Sara Muller

Trends in mortality from 1965 to 2008 across the English north-south divide: comparative observational study.

Objective To compare all cause mortality between the north and south of England over four decades. Design Population wide comparative observational study of mortality. Setting Five northernmost and four southernmost English government office regions. Population All residents in each year from 1965 to 2008. Main outcome measures Death rate ratios of north over south England by age band and sex, and northern excess mortality (percentage of excess deaths in north compared with south, adjusted for age and sex and examined for annual trends, using Poisson regression). Results During 1965 to 2008 the northern excess mortality remained substantial, at an average of 13.8% (95% confidence interval 13.7% to 13.9%). This geographical inequality was significantly larger for males than for females (14.9%, 14.7% to 15.0% v 12.7%, 12.6% to 12.9%, P<0.001). The inequality decreased significantly but temporarily for both sexes from the early 80s to the late 90s, followed by a steep significant increase from 2000 to 2008. Inequality varied with age, being higher for ages 0-9 years and 40-74 years and lower for ages 10-39 years and over 75 years. Time trends also varied with age. The strongest trend over time by age group was the increase among the 20-34 age group, from no significant northern excess mortality in 1965-95 to 22.2% (18.7% to 26.0%) in 1996-2008. Overall, the north experienced a fifth more premature (<75 years) deaths than the south, which was significant: a pattern that changed only by a slight increase between 1965 and 2008. Conclusion Inequalities in all cause mortality in the north-south divide were severe and persistent over the four decades from 1965 to 2008. Males were affected more than females, and the variation across age groups was substantial. The increase in this inequality from 2000 to 2008 was notable and occurred despite the public policy emphasis in England over this period on reducing inequalities in health.

The influence of employment social support for risk and prognosis in nonspecific back pain: a systematic review and critical synthesis.

PurposeTo examine the influence of employment social support type (e.g. co-worker, supervisor, general support) on risk of occurrence of low back pain, and prognosis (e.g. recovery, return to work status) for those who have low back pain.MethodsSystematic search of seven databases (MEDLINE, Embase, PsychINFO, CINAHL, IBSS, AMED and BNI) for prospective or case–control studies reporting findings on employment social support in populations with nonspecific back pain. Data extraction and quality assessment were carried out on included studies. A systematic critical synthesis was carried out on extracted data.ResultsThirty-two articles were included that describe 46 findings on the effect of employment social support on risk of and prognosis of back pain. Findings show that there is no effect of co-worker, supervisor or general work support on risk of new onset back pain. Weak effects of employment support were found for recovery and return to work outcomes; greater levels of co-worker support and general work support were found to be associated with less time to recovery or return to work.ConclusionsThe evidence suggests that the association between employment support and prognosis may be subject to influence from wider concepts related to the employment context. This review discusses these wider issues and offers directions for future research.

Defining disabling foot pain in older adults: further examination of the Manchester Foot Pain and Disability Index

OBJECTIVE To identify a practical definition of disabling foot pain in older adults for clinical and research use, using the Manchester Foot Pain and Disability Index (FPDI). METHODS Adults aged > or =50 years registered with three general practices were mailed a two-stage cross-sectional survey. A total of 1342 respondents who reported foot pain in the previous 12 months and completed the FPDI and 58 participants in a test-retest repeatability study were included. RESULTS Confirmatory factor analysis verified the three-construct FPDI structure (pain intensity, functional limitation and appearance). Internal consistency for the three constructs was good (Cronbachs alpha 0.74, 0.92 and 0.77, respectively). A total of 1320 (98.4%) of those persons with foot pain reported disability (at least one of the 17 FPDI items experienced on at least some days -- Definition A). After restricting this definition to problems experienced on most/every day(s) (Definition B), 996 (74.2%) of those with foot pain reported disability (percentage difference 24.2%; 95% CI 21.9, 26.5%). For each of the three constructs, the prevalence of disability among persons with foot pain was significantly higher under Definition A than under Definition B. Test-retest repeatability for the individual constructs ranged from fair to substantial. Physical function, measured by the SF-36 physical function sub-scale, was poorer in those who reported problems within the function construct compared with those with problems in pain and/or appearance constructs only. CONCLUSION A practical definition of disabling foot pain [at least one of the 10 FPDI function items experienced on most/every day(s)] is proposed, which appears valid, repeatable and suitable for use in older adults.

Trials in primary care: statistical issues in the design, conduct and evaluation of complex interventions

Trials carried out in primary care typically involve complex interventions that require considerable planning if they are to be implemented successfully. The role of the statistician in promoting both robust study design and appropriate statistical analysis is an important contribution to a multi-disciplinary primary care research group. Issues in the design of complex interventions have been addressed in the Medical Research Council’s new guidance document and over the past 7 years by the Royal Statistical Society’s Primary Health Care Study Group. With the aim of raising the profile of statistics and building research capability in this area, particularly with respect to methodological issues, the study group meetings have covered a wide range of topics that have been of interest to statisticians and non-statisticians alike. The aim of this article is to provide an overview of the statistical issues that have arisen over the years related to the design and evaluation of trials in primary care, to provide useful examples and references for further study and ultimately to promote good practice in the conduct of complex interventions carried out in primary care and other health care settings. Throughout we have given particular emphasis to statistical issues related to the design of cluster randomised trials.

Is cancer associated with polymyalgia rheumatica? A cohort study in the General Practice Research Database

Objective To investigate the incidence of new cancer diagnoses in a community sample of patients with polymyalgia rheumatica (PMR). Methods All incident cases of PMR in the UK General Practice Research Database (GPRD) (1987–99), without pre-existing cancer or vascular disease and treated with corticosteroids (n=2877) were matched with up to five age, sex and GP practice patients without PMR (n=9942). Participants were followed up until first cancer diagnosis, death, transfer out of the database or end of available records. Results The mean age of the sample was 71.6 years (SD 9.0), 73% were female. Median follow-up time was 7.8 years (IQR 3.4, 12.3). 667 (23.2%) people with a PMR diagnosis developed cancer compared with 1938 (19.5%) of those without PMR. There was an interaction between PMR status and time. In the first 6 months after diagnosis, those with a PMR diagnosis were significantly more likely to receive a cancer diagnosis (adjusted HR (95% CI): 1.69 (1.18 to 2.42)). The number of events was small, but occurrences of prostate, blood, lymph nodes, female reproductive and nervous system cancers may be more common in those with PMR in the first 6 months after PMR diagnosis. Conclusions An increase in the rate of cancer diagnoses was noted in the first 6 months of observation, but we were unable to determine whether the cancer incidence in PMR was different from controls, beyond this time point. Clinicians should ensure they fully exclude cancer as a cause of PMR-like symptoms and monitor patients for possible malignancies.

Measuring morbidity: self-report or health care records?

BACKGROUND Epidemiological surveys often rely on self-report as a measure of morbidity in a population. However, these data can also be extracted from primary care records. OBJECTIVE To compare morbidity estimates based on self-report with those obtained from primary care records. METHODS A cross-sectional survey and accompanying medical record review were carried out in all consenting adults aged > or =50 years in three general practices in North Staffordshire, UK. Self-reported morbidity was compared with computerized general practice consultation records for the 2 years prior to the survey. RESULTS Of the 7878 survey responders, 5889 consented to medical record review. Agreement between self-reported and consultation data was excellent for diabetes. Agreement between the two sources of data was lower for hypertension, heart problems, chest problems and eyesight problems. It was poor for deafness and falls. CONCLUSIONS Self-report and consultation data provide comparable estimates of the prevalence of specific diagnoses such as diabetes. For other conditions, self-report and consultation records provide different measures of prevalence, and the choice of measure will depend on the morbidity being studied.

Onset and Persistence of Disabling Foot Pain in Community-Dwelling Older Adults Over a 3-Year Period: A Prospective Cohort Study

Background. Foot pain and related disability in older adults are common yet understudied problems. This study aimed to determine the onset and persistence of disabling foot pain in community-dwelling older adults over a 3-year period. Methods. A 3-year follow-up postal survey was conducted in a population sample of older adults aged 50 years and older, recruited previously as part of the North Staffordshire Osteoarthritis Project. Disabling foot pain was defined as the report of problems on at least 1 of the 10 function items of the Manchester Foot Pain and Disability Index occurring on most/every day(s). Results. Of persons without disabling foot pain at baseline, 8.1% had developed it at 3 years. Onset was greater with increasing age (50–59 years, 6.7%; 60–69 years, 9.1%; and ≥70 years, 9.5%; p = .037), in females (2.5% difference; 95% confidence interval 0.3%–4.8%), and in those with nondisabling foot pain at baseline than those without foot pain (14.2% difference; 95% confidence interval: 10.0%–19.1%). Persistence of disabling foot pain at 3 years was 71.7%, more common in females (9.3% difference; 95% confidence interval: 0.8%–18.0%) but not associated with age. Conclusions. Accelerated onset with increasing age and frequent persistence suggests considerable public health impact of disabling foot pain as the population ages. Prevention of disabling foot pain in later life should be prioritized and predisposing factors identified as potential intervention targets.

Measurement of change in function and disability in osteoarthritis: current approaches and future challenges

Purpose of reviewThis review assessed current approaches to using objective and self-report measures to determine change in function and disability in osteoarthritis and identified key future challenges. Recent findingsNew approaches to measuring function continue to evolve. However, trials and observational studies typically adopt conventional self-report instruments of physical function as their primary outcome. A range of objective measures are also used, but this area, in particular, may benefit from greater standardization. In recognition of the wider impact of osteoarthritis, there have been some moves towards measuring participation in areas of life such as social activities and work. Approaches to take more account of areas of function and extent of change perceived by the patient to be important are increasing but are not standardized. Follow-up of participants has tended to be short and infrequent. SummaryMeasuring functional change is rightly recognized as critically important in osteoarthritis research. Key challenges that remain include capturing wider elements of disability such as ability to participate in everyday life, and in better capturing the longer, episodic nature of disability in osteoarthritis. Experience from fields outside of osteoarthritis may help advance the measurement of function in longitudinal studies of osteoarthritis and its sensible interpretation.

Risk of vascular events in patients with polymyalgia rheumatica

Background: Polymyalgia rheumatica is one of the most common inflammatory rheumatologic conditions in older adults. Other inflammatory rheumatologic disorders are associated with an excess risk of vascular disease. We investigated whether polymyalgia rheumatica is associated with an increased risk of vascular events. Methods: We used the General Practice Research Database to identify patients with a diagnosis of incident polymyalgia rheumatica between Jan. 1, 1987, and Dec. 31, 1999. Patients were matched by age, sex and practice with up to 5 patients without polymyalgia rheumatica. Patients were followed until their first vascular event (cardiovascular, cerebrovascular, peripheral vascular) or the end of available records (May 2011). All participants were free of vascular disease before the diagnosis of polymyalgia rheumatica (or matched date). We used Cox regression models to compare time to first vascular event in patients with and without polymyalgia rheumatica. Results: A total of 3249 patients with polymyalgia rheumatica and 12 735 patients without were included in the final sample. Over a median follow-up period of 7.8 (interquartile range 3.3–12.4) years, the rate of vascular events was higher among patients with polymyalgia rheumatica than among those without (36.1 v. 12.2 per 1000 person-years; adjusted hazard ratio 2.6, 95% confidence interval 2.4–2.9). The increased risk of a vascular event was similar for each vascular disease end point. The magnitude of risk was higher in early disease and in patients younger than 60 years at diagnosis. Interpretation: Patients with polymyalgia rheumatica have an increased risk of vascular events. This risk is greatest in the youngest age groups. As with other forms of inflammatory arthritis, patients with polymyalgia rheumatica should have their vascular risk factors identified and actively managed to reduce this excess risk.

A prognostic approach to defining chronic pain across a range of musculoskeletal pain sites.

Objectives:To test whether the prognostic definition of chronic pain, which has previously been applied in specific anatomic areas, performed well in a cohort of older adults with a range of musculoskeletal pain sites. Methods:Data are taken from the Prognostic Research Study of adults aged 50 years and above consulting their general practitioner with any musculoskeletal pain, who completed postal surveys immediately after consultation and 12 months later. Baseline risk of clinically significant pain persisting at 12 months’ follow-up, defined as a Chronic Pain Grade ≥II, was calculated using the prognostic approach, which includes a range of pain and related factors. The approach was implemented using logistic regression models, and the performance of the approach, including cutoffs in the score to define groups with differing levels of risk, was assessed in terms of calibration and discrimination. Results:Application of the original risk cutoffs created groups with increasing proportions of chronic pain (area under the curve =0.79). However, the probability of chronic pain in each group was higher than expected by the model. New cutoffs were defined for this group of older adults: score ⩽5=probability of chronic pain <20%, ⩽11=probability <50%, ⩽16=probability <80%, which resulted in good calibration of the model. Discussion:The prognostic approach to defining chronic pain is suitable for use in older adults consulting primary care with musculoskeletal pain at a range of sites, but new cutoffs are needed to allow for the higher risk profile in this group. An adapted version of this method may also have the potential for application directly within the clinical consultation.