UK Department of Health, NHS City and Hackney.

Background: It is unknown whether interventions known to improve the healthcare response to domestic violence and abuse (DVA)-a global health concern-are effective outside of a trial. Methods: An observational interrupted time series study in general practice. All registered women aged 16 and above were eligible for inclusion. In four implementation boroughs' general practices, there was face-to-face, practice-based, clinically relevant DVA training, a prompt in the electronic medical record, reminding clinicians to consider DVA, a simple referral pathway to a named advocate, ensuring direct access for women to specialist services, overseen by a national, health-focused DVA organisation, fostering best practice. The fifth comparator borough had only a session delivered by a local DVA specialist agency at community venues conveying information to clinicians. The primary outcome was the daily number of referrals received by DVA workers per 1000 women registered in a general practice, from 205 general practices, in all five northeast London boroughs. The secondary outcome was recorded new DVA cases in the electronic medical record in two boroughs. Data was analysed using an interrupted time series with a mixed effects Poisson regression model. Results: In the 144 general practices in the four implementation boroughs, there was a significant increase in referrals received by DVA workers-global incidence rate ratio of 30.24 (95% CI 20.55 to 44.77, p < 0.001). There was no increase in the 61 general practices in the other comparator borough (incidence rate ratio of 0.95, 95% CI 0.13 to 6.84, p = 0.959). New DVA cases recorded significantly increased with an incident rate ratio of 1.27 (95% CI 1.09 to 1.48, p < 0.002) in the implementation borough but not in the comparator borough (incidence rate ratio of 1.05, 95% CI 0.82 to 1.34, p = 0.699). Conclusions: Implementing integrated referral routes, training and system-level support, guided by a national healthfocused DVA organisation, outside of a trial setting, was effective and sustainable at scale, over four years (2012 to 2017) increasing referrals to DVA workers and new DVA cases recorded in electronic medical records.

BackgroundAtrial fibrillation (AF) is a cause of stroke, and undertreatment with anticoagulants is a persistent issue despite their effectiveness. AimTo increase the proportion of people with AF treated appropriately using anticoagulants, and reduce inappropriate antiplatelet therapy. Design of studyCross-sectional analysis. SettingElectronic patient health records on 4604 patients with AF obtained from general practices in three inner London primary care trusts between April 2011 and 2013. MethodThe Anticoagulant Programme East London (APEL) sought to achieve its aims through an intervention with three components: altering professional beliefs using new clinical guidance and related education; facilitating change using computer software to support clinical decisions and patient review optimising anticoagulation; motivating change through evaluative feedback showing individual practice performance relative to peers. ResultsFrom April 2011 to April 2013, the proportion of people with CHA 2 DS 2 -VASc ≥1 on anticoagulants increased from 52.6% to 59.8% (trend difference P<0.001). The proportion of people with CHA 2 DS 2 -VASc ≥1 on aspirin declined from 37.7% to 30.3% (trend difference P<0.001). Comparing the 2 years before the intervention with the 2 years after, numbers of new people on the AF register almost doubled from 108 to 204. ConclusionsThe APEL programme supports improvement in clinical managing AF by a combined programme of education around agreed guidance, computer aids to facilitate decisionmaking and patient review and feedback of locally identifiable results. If replicated nationally over 3 years, such a programme could result in approximately 1600 fewer strokes every year.

BackgroundLiver disease is a major cause of morbidity and mortality worldwide. Large numbers of liver function tests (LFTs) are performed in primary care, with abnormal liver biochemistry a common finding. Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver injury. Metabolic syndrome, common in people from South Asia, is an important risk factor for NAFLD.AimIt is hypothesised that a large gap exists between numbers of patients with abnormal LFTs and those with recorded liver diagnoses, and that NAFLD is more common among adults of South Asian ethnic groups.Design and settingA cross-sectional study of 690 683 adults in coterminous general practices in a region with high ethnic diversity.MethodData were extracted on LFTs, liver disease, and process of care measures from computerised primary care medical records.ResultsLFTs were performed on 218 032 patients, of whom 31 627 had elevated serum transaminases. The prevalence of abnormal LFTs was highest among individuals of Bangladeshi ethnicity. Of the patients with abnormal LFTs, 88.4% did not have a coded liver diagnosis. NAFLD was the most frequently recorded liver disease and was most common among Bangladeshi patients. In a multivariate analysis, independent risk factors for NAFLD included Bangladeshi ethnicity, diabetes, raised BMI, hypertension, and hypercholesterolaemia.ConclusionAbnormal LFTs are common in the population, but are underinvestigated and often remain undiagnosed. Bangladeshi ethnicity is an important independent risk factor for NAFLD.

Using patient-level data rather than practice-level data, the authors demonstrate that the burden of multimorbidity is the strongest clinical predictor of ED attendance, which is independently associated with social deprivation. Low use of the GP surgery is associated with low attendance at ED. Unlike other studies, the authors found that adult patient experience of GP access, reported at practice level, did not predict use.

BackgroundThe NHS Health Check programme completed its first 5 years in 2014, identifying those at highest risk of cardiovascular disease and new comorbidities, and offering behavioural change support and treatment.AimTo describe the coverage and impact of this programme on cardiovascular risk management and identification of new comorbidities.Design and settingObservational 5-year study from April 2009 to March 2014, in 139 of 143 general practices in three clinical commissioning groups (CCGs) in east London.MethodA matched analysis compared comorbidity in NHS Health Check attendees and non-attendees.ResultsA total of 252 259 adults aged 40–74 years were eligible for an NHS Health Check and, of these, 85 122 attended in 5 years. Attendance increased from 7.3% (10 900/149 867) in 2009 to 17.0% (18 459/108 525) in 2013 to 2014, representing increasing coverage from 36.4% to 85.0%. Attendance was higher in the more deprived quintiles and among South Asians. Statins were prescribed to 11.5% of attendees and 8.2% of non-attendees. In a matched analysis, newly-diagnosed comorbidity was more likely in attendees than non-attendees, with odds ratios for new diabetes 1.30 (95% confidence interval [CI] = 1.21 to 1.39), hypertension 1.50 (95% CI = 1.43 to 1.57), and chronic kidney disease 1.83 (95% CI = 1.52 to 2.21).ConclusionThe NHS Health Check programme provision in these CCGs was equitable, with recent coverage of 85%. Statins were 40% more likely to be prescribed to attendees than non-attendees, providing estimated absolute benefits of public health importance. More new cases of diabetes, hypertension, and chronic kidney disease were identified among attendees than a matched group of non-attendees.

BackgroundThe updated (2014) National Institute for Health and Care Excellence (NICE) guideline lowered the recommended threshold for statin prescription from 20% to 10% 10-year cardiovascular disease (CVD) risk. AimTo determine the characteristics of patients prescribed statins for primary prevention according to their CVD risk. Design and settingCross-sectional study in primary care settings in the three east London CCGs (Newham, City and Hackney, and Tower Hamlets). MethodData were extracted from electronic health records of 930 000 patients registered with 137 of 141 general practices for a year ending 1 April 2014. ResultsOf 341 099 patients aged 30-74 years, excluding those with CVD or diabetes, 22 393 were prescribed statins and had a 10-year CVD risk recorded. Of these, 9828 (43.9%) had a CVD risk ≥20%, 7121 (31.8%) had a CVD risk of 10-19%, and 5444 (24.3%) had a CVD risk <10%. Statins were prescribed to 9828/19 755 (49.7%) of those at ≥20% CVD risk, to 7121/37 111 (19.2%) of those with CVD risk 10-19%, and to 5444/146 676 (3.7%) of those with CVD risk <10%. Statin prescription below the 20% CVD risk threshold targeted individuals in the 10-19% risk band in association with hypertension, high serum cholesterol, positive family history, older age, and south Asian ethnicity. ConclusionThis study confirms continuing undertreatment of patients at highest CVD risk (≥20%). GPs prescribed statins to only one-fifth of those in the 10-19% risk band usually in association with known major risk factors. Only 3.7% of individuals below 10% were prescribed statins.

ObjectivesTo describe implementation and results from the National Health Service (NHS) Health Check programme.DesignThree-year observational open cohort study: 2009–2011.ParticipantsPeople of age 40–74 years eligible for an NHS Health Check.Setting139/143 general practices in three east London primary care trusts (PCTs) serving an ethnically diverse and socially disadvantaged population.MethodImplementation was supported with education, IT support and performance reports. Tower Hamlets PCT additionally used managed practice networks and prior-stratification to call people at higher cardiovascular (CVD) risk first.Main outcomes measuresAttendance, proportion of high-risk population on statins and comorbidities identified.ResultsCoverage 2009, 2010, 2011 was 33.9% (31 878/10 805), 60.6% (30 757/18 652) and 73.4% (21 194/28 890), respectively. Older people were more likely to attend than younger people. Attendance was similar across deprivation quintiles and was in accordance with population distributions of black African/Caribbean, South Asian and White ethnic groups. 1 in 10 attendees were at high-CVD risk (20% or more 10-year risk). In the two PCTs stratifying risk, 14.3% and 9.4% of attendees were at high-CVD risk compared to 8.6% in the PCT using an unselected invitation strategy. Statin prescription to people at high-CVD risk was higher in Tower Hamlets 48.9%, than in City and Hackney 23.1% or Newham 20.2%. In the 6 months following an NHS Health Check, 1349 new cases of hypertension, 638 new cases of diabetes and 89 new cases of chronic kidney disease (CKD) were diagnosed. This represents 1 new case of hypertension per 38 Checks, 1 new case of diabetes per 80 Checks and 1 new case of CKD per 568 Checks.ConclusionsImplementation of the NHS Health Check programme in these localities demonstrates limited success. Coverage and treatment of those at high-CVD risk could be improved. Targeting invitations to people at high-CVD risk and managed practice networks in Tower Hamlets improved performance.