Rebecca Whittle

Health literacy, associated lifestyle and demographic factors in adult population of an English city: a cross-sectional survey

Lower health literacy is a public health issue that follows a social gradient, potentially reinforcing existing health inequalities. However, levels of health literacy in particular populations can be unclear and are a key to identifying effective public health interventions. This research examined health literacy levels in Stoke‐on‐Trent, where 31.2% of the population live in areas classified amongst the 10% most deprived in England.

The digital divide: Examining socio-demographic factors associated with health literacy, access and use of internet to seek health information:

This article aims to examine the socio-demographic characteristics associated with access and use of Internet for health-related purposes and its relationship with health literacy. Data were drawn from a health literacy survey (N = 1046) and analysed using logistic regression. Results show a strong association between health literacy, internet access and use. Socio-demographic characteristics particularly age, education, income, perceived health and social isolation also predict internet access. Thus, in addition to widening access, the movement towards digitisation of health information and services should also consider digital skills development to enable people to utilise digital technology more effectively, especially among traditionally hard-to-reach communities.

Applying causal mediation methods to clinical trial data: What can we learn about why our interventions (don't) work?

Many randomized controlled trials (RCTs) of psychosocial interventions for low back pain (LBP) have been found to have only small effects on disability outcomes. Investigations of the specific mechanisms that may lead to an improvement in outcome have therefore been called for.

What does a primary care annual review for RA include? A national GP survey

Sir Patients with rheumatoid arthritis (RA) are at increased risk of comorbidities particularly cardiovascular disease and osteoporosis [1, 2]. NICE standards of care for rheumatoid arthritis (RA) recommend patients should receive a holistic annual review that should include an assessment of disease activity and severity, active screening for and management of comorbidities [3] and assessment of the impact of RA on quality of life. In 2013, RA was included in the Quality Outcomes Framework (QOF) of the UK general practice contract. General practitioners (GPs) were incentivised to provide a face to face annual review for RA patients, including cardiovascular and fracture risk screening, mirroring the routine care for patients with other long-term conditions such as diabetes—a model which improves quality of care and clinically important outcomes [4]. The aims of this study were to investigate what domains GPs report including in their annual review for patients with RA and to determine the role of the multidisciplinary team in providing these reviews. We conducted a national cross-sectional survey in 2013 to investigate the primary care management of RA. Five thousand randomly selected GPs were asked to complete a brief questionnaire investigating their management strategies for patients with RA. Participants were presented with a predefined list of 12 measures that could be included in an annual review (presented in Table 1: including cardiovascular disease, osteoporosis and depression screening) and asked to indicate which measures they routinely included. Furthermore, GPs were asked which screening tools they used for cardiovascular disease and osteoporosis screening and which members of the multidisciplinary team conducted these reviews. One thousand three hundred eighty-eight (27.8 %) completed questionnaires were returned. The majority (1052, 75.6 %) of responders were GP partners, with a mean (SD) age of 47 (9.4) years. Seven hundred five participants (50.8%) were female. The majority of responding GPs (1083, 80.4 %) felt that a primary care annual review was of benefit to their RA patients, although only 712 (51.2 %) GPs felt that RA should be included in the QOF component of the GP contract. Nine hundred thirty-nine (67.7 %) GPs indicated they were aware of the NICE Standards of Care for RA, although only half (693, 49.9 %) felt they impacted on their clinical practice. Only 767 (55.3 %) GPs thought their patients had access to an annual review in secondary care. The individual measures that GPs reported including in their annual review are detailed in Table 1. The most frequently incorporated components were medication review (1232, 88.8 %), followed by cardiovascular risk assessment (1139, 82.1 %). The latter was most commonly performed by practice nurses using QRISK (1214, 87.5 %). Osteoporosis risk assessment was also commonly performed (1118, 80.5 %), usually by GPs themselves (1023, 73.7 %), with a minority of GPs thought osteoporosis screening for their patients was * S. L. Hider s.hider@keele.ac.uk

Average symptom trajectories following incident radiographic knee osteoarthritis: data from the Osteoarthritis Initiative

Introduction Previous research has identified the existence of a prodromal phase of symptom worsening beginning on average 2–3 years prior to the first appearance of radiographic knee osteoarthritis (OA). The current study extends these observations to investigate the trajectory of self-reported pain, stiffness, function and other symptoms following the incidence of radiographic OA. Methods Data were from the incidence cohort of the Osteoarthritis Initiative public use data sets. Cases were defined as knees without symptoms at enrolment, which developed incident radiographic OA (Kellgren and Lawrence grade ≥2) at any of the first 4 annual follow-up visits. Symptoms investigated were knee-specific Western Ontario & McMaster Universities Osteoarthritis Index and Knee injury and Osteoarthritis Outcome Score subscale scores and individual items, available up to 3 years before and 5 years after the incidence of radiographic OA. Trajectories of having at least one of the symptoms from a subscale, and for each individual symptom over time, were fitted using multilevel logistic regression models. Results The probability of symptoms following the initial prodromal phase generally stabilised, whereas the probability of moderate, severe or extreme symptoms was consistently low. Two exceptions were pain frequency, which increased greatly in the lead up to incidence, then decreased slightly, and audible joint sounds, which had a much higher overall probability, and after increasing prior to incident radiographic OA, stabilised then started to increase again at 5 years. Conclusions Following an increase in the risk of symptoms during the prodromal phase, this risk does not continue to increase in the period up to 5 years after the incidence of radiographic OA.

Measurement error and timing of predictor values for multivariable risk prediction models are poorly reported.

OBJECTIVE Measurement error in predictor variables may threaten the validity of clinical prediction models. We sought to evaluate the possible extent of the problem. A secondary objective was to examine whether predictors are measured at the intended moment of model use. METHODS A systematic search of Medline was used to identify a sample of articles reporting the development of a clinical prediction model published in 2015. After screening according to a predefined inclusion criteria, information on predictors, strategies to control for measurement error, and intended moment of model use were extracted. Susceptibility to measurement error for each predictor was classified into low and high risks. RESULTS Thirty-three studies were reviewed, including 151 different predictors in the final prediction models. Fifty-one (33.7%) predictors were categorized as high risk of error; however, this was not accounted for in the model development. Only 8 (24.2%) studies explicitly stated the intended moment of model use and when the predictors were measured. CONCLUSION Reporting of measurement error and intended moment of model use is poor in prediction model studies. There is a need to identify circumstances where ignoring measurement error in prediction models is consequential and whether accounting for the error will improve the predictions.

Risk of fragility fracture among patients with gout and the effect of urate-lowering therapy

BACKGROUND: Previous studies that quantified the risk of fracture among patients with gout and assessed the potential effect of urate-lowering therapy have provided conflicting results. Our study aims to provide better estimates of risk by minimizing the effect of selection bias and confounding on the observed association. METHODS: We used data from the Clinical Practice Research Datalink, which records primary care consultations of patients from across the United Kingdom. We identified patients with incident gout from 1990 to 2004 and followed them up until 2015. Each patient with gout was individually matched to 4 controls on age, sex and general practice. We calculated absolute rate of fracture and hazard ratios (HRs) using Cox regression models. Among patients with gout, we assessed the impact of urate-lowering therapy on fracture, and used landmark analysis and propensity score matching to account for immortal time bias and confounding by indication. RESULTS: We identified 31 781 patients with incident gout matched to 122 961 controls. The absolute rate of fracture was similar in both cases and controls (absolute rate = 53 and 55 per 10 000 person-years, respectively) corresponding to an HR of 0.97 (95% confidence interval 0.92–1.02). Our finding remained unchanged when we stratified our analysis by age and sex. We did not observe statistically significant differences in the risk of fracture among those prescribed urate-lowering therapy within 1 and 3 years after gout diagnosis. INTERPRETATION: Overall, gout was not associated with an increased risk of fracture. Urate-lowering drugs prescribed early during the course of disease had neither adverse nor beneficial effect on the long-term risk of fracture.

Symptomatic Course of Foot Osteoarthritis Phenotypes: An 18-Month Prospective Analysis of Community-Dwelling Older Adults

Osteoarthritis (OA) is a heterogeneous disease, and symptom progression at the foot is unclear. This study investigated the symptomatic course of 3 predefined foot OA phenotypes over an 18‐month period.

SAT0672 Risk of fragility fracture among patients with psoriasis: a population based matched cohort study from the united kingdom

Background Psoriasis is a common inflammatory skin disease affecting 2–4% of the population and of these a subset will develop an associated inflammatory arthritis (psoriatic arthritis - PsA). An increased risk of osteoporosis has previously been reported in psoriasis patients but the risk of fracture in patients with both psoriasis and PsA has not been established. Objectives To estimate the effect of psoriasis, and PsA, on the risk of fracture using a large electronic primary health care database. Methods A matched cohort study was conducted utilizing data from the Clinical Practice Research Datalink, a large UK database of primary care medical records. The exposed population was defined as psoriasis patients aged over 40 years with an incident diagnosis between 1990–2004, who were followed up until 2015. Four unexposed patients were matched to each exposed based on age, sex and general practice. The incidence rate of fracture were calculated as the number of incident diagnoses per 10,000 person-years, stratified by sex. Hazard ratios (HR) and 95% confidence intervals were estimated using a Cox proportional hazards model to compare the hazard rate between the exposed and unexposed, adjusting for BMI, alcohol consumption, smoking status, Charlson comorbidity index and steroid use. Fracture risk was estimated for patients with both psoriasis and PsA, identified as patients with an incident diagnosis of psoriasis and a diagnosis of PsA between 1990–2004. Results 24,219 patients with psoriasis and 94,820 controls were included in the study. The mean age was 59 years at study entry and just over half (51%) of the patients were male. The incidence rate of fracture was 58.4 (95% CI:55.6–61.3) and 53.1 (51.7–54.5) per 10,000 person-years for the exposed and unexposed, respectively. After adjusting for confounding factors, patients with psoriasis had 12% increased risk of fracture (HR: 1.12; 95% CI: 1.06–1.19) compared to the matched unexposed group. The risk was slightly higher in males (1.22 (1.09–1.36)) than females (1.09 (1.03–1.17)). Among those with psoriasis, 4.1% were also diagnosed with PsA. An increased risk of 45% was found in those exposed to both psoriasis and PsA compared to the unexposed group (1.45 (1.09–1.94)). Conclusions This study reports for the first time, an increase in fracture risk in patients with psoriasis. A higher risk was found in males than females and the risk was further increased if the patient also had PsA. These findings suggest that fracture risk assessment needs to be considered for individuals with psoriasis and PsA. Acknowledgements This study was funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR). CDM is funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands, the NIHR School for Primary Care Research and a NIHR Research Professorship in General Practice (NIHR-RP-2014–04–026). TH is funded by an NIHR Clinical Lectureship in General Practice. AAS is funded by an NIHR Postdoctoral Fellowship. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Disclosure of Interest None declared