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Chronic Obstructive Pulmonary Disease and the Management of Cardiopulmonary Risk in the UK: A Systematic Literature Review and Modified Delphi Study.
Chronic obstructive pulmonary disease (COPD) is linked to increased mortality and morbidity, especially in patients with coexisting cardiovascular disease. These patients face heightened cardiopulmonary risk, which escalates further after acute exacerbations of COPD. While there is some guidance on the management of acute exacerbations of COPD, there is a lack of specific strategies for addressing cardiopulmonary risk in COPD. This program of work aimed to establish UK consensus statements and a clinical pathway for managing cardiopulmonary risk in patients with COPD, synthesizing evidence and expert input through a modified Delphi approach. A multidisciplinary Taskforce conducted a systematic review, focusing on the UK and addressing questions relating to the healthcare burden of acute exacerbations of COPD (AECOPDs), the link between AECOPDs and cardiopulmonary events, the management of cardiopulmonary risk in patients with COPD, and the guidelines and interventions implemented to optimize COPD management. The evidence identified was summarized and used to synthesize preliminary consensus statements reflecting the current situation and recommendations for action. Following iterative voting rounds, consensus was reached on 18 statements. Further to this, a clinical pathway framework to support the recognition and management of cardiopulmonary risk in patients with COPD using the consensus statements was formulated. AECOPDs were identified as a substantial healthcare burden in the UK, contributing to high mortality, frequent healthcare interactions, and elevated costs. These exacerbations were associated with cardiopulmonary events such as myocardial infarction and stroke. Most UK guidelines have focused on the respiratory management of COPD exacerbations, but lack strategies to specifically address cardiopulmonary risk, highlighting the need for integration of care. This consensus program has identified gaps in management, as well as a need to optimize care and reduce the cost of COPD management through the development of new UK policies and clinical guidance.
Disparities in the care and direct-acting oral anticoagulant (DOAC) management in atrial fibrillation (AF) and chronic kidney disease (CKD) in English primary care between 2018 and 2022: Primary care sentinel network database study
Background In England, most prescribing of direct-acting oral anticoagulants (DOACs) for patients with chronic kidney disease (CKD) and atrial fibrillation (AF) takes place in primary care. The 2024 European Society of Cardiology guidelines introduced the AF-CARE ((C) comorbidities and risk factors; (A) avoid stroke and thromboembolism by appropriate prescription of oral anticoagulants; (R) rate and rhythm control; (E) evaluation and reassessment should be individualised for every patient, with a dynamic approach) framework to address this. Objective To describe any health disparities in CKD and AF, including anticoagulation management and correct dosing of DOACs. Methods Using English primary care sentinel network data from 2018 to 2022, demographics of AF and CKD including anticoagulation and appropriate DOAC dosing according to creatinine clearance and other factors were assessed. The study also examined disparities in CKD and AF in relation to socioeconomic status and ethnicity. We defined socioeconomic status by Index of Multiple Deprivation (IMD), a weighted composite index combining information from the domains of deprivation including income. Results Of 10 513 950 people registered with general practices in the sentinel network, 2.9% (n=304 678) were aged ≥18 years with a diagnosis of AF. The prevalence of CKD in AF was 26.0% (n=79 210) and 63.3% of people eligible for anticoagulation were prescribed a DOAC. Among the 54 897 people with AF and CKD 3 or 4, greater likelihood of DOAC prescribing was associated with higher socioeconomic status. Socioeconomic disparities in anticoagulation increased through the 5 years. No association was identified between ethnicity and likelihood of being anticoagulated. In terms of correct dosing, there was no association with socioeconomic status. Overdosing was more frequent than underdosing. Incorrect dosing was associated with male sex (OR 0.80 (95% CI 0.74, 0.86)), dementia (OR 0.94 (0.83, 1.07)) and frailty (OR 0.42 (0.37, 0.48)). Conclusions People in the most deprived IMD quintile were least likely to be anticoagulated. Incorrect DOAC dosing was associated with male sex, increasing frailty and dementia. Socioeconomic and health disparities are apparent in anticoagulation prescribing and should be addressed in line with the AF-CARE framework.
Effect of a 2-week interruption in methotrexate treatment versus continued treatment on COVID-19 booster vaccine immunity in adults with inflammatory conditions (VROOM study): a randomised, open label, superiority trial
This article consists of a citation of a published article describing research funded by the Efficacy and Mechanism Evaluation programme under project number NIHR134607, and is provided as as part of the complete record of research outputs for this project. The original publication is available at: https://doi.org/10.1016/S2213-2600(22)00186-2 Background Immunosuppressive treatments inhibit vaccine-induced immunity against SARS-CoV-2. We evaluated whether a 2-week interruption of methotrexate treatment immediately after the COVID-19 vaccine booster improved antibody responses against the S1 receptor-binding domain (S1-RBD) of the SARS-CoV-2 spike protein compared with uninterrupted treatment in patients with immune-mediated inflammatory diseases. Methods We did an open-label, prospective, two-arm, parallel-group, multicentre, randomised, controlled, superiority trial in 26 hospitals in the UK. We recruited adults from rheumatology and dermatology clinics who had been diagnosed with an immune-mediated inflammatory disease (eg, rheumatoid arthritis, psoriasis with or without arthritis, axial spondyloarthritis, atopic dermatitis, polymyalgia rheumatica, and systemic lupus erythematosus) and who were taking low-dose weekly methotrexate (≤25 mg per week) for at least 3 months. Participants also had to have received two primary vaccine doses from the UK COVID-19 vaccination programme. We randomly assigned the participants (1:1), using a centralised validated computer randomisation program, to suspend methotrexate treatment for 2 weeks immediately after their COVID-19 booster (suspend methotrexate group) or to continue treatment as usual (continue methotrexate group). Participants, investigators, clinical research staff, and data analysts were unmasked, while researchers doing the laboratory analyses were masked to group assignment. The primary outcome was S1-RBD antibody titres 4 weeks after receiving the COVID-19 booster vaccine dose, assessed in the intention-to-treat population. This trial is registered with ISRCT, ISRCTN11442263; following the pre-planned interim analysis, recruitment was stopped early. Findings Between Sept 30, 2021 and March 3, 2022, we recruited 340 participants, of whom 254 were included in the interim analysis and had been randomly assigned to one of the two groups: 127 in the continue methotrexate group and 127 in the suspend methotrexate group. Their mean age was 59·1 years, 155 (61%) were female, 130 (51%) had rheumatoid arthritis, and 86 (34%) had psoriasis with or without arthritis. After 4 weeks, the geometric mean S1-RBD antibody titre was 22 750 U/mL (95% CI 19 314-26 796) in the suspend methotrexate group and 10 798 U/mL (8970-12 997) in the continue methotrexate group, with a geometric mean ratio (GMR) of 2·19 (95% CI 1·57-3·04; p<0·0001; mixed-effects model). The increased antibody response in the suspend methotrexate group was consistent across methotrexate dose, administration route, type of immune-mediated inflammatory disease, age, primary vaccination platform, and history of SARS-CoV-2 infection. There were no intervention-related serious adverse events. Interpretation A 2-week interruption of methotrexate treatment for people with immune-mediated inflammatory diseases resulted in enhanced boosting of antibody responses after COVID-19 vaccination. This intervention is simple, low-cost, and easy to implement, and could potentially translate to increased vaccine efficacy and duration of protection for susceptible groups. Funding National Institute for Health and Care Research. Funding This publication was funded by the Efficacy and Mechanism Evaluation programme as a part of award number NIHR134607. This article reports on one component of the research award Vaccine Response On/Off Methotrexate (VROOM): does temporarily suspending methotrexate treatment for two weeks enhance COVID-19 vaccine response? A randomised controlled trial. For more information about this research please view the award page [https://fundingawards.nihr.ac.uk/award/NIHR134607] DOI https://doi.org/10.1016/S2213-2600(22)00186-2
Presentation of B-cell lymphoma in childhood and adolescence: a systematic review and meta-analysis
Background: The diagnosis of B-cell lymphoma, one of the commonest cancers seen in childhood and adolescence, is challenging. There is a crucial need to identify and delineate the prevalence of associated symptoms in order to improve early diagnosis. Aims: To identify clinical presentations associated with childhood and adolescent B-cell lymphomas and estimate symptom prevalence. Methods: A systematic review of observational studies and meta-analysis of proportions was carried out. Medline and EMBASE were systematically searched, with no language restrictions, from inception to 1st August 2022. Observational studies with at least 10 participants, exploring clinical presentations of any childhood and adolescent lymphoma, were selected. Proportions from each study were inputted to determine the weighted average (pooled) proportion, through random-effects meta-analysis. Results: Studies reported on symptoms, signs and presentation sites at diagnosis of 12,207 children and adolescents up to the age of 20. Hodgkin’s lymphoma most frequently presented with adenopathy in the head-and-neck region (79% [95% CI 58%-91%]), whilst non-Hodgkin’s lymphoma presented abdominally (55% [95% CI 43%-68%]). Symptoms associated with lymphoma included cervical lymphadenopathy (48% [95% CI 20%-77%]), peripheral lymphadenopathy (51% [95% CI 37%-66%]), B-symptoms (40% [95% CI 34%-44%]), fever (43% [95% CI 34%-54%]), abdominal mass (46% [95% CI 29%-64%]), weight loss (53% [95% CI 39%-66%]), head-and-neck mass (21% [95% CI 6%-47%]), organomegaly (29% [95% CI 23%-37%]), night sweats (19% [95% CI 10%-32%]), abdominal pain (28% [95% CI 15%-47%]), bone pain (17% [95% CI 10%-28%]) and abnormal neurology (11% [95% CI 3%-28%]). Conclusion: This systematic review and meta-analysis of proportions provides insight into the heterogeneous clinical presentations of B-cell lymphoma in childhood and adolescence and provides estimates of symptom prevalence. This information is likely to increase public and clinical awareness of lymphoma presentations and aid earlier diagnosis. This review further highlights the lack of studies exploring childhood and adolescent lymphoma presentations in primary care, where patients are likely to present at the earliest stages of their disease.
Identifying early symptoms associated with a diagnosis of childhood, adolescent and young adult cancers: a population-based nested case-control study
Background: Childhood, teenage and young adult (CTYA, 0–24 years) cancers are rare and diverse, making timely diagnosis challenging. We aim to explore symptoms and symptom combinations associated with a subsequent cancer diagnosis and to establish their timeframe. Methods: Using the QResearch Database, we carried out a matched nested case-control study. Associations between pre-specified symptoms encountered in primary care and a subsequent diagnosis of any cancer were explored using conditional logistic regression. Median diagnostic intervals were used to split symptoms into “late” and “early” timeframes to identify relevant early symptoms. Results: 3186 cases and 50,576 controls were identified from a cohort of 3,424,771 CTYA. We identified 12 novel associations, of which hemiparesis [OR 90.9 (95%CI 24.7-335.1), PPV = 1.6%], testicular swelling [OR 186.7 (95%CI 86.1-404.8), PPV = 2.4%] and organomegaly [OR 221.6 (95%CI 28.3-1735.9), PPV = 5.4%] had significant positive predictive values (PPV). Limb pain, a known marker of serious illness in children, was a recurrent early symptom across cancer subtypes. Similar clinical presentations were observed across childhood and TYA cancers. Discussion: Using the largest cohort to date, we provide novel information on the time-varying predictive utility of symptoms in the diagnosis of CTYA cancers. Our findings will help to raise clinical and public awareness of symptoms, stratify those at higher-risk and ultimately aid earlier diagnosis.
Integrating Mobile Health App Data Into Electronic Medical or Health Record Systems and Its Impact on Health Care Delivery and Patient Health Outcomes: Scoping Review.
BACKGROUND: Mobile health (mHealth) apps are increasingly being used to capture patient health data, provide information, and guide self-management, with reported improvements in health care service delivery and outcomes. However, the impact of integrating mHealth app data into electronic medical record or electronic health record (EMR/EHR) systems remains underexplored. OBJECTIVE: This study aims to identify what is known about the impact of integrating mHealth app data into EMR/EHR systems on health care delivery and patient outcomes. METHODS: A scoping review was conducted to identify original studies that investigated the integration of patient-facing mHealth app data into EMR/EHR systems and the impact on health care outcomes. The PubMed, Embase, Web of Science, Cochrane Library, CINAHL, ProQuest, and PsycINFO databases were searched for papers published between January 2014 and July 2024. Two authors independently screened and extracted data on study characteristics, mHealth app features, details of integration with EMR/EHR systems, and effects on health care delivery and patient outcomes. RESULTS: Nineteen studies with 113,135 participants were included. Among these, 6 were randomized clinical trial studies, 8 were conducted in the United States, 12 occurred in hospital settings, 15 involved adult participants, and 6 targeted diabetes management. Main features of the apps and EMR/EHR systems can be categorized into tracking or recording health data (n=19), app data integrated into EMR/EHR systems (n=19), app data summarized or presented on EMR/EHR interface (n=19), communication with the health care team (n=12), reminders or alerts (n=10), synchronization with other apps or devices (n=8), educational information (n=4), and using existing portal credentials to app access (n=2). Most studies reported benefits of integrating the app and EMR/EHR, such as enhanced patient education and self-management (n=5), real-time data recorded and shared with clinicians (n=4), support for clinical decision-making (n=3), improved communication between patients and clinicians (n=7), and improved patient outcomes (n=13). Challenges identified included high drop-off rates in app usage (n=3), limited accessibility due to device restrictions (n=3), incompatibility between mHealth apps and EMR/EHR systems (n=3), increased clinical workload in response to additional information (n=3), data accuracy issues due to network connectivity (n=1), and data security concerns (n=1). CONCLUSIONS: Evidence suggests that the effective integration of mHealth app data into EMR/EHR systems can enhance both clinicians' health care delivery and patients' health outcomes. However, current literature is limited, and future opportunities remain to examine the impact on long-term outcomes, such as mortality, readmissions, and costs, and assess the scalability and sustainability of integration among more broader health conditions and disabilities across diverse health care settings.
The cost-effectiveness of specialist hospital discharge and intermediate care services for patients who are homeless
Background: Recognising the diverse healthcare needs of the population, there is a growing emphasis on tailoring hospital discharge processes to address the unique challenges faced by individuals who are homeless, aiming to enhance the efficiency and effectiveness of post-hospitalisation care for this vulnerable demographic. This study aimed to evaluate the costs and consequences of specialist hospital discharge and intermediate care (support after discharge) services for people who are homeless in England. Methods: We estimated the comparative costs and consequences of different types of specialist care provided by 17 homeless hospital discharge and intermediate care services. We compared ‘clinically-led’ (multidisciplinary) services with those that were ‘housing-led’ (uniprofessional). A retrospective observational study was conducted to estimate effectiveness and costs for two'intervention groups'(clinically-led and housing-led) and a previously published RCT for'standard care'. Use of resources data for specialist care was sourced through linkage with Hospital Episode Statistics. The measure of effectiveness was the number of bed days avoided (in terms of hospital stays for all readmissions in the follow-up period) per homeless user. Additional secondary analysis of three services looked at quality-adjusted life years (QALYs) and service delivery costs. The perspective adopted was NHS in England. Results: Data from the comparative analysis showed that specialist homeless hospital discharge (HHD) care is likely to be cost-effective compared with standard care. Patients accessing specialist care use fewer bed days per year (including both planned and unplanned readmissions). Patients using specialist care have more planned readmissions to hospital and, overall, use more NHS resources than those who use standard care. We interpret this as a positive outcome indicating that specialist care is likely to work more effectively than standard care to improve access to healthcare for this marginalised group. Specialist care remained cost-effective over a range of sensitivity analyses. Secondary analyses of three specific schemes found better QALY outcomes, but results are not generalisable to all 17 schemes. Conclusion: Specialist HHD services are likely to be cost-effective for the NHS compared with standard care, although further research is needed to access patient level data for both costs and outcomes to conduct a rigorous statistical analysis between groups and address possible underlying biases due to data coming from non-randomised study design.
Navigating the complexities of end-stage kidney disease (ESKD) from risk factors to outcome: insights from the UK Biobank cohort
Background: The global prevalence of end-stage kidney disease (ESKD) is increasing despite optimal management of traditional risk factors such as hyperglycaemia, hypertension, and dyslipidaemia. This study examines the influence of cardiorenal risk factors, socioeconomic status, and ethnic and cardiovascular comorbidities on ESKD outcomes in the general population. Methods: This cross-sectional study analysed data from 502,408 UK Biobank study participants recruited between 2006 and 2010. Multivariable logistic regression models were fitted to assess risk factors for ESKD, with results presented as adjusted odds ratio (aOR) and 95% confidence intervals (95% CI). Results: A total of 1191 (0.2%) of the study participants reported ESKD. Diabetes increased ESKD risk by 62% [1.62 (1.36–1.93)], with early-onset diabetes (before age 40) conferring higher odds compared to later-onset (after age 40) [2.26 (1.57–3.24)]. Similarly, early-onset hypertension (before age 40), compared to later onset (after age 40), increased ESKD odds by 73% [1.73 (1.21–2.44)]. Cardiovascular comorbidities, including stroke, hypertension, myocardial infarction and angina, were strongly associated with ESKD [5.97 (3.99–8.72), 5.35 (4.38–6.56), 4.94 (3.56–6.78), and 4.89 (3.47–6.81)], respectively. Males were at 22% higher risk of ESKD than females [1.22 (1.04–1.43)]. Each additional year of diabetes duration increased ESKD odds by 2% [1.02 (1.01–1.03)]. Non-white ethnicity, compared to white and socioeconomically most deprived, compared to the least deprived quintiles, were at 70% and 83% higher odds of ESKD. Each unit of HbA1c rise increased the odds of ESKD by 2%. Compared to microalbuminuria, macroalbuminuria increased the odds of ESKD by almost 10-fold [9.47 (7.95–11.27)] while normoalbuminuria reduced the odds by 73% [0.27 (0.22–0.32)]. Conclusions: Early onset of diabetes and hypertension, male sex, non-white ethnicity, deprivation, poor glycaemic control, and prolonged hyperglycaemia are significant risk factors for ESKD. These findings highlight the complexity of ESKD and the need for multifactorial targeted interventions in high-risk populations. Clinical trial number: Not applicable.
AZD1222 effectiveness against severe COVID-19 in individuals with comorbidity or frailty: The RAVEN cohort study
Objectives: Despite being prioritized during initial COVID-19 vaccine rollout, vulnerable individuals at high risk of severe COVID-19 (hospitalization, intensive care unit admission, or death) remain underrepresented in vaccine effectiveness (VE) studies. The RAVEN cohort study (NCT05047822) assessed AZD1222 (ChAdOx1 nCov-19) two-dose primary series VE in vulnerable populations. Methods: Using the Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub, linked to secondary care, death registration, and COVID-19 datasets in England, COVID-19 outcomes in 2021 were compared in vaccinated and unvaccinated individuals matched on age, sex, region, and multimorbidity. Results: Over 4.5 million AZD1222 recipients were matched (mean follow-up ∼5 months); 68% were ≥50 years, 57% had high multimorbidity. Overall, high VE against severe COVID-19 was demonstrated, with lower VE observed in vulnerable populations. VE against hospitalization was higher in the lowest multimorbidity quartile (91.1%; 95% CI: 90.1, 92.0) than the highest quartile (80.4%; 79.7, 81.1), and among individuals ≥65 years, higher in the ‘fit’ (86.2%; 84.5, 87.6) than the frailest (71.8%; 69.3, 74.2). VE against hospitalization was lowest in immunosuppressed individuals (64.6%; 60.7, 68.1). Conclusions: Based on integrated and comprehensive UK health data, overall population-level VE with AZD1222 was high. VEs were notably lower in vulnerable groups, particularly the immunosuppressed.
Creating a Modified Version of the Cambridge Multimorbidity Score to Predict Mortality in People Older Than 16 Years: Model Development and Validation
Background: No single multimorbidity measure is validated for use in NHS (National Health Service) England’s General Practice Extraction Service Data for Pandemic Planning and Research (GDPPR), the nationwide primary care data set created for COVID-19 pandemic research. The Cambridge Multimorbidity Score (CMMS) is a validated tool for predicting mortality risk, with 37 conditions defined by Read Codes. The GDPPR uses the more internationally used Systematized Nomenclature of Medicine clinical terms (SNOMED CT). We previously developed a modified version of the CMMS using SNOMED CT, but the number of terms for the GDPPR data set is limited making it impossible to use this version. Objective: We aimed to develop and validate a modified version of CMMS using the clinical terms available for the GDPPR. Methods: We used pseudonymized data from the Oxford-Royal College of General Practitioners Research and Surveillance Centre (RSC), which has an extensive SNOMED CT list. From the 37 conditions in the original CMMS model, we selected conditions either with (1) high prevalence ratio (≥85%), calculated as the prevalence in the RSC data set but using the GDPPR set of SNOMED CT codes, divided by the prevalence included in the RSC SNOMED CT codes or (2) conditions with lower prevalence ratios but with high predictive value. The resulting set of conditions was included in Cox proportional hazard models to determine the 1-year mortality risk in a development data set (n=500,000) and construct a new CMMS model, following the methods for the original CMMS study, with variable reduction and parsimony, achieved by backward elimination and the Akaike information stopping criterion. Model validation involved obtaining 1-year mortality estimates for a synchronous data set (n=250,000) and 1-year and 5-year mortality estimates for an asynchronous data set (n=250,000). We compared the performance with that of the original CMMS and the modified CMMS that we previously developed using RSC data. Results: The initial model contained 22 conditions and our final model included 17 conditions. The conditions overlapped with those of the modified CMMS using the more extensive SNOMED CT list. For 1-year mortality, discrimination was high in both the derivation and validation data sets (Harrell C=0.92) and 5-year mortality was slightly lower (Harrell C=0.90). Calibration was reasonable following an adjustment for overfitting. The performance was similar to that of both the original and previous modified CMMS models. Conclusions: The new modified version of the CMMS can be used on the GDPPR, a nationwide primary care data set of 54 million people, to enable adjustment for multimorbidity in predicting mortality in people in real-world vaccine effectiveness, pandemic planning, and other research studies. It requires 17 variables to produce a comparable performance with our previous modification of CMMS to enable it to be used in routine data using SNOMED CT.
COVID-19 vaccine effectiveness against hospitalisation and death of people in clinical risk groups during the Delta variant period: English primary care network cohort study
Background: COVID-19 vaccines have been shown to be highly effective against hospitalisation and death following COVID-19 infection. COVID-19 vaccine effectiveness estimates against severe endpoints among individuals with clinical conditions that place them at increased risk of critical disease are limited. Methods: We used English primary care medical record data from the Oxford-Royal College of General Practitioners Research and Surveillance Centre sentinel network (N > 18 million). Data were linked to the National Immunisation Management Service database, Second Generation Surveillance System for virology test data, Hospital Episode Statistics, and death registry data. We estimated adjusted vaccine effectiveness (aVE) against COVID-19 infection followed by hospitalisation and death among individuals in specific clinical risk groups using a cohort design during the delta-dominant period. We also report mortality statistics and results from our antibody surveillance in this population. Findings: aVE against severe endpoints was high, 14–69d following a third dose aVE was 96.4% (95.1%–97.4%) and 97.9% (97.2%–98.4%) for clinically vulnerable people given a Vaxzevria and Comirnaty primary course respectively. Lower aVE was observed in the immunosuppressed group: 88.6% (79.1%–93.8%) and 91.9% (85.9%–95.4%) for Vaxzevria and Comirnaty respectively. Antibody levels were significantly lower among the immunosuppressed group than those not in this risk group across all vaccination types and doses. The standardised case fatality rate within 28 days of a positive test was 3.9/1000 in people not in risk groups, compared to 12.8/1000 in clinical risk groups. Waning aVE with time since 2nd dose was also demonstrated, for example, Comirnaty aVE against hospitalisation reduced from 96.0% (95.1–96.7%) 14–69days post-dose 2–82.9% (81.4–84.2%) 182days+ post-dose 2. Interpretation: In all clinical risk groups high levels of vaccine effectiveness against severe endpoints were seen. Reduced vaccine effectiveness was noted among the immunosuppressed group.
Implementation of chronic kidney disease guidelines for sodium-glucose co-transporter-2 inhibitor use in primary care in the UK: a cross-sectional study
Background: The cardiovascular and kidney benefits of sodium-glucose co-transporter-2 (SGLT2) inhibitors in people with chronic kidney disease (CKD) are well established. The implementation of updated SGLT2 inhibitor guidelines and prescribing in the real-world CKD population remains largely unknown. Methods: A cross-sectional study of adults with CKD registered with UK primary care practices in the Oxford-Royal College of General Practitioners Research and Surveillance Centre network on the 31st December 2022 was undertaken. Pseudonymised data from electronic health records held securely within the Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub (ORCHID) were extracted. An update to a previously described ontological approach was used to identify the study population, using a combination of Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) indicating a diagnosis of CKD and laboratory confirmed CKD based on Kidney Disease: Improving Global Outcomes (KDIGO) diagnostic criteria. We examined the extent to which SGLT2 inhibitor guidelines apply to and are then implemented in adults with CKD. A logistic regression model was used to identify factors associated with SGLT2 inhibitor prescribing, reported as odds ratios (ORs) with 95% confidence intervals (CI). The four guidelines under investigation were the United Kingdom Kidney Association (UKKA) Clinical Practice Guideline SGLT2 Inhibition in Adults with Kidney Disease (October 2021), American Diabetes Association (ADA) and KDIGO Consensus Report on Diabetes Management in CKD (October 2022), National Institute for Health and Care Excellence (NICE) Guideline Type 2 Diabetes in Adults: Management (June 2022), and NICE Technology Appraisal Dapagliflozin for Treating CKD (March 2022). Findings: Of 6,670,829 adults, we identified 516,491 (7.7%) with CKD, including 32.8% (n = 169,443) who had co-existing type 2 diabetes (T2D). 26.8% (n = 138,183) of the overall CKD population had a guideline directed indication for SGLT2 inhibitor treatment. A higher proportion of people with CKD and co-existing T2D were indicated for treatment, compared to those without T2D (62.8% [n = 106,468] vs. 9.1% [n = 31,715]). SGLT2 inhibitors were prescribed to 17.0% (n = 23,466) of those with an indication for treatment, and prescriptions were predominantly in those with co-existing T2D; 22.0% (n = 23,464) in those with T2D, and <0.1% (n = 2) in those without T2D. In adjusted multivariable analysis of people with CKD and T2D, females (OR 0.69, 95% CI 0.67–0.72, p <0.0001), individuals of Black ethnicity (OR 0.84, 95% CI 0.77–0.91, p <0.0001) and those of lower socio-economic status (OR 0.72, 95% CI 0.68–0.76, p <0.0001) were less likely to be prescribed an SGLT2 inhibitor. Those with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 had a lower likelihood of receiving an SGLT2 inhibitor, compared to those with an eGFR ≥60 mL/min/1.73 m2 (eGFR 45–60 mL/min/1.73 m2 OR 0.65, 95% CI 0.62–0.68, p <0.0001, eGFR 30–45 mL/min/1.73 m2 OR 0.73, 95% CI 0.69–0.78, p <0.0001, eGFR 15–30 mL/min/1.73 m2 OR 0.52, 95% CI 0.46–0.60, p <0.0001, eGFR <15 mL/min/1.73 m2 OR 0.03, 95% CI 0.00–0.23, p = 0.0037, respectively). Those with albuminuria (urine albumin-to-creatinine ratio 3–30 mg/mmol) were less likely to be prescribed an SGLT2 inhibitor, compared to those without albuminuria (OR 0.78, 95% CI 0.75–0.82, p <0.0001). Interpretation: SGLT2 inhibitor guidelines in CKD have not yet been successfully implemented into clinical practice, most notably in those without co-existing T2D. Individuals at higher risk of adverse outcomes are paradoxically less likely to receive SGLT2 inhibitor treatment. The timeframe between the publication of guidelines and data extraction may have been too short to observe changes in clinical practice. Enhanced efforts to embed SGLT2 inhibitors equitably into routine care for people with CKD are urgently needed, particularly in those at highest risk of adverse outcomes and in the absence of T2D. Funding: None.