Data Resource Profile: Clinical Practice Research Datalink (CPRD)

Prevalence and outcomes of patients taking oral corticosteroids for over 1 month undergoing major surgery in England 2010-2020

INTRODUCTION

Approximately 1% of the UK population is prescribed oral corticosteroids at any one time. It is not known how many of these patients present for major surgery. We aimed to establish the prevalence, characteristics and outcomes of patients taking oral corticosteroids.

METHODS

We identified patients aged > 18 y undergoing major surgery between 1 April 2010 and 31 March 2020 from Hospital Episode Statistics with linked Clinical Practice Research Datalink data and the Office for National Statistics Mortality register in England. Prescribing data were used to define three sets of patients: 'low-dose' - taking ≤ 7.5 mg oral prednisolone equivalents per day for at least 28/91 days before surgery; 'high-dose' - taking > 7.5 mg oral prednisolone equivalents per day for at least 28/ 91 days before surgery; and a 'no-steroids' group. We used ≤ 7.5 mg of prednisolone equivalents per day as our threshold, as this would likely exclude almost all patients who were taking corticosteroids as replacement for absolute adrenal/pituitary deficiency.

RESULTS

We identified 1,999,326 adult patients for inclusion in the dataset: 1,929,291 (96.5%) in the no-steroids; 63,353 (3.2%) in the low-dose group; and 6682 (0.3%) in the high-dose group. Median (IQR [range]) duration of hospital stay increased with increasing dose of corticosteroid (no-steroid 3 (0-14 [0-14,739]); low-dose 5 (1-26 [1-8079]); and high-dose 7 (2-28 [0-6956]) days). Mortality after the index surgery was 1.5%, 3.8% and 8.9% at 30 days and 5.5%, 11.6% and 39.9% at 1 year for no-steroids, low-dose and high-dose groups, respectively.

CONCLUSION

Around 1 in 29 patients undergoing major surgery are taking oral corticosteroids for > 28 days in the 3 months before major surgery. Their outcomes are poor and warrant highlighting within care pathways to aid risk prediction and mitigation.

Missed opportunities to manage complex comorbidity of heart failure, type 2 diabetes mellitus and chronic kidney disease: a retrospective cohort study

BACKGROUND

Effective management of coexisting heart failure (HF), chronic kidney disease (CKD) and type 2 diabetes mellitus (T2D) is critical, yet evidence of adherence to guideline-recommended standards in routine care remains unclear. We aimed to assess primary care adherence to guideline-recommended standards for patients with overlapping HF, CKD and T2D in England.

METHODS

Using UK Clinical Practice Research Datalink (1998-2020), we evaluated care adherence across 161 529 individuals with HF, CKD or T2D before and after developing a second of these conditions. We analysed disease investigation rates, medication use and predictors of guideline adherence.

RESULTS

We identified 161 529 patients with CKD followed by HF (CKD+HF, 40%), CKD+T2D (51.3%) and HF+T2D (8.6%) with a median of 3.1 years follow-up after the second diagnosis. In CKD+HF, CKD+T2D and HF+T2D groups, prescription rates of renin-angiotensin system inhibitors (71%, 64.1% and 74.4%), beta-blockers (53.1%,36.2% and 55.1%), antiplatelets (56.2%, 45.2% and 54.4%) and statins (56.7%, 68.5% and 72%) were suboptimal. Advanced age, female sex, peripheral arterial disease and cancer were associated with a lower likelihood of checking blood pressure, creatinine and glycated haemoglobin (HbA1C) after HF, CKD and T2D diagnoses, respectively. The first diagnosis of HF was associated with reduced odds of having HbA1C measured after T2D diagnosis (OR 0.79, 95% CI 0.72 to 0.86), compared with CKD as the first diagnosis.

CONCLUSIONS

In overlapping HF, CKD and T2D, guideline-recommended care is suboptimal, with inequalities by age, sex, disease on first presentation and comorbidities. Quality improvement requires linked data collection, monitoring and action across diseases.

Effect of different durations of treatment with antihypertensive drugs with anticholinergic effects on the risk of dementia: a target trial emulation study

Studying the effect of duration of treatment on prognostic outcomes using real-world data is challenging because only people who survive for a long time can receive a treatment for a long time. Specifying a target trial helps overcome such challenge. We aimed to estimate the effect of different durations of treatment with antihypertensive drugs with anticholinergic properties (AC AHT) on the risk of vascular dementia and Alzheimer's disease by emulating a target trial using the UK CPRD GOLD database (2001-2017). Comparing treatment for 3-6 years vs ≤3 years yielded null results for both types of dementia. Comparing a longer duration of treatment, >6 years vs ≤3 years, yielded a 10-year risk ratio of 0.69 (95% CI, 0.54-0.90) for vascular dementia and 0.91 (95% CI, 0.77-1.10) for Alzheimer's disease. For illustration, we performed an analysis that failed to emulate a target trial by assigning exposure categories using postbaseline information, obtaining implausible beneficial estimates. Our findings indicate a modest benefit of longer duration of treatment with AC AHT on vascular dementia and highlight the value of the target trial emulation to avoid selection bias in the evaluation of the effect of different durations of treatment. This article is part of a Special Collection on Pharmacoepidemiology.

Health conditions in adults with atrial fibrillation compared with the general population: a population-based cross-sectional analysis

BACKGROUND

Atrial fibrillation (AF) prevalence is rising due to population ageing and comorbidity is an increasing problem. The aim of this study was to examine the prevalence and association of coexisting health conditions among adults with AF in the general population.

METHODS

Cross-sectional analysis of Clinical Practice Research Datalink (CPRD) primary care electronic medical records in England linked to hospital admissions as of 30 November 2015. CPRD is broadly representative of the UK general population in terms of age, sex and ethnicity. We estimated prevalence and used logistic regression examining risk factors of age, sex and socioeconomic status (SES) to compare prevalence of 252 physical and mental health conditions and 23 higher level health condition groups in adults with AF compared with adults without AF.

RESULTS

34 338 adults with AF (57% male; 83% ≥65 years) and 907 739 without AF (49% male; 23% ≥65 years) were identified. Adjusted for age and sex, adults with AF were significantly more likely to have 20/23 (87%) health condition groups than adults without AF. The most prevalent health condition groups in adults with AF were cardiovascular (prevalence of 89% in adults with AF vs 26% in adults without AF, adjusted OR (aOR) 5.82, 95% CI 5.60 to 6.05), gastrointestinal (62% vs 37%, aOR 1.34, 95% CI 1.31 to 1.38) and orthopaedic (58% vs 24%, aOR 1.32, 95% CI 1.29 to 1.35). 151/252 individual conditions were significantly more common in adults with AF including cardiovascular conditions such as cardiomyopathy (4.5% vs 0.3%, aOR 9.58, 95% CI 8.88 to 10.35) and heart failure (18% vs 0.7%, aOR 9.07, 95% CI 8.70 to 9.46), and non-cardiovascular conditions such as pleural effusion (16% vs 1.8%, aOR 3.55, 95% CI 3.42 to 3.67) and oesophageal malignancy (0.3% vs 0.0%, aOR 2.14, 95% CI 1.69 to 2.70). Associations were similar after SES adjustment.

CONCLUSIONS

While cardiovascular conditions are highly prevalent and strongly associated with AF, a wide spectrum of non-cardiovascular conditions were also strongly associated, requiring a greater understanding of managing comorbid conditions with management principles contradictory to AF.

A UK population-based case-control study of blood tests before cancer diagnosis in patients with non-specific abdominal symptoms

BACKGROUND

Abnormal results in commonly used primary care blood tests could be early markers of cancer in patients presenting with non-specific abdominal symptoms.

METHODS

Using linked data from the UK Clinical Practice Research Datalink (CPRD) and national cancer registry we compared blood test use and abnormal results from the 24-months pre-diagnosis in 10,575 cancer patients (any site), and 52,875 matched-controls aged ≥30 presenting, with abdominal pain or bloating to primary care.

RESULTS

Cancer patients had two-fold increased odds of having a blood test (odds ratio(OR):1.51-2.29) and 2-3-fold increased odds of having an abnormal blood test result (OR:2.42-3.30) in the year pre-diagnosis compared to controls. Raised inflammatory markers were the most common abnormality (74-79% of tested cases). Rates of blood test use and abnormal results progressively increased from 7 months pre-diagnosis in cancer patients, with relatively small corresponding increases in symptomatic controls. In cancer patients, the largest increases from baseline were raised platelets in males with abdominal pain (increased 33-fold), raised white blood cell count in males with abdominal bloating (increased 37-fold) and low albumin in females with either symptom (increased 22-41 fold).

CONCLUSIONS

Common blood test abnormalities are early signals of cancer in some individuals with non-specific abdominal symptoms and could support expedited cancer diagnosis.

Continuity and locum use for acute consultations: observational study of subsequent workload

BACKGROUND

Workload is probably the biggest challenge facing general practice and little is known about any modifiable factors. For GPs, both continuity and locum status are associated with differences in outcomes.

AIM

To determine whether practice and hospital workload after an index acute consultation depend on the type of GP consulted (locums and practice GPs with [regular] and without [non-regular] continuity, and locums).

DESIGN AND SETTING

An observational, cross-sectional analysis of consultation-level data from English general practices from the Clinical Practice Research Datalink from 2015 to 2017.

METHOD

Antibiotic prescription was used as a marker for acute consultations with regression models to calculate adjusted relative risks for emergency department consultations and admissions, outpatient referrals, and test ordering, as well as the patients' GP reconsultation interval following consultations with the three types of GP.

RESULTS

After adjustment, consultations with antibiotic prescriptions with regular GPs with continuity were associated with fewer subsequent hospital admissions and lower emergency department use but higher outpatient referrals relative to locums and non-regular GPs. Locums ordered tests less often (relative risk [RR] -24.3%, 95% confidence interval [CI] = -27.3 to -21.2) than regular GPs whereas non-regular GPs ordered tests more often (RR 19.1%, 95% CI = = 16.4 to 21.8). Patients seeing their regular GP had on average a 9% longer (95% CI = 8 to 10) reconsultation interval than if they saw any other GP.

CONCLUSION

The differences in outcomes were associated more with having continuity than with GP locum status. Seeing a GP with whom the patient had continuity of care was associated with reduced workload within the practice and in hospital.

Prognostic factors for colchicine prophylaxis-related adverse events when initiating allopurinol for gout: retrospective cohort study

OBJECTIVES

Colchicine is commonly used to prevent flares when starting urate-lowering therapy for gout. Patients with gout are frequently concurrently prescribed other medications (such as statins) that may interact with colchicine, increasing the risk of adverse events. The aim of this study was to describe potential prognostic factors for adverse events in patients prescribed colchicine when initiating allopurinol.

METHODS

We conducted a retrospective cohort study in linked UK Clinical Practice Research Datalink and Hospital Episode Statistics datasets. Adults initiating allopurinol for gout with colchicine (1 April 1997 to 30 November 2016) were included. Potential prognostic factors were defined, and the likelihood of adverse events, including diarrhoea, nausea or vomiting, myocardial infarction, neuropathy, myalgia, myopathy, rhabdomyolysis and bone marrow suppression, were estimated.

RESULTS

From 1 April 1997 to 30 November 2016, 13 945 people with gout initiated allopurinol with colchicine prophylaxis [mean age 63.9 (s.d. 14.7) years, 78.2% male]. One-quarter (26%, 95% CI 25%, 27%) were prescribed one or more potentially interacting medicines, most commonly statins (21%, 95% CI 20%, 22%). Statins were not associated with increased adverse events, although other drugs were associated with some adverse outcomes. Diarrhoea and myocardial infarction were associated with more comorbidities and more severe chronic kidney disease.

CONCLUSION

People were given colchicine prophylaxis despite commonly having preexisting prescriptions for medications with potential to interact with colchicine. Adverse events were more common in people who had more comorbidities and certain potentially interacting medications. Our findings will provide much-needed information about prognostic factors for colchicine-related adverse events that can inform treatment decisions about prophylaxis when initiating allopurinol.

Clinical indications associated with new opioid use for pain management in the United Kingdom: using national primary care data

ABSTRACT

Prescription opioids for noncancer pain in the United Kingdom have increased over the past 2 decades, alongside associated harms. Policies addressing opioid prescribing must be tailored to individual patient needs with specific disease systems. The aim of this study was to evaluate clinical conditions associated with new opioid initiation in noncancer pain using nationally representative UK data. Primary care electronic health records from January 1, 2006, to September 31, 2021, were used from the Clinical Research Practice Datalink to identify incident opioid prescriptions. Patient histories were reviewed using code lists for opioid-related conditions with a 5-year look-back for chronic conditions and a 1-year look-back for surgical indications before opioid initiation. In total, 3,030,077 new opioid use episodes in 2,027,402 patients were identified, with 61% being women, 77% aged 45 years and older, and 48% from the highest deprivation quintile. Ten systems associated with opioid initiation were identified, which were not mutually exclusive, as patients could have opioids prescribed for multiple indications. The most common were musculoskeletal (80.8%), respiratory (57.6%), infections (30.4%), trauma/injury (20.4%), neurology (19.9%), and postsurgical indications (5.5%). Osteoarthritis (60.7%) and low back pain (41.0%) were the most frequent musculoskeletal conditions. Orthopedic surgeries accounted for 41.2% of all postsurgical indications. This is the first study in the United Kingdom evaluating large-scale national data to assess indications associated with opioid initiation. Nearly 3 quarters of new opioid prescriptions for noncancer pain were in patients with musculoskeletal conditions, often for conditions with limited evidence for opioid efficacy. These findings could inform targeted interventions and future policies to support nonpharmacological interventions in the most common conditions where opioid harms outweigh benefits.

Uptake and safety of pneumococcal vaccination in adults with immune-mediated inflammatory diseases: a UK wide observational study

OBJECTIVE

The uptake and safety of pneumococcal vaccination in people with immune-mediated inflammatory diseases (IMIDs) is poorly understood. We investigated the UK-wide pneumococcal vaccine uptake in adults with IMIDs and explored the association between vaccination and IMID flare.

METHODS

Adults with IMIDs diagnosed on or before 1 September 2018, prescribed steroid-sparing drugs within the last 12 months and contributing data to the Clinical Practice Research Datalink Gold, were included. Vaccine uptake was assessed using a cross-sectional study design. Self-controlled case series analysis investigated the association between pneumococcal vaccination and IMID flare. The self-controlled case series observation period was up to 6 months before and after pneumococcal vaccination. This was partitioned into a 14-day pre-vaccination induction, 90 days post-vaccination exposed and the remaining unexposed periods.

RESULTS

We included 32 277 patients, 14 151 with RA, 13 631 with IBD, 3804 with axial SpA and 691 with SLE. Overall, 57% were vaccinated against pneumococcus. Vaccine uptake was lower in those younger than 45 years old (32%), with IBD (42%) and without additional indication(s) for vaccination (46%). In the vaccine safety study, data for 1067, 935 and 451 vaccinated patients with primary-care consultations for joint pain, autoimmune rheumatic disease flare and IBD flare, respectively, were included. Vaccination against pneumococcal pneumonia was not associated with primary-care consultations for joint pain, autoimmune rheumatic disease flare and IBD flare in the exposed period, with incidence rate ratios (95% CI) 0.95 (0.83-1.09), 1.05 (0.92-1.19) and 0.83 (0.65-1.06), respectively.

CONCLUSION

Uptake of pneumococcal vaccination in UK patients with IMIDs was suboptimal. Vaccination against pneumococcal disease was not associated with IMID flare.

Glucagon-Like Peptide 1 Receptor Agonists and Sodium-Glucose Cotransporter 2 Inhibitors and the Prevention of Cirrhosis Among Patients With Type 2 Diabetes

OBJECTIVE

To determine whether glucagon-like peptide 1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter 2 (SGLT-2) inhibitors, separately, compared with dipeptidyl peptidase 4 (DPP-4) inhibitors are associated with a reduced risk of cirrhosis and other adverse liver outcomes among patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

With an active comparator, new-user approach, we conducted a cohort study using the U.K. Clinical Practice Research Datalink linked with hospital and national statistics databases. Cox proportional hazards models using propensity score fine stratification weighting were used to calculate hazard ratios (HRs) and 95% CIs for cirrhosis (primary outcome) and decompensated cirrhosis, hepatocellular carcinoma, and liver-related mortality (secondary outcomes).

RESULTS

In the first cohort comparing 25,516 patients starting GLP-1RAs and 186,752 starting DPP-4 inhibitors, GLP-1RAs were not associated with the incidence of cirrhosis (HR 0.90, 95% CI 0.68-1.19) or the secondary outcomes. In a separate cohort comparing 33,161 patients starting SGLT-2 inhibitors and 124,431 starting DPP-4 inhibitors, SGLT-2 inhibitors were associated with a reduced incidence of cirrhosis (HR 0.64, 95% CI 0.46-0.90), as also decompensated cirrhosis (HR 0.74, 95% CI 0.54-1.00), but not with a lower risk of hepatocellular carcinoma or liver-related mortality.

CONCLUSIONS

In patients with type 2 diabetes in the U.K., GLP-1RAs were not associated with a lower risk of cirrhosis compared with DPP-4 inhibitors in patients with type 2 diabetes. However, SGLT-2 inhibitors were associated with a lower risk of cirrhosis compared with DPP-4 inhibitors.

An interpretable machine learning approach for detecting psoriatic arthritis in a UK primary care psoriasis cohort using electronic health records from the Clinical Practice Research Datalink

OBJECTIVES

Develop an interpretable machine learning model to detect patients with newly diagnosed psoriatic arthritis (PsA) in a cohort of psoriasis patients and identify important clinical indicators of PsA in primary care.

METHODS

We developed models using UK primary care electronic health records from the Clinical Practice Research Datalink (CPRD). The study population consisted of a cohort of (PsA free) patients with incident psoriasis who were followed prospectively. We used Bayesian networks (BNs) to identify patients who developed PsA using primary care variables measured prior to diagnosis and compared the results to a random forest (RF). Variables included patient demographics, musculoskeletal symptoms, blood tests, and prescriptions. The importance of each variable used in the models was evaluated using permutation variable importance. Model discrimination was measured using the area under the receiver operating characteristic curve (AUC) and the area under the precision-recall curve (PRAUC).

RESULTS

We identified a cohort of 122,330 patients with an incident psoriasis diagnosis between 1998 and 2019 in the CPRD, of whom 2460 patients went on to develop PsA. Our best BN achieved an AUC of 0.823, and PRAUC of 0.221, compared to the AUC of 0.851 and PRAUC of 0.261 of the RF. Psoriasis duration, nonsteroidal anti-inflammatory drug prescriptions, nonspecific arthritis, nonspecific arthralgia, and C-reactive protein blood tests were all important variables in our models.

CONCLUSIONS

We were able to identify psoriasis patients at higher risk, and important indicators, of PsA in UK primary care. Further work is required to evaluate our model's usefulness in assisting PsA screening.

Patterns of analgesic utilisation among people with knee osteoarthritis: a cohort study using UK primary care data

Background

Osteoarthritis (OA) is a prevalent disabling joint disease affecting more than 300 million people globally and knees are most commonly affected. It is associated with pain and functional limitation that adversely affect mental well-being and compromise quality of life. Analgesic use is common among patients with knee osteoarthritis (KOA), however, data on patterns of analgesics use at an individual patient level are sparse. The present study describes patterns of analgesic use, by determining the proportion of persistent users within one year of therapy initiation in patients with KOA.

Methods

A retrospective cohort study using the clinical practice research datalink. Analgesic prescriptions for adults with an incident KOA diagnosis were captured and grouped into five exposure groups including: antidepressants, antiepileptic drugs (AEDs), opioids, non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol. A persistent user was a person who used >180 defined daily doses (DDDs) per year and had prescriptions in at least three out of the four quarters of the year.

Results

Variable proportions of patients used respective analgesic classes persistently during the first year after prescribing; 36.8% of antidepressant users, 27.0% of NSAIDs, 23.8% of AEDs, 17.5% of paracetamol and 14.9% of opioid users were persistent users. Across classes, persistent users were slightly younger, were issued more prescriptions and used higher doses of analgesics compared to non-persistent users.

Conclusion

Between 14.9% and 36.8% became persistent analgesic users by the end of the first year after their initial prescription. The study applied meaningful clinical attributes to define persistence. This informs future research on clinical and adverse drug outcomes in persistent users compared to non-persistent users across five separate analgesic classes.

Glucagon-like peptide-1 receptor agonists and risk of suicidality among patients with type 2 diabetes: active comparator, new user cohort study

OBJECTIVE

To determine whether the use of glucagon-like peptide-1 (GLP-1) receptor agonists is associated with an increased risk of suicidal ideation, self-harm, and suicide among patients with type 2 diabetes compared with the use of dipeptidyl peptidase-4 (DPP-4) inhibitors or sodium-glucose cotransporter-2 (SGLT-2) inhibitors.

DESIGN

Active comparator, new user cohort study.

SETTING

Primary care practices contributing data to the UK Clinical Practice Research Datalink linked to the Hospital Episodes Statistics Admitted Patient Care and Office for National Statistics Death Registration databases.

PARTICIPANTS

Patients with type 2 diabetes.

EXPOSURES

Two cohorts were assembled, with the first composed of patients who started and continued on GLP-1 receptor agonists or DPP-4 inhibitors between 1 January 2007 and 31 December 2020 and the second composed of patients who started and continued on GLP-1 receptor agonists or SGLT-2 inhibitors between 1 January 1 2013 and 31 December 2020. Both cohorts were followed until 29 March 2021.

MAIN OUTCOME MEASURES

The primary outcome was suicidality, defined as a composite of suicidal ideation, self-harm, and suicide. Secondary outcomes were each of these events considered separately. Propensity score fine stratification weighted Cox proportional hazards models were fitted to estimate hazard ratios and 95% confidence intervals (CIs) to estimate the average treatment effect among the treated patients.

RESULTS

The first cohort included 36 082 GLP-1 receptor agonist users (median follow-up 1.3 years) and 234 028 DPP-4 inhibitor users (median follow-up 1.7 years). In crude analyses, GLP-1 receptor agonist use was associated with an increased incidence of suicidality compared with DPP-4 inhibitors (crude incidence rates 3.9 v 1.8 per 1000 person years, respectively; hazard ratio 2.08, 95% CI 1.83 to 2.36). This estimate decreased to a null value after confounding factors were accounted for (hazard ratio 1.02, 95% CI 0.85 to 1.23). The second cohort included 32 336 GLP-1 receptor agonist users (median follow-up 1.2 years) and 96 212 SGLT-2 inhibitor users (median follow-up 1.2 years). Similarly, GLP-1 receptor agonist use was associated with an increased risk of suicidality compared with SGLT-2 inhibitors in crude analyses (crude incidence rates 4.3 v 2.7 per 1000 person years; hazard ratio 1.60, 95% CI 1.37 to 1.87) but not after confounding factors were accounted for (0.91, 0.73 to 1.12). Similar findings were observed when suicidal ideation, self-harm, and suicide were analysed separately in both cohorts.

CONCLUSIONS

In this large cohort study, the use of GLP-1 receptor agonists was not associated with an increased risk of suicidality compared with the use of DPP-4 inhibitors or SGLT-2 inhibitors in patients with type 2 diabetes.

Emergency admission Predictive RIsk Stratification Models: Assessment of Implementation Consequences (PRISMATIC 2): a protocol for a mixed-methods study

BACKGROUND

Emergency admissions are costly, increasingly numerous, and associated with adverse patient outcomes. Policy responses have included the widespread introduction of emergency admission risk stratification (EARS) tools in primary care. These tools generate scores that predict patients' risk of emergency hospital admission and can be used to support targeted approaches to improve care and reduce admissions. However, the impact of EARS is poorly understood and there may be unintended consequences.

AIM

To assess effects, mechanisms, costs, and patient and healthcare professionals' views related to the introduction of EARS tools in England.

DESIGN & SETTING

Quasi-experimental mixed-methods design using anonymised routine data and qualitative methods.

METHOD

We will apply multiple interrupted time-series analysis to data, aggregated at former clinical commissioning group (CCG) level, to look at changes in emergency admission and other healthcare use following EARS introduction across England. We will investigate GP decision making at practice level using linked general practice and secondary care data to compare case-mix, demographics, indicators of condition severity, and frailty associated with emergency admissions before and after EARS introduction. We will undertake interviews (approximately 48) with GPs and healthcare staff to understand how patient care may have changed. We will conduct focus groups (n = 2) and interviews (approximately 16) with patients to explore how they perceive that communication of individual risk scores might affect their experiences and health-seeking behaviours.

CONCLUSION

Findings will provide policymakers, healthcare professionals, and patients, with a better understanding of the effects, costs, and stakeholder perspectives related to the introduction of EARS tools.

Cardiovascular disease morbidity is associated with social deprivation in subjects with familial hypercholesterolaemia (FH): A retrospective cohort study of individuals with FH in UK primary care and the UK Simon Broome register, linked with national hospital records

BACKGROUND

Social deprivation is associated with higher cardiovascular disease (CVD) morbidity and mortality. We examined whether this is also observed in people with Familial Hypercholesterolaemia (FH).

METHODS

Subjects with FH and linked secondary care records in Hospital Episode Statistics (HES) were identified from UK Clinical Practice Research Datalink (CPRD) and the Simon Broome (SB) adult FH register. Cox proportional hazards regression estimated hazard ratios (HR) for composite CVD outcomes (first HES outcome of coronary heart disease, myocardial infarction, angina, stroke, transient ischaemic attack, peripheral vascular disease, heart failure, coronary revascularisation interventions (PCI and CABG)) in Index of Multiple Deprivation (IMD) quintiles.

RESULTS

We identified 4309 patients with FH in CPRD (1988-2020) and 2956 in the SB register. Both cohorts had considerably fewer subjects in the most deprived compared to the least deprived quintile (60 % lower in CPRD and 52 % lower in SB). In CPRD, the most deprived individuals had higher unadjusted HRs for composite CVD (HR 1.71 [CI 1.22-2.40]), coronary heart disease (HR 1.63 [1.11-2.40]) and mortality (HR 1.58 [1.02-2.47]) compared to the least deprived but these became insignificant after adjusting for age, sex, smoking and alcohol consumption. In the SB register, hazard ratios for composite CVD increased with increasing deprivation quintiles and remained significant after adjustment for age, sex, smoking and alcohol consumption (adjusted HR in quintile 5 vs quintile 1 = 1.83 [1.54-2.17]).

CONCLUSIONS

Strikingly fewer individuals with FH are identified from lower socioeconomic groups, though the most deprived FH patients have the highest risk of CVD and mortality. In CPRD, this risk was largely explained by smoking and alcohol consumption, but not in the SB register. More effective strategies to detect FH and optimise risk factor management, are needed in lower socioeconomic groups.

Association between drugs and vaccines commonly prescribed to older people and bullous pemphigoid: a case-control study

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune skin disease that mainly affects older people. Based on case series and small hospital-based studies, a number of drugs have been associated with BP. More reliable and precise estimates of associations between a broad selection of drugs/vaccines and BP will enable greater awareness of any potential increased risk of BP following the administration of certain medicines and help identify clinical, histological and genomic characteristics of drug-induced BP for different culprit drugs. Greater awareness could lead to earlier recognition or suspicion of BP and referral to a dermatologist for diagnosis. Earlier diagnosis may lead to less aggressive treatment and improved wellbeing.

OBJECTIVES

To determine the association between drugs/vaccines commonly prescribed to older people and the risk of developing BP.

METHODS

We conducted a population-based nested case-control study between 1998 and 2021 using electronic primary care records from the Clinical Practice Research Datalink. We matched patients with BP with up to five controls. Exposures were drugs/vaccines commonly prescribed to older people. We used multivariable conditional logistic regression adjusting for multiple drug use. For antibiotics, in a sensitivity analysis, we considered that drugs may be prescribed for undiagnosed symptoms of BP that resemble skin infection (protopathic bias).

RESULTS

Antibiotics were associated with the highest risk of BP [odds ratio (OR) 4.60, 95% confidence interval (CI) 4.40-4.80]. However, after adjusting for protopathic bias, the OR decreased to 2.08 (95% CI 1.99-2.17). Also, after adjusting for protopathic bias, of all the antibiotic classes and subclasses, penicillins [OR 3.44, 95% CI 3.29-3.60 (sensitivity analysis OR 1.74, 95% CI 1.66-1.84)] and penicillinase-resistant penicillins [OR 7.56, 95% CI 7.15-8.00 (sensitivity analysis OR 2.64, 95% CI 2.45-2.85)] had the strongest associations with BP risk. Other drugs strongly associated with increased risk were gliptins (OR 2.77, 95% CI 2.37-3.23) and second-generation antipsychotics (OR 2.58, 95% CI 2.20-3.03).

CONCLUSIONS

Healthcare professionals need to be aware of BP risk in older people, particularly when prescribing penicillinase-resistant penicillins, gliptins and second-generation antipsychotic drugs, to recognize and manage BP early. Owing to the low disease prevalence, we do not suggest avoiding certain drugs/vaccines to prevent BP. Further research should consider recency, dosage and duration of antibiotic treatments.

Obstructive sleep apnoea syndrome and future risk of dementia among individuals managed in UK general practice

BACKGROUND

Obstructive sleep apnoea syndrome (OSAS) has been recognised as a potential risk factor for cognitive decline, yet its precise relationship with dementia remains uncertain. This study aimed to determine the risk of dementia among individuals with and without OSAS.

METHODS

Data derived from 2.3 million adults (aged ≥18 years) were extracted from the Clinical Practice Research Datalink (2000-2022), a nationally representative primary care electronic health records database in the UK. 193 600 individuals with OSAS were propensity score-matched to 536 701 individuals without OSAS. Cox proportional hazard regression models were applied to quantify the risk of developing all-cause dementia, vascular dementia and Alzheimer's disease between individuals with and without OSAS.

RESULTS

With a median follow-up of 4.0 (IQR 1.8-7.5) years, 2802 and 6211 individuals developed all-cause dementia in those with and without OSAS, corresponding to crude incidence rates of 2.47 and 2.34 per 1000 person-years, respectively. The presence of OSAS was associated with higher risks of all-cause dementia (adjusted HR (aHR) 1.12, 95% CI 1.07 to 1.17), vascular dementia (1.29, 95% CI 1.19 to 1.41) and unchanged risk of Alzheimer's disease (1.07, 95% CI 0.99 to 1.16). Individuals with OSAS who had received continuous positive airway pressure (CPAP) treatment exhibited a similar risk of all-cause dementia as their matched counterparts (0.99, 95% CI 0.74 to 1.32).

CONCLUSION

OSAS is associated with higher risks of all-cause dementia and some of its subtypes. Further investigation is needed to investigate the clinical benefits of screening for cognitive impairment in people with OSAS and to further evaluate the impact of CPAP on cognitive decline and dementia risk.

Life course trajectories of maternal cardiovascular disease risk factors by obstetric history: a UK cohort study using electronic health records

BACKGROUND

Women who experience adverse pregnancy outcomes (APOs; gestational hypertension, preeclampsia (PE), gestational diabetes (GD), preterm birth (PTB), small or large for gestational age, miscarriage, multiple miscarriages, stillbirth, and offspring with major congenital anomalies) have increased risk of developing cardiovascular disease (CVD). We aimed to compare cardiometabolic health trajectories across the life course between women with and without APOs.

METHODS

We studied 187,186 women with a registered pregnancy in the UK Clinical Practice Research Datalink (CPRD) GOLD linked to Hospital Episode Statistics. Fractional polynomial multilevel models were used to compare trajectories of cardiometabolic risk factors (body mass index [BMI], blood pressure [BP], cholesterol, and glucose) between women with and without a history of APOs (individual APOs in any pregnancy and number of APOs). We explored two underlying time axes: (1) time relative to first pregnancy (from 10 years before first pregnancy to 15 years after) and (2) age. Models controlled for age at first pregnancy, residential area deprivation, non-singleton pregnancy, parity, smoking status, ethnicity, and medications use.

RESULTS

Women with a history of PE, gestational hypertension, or GD had higher BMI, BP, and glucose 10 years before first pregnancy compared to women without these APOs. These differences persisted 15 years post-first pregnancy. Women with a history of GD had a steeper post-partum rise in glucose. Women who experienced multiple (3 +) miscarriage, stillbirth, and/or medically indicated PTB had higher BP and BMI before and after pregnancy, with BP trajectories converging 15 years after first pregnancy. Women who experienced multiple APOs had the most adverse measurements across all cardiometabolic risk factors, with more unfavourable mean levels with each additional APO. There was little difference in cardiometabolic trajectories between women with and without a history of 1 or 2 miscarriages or congenital anomalies.

CONCLUSIONS

Women with APOs had adverse cardiometabolic profiles before first pregnancy, persisting up to 15 years post-pregnancy. Findings highlight the potential for targeted public health interventions to promote good cardiometabolic health in young adults transitioning from contraceptive use to planning pregnancies. APOs may identify young women who could benefit from monitoring CVD risk factors and interventions to improve cardiometabolic health.

Population-Based Validation Results From the Drug Repurposing for Effective Alzheimer's Medicines (DREAM) Study

We evaluated whether drugs approved for other indications that also target metabolic drivers of Alzheimer's disease and related dementia (ADRD) pathogenesis are associated with delayed onset of ADRD. Using routinely collected healthcare data from two population-based data sources from the US (Medicare) and UK (CPRD), we conducted active comparator, new-user cohort studies. Four alternate analytic and design specifications were implemented: (1) an as-treated follow-up approach, (2) an as-started follow-up approach incorporating a 6-month induction period, (3) incorporating a 6-month symptom to diagnosis period to account for misclassification of ADRD onset, and (4) identifying ADRD through symptomatic prescriptions and diagnosis codes. Of the 10 drug pairs evaluated, hydrochlorothiazide vs. dihydropyridine CCBs showed meaningful reductions in 3 out of 4 analyses that addressed specific biases including informative censoring, reverse causality, and outcome misclassification (pooled hazard ratios [95% confidence intervals] across Medicare and CPRD: 0.81 [0.75-0.88] in Analysis 1, 0.98 [0.92-1.06] in Analysis 2, 0.83 [0.75-0.91] in Analysis 3, 0.75 [0.65-0.85] in Analysis 4). Amiloride vs. triamterene, although less precise, also suggested a potential reduction in risk in 3 out of 4 analyses (0.86 [0.66-1.11] in Analysis 1, 0.98 [0.79-1.23] in Analysis 2, 0.74 [0.54-1.00] in Analysis 3, 0.61 [0.36-1.05] in Analysis 4). Other analyses suggested likely no major differences in risk (probenecid, salbutamol, montelukast, propranolol/carvedilol, and anastrozole) or had limited precision precluding a definitive conclusion (semaglutide, ciloztozol, levetiracetam). Future replication studies should be considered to validate our findings.

Identifying children who develop severe chronic kidney disease using primary care records

BACKGROUND

Understanding whether symptoms suggestive of chronic kidney disease (CKD) are reported to primary care before diagnosis may provide opportunities for earlier detection, thus supporting strategies to prevent progression and improve long-term outcomes. Our aim was to determine whether symptoms/signs or consultation frequency recorded in primary care could predict a subsequent diagnosis of chronic kidney disease in children.

METHODS

We undertook a case-control study within Clinical Practice Research Datalink. Cases were children <21 years with an incident code for severe CKD during the study period (January 2000-September 2018). Controls were matched on age (+/-3 years), sex, and practice-level kidney function testing rate. Conditional logistic regression modelling was used to identify symptoms predictive of severe CKD and differences in consultation frequency in 24- and 6-month timeframes before the index date.

RESULTS

Symptoms predictive of severe CKD in the 24 months before the index date included growth concerns (OR 7.4, 95% CI 3.5, 15.4), oedema (OR 5.7, 95% CI 2.9, 11.2) and urinary tract infection (OR 3.3, 95% CI 2.1, 5.4); within 6 months of the index date, effect estimates and specificity strengthened although sensitivity decreased. Overall, positive predictive value of symptoms was low. Cases consulted more frequently than controls in both timeframes. In combination, symptoms and consultation frequency demonstrated modest discrimination for CKD (c-statistic after bootstrapping 0.70, 95% CI 0.66, 0.73).

CONCLUSION

Despite increased consultation frequency and several symptoms being associated with severe chronic kidney disease, the positive predictive value of symptoms is low given disease rarity making earlier diagnosis challenging.

Clinical Burden and Healthcare Resource Use of Asthma in Children in the UK

Background

UK pediatric asthma prevalence is among the highest in Europe, and although the clinical and economic burden of asthma in UK adults is well described, childhood asthma data is lacking. We assessed the clinical and economic burden of asthma in children in the UK to better understand the impact of pediatric asthma.

Methods

This was a retrospective, case-matched, longitudinal analysis using the Clinical Practice Research Datalink GOLD database and linked patient-level data (Hospital Episode Statistics and Office for National Statistics datasets) of selected patient (aged 6-11 years) records in 2017. Severe exacerbation and re-exacerbation rates per patient-year (PPY), all-cause healthcare resource utilization (HCRU), and HCRU-related costs were assessed in asthma patients versus matched non-asthma controls, stratified by severity.

Results

Among 5950 patients, severe exacerbation rate was 0.06, 0.17 and 0.31 PPY for mild, moderate, and severe asthma, respectively. Incident rate of severe exacerbations were higher for moderate asthma (incident rate ratios [IRR; 95% CI] 2.87 [2.30-3.56], P<0.0001) and severe asthma (5.19 [4.20-6.41], P<0.0001) versus mild asthma. Risk of re-exacerbation was significantly increased for severe versus mild asthma (hazard ratio [95% CI]: 2.98 [1.90-4.65], P<0.001). All-cause HCRU (IRR [95% CI]) was higher in severe asthma patients versus controls (primary care: 3.81 [3.54-4.09], P<0.0001; inpatient admissions: 3.23 [2.31-4.62], P<0.0001]); total-cost ratios relative to controls for mild, moderate, and severe asthma were 1.58 (1.39-1.78, P<0.0001), 2.56 (1.97-3.33, P<0.0001), and 3.42 (2.54-4.61, P<0.0001), respectively. Asthma-related costs increased with severity (total-cost ratios: moderate versus mild, 1.68 [1.45-1.97], P<0.0001; severe versus mild, 2.67 [2.21-3.25], P<0.0001).

Conclusion

In children with asthma in the UK, increasing disease severity was associated with increased risk of severe exacerbations, re-exacerbations, and increased HCRU and costs.

Perceptions of healthcare professionals on the use of a risk prediction model to inform atrial fibrillation screening: qualitative interview study in English primary care

OBJECTIVES

There is increasing interest in guiding atrial fibrillation (AF) screening by risk rather than age. The perceptions of healthcare professionals (HCPs) towards the implementation of risk prediction models to target AF screening are unknown. We aimed to explore HCP perceptions about using risk prediction models for this purpose, and how models could be implemented.

DESIGN

Semistructured interviews with HCPs engaged in the Future Innovations in Novel Detection of AF (FIND-AF) study. Data were thematically analysed and synthesised to understand barriers and facilitators to AF screening and guiding screening using risk assessment.

SETTING

Five primary care practices in England taking part in the FIND-AF study.

PARTICIPANTS

15 HCPs (doctors, nurses/nurse practitioners, healthcare assistants, receptionists and practice managers).

RESULTS

Participants knew the health implications of AF and were supportive of the risk prediction models for AF screening. Four main themes developed: (1) health implications of AF, (2) positives and negatives of risk prediction in AF screening, (3) strategies to implement a risk prediction model and (4) barriers and facilitators to risk-guided AF screening. HCPs thought risk-guided AF screening would improve patient outcomes by reducing AF-related stroke, and this outweighed concerns over health anxiety and the impact on workload. Pop-up notifications and practice worklists were the main suggestions for risk-guided screening implementation and for this to be predominantly run by administrative staff. Many recommended the need for educating staff on AF and the prediction models to help aid the implementation of a clear protocol for longitudinal follow-up of high-risk patients and communication of risk.

CONCLUSIONS

Overall, HCPs participating in the FIND-AF study were supportive of using risk prediction to guide AF screening and willing to take on extra workload to facilitate risk-guided AF screening. The best pathway design and the method of how risk is communicated to patients require further consideration.

TRIAL REGISTRATION NUMBER

NCT05898165.

Multiple states clustering analysis (MSCA), an unsupervised approach to multiple time-to-event electronic health records applied to multimorbidity associated with myocardial infarction

Multimorbidity is characterized by the accrual of two or more long-term conditions (LTCs) in an individual. This state of health is increasingly prevalent and poses public health challenges. Adapting approaches to effectively analyse electronic health records is needed to better understand multimorbidity. We propose a novel unsupervised clustering approach to multiple time-to-event health records denoted as multiple state clustering analysis (MSCA). In MSCA, patients' pairwise dissimilarities are computed using patients' state matrices which are composed of multiple censored time-to-event indicators reflecting patients' health history. The use of state matrices enables the analysis of an arbitrary number of LTCs without reducing patients' health trajectories to a particular sequence of events. MSCA was applied to analyse multimorbidity associated with myocardial infarction using electronic health records of 26 LTCs, including conventional cardiovascular risk factors (CVRFs) such as diabetes and hypertension, collected from south London general practices between 2005 and 2021 in 5087 patients using the MSCA R library. We identified a typology of 11 clusters, characterised by age at onset of myocardial infarction, sequences of conventional CVRFs and non-conventional risk factors including physical and mental health conditions. Interestingly, multivariate analysis revealed that clusters were also associated with various combinations of socio-demographic characteristics including gender and ethnicity. By identifying meaningful sequences of LTCs associated with myocardial infarction and distinct socio-demographic characteristics, MSCA proves to be an effective approach to the analysis of electronic health records, with the potential to enhance our understanding of multimorbidity for improved prevention and management.

Impact of Pharmacovigilance Interventions Targeting Fluoroquinolones on Antibiotic Use in the Netherlands and the United Kingdom

PURPOSE

Fluoroquinolones are antibiotics associated with adverse events that prompted the European Medicines Agency to implement risk minimization measures (RMMs) in 2018/19 and 2020. Our aim is to assess the RMMs' impact on antibiotic prescriptions in primary care during 2014-2023.

METHODS

We assessed antibiotic prescriptions using CPRD GOLD (the United Kingdom, UK) and PHARMO (the Netherlands, NL). Prescriptions were assessed for fluoroquinolones and alternative antibiotics. The impact of RMMs on prescribing was assessed with interrupted time series (ITS) using monthly prescription rates per 10 000 person-years (MPTPY).

RESULTS

Between 2014 and 2023, we identified cohorts of 4.0 (UK) and 0.9 million (NL) antibiotic users. Fluoroquinolones were prescribed to initiate 1.5% (UK) to 5.8% (NL) of the treatment episodes. Fluoroquinolone prescribing before the RMMs slowly decreased in the UK and was stable in the NL. The 2018/19 RMMs were associated with a steady downward post-RMMs trend in incident use of fluoroquinolones (MPTPY -0.7 [UK] and -0.8 [NL]) and opposite changes after 2020 RMMs (MPTPY 0.6 [UK] and 1.8 [NL]). The 2018/2019 RMMs were linked with increasing trends for other antibacterials (J01XX) in both countries and other beta-lactam antibacterials in the UK, but most antibiotics had decreasing trends post-RMMs in both countries. After the 2020 RMMs, some antibiotic groups showed upward trends.

CONCLUSION

The risk minimization measures in 2018/2019 were associated with a moderate decrease in fluoroquinolone prescribing, with no further decrease after 2020 RMMs. There was no sustained increase in other antibiotic prescribing, suggesting that overprescribing was negligible as an unintended impact of RMMs.

Short-Term Risk of Cardiovascular Events in People Newly Diagnosed With Gout

OBJECTIVE

To investigate the temporal association between the first diagnosis of gout and cardiovascular events in the short term.

METHODS

We performed a self-controlled case series analysis and a cohort study using data from linked primary care, hospitalization, and mortality records from the United Kingdom's Clinical Practice Research Database-GOLD. We included individuals with a new diagnosis of gout either in the primary care or secondary care between January 1, 1997 and December 31, 2020. The first consultation at which gout was diagnosed was the exposure of interest. The main outcome consisted of cardiovascular events (ie, a composite of fatal and nonfatal myocardial infarction, ischemic or hemorrhagic stroke, and transient ischemic attack).

RESULTS

The 4,398 patients (66.9% male, mean age 74.6 years) had a cardiovascular event within at least two years of their first recorded diagnosis of gout. The incidence of cardiovascular events was significantly higher in the 30 days after the first diagnosis of gout compared to baseline (adjusted incidence rate ratio 1.55, 95% confidence interval [CI] 1.33-1.83). Among 76,440 patients (72.9% male, mean age 63.2 years) included in the cohort study, the incidence of cardiovascular events in the 30 days after the first gout diagnosis (31.2 events per 1,000 person-years, 95% CI 27.1-35.9) was significantly higher than in days 31 to 730 after gout diagnosis (21.6 events per 1,000 person-years, 95% CI 20.8-22.4) with a rate difference of -9.6 events per 1,000 person-years (95% CI -14.0 to -5.1).

CONCLUSION

Individuals had a short-term increased risk of cardiovascular events in the 30 days following the first consultation at which gout was diagnosed.

Adverse childhood experiences in firstborns and mental health risk and health-care use in siblings: a population-based birth cohort study of half a million children in England

BACKGROUND

Adverse childhood experiences (ACEs) often affect multiple children within families, yet studies tend to focus on the health outcomes of individual children, underestimating the needs of affected families. We aimed to examine the association between firstborns exposed to ACEs between 1 year before and 2 years after birth (the first 1000 days) and the risks of mental health problems, mental health-related health-care contacts, and all-cause hospital admissions in multiple children from the same mother, compared to firstborns without ACEs.

METHODS

We derived a population-based birth cohort in England using linked electronic health records for first-time mothers (aged 14-55 years) with their children (born 2002-18). We followed up the cohort from 1 year before birth up to 18 years after birth across the Clinical Practice Research Datalink GOLD and Aurum databases (primary care), Hospital Episode Statistics (secondary care), and the Office of National Statistics (death registrations) between April 1, 2001, and March 31, 2020. We included six different ACE domains, including child maltreatment, intimate partner violence, maternal substance misuse, maternal mental health problems, adverse family environments, and high-risk presentations of child maltreatment, in the records of the mother or the firstborn in the first 1000 days. The primary outcome was the number of children (aged 5-18 years) with recorded mental health problems per mother. We used adjusted and weighted negative binomial regression models to estimate incidence rate ratios.

FINDINGS

Of 333 048 firstborns and their mothers, 123 573 (37·1%) had any ACEs between 1 year before and 2 years after birth, and 65 941 (19·8%) of all mothers had at least one child with a mental health problem between ages 5 years and 18 years (median follow-up 11·4 years [IQR 9·2-14·1]). Mothers with firstborns with ACEs had 1·71 (95% CI 1·68-1·73) times as many children in total with mental health problems (mean 29·8 children per 100 mothers, 29·4-30·1) compared with mothers without firstborns with ACEs (mean 17·4 children per 100 mothers, 17·3-17·6), translating into a mean difference of 12·3 (95% CI 11·9-12·7) additional children with mental health problems per 100 mothers. These mothers also had increased incidence rates of children with all-cause emergency admissions and mental health-related contacts. There was no significant difference in the risk of mental health problems between firstborn and later-born children.

INTERPRETATION

ACEs in firstborns during the first 1000 days were associated with increased mental health problems and health-care needs in multiple children in the same family. The findings highlight the importance of early identification of vulnerable first-time parents and firstborns and increased policy focus on sustained support beyond the first 1000 days to promote healthier long-term family outcomes. Future evaluations of interventions should include the health outcomes of multiple children within families.

FUNDING

NIHR Policy Research Programme.

The impact of operational trial approaches on representativeness: Comparison of decentralized clinical trial participants, conventional trial participants, and patients in daily practice

Decentralized clinical trial (DCT) approaches - in which trial activities are conducted at participants' homes - have the potential to improve representativeness. We present a study that compared the demographics and cardiovascular risk factors of participants from a DCT (ASCEND) and a conventional trial with a similar trial objective (POPADAD) to those of patients in daily practice. We adjudicate that there are relevant differences when comparing the participants of the conventional trial and the DCT, with the latter providing better representativeness in terms of age, insulin use, smoking status, and body mass index, whereas conventional trial participants were more representative in terms of biological sex. Differences in these characteristics were not explained by the eligibility criteria, but are considered attributable to the operational trial approach.

Metformin and risk of adverse pregnancy outcomes among pregnant women with gestational diabetes in the United Kingdom: A population-based cohort study

AIMS

Metformin is increasingly used off-label as the treatment of gestational diabetes (GDM). Our objective was to determine if metformin versus insulin initiation is associated with the adverse pregnancy outcomes.

MATERIALS AND METHODS

We conducted a retrospective cohort study using data from the Clinical Practice Research Datalink, its pregnancy register, and Hospital Episode Statistics from 1998 to 2018. We included pregnancies of women who initiated metformin or insulin between 20 weeks gestation and pregnancy end. The primary outcome was a composite outcome of large for gestational age (LGA) and macrosomia. The secondary outcomes included small for gestational age (SGA), preterm birth, caesarean delivery, and hypertensive disorders during pregnancy (HDP). Inverse probability weighted-Cox proportional hazards models were to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CI), comparing those who initiated metformin versus insulin at cohort entry, accounting for baseline covariates.

RESULTS

Our cohort included pregnancies of 1297 women initiating metformin and of 895 women initiating insulin. Compared to insulin initiation, metformin initiation was associated with a decreased risk of LGA or macrosomia (HR 0.64, 95% CI 0.49, 0.78), Caesarean delivery (HR 0.83, 95% CI 0.69, 0.98), and preterm birth (HR 0.83, 95% CI 0.58, 1.08). The HRs for HDP and SGA were 0.92 (95% CI 0.57, 1.27) and 1.33 (95% CI 0.67, 2.00), respectively.

CONCLUSIONS

Our study suggests that, compared to initiating insulin, initiating metformin is associated with decreased risks of adverse pregnancy outcomes among women with GDM. These findings provide important real-world evidence regarding the use of metformin for GDM.

The Clinical Practice Research Datalink (CPRD) Mother-Baby Links: A Data Resource Profile

PURPOSE

Maternal exposures before, during and after pregnancy can affect the infant. It is therefore important that researchers study mothers and their children. The CPRD GOLD Mother-Baby Link (MBL) algorithm was applied to the CPRD Aurum database, to extend the useful tool. Here, we present the algorithm and data resource profiles of the CPRD MBLs.

METHODS

Records of female patients registered with a CPRD practice between the 1st January 1987 and the 1st June 2023 were searched for evidence of delivery. Infants born and registered between 1st January 1987 and 1st June 2023 were matched to mothers on practice and household indicators. The resulting MBLs were characterised.

RESULTS

The CPRD MBL algorithm was applied to the CPRD databases resulting in nearly four-million mother-baby pairs: 2.4-million in CPRD Aurum. Mothers in the CPRD GOLD and CPRD Aurum MBL's were similar in terms of age; mean age 29.6 years (SD = 5.7) vs. 30.2 years (SD = 5.7), and length of GP registration; mean = 14.4 years (SD = 10.9) vs. mean = 13.7 (SD = 10.9). The median number of matches was slightly higher in the CPRD GOLD MBL; 2 (IQR = 1, 2) vs. 1 (IQR = 1, 2). The number of matches in both databases peaked in 2008-2011, followed by a steady decline to 2023.

CONCLUSION

The CPRD MBL's offer a valuable tool for researchers to study the mother-infant relationship. Extending the CPRD MBL algorithm to CPRD Aurum has increased the capacity for researchers to investigate rarer exposures and outcomes.

Evaluating the quality of prostate cancer diagnosis recording in CPRD GOLD and CPRD Aurum primary care databases for observational research: A study using linked English electronic health records

BACKGROUND

Primary care data in the UK are widely used for cancer research, but the reliability of recording key events like diagnoses remains uncertain. Although data linkage can improve reliability, its costs, time requirements, and sample size constraints may discourage its use. We evaluated accuracy, completeness, and date concordance of prostate cancer (PCa) diagnosis recording in Clinical Practice Research Datalink (CPRD) GOLD and Aurum compared to linked Cancer Registry (CR) and Hospital Episode Statistics (HES) Admitted Patient Care (APC) in England.

METHODS

Incident PCa diagnoses (2000-2016) for males aged ≥46 at diagnosis who remained registered with their General Practitioner (GP) by age 65 and were recorded in at least one data source were analysed. Accuracy was the proportion of diagnoses recorded in GOLD or Aurum with a corresponding record in CR or HES. Completeness was the proportion of CR or HES diagnoses with a corresponding record in GOLD or Aurum.

RESULTS

The final cohorts for comparisons included 29,500 records for GOLD and 26,475 for Aurum. Compared to CR, GOLD was 86 % accurate and 65 % complete, while Aurum was 87 % accurate and 77 % complete. Compared to HES, GOLD was 76 % accurate and 60 % complete, and Aurum was 79 % accurate and 70 % complete. Concordance in diagnosis dates improved over time in both GOLD and Aurum, with 93 % of diagnoses recorded within a year compared to CR, and 66 % (GOLD) and 71 % (Aurum) compared to HES. Delays of 2-3 weeks in primary care diagnosis recording were observed compared to CR, whereas most diagnoses appeared at least 3 months earlier in primary care than in HES.

CONCLUSIONS

Aurum demonstrated better accuracy and completeness for PCa diagnosis recording than GOLD. However, linkage to HES or CR is recommended for improved case capture. Researchers should address the limitations of each data source to ensure research validity.

Differences in recording of cancer diagnosis between datasets in England: A population-based study of linked cancer registration, hospital, and primary care data

BACKGROUND

Differences in the recording of cancer case status and diagnosis date have been observed between cancer registry (CR) - the reference standard - and electronic health records (EHRs); such differences may affect estimates of cancer risk or misclassify diagnostic pathways. This study aims to quantify differences in recording of case status and date of cancer diagnosis between cancer registry and EHRs.

METHODS

Linked primary care (Clinical Practice Research Datalink (CPRD)), secondary care (Hospital Episode Statistics (HES)) and national Cancer Registry (CR) data, were used to identify 14,301 patients with a recorded diagnosis of brain, colon, lung, ovarian, or pancreatic cancer between 1999 and 2018. Agreement in case status between datasets, differences in recorded diagnosis dates, and change in agreement over time were investigated for each cancer site.

RESULTS

Between 84 % (ovary) to 92 % (colon) of diagnoses in cancer registry were also recorded in combined CPRD-HES data. Agreement with cancer registry was slightly lower in HES (78 % (ovary) to 86 % (colon)) and CPRD (61 % (ovary, pancreas) to 72 % (brain)). The proportion of CPRD-HES diagnoses confirmed in CR varied by cancer site (50 % (brain) to 86 % (lung)). Agreement between CR and HES was relatively stable within cancer sites over time. Concordance between CR and CPRD was more heterogeneous between cancer sites and over time. Best agreement in diagnosis date was observed between CR and HES (median difference 0 or 1 days, all cancer sites).

CONCLUSION

Agreement between CR and EHR data is heterogeneous across cancer sites. Concordance does not appear to have improved over time. Combined data from primary and secondary care may be sufficient to approximate case status in CR in some circumstances, but the date we consider to represent the diagnosis may impact study outcomes.

Burden of vascular risk factors by age, sex, ethnicity and deprivation in young adults with and without newly diagnosed type 2 diabetes

AIMS

Do associations between age at diagnosis of type 2 diabetes and vascular risk factors vary by ethnicity and deprivation?

METHODS

Utilising the Clinical Practice Research Datalink, we matched 16-50-year-old individuals with newly diagnosed type 2 diabetes to ∼10 individuals without using sex, age and primary care practice. Differences in BMI, obesity, LDL-cholesterol, HbA1c, and hypertension between individuals with vs without type 2 diabetes across sex, age, ethnicity and deprivation quintiles were explored using generalised linear models.

RESULTS

We included 108,061 individuals (45.6% women) with newly diagnosed type 2 diabetes and 829,946 controls. BMI, obesity, LDL-cholesterol, and hypertension were higher in individuals with vs without type 2 diabetes. Across both sexes, all ethnic groups and deprivation quintiles, these differences were larger with an earlier age, particularly for BMI and obesity. Association between age and HbA1c were variable across subgroups. Differences in BMI, obesity, and hypertension (individuals with vs without diabetes) were largest in White individuals and with less deprivation.

CONCLUSIONS

The increased vascular risk phenotype associated with an earlier age of diagnosis of type 2 diabetes was consistent across ethnic and deprivation groups. Population-based strategies are needed to address the risk associated with early-onset type 2 diabetes, especially weight-management-based strategies.

Incidence trends in ischaemic and non-ischaemic heart failure in people with and without type 2 diabetes, 2000-2019: An observational study in England

AIM

To investigate trends in ischaemic and non-ischaemic heart failure (HF) in adults with type 2 diabetes and without diabetes between 1st January 2000 and 31st December 2019 in England.

METHODS

We used the Clinical Practice Research Datalink datasets, linked to the Hospital Episode Statistics and Office for National Statistics, to estimate sex-specific crude and age-standardised rates of incident ischaemic and non-ischaemic HF up to 10 years per calendar year of diabetes diagnosis and diabetes status.

RESULTS

In a cohort of 735,810 individuals, 5,073 ischaemic (2,038 in people with type 2 diabetes and 3,035 in those without) and 16,501 non-ischaemic (6,358 and 10,143, respectively) HF events were recorded during a median follow-up of 10 years. From 2000 to 2004 to 2005-2009, the age-standardised rates of ischaemic HF marginally declined, while rates remained stable for non-ischaemic HF and were consistently higher for non-ischaemic than ischaemic HF, regardless of diabetes status or sex. Adjusted incidence rate ratios demonstrated negligible impact on trends after accounting for differences in demographics, comorbidities and medications.

CONCLUSIONS

Improving HF prevention and management strategies remains crucial to decrease the risk of HF in the general population and reduce the persistent risk-gap associated with type 2 diabetes in England.

Gestational diabetes mellitus and subsequent cardiovascular disease in a period of rising diagnoses: Cohort study

INTRODUCTION

Evidence suggests that gestational diabetes mellitus (GDM) is associated with subsequent cardiovascular disease; however, it is unclear what impact changes in screening and diagnostic criteria have had on the association of GDM with long-term outcomes such as cardiovascular disease. The purpose of this study was to determine the association between GDM and subsequent cardiovascular disease during a period of rising gestational diabetes diagnosis in England. Specifically, associations were compared before and after 2008, when national guidelines supporting risk factor-based screening were introduced.

MATERIAL AND METHODS

We conducted a cohort study using routinely collected data from the Clinical Practice Research Datalink linked to the Hospital Episode Statistics and Office for National Statistics databases. The study consisted of persons aged 15-45 years with a livebirth or stillbirth between 1998 and 2017 and without a history of cardiovascular disease or pre-pregnancy diabetes mellitus. Cox proportional hazards models, with propensity score weighting using matching weights, were used to estimate adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for the association of GDM diagnosis in the first recorded pregnancy with subsequent cardiovascular disease.

RESULTS

Among 232 315 individuals, the incidence of cardiovascular disease was 6.6 per 1000 person-years among those with GDM and 2.2 per 1000 person-years among those without GDM over a mean follow-up duration of 5.8 years. The overall aHR, 95% CI was 1.91 (1.41, 2.60). Diagnosis of GDM increased over the study period, from 0.7% in 1998-99 to 5.3% in 2017. The effect size was not markedly different in the years before (1998-2007: adjusted HR 2.05, 95% CI 2.05 1.35, 3.12) and after 2008 (2008-2017: adjusted HR 1.79, 95% CI 1.15, 2.80).

CONCLUSIONS

There was a strong association of GDM with cardiovascular disease after accounting for social and demographic factors and multiple comorbidities, and this association was present both before and after 2008, when national gestational diabetes screening criteria were established.

Monitoring for 5-aminosalicylate nephrotoxicity in adults with inflammatory bowel disease: prognostic model development and validation using data from the Clinical Practice Research Datalink

OBJECTIVE

To develop and validate a prognostic model for risk-stratified monitoring of 5-aminosalicylate nephrotoxicity.

METHODS

This UK retrospective cohort study used data from the Clinical Practice Research Datalink Aurum and Gold for model development and validation respectively. It included adults newly diagnosed with inflammatory bowel disease and established on 5-aminosalicylic acid (5-ASA) treatment between 1 January 2007 and 31 December 2019. Drug discontinuation associated with 5-ASA nephrotoxicity defined as a prescription gap of ≥90 days with decline in kidney function was the outcome. Patients prescribed 5-ASAs for ≥6 months were followed-up for up to 5 years. Penalised Cox regression was used to develop the risk equation with bootstrapping for internal validation and optimism adjustment. Model performance was assessed in terms of calibration and discrimination.

RESULTS

13 728 and 7318 participants who contributed 40 378 and 20 679 person-years follow-up formed the development and validation cohorts with 170 (1.2%) and 98 (1.3%) outcome events respectively. Nine predictors were included in the final model, including chronic kidney disease stage 3 and hazardous alcohol use as strong predictors. Age and Body Mass Index were weak predictors. The optimism-adjusted calibration slope, C and D statistics in the development and validation data were 0.90, 0.64 and 0.98, and 1.01, 0.66 and 0.94 respectively.

CONCLUSION

This prognostic model used information from routine clinical care and performed well in an independent validation cohort. It can be used to risk-stratify blood test monitoring during established 5-ASA treatment. A key limitation is that the decline in kidney function could have been due to factors other than 5-ASA nephrotoxicity.

Prevalence and patient characteristics associated with cardiovascular disease risk factor screening in UK primary care for people with severe mental illness: an electronic healthcare record study

BACKGROUND

People with severe mental illness (SMI) are at increased risk of cardiovascular disease (CVD), and initiatives for CVD risk factor screening in the UK have not reduced disparities.

OBJECTIVES

To describe the annual screening prevalence for CVD risk factors in people with SMI from April 2000 to March 2018, and to identify factors associated with receiving no screening and regular screening.

METHODS

We identified adults with a diagnosis of SMI (schizophrenia, bipolar disorder or 'other psychosis') from UK primary care records in Clinical Practice Research Datalink. We calculated the annual prevalence of screening for blood pressure, cholesterol, glucose, body mass index, alcohol consumption and smoking status using multinomial logistic regression to identify factors associated with receiving no screening and complete screening.

RESULTS

Of 216 136 patients with SMI, 55% received screening for all six CVD risk factors at least once during follow-up and 35% received all six within a 1-month period. Our findings suggest that patient characteristics and financial incentivisation influence screening prevalence of individual CVD risk factors, the likelihood of receiving screening for all six CVD risk factors annually and risk of receiving no screening.

CONCLUSIONS

The low proportion of people with SMI receiving regular comprehensive CVD risk factor screening is concerning. Screening needs to be embedded as part of broad physical health checks to ensure the health needs of people with SMI are being met. If we are to improve cardiovascular health, interventions are needed where risk of receiving no screening or not receiving regular screening is highest.

Open challenges and opportunities in federated foundation models towards biomedical healthcare

This survey explores the transformative impact of foundation models (FMs) in artificial intelligence, focusing on their integration with federated learning (FL) in biomedical research. Foundation models such as ChatGPT, LLaMa, and CLIP, which are trained on vast datasets through methods including unsupervised pretraining, self-supervised learning, instructed fine-tuning, and reinforcement learning from human feedback, represent significant advancements in machine learning. These models, with their ability to generate coherent text and realistic images, are crucial for biomedical applications that require processing diverse data forms such as clinical reports, diagnostic images, and multimodal patient interactions. The incorporation of FL with these sophisticated models presents a promising strategy to harness their analytical power while safeguarding the privacy of sensitive medical data. This approach not only enhances the capabilities of FMs in medical diagnostics and personalized treatment but also addresses critical concerns about data privacy and security in healthcare. This survey reviews the current applications of FMs in federated settings, underscores the challenges, and identifies future research directions including scaling FMs, managing data diversity, and enhancing communication efficiency within FL frameworks. The objective is to encourage further research into the combined potential of FMs and FL, laying the groundwork for healthcare innovations.

Going beyond randomised controlled trials to assess treatment effect heterogeneity across target populations

Methods have been developed for transporting evidence from randomised controlled trials (RCTs) to target populations. However, these approaches allow only for differences in characteristics observed in the RCT and real-world data (overt heterogeneity). These approaches do not recognise heterogeneity of treatment effects (HTE) according to unmeasured characteristics (essential heterogeneity). We use a target trial design and apply a local instrumental variable (LIV) approach to electronic health records from the Clinical Practice Research Datalink, and examine both forms of heterogeneity in assessing the comparative effectiveness of two second-line treatments for type 2 diabetes mellitus. We first estimate individualised estimates of HTE across the entire target population defined by applying eligibility criteria from national guidelines (n = 13,240) within an overall target trial framework. We define a subpopulation who meet a published RCT's eligibility criteria ('RCT-eligible', n = 6497), and a subpopulation who do not ('RCT-ineligible', n = 6743). We compare average treatment effects for pre-specified subgroups within the RCT-eligible subpopulation, the RCT-ineligible subpopulation, and within the overall target population. We find differences across these subpopulations in the magnitude of subgroup-level treatment effects, but that the direction of estimated effects is stable. Our results highlight that LIV methods can provide useful evidence about treatment effect heterogeneity including for those subpopulations excluded from RCTs.

Cancer incidence and mortality among patients with new-onset atrial fibrillation: A population-based matched cohort study

BACKGROUND

Understanding the risk of cancer after the diagnosis of another condition can present opportunities for earlier diagnosis. We examined the risk of cancer diagnosis conditional on prior diagnosis of atrial fibrillation (AF).

METHODS

Linked electronic health records were used to identify patients aged ≥18 with new-onset AF and age-sex-matched controls. Cumulative incidence of and mortality from cancer (overall and cancer-site specific) within three months, three months to five years and beyond five years from diagnosis of AF were examined. Findings were further validated using Mendelian randomisation (MR).

RESULTS

The cohort included 117,173 patients with new-onset AF and 117,173 matched controls (median age 78). In the first three months, 2.2% of AF patients were diagnosed with cancer vs. 0.47% in controls (relative risk: 4.7 [95%CI 4.2-5.4] in men and 4.4 [95%CI 3.8-5.0] in women). Nearly 80% of cancers related to thoracic or abdominal organs. Differences in cumulative incidence were only evident in women between three months and five years (subdistribution hazard ratio=1.1 [95%CI 1.01-1.12]) and absent in all patients beyond five years. MR analysis did not support the presence of a causal association between AF and major cancer subtypes.

CONCLUSION

There is a large short-term increase in cancer incidence and mortality following new-onset AF. The findings may reflect incidental identification of AF or paraneoplastic manifestation. New-onset AF confers high short-term risk of cancer diagnosis, at levels comparable with symptomatic risk threshold mandating urgent assessment for suspected cancer.

Disease burden, healthcare resource utilisation, and treatment patterns in patients with newly diagnosed myasthenia gravis in England: A retrospective cohort study

BACKGROUND

Myasthenia gravis (MG), a chronic and unpredictable autoimmune disease, is associated with multiple comorbidities and high disease burden.

OBJECTIVE

To assess the disease burden, healthcare resource utilisation (HCRU), and treatment patterns of patients with newly diagnosed MG in England.

METHODS

Data from Clinical Practice Research Datalink GP practices linked to the Hospital Episode Statistics database were used. Eligible patients had ≥1 diagnostic code for MG, with the first MG diagnostic code recorded between 01 January 2010 and 31 December 2019. Non-MG controls were selected if they had no recorded MG diagnosis and ≥12 months of data. Controls were matched for age, sex and GP practice in a maximum ratio of 5:1.

RESULTS

Mean follow-up duration was 2.8 and 3.1 years for the MG and non-MG cohorts, respectively. In the MG cohort, 56% of patients were male, with a mean age of 67 years at baseline. Incidence rates of all comorbidities assessed during follow-up were higher in the MG cohort than in controls. Almost two-thirds of MG patients experienced ≥1 myasthenic exacerbation during follow-up; incidence rates (95% confidence interval) of MG exacerbations and crises were 50.0 (44.7-55.9) and 1.3 (0.8-2.0) per 100 person-years, respectively. Visits to non-neurology specialists and outpatient clinics were the most common instances of HCRU overall, each being more frequent in the MG cohort than for controls. In the first year of follow-up, acetylcholinesterase inhibitors (AChEIs) and corticosteroids were used by 56.0% and 50.2% of MG patients, respectively; the use of AChEIs declined thereafter.

CONCLUSIONS

Despite treatment, there is a high disease burden for patients with newly diagnosed MG in England, with high rates of MG exacerbation and HCRU use. Thus, there is a need for targeted treatments with sustained efficacy and improved safety to adequately manage MG symptoms and reduce MG-related disease burden.

Treatment for osteoporosis and risk of osteonecrosis of the jaw among female patients in the United Kingdom Clinical Practice Research Datalink

Osteonecrosis of the jaw (ONJ) is an adverse effect of antiresorptives. Among female patients treated for osteoporosis, ONJ risk was threefold higher after 2-3 years of treatment and eightfold after 10 years compared with past use. Absolute risks remained low (~ 0.05% after 5 years) and diminished after discontinuation.

PURPOSE

Osteonecrosis of the jaw (ONJ) is a rare adverse effect of antiresorptive drug use; however, the magnitude of risk in osteoporosis patients has not been clearly described.

METHODS

We conducted a cohort study among cancer-free female patients aged 40-89 with, or at risk for, osteoporosis in United Kingdom Clinical Practice Research Datalink (CPRD) Aurum. We followed patients from first osteoporosis treatment until first of osteonecrosis diagnosis, age 90, record end, or other prespecified censoring event, and accumulated person-time by osteoporosis treatment. ONJ cases were selected from CPRD Aurum and linked Hospital Episode Statistics data using an algorithm and manual review. We estimated incidence rates (IR) of ONJ by current treatment type and post discontinuation. We conducted a nested case-control analysis to further describe risk by cumulative dose and duration of antiresorptive therapies.

RESULTS

Among 467,654 eligible patients, there were 208 ONJ cases. IR among patients currently treated with antiresorptives (primarily alendronate) was 1.2 (95% confidence interval [CI] 1.0-1.4) per 10,000 person-years. Compared with past use of antiresorptives, odds ratios of ONJ were 3.0 (95% CI 1.5-5.7) after 2-3 years of treatment and 8.1 (95% CI 4.4-15) after 10 years. However, absolute risks remained low (~ 0.05% after 5 years and ~ 0.18% after 10 years) and elevated risks diminished to near zero within 6 to 9 months of discontinuation.

CONCLUSION

Risk of ONJ increased after 2-3 years of treatment with antiresorptives; however, the absolute risk was low and returned to baseline shortly after treatment discontinuation.

The Stockholm early detection of cancer study (STEADY-CAN): rationale, design, data collection, and baseline characteristics for 2.7 million participants

The Stockholm Early Detection of Cancer Study (STEADY-CAN) cohort was established to investigate strategies for early cancer detection in a population-based context within Stockholm County, the capital region of Sweden. Utilising real-world data to explore cancer-related healthcare patterns and outcomes, the cohort links extensive clinical and laboratory data from both inpatient and outpatient care in the region. The dataset includes demographic information, detailed diagnostic codes, laboratory results, prescribed medications, and healthcare utilisation data. Since its inception, STEADY-CAN has collected longitudinal data on 2,732,005 individuals aged ≥ 18 years old living in or having access to health care in Stockholm County during the years 2011-2021. Focusing on cancer, the cohort includes 140,042 (5.1%) individuals with incident cancer and a control group of 2,591,963 (94.9%) cancer-free individuals. The cohort's diverse adult population enables robust analyses of early symptom detection, incidental findings, and the impact of comorbidities on cancer diagnoses. Utilizing the wide range of available laboratory data and clinical variables allow for advanced statistical analyses and adjustments for important confounding factors. The cohort's primary focus is to improve understanding of the early diagnostic phase of cancer, offering a crucial resource for studying cancer detection in clinical practice. Its comprehensive data collection provides unique opportunities for research into comorbidities and cancer outcomes, making the cohort a useful resource for ongoing cancer surveillance and public health strategies. The present study gives a detailed description of the rationale for creating the STEADY-CAN cohort, its design, the data collection procedure, and baseline characteristics of collected data.

Oral Corticosteroid-Related Healthcare Resource Utilization and Associated Costs in Patients with COPD

INTRODUCTION

Oral corticosteroids (OCS) are used to manage chronic obstructive pulmonary disease (COPD) exacerbations but are associated with adverse outcomes that may increase healthcare resource utilization and costs. We compared attendance/costs associated with OCS-related adverse outcomes in patients who ever used OCS versus those who never used OCS and examined associations between cumulative OCS exposure and attendance/costs.

METHODS

This direct matched observational cohort study used the UK Clinical Practice Research Datalink GOLD database (data range 1987-2019). Patients with a COPD diagnosis on/after April 1, 2003, and Hospital Episode Statistics linkage were included. Emergency room, specialist or primary care outpatient, and inpatient attendance were analyzed. Costs, estimated using Health and Social Care 2019 and National Health Service Reference Costs 2019-2020 reports, were adjusted for sex, age, exacerbation number, and inhaler type used in the 12 months before index date.

RESULTS

The OCS cohort had higher annualized disease-specific (excluding respiratory) total attendance/costs versus the non-OCS cohort (adjusted incidence rate ratio [aIRR] with 95% confidence intervals [CIs]) ranging from 37% (1.37 [1.31, 1.43]) for emergency room attendances to 149% (2.49 [2.36, 2.63]) for specialist consultations. Disease-specific (excluding respiratory) attendance/costs increased in a positive dose-response relationship for most attendance categories versus the < 0.5 g reference dose. For the 0.5 to < 1.0 g cumulative dose category, the greatest increases in disease-specific (excluding respiratory) attendance/costs occurred for primary care consultations (aIRR [95% CI] 1.38 [1.32, 1.44]). For the ≥ 10 g cumulative dose category, the greatest increases were observed for primary care consultations (aIRR [95% CI] 2.83 [2.66, 3.00]), non-elective long stays (≥ 2 days; 2.54 [2.15, 2.99]), and non-elective short stays (≤ 1 day; 2.51 [2.12, 2.98]). Similar findings were observed for all-cause attendance/costs.

CONCLUSION

Among patients with COPD, OCS-related adverse outcomes were associated with higher attendance and costs, with a positive dose-response relationship. A graphical abstract is available with this article.

Comparative cardiometabolic safety and effectiveness of aripiprazole in people with severe mental illness: A target trial emulation

BACKGROUND

There is limited and conflicting evidence on the comparative cardiometabolic safety and effectiveness of aripiprazole in the management of severe mental illness. We investigated the hypothesis that aripiprazole has a favourable cardiometabolic profile, but similar effectiveness when compared to olanzapine, quetiapine, and risperidone.

METHODS AND FINDINGS

We conducted an observational emulation of a head-to-head trial of aripiprazole versus olanzapine, quetiapine, and risperidone in UK primary care using data from the Clinical Practice Research Datalink. We included adults diagnosed with severe mental illness (i.e., bipolar disorder, schizophrenia, and other non-organic psychoses) who were prescribed a new antipsychotic between 2005 and 2017, with a 2-year follow-up to 2019. The primary outcome was total cholesterol at 1 year (cardiometabolic safety). The main secondary outcome was psychiatric hospitalisation (effectiveness). Other outcomes included body weight, blood pressure, all-cause discontinuation, and mortality. Analyses adjusted for baseline confounders, including sociodemographics, diagnoses, concomitant medications, and cardiometabolic parameters. We included 26,537 patients (aripiprazole, n = 3,573, olanzapine, n = 8,554, quetiapine, n = 8,289, risperidone, n = 6,121). Median (IQR) age was 53 (42-67) years, 55.4% were female, 82.3% White, and 18.0% were diagnosed with schizophrenia. Patients prescribed aripiprazole had similar total cholesterol levels after 1 year to those prescribed olanzapine (adjusted mean difference [aMD], -0.03, 95% CI, -0.09 to 0.02, p = 0.261), quetiapine (aMD, -0.03, 95% CI, -0.09 to 0.03, p = 0.324), and risperidone (aMD, -0.01, 95% CI, -0.08 to 0.05, p = 0.707). However, there was evidence that patients prescribed aripiprazole had better outcomes on other cardiometabolic parameters, such as body weight and blood pressure, especially compared to olanzapine. After additional adjustment for prior hospitalisation, patients prescribed aripiprazole had similar rates of psychiatric hospitalisation as those prescribed olanzapine (adjusted hazard ratio [aHR], 0.91, 95% CI, 0.82 to 1.01, p = 0.078), quetiapine (aHR, 0.94, 95% CI, 0.85 to 1.04, p = 0.230), or risperidone (aHR, 1.01, 95% CI, 0.91 to 1.12, p = 0.854).

CONCLUSIONS

Data from our large, powered, diverse, real-world target trial emulation sample, followed over 2 years, suggest that adults diagnosed with severe mental illness prescribed aripiprazole have similar total cholesterol 1 year after first prescription compared to those prescribed olanzapine, quetiapine, and risperidone. However, patients prescribed aripiprazole had better outcomes on some other cardiometabolic parameters, and there was little evidence of differences in effectiveness. Our findings inform a common clinical dilemma and contribute to the evidence base for real-world clinical decision-making on antipsychotic choice for patients diagnosed with severe mental illness.

Identifying and Predicting Risk for Hospital Admission among Patients with Parkinsonism

BACKGROUND

Patients with parkinsonism are more likely than age-matched controls to be admitted to hospital. It may be possible to reduce the cost and negative impact by identifying patients at highest risk and intervening to reduce hospital-related costs. Predictive models have been developed in nonparkinsonism populations.

OBJECTIVES

The aims were to (1) describe the reasons for admission, (2) describe the rates of hospital admission/emergency department attendance over time, and (3) use routine data to risk stratify unplanned hospital attendance in people with parkinsonism.

METHODS

This retrospective cohort study used Clinical Practice Research Datalink GOLD, a large UK primary care database, linked to hospital admission and emergency department attendance data. The primary diagnoses for nonelective admissions were categorized, and the frequencies were compared between parkinsonism cases and matched controls. Multilevel logistic and negative binomial regression models were used to estimate the risk of any and multiple admissions, respectively, for patients with parkinsonism.

RESULTS

There were 9189 patients with parkinsonism and 45,390 controls. The odds of emergency admission more than doubled from 2010 to 2019 (odds ratio [OR] 2.33; 95% confidence interval [CI] 1.96, 2.76; P-value for trend <0.001). Pneumonia was the most common reason for admission among cases, followed by urinary tract infection. Increasing age, multimorbidity, parkinsonism duration, deprivation, and care home residence increased the odds of admission. Rural location was associated with reduced OR for admission (OR 0.79; 95% CI 0.70, 0.89).

CONCLUSIONS

Our risk stratification tool may enable empirical targeting of interventions to reduce admission risk for parkinsonism patients.

Multimorbidity in elderly patients with or without T2DM: A real-world cross-sectional analysis based on primary care and hospitalisation data

Background

Shanghai's high level of ageing has given rise to a considerable number of elderly patients with type 2 diabetes mellitus (T2DM) who are confronted with the challenge of managing multimorbidity. We aimed to determine the prevalence of multimorbidity in elderly T2DM patients in a representative Pudong New Area community and critically evaluate current guidelines' inclusiveness in addressing major comorbidities.

Methods

Through the Shanghai Health Cloud platform, we extracted medical records of residents in the Huamu community (Pudong New Area, Shanghai) to screen elderly patients with at least three outpatient visits or one hospitalisation per year between 2019 and 2022. According to International Classification of Disease, 10th edition codes and personal identification number, we identified the status of T2DM and 12 other common chronic diseases, matched T2DM patients and non-T2DM patients 1:1 by age and gender, and then calculated the prevalence of multimorbidity status and annual prevalence of each comorbidity. We analysed associations between T2DM and specific chronic diseases using logistic regression models.

Results

More than 90% of elderly T2DM patients had at least one additional chronic disease. Multimorbidity was more frequent in women and older patients. Hyperlipidemia, hypertension, and ischaemic heart disease were the most prevalent comorbidities. The diagnosis of T2DM was significantly associated with both cardiovascular-kidney-metabolic and neuropsychiatric diseases. In addition, a higher prevalence and risk of chronic obstructive pulmonary disease (COPD) were consistently detected in elderly patients with T2DM, regardless of age and gender.

Conclusions

Multimorbidity in elderly patients with T2DM needs broader acknowledgement. Current guidelines focus more on cardiovascular-kidney-metabolic and neuropsychiatric diseases with inadequate guidance on COPD management. Hence, the pleiotropic effects of glucose-lowering drugs on COPD should be further investigated to optimise the comprehensive management strategy for this population.

Impact of the COVID-19 pandemic on primary care for hypertension in the UK: a population-based cohort study

OBJECTIVES

To describe the impact of the COVID-19 pandemic on hypertension diagnosis and management in UK primary care.

DESIGN

Population-based cohort study.

SETTING

Over 2000 general practices across the UK contributing to the Clinical Practice Research Datalink.

PARTICIPANTS

A cohort of 23 076 390 patients over 18 years of age and registered with their general practice for at least 1 year between 2011 and 2022, who did not have a previous diagnosis of hypertension. From these patients, a subcohort of 712 461 patients diagnosed with hypertension between 2011 and 2022 was selected.

PRIMARY AND SECONDARY OUTCOME MEASURES

Coprimary outcomes included rates of hypertension diagnosis and rates of antihypertensive treatment initiation, treatment change and blood pressure measurement in patients newly diagnosed with hypertension.

RESULTS

In April 2020, the first month of lockdown, incident hypertension diagnosis rates fell by 65% (95% CI 64% to 67%) compared with historical trends and remained depressed until November 2021, leading to 51 000 fewer diagnoses than expected by March 2022. However, by March 2022, there were 2.6% fewer diagnoses than expected in Scotland, compared with 20%-30% fewer in other UK Nations. Rates of treatment initiation and change fell by 47% (95% CI 43% to 51%) and 36% (95% CI 33% to 38%), respectively, in April 2020. However, initiation rates rebounded above expectations and remained elevated until March 2022. Blood pressure measurements fell by 69% (95% CI 65% to 72%) in April 2020, recovering in February 2021.

CONCLUSIONS

Hypertension diagnosis and management in UK primary care were significantly disrupted during the COVID-19 pandemic. Future studies should investigate the potential clinical implications for the cardiovascular health of the UK population.