English Primary Care Research Articles

The patient’s perspectives of safe and routine proactive deprescribing in primary care for older people living with polypharmacy: a qualitative study

BackgroundThe process of identifying and discontinuing medicines in instances in which harms outweigh benefits (deprescribing) can mitigate the negative consequences of problematic polypharmacy. This process should be conducted with a focus on the patient and involve collaborative decision-making. Evidence is needed regarding patients’ views on how deprescribing should be safely and routinely implemented in English primary care to improve its application. This study aimed to identify optimal methods of introducing and actioning deprescribing from the patient’s perspective.MethodsParticipants in England aged 65 and above who were taking five or more medicines and residing in their own homes were recruited through social media and service user groups. An interview guide was created from deprescribing literature and input from patients and the public, guided by the Normalisation Process Theory (NPT). The interviews were held online using Microsoft Teams® or via phone, recorded, and then transcribed. The data was analysed using the Framework analysis.ResultsTwenty patients (mean age of 74.5, SD = 6.93), with 75% being female, were enrolled in the study. Three main themes emerged: (1) ‘Why deprescribe now?’ emphasised the significance of explaining the reasons behind deprescribing; (2) ‘Monitoring and follow-up’ underscored the necessity of safety measures during deprescribing and patients’ willingness to self-monitor post-intervention; (3) ‘Roles and relationships’ explored patient perceptions of various healthcare professionals involved in deprescribing and the essential interpersonal skills for fostering therapeutic relationships.ConclusionOptimal methods of introducing deprescribing included communicating a convincing rationale for stopping medicines and preparing patients for deprescribing conversations. Patients required support from a range of healthcare professionals with whom they had an existing therapeutic relationship. Whilst patients were motivated to self-monitor unwanted/unexpected effects post-deprescribing, timely support was required. The nature of such bolstered collective action and cognitive participation within NPT enhances the normalisation potential of deprescribing. These findings highlight the significance of considering the content and process of deprescribing consultations to enhance normalisation and tackle problematic polypharmacy. This provides a deeper understanding of patients’ needs for implementing safe and routine deprescribing in primary care, which should be considered when designing medication review and deprescribing services.

Impacts of the COVID-19 pandemic on deprivation-level differences in cardiovascular hospitalisations: a comparison of England and Denmark using the OpenSAFELY platform and National Registry Data

ObjectivesTo examine the impact of the COVID-19 pandemic on deprivation-related inequalities in hospitalisations for cardiovascular disease (CVD) conditions in Denmark and England between March 2018 and December 2021.DesignTime-series studies in...

Low-dose spironolactone and cardiovascular outcomes in moderate stage chronic kidney disease: a randomized controlled trial.

Chronic kidney disease (CKD) is associated with a substantial risk of progression to end-stage renal disease and vascular events. The nonsteroidal mineralocorticoid receptor antagonist (MRA), finerenone, offers cardiorenal protection for people with CKD and diabetes, but there is uncertainty if the steroidal MRA, spironolactone, provides the same protection. In this prospective, randomized, open, blinded endpoint trial, we assessed the effectiveness of 25 mg spironolactone in addition to usual care or usual care alone for reducing cardiovascular outcomes in stage 3b CKD among an older community cohort (mean age = 74.8 years and s.d. = 8.1). We recruited 1,434 adults from English primary care, of whom 1,372 (96%) were included in the primary analysis. The primary outcome was time from randomization until the first occurrence of death, hospitalization for heart disease, stroke, heart failure, transient ischemic attack or peripheral arterial disease, or first onset of any condition listed not present at baseline. Across 3 years of follow-up, the primary endpoint occurred in 113 of 677 participants randomized to spironolactone (16.7%) and 111 of 695 participants randomized to usual care (16.0%) with no significant difference between groups (hazard ratio = 1.05, 95% confidence interval: 0.81-1.37). Two-thirds of participants randomized to spironolactone stopped treatment within 6 months, predominantly because they met prespecified safety stop criteria. The most common reason for stopping spironolactone was a decrease in the estimated glomerular filtration rate that met prespecified stop criteria (n = 239, 35.4%), followed by participants being withdrawn due to treatment side effects (n = 128, 18.9%) and hyperkalemia (n = 54, 8.0%). In conclusion, we found that spironolactone was frequently discontinued due to safety concerns, with no evidence that it reduced cardiovascular outcomes in people with stage 3b CKD. Spironolactone should not be used for people with stage 3b CKD without another explicit treatment indication. ClinicalTrials.gov registration: ISRCTN44522369 .

Exercise as add-on therapy for smoking cessation in people with mental illness

Introduction & Purpose The prevalence of smoking among people with mental illness is two to four times higher than in the general population. Unsuccessful quit attempts, often due to low confidence in their ability to quit, suggest that smokers with mental illness may benefit from additional smoking cessation strategies (Mann-Wrobel et al., 2011). Exercise as an adjunct treatment for smoking cessation in healthy individuals is increasingly recommended in the literature (Ussher et al., 2019), but there is limited data for people with mental illness. Therefore, the aim of this study is to evaluate the effectiveness of an exercise program as an add-on therapy for smoking cessation in people with mental illness. Methods 66 smokers with a diagnosed mental illness or mood disorders were included in a randomized controlled trial and received a standardized group smoking cessation program. Out of these 66 smokers, 38 individuals additionally participated in an exercise group (Nordic walking) and 28 in a control group (social contact group discussing health issues). Outcome variables were assessed by questionnaires at baseline (data available for 59 participants: 32 exercise group, 27 control group), during (after 3 weeks), and at the end of the program (5 weeks). Results The study had a dropout rate of 32%. At the end of the program, the abstinence rate was 19% in the exercise group and 30% in the control group (intention-to-treat analysis). There were no significant time-by-group interaction effects for any outcome variables. Significant group differences were found after 3 weeks for internal stimuli of self-efficacy (smokers’ confidence to resist smoking in certain situations; p = 0.026, ƞ² = 0.121) and after 5 weeks for frequency (p = 0.003, ƞ² = 0.210) and intensity (p = 0.007, ƞ² = 0.174) of cigarette craving. The control group showed higher self-efficacy and lower frequency and intensity of cigarette craving compared to the exercise group. Main effects over time were observed in both groups with improvement in several outcome variables (e.g., self-efficacy, positive affect, frequency, and intensity of cigarette craving). Discussion Group differences may be explained by pre-existing differences in cigarette dependence, motivation to quit, and BMI at baseline. It is known from the literature that higher cigarette dependence can lead to less successful quitting and higher relapse rates (Gierisch et al., 2012). Participants also had difficulty integrating program content into their daily lives and had low attendance rates. According to Zhou et al. (2023), a higher adherence rate would lead to a higher quit rate. Since the study was conducted in groups, the influence of group dynamics on motivation to quit smoking needs to be considered. Conclusion An additional effect of exercise as an adjunctive therapy in smoking cessation could not be confirmed, since the control group showed better outcome scores. Due to the high dropout rate, further studies with larger samples are needed. Improving access to smoking cessation programs, developing additional strategies, integrating evidence-based treatment into existing settings, and training health care professionals to engage people with mental illness in smoking cessation remain important areas for improvement (Falcaro et al., 2021). References Falcaro, M., Osborn, D., Hayes, J., Coyle, G., Couperthwaite, L., Weich, S., & Walters, K. R. (2021). Time trends in access to smoking cessation support for people with depression or severe mental illness: A cohort study in English primary care. BMJ Open, 11(12), Article e048341. https://doi.org/10.1136/bmjopen-2020-048341 Gierisch, J. M., Bastian, L. A., Calhoun, P. S., McDuffie, J. R., & Williams, J. W. (2012). Smoking cessation interventions for patients with depression: A systematic review and meta-analysis. Journal of General Internal Medicine, 27(3), 351–360. https://doi.org/10.1007/s11606-011-1915-2 Mann-Wrobel, M. C., Bennett, M. E., Weiner, E. E., Buchanan, R. W., & Ball, M. P. (2011). Smoking history and motivation to quit in smokers with schizophrenia in a smoking cessation program. Schizophrenia Research, 126(1-3), 277–283. https://doi.org/10.1016/j.schres.2010.10.030 Ussher, M. H., Faulkner, G. E. J., Angus, K., Hartmann-Boyce, J., & Taylor, A. H. (2019). Exercise interventions for smoking cessation. The Cochrane Database of Systematic Reviews, 2019(10), Article CD002295. https://doi.org/10.1002/14651858.CD002295.pub6 Zhou, Y., Feng, W., Guo, Y., & Wu, J. (2023). Effect of exercise intervention on smoking cessation: A meta-analysis. Frontiers in Physiology, 14, Article 1221898. https://doi.org/10.3389/fphys.2023.1221898

GP working time and supply, and patient demand in England in 2015-2022: a retrospective study.

English primary care faces a reduction in GP supply and increased demand. To explore trends in GP working time and supply, accounting for factors influencing demand for services. Retrospective observational study in English primary care between 2015 and 2022. Trends in median GP contracted time commitment were calculated using annual workforce datasets. Three measures of demand were calculated at practice-level: numbers of patients; numbers of older patients (≥65 years); and numbers of chronic conditions using 21 Quality and Outcomes Framework disease registers. Multi-level Poisson models were used to assess associations between GP supply and practice demand, adjusted for deprivation, region, and year. Between 2015 and 2022, the median full-time equivalent (FTE) of a fully qualified GP decreased from 0.80 to 0.69. There was a 9% increase in registered population per GP FTE (incidence rate ratio [IRR] = 1.09; 95% confidence interval [CI] = 1.05 to 1.14). This increase was steeper using numbers of chronic conditions (32%, IRR = 1.32; 95% CI = 1.26 to 1.38). Practices in the most deprived decile had 17% more patients (IRR = 1.17; 95% CI = 1.08 to 1.27) and 19% more chronic conditions (IRR = 1.19; 95% CI = 1.06 to 1.33) per GP FTE, compared with the least deprived decile. These disparities persisted over time. All regions reported more chronic conditions per GP FTE than London. Population demand per GP has increased, particularly in terms of chronic conditions. This increase is driven by several factors, including a reduction in GP contracted time commitments. Persistent deprivation gradients in GP supply highlight the need to recruit and retain GPs more equitably.

The diagnostic performance of CA-125 for the detection of ovarian cancer in women from different ethnic groups: a cohort study of English primary care data

BackgroundCA-125 testing is a recommended first line investigation for women presenting with possible symptoms of ovarian cancer in English primary care, to help determine whether further investigation for ovarian cancer is needed. It is currently not known how well the CA-125 test performs in ovarian cancer detection for patients from different ethnic groups.MethodsA retrospective cohort study utilising English primary care data linked to the national cancer registry was undertaken. Women aged ≥ 40 years with a CA-125 test between 2010 and 2017 were included. Logistic regression predicted one-year ovarian cancer incidence by ethnicity, adjusting for age, deprivation status, and comorbidity score. The estimated incidence of ovarian cancer by CA-125 level was modelled for each ethnic group using restricted cubic splines.ResultsThe diagnostic performance of CA-125 differed for women from different ethnicities. In an unadjusted analysis, predicted CA-125 levels for Asian and Black women were higher than White women at corresponding probabilities of ovarian cancer. The higher PPVs for White women compared to Asian or Black women were eliminated by inclusion of covariates.ConclusionThe introduction of ethnicity-specific thresholds may increase the specificity and PPVs of CA-125 in ovarian cancer detection at the expense of sensitivity, particularly for Asian and Black women. As such, we cannot recommend the use of ethnicity-specific thresholds for CA-125.

Action plans increase advance care planning documentation and engagement among English and Spanish-speaking older adults.

Advance care planning (ACP) has been reconceptualized as a health behavior. Action plans (APs), or patient-directed mini contracts, improve behavior change. However, no prior studies have assessed whether APs can increase ACP documentation and engagement. We included English and Spanish-speaking primary care patients from San Francisco, ≥55 years of age, with ≥2 serious or chronic illnesses. Participants were in the intervention arm of the PREPAREforYOURcare.org trial and asked at baseline to choose 1 of 5 actions (e.g., choose a surrogate). At 6 months, we assessed whether participants completed their AP and if completion was associated with demographics, electronic health record (EHR) ACP documentation, and five-point ACP Engagement Survey scores. We used t-tests, chi-squared, multivariate analysis adjusted for baseline ACP and clustering by physician, and qualitative thematic analysis to explore reasons for non-completion. The mean age of 586 participants was 65 ± 10 years; 44.0% women, 45.9% Spanish-speaking, 31.4% had limited health literacy, and 43% completed an AP at 6 months; surrogate-related (47.4%), tell others about medical wishes (33.7%), ask clinicians questions (13.7%), and decide what matters most in life (5.2%). Participants with limited versus adequate health literacy were less likely to complete an AP (25.4% vs 35.9%, p = 0.01). Completing an AP was associated with greater ACP EMR documentation 49.8% vs 35.6%, p < 0.001 (adjusted odds ratio: 2.06; 95% CI [1.43-2.97]) and engagement (adjusted five-point scores [3.69; 95% CI 3.57-3.81 vs 3.10; 95% CI: 2.98-3.21], p < 0.001). Themes for non-completion included not being ready and logistical issues (e.g., surrogate deceased). Among English and Spanish-speaking older adults, creating an ACP AP resulted in greater documentation and engagement. APs may help facilitate ACP behavior change as part of effective ACP interventions. Additional support may be needed for patients with limited health literacy and those facing logistical barriers.

Underlying disease risk among fatigued patients: a population-based cohort study in primary care.

Background Presenting to primary care with fatigue is associated with a wide range of conditions, including cancer, although their relative likelihood is unknown. Aim To quantify associations between new-onset fatigue presentation and subsequent diagnosis of various diseases, including cancer. Design and setting Cohort study of patients presenting in English primary care with new-onset fatigue during 2007-2017 (fatigue presenters (FPs)), compared to non-fatigue presenters (NFPs), using Clinical Practice Research Datalink data linked to hospital episodes and national cancer registration data. Method We described excess short-term incidence of 237 diseases in FPs compared to NFPs. We modelled disease-specific 12-month risk by sex and calculated age-adjusted risk. Results We included 304,914 FPs and 423,671 NFPs. 127 of 237 diseases studied were more common in male FPs than in male NFPs, and 151 were more common in female FPs. Diseases that were most strongly associated with fatigue included: depression; insomnia & sleep disturbances, and hypo/hyperthyroidism (women only). By 80 years, cancer was the 3rd most common disease and had the 4th highest absolute excess risk in male FPs (FPs: 7.0%, CI = 6.6 to 7.5; NFPs: 3.4%, CI = 3.1 to 3.7; AER: 3.7%). In women, cancer remained relatively infrequent; by age 80 it had the 13th highest excess risk in FPs. Conclusion Our study ranks the likelihood of possible diagnoses in fatigue presenters, to inform diagnostic guidelines and doctors' decisions. Age-specific findings support recommendations to prioritise cancer investigation in older men with fatigue, but not women.

Using Twitter (X) to Mobilize Knowledge for First Contact Physiotherapists: Qualitative Study.

Twitter (now X) is a digital social network commonly used by health care professionals. Little is known about whether it helps health care professionals to share, mobilize, and cocreate knowledge or reduce the time between research knowledge being created and used in clinical practice (the evidence-to-practice gap). Musculoskeletal first contact physiotherapists (FCPs) are primary care specialists who diagnose and treat people with musculoskeletal conditions without needing to see their general practitioner (family physician) first. They often work as a sole FCP in practice; hence, they are an ideal health care professional group with whom to explore knowledge mobilization using Twitter. We aimed to explore how Twitter is and can be used to mobilize knowledge, including research findings, to inform FCPs' clinical practice. Semistructured interviews of FCPs with experience of working in English primary care were conducted. FCPs were purposively sampled based on employment arrangements and Twitter use. Recruitment was accomplished via known FCP networks and Twitter, supplemented by snowball sampling. Interviews were conducted digitally and used a topic guide exploring FCP's perceptions and experiences of accessing knowledge, via Twitter, for clinical practice. Data were analyzed thematically and informed by the knowledge mobilization mindlines model. Public contributors were involved throughout. In total, 19 FCPs consented to the interview (Twitter users, n=14 and female, n=9). Three themes were identified: (1) How Twitter meets the needs of FCPs, (2) Twitter and a journey of knowledge to support clinical practice, and (3) factors impeding knowledge sharing on Twitter. FCPs described needs relating to isolated working practices, time demands, and role uncertainty. Twitter provided rapid access to succinct knowledge, the opportunity to network, and peer reassurance regarding clinical cases, evidence, and policy. FCPs took a journey of knowledge exchange on Twitter, including scrolling for knowledge, filtering for credibility and adapting knowledge for in-service training and clinical practice. Participants engaged best with images and infographics. FCPs described misinformation, bias, echo chambers, unprofessionalism, hostility, privacy concerns and blurred personal boundaries as factors impeding knowledge sharing on Twitter. Consequently, many did not feel confident enough to actively participate on Twitter. This study explores how Twitter is and can be used to mobilize knowledge to inform FCP clinical practice. Twitter can meet the knowledge needs of FCPs through rapid access to succinct knowledge, networking opportunities, and professional reassurance. The journey of knowledge exchange from Twitter to clinical practice can be explained by considering the mindlines model, which describes how FCPs exchange knowledge in digital and offline contexts. Findings demonstrate that Twitter can be a useful adjunct to FCP practice, although several factors impede knowledge sharing on the platform. We recommend social media training and enhanced governance guidance from professional bodies to support the use of Twitter for knowledge mobilization.

Trends in weight gain recorded in English primary care before and during the Coronavirus-19 pandemic: An observational cohort study using the OpenSAFELY platform.

Obesity and rapid weight gain are established risk factors for noncommunicable diseases and have emerged as independent risk factors for severe disease following Coronavirus Disease 2019 (COVID-19) infection. Restrictions imposed to reduce COVID-19 transmission resulted in profound societal changes that impacted many health behaviours, including physical activity and nutrition, associated with rate of weight gain. We investigated which clinical and sociodemographic characteristics were associated with rapid weight gain and the greatest acceleration in rate of weight gain during the pandemic among adults registered with an English National Health Service (NHS) general practitioner (GP) during the COVID-19 pandemic. With the approval of NHS England, we used the OpenSAFELY platform inside TPP to conduct an observational cohort study of routinely collected electronic healthcare records. We investigated changes in body mass index (BMI) values recorded in English primary care between March 2015 and March 2022. We extracted data on 17,742,365 adults aged 18 to 90 years old (50.1% female, 76.1% white British) registered with an English primary care practice. We estimated individual rates of weight gain before (δ-prepandemic) and during (δ-pandemic) the pandemic and identified individuals with rapid weight gain (>0.5 kg/m2/year) in each period. We also estimated the change in rate of weight gain between the prepandemic and pandemic period (δ-change = δ-pandemic-δ-prepandemic) and defined extreme accelerators as the 10% of individuals with the greatest increase in their rate of weight gain (δ-change ≥1.84 kg/m2/year) between these periods. We estimated associations with these outcomes using multivariable logistic regression adjusted for age, sex, index of multiple deprivation (IMD), and ethnicity. P-values were generated in regression models. The median BMI of our study population was 27.8 kg/m2, interquartile range (IQR) [24.3, 32.1] in 2019 (March 2019 to February 2020) and 28.0 kg/m2, IQR [24.4, 32.6] in 2021. Rapid pandemic weight gain was associated with sex, age, and IMD. Male sex (male versus female: adjusted odds ratio (aOR) 0.76, 95% confidence interval (95% CI) [0.76, 0.76], p < 0.001), older age (e.g., 50 to 59 years versus 18 to 29 years: aOR 0.60, 95% CI [0.60, 0.61], p < 0.001]); and living in less deprived areas (least-deprived-IMD-quintile versus most-deprived: aOR 0.77, 95% CI [0.77, 0.78] p < 0.001) reduced the odds of rapid weight gain. Compared to white British individuals, all other ethnicities had lower odds of rapid pandemic weight gain (e.g., Indian versus white British: aOR 0.69, 95% CI [0.68, 0.70], p < 0.001). Long-term conditions (LTCs) increased the odds, with mental health conditions having the greatest effect (e.g., depression (aOR 1.18, 95% CI [1.17, 1.18], p < 0.001)). Similar characteristics increased odds of extreme acceleration in the rate of weight gain between the prepandemic and pandemic periods. However, changes in healthcare activity during the pandemic may have introduced new bias to the data. We found female sex, younger age, deprivation, white British ethnicity, and mental health conditions were associated with rapid pandemic weight gain and extreme acceleration in rate of weight gain between the prepandemic and pandemic periods. Our findings highlight the need to incorporate sociodemographic, physical, and mental health characteristics when formulating research, policies, and interventions targeting BMI in the period of post pandemic service restoration and in future pandemic planning.

Ongoing Decline in Continuity With GPs in English General Practices: A Longitudinal Study Across the COVID-19 Pandemic.

Relationship continuity of care has declined across English primary health care, with cross-sectional and longitudinal variations between general practices predicted by population and service factors. We aimed to describe cross-sectional and longitudinal variations across the COVID-19 pandemic and determine whether practice factors predicted the variations. We conducted a longitudinal, ecological study of English general practices during 2018-2022 with continuity data, excluding practices with fewer than 750 patients or National Health Service (NHS) payments exceeding £500 per patient. Variables were derived from published data. The continuity measure was the product of weighted responses to 2 General Practice Patient Survey questions. In a multilevel mixed-effects model, the fixed effects were 11 variables' interactions with time: baseline continuity, NHS region, deprivation, location, percentage White ethnicity, list size, general practitioner and nurse numbers, contract type, NHS payments per patient, and percentage of patients seen on the same day as booking. The random effects were practices. Main analyses were based on 6,010 practices (out of 7,190 active practices). During 2018-2022, mean continuity in these practices declined (from 29.3% to 19.0%) and the coefficient of variation across practices increased (from 48.1% to 63.6%). Both slopes were steepest between 2021 and 2022. Practices having more general practitioners and higher percentages of patients seen the same day had slower declines. Practices having higher baseline continuity, located in certain non-London regions, and having higher percentages of White patients had faster declines. The remaining variables were not predictors. Variables potentially associated with greater appointment availability predicted slower declines in continuity, with worsening declines and relative variability immediately after the COVID-19 lockdown, possibly reflecting surges in demand. To achieve better levels of continuity for those seeking it, practices can increase appointment availability within appointment systems that prioritize continuity.Annals Early Access article.

Trends in C reactive protein testing: a retrospective cohort study in paediatric ambulatory care settings

ObjectivesThis study aims to investigate C reactive protein (CRP) testing practices in paediatric ambulatory care across British primary care and accident and emergency (A&E) departments.Design, setting, participantsThis retrospective cohort study...

A Profile of Influenza Vaccine Coverage for 2019-2020: Database Study of the English Primary Care Sentinel Cohort.

Innovation in seasonal influenza vaccine development has resulted in a wider range of formulations becoming available. Understanding vaccine coverage across populations including the timing of administration is important when evaluating vaccine benefits and risks. This study aims to report the representativeness, uptake of influenza vaccines, different formulations of influenza vaccines, and timing of administration within the English Primary Care Sentinel Cohort (PCSC). We used the PCSC of the Oxford-Royal College of General Practitioners Research and Surveillance Centre. We included patients of all ages registered with PCSC member general practices, reporting influenza vaccine coverage between September 1, 2019, and January 29, 2020. We identified influenza vaccination recipients and characterized them by age, clinical risk groups, and vaccine type. We reported the date of influenza vaccination within the PCSC by International Standard Organization (ISO) week. The representativeness of the PCSC population was compared with population data provided by the Office for National Statistics. PCSC influenza vaccine coverage was compared with published UK Health Security Agency's national data. We used paired t tests to compare populations, reported with 95% CI. The PCSC comprised 7,010,627 people from 693 general practices. The study population included a greater proportion of people aged 18-49 years (2,982,390/7,010,627, 42.5%; 95% CI 42.5%-42.6%) compared with the Office for National Statistics 2019 midyear population estimates (23,219,730/56,286,961, 41.3%; 95% CI 4.12%-41.3%; P<.001). People who are more deprived were underrepresented and those in the least deprived quintile were overrepresented. Within the study population, 24.7% (1,731,062/7,010,627; 95% CI 24.7%-24.7%) of people of all ages received an influenza vaccine compared with 24.2% (14,468,665/59,764,928; 95% CI 24.2%-24.2%; P<.001) in national data. The highest coverage was in people aged ≥65 years (913,695/1,264,700, 72.3%; 95% CI 72.2%-72.3%). The proportion of people in risk groups who received an influenza vaccine was also higher; for example, 69.8% (284,280/407,228; 95% CI 69.7%-70%) of people with diabetes in the PCSC received an influenza vaccine compared with 61.2% (983,727/1,607,996; 95% CI 61.1%-61.3%; P<.001) in national data. In the PCSC, vaccine type and brand information were available for 71.8% (358,365/498,923; 95% CI 71.7%-72%) of people aged 16-64 years and 81.9% (748,312/913,695; 95% CI 81.8%-82%) of people aged ≥65 years, compared with 23.6% (696,880/2,900,000) and 17.8% (1,385,888/7,700,000), respectively, of the same age groups in national data. Vaccination commenced during ISO week 35, continued until ISO week 3, and peaked during ISO week 41. The in-week peak in vaccination administration was on Saturdays. The PCSC's sociodemographic profile was similar to the national population and captured more data about risk groups, vaccine brands, and batches. This may reflect higher data quality. Its capabilities included reporting precise dates of administration. The PCSC is suitable for undertaking studies of influenza vaccine coverage.

#58 SGLT2 inhibitor kidney outcome trials: under-representation of the majority of people with chronic kidney disease in real-world clinical practice

Abstract Background and Aims Observational studies suggest that sodium-glucose co-transporter-2 (SGLT2) inhibitor kidney outcome trials are not representative of people with chronic kidney disease (CKD). However, there are limited data on the generalisability to those without co-existing type 2 diabetes (T2D) and representativeness of the EMPA-KIDNEY trial. Method A cross-sectional analysis of adults with CKD in English primary care was conducted using the Oxford-Royal College of General Practitioners Clinical Information Digital Hub database. The proportions of people with CKD that met the eligibility criteria of SGLT2 inhibitor kidney outcome trials were determined, and their characteristics described. Logistic regression analyses were performed to identify factors associated with trial eligibility. Results Of 6 670 829 adults, 516 491 (7.7%) with CKD were identified, including 32.8% (n = 169 443) with co-existing T2D. In the total CKD cohort, 0.9%, 2.2%, and 8.0% met the CREDENCE, DAPA-CKD, and EMPA-KIDNEY eligibility criteria, respectively. All trials were more representative of people with co-existing T2D than those without T2D. Trial participants were 9-14 years younger than the trial eligible populations, and had more advanced CKD, including higher levels of albuminuria. A higher proportion of the CREDENCE (100%), DAPA-CKD (67.6%) and EMPA-KIDNEY (44.5%) trial participants had T2D compared to the total CKD population (32.8%). Renin-angiotensin-aldosterone system inhibitors were prescribed in almost all trial participants compared to less than half of the total CKD population. Females were underrepresented and less likely to be eligible for the trials. Conclusion SGLT2 inhibitor kidney outcome trials are not representative of most people with CKD in English Primary Care. These findings highlight the importance of complementing trials with real-world studies, exploring the effectiveness of SGLT2 inhibitors in the broader population of people with CKD treated in routine clinical practice.

Postpandemic Sentinel Surveillance of Respiratory Diseases in the Context of the World Health Organization Mosaic Framework: Protocol for a Development and Evaluation Study Involving the English Primary Care Network 2023-2024.

Prepandemic sentinel surveillance focused on improved management of winter pressures, with influenza-like illness (ILI) being the key clinical indicator. The World Health Organization (WHO) global standards for influenza surveillance include monitoring acute respiratory infection (ARI) and ILI. The WHO's mosaic framework recommends that the surveillance strategies of countries include the virological monitoring of respiratory viruses with pandemic potential such as influenza. The Oxford-Royal College of General Practitioner Research and Surveillance Centre (RSC) in collaboration with the UK Health Security Agency (UKHSA) has provided sentinel surveillance since 1967, including virology since 1993. We aim to describe the RSC's plans for sentinel surveillance in the 2023-2024 season and evaluate these plans against the WHO mosaic framework. Our approach, which includes patient and public involvement, contributes to surveillance objectives across all 3 domains of the mosaic framework. We will generate an ARI phenotype to enable reporting of this indicator in addition to ILI. These data will support UKHSA's sentinel surveillance, including vaccine effectiveness and burden of disease studies. The panel of virology tests analyzed in UKHSA's reference laboratory will remain unchanged, with additional plans for point-of-care testing, pneumococcus testing, and asymptomatic screening. Our sampling framework for serological surveillance will provide greater representativeness and more samples from younger people. We will create a biomedical resource that enables linkage between clinical data held in the RSC and virology data, including sequencing data, held by the UKHSA. We describe the governance framework for the RSC. We are co-designing our communication about data sharing and sampling, contextualized by the mosaic framework, with national and general practice patient and public involvement groups. We present our ARI digital phenotype and the key data RSC network members are requested to include in computerized medical records. We will share data with the UKHSA to report vaccine effectiveness for COVID-19 and influenza, assess the disease burden of respiratory syncytial virus, and perform syndromic surveillance. Virological surveillance will include COVID-19, influenza, respiratory syncytial virus, and other common respiratory viruses. We plan to pilot point-of-care testing for group A streptococcus, urine tests for pneumococcus, and asymptomatic testing. We will integrate test requests and results with the laboratory-computerized medical record system. A biomedical resource will enable research linking clinical data to virology data. The legal basis for the RSC's pseudonymized data extract is The Health Service (Control of Patient Information) Regulations 2002, and all nonsurveillance uses require research ethics approval. The RSC extended its surveillance activities to meet more but not all of the mosaic framework's objectives. We have introduced an ARI indicator. We seek to expand our surveillance scope and could do more around transmissibility and the benefits and risks of nonvaccine therapies.

The Time to Inflammatory Bowel Disease Diagnosis for Patients Presenting with Abdominal Symptoms in Primary Care and its Association with Emergency Hospital Admissions and Surgery: A Retrospective Cohort Study.

Patients with inflammatory bowel disease (IBD) presenting to primary care may experience diagnostic delays. We aimed to evaluate this and assess whether time to diagnosis is associated with clinical outcomes. A retrospective cohort study using English primary care data from January 1, 2010, to December 31, 2019, linked to hospital admission data was undertaken. Patients were followed from the first IBD-related presentation in primary care to IBD diagnosis. Associations of time to diagnosis exceeding a year were assessed using a Robust Poisson regression model. Associations between time to diagnosis and IBD-related emergency hospital admissions and surgery were assessed using Poisson and Cox proportional hazards models, respectively. Of 28 092 IBD patients, 60% had ulcerative colitis (UC) and 40% had Crohn's disease (CD). The median age was 43 (interquartile range, 30-58) years and 51.9% were female. Median time to diagnosis was 15.6 (interquartile range, 4.3-28.1) months. Factors associated with more than a year to diagnosis included female sex (adjusted risk ratio [aRR], 1.23; 95% CI, 1.21-1.26), older age (aRR, 1.05; 95% CI, 1.01-1.10; comparing >70 years of age with 18-30 years of age), obesity (aRR, 1.03; 95% CI, 1.00-1.06), smoking (aRR, 1.05; 95% CI, 1.02-1.08), CD compared with UC (aRR, 1.13; 95% CI, 1.11-1.16), and a fecal calprotectin over 500 μg/g (aRR, 0.89; 95% CI, 0.82-0.95). The highest quartile of time to diagnosis compared with the lowest was associated with IBD-related emergency admissions (incidence rate ratio, 1.06; 95% CI, 1.01-1.11). Longer times to IBD diagnoses were associated with being female, advanced age, obesity, smoking, and Crohn's disease. More IBD-related emergency admissions were observed in patients with a prolonged time to diagnosis.

Socioeconomic inequalities in accumulation of multimorbidity in England from 2019 to 2049: a microsimulation projection study

There are socioeconomic inequalities in the prevalence of multimorbidity and its accumulation across the life course. Estimates of multimorbidity prevalence in English primary care increased by more than two-thirds from 2004 to 2019. We developed a microsimulation model to quantify current and projected multimorbidity inequalities in the English adult population. We used primary care data for adults in England from the Clinical Practice Research Datalink Aurum database between 2004 and 2019, linked to the 2015 English Index of Multiple Deprivation (IMD), to model time individuals spent in four health states (healthy, one chronic condition, basic multimorbidity [two or more chronic conditions], and complex multimorbidity [three or more chronic conditions affecting three or more body systems]) by sex, age, IMD quintile, birth cohort, and region. We applied these transition times in a stochastic dynamic continuous-time microsimulation model to Office for National Statistics population estimates for adults aged 30-90 years. We calculated projected prevalence and cumulative incident cases from 2019 to 2049 by IMD quintile, age group (younger than 65 years vs 65 years and older), and years to be lived without multimorbidity at age 30 years. Under the assumption that all chronic conditions were lifelong, and that once diagnosed there was no recovery, we projected prevalence of multimorbidity (basic or complex) increases by 34% from 53·8% in 2019 to 71·9% (95% uncertainty interval 71·8-72·0) in 2049. This rise equates to an 84% increase in the number of people with multimorbidity: from 19·2 million in 2019 to 35·3 million in 2049 (35·3 million to 35·4 million). This projected increase is greatest in the most deprived quintile, with an excess 1·07 million (1·04 million to 1·10 million) cumulative incident basic multimorbidity cases and 0·70 million (0·67 million to 0·74 million) complex multimorbidity cases over and above the projected cases for the least deprived quintile, largely driven by inequalities in those younger than 65 years. The median expected number of years to be lived without multimorbidity at age 30 years in 2019 is 15·12 years (14·62-16·01) in the least deprived IMD quintile and 12·15 years (11·61-12·60) in the most deprived IMD quintile. The number of people living with multimorbidity will probably increase substantially in the next 30 years, a continuation of past observed increases partly driven by changing population size and age structure. Inequalities in the multimorbidity burden increase at each stage of disease accumulation, and are projected to widen, particularly among the working-age population. Substantial action is needed now to address population health and to prepare health-care and social-care systems for coming decades. University of Liverpool and National Institute for Health and Care Research School for Public Health Research.

The impact of COVID-19 on medication reviews in English primary care. An OpenSAFELY-TPP analysis of 20 million adult electronic health records.

The COVID-19 pandemic caused significant disruption to routine activity in primary care. Medication reviews are an important primary care activity ensuring safety and appropriateness of prescribing. A disruption could have significant negative implications for patient care. Using routinely collected data, our aim was first to describe codes used to record medication review activity and then to report the impact of COVID-19 on the rates of medication reviews. With the approval of NHS England, we conducted a cohort study of 20 million adult patient records in general practice, in-situ using the OpenSAFELY platform. For each month, between April 2019 and March 2022, we report the percentage of patients with a medication review coded monthly and in the previous 12 months with breakdowns by regional, clinical and demographic subgroups and those prescribed high-risk medications. In April 2019, 32.3% of patients had a medication review coded in the previous 12 months. During the first COVID-19 lockdown, monthly activity decreased (-21.1% April 2020), but the 12-month rate was not substantially impacted (-10.5% March 2021). The rate of structured medication review in the last 12 months reached 2.9% by March 2022, with higher percentages in high-risk groups (care home residents 34.1%, age 90+ years 13.1%, high-risk medications 10.2%). The most used medication review code was Medication review done 314530002 (59.5%). There was a substantial reduction in the monthly rate of medication reviews during the pandemic but rates recovered by the end of the study period. Structured medication reviews were prioritized for high-risk patients.

A Comparison of Sodium-Glucose Co-Transporter 2 Inhibitor Kidney Outcome Trial Participants with a Real-World Chronic Kidney Disease Primary Care Population.

Observational studies suggest sodium-glucose co-transporter-2 (SGLT2) inhibitor kidney outcome trials are not representative of the broader population of people with chronic kidney disease (CKD). However, there are limited data on the generalisability to those without co-existing type 2 diabetes (T2D), and the representativeness of the EMPA-KIDNEY trial has not been adequately explored. We hypothesised that SGLT2 inhibitor kidney outcome trials are more representative of people with co-existing T2D than those without, and that EMPA-KIDNEY is more representative than previous trials. A cross-sectional analysis of adults with CKD in English primary care was conducted using the Oxford-Royal College of General Practitioners Clinical Information Digital Hub. The proportions that met the eligibility criteria of SGLT2 inhibitor kidney outcome trials were determined, and their characteristics described. Logistic regression analyses were performed to identify factors associated with trial eligibility. Of 6,670,829 adults, 516,491 (7.7%) with CKD were identified. In the real-world CKD population, 0.9%, 2.2%, and 8.0% met the CREDENCE, DAPA-CKD, and EMPA-KIDNEY eligibility criteria, respectively. All trials were more representative of people with co-existing T2D than those without T2D. Trial participants were 9-14 years younger than the real-world CKD population, and had more advanced CKD, including higher levels of albuminuria. A higher proportion of the CREDENCE (100%), DAPA-CKD (67.6%) and EMPA-KIDNEY (44.5%) trial participants had T2D compared to the real-world CKD population (32.8%). Renin-angiotensin system inhibitors were prescribed in almost all trial participants, compared to less than half of the real-world CKD population. Females were under-represented and less likely to be eligible for the trials. SGLT2 inhibitor kidney outcome trials represent a sub-group of people with CKD at high risk of adverse kidney events. Out study highlights the importance of complementing trials with real-world studies, exploring the effectiveness of SGLT2 inhibitors in the broader population of people with CKD.

The Clinical Value of Pre-Diagnostic Thrombocytosis for the Detection of Lung Cancer in Primary Care.

Thrombocytosis is a risk marker for lung cancer in primary care. We investigated whether thrombocytosis presents pre-diagnostically for all the histological subtypes of lung cancer and its association with the stage at diagnosis. A matched cohort study used English electronic primary care data linked to the national cancer registry. Patients diagnosed with lung cancer aged ≥40 years with no prior history of malignancy were matched by age, sex, and general practice to five controls without lung cancer. Multivariable logistic regression models quantified the incidence of pre-diagnostic thrombocytosis and advanced-stage diagnoses, adjusting for COPD diagnosis, smoking status, and anti-platelet drug prescriptions. A total of 9504 cases were matched to 45,647 controls, consisting of 3260 (34%) adenocarcinomas (ADC), 2020 (21%) squamous cell carcinomas (SCC), 70 (<1%) large-cell carcinomas (LCC), and 1089 (12%) small-cell lung cancers (SCLC). The patients with lung cancer were 8.9 (95% CI 8.0-9.9) times more likely to exhibit pre-diagnostic thrombocytosis than the controls. The odds ratios were highest for the comparison between SCC and ADC (1.8, 95% CI 1.5-2.1). Thrombocytosis is associated with advanced-stage ADC and SCC but presented equally for early- and advanced-stage SCLC. Pre-diagnostic thrombocytosis may aid in the detection of all the histological subtypes in primary care.