Author Archives: Niroshan Siriwardena

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Improvement science and methods seminars: case control and self controlled case series designs

A new series of Improvement Science and Method Seminars led by Zahid Asghar, senior lecturer in health, began with our first workshop on 19 October 2012.  Zahid led the attendees, which included academic and health service staff working with the Community and Health Research Group, through case-control studies and touched on the self-controlled case series method. There have been only forty or so studies published using this novel method in the worldwide literature including one study published by the team last year in the prestigious Vaccine: Gwini SM, Coupland C, Siriwardena AN. The effect of influenza vaccination on risk of acute myocardial infarction: self-controlled case-series study. Vaccine 2011; 29: 1145-1149. 

Zahid is currently working on an NIHR Research for Patient Benefit study looking at the possible association between influenza  or pneumococcal vaccination and stroke or transient ischaemic attack (TIA) (IPVASTIA), which he used to illustrate the two study types. There have been a number of studies investigating the link between respiratory infections as a trigger for heart attack or stroke and the possible protective effect of influenza vaccination including a study published by the group in the Canadian Medical Association Journal two years ago:  Siriwardena AN, Gwini S, Coupland C. Influenza vaccination, pneumococcal vaccination, and the risk of acute myocardial infarction: matched case-control study. Canadian Medical Association Journal 2010; 182 (15): 1617- 1623.

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Pay-for-performance with caution: new systematic review published in Annals of Family Medicine

A new systematic review of the UK Quality and Outcomes Framework (QOF) is published in the Annals of Family Medicine today. The QOF, a controversial program of financial incentives and information technology to promote structured and team-based care, is the most comprehensive national primary care pay-for-performance (P4P) program in the world.

The authors, Steve Gillam (University of Cambridge), Niro Siriwardena (University of Lincoln) and Nick Steel (University of East Anglia) found, despite an annual investment of over a billion pounds per year in incentives,  only modest improvements since the QOF was introduced in 2004. The systematic review follows on from a book, co-edited by Steve Gillam and Niro Siriwardena entitled ‘The QOF: transforming general practice’ published in 2010.

The QOF has also contributed to reduced continuity of care and may have detracted from patient-centred care. In view of the findings policy makers should be cautious about implementing similar P4P programs.  Systems need to be developed which improve quality while minimizing costs and unintended consequences.

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University of Lincoln with EMAS and National Ambulance Groups shortlisted for HSJ Awards 2012

A national quality improvement project led by East Midlands Ambulance Service NHS Trust and the University of Lincoln in collaboration with the National Ambulance Services Clinical Quality Group and National Ambulance Research Steering Groups has been shortlisted for the prestigious Health Service Journal Awards 2012: Enhancing Care with Data and Information Management.

The Ambulance Services Cardiovascular Quality Initiative (ASCQI), funded by the Health Foundation, was a quality improvement collaborative involving all twelve English ambulance trusts, the first time all services have been involved in a national project. The aims was to improve pre-hospital care for cardiovascular disease by using a care-bundle approach to ensure that every patient presenting with heart attack or stroke received each element of optimal care.

The care bundle for suspected heart attack included aspirin, glyceryl trinitrate, pain scoring before and after treatment and pain relief. The suspected stroke bundle included the face-arm-speech test (FAST), and recording blood glucose and blood pressure. The project involved measuring and benchmarking performance, analysing barriers and facilitators to improvement, and using quality improvement methods to improve the quality of services.

ASCQI achieved statistically significant improvements in ten out of twelve trusts in either the stroke or heart attack care bundle, with five out of twelve trusts showing significant improvements for both heart attack and stroke. Overall performance for the care bundle for heart attack increased nationally in Englandfrom 43 to 79 percent and for stroke from 83 to 96 percent.

ASCQI achieved its aim of applying quality improvement methods to improve care for patients presenting to ambulance services inEnglandwith heart attack or stroke.

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ENACT study presented in Gothenburg at European Forum

A recently completed study,  ‘Integrating online communities and social networks with computerised treatment for insomnia: a qualitative study of service user and multiprofessional primary health care perspectives’ was presented by Prof Niro Siriwardena in the e-health session of the fourth biannual conference of the European Forum for Primary Care: The Future of Primary Healthcare in Europe IV held in September in Gothenburg’s Museum of World Culture in Sweden.

The study authors also included Jo Middlemass, Dr Zowie Davy, Dr Kate Cavanagh, Dr Conor Linehan, Professor Kevin Morgan and Professor Shaun Lawson. The study was funded by the EPSRC Healthcare Partnerships programme and is the first study in a wider project, ‘Exploring social Networks to Augment Cognitive behavioural Therapy (ENACT)’.

ENACT aims to design and test a novel mode of delivery of treatment for sleep problems including mobile phone technology, electronic assessment of sleep and computerised cognitive behavioural therapy for insomnia (CCBT-I). The study involved interviews and focus groups with service users and health professionals to elicit beliefs and intentions that might facilitate or create barriers to the uptake and adherence to CCBT-I.

The study is due to be presented at the Society for Academic Primary Care in Glasgow and to be published in the British Journal of General Practice later this year.

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Women and men doctors differ in their knowledge of sex-specific complaints during general practice training

A new study from the University of Lincoln and the Royal College of General Practitioners (RCGP) Applied Knowledge Test Development Group reveals that women doctors have greater knowledge about women’s medical problems than men doctors during their training to become general practitioners. The study entitled, ‘Comparing performance among male and female candidates in sex- specific clinical knowledge in the MRCGP‘, was published in the British Journal of General Practice this month and is the first to look at sex-specific clinical knowledge in a medical licensing examination. The Applied Knowledge Test is a component of the Membership of the Royal College of General Practitioners, which doctors training to be GPs need to pass to be deemed fit for independent practice.

Many female patients choose to see a woman doctor, because they feel more at ease with their communication style or feel more confident in their knowledge of women’s medicine. This study shows that on average women doctors know more about women’s medicine than men at a similar stage of training and after taking other factors into account – so women may be justified in choosing a woman doctor on this basis. Conversely male doctors in training did not appear to know more about men’s problems.

The reason for this difference is a matter for speculation. Women doctors are much more likely to see more female patients during training and might be encouraged to learn more about women’s problems as a result of this greater exposure as well as through their own personal experience. The implication for GP training schemes is that they should ensure that male GP trainees are enabled to see more women patients or learn more about women’s medicine so that patients consulting male trainees are not disadvantaged.