327 results found
Stone P, Adamson A, Hurst JR, et al., 2021, Does pay-for-performance improve patient outcomes in acute exacerbation of COPD admissions?, Thorax, ISSN: 0040-6376
Background: The COPD Best Practice Tariff (BPT) is a pay-for-performance scheme in England that incentivises review by a respiratory specialist within 24 hours of admission and completion of a list of key care components prior to discharge, known as a discharge bundle, for patients admitted with acute exacerbation of COPD (AECOPD). We investigated whether the two components of the COPD BPT were associated with lower 30-day mortality and readmission in people discharged following AECOPD.Methods: Longitudinal study of national audit data containing details of AECOPD admissions in England and Wales between 01 February 2017 and 13 September 2017. Data were linked with national admissions and mortality data. Mixed-effects logistic regression, using a random intercept for hospital to adjust for clustering of patients, was used to determine the relationship between the COPD BPT criteria (combined and separately) and 30-day mortality and readmission. Models were adjusted for age, sex, socioeconomic status, length of stay, smoking status, Charlson comorbidity index, mental illness and requirement for oxygen or noninvasive ventilation during admission.Results: 28 345 patients discharged from hospital following AECOPD were included. 37% of admissions conformed to the two COPD BPT criteria. No relationship was observed between BPT conforming admissions and 30-day mortality (OR: 1.09 (95% CI 0.92 to 1.29)) or readmissions (OR: 0.96 (95% CI 0.90 to 1.02)). No relationship was observed between either of the individual COPD BPT components and 30-day mortality or readmissions. However, a specialist review at any time during admission was associated with lower inpatient mortality (OR: 0.69 (95% CI 0.58 to 0.81)).Conclusion: Completion of the combined COPD BPT criteria does not appear associated with a reduction in 30-day mortality or readmission. However, specialist review was associated with reduced inpatient mortality. While it is difficult to argue that discharge bundles do not im
Whittaker H, Kiddle S, Quint J, 2021, Challenges and pitfalls of using repeat spirometry recordings in routine primary care data to measure FEV1 decline in a COPD population, Pragmatic and Observational Research
BackgroundElectronic healthcare records (EHR) are increasingly used for epidemiological studies but are often viewed as lacking quality compared to randomised control trials and prospective cohorts. Studies of patients with chronic obstructive pulmonary disease (COPD) often use rate of forced expiratory volume in 1 second (FEV1) decline as an outcome however, its definition and robustness in EHR has not be investigated. We aimed to investigate how rate of FEV1 decline differs by the criteria used in an EHR database.MethodsClinical Practice Research Datalink and Hospital Episode Statistics were used. Patient populations were defined using 8 sets of criteria around repeated FEV1 measurements. At a minimum, patients had a diagnosis of COPD, were ≥35 years old, were current or ex-smokers, and had data recorded from 2004. FEV1 measurements recorded during follow-up were identified. Thereafter, eight populations were defined based on criteria around: i) the exclusion of patients or individual measurements with potential measurement error; ii) minimum number of FEV1 measurements; iii) minimum time interval between measurements; iv) specific timing of measurements; v) minimum follow-up time; and vi) the use of linked data. For each population, rate of FEV1 decline was estimated using mixed linear regression. ResultsFor 7/8 patient populations, rates of FEV1 decline (age and sex adjusted) were similar and ranged from -18.7ml/year (95%CI -19.2 to -18.2) to -16.5ml/year (95%CI -17.3 to -15.7). Rates of FEV1 decline in populations that excluded patients with potential measurement error ranged from -79.4ml/year (95%CI -80.7 to -78.2) to -46.8ml/year (95%CI -47.6 to -46.0). ConclusionsFEV1 decline remained similar in a COPD population regardless of number of FEV1 measurements, time intervals between measurements, follow-up period, exclusion of specific FEV1 measurements, and linkage to HES. However, exclusion of individuals with questionable data led to selection bias and fast
Patel K, Li X, Quint J, et al., 2021, Increasing adiposity and the presence of cardiometabolic morbidity is associated with increased Covid-19-related mortality: results from the UK Biobank, BMC Endocrine Disorders, Vol: 21, Pages: 1-6, ISSN: 1472-6823
Background: Although obesity, defined by body mass index (BMI), has been associated with a higher risk of hospitalisation and more severe course of illness in Covid-19 positive patients amongst the British population, it is unclear if this translates into increased mortality. Furthermore, given that BMI is an insensitive indicator of adiposity, the effect of adipose volume on Covid-19 outcomes is also unknown. Methods: We used the UK Biobank repository, which contains clinical and anthropometric data, and is linked to Public Health England Covid-19 healthcare records, to address our research question. We performed age- and sex- adjusted logistic regression and Chi-squared test to compute the odds for Covid-19-related mortality as a consequence of increasing BMI, other more sensitive indices of adiposity such as waist:hip ratio (WHR) and percent body fat, as well as concomitant cardiometabolic illness.Results: 13502 participants were tested for Covid-19 (mean age 70+8 years, 48.9% male). 1,582 tested positive (mean age 68+9 years, 52.8% male), of which 305 died (mean age 75+6 years, 65.5% male). Increasing adiposity was associated with higher odds for Covid-19-related mortality. For every unit increase in BMI, WHR and percent body fat, the odds of death amongst the Covid19-positive participants increased by 1.04 (95% CI 1.01-1.07), 10.71 (95% CI 1.57-73.06) and 1.03 (95% CI 1.01-1.05), respectively (all p<0.05). Referenced to Covid-19 positive participants with a normal weight (BMI 18.5-25kg/m2), Covid-19 positive participants with BMI>35kg/m2 had significantly higher odds of Covid-19-related death (OR 1.70, 95% CI 1.06-2.74, p<0.05). Covid-19-positive participants with metabolic (diabetes, hypertension, dyslipidaemia) or cardiovascular morbidity (atrial fibrillation, angina) also had higher odds of death.Conclusions: Anthropometric indices that are more sensitive to adipose volume and its distribution than BMI, as well as concurrent cardiometabolic illnes
Ngaosuwan K, Johnston DG, Godsland IF, et al., 2021, Increased mortality risk in patients with primary and secondary adrenal insufficiency, Journal of Clinical Endocrinology and Metabolism, Vol: 106, Pages: e2759-e2768, ISSN: 0021-972X
CONTEXT: Mortality data in patients with adrenal insufficiency are inconsistent, possibly due to temporal and geographical differences between patients and their reference populations. OBJECTIVE: To compare mortality risk and causes of death in adrenal insufficiency with an individually-matched reference population. DESIGN: Retrospective cohort study. SETTING: UK general practitioner database (CPRD). PARTICIPANTS: 6821 patients with adrenal insufficiency (primary, 2052; secondary, 3948) and 67564 individually-matched controls (primary, 20366; secondary, 39134). MAIN OUTCOME MEASURES: All-cause and cause-specific mortality; hospital admission from adrenal crisis. RESULTS: With follow-up of 40799 and 406899 person-years for patients and controls respectively, the hazard ratio (HR; [95%CI]) for all-cause mortality was 1.68 [1.58 - 1.77]. HRs were greater in primary (1.83 [1.66 - 2.02]) than in secondary (1.52 [1.40 - 1.64]) disease; (HR; primary versus secondary disease, 1.16 [1.03 - 1.30]). The leading cause of death was cardiovascular disease (HR 1.54 [1.32-1.80]), along with malignant neoplasms and respiratory disease. Deaths from infection were also relatively high (HR 4.00 [2.15 - 7.46]). Adrenal crisis contributed to 10% of all deaths. In the first two years following diagnosis, the patients' mortality rate and hospitalisation from adrenal crisis were higher than in later years. CONCLUSION: Mortality was increased in adrenal insufficiency, especially primary, even with individual matching and was observed early in the disease course. Cardiovascular disease was the major cause but mortality from infection was also high. Adrenal crisis was a common contributor. Early education for prompt treatment of infections and avoidance of adrenal crisis hold potential to reduce mortality.
Zakeri R, Morgan A, Sundaram V, et al., 2021, Under-recognition of heart failure in patients with atrial fibrillation and the impact of gender: A UK population-based cohort study, BMC Medicine, ISSN: 1741-7015
Sydes MR, Barbachano Y, Bowman L, et al., 2021, Realising the full potential of data-enabled trials in the UK: a call for action., BMJ Open, Vol: 11
RATIONALE: Clinical trials are the gold standard for testing interventions. COVID-19 has further raised their public profile and emphasised the need to deliver better, faster, more efficient trials for patient benefit. Considerable overlap exists between data required for trials and data already collected routinely in electronic healthcare records (EHRs). Opportunities exist to use these in innovative ways to decrease duplication of effort and speed trial recruitment, conduct and follow-up. APPROACH: The National Institute of Health Research (NIHR), Health Data Research UK and Clinical Practice Research Datalink co-organised a national workshop to accelerate the agenda for 'data-enabled clinical trials'. Showcasing successful examples and imagining future possibilities, the plenary talks, panel discussions, group discussions and case studies covered: design/feasibility; recruitment; conduct/follow-up; collecting benefits/harms; and analysis/interpretation. REFLECTION: Some notable studies have successfully accessed and used EHR to identify potential recruits, support randomised trials, deliver interventions and supplement/replace trial-specific follow-up. Some outcome measures are already reliably collected; others, like safety, need detailed work to meet regulatory reporting requirements. There is a clear need for system interoperability and a 'route map' to identify and access the necessary datasets. Researchers running regulatory-facing trials must carefully consider how data quality and integrity would be assessed. An experience-sharing forum could stimulate wider adoption of EHR-based methods in trial design and execution. DISCUSSION: EHR offer opportunities to better plan clinical trials, assess patients and capture data more efficiently, reducing research waste and increasing focus on each trial's specific challenges. The short-term emphasis should be on facilitating patient recruitment and for postmarketing authorisation trials where research-relevant outcom
groves D, karsanji U, evans R, et al., 2021, Predicting future health risk in COPD: Differential impact of disease specific and multi-morbidity based risk stratification, International Journal of COPD, Vol: 2021, Pages: 1741-1754, ISSN: 1176-9106
Objective: Multi-morbidity contributes to mortality and hospitalisation in COPD but it is uncertain how this interacts with disease severity in risk prediction. We compared contributions of multi-morbidity and disease severity factors in modelling future health risk using UK primary care healthcare data. Method: Health records from 103,955 patients with COPD identified from the Clinical Practice Research Datalink were analysed. We compared Area Under The Curve (AUC) statistics for logistic regression (LR) models incorporating disease indices with models incorporating categorised co-morbidities. We also compared these models with performance of The John Hopkins Adjusted Clinical Groups® System (ACG) risk prediction algorithm. Results: LR models predicting all-cause mortality outperformed models predicting hospitalisation. Mortality was best predicted by disease severity (AUC & 95% CI: 0.816 (0.805 - 0.827)) and prediction was enhanced only marginally by the addition of multi-morbidity indices (AUC & 95% CI: 0.829 (0.818 – 0.839)). The model combining disease severity and multi-morbidity indices was a better predictor of hospitalisation (AUC & 95% CI: 0.679 (0.672 – 0.686)). ACG derived LR models outperformed conventional regression models for hospitalisation (AUC & 95% CI: 0.697 (0.690 – 0.704)) but not for mortality (AUC & 95% CI: 0.816 (0.805 – 0.827)). Conclusion: Stratification of future health risk in COPD can be undertaken using clinical and demographic data recorded in primary care but the impact of disease severity and multi-morbidity varies depending on the choice of health outcome. A more comprehensive risk modelling algorithm such as ACG offers enhanced prediction for hospitalisation by incorporating a wider range of coded diagnoses.
Roberts CM, Calvert J, Hickman K, et al., 2021, Addressing a system failure to diagnose COPD and asthma., Lancet Respir Med
Hopkinson N, Rossi N, El-Sayed Moustafa JS, et al., 2021, Current smoking and COVID-19 risk: results from a population symptom app in over 2.4 million people, Thorax, Vol: 76, Pages: 714-722, ISSN: 0040-6376
Background: The association between current tobacco smoking, the risk of developing symptomatic COVID-19 and the severity of illness is an important information gap.Methods: UK users of the Zoe COVID Symptom Study App provided baseline data including demographics, anthropometrics, smoking status and medical conditions, and were asked to log their condition daily. Participants who reported that they did not feel physically normal were then asked by the app to complete a series of questions, including 14 potential COVID-19 symptoms and about hospital attendance. The main study outcome was the development of “classic” symptoms of COVID-19 during the pandemic defined as fever, new persistent cough and breathlessness and their association with current smoking. The number of concurrent COVID-19 symptoms was used as a proxy for severity and the pattern of association between symptoms was also compared between smokers and non-smokers. Results: Between 24th March 2020 to 23rd April 2020, data were available on 2,401,982 participants, mean(SD) age 43.6(15.1) years, 63.3% female, overall smoking prevalence 11.0%. 834,437 (35%) participants reported being unwell and entered one or more symptoms. Current smokers were more likely to report symptoms suggesting a diagnosis of COVID-19; classic symptoms adjusted OR[95%CI] 1.14[1.10 to 1.18]; >5 symptoms 1.29[1.26 to 1.31]; >10 symptoms 1.50[1.42 to 1.58]. The pattern of association between reported symptoms did not vary between smokers and non-smokers.Interpretation: These data are consistent with people who smoke being at an increased risk of developing symptomatic COVID-19.
Quint J, O'Leary C, Venerus A, et al., 2021, Development and validation of a method to estimate COPD severity in multiple datasets: a retrospective study, Pulmonary Therapy, Vol: 7, Pages: 119-132, ISSN: 2364-1746
IntroductionOutcomes in chronic obstructive pulmonary disease (COPD) such as symptoms, hospitalisations and mortality rise with increasing disease severity. However, the heterogeneity of electronic medical records presents a significant challenge in measuring severity across geographies. We aimed to develop and validate a method to approximate COPD severity using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 classification scheme, which categorises patients based on forced expiratory volume in 1 s, hospitalisations and the modified Medical Research Council dyspnoea scale or COPD Assessment Test.MethodsThis analysis was part of a comprehensive retrospective study, including patients sourced from the IQVIA Medical Research Data [IMRD; incorporating data from The Health Improvement Network (THIN), a Cegedim database] and the Clinical Practice Research Datalink (CPRD) in the UK, the Disease Analyzer in Germany and the Longitudinal Patient Data in Italy, France and Australia. Patients in the CPRD with the complete set of information required to calculate GOLD 2011 groups were used to develop the method. Ordinal logistic models at COPD diagnosis and at index (first episode of triple therapy) were then used to validate the method to estimate COPD severity, and this was applied to the full study population to estimate GOLD 2011 categories.ResultsOverall, 4579 and 12,539 patients were included in the model at COPD diagnosis and at index, respectively. Models correctly classified 74.4% and 75.9% of patients into severe and non-severe categories at COPD diagnosis and at index, respectively. Age, gender, time between diagnosis and start of triple therapy, healthcare resource use, comorbid conditions and prescriptions were included as covariates.ConclusionThis study developed and validated a method to approximate disease severity based on GOLD 2011 categories that can potentially be used in patients without all the key parameters needed for this calculat
Ratnakumar R, Fraser J, Nicholls R, et al., 2021, Lung nodule management in Covid-19: does postponed surveillance matter?, Publisher: ELSEVIER IRELAND LTD, Pages: S19-S19, ISSN: 0169-5002
Ngaosuwan K, Johnston DG, Godsland IF, et al., 2021, Full Mortality risk in patients with adrenal insufficiency using Prednisolone or Hydrocortisone: A Retrospective Cohort study., J Clin Endocrinol Metab
CONTEXT: Prednisolone has been recommended rather than hydrocortisone for glucocorticoid replacement in adrenal insufficiency due its longer duration of action and lower cost. OBJECTIVE: To determine mortality rates with prednisolone versus hydrocortisone. DESIGN: Observational study. SETTING: A UK primary care database (Clinical Practice Research Datalink). PARTICIPANTS: Patients with primary and secondary adrenal insufficiency, treated with either prednisolone or hydrocortisone, and controls individually matched for age, sex, period and place of follow-up. INTERVENTIONS: Nil. OUTCOMES: Mortality relative to individually matched controls. RESULTS: As expected, mortality in adrenal insufficiency irrespective of cause was increased, based on 5478 patients (4228 on hydrocortisone; 1250 on prednisolone) and 54314 controls (41934 and 12380, respectively). Overall, the adjusted hazard ratio (HR) was similar with the two treatments (prednisolone, 1.76 [95% CI, 1.54-2.01] vs. hydrocortisone 1.69 [1.57-1.82]; p=0.65). This was also the case for secondary adrenal insufficiency. In primary disease (1405 on hydrocortisone vs. 137 on prednisolone:13965 and 1347 controls, respectively), prednisolone-users were older, more likely to have another autoimmune disease and malignancy, and less likely to have mineralocorticoid replacement. Nevertheless, after adjustment, the HR for prednisolone-treated patients remained higher than for those taking hydrocortisone (2.92 [2.19-3.91] vs. 1.90 [1.66-2.16]; p=0.0020). CONCLUSIONS: In primary but not in secondary adrenal insufficiency mortality was higher with prednisolone. The study was large, but the number of prednisolone-treated patients was small, and they had greater risk factors. Nonetheless the increased mortality associated with prednisolone persisted despite statistical adjustment. Further evidence is needed regarding the long-term safety of prednisolone as routine replacement.
Bachtiger P, Adamson A, Maclean WA, et al., 2021, Determinants of Shielding Behaviour During the COVID-19 Pandemic and Associations with Wellbeing in >7,000 NHS Patients: 17-week Longitudinal Observational Study (Preprint), JMIR Public Health and Surveillance
Cook S, Eggen AE, Hopstock L, et al., 2021, Chronic Obstructive Pulmonary Disease (COPD) in population studies in Russia and Norway: comparison of prevalence, awareness and management, International Journal of COPD, Vol: 16, Pages: 1353-1368, ISSN: 1176-9106
Background: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Despite a high prevalence of smoking and respiratory symptoms, two recent population-based studies in Russia found a relatively low prevalence of obstructive lung function. Here, we investigated the prevalence of both obstructive lung disease and respiratory symptoms in a population-based study conducted in two Russian cities and compared the findings with a similar study from Norway conducted in the same time period.Methods: The study population was a sub-sample of participants aged 40– 69 years participating in the Know Your Heart (KYH) study in Russia in 2015– 18 (n=1883) and in the 7th survey of the Tromsø Study (n=5271) carried out in Norway in 2015– 16 (Tromsø 7) who participated in spirometry examinations. The main outcome was obstructive lung function (FEV1/FVC ratio< lower limit of normal on pre-bronchodilator spirometry examination) with and without respiratory symptoms (chronic cough and breathlessness). In those with obstructive lung function, awareness (known diagnosis) and management (use of medications, smoking cessation) were compared.Results: The age-standardized prevalence of obstructive lung function was similar among men in both studies (KYH 11.0% vs Tromsø 7 9.8%, p=0.21) and higher in the Norwegian (9.4%) than Russian (6.8%) women (p=0.006). In contrast, the prevalence of obstructive lung function plus respiratory symptoms was higher in Russian men (KYH 8.3% vs Tromsø 7 4.7%, p< 0.001) but similar in women (KYH 5.9% vs Tromsø 7 6.4%, p=0.18). There was a much higher prevalence of respiratory symptoms in Russian than Norwegian participants of both sexes regardless of presence of obstructive lung function.Conclusion: The prevalence of respiratory symptoms was strikingly high among Russian participants but this was not explained by a higher burden of obstructive lung function on
Gulea C, Quint JK, Zakeri R, 2021, Clinical and methodological considerations when interpreting meta-analyses of beta-blocker use in patients with chronic obstructive pulmonary disease., Eur Heart J
Ngaosuwan K, Johnston DG, Godsland IF, et al., 2021, Cardiovascular disease in patients with primary and secondary adrenal insufficiency and the role of comorbidities, Journal of Clinical Endocrinology and Metabolism, Vol: 106, Pages: 1284-1293, ISSN: 0021-972X
CONTEXT: Mortality studies have established that cardiovascular disease is the leading cause of death in patients with adrenal insufficiency and the risk is greater than that observed in individually-matched controls. OBJECTIVE: Here we have performed a detailed analysis of cardiovascular morbidity and mortality, taking account of the role of co-morbidities. DESIGN: Retrospective cohort study. SETTING: UK general practitioner database (CPRD). PARTICIPANTS: 6821 patients with adrenal insufficiency (primary, 2052; secondary, 3948) compared with 67564 individually-matched controls, with and without adjustment for comorbidities (diabetes, hypertension, dyslipidaemia, previous cardiovascular disease, and smoking). MAIN OUTCOME MEASURES: Composite cardiovascular events recorded in CPRD and cardiovascular mortality in those participants with linked national mortality data. RESULTS: Hazard ratios (95%CI) for composite cardiovascular events in patients with adrenal insufficiency of any cause were 1.28 (1.20-1.36, unadjusted) and 1.07 (1.01-1.14, adjusted). Increased cerebrovascular events in patients with secondary adrenal insufficiency accounted for most of the increased hazard (1.53 (1.34-1.74, adjusted)) and were associated with cranial irradiation therapy. Cardiovascular mortality data were available for 3547 patients and 34944 controls. The adjusted hazard ratio for ischaemic heart disease mortality was 1.86 (1.25-2.78) for primary adrenal insufficiency and 1.39 (1.02-1.89) for secondary. CONCLUSION: Co-morbidities largely accounted for the increased cardiovascular events but in secondary adrenal insufficiency, cerebrovascular events were independently increased and associated with irradiation treatment. However, the risk of cardiovascular mortality remained increased even following adjustment for co-morbidities in both primary and secondary adrenal insufficiency.
Bloom C, Franklin C, Bush A, et al., 2021, Burden of preschool wheeze and progression to asthma in the UK: population-based cohort 2007 to 2017, Journal of Allergy and Clinical Immunology, Vol: 147, Pages: 1949-1958, ISSN: 0091-6749
BackgroundWheeze is one of the most common symptoms of preschool children (age 1 to 5 years), yet we have little understanding of the burden in the UK.ObjectivesDetermine prevalence and pattern of physician-confirmed preschool wheeze, related healthcare utilisation, and factors associated with progression to school-age asthma.MethodsWe used nationally representative primary and secondary care electronic medical records between 2007-2017 to identify preschool children with wheeze. Factors associated with asthma progression were identified in a nested cohort of children with follow-up from 1-2 years of age, until at least 8 years of age.ResultsFrom 1,021,624 preschool children, 69,261 were identified with wheeze. Prevalence of preschool wheeze was 7.7% in 2017. Wheeze events were lowest in August and highest in late-autumn/early-winter. During median follow-up of 2.0 years (IQR 1.2-4.0), 15.8% attended an emergency department, and 13.9% had a hospital admission, for a respiratory disorder. The nested cohort with prolonged follow-up identified 15,085 children; 35.5% progressed to asthma between 5-8 years old. Of children with preschool wheeze, without an asthma diagnosis, 34.9% were prescribed inhaled corticosteroids, and 15.6% oral corticosteroids. The factors most strongly associated with progression to asthma were wheeze frequency and severity, atopy, prematurity, maternal asthma severity and first reported wheeze event occurring in September.ConclusionsPreschool wheeze causes considerable healthcare burden, a large number of children are prescribed asthma medication and have unplanned secondary care visits. Multiple factors influence progression to asthma, including first wheeze event occurring in September.
Axson E, Bottle R, Cowie M, et al., 2021, The relationship between heart failure and the risk of acute exacerbation of COPD, Thorax, ISSN: 0040-6376
Rationale: Heart failure (HF) management in chronic obstructive pulmonary disease (COPD) is often delayed or suboptimal.Objectives: To examine the effect of HF and HF medication use on moderate-to-severe COPD exacerbations.Methods and Measurements: Retrospective cohort studies from 2006-2016 using nationally-representative English primary care electronic healthcare records linked to national hospital and mortality data. COPD patients with diagnosed and possible HF were identified. Possible HF defined as continuous loop diuretic use in the absence of a non-cardiac indication. Incident exposure to HF medications was defined as ≥2 prescriptions within 90 days with no gaps >90 days during ≤6 months of continuous use; prevalent exposure as 6+ months continuous use. HF medications investigated were angiotensin receptor blockers, angiotensin converting enzyme inhibitors, beta-blockers, loop diuretics, and mineralocorticoid receptor antagonists. Cox regression, stratified on sex and age; further adjusted for patient characteristics, was used to determine the association of HF on exacerbation risk.Main Results: 86,795 COPD patients were categorized as; no evidence of HF (n=60,047); possible HF (n=8,476); newly diagnosed HF (n=2,066). Newly diagnosed HF (adjusted hazard ratio (aHR): 1.45, 95% confidence interval (CI): 1.30, 1.62) and possible HF (aHR: 1.65, 95%CI: 1.58, 1.72) similarly increased exacerbation risk. Incident and prevalent use of all HF medications were associated with increased exacerbation risk. Prevalent use was associated with reduced exacerbation risk compared with incident use.Conclusions: Earlier opportunities to improve diagnosis and management of HF in the COPD population are missed. Managing HF may reduce exacerbation risk in the longer term.
Morgan A, Sinnott S-J, Smeeth L, et al., 2021, Concordance in the recording of stroke across UK primary and secondary care datasets: a population-based cohort study, British Journal of General Practice Open, Vol: 5, Pages: 1-11, ISSN: 2398-3795
Background: Previous work has demonstrated that the recording of acute health outcomes, such as myocardial infarction, may be suboptimal in primary healthcare databases. Aim: The aim of this analysis is to assess the completeness and accuracy of the recording of stroke in UK primary care. Design and setting: This is a population-based longitudinal cohort study. Methods: Cases of stroke were identified separately in Clinical Practice Research Datalink (CPRD) primary care records and linked Hospital Episode Statistics (HES). The recording of events in the same patient across the two datasets was compared. The reliability of strategies to identify fatal strokes in primary care and hospital records was also assessed. Results: Of the 75,674 stroke events that were identified in either CPRD or HES data during the period of our study, 54,929 (72.6%) were recorded in CPRD and 51,013 (67.4%) were recorded in HES. Two fifths (n=30,268) of all recorded strokes were found in both datasets (allowing for a time window of 120 days). Among these “matched” strokes the subtype was recorded accurately in approximately 75% of CPRD records (compared to coding in HES): however, 43.5% of ischaemic strokes in HES were coded as “non-specific” strokes in CPRD data. Furthermore, 48% had same day-recordings, and 56% were date-matched within ±1 day. Conclusion: The completeness and accuracy of stroke recording is improved by the use of linked hospital and primary care records. For studies that have a time-sensitive research question, we strongly recommend the use of linked, as opposed to stand-alone, CPRD data.
Buttery SC, Philip KEJ, Williams P, et al., 2021, Patient symptoms and experience following COVID-19: results from a UK wide survey
<jats:title>Summary</jats:title><jats:sec><jats:title>Objectives</jats:title><jats:p>To investigate the experience of people who continue to be unwell after acute COVID-19, often referred to as ‘long COVID’, both in terms of their symptoms and their interactions with healthcare.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>We conducted a mixed-methods analysis (quantitative and qualitative) of responses to a survey accessed through a UK online post-COVID support and information hub between April 2020 and December 2020 about people’s experiences after having acute COVID-19.</jats:p></jats:sec><jats:sec><jats:title>Participants</jats:title><jats:p>Of 3290 respondents, 78% were female, median age range 45-54 years, 92.1% reported white ethnicity; 12.7% had been hospitalised. 494 respondents (16.5%) completed the survey between 4 and 8 weeks of the onset of their symptoms, 641 (21.4%) between 8 and 12 weeks and 1865 (62.1%) more than 12 weeks after.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>The ongoing symptoms most frequently reported were; breathing problems (92.1%), fatigue (83.3%), muscle weakness or joint stiffness (50.6%), sleep disturbances (46.2%), problems with mental abilities (45.9%) changes in mood, including anxiety and depression (43.1%) and cough (42.3%). Symptoms did not appear to be related to the severity of the acute illness or to the presence of pre-existing medical conditions. Analysis of free text responses revealed three main themes (1) Experience of living with COVID-19 – physical and psychological symptoms that fluctuate unpredictably; (2) Interactions with healthcare; (3) Implications for the future – their own condition, society and the healthcare system and the need for research</jats:p></jats:sec><jats:sec&
Quint JK, Bottle A, 2021, The Role of Individual and Neighborhood Factors on Racial Disparity in Respiratory Outcomes Won't You Be My Neighbor?, AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, Vol: 203, Pages: 939-940, ISSN: 1073-449X
Whittaker HR, Gulea C, Koteci A, et al., 2021, Post-acute COVID-19 sequelae in cases managed in the community or hospital in the UK: a population based study
<jats:title>Abstract</jats:title><jats:sec><jats:title>Objective</jats:title><jats:p>To compare post-COVID-19 sequelae between hospitalised and non-hospitalised individuals</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>Population-based cohort study</jats:p></jats:sec><jats:sec><jats:title>Setting</jats:title><jats:p>1,383 general practices in England contributing to Clinical Practice Research Database Aurum</jats:p></jats:sec><jats:sec><jats:title>Participants</jats:title><jats:p>46,687 COVID-19 cases diagnosed between 1<jats:sup>st</jats:sup> August to 17<jats:sup>th</jats:sup> October 2020 (45.4% male; mean age 40), either hospitalised within two weeks of diagnosis or non-hospitalised, and followed-up for a maximum of three months.</jats:p></jats:sec><jats:sec><jats:title>Main outcome measures</jats:title><jats:p>Event rates of new symptoms, diseases, prescriptions and healthcare utilisation in hospitalised and non-hospitalised individuals, with between-group comparison using Cox regression. Outcomes compared at 6 and 12 months prior to index date, equating to first UK wave and pre-pandemic. Non-hospitalised group outcomes stratified by age and sex.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>45,272 of 46,687 people were non-hospitalised; 1,415 hospitalised. Hospitalised patients had higher rates of 13/26 symptoms and 11/19 diseases post-COVID-19 than the community group, received more prescriptions and utilised more healthcare. The largest differences were noted for rates per 100,000 person-weeks [95%CI] of <jats:italic>breathlessness:</jats:italic> 536 [432 to 663] v. 85 [77 to 93]; <jats:italic>joint pain:</jats:italic> 295 [221 to 392] v. 168 [158 to 179]
Kadirvelu B, Burcea G, Quint JK, et al., 2021, Covid-19 does not look like what you are looking for: Clustering symptoms by nation and multi-morbidities reveal substantial differences to the classical symptom triad
<jats:title>ABSTRACT</jats:title><jats:p>COVID-19 is by convention characterised by a triad of symptoms: cough, fever and loss of taste/smell. The aim of this study was to examine clustering of COVID-19 symptoms based on underlying chronic disease and geographical location. Using a large global symptom survey of 78,299 responders in 190 different countries, we examined symptom profiles in relation to geolocation (grouped by country) and underlying chronic disease (single, co- or multi-morbidities) associated with a positive COVID-19 test result using statistical and machine learning methods to group populations by underlying disease, countries, and symptoms. Taking the responses of 7980 responders with a COVID-19 positive test in the top 5 contributing countries, we find that the most frequently reported symptoms differ across the globe: For example, fatigue 4108(51.5%), headache 3640(45.6%) and loss of smell and taste 3563(44.6%) are the most reported symptoms globally. However, symptom patterns differ by continent; India reported a significantly lower proportion of headache (22.8% vs 45.6%, p<0.05) and itchy eyes (7.0% vs. 15.3%, p<0.05) than other countries, as does Pakistan (33.6% vs 45.6%, p<0.05 and 8.6% vs 15.3%, p<0.05). Mexico and Brazil report significantly less of these symptoms. As with geographic location, we find people differed in their reported symptoms, if they suffered from specific underlying diseases. For example, COVID-19 positive responders with asthma or other lung disease were more likely to report shortness of breath as a symptom, compared with COVID-19 positive responders who had no underlying disease (25.3% vs. 13.7%, p<0.05, and 24.2 vs.13.7%, p<0.05). Responders with no underlying chronic diseases were more likely to report loss of smell and tastes as a symptom (46%), compared with the responders with type 1 diabetes (21.3%), Type 2 diabetes (33.5%) lung disease (29.3%), or hype
Mansfield KE, Mathur R, Tazare J, et al., 2021, Indirect acute effects of the COVID-19 pandemic on physical and mental health in the UK: a population-based study, The Lancet Digital Health, Vol: 3, Pages: e217-e230, ISSN: 2589-7500
BACKGROUND: There are concerns that the response to the COVID-19 pandemic in the UK might have worsened physical and mental health, and reduced use of health services. However, the scale of the problem is unquantified, impeding development of effective mitigations. We aimed to ascertain what has happened to general practice contacts for acute physical and mental health outcomes during the pandemic. METHODS: Using de-identified electronic health records from the Clinical Research Practice Datalink (CPRD) Aurum (covering 13% of the UK population), between 2017 and 2020, we calculated weekly primary care contacts for selected acute physical and mental health conditions: anxiety, depression, self-harm (fatal and non-fatal), severe mental illness, eating disorder, obsessive-compulsive disorder, acute alcohol-related events, asthma exacerbation, chronic obstructive pulmonary disease exacerbation, acute cardiovascular events (cerebrovascular accident, heart failure, myocardial infarction, transient ischaemic attacks, unstable angina, and venous thromboembolism), and diabetic emergency. Primary care contacts included remote and face-to-face consultations, diagnoses from hospital discharge letters, and secondary care referrals, and conditions were identified through primary care records for diagnoses, symptoms, and prescribing. Our overall study population included individuals aged 11 years or older who had at least 1 year of registration with practices contributing to CPRD Aurum in the specified period, but denominator populations varied depending on the condition being analysed. We used an interrupted time-series analysis to formally quantify changes in conditions after the introduction of population-wide restrictions (defined as March 29, 2020) compared with the period before their introduction (defined as Jan 1, 2017 to March 7, 2020), with data excluded for an adjustment-to-restrictions period (March 8-28). FINDINGS: The overall population included 9 863 903 individuals
Bachtiger P, Adamson A, Chow J-J, et al., 2021, The Impact of the COVID-19 Pandemic on the Uptake of Influenza Vaccine: UK-Wide Observational Study, Publisher: JMIR PUBLICATIONS, INC
Galani J, Mulder H, Rockhold F, et al., 2021, Association of chronic obstructive pulmonary disease with morbidity and mortality in patients with peripheral artery disease: insights from the EUCLID trial, International Journal of COPD, Vol: 16, Pages: 841-851, ISSN: 1176-9106
Background: Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of developing lower extremity peripheral artery disease (PAD) and suffering PAD-related morbidity and mortality. However, the effect and burden of COPD on patients with PAD is less well defined. This post hoc analysis from EUCLID aimed to analyze the risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in patients with PAD and concomitant COPD compared with those without COPD, and to describe the adverse events specific to patients with COPD.Methods: EUCLID randomized 13,885 patients with symptomatic PAD to monotherapy with either ticagrelor or clopidogrel for the prevention of MACE. In this analysis, MACE, MALE, mortality, and adverse events were compared between groups with and without COPD using unadjusted and adjusted Cox proportional hazards model.Results: Of the 13,883 patients with COPD status available at baseline, 11% (n=1538) had COPD. Patients with COPD had a higher risk of MACE (6.02 vs 4.29 events/100 patient-years; p< 0.001) due to a significantly higher risk of myocardial infarction (MI) (3.55 vs 1.85 events/100 patient-years; p< 0.001) when compared with patients without COPD. These risks persisted after adjustment (MACE: adjusted hazard ratio (aHR) 1.30, 95% confidence interval [CI] 1.11– 1.52; p< 0.001; MI: aHR 1.45, 95% CI 1.18– 1.77; p< 0.001). However, patients with COPD did not have an increased risk of MALE or major bleeding. Patients with COPD were more frequently hospitalized for dyspnea and pneumonia (2.66 vs 0.9 events/100 patient-years; aHR 2.77, 95% CI 2.12– 3.63; p< 0.001) and more frequently discontinued study drug prematurely (19.36 vs 12.54 events/100 patient-years; p< 0.001; aHR 1.34, 95% CI 1.22– 1.47; p< 0.001).Conclusion: In patients with comorbid PAD and COPD, the risks of MACE, respiratory-related adverse events, and premature study drug discontinuation were
Shah S, Quint J, Nwaru B, et al., 2021, Impact of Covid-19 National Lockdown on Asthma Exacerbations: Interrupted Time Series Analysis of English Primary Care Data, Thorax, ISSN: 0040-6376
Background: The impact of Covid-19 and ensuing national lockdown on asthma exacerbations is unclear.Methods: We conducted an interrupted time-series (lockdown on 23rd March as point of interruption) analysis in asthma cohort identified using a validated algorithm from a national-level primary care database, the Optimum Patient Care Database (OPCRD). We derived asthma exacerbation rates for every week and compared exacerbation rates in the period: January-August 2020 with a pre-Covid-19 period; January-August 2016-2019). Exacerbations were defined as asthma-related hospital attendance/admission (including accident and emergency visit), or an acute course of oral corticosteroids with evidence of respiratory review, as recorded in primary care. We used a generalised least squares modelling approach and stratified the analyses by age, sex, English region, and healthcare setting.Results: From a database of 9,949,487 patients, there were 100,165 asthma patients who experienced at least one exacerbation during 2016-2020. Of 278,996 exacerbation episodes, 49,938 (17.1%) required hospital visit. Comparing pre-lockdown to post-lockdown period, we observed a statistically significant reduction in the level (-0.196 episodes per person-year; p-value<0.001; almost 20 episodes for every 100 asthma patients per year) of exacerbation rates across all patients. The reductions in level in stratified analyses were: 0.005-0.244 (healthcare setting, only those without hospital attendance/admission were significant), 0.210-0.277 (sex), 0.159-0.367 (age), 0.068-0.371 (region).Conclusions: There has been a significant reduction in attendance to primary care for asthma exacerbations during the pandemic. This reduction was observed in all age groups, both sexes, and across most regions in England.
wing K, williamson E, carpenter J, et al., 2021, Real world effects of COPD medications: a cohort study with validation against results from randomised controlled trials, European Respiratory Journal, Vol: 57, Pages: 1-13, ISSN: 0903-1936
Real-world data provide the potential for generating evidence on drug treatment effects in groups excluded from trials, but rigorous, validated methodology for doing so is lacking. We investigated whether non-interventional methods applied to real-world data could reproduce results from the landmark TORCH COPD trial.We performed a historical cohort study (2000–2017) of COPD drug treatment effects in the UK Clinical Practice Research Datalink (CPRD). Two control groups were selected from CPRD by applying TORCH inclusion/exclusion criteria and 1:1 matching to TORCH participants: control group 1- people with COPD not prescribed fluticasone propionate-salmeterol (FP-SAL), control group 2- people with COPD prescribed salmeterol (SAL). FP-SAL exposed groups were then selected from CPRD by propensity-score matching to each control group. Outcomes studied were COPD exacerbations, death from any cause and pneumonia.2652 FP-SAL exposed people were propensity-score matched to 2652 FP-SAL unexposed people while 991 FP-SAL exposed people were propensity-score matched to 991 SAL exposed people. Exacerbation rate ratio was comparable to TORCH for FP-SAL versus SAL (0.85, 95% CI 0.74–0.97 versus 0.88, 0.81–0.95) but not for FP-SAL versus no FP-SAL (1.30, 1.19–1.42 versus 0.75, 0.69–0.81). Active comparator results were also consistent with TORCH for mortality (hazard ratio 0.93, 0.65–1.32 versus 0.93, 0.77–1.13) and pneumonia (risk ratio 1.39, 1.04–1.87 versus 1.47, 1.25–1.73).We obtained very similar results to the TORCH trial for active comparator analyses, but were unable to reproduce placebo-controlled results. Application of these validated methods for active comparator analyses to groups excluded from RCTs provides a practical way for contributing to the evidence base and supporting COPD treatment decisions.
lekarz J, Schelbert E, Naish JH, et al., 2021, Mechanisms underlying the association of chronic obstructive pulmonary disease with heart failure, JACC: Cardiovascular Imaging, ISSN: 1876-7591
This data is extracted from the Web of Science and reproduced under a licence from Thomson Reuters. You may not copy or re-distribute this data in whole or in part without the written consent of the Science business of Thomson Reuters.