Unscheduled medical contacts in September 2013

The proportion of individuals with at least one unscheduled contact is summarised for each of the four populations (including the aforementioned primary analysis population) in Figure 5. Overall, 2399 individuals (45.2%) in the intervention arm had at least one unscheduled medical contact, compared with 2441 (43.7%) in the control arm [adjusted odds ratio (OR) 1.09, 95% CI 0.96 to 1.25]. The actual number of contacts was similar in the two groups, but there were 81 unscheduled contacts per 100 children in each arm [adjusted incidence rate ratio (IRR) 1.02, 95% CI 0.94 to 1.12]. Restricting the analyses to the PP population gave a similar (but slightly greater) increase in the effect sizes.

FIGURE 5

Unscheduled medical contacts in September 2013. (a) Number of children with one or more unscheduled contact; and (b) mean number of unscheduled contacts per child.

The ICC for the primary analysis was 2.6%, which was consistent with the ICC used for the sample size calculation.²⁹

Similar results were observed for 5- to 16-year-old children who had been prescribed preventative steroids. Among children aged under 5 years, the differences were larger, and of borderline statistical significance, with the intervention being associated with more unscheduled visits for all subgroups. In all cases the effect among the PP population was greater than that observed in the ITT population.

The percentage of children aged 5–16 years who required one or more unscheduled contact between August and December 2013 is given in Table 4. The most immediate feature is the excess unscheduled contacts in August 2013, which is out of keeping both with the following months and with the equivalent figures in the previous year. Overall, the proportion of children making an unscheduled contact was higher in 2012 than in 2013, but only August (and to a lesser extent, September) 2013 showed a pronounced difference between the groups.

TABLE 4

Percentage of children aged 5–16 years who had at least one unscheduled contact

To further investigate the effect observed in Table 4, the analysis of unscheduled contacts by month was repeated (Table 5), but only for children who received preventative medication. The effects are similar to those observed in Table 4.

TABLE 5

Percentage of children aged 5–16 years and using preventative medication who had at least one unscheduled contact

In both Tables 4 and 5, after the initial increase in unscheduled contacts associated with the intervention in August and September there is a fall. The fact that there seems to be a reduction in contacts after September will be discussed further in Chapter 3, Contacts in the extended post-intervention phase (September to December 2013) and in Health economic methods.

In Scheduled visits and steroid prescriptions in August 2013, in the analysis of prescription data it will be highlighted how the intervention caused an increase in the proportion of prescriptions being collected. A likely explanation for the possible increase in August and September in the letter group is patients who have not collected a prescription in a while needing to see their GP before a new prescription could be given. This could be caused by patients wishing to see their GP or by the GP requiring an appointment with the patient before a prescription is given. The excess observed in August/September would therefore be, for some patients, a level of planned care that would then be reflected in the subsequent reductions in following months. To investigate this we have the results in Table 6.

TABLE 6

Percentage of children aged 5–16 years and using preventative medication who had at least one unscheduled contact broken down by when they had their last prescription in the 12 months prior to the start of the study

The results in Table 6 are the same data as in Table 5 but broken down by when a patient last collected a prescription. There is little evidence of a difference in terms of the excess in unscheduled contacts in the letter arm in August. For children who last collected a prescription within the previous 3 months, 51.6% in the letter arm had an unscheduled contact in August, compared with 45.5% in the control arm, therefore 6.1% more children in the letter arm had a scheduled contact. For children who had collected a prescription within the previous 3–6 months, 38.5% in the letter arm had an unscheduled contact, compared with 34.5% in the control arm, which represents a 4.0% excess.

In September there does seem to be a difference in the proportion of children having an unscheduled contact according to when they last collected a prescription. If a prescription had been collected within 3 months, then in the letter arm 55.2% of children had an unscheduled contact in September, which is comparable to the 54.3% in the control arm. Conversely, if it was 3–6 months since the last prescription was collected, 42.1% of children had an unscheduled contact in the intervention arm, compared with just 39.7% in the control arm, which is an increase of 2.4%. Therefore, the effect in September seems to be greatest in children who had not collected a prescription recently.

One important thing to note is that when making the assessment of unscheduled contacts, we cannot determine whether the unscheduled contact is at the request of the patient or of the GP. This factor is important in the interpretation of the results in Tables 4–6.

Scheduled visits and steroid prescriptions in August 2013

An objective of the PLEASANT study was that the intervention would increase the proportion of children who had a prescription in August 2013, which would follow through to an increase in medication usage and, thereby, a reduction in unscheduled medical contacts. Although the latter was not evident from the data in Primary outcome, and adherence could not be assessed, the intervention (letter) was associated with an increased uptake of prescriptions in the month of August 2013. Among children aged 5–16 years, 876 (16.5%) requested at least one prescription, compared with 703 (12.6%) in the control group (adjusted OR 1.43, 95% CI 1.24 to 1.64); the total number of prescriptions was also higher (adjusted IRR 1.31, 95% CI 1.17 to 1.48). These findings are displayed graphically in Figure 6.

FIGURE 6

Uptake of steroid inhaler prescriptions, August 2013. (a) Number of children with one or more prescription; and (b) mean number of prescriptions.

Scheduled contacts made in August 2013 are displayed in Figure 7. The percentage of children with a scheduled medical contact was higher in the intervention group compared with the control group (see Figure 7a), but this was not statistically significant. The actual number of scheduled contacts were significantly increased in the intervention group (see Figure 7b).

FIGURE 7

Scheduled medical contacts in August 2013. (a) Number of children with one or more scheduled contact; and (b) mean number of scheduled contacts per child.

Unscheduled medical contacts associated with respiratory diagnosis in September 2013

Unscheduled respiratory-related medical contacts are important, as these are the most sensitive outcome for determining whether or not the intervention is preventing episodes of asthma exacerbation. In absolute terms, however, these contribute only a small fraction of the total attendances (Table 7). Among the primary ITT analysis population of children aged between 5–16 years, a total of 513 subjects experienced at least one unscheduled respiratory-related contact across all practices, with slightly higher uptake in the intervention group. In the intervention group, 279 (5.3%) required at least one unscheduled respiratory related contact compared with 234 (4.2%) in the control group (adjusted OR 1.30, 95% CI 1.03 to 1.66). The percentages for other subgroups are presented in Figure 8a, and the total number in Figure 8b.

TABLE 7

Breakdown of contact types for children aged 5–16 years (ITT population)

FIGURE 8

Unscheduled respiratory-related medical contacts in September 2013. (a) Number of children with one or more unscheduled respiratory-related contact; and (b) mean number of unscheduled respiratory-related contacts per child.

All medical contacts (scheduled and unscheduled) in September 2013

The total number of medical contacts (excluding those deemed irrelevant) is presented in Figure 9. In contrast to previous analyses, children in the intervention arm had fewer contacts, although, again, none of the comparisons was statistically significant. Among children aged 5–16 years, 57.8% of the intervention arm participants made one or more contact, compared with 58.4% of those in the control arm (adjusted OR 0.99, 95% CI 0.80 to 1.22). The total number of appointments per child was 1.05 in the intervention arm, compared with 1.10 in the control group (adjusted IRR 0.97, 95% CI 0.87 to 1.07). Similar findings were observed for children on preventative steroids. By contrast, an increase in contacts was observed among children under 5 years.

FIGURE 9

Total medical contacts in September 2013. (a) Number of children with one or more contacts; and (b) mean number of contacts per child.

Contacts in the extended post-intervention phase (September–December 2013)

Data on medical contacts in the extended study period (September–December 2013) were available for 65 of the original 70 intervention practices and 67 of the 71 control practices. The results are presented in Figures 10–12. In some subgroups, a statistically significant excess of contacts was observed in the intervention group, although it should be noted that this could be because of the multiple outcomes and hypotheses tested.

FIGURE 10

Unscheduled medical contacts in the period September–December 2013. (a) Number of children with one or more unscheduled contact; and (b) mean number of unscheduled contacts per child.

FIGURE 12

All medical contacts in September–December 2013. (a) Number of children with one or more contact; and (b) mean number of contacts per child.

The total number of unscheduled contacts is of particular relevance in the period September to December 2013. This includes the months (October to December) when the intervention arm seemed to reduce the number of contacts. It is this time interval that forms part of the health economic analysis, which analyses the total number of contacts rather than the percentage of children who required one.

The total number of contacts declined over the period from September to December. Although unscheduled respiratory-related contacts demonstrated a slight increase, the proportion of children aged 5–16 years requiring any medical contact remained higher in the intervention arm (although not statistically significant) for unscheduled contacts (see Figure 10a), unscheduled respiratory contacts (see Figure 11a) and all contacts (see Figure 12a). The overall number of contacts and the number of unscheduled was slightly reduced in the intervention arm (see Figures 10b and 12b) for children aged 5–16 years, but not those aged under 5 years, for whom the number of unscheduled respiratory contacts was also higher (see Figure 11b). However, these differences were, generally, not statistically significant.

FIGURE 11

Unscheduled medical contacts associated with a respiratory diagnosis in the period September–December 2013. (a) Number of children with one or more unscheduled respiratory-related contact; and (b) mean number of unscheduled respiratory-related (more...)

Contacts over 12 months (September 2013–August 2014)

Data on medical contacts in September 2013–August 2014 were available for 58 intervention practices and 54 control practices. The results are presented in Figures 13–15. The differences in percentages between the intervention and control groups were generally modest and not statistically significant on the ITT population, and differed according to the subgroups. For the primary population (the ITT among 5- to 16-year-olds), the number of unscheduled contacts was similar (see Figure 13) and respiratory contacts remained higher (see Figure 14), but overall, contacts were reduced (see Figure 15). The total number of contacts over the 12-month period was 11.5 per child in intervention group, compared with 12.1 in the control group, which equated to a 5% reduction overall (adjusted IRR 0.95, 95% CI 0.91 to 0.99). This analysis is particularly relevant to the economic analyses in the following section, which primarily considered the overall difference in resource costs between the groups and was largely based on this time period.

FIGURE 13

Unscheduled medical contacts from September 2013 to August 2014. (a) Number of children with one or more unscheduled contact; and (b) mean number of unscheduled contacts per child.

FIGURE 15

All medical contacts from September 2013 to August 2014. (a) Number of children with one or more contact; and (b) mean number of contacts per child.

FIGURE 14

Unscheduled medical contacts associated with a respiratory diagnosis from September 2013 to August 2014. (a) Number of children with one or more unscheduled respiratory contact; and (b) mean number of unscheduled respiratory contacts per child.

Echo substudy

The protocol was amended to include additional outcomes for the subsequent year. We refer to this as the ‘echo substudy’, the rationale of which was to assess whether or not any immediate intervention effect in 2013 was echoed the following year. A total of 110 practices (57 intervention and 53 control) contributed data to this time period.

In a survey of the practices in the intervention it was found that, of those that responded, 54% (13 out of 24 responding practices) had sent out the intervention again in 2014.²² This would also contribute to an echo effect

Steroid prescriptions and scheduled contacts in the echo substudy (August 2014)

Although the increase in prescriptions found in 2013 was not as marked in 2014, the under-fives subgroup (i.e. children who were now aged under 6 years) did demonstrate an increase overall in terms of prescription uptake. These findings are displayed graphically in Figure 16. Unexpectedly, the proportion of children making at least one scheduled contact was lower in the intervention arm (Figure 17a). However, this association disappeared when evaluating the total number of scheduled medical contacts (see Figure 17b).

FIGURE 16

Uptake of steroid inhaler prescriptions in August 2014. (a) Number of children with one or more prescriptions; and (b) mean number of prescriptions.

FIGURE 17

Scheduled contacts in August 2014. (a) Number of children with one or more contact; and (b) number of contacts per child.

Contacts in the echo substudy (September 2014)

The findings were similar to those of September 2013. Unscheduled contacts, unscheduled respiratory-related contacts and scheduled contacts were all marginally higher in the intervention group (Figures 18–20), although the size of the difference was more modest than that observed in the previous year.

FIGURE 18

Unscheduled medical contacts in September 2014. (a) Number of children with one or more unscheduled contact; and (b) mean number of unscheduled contacts per child.

FIGURE 20

All medical contacts in September 2014. (a) Number of children with one or more contact; and (b) mean number of contacts per child.

FIGURE 19

Unscheduled respiratory-related medical contacts in September 2014. (a) Number of children with one or more unscheduled contact; and (b) mean number of unscheduled contacts per child.

Time to first unscheduled contact

The time to first unscheduled and respiratory-related unscheduled contacts are presented in Figure 21 (September 2013) and Figure 22 (September–December 2013). Consistent with the number of contacts as previously demonstrated, the intervention group tended to make their first contact earlier than the control group. As the majority of contacts were unscheduled, the time to first contact of any type was similar to the time to first unscheduled contact.

FIGURE 21

Time to first contact in September 2013. (a) First unscheduled contact; and (b) first respiratory-related unscheduled contact.

FIGURE 22

Time to first contact in September–December 2013. (a) First unscheduled contact; and (b) first respiratory-related unscheduled contact.