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Xu S, Cobzaru R, Finkelstein SN, Welsch RE, Ng K, Middleton L. Foundational model aided automatic high-throughput drug screening using self-controlled cohort study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.08.04.24311480. [PMID: 39148849 PMCID: PMC11326319 DOI: 10.1101/2024.08.04.24311480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
Background Developing medicine from scratch to governmental authorization and detecting adverse drug reactions (ADR) have barely been economical, expeditious, and risk-averse investments. The availability of large-scale observational healthcare databases and the popularity of large language models offer an unparalleled opportunity to enable automatic high-throughput drug screening for both repurposing and pharmacovigilance. Objectives To demonstrate a general workflow for automatic high-throughput drug screening with the following advantages: (i) the association of various exposure on diseases can be estimated; (ii) both repurposing and pharmacovigilance are integrated; (iii) accurate exposure length for each prescription is parsed from clinical texts; (iv) intrinsic relationship between drugs and diseases are removed jointly by bioinformatic mapping and large language model - ChatGPT; (v) causal-wise interpretations for incidence rate contrasts are provided. Methods Using a self-controlled cohort study design where subjects serve as their own control group, we tested the intention-to-treat association between medications on the incidence of diseases. Exposure length for each prescription is determined by parsing common dosages in English free text into a structured format. Exposure period starts from initial prescription to treatment discontinuation. A same exposure length preceding initial treatment is the control period. Clinical outcomes and categories are identified using existing phenotyping algorithms. Incident rate ratios (IRR) are tested using uniformly most powerful (UMP) unbiased tests. Results We assessed 3,444 medications on 276 diseases on 6,613,198 patients from the Clinical Practice Research Datalink (CPRD), an UK primary care electronic health records (EHR) spanning from 1987 to 2018. Due to the built-in selection bias of self-controlled cohort studies, ingredients-disease pairs confounded by deterministic medical relationships are removed by existing map from RxNorm and nonexistent maps by calling ChatGPT. A total of 16,901 drug-disease pairs reveals significant risk reduction, which can be considered as candidates for repurposing, while a total of 11,089 pairs showed significant risk increase, where drug safety might be of a concern instead. Conclusions This work developed a data-driven, nonparametric, hypothesis generating, and automatic high-throughput workflow, which reveals the potential of natural language processing in pharmacoepidemiology. We demonstrate the paradigm to a large observational health dataset to help discover potential novel therapies and adverse drug effects. The framework of this study can be extended to other observational medical databases.
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Affiliation(s)
- Shenbo Xu
- Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Raluca Cobzaru
- Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Stan N Finkelstein
- Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Roy E Welsch
- Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Kenney Ng
- Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Lefkos Middleton
- Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
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Uddin J, Joshi VL, Wells V, Faruque M, Mashreky SR, Movsisyan A, Evans R, Moore G, Taylor RS. Adaptation of complex interventions for people with long-term conditions: a scoping review. Transl Behav Med 2024; 14:514-526. [PMID: 38895875 PMCID: PMC11370634 DOI: 10.1093/tbm/ibae031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
Adaptation seeks to transfer and implement healthcare interventions developed and evaluated in one context to another. The aim of this scoping review was to understand current approaches to the adaptation of complex interventions for people with long-term conditions (LTCs) and to identify issues for studies performed in low- and middle-income countries (LMICs). Bibliographic databases were searched from 2000 to October 2022. This review involved five stages: (i) definition of the research question(s); (ii) identifying relevant studies; (iii) study selection; (iv) data charting; and (v) data synthesis. Extraction included an assessment of the: rationale for adaptation; stages and levels of adaptation; use of theoretical frameworks, and quality of reporting using a checklist based on the 2021 ADAPT guidance. Twenty-five studies were included from across 21 LTCs and a range of complex interventions. The majority (16 studies) focused on macro (national or international) level interventions. The rationale for adaptation included intervention transfer across geographical settings [high-income country (HIC) to LMIC: six studies, one HIC to another: eight studies, one LMIC to another: two studies], or transfer across socio-economic/racial groups (five studies), or transfer between different health settings within a single country (one study). Overall, studies were judged to be of moderate reporting quality (median score 23, maximum 46), and typically focused on early stages of adaptation (identification and development) with limited outcome evaluation or implementation assessment of the adapted version of the intervention. Improved reporting of the adaptation for complex interventions targeted at LTCs is needed. Development of future adaptation methods guidance needs to consider the needs and priorities of the LMIC context.
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Affiliation(s)
- Jamal Uddin
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Physiotherapy and Cardiac Rehabilitation Unit, Department of Cardiac Surgery, Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh
| | - Vicky L Joshi
- Department of Physiotherapy and Paramedicine, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Valerie Wells
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Mithila Faruque
- Department of Noncommunicable Diseases (NCD), Faculty of Public Health, Bangladesh University of Health Sciences, Dhaka, Bangladesh
| | - Saidur R Mashreky
- Department of Noncommunicable Diseases (NCD), Faculty of Public Health, Bangladesh University of Health Sciences, Dhaka, Bangladesh
| | - Ani Movsisyan
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Chair of Public Health and Health Services Research, Faculty of Medicine, LMU Munich. Elisabeth-Winterhalter-Weg 6, 81377 Munich, Germany
- Pettenkofer School of Public Health. Faculty of Public Health, Elisabeth-Winterhalter-Weg 6, 81377 Munich, Germany
| | - Rhiannon Evans
- Centre for Development, Evaluation, Complexity, and Implementation in Public Health Improvement (DECIPHer), DECIPHer, School of Social Sciences, Cardiff University, Cardiff, UK
| | - Graham Moore
- Centre for Development, Evaluation, Complexity, and Implementation in Public Health Improvement (DECIPHer), DECIPHer, School of Social Sciences, Cardiff University, Cardiff, UK
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Robertson Centre for Biostatistics, MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Barlow M, Down L, Mounce LTA, Funston G, Merriel SWD, Watson J, Abel G, Kirkland L, Martins T, Bailey SER. The diagnostic performance of CA-125 for the detection of ovarian cancer in women from different ethnic groups: a cohort study of English primary care data. J Ovarian Res 2024; 17:173. [PMID: 39187847 PMCID: PMC11346194 DOI: 10.1186/s13048-024-01490-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 08/09/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND CA-125 testing is a recommended first line investigation for women presenting with possible symptoms of ovarian cancer in English primary care, to help determine whether further investigation for ovarian cancer is needed. It is currently not known how well the CA-125 test performs in ovarian cancer detection for patients from different ethnic groups. METHODS A retrospective cohort study utilising English primary care data linked to the national cancer registry was undertaken. Women aged ≥ 40 years with a CA-125 test between 2010 and 2017 were included. Logistic regression predicted one-year ovarian cancer incidence by ethnicity, adjusting for age, deprivation status, and comorbidity score. The estimated incidence of ovarian cancer by CA-125 level was modelled for each ethnic group using restricted cubic splines. RESULTS The diagnostic performance of CA-125 differed for women from different ethnicities. In an unadjusted analysis, predicted CA-125 levels for Asian and Black women were higher than White women at corresponding probabilities of ovarian cancer. The higher PPVs for White women compared to Asian or Black women were eliminated by inclusion of covariates. CONCLUSION The introduction of ethnicity-specific thresholds may increase the specificity and PPVs of CA-125 in ovarian cancer detection at the expense of sensitivity, particularly for Asian and Black women. As such, we cannot recommend the use of ethnicity-specific thresholds for CA-125.
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Affiliation(s)
- Melissa Barlow
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Liz Down
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Luke T A Mounce
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Garth Funston
- Centre for Cancer Screening, Prevention and Early Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, London, EC1M 6BQ, UK
| | - Samuel W D Merriel
- Centre for Primary Care & Health Services Research, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Jessica Watson
- Centre for Academic Primary Care (CAPC), Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Gary Abel
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Lucy Kirkland
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Tanimola Martins
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Sarah E R Bailey
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
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Kar D, Taylor KS, Joy M, Venkatesan S, Meeraus W, Taylor S, Anand SN, Ferreira F, Jamie G, Fan X, de Lusignan S. Creating a Modified Version of the Cambridge Multimorbidity Score to Predict Mortality in People Older Than 16 Years: Model Development and Validation. J Med Internet Res 2024; 26:e56042. [PMID: 39186368 PMCID: PMC11384182 DOI: 10.2196/56042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND No single multimorbidity measure is validated for use in NHS (National Health Service) England's General Practice Extraction Service Data for Pandemic Planning and Research (GDPPR), the nationwide primary care data set created for COVID-19 pandemic research. The Cambridge Multimorbidity Score (CMMS) is a validated tool for predicting mortality risk, with 37 conditions defined by Read Codes. The GDPPR uses the more internationally used Systematized Nomenclature of Medicine clinical terms (SNOMED CT). We previously developed a modified version of the CMMS using SNOMED CT, but the number of terms for the GDPPR data set is limited making it impossible to use this version. OBJECTIVE We aimed to develop and validate a modified version of CMMS using the clinical terms available for the GDPPR. METHODS We used pseudonymized data from the Oxford-Royal College of General Practitioners Research and Surveillance Centre (RSC), which has an extensive SNOMED CT list. From the 37 conditions in the original CMMS model, we selected conditions either with (1) high prevalence ratio (≥85%), calculated as the prevalence in the RSC data set but using the GDPPR set of SNOMED CT codes, divided by the prevalence included in the RSC SNOMED CT codes or (2) conditions with lower prevalence ratios but with high predictive value. The resulting set of conditions was included in Cox proportional hazard models to determine the 1-year mortality risk in a development data set (n=500,000) and construct a new CMMS model, following the methods for the original CMMS study, with variable reduction and parsimony, achieved by backward elimination and the Akaike information stopping criterion. Model validation involved obtaining 1-year mortality estimates for a synchronous data set (n=250,000) and 1-year and 5-year mortality estimates for an asynchronous data set (n=250,000). We compared the performance with that of the original CMMS and the modified CMMS that we previously developed using RSC data. RESULTS The initial model contained 22 conditions and our final model included 17 conditions. The conditions overlapped with those of the modified CMMS using the more extensive SNOMED CT list. For 1-year mortality, discrimination was high in both the derivation and validation data sets (Harrell C=0.92) and 5-year mortality was slightly lower (Harrell C=0.90). Calibration was reasonable following an adjustment for overfitting. The performance was similar to that of both the original and previous modified CMMS models. CONCLUSIONS The new modified version of the CMMS can be used on the GDPPR, a nationwide primary care data set of 54 million people, to enable adjustment for multimorbidity in predicting mortality in people in real-world vaccine effectiveness, pandemic planning, and other research studies. It requires 17 variables to produce a comparable performance with our previous modification of CMMS to enable it to be used in routine data using SNOMED CT.
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Affiliation(s)
- Debasish Kar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom
| | - Kathryn S Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sudhir Venkatesan
- Medical & Payer Evidence Statistics, BioPharmaceuticals Medical, AstraZeneca PLC, Cambridge, United Kingdom
| | - Wilhelmine Meeraus
- Medical Evidence, Vaccines and Immune Therapies, AstraZeneca PLC, Cambridge, United Kingdom
| | - Sylvia Taylor
- Medical Evidence, Vaccines and Immune Therapies, AstraZeneca PLC, Cambridge, United Kingdom
| | - Sneha N Anand
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Filipa Ferreira
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gavin Jamie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Xuejuan Fan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Royal College of General Practitioners of the United Kingdom, London, United Kingdom
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Brack C, Tenison E, Henderson E, Makin S, Ben-Shlomo Y. Impact of co-resident health and living alone on risk of hospital admission for people with Parkinson's disease. Parkinsonism Relat Disord 2024; 127:107084. [PMID: 39121562 DOI: 10.1016/j.parkreldis.2024.107084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/24/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND People with Parkinson's Disease (PwP) have a higher rate of hospitalisation compared to the general population. Little is known about the impact of having a co-resident and their health on hospitalisation rates of PwP. METHODS We utilised Clinical Practice Research Datalink (CPRD) GOLD data (2010-2015) to identify PwP and co-residents. We classed either the fittest or youngest adult as the primary caregiver in each household. Caregiver health was classified by the Cambridge Multimorbidity Score (CMS), primary care utilisation and prescriptions. We calculated the hospitalisation (elective, emergency) incidence rate ratios (IRRs) for PwP who lived alone compared to those with a caregiver using negative binomial regression, and whether worse caregiver health predicted higher risk of admissions. RESULTS We identified 3254 PwP and 4007 family members. PwP who lived alone were less likely to have an elective admission (0.79; 95 % CI 0.69-0.91) and more likely to have an emergency admission (1.40; 95 % CI 1.70-1.54). Worse caregiver health, as measured by the CMS, was associated with an increased risk of emergency admission (IRR 1.35; 95 % CI 1.17-1.57), but this attenuated and was consistent with chance in the fully adjusted model (1.04; 95 % CI 0.95-1.13). No strong associations were seen between caregiver health and elective admissions. CONCLUSION PwP who live alone are at increased risk of emergency and less likely to have elective hospital admissions. It is important that health care providers support such people and ensure they receive equitable access to the potential benefits of elective procedures.
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Affiliation(s)
- Carmen Brack
- Centre for Rural Health, University of Aberdeen, UK
| | - Emma Tenison
- Ageing and Movement Research Group, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK; Older People's Unit, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK
| | - Emily Henderson
- Ageing and Movement Research Group, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1NU, UK; Older People's Unit, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK
| | | | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, UK; The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, UK.
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Lai YS, Gao XY, Hu WH, Liu YX, Zhang YJ, Liu JC, Yang C, Liao J. Validity of the Chinese multimorbidity-weighted index in measuring disease burden using health check-ups data in primary care. BMC Public Health 2024; 24:1999. [PMID: 39061022 PMCID: PMC11282735 DOI: 10.1186/s12889-024-19479-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND As multimorbidity becomes common that imposes a considerable burden to patients, but the extent to which widely-used multimorbidity indexes can be applied to quantify disease burden using primary care data in China is not clear. We applied the Chinese Multimorbidity-Weighted Index (CMWI) to health check-ups data routinely collected among older adults by primary care, to examine its validity in measuring multimorbidity associated risks of disability and mortality in annual follow-ups. METHODS The study utilized data from annual health check-ups of older adults, which included information on individual age, sex, and 14 health conditions at primary care in a district of Guangzhou, Guangdong, China. The risk of CMWI for mortality was analysed in a total sample of 45,009 persons 65 years and older between 2014 and 2020 (average 2.70-year follow-up), and the risk for disability was in a subsample of 18,320 older adults free of physical impairment in 2019 and followed-up in 2020. Risk of death and disability were assessed with Cox proportional hazard regression and binary logistic regression, respectively, with both models adjusted for age and sex variables. The model fit was assessed by the Akaike information criterion (AIC), and C-statistic or the area under the receiver operating characteristic curve (AUC). RESULTS One unit increase in baseline-CMWI (Median= 1.70, IQR: 1.30-3.00) was associated with higher risk in subsequent disability (OR = 1.12, 95%CI = 1.05,1.20) and mortality (OR = 1.18, 95%CI = 1.14, 1.22). Participants in the top tertile of CMWI had 99% and 152% increased risks of disability and mortality than their counterparts in the bottom tertile. Model fit was satisfied with adequate AUC (0.84) or C-statistic (0.76) for both outcomes. CONCLUSIONS CMWI, calculated based on primary care's routine health check-ups data, provides valid estimates of disability and mortality risks in older adults. This validated tool can be used to quantity and monitor older patients' health risks in primary care.
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Affiliation(s)
- Ying-Si Lai
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, P.R. China
- Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, P.R. China
| | - Xin-Yuan Gao
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, P.R. China
| | - Wei-Hua Hu
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, P.R. China
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Yi-Xuan Liu
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, P.R. China
| | - Yong-Jin Zhang
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, P.R. China
| | - Jia-Cong Liu
- Department of Chronic Disease Prevention and Treatment and Health Education, Huangpu District Center for Disease Control and Prevention, Guangzhou, P.R. China
| | - Chun Yang
- Department of Chronic Disease Prevention and Treatment and Health Education, Huangpu District Center for Disease Control and Prevention, Guangzhou, P.R. China
| | - Jing Liao
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, P.R. China.
- Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, P.R. China.
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Tsang JY, Sperrin M, Blakeman T, Payne RA, Ashcroft DM. Protocol for the development and validation of a Polypharmacy Assessment Score. Diagn Progn Res 2024; 8:10. [PMID: 39010248 PMCID: PMC11251249 DOI: 10.1186/s41512-024-00171-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 05/30/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND An increasing number of people are using multiple medications each day, named polypharmacy. This is driven by an ageing population, increasing multimorbidity, and single disease-focussed guidelines. Medications carry obvious benefits, yet polypharmacy is also linked to adverse consequences including adverse drug events, drug-drug and drug-disease interactions, poor patient experience and wasted resources. Problematic polypharmacy is 'the prescribing of multiple medicines inappropriately, or where the intended benefits are not realised'. Identifying people with problematic polypharmacy is complex, as multiple medicines can be suitable for people with several chronic conditions requiring more treatment. Hence, polypharmacy is often potentially problematic, rather than always inappropriate, dependent on clinical context and individual benefit vs risk. There is a need to improve how we identify and evaluate these patients by extending beyond simple counts of medicines to include individual factors and long-term conditions. AIM To produce a Polypharmacy Assessment Score to identify a population with unusual levels of prescribing who may be at risk of potentially problematic polypharmacy. METHODS Analyses will be performed in three parts: 1. A prediction model will be constructed using observed medications count as the dependent variable, with age, gender and long-term conditions as independent variables. A 'Polypharmacy Assessment Score' will then be constructed through calculating the differences between the observed and expected count of prescribed medications, thereby highlighting people that have unexpected levels of prescribing. Parts 2 and 3 will examine different aspects of validity of the Polypharmacy Assessment Score: 2. To assess 'construct validity', cross-sectional analyses will evaluate high-risk prescribing within populations defined by a range of Polypharmacy Assessment Scores, using both explicit (STOPP/START criteria) and implicit (Medication Appropriateness Index) measures of inappropriate prescribing. 3. To assess 'predictive validity', a retrospective cohort study will explore differences in clinical outcomes (adverse drug reactions, unplanned hospitalisation and all-cause mortality) between differing scores. DISCUSSION Developing a cross-cutting measure of polypharmacy may allow healthcare professionals to prioritise and risk stratify patients with polypharmacy using unusual levels of prescribing. This would be an improvement from current approaches of either using simple cutoffs or narrow prescribing criteria.
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Affiliation(s)
- Jung Yin Tsang
- Centre for Primary Care and Health Services Research, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK.
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK.
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, UK.
| | - Matthew Sperrin
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, University of Manchester, Manchester, UK
| | - Thomas Blakeman
- Centre for Primary Care and Health Services Research, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
| | - Rupert A Payne
- Department of Health and Community Sciences, University of Exeter Medical School, Exeter, UK
| | - Darren M Ashcroft
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
- Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
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Jalali-Najafabadi F, Bailey R, Lyons J, Akbari A, Ba Dhafari T, Azadbakht N, Rafferty J, Watkins A, Martin GP, Bowes J, Lyons RA, Barton A, Peek N. 10-year multimorbidity patterns among people with and without rheumatic and musculoskeletal diseases: an observational cohort study using linked electronic health records from Wales, UK. BMJ Open 2024; 14:e079169. [PMID: 38904124 PMCID: PMC11191776 DOI: 10.1136/bmjopen-2023-079169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 05/15/2024] [Indexed: 06/22/2024] Open
Abstract
OBJECTIVES To compare the patterns of multimorbidity between people with and without rheumatic and musculoskeletal diseases (RMDs) and to describe how these patterns change by age and sex over time, between 2010 and 2019. PARTICIPANTS 103 426 people with RMDs and 2.9 million comparators registered in 395 Wales general practices (GPs). Each patient with an RMD aged 0-100 years between January 2010 and December 2019 registered in Clinical Practice Research Welsh practices was matched with up to five comparators without an RMD, based on age, gender and GP code. PRIMARY OUTCOME MEASURES The prevalence of 29 Elixhauser-defined comorbidities in people with RMDs and comparators categorised by age, gender and GP practices. Conditional logistic regression models were fitted to calculate differences (OR, 95% CI) in associations with comorbidities between cohorts. RESULTS The most prevalent comorbidities were cardiovascular risk factors, hypertension and diabetes. Having an RMD diagnosis was associated with a significantly higher odds for many conditions including deficiency anaemia (OR 1.39, 95% CI (1.32 to 1.46)), hypothyroidism (OR 1.34, 95% CI (1.19 to 1.50)), pulmonary circulation disorders (OR 1.39, 95% CI 1.12 to 1.73) diabetes (OR 1.17, 95% CI (1.11 to 1.23)) and fluid and electrolyte disorders (OR 1.27, 95% CI (1.17 to 1.38)). RMDs have a higher proportion of multimorbidity (two or more conditions in addition to the RMD) compared with non-RMD group (81% and 73%, respectively in 2019) and the mean number of comorbidities was higher in women from the age of 25 and 50 in men than in non-RMDs group. CONCLUSION People with RMDs are approximately 1.5 times as likely to have multimorbidity as the general population and provide a high-risk group for targeted intervention studies. The individuals with RMDs experience a greater load of coexisting health conditions, which tend to manifest at earlier ages. This phenomenon is particularly pronounced among women. Additionally, there is an under-reporting of comorbidities in individuals with RMDs.
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Affiliation(s)
- Farideh Jalali-Najafabadi
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Rowena Bailey
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Jane Lyons
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Ashley Akbari
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Thamer Ba Dhafari
- Division of Informatics, Imaging and Data Science, School of Health Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Narges Azadbakht
- Division of Informatics, Imaging and Data Science, School of Health Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - James Rafferty
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Alan Watkins
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Glen Philip Martin
- Division of Informatics, Imaging and Data Science, School of Health Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - John Bowes
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ronan A Lyons
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Anne Barton
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Niels Peek
- Division of Informatics, Imaging and Data Science, School of Health Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- The Healthcare Improvement Studies Institute (THIS Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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9
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Cooper R, Bunn JG, Richardson SJ, Hillman SJ, Sayer AA, Witham MD. Rising to the challenge of defining and operationalising multimorbidity in a UK hospital setting: the ADMISSION research collaborative. Eur Geriatr Med 2024; 15:853-860. [PMID: 38448710 PMCID: PMC11329381 DOI: 10.1007/s41999-024-00953-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/24/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE Greater transparency and consistency when defining multimorbidity in different settings is needed. We aimed to: (1) adapt published principles that can guide the selection of long-term conditions for inclusion in research studies of multimorbidity in hospitals; (2) apply these principles and identify a list of long-term conditions; (3) operationalise this list by mapping it to International Classification of Diseases 10th revision (ICD-10) codes. METHODS Review by independent assessors and ratification by an interdisciplinary programme management group. RESULTS Agreement was reached that when defining multimorbidity in hospitals for research purposes all conditions must meet the following four criteria: (1) medical diagnosis; (2) typically present for ≥ 12 months; (3) at least one of currently active; permanent in effect; requiring current treatment, care or therapy; requiring surveillance; remitting-relapsing and requiring ongoing treatment or care, and; (4) lead to at least one of: significantly increased risk of death; significantly reduced quality of life; frailty or physical disability; significantly worsened mental health; significantly increased treatment burden (indicated by an increased risk of hospital admission or increased length of hospital stay). Application of these principles to two existing lists of conditions led to the selection of 60 conditions that can be used when defining multimorbidity for research focused on hospitalised patients. ICD-10 codes were identified for each of these conditions to ensure consistency in their operationalisation. CONCLUSIONS This work contributes to achieving the goal of greater transparency and consistency in the approach to the study of multimorbidity, with a specific focus on the UK hospital setting.
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Affiliation(s)
- Rachel Cooper
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK.
- NIHR Newcastle Biomedical Research Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK.
| | - Jonathan G Bunn
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Sarah J Richardson
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Susan J Hillman
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Avan A Sayer
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Miles D Witham
- AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
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10
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Dibben GO, Gardiner L, Young HM, Wells V, Evans RA, Ahmed Z, Barber S, Dean S, Doherty P, Gardiner N, Greaves C, Ibbotson T, Jani BD, Jolly K, Mair FS, McIntosh E, Ormandy P, Simpson SA, Ahmed S, Krauth SJ, Steell L, Singh SJ, Taylor RS. Evidence for exercise-based interventions across 45 different long-term conditions: an overview of systematic reviews. EClinicalMedicine 2024; 72:102599. [PMID: 39010975 PMCID: PMC11247153 DOI: 10.1016/j.eclinm.2024.102599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 07/17/2024] Open
Abstract
Background Almost half of the global population face significant challenges from long-term conditions (LTCs) resulting in substantive health and socioeconomic burden. Exercise is a potentially key intervention in effective LTC management. Methods In this overview of systematic reviews (SRs), we searched six electronic databases from January 2000 to October 2023 for SRs assessing health outcomes (mortality, hospitalisation, exercise capacity, disability, frailty, health-related quality of life (HRQoL), and physical activity) related to exercise-based interventions in adults (aged >18 years) diagnosed with one of 45 LTCs. Methodological quality was assessed using AMSTAR-2. International Prospective Resister of Systematic Reviews (PROSPERO) ID: CRD42022319214. Findings Forty-two SRs plus three supplementary RCTs were included, providing 990 RCTs in 936,825 people across 39 LTCs. No evidence was identified for six LTCs. Predominant outcome domains were HRQoL (82% of SRs/RCTs) and exercise capacity (66%); whereas disability, mortality, physical activity, and hospitalisation were less frequently reported (≤25%). Evidence supporting exercise-based interventions was identified in 25 LTCs, was unclear for 13 LTCs, and for one LTC suggested no effect. No SRs considered multimorbidity in the delivery of exercise. Methodological quality varied: critically-low (33%), low (26%), moderate (26%), and high (12%). Interpretation Exercise-based interventions improve HRQoL and exercise capacity across numerous LTCs. Key evidence gaps included limited mortality and hospitalisation data and consideration of multimorbidity impact on exercise-based interventions. Funding This study was funded by the National Institute for Health and Care Research (NIHR; Personalised Exercise-Rehabilitation FOR people with Multiple long-term conditions (multimorbidity)-NIHR202020).
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Affiliation(s)
- Grace O. Dibben
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Lucy Gardiner
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Hannah M.L. Young
- University Hospitals of Leicester NHS Trust, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Valerie Wells
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Rachael A. Evans
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Zahira Ahmed
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Shaun Barber
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Sarah Dean
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | | | - Nikki Gardiner
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Colin Greaves
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Tracy Ibbotson
- General Practice & Primary Care, University of Glasgow, Glasgow, UK
| | - Bhautesh D. Jani
- General Practice & Primary Care, University of Glasgow, Glasgow, UK
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Frances S. Mair
- General Practice & Primary Care, University of Glasgow, Glasgow, UK
| | - Emma McIntosh
- Health Economics & Health Technology Assessment, University of Glasgow, Glasgow, UK
| | - Paula Ormandy
- School of Health and Society, University of Salford, Salford, UK
| | - Sharon A. Simpson
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Sayem Ahmed
- Health Economics & Health Technology Assessment, University of Glasgow, Glasgow, UK
| | | | - Lewis Steell
- General Practice & Primary Care, University of Glasgow, Glasgow, UK
| | - Sally J. Singh
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Rod S. Taylor
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
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11
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Simpson SA, Evans RA, Gilbert HR, Branson A, Barber S, McIntosh E, Ahmed Z, Dean SG, Doherty PJ, Gardiner N, Greaves C, Daw P, Ibbotson T, Jani B, Jolly K, Mair F, Ormandy P, Smith S, Singh SJ, Taylor R. Personalised Exercise-Rehabilitation FOR people with Multiple long-term conditions (PERFORM): protocol for a randomised feasibility trial. BMJ Open 2024; 14:e083255. [PMID: 38580370 PMCID: PMC11002422 DOI: 10.1136/bmjopen-2023-083255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/18/2024] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Personalised Exercise-Rehabilitation FOR people with Multiple long-term conditions (PERFORM) is a research programme that seeks to develop and evaluate a comprehensive exercise-based rehabilitation intervention designed for people with multimorbidity, the presence of multiple long-term conditions (MLTCs). This paper describes the protocol for a randomised trial to assess the feasibility and acceptability of the PERFORM intervention, study design and processes. METHODS AND ANALYSIS A multicentre, parallel two-group randomised trial with individual 2:1 allocation to the PERFORM exercise-based intervention plus usual care (intervention) or usual care alone (control). The primary outcome of this feasibility trial will be to assess whether prespecified progression criteria (recruitment, retention, intervention adherence) are met to progress to the full randomised trial. The trial will be conducted across three UK sites and 60 people with MLTCs, defined as two or more LTCs, with at least one having evidence of the beneficial effect of exercise. The PERFORM intervention comprises an 8-week (twice a week for 6 weeks and once a week for 2 weeks) supervised rehabilitation programme of personalised exercise training and self-management education delivered by trained healthcare professionals followed by two maintenance sessions. Trial participants will be recruited over a 4.5-month period, and outcomes assessed at baseline (prerandomisation) and 3 months postrandomisation and include health-related quality of life, psychological well-being, symptom burden, frailty, exercise capacity, physical activity, sleep, cognition and serious adverse events. A mixed-methods process evaluation will assess acceptability, feasibility and fidelity of intervention delivery and feasibility of trial processes. An economic evaluation will assess the feasibility of data collection and estimate the costs of the PERFORM intervention. ETHICS AND DISSEMINATION The trial has been given favourable opinion by the West Midlands, Edgbaston Research Ethics Service (Ref: 23/WM/0057). Participants will be asked to give full, written consent to take part by trained researchers. Findings will be disseminated via journals, presentations and targeted communications to clinicians, commissioners, service users and patients and the public. TRIAL REGISTRATION NUMBER ISRCTN68786622. PROTOCOL VERSION 2.0 (16 May 2023).
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Affiliation(s)
- Sharon Anne Simpson
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | | | | | - Amy Branson
- Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Shaun Barber
- Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Emma McIntosh
- Health Economics and Health Technology Assessment (HEHTA), University of Glasgow Institute of Health and Wellbeing, Glasgow, UK
| | - Zahira Ahmed
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Centre for Exercise and Rehabilitation Science, NIHR Leicester Biomedical Research Centre Respiratory Diseases, Leicester, UK
| | | | | | - Nikki Gardiner
- Department of Cardiopulmonary Rehabilitation, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Colin Greaves
- School of Sport, Exercise and Rehabilitation Science, University of Birmingham, Birmingham, UK
| | - Paulina Daw
- School of Sport, Exercise and Rehabilitation Science, University of Birmingham, Birmingham, UK
| | - Tracy Ibbotson
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Bhautesh Jani
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Frances Mair
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Paula Ormandy
- University of Salford School of Nursing Midwifery and Social Work, Manchester, UK
| | - Susan Smith
- Community Health and General Practice, Trinity College Dublin, Dublin, Ireland
| | - Sally J Singh
- Cardiac/Pulmonary Rehabilitation, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Rod Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
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12
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Meeraus W, Joy M, Ouwens M, Taylor KS, Venkatesan S, Dennis J, Tran TN, Dashtban A, Fan X, Williams R, Morris T, Carty L, Kar D, Hoang U, Feher M, Forbes A, Jamie G, Hinton W, Sanecka K, Byford R, Anand SN, Hobbs FDR, Clifton DA, Pollard AJ, Taylor S, de Lusignan S. AZD1222 effectiveness against severe COVID-19 in individuals with comorbidity or frailty: The RAVEN cohort study. J Infect 2024; 88:106129. [PMID: 38431156 DOI: 10.1016/j.jinf.2024.106129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/27/2023] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVES Despite being prioritized during initial COVID-19 vaccine rollout, vulnerable individuals at high risk of severe COVID-19 (hospitalization, intensive care unit admission, or death) remain underrepresented in vaccine effectiveness (VE) studies. The RAVEN cohort study (NCT05047822) assessed AZD1222 (ChAdOx1 nCov-19) two-dose primary series VE in vulnerable populations. METHODS Using the Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub, linked to secondary care, death registration, and COVID-19 datasets in England, COVID-19 outcomes in 2021 were compared in vaccinated and unvaccinated individuals matched on age, sex, region, and multimorbidity. RESULTS Over 4.5 million AZD1222 recipients were matched (mean follow-up ∼5 months); 68% were ≥50 years, 57% had high multimorbidity. Overall, high VE against severe COVID-19 was demonstrated, with lower VE observed in vulnerable populations. VE against hospitalization was higher in the lowest multimorbidity quartile (91.1%; 95% CI: 90.1, 92.0) than the highest quartile (80.4%; 79.7, 81.1), and among individuals ≥65 years, higher in the 'fit' (86.2%; 84.5, 87.6) than the frailest (71.8%; 69.3, 74.2). VE against hospitalization was lowest in immunosuppressed individuals (64.6%; 60.7, 68.1). CONCLUSIONS Based on integrated and comprehensive UK health data, overall population-level VE with AZD1222 was high. VEs were notably lower in vulnerable groups, particularly the immunosuppressed.
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Affiliation(s)
- Wilhelmine Meeraus
- Medical Evidence, Vaccines & Immune Therapies, BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mario Ouwens
- Medical & Payer Evidence Statistics, BioPharmaceuticals Medical, AstraZeneca, Mölndal, Sweden
| | - Kathryn S Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sudhir Venkatesan
- Medical & Payer Evidence Statistics, BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | | | - Trung N Tran
- Biopharmaceutical Medicine Respiratory and Immunology, AstraZeneca, Gaithersburg, MD, USA
| | - Ashkan Dashtban
- Institute of Health Informatics, University College London, London, UK
| | - Xuejuan Fan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Robert Williams
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tamsin Morris
- Medical and Scientific Affairs, BioPharmaceuticals Medical, AstraZeneca, London, UK
| | - Lucy Carty
- Medical & Payer Evidence Statistics, BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Debasish Kar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Uy Hoang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Michael Feher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Anna Forbes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gavin Jamie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - William Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kornelia Sanecka
- Medical Evidence, Vaccines & Immune Therapies, BioPharmaceuticals Medical, AstraZeneca, Warsaw, Poland
| | - Rachel Byford
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sneha N Anand
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David A Clifton
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Sylvia Taylor
- Medical Evidence, Vaccines & Immune Therapies, BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Royal College of General Practitioners Research and Surveillance Centre, London, UK.
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13
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Grigoroglou C, Walshe K, Kontopantelis E, Ferguson J, Stringer G, Ashcroft DM, Allen T. Comparing the clinical practice and prescribing safety of locum and permanent doctors: observational study of primary care consultations in England. BMC Med 2024; 22:126. [PMID: 38532468 DOI: 10.1186/s12916-024-03332-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/29/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Temporary doctors, known as locums, are a key component of the medical workforce in the NHS but evidence on differences in quality and safety between locum and permanent doctors is limited. We aimed to examine differences in the clinical practice, and prescribing safety for locum and permanent doctors working in primary care in England. METHODS We accessed electronic health care records (EHRs) for 3.5 million patients from the CPRD GOLD database with linkage to Hospital Episode Statistics from 1st April 2010 to 31st March 2022. We used multi-level mixed effects logistic regression to compare consultations with locum and permanent GPs for several patient outcomes including general practice revisits; prescribing of antibiotics; strong opioids; hypnotics; A&E visits; emergency hospital admissions; admissions for ambulatory care sensitive conditions; test ordering; referrals; and prescribing safety indicators while controlling for patient and practice characteristics. RESULTS Consultations with locum GPs were 22% more likely to involve a prescription for an antibiotic (OR = 1.22 (1.21 to 1.22)), 8% more likely to involve a prescription for a strong opioid (OR = 1.08 (1.06 to 1.09)), 4% more likely to be followed by an A&E visit on the same day (OR = 1.04 (1.01 to 1.08)) and 5% more likely to be followed by an A&E visit within 1 to 7 days (OR = 1.05 (1.02 to 1.08)). Consultations with a locum were 12% less likely to lead to a practice revisit within 7 days (OR = 0.88 (0.87 to 0.88)), 4% less likely to involve a prescription for a hypnotic (OR = 0.96 (0.94 to 0.98)), 15% less likely to involve a referral (OR = 0.85 (0.84 to 0.86)) and 19% less likely to involve a test (OR = 0.81 (0.80 to 0.82)). We found no evidence that emergency admissions, ACSC admissions and eight out of the eleven prescribing safety indicators were different if patients were seen by a locum or a permanent GP. CONCLUSIONS Despite existing concerns, the clinical practice and performance of locum GPs did not appear to be systematically different from that of permanent GPs. The practice and performance of both locum and permanent GPs is likely shaped by the organisational setting and systems within which they work.
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Affiliation(s)
- Christos Grigoroglou
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK.
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Jane Ferguson
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Gemma Stringer
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration, Division of Pharmacy and Optometry, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Thomas Allen
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
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14
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Harrison H, Ip S, Renzi C, Li Y, Barclay M, Usher-Smith J, Lyratzopoulos G, Wood A, Antoniou AC. Implementation and external validation of the Cambridge Multimorbidity Score in the UK Biobank cohort. BMC Med Res Methodol 2024; 24:71. [PMID: 38509467 PMCID: PMC10953059 DOI: 10.1186/s12874-024-02175-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 02/06/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Patients with multiple conditions present a growing challenge for healthcare provision. Measures of multimorbidity may support clinical management, healthcare resource allocation and accounting for the health of participants in purpose-designed cohorts. The recently developed Cambridge Multimorbidity scores (CMS) have the potential to achieve these aims using primary care records, however, they have not yet been validated outside of their development cohort. METHODS The CMS, developed in the Clinical Research Practice Dataset (CPRD), were validated in UK Biobank participants whose data is not available in CPRD (the cohort used for CMS development) with available primary care records (n = 111,898). This required mapping of the 37 pre-existing conditions used in the CMS to the coding frameworks used by UK Biobank data providers. We used calibration plots and measures of discrimination to validate the CMS for two of the three outcomes used in the development study (death and primary care consultation rate) and explored variation by age and sex. We also examined the predictive ability of the CMS for the outcome of cancer diagnosis. The results were compared to an unweighted count score of the 37 pre-existing conditions. RESULTS For all three outcomes considered, the CMS were poorly calibrated in UK Biobank. We observed a similar discriminative ability for the outcome of primary care consultation rate to that reported in the development study (C-index: 0.67 (95%CI:0.66-0.68) for both, 5-year follow-up); however, we report lower discrimination for the outcome of death than the development study (0.69 (0.68-0.70) and 0.89 (0.88-0.90) respectively). Discrimination for cancer diagnosis was adequate (0.64 (0.63-0.65)). The CMS performs favourably to the unweighted count score for death, but not for the outcomes of primary care consultation rate or cancer diagnosis. CONCLUSIONS In the UK Biobank, CMS discriminates reasonably for the outcomes of death, primary care consultation rate and cancer diagnosis and may be a valuable resource for clinicians, public health professionals and data scientists. However, recalibration will be required to make accurate predictions when cohort composition and risk levels differ substantially from the development cohort. The generated resources (including codelists for the conditions and code for CMS implementation in UK Biobank) are available online.
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Affiliation(s)
- Hannah Harrison
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Samantha Ip
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Cristina Renzi
- Department of Behavioural Science and Health, Institute of Epidemiology and Healthcare, University College London, London, UK
- Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Via Olgettina 58, Milan, Italy
| | - Yangfan Li
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Matthew Barclay
- Department of Behavioural Science and Health, Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Juliet Usher-Smith
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Georgios Lyratzopoulos
- Department of Behavioural Science and Health, Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Angela Wood
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
| | - Antonis C Antoniou
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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15
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Down L, Barlow M, Bailey SER, Mounce LTA, Merriel SWD, Watson J, Martins T. Association between patient ethnicity and prostate cancer diagnosis following a prostate-specific antigen test: a cohort study of 730,000 men in primary care in the UK. BMC Med 2024; 22:82. [PMID: 38424555 PMCID: PMC10905783 DOI: 10.1186/s12916-024-03283-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/25/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Black men have higher prostate-specific antigen (PSA) levels and higher prostate cancer incidence and mortality than White men, while Asian men tend to have lower prostate cancer incidence and mortality than White men. Much of the evidence comes from the USA, and information from UK populations is limited. METHODS This retrospective cohort study used data on patients registered at general practices in England contributing to the Clinical Practice Research Datalink (CPRD) Aurum dataset. Those eligible were men aged 40 and over with a record of ethnicity and a PSA test result recorded between 2010 and 2017 with no prior cancer diagnosis. The aim was to assess the incidence of prostate cancer following a raised PSA test result in men from different ethnic groups. Additionally, incidence of advanced prostate cancer was investigated. Cancer incidence was estimated from multi-level logistic regression models adjusting for potential confounding factors. RESULTS 730,515 men with a PSA test were included (88.9% White). Black men and men with mixed ethnicity had higher PSA values, particularly for those aged above 60 years. In the year following a raised PSA result (using age-specific thresholds), Black men had the highest prostate cancer incidence at 24.7% (95% CI 23.3%, 26.2%); Asian men had the lowest at 13.4% (12.2%, 14.7%); incidence for White men was 19.8% (19.4%, 20.2%). The peak incidence of prostate cancer for all groups was in men aged 70-79. Incidence of prostate cancer diagnosed at an advanced stage was similar between Black and White men. CONCLUSIONS More prostate cancer was diagnosed in Black men with a raised PSA result, but rates of advanced prostate cancer were not higher in this group. In this large primary care-based cohort, the incidence of prostate cancer in men with elevated PSA levels increases with increasing age, even when using age-adjusted thresholds, with Black men significantly more likely to be diagnosed compared to White or Asian men. The incidence of advanced stage prostate cancer at diagnosis was similar for Black and White men with a raised PSA result, but lower for Asian men.
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Affiliation(s)
- Liz Down
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Melissa Barlow
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Sarah E R Bailey
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Luke T A Mounce
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Samuel W D Merriel
- Centre for Primary Care & Health Services Research, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Jessica Watson
- Centre for Academic Primary Care (CAPC), Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Tanimola Martins
- Department of Health and Community Sciences, University of Exeter, St Lukes Campus, Heavitree Road, Exeter, EX1 2LU, UK
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16
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Huang F, Song J, Davies AR. Health of unpaid carers in Wales, UK: a population data linkage study. J Public Health (Oxf) 2024; 46:144-150. [PMID: 37934971 PMCID: PMC10901266 DOI: 10.1093/pubmed/fdad207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/15/2023] [Accepted: 10/06/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND The population of unpaid carers in Wales increased to record. There is no systematic approach to record unpaid caring status, resulting in limited quantitative evidence on unpaid carers' health. The aim of this study is to: (i) create an e-cohort of unpaid carers by linking routinely collected health and administrative datasets in Wales, UK. (ii) investigate whether long-term health conditions and multimorbidity are more prevalent amongst unpaid carers than non-carers. METHODS Unpaid carers were identified by linking primary care dataset, National Survey for Wales data with demographic characteristics in the Secure Anonymise Information Linkage Databank. The clinical codes identified in Cambridge Multimorbidity Score were used to explore the prevalence of long-term health conditions. RESULTS A total of 91 220 unpaid carers in Wales were identified between 1 January 2010 and 1 March 2022. Unpaid carers were found at higher risk of managing 35 of 37 long-term health conditions and multimorbidity than non-carers, exacerbated amongst younger age groups and deprived communities. CONCLUSIONS The creation of the first e-cohort of unpaid carers in Wales provides opportunities to perform rapid analysis to systematically understand health needs and evaluate initiatives in future. To better support unpaid carers, flexible approaches focusing on early identification and prevention is crucial.
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Affiliation(s)
- Fangzhou Huang
- School of Management, Swansea University, Swansea SA1 8EN, UK
| | - Jiao Song
- The Communicable Disease Surveillance Centre, Public Health Wales, Cardiff CF10 4BZ, UK
| | - Alisha R Davies
- Research and Evaluation Division, Knowledge Directorate, Public Health Wales, Cardiff CF10 4BZ, UK
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17
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Ahmad TA, Dayem Ullah AZM, Chelala C, Gopal DP, Eto F, Henkin R, Samuel M, Finer S, Taylor SJC. Prevalence of multimorbidity in survivors of 28 cancer sites: an English nationwide cross-sectional study. Am J Cancer Res 2024; 14:880-896. [PMID: 38455398 PMCID: PMC10915322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/13/2023] [Indexed: 03/09/2024] Open
Abstract
Multimorbidity, the presence of a chronic condition in addition to cancer, is of particular importance to cancer survivors. It has an impact on the progression, stage at diagnosis, prognosis, and treatment of cancer patients. Evidence is scarce on the prevalence of specific comorbidities in survivors of different cancers to inform prevention and management of multimorbidity. The objective of this study is to address this evidence gap by using large scale electronic health data from multiple linked UK healthcare databases to examine the prevalence of multimorbidity in 28 cancer sites. For this population-based cross-sectional study, we linked primary and secondary healthcare data from the UK Clinical Research Practice Datalink (CPRD) GOLD dataset and Hospital Episode Statistics (HES). We identified survivors of 28 common cancers aged 18 years or older at diagnosis who survived 2 years of cancer and compared their multimorbidity with matched controls without a history of cancer. To compare prevalence of individual comorbidity, multivariable logistic regression models, adjusted for confounding factors were used. Between January 1, 2010 and December 31, 2020, we identified 347,028 cancer survivors and 804,299 controls matched on age, sex and general practice. Cancer survivors had a higher prevalence of multimorbidity compared to non-cancer controls across all the cancer sites. Hypertension (56.2%), painful conditions (39.8%), osteoarthritis (38.0%), depression (31.8%) and constipation (31.4%) were the five most frequent chronic conditions reported. Compared to the controls, higher odds of constipation were found in survivors of 25 of the 28 cancer sites and higher odds of anaemia were found in 23 cancer sites. Prevalence of constipation, anaemia and painful conditions were higher after cancer diagnosis compared to before diagnosis. Since these comorbidities are not uniformly assessed as part of any of the comorbidity scales, they tend to be underreported among cancer survivors. The elevated risk of certain comorbidities in cancer survivors suggests the potential for preventative efforts in this population to lower disease burden and improve quality of life. Long-term conditions should not be viewed as the inevitable result of cancer diagnosis and treatment. We need to consider integrated management of chronic conditions tailored to specific cancers to improve cancer survivorship.
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Affiliation(s)
- Tahania A Ahmad
- Wolfson Institute of Population Health, Queen Mary University of LondonLondon, The United Kingdom
| | - Abu ZM Dayem Ullah
- Barts Cancer Institute, Queen Mary University of LondonLondon, The United Kingdom
| | - Claude Chelala
- Barts Cancer Institute, Queen Mary University of LondonLondon, The United Kingdom
| | - Dipesh P Gopal
- Wolfson Institute of Population Health, Queen Mary University of LondonLondon, The United Kingdom
| | - Fabiola Eto
- Wolfson Institute of Population Health, Queen Mary University of LondonLondon, The United Kingdom
| | - Rafael Henkin
- Wolfson Institute of Population Health, Queen Mary University of LondonLondon, The United Kingdom
| | - Miriam Samuel
- Wolfson Institute of Population Health, Queen Mary University of LondonLondon, The United Kingdom
| | - Sarah Finer
- Wolfson Institute of Population Health, Queen Mary University of LondonLondon, The United Kingdom
| | - Stephanie JC Taylor
- Wolfson Institute of Population Health, Queen Mary University of LondonLondon, The United Kingdom
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18
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Winn E, Kissane M, Merriel SW, Brain T, Silverwood VA, Whitehead IO, Howe LD, Payne RA, Duncan P. Using the Primary care Academic CollaboraTive to explore the characteristics and healthcare use of older housebound patients in England: protocol for a retrospective observational study and clinician survey (the CHiP study). BJGP Open 2023; 7:BJGPO.2023.0114. [PMID: 37402549 PMCID: PMC11176688 DOI: 10.3399/bjgpo.2023.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Older housebound people are an under-researched group for whom achieving good primary health care can be resource intensive. AIMS To describe the characteristics and healthcare use of older (≥65 years) housebound people; explore clinician views on delivery of care to housebound people; and assess the feasibility of using a new network of healthcare professionals to deliver high quality research. DESIGN & SETTING Retrospective observational study of electronic GP records and clinician survey in England. METHOD Clinical members of a new UK research network called the Primary care Academic CollaboraTive (PACT) will collect the data. For part A, around 20 GP practices will be recruited and clinicians will identify 20 housebound and 20 non-housebound people, matched by age and gender (around 400 total in each group). Anonymised data will be collected on characteristics (age, gender, ethnicity, deprivation decile), long-term conditions, prescribed medicines, quality of healthcare (via Quality Outcomes Framework targets), and continuity of care. Reports with benchmarked practice-level data will be provided to practices to identify areas for quality improvement and to enhance engagement. For part B, 2-4 clinicians will be recruited from around 50 practices in England (around 150 clinicians) to complete a survey about delivery of healthcare for housebound people. For part C, data will be collected to assess the feasibility of using the PACT network to deliver primary care research. CONCLUSION Older housebound people are a neglected group both in terms of research and clinical care. Understanding the characteristics and use of primary healthcare of housebound people will help identify how to improve their care.
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Affiliation(s)
- Elizabeth Winn
- Centre for Academic Primary Care and Population Health Sciences, University of Bristol, Bristol, UK
| | - Madeleine Kissane
- Centre for Academic Primary Care and Population Health Sciences, University of Bristol, Bristol, UK
| | - Samuel Wd Merriel
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Thomas Brain
- Centre for Academic Primary Care and Population Health Sciences, University of Bristol, Bristol, UK
| | | | | | - Laura D Howe
- Centre for Academic Primary Care and Population Health Sciences, University of Bristol, Bristol, UK
| | - Rupert A Payne
- Exeter Collaboration for Academic Primary Care (APEx), Exeter Medical School, University of Exeter, Exeter, UK
| | - Polly Duncan
- Centre for Academic Primary Care and Population Health Sciences, University of Bristol, Bristol, UK
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19
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Johnson R, Kovalenko AG, Blakeman T, Panagioti M, Lawton M, Dawson S, Duncan P, Fraser SD, Valderas JM, Chilcott S, Goulding R, Salisbury C. Treatment burden in multiple long-term conditions: a mixed-methods study protocol. BJGP Open 2023; 7:BJGPO.2023.0097. [PMID: 37295796 PMCID: PMC11176699 DOI: 10.3399/bjgpo.2023.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Treatment burden represents the work patients undertake because of their health care, and the impact of that effort on the patient. Most research has focused on older adults (aged >65 years) with multiple long-term conditions (multimorbidity) (MLTC-M), but there are now more younger adults (aged 18-65 years) living with MLTC-M and they may experience treatment burden differently. Understanding experiences of treatment burden, and identifying those most at risk of high treatment burden, are important for designing primary care services to meet their needs. AIM To understand the treatment burden associated with MLTC-M, for people aged 18-65 years, and how primary care services affect this burden. DESIGN & SETTING Mixed-methods study in up to 33 primary care practices in two UK regions. METHOD The following two approaches will be used: (i) in-depth qualitative interviews with adults living with MLTC-M (approximately 40 participants) to understand their experiences of treatment burden and the impact of primary care, with a think-aloud aspect to explore face validity of a novel short treatment burden questionnaire (STBQ) for routine clinical use in the initial 15 interviews; (ii) cross-sectional patient survey (approximately 1000 participants), with linked routine medical record data to examine the factors associated with treatment burden for people living with MLTC-M, and to test the validity of STBQ. CONCLUSION This study will generate in-depth understanding of the treatment burden experienced by people aged 18-65 years living with MLTC-M, and how primary care services affect this burden. This will inform further development and testing of interventions to reduce treatment burden, and potentially influence MLTC-M trajectories and improve health outcomes.
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Affiliation(s)
- Rachel Johnson
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Anastasiia G Kovalenko
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Thomas Blakeman
- Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - Maria Panagioti
- Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - Michael Lawton
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shoba Dawson
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Polly Duncan
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Simon Ds Fraser
- School of Primary Care, Population Science and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jose M Valderas
- Centre for Research in Health Systems Performance (CRiHSP) and Division of Family Medicine, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Queenstown, Singapore
| | | | - Rebecca Goulding
- Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
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20
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Parry W, Fraser C, Crellin E, Hughes J, Vestesson E, Clarke GM. Continuity of care and consultation mode in general practice: a cross-sectional and longitudinal study using patient-level and practice-level data from before and during the COVID-19 pandemic in England. BMJ Open 2023; 13:e075152. [PMID: 37968008 PMCID: PMC10660661 DOI: 10.1136/bmjopen-2023-075152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 10/16/2023] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVES Investigate trends in continuity of care with a general practitioner (GP) before and during the COVID-19 pandemic. Identify whether continuity of care is associated with consultation mode, controlling for other patient and practice characteristics. DESIGN Retrospective cross-sectional and longitudinal observational studies. SETTING Primary care records from 389 general practices participating in Clinical Practice Research Datalink Aurum in England. PARTICIPANTS In the descriptive analysis, 100 000+ patients were included each month between April 2018 and April 2021. Modelling of the association between continuity of care and consultation mode focused on 153 475 and 125 298 patients in index months of February 2020 (before the pandemic) and February 2021 (during the pandemic) respectively, and 76 281 patients in both index months. PRIMARY AND SECONDARY OUTCOMES MEASURES The primary outcome measure was the Usual Provider of Care index. Secondary outcomes included the Bice-Boxerman index and count of consultations with the most frequently seen GP. RESULTS Continuity of care was gradually declining before the pandemic but stabilised during it. There were consistent demographic, socioeconomic and regional differences in continuity of care. An average of 23% of consultations were delivered remotely in the year to February 2020 compared with 76% in February 2021. We found little evidence consultation mode was associated with continuity at the patient level, controlling for a range of covariates. In contrast, patient characteristics and practice-level supply and demand were associated with continuity. CONCLUSIONS We set out to examine the association of consultation mode with continuity of care but found that GP supply and patient demand were much more important. To improve continuity for patients, primary care capacity needs to increase. This requires sufficient, long-term investment in clinicians, staff, facilities and digital infrastructure. General practice also needs to transform ways of working to ensure continuity for those that need it, even in a capacity-constrained environment.
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Affiliation(s)
| | | | | | - Jay Hughes
- Data Analytics, The Health Foundation, London EC4Y 8AP, UK
| | - Emma Vestesson
- Data Analytics, The Health Foundation, London EC4Y 8AP, UK
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21
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Mendonça SC, Edwards DA, Lund J, Saunders CL, Mant J. Progression of stroke risk in patients aged <65 years diagnosed with atrial fibrillation: a cohort study in general practice. Br J Gen Pract 2023; 73:e825-e831. [PMID: 37487643 PMCID: PMC10394608 DOI: 10.3399/bjgp.2022.0568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 04/04/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND As a result of new technologies, atrial fibrillation (AF) is more likely to be diagnosed in people aged <65 years. AIM To investigate the risk of someone diagnosed with AF aged <65 years developing an indication for anticoagulation before they reach 65 years. DESIGN AND SETTING Population-based cohort study of patients from English practices using the Clinical Practice Research Datalink, a primary care database of electronic medical records. METHOD The study included patients aged <65 years newly diagnosed with AF. The CHA2DS2-VASc score was derived at time of diagnosis based on patients' medical records. Patients not eligible for anticoagulation were followed up until they became eligible or turned 65 years old. The primary outcome of interest was development of a risk factor for stroke in AF. RESULTS Among 18 178 patients aged <65 years diagnosed with AF, 9188 (50.5%) were eligible for anticoagulation at the time of diagnosis. Among the 8990 patients not eligible for anticoagulation, 1688 (18.8%) developed a risk factor during follow-up before reaching 65 years of age or leaving the cohort for other reasons, at a rate of 6.1 per 100 patient-years. Hypertension and heart failure were the most common risk factors to occur, with rates of 2.65 (95% CI = 2.47 to 2.84) and 1.58 (95% CI = 1.45 to 1.72) per 100 patient-years, respectively. The rate of new diabetes was 0.95 (95% CI = 0.85 to 1.06) per 100 patient-years. CONCLUSION People aged <65 years with AF are at higher risk of developing hypertension, heart failure, and diabetes than the general population, so may warrant regular review to identify new occurrence of such risk factors.
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Affiliation(s)
| | | | - Jenny Lund
- Wellcome Trust clinical PhD fellow in primary care
| | - Catherine L Saunders
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
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22
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Sosenko F, Mackay D, Pell JP, Hatton C, Jani BD, Cairns D, Ward L, Henderson A, Fleming M, Nijhof D, Melville C. Understanding covid-19 outcomes among people with intellectual disabilities in England. BMC Public Health 2023; 23:2099. [PMID: 37880687 PMCID: PMC10601171 DOI: 10.1186/s12889-023-16993-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/14/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Evidence from the UK from the early stages of the covid-19 pandemic showed that people with Intellectual Disabilities (ID) had higher rates of covid-19 mortality than people without ID. However, estimates of the magnitude of risk vary widely; different studies used different time periods; and only early stages of the pandemic have been analysed. Existing analyses of risk factors have also been limited. The objective of this study was to investigate covid-19 mortality rates, hospitalisation rates, and risk factors in people with ID in England up to the end of 2021. METHODS Retrospective cohort study of all people with a laboratory-confirmed SARS-CoV-2 infection or death involving covid-19. Datasets covering primary care, secondary care, covid-19 tests and vaccinations, prescriptions, and deaths were linked at individual level. RESULTS Covid-19 carries a disproportionately higher risk of death for people with ID, above their already higher risk of dying from other causes, in comparison to those without ID. Around 2,000 people with ID had a death involving covid-19 in England up to the end of 2021; approximately 1 in 180. The covid-19 standardized mortality ratio was 5.6 [95% CI 5.4, 5.9]. People with ID were also more likely to be hospitalised for covid-19 than people without ID. The main determinants of severe covid-19 outcomes (deaths and/or hospitalisations) in both populations were age, multimorbidity and vaccination status. The key factor responsible for the higher risk of severe covid-19 in the ID population was a much higher prevalence of multimorbidity in this population. AstraZeneca vaccine was slightly less effective in preventing severe covid-19 outcomes among people with ID than among people without ID. CONCLUSIONS People with ID should be considered a priority group in future pandemics, such as shielding and vaccinations.
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Affiliation(s)
| | | | | | - Chris Hatton
- Manchester Metropolitan University, Manchester, UK
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23
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Meza-Torres B, Forbes A, Elson W, Kar D, Jamie G, Hinton W, Fan X, Byford R, Feher M, Whyte M, Joy M, de Lusignan S. Hepatitis A Vaccination Coverage Among People With Chronic Liver Disease in England (HEALD): Protocol for a Retrospective Cohort Study. JMIR Res Protoc 2023; 12:e51861. [PMID: 37874614 PMCID: PMC10630863 DOI: 10.2196/51861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Hepatitis A outbreaks in the United Kingdom are uncommon. Most people develop mild to moderate symptoms that resolve, without sequelae, within months. However, in high-risk groups, including those with underlying chronic liver disease (CLD), hepatitis A infection can be severe, with a higher risk of mortality and morbidity. The Health Security Agency and the National Institute of Health and Care Excellence recommend preexposure hepatitis A vaccination given in 2 doses to people with CLD, regardless of its cause. There are currently no published reports of vaccination coverage for people with CLD in England or internationally. OBJECTIVE This study aims to describe hepatitis A vaccination coverage in adults with CLD in a UK primary care setting and compare liver disease etiology, sociodemographic characteristics, and comorbidities in people who are and are not exposed to the hepatitis A vaccine. METHODS We will conduct a retrospective cohort study with data from the Primary Care Sentinel Cohort of the Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub database, which is nationally representative of the English population. We will include people aged 18 years and older who have been registered in general practices in the Research and Surveillance Centre network and have a record of CLD between January 1, 2012, and December 31, 2022, including those with alcohol-related liver disease, chronic hepatitis B, chronic hepatitis C, nonalcohol fatty liver disease, Wilson disease, hemochromatosis, and autoimmune hepatitis. We will carefully curate variables using the Systematized Nomenclature of Medicine Clinical Terms. We will report the sociodemographic characteristics of those who are vaccinated. These include age, gender, ethnicity, population density, region, socioeconomic status (measured using the index of multiple deprivation), obesity, alcohol consumption, and smoking. Hepatitis A vaccination coverage for 1 and 2 doses will be calculated using an estimate of the CLD population as the denominator. We will analyze the baseline characteristics using descriptive statistics, including measures of dispersion. Pairwise comparisons of case-mix characteristics, comorbidities, and complications will be reported according to vaccination status. A multistate survival model will be fitted to estimate the transition probabilities among four states: (1) diagnosed with CLD, (2) first dose of hepatitis A vaccination, (3) second dose of hepatitis A vaccination, and (4) death. This will identify any potential disparities in how people with CLD get vaccinated. RESULTS The Research and Surveillance Centre population comprises over 8 million people. The reported incidence of CLD is 20.7 cases per 100,000. International estimates of hepatitis A vaccine coverage vary between 10% and 50% in this group. CONCLUSIONS This study will describe the uptake of the hepatitis A vaccine in people with CLD and report any disparities or differences in the characteristics of the vaccinated population. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/51861.
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Affiliation(s)
- Bernardo Meza-Torres
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Anna Forbes
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - William Elson
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Debasish Kar
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gavin Jamie
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - William Hinton
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Xuejuan Fan
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rachel Byford
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Michael Feher
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Martin Whyte
- School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Mark Joy
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Simon de Lusignan
- Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Royal College of General Practitioners, Research and Surveillance Centre, London, United Kingdom
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24
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Eto F, Samuel M, Henkin R, Mahesh M, Ahmad T, Angdembe A, Hamish McAllister-Williams R, Missier P, J. Reynolds N, R. Barnes M, Hull S, Finer S, Mathur R. Ethnic differences in early onset multimorbidity and associations with health service use, long-term prescribing, years of life lost, and mortality: A cross-sectional study using clustering in the UK Clinical Practice Research Datalink. PLoS Med 2023; 20:e1004300. [PMID: 37889900 PMCID: PMC10610074 DOI: 10.1371/journal.pmed.1004300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 09/17/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND The population prevalence of multimorbidity (the existence of at least 2 or more long-term conditions [LTCs] in an individual) is increasing among young adults, particularly in minority ethnic groups and individuals living in socioeconomically deprived areas. In this study, we applied a data-driven approach to identify clusters of individuals who had an early onset multimorbidity in an ethnically and socioeconomically diverse population. We identified associations between clusters and a range of health outcomes. METHODS AND FINDINGS Using linked primary and secondary care data from the Clinical Practice Research Datalink GOLD (CPRD GOLD), we conducted a cross-sectional study of 837,869 individuals with early onset multimorbidity (aged between 16 and 39 years old when the second LTC was recorded) registered with an English general practice between 2010 and 2020. The study population included 777,906 people of White ethnicity (93%), 33,915 people of South Asian ethnicity (4%), and 26,048 people of Black African/Caribbean ethnicity (3%). A total of 204 LTCs were considered. Latent class analysis stratified by ethnicity identified 4 clusters of multimorbidity in White groups and 3 clusters in South Asian and Black groups. We found that early onset multimorbidity was more common among South Asian (59%, 33,915) and Black (56% 26,048) groups compared to the White population (42%, 777,906). Latent class analysis revealed physical and mental health conditions that were common across all ethnic groups (i.e., hypertension, depression, and painful conditions). However, each ethnic group also presented exclusive LTCs and different sociodemographic profiles: In White groups, the cluster with the highest rates/odds of the outcomes was predominantly male (54%, 44,150) and more socioeconomically deprived than the cluster with the lowest rates/odds of the outcomes. On the other hand, South Asian and Black groups were more socioeconomically deprived than White groups, with a consistent deprivation gradient across all multimorbidity clusters. At the end of the study, 4% (34,922) of the White early onset multimorbidity population had died compared to 2% of the South Asian and Black early onset multimorbidity populations (535 and 570, respectively); however, the latter groups died younger and lost more years of life. The 3 ethnic groups each displayed a cluster of individuals with increased rates of primary care consultations, hospitalisations, long-term prescribing, and odds of mortality. Study limitations include the exclusion of individuals with missing ethnicity information, the age of diagnosis not reflecting the actual age of onset, and the exclusion of people from Mixed, Chinese, and other ethnic groups due to insufficient power to investigate associations between multimorbidity and health-related outcomes in these groups. CONCLUSIONS These findings emphasise the need to identify, prevent, and manage multimorbidity early in the life course. Our work provides additional insights into the excess burden of early onset multimorbidity in those from socioeconomically deprived and diverse groups who are disproportionately and more severely affected by multimorbidity and highlights the need to ensure healthcare improvements are equitable.
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Affiliation(s)
- Fabiola Eto
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Miriam Samuel
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Rafael Henkin
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Meera Mahesh
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Tahania Ahmad
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Alisha Angdembe
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - R. Hamish McAllister-Williams
- Translational and Clinical Research Institute, Newcastle University, Newcastle, United Kingdom
- Northern Centre for Mood Disorders, Newcastle University, Newcastle, United Kingdom
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle, United Kingdom
| | | | | | - Michael R. Barnes
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Sally Hull
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Sarah Finer
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Rohini Mathur
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
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Sidhu M, Saunders CL, Davies C, McKenna G, Wu F, Litchfield I, Olumogba F, Sussex J. Vertical integration of general practices with acute hospitals in England: rapid impact evaluation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-114. [PMID: 37839807 DOI: 10.3310/prwq4012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Background Vertical integration means merging organisations that operate at different stages along the patient pathway. We focus on acute hospitals running primary care medical practices. Evidence is scarce concerning the impact on use of health-care services and patient experience. Objectives To assess the impact of vertical integration on use of hospital services, service delivery and patient experience and whether patients with multiple long-term conditions are affected differently from others. Design Rapid, mixed methods evaluation with four work packages: (1) review of NHS trust annual reports and other sources to understand the scale of vertical integration across England; (2) development of the statistical analysis; (3) analysis of national survey data on patient experience, and national data on use of hospital services over the 2 years preceding and following vertical integration, comparing vertically integrated practices with a variety of control practices; and (4) focus groups and interviews with staff and patients across three case study sites to explore the impact of vertical integration on patient experience of care. Results At 31 March 2021, 26 NHS trusts were in vertically integrated organisations, running 85 general practices across 116 practice sites. The earliest vertical integration between trusts and general practices was in 2015; a mean of 3.3 practices run by each trust (range 1-12). On average, integrated practices have fewer patients, are slightly more likely to be in the most deprived decile of areas, are more likely to hold an alternative provider medical services contract and have worse Quality and Outcomes Framework scores compared with non-integrated practices. Vertical integration is associated with statistically significant, modest reductions in rates of accident and emergency department attendances: 2% reduction (incidence rate ratio 0.98, 95% confidence interval 0.96 to 0.99; p < 0.0001); outpatient attendances: 1% reduction (incidence rate ratio 0.99, 95% confidence interval 0.99 to 1.00; p = 0.0061), emergency inpatient admissions: 3% reduction (incidence rate ratio 0.97, 95% confidence interval 0.95 to 0.99; p = 0.0062) and emergency readmissions: 5% reduction (incidence rate ratio 0.95, 95% confidence interval 0.91 to 1.00; p = 0.039), with no impact on length of stay, overall inpatient admissions or inpatient admissions for ambulatory care sensitive conditions. The falls in accident and emergency department and outpatient attendance rates are temporary. Focus groups and interviews with staff (N = 22) and interviews with patients (N = 14) showed that with vertical integration, health service improvements are introduced following a period of cultural interchange. Patients with multiple long-term conditions continue to encounter 'navigation work' choosing and accessing health-care provision, with diminishing continuity of care. Limitations In the quantitative analysis, we could not replicate the counterfactual of what would have happened in those specific locations had practices not merged with trusts. There was imbalance across three case study sites with regard to staff and patients recruited for interview, and the latter were drawn from patient participation groups who may not be representative of local populations. Conclusions Vertical integration can lead to modest reductions in use of hospital services and has minor or no impact on patient experience of care. Our analysis does not reveal a case for widespread roll-out of the approach. Future research Further quantitative follow-up of the longer-term impact of vertical integration on hospital usage and more extensive interviewing of patients and their carers about patient experiences of navigating care. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (BRACE Project no. 16/138/31) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Manbinder Sidhu
- University of Birmingham, Health Services Management Centre, Birmingham, UK
| | - Catherine L Saunders
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Gemma McKenna
- University of Birmingham, Health Services Management Centre, Birmingham, UK
| | | | - Ian Litchfield
- University of Birmingham, Institute of Applied Health Research, Birmingham, UK
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North TL, Harrison S, Bishop DC, Wootton RE, Carter AR, Richardson TG, Payne RA, Salisbury C, Howe LD. Educational inequality in multimorbidity: causality and causal pathways. A mendelian randomisation study in UK Biobank. BMC Public Health 2023; 23:1644. [PMID: 37641019 PMCID: PMC10463319 DOI: 10.1186/s12889-023-16369-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Multimorbidity, typically defined as having two or more long-term health conditions, is associated with reduced wellbeing and life expectancy. Understanding the determinants of multimorbidity, including whether they are causal, may help with the design and prioritisation of prevention interventions. This study seeks to assess the causality of education, BMI, smoking and alcohol as determinants of multimorbidity, and the degree to which BMI, smoking and alcohol mediate differences in multimorbidity by level of education. METHODS Participants were 181,214 females and 155,677 males, mean ages 56.7 and 57.1 years respectively, from UK Biobank. We used a Mendelian randomization design; an approach that uses genetic variants as instrumental variables to interrogate causality. RESULTS The prevalence of multimorbidity was 55.1%. Mendelian randomization suggests that lower education, higher BMI and higher levels of smoking causally increase the risk of multimorbidity. For example, one standard deviation (equivalent to 5.1 years) increase in genetically-predicted years of education decreases the risk of multimorbidity by 9.0% (95% CI: 6.5 to 11.4%). A 5 kg/m2 increase in genetically-predicted BMI increases the risk of multimorbidity by 9.2% (95% CI: 8.1 to 10.3%) and a one SD higher lifetime smoking index increases the risk of multimorbidity by 6.8% (95% CI: 3.3 to 10.4%). Evidence for a causal effect of genetically-predicted alcohol consumption on multimorbidity was less strong; an increase of 5 units of alcohol per week increases the risk of multimorbidity by 1.3% (95% CI: 0.2 to 2.5%). The proportions of the association between education and multimorbidity explained by BMI and smoking are 20.4% and 17.6% respectively. Collectively, BMI and smoking account for 31.8% of the educational inequality in multimorbidity. CONCLUSIONS Education, BMI, smoking and alcohol consumption are intervenable causal risk factors for multimorbidity. Furthermore, BMI and lifetime smoking make a considerable contribution to the generation of educational inequalities in multimorbidity. Public health interventions that improve population-wide levels of these risk factors are likely to reduce multimorbidity and inequalities in its occurrence.
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Affiliation(s)
- Teri-Louise North
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK.
| | - Sean Harrison
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
| | - Deborah C Bishop
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
| | - Robyn E Wootton
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
- Nic Waals Institute, Lovisenberg Diaconal Hospital, Oslo, Norway
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Alice R Carter
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
| | - Tom G Richardson
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
- Exeter Collaboration for Academic Primary Care, Department of Health and Community Sciences, University of Exeter, Exeter, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | - Laura D Howe
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
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MacRae C, Morales D, Mercer SW, Lone N, Lawson A, Jefferson E, McAllister D, van den Akker M, Marshall A, Seth S, Rawlings A, Lyons J, Lyons RA, Mizen A, Abubakar E, Dibben C, Guthrie B. Impact of data source choice on multimorbidity measurement: a comparison study of 2.3 million individuals in the Welsh National Health Service. BMC Med 2023; 21:309. [PMID: 37582755 PMCID: PMC10426056 DOI: 10.1186/s12916-023-02970-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/03/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND Measurement of multimorbidity in research is variable, including the choice of the data source used to ascertain conditions. We compared the estimated prevalence of multimorbidity and associations with mortality using different data sources. METHODS A cross-sectional study of SAIL Databank data including 2,340,027 individuals of all ages living in Wales on 01 January 2019. Comparison of prevalence of multimorbidity and constituent 47 conditions using data from primary care (PC), hospital inpatient (HI), and linked PC-HI data sources and examination of associations between condition count and 12-month mortality. RESULTS Using linked PC-HI compared with only HI data, multimorbidity was more prevalent (32.2% versus 16.5%), and the population of people identified as having multimorbidity was younger (mean age 62.5 versus 66.8 years) and included more women (54.2% versus 52.6%). Individuals with multimorbidity in both PC and HI data had stronger associations with mortality than those with multimorbidity only in HI data (adjusted odds ratio 8.34 [95% CI 8.02-8.68] versus 6.95 (95%CI 6.79-7.12] in people with ≥ 4 conditions). The prevalence of conditions identified using only PC versus only HI data was significantly higher for 37/47 and significantly lower for 10/47: the highest PC/HI ratio was for depression (14.2 [95% CI 14.1-14.4]) and the lowest for aneurysm (0.51 [95% CI 0.5-0.5]). Agreement in ascertainment of conditions between the two data sources varied considerably, being slight for five (kappa < 0.20), fair for 12 (kappa 0.21-0.40), moderate for 16 (kappa 0.41-0.60), and substantial for 12 (kappa 0.61-0.80) conditions, and by body system was lowest for mental and behavioural disorders. The percentage agreement, individuals with a condition identified in both PC and HI data, was lowest in anxiety (4.6%) and highest in coronary artery disease (62.9%). CONCLUSIONS The use of single data sources may underestimate prevalence when measuring multimorbidity and many important conditions (especially mental and behavioural disorders). Caution should be used when interpreting findings of research examining individual and multiple long-term conditions using single data sources. Where available, researchers using electronic health data should link primary care and hospital inpatient data to generate more robust evidence to support evidence-based healthcare planning decisions for people with multimorbidity.
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Affiliation(s)
- Clare MacRae
- Advanced Care Research Centre, University of Edinburgh, Bio Cube 1, Edinburgh BioQuarter, 13 Little France Road, Edinburgh, UK.
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.
| | - Daniel Morales
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
- Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Stewart W Mercer
- Advanced Care Research Centre, University of Edinburgh, Bio Cube 1, Edinburgh BioQuarter, 13 Little France Road, Edinburgh, UK
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Nazir Lone
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Andrew Lawson
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, USA
| | - Emily Jefferson
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
| | - David McAllister
- Public Health, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 9LX, UK
| | - Marjan van den Akker
- Institute of General Practice, Goethe University Frankfurt, Frankfurt Am Main, Germany
- Department of Public Health and Primary Care, Academic Center for General Practice, KU Leuven, Louvain, Belgium
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Alan Marshall
- School of Social and Political Science, University of Edinburgh, Chrystal Macmillan Building, Edinburgh, EH8 9LD, UK
| | - Sohan Seth
- School of Informatics, The University of Edinburgh, Edinburgh, UK
| | - Anna Rawlings
- Swansea University Medical School, Data Science Building, Singleton Campus, Swansea, UK
| | - Jane Lyons
- Swansea University Medical School, Data Science Building, Singleton Campus, Swansea, UK
| | - Ronan A Lyons
- Swansea University Medical School, Data Science Building, Singleton Campus, Swansea, UK
| | - Amy Mizen
- Swansea University Medical School, Data Science Building, Singleton Campus, Swansea, UK
| | - Eleojo Abubakar
- Public Health, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 9LX, UK
| | - Chris Dibben
- University of Edinburgh Institute of Geography, Institute of Geography Edinburgh, Edinburgh, UK
| | - Bruce Guthrie
- Advanced Care Research Centre, University of Edinburgh, Bio Cube 1, Edinburgh BioQuarter, 13 Little France Road, Edinburgh, UK
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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Conroy MC, Reeves GK, Allen NE. Multi-morbidity and its association with common cancer diagnoses: a UK Biobank prospective study. BMC Public Health 2023; 23:1300. [PMID: 37415095 PMCID: PMC10326925 DOI: 10.1186/s12889-023-16202-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Whilst multi-morbidity is known to be a concern in people with cancer, very little is known about the risk of cancer in multi-morbid patients. This study aims to investigate the risk of being diagnosed with lung, colorectal, breast and prostate cancer associated with multi-morbidity. METHODS We investigated the association between multi-morbidity and subsequent risk of cancer diagnosis in UK Biobank. Cox models were used to estimate the relative risks of each cancer of interest in multi-morbid participants, using the Cambridge Multimorbidity Score. The extent to which reverse causation, residual confounding and ascertainment bias may have impacted on the findings was robustly investigated. RESULTS Of the 436,990 participants included in the study who were cancer-free at baseline, 21.6% (99,965) were multi-morbid (≥ 2 diseases). Over a median follow-up time of 10.9 [IQR 10.0-11.7] years, 9,019 prostate, 7,994 breast, 5,241 colorectal, and 3,591 lung cancers were diagnosed. After exclusion of the first year of follow-up, there was no clear association between multi-morbidity and risk of colorectal, prostate or breast cancer diagnosis. Those with ≥ 4 diseases at recruitment had double the risk of a subsequent lung cancer diagnosis compared to those with no diseases (HR 2.00 [95% CI 1.70-2.35] p for trend < 0.001). These findings were robust to sensitivity analyses aimed at reducing the impact of reverse causation, residual confounding from known cancer risk factors and ascertainment bias. CONCLUSIONS Individuals with multi-morbidity are at an increased risk of lung cancer diagnosis. While this association did not appear to be due to common sources of bias in observational studies, further research is needed to understand what underlies this association.
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Affiliation(s)
- Megan C Conroy
- Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK.
| | - Gillian K Reeves
- Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK
| | - Naomi E Allen
- Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK
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Martins T, Ukoumunne OC, Lyratzopoulos G, Hamilton W, Abel G. Are There Ethnic Differences in Recorded Features among Patients Subsequently Diagnosed with Cancer? An English Longitudinal Data-Linked Study. Cancers (Basel) 2023; 15:3100. [PMID: 37370710 PMCID: PMC10296232 DOI: 10.3390/cancers15123100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/02/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
We investigated ethnic differences in the presenting features recorded in primary care before cancer diagnosis. METHODS English population-based cancer-registry-linked primary care data were analysed. We identified the coded features of six cancers (breast, lung, prostate, colorectal, oesophagogastric, and myeloma) in the year pre-diagnosis. Logistic regression models investigated ethnic differences in first-incident cancer features, adjusted for age, sex, smoking status, deprivation, and comorbidity. RESULTS Of 130,944 patients, 92% were White. In total, 188,487 incident features were recorded in the year pre-diagnosis, with 48% (89,531) as sole features. Compared with White patients, Asian and Black patients with breast, colorectal, and prostate cancer were more likely than White patients to have multiple features; the opposite was seen for the Black and Other ethnic groups with lung or prostate cancer. The proportion with relevant recorded features was broadly similar by ethnicity, with notable cancer-specific exceptions. Asian and Black patients were more likely to have low-risk features (e.g., cough, upper abdominal pain) recorded. Non-White patients were less likely to have alarm features. CONCLUSION The degree to which these differences reflect disease, patient or healthcare factors is unclear. Further research examining the predictive value of cancer features in ethnic minority groups and their association with cancer outcomes is needed.
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Affiliation(s)
- Tanimola Martins
- Department of Health and Community Sciences, Faculty of Health and Life Sciences, College of Medicine and Health, University of Exeter St Luke’s Campus, Magdalen Road, Exeter EX1 2LU, UK; (W.H.); (G.A.)
| | - Obioha C. Ukoumunne
- National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter EX1 2LU, UK;
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, University College London, 1-19 Torrington Place, London WC1E 7HB, UK;
| | - Willie Hamilton
- Department of Health and Community Sciences, Faculty of Health and Life Sciences, College of Medicine and Health, University of Exeter St Luke’s Campus, Magdalen Road, Exeter EX1 2LU, UK; (W.H.); (G.A.)
| | - Gary Abel
- Department of Health and Community Sciences, Faculty of Health and Life Sciences, College of Medicine and Health, University of Exeter St Luke’s Campus, Magdalen Road, Exeter EX1 2LU, UK; (W.H.); (G.A.)
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Dewan P, Ferreira JP, Butt JH, Petrie MC, Abraham WT, Desai AS, Dickstein K, Køber L, Packer M, Rouleau JL, Stewart S, Swedberg K, Zile MR, Solomon SD, Jhund PS, McMurray JJV. Impact of multimorbidity on mortality in heart failure with reduced ejection fraction: which comorbidities matter most? An analysis of PARADIGM-HF and ATMOSPHERE. Eur J Heart Fail 2023; 25:687-697. [PMID: 37062869 DOI: 10.1002/ejhf.2856] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/14/2023] [Accepted: 04/08/2023] [Indexed: 04/18/2023] Open
Abstract
AIMS Multimorbidity, the coexistence of two or more chronic conditions, is synonymous with heart failure (HF). How risk related to comorbidities compares at individual and population levels is unknown. The aim of this study is to examine the risk related to comorbidities, alone and in combination, both at individual and population levels. METHODS AND RESULTS Using two clinical trials in HF - the Prospective comparison of ARNI (Angiotensin Receptor-Neprilysin Inhibitor) with ACEI (Angiotensin-Converting Enzyme Inhibitor) to Determine Impact on Global Mortality and morbidity in HF trial (PARADIGM-HF) and the Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure trials (ATMOSPHERE) - we identified the 10 most common comorbidities and examined 45 possible pairs. We calculated population attributable fractions (PAF) for all-cause death and relative excess risk due to interaction with Cox proportional hazard models. Of 15 066 patients in the study, 14 133 (93.7%) had at least one and 11 867 (78.8%) had at least two of the 10 most prevalent comorbidities. The greatest individual risk among pairs was associated with peripheral artery disease (PAD) in combination with stroke (hazard ratio [HR] 1.73; 95% confidence interval [CI] 1.28-2.33) and anaemia (HR 1.71; 95% CI 1.39-2.11). The combination of chronic kidney disease (CKD) and hypertension had the highest PAF (5.65%; 95% CI 3.66-7.61). Two pairs demonstrated significant synergistic interaction (atrial fibrillation with CKD and coronary artery disease, respectively) and one an antagonistic interaction (anaemia and obesity). CONCLUSIONS In HF, the impact of multimorbidity differed at the individual patient and population level, depending on the prevalence of and the risk related to each comorbidity, and the interaction between individual comorbidities. Patients with coexistent PAD and stroke were at greatest individual risk whereas, from a population perspective, coexistent CKD and hypertension mattered most.
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Affiliation(s)
- Pooja Dewan
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - João Pedro Ferreira
- Department of Surgery and Physiology, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jawad H Butt
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - William T Abraham
- Division of Cardiovascular Medicine, Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Kenneth Dickstein
- Stavanger University Hospital, Stavanger, and the Institute of Internal Medicine, University of Bergen, Bergen, Norway
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, QC, Canada
| | - Simon Stewart
- Institute for Health Research, University of Notre Dame, Fremantle, WA, Australia
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Michael R Zile
- Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Doherty N, Cardwell CR, Murchie P, Hill C, Azoulay L, Hicks B. 5α-Reductase Inhibitors and Risk of Kidney and Bladder Cancers in Men with Benign Prostatic Hyperplasia: A Population-Based Cohort Study. Cancer Epidemiol Biomarkers Prev 2023; 32:428-434. [PMID: 36634196 PMCID: PMC7614290 DOI: 10.1158/1055-9965.epi-22-1109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/14/2022] [Accepted: 01/10/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Preclinical evidence suggests that 5α-reductase inhibitors (5ARi), commonly used to treat benign prostatic hyperplasia (BPH), are associated with reduced incidence of certain urologic cancers, yet epidemiologic studies are conflicting. This study aimed to determine whether 5ARi's are associated with a reduced risk of kidney and bladder cancers. METHODS We conducted a new-user active-comparator cohort study in the United Kingdom Clinical Practice Research Datalink. From a base cohort of patients with incident BPH, new users of 5ARi's and α-blockers were identified. Patients were followed up until a first ever diagnosis of kidney or bladder cancer, death from any cause, end of registration, or December 31, 2017. Cox proportional hazards models were used to calculate HRs and 95% confidence intervals (CI) for incident kidney and bladder cancer. RESULTS There were 5,414 and 37,681 new users of 5ARi's and α-blockers, respectively. During a mean follow-up of 6.3 years, we found no association between the use of 5ARi's and kidney (adjusted HR, 1.26; 95% CI, 0.74-2.12; n = 23) or bladder (adjusted HR, 0.89; 95% CI, 0.64-1.23; n = 57) cancer risk compared with α-blockers. Similar results were observed across sensitivity analyses. CONCLUSIONS In this study, we found no association between the use of 5ARi's and kidney or bladder cancer incidence in men with BPH when compared with α-blocker use. IMPACT The findings of this study indicate that 5ARi's are unlikely to reduce kidney or bladder cancer risk.
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Affiliation(s)
- Niamh Doherty
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Chris R Cardwell
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Peter Murchie
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland
| | - Christopher Hill
- Regional Nephrology Unit, Belfast City Hospital, Belfast, Northern Ireland, United Kingdom
| | - Laurent Azoulay
- Centre for Clinical Epidemiology Lady Davis Institute, Jewish General Hospital, Montreal, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health and Gerald Bronfman Department of Oncology, McGill University, Montreal, Canada
| | - Blánaid Hicks
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
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Price S, Wiering B, Mounce LTA, Hamilton W, Abel G. Examining methodology to identify patterns of consulting in primary care for different groups of patients before a diagnosis of cancer: An exemplar applied to oesophagogastric cancer. Cancer Epidemiol 2023; 82:102310. [PMID: 36508967 DOI: 10.1016/j.canep.2022.102310] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Current methods for estimating the timeliness of cancer diagnosis are not robust because dates of key defining milestones, for example first presentation, are uncertain. This is exacerbated when patients have other conditions (multimorbidity), particularly those that share symptoms with cancer. Methods independent of this uncertainty are needed for accurate estimates of the timeliness of cancer diagnosis, and to understand how multimorbidity impacts the diagnostic process. METHODS Participants were diagnosed with oesophagogastric cancer between 2010 and 2019. Controls were matched on year of birth, sex, general practice and multimorbidity burden calculated using the Cambridge Multimorbidity Score. Primary care data (Clinical Practice Research Datalink) was used to explore population-level consultation rates for up to two years before diagnosis across different multimorbidity burdens. Five approaches were compared on the timing of the consultation frequency increase, the inflection point for different multimorbidity burdens, different aggregated time-periods and sample sizes. RESULTS We included 15,410 participants, of which 13,328 (86.5 %) had a measurable multimorbidity burden. Our new maximum likelihood estimation method found evidence that the inflection point in consultation frequency varied with multimorbidity burden, from 154 days (95 %CI 131.8-176.2) before diagnosis for patients with no multimorbidity, to 126 days (108.5-143.5) for patients with the greatest multimorbidity burden. Inflection points identified using alternative methods were closer to diagnosis for up to three burden groups. Sample size reduction and changing the aggregation period resulted in inflection points closer to diagnosis, with the smallest change for the maximum likelihood method. DISCUSSION Existing methods to identify changes in consultation rates can introduce substantial bias which depends on sample size and aggregation period. The direct maximum likelihood method was less prone to this bias than other methods and offers a robust, population-level alternative for estimating the timeliness of cancer diagnosis.
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Affiliation(s)
- Sarah Price
- Medical School, College of Medicine and Health, University of Exeter, St Luke's Campus, Heavitree Road, Exeter EX1 2LU, UK
| | - Bianca Wiering
- Medical School, College of Medicine and Health, University of Exeter, St Luke's Campus, Heavitree Road, Exeter EX1 2LU, UK.
| | - Luke T A Mounce
- Medical School, College of Medicine and Health, University of Exeter, St Luke's Campus, Heavitree Road, Exeter EX1 2LU, UK
| | - Willie Hamilton
- Medical School, College of Medicine and Health, University of Exeter, St Luke's Campus, Heavitree Road, Exeter EX1 2LU, UK
| | - Gary Abel
- Medical School, College of Medicine and Health, University of Exeter, St Luke's Campus, Heavitree Road, Exeter EX1 2LU, UK
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Leston M, Elson WH, Watson C, Lakhani A, Aspden C, Bankhead CR, Borrow R, Button E, Byford R, Elliot AJ, Fan X, Hoang U, Linley E, Macartney J, Nicholson BD, Okusi C, Ramsay M, Smith G, Smith S, Thomas M, Todkill D, Tsang RS, Victor W, Williams AJ, Williams J, Zambon M, Howsam G, Amirthalingam G, Lopez-Bernal J, Hobbs FDR, de Lusignan S. Representativeness, Vaccination Uptake, and COVID-19 Clinical Outcomes 2020-2021 in the UK Oxford-Royal College of General Practitioners Research and Surveillance Network: Cohort Profile Summary. JMIR Public Health Surveill 2022; 8:e39141. [PMID: 36534462 PMCID: PMC9770023 DOI: 10.2196/39141] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 10/27/2022] [Accepted: 11/02/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) is one of Europe's oldest sentinel systems, working with the UK Health Security Agency (UKHSA) and its predecessor bodies for 55 years. Its surveillance report now runs twice weekly, supplemented by online observatories. In addition to conducting sentinel surveillance from a nationally representative group of practices, the RSC is now also providing data for syndromic surveillance. OBJECTIVE The aim of this study was to describe the cohort profile at the start of the 2021-2022 surveillance season and recent changes to our surveillance practice. METHODS The RSC's pseudonymized primary care data, linked to hospital and other data, are held in the Oxford-RCGP Clinical Informatics Digital Hub, a Trusted Research Environment. We describe the RSC's cohort profile as of September 2021, divided into a Primary Care Sentinel Cohort (PCSC)-collecting virological and serological specimens-and a larger group of syndromic surveillance general practices (SSGPs). We report changes to our sampling strategy that brings the RSC into alignment with European Centre for Disease Control guidance and then compare our cohort's sociodemographic characteristics with Office for National Statistics data. We further describe influenza and COVID-19 vaccine coverage for the 2020-2021 season (week 40 of 2020 to week 39 of 2021), with the latter differentiated by vaccine brand. Finally, we report COVID-19-related outcomes in terms of hospitalization, intensive care unit (ICU) admission, and death. RESULTS As a response to COVID-19, the RSC grew from just over 500 PCSC practices in 2019 to 1879 practices in 2021 (PCSC, n=938; SSGP, n=1203). This represents 28.6% of English general practices and 30.59% (17,299,780/56,550,136) of the population. In the reporting period, the PCSC collected >8000 virology and >23,000 serology samples. The RSC population was broadly representative of the national population in terms of age, gender, ethnicity, National Health Service Region, socioeconomic status, obesity, and smoking habit. The RSC captured vaccine coverage data for influenza (n=5.4 million) and COVID-19, reporting dose one (n=11.9 million), two (n=11 million), and three (n=0.4 million) for the latter as well as brand-specific uptake data (AstraZeneca vaccine, n=11.6 million; Pfizer, n=10.8 million; and Moderna, n=0.7 million). The median (IQR) number of COVID-19 hospitalizations and ICU admissions was 1181 (559-1559) and 115 (50-174) per week, respectively. CONCLUSIONS The RSC is broadly representative of the national population; its PCSC is geographically representative and its SSGPs are newly supporting UKHSA syndromic surveillance efforts. The network captures vaccine coverage and has expanded from reporting primary care attendances to providing data on onward hospital outcomes and deaths. The challenge remains to increase virological and serological sampling to monitor the effectiveness and waning of all vaccines available in a timely manner.
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Affiliation(s)
- Meredith Leston
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - William H Elson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Conall Watson
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, Colindale, London, United Kingdom
| | - Anissa Lakhani
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, Colindale, London, United Kingdom
| | - Carole Aspden
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Clare R Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ray Borrow
- Vaccine Evaluation Unit, UK Health Security Agency, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Elizabeth Button
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rachel Byford
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Alex J Elliot
- Real-time Syndromic Surveillance Team, Field Service, UK Health Security Agency, Birmingham, United Kingdom
| | - Xuejuan Fan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Uy Hoang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ezra Linley
- Vaccine Evaluation Unit, UK Health Security Agency, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Jack Macartney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Cecilia Okusi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Mary Ramsay
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, Colindale, London, United Kingdom
| | - Gillian Smith
- Real-time Syndromic Surveillance Team, Field Service, UK Health Security Agency, Birmingham, United Kingdom
| | - Sue Smith
- Real-time Syndromic Surveillance Team, Field Service, UK Health Security Agency, Birmingham, United Kingdom
| | - Mark Thomas
- Royal College of General Practitioners, London, United Kingdom
| | - Dan Todkill
- Real-time Syndromic Surveillance Team, Field Service, UK Health Security Agency, Birmingham, United Kingdom
| | - Ruby Sm Tsang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - William Victor
- Royal College of General Practitioners, London, United Kingdom
| | - Alice J Williams
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - John Williams
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Maria Zambon
- Reference Microbiology, UK Health Security Agency, Colindale, London, United Kingdom
| | - Gary Howsam
- Royal College of General Practitioners, London, United Kingdom
| | - Gayatri Amirthalingam
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, Colindale, London, United Kingdom
| | - Jamie Lopez-Bernal
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, Colindale, London, United Kingdom
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Ronaldson A, Arias de la Torre J, Ashworth M, Hansell AL, Hotopf M, Mudway I, Stewart R, Dregan A, Bakolis I. Associations between air pollution and multimorbidity in the UK Biobank: A cross-sectional study. Front Public Health 2022; 10:1035415. [PMID: 36530697 PMCID: PMC9755180 DOI: 10.3389/fpubh.2022.1035415] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/28/2022] [Indexed: 12/03/2022] Open
Abstract
Background Long-term exposure to air pollution concentrations is known to be adversely associated with a broad range of single non-communicable diseases, but its role in multimorbidity has not been investigated in the UK. We aimed to assess associations between long-term air pollution exposure and multimorbidity status, severity, and patterns using the UK Biobank cohort. Methods Multimorbidity status was calculated based on 41 physical and mental conditions. We assessed cross-sectional associations between annual modeled particulate matter (PM)2.5, PMcoarse, PM10, and nitrogen dioxide (NO2) concentrations (μg/m3-modeled to residential address) and multimorbidity status at the baseline assessment (2006-2010) in 364,144 people (mean age: 52.2 ± 8.1 years, 52.6% female). Air pollutants were categorized into quartiles to assess dose-response associations. Among those with multimorbidity (≥2 conditions; n = 156,395) we assessed associations between air pollutant exposure levels and multimorbidity severity and multimorbidity patterns, which were identified using exploratory factor analysis. Associations were explored using generalized linear models adjusted for sociodemographic, behavioral, and environmental indicators. Results Higher exposures to PM2.5, and NO2 were associated with multimorbidity status in a dose-dependent manner. These associations were strongest when we compared the highest air pollution quartile (quartile 4: Q4) with the lowest quartile (Q1) [PM2.5: adjusted odds ratio (adjOR) = 1.21 (95% CI = 1.18, 1.24); NO2: adjOR = 1.19 (95 % CI = 1.16, 1.23)]. We also observed dose-response associations between air pollutant exposures and multimorbidity severity scores. We identified 11 multimorbidity patterns. Air pollution was associated with several multimorbidity patterns with strongest associations (Q4 vs. Q1) observed for neurological (stroke, epilepsy, alcohol/substance dependency) [PM2.5: adjOR = 1.31 (95% CI = 1.14, 1.51); NO2: adjOR = 1.33 (95% CI = 1.11, 1.60)] and respiratory patterns (COPD, asthma) [PM2.5: adjOR = 1.24 (95% CI = 1.16, 1.33); NO2: adjOR = 1.26 (95% CI = 1.15, 1.38)]. Conclusions This cross-sectional study provides evidence that exposure to air pollution might be associated with having multimorbid, multi-organ conditions. Longitudinal studies are needed to further explore these associations.
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Affiliation(s)
- Amy Ronaldson
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom
| | - Jorge Arias de la Torre
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom
- CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Institute of Biomedicine (IBIOMED), University of Leon, Leon, Spain
| | - Mark Ashworth
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
| | - Anna L. Hansell
- Centre for Environmental Health and Sustainability, University of Leicester, Leicester, United Kingdom
- National Institute for Health and Care Research, Health Protection Research Unit (HPRU) in Environmental Exposures and Health at the University of Leicester, Leicester, United Kingdom
| | - Matthew Hotopf
- Department of Psychological Medicine, King's College London, IoPPN and South London and Maudsley NHS Foundation Trust, London, United Kingdom
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Ian Mudway
- National Institute for Health and Care Research, Health Protection Unit in Environmental Exposures and Health, Imperial College London, London, United Kingdom
- MRC Centre for Environment and Health, School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Rob Stewart
- Department of Psychological Medicine, King's College London, IoPPN and South London and Maudsley NHS Foundation Trust, London, United Kingdom
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Alex Dregan
- Department of Psychological Medicine, King's College London, IoPPN and South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Ioannis Bakolis
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom
- Department of Biostatistics and Health Informatics, IoPPN, King's College London, London, United Kingdom
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Geyer S, Eberhard S. Compression and Expansion of Morbidity. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:810-815. [PMID: 36300897 PMCID: PMC9906028 DOI: 10.3238/arztebl.m2022.0324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/06/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Morbidity is said to be compressed when the interval from the onset of a disease or disability to death becomes shorter over time, or when the incidence of the disease or disability declines over time. In the reverse situation, morbidity is said to be expanded. METHODS This review is based on national and international studies retrieved by a selective literature search on secular trends in morbidity and mortality. The findings were derived from data from surveys and registries, and from the routine data of health insurance carriers. RESULTS Three different types of secular trends in morbidity were seen. For some diseases (e.g., lung cancer, stroke, and dementia), morbidity among the elderly was compressed over time. On the other hand, for multimorbidity and type 2 diabetes including comorbidities, morbidity expanded over time. Unexpectedly, a double development was seen in certain other conditions, with both compression among the elderly and expansion among the middle-aged: this was particularly so for myo - cardial infarction, grip strength, and indicators of general health. CONCLUSION The notion of morbidity being reduced by compression seems less tenable in view of the double development just mentioned. The findings suggest that the observed secular trend toward better health among the elderly has not persisted among the more recently born cohorts. This can have negative effects on social security systems, particularly with respect to retirement ages being deferred or made more flexible, as well as the cost of health care.
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Affiliation(s)
- Siegfried Geyer
- Medical Sociology Unit, Hannover Medical School, Hannover,*Medizinische Soziologie Medizinische Hochschule Hannover Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Hanlon P, Butterly E, Shah ASV, Hannigan LJ, Wild SH, Guthrie B, Mair FS, Dias S, Welton NJ, McAllister DA. Assessing trial representativeness using serious adverse events: an observational analysis using aggregate and individual-level data from clinical trials and routine healthcare data. BMC Med 2022; 20:410. [PMID: 36303169 PMCID: PMC9615407 DOI: 10.1186/s12916-022-02594-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The applicability of randomised controlled trials of pharmacological agents to older people with frailty/multimorbidity is often uncertain, due to concerns that trials are not representative. However, assessing trial representativeness is challenging and complex. We explore an approach assessing trial representativeness by comparing rates of trial serious adverse events (SAE) to rates of hospitalisation/death in routine care. METHODS This was an observational analysis of individual (125 trials, n=122,069) and aggregate-level drug trial data (483 trials, n=636,267) for 21 index conditions compared to population-based routine healthcare data (routine care). Trials were identified from ClinicalTrials.gov . Routine care comparison from linked primary care and hospital data from Wales, UK (n=2.3M). Our outcome of interest was SAEs (routinely reported in trials). In routine care, SAEs were based on hospitalisations and deaths (which are SAEs by definition). We compared trial SAEs in trials to expected SAEs based on age/sex standardised routine care populations with the same index condition. Using IPD, we assessed the relationship between multimorbidity count and SAEs in both trials and routine care and assessed the impact on the observed/expected SAE ratio additionally accounting for multimorbidity. RESULTS For 12/21 index conditions, the pooled observed/expected SAE ratio was <1, indicating fewer SAEs in trial participants than in routine care. A further 6/21 had point estimates <1 but the 95% CI included the null. The median pooled estimate of observed/expected SAE ratio was 0.60 (95% CI 0.55-0.64; COPD) and the interquartile range was 0.44 (0.34-0.55; Parkinson's disease) to 0.87 (0.58-1.29; inflammatory bowel disease). Higher multimorbidity count was associated with SAEs across all index conditions in both routine care and trials. For most trials, the observed/expected SAE ratio moved closer to 1 after additionally accounting for multimorbidity count, but it nonetheless remained below 1 for most. CONCLUSIONS Trial participants experience fewer SAEs than expected based on age/sex/condition hospitalisation and death rates in routine care, confirming the predicted lack of representativeness. This difference is only partially explained by differences in multimorbidity. Assessing observed/expected SAE may help assess the applicability of trial findings to older populations in whom multimorbidity and frailty are common.
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Affiliation(s)
- Peter Hanlon
- School for Health and Wellbeing, University of Glasgow, Glasgow, UK.
| | - Elaine Butterly
- School for Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Anoop S V Shah
- London School of Hygiene and Tropical Medicine, London, UK
| | - Laurie J Hannigan
- Nic Waals Institute, Lovisenberg Diaconal Hospital, Oslo, Norway
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
| | - Sarah H Wild
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Bruce Guthrie
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Frances S Mair
- School for Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Benitez Majano S, Lyratzopoulos G, de Wit NJ, White B, Rachet B, Helsper C, Usher-Smith J, Renzi C. Mental Health Morbidities and Time to Cancer Diagnosis Among Adults With Colon Cancer in England. JAMA Netw Open 2022; 5:e2238569. [PMID: 36315146 PMCID: PMC9623442 DOI: 10.1001/jamanetworkopen.2022.38569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/29/2022] [Indexed: 11/29/2022] Open
Abstract
Importance Mental health morbidity (MHM) in patients presenting with possible cancer symptoms may be associated with prediagnostic care and time to cancer diagnosis. Objective To compare the length of intervals to cancer diagnosis by preexisting MHM status in patients who presented with symptoms of as-yet-undiagnosed colon cancer and evaluate their risk of emergency cancer diagnosis. Design, Setting, and Participants This cohort study was conducted using linked primary care data obtained from the population-based Clinical Practice Research Datalink, which includes primary care practices in England, linked to cancer registry and hospital data. Included participants were 3766 patients diagnosed with colon cancer between 2011 and 2015 presenting with cancer-relevant symptoms up to 24 months before their diagnosis. Data analysis was performed in January 2021 to April 2022. Exposures Mental health conditions recorded in primary care before cancer diagnosis, including anxiety, depression, schizophrenia, bipolar disorder, alcohol addiction, anorexia, and bulimia. Main Outcomes and Measures Fast-track (also termed 2-week wait) specialist referral for investigations, time to colonoscopy and cancer diagnosis, and risk of emergency cancer diagnosis. Results Among 3766 patients with colon cancer (median [IQR] age, 75 [65-82] years; 1911 [50.7%] women ), 623 patients [16.5%] had preexisting MHM recorded in primary care the year before cancer diagnosis, including 562 patients (14.9%) with preexisting anxiety or depression (accounting for 90.2% of patients with preexisting MHM) and 61 patients (1.6%) with other MHM; 3143 patients (83.5%) did not have MHM. Patients with MHM had records of red-flag symptoms or signs (ie, rectal bleeding, change in bowel habit, or anemia) in the 24 months before cancer diagnosis in a smaller proportion compared with patients without MHM (308 patients [49.4%] vs 1807 patients [57.5%]; P < .001). Even when red-flag symptoms were recorded, patients with MHM had lower odds of fast-track specialist referral (adjusted odds ratio [OR] = 0.72; 95% CI, 0.55-0.94; P = .01). Among 2115 patients with red-flag symptoms or signs, 308 patients with MHM experienced a more than 2-fold longer median (IQR) time to cancer diagnosis (326 [75-552] days vs 133 [47-422] days) and higher odds of emergency diagnosis (90 patients [29.2%] vs 327 patients [18.1%]; adjusted OR = 1.63; 95% CI, 1.23-2.24; P < .001) compared with 1807 patients without MHM. Conclusions and Relevance This study found that patients with MHM experienced large and prognostically consequential disparities in diagnostic care before a colon cancer diagnosis. These findings suggest that appropriate pathways and follow-up strategies after symptomatic presentation are needed for earlier cancer diagnoses and improved health outcomes in this large patient group.
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Affiliation(s)
- Sara Benitez Majano
- Inequalities in Cancer Outcomes Network Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes Research Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Niek J. de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Becky White
- Epidemiology of Cancer Healthcare and Outcomes Research Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Bernard Rachet
- Inequalities in Cancer Outcomes Network Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charles Helsper
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Juliet Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Cristina Renzi
- Epidemiology of Cancer Healthcare and Outcomes Research Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
- Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy
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Tammes P, Payne RA, Salisbury C. Association between continuity of primary care and both prescribing and adherence of common cardiovascular medications: a cohort study among patients in England. BMJ Open 2022; 12:e063282. [PMID: 36100300 PMCID: PMC9472141 DOI: 10.1136/bmjopen-2022-063282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To investigate whether better continuity of care is associated with increased prescribing of clinically relevant medication and improved medication adherence. SETTING Random sample of 300 000 patients aged 30+ in 2017 within 83 English general practitioner (GP) practices from the Clinical Practice Research Datalink. DESIGN Patients were assigned to a randomly selected index date in 2017 on which medication use and continuity of care were determined. Adjusted associations between continuity of care and the prescribing and adherence of five cardiovascular medication groups were examined using logistic regression. PARTICIPANTS Continuity of Care Index was calculated for 173 993 patients with 4+ GP consultations 2 years prior to their index date and divided into five categories: absence of continuity, below-average continuity, average, above-average continuity and perfect continuity. MAIN OUTCOME MEASURES (A) Prescription for statins (primary or secondary prevention separately), anticoagulants, antiplatelet agents and antihypertensives covering the patient's index date. (B) Adherence (>80%) estimated using medication possession ratio. RESULTS There was strong evidence (p<0.01) that prescription of all five cardiovascular medication groups increased with greater continuity of care. Patients with absence of continuity were less likely to be prescribed cardiovascular medications than patients with above-average continuity (statins primary prevention OR 0.73, 95% CI 0.59 to 0.85; statins secondary prevention 0.77, 95% CI 0.57 to 1.03; antiplatelets 0.55, 95% CI 0.33 to 0.92; antihypertensives 0.51, 95% CI 0.39 to 0.65). Furthermore, patients with perfect continuity were more likely to be prescribed cardiovascular medications than those with above-average continuity (statins primary prevention OR 1.23, 95% CI 1.01 to 1.49; statins secondary prevention 1.37, 95% CI 1.10 to 1.71; antiplatelets 1.37, 95% CI 1.08 to 1.74; antihypertensives 1.10, 95% CI 0.99 to 1.23). Continuity was generally not associated with medication adherence, except for adherence to statins for secondary prevention (OR 0.75, 95% CI 0.60 to 0.94 for average compared with above-average continuity). CONCLUSION Better continuity of care is associated with improved prescribing of medication to patients at higher risk of cardiovascular disease but does not appear to be related to patient's medication adherence.
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Affiliation(s)
- Peter Tammes
- Centre for Academic Primary Care (CAPC), Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Rupert A Payne
- Centre for Academic Primary Care (CAPC), Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care (CAPC), Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
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Martins T, Abel G, Ukoumunne OC, Mounce LTA, Price S, Lyratzopoulos G, Chinegwundoh F, Hamilton W. Ethnic inequalities in routes to diagnosis of cancer: a population-based UK cohort study. Br J Cancer 2022; 127:863-871. [PMID: 35661833 PMCID: PMC9427836 DOI: 10.1038/s41416-022-01847-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 04/08/2022] [Accepted: 05/06/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND UK Asian and Black ethnic groups have poorer outcomes for some cancers and are less likely to report a positive care experience than their White counterparts. This study investigated ethnic differences in the route to diagnosis (RTD) to identify areas in patients' cancer journeys where inequalities lie, and targeted intervention might have optimum impact. METHODS We analysed data of 243,825 patients with 10 cancers (2006-2016) from the RTD project linked to primary care data. Crude and adjusted proportions of patients diagnosed via six routes (emergency, elective GP referral, two-week wait (2WW), screen-detected, hospital, and Other routes) were calculated by ethnicity. Adjusted odds ratios (including two-way interactions between cancer and age, sex, IMD, and ethnicity) determined cancer-specific differences in RTD by ethnicity. RESULTS Across the 10 cancers studied, most patients were diagnosed via 2WW (36.4%), elective GP referral (23.2%), emergency (18.2%), hospital routes (10.3%), and screening (8.61%). Patients of Other ethnic group had the highest proportion of diagnosis via the emergency route, followed by White patients. Asian and Black group were more likely to be GP-referred, with the Black and Mixed groups also more likely to follow the 2WW route. However, there were notable cancer-specific differences in the RTD by ethnicity. CONCLUSION Our findings suggest that, where inequalities exist, the adverse cancer outcomes among Asian and Black patients are unlikely to be arising solely from a poorer diagnostic process.
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Affiliation(s)
- Tanimola Martins
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK.
| | - Gary Abel
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
| | - Obioha C Ukoumunne
- National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter, Exeter, UK
| | - Luke T A Mounce
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
| | - Sarah Price
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Frank Chinegwundoh
- Barts Health NHS Trust & Department of Health Sciences, University of London, London, UK
| | - William Hamilton
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
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Meza-Torres B, Delanerolle G, Okusi C, Mayor N, Anand S, Macartney J, Gatenby P, Glampson B, Chapman M, Curcin V, Mayer E, Joy M, Greenhalgh T, Delaney B, de Lusignan S. Differences in Clinical Presentation With Long COVID After Community and Hospital Infection and Associations With All-Cause Mortality: English Sentinel Network Database Study. JMIR Public Health Surveill 2022; 8:e37668. [PMID: 35605170 PMCID: PMC9384859 DOI: 10.2196/37668] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/06/2022] [Accepted: 05/17/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Most studies of long COVID (symptoms of COVID-19 infection beyond 4 weeks) have focused on people hospitalized in their initial illness. Long COVID is thought to be underrecorded in UK primary care electronic records. OBJECTIVE We sought to determine which symptoms people present to primary care after COVID-19 infection and whether presentation differs in people who were not hospitalized, as well as post-long COVID mortality rates. METHODS We used routine data from the nationally representative primary care sentinel cohort of the Oxford-Royal College of General Practitioners Research and Surveillance Centre (N=7,396,702), applying a predefined long COVID phenotype and grouped by whether the index infection occurred in hospital or in the community. We included COVID-19 infection cases from March 1, 2020, to April 1, 2021. We conducted a before-and-after analysis of long COVID symptoms prespecified by the Office of National Statistics, comparing symptoms presented between 1 and 6 months after the index infection matched with the same months 1 year previously. We conducted logistic regression analysis, quoting odds ratios (ORs) with 95% CIs. RESULTS In total, 5.63% (416,505/7,396,702) and 1.83% (7623/416,505) of the patients had received a coded diagnosis of COVID-19 infection and diagnosis of, or referral for, long COVID, respectively. People with diagnosis or referral of long COVID had higher odds of presenting the prespecified symptoms after versus before COVID-19 infection (OR 2.66, 95% CI 2.46-2.88, for those with index community infection and OR 2.42, 95% CI 2.03-2.89, for those hospitalized). After an index community infection, patients were more likely to present with nonspecific symptoms (OR 3.44, 95% CI 3.00-3.95; P<.001) compared with after a hospital admission (OR 2.09, 95% CI 1.56-2.80; P<.001). Mental health sequelae were more strongly associated with index hospital infections (OR 2.21, 95% CI 1.64-2.96) than with index community infections (OR 1.36, 95% CI 1.21-1.53; P<.001). People presenting to primary care after hospital infection were more likely to be men (OR 1.43, 95% CI 1.25-1.64; P<.001), more socioeconomically deprived (OR 1.42, 95% CI 1.24-1.63; P<.001), and with higher multimorbidity scores (OR 1.41, 95% CI 1.26-1.57; P<.001) than those presenting after an index community infection. All-cause mortality in people with long COVID was associated with increasing age, male sex (OR 3.32, 95% CI 1.34-9.24; P=.01), and higher multimorbidity score (OR 2.11, 95% CI 1.34-3.29; P<.001). Vaccination was associated with reduced odds of mortality (OR 0.10, 95% CI 0.03-0.35; P<.001). CONCLUSIONS The low percentage of people recorded as having long COVID after COVID-19 infection reflects either low prevalence or underrecording. The characteristics and comorbidities of those presenting with long COVID after a community infection are different from those hospitalized. This study provides insights into the presentation of long COVID in primary care and implications for workload.
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Affiliation(s)
- Bernardo Meza-Torres
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gayathri Delanerolle
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Cecilia Okusi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Nikhil Mayor
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | - Sneha Anand
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jack Macartney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Piers Gatenby
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | - Ben Glampson
- Imperial College Healthcare NHS Trust, Imperial Clinical Analytics, Research & Evaluation (iCARE), London, United Kingdom
| | - Martin Chapman
- King's College London, Population Health Sciences, London, United Kingdom
| | - Vasa Curcin
- King's College London, Population Health Sciences, London, United Kingdom
| | - Erik Mayer
- Imperial College Healthcare NHS Trust, Imperial Clinical Analytics, Research & Evaluation (iCARE), London, United Kingdom
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Brendan Delaney
- Department of Surgery & Cancer, Institute of Global Health Innovation, Imperial College London, London, United Kingdom
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Mayor N, Meza-Torres B, Okusi C, Delanerolle G, Chapman M, Wang W, Anand S, Feher M, Macartney J, Byford R, Joy M, Gatenby P, Curcin V, Greenhalgh T, Delaney B, de Lusignan S. Developing a Long COVID Phenotype for Postacute COVID-19 in a National Primary Care Sentinel Cohort: Observational Retrospective Database Analysis. JMIR Public Health Surveill 2022; 8:e36989. [PMID: 35861678 PMCID: PMC9374163 DOI: 10.2196/36989] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/16/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Following COVID-19, up to 40% of people have ongoing health problems, referred to as postacute COVID-19 or long COVID (LC). LC varies from a single persisting symptom to a complex multisystem disease. Research has flagged that this condition is underrecorded in primary care records, and seeks to better define its clinical characteristics and management. Phenotypes provide a standard method for case definition and identification from routine data and are usually machine-processable. An LC phenotype can underpin research into this condition. OBJECTIVE This study aims to develop a phenotype for LC to inform the epidemiology and future research into this condition. We compared clinical symptoms in people with LC before and after their index infection, recorded from March 1, 2020, to April 1, 2021. We also compared people recorded as having acute infection with those with LC who were hospitalized and those who were not. METHODS We used data from the Primary Care Sentinel Cohort (PCSC) of the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database. This network was recruited to be nationally representative of the English population. We developed an LC phenotype using our established 3-step ontological method: (1) ontological step (defining the reasoning process underpinning the phenotype, (2) coding step (exploring what clinical terms are available, and (3) logical extract model (testing performance). We created a version of this phenotype using Protégé in the ontology web language for BioPortal and using PhenoFlow. Next, we used the phenotype to compare people with LC (1) with regard to their symptoms in the year prior to acquiring COVID-19 and (2) with people with acute COVID-19. We also compared hospitalized people with LC with those not hospitalized. We compared sociodemographic details, comorbidities, and Office of National Statistics-defined LC symptoms between groups. We used descriptive statistics and logistic regression. RESULTS The long-COVID phenotype differentiated people hospitalized with LC from people who were not and where no index infection was identified. The PCSC (N=7.4 million) includes 428,479 patients with acute COVID-19 diagnosis confirmed by a laboratory test and 10,772 patients with clinically diagnosed COVID-19. A total of 7471 (1.74%, 95% CI 1.70-1.78) people were coded as having LC, 1009 (13.5%, 95% CI 12.7-14.3) had a hospital admission related to acute COVID-19, and 6462 (86.5%, 95% CI 85.7-87.3) were not hospitalized, of whom 2728 (42.2%) had no COVID-19 index date recorded. In addition, 1009 (13.5%, 95% CI 12.73-14.28) people with LC were hospitalized compared to 17,993 (4.5%, 95% CI 4.48-4.61; P<.001) with uncomplicated COVID-19. CONCLUSIONS Our LC phenotype enables the identification of individuals with the condition in routine data sets, facilitating their comparison with unaffected people through retrospective research. This phenotype and study protocol to explore its face validity contributes to a better understanding of LC.
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Affiliation(s)
- Nikhil Mayor
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | - Bernardo Meza-Torres
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, United Kingdom
| | - Cecilia Okusi
- Department of Surgery & Cancer, Institute of Global Health Innovation, Imperial College London, London, United Kingdom
| | - Gayathri Delanerolle
- Department of Surgery & Cancer, Institute of Global Health Innovation, Imperial College London, London, United Kingdom
| | - Martin Chapman
- Population Health Sciences, Kings College London, London, United Kingdom
| | - Wenjuan Wang
- Population Health Sciences, Kings College London, London, United Kingdom
| | - Sneha Anand
- Department of Surgery & Cancer, Institute of Global Health Innovation, Imperial College London, London, United Kingdom
| | - Michael Feher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jack Macartney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rachel Byford
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Piers Gatenby
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | - Vasa Curcin
- Population Health Sciences, Kings College London, London, United Kingdom
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Brendan Delaney
- Department of Surgery & Cancer, Institute of Global Health Innovation, Imperial College London, London, United Kingdom
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Royal College of General Practitioners Research and Surveillance Centre, London, United Kingdom
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Price S, Landa P, Mujica-Mota R, Hamilton W, Spencer A. Revising the Suspected-Cancer Guidelines: Impacts on Patients' Primary Care Contacts and Costs. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022:S1098-3015(22)02095-2. [PMID: 35953398 DOI: 10.1016/j.jval.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 06/23/2022] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES This study aimed to explore the impact of revising suspected-cancer referral guidelines on primary care contacts and costs. METHODS Participants had incident cancer (colorectal, n = 2000; ovary, n = 763; and pancreas, n = 597) codes in the Clinical Practice Research Datalink or England cancer registry. Difference-in-differences analyses explored guideline impacts on contact days and nonzero costs between the first cancer feature and diagnosis. Participants were controls ("old National Institute for Health and Care Excellence [NICE]") or "new NICE" if their index feature was introduced during guideline revision. Model assumptions were inspected visually and by falsification tests. Sensitivity analyses reclassified participants who subsequently presented with features in the original guidelines as "old NICE." For colorectal cancer, sensitivity analysis (n = 3481) adjusted for multimorbidity burden. RESULTS Median contact days and costs were, respectively, 4 (interquartile range [IQR] 2-7) and £117.69 (IQR £53.23-£206.65) for colorectal, 5 (IQR 3-9) and £156.92 (IQR £78.46-£272.29) for ovary, and 7 (IQR 4-13) and £230.64 (IQR £120.78-£408.34) for pancreas. Revising ovary guidelines may have decreased contact days (incidence rate ratio [IRR] 0.74; 95% confidence interval 0.55-1.00; P = .05) with unchanged costs, but parallel trends assumptions were violated. Costs decreased by 13% (equivalent to -£28.05, -£50.43 to -£5.67) after colorectal guidance revision but only in sensitivity analyses adjusting for multimorbidity. Contact days and costs remained unchanged after pancreas guidance revision. CONCLUSIONS The main analyses of symptomatic patients suggested that prediagnosis primary care costs remained unchanged after guidance revision for pancreatic cancer. For colorectal cancer, contact days and costs decreased in analyses adjusting for multimorbidity. Revising ovarian cancer guidelines may have decreased primary care contact days but not costs, suggesting increased resource-use intensity; nevertheless, there is evidence of confounding.
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Affiliation(s)
- Sarah Price
- Discovery Unit, University of Exeter Medical School, University of Exeter, Exeter, England, UK.
| | - Paolo Landa
- Département d'opérations et systèmes de decision, Faculté des sciences de l'administration, Université Laval, Québec City, QC, Canada; Centre Hospitaliere Universitaire (CHU) de Québec - Université Laval, Québec City, QC, Canada
| | - Ruben Mujica-Mota
- Academic Unit of Health Economics, University of Leeds, Leeds, England, UK
| | - Willie Hamilton
- Discovery Unit, University of Exeter Medical School, University of Exeter, Exeter, England, UK
| | - Anne Spencer
- Health Economics Group, University of Exeter, Exeter, England, UK
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Kloppe T, Tetzlaff B, Mews C, Zimmermann T, Scherer M. Interprofessional collaboration to support patients with social problems in general practice-a qualitative focus group study. BMC PRIMARY CARE 2022; 23:169. [PMID: 35788186 PMCID: PMC9251943 DOI: 10.1186/s12875-022-01782-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 06/23/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Social problems of patients such as family or work-related conflicts as well as financial difficulties affect the individual health situation and the treatment of diseases in general practice. General practitioners (GPs) would like to have direct access to professionals in social care services. In Germany, there are many different social care facilities for people with a wide range of social problems. As the social and health care systems hardly interact collaborations between social professionals (SPs) and GPs are rare exceptions. This study explored perspectives of GPs regarding their patients with social problems in combination with the perspectives of SPs. Aim of this study was to explore how a systematic interprofessional collaboration between GPs and SPs could be realised. METHODS We carried out a participatory sequential qualitative study design consisting of two focus groups with GPs, two with SPs and two mixed-professional focus groups with GPs and SPs. The focus groups were conducted with semi-structured moderating guidelines and analysed with a qualitative content analysis approach using inductive and deductive categories. RESULTS GPs view themselves as the first point of contact for their patients' social problems. For persistent social problems, they expressed a desire for support and SPs were willing to provide this. We developed a stepped care implementation model for a systematic cooperation consisting of nine collaboration strategies. These strategies included: index or website of social care services, referrals to the social care system, using flyers and posters of social care services, direct contact/hotline to local social care services, participation in meetings of social care facilities, involving physician assistants, external social care advice service in GP rooms, implementation in education and training and access to volunteers. CONCLUSIONS Our stepped care implementation model for a systematic cooperation of GPs and SPs could be a feasible need- and resource-oriented approach for the collaborative care of patients with social problems to improve their medical treatment in most western healthcare systems. GPs and SPs are ready to generate the necessary evidence for policy makers in high quality RCTs.
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Affiliation(s)
- Thomas Kloppe
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Britta Tetzlaff
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Claudia Mews
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Thomas Zimmermann
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Martins T, Abel G, Ukoumunne OC, Price S, Lyratzopoulos G, Chinegwundoh F, Hamilton W. Assessing Ethnic Inequalities in Diagnostic Interval of Common Cancers: A Population-Based UK Cohort Study. Cancers (Basel) 2022; 14:3085. [PMID: 35804858 PMCID: PMC9264889 DOI: 10.3390/cancers14133085] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study investigated ethnic differences in diagnostic interval (DI)-the period between initial primary care presentation and diagnosis. METHODS We analysed the primary care-linked data of patients who reported features of seven cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, and ovarian) one year before diagnosis. Accelerated failure time (AFT) models investigated the association between DI and ethnicity, adjusting for age, sex, deprivation, and morbidity. RESULTS Of 126,627 eligible participants, 92.1% were White, 1.99% Black, 1.71% Asian, 1.83% Mixed, and 2.36% were of Other ethnic backgrounds. Considering all cancer sites combined, the median (interquartile range) DI was 55 (20-175) days, longest in lung [127, (42-265) days], and shortest in breast cancer [13 (13, 8-18) days]. DI for the Black and Asian groups was 10% (AFT ratio, 95%CI 1.10, 1.05-1.14) and 16% (1.16, 1.10-1.22), respectively, longer than for the White group. Site-specific analyses revealed evidence of longer DI in Asian and Black patients with prostate, colorectal, and oesophagogastric cancer, plus Black patients with breast cancer and myeloma, and the Mixed group with lung cancer compared with White patients. DI was shorter for the Other group with lung, prostate, myeloma, and oesophagogastric cancer than the White group. CONCLUSION We found limited and inconsistent evidence of ethnic differences in DI among patients who reported cancer features in primary care before diagnosis. Our findings suggest that inequalities in diagnostic intervals, where present, are unlikely to be the sole explanation for ethnic variations in cancer outcomes.
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Affiliation(s)
- Tanimola Martins
- College House St Luke’s Campus, College of Medicine and Health, University of Exeter, Magdalen Road, Exeter EX1 2LU, UK; (S.P.); (W.H.)
| | - Gary Abel
- National Institute for Health and Care Research (NIHR), Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter, Exeter EX1 2LU, UK; (G.A.); (O.C.U.)
| | - Obioha C. Ukoumunne
- National Institute for Health and Care Research (NIHR), Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter, Exeter EX1 2LU, UK; (G.A.); (O.C.U.)
| | - Sarah Price
- College House St Luke’s Campus, College of Medicine and Health, University of Exeter, Magdalen Road, Exeter EX1 2LU, UK; (S.P.); (W.H.)
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, University College London, 1–19 Torrington Place, London WC1E 7HB, UK;
| | - Frank Chinegwundoh
- Barts Health NHS Trust & Department of Health Sciences, University of London, London WC1E 7HB, UK;
| | - William Hamilton
- College House St Luke’s Campus, College of Medicine and Health, University of Exeter, Magdalen Road, Exeter EX1 2LU, UK; (S.P.); (W.H.)
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Sandvik H, Ruths S, Hunskaar S, Blinkenberg J, Hetlevik Ø. Construction and validation of a morbidity index based on the International Classification of Primary Care. Scand J Prim Health Care 2022; 40:305-312. [PMID: 35822650 PMCID: PMC9397422 DOI: 10.1080/02813432.2022.2097617] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVES In epidemiological studies it is often necessary to describe morbidity. The aim of the present study is to construct and validate a morbidity index based on the International Classification of Primary Care (ICPC-2). DESIGN AND SETTING This is a cohort study based on linked data from national registries. An ICPC morbidity index was constructed based on a list of longstanding health problems in earlier published Scottish data from general practice and adapted to diagnostic ICPC-2 codes recorded in Norwegian general practice 2015 - 2017. SUBJECTS The index was constructed among Norwegian born people only (N = 4 509 382) and validated in a different population, foreign-born people living in Norway (N = 959 496). MAIN OUTCOME MEASURES Predictive ability for death in 2018 in these populations was compared with the Charlson index. Multiple logistic regression was used to identify morbidities with the highest odds ratios (OR) for death and predictive ability for different combinations of morbidities was estimated by the area under receiver operating characteristic curves (AUC). RESULTS An index based on 18 morbidities was found to be optimal, predicting mortality with an AUC of 0.78, slightly better than the Charlson index (AUC 0.77). External validation in a foreign-born population yielded an AUC of 0.76 for the ICPC morbidity index and 0.77 for the Charlson index. CONCLUSIONS The ICPC morbidity index performs equal to the Charlson index and can be recommended for use in data materials collected in primary health care.Key pointsThis is the first morbidity index based on the International Classification of Primary Care, 2nd edition (ICPC-2)It predicted mortality equal to the Charlson index and validated acceptably in a different populationThe ICPC morbidity index can be used as an adjustment variable in epidemiological research in primary care databases.
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Affiliation(s)
- Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
- CONTACT Hogne Sandvik National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Årstadveien 17, Bergen, 5009, Norway
| | - Sabine Ruths
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Stafford M, Knight H, Hughes J, Alarilla A, Mondor L, Pefoyo Kone A, Wodchis WP, Deeny SR. Associations between multiple long-term conditions and mortality in diverse ethnic groups. PLoS One 2022; 17:e0266418. [PMID: 35363804 PMCID: PMC8974956 DOI: 10.1371/journal.pone.0266418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/20/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Multiple conditions are more prevalent in some minoritised ethnic groups and are associated with higher mortality rate but studies examining differential mortality once conditions are established is US-based. Our study tested whether the association between multiple conditions and mortality varies across ethnic groups in England. METHODS AND FINDINGS A random sample of primary care patients from Clinical Practice Research Datalink (CPRD) was followed from 1st January 2015 until 31st December 2019. Ethnicity, usually self-ascribed, was obtained from primary care records if present or from hospital records. Long-term conditions were counted from a list of 32 that have previously been associated with greater primary care, hospital admissions, or mortality risk. Cox regression models were used to estimate mortality by count of conditions, ethnicity and their interaction, with adjustment for age and sex for 532,059 patients with complete data. During five years of follow-up, 5.9% of patients died. Each additional condition at baseline was associated with increased mortality. The direction of the interaction of number of conditions with ethnicity showed a statistically higher mortality rate associated with long-term conditions in Pakistani, Black African, Black Caribbean and Other Black ethnic groups. In ethnicity-stratified models, the mortality rate per additional condition at age 50 was 1.33 (95% CI 1.31,1.35) for White ethnicity, 1.43 (95% CI 1.26,1.61) for Black Caribbean ethnicity and 1.78 (95% CI 1.41,2.24) for Other Black ethnicity. CONCLUSIONS The higher mortality rate associated with having multiple conditions is greater in minoritised compared with White ethnic groups. Research is now needed to identify factors that contribute to these inequalities. Within the health care setting, there may be opportunities to target clinical and self-management support for people with multiple conditions from minoritised ethnic groups.
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Affiliation(s)
| | | | - Jay Hughes
- The Health Foundation, London, United Kingdom
| | | | - Luke Mondor
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Health System Performance Network, Toronto, Ontario, Canada
| | - Anna Pefoyo Kone
- Health System Performance Network, Toronto, Ontario, Canada
- Department of Health Sciences, Lakehead University, Thunder Bay, Ontario, Canada
| | - Walter P Wodchis
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Health System Performance Network, Toronto, Ontario, Canada
- Institute of Health Policy Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
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Majano SB, Lyratzopoulos G, Rachet B, de Wit NJ, Renzi C. Do presenting symptoms, use of pre-diagnostic endoscopy and risk of emergency cancer diagnosis vary by comorbidity burden and type in patients with colorectal cancer? Br J Cancer 2022; 126:652-663. [PMID: 34741134 PMCID: PMC8569047 DOI: 10.1038/s41416-021-01603-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 09/06/2021] [Accepted: 10/13/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Cancer patients often have pre-existing comorbidities, which can influence timeliness of cancer diagnosis. We examined symptoms, investigations and emergency presentation (EP) risk among colorectal cancer (CRC) patients by comorbidity status. METHODS Using linked cancer registration, primary care and hospital records of 4836 CRC patients (2011-2015), and multivariate quantile and logistic regression, we examined variations in specialist investigations, diagnostic intervals and EP risk. RESULTS Among colon cancer patients, 46% had at least one pre-existing hospital-recorded comorbidity, most frequently cardiovascular disease (CVD, 18%). Comorbid versus non-comorbid cancer patients more frequently had records of anaemia (43% vs 38%), less frequently rectal bleeding/change in bowel habit (20% vs 27%), and longer intervals from symptom-to-first relevant test (median 136 vs 74 days). Comorbid patients were less likely investigated with colonoscopy/sigmoidoscopy, independently of symptoms (adjusted OR = 0.7[0.6, 0.9] for Charlson comorbidity score 1-2 and OR = 0.5 [0.4-0.7] for score 3+ versus 0. EP risk increased with comorbidity score 0, 1, 2, 3+: 23%, 35%, 33%, 47%; adjusted OR = 1.8 [1.4, 2.2]; 1.7 [1.3, 2.3]; 3.0 [2.3, 4.0]) and for patients with CVD (adjusted OR = 2.0 [1.5, 2.5]). CONCLUSIONS Comorbid individuals with as-yet-undiagnosed CRC often present with general rather than localising symptoms and are less likely promptly investigated with colonoscopy/sigmoidoscopy. Comorbidity is a risk factor for diagnostic delay and has potential, additionally to symptoms, as risk-stratifier for prioritising patients needing prompt assessment to reduce EP.
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Affiliation(s)
- Sara Benitez Majano
- Inequalities in Cancer Outcomes Network (ICON) Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, London, WC1E 7HB, UK
| | - Bernard Rachet
- Inequalities in Cancer Outcomes Network (ICON) Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
| | - Niek J de Wit
- University Medical Center, Utrecht University, Julius Center for Health Sciences and Primary Care, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Cristina Renzi
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, London, WC1E 7HB, UK.
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Hanlon P, Jani BD, Nicholl B, Lewsey J, McAllister DA, Mair FS. Associations between multimorbidity and adverse health outcomes in UK Biobank and the SAIL Databank: A comparison of longitudinal cohort studies. PLoS Med 2022; 19:e1003931. [PMID: 35255092 PMCID: PMC8901063 DOI: 10.1371/journal.pmed.1003931] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 01/26/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Cohorts such as UK Biobank are increasingly used to study multimorbidity; however, there are concerns that lack of representativeness may lead to biased results. This study aims to compare associations between multimorbidity and adverse health outcomes in UK Biobank and a nationally representative sample. METHODS AND FINDINGS These are observational analyses of cohorts identified from linked routine healthcare data from UK Biobank participants (n = 211,597 from England, Scotland, and Wales with linked primary care data, age 40 to 70, mean age 56.5 years, 54.6% women, baseline assessment 2006 to 2010) and from the Secure Anonymised Information Linkage (SAIL) databank (n = 852,055 from Wales, age 40 to 70, mean age 54.2, 50.0% women, baseline January 2011). Multimorbidity (n = 40 long-term conditions [LTCs]) was identified from primary care Read codes and quantified using a simple count and a weighted score. Individual LTCs and LTC combinations were also assessed. Associations with all-cause mortality, unscheduled hospitalisation, and major adverse cardiovascular events (MACEs) were assessed using Weibull or negative binomial models adjusted for age, sex, and socioeconomic status, over 7.5 years follow-up for both datasets. Multimorbidity was less common in UK Biobank than SAIL (26.9% and 33.0% with ≥2 LTCs in UK Biobank and SAIL, respectively). This difference was attenuated, but persisted, after standardising by age, sex, and socioeconomic status. The association between increasing multimorbidity count and mortality, hospitalisation, and MACE was similar between both datasets at LTC counts of ≤3; however, above this level, UK Biobank underestimated the risk associated with multimorbidity (e.g., mortality hazard ratio for 2 LTCs 1.62 (95% confidence interval 1.57 to 1.68) in SAIL and 1.51 (1.43 to 1.59) in UK Biobank, hazard ratio for 5 LTCs was 3.46 (3.31 to 3.61) in SAIL and 2.88 (2.63 to 3.15) in UK Biobank). Absolute risk of mortality, hospitalisation, and MACE, at all levels of multimorbidity, was lower in UK Biobank than SAIL (adjusting for age, sex, and socioeconomic status). Both cohorts produced similar hazard ratios for some LTCs (e.g., hypertension and coronary heart disease), but UK Biobank underestimated the risk for others (e.g., alcohol-related disorders or mental health conditions). Hazard ratios for some LTC combinations were similar between the cohorts (e.g., cardiovascular conditions); however, UK Biobank underestimated the risk for combinations including other conditions (e.g., mental health conditions). The main limitations are that SAIL databank represents only part of the UK (Wales only) and that in both cohorts we lacked data on severity of the LTCs included. CONCLUSIONS In this study, we observed that UK Biobank accurately estimates relative risk of mortality, unscheduled hospitalisation, and MACE associated with LTC counts ≤3. However, for counts ≥4, and for some LTC combinations, estimates of magnitude of association from UK Biobank are likely to be conservative. Researchers should be mindful of these limitations of UK Biobank when conducting and interpreting analyses of multimorbidity. Nonetheless, the richness of data available in UK Biobank does offers opportunities to better understand multimorbidity, particularly where complementary data sources less susceptible to selection bias can be used to inform and qualify analyses of UK Biobank.
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Affiliation(s)
- Peter Hanlon
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Bhautesh D. Jani
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Barbara Nicholl
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Jim Lewsey
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - David A. McAllister
- Public Health, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Frances S. Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
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Wang L, Qiu H, Luo L, Zhou L. Age- and Sex-Specific Differences in Multimorbidity Patterns and Temporal Trends on Assessing Hospital Discharge Records in Southwest China: Network-Based Study. J Med Internet Res 2022; 24:e27146. [PMID: 35212632 PMCID: PMC8917436 DOI: 10.2196/27146] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/06/2021] [Accepted: 01/12/2022] [Indexed: 02/06/2023] Open
Abstract
Background Multimorbidity represents a global health challenge, which requires a more global understanding of multimorbidity patterns and trends. However, the majority of studies completed to date have often relied on self-reported conditions, and a simultaneous assessment of the entire spectrum of chronic disease co-occurrence, especially in developing regions, has not yet been performed. Objective We attempted to provide a multidimensional approach to understand the full spectrum of chronic disease co-occurrence among general inpatients in southwest China, in order to investigate multimorbidity patterns and temporal trends, and assess their age and sex differences. Methods We conducted a retrospective cohort analysis based on 8.8 million hospital discharge records of about 5.0 million individuals of all ages from 2015 to 2019 in a megacity in southwest China. We examined all chronic diagnoses using the ICD-10 (International Classification of Diseases, 10th revision) codes at 3 digits and focused on chronic diseases with ≥1% prevalence for each of the age and sex strata, which resulted in a total of 149 and 145 chronic diseases in males and females, respectively. We constructed multimorbidity networks in the general population based on sex and age, and used the cosine index to measure the co-occurrence of chronic diseases. Then, we divided the networks into communities and assessed their temporal trends. Results The results showed complex interactions among chronic diseases, with more intensive connections among males and inpatients ≥40 years old. A total of 9 chronic diseases were simultaneously classified as central diseases, hubs, and bursts in the multimorbidity networks. Among them, 5 diseases were common to both males and females, including hypertension, chronic ischemic heart disease, cerebral infarction, other cerebrovascular diseases, and atherosclerosis. The earliest leaps (degree leaps ≥6) appeared at a disorder of glycoprotein metabolism that happened at 25-29 years in males, about 15 years earlier than in females. The number of chronic diseases in the community increased over time, but the new entrants did not replace the root of the community. Conclusions Our multimorbidity network analysis identified specific differences in the co-occurrence of chronic diagnoses by sex and age, which could help in the design of clinical interventions for inpatient multimorbidity.
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Affiliation(s)
- Liya Wang
- Big Data Research Center, University of Electronic Science and Technology of China, Chengdu, China
| | - Hang Qiu
- Big Data Research Center, University of Electronic Science and Technology of China, Chengdu, China.,School of Computer Science and Engineering, University of Electronic Science and Technology of China, Chengdu, China
| | - Li Luo
- Business School, Sichuan University, Chengdu, China
| | - Li Zhou
- Health Information Center of Sichuan Province, Chengdu, China
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Mahajan A, Deonarine A, Bernal A, Lyons G, Norgeot B. Developing the Total Health Profile, a Generalizable Unified Set of Multimorbidity Risk Scores Derived From Machine Learning for Broad Patient Populations: Retrospective Cohort Study. J Med Internet Res 2021; 23:e32900. [PMID: 34842542 PMCID: PMC8665380 DOI: 10.2196/32900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/15/2021] [Accepted: 09/18/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Multimorbidity clinical risk scores allow clinicians to quickly assess their patients' health for decision making, often for recommendation to care management programs. However, these scores are limited by several issues: existing multimorbidity scores (1) are generally limited to one data group (eg, diagnoses, labs) and may be missing vital information, (2) are usually limited to specific demographic groups (eg, age), and (3) do not formally provide any granularity in the form of more nuanced multimorbidity risk scores to direct clinician attention. OBJECTIVE Using diagnosis, lab, prescription, procedure, and demographic data from electronic health records (EHRs), we developed a physiologically diverse and generalizable set of multimorbidity risk scores. METHODS Using EHR data from a nationwide cohort of patients, we developed the total health profile, a set of six integrated risk scores reflecting five distinct organ systems and overall health. We selected the occurrence of an inpatient hospital visitation over a 2-year follow-up window, attributable to specific organ systems, as our risk endpoint. Using a physician-curated set of features, we trained six machine learning models on 794,294 patients to predict the calibrated probability of the aforementioned endpoint, producing risk scores for heart, lung, neuro, kidney, and digestive functions and a sixth score for combined risk. We evaluated the scores using a held-out test cohort of 198,574 patients. RESULTS Study patients closely matched national census averages, with a median age of 41 years, a median income of $66,829, and racial averages by zip code of 73.8% White, 5.9% Asian, and 11.9% African American. All models were well calibrated and demonstrated strong performance with areas under the receiver operating curve (AUROCs) of 0.83 for the total health score (THS), 0.89 for heart, 0.86 for lung, 0.84 for neuro, 0.90 for kidney, and 0.83 for digestive functions. There was consistent performance of this scoring system across sexes, diverse patient ages, and zip code income levels. Each model learned to generate predictions by focusing on appropriate clinically relevant patient features, such as heart-related hospitalizations and chronic hypertension diagnosis for the heart model. The THS outperformed the other commonly used multimorbidity scoring systems, specifically the Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI) overall (AUROCs: THS=0.823, CCI=0.735, ECI=0.649) as well as for every age, sex, and income bracket. Performance improvements were most pronounced for middle-aged and lower-income subgroups. Ablation tests using only diagnosis, prescription, social determinants of health, and lab feature groups, while retaining procedure-related features, showed that the combination of feature groups has the best predictive performance, though only marginally better than the diagnosis-only model on at-risk groups. CONCLUSIONS Massive retrospective EHR data sets have made it possible to use machine learning to build practical multimorbidity risk scores that are highly predictive, personalizable, intuitive to explain, and generalizable across diverse patient populations.
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