Disease patterns in high-cost individuals with multimorbidity: a retrospective cross-sectional study in primary care

BACKGROUND

'High-cost' individuals with multimorbidity account for a disproportionately large share of healthcare costs and are at most risk of poor quality of care and health outcomes.

AIM

To compare high-cost with lower-cost individuals with multimorbidity and assess whether these populations can be clustered based on similar disease patterns.

DESIGN AND SETTING

A cross-sectional study based on 2019/2020 electronic medical records from adults registered to primary care practices (n = 41) in a London borough.

METHOD

Multimorbidity is defined as having ≥2 long-term conditions (LTCs). Primary care costs reflected consultations, which were costed based on provider and consultation types. High cost was defined as the top 20% of individuals in the cost distribution. Descriptive analyses identified combinations of 32 LTCs and their contribution to costs. Latent class analysis explored clustering patterns.

RESULTS

Of 386 238 individuals, 101 498 (26%) had multimorbidity. The high-cost group (n = 20 304) incurred 53% of total costs and had 6833 unique disease combinations, about three times the diversity of the lower-cost group (n = 81 194). The trio of anxiety, chronic pain, and depression represented the highest share of costs (5%). High-cost individuals were best grouped into five clusters, but no cluster was dominated by a single LTC combination. In three of five clusters, mental health conditions were the most prevalent.

CONCLUSION

High-cost individuals with multimorbidity have extensive heterogeneity in LTCs, with no single LTC combination dominating their primary care costs. The frequent presence of mental health conditions in this population supports the need to enhance coordination of mental and physical health care to improve outcomes and reduce costs.

Assessment of ethnic inequalities in diagnostic coding of familial hypercholesterolaemia (FH): A cross-sectional database study in Lambeth, South London

BACKGROUND AND AIMS

Differences in the perceived prevalence of familial hypercholesterolemia (FH) by ethnicity are unclear. In this study, we aimed to assess the prevalence, determinants and management of diagnostically-coded FH in an ethnically diverse population in South London.

METHODS

A cross-sectional analysis of 40 practices in 332,357 adult patients in Lambeth was undertaken. Factors affecting a (clinically coded) diagnosis of FH were investigated by multi-level logistic regression adjusted for socio-demographic and lifestyle factors, co-morbidities, and medications.

RESULTS

The age-adjusted FH % prevalence rate (OR, 95%CI) ranged from 0.10 to 1.11, 0.00-1.31. Lower rates of FH coding were associated with age (0.96, 0.96-0.97) and male gender (0.75, 0.65-0.87), p < 0.001. Compared to a White British reference group, a higher likelihood of coded FH was noted in Other Asians (1.33, 1.01-1.76), p = 0.05, with lower rates in Black Africans (0.50, 0.37-0.68), p < 0.001, Indians (0.55, 0.34-0.89) p = 0.02, and in Black Caribbeans (0.60, 0.44-0.81), p = 0.001. The overall prevalence using Simon Broome criteria was 0.1%; we were unable to provide ethnic specific estimates due to low numbers. Lower likelihoods of FH coding (OR, 95%CI) were seen in non-native English speakers (0.66, 0.53-0.81), most deprived income quintile (0.68, 0.52-0.88), smokers (0.68,0.55-0.85), hypertension (0.62, 0.52-0.74), chronic kidney disease (0.64, 0.41-0.99), obesity (0.80, 0.67-0.95), diabetes (0.31, 0.25-0.39) and CVD (0.47, 0.36-0.63). 20% of FH coded patients were not prescribed lipid-lowering medications, p < 0.001.

CONCLUSIONS

Inequalities in diagnostic coding of FH patients exist. Lower likelihoods of diagnosed FH were seen in Black African, Black Caribbean and Indian ethnic groups, in contrast to higher diagnoses in White and Other Asian ethnic groups. Hypercholesterolaemia requiring statin therapy was associated with FH diagnosis, however, the presence of cardiovascular disease (CVD) risk factors lowered the diagnosis rate for FH.

Factors affecting the delivery of community-based salon interventions to prevent cardiovascular disease and breast cancer among ethnically diverse women in South London: a concept-mapping approach

BACKGROUND

In the UK, women from ethnically diverse and socioeconomically deprived communities are at increased risk of underdiagnosis of cardiovascular disease (CVD) and breast cancer. Promoting CVD prevention and awareness of breast cancer screening via community salons and primary health care partnerships can improve uptake of screening services and early detection.

METHODS

Concept mapping is a multistage mixed methods participatory approach comprised of six stages: preparation, brainstorming, structuring of statements, representing statements, interpretation and utilisation of maps using Group wisdom software. A target of 20 salons, excluding male-only salons were approached. Salons included Salons included hairdressing or hairdressing and beauty salons. Purposeful and convenience sampling (online and face to face) among UK salons (hair and beauty) was conducted. Participants were given a focus prompt "What would be some factors that can influence the ability of salons to deliver this service?" and required to generate statements, which were sorted into categories based on similarity and rated for importance and feasibility. Concept maps using multidimensional scaling and hierarchical cluster analyses were produced.

FINDINGS

Of 35 participants invited, 25 (71%) consented and agreed to take part in concept mapping. Reported ages were 26-35 years (n=5, 20%), 36-45 years (n=12, 48%), 46-55 years (n=3, 12%), 56-65 years (n=5, 20%), and no age reported (n=10, 40%). Around 36% (n=9) of participants were from non-White ethnic groups, with 12% (n=3) being male and 88% (n=22) female. Seven clusters emerged. Salon staff capabilities and capacities and engaging in health conversations in community salons scored average bridging values of 0·09 and 0·2 respectively, indicating good cluster homogeneity (similar meaning statements were closely sorted). Facilitating health-care access with GP practices was rated highly important to effectively promote the intervention. Engaging in health conversations in community salons and salon incentives for participation were examples of factors that were highly feasible to address. The r correlation coefficient was 0·68 between importance and feasibility to address factors affecting community health interventions.

INTERPRETATION

Salons are well positioned to support health promotion interventions. Actionable priorities were identified for a salon-GP surgery partnership to promote CVD prevention through lifestyle changes and health check uptake, raising breast cancer screening awareness and address issue of equity.

FUNDING

National Institute of Health and Care Research (NIHR), Research for Patient Benefit (RfPB) Programme NIHR202769.

Determinants of lipid clinic referral and attendance in a multi-ethnic adult population in south London: a cross-sectional study

BACKGROUND

Primary dyslipidaemias, including familial hypercholesterolaemia, are underdiagnosed genetic disorders that substantially increase risk for premature coronary artery disease in adults. Early identification of primary dyslipidaemias via lipid clinic referral optimises patient management and enables cascade screening of relatives. Improving the identification of primary dyslipidaemias, and understanding disparities in ascertainment and management, is an NHS priority. We aimed to assess determinants of lipid clinic referral or attendance (LCR) in ethnically diverse adults.

METHODS

We did a retrospective cross-sectional study using the Lambeth DataNet containing anonymised data from 41 general practitioner (GP) practices in south London. We looked at referral data for adult patients aged 18 years and older from Jan 1, 1995, until May 14, 2018. LCR was the main outcome. We used sequential multilevel logistic regression models adjusted for practice effects to estimate the odds of LCR assessed across six ethnic groups (reference group White) and patient-level factors (demographic, socioeconomic, lifestyle, comorbidities, total cholesterol [TC] >7·5mmol/L, statin prescription, and practice factors). The study was approved by NHS South East London Clinical Commissioning Group (CCG) and NHS Lambeth CCG.

FINDINGS

780 (0·23%) of 332 357 adult patients were coded as referred (n=538) or seen (n=252) in a lipid clinic. 164 487 (46·49%) were women (appendix). The fully adjusted model for odds of LCR showed the following significant associations for age (odds ratio [OR] 0·96, 95% CI 0·96-0·97, p<0·001); Black, African, Caribbean, or Black-British ethnicity (0·67, 0·53-0·84, p=0·001); ex-smoker status (1·29, 1·05-1·57, p=0·014); TC higher than 7·5 mmol/L (12·18, 9·60-15·45, p<0·001); statin prescription (14·01, 10·85-18·10, p<0·001); diabetes (0·72, 0·58-0·91, p=0·005); high-frequency GP attendance at seven or more GP consultations in the past year (1·49, 1·21-1·84, p<0·001); high GP-density (0·5-0·99 full-time equivalent GPs per 1000 patients; 2·70, 1·23-5·92, p=0·013). Sensitivity analyses for LCR restricted to familial hypercholesterolaemia-coded patients (n=581) found associations with TC higher than 7·5 mmol/L (4·26, 1·89-9·62, p<0·001), statin prescription (16·96, 2·19-131·36, p=0·007), and high GP-density (5·73, 1·27-25·93, p=0·023), with no significant associations with ethnicity. The relative contribution of GP practices to LCR was 6·32% of the total variance. There were no significant interactions between ethnicity and deprivation, age, or obesity.

INTERPRETATION

While interpretation is limited by the accuracy and completeness of coded records, the study showed factors associated with a higher likelihood of LCR included individuals recorded as having TC higher than 7·5 mmol/L, statin prescription, ex-smoker status, high-frequency GP attendance, and registration at a GP practice with 0·5-0·99 GP density. Patients with increasing age; Black, African, Caribbean, or Black-British ethnicity patients; and patients with diabetes had lower odds of LCR. Finally, the difference in odds of LCR between Black and White patients highlights potential health inequalities.

FUNDING

NHS Race & Health Observatory.

Identifying populations with chronic pain in primary care: developing an algorithm and logic rules applied to coded primary care diagnostic and medication data

BACKGROUND

Estimates of chronic pain prevalence using coded primary care data are likely to be substantially lower than estimates derived from community surveys. Most primary care studies have estimated chronic pain prevalence using data searches confined to analgesic medication prescriptions. Increasingly, following recent NICE guideline recommendations, patients and doctors opt for non-drug treatment of chronic pain thus excluding these patients from prevalence estimates based on medication codes. We aimed to develop and test an algorithm combining medication codes with selected diagnostic codes to estimate chronic pain prevalence using coded primary care data.

METHODS

Following a scoping review 4 criteria were developed to identify cohorts of people with chronic pain. These were (1) people with one of 12 ('tier 1') conditions that almost always results in the individual having chronic pain (2) people with one of 20 ('tier 2') conditions included when there are also 3 or more prescription-only analgesics issued in the last 12 months (3) chronic neuropathic pain, or (4) 4 or more prescription-only analgesics issued in the last 12 months. These were translated into 8 logic rules which included 1,932 SNOMED CT codes.

RESULTS

The algorithm was run on primary care data from 41 GP Practices in Lambeth. The total population consisted of 386,238 GP registered adults ≥ 18 years as of the 31st March 2021. 64,135 (16.6%) were identified as people with chronic pain. This definition demonstrated notably high rates in Black ethnicity females, and higher rates in the most deprived, and older population.

CONCLUSIONS

Estimates of chronic pain prevalence using structured healthcare data have previously shown lower prevalence estimates for chronic pain than reported in community surveys. This has limited the ability of researchers and clinicians to fully understand and address the complex multifactorial nature of chronic pain. Our study demonstrates that it may be possible to establish more representative prevalence estimates using structured data than previously possible. Use of logic rules offers the potential to move systematic identification and population-based management of chronic pain into mainstream clinical practice at scale and support improved management of symptom burden for people experiencing chronic pain.

Determinants of lipid-lowering medication prescribing in a multi-ethnic adult population diagnosed with familial hypercholesterolaemia in South London

BACKGROUND

Familial hypercholesterolaemia (FH) (prevalence 1 in 250) is an inherited condition that significantly increases risk of premature cardiovascular disease. Early diagnosis can potentially normalise cardiovascular risk with lipid-lowering medicines (statins and fibrates). Only 7% of patients with FH are identified in the UK. Improving identification, and understanding disparities in ascertainment and management, is an NHS priority.

AIM

To assess determinants of lipid-lowering prescribing in ethnically diverse adults with an FH code. METHOD: Retrospective cross-sectional analysis of Lambeth DataNet, containing anonymised adult patient data from 41 practices in South London. Stata 17 was used to run sequential multilevel logistic regression models, adjusted for practice effects, to estimate the odds of no lipid-lowering prescription in FH-coded adults; this was assessed across 10 ethnic groups and other patient-level factors: demographic, socioeconomic, lifestyle, comorbidities, and practice factors (consultation frequency and practice list size).

RESULTS

One hundred and sixty-one of 801 (20%) of adults with an FH code received no lipid-lowering medication. The fully adjusted model for no lipid-lowering prescriptions showed the following associations: age (years) odds ratio (OR) 0.93 (P<0.001, 95% confidence interval [CI] = 0.91 to 0.95), male sex OR 0.47 (P = 0.002, 95% CI = 0.29 to 0.76), diabetes OR 0.26 (P = 0.04, 95% CI = 0.70 to 0.96), hypertension OR 0.30 (P<0.01, 95% CI = 0.12 to 0.72), and frequency of GP attendance OR 0.48 (P = 0.03, 95% CI = 0.24 to 0.94). Sensitivity analyses examining determinants of high-intensity statin prescribing found similar results.

CONCLUSION

The study suggests important determinants of lipid-lowering prescribing in an ethnically diverse adult population included older age, male sex, hypertension, and diabetes. Ethnicity showed no significant associations with lipid-lowering prescribing after adjusting for other determinants including deprivation measures.

A concept mapping approach to assess factors influencing the delivery of community-based salon interventions to prevent cardiovascular disease and breast cancer among ethnically diverse women in south London

BACKGROUND

In the UK, women from ethnically diverse and socioeconomically deprived groups are at increased risk of underdiagnosis of cardiovascular disease (CVD) and low uptake for breast cancer screening. Raising awareness for CVD and breast cancer screening in partnership with salons can improve early detection, management and uptake of screening facilitating women and the NHS.

AIM

To explore the perceptions of hair and beauty professionals in the UK on factors that could influence the ability of salons to promote a culturally adapted educational intervention to improve CVD and breast cancer awareness and screening.

METHOD

Concept mapping is a multi-stage mixed methods participatory approach. Snowball sampling and dissemination of study information (online and face-to-face) among salon staff nationally was conducted. Participants were given a focus prompt 'What would be some factors that can influence the ability of salons to deliver this service?' and required to generate statements in response. Statements will be sorted into categories based on similarity and rated for importance and feasibility. Concept maps using multidimensional scaling and hierarchical cluster analyses will be produced.

RESULTS

A total of 19 participants participated in the first stage. We will report on statements generated by participants, statement clusters and ratings for importance and feasibility. This will be depicted in a Go-Zone map that will show statements simultaneously rated in both importance and feasibility.

CONCLUSION

Participatory approaches can support the development of educational community-based interventions aiming to establish partnerships between community assets and health systems for CVD and breast cancer awareness and prevention.

Ethnic inequalities in the impact of COVID-19 on primary care consultations: a time series analysis of 460,084 individuals with multimorbidity in South London

BACKGROUND

The COVID-19 pandemic caused rapid changes in primary care delivery in the UK, with concerns that certain groups of the population may have faced increased barriers to access. This study assesses the impact of the response to the COVID-19 pandemic on primary care consultations for individuals with multimorbidity and identifies ethnic inequalities.

METHODS

A longitudinal study based on monthly data from primary care health records of 460,084 patients aged ≥18 years from 41 GP practices in South London, from February 2018 to March 2021. Descriptive analysis and interrupted time series (ITS) models were used to analyse the effect of the pandemic on primary care consultations for people with multimorbidity and to identify if the effect varied by ethnic groups and consultation type.

RESULTS

Individuals with multimorbidity experienced a smaller initial fall in trend at the start of the pandemic. Their primary care consultation rates remained stable (879 (95% CI 869-890) per 1000 patients in February to 882 (870-894) March 2020), compared with a 7% decline among people without multimorbidity (223 consultations (95% CI 221-226) to 208 (205-210)). The gap in consultations between the two groups reduced after July 2020. The effect among individuals with multimorbidity varied by ethnic group. Ethnic minority groups experienced a slightly larger fall at the start of the pandemic. Individuals of Black, Asian, and Other ethnic backgrounds also switched from face-to-face to telephone at a higher rate than other ethnic groups. The largest fall in face-to-face consultations was observed among people from Asian backgrounds (their consultation rates declined from 676 (659-693) in February to 348 (338-359) in April 2020), which may have disproportionately affected their quality of care.

CONCLUSIONS

The COVID-19 pandemic significantly affected primary care utilisation in patients with multimorbidity. While there is evidence of a successful needs-based prioritisation of multimorbidity patients within primary care at the start of the pandemic, inequalities among ethnic minority groups were found. Strengthening disease management for these groups may be necessary to control widening inequalities in future health outcomes.

What factors influence differential uptake of NHS Health Checks, diabetes and hypertension reviews among women in ethnically diverse South London? Cross-sectional analysis of 63,000 primary care records

BACKGROUND

Uptake of health checks among women has not been examined in relation to patient and General Practitioner (GP) practice level factors. We investigated patient and practice level factors associated with differential uptake of health checks.

METHODS

Primary care records from 44 practices in Lambeth for women aged 40-74 years old (N = 62,967) from 2000-2018 were analysed using multi-level logistic regression models. An odds ratio (OR) >1 indicates increased occurrence of no health check.

FINDINGS

The mean age (IQR) of the included female sample (aged 40-74 years) was 52.9 years (45.0-59.0). Adjusted for patient-level factors (age, ethnicity, English as first language, overweight/obesity, smoking, attendance to GP practices, and co-morbidity), the odds of non-uptake of health checks were higher for Other White (OR 1.24, 95% confidence interval 1.17-1.33), and Other ethnicity (1.20, 1.07-1.35) vs. White British. It was also higher for 50-69 year olds (1.55, 1.47-1.62), 70-74 year olds (1.60, 1.49-1.72) vs. 40-49 year olds. These ORs did not change on adjustments for practice level factors (proportion of patients living in deprived areas, proportion of patients with ≥1 chronic condition, ≥3 emergency diabetes admissions annually, GP density/1000 patients, quality outcome framework score of ≥ 95%, and patient satisfaction scores of ≥80%). Non-uptake was lower for Black Caribbeans, Bangladeshis, overweight/obese patients, frequent practice attenders and comorbid patients.

INTERPRETATION

Differential uptake in health checks remained after adjustment for patient and practice level factors. Better measures of social determinants of health and of practice context are needed.

FUNDING

NIHR Research for Patient Benefit Programme (NIHR202769).

Cost Outcomes of Potentially Inappropriate Prescribing (PIP) in Middle-Aged Adults: A Delphi consensus and Cross-sectional Study

BACKGROUND

Potentially inappropriate prescribing (PIP) is common in older adults and is associated with increased medication costs and costs of associated adverse drug events (ADE). PIP also affects almost one-fifth of middle-aged adults (45-64 years old), as defined by the PRescribing Optimally in Middle-aged People's Treatments (PROMPT) criteria. However, there has been little research on PIP medication costs within this age group.

AIMS

Calculate the medication costs of PIP for middle-aged adults according to the 22 PROMPT criteria and compare with the cost of consensus-validated, evidence-based ('adequate') alternative prescribing scenarios.

METHODOLOGY

Adequate alternatives to the 22 PROMPT criteria were created via literature review. A Delphi consensus panel of experts were recruited (n=16), supported by a patient and public involvement group, to achieve consensus on the alternatives. A retrospective repeated cross-sectional study from 2014 to 2019 was then conducted utilising pseudonymised primary care data from Lambeth DataNet in South London (41 general practices, N=1,185,335, using LDN May 2020 extract) to calculate the cost of PIP.

RESULTS

The cross-sectional study included 55,880 patients. The total PIP cost was £2.79 million, with adequate alternative prescribing costing £2.74 million (cost savings of £51,278). Duplicate drug classes was the most costly criterion for both PIP and alternative prescribing.

CONCLUSIONS

This study calculated the medication costs of PIP and created alternative prescribing scenarios for the 22 PROMPT criteria. There is no substantial cost difference between adequate prescribing versus PIP. Future studies should investigate the wider health economic costs of alternative prescribing, such as reducing hospital admissions.

Determinants of long-term opioid prescribing in an urban population- a cross sectional study

BACKGROUND

Opioid prescribing has more than doubled in the UK between 1998 and 2016. Potential adverse health implications include dependency, falls and increased health expenditure.

AIM

To describe the predictors of long-term opioid prescribing (LTOP), (≥3 opioid prescriptions in a 90-day period).

DESIGN AND SETTING

A retrospective cross-sectional study in 41 General Practices in South London.

METHOD

Multi-level multivariable logistic regression to investigate the determinants of LTOP.

RESULTS

2,679 (0.8%) out of 320,639 registered patients ≥18 years were identified as having LTOP. Patients Were most likely to have LTOP, if: they had ≥5 long term conditions (LTCs) (adjusted odds ratio [AOR] 36.5, 95% confidence interval [CI] 30.4-43.8) or 2-4 LTCs (AOR 13.8, CI 11.9-16.1), in comparison to no LTCs, ≥75 years compared to 18-24 years (AOR 12.31, CI 7.1-21.5), smokers compared to non-smokers (AOR 2.2, CI 2.0-2.5), females compared to males (AOR 1.9, CI 1.7-2.0) and in the most deprived deprivation quintile (AOR 1.6, CI 1.4-1.8) compared to the least deprived. In a separate model examining individual long-term conditions (LTCs), the strongest associations for LTOP were noted for sickle cell disease (SCD) (AOR 18.4, CI 12.8-26.4), osteoarthritis (AOR 3.0, CI 2.8-3.3), rheumatoid arthritis (AOR 2.8, CI 2.2-3.4), depression (AOR 2.6, CI 2.3-2.8) and multiple sclerosis (OR 2.5, CI 1.4-4.4).

CONCLUSION

LTOP was significantly higher in those aged ≥75 years, with multi-morbidity or specific LTCs: sickle cell disease, osteoarthritis, rheumatoid arthritis, depression, and multiple sclerosis. These characteristics may enable the design of targeted interventions to reduce LTOP.

Identifying longitudinal clusters of multimorbidity in an urban setting: A population-based cross-sectional study

Background

Globally, there is increasing research on clusters of multimorbidity, but few studies have investigated multimorbidity in urban contexts characterised by a young, multi-ethnic, deprived populations. This study identified clusters of associative multimorbidity in an urban setting.

Methods

This is a population-based retrospective cross-sectional study using electronic health records of all adults aged 18 years and over, registered between April 2005 to May 2020 in general practices in one inner London borough. Multiple correspondence analysis and cluster analysis was used to identify groups of multimorbidity from 32 long-term conditions (LTCs).

Results

The population included 41 general practices with 826,936 patients registered between 2005 and 2020, with mean age 40 (SD15·6) years. The prevalence of multimorbidity was 21% (n = 174,881), with the median number of conditions being three and increasing with age. Analysis identified five consistent LTC clusters: 1) anxiety and depression (Ratio of within- to between- sum of squares (WSS/BSS <0·01 to <0·01); 2) heart failure, atrial fibrillation, chronic kidney disease (CKD), chronic heart disease (CHD), stroke/transient ischaemic attack (TIA), peripheral arterial disease (PAD), dementia and osteoporosis (WSS/BSS 0·09 to 0·12); 3) osteoarthritis, cancer, chronic pain, hypertension and diabetes (0·05 to 0·06); 4) chronic liver disease and viral hepatitis (WSS/BSS 0·02 to 0·03); 5) substance dependency, alcohol dependency and HIV (WSS/BSS 0·37 to 0·55).

Interpretation

Mental health problems, pain, and at-risk behaviours leading to cardiovascular diseases are the important clusters identified in this young, urban population.

Funding

Impact on Urban Health, United Kingdom.

Applying resolved and remission codes reduced prevalence of multimorbidity in an urban multi-ethnic population

OBJECTIVE

To estimate the prevalence and determinants of multimorbidity in an urban, multi-ethnic area over 15-years and investigate the effect of applying resolved/remission codes on prevalence estimates.

STUDY DESIGN AND SETTING

This is a population-based retrospective cross-sectional study using electronic health records of adults registered between 2005 -2020 in general practices in one inner London borough (n = 826,936). Classification of resolved/remission was based on clinical coding defined by the patient's general practitioner.

RESULTS

The crude and age-adjusted prevalence of multimorbidity over the study period were 21.2% (95% CI: 21.1 -21.3) and 30.8% (30.6 -31.0), respectively. Applying resolved/remission codes decreased the crude and age-adjusted prevalence estimates to 18.0% (95% CI: 17.9 -18.1) and 27.5% (27.4 -27.7). Asthma (53.2%) and depression (20.2%) were responsible for most resolved and remission codes. Substance use (Adjusted Odds Ratio 10.62 [95% CI: 10.30 -10.95]), high cholesterol (2.48 [2.44 -2.53]), and moderate obesity (2.19 [2.15 -2.23]) were the strongest risk factor determinants of multimorbidity outside of advanced age.

CONCLUSION

Our study highlights the importance of applying resolved/remission codes to obtain an accurate prevalence and the increased burden of multimorbidity in a young, urban, and multi-ethnic population. Understanding modifiable risk factors for multimorbidity can assist policymakers in designing effective interventions to reduce progression to multimorbidity.

A case-control and cohort study to determine the relationship between ethnic background and severe COVID-19

BACKGROUND

People of minority ethnic backgrounds may be disproportionately affected by severe COVID-19. Whether this relates to increased infection risk, more severe disease progression, or worse in-hospital survival is unknown. The contribution of comorbidities or socioeconomic deprivation to ethnic patterning of outcomes is also unclear.

METHODS

We conducted a case-control and a cohort study in an inner city primary and secondary care setting to examine whether ethnic background affects the risk of hospital admission with severe COVID-19 and/or in-hospital mortality. Inner city adult residents admitted to hospital with confirmed COVID-19 (n = 872 cases) were compared with 3,488 matched controls randomly sampled from a primary healthcare database comprising 344,083 people residing in the same region. For the cohort study, we studied 1827 adults consecutively admitted with COVID-19. The primary exposure variable was self-defined ethnicity. Analyses were adjusted for socio-demographic and clinical variables.

FINDINGS

The 872 cases comprised 48.1% Black, 33.7% White, 12.6% Mixed/Other and 5.6% Asian patients. In conditional logistic regression analyses, Black and Mixed/Other ethnicity were associated with higher admission risk than white (OR 3.12 [95% CI 2.63-3.71] and 2.97 [2.30-3.85] respectively). Adjustment for comorbidities and deprivation modestly attenuated the association (OR 2.24 [1.83-2.74] for Black, 2.70 [2.03-3.59] for Mixed/Other). Asian ethnicity was not associated with higher admission risk (adjusted OR 1.01 [0.70-1.46]). In the cohort study of 1827 patients, 455 (28.9%) died over a median (IQR) of 8 (4-16) days. Age and male sex, but not Black (adjusted HR 1.06 [0.82-1.37]) or Mixed/Other ethnicity (adjusted HR 0.72 [0.47-1.10]), were associated with in-hospital mortality. Asian ethnicity was associated with higher in-hospital mortality but with a large confidence interval (adjusted HR 1.71 [1.15-2.56]).

INTERPRETATION

Black and Mixed ethnicity are independently associated with greater admission risk with COVID-19 and may be risk factors for development of severe disease, but do not affect in-hospital mortality risk. Comorbidities and socioeconomic factors only partly account for this and additional ethnicity-related factors may play a large role. The impact of COVID-19 may be different in Asians.

FUNDING

British Heart Foundation; the National Institute for Health Research; Health Data Research UK.

Proportion of young people in the general population consulting general practitioners: Potential for mental health screening and prevention

AIM

One of the main obstacles with prevention in psychiatry is low detection of young subjects at risk for psychosis. The aim of the present work is to test whether general practitioners' (GP) offices are a possible setting for prevention of mental illness.

METHODS

We used an Electronic Health Record database (Datanet) representing South-London (Lambeth), where frequency of GP visits were available for each registered subject.

RESULTS

We show that in 2018 out of almost 175 000 subjects aged 12 to 35, almost six out of ten people were seen by their General practitioner at least once in 2018, and considering those subjects with at least one medical condition, around nine subjects out of ten did the same.

CONCLUSIONS

A high proportion of adolescents and young adults are seen by GPs at least once per year. GP offices should be tested as possible setting for detection of subjects at risk for mental illness, in particular in subjects with risk factors for mental illness.

Demographic variation in fit note receipt and long-term conditions in south London

Objectives

Introduced in the UK in 2010, the fit note was designed to address the problem of long-term sickness absence. We explored (1) associations between demographic variables and fit note receipt, ‘maybe fit’ use and long-term conditions, (2) whether individuals with long-term conditions receive more fit notes and are more likely to have the ‘maybe fit’ option selected and (3) whether long-term conditions explained associations between demographic variables and fit note receipt.

Methods

Data were extracted from Lambeth DataNet, a database containing electronic medical records of all 45 general practitioner (GP) practices within the borough of Lambeth. Individual-level anonymised data on GP consultations, prescriptions, Quality and Outcomes Framework diagnostic data and demographic information were analysed using survival analysis.

Results

In a sample of 326 415 people, 41 502 (12.7%) received a fit note. We found substantial differences in fit note receipt by gender, age, ethnicity and area-level deprivation. Chronic pain (HR 3.7 (95% CI 3.3 to 4.0)) and depression (HR 3.4 (95% CI 3.3 to 3.6)) had the highest rates for first fit note receipt. ‘Maybe fit’ recommendations were used least often in patients with epilepsy and serious mental illness. The presence of long-term conditions did not explain associations between demographic variables and fit note use.

Conclusions

For the first time, we show the relationships between fit note use and long-term conditions using individual-level primary care data from south London. Further research is required in order to evaluate this relatively new policy and to understand the needs of the population it was designed to support.

Journey to multimorbidity: longitudinal analysis exploring cardiovascular risk factors and sociodemographic determinants in an urban setting

OBJECTIVE

To study the social determinants and cardiovascular risk factors for multimorbidity and the acquisition sequence of multimorbidity.

DESIGN

Longitudinal study based on anonymised primary care data.

SETTING

General practices in an urban multiethnic borough in London, UK.

PARTICIPANTS

332 353 patients aged ≥18 years.

MAIN OUTCOME MEASURES

Clinical and sociodemographic characteristics of patients with multimorbidity, defined as ≥3 of 12 long-term conditions (LTCs) selected according to high predicted healthcare use. Multilevel logistic regression was used to model social determinants and cardiovascular risk factors. Alluvial plots were constructed to illustrate multimorbidity acquisition sequences according to age, ethnicity and social deprivation.

RESULTS

5597 (1.7%) patients had ≥3 selected LTCs, the 'multimorbidity cohort'. The the most common LTCs were diabetes (63.0%) and chronic pain (CP) (42.8%). Social deprivation and ethnicity were independent determinants of multimorbidity: most compared with the least deprived quintile (adjusted OR (AOR) 1.56 (95% CI 1.41 to 1.72)); South Asian compared with white ethnicity (AOR 1.44 (95% CI 1.29 to 1.61)); and black compared with white ethnicity (AOR 0.86 (95% CI 0.80 to 0.92)). The included cardiovascular risk factors were relatively strong determinants of multimorbidity: hypertension (AOR 5.05 (95% CI 4.69 to 5.44)), moderate obesity (AOR 3.41 (95% CI 3.21 to 3.63)) and smoking (AOR 2.30 (95% CI 2.16 to 2.45)). The most common initial onset conditions were diabetes and depression; diabetes particularly in older and black ethnic groups; and depression particularly in younger, more deprived and white ethnicity groups. CP was less common as an initial condition.

CONCLUSION

Our findings confirm the importance of age, social deprivation and ethnicity as determinants of multimorbidity. Smoking, obesity and hypertension as cardiovascular risk factors were stronger determinants of multimorbidity than deprivation or ethnicity. The acquisition sequence of multimorbidity is patterned by sociodemographic determinants. Understanding onset conditions of multimorbidity and cardiovascular cardiovascular risk factors may lead to the development of interventions to slow the progression of multimorbidity.

The Diagnosis of Urinary Tract infection in Young children (DUTY): a diagnostic prospective observational study to derive and validate a clinical algorithm for the diagnosis of urinary tract infection in children presenting to primary care with an acute illness

BACKGROUND

It is not clear which young children presenting acutely unwell to primary care should be investigated for urinary tract infection (UTI) and whether or not dipstick testing should be used to inform antibiotic treatment.

OBJECTIVES

To develop algorithms to accurately identify pre-school children in whom urine should be obtained; assess whether or not dipstick urinalysis provides additional diagnostic information; and model algorithm cost-effectiveness.

DESIGN

Multicentre, prospective diagnostic cohort study.

SETTING AND PARTICIPANTS

Children < 5 years old presenting to primary care with an acute illness and/or new urinary symptoms.

METHODS

One hundred and seven clinical characteristics (index tests) were recorded from the child's past medical history, symptoms, physical examination signs and urine dipstick test. Prior to dipstick results clinician opinion of UTI likelihood ('clinical diagnosis') and urine sampling and treatment intentions ('clinical judgement') were recorded. All index tests were measured blind to the reference standard, defined as a pure or predominant uropathogen cultured at ≥ 10(5) colony-forming units (CFU)/ml in a single research laboratory. Urine was collected by clean catch (preferred) or nappy pad. Index tests were sequentially evaluated in two groups, stratified by urine collection method: parent-reported symptoms with clinician-reported signs, and urine dipstick results. Diagnostic accuracy was quantified using area under receiver operating characteristic curve (AUROC) with 95% confidence interval (CI) and bootstrap-validated AUROC, and compared with the 'clinician diagnosis' AUROC. Decision-analytic models were used to identify optimal urine sampling strategy compared with 'clinical judgement'.

RESULTS

A total of 7163 children were recruited, of whom 50% were female and 49% were < 2 years old. Culture results were available for 5017 (70%); 2740 children provided clean-catch samples, 94% of whom were ≥ 2 years old, with 2.2% meeting the UTI definition. Among these, 'clinical diagnosis' correctly identified 46.6% of positive cultures, with 94.7% specificity and an AUROC of 0.77 (95% CI 0.71 to 0.83). Four symptoms, three signs and three dipstick results were independently associated with UTI with an AUROC (95% CI; bootstrap-validated AUROC) of 0.89 (0.85 to 0.95; validated 0.88) for symptoms and signs, increasing to 0.93 (0.90 to 0.97; validated 0.90) with dipstick results. Nappy pad samples were provided from the other 2277 children, of whom 82% were < 2 years old and 1.3% met the UTI definition. 'Clinical diagnosis' correctly identified 13.3% positive cultures, with 98.5% specificity and an AUROC of 0.63 (95% CI 0.53 to 0.72). Four symptoms and two dipstick results were independently associated with UTI, with an AUROC of 0.81 (0.72 to 0.90; validated 0.78) for symptoms, increasing to 0.87 (0.80 to 0.94; validated 0.82) with the dipstick findings. A high specificity threshold for the clean-catch model was more accurate and less costly than, and as effective as, clinical judgement. The additional diagnostic utility of dipstick testing was offset by its costs. The cost-effectiveness of the nappy pad model was not clear-cut.

CONCLUSIONS

Clinicians should prioritise the use of clean-catch sampling as symptoms and signs can cost-effectively improve the identification of UTI in young children where clean catch is possible. Dipstick testing can improve targeting of antibiotic treatment, but at a higher cost than waiting for a laboratory result. Future research is needed to distinguish pathogens from contaminants, assess the impact of the clean-catch algorithm on patient outcomes, and the cost-effectiveness of presumptive versus dipstick versus laboratory-guided antibiotic treatment.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Ethnic differences in smoking intensity and COPD risk: an observational study in primary care

Chronic obstructive pulmonary disease risk is lower in black and south Asian people than white people, when adjusting for age, sex, deprivation and smoking status. The role of smoking intensity was assessed for its contribution to ethnic differences in chronic obstructive pulmonary disease risk, a relationship not previously investigated. This cross-sectional study included routinely collected primary care data from four multi-ethnic London boroughs. Smoking intensity (estimated by cigarettes per day) was compared between ethnic groups. Chronic obstructive pulmonary disease risk was compared between ethnic groups using multiple logistic regression, controlling for age, sex, deprivation, asthma and both smoking status and smoking intensity, examined independently. In all, 1,000,388 adults were included. Smoking prevalence and intensity were significantly higher in the white British/Irish groups than other ethnic groups. Higher smoking intensity was associated with higher chronic obstructive pulmonary disease risk. Chronic obstructive pulmonary disease risk was significantly lower in all ethnic groups compared with white British/Irish after adjustment for either smoking status or smoking intensity, with lowest risk in black Africans (odds ratio 0.33; confidence interval 0.28–0.38). Ethnic differences in chronic obstructive pulmonary disease risk were not explained in this study by ethnic differences in smoking prevalence or smoking intensity. Other causes of ethnic differences in chronic obstructive pulmonary disease risk should be sought, including ethnic differences in smoking behaviour, environmental factors, repeated respiratory infections, immigrant status, metabolism and addictiveness of nicotine and differential susceptibility to the noxious effects of cigarette smoke.

Lower smoking intensity among blacks and south Asians does not explain their lower risk for chronic obstructive pulmonary disease (COPD). A UK team led by Alexander Gilkes from Kings College London analysed primary care data from more than a million people living in four multi-ethnic boroughs of the British capital. The researchers found that smoking status and intensity (as measured by number of cigarettes smoked per day) were both significantly higher in white British or Irish groups than in other ethnic populations. Even after statistically adjusting for smoking status or smoking intensity, however, the researchers couldn’t account for the fact that people of south Asian or African descent had much lower prevalence rates of COPD, a lung disease linked to smoking. The findings suggest that other explanations of ethnic differences are still needed.

Long term condition morbidity in English general practice: a cross-sectional study using three composite morbidity measures

Background

The burden of morbidity represented by patients with long term conditions (LTCs) varies substantially between general practices. This study aimed to determine the characteristics of general practices with high morbidity burden.

Method

Retrospective cross-sectional study; general practices in England, 2014/15. Three composite morbidity measures (MMs) were constructed to quantify LTC morbidity at practice level: a count of LTCs derived from the 20 LTCs included in the UK Quality and Outcomes Framework (QOF) disease registers, expressed as ‘number of QOF LTCs per 100 registered patients’; the % of patients with one or more QOF LTCs; the % of patients with one or more of 15 broadly defined LTCs included in the GP Patient Survey (GPPS). Determinants of MM scores were analysed using multi-level regression models. Analysis was based on a national dataset of English general practices (n = 7779 practices); GPPS responses (n = 903,357); general practice characteristics (e.g. list size, list size per full time GP); patient demographic characteristics (age, deprivation status); secondary care utilisation (out-patient, emergency department, emergency admission rates).

Results

Mean MM scores (95% CIs) were: 57.7 (±22.3) QOF LTCs per 100 registered patients; 22.8% (±8.2) patients with a QOF LTC; 63.5% (±11.7) patients with a GPPS LTC. The proportion of elderly patients and social deprivation scores were the strongest predictors of each MM score; scores were largely independent of practice characteristics. MM scores were positive predictors of secondary care utilization and negative predictors’ access, continuity of care and overall satisfaction.

Conclusions

Wide variation in LTC morbidity burden was observed across English general practice. Variation was determined by demographic factors rather than practice characteristics. Higher rates of secondary care utilisation in practices with higher morbidity burden have implications for resource allocation and commissioning budgets; lower reported satisfaction in these practices suggests that practices may struggle with increased workload. There is a need for a readily available metric to define the burden of morbidity and multimorbidity in general practice.

Improving the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort Study

PURPOSE

Up to 50% of urinary tract infections (UTIs) in young children are missed in primary care. Urine culture is essential for diagnosis, but urine collection is often difficult. Our aim was to derive and internally validate a 2-step clinical rule using (1) symptoms and signs to select children for urine collection; and (2) symptoms, signs, and dipstick testing to guide antibiotic treatment.

METHODS

We recruited acutely unwell children aged under 5 years from 233 primary care sites across England and Wales. Index tests were parent-reported symptoms, clinician-reported signs, urine dipstick results, and clinician opinion of UTI likelihood (clinical diagnosis before dipstick and culture). The reference standard was microbiologically confirmed UTI cultured from a clean-catch urine sample. We calculated sensitivity, specificity, and area under the receiver operator characteristic (AUROC) curve of coefficient-based (graded severity) and points-based (dichotomized) symptom/sign logistic regression models, and we then internally validated the AUROC using bootstrapping.

RESULTS

Three thousand thirty-six children provided urine samples, and culture results were available for 2,740 (90%). Of these results, 60 (2.2%) were positive: the clinical diagnosis was 46.6% sensitive, with an AUROC of 0.77. Previous UTI, increasing pain/crying on passing urine, increasingly smelly urine, absence of severe cough, increasing clinician impression of severe illness, abdominal tenderness on examination, and normal findings on ear examination were associated with UTI. The validated coefficient- and points-based model AUROCs were 0.87 and 0.86, respectively, increasing to 0.90 and 0.90, respectively, by adding dipstick nitrites, leukocytes, and blood.

CONCLUSIONS

A clinical rule based on symptoms and signs is superior to clinician diagnosis and performs well for identifying young children for noninvasive urine sampling. Dipstick results add further diagnostic value for empiric antibiotic treatment.

Does COPD risk vary by ethnicity? A retrospective cross-sectional study

BACKGROUND

Lower risk of COPD has been reported in black and Asian people, raising questions of poorer recognition or reduced susceptibility. We assessed prevalence and severity of COPD in ethnic groups, controlling for smoking.

METHOD

A retrospective cross-sectional study using routinely collected primary care data in London. COPD prevalence, severity (% predicted forced expiratory volume in 1 second [FEV1]), smoking status, and treatment were compared between ethnic groups, adjusting for age, sex, smoking, deprivation, and practice clustering.

RESULTS

Among 358,614 patients in 47 general practices, 47.6% were white, 20% black, and 5% Asian. Prevalence of COPD was 1.01% overall, 1.55% in whites, 0.58% in blacks, and 0.78% in Asians. COPD was less likely in blacks (adjusted odds ratio [OR], 0.44; 95% confidence interval [CI] 0.39-0.51) and Asians (0.82; CI, 0.68-0.98) than whites. Black COPD patients were less likely to be current smokers (OR, 0.56; CI, 0.44-0.71) and more likely to be never-smokers (OR, 4.9; CI, 3.4-7.1). Treatment of patients with similar disease severity was similar irrespective of ethnic origin, except that long-acting muscarinic antagonists were prescribed less in black COPD patients (OR, 0.53; CI, 0.42-0.68). Black ethnicity was a predictor of poorer lung function (% predicted FEV1: B coefficient, -7.6; P<0.0001), an effect not seen when ethnic-specific predicted FEV1 values were used.

CONCLUSION

Black people in London were half as likely as whites to have COPD after adjusting for lower smoking rates in blacks. It seems likely that the differences observed were due either to ethnic differences in the way cigarettes were smoked or to ethnic differences in susceptibility to COPD.

Early diagnostic suggestions improve accuracy of family physicians: a randomized controlled trial in Greece

BACKGROUND

In a recent randomized controlled trial, providing UK family physicians with 'early support' (possible diagnoses to consider before any information gathering) was associated with diagnosing hypothetical patients on computer more accurately than control. Another group of physicians, who gathered information, gave a diagnosis, and subsequently received a list of possible diagnoses to consider ('late support'), were no more accurate than control, despite being able to change their initial diagnoses.

OBJECTIVE

To replicate the UK study findings in another country with a different primary health care system.

METHODS

All study materials were translated into Greek. Greek family physicians were randomly allocated to one of three groups: control, early support and late support. Participants saw nine scenarios in random order. After reading some information about the patient and the reason for encounter, they requested more information to diagnose. The main outcome measure was diagnostic accuracy.

RESULTS

One hundred fifty Greek family physicians participated. The early support group was more accurate than control [odds ratio (OR): 1.67 (1.21-2.31)]. Like their UK counterparts, physicians in the late support group rarely changed their initial diagnoses after receiving support. The pooled OR for the early support versus control comparison from the meta-analysis of the UK and Greek data was 1.40 (1.13-1.67).

CONCLUSION

Using the same methodology with a different sample of family physicians in a different country, we found that suggesting diagnoses to consider before physicians start gathering information was associated with more accurate diagnoses. This constitutes further supportive evidence of a generalizable effect of early support.

Patient experience and the role of postgraduate GP training: a cross-sectional analysis of national Patient Survey data in England

BACKGROUND

Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care.

AIM

The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care.

DESIGN AND SETTING

Retrospective cross-sectional study in general practices in England.

METHOD

Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections.

OUTCOME MEASURES

multilevel regression models adjusted for clustering.

RESULTS

GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the 'doctor care' (n = 6) and 'overall satisfaction' (n = 2) domains but not to any of the 'nurse care' or 'out-of-hours' domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients.

CONCLUSION

Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as 'listening' or 'care and concern'.

Identifying poorly performing general practices in England: a longitudinal study using data from the quality and outcomes framework

OBJECTIVE

to determine the characteristics of general practices which perform poorly in terms of Quality and Outcome (QOF) performance indicators in England's NHS.

METHOD

retrospective, four year longitudinal study, 2005 to 2008. Data were obtained from 8515 practices (99% of practices in England) in year 1, 8264 (98%) in year 2, 8192 (98%) in year 3 and 8256 (99%) in year 4.

OUTCOME MEASURES

QOF performance scores; social deprivation (IMD-2007) and ethnicity from the 2001 national census; general practice characteristics.

RESULTS

we identified a cohort of 212 (2.7%) practices which remained in the lowest decile for total QOF scores in the four years following the introduction of the QOF. A total of 705,386 patients were registered at these practices in year 4. These practices were more likely to be singlehanded (odds ratio [OR], 13.8), non-training practices (OR, 3.9) and located in deprived areas (OR, 2.6; most vs least deprived quintiles). General practitioners (GPs) in these practices were more often aged ≥ 65 years or more (OR, 7.3; mean GP age ≥ 65 years vs <45 years), male (OR 2.0), UK qualified (OR 2.0) with small list sizes (OR 3.2; list size <1000 vs 1500-2000 patients). We identified individual QOF indicators which were poorly achieved. The reported prevalence of most chronic diseases was lower in the poorly performing cohort.

CONCLUSIONS

a small minority of practices have remained poor performers in terms of measurable performance indicators over a four-year period. The strongest predictors of poor QOF performance were singlehanded and small practices, and practices staffed by elderly GPs.

Use of chaperones by obstetricians and gynaecologists: A cross-sectional survey

The Royal College of Obstetrics and Gynaecologists (RCOG) recommends that a chaperone should be offered to every patient for an intimate examination. The use of chaperones has risen in primary care, but little is known about the practice of obstetricians and gynaecologists. Our aim was to determine the current attitudes and practices of Fellows and Members of the RCOG regarding chaperones during intimate examinations, both in public and private practice. A total of 800 Fellows and Members were asked to complete a 45-item questionnaire on their use of chaperones and how important a range of issues were in deciding whether or not to offer and provide a chaperone. A total of 449 questionnaires were returned. In summary, 23% of respondents never or occasionally offered a chaperone; 24% of NHS units have no agreed NHS policy and a further 16% did not know if a policy existed. In NHS practice, 77% used a chaperone with only 62% of women using a chaperone. Of those who did private practice, 34% never or occasionally offered a chaperone with 31% actually using a chaperone. In conclusion, obstetricians and gynaecologists use chaperones more than general practitioners but there is significant room for improvement. Chaperones are used more in NHS than private practice.

The relationship between social deprivation and the quality of primary care: a national survey using indicators from the UK Quality and Outcomes Framework

BACKGROUND

The existence of health inequalities between least and most socially deprived areas is now well established.

AIM

To use Quality and Outcomes Framework (QOF) indicators to explore the characteristics of primary care in deprived communities.

DESIGN OF STUDY

Two-year study.

SETTING

Primary care in England.

METHOD

QOF data were obtained for each practice in England in 2004-2005 and 2005-2006 and linked with census derived social deprivation data (Index of Multiple Deprivation scores 2004), national urbanicity scores and a database of practice characteristics. Data were available for 8480 practices in 2004-2005 and 8264 practices in 2005-2006. Comparisons were made between practices in the least and most deprived quintiles.

RESULTS

The difference in mean total QOF score between practices in least and most deprived quintiles was 64.5 points in 2004-2005 (mean score, all practices, 959.9) and 30.4 in 2005-2006 (mean, 1012.6). In 2005-2006, the QOF indicators displaying the largest differences between least and most deprived quintiles were: recall of patients not attending appointments for injectable neuroleptics (79 versus 58%, respectively), practices opening > or =45 hours/week (90 versus 74%), practices conducting > or = 12 significant event audits in previous 3 years (93 versus 81%), proportion of epileptics who were seizure free > or = 12 months (77 versus 65%) and proportion of patients taking lithium with serum lithium within therapeutic range (90 versus 78%). Geographical differences were less in group and training practices.

CONCLUSIONS

Overall differences between primary care quality indicators in deprived and prosperous communities were small. However, shortfalls in specific indicators, both clinical and non-clinical, suggest that focused interventions could be applied to improve the quality of primary care in deprived areas.