Publications
21 results found
Graul E, Stone P, Massen G, et al., 2023, Determining prescriptions in electronic healthcare record data: methods for development of standardized, reproducible drug codelists, JAMIA Open, Vol: 6, Pages: 1-11, ISSN: 2574-2531
Objective:To develop a standardizable, reproducible method for creating drug codelists that incorporates clinical expertise and is adaptable to other studies and databases. Materials and Methods: We developed methods to generate drug codelists and tested this using the Clinical Practice Research Datalink (CPRD) Aurum database. accounting for missing data in the database. We generated codelists for 1) cardiovascular disease and 2) inhaled Chronic Obstructive Pulmonary Disease (COPD) therapies, applying them to a sample cohort of 335,931 COPD patients. We compared comprehensively searching on all search variables (A) to B) chemical and C) ontological information only.Results: In Search A we determined 165,150 patients prescribed cardiovascular drugs(49.2% of cohort), and 317,963 prescribed COPD inhalers (94.7% of cohort). Considering output per value set, Search C missed substantial prescriptions, including vasodilator anti-hypertensives (A and B:19,696 prescriptions; C:1,145) and SAMA inhalers (A and B:35,310; C:564).Discussion: We recommend the full methods (A) for comprehensiveness. There are special considerations when generating adaptable and generalizable drug codelists, including fluctuating status, cohort-specific drug indications, underlying hierarchical ontology, and statistical analyses. Conclusions: Methods must have end-to-end clinical input, and be standardizable, reproducible, and understandable to all researchers across data contexts.
Stone P, Osen M, Ellis A, et al., 2023, Prevalence of chronic obstructive pulmonary disease in England from 2000 to 2019, The International Journal of Chronic Obstructive Pulmonary Disease, Vol: 2023, Pages: 1565-1574, ISSN: 1176-9106
BackgroundThere is considerable variation in reported chronic obstructive pulmonary disease (COPD) prevalence internationally, partly due to differing definitions in use. Accurate estimates of disease prevalence are important for allocation of healthcare resources, yet UK estimates of COPD prevalence have not been updated for a decade. We calculated yearly COPD prevalence in England between 2000 and 2019 using different definitions of COPD.MethodsWe used routinely collected primary care electronic healthcare record (EHR) data from the Clinical Practice Research Datalink (CPRD) Aurum database linked with secondary care data from the Hospital Episode Statistics (HES) Admitted Patient Care (APC) database. Mid-year point prevalence was calculated yearly from 2000 to 2019 in English adults aged ≥40 years using 5 definitions: (i) validated COPD, (ii) Quality and Outcomes Framework (QOF) COPD, (iii) COPD symptoms, inhaler prescription, and no asthma diagnosis, (iv) hospitalisation with COPD as any diagnosis, (v) hospitalisation with COPD as primary or secondary diagnosis. Prevalence was further stratified by gender, age group, and region.Results12,745,793 people were included over the 20-year period. Annual cohort sizes ranged from 4,373,538 in 2000 to 6,159,496 in 2019. Estimates of COPD prevalence increased every year from 2000 and the difference in estimated prevalence between the validated and QOF definitions has grown over time. In 2019, a COPD prevalence of 4.9% was found using validated events in either primary or secondary care (definition 1 or definition 5). Additionally including potentially undiagnosed cases (definition 3) in the COPD definition produced an increased prevalence of 6.7%.ConclusionCommon definitions of COPD (e.g., QOF codes), may underestimate the true prevalence. The extent of this underestimate has increased over time and could lead to under-allocation of resources where need is estimated based on these definitions. Standardisation of COPD c
Stone P, Osen M, Ellis A, et al., 2023, Prevalence and Description of Chronic Obstructive Pulmonary Disease Cohorts From 2000 to 2019, International Conference of the American-Thoracic-Society (ATS), Publisher: AMER THORACIC SOC, ISSN: 1073-449X
Stone P, Hickman K, Holmes S, et al., 2022, Comparison of COPD primary care in England, Scotland, Wales, and Northern Ireland, npj Primary Care Respiratory Medicine, Vol: 32, ISSN: 2055-1010
Currently the National Asthma and COPD audit programme (NACAP) only undertakes audit of COPD primary care in Wales due to its near complete data coverage. We aimed to determine if the quality of COPD primary care in the other UK nations is comparable with Wales. We found that English, Scottish, and Northern Irish practices were significantly worse than Welsh practices at recording coded lung function parameters used in COPD diagnosis (ORs: 0.51 [0.43–0.59], 0.29 [0.23–0.36], 0.42 [0.31–0.58], respectively) and referring appropriate patients for pulmonary rehabilitation (ORs: 0.10 [0.09–0.11], 0.12 [0.11–0.14], 0.22 [0.19–0.25], respectively). Completing national audits of primary care in Wales only may have led to improvements in care, or at least improvements in the recording of care in Wales that are not occurring elsewhere in the UK. This highlights the potential importance of audit in improving care quality and accurate recording of that care.
Stone P, Minelli C, Feary J, et al., 2022, NEWS2’ as an objective assessment of hospitalised COPD exacerbation severity, International Journal of COPD, Vol: 17, Pages: 763-772, ISSN: 1176-9106
Introduction: There is currently no accepted way to risk-stratify hospitalised exacerbations of chronic obstructive pulmonary disease (COPD). We hypothesised that the revised UK National Early Warning Score (NEWS2) calculated at admission would predict inpatient mortality, need for non-invasive ventilation (NIV) and length-of-stay.Methods: We included data from 52,284 admissions for exacerbation of COPD. Data were divided into development and validation cohorts. Logistic regression was used to examine relationships between admission NEWS2 and outcome measures. Predictive ability of NEWS2 was assessed using area under receiver operating characteristic curves (AUC). We assessed the benefit of including other baseline data in the prediction models and assessed whether these variables themselves predicted admission NEWS2.Results: 53% of admissions had low risk, 24% medium risk and 23% a high risk NEWS2 in the development cohort. The proportions dying as an inpatient were 2.2%, 3.6% and 6.5% by NEWS2 risk category, respectively. The proportions needing NIV were 4.4%, 9.2% and 18.0%, respectively. NEWS2 was poorly predictive of length-of-stay (AUC: 0.59[0.57– 0.61]). In the external validation cohort, the AUC (95% CI) for NEWS2 to predict inpatient death and need for NIV were 0.72 (0.68– 0.77) and 0.70 (0.67– 0.73). Inclusion of patient demographic factors, co-morbidity and COPD severity improved model performance. However, only 1.34% of the variation in admission NEWS2 was explained by these baseline variables.Conclusion: The generic NEWS2 risk assessment tool, readily calculated from simple physiological data, predicts inpatient mortality and need for NIV (but not length-of-stay) at exacerbations of COPD. NEWS2 therefore provides a classification of hospitalised COPD exacerbation severity.
Stone P, Adamson A, Hurst JR, et al., 2022, Does pay-for-performance improve patient outcomes in acute exacerbation of COPD admissions?, Thorax, Vol: 77, Pages: 239-246, 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
MacRae C, Whittaker H, Mukherjee M, et al., 2022, Deriving a standardised recommended respiratory disease codelist repository for future research, Pragmatic and Observational Research, Vol: 13, ISSN: 1179-7266
Background: Electronic health record (EHR) databases provide rich, longitudinal data on interactions with healthcare providers, and can be used to advance research into respiratory conditions. However, since these data are primarily collected to support health care delivery, clinical coding can be inconsistent, resulting in inherent challenges in using these data for research purposes.Methods: We systematically searched existing international literature and UK code repositories to find respiratory disease codelists for asthma from January 2018, and chronic obstructive pulmonary disease 1 and respiratory tract infections from January 2020, based on prior searches. Medline searches using key terms provided article lists. Full-text articles, supplementary files, and reference lists were examined for codelists, and codelists repositories were searched. A reproducible methodology for codelists creation was developed with recommended lists for each disease created based on multidisciplinary expert opinion and previously published literature. Results: Medline searches returned 1,126 asthma articles, 70 COPD articles, and 90 respiratory infection articles, with 3%, 22% and 5% including codelists, respectively. Repository searching returned 12 asthma, 23 COPD, and 64 respiratory infection codelists. We have systematically compiled respiratory disease codelists and from these derived recommended lists for use by researchers to find the most up-to-date and relevant respiratory disease codelists that can be tailored to individual research questions. Conclusions: Few published papers include codelists, and where published diverse codelists were used, even when answering similar research questions. Whilst some advances have been made. greater consistency and transparency across studies using routine data to study respiratory diseases are needed.
Stone PW, Hickman KC, Steiner MC, et al., 2021, Predictors of pulmonary rehabilitation completion in the UK, ERJ Open Research, Vol: 7, Pages: 1-10, ISSN: 2312-0541
Aim Determine characteristics of people with COPD associated with completion of pulmonary rehabilitation (PR).Methods Cross-sectional analysis of 7060 people with COPD enrolled in PR between 03/01/2017 and 31/03/2017. Data were from a UK national audit of COPD care. Factors associated with PR completion were determined using mixed-effects logistic regression with a random intercept for PR service. Factors chosen for assessment based on clinical judgement and data availability were: age, gender, country, SES, Body Mass Index (BMI), referral location, programme type, start within 90 days, smoking status, oxygen therapy, GOLD stage, MRC grade, any exercise test, and any health status questionnaire.Results 4635 (66%) people with COPD completed a PR programme. People that were 60 years or older, resident in Wales, referred within 90 days, an ex- or never smoker, received an exercise test, or received a health status questionnaire had significantly greater odds of completing PR. People that were in the most deprived quintile, underweight or very severely obese, enrolled in a rolling rather than a cohort programme, had a higher GOLD stage, and had a higher MRC grade had significantly lower odds of completing PR.Conclusion People with COPD were more likely to complete PR when best-practice guidelines were followed. People with more severe COPD symptoms and those enrolled in rolling rather than cohort programmes were less likely to complete PR. Referring people with COPD in the earlier stages of disease, ensuring programmes follow best-practice guidelines, and favouring cohort over rolling programmes could improve rates of PR completion.
Stone P, Hickman K, Steiner MC, et al., 2020, Predictors of referral to pulmonary rehabilitation from UK primary care, International Journal of Chronic Obstructive Pulmonary Disease, Vol: 15, Pages: 2941-2952, ISSN: 1178-2005
Background: A large proportion of people with COPD are not referred to pulmonary rehabilitation (PR) despite its proven benefits. No previous studies have examined predictors of referral to PR.Objective: To determine the characteristics of people with COPD associated with referral to PR.Methods: Cross-sectional analysis of a primary care cohort of 82,696 Welsh people with COPD generated as part of a UK national audit of COPD care. Data represent care received by patients as of 31/03/2017. Referral to PR was defined as any code in the patient record indicating referral to PR in the last 3 years. Potential predictors of referral to PR were chosen based on clinical judgement and data availability. Independent predictors of PR referral were determined using backward stepwise mixed-effects logistic regression with a random effect for practice. Variables assessed were: age, gender, deprivation, MRC recorded in past year, MRC grade, smoking status recorded in past year, smoking status, number of exacerbations in past year, inhaled therapy prescription, influenza vaccination, and comorbidities of diabetes, hypertension, coronary heart disease, stroke, heart failure, lung cancer, asthma, bronchiectasis, depression, anxiety, severe mental illness, osteoporosis, and painful condition.Results: A total of 13,297 people (16%) with COPD were referred from primary care for PR. Patients with a comorbidity of bronchiectasis or depression, MRC recorded in the last year, higher MRC grade, more exacerbations in the last year, a greater level of inhaled therapy, an influenza vaccination, or were an ex-smoker had significantly higher odds of referral to PR. Patients that were older, female, more deprived, or had a comorbidity of diabetes, asthma, or painful condition had significantly lower odds of referral to PR.Conclusion: Generally appropriate patients are being prioritised for PR referral; however, it is concerning that women, current smokers, and more deprived patients appear to have
Stone P, Quint J, Roberts CM, et al., 2020, Use of NEWS2 to predict length of stay and in hospital mortality at exacerbation of COPD, 2020 ERS International Congress, Publisher: European Respiratory Society, Pages: 1-2, ISSN: 0903-1936
Background: NEWS2 is a risk score based on routinely collected physiologic measures. We assessed if NEWS2 can be used to predict short-term outcomes for acute exacerbation of COPD (AECOPD) admissions.Methods: Data were collected from 167 English Hospitals participating in the National Asthma and COPD Audit Programme (NACAP) for AECOPD admissions discharged between 01/10/2018 and 30/09/2019. NEWS2 was recorded on arrival to hospital. A mixed-effects logistic regression examined the association between NEWS2 risk category (low, medium, high) and AECOPD outcomes (inpatient mortality, received NIV, length of stay > median [4 days]) using a random effect for hospital. Regression models were adjusted for age, sex, deprivation, GOLD stage, smoking status, history of cardiovascular disease, and history of mental illness.Results: Of the 78302 patients included in the study 4% died during admission, 10% required NIV, and 41% had a length of stay longer than the median. There was a significant increase in odds of death, requirement for NIV, and longer length of stay for each increase in risk category (table).
Stone P, Sood N, Feary J, et al., 2020, Validation of acute exacerbation of chronic obstructive pulmonary disease (COPD) recording in electronic health records: a systematic review protocol, BMJ Open, Vol: 10, ISSN: 2044-6055
Introduction Many patients with chronic obstructive pulmonary disease (COPD) experience a sustained worsening in symptoms termed an acute exacerbation (AECOPD). AECOPDs impact on patients’ quality of life and lung function, are costly to health services and are an important topic for research. Electronic health records (EHR) are increasingly being used to study AECOPD, requiring accurate detection of AECOPD in EHRs to ensure generalisable results. The aim of this protocol is to provide an overview of studies that validate AECOPD definitions used in EHRs and administrative claims databases.Methods and analysis Medline and Embase will be searched for terms related to COPD exacerbation, EHRs and validation. All studies published between 1 January 1990 and 30 September 2019 written in English that validate AECOPD in EHRs and administrative claims databases will be considered. Inclusion criteria: EHR data must be routinely collected; the AECOPD detection algorithm must be compared against a reference standard; and a measure of validity must be calculable. Two independent reviewers will screen articles for inclusion, extract study details and assess risk of bias using QUADAS-2. Disagreements will be resolved by consensus or arbitration by a third reviewer. This protocol has been developed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist.Ethics and dissemination This will be a review of previously published literature therefore no ethical approval is required. Results from this review will be published in a peer-reviewed journal. The results can be used in future research to identify occurrences of AECOPD.
Stone PW, Feary JR, Roberts CM, et al., 2019, HOW DO THE UK COUNTRIES COMPARE FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE PRIMARY CARE?, Winter Meeting of the British-Thoracic-Society, Publisher: BMJ PUBLISHING GROUP, Pages: A72-A73, ISSN: 0040-6376
Stone P, Stone R, Mcmillan V, et al., 2019, Does the COPD Best Practice Tariff improve patient outcomes?, International Congress of the European-Respiratory-Society (ERS), Publisher: EUROPEAN RESPIRATORY SOC JOURNALS LTD, ISSN: 0903-1936
Stone P, Stone R, Mcmillan V, et al., 2019, Does 7-day working improve outcomes for COPD?, International Congress of the European-Respiratory-Society (ERS), Publisher: EUROPEAN RESPIRATORY SOC JOURNALS LTD, ISSN: 0903-1936
Jayatunga W, Stone P, aldridge R, et al., 2019, Code sets for respiratory symptoms in electronic health records (EHR) research: a systematic review protocol, BMJ Open, Vol: 9, ISSN: 2044-6055
Introduction Asthma and chronic obstructive pulmonary disease (COPD) are common respiratory conditions, which result in significant morbidity worldwide. These conditions are associated with a range of non-specific symptoms, which in themselves are a target for health research. Such research is increasingly being conducted using electronic health records (EHRs), but computable phenotype definitions, in the form of code sets or code lists, are required to extract structured data from these large routine databases in a systematic and reproducible way. The aim of this protocol is to specify a systematic review to identify code sets for respiratory symptoms in EHRs research.Methods and analysis MEDLINE and Embase databases will be searched using terms relating to EHRs, respiratory symptoms and use of code sets. The search will cover all English-language studies in these databases between January 1990 and December 2017. Two reviewers will independently screen identified studies for inclusion, and key data will be extracted into a uniform table, facilitating cross-comparison of codes used. Disagreements between the reviewers will be adjudicated by a third reviewer. This protocol has been produced in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guidelines.Ethics and dissemination As a review of previously published studies, no ethical approval is required. The results of this review will be submitted to a peer-reviewed journal for publication and can be used in future research into respiratory symptoms that uses electronic healthcare databases.
Stone P, Baxter N, McMillan V, et al., 2019, What Influences Referral to Pulmonary Rehabilitation from Primary Care: Analysis of National Audit Data, International Conference of the American-Thoracic-Society, Publisher: AMER THORACIC SOC, ISSN: 1073-449X
Stone P, McMillan V, Mortier K, et al., 2019, Do Staffing Levels Influence Provision of Best-Practice Care for Chronic Obstructive Pulmonary Disease?, International Conference of the American-Thoracic-Society, Publisher: AMER THORACIC SOC, ISSN: 1073-449X
Stone P, Steiner M, McMillan V, et al., 2019, Predictors of Pulmonary Rehabilitation Completion in the Chronic Obstructive Pulmonary Disease Population: National Audit Data from the United Kingdom, International Conference of the American-Thoracic-Society, Publisher: AMER THORACIC SOC, ISSN: 1073-449X
Mortier K, Stone RA, McMillan V, et al., 2018, UNDERSTANDING THE IMPACT OF INTRODUCING A BEST PRACTICE TARIFF ON CLINICAL PROCESS STANDARDS IN THE NATIONAL COPD AUDIT PROGRAMME, Winter Meeting of the British-Thoracic-Society, Publisher: BMJ PUBLISHING GROUP, Pages: A29-A30, ISSN: 0040-6376
Stone P, Mcmillan V, Holzhauer-Barrie J, et al., 2018, What's in a postcode? Socioeconomic deprivation in the primary care 2015-17 COPD audit, 28th International Congress of the European-Respiratory-Society (ERS), Publisher: EUROPEAN RESPIRATORY SOC JOURNALS LTD, ISSN: 0903-1936
Garnavos G, McMillan V, Holzhauer-Barrie J, et al., 2018, Severe mental illness in COPD patients: findings from the primary care 2015-17 COPD audit, 28th International Congress of the European-Respiratory-Society (ERS), Publisher: EUROPEAN RESPIRATORY SOC JOURNALS LTD, ISSN: 0903-1936
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