Summary Background Introduced in 2004, the UK's Quality and Outcomes Framework (QOF) is the world's largest primary care pay-for-performance programme. We tested whether the QOF was associated with ...reduced population mortality. Methods We used population-level mortality statistics between 1994 and 2010 for the UK and other high-income countries that were not exposed to pay-for-performance. The primary outcome was age-adjusted and sex-adjusted mortality per 100 000 people for a composite outcome of chronic disorders that were targeted by the QOF. Secondary outcomes were age-adjusted and sex-adjusted mortality for ischaemic heart disease, cancer, and a composite of all non-targeted conditions. For each study outcome, we created a so-called synthetic UK as a weighted combination of comparison countries. We then estimated difference-in-differences models to test whether mortality fell more in the UK than in the synthetic UK after the QOF. Findings Introduction of the QOF was not significantly associated with changes in population mortality for the composite outcome (−3·68 per 100 000 population 95% CI −8·16 to 0·80; p=0·107), ischaemic heart disease (−2·21 per 100 000 –6·86 to 2·44; p=0·357), cancer (0·28 per 100 000 –0·99 to 1·55; p=0·679), or all non-targeted conditions (11·60 per 100 000 –3·91 to 27·11; p=0·143). Interpretation Although we noted small mortality reductions for a composite outcome of targeted disorders, the QOF was not associated with significant changes in mortality. Our findings have implications for the probable effects of similar programmes on population health outcomes. The relation between incentives and mortality needs to be assessed in specific disease domains. Funding None.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
routine frailty identification and management is national policy in England, but there remains a lack of evidence on the impact of frailty on healthcare resource use. We evaluated the impact of ...frailty on the use and costs of general practice and hospital care.
retrospective longitudinal analysis using linked routine primary care records for 95,863 patients aged 65-95 years registered with 125 UK general practices between 2003 and 2014. Baseline frailty was measured using the electronic Frailty Index (eFI) and classified in four categories (non, mild, moderate, severe). Negative binomial regressions and ordinary least squares regressions with multilevel mixed effects were applied on the use and costs of general practice and hospital care.
compared with non-frail status, annual general practitioner consultation incidence rate ratios (IRRs) were 1.24 (95% CI: 1.21-1.27) for mild, 1.41 (95% CI: 1.35-1.47) for moderate, and 1.52 (95% CI: 1.42-1.62) for severe frailty. For emergency hospital admissions, the respective IRRs were 1.64 (95% CI 1.60-1.68), 2.45 (95% CI 2.37-2.53) and 3.16 (95% CI: 3.00-3.33). Compared with non-frail people the IRR for inpatient days was 7.26 (95% CI 6.61-7.97) for severe frailty. Using 2013/14 reference costs, extra annual cost to the healthcare system per person was £561.05 for mild, £1,208.60 for moderate and £2,108.20 for severe frailty. This equates to a total additional cost of £5.8 billion per year across the UK.
increasing frailty is associated with substantial increases in healthcare costs, driven by increased hospital admissions, longer inpatient stay, and increased general practice consultations.
Abstract
Background
The impact of consumption of sugar-sweetened beverages (SSB) on health outcomes such as obesity have been studied extensively, but oral health has been relatively neglected. This ...study aims to assess the association between SSB consumption and dental caries and erosion.
Methods
Systematic review of observational studies. Search strategy applied to Medline, Embase, Cochrane Library, SciELO, LILACS, OpenGrey and HMIC. The risk of bias was assessed using the NIH Quality Assessment Tool for Observational Cross-Sectional Studies and evidence certainty using Grading of Recommendation Assessment Development and Evaluation. Relationships between SSB consumption and caries and erosion were estimated using random-effects model meta- and dose–response analyses.
Results
A total of 38 cross-sectional studies were included, of which 26 were rated as high quality. Comparing moderate-to-low consumption, there was significantly increased risk of both caries OR = 1.57, 95% CI: 1.28–1.92; decayed, missing and filled teeth weighted mean differences (DMFT WMD) = 0.82, 95% CI: 0.38–1.26 and erosion (OR = 1.43, 95% CI: 1.01–2.03). Comparing high-to-moderate consumption, there was further increased risk of caries (OR = 1.53, 95% CI: 1.17–1.99; DMFT WMD = 1.16, 95% CI: −0.59–2.91) and erosion (OR = 3.09, 95% CI: 1.37–6.97). A dose–response gradient and high certainty of evidence was observed for caries.
Conclusions
Increasing SSB consumption is associated with increased risk of dental caries and erosion. Studies were cross-sectional, hence temporality could not be established, but the positive dose–response suggests this relationship is likely to be causal. These findings illustrate the potential benefits to oral health of policies that reduce SSB consumption, including sugar taxation.
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NUK, OILJ, UL, UM, UPUK, VSZLJ
Summary Background The quality and outcomes framework is a financial incentive scheme that remunerates general practices in the UK for their performance against a set of quality indicators. Incentive ...schemes can increase inequalities in the delivery of care if practices in affluent areas are more able to respond to the incentives than are those in deprived areas. We examined the relation between socioeconomic inequalities and delivered quality of clinical care in the first 3 years of this scheme. Methods We analysed data extracted automatically from clinical computing systems for 7637 general practices in England, data from the UK census, and data for characteristics of practices and patients from the 2006 general medical statistics database. Practices were grouped into equal-sized quintiles on the basis of area deprivation in their locality. We calculated overall levels of achievement, defined as the proportion of patients who were deemed eligible by the practices for whom the targets were achieved, for 48 clinical activity indicators during the first 3 years of the incentive scheme (from 2004–05 to 2006–07). Findings Median overall reported achievement was 85·1% (IQR 79·0–89·1) in year 1, 89·3% (86·0–91·5) in year 2, and 90·8% (88·5–92·6) in year 3. In year 1, area deprivation was associated with lower levels of achievement, with median achievement ranging from 86·8% (82·2–89·6) for quintile 1 (least deprived) to 82·8% (75·2–87·8) for quintile 5 (most deprived). Between years 1 and 3, median achievement increased by 4·4% for quintile 1 and by 7·6% for quintile 5, and the gap in median achievement narrowed from 4·0% to 0·8% during this period. Increase in achievement during this time was inversely associated with practice performance in previous years (p<0·0001), but was not associated with area deprivation (p=0·062). Interpretation Our results suggest that financial incentive schemes have the potential to make a substantial contribution to the reduction of inequalities in the delivery of clinical care related to area deprivation. Funding None.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Objective
Patients admitted as emergencies to hospitals at the weekend have higher death rates than patients admitted on weekdays. This may be because the restricted service availability at weekends ...leads to selection of patients with greater average severity of illness. We examined volumes and rates of hospital admissions and deaths across the week for patients presenting to emergency services through two routes: (a) hospital Accident and Emergency departments, which are open throughout the week; and (b) services in the community, for which availability is more restricted at weekends.
Method
Retrospective observational study of all 140 non-specialist acute hospital Trusts in England analyzing 12,670,788 Accident and Emergency attendances and 4,656,586 emergency admissions (940,859 direct admissions from primary care and 3,715,727 admissions through Accident and Emergency) between April 2013 and February 2014.Emergency attendances and admissions to hospital and deaths in any hospital within 30 days of attendance or admission were compared for weekdays and weekends.
Results
Similar numbers of patients attended Accident and Emergency on weekends and weekdays. There were similar numbers of deaths amongst patients attending Accident and Emergency on weekend days compared with weekdays (378.0 vs. 388.3). Attending Accident and Emergency at the weekend was not associated with a significantly higher probability of death (risk-adjusted OR: 1.010).
Proportionately fewer patients who attended Accident and Emergency at weekend were admitted to hospital (27.5% vs. 30.0%) and it is only amongst the subset of patients attending Accident and Emergency who were selected for admission to hospital that the probability of dying was significantly higher at the weekend (risk-adjusted OR: 1.054).
The average volume of direct admissions from services in the community was 61% lower on weekend days compared to weekdays (1317 vs. 3404). There were fewer deaths following direct admission on weekend days than weekdays (35.9 vs. 80.8). The mortality rate was significantly higher at weekends amongst direct admissions (risk-adjusted OR: 1.212) due to the proportionately greater reduction in admissions relative to deaths.
Conclusions
There are fewer deaths following hospital admission at weekends. Higher mortality rates at weekends are found only amongst the subset of patients who are admitted. The reduced availability of primary care services and the higher Accident and Emergency admission threshold at weekends mean fewer and sicker patients are admitted at weekends than during the week. Extending services in hospitals and in the community at weekends may increase the number of emergency admissions and therefore lower mortality, but may not reduce the absolute number of deaths.
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BFBNIB, NMLJ, NUK, PNG, UL, UM, UPUK
Improving care for people with long-term conditions is central to NHS policy. It has been suggested that the Quality and Outcomes Framework (QOF), a primary care pay-for-performance scheme that ...rewards practices for delivering effective interventions in long-term conditions, does not encourage high-quality care for this group of patients.
To examine the evidence that the QOF has improved quality of care for patients with long-term conditions.
This was a systematic review of research on the effectiveness of the QOF in the UK.
The authors searched electronic databases for peer-reviewed empirical quantitative research studying the effect of the QOF on a broad range of processes and outcomes of care, including coordination and integration of care, holistic and personalised care, self-care, patient experience, physiological and biochemical outcomes, health service utilisation, and mortality. Because the studies were heterogeneous, a narrative synthesis was carried out.
The authors identified three systematic reviews and five primary research studies that met the inclusion criteria. The QOF was associated with a modest slowing of both the increase in emergency admissions and the increase in consultations in severe mental illness (SMI), and modest improvements in diabetes care. The nature of the evidence means that the authors cannot be sure that any of these associations is causal. No clear effect on mortality was found. The authors found no evidence that the QOF influences integration or coordination of care, holistic care, self-care, or patient experience.
The NHS should consider more broadly what constitutes high-quality primary care for people with long-term conditions, and consider other ways of motivating primary care to deliver it.
Atrial fibrillation (AF) is an important risk factor for ischaemic stroke, and AF incidence is expected to increase. Guidelines recommend using oral anticoagulants (OACs) to prevent the development ...of stroke. However, studies have reported the frequent underuse of OACs in AF patients. The objective of this study is to describe nonvalvular atrial fibrillation (NVAF) incidence in England and assess the clinical and socioeconomic factors associated with the underprescribing of OACs.
We conducted a population-based retrospective cohort study using the UK Clinical Practice Research Datalink (CPRD) database to identify patients with NVAF aged ≥18 years and registered in English general practices between 2009 and 2019. Annual incidence rate of NVAF by age, deprivation quintile, and region was estimated. OAC prescribing status was explored for patients at risk for stroke and classified into the following: OAC, aspirin only, or no treatment. We used a multivariable multinomial logistic regression model to estimate relative risk ratios (RRRs) and 95% confidence intervals (CIs) of the factors associated with OAC or aspirin-only prescribing compared to no treatment in patients with NVAF who are recommended to take OAC. The multivariable regression was adjusted for age, sex, comorbidities, socioeconomic status, baseline treatment, frailty, bleeding risk factors, and takes into account clustering by general practice. Between 2009 and 2019, 12,517,191 patients met the criteria for being at risk of developing NVAF. After a median follow-up of 4.6 years, 192,265 patients had an incident NVAF contributing a total of 647,876 person-years (PYR) of follow-up. The overall age-adjusted incidence of NVAF per 10,000 PYR increased from 20.8 (95% CI: 20.4; 21.1) in 2009 to 25.5 (25.1; 25.9) in 2019. Higher incidence rates were observed for older ages and males. Among NVAF patients eligible for anticoagulation, OAC prescribing rose from 59.8% (95% CI: 59.0; 60.6) in 2009 to 83.2% (95% CI: 83.0; 83.4) in 2019. Several conditions were associated with lower risk of OAC prescribing: dementia RRR 0.52 (0.47; 0.59), liver disease 0.58 (0.50; 0.67), malignancy 0.74 (0.72; 0.77), and history of falls 0.82 (0.78; 0.85). Compared to white ethnicity, patients from black and other ethnic minorities were less likely to receive OAC; 0.78 (0.65; 0.94) and 0.76 (0.64; 0.91), respectively. Patients living in the most deprived areas were less likely to receive OAC 0.85 (0.79; 0.91) than patients living in the least deprived areas. Practices located in the East of England were associated with higher risk of prescribing aspirin only over no treatment than practices in London (RRR 1.22; 95% CI 1.02 to 1.45). The main limitation of this study is that these findings depends on accurate recording of conditions by health professionals and the inevitable residual confounding due to lack of data on certain factors that could be associated with under-prescribing of OACs.
The incidence of NVAF increased between 2009 and 2015, before plateauing. Underprescribing of OACs in NVAF is associated with a range of comorbidities, ethnicity, and socioeconomic factors, demonstrating the need for initiatives to reduce inequalities in the care for AF patients.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Birds have a ZZ male and ZW female sex chromosome system. The relative roles of genetics and hormones in regulating avian sexual development have been revealed by studies on gynandromorphs. ...Gynandromorphs are rare bilateral sex chimeras, male on one side of the body and female on the other. We examined a naturally occurring gynandromorphic chicken that was externally male on the right side of the body and female on the left. The bird was diploid but with a mix of ZZ and ZW cells that correlated with the asymmetric sexual phenotype. The male side was 96% ZZ, and the female side was 77% ZZ and 23% ZW. The gonads of this bird at sexual maturity were largely testicular. The right gonad was a testis, with SOX9+ Sertoli cells, DMRT1+ germ cells, and active spermatogenesis. The left gonad was primarily testicular, but with some peripheral aromatase-expressing follicles. The bird had low levels of serum estradiol and high levels of testosterone, as expected for a male. Despite the low percentage of ZW cells on that side, the left side had female sex-linked feathering, smaller muscle mass, smaller leg and spur, and smaller wattle than the male side. This indicates that these sexually dimorphic structures must be at least partly independent of sex steroid effects. Even a small percentage of ZW cells appears sufficient to support female sexual differentiation. Given the lack of chromosome-wide dosage compensation in birds, various sexually dimorphic features may arise due to Z-gene dosage differences between the sexes.
Socioeconomic status is a key predictor of lifetime health: poorer people can expect to live shorter lives with lower average health-related quality-of-life (HRQoL) than richer people. In this study, ...we aimed to improve understanding of the socioeconomic gradient in HRQoL by exploring how inequalities in different dimensions of HRQoL differ by age. Data were derived from the Health Survey for England for 2017 and 2018 (14,412 participants). HRQoL was measured using the EQ-5D-5L instrument. We estimated mean EQ-5D utility scores and reported problems on five HRQoL dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) for ages 16 to 90+ and stratified by neighbourhood deprivation quintiles. Relative and absolute measures of inequality were assessed. Mean EQ-5D utility scores declined with age and followed a socioeconomic gradient, with the lowest scores in the most deprived areas. Gaps between the most and least deprived quintiles emerged around the age of 35, reached their greatest extent at age 60 to 64 (relative HRQoL of most deprived compared to least deprived quintile: females = 0.77 (95% CI: 0.68-0.85); males = 0.78 (95% CI: 0.69-0.87)) before closing again in older age groups. Gaps were apparent for all five EQ-5D dimensions but were greatest for mobility and self-care. There are stark socioeconomic inequalities in all dimensions of HRQoL in England. These inequalities start to develop from early adulthood and increase with age but reduce again around retirement age.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
ObjectiveTo estimate the equity impacts of the 2007 smoking ban in England, for both smokers and non-smokers.DesignDoubly robust regression discontinuity analysis of salivary cotinine levels. ...Conditional average treatment effects were used to estimate differential impacts of the ban by socioeconomic deprivation (based on the Index of Multiple Deprivation). Distributional impacts were further assessed using conditional quantile treatment effects and inequality treatment effects.SettingIn 2007, England introduced a ban on smoking in public places. This had little impact on tobacco consumption by smokers but was associated with decreases in environmental tobacco smoke exposure for non-smokers. However, the impact of the ban on socioeconomic inequalities in exposure is unclear.Participants766 smokers and 2952 non-smokers responding to the Health Survey for England in 2007.Outcome measureLevels of salivary cotinine.ResultsBefore the ban, socioeconomic deprivation was associated with higher cotinine levels for non-smokers but not for smokers. The ban caused a significant reduction in average cotinine levels for non-smokers (p=0.043) but had no effect for smokers (p=0.817). Reductions for non-smokers were greater for more deprived groups with higher levels of exposure, and there was a significant reduction in socioeconomic-related inequality in cotinine. Across the whole population (both smokers and non-smokers), there was no significant increase in the concentration of cotinine levels among the socioeconomically deprived.ConclusionThe 2007 ban on smoking in public places had little impact on smokers, but was, as intended, associated with reductions in both (1) average levels of environmental tobacco smoke exposure and (2) deprivation-related inequality in exposure among non-smokers.
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