51
|
Joseph RM, Movahedi M, Dixon WG, Symmons DP. Risks of smoking and benefits of smoking cessation on hospitalisations for cardiovascular events and respiratory infection in patients with rheumatoid arthritis: a retrospective cohort study using the Clinical Practice Research Datalink. RMD Open 2017; 3:e000506. [PMID: 29018566 PMCID: PMC5623338 DOI: 10.1136/rmdopen-2017-000506] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/18/2017] [Accepted: 08/20/2017] [Indexed: 12/26/2022] Open
Abstract
Objectives To investigate the associations between smoking status, smoking cessation and hospitalisations for cardiovascular events (CVE) and respiratory tract infections (RTI) in an inception cohort of patients with rheumatoid arthritis (RA). Methods The study was set within UK primary care electronic health records (the Clinical Practice Research Datalink) linked to hospital inpatient data (Hospital Episode Statistics). Patients with RA were followed from diagnosis to hospitalisation with a record of CVE or RTI, leaving their general practice, death, or 10 January 2012, whichever was earliest. Smoking status (never, current, former) was defined using primary care data and could vary over time. Survival analysis was performed using Cox regression (first event) and conditional risk set models (multiple RTIs). Results 5677 patients were included in the cohort: 68% female, median age 61 years. The age-adjusted and sex-adjusted risks of hospitalisation for CVE or RTI were more than twice as high in current vs never smokers (CVE HR (95% CI) 2.19 (1.44 to 3.31); RTI 2.18 (1.71 to 2.78)). The risks for both outcomes were significantly higher in current compared with former smokers (CVE 1.51 (1.04 to 2.19), RTI 1.29 (1.04 to 1.61)). For each additional year of smoking cessation, the risk of first CVE and RTI hospitalisation fell significantly, approximately 25% and 15% respectively in the adjusted models. Conclusions Patients with RA who smoke have an increased risk of hospitalisation with CVE or RTI compared with never and former smokers. The risk decreases for each additional year of smoking cessation. Patients with RA who smoke should be advised to stop smoking.
Collapse
Affiliation(s)
- Rebecca M Joseph
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Mohammad Movahedi
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - William G Dixon
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Deborah Pm Symmons
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
52
|
Hawley S, Cordtz R, Dreyer L, Edwards CJ, Arden NK, Delmestri A, Silman A, Cooper C, Judge A, Prieto-Alhambra D. Association between NICE guidance on biologic therapies with rates of hip and knee replacement among rheumatoid arthritis patients in England and Wales: An interrupted time-series analysis. Semin Arthritis Rheum 2017; 47:605-610. [PMID: 29055489 DOI: 10.1016/j.semarthrit.2017.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/18/2017] [Accepted: 09/20/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To estimate the impact of NICE approval of tumor necrosis factor inhibitor (TNFi) therapies on the incidence of total hip replacement (THR) and total knee replacement (TKR) among rheumatoid arthritis (RA) patients in England and Wales. METHODS Primary care data [Clinical Practice Research Datalink (CPRD)] for the study period (1995-2014) were used to identify incident adult RA patients. The age and sex-standardised 5-year incidence of THR and TKR was calculated separately for RA patients diagnosed in each six-months between 1995-2009. We took a natural experimental approach, using segmented linear regression to estimate changes in level and trend following the publication of NICE TA 36 in March 2002, incorporating a 1-year lag. Regression coefficients were used to calculate average change in rates, adjusted for prior level and trend. RESULTS We identified 17,505 incident RA patients of whom 465 and 650 underwent THR and TKR surgery, respectively. The modeled average incidence of THR and TKR over the biologic-era was 6.57/1000 person years (PYs) and 8.51/1000 PYs, respectively, with projected (had pre-NICE TA 36 level and trend continued uninterrupted) figures of 5.63/1000 PYs and 12.92 PYs, respectively. NICE guidance was associated with a significant average decrease in TKR incidence of -4.41/1000 PYs (95% C.I. -6.88 to -1.94), equating to a relative 34% reduction. Overall, no effect was seen on THR rates. CONCLUSIONS Among incident RA patients in England and Wales, NICE guidance on TNFi therapies for RA management was temporally associated with reduced rates of TKR but not THR.
Collapse
Affiliation(s)
- Samuel Hawley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD
| | - René Cordtz
- Centre for Rheumatology and Spine Diseases, Gentofte University Hospital, Rigshospitalet, Copenhagen, Denmark; The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Lene Dreyer
- Centre for Rheumatology and Spine Diseases, Gentofte University Hospital, Rigshospitalet, Copenhagen, Denmark; The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Christopher J Edwards
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; Musculoskeletal Research Unit, NIHR Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK
| | - Nigel K Arden
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK; MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - Antonella Delmestri
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - Alan Silman
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - Cyrus Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK; Musculoskeletal Research Unit, NIHR Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford OX3 7LD, UK; Musculoskeletal Research Unit, NIHR Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK
| | - Daniel Prieto-Alhambra
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD; GREMPAL Research Group, Idiap Jordi Gol Primary Care Research Institute and CIBERFes, Universitat Autònoma de Barcelona and Instituto de Salud Carlos III, Barcelona, Spain.
| |
Collapse
|
53
|
Joseph RM, Soames J, Wright M, Sultana K, van Staa TP, Dixon WG. Supplementing electronic health records through sample collection and patient diaries: A study set within a primary care research database. Pharmacoepidemiol Drug Saf 2017; 27:239-242. [PMID: 28924986 PMCID: PMC5846885 DOI: 10.1002/pds.4323] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 08/14/2017] [Accepted: 08/24/2017] [Indexed: 11/10/2022]
Abstract
PURPOSE To describe a novel observational study that supplemented primary care electronic health record (EHR) data with sample collection and patient diaries. METHODS The study was set in primary care in England. A list of 3974 potentially eligible patients was compiled using data from the Clinical Practice Research Datalink. Interested general practices opted into the study then confirmed patient suitability and sent out postal invitations. Participants completed a drug-use diary and provided saliva samples to the research team to combine with EHR data. RESULTS Of 252 practices contacted to participate, 66 (26%) mailed invitations to patients. Of the 3974 potentially eligible patients, 859 (22%) were at participating practices, and 526 (13%) were sent invitations. Of those invited, 117 (22%) consented to participate of whom 86 (74%) completed the study. CONCLUSIONS We have confirmed the feasibility of supplementing EHR with data collected directly from patients. Although the present study successfully collected essential data from patients, it also underlined the requirement for improved engagement with both patients and general practitioners to support similar studies.
Collapse
Affiliation(s)
- Rebecca M Joseph
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Mark Wright
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Tjeerd P van Staa
- Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, UK
| | - William G Dixon
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, UK.,Rheumatology Department, Salford Royal NHS Foundation Trust, Salford, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, UK
| |
Collapse
|
54
|
Alemao E, Cawston H, Bourhis F, Al M, Rutten-van Molken M, Liao KP, Solomon DH. Comparison of cardiovascular risk algorithms in patients with vs without rheumatoid arthritis and the role of C-reactive protein in predicting cardiovascular outcomes in rheumatoid arthritis. Rheumatology (Oxford) 2017; 56:777-786. [PMID: 28087832 DOI: 10.1093/rheumatology/kew440] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Indexed: 12/13/2022] Open
Abstract
Objectives The aims were to compare the performance of cardiovascular risk calculators, Framingham Risk Score (FRS) and QRISK2, in RA and matched non-RA patients and to evaluate whether their performance could be enhanced by the addition of CRP. Methods We conducted a retrospective analysis, using a clinical practice data set linked to Hospital Episode Statistics (HES) data from the UK. Patients presenting with at least one RA diagnosis code and no prior cardiovascular events were matched to non-RA patients using disease risk scores. The overall performance of the FRS and QRISK2 was compared between cohorts, and assessed with and without CRP in the RA cohort using C-Index, Akaike Information Criterion (AIC) and the net reclassification index (NRI). Results Four thousand seven hundred and eighty RA patients met the inclusion criteria and were followed for a mean of 3.8 years. The C-Index for the FRS in the non-RA and RA cohort was 0.783 and 0.754 (P < 0.001) and that of the QRISK2 was 0.770 and 0.744 (P < 0.001), respectively. Log[CRP] was positively associated with cardiovascular events, but improvements in the FRS and QRISK2 C-Indices as a result of inclusion of CRP were small, from 0.764 to 0.767 (P = 0.026) for FRS and from 0.764 to 0.765 (P = 0.250) for QRISK2. The NRI was 3.2% (95% CI: -2.8, 5.7%) for FRS and -2.0% (95% CI: -5.8, 4.5%) for QRISK2. Conclusion The C-Index for the FRS and QRISK2 was significantly better in the non-RA compared with RA patients. The addition of CRP in both equations was not associated with a significant improvement in reclassification based on NRI.
Collapse
Affiliation(s)
- Evo Alemao
- Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb, Princeton, NJ, USA
| | | | | | - Maiwenn Al
- Institute of Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Maureen Rutten-van Molken
- Institute of Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Katherine P Liao
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel H Solomon
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
55
|
Horton DB, Haynes K, Denburg MR, Thacker MM, Rose CD, Putt ME, Leonard MB, Strom BL. Oral glucocorticoid use and osteonecrosis in children and adults with chronic inflammatory diseases: a population-based cohort study. BMJ Open 2017; 7:e016788. [PMID: 28733303 PMCID: PMC5642748 DOI: 10.1136/bmjopen-2017-016788] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES We studied oral glucocorticoids and osteonecrosis, a rare but serious bone disease, in individuals with various chronic inflammatory diseases. We hypothesised that we would find stronger associations in adults versus children and in people with autoimmune diseases. DESIGN Retrospective cohort study. SETTING Population-representative data (1994-2013) from general practices in the UK. PARTICIPANTS Children and adults diagnosed with asthma; inflammatory bowel disease; juvenile, psoriatic or rheumatoid arthritis; psoriasis; or systemic lupus. EXPOSURES Oral glucocorticoid patterns. PRIMARY AND SECONDARY OUTCOME MEASURES Diagnosed osteonecrosis (primary) and osteonecrosis plus clinical features (eg, symptoms, pain medication, surgical repair) (secondary). Discrete time failure models estimated the adjusted hazard ratio (aHR) of incident osteonecrosis following oral glucocorticoid exposure. Hypothesis testing was one sided (with corresponding 90% CI) since glucocorticoids were unlikely protective. RESULTS After adjusting for demographic, disease-related and health utilisation factors, glucocorticoid exposure was associated with osteonecrosis in adults (ages 18-49, aHR 2.1 (90% CI 1.5 to 2.9); ages ≥50, aHR 1.3 (90% CI 1.01 to 1.7)). However, low-dose glucocorticoids, corresponding to average doses <7.5 mg prednisolone daily and maximum doses <30 mg daily, were not associated with osteonecrosis in adults. Furthermore, even at high glucocorticoid doses, there was no evidence of increased osteonecrosis among glucocorticoid-exposed children (p=0.04 for interaction by age) (any glucocorticoid exposure, ages 2-9: aHR 1.1 (90% CI 0.7 to 1.7); ages 10-17: aHR 0.6 (90% CI 0.3 to 1.6)). Arthritis, inflammatory bowel disease and lupus were independently associated with osteonecrosis, but there was a similar dose relationship between glucocorticoids and osteonecrosis among adults with low-risk and high-risk diseases. CONCLUSIONS Glucocorticoid use was clearly associated with osteonecrosis in a dose-related fashion in adults, especially young adults, but this risk was not detectable in children. The absolute risk of glucocorticoid-associated osteonecrosis in the general paediatric population and in adults taking low glucocorticoid doses is at most extremely small.
Collapse
Affiliation(s)
- Daniel B Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers School of Public Health, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey, USA
| | | | - Michelle R Denburg
- Division of Nephrology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mihir M Thacker
- Department of Orthopedics, Nemours A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware, USA
| | - Carlos D Rose
- Division of Rheumatology, Department of Pediatrics, Nemours A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware, USA
| | - Mary E Putt
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary B Leonard
- Division of Nephrology, Departments of Pediatrics and Medicine, Stanford School of Medicine, Stanford University, Stanford, California, USA
| | - Brian L Strom
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Rutgers Biomedical and Health Sciences, Newark, New Jersey, USA
| |
Collapse
|
56
|
Movahedi M, Beauchamp ME, Abrahamowicz M, Ray DW, Michaud K, Pedro S, Dixon WG. Risk of Incident Diabetes Mellitus Associated With the Dosage and Duration of Oral Glucocorticoid Therapy in Patients With Rheumatoid Arthritis. Arthritis Rheumatol 2017; 68:1089-98. [PMID: 26663814 PMCID: PMC4982029 DOI: 10.1002/art.39537] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 12/01/2015] [Indexed: 12/19/2022]
Abstract
Objective To quantify the risk of incident diabetes mellitus (DM) associated with the dosage, duration, and timing of glucocorticoid (GC) use in patients with rheumatoid arthritis (RA). Methods We undertook a cohort study using 2 databases: a UK primary care database (the Clinical Practice Research Datalink [CPRD]) including 21,962 RA patients (1992–2009) and the US National Data Bank for Rheumatic Diseases (NDB) including 12,657 RA patients (1998–2013). Information on the dosage and timing of GC use was extracted. DM in the CPRD was defined using Read codes, at least 2 prescriptions for oral antidiabetic medication, or abnormal blood test results. DM in the NDB was defined through patient self‐reports. Data were analyzed using time‐dependent Cox models and a novel weighted cumulative dose (WCD) model that accounts for dosage, duration, and timing of treatment. Results The hazard ratio (HR) was 1.30 (95% confidence interval [95% CI] 1.17–1.45) and 1.61 (95% CI 1.37–1.89) in current GC users compared to nonusers in the CPRD and the NDB, respectively. A range of conventional statistical models consistently confirmed increases in risk with the GC dosage and duration. The WCD model showed that recent GC use contributed the most to the current risk of DM, while doses taken >6 months previously did not influence current risk. In the CPRD, 5 mg of prednisolone equivalent dose for the last 1, 3, and 6 months was significantly associated with HRs of 1.20, 1.43, and 1.48, respectively, compared to nonusers. Conclusion GC use is a clinically important and quantifiable risk factor for DM. Risk is influenced by the dosage and treatment duration, although only for GC use within the last 6 months.
Collapse
Affiliation(s)
- Mohammad Movahedi
- Manchester Academic Health Science Centre and University of Manchester, Manchester, UK
| | | | - Michal Abrahamowicz
- McGill University Health Centre and McGill University, Montreal, Quebec, Canada
| | - David W Ray
- Manchester Academic Health Science Centre and University of Manchester, Manchester, UK
| | - Kaleb Michaud
- National Data Bank for Rheumatic Diseases, Wichita, Kansas, and University of Nebraska Medical Center and Omaha VA Medical Center, Omaha
| | - Sofia Pedro
- National Data Bank for Rheumatic Diseases, Wichita, Kansas
| | - William G Dixon
- Manchester Academic Health Science Centre and University of Manchester, Manchester, UK
| |
Collapse
|
57
|
Hung YM, Lin L, Chen CM, Chiou JY, Wang YH, Wang PYP, Wei JCC. The effect of anti-rheumatic medications for coronary artery diseases risk in patients with rheumatoid arthritis might be changed over time: A nationwide population-based cohort study. PLoS One 2017; 12:e0179081. [PMID: 28658301 PMCID: PMC5489160 DOI: 10.1371/journal.pone.0179081] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 05/23/2017] [Indexed: 01/14/2023] Open
Abstract
Objectives To determine whether anti-rheumatic drug usage is associated with risk of coronary artery diseases (CAD) in incident Rheumatoid Arthritis (RA) patients. Methods Data were obtained from the Taiwan National Health Insurance Research Database. The study cohort comprised 6260 patients who were newly diagnosed with RA between 2001–2010. The study endpoint was occurrence of CAD according to the ICD-9-CM codes. We used the WHO Defined Daily Dose (DDD) as a tool to assess the drugs exposure. The Cox proportional hazards regression model was used to estimate the hazard ratio (HR) of disease after controlling for demographic and other co-morbidities. When the proportionality assumption is violated, a spline curve of the Scaled Schoenfeld residuals is fitted to demonstrate the estimated effect on CAD over time for drug usage. Results Among RA patients, use of celecoxib, and etoricoxib was associated with significantly decreased incidence of CAD. The adjusted HR(95% CI) of CAD for low-dose celecoxib (DDD≦1) and high-dose user were 0.47(0.34, 0.65) and 0.37(0.24, 0.58) during the 4 year follow-up time; however, it became 0.98(0.70, 1.37) and1.29(0.85, 1.95). Adjusted HR(95% CI) of CAD for etoricoxib users remained 0.47(0.26, 0.84). Conclusions This study revealed association of decreased CAD risk in RA patients taking 2 different kinds of COX-2i in comparison with nonusers. The effect might be changed over time, after about 4 years.
Collapse
Affiliation(s)
- Yao-Min Hung
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Institute of Public Health, School of Medicine, National Yang Ming University, Taipei, Taiwan
- Yuhing Junior College of Health Care and Management, Kaohsiung, Taiwan
| | - Lichi Lin
- Department of Statistics, Oklahoma state University, Stillwater, OK, United States of America
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, and Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chyong-Mei Chen
- Institute of Public Health, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Jeng-Yuan Chiou
- School of Health Policy and Management, Chung Shan Medical University, Taichung, Taiwan
- * E-mail: (JC-CW); (J-YC)
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University, Taichung, Taiwan
| | - Paul Yung-Pou Wang
- Division of Nephrology, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, CA, United States of America
| | - James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, and Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
- * E-mail: (JC-CW); (J-YC)
| |
Collapse
|
58
|
Williams R, Kontopantelis E, Buchan I, Peek N. Clinical code set engineering for reusing EHR data for research: A review. J Biomed Inform 2017; 70:1-13. [PMID: 28442434 DOI: 10.1016/j.jbi.2017.04.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/21/2017] [Accepted: 04/13/2017] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The construction of reliable, reusable clinical code sets is essential when re-using Electronic Health Record (EHR) data for research. Yet code set definitions are rarely transparent and their sharing is almost non-existent. There is a lack of methodological standards for the management (construction, sharing, revision and reuse) of clinical code sets which needs to be addressed to ensure the reliability and credibility of studies which use code sets. OBJECTIVE To review methodological literature on the management of sets of clinical codes used in research on clinical databases and to provide a list of best practice recommendations for future studies and software tools. METHODS We performed an exhaustive search for methodological papers about clinical code set engineering for re-using EHR data in research. This was supplemented with papers identified by snowball sampling. In addition, a list of e-phenotyping systems was constructed by merging references from several systematic reviews on this topic, and the processes adopted by those systems for code set management was reviewed. RESULTS Thirty methodological papers were reviewed. Common approaches included: creating an initial list of synonyms for the condition of interest (n=20); making use of the hierarchical nature of coding terminologies during searching (n=23); reviewing sets with clinician input (n=20); and reusing and updating an existing code set (n=20). Several open source software tools (n=3) were discovered. DISCUSSION There is a need for software tools that enable users to easily and quickly create, revise, extend, review and share code sets and we provide a list of recommendations for their design and implementation. CONCLUSION Research re-using EHR data could be improved through the further development, more widespread use and routine reporting of the methods by which clinical codes were selected.
Collapse
Affiliation(s)
- Richard Williams
- MRC Health eResearch Centre, University of Manchester, Manchester, UK; NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester, UK.
| | - Evangelos Kontopantelis
- MRC Health eResearch Centre, University of Manchester, Manchester, UK; NIHR School for Primary Care Research, University of Manchester, Manchester, UK
| | - Iain Buchan
- MRC Health eResearch Centre, University of Manchester, Manchester, UK; NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester, UK; NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Niels Peek
- MRC Health eResearch Centre, University of Manchester, Manchester, UK; NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| |
Collapse
|
59
|
Ehrmann Feldman D, Vinet É, Sylvestre MP, Hazel B, Duffy C, Bérard A, Meshefedjian G, Bernatsky S. Postpartum complications in new mothers with juvenile idiopathic arthritis: a population-based cohort study. Rheumatology (Oxford) 2017; 56:1378-1385. [DOI: 10.1093/rheumatology/kex168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Indexed: 11/13/2022] Open
|
60
|
Durán J, Peloquin C, Zhang Y, Felson DT. Primary Prevention of Myocardial Infarction in Rheumatoid Arthritis Using Aspirin: A Case-crossover Study and a Propensity Score–matched Cohort Study. J Rheumatol 2017; 44:418-424. [DOI: 10.3899/jrheum.160930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2017] [Indexed: 11/22/2022]
Abstract
Objective.Subjects with rheumatoid arthritis (RA) are at higher risk of developing cardiovascular disease, which is their leading cause of death. Conflicting evidence exists regarding the efficacy of aspirin (ASA) as primary prevention. We evaluated whether a protective association exists between ASA and myocardial infarction (MI) in RA subjects.Methods.In the United Kingdom, persons age ≥ 60 years receive free ASA by prescription and 75% of use is by prescription. Subjects ≥ 60 years with RA in the population-based The Health Improvement Network database constituted our study population. We excluded patients with history of MI, angina, stroke, peripheral vascular disease, or coronary artery procedures. Our main outcome was the occurrence of fatal and nonfatal MI. We performed a case-crossover study with each subject contributing a hazard period and a control period 90 days prior to the MI. In addition, to minimize confounding by indication, a propensity score (PS)–matched cohort study was performed, considering all patients with RA with an incident prescription of low-dose ASA as our exposed group.Results.We did not find a protective effect in the case-crossover study (OR 1.83, 95% CI 0.71–4.71), with 55 subjects exposed in the hazard period and 44 in the control period. Similarly, among 1836 subjects included in the PS-matched cohort study (918 ASA users and 918 ASA non-users), we did not find a protective effect of low ASA on MI (HR 1.39, 95% CI 0.87–2.23).Conclusion.We did not find a protective effect of ASA on MI in patients with RA when used as primary prophylaxis.
Collapse
|
61
|
Datta-Nemdharry P, Thomson A, Beynon J. Opportunities and Challenges in Developing a Cohort of Patients with Type 2 Diabetes Mellitus Using Electronic Primary Care Data. PLoS One 2016; 11:e0162236. [PMID: 27861488 PMCID: PMC5115653 DOI: 10.1371/journal.pone.0162236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/20/2016] [Indexed: 11/24/2022] Open
Abstract
Purpose To develop a cohort of patients with T2DM treated with insulin using CPRD to obtain an accurate diagnosis date. This was used to analyse time from T2DM diagnosis to first ever insulin prescription between 01/01/2000 and 30/06/2012, for patients in England and Wales. Methods Patients aged 18 years and over at diagnosis, were included if prescribed an anti-diabetic drug and were excluded if first diagnosis-specific code was inconsistent with a T2DM diagnosis. Diagnosis codes were split into 8 categories based on whether they related to specific T2DM or non-specific diabetes codes. Patients were excluded if they had non-specific diagnosis codes and were prescribed insulin as their first-ever treatment for diabetes. Descriptive statistics for time from T2DM diagnosis to insulin initiation were calculated. Results Two hundred and fifty-six codes were identified which were consistent with a first-ever diagnosis of T2DM. 7 codes were considered to clearly define a diagnosis of T2DM, which were reported for 64% of patients. The final cohort comprised 11,917 patients and the median time to first insulin prescription from the date of diagnosis was 4.4 years. Conclusions A clear definition of cohort development is required to compare and interpret results from studies. Use of diagnosis and product codes is essential when examining use of drugs such as insulin, where competing diagnoses need to be considered separately.
Collapse
Affiliation(s)
- Preeti Datta-Nemdharry
- Vigilance and Risk Management of Medicines (VRMM), MHRA, Victoria, London SW1W 9SZ, United Kingdom
| | - Andrew Thomson
- Vigilance and Risk Management of Medicines (VRMM), MHRA, Victoria, London SW1W 9SZ, United Kingdom
| | - Julie Beynon
- Vigilance and Risk Management of Medicines (VRMM), MHRA, Victoria, London SW1W 9SZ, United Kingdom
| |
Collapse
|
62
|
Crooks CJ, Card TR, West J. The Use of a Bayesian Hierarchy to Develop and Validate a Co-Morbidity Score to Predict Mortality for Linked Primary and Secondary Care Data from the NHS in England. PLoS One 2016; 11:e0165507. [PMID: 27788230 PMCID: PMC5082800 DOI: 10.1371/journal.pone.0165507] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 10/13/2016] [Indexed: 11/25/2022] Open
Abstract
Background We have assessed whether the linkage between routine primary and secondary care records provided an opportunity to develop an improved population based co-morbidity score with the combined information on co-morbidities from both health care settings. Methods We extracted all people older than 20 years at the start of 2005 within the linkage between the Hospital Episodes Statistics, Clinical Practice Research Datalink, and Office for National Statistics death register in England. A random 50% sample was used to identify relevant diagnostic codes using a Bayesian hierarchy to share information between similar Read and ICD 10 code groupings. Internal validation of the score was performed in the remaining 50% and discrimination was assessed using Harrell’s C statistic. Comparisons were made over time, age, and consultation rate with the Charlson and Elixhauser indexes. Results 657,264 people were followed up from the 1st January 2005. 98 groupings of codes were derived from the Bayesian hierarchy, and 37 had an adjusted weighting of greater than zero in the Cox proportional hazards model. 11 of these groupings had a different weighting dependent on whether they were coded from hospital or primary care. The C statistic reduced from 0.88 (95% confidence interval 0.88–0.88) in the first year of follow up, to 0.85 (0.85–0.85) including all 5 years. When we stratified the linked score by consultation rate the association with mortality remained consistent, but there was a significant interaction with age, with improved discrimination and fit in those under 50 years old (C = 0.85, 0.83–0.87) compared to the Charlson (C = 0.79, 0.77–0.82) or Elixhauser index (C = 0.81, 0.79–0.83). Conclusions The use of linked population based primary and secondary care data developed a co-morbidity score that had improved discrimination, particularly in younger age groups, and had a greater effect when adjusting for co-morbidity than existing scores.
Collapse
Affiliation(s)
- Colin J. Crooks
- Division of Epidemiology and Public Health, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Nottingham, Nottinghamshire, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Unit in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre Campus, E Floor West Block, Derby Road, Nottingham, Nottinghamshire, United Kingdom
- * E-mail:
| | - Tim R. Card
- Division of Epidemiology and Public Health, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Nottingham, Nottinghamshire, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Unit in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre Campus, E Floor West Block, Derby Road, Nottingham, Nottinghamshire, United Kingdom
| | - Joe West
- Division of Epidemiology and Public Health, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Nottingham, Nottinghamshire, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Unit in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre Campus, E Floor West Block, Derby Road, Nottingham, Nottinghamshire, United Kingdom
| |
Collapse
|
63
|
Tascilar K, Dell'Aniello S, Hudson M, Suissa S. Statins and Risk of Rheumatoid Arthritis: A Nested Case-Control Study. Arthritis Rheumatol 2016; 68:2603-2611. [DOI: 10.1002/art.39774] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 05/26/2016] [Indexed: 12/29/2022]
Affiliation(s)
- Koray Tascilar
- Lady Davis Institute for Medical Research, Montreal, Quebec, Canada, and Istanbul University; Istanbul Turkey
| | | | - Marie Hudson
- Lady Davis Institute for Medical Research, Jewish General Hospital, and McGill University; Montreal Quebec Canada
| | - Samy Suissa
- Lady Davis Institute for Medical Research and McGill University; Montreal Quebec Canada
| |
Collapse
|
64
|
Joseph RM, Movahedi M, Dixon WG, Symmons DPM. Smoking-Related Mortality in Patients With Early Rheumatoid Arthritis: A Retrospective Cohort Study Using the Clinical Practice Research Datalink. Arthritis Care Res (Hoboken) 2016; 68:1598-1606. [PMID: 26990778 PMCID: PMC5091627 DOI: 10.1002/acr.22882] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 02/17/2016] [Accepted: 03/08/2016] [Indexed: 12/16/2022]
Abstract
Objective To investigate the association between smoking status and smoking cessation with mortality in patients with rheumatoid arthritis (RA). Methods An incident cohort of patients with RA was identified using the Clinical Practice Research Datalink, a database of UK primary care electronic medical records. Time‐varying smoking status, years of cessation, and amount smoked were determined from patients' medical records. The date and underlying cause of death were identified by linkage with Office for National Statistics records. The associations between smoking status and smoking cessation with all‐cause and cause‐specific mortality (circulatory disease, all cancers, lung cancer, respiratory disease, and respiratory infection) were investigated using adjusted Cox (all‐cause mortality) and Fine‐Gray (cause‐specific mortality) regression. Results The cohort comprised 5,677 patients (median age 61.4 years, 68% women), with 40% as never smokers, 34% former smokers, and 26% current smokers at baseline. Compared to never smoking, current smoking was associated with an increased risk of all‐cause mortality (hazard ratio 1.98 [95% confidence interval (95% CI) 1.56, 2.53]), and mortality due to circulatory disease (subdistribution hazard ratio [SHR] 1.96 [95% CI 1.33, 2.90]) and lung cancer (SHR 23.2 [95% CI 5.15, 105]). Each year of smoking cessation was associated with a decreased risk of all‐cause mortality (former heavy smokers SHR 0.85 [95% CI 0.77, 0.94], former light smokers SHR 0.90 [95% CI 0.84, 0.97]). Conclusion Current smoking is associated with an increased risk of all‐cause, cardiovascular, and lung cancer mortality in patients with RA. Each year of cessation is associated with a reduced risk of all‐cause mortality. This information may prove helpful in smoking cessation programs for patients with RA.
Collapse
Affiliation(s)
- Rebecca M Joseph
- NIHR Manchester Musculoskeletal Biomedical Research Centre, Central Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - Mohammad Movahedi
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | - William G Dixon
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | - Deborah P M Symmons
- NIHR Manchester Musculoskeletal Biomedical Research Centre, Central Manchester University Hospital NHS Foundation Trust, and Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK.
| |
Collapse
|
65
|
Ford E, Carroll J, Smith H, Davies K, Koeling R, Petersen I, Rait G, Cassell J. What evidence is there for a delay in diagnostic coding of RA in UK general practice records? An observational study of free text. BMJ Open 2016; 6:e010393. [PMID: 27354069 PMCID: PMC4932264 DOI: 10.1136/bmjopen-2015-010393] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES Much research with electronic health records (EHRs) uses coded or structured data only; important information captured in the free text remains unused. One dimension of EHR data quality assessment is 'currency' or timeliness, that is, data are representative of the patient state at the time of measurement. We explored the use of free text in UK general practice patient records to evaluate delays in recording of rheumatoid arthritis (RA) diagnosis. We also aimed to locate and quantify disease and diagnostic information recorded only in text. SETTING UK general practice patient records from the Clinical Practice Research Datalink. PARTICIPANTS 294 individuals with incident diagnosis of RA between 2005 and 2008; 204 women and 85 men, median age 63 years. PRIMARY AND SECONDARY OUTCOME MEASURES Assessment of (1) quantity and timing of text entries for disease-modifying antirheumatic drugs (DMARDs) as a proxy for the RA disease code, and (2) quantity, location and timing of free text information relating to RA onset and diagnosis. RESULTS Inflammatory markers, pain and DMARDs were the most common categories of disease information in text prior to RA diagnostic code; 10-37% of patients had such information only in text. Read codes associated with RA-related text included correspondence, general consultation and arthritis codes. 64 patients (22%) had DMARD text entries >14 days prior to RA code; these patients had more and earlier referrals to rheumatology, tests, swelling, pain and DMARD prescriptions, suggestive of an earlier implicit diagnosis than was recorded by the diagnostic code. CONCLUSIONS RA-related symptoms, tests, referrals and prescriptions were recorded in free text with 22% of patients showing strong evidence of delay in coding of diagnosis. Researchers using EHRs may need to mitigate for delayed codes by incorporating text into their case-ascertainment strategies. Natural language processing techniques have the capability to do this at scale.
Collapse
Affiliation(s)
- Elizabeth Ford
- Division of Primary Care and Public Health, Brighton and Sussex Medical School, Falmer, Brighton, UK
| | - John Carroll
- Department of Informatics, University of Sussex, Falmer, Brighton, UK
| | - Helen Smith
- Division of Primary Care and Public Health, Brighton and Sussex Medical School, Falmer, Brighton, UK
| | - Kevin Davies
- Division of Medicine, Brighton and Sussex Medical School, Falmer, Brighton, UK
| | - Rob Koeling
- Department of Informatics, University of Sussex, Falmer, Brighton, UK
| | - Irene Petersen
- Research Department of Primary Care and Population Health, UCL, London, UK
- Department of Clinical Epidemiology, Aarhus University, Denmark
| | - Greta Rait
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Jackie Cassell
- Division of Primary Care and Public Health, Brighton and Sussex Medical School, Falmer, Brighton, UK
| |
Collapse
|
66
|
Zhang Y, Lu N, Peloquin C, Dubreuil M, Neogi T, Aviña-Zubieta JA, Rai SK, Choi HK. Improved survival in rheumatoid arthritis: a general population-based cohort study. Ann Rheum Dis 2016; 76:408-413. [PMID: 27338777 DOI: 10.1136/annrheumdis-2015-209058] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 04/29/2016] [Accepted: 06/04/2016] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Mortality trends of rheumatoid arthritis (RA) are largely unknown over the past decade when new drugs and management strategies have been adopted to effectively treat RA. METHODS Using The Health Improvement Network, an electronic medical record database representative of the UK general population, we identified patients with incident RA and up to five individuals without RA matched for age, sex and year of diagnosis between 1999 and 2014. The RA cohort was divided in two sub-cohorts based on the year of RA diagnosis: the early cohort (1999-2006) and the late cohort (2007-2014). We compared mortality rates, HRs (using a Cox proportional hazard model) and rate differences (using an additive hazard model) between RA and non-RA cohorts adjusting for potential confounders. RESULTS Patients with RA diagnosed between 1999 and 2006 had a considerably higher mortality rate than their comparison cohort (ie, 29.1 vs 18.0 deaths/1000 person-years), as compared with a moderate difference in patients with RA diagnosed between 2007 and 2014 and their comparison cohort (17.0 vs 12.9 deaths/1000 years). The corresponding absolute mortality rate differences were 9.5 deaths/1000 person-years (95% CIs 7.5 to 11.6) and 3.1 deaths/1000 person-years (95% CI 1.5 to 4.6) and the mortality HRs were 1.56 (95% CI 1.44 to 1.69) and 1.29 (95% CI 1.17 to 1.42), respectively (both p values for interaction <0.01). CONCLUSION This general population-based cohort study indicates that the survival of patients with RA has improved over the past decade to a greater degree than in the general population. Improved management of RA and its associated comorbidities over recent years may be providing a survival benefit.
Collapse
Affiliation(s)
- Yuqing Zhang
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Na Lu
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Christine Peloquin
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Maureen Dubreuil
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Tuhina Neogi
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts, USA
| | - J Antonio Aviña-Zubieta
- Arthritis Research Canada, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sharan K Rai
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hyon K Choi
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts, USA.,Arthritis Research Canada, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
67
|
Oral glucocorticoid therapy and all-cause and cause-specific mortality in patients with rheumatoid arthritis: a retrospective cohort study. Eur J Epidemiol 2016; 31:1045-1055. [PMID: 27256352 PMCID: PMC5065607 DOI: 10.1007/s10654-016-0167-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 05/22/2016] [Indexed: 01/01/2023]
Abstract
Previous studies of glucocorticoid (GC) therapy and mortality have had inconsistent results and have not considered possible perimortal bias—a type of protopathic bias where illness in the latter stages of life influences GC exposure, and might affect the observed relationship between GC use and death. This study aimed to investigate all-cause and cause-specific mortality in association with GC therapy in patients with rheumatoid arthritis (RA), and explore possible perimortal bias. A retrospective cohort study using the primary care electronic medical records. Oral GC exposure was identified from prescriptions. Mortality data were obtained from the UK Office for National Statistics. Multivariable Cox proportional hazards regression models assessed the association between GC use models and death. Several methods to explore perimortal bias were examined. The cohort included 16,762 patients. For ever GC use there was an adjusted hazard ratio for all-cause mortality of 1.97 (95 % CI 1.81–2.15). Current GC dose of below 5 mg per day (prednisolone equivalent dose) was not associated with an increased risk of death, but a dose–response association was seen for higher dose categories. The association between ever GC use and all-cause mortality was partly explained by perimortal bias. GC therapy was associated with an increased risk of mortality for all specific causes considered, albeit to a lesser extent for cardiovascular causes. GC use was associated with an increased risk of death in RA, at least partially explained by perimortal bias. Importantly, GC doses below 5 mg were not associated with an increased risk of death.
Collapse
|
68
|
Zhou SM, Fernandez-Gutierrez F, Kennedy J, Cooksey R, Atkinson M, Denaxas S, Siebert S, Dixon WG, O’Neill TW, Choy E, Sudlow C, Brophy S. Defining Disease Phenotypes in Primary Care Electronic Health Records by a Machine Learning Approach: A Case Study in Identifying Rheumatoid Arthritis. PLoS One 2016; 11:e0154515. [PMID: 27135409 PMCID: PMC4852928 DOI: 10.1371/journal.pone.0154515] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/14/2016] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES 1) To use data-driven method to examine clinical codes (risk factors) of a medical condition in primary care electronic health records (EHRs) that can accurately predict a diagnosis of the condition in secondary care EHRs. 2) To develop and validate a disease phenotyping algorithm for rheumatoid arthritis using primary care EHRs. METHODS This study linked routine primary and secondary care EHRs in Wales, UK. A machine learning based scheme was used to identify patients with rheumatoid arthritis from primary care EHRs via the following steps: i) selection of variables by comparing relative frequencies of Read codes in the primary care dataset associated with disease case compared to non-disease control (disease/non-disease based on the secondary care diagnosis); ii) reduction of predictors/associated variables using a Random Forest method, iii) induction of decision rules from decision tree model. The proposed method was then extensively validated on an independent dataset, and compared for performance with two existing deterministic algorithms for RA which had been developed using expert clinical knowledge. RESULTS Primary care EHRs were available for 2,238,360 patients over the age of 16 and of these 20,667 were also linked in the secondary care rheumatology clinical system. In the linked dataset, 900 predictors (out of a total of 43,100 variables) in the primary care record were discovered more frequently in those with versus those without RA. These variables were reduced to 37 groups of related clinical codes, which were used to develop a decision tree model. The final algorithm identified 8 predictors related to diagnostic codes for RA, medication codes, such as those for disease modifying anti-rheumatic drugs, and absence of alternative diagnoses such as psoriatic arthritis. The proposed data-driven method performed as well as the expert clinical knowledge based methods. CONCLUSION Data-driven scheme, such as ensemble machine learning methods, has the potential of identifying the most informative predictors in a cost-effective and rapid way to accurately and reliably classify rheumatoid arthritis or other complex medical conditions in primary care EHRs.
Collapse
Affiliation(s)
- Shang-Ming Zhou
- Institute of Life Science, College of Medicine, Swansea University, Swansea, United Kingdom
| | | | - Jonathan Kennedy
- Institute of Life Science, College of Medicine, Swansea University, Swansea, United Kingdom
| | - Roxanne Cooksey
- Institute of Life Science, College of Medicine, Swansea University, Swansea, United Kingdom
| | - Mark Atkinson
- Institute of Life Science, College of Medicine, Swansea University, Swansea, United Kingdom
| | - Spiros Denaxas
- UCL Institute of Health Informatics and Farr Institute of Health Informatics Research, London, United Kingdom
| | - Stefan Siebert
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - William G. Dixon
- Arthritis Research UK Centre for Epidemiology, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Terence W. O’Neill
- Arthritis Research UK Centre for Epidemiology, Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Ernest Choy
- Arthritis Research UK CREATE Centre and Welsh Arthritis Research Network, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Cathie Sudlow
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Sinead Brophy
- Institute of Life Science, College of Medicine, Swansea University, Swansea, United Kingdom
| |
Collapse
|
69
|
Feldman DE, Vinet É, Bérard A, Duffy C, Hazel B, Meshefedjian G, Sylvestre MP, Bernatsky S. Heart Disease, Hypertension, Gestational Diabetes Mellitus, and Preeclampsia/Eclampsia in Mothers With Juvenile Arthritis: A Nested Case-Control Study. Arthritis Care Res (Hoboken) 2016; 69:306-309. [PMID: 27111101 DOI: 10.1002/acr.22925] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/04/2016] [Accepted: 04/19/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine whether women with a history of juvenile arthritis are at higher risk for heart disease and hypertension and for developing adverse maternal outcomes: gestational diabetes mellitus, maternal hypertension, and preeclampsia/eclampsia. METHODS We designed a nested case-control study from a cohort of first-time mothers with prior physician billing codes suggesting juvenile arthritis, and a matched comparison group without juvenile arthritis. For the nested case-control design, we selected 3 controls for each case for the outcomes of heart disease (n = 403), prepregnancy hypertension (n = 66), gestational diabetes mellitus (n = 285), maternal hypertension (n = 561), and preeclampsia/eclampsia (n = 236). We used conditional logistic regression, adjusting for maternal age and education. RESULTS Having juvenile arthritis was associated with heart disease (odds ratio [OR] 2.44 [95% confidence interval (95% CI) 1.15-5.15]) but not with gestational hypertension, diabetes mellitus, or preeclampsia/eclampsia. All 66 cases of prepregnancy hypertension had juvenile arthritis. Having prepregnancy hypertension was strongly associated with preeclampsia/eclampsia (OR 8.05 [95% CI 2.69-24.07]). CONCLUSION Women with a history of juvenile arthritis had a higher risk of heart disease. This risk signals the potential importance of cardiac prevention strategies in juvenile arthritis. As this was a retrospective study, it was not possible to correct for some relevant potential confounders. Further studies should assess the impact of medications, disease severity, and other factors (e.g., obesity) on cardiac outcomes in juvenile arthritis.
Collapse
Affiliation(s)
- Debbie E Feldman
- Université de Montréal and Centre de recherche interdisciplinaire en réadaptation de Montréal, Montreal, Canada
| | | | - Anick Bérard
- Université de Montréal and Centre de recherche CHU Ste-Justine, Montreal, Canada
| | - Ciarán Duffy
- Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Canada
| | - Beth Hazel
- McGill University Health Centre, Montreal, Canada
| | | | | | | |
Collapse
|
70
|
Costello R, Winthrop KL, Pye SR, Brown B, Dixon WG. Influenza and Pneumococcal Vaccination Uptake in Patients with Rheumatoid Arthritis Treated with Immunosuppressive Therapy in the UK: A Retrospective Cohort Study Using Data from the Clinical Practice Research Datalink. PLoS One 2016; 11:e0153848. [PMID: 27096429 PMCID: PMC4838312 DOI: 10.1371/journal.pone.0153848] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 04/05/2016] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Guidelines for the management of rheumatoid arthritis (RA) recommend using influenza and pneumococcal vaccinations to mitigate infection risk. The level of adherence to these guidelines is not well known in the UK. The aims of this study were to describe the uptake of influenza and pneumococcal vaccinations in patients with RA in the UK, to compare the characteristics of those vaccinated to those not vaccinated and to compare vaccination rates across regions of the UK. METHODS A retrospective cohort study of adults diagnosed with incident RA and treated with non-biologic immunosuppressive therapy, using data from a large primary care database. For the influenza vaccination, patients were considered unvaccinated on 1st September each year and upon vaccination their status changed to vaccinated. For pneumococcal vaccination, patients were considered vaccinated after their first vaccination until the end of follow-up. Patients were stratified by age 65 at the start of follow-up, given differences in vaccination guidelines for the general population. RESULTS Overall (N=15,724), 80% patients received at least one influenza vaccination, and 50% patients received a pneumococcal vaccination, during follow-up (mean 5.3 years). Of those aged below 65 years (N=9,969), 73% patients had received at least one influenza vaccination, and 43% patients received at least one pneumococcal vaccination. Of those aged over 65 years (N=5,755), 91% patients received at least one influenza vaccination, and 61% patients had received at least one pneumococcal vaccination. Those vaccinated were older, had more comorbidity and visited the GP more often. Regional differences in vaccination rates were seen with the highest rates in Northern Ireland, and the lowest rates in London. CONCLUSIONS One in five patients received no influenza vaccinations and one in two patients received no pneumonia vaccine over five years of follow-up. There remains significant scope to improve uptake of vaccinations in patients with RA.
Collapse
Affiliation(s)
- Ruth Costello
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom
- * E-mail:
| | - Kevin L. Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Stephen R. Pye
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom
| | - Benjamin Brown
- Health eResearch Centre, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom
| | - William G. Dixon
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom
- Health eResearch Centre, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom
| |
Collapse
|
71
|
Klop C, de Vries F, Bijlsma JWJ, Leufkens HGM, Welsing PMJ. Predicting the 10-year risk of hip and major osteoporotic fracture in rheumatoid arthritis and in the general population: an independent validation and update of UK FRAX without bone mineral density. Ann Rheum Dis 2016; 75:2095-2100. [PMID: 26984006 PMCID: PMC5136695 DOI: 10.1136/annrheumdis-2015-208958] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/13/2016] [Accepted: 02/28/2016] [Indexed: 01/11/2023]
Abstract
Objectives FRAX incorporates rheumatoid arthritis (RA) as a dichotomous predictor for predicting the 10-year risk of hip and major osteoporotic fracture (MOF). However, fracture risk may deviate with disease severity, duration or treatment. Aims were to validate, and if needed to update, UK FRAX for patients with RA and to compare predictive performance with the general population (GP). Methods Cohort study within UK Clinical Practice Research Datalink (CPRD) (RA: n=11 582, GP: n=38 755), also linked to hospital admissions for hip fracture (CPRD-Hospital Episode Statistics, HES) (RA: n=7221, GP: n=24 227). Predictive performance of UK FRAX without bone mineral density was assessed by discrimination and calibration. Updating methods included recalibration and extension. Differences in predictive performance were assessed by the C-statistic and Net Reclassification Improvement (NRI) using the UK National Osteoporosis Guideline Group intervention thresholds. Results UK FRAX significantly overestimated fracture risk in patients with RA, both for MOF (mean predicted vs observed 10-year risk: 13.3% vs 8.4%) and hip fracture (CPRD: 5.5% vs 3.1%, CPRD-HES: 5.5% vs 4.1%). Calibration was good for hip fracture in the GP (CPRD-HES: 2.7% vs 2.4%). Discrimination was good for hip fracture (RA: 0.78, GP: 0.83) and moderate for MOF (RA: 0.69, GP: 0.71). Extension of the recalibrated UK FRAX using CPRD-HES with duration of RA disease, glucocorticoids (>7.5 mg/day) and secondary osteoporosis did not improve the NRI (0.01, 95% CI −0.04 to 0.05) or C-statistic (0.78). Conclusions UK FRAX overestimated fracture risk in RA, but performed well for hip fracture in the GP after linkage to hospitalisations. Extension of the recalibrated UK FRAX did not improve predictive performance.
Collapse
Affiliation(s)
- Corinne Klop
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Frank de Vries
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, UK.,Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Epidemiology, Maastricht University/CAPHRI, Maastricht, The Netherlands
| | - Johannes W J Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center, Utrecht, The Netherlands
| | - Hubert G M Leufkens
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Paco M J Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center, Utrecht, The Netherlands.,Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| |
Collapse
|
72
|
Pujades-Rodriguez M, Duyx B, Thomas SL, Stogiannis D, Rahman A, Smeeth L, Hemingway H. Rheumatoid Arthritis and Incidence of Twelve Initial Presentations of Cardiovascular Disease: A Population Record-Linkage Cohort Study in England. PLoS One 2016; 11:e0151245. [PMID: 26978266 PMCID: PMC4792375 DOI: 10.1371/journal.pone.0151245] [Citation(s) in RCA: 274] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 02/25/2016] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION While rheumatoid arthritis is an established risk factor for cardiovascular disease (CVD), our knowledge of how the pattern of risk varies for different cardiovascular phenotypes is incomplete. The association between rheumatoid arthritis and the initial presentation of 12 types of CVDs were examined in a contemporary population of men and women of a wide age range. METHODS CALIBER data, which links primary care, hospital and mortality data in England, was analysed. A cohort of people aged ≥18 years and without history of CVD was assembled and included all patients with prospectively recorded rheumatoid arthritis from January 1997, until March 2010, matched with up to ten people without rheumatoid arthritis by age, sex and general practice. The associations between rheumatoid arthritis and the initial presentation of 12 types of CVDs were estimated using multivariable random effects Poisson regression models. RESULTS The analysis included 12,120 individuals with rheumatoid arthritis and 121,191 comparators. Of these, 2,525 patients with and 18,146 without rheumatoid arthritis developed CVDs during a median of 4.2 years of follow-up. Patients with rheumatoid arthritis had higher rates of myocardial infarction (adjusted incidence ratio [IRR] = 1.43, 95%CI 1.21-1.70), unheralded coronary death (IRR = 1.60, 95%CI 1.18-2.18), heart failure (IRR = 1.61, 95%CI 1.43-1.83), cardiac arrest (HR = 2.26, 95%CI 1.69-3.02) and peripheral arterial disease (HR = 1.36, 95%CI 1.14-1.62); and lower rates of stable angina (HR = 0.83, 95%CI 0.73-0.95). There was no evidence of association with cerebrovascular diseases, abdominal aortic aneurysm or unstable angina, or of interactions with sex or age. CONCLUSIONS The observed associations with some but not all types of CVDs inform both clinical practice and the selection of cardiovascular endpoints for trials and for the development of prognostic models for patients with rheumatoid arthritis.
Collapse
Affiliation(s)
- Mar Pujades-Rodriguez
- Farr Institute of Health Informatics Research, University College London, 222 Euston Road, London NW1 2DA, United Kingdom.,Leeds Institute of Biomedical and Clinical Sciences, MRC Medical Bioinformatics Centre, Worsley Building, University of Leeds, Leeds LS2 9JT, United Kingdom
| | - Bram Duyx
- Farr Institute of Health Informatics Research, University College London, 222 Euston Road, London NW1 2DA, United Kingdom
| | - Sara L Thomas
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Dimitris Stogiannis
- Farr Institute of Health Informatics Research, University College London, 222 Euston Road, London NW1 2DA, United Kingdom
| | - Anisur Rahman
- Centre of Rheumatology Research, Division of Medicine, Faculty of Medical Sciences, University College London, London WC1E 6JF, United Kingdom
| | - Liam Smeeth
- Farr Institute of Health Informatics Research, University College London, 222 Euston Road, London NW1 2DA, United Kingdom.,Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Harry Hemingway
- Farr Institute of Health Informatics Research, University College London, 222 Euston Road, London NW1 2DA, United Kingdom
| |
Collapse
|
73
|
Alemao E, Cawston H, Bourhis F, Al M, Rutten-van Mölken MPMH, Liao KP, Solomon DH. Cardiovascular risk factor management in patients with RA compared to matched non-RA patients. Rheumatology (Oxford) 2015; 55:809-16. [PMID: 26705329 PMCID: PMC4830910 DOI: 10.1093/rheumatology/kev427] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Indexed: 11/16/2022] Open
Abstract
Objective. RA is associated with a 50–60% increase in risk of cardiovascular (CV) death. This study aimed to compare management of CV risk factors in RA and matched non-RA patients. Methods. A retrospective cohort study was conducted using UK clinical practice data. Patients presenting with an incident RA diagnosis were matched 1:4 to non-RA patients based on a propensity score for RA, entry year, CV risk category and treatment received at index date (date of RA diagnosis). Patients tested and treated for CV risk factors as well as those attaining CV risk factor management goals were evaluated in both groups. Results. Between 1987 and 2010, 24 859 RA patients were identified and matched to 87 304 non-RA patients. At index date, groups had similar baseline characteristics. Annual blood pressure, lipids and diabetes-related testing were similar in both groups, although CRP and ESR were higher in RA patients at diagnosis and decreased over time. RA patients prescribed antihypertensives increased from 38.2% at diagnosis to 45.7% at 5 years, from 14.0 to 20.6% for lipid-lowering treatments and from 5.1 to 6.4% for antidiabetics. Similar treatment percentages were observed in non-RA patients, although slightly lower for antihypertensives. Modest (2%) but significantly lower attainment of lipid and diabetes goals at 1 year was observed in RA patients. Conclusion. There were no differences between groups in the frequency of testing and treatment of CV risk factors. Higher CV risk in RA patients seems unlikely to be driven by differences in traditional CV risk factor management.
Collapse
Affiliation(s)
- Evo Alemao
- Global Health Economics & Outcomes Research, Bristol-Myers Squibb, Princeton, NJ, USA,
| | | | | | - Maiwenn Al
- Erasmus University Rotterdam, Institute of Medical Technology Assessment and Institute of Health Policy and Management, The Netherlands and
| | - Maureen P M H Rutten-van Mölken
- Erasmus University Rotterdam, Institute of Medical Technology Assessment and Institute of Health Policy and Management, The Netherlands and
| | - Katherine P Liao
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel H Solomon
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
74
|
Black RJ, Joseph RM, Brown B, Movahedi M, Lunt M, Dixon WG. Half of U.K. patients with rheumatoid arthritis are prescribed oral glucocorticoid therapy in primary care: a retrospective drug utilisation study. Arthritis Res Ther 2015; 17:375. [PMID: 26702817 PMCID: PMC4718024 DOI: 10.1186/s13075-015-0895-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/10/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patients with rheumatoid arthritis (RA) have shared care between rheumatologists and general practitioners (GPs). Rheumatologists guide immunosuppressive therapy, whilst GPs rely on analgesia and glucocorticoid (GC) therapy to manage active disease. The objective of this study was to describe patterns of GC prescribing for patients with RA in primary care and to determine the influence of patient characteristics and prescriber. METHODS Incident RA patients were identified within the Clinical Practice Research Datalink, a United Kingdom (UK) primary care research database. Descriptive statistics identified patterns of oral GC prescribing. Prescribers were categorised by their tendency to prescribe GCs (high/low). Logistic regression was used to identify baseline characteristics associated with GC prescriptions during follow-up and to examine whether baseline characteristics influenced prescribing differently in high versus low prescribers. RESULTS A total of 7777 patients (47%) received ≥1 GC prescription during follow-up. The average daily dose was 7.5 mg (IQR 5-15.3 mg). Of those who received GCs, >50% were prescribed >10 mg/day and 20 % >30 mg/day. The median proportion of time spent on GCs was 26.3% (IQR 3.8-70.0%). Age and cardiovascular disease (CVD) were associated with increased likelihood of receiving GCs. High prescribers more commonly prescribed GC therapy in older patients and patients with hypertension. CONCLUSIONS Half of patients with incident RA received GCs in primary care. Average GC use was 7.5 mg for 25% of the time, perhaps higher usage than rheumatologists and GPs might expect. GCs were prescribed more commonly in certain high-risk populations, including older patients and those with CVD.
Collapse
Affiliation(s)
- Rachel J Black
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK. .,Department of Medicine, The University of Adelaide, Adelaide, SA, 5005, Australia. .,Department of Rheumatology, The Basil Hetzel Institute for Translational Health Research, Woodville Rd, Woodville South, SA, 5011, Australia.
| | - Rebecca M Joseph
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK. .,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, 29 Grafton Street, Manchester, M13 9WU, UK.
| | - Benjamin Brown
- Health e-Research Centre, Farr Institute for Health Informatics Research, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PL, UK.
| | - Mohammad Movahedi
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK.
| | - Mark Lunt
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK.
| | - William G Dixon
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PT, UK. .,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, 29 Grafton Street, Manchester, M13 9WU, UK. .,Health e-Research Centre, Farr Institute for Health Informatics Research, Manchester Academic Health Science Centre, The University of Manchester, Oxford Rd, Manchester, M13 9PL, UK. .,Department of Rheumatology, Salford Royal NHS Foundation Trust , Stott Lane, Salford, M6 8HD, UK.
| |
Collapse
|
75
|
Muller S, Hider SL, Raza K, Stack RJ, Hayward RA, Mallen CD. An algorithm to identify rheumatoid arthritis in primary care: a Clinical Practice Research Datalink study. BMJ Open 2015; 5:e009309. [PMID: 26700281 PMCID: PMC4691776 DOI: 10.1136/bmjopen-2015-009309] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Rheumatoid arthritis (RA) is a multisystem, inflammatory disorder associated with increased levels of morbidity and mortality. While much research into the condition is conducted in the secondary care setting, routinely collected primary care databases provide an important source of research data. This study aimed to update an algorithm to define RA that was previously developed and validated in the General Practice Research Database (GPRD). METHODS The original algorithm consisted of two criteria. Individuals meeting at least one were considered to have RA. Criterion 1: ≥ 1 RA Read code and a disease modifying antirheumatic drug (DMARD) without an alternative indication. Criterion 2: ≥ 2 RA Read codes, with at least one 'strong' code and no alternative diagnoses. Lists of codes for consultations and prescriptions were obtained from the authors of the original algorithm where these were available, or compiled based on the original description and clinical knowledge. 4161 people with a first Read code for RA between 1 January 2010 and 31 December 2012 were selected from the Clinical Practice Research Datalink (CPRD, successor to the GPRD), and the criteria applied. RESULTS Code lists were updated for the introduction of new Read codes and biological DMARDs. 3577/4161 (86%) of people met the updated algorithm for RA, compared to 61% in the original development study. 62.8% of people fulfilled both Criterion 1 and Criterion 2. CONCLUSIONS Those wishing to define RA in the CPRD, should consider using this updated algorithm, rather than a single RA code, if they wish to identify only those who are most likely to have RA.
Collapse
Affiliation(s)
- Sara Muller
- Arthritis Research UK Primary Care Centre, Institute for Primary Care & Health Sciences, Keele University, Keele, UK
| | - Samantha L Hider
- Arthritis Research UK Primary Care Centre, Institute for Primary Care & Health Sciences, Keele University, Keele, UK
| | - Karim Raza
- Centre for Translational Inflammation Research, School of Immunity and Infection, University of Birmingham, Birmingham, UK
- Department of Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Rebecca J Stack
- Centre for Translational Inflammation Research, School of Immunity and Infection, University of Birmingham, Birmingham, UK
| | - Richard A Hayward
- Arthritis Research UK Primary Care Centre, Institute for Primary Care & Health Sciences, Keele University, Keele, UK
| | - Christian D Mallen
- Arthritis Research UK Primary Care Centre, Institute for Primary Care & Health Sciences, Keele University, Keele, UK
| |
Collapse
|
76
|
Schoenfeld SR, Lu L, Rai SK, Seeger JD, Zhang Y, Choi HK. Statin use and mortality in rheumatoid arthritis: a general population-based cohort study. Ann Rheum Dis 2015; 75:1315-20. [PMID: 26245753 DOI: 10.1136/annrheumdis-2015-207714] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/20/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Dual lipid-lowering and anti-inflammatory properties of statins may lead to survival benefits in patients with rheumatoid arthritis (RA). However, data on this topic are limited, and the role of statins in RA remains unclear. OBJECTIVES To examine the association of statin use with overall mortality among patients with RA in a general population context. METHODS We conducted an incident user cohort study with time-stratified propensity score matching using a UK general population database. The study population included individuals aged ≥20 years who had a diagnosis of RA and had used at least one disease-modifying antirheumatic drug (DMARD) between January 2000 and December 2012. To closely account for potential confounders, we compared propensity score matched cohorts of statin initiators and comparators (non-initiators) within 1-year cohort accrual blocks. RESULTS 432 deaths occurred during follow-up (mean 4.51 years) of the 2943 statin initiators for an incidence rate of 32.6/1000 person-years (PY), while the 513 deaths among 2943 matched comparators resulted in an incidence rate of 40.6/1000 PY. Baseline characteristics were well-balanced across the two groups. Statin initiation was associated with a 21% lower risk of all-cause mortality (HR=0.79, 95% CI 0.68 to 0.91). When we defined RA by its diagnosis code alone (not requiring DMARD use), the corresponding HR was 0.81 (95% CI 0.74 to 0.90). CONCLUSIONS Statin initiation is associated with a lower risk of mortality among patients with RA. The magnitude of association is similar to that seen in previous randomised trials among the general population.
Collapse
Affiliation(s)
- Sara R Schoenfeld
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leo Lu
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA Clinical Epidemiology Unit, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sharan K Rai
- Arthritis Research Centre of Canada, University of British Columbia, Vancouver, British Columbia, Canada
| | - John D Seeger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusettes, USA
| | - Yuqing Zhang
- Clinical Epidemiology Unit, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Hyon K Choi
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA Clinical Epidemiology Unit, Boston University School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
77
|
Judge A, Wallace G, Prieto-Alhambra D, Arden NK, Edwards CJ. Can the publication of guidelines change the management of early rheumatoid arthritis? An interrupted time series analysis from the United Kingdom. Rheumatology (Oxford) 2015; 54:2244-8. [PMID: 26242858 DOI: 10.1093/rheumatology/kev268] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To assess whether publication of national treatment guidelines improved the management of early RA in the UK. METHODS Incident diagnoses of RA in persons aged over 18 years from 1995 to 2010 were identified from the Clinical Practice Research Datalink. Using a natural experimental study design, interrupted time series analysis was used to assess whether trends in the proportion of patients receiving DMARDs, within 3 and 12 months of diagnosis, changed following publication of British Society for Rheumatology guidelines in 2006. RESULTS Between 1995 and 2010, 11 772 incident cases of RA were identified. There was a progressive increase in the proportion of patients prescribed any DMARD within 12 months from 43.3% in 1995 to 78.5% in 2010. After publication of the British Society for Rheumatology guidelines, the proportion of patients prescribed any DMARD within 12 months increased by 4.2% (P = 0.053). Prior to the guidance, prescribing was increasing by 1.64% per year, compared with 3.55% per year after publication (P < 0.001). CONCLUSION Guidelines published by a national body can improve the proportion of patients receiving DMARD treatment in the first year after diagnosis of RA.
Collapse
Affiliation(s)
- Andrew Judge
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital,
| | - Gemma Wallace
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford
| | - Dani Prieto-Alhambra
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital
| | - Nigel K Arden
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital
| | - Christopher J Edwards
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, Department of Rheumatology, University Hospital Southampton NHS Foundation Trust and NIHR Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK
| |
Collapse
|
78
|
Horton DB, Scott FI, Haynes K, Putt ME, Rose CD, Lewis JD, Strom BL. Antibiotic Exposure and Juvenile Idiopathic Arthritis: A Case-Control Study. Pediatrics 2015; 136. [PMID: 26195533 PMCID: PMC4516942 DOI: 10.1542/peds.2015-0036] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Recent evidence has linked childhood antibiotic use and microbiome disturbance to autoimmune conditions. This study tested the hypothesis that antibiotic exposure was associated with newly diagnosed juvenile idiopathic arthritis (JIA). METHODS We performed a nested case-control study in a population-representative medical records database from the United Kingdom. Children with newly diagnosed JIA were compared with age- and gender-matched control subjects randomly selected from general practices containing at least 1 case, excluding those with inflammatory bowel disease, immunodeficiency, or other systemic rheumatic diseases. Conditional logistic regression was used to examine the association between antibacterial antibiotics (including number of antibiotic courses and timing) and JIA after adjusting for significant confounders. RESULTS Any antibiotic exposure was associated with an increased rate of developing JIA (adjusted odds ratio: 2.1 [95% confidence interval: 1.2-3.5]). This relationship was dose dependent (adjusted odds ratio over 5 antibiotic courses: 3.0 [95% confidence interval: 1.6-5.6]), strongest for exposures within 1 year of diagnosis, and did not substantively change when adjusting for number or type of infections. In contrast, nonbacterial antimicrobial agents (eg, antifungal, antiviral) were not associated with JIA. In addition, antibiotic-treated upper respiratory tract infections were more strongly associated with JIA than untreated upper respiratory tract infections. CONCLUSIONS Antibiotics were associated with newly diagnosed JIA in a dose- and time-dependent fashion in a large pediatric population. Antibiotic exposure may play a role in JIA pathogenesis, perhaps mediated through alterations in the microbiome.
Collapse
Affiliation(s)
- Daniel B. Horton
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania;,Division of Rheumatology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Frank I. Scott
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania;,Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin Haynes
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania;,Clinical Epidemiology, HealthCore, Wilmington, Delaware; and
| | - Mary E. Putt
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carlos D. Rose
- Division of Rheumatology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - James D. Lewis
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania;,Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian L. Strom
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania;,Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey
| |
Collapse
|
79
|
Miller A, Nightingale AL, Sammon CJ, Mahtani KR, Holt TA, McHugh NJ, Luqmani RA. Estimating the diagnostic accuracy of rheumatoid factor in UK primary care: a study using the Clinical Practice Research Datalink. Rheumatology (Oxford) 2015; 54:1882-9. [DOI: 10.1093/rheumatology/kev131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Indexed: 11/13/2022] Open
|
80
|
Carrara G, Scirè CA, Zambon A, Cimmino MA, Cerra C, Caprioli M, Cagnotto G, Nicotra F, Arfè A, Migliazza S, Corrao G, Minisola G, Montecucco C. A validation study of a new classification algorithm to identify rheumatoid arthritis using administrative health databases: case-control and cohort diagnostic accuracy studies. Results from the RECord linkage On Rheumatic Diseases study of the Italian Society for Rheumatology. BMJ Open 2015; 5:e006029. [PMID: 25631308 PMCID: PMC4316439 DOI: 10.1136/bmjopen-2014-006029] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To develop and validate a new algorithm to identify patients with rheumatoid arthritis (RA) and estimate disease prevalence using administrative health databases (AHDs) of the Italian Lombardy region. DESIGN Case-control and cohort diagnostic accuracy study. METHODS In a randomly selected sample of 827 patients drawn from a tertiary rheumatology centre (training set), clinically validated diagnoses were linked to administrative data including diagnostic codes and drug prescriptions. An algorithm in steps of decreasing specificity was developed and its accuracy assessed calculating sensitivity/specificity, positive predictive value (PPV)/negative predictive value, with corresponding CIs. The algorithm was applied to two validating sets: 106 patients from a secondary rheumatology centre and 6087 participants from the primary care. Alternative algorithms were developed to increase PPV at population level. Crude and adjusted prevalence estimates taking into account algorithm misclassification rates were obtained for the Lombardy region. RESULTS The algorithms included: RA certification by a rheumatologist, certification for other autoimmune diseases by specialists, RA code in the hospital discharge form, prescription of disease-modifying antirheumatic drugs and oral glucocorticoids. In the training set, a four-step algorithm identified clinically diagnosed RA cases with a sensitivity of 96.3 (95% CI 93.6 to 98.2) and a specificity of 90.3 (87.4 to 92.7). Both external validations showed highly consistent results. More specific algorithms achieved >80% PPV at the population level. The crude RA prevalence in Lombardy was 0.52%, and estimates adjusted for misclassification ranged from 0.31% (95% CI 0.14% to 0.42%) to 0.37% (0.25% to 0.47%). CONCLUSIONS AHDs are valuable tools for the identification of RA cases at the population level, and allow estimation of disease prevalence and to select retrospective cohorts.
Collapse
Affiliation(s)
- Greta Carrara
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - Carlo A Scirè
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - Antonella Zambon
- Department of Statistics and Quantitative Methods, Section of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Marco A Cimmino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Carlo Cerra
- Information System and Management Control, Local Health Authority (ASL), Pavia, Italy
| | - Marta Caprioli
- Department of Medicine, Istituto Clinico Beato Matteo, Vigevano, Italy
| | - Giovanni Cagnotto
- Department of Rheumatology, IRCCS San Matteo Foundation, Pavia, Italy
| | - Federica Nicotra
- Department of Statistics and Quantitative Methods, Section of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Andrea Arfè
- Department of Statistics and Quantitative Methods, Section of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Simona Migliazza
- Information System and Management Control, Local Health Authority (ASL), Pavia, Italy
| | - Giovanni Corrao
- Department of Statistics and Quantitative Methods, Section of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | | | | |
Collapse
|
81
|
Waldenlind K, Eriksson JK, Grewin B, Askling J. Validation of the rheumatoid arthritis diagnosis in the Swedish National Patient Register: a cohort study from Stockholm County. BMC Musculoskelet Disord 2014; 15:432. [PMID: 25510838 PMCID: PMC4302140 DOI: 10.1186/1471-2474-15-432] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 12/08/2014] [Indexed: 12/16/2022] Open
Abstract
Background The Swedish National Patient Register offers unique possibilities for identification of large cohorts, such as patients with rheumatoid arthritis (RA). Although the overall diagnostic validity in the register has been reported as good, the aims of this study were to a) specifically validate the RA diagnosis from contemporary outpatient specialist care in this register, and b) assess the proportion of patients identified via algorithms to define incident RA in the register who in clinical practice also have new-onset disease. Methods 211 individuals with prevalent or incident RA in the National Patient Register were included. By extracting diagnosis-related parameters from their medical records, we determined if the patient fulfilled the 2010 ACR/EULAR- and the 1987 ACR-classification criteria for RA. We also determined whether clinical diagnosis was synchronous with disease onset as defined through register-based algorithms. Results For 91% of the prevalent patients, the RA diagnosis in the National Patient Register fulfilled classification criteria or clinical diagnosis for RA. Among individuals identified with incident RA using a strict algorithm for new-onset disease, the RA diagnosis was substantiated in 91%, of whom 92% also represented new-onset disease. Conclusions The validity of the RA diagnosis in the National Patient Register was high and, by using specific algorithms, new-onset RA can be defined. These findings strengthen the notion that the National Patient Register may be used to define RA populations with high validity to allow for high-quality epidemiological studies. Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-432) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Kristin Waldenlind
- Department of Rheumatology, Karolinska University Hospital, Stockholm, Sweden.
| | | | | | | |
Collapse
|
82
|
Gibson-Smith D, Klop C, Elders PJM, Welsing PMJ, van Schoor N, Leufkens HGM, Harvey NC, van Staa TP, de Vries F. The risk of major and any (non-hip) fragility fracture after hip fracture in the United Kingdom: 2000-2010. Osteoporos Int 2014; 25:2555-63. [PMID: 25001987 DOI: 10.1007/s00198-014-2799-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/27/2014] [Indexed: 11/25/2022]
Abstract
UNLABELLED The risk of a subsequent major or any fracture after a hip fracture and secular trends herein were examined. Within 1 year, 2.7 and 8.4% of patients sustained a major or any (non-hip) fracture, which increased to 14.7 and 32.5% after 5 years. Subsequent fracture rates increased during the study period both for major and any (non-hip) fracture. INTRODUCTION Hip fractures are associated with subsequent fractures, particularly in the year following initial fracture. Age-adjusted hip fracture rates have stabilised in many developed countries, but secular trends in subsequent fracture remain poorly documented. We thus evaluated secular trends (2000-2010) and determinants for the risk of a subsequent major (humerus, vertebral, or forearm) and any (non-hip) fracture after hip fracture. METHODS Patients ≥50 years with a hip fracture between 2000 and 2010 were extracted from the UK Clinical Practice Research Datalink (n = 30,516). Incidence rates, cumulative incidence probabilities, and adjusted hazard ratios (aHRs) were calculated. RESULTS Within 1 year following hip fracture, 2.7 and 8.4% of patients sustained a major or any (non-hip) fracture, which increased to 14.7 and 32.5% after 5 years, respectively. The most important risk factors for a subsequent major fracture within 1 year were the female gender [aHR 1.90, 95% confidence interval (CI) 1.51-2.40] and a history of secondary osteoporosis (aHR 1.54, 95% CI 1.17-2.02). The annual risk increased during the study period for both subsequent major (2009-2010 vs. 2000-2002: aHR 1.44, 95% CI 1.12-1.83) and any (non-hip) facture (2009-2010 vs. 2000-2002: aHR 1.80, 95% CI 1.58-2.06). CONCLUSION The risk of sustaining a major or any (non-hip) fracture after hip fracture is small in the first year. However, given the recent rise in secondary fracture rates and the substantial risk of subsequent fracture in the longer term, fracture prevention is clearly indicated for patients who have sustained a hip fracture.
Collapse
Affiliation(s)
- D Gibson-Smith
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | | | | | | | | | | | | | | | | |
Collapse
|
83
|
Fina-Aviles F, Medina-Peralta M, Mendez-Boo L, Hermosilla E, Elorza JM, Garcia-Gil M, Ramos R, Bolibar B, Javaid MK, Edwards CJ, Cooper C, Arden NK, Prieto-Alhambra D. The descriptive epidemiology of rheumatoid arthritis in Catalonia: a retrospective study using routinely collected data. Clin Rheumatol 2014; 35:751-7. [PMID: 25344777 DOI: 10.1007/s10067-014-2801-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/01/2014] [Accepted: 10/12/2014] [Indexed: 10/24/2022]
Abstract
Information on the epidemiology of rheumatoid arthritis (RA) in Southern Europe is scarce. We estimated the age- and gender-adjusted incidence and prevalence of RA in Catalonia using routinely collected primary care records. We identified incident (2009-2012) and prevalent (on 31 December 2012) cases of RA in the SIDIAP database using ICD-10 codes. SIDIAP contains anonymized data from computerized primary care records for about five million adults (>80 % of the population). We estimated age- (5-year groups) and gender-specific, and directly standardized incidence and prevalence of RA and confidence intervals (95% CIs) assuming a Poisson distribution. A total of 20,091 prevalent (among whom 5,796 incident) cases of RA were identified among 4,796,498 study participants observed for up to 4 years. Rates of RA increased with age in both genders, peaking at the age of 65-70 years. Age- and gender-standardized incidence and prevalence rates were 0.20/1,000 person-years (95% CI 0.19-0.20) and 4.17/1,000 (4.11-4.23) respectively. Rheumatoid factor was positive (≥10 IU/mL) in 1,833 (73.9 %) of 2,482 cases tested in primary care. The incidence and prevalence of RA in Catalonia are similar to those of other Southern European regions, and lower than those of northern areas. This data will inform health care planning and resource allocation.
Collapse
Affiliation(s)
- F Fina-Aviles
- Primary Care Department, Institut Català de la Salut, Av Gran Via de les Corts Catalanes 587, 3rd floor, 08007, Barcelona, Spain
| | - M Medina-Peralta
- Primary Care Department, Institut Català de la Salut, Av Gran Via de les Corts Catalanes 587, 3rd floor, 08007, Barcelona, Spain
| | - L Mendez-Boo
- Primary Care Department, Institut Català de la Salut, Av Gran Via de les Corts Catalanes 587, 3rd floor, 08007, Barcelona, Spain
| | - E Hermosilla
- IDIAP Jordi Gol Primary Care Research Institute, Universitat Autònoma de Barcelona, Av Gran Via de les Corts Catalanes 587, Atic, 08007, Barcelona, Spain
| | - J M Elorza
- IDIAP Jordi Gol Primary Care Research Institute, Universitat Autònoma de Barcelona, Av Gran Via de les Corts Catalanes 587, Atic, 08007, Barcelona, Spain
| | - M Garcia-Gil
- Primary Care Department, Institut Català de la Salut, Av Gran Via de les Corts Catalanes 587, 3rd floor, 08007, Barcelona, Spain.,IDIAP Jordi Gol Primary Care Research Institute, Universitat Autònoma de Barcelona, Av Gran Via de les Corts Catalanes 587, Atic, 08007, Barcelona, Spain
| | - R Ramos
- Primary Care Department, Institut Català de la Salut, Av Gran Via de les Corts Catalanes 587, 3rd floor, 08007, Barcelona, Spain.,IDIAP Jordi Gol Primary Care Research Institute, Universitat Autònoma de Barcelona, Av Gran Via de les Corts Catalanes 587, Atic, 08007, Barcelona, Spain
| | - B Bolibar
- IDIAP Jordi Gol Primary Care Research Institute, Universitat Autònoma de Barcelona, Av Gran Via de les Corts Catalanes 587, Atic, 08007, Barcelona, Spain
| | - M K Javaid
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, OX3 7LD, Oxford, UK.,MRC Lifecourse Epidemiology Unit, University of Southampton, Tremona Road, SO16 6YD, Southampton, UK
| | - C J Edwards
- Southampton General Hospital, Tremona Road, SO16 6YD, Southampton, UK
| | - C Cooper
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, OX3 7LD, Oxford, UK.,MRC Lifecourse Epidemiology Unit, University of Southampton, Tremona Road, SO16 6YD, Southampton, UK
| | - N K Arden
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, OX3 7LD, Oxford, UK.,MRC Lifecourse Epidemiology Unit, University of Southampton, Tremona Road, SO16 6YD, Southampton, UK
| | - D Prieto-Alhambra
- IDIAP Jordi Gol Primary Care Research Institute, Universitat Autònoma de Barcelona, Av Gran Via de les Corts Catalanes 587, Atic, 08007, Barcelona, Spain. .,Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, OX3 7LD, Oxford, UK. .,MRC Lifecourse Epidemiology Unit, University of Southampton, Tremona Road, SO16 6YD, Southampton, UK. .,SIDIAP Database, IDIAP Jordi Gol, Av Gran Via Corts Catalanes, 587, Atic, 08007, Barcelona, Spain.
| |
Collapse
|
84
|
Relative risk of myelodysplastic syndromes in patients with autoimmune disorders in the General Practice Research Database. Cancer Epidemiol 2014; 38:544-9. [DOI: 10.1016/j.canep.2014.08.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 08/04/2014] [Accepted: 08/07/2014] [Indexed: 12/17/2022]
|
85
|
Perioperative use of anti-rheumatic agents does not increase early postoperative infection risks: a Veteran Affairs’ administrative database study. Rheumatol Int 2014; 35:265-72. [DOI: 10.1007/s00296-014-3121-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 08/22/2014] [Indexed: 12/19/2022]
|
86
|
Mukherjee S, Culliford D, Arden N, Edwards C. What is the risk of having a total hip or knee replacement for patients with lupus? Lupus 2014; 24:198-202. [DOI: 10.1177/0961203314547894] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Individuals with systemic lupus erythematosus (SLE) frequently have arthralgia but joint damage leading to surgery is thought to be less common. In addition to inflammatory damage, other reasons like avascular necrosis (AVN), which is often associated with steroid use, excessive alcohol intake and antiphospholipid syndrome (APS), may increase the likelihood of large joint failure. In this study we aimed to determine the likelihood of having a total hip replacement (THR) or total knee replacement (TKR) for individuals with SLE compared to those without lupus, by performing a retrospective matched case control study of all THRs and TKRs that were performed between 1991 and 2011 and recorded in the General Practice Research Database (GPRD). Individuals with inflammatory arthritis due to any other causes were excluded and the results were adjusted for steroid use, alcohol consumption (drinking status) and APS. The results show that patients with lupus who had a THR or TKR were younger than their peers without lupus. In addition, they appeared to have a significantly increased risk of TKR but the increased risk of THR did not remain after adjustment for steroid use, alcohol consumption and APS.
Collapse
Affiliation(s)
- S Mukherjee
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, UK
| | - D Culliford
- Faculty of Medicine, University of Southampton, UK
| | - N Arden
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, UK
- Faculty of Medicine, University of Southampton, UK
- Oxford NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, UK
| | - C Edwards
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, UK
- Faculty of Medicine, University of Southampton, UK
- Oxford NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, UK
| |
Collapse
|
87
|
Widdifield J, Bombardier C, Bernatsky S, Paterson JM, Green D, Young J, Ivers N, Butt DA, Jaakkimainen RL, Thorne JC, Tu K. An administrative data validation study of the accuracy of algorithms for identifying rheumatoid arthritis: the influence of the reference standard on algorithm performance. BMC Musculoskelet Disord 2014; 15:216. [PMID: 24956925 PMCID: PMC4078363 DOI: 10.1186/1471-2474-15-216] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 06/10/2014] [Indexed: 11/12/2022] Open
Abstract
Background We have previously validated administrative data algorithms to identify patients with rheumatoid arthritis (RA) using rheumatology clinic records as the reference standard. Here we reassessed the accuracy of the algorithms using primary care records as the reference standard. Methods We performed a retrospective chart abstraction study using a random sample of 7500 adult patients under the care of 83 family physicians contributing to the Electronic Medical Record Administrative data Linked Database (EMRALD) in Ontario, Canada. Using physician-reported diagnoses as the reference standard, we computed and compared the sensitivity, specificity, and predictive values for over 100 administrative data algorithms for RA case ascertainment. Results We identified 69 patients with RA for a lifetime RA prevalence of 0.9%. All algorithms had excellent specificity (>97%). However, sensitivity varied (75-90%) among physician billing algorithms. Despite the low prevalence of RA, most algorithms had adequate positive predictive value (PPV; 51-83%). The algorithm of “[1 hospitalization RA diagnosis code] or [3 physician RA diagnosis codes with ≥1 by a specialist over 2 years]” had a sensitivity of 78% (95% CI 69–88), specificity of 100% (95% CI 100–100), PPV of 78% (95% CI 69–88) and NPV of 100% (95% CI 100–100). Conclusions Administrative data algorithms for detecting RA patients achieved a high degree of accuracy amongst the general population. However, results varied slightly from our previous report, which can be attributed to differences in the reference standards with respect to disease prevalence, spectrum of disease, and type of comparator group.
Collapse
Affiliation(s)
- Jessica Widdifield
- University of Toronto, Toronto, 200 Elizabeth St 13EN-224, Toronto, ON M5G 2C4, Canada.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
88
|
Temporal growth and geographic variation in the use of laboratory tests by NHS general practices: using routine data to identify research priorities. Br J Gen Pract 2014; 63:e256-66. [PMID: 23540482 DOI: 10.3399/bjgp13x665224] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Laboratory tests are extensively used for diagnosis and monitoring in UK primary care. Test usage by GPs, and associated costs, have grown substantially in recent years. AIM This study aimed to quantify temporal growth and geographic variation in utilisation of laboratory tests. DESIGN AND SETTING Retrospective cohort study using data from general practices in the UK. METHOD Data from the General Practice Research Database, including patient demographics, clinical details, and laboratory test results, were used to estimate rates of change in utilisation between 2005 and 2009, and identify tests with greatest inter-regional variation, by fitting random-effects Poisson regression models. The study also investigated indications for test requests, using diagnoses and symptoms recorded in the 2 weeks before each test. RESULTS Around 660 000 tests were recorded in 230 000 person-years of follow-up. Test use increased by 24.2%, from 23 872 to 29 644 tests per 10 000 person-years, between 2005 and 2009. Tests with the largest increases were faecal occult blood (121%) and C-reactive protein (86%). There was substantial geographic variation in test utilisation; GPs in some regions requested tests such as plasma viscosity and cardiac enzymes at a rate more than three times the national average. CONCLUSION Increases in the use of laboratory tests have substantial resource implications. Rapid increases in particular tests may be supported by evidence-based guidelines, but these are often vague about who should be tested, how often, and for how long. Substantial regional variation in test use may reflect uncertainty about diagnostic accuracy and appropriate indications for the laboratory test. There is a need for further research on the diagnostic accuracy, therapeutic impact, and effect on patient health outcomes of the most rapidly increasing and geographically variable tests.
Collapse
|
89
|
Dubreuil M, Rho YH, Man A, Zhu Y, Zhang Y, Love TJ, Ogdie A, Gelfand JM, Choi HK. Diabetes incidence in psoriatic arthritis, psoriasis and rheumatoid arthritis: a UK population-based cohort study. Rheumatology (Oxford) 2013; 53:346-52. [PMID: 24185762 DOI: 10.1093/rheumatology/ket343] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the incidence of diabetes among patients with PsA and RA in the general population. METHODS We conducted a cohort study using an electronic medical records database representative of the UK general population (1986-2010). We estimated hazard ratios (HRs) for incident diabetes in PsA, psoriasis and RA cohorts compared with age- and sex-matched comparison cohorts without the corresponding conditions, adjusting for BMI, smoking, alcohol use, co-morbidities and glucocorticoids at baseline. RESULTS Cohorts included 4196 persons with PsA, 59 281 with psoriasis and 11 158 with RA, with mean follow-up times of 5.9, 5.8 and 5.5 years, respectively. Incidence rates for diabetes were 7.3, 6.4 and 6.3 cases per 1000 person-years among individuals with PsA, psoriasis and RA, respectively. Age- and sex-matched HRs for diabetes were 1.72 (95% CI 1.46, 2.02) in PsA, 1.39 (95% CI 1.32, 1.45) in psoriasis and 1.12 (95% CI 1.01, 1.25) in RA. After adjustment for BMI, smoking and alcohol, the HRs were attenuated substantially (1.43, 1.24 and 1.00, respectively). With further adjustment for baseline glucocorticoid use and co-morbidities, the HRs were 1.33 (1.09, 1.61) in PsA, 1.21 (1.15, 1.27) in psoriasis and 0.94 (0.84, 1.06) in RA. CONCLUSION This general population study suggests an increased incidence of diabetes in PsA and RA, which is substantially explained by obesity and lifestyle factors. These findings support the importance of managing such factors in PsA and RA patients.
Collapse
Affiliation(s)
- Maureen Dubreuil
- Section of Rheumatology and the Clinical Epidemiology Unit, Boston University School of Medicine, 650 Albany Street, Suite 201, Boston, MA 02118, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
90
|
Monk HL, Muller S, Mallen CD, Hider SL. Cardiovascular screening in rheumatoid arthritis: a cross-sectional primary care database study. BMC FAMILY PRACTICE 2013; 14:150. [PMID: 24106825 PMCID: PMC3851828 DOI: 10.1186/1471-2296-14-150] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 10/09/2013] [Indexed: 01/08/2023]
Abstract
Background Patients with rheumatoid arthritis (RA) are known to be at increased risk of vascular disease. It is not known whether screening for vascular risk factors occurs in primary care. The aim of this study was to determine whether guidance advocating cardiovascular screening in RA patients is being implemented in primary care. Methods This study was undertaken in a UK primary care consultation database. All patients with a diagnosis of RA between 2000 and 2008, and still registered with the GP practice in 2009 were matched by age, gender and GP practice to three non-RA patients. Evidence of screening for five traditional vascular risk factors (blood pressure, lipids, glucose, weight, smoking) was compared in those with and without RA using logistic regression models. A comparison was also made with diabetes. Results 401 RA patients were identified and matched to 1198 non-RA patients. No differences in the overall rates of screening were found (all five risk factors: RA 24.9% vs no RA 25.6%), but RA patients were more likely to have a smoking status recorded (67% versus 62%). In contrast, those with diabetes were up to 12 times as likely to receive vascular screening. Conclusions Despite the excess risk of vascular disease in patients with RA being of a similar magnitude to that seen in diabetes, patients with RA did not receive additional CVD screening in primary care, although this was achieved in patients with diabetes. More emphasis needs to be placed on ensuring those with RA are actively screened for cardiovascular disease in primary care.
Collapse
Affiliation(s)
- Helen L Monk
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, UK.
| | | | | | | |
Collapse
|
91
|
Widdifield J, Labrecque J, Lix L, Paterson JM, Bernatsky S, Tu K, Ivers N, Bombardier C. Systematic Review and Critical Appraisal of Validation Studies to Identify Rheumatic Diseases in Health Administrative Databases. Arthritis Care Res (Hoboken) 2013; 65:1490-503. [DOI: 10.1002/acr.21993] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 02/13/2013] [Indexed: 01/15/2023]
Affiliation(s)
| | | | - Lisa Lix
- University of Manitoba, Winnipeg; Manitoba; Canada
| | - J. Michael Paterson
- University of Toronto, Toronto, Institute for Clinical Evaluative Sciences, Toronto, and McMaster University, Hamilton; Ontario; Canada
| | | | - Karen Tu
- University of Toronto and Institute for Clinical Evaluative Sciences, Toronto; Ontario; Canada
| | - Noah Ivers
- University of Toronto and Women's College Hospital, Toronto; Ontario; Canada
| | | |
Collapse
|
92
|
Nicholson A, Ford E, Davies KA, Smith HE, Rait G, Tate AR, Petersen I, Cassell J. Optimising use of electronic health records to describe the presentation of rheumatoid arthritis in primary care: a strategy for developing code lists. PLoS One 2013; 8:e54878. [PMID: 23451024 PMCID: PMC3579840 DOI: 10.1371/journal.pone.0054878] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 12/18/2012] [Indexed: 11/18/2022] Open
Abstract
Background Research using electronic health records (EHRs) relies heavily on coded clinical data. Due to variation in coding practices, it can be difficult to aggregate the codes for a condition in order to define cases. This paper describes a methodology to develop ‘indicator markers’ found in patients with early rheumatoid arthritis (RA); these are a broader range of codes which may allow a probabilistic case definition to use in cases where no diagnostic code is yet recorded. Methods We examined EHRs of 5,843 patients in the General Practice Research Database, aged ≥30y, with a first coded diagnosis of RA between 2005 and 2008. Lists of indicator markers for RA were developed initially by panels of clinicians drawing up code-lists and then modified based on scrutiny of available data. The prevalence of indicator markers, and their temporal relationship to RA codes, was examined in patients from 3y before to 14d after recorded RA diagnosis. Findings Indicator markers were common throughout EHRs of RA patients, with 83.5% having 2 or more markers. 34% of patients received a disease-specific prescription before RA was coded; 42% had a referral to rheumatology, and 63% had a test for rheumatoid factor. 65% had at least one joint symptom or sign recorded and in 44% this was at least 6-months before recorded RA diagnosis. Conclusion Indicator markers of RA may be valuable for case definition in cases which do not yet have a diagnostic code. The clinical diagnosis of RA is likely to occur some months before it is coded, shown by markers frequently occurring ≥6 months before recorded diagnosis. It is difficult to differentiate delay in diagnosis from delay in recording. Information concealed in free text may be required for the accurate identification of patients and to assess the quality of care in general practice.
Collapse
Affiliation(s)
- Amanda Nicholson
- Division of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, United Kingdom
| | | | | | | | | | | | | | | |
Collapse
|
93
|
Ng B, Chu A, Khan MM. A retrospective cohort study: 10-year trend of disease-modifying antirheumatic drugs and biological agents use in patients with rheumatoid arthritis at Veteran Affairs Medical Centers. BMJ Open 2013; 3:bmjopen-2012-002468. [PMID: 23562815 PMCID: PMC3641511 DOI: 10.1136/bmjopen-2012-002468] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To evaluate the trends in patterns of disease-modifying antirheumatic drugs (DMARDs) and biological agents use from 1999 to 2009 and to identify patient characteristics associated with different patterns of their use in a national sample of Veterans with rheumatoid arthritis (RA). DESIGN A retrospective cohort study. SETTINGS Administrative databases of the USA Department of Veterans Affairs. PARTICIPANTS An incident cohort of 13 254 patients with newly diagnosed RA was identified. PRIMARY OUTCOME MEASURES Trends and choice of DMARDs and biological agents' usage, and time intervals between RA diagnosis and treatment RESULTS Methotrexate use as first-line agent increased from 39.9% to 57.2% over the study period (p<0.001). Although biological dispensations increased over other DMARDs and biological agents, from 3.4% to 25% from 1999 to 2009, the percentage of RA patients diagnosed between 1999 and 2007 who had biologics dispensations remained steady at 23.3-26.7%. Compared with Caucasian, African Americans were less likely to receive biologics (HR 0.71, 95% CI 0.63 to 0.81). Patients aged 75 and older were less likely to receive biologics than those younger than 45 (HR 0.29, 95% CI 0.23 to 0.36). The time interval between RA diagnosis and treatment with DMARDs and biological agents decreased significantly over time (median: 51 days in 1999-2001 to 28 days in 2006-2007). CONCLUSIONS Methotrexate use increased as it became the preferred first-line agent, while other traditional agents declined. Dispensation of biologics increased significantly, but the proportion of RA patients eventually given biologics stabilised below 30%. A significant shorter time between RA diagnosis and DMARD or biological agent initiation in recent years suggests improvements in quality of care. There were disproportionately lower use of biologics in certain age and ethnic groups, and further studies will be needed to elucidate these observations.
Collapse
Affiliation(s)
- Bernard Ng
- Michael E. DeBakey VA Medical Center Health Services Research and Development Center of Excellence, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Adeline Chu
- School of Nursing, University of Houston-Victoria, Katy, Texas, USA
| | - Myrna M Khan
- Michael E. DeBakey VA Medical Center Health Services Research and Development Center of Excellence, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
94
|
Dregan A, Moller H, Murray-Thomas T, Gulliford M. Validity of cancer diagnosis in a primary care database compared with linked cancer registrations in England. Population-based cohort study. Cancer Epidemiol 2012; 36:425-9. [DOI: 10.1016/j.canep.2012.05.013] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 05/28/2012] [Accepted: 05/29/2012] [Indexed: 11/24/2022]
|
95
|
Choi HK, Rho YH, Zhu Y, Cea-Soriano L, Aviña-Zubieta JA, Zhang Y. The risk of pulmonary embolism and deep vein thrombosis in rheumatoid arthritis: a UK population-based outpatient cohort study. Ann Rheum Dis 2012; 72:1182-7. [DOI: 10.1136/annrheumdis-2012-201669] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BackgroundRecent hospital-based studies have suggested a sixfold increased risk of pulmonary embolism (PE) in rheumatoid arthritis (RA) in the year following admission. We evaluated the risk of PE and deep vein thrombosis (DVT) and associated time trend among RA patients (84.5% without a history of hospitalisation during the past year) derived from the general population.MethodsWe conducted a cohort study using an electronic medical records database representative of the UK general population, collected from 1986 to 2010. Primary definitions of the RA cohort (exposure) and PE/DVT outcomes required physician diagnoses followed by corresponding treatments. We estimated relative risks (RRs) of PE and DVT compared with a matched non-RA comparison cohort, adjusting for age, sex, smoking, body mass index, comorbidities and hospitalisations.ResultsAmong 9589 individuals with RA (69% female, mean age of 58 years), 82 developed PE and 110 developed DVT (incidence rates, 1.5 and 2.1 per 1000 person-years). Compared with non-RA individuals (N=95 776), the age-, sex- and entry-time-matched RRs were 2.23 (95% CI 1.75 to 2.86) for PE and 2.20 (CI 1.78 to 2.71) for DVT. Adjusting for other covariates, the corresponding RRs were 2.16 (CI 1.68 to 2.79) and 2.16 (CI 1.74 to 2.69). The time-specific RRs for PE were 3.27, 1.88 and 2.35 for follow-up times of <1 year, 1–4.9 years, and ≥5 years, and corresponding RRs for DVT were 3.16, 1.82 and 2.32.ConclusionsThis population-based study indicates an increased risk of PE and DVT in RA, supporting increased monitoring of venous-thromboembolic complications and risk factors in RA, regardless of hospitalisation.
Collapse
|
96
|
Edwards CJ, Campbell J, van Staa T, Arden NK. Regional and temporal variation in the treatment of rheumatoid arthritis across the UK: a descriptive register-based cohort study. BMJ Open 2012; 2:bmjopen-2012-001603. [PMID: 23144258 PMCID: PMC3533005 DOI: 10.1136/bmjopen-2012-001603] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES To describe current disease-modifying antirheumatic drugs (DMARDs) prescription in rheumatoid arthritis (RA) with reference to best practice and to identify temporal and regional trends in the UK. DESIGN Descriptive, register-based cohort study. PARTICIPANTS Permanently registered patients aged ≥18 years with a recorded diagnosis of RA between 1 January 1995 and 31 March 2010 and matched controls. Participants with RA were identified through screening of all patients in the General Practice Research Database (GPRD) with a clinical or referral record for RA and at least 1 day of follow-up. SETTING 639 general practices in the UK supplying data to the GPRD. MAIN OUTCOME MEASURES Medication prescribing between 3 and 12 months of RA diagnosis by region and time period (1995-1999, 2000-2005 and 2006-April 2010). RESULTS Of the 35 911 patients in the full RA cohort, 15 259 patients (42%) had incident RA. Analysis of prescribing in incident RA patients demonstrated that between 1995 (baseline) and 2010 there was a substantial increase in DMARD, and specifically methotrexate, prescribing across all regions with a less marked increase in combination DMARD prescribing. Taking 12-month prescribing as a snapshot: DMARD prescribing was 19-49% at baseline increasing to 45-74% by 2006-April 2010; methotrexate prescribing was 4-16% at baseline increasing to 32-60%; combination DMARD prescribing was 0-8% at baseline increasing to 3-17%. However, there was marked regional variation in the proportion of RA patients receiving DMARD regardless of time period. CONCLUSIONS There has been a substantial increase in prescribing of DMARDs for RA since 1995; however, regional variation persists across the UK with relative undertreatment, according to established best practice. Improved implementation of evidence-based best clinical practice to facilitate removal of treatment variation is warranted. This may occur as a result of the implementation of published national guidance.
Collapse
Affiliation(s)
- Christopher John Edwards
- Department of Rheumatology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University of Southampton, Southampton, UK
| | - Jennifer Campbell
- General Practice Research Database, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Tjeerd van Staa
- General Practice Research Database, Medicines and Healthcare Products Regulatory Agency, London, UK
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Nigel K Arden
- University of Southampton, Southampton, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| |
Collapse
|
97
|
Dregan A, Grieve A, van Staa T, Gulliford MC. Potential application of item-response theory to interpretation of medical codes in electronic patient records. BMC Med Res Methodol 2011; 11:168. [PMID: 22176509 PMCID: PMC3261214 DOI: 10.1186/1471-2288-11-168] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 12/16/2011] [Indexed: 11/24/2022] Open
Abstract
Background Electronic patient records are generally coded using extensive sets of codes but the significance of the utilisation of individual codes may be unclear. Item response theory (IRT) models are used to characterise the psychometric properties of items included in tests and questionnaires. This study asked whether the properties of medical codes in electronic patient records may be characterised through the application of item response theory models. Methods Data were provided by a cohort of 47,845 participants from 414 family practices in the UK General Practice Research Database (GPRD) with a first stroke between 1997 and 2006. Each eligible stroke code, out of a set of 202 OXMIS and Read codes, was coded as either recorded or not recorded for each participant. A two parameter IRT model was fitted using marginal maximum likelihood estimation. Estimated parameters from the model were considered to characterise each code with respect to the latent trait of stroke diagnosis. The location parameter is referred to as a calibration parameter, while the slope parameter is referred to as a discrimination parameter. Results There were 79,874 stroke code occurrences available for analysis. Utilisation of codes varied between family practices with intraclass correlation coefficients of up to 0.25 for the most frequently used codes. IRT analyses were restricted to 110 Read codes. Calibration and discrimination parameters were estimated for 77 (70%) codes that were endorsed for 1,942 stroke patients. Parameters were not estimated for the remaining more frequently used codes. Discrimination parameter values ranged from 0.67 to 2.78, while calibration parameters values ranged from 4.47 to 11.58. The two parameter model gave a better fit to the data than either the one- or three-parameter models. However, high chi-square values for about a fifth of the stroke codes were suggestive of poor item fit. Conclusion The application of item response theory models to coded electronic patient records might potentially contribute to identifying medical codes that offer poor discrimination or low calibration. This might indicate the need for improved coding sets or a requirement for improved clinical coding practice. However, in this study estimates were only obtained for a small proportion of participants and there was some evidence of poor model fit. There was also evidence of variation in the utilisation of codes between family practices raising the possibility that, in practice, properties of codes may vary for different coders.
Collapse
Affiliation(s)
- Alex Dregan
- Division of Primary Care and Public Health Sciences, King's College London, 42 Weston Street, London, SE1 3QD, UK.
| | | | | | | | | |
Collapse
|
98
|
Navaratnam V, Ali N, Smith CJP, McKeever T, Fogarty A, Hubbard RB. Does the presence of connective tissue disease modify survival in patients with pulmonary fibrosis? Respir Med 2011; 105:1925-30. [PMID: 21924888 DOI: 10.1016/j.rmed.2011.08.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 07/28/2011] [Accepted: 08/15/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Previous studies into the survival differences between individuals with idiopathic pulmonary fibrosis and those with connective tissue disease associated pulmonary fibrosis (CTD-PF) have yielded mixed results. The aim of this study is to compare the survival of individuals with CTD-PF to those with idiopathic pulmonary fibrosis clinical syndrome (IPF-CS) using data derived from The Health Improvement network, a large primary care database in the UK. METHODS Incident cases of CTD-PF and IPF-CS between the years 2000-2009 were identified. Survival analysis was performed using Kaplan-Meier methods, stratified by type of connective tissue disease. Cox regression was then used to compare mortality rates between the groups, adjusting for age, gender and year of diagnosis. RESULTS A total of 324 cases of CTD-PF and 2209 cases of IPF-CS were followed up over a mean period of 2.3 years. During this period, 113 (34.9%) cases of CTD-PF and 1073 (48.6%) cases of IPF-CS died. The mortality rates for cases with CTD-PF and IPF-CS were 123.6 per 1000 person years (95%CI: 102.8-148.9) and 229.8 per 1000 person years (95% CI: 216.4-244.0) respectively. After adjusting for age, sex and year of diagnosis, cases with CTD-PF had a better prognosis compared to those with IPF-CS (HR 0.76,95%CI: 0.62-0.92). CONCLUSION The prognosis of individuals with CTD-PF appears to be significantly better than those with IPF-CS, but remains an important cause of death in patients with connective tissue disease, and requires more effective treatment options.
Collapse
Affiliation(s)
- V Navaratnam
- Division of Epidemiology and Public Health, University of Nottingham, Hucknall Road, Nottingham NG5 1PB, UK.
| | | | | | | | | | | |
Collapse
|
99
|
Fardet L, Petersen I, Nazareth I. Prevalence of long-term oral glucocorticoid prescriptions in the UK over the past 20 years. Rheumatology (Oxford) 2011; 50:1982-90. [PMID: 21393338 DOI: 10.1093/rheumatology/ker017] [Citation(s) in RCA: 193] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To assess trends in long-term (i.e. ≥3 months) oral glucocorticoid (GC) prescriptions over the past 20 years. METHODS Data of UK adult patients registered between January 1989 and December 2008 with general practices contributing to The Health Improvement Network (THIN) database were obtained. The annual prevalence of long-term oral GC prescriptions was assessed in the whole population and specifically in people with RA, PMR/GCA, asthma, chronic obstructive pulmonary disease (COPD), Crohn's disease and ulcerative colitis (UC). Trends over the 20-year period were estimated using sex- and age-adjusted Poisson regression models. RESULTS During the 26 035 154 person-years of follow-up, an average of 0.75% (95% CI 0.74, 0.75) of the study population was prescribed long-term oral GC therapy at any time point. This rose from 0.59% (0.52, 0.67) in 1989 to 0.79% (0.78, 0.80) in 2008. Long-term prescriptions significantly increased in patients with RA [from 10.3% (8.7, 11.9) to 13.6% (12.9, 14.2)] and PMR/GCA [from 57.6% (53.3, 62.0) to 66.5% (65.2, 67.7)], decreased in patients with asthma, COPD and Crohn's disease and remained stable in patients with UC. However, when only incident cases were considered, we found a decreased use of GCs in patients with RA and UC [odds ratio 0.97 (95% CI 0.96, 0.97) and 0.94 (95% CI 0.93, 0.96) per increasing year, respectively]. CONCLUSION Over the past 20 years, long-term oral GC prescriptions have increased by 34%. Patients newly diagnosed with RA, Crohn's disease or UC are, however, less likely to receive long-term GC prescriptions than patients with a long past medical history of the disease, suggesting changes in physicians' practice.
Collapse
Affiliation(s)
- Laurence Fardet
- MRC General Practice Research Framework, University College London Medical School, Stephenson House, 158-160 North Gower Street, London NW1 2ND, UK.
| | | | | |
Collapse
|
100
|
Love TJ, Cai T, Karlson EW. Validation of psoriatic arthritis diagnoses in electronic medical records using natural language processing. Semin Arthritis Rheum 2010; 40:413-20. [PMID: 20701955 DOI: 10.1016/j.semarthrit.2010.05.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 04/28/2010] [Accepted: 05/04/2010] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To test whether data extracted from full text patient visit notes from an electronic medical record would improve the classification of psoriatic arthritis (PsA) compared with an algorithm based on codified data. METHODS From the >1,350,000 adults in a large academic electronic medical record, all 2318 patients with a billing code for PsA were extracted and 550 were randomly selected for chart review and algorithm training. Using codified data and phrases extracted from narrative data using natural language processing, 31 predictors were extracted and 3 random forest algorithms were trained using coded, narrative, and combined predictors. The receiver operator curve was used to identify the optimal algorithm and a cut-point was chosen to achieve the maximum sensitivity possible at a 90% positive predictive value (PPV). The algorithm was then used to classify the remaining 1768 charts and finally validated in a random sample of 300 cases predicted to have PsA. RESULTS The PPV of a single PsA code was 57% (95% CI 55%-58%). Using a combination of coded data and natural language processing (NLP), the random forest algorithm reached a PPV of 90% (95% CI 86%-93%) at a sensitivity of 87% (95% CI 83%-91%) in the training data. The PPV was 93% (95% CI 89%-96%) in the validation set. Adding NLP predictors to codified data increased the area under the receiver operator curve (P < 0.001). CONCLUSIONS Using NLP with text notes from electronic medical records improved the performance of the prediction algorithm significantly. Random forests were a useful tool to accurately classify psoriatic arthritis cases to enable epidemiological research.
Collapse
Affiliation(s)
- Thorvardur Jon Love
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | | | | |
Collapse
|