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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Predicting the risk of acute kidney injury in primary care:
Background Antihypertensives reduce the risk of cardiovascular disease but are also associated with harms including acute kidney injury (AKI). Few data exist to guide clinical decision making regarding these risks. Aim To develop a prediction model estimating the risk of AKI in people potentially indicated for antihypertensive treatment. Design and setting Observational cohort study using routine primary care data from the Clinical Practice Research Datalink (CPRD) in England. Method People aged ≥40 years, with at least one blood pressure measurement between 130 mmHg and 179 mmHg were included. Outcomes were admission to hospital or death with AKI within 1, 5, and 10 years. The model was derived with data from CPRD GOLD (n = 1 772 618), using a Fine–Gray competing risks approach, with subsequent recalibration using pseudo-values. External validation used data from CPRD Aurum (n = 3 805 322). Results The mean age of participants was 59.4 years and 52% were female. The final model consisted of 27 predictors and showed good discrimination at 1, 5, and 10 years (C-statistic for 10-year risk 0.821, 95% confidence interval [CI] = 0.818 to 0.823). There was some overprediction at the highest predicted probabilities (ratio of observed to expected event probability for 10-year risk 0.633, 95% CI = 0.621 to 0.645), affecting patients with the highest risk. Most patients (>95%) had a low 1- to 5-year risk of AKI, and at 10 years only 0.1% of the population had a high AKI and low CVD risk. Conclusion This clinical prediction model enables GPs to accurately identify patients at high risk of AKI, which will aid treatment decisions. As the vast majority of patients were at low risk, such a model may provide useful reassurance that most antihypertensive treatment is safe and appropriate while flagging the few for whom this is not the case.
Disparities in the excess risk of mortality in the first wave of COVID-19: Cross sectional study of the English sentinel network
Objectives: Few studies report contributors to the excess mortality in England during the first wave of coronavirus disease 2019 (COVID-19) infection. We report the absolute excess risk (AER) of mortality and excess mortality rate (EMR) from a nationally representative COVID-19 sentinel surveillance network including known COVID-19 risk factors in people aged 45 years and above. Methods: Pseudonymised, coded clinical data were uploaded from contributing primary care providers (N = 1,970,314, ≥45years). We calculated the AER in mortality by comparing mortality for weeks 2 to 20 this year with mortality data from the Office for National Statistics (ONS) from 2018 for the same weeks. We conducted univariate and multivariate analysis including preselected variables. We report AER and EMR, with 95% confidence intervals (95% CI). Results: The AER of mortality was 197.8/10,000 person years (95%CI:194.30–201.40). The EMR for male gender, compared with female, was 1.4 (95%CI:1.35–1.44, p<0.00); for our oldest age band (≥75 years) 10.09 (95%CI:9.46–10.75, p<0.00) compared to 45–64 year olds; Black ethnicity's EMR was 1.17 (95%CI: 1.03–1.33, p<0.02), reference white; and for dwellings with ≥9 occupants 8.01 (95%CI: 9.46–10.75, p<0.00). Presence of all included comorbidities significantly increased EMR. Ranked from lowest to highest these were: hypertension, chronic kidney disease, chronic respiratory and heart disease, and cancer or immunocompromised. Conclusions: The absolute excess mortality was approximately 2 deaths per 100 person years in the first wave of COVID-19. More personalised shielding advice for any second wave should include ethnicity, comorbidity and household size as predictors of risk.
Impact of changes to national guidelines on hypertension-related workload: An interrupted time series analysis in English primary care
Background In 2011, National Institute for Health and Care Excellence (NICE) guidelines recommended the routine use of out-of-office blood pressure (BP) monitoring for the diagnosis of hypertension. These changes were predicted to reduce unnecessary treatment costs and workload associated with misdiagnosis. Aim To assess the impact of guideline change on rates of hypertension-related consultation in general practice. Design and setting A retrospective open cohort study in adults registered with English general practices contributing to the Clinical Practice Research Datalink between 1 April 2006 and 31 March 2017. Method The primary outcome was the rate of face-to-face, telephone, and home visit consultations related to hypertension with a GP or nurse. Age- and sex-standardised rates were analysed using interrupted time-series analysis. Results In 3 937 191 adults (median follow-up 4.2 years) there were 12 253 836 hypertension-related consultations. The rate of hypertension-related consultation was 71.0 per 100 person–years (95% confidence interval [CI] = 67.8 to 74.2) in April 2006, which remained flat before 2011. The introduction of the NICE hypertension guideline in 2011 was associated with a change in yearly trend (change in trend –3.60 per 100 person–years, 95% CI = –5.12 to –2.09). The rate of consultation subsequently decreased to 59.2 per 100 person–years (95% CI = 56.5 to 61.8) in March 2017. These changes occurred around the time of diagnosis, and persisted when accounting for wider trends in all consultations. Conclusion Hypertension-related workload has declined in the last decade, in association with guideline changes. This is due to changes in workload at the time of diagnosis, rather than reductions in misdiagnosis.
Is the association between blood pressure and mortality in older adults different with frailty? A systematic review and meta-analysis
to investigate whether the association between blood pressure and clinical outcomes is different in older adults with and without frailty, using observational studies. Methods: MEDLINE, EMBASE and CINAHL were searched from 1st January 2000 to 13th June 2018. PROSPERO CRD42017081635. We included all observational studies reporting clinical outcomes in older adults with an average age over 65 years living in the community with and without treatment that measured blood pressure and frailty using validated methods. Two independent reviewers evaluated study quality and risk of bias using the ROBANS tool. We used generic inverse variance modelling to pool risks of all-cause mortality adjusted for age and sex. Results: nine observational studies involving 21,906 older adults were included, comparing all-cause mortality over a mean of six years. Fixed effects meta-analysis of six studies demonstrated that in people with frailty, there was no mortality difference associated with systolic blood pressure <140 mm Hg compared to systolic blood pressure >140 mm Hg (HR 1.02, 95% CI 0.90 to 1.16). In the absence of frailty, systolic blood pressure <140 mm Hg was associated with lower risk of death compared to systolic blood pressure >140 mm Hg (HR 0.86, 95% CI 0.77 to 0.96). Conclusions: evidence from observational studies demonstrates no mortality difference for older people with frailty whose systolic blood pressure is <140 mm Hg, compared to those with a systolic blood pressure >140 mm Hg. Current evidence fails to capture the complexities of blood pressure measurement, and the association with non-fatal outcomes.
Accuracy of ambulatory blood pressure monitors: A systematic review of validation studies
Background: Recent research and guidelines recommend the routine use of ambulatory blood pressure monitoring for the diagnosis of hypertension, so accuracy of such monitors is more important than ever. Aim: To systematically review the literature regarding the accuracy of ambulatory monitors currently in use. Methods: Medline, Embase, Cinahl, the Cochrane database, Medion and the dabl Educational Trust website were searched until February 2011. No language or publication date limits were applied. Data were extracted separately by two independent reviewers. Methodological quality was assessed by whether a validation protocol had been used and followed correctly. Results: From 5420 journal articles identified, 108 met the inclusion criteria. Excluding studies assessing monitors no longer in use, 40 relevant studies were found using 21 different monitors. Thirty-eight (95%) studies used a validation protocol of which 28 studies assessed a monitor in the general population. Of these, protocols were passed in 24 of 28 studies, but 12 of 24 (50%) found a difference of at least 5 mmHg systolic between the test device and the reference standard for 30% or more of the readings. Of the 10 studies conducted in special population groups (e.g. pregnancy, elderly people), only four devices passed the protocols. Only six (16%) studies correctly adhered to the protocols. Conclusion: Published validation studies assessed most ambulatory monitors as accurate, but many failed to adhere to the underlying protocols, undermining this conclusion and peer review standards. Furthermore, most monitors which 'passed' validation showed significant variation in blood pressure from the reference standard, highlighting inadequacies in older validation protocols. Future validation studies should use protocols with simpler methodologies but more rigorous accuracy criteria. © 2013 Wolters Kluwer Health | Lippincott Williams Wilkins.
Does modifying electrode placement of the 12 lead ECG matter in healthy subjects?
Background: Limb electrodes for the 12 lead ECG are routinely placed on the torso during exercise stress testing or when limbs are clinically inaccessible. It is unclear whether such electrode modification produces ECG changes in healthy male or female subjects that are clinically important according to the 2009 AHA, ACCF, HRS guidelines. We therefore measured whether ECG modification produced clinically important or false positive ECG changes e.g., appearance of Q waves in leads V 1-3, ST changes greater than 0.1 mV, T wave changes greater than 0.5 mV (frontal plane) or 1 mV (transverse plane), QRS axis shifts or alterations to QTc/P-R/QRS intervals. Methods: The 12 lead ECG was measured in 18 healthy and semi-recumbent subjects using the standard and Takuma modified limb placements. Results: In the frontal plane we demonstrate that the modification of limb electrode placement produces small Q, R and T wave amplitude and QRS axis changes that are statistically but not clinically significant. In the transverse plane it produces no statistically or clinically significant changes in the ECG or in ST segment morphology, P-R, QRS or QTc intervals. Conclusions: We provide better and more robust evidence that routine modification of limb electrode placement produces only minor changes to the ECG waveform in healthy subjects. These are not clinically significant according to the 2009 guidelines and thus have no effect on the clinical specificity of the 12 lead ECG. © 2010 Elsevier Ireland Ltd. All rights reserved.
The association between prehospital care and in-hospital treatment decisions in acute stroke: A cohort study
Background: Hospital prealerting in acute stroke improves the timeliness of subsequent treatment, but little is known about the impact of prehospital assessments on in-hospital care. Objective: Examine the association between prehospital assessments and notification by emergency medical service staffon the subsequent acute stroke care pathway. Methods: This was a cohort study of linked patient medical records. Consenting patients with a diagnosis of stroke were recruited from two urban hospitals. Data from patient medical records were extracted and entered into a Cox regression analysis to investigate the association between time to CT request and recording of onset time, stroke recognition (using the Face Arm Speech Test (FAST)) and sending of a prealert message. Results: 151 patients (aged 71±15 years) travelled to hospital via ambulance and were eligible for this analysis. Time of symptom onset was recorded in 61 (40%) cases, the FAST test was positive in 114 (75%) and a prealert message was sent in 65 (44%). Following adjustment for confounding, patients who had time of onset recorded (HR 0.73, 95% CI 0.52 to 1.03), were FAST-positive (HR 0.54, 95% CI 0.37 to 0.80) or were prealerted (HR 0.26, 95% CI 0.18 to 0.38), were more likely to receive a timely CT request in hospital. Conclusions: This study highlights the importance of hospital prealerting, accurate stroke recognition, and recording of onset time. Those not recognised with stroke in a prehospital setting appear to be excluded from the possibility of rapid treatment in hospital, even before they have been seen by a specialist. © 2013 BMJ Publishing Group Ltd and the College of Emergency Medicine.
Health care professionals' views on discussing sexual wellbeing with patients who have had a stroke: a qualitative study.
To examine the experiences of health care professionals discussing sexual wellbeing with patients who have had a stroke. In-depth qualitative interview study with purposive sampling and thematic analysis. 30 health care professionals purposively recruited to include different roles and settings along the stroke patient pathway in secondary and primary care. Two hospitals and three general practices in the West Midlands, UK. Sexual wellbeing was a topic that participants did not raise with patients and was infrequently raised by patients. Barriers to raising discussion were on four levels: structural, health care professional, patient, and professional-patient interface. Barriers within these levels included: sexual wellbeing not present within hospital stroke policy; the perception that sexual wellbeing was not within participants' role; participants' concern that raising the issue could cause harm to the patient; and the views that discussion would be inappropriate with older people or unimportant to women. Resources exist to aid discussion but many participants were unaware of them, and most of those that were, did not use them routinely. Participants lacked motivation, ownership, and the confidence and skills to raise sexual wellbeing routinely after stroke. Similar findings have been reported in cancer care and other taboo subjects such as incontinence potentially resulting in a sub-optimal experience for patients. Normalisation of the inclusion of sensitive topics in discussions post-stroke does not seem to need significant structural intervention and simple changes such as information provision and legitimisation through consideration of the issue in standard care policies may be all that is required. The experiences recounted by professionals in this study suggest that such changes are needed now.
Cost-effectiveness of optimizing acute stroke care services for thrombolysis
Background and Purpose - Thrombolysis in acute stroke is effective up to 4.5 hours after symptom onset but relies on early recognition, prompt arrival in hospital, and timely brain scanning. This study aimed to establish the cost-effectiveness of increasing thrombolysis rates through a series of hypothetical change strategies designed to optimize the acute care pathway for stroke. Methods - A decision-tree model was constructed, which relates the acute management of patients with suspected stroke from symptom onset to outcome. Current practice was modeled and compared with 7 change strategies designed to facilitate wider eligibility for thrombolysis. The model basecase consisted of data from consenting patients following the acute stroke pathway recruited in participating hospitals with data on effectiveness of treatment and costs from published sources. Results - All change strategies were cost saving while increasing quality-adjusted life years gained. Using realistic estimates of effectiveness, the change strategy with the largest potential benefit was that of better recording of onset time, which resulted in 3.3 additional quality-adjusted life years and a cost saving of US $46 000 per 100 000 population. All strategies increased the number of thrombolysed patients and the number requiring urgent brain imaging (by 9% to 21% dependent on the scenario). Assuming a willingness-to-pay of US $30 000 per quality-adjusted life year gained, the potential budget available to deliver the interventions in each strategy ranged from US $50 000 to US $144 000. Conclusions - These results suggest that any strategy that increases thrombolysis rates will result in cost savings and improved patient quality of life. Healthcare commissioners could consider this model when planning improvements in stroke care. © 2014 American Heart Association, Inc.
Missed opportunities in prevention of cardiovascular disease in primary care: A cross-sectional study
Background: Screening cardiovascular disease (CVD) risk is an important part of CVD prevention. The success of screening is dependent on the rigour with which treatments are subsequently prescribed. Aim: To establish the extent to which treatment conforms to guidelines. Design and setting: Cross-sectional study of anonymised patient records from 19 general practices in the UK. Method: Data relating to patient characteristics, including CVD risk factors, risk score and prescribed medication were extracted. CVD risk (thus eligibility for cholesterol and blood pressurelowering treatment) was calculated using the Framingham equation. Guideline adherence was defined with descriptive statistics and comparisons by age, sex and disease were made using χ2 tests. Results: Of the 34 975 patients (aged 40-74 years) included in this study, 2550 (7%) patients had existing CVD and 12 349 (35%) had a calculable CVD risk or were on treatment. CVD risk was formally assessed in 8390 (24%) patients. Approximately 7929 (64%) patients eligible for primary prevention therapy were being treated appropriately for their CVD risk. Guideline adherence was higher in younger patients (6284 [69%] aged 40-64 years versus 1645 [50%] aged 65-74 years, P<0.001) and in females (4334 [69%] females versus 3595 [59%] males, P<0.001). There was no difference in guideline adherence between patients where CVD risk had been recorded and those where CVD was calculable. Guideline adherence in patients with existing CVD was highest in patients with ischaemic heart disease (866 [ischaemic heart disease], 52%, versus 288 [stroke], 46%, versus 276 [other CVD], 39%; P<0.001). Conclusion: There is scope for improvement in assessment and treatment for prevention of CVD in clinical practice. Increasing the uptake of evidence-based treatments would improve the cost-effectiveness of CVD risk screening programmes.