Association Between Diseases and Symptoms Diagnosed in Primary Care and the Subsequent Specific Risk of Multiple Sclerosis

BACKGROUND AND OBJECTIVES

Previous studies have reported a possible prodrome in multiple sclerosis (MS) defined by nonspecific symptoms including mood disorder or genitourinary symptoms and increased health care use detected several years before diagnosis. This study aimed to evaluate agnostically the associations between diseases and symptoms diagnosed in primary care and the risk of MS relative to controls and 2 other autoimmune inflammatory diseases with similar population characteristics, namely lupus and Crohn disease (CD).

METHODS

A case-control study was conducted using electronic health records from the Health Improvement Network database in the United Kingdom and France. We agnostically assessed the associations between 113 diseases and symptoms in the 5 years before and after diagnosis in patients with subsequent diagnosis of MS. Individuals with a diagnosis of MS were compared with individuals without MS and individuals with 2 other autoimmune diseases, CD and lupus.

RESULTS

The study population consisted of patients with MS (n = 20,174), patients without MS (n = 54,790), patients with CD (n = 30,477), and patients with lupus (n = 7,337). Twelve ICD-10 codes were significantly positively associated with the risk of MS compared with controls without MS. After considering ICD-10 codes suggestive of neurologic symptoms as the first diagnosis of MS, 5 ICD-10 codes remained significantly associated with MS: depression (UK: odds ratio 1.22, 95% CI 1.11-1.34), sexual dysfunction (1.47, 1.11-1.95), constipation (1.5, 1.27-1.78), cystitis (1.21, 1.05-1.39), and urinary tract infections of unspecified site (1.38, 1.18-1.61). However, none of these conditions was selectively associated with MS in comparisons with both lupus and CD. All 5 ICD-10 codes identified were still associated with MS during the 5 years after diagnosis.

DISCUSSION

We identified 5 health conditions associated with subsequent MS diagnosis, which may be considered not only prodromal but also early-stage symptoms. However, these health conditions overlap with prodrome of 2 other autoimmune diseases; hence, they lack specificity to MS.

Change in the incidence of Parkinson's disease in a large UK primary care database

Parkinson's disease (PD) has the fastest rising prevalence of all neurodegenerative diseases worldwide. However, it is unclear whether its incidence has increased after accounting for age and changes in diagnostic patterns in the same population. We conducted a cohort study in individuals aged ≥50 years within a large UK primary care database between January 2006 and December 2016. To account for possible changes in diagnostic patterns, we calculated the incidence of PD using four case definitions with different stringency derived from the combination of PD diagnosis, symptoms, and treatment. Using the broadest case definition, the incidence rate (IR) per 100,000 person years at risk (PYAR) was 149 (95% CI 143.3-155.4) in 2006 and 144 (95% CI 136.9-150.7) in 2016. In conclusion, the incidence of PD in the UK remained stable between 2006 and 2016, when accounting for age and diagnostic patterns, suggesting no major change in underlying risk factors for PD during this time period in the UK.

Time trends in access to smoking cessation support for people with depression or severe mental illness: a cohort study in English primary care

OBJECTIVES

To investigate delivery of smoking cessation interventions, recorded quit attempts and successful quitting rates within primary care in smokers with depression or severe mental illness (SMI) compared with those without.

DESIGN

Longitudinal cohort study using primary healthcare records.

SETTING

English primary care.

PARTICIPANTS

882 849 patients registered with participating practices recorded as current smokers during 2007-2014, including three groups: (1) 13 078 with SMI, (2) 55 630 with no SMI but recent depression and (3) 814 141 with no SMI nor recent depression.

OUTCOMES

Recorded advice to quit smoking, referrals to smoking cessation services, prescriptions for smoking cessation medication, recorded quit attempts and changes of smoking status.

RESULTS

The majority (>70%) of smokers had recorded smoking cessation advice. This was consistently higher in those with SMI than the other cohorts of patients, although the gap greatly reduced in more recent years. Increases in smoking cessation advice over time were not accompanied by increases in recorded attempts to quit or changes of smoking status. Overall nicotine replacement therapy prescribing by general practitioners (GPs) was higher in those with SMI (10.1%) and depression (8.7%) than those without (5.9%), but a downward time trend was observed in all groups. Bupropion and varenicline prescribing was very low and lower for those with SMI. Few smokers (<5%) had referrals to stop smoking services, though this increased over time, but no significant differences were observed between those with and without mental health problems.

CONCLUSIONS

There was no evidence of consistent inequalities in access to GP-delivered smoking cessation interventions for people with mental health conditions. Smoking cessation advice was widely reported as taking place in all groups. In order to address the widening gap in smoking prevalence in those with poor mental health compared with those without, the emphasis should be on addressing the quality of advice and support given.

Mortality of People with Parkinson's Disease in a Large UK-Based Cohort Study: Time Trends and Relationship to Disease Duration

Background

Parkinson’s disease (PD) is associated with increased mortality, but little is known about changes over time, and relationship to disease progression.

Objectives

To explore how PD mortality rates have changed over time and their relationship to disease duration and demographics using a large population-based cohort in the UK.

Methods

We included individuals aged 50+ years with a first recording of PD diagnosis and at least two prescriptions of any antiparkinsonian drug actively registered within a general practice from 2006 to 2016 and up to six frequency-matched controls from The Health Improvement Network (THIN) database. We estimated adjusted mortality rates using multivariable Poisson regression.

Results

A total of 10,104 people with a diagnosis of PD and 55,664 people without PD were included. Overall, PD was associated with slightly increased mortality compared to non-PD controls (adjusted mortality rate ratio: 1.14; 95% CI: 1.03 to 1.19). Adjusted mortality rates per 1000 person-years at risk for people with PD approximately doubled in the 5 years following diagnosis from 43 (95% CI: 38 to 48) to 75 (95% CI: 64 to 85). Following adjustments for age, gender, and time since diagnosis, mortality rates between 2007 and 2016 declined more slowly for people with PD (2% per year; 95% CI: 0%–4%) compared to people without PD (5% per year; 95% CI: 3%–6%).

Conclusions

Whilst mortality in PD is only slightly increased overall, it gradually increases with advancing disease. There has been a decline in mortality in PD over time, but this decrease was less pronounced than that in the general population.

Digoxin use is associated with pancreatic cancer risk but does not affect survival

PURPOSE

Digoxin affects several cellular pathways involved in tumorigenesis. We sought to determine the association between digoxin use and pancreatic cancer risk and survival.

METHODS

A nested case-control study using The Health Improvement Network (THIN), a population-representative database from the United Kingdom (UK). Cases included all individuals with incident diagnosis of pancreatic cancer. Each case was matched to up to four controls using incidence density sampling based on age, sex, practice site, calendar time, and duration of follow-up. Exposure of interest was digoxin therapy before cancer diagnosis. Odds ratios (ORs) and 95% confidence intervals (CIs) for the association between digoxin use and pancreatic cancer risk were estimated using conditional logistic regression. We further conducted a retrospective cohort study among pancreatic cancer cases using Cox regression model in order to evaluate the association between digoxin use and overall survival.

RESULTS

We identified 4,113 cases with incident pancreatic cancer and 16,072 matched controls. The adjusted OR for diagnosis of pancreatic cancer among active digoxin users was 1.41 (95% CI 1.16-1.72). The risk did not change among active users with duration of therapy of more than 1 year (adjusted OR of 1.39, 95% CI 1.11-1.76). Digoxin was not associated with change in overall survival with an adjusted hazard ratio of 0.97 (95% CI 0.81-1.18).

CONCLUSIONS

Digoxin use was associated with modestly increased pancreatic cancer risk but did not affect overall survival.

Prescribing Prevalence, Effectiveness, and Mental Health Safety of Smoking Cessation Medicines in Patients With Mental Disorders

OBJECTIVE

We conducted a prospective cohort study of the Clinical Practice Research Database to estimate rates of varenicline and nicotine replacement therapy (NRT) prescribing and the relative effects on smoking cessation, and mental health.

METHODS

We used multivariable logistic regression, propensity score matched regression, and instrumental variable analysis. Exposure was varenicline or NRT prescription. Mental disorders were bipolar, depression, neurotic disorder, schizophrenia, or prescriptions of antidepressants, antipsychotics, hypnotics/anxiolytics, mood stabilizers. Outcomes were smoking cessation, and incidence of neurotic disorder, depression, prescription of antidepressants, or hypnotics/anxiolytics. Follow-ups were 3, 6, and 9 months, and at 1, 2, and 4 years.

RESULTS

In all patients, NRT and varenicline prescribing declined during the study period. Seventy-eight thousand four hundred fifty-seven smokers with mental disorders aged ≥18 years were prescribed NRT (N = 59 340) or varenicline (N = 19 117) from September 1, 2006 to December 31, 2015. Compared with smokers without mental disorders, smokers with mental disorders had 31% (95% CI: 29% to 33%) lower odds of being prescribed varenicline relative to NRT, but had 19% (95% CI: 15% to 24%) greater odds of quitting at 2 years when prescribed varenicline relative to NRT. Overall, varenicline was associated with decreased or similar odds of worse mental health outcomes than NRT in patients both with and without mental disorders, although there was some variation when analyses were stratified by mental disorder subgroup.

CONCLUSIONS

Smoking cessation medication prescribing may be declining in primary care. Varenicline was more effective than NRT for smoking cessation in patients with mental disorders and there is not clear consistent evidence that varenicline is adversely associated with poorer mental health outcomes.

IMPLICATIONS

Patients with mental disorders were less likely to be prescribed varenicline than NRT. We triangulated results from three analytical techniques. We found that varenicline was more effective than NRT for smoking cessation in patients with mental disorders. Varenicline was generally associated with similar or decreased odds of poorer mental health outcomes (ie, improvements in mental health) when compared with NRT. We report these findings cautiously as our data are observational and are at risk of confounding.

Stillbirth Among Women Prescribed Nicotine Replacement Therapy in Pregnancy: Analysis of a Large UK Pregnancy Cohort

INTRODUCTION

We aimed to compare risk of stillbirth between maternal smokers and those prescribed nicotine replacement therapy (NRT) during pregnancy.

AIMS AND METHODS

We conducted a cross-sectional analysis on a pregnancy cohort of 220,630 singleton pregnancies ending in live or stillbirth between 2001 and 2012 from The Health Improvement Network UK general practice database. Women were categorized into three groups: NRT (prescribed during pregnancy or 1 month before conception); smokers; and controls (nonsmokers without a pregnancy NRT prescription). We calculated Odds ratios (OR) and corresponding 95% confidence intervals (CI) for stillbirth in the NRT group and smokers compared to controls.

RESULTS

A total of 805 pregnancies ended in stillbirth (3.6/1000 births). Absolute risks of stillbirth in NRT and smoker groups were both 5/1000 births compared with 3.5/1000 births in the control group. Compared with the control group, the adjusted odds of stillbirth in the NRT group was not statistically significant (OR = 1.35, 95% CI 0.91 to 2.00), although it was similar in magnitude to that in the smokers group (OR = 1.41, 95% CI 1.13 to 1.77).

CONCLUSIONS

We found no evidence of a statistically significant association between being prescribed NRT during pregnancy and odds of stillbirth compared with nonsmoking women. Although our study had much larger numbers than any previously, an even larger study with biochemically validated smoking outcome data and close monitoring of NRT use throughout pregnancy is required to exclude effects on findings of potential exposure misclassification.

The CHA2DS2-VASc score strongly correlates with glomerular filtration rate and predicts renal function decline over time in elderly patients with atrial fibrillation and chronic kidney disease

BACKGROUND

The decline of renal function affects stroke risk in patients with atrial fibrillation (AF). Here, we aim to study the predictive value of the CHA₂DS₂-VASc score, a stroke-risk stratification model in AF, for renal function and renal decline in patients with AF and chronic kidney disease (CKD).

METHODS

Two electronic health record cohorts with AF and CKD stage III/IV were evaluated (Cohort #1 (IMS-DA, Germany): 18,539 patients with 125,149 estimated glomerular filtration rate (eGFR) measurements; Cohort #2 (IMS-THIN, United Kingdom): 18,240 patients with 133,676 eGFR measurements). The eGFR trajectories were analysed with multi-level mixed-effects regression and joint models for longitudinal and survival data.

RESULTS

In IMS-DA, the mean baseline eGFR was 52.0ml/min/1.73m², and declined by 1.03ml/min/1.73m²/year (95%CI: 0.86-1.19, p<0.0001). In IMS-THIN, the mean baseline eGFR was 48.0ml/min/1.73m², and declined by 0.44ml/min/1.73m²/year (95%CI: 0.37-0.51, p<0.0001). In both datasets, higher CHA₂DS₂-VASc scores (median: 4 points) were strongly associated with both lower baseline eGFR (p<0.0001) and faster progression of CKD (p=0.002). Mean baseline eGFR values were higher in patients with a CHA₂DS₂-VASc score of 0 compared to patients with a score of 8 points. Conversely, the annual declines in eGFR were lower in patients with a score of 0 compared to patients with a score of 8 points in both databases.

CONCLUSION

The CHA₂DS₂-VASc score can identify AF patient subgroups with lower baseline eGFR and a higher risk of CKD progression, which has important implications for the management of anticoagulation in these patients.

Linking individual-level data on diagnoses and dispensing for research on antibiotic use: Evaluation of a novel data source from English secondary care

PURPOSE

There has been a focus on stewardship programmes to curb inappropriate antibiotic prescribing and reduce antimicrobial resistance. In-hospital, patient-level prescribing linked to indication is needed to support surveillance, evaluation of stewardship initiatives, as well as other antibiotic research. We evaluated whether a novel dataset linking hospital pharmacy records to Hospital Episode Statistics data can be used for antibiotic research.

METHODS

Using the Hospital Treatment Insights (HTI) database, which links Hospital Episode Statistics to pharmacy records from 43 out of 153 hospital trusts in England, we estimated the proportion of missed linkage and identified characteristics associated with missing data.

RESULTS

Linkage of antibiotics to patients was inconsistent and dependent on drug type and clinical setting, so that linkage for some specific antibiotics was high (80-100%), but overall, only 27.6% (CI: 27.4%-27.8%) for all antibiotics dispensed. Linkage was best for quinolones (62.6%; CI: 61.8%-63.8%), but only 21.1% (CI: 21.1%-21.2%) for penicillins. Linkage was lower for common antibiotics and in emergency departments; however, 80% linkage was achieved for individual drugs like clindamycin, especially on wards with reduced ward stock use.

CONCLUSIONS

For those antibiotics with high linkage, HTI might be used to study associations between indication, dispensing, and outcomes. However, the majority of common antibiotics had insufficient linkage, likely due to extensive use of ward stocks. Therefore, HTI in its current form is not suitable for general antibiotic surveillance or evaluation of stewardship initiatives. For drugs in HTI other than antibiotics, linkage should be similarly evaluated before a study is conducted.

Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000-2014

BackgroundBipolar disorder and schizophrenia are associated with increased mortality relative to the general population. There is an international emphasis on decreasing this excess mortality.AimsTo determine whether the mortality gap between individuals with bipolar disorder and schizophrenia and the general population has decreased.MethodA nationally representative cohort study using primary care electronic health records from 2000 to 2014, comparing all patients diagnosed with bipolar disorder or schizophrenia and the general population. The primary outcome was all-cause mortality.ResultsIndividuals with bipolar disorder and schizophrenia had elevated mortality (adjusted hazard ratio (HR) = 1.79, 95% CI 1.67-1.88 and 2.08, 95% CI 1.98-2.19 respectively). Adjusted HRs for bipolar disorder increased by 0.14/year (95% CI 0.10-0.19) from 2006 to 2014. The adjusted HRs for schizophrenia increased gradually from 2004 to 2010 (0.11/year, 95% CI 0.04-0.17) and rapidly after 2010 (0.34/year, 95% CI 0.18-0.49).ConclusionsThe mortality gap between individuals with bipolar disorder and schizophrenia, and the general population is widening.

Development of an algorithm for determining smoking status and behaviour over the life course from UK electronic primary care records

Background

Patients’ smoking status is routinely collected by General Practitioners (GP) in UK primary health care. There is an abundance of Read codes pertaining to smoking, including those relating to smoking cessation therapy, prescription, and administration codes, in addition to the more regularly employed smoking status codes. Large databases of primary care data are increasingly used for epidemiological analysis; smoking status is an important covariate in many such analyses. However, the variable definition is rarely documented in the literature.

Methods

The Secure Anonymised Information Linkage (SAIL) databank is a repository for a national collection of person-based anonymised health and socio-economic administrative data in Wales, UK. An exploration of GP smoking status data from the SAIL databank was carried out to explore the range of codes available and how they could be used in the identification of different categories of smokers, ex-smokers and never smokers. An algorithm was developed which addresses inconsistencies and changes in smoking status recording across the life course and compared with recorded smoking status as recorded in the Welsh Health Survey (WHS), 2013 and 2014 at individual level. However, the WHS could not be regarded as a “gold standard” for validation.

Results

There were 6836 individuals in the linked dataset. Missing data were more common in GP records (6%) than in WHS (1.1%). Our algorithm assigns ex-smoker status to 34% of never-smokers, and detects 30% more smokers than are declared in the WHS data. When distinguishing between current smokers and non-smokers, the similarity between the WHS and GP data using the nearest date of comparison was κ = 0.78. When temporal conflicts had been accounted for, the similarity was κ = 0.64, showing the importance of addressing conflicts.

Conclusions

We present an algorithm for the identification of a patient’s smoking status using GP self-reported data. We have included sufficient details to allow others to replicate this work, thus increasing the standards of documentation within this research area and assessment of smoking status in routine data.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0400-6) contains supplementary material, which is available to authorized users.

Provision of smoking cessation support in UK primary care: impact of the 2012 QOF revision

BACKGROUND

Before 2012, UK GPs were paid only to offer cessation advice to smokers and only to those with smoking-related disease, a minority of all smokers. From 2012, GPs are now paid to offer all smokers referral for behavioural support and medication to assist cessation at least once every 2 years.

AIM

To quantify the impact of this new recommendation and payment on indicators of smoking cessation activity.

DESIGN AND SETTING

Interrupted time series analysis of data from general practices in England contributing data to The Health Improvement Network (THIN).

METHOD

Data were extracted on monthly rates of recorded delivery of smoking cessation advice, referral to NHS Stop Smoking Services, and prescription of smoking cessation medications, among an average of 3.3 million patients aged >16 years registered each month in THIN. ARIMA models were used to quantify changes in rates of cessation activity after the 2012 Quality and Outcomes Framework (QOF) revision compared with beforehand.

RESULTS

The proportion of patients each month with a record of advice to quit smoking increased by 19.6% (95% CI = 7.9 to 31.4) in the year after the introduction of payments compared with the 8 years beforehand; the recording of referral to Stop Smoking Services increased by 38.8% (95% CI = 15.2 to 62.4). There was no significant change in prescription of smoking cessation medication, -7.7% (95% CI = -21.6 to 6.2).

CONCLUSION

Paying GPs to intervene with all smokers and offer support rather than just advice to quit is associated with an increase in recording of advice and referring patients for behavioural support to stop smoking, but no change in prescribing pharmacotherapy for cessation.

What are the effects of varenicline compared with nicotine replacement therapy on long-term smoking cessation and clinically important outcomes? Protocol for a prospective cohort study

INTRODUCTION

Smoking is a major avoidable cause of ill-health and premature death. Treatments that help patients successfully quit smoking have an important effect on health and life expectancy. Varenicline is a medication that can help smokers successfully quit smoking. However, there are concerns that it may cause adverse effects, such as increase in the occurrence of depression, self-harm and suicide and cardiovascular disease. In this study we aim to examine the effects of varenicline versus other smoking cessation pharmacotherapies on smoking cessation, health service use, all-cause and cause-specific mortality and physical and mental health conditions.

METHODS

In this project we will investigate the effects of varenicline compared to nicotine replacement therapies on: (1) long-term smoking cessation and whether these effects differ by area level deprivation; and (2) the following clinically-important outcomes: rate of general practice and hospital attendance; all-cause mortality and death due to diseases of the respiratory system and cardiovascular disease; and a primary care diagnosis of respiratory illness, myocardial infarction or depression and anxiety. The study is based on a cohort of patients prescribed these smoking cessation medications from the Clinical Practice Research Datalink (CPRD). We will use three methods to overcome confounding: multivariable adjusted Cox regression, propensity score matched Cox regression, and instrumental variable regression. The total expected sample size for analysis will be at least 180,000. Follow-up will end with the earliest of either an 'event' or censoring due to the end of registration or death.

ETHICS AND DISSEMINATION

Ethics approval was not required for this study. This project has been approved by the CPRD's Independent Scientific Advisory Committee (ISAC). We will disseminate our findings via publications in international peer-reviewed journals and presentations at international conferences.

General practitioner prescribing of single and combination nicotine replacement therapy in the UK: a retrospective database study

Background

Guidance in England and Wales recommends that nicotine replacement therapies (NRTs), varenicline or bupropion should be offered for smoking cessation support. Research on general practitioner (GP) NRT prescribing patterns for smoking cessation is lacking in the published literature.

Methods

UK primary care electronic health records were retrospectively analysed to identify the most common GP initiated NRT prescribing patterns, characterise people who receive NRT and determine whether NRTs given in a first quit attempt are different from subsequent attempts.

Results

The study population comprised 38,954 individuals in UK primary care data with a first ever NRT patch smoking cessation attempt for the period January 2008-December 2011. The majority (64.3%) received NRT patch monotherapy at first smoking cessation attempt, and the most common NRT was 21 mg/24 hours patch monotherapy (15.2%). Of the 35.7% first smoking cessation attempts which were NRT combination therapy, the most common combination was patch + inhalator (56.2%). The proportion of people who started a smoking cessation attempt with combination therapy increased from 25.7% in 2008 to 44.8% in 2011. The majority of the population had one recorded smoking cessation attempt but a significant minority (20.2% N = 7,868) started a second smoking cessation attempt. Second and third attempts, while predominantly patch monotherapy, also demonstrated an increasing use of NRT combinations over the study period (2^ndepisode: 20.6%-38.2%; 3^rdepisode: 20.0%-36.8%). However, a minority received only non-patch NRT during second and third NRT episodes. Taking into account the 39,068 people prescribed NRT patch during the study period with a history of NRT at baseline (excluded from the analysis), the total proportion of people prescribed NRT patch between 2008–2011 who had more than one NRT episode was 48.4% (46,936/96,986) and of 128,115 NRT users, only 14.7% (N = 18,838) were prescribed bupropion or varenicline prior to NRT use.

Conclusions

The study findings represent new data describing GP NRT prescription patterns in the UK. Given the predominance of NRT patch monotherapy observed, health policy makers and service commissioners should ensure that GPs provide equality of access to all recommended smoking cessation pharmacotherapies.

The delivery of smoking cessation interventions to primary care patients with mental health problems

AIMS

To quantify the extent to which smokers with indicators of poor mental health receive smoking cessation support in primary care consultations compared with those without.

DESIGN

Cross-sectional study within a database of electronic primary care medical records.

SETTING

A total of 495 general practices in the United Kingdom contributing data to The Health Improvement Network (THIN) database.

PARTICIPANTS

A total of 2 493 085 patients aged 16+ registered with a THIN practice for the year from 1 July 2009 to 30 June 2010.

MEASUREMENTS

The proportion of patients with a diagnostic Read code or British National Formulary (BNF) drug code indicating a mental health diagnosis or psychoactive medication prescription, respectively, who smoke and who have cessation advice or a smoking cessation medication prescription recorded during consultations within the 1-year study period.

FINDINGS

Of 32 154 smokers, 50.6% [95% confidence interval (CI): 50.0-51.2] with a mental health diagnosis and 49.3% (95% CI: 49.0-49.7) of 96 285 smokers prescribed a psychoactive medication had a record of cessation advice, higher than the prevalence of advice recording in smokers without these indicators (33.4%, 95% CI: 33.3-33.6). Similarly, smoking cessation medication prescribing was higher: 11.2% (95% CI: 10.8-11.6) of smokers with a mental health diagnosis and 11.0% (95% CI: 10.8-11.2) of smokers prescribed psychoactive medication received a prescription, compared with 6.73% of smokers without these indicators (95% CI: 6.65-6.81). Smoking cessation support was offered in a lower proportion of consultations for smokers with indicators of poor mental health than for those without. Advice was recorded in 7.9% of consultations with smokers with a mental health diagnosis, 8.2% of consultations with smokers prescribed psychoactive medication and 12.3% of consultations with smokers without these indicators; comparable figures for prescribing of cessation medication were 2.9%, 3.2% and 4.4%, respectively.

CONCLUSIONS

Approximately half of smokers with indicators of poor mental health receive advice to quit during primary care consultations in the United Kingdom, and one in 10 receive a cessation medication. Interventions are lower per consultation for smokers with mental health indicators compared with smokers without mental health indicators.

Socioeconomic variations in access to smoking cessation interventions in UK primary care: insights using the Mosaic classification in a large dataset of primary care records

BACKGROUND

Smoking prevalence is particularly high amongst more deprived social groups. This cross-sectional study uses the Mosaic classification to explore socioeconomic variations in the delivery and/or uptake of cessation interventions in UK primary care.

METHODS

Data from 460,938 smokers registered in The Health Improvement Network between 2008 and 2010 were analysed. Logistic regression was used to calculate odds ratios for smokers having a record of receiving cessation advice or a prescription for a cessation medication during the study period by Townsend quintile and for each of the 11 Mosaic groups and 61 Mosaic types. Both of these measures are area-level indicators of deprivation. Profiles of Mosaic categories were used to suggest ways to target specific groups to increase the provision of cessation support.

RESULTS

Odds ratios for smokers having a record of advice or a prescription increased with increasing Townsend deprivation quintile. Similarly, smokers in more deprived Mosaic groups and types were more likely to have a documented cessation intervention. The odds of smokers receiving cessation advice if they have uncertain employment and live in social housing in deprived areas were 35% higher than the odds for successful professionals living in desirable areas (odds ratio (OR) 1.35, 95% confidence interval (CI) 1.20-1.52; absolute risks 57.2% and 50.1% respectively), and those in low-income families living in estate-based social housing were 50% more likely to receive a prescription than these successful professionals (OR 1.50, 95% CI 1.31-1.73; absolute risks 19.5% and 13% respectively). Smokers who did not receive interventions were generally well educated, financially successful, married with no children, read broadsheet newspapers and had broadband internet access.

CONCLUSIONS

Wide socioeconomic variations exist in the delivery and/or uptake of smoking cessation interventions in UK primary care, though encouragingly the direction of this variation may help to reduce smoking prevalence-related socioeconomic inequalities in health. Groups with particularly low intervention rates may be best targeted through broadsheet media, the internet and perhaps workplace-based interventions in order to increase the delivery and uptake of effective quit support.

Body mass index and obstructive sleep apnoea in the UK: a cross-sectional study of the over-50s

BACKGROUND

An increasing prevalence of obesity in the UK has also seen a rise in the diagnosis of co-morbidities. Obstructive sleep apnoea (OSA) has previously been associated with body mass index (BMI) but has not been fully explored in a UK population.

AIMS

To quantify the association between BMI and a recorded diagnosis of OSA in primary care for people aged 50 years or over in the UK.

METHODS

A descriptive analysis is given of men and women aged 50 or over in the UK from The Health Improvement Network (THIN) database with regard to diagnosis of OSA, snoring, and BMI. Logistic regression was performed for the likelihood of OSA depending on BMI classification recorded after adjusting for gender, age, region, and socioeconomic status (Townsend quintile). The analyses were repeated for snoring.

RESULTS

After adjusting for confounders, those with a BMI recorded of 40+ kg/m2 were 27.39 times (95% CI 24.64 to 30.46) more likely to have OSA (p<0.0001). There was a lower prevalence of OSA with increasing age and levels of deprivation.

CONCLUSIONS

Obesity and snoring were both strongly associated with a diagnosis of OSA. The decreasing prevalence of OSA with increasing age and levels of deprivation needs further study to ensure that these groups are not being systematically under-investigated.

Prescribing of nicotine replacement therapy to cardiovascular disease patients in England

AIMS

  In November 2005 the indications for nicotine replacement therapy (NRT) were broadened in the United Kingdom, making all forms available to patients with stable cardiovascular disease (CVD). This study aimed to estimate the effects of this change on prescribing of NRT to CVD patients in England.

DESIGN

  Segmented regression analysis of time series of monthly rates of prescribing of NRT.

SETTING

  A total of 350 general practices in England included in The Health Improvement Network (THIN), a database of UK electronic primary care records.

PARTICIPANTS

  All adult patients with coronary heart disease (CHD) or stroke registered with a THIN practice in England.

MEASUREMENTS

  The number of patients per 100,000 with CHD and stroke that received a prescription for NRT each month between January 2002 and June 2009.

FINDINGS

  Approximately 1500 per 100,000 smokers with CVD were prescribed NRT per month. Prescribing of NRT to CHD and stroke patients increased until the end of 2005 and subsequently decreased, with no immediate change following the Medicines and Healthcare Regulatory Authority (MHRA) licensing change.

CONCLUSIONS

  Broadening the marketing licence in the United Kingdom for nicotine replacement therapy to allow it to be prescribed to patients with CVD did not increase prescribing rates for this group of patients.

Who receives prescriptions for smoking cessation medications? An association rule mining analysis using a large primary care database

AIMS

To use association rule mining methods to investigate prescribing of smoking cessation medication in the UK primary care and to identify the characteristics of numerically important groups of patients who typically do, or do not, receive cessation therapy.

DESIGN

An association rule mining study using The Health Improvement Network Database.

SETTINGS AND PARTICIPANTS

282 433 patients aged 16 years and over from 419 UK general practices, who were registered with the practice throughout 2008 and recorded as a current smoker during that year.

OUTCOME

Prescription for any type of smoking cessation medications in 2008 (nicotine replacement therapy, bupropion or varenicline).

VARIABLES

Age, gender, lifestyle indicators and co-morbidity.

RESULTS

Of the current smokers, 37 731 (13.4%) were given prescriptions for smoking cessation treatment during 2008. Prescriptions were particularly likely to be given to women, those aged 31-60 years, and people with diagnoses of chronic obstructive pulmonary disease and depression. On the contrary, of patients with dementia, with alcohol intake over recommended levels, atrial fibrillation or chronic kidney disease was extremely unlikely to be prescribed a smoking cessation medication. However, the largest group of patients who did not receive therapy was young and otherwise healthy individuals.

CONCLUSIONS

This novel approach identified sizeable and easily definable groups of patients who are systematically failing to receive support for smoking cessation in primary care. Association rule mining can be used to identify key numerically important groups at high or low risk of receiving treatment and hence potentially to improve healthcare delivery.

The impact of the introduction of smoke-free legislation on prescribing of stop-smoking medications in England

AIMS

To investigate whether there were changes in the rate of prescribing of smoking cessation medications in the months leading up to, and after, the introduction of smoke-free legislation in England.

DESIGN

Interrupted time-series analysis of prescribing rates using Autoregressive Integrated Moving Average (ARIMA) models.

SETTING

A total of 350 general practices in England who contribute data to The Health Improvement Network (THIN) database.

PARTICIPANTS

Patients in THIN aged 16+ identified from their medical records as smokers.

MEASUREMENTS

Monthly rates of prescribing of nicotine replacement therapy (NRT), bupropion and varenicline were calculated from THIN from 2000 to 2009 for all smokers and for subgroups defined by patient sex, age group, history of chronic disease and quintile of the Townsend Index of Deprivation. ARIMA models were built to assess whether there were changes in prescribing before or after the introduction of smoke-free legislation over and above any long-term and seasonal trends.

FINDINGS

There was a 6.4% (0.7-12.1) increase in prescribing of all smoking cessation medications in the 9 months before the introduction of smoke-free legislation and a 6.4% (1.1-11.7) reduction in the 9-month period afterwards. A 6.2% (1.4-11.0) increase in NRT prescribing and a 13.2% (4.3-22.2) increase in bupropion prescribing occurred in the 6- and 3-month periods, respectively, before smoke-free legislation was introduced, and a 5.5% (2.3-8.7) decline in NRT prescribing and a 13.7% (4.6-22.8) decline in bupropion prescribing in the 9 months post-legislation. The patterns of change in prescribing did not vary with patient demographics.

CONCLUSIONS

Numbers of primary care prescriptions for smoking cessation medications increased prior to the introduction of smoke-free legislation but decreased afterwards, suggesting a temporal displacement in prescribing activity rather than a change in the overall volume of prescribing. Effects observed were consistent across all population subgroups, suggesting that the changes in prescribing will neither widen nor reduce smoking-related health inequalities.

Prescribing of nicotine replacement therapy to adolescents in England

AIMS

In November 2005, the indications for nicotine replacement therapy (NRT) were broadened in the United Kingdom, making all forms available to 12-17-year-olds. This study aimed to estimate the effects of this change on prescribing of NRT to adolescents in England.

DESIGN

Segmented regression analysis of primary care data on prescribing of nicotine replacement therapy using general additive mixed models.

SETTING

A total of 350 general practices in England included in The Health Improvement Network (THIN), a database of UK electronic primary care records.

PARTICIPANTS

All 12-17-year-old patients registered with a THIN practice in England. Measurements   Monthly rates of prescribing of NRT per 100 000 12-17-year-old patients registered with a THIN practice between January 2002 and June 2009.

FINDINGS

Prescribing of NRT was highest in 16-17-year-olds and extremely low in 12-13-year-olds, generally fewer than 10 prescriptions per 100 000 adolescents per month. Girls tended to be prescribed NRT more frequently than boys. In 12-17-year-olds rates of prescribing were increasing prior to the broadening of indications, and there was no step change, but the rate of increase was lower, after the indications were broadened.

CONCLUSIONS

Recent changes to the marketing licence for nicotine replacement therapy in England to include adolescents appear to have had little or no effect on prescribing practices.

Prescribing of smoking cessation medication in England since the introduction of varenicline

AIMS

To estimate the effect of the introduction of a new smoking cessation medication, varenicline, and the publication of guidance related to its use, on trends in prescribing of smoking cessation medications in England.

DESIGN

Interrupted time series analysis of primary care data on prescribing of smoking cessation medication using autoregressive integrated moving average (ARIMA) modelling.

SETTING

A total of 446 general practices included in The Health Improvement Network (THIN), a database of UK electronic primary care records.

PARTICIPANTS

All primary care patients registered with a THIN practice in England.

MEASUREMENTS

Monthly rates of prescribing of varenicline, nicotine replacement therapy (NRT) and bupropion per 100 000 patients registered with a THIN practice between June 2000 and June 2009.

FINDINGS

NRT was the most commonly prescribed stop smoking medication, and bupropion the least frequently prescribed. After its introduction in December 2006 varenicline rapidly became the second most commonly prescribed drug. There was no statistically significant change in overall prescribing for smoking cessation medications after its introduction (P = 0.760), or after the publication of the related guidance in July 2007 (P = 0.134).

CONCLUSIONS

Soon after being introduced in England, varenicline was widely prescribed; after nicotine replacement therapy it was the most commonly prescribed cessation medication. However, this does not appear to have increased overall rates of prescribing for smoking cessation medication.

[Description of oral glucocorticoid prescriptions in general population]

PURPOSE

Very little is known about oral glucocorticoids (GCs) prescriptions in general population.

METHODS

Data of UK adult patients registered between January 1989 and December 2008 with general practices contributing to The Health Improvement Network (THIN) database were analyzed. We identified all patients aged 18 years and older who received at least one oral GCs prescription. Short-term treatments (i.e., <3 months) were differentiated from long term (i.e., ≥3 months) ones. Demographical data of patients being prescribed such treatments and reason for prescriptions over the 20 years were described. The annual prevalence of GCs prescriptions was assessed.

RESULTS

The study population consisted of 4,518,753 adult patients (26,035,154 person-years of follow-up). Overall, 810,009 oral GCs treatments (220,195,154 person-years of follow-up) were prescribed in 384,897 patients. Over the 20 years, the mean prevalence of oral GCs prescriptions was 0.85% [0.84-0.85], increasing from 0.65% [0.57-0.74] in 1989 to 0.91% [0.90-0.93] in 2008. Short-term therapies (median duration of prescription: 9 days [6-10], median cumulative prednisone equivalent (PE) dosage: 210 mg [150-420]) represented 79.3% of treatments and 11.9% of prevalence whereas it was the opposite for long term prescriptions (median duration of prescription: 215 days [126-490], median cumulative PE dosage: 2000 mg [950-4310]). Women were more prescribed GCs. Median age at first GCs prescription was 56.1 years [39.4-70.4] and 67.4 years [54.0-76.8] for short-term and long-term therapies, respectively. Reasons for prescription were mainly pulmonary diseases.

CONCLUSION

About 1% of the UK general population receives GCs therapy in any point of time. This prevalence has constantly increased over the last 20 years.

Prevalence of long-term oral glucocorticoid prescriptions in the UK over the past 20 years

OBJECTIVE

To assess trends in long-term (i.e. ≥3 months) oral glucocorticoid (GC) prescriptions over the past 20 years.

METHODS

Data of UK adult patients registered between January 1989 and December 2008 with general practices contributing to The Health Improvement Network (THIN) database were obtained. The annual prevalence of long-term oral GC prescriptions was assessed in the whole population and specifically in people with RA, PMR/GCA, asthma, chronic obstructive pulmonary disease (COPD), Crohn's disease and ulcerative colitis (UC). Trends over the 20-year period were estimated using sex- and age-adjusted Poisson regression models.

RESULTS

During the 26 035 154 person-years of follow-up, an average of 0.75% (95% CI 0.74, 0.75) of the study population was prescribed long-term oral GC therapy at any time point. This rose from 0.59% (0.52, 0.67) in 1989 to 0.79% (0.78, 0.80) in 2008. Long-term prescriptions significantly increased in patients with RA [from 10.3% (8.7, 11.9) to 13.6% (12.9, 14.2)] and PMR/GCA [from 57.6% (53.3, 62.0) to 66.5% (65.2, 67.7)], decreased in patients with asthma, COPD and Crohn's disease and remained stable in patients with UC. However, when only incident cases were considered, we found a decreased use of GCs in patients with RA and UC [odds ratio 0.97 (95% CI 0.96, 0.97) and 0.94 (95% CI 0.93, 0.96) per increasing year, respectively].

CONCLUSION

Over the past 20 years, long-term oral GC prescriptions have increased by 34%. Patients newly diagnosed with RA, Crohn's disease or UC are, however, less likely to receive long-term GC prescriptions than patients with a long past medical history of the disease, suggesting changes in physicians' practice.