Biomedical subjects

S de Lusignan

Publications and source records attributed to S de Lusignan.

At least 19 recordsLinked to original sources

PubMed2007

An educational intervention, involving feedback of routinely collected computer data, to improve cardiovascular disease management in UK primary care.

OBJECTIVES: To report the lessons learned from eight years of feeding back routinely collected cardiovascular data in an educational context METHODS: There are distinct educational and technical components. The educational component provides peer-led learning opportunities based on comparative analysis of quality of care, as represented in computer records. The technical part ensures that relevant evidence-based audit criteria are identified; an appropriate dataset is extracted and processed to facilitate quality improvement. Anonymised data are used to provide inter-practice comparisons, with lists of identifiable patients who need interventions left in individual practices. RESULTS: The progressive improvement in cholesterol management in ischaemic heart disease (IHD) is used as an exemplar of the changes achieved. Over three iterations of the cardiovascular programme the standardised prevalence of IHD recorded in GP computer systems rose from 3.8% to 4.0%. Cholesterol recording rose from 47.6% to 89.0%; and the mean cholesterol level fell from 5.18 to 4.67 mmol/L; while statin prescribing rose from 46% to 57% to 68%. The atrial fibrillation, heart failure and renal programmes (more people with chronic kidney disease go on to die from cardiovascular cause than from end-stage renal disease) are used to demonstrate the range of cardiovascular interventions amenable to this approach. CONCLUSIONS: Technical progress has meant that larger datasets can be extracted and processed. Feedback of routinely collected data in an educational context is acceptable to practitioners and results in quality improvement. Further research is needed to assess its utility as a strategy and cost-effectiveness compared with other methods.

Atrial Fibrillation↗

PubMed2006

Audit-based education to reduce suboptimal management of cholesterol in primary care: a before and after study.

BACKGROUND: Statins are recommended for the secondary prevention of cardiovascular disease, although they are often used in suboptimal doses and some patients may not receive lipid-lowering therapy. The Primary Care Data Quality (PCDQ) programme is an audit-based educational intervention. OBJECTIVE: To report the PCDQ programme's effect on the cholesterol management in cardiovascular disease. Subjects and methods Anonymized general practice data from 99 practices; 5% (n = 29 915) had cardiovascular diagnoses. RESULTS: Mean cholesterol fell from 4.75 to 4.64 mmol l(-1); patients achieving cholesterol target (< 5 mmol l(-1)) rose from 45.3 to 53.2%. Coronary heart disease patients achieved better control (mean 4.57 mmol l(-1)) than those with stroke (4.87 mmol l(-1)) or peripheral vascular disease (4.93 mmol l(-1)). Statin prescribing increased from 57.5 to 62.7%. Patients with diabetes [odds ratio (OR) 2.06, 95% confidence interval (95% CI) 1.91-2.21], prior myocardial infarction (MI) (OR 1.93, 95% CI 1.80-2.07), revascularization (OR 1.52, 95% CI 1.33-1.73) and smokers (OR 1.31, 95% CI 1.23-1.39) were more likely to receive statins, whereas people aged 75+ (OR 0.48, 95% CI 0.45-0.50), females (OR 0.90, 95% CI 0.86-0.94) and non-CHD-diagnosed (OR 0.36, 95% CI 0.34-0.38) were less likely. CONCLUSIONS: Diagnostic coding and number of patients who had their cholesterol measured and treated increased. There was no significant change in dosage used or inequity between the different groups prescribed statins.

Adolescent↗

PubMed2006

Using computers to identify non-compliant people at increased risk of osteoporotic fractures in general practice: a cross-sectional study.

BACKGROUND: National guidelines recommend bisphosphonates for secondary prevention of osteoporotic fractures; however, poor compliance may result in sub-optimal prevention. OBJECTIVE: This study reports the feasibility of using GP electronic records to identify poorly compliant post-menopausal women who may be at increased risk of fragility fractures. DESIGN: Cross-sectional study of general practice computer records. SUBJECTS: Women over 45 years, registered in 29 practices across England with a total population of approximately 200,000. METHODS: MIQUEST (Morbidity Information Query and Export Syntax) a data extraction application was used to extract prescription, diagnostic data and probable fragility fractures (hip, vertebral, wrist). All women >45 years who received a first prescription for a weekly bisphosphonate (alendronate or risedronate) at least a year before data extraction were identified. Each record was examined to determine the number of days of prescribed treatment. RESULTS: Of 97992 registered women, 44% (42734) were >45 years. Prevalence of likely fragility fractures in women over 45 was 5.1% (2195/42734). 3.0% (1286/42734, mean age 72 years) received a prescription for a bisphosphonate in the 360 day period prior to data extraction with a median duration of treatment of 267 days. 45% (584/1286) received prescriptions covering >288/360 days (Medicine Possession Ratio >80%); 13% (161/1286) collected prescriptions covering >360 days. In those prescribed bisphosphonates, 23% (294/1286) had a likely fragility fracture. CONCLUSIONS: Women >45 years with probable fragility fractures are more likely to be prescribed bisphosphonates, though less than half will be actually taking them as prescribed. GPs should use computer technology to identify poorly compliant patients who are unnecessarily at risk of fracture.

Adolescent↗

PubMed2006

Ethnicity recording in general practice computer systems.

BACKGROUND: Ethnicity data in general practice (GP) computerized medical records can be utilized to audit equity in health care. METHODS: We evaluated a patient profiling project targeted to improve ethnicity recording. RESULTS: Data extracted from 16 practices showed an increase in ethnicity recording from <1% before the intervention to 48% after. Recorded codes could be mapped onto the basic national statistics six-category ethnicity classification headings, and their proportions were similar to the 2001 census values. CONCLUSION: Recording of data using multiple coding hierarchies has reduced the utility of data as clinically important ethnic subgroups cannot be identified. Practitioners should be encouraged to use the single recommended ethnicity coding hierarchy.

Adult↗

PubMed2005

Patient perspectives on multiple medications versus combined pills: a qualitative study.

BACKGROUND: A growing number of patients are taking multiple medications. Unfortunately, adherence may fall as drug numbers and procedural complexity increase. While there are plausible theoretical reasons why combining pills might improve non-adherence, patients' attitudes are unknown. AIM: To explore attitudes and practices to medication regimens among patients already in receipt of multiple medications, and to assess whether a combined tablet would be perceived as advantageous. DESIGN: Qualitative study. METHODS: Ninety-two men and women aged >40 years currently receiving both antihypertensive and cholesterol-lowering medications took part in 14 focus groups. RESULTS: Drugs were seen as unwelcome but necessary. Some took drugs flexibly by changing dose timing, thereby increasing the complexity of their regimen. A routine was seen as the key to coping with multiple medications, although it was sometimes threatened by changes in prescriptions and life circumstances. While some participants welcomed a combined pill, there was uncertainty about whether a combination that mirrored their current doses would be available. There were also concerns about tablet size, allergies, the attribution of side-effects, timing of tablets throughout the day, and the ability to alter dose levels. CONCLUSION: While some patients would be willing to try a combined pill and would appreciate the associated convenience, they are likely to have a number of concerns that prescribers should address. Willingness to move to combined therapy may be hindered if drug combinations that mirror personalized and trusted regimens are not available.

Aged↗

PubMed2005

Management of heart failure in primary care after implementation of the National Service Framework for Coronary Heart Disease: a cross-sectional study.

OBJECTIVES: To compare the management of heart failure with the standards set out in the National Service Framework for Coronary Heart Disease. STUDY DESIGN: A cross-sectional study in 26 general practices, with a combined list size of 256,188, that are members of the Kent, Surrey and Sussex Primary Care Research Network. METHODS: Information was extracted on the management of 2129 patients with heart failure, of whom 2097 were aged 45 years and over. RESULTS: The prevalence of heart failure was 8.3 per 1000. Prevalence rates increased with age, from 0.2 per 1000 in people aged under 35 years of age to 125 per 1000 in those aged 85 years and over. Coronary heart disease (present in 47%) was the most common comorbid condition in men with heart failure, whereas hypertension (present in 46%) was the most common condition in women. Recording of cardiovascular risk factors was generally higher in younger patients than in older patients, and in men than in women. Blood pressure (92% of men and 90% of women) and smoking status (84% of men and 77% of women) were generally the best-recorded cardiovascular risk factors. Blood electrolytes were recorded in about 83% of men and 75% of women. Only 17% of men and 11% of women with heart failure had a record of undergoing an echocardiogram. Use of angiotensin-converting enzyme (ACE) inhibitors or antagonists was 76% in men with heart failure and 68% in women; lowest rates were seen in older patients. Uptake of influenza immunization was generally high, at 85% in men and 84% in women. CONCLUSIONS: The use of ACE inhibitors in patients with heart failure was higher than in some previous studies. However, many patients have no documentation in their computerized medical records of having undergone key investigations, such as echocardiography.

Adult↗

PubMed2005

Quality and variability of osteoporosis data in general practice computer records: implications for disease registers.

OBJECTIVE: To determine the extent to which routinely collected general practitioner computer data could be used to create disease registers of patients with osteoporosis, and to report any improvement in data quality since previous studies. STUDY DESIGN: Audit using anonymized data extracted from general practice computer records from across England. METHODS: Morbidity Query Information and Export Syntax (MIQUEST) software was used to extract structured data from the 78 volunteer practices that participated in the study. The data were aggregated and analysed. RESULTS: There were 100-fold differences in the rates of recording of relevant data. Many patients receiving treatment had no diagnostic codes. Data about secondary causes of osteoporosis and fractures were more consistently recorded than data relating to falls. There were no data to indicate whether fractures were low impact. T-scores, the gold-standard measure of bone density, were very infrequently recorded. CONCLUSIONS: Sufficient data about secondary causes of osteoporosis exist, and these could be searched to identify patients at risk. Meanwhile, fracture recoding could be improved, including likely fragility fractures, and T-scores could be added to computer records. A systematic approach is needed to raise the computer records to a standard where they can be used as valid and reliable disease registers.

Accidental Falls↗

PubMed2005

The barriers to clinical coding in general practice: a literature review.

Clinical coding is variable in UK general practice. The reasons for this remain undefined. This review explains why there are no readily available alternatives to recording structured clinical data and reviews the barriers to recording structured clinical data. Methods used included a literature review of bibliographic databases, university health informatics departments, and national and international medical informatics associations. The results show that the current state of development of computers and data processing means there is no practical alternative to coding data. The identified barriers to clinical coding are: the limitations of the coding systems and terminologies and the skill gap in their use; recording structured data in the consultation takes time and is distracting; the level of motivation of primary care professionals; and the priority within the organization. A taxonomy is proposed to describe the barriers to clinical coding. This can be used to identify barriers to coding and facilitate the development of strategies to overcome them.

Family Practice↗

PubMed2004

End-digit preference in blood pressure recordings of patients with ischaemic heart disease in primary care.

End-digit preference describes the disproportionate selection of specific end digits. The rounding of figures might lead to either an under- or over-recording of blood pressure (BP) and a lack of accuracy and reliability in treatment decisions. A total of 85 000 BP values taken from computerised general practice records of ischaemic heart disease patients in England between 2001 and 2003 were examined. Zero preference accounts for 64% of systolic and 59% of diastolic readings, compared with an expected frequency of 10% (P<0.000001). Even numbers are more frequently seen than odd numbers. In all, 64% of nonzero systolic recordings and 65% of diastolic recordings ended in even numbers, compared with expected proportions of 44% (P<0.0001). Among the nonzero even numbers, eight is the most frequently observed: 28% of systolic and 31% of diastolic recordings compared with an expected proportion of 25% (P<0.0001). Among the five nonzero odd numbers, five is the most frequently observed end digit, representing 59% systolic and 62% of diastolic compared with an expected level of 20% (P<0.00001). English general practice displays marked end-digit preference. This is strongly for the end-digit zero. However, there is more use of other end-digits, notably 8 and 5. This bias potentially carries important treatment consequences for this high-risk population.

Blood Pressure↗

PubMed2003

Can patients with osteoporosis, who should benefit from implementation of the national service framework for older people, be identified from general practice computer records? A pilot study that illustrates the variability of computerized medical records and problems with searching them.

Although UK general practice is highly computerized, comprehensive use of these computers is often limited to registration data and the issue of repeat prescriptions. The recording of diagnostic data is patchy. This study examines whether patients with, or at risk of, osteoporosis can be readily identified from general practice computer records. It reports the findings of a pilot study designed to show the variability of recording the diagnosis of osteoporosis and osteopenia, as well as how useful surrogate markers might be to identify these patients. The study also illustrates the difficulties that even skilled practitioners in a primary care research network experience in extracting clinical data from practice information systems. Computer searches were carried out across six practices in a general practice research network in the south-east of England. Two of these practices had previously undertaken research projects in osteoporosis and were consequently expected to have excellent data quality in osteoporosis. These two practices had a combined list size of 27,500 and the remaining practices had a combined practice population of 43,000 patients. The data were found to be variable with over 10-fold differences between practices in the recorded prevalence of osteoporosis diagnosis as well as its surrogate markers-such as fragility fractures, long-term steroid prescription, etc. There was no difference in data quality between the two practices that had conducted osteoporosis research and the rest of the group, other than in the areas of diagnostic recording and prescribing for osteoporosis and recording of fractures. Issues were raised by the practices that struggled to identify patients at risk of osteoporosis about the limitations of Read classification in this disease area. Practices need further assistance if the patients at risk are to be identified. Without urgent action, it will be difficult for practices to identify the patients who are likely to benefit from Standard 6-'Falls' of the National Service Framework for Older People. These findings also have broader implications as UK general practice moves towards the implementation of a quality-based contract.

Aged↗

PubMed2003

Managers see the problems associated with coding clinical data as a technical issue whilst clinicians also see cultural barriers.

OBJECTIVE: In UK general practice, the coding of clinical data (Read Coding) is far from universal. This study set out to examine the barriers to recording structured information in computerised medical records; and to explore whether managers and clinicians had different perspectives in how these barriers should be overcome. METHOD: A qualitative study, using semi-structured interviews of general practitioners, primary care nurses and practice managers. The interviews were recorded verbatim, and then underwent thematic analysis; additional interviews were conducted until thematic saturation was achieved. RESULTS: For clinicians the recording of structured data within a consultation is not a neutral activity, they are highly aware of diagnostic uncertainty and sensitive to the potential impact of both a correct and incorrect diagnostic label on their relationship with their patient. Clinicians accept that data has to be coded if they are to demonstrate that appropriate evidence based care has been provided to populations; but alongside this they require free-text as a more powerful reminder of the individual human encounter. Managers felt that they could encourage clinicians to code data for re-use as part of population data or as quality target indicators rather than as an enabler of the next consultation. CONCLUSIONS: The primary care consultation is a complex social interaction, and coding of the medical diagnosis in itself imposes the bio-medical model, carries assumptions about certainty, and is perceived by clinicians to potentially jeopardise their relationships with their patient. Further research to elicit patients' views may help clarify the magnitude of this barrier.

Ambulatory Care Information Systems↗

PubMed2002

Development of an assessment tool to measure the influence of clinical software on the delivery of high quality consultations. A study comparing two computerized medical record systems in a nurse run heart clinic in a general practice setting.

A rating scale was developed to assess the contribution made by computer software towards the delivery of a quality consultation, with the purpose of informing the development of the next generation of systems. Two software programmes were compared, using this scale to test their ability to enable or inhibit the delivery of an ideal consultation with a patient with heart disease. The context was a general practice based, nurse run clinic for the secondary prevention of heart disease. One of the programmes was customized for this purpose; the other was a standard general practice programme. Consultations were video-recorded, and then assessed by an expert panel using the new assessment tool. Both software programmes were oriented towards the implementation of the evidence, rather than facilitating patient-centred practice. The rating scale showed, not surprisingly, significantly greater support from the customized software in the consultation in five out of eight areas. However, the scale's reliability measured by Cronbach's Alpha, was sub-optimal. With further refinement, this rating scale may become a useful tool that will inform software developers of the effectiveness of their programmes in the consultation, and suggest where they need development.

Ambulatory Care↗

PubMed2001

Compliance and effectiveness of 1 year's home telemonitoring. The report of a pilot study of patients with chronic heart failure.

UNLABELLED: Patients with a diagnosis of heart failure, registered at the study practice, were recruited into the study. First, they had a cardiologist's assessment. They were then randomised into telemonitored patients who measured pulse, BP, weight and video consulted, and controls. AIM: To examine the acceptability, effectiveness and reliability of home telemonitoring. RESULTS: A high proportion of those invited took part (n=20/24). Compliance with measuring weight, pulse and BP remained high throughout the study. The data collection system and secure web-server were reliable. The telemonitoring group complied better with collecting prescriptions for their cardiac drugs. Video consulting started with enthusiasm, but became less useful. There were no significant differences in the quality of life (GHQ) and Chronic Heart Failure (Guyatt) questionnaire scores between the telemonitored group and the controls. CONCLUSIONS: Home telemonitoring is an acceptable reliable intervention. Baseline rates for compliance with self-monitoring are set out in this study. Benefit in terms of compliance with medication and self-monitoring is still seen after 1 year. Video consulting over ordinary telephone lines did not show sustained benefit, and was not complied with.

Aged↗

PubMed2001

The use of a new continuous wireless cardiorespiratory telemonitoring system by elderly patients at home.

The diagnosis and management of increasing numbers of patients with chronic diseases in the community require new technologies and strategies of care. We have used a new wireless cardiorespiratory telemonitoring system to monitor 14 elderly patients with a variety of chronic diseases at home. The electrocardiogram (ECG), heart rate and variability, and breathing were recorded on two separate occasions for 24 h. There was no difference in the data recorded when a research nurse applied the monitoring system and when the patients applied it themselves. The ECG and heart rate were recorded for 98% of the monitored time, and the frequency and periodicities of breathing were recorded for 74% and 61% of sleep and rest time by visual and automatic analysis, respectively. The results show that 24 h activity and cardiorespiratory telemonitoring can be performed by elderly patients at home. Significant unsuspected abnormalities of breathing and heart rhythm, amenable to treatment, were also detected.

Aged↗

PubMed2001

A survey to identify the clinical coding and classification systems currently in use across Europe.

INTRODUCTION: This is a survey to identify what clinical coding systems are currently in use across the European Union, and the states seeking membership to it. We sought to identify what systems are currently used and to what extent they were subject to local adaptation. BACKGROUND: Clinical coding should facilitate identifying key medical events in a computerised medical record, and aggregating information across groups of records. The emerging new driver is as the enabler of the life-long computerised medical record. A prerequisite for this level of functionality is the transfer of information between different computer systems. This transfer can be facilitated either by working on the interoperability problems between disparate systems or by harmonising the underlying data. This paper examines the extent to which the latter has occurred across Europe. METHOD: Literature and Internet search. Requests for information via electronic mail to pan-European mailing lists of health informatics professionals. RESULTS: Coding systems are now a de facto part of health information systems across Europe. There are relatively few coding systems in existence across Europe. ICD9 and ICD 10, ICPC and Read were the most established. However the local adaptation of these classification systems either on a by country or by computer software manufacturer basis; significantly reduces the ability for the meaning coded with patients computer records to be easily transferred from one medical record system to another. CONCLUSIONS: There is no longer any debate as to whether a coding or classification system should be used. Convergence of different classifications systems should be encouraged. Countries and computer manufacturers within the EU should be encouraged to stop making local modifications to coding and classification systems, as this practice risks significantly slowing progress towards easy transfer of records between computer systems.

Classification↗

PubMed2000

Measuring blood pressure at the wrist: more comfortable for patients and more convenient for doctors?

OBJECTIVES: To compare the agreement between conventional measurement of blood pressure and measurements obtained using two automated devices; and to compare how comfortable each of the three methods of measurement were for patients. METHODS: Blood pressure measurements and patient comfort scores were recorded using three different devices in 125-surgery and 40-community patients. The devices used were a conventional aneroid sphygmomanometer, an automated device that measured blood pressure on the upper arm and an automated device that measured blood pressure at the wrist. In each patient, the difference between the conventional and automatic measurement was calculated. The limits of agreement of each device were then calculated as the mean difference +/-1.96 standard deviations. RESULTS: In surgery patients, the width of limits of agreement of wrist measurement were 20.0 mm Hg and 12.1 mm Hg for systolic and diastolic blood pressure respectively, compared with 26. 4 mm Hg and 27.7 mm Hg for automatic arm measurement. In community patients, the width of limits of agreement of wrist measurement were 11.6 mm Hg and 11.0 mm Hg for systolic and diastolic blood pressure respectively, compared with 19.5 mm Hg and 12.1 mm Hg for automatic arm measurement. Surgery patients also reported that wrist measurement of blood pressure was significantly more comfortable than either manual or automatic arm measurement (mean comfort scores 4.03 for automatic wrist and 2.13 for automatic arm measurement, Friedman's Test, P<0.001). CONCLUSIONS: Blood pressure measurements taken using the wrist device agreed more closely with those obtained using a conventional aneroid sphygmomanometer than the arm device. The wrist device was also more comfortable for patients than two other methods of blood pressure measurement. Public Health (2000) 114, 165-168

Aged↗

PubMed2000

Computerised systematic secondary prevention in ischaemic heart disease: a study in one practice.

BACKGROUND: One of the most effective interventions that the primary health care team can make is that of secondary prevention in ischaemic heart disease (IHD). There is still a need to improve the uptake of effective interventions such as aspirin and statins in these patients. General Practice in the UK is 95% computerised, but many functions are under-utilised. In the majority of cases primary care clinicians use the keyboard rather than mouse for data entry. Methods of data entry using the keyboard or CHUI (Character User Interface) can be cumbersome and time consuming. This can limit data collection and its assimilation for patient care. The object of this study was to assess the feasibility and effectiveness of a new software programme, which provides computerised support to primary care staff in their preventive care of IHD patients. AIM: To demonstrate that a systematic computer facilitated secondary prevention programme for IHD was effective, feasible, and acceptable to patients and improved patient care. METHOD: Evidence-based guidelines and intervention levels for secondary prevention of IHD were agreed at practice level and embedded in the software. Patients aged 80 and under were identified by the use of Read codes and repeat prescribing. The nurse-run programme consisted of a detailed review of electronic and written records and then the clinical review of 141 patients. At follow-up patients were issued with a questionnaire to assess their satisfaction with the process. RESULTS: From a general practice computer search for ischaemic heart disease Read Code (G3) and/or nitrate prescription an initial cohort of 242 patients was established. 90 were excluded on clinical grounds (not IHD, deceased, over-riding other clinical problems), and eleven patients could not be recruited (eight declined and three had moved away). The final cohort consisted of 141 patients, of whom 101 patients suffered angina, 67 had a previous history of myocardial infarction, and 28 had had coronary artery bypass grafting. Hypertension had been diagnosed in 80 and hyperlipidaemia in 43. As a result of the study new diagnoses included: hyperlipidaemia where statins were indicated (38), congestive cardiac failure requiring treatment with ACE (Angiotensin Converting Enzyme) inhibitors (2) and carotid bruits requiring referral (4). In addition diabetes was diagnosed in three patients. The programme proved acceptable to patients, doctors and practice staff; follow-up continues. CONCLUSION: The use of this methodology, in a single practice, has improved the care of patients well beyond that achieved with established template-based secondary prevention programmes. The outcome has been measured in terms of increased diagnosis and active management of hyperlipidaemia and other risk factors.

Aged↗

PubMed2000

A pilot study of radiotelemetry for continuous cardiopulmonary monitoring of patients at home.

We have conducted a trial of a wireless device for continuous cardiopulmonary monitoring. Its performance, user acceptance and safety were assessed for monitoring in the patient's home. The study included 20 patients: six with chronic obstructive pulmonary disease, six with chronic heart failure, seven with atrial fibrillation and palpitations, and one with a snoring problem. The system recorded the heart rate and respiratory rate, blood pressure, electrocardiogram and body temperature. The results were transmitted automatically to a central monitoring station. The accuracy of the measurements was checked by a comparison system and also by conventional measurements performed by a nurse. The system was acceptable to patients and functioned satisfactorily in the home. An important facet of home telemonitoring may turn out to be its greater reliability in collecting objective data.

Adult↗