scholarly journals Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records

2021 ◽  
pp. bmjqs-2021-013425
Author(s):  
Bianca Wiering ◽  
Georgios Lyratzopoulos ◽  
Willie Hamilton ◽  
John Campbell ◽  
Gary Abel
Keyword(s):  
Primary Care ◽  
Rectal Bleeding ◽  
Patient Characteristics ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Care Hospital ◽  
Breast Lump ◽  
Urgent Referral ◽  
Recommendations For Action ◽  
To Receive

BackgroundClinical guidelines advise GPs in England which patients warrant an urgent referral for suspected cancer. This study assessed how often GPs follow the guidelines, whether certain patients are less likely to be referred, and how many patients were diagnosed with cancer within 1 year of non-referral.MethodsWe used linked primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics) and cancer registration data. Patients presenting with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time during 2014–2015 were included (for ages where guidelines recommend urgent referral). Logistic regression was used to investigate whether receiving a referral was associated with feature type and patient characteristics. Cancer incidence (based on recorded diagnoses in cancer registry data within 1 year of presentation) was compared between those receiving and those not receiving referrals.Results48 715 patients were included, of which 40% (n=19 670) received an urgent referral within 14 days of presentation, varying by feature from 17% (dysphagia) to 68% (breast lump). Young patients (18–24 vs 55–64 years; adjusted OR 0.20, 95% CI 0.10 to 0.42, p<0.001) and those with comorbidities (4 vs 0 comorbidities; adjusted OR 0.87, 95% CI 0.80 to 0.94, p<0.001) were less likely to receive a referral. Associations between patient characteristics and referrals differed across features: among patients presenting with anaemia, breast lump or haematuria, those with multi-morbidity, and additionally for breast lump, more deprived patients were less likely to receive a referral. Of 29 045 patients not receiving a referral, 3.6% (1047) were diagnosed with cancer within 1 year, ranging from 2.8% for rectal bleeding to 9.5% for anaemia.ConclusionsGuideline recommendations for action are not followed for the majority of patients presenting with common possible cancer features. A significant number of these patients developed cancer within 1 year of their consultation, indicating scope for improvement in the diagnostic process.

scholarly journals Trends and determinants of length of stay and hospital reimbursement following knee and hip replacement: evidence from linked primary care and NHS hospital records from 1997 to 2014

BMJ Open ◽  
2018 ◽  
Vol 8 (1) ◽  
pp. e019146 ◽  
Author(s):  
Edward Burn ◽  
Christopher J Edwards ◽  
David W Murray ◽  
Alan Silman ◽  
Cyrus Cooper ◽  
...  
Keyword(s):  
Primary Care ◽  
Length Of Stay ◽  
Hip Replacement ◽  
Patient Characteristics ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Hospital Inpatient ◽  
Hospital Reimbursement ◽  
Patient Profiles ◽  
The Impact

ObjectivesTo measure changes in length of stay following total knee and hip replacement (TKR and THR) between 1997 and 2014 and estimate the impact on hospital reimbursement, all else being equal. Further, to assess the degree to which observed trends can be explained by improved efficiency or changes in patient profiles.DesignCross-sectional study using routinely collected data.SettingNational Health Service primary care records from 1995 to 2014 in the Clinical Practice Research Datalink were linked to hospital inpatient data from 1997 to 2014 in Hospital Episode Statistics Admitted Patient Care.ParticipantsStudy participants had a diagnosis of osteoarthritis or rheumatoid arthritis.InterventionsPrimary TKR, primary THR, revision TKR and revision THR.Primary outcome measuresLength of stay and hospital reimbursement.Results10 260 primary TKR, 10 961 primary THR, 505 revision TKR and 633 revision THR were included. Expected length of stay fell from 16.0 days (95% CI 14.9 to 17.2) in 1997 to 5.4 (5.2 to 5.6) in 2014 for primary TKR and from 14.4 (13.7 to 15.0) to 5.6 (5.4 to 5.8) for primary THR, leading to savings of £1537 and £1412, respectively. Length of stay fell from 29.8 (17.5 to 50.5) to 11.0 (8.3 to 14.6) for revision TKR and from 18.3 (11.6 to 28.9) to 12.5 (9.3 to 16.8) for revision THR, but no significant reduction in reimbursement was estimated. The estimated effect of year of surgery remained similar when patient characteristics were included.ConclusionsLength of stay for joint replacement fell substantially from 1997 to 2014. These reductions have translated into substantial savings. While patient characteristics affect length of stay and reimbursement, patient profiles have remained broadly stable over time. The observed reductions appear to be mostly explained by improved efficiency.

Preliminary results from the COPE study using primary-care electronic health records and environmental modelling to examine COPD exacerbations

2018 ◽  
Vol 68 (suppl 1) ◽  
pp. bjgp18X696749 ◽  
Author(s):  
Maimoona Hashmi ◽  
Mark Wright ◽  
Kirin Sultana ◽  
Benjamin Barratt ◽  
Lia Chatzidiakou ◽  
...  
Keyword(s):  
Primary Care ◽  
Electronic Health Records ◽  
Health Management ◽  
Practice Research ◽  
Chronic Obstructive ◽  
Clinical Practice Research Datalink ◽  
Health Records ◽  
Preliminary Results ◽  
Copd Exacerbations ◽  
Electronic Health

BackgroundChronic Obstructive Airway Disease (COPD) is marked by often severely debilitating exacerbations. Efficient patient-centric research approaches are needed to better inform health management primary-care.AimThe ‘COPE study’ aims to develop a method of predicting COPD exacerbations utilising personal air quality sensors, environmental exposure modelling and electronic health records through the recruitment of patients from consenting GPs contributing to the Clinical Practice Research Datalink (CPRD).MethodThe study made use of Electronic Healthcare Records (EHR) from CPRD, an anonymised GP records database to screen and locate patients within GP practices in Central London. Personal air monitors were used to capture data on individual activities and environmental exposures. Output from the monitors were then linked with the EHR data to obtain information on COPD management, severity, comorbidities and exacerbations. Symptom changes not equating to full exacerbations were captured on diary cards. Linear regression was used to investigate the relationship between subject peak flow, symptoms, exacerbation events and exposure data.ResultsPreliminary results on the first 80 patients who have completed the study indicate variable susceptibility to environmental stressors in COPD patients. Some individuals appear highly susceptible to environmental stress and others appear to have unrelated triggers.ConclusionRecruiting patients through EHR for a study is feasible and allows easy collection of data for long term follow up. Portable environmental sensors could now be used to develop personalised models to predict risk of COPD exacerbations in susceptible individuals. Identification of direct links between participant health and activities would allow improved health management thus cost savings.

scholarly journals Real-world presentation with heart failure in primary care: do patients selected to follow diagnostic and management guidelines have better outcomes?

Open Heart ◽  
2018 ◽  
Vol 5 (2) ◽  
pp. e000935
Author(s):  
Alex Bottle ◽  
Dani Kim ◽  
Paul P Aylin ◽  
F Azeem Majeed ◽  
Martin R Cowie ◽  
...  
Keyword(s):  
Heart Failure ◽  
Primary Care ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Initial Management ◽  
Risk Of Death ◽  
Specialist Referral ◽  
Partial Completion ◽  
General Practices ◽  
Using Data

ObjectiveTo describe associations between initial management of people presenting with heart failure (HF) symptoms in primary care, including compliance with the recommendations of the National Institute for Health and Care Excellence (NICE), and subsequent unplanned hospitalisation for HF and death.MethodsThis is a retrospective cohort study using data from general practices submitting records to the Clinical Practice Research Datalink. The cohort comprised patients diagnosed with HF during 2010–2013 and presenting to their general practitioners with breathlessness, fatigue or ankle swelling.Results13 897 patients were included in the study. Within the first 6 months, only 7% had completed the NICE-recommended pathway; another 18.6% had followed part of it (B-type natriuretic peptide testing and/or echocardiography, or specialist referral). Significant differences in hazards were seen in unadjusted analysis in favour of full or partial completion of the NICE-recommended pathway. Covariate adjustment attenuated the relations with death much more than those for HF admission. Compared with patients placed on the NICE pathway, treatment with HF medications had an HR of 1.16 (95% CI 1.05 to 1.28, p=0.003) for HF admission and 1.03 (95% CI 0.90 to 1.17, p= 0.674) for death. Patients who partially followed the NICE pathway had similar hazards to those who completed it. Patients on no pathway had the highest hazard for HF admission at 1.30 (95% 1.18 to 1.43, p<0.001) but similar hazard for death.ConclusionsPatients not put on at least some elements of the NICE-recommended pathway had significantly higher risk of HF admission but non-significant higher risk of death than other patients had.

scholarly journals Primary Care Consultations after Hospitalisation for Pneumonia: A Large Population-based Cohort Study

2020 ◽  
pp. BJGP.2020.0890
Author(s):  
Vadsala Baskaran ◽  
Fiona Pearce ◽  
Rowan H Harwood ◽  
Tricia McKeever ◽  
Wei Shen Lim
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Large Population ◽  
Significant Proportion ◽  
Antibiotic Use ◽  
Population Based ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Respiratory Disorder ◽  
The Impact

Background: Up to 70% of patients report ongoing symptoms four weeks after hospitalisation for pneumonia, and the impact on primary care is poorly understood. Aim: To investigate the frequency of primary care consultations after hospitalisation for pneumonia, and the reasons for consultation. Design: Population-based cohort study. Setting: UK primary care database of anonymised medical records (Clinical Practice Research Datalink, CPRD) linked to Hospital Episode Statistics (HES), England. Methods: Adults with the first ICD-10 code for pneumonia (J12-J18) recorded in HES between July 2002-June 2017 were included. Primary care consultation within 30 days of discharge was identified as the recording of any medical Read code (excluding administration-related codes) in CPRD. Competing-risks regression analyses were conducted to determine the predictors of consultation and antibiotic use at consultation; death and readmission were competing events. Reasons for consultation were examined. Results: Of 56,396 adults, 55.9% (n=31,542) consulted primary care within 30 days of discharge. The rate of consultation was highest within 7 days (4.7 per 100 person-days). The strongest predictor for consultation was a higher number of primary care consultations in the year prior to index admission (adjusted sHR 8.98, 95% CI 6.42-12.55). The commonest reason for consultation was for a respiratory disorder (40.7%, n=12,840), 12% for pneumonia specifically. At consultation, 31.1% (n=9,823) received further antibiotics. Penicillins (41.6%, n=5,753) and macrolides (21.9%, n=3,029) were the commonest antibiotics prescribed. Conclusion: Following hospitalisation for pneumonia, a significant proportion of patients consulted primary care within 30 days, highlighting the morbidity experienced by patients during recovery from pneumonia.

scholarly journals Antibiotic prescribing for lower UTI in elderly patients in primary care and risk of bloodstream infection: a cohort study using electronic health records

2020 ◽  
Author(s):  
Laura Shallcross ◽  
Patrick Rockenschaub ◽  
Ruth Blackburn ◽  
Irwin Nazareth ◽  
Nick Freemantle ◽  
...  
Keyword(s):  
Primary Care ◽  
Bloodstream Infection ◽  
Census Data ◽  
Asymptomatic Bacteriuria ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Antibiotic Prescribing ◽  
The Public ◽  
Health Need ◽  
Community Onset

AbstractBackgroundResearch has questioned the safety of delaying or withholding antibiotics for suspected urinary tract infection (UTI) in older patients. We evaluated the association between antibiotic treatment for lower UTI and risk of bloodstream infection (BSI) in adults aged ≥65 years in primary care.MethodsWe analysed primary care records from patients aged ≥65 years in England with community-onset UTI using the Clinical Practice Research Datalink (2007-2015) linked to Hospital Episode Statistics and census data. The primary outcome was BSI within 60 days, comparing patients treated immediately with antibiotics and those not treated immediately.Findings147,334 patients were included representing 280,462 episodes of lower UTI. BSI occurred in 0·4% (1,025 / 244,963) of UTI episodes with immediate antibiotics versus 0·6% (228 / 35,499) of episodes without immediate antibiotics. The odds of BSI were equivalent in patients who were not treated with antibiotics immediately and those who were treated on the date of their UTI consultation (adjusted odds ratio aOR 1·13; 95%-CI: 0·97-1·31). However, delaying or withholding antibiotics was associated with increased odds of death in the subsequent 60 days (aOR 1·17; 95% CI: 1·09-1·26).InterpretationEvidence on the safety of delaying or withholding antibiotics in older adults with suspected UTI is conflicting. Given the prevalence of asymptomatic bacteriuria in this population, their risk of antibiotic-related side effects, and the public health need to tackle antibiotic resistance, we recommend a trial to address this uncertainty.

Risk of ischemic stroke in asymptomatic atrial fibrillation incidentally-detected in primary care compared with other clinical presentations

2021 ◽  
Author(s):  
Christopher Wallenhorst ◽  
Carlos Martinez ◽  
Ben FREEDMAN
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Ischemic Stroke ◽  
Stroke Risk ◽  
Practice Research ◽  
Mortality Data ◽  
Clinical Practice Research Datalink ◽  
Primary Hospital ◽  
Ischemic Stroke Risk ◽  
The Uk

Background: It is uncertain whether stroke risk of asymptomatic ambulatory atrial fibrillation (AA-AF) incidentally-detected in primary care is comparable with other clinical AF presentations in primary care or hospital. Methods: The stoke risk of 22,035 patients with incident non-valvular AF from the UK primary care Clinical Practice Research Datalink with linkage to hospitalization and mortality data, was compared to 23,605 controls without AF (age and sex-matched 5:1 to 5,409 AA-AF patients). Incident AF included 5,913 with symptomatic ambulatory AF (SA-AF); 4,989 with Primary and 5,724 with non-Primary Hospital AF discharge diagnosis (PH-AF and Non-PH-AF); and 5,409 with AA-AF. Ischemic stroke adjusted subhazard ratios (aSHR) within 3 years of AA-AF were compared with SA-AF, PH-AF, Non-PH-AF and controls, accounting for mortality as competing risk and adjusted for ischemic stroke risk factors. Results: There were 1026 ischemic strokes in 49,544 person-years in patients with incident AF (crude incidence rate 2.1 ischemic strokes/100 person-years). Ischemic stroke aSHR over 3 years showed no differences between AA-AF, and SA-AF, PH-AF and nonPH-AF groups (aSHR 0.87-1.01 vs AA-AF). All AF groups showed a significantly higher aSHR compared to controls. (subhazard rate ratio 0.40 [0.34 - 0.47]. Conclusion: Ischemic stroke risk in patients with AA-AF incidentally-detected in primary care is far from benign, and not less than incident AF presenting clinically in general practice or hospital. This provides justification for identification of previously undetected AF, e.g. by opportunistic screening, and subsequent stroke prevention with thromboprophylaxis, to reduce the approximately 10% of ischemic strokes related to unrecognized AF.

scholarly journals P63 The association between presenting clinical features and subsequent diagnosis of giant cell arteritis

Rheumatology ◽  
2020 ◽  
Vol 59 (Supplement_2) ◽  
Author(s):  
Lauren A Barnett ◽  
Toby Helliwell ◽  
Kelvin P Jordan ◽  
James A Prior
Keyword(s):  
Primary Care ◽  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Clinical Features ◽  
Smoking Status ◽  
Conditional Logistic Regression ◽  
Diagnostic Delay ◽  
Practice Research ◽  
Clinical Feature ◽  
Clinical Practice Research Datalink

Abstract Background The diagnosis of giant cell arteritis (GCA) remains challenging due to the varied number and type of clinical features (symptoms and comorbidities) that patients with GCA can present with. Prompt diagnosis is important, as if left undiagnosed and untreated, some patients may experience irreversible sight loss. Given the rarity of GCA and that many of the presenting clinical features may pertain to other, more prevalent illnesses in the typical age range for GCA, diagnostic delay is common. Such delay may increase the risk of GCA related complications. The aim of this study was to quantify the association between a diagnosis of GCA and the clinical features observed prior to diagnosis. Methods Patients with a coded record of GCA and aged 40 years or older at the time of diagnosis, were identified from the Clinical Practice Research Datalink (CPRD) between 1990 and 2017. CPRD is a large, national UK database of primary care records. Every GCA case was matched to 5 controls with no GCA diagnosis, by year of birth, gender and practice. Clinical features linked to GCA in previous research studies were identified in the patient’s primary care records at any time prior to GCA diagnosis. Conditional logistic regression was used to determine associations between clinical features and a subsequent diagnosis of GCA, adjusting for Body Mass Index, smoking status, and alcohol consumption. Results 9,205 patients with GCA were included, the majority of which were female (70.9%). 15 clinical features were examined. For example, 53.3% of GCA cases had a recorded consultation for headache prior to diagnosis (38.4% within six months prior to diagnosis), compared to 9.9% of controls; 3.2% of cases had recorded jaw pain (0.3% within six months prior to diagnosis) compared to 0.5% of controls; 39.4% of cases had a diagnosis for hypertension prior to their diagnosis of GCA. GCA cases were more likely than controls to have recorded consultations for headache (adjusted OR 10.57; 95% CI: 9.93, 11.25), jaw pain (5.37; 4.47, 6.44) and hypertension (1.33; 1.26, 1.40). Other clinical features that were statistically significantly associated with GCA included fever, anxiety/depression, and PMR. Cancer was the only clinical feature not associated with GCA. Conclusion Symptoms such as headache, jaw pain and hypertension are highly prevalent in GCA, but are also common symptoms in the usual age group affected by GCA and common features of many conditions. In isolation and considering the rarity of GCA in the UK population, these symptoms may not be immediately attributed to GCA by the diagnosing GP. It is therefore necessary to conduct further research where clinical features are not treated independently, but as groups or clusters, which together may more accurately help clinicians to diagnose GCA early. Disclosures L.A. Barnett None. T. Helliwell None. K.P. Jordan None. J.A. Prior None.

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