Diabetes care in developing countries.
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Data Collection↗
Biomedical subjects
Azeem Majeed
Publications and source records attributed to Azeem Majeed.
Trends in the prescription and cost of diabetic medications and monitoring equipment in England 1991-2004.
BACKGROUND: To report the trend in prescriptions and cost of antidiabetic drugs and glucose monitoring equipment in England from 1991 to 2004. METHODS: We analysed data on all community antidiabetic drug prescriptions in England collated from the Prescription Cost Analysis system. RESULTS: The total number of diabetes prescriptions (medicines and monitoring) rose from 7,613,000 (1991) to 24,325,640 (2004) (>300% increase). Meanwhile, total costs increased by 650%. Insulins are the biggest contributor to cost followed by monitoring equipment and then oral medications. Three times as many items of oral tablets are prescribed than insulins. Metformin accounts for 40% of all diabetic drug dispensations but only 7% of the costs. More is spent on glitazones now than on either metformin or sulphonylureas. CONCLUSIONS: There has been a substantial increase in the cost of managing diabetes in the community. Costs are likely to continue to rise in the future, as the prevalence of diabetes increases and through more aggressive identification and management of patients with diabetes in the hope of reducing the even more costly complications. The cost implications of glucose monitoring merits further study.
Administration, Oral↗
Management of cardiovascular risk factors in people with diabetes in primary care: cross-sectional study.
OBJECTIVES: Cardiovascular disease is the major cause of morbidity and mortality in people with diabetes. The management of cardiovascular risk factors in people with diabetes in primary care was compared with National Institute of Clinical Excellence guidelines. DESIGN: A cross-sectional study in 26 general practices, with a combined list size of 256,188 patients, participating in the Kent, Surrey and Sussex Primary Care Research Network. Primary outcomes were process of care measures. METHODS: Analysis of general practice computer data on the management of 5980 patients with diabetes, of whom 86% were aged 45 years and over. RESULTS: The prevalence of diabetes was 2.0% in women and 2.6% in men, much lower than the estimated expected prevalence of 4.8% for women and 3.3% in men. Blood pressure was well recorded (96% in both sexes), cholesterol levels less well (79% of women, 84% of men). Hypertension (78% of women, 72% of men) was common. Twenty-one percent of women and 16% of men had a blood pressure above 160/100 mmHg, suggesting under use of antihypertensive therapy. Cholesterol levels were >or=5 mmol/l in 46% of women and 38% of men. Lipid-lowering drugs were prescribed in 38% of women and men. Aspirin was prescribed in 38% of women and 40% of men. CONCLUSIONS: There is an under-diagnosis of diabetes and an under-treatment of blood pressure and blood cholesterol, more marked in women than in men. There is scope for improved management within general practice, including addressing sex inequalities.
Adolescent↗
Trends in sexually transmitted infections in general practice 1990-2000: population based study using data from the UK general practice research database.
OBJECTIVE: To describe the contribution of primary care to the diagnosis and management of sexually transmitted infections in the United Kingdom, 1990-2000, in the context of increasing incidence of infections in genitourinary medicine clinics. DESIGN: Population based study. SETTING: UK primary care. PARTICIPANTS: Patients registered in the UK general practice research database. MAIN OUTCOME MEASURES: Incidence of diagnosed sexually transmitted infections in primary care and estimation of the proportion of major such infections diagnosed in primary care. RESULTS: An estimated 23.0% of chlamydia cases in women but only 5.3% in men were diagnosed and treated in primary care during 1998-2000, along with 49.2% cases of non-specific urethritis and urethral discharge in men and 5.7% cases of gonorrhoea in women and 2.9% in men. Rates of diagnosis in primary care rose substantially in the late 1990s. CONCLUSIONS: A substantial and increasing number of sexually transmitted infections are diagnosed and treated in primary care in the United Kingdom, with sex ratios differing from those in genitourinary medicine clinics. Large numbers of men are treated in primary care for presumptive sexually transmitted infections.
Adolescent↗
Association of population and practice factors with potentially avoidable admission rates for chronic diseases in London: cross sectional analysis.
OBJECTIVES: To examine the association between underlying ill health, material deprivation and primary care supply factors and hospital admission rates for potentially avoidable admissions in primary care trusts in London. DESIGN: Cross sectional analysis at primary care trusts level using routine data from multiple sources. SETTING: All 31 primary care trusts in London with a total resident population of 7 million patients. MAIN OUTCOME MEASURES: Age-standardized hospital admission rates for asthma, diabetes, heart failure, hypertension and chronic obstructive pulmonary disease. RESULTS: Admission rates varied widely for the conditions examined across the 31 primary care trusts. In 2001, age adjusted admission rates for asthma varied from 76 to 189 per 100,000 and for diabetes from 38 to 183 per 100,000. There was a significant association between higher admission rates and measures of underlying ill health and material deprivation but not quantitative measures of primary care service provision. Provision of specialist chronic disease services in primary care for diabetes but not for asthma were significantly associated with reduced admission rates. There was no association of prescribing levels in primary care trusts with admission rates for any of the conditions examined. CONCLUSIONS: Although hospital admission for some chronic diseases is potentially avoidable and rates of hospital admission for these conditions are possible indicators of the quality of care, they should be interpreted in conjunction with measures of population composition and deprivation. Failure to do this may result in primary care trusts and general practitioners being criticized for aspects of health care utilization that are not under their direct control.
Adolescent↗
Ambulatory antibiotic prescribing for acute bronchitis and cough and hospital admissions for respiratory infections: time trends analysis.
OBJECTIVES: To examine the relationship between ambulatory antibiotic prescribing for acute bronchitis and cough with hospital admissions for respiratory infections in the USA between 1996 and 2003. DESIGN: Analysis of data on antibiotic prescribing for episodes of acute bronchitis/cough illness in ambulatory care and hospitalization for respiratory infections for adults between 1996 and 2003 in the USA. SETTING: USA: ambulatory prescribing behaviour was derived from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey while hospitalizations in acute care hospitals were assessed in the National Hospital Discharge Survey. PARTICIPANTS: Adults 18-64 years old. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Proportion of visits for acute bronchitis/cough receiving a prescription for antibiotics and hospitalization for respiratory infections. RESULTS: Ambulatory antibiotic prescribing practices for acute bronchitis/cough and hospitalizations for respiratory infections exhibited non-linear patterns over the 8 year period. However, antibiotic prescribing practices for acute bronchitis/cough and hospitalizations for respiratory infections had a weak/moderate negative association. For three of the seven yearly changes in prescribing and hospitalizations as one increased the other decreased (P<0.01). CONCLUSIONS: Ambulatory antibiotic prescribing for respiratory tract infections was inversely associated with hospital admissions for respiratory tract infections.
Acute Disease↗
Identifying patients at high risk of emergency hospital admissions: a logistic regression analysis.
OBJECTIVE: To use routine data to identify patients at high risk of future emergency hospital admissions. DESIGN: Descriptive analysis of inpatient hospital episode statistics. Predictive model developed using multiple logistic regression. SETTING: National Health Service hospital trusts in England. PARTICIPANTS: All patients with an emergency admission to an NHS hospital between 1 April 2000 and 31 March 2001. MAIN OUTCOME MEASURES: 'High-impact users' were defined as patients who had at least one emergency inpatient admission and who then went on to have at least two further emergency hospital admissions in the 12 months following the start date of that index admission. RESULTS: 2,895,234 patients were admitted as emergencies in 2000/2001, of whom 147,725 (5.1%) did not survive their first spell. Of the 2,747,509 surviving patients, 269,686 (9.8%) subsequently had at least two or more emergency admissions within 365 days of the index date of admission. A further 236,779 (8.6%) died during this period. Risk factors for becoming a high-impact user included the number of emergencies in the 36 months before index spell, comorbidity, age, an admission for an ambulatory care sensitive condition, ethnicity, area-level socioeconomic data, local admission rates, the number of episodes in the index spell, sex and the source of admission. The predictive model based on all emergency admissions produced a receiver operating characteristic curve score of 0.72. CONCLUSIONS: Routine hospital episode statistics can be used to identify patients who are at high risk of suffering future multiple emergency hospital admissions. The potential cost savings in preventing a proportion of these subsequent admissions need to be compared with the costs of case management of these patients.
Adolescent↗
Diabetes management in the USA and England: comparative analysis of national surveys.
OBJECTIVES: To compare diabetes management in adults between England and the United States, particularly focusing on the impact of a universal access health insurance system. DESIGN: Analysis of the nationally-representative surveys Health Survey of England, 2003 (unweighted n =14 057) and the National Health and Nutrition Examination Survey, 2001-2002 (unweighted n =5411). SETTING AND PARTICIPANTS: Adults 20-64 years of age; individuals >65. MAIN OUTCOME MEASURES: Glycaemic, lipid and blood pressure control and medication use among individuals with previously diagnosed diabetes. RESULTS: Among those aged 20-64 the prevalence of diagnosed diabetes was lower in England (2.7%) than in the USA (5.0%). The proportion with diabetes receiving treatment was similar for the two countries. However, the mean HbA1c in England was 7.6%: in the USA it was 7.5% for those with insurance and 8.6% for those without insurance. The proportion of individuals on ACE inhibitors in England was 39%: in USA it was 39% for those with insurance, and 14% for those without. CONCLUSIONS: Individuals in a healthcare system providing universal access have better managed diabetes than those in a market based system once one accounts for insurance.
Adult↗
Association of age, sex and deprivation with quality indicators for diabetes: population-based cross sectional survey in primary care.
OBJECTIVES: To determine the quality of diabetes management in primary care after the publication of the National Service Framework and examine the impact of age, gender and deprivation on the achievement of established quality indicators. DESIGN: Population-based cross sectional survey using electronic general practice records carried out between June-October 2003. SETTING: Thirty-four practices in Wandsworth, South-West London, UK. PARTICIPANTS: 6035 adult patients (> or =18 years) with diabetes from a total registered population of 201,572 patients. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Success rates for the diabetes quality indicators within the General Medical Services contract for general practitioners. RESULTS: We identified large variations in diabetes management between general practitioner practices with poorer recording of quality care in younger patients (18-44 years). In addition, younger patients had a worse cholesterol and glycaemia profile, although hypertension was more common in older patients. Gender and deprivation did not appear to be important determinants of the quality of care received. CONCLUSIONS: There are large variations in diabetes management between general practitioner practices, with care seemingly worse for younger adults. Longitudinal studies are required to determine whether current UK quality improvement initiatives have been successful in attenuating existing variations in care and treatment outcomes.
Adolescent↗
Trends in deaths related to drug misuse in England and Wales, 1993-2004.
In this article we report trends in deaths related to drug misuse in England and Wales from 1993 to 2004, looking particularly at the period between 1999 and 2004, for which there was a Government target to reduce these deaths by 20 per cent. Although there was an overall decline in deaths related to drug misuse between 1999 and 2004, the percentage reduction, at 9 per cent, was less than the Government target. There was an increase in deaths between 2003 and 2004, largely accounted for by deaths involving heroin/methadone and morphine. Mortality rates were highest in young adults and an increase in mortality rates within this group appears to have been the driver behind rising mortality trends during the 1990s.
Adolescent↗
How Islam changed medicine.
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History, 15th Century↗
The ageing population of the United Kingdom and cardiovascular disease.
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Aged↗
Impact on contraceptive practice of making emergency hormonal contraception available over the counter in Great Britain: repeated cross sectional surveys.
OBJECTIVE: To examine the impact on contraceptive practice of making emergency hormonal contraception available over the counter. DESIGN: Analysis of data on contraceptive practice for women aged 16-49 years in the period 2000-2 from the Omnibus Survey, a multipurpose survey in which around 7600 adults living in private households are interviewed each year. SETTING: Private households in Great Britain. MAIN OUTCOME MEASURES: Use of different types of contraception and rates of unprotected sex. RESULTS: After emergency hormonal contraception was made available over the counter, levels of use of different types of contraception by women aged 16-49 remained similar. No significant change occurred in the proportion of women using emergency hormonal contraception (8.4% in 2000, 7.9% in 2001, 7.2% in 2002) or having unprotected sex. A change did, however, occur in where women obtained emergency hormonal contraception; a smaller proportion of women obtained emergency hormonal contraception from physicians and a greater proportion bought it over the counter. No significant change occurred in the proportion of women using more reliable methods of contraception, such as the oral contraceptive pill, or in the proportion of women using emergency hormonal contraception more than once during a year. CONCLUSIONS: Making emergency hormonal contraception available over the counter does not seem to have led to an increase in its use, to an increase in unprotected sex, or to a decrease in the use of more reliable methods of contraception.
Adolescent↗
Which general practices have higher list inflation? An exploratory study.
BACKGROUND: There is a 7% discrepancy between English population estimates based on census figures and those based on the registered lists of GPs. GP income under the 2004 new contract will be based on registered patient populations but a national 'de-ghosting' exercise will ensue, aiming to eliminate list inflation. OBJECTIVE: To derive an estimate of the variation in list inflation between individual general practices. METHODS: Letters were sent to all men aged 20-29 years and registered at practices based in three inner city Primary Care Trusts (n = 42 712). Non respondents received one further reminder. Cards were issued to each GP listing non responders. Patients were deducted from the GP list after six months if the GP did not verify the address. RESULTS: 42 712 letters were sent. 33.5% of registered patients were eventually deducted from the GP list (deduction figures only available for 20-24 year old group). Practice level deduction rates ranged from 7-76%. Practices with higher deduction rates achieved lower vaccination rates for 2 year olds (Pearson's r = 20.25; P = 0.005) and cervical smear rates (Pearson's r = 20.18; P = 0.04); they also had cheaper prescribing costs per ASTRO-PU (Pearson's r = 20.20; P = 0.03). CONCLUSIONS: If these findings apply to the whole registered population, the national de-ghosting exercise is likely to result in large changes to the list size of some practices. Without correcting for list inflation, primary care research based on patient list size as the denominator may underestimate various measures of GP activity, particularly in deprived inner city areas. Resource allocation is also likely to be distorted by differences in list inflation.
Adult↗
The future of singlehanded general practices.
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Family Practice↗
Primary care trusts and primary care research.
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Financing, Government↗
Impact of paracetamol pack size restrictions on poisoning from paracetamol in England and Wales: an observational study.
BACKGROUND: About 500 drug poisoning deaths involving paracetamol (acetaminophen) occur every year in England and Wales. To reduce the number of deaths, regulations were introduced in 1998 to restrict the sale of paracetamol. In this paper, we evaluate the impact of these regulations. METHODS: Mortality data for England and Wales were provided by the Office for National Statistics. Deaths were defined as due to compound paracetamol (paracetamol in combination with another analgesic, a low dose opioid or other ingredients) or paracetamol only, with or without alcohol or other drugs. The Department of Health provided data on all hospital admissions with a primary diagnosis of paracetamol poisoning. RESULTS: Mortality rates for paracetamol only were similar for males and females, and decreased from about 4.5 to 2.8 per million between 1997 and 1999 and again from about 3.1 to 2.2 per million between 2001 and 2002. These falls may be attributable to random variation in the rates. Deaths involving compound paracetamol, which were not subject to the 1998 regulations, remained relatively constant over the study period. There was evidence of a decreasing trend in paracetamol only mortality rates and this followed overall trends for other drug poisoning excluding opioids and drugs of misuse. Hospital admissions due to paracetamol poisoning increased from about 27 000 to 33 000 between 1995/1996 and 1997/1998 and then decreased to 25 000 in 2001/2002. There were almost 50 per cent more admissions for females than males, with the highest admission rates amongst females aged 15-24 years old. CONCLUSIONS: Between 1993 and 2002, mortality rates and hospital admissions due to paracetamol poisoning declined. However, the contribution of the 1998 regulations to this decline is not clear. Paracetamol poisoning continues to be an important public health issue in England and Wales and represents significant workload for the NHS in England.
Acetaminophen↗
Case-mix and variation in specialist referrals in general practice.
BACKGROUND: The potential of a comprehensive measure of patient morbidity to explain variation in referrals to secondary care has not previously been examined in the UK. AIM: To examine the relative role of age, sex and morbidity as defined by the Johns Hopkins ACG Case-Mix System in explaining variations in specialist referrals in general practice. DESIGN OF STUDY: Retrospective study of a cohort of patients followed for 1 year. SETTING: Two hundred and two general practices, with a total list size of 1,161,892, contributing data to the General Practice Research Database. METHOD: Each patient was assigned an ACG and morbidity group, based on their diagnoses, age and sex. The variability in referrals explained by these factors was examined using multilevel logistic regression models by splitting it into variation between practices and variation between patients within practices. RESULTS: The annual median (range) percentage of patients referred was 14.8% (range = 2.4-24.4%). The percentage of patients referred increased with age and morbidity. Morbidity explained 30.4% of the total variation in referrals (composed of variability between and within practices). Age and sex only explained 5.3% of the total variation. The variation attributable to practices was approximately 5%, thus most of the variation occurred within practices. Morbidity was also identified as a better predictor of referral compared to age and sex. CONCLUSIONS: Morbidity explains almost six times more of the variation in general practice referrals than age and sex, although about two-thirds of the variation remains unexplained. Most of the unexplained variation is due to differences within rather than between practices. The amount of variability in referrals between practices may be less than implied by previous studies based on aggregate information. The implications are that any investigation of specialist referrals from general practice should be interpreted cautiously, even after adjustment for age, sex and morbidity.
Adolescent↗