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Bene BA, Fadahunsi K, Mastellos N, et al., The impact of mobile health applications on self- management in patients with type 2 diabetes mellitus: protocol of a systematic review, BMJ Open, ISSN: 2044-6055
Introduction: The emergence of mobile health (mHealth) solutions, particularly mHealth applications (apps), has shown promise in self-management of chronic diseases including Type 2 Diabetes Mellitus (T2DM). While majority of the previous systematic reviews have focused on the effectiveness of mHealth apps in improving treatment outcomes in patients with T2DM, there is a need to also understand how mHealth apps influence self-management of T2DM. This is crucial to ensure improvement in the design and use of mHealth apps for T2DM. This protocol describes how a systematic review will be conducted to determine in which way(s) mHealth apps might impact on self-management of T2DM.Methods: The following electronic databases will be searched from inception to April 2019: PubMed; MEDLINE; EMBASE; Global Health; PsycINFO; CINAHL; The Cochrane Central Register of Controlled Trials [CENTRAL]); Scopus; Web of Science; ProQuest Dissertations & Theses Global; HMIC database; Google Scholar; and ClinicalTrials.gov. The Cochrane risk of bias tool will be used to assess methodological quality. The primary outcome measures to be assessed will be ‘change in blood glucose’. The secondary outcomes measures will be ‘changes in cardiovascular risk markers’ (including blood pressure, body mass index, and blood lipids), and self-management practices. Others will include: health-related quality of life, economic data, social support, harms (e.g. death or complications leading to hospital admissions or emergency unit attendances), death from any cause, anxiety or depression, and adverse events (e.g. hypoglycaemic episodes).Ethics and Dissemination: This study will not involve the collection of primary data and will not require ethical approval. The review will be published in a peer-reviewed journal and a one-page summary of the findings will be shared with relevant organisations. Presentation of
Salman D, Farooqi M, McGregor A, et al., 2019, Time spent being sedentary: an emerging risk factor for poor health, British Journal of General Practice, Vol: 69, Pages: 278-279, ISSN: 0960-1643
Greenfield G, Majeed B, Hayhoe B, et al., 2019, Rethinking primary care user fees: is charging a fee for appointments a solution to NHS underfunding?, Br J Gen Pract, Vol: 69, Pages: 280-281
Johnson CO, Minh N, Roth GA, et al., 2019, Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016, Lancet Neurology, Vol: 18, Pages: 439-458, ISSN: 1474-4422
BackgroundStroke is a leading cause of mortality and disability worldwide and the economic costs of treatment and post-stroke care are substantial. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic, comparable method of quantifying health loss by disease, age, sex, year, and location to provide information to health systems and policy makers on more than 300 causes of disease and injury, including stroke. The results presented here are the estimates of burden due to overall stroke and ischaemic and haemorrhagic stroke from GBD 2016.MethodsWe report estimates and corresponding uncertainty intervals (UIs), from 1990 to 2016, for incidence, prevalence, deaths, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs). DALYs were generated by summing YLLs and YLDs. Cause-specific mortality was estimated using an ensemble modelling process with vital registration and verbal autopsy data as inputs. Non-fatal estimates were generated using Bayesian meta-regression incorporating data from registries, scientific literature, administrative records, and surveys. The Socio-demographic Index (SDI), a summary indicator generated using educational attainment, lagged distributed income, and total fertility rate, was used to group countries into quintiles.FindingsIn 2016, there were 5·5 million (95% UI 5·3 to 5·7) deaths and 116·4 million (111·4 to 121·4) DALYs due to stroke. The global age-standardised mortality rate decreased by 36·2% (−39·3 to −33·6) from 1990 to 2016, with decreases in all SDI quintiles. Over the same period, the global age-standardised DALY rate declined by 34·2% (−37·2 to −31·5), also with decreases in all SDI quintiles. There were 13·7 million (12·7 to 14·7) new stroke cases in 2016. Global age-standardised incidence declined by 8·1% (&m
Hayhoe B, Acuyo Cespedes J, Foley K, et al., Impact of integrating pharmacists into primary care teams on health systems indicators: a systematic review, British Journal of General Practice, ISSN: 0960-1643
Background: Evidence suggests that pharmacists integrated in primary care can improve patient outcomes and satisfaction, but their impact on healthcare systems is unclear. Aim: To identify key impacts of integration of pharmacists in primary care on health system indicators such as healthcare utilisation and costs.Design and setting: A systematic review of literature.Method: We examined EMBASE, MEDLINE, SCOPUS, HMIC, CINAHL and CENTRAL, and reference lists of relevant studies. RCTs and observational studies were included, published up to June 2018, which considered health system outcomes of integration of pharmacists in primary care. Risk of bias assessment used the Cochrane Risk of Bias Quality Assessment tool for RCTs, and the NIH National Heart, Lung and Blood Institute quality assessment tool for observational studies. Data were extracted from published reports and findings synthesized.Results: Searches identified 3,058 studies; 28 met the inclusion criteria. Most included studies were of fair quality. Pharmacists in primary care resulted in reduced use of GP appointments and reduced emergency department attendance, but increased overall primary care use. There was no impact on hospitalisations, but some evidence of savings in overall health system costs and medication costs.Conclusion: Integration of pharmacists in primary care may reduce GP workload, as well emergency department use. Further higher quality studies are needed, including research to clarify cost-effectiveness and long-term impact on health system outcomes.
Rao A, Dani K, Darzi A, et al., 2019, Regional variation in trajectories of long-term readmission rates among patients in England with heart failure, BMC Cardiovascular Disorders, Vol: 19, ISSN: 1471-2261
BackgroundWe aimed to compare the characteristics and types of heart failure (HF) patients termed “high-impact users”, with high long-term readmission rates, in different regions in England. This will allow clinical factors to be identified in areas with potentially poor quality of care.MethodsPatients with a primary diagnosis of heart failure (HF) in the period 2008–2009 were identified using nationally representative primary care data linked to national hospital data and followed up for 5 years. Group-based trajectory models and sequence analysis were applied to their readmissions.ResultsIn each of the 8 NHS England regions, multiple discrete groups were identified. All the regions had high-impact users. The group with an initially high readmission rate followed by a rapid decline in the rate ranged from 2.5 to 11.3% across the regions. The group with constantly high readmission rate compared with other groups ranged from 1.9 to 12.1%. Covariates that were commonly found to have an association with high-impact users among most of the regions were chronic respiratory disease, chronic renal disease, stroke, anaemia, mood disorder, and cardiac arrhythmia. Respiratory tract infection, urinary infection, cardiopulmonary signs and symptoms and exacerbation of heart failure were common causes in the sequences of readmissions among high-impact users in all regions.ConclusionThere is regional variation in England in readmission and mortality rates and in the proportions of HF patients who are high-impact users.
Beghi E, Giussani G, Abd-Allah F, et al., 2019, Global, regional, and national burden of epilepsy, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016, Lancet Neurology, Vol: 18, Pages: 357-375, ISSN: 1474-4422
BackgroundSeizures and their consequences contribute to the burden of epilepsy because they can cause health loss (premature mortality and residual disability). Data on the burden of epilepsy are needed for health-care planning and resource allocation. The aim of this study was to quantify health loss due to epilepsy by age, sex, year, and location using data from the Global Burden of Diseases, Injuries, and Risk Factors Study.MethodsWe assessed the burden of epilepsy in 195 countries and territories from 1990 to 2016. Burden was measured as deaths, prevalence, and disability-adjusted life-years (DALYs; a summary measure of health loss defined by the sum of years of life lost [YLLs] for premature mortality and years lived with disability), by age, sex, year, location, and Socio-demographic Index (SDI; a compound measure of income per capita, education, and fertility). Vital registrations and verbal autopsies provided information about deaths, and data on the prevalence and severity of epilepsy largely came from population representative surveys. All estimates were calculated with 95% uncertainty intervals (UIs).FindingsIn 2016, there were 45·9 million (95% UI 39·9–54·6) patients with all-active epilepsy (both idiopathic and secondary epilepsy globally; age-standardised prevalence 621·5 per 100 000 population; 540·1–737·0). Of these patients, 24·0 million (20·4–27·7) had active idiopathic epilepsy (prevalence 326·7 per 100 000 population; 278·4–378·1). Prevalence of active epilepsy increased with age, with peaks at 5–9 years (374·8 [280·1–490·0]) and at older than 80 years of age (545·1 [444·2–652·0]). Age-standardised prevalence of active idiopathic epilepsy was 329·3 per 100 000 population (280·3–381·2) in men and 318·9 per 100 000 population (271·1–369&
Chang AY, Cowling K, Micah AE, et al., 2019, Past, present, and future of global health financing: A review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995–2050, The Lancet, Pages: 1-28, ISSN: 0140-6736
SummaryBackgroundComprehensive and comparable estimates of health spending in each country are a key input for health policy and planning, and are necessary to support the achievement of national and international health goals. Previous studies have tracked past and projected future health spending until 2040 and shown that, with economic development, countries tend to spend more on health per capita, with a decreasing share of spending from development assistance and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending, with an emphasis on equity in spending across countries.MethodsWe estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories—government, out-of-pocket, and prepaid private health spending—and estimated development assistance for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. We used demographic decomposition methods to assess a set of factors associated with changes in government health spending between 1995 and 2016 and to examine evidence to support the theory of the health financing transition. We projected two alternative future scenarios based on higher government health spending to assess the potential ability of governments to gene
Sripa P, Hayhoe B, Garg P, et al., 2019, Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: a systematic review, British Journal of General Practice, ISSN: 0960-1643
BACKGROUND: GPs often act as gatekeepers, authorising patients' access to specialty care. Gatekeeping is frequently perceived as lowering health service use and health expenditure. However, there is little evidence suggesting that gatekeeping is more beneficial than direct access in terms of patient- and health-related outcomes. AIM: To establish the impact of GP gatekeeping on quality of care, health use and expenditure, and health outcomes and patient satisfaction. DESIGN AND SETTING: A systematic review. METHOD: The databases MEDLINE, PreMEDLINE, Embase, and the Cochrane Library were searched for relevant articles using a search strategy. Two authors independently screened search results and assessed the quality of studies. RESULTS: Electronic searches identified 4899 studies (after removing duplicates), of which 25 met the inclusion criteria. Gatekeeping was associated with better quality of care and appropriate referral for further hospital visits and investigation. However, one study reported unfavourable outcomes for patients with cancer under gatekeeping, and some concerns were raised about the accuracy of diagnoses made by gatekeepers. Gatekeeping resulted in fewer hospitalisations and use of specialist care, but inevitably was associated with more primary care visits. Patients were less satisfied with gatekeeping than direct-access systems. CONCLUSION: Gatekeeping was associated with lower healthcare use and expenditure, and better quality of care, but with lower patient satisfaction. Survival rate of patients with cancer in gatekeeping schemes was significantly lower than those in direct access, although primary care gatekeeping was not otherwise associated with delayed patient referral. The long-term outcomes of gatekeeping arrangements should be carefully studied before devising new gatekeeping policies.
Huckvale K, Wang CJ, Majeed A, et al., 2019, Digital health at fifteen: more human (more needed), BMC Medicine, Vol: 17, ISSN: 1741-7015
There is growing appreciation that the success of digital health – whether digital tools, digital interventions or technology-based change strategies – is linked to the extent to which human factors are considered throughout design, development and implementation. A shift in focus to individuals as users and consumers of digital health highlights the capacity of the field to respond to secular developments, such as the adoption of person-centred care and consumer health technologies. We argue that this project is not only incomplete, but is fundamentally ‘uncompletable’ in the face of a highly dynamic landscape of both technological and human challenges. These challenges include the effects of consumerist, technology-supported care on care delivery, the rapid growth of digital users in low-income and middle-income countries and the impacts of machine learning. Digital health research will create most value by retaining a clear focus on the role of human factors in maximising health benefit, by helping health systems to anticipate and understand the person-centred effects of technology changes and by advocating strongly for the autonomy, rights and safety of consumers.
GBD 2016 Neurology Collaborators, 2019, Global, regional, and national burden of neurological disorders, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016., Lancet Neurology, ISSN: 1474-4422
BACKGROUND: Neurological disorders are increasingly recognised as major causes of death and disability worldwide. The aim of this analysis from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 is to provide the most comprehensive and up-to-date estimates of the global, regional, and national burden from neurological disorders. METHODS: We estimated prevalence, incidence, deaths, and disability-adjusted life-years (DALYs; the sum of years of life lost [YLLs] and years lived with disability [YLDs]) by age and sex for 15 neurological disorder categories (tetanus, meningitis, encephalitis, stroke, brain and other CNS cancers, traumatic brain injury, spinal cord injury, Alzheimer's disease and other dementias, Parkinson's disease, multiple sclerosis, motor neuron diseases, idiopathic epilepsy, migraine, tension-type headache, and a residual category for other less common neurological disorders) in 195 countries from 1990 to 2016. DisMod-MR 2.1, a Bayesian meta-regression tool, was the main method of estimation of prevalence and incidence, and the Cause of Death Ensemble model (CODEm) was used for mortality estimation. We quantified the contribution of 84 risks and combinations of risk to the disease estimates for the 15 neurological disorder categories using the GBD comparative risk assessment approach. FINDINGS: Globally, in 2016, neurological disorders were the leading cause of DALYs (276 million [95% UI 247-308]) and second leading cause of deaths (9·0 million [8·8-9·4]). The absolute number of deaths and DALYs from all neurological disorders combined increased (deaths by 39% [34-44] and DALYs by 15% [9-21]) whereas their age-standardised rates decreased (deaths by 28% [26-30] and DALYs by 27% [24-31]) between 1990 and 2016. The only neurological disorders that had a decrease in rates and absolute numbers of deaths and DALYs were tetanus, meningitis, and encephalitis. The four largest contributors of neurological DALYs we
Foley K, Alturkistani A, Carter A, et al., 2019, Massive Open Online Courses (MOOC) evaluation methods: protocol for a systematic review, JMIR Research Protocols, Vol: 8, ISSN: 1929-0748
BACKGROUND: Massive open online courses (MOOCs) have increased in popularity in recent years. They target a wide variety of learners and use novel teaching approaches, yet often exhibit low completion rates (10%). It is important to evaluate MOOCs to determine their impact and effectiveness, but little is known at this point about the methodologies that should be used for evaluation. OBJECTIVE: The purpose of this paper is to provide a protocol for a systematic review on MOOC evaluation methods. METHODS: We will use the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines for reporting this protocol. We developed a population, intervention, comparator, and outcome (PICO) framework to guide the search strategy, based on the overarching question, "What methods have been used to evaluate MOOCs?" The review will follow six stages: 1) literature search, 2) article selection, 3) data extraction, 4) quality appraisal, 5) data analysis, and 6) data synthesis. RESULTS: The systematic review is ongoing. We completed the data searches and data abstraction in October and November 2018. We are now analyzing the data and expect to complete the systematic review by March 2019. CONCLUSIONS: This systematic review will provide a useful summary of the methods used for evaluation of MOOCs and the strengths and limitations of each approach. It will also identify gaps in the literature and areas for future work. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12087.
Fadahunsi KP, Akinlua JT, O'Connor S, et al., 2019, Protocol for a systematic review and qualitative synthesis of information quality frameworks in eHealth, BMJ Open, Vol: 9, ISSN: 2044-6055
Introduction: Electronic health (eHealth) applications have become a very large repository of health information which informs critical decisions relating to the diagnosis, treatment and prognosis of patients. Poor information quality (IQ) within eHealth may compromise patient safety. Evaluation of IQ in eHealth is therefore necessary to promote patient safety. An IQ framework specifies what aspects of information to assess and how to conduct the assessment. This systematic review aims to identify dimensions within existing IQ frameworks in eHealth and develop a new IQ framework for assessment of eHealth.Method and Analysis: We will search EMBASE, Medline, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Maternity and Infant Care, PsycINFO, Global Health, Scopus, ProQuest Dissertations and Theses Global, Health Management Information Consortium and reference lists of relevant publications for articles published in English until November 2018. Studies will be selected by two independent reviewers based on pre-specified eligibility criteria. Two reviewers will independently extract data in each eligible study using a pre-piloted Microsoft Excel data extraction form. Thematic synthesis will be employed to define IQ dimensions and develop a new IQ framework for eHealth. Ethics and Dissemination: Ethical approval is not required for this systematic review as primary data will not be collected. The result of the review will be disseminated through publication in an academic journal and scientific conferences. Keywords: Quality in healthcare, health informatics, telemedicine, systematic review, information qualityReview Registration: PROSPERO CRD42018097142
Car J, Carlstedt-Duke J, Car LT, et al., 2019, Digital education in health professions: the need for overarching evidence synthesis, Journal of Medical Internet Research, Vol: 21, ISSN: 1438-8871
Synthesizing evidence from randomized controlled trials of digital health education poses some challenges. These include a lack of clear categorization of digital health education in the literature; constantly evolving concepts, pedagogies, or theories; and a multitude of methods, features, technologies, or delivery settings. The Digital Health Education Collaboration was established to evaluate the evidence on digital education in health professions; inform policymakers, educators, and students; and ultimately, change the way in which these professionals learn and are taught. The aim of this paper is to present the overarching methodology that we use to synthesize evidence across our digital health education reviews and to discuss challenges related to the process. For our research, we followed Cochrane recommendations for the conduct of systematic reviews; all reviews are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance. This included assembling experts in various digital health education fields; identifying gaps in the evidence base; formulating focused research questions, aims, and outcome measures; choosing appropriate search terms and databases; defining inclusion and exclusion criteria; running the searches jointly with librarians and information specialists; managing abstracts; retrieving full-text versions of papers; extracting and storing large datasets, critically appraising the quality of studies; analyzing data; discussing findings; drawing meaningful conclusions; and drafting research papers. The approach used for synthesizing evidence from digital health education trials is commonly regarded as the most rigorous benchmark for conducting systematic reviews. Although we acknowledge the presence of certain biases ingrained in the process, we have clearly highlighted and minimized those biases by strictly adhering to scientific rigor, methodological integrity, and standard operating procedures.
Meinert E, Alturkistani A, Foley K, et al., 2019, Implementation of blockchains in healthcare: protocol for a systematic review, JMIR Research Protocols, Vol: 8, ISSN: 1929-0748
BackgroundA blockchain is a digitised, decentralised, distributed public ledger; a shared and synchronised database that records cryptocurrency transactions. Despite the shift towards digital platforms enabled by Electronic Medical Records (EMRs), demonstrating a will to reform the healthcare sector, health systems face issues including security, interoperability, data fragmentation, timely access to patient data and silos. Application of healthcare blockchains could enable data interoperability, enhancement of precision medicine and reduction in prescription frauds through implementing novel methods in access and patient consent. Objectives To summarise the evidence on the strategies and frameworks utilised to implement blockchains for patient data in healthcare to ensure privacy and improve interoperability and scalability. It is anticipated this review will assist in development of recommendations that will assist key stakeholders in healthcare blockchain implementation and we predict that the evidence generated will challenge the healthcare status quo, moving away from more traditional approaches and facilitating decision-making of patients, healthcare providers and researchers. ResultsDatabase searches will be initiated in September 2018. We expect to complete the review in December 2018. ConclusionsThis review will summarize the strategies and frameworks used to implement blockchains in healthcare to increase data privacy, interoperability and scalability. This review will also help clarify if the strategies and frameworks required for the operationalisation of blockchains in healthcare ensure the privacy of patient data whilst enabling efficiency, interoperability and scalability.
Meinert E, Alturkistani A, Osama T, et al., 2019, Digital technology in somatic and gene therapy trials of paediatric patients with ocular diseases: a systematic scoping review protocol, JMIR Research Protocols, Vol: 8, ISSN: 1929-0748
BackgroundPharmacogenomics suggests that diseases with similar symptomatic presentations often have varying genetic causes, affecting an individual patient’s response to a specific therapeutic strategy. Gene therapies and somatic cell therapies offer unique therapeutic pathways for ocular diseases and often depend on increased understanding of the genotype-phenotype relationship in disease presentation and progression. While demand for personalised medicine is increasing and the required molecular tools are available, its adoption within paediatric ophthalmology remains to be maximised in the post-genomic era. To address the individual hurdles encountered in the field of genomic-related clinical trials and facilitate the uptake of personalised medicine, we propose to conduct a review that will examine and identify the digital technologies used to facilitate data analysis in somatic and gene therapy trials in paediatric patients with ocular diseases.Objectives To present an outline of HIT/ICT resources used in somatic and gene therapy clinical trials in children with ocular diseases. This review will enable authors to identify challenges and provide recommendations facilitating the uptake of genetic and somatic therapies as therapeutic tools in paediatric ophthalmology. The review will also determine whether conducting a systematic review will be beneficial.ResultsDatabase searches will be initiated in September 2018. We expect to complete the review in December 2018. ConclusionsBased on review findings, the authors will summarise methods used for facilitating IT integration in personalised medicine. Additionally, it will identify further research gaps and determine whether conduction of further reviews will be beneficial.
Meinert E, Alturkistani A, Foley KA, et al., 2019, Blockchain implementation in health care: Protocol for a systematic review, JMIR Research Protocols, Vol: 8, Pages: 153-159, ISSN: 1929-0748
Background: A blockchain is a digitized, decentralized, distributed public ledger that acts as a shared and synchronized database that records cryptocurrency transactions. Despite the shift toward digital platforms enabled by electronic medical records, demonstrating a will to reform the health care sector, health systems face issues including security, interoperability, data fragmentation, timely access to patient data, and silos. The application of health care blockchains could enable data interoperability, enhancement of precision medicine, and reduction in prescription frauds through implementing novel methods in access and patient consent.Objective: To summarize the evidence on the strategies and frameworks utilized to implement blockchains for patient data in health care to ensure privacy and improve interoperability and scalability. It is anticipated this review will assist in the development of recommendations that will assist key stakeholders in health care blockchain implementation, and we predict that the evidence generated will challenge the health care status quo, moving away from more traditional approaches and facilitating decision making of patients, health care providers, and researchers.Methods: A systematic search of MEDLINE/PubMed, Embase, Scopus, ProQuest Technology Collection and Engineering Index will be conducted. Two experienced independent reviewers will conduct titles and abstract screening followed by full-text reading to determine study eligibility. Data will then be extracted onto data extraction forms before using the Cochrane Collaboration Risk of Bias Tool to appraise the quality of included randomized studies and the Risk of Bias in nonrandomized studies of Interventions to assess the quality of nonrandomized studies. Data will then be analyzed and synthesized.Results: Database searches will be initiated in September 2018. We expect to complete the review in January 2019.Conclusions: This review will summarize the strategies and fra
Hayhoe BWJ, Greenfield G, Majeed A, Is it getting easier to obtain antibiotics in the UK?, British Journal of General Practice, ISSN: 0960-1643
Public knowledge and understanding of antibiotics is poor, with only 56% of the UK general public aware that antibiotics cannot kill viruses,(1) and those with poorer knowledge are more likely to use them.(1) Clinical assessment therefore remains a vital step in assessing the need for and safety of antibiotics, and an essential opportunity for education about appropriate use, antimicrobial resistance (AMR), and self-care. In the UK, antibiotics are with very few exceptions only prescribable by doctors or other health professionals with prescribing qualifications. This has meant that until recently access to antibiotics has been possible only through face to face medical assessment in primary or secondary care, providing a significant disincentive to seeking antibiotics unnecessarily.Inappropriate prescribing of antibiotics in UK primary care remains of concern,(2) but antimicrobial stewardship (AMS) initiatives are having a measurable effect, with prescribing rates falling in response to interventions.(3) However, novel routes to obtaining antibiotics, associated with either a lower threshold for prescribing or issuing of antibiotics without medical assessment, undermine these strategies and are likely to increase inappropriate use.
Bottle A, Kim D, Hayhoe B, et al., 2019, Frailty and comorbidity predict first hospitalisation after heart failure diagnosis in primary care: population-based observational study in England, Age and Ageing, ISSN: 1468-2834
Background: frailty has only recently been recognised as important in patients with heart failure (HF), but little has been done to predict the first hospitalisation after diagnosis in unselected primary care populations. Objectives: to predict the first unplanned HF or all-cause admission after diagnosis, comparing the effects of comorbidity and frailty, the latter measured by the recently validated electronic frailty index (eFI). Design: observational study. Setting: primary care in England. Subjects: all adult patients diagnosed with HF in primary care between 2010 and 2013. Methods: we used electronic health records of patients registered with primary care practices sending records to the Clinical Practice Research Datalink (CPRD) in England with linkage to national hospital admissions and death data. Competing-risk time-to-event analyses identified predictors of first unplanned hospitalisation for HF or for any condition after diagnosis. Results: of 6,360 patients, 9% had an emergency hospitalisation for their HF, and 39% had one for any cause within a year of diagnosis; 578 (9.1%) died within a year without having any emergency admission. The main predictors of HF admission were older age, elevated serum creatinine and not being on a beta-blocker. The main predictors of all-cause admission were age, comorbidity, frailty, prior admission, not being on a beta-blocker, low haematocrit and living alone. Frailty effects were largest in patients aged under 85. Conclusions: this study suggests that frailty has predictive power beyond its comorbidity components. HF patients in the community should be assessed for frailty, which should be reflected in future HF guidelines.
James SL, Theadom A, Ellenbogen RG, et al., 2019, Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016, The Lancet Neurology, Vol: 18, Pages: 56-87, ISSN: 1474-4422
BackgroundTraumatic brain injury (TBI) and spinal cord injury (SCI) are increasingly recognised as global health priorities in view of the preventability of most injuries and the complex and expensive medical care they necessitate. We aimed to measure the incidence, prevalence, and years of life lived with disability (YLDs) for TBI and SCI from all causes of injury in every country, to describe how these measures have changed between 1990 and 2016, and to estimate the proportion of TBI and SCI cases caused by different types of injury.MethodsWe used results from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016 to measure the global, regional, and national burden of TBI and SCI by age and sex. We measured the incidence and prevalence of all causes of injury requiring medical care in inpatient and outpatient records, literature studies, and survey data. By use of clinical record data, we estimated the proportion of each cause of injury that required medical care that would result in TBI or SCI being considered as the nature of injury. We used literature studies to establish standardised mortality ratios and applied differential equations to convert incidence to prevalence of long-term disability. Finally, we applied GBD disability weights to calculate YLDs. We used a Bayesian meta-regression tool for epidemiological modelling, used cause-specific mortality rates for non-fatal estimation, and adjusted our results for disability experienced with comorbid conditions. We also analysed results on the basis of the Socio-demographic Index, a compound measure of income per capita, education, and fertility.FindingsIn 2016, there were 27·08 million (95% uncertainty interval [UI] 24·30–30·30 million) new cases of TBI and 0·93 million (0·78–1·16 million) new cases of SCI, with age-standardised incidence rates of 369 (331–412) per 100 000 population for TBI and 13 (11–16) per 100 000 for SC
Feigin VL, Nguyen G, Cercy K, et al., 2018, Global, regional, and country-specific lifetime risks of stroke, 1990 and 2016, New England Journal of Medicine, Vol: 379, Pages: 2429-2437, ISSN: 0028-4793
BackgroundThe lifetime risk of stroke has been calculated in a limited number of selected populations. We sought to estimate the lifetime risk of stroke at the regional, country, and global level using data from a comprehensive study of the prevalence of major diseases.MethodsWe used the Global Burden of Disease (GBD) Study 2016 estimates of stroke incidence and the competing risks of death from any cause other than stroke to calculate the cumulative lifetime risks of first stroke, ischemic stroke, or hemorrhagic stroke among adults 25 years of age or older. Estimates of the lifetime risks in the years 1990 and 2016 were compared. Countries were categorized into quintiles of the sociodemographic index (SDI) used in the GBD Study, and the risks were compared across quintiles. Comparisons were made with the use of point estimates and uncertainty intervals representing the 2.5th and 97.5th percentiles around the estimate.ResultsThe estimated global lifetime risk of stroke from the age of 25 years onward was 24.9% (95% uncertainty interval, 23.5 to 26.2); the risk among men was 24.7% (95% uncertainty interval, 23.3 to 26.0), and the risk among women was 25.1% (95% uncertainty interval, 23.7 to 26.5). The risk of ischemic stroke was 18.3%, and the risk of hemorrhagic stroke was 8.2%. In high-SDI, high-middle–SDI, and low-SDI countries, the estimated lifetime risk of stroke was 23.5%, 31.1% (highest risk), and 13.2% (lowest risk), respectively; the 95% uncertainty intervals did not overlap between these categories. The highest estimated lifetime risks of stroke according to GBD region were in East Asia (38.8%), Central Europe (31.7%), and Eastern Europe (31.6%), and the lowest risk was in eastern sub-Saharan Africa (11.8%). The mean global lifetime risk of stroke increased from 22.8% in 1990 to 24.9% in 2016, a relative increase of 8.9% (95% uncertainty interval, 6.2 to 11.5); the competing risk of death from any cause other than stroke was considered in this calcul
Hayhoe B, Kim D, Aylin P, et al., 2018, Adherence to guidelines in management of symptoms suggestive of heart failure in primary care, Heart, ISSN: 1355-6037
Objective Clinical guidelines on heart failure (HF) suggest timings for investigation and referral in primary care. We calculated the time for patients to achieve key elements in the recommended pathway to diagnosis of HF.Methods In this observational study, we used linked primary and secondary care data (Clinical Practice Research Datalink, a database of anonymised electronic records from UK general practices) between 2010 and 2013. Records were examined for presenting symptoms (breathlessness, fatigue, ankle swelling) and key elements of the National Institute for Health and Care Excellence-recommended pathway to diagnosis (serum natriuretic peptide (NP) test, echocardiography, specialist referral).Results 42 403 patients were diagnosed with HF, of whom 16 597 presented in primary care with suggestive symptoms. 6464 (39%) had recorded NP or echocardiography, and 6043 (36%) specialist referral. Median time from recorded symptom(s) to investigation (NP or echocardiography) was 292 days (IQR 34–844) and to referral 236 days (IQR 42–721). Median time from symptom(s) to diagnosis was 972 days (IQR 337–1468) and to treatment with HF-relevant medication 803 days (IQR 230–1364). Factors significantly affecting timing of referral, treatment and diagnosis included patients’ sex (p=0.001), age (p<0.001), deprivation score (p=0.001), comorbidities (p<0.001) and presenting symptom type (p<0.001).Conclusions Median times to investigation or referral of patients presenting in primary care with symptoms suggestive of HF considerably exceeded recommendations. There is a need to support clinicians in the diagnosis of HF in primary care, with improved access to investigation and specialist assessment to support timely management.
Hayhoe BWJ, Cowling T, Pillutla V, et al., 2018, Integrating a nationally scaled workforce of community health workers in primary care: a modelling study, Journal of the Royal Society of Medicine, Vol: 111, Pages: 453-461, ISSN: 1758-1095
ObjectiveTo model cost and benefit of a national community health worker workforce.DesignModelling exercise based on all general practices in England.SettingUnited Kingdom National Health Service Primary Care.ParticipantsNot applicable.Data sourcesPublicly available data on general practice demographics, population density, household size, salary scales and screening and immunisation uptake.Main outcome measuresWe estimated numbers of community health workers needed, anticipated workload and likely benefits to patients.ResultsConservative modelling suggests that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workerss could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease.ConclusionA scaled community health worker workforce integrated into primary care may be a valuable policy alternative. Pilot studies are required to establish feasibility and impact in NHS primary care.
Zunt JR, Kassebaum NJ, Blake N, et al., 2018, Global, regional, and national burden of meningitis, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016, Lancet Neurology, Vol: 17, Pages: 1061-1082, ISSN: 1474-4422
BackgroundAcute meningitis has a high case-fatality rate and survivors can have severe lifelong disability. We aimed to provide a comprehensive assessment of the levels and trends of global meningitis burden that could help to guide introduction, continuation, and ongoing development of vaccines and treatment programmes.MethodsThe Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2016 study estimated meningitis burden due to one of four types of cause: pneumococcal, meningococcal, Haemophilus influenzae type b, and a residual category of other causes. Cause-specific mortality estimates were generated via cause of death ensemble modelling of vital registration and verbal autopsy data that were subject to standardised data processing algorithms. Deaths were multiplied by the GBD standard life expectancy at age of death to estimate years of life lost, the mortality component of disability-adjusted life-years (DALYs). A systematic analysis of relevant publications and hospital and claims data was used to estimate meningitis incidence via a Bayesian meta-regression tool. Meningitis deaths and cases were split between causes with meta-regressions of aetiological proportions of mortality and incidence, respectively. Probabilities of long-term impairment by cause of meningitis were applied to survivors and used to estimate years of life lived with disability (YLDs). We assessed the relationship between burden metrics and Socio-demographic Index (SDI), a composite measure of development based on fertility, income, and education.FindingsGlobal meningitis deaths decreased by 21·0% from 1990 to 2016, from 403 012 (95% uncertainty interval [UI] 319 426–458 514) to 318 400 (265 218–408 705). Incident cases globally increased from 2·50 million (95% UI 2·19–2·91) in 1990 to 2·82 million (2·46–3·31) in 2016. Meningitis mortality and incidence were closely related to SDI. The highest mortality rates an
Elmontsri M, Banarsee R, Majeed A, Improving patient safety in developing countries - moving towards an integrated approach, JRSM Open, ISSN: 2054-2704
Patient safety is as major public health issue. It has also been recognised as an area for improvement. The purpose of this article is to discuss the need for developing an integrated approach to patient safety improvement in developing countries. Relevant literature to identify the common themes and patterns associated with patient safety improvement was conducted through a search of the online databases (MEDLINE, EMBASE, PUBMED and Google Scholar) for the years 2000 to 2017. Lessons and interventions from developed countries have been taken into consideration to identify the themes needed for patient safety improvement in developing countries. This review provides an integrated approach based on best practice which can be used to guide the development of a national strategy for improving patient safety. Policy makers need to focus on developing a holistic and comprehensive approach to patient safety improvement that takes into account the themes discussed in this article.
Bottle R, Kim D, Aylin P, et al., 2018, Real-world presentation with heart failure in primary care: Do patients selected to follow diagnostic and management guidelines have better outcomes?, Open Heart, Vol: 5, ISSN: 2053-3624
Objective To describe associations between initial management of people presenting with heart failure (HF) symptoms in primary care, including compliance with the recommendations of the National Institute for Health and Care Excellence (NICE), and subsequent unplanned hospitalisation for HF and death.Methods This is a retrospective cohort study using data from general practices submitting records to the Clinical Practice Research Datalink. The cohort comprised patients diagnosed with HF during 2010–2013 and presenting to their general practitioners with breathlessness, fatigue or ankle swelling.Results 13 897 patients were included in the study. Within the first 6 months, only 7% had completed the NICE-recommended pathway; another 18.6% had followed part of it (B-type natriuretic peptide testing and/or echocardiography, or specialist referral). Significant differences in hazards were seen in unadjusted analysis in favour of full or partial completion of the NICE-recommended pathway. Covariate adjustment attenuated the relations with death much more than those for HF admission. Compared with patients placed on the NICE pathway, treatment with HF medications had an HR of 1.16 (95% CI 1.05 to 1.28, p=0.003) for HF admission and 1.03 (95% CI 0.90 to 1.17, p= 0.674) for death. Patients who partially followed the NICE pathway had similar hazards to those who completed it. Patients on no pathway had the highest hazard for HF admission at 1.30 (95% 1.18 to 1.43, p<0.001) but similar hazard for death.Conclusions Patients not put on at least some elements of the NICE-recommended pathway had significantly higher risk of HF admission but non-significant higher risk of death than other patients had.
Stanaway JD, Afshin A, Gakidou E, et al., 2018, Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017, LANCET, Vol: 392, Pages: 1923-1994, ISSN: 0140-6736
BackgroundThe Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk–outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk–outcome pairs, and new data on risk exposure levels and risk–outcome associations.MethodsWe used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk–outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risk
James SL, Abate D, Abate KH, et al., 2018, Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017, The Lancet, Vol: 392, Pages: 1789-1858, ISSN: 0140-6736
BackgroundThe Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data.MethodsWe estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calcula
Roth GA, Abate D, Abate KH, et al., 2018, Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017, The Lancet, Vol: 392, Pages: 1736-1788, ISSN: 0140-6736
BackgroundGlobal development goals increasingly rely on country-specific estimates for benchmarking a nation's progress. To meet this need, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 estimated global, regional, national, and, for selected locations, subnational cause-specific mortality beginning in the year 1980. Here we report an update to that study, making use of newly available data and improved methods. GBD 2017 provides a comprehensive assessment of cause-specific mortality for 282 causes in 195 countries and territories from 1980 to 2017.MethodsThe causes of death database is composed of vital registration (VR), verbal autopsy (VA), registry, survey, police, and surveillance data. GBD 2017 added ten VA studies, 127 country-years of VR data, 502 cancer-registry country-years, and an additional surveillance country-year. Expansions of the GBD cause of death hierarchy resulted in 18 additional causes estimated for GBD 2017. Newly available data led to subnational estimates for five additional countries—Ethiopia, Iran, New Zealand, Norway, and Russia. Deaths assigned International Classification of Diseases (ICD) codes for non-specific, implausible, or intermediate causes of death were reassigned to underlying causes by redistribution algorithms that were incorporated into uncertainty estimation. We used statistical modelling tools developed for GBD, including the Cause of Death Ensemble model (CODEm), to generate cause fractions and cause-specific death rates for each location, year, age, and sex. Instead of using UN estimates as in previous versions, GBD 2017 independently estimated population size and fertility rate for all locations. Years of life lost (YLLs) were then calculated as the sum of each death multiplied by the standard life expectancy at each age. All rates reported here are age-standardised.FindingsAt the broadest grouping of causes of death (Level 1), non-communicable diseases (NCDs) comprised the greatest f
Kyu HH, Abate D, Abate KH, et al., 2018, Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017, The Lancet, Vol: 392, Pages: 1859-1922, ISSN: 0140-6736
BackgroundHow long one lives, how many years of life are spent in good and poor health, and how the population's state of health and leading causes of disability change over time all have implications for policy, planning, and provision of services. We comparatively assessed the patterns and trends of healthy life expectancy (HALE), which quantifies the number of years of life expected to be lived in good health, and the complementary measure of disability-adjusted life-years (DALYs), a composite measure of disease burden capturing both premature mortality and prevalence and severity of ill health, for 359 diseases and injuries for 195 countries and territories over the past 28 years.MethodsWe used data for age-specific mortality rates, years of life lost (YLLs) due to premature mortality, and years lived with disability (YLDs) from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to calculate HALE and DALYs from 1990 to 2017. We calculated HALE using age-specific mortality rates and YLDs per capita for each location, age, sex, and year. We calculated DALYs for 359 causes as the sum of YLLs and YLDs. We assessed how observed HALE and DALYs differed by country and sex from expected trends based on Socio-demographic Index (SDI). We also analysed HALE by decomposing years of life gained into years spent in good health and in poor health, between 1990 and 2017, and extra years lived by females compared with males.FindingsGlobally, from 1990 to 2017, life expectancy at birth increased by 7·4 years (95% uncertainty interval 7·1–7·8), from 65·6 years (65·3–65·8) in 1990 to 73·0 years (72·7–73·3) in 2017. The increase in years of life varied from 5·1 years (5·0–5·3) in high SDI countries to 12·0 years (11·3–12·8) in low SDI countries. Of the additional years of life expected at birth, 26·3% (20·1&ndash
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