Showing papers by "Mark Ashworth published in 2023"

The impact of the COVID-19 pandemic on cardiovascular disease prevention and management

Abstract: How the Coronavirus Disease 2019 (COVID-19) pandemic has affected prevention and management of cardiovascular disease (CVD) is not fully understood. In this study, we used medication data as a proxy for CVD management using routinely collected, de-identified, individual-level data comprising 1.32 billion records of community-dispensed CVD medications from England, Scotland and Wales between April 2018 and July 2021. Here we describe monthly counts of prevalent and incident medications dispensed, as well as percentage changes compared to the previous year, for several CVD-related indications, focusing on hypertension, hypercholesterolemia and diabetes. We observed a decline in the dispensing of antihypertensive medications between March 2020 and July 2021, with 491,306 fewer individuals initiating treatment than expected. This decline was predicted to result in 13,662 additional CVD events, including 2,281 cases of myocardial infarction and 3,474 cases of stroke, should individuals remain untreated over their lifecourse. Incident use of lipid-lowering medications decreased by 16,744 patients per month during the first half of 2021 as compared to 2019. By contrast, incident use of medications to treat type 2 diabetes mellitus, other than insulin, increased by approximately 623 patients per month for the same time period. In light of these results, methods to identify and treat individuals who have missed treatment for CVD risk factors and remain undiagnosed are urgently required to avoid large numbers of excess future CVD events, an indirect impact of the COVID-19 pandemic. Analysis of 1.32 billion records of medication data from England, Scotland and Wales reveals that the COVID-19 pandemic led to substantial declines in dispensing of antihypertensive and lipid-lowering medications, leading to increased risks for future cardiovascular disease.

Antidepressant Advisor (ADeSS): a decision support system for antidepressant treatment for depression in UK primary care – a feasibility study

Abstract: Objectives To develop and probe the first computerised decision-support tool to provide antidepressant treatment guidance to general practitioners (GPs) in UK primary care. Design A parallel group, cluster-randomised controlled feasibility trial, where individual participants were blind to treatment allocation. Setting South London NHS GP practices. Participants Ten practices and eighteen patients with treatment-resistant current major depressive disorder. Interventions Practices were randomised to two treatment arms: (a) treatment-as-usual, (b) computerised decision support tool. Results Ten GP practices participated in the trial, which was within our target range (8–20). However, practice and patient recruitment were slower than anticipated and only 18 of 86 intended patients were recruited. This was due to fewer than expected patients being eligible for the study, as well as disruption resulting from the COVID-19 pandemic. Only one patient was lost to follow-up. There were no serious or medically important adverse events during the trial. GPs in the decision tool arm indicated moderate support for the tool. A minority of patients fully engaged with the mobile app-based tracking of symptoms, medication adherence and side effects. Conclusions Overall, feasibility was not shown in the current study and the following modifications would be needed to attempt to overcome the limitations found: (a) inclusion of patients who have only tried one Selective Serotonin Reuptake Inhibitor, rather than two, to improve recruitment and pragmatic relevance of the study; (b) approaching community pharmacists to implement tool recommendations rather than GPs; (c) further funding to directly interface between the decision support tool and self-reported symptom app; (d) increasing the geographic reach by not requiring detailed diagnostic assessments and replacing this with supported remote self-report. Trial registration number NCT03628027.

Outcomes of Pre-Existing Diabetes in People With/without New Onset Severe Mental Illness: A Primary-Secondary Mental Healthcare Linkage in South London, United Kingdom

Abstract: Aims To compare people with diabetes developing severe mental illness (SMI) to those with diabetes alone with respect to risk status, diabetes care receipt, and diabetes-relevant outcomes in primary care. Methods Data from mental health care (Clinical Record Interactive Search; CRIS) linked to primary care (Lambeth DataNet; LDN) were used. From patients with a type 2 diabetes mellitus (T2DM) diagnosis in primary care, those with a new SMI diagnosis were matched (by age, gender, and practice) with up to five randomly selected controls. Mixed models were used to estimate associations with trajectories of recorded HbA1c levels; Poisson regression models compared total and cardiovascular comorbidity levels and number of diabetes complications; linear regression models compared BMI and total cholesterol levels; conditional logistic regression models investigated microalbuminuria, receipt of a foot or retinal examination, use of statins and receipt of insulin; Cox proportional hazards were used to model incident microvascular and macrovascular events, foot morbidity and mortality. Results In a cohort of 693 cases with SMI (122 bipolar disorder, 571 schizophrenia and related) and T2DM compared to 3366 controls, all-cause mortality was increased substantially in the cohort with SMI (adjusted hazard ratio 4.52, 95% CI 3.73–5.47; for bipolar 5.59, 3.37–9.28; for schizophrenia 4.42, 3.60–5.44). However, for all the other outcome comparisons, the only significant findings were of reduced foot examination (adjusted odds ratio 0.75, 0.54–0.98) and reduced retinal screening (0.77, 0.61–0.96). Conclusion Higher mortality suggests increased risk of adverse outcomes for people with pre-existing T2DM who develop SMI, and reduced foot/retinal examinations suggest disadvantaged healthcare receipt. However, other potential explanations for the mortality difference could not be identified from the outcomes analysed, so further investigation is needed into underlying causal pathways.

Completeness, agreement, and representativeness of ethnicity recording in the United Kingdom’s Clinical Practice Research Datalink (CPRD) and linked Hospital Episode Statistics (HES)

Abstract: This descriptive study assessed the completeness, agreement, and representativeness of ethnicity recording in the United Kingdom (UK) Clinical Practice Research Datalink (CPRD) primary care databases alone and, for those patients registered with a GP in England, when linked to secondary care data from Hospital Episode Statistics (HES).Ethnicity records were assessed for all patients in the May 2021 builds of the CPRD GOLD and CPRD Aurum databases for all UK patients. In analyses of the UK, English data was from combined CPRD-HES, whereas data from Northern Ireland, Scotland, and Wales drew from CPRD only. The agreement of ethnicity records per patient was assessed within each dataset (CPRD GOLD, CPRD Aurum, and HES datasets) and between datasets at the highest level ethnicity categorisation ('Asian', 'black', 'mixed', 'white', 'other'). Representativeness was assessed by comparing the ethnic distributions at the highest-level categorisation of CPRD-HES to those from the Census 2011 across the UK's devolved administrations. Additionally, CPRD-HES was compared to the experimental ethnic distributions for England and Wales from the Office for National Statistics in 2019 (ONS2019) and the English ethnic distribution from May 2021 from NHS Digital's General Practice Extraction Service Data for Pandemic Planning and Research with HES data linkage (GDPPR-HES).In CPRD-HES, 81.7% of currently registered patients in the UK had ethnicity recorded in primary care. For patients with multiple ethnicity records, mismatched ethnicity within individual primary and secondary care datasets was < 10%. Of English patients with ethnicity recorded in both CPRD and HES, 93.3% of records matched at the highest-level categorisation; however, the level of agreement was markedly lower in the 'mixed' and 'other' ethnic groups. CPRD-HES was less proportionately 'white' compared to the UK Census 2011 (80.3% vs. 87.2%) and experimental ONS2019 data (80.4% vs. 84.3%). CPRD-HES was aligned with the ethnic distribution from GDPPR-HES ('white' 80.4% vs. 80.7%); however, with a smaller proportion classified as 'other' (1.1% vs. 2.8%).CPRD-HES has suitable representation of all ethnic categories with some overrepresentation of minority ethnic groups and a smaller proportion classified as 'other' compared to the UK general population from other data sources. CPRD-HES data is useful for studying health risks and outcomes in typically underrepresented groups.

Ethnic inequalities in the impact of COVID-19 on primary care consultations: a time series analysis of 460,084 individuals with multimorbidity in South London

Abstract: Abstract Background The COVID-19 pandemic caused rapid changes in primary care delivery in the UK, with concerns that certain groups of the population may have faced increased barriers to access. This study assesses the impact of the response to the COVID-19 pandemic on primary care consultations for individuals with multimorbidity and identifies ethnic inequalities. Methods A longitudinal study based on monthly data from primary care health records of 460,084 patients aged ≥18 years from 41 GP practices in South London, from February 2018 to March 2021. Descriptive analysis and interrupted time series (ITS) models were used to analyse the effect of the pandemic on primary care consultations for people with multimorbidity and to identify if the effect varied by ethnic groups and consultation type. Results Individuals with multimorbidity experienced a smaller initial fall in trend at the start of the pandemic. Their primary care consultation rates remained stable (879 (95% CI 869–890) per 1000 patients in February to 882 (870–894) March 2020), compared with a 7% decline among people without multimorbidity (223 consultations (95% CI 221–226) to 208 (205–210)). The gap in consultations between the two groups reduced after July 2020. The effect among individuals with multimorbidity varied by ethnic group. Ethnic minority groups experienced a slightly larger fall at the start of the pandemic. Individuals of Black, Asian, and Other ethnic backgrounds also switched from face-to-face to telephone at a higher rate than other ethnic groups. The largest fall in face-to-face consultations was observed among people from Asian backgrounds (their consultation rates declined from 676 (659–693) in February to 348 (338–359) in April 2020), which may have disproportionately affected their quality of care. Conclusions The COVID-19 pandemic significantly affected primary care utilisation in patients with multimorbidity. While there is evidence of a successful needs-based prioritisation of multimorbidity patients within primary care at the start of the pandemic, inequalities among ethnic minority groups were found. Strengthening disease management for these groups may be necessary to control widening inequalities in future health outcomes.