that the diagnostic process is an example of science in action and is therefore subject to the principles encompassed by the scientific method. Although a number of the different forms of reasoning are used readily by clinicians in practice, without a clear understanding of their pitfalls and the assumptions on which they are based, it leaves doctors open to diagnostic error. We conclude by providing a case example from the medico-legal literature in which diagnostic errors were made, to illustrate how applying the scientific method may mitigate the chance for diagnostic error.

Impact on cardiovascular risk follow-up from a shift to the CKD-EPI formula for eGFR reporting: a cross-sectional population-based primary care study

OBJECTIVE

To assess the impact on cardiovascular risk factor management in primary care by the introduction of chronic kidney disease epidemiological collaboration (CKD-EPI) for estimated-glomerular filtration rate (eGFR) reporting.

DESIGN AND SETTING

Cross-sectional study of routine healthcare provision in 47 primary care practices in The Netherlands with Modification of Diet and Renal Disease Study eGFR reporting.

METHODS

eGFR values were recalculated using CKD-EPI in patients with available creatine tests. Patients reclassified from CKD stage 3a to CKD stage 2 eGFR range were compared to those who remained in stage 3a for differences in demographic variables, blood pressure, comorbidity, medication usage and laboratory results.

RESULTS

Among the 60 673 adult patients (37% of adult population) with creatine values, applying the CKD-EPI equation resulted in a 16% net reduction in patients with CKD stage 3 or worse. Patients reclassified from stage 3a to 2 had lower systolic blood pressure (139.7 vs 143.3 mm Hg p<0.0001), higher diastolic blood pressure (81.5 vs 78.4 mm Hg p<0.0001) and higher cholesterol (5.4 vs 5.1 mmol/L p<0.0001) compared to those who remained in stage 3a. Of those reclassified out of a CKD diagnosis 463 (32%) had no comorbidities that would qualify for annual CVD risk factor assessment and 20 (12% of those with sufficient data) had a EuroSCORE CVD risk >20% within 10 years.

CONCLUSIONS

Use of the CKD-EPI equation will result in many patients being removed from CKD registers and the associated follow-up. Current risk factor assessment in this group may be lacking from routine data and some patients within this group are at an increased risk for cardiovascular events.

Under-reporting of socioeconomic status of patients in stroke trials: adherence to CONSORT principles

BACKGROUND AND PURPOSE

The 2001 Revised Consolidated Standards of Reporting of Trials (CONSORT) statement requires reporting of Randomized Controlled Trials (RCTs) to include participants' baseline demographics. This enables comparison of intervention and control groups on potential confounding variables as well as assessment of study generalizability. Socioeconomic status (SES) is associated with access to care and outcomes (mortality, functional outcome, recurrent stroke, and hospital readmission) poststroke. We aimed to document the reporting of baseline SES in reports of RCTs of stroke and transient ischemic attack.

METHODS

Measures of SES were extracted from studies reporting trials of stroke or transient ischemic attack published in 12 major journals in the disciplines of general medicine, general neurology, cerebrovascular disease, and rehabilitation subsequent to revised CONSORT. Percentages of studies reporting SES measures were calculated. Differences in reporting between journal categories, and temporal trends in reporting, were tested.

RESULTS

Only 12% of studies reported any SES measure. Journal categories did not differ in rate of SES reporting. SES reporting did not increase over time.

CONCLUSIONS

Improving reporting of SES could enhance clinicians' ability to evaluate RCT findings and apply them to their patients.

Transient neurological symptoms in the older population: report of a prospective cohort study--the Medical Research Council Cognitive Function and Ageing Study (CFAS)

OBJECTIVE

Transient ischaemic attack (TIA) is a recognised risk factor for stroke in the older population requiring timely assessment and treatment by a specialist. The need for such TIA services is driven by the epidemiology of transient neurological symptoms, which may not be caused by TIA. We report prevalence and incidence of transient neurological symptoms in a large UK cohort study of older people.

DESIGN

Longitudinal cohort study

SETTING

The Medical Research Council Cognitive Function and Aging Study (CFAS) is a population representative study based on six centres across England and Wales.

PARTICIPANTS

Random samples of people in their 65th year were obtained from Family Health Service Authority lists. The participation rate was 80% (n=13 004). Interview at baseline included questions about stroke and three transient neurological symptoms, repeated in a subsample after 2 years. Patients were flagged for mortality.

MAIN OUTCOME MEASURES

Prevalence and 2-year incidence of transient neurological symptoms.

RESULTS

In 11 903 participants without a history of stroke, 271 (2.3%) reported transient problems with speech, 872 (7.6%) with sight and 596 (5.1%) weakness in a limb with 1456 (12.7%) reporting at least one symptom. Of those reinterviewed (n=6748), 675 (9.8%) reported at least one symptom over 2 years.

CONCLUSIONS

Lifetime prevalence and incidence of transient neurological symptoms in people aged 65 years and over is high and is substantially greater than the incidence of TIA in hospital-based and population-based studies. These high rates of transient neurological symptoms in the community in the older population should be considered when planning TIA services.

Questionnaire study of the association between patient numbers and regular visiting by general practitioners in care homes

BACKGROUND

regular visiting in care homes enables proactive care. Surveys of managers found variation in medical care yet little is known about factors influencing general practitioners (GPs) visiting patterns. We examined whether practice factors including numbers of registered patients are associated with regular visiting.

DESIGN AND SETTING

postal questionnaires sent to 73 care homes of European Care Group and separate questionnaires to visiting practices.

METHODS

information on regularity of visiting was requested from homes and practices. Practices were asked for numbers of doctors and training status. As data were not normally distributed, non-parametric tests were used to compare practices regularly visiting with those visiting only on request in terms of numbers of registered care home patients.

RESULTS

forty-seven (64%) of homes responded, with care provided for 1,867 patients by 162 practices. Practices visiting regularly had significantly more patients than practices that did not [median (IQR) 32 (28) versus 3 (5), P < 0.001]. Ninety-five (31%) of practices responded showing a similar association of registrations with regular visiting [median (IQR) 20 (37) versus 4 (4), P < 0.001]. There was no association between numbers of doctors or training status on regular visiting.

CONCLUSION

the number of registered patients is strongly associated with regular care home visiting. Aligning practices with care homes thereby increasing registered patients per practice could encourage proactive care.

The evidence underpinning sports performance products: a systematic assessment

BACKGROUND

To assess the extent and nature of claims regarding improved sports performance made by advertisers for a broad range of sports-related products, and the quality of the evidence on which these claims are based.

METHODS

The authors analysed magazine adverts and associated websites of a broad range of sports products. The authors searched for references supporting the performance and/or recovery claims of these products. The authors critically appraised the methods in the retrieved references by assessing the level of evidence and the risk of bias. The authors also collected information on the included participants, adverse events, study limitations, the primary outcome of interest and whether the intervention had been retested.

RESULTS

The authors viewed 1035 web pages and identified 431 performance-enhancing claims for 104 different products. The authors found 146 references that underpinned these claims. More than half (52.8%) of the websites that made performance claims did not provide any references, and the authors were unable to perform critical appraisal for approximately half (72/146) of the identified references. None of the references referred to systematic reviews (level 1 evidence). Of the critically appraised studies, 84% were judged to be at high risk of bias. Randomisation was used in just over half of the studies (58.1%), allocation concealment was only clear in five (6.8%) studies; and blinding of the investigators, outcome assessors or participants was only clearly reported as used in 20 (27.0%) studies. Only three of the 74 (2.7%) studies were judged to be of high quality and at low risk of bias.

CONCLUSIONS

The current evidence is not of sufficient quality to inform the public about the benefits and harms of sports products. There is a need to improve the quality and reporting of research, a move towards using systematic review evidence to inform decisions.

How quickly should we titrate antihypertensive medication? Systematic review modelling blood pressure response from trial data

CONTEXT

There are no evidence syntheses available to guide clinicians on when to titrate antihypertensive medication after initiation.

OBJECTIVE

To model the blood pressure (BP) response after initiating antihypertensive medication. Data sources electronic databases including Medline, Embase, Cochrane Register and reference lists up to December 2009.

STUDY SELECTION

Trials that initiated antihypertensive medication as single therapy in hypertensive patients who were either drug naive or had a placebo washout from previous drugs.

DATA EXTRACTION

Office BP measurements at a minimum of two weekly intervals for a minimum of 4 weeks. An asymptotic approach model of BP response was assumed and non-linear mixed effects modelling used to calculate model parameters.

RESULTS AND CONCLUSIONS

Eighteen trials that recruited 4168 patients met inclusion criteria. The time to reach 50% of the maximum estimated BP lowering effect was 1 week (systolic 0.91 weeks, 95% CI 0.74 to 1.10; diastolic 0.95, 0.75 to 1.15). Models incorporating drug class as a source of variability did not improve fit of the data. Incorporating the presence of a titration schedule improved model fit for both systolic and diastolic pressure. Titration increased both the predicted maximum effect and the time taken to reach 50% of the maximum (systolic 1.2 vs. 0.7 weeks; diastolic 1.4 vs. 0.7 weeks).

CONCLUSIONS

Estimates of the maximum efficacy of antihypertensive agents can be made early after starting therapy. This knowledge will guide clinicians in deciding when a newly started antihypertensive agent is likely to be effective or not at controlling BP.

Chronic kidney disease: a large-scale population-based study of the effects of introducing the CKD-EPI formula for eGFR reporting

Objective To evaluate the effects of introducing the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) formula for estimated glomerular filtration rate (eGFR) reporting in the adult population in routine clinical practice with clinician-directed testing. Design Retrospective study of all creatinine measurements and calculation of eGFRs using Modification of Diet in Renal Disease (MDRD) and CKD-EPI formulae. Setting General population, Oxfordshire, UK. Participants An unselected population of around 660 000. Interventions Reporting of eGFRs using MDRD or CKD-EPI formulae. Primary and secondary outcome measures Evaluation of the effects of the CKD-EPI formula on the prevalence of different stages of chronic kidney disease (CKD). Results The CKD-EPI formula reduced the prevalence of CKD (stages 2-5) by 16.4% in patients tested in primary care. At the important stage 2-stage 3 cut-off, there was a relative reduction of 7.5% in the prevalence of CKD stages 3-5 from 15.7% to 14.5%. The CKD-EPI formula reduced the prevalence of CKD stages 3-5 in those aged <70 but increased it at ages >70. Above 70 years, the prevalence of stages 3-5 was similar with both equations for women (around 41.2%) but rose in men from 33.3% to 35.5%. CKD stages 4-5 rose by 15% due exclusively to increases in the over 70s, which could increase specialist referral rates. The CKD classification of 18.3% of all individuals who had a creatinine measurement was altered by a change from the MDRD to the CKD-EPI formula. In the UK population, the classification of up to 3 million patients could be altered, the prevalence of CKD could be reduced by up to 1.9 million and the prevalence of CKD stages 3-5 could fall by around 200 000. Conclusions Introduction of the CKD-EPI formula for eGFR reporting will reduce the prevalence of CKD in a primary care setting with current testing practice but will raise the prevalence in the over 70s age group. This has implications for clinical practice, healthcare policy and current prevalence-based funding arrangements.

Population-Based Study of Behavior Immediately After Transient Ischemic Attack and Minor Stroke in 1000 Consecutive Patients

Background and Purpose— Most guidelines now recommend that patients with minor stroke or high-risk transient ischemic attack (TIA) are assessed within 24 hours of their event, but the feasibility of this depends on patients’ behavior. We studied behavior immediately after TIA and minor stroke according to clinical characteristics, patients’ perception of the nature of the event, and their predicted stroke risk.

Methods— In a population-based study in Oxfordshire, UK, with face-to-face interview of 1000 consecutive patients with TIA and minor stroke (National Institutes of Health Stroke Scale ≤5) from 2002 to 2007 (Oxford Vascular Study), we studied delay in seeking medical attention and identified patients who did not seek attention after an initial event and only presented after a recurrent stroke.

Results— Of 1000 patients (459 TIAs, 541 minor strokes), 300 (67%) with TIA and 400 (74%) with minor stroke sought medical attention within 24 hours and 208 (47%) and 234 (46%), respectively, sought attention within 3 hours. Most patients (77%) first sought attention through their primary care physician. In patients with TIA, incorrect recognition of symptoms, absence of motor or speech symptoms, shorter duration of event, lower ABCD 2 score, no history of stroke or atrial fibrillation, and weekend presentation were associated with significantly longer delays. However, age, sex, social class, and educational level were all unrelated to either correct recognition of symptoms or to delay in seeking attention. Of 129 patients with TIA or minor stroke who had a recurrent stroke within 90 days, 41 (31%) did not seek medical attention after their initial event. These patients were more likely to have had a TIA ( P =0.003), shorter duration of event ( P =0.02), and a history of TIA ( P =0.09) and less likely to have had motor ( P =0.004) or speech symptoms ( P =0.04) compared with those patients who sought medical attention for their initial event.

Conclusion— Approximately 70% of patients do not correctly recognize their TIA or minor stroke, 30% delay seeking medical attention for >24 hours, regardless of age, sex, social class, or educational level, and approximately 30% of early recurrent strokes occur before seeking attention. Without more effective public education of all demographic groups, the full potential of acute prevention will not be realized.

Optimal insulin regimens in type 2 diabetes mellitus: systematic review and meta-analyses

AIMS/HYPOTHESIS

We compared the effect of biphasic, basal or prandial insulin regimens on glucose control, clinical outcomes and adverse events in people with type 2 diabetes.

METHODS

We searched the Cochrane Library, MEDLINE, EMBASE and major American and European conference abstracts for randomised controlled trials up to October 2008. A systematic review and meta-analyses were performed.

RESULTS

Twenty-two trials that randomised 4,379 patients were included. Seven trials reported both starting insulin dose and titration schedules. Hypoglycaemia definitions and glucose targets varied. Meta-analyses were performed pooling data from insulin-naive patients. Greater HbA(1c) reductions were seen with biphasic and prandial insulin, compared with basal insulin, of 0.45% (95% CI 0.19-0.70, p = 0.0006) and 0.45% (95% CI 0.16-0.73, p = 0.002), respectively, but with lesser reductions of fasting glucose of 0.93 mmol/l (95% CI 0.21-1.65, p = 0.01) and 2.20 mmol/l (95% CI 1.70-2.70, p < 0.00001), respectively. Larger insulin doses at study end were reported in biphasic and prandial arms compared with basal arms. No studies found differences in major hypoglycaemic events, but minor hypoglycaemic events for prandial and biphasic insulin were inconsistently reported as either higher than or equivalent to basal insulin. Greater weight gain was seen with prandial compared with basal insulin (1.86 kg, 95% CI 0.80-2.92, p = 0.0006).

CONCLUSIONS/INTERPRETATION

Greater HbA(1c) reduction may be obtained in type 2 diabetes when insulin is initiated using biphasic or prandial insulin rather than a basal regimen, but with an unquantified risk of hypoglycaemia. Studies with longer follow-up are required to determine the clinical relevance of this finding.

Influence of general practice opening hours on delay in seeking medical attention after transient ischaemic attack (TIA) and minor stroke: prospective population based study

OBJECTIVE

To assess the influence of general practice opening hours on healthcare seeking behaviour after transient ischaemic attack (TIA) and minor stroke and feasibility of clinical assessment within 24 hours of symptom onset.

DESIGN

Population based prospective incidence study (Oxford vascular study).

SETTING

Nine general practices in Oxfordshire.

PARTICIPANTS

91 000 patients followed from 1 April 2002 to 31 March 2006.

MAIN OUTCOME MEASURES

Events that occurred overnight and at weekends (out of hours) and events that occurred during surgery hours.

RESULTS

Among 359 patients with TIA and 434 with minor stroke, the median (interquartile range) time to call a general practitioner after an event during surgery hours was 4.0 (1.0-45.5) hours, and 68% of patients with events during surgery hours called within 24 hours of onset of symptoms. Median (interquartile range) time to call a general practitioner after events out of hours was 24.8 (9.0-54.5) hours for patients who waited to contact their registered practice compared with 1.0 (0.3-2.6) hour in those who used an emergency general practitioner service (P<0.001). In patients with events out of hours who waited to see their own general practitioner, seeking attention within 24 hours was considerably less likely for events at weekends than weekdays (odds ratio 0.10, 95% confidence interval 0.05 to 0.21): 70% with events Monday to Friday, 33% on Sundays, and none on Saturdays. Thirteen patients who had events out of hours and did not seek emergency care had a recurrent stroke before they sought medical attention. A primary care centre open 8 am-8 pm seven days a week would have offered cover to 73 patients who waited until surgery hours to call their general practitioner, reducing median delay from 50.1 hours to 4.0 hours in that group and increasing those calling within 24 hours from 34% to 68%.

CONCLUSIONS

General practitioners' opening hours influence patients' healthcare seeking behaviour after TIA and minor stroke. Current opening hours can increase delay in assessment. Improved access to primary care and public education about the need for emergency care are required if the relevant targets in the national stroke strategy are to be met.