United Kingdom Primary Care Research Articles

Relative incidence of common cancers in people with severe mental illness. Cohort study in the United Kingdom THIN primary care database

BackgroundA recent United Kingdom (UK) report found that breast and colorectal cancers were more common in people with severe mental illness (SMI) and recommended targeted screening. Epidemiological evidence is however inconsistent. ObjectivesTo estimate relative incidence rates for colorectal, breast and lung cancer, and the overall incidence of the commonest other UK cancers, in people with SMI compared with people without SMI. MethodCohort study in the UK using The Health Improvement Network (THIN) primary care database between 1990 and June 2008. Poisson regression was used to obtain adjusted incidence rate ratios (IRRs) for cancer, comparing two cohorts of people over 18; with and without a diagnosis of SMI. ResultsWe identified 20,632 people with SMI and 116,152 people without, with median follow up of over 6years. No significant associations were observed between SMI and cancers of the breast (adjusted IRR 1.17; 95% confidence interval 0.95–1.45), colon (0.70; 0.46–1.05), rectum (1.05; 0.65–1.69) or lung (0.84; 0.65–1.10). The adjusted IRR for an aggregate cancer outcome in SMI was 0.95; 0.85–1.06. Results were similar for schizophrenia and bipolar disorder. ConclusionsIn a cohort analysis within a large UK primary care database, the incidence of colo-rectal, breast and lung cancer, and of all common cancers, did not differ significantly in people with SMI, including schizophrenia, compared with people without SMI. Our results do not support enhanced screening procedures for cancer in people with SMI.

Observational Study of the Association of First Insulin Type in Uncontrolled Type 2 Diabetes with Macrovascular and Microvascular Disease

AimsTo compare the risk of vascular disease, HbA1c and weight change, between first prescribed insulins in people with type 2 diabetes.MethodsPeople included in THIN United Kingdom primary care record database who began insulin (2000–2007) after poor control on oral glucose-lowering agents (OGLD) were grouped by the number of OGLDs in their treatment regimen immediately before starting insulin (n = 3,485). Within OGLD group, Cox regression compared macrovascular (all-cause mortality, myocardial infarction, acute coronary syndrome and stroke) and microvascular disease (peripheral neuropathy, nephropathy, and retinopathy) between insulin type (basal, pre-mix or Neutral Protamine Hagedorn, NPH) while ANCOVAs compared haemoglobin A1c (HbA1c) and weight change.ResultsMean follow-up was 3.6 years. Rates of incident macrovascular events were similar when basal insulin was compared to pre-mix or NPH, adjusted hazard ratio versus basal: pre-mix 1.08 (95% CI 0.73, 1.59); NPH 1.00 (0.63, 1.58) after two OGLDs, and pre-mix 0.97 (0.46, 2.02); NPH 0.77 (0.32, 1.86) after three OGLDs. An increased risk of microvascular disease in NPH versus basal after 3 OGLDs, adjusted hazard ratio1.87 (1.04, 3.36), was not seen after two agents or in comparisons of basal and pre-mix. At one year, after two OGLDs, weight increase was less with basal compared with pre-mix. After three OGLDs, mean HbA1c had reduced less in basal versus pre-mix or NPH at 6–8 and at 9–11 months, and versus pre-mix at 12–14 months.ConclusionWe found no difference in the risk of macrovascular events between first insulins in the medium term when started during poor glycaemia control. The increased risk of microvascular events with NPH warrants further study. In certain groups, first use of basal insulin was associated with less gain in weight and decrease in HbA1c compared to other insulins.

Developing Primary Care: The Contribution of Primary Care Research Networks

The performance of Canada's primary care sector remains lacklustre relative to other wealthy industrialized countries, and it has been suggested that a lack of investment in research and evaluation may be a cause. One approach to improving and sustaining primary care research is through research networks. Over the past few years, significant investments have begun to be made in developing primary care networks in Canada. While Canadian experience in this area is relatively new, in the United Kingdom primary care research networks were first established in the 1980s. Initially developed at a local level, these have more recently been incorporated into large-scale national networks. This paper reviews the UK experience and highlights potential lessons for the development of networks in Canada.

Cardiovascular Events as a Function of Serum Bilirubin Levels in a Large, Statin-Treated Cohort

Serum bilirubin is an endogenous antioxidant that is routinely measured before a statin is prescribed primarily to assess liver function, but the association with cardiovascular disease (CVD) in this population has not been explored. We identified patients from a United Kingdom primary care database (The Health Improvement Network) with measurements of serum total bilirubin levels recorded 3 months before the first statin treatment between January 1, 2000, and December 31, 2010, and no history of liver disease or CVD. In total, 130 052 patients met the inclusion criteria, and after a median follow-up of 43 months, there were 7850 CVD events. In men, the incidence of CVD in the lowest decile category of bilirubin (1-6 μmol/L [0.06-0.35 mg/dL]) was 215 per 10 000 person-years compared with 163 per 10 000 person-years in the highest decile (19-40 μmol/L [1.1-2.3 mg/dL]). Similar differences were seen for women. After conventional CVD risk factors were accounted for, the associations with bilirubin were nonlinear (L shaped), and the models predicted that, compared with patients with a bilirubin level of 10 μmol/L (0.6 mg/dL), those with a similar CVD risk profile but a bilirubin level of 5 μmol/L (0.3 mg/dL) had an 18% (95% confidence interval, 9-27) higher risk of any CVD event, a 34% (95% confidence interval, 13-56) higher risk of myocardial infarction, and a 33% (95% confidence interval, 21-46) higher risk of death resulting from any cause. Serum bilirubin level measured before a statin prescription to assess liver function is an independent risk factor for CVD and death in both men and women.

Do Good Health and Material Circumstances Protect Older People From the Increased Risk of Death After Bereavement?

An increased risk of death in persons who have suffered spousal bereavement has been described in many populations. The impact of modifying factors, such as chronic disease and material circumstances, is less well understood. The authors followed 171,120 couples 60 years of age or older in a United Kingdom primary care database between 2005 and 2010 for an average of 4 years. A total of 26,646 (15.5%) couples experienced bereavement, with mean follow up after bereavement of 2 years. In a model adjusted for age, sex, comorbid conditions at baseline, material deprivation based on area of residence, season, and smoking status, the hazard ratio for mortality in the first year after bereavement was 1.25 (95% confidence interval: 1.18, 1.33). Further adjustment for changes in comorbid conditions throughout follow up did not alter the hazard ratio for bereavement (hazard ratio = 1.27, 95% confidence interval: 1.19, 1.35). The association was strongest in individuals with no significant chronic comorbid conditions throughout follow up (hazard ratio = 1.50, 95% confidence interval: 1.28, 1.77) and in more affluent couples (P = 0.035). In the first year after bereavement, the association between bereavement and death is not primarily mediated through worsening or new onset of chronic disease. Good health and material circumstances do not protect individuals from increased mortality rates after bereavement.

Association between appendicectomy in females and subsequent pregnancy rate: a cohort study

To study whether subsequent pregnancy rate is reduced after appendicectomy. A cohort study was carried out in the General Practice Research Database, a United Kingdom primary care database. University hospital. Female patients who underwent appendicectomy between 1986 and 2009 and appropriate comparators were followed until first pregnancy. None. The association between appendicectomy and subsequent pregnancy was determined by Cox regression models. The analyses included 76,426 appendicectomy patients, with 152,852 comparators from the database. There were 30,030 pregnancies (39.3%) in the appendicectomy cohort and 43,321 (28.3%) in the comparator cohort during a mean (SD) follow-up of 10.5 (6.6) years. Adjusted hazard ratios for subsequent birth rates were 1.54 (95% confidence interval, 1.52-1.56). Appendicectomy was associated with increased subsequent pregnancy rate in this study. This suggests that a history of appendicectomy is not associated with impaired fertility.

Adjunctive pharmacotherapy and treatment patterns among initiators of SSRI therapy for major depressive disorder: A cohort study using a primary care database

Objective: Adjunctive therapy is often used for treatment of major depressive disorder (MDD) following an inadequate response to an antidepressant. However, there is little information regarding its practice within primary care in the United Kingdom (UK). Objectives of the study were to examine incidence and predictors of adjunctive pharmacotherapy among patients with MDD treated with selective serotonin reuptake inhibitors (SSRIs) by UK general practitioners (GPs). Methods: The General Practice Research Database was used to identify 15,274 MDD patients prescribed first-line treatment with SSRIs from 2006-2008 (latest patient follow-up towards end of 2010). Treatment trajectories were identified and classified as adjunctive therapy, combination therapy, drug switches, dose increases, and restart of therapy. Incidence and predictors of adjunctive therapy were assessed, and healthcare resource utilization was evaluated. Results: Overall incidence of adjunctive therapy was 3.07/100 person years (95% CI 2.90-3.25). Patients prescribed adjunctive therapy were more likely to be female (IRR 1.15, p = 0.03), of higher age (IRRs 1.51-2.60, p ≤ 0.001), and had a greater depression severity score (IRR 1.02, p = 0.003). Presence of irritable bowel syndrome (IRR 1.53, p = 0.001), and an increasing Charlson Comorbidity Index (IRR 1.15, p = 0.01) were associated with a higher incidence of adjunctive therapy. MDD-related general practitioner consultations among patients who received adjunctive therapy was lower compared with patients receiving other treatment interventions (IRRs 0.79 - 0.87, p ≤ 0.001). Conclusions: Adjunctive therapy is infrequently utilized relative to other treatment options for management of MDD among patients who are inadequate responders to their SSRI treatments in UK primary care; however some groups are more likely to receive adjunctive therapy than others.

Discontinuation of antidepressant therapy among patients with major depressive disorder

Objective: Patients with major depressive disorder (MDD) often discontinue antidepressant therapy pre- maturely risking relapse, despite United Kingdom (UK) guidelines recommending therapy for up to at least six months after remission. More information is needed on the patterns of antidepressant discontinuation in UK primary care. Objectives of the study were to assess the patterns, incidence and predictors of therapy discontinuation among MDD patients initiating treatment with selective serotonin reuptake inhibitors (SSRIs). Methods: This was a retrospective cohort study using general practices registered with the General Practice Research Database (GPRD). 15,274 patients with MDD receiving a first ever prescription (index) for an SSRI between 2006-2008 were identified in GPRD. Discontinuation (including temporary gaps) and cessation of antidepressant therapy were examined over follow-up. Predictors of incidence of discontinuation in the six months after index were assessed. Results: Incidence of discontinuation of antidepressant therapy over follow-up was 80.05 per 100 person years (95% CI 78.94 - 81.17). At six months after index 42% of patients had discontinued and 33% had ceased therapy altogether. Lower discontinuation of index SSRI therapy in the first six months after initiation was associated with higher age, higher body mass index (BMI), and comorbid irritable bowel syndrome. Higher discontinuation was associated with paroxetine or fluoxetine at index, and a more recent index calendar year. Conclusions: There is a significant risk of discontinuation of antidepressant therapy in the 6 months after initiation of treatment for MDD. This finding requires awareness by the general practitioner (GP) to ensure implementation of optimal treatment regimens, and minimization of therapy non-compliance among MDD patients.

The effects of pay for performance on disparities in stroke, hypertension, and coronary heart disease management: interrupted time series study.

BackgroundThe Quality and Outcomes Framework (QOF), a major pay-for-performance programme, was introduced into United Kingdom primary care in April 2004. The impact of this programme on disparities in health care remains unclear. This study examines the following questions: has this pay for performance programme improved the quality of care for coronary heart disease, stroke and hypertension in white, black and south Asian patients? Has this programme reduced disparities in the quality of care between these ethnic groups? Did general practices with different baseline performance respond differently to this programme?Methodology/Principal FindingsRetrospective cohort study of patients registered with family practices in Wandsworth, London during 2007. Segmented regression analysis of interrupted time series was used to take into account the previous time trend. Primary outcome measures were mean systolic and diastolic blood pressure, and cholesterol levels. Our findings suggest that the implementation of QOF resulted in significant short term improvements in blood pressure control. The magnitude of benefit varied between ethnic groups with a statistically significant short term reduction in systolic BP in white and black but not in south Asian patients with hypertension. Disparities in risk factor control were attenuated only on few measures and largely remained intact at the end of the study period.Conclusions/SignificancePay for performance programmes such as the QOF in the UK should set challenging but achievable targets. Specific targets aimed at reducing ethnic disparities in health care may also be needed.

When big isn't beautiful: lessons from England and Scotland on primary health care organisations

United Kingdom primary care trusts resembled the primary health care organisations (PHCOs) that have been proposed for Australia--for example, Medicare Locals. They resulted in a loss of innovation, creativity, motivation and morale among general practitioners and other front-line staff. English primary care trusts are being abolished and £80 billion will be handed over to GP commissioners. Management theory and practical experience shows repeatedly the dangers of reorganising into larger units. Lessons for Australia are to defer deciding on the size of PHCOs until their purposes are clear, to enshrine the principle of subsidiarity, and to opt for networking of the current Divisions of General Practice over mergers. So far, debate on the functions and structures of PHCOs has been muted. It is now time for vigorous debate.

Assessing patient safety culture in New Zealand primary care: a pilot study using a modified Manchester Patient Safety Framework in Dunedin general practices

Patient safety is a major concern, both in hospitals and in primary care settings. The current focus internationally is on the prospect of improving patient safety through cultural transformation. There are no tools designed to assess and strengthen safety culture in New Zealand (NZ) general practices, but a United Kingdom (UK) group have developed a tool--the Manchester Patient Safety Framework (MaPSaF)--to assess safety culture in UK Primary Care Trusts. We aimed to modify the MaPSaF and test its acceptability and utility in the NZ primary care setting. We modified the MaPSaF to suit the NZ context and then used it in 12 Dunedin general practices at baseline and at three months. Participants were all practice personnel present in the practice on the day. Participants rated their practice individually on each of the nine MaPSaF dimensions of safety culture, then discussed the dimensions and their scores and chose a practice-wide consensus score for each dimension in turn. These discussions were recorded, transcribed and analysed to determine acceptability and utility of the modified framework in NZ practices. The framework process took about one hour. Most participants found the process acceptable and useful. The framework directed team discussion about patient safety issues and facilitated communication and prompted some practices to make changes. Some participants from smaller practices deemed the systems advocated in the framework superfluous. The framework can be adapted and used in NZ practices to stimulate learning about safety culture and to facilitate team communication.

Long-term Use of Anti-inflammatory Drugs and Risk of Atrial Fibrillation

Previous reports have described an association between the use of corticosteroids (steroidal anti-inflammatory drugs [SAIDs]) and the risk of atrial fibrillation (AF). We sought to determine the existence of a similar association for non-SAIDs (NSAIDs). We identified patients aged 40 to 89 years with a first-ever diagnosis of AF in 1996 in a United Kingdom primary care database and classified them as having paroxysmal or chronic AF. After validation with their primary care physicians, 1035 patients were confirmed as having incident chronic AF and 525 as having paroxysmal AF. Two separate nested case-control analyses estimated the risk of first-time chronic and paroxysmal AF among users of SAIDs and NSAIDs. We confirmed the previously reported association between current use of SAIDs and chronic AF (rate ratio [RR], 2.49; 95% confidence interval [CI], 1.56-3.97). However, we also found that the current use of NSAIDs was associated with an increased risk of chronic AF (RR, 1.44; 95% CI, 1.08-1.91). Such risk was further increased among long-term users with a treatment duration of longer than 1 year (RR, 1.80; 95% CI, 1.20-2.72). The increased risk of chronic AF was not explained by the occurrence of heart failure. The use of NSAIDs was not associated with paroxysmal AF. The use of NSAIDs, as for SAIDs, is associated with an increased risk of chronic AF. Because the use of anti-inflammatory drugs in general is a marker for underlying inflammatory disorders, inflammation may be the common cause for the use of anti-inflammatory drugs and chronic AF.

Acid-suppressive Drugs and Community-acquired Pneumonia

Acid suppression may increase the risk of community-acquired pneumonia. We investigated this association in the United Kingdom primary care system taking account of the potential for confounding by indication. We identified patients aged 20-79 years in The Health Improvement Network database with a new diagnosis of pneumonia between 2000 and 2005 (n = 7297). Cases were validated by manual review and compared with age- and sex-matched controls (n = 9993). Using unconditional logistic regression, we estimated the relative risk (RR) of pneumonia associated with current use of acid-suppressive drugs compared to nonuse. Newly diagnosed community-acquired pneumonia was increased with current use of proton pump inhibitors (RR = 1.16 [95% confidence interval 1.03-1.31]) but not H2-receptor antagonists (0.98 [0.80-1.20]). An increased risk of pneumonia was evident only in the first 12 months of treatment with proton pump inhibitors. There was some evidence of a dose response. Among patients taking proton pump inhibitors for less than 1 year, the risk of community-acquired pneumonia was stronger when current use was for dyspepsia or peptic ulcer (1.73 [1.29-2.34]) than for gastroesophageal reflux disease or prevention of upper gastrointestinal injury associated with aspirin or nonsteroidal anti-inflammatory drugs (1.22 [0.97-1.52]). We observed a small increase in the risk of community-acquired pneumonia associated with current proton pump inhibitor use, particularly during the first 12 months of treatment and at higher doses. This may be due in part to the underlying indication.

Ethnic Disparities in Coronary Heart Disease Management and Pay for Performance in the UK

Few pay for performance schemes have been subject to rigorous evaluation, and their impact on disparities in chronic disease management is uncertain. To examine disparities in coronary heart disease management and intermediate clinical outcomes within a multiethnic population before and after the introduction of a major pay for performance initiative in April 2004. Comparison of two cross-sectional surveys using electronic general practice records. Thirty-two family practices in south London, United Kingdom (UK). Two thousand eight hundred and ninety-one individuals with coronary heart disease registered with participating practices in 2003 and 3,101 in 2005. Percentage achievement by ethnic group of quality indicators in the management of coronary heart disease The proportion of patients reaching national treatment targets increased significantly for blood pressure (51.2% to 58.9%) and total cholesterol (65.7% to 73.8%) after the implementation of a major pay for performance initiative in April 2004. Improvements in blood pressure control were greater in the black group compared to whites, with disparities evident at baseline being attenuated (black 54.8% vs. white 58.3% reaching target in 2005). Lower recording of blood pressure in the south Asian group evident in 2003 was attenuated in 2005. Statin prescribing remained significantly lower (p < 0.001) in the black group compared with the south Asian and white groups after the implementation of pay for performance (black 74.8%, south Asian 83.8%, white 80.2% in 2005). The introduction of pay for performance incentives in UK primary care has been associated with better and more equitable management of coronary heart disease across ethnic groups.

Responsive regulation of treatment duration in routine practice in United Kingdom primary care settings: Replication in a larger sample.

Replicating a previous study (M. Barkham et al., 2006), the authors examined rates of improvement in psychotherapy in United Kingdom primary care settings as a function of the number of sessions attended. Included in the study were adult clients who returned valid assessments at the beginning and the end of their treatment, had planned endings, began treatment above the clinical cutoff score, and were seen for 20 or fewer sessions (N = 9,703; 72.4% female; 87.7% Caucasian; average age = 40.9 years). Clients' average assessment scores improved substantially across treatment, with a pretreatment-posttreatment effect size of 1.96; 62.0% achieved reliable and clinically significant improvement (RCSI). Clients' mean pretreatment-posttreatment change was approximately constant regardless of treatment duration (in the range of 0 to 20 sessions); the RCSI rate decreased slightly with treatment duration, as fewer clients fell below the cutoff at longer durations. Results were interpreted as suggesting that therapists and clients tend to make appropriately responsive decisions about treatment duration.

M2008 Risk Factors for the Development of Oesophageal Adenocarcinoma: A United Kingdom Primary Care Case-Control Study

M2008 Risk Factors for the Development of Oesophageal Adenocarcinoma: A United Kingdom Primary Care Case-Control Study

Drug treatment discontinuation and achievement of target blood pressure and cholesterol in United Kingdom primary care

ABSTRACTAim: This cohort study evaluated medication discontinuation and target achievement in a United Kingdom primary care setting.Methods: The study population comprised patients within the General Practice Research Database who began treatment for hypertension, dyslipidaemia or both between 1997 and 2001. Discontinuation (absence of prescription refill ≥ 6 months) and reaching treatment targets (blood pressure < 140/90 mmHg, or < 130/80 mmHg in patients with diabetes; total cholesterol < 193 mg/dL [5 mmol/L] or low-density lipoprotein cholesterol < 116 mg/dL [3 mmol/L]) were determined for patients treated for hypertension alone (cohort HT), dyslipidaemia alone (cohort DYS) and both conditions (cohort HT+DYS).Results: At 2 years, 41.3% (95% CI: 40.8, 41.9%) of patients had stopped treatment in cohort HT, 29.2% (27.6, 30.9%) in cohort DYS and 25.0% (24.3, 25.8%) stopped either treatment in cohort HT+DYS. The cumulative proportion reaching treatment targets at this time was 28.2% (27.8, 28.7%) in cohort HT and 49.9% (47.8, 51.9%) in cohort DYS; in cohort HT+DYS, 43.4% (42.6, 44.2%) achieved blood pressure target, 53.7% (52.8, 54.6%) cholesterol target and 24.8% (24.0, 25.5%) reached target for both. Diabetic patients generally stayed on treatment longer and were less likely to attain their blood pressure targets, and more likely to reach cholesterol targets, compared with all patients.Conclusion: Patients prescribed both antihypertensive and lipid-lowering therapy remained on treatment longer; more patients achieved treatment target than those treated for single risk factors. Nevertheless, there is a large unmet need for initiating and maintaining antihypertensive and lipid-lowering therapy in patients with hypertension and dyslipidaemia.

Current management of psoriasis in the United Kingdom: patterns of prescribing and resource use in primary care

The current management of psoriasis and its associated resource use in the United Kingdom (UK) was investigated in this retrospective analysis of 789,300 primary care patient records. Most patients with psoriasis (94%) were managed on topical psoriasis agents only, 4% were prescribed systemic psoriasis agents and 2% had no recorded psoriasis treatment at all during the 12-month study period. Co-medications to treat physical or psychological comorbidities were required by 22% of patients. Referral rates into secondary care were low, 5% of patients prescribed systemic psoriasis agents and 0.7% of patients prescribed topical psoriasis agents had secondary care appointments documented in their medical records. This study demonstrates that most patients with psoriasis in UK primary care are managed on topical agents even though there are surrogate markers, such as resource use and co-medication prescriptions, which indicate that their psoriasis is not optimally controlled.

Information needs of United Kingdom primary care clinicians1

The scope of primary care makes knowledge management in this context very challenging, especially as access to information increases and the role of primary care within the NHS expands. This paper reviews the literature on the information needs of primary care clinicians to enable evidence-based decision making. Drawing on the literature, and using a specific example of a clinical informaticist service, some lessons are drawn on the role of information professionals in facilitating evidence-based health care. Literature review. Case study of clinical informaticist service. There are numerous barriers to clinicians engaging with evidence-based practice. However, providing evidence-based information to clinicians' questions in a user-friendly format has the potential to facilitate changes in practice. The successful implementation of information services requires attention to both academic and service dimensions, fostering closer working relationships between clinicians and information professionals.

P2997 Persistency of lipid-lowering therapy in United Kingdom primary care practices and associated factors

P2997 Persistency of lipid-lowering therapy in United Kingdom primary care practices and associated factors