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Trends in antidepressant prescriptions in children and young people in England, 1998-2017: Protocol of a cohort study using linked primary care and secondary care datasets
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. Introduction: Increasing numbers of children and young people (CYP) are receiving prescriptions for antidepressants. This is the protocol of a study aiming to describe the trends and variation in antidepressant prescriptions in CYP in England, and to examine the indications for the prescriptions recorded and whether there was contact with secondary care specialists on or around the time of the first antidepressant prescription. Methods and analysis: All eligible CYP aged between 5 and 17 years in 1998-2017 from the QResearch primary care database will be included. Incidence and prevalence rates of any antidepressant prescription in each year will be calculated. We will examine four different antidepressant classes: selective serotonin reuptake inhibitors, tricyclic and related antidepressants, serotonin and norepinephrine reuptake inhibitors and other antidepressants, as well as for individual drugs. Linked primary and secondary care data (hospital episode statistics) in the year before and up to 6 months after the first antidepressant prescription will be examined for CYP whose first antidepressant prescription was in 2006-2017. Whether there were records of indications and being seen by psychiatric or paediatric specialists will be identified. Trends over time and differences by region, deprivation and ethnicity will be examined using Poisson regression. Discussion: This large, population-based study will give an up-to-date picture of antidepressant prescribing in CYP and identify any variation. Understanding what indications are recorded when CYP are being prescribed antidepressants, and whether this was done in partnership with secondary care specialists, will provide evidence of whether appropriate guidelines are being followed.
Ontology to identify pregnant women in electronic health records: primary care sentinel network database study.
OBJECTIVE: To develop an ontology to identify pregnant women from computerised medical record systems with dissimilar coding systems in a primary care sentinel network. MATERIALS AND METHODS: We used a three-step approach to develop our pregnancy ontology in two different coding schemata, one hierarchical and the other polyhierarchical. We developed a coding system-independent pregnancy case identification algorithm using the Royal College of General Practitioners Research and Surveillance Centre sentinel network database which held 1.8 million patients' data drawn from 150 primary care providers. We tested the algorithm by examining individual patient records in a 10% random sample of all women aged 29 in each year from 2004 to 2016. We did an external comparison with national pregnancy data. We used χ2 test to compare results obtained for the two different coding schemata. RESULTS: 243 005 women (median age 29 years at start of pregnancy) had 405 591 pregnancies from 2004 to 2016 of which 333 689 went to term. We found no significant difference between results obtained for two populations using different coding schemata. Pregnancy mean ages did not differ significantly from national data. DISCUSSION: This ontologically driven algorithm enables consistent analysis across data drawn from populations using different coding schemata. It could be applied to other hierarchical coding systems (eg, International Classification of Disease) or polyhierarchical systems (eg, SNOMED CT to which our health system is currently migrating). CONCLUSION: This ontological approach will improve our surveillance in particular of influenza vaccine exposure in pregnancy.
© 2019, International Osteoporosis Foundation and National Osteoporosis Foundation. Summary: We investigated the association between bisphosphonate treatment and the risk of stroke using a large routine clinical dataset. We found no association between bisphosphonate treatment and risk of stroke, after adjusting for large number of clinical and demographic confounders. Introduction: There is conflicting evidence on the link between bisphosphonates and stroke with studies variously showing increased, decreased or unchanged risk. We investigated the association between bisphosphonate treatment and the risk of stroke using a large routine clinical dataset. Methods: We used a matched nested case-control study design analysing routinely collected electronic data from patients registered at primary care practices in England participating in the Royal College of General Practitioners Research and Surveillance Centre. Cases were patients aged 18 years or over, either living or dead, recorded as having had a stroke in the period 1 January 2005 to 31 March 2016. Each case was matched to one control according to age, sex, general practice attended and calendar time. Data were analysed using Stata, version 14.2. and RStudio, version 1.1.463. Conditional logistic regression was used to determine odds ratios for stroke according to bisphosphonate treatment and duration in cases compared with controls. We adjusted for disease risk groups, cardiovascular risk factors, treatments, smoking status, alcohol consumption, ethnicity, bisphosphonate types, fracture and socioeconomic status using IMD (Index of Multiple Deprivation). Results: We included 31,414 cases of stroke with an equal number of matched controls. Overall, 83.2% of cases and controls were aged 65 years or older, and there were similar proportions of females (51.5%) and males (48.5%). Bisphosphonate treatment was not associated with stroke after adjusting for the wide range of confounders considered (OR 0.86, 95% CI 0.62–1.19). Conclusions: We found no association between bisphosphonate treatment and risk of stroke, after adjusting for other confounders.
'We're all in the same boat': A qualitative study on how groups work in a diabetes prevention and management programme.
OBJECTIVES:Although many health interventions are delivered in groups, it is unclear how group context can be best used to promote health-related behaviour change and what change processes are most helpful to participants. This study explored participants' experiences of attending type 2 diabetes prevention and management programme, and their perceptions of how group participation influenced changes in diet and physical activity. DESIGN:Qualitative. METHODS:Semi-structured telephone interviews were conducted with 20 participants (twelve men) from nine groups in the Norfolk Diabetes Prevention Study. Interviews were audio-recorded, transcribed verbatim, and analysed using thematic analysis in NVivo. RESULTS:Participants benefited from individual change processes, including information provision, structuring and prioritizing health goals, action planning, self-monitoring, and receiving feedback. They also benefited from group processes, including having a common purpose, sharing experiences, making social comparisons, monitoring and accountability, and providing and receiving social support in the groups. Participants' engagement with, and benefits from, the groups were enhanced when there was a supportive group context (i.e., group cohesion, homogeneous group composition, and a positive group atmosphere). Optimal facilitation to develop an appropriate group context and initiate effective change processes necessitated good facilitator interpersonal and professional skills, credibility and empathy, and effective group facilitation methods. Participants reported developing a sense of responsibility and making behaviour changes that resulted in improvements in health outcomes and weight loss. CONCLUSIONS:This study highlights the role of individual and group processes in facilitating health-promoting behaviour change, and the importance of group context and optimal facilitation in promoting engagement with the programme. Statement of contribution What is already known on this subject? Many health interventions, including programmes to help prevent or manage diabetes and facilitate weight loss, are delivered in groups. Such group-based behaviour-change interventions are often effective in facilitating psychological and behaviour change. There is considerable research and theory on individual change processes and techniques, but less is known about which change processes and techniques facilitate behaviour change in group settings. What does this study add? This study contributes to our understanding of how participating in group-based health programmes may enhance or impede individual behaviour change. It identified individual (intrapersonal) and group (interpersonal, facilitated through group interaction) change processes that were valued by group participants. The findings also show how these change processes may be affected by the group context. A diagram summarizes the identified themes helping to understand interactions between these key processes occurring in groups. The study offers an insight into participants' views on, and experiences of, attending a group-based diabetes prevention and management programme. Thus, it helps better understand how the intervention might have helped them (or not) and what processes may have influenced intervention outcomes. Key practical recommendations for designing and delivering group-based behaviour-change interventions are presented, which may be used to improve future group-based health interventions.
An investigation into the empirical validity of the EQ-5D and SF-6D based on hypothetical preferences in a general population.
BACKGROUND: An important consideration for studies that derive utility scores using multi-attribute utility measures is the psychometric integrity of the measurement instrument. Of particular importance is the requirement to establish the empirical validity of multi-attribute utility measures; that is, whether they generate utility scores that, in practice, reflect people's preferences. We compared the empirical validity of EQ-5D versus SF-6D utility scores based on hypothetical preferences in a large, representative sample of the English population. METHODS: Adult participants in the 1996 Health Survey for England (n=16 443) formed the basis of the investigation. The subjects were asked to complete the EQ-5D and SF-36 measures. Their responses were converted into utility scores using the York A1 tariff set and the SF-6D utility algorithm, respectively. One-way analysis of variance was used to test the hypothetically constructed preference rule that each set of utility scores differs significantly by self-reported health status (categorised as very good, good, fair, bad or very bad). The degree to which EQ-5D and SF-6D utility scores reflect alternative configurations of self-reported health status; illness, disability or infirmity, and medication use was tested using the relative efficiency statistic and receiver operating characteristic (ROC) curves. RESULTS: The mean utility score for the EQ-5D was 0.845 (95% CI: 0.842, 0.849), whilst the mean utility score for the SF-6D was 0.799 (95% CI: 0.797, 0.802), representing a mean difference in utility score of 0.046 (95% CI: 0.044, 0.049; p<0.001). Bland-Altman plots displayed considerable lack of agreement between the two measures, particularly at the lower end of the utility scale. Both measures demonstrated statistically significant differences between subjects who described their health status as very good, good, fair, bad or very bad (p<0.001), as well as monotonically decreasing utility scores (test for linear trend: p<0.001). The SF-6D was between 30.9 and 100.4% more efficient than the EQ-5D at detecting differences in self-reported health status, and between 10.4 and 45.6% more efficient at detecting differences in illness, disability or infirmity and medication use. The area under the curve scores generated by the ROC curves were significantly higher for the SF-6D at the 0.1% significance level when self-reported health status was dichotomised as very good versus good, fair, bad or very bad. However, the AUC scores did not reveal any significant differences in the discriminatory powers of the measures when alternative configurations of illness, disability or infirmity and medication use were examined. CONCLUSIONS: This study provides evidence that the SF-6D is an empirically valid and efficient alternative multi-attribute utility measure to the EQ-5D, and is capable of discriminating between external indicators of health status. However, health economists should also consider other psychometric properties, such as practicality and reliability, when selecting either measure for evaluative purposes.
The importance of reducing childhood undernutrition has been enshrined in the United Nations' Millennium Development Goals. This study explores the relationship between alternative indicators of poverty and childhood undernutrition in developing countries within the context of a multi-national cohort study (Young Lives). Approximately 2000 children in each of four countries - Ethiopia, India (Andhra Pradesh), Peru and Vietnam - had their heights measured and were weighed when they were aged between 6 and 17 months (survey one) and again between 4.5 and 5.5 years (survey two). The anthropometric outcomes of stunted, underweight and wasted were calculated using World Health Organization 2006 reference standards. Maximum-likelihood probit estimation was employed to model the relationship within each country and survey between alternative measures of living standards (principally a wealth index developed using principal components analysis) and each anthropometric outcome. An extensive set of covariates was incorporated into the models to remove as much individual heterogeneity as possible. The fully adjusted models revealed a negative and statistically significant coefficient on wealth for all outcomes in all countries, with the exception of the outcome of wasted in India (Andhra Pradesh) and Vietnam (survey one) and the outcome of underweight in Vietnam (surveys one and two). In survey one, the partial effects of wealth on the probabilities of stunting, being underweight and wasting was to reduce them by between 1.4 and 5.1 percentage points, 1.0 and 6.4 percentage points, and 0.3 and 4.5 percentage points, respectively, with each unit (10%) increase in wealth. The partial effects of wealth on the probabilities of anthropometric outcomes were larger in the survey two models. In both surveys, children residing in the lowest wealth quintile households had significantly increased probabilities of being stunted in all four study countries and of being underweight in Ethiopia, India (Andhra Pradesh) and Peru in comparison to children residing in the highest wealth quintile households. Random effects probit models confirmed the statistical significance of increased wealth in reducing the probability of being stunted and underweight across all four study countries. We conclude that, although multi-faceted, childhood undernutrition in developing countries is strongly rooted in poverty.
Socioeconomic differences in childhood hospital inpatient service utilisation and costs: prospective cohort study.
STUDY OBJECTIVE: To examine the association between socioeconomic position at the time of birth and the use and cost of hospital inpatient services during the first 10 years of life. DESIGN: Analysis of a database of linked birth registrations, hospital records, and death certificates. Associations between the social class of the head of household and hospital inpatient service utilisation and costs during the first 10 years of life were analysed using multilevel multiple regression modelling. PARTICIPANTS AND SETTING: All 117 212 children born to women who both lived and delivered in hospital in Oxfordshire or West Berkshire, southern England, during the period 1 January 1979 to 31 December 1988. MAIN RESULTS: The study showed that children born into social classes II, III-NM, III-M, IV, and V were more likely to be admitted to hospital, spend longer in hospital overall, and generate greater hospital costs than children born into social class I. The adjusted effect regarding hospital inpatient admissions, days, and costs was 1.27 (95% CI: 1.26, 1.27), 1.20 (1.19, 1.21), and 1.50 (1.49, 1.53), respectively, for children born into social class V when compared with children born into social class I. The impact of social class on hospital inpatient admissions, days, and costs was most acutely felt during years 3-10 of life as compared with the first two years of life. CONCLUSIONS: Health service decision makers need to be alert to the adverse sequelae that might result from socioeconomic disadvantage when planning health services for children. Particular attention should be paid to targeting deprived populations with prevention interventions that are known to be effective.
Estimating preference-based health utilities index mark 3 utility scores for childhood conditions in England and Scotland.
BACKGROUND: A common feature of studies that have compiled lists or catalogues of preference-based health-related quality-of-life weights for inclusion within quality-adjusted life years (QALYs) is their focus upon adult populations.More generally, utility measurement in or on behalf of children has been constrained by a number of methodological concerns. OBJECTIVE: To augment previous catalogues of preference-based health-related quality-of-life weights by estimating preference-based Health Utilities Index Mark 3 (HUI3) multiattribute utility scores associated with a wide range of childhood conditions. METHODS: Data for 2236 children from the "Disability Survey 2000: Survey of Young People With a Disability and Sport" formed the basis of this investigation. Ordinary least squares (OLS), Tobit, and censored least absolute deviations(CLAD) regression methods were used to estimate adjusted marginal disutilities for each condition from 2 thresholds: 1) a threshold of 1.0 representing perfect health and 2) a normative childhood utility threshold. RESULTS: Prespecified statistical tests indicated a preference for the OLS regression model over the Tobit and CLAD models. The unadjusted mean, median, 25th percentile and 75th percentile HUI3 multiattribute utility scores and adjusted marginal disutilities are presented for 43 conditions. Notably, based on the OLS estimator, the adjusted marginal disutilities for hydrocephalus; learning and physical disabilities; other syndromes and associations; meningitis, encephalitis, and other infections of the central nervous system; and microcephaly were estimated at -0.889 (95% confidence interval [CI]: -0.727, -1.000), -0.858 (95% CI: -0.727, -0.989), -0.838 (95% CI: -0.668, -1.000), -0.826(95% CI: -0.677, -0.975), and -0.820 (95% CI: -0.670, -0.970), respectively, when a perfect health threshold was applied, and -0.814 (95% CI: -0.656, -0.979), -0.783 (95%CI: -0.656, -0.918), -0.763 (95% CI: -0.597, -0.937), -0.751 (95% CI: -0.606, -0.904), and -0.745 (95% CI: -0.598, -0.899), respectively, when a normative childhood utility threshold was applied. CONCLUSION: Our estimates and their associated distributions can be used for the purposes of QALY estimation by analysts conducting economic evaluations within the childhood context.
The objective of this study was to examine the association between social class of the head of household at the time of birth and mortality and morbidity during the first 10 years of life in a cohort of all 117 212 children born to women who both lived, and delivered in hospital, in Oxfordshire or West Berkshire during the period 1 January 1979 to 31 December 1988. Logistic regression was used to estimate social class gradients, with odds ratios (OR), for mortality during the early neonatal period, late neonatal period, post-neonatal period, post-infancy period and throughout the first 10 years of life. Logistic regression was also used to estimate social class gradients, with ORs, for hospital admission rates for 16 broad groups of diseases during years 0-3, 4-6, 7-10 and throughout the first 10 years of life. Poisson regression was used to estimate social class gradients, with effect sizes, for overall hospital admission rates during years 0-3, 4-6, 7-10 and throughout the first 10 years of life. The study revealed a significant social class gradient in mortality during the first 10 years of life (adjusted OR for each decrement in social class category 1.08; [95% confidence interval 1.03, 1.14]). The study also revealed a significant adjusted social class gradient in hospital admission rates for 14 of the 16 groups of diseases during the first 10 years of life. For the majority of these, the social class gradients had attenuated somewhat by the later childhood years. However, the social class gradient persisted throughout the first 10 years of life for diseases of the respiratory system (1.07 [1.05, 1.08]), diseases of the digestive system (1.06 [1.04, 1.09]), and injury and poisoning (1.07 [1.06, 1.09]). In addition, a significant adjusted social class gradient was found in overall hospital admission rates for each age group studied. This study suggests that there are significant social class inequalities in a wide range of adverse child health outcomes.
Assessing the empirical validity of alternative multi-attribute utility measures in the maternity context.
BACKGROUND: Multi-attribute utility measures are preference-based health-related quality of life measures that have been developed to inform economic evaluations of health care interventions. The objective of this study was to compare the empirical validity of two multi-attribute utility measures (EQ-5D and SF-6D) based on hypothetical preferences in a large maternity population in England. METHODS: Women who participated in a randomised controlled trial of additional postnatal support provided by trained community support workers represented the study population for this investigation. The women were asked to complete the EQ-5D descriptive system (which defines health-related quality of life in terms of five dimensions: mobility, self care, usual activities, pain/discomfort and anxiety/depression) and the SF-36 (which defines health-related quality of life, using 36 items, across eight dimensions: physical functioning, role limitations (physical), social functioning, bodily pain, general health, mental health, vitality and role limitations (emotional)) at six months postpartum. Their responses were converted into utility scores using the York A1 tariff set and the SF-6D utility algorithm, respectively. One-way analysis of variance was used to test the hypothetically-constructed preference rule that each set of utility scores differs significantly by self-reported health status (categorised as excellent, very good, good, fair or poor). The degree to which EQ-5D and SF-6D utility scores reflected alternative dichotomous configurations of self-reported health status and the Edinburgh Postnatal Depression Scale score was tested using the relative efficiency statistic and receiver operating characteristic (ROC) curves. RESULTS: The mean utility score for the EQ-5D was 0.861 (95% CI: 0.844, 0.877), whilst the mean utility score for the SF-6D was 0.809 (95% CI: 0.796, 0.822), representing a mean difference in utility score of 0.052 (95% CI: 0.040, 0.064; p < 0.001). Both measures demonstrated statistically significant differences between subjects who described their health status as excellent, very good, good, fair or poor (p < 0.001), as well as monotonically decreasing utility scores (test for linear trend: p < 0.001). The SF-6D was between 29.1% and 423.6% more efficient than the EQ-5D at detecting differences in self-reported health status, and between 129.8% and 161.7% more efficient at detecting differences in the Edinburgh Postnatal Depression Scale score. In addition, the SF-6D generated higher area under the curve (AUC) scores generated by the ROC curves than the EQ-5D, indicating greater discriminatory power, although in all but one analysis the differences in AUC scores between the measures were not statistically significant. CONCLUSION: This study provides evidence that the SF-6D is an empirically valid and efficient alternative multi-attribute utility measure to the EQ-5D, and is capable of discriminating between external indicators of maternal health.
Dissection of the rib in a flank incision is often tedious and difficult. Entry into the pleural space and subcostal nerve injury are two frequent complications. in an effort to reduce the frequency of these complications and to facilitate the ease of rib dissection and resection, we describe a technique that uses a moistened surgical sponge to dissect free the posterior surface of the rib. (C) 1997, Elsevier Science Inc.
The objectives of this study were to describe the expressed needs for community services of HN-infected individuals by disease stage, gender and transmission category and the barriers which prevent the receipt of such services. Structured interviewer-administered questionnaires concerning a 6-month retrospective period were used to obtain information on need for community services and problems which prevented the receipt of services. The study sample included 70 homosexual men with asymptomatic HN disease, 42 homosexual men with symptomatic non-AIDS, 53 homosexual men with AIDS, 23 heterosexual men, 29 heterosexual women, 9 male and 9 female injecting drug users. The main outcome measures were the extent to which needs for community services were met and person/service combinations for which problems or barriers prevented the receipt of community services. On average, subjects expressed a need for to categories of community services over the 6-month period: homosexuals expressed a mean of 10, heterosexuals 10, injecting drug users II, subjects with asymptomatic HIV infection 9, subjects with symptomatic non-AIDS 11, subjects with AIDS 13, men 9 and women 14. A total of 58% of community service needs were always met, 6% were rarely not met, 16% were sometimes not met, 6% were often not met and 14% were not met at all. The extent to which subjects felt that their needs were met was similar for the different study groups, but the needs of women were met somewhat less frequently than those of men. Similarly, people with AIDS felt that their needs were met slightly less often. Reported levels of unmet need were high for a wide range of services. The most common reason subjects gave for not having received a community service for which they expressed a need was ignorance of where or how to obtain the service. This was mentioned in one-third of aa such cases. Anxieties over the competence with which a service would be rendered was mentioned in 13% of cases and long waiting times in 11%. The frequencies of unmet need for many community services were high and often seemed to arise either fi om a lack of awareness on the part of subjects on how and where services could be obtained or from doubts about the relevance of services offered Both of these barriers should be surmountable through the provision of better information to patients, extending user involvement in service development and the better co-ordination of service delivery through care management approaches.