Author: Azeem Majeed

I am Professor of Primary Care and Public Health, and Head of the Department of Primary Care & Public Health at Imperial College London. I am also involved in postgraduate education and training in both general practice and public health, and I am the Course Director of the Imperial College Master of Public Health (MPH) programme.

Sex differences in cardiovascular events and procedures in people with and without diabetes

An article published in the journal Cardiovascular Diabetology examines gender differences in hospital admissions for major cardiovascular events and procedures in people with and without diabetes.

Secondary prevention of cardiovascular disease (CVD) has improved immensely during the past few decades but controversies persist about the cardiovascular benefits among women with diabetes. We investigated 11-year trends in hospital admission rates for acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in people with and without diabetes by gender in England.

We found that diabetes-related admission rates remained unchanged for AMI, increased for stroke by 2% and for PCI by 3%; and declined for CABG by 3% annually. Trends did not differ significantly by diabetes status. Women with diabetes had significantly lower rates of AMI and stroke compared with men with diabetes. However, gender differences in admission rates for AMI attenuated in diabetes compared with the non-diabetic group.

While diabetes tripled admission rates for AMI in men, it increased it by over four-fold among women. Furthermore, while the presence of diabetes was associated with a three-fold increase in rates for PCI and a five-fold increase in rates for CABG in men; among women, diabetes was associated with a 4.4-fold increased admission rates for PCI and 6.2-fold increased rates for CABG. Proportional changes in rates were similar in men and women for all study outcomes, leaving the relative risk of admissions largely unchanged.

We concluded that diabetes still confers a greater increase in risk of hospital admission for AMI in women relative to men. However, the absolute risk remains higher in men. These results call for intensified CVD risk factor management among people with diabetes, consideration of gender-specific treatment targets, and treatment intensity to be aligned with levels of CVD risk.

https://doi.org/10.1186/s12933-017-0580-0

Use of interrupted time series analysis in health services research

Although randomized control trials (RCTs) are the ‘gold standard’ to evaluate treatment effects in health care, they are frequently not practical, ethical or politically acceptable in the evaluation of many health system or public health interventions. In the absence of an RCT, evaluations often use quasi-experimental designs such as a pre-post study design with measurements before and after the intervention period, such as interupted time series (ITS). An ITS compares the intercept and slope of the regression line before the intervention with the intercept and slope after intervention. A one-time baseline effect of the intervention without influencing the secular trend can be detected as an intercept change. If the intervention changed the secular trend, there will also be a significant difference in the slope between the two periods. Use of ITS in biomedical research is described in more detail in an article published by Utz Pape and colleagues in the Journal of the Royal Society of Medicine.

The Self-Care Academic Research Unit (SCARU) at Imperial College London

In a recent horizon scanning exercise, the School of Public Health recognised the rising importance of self-care as a means to empower patients and support an NHS fit for 21st Century Britain, identifying ‘self-care’ as an important area of academic interest. Further to participation in the annual Self-Care Conference, the Department of Primary & Public Health recently met with Dr Pete Smith OBE (Co-Chair of the Self Care Forum) and Dr David Webber (Head of the international Self Care Foundation) with a view to help establish Imperial College as an academic base of self-care in England.

The Self Care Forum is a national charity that seeks to develop and promote self-care throughout life and work, and encourages the recognition and embedding of self-care in all our lives. It defines self-care as the actions that individuals take for themselves and on behalf of or with others in order to develop, protect, maintain and improve their health, wellbeing or wellness. This includes Health Literacy. The International Self Care Foundation continues to develop evidence-based self-care concepts and practices, whilst promoting the role of self-care in health worldwide.

This tripartite collaboration will ensure that Self-Care is researched as a cross-cutting theme in the contemporary setting for patient benefit, and will strive to make the absolute case for self-care to inform policy makers via an extensive portfolio of research activity. SCARU will help identify how empowering patients via increased health literacy would result in improved outcomes, lower dependency on NHS resources, whilst also identifying key evidence-based recommendations for the consideration of policy makers.

Activity at the newly established Self Care Academic and Research Unit (SCARU) will focus primarily on producing evidence to advance our understanding of self-care in the context of 21st century healthcare by research in the following domains:

  • Evidence synthesis via development of high quality protocols to investigate various aspects related to Self-Care and how this links to empowerment, health literacy, and resilience in the community
  • Understanding how Self-Care can benefit the wider health economy (starting with England, but also looking at European and international examples)
  • Health economic modelling and cost benefit analysis of Self-Care initiatives from the perspective of funding of outcomes as opposed to activities
  • Social science/Qualitative research to better understand patient/GP/Commissioner knowledge, attitude & perspectives (KAP) in relation to Self-Care
  • Explore the use of E&M Health Technologies, digital health & wearable tech in supporting Self-Care in the new setting
  • Service evaluations and audits of local/national importance- including HQIP
  • Self-Care in mental health theme
  • Policy reviews and position papers
  • Establishing a database of evidence on Self-Care

SCARU will work closely with Hammersmith & Fulham GP Practice Federation and Imperial College Health Care Trust (ICHT) Directorate of Public Health & Primary Care to pilot small interventions and to better understand knowledge attitude & perceptions of Self-Care from NHS staff and patient perspectives. The H&F GP Practice Federation and ICHT will also consider participating in the Self Care Week 2017, including participation in the Self-Care Forum Annual Conference.

For further information, contact Dr Austen El Osta.

A woman with a suspected viral rash in pregnancy

My article in the BMJ considers how doctors should approach the management of a woman with a suspected viral rash during pregnancy. Key points in the article include:

  • Consider country of origin in a woman presenting with a rash in pregnancy and ask for immunisation history.
  • Test for measles and rubella IgM and IgG antibodies, particularly if immunisation history is not clear.
  • Refer women with an active infection to the fetal medicine unit for fetal monitoring.

The full article can be read in the BMJ.

The diagnosis and management of Scarlet Fever in primary care

An article from the Department of Primary Care and Public Health published in the London Journal of Primary Care discusses the diagnosis and management of Scarlet Fever. There has been a recent increase in the incidence of scarlet fever with most cases presenting in General Practice and Emergency Departments. Cases present with a distinctive macro-papular rash, usually in children. In patients who have the typical symptoms, a prescription of a suitable antibiotic such as phenoxymethylpenicillin (Penicillin V) should be made immediately to reduce the risk of complications and the spread of infection.

A typical presentation of scarlet fever
An 8-year-old girl is brought to see you at your practice. She has a sore throat, abdominal pain and has been vomiting. Her health was fine until two days ago. Initially, she noticed pain on swallowing and had a temperature of 38 °C. Her parents decided to seem medical advice once they noticed the ‘sandpaper-like’ rash on her trunk and the inside of her elbows. When you examine her tongue, the enlarged papillae become immediately obvious giving it a ‘strawberry’ like appearance. Petechiae are also visible on her soft palate. Her anterior-cervical nodes are swollen and tender.

Read more in the London Journal of Primary Care.

DOI: http://dx.doi.org/10.1080/17571472.2017.1365677

Warning signs might have been missed in one in six heart attack deaths in England

Heart attack symptoms might have been missed in many patients, according to a study on all heart attack hospital admissions and deaths in England from Imperial College London. More research is urgently needed to establish whether it is possible to predict the risk of fatal heart attacks in patients for whom this condition was not recorded as the main reason for hospital admission. The study was published in The Lancet Public Health.

Heart disease is one of the leading killers in the UK. According to the British Heart Foundation, heart attacks lead to one hospital visit every three minutes. They are caused by a decrease in blood flow to the heart, usually as a result of coronary heart disease. Symptoms may include sudden chest pain or a ‘crushing’ sensation that might spread down either arm. Patients might also experience nausea or shortness of breath. However, some heart attacks have more subtle symptoms and may therefore be missed or overlooked.

In this study, we examined records of all 446,744 NHS hospital stays in England between 2006 and 2010 that recorded heart attacks, as well as the hospitalisation history of all 135,950 heart attack deaths. The records included whether or not patients who died of a heart attack had been admitted to hospital in the past four weeks and if so, whether signs of heart attack were recorded as the main cause of admission (primary diagnosis), additional to the main reason (secondary diagnosis), or not recorded at all.

Of the 135,950 patients who died from heart attack, around half died without a hospital admission in the prior four weeks, and around half died within four weeks of having been in hospital. 21,677 (16 per cent, or one in six) of the patients who died from heart attack had been hospitalised during the four weeks prior, but heart attack symptoms were not mentioned on their hospital records.

There were certain symptoms, such as fainting, shortness of breath and chest pain, that were apparent up to a month before death in some of these patients, but doctors may not have been alert to the possibility that these signalled an upcoming fatal heart attack, possibly because there was no obvious damage to the heart at the time.

These results suggest that possible signs of upcoming fatal heart attack may have been missed. The authors’ next step is to look into why this pattern emerged, and to try to prevent more heart attack deaths. We also found that of all patients admitted with a heart attack, those whose heart attack was recorded as secondary to the main condition were two to three times more likely to die than patients whose records stated heart attack as the main condition.

The study received extensive media coverage including by the BBC, The Independent and the Daily Telegraph.

DOI: http://dx.doi.org/10.1016/S2468-2667(17)30032-4

Releasing student potential: Widening access to opportunities in community healthcare

The WATCCH Team at the Department of Primary Care and Public Health

This summer, the Department of Primary Care and Public Health kicked off an exciting new programme: Widening Access to Careers in Community Healthcare (WATCCH). We hosted twenty 16-17 year olds who are aspiring to be the first in their families to go to university – at the Charing Cross campus for the inaugural WATCCH project. Our aim was to change perceptions of wider healthcare careers and provide vital work experience for their University applications. Competition was high and the team was very impressed by the number of high calibre students that applied for a place.

Year 12 Pupils from 19 London secondary schools attended an induction day in late July. During the workshop, an experienced multi-professional panel consisting of five professionals including an Imperial final year medical student, shared their career journeys with the pupils from their A level to postgraduate degrees. This was followed by pupils creating individual mind maps, which they thoroughly enjoyed, of where they are now and where they would like to be in the future. This was followed by a fun exercise in the clinical skills lab at Charing Cross where they could experience clinical skills such as phlebotomy, measuring blood pressure, and inserting nasogastric tubes into mannequins.

The pupils, in pairs, will now attend a 3-day work experience attachment at a General Practice over the summer, where they shadow various health care professionals ranging from pharmacists, to phlebotomists, nurses, physiotherapists and GPs.

Our budding health professionals reported that they had their eyes opened to new and different careers in healthcare they were not previously aware of. One pupil commented that they had learnt “how the different healthcare professionals work together to provide the best quality care”. Another said they had “learnt more about the opportunities available and how to find them”. Pupils also felt they got an insight into how to provide the best quality care, with admiration for the way in which different healthcare professionals worked as a team. It was even said that you “will never get bored” in healthcare!

In early September, we will run a final workshop day to review their reflections of what they have learnt and gained from their work experience. They have been advised to do a placement project to showcase something they have learnt from their attachment which they will share at the final workshop. The mind maps will be revisited to review if their thoughts have changed following the placement. We also hope to discuss how to incorporate their work experience into their personal statements for UCAS applications.

The WATCCH project is needed now more than ever. Figures from the Office for Fair Access (OFFA) show that in 2016 entry rates to “higher tariff” universities for 18-year-olds from the most disadvantaged neighbourhoods stood at just 3.6%. This is exaggerated within the health sector, where there is also a shortage of work experience, despite it being essential for applications. The shortage is particularly acute for those who have no family or social connections to healthcare professionals, despite good GCSE grades.

The NHS workforce is certainly facing a recruitment crisis and our aim is to help channel and support able and enthusiastic applicants towards a brighter future in healthcare. A well-functioning multi-professional team in the community will aid primary care in delivering better patient care

Students at the Clinical Skills Lab at Charing Cross Hospital

The GP teaching team at the Department of Primary Care and Public Health were instrumental in facilitating the induction day. If you would like further information about the WATCCH programme contact Dr Farah Jamil, lead GP for the WATCCH programme, at f.jamil@imperial.ac.uk.

Is there still a role for smaller hospitals in the NHS?

A paper published in the British Journal of Hospital Medicine asks the questions “Is there a role for smaller hospitals in the future NHS?”

The NHS is challenged by rising demand as a consequence of a population with more complex conditions and the rising costs of paying for that care. Inefficiencies resulting from fragmented primary, secondary and social care services highlight the need for greater coordination and continuity to improve patient outcomes at lower cost. Financial constraints can drive health system review, providing impetus to modify health service delivery within the NHS to maximize value and better align with the needs of our population.

The Naylor (2017) review calls for urgent rationalization of the NHS estate to meet the mandate of the Five Year Forward View. Smaller acute hospitals could be seen as a potential starting point for reconfiguring health services in England. However, local change is not always welcome and the perceived loss of services is often met with staunch political and public opposition.

The NHS Chief Executive Officer, Simon Stevens, has expressed his support for smaller hospitals. In the Five Year Forward View, smaller hospitals have an opportunity to once again be at the centre of defining patient pathways. This will require some change in provision of services. Gaining local public and clinician support will be crucial and small hospital leaders must be visionary. Support programmes such as the New Cavendish Group and New Care Models programme will be increasingly important in helping to ensure that smaller hospitals remain part of the fabric of the English NHS.

DOI: https://doi.org/10.12968/hmed.2017.78.8.424

The burden of disease in the World Health Organization’s Eastern Mediterranean Region

I contributed to a series of papers on health in the World Health Organization’s Eastern Mediterranean Region. Key steps that need to be taken to improve the health and well-being of people in the region must include ending the wars and conflicts in the region, as well as improving education and employment opportunities, particularly among women. Health systems must be strengthened as well, for example, through building up primary care and using health programmes to target the causes of ill-health, such as high-calorie diets, smoking, physical inactivity and obesity. In addition, health workers and governments should aim to improve maternal and child health and ensure that immunisation rates are high, as well as addressing environmental factors such as air pollution. You can read more on the Imperial College Website.

The papers were published in the International Journal of Public Health. Papers in the series include:

Diabetes mellitus and chronic kidney disease in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 study

doi:10.1007/s00038-017-1014-1

Burden of obesity in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 study

doi:10.1007/s00038-017-1002-5

Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 Study

Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare?

Policy-makers in many countries are increasingly considering charging people different fees for using primary and secondary care services (differential user charges). The aim of such ‘differential fees’ is to encourage use of primary health care in health systems with limited gate keeping.

We carried out a systematic review to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively.

Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased primary care utilisation. One study identified an increase in primary care utilisation after primary care user charges were reduced. The introduction of a non-referral charge in secondary care was associated with lower primary care utilisation in one study. One study compared user charges across insurance plans, associating higher charges in secondary care with higher utilisation in both primary and secondary care.

Our conclusion was that the impact of introducing differential user-charges on use of primary care remains uncertain. Further research is required to understand their impact, including implications for health system costs and on utilisation among low-income patients.

The full article can be read in the journal Health Policy and Planning.