Publications by authors named "Graham C M Watt"

39 Publications

Multimorbidity and Socioeconomic Deprivation in Primary Care Consultations.

Ann Fam Med 2018 03;16(2):127-131

Academic Unit of General Practice and Primary Care, Institute of Health and Well-being, University of Glasgow, Scotland, United Kingdom.

Purpose: The influence of multimorbidity on the clinical encounter is poorly understood, especially in areas of high socioeconomic deprivation where burdensome multimorbidity is concentrated. The aim of the current study was to examine the effect of multimorbidity on general practice consultations, in areas of high and low deprivation.

Methods: We conducted secondary analyses of 659 video-recorded routine consultations involving 25 general practitioners (GPs) in deprived areas and 22 in affluent areas of Scotland. Patients rated the GP's empathy using the Consultation and Relational Empathy (CARE) measure immediately after the consultation. Videos were analyzed using the Measure of Patient-Centered Communication. Multilevel, multi-regression analysis identified differences between the groups.

Results: In affluent areas, patients with multimorbidity received longer consultations than patients without multimorbidity (mean 12.8 minutes vs 9.3, respectively; = .015), but this was not so in deprived areas (mean 9.9 minutes vs 10.0 respectively; = .774). In affluent areas, patients with multimorbidity perceived their GP as more empathic ( = .009) than patients without multimorbidity; this difference was not found in deprived areas ( = .344). Video analysis showed that GPs in affluent areas were more attentive to the disease and illness experience in patients with multimorbidity ( < .031) compared with patients without multimorbidity. This was not the case in deprived areas ( = .727).

Conclusions: In deprived areas, the greater need of patients with multimorbidity is not reflected in the longer consultation length, higher GP patient centeredness, and higher perceived GP empathy found in affluent areas. Action is required to redress this mismatch of need and service provision for patients with multimorbidity if health inequalities are to be narrowed rather than widened by primary care.
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March 2018

The CARE Plus study - a whole-system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation: exploratory cluster randomised controlled trial and cost-utility analysis.

BMC Med 2016 06 22;14(1):88. Epub 2016 Jun 22.

Institute of Health and Wellbeing, University of Glasgow, 27 Bute Gardens, Glasgow, G12 8RS, UK.

Background: Multimorbidity is common in deprived communities and reduces quality of life. Our aim was to evaluate a whole-system primary care-based complex intervention, called CARE Plus, to improve quality of life in multimorbid patients living in areas of very high deprivation.

Methods: We used a phase 2 exploratory cluster randomised controlled trial with eight general practices in Glasgow in very deprived areas that involved multimorbid patients aged 30-65 years. The intervention comprised structured longer consultations, relationship continuity, practitioner support, and self-management support. Control practices continued treatment as usual. Primary outcomes were quality of life (EQ-5D-5L utility scores) and well-being (W-BQ12; 3 domains). Cost-effectiveness from a health service perspective, engagement, and retention were assessed. Recruitment and baseline measurements occurred prior to randomisation. Blinding post-randomisation was not possible but outcome measurement and analysis were masked. Analyses were by intention to treat.

Results: Of 76 eligible practices contacted, 12 accepted, and eight were selected, randomised and participated for the duration of the trial. Of 225 eligible patients, 152 (68 %) participated and 67/76 (88 %) in each arm completed the 12-month assessment. Two patients died in the control group. CARE Plus significantly improved one domain of well-being (negative well-being), with an effect size of 0.33 (95 % confidence interval [CI] 0.11-0.55) at 12 months (p = 0.0036). Positive well-being, energy, and general well-being (the combined score of the three components) were not significantly influenced by the intervention at 12 months. EQ-5D-5L area under the curve over the 12 months was higher in the CARE Plus group (p = 0.002). The incremental cost in the CARE Plus group was £929 (95 % CI: £86-£1788) per participant with a gain in quality-adjusted life years of 0.076 (95 % CI: 0.028-0.124) over the 12 months of the trial, resulting in a cost-effectiveness ratio of £12,224 per quality-adjusted life year gained. Modelling suggested that cost-effectiveness would continue.

Conclusions: It is feasible to conduct a high-quality cluster randomised control trial of a complex intervention with multimorbid patients in primary care in areas of very high deprivation. Enhancing primary care through a whole-system approach may be a cost-effective way to protect quality of life for multimorbid patients in deprived areas.

Trial Registration:

Trial Registration: ISRCTN 34092919 , assigned 14/1/2013.
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June 2016

General Practitioners' Empathy and Health Outcomes: A Prospective Observational Study of Consultations in Areas of High and Low Deprivation.

Ann Fam Med 2016 Mar;14(2):117-24

Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland.

Purpose: We set out to compare patients' expectations, consultation characteristics, and outcomes in areas of high and low socioeconomic deprivation, and to examine whether the same factors predict better outcomes in both settings.

Methods: Six hundred fifty-nine patients attending 47 general practitioners in high- and low-deprivation areas of Scotland participated. We assessed patients' expectations of involvement in decision making immediately before the consultation and patients' perceptions of their general practitioners' empathy immediately after. Consultations were video recorded and analyzed for verbal and non-verbal physician behaviors. Symptom severity and related well-being were measured at baseline and 1 month post-consultation. Consultation factors predicting better outcomes at 1 month were identified using backward selection methods.

Results: Patients in deprived areas had less desire for shared decision-making (P <.001). They had more problems to discuss (P = .01) within the same consultation time. Patients in deprived areas perceived their general practitioners (GPs) as less empathic (P = .02), and the physicians displayed verbal and nonverbal behaviors that were less patient centered. Outcomes were worse at 1 month in deprived than in affluent groups (70% response rate; P <.001). Perceived physician empathy predicted better outcomes in both groups.

Conclusions: Patients' expectations, GPs' behaviors within the consultation, and health outcomes differ substantially between high- and low-deprivation areas. In both settings, patients' perceptions of the physicians' empathy predict health outcomes. These findings are discussed in the context of inequalities and the "inverse care law."
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March 2016

General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland.

Br J Gen Pract 2015 Dec;65(641):e799-805

General Practice and Primary Care, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow.

Background: Universal access to health care, as provided in the NHS, does not ensure that patients' needs are met.

Aim: To explore the relationships between multimorbidity, general practice funding, and workload by deprivation in a national healthcare system.

Design And Setting: Cross-sectional study using routine data from 956 general practices in Scotland.

Method: Estimated numbers of patients with multimorbidity, estimated numbers of consultations per 1000 patients, and payments to practices per patient are presented and analysed by deprivation decile at practice level.

Results: Levels of multimorbidity rose with practice deprivation. Practices in the most deprived decile had 38% more patients with multimorbidity compared with the least deprived (222.8 per 1000 patients versus 161.1; P<0.001) and over 120% more patients with combined mental-physical multimorbidity (113.0 per 1000 patients versus 51.5; P<0.001). Practices in the most deprived decile had 20% more consultations per annum compared with the least deprived (4616 versus 3846, P<0.001). There was no association between total practice funding and deprivation (Spearman ρ -0.09; P = 0.03). Although consultation rates increased with deprivation, the social gradients in multimorbidity were much steeper. There was no association between consultation rates and levels of funding.

Conclusion: No evidence was found that general practice funding matches clinical need, as estimated by different definitions of multimorbidity. Consultation rates provide only a partial estimate of the work involved in addressing clinical needs and are poorly related to the prevalence of multimorbidity. In these circumstances, general practice is unlikely to mitigate health inequalities and may increase them.
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December 2015

Occupational class differences in later life hospital use by women who survived to age 80: the Renfrew and Paisley prospective cohort study.

Age Ageing 2015 May 28;44(3):515-9. Epub 2014 Nov 28.

Institute of Health and Wellbeing, University of Glasgow, Public Health 1 Lilybank Gardens, Glasgow G12 8RZ, UK.

Background: population ageing challenges the sustainability of healthcare provision.

Objective: to investigate occupational class differences in hospital use in women aged 80+ years.

Methods: a total of 8,353 female residents, aged 45-64, took part in the Renfrew and Paisley prospective cohort study in 1972-76. Information on general and mental health hospital discharges was provided from computerised linkage with the Scottish Morbidity Records data to 31 December 2012. Numbers of admissions and bed-days after the 80th birthday were calculated for all and specific causes. Rate ratios by occupational class were calculated using negative binomial regression analysis, adjusting for age and a range of risk factors.

Results: four thousand and four hundred and seven (56%) women survived to age 80 and had 17,563 general admissions thereafter, with a mean stay of 19.4 days. There were no apparent relationships with occupational class for all general admissions, but lower occupational class was associated with higher rate ratios for coronary heart disease and stroke and lower rate ratios for cancer. Adjustment for risk factors could not fully explain the raised rate ratios. Bed-day use was higher in lower occupational classes, especially for stroke. There were strong associations with mental health admissions, especially dementia. Compared with the highest occupational class, admission rate ratios for dementia were higher for the lowest occupational class (adjusted rate ratio = 2.60, 95% confidence interval 1.79-3.77).

Conclusion: in this population, there were no socio-economic gradients seen in hospital utilisation for general admissions in old age. However, occupational class was associated with mental health admissions, coronary heart disease, stroke and cancer.
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May 2015

The influence of socioeconomic deprivation on multimorbidity at different ages: a cross-sectional study.

Br J Gen Pract 2014 Jul;64(624):e440-7

Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.

Background: Multimorbidity occurs at a younger age in individuals in areas of high socioeconomic deprivation but little is known about the 'typology' of multimorbidity in different age groups and its association with socioeconomic status.

Aim: To characterise multimorbidity type and most common conditions in a large nationally representative primary care dataset in terms of age and deprivation.

Design And Setting: Cross-sectional analysis of 1 272 685 adults in Scotland.

Method: Multimorbidity type of participants (physical-only, mental-only, mixed physical, and mental) and most common conditions were analysed according to age and deprivation.

Results: Multimorbidity increased with age, ranging from 8.1% in those aged 25-34 to 76.1% for those aged ≥75 years. Physical-only (56% of all multimorbidity) was the most common type of multimorbidity in those aged ≥55 years, and did not vary substantially with deprivation. Mental-only was uncommon (4% of all multimorbidity), whereas mixed physical and mental (40% of all multimorbidity) was the most common type of multimorbidity in those aged <55 years and was two- to threefold more common in the most deprived compared with the least deprived in most age groups. Ten conditions (seven physical and three mental) accounted for the top five most common conditions in people with multimorbidity in all age groups. Depression and pain featured in the top five conditions across all age groups. Deprivation was associated with a higher prevalence of depression, drugs misuse, anxiety, dyspepsia, pain, coronary heart disease, and diabetes in multimorbid patients at different ages.

Conclusion: Mixed physical and mental multimorbidity is common across the life-span and is exacerbated by deprivation from early adulthood onwards.
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July 2014

Genetic association study of QT interval highlights role for calcium signaling pathways in myocardial repolarization.

Nat Genet 2014 Aug 22;46(8):826-36. Epub 2014 Jun 22.

Center for Biomedicine, European Academy Bozen/Bolzano (EURAC), Bolzano, Italy (affiliated institute of the University of Lübeck, Lübeck, Germany).

The QT interval, an electrocardiographic measure reflecting myocardial repolarization, is a heritable trait. QT prolongation is a risk factor for ventricular arrhythmias and sudden cardiac death (SCD) and could indicate the presence of the potentially lethal mendelian long-QT syndrome (LQTS). Using a genome-wide association and replication study in up to 100,000 individuals, we identified 35 common variant loci associated with QT interval that collectively explain ∼8-10% of QT-interval variation and highlight the importance of calcium regulation in myocardial repolarization. Rare variant analysis of 6 new QT interval-associated loci in 298 unrelated probands with LQTS identified coding variants not found in controls but of uncertain causality and therefore requiring validation. Several newly identified loci encode proteins that physically interact with other recognized repolarization proteins. Our integration of common variant association, expression and orthogonal protein-protein interaction screens provides new insights into cardiac electrophysiology and identifies new candidate genes for ventricular arrhythmias, LQTS and SCD.
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August 2014

Double trouble: the impact of multimorbidity and deprivation on preference-weighted health related quality of life a cross sectional analysis of the Scottish Health Survey.

Int J Equity Health 2013 Aug 20;12:67. Epub 2013 Aug 20.

Health Economics and HTA, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, UK.

Objective: To investigate the association between multimorbidity and Preference_Weighted Health Related Quality of Life (PW_HRQoL), a score that combines physical and mental functioning, and how this varies by socioeconomic deprivation and age.

Design: The Scottish Health Survey (SHeS) is a cross-sectional representative survey of the general population which included the SF-12, a survey of HRQoL, for individuals 20 years and over.

Methods: For 7,054 participants we generated PW_HRQoL scores by running SF-12 responses through the SF-6D algorithm. The resulting scores ranged from 0.29 (worst health) to 1 (perfect health). Using ordinary least squares, we first investigated associations between scores and increasing counts of longstanding conditions, and then repeated for multimorbidity (2+ conditions). Estimates were made for the general population and quintiles of socioeconomic deprivation. For multimorbidity, the analyses were repeated stratifying the population by age group (20-44, 45-64, 65+).

Results: 45% of participants reported a longstanding condition and 18% reported multimorbidity. The presence of 1, 2, or 3+ longstanding conditions were associated with average reductions in PW_HRQoL scores of 0.081, 0.151 and 0.212 respectively. Reduction in scores associated with multimorbidity was 33% greater in the most deprived quintile compared to the least deprived quintile, with the biggest difference (80%) in the 20-44 age groups. There were no significant gender differences.

Conclusions: PW_HRQoL decreases markedly with multimorbidity, and is exacerbated by higher deprivation and younger age. There is a need to prioritise interventions to improve the HRQoL for (especially younger) adults with multimorbidity in deprived areas. BOX 1: What Is Known?Prevalence and premature onset of multimorbidity increases as socioeconomic position worsens. Previous studies have investigated the effect of multimorbidity on Health Related Quality of Life (HRQoL) on separate physical and mental health states. There is limited data on how HRQoL falls as the number of conditions increase, and how estimates vary across the general population.Leaving physical and mental health as separate categories can inhibit assessment of overall HRQoL. The use of a Preference_Weighted Health Related Quality of Life (PW_HRQoL) score provides a single summary measure of overall health, by weighting mental and physical states by their perceived importance as part of overall HRQoL. The use of a single score enables a simple and consistent assessment of the impact of conditions and how this varies across the population. Economists term PW_HRQoL scores health utilities.What this study adds?This is the first study to estimate how the impact of multimorbidity on PW_HRQoL scores varies by age group and socioeconomic deprivation. Multimorbidity has a substantial negative impact on HRQoL which is most severe in areas of deprivation, especially in younger adults.Measuring the burden of multimorbidity using PW_HRQoL provides consistency with how economists measure HRQoL; changes in which can be used in economic evaluation to assess the cost effectiveness of interventions.
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August 2013

Explaining the social patterning of lung function in adulthood at different ages: the roles of childhood precursors, health behaviours and environmental factors.

J Epidemiol Community Health 2013 Nov 8;67(11):905-11. Epub 2013 Aug 8.

MRC/CSO Social and Public Health Sciences Unit, , University of Glasgow, Glasgow, UK.

Background: Lung function successfully predicts subsequent health. Although lung function is known to decline over age, little is known about changes in association with socioeconomic status (SES) throughout life, and whether explanatory factors for association vary with age or patterns for non smokers.

Methods: Analyses were based on data on 24 500 participants aged ≥18 years from the 1995, 1998 and 2003 Scottish Health Surveys who were invited to provide 1 s forced expiratory volume (FEV1) and forced vital capacity (FVC) lung measurements. Sex-stratified multiple linear regression assessed lung function-SES (occupational social class) associations and attenuation by covariates in three age groups (2003 data (n=7928)).

Results: The FEV1-SES patterns were clear (p<0.001) and constant over time. Relative to the least disadvantaged, FEV1 in the most disadvantaged was lower by 0.28 L in men and 0.20 L in women under 40 years compared with differences of 0.51 L in men and 0.25 L in women over 64 years (p(interaction)<0.001 men, p(interaction)=0.004 women). The greatest attenuation of these results was seen by height, parental social class and smoking, especially among the under 65s. Second-hand smoke exposure and urban/rural residence had some impact among older groups. Adjusting for physical activity and weight had little effect generally. Similar patterns were seen for FVC and among never smokers.

Conclusions: We found cross-sectional evidence that SES disparity in lung function increases with age, especially for men. Our findings indicate that early-life factors may predict inequity during younger adulthood, with environmental factors becoming more important at older ages.
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November 2013

Attitudes towards health inequalities amongst GP trainers in Glasgow, and their ideas for changes in training.

Educ Prim Care 2013 Feb;24(2):97-104

Academic Clinical Fellow, General Practice & Primary Care, Institute of Health & Wellbeing, 1 Horselethill Road, Glasgow G12 9LX, Scotland, UK.

WHAT IS ALREADY KNOWN IN THIS AREA: Recent government policy has emphasised the important role that GPs have to play in addressing health inequalities. The RCGP curriculum asserts the importance of gaining a better understanding of health inequalities during GP training. GP training in Scotland continues to take place in disproportionately affluent areas. WHAT THIS WORK ADDS: This is the first study to look at attitudes of GP trainers towards health inequalities and to explore their ideas for changes in training that may address health inequalities. There were noticeable differences in the views of GP trainers--both in terms of the causes of health inequalities and the role of primary care in tackling inequalities--depending on whether they were based in more affluent or more deprived practices. Practice rotations were suggested by all groups as a means to give GP trainees exposure to the particular challenges of both affluent and deprived practice populations. SUGGESTIONS FOR FUTURE RESEARCH: Pilot studies of practice rotations between deprived and affluent areas would be of value. Evaluation of nMRCGP assessments (particularly the Clinical Skills Assessment, CSA) with regard to representativeness of general practice in deprived areas should be considered. Further qualitative research into the attitudes of GP trainees towards health inequalities, and GP trainers from different--less deprived--practice areas, would also be of interest. [corrected].
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February 2013

Parental height in relation to offspring coronary heart disease: examining transgenerational influences on health using the west of Scotland Midspan Family Study.

Int J Epidemiol 2012 Dec 19;41(6):1776-85. Epub 2012 Oct 19.

Medical Research Council Social and Public Health Sciences Unit, Glasgow, UK.

Background: Adult height is known to be inversely related to coronary heart disease (CHD) risk. We sought to investigate transgenerational influence of parental height on offspring's CHD risk.

Methods: Parents took part in a cardiorespiratory disease survey in two Scottish towns during the 1970s, in which their physical stature was measured. In 1996, their offspring were invited to participate in a similar survey, which included an electrocardiogram recording and risk factor assessment.

Results: A total of 2306 natural offspring aged 30-59 years from 1456 couples were subsequently flagged for notification of mortality and followed for CHD-related hospitalizations. Taller paternal and/or maternal height was associated with socio-economic advantage, heavier birthweight and increased high-density lipoprotein cholesterol in offspring. Increased height in fathers, but more strongly in mothers (risk ratio for 1 SD change in maternal height = 0.85; 95% confidence interval: 0.76 to 0.95), was associated with a lower risk of offspring CHD, adjusting for age, sex, other parental height and CHD risk factors.

Conclusion: There is evidence of an association between taller parental, particularly maternal, height and lower offspring CHD risk. This may reflect an influence of early maternal growth on the intrauterine environment provided for her offspring.
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December 2012

Health-related quality of life of Gaza Palestinians in the aftermath of the winter 2008-09 Israeli attack on the Strip.

Eur J Public Health 2012 Oct 15;22(5):732-7. Epub 2011 Sep 15.

Institute of Community and Public Health, Birzeit University, occupied Palestinian territory.

Background: We document the health-related quality of life (HRQoL) of people living in the Gaza Strip 6 months after 27 December 2008 to 18 January 2009, Israeli attack.

Methods: Cross-sectional survey 6 months after the Israeli attack. Households were selected by cluster sampling in two stages: a random sample of enumeration areas (EAs) and a random sample of households within each chosen EA. One randomly chosen adult from each of 3017 households included in the survey completed the World Health Organization Quality of Life instrument, in addition to reported information on distress, insecurities and threats.

Results: Mean HRQoL score (range 0-100) for the physical domain was 69.7, followed by the psychological (59.8) and the environmental domain score (48.4). Predictors of lower (worse) scores for all three domains were: lower educational levels, residence in rural areas, destruction to one's private property or high levels of distress and suffering. Worse physical and psychological domain scores were reported by people who were older and those living in North Gaza governorate. Worse physical and environmental domain scores were reported by people with no one working at home, and those with worse standard of living levels. Respondents who reported suffering stated that the main causes were the ongoing siege, the latest war on the Strip and internal Palestinian factional violence.

Conclusion: Results reveal poor HRQoL of adult Gazans compared with the results of WHO multi-country field trials and significant associations between low HRQoL and war-related factors, especially reports of distress, insecurity and suffering.
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October 2012

Genetic variation in the 15q25 nicotinic acetylcholine receptor gene cluster (CHRNA5-CHRNA3-CHRNB4) interacts with maternal self-reported smoking status during pregnancy to influence birth weight.

Hum Mol Genet 2012 Dec 5;21(24):5344-58. Epub 2012 Sep 5.

European Centre for Environment and Human Health, University of Exeter, The Knowledge Spa, Truro, UK.

Maternal smoking during pregnancy is associated with low birth weight. Common variation at rs1051730 is robustly associated with smoking quantity and was recently shown to influence smoking cessation during pregnancy, but its influence on birth weight is not clear. We aimed to investigate the association between this variant and birth weight of term, singleton offspring in a well-powered meta-analysis. We stratified 26 241 European origin study participants by smoking status (women who smoked during pregnancy versus women who did not smoke during pregnancy) and, in each stratum, analysed the association between maternal rs1051730 genotype and offspring birth weight. There was evidence of interaction between genotype and smoking (P = 0.007). In women who smoked during pregnancy, each additional smoking-related T-allele was associated with a 20 g [95% confidence interval (95% CI): 4-36 g] lower birth weight (P = 0.014). However, in women who did not smoke during pregnancy, the effect size estimate was 5 g per T-allele (95% CI: -4 to 14 g; P = 0.268). To conclude, smoking status during pregnancy modifies the association between maternal rs1051730 genotype and offspring birth weight. This strengthens the evidence that smoking during pregnancy is causally related to lower offspring birth weight and suggests that population interventions that effectively reduce smoking in pregnant women would result in a reduced prevalence of low birth weight.
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December 2012

Patient centredness and the outcome of primary care consultations with patients with depression in areas of high and low socioeconomic deprivation.

Br J Gen Pract 2012 Aug;62(601):e576-81

General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland.

Background: Most patients with depression are managed in general practice. In deprived areas, depression is more common and poorer outcomes have been reported.

Aim: To compare general practice consultations and early outcomes for patients with depression living in areas of high or low socioeconomic deprivation.

Design And Setting: Secondary data analysis of a prospective observational study involving 25 GPs and 356 consultations in deprived areas, and 20 GPs and 303 consultations in more affluent areas, with follow-up at 1 month.

Method: Validated measures were used to (a) objectively assess the patient centredness of consultations, and (b) record patient perceptions of GP empathy.

Results: PHQ-9 scores >10 (suggestive of caseness for moderate to severe depression) were significantly more common in deprived than in affluent areas (30.1% versus 18.5%, P<0.001). Patients with depression in deprived areas had more multimorbidity (65.4% versus 48.2%, P<0.05). Perceived GP empathy and observer-rated patient-centred communication were significantly lower in consultations in deprived areas. Outcomes at 1 month were significantly worse (persistent caseness 71.4% deprived, 43.2% affluent, P = 0.01). After multilevel multiregression modelling, observer-rated patient centredness in the consultation was predictive of improvement in PHQ-9 score in both affluent and deprived areas.

Conclusion: In deprived areas, patients with depression are more common and early outcomes are poorer compared with affluent areas. Patient-centred consulting appears to improve early outcome but may be difficult to achieve in deprived areas because of the inverse care law and the burden of multimorbidity.
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August 2012

Patient enablement requires physician empathy: a cross-sectional study of general practice consultations in areas of high and low socioeconomic deprivation in Scotland.

BMC Fam Pract 2012 Feb 8;13. Epub 2012 Feb 8.

General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, 1 Horselethill Road, Glasgow, UK.

Background: Patient 'enablement' is a term closely aligned with 'empowerment' and its measurement in a general practice consultation has been operationalised in the widely used patient enablement instrument (PEI), a patient-rated measure of consultation outcome. However, there is limited knowledge regarding the factors that influence enablement, particularly the effect of socio-economic deprivation. The aim of the study is to assess the factors influencing patient enablement in GP consultations in areas of high and low deprivation.

Methods: A questionnaire study was carried out on 3,044 patients attending 26 GPs (16 in areas of high socio-economic deprivation and 10 in low deprivation areas, in the west of Scotland). Patient expectation (confidence that the doctor would be able to help) was recorded prior to the consultation. PEI, GP empathy (measured by the CARE Measure), and a range of other measures and variables were recorded after the consultation. Data analysis employed multi-level modelling and multivariate analyses with the PEI as the dependant variable.

Results: Although numerous variables showed a univariate association with patient enablement, only four factors were independently predictive after multilevel multivariate analysis; patients with multimorbidity of 3 or more long-term conditions (reflecting poor chronic general health), and those consulting about a long-standing problem had reduced enablement scores in both affluent and deprived areas. In deprived areas, emotional distress (GHQ-caseness) had an additional negative effect on enablement. Perceived GP empathy had a positive effect on enablement in both affluent and deprived areas. Maximal patient enablement was never found with low empathy.

Conclusions: Although other factors influence patient enablement, the patients' perceptions of the doctors' empathy is of key importance in patient enablement in general practice consultations in both high and low deprivation settings.
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February 2012

Cause specific mortality, social position, and obesity among women who had never smoked: 28 year cohort study.

BMJ 2011 Jun 28;342:d3785. Epub 2011 Jun 28.

Institute of Health and Wellbeing, Public Health, University of Glasgow, Glasgow G12 8RZ, UK.

Objective: To investigate the relations between causes of death, social position, and obesity in women who had never smoked.

Design: Prospective cohort study.

Setting: Renfrew and Paisley, Scotland.

Participants: 8353 women and 7049 men aged 45-64 were recruited to the Renfrew and Paisley Study in 1972-6. Of these, 3613 women had never smoked and were the focus of this study. They were categorised by occupational class (I and II, III non-manual, III manual, and IV and V) and body mass index groups (normal weight, overweight, moderately obese, and severely obese).

Main Outcome Measures: All cause and cause specific mortality during 28 years of follow-up by occupational class and body mass index, using Cox proportional hazards models adjusted for age and other confounders.

Results: The women in lower occupational classes who had never smoked were on average shorter and had poorer lung function and higher systolic blood pressure than women in the higher occupational classes. Overall, 43% (n = 1555) were overweight, 14% (n = 515) moderately obese, and 5% (n = 194) severely obese. Obesity rates were higher in lower occupational classes and much higher in all occupational classes than in current smokers in the full cohort. Half the women died, 51% (n = 916) from cardiovascular disease and 27% (n = 487) from cancer. Relative to occupational class I and II, all cause mortality rates were more than a third higher in occupational classes III manual (relative rate 1.35, 95% confidence interval 1.16 to 1.57) and IV and V (1.34, 1.17 to 1.55) and largely explained by differences in obesity, systolic blood pressure, and lung function. Similar upward gradients were seen for cardiovascular disease and respiratory disease but not for cancer. Mortality rates were highest in severely obese women in the lowest occupational classes.

Conclusions: Women who had never smoked and were not obese had the lowest mortality rates, regardless of their social position. Where obesity is socially patterned as in this cohort, it may contribute to health inequalities and increase pressure on health and social services serving more disadvantaged populations.
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June 2011

The combined effect of smoking tobacco and drinking alcohol on cause-specific mortality: a 30 year cohort study.

BMC Public Health 2010 Dec 24;10:789. Epub 2010 Dec 24.

Centre for Population & Health Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Public Health & Health Policy, 1 Lilybank Gardens, Glasgow G12 8RZ, UK.

Background: Smoking and consuming alcohol are both related to increased mortality risk. Their combined effects on cause-specific mortality were investigated in a prospective cohort study.

Methods: Participants were 5771 men aged 35-64, recruited during 1970-73 from various workplaces in Scotland. Data were obtained from a questionnaire and a screening examination. Causes of death were all cause, coronary heart disease (CHD), stroke, alcohol-related, respiratory and smoking-related cancer. Participants were divided into nine groups according to their smoking status (never, ex or current) and reported weekly drinking (none, 1-14 units and 15 or more). Cox proportional hazards models were used to obtain relative rates of mortality, adjusted for age and other risk factors.

Results: In 30 years of follow-up, 3083 men (53.4%) died. Compared with never smokers who did not drink, men who both smoked and drank 15+ units/week had the highest all-cause mortality (relative rate = 2.71 (95% confidence interval 2.31-3.19)). Relative rates for CHD mortality were high for current smokers, with a possible protective effect of some alcohol consumption in never smokers. Stroke mortality increased with both smoking and alcohol consumption. Smoking affected respiratory mortality with little effect of alcohol. Adjusting for a wide range of confounders attenuated the relative rates but the effects of alcohol and smoking still remained. Premature mortality was particularly high in smokers who drank 15 or more units, with a quarter of the men not surviving to age 65. 30% of men with manual occupations both smoked and drank 15+ units/week compared with only 13% with non-manual ones.

Conclusions: Smoking and drinking 15+ units/week was the riskiest behaviour for all causes of death.
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December 2010

Distilling the essence of general practice: a learning journey in progress.

Br J Gen Pract 2009 May;59(562):e167-76

Selkirk Health Centre, Selkirk.

Over the past 5 years, general practice in the UK has undergone major change. Starting with the introduction of the new GMS contract in 2004, it has continued apace with the establishment of Postgraduate Medical Education Training Board, a GP training curriculum, and nMRCGP. The NHS is developing very differently in the four countries of the UK. Regulation of the profession is under review, and a system of relicensing, recertification, and revalidation is being introduced. The Essence project, initiated by RCGP Scotland in conjunction with International Futures Forum 4 years ago is a constructive response to these changes. It has included learning journeys, a discussion day for GPs, and commissioned short pieces of 100 words from GPs and patients. From an analysis of these, some characteristics of the essence of general practice have been defined. These include key roles and core personal qualities for GPs. It is argued that general practice has important and unique advantages - trust, coordination, continuity, flexibility, universal coverage, and leadership - which mean that it should continue to be central to the development of primary care throughout the UK.
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May 2009

Effect of tobacco smoking on survival of men and women by social position: a 28 year cohort study.

BMJ 2009 Feb 17;338:b480. Epub 2009 Feb 17.

NHS Health Scotland, Elphinstone House, Glasgow G2 2AF.

Objective: To assess the impact of tobacco smoking on the survival of men and women in different social positions.

Design: A cohort observational study.

Setting: Renfrew and Paisley, two towns in west central Scotland.

Participants: 8353 women and 7049 men aged 45-64 years recruited in 1972-6 (almost 80% of the population in this age group). The cohort was divided into 24 groups by sex (male, female), smoking status (current, former, or never smokers), and social class (classes I + II, III non-manual, III manual, and IV + V) or deprivation category of place of residence.

Main Outcome Measure: Relative mortality (adjusted for age and other risk factors) in the different groups; Kaplan-Meier survival curves and survival rates at 28 years.

Results: Of those with complete data, 4387/7988 women and 4891/6967 men died over the 28 years. Compared with women in social classes I + II who had never smoked (the group with lowest mortality), the adjusted relative mortality of smoking groups ranged from 1.7 (95% confidence interval 1.3 to 2.3) to 4.2 (3.3 to 5.5). Former smokers' mortalities were closer to those of never smokers than those of smokers. By social class (highest first), age adjusted survival rates after 28 years were 65%, 57%, 53%, and 56% for female never smokers; 41%, 42%, 33%, and 35% for female current smokers; 53%, 47%, 38%, and 36% for male never smokers; and 24%, 24%, 19%, and 18% for male current smokers. Analysis by deprivation category gave similar results.

Conclusions: Among both women and men, never smokers had much better survival rates than smokers in all social positions. Smoking itself was a greater source of health inequality than social position and nullified women's survival advantage over men. This suggests the scope for reducing health inequalities related to social position in this and similar populations is limited unless many smokers in lower social positions stop smoking.
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February 2009

Alcohol consumption behaviours and social mobility in men and women of the Midspan Family study.

Alcohol Alcohol 2009 May-Jun;44(3):332-6. Epub 2009 Jan 23.

Public Health & Health Policy, Division of Community Based Sciences, Faculty of Medicine, University of Glasgow, Glasgow, UK.

Aims: The aim of this study was to investigate relationships between alcohol consumption and social mobility in a cohort study in Scotland.

Methods: 1040 sons and 1298 daughters aged 30-59 from 1477 families reported their alcohol consumption from which was derived: weekly units (1 UK unit being 8 g ethanol), exceeding daily or weekly limits, binge drinking and consuming alcohol on 5+ days per week. Own and father's social class were available enabling social mobility to be investigated.

Results: More downwardly mobile men exceeded the weekly limit, the daily limit, were defined as binge drinkers and drank the most units per week of the four social mobility groups. Stable non-manual women were more likely to consume alcohol on 5+ days a week but very few were binge drinkers. Stable non-manual and upwardly mobile men and women were more likely to drink wine, and downwardly mobile men to drink beer.

Conclusions: Downward mobility was associated with less favourable alcohol behaviours, especially in men. Wine consumption was more closely related to the social mobility groups than beer and spirits consumption. Drinking patterns could both influence and be influenced by social mobility.
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January 2010

Contribution of Midparental BMI and other determinants of obesity in adult offspring.

Obesity (Silver Spring) 2008 Jun 10;16(6):1388-93. Epub 2008 Apr 10.

General Practice and Primary Care, Division of Community Based Sciences, University of Glasgow, Glasgow, UK.

The aim of this study was to evaluate midparental BMI among intergenerational factors associated with obesity in adult offspring. The data was from an unusual two-generational observational design of 1,477 married couples from Renfrew and Paisley in Scotland who were aged 45-64 years when screened in 1972-1976, and 1,040 sons and 1,298 daughters aged 30-59 years when screened in 1996. BMI was categorized as normal (< 25 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (> or = 30 kg/m(2)) in offspring and parents. Midparental BMI was defined as the mean of the mother's and father's BMI. Low physical activity, nonsmoking status, higher cholesterol level, and manual social class were all associated with increased BMI in offspring. The effect of reported dietary intake was less clear. Offspring of obese parents (defined by midparental BMI) were over four times more likely to be obese than offspring of normal weight parents. Midparental BMI had a strong effect on offspring BMI, independent of social class, smoking habit, physical activity, and reported dietary intake. Adding midparental BMI to the regression model more than doubled the explained variation of offspring BMI from 7.7 to 17%. Every 1 kg/m(2) increment in midparental BMI was associated with a BMI greater by 0.51 kg/m(2) in offspring. We conclude that midparental BMI is a useful simple tool to predict offspring BMI. Whether it represents genetic or environmental family effects, it is easily ascertained by the individual and could be used in health promotion and clinical settings to target individuals who are at increased risk of becoming obese.
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June 2008

The impact of consent on observational research: a comparison of outcomes from consenters and non consenters to an observational study.

BMC Med Res Methodol 2008 Apr 3;8:15. Epub 2008 Apr 3.

General Practice and Primary Care, Division of Community Based Sciences, Faculty of Medicine, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK.

Background: Public health benefits from research often rely on the use of data from personal medical records. When neither patient consent nor anonymisation is possible, the case for accessing such records for research purposes depends on an assessment of the probabilities of public benefit and individual harm.

Methods: In the late 1990s, we carried out an observational study which compared the care given to affluent and deprived women with breast cancer. Patient consent was not required at that time for review of medical records, but was obtained later in the process prior to participation in the questionnaire study. We have re-analysed our original results to compare the whole sample with those who later provided consent.

Results: Two important findings emerged from the re-analysis of our data which if presented initially would have resulted in insufficient and inaccurate reporting. Firstly, the reduced dataset contains no information about women presenting with locally advanced or metastatic cancer and we would have been unable to demonstrate one of our initial key findings: namely a larger number of such women in the deprived group. Secondly, our re-analysis of the consented women shows that significantly more women from deprived areas (51 v 31%, p = 0.018) received radiotherapy compared to women from more affluent areas. Previously published data from the entire sample demonstrated no difference in radiotherapy treatment between the affluent and deprived groups.

Conclusion: The risk benefit assessment made regarding the use of medical records without consent should include the benefits of obtaining research evidence based on 100% of the population and the possibility of inappropriate or insufficient findings if research is confined to consented populations.
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April 2008

More time for complex consultations in a high-deprivation practice is associated with increased patient enablement.

Br J Gen Pract 2007 Dec;57(545):960-6

General Practice and Primary Care, Division of Community-Based Sciences, University of Glasgow,

Background: Evidence of the beneficial effects of longer consultations in general practice is limited.

Aim: To evaluate the effect of increasing consultation length on patient enablement in general practice in an area of extreme socioeconomic deprivation.

Design Of Study: Longitudinal study using a 'before and after' design.

Setting: Keppoch Medical Centre in Glasgow, which serves the most deprived practice area in Scotland.

Method: Participants were 300 adult patients at baseline, before the introduction of longer consultations, and 324 at follow-up, more than 1 year after the introduction of longer consultations. The intervention studied was more time in complex consultations. Patient satisfaction, perceptions of the GPs' empathy, GP stress, and patient enablement were collected by face-to-face interview. Additional qualitative data were obtained by individual interviews with the GPs, relating to their perceptions of the impact of the longer consultations.

Results: Response rates of 70% were obtained. Overall, 53% of consultations were complex. GP stress was higher in complex consultations. Patient satisfaction and perception of the GPs' empathy were consistently high. Average consultation length in complex consultations was increased by 2.5 minutes by the intervention. GP stress in consultations was decreased after the introduction of longer consultations, and patient enablement was increased. GPs' views endorsed these findings, with more anticipatory and coordinated care being possible in the longer consultations.

Conclusion: More resource to provide more time in complex consultations in an area of extreme deprivation is associated with an increase in patient enablement.
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December 2007

The inverse care law: clinical primary care encounters in deprived and affluent areas of Scotland.

Ann Fam Med 2007 Nov-Dec;5(6):503-10

General Practice and Primary Care, Division of Community-Based Sciences, University of Glasgow, Glasgow, Scotland.

Purpose: The inverse care law states that the availability of good medical care tends to vary inversely with the need for it in the population served, but there is little research on how the inverse care law actually operates.

Methods: A questionnaire study was carried out on 3,044 National Health Service (NHS) patients attending 26 general practitioners (GPs); 16 in poor areas (most deprived) and 10 in affluent areas (least deprived) in the west of Scotland. Data were collected on demographic and socioeconomic factors, health variables, and a range of factors relating to quality of care.

Results: Compared with patients in least deprived areas, patients in the most deprived areas had a greater number of psychological problems, more long-term illness, more multimorbidity, and more chronic health problems. Access to care generally took longer, and satisfaction with access was significantly lower in the most deprived areas. Patients in the most deprived areas had more problems to discuss (especially psychosocial), yet clinical encounter length was generally shorter. GP stress was higher and patient enablement was lower in encounters dealing with psychosocial problems in the most deprived areas. Variation in patient enablement between GPs was related to both GP empathy and severity of deprivation.

Conclusions: The increased burden of ill health and multimorbidity in poor communities results in high demands on clinical encounters in primary care. Poorer access, less time, higher GP stress, and lower patient enablement are some of the ways that the inverse care law continues to operate within the NHS and confounds attempts to narrow health inequalities.
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January 2008

Genetic epidemiology and primary care.

Br J Gen Pract 2006 Mar;56(524):214-21

Department of General Practice and Primary Care, University of Aberdeen, Aberdeen.

Large-scale, population-based studies of genetic epidemiology are under way or planned in several countries, including the UK. The results will have many implications for GPs and their patients. Primary care has much to contribute to this research, and basing genetic epidemiology studies in primary care will confer several advantages. These include enhanced public engagement, building on the personal relationships and trust that are at the core of primary care practice; methodological factors that will strengthen study design; and the potential of linkage of multiple datasets and between networks of research practices. Essential development work with primary care professionals and the public is, however, required for this to happen, and, if undertaken, this work will have the additional important benefit of increasing the uptake of new knowledge into general practice.
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March 2006