scholarly journals Trends and variation in prescribing of suboptimal statin treatment regimes: a cohort study in English primary care

2019 ◽  
Author(s):  
Helen J Curtis ◽  
Alex J Walker ◽  
Brian MacKenna ◽  
Richard Croker ◽  
Ben Goldacre
Keyword(s):  
Primary Care ◽  
Logistic Regression ◽  
Cohort Study ◽  
Behaviour Change ◽  
High Intensity ◽  
Mixed Effects ◽  
Substantial Variation ◽  
Practice Characteristics ◽  
National Guidance ◽  
Prescribing Behaviour

AbstractObjectivesWe set out to describe trends and variation in statin prescribing in England that breaches 2014 national guidance on “high-intensity” statins. We identify factors associated with breaching; and assess the feasibility of rapid prescribing behaviour change.Design, Setting and ParticipantsRetrospective cohort study in NHS primary care in England, including all 8,142 standard general practices from August 2010 to March 2019.Main Outcome MeasuresWe categorised statins as high or low/medium-intensity based on two different thresholds, and calculated the proportion prescribed below these thresholds across all practices. We plotted trends and geographical variation, carried out mixed effects logistic regression to identify practice characteristics associated with breaching guidance, and used indicator saturation to identify practices exhibiting sudden changes in prescribing.ResultsWe included all 8,142 practices across the study period. The proportion of statin prescriptions below the recommended 40% LDL-lowering threshold decreased gradually since 2012 from 80% to 45%; the proportion below a pragmatic 37% threshold decreased from 30% to 18%. The 2014 guidance had minimal impact on these trends. We found wide variation between practices (interdecile ranges 20% to 85% and 10% to 30% respectively in 2018). Mixed effects logistic regression did not identify practice characteristics strongly associated with breaching guidance. Indicator saturation identified several practices exhibiting sudden changes in prescribing towards greater guideline compliance.ConclusionsBreaches of English guidance on choice of statin remain common, with substantial variation between GP practices. Some practices and regions have implemented rapid change, indicating the feasibility of rapid prescribing behaviour change. We discuss the potential for a national strategic approach, using data and evidence to optimise care, including targeted education alongside audit and feedback to outliers through services such as OpenPrescribing.SummaryWhat is already known on this topicEnglish national guidance recommends the use of a high-intensity statin, capable of reducing LDL (low-density lipoprotein) cholesterol by 40% or more. Adherence at the time of guideline release was low, but has not been documented since.What this study addsAdherence is improving, but breaches of national guidance remain common, with 45% of prescriptions below the recommended strength, and there is very substantial variation between practices. Some practices have exhibited rapid positive change in prescribing, which indicates that better adherence could readily be achieved. We have produced a live data tool allowing anyone to explore any practice’s current statin prescribing behaviour.

scholarly journals Trends and variation in unsafe prescribing of methotrexate: a cohort study in English NHS primary care

2019 ◽  
Author(s):  
Brian MacKenna ◽  
Helen J Curtis ◽  
Alex J Walker ◽  
Richard Croker ◽  
Seb Bacon ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Retrospective Cohort ◽  
Geographical Variation ◽  
Freedom Of Information ◽  
Substantial Variation ◽  
National Guidance ◽  
General Practices ◽  
Safety Recommendations ◽  
Over Time

AbstractObjectiveTo describe trends and geographical variation in methotrexate prescribing that breaches national safety recommendations; deaths from methotrexate poisoning; and associated litigation.MethodsA retrospective cohort study of English NHS primary care prescribing data, complemented by information obtained through Freedom of Information (FOI) requests. The main outcome measures were: (1) variation in ratio of breaching / adherent prescribing, geographically and over time, between General Practices and Clinical Commissioning Groups; (2) description of responses to FOI requests.ResultsOut of 7349 NHS General Practices in England, 1689 practices prescribed both 2.5mg and 10mg tablets to individual patients in 2017, breaching national guidance. In April 2018, 697 practices (at the 90th centile and above) prescribed at least 14.3% of all methotrexate as 10mg tablets, breaching national guidance. The 66 practices at the 99th percentile and above gave at least 52.4% of all prescribed methotrexate in the form of 10 mg tablets. The prescribing of 10mg tablets has fallen over 7 years, with 10mg tablets as a proportion of all methotrexate tablets falling from 9.1% to 3.4%. 21 deaths caused by methotrexate poisoning have been reported from 1993-2017.ConclusionsThe prevalence of unsafe methotrexate prescribing has reduced but it remains common, with substantial variation between organisations. We recommend the NHS invests in better strategies around implementation of safety recommendations. 21 deaths have been attributed to methotrexate poisoning but with no further details easily available: the full coroners reports for these deaths should be reviewed to identify recurring themes.

scholarly journals Trends and variation in unsafe prescribing of methotrexate: a cohort study in English NHS primary care

2020 ◽  
Vol 70 (696) ◽  
pp. e481-e488 ◽  
Author(s):  
Brian MacKenna ◽  
Helen J Curtis ◽  
Alex J Walker ◽  
Richard Croker ◽  
Seb Bacon ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Retrospective Cohort ◽  
National Level ◽  
Freedom Of Information ◽  
Substantial Variation ◽  
England And Wales ◽  
National Guidance ◽  
High Doses ◽  
Over Time

BackgroundPrescribing high doses of methotrexate increases the potentially fatal risk of toxicity. To minimise risk, it is recommended that only 2.5 mg tablets are used.AimTo describe trends in GP prescribing of methotrexate over time; the harm associated with methotrexate errors at a national level; ascertain variation between practices and clinical commissioning groups (CCGs) in their implementation of the safety guidance; and map current variations at CCG and practice level.Design and settingA retrospective cohort study of English GP prescribing data (August 2010–April 2018), and data acquired via freedom of information (FOI) requests.MethodThe main outcome measures were: variation in ratio of non-adherent/adherent prescribing, geographically and over time, between practices and CCGs; and description of responses to FOI requests.ResultsOf 7349 practices in England, 1689 prescribed both 2.5 mg and 10 mg tablets to individual patients in 2017, breaching national guidance. In April 2018, 697 practices (≥90th percentile) prescribed >14.3% of all methotrexate as 10 mg tablets, likewise breaching national guidance. The 66 practices at ≥99th percentile gave >52.4% of all prescribed methotrexate in the form of 10 mg tablets. The prescribing of 10 mg tablets fell during the study period, with 10 mg tablets as a proportion of all prescribed methotrexate tablets falling from 9.1% to 3.4%. Twenty-one deaths caused by methotrexate poisoning were reported from 1993–2017 in England and Wales.ConclusionThe prevalence of unsafe methotrexate prescribing has reduced but remains common, with substantial variation between practices and CCGs. The authors recommend investment in better strategies around implementation. As 21 deaths that occurred from 1993–2017 in England and Wales were attributed to methotrexate poisoning, the coroners’ reports for these deaths should be reviewed to identify recurring themes.

scholarly journals Trends and variation in antidepressant prescribing in English primary care

BJGP Open ◽  
2021 ◽  
pp. BJGPO.2021.0020
Author(s):  
Paul Bogowicz ◽  
Helen J Curtis ◽  
Alex J Walker ◽  
Philip Cowen ◽  
John Geddes ◽  
...  
Keyword(s):  
Primary Care ◽  
Regression Analysis ◽  
Mixed Methods Research ◽  
Descriptive Statistics ◽  
Marked Variation ◽  
Substantial Variation ◽  
National Guidelines ◽  
Level Data ◽  
Prescribing Behaviour ◽  
Treatment Sequencing

BackgroundAntidepressants are commonly prescribed. There are clear national guidelines in relation to treatment sequencing. The study examined trends and variation in antidepressant prescribing across English primary care.AimTo examine trends and variation in antidepressant prescribing in England, with a focus on: monoamine oxidase inhibitors (MAOIs); paroxetine; and dosulepin and trimipramine.Design & settingRetrospective longitudinal study using national and practice level data on antidepressant items prescribed per year (1998–2018) and per month (2010–2019).MethodClass- and drug-specific proportions were calculated at national and practice levels. Descriptive statistics were generated, percentile charts and maps were plotted, and conducted logistic regression analysis was conducted.ResultsAntidepressant prescriptions more than tripled between 1998 and 2018, from 377 items per 1000 population to 1266 per 1000. MAOI prescribing fell substantially, from 0.7% of all antidepressant items in 1998 to 0.1% in 2018. There was marked variation between practices in past year prescribing of paroxetine (median practice proportion [MPP] = 1.7%, interdecile range [IDR] = 0.7% to 3.3%) and dosulepin (MPP = 0.7%, IDR = 0% to 1.9%), but less for trimipramine (MPP = 0%, IDR = 0% to 0.2%).ConclusionRapid growth and substantial variation in antidepressant prescribing behaviour was found between practices. The causes could be explored using mixed-methods research. Interventions to reduce prescribing of specific antidepressants, such as dosulepin, could include review prompts, alerts at the time of prescribing, and clinician feedback through tools like OpenPrescribing.net.

scholarly journals Prescription of suboptimal statin treatment regimens: a retrospective cohort study of trends and variation in English primary care

2020 ◽  
Vol 70 (697) ◽  
pp. e525-e533
Author(s):  
Helen J Curtis ◽  
Alex J Walker ◽  
Brian MacKenna ◽  
Richard Croker ◽  
Ben Goldacre
Keyword(s):  
Cohort Study ◽  
Behaviour Change ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Rapid Change ◽  
Density Lipoprotein ◽  
Audit And Feedback ◽  
Minimal Impact ◽  
Medium Intensity ◽  
Prescribing Behaviour

BackgroundSince 2014 English national guidance recommends ‘high-intensity’ statins, reducing low-density lipoprotein (LDL) cholesterol by ≥40%.AimTo describe trends and variation in low-/medium-intensity statin prescribing and assess the feasibility of rapid prescribing behaviour change.Design and settingA retrospective cohort study using OpenPrescribing data from all 8142 standard NHS general practices in England from August 2010 to March 2019.MethodStatins were categorised as high- or low-/medium-intensity using two different thresholds, and the proportion prescribed below these thresholds was calculated. The authors plotted trends and geographical variation, carried out mixed-effects logistic regression to identify practice characteristics associated with breaching of guidance, and used indicator saturation to identify sudden prescribing changes.ResultsThe proportion of statins prescribed below the recommended 40% LDL-lowering threshold has decreased gradually from 80% in 2011/2012 to 45% in 2019; the proportion below a pragmatic 37% threshold decreased from 30% to 18% in 2019. Guidance from 2014 had minimal impact on trends. Wide variation was found between practices (interdecile ranges 20% to 85% and 10% to 30% respectively in 2018). Regression identified no strong associations with breaching of guidance. Indicator saturation identified several practices exhibiting sudden changes towards greater guideline compliance.ConclusionBreaches of guidance on choice of statin remain common, with substantial variation between practices. Some have implemented rapid change, indicating the feasibility of rapid prescribing behaviour change. This article discusses the potential for a national strategic approach, using data and evidence to optimise care, including targeted education alongside audit and feedback to outliers through services such as OpenPrescribing.

scholarly journals Prediction of risk of prolonged post-concussion symptoms: Derivation and validation of the TRICORDRR (Toronto Rehabilitation Institute Concussion Outcome Determination and Rehab Recommendations) score

PLoS Medicine ◽  
2021 ◽  
Vol 18 (7) ◽  
pp. e1003652
Author(s):  
Laura Kathleen Langer ◽  
Seyed Mohammad Alavinia ◽  
David Wyndham Lawrence ◽  
Sarah Elizabeth Patricia Munce ◽  
Alice Kam ◽  
...  
Keyword(s):  
Primary Care ◽  
Logistic Regression ◽  
Cohort Study ◽  
Risk Score ◽  
Demographic Factors ◽  
Limited Information ◽  
Derivation Cohort ◽  
Injury Index ◽  
Increased Risk ◽  
Image Position

Background Approximately 10% to 20% of people with concussion experience prolonged post-concussion symptoms (PPCS). There is limited information identifying risk factors for PPCS in adult populations. This study aimed to derive a risk score for PPCS by determining which demographic factors, premorbid health conditions, and healthcare utilization patterns are associated with need for prolonged concussion care among a large cohort of adults with concussion. Methods and findings Data from a cohort study (Ontario Concussion Cohort study, 2008 to 2016; n = 1,330,336) including all adults with a concussion diagnosis by either primary care physician (ICD-9 code 850) or in emergency department (ICD-10 code S06) and 2 years of healthcare tracking postinjury (2008 to 2014, n = 587,057) were used in a retrospective analysis. Approximately 42.4% of the cohort was female, and adults between 18 and 30 years was the largest age group (31.0%). PPCS was defined as 2 or more specialist visits for concussion-related symptoms more than 6 months after injury index date. Approximately 13% (73,122) of the cohort had PPCS. Total cohort was divided into Derivation (2009 to 2013, n = 417,335) and Validation cohorts (2009 and 2014, n = 169,722) based upon injury index year. Variables selected a priori such as psychiatric disorders, migraines, sleep disorders, demographic factors, and pre-injury healthcare patterns were entered into multivariable logistic regression and CART modeling in the Derivation Cohort to calculate PPCS estimates and forward selection logistic regression model in the Validation Cohort. Variables with the highest probability of PPCS derived in the Derivation Cohort were: Age >61 years (p^ = 0.54), bipolar disorder (p^ = 0.52), high pre-injury primary care visits per year (p^ = 0.46), personality disorders (p^ = 0.45), and anxiety and depression (p^ = 0.33). The area under the curve (AUC) was 0.79 for the derivation model, 0.79 for bootstrap internal validation of the Derivation Cohort, and 0.64 for the Validation model. A limitation of this study was ability to track healthcare usage only to healthcare providers that submit to Ontario Health Insurance Plan (OHIP); thus, some patients seeking treatment for prolonged symptoms may not be captured in this analysis. Conclusions In this study, we observed that premorbid psychiatric conditions, pre-injury health system usage, and older age were associated with increased risk of a prolonged recovery from concussion. This risk score allows clinicians to calculate an individual’s risk of requiring treatment more than 6 months post-concussion.

scholarly journals Variation of Neonatal Outcomes and Care Practices for Preterm Infants <34 Weeks' Gestation in Different Regions of China: A Cohort Study

2021 ◽  
Vol 9 ◽  
Author(s):  
Ruimiao Bai ◽  
Siyuan Jiang ◽  
Jinzhen Guo ◽  
Shanyu Jiang ◽  
Shoo K. Lee ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Cohort Study ◽  
Hospital Mortality ◽  
Preterm Infants ◽  
Eastern China ◽  
Mixed Effects ◽  
Central China ◽  
Western China ◽  
Care Practices ◽  
Overall Mortality

Background: To compare outcomes and care practices of preterm infants born at &lt;34 weeks' gestation in the different regions of China from 2015 to 2018.Methods: This cohort study enrolled all infants born at &lt;34 weeks and admitted to 25 tertiary neonatal intensive care units across China from May 1st, 2015, to April 30th, 2018. The participating hospitals were categorized into three groups according to their distinct geographic locations: eastern China, central China, and western China. Multilevel mixed-effects logistic regression models were used to assess the independent association between neonatal outcomes and regions.Results: A total of 27,532 infants at &lt;34 weeks' gestation were enrolled in our study. Overall, 14,178 (51.5%) infants were from 12 hospitals in eastern China, 8,069 (29.3%) from 9 hospitals in central China, and 5,285 (19.2%) from 4 hospitals in western China. Infants in eastern China had the lowest rates of mortality or any morbidity (23.3%), overall mortality (7.6%), in-hospital mortality (3.7%), and discharge against medical advice (DAMA, 6.3%), compared with central (27.8, 11.3, 5.0, and 10.6%, respectively) and western China (37.4, 19.4, 7.7, and 19.4%, respectively). Multilevel mixed-effects logistic regression showed that infants in western China were exposed to the highest risks of mortality or any morbidity, overall mortality, in-hospital mortality, and DAMA. Significant variations of care practices existed in three regions. Infants in central China had the longest duration of the first course of invasive ventilation, the lowest rate of continuous positive airway pressure within 24 h after birth, the lowest rate of breast milk feeding, the latest initiation of feeds, and the longest duration of total parenteral nutrition among the three regions.Conclusions: We identified marked disparities in outcomes and clinical care practices of preterm infants born at &lt;34 weeks' gestation in different regions of China. Targeted quality improvement efforts are needed to improve the outcomes of premature infants in different regions of China.

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

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

scholarly journals Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases: A pragmatic randomized trial

2020 ◽  
Author(s):  
Elaine C Khoong ◽  
Valy Fontil ◽  
Natalie A Rivadeneira ◽  
Mekhala Hoskote ◽  
Shantanu Nundy ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Randomized Trial ◽  
Odds Ratio ◽  
Primary Outcome ◽  
Mixed Effects ◽  
Regression Analyses ◽  
Diagnostic Confidence ◽  
Diagnostic Uncertainty ◽  
Intervention Impact ◽  
High Uncertainty

Abstract Objective The study sought to evaluate if peer input on outpatient cases impacted diagnostic confidence. Materials and Methods This randomized trial of a peer input intervention occurred among 28 clinicians with case-level randomization. Encounters with diagnostic uncertainty were entered onto a digital platform to collect input from ≥5 clinicians. The primary outcome was diagnostic confidence. We used mixed-effects logistic regression analyses to assess for intervention impact on diagnostic confidence. Results Among the 509 cases (255 control; 254 intervention), the intervention did not impact confidence (odds ratio [OR], 1.46; 95% confidence interval [CI], 0.999-2.12), but after adjusting for clinician and case traits, the intervention was associated with higher confidence (OR, 1.53; 95% CI, 1.01-2.32). The intervention impact was greater in cases with high uncertainty (OR, 3.23; 95% CI, 1.09- 9.52). Conclusions Peer input increased diagnostic confidence primarily in high-uncertainty cases, consistent with findings that clinicians desire input primarily in cases with continued uncertainty.

scholarly journals Characteristics and health status of patients with and without confirmed HFpEF

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 (&gt;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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