Imperial College London

DrGevaGreenfield

Faculty of MedicineSchool of Public Health

Research Fellow in Public Health
 
 
 
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Contact

 

+44 (0)20 7594 8595g.greenfield Website

 
 
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Location

 

314Reynolds BuildingCharing Cross Campus

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Summary

 

Publications

Publication Type
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84 results found

Porras-Segovia A, Pascual-Sanchez A, Greenfield G, Creese H-M, Saxena S, Hargreaves D, Nicholls Det al., 2023, Early risk factors for self-injurious thoughts and behaviours: a UK population-based study of 219,581 people, Behavioral Sciences, Vol: 14, ISSN: 2076-328X

Mental disorders are a major problem among young people. To identify early risk factors of self-injurious thoughts and behaviours (SITB) among young adults with mental health problems, this case-control study drew data from the Clinical Practice Research Datalink (CPRD), a primary care database covering 8% of the UK population. We explored the role of early factors (presenting at 8-14 years old) for suicidal ideation, suicide attempts, and non-suicidal self-injury (NSSI) in young adulthood (age 18-25 years) by performing logistic regressions. Our sample consisted of 219,581 participants, of which 6.51% had at least one SITB in young adulthood. Early risk factors for SITB included early NSSI, suicidal ideation, sexual abuse, behavioural problems, and mood and psychotic symptoms. Frequency of GP visits had a protective effect. Lack of access to mortality data, ethnicity, and socioeconomic status was a limitation of the current study. In conclusion, early symptoms in late childhood/early adolescence can be the start of long-standing problems going into adult life. The training of primary care providers in suicide risk assessment and proper co-ordination with child and adolescent mental health services are crucial for suicide prevention.

Journal article

Alturkistani A, Beaney T, Greenfield G, Costelloe CEet al., 2023, Patient portal registration and healthcare utilisation in general practices in England., BJGP Open

BACKGROUND: Patient portals introduced in most of England's General Practice (GP) practices since 2015 have the potential to improve healthcare efficiency. There is a paucity of information on the use of patient portal within the National Health Service (NHS) GP practices and the potential impact on healthcare utilisation. AIM: To investigate the association between patient portal registration and care utilisation (measured by the number of GP practice consultations) among GP practice patients. DESIGN & SETTING: A longitudinal analysis using electronic health record data from the Clinical Practice Research Datalink (CPRD). METHOD: We analysed patients registered for patient portals (n=284,666), aggregating their consultations one year prior to and one year after registration. We ran a multilevel negative binomial regression model to examine patient portal registration's association with face-to-face and remote consultations. RESULTS: Patients who registered to the portal had a small decrease in the total number of face-to-face consultations after registering to the patient portal (incidence rate ratio =0.93, 95% CI:0.93, 0.94). Patients who registered to the portal had an increase in the total number of remote consultations after registering to the portal (incidence rate ratio =1.16, 95% CI: 1.15, 1.18). CONCLUSION: The study found minor changes in consultation numbers post-patient portal registration, notably with an increase in remote consultations. While causality between portal registration and consultation number remains unclear, the potential link between patient portal use and healthcare utilisation warrants further investigation, especially within the NHS, where portal impacts are not well-studied. Detailed portal utilisation data could clarify this relationship.

Journal article

Kerr G, Greenfield G, Hayhoe B, Gaughran F, Halvorsrud K, Pinto da Costa M, Rehill N, Raine R, Majeed A, Costelloe C, Neves AL, Beaney Tet al., 2023, Attendance at remote versus in-person outpatient appointments in an NHS Trust, Journal of Telemedicine and Telecare, Pages: 1357633X231216501-1357633X231216501, ISSN: 1357-633X

INTRODUCTION: With the growing use of remote appointments within the National Health Service, there is a need to understand potential barriers of access to care for some patients. In this observational study, we examined missed appointments rates, comparing remote and in-person appointments among different patient groups. METHODS: We analysed adult outpatient appointments at Imperial College Healthcare NHS Trust in Northwest London in 2021. Rates of missed appointments per patient were compared between remote versus in-person appointments using negative binomial regression models. Models were stratified by appointment type (first or a follow-up). RESULTS: There were 874,659 outpatient appointments for 189,882 patients, 29.5% of whom missed at least one appointment. Missed rates were 12.5% for remote first appointments and 9.2% for in-person first appointments. Remote and in-person follow-up appointments were missed at similar rates (10.4% and 10.7%, respectively). For remote and in-person appointments, younger patients, residents of more deprived areas, and patients of Black, Mixed and 'other' ethnicities missed more appointments. Male patients missed more in-person appointments, particularly at younger ages, but gender differences were minimal for remote appointments. Patients with long-term conditions (LTCs) missed more first appointments, whether in-person or remote. In follow-up appointments, patients with LTCs missed more in-person appointments but fewer remote appointments. DISCUSSION: Remote first appointments were missed more often than in-person first appointments, follow-up appointments had similar attendance rates for both modalities. Sociodemographic differences in outpatient appointment attendance were largely similar between in-person and remote appointments, indicating no widening of inequalities in attendance due to appointment modality.

Journal article

Costa Carvalho JM, Li E, Hayhoe B, Beaney T, Majeed A, Greenfield G, Neves ALet al., 2023, Validating a framework to guide the implementation of high-quality virtual primary care: An international eDelphi study protocol, BMJ Open, Vol: 13, ISSN: 2044-6055

Background: There is an urgent need to support primary care organisations in implementing safe and high-quality virtual consultations. We have previously performed qualitative research to capture the views of 1600 primary care physicians across 20 countries on the main benefits and challenges of using virtual consultations. Subsequently, a prototype of a framework to guide the implementation of high-quality virtual primary care was developed.Aim: To explore general practitioners’ perspectives on the appropriateness and relevance of each component of the framework’s prototype, to further refine it and optimise its practical use in primary care facilities.Methods and analysis: Participants will be primary care physicians with active experience providing virtual care, recruited through convenience and snowball sampling. This study will use a systematic and iterative online Delphi research approach (eDelphi), with a minimum of three rounds. A pre-round will be used to circulate items for initial feedback and adjustment. In subsequent rounds, participants will be asked to rate the relevance of the framework’s components. Consensus will be defined as >70% of participants agreeing/strongly agreeing or disagreeing/strongly disagreeing with a component. Data will be collected using structured online questionnaires. The primary outcome of the study will be a list of the essential components to be incorporated in the final version of the framework.Ethics and dissemination: The study has received ethical approval conceded by the Imperial College London Science, Engineering and Technology Research Ethics Committee (SETREC) (reference no .6559176/2023). Anonymous results will be made available to the public, academic organisations and policymakers.

Journal article

Alturkistani A, Greenfield G, Beaney T, Norton J, Costelloe CEet al., 2023, Cross-sectional analyses of online appointment booking and repeat prescription ordering user characteristics in General Practices of England in the years 2018-2020, BMJ Open, Vol: 13, ISSN: 2044-6055

Objectives To explore the characteristics of the General Practice Patient Survey (GPPS) respondents using the different functionalities of the online services in the context of England’s National Health Service General Practices. We hypothesised that respondents who are older, with lower socioeconomic status and non-white ethnicity would be less likely to use online services, while long-term conditions might increase their usage.Design Cross-sectional study using respondent-level data from the GPPS in England of the years 2018, 2019 and 2020. We assessed the association between online services use and respondent characteristics using two-level mixed-effects logistic regression.Participants Survey respondents of the GPPS 2018–2020.Primary outcome measures Online appointment booking and online repeat prescription ordering.Results 1 807 049 survey respondents were included in this study. 15% (n=263 938) used online appointment booking in the previous 12 months, and 19% (n=339 449) had ordered a repeat prescription in the previous 12 months. Respondents with a long-term condition, on regular multiple medications, who have deafness or hearing loss and who are from the lowest deprivation quintile were more likely to have used online services. Male respondents (compared with females) and respondents with black and other ethnicity compared with white ethnicity were less likely to use online services. Respondents over 85 years old were less likely to use online appointment booking and online repeat prescription ordering compared with the younger age groups.Conclusions Specific groups of respondents were more likely to use online services such as patients with long-term conditions or those with deafness or hearing loss. While online services could provide efficiency to patients and practices it is essential that alternatives continue to be provided to those that cannot use or choose not to use online services. Understanding the differen

Journal article

Campbell K, Greenfield G, Li E, O'Brien N, Hayhoe B, Beaney T, Majeed A, Neves ALet al., 2023, The impact of virtual consultations on the quality of primary care: a systematic review, Journal of Medical Internet Research, Vol: 25, Pages: 1-17, ISSN: 1438-8871

Background: The adoption of virtual consultations, catalysed by the COVID-19 pandemic, has transformed the delivery of primary care services. Due to its rapid global proliferation, there is a need to comprehensively evaluate the impact of virtual consultations on all aspects of care quality.Objective: We evaluated the impact of virtual consultations on the quality of primary care. Methods: Six databases were searched. Studies evaluating the impact of virtual consultations, for any disease, were included. Title and abstract screening, and full-text screening were performed by two pairs of investigators. Risk of bias was assessed using the Mixed Methods Appraisal Tool. A narrative synthesis of the results was performed.Findings: Thirty studies (5,469,333 participants) were included in the review. Our findings suggest that virtual consultations are equally or more effective than F2F care for the management of conditions including mental illness, excessive smoking, and alcohol consumption. Four studies indicated positive impacts on some aspects of patient-centredness, however, a negative impact was noted on patients’ perceived autonomy support (i.e., the degree to which people perceive others in positions of authority to be autonomy supportive). Virtual consultations may reduce waiting times, lower patient costs, and reduce rates of follow-up in secondary and tertiary care. The evidence for the impact on clinical safety is extremely limited. Evidence regarding equity was considerably mixed. Overall, it appears that virtual care is more likely to be used by younger, female patients, with disparities between other subgroups depending on contextual factors.Conclusions: Our systematic review has demonstrated that virtual consultations may be equally as effective as F2F care and have a potentially positive impact on the efficiency and timeliness of care However, there is a considerable lack of evidence on the impacts on patient safety, equity, and patient-centredness

Journal article

Wasan T, Hayhoe B, Cicek M, Lammila-Escalera E, Nicholls D, Majeed A, Greenfield Get al., 2023, The effects of community interventions on unplanned healthcare use in patients with multimorbidity: a systematic review, Journal of the Royal Society of Medicine, Pages: 1-12, ISSN: 0141-0768

OBJECTIVES: To summarise the impact of community-based interventions for multimorbid patients on unplanned healthcare use. The prevalence of multimorbidity (co-existence of multiple chronic conditions) is rapidly increasing and affects one-third of the global population. Patients with multimorbidity have complex healthcare needs and greater unplanned healthcare usage. Community-based interventions allow for continued care of patients outside hospitals, but few studies have explored the effects of these interventions on unplanned healthcare usage. DESIGN: A systematic review was conducted. MEDLINE, EMBASE, PsychINFO and Cochrane Library online databases were searched. Studies were screened and underwent risk of bias assessment. Data were synthesised using narrative synthesis. SETTING: Community-based interventions. PARTICIPANTS: Patients with multimorbidity. MAIN OUTCOME MEASURES: Unplanned healthcare usage. RESULTS: Thirteen studies, including a total of 6148 participants, were included. All included studies came from high-income settings and had elderly populations. All studies measured emergency department attendances as their primary outcome. Risk of bias was generally low. Most community interventions were multifaceted with emphasis on education, self-monitoring of symptoms and regular follow-ups. Four studies looked at improved care coordination, advance care planning and palliative care. All 13 studies found a decrease in emergency department visits post-intervention with risk reduction ranging from 0 (95% confidencec interval [CI]: -0.37 to 0.37) to 0.735 (95% CI: 0.688-0.785). CONCLUSIONS: Community-based interventions have potential to reduce emergency department visits in patients with multimorbidity. Identification of specific successful components of interventions was challenging given the overlaps between interventions. Policymakers should recognise the importance of community interventions and aim to integrate aspects of these into existing healthcare

Journal article

Woodcock T, Greenfield G, Lalvani A, Majeed A, Aylin Pet al., 2023, Patient outcomes following emergency admission to hospital for COVID-19 compared with influenza: retrospective cohort study, Thorax, Vol: 78, Pages: 706-712, ISSN: 0040-6376

Background We examine differences in posthospitalisation outcomes, and health system resource use, for patients hospitalised with COVID-19 during the UK’s first pandemic wave in 2020, and influenza during 2018 and 2019.Methods This retrospective cohort study used routinely collected primary and secondary care data. Outcomes, measured for 90 days follow-up after discharge were length of stay in hospital, mortality, emergency readmission and primary care activity.Results The study included 5132 patients admitted to hospital as an emergency, with COVID-19 and influenza cohorts comprising 3799 and 1333 patients respectively. Patients in the COVID-19 cohort were more likely to stay in hospital longer than 10 days (OR 3.91, 95% CI 3.14 to 4.65); and more likely to die in hospital (OR 11.85, 95% CI 8.58 to 16.86) and within 90 days of discharge (OR 7.92, 95% CI 6.20 to 10.25). For those who survived, rates of emergency readmission within 90 days were comparable between COVID-19 and influenza cohorts (OR 1.07, 95% CI 0.89 to 1.29), while primary care activity was greater among the COVID-19 cohort (incidence rate ratio 1.30, 95% CI 1.23 to 1.37).Conclusions Patients admitted for COVID-19 were more likely to die, more likely to stay in hospital for over 10 days and interact more with primary care after discharge, than patients admitted for influenza. However, readmission rates were similar for both groups. These findings, while situated in the context of the first wave of COVID-19, with the associated pressures on the health system, can inform health service planning for subsequent waves of COVID-19, and show that patients with COVID-19 interact more with healthcare services as well as having poorer outcomes than those with influenza.

Journal article

Barber S, Otis M, Greenfield G, Razzaq N, Solanki D, Norton J, Richardson S, Hayhoe Bet al., 2023, Improving multidisciplinary team working to support integrated care for people with frailty amidst the COVID-19 pandemic, International Journal of Integrated Care, Vol: 23, Pages: 1-13, ISSN: 1568-4156

Multidisciplinary team (MDT) working is essential to optimise and integrate services for people who are frail. MDTs require collaboration. Many health and social care professionals have not received formal training in collaborative working. This study investigated MDT training designed to help participants deliver integrated care for frail individuals during the Covid-19 pandemic.Researchers utilised a semi-structured analytical framework to support observations of the training sessions and analyse the results of two surveys designed to assess the training process and its impact on participants knowledge and skills.115 participants from 5 Primary Care Networks in London attended the training. Trainers utilised a video of a patient pathway, encouraged discussion of it, and demonstrated the use of evidence-based tools for patient needs assessment and care planning. Participants were encouraged to critique the patient pathway, reflect on their own experiences of planning and providing patient care.38% of participants completed a pre-training survey, 47% a post-training survey. Significant improvement in knowledge and skills were reported including understanding roles in contributing to MDT working, confidence to speak in MDT meetings, using a range of evidence-based clinical tools for comprehensive assessment and care planning. Greater levels of autonomy, resilience, and support for MDT working were reported. Training proved effective; it could be scaled up and adopted to other settings.

Journal article

Amati F, Green J, Kitchin L, Watt H, Jones S, AlRubaye N, McCann L, Greenfield Get al., 2023, Ethnicity as a predictor of outcomes of psychological therapies for anxiety and depression: a retrospective cohort analysis, Behavioural and Cognitive Psychotherapy, Vol: 51, Pages: 164-173, ISSN: 1352-4658

Background:Studies on predictors of outcomes of treatment for common mental health disorders (CMDs) in community mental health settings are scarce, and sample sizes are often small. Research on the impact of identifying as a member of an ethnic minority group on treatment outcomes is limited.Aims:To ascertain whether ethnicity is an independent predictor of outcome and the extent to which any association is mediated by other sociodemographic factors.Method:Retrospective observational study of anonymised treatment data collected for routine clinical purposes. Data were analysed from nine Improving Access to Psychological Therapy (IAPT) services from 2009 to 2016. Social functioning, ethnic group, age, gender, occupation and baseline severity of the mental health disorder were analysed as predictors of outcome.Results:Outcomes varied with ethnic group. Levels of occupation, social deprivation, initial morbidity and social functioning varied between ethnic groups at baseline. After adjustment for these factors the impact of ethnicity was attenuated and only some ethnic groups remained as significant independent predictors of treatment outcome.Conclusions:Ethnic minority status is a marker for multiple disadvantages. Some of the differences in outcome seen between ethnic groups may be the result of more general factors present in all ethnic groups but at greater intensity in some ethnic minority groups.

Journal article

Greenfield G, 2022, A systematic review of interventions that use multidisciplinary team meetings to manage multimorbidity in primary care, International Journal of Integrated Care, Vol: 22, Pages: 1-10, ISSN: 1568-4156

Introduction: Multidisciplinary team (MDT) meetings could facilitate coordination of care for individuals living with multimorbidity, yet there is limited evidence on their effectiveness. We hence explored the common characteristics of MDT meetings in primary care and assessed the effectiveness of interventions that include such meetings, designed to improve outcomes for adults living with multimorbidity.Methods: A systematic review of literature was conducted using MEDLINE and EMBASE. A narrative synthesis was performed, extracting study and MDT meeting characteristics, in addition to any outcomes reported.Results: Four randomised controlled trials that were conducted in the United States of America were identified as eligible, recruiting a total of 3,509 adults living with multimorbidity. Common MDT meeting themes include regular frequency of discussion, the absence of patient involvement and the participation of three or four multiprofessionals. Significant improvements were observed in response to interventions with an MDT component across most measures, yet this trend did not extend to physical health outcomes. Discussion: It is unclear if the results in this review are sufficient to support the widespread implementation of MDT meetings in primary care, for adults living with multimorbidity. Due to the paucity of studies collated, further research is required to inform widespread implementation.

Journal article

Alturkistani A, Greenfield G, Beaney T, Norton J, Costelloe CEet al., 2022, Ethnicity, deprivation, and the use of patient portals in England's general practices 2018-2020, Publisher: OXFORD UNIV PRESS, ISSN: 1101-1262

Conference paper

Nachiappan N, Mackinnon S, Ndayizeye JP, Greenfield G, Hargreaves Det al., 2022, Barriers to accessing health care among young people in 30 low-middle income countries, HEALTH SCIENCE REPORTS, Vol: 5

Journal article

Nakubulwa MA, Greenfield G, Pizzo E, Magusin A, Maconochie I, Blair M, Bell D, Majeed A, Sathyamoorthy G, Woodcock Tet al., 2022, To what extent do callers follow the advice given by a non-emergency medical helpline (NHS 111): A retrospective cohort study, PLoS One, Vol: 17, ISSN: 1932-6203

National Health Service (NHS) 111 helpline was set up to improve access to urgent care in England, efficiency and cost-effectiveness of first-contact health services. Following trusted, authoritative advice is crucial for improved clinical outcomes. We examine patient and call-related characteristics associated with compliance with advice given in NHS 111 calls. The importance of health interactions that are not face-to-face has recently been highlighted by COVID-19 pandemic. In this retrospective cohort study, NHS 111 call records were linked to urgent and emergency care services data. We analysed data of 3,864,362 calls made between October 2013 and September 2017 relating to 1,964,726 callers across London. A multiple logistic regression was used to investigate associations between compliance with advice given and patient and call characteristics. Caller’s action is ‘compliant with advice given if first subsequent service interaction following contact with NHS 111 is consistent with advice given. We found that most calls were made by women (58%), adults aged 30–59 years (33%) and people in the white ethnic category (36%). The most common advice was for caller to contact their General Practitioner (GP) or other local services (18.2%) with varying times scales. Overall, callers followed advice given in 49% of calls. Compliance with triage advice was more likely in calls for children aged <16 years, women, those from Asian/Asian British ethnicity, and calls made out of hours. The highest compliance was among callers advised to self-care without the need to contact any other healthcare service. This is one of the largest studies to describe pathway adherence following telephone advice and associated clinical and demographic features. These results could inform attempts to improve caller compliance with advice given by NHS 111, and as the NHS moves to more hybrid way of working, the lessons from this study are key to the development of remote heal

Journal article

Cicek M, Hayhoe B, Otis M, Nicholls D, Majeed A, Greenfield Get al., 2022, Depression and unplanned secondary healthcare use in patients with multimorbidity: a systematic review, PLoS One, Vol: 17, ISSN: 1932-6203

Background:Growing numbers of people with multimorbidity have a co-occurring mental health condition such as depression. Co-occurring depression is associated with poor patient outcomes and increased healthcare costs including unplanned use of secondary healthcare which may be avoidable.Aim:To summarise the current evidence on the association between depression and unplanned secondary healthcare use among patients with multimorbidity.Methods:We conducted a systematic review by searching MEDLINE, EMBASE, PsychINFO, Web of Science, CINAHL, and Cochrane Library from January 2000 to March 2021. We included studies on adults with depression and at least one other physical long-term condition that examined risk of emergency hospital admissions as a primary outcome, alongside emergency department visits or emergency readmissions. Studies were assessed for risk of bias using The National Institute of Health National Heart, Lung, and Blood Institute quality assessment tool. Relevant data were extracted from studies and a narrative synthesis of findings produced.Results:Twenty observational studies were included in the review. Depression was significantly associated with different outcomes of unplanned secondary healthcare use, across various comorbidities. Among the studies examining these outcomes, depression predicted emergency department visits in 7 out of 9 studies; emergency hospital admissions in 19 out of 20 studies; and emergency readmissions in 4 out of 4 studies. This effect increased with greater severity of depression. Other predictors of unplanned secondary care reported include increased age, being female, and presence of greater numbers of comorbidities.Conclusion:Depression predicted increased risk of unplanned secondary healthcare use in individuals with multimorbidity. The literature indicates a research gap in identifying and understanding the impact of complex multimorbidity combinations, and other patient characteristics on unplanned care in patients wit

Journal article

Palladino R, More A, Greenfield G, Anokye N, Piggot E, Willis T, Edward G, Majeed F, Kong WMet al., 2022, Evaluation of the North West London Diabetes Foot Care Transformation Project: a mixed-methods evaluation, International Journal of Integrated Care, Vol: 22, Pages: 1-9, ISSN: 1568-4156

Introduction: Diabetes foot ulceration (DFU) presents an enormous burden to those living with diabetes and to the local health systems and economies. There is an increasing interest in implementing integrated care models to enhance the quality of care for people living with diabetes and related complications and the value of co-production approaches to achieve sustainable change. This paper aims to describe the evaluation methodology for the North West London (NWL) Diabetes Foot Care Transformation project. Description: A mixed methods design including: i) a quasi-experimental quantitative analysis assessing the impact of the implementation of the local secondary care multi-disciplinary diabetes foot team clinics on service utilisation and clinical outcomes (amputations and number of healed patients); ii) a phenomenological, qualitative study to explore patient and staff experience; and iii) a within-trial cost-effectiveness analysis (pre and post 2017) to evaluate the programme cost-effectiveness.Discussion and Conclusion: Demonstrating the impact of multidisciplinary, integrated care models and the value of co-production approaches is important for health providers and commissioners trying to improve health outcome. Evaluation is also needed to identify strategies to overcome barriers which might have reduced the impact of the programme and key elements for improvement.

Journal article

Hargreaves D, Mates E, Menon P, Alderman H, Devakumar D, Fawzi W, Greenfield G, Hammoudeh W, He S, Lahiri A, Liu Z, Nguyen P, Sethi V, Wang H, Neufeld L, Patton Get al., 2022, Strategies and interventions for healthy adolescent growth, nutrition and development, The Lancet, Vol: 399, Pages: 198-210, ISSN: 0140-6736

Adolescence is a pivotal point in the life-course, characterised by transformative physical, cognitive and emotional growth, an openness to change and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems including micronutrient deficiencies, food insecurity and poor-quality diets persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation with few taking into account the multiple drivers of adolescent diets. Effective interventions and policies will need to cut across sectors, be supported by multifaceted and multilevel policy and extend across education, health, food systems, social protection and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations.

Journal article

Greenfield G, Okoli O, Quezada Yamamoto H, Blair M, Saxena S, Majeed F, Hayhoe Bet al., 2021, Characteristics of frequently attending children in hospital emergency departments: a systematic review, BMJ Open, Vol: 11, Pages: 1-7, ISSN: 2044-6055

Objective: To summarise the literature on frequent attendances to hospital emergency departments and describe sociodemographic and clinical characteristics of children who attend EDs frequently.Setting: Hospital emergency departments.Participants: Children <21 years, attending hospital emergency departments frequently.Primary outcome measures: Outcomes measures were defined separately in each study, and were predominantly the number of ED attendances per year.Results: We included 21 studies representing 6,513,627 children. Between 0.3% to 75% of all paediatric ED users were frequent users. Most studies defined 4 or more visits per year as a “frequent ED” usage. Children who were frequent ED users were more likely to be less than 5 years old. In the US, patients with public insurance were more likely to be frequent attenders. Frequent ED users more likely to be frequent users of primary care and have long-term conditions; the most common diagnoses were infections and gastroenteritis.Conclusions: The review included a wide range of information across various health systems, however children who were frequent ED users have some universal characteristics in common. Policies to reduce frequent attendance might usefully focus on preschool children and supporting primary care in responding to primary-care oriented conditions.

Journal article

Greenfield G, Shmueli L, Harvey A, Quezada-Yamamoto H, Davidovitch N, Pliskin J, Rawaf S, Majeed FAA, Hayhoe Bet al., 2021, Patient-initiated second medical consultations: patient characteristics and motivating factors, impact on care and satisfaction: A systematic review, BMJ Open, Vol: 11, Pages: 1-7, ISSN: 2044-6055

Objectives: To review the characteristics and motivations of patients seeking second opinions, and the impact of such opinions on patient management, satisfaction, and cost-effectiveness. Data sources: Embase, Medline, PsycINFO and HMIC databases.Study design: A systematic literature search was performed for terms related to second opinion and patient characteristics. Study quality was assessed using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data collection / Extraction methods: We included articles focused on patient-initiated second opinions, which provided quantitative data on their impact on diagnosis, treatment, prognosis or patient satisfaction, described the characteristics or motivating factors of patients who initiated a second opinion, or the cost-effectiveness of patient-initiated second opinions. Principal findings: Thirty-one articles were included in the review. 27 studies considered patient characteristics, 18 patient motivating factors, 10 patient satisfaction, and 17 clinical agreement between the first and second opinion. Seeking a second opinion was more common in women, middle age patients, more educated patients; and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain more information or reassurance about their diagnosis or treatment. While many second opinions confirm the original diagnosis or treatment, discrepancies in opinions had a potential major impact on patient outcomes in up to 58% of cases. No studies reporting on the cost-effectiveness of patient initiated second opinions.Conclusions: Seeking a second opinion was more common in women, middle-age patients, and more educated patients, and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain m

Journal article

Greenfield G, Blair M, Aylin P, Saxena S, Majeed F, Bottle Ret al., 2021, Characteristics of frequent paediatric users of emergency departments in England: an observational study using routine national data, Emergency Medicine Journal, Vol: 38, Pages: 146-150, ISSN: 1472-0205

BACKGROUND:Frequent attendances of the same users in emergency departments (ED) can intensify workload pressures and are common among children, yet little is known about the characteristics of paediatric frequent users in EDs. AIM:To describe the volume of frequent paediatric attendance in England and the demographics of frequent paediatric ED users in English hospitals. METHOD:We analysed the Hospital Episode Statistics dataset for April 2014-March 2017. The study included 2 308 816 children under 16 years old who attended an ED at least once. Children who attended four times or more in 2015/2016 were classified as frequent users. The preceding and subsequent years were used to capture attendances bordering with the current year. We used a mixed effects logistic regression with a random intercept to predict the odds of being a frequent user in children from different sociodemographic groups. RESULTS:One in 11 children (9.1%) who attended an ED attended four times or more in a year. Infants had a greater likelihood of being a frequent attender (OR 3.24, 95% CI 3.19 to 3.30 vs 5 to 9 years old). Children from more deprived areas had a greater likelihood of being a frequent attender (OR 1.57, 95% CI 1.54 to 1.59 vs least deprived). Boys had a slightly greater likelihood than girls (OR 1.05, 95% CI 1.04 to 1.06). Children of Asian and mixed ethnic groups were more likely to be frequent users than those from white ethnic groups, while children from black and 'other' had a lower likelihood (OR 1.03, 95% CI 1.01 to 1.05; OR 1.04, 95% CI 1.01 to 1.06; OR 0.88, 95% CI 0.86 to 0.90; OR 0.90, 95% CI 0.87 to 0.92, respectively). CONCLUSION:One in 11 children was a frequent attender. Interventions for reducing paediatric frequent attendance need to target infants and families living in deprived areas.

Journal article

Woods J-B, Greenfield G, Majeed A, Hayhoe Bet al., 2020, Clinical effectiveness and cost effectiveness of individual mental health workers colocated within primary care practices: a systematic literature review, BMJ Open, Vol: 10, ISSN: 2044-6055

Objectives Mental health disorders contribute significantly to the global burden of disease and lead to extensive strain on health systems. The integration of mental health workers into primary care has been proposed as one possible solution, but evidence of clinical and cost effectiveness of this approach is unclear. We reviewed the clinical and cost effectiveness of mental health workers colocated within primary care practices.Design Systematic literature review.Data sources We searched the Medline, Embase, PsycINFO, Healthcare Management Information Consortium (HMIC) and Global Health databases.Eligibility criteria All quantitative studies published before July 2019 were eligible for the review; participants of any age and gender were included. Studies did not need to report a certain outcome measure or comparator in order to be eligible.Data extraction and synthesis Data were extracted using a standardised table; however, pooled analysis proved unfeasible. Studies were assessed for risk of bias using the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool and the Cochrane collaboration’s tool for assessing risk of bias in randomised trials.Results Fifteen studies from four countries were included. Mental health worker integration was associated with mental health benefits to varied populations, including minority groups and those with comorbid chronic diseases. Furthermore, the interventions were correlated with high patient satisfaction and increases in specialist mental health referrals among minority populations. However, there was insufficient evidence to suggest clinical outcomes were significantly different from usual general practitioner care.Conclusions While there appear to be some benefits associated with mental health worker integration in primary care practices, we found insufficient evidence to conclude that an onsite primary care mental health worker is significantly more clinically or cost effective when compared with u

Journal article

Neves AL, Lawrence-Jones A, Naar L, Greenfield G, Sanderson F, Hyde T, Wingfield D, Cassidy I, Mayer Eet al., 2020, Multidisciplinary teams must work together to co-develop inclusive digital primary care for older people, British Journal of General Practice, Vol: 70, Pages: 582-582, ISSN: 0960-1643

Journal article

Han SM, Greenfield G, Majeed F, Hayhoe Bet al., 2020, Impact of Remote Consultations on Antibiotic Prescribing in Primary Healthcare: Systematic Review, Journal of Medical Internet Research, Vol: 22, ISSN: 1438-8871

Background: There has been growing international interest in performing remote consultations in primary care, particularly amidst the current COVID-19 pandemic. Despite this, the evidence surrounding the safety of remote consultations is inconclusive. The appropriateness of antibiotic prescribing in remote consultations is an important aspect of patient safety that needs to be addressed.Objective: This study aimed to summarize evidence on the impact of remote consultation in primary care with regard to antibiotic prescribing.Methods: Searches were conducted in MEDLINE, Embase, HMIC, PsycINFO, and CINAHL for literature published since the databases’ inception to February 2020. Peer-reviewed studies conducted in primary health care settings were included. All remote consultation types were considered, and studies were required to report any quantitative measure of antibiotic prescribing to be included in this systematic review. Studies were excluded if there were no comparison groups (face-to-face consultations).Results: In total, 12 studies were identified. Of these, 4 studies reported higher antibiotic-prescribing rates, 5 studies reported lower antibiotic-prescribing rates, and 3 studies reported similar antibiotic-prescribing rates in remote consultations compared with face-to-face consultations. Guideline-concordant prescribing was not significantly different between remote and face-to-face consultations for patients with sinusitis, but conflicting results were found for patients with acute respiratory infections. Mixed evidence was found for follow-up visit rates after remote and face-to-face consultations.Conclusions: There is insufficient evidence to confidently conclude that remote consulting has a significant impact on antibiotic prescribing in primary care. However, studies indicating higher prescribing rates in remote consultations than in face-to-face consultations are a concern. Further, well-conducted studies are needed to inform safe and appropri

Journal article

Al-Saffar M, Hayhoe B, Harris M, Majeed A, Greenfield Get al., 2020, Children as frequent attenders in primary care: a systematic review, BJGP Open, Vol: 4, ISSN: 2398-3795

Background: Frequent paediatric attendances make up a large proportion of the general practitioner (GP) workload. Currently no systematic reviews on frequent paediatric attendances in primary care exists. Aim: To identify the socio-demographic and clinical characteristics of children who attend primary care frequently. Design and setting: A systematic review.Methods: The electronic databases MEDLINE, EMBASE and PsycINFO were searched up to January 2020, using terms relating to frequent attendance in primary care settings. Studies were eligible if they considered children frequently attending in primary care (0-19 years). Relevant data were extracted and analysed by narrative synthesis.Results: Six studies, of overall fair quality, were included in the review. Frequent attendance was associated with presence of psycho-social and mental health problems, younger age, school absence, presence of chronic conditions, and high level of anxiety in their parents.Conclusions: Various sociodemographic and medical characteristics of children were associated with frequent attendance in primary care. Research on interventions needs to account for the social context and community characteristics. Integrating GP services with mental health and social care could potentially provide a response to medical and psycho-social needs of frequently attending children and their families.

Journal article

Greenfield G, Blair M, Aylin P, Saxena S, Majeed F, Hoffman M, Bottle Aet al., 2020, Frequent attendances at emergency departments in England, Emergency Medicine Journal, Vol: 37, Pages: 597-599, ISSN: 1472-0205

Background: A small proportion of patients referred to as ‘frequent attenders’ account for a large proportion of hospital activity such as emergency departments (ED) attendances and admissions. There is lack of recent, national estimates of the volume of frequent ED attenders. We aimed to estimate the volume and age distribution of frequent ED attenders in English hospitals.Method: We included all attendances at all major EDs across England in the financial year 2016–2017. Patients who attended 3 times or more were classified as frequent attenders. We used a logistic regression model to predict the odds of being a frequent attender by age group.Results: 14,829,519 attendances were made by 10,062,847 patients who attended at least once. 73.5% of ED attenders attended once and accounted for 49.8% of the total ED attendances. 9.5% of ED attenders attended 3 times or more; they accounted for 27.1% of the ED attendances. While only 1.2% attended 6 times or more, their contribution was 7.6% of the total attendances. Infants and adults aged over 80 years were significantly more likely to be frequent attenders than adults aged 30-59 years (OR=2.11, 95% CI 2.09 to 2.13, OR=2.22, 95% CI 2.20 to 2.23, respectively). The likelihood of hospital admission rose steeply with the number of attendances a patient had.Conclusion: One in ten patients attending the ED are frequent attenders and account for over a quarter of attendances. Emergency care systems should consider better ways of reorganising health services to meet the needs of patients who attend EDs frequently.

Journal article

Han SM, Greenfield G, Majeed A, Hayhoe Bet al., 2020, Impact of Remote Consultations on Antibiotic Prescribing in Primary Healthcare: Systematic Review (Preprint), Publisher: JMIR Publications Inc.

<sec> <title>BACKGROUND</title> <p>There is growing interest internationally in using remote consultations in primary care, particularly amidst the current COVID-19 pandemic. Despite this, the evidence surrounding safety of remote consultations is inconclusive. Appropriateness of antibiotic prescribing in remote consultations is an important aspect of patient safety that needs to be addressed.</p> </sec> <sec> <title>OBJECTIVE</title> <p>To summarise evidence on the impact of remote consultation in primary care on antibiotic prescribing.</p> </sec> <sec> <title>METHODS</title> <p>Searches were conducted in MEDLINE, Embase, HMIC, PSYCINFO and CINAHL from their inception to February 2020. Peer-reviewed publications conducted in primary healthcare settings were included. All remote consultation types were considered, and studies were required to report any quantitative measure of antibiotic prescribing. Studies were excluded if there were no comparison group (face-to-face consultations).</p> </sec> <sec> <title>RESULTS</title> <p>Thirteen studies were identified. Five studies demonstrated higher antibiotic prescribing rates in remote consultations compared to face-to-face consultations, three studies demonstrated lower antibiotic prescribing rate and two studies found no significant difference. Guideline-concordant prescribing was not significantly different between remote and face-to-face consultations for sinusitis patients, but conflicting results were found for patients with acute respiratory infections.</p> </s

Working paper

Alturkistani A, Qavi A, Anyanwu PE, Greenfield G, Greaves F, Costelloe Cet al., 2020, Patient portal functionalities and patient outcomes among patients with diabetes: systematic review (Preprint), Publisher: JMIR Publications

Background:Patient portal use could help improve diabetes patients’ care and health outcomes due to the features such as appointment booking, e-messaging, repeat prescription ordering that enable patient-centred care and improved patient self-management of the disease.Objective:To assess health and healthcare quality outcomes associated with the use of tethered (portals that are connected to the electronic healthcare record) patient portals by adult patients (18 years or older) with diabetes.Methods:We searched the databases including Medline, Embase and Scopus and reported the review methodology using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent reviewers screened titles and abstracts, and two reviewers assessed full-texts of relevant studies and performed data extraction and quality assessments of the included studies. We used the Cochrane Collaboration Risk of Bias Tool and the National Heart, Lung and Blood Institute (NIH) Study Quality Assessment Tools to assess the risk of bias of the included studies. Data were summarised through narrative synthesis.Results:Twelve studies were included in this review. Nine studies reported outcomes related to glycaemic control and most of them found statistically significant associations between using a patient portal and glycaemic control. Some studies also found an inverse association or no association between patient portal use and blood pressure, LDL cholesterol or BMI. Studies reported mixed outcomes regarding the use of patient portals and healthcare utilisation measures such as office visits, emergency department visits and hospitalisations. Few studies reported overall improved quality of care for diabetes patients who used patient portals.Conclusions:Studies mostly reported improved health outcomes for diabetes patients who used patient portals. However, the limitations of studying the effects of patient portals exist that do not guarantee whether

Working paper

Alturkistani A, Qavi A, Anyanwu PE, Greenfield G, Greaves F, Costelloe Cet al., 2020, Patient portal functionalities and patient outcomes among diabetes patients: a systematic, Journal of Medical Internet Research, Vol: 22, Pages: 1-9, ISSN: 1438-8871

Background:Patient portal use could help improve diabetes patients’ care and health outcomes due to the functionalities such as appointment booking, e-messaging, repeat prescription ordering that enable patient-centred care and improve the patient’s self-management of the disease.Objective:To summarise the evidence regarding the use of patient portal (portals that are connected to the electronic healthcare record) or patient portal functionality (e.g. appointment booking or e-messages) and their reported associations with health and healthcare quality outcomes among adult diabetes patients.Methods:We searched the databases including Medline, Embase and Scopus and reported the review methodology using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent reviewers screened titles and abstracts, and two reviewers assessed full-texts of relevant studies and performed data extraction and quality assessments of the included studies. We used the Cochrane Collaboration Risk of Bias Tool and the National Heart, Lung and Blood Institute (NHLBI) Study Quality Assessment Tools to assess the risk of bias of the included studies. Data was summarised through narrative synthesis.Results:Twelve studies were included in this review. Five studies reported overall patient portal use and its association with diabetes health and healthcare quality outcomes. Six studies reported E-messaging or email use associated outcomes and two studies reported prescription refill associated outcomes. Reported associations included the association between patient portal use and blood pressure, LDL cholesterol or BMI. Few studies reported outcomes regarding the use of patient portals and healthcare utilisation measures such as office visits, emergency department visits and hospitalisations. Limited number of studies reported overall quality of care for diabetes patients who used patient portals.Conclusions:The included studies mostly r

Journal article

Alturkistani A, Greenfield G, Greaves F, Aliabadi S, Jenkins RH, Costelloe Cet al., 2020, Patient portal functionalities and uptake: a systematic review protocol, JMIR Research Protocols, Vol: 9, ISSN: 1929-0748

Background: Patient portals are digital health tools adopted by healthcare organisations. The portals are generally connected to the electronic health record of the healthcare organisation and offer patients functionalities such as access to the medical record, ability to order repeat prescriptions, make appointments or message the healthcare provider. Patient portals may be beneficial for patients and for the healthcare system. Patient portals can widely differ from one context to another due to the differences in the portal functionalities and capabilities and it is anticipated that outcomes associated with the functionalities to differ as well. Current systematic reviews report outcomes associated with patient portal uptake but do not explicitly specify the patient portal functionalities. Objective: The aim of this systematic review is to synthesise the evidence on health and healthcare quality outcomes associated with patient portal use among adult (18 years or older) patients. The review research questions are: What kind of health outcomes do tethered patient portals and patient portal functionalities contribute to in adult patients (18 years or older)? and What kind of healthcare quality outcomes including healthcare utilisation outcomes, do tethered patient portals and patient portal functionalities contribute to in adult patients (18 years or older)? Methods: The systematic review will be conducted by searching the Medline, Embase, and Scopus databases for relevant literature. The review inclusion criteria will be studies about adult patients (18 years or older), studies only about tethered patient portals and studies with or without a comparator. We will report patient portal-associated health and healthcare quality outcomes based on the patient portal functionalities. All quantitative primary study types will be included. Risk of bias of included studies will be assessed using the Cochrane Collaboration’s tool for assessing risk of bias in randomised

Journal article

Ruzangi J, Blair M, Cecil E, Greenfield G, Bottle R, Hargreaves D, Saxena Set al., 2020, Trends in healthcare use in children aged less than 15 years; a population-based cohort study in England from 2007 to 2017, BMJ Open, Vol: 10, ISSN: 2044-6055

Objective To describe changing use of primary care in relation to use of urgent care and planned hospital services by children aged less than 15 years in England in the decade following major primary care reforms from 2007 to 2017Design Population-based retrospective cohort study.Methods We used linked data from the Clinical Practice Research Datalink to study children’s primary care consultations and use of hospital care including emergency department (ED) visits, emergency and elective admissions to hospital and outpatient visits to specialists.Results Between 1 April 2007 and 31 March 2017, there were 7 604 024 general practitioner (GP) consultations, 981 684 ED visits, 287 719 emergency hospital admissions, 2 253 533 outpatient visits and 194 034 elective admissions among 1 484 455 children aged less than 15 years. Age-standardised GP consultation rates fell (−1.0%/year) to 1864 per 1000 child-years in 2017 in all age bands except infants rising by 1%/year to 6722 per 1000/child-years in 2017. ED visit rates increased by 1.6%/year to 369 per 1000 child-years in 2017, with steeper rises of 3.9%/year in infants (780 per 1000 child-years in 2017). Emergency hospital admission rates rose steadily by 3%/year to 86 per 1000 child-years and outpatient visit rates rose to 724 per 1000 child-years in 2017.Conclusions Over the past decade since National Health Service primary care reforms, GP consultation rates have fallen for all children, except for infants. Children’s use of hospital urgent and outpatient care has risen in all ages, especially infants. These changes signify the need for better access and provision of specialist and community-based support for families with young children.

Journal article

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