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Teenagers at risk of unintended pregnancy: Identification of practical risk markers for use in general practice from a retrospective analysis of case records in the United Kingdom
The United Kingdom has one of the highest teenage pregnancy rates in Western Europe with a high proportion of unintended pregnancies resulting in termination. General practice is one source of contraceptive and sexual advice for teenagers but it is difficult to target young women most at risk. This study was performed to determine whether it was possible to identify any markers that could alert general practitioners to the need to give appropriate opportunistic preventive advice. This was a retrospective case-control study in which the general practice medical records of young women with a recorded history of termination of pregnancy resulting from conception between the ages of 13-19 years inclusive were examined for details of consultations and contraceptive provision prior to conception. Where appropriate, comparison was made with an age and practice-matched control group. A total of 53 cases were identified and compared with 159 controls. In the 12 months prior to conception approximately half of the cases had discussed contraception and two-fifths had been prescribed oral contraception. A significantly higher proportion of cases than controls had consulted for emergency contraception and also for urinary tract symptoms. Weaker associations were also found with younger age of starting contraception, and also recorded side-effects or dissatisfaction with contraception. Lapsed contraception and previous pregnancy were noted as other potential markers of risk. The findings from this study may assist primary care professionals in focussing opportunistic sexual health interventions at some teenagers who are at higher risk of unintended pregnancy.
Young people in the United Kingdom (UK) are experiencing sex at an earlier age than ever before and many of these are putting themselves at risk of pregnancy and or sexually transmitted diseases. United Kingdom has a rate of teenage pregnancy at present at 9 per 1,000 for women under 16 years, which is double that of some countries in Europe. This review provides background information on teenage pregnancy in the UK, characteristics of the young women who become pregnant, health and social outcomes, options, the legal aspects, contraception, service aspects, interventions and educational aspects. There is a need for further studies into the differences between the attitudes and sexual behaviour in the UK and other European countries in order to learn, where and how intervention and prevention should take place.
Purpose: Previous studies of the association between hypertension and panic disorder were uncontrolled or involved small numbers of patients. Patients and Methods: We compared the prevalence of panic disorder and panic attacks in 351 patients with documented hypertension who were randomly selected from all hypertensive patients registered in one primary care practice with age- and gender-matched normotensive patients from the same practice and with hypertensive patients attending a hospital clinic. All three groups completed questionnaires for panic disorder based on standard criteria, as well as the Hospital Anxiety and Depression scale.Results: The prevalence of current (previous 6 months) panic attacks was significantly greater in primary care patients with hypertension (17%, P <0.05) and hospital-based hypertensive patients (19%, P <0.01) than in normotensive patients (11%). Similar results were seen for lifetime panic attacks (35% versus 39% versus 22%; both P for comparisons with normotensive patients <0.001). The prevalence of panic disorder was significantly greater in primary care patients with hypertension (13%) than normotensive patients (8%, P <0.05). Anxiety scores were significantly higher in both hypertensive groups than in normotensive patients. Depression scores were significantly higher in hospital-based hypertensive patients than in the other two groups. The reported diagnosis of hypertension antedated the onset of panic attacks in a large majority of patients (P <0.01). Conclusions: Physicians caring for patients with hypertension should be aware of the significantly greater prevalence of panic attacks in these patients. Copyright (C) 1999 Excerpta Medica Inc.
Objective: To investigate recent trends in the recorded incidence, lifetime prevalence and prescribing of symptom relief medication for allergic rhinitis in England. Design: Analysis of primary healthcare datasets. Setting: The UK prevalence of allergic rhinitis has increased very significantly over recent decades. Analysis of primary healthcare datasets offers the possibility to advance understanding about the changing epidemiology and management of allergic rhinitis. QRESEARCH is one of the world's largest national aggregated health databases containing the records of over nine million patients.We extracted data on all patients with a recorded diagnosis of allergic rhinitis and calculated annual age-sex standardized incidence and lifetime period prevalence rates for each year from 2001-2005.We also analysed prescribing trends for antihistamines and drugs used in nasal allergy in those with a recorded diagnosis of allergic rhinitis. Main outcome measures: Age-sex standardized incidence, lifetime prevalence rates and prescribing trends for symptom relief medication for allergic rhinitis in England. Results: The age-sex standardized incidence of allergic rhinitis was 5.57 per 1000 person-years in 2001 and increased by 33.0% to 7.41 per 1000 person-years in 2005 (P<0.001). Lifetime age-sex standardized prevalence of a recorded diagnosis of allergic rhinitis increased by 43.2% from 46.35 per 1000 in 2001 to 66.37 per 1000 in 2005 (P<0.001). Over this period a 41.7% overall increase in prescriptions for antihistamines and drugs used in nasal allergy was observed (antihistamines 45.5%, drugs used in nasal allergies 35.5%). Conclusions: Recorded incidence and lifetime prevalence of allergic rhinitis have increased substantially in recent years. A similar increase in prescriptions for antihistamines and drugs used in nasal allergy in patients with allergic rhinitis is also observed.
A study of the safety and harms of antidepressant drugs for older people: A cohort study using a large primary care database
Objectives: The aim of this study was to establish the relative safety and balance of risks for antidepressant treatment in older people. The study objectives were to (1) determine relative and absolute risks of predefined adverse events in older people with depression, comparing classes of antidepressant drugs [tricyclic and related antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs) and other antidepressants] and commonly prescribed individual drugs with non-use of antidepressant drugs; (2) directly compare the risk of adverse events for SSRIs with TCAs; (3) determine associations with dose and duration of antidepressant medication; (4) describe patterns of antidepressant use in older people with depression; and (5) estimate costs of antidepressant medication and primary care visits. Design: A cohort study of patients aged 65 years and over diagnosed with depression. Setting: The study was based in 570 general practices in the UK supplying data to the QResearch database. Participants: Patients diagnosed with a new episode of depression between the ages of 65 and 100 years, from 1 January 1996 to 31 December 2007. Participants were followed up until 31 December 2008. Interventions: The exposure of interest was treatment with antidepressant medication. Antidepressant drugs were grouped into the major classes and commonly prescribed individual drugs were identified. Main outcome measures: There were 13 predefined outcome measures: all-cause mortality, sudden cardiac death, suicide, attempted suicide/self-harm, myocardial infarction, stroke/transient ischaemic attack (TIA), falls, fractures, upper gastrointestinal bleeding, epilepsy/seizures, road traffic accidents, adverse drug reactions and hyponatraemia. Results: In total, 60,746 patients were included in the study cohort. Of these, 54,038 (89.0%) received at least one prescription for an antidepressant during follow-up. The associations with the adverse outcomes were significantly different between the classes of antidepressant drugs for seven outcomes. SSRIs were associated with the highest adjusted hazard ratios (HRs) for falls [1.66, 95% confidence interval (CI) 1.58 to 1.73] and hyponatraemia (1.52, 95% CI 1.33 to 1.75), and the group of other antidepressants was associated with the highest HRs for all-cause mortality (1.66, 95% CI 1.56 to 1.77), attempted suicide/self-harm (5.16, 95% CI 3.90 to 6.83), stroke/TIA (1.37, 95% CI 1.22 to 1.55), fracture (1.63, 95% CI 1.45 to 1.83) and epilepsy/seizures (2.24, 95% CI 1.60 to 3.15) compared with when antidepressants were not being used. TCAs did not have the highest HR for any of the outcomes. There were also significantly different associations between the individual drugs for seven outcomes, with trazodone, mirtazapine and venlafaxine associated with the highest rates for several of these outcomes. The mean incremental cost (for all antidepressant prescriptions) ranged between £51.58 (amitriptyline) and £641.18 (venlafaxine) over the 5-year post-diagnosis period. Conclusions: This study found associations between use of antidepressant drugs and a number of adverse events in older people. There was no evidence that SSRIs or drugs in the group of other antidepressants were associated with a reduced risk of any of the adverse outcomes compared with TCAs; however, they may be associated with an increased risk for certain outcomes. Among individual drugs trazodone, mirtazapine and venlafaxine were associated with the highest rates for some outcomes. Indication bias and residual confounding may explain some of the study findings. The risks of prescribing antidepressants need to be weighed against the potential benefits of these drugs. © Queen's Printer and Controller of HMSO 2011.
General practice characteristics associated with rates of testing and detection of hepatitis C: Cross-sectional study in Nottingham and Derbyshire
The aim of this study was to determine general practice characteristics associated with testing rates for hepatitis C virus (HCV) and the proportion of tests with a positive result. The study included all patients tested for HCV from all general practices in the primary care trusts in Nottingham and Southern Derbyshire, UK over 2 years. There was a large variation between practices in HCV testing rates and the proportion of positive tests. Single-handed practices had higher testing rates and rates of positive results. Practices where at least half of the GPs were female had higher testing rates but lower positivity rates. The variation observed was not explained by deprivation or rurality of the practice. © British Journal of General Practice 2006.
Objective: To compare the characteristics of smokers who do and do not receive smoking cessation treatment in primary care. Design: Prospective cohort study using practices registered with the pilot QRESEARCH database. Setting: 156 550 patients aged 18 years and over from 39 general practices located within four strategic health authorities, representing the former Trent Region, UK. Subjects: Patients registered with practices between 1 April 2001 and 31 March 2003 aged 18 years and over who were identified as smokers before the two year study period. Outcome: Prescription for smoking cessation treatment (nicotine replacement therapy (NRT) or bupropion) in the two year study period. Variables: Age, sex, deprivation score, co-morbidity. Results: Of the 29 492 patients recorded as current smokers at the start of the study period 1892 (6.4%) were given prescriptions for smoking cessation treatment during the subsequent two years. Of these, 1378 (72.8%) were given NRT alone, 406 (21.5%) bupropion alone, and 108 (5.7%) both treatments. Smokers were more likely to receive smoking cessation treatment if they lived in the most deprived areas (odds ratio (OR) for the most relative to the least deprived fifth, adjusted for sex, age, and co-morbidity, 1.50, 95% confidence interval (CI) 1.26 to 1.78), and if they were aged 25-74 years compared to 18-24 years or 75 and over. Smokers with co-morbidity were also more likely to receive smoking cessation treatment. Smokers were less likely to receive smoking cessation treatment if they were male (adjusted OR 0.68, 95% CI 0.62 to 0.75). Conclusion: The low proportion of smokers being prescribed these products strongly suggests that a major public health opportunity to prevent smoking related illness is being missed.
Trends in the epidemiology of chronic obstructive pulmonary disease in England: A national study of 51 804 patients
Background Patients with chronic obstructive pulmonary disease (COPD) constitute a substantial burden to healthcare services. Analysis of national healthcare datasets offers the possibility to advance understanding about the changing epidemiology of COPD. Aim To investigate the epidemiology of physician-diagnosed COPD in general practice. Design of study Cross-sectional study. Settings A total of 422 general practices in England contributing to the QRESEARCH database. Method Data were extracted on 2.8 million patients, including age, sex, socioeconomic status, and geographical area. Trends over time for recorded physician diagnosis of COPD were analysed (2001-2005). Results There was little change over time in the incidence rate of COPD (2005:2.0 per 1000 patient-years, 95% confidence interval [Cl] = 2.0 to 2.1), but a significant increase in lifetime prevalence rate (2001:13.5 per 1000 patients [95% Cl = 13.4 to 13.7]; 2005: 16.8 [95% Cl= 16.7 to 17.0]; P<0.001). In 2005, 51 804 individuals or one in 59 people in England were recorded with physician-diagnosed COPD. The most deprived people (31.1 per 1000 patients; 95% Cl = 30.6 to 31.7) and those living in the north east of England (29.2 per 1000 patients; 95% Cl = 28.4 to 30.1) had the highest prevalence. The observed reduction in the rate of smoking by patients with COPD (overall decrease: 2.5%; P<0.001) varied according to socioeconomic group (most affluent: 6.5% decrease, most deprived: 1.3% decrease). Conclusion Given the peak in the incidence rate of COPD, we may be approaching the summit of COPD incidence and prevalence in England. However, the number of people affected remains high and poses a major challenge for health services, particularly those in the north east of the country and in the most deprived communities in England. The very limited decrease in smoking rates among the more deprived groups of patients with COPD is also a cause for concern. © British Journal of General Practice.
Derivation and validation of QStroke score for predicting risk of ischaemic stroke in primary care and comparison with other risk scores: A prospective open cohort study
Objective: To develop and validate a risk algorithm (QStroke) to estimate risk of stroke or transient ischaemic attack in patients without prior stroke or transient ischaemic attack at baseline; to compare (a) QStroke with CHADS 2 and CHA2DS2VASc scores in patients with atrial fibrillation and (b) the performance of QStroke with the Framingham stroke score in the full population free of stroke or transient ischaemic attack. Design: Prospective open cohort study using routinely collected data from general practice during the study period 1 January 1998 to 1 August 2012. Setting: 451 general practices in England and Wales contributing to the national QResearch database to develop the algorithm and 225 different QResearch practices to validate the algorithm. Participants: 3.5 million patients aged 25-84 years with 24.8 million person years in the derivation cohort who experienced 77 578 stroke events. For the validation cohort, we identified 1.9 million patients aged 25-84 years with 12.7 million person years who experienced 38 404 stroke events. We excluded patients with a prior diagnosis of stroke or transient ischaemic attack and those prescribed oral anticoagulants at study entry. Main outcome measures: Incident diagnosis of stroke or transient ischaemic attack recorded in general practice records or linked death certificates during follow-up. Risk factors: Self assigned ethnicity, age, sex, smoking status, systolic blood pressure, ratio of total serum cholesterol to high density lipoprotein cholesterol concentrations, body mass index, family history of coronary heart disease in first degree relative under 60 years, Townsend deprivation score, treated hypertension, type 1 diabetes, type 2 diabetes, renal disease, rheumatoid arthritis, coronary heart disease, congestive cardiac failure, valvular heart disease, and atrial fibrillation Results: The QStroke algorithm explained 57% of the variation in women and 55% in men without a prior stroke. The D statistic for QStroke was 2.4 in women and 2.3 in men. QStroke had improved performance on all measures of discrimination and calibration compared with the Framingham score in patients without a prior stroke. Among patients with atrial fibrillation, levels of discrimination were lower, but QStroke had some improved performance on all measures of discrimination compared with CHADS2 and CHA2DS 2VASc. Conclusion: QStroke provides a valid measure of absolute stroke risk in the general population of patients free of stroke or transient ischaemic attack as shown by its performance in a separate validation cohort. QStroke also shows some improvement on current risk scoring methods, CHADS 2 and CHA2DS2VASc, for the subset of patients with atrial fibrillation for whom anticoagulation may be required. Further research is needed to evaluate the cost effectiveness of using these algorithms in primary care.
Purpose: To provide estimates of the number and types of drugs that can be monitored for safety surveillance using electronic healthcare databases. Methods: Using data from eight European databases (administrative claims, medical records) and in the context of a cohort study, we determined the amount of drug exposure required for signal detection across varying magnitudes of relative risk (RR). We provide estimates of the number and types of drugs that can be monitored as a function of actual use, minimal detectable RR, and empirically derived incidence rates for the following adverse events: (i) acute myocardial infarction; (ii) acute renal failure; (iii) anaphylactic shock; (iv) bullous eruptions; (v) rhabdomyolysis; and (vi) upper gastrointestinal bleeding. We performed data simulation to see how expansion of database size would influence the capabilities of such system. Results: Data from 19647452 individuals (59594132person-years follow-up) who used 2289 drugs in the EU-ADR network show that for a frequent event such as acute myocardial infarction, there are 531 drugs (23% of total) for which an association with RR=2, if present, can be investigated. For a rare event such as rhabdomyolysis, there are 19 drugs (1%) for which an association of same magnitude can be investigated. Conclusion: Active surveillance using healthcare data-based networks for signal detection is feasible, although the leverage to do so may be low for infrequently used drugs and for rare outcomes. Extending database network size to include data from heterogeneous populations and increasing follow-up time are warranted to maximize leverage of these surveillance systems. © 2012 John Wiley & Sons, Ltd.
Individualising the risks of statins in men and women in England and Wales: Population-based cohort study
Objective: To derive and validate risk algorithms so that the risks of four clinical outcomes associated with statin use can be estimated for individual patients. Design: Prospective open cohort study using routinely collected data from 368 QResearch general practices in England and Wales to develop the scores. The scores were validated using two separate sets of practices - 188 separate QResearch practices and 364 practices contributing to the THIN database. Subjects: In the QResearch derivation cohort 225 922 new users of statins and 1 778 770 non-users of statins were studied. In the QResearch validation cohort 118 372 statin users and 877 812 non-users of statins were studied. In the THIN validation cohort, we studied 282 056 statin users and 1 923 840 non-users of statins were studied. Methods: Cox proportional hazards models in the derivation cohort to derive risk equations. Measures of calibration and discrimination in both validation cohorts. Outcomes: 5-Year risk of moderate/serious myopathic events; moderate/serious liver dysfunction; acute renal failure and cataract. Results: The performance of three of the risk prediction algorithms in the THIN cohort was very good. For example, in women, the algorithm for moderate/serious myopathy explained 42.15% of the variation. The corresponding D statistics was 1.75. The acute renal failure algorithm explained 59.62% of the variation (D statistic=2.49). The cataract algorithm explained 59.14% of the variation (D statistic=2.46). The algorithms to predict moderate/severe liver dysfunction only explained 15.55% of the variation (D statistics=0.89). The performance of each algorithm was similar for both sexes when tested on the QResearch validation cohort. Conclusions: The algorithms to predict acute renal failure, moderate/serious myopathy and cataract could be used to identify patients at increased risk of these adverse effects enabling patients to be monitored more closely. Further research is needed to develop a better algorithm to predict liver dysfunction.
Objective: To determine the relationship between deprivation and hospital admission rates for unintentional poisoning, by poisoning agent in children aged 0-4 years. Design: Cross sectional study of routinely collected hospital admissions data. Setting: East Midlands, UK. Participants: 1469 admissions due to unintentional poisoning over two years. Main outcome measure: Hospital admission rates for unintentional poisoning. Incidence rate ratios (IRRs) comparing hospital admission rates for poisoning in the most and least deprived electoral wards. Results: Children in the most deprived wards had admission rates for medicinal poisoning that were 2-3 times higher than those in the least deprived wards (IRR 2.49, 95% CI 1.87 to 3.30). Admission rates for non-medicinal poisoning were about twice as high in the most compared to the least deprived wards (IRR 1.77, 95% CI 1.19 to 2.64). Deprivation gradients were particularly steep for benzodiazepines (IRR 5.63, 95% CI 1.72 to 18.40), antidepressants (IRR 4.58, 95% CI 1.80 to 11.66), cough and cold remedies (IRR 3.93, 95% CI 1.67 to 9.24), and organic solvents (IRR 3.69, 95% CI 1.83 to 7.44). Conclusions: There are steep deprivation gradients for admissions to hospital for childhood poisoning, with particularly steep gradients for some psychotropic medicines. Interventions to reduce these inequalities should be directed towards areas of greater deprivation.
Effect of statins on the mortality of patients with ischaemic heart disease: Population based cohort study with nested case-control analysis
Objective: To measure the effect of statins on mortality for community based patients with ischaemic heart disease and determine whether the likely benefits are similar for women, the elderly, and patients with diabetes. Design: Open prospective cohort study with nested case-control analysis. Setting: 1.18 million patients registered with 89 practices spread across 23 strategic health authority areas within the UK. All practices had a minimum of eight years of longitudinal data and were contributing to the UK QRESEARCH database. Subjects: All patients with a first diagnosis of ischaemic heart disease between January 1996 and December 2003 Outcomes: Adjusted hazard ratio with 95% confidence intervals (CIs) for all cause mortality (cohort analysis) and odds ratio (OR) with 95% CI (case-control analysis) for current use of statins. Adjustments were made for current use of aspirin, β blockers, and angiotensin converting enzyme inhibitors, comorbidity (myocardial infarction, diabetes, hypertension, congestive cardiac failure), smoking, body mass index, and quintile of deprivation. Results: 13 029 patients had a first diagnosis of ischaemic heart disease in the study period giving an incidence rate of 3.38/1000 person years. 2266 patients with ischaemic heart disease died during the 43 460 person years of observation giving an overall mortality rate of 52.1/1000 person years (95% CI 50.0 to 54.3). In the case-control analysis, patients taking statins had a 39% lower risk of death than did patients not taking statins (adjusted OR 0.61, 95% CI 0.52 to 0.72) after use of other medication, comorbidity, smoking, body mass index, and deprivation were taken into account. The benefits found in this study compared favourably with those found in the randomised controlled trials, although the current study population is at higher overall risk. The benefits extend to women, patients with diabetes, and the elderly and can be seen within two years of treatment. Longer duration of usage was associated with lower OR for risk of death with a 19% reduction in risk of death with each additional year of treatment (adjusted OR 0.81, 95% CI 0.77 to 0.86 per year). Mortality was similarly reduced among patients prescribed atorvastatin (adjusted OR 0.62, 95% CI 0.48 to 0.79) and simvastatin (adjusted OR 0.62, 95% CI 0.50 to 0.76). Conclusions: The benefits of statins found in randomised controlled trials extend to unselected community based patients. The benefits can be seen within the first two years of treatment and continue to accrue over time. Since patients in the community are likely to be at higher risk than those in trials, the potential benefits from statins are likely to be greater than expected.
Assessing the accuracy of a computerized decision support system for digoxin dosing in primary care: An observational study
Background: This study was carried out as part of a European Union funded project (PharmDIS-e+), to develop and evaluate software aimed at assisting physicians with drug dosing. A drug that causes particular problems with drug dosing in primary care is digoxin because of its narrow therapeutic range and low therapeutic index. Objectives: To determine (i) accuracy of the PharmDIS-e+ software for predicting serum digoxin levels in patients who are taking this drug regularly; (ii) whether there are statistically significant differences between predicted digoxin levels and those measured by a laboratory and (iii) whether there are differences between doses prescribed by general practitioners and those suggested by the program. Methods: We needed 45 patients to have 95% Power to reject the null hypothesis that the mean serum digoxin concentration was within 10% of the mean predicted digoxin concentration. Patients were recruited from two general practices and had been taking digoxin for at least 4 months. Exclusion criteria were dementia, low adherence to digoxin and use of other medications known to interact to a clinically important extent with digoxin. Results: Forty-five patients were recruited. There was a correlation of 0·65 between measured and predicted digoxin concentrations (P < 0·001). The mean difference was 0·12 μg/L (SD 0·26; 95% CI 0·04, 0·19, P = 0·005). Forty-seven per cent of the patients were prescribed the same dose as recommended by the software, 44% were prescribed a higher dose and 9% a lower dose than recommended. Conclusion: PharmDIS-e+ software was able to predict serum digoxin levels with acceptable accuracy in most patients. © 2005 Blackwell Publishing Ltd.