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Title: Missed opportunities for the diagnosis of malaria in UK primary care : evidence from "The Health Improvement Network" electronic health record database
Author: Bastaki, Hamad
ISNI:       0000 0004 8500 5846
Awarding Body: UCL (University College London)
Current Institution: University College London (University of London)
Date of Award: 2019
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Background: Delays in malaria diagnosis are associated with increased morbidity and mortality. Low incidence and non-specificity of malaria symptoms make prompt diagnosis in primary care challenging. The aim of this thesis was to explore diagnostic delay, consultation patterns and healthcare provision in primary care prior to a malaria diagnosis in the UK. Methods: A systematic review quantified the duration of diagnostic delay in non-endemic countries. Three studies using prospectively collected UK primary care electronic health records (THIN; The Health Improvement Network) examined: 1.Incidence of imported malaria; 2. Temporal trends in antimalarial prescribing; 3.Extent of missed opportunities for malaria diagnosis in primary care using a self-controlled case-series approach. Findings: 69 studies reviewed showed median diagnosis delays of four or more days were common and patient delays accounted for a large proportion of diagnostic delay. However, the retrospective nature of included studies could have overestimated patient delay. Empirical THIN studies in this thesis supported this hypothesis. 1,474 individuals with a first diagnosis of malaria were identified in THIN (2005-2016). The incidence of recorded malaria decreased from 3.33 cases per 100,000 person-years-at-risk in 2005 to 1.36 in 2016. A third who consulted primary care prior to a malaria diagnosis presented with malaria symptoms where a diagnosis was not made. The median duration of delay from first presentation with fever to diagnosis was six days (IQR 2-17). Absence of fever at first presentation resulted in a median duration to diagnosis of nine days (IQR 5-18). Men and those most deprived were more likely to be diagnosed with malaria (Female:Male IRR: 0.72 95%CI: 0.65-0.80. Most-deprived:Least-deprived IRR: 1.86 95%CI 1.54-2.25) and least likely to receive a prescription for malaria prophylaxis. Conclusions: Findings highlight the extent of potential opportunities where an earlier diagnosis of malaria could be made in primary care. This has informed recommendations for clinical practice, public health policy and directions for future research.
Supervisor: Rait, G. ; Cassell, J. ; Marston, L. Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available