Alison Wynn

Sex inequalities in ischaemic heart disease in general practice: cross sectional survey

Abstract Objective: To study differences in treatment for men and women with ischaemic heart disease by using standards defined in Englands national service framework for coronary artery disease. Design: Cross sectional survey using routinely collected data. Setting: 18 practices in 18 primary care groups in Trent Region. Subjects: 5891 men and women aged over 35 years with a diagnosis of ischaemic heart disease or prescription for nitrates recorded on computer. Main outcome measure: Difference in the proportion of men and women with ischaemic heart disease and taking lipid lowering treatment. Results: Women were less likely than men to have a recording of body mass index (79% (2197/2783) v 82% (2552/3102), P=0.002), smoking (86% (2386) v 89% (2779), P<0.0001), and blood pressure (95% (2643) v 96% (2986), P=0.04). Women were also less likely to have a recording of fasting cholesterol concentration (35% (968) v 50% (1550), P<0.0001) but were more likely to be obese (25% (558/2197) v 20% (514/2552), P<0.0001) and have their most recently recorded blood pressure value over the recommended 140/85 mm Hg (60% (1598/2643) v 52% (1553/2986), P<0.0001). Although a higher proportion of women had a raised serum cholesterol concentration (77% (749/968) v 67% (1043/1550), P<0.0001), men were more likely to take aspirin (76% (2358) v 71% (1979), P<0.0001), have a recorded diagnosis of hyperlipidaemia (13% (418) v 10% (274), P<0.0001), and be prescribed lipid lowering drugs (31% (973) v 21% (596), P<0.0001). These differences remained despite adjustments for the practice where the patient is registered, age, smoking status, obesity, diabetes, and hypertension. Conclusion: The results suggest a systematic bias towards men compared with women in terms of secondary prevention of ischaemic heart disease. What is already known on this topic Englands national service framework for coronary artery disease requires general practitioners to identify and treat patients at high risk of ischaemic heart disease Substantial evidence of sex inequality for this disease exists for access to secondary care less but less is known about equity for its management in general practice What this study adds Among patients with ischaemic heart disease, men were more likely than women to have cardiovascular risk factors and serum cholesterol concentration recorded on computer A higher proportion of women, however, had raised cholesterol concentrations recorded on computer, but more men were treated with lipid lowering drugs The results suggest a systematic bias towards men compared with women in terms of secondary prevention of ischaemic heart disease.

The electronic patient record in primary care—regression or progression? A cross sectional study

Abstract Objectives To determine whether paperless medical records contained less information than paper based medical records and whether that information was harder to retrieve. Design Cross sectional study with review of medical records and interviews with general practitioners. Setting 25 general practices in Trent region. Participants 53 British general practitioners (25 using paperless records and 28 using paper based records) who each provided records of 10 consultations. Main outcome measures Content of a sample of records and doctor recall of consultations for which paperless or paper based records had been made. Results Compared with paper based records, more paperless records were fully understandable (89.2% v 69.9%, P=0.0001) and fully legible (100% v 64.3%, P < 0.0001). Paperless records were significantly more likely to have at least one diagnosis recorded (48.2% v 33.2%, P=0.05), to record that advice had been given (23.7% vs 10.7%, P=0.017), and, when a referral had been made, were more likely to contain details of the specialty (77.4% v 59.5%, P=0.03). When a prescription had been issued, paperless records were more likely to specify the drug dose (86.6% v 66.2%, P=0.005). Paperless records contained significantly more words, abbreviations, and symbols (P < 0.01 for all). At doctor interview, there was no difference between the groups for the proportion of patients or consultations that could be recalled. Doctors using paperless records were able to recall more advice given to patients (38.6% v 26.8%, P=0.03). Conclusion We found no evidence to support our hypotheses that paperless records would be truncated and contain more local abbreviations; and that the absence of writing would decrease subsequent recall. Conversely we found that the paperless records compared favourably with manual records.

Antidepressants as risk factor for ischaemic heart disease: case-control study in primary care.

Abstract Objectives: To determine whether antidepressants are a risk factor for ischaemic heart disease and to compare the risk for different subgroups of antidepressants and individual antidepressants. Design: Case-control study. Setting: Nine general practices recruited from the Trent Focus Collaborative Research Network. Participants: 933 men and women with ischaemic heart disease matched by age, sex, and practice to 5516 controls. Main outcome measure: Adjusted odds ratio for ischaemic heart disease calculated by logistic regression. Results: Odds ratios for ischaemic heart disease were significantly raised for patients who had ever received a prescription for tricyclic antidepressants even after diabetes, hypertension, smoking, body mass index, and use of selective serotonin reuptake inhibitors had been adjusted for (1.56; 95% confidence interval 1.18 to 2.05). Patients who had ever taken dosulepin (dothiepin) had a significantly raised odds ratio for ischaemic heart disease after adjustment for confounding factors and use of other antidepressants (1.67, 1.17 to 2.36). There was no significant increase in the odds ratios for amitriptyline, lofepramine, and selective serotonin reuptake inhibitors in multivariate analysis. Increasing maximum doses of dosulepin were associated with increasing odds ratios for ischaemic heart disease. Similarly, there was a significant positive trend associated with increasing numbers of prescriptions of dosulepin (adjusted odds ratio 1.52 for 1 prescription, 1.39 for 2-3, and 1.96 for ≥4, P<0.002). Conclusion: There is good evidence for an association between dosulepin and subsequent ischaemic heart disease and for a dose-response relation. What is already known on this topic Over 45% of patients in hospital after myocardial infarction have depression Depression is an independent risk factor for increased mortality and morbidity after myocardial infarction What this study adds Patients who had ever taken dosulepin (dothiepin) had significantly increased risk of ischaemic heart disease after confounding factors had been adjusted for The association followed a dose-response relation The effect of other antidepressants was not significant after adjustment for confounders

Economic evaluation of hospital at home versus hospital care: cost minimisation analysis of data from randomised controlled trial

Abstract Objectives: To compare the costs of admission to a hospital at home scheme with those of acute hospital admission. Design: Cost minimisation analysis within a pragmatic randomised controlled trial. Setting: Hospital at home scheme in Leicester and the citys three acute hospitals. Participants: 199 consecutive patients assessed as being suitable for admission to hospital at home for acute care during the 18 month trial period (median age 84 years). Intervention: Hospital at home or hospital inpatient care. Main outcome measures: Costs to NHS, social services, patients, and families during the initial episode of treatment and the three months after admission. Results: Mean (median) costs per episode (including any transfer from hospital at home to hospital) were similar when analysed by intention to treat—hospital at home £2569 (£1655), hospital ward £2881 (£2031), bootstrap mean difference −305 (95% confidence interval −1112 to 448). When analysis was restricted to those who accepted their allocated place of care, hospital at home was significantly cheaper—hospital at home £2557 (£1710), hospital ward £3660 (£2903), bootstrap mean difference −1071 (−1843 to −246). At three months the cost differences were sustained. Costs with all cases included were hospital at home £3671 (£2491), hospital ward £3877 (£3405), bootstrap mean difference −210 (−1025 to 635). When only those accepting allocated care were included the costs were hospital at home £3698 (£2493), hospital ward £4761 (£3940), bootstrap mean difference −1063 (−2044 to −163); P=0.009. About 25% of the costs for episodes of hospital at home were incurred through transfer to hospital. Costs per day of care were higher in the hospital at home arm (mean £207 v £134 in the hospital arm, excluding refusers, P<0.001). Conclusions: Hospital at home can deliver care at similar or lower cost than an equivalent admission to an acute hospital.

Performance of hospital-at-home after a randomised controlled trial.

Objective: To compare the performance of an admission-avoidance hospital-at-home scheme one year after the end of a randomised trial with its performance during the trial. Methods: Observational study of patients admitted to the scheme during a period of 12-19 months after the trial ended. In addition to routine data from service records, patients were interviewed at three days, two weeks and three months after admission, using the same instruments as used in the trial. Results: All 78 patients admitted to hospital-at-home during the follow-up period were included, and compared with the 95 patients admitted during the trial. The referral rate to hospital-at-home was the same (11 per month) as during the trial. During the trial, patients were randomised to hospital-at-home or hospital, meaning that hospital-at-home worked at about double the trial volume in the post-trial period. Baseline characteristics showed no statistically significant differences except that post-trial patients were less cognitively impaired. There were no statistically significant differences between the groups in survival at two weeks and three months, or in Barthel index, Sickness Impact Profile 68 and Philadelphia Geriatric Morale Scale. Length of stay in hospital-at-home was significantly shorter in the post-trial period (median of five days versus seven, P < 0.001), and more patients received a visit from their general practitioner during the period of admission (54% versus 38%, P = 0.04); otherwise there were no significant differences in process measures. Conclusion: Apart from working at higher volume and achieving a shorter length of stay, performance of the hospital-at-home scheme a year after the trial ended was little different from that reported during the trial. This is an example of an observational study providing evidence to support the generalisability of trial findings.