Incidence and mortality of relapsing polychondritis in the UK: a population-based cohort study

OBJECTIVE

Relapsing polychondritis is a rare disease characterized by cartilage inflammation. Our aim was to estimate the incidence, prevalence and mortality of relapsing polychondritis and describe the clinical features of relapsing polychondritis in a large population.

METHODS

All participants diagnosed with relapsing polychondritis were sampled from the Clinical Practice Research Datalink. Prevalence and incidence rates for 1990-2012 were estimated. Relative mortality rates were estimated in a time-to-event framework using reference UK life tables. A questionnaire validation study assessed diagnostic accuracy.

RESULTS

There were 117 participants with relapsing polychondritis ever recorded. Fifty (82%) of 61 cases were validated by a physician and unconfirmed cases were excluded. The analysis included 106 participants (42 men, 64 women) diagnosed with relapsing polychondritis. The mean age (range) at diagnosis in men was 55 (range 17-81) years and in women 51 (range 11-79) years. The median interval from first symptom to diagnosis was 1.9 years. The incidence of relapsing polychondritis between 1990 and 2012 was 0.71 (95% CI 0.55, 0.91) per million population per year. There were 19 deaths from any cause. There were 16 observed deaths eligible for survival analysis and 7.4 deaths expected for the UK population of the same age, sex and period. The standardized mortality ratio was 2.16 (95% CI 1.24, 3.51), P < 0.01. Respiratory disease, cardiac conditions and cancer were the most frequent causes of death.

CONCLUSION

The incidence of relapsing polychondritis may be lower than previously estimated, and diagnostic misclassification and delay are common. Mortality in relapsing polychondritis is more than twice that of the general population.

Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records

OBJECTIVES

We examined the probability of an obese person attaining normal body weight.

METHODS

We drew a sample of individuals aged 20 years and older from the United Kingdom's Clinical Practice Research Datalink from 2004 to 2014. We analyzed data for 76,704 obese men and 99,791 obese women. We excluded participants who received bariatric surgery. We estimated the probability of attaining normal weight or 5% reduction in body weight.

RESULTS

During a maximum of 9 years' follow-up, 1283 men and 2245 women attained normal body weight. In simple obesity (body mass index = 30.0-34.9 kg/m(2)), the annual probability of attaining normal weight was 1 in 210 for men and 1 in 124 for women, increasing to 1 in 1290 for men and 1 in 677 for women with morbid obesity (body mass index = 40.0-44.9 kg/m(2)). The annual probability of achieving a 5% weight reduction was 1 in 8 for men and 1 in 7 for women with morbid obesity.

CONCLUSIONS

The probability of attaining normal weight or maintaining weight loss is low. Obesity treatment frameworks grounded in community-based weight management programs may be ineffective.

Antidiabetic and cardiovascular drug utilisation in patients diagnosed with type 2 diabetes mellitus over the age of 80 years: a population-based cohort study

BACKGROUND

there is a lack of evidence to inform treatment recommendations for very old people with type 2 diabetes mellitus (T2DM).

OBJECTIVE

to evaluate trends in antidiabetic and cardiovascular drug utilisation for patients developing T2DM over 80 years of age.

METHODS

a population-based cohort was sampled from the UK Clinical Practice Research Datalink between 1990 and 2013. Eligible patients were those with T2DM diagnosed after the age of 80 years and prescribed antidiabetic drugs.

RESULTS

twelve thousand eight hundred and eighty-one patients, with 61% of females, were included. From 1990 to 2013, use of sulphonylureas declined from 94 to 29%, while metformin use increased from 22 to 86%. Prescribing of antihypertensive drugs increased substantially from 46 to 77%, lipid-lowering drugs from 1 to 64%, antiplatelets from 34 to 47% and oral anticoagulants from 5 to 19%. Women were more frequently prescribed antihypertensive drugs (odds ratio 1.26, 95% confidence interval 1.17 to 1.37) but less prescribed antiplatelets (0.83, 0.78 to 0.89). Compared with those diagnosed with T2DM from 80 to 89 years (n = 11,467, 89%), patients diagnosed after the age of 90 years (n = 1,414, 11%) were less likely to be prescribed insulin (0.37, 0.24 to 0.58), metformin (0.67, 0.60 to 0.75), antihypertensive drugs (0.42, 0.38 to 0.48), lipid-lowering drugs (0.26, 0.23 to 0.30) and anticoagulants (0.55, 0.44 to 0.68).

CONCLUSIONS

there have been major increases in the intensity of pharmacological management of patients diagnosed with T2DM over 80 years of age, but the effectiveness and safety of these interventions in very old people require further evaluation.

Differences in Health at Age 100 According to Sex: Population-Based Cohort Study of Centenarians Using Electronic Health Records

OBJECTIVES

To use primary care electronic health records (EHRs) to evaluate the health of men and women at age 100.

DESIGN

Population-based cohort study.

SETTING

Primary care database in the United Kingdom, 1990-2013.

PARTICIPANTS

Individuals reaching the age of 100 between 1990 and 2013 (N = 11,084, n = 8,982 women, n = 2,102 men).

MEASUREMENTS

Main categories of morbidity and an index of multiple morbidities, geriatric syndromes and an index of multiple impairments, cardiovascular risk factors.

RESULTS

The number of new female centenarians per year increased from 16 per 100,000 in 1990-94 to 25 per 100,000 in 2010-13 (P < .001) and of male centenarians from four per 100,000 to six per 100,000 (P = .06). The most prevalent morbidities at the age of 100 were musculoskeletal diseases, disorders of the senses, and digestive diseases. Women had greater multiple morbidity than men (odds ratio (OR) = 1.64, 95% confidence interval (CI) = 1.42-1.89, P < .001). Geriatric syndromes, including falls, fractures, hearing and vision impairment, and dementia, were frequent; 30% of women and 49% of men had no recorded geriatric syndromes. Women had greater likelihood of having multiple geriatric syndromes (OR = 2.14, 95% CI = 1.90-2.41, P < .001).

CONCLUSION

Fewer men than women reach the age of 100, but male centenarians have lower morbidity and fewer geriatric syndromes than women. Research using EHRs offers opportunities to understand the epidemiology of aging and improve care of the oldest old.

Childhood obesity trends from primary care electronic health records in England between 1994 and 2013: population-based cohort study

OBJECTIVE

This study aimed to use primary care electronic health records to evaluate the prevalence of overweight and obesity in 2-15-year-old children in England and compare trends over the last two decades.

DESIGN

Cohort study of primary care electronic health records.

SETTING

375 general practices in England that contribute to the UK Clinical Practice Research Datalink.

PATIENTS

Individual participants were sampled if they were aged between 2 and 15 years during the period 1994-2013 and had one or more records of body mass index (BMI).

MAIN OUTCOME MEASURE

Prevalence of overweight (including obesity) was defined as a BMI equal to or greater than the 85th centile of the 1990 UK reference population.

RESULTS

Data were analysed for 370 544 children with 507 483 BMI records. From 1994 to 2003, the odds of overweight and obesity increased by 8.1% per year (95% CI 7.2% to 8.9%) compared with 0.4% (-0.2% to 1.1%) from 2004 to 2013. Trends were similar for boys and girls, but differed by age groups, with prevalence stabilising in 2004 to 2013 in the younger (2-10 year) but not older (11-15 year) age group, where rates continued to increase.

CONCLUSIONS

Primary care electronic health records in England may provide a valuable resource for monitoring obesity trends. More than a third of UK children are overweight or obese, but the prevalence of overweight and obesity may have stabilised between 2004 and 2013.

Access to weight reduction interventions for overweight and obese patients in UK primary care: population-based cohort study

OBJECTIVES

To investigate access to weight management interventions for overweight and obese patients in primary care.

SETTING

UK primary care electronic health records.

PARTICIPANTS

A cohort of 91 413 overweight and obese patients aged 30-100 years was sampled from the Clinical Practice Research Datalink (CPRD). Patients with body mass index (BMI) values ≥25 kg/m(2) recorded between 2005 and 2012 were included. BMI values were categorised using WHO criteria.

INTERVENTIONS

Interventions for body weight management, including advice, referrals and prescription of antiobesity drugs, were evaluated.

PRIMARY AND SECONDARY OUTCOME MEASURES

The rate of body weight management interventions and time to intervention were the main outcomes.

RESULTS

Data were analysed for 91 413 patients, mean age 56 years, including 55 094 (60%) overweight and 36 319 (40%) obese, including 4099 (5%) with morbid obesity. During the study period, 90% of overweight patients had no weight management intervention recorded. Intervention was more frequent among obese patients, but 59% of patients with morbid obesity had no intervention recorded. Rates of intervention increased with BMI category. In morbid obesity, rates of intervention per 1000 patient years were: advice, 60.2 (95% CI 51.8 to 70.4); referral, 75.7 (95% CI 69.5 to 82.6) and antiobesity drugs 89.9 (95% CI 85.0 to 95.2). Weight management interventions were more often accessed by women, older patients, those with comorbidity and those in deprivation. Follow-up of body weight subsequent to interventions was infrequent.

CONCLUSIONS

Limited evidence of weight management interventions in primary care electronic health records may result from poor recording of advice given, but may indicate a lack of patient access to appropriate body weight management interventions in primary care.

Incidence of type 2 diabetes after bariatric surgery: population-based matched cohort study

BACKGROUND

The effect of currently used bariatric surgical procedures on the development of diabetes in obese people is not well defined. We aimed to assess the effect of bariatric surgery on development of type 2 diabetes in a large population of obese individuals.

METHODS

We did a matched cohort study of adults (age 20–100 years) identified from a UK-wide database of family practices, who were obese (BMI ≥30 kg/m2) and did not have diabetes. We enrolled 2167 patients who had undergone bariatric surgery between Jan 1, 2002, and April 30, 2014, and matched them--according to BMI, age, sex, index year, and HbA1c--with 2167 controls who had not had surgery. Procedures included laparoscopic gastric banding (n=1053), gastric bypass (795), and sleeve gastrectomy (317), with two procedures undefined. The primary outcome was development of clinical diabetes, which we extracted from electronic health records. Analyses were adjusted for matching variables, comorbidity, cardiovascular risk factors, and use of antihypertensive and lipid-lowering drugs.

FINDINGS

During a maximum of 7 years of follow-up (median 2·8 years [IQR 1·3–4·5]), 38 new diagnoses of diabetes were made in bariatric surgery patients and 177 were made in controls. By the end of 7 years of follow-up, 4·3% (95% CI 2·9–6·5) of bariatric surgery patients and 16·2% (13·3–19·6) of matched controls had developed diabetes. The incidence of diabetes diagnosis was 28·2 (95% CI 24·4–32·7) per 1000 person-years in controls and 5·7 (4·2–7·8) per 1000 person-years in bariatric surgery patients; the adjusted hazard ratio was 0·20 (95% CI 0·13–0·30, p<0·0001). This estimate was robust after varying the comparison group in sensitivity analyses, excluding gestational diabetes, or allowing for competing mortality risk.

INTERPRETATION

Bariatric surgery is associated with reduced incidence of clinical diabetes in obese participants without diabetes at baseline for up to 7 years after the procedure.

FUNDING

UK National Institute for Health Research.

Effectiveness of behavioural weight loss interventions delivered in a primary care setting: a systematic review and meta-analysis

BACKGROUND

Overweight and obesity have negative health effects. Primary care clinicians are best placed to intervene in weight management. Previous reviews of weight loss interventions have included studies from specialist settings. The aim of this review was to estimate the effect of behavioural interventions delivered in primary care on body weight in overweight and obese adults.

METHODS

The review included randomized controlled trials (RCTs) of behavioural interventions in obese or overweight adult participants in a primary care setting, with weight loss as the primary outcome, and a minimum of 12 months of follow-up. A systematic search strategy was implemented in Medline, Embase, Web of Science and the Cochrane Central Registry of Controlled Trials. Risk of bias was assessed using the Cochrane Risk of Bias tool and behavioural science components of interventions were evaluated. Data relating to weight loss in kilograms were extracted, and the results combined using meta-analysis.

RESULTS

Fifteen RCTs, with 4539 participants randomized, were selected for inclusion. The studies were heterogeneous with respect to inclusion criteria and type of intervention. Few studies reported interventions informed by behavioural science theory. Pooled results from meta-analysis indicated a mean weight loss of -1.36 kg (-2.10 to -0.63, P < 0.0001) at 12 months, and -1.23 kg (-2.28 to -0.18, P = 0.002) at 24 months.

CONCLUSION

Behavioural weight loss interventions in primary care yield very small reductions in body weight, which are unlikely to be clinically significant. More effective management strategies are needed for the treatment of overweight and obesity.

Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices

OBJECTIVES

Overutilisation of antibiotics may contribute to the emergence of antimicrobial drug resistance, a growing international concern. This study aimed to analyse the performance of UK general practices with respect to antibiotic prescribing for respiratory tract infections (RTIs) among young and middle-aged adults.

SETTING

Data are reported for 568 UK general practices contributing to the Clinical Practice Research Datalink.

PARTICIPANTS

Participants were adults aged 18-59 years. Consultations were identified for acute upper RTIs including colds, cough, otitis-media, rhino-sinusitis and sore throat.

PRIMARY AND SECONDARY OUTCOME MEASURES

For each consultation, we identified whether an antibiotic was prescribed. The proportion of RTI consultations with antibiotics prescribed was estimated.

RESULTS

There were 568 general practices analysed. The median general practice prescribed antibiotics at 54% of RTI consultations. At the highest prescribing 10% of practices, antibiotics were prescribed at 69% of RTI consultations. At the lowest prescribing 10% of practices, antibiotics were prescribed at 39% RTI consultations. The median practice prescribed antibiotics at 38% of consultations for 'colds and upper RTIs', 48% for 'cough and bronchitis', 60% for 'sore throat', 60% for 'otitis-media' and 91% for 'rhino-sinusitis'. The highest prescribing 10% of practices issued antibiotic prescriptions at 72% of consultations for 'colds', 67% for 'cough', 78% for 'sore throat', 90% for 'otitis-media' and 100% for 'rhino-sinusitis'.

CONCLUSIONS

Most UK general practices prescribe antibiotics to young and middle-aged adults with respiratory infections at rates that are considerably in excess of what is clinically justified. This will fuel antibiotic resistance.

Estimating the yield of NHS Health Checks in England: a population-based cohort study

BACKGROUND

This study aimed to evaluate the yield of the NHS Health Checks programme.

METHODS

A cohort study, conducted in the Clinical Practice Research Datalink in England. Electronic health records were analysed for patients aged 40-74 receiving an NHS Health Check between 2010 and 2013.

RESULTS

There were 65 324 men and 75 032 women receiving a health check. For every 1000 men assessed, there were 205 smokers (95% confidence interval 195-215), 355 (340-369) with hypertension (≥140/90 mmHg) and 633 (607-658) with elevated cholesterol (≥5 mmol/l). Among 1000 women, there were 161 (151-171) smokers, 247 (238-257) with hypertension and 668 (646-689) with elevated cholesterol. In the 12 months following the check, statins were prescribed to 18% of men and 21% of women with ≥20% cardiovascular risk and antihypertensive drugs to 11% of men and 16% of women with ≥20% cardiovascular risk. Slight reductions in risk factor values were observed in the minority of participants with follow-up values recorded in the 15 months following the check.

CONCLUSIONS

A universal primary prevention programme identifies substantial risk factor burden in a population without known cardiovascular disease. Research is needed to monitor interventions, and intermediate- and long-term outcomes, in those identified at high risk.

Enhanced invitation methods to increase uptake of NHS health checks: study protocol for a randomized controlled trial

BACKGROUND

NHS Health Checks is a new program for primary prevention of heart disease, stroke, diabetes, chronic kidney disease, and vascular dementia in adults aged 40 to 74 years in England. Individuals without existing cardiovascular disease or diabetes are invited for a Health Check every 5 years. Uptake among those invited is lower than anticipated.

METHOD

The project is a three-arm randomized controlled trial to test the hypothesis that enhanced invitation methods, using the Question-Behaviour Effect (QBE), will increase uptake of NHS Health Checks compared with a standard invitation. Participants comprise individuals eligible for an NHS Health Check registered in two London boroughs. Participants are randomized into one of three arms. Group A receives the standard NHS Health Check invitation letter, information sheet, and reminder letter at 12 weeks for nonattenders. Group B receives a QBE questionnaire 1 week before receiving the standard invitation, information sheet, and reminder letter where appropriate. Group C is the same as Group B, but participants are offered a £5 retail voucher if they return the questionnaire. Participants are randomized in equal proportions, stratified by general practice. The primary outcome is uptake of NHS Health Checks 6 months after invitation from electronic health records. We will estimate the incremental health service cost per additional completed Health Check for trial groups B and C versus trial arm A, as well as evaluating the impact of the QBE questionnaire, and questionnaire plus voucher, on the socioeconomic inequality in uptake of Health Checks.The trial includes a nested comparison of two methods for implementing allocation, one implemented manually at general practices and the other implemented automatically through the information systems used to generate invitations for the Health Check.

DISCUSSION

The research will provide evidence on whether asking individuals to complete a preliminary questionnaire, by using the QBE, is effective in increasing uptake of Health Checks and whether an incentive alters questionnaire return rates as well as uptake of Health Checks. The trial interventions can be readily translated into routine service delivery if they are shown to be cost-effective.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN42856343. Date registered: 21.03.2013.

Electronic health records for intervention research: a cluster randomized trial to reduce antibiotic prescribing in primary care (eCRT study)

PURPOSE

This study aimed to implement a point-of-care cluster randomized trial using electronic health records. We evaluated the effectiveness of electronically delivered decision support tools at reducing antibiotic prescribing for respiratory tract infections in primary care.

METHODS

Family practices from England and Scotland participating in the Clinical Practice Research Datalink (CPRD) were included in the trial; 53 family practices were allocated to intervention and 51 practices were allocated to usual care. Patients aged 18 to 59 years consulting for respiratory tract infections were eligible. The intervention was through remotely installed, computer-delivered decision support tools accessed during the consultations. Control practices provided usual care. The primary outcome was the proportion of consultations for respiratory tract infections with an antibiotic prescribed based on electronic health records. Family practice-specific proportions were included in a cluster-level analysis.

RESULTS

Data were analyzed for 603,409 patients: 317,717 at intervention practices and 285,692 at control practices. Use of the intervention was less than anticipated, varying among practices. There was a reduction in proportion of consultations with antibiotics prescribed of 1.85% (95% CI, 0.10%-3.59%, P=.038) and in the rate of antibiotic prescribing for respiratory tract infections (9.69%; 95% CI, 0.75%-18.63%, fewer prescriptions per 1,000 patient-years, P=.034). There were no adverse events.

CONCLUSIONS

Cluster randomized trials may be implemented efficiently in large samples from routine care settings by using primary care electronic health records. Future studies should develop and test multicomponent methods for remotely delivered intervention.

Chronic inflammatory disorders and risk of type 2 diabetes mellitus, coronary heart disease, and stroke: a population-based cohort study

BACKGROUND

This study sought to evaluate whether risks of diabetes mellitus and cardiovascular disease are elevated across a range of organ-specific and multisystem chronic inflammatory disorders.

METHODS AND RESULTS

A matched cohort study was implemented in the UK Clinical Practice Research Datalink including participants with severe psoriasis (5648), mild psoriasis (85 232), bullous skin diseases (4284), ulcerative colitis (12 203), Crohn's disease (7628), inflammatory arthritis (27 358), systemic autoimmune disorders (7472), and systemic vasculitis (6283) and in 373 851 matched controls. The main outcome measures were new diagnoses of type 2 diabetes mellitus, stroke, or coronary heart disease. The outcomes were evaluated for each condition in a multiple outcomes model, with adjustment for conventional cardiovascular risk factors. Estimates for different inflammatory conditions were pooled in a random-effects meta-analysis. There were 4695 new diagnoses of type 2 diabetes mellitus, 3266 of coronary heart disease, and 1715 of stroke. The hazard ratio for pooled multiple failure estimate was 1.20 (95% confidence interval [CI], 1.15-1.26). The highest relative hazards were observed in systemic autoimmune disorders (1.32; 95% CI, 1.16-1.50) and systemic vasculitis (1.29; 95% CI, 1.16-1.44). Hazards were increased in organ-specific disorders, including severe psoriasis (1.29; 95% CI, 1.12-1.47) and ulcerative colitis (1.26; 95% CI, 1.14-1.40). Participants in the highest tertile of C-reactive protein had greater risk of multiple outcomes (1.52; 95% CI, 1.37-1.68).

CONCLUSIONS

The risk of cardiovascular diseases and type 2 diabetes mellitus is increased across a range of organ-specific and multisystem chronic inflammatory disorders with evidence that risk is associated with severity of inflammation. Clinical management of patients with chronic inflammatory disorders should seek to reduce cardiovascular risk.

Cluster randomized trials utilizing primary care electronic health records: methodological issues in design, conduct, and analysis (eCRT Study)

Background

There is growing interest in conducting clinical and cluster randomized trials through electronic health records. This paper reports on the methodological issues identified during the implementation of two cluster randomized trials using the electronic health records of the Clinical Practice Research Datalink (CPRD).

Methods

Two trials were completed in primary care: one aimed to reduce inappropriate antibiotic prescribing for acute respiratory infection; the other aimed to increase physician adherence with secondary prevention interventions after first stroke. The paper draws on documentary records and trial datasets to report on the methodological experience with respect to research ethics and research governance approval, general practice recruitment and allocation, sample size calculation and power, intervention implementation, and trial analysis.

Results

We obtained research governance approvals from more than 150 primary care organizations in England, Wales, and Scotland. There were 104 CPRD general practices recruited to the antibiotic trial and 106 to the stroke trial, with the target number of practices being recruited within six months. Interventions were installed into practice information systems remotely over the internet. The mean number of participants per practice was 5,588 in the antibiotic trial and 110 in the stroke trial, with the coefficient of variation of practice sizes being 0.53 and 0.56 respectively. Outcome measures showed substantial correlations between the 12 months before, and after intervention, with coefficients ranging from 0.42 for diastolic blood pressure to 0.91 for proportion of consultations with antibiotics prescribed, defining practice and participant eligibility for analysis requires careful consideration.

Conclusions

Cluster randomized trials may be performed efficiently in large samples from UK general practices using the electronic health records of a primary care database. The geographical dispersal of trial sites presents a difficulty for research governance approval and intervention implementation. Pretrial data analyses should inform trial design and analysis plans.

Trial registration

Current Controlled Trials ISRCTN 47558792 and ISRCTN 35701810 (both registered on 17 March 2010).

Point-of-care cluster randomized trial in stroke secondary prevention using electronic health records

BACKGROUND AND PURPOSE

The aim of this study was to evaluate whether the remote introduction of electronic decision support tools into family practices improves risk factor control after first stroke. This study also aimed to develop methods to implement cluster randomized trials in stroke using electronic health records.

METHODS

Family practices were recruited from the UK Clinical Practice Research Datalink and allocated to intervention and control trial arms by minimization. Remotely installed, electronic decision support tools promoted intensified secondary prevention for 12 months with last measure of systolic blood pressure as the primary outcome. Outcome data from electronic health records were analyzed using marginal models.

RESULTS

There were 106 Clinical Practice Research Datalink family practices allocated (intervention, 53; control, 53), with 11 391 (control, 5516; intervention, 5875) participants with acute stroke ever diagnosed. Participants at trial practices had similar characteristics as 47,887 patients with stroke at nontrial practices. During the intervention period, blood pressure values were recorded in the electronic health records for 90% and cholesterol values for 84% of participants. After intervention, the latest mean systolic blood pressure was 131.7 (SD, 16.8) mm Hg in the control trial arm and 131.4 (16.7) mm Hg in the intervention trial arm, and adjusted mean difference was -0.56 mm Hg (95% confidence interval, -1.38 to 0.26; P=0.183). The financial cost of the trial was approximately US $22 per participant, or US $2400 per family practice allocated.

CONCLUSIONS

Large pragmatic intervention studies may be implemented at low cost by using electronic health records. The intervention used in this trial was not found to be effective, and further research is needed to develop more effective intervention strategies.

CLINICAL TRIAL REGISTRATION URL

http://www.controlled-trials.com. Current Controlled Trials identifier: ISRCTN35701810.

Influences on individuals' decisions to take up the offer of a health check: a qualitative study

BACKGROUND

Health checks are promoted to evaluate individuals' risk of developing disease and to initiate health promotion and disease prevention interventions. The NHS Health Check is a cardiovascular risk assessment programme introduced in the UK aimed at preventing cardiovascular disease (CVD). Uptake of health checks is lower than anticipated. This study aimed to explore influences on people's decisions to take up the offer of a health check.

METHODS

Semi-structured interviews were conducted with people registered at four general practices in South London. The interview schedule was informed by the Theoretical Domains Framework. Data were analysed qualitatively using the Framework method using NVivo for data management.

RESULTS

Twenty-seven participants invited for a health check were included in the study. Seventeen received the health check while 10 either did not attend or failed to complete the check. Five themes emerging from the data included a lack of awareness of the health check programme, beliefs about susceptibility to CVD, beliefs about civic responsibility, issues concerning access to appointments, and beliefs about the consequences of having a check.

CONCLUSIONS

Health check programmes need to raise public awareness to ensure that people are informed about the objectives and nature of the programme in order to reach an informed decision about taking up the invitation. Emphasizing the benefits of prevention and early detection might encourage attendance in those who are reluctant to burden the public health-care systems. Extending outreach initiatives and increasing 'out of hours' provision at local community sites could facilitate access.

Is sodium valproate, an HDAC inhibitor, associated with reduced risk of stroke and myocardial infarction? A nested case-control study

Background

This study aimed to evaluate whether treatment with sodium valproate (SV) was associated with reduced risk of stroke or myocardial infarction (MI).

Methods

Electronic health records data were extracted from Clinical Practice Research Database for participants ever diagnosed with epilepsy and prescribed antiepileptic drugs. A nested case–control study was implemented with cases diagnosed with incident non-haemorrhagic stroke and controls matched for sex, year of birth, and study start date (ratio of 1:6). A second nested study was implemented with MI as outcome. The main exposure variable was SV therapy assessed as: ever prescribed, pre-stroke year treatment, number of SV prescriptions, and cumulative time on SV drug therapy. Odds ratios were estimated using conditional logistic regression.

Results

Data were analysed for 2002 stroke cases and 13 098 controls. MI analyses included 1153 cases and 7109 controls. Pre-year stroke SV treatment (28%) was associated with increased stroke risk (odds ratio 1.22, 95% confidence interval (CI): 1.09 to 1.38, p < 0.001). No association was observed between ever being prescribed SV with ischemic stroke (OR = 1.01, 95% CI: 0.91 to 1.12, p = 0.875). A significant association was observed between ever being prescribed SV with MI (OR = 0.78, 95% CI: 0.67 to 0.90, p < 0.001). Patients in the highest quarter of SV treatment duration had lower odds of ischemic stroke (OR = 0.57, 95% CI: 0.44 to 0.72, p < 0.001) and MI (OR = 0.29, 95% CI: 0.20 to 0.44, p < 0.001).

Conclusion

Sodium valproate exposure was associated with the risk of MI, but not ischemic stroke. However, longer exposure to SV was associated with lower odds of stroke, but this might be explained by survivor bias.

Impact and cost-effectiveness of a universal strategy to promote physical activity in primary care: population-based cohort study and Markov model

BACKGROUND

This study aimed to estimate the cost-effectiveness of a universal strategy to promote physical activity in primary care.

METHODS

Data were analysed for a cohort of participants from the general practice research database. Empirical estimates informed a Markov model that included five long-term conditions (diabetes, coronary heart disease, stroke, colorectal cancer and depression). Simulations compared an intervention promoting physical activity in healthy adults with standard care. The intervention effect on physical activity was from a meta-analysis of randomised trials. The annual cost of intervention, in the base case, was one family practice consultation per participant year. The primary outcome was net health benefit in quality adjusted life years (QALYs).

RESULTS

A cohort of 262,704 healthy participants entered the model. Intervention was associated with an increase in life years lived free from physical disease. With 5 years intervention the increase was 52 (95 % interval -11 to 115) per 1,000 participants entering the model (probability increased 91.9 %); with 10 years intervention the increase was 102 (42-164) per 1,000 (probability 99.7 %). Net health benefits at a threshold of £30,000 per QALY were 3.2 (-11.1 to 16.9) QALYs per 1,000 participants with 5 years intervention (probability cost-effective 64.7 %) and 5.0 (-9.5 to 19.3) with 10 years intervention (probability cost-effective 72.4 %).

CONCLUSIONS

A universal strategy to promote physical activity in primary care has the potential to increase life years lived free from physical disease. There is only weak evidence that a universal intervention strategy might prove cost-effective.

Cost-effectiveness of a universal strategy of brief dietary intervention for primary prevention in primary care: population-based cohort study and Markov model

BACKGROUND

A healthy diet is associated with reduced risk of diabetes, cardiovascular disease and cancer. The study aimed to evaluate the cost-effectiveness of a universal strategy to promote healthy diet through brief intervention in primary care.

METHODS

The research was informed by a systematic review of randomised trials which found that brief interventions in primary care may be associated with a 0.5 portion per day increase in fruit and vegetable consumption. A Markov model that included five long-term conditions (diabetes, coronary heart disease, stroke, colorectal cancer and depression) was developed. Empirical data from a large cohort of United Kingdom-based participants sampled from the Clinical Practice Research Datalink populated the model. Simulations compared an intervention promoting healthy diet over 5 years in healthy adults, and standard care in which there was no intervention. The annual cost of intervention, in the base case, was one family practice consultation per participant year. Health service costs were included and the model adopted a lifetime perspective. The primary outcome was net health benefit in quality adjusted life years (QALYs).

RESULTS

A cohort of 262,704 healthy participants entered the model. Intervention was associated with an increase in life years lived free from physical disease of 41.9 (95% confidence interval -17.4 to 101.0) per 1,000 participants entering the model (probability of increase 88.0%). New incidences of disease states were reduced by 28.4 (18.7 to 75.8) per 1,000, probability reduced 84.6%. Discounted incremental QALYs were 4.3 (-8.8 to 18.0) per 1,000, while incremental costs were £139,755 (£60,466 to 220,059) per 1,000. Net health benefits at £30,000 per QALY were -0.32 (-13.8 to 13.5) QALYs per 1,000 participants (probability cost-effective 47.9%). When the intervention was restricted to adults aged 50 to 74 years, net health benefits were 2.94 (-21.3 to 26.4) QALYs per 1000, probability increased 59.0%.

CONCLUSIONS

A universal strategy to promote healthy diet through brief intervention in primary care is unlikely to be cost-effective, even when delivered at low unit cost. A targeted strategy aimed at older individuals at higher risk of disease might be more cost-effective. More effective dietary change interventions are needed.

Impact of body mass index on prevalence of multimorbidity in primary care: cohort study

BACKGROUND

Multimorbidity is the co-occurrence of long-term conditions. Obesity is associated with an increased risk of long-term conditions including type 2 diabetes and depression.

OBJECTIVE

To quantify the association between body mass index (BMI) category and multimorbidity in a large cohort registered in primary care.

METHODS

The sample comprised primary care electronic health records of adults aged ≥30 years, sampled from the Clinical Practice Research Datalink between 2005 and 2011. Multimorbidity was defined as the co-occurrence of ≥2 of 11 conditions affecting seven organ systems. Age- and sex-standardized prevalence of multimorbidity was estimated by BMI category. Adjusted odds ratios associating BMI with additional morbidity were estimated adjusting for socioeconomic deprivation and smoking.

RESULTS

The sample comprised 300 006 adults. After excluding participants with BMI never recorded, data were analysed for 223 089 (74%) contributing 1 374 109 person-years. In normal weight men, the standardized prevalence of multimorbidity was 23%, rising to 27% in overweight, 33% in category I obesity, 38% in category II and 44% in category III obesity. In women, the corresponding values were 28%, 34%, 41%, 45% and 51%. In category III obesity, the adjusted odds, relative to normal BMI, were 2.24 (2.13-2.36) for a first condition; 2.63 (2.51-2.76) for a second condition and 3.09 (2.92-3.28) for three or more conditions. In a cross-sectional analysis, 32% of multimorbidity was attributable to overweight and obesity.

CONCLUSIONS

Multiple morbidity is highly associated with increasing BMI category and obesity, highlighting the potential for targeted primary and secondary prevention interventions in primary care.

Effectiveness of interventions to promote healthy diet in primary care: systematic review and meta-analysis of randomised controlled trials

BACKGROUND

A diet rich in fruit, vegetables and dietary fibre and low in fat is associated with reduced risk of chronic disease. This review aimed to estimate the effectiveness of interventions to promote healthy diet for primary prevention among participants attending primary care.

METHODS

A systematic review of trials using individual or cluster randomisation of interventions delivered in primary care to promote dietary change over 12 months in healthy participants free from chronic disease or defined high risk states. Outcomes were change in fruit and vegetable intake, consumption of total fat and fibre and changes in serum cholesterol concentration.

RESULTS

Ten studies were included with 12,414 participants. The design and delivery of interventions were diverse with respect to grounding in behavioural theory and intervention intensity. A meta-analysis of three studies showed an increase in fruit consumption of 0.25 (0.01 to 0.49) servings per day, with an increase in vegetable consumption of 0.25 (0.06 to 0.44) serving per day. A further three studies that reported on fruit and vegetable consumption together showed a pooled increment of 0.50 (0.13 to 0.87) servings per day. The pooled effect on consumption of dietary fibre, from four studies, was estimated to be 1.97 (0.43 to 3.52) gm fibre per day. Data from five studies showed a mean decrease in total fat intake of 5.2% of total energy (1.5 to 8.8%). Data from three studies showed a mean decrease in serum cholesterol of 0.10 (-0.19 to 0.00) mmol/L.

CONCLUSION

Presently-reported interventions to promote healthy diet for primary prevention in primary care, which illustrate a diverse range of intervention methods, may yield small beneficial changes in consumption of fruit, vegetables, fibre and fat over 12 months. The present results do not exclude the possibility that more effective intervention strategies might be developed.

Leisure-time physical activity over the life course and cognitive functioning in late mid-adult years: a cohort-based investigation

BACKGROUND

The objective of the present study was to estimate the association between different leisure-time physical activity (LTPA) parameters from 11 to 50 years and cognitive functioning in late mid-adulthood.

METHOD

The study used a prospective birth cohort study including participants in the UK National Child Development Study (NCDS) from age 11 to 50 years. Standardized z scores for cognitive, memory and executive functioning at age 50 represented the primary outcome measures. Exposures included self-reported LTPA at ages 11, 16, 33, 42, 46 and 50 years. Analyses were adjusted for important confounders including educational attainment and long-standing illness.

RESULTS

The adjusted difference in cognition score between women who reported LTPA for at least 4 days/week in five surveys or more and those who never reported LTPA for at least 4 days/week was 0.28 [95% confidence interval (CI) 0.20-0.35], 0.10 (95% CI 0.01-0.19) for memory score and 0.30 (95% CI 0.23-0.38) for executive functioning score. For men, the equivalent differences were: cognition 0.12 (95% CI 0.05-0.18), memory 0.06 (95% CI -0.02 to 0.14) and executive functioning 0.16 (95% CI 0.10-0.23).

CONCLUSIONS

This study provides novel evidence about the lifelong association between LTPA and memory and executive functioning in mid-adult years. Participation in low-frequency and low-intensity LTPA was positively associated with cognitive functioning in late mid-adult years for men and women. The greatest benefit emerged from participating in lifelong intensive LTPA.

Does the influence of stroke on dementia vary by different levels of prestroke cognitive functioning?: a cohort study

BACKGROUND AND PURPOSE

The association between stroke and subsequent dementia or Alzheimer disease is well established. What is less understood is the extent to which this association is dependent on prestroke cognitive functioning. The study estimated the occurrence in poststroke dementia as a function of prestroke cognitive status and incident stroke.

METHODS

Study data were derived from the English Longitudinal Study of Ageing, a 10-year long prospective cohort study of older adults living in England. Baseline data (2002/2003) were used to group participants into tertiles of cognitive, memory, and executive functioning before an incident stroke. Data from 4 follow-up surveys were used to identify new stroke and poststroke dementia events.

RESULTS

The analyses were based on 10 809 participants aged≥50 years at baseline. High prestroke executive functioning was associated with lower relative risk (RR) of dementia (RR, 0.24; 95% confidence interval, 0.13-0.45; P<0.001). Stroke was associated with increased RR of poststroke dementia (RR, 2.63; 95% confidence interval, 1.80-3.84; P<0.001). The association of stroke with poststroke dementia was greater for participants with higher prestroke executive functioning (interaction term RR, 4.4; 95% confidence interval, 1.35-14.63; P=0.014). For participants with higher executive functioning, the probability of dementia was 0.3% without stroke and 3.1% after stroke, compared with 1.9% and 5.2% for lower executive functioning.

CONCLUSIONS

Stroke and prestroke cognition were independently associated with increased probability of poststroke dementia. Stroke results in disproportionate increase in the risk of dementia when premorbid cognitive functioning is high.

Trends in cardiovascular risk factors among people with diabetes in a population based study, Health Survey for England 1994-2009

AIMS

We evaluated trends in cardiovascular risk factors in a population-based sample of people with diabetes in England from 1994 to 2009.

METHODS

Data were obtained from Health Survey for England for 1994, 1998, 2003, 2006, 2008 and 2009. Participants were aged ≥30 years with self-reported diabetes.

RESULTS

The standerdised prevalence of diabetes increased from 2.8% in 1994 to 6.4% in 2009 and the prevalence among males was higher than females throughout. The trend in prevalence was more apparent in manual workers. From 1994 to 2009, mean systolic blood pressure declined from 148 mmHg to 137 mmHg; mean diastolic pressure declined from 80 mmHg to 70 mmHg; mean total cholesterol declined from 6.1 mmol/L to 4.5 mmol/L over the 15 years with linear trends. The proportion prescribed lipid lowering drugs increased from 2.2% to 47.4%. The percentage of current smokers declined from 17.5% to 13.4%. Mean body mass index increased from 27.7 kg/m(2) to 31.6 kg/m(2) with an overall increase of 0.24 kg/m(2) per year. Risk factor trends were generally similar between genders and social classes but the decline in smoking was not significant for men or for manual workers.

CONCLUSIONS

People with clinical diabetes have experienced substantial reductions in blood pressure, total cholesterol and smoking over 15 years. Increasing body mass index and persistence of smoking in lower socioeconomic groups, may compromise these improvements.