Introduction
General practice (GP) antidepressants (ADs) prescribing in England has almost doubled in the past decade: how does location, GP characteristics, and prescribing selection influence ...antidepressant prescribing rate (ADPR) and growth.
Methods
Stepwise multivariate regression analysis was applied to national public relevant data for each general practice to establish associations between these factors and ADPR. The regression coefficient was applied to the actual change in the number of different ADs and costs/dose to extrapolate the impact of these on growth.
Results
In 2017–2018, 2.1 billion doses of antidepressant were prescribed into a population of 52 million people in 6,146 larger practices. In the model, location demographics accounted for 62% of the variation in ADPR: including practice size and health raised this to 71%, and local prescribing behaviour to 80%. Practices using more different drugs and lower‐cost/dose had higher ADPR. Extrapolation showed that 40% of growth in ADPR could be attributed to the historic changes in these factors.
Conclusions
While practice location factors do impact on AD prescription rates, local long‐term physical health condition prevalence and prescribing behaviours are almost as important. We hope that our findings can provide insights that are helpful to local clinical behaviour and medicines management.
Abstract Purpose of study To evaluate the 3-year impact of initiating basal insulin on glycaemic control (HbA1c) and weight gain in patients with poorly controlled type 2 diabetes registered with UK ...general practices that volunteered to participate in an insulin initiation training programme. Methods Audit utilising data collected from practice record systems, which included data at baseline, 3, 6 months and subsequent six-monthly intervals post-insulin initiation for up to 10 patients per participating practice. Results Of 115 eligible practices, 55 (47.8%) contributed data on a total of 516 patients. The mean improvement in HbA1c levels in the first 6 months was 1.4% (range −3.8% to 8.2%, median = 1.40%). Thereafter, there was no overall change in HbA1c levels, although the change for individual patients ranged from −4.90% to +7.50%. At 36 months, 141 (41%) patients for whom data were provided had achieved the pre-2006/2007 UK Quality and Outcomes Framework (QOF) target of 7.4% or less, including 98 (29%) who had achieved an HbA1c of 7% or less. Patients who achieved target had a lower HbA1c at baseline (mean 9.1% compared to 9.7%; p < 0.001); had a lower weight at 36 months (mean 88.0 kg compared to 93.5 kg; p = 0.05); were more likely to be on basal insulin alone (88, 47.1% compared to 46, 34.6%; p < 0.05); and were slightly older (mean 64.5 years compared to 61.7 years; p < 0.05). Conclusion Attending an insulin initiation training programme may successfully prepare primary healthcare professionals to initiate insulin therapy as part of everyday practice for patients with poorly controlled type 2 diabetes. The impact on glycaemic control is maintained over a 3-year period. Although intensification of treatment occurred during this period, the findings suggest scope for further intensification of insulin therapy in order to improve on the glycaemic control achieved during the first 6 months post-insulin initiation.
The management of long-term conditions in primary care has hit the headlines thanks to a report from the Academy of Medical Sciences, which highlighted the clustering of different physical and mental ...health conditions in a single patient, and estimated that millions of Britons suffer from multimorbidity. Diabetes is acknowledged as a condition where primary care clinicians should be well used to managing multimorbidity, and lessons may be learnt from this area. The National Diabetes Audit data provide practice-level measures of diabetes outcomes including the numbers achieving target HbA1c and those at elevated risk of complications.
Both dementia and diabetes mellitus are long‐term disabling conditions and each may be a co‐morbidity of the other. Type 2 diabetes is associated with a 1.5‐ to 2‐fold higher risk of dementia. ...Diabetes also may occur for the first time in many individuals with mental ill health, including cognitive impairment and dementia, and this may complicate management and lead to difficulties in self‐care. Case finding is often poor for cognitive impairment in medical settings and for diabetes in mental health settings and this needs to be addressed in the development of care pathways for both conditions. Many other deficiencies in quality care (both for dementia and diabetes) currently exist, but we hope that this Best Clinical Practice Statement will provide a platform for further work in this area. We have outlined the key steps in an integrated care pathway for both elements of this clinical relationship, produced guidance on identifying each condition, dealt with the potentially hazardous issue of hypoglycaemia, and have outlined important competencies required of healthcare workers in both medical/diabetes and mental health settings to enhance clinical care.
ObjectiveEvaluate relative clinical effectiveness of treatment options for type 2 diabetes mellitus (T2DM) using a statistical model of real-world evidence within UK general practitioner practices ...(GPP), to quantify the opportunities for diabetes care performance improvement.MethodFrom the National Diabetes Audit in 2015–2016 and 2016–2017, GPP target glycaemic control (TGC—%HbA1c ≤58 mmol/mol) and higher glycaemic risk (HGR —%HbA1c results >86 mmol/mol) outcomes were linked using multivariate linear regression to prescribing, demographics and practice service indicators. This was carried out both cross-sectionally (XS) (within year) and longitudinally (Lo) (across years) on 35 indicators. Standardised β coefficients were used to show relative level of impact of each factor. Improvement opportunity was calculated as impact on TGC & HGR numbers.ResultsValues from 6525 GPP with 2.7 million T2DM individuals were included. The cross-sectional model accounted for up to 28% TGC variance and 35% HGR variance, and the longitudinal model accounted for up to 9% TGC and 17% HGR variance. Practice service indicators including % achieving routine checks/blood pressure/cholesterol control targets were positively correlated, while demographic indicators including % younger age/social deprivation/white ethnicity were negatively correlated. The β values for selected molecules are shown as (increased TGC; decreased HGR), canagliflozin (XS 0.07;0.145/Lo 0.04;0.07), metformin (XS 0.12;0.04/Lo –;–), sitagliptin (XS 0.06;0.02/Lo 0.10;0.06), empagliflozin (XS–;0.07/Lo 0.09;0.07), dapagliflozin (XS –;0.04/Lo –;0.4), sulphonylurea (XS −0.18;−0.12/Lo–;–) and insulin (XS−0.14;0.02/ Lo−0.09;–). Moving all GPP prescribing and interventions to the equivalent of the top performing decile of GPP could result in total patients in TGC increasing from 1.90 million to 2.14 million, and total HGR falling from 191 000 to 123 000.ConclusionsGPP using more legacy therapies such as sulphonylurea/insulin demonstrate poorer outcomes, while those applying holistic patient management/use of newer molecules demonstrate improved glycaemic outcomes. If all GPP moved service levels/prescribing to those of the top decile, both TGC/HGR could be substantially improved.
Key learning points: The difference between mild, moderate and severe pregnancy sickness and hyperemesis gravidarum; Understanding the possible causes of the condition; What support and treatment to ...offer to women suffering with pregnancy sickness or hyperemesis gravidarium 14 references
PDF
