Chronic pain-mental health comorbidity and excess prevalence of health risk behaviours: a cross-sectional study

BACKGROUND

Chronic musculoskeletal pain and anxiety/depression are significant public health problems. We hypothesised that adults with both conditions constitute a group at especially high risk of future cardiovascular health outcomes.

AIM

To determine whether having comorbid chronic musculoskeletal pain and anxiety/depression is associated with the excess prevalence of selected known cardiovascular health risk behaviours.

METHOD

A cross-sectional survey of adults aged 35+ years randomly sampled from 26 GP practice registers in West Midlands, England. Respondents were classified into four groups based on self-reported presence/absence of chronic musculoskeletal pain (pain present on most days for six months) and anxiety or depression (Hospital Anxiety and Depression Score 11+). Standardised binomial models were used to estimate standardised prevalence ratios and prevalence differences between the four groups in self-reported obesity, tobacco smoking, physical inactivity, and unhealthy alcohol consumption after controlling for age, sex, ethnicity, deprivation, employment status and educational attainment. The excess prevalence of each risk factor in the group with chronic musculoskeletal pain-anxiety/depression comorbidity was estimated.

FINDINGS

Totally, 14 519 respondents were included, of whom 1329 (9%) reported comorbid chronic musculoskeletal pain-anxiety/depression, 3612 (25%) chronic musculoskeletal pain only, 964 (7%) anxiety or depression only, and 8614 (59%) neither. Those with comorbid chronic musculoskeletal pain-anxiety/depression had the highest crude prevalence of obesity (41%), smoking (16%) and physical inactivity (83%) but the lowest for unhealthy alcohol consumption (18%). After controlling for covariates, the standardised prevalence ratios and differences for the comorbid group compared with those with neither chronic musculoskeletal pain nor anxiety/depression were as follows: current smoking [1.86 (95% CI 1.58, 2.18); 6.8%], obesity [1.93 (1.76, 2.10); 18.9%], physical inactivity [1.21 (1.17, 1.24); 14.3%] and unhealthy alcohol consumption [0.81 (0.71, 0.92); -5.0%]. The standardised prevalences of smoking and obesity in the comorbid group exceeded those expected from simple additive interaction.

Pregnancy-Associated Cancer: A Systematic Review and Meta-Analysis

This study aimed to systematically evaluate and quantify the risk of adverse maternal and neonatal outcomes in patients with pregnancy-associated cancer (PAC). This study was conducted from February 13, 2021, through July 24, 2023. A systematic search of MEDLINE, Embase, Web of Science Core Collection, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials was conducted to identify studies reporting outcomes for patients with PAC. The study was registered on PROSPERO. Two reviewers independently conducted screening, data extraction, and quality assessment. The associations were quantified using random-effects meta-analysis. The initial search produced 29,401 titles and abstracts, after which 147 unique full-text articles were screened, of which 22 articles with 59,190 pregnancies with PAC from 70,097,167 births were included in the meta-analysis. Women with PAC were at significantly increased risk of cesarean deliveries (risk ratio [RR], 1.58; 95% CI, 1.31-1.89), preterm birth (RR, 3.07; 95% CI, 2.37-3.98), venous thromboembolism (RR, 6.76; 95% CI, 5.08-8.99), and maternal death (RR, 41.58; 95% CI, 20.38-84.83). The only outcome with reduced risk was instrumental mode of delivery (RR, 0.67; 95% CI, 0.52-0.87). Pregnancy-associated cancer increases risk of adverse outcomes, including a 7-fold risk of venous thromboembolism and a 42-fold risk of maternal death. Further research is required to better understand the mechanisms leading to these adverse outcomes, especially for women who are not diagnosed until the postpartum period. Affected women should have counseling regarding their increased risk of adverse outcomes.

Perceived Epidemic Impacts and Mental Symptom Trajectories in Adolescents Back to School After COVID-19 Restriction: A Longitudinal Latent Class Analysis

PURPOSE

This study aimed to assess the impacts of COVID-19 epidemic on various life aspects and identify the trajectories of common mental symptoms among adolescents back to school after COVID-19 restriction. Furthermore, potential predictors associated with those trajectories were investigated.

METHODS

This longitudinal study, with five data collection points and a total follow-up of 68.4 days, was conducted among 1,393 junior high school students (mean age: 13.8 years; male, 53.3%) shortly after school reopened during the first COVID-19 outbreak in China. Questions on sociodemographics and perceived COVID-19 epidemic impacts were completed at the baseline while the Patient Health Questionnaire, Generalized Anxiety Disorder Scale, and Insomnia Severity Index were measured throughout the study for depression, anxiety, and insomnia symptoms, respectively. Trajectories of mental symptoms were classified by longitudinal latent class analysis, and the associated predictive factors were identified with multinomial regression modelling.

RESULTS

Our study revealed high but steadily declining prevalence of depression, anxiety, and insomnia symptoms (p trend < .001). Five distinctive trajectories were identified for both depression and anxiety ("resistance," "low symptom," "recovery," "chronic dysfunction," and "delayed dysfunction") and three for insomnia ("resistance," "low symptom," and "chronic dysfunction"). Besides the significant association between the mental symptom trajectories and students' perceived COVID-19 impacts on study practice, family income, and family relationship, female gender, lower school grade, and higher body mass index were found to be predictive of high severity trajectories.

DISCUSSION

Our findings may help locate the most psychologically vulnerable adolescents during the epidemic and foster better implementation of targeted intervention.

The SelfSTarT intervention for low back pain patients presenting to first contact physiotherapists: A mixed methods service evaluation

INTRODUCTION

Globally, back pain is the leading cause of years of disability. In the United Kingdom, over 20 million people live with musculoskeletal (MSK) pain, with low back pain being one of the most common causes. National strategies promote self-management and the use of digital technologies to empower populations.

AIMS

To evaluate the uptake and impact of providing the SelfSTart approach (STarT Back and SelfBACK App) when delivered by a First Contact Physiotherapist (FCP) to people presenting with low back pain in primary care.

METHODS

Patients presenting with a new episode of low back pain underwent routine assessment and completion of a STarT Back questionnaire. Patients with low/medium scores were offered the SelfBACK App. A control population was provided by the MIDAS-GP study. Patient Experience, outcome measures, healthcare utilisation and retention were captured through the app and clinical systems (EMIS). Interviews with five FCPs explored the experiences of using the SelfSTart approach.

RESULTS

SelfSTarT was taken up by almost half (48%) of those to whom it was offered. Compared to MIDAS-GP, users were more likely to be younger, male, in work, and with higher health literacy. SelfSTarT users reported significant improved experiences relating to receiving an agreed care plan and receiving sufficient information. There were no significant differences in treatments offered. FCPs were positive about the app and felt it had value but wanted feedback on patient progress. They recognised that a digital solution would not be suitable for all.

CONCLUSION

This approach offers an opportunity to empower and support self-management, using robustly evaluated digital technology.

Clinical effectiveness of pharmacological and non-pharmacological treatments for the management of anxiety in community dwelling people living with dementia: A systematic review and meta-analysis

People living with dementia commonly experience anxiety, which is often challenging to manage. We investigated the effectiveness of treatments for the management of anxiety in this population. We conducted a systematic review and meta-analysis of randomised controlled trials, and searched EMBASE, CINAHL, MEDLINE and PsycInfo. We estimated standardised mean differences at follow-up between treatments relative to control groups and pooled these across studies using random-effects models where feasible. Thirty-one studies were identified. Meta-analysis demonstrated non-pharmacological interventions were effective in reducing anxiety in people living with dementia, compared to care as usual or active controls. Specifically, music therapy (SMD-1.92(CI:-2.58,-1.25)), muscular approaches (SMD-0.65(CI:-1.02,-0.28)) and stimulating cognitive and physical activities (SMD-0.31(CI:-0.53,-0.09)). Pharmacological interventions with evidence of potential effectiveness included Ginkgo biloba, probiotics, olanzapine, loxapine and citalopram compared to placebo, olanzapine compared to bromazepam and buspirone and risperidone compared to haloperidol. Meta-analyses were not performed for pharmacological interventions due to studies' heterogeneity. This has practice implications when promoting the use of more non-pharmacological interventions to help reduce anxiety among people living with dementia.

Trends in consultations and prescribing for rheumatic and musculoskeletal diseases: an electronic primary care records study

BACKGROUND

Rheumatic and musculoskeletal diseases (RMDs) are common and generally managed in primary care through supported self-care, physiotherapy, analgesia, and specialist referral where indicated. The COVID-19 pandemic led to abrupt changes in primary care delivery, including moves to remote consulting, pauses on group-based self-care, and restricted referrals.

AIM

To describe how patterns of UK primary healthcare consultations and analgesic prescribing relating to RMDs changed during the COVID-19 pandemic.

DESIGN AND SETTING

Observational study using routinely collected national primary care electronic health record data from the Clinical Practice Research Datalink between 1 April 2017 and 1 October 2021.

METHOD

RMD and analgesic SNOMED-CT codes were derived through consensus and published work. Prevalent and incident RMD-related consultations were determined, and RMD consultations matched to prevalent and incident analgesia prescriptions. Joinpoint regression was used to describe trends over time.

RESULTS

Prevalent and incident RMD consultations steadily increased until March 2020 when a substantial drop occurred as pandemic- related restrictions were introduced; levels had not recovered to pre-pandemic highs by October 2021. While incident and prevalent analgesic prescribing also reduced around March 2020, the proportion of patients with an RMD consultation prescribed any analgesic increased from 27.72% in February 2020 to 38.15% in April 2020, with increases across all analgesic groups. A higher proportion of strong opioid prescriptions was seen in the most deprived areas.

CONCLUSION

Pandemic-associated restrictions led to fewer primary care consultations and relative increases in analgesic prescribing, including strong opioids, for RMDs in the UK. Policymakers must consider the impact of these changes in future healthcare resource planning.

Estimating the direct healthcare utilization and cost of musculoskeletal pain among people with comorbidity: a retrospective electronic health record study

OBJECTIVE

To investigate the impact of pre-existing painful musculoskeletal conditions on healthcare utilization and costs among patients with five common conditions: acute coronary syndrome (ACS), stroke, cancer, dementia and pneumonia.

METHODS

Using primary and secondary care services data from electronic health records, a negative binomial regression model was used to compare resource use while a two-part model was used to compare costs across the five conditions, between those with and without a pre-existing musculoskeletal pain.

RESULTS

The study included 760,792 patients (144,870 with ACS, 121,208 with stroke, 231,702 with cancer, 134,638 with dementia, and 128,374 with pneumonia) in the complete case analysis. Pre-existing musculoskeletal pain had an incident rate ratio of above one for most healthcare resources over the follow-up period and an adjusted additional mean cumulative total healthcare costs per patient of £674.59 (95%CI 570.30 to 778.87) for ACS; £613.34 (95%CI 496.87 to 729.82) for stroke; £459.26 (95%CI 376.60 to 541.91) for cancer; and £766.23 (95%CI 655.06 to 877.39) for dementia over five years after diagnosis; and £200.85 (95%CI 104.16 to 297.55) for pneumonia over one year after diagnosis compared to those without musculoskeletal pain.

CONCLUSION

This study highlights that individuals with painful musculoskeletal conditions have higher healthcare utiliszation and costs than those without painful musculoskeletal conditions. Given the high occurrence of musculoskeletal pain in patients with other conditions, effective management strategies are needed to reduce the burden on healthcare resources.

Analgesic prescribing in patients with inflammatory arthritis in England: observational studies in the Clinical Practice Research Datalink

OBJECTIVES

Despite little evidence that analgesics are effective in inflammatory arthritis (IA), studies report substantial opioid prescribing. The extent this applies to other analgesics is uncertain. We undertook a comprehensive evaluation of analgesic prescribing in patients with IA in the Clinical Practice Research Datalink Aurum to evaluate this.

METHODS

From 2004 to 2020, cross-sectional analyses evaluated analgesic prescription annual prevalence in RA, PsA and axial spondyloarthritis (axSpA), stratified by age, sex, ethnicity, deprivation and geography. Joinpoint regression evaluated temporal prescribing trends. Cohort studies determined prognostic factors at diagnosis for chronic analgesic prescriptions using Cox proportional hazards models.

RESULTS

Analgesic prescribing declined over time but remained common: 2004 and 2020 IA prescription prevalence was 84.2/100 person-years (PY) (95% CI 83.9, 84.5) and 64.5/100 PY (64.2, 64.8), respectively. In 2004, NSAIDs were most prescribed (56.1/100 PY; 55.8, 56.5), falling over time. Opioids were most prescribed in 2020 (39.0/100 PY; 38.7, 39.2). Gabapentinoid prescribing increased: 2004 prevalence 1.1/100 PY (1.0, 1.2); 2020 prevalence 9.9/100 PY (9.7, 10.0). Most opioid prescriptions were chronic (2020 prevalence 23.4/100 PY [23.2, 23.6]). Non-NSAID analgesic prescribing was commoner in RA, older people, females and deprived areas/northern England. Conversely, NSAID prescribing was commoner in axSpA/males, varying little by deprivation/geography. Peri-diagnosis was high-risk for starting chronic opioid/NSAID prescriptions. Prognostic factors for chronic opioid/gabapentinoid and NSAID prescriptions differed, with NSAIDs having no consistently significant association with deprivation (unlike opioids/gabapentinoids).

CONCLUSION

IA analgesic prescribing of all classes is widespread. This is neither evidence-based nor in line with guidelines. Peri-diagnosis is an opportune moment to reduce chronic analgesic prescribing.

Musculoskeletal pain and its impact on prognosis following acute coronary syndrome or stroke: A linked electronic health record cohort study

OBJECTIVE

Musculoskeletal painful conditions are a risk factor for cardiovascular disease (CVD), but less is known about whether musculoskeletal pain also worsens prognosis from CVD. The objective was to determine whether patients with musculoskeletal pain have poorer prognosis following acute coronary syndrome (ACS) or stroke.

METHODS

The study utilised UK electronic primary care records (CPRD Aurum) with linkage to hospital and mortality records. Patients aged ≥45 years admitted to hospital with incident ACS/stroke were categorised by healthcare use for musculoskeletal pain (inflammatory conditions, osteoarthritis [OA], and regional pain) based on primary care consultations in the prior 24 months. Outcomes included mortality, length of stay, readmission and management of index condition (ACS/stroke).

RESULTS

There were 171,670 patients with incident ACS and 138,512 with stroke; 30% consulted for musculoskeletal pain prior to ACS/stroke and these patients had more comorbidity than those without musculoskeletal pain. Rates of mortality and readmission, and length of stay were higher in those with musculoskeletal pain, particularly OA and inflammatory conditions, in ACS. Readmission was also higher for patients with musculoskeletal pain in stroke. However, increased risks associated with musculoskeletal pain did not remain after adjustment for age and polypharmacy. Inflammatory conditions were associated with increased likelihood of prescriptions for dual anti-platelets (ACS only) and anti-coagulants.

CONCLUSIONS

Patients with musculoskeletal pain have higher rates of poor outcome from ACS which relates to being older but also increased polypharmacy. The high rates of comorbidity including polypharmacy highlight the complexity of patients with musculoskeletal pain who have new onset ACS/stroke.

Determining cardiovascular risk in patients with unattributed chest pain in UK primary care: an electronic health record study

AIMS

Most adults presenting in primary care with chest pain symptoms will not receive a diagnosis ('unattributed' chest pain) but are at increased risk of cardiovascular events. To assess within patients with unattributed chest pain, risk factors for cardiovascular events and whether those at greatest risk of cardiovascular disease can be ascertained by an existing general population risk prediction model or by development of a new model.

METHODS AND RESULTS

The study used UK primary care electronic health records from the Clinical Practice Research Datalink linked to admitted hospitalizations. Study population was patients aged 18 plus with recorded unattributed chest pain 2002-2018. Cardiovascular risk prediction models were developed with external validation and comparison of performance to QRISK3, a general population risk prediction model. There were 374 917 patients with unattributed chest pain in the development data set. The strongest risk factors for cardiovascular disease included diabetes, atrial fibrillation, and hypertension. Risk was increased in males, patients of Asian ethnicity, those in more deprived areas, obese patients, and smokers. The final developed model had good predictive performance (external validation c-statistic 0.81, calibration slope 1.02). A model using a subset of key risk factors for cardiovascular disease gave nearly identical performance. QRISK3 underestimated cardiovascular risk.

CONCLUSION

Patients presenting with unattributed chest pain are at increased risk of cardiovascular events. It is feasible to accurately estimate individual risk using routinely recorded information in the primary care record, focusing on a small number of risk factors. Patients at highest risk could be targeted for preventative measures.

The impact of the COVID-19 pandemic on referrals to musculoskeletal services from primary care and subsequent incidence of inflammatory rheumatic musculoskeletal disease: an observational study

Objective

The aim was to describe the impact of the COVID-19 pandemic upon referral patterns and incident diagnosis of inflammatory rheumatic and musculoskeletal diseases (iRMDs).

Methods

UK primary care data were used to describe referral patterns for patients with musculoskeletal conditions. Trends in referrals to musculoskeletal services and incident diagnoses of iRMDs (specifically, RA and JIA) were described using Joinpoint Regression and comparisons made between key pandemic time periods.

Results

The incidence of RA and JIA reduced by -13.3 and -17.4% per month, respectively, between January 2020 and April 2020, then increased by 1.9 and 3.7% per month, respectively, between April 2020 and October 2021. The incidence of all diagnosed iRMDs was stable until October 2021. Referrals decreased between February 2020 and May 2020 by -16.8% per month from 4.8 to 2.4% in patients presenting with a musculoskeletal condition. After May 2020, referrals increased significantly (16.8% per month) to 4.5% in July 2020. The time from first musculoskeletal consultation to RA diagnosis and from referral to RA diagnosis increased in the early pandemic period [rate ratio (RR) 1.11, 95% CI 1.07, 1.15 and RR 1.23, 95% CI 1.17, 1.30, respectively] and remained consistently higher in the late pandemic period (RR 1.13, 95% CI 1.11, 1.16 and RR 1.27, 95% CI 1.23, 1.32, respectively), compared with the pre-COVID-19 pandemic period.

Conclusion

Patients with underlying RA and JIA that developed during the pandemic might be yet to present or might be in the referral and/or diagnostic process. Clinicians should remain alert to this possibility, and commissioners should be aware of these findings, enabling the appropriate planning and commissioning of services.

Persistent inequalities in consultation incidence and prevalence of low back pain and osteoarthritis in England between 2004 and 2019

Objective

We wanted to determine whether socioeconomic inequalities in primary care consultation rates for two major, disabling musculoskeletal conditions in England narrowed or widened between 2004 and 2019.

Methods

We analysed data from Clinical Practice Research Datalink Aurum, a national general practice electronic health records database, linked to national deprivation ranking of each patient's registered residential postcode. For each year, we estimated the age- and sex-standardized consultation incidence and prevalence for low back pain and OA for the most deprived 10% of neighbourhoods through to the least deprived 10%. We then calculated the slope index of inequality and relative index of inequality overall and by sex, age group and geographical region.

Results

Inequalities in low back pain incidence and prevalence over socioeconomic status widened between 2004 and 2013 and stabilized between 2014 and 2019. Inequalities in OA incidence remained stable over socioeconomic status within the study period, whereas inequalities in OA prevalence widened markedly over socioeconomic status between 2004 and 2019. The widest gap in low back pain incidence and prevalence over socioeconomic status was observed in populations resident in northern English regions and London and in those of working age, peaking at 45-54 years.

Conclusion

We found persistent, and generally increasing, socioeconomic inequalities in the rate of adults presenting to primary care in England with low back pain and OA between 2004 and 2019.

Rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis epidemiology in England from 2004 to 2020: An observational study using primary care electronic health record data

BACKGROUND

Contemporary data on rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritits (SpA) epidemiology in England are lacking. This knowledge is crucial to planning healthcare services. We updated algorithms defining patients with diagnoses of RA, PsA, and axial SpA in primary care and applied them to describe their incidence and prevalence in the Clinical Practice Research Datalink Aurum, an electronic health record (EHR) database covering ∼20% of England.

METHODS

Algorithms for ascertaining patients with RA, axial SpA, and PsA diagnoses validated in primary care EHR databases using Read codes were updated (to account for the English NHS change to SNOMED CT diagnosis coding) and applied. Updated diagnosis and synthetic disease-modifying anti-rheumatic drug code lists were devised by rheumatologists and general practitioners. Annual incidence/point-prevalence of RA, PsA, and axial SpA diagnoses were calculated from 2004 to 2020 and stratified by age/sex.

FINDINGS

Point-prevalence of RA/PsA diagnoses increased annually, peaking in 2019 (RA 0·779% [95% confidence interval (CI) 0·773, 0·784]; PsA 0·287% [95% CI 0·284, 0·291]) then falling slightly. Point-prevalence of axial SpA diagnoses increased annually (except in 2018/2019), peaking in 2020 (0·113% [95% CI 0·111, 0·115]). RA diagnosis annual incidence was higher between 2013-2019 (after inclusion in the Quality and Outcomes Framework, range 49·1 [95% CI 47·7, 50·5] to 52·1 [95% CI 50·6, 53·6]/100,000 person-years) than 2004-2012 (range 34·5 [95% CI 33·2, 35·7] to 40·0 [95% CI 38·6, 41·4]/100,000 person-years). Increases in the annual incidence of PsA/axial SpA diagnosis occurred following new classification criteria publication. Annual incidence of RA, PsA and axial SpA diagnoses fell by 40·1%, 67·4%, and 38·1%, respectively between 2019 and 2020, likely reflecting the COVID-19 pandemic's impact on their diagnosis.

INTERPRETATION

Recorded RA, PsA, and axial SpA diagnoses are increasingly prevalent in England, underlining the importance of organising healthcare services to provide timely, treat-to-target care to optimise the health of >1% of adults in England.

FUNDING

National Institute for Health and Care Research (NIHR300826).

P181 Musculoskeletal pain and prognosis of acute coronary syndrome and cerebrovascular accident: a linked electronic health record cohort study

Background/Aims

There is some evidence of an increased risk of cardiovascular disease in patients with painful musculoskeletal conditions, but it is unclear if musculoskeletal pain also worsens its prognosis. The aim was to determine whether patients with musculoskeletal pain have poorer prognosis following acute coronary syndrome (ACS) or cerebrovascular accident (CVA).

Methods

Data were obtained from national primary care electronic health records (Clinical Practice Research Datalink; CPRD) with linkage to hospital admissions and mortality records. Patients aged 45 years and over with ACS or CVA recorded in primary care and as the primary reason for hospital admission within ±30 days were included. Patients were grouped by consultations in primary care for painful musculoskeletal conditions (by recency/severity and by condition) in the 24 months prior to ACS or CVA. Severe musculoskeletal pain was defined as prescription of strong analgesia or relevant secondary care referral in the 6 months before ACS or CVA. Short-term outcomes included length of hospital stay, mortality during admission or within 30 days of discharge, and readmission within 30 days of discharge. Management outcomes included procedures during admission and prescriptions for anti-hypertensives, anti-platelets and anti-coagulants in the 3 months following admission. Longer term outcomes included further ACS or CVA and mortality in those who survived &gt;30 days after discharge.

Results

There were 171,670 patients with ACS (36% females; median age 70 years) and 138,512 patients with CVA (49% females; median age 76 years); 30% of patients in each cohort consulted for a painful musculoskeletal condition prior to admission for ACS or CVA. An increased prevalence of cardiovascular risk factors was observed for patients with severe musculoskeletal pain compared to those without pain for comorbidities such as obesity (ACS 26% vs 16%, CVA 25% vs 15%), diabetes (ACS 24% vs 17%, CVA 23% vs 17%) and lifestyle characteristics such as current/ex-smoker (ACS 58% vs 52%, CVA 52% vs 46%), respectively. Patients with severe musculoskeletal pain had similar lengths of stay, rates of readmission and further ACS/CVA after adjustment for sociodemographic characteristics and comorbidities than those without musculoskeletal pain. They were more likely to receive a procedure during admission for ACS (adjusted risk ratio [aRR] 1.15, 95% confidence interval [CI] 1.03-1.28). Prescriptions for ACS (severe pain aRR 1.01, 95% CI 1.00-1.02; inflammatory condition aRR 1.01, 95% CI 1.00-1.02) and CVA (inflammatory condition aRR 1.04, 95% CI 1.01-1.06) were higher in the 3 months post-admission for those with musculoskeletal pain.

Conclusion

Musculoskeletal pain did not independently worsen the prognosis following hospitalisation for incident ACS or CVA. The findings are reassuring, but also highlight the need for closer surveillance due to the complexities of patients with severe musculoskeletal presenting with incident ACS or CVA.

Disclosure

K.J. Mason: None. K.P. Jordan: None. F.A. Achana: None. J. Bailey: None. Y. Chen: None. M. Frisher: None. A.L. Huntley: None. C.D. Mallen: None. M.A. Mamas: None. M. Png: None. S. Tatton: None. S. White: None. J.J. Edwards: None.

Long-Term Cardiovascular Risk and Management of Patients Recorded in Primary Care With Unattributed Chest Pain: An Electronic Health Record Study

Background Most adults presenting with chest pain will not receive a diagnosis and be recorded with unattributed chest pain. The objective was to assess if they have increased risk of cardiovascular disease compared with those with noncoronary chest pain and determine whether investigations and interventions are targeted at those at highest risk. Methods and Results We used records from general practices in England linked to hospitalization and mortality information. The study population included patients aged 18 years or over with a new record of chest pain with a noncoronary cause or unattributed between 2002 and 2018, and no cardiovascular disease recorded up to 6 months (diagnostic window) afterward. We compared risk of a future cardiovascular event by type of chest pain, adjusting for cardiovascular risk factors and alternative explanations for chest pain. We determined prevalence of cardiac diagnostic investigations and preventative medication during the diagnostic window in patients with estimated cardiovascular risk ≥10%. There were 375 240 patients with unattributed chest pain (245 329 noncoronary chest pain). There was an increased risk of cardiovascular events for patients with unattributed chest pain, highest in the first year (hazard ratio, 1.25 [95% CI, 1.21-1.29]), persistent up to 10 years. Patients with unattributed chest pain had consistently increased risk of myocardial infarction over time but no increased risk of stroke. Thirty percent of patients at higher risk were prescribed lipid-lowering medication. Conclusions Patients presenting to primary care with unattributed chest pain are at increased risk of cardiovascular events. Primary prevention to reduce cardiovascular events appears suboptimal in those at higher risk.

Do recommended interventions widen or narrow inequalities in musculoskeletal health? An equity-focussed systematic review of differential effectiveness

Background

It is unclear whether seven interventions recommended by Public Health England for preventing and managing common musculoskeletal conditions reduce or widen health inequalities in adults with musculoskeletal conditions.

Methods

We used citation searches of Web of Science (date of ‘parent publication’ for each intervention to April 2021) to identify original research articles reporting subgroup or moderator analyses of intervention effects by social stratifiers defined using the PROGRESS-Plus frameworks. Randomized controlled trials, controlled before-after studies, interrupted time series, systematic reviews presenting subgroup/stratified analyses or meta-regressions, individual participant data meta-analyses and modelling studies were eligible. Two reviewers independently assessed the credibility of effect moderation claims using Instrument to assess the Credibility of Effect Moderation Analyses. A narrative approach to synthesis was used (PROSPERO registration number: CRD42019140018).

Results

Of 1480 potentially relevant studies, seven eligible analyses of single trials and five meta-analyses were included. Among these, we found eight claims of potential differential effectiveness according to social characteristics, but none that were judged to have high credibility.

Conclusions

In the absence of highly credible evidence of differential effectiveness in different social groups, and given ongoing national implementation, equity concerns may be best served by investing in monitoring and action aimed at ensuring fair access to these interventions.

In-Hospital Complications in Pregnancies Conceived by Assisted Reproductive Technology

Background Assisted reproductive technology (ART) has emerged as a common treatment option for infertility, a problem that affects an estimated 48 million couples worldwide. Advancing maternal age with increasing prepregnancy cardiovascular risk factors, such as chronic hypertension, obesity, and diabetes, has raised concerns about pregnancy complications associated with ART. However, in-hospital complications following pregnancies conceived by ART are poorly described. Methods and Results To assess the patient characteristics, obstetric outcomes, vascular complications and temporal trends of pregnancies conceived by ART, we analyzed hospital deliveries conceived with or without ART between January 1, 2008, and December 31, 2016, from the United States National Inpatient Sample database. We included 106 248 deliveries conceived with ART and 34 167 246 deliveries conceived without ART. Women who conceived with ART were older (35 versus 28 years; P<0.0001) and had more comorbidities. ART-conceived pregnancies were independently associated with vascular complications (acute kidney injury: adjusted odds ratio [aOR], 2.52; 95% CI 1.99-3.19; and arrhythmia: aOR, 1.65; 95% CI, 1.46-1.86), and adverse obstetric outcomes (placental abruption: aOR, 1.57; 95% CI, 1.41-1.74; cesarean delivery: aOR, 1.38; 95% CI, 1.33-1.43; and preterm birth: aOR, 1.26; 95% CI, 1.20-1.32), including in subgroups without cardiovascular disease risk factors or without multifetal pregnancies. Higher hospital charges ($18 705 versus $11 983; P<0.0001) were incurred compared with women who conceived without ART. Conclusions Pregnancies conceived by ART have higher risks of adverse obstetric outcomes and vascular complications compared with spontaneous conception. Clinicians should have detailed discussions on the associated complications of ART in women during prepregnancy counseling.

Trends in the Annual Consultation Incidence and Prevalence of Low Back Pain and Osteoarthritis in England from 2000 to 2019: Comparative Estimates from Two Clinical Practice Databases

Purpose

To compare estimates of annual person-consulting incidence and prevalence of low back pain (LBP) and osteoarthritis for two national English electronic health record databases (Clinical Practice Research Datalink (CPRD) Aurum and CPRD GOLD).

Patients and Methods

Retrospective, population-based, longitudinal cohort study. LBP and osteoarthritis cases were defined using established codelists in people aged ≥15 and ≥45 years, respectively. Incident cases were new recorded cases in a given calendar year with no relevant consultation in the previous 3 years (denominator = exact person-time in the same calendar year for the at-risk population). Prevalent cases were individuals with ≥1 consultation for the condition of interest recorded in a given calendar year, irrespective of prior consultations for the same condition (denominator = all patients with complete registration history in the previous 3 years). We estimated age-sex standardised incidence and annual (12-month period) prevalence for both conditions in 2000–2019, overall, and by sex, age group, and region.

Results

Standardised incidence and prevalence of LBP from Aurum were lower than those from GOLD until 2014, after which estimates were similar. Both databases showed recent declines in incidence and prevalence of LBP: declines began earlier in GOLD (after 2012–2014) than Aurum (after 2014–2015). Standardised incidence (after 2011) and prevalence of osteoarthritis (after 2003) were higher in Aurum than GOLD and showed different trends: incidence and prevalence were stable or increasing in Aurum, decreasing in GOLD. Stratified estimates in CPRD Aurum suggested consistently higher occurrence among women, older age groups, and those living in the north of England.

Conclusion

Comparative analyses of two English databases produced conflicting estimates and trends for two common musculoskeletal conditions. Aurum estimates appeared more consistent with external sources and may be useful for monitoring population musculoskeletal health and healthcare demand, but they remain sensitive to analytic decisions and data quality.

In-Hospital Complications in Pregnant Women With Current or Historical Cancer Diagnoses

OBJECTIVE

To assess the temporal trends, characteristics and comorbidities, and in-hospital cardiovascular and obstetric complications and outcomes of pregnant women with current or historical cancer diagnosis at the time of admission for delivery.

METHODS

We analyzed delivery hospitalizations with or without current or historical cancer between January 1, 2004, and December 31, 2014, from the US National Inpatient Sample database.

RESULTS

We included 43,132,097 delivery hospitalizations with no cancer, 39,118 with current cancer, and 67,336 with historical diagnosis of cancer. The 5 most common types of current cancer were hematologic, thyroid, cervical, skin, and breast cancer. Women with current and historical cancer were older (29 years and 32 years vs 27 years) and incurred higher hospital costs ($4131 and $4078 vs $3521) compared with women without cancer. Most of the cancer types were associated with preterm birth (hematologic: adjusted odds ratio [aOR], 1.48 [95% CI, 1.35 to 1.62]; cervical: aOR, 1.47 [95% CI, 1.32 to 1.63]; breast: aOR, 1.93 [95% CI, 1.72 to 2.16]). Current hematologic cancer was associated with the highest risk of peripartum cardiomyopathy (aOR, 12.19 [95% CI, 7.75 to 19.19]), all-cause mortality (aOR, 6.50 [95% CI, 2.22 to 19.07]), arrhythmia (aOR, 3.82 [95% CI, 2.04 to 7.15]), and postpartum hemorrhage (aOR, 1.31 [95% CI, 1.11 to 1.54]). Having a current or historical cancer diagnosis did not confer additional risk for stillbirth; however, metastases increased the risk of maternal mortality and preterm birth.

CONCLUSION

Women with a current or historical diagnosis of cancer at delivery have more comorbidities compared with women without cancer. Clinicians should communicate the risks of multisystem complications to these complex patients.

Evaluation of the First Contact Physiotherapy (FCP) model of primary care: patient characteristics and outcomes

OBJECTIVE

First Contact Physiotherapy (FCP) is a primary care model where expert musculoskeletal (MSK) physiotherapists undertake the first patient consultation, to enhance MSK-patient care and free-up GP capacity. The authors report the quantitative findings from the FCP National Evaluation (Phase 3) which evaluated the FCP model against success criteria.

DESIGN AND SETTING

A mixed-methods 24-month service evaluation involving 40 FCP sites and 240 FCPs across England.

METHODS

An online platform collected patient-reported experience and outcomes following the FCP consultation and at 1, 2 and 3-months follow-up. These included the Keele STarT MSK Tool, pain intensity (0-10 NRS scale), Musculoskeletal Health Questionnaire (MSK-HQ, range 0-56), and Friends-and-Family Test.

RESULTS

Over 13 months, 2825 patients were invited by email and 24% (n=680) completed their initial questionnaire. Their mean age was 56.2 (SD 14.9), 61% were female, ethnicity was 97% white, mean pain intensity was 6.1 (SD 2.13) and mean MSK-HQ score was 33.8 (SD 9.5). At 3-months follow-up (n=370) there was a 2.8 (CI 2.5 to 3.1) mean pain intensity reduction from baseline, a mean 7.1 (6.0 to 8.2) score improvement in MSK-HQ and 64% reporting overall improvement (much better/better) since seeing the FCP. One of the six success criteria was not met; 29% of those in employment reported receiving specific work advice from the FCP (target ≥75%).

CONCLUSION

Ahead of the planned scale-up of the FCP primary care model across the UK, this evaluation provides useful data on patients who access this service, their short-term clinical outcomes and whether key success criteria are being met.

Estimating the population health burden of musculoskeletal conditions using primary care electronic health records

OBJECTIVES

Better indicators from affordable, sustainable data sources are needed to monitor population burden of musculoskeletal conditions. We propose five indicators of musculoskeletal health and assessed if routinely available primary care electronic health records (EHR) can estimate population levels in musculoskeletal consulters.

METHODS

We collected validated patient-reported measures of pain experience, function and health status through a local survey of adults (≥35 years) presenting to English general practices over 12 months for low back pain, shoulder pain, osteoarthritis and other regional musculoskeletal disorders. Using EHR data we derived and validated models for estimating population levels of five self-reported indicators: prevalence of high impact chronic pain, overall musculoskeletal health (based on Musculoskeletal Health Questionnaire), quality of life (based on EuroQoL health utility measure), and prevalence of moderate-to-severe low back pain and moderate-to-severe shoulder pain. We applied models to a national EHR database (Clinical Practice Research Datalink) to obtain national estimates of each indicator for three successive years.

RESULTS

The optimal models included recorded demographics, deprivation, consultation frequency, analgesic and antidepressant prescriptions, and multimorbidity. Applying models to national EHR, we estimated that 31.9% of adults (≥35 years) presenting with non-inflammatory musculoskeletal disorders in England in 2016/17 experienced high impact chronic pain. Estimated population health levels were worse in women, older aged and those in the most deprived neighbourhoods, and changed little over 3 years.

CONCLUSION

National and subnational estimates for a range of subjective indicators of non-inflammatory musculoskeletal health conditions can be obtained using information from routine electronic health records.

Does pre-existing morbidity influences risks and benefits of total hip replacement for osteoarthritis: a prospective study of 6682 patients from linked national datasets in England

Total hip arthroplasty (THA) surgery for elderly people with multimorbidity increases the risk of serious health hazards including mortality. Whether such background morbidity reduces the clinical benefit is less clear.

OBJECTIVE

To evaluate how pre-existing health status, using multiple approaches, influences risks of, and quality of life benefits from, THA.

SETTING

Longitudinal record linkage study of a UK sample linking their primary care to their secondary care records.

PARTICIPANTS

A total of 6682 patients were included, based on the recording of the diagnosis of hip osteoarthritis in a national primary care register and the recording of the receipt of THA in a national secondary care register.Data were extracted from the primary care register on background health and morbidity status using five different constructs: Charlson Comorbidity Index, Electronic Frailty Index (eFI) and counts of comorbidity disorders (from list of 17), prescribed medications and number of primary care visits prior to recording of THA.

OUTCOME MEASURES

(1) Postoperative complications and mortality; (2) postoperative hip pain and function using the Oxford Hip Score (OHS) and health-related quality of life using the EuroQoL (EQ)-5D score.

RESULTS

Perioperative complication rate was 3.2% and mortality was 0.9%, both increased with worse preoperative health status although this relationship varied depending on the morbidity construct: the eFI showing the strongest relationship but number of visits having no predictive value. By contrast, the benefits were not reduced in those with worse preoperative health, and improvement in both OHS and EQ-5D was observed in all the morbidity categories.

CONCLUSIONS

Independent of preoperative morbidity, THA leads to similar substantial improvements in quality of life. These are offset by an increase in medical complications in some subgroups of patients with high morbidity, depending on the definition used. For most elderly people, their other health disorders should not be a barrier for THA.

Influence of pre-existing multimorbidity on receiving a hip arthroplasty: cohort study of 28 025 elderly subjects from UK primary care

The median age for total hip arthroplasty (THA) is over 70 years with the corollary that many individuals have multiple multimorbidities. Despite the predicted improvement in quality of life, THA might be denied even to those with low levels of multimorbidity.

OBJECTIVE

To evaluate how pre-existing levels of multimorbidity influence the likelihood and timing of THA.

SETTING

Longitudinal record linkage study of a UK sample linking their primary care to their secondary care records.

PARTICIPANTS

A total of 28 025 patients were included, based on the recording of the diagnosis of hip osteoarthritis in a national primary care register, Clinical Practice Research Datalink. Data were extracted from the database on background health and morbidity status using five different constructs: Charlson Comorbidity Index, Electronic Frailty Index and counts of chronic diseases (from list of 17), prescribed medications and number of primary care visits prior to recording of osteoarthritis.

OUTCOME MEASURES

The record of having received a THA as recorded in the primary care record and the linked secondary care database: Hospital Episode Statistics.

RESULTS

40% had THA: median follow 10 months (range 1-17 years). Increased multimorbidity was associated with a decreased likelihood of undergoing THA, irrespective of the method of assessing multimorbidity although the impact varied by approach.

CONCLUSION

Markers of pre-existing ill health influence the decision for THA in the elderly with end-stage hip osteoarthritis, although these effects are modest for indices of multimorbidity other than eFI. There is evidence of this influence being present even in people with moderate decrements in their health, despite the balance of benefits to risk in these individuals being positive.

Markers of dementia-related health in primary care electronic health records

OBJECTIVES

Identifying routinely recorded markers of poor health in patients with dementia may help treatment decisions and evaluation of earlier outcomes in research. Our objective was to determine whether a set of credible markers of dementia-related health could be identified from primary care electronic health records (EHR).

METHODS

The study consisted of (i) rapid review of potential measures of dementia-related health used in EHR studies; (ii) consensus exercise to assess feasibility of identifying these markers in UK primary care EHR; (iii) development of UK EHR code lists for markers; (iv) analysis of a regional primary care EHR database to determine further potential markers; (v) consensus exercise to finalise markers and pool into higher domains; (vi) determination of 12-month prevalence of domains in EHR of 2328 patients with dementia compared to matched patients without dementia.

RESULTS

Sixty-three markers were identified and mapped to 13 domains: Care; Home Pressures; Severe Neuropsychiatric; Neuropsychiatric; Cognitive Function; Daily Functioning; Safety; Comorbidity; Symptoms; Diet/Nutrition; Imaging; Increased Multimorbidity; Change in Dementia Drug. Comorbidity was the most prevalent recorded domain in dementia (69%). Home Pressures were the least prevalent domain (1%). Ten domains had a statistically significant higher prevalence in dementia patients, one (Comorbidity) was higher in non-dementia patients, and two (Home Pressures, Diet/Nutrition) showed no association with dementia.

CONCLUSIONS

EHR captures important markers of dementia-related health. Further research should assess if they indicate dementia progression. These markers could provide the basis for identifying individuals at risk of faster progression and outcome measures for use in research.

Musculoskeletal consultations from childhood to adulthood: a longitudinal study

BACKGROUND

The Global Burden of Disease reports indicate that musculoskeletal conditions are important causes of disability worldwide. Such conditions may originate in childhood, but studies investigating changes longitudinally and from childhood to adulthood are infrequent.

METHODS

Nine birth cohorts of children (starting at ages 7-15 years) were followed. Participants were identified from Consultations in Primary Care Archive, an electronic health record database of 11 English general practices. Musculoskeletal consultation prevalence figures were calculated, and reasons for consultation evaluated.

RESULTS

Annual musculoskeletal consultation prevalence was similar across cohorts for each age. Prevalence increased from 6 to 16% between ages 7 and 22 and was higher in males until age 15, after which prevalence was higher in females. Pain was the most common reason for consultation. Back pain consultations increased from 1 consultation/1000 7 year olds to 84 consultations/1000 22 year olds. Lower limb pain consultations increased from 21 consultations/1000 7 year olds to 56 consultations/1000 22 year olds.

CONCLUSIONS

This study shows that from childhood, individuals are more likely to seek healthcare for musculoskeletal consultations as they age, but rates are not increasing over time. Changes in consultation rates by age, gender and pain region may inform studies on the development of chronic musculoskeletal pain over the life-course.

Long-term trajectories of chronic musculoskeletal pain: a 21-year prospective cohort latent class analysis

ABSTRACT

Our knowledge of the prevalence, impact, and outcomes of chronic pain in the general population is predominantly based on studies over relatively short periods of time. The aim of this study was to identify and describe trajectories of the chronic pain status over a period of 21 years. Self-reported population data (n = 1858) from 5 timepoints were analyzed. Pain was categorized by: no chronic pain (NCP), chronic regional pain (CRP), and chronic widespread pain (CWP). Latent class growth analysis was performed for identification of trajectories and logistic regression analysis for identification of predictors for pain prognosis. Five trajectories were identified: (1) persistent NCP (57%), (2) migrating from NCP to CRP or CWP (5%), (3) persistent CRP or migration between CRP and NCP (22%), (4) migration from CRP to CWP (10%), and (5) persistent CWP (6%). Age, sleeping problems, poor vitality, and physical function at baseline were associated with pain progression from NCP. Female gender, seeking care for pain, lack of social support, poor physical function, vitality, and mental health predicted poor pain prognosis among those with CRP. In conclusion, chronic pain was common in the population including 6% reporting persistent CWP, although the majority persistently reported NCP. Most people had stable pain status, but some had ongoing change in pain status over time including people who improved from chronic pain. It was possible to identify clinically relevant factors, characterizing trajectories of chronic pain development, that can be useful for identifying individuals at risk and potential targets for intervention.

Indicators of dementia disease progression in primary care: An electronic health record cohort study

BACKGROUND AND PURPOSE

The objectives were to assess the feasibility and validity of using markers of dementia-related health as indicators of dementia progression in primary care, by assessing the frequency with which they are recorded and by testing the hypothesis that they are associated with recognised outcomes of dementia. The markers, in 13 domains, were derived previously through literature review, expert consensus, and analysis of regional primary care records.

METHODS

The study population consisted of patients with a recorded dementia diagnosis in the Clinical Practice Research Datalink, a UK primary care database linked to secondary care records. Incidence of recorded domains in the 36 months after diagnosis was determined. Associations of recording of domains with future hospital admission, palliative care, and mortality were derived.

RESULTS

There were 30,463 people with diagnosed dementia. Incidence of domains ranged from 469/1000 person-years (Increased Multimorbidity) to 11/1000 (Home Pressures). An increasing number of domains in which a new marker was recorded in the first year after diagnosis was associated with hospital admission (hazard ratio for ≥4 domains vs. no domains = 1.24; 95% confidence interval = 1.15-1.33), palliative care (1.87; 1.62-2.15), and mortality (1.57; 1.47-1.67). Individual domains were associated with outcomes with varying strengths of association.

CONCLUSIONS

Feasibility and validity of potential indicators of progression of dementia derived from primary care records are supported by their frequency of recording and associations with recognised outcomes. Further research should assess whether these markers can help identify patients with poorer prognosis to improve outcomes through stratified care and targeted support.

Temporal Trends in Pregnancy-Associated Stroke and Its Outcomes Among Women With Hypertensive Disorders of Pregnancy

Background

Stroke is a serious complication of hypertensive disorders of pregnancy (HDP), with potentially severe and long‐term sequelae. However, the temporal trends, predictors, and outcomes of stroke in women with HDP at delivery remain unknown.

Methods and Results

All HDP delivery hospitalizations with or without stroke event (ischemic, hemorrhagic, or unspecified) between 2004 and 2014 in the United States National Inpatient Sample were analyzed to examine incidence, predictors, and prognostic impact of stroke. Of 4 240 284 HDP delivery hospitalizations, 3391 (0.08%) women had stroke. While the prevalence of HDP increased over time, incident stroke rates decreased from 10 to 6 per 10 000 HDP delivery hospitalizations between 2004 and 2014. Women with stroke were increasingly multimorbid, with some risk factors being more strongly associated with ischemic strokes, including congenital heart disease, peripheral vascular disease, dyslipidemia, and sickle cell disease. Delivery complications were also associated with stroke, including cesarean section (odds ratio [OR], 1.58; 95% CI, 1.33–1.86), postpartum hemorrhage (OR, 1.91; 95% CI, 1.33–1.86), and maternal mortality (OR, 99.78; 95% CI, 59.15–168.31), independently of potential confounders. Women with stroke had longer hospital stays (median, 6 versus 3 days), higher hospital charges (median, $14 655 versus $4762), and a higher proportion of nonroutine discharge locations (38% versus 4%).

Conclusions

The incidence of stroke in women with HDP has declined over time. While a relatively rare event, identification of women at highest risk of ischemic or hemorrhagic stroke on admission for delivery is important to reduce long‐term sequelae.

Temporal Changes in Hypertensive Disorders of Pregnancy and Impact on Cardiovascular and Obstetric Outcomes

Hypertensive disorders of pregnancy (HDP) are a major cause of maternal morbidity. However, short-term outcomes of HDP subgroups remain unknown. Using National Inpatient Sample database, all delivery hospitalizations between 2004 and 2014 with or without HDP (preeclampsia/eclampsia, chronic hypertension, superimposed preeclampsia on chronic hypertension, and gestational hypertension) were analyzed to examine the association between HDP and adverse in-hospital outcomes. We identified >44 million delivery hospitalizations, within which the prevalence of HDP increased from 8% to 11% over a decade with increasing comorbidity burden. Women with chronic hypertension have higher risks of myocardial infarction, peripartum cardiomyopathy, arrhythmia, and stillbirth compared to women with preeclampsia. Out of all HDP subgroups, the superimposed preeclampsia population had the highest risk of stroke (odds ratio [OR] 7.83, 95% confidence interval [CI] 6.25 to 9.80), myocardial infarction (OR 5.20, 95% CI 3.11 to 8.69), peripartum cardiomyopathy (OR 4.37, 95% CI 3.64 to 5.26), preterm birth (OR 4.65, 95% CI 4.48 to 4.83), placental abruption (OR 2.22, 95% CI 2.09 to 2.36), and stillbirth (OR 1.78, 95% CI 1.66 to 1.92) compared to women without HDP. In conclusion, we are the first to evaluate chronic systemic hypertension without superimposed preeclampsia as a distinct subgroup in HDP and show that women with chronic systemic hypertension are at even higher risk of some adverse outcomes compared to women with preeclampsia. In conclusion, the chronic hypertension population, with and without superimposed preeclampsia, is a particularly high-risk group and may benefit from increased antenatal surveillance and the use of a prognostic risk assessment model incorporating HDP to stratify intrapartum care.

Patterns of symptoms before a diagnosis of first episode psychosis: a latent class analysis of UK primary care electronic health records

BACKGROUND

The nature of symptoms in the prodromal period of first episode psychosis (FEP) remains unclear. The objective was to determine the patterns of symptoms recorded in primary care in the 5 years before FEP diagnosis.

METHODS

The study was set within 568 practices contributing to a UK primary care health record database (Clinical Practice Research Datalink). Patients aged 16-45 years with a first coded record of FEP, and no antipsychotic prescription more than 1 year prior to FEP diagnosis (n = 3045) was age, gender, and practice matched to controls without FEP (n = 12,180). Fifty-five symptoms recorded in primary care in the previous 5 years, categorised into 8 groups (mood-related, 'neurotic', behavioural change, volition change, cognitive change, perceptual problem, substance misuse, physical symptoms), were compared between cases and controls. Common patterns of symptoms prior to FEP diagnosis were identified using latent class analysis.

RESULTS

Median age at diagnosis was 30 years, 63% were male. Non-affective psychosis (67%) was the most common diagnosis. Mood-related, 'neurotic', and physical symptoms were frequently recorded (> 30% of patients) before diagnosis, and behavioural change, volition change, and substance misuse were also common (> 10%). Prevalence of all symptom groups was higher in FEP patients than in controls (adjusted odds ratios 1.33-112). Median time from the first recorded symptom to FEP diagnosis was 2-2.5 years except for perceptual problem (70 days). The optimal latent class model applied to FEP patients determined three distinct patient clusters: 'no or minimal symptom cluster' (49%) had no or few symptoms recorded; 'affective symptom cluster' (40%) mainly had mood-related and 'neurotic' symptoms; and 'multiple symptom cluster' (11%) consulted for three or more symptom groups before diagnosis. The multiple symptom cluster was more likely to have drug-induced psychosis, female, obese, and have a higher morbidity burden. Affective and multiple symptom clusters showed a good discriminative ability (C-statistic 0.766; sensitivity 51.2% and specificity 86.7%) for FEP, and many patients in these clusters had consulted for their symptoms several years before FEP diagnosis.

CONCLUSIONS

Distinctive patterns of prodromal symptoms may help alert general practitioners to those developing psychosis, facilitating earlier identification and referral to specialist care, thereby avoiding potentially detrimental treatment delay.

Bleeding After Hospital Discharge Following Acute Coronary Syndrome: Incidence, Types, Timing, and Predictors

Background

The incidence and predictors of bleeding after acute coronary syndrome are unclear within the real‐world setting. Our objective was to determine the incidence, types, timing, and predictors of bleeding complications following hospital discharge after acute coronary syndrome.

Methods and Results

We used the Clinical Practice Research Datalink, with linkage to Hospital Episode Statistics, to determine the incidence, timing, and types of bleeding events within 12 months after hospital discharge for acute coronary syndrome. We assessed independent associations between postdischarge bleeding and baseline patient characteristics using a competing risk regression model, accounting for death as a competing event. Among 27 660 patients surviving to hospital discharge, 3620 (13%) experienced bleeding complications at a median time of 123 days (interquartile range, 45–223 days) after discharge. The incidence of bleeding was 162/1000 person‐years (95% CI, 157–167/1000 person‐years) within the first 12 months after hospital discharge. Bruising (949 bleeds [26%]) was the most common type of first bleeding event, followed by gastrointestinal bleed (705 bleeds [20%]), whereas intracranial bleed was relatively rare (81 bleeds [2%]). Significant predictors of postdischarge bleeding included history of bleeding complication, oral anticoagulant prescription, history of peripheral vascular disease, chronic obstructive pulmonary disease, and advanced age (>80 years). Predictors for postdischarge bleeding varied, depending on the anatomic site of the bleeding event.

Conclusions

Bleeding complications after hospital discharge for acute coronary syndrome are common. Patients who experience these bleeding events have distinct baseline characteristics, which vary by anatomic site of the bleed. These characteristics can inform risk‐benefit considerations in deciding on favorable combination and duration of secondary antithrombotic therapy.

Protocol for establishing a child and adolescent twin register for mental health research and capacity building in Sri Lanka and other low and middle-income countries in South Asia

INTRODUCTION

Worldwide, 10%-20% of children and adolescents experience mental health conditions. However, most such disorders remain undiagnosed until adolescence or adulthood. Little is known about the factors that influence mental health in children and adolescents, especially in low and middle-income countries (LMIC), where environmental threats, such as poverty and war, may affect optimal neurodevelopment. Cohort studies provide important information on risks and resilience across the life course by enabling tracking of the effects of early life environment on health during childhood and beyond. Large birth cohort studies, including twin cohorts that can be aetiologically informative, have been conducted within high-income countries but are not generalisable to LMIC. There are limited longitudinal birth cohort studies in LMIC.

METHODS

We sought to enhance the volume of impactful research in Sri Lanka by establishing a Centre of Excellence for cohort studies. The aim is to establish a register of infant, child and adolescent twins, including mothers pregnant with twins, starting in the districts of Colombo (Western Province) and Vavuniya (Northern Province). We will gain consent from twins or parents for future research projects. This register will provide the platform to investigate the aetiology of mental illness and the impact of challenges to early brain development on future mental health. Using this register, we will be able to conduct research that will (1) expand existing research capacity on child and adolescent mental health and twin methods; (2) further consolidate existing partnerships and (3) establish new collaborations. The initiative is underpinned by three pillars: high-quality research, ethics, and patient and public involvement and engagement (PPIE).

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the Ethics Review Committee of Sri Lanka Medical Association and Keele University's Ethical Review Panel. In addition to journal publications, a range of PPIE activities have been conducted.

Incidence and prognostic impact of post discharge bleeding post acute coronary syndrome within an outpatient setting: a systematic review

OBJECTIVE

The primary objective was to determine the incidence of bleeding events post acute coronary syndrome (ACS) following hospital discharge. The secondary objective was to determine the prognostic impact of bleeding on mortality, major adverse cardiovascular events (MACE), myocardial re-infarction and rehospitalisation in the postdischarge setting.

DESIGN

A narrative systematic review.

DATA SOURCE

Medline, Embase, Amed and Central (Cochrane) were searched up to August 2018.

STUDY SELECTION

For the primary objective, randomised controlled trials (RCT) and observational studies reporting on the incidence of bleeding post hospital discharge were included. For the secondary objective, RCTs and observational studies that compared patients with bleeding versus those without bleeding post hospital discharge vis-à-vis mortality, MACE, myocardial re-infarction and rehospitalisation were included.

RESULTS

53 studies (36 observational studies and 17 RCTs) with a combined cohort of 714 458 participants for the primary objectives and 187 317 for the secondary objectives were included. Follow-up ranged from 1 month to just over 4 years. The incidence of bleeding within 12 months post hospital discharge ranged from 0.20% to 37.5% in observational studies and between 0.96% and 39.4% in RCTs. The majority of bleeds occurred in the initial 3 months after hospital discharge with bruising the most commonly reported event. Major bleeding increased the risk of mortality by nearly threefold in two studies. One study showed an increased risk of MACE (HR 3.00,95% CI 2.75 to 3.27; p<0.0001) with bleeding and another study showed a non-significant association with rehospitalisation (HR 1.20,95% CI 0.95 to 1.52; p=0.13).

CONCLUSION

Bleeding complications following ACS management are common and continue to occur in the long term after hospital discharge. These bleeding complications may increase the risk of mortality and MACE, but greater evidence is needed to assess their long-term effects.

PROSPERO REGISTRATION NUMBER

CRD42017062378.

Development and validation of prediction models to estimate risk of primary total hip and knee replacements using data from the UK: two prospective open cohorts using the UK Clinical Practice Research Datalink

Objectives

The ability to efficiently and accurately predict future risk of primary total hip and knee replacement (THR/TKR) in earlier stages of osteoarthritis (OA) has potentially important applications. We aimed to develop and validate two models to estimate an individual’s risk of primary THR and TKR in patients newly presenting to primary care.

Methods

We identified two cohorts of patients aged ≥40 years newly consulting hip pain/OA and knee pain/OA in the Clinical Practice Research Datalink. Candidate predictors were identified by systematic review, novel hypothesis-free ‘Record-Wide Association Study’ with replication, and panel consensus. Cox proportional hazards models accounting for competing risk of death were applied to derive risk algorithms for THR and TKR. Internal–external cross-validation (IECV) was then applied over geographical regions to validate two models.

Results

45 predictors for THR and 53 for TKR were identified, reviewed and selected by the panel. 301 052 and 416 030 patients newly consulting between 1992 and 2015 were identified in the hip and knee cohorts, respectively (median follow-up 6 years). The resultant model C-statistics is 0.73 (0.72, 0.73) and 0.79 (0.78, 0.79) for THR (with 20 predictors) and TKR model (with 24 predictors), respectively. The IECV C-statistics ranged between 0.70–0.74 (THR model) and 0.76–0.82 (TKR model); the IECV calibration slope ranged between 0.93–1.07 (THR model) and 0.92–1.12 (TKR model).

Conclusions

Two prediction models with good discrimination and calibration that estimate individuals’ risk of THR and TKR have been developed and validated in large-scale, nationally representative data, and are readily automated in electronic patient records.

Underrecording of osteoarthritis in United Kingdom primary care electronic health record data

Purpose

Primary care electronic health records are increasingly used to estimate the occurrence of osteoarthritis (OA). We aimed to estimate the extent and trend over time of underrecording of severe OA patients in UK primary care electronic health records using first primary total hip and knee replacements (THR/TKR) - >90% of which are performed for OA - as the reference population.

Patients and methods

We identified patients with a first primary THR or TKR recorded in the UK Clinical Practice Research Datalink between 2000 and 2015. We then searched for a diagnostic/problem code for OA up to 10 years prior to THR/TKR using 3 definitions: "diagnosed OA (joint-specific)," "diagnosed OA (any joint)," "clinical OA" (diagnosed OA or relevant peripheral joint pain symptom code).

Results

Among 34,299 THR patients identified, 28.1%, 53.4%, and 74.4% had a prior record of diagnosed OA (hip), diagnosed OA (any), and clinical OA, respectively. Among 47,588 TKR patients, the corresponding figures were, 25.5% (diagnosed OA [knee]), 43.7%, and 74.8%. In the UK Clinical Practice Research Datalink, the proportion of patients with prior recorded OA decreased between 2000 and 2015.

Conclusion

An increasing trend of underrecording of OA or joint pain among patients with THR or TKR (severe OA patients) between 2000 and 2015 was identified. An underestimate health care demand could be derived based on consultation incidence and prevalence of OA from electronic health record data that relies on osteoarthritis diagnostic codes. Further studies are warranted to investigate the validity of OA or joint pain recorded in primary care settings, which might be used to correct the consultation incidence and prevalence of OA.

Relationship of anxiety with joint pain and its management: A population survey

OBJECTIVES

The aims of the present study was to examine the associations between the severity of pain and anxiety in a community population reporting joint pain, and to investigate the management of joint pain in the presence of comorbid anxiety.

METHODS

A population survey was carried out of people aged ≥45 years, registered with eight general practices in Cheshire, Shropshire and Staffordshire, UK. Respondents were asked to report pain intensity in their hands, hips, knees and feet (on a numerical rating scale), anxiety symptoms (Generalized Anxiety Disorder seven-item [GAD-7] scale) and guideline-recommended treatments used to manage pain. Clinical anxiety was defined by a GAD-7 score of 10 or more.

RESULTS

A total of 11,222 respondents with joint pain were included in the analysis, with 1,802 (16.1%) reporting clinical anxiety. Respondents reporting more severe pain were more likely to report clinical anxiety (severe versus mild pain, odds ratio [OR] 5.36, 95% confidence interval [CI] 4.56 to 6.31). The number of pain sites was also positively associated with clinical anxiety (four versus one site; OR 3.64, 95% CI 3.09 to 4.30). Those with clinical anxiety were less likely to undertake general fitness exercises (OR 0.60, 95% CI 0.52 to 0.70), but more likely to diet (OR 1.43, 95% CI 1.21 to 1.69), use walking aids (OR 1.53, 95% CI 1.32 to 1.77) and assistive devices (OR 1.24, 95% CI 1.04 to 1.49), and more likely to use opioids (OR 1.34, 95% CI 1.18 to1.52).

CONCLUSIONS

Anxiety is common among patients presenting to primary care with joint pain. Patients with anxiety are likely to manage their joint pain differently to those without. Case-finding to identify and treat anxiety would be appropriate in this population, with caution about opioid prescribing and consideration of exercise as an intervention.

Uptake of the NICE osteoarthritis guidelines in primary care: a survey of older adults with joint pain

Background

Osteoarthritis (OA) is a leading cause of pain and disability. NICE OA guidelines (2008) recommend that patients with OA should be offered core treatments in primary care. Assessments of OA management have identified a need to improve primary care of people with OA, as recorded use of interventions concordant with the NICE guidelines is suboptimal in primary care. The aim of this study was to i) describe the patient-reported uptake of non-pharmacological and pharmacological treatments recommended in the NICE OA guidelines in older adults with a self-reported consultation for joint pain and ii) determine whether patient characteristics or OA diagnosis impact uptake.

Methods

A cross-sectional survey mailed to adults aged ≥45 years (n = 28,443) from eight general practices in the UK as part of the MOSAICS study. Respondents who reported the presence of joint pain, a consultation in the previous 12 months for joint pain, and gave consent to medical record review formed the sample for this study.

Results

Four thousand fifty-nine respondents were included in the analysis (mean age 65.6 years (SD 11.2), 2300 (56.7%) females). 502 (12.4%) received an OA diagnosis in the previous 12 months. More participants reported using pharmacological treatments (e.g. paracetamol (31.3%), opioids (40.4%)) than non-pharmacological treatments (e.g. exercise (3.8%)). Those with an OA diagnosis were more likely to use written information (OR 1.57; 95% CI 1.26,1.96), paracetamol (OR 1.30; 95% CI 1.05,1.62) and topical NSAIDs (OR 1.30; 95% CI 1.04,1.62) than those with a joint pain code. People aged ≥75 years were less likely to use written information (OR 0.56; 95% CI 0.40,0.79) and exercise (OR 0.37; 95% CI 0.25,0.55) and more likely to use paracetamol (OR 1.91; 95% CI 1.38,2.65) than those aged < 75 years.

Conclusion

The cross-sectional population survey was conducted to examine the uptake of the treatments that are recommended in the NICE OA guidelines in older adults with a self-reported consultation for joint pain and to determine whether patient characteristics or OA diagnosis impact uptake. Non-pharmacological treatment was suboptimal compared to pharmacological treatment. Implementation of NICE guidelines needs to examine why non-pharmacological treatments, such as exercise, remain under-used especially among older people.

Trends in prescribing of non-steroidal anti-inflammatory drugs in patients with cardiovascular disease: influence of national guidelines in UK primary care

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat pain, but have potential side effects in patients with cardiovascular disease (CVD).

OBJECTIVES

To determine trends in NSAIDs prescribing between 2002 and 2010 in patients with CVD, and ascertain whether prescribing patterns changed following publication of major national (the Medicines and Healthcare products Regulatory Agency (MHRA) and the National Institute for Health and Clinical Excellence (NICE)) guidance to GPs.

METHODS

This was an observational database study of adult patients in 11 practices (Staffordshire, England). NSAIDs were categorised into basic, COX-2 and topical. Study duration was divided on a quarterly basis from 2002-quarter-1 to 2010q4. CVD patients were identified using pre-defined Read Codes recorded in the two years prior to each quarter. Quarterly prevalence was determined. Times of significant changes in prescribing trends were determined using Joinpoint Regression, and compared to dates of the five major guidelines (in 2004q4, 2005q1, 2005q3, 2006q4, 2008q1).

RESULTS

In CVD patients, the prescription of basic NSAIDs showed a decreasing trend throughout the study period, from 774 (95% CI, 691-863) per 10000 patients in 2002q1 to 245 (204-291) in 2010q4. COX-2 prescribing increased from 232/10000 (187-286) in 2002q1 to 403/10000 (348-464) in 2004q3. Prescribing then fell sharply to 102/10000 (76-134) in 2005q2 before stabilising around 55/10000. Topical NSAIDs prescribing showed a steady increase, starting at 115/10000 (108-123) in 2002q1 and ending at 270/10000 (258-281) in 2010q4. Similar trends were observed in patients without CVD, particularly a sharp drop in COX-2 prescribing also occurred from 2004q4 when initial MHRA guidance was issued.

CONCLUSION

Despite guidelines and a trend toward decreased prescribing, the use of potentially harmful NSAIDs continued in CVD patients. The MHRA directives potentially might have affected patients without CVD who may have inappropriately restricted their use of COX-2.

Cost-effectiveness of a model consultation to support self-management in patients with osteoarthritis

Objectives

The aim of this study was to estimate the cost-effectiveness of a model OA consultation for OA to support self-management compared with usual care.

Methods

An incremental cost-utility analysis using patient responses to the three-level EuroQoL-5D (EQ-5D) questionnaire was undertaken from a UK National Health Service perspective alongside a two-arm cluster-randomized controlled trial. Uncertainty was explored through the use of cost-effectiveness acceptability curves.

Results

Differences in health outcomes between the model OA consultation and usual care arms were not statistically significant. On average, visits to the orthopaedic surgeon were lower in the model OA consultation arm by -0.28 (95% CI: -0.55, -0.06). The cost-utility analysis indicated that the model OA consultation was associated with a non-significant incremental cost of £-13.11 (95% CI: -81.09 to 54.85) and an incremental quality adjusted life year (QALY) of -0.003 (95% CI: -0.03 to 0.02), with a 44% chance of being cost-effective at a threshold of £20 000 per QALY gained. The percentage of participants who took time off and the associated productivity cost were lower in the model OA consultation arm.

Conclusion

Implementing National Institute for Health and Care Excellence guidelines using a model OA consultation in primary care does not appear to lead to increased costs, but health outcomes remain very similar to usual care. Even though the intervention seems to reduce the demand for orthopaedic surgery, overall it is unlikely to be cost-effective.

Chronic pain in families: a cross-sectional study of shared social, behavioural, and environmental influences

Chronic pain is common and creates a significant burden to the individual and society. Emerging research has shown the influence of the family environment on pain outcomes. However, it is not clear what shared factors between family members associate with chronic pain. This study aimed to investigate the family-level contribution to an individual's chronic pain status. This was a cross-sectional study using the Generation Scotland: Scottish Family Health Study data set. This study focused on a nested cohort of dyads (only 2 relatives per family, n = 2714). Multi-level modelling was first performed to estimate the extent of variance in chronic pain at the family level. Then each member of the dyad was randomly assigned as either the exposure or outcome family member, and logistic regression was used to identify shared factors associated with the outcome of chronic pain status. Multi-level modelling showed just under 10% of variation in chronic pain status was at a family level. There was an increase in odds of chronic pain if exposure family member had chronic pain (odds ratio [OR]: 1.30, 95% confidence interval [CI]: 1.02-1.65), if both were women (OR: 1.39, 95% CI: 0.99-1.94), if both were older in age (OR: 1.80, 95% CI: 1.31-2.48), and if both had low household income (OR: 3.27, 95% CI: 1.72-6.21). These findings show that most explanation for chronic pain is still at the individual level. However, some significant shared effects between family members associate with chronic pain, and this highlights the influence of the family context.

Patterns of routine primary care for osteoarthritis in the UK: a cross-sectional electronic health records study

OBJECTIVE

To determine common patterns of recorded primary care for osteoarthritis (OA), and patient and provider characteristics associated with the quality of recorded care.

DESIGN

An observational study nested within a cluster-randomised controlled trial.

SETTING

Eight UK general practices who were part of the Management of Osteoarthritis in Consultations study.

PARTICIPANTS

Patients recorded as consulting within the eight general practices for clinical OA.

PRIMARY OUTCOMES

Achievement of seven quality indicators of care (pain/function assessment, information provision, exercise/weight advice, analgesics, physiotherapy), recorded through an electronic template or routinely recorded in the electronic healthcare records, was identified for patients aged ≥45 years consulting over a 6-month period with clinical OA. Latent class analysis was used to cluster patients based on care received. Clusters were compared on patient and clinician-level characteristics.

RESULTS

1724 patients (median by practice 183) consulted with clinical OA. Common patterns of recorded quality care were: cluster 1 (38%, High) received most quality indicators of care; cluster 2 (11%, Moderate) had pain and function assessment, and received or were considered for other indicators; cluster 3 (17%, Low) had pain and function assessment, and received or were considered for paracetamol or topical non-steroidal anti-inflammatory drugs; cluster 4 (35%, None) had no recorded quality indicators. Patients with higher levels of recorded care consulted a clinician who saw more patients with OA, consulted multiple times and had less morbidity. Those in the High cluster were more likely to have recorded diagnosed OA and have knee/hip OA.

CONCLUSIONS

Patterns of recorded care for OA fell into four natural clusters. Appropriate delivery of core interventions and relatively safe pharmacological options for OA are still not consistently recorded as provided in primary care. Further research to understand clinical recording behaviours and determine potential barriers to quality care alongside effective training for clinicians is needed.

TRIAL REGISTRATION NUMBER

ISRCTN06984617; Results.

Population trends in the incidence and initial management of osteoarthritis: age-period-cohort analysis of the Clinical Practice Research Datalink, 1992-2013

Objective

To determine recent trends in the rate and management of new cases of OA presenting to primary healthcare using UK nationally representative data.

Methods

Using the Clinical Practice Research Datalink we identified new cases of diagnosed OA and clinical OA (including OA-relevant peripheral joint pain in those aged over 45 years) using established code lists. For both definitions we estimated annual incidence density using exact person-time, and undertook descriptive analysis and age-period-cohort modelling. Demographic characteristics and management were described for incident cases in each calendar year. Sensitivity analyses explored the robustness of the findings to key assumptions.

Results

Between 1992 and 2013 the annual age-sex standardized incidence rate for clinical OA increased from 29.2 to 40.5/1000 person-years. After controlling for period effects, the consultation incidence of clinical OA was higher for successive cohorts born after the mid-1950s, particularly women. In contrast, with the exception of hand OA, we observed no increase in the incidence of diagnosed OA: 8.6/1000 person-years in 2004 down to 6.3 in 2013. In 2013, 16.4% of clinical OA cases had an X-ray referral. While NSAID prescriptions fell from 2004, the proportion prescribed opioid analgesia rose markedly (0.1% of diagnosed OA in 1992 to 1.9% in 2013).

Conclusion

Rising rates of clinical OA, continued use of plain radiography and a shift towards opioid analgesic prescription are concerning. Our findings support the search for policies to tackle this common problem that promote joint pain prevention while avoiding excessive and inappropriate health care.

Validity of the Visual Trajectories Questionnaire for Pain

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There is growing clinical/research interest in longitudinal patient pain trajectories.

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Validity of a self-report trajectories question was tested in a back pain population.

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Self-report trajectories were compared with derived longitudinal trajectories.

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Acceptable validity is reported of a new self-report measure of trajectories.

Researchers have identified trajectories of pain derived using statistical techniques on longitudinal data. These trajectories have potential to be of use clinically but the repeated data collection required is currently impractical for such situations. Our aim was to investigate the validity of a self-report (Visual Trajectories Questionnaire-Pain) for pain. Analysis included participants from 2 prospective cohorts of people seeking primary health care for back pain (n = 622). A question was developed asking people to classify their pain experience into one of a number of trajectories using visual and word descriptions. Overall 98% of participants completed the question; criterion validity was established by comparing self-report trajectories and trajectories derived using longitudinal latent class analysis, and construct validity was established by comparing responses to the questionnaire against an existing model of back pain stages. As expected variables such as pain intensity and widespreadness, other symptoms, and psychological distress showed an increasing trend of severity across trajectory categories in line with the hypothesized model. In conclusion, the self-report single-item Visual Trajectories Questionnaire-Pain is acceptable to patients and supported by evidence of face, criterion, and construct validity. Further research is needed to investigate the clinical usefulness of the question.

Perspective

This study provides a new questionnaire (Visual Trajectories Questionnaire-Pain) that captures the longitudinal state of a patient's pain experience. The Visual Trajectories Questionnaire-Pain has shown aspects of face, criterion, and construct validity, and has the potential to be clinically useful.

Chest pain and shortness of breath in cardiovascular disease: a prospective cohort study in UK primary care

OBJECTIVE

To determine characteristics associated with monthly chest pain and shortness of breath (SoB) during activity in cardiovascular disease (CVD) and trajectories of these symptoms over 10 months.

STUDY DESIGN AND SETTING

Baseline questionnaire was sent to patients aged ≥40 years from 10 UK general practices. Responders were sent monthly questionnaires for 10 months. For patients with CVD (ischaemic heart disease and heart failure), the association of sociodemographic characteristics, pain elsewhere and anxiety and depression with monthly reports of chest pain and SoB during activity were determined using multilevel, multinomial logistic regression. Common symptom trajectories were determined using dual trajectory latent class growth analysis.

RESULTS

661 patients with CVD completed at least 5 monthly questionnaires. Multiple other pain sites (relative risk ratio: 4.03; 95% CI 1.64 to 9.91) and anxiety or depression (relative risk ratio: 3.31; 95% CI 1.89 to 5.79) were associated with reporting weekly chest pain. Anxiety or depression (relative risk ratio: 4.10; 95% CI 2.72 to 6.17), obesity (relative risk ratio: 2.53; 95% CI 1.49 to 4.30), older age (80+: relative risk ratio: 2.51; 95% CI 1.19 to 5.26), increasing number of pain sites (4+: relative risk ratio: 4.64; 95% CI 2.35 to 9.18) and female gender (relative risk ratio: 1.81; 95% CI 1.20 to 2.75) were associated with reporting weekly SoB. Eight symptom trajectories were identified, with SoB symptoms more common than chest pain.

CONCLUSIONS

Potentially modifiable characteristics are associated with the experience of chest pain and SoB. Identified symptom trajectories may facilitate tailored care to improve outcomes in patients with CVD.

Brief pain re-assessment provided more accurate prognosis than baseline information for low-back or shoulder pain

Background

Research investigating prognosis in musculoskeletal pain conditions has only been moderately successful in predicting which patients are unlikely to recover. Clinical decision making could potentially be improved by combining information taken at baseline and re-consultation.

Methods

Data from four prospective clinical cohorts of adults presenting to UK and Dutch primary care with low-back or shoulder pain was analysed, assessing long-term disability at 6 or 12 months and including baseline and 4–6 week assessments of pain. Baseline versus short-term assessments of pain, and previously validated multivariable prediction models versus repeat assessment, were compared to assess predictive performance of long-term disability outcome. A hypothetical clinical scenario was explored which made efficient use of both baseline and repeated assessment to identify patients likely to have a poor prognosis and decide on further treatment.

Results

Short-term repeat assessment of pain was better than short-term change or baseline score at predicting long-term disability improvement across all cohorts. Short-term repeat assessment of pain was only slightly more predictive of long-term recovery (c-statistics 0.78, 95% CI 0.74 to 0.83 and 0.75, 95% CI 0.69 to 0.82) than a multivariable baseline prognostic model in the two cohorts presenting such a model (c-statistics 0.71, 95% CI 0.67 to 0.76 and 0.72, 95% CI 0.66 to 0.78). Combining optimal prediction at baseline using a multivariable prognostic model with short-term repeat assessment of pain in those with uncertain prognosis in a hypothetical clinical scenario resulted in reduction in the number of patients with an uncertain probability of recovery, thereby reducing the instances where patients may be inappropriately referred or reassured.

Conclusions

Incorporating short-term repeat assessment of pain into prognostic models could potentially optimise the clinical usefulness of prognostic information.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1502-8) contains supplementary material, which is available to authorized users.

Prognosis of undiagnosed chest pain: linked electronic health record cohort study

Objective To ascertain long term cardiovascular outcomes in patients whose chest pain remained undiagnosed six months after first presentation.Design Cohort study.Setting UK electronic health record database (CALIBER) linking primary care, secondary care, coronary registry, and death registry information.Participants 172 180 adults aged ≥18 from 223 general practices presenting with a first episode of recorded chest pain, classified from medical records as diagnosed (non-coronary condition or angina) or undiagnosed (cause unattributed) at first consultation between 2002 and 2009 and with no previous record of cardiovascular disease.Main outcome measures Fatal or non-fatal cardiovascular events over 5.5 years' follow-up. Adjustments were made for age, sex, deprivation, body mass index, smoking status, year of index presentation, and previous records of diabetes or hypertension or previous prescriptions for lipid lowering drugs.Results At the index presentation, 72.4% of patients (124 688) did not have a cause attributed for their chest pain; 118 687 (95.2%) of these did not receive any type of cardiovascular diagnosis over the next six months. Only a minority of patients in all three groups (non-coronary 2.0% (769 of 39 232); unattributed 11.7% (14 582 of 124 688); angina 31.5% (2606 of 8260)) had a recorded cardiac diagnostic investigation in the first six months after presentation. The long term incidence of cardiovascular events was higher in those whose chest pain remained unattributed after six months (5126 of 109 628; 4.7%) compared with patients with an initial diagnosis of non-coronary pain (1073 of 36 097; 3.0%) (adjusted hazard ratios for 0.5-1 year after presentation: 1.95, 95% confidence interval 1.66 to 2.31; for 1-3 years: 1.35, 1.23 to 1.48); for 3-5.5 years: 1.21, 1.08 to 1.37). Owing to the larger number of patients in the unattributed group, there were more excess myocardial infarctions in the long term in this group (214 more than expected based on the rate in the non-coronary group) than in the angina group (132 more than expected). Patients who had cardiac diagnostic investigations in the first six months had a higher long term risk of cardiovascular events, regardless of the initial chest pain label. Incidence of unattributed chest pain and angina decreased between 2002 (124 per 10 000 person years and 13 per 10 000 person years, respectively) and 2009 (107 per 10 000 person years and 5 per 10 000 person years, respectively), but the incidence of chest pain attributed to a non-coronary cause remained stable (37-40 per 10 000 person years). Risk of cardiovascular events did not change over time.Conclusions Most patients with first onset chest pain do not have a diagnosis recorded at presentation or in the subsequent six months, including those who undergo cardiac investigations. These patients have an increased risk of cardiovascular events for at least five years. Efforts to better assess and reduce the cardiovascular risk of such patients are warranted.

Prognosis research ideally should measure time-varying predictors at their intended moment of use

BACKGROUND

Prognosis research studies (e.g. those deriving prognostic models or examining potential predictors of outcome) often collect information on time-varying predictors after their intended moment of use, sometimes using a measurement method different to that which would be used. We aimed to illustrate how estimates of predictor-outcome associations and prognostic model performance obtained from such studies may differ to those at the earlier, intended moment of use.

METHODS

We analysed data from two primary care cohorts of patients consulting for non-inflammatory musculoskeletal conditions: the Prognostic Research Study (PROG-RES: n = 296, aged >50 years) and the Primary care Osteoarthritis Screening Trial (POST: n = 756, >45 years). Both cohorts had collected comparable information on a potentially important time-varying predictor (current pain intensity: 0-10 numerical rating scale), other predictors (age, gender, practice) and outcome (patient-perceived non-recovery at 6 months). Using logistic regression models, we compared the direction and magnitude of predictor-outcome associations and model performance measures under two scenarios: (i) current pain intensity ascertained by the treating general practitioner in the consultation (the intended moment of use) and (ii) current pain intensity ascertained by a questionnaire mailed several days after the consultation.

RESULTS

In both cohorts, the predictor-outcome association was substantially weaker for pain measured at the consultation (OR (95% CI): PROG-RES 1.06 (0.95, 1.18); POST 1.04 (0.96, 1.12)) than for pain measured in the questionnaire (PROG-RES 1.34 (1.20, 1.48); POST 1.26 (1.18, 1.34)). The c-statistic of the multivariable model was lower when pain was measured at the consultation (c-statistic (95% CI): PROG-RES 0.57 (0.51, 0.64); POST 0.66 (0.62, 0.70)) than when pain was measured in the questionnaire (PROG-RES 0.69 (0.63, 0.75); POST 0.72 (0.68, 0.76)), reflecting the lower OR for pain at the consultation.

CONCLUSIONS

Prognostic research studies ideally should measure time-varying predictors at their intended moment of use and using the intended measurement method. Otherwise, they may produce substantially different estimates of predictor-outcome associations and model performance. Researchers should report when, how and where predictors were measured and identify any significant departures from their intended use that may limit the applicability of findings in practice.

TRIAL REGISTRATION

The protocol for the PROG-RES cohort data collection and primary analysis has been published in an open-access journal (Mallen et al., BMC Musculoskelet Disord 7:84, 2006). The POST trial was registered (ISRCTN40721988; date of registration: 21 June 2011; date of enrolment of the first participant: 3 October 2011) and had a pre-specified protocol covering primary analysis. There was no published protocol for the current secondary analyses presented in this manuscript.