Mortality Among Adults With Intellectual Disability in England: Comparisons With the General Population.

OBJECTIVES: To describe mortality among adults with intellectual disability in England in comparison with the general population. METHODS: We conducted a cohort study from 2009 to 2013 using data from 343 general practices. Adults with intellectual disability (n = 16 666; 656 deaths) were compared with age-, gender-, and practice-matched controls (n = 113 562; 1358 deaths). RESULTS: Adults with intellectual disability had higher mortality rates than controls (hazard ratio [HR] = 3.6; 95% confidence interval [CI] = 3.3, 3.9). This risk remained high after adjustment for comorbidity, smoking, and deprivation (HR = 3.1; 95% CI = 2.7, 3.4); it was even higher among adults with intellectual disability and Down syndrome or epilepsy. A total of 37.0% of all deaths among adults with intellectual disability were classified as being amenable to health care intervention, compared with 22.5% in the general population (HR = 5.9; 95% CI = 5.1, 6.8). CONCLUSIONS: Mortality among adults with intellectual disability is markedly elevated in comparison with the general population, with more than a third of deaths potentially amenable to health care interventions. This mortality disparity suggests the need to improve access to, and quality of, health care among people with intellectual disability.

The mental health and mortality impact of death of a partner with dementia.

OBJECTIVE: Caring for a partner with dementia and partner bereavement are independently associated with poor health. An understanding of the health effects of living with a partner dying with dementia can help optimise support. We describe health in the year before and after loss of a partner with dementia compared with other bereavements. METHODS: In a UK primary care database, 2624 older individuals whose partner died with dementia during 2005-2012 were matched with 7512 individuals experiencing bereavement where the deceased partner had no dementia recorded. RESULTS: Prior to bereavement, partners of the deceased with dementia were more likely to be diagnosed with depression (OR 2.31, 1.69-3.14) and receive psychotropic medication (OR 1.34, 1.21-1.49) than partners from bereavements without dementia. In contrast, psychotropic medication initiation two months after dementia bereavement was lower (HR 0.69, 0.56-0.85). Compared with other bereaved individuals, mortality after bereavement was lower in men experiencing a dementia bereavement (HR 0.68, 0.49-0.94) but similar in women (HR 1.02, 0.75-1.38). Prior to bereavement, those who died with dementia were less likely to receive palliative care (OR 0.47, 0.41-0.54). CONCLUSION: In the year before bereavement, partners of individuals dying with dementia experience poorer mental health than those facing bereavement from other causes, and their partner is less likely to receive palliative care. In the year after, individuals whose partner died with dementia experience some attenuation of the adverse health effects of bereavement. Services need to address the needs of carers for individuals dying with dementia and improve access to palliative care. Copyright © 2016 John Wiley & Sons, Ltd.

Impact of partner bereavement on quality of cardiovascular disease management.

BACKGROUND: Bereavement is a period of increased risk of cardiovascular death. There is limited understanding of the potential contribution of quality of cardiovascular disease management to this increased risk. METHODS AND RESULTS: In a UK primary-care database, 12 722 older individuals with preexisting cardiovascular disease (coronary heart disease, hypertension, diabetes mellitus, stroke) and a partner bereavement were matched with a non-bereaved control group (n=33 911). We examined key routine annual process measures of care in the year before and after bereavement and cardiovascular medication prescribing (lipid-lowering, antiplatelet, renin-angiotensin system drugs). Odds ratios for change after bereavement compared with the change in non-bereaved matched controls are presented. In the bereaved, uptake of all annual measures was lower in the year before bereavement, with improvement in the year after, whereas in the controls, uptake was relatively stable. The odds ratio for change was 1.30 (95% confidence interval, 1.15-1.46) for cholesterol measurement and 1.40 (95% confidence interval, 1.22-1.61) for blood pressure measurement. For all medication, there was a transient fall in prescribing in the peri-bereavement period lasting until about 3 months after bereavement. The odds ratio for at least 80% prescription coverage in the 30 days after bereavement was 0.80 (95% confidence interval, 0.73-0.88) for lipid-lowering medication and 0.82 (95% confidence interval, 0.74-0.91) for antiplatelet medication compared with the change in non-bereaved individuals. CONCLUSIONS: Lower uptake of key cardiovascular care measures in the year before bereavement and reduced medication coverage after bereavement may contribute to increased cardiovascular risk. Clinicians need to ensure that quality of cardiovascular care is maintained in the pre- and post-bereavement periods.

The effect of unexpected bereavement on mortality in older couples.

OBJECTIVES: We sought to determine whether unexpected bereavement has a greater impact on mortality in the surviving partner than death of a partner with preexisting chronic disease or disability. METHODS: In a UK primary care database (The Health Improvement Network), we identified 171,720 couples aged 60 years and older. We compared the rise in mortality in the first year after bereavement in those whose partner died without recorded chronic disease (unexpected bereavement) to those whose deceased partner had a diagnosis of chronic disease (known morbidity). RESULTS: For unexpected bereavement (13.4% of all bereavements), the adjusted hazard ratio for death in the first year after bereavement was 1.61 (95% confidence interval [CI] = 1.39, 1.86) compared with 1.21 (95% CI = 1.14, 1.30) where the partner had known morbidity. Differences between bereaved groups were significant (P = .001) and present for both men and women. CONCLUSIONS: Unexpected bereavement has a greater relative mortality impact than bereavement preceded by chronic disease. Our findings highlight the potential value of preparing individuals for the death of a spouse with known morbidity and providing extra support after bereavement for those experiencing sudden unexpected bereavement.

Mortality in older care home residents in England and Wales.

BACKGROUND: mortality in UK care homes is not well described. OBJECTIVE: to describe 1-year mortality and predictors in older care home residents compared with community residents. METHOD: cohort study using the THIN primary care database with 9,772 care home and 354,306 community residents aged 65-104 years in 293 English and Welsh general practices in 2009. RESULTS: a total of 2,558 (26.2%) care home and 11,602 (3.3%) community residents died within 1 year. The age and sex standardised mortality ratio for nursing homes was 419 (95% CI: 396-442) and for residential homes was 284 (266-302). Age-related increases in mortality were less marked in care homes than community. Comorbidities and identification as inappropriate for chronic disease management targets predicted mortality in both settings, but associations were weaker in care homes. The number of drug classes prescribed and primary care contact were the strongest clinical predictors of mortality in care homes. CONCLUSIONS: older care home residents experience high mortality. Age and diagnostic characteristics are weaker predictors of risk of death within care homes than the community. Measures of primary care utilisation may be useful proxies for frailty and improve difficult end of life care decisions in care homes.

Do good health and material circumstances protect older people from the increased risk of death after bereavement?

An increased risk of death in persons who have suffered spousal bereavement has been described in many populations. The impact of modifying factors, such as chronic disease and material circumstances, is less well understood. The authors followed 171,720 [corrected] couples 60 years of age or older in a United Kingdom primary care database between 2005 and 2010 for an average of 4 years. A total of 26,646 (15.5%) couples experienced bereavement, with mean follow up after bereavement of 2 years. In a model adjusted for age, sex, comorbid conditions at baseline, material deprivation based on area of residence, season, and smoking status, the hazard ratio for mortality in the first year after bereavement was 1.25 (95% confidence interval: 1.18, 1.33). Further adjustment for changes in comorbid conditions throughout follow up did not alter the hazard ratio for bereavement (hazard ratio = 1.27, 95% confidence interval: 1.19, 1.35). The association was strongest in individuals with no significant chronic comorbid conditions throughout follow up (hazard ratio = 1.50, 95% confidence interval: 1.28, 1.77) and in more affluent couples (P = 0.035). In the first year after bereavement, the association between bereavement and death is not primarily mediated through worsening or new onset of chronic disease. Good health and material circumstances do not protect individuals from increased mortality rates after bereavement.

The impact of dementia on influenza vaccination uptake in community and care home residents.

BACKGROUND: Influenza vaccination is recommended for older people irrespective of cognitive decline or residential setting. OBJECTIVE: To examine the effect of dementia diagnosis on flu vaccination uptake in community and care home residents in England and Wales. METHODS: Retrospective analysis of a primary care database with 378,462 community and 9,106 care (nursing and residential) home residents aged 65-104 in 2008-09. Predictors of vaccine uptake were examined adjusted for age, sex, area deprivation and major chronic diseases. RESULTS: Age and sex standardised uptake of influenza vaccine was 74.7% (95% CI: 73.7-75.8%) in community patients without dementia, 71.4% (69.3-73.5%) in community patients with dementia, 80.5% (78.9-82.2%) in care home patients without dementia and 83.3% (81.4-85.3%) in care home patients with dementia. In a fully adjusted model, compared with community patients without dementia, patients with dementia in the community were less likely to receive vaccination (RR: 0.96, 95% CI: 0.94-0.97) while care home patients with (RR: 1.06, 1.03-1.09) and without (RR: 1.03, 1.01-1.05) dementia were more likely to receive vaccination. Area deprivation and chronic diseases were, respectively, negative and positive predictors of uptake. CONCLUSION: Lower influenza vaccine uptake among community patients with dementia, compared with care home residents, suggests organisational barriers to community uptake but high uptake among patients with dementia in care homes does not suggest concern over informed consent acts as a barrier. Primary care for community patients with dementia needs to ensure that they receive all appropriate preventive interventions.

Does ß-adrenoceptor blocker therapy improve cancer survival? Findings from a population-based retrospective cohort study.

AIMS: To examine the effect of ß-adrenoceptor blocker treatment on cancer survival. METHODS: In a UK primary care database, we compared patients with a new cancer diagnosis receiving ß-adrenoceptor blockers regularly (n= 1406) with patients receiving other antihypertensive medication (n= 2056). RESULTS: Compared with cancer patients receiving other antihypertensive medication, patients receiving ß-adrenoceptor blocker therapy experienced slightly poorer survival (HR = 1.18, 95% CI 1.04, 1.33 for all ß-adrenoceptor blockers; HR = 1.21, 95% CI 0.94, 1.55 for non-selective ß-adrenoceptor blockers). This poorer overall survival was explained by patients with pancreatic and prostate cancer with no evidence of an effect on survival for patients with lung, breast or colorectal cancer. Analysis in a cancer-free matched parallel cohort did not suggest selection bias masked a beneficial effect. CONCLUSION: Our study does not support the hypothesis that ß-adrenoceptor blockers improve survival for common cancers.

Calcium supplementation, cardiovascular disease and mortality in older women.

PURPOSE: To investigate the long-term cumulative effect of calcium and vitamin D supplementation on cardiovascular outcomes and death in older women. METHODS: We undertook an observational cohort study using UK electronic primary care records in the Doctor's Independent Network (DIN-LINK) database; 9910 women aged 60-89 who started calcium and vitamin D supplementation between 2000 and 2005, with no heart disease or stroke history and who survived disease free for 2 years after supplement initiation were studied. The main outcome was first occurrence of myocardial infarction (MI), stroke or death more than 2 years after initiation. RESULTS: In the period from 2 years after supplement initiation, women who had received >600 days supplementation in these first 2 years were no more at risk of MI, stroke or death (hazard ratio 0.82 (0.67-1.01)) compared to women who received < or = 90 days supplementation in the first 2 years. Outcomes in the first 2 years were analysed separately and showed similar baseline risks in our comparison groups. CONCLUSION: Two years after initiation, women who have consistently received supplementation with calcium and vitamin D do not experience more cardiovascular events or deaths than women who received minimal supplementation.

Identifying the clinical characteristics of older people living in care homes using a novel approach in a primary care database.

OBJECTIVES: to enhance identification of older nursing and residential home residents in a national sample and describe their chronic disease prevalence. DESIGN: cross-sectional analysis of an established primary care database (The Health Improvement Network). SETTING: 326 English and Welsh general practices. SUBJECTS: 435,568 patients aged > or = 65. Care home residents were identified by either a Read code for care home residence or multiple care home residence markers (postcode linkage, household size identifier and location of consultation). COMPARISONS: nursing and residential home residents were compared with a community control group with no markers of care home residence using age and sex standardised chronic disease prevalence ratios. MAIN OUTCOME MEASURES: chronic disease prevalence using definitions from the national primary care contract. RESULTS: 11,547 (2.7%) older people were identified as care home residents, of whom only 4,403 (38.1%) were directly identified by their primary care record. Mean age for nursing and residential homes was 84.9 and 86.1 years compared to 74.7 for controls. Prevalence ratios for dementia were 14.8 (95% CI 13.4-16.4) for nursing and 13.5 (12.4-14.8) for residential homes compared to controls. Stroke and severe mental illness were commoner in nursing and residential homes but hypertension, respiratory and cancer diagnoses were slightly less common. Recorded disease prevalences in nursing and residential homes were similar. CONCLUSIONS: recording of care home residence is limited in primary care and this is a barrier to routine monitoring of this group. Higher dementia and stroke prevalence in care home residents confirms high clinical need, but the small differences in disease prevalence between nursing and residential homes have implications for delivering medical and nursing care to residential homes. Lower prevalence of some chronic diseases suggests incomplete recording or case finding. Routine flagging of care home residents in health care systems is a potential tool for improving monitoring and outcomes.

Do health checks for adults with intellectual disability reduce emergency hospital admissions? Evaluation of a natural experiment.

BACKGROUND: Annual health checks for adults with intellectual disability (ID) have been incentivised by National Health Service (NHS) England since 2009, but it is unclear what impact they have had on important health outcomes such as emergency hospitalisation. METHODS: An evaluation of a 'natural experiment', incorporating practice and individual-level designs, to assess the effectiveness of health checks for adults with ID in reducing emergency hospital admissions using a large English primary care database. For practices, changes in admission rates for adults with ID between 2009-2010 and 2011-2012 were compared in 126 fully participating versus 68 non-participating practices. For individuals, changes in admission rates before and after the first health check for 7487 adults with ID were compared with 46 408 age-sex-practice matched controls. Incident rate ratios (IRRs) comparing changes in admission rates are presented for: all emergency, preventable emergency (for ambulatory care sensitive conditions (ACSCs)) and elective emergency. RESULTS: Practices with high health check participation showed no change in emergency admission rate among patients with ID over time compared with non-participating practices (IRR=0.97, 95% CI 0.78 to 1.19), but emergency admissions for ACSCs did fall (IRR=0.74, 0.58 to 0.95). Among individuals with ID, health checks had no effect on overall emergency admissions compared with controls (IRR=0.96, 0.87 to 1.07), although there was a relative reduction in emergency admissions for ACSCs (IRR=0.82, 0.69 to 0.99). Elective admissions showed no change with health checks in either analysis. CONCLUSIONS: Annual health checks in primary care for adults with ID did not alter overall emergency admissions, but they appeared influential in reducing preventable emergency admissions.

Health characteristics and consultation patterns of people with intellectual disability: a cross-sectional database study in English general practice.

BACKGROUND: People with intellectual disability (ID) are a group with high levels of healthcare needs; however, comprehensive information on these needs and service use is very limited. AIM: To describe chronic disease, comorbidity, disability, and general practice use among people with ID compared with the general population. DESIGN AND SETTING: This study is a cross-sectional analysis of a primary care database including 408 English general practices in 2012. METHOD: A total of 14 751 adults with ID, aged 18-84 years, were compared with 86 221 age-, sex- and practice-matched controls. Depending on the outcome, prevalence (PR), risk (RR), or odds (OR) ratios comparing patients with ID with matched controls are shown. RESULTS: Patients with ID had a markedly higher prevalence of recorded epilepsy (18.5%, PR 25.33, 95% confidence interval [CI] = 23.29 to 27.57), severe mental illness (8.6%, PR 9.10, 95% CI = 8.34 to 9.92), and dementia (1.1%, PR 7.52, 95% CI = 5.95 to 9.49), as well as moderately increased rates of hypothyroidism and heart failure (PR>2.0). However, recorded prevalence of ischaemic heart disease and cancer was approximately 30% lower than the general population. The average annual number of primary care consultations was 6.29 for patients with ID, compared with 3.89 for matched controls. Patients with ID were less likely to have longer doctor consultations (OR 0.73, 95% CI = 0.69 to 0.77), and had lower continuity of care with the same doctor (OR 0.77, 95% CI = 0.73 to 0.82). CONCLUSION: Compared with the general population, people with ID have generally higher overall levels of chronic disease and greater primary care use. Ensuring access to high-quality chronic disease management, especially for epilepsy and mental illness, will help address these greater healthcare needs. Continuity of care and longer appointment times are important potential improvements in primary care.

Increased risk of acute cardiovascular events after partner bereavement: a matched cohort study.

IMPORTANCE The period immediately after bereavement has been reported as a time of increased risk of cardiovascular events. However, this risk has not been well quantified, and few large population studies have examined partner bereavement. OBJECTIVE To compare the rate of cardiovascular events between older individuals whose partner dies with those of a matched control group of individuals whose partner was still alive on the same day. DESIGN, SETTING, AND PARTICIPANTS Matched cohort study using a UK primary care database containing availale data of 401 general practices from February 2005 through September 2012. In all, 30 447 individuals aged 60 to 89 years at study initiation who experienced partner bereavement during follow-up were matched by age, sex, and general practice with the nonbereaved control group (n = 83 588) at the time of bereavement. EXPOSURES Partner bereavement. MAIN OUTCOMES AND MEASURES The primary outcome was occurrence of a fatal or nonfatal myocardial infarction (MI) or stroke within 30 days of bereavement. Secondary outcomes were non-MI acute coronary syndrome and pulmonary embolism. All outcomes were compared between the groups during prespecified periods after bereavement (30, 90, and 365 days). Incidence rate ratios (IRRs) from a conditional Poisson model were adjusted for age, smoking status, deprivation, and history of cardiovascular disease. RESULTS Within 30 days of their partner's death, 50 of the bereaved group (0.16%) experienced an MI or a stroke compared with 67 of the matched nonbereaved controls (0.08%) during the same period (IRR, 2.20 [95% CI, 1.52-3.15]). The increased risk was seen in bereaved men and women and attenuated after 30 days. For individual outcomes, the increased risk was found separately for MI (IRR, 2.14 [95% CI, 1.20-3.81]) and stroke (2.40 [1.22-4.71]). Associations with rarer events were also seen after bereavement, including elevated risk of non-MI acute coronary syndrome (IRR, 2.20 [95% CI, 1.12-4.29]) and pulmonary embolism (2.37 [1.18-4.75]) in the first 90 days. CONCLUSIONS AND RELEVANCE This study provides further evidence that the death of a partner is associated with a range of major cardiovascular events in the immediate weeks and months after bereavement. Understanding psychosocial factors associated with acute cardiovascular events may provide opportunities for prevention and improved clinical care.

A new simple primary care morbidity score predicted mortality and better explains between practice variations than the Charlson index.

OBJECTIVES: Adjustment for morbidity is important to ensure fair comparison of outcomes between patient groups and health care providers. The Quality and Outcomes Framework (QOF) in UK primary care offers potential for developing a standardized morbidity score for low-risk populations. STUDY DESIGN AND SETTING: Retrospective cohort study of 653,780 patients aged 60 years or older registered with 375 practices in 2008 in a large primary care database (The Health Improvement Network). Half the practices were randomly selected to derive a morbidity score predicting 1-year mortality; the others assessed predictive performance. RESULTS: Nine chronic conditions were robust copredictors (hazard ratio = ≥1.2) of mortality independent of age and sex, producing high predictive discrimination (c-statistic = 0.82). An individual's QOF score explained more between practice variation in mortality than the Charlson index (46% vs. 32%). At practice level, mean QOF score was strongly correlated with practice standardized mortality ratios (r = 0.64), explaining more variation in practice death rates than the Charlson index. CONCLUSION: A simple nine-item score derived from routine primary care recording provides a morbidity index highly predictive of mortality and between practice variation in older UK primary care populations. This has utility in research and health care outcome monitoring and can be easily implemented in other primary and ambulatory care settings.

Initiation of psychotropic medication after partner bereavement: a matched cohort study.

BACKGROUND: Recent changes to diagnostic criteria for depression in DSM-5 remove the bereavement exclusion, allowing earlier diagnosis following bereavement. Evaluation of the potential effect of this change requires an understanding of existing psychotropic medication prescribing by non-specialists after bereavement. AIMS: To describe initiation of psychotropic medication in the first year after partner bereavement. METHODS: In a UK primary care database, we identified 21,122 individuals aged 60 and over with partner bereavement and no psychotropic drug use in the previous year. Prescribing (anxiolytic/hypnotic, antidepressant, antipsychotic) after bereavement was compared to age, sex and practice matched controls. RESULTS: The risks of receiving a new psychotropic prescription within two and twelve months of bereavement were 9.5% (95% CI 9.1 to 9.9%) and 17.9% (17.3 to 18.4%) respectively; an excess risk of initiation in the first year of 12.4% compared to non-bereaved controls. Anxiolytic/hypnotic and antidepressant initiation rates were highest in the first two months. In this period, the hazard ratio for initiation of anxiolytics/hypnotics was 16.7 (95% CI 14.7 to 18.9) and for antidepressants was 5.6 (4.7 to 6.7) compared to non-bereaved controls. 13.3% of those started on anxiolytics/hypnotics within two months continued to receive this drug class at one year. The marked variation in background family practice prescribing of anxiolytics/hypnotics was the strongest determinant of their initiation in the first two months after bereavement. CONCLUSION: Almost one in five older people received a new psychotropic drug prescription in the year after bereavement. The early increase and trend in antidepressant use after bereavement suggests some clinicians did not adhere to the bereavement exclusion, with implications for its recent removal in DSM-5. Family practice variation in use of anxiolytics/hypnotics suggests uncertainty over their role in bereavement with the potential for inappropriate long term use.

PACE-UP (Pedometer and consultation evaluation--UP)--a pedometer-based walking intervention with and without practice nurse support in primary care patients aged 45-75 years: study protocol for a randomised controlled trial.

BACKGROUND: Most adults do not achieve the 150 minutes weekly of at least moderate intensity activity recommended for health. Adults' most common physical activity (PA) is walking, light intensity if strolling, moderate if brisker. Pedometers can increase walking; however, most trials have been short-term, have combined pedometer and support effects, and have not reported PA intensity. This trial will investigate whether pedometers, with or without nurse support, can help less active 45-75 year olds to increase their PA over 12 months. DESIGN: Primary care-based 3-arm randomized controlled trial with 12-month follow-up and health economic and qualitative evaluations. PARTICIPANTS: Less active 45-75 year olds (n = 993) will be recruited by post from six South West London general practices, maximum of two per household and households randomised into three groups. Step-count and time spent at different PA intensities will be assessed for 7 days at baseline, 3 and 12 months by accelerometer. Questionnaires and anthropometric assessments will be completed. INTERVENTION: The pedometer-alone group will be posted a pedometer (Yamax Digi-Walker SW-200), handbook and diary detailing a 12-week pedometer-based walking programme, using targets from their baseline assessment. The pedometer-plus-support group will additionally receive three practice nurse PA consultations. The handbook, diary and consultations include behaviour change techniques (e.g., self-monitoring, goal-setting, relapse prevention planning). The control group will receive usual care. OUTCOMES: Changes in average daily step-count (primary outcome), time spent sedentary and in at least moderate intensity PA weekly at 12 months, measured by accelerometry. Other outcomes include change in body mass index, body fat, self-reported PA, quality of life, mood and adverse events. Cost-effectiveness will be assessed by the incremental cost of the intervention to the National Health Service and incremental cost per change in step-count and per quality adjusted life year. Qualitative evaluations will explore reasons for trial non-participation and the interventions' acceptability. DISCUSSION: The PACE-UP trial will determine the effectiveness and cost-effectiveness of a pedometer-based walking intervention delivered by post or practice nurse to less active primary care patients aged 45-75 years old. Approaches to minimise bias and challenges anticipated in delivery will be discussed. TRIAL REGISTRATION: ISRCTN98538934.

Antidepressant prescribing in older primary care patients in community and care home settings in England and Wales.

OBJECTIVE: To compare the prevalence and predictors of antidepressant prescribing in older care home and community residents in England and Wales. DESIGN: Retrospective analysis of primary care consultation and antidepressant prescribing data. SETTING: The setting included 326 general (family) practices in England and Wales supplying data to The Health Improvement Network database between 2008 and 2009. PARTICIPANTS: Participants were 10,387 care home and 403,259 community residents aged 65 to 104. MAIN OUTCOME MEASURE: Antidepressant prescription in the last 3 months of recorded data for each patient. RESULTS: Prevalence rates for antidepressant prescribing were 10.3% (95% confidence interval 10%-10.6%) for community and 37.5% (36.2%-38.9%) for care home residents. After excluding low-dose tricyclics (often used for other indications) prevalences were 7.3% (7.1%-7.5%) and 33.6% (32.3%-34.9%) respectively; of these, 21.7% (20.8%-22.6%) of community and 4.8% (3.9%-5.6%) of care home prescriptions were for antidepressants advised as best avoided in this age group. After indirect standardization for age, sex, and chronic disease prevalence, the ratio for prescribing was 2.4 (2.3-2.5) in care homes compared with the community; 28.3% (26.6%-30.1%) of community and 42.5% (39.4%-45.7%) of care home residents prescribed antidepressants had no appropriate recorded indication. CONCLUSIONS: This national sample confirms the high prevalence of antidepressant prescribing to older people, particularly in care homes, frequently without a documented indication. The strong association found between chronic disease and antidepressant prescribing did not explain the higher care home prescribing rate. Widespread community use of nonrecommended antidepressants is also a concern.

Quality of prescribing in care homes and the community in England and Wales.

BACKGROUND: Care home residents are vulnerable to the adverse effects of prescribing but there is limited monitoring in the UK. AIM: To compare prescribing quality in care homes in England and Wales with the community and with US nursing homes. DESIGN AND SETTING: Cross-sectional analysis of a UK primary care database and comparison with the US National Nursing Home Survey including 326 general practices in 2008-2009 in England and Wales, with 10 387 care home and 403 259 community residents aged 65 to 104 years. METHOD: Comparison of age- and sex-standardised use of 'concern' and common drug groups in the last 90 days and potentially inappropriate prescribing based on a consensus list of medications best avoided in older people (Beers criteria). RESULTS: Compared to the community, care home residents were more likely to receive 'concern' drugs, including benzodiazepines (relative risk (RR) = 2.05, 95% confidence interval (CI) = 1.90 to 2.22), anticholinergic antihistamines (RR = 2.78, 95% CI = 2.38 to 3.23), loop diuretics (RR = 1.47, 95% CI = 1.41 to 1.53), and antipsychotics (RR = 22.7, 95% CI = 20.6 to 24.9). Use of several common drug groups, including laxatives, antidepressants, and antibiotics, was higher, but use of cardiovascular medication was lower. Thirty-three per cent (95% CI = 31.7% to 34.3%) of care home residents in England and Wales received potentially inappropriate medication, compared to 21.4% (95% CI = 20.9% to 21.8%) in the community. The potentially inappropriate prescribing rate in US nursing homes was similar to England and Wales. CONCLUSION: Care home prescribing has the potential for improvement. High use of anticholinergic and psychotropic medication may contribute to functional and cognitive decline. The targeting and effectiveness of medication reviews in care homes needs to be improved.

Depression indicators in a national sample of older community and care home patients: applying the Quality and Outcomes Framework.

In a national primary care database sample of older people (≥65 years), 81% (83 588/103 821) of community and 58% (1702/2940) of care home residents with diabetes or heart disease had depression case finding recently recorded; 66% (1418/2145) of community and 22% (26/118) of care home residents with a new depression episode had a depression-severity assessment recorded. Age, sex, and higher care home dementia prevalence did not explain these differences. Case finding and assessment of depression need to be improved in older people, particularly care home residents.

Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study.

OBJECTIVE: To describe the quality of care for chronic diseases among older people in care homes (nursing and residential) compared with the community in a pay for performance system. DESIGN: Retrospective analysis of The Health Improvement Network (THIN), a large primary care database. SETTING: 326 English and Welsh general practices, 2008-9. PARTICIPANTS: 10,387 residents of care homes and 403,259 residents in the community aged 65 to 104 and registered for 90 or more days with their general practitioner. MAIN OUTCOME MEASURE: 16 process quality indicators for chronic disease management appropriate for vulnerable older people for conditions included in the UK Quality and Outcomes Framework. RESULTS: After adjustment for age, sex, dementia, and length of registration, attainment of quality indicators was significantly lower for residents of care homes than for those in the community for 14 of 16 indicators. The largest differences were for prescribing in heart disease (ß blockers in coronary heart disease, relative risk 0.70, 95% confidence interval 0.65 to 0.75) and monitoring of diabetes (retinal screening, 0.75, 0.71 to 0.80). Monitoring hypothyroidism (0.93, 0.90 to 0.95), blood pressure in people with stroke (0.92, 0.90 to 0.95), and electrolytes for those receiving loop diuretics (0.89, 0.87 to 0.92) showed smaller differences. Attainment was lower in nursing homes than in residential homes. Residents of care homes were more likely to be identified by their doctor as unsuitable or non-consenting for all Quality and Outcomes Framework indicators for a condition allowing their exclusion from targets; 33.7% for stroke and 34.5% for diabetes. CONCLUSION: There is scope for improving the management of chronic diseases in care homes, but high attainment of some indicators shows that pay for performance systems do not invariably disadvantage residents of care homes compared with those living in the community. High use of exception reporting may compromise care for vulnerable patient groups. The Quality and Outcomes Framework, and other pay for performance systems, should monitor attainment and exception reporting in vulnerable populations such as residents of care homes and consider measures that deal with the specific needs of older people.