Colin R Simpson

Long-term trends in first hospitalization for heart failure and subsequent survival between 1986 and 2003: a population study of 5.1 million people.

Background— We examined whether population-level hospitalization rates for heart failure (HF) and subsequent survival have continued to improve since the turn of the century. We also examined trends in the prescribing of evidence-based pharmacological treatment for HF. Methods and Results— All patients in Scotland hospitalized with a first episode of HF between 1986 and 2003 were followed up until death or the end of 2004. Prescriptions of evidence-based treatments issued from 1997 to 2003 by a sample of primary care practices were also examined. A total of 116 556 individuals (52.6% women) had a first hospital discharge for HF. Age-adjusted first hospitalization rates for HF (per 100 000; 95% CI in parentheses) rose from 124 (119 to 129) in 1986 to 162 (157 to 168) in 1994 and then fell to 105 (101 to 109) in 2003 in men; in women, they rose from 128 (123 to 132) in 1986 to 160 (155 to 165) in 1993, falling to 101 (97 to 105) in 2003. Case-fatality rates fell steadily over the period. Adjusted 30-day case-fatality rates fell after discharge (adjusted odds [2003 versus 1986] 0.59 [95% CI 0.45 to 0.63] in men and 0.77 [95% CI 0.67 to 0.88] in women). Adjusted 1- and 5-year survival improved similarly. Median survival increased from 1.33 to 2.34 years in men and from 1.32 to 1.79 years in women. Age-adjusted prescribing rates for angiotensin-converting enzyme inhibitors, β-blockers, and spironolactone increased from 1997 to 2003 (all P<0.0001 for trend). Conclusions— After rising between 1986 and 1994, rates of first hospitalization for HF declined. Case-fatality rates also fell. Prescribing rates for HF therapies increased from 1997 to 2003. These findings suggest that improvements in the prevention and treatment of HF may have had progressive, sustained effects on outcomes at the population level; however, prognosis remains poor in HF.

High risk prescribing in primary care patients particularly vulnerable to adverse drug events: cross sectional population database analysis in Scottish general practice.

Objective To examine the prevalence and patterns of high risk prescribing, defined as potentially inappropriate prescribing of drugs to primary care patients particularly vulnerable to adverse drug events. Design Cross sectional population database analysis. Setting General practices in Scotland. Participants 315 Scottish general practices with 1.76 million registered patients, 139 404 (7.9%) of whom were defined as particularly vulnerable to adverse drug events because of age, comorbidity, or co-prescription. Main outcome measures How reliably each of 15 indicators—four each for non-steroidal anti-inflammatory drugs, co-prescription with warfarin, and prescribing in heart failure, two for dose instructions for methotrexate, and one for antipsychotic prescribing in dementia—and a composite of all 15 could distinguish practices in terms of their rates of high risk prescribing; and characteristics of patients and practices associated with high risk prescribing in a multilevel model. Results 19 308 of 139 404 (13.9%, 95% confidence interval 13.7% to 14.0%) patients had received at least one high risk prescription in the past year. This composite indicator was a reasonably reliable measure of practice rates of high risk prescribing (reliability >0.7 for 95.6% of practices, >0.8 for 88.2%). The patient characteristic most strongly associated with high risk prescribing was the number of drugs prescribed (>11 long term prescribed drugs v 0; odds ratio 7.90, 95% confidence interval 7.19 to 8.68). After adjustment for patient characteristics, rates of high risk prescribing varied by fourfold between practices, which was not explained by structural characteristics of the practices. Conclusions Almost 14% of patients defined as particularly vulnerable to adverse drug events were prescribed one or more high risk drugs. The composite indicator of high risk prescribing used could identify practices as having above average or below average high risk prescribing rates with reasonable confidence. After adjustment, only the number of drugs prescribed long term to patients was strongly associated with high risk prescribing, and considerable unexplained variation existed between practices. High risk prescribing will often be appropriate, but the large variation between practices suggests opportunities for improvement.

A national survey of the prevalence, incidence, primary care burden and treatment of atrial fibrillation in Scotland

Objective: To examine the epidemiology, primary care burden and treatment of atrial fibrillation (AF). Design: Cross-sectional data from primary care practices participating in the Scottish Continuous Morbidity Recording scheme between April 2001 and March 2002. Setting: 55 primary care practices (362 155 patients). Participants: 3135 patients with AF. Results: The prevalence of AF in Scotland was 9.4/1000 in men and 7.9/1000 in women (p<0.001) and increased with age (to 71/1000 in individuals aged >85 years). The prevalence of AF decreased with increasing socioeconomic deprivation (9.2/1000 least deprived and 7.5/1000 most deprived category, p = 0.02 for trend). 71% of patients with AF received rate-controlling medication: β-blocker 28%, rate-limiting calcium-channel blocker 42% and digoxin 43%. 42% of patients received warfarin, 44% received aspirin and 78% receeved more than one of these. Multivariable analysis showed that men and women aged ⩾75 years were more likely (than those aged <75 years) to be prescribed digoxin (men OR 1.41, 95% CI 1.14 to 1.74; women OR 1.88, 95% CI 1.50 to 2.37) and aspirin (2.04, 1.66 to 2.51; 1.79, 1.42 to 2.25) and less likely to receive an antiarrhythmic drug (0.62, 0.48 to 0.81; 0.52, 0.39 to 0.70) or warfarin (0.74, 0.60 to 0.91; 0.58, 0.46 to 0.73). Adjusted analysis showed no socioeconomic gradient in prescribing. Conclusions: AF is a common condition, more so in men than in women. Deprived individuals are less likely to have AF, a finding raising concerns about socioeconomic gradients in detection and prognosis. Recommended treatments for AF were underused in women and older people. This is of particular concern, given the current trends in population demographics and the evidence that both groups are at higher risk of stroke.

Trends in the epidemiology of asthma in England: a national study of 333,294 patients.

Summary Background Observations in the UK at the end of the last century found increasing trends of asthma prevalence over time. However, it has been reported that the number of new cases of asthma presenting to general practice has declined, especially among younger children. Aim To study national trends in the epidemiology of asthma. Methods A cross-sectional observation analysis was performed using the QRESEARCH database, which is one of the worlds largest national aggregated health databases containing records from 422 English practices yielding 30 million patient-years of observation. Data was extracted on 333,294 individuals with a recorded diagnosis of asthma and calculated annual age–sex standardized incidence, lifetime period prevalence and asthma-related prescribing rates for each year from 2001–2005. Results The incidence rate of asthma decreased in all patients (2001: 6.9 (95% confidence intervals [CI] 6.8–7.0); 2005: 5.2 (95% CI 5.1–5.3) per 1000 patient-years, p<0.001), but most particularly in children under 5 years of age (–38.4%) where a decrease in the lifetime prevalence of asthma (–34.3%) was also found. However, the lifetime prevalence rate of asthma for adults increased (15–44 years: 23.3%; 45–64 years: 27.7%; >65 years: 21.5%) with an estimated 5,658,900 (95% CI 5,639,700–5,678,200) or approximately one person in nine having being diagnosed with asthma in England. The number of asthma-related prescriptions also increased over the study period (17.1%), such that in 2005 an estimated 32,577,300 (95%CI 32,531,600–32,623,000) prescriptions were issued. Conclusions This large national study reveals that the rate of new diagnoses of asthma appears to have passed its peak; however, the number of adults with a lifetime asthma diagnosis continues to rise. Whether these trends are genuine or are a result of the introduction of incentives and guidelines to improve identification and recording of asthma or changing diagnostic trends is a question with important public health implications and one, therefore, that warrants detailed further enquiry.

Influence of socioeconomic deprivation on the primary care burden and treatment of patients with a diagnosis of heart failure in general practice in Scotland: population based study

Abstract ObjectiveTo examine whether there are socioeconomic gradients in the incidence, prevalence, treatment, and follow up of patients with heart failure in primary care. DesignPopulation based study. Setting53 general practices (307 741 patients) participating in the Scottish continuous morbidity recording project between 1April 1999 and 31 March 2000. Participants2186 adults with heart failure. Main outcome measuresComorbid diagnoses, frequency of visits to general practitioner, and prescribed drugs. Results2186 patients with heart failure were seen (prevalence 7.1 per 1000 population, incidence 2.0 per 1000 population). The age and sex standardised incidence of heart failure increased with greater socioeconomic deprivation, from 1.8 per 1000 population in the most affluent stratum to 2.6 per 1000 population in the most deprived stratum (odds ratio 1.44, P = 0.0003). On average, patients were seen 2.4 times yearly, but follow up rates were less frequent with increasing socioeconomic deprivation (from 2.6 yearly in the most affluent subgroup to 2.0 yearly in the most deprived subgroup, P = 0.00009). Overall, 812 (80.6%) patients were prescribed diuretics, 396 (39.3%) angiotensin converting enzyme inhibitors, 216 (21.4%)βblockers, 208 (20.7%) digoxin, and 86 (8.5%) spironolactone. The wide discrepancies in prescribing between different general practices disappeared after adjustment for patient age and sex. Prescribing patterns did not vary by deprivation categories on univariate or multivariate analyses. Conclusions Compared with affluent patients, socioeconomically deprived patients were 44% more likely to develop heart failure but 23% less likely to see their general practitioner on an ongoing basis. Prescribed treatment did not differ across socioeconomic gradients.

Primary care burden and treatment of patients with heart failure and chronic obstructive pulmonary disease in Scotland

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) frequently coexist and present major challenges to healthcare providers. The epidemiology, consultation rate, and treatment of patients with HF and COPD in primary care are ill‐defined.

Evidence for Age and Sex Differences in the Secondary Prevention of Stroke in Scottish Primary Care

Background and Purpose— Secondary preventive measures play an important role in the reduction of stroke, the third largest cause of death in Scotland. We investigated whether sex, age, or deprivation differences existed in the secondary prevention of stroke in primary care. Methods– A retrospective cross-sectional study using a computerized database with 61 practices (377 439 patients) to identify group differences in secondary preventive therapy between March 2003 and April 2004 for 10 076 patients with a diagnosis of any stroke. Results— Women with any stroke were more likely than men to be prescribed a thiazide (odds ratios [OR], 1.60; 95% confidence interval [CI], 1.46 to 1.75) but less likely to be prescribed an angiotensin-converting enzyme inhibitor (OR, 0.73; 95% CI, 0.67 to 0.81). Women with ischemic stroke were less likely to receive either an antiplatelet or warfarin (OR, 0.84; 95% CI, 0.75 to 0.94) or statin therapy (OR, 0.82; 95% CI, 0.74 to 0.90) than men. Women with atrial fibrillation received less warfarin (OR, 0.62; 95% CI, 0.48 to 0.81) but more antiplatelet therapy than men (OR, 1.30; 95% CI, 1.00 to 1.68). The oldest patients (older than 75 years) with ischemic stroke received more antiplatelet therapy than the youngest patients (younger than 65 years) (OR, 1.83; 95% CI, 1.64 to 2.06). No significant differences in secondary preventative treatment across deprivation groups were found. Conclusion— Important sex and age differences exist in the care of patients with stroke and suggest that women and the elderly need to be targeted for secondary prevention therapy.

Incidence, prevalence, and trends of general practitioner–recorded diagnosis of peanut allergy in England, 2001 to 2005

BACKGROUND Previous descriptions of the epidemiology of peanut allergy have mainly been derived from small cross-sectional studies. OBJECTIVE To interrogate a large national research database to provide estimates for the incidence, prevalence, and trends of general practitioner (GP)-recorded diagnosis of peanut allergy in the English population. METHODS Version 10 of the QRESEARCH database was used with data from 2,958,366 patients who were registered with 422 United Kingdom general practices in the years 2001 to 2005. The primary outcome was a recording of clinician-diagnosed peanut allergy. RESULTS The age-sex standardized incidence rate of peanut allergy in 2005 was 0.08 per 1000 person-years (95% CI, 0.07-0.08), and the prevalence rate was 0.51 per 1000 patients (95% CI, 0.49-0.54). This translated into an estimated 4000 incident cases (95% CI, 3500-4600) and 25,700 prevalent cases (95% CI, 24,400-27,100) of GP-recorded diagnosis of peanut allergy in England in 2005. During the study period, the incidence rate of peanut allergy remained fairly stable, whereas the prevalence rate doubled. In those under 18 years of age, the crude lifetime prevalence rate was higher in males than females. A significant inverse relationship between prevalence and socioeconomic status was found. CONCLUSION These data on GP-recorded diagnosis of peanut allergy from a large general practice database suggest a much lower prevalence in peanut allergy than has hitherto been found. This difference may in part be explained by underrecording of peanut allergy in general practice. Further research is needed to assess the true frequency of peanut allergy in the population and whether there has been a true increase in recent years.

National survey of the prevalence, incidence, primary care burden, and treatment of heart failure in Scotland

Objective: To examine the epidemiology, primary care burden, and treatment of heart failure in Scotland, UK. Design: Cross sectional data from primary care practices participating in the Scottish continuous morbidity recording scheme between 1 April 1999 and 31 March 2000. Setting: 53 primary care practices (307 741 patients). Subjects: 2186 adult patients with heart failure. Results: The prevalence of heart failure in Scotland was 7.1 in 1000, increasing with age to 90.1 in 1000 among patients ⩾ 85 years. The incidence of heart failure was 2.0 in 1000, increasing with age to 22.4 in 1000 among patients ⩾ 85 years. For older patients, consultation rates for heart failure equalled or exceeded those for angina and hypertension. Respiratory tract infection was the most common co-morbidity leading to consultation. Among men, 23% were prescribed a β blocker, 11% spironolactone, and 46% an angiotensin converting enzyme inhibitor. The corresponding figures for women were 20% (p  =  0.29 versus men), 7% (p  =  0.02), and 34% (p < 0.001). Among patients < 75 years 26% were prescribed a β blocker, 11% spironolactone, and 50% an angiotensin converting enzyme inhibitor. The corresponding figures for patients ⩾ 75 years were 19% (p  =  0.04 versus patients < 75), 7% (p  =  0.04), and 33% (p < 0.001). Conclusions: Heart failure is a common condition, especially with advancing age. In the elderly, the community burden of heart failure is at least as great as that of angina or hypertension. The high rate of concomitant respiratory tract infection emphasises the need for strategies to immunise patients with heart failure against influenza and pneumococcal infection. Drugs proven to improve survival in heart failure are used less frequently for elderly patients and women.

Vaccine effectiveness in pandemic influenza - primary care reporting (VIPER): an observational study to assess the effectiveness of the pandemic influenza A (H1N1)v vaccine

OBJECTIVES To determine influenza A (H1N1)v vaccine effectiveness (VE) in the Scottish population at an early stage of the 2009-10 H1N1v vaccination programme, using a sentinel surveillance network of 41 general practices contributing to the Practice Team Information (PTI) network. METHODS Retrospective cohort study using record linkage. Using the Community Health Index (CHI) number, general practice patient-level data were extracted and linked to the Scottish Morbidity Record (SMR) catalogue, containing information on all inpatient hospitalisations in Scotland. The Health Protection Scotland (HPS) data set was also used, consisting of laboratory-confirmed cases of influenza A (H1N1)v from the practices. The study involved a longitudinal evaluation of the aspect of the influenza A (H1N1)v vaccination programme implemented through general practice in autumn/winter 2009. RESULTS At 25 December 2009, vaccine uptake estimates for the study population were 12.0% (95% CI 11.9 to 12.1). For those patients in an at-risk group (n = 59,721), the uptake rate was 37.5% (95% CI 37.1 to 37.9). Among the 1492 patients swabbed, 467 were positive for H1N1, giving a positivity rate of 31.3% [95% confidence interval (CI) 29.0 to 33.7]. Among those in a clinical risk group who were not vaccinated, 41.3% (95% CI 35.6 to 46.9) tested positive for influenza A (H1N1)v, a significant difference from the H1N1 positivity percentage among patients with no clinical risk (p < 0.01). Among those vaccinated and in a clinical risk group, only one patient (5%, 95% CI 0.3 to 23.6) tested after vaccination was positive for influenza A (H1N1)v. By comparing postvaccination swabs in those who were vaccinated with swabs taken in those who remained unvaccinated, the VE was found to be 95.0% (95% CI 76.0 to 100.0). In the study population there were 2739 admissions to hospital, of which 1241 were emergency admissions; all 48 emergency hospitalisations for influenza and pneumonia occurred in patients who did not receive the vaccine. VE for single or combined end points of influenza and pneumonia hospitalisation for all patients was estimated at 100.0% (95% CI infinity to 100.0). There were 132 hospitalisations in the unvaccinated group versus five in the vaccinated group for cardiovascular-related conditions. There were 193 hospitalisations in the unvaccinated group versus nine in those vaccinated in the group of patients admitted for influenza, pneumonia, chronic obstructive pulmonary disease (COPD) and cardiovascular-related conditions. VE for cardiovascular-related conditions alone, or in individuals with influenza, pneumonia COPD and cardiovascular-related conditions, was 71.1% (95% CI 11.3 to 90.6) and 64.7% (95% CI 12.0 to 85.8) respectively. CONCLUSIONS Evidence from swabs submitted from patients in the cohort who presented in general practice with influenza-like illness suggests that the introduction of influenza A (H1N1)v vaccine in Scotland during 2009 was associated with a high degree of protection. Influenza A (H1N1)v immunisation in primary health-care settings appears to be both effective and widely acceptable, and should continue to be the mainstay of disease prevention for at-risk patients. A further analysis encompassing the whole influenza season is required to cover more days of vaccination exposure and increase precision.