Leone Ridsdale

Headache and migraine in primary care: consultation, prescription, and referral rates in a large population

Background/Aims: Headache is the most common new neurological symptom seen by general practitioners and neurologists. This study describes headache consultation, prescription, and referral rates in a large sample of UK general practices. Methods: Analysis of data from patients ⩾15 years registered at 253 UK general practices diagnosed with headache/migraine from 1992 to 2000. Rates were age standardised using the European standard population for reference. Results: There were 13.2 million patient years of observation. Headache consultation rates were 6.4/100 patients/year in women and 2.5 in men. They were highest at 15–24 years (15.8/100 in women; 5.8/100 in men), decreasing with age. Antimigraine drugs were prescribed at 36.7% of consultations for women and 26.6% for men. Among referrals to specialists, 55% were to neurology and 30% to general medicine. The neurology referral rate in patients with headache was 2.1/100, and was higher in men (2.7/100) than women (1.9/100). Conclusions: These results provide precise age specific and age standardised estimates for headache consulting in general practice, in addition to prescribing and referral to specialist care. Consultation rates are highest in young women; hospital referrals peak in middle aged men. Research is needed into reasons for referral, and on better ways of delivering headache services.

The economic cost of chronic fatigue and chronic fatigue syndrome in UK primary care.

BACKGROUND Chronic fatigue and chronic fatigue syndrome are most often encountered in primary care settings. Given the disabling nature of chronic fatigue it may have a substantial impact on service use and costs as well as on employment. This study estimates this impact. METHOD Patients presenting to general practitioners with unexplained chronic fatigue were recruited to the study. Service use over a 3 month period was measured and lost employment recorded. These data were used to estimate economic costs. Patients with chronic fatigue syndrome were compared to patients with only chronic fatigue using a multiple regression model with sample differences controlled. RESULTS The mean total cost of services and lost employment across the sample was Pound Sterling1906 for the 3-month period with formal services accounting for 9.3% of this figure. Service use was higher for patients with chronic fatigue syndrome compared to those with chronic fatigue alone. Total 3-month costs were on average higher for chronic fatigue syndrome (Pound Sterling3515 v. Pound Sterling1176) but when sample differences were taken account of the mean difference was reduced to Pound Sterling1406 (P = 0.086). Over 90% of the cost was accounted for by care provided by friends and family members and by lost employment. Patients with dependants had significantly higher costs than those with none and costs were also significantly higher for greater levels of functional impairment. CONCLUSION Chronic fatigue imposes substantial economic costs on society, mainly in the form of informal care and lost employment. Treatments need to be developed which recognize these impacts.

Trends in antiepileptic drug utilisation in UK primary care 1993-2008: Cohort study using the General Practice Research Database.

PURPOSE To describe changes in utilisation of antiepileptic drugs (AED) by people with epilepsy in the United Kingdom during 1993-2008. METHODS Cohort study of 63,586 participants with epilepsy and prescribed AEDs from 434 UK family practices. Prescriptions for different AEDs and AED combinations were evaluated by calendar year, gender and age group. RESULTS Total follow-up was 361,207 person-years, with 282,080 person-years treated with AEDs and 79,126 person-years untreated. AED monotherapy accounted for 72.6% of treated person years of follow-up. Carbamazepine and valproates were among the most commonly used medications throughout 1993-2008. Phenytoin accounted for 39.5% of treated person-years in 1993 declining to 18.3% by 2008. Use of barbiturates declined from 14.3% in 1993 to 6.0% in 2008. In contrast between 1993 and 2008 there were substantial increases in the use of lamotrigine (2.0% to 17.0%) and to a lesser extent levetiracetam (0% to 8.6%). Newer AEDs were more frequently prescribed to younger participants, especially women aged 15-44 years, while older adults were more likely to be prescribed longer established AEDs. In 1993, 201 different AED combinations were prescribed, increasing to 500 different combinations in 2008. Combinations of sodium valproate and carbamazepine were frequent throughout, while sodium valproate and lamotrigine was frequent in 2008. CONCLUSIONS Utilisation of newer AEDs in UK primary care has increased between 1993 and 2008 with increasing use of diverse combinations of AEDs. The data quantify exposure to AEDs relevant to planning analytical pharmaco-epidemiological studies, as well as providing information to inform prescribing policies.

Epilepsy mortality and risk factors for death in epilepsy: a population-based study

BACKGROUND Epilepsy is an important cause of amenable mortality but risk factors for death in epilepsy are not well understood. AIM To evaluate trends in epilepsy mortality in a large population and identify risk factors for death in epilepsy. DESIGN AND SETTING Nested case-control study in the UK, using data from the General Practice Research Database (GPRD) from 1993 to 2007. METHOD Participants were included if they had ever been diagnosed with epilepsy and prescribed anticonvulsant drugs. Trends in all-cause mortality in persons with epilepsy in the GPRD were compared with death registrations with epilepsy as the underlying cause. A nested case-control study was implemented to compare participants with epilepsy who died with those who did not die. RESULTS The prevalence of epilepsy increased from 9 per 1000 in 1993 to 12 per 1000 in 2007, and epilepsy deaths also increased in this period. In a nested case-control study, mortality was associated with: recorded alcohol problems (odds ratio [OR] 2.96, 95% confidence interval [CI] = 2.25 to 3.89, P<0.001); having collected the last anticonvulsant prescription 90-182 days previously (OR 1.83, CI = 1.66 to 2.03, P<0.001); having an injury in the previous year (OR 1.41, 95% CI = 1.30 to 1.53, P<0.001), and having been treated for depression (OR 1.39, 95% CI = 1.28 to 1.50, P<0.001). In data available from 2004 onwards, being recorded seizure free in the previous 12 months was associated with lower mortality (OR 0.78, 95% CI = 0.71 to 0.86, P<0.001). CONCLUSION Mortality with epilepsy appears to be increasing. Patients who have alcohol problems, do not collect repeat prescriptions for anticonvulsant drugs, have recent injuries, or have been treated for depression may be at increased risk of death; patients who remain seizure free over 12 months are at a lower risk.

Predictors of outcome in a fatigued population in primary care following a randomized controlled trial

BACKGROUND The objective of this study was to examine factors that predicted outcome in a chronically fatigued group of patients who were randomized to cognitive behaviour therapy or counselling in primary care. METHOD Illness perceptions, attributions, fatigue, disability and demographic variables were recorded at assessment and levels of fatigue and disability were measured at 6 months post randomization. Logistic regression was used to examine associations. RESULTS Factors that predicted a poor outcome (four or more on the fatigue questionnaire) were: poor social adjustment at assessment; the patients self-report that they had never seen the GP for an emotional reason; a physical illness attribution; and, a long perceived future illness duration. CONCLUSIONS Patients who are more psychologically minded are more likely to improve with psychological treatments in primary care. General practitioners need to assess this before referring to an appropriate therapist.

Cost-effectiveness of cognitive behavioural therapy, graded exercise and usual care for patients with chronic fatigue in primary care

BACKGROUND Chronic fatigue is a common condition, frequently presenting in primary care. The aim of this study was to compare the cost-effectiveness of cognitive behavioural therapy (CBT) and graded exercise therapy (GET), and to compare therapy with usual care plus a self-help booklet (BUC). METHOD Patients drawn from general practices in South East England were randomized to CBT or GET. The therapy groups were then compared to a group receiving BUC recruited after the randomized phase. The main outcome measure was clinically significant improvements in fatigue. Cost-effectiveness was assessed using the net-benefit approach and cost-effectiveness acceptability curves. RESULTS Costs were available for 132 patients, and cost-effectiveness results for 130. Costs were dominated by informal care. There were no significant outcome or cost differences between the therapy groups. The combined therapy group had significantly better outcomes than the standard care group, and costs that were on average 149 pounds higher (a non-significant difference). Therapy would have an 81.9% chance of being cost-effective if society were willing to attach a value of around 500 pounds to each four-point improvement in fatigue. CONCLUSION The cost-effectiveness of cognitive behavioural therapy and graded exercise were similar unless higher values were placed on outcomes, in which case CBT showed improved cost-effectiveness. The cost of providing therapy is higher than usual GP care plus a self-help booklet, but the outcome is better. The strength of this evidence is limited by the use of a non-randomized comparison. The cost-effectiveness of therapy depends on how much society values reductions in fatigue.

Characteristics of people with epilepsy who attend emergency departments:: Prospective study of metropolitan hospital attendees

Purpose:  One fifth of people with established epilepsy attend hospital emergency departments (EDs) and one half are admitted each year. These ED visits are not necessarily required, and unplanned hospitalizations are costly. Reducing avoidable ED visits and admissions is a target in most health services. The development of interventions is, however, challenging. Policymakers lack information about users’ characteristics, factors associated with ED use, as well as quality of care. This study provides this information.

Towards an evaluation of the effectiveness of an epilepsy nurse in primary care

This paper reports on early results of an investigation of the effectiveness of a specialist epilepsy nurse in primary care. Based on before-and-after interviews with sub-samples of adults with epilepsy, these results suggest that not only are expectations of the usefulness of epilepsy nurse interventions high, but also that these expectations are not disappointed in practice. Particular areas where epilepsy nurses may be able to complement and enhance medical approaches to treatment and care are identified.

Decision-making by ambulance clinicians in London when managing patients with epilepsy: a qualitative study

Background In the UK, epilepsy is the neurological condition with the highest rate of accident and emergency department re-attendance, with most arriving by ambulance. Ambulance clinicians triage patients and assess their need for attendance. This study examined the decision-making process of ambulance clinicians in these situations. Methods In-depth interviews with 15 ambulance clinicians working in South London. Results Interviewees identified that epileptic seizures that self-resolve present a triage challenge. They reported insufficient training and guidance available for these situations and substantial reliance on experience to direct their practice. Fears of litigation in the event of complications, pressures of public expectation and limited on-scene access to relevant patient information or appropriate alternative care pathways were reported to be significant factors influencing decisions for care for epilepsy seizures. Discussion Ambulance clinicians reported negotiating a balance between patient safety and patient choice, when deciding whether to transport a patient with epilepsy to hospital or not. Clinician fears and the pressures and limitations of practice may result in hospital conveyance being used as a safety precaution in some instances. Conclusions Decisions regarding conveyance of patients with epilepsy in this study were substantially guided by ambulance clinician experience rather than by robust training and guidelines. This study supports the need for improved guidance that addresses this common area of practice and the development of alternative care pathways that may be used by ambulance clinicians for patients with epilepsy.

Fracture risk with use of liver enzyme inducing antiepileptic drugs in people with active epilepsy: Cohort study using the General Practice Research Database

PURPOSE Liver enzyme inducing antiepileptic drugs (LEI AEDs) have adverse effects on bone metabolism but it is unclear whether this translates into increased fracture risk. This population based cohort study aimed to evaluate whether treatment with LEI AEDs is associated with increased risk of fracture in people with active epilepsy. METHODS The cohort included patients diagnosed with epilepsy and prescribed AEDs while registered at a GPRD general practice during 1993-2008. The hazard ratio with current use of LEI AEDs for fracture at any site and hip fracture was estimated using Cox proportional hazards models. RESULTS There were 7356 fractures (788 hip fractures) in 63259 participants. In women, the adjusted hazard ratio with use of LEI AEDs was 1.22 for fracture (95% CI 1.12-1.34; p<0.001) and 1.49 for hip fracture (1.15-1.94; p=0.002). In men, the hazard ratio for fracture was 1.09 (0.98-1.20; p=0.123) and for hip fracture 1.53 (1.10-2.12; p=0.011). For every 10000 women treated with LEI AEDs for one year, there could be 48 additional fractures, including 10 additional hip fractures. For every 10000 men treated with LEI AEDs for one year, there could be 4 additional hip fractures. CONCLUSIONS LEI AEDs may increase the risk of fracture in people with epilepsy. In patients at high risk of osteoporotic fracture alternative AED therapy may be appropriate. Further information is urgently needed on the safety of valproate and newer AEDs and on strategies to maintain bone health in people who need to be treated with LEI.