Trajectories of Disease Accumulation Using Electronic Health Records.

Multimorbidity is a major problem for patients and health services. However, we still do not know much about the common trajectories of disease accumulation that patients follow. We apply a data-driven method to an electronic health record dataset (CPRD) to analyse and condense the main trajectories to multimorbidity into simple networks. This analysis has never been done specifically for multimorbidity trajectories and using primary care based electronic health records. We start the analysis by evaluating temporal correlations between diseases to determine which pairs of disease appear significantly in sequence. Then, we use patient trajectories together with the temporal correlations to build networks of disease accumulation. These networks are able to represent the main pathways that patients follow to acquire multiple chronic conditions. The first network that we find contains the common diseases that multimorbid patients suffer from and shows how diseases like diabetes, COPD, cancer and osteoporosis are crucial in the disease trajectories. The results we present can help better characterize multimorbid patients and highlight common combinations helping to focus treatment to prevent or delay multimorbidity progression.

Socio-economic inequalities in life expectancy of older adults with and without multimorbidity: a record linkage study of 1.1 million people in England.

BACKGROUND: Age of onset of multimorbidity and its prevalence are well documented. However, its contribution to inequalities in life expectancy has yet to be quantified. METHODS: A cohort of 1.1 million English people aged 45 and older were followed up from 2001 to 2010. Multimorbidity was defined as having 2 or more of 30 major chronic diseases. Multi-state models were used to estimate years spent healthy and with multimorbidity, stratified by sex, smoking status and quintiles of small-area deprivation. RESULTS: Unequal rates of multimorbidity onset and subsequent survival contributed to higher life expectancy at age 65 for the least (Q1) compared with most (Q5) deprived: there was a 2-year gap in healthy life expectancy for men [Q1: 7.7 years (95% confidence interval: 6.4-8.5) vs Q5: 5.4 (4.4-6.0)] and a 3-year gap for women [Q1: 8.6 (7.5-9.4) vs Q5: 5.9 (4.8-6.4)]; a 1-year gap in life expectancy with multimorbidity for men [Q1: 10.4 (9.9-11.2) vs Q5: 9.1 (8.7-9.6)] but none for women [Q1: 11.6 (11.1-12.4) vs Q5: 11.5 (11.1-12.2)]. Inequalities were attenuated but not fully attributable to socio-economic differences in smoking prevalence: multimorbidity onset was latest for never smokers and subsequent survival was longer for never and ex smokers. CONCLUSIONS: The association between social disadvantage and multimorbidity is complex. By quantifying socio-demographic and smoking-related contributions to multimorbidity onset and subsequent survival, we provide evidence for more equitable allocation of prevention and health-care resources to meet local needs.

Explaining trends in Scottish coronary heart disease mortality between 2000 and 2010 using IMPACTSEC model: retrospective analysis using routine data.

OBJECTIVE: To quantify the contributions of prevention and treatment to the trends in mortality due to coronary heart disease in Scotland. DESIGN: Retrospective analysis using IMPACTSEC, a previously validated policy model, to apportion the recent decline in coronary heart disease mortality to changes in major cardiovascular risk factors and to increases in more than 40 treatments in nine non-overlapping groups of patients. SETTING: Scotland. PARTICIPANTS: All adults aged 25 years or over, stratified by sex, age group, and fifths of Scottish Index of Multiple Deprivation. MAIN OUTCOME MEASURE: Deaths prevented or postponed. RESULTS: 5770 fewer deaths from coronary heart disease occurred in 2010 than would be expected if the 2000 mortality rates had persisted (8042 rather than 13,813). This reflected a 43% fall in coronary heart disease mortality rates (from 262 to 148 deaths per 100,000). Improved treatments accounted for approximately 43% (95% confidence interval 33% to 61%) of the fall in mortality, and this benefit was evenly distributed across deprivation fifths. Notable treatment contributions came from primary prevention for hypercholesterolaemia (13%), secondary prevention drugs (11%), and chronic angina treatments (7%). Risk factor improvements accounted for approximately 39% (28% to 49%) of the fall in mortality (44% in the most deprived fifth compared with only 36% in the most affluent fifth). Reductions in systolic blood pressure contributed more than one third (37%) of the decline in mortality, with no socioeconomic patterning. Smaller contributions came from falls in total cholesterol (9%), smoking (4%), and inactivity (2%). However, increases in obesity and diabetes offset some of these benefits, potentially increasing mortality by 4% and 8% respectively. Diabetes showed strong socioeconomic patterning (12% increase in the most deprived fifth compared with 5% for the most affluent fifth). CONCLUSIONS: Increases in medical treatments accounted for almost half of the large recent decline in mortality due to coronary heart disease in Scotland. Furthermore, the Scottish National Health Service seems to have delivered these benefits equitably. However, the substantial contributions from population falls in blood pressure and other risk factors were diminished by adverse trends in obesity and diabetes. Additional population-wide interventions are urgently needed to reduce coronary heart disease mortality and inequalities in future decades.

Quantifying policy options for reducing future coronary heart disease mortality in England: a modelling study.

AIMS: To estimate the number of coronary heart disease (CHD) deaths potentially preventable in England in 2020 comparing four risk factor change scenarios. METHODS AND RESULTS: Using 2007 as baseline, the IMPACTSEC model was extended to estimate the potential number of CHD deaths preventable in England in 2020 by age, gender and Index of Multiple Deprivation 2007 quintiles given four risk factor change scenarios: (a) assuming recent trends will continue; (b) assuming optimal but feasible levels already achieved elsewhere; (c) an intermediate point, halfway between current and optimal levels; and (d) assuming plateauing or worsening levels, the worst case scenario. These four scenarios were compared to the baseline scenario with both risk factors and CHD mortality rates remaining at 2007 levels. This would result in approximately 97,000 CHD deaths in 2020. Assuming recent trends will continue would avert approximately 22,640 deaths (95% uncertainty interval: 20,390-24,980). There would be some 39,720 (37,120-41,900) fewer deaths in 2020 with optimal risk factor levels and 22,330 fewer (19,850-24,300) in the intermediate scenario. In the worst case scenario, 16,170 additional deaths (13,880-18,420) would occur. If optimal risk factor levels were achieved, the gap in CHD rates between the most and least deprived areas would halve with falls in systolic blood pressure, physical inactivity and total cholesterol providing the largest contributions to mortality gains. CONCLUSIONS: CHD mortality reductions of up to 45%, accompanied by significant reductions in area deprivation mortality disparities, would be possible by implementing optimal preventive policies.

The UK National Health Service: delivering equitable treatment across the spectrum of coronary disease.

BACKGROUND: Social gradients in cardiovascular mortality across the United Kingdom may reflect differences in incidence, disease severity, or treatment. It is unknown whether a universal healthcare system delivers equitable lifesaving medical therapy for coronary heart disease. We therefore examined secular trends in the use of key medical therapies stratified by socioeconomic circumstances across a broad spectrum of coronary disease presentations, including acute coronary syndromes, secondary prevention, and clinical angina. METHODS AND RESULTS: This was a cross-sectional observational analysis of nationally representative primary and secondary care data from the United Kingdom. Data on treatments for all myocardial infarction patients in 2003 and 2007 were derived from the Myocardial Ischemia National Audit Project (n=51 755). Data on treatments for patients with chronic angina (n=33 211) or requiring secondary prevention (n=32 976) in 1999 and 2007 were extracted from the General Practice Research Database. Socioeconomic circumstances were defined using a weighted composite of 7 area-level deprivation domains. Treatment estimates were age-standardized. Use of all therapies increased in all patient groups, both men and women. Improvements were most marked in primary care, where use of ß-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for secondary prevention and treatment of angina doubled, from ≈30% to >60%. Small age gradients persisted for some therapies. No consistent socioeconomic gradients or sex differences were observed for myocardial infarction and postrevascularization (hard diagnoses). However, some sex inequality was apparent in the treatment of younger women with angina. CONCLUSIONS: Cardiovascular treatment is generally equitable and independent of socioeconomic circumstances. Future strategies should aim to further increase overall treatment levels and to eradicate remaining age and sex inequalities.

Unequal trends in coronary heart disease mortality by socioeconomic circumstances, England 1982-2006: an analytical study.

BACKGROUND: Coronary heart disease (CHD) remains a major public health burden, causing 80,000 deaths annually in England and Wales, with major inequalities. However, there are no recent analyses of age-specific socioeconomic trends in mortality. We analysed annual trends in inequalities in age-specific CHD mortality rates in small areas in England, grouped into deprivation quintiles. METHODS: We calculated CHD mortality rates for 10-year age groups (from 35 to ≥ 85 years) using three year moving averages between 1982 and 2006. We used Joinpoint regression to identify significant turning points in age- sex- and deprivation-specific time trends. We also analysed trends in absolute and relative inequalities in age-standardised rates between the least and most deprived areas. RESULTS: Between 1982 and 2006, CHD mortality fell by 62.2% in men and 59.7% in women. Falls were largest for the most deprived areas with the highest initial level of CHD mortality. However, a social gradient in the pace of fall was apparent, being steepest in the least deprived quintile. Thus, while absolute inequalities narrowed over the period, relative inequalities increased. From 2000, declines in mortality rates slowed or levelled off in the youngest groups, notably in women aged 45-54 in the least deprived groups. In contrast, from age 55 years and older, rates of fall in CHD mortality accelerated in the 2000s, likewise falling fastest in the least deprived quintile. CONCLUSIONS: Age-standardised CHD mortality rates have declined substantially in England, with the steepest falls in the most affluent quintiles. However, this concealed contrasting patterns in underlying age-specific rates. From 2000, mortality rates levelled off in the youngest groups but accelerated in middle aged and older groups. Mortality analyses by small areas could provide potentially valuable insights into possible drivers of inequalities, and thus inform future strategies to reduce CHD mortality across all social groups.

Recent UK trends in the unequal burden of coronary heart disease.

INTRODUCTION: The burden of coronary heart disease (CHD) in the UK is substantial. However, recent trends and associated socioeconomic inequalities are not well studied. We aim to identify and analyse these trends stratified by age, gender and socioeconomic quintiles. METHODS: We quantified the CHD burden and analysed trends from 1999 to 2007 in all adults aged over 25 years resident in England. Data sources included deaths (from ONS), health surveys, and hospital admissions (from Hospital Episode Statistics), all using ICD9 and ICD10 coding. Socioeconomic inequalities were calculated in both absolute and relative terms. RESULTS: In 2007, the CHD burden comprised approximately 205 000 hospital admissions (acute and elective), including approximately 110 000 admissions with acute coronary syndrome. There were approximately 1.5 million CHD patients with chronic disease living in the community. Approximately 67 500 of these were admitted during 2007 for revascularisation. There were approximately 173 000 CHD patients living with heart failure, of whom some 14% required hospital admission during 2007. Between 1999 and 2007, age-specific hospital admission rates generally decreased by 20%-35%. Community prevalence decreased by 10%-20%. Strong socioeconomic gradients were apparent in all patient groups, persisting or worsening between 1999 and 2007. CONCLUSIONS: The burden of CHD is immense, costly and unequal. Hospital admissions attract more attention than the far more numerous patients living with chronic disease in the community. Population-based rates for hospital admissions and CHD prevalence have been declining by 3%-4% per annum. However, marked socioeconomic gradients have persisted or worsened-there is no room for complacency.

Community care in England: reducing socioeconomic inequalities in heart failure.

BACKGROUND: Socioeconomic deprivation is associated with increased heart failure (HF) incidence, hospitalization rates, and mortality. However, whether the delivery of survival-enhancing medical therapy is equitable remains uncertain. We examined secular trends in the uptake of key medical therapies (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, ß-blockers, spironolactone) stratified by socioeconomic circumstances in patients with HF. Secondary analyses examined trends in HF incidence, prevalence, and survival. METHODS AND RESULTS: This study was a cross-sectional observational analysis of nationally representative primary care data from England. Treatments for patients with HF in 1999 and 2007 (n=13 330) were extracted from the General Practice Research Database. Socioeconomic circumstances were defined with the Index of Multiple Deprivation 2007, a weighted composite of 7 area-level deprivation domains. Treatment uptake estimates were age standardized. The incidence and prevalence of HF decreased year to year. Although clear socioeconomic gradients in both the incidence and prevalence of HF were apparent, the absolute difference between most and least deprived reduced over time. Uptake of therapies improved over time in both men and women. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker uptake increased from 46% to 64%, ß-blocker uptake from 12% to 41%, and spironolactone uptake from 3% to 20%. Modest age and sex inequalities were apparent. However, no consistent socioeconomic gradients were observed in either treatment or case fatality. CONCLUSIONS: Socioeconomic gradients in the incidence and prevalence of HF are reducing. Treatment is generally equitable and independent of socioeconomic circumstances. Most important, no significant inequality in outcomes was apparent. Future strategies should continue to address inequalities in the underlying causes of HF and to increase overall treatment levels further.

Analysing recent socioeconomic trends in coronary heart disease mortality in England, 2000-2007: a population modelling study.

BACKGROUND: Coronary heart disease (CHD) mortality in England fell by approximately 6% every year between 2000 and 2007. However, rates fell differentially between social groups with inequalities actually widening. We sought to describe the extent to which this reduction in CHD mortality was attributable to changes in either levels of risk factors or treatment uptake, both across and within socioeconomic groups. METHODS AND FINDINGS: A widely used and replicated epidemiological model was used to synthesise estimates stratified by age, gender, and area deprivation quintiles for the English population aged 25 and older between 2000 and 2007. Mortality rates fell, with approximately 38,000 fewer CHD deaths in 2007. The model explained about 86% (95% uncertainty interval: 65%-107%) of this mortality fall. Decreases in major cardiovascular risk factors contributed approximately 34% (21%-47%) to the overall decline in CHD mortality: ranging from about 44% (31%-61%) in the most deprived to 29% (16%-42%) in the most affluent quintile. The biggest contribution came from a substantial fall in systolic blood pressure in the population not on hypertension medication (29%; 18%-40%); more so in deprived (37%) than in affluent (25%) areas. Other risk factor contributions were relatively modest across all social groups: total cholesterol (6%), smoking (3%), and physical activity (2%). Furthermore, these benefits were partly negated by mortality increases attributable to rises in body mass index and diabetes (-9%; -17% to -3%), particularly in more deprived quintiles. Treatments accounted for approximately 52% (40%-70%) of the mortality decline, equitably distributed across all social groups. Lipid reduction (14%), chronic angina treatment (13%), and secondary prevention (11%) made the largest medical contributions. CONCLUSIONS: The model suggests that approximately half the recent CHD mortality fall in England was attributable to improved treatment uptake. This benefit occurred evenly across all social groups. However, opposing trends in major risk factors meant that their net contribution amounted to just over a third of the CHD deaths averted; these also varied substantially by socioeconomic group. Powerful and equitable evidence-based population-wide policy interventions exist; these should now be urgently implemented to effectively tackle persistent inequalities.

Persistent socioeconomic inequalities in cardiovascular risk factors in England over 1994-2008: a time-trend analysis of repeated cross-sectional data.

BACKGROUND: Our aims were to determine the pace of change in cardiovascular risk factors by age, gender and socioeconomic groups from 1994 to 2008, and quantify the magnitude, direction and change in absolute and relative inequalities. METHODS: Time trend analysis was used to measure change in absolute and relative inequalities in risk factors by gender and age (16-54, ≥ 55 years), using repeated cross-sectional data from the Health Survey for England 1994-2008. Seven risk factors were examined: smoking, obesity, diabetes, high blood pressure, raised cholesterol, consumption of five or more daily portions of fruit and vegetables, and physical activity. Socioeconomic group was measured using the Index of Multiple Deprivation 2007. RESULTS: Between 1994 and 2008, the prevalence of smoking, high blood pressure and raised cholesterol decreased in most deprivation quintiles. However, obesity and diabetes increased. Increasing absolute inequalities were found in obesity in older men and women (p = 0.044 and p = 0.027 respectively), diabetes in young men and older women (p = 0.036 and p = 0.019 respectively), and physical activity in older women (p = 0.025). Relative inequality increased in high blood pressure in young women (p = 0.005). The prevalence of raised cholesterol showed widening absolute and relative inverse gradients from 1998 onwards in older men (p = 0.004 and p ≤ 0.001 respectively) and women (p ≤ 0.001 and p ≤ 0.001). CONCLUSIONS: Favourable trends in smoking, blood pressure and cholesterol are consistent with falling coronary heart disease death rates. However, adverse trends in obesity and diabetes are likely to counteract some of these gains. Furthermore, little progress over the last 15 years has been made towards reducing inequalities. Implementation of known effective population based approaches in combination with interventions targeted at individuals/subgroups with poorer cardiovascular risk profiles are therefore recommended to reduce social inequalities.

Quantifying the contribution of leading causes of death to mortality decline among older people in England, 1991-2005.

BACKGROUND: This paper quantifies the contribution of leading causes of death to mortality change between 1991 and 2005 for people aged 50 years and over in England. Between 1971 and 2005 the life expectancy of men aged 50 years increased by more than in the whole of the rest of the 20(th) century. The ageing population has not only had an important impact on health and social services, but was responsible for sparking the pensions crisis affecting both the public and commercial sector. METHODS: A cross-sectional analysis was used to quantify trends in cause-specific mortality in terms of absolute and relative change between 1991 and 2005 in the population aged 50 and over. Absolute change is quantified in terms of the numbers of deaths prevented or postponed (or conversely, increased or brought-forward) in a year compared to deaths in the baseline year. The percentage change in age-standardised rates was used to identify relative change in causes of death. RESULTS: Between 1991 and 2005 there was a continuous decline in overall all-cause death rates for people aged 50 and over. Age-standardised mortality declined by 30 per cent for men, from 3,216 per 100,000 men to 2,267 per 100,000. This resulted in 86,477 fewer male deaths in 2005 than would have occurred had 1991 rates persisted. For women the age-standardised mortality rate declined by 20 per cent from 2,032 per 100,000 to 1,626 per 100,000, resulting in 48,406 deaths postponed (or fewer deaths) in 2005.Of the total numbers of deaths postponed in 2005, ischaemic heart disease contributed the largest share for both men (45,244 deaths - 52.3 per cent) and women (33,601 - 69.4 per cent).The greatest decline in the mortality rate was observed for influenza, for which age-standardised rates fell by 89 per cent for men and 93 per cent for women. However the proportion of deaths in which influenza was the underlying cause was extremely small and so did not contribute a large proportion in terms of the total fall in numbers of deaths.Mortality rates from some conditions increased. Liver disease rates demonstrated some of the largest increases for both men and women aged 50 and over. For men the age-standardised mortality rate from liver disease increased by 104 per cent, resulting in 1,434 more deaths in 2005 than in 1991. CONCLUSIONS: The trends of decreasing mortality rates from ischaemic heart disease and stroke have continued into the 21(st) century, however both causes continue to be the biggest killers in England. They are projected to remain so, and consequently, to contribute significantly to the burden of disease in the population.The steady increase in liver disease mortality identified highlights the importance of tackling alcohol misuse as a public health priority.

[Inequalities in health expectancies in England and Wales--small area analysis from the 2001 Ccensus.

This study investigates inequalities in the expectation of life without disability and life in good health using 2001 Census data at small area (ward) level for England and Wales. Inequalities were examined both nationally and within regions by computing life expectancies and health expectancies in groups of wards (twentieths) aggregated according to the Carstairs deprivation score. The results showed that the inequality gaps were significantly larger for health expectancies compared with life expectancy; they were wider for disability-free life expectancy than healthy life expectancy; and, for all measures, were wider for males. Within regions, the gradient in health inequalities with increasing deprivation varied. Those living in the least deprived wards had similar levels of health expectations across all regions. There was more geographical variation in the most deprived areas with lowest health expectations in the northern regions.

Socio-demographic characteristics of the healthcare workforce in England and Wales-- results from the 2001 Census.

Based on Census 2001 data, this article presents analysis of the socio-demographic characteristics of people working in the healthcare sector, focusing particularly on four key healthcare occupations: doctors, dentists, nurses and midwives. Unlike the NHS workforce statistics, which only include people directly employed by the NHS, census data also include those working in the private healthcare market and those who are self-employed. The article als examines patterns of distribution key healthcare professions per head of population by local authority and by area deprivation.

Estimating residents and staff in communal establishments from the 2001 Census.

Censuses of population in the UK provide the only comprehensive source of data on the population resident in communal establishments. Accurate information on the population resident in institutions and, in particular, counts of those living in medical and care establishments, is important for a range of social policy issues and for local service planning and resource allocation. This article identifies issues in distinguishing residents from staff when using the 2001 Census communal establishment data in England and Wales. Possible options to improve the reliability of institutional population estimates for analysis and reporting are evaluated against quality and credibility criteria and the impact of each adjustment option assessed. The article concludes with a recommendation on what users can do when using 2001 Census outputs at both the aggregate level (e.g. area-based figures) and the individual level (e.g. the sample of anonymised records).

Health expectancies in the UK and its constituent countries, 2001.

A previous article set out proposals for constructing a new series of health expectancies which aimed to widen the coverage to the UK and all four of its constituent countries and to improve the methods used in the calculations. This article investigates the impact of applying the new methods by comparing estimates of healthy life expectancy (HLE) and disability-free life expectancy (DFLE) based on the old and new methods for one year (2001). It then goes on to present and compare health expectancies based on the new methodology across England, Wales, Scotland and Northern Ireland and the entire UK in 2001.

Review of sources and methods to monitor healthy life expectancy.

This article presents the rationale for proposed changes in the methods used to calculate Healthy Life Expectancy (HLE). HLE is currently calculated for Great Britain and England based on data from the General Household Survey (GHS). The proposed revisions have been prompted by three sets of changes reflecting improvements to sources and methods. Changes in GHS methodology and survey coverage which affect estimates of the rates of ill-health in the noninstitutional population. Availability of data from the 2001 Census to update estimates of the ill-health rates and the size of the institutional population. Inclusion of data from the Continuous Household Survey of Northern Ireland (CHS-NI) to produce a HLE estimate for the UK.

Scientific evaluation of community-based Parkinson's disease nurse specialists on patient outcomes and health care costs.

OBJECTIVE: To determine the effects of community based nurses specialising in Parkinson's disease on health outcomes and healthcare costs. DESIGN: Two year randomised controlled trial in 438 general practices in nine randomly selected health authority areas of England. PARTICIPANTS: 1859 patients with Parkinson's disease identified by the participating general practices. MAIN OUTCOME MEASURES: Survival, stand-up test, dot in square test, bone fracture, global health question, PDQ-39, Euroqol, and healthcare costs. RESULTS: After two years 315 (17.3%) patients had died, although mortality did not differ between those who were attended by nurse specialists and those receiving standard care from their general practitioner (hazard ratio for nurse group v control group 0.91, 95% confidence interval 0.73 to 1.13). No significant differences were found between the two groups for the stand-up test (odds ratio 1.15, 0.93 to 1.42) and dot in square score (difference -0.7, -3.25 to 1.84). Scores on the global health question were significantly better in patients attended by nurse specialists than in controls (difference -0.23, -0.4 to -0.06), but no difference was observed in the results of the PDQ-39 or Euroqol questionnaires. Direct costs for patient health care increased by an average of pound2658 during the study, although not differentially between groups: the average increase was pound266 lower among patients attended by a nurse specialist (- pound981 to pound449). CONCLUSIONS: Nurse specialists in Parkinson's disease had little effect on the clinical condition of patients, but they did improve their patients' sense of wellbeing, with no increase in patients' healthcare costs.

Healthy life expectancy by area deprivation: magnitude and trends in England, 1994-1999.

This article examines the magnitude of inequalities in health by area deprivation using two composite indices of health expectancy, one based on a subjective assessment of general health status (healthy life expectancy) and the second on reported limiting longstanding illness (disability-free life expectancy). Trends in healthy life expectancy by deprivation for the period 1994-1999 were also examined. Results show that males and females living in the most deprived wards spend twice as many years in poor health, both in absolute (years of life) and relative (proportion of life) terms, than those living in the least deprived wards. There was no change in the healthy life expectancy gap between the most and least deprived areas over the study period.

Effects of community based nurses specialising in Parkinson's disease on health outcome and costs: randomised controlled trial.

OBJECTIVE: To determine the effects of community based nurses specialising in Parkinson's disease on health outcomes and healthcare costs. DESIGN: Two year randomised controlled trial. SETTING: 438 general practices in nine randomly selected health authority areas of England. PARTICIPANTS: 1859 patients with Parkinson's disease identified by the participating general practices. MAIN OUTCOME MEASURES: Survival, stand-up test, dot in square test, bone fracture, global health question, PDQ-39, Euroqol, and healthcare costs. RESULTS: After two years 315 (17.3%) patients had died, although mortality did not differ between those who were attended by nurse specialists and those receiving standard care from their general practitioner (hazard ratio for nurse group v control group 0.91, 95% confidence interval 0.73 to 1.13). No significant differences were found between the two groups for the stand-up test (odds ratio 1.15, 0.93 to 1.42) and dot in square score (difference -0.7, -3.25 to 1.84). Scores on the global health question were significantly better in patients attended by nurse specialists than in controls (difference -0.23, -0.4 to -0.06), but no difference was observed in the results of the PDQ-39 or Euroqol questionnaires. Direct costs for patient health care increased by an average of 2658 pounds sterling during the study, although not differentially between groups: the average increase was 266 pounds sterling lower among patients attended by a nurse specialist (-981 pounds sterling to 449 pounds sterling ). CONCLUSIONS: Nurse specialists in Parkinson's disease had little effect on the clinical condition of patients, but they did improve their patients' sense of wellbeing, with no increase in patients' healthcare costs.