A diet rich in fruit, vegetables and dietary fibre and low in fat is associated with reduced risk of chronic disease. This review aimed to estimate the effectiveness of interventions to promote healthy diet for primary prevention among participants attending primary care.
A systematic review of trials using individual or cluster randomisation of interventions delivered in primary care to promote dietary change over 12 months in healthy participants free from chronic disease or defined high risk states. Outcomes were change in fruit and vegetable intake, consumption of total fat and fibre and changes in serum cholesterol concentration.
Ten studies were included with 12,414 participants. The design and delivery of interventions were diverse with respect to grounding in behavioural theory and intervention intensity. A meta-analysis of three studies showed an increase in fruit consumption of 0.25 (0.01 to 0.49) servings per day, with an increase in vegetable consumption of 0.25 (0.06 to 0.44) serving per day. A further three studies that reported on fruit and vegetable consumption together showed a pooled increment of 0.50 (0.13 to 0.87) servings per day. The pooled effect on consumption of dietary fibre, from four studies, was estimated to be 1.97 (0.43 to 3.52) gm fibre per day. Data from five studies showed a mean decrease in total fat intake of 5.2% of total energy (1.5 to 8.8%). Data from three studies showed a mean decrease in serum cholesterol of 0.10 (-0.19 to 0.00) mmol/L.
Presently-reported interventions to promote healthy diet for primary prevention in primary care, which illustrate a diverse range of intervention methods, may yield small beneficial changes in consumption of fruit, vegetables, fibre and fat over 12 months. The present results do not exclude the possibility that more effective intervention strategies might be developed.
Diet; Health promotion; Primary care; Systematic review; Meta-analysis
Multimorbidity is the co-occurrence of long-term conditions. Obesity is associated with an increased risk of long-term conditions including type 2 diabetes and depression.
To quantify the association between body mass index (BMI) category and multimorbidity in a large cohort registered in primary care.
The sample comprised primary care electronic health records of adults aged ≥30 years, sampled from the Clinical Practice Research Datalink between 2005 and 2011. Multimorbidity was defined as the co-occurrence of ≥2 of 11 conditions affecting seven organ systems. Age- and sex-standardized prevalence of multimorbidity was estimated by BMI category. Adjusted odds ratios associating BMI with additional morbidity were estimated adjusting for socioeconomic deprivation and smoking.
The sample comprised 300 006 adults. After excluding participants with BMI never recorded, data were analysed for 223 089 (74%) contributing 1 374 109 person–years. In normal weight men, the standardized prevalence of multimorbidity was 23%, rising to 27% in overweight, 33% in category I obesity, 38% in category II and 44% in category III obesity. In women, the corresponding values were 28%, 34%, 41%, 45% and 51%. In category III obesity, the adjusted odds, relative to normal BMI, were 2.24 (2.13–2.36) for a first condition; 2.63 (2.51–2.76) for a second condition and 3.09 (2.92–3.28) for three or more conditions. In a cross-sectional analysis, 32% of multimorbidity was attributable to overweight and obesity.
Multiple morbidity is highly associated with increasing BMI category and obesity, highlighting the potential for targeted primary and secondary prevention interventions in primary care.
Cardiovascular diseases; comorbidity; diabetes mellitus; family practice; obesity; primary health care.
Background: Socio-economic status has been associated with diabetes in cross-sectional studies. This study aimed to evaluate associations of household income and wealth with both prevalent and incident diabetes among older adults in the UK. It also evaluated the association between obesity and socio-economic status. Methods: A cohort of people aged ≥50 years was selected from the English Longitudinal Study of Ageing. The relation of prevalent and incident self-reported physician diagnosed diabetes to household income and wealth was evaluated in logistic regression models adjusting for education, social class, housing tenure, age, ethnicity, marital status, body mass index (BMI), smoking, alcohol use and physical activity stratified by sex. The relation of prevalent obesity to household income and wealth was also evaluated using logistic regression models. Results: There were 9053 participants (4021 men and 5032 women) including 721 (8.0%) with diabetes at baseline. Among 8332 participants initially free from diabetes, 246 (3.0%) were diagnosed with diabetes during ∼4 years follow-up. The adjusted odds ratio for prevalent diabetes in the lowest quintile of wealth compared with the highest was 1.56 for men and 2.08 for women. Incident diabetes was associated with lower wealth (P for trend 0.05 for men and 0.004 for women) after adjusting for socio-economic and demographic factors, but attenuated after further adjustment for lifestyle and BMI. Prevalent obesity was significantly associated with lower wealth in women but not in men. Conclusion: Lower wealth, but not income, may be associated with prevalent and incident diabetes among older adults in UK.
OBJECTIVE—To evaluate diabetes outcomes under a national “pay-for-performance” program.
RESEARCH DESIGN AND METHODS—Data were analyzed for 98% of all English family practices. For each practice, the proportion of diabetic subjects with A1C ≤7.5%, blood pressure ≤145/85 mmHg, and cholesterol ≤5 mmol/l was determined. Practices achieving less than the 25th centile for the A1C target for 2006–2007 were classified as low performing.
RESULTS—The proportion achieving the A1C target at the median practice increased from 59.1% (interquartile range [IQR] 51.7–65.9) in 2004–2005 to 66.7% (IQR 60.6–72.7) in 2007–2008, blood pressure from 70.9% in 2004–2005 to 80.2% in 2007–2008, and cholesterol from 72.6% in 2004–2005 to 83.6% in 2007–2008. In 2004–2005, 57% of practices were low performing (range by region 42.4–69.9). In 2007–2008, 26% of practices were low performing (range 11.6–37.5).
CONCLUSIONS—Introduction of pay-for-performance may be one factor contributing to increasing achievement of targets and reducing problems of low performance.
To provide estimates of visual impairment in people with diabetes attending screening in a multi-ethnic population in England (United Kingdom).
The Diabetic Retinopathy In Various Ethnic groups in UK (DRIVE UK) Study is a cross-sectional study on the ethnic variations of the prevalence of DR and visual impairment in two multi-racial cohorts in the UK. People on the diabetes register in West Yorkshire and South East London who were screened, treated or monitored between April 2008 to July 2009 (London) or August 2009 (West Yorkshire) were included in the study. Data on age, gender, ethnic group, visual acuity and diabetic retinopathy were collected. Ethnic group was defined according to the 2011 census classification. The two main ethnic minority groups represented here are Blacks (“Black/African/Caribbean/Black British”) and South Asians (“Asians originating from the Indian subcontinent”). We examined the prevalence of visual impairment in the better eye using three cut-off points (a) loss of vision sufficient for driving (approximately <6/9) (b) visual impairment (<6/12) and (c) severe visual impairment (<6/60), standardising the prevalence of visual impairment in the minority ethnic groups to the age-structure of the white population.
Data on visual acuity and were available on 50,331individuals 3.4% of people diagnosed with diabetes and attending screening were visually impaired (95% confidence intervals (CI) 3.2% to 3.5%) and 0.39% severely visually impaired (0.33% to 0.44%). Blacks and South Asians had a higher prevalence of visual impairment (directly age standardised prevalence 4.6%, 95% CI 4.0% to 5.1% and 6.9%, 95% CI 5.8% to 8.0% respectively) compared to white people (3.3%, 95% CI 3.1% to 3.5%). Visual loss was also more prevalent with increasing age, type 1 diabetes and in people living in Yorkshire.
Visual impairment remains an important public health problem in people with diabetes, and is more prevalent in the minority ethnic groups in the UK.
Epilepsy is an important cause of amenable mortality but risk factors for death in epilepsy are not well understood.
To evaluate trends in epilepsy mortality in a large population and identify risk factors for death in epilepsy.
Design and setting
Nested case–control study in the UK, using data from the General Practice Research Database (GPRD) from 1993 to 2007.
Participants were included if they had ever been diagnosed with epilepsy and prescribed anticonvulsant drugs. Trends in all-cause mortality in persons with epilepsy in the GPRD were compared with death registrations with epilepsy as the underlying cause. A nested case–control study was implemented to compare participants with epilepsy who died with those who did not die.
The prevalence of epilepsy increased from 9 per 1000 in 1993 to 12 per 1000 in 2007, and epilepsy deaths also increased in this period. In a nested case–control study, mortality was associated with: recorded alcohol problems (odds ratio [OR] 2.96, 95% confidence interval [CI] = 2.25 to 3.89, P<0.001); having collected the last anticonvulsant prescription 90–182 days previously (OR 1.83, CI = 1.66 to 2.03, P<0.001); having an injury in the previous year (OR 1.41, 95% CI = 1.30 to 1.53, P<0.001), and having been treated for depression (OR 1.39, 95% CI = 1.28 to 1.50, P<0.001). In data available from 2004 onwards, being recorded seizure free in the previous 12 months was associated with lower mortality (OR 0.78, 95% CI = 0.71 to 0.86, P<0.001).
Mortality with epilepsy appears to be increasing. Patients who have alcohol problems, do not collect repeat prescriptions for anticonvulsant drugs, have recent injuries, or have been treated for depression may be at increased risk of death; patients who remain seizure free over 12 months are at a lower risk.
cohort study; epilepsy mortality; epilepsy prevalence; nested case-control study; primary care
To compare the prevalence of diabetic retinopathy (DR) in people of various ethnic groups with diabetes in the United Kingdom (UK).
The Diabetic Retinopathy In Various Ethnic groups in UK (DRIVE UK) Study is a cross-sectional study on the ethnic variations of the prevalence of DR and visual impairment in two multi-racial cohorts in the UK. People on the diabetes register in West Yorkshire and South East London who were screened, treated or monitored between April 2008 to July 2009 (London) or August 2009 (West Yorkshire) were included in the study. Data included age, sex, ethnic group, type of diabetes, presenting visual acuity and the results of grading of diabetic retinopathy. Prevalence estimates for the ethnic groups were age-standardised to the white European population for comparison purposes.
Out of 57,144 people on the two diabetic registers, data were available on 50,285 individuals (88.0%), of these 3,323 had type 1 and 46,962 had type 2 diabetes. In type 2 diabetes, the prevalence of any DR was 38.0% (95% confidence interval(CI) 37.4% to 38.5%) in white Europeans compared to 52.4% (51.2% to 53.6%) in African/Afro-Caribbeans and 42.3% (40.3% to 44.2%) in South Asians. Similarly, sight threatening DR was also significantly more prevalent in Afro-Caribbeans (11.5%, 95% CI 10.7% to 12.3%) and South Asians (10.3%, 9.0% to 11.5%) compared to white Europeans (5.5%, 5.3% to 5.8%). Differences observed in Type 1 diabetes did not achieve conventional levels of statistical significance, but there were lower numbers for these analyses.
Minority ethnic communities with type 2 diabetes in the UK are more prone to diabetic retinopathy, including sight-threatening retinopathy and maculopathy compared to white Europeans.
To evaluate the coding, recording and incidence of coronary heart disease (CHD) in primary care electronic medical records.
Data were drawn from the UK General Practice Research Database. Analyses evaluated the occurrence of 271 READ medical diagnostic codes, including categories for ‘Angina’, ‘Myocardial Infarction’, ‘Coronary Artery Bypass Grafting’ (CABG), ‘percutaneous transluminal coronary angioplasty’ (PCTA) and ‘Other Coronary Heart Disease’. Time-to-event analyses were implemented to evaluate occurrences of different groups of codes after the index date.
Among 300,020 participants aged greater than 30 years there were 75,197 unique occurrences of coronary heart disease codes in 24,244 participants, with 12,495 codes for incident events and 62,702 for prevalent events. Among incident event codes, 3,607 (28.87%) were for angina, 3,262 (26.11%) were for MI, 514 (4.11%) for PCTA, 161 (1.29%) for CABG and 4,951 (39.62%) were for ‘Other CHD’. Among prevalent codes, 20,254 (32.30%) were for angina, 3,644 (5.81%) for MI, 34,542 (55.09%) for ‘Other CHD’ and 4,262 (6.80%) for CABG or PCTA. Among 3,685 participants initially diagnosed exclusively with ‘Other CHD’ codes, 17.1% were recorded with angina within 5 years, 5.6% with myocardial infarction, 6.3% with CABG and 8.6% with PCTA. From 2000 to 2010, the overall incidence of CHD declined, as did the incidence of angina, but the incidence of MI did not change. The frequency of CABG declined, while PCTA increased.
In primary care electronic records, a substantial proportion of coronary heart disease events are recorded with codes that do not distinguish between different clinical presentations of CHD. The results draw attention to the need to improve coding practice in primary care. The results also draw attention to the importance of code selection in research studies and the need for sensitivity analyses using different sets of codes.
Electronic patient records are generally coded using extensive sets of codes but the significance of the utilisation of individual codes may be unclear. Item response theory (IRT) models are used to characterise the psychometric properties of items included in tests and questionnaires. This study asked whether the properties of medical codes in electronic patient records may be characterised through the application of item response theory models.
Data were provided by a cohort of 47,845 participants from 414 family practices in the UK General Practice Research Database (GPRD) with a first stroke between 1997 and 2006. Each eligible stroke code, out of a set of 202 OXMIS and Read codes, was coded as either recorded or not recorded for each participant. A two parameter IRT model was fitted using marginal maximum likelihood estimation. Estimated parameters from the model were considered to characterise each code with respect to the latent trait of stroke diagnosis. The location parameter is referred to as a calibration parameter, while the slope parameter is referred to as a discrimination parameter.
There were 79,874 stroke code occurrences available for analysis. Utilisation of codes varied between family practices with intraclass correlation coefficients of up to 0.25 for the most frequently used codes. IRT analyses were restricted to 110 Read codes. Calibration and discrimination parameters were estimated for 77 (70%) codes that were endorsed for 1,942 stroke patients. Parameters were not estimated for the remaining more frequently used codes. Discrimination parameter values ranged from 0.67 to 2.78, while calibration parameters values ranged from 4.47 to 11.58. The two parameter model gave a better fit to the data than either the one- or three-parameter models. However, high chi-square values for about a fifth of the stroke codes were suggestive of poor item fit.
The application of item response theory models to coded electronic patient records might potentially contribute to identifying medical codes that offer poor discrimination or low calibration. This might indicate the need for improved coding sets or a requirement for improved clinical coding practice. However, in this study estimates were only obtained for a small proportion of participants and there was some evidence of poor model fit. There was also evidence of variation in the utilisation of codes between family practices raising the possibility that, in practice, properties of codes may vary for different coders.
The purpose of this research is to develop and evaluate methods for conducting cluster randomised trials in a primary care database that contains electronic patient records for large numbers of family practices. Cluster randomised trials are trials in which the units allocated represent groups of individuals, in this case family practices and their registered patients. Cluster randomised trials often suffer from the limitation that they include too few clusters, leading to problems of insufficient power and only imprecise estimation of the intraclass correlation coefficient, a key design parameter. This difficulty might be overcome by utilising databases that already hold electronic patient records for large numbers of practices. The protocol describes one application: a study of antibiotic prescribing for acute respiratory infection; a second protocol outlines an intervention in a less frequent chronic condition of public health importance, stroke.
The objective of the study is to implement a cluster randomised trial to test the effectiveness of an electronic record-based intervention at achieving a reduction in antibiotic prescribing at consultations for respiratory illness in patients aged 18 and 59 years old in intervention family practices as compared with controls. Family practices will be recruited from the practices that presently contribute data to the UK General Practice Research Database (GPRD). Following randomisation, electronic prompts will be installed remotely at intervention practices to promote adherence with evidence-based standards of medical practice. The intervention was developed through qualitative research at non-intervention practices. Data for outcome assessment will be obtained from anonymised electronic patient records that are routinely collected into GPRD. This protocol outlines the proposed study designs, data sources, sample size requirements, analysis methods and dissemination plans. Ethical issues are also discussed.
Results from this study will provide methodological evidence concerning the use of electronic patient records and databases for implementing cluster randomised trials in primary care. The study will also provide substantive findings in respect of electronic record-based interventions to reduce antibiotic prescribing in primary care.
Current Controlled Trials ISRCTN 47558792.
Objectives To evaluate whether country of medical qualification is associated with “higher impact” decisions at different stages of the UK General Medical Council’s (GMC’s) “fitness to practise” process after allowing for other characteristics of doctors and inquiries.
Design Retrospective cohort study.
Setting Medical practice in the United Kingdom.
Participants 7526 inquiries to the GMC concerning 6954 doctors.
Main outcome measures Proportion of inquiries referred for further investigation at initial triage by the GMC, proportion of inquiries investigated that were subsequently referred for adjudication, and proportion of inquiries resulting in doctors being erased or suspended from the medical register; relative odds of higher impact decisions, by country of qualification, adjusted for doctors’ sex, years since primary medical qualification, medical specialty, source and type of inquiry, and nature of allegations.
Results Of 7526 inquiries, 4702 concerned doctors who qualified in the UK, 624 concerned doctors who qualified elsewhere in the European Union (EU), and 2190 concerned doctors who qualified outside the EU. At the initial triage, 30% (n=1398) of inquiries concerning doctors who qualified in the UK had a high impact decision, compared with 43% (267) for doctors who qualified elsewhere in the EU and 46% (998) for those who qualified outside the EU. The adjusted relative odds of an inquiry being referred for further investigation were 1.67 (95% confidence interval 1.28 to 2.17) for doctors who qualified elsewhere in the EU and 1.61 (1.38 to 1.88) for those who qualified outside the EU, compared with doctors who qualified in the UK. At the investigation stage, 5% (228) of inquiries received concerning UK qualified doctors were referred for adjudication, compared with 10% for EU (63) or non-EU (221) qualified doctors. The adjusted relative odds of referral for adjudication were 2.14 (1.46 to 3.16) for doctors who qualified elsewhere in the EU and 1.68 (1.31 to 2.16) for those who qualified outside the EU. At the adjudication stage, 1% (69) of inquiries received concerning UK qualified doctors led to erasure or suspension, compared with 4% (24) for doctors who qualified elsewhere in the EU and 3% (71) for non-EU qualified doctors. The adjusted relative odds of erasure or suspension were 2.16 (1.22 to 3.80) for doctors who qualified elsewhere in the EU and 1.48 (1.00 to 2.19) for those who qualified outside the EU.
Conclusions Inquiries to the GMC concerning doctors qualified outside the UK are more likely to be associated with higher impact decisions at each stage of the fitness to practice process. These associations were not explained by measured inquiry related and doctor related characteristics, but residual confounding cannot be excluded.
This study aimed to inform the design of a pragmatic trial of stroke prevention in primary care by evaluating data recorded in electronic patient records (EPRs) as potential outcome measures. The study also evaluated achievement of recommended standards of care; variation between family practices; and changes in risk factor values from before to after stroke.
Data from the UK General Practice Research Database (GPRD) were analysed for 22,730 participants with an index first stroke between 2003 and 2006 from 414 family practices. For each subject, the EPR was evaluated for the 12 months before and after stroke. Measures relevant to stroke secondary prevention were analysed including blood pressure (BP), cholesterol, smoking, alcohol use, body mass index (BMI), atrial fibrillation, utilisation of antihypertensive, antiplatelet and cholesterol lowering drugs. Intraclass correlation coefficients (ICC) were estimated by family practice. Random effects models were fitted to evaluate changes in risk factor values over time.
In the 12 months following stroke, BP was recorded for 90%, cholesterol for 70% and body mass index (BMI) for 47%. ICCs by family practice ranged from 0.02 for BP and BMI to 0.05 for LDL and HDL cholesterol. For subjects with records available both before and after stroke, the mean reductions from before to after stroke were: mean systolic BP, 6.02 mm Hg; diastolic BP, 2.78 mm Hg; total cholesterol, 0.60 mmol/l; BMI, 0.34 Kg/m2. There was an absolute reduction in smokers of 5% and heavy drinkers of 4%. The proportion of stroke patients within the recommended guidelines varied from less than a third (29%) for systolic BP, just over half for BMI (54%), and over 90% (92%) on alcohol consumption.
Electronic patient records have potential for evaluation of outcomes in pragmatic trials of stroke secondary prevention. Stroke prevention interventions in primary care remain suboptimal but important reductions in vascular risk factor values were observed following stroke. Better recording of lifestyle factors in the GPRD has the potential to expand the scope of the GPRD for health care research and practice.
We aimed to determine whether family practices' achievement of diabetes quality of care targets is associated with diabetic retinal disease in registered patients.
Data for achievement of diabetes quality of care targets, including the proportion of patients with HbA1c≤7.5%, for 144 family practices in London UK, for the years 2004/5 to 2007/8, were linked to data from a population-based diabetes eye screening programme collected from September 2007 to February 2009. Analyses were adjusted for age, sex, duration and type of diabetes, unadjusted diabetes prevalence, ethnicity and deprivation category.
Data were analysed for 24,458 participants with one or more eye screening results in the period. There were 9,332 (38%) with any diabetic retinopathy and 2,819 (11.5%) with sight threatening diabetic retinopathy (STDR), including 2,654 (10.9%) with maculopathy. Among participants registered at 13 family practices that were in the highest quartile for achievement of the HbA1c quality of care target for all four years of study, the relative odds of any diabetic retinopathy were 0.78 (0.69 to 0.88) P<0.001. For participants at 12 practices consistently in the lowest quartile of HbA1c achievement, the relative odds of any diabetic retinopathy were 1.16 (1.03 to 1.30), P = 0.015. In the highest achieving practices, the relative odds of maculopathy were 0.74 (0.62 to 0.89), P = 0.001 and STDR 0.77 (0.65 to 0.92), P = 0.004.
The risk of diabetic retinopathy might be lower at family practices that consistently achieve highly on diabetes quality of care targets for HbA1c.
The authors estimated trends in 1-year case-fatality of stroke in relation to changes in vascular risk management from 1997 to 2005.
A cohort study was implemented using data for 407 family practices in the UK General Practice Research Database, including subjects with first acute strokes between 1997 and 2005. One-year case-fatality was estimated by year and sex. Rate ratios were estimated using Poisson regression.
There were 19 143 women and 16 552 men who had first acute strokes between 1997 and 2005. In women, the 1-year case-fatality declined from 41.2% in 1997 to 29.2% in 2005. In men, the decline was from 29.2% in 1997 to 22.2% in 2005. The proportion of general practices that prescribed antihypertensive drugs to two-thirds or more of new patients with stroke increased from 6% in 1997 to 48% in 2005, for statins from 1% to 39% and for antiplatelet drugs from 11% to 39%. The rate ratio for 1-year mortality in 2005, compared with 1997–1998, adjusted for age group, sex, prevalent coronary heart disease, prevalent hypertension and deprivation quintile was 0.79 (0.74 to 0.86, p<0.001). After adjustment for antihypertensive, statin and antiplatelet prescribing, the rate ratio was 1.29 (1.17 to 1.42).
Reducing 1-year case-fatality after acute stroke may be partly explained by increased prescribing of antihypertensive, statin and antiplatelet drugs to patients with recent strokes. However, these analyses did not include measures of possible changes over time in stroke severity or acute stroke management.
Stroke; mortality; survival rate; primary healthcare; hypertension; Hydroxymethylglutaryl-CoA reductase inhibitors; platelet aggregation inhibitors
Electronic patient records from primary care databases are increasingly used in public health and health services research but methods used to identify cases with disease are not well described. This study aimed to evaluate the relevance of different codes for the identification of acute stroke in a primary care database, and to evaluate trends in the use of different codes over time.
Data were obtained from the General Practice Research Database from 1997 to 2006. All subjects had a minimum of 24 months of up-to-standard record before the first recorded stroke diagnosis. Initially, we identified stroke cases using a supplemented version of the set of codes for prevalent stroke used by the Office for National Statistics in Key health statistics from general practice 1998 (ONS codes). The ONS codes were then independently reviewed by four raters and a restricted set of 121 codes for ‘acute stroke’ was identified but the kappa statistic was low at 0.23.
Initial extraction of data using the ONS codes gave 48,239 cases of stroke from 1997 to 2006. Application of the restricted set of codes reduced this to 39,424 cases. There were 2,288 cases whose index medical codes were for ‘stroke annual review’ and 3,112 for ‘stroke monitoring’. The frequency of stroke review and monitoring codes as index codes increased from 9 per year in 1997 to 1,612 in 2004, 1,530 in 2005 and 1,424 in 2006. The one year mortality of cases with the restricted set of codes was 29.1% but for ‘stroke annual review,’ 4.6% and for ‘stroke monitoring codes’, 5.7%.
In the analysis of electronic patient records, different medical codes for a single condition may have varying clinical and prognostic significance; utilisation of different medical codes may change over time; researchers with differing clinical or epidemiological experience may have differing interpretations of the relevance of particular codes. There is a need for greater transparency in the selection of sets of codes for different conditions, for the reporting of sensitivity analyses using different sets of codes, as well as sharing of code sets among researchers.
OBJECTIVE—The purpose of this study was to test the hypothesis that changing utilization of lipid-lowering, antihypertensive, and oral hypoglycemic drugs may be associated with trends in all-cause mortality in men and women with type 2 diabetes.
RESEARCH DESIGN AND METHODS—This was a cohort study in 197 general practices in the U.K. General Practice Research Database including 48,579 subjects with type 2 diabetes first diagnosed between 1996 and 2006. Measures included all-cause mortality and prescription of hypoglycemic, lipid-lowering, and antihypertensive drugs.
RESULTS—From 1996 to 2006, incidence of type 2 diabetes increased and the mean age at diagnosis declined in women. Prescription of statins within 12 months of diagnosis increased (1996, women 4.9%, men 5.1%; 2005, women 63.5%, men 71.0%), as did drugs acting on the renin-angiotensin system (1996, women 19.4%, men 21.5%; 2005, women 45.5%, men 54.6%) and metformin (1996, women 19.1%, men 15.8%; 2005, women 45.5%, men 42.8%), whereas prescription of sulfonylureas declined. All-cause mortality in the first 24 months after diabetes diagnosis declined in men from 47.9 per 1,000 person-years for subjects with diabetes diagnosed in 1996 to 25.2 for subjects with diabetes diagnosed in 2006 and in women from 37.4 in 1996 to 27.6 in 2006. In a multiple regression model adjusting for age and comorbidity, prescription of statins before or after diagnosis, renin-angiotensin system drugs before or after diagnosis, and metformin after diagnosis were associated with lower mortality.
CONCLUSIONS—Widespread implementation of more effective prescribing to control lipids, blood glucose, and blood pressure may have contributed to recent declines in early mortality in men and women with type 2 diabetes.
Objective To evaluate the predictive value of alarm symptoms for specified non-cancer diagnoses and cancer diagnoses in primary care.
Design Cohort study using the general practice research database.
Setting 128 general practices in the UK contributing data, 1994-2000.
Participants 762 325 patients aged 15 or older.
Main outcome measures Up to 15 pre-specified, non-cancer diagnoses associated with four alarm symptoms (haematuria, haemoptysis, dysphagia, rectal bleeding) at 90 days and three years after the first recorded alarm symptom. For each outcome analyses were implemented separately in a time to event framework. Data were censored if patients died, left the practice, or reached the end of the study period.
Results We analysed data on first episodes of haematuria (11 108), haemoptysis (4812), dysphagia (5999), or rectal bleeding (15 289). Non-cancer diagnoses were common in patients who presented with alarm symptoms. The proportion diagnosed with either cancer or non-cancer diagnoses generally increased with age. In patients presenting with haematuria, the proportions diagnosed with either cancer or non-cancer diagnoses within 90 days were 17.5% (95% confidence interval 16.4% to 18.6%) in women and 18.3% (17.4% to 19.3%) in men. For the other symptoms the proportions were 25.7% (23.8% to 27.8%) and 24% (22.5% to 25.6%) for haemoptysis, 17.2% (16% to 18.5%) and 22.6% (21% to 24.3%) for dysphagia, and 14.5% (13.7% to 15.3%) and 16.7% (15.8% to 17.5%) for rectal bleeding.
Conclusion Clinically relevant diagnoses are made in a high proportion of patients presenting with alarm symptoms. For every four to seven patients evaluated for haematuria, haemoptysis, dysphagia, or rectal bleeding, relevant diagnoses will be identified in one patient within 90 days.
Alarm symptom presentations are predictive of cancer diagnosis but may also be associated with cancer survival.
To evaluate diagnostic time intervals, and consultation patterns after presentation with alarm symptoms, and their association with cancer diagnosis and survival.
Design and setting
Cohort study using the Clinical Practice Research Database, with linked Cancer Registry data, in 158 general practices.
Participants included those with haematuria, haemoptysis, dysphagia, and rectal bleeding or urinary tract cancer, lung cancer, gastro-oesophageal cancer, and colorectal cancer.
The median (interquartile range) interval in days from first symptom presentation to the corresponding cancer diagnosis was: haematuria and urinary tract cancer, 59 (28–109); haemoptysis and lung cancer, 35 (18–89); dysphagia and gastro-oesophageal cancer, 25 (12–48); rectal bleeding and colorectal cancer, 49 (20–157). Three or more alarm symptom consultations were associated with increased odds of diagnosis of urinary tract cancer (odds ratio [OR] 1.84, 95% CI = 1.50 to 2.27), lung cancer (OR = 1.76, 95% CI = 1.07 to 2.90) and gastro-oesophageal cancer (OR = 2.17, 95% CI = 1.48 to 3.19). Longer diagnostic intervals were associated with increased mortality only for urinary tract cancer (hazard ratio 2.23, 95% CI = 1.35 to 3.69). Patients with no preceding alarm symptom had shorter survival from diagnosis of urinary tract, lung or colorectal cancer than those presenting with a relevant alarm symptom.
After alarm symptom presentation, repeat consultations are associated with cancer diagnoses. Longer diagnostic intervals appeared to be associated with a worse prognosis for urinary tract cancer only. Mortality is higher when cancer is diagnosed in the absence of alarm symptoms.
alarm symptom; colorectal cancer; gastro-oesophageal cancer; general practice; primary care; survival
Antenatal sickle cell and thalassaemia screening sometimes occurs too late to allow couples a choice regarding termination of affected fetuses. The target gestational age for offering the test in the UK is 10 weeks.
To describe the proportion of women screened before 70 days' (10 weeks') gestation and the delay between pregnancy confirmation in primary care and antenatal sickle cell and thalassaemia screening.
Design of study
Cohort study of reported pregnancies.
Twenty-five general practices in two UK inner-city primary care trusts offering universal screening.
Anonymised data on all pregnancies reported to participating general practices was collected for a minimum of 6 months.
There were 1441 eligible women intending to proceed with their pregnancies, whose carrier status was not known. The median (interquartile range [IQR]) gestational age at pregnancy confirmation was 7.6 weeks (6.0–10.7 weeks) and 74% presented before 10 weeks. The median gestational age at screening was 15.3 weeks (IQR = 12.6–18.0 weeks), with only 4.4% being screened before 10 weeks. The median delay between pregnancy confirmation and screening was 6.9 weeks (4.7–9.3 weeks) After allowing for practice level variation, there was no association between delay times and maternal age, parity, and ethnic group.
About 74% of women consulted for pregnancy before 10 weeks' gestation but fewer than 5% of women were screened before the target time of 10 weeks. Reducing the considerable delay between pregnancy confirmation in primary care and antenatal sickle cell and thalassaemia screening requires methods of organising and delivering antenatal care that facilitate earlier screening to be developed and evaluated.
Anaemia; genetic screening; pregnancy; primary health care; sickle cell; thalassaemia
Objective To evaluate the association between alarm symptoms and the subsequent diagnosis of cancer in a large population based study in primary care.
Design Cohort study.
Setting UK General Practice Research Database.
Patients 762 325 patients aged 15 years and older, registered with 128 general practices between 1994 and 2000. First occurrences of haematuria, haemoptysis, dysphagia, and rectal bleeding were identified in patients with no previous cancer diagnosis..
Main outcome measure Positive predictive value of first occurrence of haematuria, haemoptysis, dysphagia, or rectal bleeding for diagnoses of neoplasms of the urinary tract, respiratory tract, oesophagus, or colon and rectum during three years after symptom onset. Likelihood ratio and sensitivity were also estimated.
Results 11 108 first occurrences of haematuria were associated with 472 new diagnoses of urinary tract cancers in men and 162 in women, giving overall three year positive predictive values of 7.4% (95% confidence interval 6.8% to 8.1%) in men and 3.4% (2.9% to 4.0%) in women. After 4812 new episodes of haemoptysis, 220 diagnoses of respiratory tract cancer were made in men (positive predictive value 7.5%, 6.6% to 8.5%) and 81 in women (4.3%, 3.4% to 5.3%). After 5999 new diagnoses of dysphagia, 150 diagnoses of oesophageal cancer were made in men (positive predictive value 5.7%, 4.9% to 6.7%) and 81 in women (2.4%, 1.9 to 3.0%). After 15 289 episodes of rectal bleeding, 184 diagnoses of colorectal cancer were made in men (positive predictive value 2.4%, 2.1% to 2.8%) and 154 in women (2.0%, 1.7% to 2.3%). Predictive values increased with age and were strikingly high, for example, in men with haemoptysis aged 75-84 (17.1%, 13.5% to 21.1%) and in men with dysphagia aged 65-74 (9.0%, 6.8% to 11.7%).
Conclusion New onset of alarm symptoms is associated with an increased likelihood of a diagnosis of cancer, especially in men and in people aged over 65. These data provide support for the early evaluation of alarm symptoms in an attempt to identify underlying cancers at an earlier and more amenable stage.
We tested the properties of the 18 Household Food Security Survey (HFSS) items, and the validity of the resulting food security classifications, in an English-speaking middle-income country.
Survey of primary school children in Trinidad and Tobago. Parents completed the HFSS. Responses were analysed for the 10 adult-referenced items and the eight child-referenced items. Item response theory models were fitted. Item calibrations and subject scores from a one-parameter logistic (1PL) model were compared with those from either two-parameter logistic model (2PL) or a model for differential item functioning (DIF) by ethnicity.
There were 5219 eligible with 3858 (74%) completing at least one food security item. Adult item calibrations (standard error) in the 1PL model ranged from -4.082 (0.019) for the 'worried food would run out' item to 3.023 (0.042) for 'adults often do not eat for a whole day'. Child item calibrations ranged from -3.715 (0.025) for 'relied on a few kinds of low cost food' to 3.088 (0.039) for 'child didn't eat for a whole day'. Fitting either a 2PL model, which allowed discrimination parameters to vary between items, or a differential item functioning model, which allowed item calibrations to vary between ethnic groups, had little influence on interpretation. The classification based on the adult-referenced items showed that there were 19% of respondents who were food insecure without hunger, 10% food insecure with moderate hunger and 6% food insecure with severe hunger. The classification based on the child-referenced items showed that there were 23% of children who were food insecure without hunger and 9% food insecure with hunger. In both children and adults food insecurity showed a strong, graded association with lower monthly household income (P < 0.001).
These results support the use of 18 HFSS items to classify food security status of adults or children in an English-speaking country where food insecurity and hunger are more frequent overall than in the US.
We evaluated the reliability and validity of the short form household food security scale in a different setting from the one in which it was developed.
The scale was interview administered to 531 subjects from 286 households in north central Trinidad in Trinidad and Tobago, West Indies. We evaluated the six items by fitting item response theory models to estimate item thresholds, estimating agreement among respondents in the same households and estimating the slope index of income-related inequality (SII) after adjusting for age, sex and ethnicity.
Item-score correlations ranged from 0.52 to 0.79 and Cronbach's alpha was 0.87. Item responses gave within-household correlation coefficients ranging from 0.70 to 0.78. Estimated item thresholds (standard errors) from the Rasch model ranged from -2.027 (0.063) for the 'balanced meal' item to 2.251 (0.116) for the 'hungry' item. The 'balanced meal' item had the lowest threshold in each ethnic group even though there was evidence of differential functioning for this item by ethnicity. Relative thresholds of other items were generally consistent with US data. Estimation of the SII, comparing those at the bottom with those at the top of the income scale, gave relative odds for an affirmative response of 3.77 (95% confidence interval 1.40 to 10.2) for the lowest severity item, and 20.8 (2.67 to 162.5) for highest severity item. Food insecurity was associated with reduced consumption of green vegetables after additionally adjusting for income and education (0.52, 0.28 to 0.96).
The household food security scale gives reliable and valid responses in this setting. Differing relative item thresholds compared with US data do not require alteration to the cut-points for classification of 'food insecurity without hunger' or 'food insecurity with hunger'. The data provide further evidence that re-evaluation of the 'balanced meal' item is required.
food security; food insecurity; reliability; validity; questionnaires; West Indies; Trinidad and Tobago
It has been proposed that greater availability of primary medical care practitioners (GPs) contributes to better population health. We evaluated whether measures of the supply and structure of primary medical services are associated with health and health care indicators after adjusting for confounding.
Data for the supply and structure of primary medical services and the characteristics of registered patients were analysed for 99 health authorities in England in 1999. Health and health care indicators as dependent variables included standardised mortality ratios (SMR), standardised hospital admission rates, and conceptions under the age of 18 years. Linear regression analyses were adjusted for Townsend score, proportion of ethnic minorities and proportion of social class IV/ V.
Higher proportions of registered rural patients and patients ≥ 75 years were associated with lower Townsend deprivation scores, with larger partnership sizes and with better health outcomes. A unit increase in partnership size was associated with a 4.2 (95% confidence interval 1.7 to 6.7) unit decrease in SMR for all-cause mortality at 15–64 years (P = 0.001). A 10% increase in single-handed practices was associated with a 1.5 (0.2 to 2.9) unit increase in SMR (P = 0.027). After additional adjustment for percent of rural and elderly patients, partnership size and proportion of single-handed practices, GP supply was not associated with SMR (-2.8, -6.9 to 1.3, P = 0.183).
After adjusting for confounding with health needs of populations, mortality is weakly associated with the degree of organisation of practices as represented by the partnership size but not with the supply of GPs.
primary health care; socio-economic inequalities; access to medical care; hospital utilisation; social justice