Sunil M. Shah

Does β‐adrenoceptor blocker therapy improve cancer survival? Findings from a population‐based retrospective cohort study

AIMS To examine the effect of β-adrenoceptor blocker treatment on cancer survival. METHODS In a UK primary care database, we compared patients with a new cancer diagnosis receiving β-adrenoceptor blockers regularly (n= 1406) with patients receiving other antihypertensive medication (n= 2056). RESULTS Compared with cancer patients receiving other antihypertensive medication, patients receiving β-adrenoceptor blocker therapy experienced slightly poorer survival (HR = 1.18, 95% CI 1.04, 1.33 for all β-adrenoceptor blockers; HR = 1.21, 95% CI 0.94, 1.55 for non-selective β-adrenoceptor blockers). This poorer overall survival was explained by patients with pancreatic and prostate cancer with no evidence of an effect on survival for patients with lung, breast or colorectal cancer. Analysis in a cancer-free matched parallel cohort did not suggest selection bias masked a beneficial effect. CONCLUSION Our study does not support the hypothesis that β-adrenoceptor blockers improve survival for common cancers.

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.

Socio-economic determinants of casualty and NHS Direct use

BACKGROUND There is limited evidence on the social determinants of A&E use and concerns over the equity of NHS Direct utilization. METHODS We analysed data from the 2004-05 British General Household Survey, which included 20,421 participants. Logistic regression was used to examine individual casualty use in the last 3 months and household NHS Direct use in the last year. RESULTS Casualty use was higher for individuals living in rented accommodation or without car access, lower income groups, unskilled manual workers, current smokers and for individuals with limiting illness. In contrast, NHS Direct use was lower in households with older residents, low income, no car access and where the head of household was from a manual occupational group, a minority ethnic group or born outside the UK. The odds ratio for use of NHS Direct for households in the lowest equivalized income quintile was 0.67 (0.55-0.81). Adjustment for limiting illness increased the effect of socio-economic factors on NHS Direct use. CONCLUSIONS Reduced access to A&E services will disproportionately affect poorer individuals, whereas increased investment in telephone services will benefit affluent populations. Current national policy may widen inequities in access to emergency care.

Inequalities in the treatment and control of hypertension : age, social isolation and lifestyle are more important than economic circumstances

Objective: To describe socio-economic variations in the treatment and control of hypertension in England. Design: Population based survey. Subjects: Hypertensives numbering 5019, identified in the Health Survey for England for 1993–1994. Outcome: Drug treatment and control of hypertension. Results: A total of 1119/2208 (50.7%) hypertensive men, and 1620/2811 (57.6%) hypertensive women, were receiving anti-hypertensive medication. For men, the likelihood of receiving treatment increased with age, widowerhood or divorce, a family history of heart disease, low social support and increasing weight, but was decreased for men who lived alone, owned their own house, smoked or drank heavily. For women, obesity, a family history of heart disease and low social support increased their chance of treatment. A total of 534/1119 (47.7%) men, and 816/1620 (50.4%) of women on treatment, had their hypertension controlled to below 160/90 mmHg. Lack of control was more commonly due to isolated systolic hypertension rather than diastolic hypertension. Increasing age and smoking were associated with poorer control. Men who lived alone and had low social support were less likely to have their hypertension controlled, while those with a family history of heart disease were more likely to be controlled. Discussion: We found little evidence for socio-economic or geographic differences in the management of hypertension. Variations in treatment rates can be explained by variations in use of primary care and opportunistic screening. Control was poorest among older people who are at the highest risk of cardiovascular events. Socially isolated men and smokers were less likely to be treated or controlled, and need to be targeted by future programmes to detect and treat hypertension.

Deprivation and excess winter mortality.

OBJECTIVE: To investigate the effect of material deprivation on the winter rise in mortality and temperature dependent variations in mortality. DESIGN: Ecological comparison of seasonal mortality at electoral ward level. Main outcome measures were ratios of winter to rest of the year mortality rates (seasonality ratios) and monthly deaths as the outcome variable in a model with monthly average temperature and Townsend score as main predictors. SETTING: Croydon, London, United Kingdom. SUBJECTS: All deaths of Croydon residents for the period 1990-1995. MAIN RESULTS: There was a clear relation between overall mortality and deprivation. There was no evidence of a relation between age and sex standardised seasonality ratios and Townsend scores for all deaths (Kendalls tau = -0.066, p = 0.63) or cardiovascular deaths or respiratory deaths. There was no evidence of an interaction between Townsend score and temperature in the model of ward mortality rates (p = 0.73). These findings were not affected by exclusion of deaths of nursing and residential home residents. CONCLUSION: This study provides no evidence of an effect of deprivation on excess winter mortality or temperature dependent variations in mortality. The findings question simple assumptions about the relation between deprivation and excess winter mortality and highlight the need for further study to guide interventions.

Increased risk of acute cardiovascular events after partner bereavement: a matched cohort study.

IMPORTANCE The period immediately after bereavement has been reported as a time of increased risk of cardiovascular events. However, this risk has not been well quantified, and few large population studies have examined partner bereavement. OBJECTIVE To compare the rate of cardiovascular events between older individuals whose partner dies with those of a matched control group of individuals whose partner was still alive on the same day. DESIGN, SETTING, AND PARTICIPANTS Matched cohort study using a UK primary care database containing availale data of 401 general practices from February 2005 through September 2012. In all, 30 447 individuals aged 60 to 89 years at study initiation who experienced partner bereavement during follow-up were matched by age, sex, and general practice with the nonbereaved control group (n = 83 588) at the time of bereavement. EXPOSURES Partner bereavement. MAIN OUTCOMES AND MEASURES The primary outcome was occurrence of a fatal or nonfatal myocardial infarction (MI) or stroke within 30 days of bereavement. Secondary outcomes were non-MI acute coronary syndrome and pulmonary embolism. All outcomes were compared between the groups during prespecified periods after bereavement (30, 90, and 365 days). Incidence rate ratios (IRRs) from a conditional Poisson model were adjusted for age, smoking status, deprivation, and history of cardiovascular disease. RESULTS Within 30 days of their partners death, 50 of the bereaved group (0.16%) experienced an MI or a stroke compared with 67 of the matched nonbereaved controls (0.08%) during the same period (IRR, 2.20 [95% CI, 1.52-3.15]). The increased risk was seen in bereaved men and women and attenuated after 30 days. For individual outcomes, the increased risk was found separately for MI (IRR, 2.14 [95% CI, 1.20-3.81]) and stroke (2.40 [1.22-4.71]). Associations with rarer events were also seen after bereavement, including elevated risk of non-MI acute coronary syndrome (IRR, 2.20 [95% CI, 1.12-4.29]) and pulmonary embolism (2.37 [1.18-4.75]) in the first 90 days. CONCLUSIONS AND RELEVANCE This study provides further evidence that the death of a partner is associated with a range of major cardiovascular events in the immediate weeks and months after bereavement. Understanding psychosocial factors associated with acute cardiovascular events may provide opportunities for prevention and improved clinical care.

Mortality in older care home residents in England and Wales

BACKGROUND mortality in UK care homes is not well described. OBJECTIVE to describe 1-year mortality and predictors in older care home residents compared with community residents. METHOD cohort study using the THIN primary care database with 9,772 care home and 354,306 community residents aged 65-104 years in 293 English and Welsh general practices in 2009. RESULTS a total of 2,558 (26.2%) care home and 11,602 (3.3%) community residents died within 1 year. The age and sex standardised mortality ratio for nursing homes was 419 (95% CI: 396-442) and for residential homes was 284 (266-302). Age-related increases in mortality were less marked in care homes than community. Comorbidities and identification as inappropriate for chronic disease management targets predicted mortality in both settings, but associations were weaker in care homes. The number of drug classes prescribed and primary care contact were the strongest clinical predictors of mortality in care homes. CONCLUSIONS older care home residents experience high mortality. Age and diagnostic characteristics are weaker predictors of risk of death within care homes than the community. Measures of primary care utilisation may be useful proxies for frailty and improve difficult end of life care decisions in care homes.

Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study

Objective To describe the quality of care for chronic diseases among older people in care homes (nursing and residential) compared with the community in a pay for performance system. Design Retrospective analysis of The Health Improvement Network (THIN), a large primary care database. Setting 326 English and Welsh general practices, 2008-9. Participants 10 387 residents of care homes and 403 259 residents in the community aged 65 to 104 and registered for 90 or more days with their general practitioner. Main outcome measure 16 process quality indicators for chronic disease management appropriate for vulnerable older people for conditions included in the UK Quality and Outcomes Framework. Results After adjustment for age, sex, dementia, and length of registration, attainment of quality indicators was significantly lower for residents of care homes than for those in the community for 14 of 16 indicators. The largest differences were for prescribing in heart disease (β blockers in coronary heart disease, relative risk 0.70, 95% confidence interval 0.65 to 0.75) and monitoring of diabetes (retinal screening, 0.75, 0.71 to 0.80). Monitoring hypothyroidism (0.93, 0.90 to 0.95), blood pressure in people with stroke (0.92, 0.90 to 0.95), and electrolytes for those receiving loop diuretics (0.89, 0.87 to 0.92) showed smaller differences. Attainment was lower in nursing homes than in residential homes. Residents of care homes were more likely to be identified by their doctor as unsuitable or non-consenting for all Quality and Outcomes Framework indicators for a condition allowing their exclusion from targets; 33.7% for stroke and 34.5% for diabetes. Conclusion There is scope for improving the management of chronic diseases in care homes, but high attainment of some indicators shows that pay for performance systems do not invariably disadvantage residents of care homes compared with those living in the community. High use of exception reporting may compromise care for vulnerable patient groups. The Quality and Outcomes Framework, and other pay for performance systems, should monitor attainment and exception reporting in vulnerable populations such as residents of care homes and consider measures that deal with the specific needs of older people.

A new simple primary care morbidity score predicted mortality and better explains between practice variations than the Charlson index

OBJECTIVES Adjustment for morbidity is important to ensure fair comparison of outcomes between patient groups and health care providers. The Quality and Outcomes Framework (QOF) in UK primary care offers potential for developing a standardized morbidity score for low-risk populations. STUDY DESIGN AND SETTING Retrospective cohort study of 653,780 patients aged 60 years or older registered with 375 practices in 2008 in a large primary care database (The Health Improvement Network). Half the practices were randomly selected to derive a morbidity score predicting 1-year mortality; the others assessed predictive performance. RESULTS Nine chronic conditions were robust copredictors (hazard ratio = ≥1.2) of mortality independent of age and sex, producing high predictive discrimination (c-statistic = 0.82). An individuals QOF score explained more between practice variation in mortality than the Charlson index (46% vs. 32%). At practice level, mean QOF score was strongly correlated with practice standardized mortality ratios (r = 0.64), explaining more variation in practice death rates than the Charlson index. CONCLUSION A simple nine-item score derived from routine primary care recording provides a morbidity index highly predictive of mortality and between practice variation in older UK primary care populations. This has utility in research and health care outcome monitoring and can be easily implemented in other primary and ambulatory care settings.

Trends and inequities in beta-blocker prescribing for heart failure

BACKGROUND Treatment with specific beta-blockers reduces mortality and hospitalisation in heart failure. AIM To describe trends and inequities in beta-blocker prescribing for heart failure. DESIGN OF STUDY Repeated cross-sectional analysis of a nationally representative primary care database (DIN-LINK). SETTING A total of 152 UK general practices. METHOD Prescribing of beta-blockers between 2000 and 2005 was examined among a yearly average of 7294 patients aged>or=50 years who had actively managed heart failure - defined as a recorded diagnosis of heart failure and two prescriptions of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker during the calendar year. The main outcome was the prescription of a guideline-recommended beta-blocker (bisoprolol, carvedilol, metoprolol, or nebivolol) in the year. Determinants of beta-blocker prescribing were analysed using logistic regression. RESULTS Between 2000 and 2005, age-adjusted use of recommended beta-blockers rose from 6.1% to 27.0% in men, and from 4.2% to 21.5% in women. In 2005, younger patients were more likely to be treated; the fully adjusted odds ratio was 4.83 (95% confidence interval=3.78 to 6.17) for patients aged 60-64 years compared with those aged 85 years. Women and patients living in areas of socioeconomic deprivation were less likely to be treated. In 2005, in addition to treatment with guideline-recommended beta-blockers, a further 11.7% of men and 12.5% of women were prescribed other beta-blockers. CONCLUSION Recommended beta-blocker use has risen in the UK but remains low and inequitable, with many patients still treated with beta-blockers that are not recommended in guidelines. This suggests further improvements in prescribing are still possible.