Can primary care data be used to monitor regional smoking prevalence? An analysis of The Health Improvement Network primary care data

Use of contraceptives and risk of inflammatory bowel disease: a nested case-control study

BACKGROUND

How contraceptive formulation, dose, duration of therapy and mode of delivery affects the risk of inflammatory bowel disease (IBD) is poorly described.

AIM

To examine associations between types of hormonal contraception and development of IBD.

METHODS

This was a nested case-control study using IQVIA Medical Research Data. Women aged 15-49 years with a new diagnosis of IBD were matched with up to six controls by age, practice and year. Odds ratios (OR) and 95% confidence intervals (95% CI) for incident IBD and use of contraception were calculated.

RESULTS

4932 incident cases of IBD were matched to 29 340 controls. Use of combined oral contraceptive pills (COCPs) was associated with the development of Crohn's disease and ulcerative colitis (OR 1.60 [1.41-1.82] and 1.30 [1.15-1.45], respectively). Each additional month of COCP exposure per year of follow-up increased risk of Crohn's disease by 6.4% (5.1%-7.7%) and ulcerative colitis by 3.3% (2.1%-4.4%). Progestogen-only pills had no effect on Crohn's disease risk (OR 1.09 [0.84-1.40]) but there was a modest association with ulcerative colitis (OR 1.35 [1.12-1.64]). Parenteral contraception was not associated with the development of Crohn's disease or ulcerative colitis (OR 1.15 [0.99-1.47] and 1.17 [0.98-1.39], respectively).

CONCLUSIONS

We observed an increase in the risk of IBD with increasing duration of exposure to COCPs. Progestogen-only pills were not associated with Crohn's disease but there was a modest association with ulcerative colitis. There was no association between parenteral progestogen-only contraception and IBD. These findings are broadly consistent with a hypothesis that the oestrogen component of contraception may drive IBD pathogenesis.

Selection of eligible participants for screening for lung cancer using primary care data

Lung cancer screening is effective if offered to people at increased risk of the disease. Currently, direct contact with potential participants is required for evaluating risk. A way to reduce the number of ineligible people contacted might be to apply risk-prediction models directly to digital primary care data, but model performance in this setting is unknown.

METHOD

The Clinical Practice Research Datalink, a computerised, longitudinal primary care database, was used to evaluate the Liverpool Lung Project V.2 (LLP_v2) and Prostate Lung Colorectal and Ovarian (modified 2012) (PLCO_m2012) models. Lung cancer occurrence over 5-6 years was measured in ever-smokers aged 50-80 years and compared with 5-year (LLP_v2) and 6-year (PLCO_m2012) predicted risk.

RESULTS

Over 5 and 6 years, 7123 and 7876 lung cancers occurred, respectively, from a cohort of 842 109 ever-smokers. After recalibration, LLP_V2 produced a c-statistic of 0.700 (0.694-0.710), but mean predicted risk was over-estimated (predicted: 4.61%, actual: 0.9%). PLCO_m2012 showed similar performance (c-statistic: 0.679 (0.673-0.685), predicted risk: 3.76%. Applying risk-thresholds of 1% (LLP_v2) and 0.15% (PLCO_m2012), would avoid contacting 42.7% and 27.4% of ever-smokers who did not develop lung cancer for screening eligibility assessment, at the cost of missing 15.6% and 11.4% of lung cancers.

CONCLUSION

Risk-prediction models showed only moderate discrimination when applied to routinely collected primary care data, which may be explained by quality and completeness of data. However, they may substantially reduce the number of people for initial evaluation of screening eligibility, at the cost of missing some lung cancers. Further work is needed to establish whether newer models have improved performance in primary care data.

Association Between Statin Use at the Time of Intra-abdominal Surgery and Postoperative Adhesion-Related Complications and Small-Bowel Obstruction

IMPORTANCE

Adhesion-related complications (ARCs), including small-bowel obstruction, are common complications of intra-abdominal surgery. Statins, which have antifibrotic pleiotropic effects, inhibit adhesion formation in murine models but have not been assessed in humans.

OBJECTIVE

To assess whether statin use at the time of intra-abdominal surgery is associated with a reduction in ARCs.

DESIGN, SETTING, AND PARTICIPANTS

These 2 separate retrospective cohort studies (The Health Improvement Network [THIN] and Optum's Clinformatics Data Mart [Optum]) compared adults receiving statins with those not receiving statins at the time of intra-abdominal surgery. Individuals undergoing intra-abdominal surgery from January 1, 1996, to December 31, 2013, in the United Kingdom and from January 1, 2000, to December 31, 2016, in the US were included in the study. Those with obstructive events before surgery or a history of inflammatory bowel disease were excluded. Data analysis was performed from September 1, 2012, to November 24, 2020.

EXPOSURE

The primary exposure was statin use at the time of surgery.

MAIN OUTCOMES AND MEASURES

The primary outcome was ARCs, defined as small-bowel obstruction or need for adhesiolysis, occurring after surgery. Sensitivity analyses included statin use preceding but not concurrent with surgery, fibrate use, and angiotensin-converting enzyme inhibitor use. All analyses were adjusted for age, sex, and conditions associated with microvascular disease, such as hypertension, hyperlipidemia, obesity, and tobacco use; surgical approach and site; and diagnosis of a malignant tumor.

RESULTS

A total of 148 601 individuals met the inclusion criteria for THIN (mean [SD] age, 49.6 [17.7] years; 70.1% female) and 1 188 217 for Optum (mean [SD] age, 48.2 [16.4] years; 72.6% female). A total of 2060 participants (1.4%) experienced an ARC in THIN and 54 136 (4.6%) in Optum. Statin use at the time of surgery was associated with decreased risk of ARCs (THIN: adjusted hazard ratio [HR], 0.81; 95% CI, 0.71-0.92; Optum: adjusted HR, 0.92; 95% CI, 0.90-0.95). Similar associations were appreciated between statins and small-bowel obstruction (THIN: adjusted HR, 0.80; 95% CI, 0.70-0.92; Optum: adjusted HR, 0.88; 95% CI, 0.85-0.91).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that, among individuals in 2 separate cohorts undergoing intra-abdominal surgery, statin use may be associated with a reduced risk of postoperative ARCs. Statins may represent an inexpensive, well-tolerated pharmacologic option for preventing ARCs.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

The effectiveness of varenicline versus nicotine replacement therapy on long-term smoking cessation in primary care: a prospective cohort study of electronic medical records

Background

There is limited evidence about the effectiveness of varenicline and nicotine replacement therapy (NRT) for long-term smoking cessation in primary care, or whether the treatment effectiveness differs by socioeconomic position (SEP). Therefore, we estimated the long-term effectiveness of varenicline versus NRT (> 2 years) on smoking cessation, and investigated whether effectiveness differs by SEP.

Methods

This is a prospective cohort study of electronic medical records from 654 general practices in England, within the Clinical Practice Research Datalink, using three different analytical methods: multivariable logistic regression, propensity score matching and instrumental variable analyses. Exposure was prescription of varenicline versus NRT, and the primary outcome was smoking cessation at 2 years' follow-up; outcome was also assessed at 3, 6, and 9 months, and at 1 and 4 years after exposure. SEP was defined using the Index of Multiple Deprivation.

Results

At 2 years, 28.8% (N = 20 362/70 610) of participants prescribed varenicline and 24.3% (N = 36 268/149 526) of those prescribed NRT quit; adjusted odds ratio was 1.26 [95% confidence interval (CI): 1.23 to 1.29], P < 0.0001. The association persisted for up to 4 years and was consistent across all analyses. We found little evidence that the effectiveness of varenicline differed greatly by SEP. However, patients from areas of higher deprivation were less likely to be prescribed varenicline; adjusted odds ratio was 0.91 (95% CI: 0.90 to 0.92), P < 0.0001.

Conclusions

Patients prescribed varenicline were more likely to be abstinent up to 4 years after first prescription than those prescribed NRT. In combination with other evidence, the results from this study may be used to update clinical guidelines on the use of varenicline for smoking cessation.

Factors influencing treatment escalation from long-acting muscarinic antagonist monotherapy to triple therapy in patients with COPD: a retrospective THIN-database analysis

Purpose

Inappropriate use of an inhaled corticosteroid (ICS) for COPD has clinical and economic disadvantages. This retrospective analysis of The UK Health Improvement Network (THIN) database identified factors influencing treatment escalation (step-up) from a long-acting muscarinic antagonist (LAMA) to triple therapy (LAMA + long-acting β-agonist-ICS). Secondary objectives included time to step up from first LAMA prescription, Global Initiative for Chronic Obstructive Lung Disease (GOLD) grouping (2011/2013, 2017), and Medical Research Council (MRC) grade prior to treatment escalation.

Materials and methods

Data were included from 14,866 people ≥35 years old with a COPD diagnosis (June 1, 2010–May 10, 2015) and initiated on LAMA monotherapy. The most commonly used LAMA at baseline was tiotropium (92%).

Results

Multivariate analysis (10,492 patients) revealed that COPD exacerbations, lower forced expiratory volume in 1 second (FEV₁), “asthma”, MRC grade, proactive and reactive COPD primary care, elective secondary-care contact, cough, and number of short-acting bronchodilator prescriptions were positively associated with treatment escalation (P<0.05). Being older, a current/ex-smoker, or having increased sputum symptom codes were negatively associated with treatment escalation (P<0.05). Median MRC score was 2 at baseline and 3 prior to treatment escalation. Using the last MRC reading and exacerbation history in the year prior to escalation, GOLD 2017 groupings were A 27.4%, B 37.3%, C 15.3%, and D 20%. In patients with available FEV₁ measures, exacerbations, and MRC code (n=1,064), GOLD 2011/2013 groupings were A 20.4%, B 19.2%, C 24.8%, and D 35.6%.

Conclusion

While the presence of COPD exacerbations seems to be the main driver for treatment escalation, according to the 2017 GOLD strategy many patients appear to be overtreated, as they would not be recommended for treatment escalation. Reviewing patients’ treatment in the light of the new GOLD strategy has the potential to reduce inappropriate use of triple therapy.

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

Smoking cessation interventions for patients with coronary heart disease and comorbidities: an observational cross-sectional study in primary care

BACKGROUND

Little is known about how smoking cessation practices in primary care differ for patients with coronary heart disease (CHD) who have different comorbidities.

AIM

To determine the association between different patterns of comorbidity and smoking rates and smoking cessation interventions in primary care for patients with CHD.

DESIGN AND SETTING

Cross-sectional study of 81 456 adults with CHD in primary care in Scotland.

METHOD

Details of eight concordant physical comorbidities, 23 discordant physical comorbidities, and eight mental health comorbidities were extracted from electronic health records between April 2006 and March 2007. Multilevel binary logistic regression models were constructed to determine the association between these patterns of comorbidity and smoking status, smoking cessation advice, and smoking cessation medication (nicotine replacement therapy) prescribed.

RESULTS

The most deprived quintile had nearly three times higher odds of being current smokers than the least deprived (odds ratio [OR] 2.76; 95% confidence interval [CI] = 2.49 to 3.05). People with CHD and two or more mental health comorbidities had more than twice the odds of being current smokers than those with no mental health conditions (OR 2.11; 95% CI = 1.99 to 2.24). Despite this, those with two or more mental health comorbidities (OR 0.77; 95% CI = 0.61 to 0.98) were less likely to receive smoking cessation advice, but absolute differences were small.

CONCLUSION

Patterns of comorbidity are associated with variation in smoking status and the delivery of smoking cessation advice among people with CHD in primary care. Those from the most deprived areas and those with mental health problems are considerably more likely to be current smokers and require additional smoking cessation support.

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

BACKGROUND

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

AIM

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

DESIGN AND SETTING

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

METHOD

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

RESULTS

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

CONCLUSION

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

Prescribing of nicotine replacement therapy in and around pregnancy: a population-based study using primary care data

BACKGROUND

Licensing arrangements for nicotine replacement therapy (NRT) in the UK were broadened in 2005 to allow prescribing to pregnant smokers. However, estimates of NRT prescribing in pregnant females in the UK are currently lacking.

AIM

To assess trends in NRT prescribing around pregnancy, and variation in prescribing by maternal characteristics.

DESIGN AND SETTING

Population-based descriptive study using pregnancy data from The Health Improvement Network primary care database, 2001-2012.

METHOD

NRT prescriptions were identified during pregnancy and in the 9 months before and after. Annual prescribing prevalence was calculated. Logistic regression was used to assess females' likelihood of receiving prescriptions by maternal characteristics.

RESULTS

Of 388 142 pregnancies studied, NRT was prescribed in 7551 for an average duration of 2 weeks. The prescribing prevalence of NRT increased from 0.03% (0.7% in smokers) in 2001 to 2.6% (11.4% in smokers) in 2005, after which it remained stable. Prescribing prevalence of NRT before and after pregnancy was half the prevalence during pregnancy. The odds of prescribing NRT during pregnancy in smokers increased with socioeconomic deprivation (OR = 1.29, 95% CI = 1.15 to 1.45 in the most compared with the least deprived group). Prescribing was 33% higher in pregnant smokers with asthma (OR = 1.33, 95% CI = 1.22 to 1.45) and mental illness (OR = 1.33, 95% CI = 1.23 to 1.44) compared with smokers without these diagnoses.

CONCLUSION

NRT prescribing is higher during pregnancy compared with before and after, and is higher in smokers from more socioeconomically deprived groups, those with asthma or those diagnosed mental illness.

Risk of community-acquired pneumonia in patients with a diagnosis of pernicious anemia: a population-based retrospective cohort study

OBJECTIVE

Pernicious anemia (PA) is an autoimmune disease that causes achlorhydria or profound hypochlorhydria. We conducted a population-based study to determine whether individuals with PA are at an increased risk for community-acquired pneumonia (CAP).

METHODS

We performed a retrospective cohort study using The Health Improvement Network (THIN) from the UK (1993-2009). The eligible study cohort included individuals 18 years of age or older, with at least 1 year of THIN follow-up. The exposed group consisted of individuals with a diagnosis code for PA. The unexposed group consisted of individuals without a diagnosis of PA and was frequency matched with the exposed group with respect to age, sex, and practice site. Cox regression analysis was used to determine the hazard ratio with the 95% confidence interval for CAP associated with PA, accounting for a comprehensive list of potential confounders.

RESULTS

The study included 13,605 individuals with PA and 50,586 non-PA individuals. The crude incidence rate of CAP was 9.4/1000 person-years for those with PA, versus 6.4/1000 person-years for those without PA. The multivariable adjusted hazard ratio for CAP associated with PA was 1.18 (95% confidence interval 1.08-1.29).

CONCLUSION

In this large population-based cohort study, individuals with PA and presumed chronic achlorhydria were at an increased risk for CAP.

Nicotine replacement therapy in pregnancy and major congenital anomalies in offspring

BACKGROUND AND OBJECTIVES

Nicotine replacement therapy (NRT) is now being used as a smoking cessation aid during pregnancy, although little is known about fetal safety. We assessed the relationship between early pregnancy exposure to NRT or smoking with major congenital anomalies (MCA) in offspring.

METHODS

We studied 192,498 children born in the United Kingdom between 2001 and 2012 with linked mother-child primary care records. The absolute risks of MCAs in the NRT group (women prescribed NRT during the first trimester or 1 month before conception [and therefore likely consumed during the first trimester]) and odds ratios (ORs) and 99% confidence intervals (CIs) were compared with those of women who smoked during pregnancy and with a control group (women who neither smoked nor were prescribed NRT); logistic regression models adjusted for maternal morbidities that increase MCA risk were used for analysis.

RESULTS

MCA prevalence was 288 per 10,000 live births (5535 children with ≥ 1 MCA). Maternal morbidities were most common in the NRT group (35%) followed by smokers (27%) and the control group (20%). Compared with the control group, adjusted ORs for MCAs in the NRT group and smokers were 1.12 (99% CI: 0.84-1.48) and 1.05 (99% CI: 0.89-1.23), respectively. The OR comparing the NRT group directly with smokers was 1.07 (99% CI: 0.78-1.47). There were no statistically significant associations between maternal NRT and system-specific anomalies except for respiratory anomalies (OR: 4.65 [99% CI: 1.76-12.25]; absolute risk difference: 3 per 1000 births), which was based on 10 exposed cases.

CONCLUSIONS

For most system-specific MCAs, we found no statistically significant increased risks associated with maternal NRT prescribed during pregnancy, except for respiratory anomalies. Although this study is the largest published to date, NRT use in pregnancy remains rare; thus, the statistical power was limited. Higher morbidities in those women prescribed NRT may also be an explanatory factor. Nevertheless, absolute MCA risks were similar between women who smoked and those prescribed NRT during pregnancy.

Prediagnostic presentations of Parkinson's disease in primary care: a case-control study

BACKGROUND

Parkinson's disease has an insidious onset and is diagnosed when typical motor features occur. Several motor and non-motor features can occur before diagnosis, early in the disease process. We aimed to assess the association between first presentation of several prediagnostic features in primary care and a subsequent diagnosis of Parkinson's disease, and to chart the timeline of these first presentations before diagnosis.

METHODS

We identified individuals with a first diagnosis of Parkinson's disease and those without Parkinson's disease from Jan 1, 1996, to Dec 31, 2012, from The Health Improvement Network UK primary care database. Codes were extracted for a range of possible prediagnostic or early symptoms, comprising motor features (tremor, rigidity, balance impairments, neck pain or stiffness, and shoulder pain or stiffness), autonomic features (constipation, hypotension, erectile dysfunction, urinary dysfunction, and dizziness), neuropsychiatric disturbances (memory problems, late-onset anxiety or depression, cognitive decline, and apathy), and additional features (fatigue, insomnia, anosmia, hypersalivation and rapid-eye-movement sleep behaviour disorder) in the years before diagnosis. We report the incidence of symptoms recorded in more than 1% of cases per 1000 person-years and incidence risk ratios (RRs) for individuals with and without Parkinson's disease at 2, 5, and 10 years before diagnosis.

FINDINGS

8166 individuals with and 46,755 individuals without Parkinson's disease were included in the study. Apathy, REM sleep behaviour disorder, anosmia, hypersalivation, and cognitive decline were all reported in less than 1% of people per 1000 person-years and were excluded from further analyses. At 2 years before Parkinson's disease diagnosis, the incidence of all studied prediagnostic features except neck pain or stiffness was higher in patients who went on to develop Parkinson's disease (n=7232) than in controls (n=40,541). At 5 years before diagnosis, compared with controls (n=25,544), patients who went on to develop Parkinson's disease (n=4769) had a higher incidence of tremor (RR 13·70, 95% CI 7·82-24·31), balance impairments (2·19, 1·09-4·16), constipation (2·24, 2·04-2·46), hypotension (3·23, 1·85-5·52), erectile dysfunction (1·30, 1·11-1·51), urinary dysfunction (1·96, 1·34-2·80), dizziness (1·99, 1·67-2·37), fatigue (1·56, 1·27-1·91), depression (1·76, 1·41-2·17), and anxiety (1·41, 1·09-1·79). At 10 years before diagnosis of Parkinson's disease, the incidence of tremor (RR 7·59, 95% CI 1·11-44·83) and constipation (2·01, 1·62-2·49) was higher in those who went on to develop Parkinson's disease (n=1680) than in controls (n=8305).

INTERPRETATION

A range of prediagnostic features can be detected several years before diagnosis of Parkinson's disease in primary care. These data can be incorporated into ongoing efforts to identify individuals at the earliest stages of the disease for inclusion in future trials and to help understand progression in the earliest phase of Parkinson's disease.

FUNDING

Parkinson's UK.

The cumulative incidence of conventional risk factors of cardiovascular disease and their population attributable risk in an Iranian population: The Isfahan Cohort Study

Background:

Cardiovascular diseases (CVDs) are the leading cause of death in Iran. The present study evaluated the 7-year incidence of CVD risk factors among the participants of Isfahan cohort study (ICS).

Materials and Methods:

ICS was a longitudinal study on adults over 35 years of age from the urban and rural areas in three counties in central Iran. Data on clinical examination and blood measurements were collected in 2001. Subjects were followed and similar data were collected in 2007. Cumulative incidence was calculated through dividing new cases of each risk factor by the population free of that risk factor at baseline. Incidence proportion was determined for major CVD risk factors including hypertension (HTN), hypercholesterolemia (HC), hypertriglyceridemia (HTg), obesity, diabetes mellitus (DM), metabolic syndrome (MetS), and smoking.

Results:

A total number of 6323 adults free of CVDs were recruited. After 7 years of follow-up, 3283 individuals were re-evaluated in 2007. The participants’ age was 49.2 ± 10.3 years in 2001 (mean ± SD). The 7-year cumulative incidence of HTN, HC, HTg, overweight, obesity, DM, MetS, and smoking was 22.8%, 37.4%, 28.0%, 26.3%, 7.4%, 9.5%, 23.9%, and 5.9% in men and 22.2%, 55.4%, 33.5%, 35.0%, 18.8%, 11.3%, 36.1%, and 0.7% in women, respectively. Among those with overweight or obesity, 14.7% of men and 7.9% of women decreased their weight up to the normal level.

Conclusions:

The present study revealed a high incidence of CVD risk factors especially dyslipidemia, obesity, MetS and HTN. Therefore, the application of life-style modification interventions seems necessary.

Responsiveness of primary care services: development of a patient-report measure – qualitative study and initial quantitative pilot testing

Background

Primary care service providers do not always respond to the needs of diverse groups of patients, and so certain patients groups are disadvantaged. General practitioner (GP) practices are increasingly encouraged to be more responsive to patients’ needs in order to address inequalities.

Objectives

(1) Explore the meaning of responsiveness in primary care. (2) Develop a patient-report questionnaire for use as a measure of patient experience of responsiveness by a range of primary care organisations (PCOs). (3) Investigate methods of population mapping available to GP practices.

Design setting

PCOs, including GP practices, walk-in centres and community pharmacies.

Participants

Patients and staff from 12 PCOs in the East Midlands in the development stage, and 15 PCOs across three different regions of England in stage 3.

Interventions

To investigate what responsiveness means, we conducted a literature review and interviews with patients and staff in 12 PCOs. We developed, tested and piloted the use of a questionnaire. We explored approaches for GP practices to understand the diversity of their populations.

Main outcome measures

(1) Definition of primary care responsiveness. (2) Three patient-report questionnaires to provide an assessment of patient experience of GP, pharmacy and walk-in centre responsiveness. (3) Insight into challenges in collecting diversity data in primary care.

Results

The literature covers three overlapping themes of service quality, inequalities and patient involvement. We suggest that responsiveness is achieved through alignment between service delivery and patient needs, involving strategies to improve responsive service delivery, and efforts to manage patient expectations. We identified three components of responsive service delivery: proactive population orientation, reactive population orientation and individual patient orientation. PCOs tend to utilise reactive strategies rather than proactive approaches. Questionnaire development involved efforts to include patients who are ‘seldom heard’. The questionnaire was checked for validity and consistency and is available in three versions (GP, pharmacy, and walk-in centre), and in Easy Read format. We found the questionnaires to be acceptable to patients, and to have content validity. We produced some preliminary evidence of reliability and construct validity. Measuring and improving responsiveness requires PCOs to understand the characteristics of their patient population, but we identified significant barriers and challenges to this.

Conclusions

Responsiveness is a complex concept. It involves alignment between service delivery and the needs of diverse patient groups. Reactive and proactive strategies at individual and population level are required, but PCOs mainly rely on reactive approaches. Being responsive means giving good care equally to all, and some groups may require extra support. What this extra support is will differ in different patient populations, and so knowledge of the practice population is essential. Practices need to be motivated to collect and use diversity data. Future work needed includes further evaluation of the patient-report questionnaires, including Easy Read versions, to provide further evidence of their quality and acceptability; research into how to facilitative the use of patient experience data in primary care; and implementation of strategies to improve responsiveness, and evaluation of effectiveness.

Funding

The National Institute for Health Research Service Delivery and Organisation programme.

A comparison of UK primary care data with other national data sources for monitoring the prevalence of smoking during pregnancy

Background

We aimed to assess the potential usefulness of primary care data in the UK for estimating smoking prevalence in pregnancy by comparing the primary care data estimates with those obtained from other data sources.

Methods

In The Health Improvement Network (THIN) primary care database, we identified pregnant smokers using smoking information recorded during pregnancy. Where this information was missing, we used smoking information recorded prior to pregnancy. We compared annual smoking prevalence from 2000 to 2012 in THIN with measures from the Infant Feeding Survey (IFS), Smoking At Time of Delivery (SATOD), Child Health Systems Programme (CHSP) and Scottish Morbidity Record (SMR).

Results

Smoking estimates from THIN data converged with estimates from other sources after 2004, though still do not agree completely. For example, in 2012 smoking prevalence at booking was 11.6% in THIN using data recorded only during pregnancy, compared with 19.6% in SMR data. However, the use of smoking data recorded up to 27 months before conception increased the THIN prevalence to 20.3%, improving the comparability.

Conclusions

Under-recording of smoking status during pregnancy results in unreliable prevalence estimates from primary care data and needs improvement. However, in the absence of gestational smoking data, the inclusion of pre-conception smoking records may increase the utility of primary care data. One strategy to improve gestational smoking status recording in primary care could be the inclusion of pregnancy in the Quality and Outcome’s Framework as a condition for which smoking status and smoking cessation advice must be recorded electronically in patient records.

Serum uric acid and the risk of respiratory disease: a population-based cohort study

Introduction

Uric acid is the most abundant molecule with antioxidant properties found in human blood serum. We examined the relationship between serum uric acid and the incidence of respiratory disease including any effect modification by smoking status.

Methods

A cohort with serum uric acid measured between 1 January 2000 and 31 December 2012 was extracted from The Health Improvement Network primary care research database. New diagnoses of COPD and lung cancer were ascertained based on diagnostic codes entered into the medical records.

Results

During 1 002 496 person years (PYs) of follow-up, there were 3901 COPD diagnoses and 1015 cases of lung cancer. After multivariable adjustment, strong interactions with smoking status were detected (p<0.001) for both outcomes with significant negative relationships between serum uric acid and respiratory disease for current smokers but no strong relationships for never-smokers or ex-smokers. The relationships were strongest for lung cancer in heavy smokers (≥20 cigarettes per day) with predicted incidence rates 97 per 10 000 PYs (95% CI 68 to 126) in the lowest serum uric acid quintile (100–250 µmol/L) compared with a predicted 28 per 10 000 PYs (95% CI 14 to 41) in the highest quintile (438–700 µmol/L).

Conclusions

Low levels of serum uric acid are associated with higher rates of COPD and lung cancer in current smokers after accounting for conventional risk factors.

Smoker, ex-smoker or non-smoker? The validity of routinely recorded smoking status in UK primary care: a cross-sectional study

OBJECTIVE

To investigate how smoking status is recorded in UK primary care; to evaluate whether appropriate multiple imputation (MI) of smoking status yields results consistent with health surveys.

SETTING

UK primary care and a population survey conducted in the community.

PARTICIPANTS

We identified 354 204 patients aged 16 or over in The Health Improvement Network (THIN) primary care database registered with their general practice 2008-2009 and 15 102 individuals aged 16 or over in the Health Survey for England (HSE).

OUTCOME MEASURES

Age-standardised and age-specific proportions of smokers, ex-smokers and non-smokers in THIN and the HSE before and after MI. Using information on time since quitting in the HSE, we estimated when ex-smokers are typically recorded as non-smokers in primary care records.

RESULTS

In THIN, smoking status was recorded for 84% of patients within 1 year of registration. Of these, 28% were smokers (21% in the HSE). After MI of missing smoking data, the proportion of smokers was 25% (missing at random) and 20% (missing not at random). With increasing age, more were identified as ex-smokers in the HSE than THIN. It appears that those who quit before age 30 were less likely to be recorded as an ex-smoker in primary care than people who quit later.

CONCLUSIONS

Smoking status was relatively well recorded in primary care. Misclassification of ex-smokers as non-smokers is likely to occur in those quitting smoking at an early age and/or a long time ago. Those with no smoking status information are more likely to be ex-smokers or non-smokers than smokers.

Smoking cessation advice recorded during pregnancy in United Kingdom primary care

BACKGROUND

United Kingdom (UK) national guidelines recommend that all pregnant women who smoke should be advised to quit at every available opportunity, and brief cessation advice is an efficient and cost-effective means to increase quit rates. The Quality and Outcomes Framework (QOF) implemented in 2004 requires general practitioners to document their delivery of smoking cessation advice in patient records. However, no specific targets have been set in QOF for the recording of this advice in pregnant women. We used a large electronic primary care database from the UK to quantify the pregnancies in which women who smoked were recorded to have been given smoking cessation advice, and the associated maternal characteristics.

METHODS

Using The Health Improvement Network database we calculated annual proportions of pregnant smokers between 2000 and 2009 with cessation advice documented in their medical records during pregnancy. Logistic regression was used to assess variation in the recording of cessation advice with maternal characteristics.

RESULTS

Among 45,296 pregnancies in women who smoked, recorded cessation advice increased from 7% in 2000 to 37% in 2004 when the QOF was introduced and reduced slightly to 30% in 2009. Pregnant smokers from the youngest age group (15-19) were 21% more likely to have a record of cessation advice compared to pregnant smokers aged 25-29 (OR 1.21, 95% CI 1.10-1.35) and pregnant smokers from the most deprived group were 38% more likely to have a record for cessation advice compared to pregnant smokers from the least deprived group (OR 1.38, 95% CI 1.14-1.68). Pregnant smokers with asthma were twice as likely to have documentation of cessation advice in their primary care records compared to pregnant smokers without asthma (OR 1.97, 95% CI 1.80-2.16). Presence of comorbidities such as diabetes, hypertension and mental illness also increased the likelihood of having smoking cessation advice recorded. No marked variations were observed in the recording of cessation advice with body mass index.

CONCLUSION

Recorded delivery of smoking cessation advice for pregnant smokers in primary care has increased with some fluctuation over the years, especially after the implementation of the QOF, and varies with maternal characteristics.

Completeness of maternal smoking status recording during pregnancy in United Kingdom primary care data

BACKGROUND

Given the health impacts of smoking during pregnancy and the opportunity for primary healthcare teams to encourage pregnant smokers to quit, our primary aim was to assess the completeness of gestational smoking status recording in primary care data and investigate whether completeness varied with women's characteristics. As a secondary aim we assessed whether completeness of recording varied before and after the introduction of the Quality and Outcomes Framework (QOF).

METHODS

In The Health Improvement Network (THIN) database we calculated the proportion of pregnancies ending in live births or stillbirths where there was a recording of maternal smoking status for each year from 2000 to 2009. Logistic regression was used to assess variation in the completeness of maternal smoking recording by maternal characteristics, before and after the introduction of QOF.

RESULTS

Women had a record of smoking status during the gestational period in 28% of the 277,552 pregnancies identified. In 2000, smoking status was recorded in 9% of pregnancies, rising to 43% in 2009. Pregnant women from the most deprived group were 17% more likely to have their smoking status recorded than pregnant women from the least deprived group before QOF implementation (OR 1.17, 95% CI 1.10-1.25) and 42% more likely afterwards (OR 1.42, 95% CI 1.37-1.47). A diagnosis of asthma was related to recording of smoking status during pregnancy in both the pre-QOF (OR 1.63, 95% CI 1.53-1.74) and post-QOF periods (OR 2.08, 95% CI 2.02-2.15). There was no association between having a diagnosis of diabetes and recording of smoking status during pregnancy pre-QOF however, post-QOF diagnosis of diabetes was associated with a 12% increase in recording of smoking status (OR 1.12, 95% CI 1.05-1.19).

CONCLUSION

Recording of smoking status during pregnancy in primary care data is incomplete though has improved over time, especially after the implementation of the QOF, and varies by maternal characteristics and QOF-incentivised morbidities.

Use of practice-based research network data to measure neighborhood smoking prevalence

Introduction

Practice-Based Research Networks (PBRNs) and health systems may provide timely, reliable data to guide the development and distribution of public health resources to promote healthy behaviors, such as quitting smoking. The objective of this study was to determine if PBRN data could be used to make neighborhood-level estimates of smoking prevalence.

Methods

We estimated the smoking prevalence in 32 greater Boston neighborhoods (population = 877,943 adults) by using the electronic health record data of adults who in 2009 visited one of 26 Partners Primary Care PBRN practices (n = 77,529). We compared PBRN-derived estimates to population-based estimates derived from 1999–2009 Behavioral Risk Factor Surveillance System (BRFSS) data (n = 20,475).

Results

The PBRN estimates of neighborhood smoking status ranged from 5% to 22% and averaged 11%. The 2009 neighborhood-level smoking prevalence estimates derived from the BRFSS ranged from 5% to 26% and averaged 13%. The difference in smoking prevalence between the PBRN and the BRFSS averaged −2 percentage points (standard deviation, 3 percentage points).

Conclusion

Health behavior data collected during routine clinical care by PBRNs and health systems could supplement or be an alternative to using traditional sources of public health data.