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Winn E, Kissane M, Merriel SW, Brain T, Silverwood VA, Whitehead IO, Howe LD, Payne RA, Duncan P. Using the Primary care Academic CollaboraTive to explore the characteristics and healthcare use of older housebound patients in England: protocol for a retrospective observational study and clinician survey (the CHiP study). BJGP Open 2023; 7:BJGPO.2023.0114. [PMID: 37402549 DOI: 10.3399/bjgpo.2023.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Older housebound people are an under-researched group for whom achieving good primary health care can be resource intensive. AIMS To describe the characteristics and healthcare use of older (≥65 years) housebound people; explore clinician views on delivery of care to housebound people; and assess the feasibility of using a new network of healthcare professionals to deliver high quality research. DESIGN & SETTING Retrospective observational study of electronic GP records and clinician survey in England. METHOD Clinical members of a new UK research network called the Primary care Academic CollaboraTive (PACT) will collect the data. For part A, around 20 GP practices will be recruited and clinicians will identify 20 housebound and 20 non-housebound people, matched by age and gender (around 400 total in each group). Anonymised data will be collected on characteristics (age, gender, ethnicity, deprivation decile), long-term conditions, prescribed medicines, quality of healthcare (via Quality Outcomes Framework targets), and continuity of care. Reports with benchmarked practice-level data will be provided to practices to identify areas for quality improvement and to enhance engagement. For part B, 2-4 clinicians will be recruited from around 50 practices in England (around 150 clinicians) to complete a survey about delivery of healthcare for housebound people. For part C, data will be collected to assess the feasibility of using the PACT network to deliver primary care research. CONCLUSION Older housebound people are a neglected group both in terms of research and clinical care. Understanding the characteristics and use of primary healthcare of housebound people will help identify how to improve their care.
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Affiliation(s)
- Elizabeth Winn
- Centre for Academic Primary Care and Population Health Sciences, University of Bristol, Bristol, UK
| | - Madeleine Kissane
- Centre for Academic Primary Care and Population Health Sciences, University of Bristol, Bristol, UK
| | - Samuel Wd Merriel
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Thomas Brain
- Centre for Academic Primary Care and Population Health Sciences, University of Bristol, Bristol, UK
| | | | | | - Laura D Howe
- Centre for Academic Primary Care and Population Health Sciences, University of Bristol, Bristol, UK
| | - Rupert A Payne
- Exeter Collaboration for Academic Primary Care (APEx), Exeter Medical School, University of Exeter, Exeter, UK
| | - Polly Duncan
- Centre for Academic Primary Care and Population Health Sciences, University of Bristol, Bristol, UK
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Edwards PJ, Sellers GM, Leach I, Holt L, Ridd MJ, Payne RA, Barnes RK. Ideas, concerns, expectations, and effects on life (ICEE) in GP consultations: an observational study using video-recorded UK consultations. BJGP Open 2023; 7:BJGPO.2023.0008. [PMID: 37277172 DOI: 10.3399/bjgpo.2023.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/24/2023] [Accepted: 05/31/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Eliciting patients' ideas, concerns, expectations, and whether a problem has an 'effect' on their life (ICEE), is a widely recommended communication technique. However, it is not known how frequently ICEE components are raised in UK GP consultations. AIM To assess the frequency of ICEE in routine GP consultations with adult patients and explore variables associated with ICEE. DESIGN & SETTING An observational study was undertaken. It involved secondary analysis of a pre-existing archive of video-recorded, face-to-face GP consultations in the UK. METHOD Observational coding of 92 consultations took place. Associations were assessed using binomial and ordered logistic regression. RESULTS Most consultations included at least one ICEE component (90.2%). The most common ICEE component per consultation was patient ideas (79.3%), followed by concerns (55.4%), expectations (51.1%), and then effects on life (42.4%). For all ICEE components patients more commonly initiated the ICEE dialogue, and in only three consultations (3.3%) did GPs directly ask patients about their expectations. Problems that were acute (odds ratio [OR] 2.98, 95% confidence interval [CI] = 1.36 to 6.53, P = 0.007) or assessed by GPs aged ≥50 years (OR 2.10, 95% CI = 1.07 to 4.13, P = 0.030) were associated with more ICEE components. Problems assessed later in the consultation (OR 0.60 per problem order increase, 95% CI = 0.41 to 0.87, P = 0.007) by patients aged ≥75 years (OR 0.40, 95% CI = 0.16 to 0.98, P = 0.046) and from the most deprived cohort (OR 0.39, 95% CI = 0.17 to 0.92, P = 0.032) were associated with fewer ICEE components. Patient ideas were associated with more patients being 'very satisfied' post-consultation (OR 10.74, 95% CI = 1.60 to 72.0, P = 0.014) and the opposite was true of concerns (OR 0.14, 95% CI = 0.02 to 0.86, P = 0.034). CONCLUSION ICEE components were associated with patient satisfaction and demographic variables. Further research is required to assess if the way ICEE are communicated affects these associations and other potential confounders.
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Affiliation(s)
- Peter J Edwards
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Grace M Sellers
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Isabel Leach
- University of Sheffield Medical School, University of Sheffield, Sheffield, UK
| | - Lydia Holt
- National Institute for Health and Care Research Health Protection Research Unit, University of Bristol, Bristol, UK
| | - Matthew J Ridd
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rupert A Payne
- Exeter Collaboration for Academic Primary Care, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Rebecca K Barnes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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North TL, Harrison S, Bishop DC, Wootton RE, Carter AR, Richardson TG, Payne RA, Salisbury C, Howe LD. Educational inequality in multimorbidity: causality and causal pathways. A mendelian randomisation study in UK Biobank. BMC Public Health 2023; 23:1644. [PMID: 37641019 PMCID: PMC10463319 DOI: 10.1186/s12889-023-16369-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Multimorbidity, typically defined as having two or more long-term health conditions, is associated with reduced wellbeing and life expectancy. Understanding the determinants of multimorbidity, including whether they are causal, may help with the design and prioritisation of prevention interventions. This study seeks to assess the causality of education, BMI, smoking and alcohol as determinants of multimorbidity, and the degree to which BMI, smoking and alcohol mediate differences in multimorbidity by level of education. METHODS Participants were 181,214 females and 155,677 males, mean ages 56.7 and 57.1 years respectively, from UK Biobank. We used a Mendelian randomization design; an approach that uses genetic variants as instrumental variables to interrogate causality. RESULTS The prevalence of multimorbidity was 55.1%. Mendelian randomization suggests that lower education, higher BMI and higher levels of smoking causally increase the risk of multimorbidity. For example, one standard deviation (equivalent to 5.1 years) increase in genetically-predicted years of education decreases the risk of multimorbidity by 9.0% (95% CI: 6.5 to 11.4%). A 5 kg/m2 increase in genetically-predicted BMI increases the risk of multimorbidity by 9.2% (95% CI: 8.1 to 10.3%) and a one SD higher lifetime smoking index increases the risk of multimorbidity by 6.8% (95% CI: 3.3 to 10.4%). Evidence for a causal effect of genetically-predicted alcohol consumption on multimorbidity was less strong; an increase of 5 units of alcohol per week increases the risk of multimorbidity by 1.3% (95% CI: 0.2 to 2.5%). The proportions of the association between education and multimorbidity explained by BMI and smoking are 20.4% and 17.6% respectively. Collectively, BMI and smoking account for 31.8% of the educational inequality in multimorbidity. CONCLUSIONS Education, BMI, smoking and alcohol consumption are intervenable causal risk factors for multimorbidity. Furthermore, BMI and lifetime smoking make a considerable contribution to the generation of educational inequalities in multimorbidity. Public health interventions that improve population-wide levels of these risk factors are likely to reduce multimorbidity and inequalities in its occurrence.
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Affiliation(s)
- Teri-Louise North
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK.
| | - Sean Harrison
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
| | - Deborah C Bishop
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
| | - Robyn E Wootton
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
- Nic Waals Institute, Lovisenberg Diaconal Hospital, Oslo, Norway
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Alice R Carter
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
| | - Tom G Richardson
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
- Exeter Collaboration for Academic Primary Care, Department of Health and Community Sciences, University of Exeter, Exeter, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | - Laura D Howe
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
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Sheppard JP, Koshiaris C, Stevens R, Lay-Flurrie S, Banerjee A, Bellows BK, Clegg A, Hobbs FDR, Payne RA, Swain S, Usher-Smith JA, McManus RJ. The association between antihypertensive treatment and serious adverse events by age and frailty: A cohort study. PLoS Med 2023; 20:e1004223. [PMID: 37075078 PMCID: PMC10155987 DOI: 10.1371/journal.pmed.1004223] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 05/03/2023] [Accepted: 03/24/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Antihypertensives are effective at reducing the risk of cardiovascular disease, but limited data exist quantifying their association with serious adverse events, particularly in older people with frailty. This study aimed to examine this association using nationally representative electronic health record data. METHODS AND FINDINGS This was a retrospective cohort study utilising linked data from 1,256 general practices across England held within the Clinical Practice Research Datalink between 1998 and 2018. Included patients were aged 40+ years, with a systolic blood pressure reading between 130 and 179 mm Hg, and not previously prescribed antihypertensive treatment. The main exposure was defined as a first prescription of antihypertensive treatment. The primary outcome was hospitalisation or death within 10 years from falls. Secondary outcomes were hypotension, syncope, fractures, acute kidney injury, electrolyte abnormalities, and primary care attendance with gout. The association between treatment and these serious adverse events was examined by Cox regression adjusted for propensity score. This propensity score was generated from a multivariable logistic regression model with patient characteristics, medical history and medication prescriptions as covariates, and new antihypertensive treatment as the outcome. Subgroup analyses were undertaken by age and frailty. Of 3,834,056 patients followed for a median of 7.1 years, 484,187 (12.6%) were prescribed new antihypertensive treatment in the 12 months before the index date (baseline). Antihypertensives were associated with an increased risk of hospitalisation or death from falls (adjusted hazard ratio [aHR] 1.23, 95% confidence interval (CI) 1.21 to 1.26), hypotension (aHR 1.32, 95% CI 1.29 to 1.35), syncope (aHR 1.20, 95% CI 1.17 to 1.22), acute kidney injury (aHR 1.44, 95% CI 1.41 to 1.47), electrolyte abnormalities (aHR 1.45, 95% CI 1.43 to 1.48), and primary care attendance with gout (aHR 1.35, 95% CI 1.32 to 1.37). The absolute risk of serious adverse events with treatment was very low, with 6 fall events per 10,000 patients treated per year. In older patients (80 to 89 years) and those with severe frailty, this absolute risk was increased, with 61 and 84 fall events per 10,000 patients treated per year (respectively). Findings were consistent in sensitivity analyses using different approaches to address confounding and taking into account the competing risk of death. A strength of this analysis is that it provides evidence regarding the association between antihypertensive treatment and serious adverse events, in a population of patients more representative than those enrolled in previous randomised controlled trials. Although treatment effect estimates fell within the 95% CIs of those from such trials, these analyses were observational in nature and so bias from unmeasured confounding cannot be ruled out. CONCLUSIONS Antihypertensive treatment was associated with serious adverse events. Overall, the absolute risk of this harm was low, with the exception of older patients and those with moderate to severe frailty, where the risks were similar to the likelihood of benefit from treatment. In these populations, physicians may want to consider alternative approaches to management of blood pressure and refrain from prescribing new treatment.
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Affiliation(s)
- James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Brandon K Bellows
- Columbia University Irving Medical Center, New York, New York, United States of America
| | - Andrew Clegg
- Academic Unit for Ageing & Stroke Research, University of Leeds, Leeds, United Kingdom
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Health and Community Sciences, University of Exeter Medical School, Exeter, United Kingdom
| | - Subhashisa Swain
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Hodkinson A, Zghebi SS, Kontopantelis E, Grigoroglou C, Ashcroft D, Hann M, Chew-Graham CA, Payne RA, Little P, de Lusignan S, Zhou A, Esmail A, Maria P. The association of strong opioids and antibiotics prescribing with general practitioner burnout. Br J Gen Pract 2023. [PMID: 37500457 PMCID: PMC10227993 DOI: 10.3399/bjgp.2022.0394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
Background: Prescribing of strong-opioids and antibiotics has important implications for patient safety. General Practitioner (GP) wellness can affect the overprescribing of both medications in primary care. Aim: To examine the associations between strong opioid and antibiotic prescribing with practice-weighted GP-burnout and wellness scores. Design and Setting: A cross-sectional study using prescription data on strong-opioids/antibiotics from the Oxford-RCGP-RSC linking to a GP-wellbeing survey overlaying the same 4-month period December2019-April2020. Methods: Adult prescriptions were measured as tablets per-patient. Burnout in GPs was measured using the shortened versions of the emotional exhaustion and depersonalisation dimensions. Association was examined by fitting a multilevel generalised-linear-model with negative-binomial distribution. Results: Data for 40,227 patients (13,483 strong opioids and 26,744 antibiotics) were linked to 57 practices and 320 GPs. Greater strong opioid prescribing was associated with increased emotional exhaustion (IRR 1.19, 95%CI 1.10-1.24), depersonalisation (1.10, 1.01-1.16), job dissatisfaction (1.25, 1.19-1.32), diagnostic-uncertainty (1.12, 1.08-1.19) and turnover intention (1.32, 1.27-1.37) in GPs. Greater antibiotic prescribing was associated with increased emotional exhaustion (1.19, 1.05-1.37), depersonalisation (1.24, 1.08-1.49), job dissatisfaction (1.11, 1.04-1.19), sickness-presenteeism (1.18, 1.11-1.25) and turnover intention (1.38, 1.31-1.45) in GPs. Increased strong-opioid and antibiotic prescribing was also found in GPs working longer hours (3.95, 3.39-4.61; 5.02, 4.07-6.19, respectively) and in practices in the north of England (1.96, 1.61-2.33; 1.56, 1.12-3.70, respectively). Conclusion: We found higher rates of prescribing of strong opioids/antibiotics in practices with GPs with more burnout symptoms, job dissatisfaction and turnover intentions, working longer hours and in practices in the north of England serving more deprived populations.
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Naughton M, Payne RA. The fight against climate change in primary care: a prescription for change. Fam Pract 2023; 40:508-510. [PMID: 36821486 DOI: 10.1093/fampra/cmac119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Affiliation(s)
- Michael Naughton
- Department of Population Health Sciences, King's College London, London, United Kingdom
| | - Rupert A Payne
- Department of Primary Care, The University of Exeter, Exeter, United Kingdom
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Payne RA, Blair PS, Caddick B, Chew-Graham CA, Dreischulte T, Duncan LJ, Guthrie B, Mann C, Parslow RM, Round J, Salisbury C, Turner KM, Turner NL, McCahon D. Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP): Protocol for a multicentre cluster randomised trial comparing a complex intervention for medication optimization against usual care. NIHR Open Res 2022; 2:54. [PMID: 37881305 PMCID: PMC10593356 DOI: 10.3310/nihropenres.13285.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 10/27/2023]
Abstract
Introduction Polypharmacy is increasingly common, and associated with undesirable consequences. Polypharmacy management necessitates balancing therapeutic benefits and risks, and varying clinical and patient priorities. Current guidance for managing polypharmacy is not supported by high quality evidence. The aim of the Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP) trial is to evaluate the effectiveness of an intervention to optimise medication use for patients with polypharmacy in a general practice setting. Methods This trial will use a multicentre, open-label, cluster-randomised controlled approach, with two parallel groups. Practices will be randomised to a complex intervention comprising structured medication review (including interprofessional GP/pharmacist treatment planning and patient-facing review) supported by performance feedback, financial incentivisation, clinician training and clinical informatics (intervention), or usual care (control). Patients with polypharmacy and triggering potentially inappropriate prescribing (PIP) indicators will be recruited in each practice using a computerised search of health records. 37 practices will recruit 50 patients, and review them over a 26-week intervention delivery period. The primary outcome is the mean number of PIP indicators triggered per patient at 26 weeks follow-up, determined objectively from coded GP electronic health records. Secondary outcomes will include patient reported outcome measures, and health and care service use. The main intention-to-treat analysis will use linear mixed effects regression to compare number of PIP indicators triggered at 26 weeks post-review between groups, adjusted for baseline (pre-randomisation) values. A nested process evaluation will explore implementation of the intervention in primary care. Ethics and dissemination The protocol and associated study materials have been approved by the Wales REC 6, NHS Research Ethics Committee (REC reference 19/WA/0090), host institution and Health Research Authority. Research outputs will be published in peer-reviewed journals and relevant conferences, and additionally disseminated to patients and the public, clinicians, commissioners and policy makers. ISRCTN Registration 90146150 (28/03/2019).
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Affiliation(s)
- Rupert A. Payne
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Peter S. Blair
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Barbara Caddick
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | | | - Tobias Dreischulte
- Institute of General Practice and Family Medicine, Medical Center of the Ludwig-Maximilians-University, Munich, Germany
| | - Lorna J. Duncan
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Bruce Guthrie
- Advanced Care Research Centre, University of Edinburgh, Edinburgh, UK
| | - Cindy Mann
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | | | - Jeff Round
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Chris Salisbury
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Katrina M. Turner
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | | | - Deborah McCahon
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Archer L, Koshiaris C, Lay-Flurrie S, Snell KIE, Riley RD, Stevens R, Banerjee A, Usher-Smith JA, Clegg A, Payne RA, Hobbs FDR, McManus RJ, Sheppard JP. Development and external validation of a risk prediction model for falls in patients with an indication for antihypertensive treatment: retrospective cohort study. BMJ 2022; 379:e070918. [PMID: 36347531 PMCID: PMC9641577 DOI: 10.1136/bmj-2022-070918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To develop and externally validate the STRAtifying Treatments In the multi-morbid Frail elderlY (STRATIFY)-Falls clinical prediction model to identify the risk of hospital admission or death from a fall in patients with an indication for antihypertensive treatment. DESIGN Retrospective cohort study. SETTING Primary care data from electronic health records contained within the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS Patients aged 40 years or older with at least one blood pressure measurement between 130 mm Hg and 179 mm Hg. MAIN OUTCOME MEASURE First serious fall, defined as hospital admission or death with a primary diagnosis of a fall within 10 years of the index date (12 months after cohort entry). Model development was conducted using a Fine-Gray approach in data from CPRD GOLD, accounting for the competing risk of death from other causes, with subsequent recalibration at one, five, and 10 years using pseudo values. External validation was conducted using data from CPRD Aurum, with performance assessed through calibration curves and the observed to expected ratio, C statistic, and D statistic, pooled across general practices, and clinical utility using decision curve analysis at thresholds around 10%. RESULTS Analysis included 1 772 600 patients (experiencing 62 691 serious falls) from CPRD GOLD used in model development, and 3 805 366 (experiencing 206 956 serious falls) from CPRD Aurum in the external validation. The final model consisted of 24 predictors, including age, sex, ethnicity, alcohol consumption, living in an area of high social deprivation, a history of falls, multiple sclerosis, and prescriptions of antihypertensives, antidepressants, hypnotics, and anxiolytics. Upon external validation, the recalibrated model showed good discrimination, with pooled C statistics of 0.833 (95% confidence interval 0.831 to 0.835) and 0.843 (0.841 to 0.844) at five and 10 years, respectively. Original model calibration was poor on visual inspection and although this was improved with recalibration, under-prediction of risk remained (observed to expected ratio at 10 years 1.839, 95% confidence interval 1.811 to 1.865). Nevertheless, decision curve analysis suggests potential clinical utility, with net benefit larger than other strategies. CONCLUSIONS This prediction model uses commonly recorded clinical characteristics and distinguishes well between patients at high and low risk of falls in the next 1-10 years. Although miscalibration was evident on external validation, the model still had potential clinical utility around risk thresholds of 10% and so could be useful in routine clinical practice to help identify those at high risk of falls who might benefit from closer monitoring or early intervention to prevent future falls. Further studies are needed to explore the appropriate thresholds that maximise the model's clinical utility and cost effectiveness.
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Affiliation(s)
- Lucinda Archer
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Kym I E Snell
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Richard D Riley
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK
| | - Andrew Clegg
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, University of Leeds, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, UK
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Tammes P, Payne RA, Salisbury C. Association between continuity of primary care and both prescribing and adherence of common cardiovascular medications: a cohort study among patients in England. BMJ Open 2022; 12:e063282. [PMID: 36100300 PMCID: PMC9472141 DOI: 10.1136/bmjopen-2022-063282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To investigate whether better continuity of care is associated with increased prescribing of clinically relevant medication and improved medication adherence. SETTING Random sample of 300 000 patients aged 30+ in 2017 within 83 English general practitioner (GP) practices from the Clinical Practice Research Datalink. DESIGN Patients were assigned to a randomly selected index date in 2017 on which medication use and continuity of care were determined. Adjusted associations between continuity of care and the prescribing and adherence of five cardiovascular medication groups were examined using logistic regression. PARTICIPANTS Continuity of Care Index was calculated for 173 993 patients with 4+ GP consultations 2 years prior to their index date and divided into five categories: absence of continuity, below-average continuity, average, above-average continuity and perfect continuity. MAIN OUTCOME MEASURES (A) Prescription for statins (primary or secondary prevention separately), anticoagulants, antiplatelet agents and antihypertensives covering the patient's index date. (B) Adherence (>80%) estimated using medication possession ratio. RESULTS There was strong evidence (p<0.01) that prescription of all five cardiovascular medication groups increased with greater continuity of care. Patients with absence of continuity were less likely to be prescribed cardiovascular medications than patients with above-average continuity (statins primary prevention OR 0.73, 95% CI 0.59 to 0.85; statins secondary prevention 0.77, 95% CI 0.57 to 1.03; antiplatelets 0.55, 95% CI 0.33 to 0.92; antihypertensives 0.51, 95% CI 0.39 to 0.65). Furthermore, patients with perfect continuity were more likely to be prescribed cardiovascular medications than those with above-average continuity (statins primary prevention OR 1.23, 95% CI 1.01 to 1.49; statins secondary prevention 1.37, 95% CI 1.10 to 1.71; antiplatelets 1.37, 95% CI 1.08 to 1.74; antihypertensives 1.10, 95% CI 0.99 to 1.23). Continuity was generally not associated with medication adherence, except for adherence to statins for secondary prevention (OR 0.75, 95% CI 0.60 to 0.94 for average compared with above-average continuity). CONCLUSION Better continuity of care is associated with improved prescribing of medication to patients at higher risk of cardiovascular disease but does not appear to be related to patient's medication adherence.
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Affiliation(s)
- Peter Tammes
- Centre for Academic Primary Care (CAPC), Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Rupert A Payne
- Centre for Academic Primary Care (CAPC), Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care (CAPC), Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
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Abstract
BACKGROUND Antidepressants are one of the most widely prescribed drugs in the global north. However, little is known about the health consequences of long-term treatment. AIMS This study aimed to investigate the association between antidepressant use and adverse events. METHOD The study cohort consisted of UK Biobank participants whose data was linked to primary care records (N = 222 121). We assessed the association between antidepressant use by drug class (selective serotonin reuptake inhibitors (SSRIs) and 'other') and four morbidity (diabetes, hypertension, coronary heart disease (CHD), cerebrovascular disease (CV)) and two mortality (cardiovascular disease (CVD) and all-cause) outcomes, using Cox's proportional hazards model at 5- and 10-year follow-up. RESULTS SSRI treatment was associated with decreased risk of diabetes at 5 years (hazard ratio 0.64, 95% CI 0.49-0.83) and 10 years (hazard ratio 0.68, 95% CI 0.53-0.87), and hypertension at 10 years (hazard ratio 0.77, 95% CI 0.66-0.89). At 10-year follow-up, SSRI treatment was associated with increased risks of CV (hazard ratio 1.34, 95% CI 1.02-1.77), CVD mortality (hazard ratio 1.87, 95% CI 1.38-2.53) and all-cause mortality (hazard ratio 1.73, 95% CI 1.48-2.03), and 'other' class treatment was associated with increased risk of CHD (hazard ratio 1.99, 95% CI 1.31-3.01), CVD (hazard ratio 1.86, 95% CI 1.10-3.15) and all-cause mortality (hazard ratio 2.20, 95% CI 1.71-2.84). CONCLUSIONS Our findings indicate an association between long-term antidepressant usage and elevated risks of CHD, CVD mortality and all-cause mortality. Further research is needed to assess whether the observed associations are causal, and elucidate the underlying mechanisms.
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Affiliation(s)
- Narinder Bansal
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Mohammed Hudda
- Population Health Research Institute, St George's, University of London, UK
| | - Rupert A Payne
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Daniel J Smith
- Centre for Clinical Brain Sciences, University of Edinburgh, Royal Edinburgh Hospital, UK
| | - David Kessler
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Nicola Wiles
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, UK
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11
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Oliver-Williams C, Stevens D, Payne RA, Wilkinson IB, Smith GCS, Wood A. Association between hypertensive disorders of pregnancy and later risk of cardiovascular outcomes. BMC Med 2022; 20:19. [PMID: 35073907 PMCID: PMC8787919 DOI: 10.1186/s12916-021-02218-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 12/14/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy are common pregnancy complications that are associated with greater cardiovascular disease risk for mothers. However, risk of cardiovascular disease subtypes associated with gestational hypertension or pre-eclampsia is unclear. The present study aims to compare the risk of cardiovascular disease outcomes for women with and without a history of gestational hypertension and pre-eclampsia using national hospital admissions data. METHODS This was a retrospective cohort study of national medical records from all National Health Service hospitals in England. Women who had one or more singleton live births in England between 1997 and 2015 were included in the analysis. Risk of total cardiovascular disease and 19 pre-specified cardiovascular disease subtypes, including stroke, coronary heart disease, cardiomyopathy and peripheral arterial disease, was calculated separately for women with a history of gestational hypertension and pre-eclampsia compared to normotensive pregnancies. RESULTS Amongst 2,359,386 first live births, there were 85,277 and 74,542 hospital admissions with a diagnosis of gestational hypertension and pre-eclampsia, respectively. During 18 years (16,309,386 person-years) of follow-up, the number and incidence of total CVD for normotensive women, women with prior gestational hypertension and women with prior pre-eclampsia were n = 8668, 57.1 (95% CI: 55.9-58.3) per 100,000 person-years; n = 521, 85.8 (78.6-93.5) per 100,000 person-years; and n = 518, 99.3 (90.9-108.2) per 100,000 person-years, respectively. Adjusted HRs (aHR) for total CVD were aHR (95% CI) = 1.45 (1.33-1.59) for women with prior gestational hypertension and aHR = 1.62 (1.48-1.78) for women with prior pre-eclampsia. Gestational hypertension was strongly associated with dilated cardiomyopathy, aHR = 2.85 (1.67-4.86), and unstable angina, aHR = 1.92 (1.33-2.77). Pre-eclampsia was strongly associated with hypertrophic cardiomyopathy, aHR = 3.27 (1.49-7.19), and acute myocardial infarction, aHR = 2.46 (1.72-3.53). Associations were broadly homogenous across cardiovascular disease subtypes and increased with a greater number of affected pregnancies. CONCLUSIONS Women with either previous gestational hypertension or pre-eclampsia are at greater risk of a range of cardiovascular outcomes. These women may benefit from clinical risk assessment or early interventions to mitigate their greater risk of various cardiovascular outcomes.
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Affiliation(s)
- Clare Oliver-Williams
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, England, UK. .,Homerton College, Hills Road, Cambridge, UK. .,Department of Health Sciences, University of Leicester, George Davies Centre, University Road, Leicester, UK.
| | - David Stevens
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, England, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ian B Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, England, UK.,Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, England, UK
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, UK.,NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Angela Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, England, UK.,British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, England, UK.,National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, England, UK.,National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals, Cambridge, England, UK.,Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, England, UK
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12
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McCahon D, Denholm RE, Huntley AL, Dawson S, Duncan P, Payne RA. Development of a model of medication review for use in clinical practice: Bristol medication review model. BMC Med 2021; 19:262. [PMID: 34753511 PMCID: PMC8579564 DOI: 10.1186/s12916-021-02136-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medication review is a core aspect of medicine optimisation, yet existing models of review vary substantially in structure and content and are not necessarily easy to implement in clinical practice. This study aimed to use evidence from the existing literature to identify key medication review components and use this to inform the design of an improved review model. METHODS A systematic review was conducted (PROSPERO: CRD42018109788) to identify randomised control trials of stand-alone medication review in adults (18+ years). The review updated that by Huiskes et al. (BMC Fam Pract. 18:5, 2017), using the same search strategy implemented in MEDLINE and Embase. Studies were assessed using the Cochrane risk of bias tool. Key review components were identified, alongside relevant clinical and health service outcomes. A working group (patients, doctors and pharmacists) developed the model through an iterative consensus process (appraisal of documents plus group discussions), working from the systematic review findings, brief evidence summaries for core review components and examples of previous models, to agree on the main purpose of the review model, overarching model structure, review components and supporting material. RESULTS We identified 28 unique studies, with moderate bias overall. Consistent medication review components included reconciliation (26 studies), safety assessment (22), suboptimal treatment (19), patient knowledge/preferences (18), adherence (14), over-the-counter therapy (13) and drug monitoring (10). There was limited evidence from studies for improvement in key clinical outcomes. The review structure was underpinned by patient values and preferences, with parallel information gathering and evaluation stages, feeding into the final decision-making and implementation. Most key components identified in the literature were included. The final model was considered to benefit from a patient-centred, holistic approach, which captured both patient-orientated and medication-focused problems, and aligned with traditional consultation methods thus facilitating implementation in practice. CONCLUSIONS The Bristol Medication Review Model provides a framework for standardised delivery of structured reviews. The model has the potential for use by all healthcare professionals with relevant clinical experience and is designed to offer flexibility of implementation not limited to a particular healthcare setting.
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Affiliation(s)
- D McCahon
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK
| | - R E Denholm
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK
| | - A L Huntley
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK
| | - S Dawson
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK
| | - P Duncan
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK
| | - R A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK.
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13
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Scott L, Redaniel MT, Booker M, Payne RA, Tilling K. Regression discontinuity analysis for pharmacovigilance: statin example reflected trial findings showing little evidence of harm. J Clin Epidemiol 2021; 141:121-131. [PMID: 34648942 PMCID: PMC8982642 DOI: 10.1016/j.jclinepi.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 09/19/2021] [Accepted: 10/04/2021] [Indexed: 11/30/2022]
Abstract
RDA can be used with routine healthcare data, resulting in findings similar to Randomized controlled trials. Application of regression discontinuity analysis (RDA) in epidemiology should include examination of the assumptions. RDA should employ sensitivity analyses and negative control analyses. RDA should carefully consider choice of model and bandwidth.
Objectives The study aims to explore the use of regression discontinuity analysis (RDA) to examine effects of prescription of statins on total cholesterol and adverse outcomes (type 2 diabetes, rhabdomyolysis and myopathy, myalgia and myositis, liver disease, CVD, and mortality). Study Design and Setting We conducted a prospective cohort study using the Clinical Practice Research Datalink including patients with QRISK scores of 10 to 30 in 2010 to 2013 who were last followed-up in October 2016. Comparing patients with QRISK≥20 and QRISK<20, we explored RDA assumptions, provided proof of concept analyses (total cholesterol as outcome), and investigated the effect of statins prescription on adverse outcomes. Result RDA confirmed statin prescription reduced total cholesterol (Mean difference (MD) -1.33 mmol/L, 95%Confidence Interval (CI) -1.93 to -0.73). RDA provided little evidence for adverse effects on diabetes, myalgia and myositis, liver disease, CVD, or mortality. The RDA analysis findings are similar to RCT results. Findings from non-RDA analysis agree with published observational studies. Conclusion RDA can be used with large routine clinical datasets to provide evidence on effects of medications which are prescribed according to a threshold. Testable RDA assumptions were satisfied, but confidence intervals were wide, partly due to the low compliance with the prescribing threshold.
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Affiliation(s)
- Lauren Scott
- National Institute for Health Research Applied Research Collaboration West, University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK; Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Maria Theresa Redaniel
- National Institute for Health Research Applied Research Collaboration West, University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK; Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Matthew Booker
- Centre for Academic Primary Care, Bristol Medical School, Canynge Hall, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Bristol Medical School, Canynge Hall, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Kate Tilling
- National Institute for Health Research Applied Research Collaboration West, University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK; Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK; MRC Integrative Epidemiology Unit, Bristol Medical School, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
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14
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Culeddu G, Su L, Cheng Y, Pereira DIA, Payne RA, Powell JJ, Hughes DA. Novel oral iron therapy for iron deficiency anaemia: How to value safety in a new drug? Br J Clin Pharmacol 2021; 88:1347-1357. [PMID: 34510516 DOI: 10.1111/bcp.15078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 09/02/2021] [Accepted: 09/05/2021] [Indexed: 10/20/2022] Open
Abstract
AIMS Novel oral iron supplements may be associated with a reduced incidence of adverse drug reactions compared to standard treatments of iron deficiency anaemia. The aim was to establish their value-based price under conditions of uncertainty surrounding their tolerability. METHODS A discrete-time Markov model was developed to assess the value-based price of oral iron preparations based on their incremental cost per quality-adjusted life year (QALY) gained from the perspective of the NHS in the UK. Primary and secondary care resource use and health state occupancy probabilities were estimated from routine electronic health records; and unit costs and health state utilities were derived from published sources. Patients were pre-menopausal women with iron deficiency anaemia who were prescribed oral iron supplementation between 2000 and 2014. RESULTS The model reflecting current use of iron salts yielded a mean total cost to the NHS of £779, and 0.84 QALYs over 12 months. If a new iron preparation were to reduce the risk of adverse drug reactions by 30-40%, then its value-based price, based on a threshold of £20 000 per QALY, would be in the region of £10-£13 per month, or about 7-9 times the average price of basic iron salts. CONCLUSIONS There are no adequate, direct comparisons of new oral iron supplements to ferrous iron salts, and therefore other approaches are needed to assess their value. Our modelling shows that they are potentially cost-effective at prices that are an order of magnitude higher than existing iron salts.
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Affiliation(s)
- Giovanna Culeddu
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, United Kingdom
| | - Li Su
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Yafeng Cheng
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Dora I A Pereira
- Department of Pathology, University of Cambridge, Cambridge, United Kingdom.,MRC Human Nutrition Research, Cambridge, United Kingdom
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Jonathan J Powell
- Biomineral Research Group, Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, United Kingdom
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15
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Arnold DT, Hamilton FW, Morris TT, Suri T, Morley A, Frost V, Vipond IB, Medford AR, Payne RA, Muir P, Maskell NA. Epidemiology of pleural empyema in English hospitals and the impact of influenza. Eur Respir J 2021; 57:2003546. [PMID: 33334937 PMCID: PMC8411895 DOI: 10.1183/13993003.03546-2020] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023]
Abstract
Pleural empyema represents a significant healthcare burden due to extended hospital admissions and potential requirement for surgical intervention. This study aimed to assess changes in incidence and management of pleural empyema in England over the past 10 years and the potential impact of influenza on rates.Hospital Episode Statistics data were used to identify patients admitted to English hospitals with pleural empyema between 2008 and 2018. Linear regression was used to analyse the relationship between empyema rates and influenza incidence recorded by Public Health England. The relationship between influenza and empyema was further explored using serological data from a prospective cohort study of patients presenting with pleural empyema.Between April 2008 and March 2018 there were 55 530 patients admitted with pleural empyema. There was male predominance (67% versus 33%), which increased with age. Cases have increased significantly from 4447 in 2008 to 7268 in 2017. Peaks of incidence correlated moderately with rates of laboratory-confirmed influenza in children and young adults (r=0.30). For nine of the 10 years studied, the highest annual point incidence of influenza coincided with the highest admission rate for empyema (with a 2-week lag). In a cohort study of patients presenting to a single UK hospital with pleural empyema/infection, 24% (17 out of 72) had serological evidence of recent influenza infection, compared to 7% in seasonally matched controls with simple parapneumonic or cardiogenic effusions (p<0.001).Rates of empyema admissions in England have increased steadily with a seasonal variation that is temporally related to influenza incidence. Patient-level serological data from a prospective study support the hypothesis that influenza may play a pathogenic role in empyema development.
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Affiliation(s)
- David T Arnold
- Bristol Academic Respiratory Unit, Learning and Research Centre, Southmead Hospital, Bristol, UK
| | | | - Tim T Morris
- MRC Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim Suri
- Public Health England South West Regional Laboratory, National Infection Service, Pathology Sciences Building, Science Quarter, Southmead Hospital, Bristol, UK
| | - Anna Morley
- Bristol Academic Respiratory Unit, Learning and Research Centre, Southmead Hospital, Bristol, UK
| | - Vicky Frost
- Public Health England South West Regional Laboratory, National Infection Service, Pathology Sciences Building, Science Quarter, Southmead Hospital, Bristol, UK
| | - Ian B Vipond
- Public Health England South West Regional Laboratory, National Infection Service, Pathology Sciences Building, Science Quarter, Southmead Hospital, Bristol, UK
| | - Andrew R Medford
- Bristol Academic Respiratory Unit, Learning and Research Centre, Southmead Hospital, Bristol, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Muir
- Public Health England South West Regional Laboratory, National Infection Service, Pathology Sciences Building, Science Quarter, Southmead Hospital, Bristol, UK
| | - Nick A Maskell
- Bristol Academic Respiratory Unit, Learning and Research Centre, Southmead Hospital, Bristol, UK
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16
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Hayward S, Hole B, Denholm R, Duncan P, Morris JE, Fraser SDS, Payne RA, Roderick P, Chesnaye NC, Wanner C, Drechsler C, Postorino M, Porto G, Szymczak M, Evans M, Dekker FW, Jager KJ, Caskey FJ. International prescribing patterns and polypharmacy in older people with advanced chronic kidney disease: results from the European Quality study. Nephrol Dial Transplant 2021; 36:503-511. [PMID: 32543669 DOI: 10.1093/ndt/gfaa064] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND People with chronic kidney disease (CKD) are at high risk of polypharmacy. However, no previous study has investigated international prescribing patterns in this group. This article aims to examine prescribing and polypharmacy patterns among older people with advanced CKD across the countries involved in the European Quality (EQUAL) study. METHODS The EQUAL study is an international prospective cohort study of patients ≥65 years of age with advanced CKD. Baseline demographic, clinical and medication data were analysed and reported descriptively. Polypharmacy was defined as ≥5 medications and hyperpolypharmacy as ≥10. Univariable and multivariable linear regressions were used to determine associations between country and the number of prescribed medications. Univariable and multivariable logistic regression were used to determine associations between country and hyperpolypharmacy. RESULTS Of the 1317 participants from five European countries, 91% were experiencing polypharmacy and 43% were experiencing hyperpolypharmacy. Cardiovascular medications were the most prescribed medications (mean 3.5 per person). There were international differences in prescribing, with significantly greater hyperpolypharmacy in Germany {odds ratio (OR) 2.75 [95% confidence interval (CI) 1.73-4.37]; P < 0.001, reference group UK}, the Netherlands [OR 1.91 (95% CI 1.32-2.76); P = 0.001] and Italy [OR 1.57 (95% CI 1.15-2.15); P = 0.004]. People in Poland experienced the least hyperpolypharmacy [OR 0.39 (95% CI 0.17-0.87); P = 0.021]. CONCLUSIONS Hyperpolypharmacy is common among older people with advanced CKD, with significant international differences in the number of medications prescribed. Practice variation may represent a lack of consensus regarding appropriate prescribing for this high-risk group for whom pharmacological treatment has great potential for harm as well as benefit.
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Affiliation(s)
- Samantha Hayward
- UK Renal Registry, Southmead Hospital, Bristol, UK.,Bristol Medical School, University of Bristol, Bristol, UK.,Department of Nephrology, Southmead Hospital, North Bristol Trust, Bristol, UK
| | - Barnaby Hole
- UK Renal Registry, Southmead Hospital, Bristol, UK.,Bristol Medical School, University of Bristol, Bristol, UK.,Department of Nephrology, Southmead Hospital, North Bristol Trust, Bristol, UK
| | - Rachel Denholm
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Polly Duncan
- Bristol Medical School, University of Bristol, Bristol, UK
| | - James E Morris
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton UK
| | - Simon D S Fraser
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton UK
| | - Rupert A Payne
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Roderick
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton UK
| | - Nicholas C Chesnaye
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Christiane Drechsler
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Maurizio Postorino
- Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, CNR-IFC, Reggio Calabria, Italy
| | - Gaetana Porto
- Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, CNR-IFC, Reggio Calabria, Italy
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Marie Evans
- Department of Clinical Sciences Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Fergus J Caskey
- Bristol Medical School, University of Bristol, Bristol, UK.,Department of Nephrology, Southmead Hospital, North Bristol Trust, Bristol, UK
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17
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Sheppard JP, Lown M, Burt J, Ford GA, Hobbs FDR, Little P, Mant J, Payne RA, McManus RJ. Blood Pressure Changes Following Antihypertensive Medication Reduction, by Drug Class and Dose Chosen for Withdrawal: Exploratory Analysis of Data From the OPTiMISE Trial. Front Pharmacol 2021; 12:619088. [PMID: 33959004 PMCID: PMC8093867 DOI: 10.3389/fphar.2021.619088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/03/2021] [Indexed: 11/13/2022] Open
Abstract
Aims: Deprescribing of antihypertensive drugs is recommended for some older patients with polypharmacy, but there is little evidence to inform which drug (or dose) should be withdrawn. This study used data from the OPTiMISE trial to examine whether short-term outcomes of deprescribing vary by drug class and dose of medication withdrawn. Methods: The OPTiMISE trial included patients aged ≥80 years with controlled systolic blood pressure (SBP; <150 mmHg), receiving ≥2 antihypertensive medications. This study compared SBP control, mean change in SBP and frequency of adverse events after 12 weeks in participants stopping one medication vs. usual care, by drug class and equivalent dose of medication withdrawn. Equivalent dose was determined according to the defined daily dose (DDD) of each medication type. Drugs prescribed below the DDD were classed as low dose and those prescribed at ≥DDD were described as higher dose. Outcomes were examined by generalized linear mixed effects models. Results: A total of 569 participants were randomized, aged 85 ± 3 years with controlled blood pressure (mean 130/69 mmHg). Within patients prescribed calcium channel blockers, higher dose medications were more commonly selected for withdrawal (90 vs. 10%). In those prescribed beta-blockers, low dose medications were more commonly chosen (87 vs. 13%). Withdrawal of calcium channel blockers was associated with an increase in SBP (5 mmHg, 95%CI 0-10 mmHg) and reduced SBP control (adjusted RR 0.89, 95%CI 0.80-0.998) compared to usual care. In contrast, withdrawal of beta-blockers was associated with no change in SBP (-4 mmHg, 95%CI -10 to 2 mmHg) and no difference in SBP control (adjusted RR 1.15, 95%CI 0.96-1.37). Similarly, withdrawal of higher dose medications was associated with an increase in SBP but no change in BP control. Withdrawal of lower dose medications was not associated with a difference in SBP or SBP control. There was no association between withdrawal of specific drug classes and adverse events. Conclusion: These exploratory data suggest withdrawal of higher dose calcium channel blockers should be avoided if the goal is to maintain BP control. However, low dose beta-blockers may be removed with little impact on blood pressure over 12-weeks of follow-up. Larger studies are needed to confirm these associations.
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Affiliation(s)
- James P. Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Mark Lown
- Primary Care Research Group, University of Southampton, Southampton, United Kingdom
| | - Jenni Burt
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, United Kingdom
| | - Gary A. Ford
- Radcliffe Department of Medicine, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - F. D. Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, United Kingdom
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Rupert A. Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Richard J. McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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18
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Dambha-Miller H, Griffin SJ, Young D, Watkinson P, Tan PS, Clift AK, Payne RA, Coupland C, Hopewell JC, Mant J, Martin RM, Hippisley-Cox J. The Use of Primary Care Big Data in Understanding the Pharmacoepidemiology of COVID-19: A Consensus Statement From the COVID-19 Primary Care Database Consortium. Ann Fam Med 2021; 19:135-140. [PMID: 33685875 PMCID: PMC7939714 DOI: 10.1370/afm.2658] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/07/2020] [Accepted: 08/31/2020] [Indexed: 01/12/2023] Open
Abstract
The use of big data containing millions of primary care medical records provides an opportunity for rapid research to help inform patient care and policy decisions during the first and subsequent waves of the coronavirus disease 2019 (COVID-19) pandemic. Routinely collected primary care data have previously been used for national pandemic surveillance, quantifying associations between exposures and outcomes, identifying high risk populations, and examining the effects of interventions at scale, but there is no consensus on how to effectively conduct or report these data for COVID-19 research. A COVID-19 primary care database consortium was established in April 2020 and its researchers have ongoing COVID-19 projects in overlapping data sets with over 40 million primary care records in the United Kingdom that are variously linked to public health, secondary care, and vital status records. This consensus agreement is aimed at facilitating transparency and rigor in methodological approaches, and consistency in defining and reporting cases, exposures, confounders, stratification variables, and outcomes in relation to the pharmacoepidemiology of COVID-19. This will facilitate comparison, validation, and meta-analyses of research during and after the pandemic.
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Affiliation(s)
- Hajira Dambha-Miller
- CORRESPONDING AUTHOR Hajira Dambha-Miller Primary Care and Population Health University of Southampton Southampton, SO16 5ST United Kingdom
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Albasri A, Hattle M, Koshiaris C, Dunnigan A, Paxton B, Fox SE, Smith M, Archer L, Levis B, Payne RA, Riley RD, Roberts N, Snell KIE, Lay-Flurrie S, Usher-Smith J, Stevens R, Hobbs FDR, McManus RJ, Sheppard JP. Association between antihypertensive treatment and adverse events: systematic review and meta-analysis. BMJ 2021; 372:n189. [PMID: 33568342 PMCID: PMC7873715 DOI: 10.1136/bmj.n189] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the association between antihypertensive treatment and specific adverse events. DESIGN Systematic review and meta-analysis. ELIGIBILITY CRITERIA Randomised controlled trials of adults receiving antihypertensives compared with placebo or no treatment, more antihypertensive drugs compared with fewer antihypertensive drugs, or higher blood pressure targets compared with lower targets. To avoid small early phase trials, studies were required to have at least 650 patient years of follow-up. INFORMATION SOURCES Searches were conducted in Embase, Medline, CENTRAL, and the Science Citation Index databases from inception until 14 April 2020. MAIN OUTCOME MEASURES The primary outcome was falls during trial follow-up. Secondary outcomes were acute kidney injury, fractures, gout, hyperkalaemia, hypokalaemia, hypotension, and syncope. Additional outcomes related to death and major cardiovascular events were extracted. Risk of bias was assessed using the Cochrane risk of bias tool, and random effects meta-analysis was used to pool rate ratios, odds ratios, and hazard ratios across studies, allowing for between study heterogeneity (τ2). RESULTS Of 15 023 articles screened for inclusion, 58 randomised controlled trials were identified, including 280 638 participants followed up for a median of 3 (interquartile range 2-4) years. Most of the trials (n=40, 69%) had a low risk of bias. Among seven trials reporting data for falls, no evidence was found of an association with antihypertensive treatment (summary risk ratio 1.05, 95% confidence interval 0.89 to 1.24, τ2=0.009). Antihypertensives were associated with an increased risk of acute kidney injury (1.18, 95% confidence interval 1.01 to 1.39, τ2=0.037, n=15), hyperkalaemia (1.89, 1.56 to 2.30, τ2=0.122, n=26), hypotension (1.97, 1.67 to 2.32, τ2=0.132, n=35), and syncope (1.28, 1.03 to 1.59, τ2=0.050, n=16). The heterogeneity between studies assessing acute kidney injury and hyperkalaemia events was reduced when focusing on drugs that affect the renin angiotensin-aldosterone system. Results were robust to sensitivity analyses focusing on adverse events leading to withdrawal from each trial. Antihypertensive treatment was associated with a reduced risk of all cause mortality, cardiovascular death, and stroke, but not of myocardial infarction. CONCLUSIONS This meta-analysis found no evidence to suggest that antihypertensive treatment is associated with falls but found evidence of an association with mild (hyperkalaemia, hypotension) and severe adverse events (acute kidney injury, syncope). These data could be used to inform shared decision making between doctors and patients about initiation and continuation of antihypertensive treatment, especially in patients at high risk of harm because of previous adverse events or poor renal function. REGISTRATION PROSPERO CRD42018116860.
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Affiliation(s)
- Ali Albasri
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | | | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Anna Dunnigan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ben Paxton
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Emma Fox
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Margaret Smith
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | | | - Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Juliet Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford, OX2 6GG, UK
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Fellenor J, Britten N, Courtenay M, Payne RA, Valderas J, Denholm R, Duncan P, McCahon D, Tatnell L, Fitzgerald R, Warmoth K, Gillespie D, Turner K, Watson M. A multi-stakeholder approach to the co-production of the research agenda for medicines optimisation. BMC Health Serv Res 2021; 21:64. [PMID: 33441135 PMCID: PMC7804576 DOI: 10.1186/s12913-021-06056-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 01/02/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Up to 50% of medicines are not used as intended, resulting in poor health and economic outcomes. Medicines optimisation is 'a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines'. The purpose of this exercise was to co-produce a prioritised research agenda for medicines optimisation using a multi-stakeholder (patient, researcher, public and health professionals) approach. METHODS A three-stage, multiple method process was used including: generation of preliminary research questions (Stage 1) using a modified Nominal Group Technique; electronic consultation and ranking with a wider multi-stakeholder group (Stage 2); a face-to-face, one-day consensus meeting involving representatives from all stakeholder groups (Stage 3). RESULTS In total, 92 research questions were identified during Stages 1 and 2 and ranked in order of priority during stage 3. Questions were categorised into four areas: 'Patient Concerns' [e.g. is there a shared decision (with patients) about using each medicine?], 'Polypharmacy' [e.g. how to design health services to cope with the challenge of multiple medicines use?], 'Non-Medical Prescribing' [e.g. how can the contribution of non-medical prescribers be optimised in primary care?], and 'Deprescribing' [e.g. what support is needed by prescribers to deprescribe?]. A significant number of the 92 questions were generated by Patient and Public Involvement representatives, which demonstrates the importance of including this stakeholder group when identifying research priorities. CONCLUSIONS A wide range of research questions was generated reflecting concerns which affect patients, practitioners, the health service, as well the ethical and philosophical aspects of the prescribing and deprescribing of medicines. These questions should be used to set future research agendas and funding commissions.
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Affiliation(s)
- John Fellenor
- Department of Pharmacy & Pharmacology, University of Bath, Bath, England
| | - Nicky Britten
- University of Exeter Medical School, University of Exeter, Exeter, England
| | - Molly Courtenay
- School of Healthcare Sciences, Cardiff University, Cardiff, Wales
| | - Rupert A Payne
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, England
| | - Jose Valderas
- Health Services & Policy Research Group, Collaboration for Academic Primary Care (APEx), University of Exeter, Exeter, England
| | - Rachel Denholm
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, England
| | - Polly Duncan
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, England
| | - Deborah McCahon
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, England
| | - Lynn Tatnell
- Peninsula Public Involvement Group, University of Exeter, Exeter, England
| | - Richard Fitzgerald
- Peninsula Public Involvement Group, University of Exeter, Exeter, England
| | - Krystal Warmoth
- University of Exeter Medical School, University of Exeter, Exeter, England
| | - David Gillespie
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, Wales
| | - Katrina Turner
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, England
| | - Margaret Watson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow, G4 0RE, Scotland.
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Hamilton F, Arnold D, Henley W, Payne RA. Aspirin reduces cardiovascular events in patients with pneumonia: a prior event rate ratio analysis in a large primary care database. Eur Respir J 2020; 57:13993003.02795-2020. [PMID: 32943408 DOI: 10.1183/13993003.02795-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/24/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ischaemic stroke and myocardial infarction (MI) are common after pneumonia and are associated with long-term mortality. Aspirin may attenuate this risk and should be explored as a therapeutic option. METHODS We extracted all patients with pneumonia (aged over 50 years) from the Clinical Practice Research Datalink (CPRD), a large UK primary care database, from inception until January 2019. We then performed a prior event rate ratio (PERR) analysis with propensity score matching (PSM), an approach that allows for control of measured and unmeasured confounding, with aspirin usage as the exposure and ischaemic events as the outcome. The primary outcome was the combined outcome of ischaemic stroke and MI. Secondary outcomes were ischaemic stroke and MI individually. Relevant confounders (smoking, comorbidities, age and gender) were included in the analysis. FINDINGS 48 743 patients were eligible for matching. Of these, 9864 were aspirin users who were matched to 9864 non-users. Aspirin users had a reduced risk of the primary outcome (adjusted hazard ratio 0.64, 95% CI 0.52-0.79) in the PERR analysis. For both secondary outcomes, aspirin use was also associated with a reduced risk for MI (hazard ratio 0.46, 95% CI 0.30-0.72) and stroke (hazard ratio 0.70, 95% CI 0.55-0.91), respectively. INTERPRETATION This study provides supporting evidence that aspirin use is associated with reduced ischaemic events after pneumonia in a primary care setting. This drug may have a future clinical role in preventing this important complication.
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Affiliation(s)
- Fergus Hamilton
- Centre for Academic Primary Care, University of Bristol, Bristol, UK.,Department of Infection Science, Southmead Hospital, Bristol, UK
| | - David Arnold
- Academic Respiratory Unit, Southmead Hospital, Bristol, UK.,Translational Health Sciences, University of Bristol, Bristol, UK
| | - William Henley
- Health Statistics Group, University of Exeter, Exeter, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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22
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Payne RA, Mendonca SC, Elliott MN, Saunders CL, Edwards DA, Marshall M, Roland M. Development and validation of the Cambridge Multimorbidity Score. CMAJ 2020; 192:E107-E114. [PMID: 32015079 DOI: 10.1503/cmaj.190757] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Health services have failed to respond to the pressures of multimorbidity. Improved measures of multimorbidity are needed for conducting research, planning services and allocating resources. METHODS We modelled the association between 37 morbidities and 3 key outcomes (primary care consultations, unplanned hospital admission, death) at 1 and 5 years. We extracted development (n = 300 000) and validation (n = 150 000) samples from the UK Clinical Practice Research Datalink. We constructed a general-outcome multimorbidity score by averaging the standardized weights of the separate outcome scores. We compared performance with the Charlson Comorbidity Index. RESULTS Models that included all 37 conditions were acceptable predictors of general practitioner consultations (C-index 0.732, 95% confidence interval [CI] 0.731-0.734), unplanned hospital admission (C-index 0.742, 95% CI 0.737-0.747) and death at 1 year (C-index 0.912, 95% CI 0.905-0.918). Models reduced to the 20 conditions with the greatest combined prevalence/weight showed similar predictive ability (C-indices 0.727, 95% CI 0.725-0.728; 0.738, 95% CI 0.732-0.743; and 0.910, 95% CI 0.904-0.917, respectively). They also predicted 5-year outcomes similarly for consultations and death (C-indices 0.735, 95% CI 0.734-0.736, and 0.889, 95% CI 0.885-0.892, respectively) but performed less well for admissions (C-index 0.708, 95% CI 0.705-0.712). The performance of the general-outcome score was similar to that of the outcome-specific models. These models performed significantly better than those based on the Charlson Comorbidity Index for consultations (C-index 0.691, 95% CI 0.690-0.693) and admissions (C-index 0.703, 95% CI 0.697-0.709) and similarly for mortality (C-index 0.907, 95% CI 0.900-0.914). INTERPRETATION The Cambridge Multimorbidity Score is robust and can be either tailored or not tailored to specific health outcomes. It will be valuable to those planning clinical services, policymakers allocating resources and researchers seeking to account for the effect of multimorbidity.
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Affiliation(s)
- Rupert A Payne
- Centre for Academic Primary Care (Payne), Population Health Sciences, University of Bristol, Bristol, UK; Primary Care Unit (Mendonca, Saunders, Edwards, Roland), Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK; RAND Corporation (Elliott), Santa Monica, Calif.; Research Department of Primary Care and Population Health (Marshall), University College London Medical School, Royal Free Campus, London, UK
| | - Silvia C Mendonca
- Centre for Academic Primary Care (Payne), Population Health Sciences, University of Bristol, Bristol, UK; Primary Care Unit (Mendonca, Saunders, Edwards, Roland), Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK; RAND Corporation (Elliott), Santa Monica, Calif.; Research Department of Primary Care and Population Health (Marshall), University College London Medical School, Royal Free Campus, London, UK
| | - Marc N Elliott
- Centre for Academic Primary Care (Payne), Population Health Sciences, University of Bristol, Bristol, UK; Primary Care Unit (Mendonca, Saunders, Edwards, Roland), Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK; RAND Corporation (Elliott), Santa Monica, Calif.; Research Department of Primary Care and Population Health (Marshall), University College London Medical School, Royal Free Campus, London, UK
| | - Catherine L Saunders
- Centre for Academic Primary Care (Payne), Population Health Sciences, University of Bristol, Bristol, UK; Primary Care Unit (Mendonca, Saunders, Edwards, Roland), Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK; RAND Corporation (Elliott), Santa Monica, Calif.; Research Department of Primary Care and Population Health (Marshall), University College London Medical School, Royal Free Campus, London, UK
| | - Duncan A Edwards
- Centre for Academic Primary Care (Payne), Population Health Sciences, University of Bristol, Bristol, UK; Primary Care Unit (Mendonca, Saunders, Edwards, Roland), Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK; RAND Corporation (Elliott), Santa Monica, Calif.; Research Department of Primary Care and Population Health (Marshall), University College London Medical School, Royal Free Campus, London, UK
| | - Martin Marshall
- Centre for Academic Primary Care (Payne), Population Health Sciences, University of Bristol, Bristol, UK; Primary Care Unit (Mendonca, Saunders, Edwards, Roland), Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK; RAND Corporation (Elliott), Santa Monica, Calif.; Research Department of Primary Care and Population Health (Marshall), University College London Medical School, Royal Free Campus, London, UK
| | - Martin Roland
- Centre for Academic Primary Care (Payne), Population Health Sciences, University of Bristol, Bristol, UK; Primary Care Unit (Mendonca, Saunders, Edwards, Roland), Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK; RAND Corporation (Elliott), Santa Monica, Calif.; Research Department of Primary Care and Population Health (Marshall), University College London Medical School, Royal Free Campus, London, UK
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Sheppard JP, Burt J, Lown M, Temple E, Lowe R, Fraser R, Allen J, Ford GA, Heneghan C, Hobbs FDR, Jowett S, Kodabuckus S, Little P, Mant J, Mollison J, Payne RA, Williams M, Yu LM, McManus RJ. Effect of Antihypertensive Medication Reduction vs Usual Care on Short-term Blood Pressure Control in Patients With Hypertension Aged 80 Years and Older: The OPTIMISE Randomized Clinical Trial. JAMA 2020; 323:2039-2051. [PMID: 32453368 PMCID: PMC7251449 DOI: 10.1001/jama.2020.4871] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Deprescribing of antihypertensive medications is recommended for some older patients with polypharmacy and multimorbidity when the benefits of continued treatment may not outweigh the harms. OBJECTIVE This study aimed to establish whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events during 12-week follow-up. DESIGN, SETTING, AND PARTICIPANTS The Optimising Treatment for Mild Systolic Hypertension in the Elderly (OPTIMISE) study was a randomized, unblinded, noninferiority trial conducted in 69 primary care sites in England. Participants, whose primary care physician considered them appropriate for medication reduction, were aged 80 years and older, had systolic blood pressure lower than 150 mm Hg, and were receiving at least 2 antihypertensive medications were included. Participants enrolled between April 2017 and September 2018 and underwent follow-up until January 2019. INTERVENTIONS Participants were randomized (1:1 ratio) to a strategy of antihypertensive medication reduction (removal of 1 drug [intervention], n = 282) or usual care (control, n = 287), in which no medication changes were mandated. MAIN OUTCOMES AND MEASURES The primary outcome was systolic blood pressure lower than 150 mm Hg at 12-week follow-up. The prespecified noninferiority margin was a relative risk (RR) of 0.90. Secondary outcomes included the proportion of participants maintaining medication reduction and differences in blood pressure, frailty, quality of life, adverse effects, and serious adverse events. RESULTS Among 569 patients randomized (mean age, 84.8 years; 276 [48.5%] women; median of 2 antihypertensive medications prescribed at baseline), 534 (93.8%) completed the trial. Overall, 229 (86.4%) patients in the intervention group and 236 (87.7%) patients in the control group had a systolic blood pressure lower than 150 mm Hg at 12 weeks (adjusted RR, 0.98 [97.5% 1-sided CI, 0.92 to ∞]). Of 7 prespecified secondary end points, 5 showed no significant difference. Medication reduction was sustained in 187 (66.3%) participants at 12 weeks. Mean change in systolic blood pressure was 3.4 mm Hg (95% CI, 1.1 to 5.8 mm Hg) higher in the intervention group compared with the control group. Twelve (4.3%) participants in the intervention group and 7 (2.4%) in the control group reported at least 1 serious adverse event (adjusted RR, 1.72 [95% CI, 0.7 to 4.3]). CONCLUSIONS AND RELEVANCE Among older patients treated with multiple antihypertensive medications, a strategy of medication reduction, compared with usual care, was noninferior with regard to systolic blood pressure control at 12 weeks. The findings suggest antihypertensive medication reduction in some older patients with hypertension is not associated with substantial change in blood pressure control, although further research is needed to understand long-term clinical outcomes. TRIAL REGISTRATION EudraCT Identifier: 2016-004236-38; ISRCTN identifier: 97503221.
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Affiliation(s)
- James P. Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jenni Burt
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, United Kingdom
| | - Mark Lown
- Primary Care Research Group, University of Southampton, Southampton, United Kingdom
| | - Eleanor Temple
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rebecca Lowe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rosalyn Fraser
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Julie Allen
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gary A Ford
- Radcliffe Department of Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - F. D. Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sue Jowett
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Shahela Kodabuckus
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Paul Little
- Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, United Kingdom
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Jill Mollison
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rupert A. Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Marney Williams
- Patient and public involvement representative, London, United Kingdom
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Richard J. McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Zhu Y, Edwards D, Mant J, Payne RA, Kiddle S. Characteristics, service use and mortality of clusters of multimorbid patients in England: a population-based study. BMC Med 2020; 18:78. [PMID: 32272927 PMCID: PMC7147068 DOI: 10.1186/s12916-020-01543-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/26/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Multimorbidity is associated with mortality and service use, with specific types of multimorbidity having differential effects. Additionally, multimorbidity is often negatively associated with participation in research cohorts. Therefore, we set out to identify clusters of multimorbidity patients and how they are differentially associated with mortality and service use across age groups in a population-representative sample. METHODS Linked primary and secondary care electronic health records contributed by 382 general practices in England to the Clinical Practice Research Datalink (CPRD) were used. The study included a representative set of multimorbid adults (18 years old or more, N = 113,211) with two or more long-term conditions (a total of 38 conditions were included). A random set of 80% of the multimorbid patients (N = 90,571) were stratified by age groups and clustered using latent class analysis. Consistency between obtained multimorbidity phenotypes, classification quality and associations with demographic characteristics and primary outcomes (GP consultations, hospitalisations, regular medications and mortality) was validated in the remaining 20% of multimorbid patients (N = 22,640). RESULTS We identified 20 patient clusters across four age strata. The clusters with the highest mortality comprised psychoactive substance and alcohol misuse (aged 18-64); coronary heart disease, depression and pain (aged 65-84); and coronary heart disease, heart failure and atrial fibrillation (aged 85+). The clusters with the highest service use coincided with those with the highest mortality for people aged over 65. For people aged 18-64, the cluster with the highest service use comprised depression, anxiety and pain. The majority of 85+-year-old multimorbid patients belonged to the cluster with the lowest service use and mortality for that age range. Pain featured in 13 clusters. CONCLUSIONS This work has highlighted patterns of multimorbidity that have implications for health services. These include the importance of psychoactive substance and alcohol misuse in people under the age of 65, of co-morbid depression and coronary heart disease in people aged 65-84 and of cardiovascular disease in people aged 85+.
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Affiliation(s)
- Yajing Zhu
- MRC Biostatistics Unit, University of Cambridge, Cambridge, CB2 0SR, UK.
| | - Duncan Edwards
- Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Worts' Causeway, Cambridge, CB1 8RN, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Worts' Causeway, Cambridge, CB1 8RN, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Steven Kiddle
- MRC Biostatistics Unit, University of Cambridge, Cambridge, CB2 0SR, UK
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Tammes P, Payne RA, Salisbury C, Chalder M, Purdy S, Morris RW. The impact of a named GP scheme on continuity of care and emergency hospital admission: a cohort study among older patients in England, 2012-2016. BMJ Open 2019; 9:e029103. [PMID: 31548353 PMCID: PMC6773345 DOI: 10.1136/bmjopen-2019-029103] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To investigate whether the introduction of a named general practitioner (GP, family physician) improved patients' healthcare for patients aged 75 and over in England. SETTING Random sample of 27 500 patients aged 65 to 84 in 2012 within 139 English practices from the Clinical Practice Research Datalink linked with Hospital Episode Statistics. DESIGN Prospective cohort approach, measuring patients' GP consultations and emergency hospital admissions 2 years before/after the intervention. Patients were grouped in (i) aged over 74 and (ii) younger than 75 in both periods in order to compare who were or were not subject to the intervention. Adjusted associations between the named GP scheme, continuity of care and emergency hospital admission were examined using multilevel modelling. INTERVENTION National Health Service policy to introduce a named accountable GP for patients aged over 74 in April 2014. MAIN OUTCOME MEASURES (A) Continuity of care index-score, (B) risk of emergency hospital admissions, (C) number of emergency hospital admissions. RESULTS The intervention was associated with a decrease in continuity index-scores of -0.024 (95% CI -0.030 to -0.018, p<0.001); there were no differences in the decrease between the two age groups (-0.005, 95% CI -0.014 to 0.005). In the pre-intervention and post-intervention periods, respectively, 15.4% and 19.4% patients had an emergency admission. The probability of an emergency hospital admission increased after the intervention (OR 1.156, 95% CI 1.064 to 1.257, p=0.001); this increase was bigger for patients over 74 (relative OR 1.191, 95% CI 1.066 to 1.330, p=0.002). The average number of emergency hospital admissions increased after the intervention (rate ratio (RR) 1.178, 95% CI 1.103 to 1.259, p<0.001); this increase was greater for patients over 74 (relative RR 1.143, 95% CI 1.052 to 1.242, p=0.001). CONCLUSION The introduction of the named GP scheme was not associated with improvements in either continuity of care or rates of unplanned hospitalisation.
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Affiliation(s)
- Peter Tammes
- Bristol Medical School: Population Health Sciences, Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Rupert A Payne
- Bristol Medical School: Population Health Sciences, Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Bristol Medical School: Population Health Sciences, Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Melanie Chalder
- Bristol Medical School: Population Health Sciences, Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Sarah Purdy
- Bristol Medical School: Population Health Sciences, Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Richard W Morris
- Bristol Medical School: Population Health Sciences, Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Silarova B, Sharp S, Usher-Smith JA, Lucas J, Payne RA, Shefer G, Moore C, Girling C, Lawrence K, Tolkien Z, Walker M, Butterworth A, Di Angelantonio E, Danesh J, Griffin SJ. Effect of communicating phenotypic and genetic risk of coronary heart disease alongside web-based lifestyle advice: the INFORM Randomised Controlled Trial. Heart 2019; 105:982-989. [PMID: 30928969 PMCID: PMC6582721 DOI: 10.1136/heartjnl-2018-314211] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/21/2019] [Accepted: 01/25/2019] [Indexed: 02/05/2023] Open
Abstract
Objective To determine whether provision of web-based lifestyle advice and coronary heart disease risk information either based on phenotypic characteristics or phenotypic plus genetic characteristics affects changes in objectively measured health behaviours. Methods A parallel-group, open randomised trial including 956 male and female blood donors with no history of cardiovascular disease (mean [SD] age=56.7 [8.8] years) randomised to four study groups: control group (no information provided); web-based lifestyle advice only (lifestyle group); lifestyle advice plus information on estimated 10-year coronary heart disease risk based on phenotypic characteristics (phenotypic risk estimate) (phenotypic group) and lifestyle advice plus information on estimated 10-year coronary heart disease risk based on phenotypic (phenotypic risk estimate) and genetic characteristics (genetic risk estimate) (genetic group). The primary outcome was change in physical activity from baseline to 12 weeks assessed by wrist-worn accelerometer. Results 928 (97.1%) participants completed the trial. There was no evidence of intervention effects on physical activity (difference in adjusted mean change from baseline): lifestyle group vs control group 0.09 milligravity (mg) (95% CI −1.15 to 1.33); genetic group vs phenotypic group −0.33 mg (95% CI −1.55 to 0.90); phenotypic group and genetic group vs control group −0.52 mg (95% CI −1.59 to 0.55) and vs lifestyle group −0.61 mg (95% CI −1.67 to 0.46). There was no evidence of intervention effects on secondary biological, emotional and health-related behavioural outcomes except self-reported fruit and vegetable intake. Conclusions Provision of risk information, whether based on phenotypic or genotypic characteristics, alongside web-based lifestyle advice did not importantly affect objectively measured levels of physical activity, other health-related behaviours, biological risk factors or emotional well-being. Trial registration number ISRCTN17721237; Pre-results.
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Affiliation(s)
- Barbora Silarova
- MRC Epidemiology Unit, School of Clinical Medicine, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Stephen Sharp
- MRC Epidemiology Unit, School of Clinical Medicine, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juliet A Usher-Smith
- Department of Public Health and Primary Care, The Primary Care Unit, Cambridge, UK
| | - Joanne Lucas
- Department of Public Health and Primary Care, MRC/BHF Cardiovascular Epidemiology Unit, Cambridge, UK
| | - Rupert A Payne
- University of Bristol Centre for Academic Primary Care, Bristol, Bristol, UK.,Institute of Public Health, Cambridge Centre for Health Services Research, Cambridge, UK
| | - Guy Shefer
- MRC Epidemiology Unit, School of Clinical Medicine, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Carmel Moore
- Department of Public Health and Primary Care, MRC/BHF Cardiovascular Epidemiology Unit, Cambridge, UK.,Department of Public Health and Primary Care, NIHR Blood and Transplant Research Unit in Donor Health and Genomics, Cambridge, UK
| | | | | | - Zoe Tolkien
- Department of Public Health and Primary Care, MRC/BHF Cardiovascular Epidemiology Unit, Cambridge, UK
| | - Matthew Walker
- Department of Public Health and Primary Care, MRC/BHF Cardiovascular Epidemiology Unit, Cambridge, UK.,Department of Public Health and Primary Care, NIHR Blood and Transplant Research Unit in Donor Health and Genomics, Cambridge, UK
| | - Adam Butterworth
- Department of Public Health and Primary Care, MRC/BHF Cardiovascular Epidemiology Unit, Cambridge, UK.,Department of Public Health and Primary Care, NIHR Blood and Transplant Research Unit in Donor Health and Genomics, Cambridge, UK
| | - Emanuele Di Angelantonio
- Department of Public Health and Primary Care, MRC/BHF Cardiovascular Epidemiology Unit, Cambridge, UK.,Department of Public Health and Primary Care, NIHR Blood and Transplant Research Unit in Donor Health and Genomics, Cambridge, UK
| | - John Danesh
- Department of Public Health and Primary Care, MRC/BHF Cardiovascular Epidemiology Unit, Cambridge, UK.,Department of Public Health and Primary Care, NIHR Blood and Transplant Research Unit in Donor Health and Genomics, Cambridge, UK
| | - Simon J Griffin
- MRC Epidemiology Unit, School of Clinical Medicine, Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Department of Public Health and Primary Care, The Primary Care Unit, Cambridge, UK
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Rhodes KM, Turner RM, Payne RA, White IR. Computationally efficient methods for fitting mixed models to electronic health records data. Stat Med 2018; 37:4557-4570. [PMID: 30155902 PMCID: PMC6240345 DOI: 10.1002/sim.7944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 06/27/2018] [Accepted: 07/20/2018] [Indexed: 11/12/2022]
Abstract
Motivated by two case studies using primary care records from the Clinical Practice Research Datalink, we describe statistical methods that facilitate the analysis of tall data, with very large numbers of observations. Our focus is on investigating the association between patient characteristics and an outcome of interest, while allowing for variation among general practices. We explore ways to fit mixed-effects models to tall data, including predictors of interest and confounding factors as covariates, and including random intercepts to allow for heterogeneity in outcome among practices. We introduce (1) weighted regression and (2) meta-analysis of estimated regression coefficients from each practice. Both methods reduce the size of the dataset, thus decreasing the time required for statistical analysis. We compare the methods to an existing subsampling approach. All methods give similar point estimates, and weighted regression and meta-analysis give similar standard errors for point estimates to analysis of the entire dataset, but the subsampling method gives larger standard errors. Where all data are discrete, weighted regression is equivalent to fitting the mixed model to the entire dataset. In the presence of a continuous covariate, meta-analysis is useful. Both methods are easy to implement in standard statistical software.
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Affiliation(s)
- K M Rhodes
- MRC Biostatistics Unit, University of Cambridge, Cambridge Institute of Public Health, Cambridge, UK
| | - R M Turner
- MRC Biostatistics Unit, University of Cambridge, Cambridge Institute of Public Health, Cambridge, UK
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK
| | - R A Payne
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - I R White
- MRC Biostatistics Unit, University of Cambridge, Cambridge Institute of Public Health, Cambridge, UK
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK
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Cherskov A, Pohl A, Allison C, Zhang H, Payne RA, Baron-Cohen S. Polycystic ovary syndrome and autism: A test of the prenatal sex steroid theory. Transl Psychiatry 2018; 8:136. [PMID: 30065244 PMCID: PMC6068102 DOI: 10.1038/s41398-018-0186-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/08/2018] [Indexed: 12/28/2022] Open
Abstract
Elevated levels of prenatal testosterone may increase the risk for autism spectrum conditions (autism). Given that polycystic ovary syndrome (PCOS) is also associated with elevated prenatal testosterone and its precursor sex steroids, a hypothesis from the prenatal sex steroid theory is that women with PCOS should have elevated autistic traits and a higher rate of autism among their children. Using electronic health records obtained from the Clinical Practice Research Datalink (CPRD) in the UK between 1990 and 2014, we conducted three matched case-control studies. Studies 1 and 2 examined the risk of PCOS in women with autism (n = 971) and the risk of autism in women with PCOS (n = 26,263), respectively, compared with matched controls. Study 3 examined the odds ratio (OR) of autism in first-born children of women with PCOS (n = 8588), matched to 41,127 controls. In Studies 1 and 2 we found increased prevalence of PCOS in women with autism (2.3% vs. 1.1%; unadjusted OR: 2.01, 95% CI: 1.22-3.30) and elevated rates of autism in women with PCOS (0.17% vs. 0.09%, unadjusted OR: 1.94 CI: 1.37-2.76). In Study 3 we found the odds of having a child with autism were significantly increased, even after adjustment for maternal psychiatric diagnoses, obstetric complications, and maternal metabolic conditions (unadjusted OR: 1.60, 95% CI: 1.28-2.00; adjusted OR: 1.35, 95% CI: 1.06-1.73). These studies provide further evidence that women with PCOS and their children have a greater risk of autism.
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Affiliation(s)
- Adriana Cherskov
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Douglas House, 18B Trumpington Road, Cambridge, CB2 8AH, UK.
| | - Alexa Pohl
- 0000000121885934grid.5335.0Autism Research Centre, Department of Psychiatry, University of Cambridge, Douglas House, 18B Trumpington Road, Cambridge, CB2 8AH UK
| | - Carrie Allison
- 0000000121885934grid.5335.0Autism Research Centre, Department of Psychiatry, University of Cambridge, Douglas House, 18B Trumpington Road, Cambridge, CB2 8AH UK
| | - Heping Zhang
- 0000000419368710grid.47100.32Department of Biostatistics, Yale University School of Public Health, New Haven, CT 06520 USA
| | - Rupert A. Payne
- 0000000121885934grid.5335.0Primary Care Unit, Institute of Public Health, University of Cambridge, Cambridge, CB2 OSR UK ,0000 0004 1936 7603grid.5337.2Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK
| | - Simon Baron-Cohen
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Douglas House, 18B Trumpington Road, Cambridge, CB2 8AH, UK. .,CLASS Clinic, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK.
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29
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Harshfield A, Abel GA, Barclay S, Payne RA. Do GPs accurately record date of death? A UK observational analysis. BMJ Support Palliat Care 2018; 10:e24. [PMID: 29950293 DOI: 10.1136/bmjspcare-2018-001514] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/17/2018] [Accepted: 06/06/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To examine the concordance between dates of death recorded in UK primary care and national mortality records. METHODS UK primary care data from the Clinical Practice Research Datalink were linked to Office for National Statistics (ONS) data, for 118 571 patients who died between September 2010 and September 2015. Logistic regression was used to examine factors associated with discrepancy in death dates between data sets. RESULTS Death dates matched in 76.8% of cases with primary care dates preceding ONS date in 2.9%, and following in 20.3% of cases; 92.2% of cases differed by <2 weeks. Primary care date was >4 weeks later than ONS in 1.5% of cases and occurred more frequently with deaths categorised as 'external' (15.8% vs 0.8% for cancer), and in younger patients (15.9% vs 1% for 18-29 and 80-89 years, respectively). General practices with the greatest discrepancies (97.5th percentile) had around 200 times higher odds of recording substantially discordant dates than practices with the lowest discrepancies (2.5th percentile). CONCLUSION Dates of death in primary care records often disagree with national records and should be treated with caution. There is marked variation between practices, and studies involving young patients, unexplained deaths and where precise date of death is important are particularly vulnerable to these issues.
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Affiliation(s)
- Amelia Harshfield
- Primary Care Unit, University of Cambridge, Cambridge, UK.,RAND Europe, Cambridge, UK
| | - Gary A Abel
- Primary Care, University of Exeter Medical School, Exeter, UK
| | | | - Rupert A Payne
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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30
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Burt J, Elmore N, Campbell SM, Rodgers S, Avery AJ, Payne RA. Developing a measure of polypharmacy appropriateness in primary care: systematic review and expert consensus study. BMC Med 2018; 16:91. [PMID: 29895310 PMCID: PMC5998565 DOI: 10.1186/s12916-018-1078-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 05/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Polypharmacy is an increasing challenge for primary care. Although sometimes clinically justified, polypharmacy can be inappropriate, leading to undesirable outcomes. Optimising care for polypharmacy necessitates effective targeting and monitoring of interventions. This requires a valid, reliable measure of polypharmacy, relevant for all patients, that considers clinical appropriateness and generic prescribing issues applicable across all medications. Whilst there are several existing measures of potentially inappropriate prescribing, these are not specifically designed with polypharmacy in mind, can require extensive clinical input to complete, and often cover a limited number of drugs. The aim of this study was to identify what experts consider to be the key elements of a measure of prescribing appropriateness in the context of polypharmacy. METHODS Firstly, we conducted a systematic review to identify generic (not drug specific) prescribing indicators relevant to polypharmacy appropriateness. Indicators were subject to content analysis to enable categorisation. Secondly, we convened a panel of 10 clinical experts to review the identified indicators and assess their relative clinical importance. For each indicator category, a brief evidence summary was developed, based on relevant clinical and indicator literature, clinical guidance, and opinions obtained from a separate patient discussion panel. A two-stage RAND/UCLA Appropriateness Method was used to reach consensus amongst the panel on a core set of indicators of polypharmacy appropriateness. RESULTS We identified 20,879 papers for title/abstract screening, obtaining 273 full papers. We extracted 189 generic indicators, and presented 160 to the panel grouped into 18 classifications (e.g. adherence, dosage, clinical efficacy). After two stages, during which the panel introduced 18 additional indicators, there was consensus that 134 indicators were of clinical importance. Following the application of decision rules and further panel consultation, 12 indicators were placed into the final selection. Panel members particularly valued indicators concerned with adverse drug reactions, contraindications, drug-drug interactions, and the conduct of medication reviews. CONCLUSIONS We have identified a set of 12 indicators of clinical importance considered relevant to polypharmacy appropriateness. Use of these indicators in clinical practice and informatics systems is dependent on their operationalisation and their utility (e.g. risk stratification, targeting and monitoring polypharmacy interventions) requires subsequent evaluation. TRIAL REGISTRATION Registration number: PROSPERO ( CRD42016049176 ).
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Affiliation(s)
- Jenni Burt
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK.
| | - Natasha Elmore
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK
| | - Stephen M Campbell
- NIHR Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, HSR & Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Sarah Rodgers
- Division of Primary Care, University of Nottingham, Room 1312, Tower Building, University Park, Nottingham, NG7 2RD, UK
| | - Anthony J Avery
- Division of Primary Care, School of Medicine, University of Nottingham, Dean's Office, B Floor, Medical School, Queens Medical Centre, Nottingham, NG7 2UH, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
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31
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Mossakowska TJ, Saunders CL, Corbett J, MacLure C, Winpenny EM, Dujso E, Payne RA. Current and future cardiovascular disease risk assessment in the European Union: an international comparative study. Eur J Public Health 2018; 28:748-754. [DOI: 10.1093/eurpub/ckx216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
| | - Catherine L Saunders
- RAND Europe, Westbrook Centre, Cambridge, UK
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | | | | | | | - Elma Dujso
- RAND Europe, Westbrook Centre, Cambridge, UK
| | - Rupert A Payne
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Usher-Smith JA, Winther LR, Shefer GS, Silarova B, Payne RA, Griffin SJ. Factors Associated With Engagement With a Web-Based Lifestyle Intervention Following Provision of Coronary Heart Disease Risk: Mixed Methods Study. J Med Internet Res 2017; 19:e351. [PMID: 29038095 PMCID: PMC5662793 DOI: 10.2196/jmir.7697] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/21/2017] [Accepted: 08/20/2017] [Indexed: 12/05/2022] Open
Abstract
Background Web-based interventions provide the opportunity to combine the tailored approach of face-to-face interventions with the scalability and cost-effectiveness of public health interventions. This potential is often limited by low engagement. A number of studies have described the characteristics of individuals who engage more in Web-based interventions but few have explored the reasons for these variations. Objective We aimed to explore individual-level factors associated with different degrees of engagement with a Web-based behavior change intervention following provision of coronary heart disease (CHD) risk information, and the barriers and facilitators to engagement. Methods This study involved the secondary analysis of data from the Information and Risk Modification Trial, a randomized controlled trial of a Web-based lifestyle intervention alone, or alongside information on estimated CHD risk. The intervention consisted of three interactive sessions, each lasting up to 60 minutes, delivered at monthly intervals. Participants were characterized as high engagers if they completed all three sessions. Thematic analysis of qualitative data from interviews with 37 participants was combined with quantitative data on usage of the Web-based intervention using a mixed-methods matrix, and data on the views of the intervention itself were analyzed across all participants. Results Thirteen participants were characterized as low engagers and 24 as high engagers. There was no difference in age (P=.75), gender (P=.95), or level of risk (P=.65) between the groups. Low engagement was more often associated with: (1) reporting a negative emotional reaction in response to the risk score (P=.029), (2) perceiving that the intervention did not provide any new lifestyle information (P=.011), and (3) being less likely to have reported feeling an obligation to complete the intervention as part of the study (P=.019). The mixed-methods matrix suggested that there was also an association between low engagement and less success with previous behavior change attempts, but the statistical evidence for this association was weak (P=.16). No associations were seen between engagement and barriers or facilitators to health behavior change, or comments about the design of the intervention itself. The most commonly cited barriers related to issues with access to the intervention itself: either difficulties remembering the link to the site or passwords, a perceived lack of flexibility within the website, or lack of time. Facilitators included the nonjudgmental presentation of lifestyle information, the use of simple language, and the personalized nature of the intervention. Conclusions This study shows that the level of engagement with a Web-based intervention following provision of CHD risk information is not influenced by the level of risk but by the individual’s response to the risk information, their past experiences of behavior change, the extent to which they consider the lifestyle information helpful, and whether they felt obliged to complete the intervention as part of a research study. A number of facilitators and barriers to Web-based interventions were also identified, which should inform future interventions.
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Affiliation(s)
- Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Laura R Winther
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Guy S Shefer
- Faculty of Health, Social Care and Education, Anglia Ruskin University, Cambridge, United Kingdom
| | - Barbora Silarova
- MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Rupert A Payne
- Centre for Academic Primary Care, University of Bristol, Bristol, United Kingdom
| | - Simon J Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.,MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
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Affiliation(s)
- Vincent A van Vugt
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Centre, 1081 BT Amsterdam, The Netherlands
| | - Henriëtte E van der Horst
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Centre, 1081 BT Amsterdam, The Netherlands
| | - Rupert A Payne
- Centre for Academic Primary Care, University of Bristol, UK
| | - Otto R Maarsingh
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Centre, 1081 BT Amsterdam, The Netherlands
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Wilson CL, Rhodes KM, Payne RA. Financial incentives improve recognition but not treatment of cardiovascular risk factors in severe mental illness. PLoS One 2017; 12:e0179392. [PMID: 28598998 PMCID: PMC5466340 DOI: 10.1371/journal.pone.0179392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 05/30/2017] [Indexed: 11/18/2022] Open
Abstract
Objectives Severe mental illness (SMI) is associated with premature cardiovascular disease, prompting the UK primary care payment-for-performance system (Quality and Outcomes Framework, QOF) to incentivise annual physical health reviews. This study aimed to assess the QOF’s impact on detection and treatment of cardiovascular risk factors in people with SMI. Methods A retrospective open cohort study of UK general practice was conducted between 1996 and 2014, using segmented logistic regression with 2004 and 2011 as break points, reflecting the introduction of relevant QOF incentives in these years. 67239 SMI cases and 359951 randomly-selected unmatched controls were extracted from the Clinical Practice Research Datalink (CPRD). Results There was strong evidence (p≤0.015) the 2004 QOF indicator (general health) resulted in an immediate increase in recording of elevated cholesterol (odds ratio 1.37 (95% confidence interval 1.24 to 1.51)); obesity (OR 1.21 (1.06 to 1.38)); and hypertension (OR 1.19 (1.04 to 1.38)) in the SMI group compared with the control group, which was sustained in subsequent years. Similar findings were found for diabetes, although the evidence was weaker (p = 0.059; OR 1.21 (0.99 to 1.49)). There was evidence (p<0.001) of a further, but unsustained, increase in recording of elevated cholesterol and obesity in the SMI group following the 2011 QOF indicator (cardiovascular specific). There was no clear evidence that the QOF indicators affected the prescribing of lipid modifying medications or anti-diabetic medications. Conclusion Incentivising general physical health review for SMI improves identification of cardiovascular risk factors, although the additional value of specifically incentivising cardiovascular risk factor assessment is unclear. However, incentives do not affect pharmacological management of these risks.
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Affiliation(s)
- Carol L. Wilson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | | | - Rupert A. Payne
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
- * E-mail:
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35
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Browne J, Edwards DA, Rhodes KM, Brimicombe DJ, Payne RA. Association of comorbidity and health service usage among patients with dementia in the UK: a population-based study. BMJ Open 2017; 7:e012546. [PMID: 28279992 PMCID: PMC5353300 DOI: 10.1136/bmjopen-2016-012546] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 10/19/2016] [Accepted: 01/09/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The majority of people with dementia have other long-term diseases, the presence of which may affect the progression and management of dementia. This study aimed to identify subgroups with higher healthcare needs, by analysing how primary care consultations, number of prescriptions and hospital admissions by people with dementia varies with having additional long-term diseases (comorbidity). METHODS A retrospective cohort study based on health data from the Clinical Practice Research Datalink (CPRD) was conducted. Incident cases of dementia diagnosed in the year starting 1/3/2008 were selected and followed for up to 5 years. The number of comorbidities was obtained from a set of 34 chronic health conditions. Service usage (primary care consultations, hospitalisations and prescriptions) and time-to-death were determined during follow-up. Multilevel negative binomial regression and Cox regression, adjusted for age and gender, were used to model differences in service usage and death between differing numbers of comorbidities. RESULTS Data from 4999 people (14 866 person-years of follow-up) were analysed. Overall, 91.7% of people had 1 or more additional comorbidities. Compared with those with 2 or 3 comorbidities, people with ≥6 comorbidities had higher rates of primary care consultations (rate ratio (RR) 1.31, 95% CI 1.25 to 1.36), prescriptions (RR 1.68, 95% CI 1.57 to 1.81), and hospitalisation (RR 1.62, 95% CI 1.44 to 1.83), and higher risk of death (HR 1.56, 95% CI 1.37 to 1.78). DISCUSSION In the UK, people with dementia with higher numbers of comorbidities die earlier and have considerably higher health service usage in terms of primary care consultations, hospital admissions and prescribing. This study provides strong evidence that comorbidity is a key factor that should be considered when allocating resources and planning care for people with dementia.
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Affiliation(s)
- Jorge Browne
- Department of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Primary Care Unit, University of Cambridge, Cambridge, UK
| | - Duncan A Edwards
- Primary Care Unit, University of Cambridge, Cambridge, UK
- Grove Lane Surgery, Thetford and National Institute for Health Research Doctoral Research Fellow at Primary Care Unit, University of Cambridge, Worts Causeway Cambridge, UK
| | - Kirsty M Rhodes
- Grove Lane Surgery, Thetford and National Institute for Health Research Doctoral Research Fellow at Primary Care Unit, University of Cambridge, Worts Causeway Cambridge, UK
| | - D James Brimicombe
- Primary Care Unit, University of Cambridge, Cambridge, UK
- Primary Care Unit, University of Cambridge, Cambridge, UK
| | - Rupert A Payne
- Primary Care Unit, University of Cambridge, Cambridge, UK
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Abstract
Polypharmacy is an increasing and global issue affecting primary care. Although sometimes appropriate, polypharmacy can also be problematic, leading to a range of adverse consequences. Deprescribing is the process of supervised withdrawal of an inappropriate medication and has the potential to reduce some of the problems associated with polypharmacy. It is a complex and sensitive process. We examine the issue of deprescribing from the perspective of primary care. Key steps in the deprescribing process are a review of medications and corresponding indications, consideration of harms, assessment of eligibility for discontinuation, prioritisation of medications and implementation of a stopping plan with appropriate monitoring. Patient involvement is a key feature of this process. Deprescribing should be considered in the context of end-of-life care and medication safety, but approaches are also required to identify other situations where deprescribing is appropriate. General practitioners are well positioned to facilitate deprescribing, usually through formal medication review, with decisions informed by a range of other healthcare professionals. Guidelines are available that help guide these processes. A range of studies have explored attitudes towards deprescribing; patients are generally supportive of the concept, although clinician views are varied. The successful implementation of deprescribing strategies still requires important patient and clinician barriers to be overcome, and clinical trial evidence of effectiveness and safety is essential.
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Affiliation(s)
- Polly Duncan
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Martin Duerden
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Abel GA, Barclay ME, Payne RA. Adjusted indices of multiple deprivation to enable comparisons within and between constituent countries of the UK including an illustration using mortality rates. BMJ Open 2016; 6:e012750. [PMID: 27852716 PMCID: PMC5128942 DOI: 10.1136/bmjopen-2016-012750] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Social determinants can have a major impact on health and as a consequence substantial inequalities are seen between and within countries. The study of inequalities between countries relies on having accurate and consistent measures of deprivation across the country borders. However, in the UK most socioeconomic deprivation measures are not comparable between countries. We give a method of adjusting the Indices of Multiple Deprivation (IMD) for use across the UK, describe the deprivation of each UK country, and show the problems introduced by naïvely using country-specific deprivation measures in a UK-wide analysis of mortality rates. SETTING/PARTICIPANTS 42 148 geographic areas covering the population of the UK. OUTCOME MEASURES Adjusted IMD scores based on the income and employment domains of country-specific IMD scores, adjusting for the contribution of other domains. The mortality rate among people aged under 75 years standardised to the UK age structure was compared between country-specific and UK-adjusted IMD quintiles. RESULTS Of the constituent countries of the UK, Northern Ireland was the most deprived with 37% of the population living in areas in the most deprived fifth of the UK, followed by Wales with 22% of the population living in the most deprived fifth of the UK. England and Scotland had similar levels of deprivation. Deprivation-specific mortality rates were similar in England and Wales. Northern Ireland had lower mortality rates than England for each deprivation group, with similar differences for each group. Scotland had higher mortality rates than England for each deprivation group, with larger differences for more deprived groups. CONCLUSIONS Analyses of between-country and within-country inequalities by socioeconomic position should use consistent measures; failing to use consistent measures may give misleading results. The published adjusted IMD scores we describe allow consistent analysis across the UK.
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Affiliation(s)
- Gary A Abel
- University of Exeter Medical School, Exeter, UK
- Primary Care Unit, Cambridge Centre for Health Services Research, Institute of Public Health, Forvie Site, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Matthew E Barclay
- Primary Care Unit, Cambridge Centre for Health Services Research, Institute of Public Health, Forvie Site, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Rupert A Payne
- Primary Care Unit, Cambridge Centre for Health Services Research, Institute of Public Health, Forvie Site, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
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38
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Abstract
Polypharmacy describes, in simplistic terms, the use of multiple medications in an individual. It has become a normal aspect of modern medicine, driven by an ageing, multimorbid population, the increasing availability of preventative medications and an increasing use of single-disease guidelines and adherence to evidence-based practice. However, polypharmacy is also associated with a range of adverse outcomes, and is considered an important and increasing challenge for clinical practice. Here, we consider the definitions of polypharmacy, the extent and nature of medication use in different settings, and the type of problems encountered as a consequence of polypharmacy.
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Affiliation(s)
- Rupert A Payne
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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39
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Affiliation(s)
- R A Payne
- North Middlesex Hospital, London N18
| | - R Wighton
- North Middlesex Hospital, London N18
| | - M. Bluhm
- North Middlesex Hospital, London N18
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40
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Sinnott C, Mercer SW, Payne RA, Duerden M, Bradley CP, Byrne M. Improving medication management in multimorbidity: development of the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention using the Behaviour Change Wheel. Implement Sci 2015; 10:132. [PMID: 26404642 PMCID: PMC4582886 DOI: 10.1186/s13012-015-0322-1] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 09/09/2015] [Indexed: 11/21/2022] Open
Abstract
Background Multimorbidity, the presence of two or more chronic conditions, affects over 60 % of patients in primary care. Due to its association with polypharmacy, the development of interventions to optimise medication management in patients with multimorbidity is a priority. The Behaviour Change Wheel is a new approach for applying behavioural theory to intervention development. Here, we describe how we have used results from a review of previous research, original research of our own and the Behaviour Change Wheel to develop an intervention to improve medication management in multimorbidity by general practitioners (GPs), within the overarching UK Medical Research Council guidance on complex interventions. Methods Following the steps of the Behaviour Change Wheel, we sought behaviours associated with medication management in multimorbidity by conducting a systematic review and qualitative study with GPs. From the modifiable GP behaviours identified, we selected one and conducted a focused behavioural analysis to explain why GPs were or were not engaging in this behaviour. We used the behavioural analysis to determine the intervention functions, behavioural change techniques and implementation plan most likely to effect behavioural change. Results We identified numerous modifiable GP behaviours in the systematic review and qualitative study, from which active medication review (rather than passive maintaining the status quo) was chosen as the target behaviour. Behavioural analysis revealed GPs’ capabilities, opportunities and motivations relating to active medication review. We combined the three intervention functions deemed most likely to effect behavioural change (enablement, environmental restructuring and incentivisation) to form the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention. MY COMRADE primarily involves the technique of social support: two GPs review the medications prescribed to a complex multimorbid patient together. Four other behavioural change techniques are incorporated: restructuring the social environment, prompts/cues, action planning and self-incentives. Conclusions This study is the first to use the Behaviour Change Wheel to develop an intervention targeting multimorbidity and confirms the usability and usefulness of the approach in a complex area of clinical care. The systematic development of the MY COMRADE intervention will facilitate a thorough evaluation of its effectiveness in the next phase of this work. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0322-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carol Sinnott
- Department of General Practice, University College Cork, Cork, Ireland.
| | - Stewart W Mercer
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
| | - Rupert A Payne
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, UK.
| | - Martin Duerden
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK.
| | - Colin P Bradley
- Department of General Practice, University College Cork, Cork, Ireland.
| | - Molly Byrne
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland, Galway, Ireland.
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Silarova B, Lucas J, Butterworth AS, Di Angelantonio E, Girling C, Lawrence K, Mackintosh S, Moore C, Payne RA, Sharp SJ, Shefer G, Tolkien Z, Usher-Smith J, Walker M, Danesh J, Griffin S. Information and Risk Modification Trial (INFORM): design of a randomised controlled trial of communicating different types of information about coronary heart disease risk, alongside lifestyle advice, to achieve change in health-related behaviour. BMC Public Health 2015; 15:868. [PMID: 26345710 PMCID: PMC4562192 DOI: 10.1186/s12889-015-2192-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 08/26/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) remains the leading cause of death globally. Primary prevention of CVD requires cost-effective strategies to identify individuals at high risk in order to help target preventive interventions. An integral part of this approach is the use of CVD risk scores. Limitations in previous studies have prevented reliable inference about the potential advantages and the potential harms of using CVD risk scores as part of preventive strategies. We aim to evaluate short-term effects of providing different types of information about coronary heart disease (CHD) risk, alongside lifestyle advice, on health-related behaviours. METHODS/DESIGN In a parallel-group, open randomised trial, we are allocating 932 male and female blood donors with no previous history of CVD aged 40-84 years in England to either no intervention (control group) or to one of three active intervention groups: i) lifestyle advice only; ii) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic characteristics; and iii) lifestyle advice plus information on estimated 10-year CHD risk based on phenotypic and genetic characteristics. The primary outcome is change in objectively measured physical activity. Secondary outcomes include: objectively measured dietary behaviours; cardiovascular risk factors; current medication and healthcare usage; perceived risk; cognitive evaluation of provision of CHD risk scores; and psychological outcomes. The follow-up assessment takes place 12 weeks after randomisation. The experiences, attitudes and concerns of a subset of participants will be also studied using individual interviews and focus groups. DISCUSSION The INFORM study has been designed to provide robust findings about the short-term effects of providing different types of information on estimated 10-year CHD risk and lifestyle advice on health-related behaviours. TRIAL REGISTRATION Current Controlled Trials ISRCTN17721237 . Registered 12 January 2015.
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Affiliation(s)
- Barbora Silarova
- MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge, CB2 0QQ, UK.
| | - Joanne Lucas
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK.
| | - Adam S Butterworth
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK. .,The INTERVAL trial coordinating centre, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK.
| | - Emanuele Di Angelantonio
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK. .,The INTERVAL trial coordinating centre, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK.
| | | | | | - Stuart Mackintosh
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK.
| | - Carmel Moore
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK. .,The INTERVAL trial coordinating centre, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK.
| | - Rupert A Payne
- Cambridge Centre for Health Services Research, University of Cambridge, Institute of Public Health, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK.
| | - Stephen J Sharp
- MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge, CB2 0QQ, UK.
| | - Guy Shefer
- MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge, CB2 0QQ, UK.
| | - Zoe Tolkien
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK. .,The INTERVAL trial coordinating centre, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK.
| | - Juliet Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, 2 Wort's Causeway, Cambridge, CB1 8RN, UK.
| | - Matthew Walker
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK. .,The INTERVAL trial coordinating centre, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK.
| | - John Danesh
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK. .,The INTERVAL trial coordinating centre, Department of Public Health and Primary Care, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, UK.
| | - Simon Griffin
- MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge, CB2 0QQ, UK. .,The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, 2 Wort's Causeway, Cambridge, CB1 8RN, UK.
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Mercer SW, Payne RA, Nicholl BI, Morrison J. Authors' reply to Lewis and Bray. BMJ 2015; 351:h4446. [PMID: 26286087 DOI: 10.1136/bmj.h4446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Stewart W Mercer
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 9LX, UK
| | - Rupert A Payne
- Primary Care Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Barbara I Nicholl
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 9LX, UK
| | - Jill Morrison
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 9LX, UK
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43
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Affiliation(s)
- Stewart W Mercer
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 9LX, UK
| | - Rupert A Payne
- Primary Care Unit, Institute of Public Health, University of Cambridge, Cambridge CB2 0SR, UK
| | - Barbara I Nicholl
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 9LX, UK
| | - Jill Morrison
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 9LX, UK
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Paddison CAM, Saunders CL, Abel GA, Payne RA, Campbell JL, Roland M. Why do patients with multimorbidity in England report worse experiences in primary care? Evidence from the General Practice Patient Survey. BMJ Open 2015; 5:e006172. [PMID: 25805528 PMCID: PMC4386239 DOI: 10.1136/bmjopen-2014-006172] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To describe and explain the primary care experiences of people with multiple long-term conditions in England. DESIGN AND METHODS Using questionnaire data from 906,578 responders to the English 2012 General Practice Patient Survey, we describe the primary care experiences of patients with long-term conditions, including 583,143 patients who reported one or more long-term conditions. We employed mixed effect logistic regressions to analyse data on six items covering three care domains (access, continuity and communication) and a single item on overall primary care experience. We controlled for sociodemographic characteristics, and for general practice using a random effect, and further, controlled for, and explored the importance of, health-related quality of life measured using the EuroQoL (EQ-5D) scale. RESULTS Most patients with long-term conditions report a positive experience of care at their general practice (after adjusting for sociodemographic characteristics and general practice, range 74.0-93.1% reporting positive experience of care across seven questions) with only modest variation by type of condition. For all three domains of patient experience, an increasing number of comorbid conditions is associated with a reducing percentage of patients reporting a positive experience of care. For example, compared with respondents with no long-term condition, the OR for reporting a positive experience is 0.83 (95% CI 0.80 to 0.87) for respondents with four or more long-term conditions. However, this relationship is no longer observed after adjusting for health-related quality of life (OR (95% CI) single condition=1.23 (1.21 to 1.26); four or more conditions=1.31 (1.25 to 1.37)), with pain making the greatest difference among five quality of life variables included in the analysis. CONCLUSIONS Patients with multiple long-term conditions more frequently report worse experiences in primary care. However, patient-centred measures of health-related quality of life, especially pain, are more important than the number of conditions in explaining why patients with multiple long-term conditions report worse experiences of care.
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Affiliation(s)
| | | | - Gary A Abel
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Rupert A Payne
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - John L Campbell
- Department of Primary Care, University of Exeter, Exeter, UK
| | - Martin Roland
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
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Payne RA, Abel GA, Avery AJ, Mercer SW, Roland MO. Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. Br J Clin Pharmacol 2015; 77:1073-82. [PMID: 24428591 DOI: 10.1111/bcp.12292] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 06/14/2013] [Indexed: 01/04/2023] Open
Abstract
AIMS Prescribing multiple medications is associated with various adverse outcomes, and polypharmacy is commonly considered suggestive of poor prescribing. Polypharmacy might thus be associated with unplanned hospitalization. We sought to test this assumption. METHODS Scottish primary care data for 180 815 adults with long-term clinical conditions and numbers of regular medications were linked to national hospital admissions data for the following year. Using logistic regression (age, gender and deprivation adjusted), we modelled the association of prescribing with unplanned admission for patients with different numbers of long-term conditions. RESULTS Admissions were more common in patients on multiple medications, but admission risk varied with the number of conditions. For patients with one condition, the odds ratio for unplanned admission for four to six medications was 1.25 (95% confidence interval 1.11-1.42) vs. one to three medications, and 3.42 (95% confidence interval 2.72-4.28) for ≥10 medications vs. one to three medications. However, this effect was greatly reduced for patients with multiple conditions; amongst patients with six or more conditions, those on four to six medications were no more likely to have unplanned admissions than those taking one to three medications (odds ratio 1.00; 95% confidence interval 0.88-1.14), and those taking ≥10 medications had a modestly increased risk of admission (odds ratio 1.50; 95% confidence interval 1.31-1.71). CONCLUSIONS Unplanned hospitalization is strongly associated with the number of regular medications. However, the effect is reduced in patients with multiple conditions, in whom only the most extreme levels of polypharmacy are associated with increased admissions. Assumptions that polypharmacy is always hazardous and represents poor care should be tempered by clinical assessment of the conditions for which those drugs are being prescribed.
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Affiliation(s)
- Rupert A Payne
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, CB2 0SR, UK
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46
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Paddison CAM, Saunders CL, Abel GA, Payne RA, Adler AI, Graffy JP, Roland MO. How do people with diabetes describe their experiences in primary care? Evidence from 85,760 patients with self-reported diabetes from the English General Practice Patient Survey. Diabetes Care 2015; 38:469-75. [PMID: 25271208 DOI: 10.2337/dc14-1095] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Developing primary care is an important current health policy goal in the U.S. and England. Information on patients' experience can help to improve the care of people with diabetes. We describe the experiences of people with diabetes in primary care and examine how these experiences vary with increasing comorbidity. RESEARCH DESIGN AND METHODS Using data from 906,578 responders to the 2012 General Practice Patient Survey (England), including 85,760 with self-reported diabetes, we used logistic regressions controlling for age, sex, ethnicity, and socioeconomic status to analyze patient experience using seven items covering three domains of primary care: access, continuity, and communication. RESULTS People with diabetes were significantly more likely to report better experience on six out of seven primary care items than people without diabetes after adjusting for age, sex, ethnicity, and socioeconomic status (adjusted differences 0.88-3.20%; odds ratios [ORs] 1.07-1.18; P < 0.001). Those with diabetes and additional comorbid long-term conditions were more likely to report worse experiences, particularly for access to primary care appointments (patients with diabetes alone compared with patients without diabetes: OR 1.22 [95% CI 1.17-1.28] and patients with diabetes plus three or more conditions compared with patients without diabetes: OR 0.87 [95% CI 0.83-0.91]). CONCLUSIONS People with diabetes in England report primary care experiences that are at least as good as those without diabetes for most domains of care. However, improvements in primary care are needed for diabetes patients with comorbid long-term conditions, including better access to appointments and improved communication.
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Affiliation(s)
- Charlotte A M Paddison
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, U.K.
| | - Catherine L Saunders
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, U.K
| | - Gary A Abel
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, U.K
| | - Rupert A Payne
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, U.K
| | - Amanda I Adler
- Wolfson Diabetes and Endocrine Clinic, Addenbrooke's Hospital, Institute of Metabolic Science, Cambridge, U.K
| | - Jonathan P Graffy
- Primary Care Unit, Institute of Public Health, University of Cambridge, Cambridge, U.K
| | - Martin O Roland
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, U.K
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Payne RA, Abel GA, Avery AJ, Mercer SW, Roland MO. Response to: Assessing the harms of polypharmacy requires careful interpretation and consistent definitions. Br J Clin Pharmacol 2014; 78:672-3. [DOI: 10.1111/bcp.12358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Rupert A. Payne
- Cambridge Centre for Health Services Research; Institute of Public Health; University of Cambridge; Cambridge CB2 0SR UK
| | - Gary A. Abel
- Cambridge Centre for Health Services Research; Institute of Public Health; University of Cambridge; Cambridge CB2 0SR UK
| | - Anthony J. Avery
- Division of Primary Care; University of Nottingham Medical School; Nottingham NG7 2UH UK
| | - Stewart W. Mercer
- General Practice and Primary Care; University of Glasgow; Glasgow G12 9LX UK
| | - Martin O. Roland
- Cambridge Centre for Health Services Research; Institute of Public Health; University of Cambridge; Cambridge CB2 0SR UK
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48
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Appleton SC, Abel GA, Payne RA. Cardiovascular polypharmacy is not associated with unplanned hospitalisation: evidence from a retrospective cohort study. BMC Fam Pract 2014; 15:58. [PMID: 24684851 PMCID: PMC3997839 DOI: 10.1186/1471-2296-15-58] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 03/25/2014] [Indexed: 11/10/2022]
Abstract
Background Polypharmacy is often considered suggestive of suboptimal prescribing, and is associated with adverse outcomes. It is particularly common in the context of cardiovascular disease, but it is unclear whether prescribing of multiple cardiovascular medicines, which may be entirely appropriate and consistent with clinical guidance, is associated with adverse outcome. The aim of this study was to assess the relationship between number of prescribed cardiovascular medicines and unplanned non-cardiovascular hospital admissions. Methods A retrospective cohort analysis of 180,815 adult patients was conducted using Scottish primary care data linked to hospital discharge data. Patients were followed up for one year for the outcome of unplanned non-cardiovascular hospital admission. The association between number of prescribed cardiovascular medicines and hospitalisation was modelled using logistic regression, adjusting for key confounding factors including cardiovascular and non-cardiovascular morbidity and non-cardiovascular prescribing. Results 25.4% patients were prescribed ≥1 cardiovascular medicine, and 5.7% were prescribed ≥5. At least one unplanned non-cardiovascular admission was experienced by 4.2% of patients. Admissions were more common in patients receiving multiple cardiovascular medicines (6.4% of patients prescribed 5 or 6 cardiovascular medicines) compared with those prescribed none (3.5%). However, after adjusting for key confounders, cardiovascular prescribing was associated with fewer non-cardiovascular admissions (OR 0.66 for 5 or 6 vs. no cardiovascular medicines, 95% CI 0.57-0.75). Conclusions We found no evidence that increasing numbers of cardiovascular medicines were associated with an increased risk of unplanned non-cardiovascular hospitalisation, following adjustment for confounding. Assumptions that polypharmacy is hazardous and represents poor care should be moderated in the context of cardiovascular disease.
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Affiliation(s)
| | | | - Rupert A Payne
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, UK.
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Payne RA, Avery AJ, Duerden M, Saunders CL, Simpson CR, Abel GA. Prevalence of polypharmacy in a Scottish primary care population. Eur J Clin Pharmacol 2014; 70:575-81. [PMID: 24487416 DOI: 10.1007/s00228-013-1639-9] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 12/29/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Polypharmacy-the use of multiple medications by a single patient-is an important issue associated with various adverse clinical outcomes and rising costs. It is also a topic rarely addressed by clinical guidelines. We used routine Scottish health records to address the lack of data on the prevalence of polypharmacy in the broader, adult primary care population, particularly in relation to long-term conditions. METHODS We conducted a cross-sectional analysis of adult electronic primary healthcare records and used linear regression models to examine the association between the number of medicines prescribed regularly and both multimorbidity and specific clinical conditions, adjusting for age, gender and socioeconomic deprivation. RESULTS Overall, 16.9 % of the adults assessed were receiving four to nine medications, and 4.6 % were receiving ten or more medications, increasing with age (28.6 and 7.4 %, respectively, in those aged 60-69 years; 51.8 and 18.6 %, respectively, in those aged ≥ 80 years), but relatively unaffected by gender or deprivation. Of those patients with two clinical conditions, 20.8 % were receiving four to nine medications, and 1.1 % were receiving ten or more medications; in those patients with six or more comorbidities, these values were 47.7 and 41.7 %, respectively. The number of medications varied considerably between clinical conditions, with cardiovascular conditions associated with the greatest number of additional medications. The accumulation of additional medicines was less with concordant conditions. CONCLUSIONS Polypharmacy is common in UK primary care. The main factor associated with this is multimorbidity, although considerable variation exists between different conditions. The impact of clinical conditions on the number of medicines is generally less in the presence of co-existing concordant conditions.
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Affiliation(s)
- R A Payne
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK,
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Payne RA, Abel GA, Simpson CR, Maxwell SRJ. Association between prescribing of cardiovascular and psychotropic medications and hospital admission for falls or fractures. Drugs Aging 2014; 30:247-54. [PMID: 23386267 DOI: 10.1007/s40266-013-0058-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Falls are a major cause of morbidity and mortality in the elderly. This study examined the frequency of hospital admission for falls or fractures, and the association with a recent change in the use of cardiovascular and psychotropic medications. METHODS We conducted a retrospective case-cohort study of 39,813 patients aged >65 years from 40 Scottish general practices. Data on current prescriptions, dates of drug changes (defined as increases in dose or starting new drugs), diagnoses and clinical measurements were extracted from primary care electronic records, linked to national hospital admissions data. Multivariable logistic regression was used to model the association of change in prescribing of cardiovascular or psychotropic medication with admission to hospital for falls or fractures in the following 60 days. RESULTS A total of 838 patients (2.1 %) were admitted in the 1-year study period. Following adjustment for factors including age, sex, socioeconomic deprivation, co-morbidity and current prescribing, changes in both cardiovascular and psychotropic medications were associated with subsequent admission for falls or fractures (odds ratio [OR] 1.54 [95 % confidence interval (CI) 1.17-2.03] and 1.68 [95 % CI 1.28-2.22], respectively). There was no evidence for a difference in the effect of change in medication for different cardiovascular drug types (p = 0.86), but there was evidence (p = 0.003) for variation in the association between change in different psychotropic medications and admission; the strongest associations were observed for changes in selective serotonin reuptake inhibitor (SSRI) antidepressants (OR 1.99 [95 % CI 1.29-3.08]), non-SSRI/tricyclic antidepressants (OR 4.39 [95 % CI 2.21-8.71]) and combination psychotropic medication (OR 3.05 [95 % CI 1.66-5.63]). CONCLUSIONS Recent changes in psychotropic and cardiovascular medications are associated with a substantial increase in risk of hospital admission for falls and fractures. Caution should thus be taken when instigating prescribing changes in relation to these medicines, particularly in individuals already considered to be at high risk, such as those with multiple co-morbidities and the oldest old.
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Affiliation(s)
- Rupert A Payne
- Primary Care Unit, University of Cambridge, Institute of Public Health, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK.
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