General Practitioner Database Research Articles

A half ounce of prevention ...

This editorial refers to ‘Achievement of treatment goals for primary prevention of cardiovascular disease in clinical practice across Europe. The EURIKA study’, by J.R. Banegas et al. doi:10.1093/eurheartj/ehr080 An ounce of prevention is worth a pound of cure. Enormous progress has been made in diagnosis and management of cardiovascular disease, resulting in improved life expectancy in most countries in Europe. Similarly we know that the onset of atherosclerosis and its sequellae (angina, myocardial infarction, stroke, heart failure, and sudden death) can be prevented, or rather deferred, by optimal management of hypertension and diabetes, by avoidance of smoking and overweight, and by lowering of LDL-cholesterol through diet or medication with statins. However, this is easily said but difficult to achieve in practice. The EURIKA study1 demonstrates again that many subjects known to be at increased risk for development of cardiovascular disease have an undesirable lifestyle and risk factors that remain uncontrolled. EURIKA analysed 7641 subjects with known risk factors from 12 European countries, ∼650 subjects from each country, sampled using a database of general practitioners. Of these ∼44% were obese, 21% were smokers, 27% had diabetes, 73% had hypertension, and 58% were known to have elevated lipid concentrations.1 In spite of medical treatment, diabetes was not adequately controlled since glycated haemoglobin (HbA1c) remained >6.5% in 73% of the patients. Blood pressure was not controlled in 61% of treated …

Time-Trends in Use of Gastroprotective Strategies With NSAID Treatment in the United Kingdom, Italy, and the Netherlands; A Comparative Study

Background: To reduce the risk of upper gastrointestinal (UGI) complications related to non-steroidal anti-inflammatory drugs (NSAIDs), gastroprotective strategies (GPS) are recommended in patients at risk. Aim: To compare GPS prescription behaviour by general practitioners (GP) in 3 European countries. Methods: We conducted a population-based cohort study in 3 GP databases: 1) United Kingdom's (UK) GP Research Database (1998-2008), 2) Italy's (IT) Health Search/Thales Database (2000-2007), and 3) the Dutch (NL) Integrated Primary Care Information database (1996-2006). Study cohorts comprised all incident NSAID users ≥50 yrs. As preventive strategies we considered: 1) co-prescription of proton pump inhibitors, double dose H2-receptor antagonists, or misoprostol, or 2) use of a cyclooxygenase-2-specific inhibitor (coxib). Consistent with American College of Gastroenterology treatment guidelines, appropriate prescription was defined as the use of a GPS in NSAID users with≥1 UGI risk factor (history of UGI bleeding/ulceration, age≥ 65 yrs, concomitant use of anticoagulants, aspirin, or corticosteroids) and also no GPS in patients without UGI risk factors. Under-prescription was defined as no GPS in patients with ≥1 UGI risk factor. Over-prescription was the presence of a GPS in patients with no UGI risk factors. Results: The study populations comprised of 384,649 UK (mean age: 64.8 yrs, 41% male), 179,030 IT (mean age: 64.6 yrs, 41.7% male) and 55,005 NL NSAID users (mean age: 63.4 yrs, 42.6% male). In the UK, appropriate prescription increased from 51% in 1998 to 59% in 2008 (linear trend (lt) p<0.001) and over-prescription from 3% to 7% (lt p=0.04). Underprescription fell from 46% to 34% (lt p<0.001). In IT, appropriate prescription rose from 46% in 2000 to 60% in 2007 (lt p<0.001) and over-prescription from 3% to 8% (lt p= 0.74), while under-prescription fell from 51% to 32% (lt p=0.01). In the NL, appropriate prescription rose from 53% in 1996 to 63% in 2006 (lt p<0.001) and over-prescription from 4% to 14% (lt p<0.001). Under-prescription decreased from 43% to 23% (lt p<0.001). Between 2000 and 2006, appropriate prescription was significantly higher and underprescription significantly lower in NL compared to UK and IT (p<0.001). Conclusions: The appropriate prescription of GPS has increased over the past years in all three countries assessed. Although under-prescription of GPS use has decreased, it still occurred in 23-34% of NSAID users with upper GI risk factors. This still requires major improvement. The variability across countries was smaller than expected, considering the cultural and structural differences between national health care systems. However, differences across countries are likely to influence the incidence of NSAID-related UGI complications and health care costs.

Use of a large general practice syndromic surveillance system to monitor the progress of the influenza A(H1N1) pandemic 2009 in the UK

The Health Protection Agency/QSurveillance national surveillance system utilizes QSurveillance®, a recently developed general practitioner database covering over 23 million people in the UK. We describe the spread of the first wave of the influenza A(H1N1) pandemic 2009 using data on consultations for influenza-like illness (ILI), respiratory illness and prescribing for influenza from 3400 contributing general practices. Daily data, provided from 27 April 2009 to 28 January 2010, were used to give a timely overview for those managing the pandemic nationally and locally. The first wave particularly affected London and the West Midlands with a peak in ILI in week 30. Children aged between 1 and 15 years had consistently high consultation rates for ILI. Daily ILI rates were used for modelling national weekly case estimates. The system enabled the 'real-time' monitoring of the pandemic to a small geographical area, linking morbidity and prescribing for influenza and other respiratory illnesses.

Value of syndromic surveillance in monitoring a focal waterborne outbreak due to an unusual Cryptosporidium genotype in Northamptonshire, United Kingdom, June – July 2008

The United Kingdom (UK) has several national syndromic surveillance systems. The Health Protection Agency (HPA)/NHS Direct syndromic surveillance system uses pre-diagnostic syndromic data from a national telephone helpline, while the HPA/QSurveillance national surveillance system uses clinical diagnosis data extracted from general practitioner (GP)-based clinical information systems. Data from both of these systems were used to monitor a local outbreak of cryptosporidiosis that occurred following Cryptosporidium oocyst contamination of drinking water supplied from the Pitsford Reservoir in Northamptonshire, United Kingdom, in June 2008. There was a peak in the number of calls to NHS Direct concerning diarrhoea that coincided with the incident. QSurveillance data for the local areas affected by the outbreak showed a significant increase in GP consultations for diarrhoea and gastroenteritis in the week of the incident but there was no increase in consultations for vomiting. A total of 33 clinical cases of cryptosporidiosis were identified in the outbreak investigation, of which 23 were confirmed as infected with the outbreak strain. However, QSurveillance data suggest that there were an estimated 422 excess diarrhoea cases during the outbreak, an increase of about 25% over baseline weekly levels. To our knowledge, this is the first time that data from a syndromic surveillance system, the HPA/QSurveillance national surveillance system, have been able to show the extent of such a small outbreak at a local level. QSurveillance, which covers about 38% of the UK population, is currently the only GP database that is able to provide data at local health district (primary care trust) level. The Cryptosporidium contamination incident described demonstrates the potential usefulness of this information, as it is unusual for syndromic surveillance systems to be able to help monitor such a small-scale outbreak.

Using suitability profiles to better inform consumers' choice of commonly used over-the-counter analgesics

Abstract Objective To quantify the impact of labelled contraindications, precautions and warnings for use on the population that may take commonly used over-the-counter (OTC) analgesics. Setting Primary care: data were collected from a general practitioner database in Australia. Methods Patient data were audited retrospectively (n = 107553) to determine the number of patients with contraindications, warnings or precautions to the use of OTC paracetamol and the non-steroidal anti-inflammatory drugs aspirin and ibuprofen. The primary outcome measure was the suitability rate (i.e. the proportion of patients with no contraindications, warnings or precautions) of these commonly used analgesics. Key findings In this Australian dataset, the proportions of patients who had no contraindications, warnings or precautions to the use of paracetamol or ibuprofen were 98.1 and 76.9%, respectively (P = 0.0001); 83.4% of patients had no contraindications, warnings or precautions to the use of aspirin (P = 0.005 compared with paracetamol). Conclusion Of the three OTC analgesics examined, paracetamol is suitable for use by a larger proportion of the general population without the need to seek medical advice.

Outcome of the Complex Regional Pain Syndrome

The outcome of complex regional pain syndrome (CRPS) is relatively unknown. High disease resolution rates have been reported, but also long-lasting impairments in many patients. This study aims to assess CRPS outcome in a population-based cohort of CRPS patients. CRPS patients were retrospectively identified (1996 to 2005) in a Dutch general practitioners database, the integrated primary care information project, and included if at onset (ie, in the past) they had complied with the International Association for the Study of Pain (IASP) diagnostic criteria. The disease status at minimum of 2 years since onset was assessed during visits using questionnaires, interviews, and physical examination. Symptoms and signs were compared with reference patients with an identical past injury but without CRPS. Actual fulfillment of the IASP criteria, treatment status, self-reported recovery, and working status were recorded. Moreover, to identify the potential prognostic factors, baseline patient characteristics were compared across subgroups according to the CRPS outcome. These subgroups were derived by cluster analysis on actual symptoms and signs. One hundred and two CRPS patients were assessed at on average 5.8 years (range: 2.1 to 10.8) since onset. CRPS patients displayed higher symptom and sign prevalences in all categories (sensory, vasomotor, sudomotor, and motor/trophic) than controls. Sixteen percent (95% CI: 9-22) reported the CRPS as still progressive, whereas 31% (95% CI: 19-43) were incapable of working. Patients in the poorest outcome cluster more often had their upper extremity affected, event other than a fracture, and cold CRPS. Severe CRPS outcome is rare, but a majority of patients has persistent impairments at 2 or more years since onset.

Impact of influenza vaccination on mortality risk among the elderly

Estimates of influenza vaccine effectiveness have mostly been derived from nonrandomized studies and therefore are potentially confounded. The aim of the current study was to estimate influenza vaccine effectiveness in preventing mortality among the elderly, taking both measured and unmeasured confounding into account. Information on patients aged >or=65 yrs from the computerised Utrecht General Practitioner database on eight influenza epidemic periods and summer periods was pooled to estimate influenza vaccine effectiveness in preventing mortality. Summer periods (during which no effect of vaccination was expected) were used as a reference to control for unmeasured confounding in epidemic periods. After adjustment for measured confounders using multivariable regression analysis, propensity score matching and propensity score regression analysis, influenza vaccination reduced mortality risk (odds ratios (ORs) 0.58 (95% confidence interval (CI) 0.46-0.72), 0.56 (95% CI 0.44-0.71) and 0.56 (95% CI 0.45-0.69), respectively). After additional adjustment for unmeasured confounding (as observed during summer periods), the association between influenza vaccination and mortality risk decreased (OR 0.69 (95% CI 0.52-0.92)). We conclude that after state-of-the-art adjustment for typical confounders such as age, sex and comorbidity status, unmeasured confounding still biased estimates of influenza vaccine effectiveness. After taking unmeasured confounding into account, influenza vaccination is still associated with substantial reduction in mortality risk.

Appropriateness and surveillance of medication in a cohort of diabetic patients on polypharmacy

It is assumed that with increasing polypharmacy, medication surveillance by the General Practitioner (GP) and adherence to the therapy regimen by the patient will both decline. We evaluated clinical and medication records taken from GP documentations in a cohort of 102 diabetic patients (48 f, 54 m, median age 70, range 39 - 81) with 3 or more chronic prescriptions. Patients were asked about their current medication and its tolerability by means of a structured telephone interview. 45% of the patients received up to 6 medications, 36% 7 - 9 and 19% > 10. The main comorbidity was hypertension (93%) and symptomatic CAD (39%). The use of established medications (beta-blockers and ACE inhibitors) for these comorbidities was appropriate. Although 76% were eligible for a statin therapy, only 51% actually took a statin, and 28% had a dose lower than the defined daily dose. 68% of the patients had no prescriptions other than those recorded in the GP documentation, but 8% of the total number of medicines taken by the patients were not recorded in the GP's database. 62% of patients took all the medication prescribed by the GP, while 7% of all medicines recorded in the GP's database were not taken by the patients. In 10% of cases, an incompatible medication (defined in accordance with a consented list) was taken by the patient. 81% of patients regularly (twice per year) had their HbA1c checked, but only 62% had their potassium levels checked, despite the use of ACI and diuretics. Most patients knew the reason for taking at least one medication, but 18% knew this for less than half of their (multiple) medications. 70% of the patients said they had been informed about the possible risks of their medication by the GP, and 7% knew the risks for only one medication. In this cohort of patients on polypharmacy and with a high risk profile for adverse drug reactions, we found a mismatch between GPs' documentation of prescriptions and the medication taken by the patient. Patients had no detailed knowledge about indications and almost no knowledge about risks. Although the overall performance of therapy (appropriateness) was deemed sufficient, there would appear to be room for improvement in order to fill information gaps and strive for stricter surveillance.

Quantifying the potential role of unmeasured confounders: the example of influenza vaccination

The validity of non-randomized studies using healthcare databases is often challenged because they lack information on potentially important confounders, such as functional health status and socioeconomic status. In a study quantifying the effects of influenza vaccination among community-dwelling elderly we assessed whether additional information on not routinely available covariates was indeed associated with exposure to influenza vaccination and could, therefore, have led to residual confounding in healthcare databases. We randomly selected 500 persons aged 65 years and older from the computerized Utrecht General Practitioner database. Information on exposure status and on demographics, co-morbidity status, prior healthcare use and medication use was extracted from the database. A questionnaire was used to obtain additional information on not routinely available risk factors [e.g. functional health status (SF-20), smoking status and alcohol consumption]. Missing data from the questionnaire was imputed and multivariable logistic regression analysis was applied to quantify the influence of covariates on the prediction of exposure to influenza vaccination. Within an existing dataset the potential impact of functional health status on the relation between influenza vaccination and mortality was simulated. We obtained questionnaire data from 365 of 500 (73%) subjects. The model including routinely available data from the database appeared accurate in predicting exposure to influenza vaccination (c-statistic 0.86, 95% CI: 0.82-0.89). Functional health status was the only additional characteristic measured with the questionnaire that was not similar in vaccinated and unvaccinated subjects. However, extending the multivariable regression model with functional health status did not significantly improve the prediction of exposure to influenza vaccination, nor did it affect the relation between influenza vaccination and mortality. The potential for unmeasured confounding on the association between influenza vaccination and health outcomes as quantified in healthcare databases seems small for non-randomized intervention studies within extensive and reliable databases.

Bright light in elderly subjects with nonseasonal major depressive disorder: a double blind randomised clinical trial using early morning bright blue light comparing dim red light treatment

BackgroundDepression frequently occurs in the elderly. Its cause is largely unknown, but several studies point to disturbances of biological rhythmicity. In both normal aging, and depression, the functioning of the suprachiasmatic nucleus (SCN) is impaired, as evidenced by an increased prevalence of day-night rhythm perturbations, such as sleeping disorders. Moreover, the inhibitory SCN neurons on the hypothalamus-pituitary adrenocortical axis (HPA-axis) have decreased activity and HPA-activity is enhanced, when compared to non-depressed elderly. Using bright light therapy (BLT) the SCN can be stimulated. In addition, the beneficial effects of BLT on seasonal depression are well accepted. BLT is a potentially safe, nonexpensive and well accepted treatment option. But the current literature on BLT for depression is inconclusive.Methods/DesignThis study aims to show whether BLT can reduce non-seasonal major depression in elderly patients. Randomized double blind placebo controlled trial in 126 subjects of 60 years and older with a diagnosis of major depressive disorder (MDD, DSM-IV/SCID-I). Subjects are recruited through referrals of psychiatric outpatient clinics and from case finding from databases of general practitioners and old-people homes in the Amsterdam region. After inclusion subjects are randomly allocated to the active (bright blue light) vs. placebo (dim red light) condition using two Philips Bright Light Energy boxes type HF 3304 per subject, from which the light bulbs have been covered with bright blue- or dim red light- permitting filters. Patients will be stratified by use of antidepressants. Prior to treatment a one-week period without light treatment will be used. At three time points several endocrinological, psychophysiological, psychometrically, neuropsychological measures are performed: just before the start of light therapy, after completion of three weeks therapy period, and three weeks thereafter.DiscussionIf BLT reduces nonseasonal depression in elderly patients, then additional lightning may easily be implemented in the homes of patients to serve as add-on treatment to antidepressants or as a stand-alone treatment in elderly depressed patients. In addition, if our data support the role of a dysfunctional biological clock in depressed elderly subjects, such a finding may guide further development of novel chronobiological oriented treatment strategies.Trial registrationClinicalTrials.gov identifier: NCT00332670

Feasibility of conducting a primary prevention trial of low‐dose aspirin for major adverse cardiovascular events in older people in Australia: results from the ASPirin in Reducing Events in the Elderly (ASPREE) pilot study

To determine the feasibility of performing a large clinical trial of the use of aspirin for the primary prevention of cardiovascular disease in older participants--the ASPirin in Reducing Events in the Elderly (ASPREE) trial. A randomised double-blind placebo-controlled pilot trial of 100 mg of enteric-coated aspirin tablets daily, in men and women aged 70 years and over who did not have overt cardiovascular disease, and who were followed for 12 months. Participants were identified from the computer databases of general practitioners who were co-investigators in a previous trial. The Melbourne metropolitan area between March 2003 and June 2005. The level of response to participation by GPs; the level of response from potential trial participants; the screening-to-randomisation rate to ensure the recruitment target could be achieved; and the retention of participants in the trial after 12 months. Forty-two GPs (23% of 180 mailed) expressed interest in participating in the pilot trial. Nineteen became co-investigators, of whom six were not required to meet recruitment targets. Letters were sent to 2614 patients, of whom 243 were screened and 209 (86%) were randomly allocated to receive aspirin or placebo. At 12 months,192 (92%) returned for follow-up, and 153 of these (80%) were still taking trial medication. There was a significant reduction in mean haemoglobin level in those taking aspirin. The recruitment strategy for ASPREE, based on methods developed for the conduct of a previous large-scale trial conducted in general practice, was successfully redeployed in this pilot study, with improved efficiency resulting from computerised database searching, telephone pre-screening, a simpler run-in phase and participant familiarity with the trial drug. We conclude that conducting ASPREE in Australian general practice with 18 000 participants is feasible. International Standard Randomised Controlled Trial Number Register ISRCTN83772183.

Detection and Awareness of Moderate to Advanced CKD by Primary Care Practitioners: A Cross-sectional Study From Italy

Chronic kidney disease (CKD) is a strong independent predictor of cardiovascular disease. Although general practitioners (GPs) represent the first line for identification of these high-risk patients, their diagnostic approach to CKD is ill defined. Cross-sectional evaluation of database of Italian GPs. Representative sample of adult Italian population regularly followed up by GPs in 2003. Frequency of serum creatinine testing, prevalence of CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m(2)), awareness of CKD assessed from use of diagnostic codes (Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]) for CKD, and referral to nephrologists. Of 451,548 individuals in the entire practice population, only 77,630 (17.2%) underwent serum creatinine testing. Female sex (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.06 to 1.12), advanced age (OR, 2.70; 95% CI, 2.63 to 2.78), diabetes (OR, 1.31; 95% CI, 1.20 to 1.42), hypertension (OR, 1.10; 95% CI, 1.02 to 1.19), autoimmune diseases (OR, 1.42; 95% CI, 1.11 to 1.82), and recurrent urinary tract infections (OR, 1.63; 95% CI, 1.10 to 2.42) were all associated with serum creatinine testing. Conversely, use of either nonsteroidal anti-inflammatory drugs (OR, 1.03; 95% CI, 0.89 to 1.21) or aminoglycosides or contrast media (OR, 0.78; 95% CI, 0.54 to 1.14) was not associated with serum creatinine testing. In the subgroup with serum creatinine data, the age-adjusted prevalence of CKD was 9.33% (11.93% in women, 6.49% in men). However, in patients with eGFR less than 60 mL/min/1.73 m(2), serum creatinine values were apparently normal (<1.2 mg/dL in women, <1.4 mg/dL in men) in 54%, and GPs used ICD-9-CM codes for CKD in only 15.2%. Referral to nephrologists ranged from 4.9% for patients with eGFR of 59 to 30 mL/min/1.73 m(2) to 55.7% for those with eGFR less than 30 mL/min/1.73 m(2). The prevalence of decreased kidney function may be overestimated because of the more frequent serum creatinine testing in sicker individuals and lack of creatinine calibration. In primary care, CKD stages 3 to 5 are frequent, but its awareness is scarce because of limited rates of serum creatinine testing and difficulty recognizing decreased eGFR in the absence of increased serum creatinine testing.

Antibiotics in Dutch general practice: nationwide electronic GP database and national reimbursement rates

In order to assess whether different databases generate information which can be reliable compared with each other, this study aimed to assess to which degree prescribing rates for systemic antibiotics from a nationwide electronic general practitioner (GP) database correspond with national reimbursement rates, and to investigate for which indications antibiotics are prescribed. Nationwide GP prescribing data were collected from the Second Dutch National Survey of General Practice (DNSGP-2) based on 90 general practices serving 358 008 patients in 2001. Dutch national reimbursement rates for GPs were derived from claims data of the Dutch Drug Information System/Health Care Insurance Board (GIP/CVZ) from 2001. We calculated antibiotic prescribing rates per 1000 patients/inhabitants for each database, and these rates were compared for the total rates and according to antibiotic subgroups. Indications for which GPs prescribed antibiotics were described. In national reimbursement data, 339 antibiotic prescriptions per 1000 inhabitants were prescribed by GPs, while the nationwide GP database showed 255 prescriptions per 1000 patients (75% coverage with reimbursement rates). The nationwide GP database showed high volumes of sulphonamides & trimethoprim, and small volumes of macrolides and quinolones. Half of the prescriptions (48%) were prescribed for respiratory diseases, a quarter (26%) for urinary diseases and 7% for ear diseases. GPs voluntarily participating in a research network prescribe less antibiotics than Dutch GPs in general, and are cautious in prescribing newer and more broad-spectrum antibiotics. This point has to be taken into account when databases will be compared with each other.

Identification of severe potential drug-drug interactions using an Italian general-practitioner database

To analyze prescriptions in a general-practitioner database over 1 year to determine the frequency, the characteristics, and the monitoring of the severe potential drug-drug interactions (DDIs). We retrospectively analyzed the clinical records from 16 general practitioners in the Veneto region, an area in northern Italy. The study covered the period from January 1 to December 31, 2004. We selected all severe and well-documented interactions according to the book Drug Interaction Facts by David S. Tatro (Facts and Comparisons, St. Louis, MO, 2006). We grouped severe potential DDIs according to their specific potential risk, and for the most frequently interacting drug pairs, we investigated whether some specific tests had been prescribed by physicians for safety monitoring. During the study period, 16,037 patients (55% female) with at least one drug prescription were recorded, and a total of 185,704 prescriptions relating to 1,020 different drugs were analyzed. Ramipril was the most frequently prescribed drug followed by acetylsalicylic acid and atorvastatin. The final number of different types of severe potential DDIs was 119, which occurred 1,037 times in 758 patients (4.7% of the total number of patients). More than 80% of drugs involved in severe potential DDIs were cardiovascular drugs. Digoxin was the most frequently involved drug. Electrolyte disturbances, increase in serum digoxin levels, risk of hemorrhage, severe myopathy or rhabdomyolysis, and cardiac arrhythmias were the most commonly implicated potential risks. When considering patients using digoxin with loop or thiazide diuretics for more than 5 months, 72% had at least one test to monitor potential digoxin toxicity, whereas 28% had no tests. Sixty-four percent of patients using digoxin with amiodarone, verapamil, or propafenone had an ECG and/or digoxin monitoring, and 36% of them did not have any tests. The present study revealed that, in a group of Italian general practitioners, the risks of severe potential drug interactions are relatively low and the drugs concerned are few. Analyses of specific tests showed that physicians are generally aware of the potential risks caused by digoxin drug associations. However not all patients were closely monitored and this should be improved.

The Cost-Effectiveness of Bisphosphonates in Postmenopausal Women Based on Individual Long-Term Fracture Risks

Objective Cost-effectiveness analyses are routinely based on data from group averages, restricting its generalizibility to those with below- or above-average risk. A pharmaco-economic model that used individualized risks for fractures was developed in order to take into account patient heterogeneity. Methods Data were obtained from The Health Improvement Network research database of general practitioners, comprising a UK general population of women aged more than 50 years (N = 330,000). Mortality and hip, vertebral, and other osteoporotic fracture risks for each individual were estimated by age, body mass index (BMI), smoking, and other clinical risk factors. Estimates on costs, EuroQol (EQ-5D) utilities, and treatment efficacy were obtained from a UK national report (the National Institute for Clinical Excellence) and outcomes were simulated over a 10-year period. Results It was found that the cost per quality-adjusted life-year (QALY) gained was lower in elderly women and inwomen with fracture history. There was a large variability in the cost-effectiveness with baseline fracture risk and with clinical risk factors. Patients with low BMI (<20) had considerable better cost-effectiveness than patients with high BMI (≥26). Using a cost-acceptability ratio of £30k per QALY gained, bisphosphonate treatment became cost-effective for patients with a 5-year risk of 9.3% (95% confidence interval [CI] 8.0–10.5%) for osteoporotic fractures and of 2.1% (95% CI 1.5–2.7%) for hip fractures. Including bone mineral density in the risk assessment, the cost per QALY gained was £35k in women at age 60 with a fracture history and a T-score of −2.5 (at age 80, this was £3k). Conclusion A pharmacoeconomic model based on individual long-term risks of fracture improves the selection of postmenopausal women for cost-effective treatment with bisphosphonates.

Prevalence of allergic rhinitis in Italy according to general practitioners and mailed epidemiological surveys

ECRHS I responses to the mailed questionnaire were compared with detailed clinical examination and allergy tests in a sub sample of responders. In Northern Italy, 79% of subjects reporting allergic rhinitis were found to be atopic according to skin prick test and/or specific IgE positivity, and this percentage dropped to 21% in subjects not reporting the disease (2). Median total IgE were 36.1 kU/l (interquartile range 13.2–101) in subjects not reporting allergic rhinitis and three times higher in subjects reporting the disease (2). Moreover, while according to the national database of general practitioners (1), 73.7% of the subjects with allergic rhinitis had received one or more prescriptions of oral antihistamines, in the ECRHS performed in 1991–93, only 17.2% of people reporting allergic rhinitis had used oral antihistamines in the year before (2). Interestingly, when these percentages were multiplied by the corresponding prevalence of allergic rhinitis, the resulting prevalence of oral antihistamine-treated allergic rhinitis was comparable between the two studies, being 4.5% * 73.7% = 3.32% in the GP database and 15.9% * 17.2% = 2.73% in the ECRHS 91–93. As treatment usually occurs in the more severe forms of the disease, this observation suggests that the discrepancy between the two surveys could involve the milder forms of the disease and not the severe ones. It should be reminded that the general

Allergic rhinitis in the Italian population evaluated through the national database of general practitioners

Allergic rhinitis in the Italian population evaluated through the national database of general practitioners

Prevalence of people with intellectual disability in the Netherlands

Since the 1990s, people with intellectual disability (ID) in the Netherlands have been moving from institutions to supported accommodation in the community. The Government is in need of recent data on the numbers of these people, to ensure adequate care provision and funding. This paper reports on the prevalence of people with ID in the Netherlands. The research question was: what is the lowest and highest estimation of prevalence of people with ID in the Netherlands? Two extrapolation methods were used, each consisting of a number of stages, using general practice databases and ID care services records. The prevalence of people with ID in the Netherlands was 0.7% (111,750 persons). Other assumptions yielded 0.54-0.64%. Arguments for the two extrapolation methods and the lowest and highest estimation of prevalence are discussed. Compared with 1988, there has been a slight decrease in the prevalence of people with ID in the Netherlands, even though we included all age groups and even people with ID of who were not included in ID care services records. By using general practitioner databases it was possible to identify these not registered people with ID.

Use of margarine enriched in phytosterols by patients at high cardiovascular risk and treated by hypolipidemic drugs

Background and aims The use of phytosterol-enriched margarines (PEM) in patients at cardiovascular risk has not been thoroughly explored. We determined the proportion of users of PEM in a population at high cardiovascular risk, and their characteristics. In addition, the correlates of using at least 25 g/d of PEM were identified. Methods and results Patients with at least two cardiovascular risk factors in addition to dyslipidemia (primary prevention) or with past cardiovascular disease (secondary prevention) were recruited by general practitioners (GPs). Baseline characteristics were collected from a computerized GP database linked to a survey. GPs recorded patterns of PEM use. First, users were compared with non-users. Then, analyses were conducted to identify characteristics of patients using PEM at a recommended dose (≥25 g/d). Among 1631 patients with documented consumption, a minority used PEM (15.2%), and only 36.4% of consumers used it at recommended level. Overall, PEM users did not differ from non-users as to general characteristics, nor as to the level of cardiovascular risk in primary prevention. However, PEM users reported significantly more cardiovascular events among their parents (OR = 1.4; 95% CI = [1.0–1.9]). Consumers who used at least 25 g/d of PEM were more likely to be men (OR = 3.1; 95% CI = [1.6–5.8]), to be aged 60–74 (OR = 3.0; 95% CI = [1.4–6.4]), or 75 or older (OR = 4.0; 95% CI = [1.5–10.6]). Again, no difference was observed regarding the level of cardiovascular risk. Conclusions The level of use of PEM was low in this population of high cardiovascular risk patients. In addition, only a third of users consumed margarine at the recommended level. Our data suggest that pattern of use of PEM is not related to the level of cardiovascular risk.

Use of antihypertensive and lipid-lowering drugs: the management of cardiovascular risk in clinical practice

The objective of the study was to analyse the treatment of high blood pressure (BP) and hypercholesterolaemia, as well as the effect of individual or combined antihypertensive-hypocholesterolaemic therapy on BP control and on circulating cholesterol. A retrospective study was performed using clinical data recorded in the general practitioner's database. The sample included all patients, aged > or =18 years, with BP reading or low-density lipoprotein (LDL) cholesterol measurement recorded between January 2003 and December 2004. BP and LDL cholesterol targets were defined using cutoffs based on the guidelines of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7) and the National Cholesterol Education Program (NCEP/ATPIII). The study included 4764 patients (mean age 67.6+/-11.8 years, 43.5% males). Target BP was achieved in a higher number of patients under combined antihypertensive-hypocholesterolaemic therapy than in those treated only with antihypertensives: 57.0 vs 50.0% in patients with history of cardio/cerebrovascular (CV) hospitalization, 27.0 vs 16.9% in patients with diabetes or chronic renal insufficiency (CRI) and 59.7 vs 49.1% in patients with no CV hospitalization nor diabetes and nor CRI. The LDL cholesterol target was achieved in 61.3% of the subjects: it was independent on the therapy (individual or combined), but related to the degree of cardiovascular risk. Analysing the data contained in the general medicine database made it possible to evaluate the treatment of high BP and hypercholesterolaemia in relation to cardiovascular risk in clinical practice and to establish the need to pay greater attention to achieving the objective set by guidelines.