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Objective The objective of this study is to determine demographic and diagnostic distributions of physical pain recorded in clinical notes of a mental health electronic health records database by using natural language processing and examine the overlap in recorded physical pain between primary and secondary care.Design, setting and participants The data were extracted from an anonymised version of the electronic health records of a large secondary mental healthcare provider serving a catchment of 1.3 million residents in south London. These included patients under active referral, aged 18+ at the index date of 1 July 2018 and having at least one clinical document (≥30 characters) between 1 July 2017 and 1 July 2019. This cohort was compared with linked primary care records from one of the four local government areas.Outcome The primary outcome of interest was the presence of recorded physical pain within the clinical notes of the patients, not including psychological or metaphorical pain.Results A total of 27 211 patients were retrieved. Of these, 52% (14,202) had narrative text containing relevant mentions of physical pain. Older patients (OR 1.17, 95% CI 1.15 to 1.19), females (OR 1.42, 95% CI 1.35 to 1.49), Asians (OR 1.30, 95% CI 1.16 to 1.45) or black (OR 1.49, 95% CI 1.40 to 1.59) ethnicities, living in deprived neighbourhoods (OR 1.64, 95% CI 1.55 to 1.73) showed higher odds of recorded pain. Patients with severe mental illnesses were found to be less likely to report pain (OR 0.43, 95% CI 0.41 to 0.46, p

Objectives To develop and probe the first computerised decision-support tool to provide antidepressant treatment guidance to general practitioners (GPs) in UK primary care.Design A parallel group, cluster-randomised controlled feasibility trial, where individual participants were blind to treatment allocation.Setting South London NHS GP practices.Participants Ten practices and eighteen patients with treatment-resistant current major depressive disorder.Interventions Practices were randomised to two treatment arms: (a) treatment-as-usual, (b) computerised decision support tool.Results Ten GP practices participated in the trial, which was within our target range (8–20). However, practice and patient recruitment were slower than anticipated and only 18 of 86 intended patients were recruited. This was due to fewer than expected patients being eligible for the study, as well as disruption resulting from the COVID-19 pandemic. Only one patient was lost to follow-up. There were no serious or medically important adverse events during the trial. GPs in the decision tool arm indicated moderate support for the tool. A minority of patients fully engaged with the mobile app-based tracking of symptoms, medication adherence and side effects.Conclusions Overall, feasibility was not shown in the current study and the following modifications would be needed to attempt to overcome the limitations found: (a) inclusion of patients who have only tried one Selective Serotonin Reuptake Inhibitor, rather than two, to improve recruitment and pragmatic relevance of the study; (b) approaching community pharmacists to implement tool recommendations rather than GPs; (c) further funding to directly interface between the decision support tool and self-reported symptom app; (d) increasing the geographic reach by not requiring detailed diagnostic assessments and replacing this with supported remote self-report.Trial registration number NCT03628027.

Objectives Explore inequalities in risk factors, mental and physical health morbidity in non-pregnant women of reproductive age in contact with mental health services and how these vary per ethnicity.Design Retrospective cohort study.Setting Data from Lambeth DataNet, anonymised primary care records of this ethnically diverse London borough, linked to anonymised electronic mental health records (‘CRIS secondary care database’).Participants Women aged 15–40 years with an episode of secondary mental health care between January 2008 and December 2018 and no antenatal or postnatal Read codes (n=3817) and a 4:1 age-matched comparison cohort (n=14 532).Main outcome measures Preconception risk factors including low/high body mass index, smoking, alcohol, substance misuse, micronutrient deficiencies and physical diagnoses.Results Women in contact with mental health services (whether with or without severe mental illness (SMI)) had a higher prevalence of all risk factors and physical health diagnoses studied. Women from minority ethnic groups were less likely to be diagnosed with depression in primary care compared with white British women (adjusted OR 0.66 (0.55–0.79) p

Objectives Sickness absence is strongly associated with poor mental health, and mental disorders often go untreated. In this population-based cohort study, we identified people receiving fit notes from their general practitioner (GP) and determined access to mental health treatment stratified by health complaint and demographic variables.Design Longitudinal study of health records.Setting Primary care and secondary mental health care in the borough of Lambeth, South London. Forty-five GP practices in Lambeth and the local secondary mental healthcare trust.Participants The analytical sample included 293 933 working age adults (16–60 years) registered at a Lambeth GP practice between 1 January 2014 and 30 April 2016.Primary and secondary outcome measures Three indicators of mental healthcare in the year after first fit note were antidepressant prescription, contact with Improving Access to Psychological Therapy (IAPT) services and contact with secondary mental health services.Results 75% of people with an identified mental health condition at first fit note had an indicator of mental healthcare in the following year. Black Caribbean and Black African groups presenting with mental disorders were less likely to have a mental healthcare indicator compared with White British groups.Conclusions The majority of those with an identified mental health need receive some treatment in the year following a fit note; however, our results suggest Black African and Black Caribbean groups with an identified mental healthcare need have less complete access compared to the White British group.

Objectives People with epilepsy (PWE) have a higher mortality rate than the general population. Epilepsy-related deaths have increased despite all-cause mortality decreasing in the general population pre-COVID-19. We hypothesised that clinical and lifestyle factors may identify people more at risk.Design We used a retrospective cohort study to explore cause of death and a nested case–control study to identify risk factors.Setting We explored factors associated with mortality using primary care population data from 1 April 2004 to 31 March 2014. Data were obtained from the Clinical Practice Research Datalink which compiles anonymised patient data from primary care in the UK. Cause of death data was supplemented from the Office of National Statistics when available.Participants The analysis included 70 431 PWE, with 11 241 registered deaths.Results The number of deaths within the database increased by 69% between the first and last year of the study. Epilepsy was considered as a contributing cause in approximately 45% of deaths of PWE under 35. Factors associated with increased risk of death included attendance at emergency departments and/or emergency admissions (OR 3.48, 95% CI 3.19 to 3.80), antiepileptic drug (AED) polytherapy (2 AEDs: OR 1.60, 95% CI 1.51 to 1.71; 3 AEDs: OR 2.06, 95% CI 1.86 to 2.29; 4+AEDs: OR 2.62, 95% CI 2.23 to 3.08), status epilepticus (OR 2.78, 95% CI 1.64 to 4.71), depression (OR 1.67, 95% CI 1.57 to 1.76) and injuries (OR 1.54, 95% CI 1.43 to 1.67). No seizures in the prior year (OR 0.52, 95% CI 0.41 to 0.65).Conclusion Our results add to existing evidence that deaths in epilepsy are increasing. Future studies could focus on identifying PWE at high risk and addressing them with clinical interventions or better self-management. Identifying specific risk factors for younger people should be a priority as epilepsy may be a factor in close to half of deaths of PWE under 35 years of age.

Objectives The fit note replaced the sick note in the UK in 2010, with the aim of improving support for patients requiring sickness absence, yet there has been very little research into fit note use. This study aims to describe number of fit notes by condition, to improve our understanding of patterns of fit note use in primary care. Previous fit note research has relied on extracting diagnoses directly from fit notes, rather than extracting information from clinical records. In this paper, we extract information from clinical records to explore demographic factors and conditions associated with number of fit notes issued.Design This is a longitudinal study of clinical data. We analysed individual-level anonymised data from general practitioner consultations, including demographic information and condition recorded at first fit note. The latter encompassed diagnoses, individual symptoms and psychosocial issues.Setting A database called Lambeth DataNet, containing electronic clinical records on 326 415 adults (ages 16–60) from all 45 general practices within the London Borough of Lambeth from 1 January 2014 to 30 April 2017.Participants Our analytical sample contained 40 698 people with a condition recorded at first fit note.Primary outcome measure Predicted number of fit notes in the period January 2014–April 2017Results Of all studied diagnostic groups, mental illness had the highest predicted number of fit notes (n=3.3; 95% CI: 3.1 to 3.4) after controlling for demographic factors and long-term conditions. The highest predicted number of fit notes for any condition subgroup was among patients presenting for drug and/or alcohol misuse (n=4.5; 95% CI: 4.1 to 4.8).Conclusions For the first time, we show drug and/or alcohol misuse at first fit note are associated with the highest number of fit notes. Research is needed to understand the trajectories of individuals at highest risk of long-term sickness absence, in particular, people presenting with drug and/or alcohol misuse.

Purpose The emergence of antimicrobial resistance has led to increasing efforts to reduce unnecessary use of antibiotics in primary care, but potential hazards from bacterial infection continue to cause concern. This study investigated how primary care prescribers perceive risk and safety concerns associated with reduced antibiotic prescribing.Methods Qualitative study using semistructured interviews conducted with primary care prescribers from 10 general practices in an urban area and a shire town in England. A thematic analysis was conducted.Results Thirty participants were recruited, including twenty-three general practitioners, five nurses and two pharmacists. Three main themes were identified: risk assessment, balancing treatment risks and negotiating decisions and risks. Respondents indicated that their decisions were grounded in clinical risk assessment, but this was informed by different approaches to antibiotic use, with most leaning towards reduced prescribing. Prescribers’ perceptions of risk included the consequences of both inappropriate prescribing and inappropriate withholding of antibiotics. Sepsis was viewed as the most concerning potential outcome of non-prescribing, leading to possible patient harm and potential litigation. Risks of antibiotic prescribing included antibiotic resistant and Clostridium difficile infections, as well as side effects, such as rashes, that might lead to possible mislabelling as antibiotic allergy. Prescribers elicited patient preferences for use or avoidance of antibiotics to inform management strategies, which included educational advice, advice on self-management including warning signs, use of delayed prescriptions and safety netting.Conclusions Attitudes towards antibiotic prescribing are evolving, with reduced antibiotic prescribing now being approached more systematically. The safety trade-offs associated with either use or non-use of antibiotics present difficulties especially when prescribing decisions are inconsistent with patients’ expectations.

Introduction The Antidepressant Advisor Study is a feasibility trial of a computerised decision-support tool which uses an algorithm to provide antidepressant treatment guidance for general practitioners (GPs) in the UK primary care service. The tool is the first in the UK to implement national guidelines on antidepressant treatment guidance into a computerised decision-support tool.Methods and analysis The study is a parallel group, cluster-randomised controlled feasibility trial where participants are blind to treatment allocation. GPs were assigned to two treatment arms: (1) treatment-as-usual (TAU) and (2) computerised decision-support tool to assist with antidepressant choices. The study will assess recruitment and lost to follow-up rates, GP satisfaction with the tool and impact on health service use. A meaningful long-term roll-out unit cost will be calculated for the tool, and service use data will be collected at baseline and follow-up to inform a full economic evaluation of a future trial.Ethics and dissemination The study has received National Health Service ethical approval from the London—Camberwell St Giles Research Ethics Committee (ref: 17/LO/2074). The trial was pre-registered in the Clinical Trials.gov registry. The results of the study will be published in a pre-publication archive within 1 year of completion of the last follow-up assessment.Trial registration number NCT03628027.

ObjectiveThis study evaluated whether serious bacterial infections are more frequent at family practices with lower antibiotic prescribing rates.DesignCohort study.Setting706 UK family practices in the Clinical Practice Research Datalink from 2002 to 2017.Participants10.1 million registered patients with 69.3 million patient-years’ follow-up.ExposuresAll antibiotic prescriptions, subgroups of acute and repeat antibiotic prescriptions, and proportion of antibiotic prescriptions associated with specific-coded indications.Main outcome measuresFirst episodes of serious bacterial infections. Poisson models were fitted adjusting for age group, gender, comorbidity, deprivation, region and calendar year, with random intercepts representing family practice-specific estimates.ResultsThe age-standardised antibiotic prescribing rate per 1000 patient-years increased from 2002 (male 423; female 621) to 2012 (male 530; female 842) before declining to 2017 (male 449; female 753). The median family practice had an antibiotic prescribing rate of 648 per 1000 patient-years with 95% range for different practices of 430–1038 antibiotic prescriptions per 1000 patient-years. Specific coded indications were recorded for 58% of antibiotic prescriptions at the median family practice, the 95% range at different family practices was from 10% to 75%. There were 139 759 first episodes of serious bacterial infection. After adjusting for covariates and the proportion of coded consultations, there was no evidence that serious bacterial infections were lower at family practices with higher total antibiotic prescribing. The adjusted rate ratio for 20% higher total antibiotic prescribing was 1.03, (95% CI 1.00 to 1.06, p=0.074).ConclusionsWe did not find population-level evidence that family practices with lower total antibiotic prescribing might have more frequent occurrence of serious bacterial infections overall. Improving the recording of infection episodes has potential to inform better antimicrobial stewardship in primary care.

Objective To study the social determinants and cardiovascular risk factors for multimorbidity and the acquisition sequence of multimorbidity.Design Longitudinal study based on anonymised primary care data.Setting General practices in an urban multiethnic borough in London, UK.Participants 332 353 patients aged ≥18 years.Main outcome measures Clinical and sociodemographic characteristics of patients with multimorbidity, defined as ≥3 of 12 long-term conditions (LTCs) selected according to high predicted healthcare use. Multilevel logistic regression was used to model social determinants and cardiovascular risk factors. Alluvial plots were constructed to illustrate multimorbidity acquisition sequences according to age, ethnicity and social deprivation.Results 5597 (1.7%) patients had ≥3 selected LTCs, the ‘multimorbidity cohort’. The the most common LTCs were diabetes (63.0%) and chronic pain (CP) (42.8%). Social deprivation and ethnicity were independent determinants of multimorbidity: most compared with the least deprived quintile (adjusted OR (AOR) 1.56 (95% CI 1.41 to 1.72)); South Asian compared with white ethnicity (AOR 1.44 (95% CI 1.29 to 1.61)); and black compared with white ethnicity (AOR 0.86 (95% CI 0.80 to 0.92)). The included cardiovascular risk factors were relatively strong determinants of multimorbidity: hypertension (AOR 5.05 (95% CI 4.69 to 5.44)), moderate obesity (AOR 3.41 (95% CI 3.21 to 3.63)) and smoking (AOR 2.30 (95% CI 2.16 to 2.45)). The most common initial onset conditions were diabetes and depression; diabetes particularly in older and black ethnic groups; and depression particularly in younger, more deprived and white ethnicity groups. CP was less common as an initial condition.Conclusion Our findings confirm the importance of age, social deprivation and ethnicity as determinants of multimorbidity. Smoking, obesity and hypertension as cardiovascular risk factors were stronger determinants of multimorbidity than deprivation or ethnicity. The acquisition sequence of multimorbidity is patterned by sociodemographic determinants. Understanding onset conditions of multimorbidity and cardiovascular cardiovascular risk factors may lead to the development of interventions to slow the progression of multimorbidity.

Objective To explore the relationship between general practice capitation funding and quality ratings based on general practice inspections.Design Cross-sectional study pooling 3 years of primary care administrative data.Setting UK primary care.Participants 7310 practices (95% of all practices) in England which underwent Care Quality Commission (CQC) inspections between November 2014 and December 2017.Main outcome measures CQC ratings. Ordered logistic regression methods were used to predict the relationship between practice capitation funding and CQC ratings in each of five domains of quality: caring, effective, responsive, safe and well led, together with an overall practice rating.Results Higher capitation funding per patient was significantly associated with higher CQC ratings across all five quality domains: caring (OR 1.14, 95% CI 1.04 to 1.23), effective (OR 1.08, 95% CI 1.00 to 1.16), responsive (OR 1.09, 95% CI 1.02 to 1.17), safe (OR 1.11, 95% CI 1.05 to 1.18), well led (OR 1.13, 95% CI 1.06 to 1.20) and overall rating (OR 1.13, 95% CI 1.06 to 1.19).Conclusion Higher capitation funding was consistently associated with higher ratings across all CQC domains and in the overall practice rating. This study suggests that measured dimensions of the quality of care are related to the underlying capitation funding allocated to each general practice, implying that additional capitation funding may be associated with higher levels of primary care quality.

Introduction Persistent physical symptoms (PPS), also known as medically unexplained symptoms are associated with profound physical disability, psychological distress and high healthcare costs. England’s annual National Health Service costs of attempting to diagnose and treat PPS amounts to approximately £3 billion. Current treatment relies on a positive diagnosis, life-style advice and drug therapy. However, many patients continue to suffer from ongoing symptoms and general practitioners (GPs) are challenged to find effective treatments. Training GPs in basic cognitive behavioural skills and providing self-help materials to patients could be useful, but availability in primary care settings is limited.Methods and analysis A cluster randomised waiting list, controlled trial will be conducted to assess the feasibility of an integrated approach to care in general practice. Approximately 240 patients with PPS will be recruited from 8 to 12 GP practices in London. GP practices will be randomised to ‘integrated GP care plus treatment as usual’ or waiting list control. Integrated GP care plus treatment as usual will include GP training in cognitive behavioural skills, GP supervision and written and audio visual materials for both GPs and participants. The primary objectives will be assessment of trial and intervention feasibility. Secondary objectives will include estimating the intracluster correlation coefficient for potential outcome measures for cluster effects in a sample size calculation. Feasibility parameters and identification of suitable primary and secondary outcomes for future trial evaluations will be assessed prerandomisation and at 12 and 24 weeks’ postrandomisation, using a mixed-methods approach.Ethics and dissemination Ethical approval was granted by the Camberwell St Giles Ethics Committee. Results will be disseminated via peer-reviewed publications and conference presentations. This trial will inform researchers, clinicians, patients and healthcare providers about the feasibility and potential cost-effectiveness of an integrated approach to managing PPS in primary care.Trial registration number NCT02444520; Pre-results.