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Ghosh S, Antunes A, Rinta-Kokko H, Chaparova E, Lay-Flurrie S, Tricotel A, Andersson FL. Estimating excess mortality and economic burden of Clostridioides difficile infections and recurrences during 2015-2019: The RECUR England study. Int J Infect Dis 2024; 142:106967. [PMID: 38368927 DOI: 10.1016/j.ijid.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/05/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024] Open
Abstract
OBJECTIVES To generate real-world evidence on all-cause mortality and economic burden of Clostridioides difficile infections (CDIs) and recurrences (rCDIs) in England. METHODS We conducted a cohort study using retrospective data from Clinical Practice Research Datalink linked to Hospital Episode Statistics. Patients diagnosed with CDI in hospital and community settings during 2015-2018 were included and followed for ≥1 year. All-cause mortality was described at 6, 12, and 24 months. Healthcare resource usage (HCRU) and associated costs were assessed at 12 months of follow-up. A cohort of non-CDI patients, matched by demographic and clinical characteristics including Charlson Comorbidity Index score, was used to assess excess mortality and incremental costs of HCRU. RESULTS All-cause mortality among CDI patients at 6, 12, and 24 months was 15.87%, 20.37%, and 27.03%, respectively. A higher proportion of rCDI patients died at any point during follow-up. Compared with matched non-CDI patients, excess mortality was highest at 6 months with 1.81 and 2.53 deaths per 100 patient-months among CDI and ≥1 rCDI patients. Hospitalizations were the main drivers of costs, with an incremental cost of £1209.21 per CDI patient. HCRU and costs increased with rCDIs. CONCLUSION CDI poses a substantial mortality and economic burden, further amplified by rCDIs.
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Affiliation(s)
- Subrata Ghosh
- College of Medicine and Health, University College Cork, Cork, Ireland; University of Birmingham, Birmingham, United Kingdom
| | - Ana Antunes
- IQVIA, Global Database Studies, Real World Solutions, Lisbon, Portugal.
| | - Hanna Rinta-Kokko
- IQVIA, Global Database Studies, Real World Solutions, Espoo, Finland
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Ghosh S, Antunes A, Rinta-Kokko H, Chaparova E, Lay-Flurrie S, Tricotel A, Andersson FL. Clostridioides difficile infections, recurrences, and clinical outcomes in real-world settings from 2015 to 2019: The RECUR England study. Int J Infect Dis 2024; 140:31-38. [PMID: 38185320 DOI: 10.1016/j.ijid.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/27/2023] [Accepted: 01/02/2024] [Indexed: 01/09/2024] Open
Abstract
OBJECTIVE To estimate the epidemiological and clinical burden of Clostridioides difficile infections (CDIs) and recurrences (rCDIs) in England. METHODS This retrospective study included adult patients diagnosed with CDI (community or hospital settings) over 2015-2019 from Clinical Practice Research Datalink and Hospital Episode Statistics databases. Incidences of CDI and rCDI were determined annually. Time to subsequent rCDI was estimated by Kaplan-Meier method. Rates of complications were assessed within 12 months from index episode. Association of risk factors with complications was evaluated using a Cox regression model. RESULTS A total of 52,443 CDI episodes were recorded among 36,913 patients. Of these, 75% were aged ≥65 years, 59% were women; 73% were treated in community settings. CDI incidence remained stable (111 episodes per 100,000 patients in 2019). Around 21% of patients had ≥1 rCDI. Sepsis (12%) was the most common complication, followed by colectomy and ulcerative colitis. Age, gender, comorbidities, rCDI, preindex medical procedures, hospitalizations and consultations, and CDI treatment in hospital, were found to increase the risk of complication. CONCLUSIONS CDI remains a concern in England. The study highlights the importance of managing primary and rCDI episodes via effective and improved therapies to prevent fatal complications.
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Affiliation(s)
- Subrata Ghosh
- College of Medicine and Health, University College Cork, Cork, Ireland; University of Birmingham, Birmingham, UK
| | - Ana Antunes
- IQVIA, Global Database Studies, Real World Solutions, Lisbon, Portugal.
| | - Hanna Rinta-Kokko
- IQVIA, Global Database Studies, Real World Solutions, Espoo, Finland
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Sheppard JP, Koshiaris C, Stevens R, Lay-Flurrie S, Banerjee A, Bellows BK, Clegg A, Hobbs FDR, Payne RA, Swain S, Usher-Smith JA, McManus RJ. The association between antihypertensive treatment and serious adverse events by age and frailty: A cohort study. PLoS Med 2023; 20:e1004223. [PMID: 37075078 PMCID: PMC10155987 DOI: 10.1371/journal.pmed.1004223] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 05/03/2023] [Accepted: 03/24/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Antihypertensives are effective at reducing the risk of cardiovascular disease, but limited data exist quantifying their association with serious adverse events, particularly in older people with frailty. This study aimed to examine this association using nationally representative electronic health record data. METHODS AND FINDINGS This was a retrospective cohort study utilising linked data from 1,256 general practices across England held within the Clinical Practice Research Datalink between 1998 and 2018. Included patients were aged 40+ years, with a systolic blood pressure reading between 130 and 179 mm Hg, and not previously prescribed antihypertensive treatment. The main exposure was defined as a first prescription of antihypertensive treatment. The primary outcome was hospitalisation or death within 10 years from falls. Secondary outcomes were hypotension, syncope, fractures, acute kidney injury, electrolyte abnormalities, and primary care attendance with gout. The association between treatment and these serious adverse events was examined by Cox regression adjusted for propensity score. This propensity score was generated from a multivariable logistic regression model with patient characteristics, medical history and medication prescriptions as covariates, and new antihypertensive treatment as the outcome. Subgroup analyses were undertaken by age and frailty. Of 3,834,056 patients followed for a median of 7.1 years, 484,187 (12.6%) were prescribed new antihypertensive treatment in the 12 months before the index date (baseline). Antihypertensives were associated with an increased risk of hospitalisation or death from falls (adjusted hazard ratio [aHR] 1.23, 95% confidence interval (CI) 1.21 to 1.26), hypotension (aHR 1.32, 95% CI 1.29 to 1.35), syncope (aHR 1.20, 95% CI 1.17 to 1.22), acute kidney injury (aHR 1.44, 95% CI 1.41 to 1.47), electrolyte abnormalities (aHR 1.45, 95% CI 1.43 to 1.48), and primary care attendance with gout (aHR 1.35, 95% CI 1.32 to 1.37). The absolute risk of serious adverse events with treatment was very low, with 6 fall events per 10,000 patients treated per year. In older patients (80 to 89 years) and those with severe frailty, this absolute risk was increased, with 61 and 84 fall events per 10,000 patients treated per year (respectively). Findings were consistent in sensitivity analyses using different approaches to address confounding and taking into account the competing risk of death. A strength of this analysis is that it provides evidence regarding the association between antihypertensive treatment and serious adverse events, in a population of patients more representative than those enrolled in previous randomised controlled trials. Although treatment effect estimates fell within the 95% CIs of those from such trials, these analyses were observational in nature and so bias from unmeasured confounding cannot be ruled out. CONCLUSIONS Antihypertensive treatment was associated with serious adverse events. Overall, the absolute risk of this harm was low, with the exception of older patients and those with moderate to severe frailty, where the risks were similar to the likelihood of benefit from treatment. In these populations, physicians may want to consider alternative approaches to management of blood pressure and refrain from prescribing new treatment.
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Affiliation(s)
- James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Brandon K Bellows
- Columbia University Irving Medical Center, New York, New York, United States of America
| | - Andrew Clegg
- Academic Unit for Ageing & Stroke Research, University of Leeds, Leeds, United Kingdom
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Health and Community Sciences, University of Exeter Medical School, Exeter, United Kingdom
| | - Subhashisa Swain
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Archer L, Koshiaris C, Lay-Flurrie S, Snell KIE, Riley RD, Stevens R, Banerjee A, Usher-Smith JA, Clegg A, Payne RA, Hobbs FDR, McManus RJ, Sheppard JP. Development and external validation of a risk prediction model for falls in patients with an indication for antihypertensive treatment: retrospective cohort study. BMJ 2022; 379:e070918. [PMID: 36347531 PMCID: PMC9641577 DOI: 10.1136/bmj-2022-070918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To develop and externally validate the STRAtifying Treatments In the multi-morbid Frail elderlY (STRATIFY)-Falls clinical prediction model to identify the risk of hospital admission or death from a fall in patients with an indication for antihypertensive treatment. DESIGN Retrospective cohort study. SETTING Primary care data from electronic health records contained within the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS Patients aged 40 years or older with at least one blood pressure measurement between 130 mm Hg and 179 mm Hg. MAIN OUTCOME MEASURE First serious fall, defined as hospital admission or death with a primary diagnosis of a fall within 10 years of the index date (12 months after cohort entry). Model development was conducted using a Fine-Gray approach in data from CPRD GOLD, accounting for the competing risk of death from other causes, with subsequent recalibration at one, five, and 10 years using pseudo values. External validation was conducted using data from CPRD Aurum, with performance assessed through calibration curves and the observed to expected ratio, C statistic, and D statistic, pooled across general practices, and clinical utility using decision curve analysis at thresholds around 10%. RESULTS Analysis included 1 772 600 patients (experiencing 62 691 serious falls) from CPRD GOLD used in model development, and 3 805 366 (experiencing 206 956 serious falls) from CPRD Aurum in the external validation. The final model consisted of 24 predictors, including age, sex, ethnicity, alcohol consumption, living in an area of high social deprivation, a history of falls, multiple sclerosis, and prescriptions of antihypertensives, antidepressants, hypnotics, and anxiolytics. Upon external validation, the recalibrated model showed good discrimination, with pooled C statistics of 0.833 (95% confidence interval 0.831 to 0.835) and 0.843 (0.841 to 0.844) at five and 10 years, respectively. Original model calibration was poor on visual inspection and although this was improved with recalibration, under-prediction of risk remained (observed to expected ratio at 10 years 1.839, 95% confidence interval 1.811 to 1.865). Nevertheless, decision curve analysis suggests potential clinical utility, with net benefit larger than other strategies. CONCLUSIONS This prediction model uses commonly recorded clinical characteristics and distinguishes well between patients at high and low risk of falls in the next 1-10 years. Although miscalibration was evident on external validation, the model still had potential clinical utility around risk thresholds of 10% and so could be useful in routine clinical practice to help identify those at high risk of falls who might benefit from closer monitoring or early intervention to prevent future falls. Further studies are needed to explore the appropriate thresholds that maximise the model's clinical utility and cost effectiveness.
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Affiliation(s)
- Lucinda Archer
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Kym I E Snell
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Richard D Riley
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK
| | - Andrew Clegg
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, University of Leeds, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
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Jones N, Smith M, Lay-Flurrie S, Roalfe AK, Yang Y, Hobbs FDR, Taylor CJ. Survival among people with heart failure and atrial fibrillation; a population cohort study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
People with chronic heart failure (HF) have a poor prognosis, with survival rates at five year follow-up close to 50%.1 More than half of patients with HF will develop atrial fibrillation (AF). The presence of AF in people with HF has been associated with a poor prognosis, irrespective of left ventricular ejection fraction. 2,3 However, the majority of studies to date have analysed prognosis among secondary care cohorts or randomised trial participants, who may not be representative of patients with chronic HF in the community.2
Purpose
To examine the association between survival in patients with HF and AF compared to either condition alone, among a large primary care cohort.
Methods
We extracted data from the Clinical Practice Research Datalink of primary care records from 1st January 2000 to 31st December 2018 and included all patients aged 45 years and over who were registered at an up-to-standard practice for a minimum of 12 months. Records were linked to Hospital Episode Statistics for secondary care data. The primary outcome was all-cause mortality. Exposure groups were defined as HF+AF, HF or AF, with exposure status treated as a time-varying covariate across follow-up. We used Cumulative Hazard plots to compare survival in people with HF and AF, compared to people with either condition alone or neither. We also report a Cox regression model for risk of all-cause mortality among people with HF and AF, adjusting for age, sex, ethnicity, smoking status and comorbid cardiovascular disease.
Results
There were 314,042 deaths during the study follow-up. The average age of participants was 58.0 years (SD 10.6) and 51.4% were women. At some point across follow-up, 94,990 people had HF alone, 147,815 had AF alone and 74,470 had both HF and AF. In an unadjusted Cox regression analysis, people with HF and AF were at the greatest risk of death (HR 17.94, 95% CI 17.75 to 18.13), followed by people with HF alone (HR 12.00, 95% CI 11.87 to 12.13), and AF alone (HR 6.14, 95% CI 6.08 to 6.21) compared to people with neither HF nor AF. In the fully adjusted analysis, the risk of death remained highest among people with HF and AF (HR 3.78, 95% CI 3.73 to 3.83), followed by people with HF alone (HR 3.06, 95% CI 3.02 to 3.10), then people with AF alone (HR 1.85, 95%, CI 1.82 to 1.87). In a cumulative hazard plot, the risk of death across follow-up was similar among people with HF and AF, compared to those with HF alone.
Conclusion
In our large community cohort, we found HF and AF was associated with a worse prognosis than either condition alone. Both HF and AF were also associated with a poor prognosis. These results support the findings of previous secondary care and trial studies regarding the importance of AF as a prognostic indicator among people with HF. Further research could aim to identify preventive strategies that might improve prognosis among this high-risk group of patients.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was undertaken as part of NRJ's Doctoral Research Fellowship, supported by the Wellcome Trust (grant number 203921/Z/16/Z), with additional funding for this project from the National Institute for Health Research (NIHR) Collaboration for Applied Health Research (CLAHRC) Oxford at Oxford Health NHS Foundation Trust (P2-001).
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Affiliation(s)
- N Jones
- University of Oxford , Oxford , United Kingdom
| | - M Smith
- University of Oxford , Oxford , United Kingdom
| | | | - A K Roalfe
- University of Oxford , Oxford , United Kingdom
| | - Y Yang
- University of Oxford , Oxford , United Kingdom
| | - F D R Hobbs
- University of Oxford , Oxford , United Kingdom
| | - C J Taylor
- University of Oxford , Oxford , United Kingdom
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McFadden E, Lay-Flurrie S, Koshiaris C, Richards GC, Heneghan C. The Long-Term Impact of Vaginal Surgical Mesh Devices in UK Primary Care: A Cohort Study in the Clinical Practice Research Datalink. Clin Epidemiol 2021; 13:1167-1180. [PMID: 35002329 PMCID: PMC8728093 DOI: 10.2147/clep.s333775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/18/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) may be treated with surgical mesh devices; evidence of their long-term complications is lacking. PATIENTS AND METHODS Rates of diagnoses of depression, anxiety or self-harm (composite measure) and sexual dysfunction, and rates of prescriptions for antibiotics and opioids were estimated in women with and without mesh surgery, with a diagnostic SUI/POP code, registered in the Clinical Practice Research Datalink (CPRD) gold database. RESULTS There were 220,544 women eligible for inclusion; 74% (n = 162,687) had SUI, 37% (n = 82,123) had POP, and 11% (n = 24,266) had both. Women undergoing mesh surgery for SUI or POP had about 1.1 times higher rates of antibiotic use. Women with no previous history of the outcome, who underwent mesh surgery had 2.43 (95% CI 2.19-2.70) and 1.47 (95% CI 1.19-1.81) times higher rates of depression, anxiety, or self-harm, 1.88 (95% CI 1.50-2.36) and 1.64 (95% CI 1.02-2.63) times higher rates of sexual dysfunction and 1.40 (95% CI 1.26-1.56) and 1.23 (95% CI 1.01-1.49) times higher opioid use for SUI and POP, respectively. Women with a history of depression, anxiety and self-harm had 0.3 times lower rates of these outcomes with SUI or POP mesh surgery (HR for SUI 0.70 (95% CI 0.67-0.73), HR for POP 0.72 (95% CI 0.65-0.79)). Women with a history of opioid use who had POP mesh surgery had about 0.09 times lower rates (HR 0.91 (95% CI 0.86-0.96)) of prescriptions. Negative control outcome analyses showed no evidence of an association between asthma consultations and mesh surgery in women with POP, but the rate was 0.09 times lower (HR 0.91 (95% CI 0.87-0.94)) in women with SUI mesh surgery, suggesting that study results are subject to some residual confounding. CONCLUSION Mesh surgery was associated with poor mental and sexual health outcomes, alongside increased opioid and antibiotic use, in women with no history of these outcomes and improved mental health, and lower opioid use, in women with a previous history of these outcomes. Although our results suggest an influence of residual confounding, careful consideration of the benefits and risk of mesh surgery for women with SUI or POP on an individual basis is required.
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Affiliation(s)
- Emily McFadden
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Lay-Flurrie
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- EMEA Real World Methods and Evidence Generation, IQVIA, London, UK
| | - Constantinos Koshiaris
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Georgia C Richards
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Global Centre on Healthcare and Urbanisation, Kellogg College, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Global Centre on Healthcare and Urbanisation, Kellogg College, University of Oxford, Oxford, UK
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Taylor C, Ordonez-Mena J, Lay-Flurrie S, Goyder C, Jones N, Roalfe A, Hobbs F. Natriuretic peptide referral thresholds and heart failure diagnosis: population-based cohort study. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Natriuretic peptide (NP) testing is recommended by both the European Society of Cardiology (ESC) and the National Institute for Health and Care Excellence (NICE) for people presenting with symptoms of heart failure (HF) in primary care. However, ESC and NICE guidelines suggest different NP referral thresholds: ESC recommend referral at a lower NP level (BNP≥35pg/ml / NT-proBNP≥125pg/ml) compared to NICE (BNP≥100pg/ml/NT-proBNP≥400pg/ml).
Purpose
We aimed to evaluate NP test performance for HF diagnosis for ESC and NICE guideline-defined thresholds.
Methods
Population-based cohort study using linked primary and secondary care data from the Clinical Practice Research Datalink in England between 1st January 2000 and 31st December 2018. Participants were adults aged 45 years and above with a NP result: 74,233 had a BNP and 155,347 had a NT-proBNP measurement. The main outcome measures were diagnostic performance of NP test (sensitivity, specificity, positive predictive value, negative predictive value) by threshold.
Results
A total of 229,580 patients had a NP test and 21,102 (9.2%) were diagnosed with HF. The ESC NT-proBNP threshold of 125pg/ml had a sensitivity of 94.6% (94.2 to 95.0) and specificity of 50.0% (49.7 to 50.3) compared to sensitivity of 81.7% (81.0 to 82.3) and specificity of 80.3% (80.0 to 80.5) for the NICE NT-proBNP 400pg/ml threshold. For both guidelines, nearly all patients with a NP level below the threshold did not have HF (negative predictive value ESC 98.9% (98.8 to 99.0) and NICE 97.7% (97.6 to 97.8). Similar performance was found for BNP.
Conclusions
The performance of NP testing is dependent on the guideline-specified threshold for referral. In 100 people with HF, using the NICE threshold would falsely reassure 18 patients, whereas the lower ESC threshold would miss just 5 people but twice as many patients would be referred for diagnostic assessment. The optimal NP threshold for referral for HF diagnosis will depend on the healthcare setting. The trade-off between missing HF cases and overwhelming diagnostic services needs to be determined at a national level.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute for Health Research
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Affiliation(s)
- C Taylor
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - J.M Ordonez-Mena
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - S Lay-Flurrie
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - C Goyder
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - N Jones
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - A Roalfe
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - F.D.R Hobbs
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
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8
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Cai T, Abel L, Langford O, Monaghan G, Aronson JK, Stevens RJ, Lay-Flurrie S, Koshiaris C, McManus RJ, Hobbs FDR, Sheppard JP. Associations between statins and adverse events in primary prevention of cardiovascular disease: systematic review with pairwise, network, and dose-response meta-analyses. BMJ 2021; 374:n1537. [PMID: 34261627 PMCID: PMC8279037 DOI: 10.1136/bmj.n1537] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the associations between statins and adverse events in primary prevention of cardiovascular disease and to examine how the associations vary by type and dosage of statins. DESIGN Systematic review and meta-analysis. DATA SOURCES Studies were identified from previous systematic reviews and searched in Medline, Embase, and the Cochrane Central Register of Controlled Trials, up to August 2020. REVIEW METHODS Randomised controlled trials in adults without a history of cardiovascular disease that compared statins with non-statin controls or compared different types or dosages of statins were included. MAIN OUTCOME MEASURES Primary outcomes were common adverse events: self-reported muscle symptoms, clinically confirmed muscle disorders, liver dysfunction, renal insufficiency, diabetes, and eye conditions. Secondary outcomes included myocardial infarction, stroke, and death from cardiovascular disease as measures of efficacy. DATA SYNTHESIS A pairwise meta-analysis was conducted to calculate odds ratios and 95% confidence intervals for each outcome between statins and non-statin controls, and the absolute risk difference in the number of events per 10 000 patients treated for a year was estimated. A network meta-analysis was performed to compare the adverse effects of different types of statins. An Emax model based meta-analysis was used to examine the dose-response relationships of the adverse effects of each statin. RESULTS 62 trials were included, with 120 456 participants followed up for an average of 3.9 years. Statins were associated with an increased risk of self-reported muscle symptoms (21 trials, odds ratio 1.06 (95% confidence interval 1.01 to 1.13); absolute risk difference 15 (95% confidence interval 1 to 29)), liver dysfunction (21 trials, odds ratio 1.33 (1.12 to 1.58); absolute risk difference 8 (3 to 14)), renal insufficiency (eight trials, odds ratio 1.14 (1.01 to 1.28); absolute risk difference 12 (1 to 24)), and eye conditions (six trials, odds ratio 1.23 (1.04 to 1.47); absolute risk difference 14 (2 to 29)) but were not associated with clinically confirmed muscle disorders or diabetes. The increased risks did not outweigh the reduction in the risk of major cardiovascular events. Atorvastatin, lovastatin, and rosuvastatin were individually associated with some adverse events, but few significant differences were found between types of statins. An Emax dose-response relationship was identified for the effect of atorvastatin on liver dysfunction, but the dose-response relationships for the other statins and adverse effects were inconclusive. CONCLUSIONS For primary prevention of cardiovascular disease, the risk of adverse events attributable to statins was low and did not outweigh their efficacy in preventing cardiovascular disease, suggesting that the benefit-to-harm balance of statins is generally favourable. Evidence to support tailoring the type or dosage of statins to account for safety concerns before starting treatment was limited. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020169955.
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Affiliation(s)
- Ting Cai
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Oliver Langford
- Alzheimer's Therapeutic Research Institute, University of Southern California, Los Angeles, USA
| | - Genevieve Monaghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jeffrey K Aronson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard J Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Richard J McManus
- 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
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Koshiaris C, Van den Bruel A, Nicholson BD, Lay-Flurrie S, Hobbs FR, Oke JL. Clinical prediction tools to identify patients at highest risk of myeloma in primary care: a retrospective open cohort study. Br J Gen Pract 2021; 71:e347-e355. [PMID: 33824161 PMCID: PMC8049204 DOI: 10.3399/bjgp.2020.0697] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/01/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patients with myeloma experience substantial delays in their diagnosis, which can adversely affect their prognosis. AIM To generate a clinical prediction rule to identify primary care patients who are at highest risk of myeloma. DESIGN AND SETTING Retrospective open cohort study using electronic health records data from the UK's Clinical Practice Research Datalink (CPRD) between 1 January 2000 and 1 January 2014. METHOD Patients from the CPRD were included in the study if they were aged ≥40 years, had two full blood counts within a year, and had no previous diagnosis of myeloma. Cases of myeloma were identified in the following 2 years. Derivation and external validation datasets were created based on geographical region. Prediction equations were estimated using Cox proportional hazards models including patient characteristics, symptoms, and blood test results. Calibration, discrimination, and clinical utility were evaluated in the validation set. RESULTS Of 1 281 926 eligible patients, 737 (0.06%) were diagnosed with myeloma within 2 years. Independent predictors of myeloma included: older age; male sex; back, chest and rib pain; nosebleeds; low haemoglobin, platelets, and white cell count; and raised mean corpuscular volume, calcium, and erythrocyte sedimentation rate. A model including symptoms and full blood count had an area under the curve of 0.84 (95% CI = 0.81 to 0.87) and sensitivity of 62% (95% CI = 55% to 68%) at the highest risk decile. The corresponding statistics for a second model, which also included calcium and inflammatory markers, were an area under the curve of 0.87 (95% CI = 0.84 to 0.90) and sensitivity of 72% (95% CI = 66% to 78%). CONCLUSION The implementation of these prediction rules would highlight the possibility of myeloma in patients where GPs do not suspect myeloma. Future research should focus on the prospective evaluation of further external validity and the impact on clinical practice.
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Affiliation(s)
| | | | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Albasri A, Hattle M, Koshiaris C, Dunnigan A, Paxton B, Fox SE, Smith M, Archer L, Levis B, Payne RA, Riley RD, Roberts N, Snell KIE, Lay-Flurrie S, Usher-Smith J, Stevens R, Hobbs FDR, McManus RJ, Sheppard JP. Association between antihypertensive treatment and adverse events: systematic review and meta-analysis. BMJ 2021; 372:n189. [PMID: 33568342 PMCID: PMC7873715 DOI: 10.1136/bmj.n189] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the association between antihypertensive treatment and specific adverse events. DESIGN Systematic review and meta-analysis. ELIGIBILITY CRITERIA Randomised controlled trials of adults receiving antihypertensives compared with placebo or no treatment, more antihypertensive drugs compared with fewer antihypertensive drugs, or higher blood pressure targets compared with lower targets. To avoid small early phase trials, studies were required to have at least 650 patient years of follow-up. INFORMATION SOURCES Searches were conducted in Embase, Medline, CENTRAL, and the Science Citation Index databases from inception until 14 April 2020. MAIN OUTCOME MEASURES The primary outcome was falls during trial follow-up. Secondary outcomes were acute kidney injury, fractures, gout, hyperkalaemia, hypokalaemia, hypotension, and syncope. Additional outcomes related to death and major cardiovascular events were extracted. Risk of bias was assessed using the Cochrane risk of bias tool, and random effects meta-analysis was used to pool rate ratios, odds ratios, and hazard ratios across studies, allowing for between study heterogeneity (τ2). RESULTS Of 15 023 articles screened for inclusion, 58 randomised controlled trials were identified, including 280 638 participants followed up for a median of 3 (interquartile range 2-4) years. Most of the trials (n=40, 69%) had a low risk of bias. Among seven trials reporting data for falls, no evidence was found of an association with antihypertensive treatment (summary risk ratio 1.05, 95% confidence interval 0.89 to 1.24, τ2=0.009). Antihypertensives were associated with an increased risk of acute kidney injury (1.18, 95% confidence interval 1.01 to 1.39, τ2=0.037, n=15), hyperkalaemia (1.89, 1.56 to 2.30, τ2=0.122, n=26), hypotension (1.97, 1.67 to 2.32, τ2=0.132, n=35), and syncope (1.28, 1.03 to 1.59, τ2=0.050, n=16). The heterogeneity between studies assessing acute kidney injury and hyperkalaemia events was reduced when focusing on drugs that affect the renin angiotensin-aldosterone system. Results were robust to sensitivity analyses focusing on adverse events leading to withdrawal from each trial. Antihypertensive treatment was associated with a reduced risk of all cause mortality, cardiovascular death, and stroke, but not of myocardial infarction. CONCLUSIONS This meta-analysis found no evidence to suggest that antihypertensive treatment is associated with falls but found evidence of an association with mild (hyperkalaemia, hypotension) and severe adverse events (acute kidney injury, syncope). These data could be used to inform shared decision making between doctors and patients about initiation and continuation of antihypertensive treatment, especially in patients at high risk of harm because of previous adverse events or poor renal function. REGISTRATION PROSPERO CRD42018116860.
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Affiliation(s)
- Ali Albasri
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | | | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Anna Dunnigan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ben Paxton
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Emma Fox
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Margaret Smith
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | | | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Juliet Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
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11
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Sheppard JP, Nicholson BD, Lee J, McGagh D, Sherlock J, Koshiaris C, Oke J, Jones NR, Hinton W, Armitage L, Van Hecke O, Lay-Flurrie S, Bankhead CR, Liyanage H, Williams J, Ferreira F, Feher MD, Ashworth AJ, Joy MP, de Lusignan S, Hobbs FDR. Association Between Blood Pressure Control and Coronavirus Disease 2019 Outcomes in 45 418 Symptomatic Patients With Hypertension: An Observational Cohort Study. Hypertension 2020; 77:846-855. [PMID: 33325240 PMCID: PMC7884248 DOI: 10.1161/hypertensionaha.120.16472] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Supplemental Digital Content is available in the text. Hypertension has been identified as a risk factor for coronavirus disease 2019 (COVID-19) and associated adverse outcomes. This study examined the association between preinfection blood pressure (BP) control and COVID-19 outcomes using data from 460 general practices in England. Eligible patients were adults with hypertension who were tested or diagnosed with COVID-19. BP control was defined by the most recent BP reading within 24 months of the index date (January 1, 2020). BP was defined as controlled (<130/80 mm Hg), raised (130/80–139/89 mm Hg), stage 1 uncontrolled (140/90–159/99 mm Hg), or stage 2 uncontrolled (≥160/100 mm Hg). The primary outcome was death within 28 days of COVID-19 diagnosis. Secondary outcomes were COVID-19 diagnosis and COVID-19–related hospital admission. Multivariable logistic regression was used to examine the association between BP control and outcomes. Of the 45 418 patients (mean age, 67 years; 44.7% male) included, 11 950 (26.3%) had controlled BP. These patients were older, had more comorbidities, and had been diagnosed with hypertension for longer. A total of 4277 patients (9.4%) were diagnosed with COVID-19 and 877 died within 28 days. Individuals with stage 1 uncontrolled BP had lower odds of COVID-19 death (odds ratio, 0.76 [95% CI, 0.62–0.92]) compared with patients with well-controlled BP. There was no association between BP control and COVID-19 diagnosis or hospitalization. These findings suggest BP control may be associated with worse COVID-19 outcomes, possibly due to these patients having more advanced atherosclerosis and target organ damage. Such patients may need to consider adhering to stricter social distancing, to limit the impact of COVID-19 as future waves of the pandemic occur.
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Affiliation(s)
- James P Sheppard
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Brian D Nicholson
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Joseph Lee
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Dylan McGagh
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Julian Sherlock
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Constantinos Koshiaris
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Jason Oke
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Nicholas R Jones
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - William Hinton
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Laura Armitage
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Oliver Van Hecke
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Sarah Lay-Flurrie
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Clare R Bankhead
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Harshana Liyanage
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - John Williams
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Filipa Ferreira
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Michael D Feher
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | | | - Mark P Joy
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - Simon de Lusignan
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
| | - F D Richard Hobbs
- From the Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (J.P.S., B.D.N., J.L., D.M., J.S., C.K., J.O., N.R.J., W.H., L.A., O.V.H., S.L.-F., C.R.B., H.L., J.W., F.F., M.D.F., M.P.J., S.d.L., F.D.R.H.)
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12
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Taylor CJ, Ordóñez-Mena JM, Jones NR, Roalfe AK, Lay-Flurrie S, Marshall T, Hobbs FDR. National trends in heart failure mortality in men and women, United Kingdom, 2000-2017. Eur J Heart Fail 2020; 23:3-12. [PMID: 32892471 PMCID: PMC8287578 DOI: 10.1002/ejhf.1996] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/10/2020] [Accepted: 08/30/2020] [Indexed: 12/11/2022] Open
Abstract
Aims To understand gender differences in the prognosis of women and men with heart failure, we compared mortality, cause of death and survival trends over time. Methods and results We analysed UK primary care data for 26 725 women and 29 234 men over age 45 years with a new diagnosis of heart failure between 1 January 2000 and 31 December 2017 using the Clinical Practice Research Datalink, inpatient Hospital Episode Statistics and the Office for National Statistics death registry. Age‐specific overall survival and cause‐specific mortality rates were calculated by gender and year. During the study period 15 084 women and 15 822 men with heart failure died. Women were on average 5 years older at diagnosis (79.6 vs. 74.8 years). Median survival was lower in women compared to men (3.99 vs. 4.47 years), but women had a 14% age‐adjusted lower risk of all‐cause mortality [hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.84–0.88]. Heart failure was equally likely to be cause of death in women and men (HR 1.03, 95% CI 0.96–1.12). There were modest improvements in survival for both genders, but these were greater in men. The reduction in mortality risk in women was greatest for those diagnosed in the community (HR 0.83, 95% CI 0.80–0.85). Conclusions Women are diagnosed with heart failure older than men but have a better age‐adjusted prognosis. Survival gains were less in women over the last two decades. Addressing gender differences in heart failure diagnostic and treatment pathways should be a clinical and research priority.
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Affiliation(s)
- Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - José M Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Nicholas R Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrea K Roalfe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Garriga C, Robson J, Coupland C, Lay-Flurrie S, Hippisley-Cox J. Nationwide health check program by patients with severe mental illness or long-term antidepressants. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa165.1193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The English NHS Health Check is a unique national risk assessment, awareness and management programme for preventing cardiovascular disease (CVD), diabetes and chronic kidney disease (CKD). We aimed to assess their uptake and association with new diagnoses (CVD, hypertension, type-2 diabetes and CKD) in patients with severe mental illness (SMI) compared to patients without this condition and for patients on long-term antidepressant treatment (LTAD) (≥6 prescriptions vs < 6).
Methods
Cohort study (2013-2017) using the QResearch database. 1,319 general practices across England contributed of over nine million patients aged 40-74 years. 3,492,186 patients were eligible for NHS Health Checks of which 590,218 attended. Outcomes: hazard ratios (HR) with 95% confidence intervals (CI) for uptake of NHS Health Checks and for new diagnoses within 1 year in attendees. Models were adjusted for sex, age, ethnicity, deprivation and region.
Results
65,490 people with SMI and 46,437 people on LTAD (20% of the total eligible with SMI/LTAD, respectively) attended an NHS Health Check. People with SMI or on LTAD were more likely to attend compared to people without those conditions, adjusted HRs 1.05 (95% CI 1.02-1.08) and 1.10 (95% CI 1.08-1.13), respectively. Among attendees, people with SMI and on LTAD were 23% and 55% more likely to be diagnosed with CKD (95% CI 1.12-1.34 and 1.42-1.70, respectively) than people without these conditions. Attendees on LTAD were 66% more likely to have a major CVD event within 1 year than those without LTAD (95% CI 1.41-1.94) or a new diagnosis of hypertension and type 2 diabetes, HRs 1.12 (95% CI 1.05-1.20) and 1.45 (95% CI 1.31-1.60), respectively.
Conclusions
People with SMI or on LTAD were more likely to attend NHS Health Checks than people without these conditions. Higher rates of CKD in patients with SMI/LTAD and CVD, hypertension and type 2 diabetes in the latter might indicate increased risks and unmet need in these patient groups
Key messages
People with SMI/LTAD were more likely to attend NHS Health Checks. People on LTAD were more likely to be diagnosed with CVD, CKD, hypertension and type-2 diabetes than people without these conditions. SMI attendees were more likely to be diagnosed with CKD.
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Affiliation(s)
- C Garriga
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - J Robson
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - C Coupland
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - S Lay-Flurrie
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - J Hippisley-Cox
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
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Magee LA, Singer J, Lee T, McManus RJ, Lay-Flurrie S, Rey E, Chappell LC, Myers J, Logan AG, von Dadelszen P. Are blood pressure level and variability related to pregnancy outcome? Analysis of control of hypertension in pregnancy study data. Pregnancy Hypertens 2020; 19:87-93. [PMID: 31927325 DOI: 10.1016/j.preghy.2019.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 10/15/2019] [Accepted: 12/08/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To examine the relationship between pregnancy outcomes and BP level and variability. DESIGN Secondary analysis of CHIPS trial data (Control of Hypertension In Pregnancy Study, NCT01192412). SETTING International. POPULATION OR SAMPLE Women with chronic or gestational hypertension. METHODS BP measurement was standardised in outpatient clinics. Adjusted (including for allocated group) mixed effects logistic regression was used to assess relationships between major CHIPS outcomes and both BP level (mean of clinic readings) and visit-to-visit within-participant BP variability (standard deviation and average real variability of absolute successive difference of BP values). BP values 7-28 days prior to outcomes (or birth for perinatal outcomes) were excluded in sensitivity analyses. MAIN OUTCOME MEASURES Major CHIPS outcomes. RESULTS Among 961 (97.4%) women, higher BP level was associated with more adverse maternal and perinatal outcomes (usually at p < 0.001) except for serious maternal complications. Among 913 (92.5%) women with at least two post-randomisation outpatient visits, higher BP variability was associated with increased odds of severe hypertension and pre-eclampsia (usually at p < 0.01). Sensitivity analyses suggested reverse causality for these maternal outcomes, but greater diastolic BP variability may have been associated with fewer adverse perinatal outcomes. CONCLUSIONS Higher BP is an adverse prognostic marker, regardless of target BP. While the association between higher BP variability and severe hypertension and pre-eclampsia may be related to higher BP at diagnosis, our results suggest a possible advantage of BP variability for the fetus, through undefined mechanisms. TWEETABLE ABSTRACT Higher blood pressure (BP) is associated with more adverse pregnancy outcomes, but higher BP variability may be good for the baby.
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Affiliation(s)
- Laura A Magee
- Department of Women and Children's Health, King's College London, UK.
| | - Joel Singer
- School of Population and Public Health, Centre for Health Evaluation and Outcome Science, Providence Health Care Research Institute, University of British Columbia, Vancouver, Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Science, Providence Health Care Research Institute, University of British Columbia, Vancouver, Canada
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Evelyne Rey
- Departments of Medicine and Obstetrics and Gynaecology, Université de Montreal, Canada
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, UK
| | - Jenny Myers
- Division of Developmental Biology and Medicine, Manchester Maternal & Fetal Health Research Centre, UK
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Chapman N, Breslin M, Lay-Flurrie S, Zhou Z, Sharman J, Nelson M, McManus R. YI 2.6 Comparison of Cardiovascular Disease Primary Prevention Guidelines between Australia, England and the United States. Artery Res 2020. [DOI: 10.2991/artres.k.201209.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Nicholson BD, Aveyard P, Bankhead CR, Hamilton W, Hobbs FDR, Lay-Flurrie S. Determinants and extent of weight recording in UK primary care: an analysis of 5 million adults' electronic health records from 2000 to 2017. BMC Med 2019; 17:222. [PMID: 31783757 PMCID: PMC6883613 DOI: 10.1186/s12916-019-1446-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Excess weight and unexpected weight loss are associated with multiple disease states and increased morbidity and mortality, but weight measurement is not routine in many primary care settings. The aim of this study was to characterise who has had their weight recorded in UK primary care, how frequently, by whom and in relation to which clinical events, symptoms and diagnoses. METHODS A longitudinal analysis of UK primary care electronic health records (EHR) data from 2000 to 2017. Descriptive statistics were used to summarise weight recording in terms of patient sociodemographic characteristics, health professional encounters, clinical events, symptoms and diagnoses. Negative binomial regression was used to model the likelihood of having a weight record each year, and Cox regression to the likelihood of repeated weight recording. RESULTS A total of 14,049,871 weight records were identified in the EHR of 4,918,746 patients during the study period, representing 26,998,591 person-years of observation. Around a third of patients had a weight record each year. Forty-nine percent of weight records were repeated within a year with an average time to a repeat weight record of 1.92 years. Weight records were most often taken by nursing staff (38-42%) and GPs (37-39%) as part of a routine clinical care, such as chronic disease reviews (16%), medication reviews (6-8%) and health checks (6-7%), or were associated with consultations for contraception (5-8%), respiratory disease (5%) and obesity (1%). Patient characteristics independently associated with an increased likelihood of weight recording were as follows: female sex, younger and older adults, non-drinkers, ex-smokers, low or high BMI, being more deprived, diagnosed with a greater number of comorbidities and consulting more frequently. The effect of policy-level incentives to record weight did not appear to be sustained after they were removed. CONCLUSION Weight recording is not a routine activity in UK primary care. It is recorded for around a third of patients each year and is repeated on average every 2 years for these patients. It is more common in females with higher BMI and in those with comorbidity. Incentive payments and their removal appear to be associated with increases and decreases in weight recording.
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Affiliation(s)
- B D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK.
| | - P Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
| | - C R Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
| | - W Hamilton
- Medical School, University of Exeter, Exeter, UK
| | - F D R Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
| | - S Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
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17
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Lay-Flurrie S, Mathieu E, Bankhead C, Nicholson BD, Perera-Salazar R, Holt T, Hobbs FDR, Salisbury C. Patient consultation rate and clinical and NHS outcomes: a cross-sectional analysis of English primary care data from 2.7 million patients in 238 practices. BMC Health Serv Res 2019; 19:219. [PMID: 30954074 PMCID: PMC6451312 DOI: 10.1186/s12913-019-4036-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 03/24/2019] [Indexed: 12/04/2022] Open
Abstract
Background Primary care workload is high and increasing in the United Kingdom. We sought to examine the association between rates of primary care consultation and outcomes in England. Methods Cross sectional observational study of routine electronic health care records in 283 practices from the Clinical Practice Research Datalink from April 2013 to March 2014. Outcomes included mortality rate, hospital admission rate, Quality and Outcomes Framework (QOF) performance and patient satisfaction. Relationships between consultation rates (with a general practitioner (GP) or nurse) and outcomes were investigated using negative binomial and ordinal logistic regression models. Results Rates of GP and nurse consultation (per patient person-year) were not associated with mortality or hospital admission rates: mortality incidence rate ratio (IRR) per unit change in GP/ nurse consultation rate = 1.01, 95% CI [0.98 to 1.04]/ 0.97, 95% CI [0.93 to 1.02]; hospital admission IRR per unit change in GP/ nurse consultation rate = 1.02, 95% CI [0.99 to 1.04]/ 0.98, 95% CI [0.94 to 1.032]. Higher rates of nurse but not GP consultation were associated with higher QOF achievement: OR = 1.91, 95% CI [1.39 to 2.62] per unit change in nurse consultation rate vs. OR = 1.04, 95% CI [0.87 to 1.24] per unit change in GP consultation rate. The association between the rates of GP/ nurse consultations and patient satisfaction was mixed. Conclusion There are few associations between primary care consultation rates and outcomes. Previously identified demographic and staffing factors, rather than practice workload, appear to have the strongest relationships with mortality, admissions, performance and satisfaction. Studies with more detailed patient-level data would be required to explore these findings further. Electronic supplementary material The online version of this article (10.1186/s12913-019-4036-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Edouard Mathieu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Clare Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Rafael Perera-Salazar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Tim Holt
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Chris Salisbury
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
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18
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Taylor CJ, Ordóñez-Mena JM, Roalfe AK, Lay-Flurrie S, Jones NR, Marshall T, Hobbs FDR. Trends in survival after a diagnosis of heart failure in the United Kingdom 2000-2017: population based cohort study. BMJ 2019; 364:l223. [PMID: 30760447 PMCID: PMC6372921 DOI: 10.1136/bmj.l223] [Citation(s) in RCA: 253] [Impact Index Per Article: 50.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To report reliable estimates of short term and long term survival rates for people with a diagnosis of heart failure and to assess trends over time by year of diagnosis, hospital admission, and socioeconomic group. DESIGN Population based cohort study. SETTING Primary care, United Kingdom. PARTICIPANTS Primary care data for 55 959 patients aged 45 and overwith a new diagnosis of heart failure and 278 679 age and sex matched controls in the Clinical Practice Research Datalink from 1 January 2000 to 31 December 2017 and linked to inpatient Hospital Episode Statistics and Office for National Statistics mortality data. MAIN OUTCOME MEASURES Survival rates at one, five, and 10 years and cause of death for people with and without heart failure; and temporal trends in survival by year of diagnosis, hospital admission, and socioeconomic group. RESULTS Overall, one, five, and 10 year survival rates increased by 6.6% (from 74.2% in 2000 to 80.8% in 2016), 7.2% (from 41.0% in 2000 to 48.2% in 2012), and 6.4% (from 19.8% in 2000 to 26.2% in 2007), respectively. There were 30 906 deaths in the heart failure group over the study period. Heart failure was listed on the death certificate in 13 093 (42.4%) of these patients, and in 2237 (7.2%) it was the primary cause of death. Improvement in survival was greater for patients not requiring admission to hospital around the time of diagnosis (median difference 2.4 years; 5.3 v 2.9 years, P<0.001). There was a deprivation gap in median survival of 0.5 years between people who were least deprived and those who were most deprived (4.6 v 4.1 years, P<0.001) [corrected]. CONCLUSIONS Survival after a diagnosis of heart failure has shown only modest improvement in the 21st century and lags behind other serious conditions, such as cancer. New strategies to achieve timely diagnosis and treatment initiation in primary care for all socioeconomic groups should be a priority for future research and policy.
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Affiliation(s)
- Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - José M Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Andrea K Roalfe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Nicholas R Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
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