Frailty and rate of fractures in patients initiating antihypertensive medications: a cohort study in primary care

Background Treatment for hypertension improves cardiovascular outcomes. Frailty is common in people treated for hypertension, and associated with increases in adverse drug effects, potentially including falls resulting in fractures. We aimed to determine the association between baseline frailty and fractures in patients initiated on antihypertensive treatment. Methods We conducted a retrospective cohort study using United Kingdom primary care data, including new-users of first-line antihypertensives aged 65 years or over. We reported degree of frailty (fit, mild, moderate, severe) at antihypertensive initiation using the Electronic Frailty Index. We examined the association of frailty with fractures using multivariable Poisson regression, and assessed for interaction between antihypertensive class and frailty. Results 49634 (43%) people initiated on first-line antihypertensives were mildly or more frail. Over 4.1 years mean follow-up, 6567 (5.8%) experienced a fracture, with 3832 (58%) of these fractures occurring in frail people. Among those with severe frailty doubling of fracture risk was observed after antihypertensive initiation, compared with fit people [adjusted rate ratio 2.26 (95% CI 1.93-2.65)]. This pattern was replicated for hip and arm fractures, and strongest for spine fractures. The association between different types of antihypertensives and fractures varied by frailty (P=0.004), with a lower rate in moderately frail users of renin-angiotensin blockers compared with calcium-channel blockers (RR 0.81 95% CI 0.71-0.94) Conclusions Frailty is common among people initiating first-line antihypertensive treatment, and was associated with an increased fracture rate. Awareness of this is important to encourage clinicians to consider risk of falls and fractures when treating hypertension.

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Patterns of persistence with antihypertensive medications in newly diagnosed hypertensive patients in Italy: a retrospective cohort study in primary care

Journal of Hypertension ◽

10.1097/01.hjh.0000186832.41125.8a ◽

2005 ◽

Vol 23 (11) ◽

pp. 2093-2100 ◽

Cited By ~ 136

Author(s):

Giampiero Mazzaglia ◽

Lorenzo G Mantovani ◽

Miriam CJM Sturkenboom ◽

Alessandro Filippi ◽

Gianluca Trifirò ◽

...

Keyword(s):

Primary Care ◽

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Newly Diagnosed ◽

Antihypertensive Medications ◽

Hypertensive Patients

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Faculty Opinions recommendation of Effect of antibiotic prescribing on antibiotic resistance in individual children in primary care: prospective cohort study.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1090146.543362 ◽

2007 ◽

Author(s):

Marilyn Roberts

Keyword(s):

Primary Care ◽

Antibiotic Resistance ◽

Cohort Study ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Antibiotic Prescribing

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A Retrospective Cohort Study of SARS-CoV-2 Infection in Hypertenses Patients in a Primary Care Center

SSRN Electronic Journal ◽

10.2139/ssrn.3605259 ◽

2020 ◽

Author(s):

Esther Hernandez Castilla ◽

Lucia Vallejo Serrano ◽

Monica Saenz Ausejo ◽

Beatriz Pax Sanchez ◽

Katharina Ramrath ◽

...

Keyword(s):

Primary Care ◽

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Care Center ◽

Primary Care Center

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Characteristics and health status of patients with and without confirmed HFpEF

European Heart Journal ◽

10.1093/ehjci/ehaa946.3139 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

C Deaton ◽

F Forsyth ◽

J Mant ◽

D Edwards ◽

R Hobbs ◽

...

Keyword(s):

Quality Of Life ◽

Primary Care ◽

Cohort Study ◽

Health Status ◽

Functional Impairment ◽

Funding Source ◽

Walk Distance ◽

Minute Walk Distance ◽

Minute Walk

Abstract Aims Patients with heart failure with preserved ejection fraction (HFpEF) are usually older and multi-morbid and diagnosis can be challenging. The aims of this cohort study were to confirm diagnosis of HFpEF in patients with possible HFpEF recruited from primary care, to compare characteristics and health status between those with and without HFpEF, and to determine factors associated with health status in patients with HFpEF. Methods Patients with presumed HFpEF were recruited from primary care practices and underwent clinical assessment and diagnostic evaluation as part of a longitudinal cohort study. Health status was measured by Montreal Cognitive Assessment (MOCA), 6-minute walk test, symptoms, and the Kansas City Cardiomyopathy Questionnaire (KCCQ), and quality of life (QoL) by EQ-5D-5L visual analogue scale (VAS). Results 151 patients (mean age 78.5±8.6 years, 40% women, mean EF 56% + 9.4) were recruited and 93 (61.6%) were confirmed HFpEF (those without HFpEF had other HF and cardiac diagnoses). Patients with and without HFpEF did not differ by age, MOCA, blood pressure, heart rate, NYHA class, proportion with atrial fibrillation, Charlson Comorbidity Index, or NT-ProBNP levels. Patients with HFpEF were more likely to be women, overweight or obese, frail, and to be more functionally impaired by 6 minute walk distance and gait speed than those without. Although not statistically significant, patients with HFpEF had clinically significant differences (>5 points) on the physical limitations, symptom burden and clinical summary subscales of the KCCQ, but did not differ by other subscales or by EQ-5D-5L VAS (70±17 vs 73±19, p=0.385). More patients with HFpEF reported daytime dyspnoea (63% vs 46%, p=0.035) and fatigue (81% vs 61%, p=0.008), but not other symptoms compared to those without HFpEF. For both groups BMI was moderately negatively correlated with KCCQ subscale scores, and 6 minute walk distance was positively correlated with KCCQ subscales. Conclusions Nearly 40% were not confirmed as HFpEF indicating the challenges of diagnosis. Patients with confirmed HFpEF differed by sex, overweight/obesity, frailty, functional impairment, and symptoms but not by age or comorbidities from those without HFpEF. These differences were reflected in some subscale scores of the KCCQ, but not how patients reported their quality of life on the KCCQ QoL subscale and EQ-5D-5L VAS. Older patients with HFpEF reported relatively high QoL despite poor health status by functional impairment, frailty and symptoms. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Research School of Primary Care Research

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O08: The epidemiology of alopecia areata: a population‐based cohort study in UK primary care

British Journal of Dermatology ◽

10.1111/bjd.19939 ◽

2021 ◽

Vol 185 (S1) ◽

pp. 11-12

Keyword(s):

Primary Care ◽

Cohort Study ◽

Alopecia Areata ◽

Population Based

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Treatment of chronic noncancer pain in patients on opioid therapy in primary care: A retrospective cohort study

Canadian Pharmacists Journal / Revue des Pharmaciens du Canada ◽

10.1177/1715163519887766 ◽

2019 ◽

Vol 153 (1) ◽

pp. 52-58

Author(s):

Arden R. Barry ◽

Chantal E. Chris

Keyword(s):

Primary Care ◽

Cohort Study ◽

Back Pain ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Opioid Therapy ◽

Opioid Agonist ◽

Chronic Noncancer Pain ◽

Opioid Dose ◽

Noncancer Pain

Background: This study sought to characterize the real-world treatment of chronic noncancer pain (CNCP) in patients on opioid therapy in primary care. Methods: A retrospective cohort study from 2014-18 was conducted at a multidisciplinary primary care clinic in Chilliwack, British Columbia. Included were adults on daily opioid therapy for CNCP. Patients receiving palliative care or ≤1 visit were excluded. Outcomes of interest included use of opioid/nonopioid pharmacotherapy, number/frequency of visits and proportion of patients able to reduce/discontinue opioid therapy. Results: Seventy patients (mean age 53 years, 53% male, 51% back pain) were included. Median follow-up was 6 visits over 12 months. Sixty-two patients (89%) reduced their opioid dose, 6 patients had no change and 2 patients required a dose increase. Mean opioid dose was reduced from 183 to 70 mg morphine equivalents daily. Twenty-four patients (34%) discontinued opioid therapy, 6 patients (9%) transitioned to opioid agonist therapy and 6 patients (9%) breached their opioid treatment agreement. Nonopioid pharmacotherapy included nonsteroidal anti-inflammatory drugs (64%), gabapentinoids (63%), tricyclic antidepressants (56%) and nabilone (51%). Discussion: Over half of patients were no longer on opioid therapy by the end of the study. Most patients had a disorder (e.g., back pain) for which opioids are generally not recommended. Overall mean opioid dose was reduced from baseline by approximately 60% over 1 year. Lack of access to specialized pain treatments may have accounted for high nonopioid pharmacotherapy usage. Conclusions: This study demonstrates that treatment of CNCP and opioid tapering can successfully be achieved in a primary care setting. Can Pharm J (Ott) 2020;153:xx-xx.

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Developing a clinical prediction rule for repeated consultations with functional somatic symptoms in primary care: a cohort study

BMJ Open ◽

10.1136/bmjopen-2020-040730 ◽

2021 ◽

Vol 11 (1) ◽

pp. e040730

Author(s):

Gea A Holtman ◽

Huibert Burger ◽

Robert A Verheij ◽

Hans Wouters ◽

Marjolein Y Berger ◽

...

Keyword(s):

Primary Care ◽

Cohort Study ◽

Somatic Symptoms ◽

Prediction Rule ◽

Clinical Prediction Rule ◽

Model Discrimination ◽

Clinical Prediction ◽

Internal Validation ◽

Predictive Values ◽

Healthy Activity

ObjectivesPatients who present in primary care with chronic functional somatic symptoms (FSS) have reduced quality of life and increased health care costs. Recognising these early is a challenge. The aim is to develop and internally validate a clinical prediction rule for repeated consultations with FSS.Design and settingRecords from the longitudinal population-based (‘Lifelines’) cohort study were linked to electronic health records from general practitioners (GPs).ParticipantsWe included patients consulting a GP with FSS within 1 year after baseline assessment in the Lifelines cohort.Outcome measuresThe outcome is repeated consultations with FSS, defined as ≥3 extra consultations for FSS within 1 year after the first consultation. Multivariable logistic regression, with bootstrapping for internal validation, was used to develop a risk prediction model from 14 literature-based predictors. Model discrimination, calibration and diagnostic accuracy were assessed.Results18 810 participants were identified by database linkage, of whom 2650 consulted a GP with FSS and 297 (11%) had ≥3 extra consultations. In the final multivariable model, older age, female sex, lack of healthy activity, presence of generalised anxiety disorder and higher number of GP consultations in the last year predicted repeated consultations. Discrimination after internal validation was 0.64 with a calibration slope of 0.95. The positive predictive value of patients with high scores on the model was 0.37 (0.29–0.47).ConclusionsSeveral theoretically suggested predisposing and precipitating predictors, including neuroticism and stressful life events, surprisingly failed to contribute to our final model. Moreover, this model mostly included general predictors of increased risk of repeated consultations among patients with FSS. The model discrimination and positive predictive values were insufficient and preclude clinical implementation.

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Platelet aggregation inhibitor prescription for newly diagnosed peripheral arterial disease in the Netherlands: a cohort study

BMJ Open ◽

10.1136/bmjopen-2020-041715 ◽

2021 ◽

Vol 11 (1) ◽

pp. e041715

Author(s):

Aarent RT Brand ◽

Eline Houben ◽

Irene D Bezemer ◽

Frank L J Visseren ◽

Michiel L Bots ◽

...

Keyword(s):

Primary Care ◽

Cohort Study ◽

The Netherlands ◽

Peripheral Arterial Disease ◽

Arterial Disease ◽

Free Text ◽

Newly Diagnosed ◽

Patient Journey ◽

P2y12 Inhibitors ◽

Peripheral Arterial

ObjectivesPharmacological treatment of peripheral arterial disease (PAD) comprises of antiplatelet therapy (APT), blood pressure control and cholesterol optimisation. Guidelines provide class-I recommendations on the prescription, but there are little data on the actual prescription practices. Our study provides insight into the prescription of medication among patients with PAD in the Netherlands and reports a ‘real-world’ patient journey through primary and secondary care.DesignWe conducted a cohort study among patients newly diagnosed with PAD between 2010 and 2014.SettingData were obtained from the PHARMO Database Network, a population-based network of electronic pharmacy, primary and secondary healthcare setting records in the Netherlands. The source population for this study comprised almost 1 million individuals.Participants‘Newly diagnosed’ was defined as a recorded International Classification of Primary Care code for PAD, a PAD-specific WCIA examination code or a diagnosis recorded as free text episode in the general practitioner records with no previous PAD diagnosis record and no prescription of P2Y12 inhibitors or aspirin the preceding year. The patient journey was defined by at least 1 year of database history and follow-up relative to the index date.ResultsBetween 2010 and 2014, we identified 3677 newly diagnosed patients with PAD. Most patients (91%) were diagnosed in primary care. Almost half of all patients (49%) had no APT dispensing record. Within this group, 33% received other anticoagulant therapy (vitamin K antagonist or direct oral anticoagulant). Mono-APT was dispensed as aspirin (40% of patients) or P2Y12 inhibitors (2.5% of patients). Dual APT combining aspirin with a P2Y12 inhibitor was dispensed to 8.5% of the study population.ConclusionHalf of all patients with newly diagnosed PAD are not treated conforming to (international) guideline recommendations on thromboembolism prevention through APT. At least 33% of all patients with newly diagnosed PAD do not receive any antithrombotic therapy. Evaluation and improvement of APT prescription and thereby improved prevention of (secondary) cardiovascular events is warranted.

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