Health Improvement Network Database Research Articles

Impact of glycaemic control on fracture risk in 5368 people with newly diagnosed Type 1 diabetes: a time-dependent analysis.

To assess whether glycaemic control is associated with a lifelong increased risk of fracture in people with newly diagnosed Type 1 diabetes. People with newly diagnosed Type 1 diabetes between 1 January 1995 and 10 May 2016 were identified in The Health Improvement Network database. Longitudinal HbA1c measurements from diagnosis to fracture or study end or loss to follow-up were collected. A Cox proportional hazards model with HbA1c included as a time-dependent variable was fitted to these data. Some 5368 people with newly diagnosed Type 1 diabetes were included. The estimated adjusted hazard ratio (aHR) for HbA1c was statistically significant [aHR 1.007; 95% confidence interval (CI) 1.002-1.011 (mmol/mol) and aHR 1.07; 95% CI 1.03-1.12 (%)]. An incremental higher risk of fracture was observed with increasing levels of HbA1c . In people with newly diagnosed Type 1 diabetes, higher HbA1c is associated with an increased risk for fractures.

Association of Tramadol With All-Cause Mortality Among Patients With Osteoarthritis

An American Academy of Orthopaedic Surgeons guideline recommends tramadol for patients with knee osteoarthritis, and an American College of Rheumatology guideline conditionally recommends tramadol as first-line therapy for patients with knee osteoarthritis, along with nonsteroidal anti-inflammatory drugs. To examine the association of tramadol prescription with all-cause mortality among patients with osteoarthritis. Sequential, propensity score-matched cohort study at a general practice in the United Kingdom. Individuals aged at least 50 years with a diagnosis of osteoarthritis in the Health Improvement Network database from January 2000 to December 2015, with follow-up to December 2016. Initial prescription of tramadol (n = 44 451), naproxen (n = 12 397), diclofenac (n = 6512), celecoxib (n = 5674), etoricoxib (n = 2946), or codeine (n = 16 922). All-cause mortality within 1 year after initial tramadol prescription, compared with 5 other pain relief medications. After propensity score matching, 88 902 patients were included (mean [SD] age, 70.1 [9.5] years; 61.2% were women). During the 1-year follow-up, 278 deaths (23.5/1000 person-years) occurred in the tramadol cohort and 164 (13.8/1000 person-years) occurred in the naproxen cohort (rate difference, 9.7 deaths/1000 person-years [95% CI, 6.3-13.2]; hazard ratio [HR], 1.71 [95% CI, 1.41-2.07]), and mortality was higher for tramadol compared with diclofenac (36.2/1000 vs 19.2/1000 person-years; HR, 1.88 [95% CI, 1.51-2.35]). Tramadol was also associated with a higher all-cause mortality rate compared with celecoxib (31.2/1000 vs 18.4/1000 person-years; HR, 1.70 [95% CI, 1.33-2.17]) and etoricoxib (25.7/1000 vs 12.8/1000 person-years; HR, 2.04 [95% CI, 1.37-3.03]). No statistically significant difference in all-cause mortality was observed between tramadol and codeine (32.2/1000 vs 34.6/1000 person-years; HR, 0.94 [95% CI, 0.83-1.05]). Among patients aged 50 years and older with osteoarthritis, initial prescription of tramadol was associated with a significantly higher rate of mortality over 1 year of follow-up compared with commonly prescribed nonsteroidal anti-inflammatory drugs, but not compared with codeine. However, these findings may be susceptible to confounding by indication, and further research is needed to determine if this association is causal.

Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines

ObjectiveTo evaluate the duration of prescriptions for antibiotic treatment for common infections in English primary care and to compare this with guideline recommendations.DesignCross sectional study.SettingGeneral practices contributing to The Health...

Prediction Tools for Psychiatric Adverse Effects After Levetiracetam Prescription

Levetiracetam is a commonly used antiepileptic drug, yet psychiatric adverse effects are common and may lead to treatment discontinuation. To derive prediction models to estimate the risk of psychiatric adverse effects from levetiracetam use. Retrospective open cohort study. All patients meeting the case definition for epilepsy after the Acceptable Mortality Reporting date in The Health Improvement Network (THIN) database based in the United Kingdom (inclusive January 1, 2000, to May 31, 2012) who received a first-ever prescription for levetiracetam were included. Of 11 194 182 patients registered in THIN, this study identified 7400 presumed incident cases (66.1 cases per 100 000 persons) over a maximum of 12 years' follow-up. The index date was when patients received their first prescription code for levetiracetam, and follow-up lasted 2 years or until an event, loss to follow-up, or censoring. The analyses were performed on April 22, 2018. A presumed first-ever prescription for levetiracetam. The outcome of interest was a Read code for any psychiatric sign, symptom, or disorder as reached through consensus by 2 authors. This study used regression techniques to derive 2 prediction models, one for the overall population and one for those without a history of a psychiatric sign, symptom, or disorder during the study period. Among 1173 patients with epilepsy receiving levetiracetam, the overall median age was 39 (interquartile range, 25-56) years, and 590 (50.3%) were female. A total of 14.1% (165 of 1173) experienced a psychiatric symptom or disorder within 2 years of index prescription. The odds of reporting a psychiatric symptom were significantly elevated for women (odds ratio [OR], 1.41; 95% CI, 0.99-2.01; P = .05) and those with a preexposure history of higher social deprivation (OR, 1.15; 95% CI, 1.01-1.31; P = .03), depression (OR, 2.20; 95% CI, 1.49-3.24; P < .001), anxiety (OR, 1.74; 95% CI, 1.11-2.72; P = .02), or recreational drug use (OR, 2.02; 95% CI, 1.20-3.37; P = .008). The model performed well after stratified k = 5-fold cross-validation (area under the curve [AUC], 0.68; 95% CI, 0.58-0.79). There was a gradient in risk, with probabilities increasing from 8% for 0 risk factors to 11% to 17% for 1, 17% to 31% for 2, 30% to 42% for 3, and 49% when all risk factors were present. For those free of a preexposure psychiatric code, a second model performed comparably well after k = 5-fold cross-validation (AUC, 0.72; 95% CI, 0.54-0.90). Specificity was maximized using threshold cutoffs of 0.10 (full model) and 0.14 (second model); a score below these thresholds indicates safety of prescription. This study derived 2 simple models that predict the risk of a psychiatric adverse effect from levetiracetam. These algorithms can be used to guide prescription in clinical practice.

The validity of dementia diagnoses in routinely collected electronic health records in the United Kingdom: A systematic review.

PurposeThe purpose of the study is to assess the validity of codes or algorithms used to identify dementia in UK electronic health record (EHR) primary care and hospitalisation databases.MethodsRelevant studies were identified by searching the MEDLINE/EMBASE databases from inception to June 2018, hand‐searching reference lists, and consulting experts. The search strategy included synonyms for “Dementia”, “Europe”, and “EHR”. Studies were included if they validated dementia diagnoses in UK primary care or hospitalisation databases, irrespective of validation method used. The Quality Assessment for Diagnostic Accuracy Studies‐2 (QUADAS‐2) tool was used to assess risk of bias.ResultsFrom 1469 unique records, 14 relevant studies were included. Thirteen validated individual diagnoses against a reference standard, reporting high estimates of validity. Most reported only the positive predictive value (PPV), with estimates ranging between 0.09 and 1.0 and 0.62 and 0.85 in primary care and hospitalisation databases, respectively. One study performed a rate comparison, indicating good generalisability of dementia diagnoses in The Health Improvement Network (THIN) database to the UK population. Studies were of low methodological quality. As studies were not comparable, no summary validity estimates were produced.ConclusionWhile heterogenous across studies, reported validity estimates were generally high. However, the credibility of these estimates is limited by the methodological quality of studies, primarily resulting from insufficient blinding of researchers interpreting the reference test. Inadequate reporting, particularly of the specific codes validated, hindered comparison of estimates across studies. Future validation studies should make use of more robust reference tests, follow established reporting guidelines, and calculate all measures of validity.

Feasibility and validity of The Health Improvement Network database of primary care electronic health records to identify and characterise patients with small cell lung cancer in the United Kingdom

BackgroundEpidemiological research on small cell lung cancer (SCLC) is limited and based on cancer registry data. We evaluated the feasibility and validity of using primary care electronic health records (The Health Improvement Network [THIN]) in the UK to identify and characterise SCLC.MethodsWe searched THIN records of individuals aged 18–89 years between 2000 and 2014 for a first diagnostic code suggestive of lung cancer (group 1) or small cell cancer (SCC; group 2) and for text strings among free text comments to identify and characterise incident SCLC cases. We validated our case identification strategy by manual review of patient EHRs, including free text comments, for a random sample of 400 individuals initially detected with a diagnostic code (300 from group 1 and 100 from group 2).ResultsTwenty five thousand two hundred fourty one individuals had a code for lung cancer (n = 24,508 [97.1%]) or SCC (733 [2.9%]). Following free-text searches, there were 3530 incident SCLC cases (2956 from group 1; 574 from group 2) corresponding to an incidence rate of 1.01 per 10,000 person-years. In the validation exercise, SCLC confirmation rates were 99% (group 1) and 85% (group 2). Mean age at diagnosis among confirmed cases was 68.5 years; staging information was present in 63.5% of cases of whom 17.8% had limited disease and 82.2% had extensive disease. The majority (84.5%) had a recorded symptom suggestive of lung cancer; chest infection was the most common (18%) followed by cough (15.8%) and chest/abdominal/back pain (15.2%). The first year crude mortality rates was 9.9 per 100 person-months (95% confidence interval [CI] 9.5–10.4), was higher among men and those aged 80 years and above. A total of 144 (37.8%) confirmed cases had metastases recorded. Median survival among the whole study cohort was 7.37 months.ConclusionsOur SCLC case identification method appears to be valid and could potentially be adapted to identify other cancer types. However, complete characterisation of staging requires information from additional data sources including cancer registries.

Association between metabolic syndrome and hepatobiliary cancers: A case-control study.

The incidence of hepatobiliary cancer is steadily increasing. It is unclear if this rise is related to increasing trends in obesity, metabolic syndrome, and lifestyle changes. A case-control study was performed using the Health Improvement Network (THIN) database. Cases with a diagnosis of liver, bile duct, and gallbladder cancers were matched in a 1:2 fashion with controls and analyzed for potential associations between hepatobiliary cancer and obesity/metabolic syndrome. Four thousand two hundred and eighty-seven patients (62% male, 38% female) with hepatobiliary cancers were matched with 8574 controls. On univariate analysis, body mass index (BMI), smoking, diabetes, alcohol consumption, ischemic heart disease, and hypertension were associated with hepatobiliary cancer. Statin use and non-smoking status had an inverse association. On multivariate analysis, BMI, diabetes, hypertension, ischemic heart disease, and insulin use were associated with the risk of hepatobiliary cancer. Statin use and non-smoking status were protective. On modeling BMI, each ofdiabetes and hypertension as a single covariate, there was a significant association with hepatobiliary cancer (1.59 [1.49-1.69], p < 0.001) which persisted despite adjusting for increasing age (1.006 [1005-1.006], p < 0.001) and background liver cirrhosis (1.037 [1.03-1.044], p < 0.001). Obesity and metabolic syndrome are associated with the risk of hepatobiliary cancer. Statin use seems to be protective.

Relationship between HbA1c and all-cause mortality in older patients with insulin-treated type 2 diabetes: results of a large UK Cohort Study.

our aim was to study the relationship between HbA1c and cardiovascular morbidity and all-cause mortality among older insulin-treated patients with type 2 diabetes (T2D) after adjustment for multiple confounders. data for 4589 adults with T2D (>65 years) on insulin treatment were sourced from 532 UK General Practices via the Health Improvement Network (THIN) database. Cox proportional hazard models and Kaplan-Meier estimators were fitted to derive the hazards of all-cause mortality by HbA1c categories (<6.5, 6.5-7.4, 7.5-8.4, 8.5-9.4, 9.5-10.4, 10.5-11.4%; and 11.5% and above) after 5 years of follow-up following insulin initiation. we observed a U-shaped relationship between all-cause mortality and HbA1c, with the lowest risk seen in the HbA1c range of 6.5-7.4% and marked increased in risk with HbA1c > 11%. The highest mortality risks of 31 and 40% were significantly associated with the lowest (<6.5%) and highest (11.5% and above) HbA1c categories: aHR: 1.31; (95%CI: 1.10-1.56; P = 0.002) and aHR: 1.40; (95%CI: 1.01-1.96; P = 0.039), respectively. both low and high HbA1c were associated with increased all-cause mortality, among older patients with insulin-treated T2D. This cohort study supports the need for individualisation of care and suggests better outcomes with HbA1c levels around 6.5-7.4% and markedly excess risk with HbA1c > 11.

Hypoglycaemia is associated with increased risk of fractures in patients with type 2 diabetes mellitus: a cohort study.

Objective Type 2 diabetes is associated with an increased risk of fracture. Any factor that incrementally increases this risk should be taken into account when individualising treatment. Hypoglycaemia is a common complication of antidiabetes medications and suggested as a risk factor for fractures; yet, its real-life clinical impact is unclear. Design A population-based, retrospective open cohort study using routinely collected data between 1st of January 1995 and 1st of May 2016 in The Health Improvement Network (THIN) database. Methods Patients with type 2 diabetes mellitus with documented hypoglycaemic events were compared to randomly matched patients with type 2 diabetes mellitus without documented hypoglycaemic events matched to exposed patients on age, sex, duration of diabetes and BMI. The primary outcome was any incident fracture. Secondary outcome was incident fragility (osteoporotic) fracture. Results A total of 41 163 patients with type 2 diabetes were included: 14 147 patients in the exposed cohort and 27 016 patients in the unexposed cohort. Patients with a documented hypoglycaemic event were significantly more likely to sustain any fracture compared to patients with no record of hypoglycaemic events: adjusted IRR = 1.20 (95% CI: 1.12-1.30; P < 0.0001). Patients who had a documented hypoglycaemic event were significantly more likely to suffer a fragility fracture compared to controls: adjusted IRR = 1.24 (95% CI: 1.13-1.37; P < 0.0001). Conclusions Hypoglycaemic events are a significant risk factor for fractures in patients with diabetes mellitus. This observation is clinically relevant when individualising targets for glycaemic control and selecting antidiabetic agents.

Analysis of effect of National Institute for Health and Care Excellence Clinical Guideline CG168 on management of varicose veins in primary care using The Health Improvement Network database

Objective/Background In July 2013, new UK guidelines recommended that all patients with symptomatic varicose veins (VV) be referred to a specialist vascular service for consideration of superficial venous intervention (SVI). In the UK, general practitioners (GPs) in primary care control access to publicly funded vascular services provided through the National Health Service. GP awareness and concordance with Clinical Guideline (CG)168 recommendations is vital if patients with VV are to receive evidence-based treatment in line with national recommendations. The aim was to assess the UK-wide impact of new guidelines on GP management of VV using a large database of electronic GP records. Methods An eligible population of patients aged ≥ 18 years was analysed over two 18-month periods, before and after guideline publication. Those with a new diagnosis of VV in each time period were analysed in terms of demographics, specialist referral, compression hosiery prescriptions, and recorded SVI. Results Analysis included approximately two million patients from 285 GP practices. Before and after CG168 cohorts were well matched. Study populations included 13,014 patients before and 12,466 patients after guideline publication. There was an increase in specialist referrals from 24% (n = 3173) to 28% (n = 3457) (Cox hazard ratio [HR] 1.15, 95% confidence interval [CI] 1.09–1.20; p Conclusion Encouragingly, following publication of National Institute for Health and Care Excellence CG168, there has been a statistically significant improvement in the management of VV in primary care in line with the CG recommendations.

Vitiligo and major depressive disorder: A bidirectional population-based cohort study

Vitiligo patients often report their mental health has an effect on their skin. However, it is unknown as to whether a common mental disorder, such as major depressive disorder (MDD), can also precipitate the onset of vitiligo. Evaluate a bidirectional relationship between MDD and vitiligo using The Health Improvement Network database. Incident MDD and referent cohorts were followed until the development of vitiligo. Also, incident vitiligo and referent cohorts were followed until the development of MDD. Cox proportional hazards models were used, and numerous covariates were adjusted for. In adjusted models, MDD patients (n=405,397) were at a 64% increased risk for vitiligo (hazard ratio 1.64, 95% confidence interval [CI] 1.43-1.87, P<.0001) compared with the referent cohort (n=5,739,048). This risk was decreased in patients using antidepressants. Compared with the referent cohort (n=6,137,696), patients with vitiligo (n=7104) that were <30years of age at diagnosis had a higher risk of developing MDD than patients ≥30years of age (hazard ratio 1.31, 95% CI 1.14-1.50, P<.0001 vs 1.22, 95% CI 1.08-1.37, P=.001, respectively). This study did not evaluate the severity of MDD or vitiligo on outcome development. These results highlight the burden of depression in patients with vitiligo and support the possible existence of pathophysiological connections between these 2 conditions.

Costs and outcomes in evaluating management of unhealed surgical wounds in the community in clinical practice in the UK: a cohort study

ObjectiveTo evaluate the patient pathways and associated health outcomes, resource use and corresponding costs attributable to managing unhealed surgical wounds in clinical practice, from initial presentation in the community in...

Resource use and cost of annual health checks in primary care for people with intellectual disabilities.

The annual health check (AHC) programme, as part of a Directed Enhanced Service, offers an incentive to general practitioners in England to conduct health checks for people with intellectual disabilities (IDs). The aim of this analysis was to estimate the impact on health care costs of AHCs in primary care to the National Health Service in England by comparing adults with ID who did or did not have AHCs using data obtained from The Health Improvement Network. Two hundred eight records of people with ID from The Health Improvement Network database were analysed. Baseline health care resource use was captured at the time the first AHC was recorded (i.e. index date), or the earliest date after 1 April 2008 for those without an AHC. We examined the volume of resource use and associated costs that occurred at the time AHCs were performed, as well as before and after the index date. We then estimated the impact of AHCs on health care costs. The average cost of AHC was estimated at £142.57 (95%CI £135.41 to £149.74). Primary, community and secondary health care costs increased significantly after the index date in the no AHC group owing to higher increase in resource utilisation. Regression analysis showed that the expected health care cost for those who have an AHC is 56% higher than for those who did not have an AHC. Age and gender were also associated with increase in expected health care cost. The level of resource utilisation increased in both (AHC and no AHC) groups after the index date. Although the level of resource use before index date was lower in the no AHC group, it increased after the index date up to almost reaching the level of resource utilisation in the AHC group. Further research is needed to explore if the AHCs are effective in reducing health inequalities.

Tuberculosis and diabetes: bidirectional association in a UK primary care data set

BackgroundMany studies have found an increased risk of pulmonary tuberculosis (PTB) among those with diabetes mellitus (DM). However, evidence on whether the association is bidirectional remains sparse. This study investigates...

Incidence and risk of celiac disease after type 1 diabetes: A population-based cohort study using the health improvement network database.

To determine the incidence of and risk factors for development of celiac disease (CD) in individuals with type 1 diabetes. Cohort study using The Health Improvement Network (THIN), a UK primary care database of >13 million people. Individuals with incident type 1 diabetes diagnosed at 1 to 35 years of age between 1995 and 2015 with no previous diagnosis of CD were included. Cox regression was used to identify risk factors for CD, including age at diabetes diagnosis and sex, while adjusting for year of diagnosis to control for potential rising incidence in CD over time. Subjects (n = 9180; 43% female) had a median observation time of 5.1 years (interquartile range 2.0-10.1). CD was diagnosed in 196 (2%) during follow up. Median time to diagnosis was 2.1 years, but 25% were diagnosed more than 5 years after diabetes diagnosis. Incidence (per 10 000 person-years) was greater in females (43.0 [95% confidence interval [CI] 35.2-52.0]) vs males (26.8 [95% CI 21.5-32.9]). In multivariable Cox regression stratified by childhood- vs young adult-onset diabetes, younger age at diabetes diagnosis within childhood (hazard ratio [HR] 0.91 [95% CI 0.88-0.94]) and female sex among the adult-onset diabetes group (HR 3.19 [95% CI 1.39-7.34]) were associated with greater risk of CD. As expected, incidence of CD was higher in individuals with childhood-onset diabetes vs those with adult-onset diabetes. However, individuals with diabetes are at risk of developing CD throughout childhood and adulthood, and prolonged screening after diagnosis may be warranted. Prospective studies are needed in order to guide risk-stratified approaches to screening.

Analysis of Effect of National Institute for Health and Care Excellence Clinical Guideline CG168 on Management of Varicose Veins in Primary Care Using the Health Improvement Network Database

In July 2013, new UK guidelines recommended that all patients with symptomatic varicose veins (VV) be referred to a specialist vascular service for consideration of superficial venous intervention (SVI). In the UK, general practitioners (GPs) in primary care control access to publicly funded vascular services provided through the National Health Service. GP awareness and concordance with Clinical Guideline (CG)168 recommendations is vital if patients with VV are to receive evidence-based treatment in line with national recommendations. The aim was to assess the UK-wide impact of new guidelines on GP management of VV using a large database of electronic GP records. An eligible population of patients aged ≥ 18 years was analysed over two 18-month periods, before and after guideline publication. Those with a new diagnosis of VV in each time period were analysed in terms of demographics, specialist referral, compression hosiery prescriptions, and recorded SVI. Analysis included approximately two million patients from 285GP practices. Before and after CG168 cohorts were well matched. Study populations included 13,014 patients before and 12,466 patients after guideline publication. There was an increase in specialist referrals from 24% (n=3173) to 28% (n=3457) (Cox hazard ratio [HR] 1.15, 95% confidence interval [CI] 1.09-1.20; p<.001). Median time to referral was 1.5 days. Prescribed compression hosiery declined from 20% (n=2558) before the new guidelines to 18% (n=2292) after the new guidelines (HR 0.93, 95% CI 0.88-0.98; p=.008). There were similar increases in proportions recorded as having SVI, from 3.6% (n=469) before the new guidelines to 4.2% (n=526) after the new guidelines (HR 1.16, 95% CI 1.02-1.31; p=.023). There was a statistically significant increase in endothermal ablation after CG168. In Cox models, age, sex, Townsend quintile, and body mass index were significantly related to the chance of referral and SVI. Encouragingly, following publication of National Institute for Health and Care Excellence CG168, there has been a statistically significant improvement in the management of VV in primary care in line with the CG recommendations.

Risk of depression among patients with acne: A population-based cohort study using The Health Improvement Network (THIN) database

Risk of depression among patients with acne: A population-based cohort study using The Health Improvement Network (THIN) database

Trends in dementia diagnosis rates in UK ethnic groups: analysis of UK primary care data.

ObjectivesWe compared incidence of dementia diagnosis by white, black, and Asian ethnic groups and estimated the proportion of UK white and black people developing dementia in 2015 who had a diagnosis for the first time in a UK-wide study.MethodsWe analyzed primary care electronic health records from The Health Improvement Network database between 2007 and 2015 and compared incidence of dementia diagnosis to dementia incidence from community cohort studies. The study sample comprised of 2,511,681 individuals aged 50–105 years who did not have a dementia diagnosis prior to the start of follow-up.ResultsA total of 66,083 individuals had a dementia diagnosis (4.87/1,000 person-years at risk, 95% CI 4.83–4.90); this incidence increased from 3.75 to 5.65/1,000 person-years at risk between 2007 and 2015. Compared with white women, the incidence of dementia diagnosis was 18% lower among Asian women (adjusted incidence rate ratio (IRR) 0.82, 95% CI 0.72–0.95) and 25% higher among black women (IRR 1.25, 95% CI 1.07–1.46). For men, incidence of dementia diagnosis was 28% higher in the black ethnic group (IRR 1.28, 95% CI 1.08–1.50) and 12% lower in the Asian ethnic group (IRR 0.88, 95% CI 0.76–1.01) relative to the white ethnic group. Based on diagnosis incidence in The Health Improvement Network data and projections of incidence from community cohort studies, we estimated that 42% of black men developing dementia in 2015 were diagnosed compared with 53% of white men.ConclusionPeople from the black ethnic group had a higher incidence of dementia diagnosis and those from the Asian ethnic group had lower incidence compared with the white ethnic group. We estimated that black men developing dementia were less likely than white men to have a diagnosis of dementia, indicating that the increased risk of dementia diagnosis reported in the black ethnic group might underestimate the higher risk of dementia in this group. It is unclear whether the lower incidence of dementia diagnosis in the Asian ethnic group reflects lower community incidence or underdiagnosis. A cohort study to determine this is needed.

Depression as a risk factor for the development of rheumatoid arthritis: a population-based cohort study

ObjectivesMajor depressive disorder (MDD) is associated with increased levels of systemic proinflammatory cytokines, including tumour necrosis factor alpha. As these cytokines are pathogenic in autoimmune diseases such as rheumatoid arthritis...

Cohort study evaluating pressure ulcer management in clinical practice in the UK following initial presentation in the community: costs and outcomes

ObjectivesThe aim of this study was to estimate the patterns of care and annual levels of healthcare resource use attributable to managing pressure ulcers (PUs) in clinical practice in the...