An observational study to understand burden and cost of care in adults diagnosed with refractory chronic cough (RCC) or unexplained chronic cough (UCC).

BACKGROUND: Refractory and unexplained chronic cough (RCC and UCC) necessitate frequent referral for specialist evaluations, but data on healthcare resource utilisation and costs are lacking. METHODS: This observational study enrolled adults with RCC or UCC attending a specialist cough clinic and included a control cohort, both from North West England, matched 1:5 for age, gender and smoking history. Primary and secondary care data were obtained for the 5 years prior to and 2 years post initial clinic visit (index). The primary endpoint was the total 5-year healthcare cost to the UK NHS pre-RCC or UCC diagnosis compared to the control cohort. RESULTS: Mean age at index for the 200 RCC or UCC consented patients was 62.2 ± 11.4 years; 71% were female, and 68% had never smoked. Mean duration of symptoms pre-diagnosis was 8.0 ± 9.4 years. Mean cough severity score was 63.7 ± 23.2 mm at index on a Visual Analog Scale, and Leicester Cough Questionnaire total score was 10.9 ± 4.1. GP data were available for 80 patients and mean total cost over the 5 years pre-diagnosis (index date) was 3.0-fold higher (95% CI 2.3, 3.9) than in the control cohort (p < 0.001). Most excess costs were related to visits and procedures carried out in secondary care. RCC- or UCC-associated costs decreased post-diagnosis, but remained higher than those of controls. CONCLUSION: Diagnosis of RCC or UCC requires significant health resource utilisation in the 5 years prior to a specialist clinic diagnosis. Resource utilisation was less after diagnosis, but remained higher than in a matched control cohort.

Cardiovascular events and all-cause mortality associated with sulphonylureas compared with other antihyperglycaemic drugs: A Bayesian meta-analysis of survival data.

AIM: To conduct a systematic review and meta-analysis to determine the risk of cardiovascular events and all-cause mortality associated with sulphonylureas (SUs) vs other glucose lowering drugs in patients with T2DM (T2DM). MATERIALS AND METHODS: A systematic review of Medline, Embase, Cochrane and clinicaltrials.gov was conducted for studies comparing SUs with placebo or other antihyperglycaemic drugs in patients with T2DM. A cloglog model was used in the Bayesian framework to obtain comparative hazard ratios (HRs) for the different interventions. For the analysis of observational data, conventional fixed-effect pairwise meta-analyses were used. RESULTS: The systematic review identified 82 randomized controlled trials (RCTs) and 26 observational studies. Meta-analyses of RCT data showed an increased risk of all-cause mortality and cardiovascular-related mortality for SUs compared with all other treatments combined (HR 1.26, 95% confidence interval [CI] 1.10-1.44 and HR 1.46, 95% CI 1.21-1.77, respectively). The risk of myocardial infarction was significantly higher for SUs compared with dipeptidyl peptidase-4 (DPP-4) inhibitors and sodium-glucose co-transporter-2 inhibitors (HR 2.54, 95% CI 1.14-6.57 and HR 41.80, 95% CI 1.64-360.4, respectively). The risk of stroke was significantly higher for SUs than for DPP-4 inhibitors, glucagon-like peptide-1 agonists, thiazolidinediones and insulin. CONCLUSIONS: The present meta-analysis showed an association between SU therapy and a higher risk of major cardiovascular disease-related events compared with other glucose lowering drugs. Results of ongoing RCTs, which should be available in 2018, will provide definitive results on the risk of cardiovascular events and all-cause mortality associated with SUs vs other antihyperglycaemic drugs.

A real world study of cough burden and quality of life of UK patients who have undergone evaluation for chronic cough.

OBJECTIVE: Treatment options for adults with chronic cough (CC) are limited. This study reports on the health status and experiences of patients with recent healthcare evaluation for CC. METHODS: This prospective, UK, cross-sectional study surveyed adults with a CC evaluation within the previous 12 months. All were never smokers (or ex-smokers for ≥12 months). Subjects completed five validated patient-reported outcome measures: cough visual analogue scale (VAS), EuroQoL 5 dimension, 5 level (EQ-5D-5L), EQ-5D VAS, Leicester Cough Questionnaire (LCQ), and Work Productivity and Activity Impairment (WPAI) questionnaire. RESULTS: A total of 101 participants were recruited: 71% were female, mean age was 54.9 ± 15.2 years. Median (IQR) CC duration was 36 (11, 120) months. Mean self-reported CC severity (Cough-VAS) was 51.3 ± 22.9 over the previous 2 weeks and 62.9 ± 23.7 on the worst day of coughing. EQ-5D values were lower for CC patients than population norms. Subanalyses revealed that EQ-5D and LCQ scores were significantly impacted by CC duration and the number of healthcare providers (HCPs) visited. WPAI analysis showed a 27.6% work time impairment because of participants' CC. The number of HCP attendances ranged from 1 to 10 (3.3 ± 2.8) before diagnosis was confirmed. Treatment was being prescribed to 87% of participants and comprised mainly steroids (nasal [19%] and inhaled [25%]), beta agonists (24%), and proton pump inhibitors (21%); 44% of patients were dissatisfied with treatment efficacy. CONCLUSION: Real-world data from a nationally representative UK population show significant unmet needs associated with CC, including multiple healthcare visits and limited treatment effectiveness, resulting in inadequate cough control and impaired health status.

Burden and impact of chronic cough in UK primary care: a dataset analysis.

OBJECTIVE: Chronic cough (CC) is a debilitating respiratory symptom, now increasingly recognised as a discrete disease entity. This study evaluated the burden of CC in a primary care setting. DESIGN: Cross-sectional, retrospective cohort study. SETTING: Discover dataset from North West London, which links coded data from primary and secondary care. The index date depicted CC persisting for ≥8 weeks and was taken as a surrogate for date of CC diagnosis. PARTICIPANTS: Data were extracted for individuals aged ≥18 years with a cough persisting ≥8 weeks or cough remedy prescription, between Jan 2015 and Sep 2019. MAIN OUTCOME MEASURES: Demographic characteristics, comorbidities and service utilisation cost, including investigations performed and treatments prescribed were determined. RESULTS: CC was identified in 43 453 patients from a total cohort of 2 109 430 (2%). Median (IQR) age was 64 years (41-87). Among the cohort, 31% had no recorded comorbidities, 26% had been given a diagnosis of asthma, 17% chronic obstructive pulmonary disease, 12% rhinitis and 15% reflux. Prevalence of CC was greater in women (57%) and highest in the 65-74 year age range. There was an increase in the number of all investigations performed in the 12 months before and after the index date of CC diagnosis, and in particular for primary care chest X-ray and spirometry which increased from 6535 to 12 880 and from 5791 to 8720, respectively. This was accompanied by an increase in CC-associated healthcare utilisation costs. CONCLUSION: One-third of individuals had CC in the absence of associated comorbidities, highlighting the importance of recognising CC as a condition in its own right. Overall outpatient costs increased in the year after the CC index date for all comorbidities, but varied significantly with age. Linked primary-care datasets may enable earlier detection of individuals with CC for specialist clinic referral and targeted treatment.

The financial burden of treating patients presenting with acute and chronic cough.

OBJECTIVE: Coughing is a common symptom and responsible for a large number of healthcare visits. This study aimed to characterize healthcare resource use and associated financial costs in people with acute or chronic cough. METHODS: A retrospective cohort study using routine data from the UK National Health Service. Adults (≥18 years) were selected if they had a cough record between 1 March 2014 and 28 February 2015 and were classified by duration. RESULTS: A cohort of 150,231 patients was identified, of whom 12,513 (8.3%) had chronic cough, 38,599 (25.7%) had an acute cough with more than one cough event, and 99,119 (66.0%) had acute cough with one event in the study year. Resource use and combined costs of all healthcare contacts differed between cough groups. The healthcare cost per person-year in patients with a single record of acute cough was £739; for those with chronic cough, the cost was £3,663. CONCLUSIONS: Patients with cough represented a substantial financial burden to the NHS. It was difficult to discern the specific portion of treatment associated with cough itself. However, people with chronic cough were associated with substantially increased healthcare use and costs than were those with acute cough.

Cough presentation in primary care and the identification of chronic cough: a need for diagnostic clarity?

Objective: To investigate patterns of presentation of cough in primary care and develop an algorithm to identify probable and possible chronic cough (CC).Methods: This retrospective observational study used routine English primary care data and linked hospital data. Patients with ≥1 cough event in the study period (March 2014-February 2015) were selected. Index date was that of the earliest cough event in this period. Adults (aged ≥18 years) were classified as having probable CC if they had an explicit CC diagnosis; as having possible CC if they had ≥3 cough events recorded over 8-26 weeks; or, otherwise, as having acute cough. Underlying conditions associated with CC were identified.Results: 198,151 people were identified. 56.5% were female; median age was 47.0 years. The prevalence of cough in the study year was 17.6%. Of the 150,213 identified adults, 1600 (1.1%), 10,913 (7.3%) and 137,718 (91.7%) were classified as having probable CC, possible CC or acute cough, respectively. Compared with probable CC and acute cough, a higher percentage of possible CC cases had a record on or prior to index date indicative of chronic obstructive pulmonary disease (30.6% versus 10.1% and 9.7%), gastro-esophageal reflux disease (32.6% versus 24.9% and 21.1%) or asthma (45.9% versus 27.6% and 27.9%). Prevalences of probable and possible CC were 0.18% and 1.2%, respectively.Conclusions: The prevalence of CC was lower than reported in previous studies. People with possible CC had higher rates of underlying conditions associated with CC. These observations may suggest poor recognition and/or under-recording of CC in primary care.

Alzheimer's Disease - Why We Need Early Diagnosis.

Alzheimer's disease is the leading cause of dementia. However, neither Alzheimer's disease nor Alzheimer's dementia are an inevitable consequence of aging. This review provides an overview of the issues involved in a diagnosis of Alzheimer's disease before an individual meets the criteria for Alzheimer's dementia. It examines how Alzheimer's disease diagnosis rates can be improved, the implications of an early diagnosis for the individual, carer and society, and the importance of risk reduction to prevent or delay progression. Although no disease-modifying agents capable of reversing the initial pathological changes are currently available, it may be possible to prevent or delay the development of dementia in a proportion of the population by modifying exposure to common risk factors. In other individuals, diagnosing the disease or risk of disease early is still valuable so that the individual and their carers have time to make choices and plan for the future, and to allow access to treatments that can help manage symptoms. Primary healthcare professionals play a pivotal role in recognising individuals at risk, recommending lifestyle changes in mid-adult life that can prevent or slow down the disease, and in timely diagnosis. Early intervention is the optimal strategy, because the patient's level of function is preserved for longer.

Hypoglycemia, diabetes therapies and driving categories in type 2 diabetes.

OBJECTIVE: To assess the experiences of hypoglycemia in drivers with type 2 diabetes according to types of diabetes treatment; to determine experiences in different driving groups; and to ascertain whether UK-based Driving and Vehicle Licensing Agency (DVLA) guidance concerning hypoglycemia and driving is understood. Research, design, and methods: An online questionnaire was sent to UK drivers with type 2 diabetes between June and September 2014. Study limitations included selection bias inherent in online surveys, and lack of validation of the definition of hypoglycemic symptoms by an expert patient group. RESULTS: The survey was completed by 1569 (457 social, 590 commuters, and 522 business/work) drivers. Vocational drivers were more likely to be treated with an insulin secretagogue (sulfonylureas and glinides) (52%) than diet alone (18%), a non-insulin secretagogue (26%) or insulin (16%). Symptoms of hypoglycemia (both mild and severe) were reported by 62% of the total cohort in the past year. Risk was greatest in those with poor diabetes self-management behavior and those receiving an insulin secretagogue. Among the 1112 respondents commuting or driving for a living, 16.8% had poor, 49.6% average, and 33.6% good diabetes self-management. Poor self-management was more frequent among vocational drivers and those receiving insulin secretagogues. Following a hypoglycemic episode, only 24% of insulin-secretagogue-treated drivers and 39% of insulin-treated drivers would discontinue driving for the DVLA-recommended 45 minutes. Insulin-treated drivers were best informed about diabetes and driving. Healthcare providers were the preferred source of information on driving and diabetes for 78% of drivers. CONCLUSION: Hypoglycemia risk is highest among drivers with poor diabetes self-management, those commuting or driving for a living and those taking insulin secretagogues. There is an educational need for all drivers concerning driving and hypoglycemia.

Consequences of delaying treatment intensification in type 2 diabetes: evidence from a UK database.

OBJECTIVE: Type 2 diabetes mellitus (TD2M) treatment focuses on achieving glycemic control, with HbA1c targeted at 6.5-7.5%. Clinicians commonly delay treatment intensification despite patients failing glycemic targets. This study evaluated longitudinal clinical and cost outcomes in patients failing metformin monotherapy using electronic medical records. RESEARCH DESIGN AND METHODS: Adults with incident T2DM were identified in the UK Clinical Practice Research Datalink (CPRD) from 1 January 2000 to 31 March 2014. Patients were initiated on metformin monotherapy but had not reached target (HbA1c <7%). Patients were grouped by time to intensification of second-line therapy from first recorded HbA1c ≥7%: Group A, rapid intensification within 365 days; Group B, delayed intensification days 366-1824; Group C, never intensified. Patients were followed from day 366 for 5 years until end of study, switch to insulin, migration or death. MAIN OUTCOME MEASURES: The study evaluated baseline clinical and medication characteristics which were re-evaluated each year, including HbA1c, weight, cholesterol and concomitant prescribing. RESULTS: A total of 6710 patients were included (Group A 2647, Group B 2452, Group C 1611). Group A achieved a significant decline in HbA1c at 1 year post-index date compared to Groups B and C (-1.13% Group A; +0.26% Group B, +0.16% Group C). A significantly higher proportion of patients achieved HbA1c target < 7% in Group A (Group A [45.8%]; Group B [19.1%], p < 0.0001). Using an adjusted hazard model, Group A was found to achieve the HbA1c target from the index date significantly faster than Group B (hazard ratio 3.25 [95% CI 2.87-3.69]). The most commonly prescribed second-line medications were sulfonylureas in Groups A and B throughout observation and were associated with significant weight gain (+1.3 kg per patient) in the adjusted models. CONCLUSIONS: Patients who were rapidly intensified achieved a maintained reduction in HbA1c faster than those with delayed intensification or no second-line therapy, despite a higher baseline HbA1c.