Search

OBJECTIVE People living with type 2 diabetes (T2D) are at higher infection risk, but it is unknown how this risk varies by ethnicity or whether the risk is similarly observed in people with nondiabetic hyperglycemia (“prediabetes”). RESEARCH DESIGN AND METHODS We included 527,151 patients in England with T2D and 273,216 with prediabetes, aged 18–90, and alive on 1 January 2015 on the Clinical Practice Research Datalink. Each was matched to two patients without diabetes or prediabetes on age, sex, and ethnic group. Infections during 2015–2019 were collated from primary care and linked hospitalization records. Infection incidence rate ratios (IRRs) for those with prediabetes or T2D were estimated, unadjusted and adjusted for confounders. RESULTS People with T2D had increased risk for infections presenting in primary care (IRR 1.51, 95% CI 1.51–1.52) and hospitalizations (IRR 1.91, 1.90–1.93). This was broadly consistent overall within each ethnic group, although younger White T2D patients (age CONCLUSIONS The elevated infection risk for people with T2D appears similar for different ethnic groups and is also seen in people with prediabetes. Infections are a substantial cause of ill-health and health service use for people with prediabetes and T2D. This has public health implications with rising prediabetes and diabetes prevalence.

Aims To investigate the longitudinal exposure of English primary care patients to pharmacogenomic drugs to inform design of pre-emptive testing. Methods Sixty-three drugs were identified with dosing guidelines based on variants of 19 pharmacogenes in the Pharmacogenomics Knowledgebase on 01 September 2018. Prescribing of these pharmacogenomic drugs between 1993 and 2017 was summarised for a sample of 648 141 English patients aged 50-99 years on 01 January 2013, registered with Clinical Practice Research Datalink practices during 2011-12. Exposure of patients to pharmacogenomic drugs retrospectively (2, 10, 20 y) and prospectively (5 y) was described. Results During 2011-12, 58% of patients were prescribed at least 1 pharmacogenomic drug, increasing to 80% over the previous 20 years. Multiple exposure was common, with 47% patients prescribed ≥2 pharmacogenomic drugs and 7% prescribed ≥5 pharmacogenomic drugs over the next 5 years. The likelihood of exposure to pharmacogenomic drugs increased with age, with 89% patients ≥70 years prescribed at least 1 pharmacogenomic drug over the previous 20 years. Even among those aged 50-59 years, 71% were prescribed at least 1 pharmacogenomic drug over the previous 20 years. The pharmacogenomic drugs prescribed to the most patients were for pain relief, gastroprotection, psychiatric and cardiovascular conditions. Three pharmacogenes (CYP2D6, CYP2C19 and SLCO1B1) accounted for >95% pharmacogenomic drugs prescribed. Conclusions In primary care patients, exposure to pharmacogenomic drugs is extremely common, multiplicitous and has commenced by relatively early adulthood. A small number of pharmacogenes account for the majority of drugs prescribed. These findings could inform design of pre-emptive pharmacogenomic testing for implementation in primary care.

OBJECTIVE Diabetes guidelines focus on target glycated hemoglobin (HbA1c) levels. Long-term variability in HbA1c may be predictive of hospitalization or mortality, but its importance at different average levels or trajectories is unclear. RESEARCH DESIGN AND METHODS Using English primary care data, 58,832 patients with type 2 diabetes had HbA1c average (mean of annual means), variability (coefficient of variation), and trajectory (annual regression slope) estimated during 2006–2009. Hazard ratios (HRs) for mortality and emergency hospitalization during 2010–2015, with adjustment for age, sex, smoking, BMI, duration of diabetes, and deprivation, were estimated using Cox regression. The simultaneous impact of HbA1c average, variability, and trajectory was estimated using percentiles. RESULTS In mutually adjusted models, HbA1c variability showed a consistent dose-response relationship with all-cause mortality, while average level was only important among individuals in the highest or lowest 10% of the distribution, and trajectory had no independent effect. Individuals with the most unstable HbA1c (top 10%) were almost twice as likely to die (HR 1.93 [95% CI 1.72–2.16]) than were those with the most stable (bottom 10%)—an association attenuated but not explained by hypoglycemia. For emergency hospitalizations, similar trends were seen except for coronary artery disease (CAD) and ischemic stroke (IS), where increasing average rather than variability was predictive. CONCLUSIONS HbA1c variability was strongly associated with overall mortality and emergency hospitalization and not explained by average HbA1c or hypoglycemic episodes. Only for CAD and IS hospitalizations was no association found, with average HbA1c strongly predictive. Targets should focus on both stability and absolute level of HbA1c.

Background The first wave of the COVID-19 pandemic in England resulted in an approximate 50% increase in all-cause mortality during mid-March to mid-May 2020. Previous analyses have studied COVID-related deaths, but these were under-recorded early in the pandemic due to paucity of virological testing. We propose a novel method to identify excess mortality during the pandemic by accounting for usual all-cause mortality in pre-pandemic years using a large electronic primary care database. We estimated the impact of risk factors (RFs) on excess mortality during the first wave and compared these with the impact of the same RFs on total mortality in non-pandemic times. Methods An average of 4.8 million patients aged 30–104 years active in 770 CPRD Aurum practices between 18th March and 19th May over a 6-year period (2015–2020) were included. Concurrent medical history, ethnicity, area-based deprivation and fatalities were extracted for each year. Poisson regression models fitted total mortality adjusting for age and sex, with interactions between each RF and the pandemic and reference periods. Total mortality during the pandemic was partitioned into ‘usual’ and ‘excess’ components, assuming 2015–19 rates represented ‘usual’ mortality. The association of each RF with the 2020 ‘excess’ component was derived as the excess mortality ratio (EMR), to compare with the usual mortality ratio (UMR). Results RFs where excess mortality was greatest and notably higher than usual were age >80, black ethnicity, BMI>40, dementia, learning disability, London practices and people in care-homes. For example, people of black ethnicity vs. white had an EMR=2.50 (95%CI 1.97–3.18) compared to a UMR=0.92 (95%CI 0.85–1.00). Excess mortality was more comparable to usual mortality for sex and area deprivation. The EMR for men (1.46, 95%CI 1.32–1.60) was not significantly different than the UMR=1.34 (95%CI 1.32–1.37). The EMR=2.05 (95%CI 1.76–2.38) in the most deprived quintile (vs. least) was only slightly higher than the UMR=1.70 (95%CI 1.65–1.75). Although some RFs produced EMRs significantly lower than their UMRs (Cancer, COPD), the EMRs were still >1. However, current smoking was inversely associated with excess mortality: while current smokers were 64% more likely to die than non-smokers in 2020, when the UMR=2.12 (95%CI 2.07–2.18) was accounted for, the EMR=0.80 (95%CI 0.65–0.98). Conclusion Utilising large electronic patient databases to study trends in excess mortality during the pandemic confirmed some reported findings (e.g. ethnicity, obesity and care-homes), but also highlighted important differences not apparent from studying cause specific mortality during the pandemic (e.g. smoking, sex and area deprivation).

Background Large-scale electronic primary care datasets can provide up-to-date, accurate epidemiological information on rarer diseases. In the UK, approximately 70,000 people are estimated to be living with neuromuscular disease (NMD), but this approximation is over 10 years old and used historical estimates from different sources. While GPs are unlikely to make NMD diagnoses themselves, specialist diagnoses from hospital discharges and clinic letters are well recorded and electronically searchable within primary care records. The recent expansion of the Clinical Practice Research Datalink (CPRD) allows timely reporting on the recorded incidence and prevalence of NMD in the UK over the last 20 years. Methods A harmonised dataset of CPRD GOLD and Aurum was developed to provide annual denominators of actively registered patients between 2000 and 2019. A Read code hierarchy was developed for a wide range of NMDs; the database was then searched electronically to estimate incidence and (lifetime) prevalence rates in each year. To compare trends over time, rates were age standardised to the most recent CPRD population (2019). Results The combined CPRD database contained approximately 13 million patients actively registered in each year. By 2019, 28,230 active patients had ever received a Read code for one of the NMDs (223.6 per 100,000), which would scale up to approximately 149,000 people in the UK. Lifetime prevalence rates per 100,000 were higher among males (239.0) than females (208.3). The most common classifications were Guillain-Barre syndrome (40.1), myasthenia gravis (33.7), muscular dystrophy (29.5), Charcot-Marie-Tooth (29.5) and inflammatory myopathies (25.0). Since 2000, overall prevalence grew by 63% but incidence remained steady over time. All age groups showed an increase in prevalence, with the largest increases seen at older ages (≥65-years). Among individual conditions since about 2008, incidence of myasthenia gravis has been steadily rising while new cases of muscular dystrophy fell over the same period. Conclusions Lifetime recording of many NMDs on primary care records exceeds current estimates of people living with these conditions; these are important data for health service and care planning. Temporal trends suggest this number is steadily increasing and there may be twice as many people living with these conditions than currently thought. While this may be partially due to increases in recording, it cannot be simply explained by new cases as incidence is largely unchanged over time. The increase in prevalence among older ages suggest increases in life expectancy among those living with NMDs may have taken place.

Aims Polypharmacy is widespread and associated with medication-related harms, including adverse drug reactions, medication errors and poor treatment adherence. General practitioners and pharmacists cite limited time and training to perform effective medication reviews for patients with complex polypharmacy, yet no specialist referral mechanism exists. To develop a structured framework for specialist review of primary care patients with complex polypharmacy. Methods We developed the clinical pharmacology structured review (CPSR) and stopping by indication tool (SBIT). We tested these in an age-sex stratified sample of 100 people with polypharmacy aged 65-84 years from the Clinical Practice Research Datalink, an anonymised primary care database. Simulated medication reviews based on electronic records using the CPSR and SBIT were performed. We recommended medication changes or review to optimise treatment benefits, reduce risk of harm or reduce treatment burden. Results Recommendations were made for all patients, for almost half (4.8 ± 2.4) of existing medicines (9.8 ± 3.1), most commonly stopping a drug (1.7 ± 1.3/patient) or reviewing with the patient (1.4 ± 1.2/patient). At least 1 new medicine (0.7 ± 0.9) was recommended for 51% patients. Recommendations predominantly aimed to reduce harm (44%). There was no relationship between number of recommendations made and time since last primary care medication review. We identified a core set of clinical information and investigations (polypharmacy workup) that could inform a standard screen prior to specialist review. Conclusion The CPSR, SBIT and polypharmacy workup could form the basis of a specialist review for patients with complex polypharmacy. Further research is needed to test this approach in patients in general practice.

OBJECTIVE Diabetes mellitus (DM) increases the risk of infections, but the effect of better control has not been thoroughly investigated. RESEARCH DESIGN AND METHODS With the use of English primary care data, average glycated hemoglobin (HbA1c) during 2008–2009 was estimated for 85,312 patients with DM ages 40–89 years. Infection rates during 2010–2015 compiled from primary care, linked hospital, and mortality records were estimated across 18 infection categories and further summarized as any requiring a prescription or hospitalization or as cause of death. Poisson regression was used to estimate adjusted incidence rate ratios (IRRs) by HbA1c categories across all DM, and type 1 and type 2 DM separately. IRRs also were compared with 153,341 age-sex-practice–matched controls without DM. Attributable fractions (AF%) among patients with DM were estimated for an optimal control scenario (HbA1c 6–7% [42–53 mmol/mol]). RESULTS Long-term infection risk rose with increasing HbA1c for most outcomes. Compared with patients without DM, those with DM and optimal control (HbA1c 6–7% [42–53 mmol/mol], IRR 1.41 [95% CI 1.36–1.47]) and poor control (≥11% [97 mmol/mol], 4.70 [4.24–5.21]) had elevated hospitalization risks for infection. In patients with type 1 DM and poor control, this risk was even greater (IRR 8.47 [5.86–12.24]). Comparisons within patients with DM confirmed the risk of hospitalization with poor control (2.70 [2.43–3.00]) after adjustment for duration and other confounders. AF% of poor control were high for serious infections, particularly bone and joint (46%), endocarditis (26%), tuberculosis (24%), sepsis (21%), infection-related hospitalization (17%), and mortality (16%). CONCLUSIONS Poor glycemic control is powerfully associated with serious infections and should be a high priority.

Background Annual health checks for adults with intellectual disability (ID) have been incentivised by National Health Service (NHS) England since 2009, but it is unclear what impact they have had on important health outcomes such as emergency hospitalisation. Methods An evaluation of a ‘natural experiment’, incorporating practice and individual-level designs, to assess the effectiveness of health checks for adults with ID in reducing emergency hospital admissions using a large English primary care database. For practices, changes in admission rates for adults with ID between 2009–2010 and 2011–2012 were compared in 126 fully participating versus 68 non-participating practices. For individuals, changes in admission rates before and after the first health check for 7487 adults with ID were compared with 46 408 age-sex-practice matched controls. Incident rate ratios (IRRs) comparing changes in admission rates are presented for: all emergency, preventable emergency (for ambulatory care sensitive conditions (ACSCs)) and elective emergency. Results Practices with high health check participation showed no change in emergency admission rate among patients with ID over time compared with non-participating practices (IRR=0.97, 95% CI 0.78 to 1.19), but emergency admissions for ACSCs did fall (IRR=0.74, 0.58 to 0.95). Among individuals with ID, health checks had no effect on overall emergency admissions compared with controls (IRR=0.96, 0.87 to 1.07), although there was a relative reduction in emergency admissions for ACSCs (IRR=0.82, 0.69 to 0.99). Elective admissions showed no change with health checks in either analysis. Conclusions Annual health checks in primary care for adults with ID did not alter overall emergency admissions, but they appeared influential in reducing preventable emergency admissions.

Background People with intellectual disability (ID) are a group with high levels of healthcare needs; however, comprehensive information on these needs and service use is very limited. Aim To describe chronic disease, comorbidity, disability, and general practice use among people with ID compared with the general population. Design and setting This study is a cross-sectional analysis of a primary care database including 408 English general practices in 2012. Method A total of 14 751 adults with ID, aged 18–84 years, were compared with 86 221 age-, sex- and practice-matched controls. Depending on the outcome, prevalence (PR), risk (RR), or odds (OR) ratios comparing patients with ID with matched controls are shown. Results Patients with ID had a markedly higher prevalence of recorded epilepsy (18.5%, PR 25.33, 95% confidence interval [CI] = 23.29 to 27.57), severe mental illness (8.6%, PR 9.10, 95% CI = 8.34 to 9.92), and dementia (1.1%, PR 7.52, 95% CI = 5.95 to 9.49), as well as moderately increased rates of hypothyroidism and heart failure (PR>2.0). However, recorded prevalence of ischaemic heart disease and cancer was approximately 30% lower than the general population. The average annual number of primary care consultations was 6.29 for patients with ID, compared with 3.89 for matched controls. Patients with ID were less likely to have longer doctor consultations (OR 0.73, 95% CI = 0.69 to 0.77), and had lower continuity of care with the same doctor (OR 0.77, 95% CI = 0.73 to 0.82). Conclusion Compared with the general population, people with ID have generally higher overall levels of chronic disease and greater primary care use. Ensuring access to high-quality chronic disease management, especially for epilepsy and mental illness, will help address these greater healthcare needs. Continuity of care and longer appointment times are important potential improvements in primary care.

Objective Caring for a partner with dementia and partner bereavement are independently associated with poor health. An understanding of the health effects of living with a partner dying with dementia can help optimise support. We describe health in the year before and after loss of a partner with dementia compared with other bereavements. Methods In a UK primary care database, 2624 older individuals whose partner died with dementia during 2005–2012 were matched with 7512 individuals experiencing bereavement where the deceased partner had no dementia recorded. Results Prior to bereavement, partners of the deceased with dementia were more likely to be diagnosed with depression (OR 2.31, 1.69–3.14) and receive psychotropic medication (OR 1.34, 1.21–1.49) than partners from bereavements without dementia. In contrast, psychotropic medication initiation two months after dementia bereavement was lower (HR 0.69, 0.56–0.85). Compared with other bereaved individuals, mortality after bereavement was lower in men experiencing a dementia bereavement (HR 0.68, 0.49–0.94) but similar in women (HR 1.02, 0.75–1.38). Prior to bereavement, those who died with dementia were less likely to receive palliative care (OR 0.47, 0.41–0.54). Conclusion In the year before bereavement, partners of individuals dying with dementia experience poorer mental health than those facing bereavement from other causes, and their partner is less likely to receive palliative care. In the year after, individuals whose partner died with dementia experience some attenuation of the adverse health effects of bereavement. Services need to address the needs of carers for individuals dying with dementia and improve access to palliative care. Copyright © 2016 John Wiley & Sons, Ltd.

Few trials have compared estimates of change in physical activity (PA) levels using self-reported and objective PA measures when evaluating trial outcomes. The PACE-UP trial offered the opportunity to assess this, using the self-administered International Physical Activity Questionnaire (IPAQ) and waist-worn accelerometry. The PACE-UP trial (N = 1023) compared usual care (n = 338) with two pedometer-based walking interventions, by post (n = 339) or with nurse support (n = 346). Participants wore an accelerometer at baseline and 12 months and completed IPAQ for the same 7-day periods. Main outcomes were weekly minutes, all in ≥10 min bouts as per UK PA guidelines of: i) accelerometer moderate-to-vigorous PA (Acc-MVPA) ii) IPAQ moderate+vigorous PA (IPAQ-MVPA) and iii) IPAQ walking (IPAQ-Walk). For each outcome, 12 month values were regressed on baseline to estimate change. Analyses were restricted to 655 (64%) participants who provided data on all outcomes at baseline and 12 months. Both intervention groups significantly increased their accelerometry MVPA minutes/week compared with control: postal group 42 (95% CI 22, 61), nurse group 43 (95% CI 24, 63). IPAQ-Walk minutes/week also increased: postal 57 (95% CI 2, 112), nurse 43 (95% CI -11, 97) but IPAQ-MVPA minutes/week showed non-significant decreases: postal -11 (95% CI -65, 42), nurse -34 (95% CI -87, 19). Our results demonstrate the necessity of using a questionnaire focussing on the activities being altered, as with IPAQ-Walk questions. Even then, the change in PA was estimated with far less precision than with accelerometry. Accelerometry is preferred to self-report measurement, minimising bias and improving precision when assessing effects of a walking intervention. Trial registration: ISRCTN, ISRCTN98538934 . Registered 2 March 2012.

OBJECTIVE We describe in detail the burden of infections in adults with diabetes within a large national population cohort. We also compare infection rates between patients with type 1 and type 2 diabetes mellitus (T1DM and T2DM). RESEARCH DESIGN AND METHODS A retrospective cohort study compared 102,493 English primary care patients aged 40–89 years with a diabetes diagnosis by 2008 (n = 5,863 T1DM and n = 96,630 T2DM) with 203,518 age-sex-practice–matched control subjects without diabetes. Infection rates during 2008–2015, compiled from primary care and linked hospital and mortality records, were compared across 19 individual infection categories. These were further summarized as any requiring a prescription or hospitalization or as cause of death. Poisson regression was used to estimate incidence rate ratios (IRRs) between 1) people with diabetes and control subjects and 2) T1DM and T2DM adjusted for age, sex, smoking, BMI, and deprivation. RESULTS Compared with control subjects without diabetes, patients with diabetes had higher rates for all infections, with the highest IRRs seen for bone and joint infections, sepsis, and cellulitis. IRRs for infection-related hospitalizations were 3.71 (95% CI 3.27–4.21) for T1DM and 1.88 (95% CI 1.83–1.92) for T2DM. A direct comparison of types confirmed higher adjusted risks for T1DM versus T2DM (death from infection IRR 2.19 [95% CI 1.75–2.74]). We estimate that 6% of infection-related hospitalizations and 12% of infection-related deaths were attributable to diabetes. CONCLUSIONS People with diabetes, particularly T1DM, are at increased risk of serious infection, representing an important population burden. Strategies that reduce the risk of developing severe infections and poor treatment outcomes are under-researched and should be explored.

PURPOSE Adults with intellectual disabilities experience poorer physical health and health care quality, but there is limited information on the potential for reducing emergency hospital admissions in this population. We describe overall and preventable emergency admissions for adults with vs without intellectual disabilities in England and assess differences in primary care management before admission for 2 common ambulatory care–sensitive conditions (ACSCs). METHODS We used electronic records to study a cohort of 16,666 adults with intellectual disabilities and 113,562 age-, sex-, and practice-matched adults without intellectual disabilities from 343 English family practices. Incident rate ratios (IRRs) from conditional Poisson regression were analyzed for all emergency and preventable emergency admissions. Primary care management of lower respiratory tract infections and urinary tract infections, as exemplar ACSCs, before admission were compared in unmatched analysis between adults with and without intellectual disabilities. RESULTS The overall rate for emergency admissions for adults with vs without intellectual disabilities was 182 vs 68 per 1,000 per year (IRR = 2.82; 95% CI, 2.66–2.98). ACSCs accounted for 33.7% of emergency admissions among the former compared with 17.3% among the latter (IRR = 5.62; 95% CI, 5.14–6.13); adjusting for comorbidity, smoking, and deprivation did not fully explain the difference (IRR = 3.60; 95% CI, 3.25–3.99). Although adults with intellectual disability were at nearly 5 times higher risk for admission for lower respiratory tract infections and urinary tract infections, they had similar primary care use, investigation, and management before admission as the general population. CONCLUSIONS Adults with intellectual disabilities are at high risk for preventable emergency admissions. Identifying strategies for better detecting and managing ACSCs, including lower respiratory and urinary tract infections, in primary care could reduce hospitalizations.

Background People with intellectual disability (ID) have poorer health than the general population; however, there is a lack of comprehensive national data describing their health-care needs and utilisation. Annual health checks for adults with ID have been incentivised through primary care since 2009, but only half of those eligible for such a health check receive one. It is unclear what impact health checks have had on important health outcomes, such as emergency hospitalisation. Objectives To evaluate whether or not annual health checks for adults with ID have reduced emergency hospitalisation, and to describe health, health care and mortality for adults with ID. Design A retrospective matched cohort study using primary care data linked to national hospital admissions and mortality data sets. Setting A total of 451 English general practices contributing data to Clinical Practice Research Datalink (CPRD). Participants A total of 21,859 adults with ID compared with 152,846 age-, gender- and practice-matched controls without ID registered during 2009–13. Interventions None. Main outcome measures Emergency hospital admissions. Other outcomes – preventable admissions for ambulatory care sensitive conditions, and mortality. Data sources CPRD, Hospital Episodes Statistics and Office for National Statistics. Results Compared with the general population, adults with ID had higher levels of recorded comorbidity and were more likely to consult in primary care. However, they were less likely to have long doctor consultations, and had lower continuity of care. They had higher mortality rates [hazard ratio (HR) 3.6, 95% confidence interval (CI) 3.3 to 3.9], with 37.0% of deaths classified as being amenable to health-care intervention (HR 5.9, 95% CI 5.1 to 6.8). They were more likely to have emergency hospital admissions [incidence rate ratio (IRR) 2.82, 95% CI 2.66 to 2.98], with 33.7% deemed preventable compared with 17.3% in controls (IRR 5.62, 95% CI 5.14 to 6.13). Health checks for adults with ID had no effect on overall emergency admissions compared with controls (IRR 0.96, 95% CI 0.87 to 1.07), although there was a relative reduction in emergency admissions for ambulatory care-sensitive conditions (IRR 0.82, 95% CI 0.69 to 0.99). Practices with high health check participation also showed a relative fall in preventable emergency admissions for their patients with ID, compared with practices with minimal participation (IRR 0.73, 95% CI 0.57 to 0.95). There were large variations in the health check-related content that was recorded on electronic records. Limitations Patients with milder ID not known to health services were not identified. We could not comment on the quality of health checks. Conclusions Compared with the general population, adults with ID have more chronic diseases and greater primary and secondary care utilisation. With more than one-third of deaths potentially amenable to health-care interventions, improvements in access to, and quality of, health care are required. In primary care, better continuity of care and longer appointment times are important examples that we identified. Although annual health checks can also improve access, not every eligible adult with ID receives one, and health check content varies by practice. Health checks had no impact on overall emergency admissions, but they appeared influential in reducing preventable emergency admissions. Future work No formal cost-effectiveness analysis of annual health checks was performed, but this could be attempted in relation to our estimates of a reduction in preventable emergency admissions. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Background— Bereavement is a period of increased risk of cardiovascular death. There is limited understanding of the potential contribution of quality of cardiovascular disease management to this increased risk. Methods and Results— In a UK primary-care database, 12 722 older individuals with preexisting cardiovascular disease (coronary heart disease, hypertension, diabetes mellitus, stroke) and a partner bereavement were matched with a non-bereaved control group (n=33 911). We examined key routine annual process measures of care in the year before and after bereavement and cardiovascular medication prescribing (lipid-lowering, antiplatelet, renin–angiotensin system drugs). Odds ratios for change after bereavement compared with the change in non-bereaved matched controls are presented. In the bereaved, uptake of all annual measures was lower in the year before bereavement, with improvement in the year after, whereas in the controls, uptake was relatively stable. The odds ratio for change was 1.30 (95% confidence interval, 1.15–1.46) for cholesterol measurement and 1.40 (95% confidence interval, 1.22–1.61) for blood pressure measurement. For all medication, there was a transient fall in prescribing in the peri-bereavement period lasting until about 3 months after bereavement. The odds ratio for at least 80% prescription coverage in the 30 days after bereavement was 0.80 (95% confidence interval, 0.73–0.88) for lipid-lowering medication and 0.82 (95% confidence interval, 0.74–0.91) for antiplatelet medication compared with the change in non-bereaved individuals. Conclusions— Lower uptake of key cardiovascular care measures in the year before bereavement and reduced medication coverage after bereavement may contribute to increased cardiovascular risk. Clinicians need to ensure that quality of cardiovascular care is maintained in the pre- and post-bereavement periods.

We thank Russell and House for raising an important issue that we lacked space to discuss in our paper.1 Although we noted that ‘practices may not identify all [intellectual disability] ID individuals, especially those with mild ID’, it was not our intention to underestimate this difficult task. Adults with ID not known to primary care in England have been described as a ‘hidden majority’, due to administrative health systems failing to detect a …

This is an open access Article. Copyright @ 2012 The Authors An increased risk of death in persons who have suffered spousal bereavement has been described in many populations. The impact of modifying factors, such as chronic disease and material circumstances, is less well understood. The authors followed 171,120 couples 60 years of age or older in a United Kingdom primary care database between 2005 and 2010 for an average of 4 years. A total of 26,646 (15.5%) couples experienced bereavement, with mean follow up after bereavement of 2 years. In a model adjusted for age, sex, comorbid conditions at baseline, material deprivation based on area of residence, season, and smoking status, the hazard ratio for mortality in the first year after bereavement was 1.25 (95% confidence interval: 1.18, 1.33). Further adjustment for changes in comorbid conditions throughout follow up did not alter the hazard ratio for bereavement (hazard ratio = 1.27, 95% confidence interval: 1.19, 1.35). The association was strongest in individuals with no significant chronic comorbid conditions throughout follow up (hazard ratio = 1.50, 95% confidence interval: 1.28, 1.77) and in more affluent couples (P = 0.035). In the first year after bereavement, the association between bereavement and death is not primarily mediated through worsening or new onset of chronic disease. Good health and material circumstances do not protect individuals from increased mortality rates after bereavement. This study was funded by a grant from the Dunhill Medical Trust.

Objective To compare the prevalence and predictors of antidepressant prescribing in older care home and community residents in England and Wales. Design Retrospective analysis of primary care consultation and antidepressant prescribing data. Setting The setting included 326 general (family) practices in England and Wales supplying data to The Health Improvement Network database between 2008 and 2009. Participants Participants were 10,387 care home and 403,259 community residents aged 65 to 104. Main Outcome Measure Antidepressant prescription in the last 3 months of recorded data for each patient. Results Prevalence rates for antidepressant prescribing were 10.3% (95% confidence interval 10%–10.6%) for community and 37.5% (36.2%–38.9%) for care home residents. After excluding low-dose tricyclics (often used for other indications) prevalences were 7.3% (7.1%–7.5%) and 33.6% (32.3%–34.9%) respectively; of these, 21.7% (20.8%–22.6%) of community and 4.8% (3.9%–5.6%) of care home prescriptions were for antidepressants advised as best avoided in this age group. After indirect standardization for age, sex, and chronic disease prevalence, the ratio for prescribing was 2.4 (2.3–2.5) in care homes compared with the community; 28.3% (26.6%–30.1%) of community and 42.5% (39.4%–45.7%) of care home residents prescribed antidepressants had no appropriate recorded indication. Conclusions This national sample confirms the high prevalence of antidepressant prescribing to older people, particularly in care homes, frequently without a documented indication. The strong association found between chronic disease and antidepressant prescribing did not explain the higher care home prescribing rate. Widespread community use of nonrecommended antidepressants is also a concern.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • In vitro studies suggest that β-adrenoceptor blocker therapy inhibits cancer cell proliferation and migration leading to their consideration as novel therapeutic agents for cancer. • While trials in humans have suggested β-adrenoceptor blockers have no effect on cancer incidence, their effect on cancer survival has not been studied. • Recent limited evidence in breast cancer patients suggests that β-adrenoceptor blockers may improve cancer-specific survival. WHAT THIS STUDY ADDS • This study is the first to examine cancer survival in patients receiving β-adrenoceptor blockers across a range of common cancers in a large population-based sample. • For common tumour sites, including lung, breast and colon, there was no evidence that β-adrenoceptor blocker treatment modified overall survival but poorer survival was seen in patients with prostate and pancreatic cancer. • Our findings do not support development of clinical trials on β-adrenoceptor blocker therapy for cancer without further evidence of a beneficial effect in humans. AIMS To examine the effect of β-adrenoceptor blocker treatment on cancer survival. METHODS In a UK primary care database, we compared patients with a new cancer diagnosis receiving β-adrenoceptor blockers regularly (n= 1406) with patients receiving other antihypertensive medication (n= 2056). RESULTS Compared with cancer patients receiving other antihypertensive medication, patients receiving β-adrenoceptor blocker therapy experienced slightly poorer survival (HR = 1.18, 95% CI 1.04, 1.33 for all β-adrenoceptor blockers; HR = 1.21, 95% CI 0.94, 1.55 for non-selective β-adrenoceptor blockers). This poorer overall survival was explained by patients with pancreatic and prostate cancer with no evidence of an effect on survival for patients with lung, breast or colorectal cancer. Analysis in a cancer-free matched parallel cohort did not suggest selection bias masked a beneficial effect. CONCLUSION Our study does not support the hypothesis that β-adrenoceptor blockers improve survival for common cancers.

Objectives A short-term and long-term cost-effectiveness analysis (CEA) of two pedometer-based walking interventions compared with usual care. Design (A) Short-term CEA: parallel three-arm cluster randomised trial randomised by household. (B) Long-term CEA: Markov decision model. Setting Seven primary care practices in South London, UK. Participants (A) Short-term CEA: 1023 people (922 households) aged 45–75 years without physical activity (PA) contraindications. (b) Long-term CEA: a cohort of 100 000 people aged 59–88 years. Interventions Pedometers, 12-week walking programmes and PA diaries delivered by post or through three PA consultations with practice nurses. Primary and secondary outcome measures Accelerometer-measured change (baseline to 12 months) in average daily step count and time in 10 min bouts of moderate to vigorous PA (MVPA), and EQ-5D-5L quality-adjusted life-years (QALY). Methods Resource use costs (£2013/2014) from a National Health Service perspective, presented as incremental cost-effectiveness ratios for each outcome over a 1-year and lifetime horizon, with cost-effectiveness acceptability curves and willingness to pay per QALY. Deterministic and probabilistic sensitivity analyses evaluate uncertainty. Results (A) Short-term CEA: At 12 months, incremental cost was £3.61 (£109)/min in ≥10 min MVPA bouts for nurse support compared with control (postal group). At £20 000/QALY, the postal group had a 50% chance of being cost saving compared with control. (B) Long-term CEA: The postal group had more QALYs (+759 QALYs, 95% CI 400 to 1247) and lower costs (−£11 million, 95% CI −12 to −10) than control and nurse groups, resulting in an incremental net monetary benefit of £26 million per 100 000 population. Results were sensitive to reporting serious adverse events, excluding health service use, and including all participant costs. Conclusions Postal delivery of a pedometer intervention in primary care is cost-effective long term and has a 50% chance of being cost-effective, through resource savings, within 1 year. Further research should ascertain maintenance of the higher levels of PA, and its impact on quality of life and health service use., This research was supported by the Health Technology Assessment (HTA) Programme, National Institute for Health Research (project number HTA 10/32/02 ISRCTN42122561).

Purpose To investigate the long-term cumulative effect of calcium and vitamin D supplementation on cardiovascular outcomes and death in older women. Methods We undertook an observational cohort study using UK electronic primary care records in the Doctor's Independent Network (DIN-LINK) database; 9910 women aged 60–89 who started calcium and vitamin D supplementation between 2000 and 2005, with no heart disease or stroke history and who survived disease free for 2 years after supplement initiation were studied. The main outcome was first occurrence of myocardial infarction (MI), stroke or death more than 2 years after initiation. Results In the period from 2 years after supplement initiation, women who had received >600 days supplementation in these first 2 years were no more at risk of MI, stroke or death (hazard ratio 0.82 (0.67–1.01)) compared to women who received ≤90 days supplementation in the first 2 years. Outcomes in the first 2 years were analysed separately and showed similar baseline risks in our comparison groups. Conclusion Two years after initiation, women who have consistently received supplementation with calcium and vitamin D do not experience more cardiovascular events or deaths than women who received minimal supplementation. Copyright © 2009 John Wiley & Sons, Ltd.

Caring for a partner with dementia and partner bereavement are independently associated with poor health. An understanding of the health effects of living with a partner dying with dementia can help optimise support. We describe health in the year before and after loss of a partner with dementia compared with other bereavements.In a UK primary care database, 2624 older individuals whose partner died with dementia during 2005-2012 were matched with 7512 individuals experiencing bereavement where the deceased partner had no dementia recorded.Prior to bereavement, partners of the deceased with dementia were more likely to be diagnosed with depression (OR 2.31, 1.69-3.14) and receive psychotropic medication (OR 1.34, 1.21-1.49) than partners from bereavements without dementia. In contrast, psychotropic medication initiation two months after dementia bereavement was lower (HR 0.69, 0.56-0.85). Compared with other bereaved individuals, mortality after bereavement was lower in men experiencing a dementia bereavement (HR 0.68, 0.49-0.94) but similar in women (HR 1.02, 0.75-1.38). Prior to bereavement, those who died with dementia were less likely to receive palliative care (OR 0.47, 0.41-0.54).In the year before bereavement, partners of individuals dying with dementia experience poorer mental health than those facing bereavement from other causes, and their partner is less likely to receive palliative care. In the year after, individuals whose partner died with dementia experience some attenuation of the adverse health effects of bereavement. Services need to address the needs of carers for individuals dying with dementia and improve access to palliative care. Copyright © 2016 John WileySons, Ltd.

Objectives: To examine trends in the prevalence of diagnosed atrial fibrillation (AF), its treatment with oral anticoagulants between 1994 and 2003, and predictors of anticoagulant treatment in 2003. Methods: Analysis of electronic data from 131 general practices (about one million registered patients annually) contributing to the DIN-LINK database. Results: From 1994 to 2003 the prevalence of “active” AF rose from 0.78% to 1.31% in men and from 0.79% to 1.15% in women. The proportion of patients with AF taking anticoagulants rose from 25% to 53% in men and from 21% to 40% in women. Most others received antiplatelets. The likelihood of receiving anticoagulants was greater for men and with increasing stroke risk. It decreased sharply with age after 75 years. Socioeconomic status, urbanisation and region had no influence. Non-steroidal anti-inflammatory drugs, antiplatelet drugs and ulcer healing drugs were associated with reduced likelihood of receiving anticoagulants, as were peptic ulcers, chronic gut disorders, anaemias, psychoses and poor compliance. Anticoagulant treatment was associated with several cardiovascular co-morbidities and drugs, possibly due to secondary care treatment. Nevertheless, only 56.5% of patients at very high risk of stroke were taking anticoagulants in 2003, whereas 38.2% of patients at low risk of stroke received anticoagulants. Conclusions: This study confirms previously observed trends of increasing AF prevalence and warfarin treatment. Many patients who may benefit from anticoagulation still do not receive it, whereas others at lower risk of stroke do. The lower likelihood of women receiving anticoagulants is of particular concern.

To study trends in the use of lipid lowering drugs in the UK, and to assess which patient factors influence prescribing.Routinely collected computerised medical data were analysed from 142 general practices across England and Wales that provide data for the Doctors' Independent Network database. Subjects included were people aged 35 years or more with treated ischaemic heart disease, averaging annually over 30,000. The temporal trend from 1994 to 2001 in prescription of lipid lowering drugs and daily statin dose and the odds ratios (ORs) for receiving a statin prescription in 1998 were examined.Lipid lowering drug prescribing increased greatly over time, entirely because of statins, so that in 2001 56.3% of men and 41.1% of women with ischaemic heart disease received lipid lowering drugs. However, 33% of these patients were on a20 mg simvastatin daily equivalent. In 1998 the OR for receiving a statin fell from 1 at age 55-64 to 0.64 at 65-74 and 0.16 at 75-84 years. The age effect was similar in those without major comorbidity. Revascularised patients were much more likely to receive a statin than those with angina (OR 3.92, 95% confidence interval (CI) 3.57 to 4.31). Men were more likely to receive a statin than women (OR 1.62, 95% CI 1.54 to 1.71) but this difference disappeared after adjustment for age and severity of disease (OR 1.06). Geographical region had little effect but there was a very weak socioeconomic gradient.Although prescribing has increased, many patients who may benefit from lipid lowering drugs either do not receive it or are undertreated, possibly because of lack of awareness of the relative potency of the different statins. Patients with angina and the elderly are less likely to receive treatment that may prevent a coronary event.

Background Maintenance of physical activity is important for health, but few trials provide long-term objective data or qualitative evaluation of factors affecting this maintenance. The PACE-UP three-arm (postal, nurse-support, control) primary care cluster-randomised controlled trial recruited 1023 adults aged 45–75 years into a 12 week pedometer-based intervention including a physical activity diary and handbook incorporating behaviour change techniques; controls received usual care. Recruitment was from Sept 1, 2012, to Oct 31, 2013. At 12 months, step-counts increased by around a tenth, and time in moderate-to-vigorous physical activity (MVPA) in bouts by around a third in postal and nurse-supported arms compared with control. Using a mixed-methods approach at 3 year follow-up of the PACE-UP cohort, we aimed to assess whether the intervention effects persisted. Methods Assessments were done between Oct 1, 2015, and Nov 30, 2016. Mean daily step-counts and total weekly minutes of MVPA in bouts of 10 min or more at 3 years were collected with 7 day GT3X+ accelerometry (Actigraph, Pensacola, FL, USA) for all trial arms. Outcomes were regressed on baseline values to estimate change in treatment groups compared with control. Sensitivity analysis assessed missing data effects. Semi-structured telephone interviews were conducted with 60 participants. Interviews were audio recorded, transcribed, and coded, and thematic analysis was performed. Ethics approval was given by the National Research Ethics Service Committee London (Hampstead). Findings 3 year follow-up with accelerometry was 67% (681/1023). Compared with controls, intervention groups maintained higher steps per day (postal 627 additional steps[95% CI 198–1056], p=0·004; nurse 670 [237–1102], p=0·002), and more total weekly minutes of MVPA in bouts (postal 28 [7–49], p=0·009; nurse 24 [3–45], p=0·03). Results were robust to sensitivity analyses. Most interviewees felt that PACE-UP had increased their awareness of their physical activity. Facilitators to physical activity maintenance included self-motivation, social-support, and maintaining good health, with poor health and lack of time as barriers. Interpretation At 3 year follow-up of PACE-UP, step-counts and bouts of MVPA persisted, with no difference between intervention groups, suggesting that a primary care pedometer intervention, delivered by post or with nurse support, could help address the public health physical inactivity challenge. Major future challenges are how to apply this kind of effective intervention widely in the population and how to transform perceived barriers into facilitators (eg, poor physical health). Funding National Institute for Health Research Health Technology Assessment Programme (project number HTA 10/32/02).

Objectives Clinical reports suggest that various emotions and types of stress can precipitate asthmatic symptoms, but there is little experimental evidence to substantiate this claim. We studied the impact of different emotional states and stress on respiratory resistance in asthmatic and nonasthmatic individuals. Methods Participants (24 asthmatic and 24 nonasthmatic patients) viewed short film sequences selected to induce anxiety, anger, depression, elation, happiness, contentment, or a neutral affective state and completed two stressful tasks, mental arithmetic to induce active coping efforts and viewing of medical slides to induce passive coping efforts. Oscillatory resistance, heart rate, blood pressure, baroreflex sensitivity, skin conductance level, respiration rate and volume, and self-reported affective state were measured throughout the session. Results Uniform increases in oscillatory resistance were found in all emotional states compared with the neutral state and during mental arithmetic in both groups. Asthmatic patients showed stronger reactions to the medical slides than healthy control subjects, with significant increases in oscillatory resistance, blood pressure, skin conductance level, and minute volume, as well as higher levels of self-reported depression, arousal, and shortness of breath. Changes in oscillatory resistance were inconsistently correlated with other physiological indices. Conclusions Various emotional states and stress increase oscillatory resistance largely independently of concurrent increases in autonomic or ventilatory activity. The particular sensitivity of asthmatics to passive coping demand requires additional research.

Importance The period immediately after bereavement has been reported as a time of increased risk of cardiovascular events. However, this risk has not been well quantified, and few large population studies have examined partner bereavement. Objective To compare the rate of cardiovascular events between older individuals whose partner dies with those of a matched control group of individuals whose partner was still alive on the same day. Design, Setting, and Participants Matched cohort study using a UK primary care database containing availale data of 401 general practices from February 2005 through September 2012. In all, 30 447 individuals aged 60 to 89 years at study initiation who experienced partner bereavement during follow-up were matched by age, sex, and general practice with the nonbereaved control group (n = 83 588) at the time of bereavement. Exposures Partner bereavement. Main Outcomes and Measures The primary outcome was occurrence of a fatal or nonfatal myocardial infarction (MI) or stroke within 30 days of bereavement. Secondary outcomes were non-MI acute coronary syndrome and pulmonary embolism. All outcomes were compared between the groups during prespecified periods after bereavement (30, 90, and 365 days). Incidence rate ratios (IRRs) from a conditional Poisson model were adjusted for age, smoking status, deprivation, and history of cardiovascular disease. Results Within 30 days of their partner’s death, 50 of the bereaved group (0.16%) experienced an MI or a stroke compared with 67 of the matched nonbereaved controls (0.08%) during the same period (IRR, 2.20 [95% CI, 1.52-3.15]). The increased risk was seen in bereaved men and women and attenuated after 30 days. For individual outcomes, the increased risk was found separately for MI (IRR, 2.14 [95% CI, 1.20-3.81]) and stroke (2.40 [1.22-4.71]). Associations with rarer events were also seen after bereavement, including elevated risk of non-MI acute coronary syndrome (IRR, 2.20 [95% CI, 1.12-4.29]) and pulmonary embolism (2.37 [1.18-4.75]) in the first 90 days. Conclusions and Relevance This study provides further evidence that the death of a partner is associated with a range of major cardiovascular events in the immediate weeks and months after bereavement. Understanding psychosocial factors associated with acute cardiovascular events may provide opportunities for prevention and improved clinical care.

Primary care databases provide rich consultation and prescribing information,1 but lack individual background detail. Linking to information from questionnaires can overcome this, but requires individual informed consent.2,3 The generalisability of linked data will be constrained by low consent rates and any differences between those giving and those withholding consent, in addition to any non-response bias. Most studies examining the consent issue, have either focused on patients with specific illnesses,3 or have had limited comparison measures.4 A recent large study found that men, younger people, and subjects with the symptom under investigation, were more likely to give consent, but lacked information on service use, or other measures of physical and psychological health.5 We conducted a wide ranging health and social survey and compared older people who gave and withheld consent to link questionnaire data to their primary care records. A detailed account of the survey methods has already been published.6 A postal survey was conducted, with an offer of assistance in completion, with patients aged ⩾65 years from two London practices. The questionnaire is available on request from the authors and is also on the journal web site (http://www.jech.com/supplemental) and included details on: demographic factors; physical health; psychological measures …

Objectives. We sought to determine whether unexpected bereavement has a greater impact on mortality in the surviving partner than death of a partner with preexisting chronic disease or disability. Methods. In a UK primary care database (The Health Improvement Network), we identified 171 720 couples aged 60 years and older. We compared the rise in mortality in the first year after bereavement in those whose partner died without recorded chronic disease (unexpected bereavement) to those whose deceased partner had a diagnosis of chronic disease (known morbidity). Results. For unexpected bereavement (13.4% of all bereavements), the adjusted hazard ratio for death in the first year after bereavement was 1.61 (95% confidence interval [CI] = 1.39, 1.86) compared with 1.21 (95% CI = 1.14, 1.30) where the partner had known morbidity. Differences between bereaved groups were significant (P = .001) and present for both men and women. Conclusions. Unexpected bereavement has a greater relative mortality impact than bereavement preceded by chronic disease. Our findings highlight the potential value of preparing individuals for the death of a spouse with known morbidity and providing extra support after bereavement for those experiencing sudden unexpected bereavement.

Background mortality in UK care homes is not well described. Objective to describe 1-year mortality and predictors in older care home residents compared with community residents. Method cohort study using the THIN primary care database with 9,772 care home and 354,306 community residents aged 65-104 years in 293 English and Welsh general practices in 2009. Results a total of 2,558 (26.2%) care home and 11,602 (3.3%) community residents died within 1 year. The age and sex standardised mortality ratio for nursing homes was 419 (95% CI: 396-442) and for residential homes was 284 (266-302). Age-related increases in mortality were less marked in care homes than community. Comorbidities and identification as inappropriate for chronic disease management targets predicted mortality in both settings, but associations were weaker in care homes. The number of drug classes prescribed and primary care contact were the strongest clinical predictors of mortality in care homes. Conclusions older care home residents experience high mortality. Age and diagnostic characteristics are weaker predictors of risk of death within care homes than the community. Measures of primary care utilisation may be useful proxies for frailty and improve difficult end of life care decisions in care homes.

Background Care home residents are vulnerable to the adverse effects of prescribing but there is limited monitoring in the UK. Aim To compare prescribing quality in care homes in England and Wales with the community and with US nursing homes. Design and setting Cross-sectional analysis of a UK primary care database and comparison with the US National Nursing Home Survey including 326 general practices in 2008–2009 in England and Wales, with 10 387 care home and 403 259 community residents aged 65 to 104 years. Method Comparison of age- and sex-standardised use of ‘concern’ and common drug groups in the last 90 days and potentially inappropriate prescribing based on a consensus list of medications best avoided in older people (Beers criteria). Results Compared to the community, care home residents were more likely to receive ‘concern’ drugs, including benzodiazepines (relative risk (RR) = 2.05, 95% confidence interval (CI) = 1.90 to 2.22), anticholinergic antihistamines (RR = 2.78, 95% CI = 2.38 to 3.23), loop diuretics (RR = 1.47, 95% CI = 1.41 to 1.53), and antipsychotics (RR = 22.7, 95% CI = 20.6 to 24.9). Use of several common drug groups, including laxatives, antidepressants, and antibiotics, was higher, but use of cardiovascular medication was lower. Thirty-three per cent (95% CI = 31.7% to 34.3%) of care home residents in England and Wales received potentially inappropriate medication, compared to 21.4% (95% CI = 20.9% to 21.8%) in the community. The potentially inappropriate prescribing rate in US nursing homes was similar to England and Wales. Conclusion Care home prescribing has the potential for improvement. High use of anticholinergic and psychotropic medication may contribute to functional and cognitive decline. The targeting and effectiveness of medication reviews in care homes needs to be improved.

Background Influenza vaccination is recommended for older people irrespective of cognitive decline or residential setting. Objective To examine the effect of dementia diagnosis on flu vaccination uptake in community and care home residents in England and Wales. Methods Retrospective analysis of a primary care database with 378,462 community and 9,106 care (nursing and residential) home residents aged 65-104 in 2008-09. Predictors of vaccine uptake were examined adjusted for age, sex, area deprivation and major chronic diseases. Results Age and sex standardised uptake of influenza vaccine was 74.7% (95% CI: 73.7-75.8%) in community patients without dementia, 71.4% (69.3-73.5%) in community patients with dementia, 80.5% (78.9-82.2%) in care home patients without dementia and 83.3% (81.4-85.3%) in care home patients with dementia. In a fully adjusted model, compared with community patients without dementia, patients with dementia in the community were less likely to receive vaccination (RR: 0.96, 95% CI: 0.94-0.97) while care home patients with (RR: 1.06, 1.03-1.09) and without (RR: 1.03, 1.01-1.05) dementia were more likely to receive vaccination. Area deprivation and chronic diseases were, respectively, negative and positive predictors of uptake. Conclusion Lower influenza vaccine uptake among community patients with dementia, compared with care home residents, suggests organisational barriers to community uptake but high uptake among patients with dementia in care homes does not suggest concern over informed consent acts as a barrier. Primary care for community patients with dementia needs to ensure that they receive all appropriate preventive interventions.

To examine the effect of β-adrenoceptor blocker treatment on cancer survival.In a UK primary care database, we compared patients with a new cancer diagnosis receiving β-adrenoceptor blockers regularly (n= 1406) with patients receiving other antihypertensive medication (n= 2056).Compared with cancer patients receiving other antihypertensive medication, patients receiving β-adrenoceptor blocker therapy experienced slightly poorer survival (HR = 1.18, 95% CI 1.04, 1.33 for all β-adrenoceptor blockers; HR = 1.21, 95% CI 0.94, 1.55 for non-selective β-adrenoceptor blockers). This poorer overall survival was explained by patients with pancreatic and prostate cancer with no evidence of an effect on survival for patients with lung, breast or colorectal cancer. Analysis in a cancer-free matched parallel cohort did not suggest selection bias masked a beneficial effect.Our study does not support the hypothesis that β-adrenoceptor blockers improve survival for common cancers.

In a national primary care database sample of older people (≥65 years), 81% (83 588/103 821) of community and 58% (1702/2940) of care home residents with diabetes or heart disease had depression case finding recently recorded; 66% (1418/2145) of community and 22% (26/118) of care home residents with a new depression episode had a depression-severity assessment recorded. Age, sex, and higher care home dementia prevalence did not explain these differences. Case finding and assessment of depression need to be improved in older people, particularly care home residents.

Objectives: to enhance identification of older nursing and residential home residents in a national sample and describe their chronic disease prevalence. Design: cross-sectional analysis of an established primary care database (The Health Improvement Network). Setting: 326 English and Welsh general practices. Subjects: 435,568 patients aged ≥65. Care home residents were identified by either a Read code for care home residence or multiple care home residence markers (postcode linkage, household size identifier and location of consultation). Comparisons: nursing and residential home residents were compared with a community control group with no markers of care home residence using age and sex standardised chronic disease prevalence ratios. Main outcome measures: chronic disease prevalence using definitions from the national primary care contract. Results: 11,547 (2.7%) older people were identified as care home residents, of whom only 4,403 (38.1%) were directly identified by their primary care record. Mean age for nursing and residential homes was 84.9 and 86.1 years compared to 74.7 for controls. Prevalence ratios for dementia were 14.8 (95% CI 13.4–16.4) for nursing and 13.5 (12.4–14.8) for residential homes compared to controls. Stroke and severe mental illness were commoner in nursing and residential homes but hypertension, respiratory and cancer diagnoses were slightly less common. Recorded disease prevalences in nursing and residential homes were similar. Conclusions: recording of care home residence is limited in primary care and this is a barrier to routine monitoring of this group. Higher dementia and stroke prevalence in care home residents confirms high clinical need, but the small differences in disease prevalence between nursing and residential homes have implications for delivering medical and nursing care to residential homes. Lower prevalence of some chronic diseases suggests incomplete recording or case finding. Routine flagging of care home residents in health care systems is a potential tool for improving monitoring and outcomes.

Background Treatment with specific beta-blockers reduces mortality and hospitalisation in heart failure. Aim To describe trends and inequities in beta-blocker prescribing for heart failure. Design of study Repeated cross-sectional analysis of a nationally representative primary care database (DIN-LINK). Setting A total of 152 UK general practices. Method Prescribing of beta-blockers between 2000 and 2005 was examined among a yearly average of 7294 patients aged ≥50 years who had actively managed heart failure — defined as a recorded diagnosis of heart failure and two prescriptions of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker during the calendar year. The main outcome was the prescription of a guideline-recommended beta-blocker (bisoprolol, carvedilol, metoprolol, or nebivolol) in the year. Determinants of beta-blocker prescribing were analysed using logistic regression. Results Between 2000 and 2005, age-adjusted use of recommended beta-blockers rose from 6.1% to 27.0% in men, and from 4.2% to 21.5% in women. In 2005, younger patients were more likely to be treated; the fully adjusted odds ratio was 4.83 (95% confidence interval = 3.78 to 6.17) for patients aged 60–64 years compared with those aged 85 years. Women and patients living in areas of socioeconomic deprivation were less likely to be treated. In 2005, in addition to treatment with guideline-recommended beta-blockers, a further 11.7% of men and 12.5% of women were prescribed other beta-blockers. Conclusion Recommended beta-blocker use has risen in the UK but remains low and inequitable, with many patients still treated with beta-blockers that are not recommended in guidelines. This suggests further improvements in prescribing are still possible.

Comparisons of the same patient data in 2004 and 2006 downloads of the DIN-LINK UK primary care database demonstrated unexpected differences in the rates of coronary heart disease between the datasets. Incidence rates were lower between 1996–2003 in the new (2006) download. Patient record checks demonstrated that coronary heart disease codes had been removed in the new download during the run-up to the new contract. Planners need to be aware of such issues when evaluating trends in CHD or other similar conditions.

Background: Statins, antiplatelet drugs, β-blockers and ACE inhibitors may produce marked benefits in secondary prevention of ischaemic heart disease (IHD), especially in combination. Objective: To examine trends in treatment and factors associated with treatment using a population-based general practice database. Design: Analysis of routinely collected computerised data from 201 general practices using iSOFT software contributing to the DIN-LINK database. Setting and patients: Subjects aged ⩾35 years and registered with the practices; on average, 30 000 men and 21 000 women with IHD each year. Main outcome measure: Percentage of subjects with IHD receiving individual drugs and combined treatment in any given year. Results: Between 1994 and 2005 use of drugs for secondary prevention increased markedly. By 2005, 80% of men and 70% of women were receiving a statin, 75% and 74% were receiving antiplatelet drugs, 55% and 48% were receiving β-blockers and 57% and 51% were receiving an ACE inhibitor; 55% of men and 46% of women were receiving a statin, antiplatelet drug and either β-blocker or ACE inhibitor, of whom just under half were receiving all four classes of drug. Gender differences were largely explained by more severe disease in men. In 2005, subjects less likely to receive combination therapy were older, had not had a myocardial infarction or revascularisation, and lacked comorbidities such as diabetes or hypertension. Conclusions: Despite high levels of statin and antiplatelet prescribing, opportunities exist for increasing the benefits of secondary prevention, especially through the wider use of combined treatments. Future targets could usefully include combination therapy.