Michael J Goldacre

Risk of venous thromboembolism in people admitted to hospital with selected immune-mediated diseases: record-linkage study

BackgroundVenous thromboembolism (VTE) is a common complication during and after a hospital admission. Although it is mainly considered a complication of surgery, it often occurs in people who have not undergone surgery, with recent evidence suggesting that immune-mediated diseases may play a role in VTE risk. We, therefore, decided to study the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) in people admitted to hospital with a range of immune-mediated diseases.MethodsWe analysed databases of linked statistical records of hospital admissions and death certificates for the Oxford Record Linkage Study area (ORLS1:1968 to 1998 and ORLS2:1999 to 2008) and the whole of England (1999 to 2008). Rate ratios for VTE were determined, comparing immune-mediated disease cohorts with comparison cohorts.ResultsSignificantly elevated risks of VTE were found, in all three populations studied, in people with a hospital record of admission for autoimmune haemolytic anaemia, chronic active hepatitis, dermatomyositis/polymyositis, type 1 diabetes mellitus, multiple sclerosis, myasthenia gravis, myxoedema, pemphigus/pemphigoid, polyarteritis nodosa, psoriasis, rheumatoid arthritis, Sjogrens syndrome, and systemic lupus erythematosus. Rate ratios were considerably higher for some of these diseases than others: for example, for systemic lupus erythematosus the rate ratios were 3.61 (2.36 to 5.31) in the ORLS1 population, 4.60 (3.19 to 6.43) in ORLS2 and 3.71 (3.43 to 4.02) in the England dataset.ConclusionsPeople admitted to hospital with immune-mediated diseases may be at an increased risk of subsequent VTE. Our findings need independent confirmation or refutation; but, if confirmed, there may be a role for thromboprophylaxis in some patients with these diseases.

Caesarean section is associated with an increased risk of childhood-onset type 1 diabetes mellitus: a meta-analysis of observational studies

Aims/hypothesisThe aim of this study was to investigate the evidence of an increased risk of childhood-onset type 1 diabetes in children born by Caesarean section by systematically reviewing the published literature and performing a meta-analysis with adjustment for recognised confounders.MethodsAfter MEDLINE, Web of Science and EMBASE searches, crude ORs and 95% CIs for type 1 diabetes in children born by Caesarean section were calculated from the data reported in each study. Authors were contacted to facilitate adjustments for potential confounders, either by supplying raw data or calculating adjusted estimates. Meta-analysis techniques were then used to derive combined ORs and to investigate heterogeneity between studies.ResultsTwenty studies were identified. Overall, there was a significant increase in the risk of type 1 diabetes in children born by Caesarean section (OR 1.23, 95% CI 1.15–1.32, p < 0.001). There was little evidence of heterogeneity between studies (p = 0.54). Seventeen authors provided raw data or adjusted estimates to facilitate adjustments for potential confounders. In these studies, there was evidence of an increase in diabetes risk with greater birthweight, shorter gestation and greater maternal age. The increased risk of type 1 diabetes after Caesarean section was little altered after adjustment for gestational age, birth weight, maternal age, birth order, breast-feeding and maternal diabetes (adjusted OR 1.19, 95% CI 1.04–1.36, p = 0.01).Conclusions/interpretationThis analysis demonstrates a 20% increase in the risk of childhood-onset type 1 diabetes after Caesarean section delivery that cannot be explained by known confounders.

Suicide after discharge from psychiatric inpatient care

People with a history of psychiatric disorder are at higher risk of suicide than people without such a history. The policy of reducing inpatient care in psychiatry has probably meant that some of the risk of suicide has shifted from the hospital to the community setting. We have quantified the risk of suicide within a year of psychiatric discharge in a population-based study in the Oxford health region, UK. We calculated suicide rates per 1000 person-years at risk (time from discharge to death, subsequent readmission, or the end of the study) and the standardised mortality ratio (SMR) for suicide, taking the value among the general population as 1. Among male patients the SMR for suicide (defined by coroners verdict of suicide) in the first 28 days after discharge from inpatient care was 213 (95% CI 137-317); the equivalent SMR for female patients was 134 (67-240). The result was similar when we defined suicide more broadly as a suicide, open, or misadventure verdict. The suicide rate in the first 28 days after discharge was 7.1 (4.1-12) times higher for male patients and 3.0 (1.5-6.0) times higher for female patients than the rate during the remaining 48 weeks of the first year after discharge. Most of the patients studied (both those who committed suicide and those who did not) had been psychiatric inpatients for only a short time. The findings confirm that there is significant clustering of suicide soon after discharge from psychiatric care. Skilled support after discharge for high-risk patients in the community is essential. Audit of suicides that occur soon after discharge may help identify the patients at highest risk and thereby reduce the number of avoidable deaths.

Time trends and demography of mortality after fractured neck of femur in an English population, 1968–98: database study

Abstract Objectives To investigate time trends in mortality after admission to hospital for fractured neck of femur from 1968 to 1998, and to report on the effects of demographic factors on mortality. Design Analysis of hospital inpatient statistics for fractured neck of femur, incorporating linkage to death certificates. Setting Four counties in southern England. Subjects 32 590 people aged 65 years or over admitted to hospital with fractured neck of femur between 1968 and 1998. Main outcome measures Case fatality rates at 30, 90, and 365 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission. Results Case fatality rates declined between the 1960s and the early 1980s, but there was no appreciable fall thereafter. They increased sharply with increasing age: for example, fatality rates at 30 days in 1984–98 increased from 4% in men aged 64–69 years to 31% in those aged ≥ 90. They were higher in men than women, and in social classes IV and V than in classes I and II. In the first month after fracture, standardised mortality ratios in women were 16 times higher, and those in men 12 times higher, than mortality in the same age group in the general population. Conclusions The high mortality rates, and the fact that they have not fallen over the past 20 years, reinforce the need for measures to prevent osteoporosis and falls and their consequences in elderly people. Whether post-fracture mortality has fallen to an irreducible minimum, or whether further decline is possible, is unclear.

Depression and anxiety in people with inflammatory bowel disease.

STUDY OBJECTIVE To determine whether depression or anxiety co-occurs with ulcerative colitis (UC) or Crohns disease (CD) more often than expected by chance, and, if so, whether the mental disorders generally precede or follow the inflammatory bowel diseases (IBD). DESIGN Nested case-control studies using a database of linked hospital record abstracts. SETTING Southern England. MAIN RESULTS Both depression and anxiety preceded UC significantly more often than would be predicted from the control populations experience. The associations were strongest when the mental conditions were diagnosed shortly before UC, although the association between depression and UC was also significant when depression preceded UC by five or more years. Neither depression nor anxiety occurred before CD more often than expected by chance. However, depression and anxiety were significantly more common after CD; the associations were strongest in the year after the initial record of CD. UC was followed by anxiety, but not by depression, more often than expected by chance and, again, the association was strongest within one year of diagnosis with UC. CONCLUSIONS The concentration of risk of depression or anxiety one year or less before diagnosis with UC suggests that the two psychiatric disorders might be a consequence of early symptoms of the as yet undiagnosed gastrointestinal condition. The data are also, however, compatible with the hypothesis that the psychiatric disorders could be aetiological factors in some patients with UC. Most of the excess anxiety or depression diagnosed subsequent to diagnosis of IBD occurs during the year after IBD is diagnosed and the probable explanation is that the mental disorders are sequelae of IBD.

Determinants of the decline in mortality from acute myocardial infarction in England between 2002 and 2010: linked national database study.

Objective To report trends in event and case fatality rates for acute myocardial infarction and examine the relative contributions of changes in these rates to changes in total mortality from acute myocardial infarction by sex, age, and geographical region between 2002 and 2010. Design Population based study using person linked routine hospital and mortality data. Setting England. Participants 840 175 people of all ages who were admitted to hospital for acute myocardial infarction or died suddenly from acute myocardial infarction. Main outcome measures Acute myocardial infarction event, 30 day case fatality, and total mortality rates. Results From 2002 to 2010 in England, the age standardised total mortality rate fell by about half, whereas the age standardised event and case fatality rates both declined by about one third. In men, the acute myocardial infarction event, case fatality, and total mortality rates declined at an average annual rate of, respectively, 4.8% (95% confidence interval 3.0% to 6.5%), 3.6% (3.4% to 3.7%), and 8.6% (5.4% to 11.6%). In women, the corresponding figures were 4.5% (1.7% to 7.1%), 4.2% (4.0% to 4.3%), and 9.1% (4.5% to 13.6%). Overall, the relative contributions of the reductions in event and case fatality rates to the decline in acute myocardial infarction mortality rate were, respectively, 57% and 43% in men and 52% and 48% in women; however, the relative contributions differed by age, sex, and geographical region. Conclusions Just over half of the decline in deaths from acute myocardial infarction during the 2000s in England can be attributed to a decline in event rate and just less than half to improved survival at 30 days. Both prevention of acute myocardial infarction and acute medical treatment have contributed to the decline in deaths from acute myocardial infarction over the past decade.

Elective total hip replacement: incidence, emergency readmission rate, and postoperative mortality.

OBJECTIVES--To report the incidence of elective total hip replacement and postoperative mortality, emergency readmission rates, and the demographic factors associated with these rates in a large defined population. DESIGN--Analysis of linked, routine abstracts of hospital inpatient records and death certificates. SETTING--10 hospitals in six districts in Oxford Regional Health Authority covered by the Oxford record linkage study. SUBJECTS--Records for 11,607 total hip replacements performed electively in 1976-85. MAIN OUTCOME MEASURES--Incidence of operation, postoperative mortality, relative mortality ratios, and incidence of emergency readmission. RESULTS--NHS operation rates increased over time from 43 to 58 operations/100,000 population. Variation in operation rates between districts reduced over time. Operation rates were on average 25% higher in women than men. There were 93 deaths (11/1000 operations) within 90 days of the operation and 208 emergency readmissions (28/1000 operations) within 28 days of discharge. Postoperative mortality and emergency readmission rates increased with age. No significant trend with time was found. Mortality in the 90 days after the operation was 2.5-fold higher (1.9 to 3.0) than in the rest of the first postoperative year. This represented an estimated excess of 6.5 (4.2 to 8.8) early postoperative deaths/1000 operations. Most deaths were ascribed to cardiovascular events. Thromboembolic disease was the commonest reason for emergency readmission. CONCLUSIONS--The pronounced increase in operations in districts with initially low rates suggests a trend towards greater equity in the local provision of NHS hip arthroplasty. The early postoperative clusters of deaths attributed to cardiovascular disease and of readmissions for thromboembolic disease suggest that there is scope for investigating ways of reducing the incidence of major adverse postoperative events.

Hospital admission for acute pancreatitis in an English population, 1963-98: database study of incidence and mortality.

Abstract Objectives To investigate trends in the incidence of acute pancreatitis resulting in admission to hospital, and mortality after admission, from 1963 to 1998. Design Analysis of hospital inpatient statistics for acute pancreatitis, linked to data from death certificates. Setting Southern England. Subjects 5312 people admitted to hospital with acute pancreatitis. Main outcome measures Incidence rates for admission to hospital, case fatality rates at 0-29 and 30-364 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission. Results The incidence of acute pancreatitis with admission to hospital increased from 1963-98: age standardised incidence rates were 4.9 per 100 000 population in 1963-74, 7.7 in 1975-86, and 9.8 in 1987-98. Age standardised case fatality rates within 30 days of admission were 14.2% in 1963-74, 7.6% in 1975-86, and 6.7% in 1987-98. From 1975-98, standardised mortality ratios at 30 days were 30 in men and 31 in women (compared with the general population of equivalent age in the same period = 1), and they remained significantly increased until month 5 for men and month 6 for women. Conclusions Incidence rates for acute pancreatitis with admission to hospital rose in both men and women from 1963 to 1998, particularly among younger age groups. This probably reflects, at least in part, an increase in alcoholic pancreatitis. Mortality after admission has not declined since the 1970s. This presumably reflects the fact that no major innovations in the treatment of acute pancreatitis have been introduced. Pancreatitis remains a disease with a poor prognosis during the acute phase.

Career preferences of doctors who qualified in the United Kingdom in 1993 compared with those of doctors qualifying in 1974, 1977, 1980, and 1983

Abstract Objective: To report the career preferences of doctors who qualified in the United Kingdom in 1993 and to compare their choices with those of earlier cohorts of qualifiers. Design: Postal questionnaires with structured questions, including questions about choice of future long term career, were sent to doctors a year after qualification. Setting: United Kingdom. Subjects: All medical qualifiers of 1993, comparing their replies with those from earlier studies of the qualifiers of 1974, 1977, 1980, and 1983. Main outcome measures: Choice of future long term career and certainty of choice expressed at the end of the first year after qualification. Results: Questionnaires were sent to 3657 doctors. 2621 (71.7%) replied. Of the 2621 respondents, 70.5% (1849) stated that their first preference was for a career in hospital practice, 25.8% (677) specified general practice, 1.0% (25) specified public health medicine or community health, 1.4% (36) specified careers outside medicine, and 1.3% (34) did not state a choice. By contrast, 44.7% (1416/3168) of the doctors in the 1983 cohort had specified that their first preference was general practice. Among the 1993 qualifiers, general practice was the first career choice of 17.5% of men (227/1297) and 34.0% of women (450/1324). Only 7.4% of men (96/1297) stated that they definitely wanted to enter general practice. Only 7.8% (103/1324) of women qualifiers in 1993 expressed a career preference for surgical specialties. Within hospital practice, comparing 1993 with 1983, choices for the medical specialties and for accident and emergency medicine rose and those for pathology fell. Women were less definite than men about their choice of future long term career. Conclusions: If the 1993 cohort is typical of the current generation of young doctors, there has been a substantial shift away from general practice as a career choice expressed at the end of the preregistration year. General practice was much more popular among women than men. Few women opted for surgery. The sex imbalance in the percentage of doctors who choose different mainstreams of medical practice seems set to continue.

Mortality after hospital discharge for people with schizophrenia or bipolar disorder: retrospective study of linked English hospital episode statistics, 1999-2006.

Objective To investigate whether the mortality gap has reduced in recent years between people with schizophrenia or bipolar disorder and the general population. Design Record linkage study. Setting English hospital episode statistics and death registration data for patients discharged 1999-2006. Participants People discharged from inpatient care with a diagnosis of schizophrenia or bipolar disorder, followed for a year after discharge. Main outcome measures Age standardised mortality ratios at each time, comparing the mortality in people with schizophrenia or bipolar disorder with mortality in the general population. Poisson test of trend was used to investigate trend in ratios over time. Results By 2006 standardised mortality ratios in the psychiatric cohorts were about double the population average. The mortality gap widened over time. For people discharged with schizophrenia, the ratio was 1.6 (95% confidence interval 1.5 to 1.8) in 1999 and 2.2 (2.0 to 2.4) in 2006 (P<0.001 for trend). For bipolar disorder, the ratios were 1.3 (1.1 to 1.6) in 1999 and 1.9 (1.6 to 2.2) in 2006 (P=0.06 for trend). Ratios were higher for unnatural than for natural causes. About three quarters of all deaths, however, were certified as natural, and increases in ratios for natural causes, especially circulatory disease and respiratory diseases, were the main components of the increase in all cause mortality. Conclusions The total burden of premature deaths from natural causes in people with schizophrenia or bipolar disorder is substantial. There is a need for better understanding of the reasons for the persistent and increasing gap in mortality between discharged psychiatric patients and the general population, and for continued action to target risk factors for both natural and unnatural causes of death in people with serious mental illness.