BackgroundIll health and relative poverty are connected. This study aimed to determine first whether the worse health experienced by poorer participants was matched by appropriately greater receipt ...of healthcare, and second whether any inequalities in receipt occurred at the stage of diagnosis or treatment.MethodsThe English Longitudinal Study of Ageing is a cohort of participants aged 50 years or older. The relative distributions by wealth of symptoms, diagnosis and treatment of five common chronic conditions (angina, diabetes, depression, osteoarthritis, and cataract) were analysed in four waves of data collected from 2002 to 2010. Symptoms were defined for angina using the Rose Angina scale, diabetes using fasting HbA1c level, depression using the Centre for Epidemiologic Studies Depression Scale, osteoarthritis as self-reported pain and disability, and cataract as self-reported poor vision. Doctors' diagnoses for all conditions were self-reported. Treatment was defined for angina as beta-blocker prescription, osteoarthritis and cataract as surgery, and diabetes and depression as receiving treatment described in quality indicators. Binomial regression models tested variations between the hypothetically poorest and richest individuals for age and sex adjusted symptoms, diagnosis and treatment across the waves, using a slope index of inequality.ResultsSymptoms were commoner in poorer participants in all 5 conditions at all 4 timepoints, with ORs ranging from 2.5 to 7.0. In angina, depression and diabetes, receipt of diagnosis and treatment was similarly higher in poorer participants, with ORs ranging from 1.9 to 5.6. In osteoarthritis and cataract, receipt of diagnosis and treatment did not show substantial matching variations by wealth, with ORs ranging from 0.8 to 1.9. For example, ORs for diabetes in 2008 were broadly similar for symptoms (2.5 95% CI 1.5, 4.0, diagnosis (3.8 3.0, 4.9) and treatment (3.1 2.4, 4.0). In contrast, osteoarthritis ORs were substantially larger for symptoms (6.9 5.2, 9.1) than for diagnosis (1.4 1.2, 1.7) or treatment (0.8 0.5, 1.3).ConclusionPoorer participants were much more likely to have symptoms of osteoarthritis and cataract, but not much more likely to receive a diagnosis. The block in equitable receipt of healthcare was at the stage of diagnosis rather than treatment, and so interventions to reduce inequalities in osteoarthritis and cataract should focus on the diagnostic process. The same relative inequalities in diagnosis were not seen in angina, depression and diabetes, which have all been the target of multiple quality improvement initiatives. These patterns remained consistent over 8 years.
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A new contract between UK primary care practices and government was implemented in April 2004, with substantial financial rewards to general practices for achievement of standards set out in the ...Quality and Outcomes Framework (QOF).
We aimed to review the evidence about the effects of the QOF on health care, including unintended outcomes, and equity.
Relevant papers were identified by searching Medline and from the reference lists of published reviews and papers. A separate systematic literature review was conducted to identify papers with information on the impact of the framework on inequalities.
All studies were observational, and so it cannot be assumed that any changes were caused by the framework. The results both for individual indicators and from different studies vary substantially. The diverse nature of the research precluded formal synthesis of data from different studies. Achievement of quality standards was high when the contract was introduced, and has risen each year roughly in line with the pre-existing trend. Inequalities in achievement of standards were generally small when the framework was implemented, and most have reduced further since. There is weak evidence that achievement for conditions outside the framework was lower initially, and has neither worsened nor improved since. Some interventions in the framework may be cost-effective. Professionals feel consultations and continuity have suffered to some extent. There is very little research about patients' views, or about the aspects of general practice not measured, such as caring, context and complexity.
The evidence base about the impact of the QOF is growing, but remains patchy and inconclusive. More high quality research is needed to inform decisions about how the framework should change to maximise improvements in health and equity.
Background National clinical guideline developers, such as the UK’s National Institute for Health and Clinical Excellence (NICE), produce high quality guidelines, yet primary care practitioners ...(PCPs) may question the relevance of the evidence and recommendations to a primary care (PC) population. Objectives To evaluate PCPs’ views about the relevance of NICE clinical guidelines to PC. Methods An online Delphi panel of 28 PCPs, recruited regionally and nationally, reviewed 14 guideline recommendations: 8 supported by PC relevant evidence and 6 by evidence from elsewhere. Panellists scored recommendations twice, on a scale of 1–9 (9 = highly relevant for PC), before and then again after reading a summary of the evidence, including study setting and population. They also commented on factors influencing guideline validity and PC implementability. Results 25 PCPs (89%) completed the Delphi. Overall mean scores were 7.4 (range 6.2–8.2) before reading the evidence summary, and 6.6 (4.6–8.3) after. Mean scores for the 8 recommendations supported by PC evidence were 7.4 before and 7.2 after (change -0.2). Mean scores for the 6 with evidence from elsewhere were 7.4 before and 5.8 after (change -1.6). Factors perceived to influence implementation included clarity, brevity, and relevance to PC. Discussion PCPs’ ratings of PC guideline validity dropped when they became aware that substantial supporting evidence for the guidelines had come from non PC settings. The relevance of the evidence to PC patients was important. Implications for Guideline Developers/Users Developers should explicitly describe the relevance of available evidence for PCPs and their patients.
Background. Hip and knee joint replacement rates vary by demographic group. This article describes the epidemiology of need for joint replacement, and of subsequent receipt of a joint replacement by ...those in need. Methods. Data from the Health and Retirement Study were used to assess need for hip or knee joint replacement in a total of 14,807 adults aged 60 years or older in 1998, 2000, and 2002 and receipt of needed surgery 2 years later. “Need” classification was based on difficulty walking, joint pain, stiffness, or swelling and receipt of treatment for arthritis, without contraindications to surgery. Results. Need in 2002 was greater in participants who were older than 74 years (vs 60–64: adjusted odds ratio 2.06; 95% confidence interval, 1.68–2.53), women (vs men: 1.81; 1.53–2.14), less educated (vs college educated: 1.27; 1.06–1.52), in the poorest third (vs richest: 2.20; 1.78–2.72), or obese (vs nonobese: 2.39; 2.02–2.81). One hundred sixty-eight participants in need received a joint replacement, with lower receipt in black or African American participants (vs white: 0.47; 0.26–0.83) or less educated (vs college educated: 0.65; 0.44–0.96). These differences were not explained by current employment, access to medical care, family responsibilities, disability, living alone, comorbidity, or exclusion of those younger than Medicare eligibility age. Conclusions. After taking variations in need into consideration, being black or African American or lacking a college education appears to be a barrier to receiving surgery, whereas age, sex, relative poverty, and obesity do not. These disparities maintain disproportionately high levels of pain and disability in disadvantaged groups.
little is known about changes in the quality of medical care for older adults over time.
to assess changes in technical quality of care over 6 years, and associations with participants' ...characteristics.
a national cohort survey covering RAND Corporation-derived quality indicators (QIs) in face-to-face structured interviews in participants' households.
a total of 5,114 people aged 50 or more in four waves of the English Longitudinal Study of Ageing.
the percentage achievement of 24 QIs in 10 general medical and geriatric clinical conditions was calculated for each time point, and associations with participants' characteristics were estimated using logistic regression.
participants were eligible for 21,220 QIs. QI achievement for geriatric conditions (cataract, falls, osteoarthritis and osteoporosis) was 41% 95% confidence interval (CI): 38-44 in 2004-05 and 38% (36-39) in 2010-11. Achievement for general medical conditions (depression, diabetes mellitus, hypertension, ischaemic heart disease, pain and cerebrovascular disease) improved from 75% (73-77) in 2004-05 to 80% (79-82) in 2010-11. Achievement ranged from 89% for cerebrovascular disease to 34% for osteoarthritis. Overall achievement was lower for participants who were men, wealthier, infrequent alcohol drinkers, not obese and living alone.
substantial system-level shortfalls in quality of care for geriatric conditions persisted over 6 years, with relatively small and inconsistent variations in quality by participants' characteristics. The relative lack of variation by participants' characteristics suggests that quality improvement interventions may be more effective when directed at healthcare delivery systems rather than individuals.
The Southern Apennine orogenic belt is composed of allochthonous continental units derived from the African and European palaeo‐margins of NeoTethys (the Adria and Corsica‐Sardinia Blocks, ...respectively), together with oceanic units derived from the intervening NeoTethyan domain. The frontal part of the belt has been thrust over a foredeep‐foreland system consisting of the Bradano Trough and Apulian Platform. The belt can be divided into two structural levels which are separated by a major detachment surface. The upper level consists of a multilayer complex made up of allochthonous NeoTethyan nappes; these were deformed during oceanic subduction, and are now emplaced on the Adria Block as a consequence of continent‐continent collision. The lower structural level is characterised by large‐scale duplexes involving the Mesozoic‐Cenozoic sedimentary cover of the Adria Block which in recent years has formed an important target for oil exploration. On top of these allochthonous terranes, a series of small Plio‐Pleistocene basins developed during the final phases of the migration of the thrust belt into the foreland. During the last stages of orogenesis, thrust migration became locked as a result of collisional thickening of the continental crust, and deformation in the southern Apennines was taken up by strike‐slip faults which now cut across the fold and thrust belt.
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Background An index of the need for health visiting in general practice populations in the United Kingdom was developed, using routinely held data, to inform decisions about the deployment of health ...visitors. Methods The following indicators of need for health visiting were developed by consensus among health visitors and others: the population aged under 5 years; elective admissions under 5 years; births under 2500 g; deaths under 65 years; all expressed as rates per 10000 people registered with general practices irv Norfolk. All indicators were compared with the number of health visitors per 10000 people, obtained by a postal survey of health visitors. The indicators were converted to Z-scores and summed to produce a composite score of need for each general practice. The results were compared with the results of a workload profile using data compiled by health visitors within one Primary Care Group. Results Health visitors are not allocated according to need at either the practice or Primary Care Group level. The Pearson's correlation coefficient between the allocation suggested by this method and current allocation is 0.37 (p < 0.01). The correlation between this method and the allocation suggested by health visitors' workload profiling in one Primary Care Group was 0.76 (p < 0.01 ). Conclusions Health visitors are currently distributed according to historic patterns rather than need. This paper describes a simple method of determining need at general practice level, which can be used to allocate health visitors equitably.
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1 2 3 They, however, only partially explore the roles of the National Institute for Health and Care Excellence (NICE) and NHS England in retiring indicators from QOF, and the implications for patient ...care. The fact that the negotiators chose not to accept NICE's advice in full also raises questions about the impact of NICE in further developing the QOF, and the resulting loss of public accountability in the decision making process.
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Background. Asthma is a common and important health condition in the UK, predominantly managed in primary care. Little is known about how characteristics of practices and patients are associated with ...achievement of quality indicators (QIs) for asthma. Objective. To measure the recorded quality of primary care for asthma and to assess whether quality of care differed by patient and practice characteristics. Methods. Medical records were examined for 253 randomly selected asthma patients from 18 general practices in England. Quality of care was assessed against seven predetermined QIs. Logistic regression models were used to test variations in quality of care by age, gender, patient postcode deprivation rank, practice size and time point. Results. There was substantial variation in achievement of individual QIs (range 39–97%). Participants whose postcodes were in the most deprived areas were more likely to be asked about difficulties sleeping odds ratios (ORs) 1.7, 95% confidence interval (CI) 1.2–2.5 or whether asthma interfered with daily activities (OR 1.8, CI 1.2–2.7) than those from middle or least deprived postcode areas. QIs were more likely to be achieved in 2005 than 2003 (ORs 4.4, 2.4, 3.0). There were no significant differences by other characteristics. Conclusions. Great variations exist in the quality of primary care for asthma and considerable scope for improvement. Asthma care improved over time. The preliminary findings that quality of asthma care varied with deprivation support the idea that primary care may be targeting care to those in most need. However, variations were small and only significant for two QIs.
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