S DeWilde

Antipsychotic prescribing to older people living in care homes and the community in England and Wales

Excessive use of antipsychotic medication by older people is an international concern, but there is limited comparative information on their use in different residential settings. This paper describes and compares antipsychotic prescribing to older people in care homes and the community in England and Wales.

Statin use after first myocardial infarction in UK men and women from 1997 to 2006: Who started and who continued treatment?

BACKGROUND AND AIMS To examine trends in initiation and continuation of statin treatment after myocardial infarction (MI) and their determinants, during a period of increasing usage. METHODS AND RESULTS 9367 patients aged 30-84 with a first Myocardial Infarction (MI) in 1997-2006 were identified in DIN-LINK, an anonymised, UK primary care database. We assessed statin initiation (prescription within 6 months of MI) and continued therapy (% covered by a prescription on a given day of those prescribed a statin within 6 months). The influences of co-morbidities and socio-economic deprivation (Index of Multiple Deprivation) were examined. Statin initiation increased from 37% for MIs in 1997 to 92% in 2006. Continuation at 1 year remained stable over successive cohorts at approximately 80%, settling to about 76% in patients with 5-10 years follow up. Younger age, affluence, revascularisation in 6 months after MI, and absence of congestive heart failure, predicted higher initiation and continuation; a diagnosis of hypertension or diabetes predicted higher initiation, while smoking was associated with poorer continuation. Men had higher initiation and continued therapy, but these effects were largely explained by their younger age. Type of statin initially prescribed did not influence continued usage. CONCLUSION Statin use after MI increased markedly between 1997 and 2006, whilst continued therapy remained high and stable. Importantly, first choice of statin had no effect on continuation. Whilst the high current levels of initiation may have reached a ceiling, increasing continuation rates among smokers, older patients and those from lower socio-economic groups, should remain a priority.

Effect of a Primary Care Walking Intervention with and without Nurse Support on Physical Activity Levels in 45- to 75-Year-Olds: The Pedometer And Consultation Evaluation (PACE-UP) Cluster Randomised Clinical Trial.

Background Pedometers can increase walking and moderate-to-vigorous physical activity (MVPA) levels, but their effectiveness with or without support has not been rigorously evaluated. We assessed the effectiveness of a pedometer-based walking intervention in predominantly inactive adults, delivered by post or through primary care nurse-supported physical activity (PA) consultations. Methods and Findings A parallel three-arm cluster randomised trial was randomised by household, with 12-mo follow-up, in seven London, United Kingdom, primary care practices. Eleven thousand fifteen randomly selected patients aged 45–75 y without PA contraindications were invited. Five hundred forty-eight self-reporting achieving PA guidelines were excluded. One thousand twenty-three people from 922 households were randomised between 2012–2013 to one of the following groups: usual care (n = 338); postal pedometer intervention (n = 339); and nurse-supported pedometer intervention (n = 346). Of these, 956 participants (93%) provided outcome data (usual care n = 323, postal n = 312, nurse-supported n = 321). Both intervention groups received pedometers, 12-wk walking programmes, and PA diaries. The nurse group was offered three PA consultations. Primary and main secondary outcomes were changes from baseline to 12 mo in average daily step-counts and time in MVPA (in ≥10-min bouts), respectively, measured objectively by accelerometry. Only statisticians were masked to group. Analysis was by intention-to-treat. Average baseline daily step-count was 7,479 (standard deviation [s.d.] 2,671), and average time in MVPA bouts was 94 (s.d. 102) min/wk. At 12 mo, mean steps/d, with s.d. in parentheses, were as follows: control 7,246 (2,671); postal 8,010 (2,922); and nurse support 8,131 (3,228). PA increased in both intervention groups compared with the control group; additional steps/d were 642 for postal (95% CI 329–955) and 677 for nurse support (95% CI 365–989); additional MVPA in bouts (min/wk) were 33 for postal (95% CI 17–49) and 35 for nurse support (95% CI 19–51). There were no significant differences between the two interventions at 12 mo. The 10% (1,023/10,467) recruitment rate was a study limitation. Conclusions A primary care pedometer-based walking intervention in predominantly inactive 45- to 75-y-olds increased step-counts by about one-tenth and time in MVPA in bouts by about one-third. Nurse and postal delivery achieved similar 12-mo PA outcomes. A primary care pedometer intervention delivered by post or with minimal support could help address the public health physical inactivity challenge. Clinical Trial Registration isrctn.com ISRCTN98538934.

'I'm sure we made it a better study…': Experiences of adults with intellectual disabilities and parent carers of patient and public involvement in a health research study.

Patient and public involvement is considered integral to health research in the United Kingdom; however, studies documenting the involvement of adults with intellectual disabilities and parent carers in health research studies are scarce. Through group interviews, this study explored the perspectives and experiences of a group of adults with intellectual disabilities and a group of parent carers about their collaborative/participatory involvement in a 3-year study which explored the effectiveness of annual health checks for adults with intellectual disabilities. Thematic analysis identified five key themes consistent across both groups; authenticity of participation, working together, generating new outcome measures, dissemination of findings and involvement in future research. Although reported anecdotally rather than originating from the analysis, increased self-confidence is also discussed. The groups’ unique perspectives led to insights not previously considered by the research team which led to important recommendations to inform healthcare practice.

PS07 Trends in Blood Pressure in England: Good Treatment or Good Luck?

Background For 30 years, adult blood pressure (BP) has declined in many developed countries. This is likely to have contributed to declining cardiovascular disease mortality. However, the reasons for this, particularly the impact of increased antihypertensive treatment, have been little studied. Diagnostic criteria have changed, meaning that more patients are treated at lower levels of BP than previously; and treatment intensity is greater. Accounting for the effects of treatment on BP trends is complex and open to misinterpretation. Methods Using the Health Survey for England we examined BP measures and treatment in white subjects aged 18+ years over two periods, 1994–2002 and 2003–2009. To examine trends independent of anti-hypertensive treatment, untreated BP was estimated from the recorded BP on treatment. To do this, a model was derived using published data on the effect of anti-hypertensives used singly and in combination at differing pre-treatment BP levels. BP untreated with statins was similarly estimated. Results Among an average 9,147 subjects per year, mean systolic BP (SBP) in men declined by 0.55 mmHg annually (95% CI 0.46 to 0.64) between 1995–2002; 0.34 mmHg annually (95% CI 0.21 to 0.46) between 2003–2009. Similar trends occurred in women. The decline was greater in older groups, but present in young, largely untreated groups, although the trend was greatly reduced in young men by 2009. Trends in estimated SBP adjusting for the influence of treatment, where present, exhibited only slightly lower declines; for men: 0.47 mmHg annually (95% CI 0.37 to 0.57) between 1995–2002; 0.27 mmHg annually (95% CI 0.13 to 0.41) between 2003–2009. Statin therapy had little additional effect. Diastolic blood pressure showed similar but weaker trends. Conclusion For 15 years, BP declined in English adults. The overall decline in SBP of nearly 5 mmHg over the study period is likely to be of clinical significance in reducing CVD events. For an individual aged 40–49 a 5 mmHg reduction in SBP, as seen here, would be expected to reduce the risk of stroke by 23% and of IHD by 16%. It is therefore of concern that, in recent years, the decline has essentially ceased in the youngest age groups, particularly in younger men. The effect of treatment was modest; less than 25% of the male SBP decline is attributable to it. Other explanations for this fall, occurring whilst obesity has increased, need further exploration, but reduced salt intake is a likely candidate.

P86 Are process evaluation measures related to intervention outcomes in the pace-up primary care pedometer-based walking trial?

Background PACE-UP trial results demonstrated positive effects of a pedometer-based walking intervention on objective physical activity (PA) outcomes at 3 and 12 months in 45–75 year old primary care patients, in both postal and nurse-supported trial arms compared to controls. We explored associations between intervention implementation measures and change in PA outcomes. Methods In accordance with the MRC guidance and framework (2014), the methods were selected through a key function model. Three quantitative aspects of the process evaluation relating directly to PA outcomes at 12 months were identified to assess intervention implementation: nurse session attendance (dose); PA diary completion (fidelity); and pedometer use (fidelity). These were considered as independent variables in the multi-level models estimating the effectiveness of the intervention on PA outcomes (changes in step-counts and time in moderate-to-vigorous PA (MVPA) levels in ≥10 min bouts). Results Dose participants attending all 3 nurse sessions increased their step-count at 3 months by 961 steps more than those attending 0–2 sessions (95% CI 401–1520, p=0.001). Minutes of MVPA were also significantly increased by 64 (36, 92) at 3 months and by 28 (1, 54) at 12 months. Fidelity: both postal and nurse groups showed strong positive associations of diary return on step-count and minutes of MVPA at 3 months compared with those who didn’t return the diary: postal steps 1458 (854, 20161), nurse steps 873 (190, 1555), postal MVPA 64 (33, 94), nurse MVPA 47 (17, 75). These differences had decreased by 12 months, and only the postal group effects remained statistically significant: steps 1114 (538, 1689), MVPA 47 (17, 75). Regular pedometer use in the postal group was associated with higher step counts at 3 and 12 months: 1029 (383, 1675) and 606 (22, 1990) respectively. Regular pedometer use was not associated with PA outcomes in the nurse group. Discussion Process evaluation measures showed significant associations with most PA outcomes at 3 and 12 months. These were stronger for the postal than the nurse group for diary and pedometer use. We cannot infer causality from these results, but the strong associations between nurse appointments, diary return, pedometer use and PA outcomes suggests that they were important factors in enabling the trial changes observed. We have shown the MRC framework to be an effective tool for process evaluation of intervention implementation.

OP85 Do Good Health and Material Circumstances Protect Older People from the Increase in Mortality after Bereavement

Background Death of a spouse or partner is a common major life event for older people. The adverse health effects of bereavement are well recognised with an increased risk of death described in several populations. The impact of modifying factors, such as chronic disease and material circumstances, is less well understood. In this study, we use a large UK primary care database to examine the modifying and mediating effect of physical comorbidity and material socio-economic circumstances on the rise in mortality in the first year after bereavement. Methods We identified 171,120 older (60 years and over) couples in a UK primary care database (THIN) based on a shared household identifier. The couples were followed up between 2005 and 2010 for an average of 4 years. 26,646 (15.5%) couples experienced bereavement with mean follow up after bereavement of 2 years. The effect of bereavement on risk of death in the surviving partner was examined in a survival model adjusted for age, sex, comorbidity at baseline, material deprivation based on area of residence, season and smoking. Further analysis examined the effect of changes in comorbidity during follow up. Results The fully adjusted hazard ratio (HR) for bereavement in the first year after bereavement was 1.25 (95% CI: 1.18 to 1.33). Further adjustment for changes in comorbidity throughout follow up did not alter the hazard ratio for bereavement (HR 1.27, 95% CI: 1.19 to 1.35). The effect of bereavement was not modified by age, gender or baseline comorbidity. The relative rise in mortality after bereavement was greatest in individuals with no significant chronic comorbidity throughout follow up (HR 1.50, 95% CI: 1.28 to 1.77) and in more affluent couples (P=0.035). Conclusion We have confirmed the increased risk of mortality after bereavement and demonstrated its independence of pre-existing physician recorded chronic comorbidity and social status. Our analysis, taking account of changes in morbidity before and after bereavement, suggests that the rise in mortality after bereavement is not primarily mediated through new or worsening chronic physical disease. Furthermore, there was no evidence that pre-existing or continuing good health or affluence protect individuals. The results also suggest that, paradoxically, good health and high social status may accentuate the rise in mortality after bereavement. Our findings suggest that the rise in mortality after bereavement acts as a leveller, affording no protection to the affluent or healthy, and is best explained by an increase in sudden unexpected deaths.

PL01 A Simple Morbidity Score for UK Primary Care: A New Tool for Research and Healthcare Outcome Monitoring

Background Adjustment for morbidity level is important in ensuring fair comparison of outcomes between patient groups and healthcare providers. The Quality and Outcomes Framework (QOF) in UK primary care, which records numerous diseases systematically, offers potential for developing a standardised morbidity score that can be easily applied in research and service settings. Methods Using The Health Improvement Network (THIN), a large primary care database of 375 UK general practices in 2008–9, half the practices were randomly selected as a training set to derive a morbidity score based on chronic conditions recorded in QOF, and the other practices formed a validation set to assess predictive performance. A total of 653,780 patients aged 60 and over registered in 2008 were included, and mortality at one year was assessed. Results Nine QOF conditions were identified as robust co-predictors (Hazard Ratio ≥1.2) of mortality independent of age and sex, and were assigned integer score weights based on the strength of their association with mortality. Cancer (HR=3.4) and Dementia (HR=2.8) were the strongest predictors. In a Cox model with age and sex included, the addition of the QOF score improved model discrimination in predicting mortality (c-statistic=0.82 vs. 0.78), performing similarly to the Charlson index, an established morbidity index. In a multilevel logistic model, an individual’s QOF score explained more of the variation in mortality between practices than the Charlson index (46% compared to 32%). At practice level, the mean QOF score per patient was strongly correlated with practice standardised mortality ratios (r=0.64) and explained more variation in practice death rates than the Charlson index. Conclusion A simple score derived from routine QOF recording provides a morbidity index which is highly predictive of one year mortality in older UK Primary Care patients, is simpler to implement than existing morbidity scores, and explains practice level variations in mortality. This new score has potential utility in research and healthcare outcome monitoring and could be easily implemented nationally through existing mechanisms for anonymised collection of QOF data from practices.