Type 2 diabetes can often be prevented by lifestyle modification; however, successful lifestyle intervention programmes are labour intensive. Mobile phone messaging is an inexpensive alternative way ...to deliver educational and motivational advice about lifestyle modification. We aimed to assess whether mobile phone messaging that encouraged lifestyle change could reduce incident type 2 diabetes in Indian Asian men with impaired glucose tolerance.
We did a prospective, parallel-group, randomised controlled trial between Aug 10, 2009, and Nov 30, 2012, at ten sites in southeast India. Working Indian men (aged 35-55 years) with impaired glucose tolerance were randomly assigned (1:1) with a computer-generated randomisation sequence to a mobile phone messaging intervention or standard care (control group). Participants in the intervention group received frequent mobile phone messages compared with controls who received standard lifestyle modification advice at baseline only. Field staff and participants were, by necessity, not masked to study group assignment, but allocation was concealed from laboratory personnel as well as principal and co-investigators. The primary outcome was incidence of type 2 diabetes, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00819455.
We assessed 8741 participants for eligibility. 537 patients were randomly assigned to either the mobile phone messaging intervention (n=271) or standard care (n=266). The cumulative incidence of type 2 diabetes was lower in those who received mobile phone messages than in controls: 50 (18%) participants in the intervention group developed type 2 diabetes compared with 73 (27%) in the control group (hazard ratio 0·64, 95% CI 0·45-0·92; p=0·015). The number needed to treat to prevent one case of type 2 diabetes was 11 (95% CI 6-55). One patient in the control group died suddenly at the end of the first year. We recorded no other serious adverse events.
Mobile phone messaging is an effective and acceptable method to deliver advice and support towards lifestyle modification to prevent type 2 diabetes in men at high risk.
The UK India Education and Research Initiative, the World Diabetes Foundation.
Abstract Background Recent health-care reforms in England have opened up the provision of general practice to new models of care, and primary care can now be provided under various contractual ...mechanisms. Previous research has highlighted population-level variation in quality indicators across practices under different contract types. We present differences in patient-reported experience of general practice services across three contract types in England. Methods Data come from the national General Practice Patient Survey 2013–14 (903 357 responders from 7949 general practices in England; 34% response rate, range 29–44). The primary outcome was overall patient experience of a general practice (on a five-point scale, rescaled to 0–100 for all measures). Sociodemographic data included patient age, sex, ethnicity, deprivation, and self-reported health, and the profile of each practice's registered population. We used mixed-effects linear regression, using a random intercept for each general practice to estimate case-mix-adjusted associations between contract type and patient experience. Findings The mean score for overall experience across all practices was 83·3 (SD 20·3), indicating a fairly good experience nationally. Practices run as limited companies were uncommon (n=118, 1·5%) but overall their levels of patient experience were lower. Relative to general medical services (GMS) practices (mean 83·7), the adjusted means for overall experience for limited company-owned alternative provider of medical services (APMS) and personal medical services (PMS) practices were 3·0 (p<0·0001) and 3·6 (p=0·0176) lower. Results were similar for the other indicators: ability to see a preferred doctor (GMS mean 70·3; mean difference limited company APMS −12·8 p<0·0001, mean difference limited company PMS −11·6 p=0·0003), appointment convenience (78·5; −3·0 p<0·0001, −2·8 p=0·1330), doctor communication (84·1; −2·9 p<0·0001, −3·5 p=0·0052), and ease of telephone contact (69·6; −0·2 p=0·5527, −6·2 p=0·0465). Interpretation General practices run as limited companies had worse scores for overall patient experience. Strengths of this study include the large, nationally representative sample. Limitations include the possibility for residual confounding, and the cross-sectional nature of available data. The results support continued monitoring of quality of care across different forms of general practice service provision. Funding This research was supported by the National Institute for Health Research (NIHR) (Doctoral Research Fellowship for TEC, DRF-2013-06-142).
Abstract Background Some patients attend emergency departments more frequently than others and account for a disproportionate number of attendances. However, little is known about repeat attenders at ...National Health Service urgent care centres. We aimed to describe the volume and characteristics of repeat attenders at such centres. Methods In an observational study, we analysed routine attendance data at two urgent care centres in London. We included all adult patients (aged 18 years and older) who attended either centre at least once between Jan 1, 2010, and Dec 31, 2012. We used Poisson regression models to predict the characteristics of frequent attenders. For each patient, the outcome variable was the numbers of repeat visits, and the exposure variable was length of follow-up. The predictors were age, sex, and risk factors recorded at the first visit (socioeconomic status, ethnicity, centre attended, referral to an accident and emergency A&E department, referral to a non-A&E service, mental health indication, number of diagnoses, and general practitioner GP registration status). We also estimated population attributable fractions for the non-base levels of each risk factor. Findings 189 614 attendances were made by 108 677 patients. Although only 3116 (2·9%) attended more than five times, they accounted for a disproportionate number (26 826, 14·1%) of the total attendances. The strongest predictor of frequent attendance was low socioeconomic status (population attributable fraction for men 0·501, 95% CI 0·446–0·550; women 0·353, 0·281–0·418). Frequent attendees were commonly of non-white ethnicity (men 0·057, 0·038–0·076; women 0·030, 0·017–0·044) and unregistered with a GP (men 0·021, 0·015–0·027; women 0·017, 0·013–0·020). Patients referred to non-A&E services at their first visit were less likely to re-attend (men −0·020, −0·024 to −0·015; women −0·011, −0·015 to −0·007). Interpretation Although very few patients attended the centres frequently, they contributed disproportionally to the workload of the centres. Patients of low socioeconomic status, non-white ethnicity, and unregistered with a GP were more likely to attend frequently. Interventions to reduce repeat attendances could target these populations via educational programmes or enhanced access to community-based services. The generalisability of these findings is limited because data come from only two urgent care centres in London. Funding This study was funded by a grant from the Imperial College NHS Trust Healthcare Charity and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Northwest London.
Abstract Background Health system reforms in England have welcomed competition by opening broad areas of clinical practice to new providers of care. As part of these reforms new entrants, including ...private companies, have been allowed into the primary care market since 2004 under contracting mechanisms known as alternative provider of medical services. The characteristics and performance of general practices working under new alternative provider contracts are not well described. Methods Between 2008–09 and 2012–13, we compared performance on 17 established quality indicators that included clinical effectiveness, efficiency, access, and patient experience in all general practices in England by contract type. Data were obtained from the Quality and Outcomes Framework and General Practice Patient Survey. We used linear regression in cross-sectional and time series analyses, adjusting for practice and population characteristics and underlying trends, to compare quality in practices using alternative provider contracts to traditional practices. We created a regression model using practice fixed effects to estimate the effect on performance of practices changing to the new contract type. Findings 347 (4·1%) of 8300 general practices in England were run by alternative contract providers. These practices tended to be smaller, and serve younger, more diverse, and more deprived populations than traditional providers. Practices run by alternative providers performed worse than traditional providers on 15 of 17 indicators after adjustment for practice and population characteristics (p<0·001 for all 15), including diabetes and hypertension control, admissions for ambulatory care sensitive conditions, and overall satisfaction with care. Alternative providers had a higher percentage of patients reporting satisfaction with opening hours and higher prescribing of generic medications than did general practices not run by alternative providers. Switching to a new alternative provider contract did not result in improved performance in our fixed-effect models. Interpretation The introduction of contracts for new alternative providers to deliver primary care services in England has not led to improvements in quality and might have resulted in worse care. Strengths of our study include use of a 5-year national data sample. Limitations include risk of lack of adjustment for unmeasured confounding factors. Regulators should ensure that new entrants to clinical-provider markets are performing to adequate standards and at least as well as traditional providers. Funding There was no specific funding for this work. FG is funded by London Deanery and the Commonwealth Fund. CM is funded by the Northwest London National Institute for Health Reasearch Collaboration for Leadership in Applied Health Research & Care and the Higher Education Funding Council for England.
Abstract Background In the context of integrated care, multidisciplinary group (MDG) meetings involve participants who are not only from different professional groups but also from different ...organisational backgrounds within a complex local health economy. Such meetings therefore provide opportunities for participants to discuss complex care of individual patients, as well as ways to improve working within that local health economy—ie, working in a more integrative manner. We used an innovative coding scheme and method to explore the communication patterns within MDGs of a large-scale integrated care pilot (the North-West London Integrated Care Pilot). We investigated the extent to which case discussions foster an integrative way of working between MDG participants. Methods Case discussions in four MDG meetings were audio recorded and transcribed. Scripts were divided into utterances, or units of meaning, of about equal length representing a complete phrase or sentence. A second researcher then checked these utterances, and disagreements were resolved through consensus. Two coders independently coded utterances according to their integrative potential, which was defined against three independent domains: the level (ie, individual, collective, and systems); the valence (problem, information, and solution); and the focus (concrete and abstract). Utterances were coded first with respect to level, then valence, and then focus, to avoid any bias to code preferentially towards one permutation of the three codes. Inter-rater and intra-rater reliability was tested with kappa scores on one randomly selected case discussion. Intra-rater scores were taken 2 weeks apart to avoid possible code recall. We developed an ordinal scale based on mathematical weights for the 18 permutations of level, valence, and focus. Standardised mean integration scores were calculated for case discussions across utterance deciles, corresponding roughly to time deciles, indicating how integrative intensity changed during the conversation. Findings We transcribed and coded 23 case discussions in four different MDG groups. Inter-rater and intra-rater reliability was good, as shown by the prevalence and bias-adjusted kappa scores for one randomly selected case discussion. We coded 4209 utterances. The proportion of utterances differed according to participant type (consultant 14·6%; presenting general practitioner 38·8%; chair 7·8%; non-presenting general practitioner 2·3%; allied health professional 4·8%). Utterances were predominantly coded at low levels of integrative intensity. Allied health professionals accounted for a fairly low proportion of utterances; however, they tended to speak at higher integrative levels. We noted evidence for a gradual increase (R2 0·66) in integrative intensity during the case discussions, but on the basis of analysis of the minutes and action points arising from these discussions, this evidence did not translate into future actions. Interpretation We characterise the MDGs as having consultative characteristics with some trend towards collaboration, but best resemble community-based ward rounds. The increase in integration scores did not tend to translate into actions for the groups to take forward. The role of the chair and the improved participation of non-presenting general practitioners and allied health professionals seem important, especially because allied health professionals contribute greatly to higher integrative scores. Traditional communication patterns of medical dominance are being perpetuated in the MDGs, suggesting that more could be done to sensitise participants to the value of full participation from all members of the group. Case discussions in integrated care MDGs are opportunities for health professionals to learn from each other's cases and explore how services could work together better to improve care generally. Our characterisation of these MDGs shows that more could be done in this regard. Reviews of decision making and communication in primary and community care show a dearth of empirical research examining real-time dynamics. Our method enables researchers to detect evolutionary changes in the integrative intensity of the group over time and make comparisons between MDGs. Funding Imperial College Healthcare Charity.
The head to head debate on general practice opening hours does not specify the number of additional opening hours. 1 Similarly, the proposal for GPs in England to see patients from 8 am to 8 pm, ...seven days a week, tells us little about how much longer GPs would provide consultations. 2 We analysed NHS Choices data, obtained on 1 October 2013, on surgery (rather than reception) opening hours for 8973 general practices in England ( www.nhs.uk/ ). ...does the government intend to increase the number of consultation hours each week, as well as extending surgery opening hours (for example, two GPs could provide two hours of consultation in one or two surgery opening hours)?
Technologies for global health Howitt, Peter, MA; Darzi, Ara, Prof; Yang, Guang-Zhong, Prof ...
The Lancet (British edition),
08/2012, Volume:
380, Issue:
9840
Journal Article
Peer reviewed
Mechanical ventilation and intravenous sedation were initiated. Because of continuing spasms, intrathecal baclofen (1200 µg per day) was started on day 3 with a good clinical response. No ...recommendations about tetanus prophylaxis procedures for wound man agement in patients with blood diseases are available, except for bone-marrow transplantation.
