Clustering long-term health conditions among 67728 people with multimorbidity using electronic health records in Scotland

There is still limited understanding of how chronic conditions co-occur in patients with multimorbidity and what are the consequences for patients and the health care system. Most reported clusters of conditions have not considered the demographic characteristics of these patients during the clustering process. The study used data for all registered patients that were resident in Fife or Tayside, Scotland and aged 25 years or more on 1st January 2000 and who were followed up until 31st December 2018. We used linked demographic information, and secondary care electronic health records from 1st January 2000. Individuals with at least two of the 31 Elixhauser Comorbidity Index conditions were identified as having multimorbidity. Market basket analysis was used to cluster the conditions for the whole population and then repeatedly stratified by age, sex and deprivation. 318,235 individuals were included in the analysis, with 67,728 (21·3%) having multimorbidity. We identified five distinct clusters of conditions in the population with multimorbidity: alcohol misuse, cancer, obesity, renal failure, and heart failure. Clusters of long-term conditions differed by age, sex and socioeconomic deprivation, with some clusters not present for specific strata and others including additional conditions. These findings highlight the importance of considering demographic factors during both clustering analysis and intervention planning for individuals with multiple long-term conditions. By taking these factors into account, the healthcare system may be better equipped to develop tailored interventions that address the needs of complex patients.

Impact of a Prior Cancer Diagnosis on Quality of Care and Survival Following Acute Myocardial Infarction: Retrospective Population-Based Cohort Study in England

BACKGROUND

An increasing proportion of patients with cancer experience acute myocardial infarction (AMI). We investigated differences in quality of AMI care and survival between patients with and without previous cancer diagnoses.

METHODS

A retrospective cohort study using Virtual Cardio-Oncology Research Initiative data. Patients aged 40+ years hospitalized in England with AMI between January 2010 and March 2018 were assessed, ascertaining previous cancers diagnosed within 15 years. Multivariable regression was used to assess effects of cancer diagnosis, time, stage, and site on international quality indicators and mortality.

RESULTS

Of 512 388 patients with AMI (mean age, 69.3 years; 33.5% women), 42 187 (8.2%) had previous cancers. Patients with cancer had significantly lower use of ACE (angiotensin-converting enzyme) inhibitors/angiotensin receptor blockers (mean percentage point decrease [mppd], 2.6% [95% CI, 1.8-3.4]) and lower overall composite care (mppd, 1.2% [95% CI, 0.9-1.6]). Poorer quality indicator attainment was observed in patients with cancer diagnosed in the last year (mppd, 1.4% [95% CI, 1.8-1.0]), with later stage disease (mppd, 2.5% [95% CI, 3.3-1.4]), and with lung cancer (mppd, 2.2% [95% CI, 3.0-1.3]). Twelve-month all-cause survival was 90.5% in noncancer controls and 86.3% in adjusted counterfactual controls. Differences in post-AMI survival were driven by cancer-related deaths. Modeling improving quality indicator attainment to noncancer patient levels showed modest 12-month survival benefits (lung cancer, 0.6%; other cancers, 0.3%).

CONCLUSIONS

Measures of quality of AMI care are poorer in patients with cancer, with lower use of secondary prevention medications. Findings are primarily driven by differences in age and comorbidities between cancer and noncancer populations and attenuated after adjustment. The largest impact was observed in recent cancer diagnoses (<1 year) and lung cancer. Further investigation will determine whether differences reflect appropriate management according to cancer prognosis or whether opportunities to improve AMI outcomes in patients with cancer exist.

Acute heart failure presentation, management and outcomes in cancer patients: a national longitudinal study

BACKGROUND

Currently, little evidence exists on survival and quality of care in cancer patients presenting with acute heart failure (HF). To investigate the presentation and outcomes of hospital admission with acute HF in a national cohort of patients with prior cancer.

METHODS

This retrospective, population-based cohort study, identified 221,953 patients admitted to hospital in England for HF during 2012-2018 (12,867 with a breast, prostate, colorectal or lung cancer diagnosis in the previous 10 years). We examined the impact of cancer on 1) HF presentation and in-hospital mortality, 2) place of care, 3) HF medication prescribing, and 4) post-discharge survival, using propensity score weighting and model-based adjustment.

RESULTS

HF presentation was similar between cancer and non-cancer patients. A lower percentage of patients with prior cancer were cared for in a cardiology ward (-2.4 percentage point difference [ppd] [95% CI -3.3, -1.6]) or were prescribed ACEi/ARB for HFrEF (-2.1 ppd [-3.3, -0.9]) than non-cancer patients. Survival after HF discharge was poor with median survival of 1.6 years in prior cancer and 2.6 years in non-cancer patients. Mortality in prior cancer patients was driven primarily by non-cancer causes (68% of post-discharge deaths).

CONCLUSIONS

Survival in prior cancer patients presenting with acute HF was poor, with a significant proportion due to non-cancer causes of death. Despite this, cardiologists were less likely to manage cancer patients with HF. Cancer patients who develop HF were less likely to be prescribed guideline-based HF medications compared with non-cancer patients. This was particularly driven by patients with a poorer cancer prognosis.

Glycosylated haemoglobin and prognosis in 10,536 people with cancer and pre-existing diabetes: a meta-analysis with dose-response analysis

AIMS

To assess whether glycaemic control is associated with prognosis in people with cancer and pre-existing diabetes.

METHODS

In this pre-registered systematic review (PROSPERO: CRD42020223956), PubMed and Web of Science were searched on 25th Nov 2021 for studies investigating associations between glycosylated haemoglobin (HbA1c) and prognosis in people with diabetes and cancer. Summary relative risks (RRs) and 95% Confidence Intervals (CIs) for associations between poorly controlled HbA1c or per 1-unit HbA1c increment and cancer outcomes were estimated using a random-effects meta-analysis. We also investigated the impact of potential small-study effects using the trim-and-fill method and potential sources of heterogeneity using subgroup analyses.

RESULTS

Fifteen eligible observational studies, reporting data on 10,536 patients with cancer and pre-existing diabetes, were included. Random-effects meta-analyses indicated that HbA1c ≥ 7% (53 mmol/mol) was associated with increased risks of: all-cause mortality (14 studies; RR: 1.14 [95% CI: 1.03-1.27]; p-value: 0.012), cancer-specific mortality (5; 1.68 [1.13-2.49]; p-value: 0.011) and cancer recurrence (8; 1.68 [1.18-2.38; p-value: 0.004]), with moderate to high heterogeneity. Dose-response meta-analyses indicated that 1-unit increment of HbA1c (%) was associated with increased risks of all-cause mortality (13 studies; 1.04 [1.01-1.08]; p-value: 0.016) and cancer-specific mortality (4; 1.11 [1.04-1.20]; p-value: 0.003). All RRs were attenuated in trim-and-fill analyses.

CONCLUSIONS

Our findings suggested that glycaemic control might be a modifiable risk factor for mortality and cancer recurrence in people with cancer and pre-existing diabetes. High-quality studies with a larger sample size are warranted to confirm these findings due to heterogeneity and potential small-study effects. In the interim, it makes clinical sense to recommend continued optimal glycaemic control.

Development of 2 Short Patient-Report Questionnaires of Patient Safety in Primary Care

OBJECTIVES

The Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) is a valid and reliable instrument (61 items across 5 domains) of patients' perceptions of safety. Stakeholder feedback has supported shorter versions for improving choice and facilitating uptake of routine patient-centered evaluation. We sought to develop 2 shorter versions of PREOS-PC: one including the shortest possible scales that met established measurement performance standards and a screening version including a single item per domain.

METHODS

A total of 1244 patients from 45 general practices across England completed PREOS-PC questionnaires. All scale items in PREOS-PC underwent Item Response Theory analysis, applying standard criteria for the item reduction. Cognitive debriefing from 10 patient interviews allowed for the assessment of the instruments' readability. The instruments' psychometrics properties were reassessed in a validation sample of 1557 patients in 21 English general practices.

RESULTS

"PREOS-PC Compact" includes 25 items and 2 open-ended questions across the 5 domains, 44% of the length of the original instrument. "PREOS-PC Screen" consists of 6 items: the best-performing single items for 2 domains, 1 item modified from original items for each of the remaining 3 domains, and 1 open-ended question. The evaluation of the instruments confirmed they were acceptable to patients and met standards for readability; construct, convergent, and divergent validity; and reliability.

CONCLUSIONS

PREOS-PC Compact meets high-performance standards while reducing patient burden for routine monitoring of patient safety in primary care. PREOS-PC Screen is a concise tool apt for incorporation into audits and to target more in-depth review as needed.

In-Hospital Complications in Pregnancies Conceived by Assisted Reproductive Technology

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

Measuring multimorbidity in research: Delphi consensus study

Objective

To develop international consensus on the definition and measurement of multimorbidity in research.

Design

Delphi consensus study.

Setting

International consensus; data collected in three online rounds from participants between 30 November 2020 and 18 May 2021.

Participants

Professionals interested in multimorbidity and people with long term conditions were recruited to professional and public panels.

Results

150 professional and 25 public participants completed the first survey round. Response rates for rounds 2/3 were 83%/92% for professionals and 88%/93% in the public panel, respectively. Across both panels, the consensus was that multimorbidity should be defined as two or more long term conditions. Complex multimorbidity was perceived to be a useful concept, but the panels were unable to agree on how to define it. Both panels agreed that conditions should be included in a multimorbidity measure if they were one or more of the following: currently active; permanent in their effects; requiring current treatment, care, or therapy; requiring surveillance; or relapsing-remitting conditions requiring ongoing care. Consensus was reached for 24 conditions to always include in multimorbidity measures, and 35 conditions to usually include unless a good reason not to existed. Simple counts were preferred for estimating prevalence and examining clustering or trajectories, and weighted measures were preferred for risk adjustment and outcome prediction.

Conclusions

Previous multimorbidity research is limited by inconsistent definitions and approaches to measuring multimorbidity. This Delphi study identifies professional and public panel consensus guidance to facilitate consistency of definition and measurement, and to improve study comparability and reproducibility.

Socioeconomic Status and Outcomes in Heart Failure With Reduced Ejection Fraction From Asia

BACKGROUND

Little is known regarding the impact of socioeconomic factors on the use of evidence-based therapies and outcomes in patients with heart failure with reduced ejection fraction across Asia.

METHODS

We investigated the association of both patient-level (household income, education levels) and country-level (regional income level by World Bank classification, income disparity by Gini index) socioeconomic indicators on use of guideline-directed therapy and clinical outcomes (composite of 1-year mortality or HF hospitalization, quality of life) in the prospective multinational ASIAN-HF study (Asian Sudden Cardiac Death in Heart Failure).

RESULTS

Among 4540 patients (mean age: 60±13 years, 23% women) with heart failure with reduced ejection fraction, 39% lived in low-income regions; 34% in regions with high-income disparity (Gini ≥42.8%); 64.4% had low monthly household income (<US$1000); and 29.5% had no/only primary education. The largest disparity in treatment across regional income levels pertained to β-blocker and device therapies, with patients from low-income regions being less likely to receive these treatments compared with those from high-income regions and even greater disparity among patients with lower education status and lower household income within each regional income strata. Higher country- and patient-level socioeconomic indicators related to higher quality of life scores and lower risk of the primary composite outcome. Notably, we found a significant interaction between regional income level and both household income and education status (P_interaction <0.001 for both), where the association of low household income and low education status with poor outcomes was more pronounced in high-income compared with lower income regions.

CONCLUSIONS

These findings highlight the importance of socioeconomic determinants among patients with heart failure in Asia and suggest that attention should be paid to address disparities in access to care among the poor and less educated, including those from wealthy regions. Registration: URL: https://clinicaltrials.gov; Unique Identifier: NCT01633398.

Outcome trends in people with heart failure, type 2 diabetes mellitus and chronic kidney disease in the UK over twenty years

BACKGROUND

Heart failure (HF) together with type 2 diabetes (T2D) and chronic kidney disease (CKD) are major pandemics of the twenty first century. It is not known in people with new onset HF, what the distinct and combined associations are between T2D and CKD comorbidities and cause-specific hospital admissions and death, over the past 20 years.

METHODS

An observational study using the UK Clinical Practice Research Datalink linked to the Hospital Episode Statistics in England (1998-2017). Participants were people aged ≥30 years with new onset HF. Exposure groups were HF with: (i) no T2D and no CKD (reference group); (ii) CKD-only (estimated glomerular filtration rate (eGFR) <60 ml/min per 1.73 m²); (iii) T2D-only; (iv) T2D and CKD. CKD severity groups were: CKD-3a (eGFR 45-59); CKD-3b (30-44); CKD-4 (15-29); CKD-5 (<15). Outcomes were cardiovascular and non-cardiovascular hospitalisations and all-cause death.

FINDINGS

In 87,709 HF patients (mean age, 78 years; 49% female), 40% had CKD-only, 12% T2D-only, and 16% both. Age-standardised first-year CVD hospitalisation rates were significantly higher in HF patients with CKD-only (46.4; 95% CI 44.9,47.9 per 100 person years) and T2D-only (49.2; 46.7,58.8) than in the reference group (35.1; 34.0,36.1); the highest rate was in patients with T2D-CKD-5: 89.1 (65.8,112.4). Similar patterns were observed for non-CVD hospitalisations and deaths. Group differences remained significant after adjustment for potential confounders. Median survival was highest in the reference (4.4 years) and HF-T2D-only (4.1 years) groups, compared to HF-CKD-only (2.2 years). HF-T2D-CKD group survival ranged from 2.8 (CKD-3a) to 0.7 years (CKD-5). Over time, CVD hospitalisation rates significantly increased for HF-CKD-only (+26%) and reduced (-24%) for HF-T2D-only groups; no reductions were observed in any of the HF-T2D-CKD groups. Trends were similar for non-CVD hospitalisations and death: whilst death rates significantly reduced for HF-T2D-only (-37%), improvement was not observed in any of the T2D-CKD groups.

INTERPRETATION

In a cohort of people with new onset HF, hospitalisations and deaths are high in patients with T2D or CKD, and worst in those with both comorbidities. Whilst outcomes have improved over time for patients with HF and comorbid T2D, similar trends were not seen in those with comorbid CKD. Strategies to prevent and manage CKD in people with HF are urgently needed.

FUNDING

NIHR fellowship [reference: NIHR 30011].

Risk Factors for Heart Failure

Background:

There are multiple risk factors for heart failure, but contemporary temporal trends according to sex, socioeconomic status, and ethnicity are unknown.

Methods:

Using a national UK general practice database linked to hospitalizations (1998–2017), 108 638 incident heart failure patients were identified. Differences in risk factors among patient groups adjusted for sociodemographic factors and age-adjusted temporal trends were investigated using logistic and linear regression.

Results:

Over time, a 5.3 year (95% CI, 5.2–5.5) age difference between men and women remained. Women had higher blood pressure, body mass index, and cholesterol than men ( P <0.0001). Ischemic heart disease prevalence increased for all to 2006 before reducing in women by 0.5% per annum, reaching 42.7% (95% CI, 41.7–43.6), but not in men, remaining at 57.7% (95% CI, 56.9–58.6; interaction P =0.002). Diabetes mellitus prevalence increased more in men than in women (interaction P <0.0001). Age between the most deprived (74.6 years [95% CI, 74.1–75.1]) and most affluent (79.9 [95% CI, 79.6–80.2]) diverged (interaction P <0.0001), generating a 5-year gap. The most deprived had significantly higher annual increases in comorbidity numbers (+0.14 versus +0.11), body mass index (+0.14 versus +0.11 kg/m 2 ), and lower smoking reductions (−1.2% versus −1.7%) than the most affluent. Ethnicity trend differences were insignificant, but South Asians were overall 6 years and the black group 9 years younger than whites. South Asians had more ischemic heart disease (+16.5% [95% CI, 14.3–18.6]), hypertension (+12.5% [95% CI, 10.5–14.3]), and diabetes mellitus (+24.3% [95% CI, 22.0–26.6]), and the black group had more hypertension (+12.3% [95% CI, 9.7–14.8]) and diabetes mellitus (+13.1% [95% CI, 10.1–16.0]) but lower ischemic heart disease (−10.6% [95% CI, −13.6 to −7.6]) than the white group.

Conclusions:

Population groups show distinct risk factor trend differences, indicating the need for contemporary tailored prevention programs.

Trends in Cause-Specific Outcomes Among Individuals With Type 2 Diabetes and Heart Failure in the United Kingdom, 1998-2017

IMPORTANCE

The phenotype of individuals with type 2 diabetes and heart failure (HF) is changing. Successful public health interventions for type 2 diabetes mean that patients more frequently present with HF without a prior ischemic event, which is likely to change outcomes, but trends in cause-specific outcomes are unknown.

OBJECTIVE

To investigate cause-specific outcomes and trends associated with type 2 diabetes among individuals with incident HF.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used UK primary care data, linked to hospital admissions and mortality, for 87 709 patients with incident HF from 1998 to 2017. Patients were 30 years or older and observed to death or July 31, 2017. Data analysis was conducted in March and April 2019.

EXPOSURE

Preexisting type 2 diabetes at diagnosis of HF. Individuals with type 1 diabetes were excluded.

MAIN OUTCOMES AND MEASURES

All-cause, cardiovascular (CVD), and non-CVD unplanned hospitalizations and mortality rates.

RESULTS

Of 87 709 patients with HF (43 173 [49.2%] women; 78 211 [89.2%] white), 20 858 (23.8%) had type 2 diabetes (median [interquartile range] age, 78.0 [70.0 to 84.0] years), and 66 851 (76.2%) had no diabetes (median [interquartile range] age, 80.0 [72.0 to 86.0] years). In patients with HF, type 2 diabetes was associated with an increase in the risk of unplanned hospital admission (adjusted incidence rate ratio for CVD hospitalizations: 1.24; 95% CI, 1.19 to 1.30; for non-CVD hospitalizations: 1.26; 95% CI, 1.22 to 1.30) and an increase in the risk of mortality (adjusted hazard ratio for CVD mortality: 1.06; 95% CI, 1.02 to 1.10; for non-CVD mortality: 1.24; 95% CI, 1.19 to 1.29). Age-standardized mortality risk at 1 year was 35.6% (95% CI, 35.1% to 36.1%) in the type 2 diabetes group vs 29.2% (95% CI, 29.0% to 29.5%) in the group with no diabetes. During the study period (ie, 1998 to 2017), associations of type 2 diabetes with hospitalization and mortality rates decreased for CVD outcomes but not for non-CVD outcomes. Age-adjusted hospitalization rates during the first year following HF diagnosis increased similarly for both groups over time (eg, HF with type 2 diabetes, 1998 to 2001: 133.3 per 100 person-years; 95% CI, 102.2 to 105.4 per 100 person-years; 2012 to 2015: 152.5 per 100 person-years; 95% CI, 145.5 to 159.5 per 100 person-years; P for difference in trend = .06), but trends diverged by cause. For example, hospitalizations for HF decreased for patients with type 2 diabetes at approximately the same annual rate (-2.2%; 95% CI, -3.9% to -0.5%) as they increased for those without diabetes (1.7%; 95% CI, 1.1% to 2.3%; P for difference in trend < .001). After 2004, a trend emerged showing a greater increase in non-CVD admissions among patients with HF and type 2 diabetes than among patients with no diabetes (2.3% [95% CI, 0.9% to 3.6%] vs 1.1% [95% CI, 0.8% to 1.4%]). In contrast to hospitalization rates, mortality rates reduced over time in both groups, but the reduction was greater among those with type 2 diabetes than without (-1.4% [95% CI, -1.8% to -0.9%] vs -0.7% [95% CI, -1.2% to -0.2%]; P for difference in trend < .001).

CONCLUSIONS AND RELEVANCE

In this study, the higher risk of all cause-specific outcomes and emerging non-CVD trends associated with patients with type 2 diabetes who experienced HF indicated an urgent need for earlier comorbidity management and patient-centered multimorbidity care.

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

Background

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

Methods and Results

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

Conclusions

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

20-year trends in cause-specific heart failure outcomes by sex, socioeconomic status, and place of diagnosis: a population-based study

BACKGROUND

Heart failure is an important public health issue affecting about 1 million people in the UK, but contemporary trends in cause-specific outcomes among different population groups are unknown.

METHODS

In this retrospective, population-based study, we used the UK Clinical Practice Research Datalink and Hospital Episodes Statistics databases to identify a cohort of patients who had a diagnosis of incident heart failure between Jan 1, 1998, and July 31, 2017. Patients were eligible for inclusion if they were aged 30 years or older with a first code for heart failure in their primary care or hospital record during the study period. We assessed cause-specific admission to hospital (ie, hospitalisation) and mortality, by age, sex, socioeconomic status, and place of diagnosis (ie, hospital vs community diagnosis). We calculated outcome rates separately for the first year (first-year rates) and for the second-year onwards (subsequent-year rates). Patients were followed up until death or study end. This study is registered with Clinical Practice Research Datalink Independent Scientific Advisory Committee, protocol number 18_037R.

FINDINGS

We identified 88 416 individuals with incident heart failure over the study period, of whom 43 461 (49%) were female. The mean age was 77·8 years (SD 11·3) and median follow-up was 2·4 years (IQR 0·5 to 5·7). Age-adjusted first-year rates of hospitalisation increased by 28% for all-cause admissions, from 97·1 (95% CI 94·3 to 99·9) to 124·2 (120·9 to 127·5) per 100 person-years; by 28% for heart failure-specific admissions, from 17·2 (16·2 to 18·2) to 22·1 (20·9 to 23·2) per 100 person-years; and by 42% for non-cardiovascular admissions, from 59·2 (57·2 to 61·2) to 83·9 (81·3 to 86·5) per 100 person-years. 167 641 (73%) of 228 113 hospitalisations were for non-cardiovascular causes and annual rate increases were higher for women (3·9%, 95% CI 2·8 to 4·9) than for men (1·4%, 0·6 to 2·1; p<0·0001); and for patients diagnosed with heart failure in hospital (2·4%, 1·4 to 3·3) than those diagnosed in the community (1·2%, 0·3 to 2·2). Annual increases in hospitalisation due to heart failure were 2·6% (1·9 to 3·4) for women compared with stable rates in men (0·6%, -0·9 to 2·1), and 1·6% (0·6 to 2·6) for the most deprived group compared with stable rates for the most affluent group (1·2%, -0·3 to 2·8). A significantly higher risk of all-cause hospitalisation was found for the most deprived than for the most affluent (incident rate ratio 1·34, 95% CI 1·32 to 1·35) and for the hospital-diagnosed group than for the community-diagnosed group (1·76, 1·73 to 1·80). Age-adjusted first-year rates of all-cause mortality decreased by 6% from 24·5 (95% CI 23·4 to 39·2) to 23·0 (22·0 to 24·1) per 100 person-years. Annual change in mortality was -1·4% (95% CI -2·3 to -0·5) in men but was stable for women (0·3%, -0·5 to 1·1), and -2·7% (-3·2 to -2·2) for the community-diagnosed group compared with -1·1% (-1·8 to -0·4) in the hospital-diagnosed group (p<0·0001). A significantly higher risk of all-cause mortality was seen in the most deprived group than in the most affluent group (hazard ratio 1·08, 95% CI 1·05 to 1·11) and in the hospital-diagnosed group than in the community-diagnosed group (1·55, 1·53 to 1·58).

INTERPRETATION

Tailored management strategies and specialist care for patients with heart failure are needed to address persisting and increasing inequalities for men, the most deprived, and for those who are diagnosed with heart failure in hospital, and to address the worrying trends in women.

FUNDING

Wellcome Trust.

Cardiometabolic Polygenic Risk Scores and Osteoarthritis Outcomes: A Mendelian Randomization Study Using Data From the Malmö Diet and Cancer Study and the UK Biobank

Objective

To investigate the causal role of cardiometabolic risk factors in osteoarthritis (OA) using associated genetic variants.

Methods

We studied 27,691 adults from the Malmö Diet and Cancer Study (MDCS) and replicated novel findings among 376,435 adults from the UK Biobank. Trait‐specific polygenic risk scores for low‐density lipoprotein (LDL) and high‐density lipoprotein (HDL) cholesterol levels, triglyceride levels, body mass index (BMI), fasting plasma glucose (FPG) levels, and systolic blood pressure (BP) were used to test the associations of genetically predicted elevations in each trait with incident OA diagnosis (n = 3,559), OA joint replacement (n = 2,780), or both (total OA; n = 4,226) in Mendelian randomization (MR) analyses in the MDCS, and with self‐reported and/or hospital‐diagnosed OA (n = 65,213) in the UK Biobank. Multivariable MR, MR‐Egger, and weighted median MR were used to adjust for potential pleiotropic biases.

Results

In the MDCS, genetically predicted elevation in LDL cholesterol level was associated with a lower risk of OA diagnosis (odds ratio [OR] 0.83 [95% confidence interval (95% CI) 0.73–0.95] per 1SD increase) and total OA (OR 0.87 [95% CI 0.78–0.98]), which was supported by multivariable MR for OA diagnosis (OR 0.84 [95% CI 0.75–0.95]) and total OA (0.87 [95% CI 0.78–0.97]), and by conventional 2‐sample MR for OA diagnosis (OR 0.86 [95% CI 0.75–0.98]). MR‐Egger indicated no pleiotropic bias. Genetically predicted elevation in BMI was associated with an increased risk of OA diagnosis (OR 1.65 [95% CI 1.14–2.41]), while MR‐Egger indicated pleiotropic bias and a larger association with OA diagnosis (OR 3.25 [1.26–8.39]), OA joint replacement (OR 3.81 [95% CI 1.39–10.4]), and total OA (OR 3.41 [95% CI 1.43–8.15]). No associations were observed between genetically predicted HDL cholesterol level, triglyceride level, FPG level, or systolic BP and OA outcomes. The associations with LDL cholesterol levels were replicated in the UK Biobank (OR 0.95 [95% CI 0.93–0.98]).

Conclusion

Our MR study provides evidence of a causal role of lower LDL cholesterol level and higher BMI in OA.

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

OBJECTIVE

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

DESIGN

A narrative systematic review.

DATA SOURCE

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

STUDY SELECTION

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

RESULTS

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

CONCLUSION

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

PROSPERO REGISTRATION NUMBER

CRD42017062378.

Association of Medication Intensity and Stages of Airflow Limitation With the Risk of Hospitalization or Death in Patients With Heart Failure and Chronic Obstructive Pulmonary Disease

IMPORTANCE

In heart failure (HF), chronic obstructive pulmonary disease (COPD) increases the risk of poor outcomes, but the effect of COPD severity is unknown. This information is important for early intervention tailored to the highest-risk groups.

OBJECTIVES

To determine the associations between COPD medication intensity or stage of airflow limitation and the risk of hospitalization or death in patients with HF.

DESIGN, SETTING, AND PARTICIPANTS

This UK population-based, nested case-control study with risk-set sampling used the Clinical Practice Research Datalink linked to Hospital Episode Statistics between January 1, 2002, to January 1, 2014. Participants included patients aged 40 years and older with a new diagnosis of HF in their family practice clinical record. Data analysis was conducted from 2017 to 2018.

EXPOSURES

In patients with HF, those with COPD were compared with those without it. International COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD]) guidelines were used to stratify patients with COPD by 7 medication intensity levels and 4 airflow limitation severity stages using automatically recorded prescriptions and routinely requested forced expiratory volume in 1 second (FEV1) data.

MAIN OUTCOMES AND MEASURES

First all-cause admission or all-cause death.

RESULTS

There were 50 114 patients with new HF (median age, 79 years [interquartile range, 71-85 years]; 46% women) during the study period. In patients with HF, COPD (18 478 [13.8%]) was significantly associated with increased mortality (adjusted odds ratio [AOR], 1.31; 95% CI, 1.26-1.36) and hospitalization (AOR, 1.33; 95% CI, 1.26-1.39). The 3 most severe medication intensity levels showed significantly increasing mortality associations from full inhaler therapy (AOR, 1.17; 95% CI, 1.06-1.29) to oral corticosteroids (AOR, 1.69; 95% CI, 1.57-1.81) to oxygen therapy (AOR, 2.82; 95% CI, 2.42-3.28). The respective estimates for hospitalization were AORs of 1.17 (95% CI, 1.03-1.33), 1.75 (95% CI, 1.59-1.92), and 2.84 (95% CI, 1.22-3.63). Availability of spirometry data was limited but showed that increasing airflow limitation was associated with increased risk of mortality, with the following AORs: FEV1 80% or more, 1.63 (95% CI, 1.42-1.87); FEV1 50% to 79%, 1.69 (95% CI, 1.56-1.83); FEV1 30% to 49%, 2.21 (95% CI, 2.01-2.42); FEV1 less than 30%, 2.93 (95% CI, 2.49-3.43). The strength of associations between FEV1 and hospitalization risk were similar among stages ranging from FEV1 80% or more (AOR, 1.48; 95% CI, 1.31-1.68) to FEV1 less than 30% (AOR, 1.73; 95% CI, 1.40-2.12).

CONCLUSIONS AND RELEVANCE

In the UK HF community setting, increasing COPD severity was associated with increasing risk of mortality and hospitalization. Prescribed COPD medication intensity and airflow limitation provide the basis for targeting high-risk groups.

Conceptualizing multiple drug use in patients with comorbidity and multimorbidity: proposal for standard definitions beyond the term polypharmacy

With older and aging populations, patients experience multiple chronic diseases at the same time. Individual chronic disease guidelines often recommend pharmacological therapies as a key intervention, resulting in patients being prescribed multiple regular medications for their different diseases. Although the term "polypharmacy" has been applied to the use of multiple medications, there is no consistent definition, and this term is now being used all inclusively. To improve both scientific rigor and optimal patient care, it is crucial that a standard terminology is used, which reclassifies the term "polypharmacy" into distinct phenotypes relating to the index chronic disease, additional conditions to the index (comorbidity), or the experience of multiple chronic conditions at the same time (multimorbidity). Using three exemplar index conditions; heart failure, type 2 diabetes, and breast cancer, we propose the reclassification of the term "polypharmacy" into three distinct phenotypes. First, index drug or multi-index drug therapy, where each index condition creates multiple drug use for that condition; second, codrug therapy, where addition of other comorbid conditions increases the multiple drug use and may influence the management of the index disease and third, multidrug therapy, where adult population with multimorbidity may be on many drugs. This article reviews guidelines for the individual exemplars to develop the basis for the new terms and then develops the pharmacoepidemiology of multiple drug use further by reviewing the evidence on the relationship between the phenotypic classification and important outcomes. The importance of standardizing "polypharmacy" terminology for the scientific agenda and clinical practice is that it relates to an index condition or disease safety outcomes including drug interactions, adverse side effects in hospital admissions, and related "polypill" concept.

Chronic kidney disease, worsening renal function and outcomes in a heart failure community setting: A UK national study

BACKGROUND

Routine heart failure (HF) monitoring and management is in the community but the natural course of worsening renal function (WRF) and its influence on HF prognosis is unknown. We investigated the influence of routinely monitored renal decline and related comorbidities on imminent hospitalisation and death in the HF community population.

METHODS

A nested case-control study within an incident HF cohort (N = 50,114) with 12-years follow-up. WRF over 6-months before first hospitalisation and 12-months before death was defined by >20% reduction in estimated glomerular filtration rate (eGFR). Additive interactions between chronic kidney disease (CKD) and comorbidities were investigated.

RESULTS

Prevalence of CKD (eGFR<60 ml/min/1.73m2) in the HF community was 63%, which was associated with an 11% increase in hospitalisation and 17% in mortality. Both risk associations were significantly worse in the presence of diabetes. Compared to HF patients with eGFR,60-89, there was no or minimal increase in risk for mild to moderate CKD (eGFR,30-59) for both outcomes. Adjusted risk estimates for hospitalisation were increased only for severe CKD(eGFR,15-29); Odds Ratio 1.49 (95%CI;1.36,1.62) and renal failure(eGFR,<15); 3.38(2.67,4.29). The relationship between eGFR and mortality was U-shaped; eGFR, ≥90; 1.32(1.17,1.48), eGFR,15-29; 1.68(1.58,1.79) and eGFR,<15; 3.04(2.71,3.41). WRF is common and associated with imminent hospitalisation (1.50;1.37,1.64) and mortality (1.92;1.79,2.06).

CONCLUSIONS

In HF, the risk associated with CKD differs between the community and the acute HF setting. In the community setting, moderate CKD confers no risk but severe CKD, WRF or CKD with other comorbidities identifies patients at high risk of imminent hospitalisation and death.

Do frailty measures improve prediction of mortality and morbidity following transcatheter aortic valve implantation? An analysis of the UK TAVI registry

OBJECTIVES

Previous studies indicate frailty to be associated with poor outcomes following transcatheter aortic valve implantation (TAVI), but there is limited evidence from multicentre registries. The aim was to investigate the independent association of frailty with TAVI outcomes, and the prognostic utility of adding frailty into existing clinical prediction models (CPMs).

DESIGN

The UK TAVI registry incorporated three frailty measures since 2013: Canadian Study of Health and Ageing, KATZ and poor mobility. We investigated the associations between these frailty measures with short-term and long-term outcomes, using logistic regression to estimate multivariable adjusted ORs, and Cox proportional hazards models to explore long-term survival. We compared the predictive performance of existing TAVI CPMs before and after updating them to include each frailty measure.

SETTING

All patients who underwent a TAVI procedure in England or Wales between 2013 and 2014.

PARTICIPANTS

2624 TAVI procedures were analysed in this study.

PRIMARY AND SECONDARY OUTCOMES

The primary endpoints in this study were 30-day mortality and long-term survival. The Valve Academic Research Consortium (VARC)-2 composite early safety endpoint was considered as a secondary outcome.

RESULTS

KATZ <6 (OR 2.10, 95% CI 1.39 to 3.15) and poor mobility (OR 2.15, 95% CI 1.41 to 3.28) predicted 30-day mortality after multivariable adjustment. All frailty measures were associated with increased odds of the VARC-2 composite early safety endpoint. We observed a significant increase in the area under the receiver operating characteristic curves by approximately 5% after adding KATZ <6 or poor mobility into the TAVI CPMs. Risk stratification agreement was significantly improved by the addition of each frailty measure, with an increase in intraclass correlation coefficient of between 0.15 and 0.31.

CONCLUSION

Frailty was associated with worse outcomes following TAVI, and incorporating frailty metrics significantly improved the predictive performance of existing CPMs. Physician-estimated frailty measures could aid TAVI risk stratification, until more objective scales are routinely collected.

Consumer segmentation and time interval between types of hospital admission: a clinical linkage database study

Background

Healthcare policies target unplanned hospital admissions and 30-day re-admission as key measures of efficiency, but do not focus on factors that influence trajectories of different types of admissions in the same patient over time.

Objectives

To investigate the influence of consumer segmentation and patient factors on the time intervals between different types of hospital admission.

Research design, subjects and measures

A cohort design was applied to an anonymised linkage database for adults aged 40 years and over (N = 58 857). Measures included Mosaic segmentation, multimorbidity defined on six chronic condition registers and hospital admissions over a 27-month time period.

Results

The shortest mean time intervals between two consecutive planned admissions were: 90 years and over (160 days (95% confidence interval (CI): 146-175)), Mosaic groups 'Twilight subsistence' (171 days (164-179)) or 'Welfare borderline' and 'Municipal dependency' (177 days (172-182)) compared to the reference Mosaic groups (186 days (180-193)), and multimorbidity count of four or more (137 days (130-145)). Mosaic group 'Twilight subsistence' (rate ratio (RR) 1.22 (95% CI: 1.08-1.36)) or 'Welfare borderline' and 'Municipal dependency' RR 1.20 (1.10-1.31) were significantly associated with higher rate to an unplanned admission following a planned event. However, associations between patient factors and unplanned admissions were diminished by adjustment for planned admissions.

Conclusion

Specific consumer segmentation and patient factors were associated with shorter time intervals between different types of admissions. The findings support innovation in public health approaches to prevent by a focus on long-term trajectories of hospital admissions, which include planned activity.

Preterm Delivery and Future Risk of Maternal Cardiovascular Disease: A Systematic Review and Meta-Analysis

Background

Preterm delivery (<37 weeks gestational age) affects 11% of all pregnancies, but data are conflicting whether preterm birth is associated with long‐term adverse maternal cardiovascular outcomes. We aimed to systematically evaluate and summarize the evidence on the relationship between preterm birth and future maternal risk of cardiovascular diseases.

Methods and Results

A systematic search of MEDLINE and EMBASE was performed to identify relevant studies that evaluated the association between preterm birth and future maternal risk of composite cardiovascular disease, coronary heart disease, stroke, and death caused by cardiovascular or coronary heart disease and stroke. We quantified the associations using random effects meta‐analysis. Twenty‐one studies with over 5.8 million women, including over 338 000 women with previous preterm deliveries, were identified. Meta‐analysis of studies that adjusted for potential confounders showed that preterm birth was associated with an increased risk of maternal future cardiovascular disease (risk ratio [RR] 1.43, 95% confidence interval [CI], 1.18, 1.72), cardiovascular disease death (RR 1.78, 95% CI, 1.42, 2.21), coronary heart disease (RR 1.49, 95% CI, 1.38, 1.60), coronary heart disease death (RR 2.10, 95% CI, 1.87, 2.36), and stroke (RR 1.65, 95% CI, 1.51, 1.79). Sensitivity analysis showed that the highest risks occurred when the preterm deliveries occurred before 32 weeks gestation or were medically indicated.

Conclusions

Preterm delivery is associated with an increase in future maternal adverse cardiovascular outcomes, including a 2‐fold increase in deaths caused by coronary heart disease. These findings support the assessment of preterm delivery in cardiovascular risk assessment in women.

Association Between Type 2 Diabetes and All-Cause Hospitalization and Mortality in the UK General Heart Failure Population: Stratification by Diabetic Glycemic Control and Medication Intensification

OBJECTIVES

This study sought to investigate in the general heart failure (HF) population, whether the associations between type 2 diabetes (T2D) and risk of hospitalization and death, are modified by changing glycemic or drug treatment intensity.

BACKGROUND

In the general HF population, T2D confers a higher risk of poor outcomes, but whether this risk is modified by the diabetes status is unknown.

METHODS

A nested case-control study in an incident HF database cohort (2002 to 2014) compared patients with T2D with those without for risk of all-cause first hospitalization and death. T2D was stratified by categories of glycosylated hemoglobin (HbA_1c) or drug treatments measured 6 months before hospitalization and 1 year before death and compared with the HF group without T2D.

RESULTS

In HF, T2D was associated with risk of first hospitalization (adjusted odds ratio [aOR]: 1.29; 95% confidence interval [CI]: 1.24 to 1.34) and mortality (aOR: 1.24; 95% CI: 1.29 to 1.40). Stratification of T2D by HbA_1c levels, compared with the reference HF group without T2D, showed U-shaped associations with both outcomes. Highest risk categories were HbA_1c >9.5% (hospitalization, aOR: 1.75; 95% CI: 1.52 to 2.02; mortality, aOR: 1.30; 95% CI: 1.24 to 1.47) and <5.5% (hospitalization, aOR: 1.42; 95% CI: 1.12 to 1.80; mortality, aOR: 1.29; 95% CI: 1.10 to 1.51, respectively). T2D group with change in HbA_1c of >1% decrease was associated with hospitalization (aOR: 1.33; 95% CI: 1.18 to 1.49) and mortality (aOR: 1.36; 95% CI: 1.24 to 1.48). T2D drug group associations with hospitalization were no medication (aOR: 1.12; 95% CI: 1.04 to 1.19), oral antihyperglycemic only (aOR: 1.34; 95% CI: 1.27 to 1.41), oral antihyperglycemic+insulin (aOR: 1.36; 95% CI: 1.21 to 1.52), and insulin only (aOR: 1.61; 95% CI: 1.43 to 1.81); and with mortality for the same drug groups were 1.31 (95% CI: 1.23 to 1.39), 1.16 (95% CI: 1.11 to 1.22), 1.19 (95% CI: 1.06 to 1.34), and 1.43 (95% CI: 1.31 to 1.57), respectively. The T2D group with reduced drug treatments were associated with hospitalization (aOR: 2.13; 95% CI: 1.68 to 2.69) and mortality (aOR: 2.09; 95% CI: 1.81 to 2.41).

CONCLUSIONS

In the general HF population, T2D stratified by glycemic control and drug treatments showed differential risk associations. Routine measures of dynamic diabetes status provide important prognostic indication of poor outcomes in HF.

Development of an international comorbidity education framework

CONTEXT

The increasing number of people living with multiple chronic conditions in addition to an index condition has become an international healthcare priority. Health education curricula have been developed alongside single condition frameworks in health service policy and practice and need redesigning to incorporate optimal management of multiple conditions.

AIM

Our aims were to evaluate current teaching and learning about comorbidity care amongst the global population of healthcare students from different disciplines and to develop an International Comorbidity Education Framework (ICEF) for incorporating comorbidity concepts into health education.

METHODS

We surveyed nursing, medical and pharmacy students from England, India, Italy and Sweden to evaluate their understanding of comorbidity care. A list of core comorbidity content was constructed by an international group of higher education academics and clinicians from the same disciplines, by searching current curricula and analysing clinical frameworks and the student survey data. This list was used to develop the International Comorbidity Education Framework.

RESULTS

The survey sample consisted of 917 students from England (42%), India (48%), Italy (8%) and Sweden (2%). The majority of students across all disciplines said that they lacked knowledge, training and confidence in comorbidity care and were unable to identify specific teaching on comorbidities. All student groups wanted further comorbidity training. The health education institution representatives found no specific references to comorbidity in current health education curricula. Current clinical frameworks were used to develop an agreed list of core comorbidity content and hence an International Comorbidity Education Framework.

CONCLUSIONS

Based on consultation with academics and clinicians and on student feedback we developed an International Comorbidity Education Framework to promote the integration of comorbidity concepts into current healthcare curricula.

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

OBJECTIVE

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

STUDY DESIGN AND SETTING

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

RESULTS

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

CONCLUSIONS

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

Do patients have worse outcomes in heart failure than in cancer? A primary care-based cohort study with 10-year follow-up in Scotland

AIMS

This study was designed to evaluate whether survival rates in patients with heart failure (HF) are better than those in patients with diagnoses of the four most common cancers in men and women, respectively, in a contemporary primary care cohort in the community in Scotland.

METHODS AND RESULTS

Data were obtained from the Primary Care Clinical Informatics Unit from a database of 1.75 million people registered with 393 general practices in Scotland. Sex-specific survival modelling was undertaken using Cox proportional hazards models, adjusted for potential confounders. A total of 56 658 subjects were eligible for inclusion in the study. These represented a total of 147 938 person-years of follow-up (median follow-up: 2.04 years). In men, HF (reference group; 5-year survival: 55.8%) had worse mortality outcomes than prostate cancer [hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.57-0.65; 5-year survival: 68.3%], and bladder cancer (HR 0.88, 95% CI 0.81-0.96; 5-year survival: 57.3%), but better outcomes than lung cancer (HR 3.86, 95% CI 3.65-4.07; 5-year survival: 8.4%) and colorectal cancer (HR 1.23, 95% CI 1.16-1.31; 5-year survival: 48.9%). In women, HF (reference group; 5-year survival: 49.5%) had worse mortality outcomes than breast cancer (HR 0.55, 95% CI 0.51-0.59; 5-year survival 77.7%), but better outcomes than colorectal cancer (HR 1.21, 95% CI 1.13-1.29; 5-year survival 51.5%), lung cancer (HR 3.82, 95% CI 3.60-4.05; 5-year survival 10.4%), and ovarian cancer (HR 1.98, 95% CI 1.80-2.17; 5-year survival 38.2%).

CONCLUSIONS

Despite advances in management, HF remains as 'malignant' as some of the common cancers in both men and women.

The implications of living with heart failure; the impact on everyday life, family support, co-morbidities and access to healthcare: a secondary qualitative analysis

Background

The aim of this study was to use secondary analysis to interrogate a qualitative data set to explore the experiences of patients living with heart failure.

Methods

The data-set comprised interviews with 11 patients who had participated in an ethnographic study of heart failure focusing on unplanned hospital admissions. Following an initial review of the literature, a framework was developed with which to interrogate the data-set. This was modified in light of analysis of the first two interviews, to focus on the rich data around patients’ perceptions of living with heart failure, managing co-morbidities, accessing healthcare and the role of their family and friends, during their illness journey.

Results

Respondents described how the symptoms of heart failure impacted on their daily lives and how disruption of routine activity due to their symptoms caused them to seek medical care. Respondents disclosed the difficulties of living with other illnesses, in addition to their heart failure, particularly managing multiple and complex medication regimes and negotiating multiple appointments; all expressed a desire to return to their pre-morbid, more independent lives. Many respondents described uncertainty around diagnosis and delays in communication from their healthcare providers. The importance of family support was emphasised, but respondents worried about burdening relatives with their illness.

Conclusion

Living with heart failure causes disruption to the lives of sufferers. Facilitation of access to healthcare, through good communication between services and having a strong support network of both family and clinicians can reduce the impact of heart failure on the lives of the patient and those around them.

Measuring Patient Safety in Primary Care: The Development and Validation of the "Patient Reported Experiences and Outcomes of Safety in Primary Care" (PREOS-PC)

PURPOSE

We set out to develop and validate a patient-reported instrument for measuring experiences and outcomes related to patient safety in primary care.

METHOD

The instrument was developed in a multistage process supported by an international expert panel and informed by a systematic review of instruments, a meta-synthesis of qualitative studies, 4 patient focus groups, 18 cognitive interviews, and a pilot study. The trial version of Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) covered 5 domains and 11 scales: practice activation (1 scale); patient activation (1 scale); experiences of patient safety events (1 scale); harm (6 scales); and general perceptions of patient safety (2 scales). The questionnaire was posted to 6,736 patients in 45 practices across England. We used "gold standard" psychometric methods to evaluate its acceptability, reliability, structural and construct validity, and ability to discriminate among practices.

RESULTS

1,244 completed questionnaires (18.5%) were returned. Median item-specific response rate was 91.3% (interquartile range 28.0%). No major ceiling or floor effects were observed. All 6 multi-item scales showed high internal consistency (Cronbach's α 0.75-0.96). Factor analysis, correlation between scales, and known group analyses generally supported structural and construct validity. The scales demonstrated a heterogeneous ability to discriminate between practices. The final version of PREOS-PC consisted of 5 domains, 8 scales, and 58 items.

CONCLUSIONS

PREOS-PC is a new multi-dimensional patient safety instrument for primary care developed with experts and patients. Initial testing shows its potential for use in primary care, and future developments will further address its use in actual clinical practice.

"Sometimes we can't fix things": a qualitative study of health care professionals' perceptions of end of life care for patients with heart failure

BACKGROUND

Although heart failure has a worse prognosis than some cancers, patients often have restricted access to well-developed end of life (EoL) models of care. Studies show that patients with advanced heart failure may have a poor understanding of their condition and its outcome and, therefore, miss opportunities to discuss their wishes for EoL care and preferred place of death. We aimed to explore the perceptions and experiences of health care professionals (HCPs) working with patients with heart failure around EoL care.

METHODS

A qualitative in-depth interview study nested in a wider ethnographic study of unplanned admissions in patients with heart failure (HoldFAST). We interviewed 24 HCPs across primary, secondary and community care in three locations in England, UK - the Midlands, South Central and South West.

RESULTS

The study revealed three issues impacting on EoL care for heart failure patients. Firstly, HCPs discussed approaches to communicating with patients about death and highlighted the challenges involved. HCPs would like to have conversations with patients and families about death and dying but are aware that patient preferences are not easy to predict. Secondly, professionals acknowledged difficulties recognising when patients have reached the end of their life. Lack of communication between patients and professionals can result in situations where inappropriate treatment takes place at the end of patients' lives. Thirdly, HCPs discussed the struggle to find alternatives to hospital admission for patients at the end of their life. Patients may be hospitalised because of a lack of planning which would enable them to die at home, if they so wished.

CONCLUSIONS

The HCPs regarded opportunities for patients with heart failure to have ongoing discussions about their EoL care with clinicians they know as essential. These key professionals can help co-ordinate care and support in the terminal phase of the condition. Links between heart failure teams and specialist palliative care services appear to benefit patients, and further sharing of expertise between teams is recommended. Further research is needed to develop prognostic models to indicate when a transition to palliation is required and to evaluate specialist palliative care services where heart failure patients are included.

Managing patients with heart failure: a qualitative study of multidisciplinary teams with specialist heart failure nurses

PURPOSE

The purpose of this study was to explore the perceptions and experiences of health care clinicians working in multidisciplinary teams that include specialist heart failure nurses when caring for the management of heart failure patients.

METHODS

We used a qualitative in-depth interview study nested in a broader ethnographic study of unplanned admissions in heart failure patients (HoldFAST). We interviewed 24 clinicians across primary, secondary, and community care in 3 locations in the Midlands, South Central, and South West of England.

RESULTS

Within a framework of the role and contribution of the heart failure specialist nurse, our study identified 2 thematic areas that the clinicians agreed still represent particular challenges when working with heart failure patients. The first was communication with patients, in particular explaining the diagnosis and helping patients to understand the condition. The participants recognized that such communication was most effective when they had a long-term relationship with patients and families and that the specialist nurse played an important part in achieving this relationship. The second was communication within the team. Multidisciplinary input was especially needed because of the complexity of many patients and issues around medications, and the participants believed the specialist nurse may facilitate team communication.

CONCLUSIONS

The study highlights the role of specialist heart failure nurses in delivering education tailored to patients and facilitating better liaison among all clinicians, particularly when dealing with the management of comorbidities and drug regimens. The way in which specialist nurses were able to be caseworkers for their patients was perceived as a method of ensuring coordination and continuity of care.

The challenge of multimorbidity in nurse education: an international perspective

The rise in prevalence of chronic diseases has become a global healthcare priority and a system wide approach has been called for to manage this growing epidemic. Whilst healthcare reform to tackle the scale of chronic disease and other long term conditions is still in its infancy, there is an emerging recognition that in an ageing society, people often suffer from more than one chronic disease at the same time. Multimorbidity poses new and distinct challenges and was the focus of a global conference held by the Organization of Economic Cooperation and Development (OECD) in 2011. Health education was raised as requiring radical redesign to equip graduates with the appropriate skills to face the challenges ahead. We wanted to explore how different aspects of multimorbidity were addressed within pre-registration nurse education and held an international (United Kingdom-Sweden) nurse workshop in Linköping, Sweden in April 2013, which included nurse academics and clinicians. We also sent questionnaire surveys to final year student nurses from both countries. This paper explores the issues of multimorbidity from a patient, healthcare and nurse education perspective and presents the preliminary discussions from the workshop and students' survey.

Multi-drug therapy in chronic condition multimorbidity: a systematic review

BACKGROUND

Older populations often suffer from multimorbidity and guidelines for each condition are often associated with recommended drug therapy management. Yet, how different and specific multimorbidity is associated with number and type of multi-drug therapies in general populations is unknown.

AIM

The aim of this systematic review was to synthesize the current evidence on patterns of multi-drug prescribing in family practice.

METHODS

A systematic review on six common chronic conditions: diabetes mellitus, cardiovascular disease, cerebrovascular disease, chronic obstructive pulmonary disease (COPD), osteoarthritis and depression was conducted, with a focus on studies which looked at any potential combination of two or more multimorbidity. Studies were identified from searches of MEDLINE, EMBASE, PsychINFO, the Allied and Complementary Medicine Database (AMED) and the Health Management Information Consortium (HMIC) databases from 1960 to 2013.

RESULTS

A total of eleven articles were selected based on study criteria. Our review identified very few specific studies which had explicitly investigated the association between multimorbidity and multi-drug therapy. Relevant chronic conditions literature showed nine observational studies and two reviews of comorbid depression drug treatment. Most (seven) of the articles had focused on the chronic condition and comorbid depression and whether antidepressant management had been optimal or not, while four studies focused on other multimorbidities mainly heart failure, COPD and diabetes.

CONCLUSIONS

Very few studies have investigated associations between specific multimorbidity and multi-drug therapy, and most currently focus on chronic disease comorbid depression outcomes. Further research needs to identify this area as key priority for older populations who are prescribed high levels of multiple drug therapy.

Analgesia dose prescribing and estimated glomerular filtration rate decline: a general practice database linkage cohort study

OBJECTIVE

We aimed to quantify the short-term effect of non-steroidal anti-inflammatory drugs (NSAIDs), aspirin and paracetamol analgesia dose prescribing on estimated glomerular filtration rate (eGFR) decline in the general practice population.

DESIGN

A population-based longitudinal clinical data linkage cohort study.

SETTING

Two large general practices in North Staffordshire, UK.

PARTICIPANTS

Patients aged 40 years and over with ≥2 eGFR measurements spaced ≥90 days apart between 1 January 2009 and 31 December 2010 were selected.

EXPOSURE

Using WHO Defined Daily Dose standardised cumulative analgesia prescribing, patients were categorised into non-user, normal and high-dose groups.

OUTCOME MEASURE

The primary outcome was defined as a >5 mL/min/1.73 m(2)/year eGFR decrease between the first and last eGFR. Logistic regression analyses were used to estimate risk, adjusting for sociodemographics, comorbidity, baseline chronic kidney disease (CKD) status, renin-angiotensin-system inhibitors and other analgesia prescribing.

RESULTS

There were 4145 patients (mean age 66 years, 55% female) with an analgesia prescribing prevalence of 17.2% for NSAIDs, 39% for aspirin and 22% for paracetamol and stage 3-5 CKD prevalence was 16.1% (n=667). Normal or high-dose NSAID and paracetamol prescribing was not significantly associated with eGFR decline. High-dose aspirin prescribing was associated with a reduced risk of eGFR decline in patients with a baseline (first) eGFR ≥60 mL/min/1.73 m(2); OR=0.52 (95% CI 0.35 to 0.77).

CONCLUSIONS

NSAID, aspirin and paracetamol prescribing over 2 years did not significantly affect eGFR decline with a reduced risk of eGFR decline in high-dose aspirin users with well-preserved renal function. However, the long-term effects of analgesia use on eGFR decline remain to be determined.

Distinct trajectories of multimorbidity in primary care were identified using latent class growth analysis

Objectives

To investigate the use of latent class growth analysis (LCGA) in understanding onset and changes in multimorbidity over time in older adults.

Study Design and Setting

This study used primary care consultations for 42 consensus-defined chronic morbidities over 3 years (2003–2005) by 24,615 people aged >50 years at 10 UK general practices, which contribute to the Consultations in Primary Care Archive database. Distinct groups of people who had similar progression of multimorbidity over time were identified using LCGA. These derived trajectories were tested in another primary care consultation data set with linked self-reported health status.

Results

Five clusters of people representing different trajectories were identified: those who had no recorded chronic problems (40%), those who developed a first chronic morbidity over 3 years (10%), a developing multimorbidity group (37%), a group with increasing number of chronic morbidities (12%), and a multi-chronic group with many chronic morbidities (1%). These trajectories were also identified using another consultation database and associated with self-reported physical and mental health.

Conclusion

There are distinct trajectories in the development of multimorbidity in primary care populations, which are associated with poor health. Future research needs to incorporate such trajectories when assessing progression of disease and deterioration of health.

Chronic condition comorbidity and multidrug therapy in general practice populations: a cross-sectional linkage study

OBJECTIVES

The study investigated (1) the association between comorbidity and multidrug prescribing compared with the index condition, and (2) the association between vascular comorbidity and non-vascular condition key drug prescribing.

DESIGN

Cross-sectional study linking anonymised computer consultations with prescription records for a 2-year time period.

SETTING

11 general practices in North Staffordshire, England.

PARTICIPANTS

Study groups aged 40 years and over (N=12 875). Within six conditions, comorbid group with the other five conditions was compared with an 'alone' group without them. Additionally, how the 'vascular' (one of diabetes, cardiovascular disease and cerebrovascular disease) comorbidity influenced chronic obstructive pulmonary disease (COPD), osteoarthritis (OA) or depression drug prescribing was investigated.

OUTCOME MEASURES

Based on the British National Formulary, five main drug chapters constituted a measure of drug counts, with low count as 2 or less and high multidrug count as 3 or more. Key drugs prescribed for COPD, OA and depression were derived from guidelines.

RESULTS

The adjusted associations between the comorbid groups and higher multidrug count compared with their respective 'alone' group were: odds ratio (OR) 7.1 (95% CI 5.6 to 9.0) for depression, OR 5.4 (95% CI 4.6 to 6.3) for cardiovascular disease, OR 3.7 (95% CI 2.8 to 5.0) for cerebrovascular disease, OR 3.6 (95% CI 3.1 to 4.3) for OA, OR 3.5 (95% CI 3.0 to 4.2) for diabetes and OR 3.2 (95% CI 2.6 to 4.0) for COPD. In COPD, vascular comorbidity was associated with a significant reduction in key COPD drug treatments (adjusted OR 0.6 (95% CI 0.4 to 0.8). In depression, vascular comorbidity was associated with a reduction in key depression drug treatments (OR 0.6 (95% CI 0.4 to 0.7)).

CONCLUSIONS

Our findings show that multidrug prescribing for different body systems is higher with comorbidity and may be associated with lower likelihood of prescribing for specific conditions. Further research is required on whether multidrug prescribing influences the outcomes of care for chronic conditions.

Heart failure and chronic obstructive pulmonary disease multimorbidity at hospital discharge transition: a study of patient and carer experience

BACKGROUND

Care for patients with multimorbidity represents a major challenge not only for patients and carers but to health-care systems. Hospital discharge transition is a critical point at which challenges for multimorbidity may amplify.

OBJECTIVES

The main objective of the study was to explore the experiences of heart failure (HF) and chronic obstructive pulmonary disease (COPD) multimorbid patients and their carers on hospital discharge. Secondary objectives included identification of gaps in the health care of multimorbidity and optimal solutions from patients and carers' perspectives.

DESIGN

Mixed methods were applied to collect data using patient self-completion questionnaire from an adapted version of the American Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and in-depth interviews.

SETTING

Participants were recruited from two cardiology and respiratory wards at a large regional hospital in England, and all had a multimorbidity diagnosis of COPD and HF.

RESULTS AND CONCLUSIONS

Findings revealed that patients experienced difficulties in their communication with health-care professionals and there were specific challenges with information about medication. Qualitative descriptions revealed that experiences fell into two main categories: (i) information transfer to patients with multimorbidity in terms of issues with medication and clarity of information on diagnosis and (ii) communication and continuity of care after discharge. Respondents highlighted gaps in the management of patients with multimorbidity of HF and COPD at the critical time of care transition. They suggested the need for a comprehensive, coordinated and integrated approach to incorporate patients, carers and staff preferences for treatment on discharge from hospital.

Impact of non-cardiovascular disease comorbidity on cardiovascular disease symptom severity: a population-based study

Objectives

Non-cardiovascular comorbidity is common in cardiovascular disease (CVD) populations but its influence on chest pain (CP) and shortness of breath (SOB) symptom-specific physical limitations is unknown. We wanted to test the a priori hypothesis that an unrelated comorbidity would influence symptom-specific physical limitations and to investigate this impact in different severities of CVD.

Method and results

The study was based on 5426 patients from ten family practices, organised into eight a priori exclusive severity groups: (i) no CVD or osteoarthritis (OA) (reference), (ii) index hypertension, ischaemic heart disease (IHD) and heart failure (HF) without OA, (iii) index OA without CVD and (iv) same CVD groups with comorbid OA. The measure of CP physical limitations was Seattle Angina Questionnaire and for SOB physical limitations was the Kansas City Cardiomyopathy Questionnaire. Adjusted baseline associations between the cohorts and symptom-specific physical limitations were assessed using linear regression methods. In the study population, 1443 (27%) reported CP and 2097 (39%) SOB. CP and SOB physical limitations increased with CVD severity in the index and comorbid groups. Compared with the respective index CVD group, the CP physical limitation scores for comorbid CVD groups with OA were lower by: − 14.7 (95% CI − 21.5, 7.8) for hypertension, − 5.5 (− 10.4, − 0.7) for IHD and − 22.1 (− 31.0, − 6.7) for HF. For SOB physical limitations, comorbid scores were lower by: − 9.2 (− 13.8, − 4.6) for hypertension, − 6.4 (− 11.1, − 1.8) for IHD and − 8.8 (− 19.3, 1.65) for HF.

Conclusions

CP and SOB are common symptoms, and OA increases the CVD symptom-specific physical limitations additively. Comorbidity interventions need to be developed for CVD specific health outcomes.

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The study was based on 5426 patients from 10 general practices in the UK.

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A priori exclusive groups included index CVD severity groups with and without OA.

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Increasing CVD severity and comorbid OA are associated with CVD symptom limitation.

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Comorbid OA in CVD groups increases symptom physical limitations additively.

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Comorbidity interventions need to be developed for CVD specific health outcomes.

Associations between cardiovascular disease severity, osteoarthritis co-morbidity and physical health: a population-based study

OBJECTIVE

The aim of this study was to investigate the interaction between cardiovascular disease severity and OA co-morbidity on physical health.

METHODS

A baseline questionnaire was mailed to 9676 patients aged ≥40 years from UK family practices. A priori exclusive morbidity groups were constructed as follows, based on records 3 years before baseline: (i) reference group--neither cardiovascular disease nor OA; (ii) cardiovascular disease severity index groups--with hypertension, ischaemic heart disease or heart failure without OA; (iii) OA index group without cardiovascular disease and (iv) co-morbid severity groups with hypertension, ischaemic heart disease or heart failure with OA. Adjusted associations between morbidity groups and physical health [mean physical component summary (PCS) score based on the 12-item Short Form Health Survey (SF-12)] compared with the reference group were assessed using linear regression methods.

RESULTS

A total of 5426 patients responded to the baseline questionnaire (56% response). The adjusted mean difference in PCS score between the reference group and the cardiovascular disease index were -2.4 (95% CI -3.4, -1.4) for hypertension, -5.3 (-6.3, -4.3) for ischaemic heart disease and -11.8 (-13.6, -9.9) for heart failure. The difference in the score for the index OA group was -5.6 (-6.5, -4.6). Estimates for co-morbid OA groups were -6.8 (-7.9, -5.7) for hypertension, -9.1 (-10.6, -7.6) for ischaemic heart disease and -12.8 (-16.0, -9.7) for heart failure.

CONCLUSION

In cardiovascular populations with differing severity, the co-morbid addition of OA was associated with incrementally poorer physical health, but such interactions were less than additive.

Multidrug and optimal heart failure therapy prescribing in older general practice populations: a clinical data linkage study

OBJECTIVE

To investigate multidrug therapy in the cardiovascular disease (CVD) population and whether it was associated with suboptimal drug prescribing in heart failure (HF).

DESIGN

A population-based cross-sectional clinical data linkage study.

SETTING

The clinical database populations were registered with three general practices in North Staffordshire that are part of a research network.

PARTICIPANTS

3155 patients aged 50 years and over were selected on the basis of a CVD-related prescription and a CVD consultation code applied to their electronic medical record in a 2-year time period. All available diagnostic data were linked to all drugs prescribed data during this time period. Two study groups were: (1) HF and (2) non-HF CVD (reference group).

EXPOSURE

A standard drug formulary system was used to define four multidrug count categories based on the number of different British National Formulary drug chapters prescribed at the same time.

PRIMARY AND SECONDARY OUTCOME MEASURES

Optimal HF therapy was defined as the prescribing of ACE inhibitor (ACEi) or a combination of ACEi and β-blocker in the 2-year time window. An additional three specific CVD drug categories that are indicated in HF were also measured.

RESULTS

The HF group, compared with the reference group, had higher non-CVD multidrug therapy (26% with 7 or more counts compared with 14% in the non-HF CVD reference group). For the first-choice optimal drug treatment for HF with ACEi (64%) or ACEi and β-blocker combined therapy (23%), the multidrug-adjusted associations between the HF group and the reference group were OR 3.89; 95% CI 2.8 to 5.5 and 1.99; 1.4 to 2.9, respectively. These estimates were not influenced by adjustment for sociodemographic factors and multidrug counts.

CONCLUSIONS

Multidrug therapy prescribing is much higher in the HF group than in a comparable CVD group but did not influence optimal drug prescribing.

The relationship of individual and neighbourhood deprivation with morbidity in older adults: an observational study

The objective was to determine the relative association of social class and neighbourhood deprivation with primary care consultation for eight morbidities. In 18 047 survey responders aged ≥50 years, living in more deprived neighbourhoods was independently associated with new consultation for chronic obstructive pulmonary disease, ischaemic heart disease, diabetes, asthma and depression. Lower social class was associated with diabetes and chronic obstructive pulmonary disease. No such associations were found with otitis media, osteoarthritis or upper respiratory tract infection. These findings suggest a role of social environment in certain morbidities and indicate the importance of identifying and acting on neighbourhood deprivation to reduce health inequalities.

Mosaic segmentation, COPD and CHF multimorbidity and hospital admission costs: a clinical linkage study

BACKGROUND

How multimorbidity and socio-economic factors influence healthcare costs is unknown. Geo-demographic profiling system, Mosaic, which adds to socio-economic factors, provides the potential for an investigation of the relationship with multimorbidity, and their influence on healthcare costs.

METHODS

Using chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) registers from 53 general practices for a population aged 40 years and over in Stoke-on-Trent, England (N = 10,113), were linked to hospital admissions data and Healthcare Resource Groups as a measure of hospital cost (2007-09). Eleven Mosaic groups were linked on the basis of individual patients' post codes.

RESULTS

The COPD and CHF multimorbid group (n = 763) had the highest proportion with at least one hospital admission in the 3-year time period (n = 550, 72%), compared with the index COPD (56%) and CHF (66%) groups. Multimorbid patients had significantly higher mean costs for hospital admission (£4896) compared with the index COPD (£2769) or CHF (£3876). The associations between multimorbid groups and hospital admission costs compared with index groups varied by different Mosaic groups.

CONCLUSIONS

CHF and COPD multimorbidity is associated with high costs, and average hospital admission costs vary by Mosaic segmentation. Multimorbidity and Mosaic provide an innovative basis for developing and targeting healthcare interventions in high-hospital-cost patients.

Statin use and clinical osteoarthritis in the general population: a longitudinal study

BACKGROUND

One hypothesis has posited whether abnormal lipid metabolism might be a causal factor in the pathogenesis of osteoarthritis (OA). Routine statin use in clinical practice provides the basis for a natural experiment in testing this hypothesis.

OBJECTIVE

To test the hypothesis that statins reduce the long-term occurrence of clinically defined OA.

DESIGN

Cohort design with a 10-year follow-up.

PARTICIPANTS

16,609 adults cardiovascular disease cohorts aged 40 years and over from the UK General Practice Research Database with data available to 31 December 2006.

INTERVENTION

Statins were summarised as annual mean daily dose and dose change over two-year time periods.

MAIN MEASURES

Incident episode of clinically defined osteoarthritis was assessed within 2 years, and at 4-year and 10-year follow-up time periods, using Cox and discrete time survival analysis. Covariates included age, gender, deprivation, body mass index, cholesterol level, pain-modifying drug co-therapies, and duration and severity of cardiovascular disease.

KEY RESULTS

Higher therapeutic dose of statin, with a treatment duration of at least 2 years was associated with a significant reduction in clinical OA compared to non-statin users in the follow-up time period. The estimated adjusted rate ratios were as follows: lowest statin dose quartile 1: 2.5 (95 % CI 2.3, 2.9); quartile 2: 1.3 (1.1, 1.5); quartile 3: 0.8 (0.7, 0.95); and highest statin dose quartile 4: 0.4 (0.3, 0.5). The largest statin dose increments were associated with significant reductions estimated at 18 % in OA outcome within 2 years and 40 % after 4 years, compared to non-statin users.

CONCLUSIONS

This longitudinal study from a national clinical practice setting provides evidence that higher statin dose and larger statin dose increments were associated with a reduction in clinically defined OA outcome.

Non-steroidal anti-inflammatory drugs and chronic kidney disease progression: a systematic review

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely regarded as one risk factor, which influences chronic kidney disease (CKD) progression. However, previous literature reviews have not quantified the risk in moderate to severe CKD patients.

OBJECTIVE

To estimate the strength of association between chronic NSAID use and CKD progression.

METHODS

We conducted a systematic review and meta-analysis of observational general practice or population studies featuring patients aged 45 years and over. The electronic databases searched were MEDLINE, EMBASE, Cochrane, AMED, BNI and CINAHL until September 2011 without date or language restrictions. Searches included the reference lists of relevant identified studies, WEB of KNOWLEDGE, openSIGLE, specific journals, the British Library and expert networks. For relevant studies, random effects meta-analysis was used to estimate the association between NSAID use and accelerated CKD progression (estimated glomerular filtration rate decline ≥ 15 ml/min/1.73 m2).

RESULTS

From a possible 768 articles, after screening and selection, seven studies were identified (5 cohort, 1 case-control and 1 cross-sectional) and three were included in the meta-analysis. Regular-dose NSAID use did not significantly affect the risk of accelerated CKD progression; pooled odds ratio (OR) = 0.96 (95%CI: 0.86-1.07), but high-dose NSAID use significantly increased the risk of accelerated CKD progression; pooled OR = 1.26 (95%CI: 1.06-1.50).

CONCLUSIONS

The avoidance of NSAIDs in the medium term is unnecessary in patients with moderate to severe CKD, if not otherwise contraindicated. As the definition of high-dose of NSAID use remains unclear, the lowest effective dose of NSAIDs should be prescribed where indicated.

Chronic disease multimorbidity transitions across healthcare interfaces and associated costs: a clinical-linkage database study

OBJECTIVE

To investigate multimorbidity transitions from general practice populations across healthcare interfaces and the associated healthcare costs.

DESIGN

Clinical-linkage database study.

SETTING

Population (N=60 660) aged 40 years and over registered with 53 general practices in Stoke-on-Trent.

PARTICIPANTS

Population with six specified multimorbidity pairs were identified based on hypertension, diabetes mellitus (DM), coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and chronic kidney disease (CKD).

MAIN OUTCOMES MEASURES

Chronic disease registers were linked to accident and emergency (A&E) and hospital admissions for a 3-year time period (2007-2009), and associated costs measured by Healthcare Resource Groups. Associations between multimorbid groups and direct healthcare costs were compared with their respective single disease groups using linear regression methods, adjusting for age, gender and deprivation.

RESULTS

In the study population, there were 9735 patients with hypertension and diabetes (16%), 3574 with diabetes and CHD (6%), 2894 with diabetes and CKD (5%), 1855 with COPD and CHD (3%), 754 with CHF and COPD (1%) and 1425 with CHF and CKD (2%). Transition, defined as at least one episode in each of the 3-year time periods, was as follows: patients with hypertension and DM had the fewest transitions in the 3-year time period (37% A&E episode and 51% hospital admission), but those with CHF and CKD had the most transitions (67% A&E episode and 79% hospital admission). The average 3-year total costs per multimorbid patient for A&E episodes ranged from £69 to £166 and for hospital admissions ranged from between £2289 and £5344. The adjusted costs were significantly higher for all six multimorbid groups compared with their respective single disease groups.

CONCLUSIONS

Specific common multimorbid pairs are associated with higher healthcare transitions and differential costs. Identification of multimorbidity type and linkage of information across interfaces provides opportunities for targeted intervention and delivery of integrated care.

Comorbidity Cohort (2C) study: cardiovascular disease severity and comorbid osteoarthritis in primary care

Background

Two of the commonest chronic diseases experienced by older people in the general population are cardiovascular diseases and osteoarthritis. These conditions also commonly co-occur, which is only partly explained by age. Yet, there have been few studies investigating specific a priori hypotheses in testing the comorbid interaction between two chronic diseases and related health and healthcare outcomes. It is also unknown whether the stage or severity of the chronic disease influences the comorbidity impact. The overall plan is to investigate the interaction between cardiovascular severity groups (hypertension, ischaemic heart disease and heart failure) and osteoarthritis comorbidity, and their longitudinal impact on health and healthcare outcomes relative to either condition alone.

Methods

From ten general practices participating in a research network, adults aged 40 years and over were sampled to construct eight exclusive cohort groups (n = 9,676). Baseline groups were defined on the basis of computer clinical diagnostic data in a 3-year time-period (between 2006 and 2009) as: (i) without cardiovascular disease or osteoarthritis (reference group), (ii) index cardiovascular disease groups (hypertension, ischaemic heart disease and heart failure) without osteoarthritis, (iii) index osteoarthritis group without cardiovascular disease, and (vi) index cardiovascular disease groups comorbid with osteoarthritis. There were three main phases to longitudinal follow-up. The first (survey population) was to invite cohorts to complete a baseline postal health questionnaire, with 10 monthly brief interval health questionnaires, and a final 12-month follow-up questionnaire. The second phase (linkage population) was to link the collected survey data to patient clinical records with consent for the 3-year time-period before baseline, during the 12-month survey period and the 12 months after final questionnaire (total 5 years). The third phase (denominator population) was to construct an anonymised clinical data archive for the study five year period for the total baseline cohorts, linking clinical information such as diagnosis, prescriptions and referrals.

Discussion

The outcomes of the study will result in the determination of the specific interaction between cardiovascular severity and osteoarthritis comorbidity on the change and progression of physical health status in individuals and on the linked and associated clinical-decision making process in primary care.

Cardiovascular disease and musculoskeletal disorder labels in family practice acted as markers of physical health severity

OBJECTIVE

Family practitioner diagnostic labels applied in consultation provide a signpost for treatment and management. Yet, it is unknown whether each label reflects the health of the respective patient group.

STUDY DESIGN AND SETTING

Consultation records of 7,799 patients aged 50 years and older from six family practices were linked to a cross-sectional baseline health survey. Associations between six mutually exclusive cardiovascular disease and nine mutually exclusive musculoskeletal disorder categories, and physical health severity as measured by the Short Form-12 questionnaire were examined.

RESULTS

There were 2,447 (31.4%) cardiovascular disease and 3,321 (42.6%) musculoskeletal disorder consulters. The mean physical health scores ranged from 38.38 (95% confidence interval [CI]: 37.8-39.0) for hypertension to the poorest score of health 28.98 (95% CI: 27.5-30.5) for consulters with heart failure, whereas in the musculoskeletal disorder group, scores ranged from 44.85 (95% CI: 42.2-47.5) for soft tissue disorder to 28.79 (95% CI: 26.8-30.8) for consulters with inflammatory polyarthropathy (trend P<0.001). This trend in the association between diagnostic categories and physical health severity within both spectrums remained after adjustment for confounders.

CONCLUSION

Specific diagnostic labels for selected chronic illness indicate the severity of physical health for the corresponding consulting population.

Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study

Background

Regional musculoskeletal pain such as back or shoulder pain are commonly reported symptoms in the community. The extent of consultation to primary care with such problems is unknown as a variety of labels may be used to record such consultations. The objective was to classify musculoskeletal morbidity codes used in routine primary care by body region, and to determine the annual consultation prevalence of regional musculoskeletal problems.

Methods

Musculoskeletal codes within the Read morbidity Code system were identified and grouped by relevant body region by four GPs. Consultations with these codes were then extracted from the recorded consultations at twelve general practices contributing to a general practice consultation database (CiPCA). Annual consultation prevalence per 10,000 registered persons for the year 2006 was determined, stratified by age and gender, for problems in individual regions and for problems affecting multiple regions.

Results

5,908 musculoskeletal codes were grouped into regions. One in seven of all recorded consultations were for a musculoskeletal problem. The back was the most common individual region recorded (591 people consulting per 10,000 registered persons), followed by the knee (324/10,000). In children, the foot was the most common region. Different age and gender trends were apparent across body regions although women generally had higher consultation rates. The annual consultation-based prevalence for problems encompassing more than one region was 556 people consulting per 10,000 registered persons and increased in older people and in females.

Conclusions

There is an extensive and varied regional musculoskeletal workload in primary care. Musculoskeletal problems are a major constituent of general practice. The output from this study can be used as a resource for planning future studies.

Clinical multimorbidity and physical function in older adults: a record and health status linkage study in general practice

BACKGROUND

Multiple chronic conditions occurring in the same individual are associated with adverse health outcomes. In family practice, individuals are seen who, over time, may experience many different symptoms, illnesses and chronic diseases. Measures for defining multimorbidity, which incorporate the diverse range of health problems seen in population-based family practice, remain to be developed. We have investigated whether routinely collected consultation data could be used as the basis for a simple classification of multimorbidity that reflects an individual's overall health status.

METHODS

Morbidity consultation data for 9,439 English patients aged 50 years and over in an 18-month time period were linked to their self-reported physical health status measured by Short-Form 12 at the end point. Associations between physical function and all-cause multimorbidity counts were estimated relative to single morbidity only, and between physical function and morbidity severity (185 morbidities categorized on four ordinal scales of severity) relative to persons who had not consulted about any of the 185.

RESULTS

In the 18-month period, 19% had consulted for a single morbidity and 23% for six or more (a high multimorbidity count). An estimated 24% of poor physical function in the family practice consulting population may be attributable to high multimorbidity. There was an increasing strength of association between poor physical function and increasing severity of multimorbidity on all four severity scales. Estimated associations (adjusted odds ratios) of the most severe morbidity categories with poor physical function were, for each of the four scales, respectively, 5.6 for chronicity [95% confidence interval (CI) 4.4-7.1], 7.0 for time course (4.5-10.6) and 3.6 for health care use (2.0-6.6) and for patient impact (6.7; 5.2-8.8).

CONCLUSIONS

Multimorbidity defined by using routinely collected family practice consultation data and classified by count and by severity was associated with poorer physical function. This approach offers the potential for systematic use of routine records to classify multimorbidity and to identify groups with high likelihood of poor physical status for needs assessment and targeted intervention.