Life, death, and statins: association of statin prescriptions and survival in older general practice patients.

AIMS: This study serves as an exemplar to demonstrate the scalability of a research approach using survival analysis applied to general practice electronic health record data from multiple sites. Collection of these data, the subsequent analysis, and the preparation of practice-specific reports were performed using a bespoke distributed data collection and analysis software tool. BACKGROUND: Statins are a very commonly prescribed medication, yet there is a paucity of evidence for their benefits in older patients. We examine the relationship between statin prescriptions for general practice patients over 75 and all-cause mortality. METHODS: We carried out a retrospective cohort study using survival analysis applied to data extracted from the electronic health records of five Australian general practices. FINDINGS: The data from 8025 patients were analysed. The median duration of follow-up was 6.48 years. Overall, 52 015 patient-years of data were examined, and the outcome of death from any cause was measured in 1657 patients (21%), with the remainder being censored. Adjusted all-cause mortality was similar for participants not prescribed statins versus those who were (HR 1.05, 95% CI 0.92-1.20, P = 0.46), except for patients with diabetes for whom all-cause mortality was increased (HR = 1.29, 95% CI: 1.00-1.68, P = 0.05). In contrast, adjusted all-cause mortality was significantly lower for patients deprescribed statins compared to those who were prescribed statins (HR 0.81, 95% CI 0.70-0.93, P < 0.001), including among females (HR = 0.75, 95% CI: 0.61-0.91, P < 0.001) and participants treated for secondary prevention (HR = 0.72, 95% CI: 0.60-0.86, P < 0.001). This study demonstrated the scalability of a research approach using survival analysis applied to general practice electronic health record data from multiple sites. We found no evidence of increased mortality due to statin-deprescribing decisions in primary care.

Australian general practitioners' attitudes to the extraction of research data from electronic health records.

BACKGROUND AND OBJECTIVES: General practice electronic health records (EHRs) are a rich source of primary care data that can be used for important research. The aim of this qualitative study was to analyse the attitudes of Australian general practitioners (GPs) to the use of data extracted from primary care EHRs for clinical research. METHOD: Semi-structured interviews were conducted with 13 Australian GPs. Interviews were recorded, transcribed and thematically analysed. RESULTS: Two main themes emerged. The data custodian role encompassed GPs' determination to maintain privacy, their trust of organisations involved and benefits of research outcomes. The theme of protecting practice resources included concerns about unrecompensed staff time and potential risks to data and systems. DISCUSSION: This study highlights that while Australian GPs have concerns about the use of data stored on their EHRs, they also recognise the benefits of using this data for research purposes. Addressing these concerns could help to ensure that researchers have access to this valuable and rich data resource.

The Use of Primary Care Electronic Health Records for Research: Lipid Medications and Mortality in Elderly Patients.

General practice electronic health record (EHR) data have significant potential for clinical research. This study demonstrates the feasibility of utilising longitudinal EHR data analysis to address clinically relevant outcomes and uses the relationship between lipid medication prescription and all-cause mortality in the elderly as an exemplar for the validity of this methodology. EHR data were analysed to describe the association of lipid medication use, non-use or cessation with all-cause mortality in patients aged ≥75 years. Survival analysis with Cox regression was used to calculate hazard ratios, which were adjusted for confounders. There was no significant difference in all-cause mortality among patients according to their use, non-use, or cessation of lipid medications. The outcomes of this study correlate well with the results of other research works. This single-practice study demonstrates the feasibility and potential of analysing EHR data to address important clinical issues such as the relationship between all-cause mortality and lipid medication prescription in the elderly.

Validation of electronic medical data: Identifying diabetes prevalence in general practice.

BACKGROUND:: Electronic medical records are increasingly used for research with limited external validation of their data. OBJECTIVE:: This study investigates the validity of electronic medical data (EMD) for estimating diabetes prevalence in general practitioner (GP) patients by comparing EMD with national Bettering the Evaluation and Care of Health (BEACH) data. METHOD:: A "decision tree" was created using inclusion/exclusion of pre-agreed variables to determine the probability of diabetes in absence of diagnostic label, including diagnoses (coded/free-text diabetes, polycystic ovarian syndrome, impaired glucose tolerance, impaired fasting glucose), diabetic annual cycle of care (DACC), glycated haemoglobin (HbA1c) > 6.5%, and prescription (metformin, other diabetes medications). Via SQL query, cases were identified in EMD of five Illawarra and Southern Practice Network practices (30,007 active patients; from 2 years to January 2015). Patient-based Supplementary Analysis of Nominated Data (SAND) sub-studies from BEACH investigating diabetes prevalence (1172 GPs; 35,162 patients; November 2012 to February 2015) were comparison data. SAND results were adjusted for number of GP encounters per year, per patient, and then age-sex standardised to match age-sex distribution of EMD patients. Cluster-adjusted 95% confidence intervals (CIs) were calculated for both datasets. RESULTS:: EMD diabetes prevalence (T1 and/or T2) was 6.5% (95% CI: 4.1-8.9). Following age-sex standardisation, SAND prevalence, not significantly different, was 6.7% (95% CI: 6.3-7.1). Extracting only coded diagnosis missed 13.0% of probable cases, subsequently identified through the presence of metformin/other diabetes medications (*without other indicator variables) (6.1%), free-text diabetes label (3.8%), HbA1c result* (1.6%), DACC* (1.3%), and diabetes medications* (0.2%). DISCUSSION:: While complex, proxy variables can improve usefulness of EMD for research. Without their consideration, EMD results should be interpreted with caution. CONCLUSION:: Enforceable, transparent data linkages in EMRs would resolve many problems with identification of diagnoses. Ongoing data quality improvement remains essential.

Survival analysis using primary care electronic health record data: A systematic review of the literature.

PURPOSE: An emerging body of research involves observational studies in which survival analysis is applied to data obtained from primary care electronic health records (EHRs). This systematic review of these studies examined the utility of using this approach. METHOD: An electronic literature search of the Scopus, PubMed, Web of Science, CINAHL, and Cochrane databases was conducted. Search terms and exclusion criteria were chosen to select studies where survival analysis was applied to the data extracted wholly from EHRs used in primary care medical practice. RESULTS: A total of 46 studies that met the inclusion criteria for the systematic review were examined. All were published within the past decade (2005-2014) with a majority ( n = 26, 57%) being published between 2012 and 2014. Even though citation rates varied from nil to 628, over half ( n = 27, 59%) of the studies were cited 10 times or more. The median number of subjects was 18,042 with five studies including over 1,000,000 patients. Of the included studies, 35 (76%) were published in specialty journals and 11 (24%) in general medical journals. The many conditions studied largely corresponded well with conditions important to general practice. CONCLUSION: Survival analysis applied to primary care electronic medical data is a research approach that has been frequently used in recent times. The utility of this approach was demonstrated by the ability to produce research with large numbers of subjects, across a wide range of conditions and with the potential of a high impact. Importantly, primary care data were thus available to inform primary care practice.

A valuable approach to the use of electronic medical data in primary care research: Panning for gold.

BACKGROUND: Electronic medical data (EMD) from electronic health records of general practice computer systems have enormous research potential, yet many variables are unreliable. OBJECTIVE: The aim of this study was to compare selected data variables from general practice EMD with a reliable, representative national dataset (Bettering the Evaluation and Care of Health (BEACH)) in order to validate their use for primary care research. METHOD: EMD variables were compared with encounter data from the nationally representative BEACH program using χ2 tests and robust 95% confidence intervals to test their validity (measure what they reportedly measure). The variables focused on for this study were patient age, sex, smoking status and medications prescribed at the visit. RESULTS: The EMD sample from six general practices in the Illawarra region of New South Wales, Australia, yielded data on 196,515 patient encounters. Details of 90,553 encounters were recorded in the 2013 BEACH dataset from 924 general practitioners. No significant differences in patient age ( p = 0.36) or sex ( p = 0.39) were found. EMD had a lower rate of current smokers and higher average scripts per visit, but similar prescribing distribution patterns. CONCLUSION: Validating EMD variables offers avenues for improving primary care delivery and measuring outcomes of care to inform clinical practice and health policy.

Patients' perspectives about why they have their contraceptive Implanon NXT device removed early.

BACKGROUND: Women with long-acting, reversible contraceptive devices inserted may choose to remove them prior to their planned expiry dates. OBJECTIVE: The objective of this study was to explore Australian women's experiences with the etonogestrel subdermal contraceptive implant (Implanon NXT) and why they had it removed early. METHODS: Semi-structured interviews were conducted with 18 women between June 2013 and January 2014. Transcriptions of the audio-taped interviews were analysed using a constant comparative analysis framework. RESULTS: Two core themes of participants' responses that were identified in this study were influences on choice of contraception, which included convenience and information sources; and influences on removal of contraception, which included side effects and their negative impacts on relationships and financial costs. DISCUSSION: This study highlights that women's experiences with side effects contribute to the early removal of long-acting contraceptive devices such as Implanon NXT. This study emphasises the importance of general practitioners (GPs) in providing comprehensive information about the benefits and potential side effects associated with using these implants.

Feasibility of implementing routine nutritional screening for older adults in Australian general practices: a mixed-methods study.

BACKGROUND: Nutrition screening in older adults is not routinely performed in Australian primary care settings. Low awareness of the extent of malnutrition in this patient group, lack of training and time constraints are major barriers that practice staff face. This study aimed to demonstrate the feasibility of including a validated nutrition screening tool and accompanying nutrition resource kit for use with older patients attending general practice. Secondary aims were to assess nutrition-related knowledge of staff and to identify the extent of malnutrition in this patient group. METHODS: Nine general practitioners, two general practice registrars and 11 practice nurses from three participating general practices in a rural, regional and metropolitan area within a local health district of New South Wales, Australia were recruited by convenience sampling. RESULTS: Four key themes were determined regarding the feasibility of performing MNA -SF: ease of use; incorporation into existing practice; benefit to patients' health; and patients' perception of MNA-SF. Two key themes related to the nutrition resource kit: applicability and improvement. These findings were supported by open ended questionnaire responses. Knowledge scores of staff significantly improved from baseline (52% to 66%; P < 0.05). Of the 143 patients that had been screened, 4.2% (n = 6) were classified as malnourished, 26.6% (n = 38) 'at risk' of malnutrition and 69.2% (n = 99) as well-nourished. CONCLUSION: It is feasible to include the MNA-SF and a nutrition resource kit within routine general practice, but further refinement of patients' electronic clinical records in general practice software would streamline this process.

'We are all time poor' -- is routine nutrition screening of older patients feasible?

BACKGROUND: Despite clinical guidelines that recommend routine nutrition screening of older patients, this does not generally occur in the Australian general practice setting. This study aimed to identify perceived barriers and opportunities to implementing nutrition screening of older people in general practice. METHODS: Twenty-five in-depth individual interviews were conducted with general practitioners, general practice registrars and practice nurses. Interviews were audio-recorded, transcribed verbatim and analysed thematically. Observations were performed to identify opportunities to conduct nutrition screening within general practice workflow. RESULTS: The primary identified barrier to screening related to time constraints, which was further validated by the observational component of the study. The main opportunity for screening was seen to be within the existing Australian Government Medicare Benefits Schedule Primary Care Item, 'Health assessment for people aged 75 years and older'. DISCUSSION: Incorporation of a validated and short nutrition screening instrument into the existing Health assessment was identified as the most feasible way to encourage the uptake of nutrition screening in general practice.