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Fitzmaurice C, Abate D, Abbasi N, et al., Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 29 cancer groups, 1990 to 2017, JAMA Oncology, ISSN: 2374-2437
Importance Cancer and other noncommunicable diseases (NCDs) are now widely recognized as a threat to global development. The latest United Nations high-level meeting on NCDs reaffirmed this observation and also highlighted the slow progress in meeting the 2011 Political Declaration on the Prevention and Control of Noncommunicable Diseases and the third Sustainable Development Goal. Lack of situational analyses, priority setting, and budgeting have been identified as major obstacles in achieving these goals. All of these have in common that they require information on the local cancer epidemiology. The Global Burden of Disease (GBD) study is uniquely poised to provide these crucial data.Objective To describe cancer burden for 29 cancer groups in 195 countries from 1990 through 2017 to provide data needed for cancer control planning.Evidence Review We used the GBD study estimation methods to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs). Results are presented at the national level as well as by Socio-demographic Index (SDI), a composite indicator of income, educational attainment, and total fertility rate. We also analyzed the influence of the epidemiological vs the demographic transition on cancer incidence.Findings In 2017, there were 24.5 million incident cancer cases worldwide (16.8 million without nonmelanoma skin cancer [NMSC]) and 9.6 million cancer deaths. The majority of cancer DALYs came from years of life lost (97%), and only 3% came from years lived with disability. The odds of developing cancer were the lowest in the low SDI quintile (1 in 7) and the highest in the high SDI quintile (1 in 2) for both sexes. In 2017, the most common incident cancers in men were NMSC (4.3 million incident cases); tracheal, bronchus, and lung (TBL) cancer (1.5 million incident cases); and prostate cancer (1.3 million incident cases). The most common causes of cancer deaths and DALYs for m
Green K, Cooke O'Dowd N, Watt H, et al., 2019, Prescribing trends of gabapentin, pregabalin and oxycodone; a secondary analysis of primary care prescribing patterns in England, BJGP Open, ISSN: 2398-3795
BackgroundThe risk of iatrogenic harm from prescription drug use, misuse and abuse of drugssuch as gabapentin, pregabalin and oxycodone is substantial. In recent years, deathsassociated with these drugs in England have increased.AimsTo characterise general practice prescribing trends for gabapentin, pregabalin andoxycodone – termed dependence forming medicines (DFM) – in England and describepotential drivers of unwarranted variation.Design and SettingThis study is a retrospective secondary analysis of open source, publicly availablegovernment data from various sources pertaining to primary care demographics andprescriptions.MethodsThis study used five consecutive years (April 2013 – March 2018) of aggregate datato investigate longitudinal trends of prescribing and variation in prescribing trends atpractice and clinical commissioning group (CCG) level.ResultsAnnual prescriptions of gabapentin, pregabalin and oxycodone have increased eachyear over the period. Variation in prescribing trends were associated with GP practicedeprivation quintile, where the most deprived GP practices prescribe 313% (p<0.001)and 238% (p<0.001) greater volumes of gabapentin and pregabalin per person thanpractices in the least deprived quintile. The highest prescribing CCGs of each of thesedrugs were predominantly in northern and eastern regions of England.ConclusionsSubstantial increases in gabapentin, pregabalin and oxycodone prescriptions areconcerning and will increase iatrogenic harm from drug-related morbidity and mortality.More research is needed to understand the large variation in prescribing between general practices; and to develop and implement interventions to reduce unwarrantedvariation and increase the appropriateness of prescribing of these drugs.
Vamos EP, Palladino R, Tabak AG, et al., 2019, Association of non-diabetic hyperglycaemia and microvascular and macrovascular complications of type 2 diabetes: a retrospective cohort study, 55th Annual Meeting of the European-Association-for-the-Study-of-Diabetes (EASD), Publisher: SPRINGER, Pages: S500-S500, ISSN: 0012-186X
Modi N, Ashby D, Battersby C, et al., Developing routinely recorded clinical data from electronic patient records as a national resource to improve neonatal health care: the Medicines for Neonates research programme, Programme Grants for Applied Research, Vol: 7, Pages: 1-396, ISSN: 2050-4322
<jats:sec id="abs1-1"> <jats:title>Background</jats:title> <jats:p>Clinical data offer the potential to advance patient care. Neonatal specialised care is a high-cost NHS service received by approximately 80,000 newborn infants each year.</jats:p> </jats:sec> <jats:sec id="abs1-2"> <jats:title>Objectives</jats:title> <jats:p>(1) To develop the use of routinely recorded operational clinical data from electronic patient records (EPRs), secure national coverage, evaluate and improve the quality of clinical data, and develop their use as a national resource to improve neonatal health care and outcomes. To test the hypotheses that (2) clinical and research data are of comparable quality, (3) routine NHS clinical assessment at the age of 2 years reliably identifies children with neurodevelopmental impairment and (4) trial-based economic evaluations of neonatal interventions can be reliably conducted using clinical data. (5) To test methods to link NHS data sets and (6) to evaluate parent views of personal data in research.</jats:p> </jats:sec> <jats:sec id="abs1-3"> <jats:title>Design</jats:title> <jats:p>Six inter-related workstreams; quarterly extractions of predefined data from neonatal EPRs; and approvals from the National Research Ethics Service, Health Research Authority Confidentiality Advisory Group, Caldicott Guardians and lead neonatal clinicians of participating NHS trusts.</jats:p> </jats:sec> <jats:sec id="abs1-4"> <jats:title>Setting</jats:title> <jats:p>NHS neonatal units.</jats:p> </jats:sec> <jats:sec id="abs1-5">
Kim D, Hayhoe B, Aylin P, et al., 2019, Route to heart failure diagnosis in English primary care: a retrospective cohort study of variation, British Journal of General Practice, ISSN: 0960-1643
BACKGROUND: Despite the existence of evidence-based guidelines supporting the identification of heart failure (HF) in primary care, the proportion of patients diagnosed in this setting remains low. Understanding variation in patients' routes to diagnosis will better inform HF management. AIM: To identify the factors associated with variation in patients' routes to HF diagnosis in primary care. DESIGN AND SETTING: A retrospective cohort study of 13 897 patients diagnosed with HF between 1 January 2010 and 31 March 2013 in English primary care. METHOD: This study used primary care electronic health records to identify routes to HF diagnosis, defined using the National Institute for Health and Care Excellence (NICE) guidelines, and adherence to the NICE-recommended guidelines. Multilevel logistic regression was used to investigate factors associated with the recommended route to HF diagnosis, and funnel plots were used to visualise variation between practices. RESULTS: Few patients (7%, n = 976) followed the recommended route to HF diagnosis. Adherence to guidelines was significantly associated with younger age (P = 0.001), lower deprivation level (P = 0.007), HF diagnosis source (P<0.001), not having chronic pulmonary disease (P<0.001), receiving further consultation for symptom(s) suggestive of HF (P<0.001), and presenting with breathlessness (P<0.001). Route to diagnosis also varied significantly between GP practices (P<0.001). CONCLUSION: The significant association of certain patient characteristics with route to HF diagnosis and the variation between GP practices raises concerns about equitable HF management. Further studies should investigate reasons for this variation to improve the diagnosis of HF in primary care. However, these must consider the complexities of a patient group often affected by frailty and multiple comorbidities.
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.
Saxena S, Cecil E, Majeed A, et al., The impact of smoking and smoking-cessation on disease outcomes in Ulcerative Colitis: a nationwide population-based study, Alimentary Pharmacology and Therapeutics, ISSN: 0269-2813
BackgroundSmokers are less likely to develop Ulcerative Colitis (UC) but the impact of smoking and subsequentcessation on clinical outcomes in UC is unclear. Aim: To evaluate the effect of smoking status andsmoking cessation on disease outcomes.MethodsUsing a nationally representative clinical research database, we identified incident cases of UCduring 2005-2016. Patients were grouped as never-smokers, ex-smokers and smokers, based onsmoking status recorded in the two years preceding UC diagnosis. We defined subgroups ofpersistent smokers and smokers who quit within 2 years after diagnosis. We compared rates ofoverall corticosteroid use, corticosteroid-requiring flares, corticosteroid dependency, thiopurineuse, hospitalization and colectomy between these groups.ResultsWe identified 6754 patients with a new diagnosis of UC over the study period with data on smokingstatus, of whom 878 were smokers at diagnosis. Smokers had a similar risk of corticosteroidrequiring flares (OR 1.16, 95%CI 0.92-1.25), thiopurine use (HR 0.84, 95%CI 0.62-1.14),corticosteroid dependency (HR 0.85, 95%CI 0.60-1.11), hospitalization (HR 0.92, 95%CI 0.72-1.18),and colectomy (HR 0.78, 95%CI 0.50-1.21) in comparison with never-smokers.Rates of flares, thiopurine use, corticosteroid dependency, hospitalization and colectomy were notsignificantly different between persistent smokers and those who quit smoking after a diagnosis ofUC.ConclusionsSmokers and never-smokers with UC have similar outcomes with respect to flares, thiopurine use,corticosteroid dependency, hospitalization and colectomy. Smoking cessation was not associatedwith worse disease course. The risks associated with smoking outweigh any benefits. UC patientsshould be counselled against smoking.
Tudor Car L, 2019, Health professions digital education on clinical practice guidelines: a systematic review by Digital Health Education collaboration, BMC Medicine, Vol: 17, Pages: 1-16, ISSN: 1741-7015
BackgroundClinical practice guidelines are an important source of information, designed to help clinicians integrate research evidence into their clinical practice. Digital education is increasingly used for clinical practice guideline dissemination and adoption. Our aim was to evaluate the effectiveness of digital education in improving the adoption of clinical practice guidelines.MethodsWe performed a systematic review and searched seven electronic databases from January 1990 to September 2018. Two reviewers independently screened studies, extracted data and assessed risk of bias. We included studies in any language evaluating the effectiveness of digital education on clinical practice guidelines compared to other forms of education or no intervention in healthcare professionals. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to assess the quality of the body of evidence.ResultsSeventeen trials involving 2382 participants were included. The included studies were diverse with a largely unclear or high risk of bias. They mostly focused on physicians, evaluated computer-based interventions with limited interactivity and measured participants’ knowledge and behaviour. With regard to knowledge, studies comparing the effect of digital education with no intervention showed a moderate, statistically significant difference in favour of digital education intervention (SMD = 0.85, 95% CI 0.16, 1.54; I2 = 83%, n = 3, moderate quality of evidence). Studies comparing the effect of digital education with traditional learning on knowledge showed a small, statistically non-significant difference in favour of digital education (SMD = 0.23, 95% CI − 0.12, 0.59; I2 = 34%, n = 3, moderate quality of evidence). Three studies measured participants’ skills and reported mixed results. Of four studies measuring satisfaction, three studies favoured digital educa
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
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, Vol: 48, Pages: 347-354, 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.
Hayhoe B, Kim D, Aylin P, et al., 2019, Adherence to guidelines in management of symptoms suggestive of heart failure in primary care, Heart, Vol: 105, Pages: 678-685, 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.
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
El-Osta A, Bagkeris E, Coker D, et al., 2019, Workplace health promotion using a digital health programme with monthly telecoaching to improve clinical and lifestyle-related outcomes., Future Healthcare Journal, Vol: 6, Pages: 91-91, ISSN: 2055-3331
AimsTo evaluate the effectiveness of a workplace digital health promotion programme with monthly telecoaching on various lifestyle and clinical outcome measures.MethodsWe recruited 103 participants from an occupational setting in the UK. Participants were assessed at baseline, and 3 and 6 months following intervention to determine the effect of an employer sponsored digital telecoaching intervention on various lifestyle and clinical outcome measures.ResultsA pragmatic sample size of 103 participants from a wide demographic background was recruited at baseline, with 95 participants (92%) completing the programme by 6 months. Almost all participants showed a significant improvement in the health score and 24 secondary outcome measures including HbA1c, blood pressure and reduction in smoking. Linear regression model showed that after adjusting for age and gender, the LiveSmart health score appeared to significantly improve by 6.22 units at 3 months (95% confidence interval (CI) 4.38 to 8.06) and by 7.73 units at 6 months (95% CI 5.75 to 9.71), compared with baseline visit, p<0.001.ConclusionThe LiveSmart digital health promotion programme with monthly coaching was a largely successful intervention programme achieving good traction with participants and significant improvement in a number of key outcomes, including lower HbA1c and reduced salt intake among other clinical and healthy lifestyle-related behaviours. A simplistic approach to modelling suggests that the programme has a good return on investment overall and offers a number of tangible and intangible benefits to the service user and the employer, and in the context of the wider health economy. A larger study with a longer follow-up is recommended to better understand the cost-effectiveness of health promotion interventions in the occupational setting.
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, Reeves S, Eerens J, et al., 2019, Exploring the cost of eLearning within the field of health professions education: key findings from a Systematic Scoping Review (Preprint), Publisher: JMIR Publications Inc.
Background:Existing research on the costs of delivering courses online courses is limited. The way in which these learning platforms compare in cost to face-to-face learning is also poorly understood. This lack of data has made it difficult to evaluate whether the investments spent by organisations on online learning are effective in comparison to face-to-face instruction.Objective:The key aim of this scoping literature review is to better understand the state of evidence about whether eLearning demonstrates cost advantages over face-to-face instruction and report the results of a research question centred on: What data exists to define cost calculations related to eLearning? Specifically, we investigate the extent to which the literature can provide details for calculation of the costs for eLearning design, development, and delivery.Methods:Scoping review using a search strategy of MeSH terms and related keywords centred on eLearning and cost calculation with a population scope of health professionals in all countries. The search was limited to English language studies. No restriction was placed on literature publication date.Results:In total, 7344 articles were returned from the original search of the literature. Of these, 232 were relevant to associated keywords or abstract references to cost following screening. Full-text review resulted in 168 studies being excluded, with 42 studies providing data and analysis of the impact of cost and value in health professions education. A further 22 studies provided details of costing approaches for the production and delivery of eLearning.Conclusions:There is an emerging body of studies capturing costs in eLearning. However, costs in these studies were collected inconsistently and in relation to a wide variety of factors or had an alternate study-related focus. Although there is a perception that eLearning is more cost-effective than face-to-face instruction, there is not yet sufficient evidence to assert this conclusively
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.
Kim D, Hayhoe B, Aylin P, et al., Variation in the route to heart failure diagnosis in English primary care: retrospective cohort study, British Journal of General Practice, ISSN: 0960-1643
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.
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