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 Adherence to guidelines in management of symptoms suggestive of heart failure in primary care

Heart ◽  
2018 ◽  
Vol 105 (9) ◽  
pp. 678-685 ◽  
Author(s):  
Benedict Hayhoe ◽  
Dani Kim ◽  
Paul P Aylin ◽  
F Azeem Majeed ◽  
Martin R Cowie ◽  
...  
Keyword(s):  
Heart Failure ◽  
Primary Care ◽  
Median Time ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Presenting Symptoms ◽  
Specialist Referral ◽  
General Practices ◽  
Treatment And Diagnosis ◽  
Symptom Type

ObjectiveClinical guidelines on heart failure (HF) suggest timings for investigation and referral in primary care. We calculated the time for patients to achieve key elements in the recommended pathway to diagnosis of HF.MethodsIn this observational study, we used linked primary and secondary care data (Clinical Practice Research Datalink, a database of anonymised electronic records from UK general practices) between 2010 and 2013. Records were examined for presenting symptoms (breathlessness, fatigue, ankle swelling) and key elements of the National Institute for Health and Care Excellence-recommended pathway to diagnosis (serum natriuretic peptide (NP) test, echocardiography, specialist referral).Results42 403 patients were diagnosed with HF, of whom 16 597 presented in primary care with suggestive symptoms. 6464 (39%) had recorded NP or echocardiography, and 6043 (36%) specialist referral. Median time from recorded symptom(s) to investigation (NP or echocardiography) was 292 days (IQR 34–844) and to referral 236 days (IQR 42–721). Median time from symptom(s) to diagnosis was 972 days (IQR 337–1468) and to treatment with HF-relevant medication 803 days (IQR 230–1364). Factors significantly affecting timing of referral, treatment and diagnosis included patients’ sex (p=0.001), age (p<0.001), deprivation score (p=0.001), comorbidities (p<0.001) and presenting symptom type (p<0.001).ConclusionsMedian times to investigation or referral of patients presenting in primary care with symptoms suggestive of HF considerably exceeded recommendations. There is a need to support clinicians in the diagnosis of HF in primary care, with improved access to investigation and specialist assessment to support timely management.

Routes to diagnosis of heart failure: observational study using linked data in England

Heart ◽  
2017 ◽  
Vol 104 (7) ◽  
pp. 600-605 ◽  
Author(s):  
Alex Bottle ◽  
Dani Kim ◽  
Paul Aylin ◽  
Martin R Cowie ◽  
Azeem Majeed ◽  
...  
Keyword(s):  
Heart Failure ◽  
Primary Care ◽  
Natriuretic Peptide ◽  
Hospital Admissions ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Missed Opportunities ◽  
Specialist Referral ◽  
Care Consultation ◽  
Primary Care Practices

ObjectiveTimely diagnosis and management of heart failure (HF) is critical, but identification of patients with suspected HF can be challenging, especially in primary care. We describe the journey of people with HF in primary care from presentation through to diagnosis and initial management.MethodsWe used the Clinical Practice Research Datalink (primary care consultations linked to hospital admissions data and national death registrations for patients registered with participating primary care practices in England) to describe investigation and referral pathways followed by patients from first presentation with relevant symptoms to HF diagnosis, particularly alignment with recommendations of the National Institute for Health and Care Excellence guideline for HF diagnosis.Results36 748 patients had a diagnosis of HF recorded that met the inclusion criteria between 1 January 2010 and 31 March 2013. For 29 113 (79.2%) patients, this was first recorded in hospital. In the 5 years prior to diagnosis, 15 057 patients (41.0%) had a primary care consultation with one of three key HF symptoms recorded, 17 724 (48.2%) attended for another reason and 3967 (10.8%) did not see their general practitioner. Only 24% of those with recorded HF symptoms followed a pathway aligned with guidelines (echocardiogram and/or serum natriuretic peptide test and specialist referral), while 44% had no echocardiogram, natriuretic peptide test or referral.ConclusionsPatients follow various pathways to the diagnosis of HF. However, few appear to follow a pathway supported by guidelines for investigation and referral. There are likely to be missed opportunities for earlier HF diagnosis in primary care.

scholarly journals Do GPs accurately record date of death? A UK observational analysis

2018 ◽  
Vol 10 (3) ◽  
pp. e24-e24 ◽  
Author(s):  
Amelia Harshfield ◽  
Gary A Abel ◽  
Stephen Barclay ◽  
Rupert A Payne
Keyword(s):  
Primary Care ◽  
Young Patients ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Data Sets ◽  
Factors Associated ◽  
National Statistics ◽  
Primary Care Data ◽  
National Mortality ◽  
General Practices

ObjectiveTo examine the concordance between dates of death recorded in UK primary care and national mortality records.MethodsUK primary care data from the Clinical Practice Research Datalink were linked to Office for National Statistics (ONS) data, for 118 571 patients who died between September 2010 and September 2015. Logistic regression was used to examine factors associated with discrepancy in death dates between data sets.ResultsDeath dates matched in 76.8% of cases with primary care dates preceding ONS date in 2.9%, and following in 20.3% of cases; 92.2% of cases differed by <2 weeks. Primary care date was >4 weeks later than ONS in 1.5% of cases and occurred more frequently with deaths categorised as ‘external’ (15.8% vs 0.8% for cancer), and in younger patients (15.9% vs 1% for 18–29 and 80–89 years, respectively). General practices with the greatest discrepancies (97.5th percentile) had around 200 times higher odds of recording substantially discordant dates than practices with the lowest discrepancies (2.5th percentile).ConclusionDates of death in primary care records often disagree with national records and should be treated with caution. There is marked variation between practices, and studies involving young patients, unexplained deaths and where precise date of death is important are particularly vulnerable to these issues.

scholarly journals Prior lymphopenia is associated with mortality in primary care pneumonia: a cohort study

2020 ◽  
pp. bjgp20X713981
Author(s):  
Fergus W Hamilton ◽  
Rupert Payne ◽  
David T Arnold
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Lymphocyte Count ◽  
Cox Regression ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Risk Of Death ◽  
Increased Risk ◽  
One Year ◽  
The Relationship

Abstract Background: Lymphopenia (reduced lymphocyte count) during infections such as pneumonia is common and is associated with increased mortality. Little is known about the relationship between lymphocyte count prior to developing infections and mortality risk. Aim: To identify whether patients with lymphopenia who develop pneumonia have increased risk of death. Design and Setting: A cohort study in the Clinical Practice Research Datalink (CPRD), linked to national death records. This database is representative of the UK population, and is extracted from routine records. Methods: Patients aged >50 years with a pneumonia diagnosis were included. We measured the relationship between lymphocyte count and mortality, using a time-to-event (multivariable Cox regression) approach, adjusted for age, sex, social factors, and potential causes of lymphopenia. Our primary analysis used the most recent test prior to pneumonia. The primary outcome was 28 day, all-cause mortality. Results: 40,909 participants with pneumonia were included from 1998 until 2019, with 28,556 having had a lymphocyte test prior to pneumonia (median time between test and diagnosis 677 days). When lymphocyte count was categorised (0-1×109/L, 1-2×109/L, 2-3×109/L, >3×109/L, never tested), both 28-day and one-year mortality varied significantly: 14%, 9.2%, 6.5%, 6.1% and 25% respectively for 28-day mortality, and 41%, 29%, 22%, 20% and 52% for one-year mortality. In multivariable Cox regression, lower lymphocyte count was consistently associated with increased hazard of death. Conclusion: Lymphopenia is an independent predictor of mortality in primary care pneumonia. Even low-normal lymphopenia (1-2×109/L) is associated with an increase in short- and long-term mortality compared with higher counts.

scholarly journals Sepsis Recording in Primary Care Electronic Health Records, Linked Hospital Episodes and Mortality Records: Population-based Cohort Study in England

2020 ◽  
Author(s):  
Emma Rezel-Potts ◽  
Martin C. Gulliford ◽  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Population Based ◽  
Incidence Rates ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Recent Period ◽  
General Practices ◽  
Different Sources

AbstractObjectivesSepsis is a growing concern for health systems, but the epidemiology of sepsis is poorly characterised. We evaluated sepsis recording across primary care electronic records, hospital episodes and mortality registrations.Methods and FindingsCohort study including 378 general practices in England from Clinical Practice Research Datalink (CPRD) GOLD database from 2002 to 2017 with 36,209,676 patient-years of follow-up with linked Hospital Episode Statistics (HES) and Office for National Statistics (ONS) mortality registrations. Incident sepsis episodes were identified for each source. Concurrent records from different sources were identified and age-standardised and age-specific incidence rates compared. Logistic regression analysis evaluated associations of gender, age-group, fifth of deprivation and period of diagnosis with concurrent sepsis recording.There were 20,206 first episodes of sepsis from primary care, 20,278 from HES and 13,972 from ONS. There were 4,117 (20%) first HES sepsis events and 2,438 (17%) mortality records concurrent with incident primary care sepsis records within 30 days. Concurrent HES and primary care records of sepsis within 30 days before or after first diagnosis were higher at younger or older ages and for patients with the most recent period of diagnosis with those diagnosed during 2007:2011 less likely to have a concurrent HES record given CPRD compared to those diagnosed during 2012 to 2017 (odd ratio 0.65, 95% confidence interval 0.60 to 0.70). At age 85 and older, primary care incidence was 5.22 per 1,000 patient years (95% CI 1.75 to 11.97) in men and 3.55 (0.87 to 9.58) in women which increased to 10.09 (4.86 to 18.51) for men and 7.22 (2.96 to 14.72) for women after inclusion of all three sources.ConclusionExplicit recording of sepsis is inconsistent across healthcare sectors with a high proportion of non-concurrent records. Incidence estimates are higher when linked data are analysed.

scholarly journals Sepsis recording in primary care electronic health records, linked hospital episodes and mortality records: Population-based cohort study in England

PLoS ONE ◽  
2020 ◽  
Vol 15 (12) ◽  
pp. e0244764
Author(s):  
Emma Rezel-Potts ◽  
Martin C. Gulliford ◽  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Population Based ◽  
Incidence Rates ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Recent Period ◽  
General Practices ◽  
Different Sources

Background Sepsis is a growing concern for health systems, but the epidemiology of sepsis is poorly characterised. We evaluated sepsis recording across primary care electronic records, hospital episodes and mortality registrations. Methods and findings Cohort study including 378 general practices in England from Clinical Practice Research Datalink (CPRD) GOLD database from 2002–2017 with 36,209,676 patient-years of follow-up with linked Hospital Episode Statistics (HES) and Office for National Statistics (ONS) mortality registrations. Incident sepsis episodes were identified for each source. Concurrent records from different sources were identified and age-standardised and age-specific incidence rates compared. Logistic regression analysis evaluated associations of gender, age-group, fifth of deprivation and period of diagnosis with concurrent sepsis recording. There were 20,206 first episodes of sepsis from primary care, 20,278 from HES and 13,972 from ONS. There were 4,117 (20%) first HES sepsis events and 2,438 (17%) mortality records concurrent with incident primary care sepsis records within 30 days. Concurrent HES and primary care records of sepsis within 30 days before or after first diagnosis were higher at younger or older ages and for patients with the most recent period of diagnosis. Those diagnosed during 2007:2011 were less likely to have a concurrent HES record given CPRD compared to those diagnosed during 2012–2017 (odd ratio 0.65, 95% confidence interval 0.60–0.70). At age 85 and older, primary care incidence was 5.22 per 1,000 patient years (95% CI 1.75–11.97) in men and 3.55 (0.87–9.58) in women which increased to 10.09 (4.86–18.51) for men and 7.22 (2.96–14.72) for women after inclusion of all three sources. Conclusion Explicit recording of ‘sepsis’ is inconsistent across healthcare sectors with a high proportion of non-concurrent records. Incidence estimates are higher when linked data are analysed.

scholarly journals Antibiotic Prescribing Before and After the Diagnosis of Comorbidity: A Cohort Study Using Primary Care Electronic Health Records

2019 ◽  
Vol 71 (7) ◽  
pp. e50-e57 ◽  
Author(s):  
Patrick Rockenschaub ◽  
Andrew Hayward ◽  
Laura Shallcross
Keyword(s):  
Heart Failure ◽  
Primary Care ◽  
Respiratory Symptoms ◽  
Antibiotic Use ◽  
Arterial Disease ◽  
Practice Research ◽  
Chronic Obstructive ◽  
Clinical Practice Research Datalink ◽  
Antibiotic Prescribing ◽  
Before And After

Abstract Background Comorbidities such as diabetes and chronic obstructive pulmonary disease (COPD) increase patients’ susceptibility to infections, but it is unclear how the onset of comorbidity impacts antibiotic use. We estimated rates of antibiotic use before and after diagnosis of comorbidity in primary care to identify opportunities for antibiotic stewardship. Methods We analyzed UK primary care records from the Clinical Practice Research Datalink. Adults registered between 2008–2015 without prior comorbidity diagnoses were eligible for inclusion. Monthly adjusted rates of antibiotic prescribing were estimated for patients with new-onset stroke, coronary heart disease, heart failure, peripheral arterial disease, asthma, chronic kidney disease, diabetes, or COPD in the 12 months before and after diagnosis and for controls without comorbidity. Results 106 540/1 071 943 (9.9%) eligible patients were diagnosed with comorbidity. Antibiotic prescribing rates increased 1.9- to 2.3-fold in the 4–9 months preceding diagnosis of asthma, heart failure, and COPD before declining to stable levels within 2 months after diagnosis. A less marked trend was seen for diabetes (rate ratio, 1.55; 95% confidence interval, 1.48–1.61). Prescribing rates for patients with vascular conditions increased immediately before diagnosis and remained 30%–39% higher than baseline afterwards. Rates of prescribing to controls increased by 17%–28% in the months just before and after consultation. Conclusions Antibiotic prescribing increased rapidly before diagnosis of conditions that present with respiratory symptoms (COPD, heart failure, asthma) and declined afterward. Onset of respiratory symptoms may be misdiagnosed as infection. Earlier diagnosis of these comorbidities could reduce avoidable antibiotic prescribing.

scholarly journals Heart failure in primary care: prevalence related to age and comorbidity

2019 ◽  
Vol 20 ◽  
Author(s):  
Lieke Bosch ◽  
Patricia Assmann ◽  
Wim J. C. de Grauw ◽  
Bianca W. M. Schalk ◽  
Marion C. J. Biermans
Keyword(s):  
Heart Failure ◽  
Primary Care ◽  
General Practice ◽  
Elderly Patients ◽  
Chronic Obstructive ◽  
Routine Practice ◽  
Chronic Obstructive Pulmonary Disorder ◽  
Pulmonary Disorder ◽  
General Practices ◽  
Using Data

Abstract Background Diagnosing heart failure (HF) in primary care can be challenging, especially in elderly patients with comorbidities. Insight in the prevalence, age, comorbidity and routine practice of diagnosing HF in general practice may improve the process of diagnosing HF. Aim To examine the prevalence of HF in relation to ageing and comorbidities, and routine practice of diagnosing HF in general practice. Methods A retrospective cohort study was performed using data from electronic health records of 56 320 adult patients of 11 general practices. HF patients were compared with patients without HF using descriptive analyses and χ2 tests. The following comorbidities were considered: chronic obstructive pulmonary disorder (COPD), diabetes mellitus (DM), hypertension, anaemia and renal function disorder (RFD). Separate analyses were performed for men and women. Findings The point prevalence of HF was 1.2% (95% confidence interval 1.13–1.33) and increased with each age category from 0.04% (18–44 years) to 20.9% (⩾85 years). All studied comorbidities were significantly (P<0.001) more common in HF patients than in patients without HF: COPD (24.1% versus 3.1%), DM (34.7% versus 6.5%), hypertension (52.7% versus 16.0%), anaemia (10.9% versus 2.3%) and RFD (61.8% versus 7.5%). N-terminal pro-BNP (NT-proBNP) was recorded in 38.1% of HF patients. Conclusions HF is highly associated with ageing and comorbidities. Diagnostic use of NT-proBNP in routine primary care seems underutilized. Instruction of GPs to determine NT-proBNP in patients suspected of HF is recommended, especially In elderly patients with comorbidities.

Delays in referral from primary care are associated with a worse survival in patients with esophagogastric cancer

2019 ◽  
Vol 32 (10) ◽  
pp. 1-11 ◽  
Author(s):  
Chanpreet S Arhi ◽  
S Markar ◽  
E M Burns ◽  
G Bouras ◽  
A Bottle ◽  
...  
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Retrospective Cohort ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Stage At Diagnosis ◽  
Risk Of Death ◽  
Esophagogastric Cancer ◽  
Cancer Experience ◽  
Worse Prognosis

SUMMARY NICE referral guidelines for suspected cancer were introduced to improve prognosis by reducing referral delays. However, over 20% of patients with esophagogastric cancer experience three or more consultations before referral. In this retrospective cohort study, we hypothesize that such a delay is associated with a worse survival compared with patients referred earlier. By utilizing Clinical Practice Research Datalink, a national primary care linked database, the first presentation, referral date, a number of consultations before referral and stage for esophagogastric cancer patients were determined. The risk of a referral after one or two consultations compared with three or more consultations was calculated for age and the presence of symptom fulfilling the NICE criteria. The risk of death according to the number of consultations before referral was determined, while accounting for stage and surgical management. 1307 patients were included. Patients referred after one (HR 0.80 95% CI 0.68–0.93 p = 0.005) or two consultations (HR 0.81 95% CI 0.67–0.98 p = 0.034) demonstrated significantly improved prognosis compared with those referred later. The risk of death was also lower for patients who underwent a resection, were younger or had an earlier stage at diagnosis. Those presenting with a symptom fulfilling the NICE criteria (OR 0.27 95% CI 0.21–0.35 p &lt; 0.0001) were more likely to be referred earlier. This is the first study to demonstrate an association between a delay in referral and worse prognosis in esophagogastric patients. These findings should prompt further research to reduce primary care delays.

scholarly journals Impact of lowering the risk threshold for statin treatment on statin prescribing: a descriptive study in English primary care

2020 ◽  
Vol 70 (700) ◽  
pp. e765-e771
Author(s):  
Alexander Pate ◽  
Richard Emsley ◽  
Tjeerd van Staa
Keyword(s):  
Primary Care ◽  
Medical Record ◽  
Descriptive Study ◽  
Risk Scores ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Average Risk ◽  
Cvd Risk ◽  
Using Data ◽  
The Impact

BackgroundIn 2014, the National Institute for Health and Care Excellence (NICE) changed the recommended threshold for initiating statins from a 10-year risk of cardiovascular disease (CVD) of 20% to 10% (Clinical Guideline 181), making 4.5 million extra people eligible for treatment.AimTo evaluate the impact of this guideline change on statin prescribing behaviour.Design and settingA descriptive study using data from Clinical Practice Research Datalink (CPRD), a primary care database in England.MethodPeople aged 25–84 years being initiated on statins for the primary prevention of CVD were identified. CVD risk predictions were calculated for every person using data in their medical record (calculated risks), and were extracted directly from their medical record if a QRISK score was recorded (coded risks). The 10-year CVD risks of people initiated on statins in each calendar year were compared.ResultsThe average ‘calculated risk’ of all people being initiated on statins was 20.65% in the year before the guideline change, and 20.27% after. When considering only the ‘coded risks’, the average risk was 21.85% before the guideline change, and 18.65% after. The proportion of people initiating statins that had a coded risk score in their medical record increased significantly from 2010–2017.ConclusionCurrently available evidence, which only considers people with coded risk scores in their medical record, indicates the guideline change had a large impact on statin prescribing. However, that analysis likely suffers from selection bias. This new evidence indicates only a modest impact of the guideline change. Further qualitative research about the lack of response to the guideline change is needed.

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