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Assessment of pressure ulcer (PU) risk remains a challenge in clinical practice. The first part of this article (Martin and Holloway, 2024) discussed the evidence base underpinning the development of clinical guidelines for PUs alongside the creation of the bundle approach regarding PU prevention. This article, part two, presents the results of a clinical audit that explores compliance against a PU prevention bundle (the aSSKINg framework) in an adult community nursing setting in the south-east of England. The clinical audit was conducted between July-December 2021 and included records of 150 patients. Overall, compliance against the aSSKINg framework was poor, with only two criterion being met: equipment provision for chair and referral to the tissue viability team. Short-term recommendations are that mandatory PU training for staff in the management of PUs should be implemented, and the tissue viability nurse network should be increased. The long-term recommendation was the introduction of the aSSKINg framework as a template into the electronic patient record. [ABSTRACT FROM AUTHOR]

Simple Summary: The platelet count is an established marker of cancer. In healthy populations, platelet count varies by age and sex; despite that variation, a single reference range is used. This study aimed to identify age- and sex-specific upper thresholds for platelet count at which cancer should be considered in primary care, using audits of primary care-based clinical data in England, Canada, and Australia. Across all three cohorts, there was a clear upwards trend in cancer incidence with increasing platelet count for both sexes and at all age groups. The appropriate threshold will vary by country and will depend on local healthcare needs and priorities. As colorectal and lung cancers predominate, initial investigation may target these sites. Further investigation, depending on the patient's symptoms, could be CT imaging, endoscopy, or CA125. The platelet count, a component of the full blood count, has been identified as a useful diagnostic marker for cancer in primary care. The reference range for the platelet count is 150 to 400 or 450 × 109/L; this range does not account for natural variation in platelet count by age and sex. This study used three primary care cohorts from England, Canada, and Australia. Patients aged 40 years and over with a full blood count were included and stratified by age (in 10-year bands), sex, (male/female), and platelet count group. Cancer incidence within one year of the test date was estimated from linked registry data. In all three countries, there was a clear upwards trend in cancer incidence with increasing platelet count for both sexes and at all age groups. Lung and colorectal were the most common sites. These results have important implications for the international application of this work; analysis of local health datasets will be crucial to determining appropriate thresholds. Appropriate upper thresholds will depend on local populations, healthcare needs, and priorities. Further research is needed to assess the likely impact of new recommendations on the healthcare system, on cancer outcomes, and patient benefit. [ABSTRACT FROM AUTHOR]

The aim of this research was to describe the epidemiology, presentation and healthcare use in primary care for foot and ankle problems in children and young people (CYP) across England. We undertook a population-based cohort study using data from the Clinical Practice Research Datalink Aurum database, a database of anonymised electronic health records from general practices across England. Data was accessed for all CYP aged 0–18 years presenting to their general practitioner between January 2015 and December 2021 with a foot and/or ankle problem. Consultation rates were calculated and used to estimate numbers of consultations in an average practice. Hierarchical Poisson regression estimated relative rates of consultations across sociodemographic groups and logistic regression evaluated factors associated with repeat consultations. A total of 416,137 patients had 687,753 foot and ankle events, of which the majority were categorised as "musculoskeletal" (34%) and "unspecified pain" (21%). Rates peaked at 601 consultations per 10,000 patient-years among males aged 10–14 years in 2018. An average practice might observe 132 (95% CI 110 to 155) consultations annually. Odds for repeat consultations were higher among those with pre-existing diagnoses including juvenile arthritis (OR 1.73, 95% CI 1.48 to 2.03). Conclusions: Consultations for foot and ankle problems were high among CYP, particularly males aged 10 to 14 years. These data can inform service provision to ensure CYP access appropriate health professionals for accurate diagnosis and treatment. What is Known: • Foot and ankle problems can have considerable impact on health-related quality of life in children and young people (CYP). • There is limited data describing the nature and frequency of foot and ankle problems in CYP. What is New: • Foot and ankle consultations were higher in English general practice among CYP aged 10 to 14 years compared to other age groups, and higher among males compared to females. • The high proportion of unspecified diagnoses and repeat consultations suggests there is need for greater integration between general practice and allied health professionals in community-based healthcare settings. [ABSTRACT FROM AUTHOR]

Background: Ethnicity is known to be an important correlate of health outcomes, particularly during the COVID-19 pandemic, where some ethnic groups were shown to be at higher risk of infection and adverse outcomes. The recording of patients' ethnic groups in primary care can support research and efforts to achieve equity in service provision and outcomes; however, the coding of ethnicity is known to present complex challenges. We therefore set out to describe ethnicity coding in detail with a view to supporting the use of this data in a wide range of settings, as part of wider efforts to robustly describe and define methods of using administrative data. Methods: We describe the completeness and consistency of primary care ethnicity recording in the OpenSAFELY-TPP database, containing linked primary care and hospital records in > 25 million patients in England. We also compared the ethnic breakdown in OpenSAFELY-TPP with that of the 2021 UK census. Results: 78.2% of patients registered in OpenSAFELY-TPP on 1 January 2022 had their ethnicity recorded in primary care records, rising to 92.5% when supplemented with hospital data. The completeness of ethnicity recording was higher for women than for men. The rate of primary care ethnicity recording ranged from 77% in the South East of England to 82.2% in the West Midlands. Ethnicity recording rates were higher in patients with chronic or other serious health conditions. For each of the five broad ethnicity groups, primary care recorded ethnicity was within 2.9 percentage points of the population rate as recorded in the 2021 Census for England as a whole. For patients with multiple ethnicity records, 98.7% of the latest recorded ethnicities matched the most frequently coded ethnicity. Patients whose latest recorded ethnicity was categorised as Other were most likely to have a discordant ethnicity recording (32.2%). Conclusions: Primary care ethnicity data in OpenSAFELY is present for over three quarters of all patients, and combined with data from other sources can achieve a high level of completeness. The overall distribution of ethnicities across all English OpenSAFELY-TPP practices was similar to the 2021 Census, with some regional variation. This report identifies the best available codelist for use in OpenSAFELY and similar electronic health record data. [ABSTRACT FROM AUTHOR]

Aims: The COVID‐19 pandemic caused significant disruption to routine activity in primary care. Medication reviews are an important primary care activity ensuring safety and appropriateness of prescribing. A disruption could have significant negative implications for patient care. Using routinely collected data, our aim was first to describe codes used to record medication review activity and then to report the impact of COVID‐19 on the rates of medication reviews. Methods: With the approval of NHS England, we conducted a cohort study of 20 million adult patient records in general practice, in‐situ using the OpenSAFELY platform. For each month, between April 2019 and March 2022, we report the percentage of patients with a medication review coded monthly and in the previous 12 months with breakdowns by regional, clinical and demographic subgroups and those prescribed high‐risk medications. Results: In April 2019, 32.3% of patients had a medication review coded in the previous 12 months. During the first COVID‐19 lockdown, monthly activity decreased (−21.1% April 2020), but the 12‐month rate was not substantially impacted (−10.5% March 2021). The rate of structured medication review in the last 12 months reached 2.9% by March 2022, with higher percentages in high‐risk groups (care home residents 34.1%, age 90+ years 13.1%, high‐risk medications 10.2%). The most used medication review code was Medication review done 314530002 (59.5%). Conclusions: There was a substantial reduction in the monthly rate of medication reviews during the pandemic but rates recovered by the end of the study period. Structured medication reviews were prioritized for high‐risk patients. [ABSTRACT FROM AUTHOR]

There is a statutory duty for all practitioners to record information in child protection work in England. Case recording is a daily task for practitioners, yet an under-researched area of practice. This continuing professional development (CPD) paper will consider the context in which case recording takes place and highlight messages from child protection reviews and enquiries before exploring learning from contemporary research. The complexities of case recording will be considered and how practitioners can reflect upon and improve their daily case recording skills. Practitioners are encouraged to keep the child's views and experiences central and consider the long-term impact of case recording on adults who have experienced abuse and neglect in childhood. Key Practitioner Messages • Case recording is a complex and nuanced task, often missing the multiple perspectives inherent in a child's narrative. • The views, experiences and identity of individual children and young people can be lost in case recording, especially for very young children, older children and those in sibling groups. • Case recording has a support function for care experienced adults to understand their childhood histories, aiding recovery from abuse and neglect. [ABSTRACT FROM AUTHOR]

Population Health Management – often abbreviated to PHM – is a relatively new approach for healthcare planning, requiring the application of analytical techniques to linked patient level data. Despite expectations for greater uptake of PHM, there is a deficit of available solutions to help health services embed it into routine use. This paper concerns the development, application and use of an interactive tool which can be linked to a healthcare system's data warehouse and employed to readily perform key PHM tasks such as population segmentation, risk stratification, and deriving various performance metrics and descriptive summaries. Developed through open-source code in a large healthcare system in South West England, and used by others around the country, this paper demonstrates the importance of a scalable, purpose-built solution for improving the uptake of PHM in health services. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 pandemic many patients were switched from warfarin to direct)acting oral anticoagulants (DOACs), which require the creatinine clearance (CrCl) calculated to ensure the correct dose is prescribed to avoid bleeding or reduced efficacy. Aim: To identify the study population proportion prescribed a DOAC. Of these, the proportion with recorded: weight, estimated glomerular filtration rate (eGFR), creatinine, CrCl and atrial fibrillation (AF). To analyse the proportion of patients with recorded AF and CrCl prescribed a recommended DOAC dose. Design & setting: A retrospective cohort study of 20.5 million adult NHS patients’ electronic health records (EHRs) in England in the OpenSAFELY-TPP platform (January 2018–February 2023). Method: Patients on DOACs were analysed for age, sex, recorded weight, eGFR, creatinine, CrCl and AF. Prescribed DOAC doses in patients with recorded AF were compared with recommended doses for recorded CrCl and determined as either recommended, higher than recommended (overdose), or lower than recommended (underdose). Results: In February 2023, weight, eGFR, creatinine, CrCl, and AF were recorded in 72.8%, 92.4%, 94.3%, 73.5%, and 73.9% of study population, respectively. Both AF and CrCl were recorded for 56.7% of patients. Of these, 86.2% received the recommended, and 13.8% non-recommended, DOAC doses. Conclusion: CrCl is not recorded for a substantial number of patients on DOACs. We recommend that national organisations tasked with safety, collectively update guidance on the appropriate weight to use in the Cockcroft–Gault equation, clarify that CrCl is not equivalent to eGFR, and work with GP clinical system suppliers to standardise the calculation of CrCl in the EHR. [ABSTRACT FROM AUTHOR]

Background: Oral anticoagulation (OAC) is the mainstay of treatment for the prevention of strokes in patients with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) account for increasing OAC in patients with AF. However, prescribing DOACs for patients with established AF poses various challenges and general practice pharmacists may have an important role in supporting their management. Aim: To investigate the effectiveness of pharmacist-led interventions in general practice in optimising the use of OAC therapies in AF. Design & setting: A retrospective observational study in general practices in Bradford. Method: The data were collected retrospectively from 1 November 2018–31 December 2019 using electronic health record data. The data were analysed: 1) to identify patients with AF not on OAC; 2) to describe inappropriate DOAC prescriptions; and 3) to calculate HAS-BLED scores. Results: Overall, 76.3% (n = 470) of patients with AF received OAC therapy, and of these, 63.4% received DOACs. Pharmacist-led interventions increased DOAC prescribing by 6.0% (P = 0.03). Inappropriate DOAC use was identified in 24.5% of patients with AF, with underdosed and overdosed identified in 9.7% and 14.8%, respectively. Post-intervention, inappropriate prescribing was reduced to 1.7%. The mean HAS-BLED score decreased from 3.00 to 2.22 (P<0.01). Successful transition from vitamin K antagonist (VKA) therapy to DOACs was achieved in 25.7% of patients. Conclusion: Pharmacist-led interventions have successfully improved the use of OAC therapies in patients with AF, and effectively managed the bleeding risks and transition from VKA to DOAC therapy, in line with guidelines. [ABSTRACT FROM AUTHOR]

Background: Patient portals introduced in most of England’s general practices since 2015 have the potential to improve healthcare efficiency. There is a paucity of information on the use of patient portals within the NHS general practices and the potential impact on healthcare utilisation. Aim: To investigate the association between patient portal registration and care utilisation (measured by the number of general practice consultations) among general practice patients. Design & setting: A longitudinal analysis using electronic health record data from the Clinical Practice Research Datalink (CPRD). Method: We analysed patients registered for patient portals (n = 284 666), aggregating their consultations 1 year before and 1 year after registration. We ran a multilevel negative binomial regression model to examine patient portal registration’s association with face-to-face and remote consultations. Results: Patients who registered to the portal had a small decrease in the total number of face-to-face consultations after registering to the patient portal (incidence rate ratio = 0.93, 95% confidence interval [CI] = 0.93 to 0.94). Patients who registered to the portal had an increase in the total number of remote consultations after registering to the portal (incidence rate ratio = 1.16, 95% CI = 1.15 to 1.18). Conclusion: The study found minor changes in consultation numbers post-patient portal registration, notably with an increase in remote consultations. While causality between portal registration and consultation number remains unclear, the potential link between patient portal use and healthcare utilisation warrants further investigation, especially within the NHS, where portal impacts are not well-studied. Detailed portal utilisation data could clarify this relationship. [ABSTRACT FROM AUTHOR]

Background: Long COVID potentially increases healthcare utilisation and costs. However, its impact on the NHS remains to be determined. Methods: This study aims to assess the healthcare utilisation of individuals with long COVID. With the approval of NHS England, we conducted a matched cohort study using primary and secondary care data via OpenSAFELY, a platform for analysing anonymous electronic health records. The long COVID exposure group, defined by diagnostic codes, was matched with five comparators without long COVID between Nov 2020 and Jan 2023. We compared their total healthcare utilisation from GP consultations, prescriptions, hospital admissions, A&E visits, and outpatient appointments. Healthcare utilisation and costs were evaluated using a two-part model adjusting for covariates. Using a difference-in-difference model, we also compared healthcare utilisation after long COVID with pre-pandemic records. Results: We identified 52,988 individuals with a long COVID diagnosis, matched to 264,867 comparators without a diagnosis. In the 12 months post-diagnosis, there was strong evidence that those with long COVID were more likely to use healthcare resources (OR: 8.29, 95% CI: 7.74–8.87), and have 49% more healthcare utilisation (RR: 1.49, 95% CI: 1.48–1.51). Our model estimated that the long COVID group had 30 healthcare visits per year (predicted mean: 29.23, 95% CI: 28.58–29.92), compared to 16 in the comparator group (predicted mean visits: 16.04, 95% CI: 15.73–16.36). Individuals with long COVID were more likely to have non-zero healthcare expenditures (OR = 7.66, 95% CI = 7.20–8.15), with costs being 44% higher than the comparator group (cost ratio = 1.44, 95% CI: 1.39–1.50). The long COVID group costs approximately £2500 per person per year (predicted mean cost: £2562.50, 95% CI: £2335.60–£2819.22), and the comparator group costs £1500 (predicted mean cost: £1527.43, 95% CI: £1404.33–1664.45). Historically, individuals with long COVID utilised healthcare resources more frequently, but their average healthcare utilisation increased more after being diagnosed with long COVID, compared to the comparator group. Conclusions: Long COVID increases healthcare utilisation and costs. Public health policies should allocate more resources towards preventing, treating, and supporting individuals with long COVID. [ABSTRACT FROM AUTHOR]

OBJECTIVES Lung volume reduction surgery (LVRS) is a clinically effective palliation procedure for patients with chronic obstructive pulmonary disease. LVRS has recently been commissioned by the NHS England. In this study, a costing model was developed to analyse cost and resource implications of different LVRS procedures. METHODS Three pathways were defined by their surgical procedures: bronchoscopic endobronchial valve insertion (EBV-LVRS), video-assisted thoracic surgery LVRS and robotic-assisted thoracic surgery LVRS. The costing model considered use of hospital resources from the LVRS decision until 90 days after hospital admission. The model was calibrated with data obtained from an observational study, electronic health records and expert opinion. Unit costs were obtained from the hospital finance department and reported in 2021 Euros. RESULTS Video-assisted thoracic surgery LVRS was associated with the lowest cost at €12 896 per patient. This compares to the costs of EBV-LVRS at €15 598 per patient and €13 305 per patient for robotic-assisted thoracic surgery LVRS. A large component of EBV-LVRS costs were accrued secondary to complications, including revision EBV-LVRS. CONCLUSIONS This study presents a comprehensive model framework for the analysis of hospital-related resource use and costs for the 3 surgical modalities. In the future, service commissioning agencies, hospital management and clinicians can use this framework to determine their modifiable resource use (composition of surgical teams, use of staff and consumables, planned length of stay and revision rates for EBV-LVRS) and to assess the potential cost implications of changes in these parameters. [ABSTRACT FROM AUTHOR]

The UK Biobank study contains several sources of diagnostic data, including hospital inpatient data and data on self-reported conditions for approximately 500,000 participants and primary-care data for approximately 177,000 participants (35%). Epidemiologic investigations require a primary disease definition, but whether to combine data sources to maximize statistical power or focus on only 1 source to ensure a consistent outcome is not clear. The consistency of disease definitions was investigated for venous thromboembolism (VTE) by evaluating overlap when defining cases from 3 sources: hospital inpatient data, primary-care reports, and self-reported questionnaires. VTE cases showed little overlap between data sources, with only 6% of reported events for persons with primary-care data being identified by all 3 sources (hospital, primary-care, and self-reports), while 71% appeared in only 1 source. Deep vein thrombosis–only events represented 68% of self-reported VTE cases and 36% of hospital-reported VTE cases, while pulmonary embolism–only events represented 20% of self-reported VTE cases and 50% of hospital-reported VTE cases. Additionally, different distributions of sociodemographic characteristics were observed; for example, patients in 46% of hospital-reported VTE cases were female, compared with 58% of self-reported VTE cases. These results illustrate how seemingly neutral decisions taken to improve data quality can affect the representativeness of a data set. [ABSTRACT FROM AUTHOR]

Rationale: Cardiovascular events after chronic obstructive pulmonary disease (COPD) exacerbations are recognized. Studies to date have been post hoc analyses of trials, did not differentiate exacerbation severity, included death in the cardiovascular outcome, or had insufficient power to explore individual outcomes temporally. Objectives: We explore temporal relationships between moderate and severe exacerbations and incident, nonfatal hospitalized cardiovascular events in a primary care–derived COPD cohort. Methods: We included people with COPD in England from 2014 to 2020, from the Clinical Practice Research Datalink Aurum primary care database. The index date was the date of first COPD exacerbation or, for those without exacerbations, date upon eligibility. We determined composite and individual cardiovascular events (acute coronary syndrome, arrhythmia, heart failure, ischemic stroke, and pulmonary hypertension) from linked hospital data. Adjusted Cox regression models were used to estimate average and time-stratified adjusted hazard ratios (aHRs). Measurements and Main Results: Among 213,466 patients, 146,448 (68.6%) had any exacerbation; 119,124 (55.8%) had moderate exacerbations, and 27,324 (12.8%) had severe exacerbations. A total of 40,773 cardiovascular events were recorded. There was an immediate period of cardiovascular relative rate after any exacerbation (1–14 d; aHR, 3.19 [95% confidence interval (CI), 2.71–3.76]), followed by progressively declining yet maintained effects, elevated after one year (aHR, 1.84 [95% CI, 1.78–1.91]). Hazard ratios were highest 1–14 days after severe exacerbations (aHR, 14.5 [95% CI, 12.2–17.3]) but highest 14–30 days after moderate exacerbations (aHR, 1.94 [95% CI, 1.63–2.31]). Cardiovascular outcomes with the greatest two-week effects after a severe exacerbation were arrhythmia (aHR, 12.7 [95% CI, 10.3–15.7]) and heart failure (aHR, 8.31 [95% CI, 6.79–10.2]). Conclusions: Cardiovascular events after moderate COPD exacerbations occur slightly later than after severe exacerbations; heightened relative rates remain beyond one year irrespective of severity. The period immediately after an exacerbation presents a critical opportunity for clinical intervention and treatment optimization to prevent future cardiovascular events. [ABSTRACT FROM AUTHOR]

Background: Identifying clusters of co-occurring diseases may help characterise distinct phenotypes of Multiple Long-Term Conditions (MLTC). Understanding the associations of disease clusters with health-related outcomes requires a strategy to assign clusters to people, but it is unclear how the performance of strategies compare. Aims: First, to compare the performance of methods of assigning disease clusters to people at explaining mortality, emergency department attendances and hospital admissions over one year. Second, to identify the extent of variation in the associations with each outcome between and within clusters. Methods: We conducted a cohort study of primary care electronic health records in England, including adults with MLTC. Seven strategies were tested to assign patients to fifteen disease clusters representing 212 LTCs, identified from our previous work. We tested the performance of each strategy at explaining associations with the three outcomes over 1 year using logistic regression and compared to a strategy using the individual LTCs. Results: 6,286,233 patients with MLTC were included. Of the seven strategies tested, a strategy assigning the count of conditions within each cluster performed best at explaining all three outcomes but was inferior to using information on the individual LTCs. There was a larger range of effect sizes for the individual LTCs within the same cluster than there was between the clusters. Conclusion: Strategies of assigning clusters of co-occurring diseases to people were less effective at explaining health-related outcomes than a person's individual diseases. Furthermore, clusters did not represent consistent relationships of the LTCs within them, which might limit their application in clinical research. [ABSTRACT FROM AUTHOR]

Aims: Population‐wide, person‐level, linked electronic health record data are increasingly used to estimate epidemiology, guide resource allocation, and identify events in clinical trials. The accuracy of data from NHS Digital (now part of NHS England) for identifying hospitalization for heart failure (HHF), a key HF standard, is not clear. This study aimed to evaluate the accuracy of NHS Digital data for identifying HHF. Methods and results: Patients experiencing at least one HHF, as determined by NHS Digital data, and age‐ and sex‐matched patients not experiencing HHF, were identified from a prospective cohort study and underwent expert adjudication. Three code sets commonly used to identify HHF were applied to the data and compared with expert adjudication (I50: International Classification of Diseases‐10 codes beginning I50; OIS: Clinical Commissioning Groups Outcomes Indicator Set; and NICOR: National Institute for Cardiovascular Outcomes Research, used as the basis for the National Heart Failure Audit in England and Wales). Five hundred four patients underwent expert adjudication, of which 10 (2%) were adjudicated to have experienced HHF. Specificity was high across all three code sets in the first diagnosis position {I50: 96.2% [95% confidence interval (CI) 94.1–97.7%]; NICOR: 93.3% [CI 90.8–95.4%]; OIS: 95.6% [CI 93.3–97.2%]} but decreased substantially as the number of diagnosis positions expanded. Sensitivity [40.0% (CI 12.2–73.8%)] and positive predictive value (PPV) [highest with I50: 17.4% (CI 8.1–33.6%)] were low in the first diagnosis position for all coding sets. PPV was higher for the National Heart Failure Audit criteria, albeit modestly [36.4% (CI 16.6–62.2%)]. Conclusions: NHS Digital data were not able to accurately identify HHF and should not be used in isolation for this purpose. [ABSTRACT FROM AUTHOR]

Background: Temporary doctors, known as locums, are a key component of the medical workforce in the NHS but evidence on differences in quality and safety between locum and permanent doctors is limited. We aimed to examine differences in the clinical practice, and prescribing safety for locum and permanent doctors working in primary care in England. Methods: We accessed electronic health care records (EHRs) for 3.5 million patients from the CPRD GOLD database with linkage to Hospital Episode Statistics from 1st April 2010 to 31st March 2022. We used multi-level mixed effects logistic regression to compare consultations with locum and permanent GPs for several patient outcomes including general practice revisits; prescribing of antibiotics; strong opioids; hypnotics; A&E visits; emergency hospital admissions; admissions for ambulatory care sensitive conditions; test ordering; referrals; and prescribing safety indicators while controlling for patient and practice characteristics. Results: Consultations with locum GPs were 22% more likely to involve a prescription for an antibiotic (OR = 1.22 (1.21 to 1.22)), 8% more likely to involve a prescription for a strong opioid (OR = 1.08 (1.06 to 1.09)), 4% more likely to be followed by an A&E visit on the same day (OR = 1.04 (1.01 to 1.08)) and 5% more likely to be followed by an A&E visit within 1 to 7 days (OR = 1.05 (1.02 to 1.08)). Consultations with a locum were 12% less likely to lead to a practice revisit within 7 days (OR = 0.88 (0.87 to 0.88)), 4% less likely to involve a prescription for a hypnotic (OR = 0.96 (0.94 to 0.98)), 15% less likely to involve a referral (OR = 0.85 (0.84 to 0.86)) and 19% less likely to involve a test (OR = 0.81 (0.80 to 0.82)). We found no evidence that emergency admissions, ACSC admissions and eight out of the eleven prescribing safety indicators were different if patients were seen by a locum or a permanent GP. Conclusions: Despite existing concerns, the clinical practice and performance of locum GPs did not appear to be systematically different from that of permanent GPs. The practice and performance of both locum and permanent GPs is likely shaped by the organisational setting and systems within which they work. [ABSTRACT FROM AUTHOR]

Background Falls are common in older adults and can devastate personal independence through injury such as fracture and fear of future falls. Methods to identify people for falls prevention interventions are currently limited, with high risks of bias in published prediction models. We have developed and externally validated the eFalls prediction model using routinely collected primary care electronic health records (EHR) to predict risk of emergency department attendance/hospitalisation with fall or fracture within 1 year. Methods Data comprised two independent, retrospective cohorts of adults aged ≥65 years: the population of Wales, from the Secure Anonymised Information Linkage Databank (model development); the population of Bradford and Airedale, England, from Connected Bradford (external validation). Predictors included electronic frailty index components, supplemented with variables informed by literature reviews and clinical expertise. Fall/fracture risk was modelled using multivariable logistic regression with a Least Absolute Shrinkage and Selection Operator penalty. Predictive performance was assessed through calibration, discrimination and clinical utility. Apparent, internal–external cross-validation and external validation performance were assessed across general practices and in clinically relevant subgroups. Results The model's discrimination performance (c-statistic) was 0.72 (95% confidence interval, CI: 0.68 to 0.76) on internal–external cross-validation and 0.82 (95% CI: 0.80 to 0.83) on external validation. Calibration was variable across practices, with some over-prediction in the validation population (calibration-in-the-large, −0.87; 95% CI: −0.96 to −0.78). Clinical utility on external validation was improved after recalibration. Conclusion The eFalls prediction model shows good performance and could support proactive stratification for falls prevention services if appropriately embedded into primary care EHR systems. [ABSTRACT FROM AUTHOR]

An open group intervention for stroke inpatients, based on Acceptance and Commitment Therapy, is evaluated using retrospective clinical service data. Participants were included unless severely unwell or unable to provide informed consent. 117 participants attended at least two sessions in a non-controlled, repeated measures design. Two session protocols were delivered on alternating weeks by an Assistant Psychologist and Trainee Psychologist, covering values, committed action, and acceptance. Participants rated their mood each session using the Depression Intensity Scale Circles (DISCs). Attended sessions ranged from 1 to 11 (Md: 2). Significant reductions in DISCs scores with medium effect sizes were found among those scoring above the cut-off for depression at baseline, Χ2(3) = 20.87, p <.001. The likelihood of scoring below the cut-off for depression did not change between participants' first and last sessions, X2(1, N = 117) = 1.36, p =.24. The number of sessions attended did not predict outcome, rs(117) =.09, p =.33. Design limitations prevented inferences of clinical effectiveness, but the group met several clinical utility criteria by providing a flexible intervention on a rehabilitation ward with competing demands. We highlight the importance of contrasting findings of clinical trials with data from clinical services. In an uncontrolled, within-subjects analysis, we found that attendance of an open-group Acceptance and Commitment Therapy (ACT) based intervention was associated with reduced depressive symptoms in stroke rehabilitation inpatients Open-group psychological interventions may be an accessible and low-cost option for stroke clinicians on inpatient wards where flexibility is important [ABSTRACT FROM AUTHOR]

Background: When parents bring their child to appointments and then adhere to agreed speech and language therapy (SLT) recommendations, there is the potential to increase the intensity of the intervention, support generalization and improve outcomes. In SLT, however, little is known about factors that may promote attendance or adherence. Studies in other clinical areas such in medicine, psychology and physiotherapy have identified risk factors for non‐attendance or non‐adherence that are multifactorial and variable dependent on, for example, population and intervention. Aims: To identify rates of non‐attendance and non‐adherence, and to identify parent or child factors associated with parent involvement in intervention for children under 5 years of age receiving SLT. Methods: Parents completed questionnaires at two time points assessing the domains of parents' beliefs (problem perceptions, self‐efficacy), personal circumstances (socio‐demographics, family functioning), treatment experience and child factors. Predictors of parent attendance and adherence were identified through multiple regression analyses. Non‐attendance rates were identified via local health records and non‐adherence ascertained using a specific parent‐reported measure within the treatment experience domain. Results: Participants (N = 199) were predominantly mothers, and were ethnically and socio‐economically diverse, speaking a wide range of languages. Their children presented with a range of speech, language communication needs (SLCN). The rate of non‐attendance was 25% and the main predictors of non‐attendance were maternal age, education level and two factors within the parent beliefs domain. This model explained 40% of the variance in attendance. The rate of non‐adherence in this cohort was 26% with parental rating of the importance of a recommendation and self‐efficacy beliefs predicting adherence; this explained 56% of the variance in adherence to SLT recommendations at home. Conclusions & Implications: Our research has provided preliminary evidence of the influence of parents' beliefs, personal circumstances and treatment experiences on their involvement in their child's therapy. Speech and language therapists should consider factors impacting attendance and adherence to treatment and explore parental perceptions of their child's SLCN before embarking on an intervention, a foundation for collaborative practice. A possible limitation of this study is that the levels of attrition in our sample led to generally high measured rates of participation, which should be considered in future studies. Future research should explore adherence in treatments with varying doses, with different types of SLCN or interventions and in different settings. WHAT THIS PAPER ADDS: What is already known on the subject: It is acknowledged that parent involvement in their child's therapy, such as attending and adhering to recommendations, is important but little is known about the rates of involvement and what factors may be associated with attendance and adherence in SLT. Qualitative research has explored parental involvement suggesting that beliefs about an intervention may be pertinent. Extensive research in other clinical areas suggest multiple and varied factors are influential and further exploration of particular populations and interventions is necessary. What this paper adds to the existing knowledge: This study identified rates of parental non‐attendance and non‐adherence in a cohort of predominantly mothers of children under the age of 5 years. It is the first study to measure parent adherence in SLT and identify factors that are associated parental adherence to SLT recommendations. It adds to the small body of SLT specific research in understanding risk factors for non‐attendance. What are the potential or actual clinical implications of this work?: This study highlights the need for a speech and language therapist to consider and explore parents' perspectives of their child's SLCN as a part of achieving collaboration with a parent in order to achieve the best outcomes. It provides a foundation for further systematic research into parent involvement with the ultimate aim of enhancing outcomes for children with SLCN. [ABSTRACT FROM AUTHOR]

Frailty represents an integrative prognostic marker of risk that associates with a myriad of age-related adverse outcomes in older adults. As a concept, frailty can help to target scarce resources and identify subgroups of vulnerable older adults that may benefit from interventions or changes in medical management, such as pursing less aggressive glycaemic targets for frail older adults with diabetes. In practice, however, there are several operational challenges to implementing frailty screening outside the confines of geriatric medicine. Electronic frailty indices (eFIs) based on the theory of deficit accumulation, derived from routine data housed in the electronic health record, have emerged as a rapid, feasible and valid approach to screen for frailty at scale. The goal of this paper is to describe the early experience of three diverse groups in developing, implementing and adopting eFIs (The English National Health Service, US Department of Veterans Affairs and Atrium Health—Wake Forest Baptist). These groups span different countries and organisational complexity, using eFIs for both research and clinical care, and represent different levels of progress with clinical implementation. Using an implementation science framework, we describe common elements of successful implementation in these settings and set an agenda for future research and expansion of eFI-informed initiatives. [ABSTRACT FROM AUTHOR]

We set out to characterise chronic hepatitis B (CHB) in the primary care population in England and investigate risk factors for progression to hepatocellular carcinoma (HCC). Retrospective cohort study. We identified 8039 individuals with CHB in individuals aged ≥18 years between 1999 and 2019 in the English primary care database QResearch. HCC risk factors were investigated using Cox proportional hazards modelling. Most of those with a record of CHB were males (60%) of non-White ethnicity (>70%), and a high proportion were in the most deprived Townsend deprivation quintile (44%). Among 7029 individuals with longitudinal data, 161 HCC cases occurred. Increased HCC hazards were significantly associated with male sex (adjusted hazards ratio [aHR] 3.17, 95% confidence interval [95% CI] 1.92–5.23), in the fifth deprivation quintile as compared to the third quintile (aHR 1.69, 95% CI 1.01–2.84), with older age (for age groups 56–65 and ≥66 years, compared to 26–35 years, aHRs 2.82 [95% CI 1.45–5.46] and 3.76 [95% CI 1.79–7.9], respectively), Caribbean ethnicity (aHR 3.32, 95% CI 1.43–7.71, compared to White ethnicity), ascites (aHR 3.15, 95% CI 1.30–7.67), cirrhosis (aHR 6.55, 95% CI 4.57–9.38) and peptic ulcer disease (aHR 2.26, 95% CI 1.45–3.51). Targeting interventions and HCC surveillance at vulnerable groups is essential to improve CHB outcomes and to support progress towards international goals for the elimination of hepatitis infection as a public health threat. [ABSTRACT FROM AUTHOR]

Background: The Manchester University National Health Service (NHS) Foundation Trust (MFT) is one of the largest NHS Trusts in England. Historically, the Trust has had very mixed clinical record keeping, including over 1000 individual information systems. None of these health information technology systems had the full functionality of an integrated electronic patient record (EPR). MFT evolved to its current size and complexity with a vision to improve patient care in Greater Manchester by adopting a Trust-wide EPR. The EPR "Go Live" occurred in September 2022. Aim: To describe the process of EPR integration as it reflected and impacted upon MFT's health information management (HIM) teams. Method: MFT worked through a 2-year readiness program of work. This included technical readiness, software development and migration planning. Migration of data from the approximately 1000 systems was a major undertaking, during which access to the clinical history and ongoing operational reporting needed to be maintained. Pre-implementation requirements were outlined, a change management program was implemented, and the overall implementation was managed to tight timelines. Discussion: "Go Live" was achieved for the EPIC EPR product (HIVE) within MFT. Legacy systems are still in the process of being decommissioned and staff are transacting within HIVE. Significant changes in processes and reporting continue to be made, despite some challenges. Conclusion: The Trust delivered the single largest EPIC European "Go live." Lessons learnt continue to be identified. The impact of what the EPR means for the HIM function is described. [ABSTRACT FROM AUTHOR]

Purpose: Emotional and behavioral problems in children and young people (CYP) have increased over the pandemic. Those with pre-existing mental disorders are more vulnerable but have been understudied. We investigated emotional and behavioral outcomes in this population; differences across diagnostic groups; and social, educational, and clinical determinants. Methods: We invited 5386 caregivers and CYP (aged 5–17) under child mental health services pre-pandemic to complete an online survey on CYP's emotional/behavioral symptoms and pandemic-related circumstances, and integrated responses with clinicodemographic information extracted from electronic health records. We compared four parent-rated outcomes (total emotional/behavioral scores and emotional/behavioral changes as compared to before the pandemic) across the three most common diagnostic groups in our population (Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD) and emotional disorders (EmD)). We then estimated the association of clinicodemographic and pandemic-related characteristics with emotional/behavioral outcomes. Results: A total of 1741 parents (32.3%) completed the survey. Parents of CYP with ADHD or ASD reported more behavioral difficulties (t(591) = 5.618 (0.001); t(663) = 6.527 (0.001)); greater emotional deterioration (t(591) = 2.592 (0.009); t(664) = 4.670 (< 0.001); and greater behavioral deterioration (t(594) = 4.529 (< 0.001); t(664) = 5.082 (< 0.001)) as compared to the EmD group. Those with ASD and EmD showed more emotional difficulties than ADHD (t(891) = − 4.431 (< 0.001); t(590) = − 3.254 (0.001)). Across diagnoses, poor parental mental health and challenges with education were most strongly associated with worse outcomes. Conclusions: Within our clinical population, CYP with ADHD/ASD were the most adversely affected during lockdown. Enhancing clinical service provision that tackles parental stress and supports education may help mitigate the impact of future restrictions. [ABSTRACT FROM AUTHOR]

The article focuses on the implementation of American company 3M's M Modal speech-recognition software for automated transcription of hospital letters at University Hospital Southampton NHS Foundation Trust. It discusses the Trust's journey to streamline administrative tasks, the challenges faced, and the positive impact on cost savings, time efficiency, and staff wellbeing achieved through the adoption of this technology.

• Overall levels of vaccine uptake in England are high. • Children from London or of Black ethnicity show different vaccine uptake patterns in comparison to children from other regions or other ethnicities. • The later a vaccine was recommended within the vaccination schedule, the more likely it was not given in time. • Delay of previous vaccine doses was an indicator of delaying subsequential doses. Vaccine surveillance for children in England focuses on coverage at ages 1, 2, and 5 years. Previous studies exploring vaccine timeliness have used different arbitrary categories to define whether vaccines were received 'late' or 'on time'. This paper aims to provide more detailed and holistic information on timing and patterns of vaccine uptake across the childhood immunisation schedule in England. We included all children born in England between 2006 and 2014 and registered in the Clinical Practice Research Datalink (CPRD) Aurum, a primary care electronic health record. We described vaccine uptake for representative antigens (pertussis, pneumococcus, measles) by age in days and stratified by ethnicity, region and birth cohort. Alluvial diagrams were used to illustrate common journeys through the vaccination schedule, and we applied survival analysis using accelerated failure time models (AFT) to predict age of vaccine receipt based on timing of previous doses. 573,015 children were followed up until their fifth birthday, when they had 90.16 % coverage for two doses of measles, mumps, rubella (MMR) vaccine and 88.78% coverage for four doses of diphtheria, tetanus, pertussis (DTP) vaccine. Overall, the later the age at which a vaccine was due, the more delay in vaccination. Children of Black Ethnicity or from London showed deviating uptake patterns. If a child received their third DTP dose more than a year later than recommended, they would receive the next dose 2.7 times later than a child who was vaccinated on time. A smaller delay was found for children who did not receive first MMR dose on time. We showed that the risk of vaccination delay increased with the age of the child and significant delay of previous doses. Primary care data can help to promptly identify children at higher risk of delayed vaccination. [ABSTRACT FROM AUTHOR]

Background: Within the relatively early stages of the COVID-19 pandemic, there had been an awareness of the potential longer-term effects of infection (so called Long-COVID) but little was known of the ongoing demands such patients may place on healthcare services. Objective: To investigate whether COVID-19 illness is associated with increased post-acute healthcare utilisation. Method: Using linked data from primary care, secondary care, mental health and community services, activity volumes were compared across the 3 months preceding and proceeding COVID-19 diagnoses for 7,791 individuals, with a distinction made between whether or not patients were hospitalised for treatment. Differences were assessed against those of a control group containing individuals who had not received a COVID-19 diagnosis. All data were sourced from the authors' healthcare system in South West England. Results: For hospitalised COVID-19 cases, a statistically significant increase in non-elective admissions was identified for males and females <65 years. For non-hospitalised cases, statistically significant increases were identified in GP Doctor and Nurse attendances and GP prescriptions (males and females, all ages); Emergency Department attendances (females <65 years); Mental Health contacts (males and females ≥65 years); and Outpatient consultations (males ≥65 years). Conclusion: There is evidence of an association between positive COVID-19 diagnosis and increased post-acute activity within particular healthcare settings. Linked patient-level data provides information that can be useful to understand ongoing healthcare needs resulting from Long-COVID, and support the configuration of Long-COVID pathways of care. [ABSTRACT FROM AUTHOR]

Purpose: To assess the risk of incident cardiovascular outcomes after COVID-19 by level of cardiovascular risk in waves one and two of the pandemic in England in 2020.Patients and methods: We conducted a self-controlled case-series study among adults aged 40– 84 years with no pre-existing cardiovascular disease using linked data from the Clinical Practice Research Datalink. We generated season-adjusted incidence ratios (IRs) for first acute cardiovascular event after SARS-CoV-2 infection compared with baseline time before and > 91 days after infection. We used composite and individual acute cardiovascular event outcomes including myocardial infarction, major ventricular arrhythmia, left ventricular heart failure, and ischemic stroke. We stratified by cardiovascular risk, using diagnosed hypertension and QRISK3 predicted risk, and by wave one and two of the pandemic.Results: We included 1762 individuals, 76.6% had a QRISK3 score ≥ 10% and 59.4% had hypertension. The risk of any cardiovascular event was elevated in the 1– 7 days after infection (IR 7.14 [95% CI 6.06– 8.41]) and, while the effect size tapered, the risk remained for 15– 28 days after infection (1.74 [1.33– 2.26]). Risks were similar for individual event type, differing by level of cardiovascular risk, and in wave one and two of the pandemic.  Conclusion: SARS-CoV-2 infection is associated with early elevations in the risk of first acute cardiovascular event, across cardiovascular risk levels and in both wave one and two of the pandemic. Prevention of COVID-19 is important to avert cardiovascular complications. [ABSTRACT FROM AUTHOR]

Background: Acute Kidney Injury (AKI) is a multifactorial condition which presents a substantial burden to healthcare systems. There is limited evidence on whether it is seasonal. We sought to investigate the seasonality of AKI hospitalisations in England and use unsupervised machine learning to explore clustering of underlying comorbidities, to gain insights for future intervention. Methods: We used Hospital Episodes Statistics linked to the Clinical Practice Research Datalink to describe the overall incidence of AKI admissions between 2015 and 2019 weekly by demographic and admission characteristics. We carried out dimension reduction on 850 diagnosis codes using multiple correspondence analysis and applied k-means clustering to classify patients. We phenotype each group based on the dominant characteristics and describe the seasonality of AKI admissions by these different phenotypes. Results: Between 2015 and 2019, weekly AKI admissions peaked in winter, with additional summer peaks related to periods of extreme heat. Winter seasonality was more evident in those diagnosed with AKI on admission. From the cluster classification we describe six phenotypes of people admitted to hospital with AKI. Among these, seasonality of AKI admissions was observed among people who we described as having a multimorbid phenotype, established risk factor phenotype, and general AKI phenotype. Conclusion: We demonstrate winter seasonality of AKI admissions in England, particularly among those with AKI diagnosed on admission, suggestive of community triggers. Differences in seasonality between phenotypes suggests some groups may be more likely to develop AKI as a result of these factors. This may be driven by underlying comorbidity profiles or reflect differences in uptake of seasonal interventions such as vaccines. [ABSTRACT FROM AUTHOR]

Aims: The Evaluation of the Methods and Management of Acute Coronary Events (EMMACE) longitudinal cohort study aims to investigate health trajectories of individuals following hospitalization for myocardial infarction (MI). Methods and results: EMMACE is a linked multicentre prospective cohort study of 14 899 patients with MI admitted to 77 hospitals in England who participated in the EMMACE-3 and -4 studies between 1st November 2011 and 24th June 2015. Long-term followup of the EMMACE cohorts was conducted through the EMMACE-XL (27th September 2020 to 31st March 2022) and EMMACE-XXL (1st July 2021 to 1st July 2023) studies. EMMACE collected individual participant data for health-related quality of life (HRQoL) measured by three-level EuroQol five-dimension and visual analogy scale at admission, 1 month, 6 months, 12 months, and 10 years follow-up, as well as medications, medication adherence, beliefs about medicines, Satisfaction with Information about Medicines Scale, and illness perceptions. Participant data were deterministically linked to the Myocardial Infarction National Audit Project (MINAP) for information on baseline treatments and comorbidities, Hospit al Episode St atistics Admitted Patient Care (for cause-specific hospitalization data), and the Office for National St atistics (for mort ality dat a) up to 2020. Conclusion: EMMACE is a nationwide prospective cohort that will provide unique insights into fatal and non-fatal outcomes, medication adherence, and HRQoL following MI. [ABSTRACT FROM AUTHOR]

Background Few studies describe the epidemiology of childhood acute kidney injury (AKI) nationally. Laboratories in England are required to issue electronic (e-)alerts for AKI based on serum creatinine changes. This study describes a national cohort of children who received an AKI alert and their clinical course. Methods A cross-section of AKI episodes from 2017 are described. Hospital record linkage enabled description of AKI-associated hospitalizations including length of stay (LOS) and critical care requirement. Risk associations with critical care (hospitalized cohort) and 30-day mortality (total cohort) were examined using multivariable logistic regression. Results In 2017, 7788 children (52% male, median age 4.4 years, interquartile range 0.9–11.5 years) experienced 8927 AKI episodes; 8% occurred during birth admissions. Of 5582 children with hospitalized AKI, 25% required critical care. In children experiencing an AKI episode unrelated to their birth admission, Asian ethnicity, young (<1 year) or old (16–<18 years) age (reference 1–<5 years), and high peak AKI stage had higher odds of critical care. LOS was higher with peak AKI stage, irrespective of critical care admission. Overall, 30-day mortality rate was 3% (n =  251); youngest and oldest age groups, hospital-acquired AKI, higher peak stage and critical care requirement had higher odds of death. For children experiencing AKI alerts during their birth admission, no association was seen between higher peak AKI stage and critical care admission. Conclusions Risk associations for adverse AKI outcomes differed among children according to AKI type and whether hospitalization was related to birth. Understanding the factors driving AKI development and progression may help inform interventions to minimize morbidity. [ABSTRACT FROM AUTHOR]

Background: Antihypertensives reduce the risk of cardiovascular disease but are also associated with harms including acute kidney injury (AKI). Few data exist to guide clinical decision making regarding these risks. Aim: To develop a prediction model estimating the risk of AKI in people potentially indicated for antihypertensive treatment. Design and setting: Observational cohort study using routine primary care data from the Clinical Practice Research Datalink (CPRD) in England. Method: People aged ≥40 years, with at least one blood pressure measurement between 130 mmHg and 179 mmHg were included. Outcomes were admission to hospital or death with AKI within 1, 5, and 10 years. The model was derived with data from CPRD GOLD (n = 1 772 618), using a Fine–Gray competing risks approach, with subsequent recalibration using pseudo-values. External validation used data from CPRD Aurum (n = 3 805 322). Results: The mean age of participants was 59.4 years and 52% were female. The final model consisted of 27 predictors and showed good discrimination at 1, 5, and 10 years (C-statistic for 10-year risk 0.821, 95% confidence interval [CI] = 0.818 to 0.823). There was some overprediction at the highest predicted probabilities (ratio of observed to expected event probability for 10-year risk 0.633, 95% CI = 0.621 to 0.645), affecting patients with the highest risk. Most patients (>95%) had a low 1- to 5-year risk of AKI, and at 10 years only 0.1% of the population had a high AKI and low CVD risk. Conclusion: This clinical prediction model enables GPs to accurately identify patients at high risk of AKI, which will aid treatment decisions. As the vast majority of patients were at low risk, such a model may provide useful reassurance that most antihypertensive treatment is safe and appropriate while flagging the few for whom this is not the case. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has had a significant impact on delivery of NHS care. We have developed the OpenSAFELY Service Restoration Observatory (SRO) to develop key measures of primary care activity and describe the trends in these measures throughout the COVID-19 pandemic. Methods: With the approval of NHS England, we developed an open source software framework for data management and analysis to describe trends and variation in clinical activity across primary care electronic health record (EHR) data on 48 million adults. We developed SNOMED-CT codelists for key measures of primary care clinical activity such as blood pressure monitoring and asthma reviews, selected by an expert clinical advisory group and conducted a population cohort-based study to describe trends and variation in these measures January 2019-December 2021, and pragmatically classified their level of recovery one year into the pandemic using the percentage change in the median practice level rate. Results: We produced 11 measures reflective of clinical activity in general practice. A substantial drop in activity was observed in all measures at the outset of the COVID-19 pandemic. By April 2021, the median rate had recovered to within 15% of the median rate in April 2019 in six measures. The remaining measures showed a sustained drop, ranging from a 18.5% reduction in medication reviews to a 42.0% reduction in blood pressure monitoring. Three measures continued to show a sustained drop by December 2021. Conclusions: The COVID-19 pandemic was associated with a substantial change in primary care activity across the measures we developed, with recovery in most measures. We delivered an open source software framework to describe trends and variation in clinical activity across an unprecedented scale of primary care data. We will continue to expand the set of key measures to be routinely monitored using our publicly available NHS OpenSAFELY SRO dashboards with near real-time data. [ABSTRACT FROM AUTHOR]

Background: Medication reviews in primary care provide an opportunity to review and discuss the safety and appropriateness of a person's medicines. However, there is limited evidence about access to and the impact of routine medication reviews for older adults in the general population, particularly in the UK. We aimed to quantify the proportion of people aged 65 years and over with a medication review recorded in 2019 and describe changes in the numbers and types of medicines prescribed following a review. Methods: We used anonymised primary care electronic health records from the UK's Clinical Practice Research Datalink (CPRD GOLD) to define a population of people aged 65 years or over in 2019. We counted people with a medication review record in 2019 and used Cox regression to estimate associations between demographic characteristics, diagnoses, and prescribed medicines and having a medication review. We used linear regression to compare the number of medicines prescribed as repeat prescriptions in the three months before and after a medication review. Specifically, we compared the 'prescription count' - the maximum number of different medicines with overlapping prescriptions people had in each period. Results: Of 591,726 people prescribed one or more medicines at baseline, 305,526 (51.6%) had a recorded medication review in 2019. Living in a care home (hazard ratio 1.51, 95% confidence interval 1.40-1.62), medication review in the previous year (1.83, 1.69-1.98), and baseline prescription count (e.g. 5-9 vs 1 medicine 1.41, 1.37-1.46) were strongly associated with having a medication review in 2019. Overall, the prescription count tended to increase after a review (mean change 0.13 medicines, 95% CI 0.12-0.14). Conclusions: Although medication reviews were commonly recorded for people aged 65 years or over, there was little change overall in the numbers and types of medicines prescribed following a review. This study did not examine whether the prescriptions were appropriate or other metrics, such as dose or medicine changes within the same class. However, by examining the impact of medication reviews before the introduction of structured medication review requirements in England in 2020, it provides a useful benchmark which these new reviews can be compared with. [ABSTRACT FROM AUTHOR]

Background: Antipsychotic polypharmacy (APP) occurs commonly but it is unclear whether it is associated with an increased risk of adverse drug reactions (ADRs). Electronic health records (EHRs) offer an opportunity to examine APP using real-world data. In this study, we use EHR data to identify periods when patients were prescribed 2 + antipsychotics and compare these with periods of antipsychotic monotherapy. To determine the relationship between APP and subsequent instances of ADRs: QT interval prolongation, hyperprolactinaemia, and increased body weight [body mass index (BMI) ⩾ 25]. Methods: We extracted anonymised EHR data. Patients aged 16 + receiving antipsychotic medication at Camden & Islington NHS Foundation Trust between 1 January 2008 and 31 December 2018 were included. Multilevel mixed-effects logistic regression models were used to elucidate the relationship between APP and the subsequent presence of QT interval prolongation, hyperprolactinaemia, and/or increased BMI following a period of APP within 7, 30, or 180 days respectively. Results: We identified 35 409 observations of antipsychotic prescribing among 13 391 patients. Compared with antipsychotic monotherapy, APP was associated with a subsequent increased risk of hyperprolactinaemia (adjusted odds ratio 2.46; 95% CI 1.87–3.24) and of registering a BMI > 25 (adjusted odds ratio 1.75; 95% CI 1.33–2.31) in the period following the APP prescribing. Conclusions: Our observations suggest that APP should be carefully managed with attention to hyperprolactinaemia and obesity. [ABSTRACT FROM AUTHOR]

Purpose: Lengthy and complex routes to specialist care may negatively affect clinical profiles of trauma survivors accessing mental health services. The purpose of this study was to describe the characteristics and referral pathways of a cohort of clients accepted by a specialist trauma service in England; and investigate the associations between referral pathways and clients' clinical profiles, namely, pre-treatment levels of post-traumatic stress, depression, anxiety, stress and post-traumatic growth. Design/methodology/approach: Data on 117 consecutive, accepted referrals were extracted from clients' clinical records. Information on demographics, trauma histories, clinical presentations and referral pathways was synthesised through summary statistics. Correlational analyses were conducted to test associations with pre-treatment scores. Findings: Clients accessing the service were highly complex and mostly experienced prolonged, interpersonal trauma. Pathways to the service varied, but 50% of the sample had at least four "steps" in their referral histories and seven previous clinical contacts. The average time between trauma and specialist referral was 16.34 years. The number of referral steps positively, significatively and moderately correlated with anxiety and stress at pre-treatment. Research limitations/implications: Limitations include issues around collecting past referral information, the small sample size for clients with available pre-treatment data and the lack of post-treatment scores. Originality/value: This evaluation provides an informative overview of the characteristics and referral pathways of clients accessing a specialist trauma service. It also offers preliminary insights on the relationship between clients' routes into the service and their clinical profiles. Practice, commissioning and research implications are discussed. [ABSTRACT FROM AUTHOR]

Fleas in the genus Ctenocephalides are the most clinically important parasitic arthropods of dogs and cats worldwide yet risk factors that might increase the risk of infestation in small animals remains unclear. Here we developed a supervised text mining approach analysing key aspects of flea epidemiology using electronic health records from domestic cats and dogs seen at a sentinel network of 191 voluntary veterinary practices across Great Britain between March 2014 and July 2020. Our methods identified fleas as likely to have been present during 22,276 of 1,902,016 cat consultations (1.17%) and 12,168 of 4,844,850 dog consultations (0.25%). Multivariable logistic regression modelling found that animals originating from areas of least deprivation were associated with 50% reductions in odds of veterinary‐recorded flea infestation compared to the most deprived regions in England. Age of the animal was significantly associated with flea presentation in both cats and dogs, with cases peaking before animals reached 12 months. Cases were recorded through each study years, peaking between July and October, with fluctuations between each year. Our findings can be used towards healthcare messaging for veterinary practitioners and owners. [ABSTRACT FROM AUTHOR]

Background: NHS England have announced plans to enable all adult patients to have full prospective access to their primary care record by default. Despite this, little is known about the views and experiences of primary care staff regarding patients' online records access (ORA). Aim: To examine the views and experiences of primary care staff regarding patients having online access to their primary care health record, and how this service could be supported and improved. Design and setting: A qualitative study of a purposive sample of 30 primary care staff in England. Method: Online semi-structured interviews with primary care staff were conducted between December 2021 and March 2022. Verbatim transcripts were analysed inductively using thematic analysis. Results: Most staff agreed with the principle of patient access to online health records but had mixed feelings regarding the potential benefits and drawbacks of applying this in practice. Staff identified opportunities for improving patient engagement, health literacy, and efficiencies in some administrative workloads, as well as concerns about maintaining the clinical integrity of patient records and ensuring that staff and patient safety and wellbeing are protected. Conclusion: Participants acknowledged that ORA may transform the purpose and function of the record and that ORA has potential to instigate a significant cultural shift in primary care, changing how staff work and relate to patients. This underlines the need for additional staff training and support to expand capability and capacity to adapt practice and enhance patient engagement with, and understanding of, their health records. [ABSTRACT FROM AUTHOR]

PURPOSE: To identify early-phase clinical trial (EP-CT) participants at risk for experiencing worse clinical outcomes and describe receipt of supportive care services. METHODS: A retrospective review of the electronic health records of consecutive patients enrolled in EP-CTs from 2017 to 2019 examined baseline characteristics, clinical outcomes, and receipt of supportive care services. The validated Royal Marsden Hospital (RMH) prognosis score was calculated using data at the time of EP-CT enrollment (scores range from 0 to 3; scores = 2 indicate poor prognosis). Differences in patient characteristics, clinical outcomes, and receipt of supportive care services were compared on the basis of RMH scores. RESULTS: Among 350 patients (median age = 63.2 years [range, 23.0-84.3 years], 57.1% female, 98.0% metastatic cancer), 31.7% had an RMH score indicating a poor prognosis. Those with poor prognosis RMH scores had worse overall survival (hazard ratio [HR], 2.00; P < .001), shorter time on trial (HR, 1.53; P < .001), and lower likelihood of completing the dose-limiting toxicity period (odds ratio, 0.42; P = .006) versus those with good prognosis scores. Patients with poor prognosis scores had greater risk of emergency room visits (HR, 1.66; P = .037) and hospitalizations (HR, 1.69; P = .016) while on trial, and earlier hospice enrollment (HR, 2.22; P = .006). Patients with poor prognosis scores were significantly more likely to receive palliative care consultation (46.8% v 27.6%; P < .001), but not other supportive care services. CONCLUSION: This study found that RMH prognosis score could identify patients at risk for decreased survival, shorter time on trial, and greater use of health care services. The findings underscore the need to develop supportive care interventions targeting EP-CT participants' distinct needs. [ABSTRACT FROM AUTHOR]

Objectives This study aimed to measure (1) the proportion of children who continue to receive specialist care (rheumatology/ophthalmology) as adults, (2) the characteristics associated with continuing specialist care, and (3) the frequency of specialist care appointments in both paediatric and adult services. Methods A retrospective cohort of young people with JIA was identified from UK primary care electronic health records (Clinical Practice Research Datalink) between 1 April 2003 and 31 December 2018. To be included in the study, cases needed to have at least 1 year of registration at their general practice beyond age 18 and linkage to Hospital Episodes Statistics data for secondary care information. All specialist care outpatient visits were identified from Hospital Episodes Statistics outpatient data. Results There were 666 young people included in the study. Of these, 427 (64%) received specialist care beyond age 18, 90 (13%) had their last recorded contact at 16–17 years and 149 (22%) did not continue after 16 years. Older age at diagnosis, female gender, less deprivation and a childhood diagnosis of uveitis were associated with continuing specialist care beyond age 18. Of those continuing beyond 18, 35% (n  = 153) were subsequently discharged by the study end date. Of all those discharged, 32% had a missed appointment recorded after the last attended visit, suggesting failure to attend. Conclusions Two-thirds of young people with JIA continue to receive specialist care beyond age 18. This is useful information for children and young people with JIA and their families planning for their future, and for clinicians planning health-care services. [ABSTRACT FROM AUTHOR]

Introduction frailty is common in older adults and is associated with increased health and social care use. Longitudinal information is needed on population-level incidence, prevalence and frailty progression to plan services to meet future population needs. Methods retrospective open cohort study using electronic health records of adults aged ≥50 from primary care in England, 2006–2017. Frailty was calculated annually using the electronic Frailty Index (eFI). Multistate models estimated transition rates between each frailty category, adjusting for sociodemographic characteristics. Prevalence overall for each eFI category (fit, mild, moderate and severe) was calculated. Results the cohort included 2,171,497 patients and 15,514,734 person-years. Frailty prevalence increased from 26.5 (2006) to 38.9% (2017). The average age of frailty onset was 69; however, 10.8% of people aged 50–64 were already frail in 2006. Estimated transitions from fit to any level of frailty were 48/1,000 person-years aged 50–64, 130/1,000 person-years aged 65–74, 214/1,000 person-years aged 75–84 and 380/1,000 person-years aged ≥ 85. Transitions were independently associated with older age, higher deprivation, female sex, Asian ethnicity and urban dwelling. Mean time spent in each frailty category decreased with age, with the longest period spent in severe frailty at all ages. Conclusions frailty is prevalent in adults aged ≥50 and time spent in successive frailty states is longer as frailty progresses, resulting in extended healthcare burden. Larger population numbers and fewer transitions in adults aged 50–64 present an opportunity for earlier identification and intervention. A large increase in frailty over 12 years highlights the urgency of informed service planning in ageing populations. [ABSTRACT FROM AUTHOR]

Background: The accuracy of prognostication has important implications for patients, families, and health services since it may be linked to clinical decision-making, patient experience and outcomes and resource allocation. Study aim is to evaluate the accuracy of temporal predictions of survival in patients with cancer, dementia, heart, or respiratory disease. Methods: Accuracy of clinical prediction was evaluated using retrospective, observational cohort study of 98,187 individuals with a Coordinate My Care record, the Electronic Palliative Care Coordination System serving London, 2010–2020. The survival times of patients were summarised using median and interquartile ranges. Kaplan Meier survival curves were created to describe and compare survival across prognostic categories and disease trajectories. The extent of agreement between estimated and actual prognosis was quantified using linear weighted Kappa statistic. Results: Overall, 3% were predicted to live "days"; 13% "weeks"; 28% "months"; and 56% "year/years". The agreement between estimated and actual prognosis using linear weighted Kappa statistic was highest for patients with dementia/frailty (0.75) and cancer (0.73). Clinicians' estimates were able to discriminate (log-rank p < 0.001) between groups of patients with differing survival prospects. Across all disease groups, the accuracy of survival estimates was high for patients who were likely to live for fewer than 14 days (74% accuracy) or for more than one year (83% accuracy), but less accurate at predicting survival of "weeks" or "months" (32% accuracy). Conclusion: Clinicians are good at identifying individuals who will die imminently and those who will live for much longer. The accuracy of prognostication for these time frames differs across major disease categories, but remains acceptable even in non-cancer patients, including patients with dementia. Advance Care Planning and timely access to palliative care based on individual patient needs may be beneficial for those where there is significant prognostic uncertainty; those who are neither imminently dying nor expected to live for "years". [ABSTRACT FROM AUTHOR]

Despite associations between alcohol use and suicidal acts, little research measures prognoses of alcohol‐using patients treated by Crisis Resolution Teams (CRTs), an intensive community‐based intervention. We estimated the association of alcohol use amongst patients accepted following suicidal acts or ideation in four London‐based Crisis Resolution Teams, with death‐by‐any‐cause or recontact with crisis care. We analysed the electronic health records of 1615 CRT patients accepted following suicidal acts or ideation over 38 months, following STROBE guidelines. Using logistic regression we estimated the association of alcohol use (indicated by risk‐assessment, AUDIT, or ICD‐10 diagnosis) with death‐or‐recontact at (i) 30‐days and (ii) 1‐year after treatment start, adjusted for age, sex, ethnicity, psychiatric diagnosis, and severity of need. Hazardous, harmful, or dependent drinking was identified in 270 cases at baseline (16.7%); 73 (4.5%) were alcohol dependent. By 1‐year, 622 patients (38.5%) had recontacted crisis care or died. After adjustment, alcohol use at a hazardous, harmful, or dependent level was not associated with increased odds of death‐or‐recontact at 30‐days (AOR 1.17, 95%CI 0.73, 1.88) or 1‐year (AOR 1.17, 95%CI 0.85, 1.60). Patients with hazardous, harmful, and dependent alcohol use are a small proportion of CRT patients, despite being more commonly encountered in emergency settings from which patients may be referred to CRTs, indicating a potential gap in provision. Those who are included in CRTs are not at increased risk of death‐or‐recontact within 1 year of treatment, suggesting that their inclusion can work, at least in a sample with predominantly hazardous or harmful alcohol use. [ABSTRACT FROM AUTHOR]

Background: Understanding how socioeconomic position influences the symptoms and concerns of patients approaching the end of life is important for planning more equitable care. Data on this relationship is lacking, particularly for patients with non-cancer conditions. Aim: To analyse the association between socioeconomic position and the symptoms and concerns of older adult patients seen by specialist palliative care. Design: Secondary analysis of cross-sectional, routinely collected electronic patient data. We used multivariable linear regression with robust standard errors, to predict scores on the three subscales of the Integrated Palliative care Outcome Scale (IPOS; physical symptoms, emotional symptoms and communication and practical concerns) based on patient level of deprivation, measured using Index of Multiple Deprivation. Setting/participants: Consecutive inpatients aged 60 years and over, seen by specialist palliative care at two large teaching hospitals in London between 1st January 2016 and 31st December 2019. Results: Seven thousand eight hundred and sixty patients were included, 38.3% had cancer. After adjusting for demographic and clinical characteristics, patients living in the most deprived areas had higher (worse) predicted mean scores on the communication and practical subscale than patients living in the least deprived areas, 5.38 (95% CI: 5.10, 5.65) compared to 4.82 (4.62, 5.02) respectively. This effect of deprivation diminished with increasing age. Deprivation was not associated with scores on the physical or emotional symptoms subscales. Conclusions: Targetting resources to address practical and communication concerns could be a strategy to reduce inequalities. Further research in different hospitals and across different settings using patient centred outcome measures is needed to examine inequalities. [ABSTRACT FROM AUTHOR]

Aims: Many risk prediction models have been proposed for heart failure (HF), but few studies have used only information available to general practitioners (GPs) in primary care electronic health records (EHRs). We describe the predictors and performance of models built from GP‐based EHRs in two cohorts of patients 10 years apart. Methods and results: Linked primary and secondary care data for incident HF cases in England were extracted from the Clinical Practice Research Datalink for 2001–02 and 2011–12. Time‐to‐event models for all‐cause mortality were developed using a long list of potential baseline predictors. Discrimination and calibration were calculated. A total of 5966 patients in 156 general practices were diagnosed in 2001–02, and 12 827 patients in 331 practices were diagnosed in 2011–12. The 5‐year survival rate was 40.0% in 2001–02 and 40.2% in 2011–12, though the latter population were older, frailer, and more comorbid; for 2001–02, the 10‐year survival was 20.8% and 15‐year survival 11.1%. Consistent predictors included age, male sex, systolic blood pressure, body mass index, GP domiciliary visits before diagnosis, and some comorbidities. Model performance for both time windows was modest (c = 0.70), but calibration was generally excellent in both time periods. Conclusions: Information routinely available to UK GPs at the time of diagnosis of HF gives only modest predictive accuracy of all‐cause mortality, making it hard to decide on the type, place, and urgency of follow‐up. More consistent recording of data relevant to HF (such as echocardiography and natriuretic peptide results) in GP EHRs is needed to support accurate prediction of healthcare needs in individuals with HF. [ABSTRACT FROM AUTHOR]

Background: Individuals from minority ethnic groups in the UK are thought to be at higher risk of developing dementia while facing additional barriers to receiving timely care. However, few studies in the UK have examined if there are ethnic disparities in survival once individuals receive a dementia diagnosis. Methods: We conducted a retrospective cohort study using electronic health record data of individuals diagnosed with dementia from a large secondary mental healthcare provider in London. Patients from Black African, Black Caribbean, South Asian, White British, and White Irish ethnic backgrounds were followed up for a 10-year period between 01 January 2008 and 31 December 2017. Data were linked to death certificate data from the Office of National Statistics to determine survival from dementia diagnosis. Standardised mortality ratios were calculated to estimate excess deaths in each ethnicity group as compared to the gender- and age-standardised population of England and Wales. We used Cox regression models to compare survival after dementia diagnosis across each ethnicity group. Results: Mortality was elevated at least twofold across all ethnicity groups with dementia compared to the general population in England and Wales. Risk of death was lower in Black Caribbean, Black African, White Irish, and South Asian groups as compared to the White British population, even after adjusting for age, gender, neighbourhood-level deprivation, indicators of mental and physical comorbidities. Risk of death remained lower after additionally accounting for those who emigrated out of the cohort. Conclusions: While mortality in dementia is elevated across all ethnic groups as compared to the general population, reasons for longer survival in minority ethnic groups in the UK as compared to the White British group are unclear and merit further exploration. Implications of longer survival, including carer burden and costs, should be considered in policy and planning to ensure adequate support for families and carers of individuals with dementia. [ABSTRACT FROM AUTHOR]

Background: This descriptive study assessed the completeness, agreement, and representativeness of ethnicity recording in the United Kingdom (UK) Clinical Practice Research Datalink (CPRD) primary care databases alone and, for those patients registered with a GP in England, when linked to secondary care data from Hospital Episode Statistics (HES). Methods: Ethnicity records were assessed for all patients in the May 2021 builds of the CPRD GOLD and CPRD Aurum databases for all UK patients. In analyses of the UK, English data was from combined CPRD-HES, whereas data from Northern Ireland, Scotland, and Wales drew from CPRD only. The agreement of ethnicity records per patient was assessed within each dataset (CPRD GOLD, CPRD Aurum, and HES datasets) and between datasets at the highest level ethnicity categorisation ('Asian', 'black', 'mixed', 'white', 'other'). Representativeness was assessed by comparing the ethnic distributions at the highest-level categorisation of CPRD-HES to those from the Census 2011 across the UK's devolved administrations. Additionally, CPRD-HES was compared to the experimental ethnic distributions for England and Wales from the Office for National Statistics in 2019 (ONS2019) and the English ethnic distribution from May 2021 from NHS Digital's General Practice Extraction Service Data for Pandemic Planning and Research with HES data linkage (GDPPR-HES). Results: In CPRD-HES, 81.7% of currently registered patients in the UK had ethnicity recorded in primary care. For patients with multiple ethnicity records, mismatched ethnicity within individual primary and secondary care datasets was < 10%. Of English patients with ethnicity recorded in both CPRD and HES, 93.3% of records matched at the highest-level categorisation; however, the level of agreement was markedly lower in the 'mixed' and 'other' ethnic groups. CPRD-HES was less proportionately 'white' compared to the UK Census 2011 (80.3% vs. 87.2%) and experimental ONS2019 data (80.4% vs. 84.3%). CPRD-HES was aligned with the ethnic distribution from GDPPR-HES ('white' 80.4% vs. 80.7%); however, with a smaller proportion classified as 'other' (1.1% vs. 2.8%). Conclusions: CPRD-HES has suitable representation of all ethnic categories with some overrepresentation of minority ethnic groups and a smaller proportion classified as 'other' compared to the UK general population from other data sources. CPRD-HES data is useful for studying health risks and outcomes in typically underrepresented groups. [ABSTRACT FROM AUTHOR]

Background Methods for linking records between two datasets are well established. However, guidance is needed for linking more than two datasets. Using all 'pairwise linkages'—linking each dataset to every other dataset—is the most inclusive, but resource-intensive, approach. The 'spine' approach links each dataset to a designated 'spine dataset', reducing the number of linkages, but potentially reducing linkage quality. Methods We compared the pairwise and spine linkage approaches using real-world data on patients undergoing emergency bowel cancer surgery between 31 October 2013 and 30 April 2018. We linked an administrative hospital dataset (Hospital Episode Statistics; HES) capturing patients admitted to hospitals in England, and two clinical datasets comprising patients diagnosed with bowel cancer and patients undergoing emergency bowel surgery. Results The spine linkage approach, with HES as the spine dataset, created an analysis cohort of 15 826 patients, equating to 98.3% of the 16 100 patients identified using the pairwise linkage approach. There were no systematic differences in patient characteristics between these analysis cohorts. Associations of patient and tumour characteristics with mortality, complications and length of stay were not sensitive to the linkage approach. When eligibility criteria were applied before linkage, spine linkage included 14 509 patients (90.0% compared with pairwise linkage). Conclusion Spine linkage can be used as an efficient alternative to pairwise linkage if case ascertainment in the spine dataset and data quality of linkage variables are high. These aspects should be systematically evaluated in the nominated spine dataset before spine linkage is used to create the analysis cohort. [ABSTRACT FROM AUTHOR]