In a world where genetic tests for coronary heart disease (CHD) are becoming increasingly commercially available, how do patients make sense of the results particularly when considered alongside the results from routine cardiovascular risk assessments undertaken by their general practitioner? This was the subject of a qualitative study with Dr Jo Middlemass, research fellow at CaHRU, as lead author: ‘Introducing genetic testing for cardiovascular disease in primary care: a qualitative study’. The authors interviewed 29 patients from 12 practices in Nottingham, who had received a routine cardiovascular risk assessment, followed by genetic testing to assess their CHD risk, to assess their understanding and response to both tests.
The results showed that genetic testing procedures were acceptable for patients. However, there was limited recall of the results for either the genetic test or the conventional cardiovascular disease (CVD) assessment undertaken in the practice. There was also some confusion on how to interpret the results, for example was being ‘above average risk’ better than being ‘average’? In addition there were sometimes contradictory findings in terms of being ‘above average genetic risk’ but ‘average’ conventional CVD risk and vice versa. Patients dealt with these conflicting findings in different ways. Some thought that healthy behaviour had mitigated their increased genetic risk while others were falsely reassured when their genetic risk was ‘average’ but their conventional risk was ‘above average’.
Patients often said that their main motivation to have genetic test for CHD was because they had a perceived family history of CHD and wanted to be able to share the genetic predisposition results with their adult children. However, despite this, very few did actually discuss the results with their offspring. The findings indicate that health professionals should discuss patient’s perceptions about the results of CHD risk assessments (both conventional and genetic) in order to facilitate greater awareness and understanding and to maximise any potential for behaviour change.
For the full article see Br J Gen Pract 2014; DOI: 10.3399/bjgp14X679714. Authors: Jo B Middlemass, Momina F Yazdani, Joe Kai, Penelope J Standen and Nadeem Qureshi.
By Jo Middlemass
Viet-Hai Phung, Fiona Clapton, Dr Karen Windle, Dr Zahid Asghar, Professor Niro Siriwardena attended the 999 EMS Research Forum in Sheffield on 19 February 2014. Also attending were Nadya Essam, Debbie Shaw, Mohammad Iqbal and Anne Spaight, visiting research fellows at CaHRU based at East Midlands Ambulance Services NHS Trust. This conference was aimed at emergency care practitioners, health service managers, policy makers, as well as academics and researchers like ourselves. Fiona, Zahid and Nadya presented posters and fielded questions on our work on the use of 999 and NHS 111 in Lincolnshire, ethnic differences in cardiac chest pain and the use of Modified Early Warning Scores (MEWS) to inform decision-making among ambulance clinicians respectively.
Viet-Hai , whose abstract submission was among the four most highly-rated, gave an oral presentation on the systematic review he has been undertaking with Dr Windle and other members of the team on the barriers and facilitators for minority ethnic groups in accessing prehospital care. The presentation was well-received, with thought-provoking questions both from delegates on the conference floor and outside. The day began with International Exchange Prize Winner, Rachael Wallen, a paramedic from New Zealand, presenting her work on women’s attitudes to 12 lead electrocardiogram acquisition in the ambulance setting. This was followed by Professor Siriwardena and Jo Coster from the University of Sheffield’s School of Health And Related Research (ScHARR) providing an update on the Pre-hospital Outcomes for Evidence-Based Evaluation (PhOEBE) programme.
The afternoon session began with representatives from two Patient Public Involvement (PPI) bodies talking about how best to involve patients and the public in pre-hospital emergency care research. This was followed by keynote speaker, Professor Keith Willett from NHS England who presented his organisation’s review of urgent and emergency care and potential future directions. The conference concluded with a panel discussion of the issues raised by Professor Willett’s presentation with Professor Siriwardena and others with particular perspectives on urgent and emergency care.
A new study from CaHRU published online this month in the journal Vaccine, ‘Influenza and pneumococcal vaccination and risk of stroke or transient ischaemic attack – matched case-control study’ has shown that influenza vaccination is associated with a 24% reduction in risk of stroke. The study involved statistical analysis of a large routine primary care dataset from the Clinical Practice Research Datalink (previously the General Practice Research Database).
The analysis was carried out by Dr Zahid Asghar (senior lecturer and statistician at CaHRU pictured left) supported by Dr Carol Coupland (University of Nottingham).This was the latest in a series of studies funded by the National Institute for Health Research (NIHR), Research for Patient Benefit Programme led by Professor Niroshan Siriwardena into the link between influenza vaccination and cardiovascular disease.
Previous studies published in Vaccine and the Canadian Medical Association Journal showed a similar link between influenza vaccination and prevention of acute myocardial infarction (‘heart attack’). The study provides further reasons for people to have their flu jab each autumn.
The results of a national Quality Improvement Collaborative study, the Ambulance Services Cardiovascular Quality Initiative (ASCQI) were published this week in the international academic journal Implementation Science. The article entitled The effect of a national quality improvement collaborative on prehospital care for acute myocardial infaction and stroke in England showed large and significant improvements in the quality of care provided by 11 ambulance services (out of 12) in England for people with heart attack and stroke. Members of the CaHRU team involved in the study included Professor Siriwardena, Dr Zowie Davy and Fiona Togher together with visiting fellows at CaHRU who are members of the research team at EMAS including Anne Spaight, Debbie Shaw and Nadya Essam. Professor Michael Dewey, chair in epidemiological statistics in London was the statistician on the project.
The project has been part of a programme of work, Prehospital and Emergency Quality and Outcomes, developed through collaboration between academics from the Community and Health Research Unit and ambulance services across the United Kingdom, particularly East Midlands Ambulance Service NHS Trust (EMAS). This collaboration has enabled a strategic partnership between the University of Lincoln and EMAS to undertake research which is relevant to ambulance services, focusing on health issues of regional and national importance, and conducted with ambulance staff in order to increase the impact of the research by improving prehospital care for emergencies.
The study examined the period between January 2010 and February 2012. Across England overall, the percentage of emergency cases where care bundles (packages of essential care) were delivered in full increased from 43% to 79% for heart attack and from 83% to 96% for stroke. ASCQI supported frontline staff, and their management, to introduce improvements using checklists, aide memoires, individual and group feedback and sharing of information within and between different trusts to improve the reliability of care for people with heart attack and stroke. The project was shortlisted for an HSJ award in 2012.
Tim Norfolk and Prof Niro Siriwardena have recently published a discussion paper in Quality in Primary Care describing ‘A comprehensive model for diagnosing the causes of individual medical performance problems: skills, knowledge, internal, past and external factors (SKIPE)‘.
The SKIPE model, developed by Tim Norfolk, an occupational psychologist, through his work with underperforming doctors, sets out in logical relationship and progression the causal factors determining effective medical performance or underperformance. It highlights how the relationship between competence and performance is moderated by specific, discrete causal factors both within the individual and external to the individual.
This model builds on a previous paper describing a unifying theory of clinical practice, the RDM-p model, which captures the primary skill sets required for effective medical performance (relationship, diagnostics and management), and the professionalism that needs to underpin them. The SKIPE model is currently being used, in conjunction with the RDM-p model, for the in-depth assessment and management of doctors whose performance is a cause for concern.