Health Improvement Network Database Research Articles

Obesity independently predicts responders to biphasic insulin 50/50 (Humalog Mix50 and Insuman Comb 50) following conversion from other insulin regimens: a retrospective cohort study

AimsThis study aims to examine the metabolic effects of intensification or initiation of insulin treatment with biphasic insulin 50/50, and determine the predictors of responders or non-responders to biphasic insulin...

Clinical Outcomes and Cost-effectiveness of Continuous Positive Airway Pressure to Manage Obstructive Sleep Apnea in Patients With Type 2 Diabetes in the U.K.

To assess clinical outcomes and cost-effectiveness of using continuous positive airway pressure (CPAP) to manage obstructive sleep apnea (OSA) in patients with type 2 diabetes (T2D) from the perspective of the U.K.'s National Health Service (NHS). Using a case-control design, 150 CPAP-treated patients with OSA and T2D were randomly selected from The Health Improvement Network (THIN) database (a nationally representative database of patients registered with general practitioners in the U.K.) and matched with 150 OSA and T2D patients from the same database who were not treated with CPAP. The total NHS cost and outcomes of patient management in both groups over 5 years and the cost-effectiveness of CPAP compared with no CPAP treatment were estimated. Using CPAP was associated with significantly lower blood pressure at 5 years and increasingly lower HbA1c levels over 5 consecutive years compared with untreated OSA patients. At 5 years, the HbA1c level in the CPAP-treated group was 8.2% (66.0 mmol/mol) vs. 12.1% (108.4 mmol/mol) in the control group (P < 0.03). Use of CPAP significantly increased patients' health status by 0.27 quality-adjusted life years (QALYs) per patient over 5 years (P < 0.001) and NHS management costs by £4,141 per patient over 5 years; the cost per QALY gained with CPAP was £15,337. Initiating treatment with CPAP in OSA patients with T2D leads to significantly lower blood pressure and better controlled diabetes and affords a cost-effective use of NHS resources. These observations have the potential for treatment modification if confirmed in a prospective study.

Autoimmune thyroiditis as a risk factor for stroke: a historical cohort study.

Objective:To investigate the effect of autoimmune thyroiditis (AIT) on risk of stroke and to assess whether any increased risk (1) varied by AIT duration, and (2) was independent of classic cardiovascular risk factors.Methods:This was a large historical cohort study using data from The Health Improvement Network Database. Rates of first stroke during follow-up in thyroxine-treated patients with AIT (n = 34,907) were compared with those in matched individuals without AIT (n = 149,632) using random-effects Poisson regression models.Results:There was strong evidence for a slightly increased risk of stroke in patients with AIT (adjusted rate ratio = 1.10, 95% confidence interval: 1.01–1.20). The observed increase was partly independent of cardiovascular risk factors. Higher effect sizes were identified in the first year after AIT diagnosis (rate ratio = 1.33, 95% confidence interval: 1.14–1.56) but not in the long-term, consistent with a residual effect of hypothyroidism.Conclusion:Our results support the hypothesis of a slightly increased risk of stroke in patients with AIT. The higher effect size found soon after AIT diagnosis suggests an increased cardiovascular risk due to thyroid-hormone deficiency rather than a cumulative effect of autoimmune pathology. Better screening and early treatment of patients with asymptomatic hypothyroid AIT could help reduce excess risk of stroke in the first year after diagnosis.

Diagnosis of Pernicious Anemia and the Risk of Pancreatic Cancer

A number of studies have demonstrated a trophic effect of gastrin on pancreatic cancer cells in vitro. Pernicious anemia (PA) is a clinical condition characterized by chronic hypergastrinemia. The aim of this study was to determine if PA is a risk factor for pancreatic cancer. This study is a retrospective cohort study using The Health Improvement Network database, which contains comprehensive health information on 7.5 million patients in the United Kingdom from 1993 to 2009. All patients with PA in the study cohort were identified and composed of the exposed group. Each exposed patient was matched on practice site, sex, and age with up to 4 unexposed patients without PA. The outcome was incident pancreatic cancer. The hazard ratio and 95% confidence intervals were estimated using multivariable Cox regression analysis. We identified 15,324 patients with PA and 55,094 unexposed patients. Mean follow-up time was similar between groups (exposed 4.31 [SD, 3.38] years, unexposed 4.63 [SD, 3.44] years). The multivariable adjusted hazard ratio for pancreatic cancer associated with PA was 1.16 (95% confidence interval, 0.77-1.76; P = 0.47). There is no significant association between PA and the risk of pancreatic cancer.

Risk factors for the development of oesophageal adenocarcinoma in Barrett's oesophagus: a UK primary care retrospective nested case-control study.

Oesophageal adenocarcinoma (OAC) incidence is rising rapidly and prognosis remains poor. Endoscopic surveillance of Barrett's oesophagus (BO) remains controversial. A nested case-control study was undertaken to evaluate risk factors for progression of BO to OAC, potentially guiding surveillance efforts. The Health Improvement Network database includes general practitioner consultations from 5 million UK subjects. BO subjects with 1-year minimum of follow up were followed until development of OAC or end of time on database. Demographic variables (age, gender, smoking, body mass index) and data on medication considered negatively (aspirin/nonsteroidal anti-inflammatory drugs/proton pump inhibitors) or positively associated (lower oesophageal sphincter-relaxing and asthma drugs) with OAC development were studied. Cox regression analysis-derived hazard ratios with 95% confidence intervals estimated the relative risk for OAC progression. A total of 3749 BO subjects were studied: 55 developed OAC during 17,743 patient years of follow up, a progression rate of 0.3% per annum. There was 96.7% of the cohort who took proton-pump inhibitors, with no association observed. Increasing age (1.03, 95% CI 1.01-1.05, p = 0.005), male gender (3.06, 95% CI 1.50-6.24, p = 0.002), and having ever smoked (2.36, 95% CI 1.13-4.93, p = 0.023) were associated with progression to OAC, (although smoking lost association on multivariate analysis). Increasing number of drugs used for asthma (2.91, 95% CI 1.10-7.68, p= 0.0314) was also associated. In this nested case-control study of BO, male gender, increasing age, and increasing use of asthma drugs were associated with progression to OAC.

Comorbidities in rotator cuff disease: a case-control study

Rotator cuff disease is a common condition in the general population, but relatively little is known about its associated risk factors. We have undertaken a large case-control study using The Health Improvement Network database to assess and to quantify the relative contributions of some constitutional and environmental risk factors for rotator cuff disease in the community. Our data set included 5000 patients with rotator cuff disease who were individually matched with a single control by age, sex, and general practice (primary care practice). The median age at diagnosis was 55 years (interquartile range, 44-65 years). Multivariate analysis showed that the risk factors associated with rotator cuff disease were Achilles tendinitis (odds ratio [OR] = 1.78), trigger finger (OR = 1.99), lateral epicondylitis (OR = 1.71), and carpal tunnel syndrome (OR = 1.55). Oral corticosteroid therapy (OR = 2.03), oral antidiabetic use (OR = 1.66), insulin use (OR= 1.77), and "overweight" body mass index of 25.1 to 30 (OR = 1.15) were also significantly associated. Current or previous smoking history, body mass index of greater than 30, any alcohol intake, medial epicondylitis, de Quervain syndrome, cubital tunnel syndrome, and rheumatoid arthritis were not found to be associated with rotator cuff disease. We have identified a number of comorbidities and risk factors for rotator cuff disease. These include lateral epicondylitis, carpal tunnel syndrome, trigger finger, Achilles tendinitis, oral corticosteroid use, and diabetes mellitus. The findings should alert the clinician to comorbid pathologic processes and guide future research into the etiology of this condition.

An epidemiological study of rotator cuff pathology using The Health Improvement Network database

Little is known about the incidence of rotator cuff pathology or its demographic associations in the general population. We undertook a large epidemiological study of rotator cuff pathology in the United Kingdom using The Health Improvement Network (THIN) database. The incidence of rotator cuff pathology was 87 per 100,000 person-years. It was more common in women than in men (90 cases per 100,000 person-years in women and 83 per 100,000 person-years in men; p < 0.001). The highest incidence of 198 per 100,000 person-years was found in those aged between 55 and 59 years. The regional distribution of incidence demonstrated an even spread across 13 UK health authorities except Wales, where the incidence was significantly higher (122 per 100,000 person-years; p < 0.001). The lowest socioeconomic group had the highest incidence (98 per 100,000 person-years). The incidence has risen fourfold since 1987 and as of 2006 shows no signs of plateauing. This study represents the largest general population study of rotator cuff pathology reported to date. The results obtained provide an enhanced appreciation of the epidemiology of rotator cuff pathology and may help to direct future upper limb orthopaedic services.

Smoking cessation advice recorded during pregnancy in United Kingdom primary care

BackgroundUnited Kingdom (UK) national guidelines recommend that all pregnant women who smoke should be advised to quit at every available opportunity, and brief cessation advice is an efficient and cost-effective means to increase quit rates. The Quality and Outcomes Framework (QOF) implemented in 2004 requires general practitioners to document their delivery of smoking cessation advice in patient records. However, no specific targets have been set in QOF for the recording of this advice in pregnant women. We used a large electronic primary care database from the UK to quantify the pregnancies in which women who smoked were recorded to have been given smoking cessation advice, and the associated maternal characteristics.MethodsUsing The Health Improvement Network database we calculated annual proportions of pregnant smokers between 2000 and 2009 with cessation advice documented in their medical records during pregnancy. Logistic regression was used to assess variation in the recording of cessation advice with maternal characteristics.ResultsAmong 45,296 pregnancies in women who smoked, recorded cessation advice increased from 7% in 2000 to 37% in 2004 when the QOF was introduced and reduced slightly to 30% in 2009. Pregnant smokers from the youngest age group (15–19) were 21% more likely to have a record of cessation advice compared to pregnant smokers aged 25–29 (OR 1.21, 95% CI 1.10-1.35) and pregnant smokers from the most deprived group were 38% more likely to have a record for cessation advice compared to pregnant smokers from the least deprived group (OR 1.38, 95% CI 1.14-1.68). Pregnant smokers with asthma were twice as likely to have documentation of cessation advice in their primary care records compared to pregnant smokers without asthma (OR 1.97, 95% CI 1.80-2.16). Presence of comorbidities such as diabetes, hypertension and mental illness also increased the likelihood of having smoking cessation advice recorded. No marked variations were observed in the recording of cessation advice with body mass index.ConclusionRecorded delivery of smoking cessation advice for pregnant smokers in primary care has increased with some fluctuation over the years, especially after the implementation of the QOF, and varies with maternal characteristics.

Availability and Quality of Coronary Heart Disease Family History in Primary Care Medical Records: Implications for Cardiovascular Risk Assessment

BackgroundThe potential to use data on family history of premature disease to assess disease risk is increasingly recognised, particularly in scoring risk for coronary heart disease (CHD). However the quality of family health information in primary care records is unclear.AimTo assess the availability and quality of family history of CHD documented in electronic primary care recordsDesignCross-sectional studySetting537 UK family practices contributing to The Health Improvement Network database.MethodData were obtained from patients aged 20 years or more, registered with their current practice between 1st January 1998 and 31st December 2008, for at least one year. The availability and quality of recorded CHD family history was assessed using multilevel logistic and ordinal logistic regression respectively.ResultsIn a cross-section of 1,504,535 patients, 19% had a positive or negative family history of CHD recorded. Multilevel logistic regression showed patients aged 50–59 had higher odds of having their family history recorded compared to those aged 20–29 (OR:1.23 (1.21 to 1.25)), however most deprived patients had lower odds compared to those least deprived (OR: 0.86 (0.85 to 0.88)). Of the 140,058 patients with a positive family history recorded (9% of total cohort), age of onset was available in 45%; with data specifying both age of onset and relative affected available in only 11% of records. Multilevel ordinal logistic regression confirmed no statistical association between the quality of family history recording and age, gender, deprivation and year of registration.ConclusionFamily history of CHD is documented in a small proportion of primary care records; and where positive family history is documented the details are insufficient to assess familial risk or populate cardiovascular risk assessment tools. Data capture needs to be improved particularly for more disadvantaged patients who may be most likely to benefit from CHD risk assessment.

Aspirin for Prevention of Subarachnoid Hemorrhage

Aspirin for Prevention of Subarachnoid Hemorrhage

Comparison of Distance Metrics for Hierarchical Data in Medical Databases

Distance metrics are broadly used in different research areas and applications, such as bio-informatics, data mining and many other fields. However, there are some metrics, like pq-gram and Edit Distance used specifically for data with a hierarchical structure. Other metrics used for non-hierarchical data are the geometric and Hamming metrics. We have applied these metrics to The Health Improvement Network (THIN) database which has some hierarchical data. The THIN data has to be converted into a tree-like structure for the first group of metrics. For the second group of metrics, the data are converted into a frequency table or matrix, then for all metrics, all distances are found and normalised. Based on this particular data set, our research question: which of these metrics is useful for THIN data?. This paper compares the metrics, particularly the pqgram metric on finding the similarities of patients’ data. It also investigates the similar patients who have the same close distances as well as the metrics suitability for clustering the whole patient population. Our results show that the two groups of metrics perform differently as they represent different structures of the data. Nevertheless, all the metrics could represent some similar data of patients as well as discriminate sufficiently well in clustering the patient population using k-means clustering algorithm.

Low-Dose Aspirin and Upper Gastrointestinal Bleeding in Primary Versus Secondary Cardiovascular Prevention

The benefit-risk profile of low-dose aspirin in primary prevention of cardiovascular disease is unclear. We sought to quantify upper gastrointestinal bleeding (UGIB) risk associated with low-dose aspirin in secondary versus primary prevention patients. We performed a population-based nested case-control study using The Health Improvement Network (THIN) Database between 2000 and 2007. We identified 2049 cases of UGIB and 20,000 controls, frequency-matched to the cases on age, sex, and calendar year, who were subdivided into primary (without previous cardiovascular disease) and secondary (with previous cardiovascular disease) prevention populations. We estimated the relative risk of UGIB associated with the use of low-dose aspirin by multivariate logistic regression. The UGIB risk in patients taking low-dose aspirin relative to nonusers was significantly higher in the primary (adjusted relative risk, 1.90; 95% confidence interval, 1.59-2.26) than in the secondary (relative risk, 1.40; 95% confidence interval, 1.14-1.72; P value for the difference=0.0014) prevention cohort. However, as the baseline risk of UGIB was lower in the primary than in the secondary prevention cohort, numbers needed to harm per 1 year of low-dose aspirin use were 601 and 391 for primary and secondary prevention, respectively. The relative risk of UGIB in patients taking low-dose aspirin is higher when used for primary than for secondary cardiovascular disease prevention, but this difference is more than compensated by the lower baseline risk in the primary prevention population. Such estimates are important for an assessment of the net clinical benefit in primary prevention.

Regional variations of basal cell carcinoma incidence in the U.K. using The Health Improvement Network database (2004-10)

Basal cell carcinoma (BCC) is one of the most common types of nonmelanoma skin cancer affecting the white population; however, little is known about how the incidence varies across the U.K. To determine the variation in BCC throughout the U.K. Data from 2004 to 2010 were obtained from The Health Improvement Network database. European and world age-standardized incidence rates (EASRs and WASRs, respectively) were obtained for country-level estimates and levels of socioeconomic deprivation, while strategic health-authority-level estimates were directly age and sex standardized to the U.K. standard population. Incidence-rate ratios were estimated using multivariable Poisson regression models. The overall EASR and WASR of BCC in the U.K. were 98.6 per 100,000 person-years and 66.9 per 100,000 person-years, respectively. Regional-level incidence rates indicated a significant geographical variation in the distribution of BCC, which was more pronounced in the southern parts of the country. The South East Coast had the highest BCC rate followed by South Central, Wales and the South West. Incidence rates were substantially higher in the least deprived groups and we observed a trend of decreasing incidence with increasing levels of deprivation (P < 0.001). Finally, in terms of age groups, the largest annual increase was observed among those aged 30-49 years. Basal cell carcinoma is an increasing health problem in the U.K.; the southern regions of the U.K. and those in the least deprived groups had a higher incidence of BCC. Our findings indicate an increased incidence of BCC for younger age groups below 49 years.

Financial implication for being the national centre for the treatment and management of pelvic and acetabular fractures in Ireland: The need for a new budget strategy?

Financial implication for being the national centre for the treatment and management of pelvic and acetabular fractures in Ireland: The need for a new budget strategy?

Study of rotator cuff pathology using the health improvement network (THIN) database

Study of rotator cuff pathology using the health improvement network (THIN) database

Completeness of maternal smoking status recording during pregnancy in United Kingdom primary care data.

BackgroundGiven the health impacts of smoking during pregnancy and the opportunity for primary healthcare teams to encourage pregnant smokers to quit, our primary aim was to assess the completeness of gestational smoking status recording in primary care data and investigate whether completeness varied with women's characteristics. As a secondary aim we assessed whether completeness of recording varied before and after the introduction of the Quality and Outcomes Framework (QOF).MethodsIn The Health Improvement Network (THIN) database we calculated the proportion of pregnancies ending in live births or stillbirths where there was a recording of maternal smoking status for each year from 2000 to 2009. Logistic regression was used to assess variation in the completeness of maternal smoking recording by maternal characteristics, before and after the introduction of QOF.ResultsWomen had a record of smoking status during the gestational period in 28% of the 277,552 pregnancies identified. In 2000, smoking status was recorded in 9% of pregnancies, rising to 43% in 2009. Pregnant women from the most deprived group were 17% more likely to have their smoking status recorded than pregnant women from the least deprived group before QOF implementation (OR 1.17, 95% CI 1.10–1.25) and 42% more likely afterwards (OR 1.42, 95% CI 1.37–1.47). A diagnosis of asthma was related to recording of smoking status during pregnancy in both the pre-QOF (OR 1.63, 95% CI 1.53–1.74) and post-QOF periods (OR 2.08, 95% CI 2.02–2.15). There was no association between having a diagnosis of diabetes and recording of smoking status during pregnancy pre-QOF however, post-QOF diagnosis of diabetes was associated with a 12% increase in recording of smoking status (OR 1.12, 95% CI 1.05–1.19).ConclusionRecording of smoking status during pregnancy in primary care data is incomplete though has improved over time, especially after the implementation of the QOF, and varies by maternal characteristics and QOF-incentivised morbidities.

Identifying patients with undetected pancreatic cancer in primary care: an independent and external validation of QCancer® (Pancreas)

Despite its rarity, the prognosis of pancreatic cancer is very poor and it is a major cause of cancer mortality; being ranked fourth in the world, it has one of the worst survival rates of any cancer. To evaluate the performance of QCancer(®) (Pancreas) for predicting the absolute risk of pancreatic cancer in an independent UK cohort of patients, from general practice records. Prospective cohort study to evaluate the performance QCancer (Pancreas) prediction models in 364 practices from the UK, contributing to The Health Improvement Network (THIN) database. Records were extracted from the THIN database for 2.15 million patients registered with a general practice surgery between 1 January 2000 and 30 June 2008, aged 30-84 years (3.74 million person-years), with 618 pancreatic cancer cases. Pancreatic cancer was defined as incident diagnosis of pancreatic cancer during the 2 years after study entry. The results from this independent and external validation of QCancer (Pancreas) demonstrated good performance data on a large cohort of general practice patients. QCancer (Pancreas) had very good discrimination properties, with areas under the receiver operating characteristic curve of 0.89 and 0.92 for females and males respectively. QCancer (Pancreas) explained 60% and 67% of the variation in females and males respectively. QCancer (Pancreas) over-predicted risk in both females and males, notably in older patients. QCancer (Pancreas) is potentially useful for identifying undetected cases of pancreatic cancer in primary care in the UK.

OP91 Are there Gender Differences in Consultation Patterns Prior to Melanoma, CRC and Lung Cancer Diagnosis and Cancer Survival: An Analysis of Routinely Collected General Practice Data?

BackgroundConsultation rates with general practitioners (GPs) are higher in women than in men from late childhood through middle age, though not in childhood and later life. This gender patterning, and...

Treatment and referral patterns for psoriasis in United Kingdom primary care: a retrospective cohort study.

BackgroundIn the UK, referrals to specialists are initiated by general practitioners (GPs). Study objectives were to estimate the incidence of diagnosed psoriasis in the UK and identify factors associated with GP referrals to dermatologists.MethodsNewly diagnosed patients with psoriasis were identified in The Health Improvement Network (THIN) database between 01 July 2007-31 Oct 2009. Incidence of diagnosed psoriasis was calculated using the number of new psoriasis patients in 2008 and the mid-year total patient count for THIN in 2008. A nested case–control design and conditional logistic regression were used to identify factors associated with referral.ResultsIncidence rate of diagnosed adult psoriasis in 2008 was 28/10,000 person-years. Referral rate to dermatologists was 18.1 (17.3-18.9) per 100 person-years. In the referred cohort (N=1,950), 61% were referred within 30 days of diagnosis and their median time to referral was 0 days from diagnosis. For those referred after 30 days (39%, median time to referral: 5.6 months), an increase in the number of GP visits prior to referral increased the likelihood of referral (OR=1.87 95% CI:1.73-2.01). A prescription of topical agents such as vitamin D3 analogues 30 days before referral increased the likelihood of being referred (OR=4.67 95% CI: 2.78-7.84), as did corticosteroids (OR=2.45 95% CI: 1.45-4.07) and tar products (OR=1.95 95% CI: 1.02-3.75).ConclusionsEstimates of the incidence of diagnosed adult psoriasis, referral rates to dermatologists, and characteristics of referred patients may assist in understanding the burden on the UK healthcare system and managing this population in primary and secondary care.

Cost Effectiveness of Insulin Glargine versus Neutral Protamin Hagedorn Insulin in the Treatment of Type 2 Diabetes Patients in Turkey.

Background: Type 2 diabetes mellitus (T2DM) poses a significant burden on population well being and healthcare expenditure in Turkey, with disease prevalence continuing to increase. Insulin treatment is necessary for patients failing to achieve glycaemic control with lifestyle modification or oral antidiabetic drugs. While neutral protamin Hagedorn (NPH) insulin has been traditionally prescribed for insulin introduction, insulin glargine has been shown to reduce glycated hemoglobin (HbA1c) with a more favourable hypoglycaemic profile. Objective: To evaluate the cost-effectiveness of insulin glargine compared to NPH insulin in patients with T2DM in Turkey, from a Social Security Institution perspective. Methods: A previously published discrete event simulation model of T2DM progression was utilised to characterise the cost-effectiveness of insulin glargine in a Turkish population given the benefits observed in clinical practice. Improvements in glycaemic control have been incorporated using data from The Health Improvement Network (THIN) database in the United Kingdom, combined with meta-regression results describing the relationship between hypoglycaemia and glycaemic control. Outcomes were evaluated over a 40-year horizon, and costs and benefits discounted at an annual rate of 3.5%. Results are reported in Turksih lira (TL), 2012. Results: Over a lifetime, the Incremental Cost-effectiveness Ratio (ICER) of insulin glargine compared to NPH was 40,101 TL per Quality-adjusted Life Year (QALY). Almost 52 hypoglycaemic events per patient were avoided with the use of insulin glargine compared to NPH, at an incremental lifetime cost of 7,140 TL per patient. The cost-effectiveness of insulin glargine is reduced when modelling only those benefits considered in the trial setting, while the cost-effectiveness profile can be expected to further improve in patients with higher HbA1c levels at baseline. Conclusion: It is difficult to interpret the results of modelling as there is no official cost-effectiveness threshold in Turkey. However, the results may be evaluated using thresholds derived according to methodology proposed by the World Health Organisation (WHO). Insulin glargine is expected to be costeffective compared to NPH insulin, with an ICER below three times the estimated gross domestic product (GDP) per capita; 56,850 TL.