Assessment of ethnic inequalities in diagnostic coding of familial hypercholesterolaemia (FH): A cross-sectional database study in Lambeth, South London.

BACKGROUND AND AIMS: Differences in the perceived prevalence of familial hypercholesterolemia (FH) by ethnicity are unclear. In this study, we aimed to assess the prevalence, determinants and management of diagnostically-coded FH in an ethnically diverse population in South London. METHODS: A cross-sectional analysis of 40 practices in 332,357 adult patients in Lambeth was undertaken. Factors affecting a (clinically coded) diagnosis of FH were investigated by multi-level logistic regression adjusted for socio-demographic and lifestyle factors, co-morbidities, and medications. RESULTS: The age-adjusted FH % prevalence rate (OR, 95%CI) ranged from 0.10 to 1.11, 0.00-1.31. Lower rates of FH coding were associated with age (0.96, 0.96-0.97) and male gender (0.75, 0.65-0.87), p < 0.001. Compared to a White British reference group, a higher likelihood of coded FH was noted in Other Asians (1.33, 1.01-1.76), p = 0.05, with lower rates in Black Africans (0.50, 0.37-0.68), p < 0.001, Indians (0.55, 0.34-0.89) p = 0.02, and in Black Caribbeans (0.60, 0.44-0.81), p = 0.001. The overall prevalence using Simon Broome criteria was 0.1%; we were unable to provide ethnic specific estimates due to low numbers. Lower likelihoods of FH coding (OR, 95%CI) were seen in non-native English speakers (0.66, 0.53-0.81), most deprived income quintile (0.68, 0.52-0.88), smokers (0.68,0.55-0.85), hypertension (0.62, 0.52-0.74), chronic kidney disease (0.64, 0.41-0.99), obesity (0.80, 0.67-0.95), diabetes (0.31, 0.25-0.39) and CVD (0.47, 0.36-0.63). 20% of FH coded patients were not prescribed lipid-lowering medications, p < 0.001. CONCLUSIONS: Inequalities in diagnostic coding of FH patients exist. Lower likelihoods of diagnosed FH were seen in Black African, Black Caribbean and Indian ethnic groups, in contrast to higher diagnoses in White and Other Asian ethnic groups. Hypercholesterolaemia requiring statin therapy was associated with FH diagnosis, however, the presence of cardiovascular disease (CVD) risk factors lowered the diagnosis rate for FH.

Corrigendum: A scoping review of the evidence available for the use of salons as health promotion environments, for the prevention and management of non-communicable diseases in women from different ethnic backgrounds.

[This corrects the article DOI: 10.3389/fpubh.2023.1161645.].

Determinants of lipid clinic referral and attendance in a multi-ethnic adult population in south London: a cross-sectional study.

BACKGROUND: Primary dyslipidaemias, including familial hypercholesterolaemia, are underdiagnosed genetic disorders that substantially increase risk for premature coronary artery disease in adults. Early identification of primary dyslipidaemias via lipid clinic referral optimises patient management and enables cascade screening of relatives. Improving the identification of primary dyslipidaemias, and understanding disparities in ascertainment and management, is an NHS priority. We aimed to assess determinants of lipid clinic referral or attendance (LCR) in ethnically diverse adults. METHODS: We did a retrospective cross-sectional study using the Lambeth DataNet containing anonymised data from 41 general practitioner (GP) practices in south London. We looked at referral data for adult patients aged 18 years and older from Jan 1, 1995, until May 14, 2018. LCR was the main outcome. We used sequential multilevel logistic regression models adjusted for practice effects to estimate the odds of LCR assessed across six ethnic groups (reference group White) and patient-level factors (demographic, socioeconomic, lifestyle, comorbidities, total cholesterol [TC] >7·5mmol/L, statin prescription, and practice factors). The study was approved by NHS South East London Clinical Commissioning Group (CCG) and NHS Lambeth CCG. FINDINGS: 780 (0·23%) of 332 357 adult patients were coded as referred (n=538) or seen (n=252) in a lipid clinic. 164 487 (46·49%) were women (appendix). The fully adjusted model for odds of LCR showed the following significant associations for age (odds ratio [OR] 0·96, 95% CI 0·96-0·97, p<0·001); Black, African, Caribbean, or Black-British ethnicity (0·67, 0·53-0·84, p=0·001); ex-smoker status (1·29, 1·05-1·57, p=0·014); TC higher than 7·5 mmol/L (12·18, 9·60-15·45, p<0·001); statin prescription (14·01, 10·85-18·10, p<0·001); diabetes (0·72, 0·58-0·91, p=0·005); high-frequency GP attendance at seven or more GP consultations in the past year (1·49, 1·21-1·84, p<0·001); high GP-density (0·5-0·99 full-time equivalent GPs per 1000 patients; 2·70, 1·23-5·92, p=0·013). Sensitivity analyses for LCR restricted to familial hypercholesterolaemia-coded patients (n=581) found associations with TC higher than 7·5 mmol/L (4·26, 1·89-9·62, p<0·001), statin prescription (16·96, 2·19-131·36, p=0·007), and high GP-density (5·73, 1·27-25·93, p=0·023), with no significant associations with ethnicity. The relative contribution of GP practices to LCR was 6·32% of the total variance. There were no significant interactions between ethnicity and deprivation, age, or obesity. INTERPRETATION: While interpretation is limited by the accuracy and completeness of coded records, the study showed factors associated with a higher likelihood of LCR included individuals recorded as having TC higher than 7·5 mmol/L, statin prescription, ex-smoker status, high-frequency GP attendance, and registration at a GP practice with 0·5-0·99 GP density. Patients with increasing age; Black, African, Caribbean, or Black-British ethnicity patients; and patients with diabetes had lower odds of LCR. Finally, the difference in odds of LCR between Black and White patients highlights potential health inequalities. FUNDING: NHS Race & Health Observatory.

Factors affecting the delivery of community-based salon interventions to prevent cardiovascular disease and breast cancer among ethnically diverse women in South London: a concept-mapping approach.

BACKGROUND: In the UK, women from ethnically diverse and socioeconomically deprived communities are at increased risk of underdiagnosis of cardiovascular disease (CVD) and breast cancer. Promoting CVD prevention and awareness of breast cancer screening via community salons and primary health care partnerships can improve uptake of screening services and early detection. METHODS: Concept mapping is a multistage mixed methods participatory approach comprised of six stages: preparation, brainstorming, structuring of statements, representing statements, interpretation and utilisation of maps using Group wisdom software. A target of 20 salons, excluding male-only salons were approached. Salons included Salons included hairdressing or hairdressing and beauty salons. Purposeful and convenience sampling (online and face to face) among UK salons (hair and beauty) was conducted. Participants were given a focus prompt "What would be some factors that can influence the ability of salons to deliver this service?" and required to generate statements, which were sorted into categories based on similarity and rated for importance and feasibility. Concept maps using multidimensional scaling and hierarchical cluster analyses were produced. FINDINGS: Of 35 participants invited, 25 (71%) consented and agreed to take part in concept mapping. Reported ages were 26-35 years (n=5, 20%), 36-45 years (n=12, 48%), 46-55 years (n=3, 12%), 56-65 years (n=5, 20%), and no age reported (n=10, 40%). Around 36% (n=9) of participants were from non-White ethnic groups, with 12% (n=3) being male and 88% (n=22) female. Seven clusters emerged. Salon staff capabilities and capacities and engaging in health conversations in community salons scored average bridging values of 0·09 and 0·2 respectively, indicating good cluster homogeneity (similar meaning statements were closely sorted). Facilitating health-care access with GP practices was rated highly important to effectively promote the intervention. Engaging in health conversations in community salons and salon incentives for participation were examples of factors that were highly feasible to address. The r correlation coefficient was 0·68 between importance and feasibility to address factors affecting community health interventions. INTERPRETATION: Salons are well positioned to support health promotion interventions. Actionable priorities were identified for a salon-GP surgery partnership to promote CVD prevention through lifestyle changes and health check uptake, raising breast cancer screening awareness and address issue of equity. FUNDING: National Institute of Health and Care Research (NIHR), Research for Patient Benefit (RfPB) Programme NIHR202769.

A scoping review of the evidence available for the use of salons as health promotion environments, for the prevention and management of non-communicable diseases in women from different ethnic backgrounds.

Introduction: Women from different ethnic backgrounds are disproportionately affected by non-communicable diseases (NCDs). Underpinned by the community capital they harness, hairdressers have successfully delivered NCD prevention programmes, particularly for African-American women in disadvantaged areas. Integrating community organisations and networks into existing primary care pathways can provide a sustainable process to address inequalities in access to health care. This scoping review aimed to map the evidence about interventions based in beauty salons, particularly formative research phases, including co-development, community participation, theoretical or conceptual underpinnings, as well as aspects related to training and incentivisation of salon staff, evaluation and equity. Methods: The methodological framework was based on the seminal guidance of Arksey and O'Malley, using the 'PCC' (participants, concept, context) structure with incorporation of other relevant materials. Studies eligible for inclusion were salon-based health interventions (concept) focused on NCDs prevention (context), targeting women (participants) from different ethnic backgrounds and published in English. The searches were conducted across PubMed, Web of Science and OVID in June 2020 and updated in January 2023, with reference lists also screened. The Reach, Effectiveness, Adoption, Implementation, and Maintenance RE-AIM framework was used to explore the potential public health impact. Results: 419 titles and abstracts were screened, with eight (2%) meeting the inclusion criteria, all based in the United States of America. Two used formative phases to inform intervention development, three described evidence of co-development with key stakeholders or experts within the community and five studies referred to theoretical or conceptual frameworks. Incentivisation was provided to salon staff in five of the studies, and to clients in three of the studies. Four of the investigations collated data on socioeconomic characteristics of the target population. Discussion: Formative research in the scoped studies was weakly reported upon. Community participation was implicit in each of the scoped studies, yet its application varied considerably. Theoretical and conceptual frameworks were not consistently used, and there was inadequate process evaluation to ensure equitable reach and retention of targeted groups, suggesting a more concerted effort to address health equity is needed for future interventions.

Stratified genome-wide association analysis of type 2 diabetes reveals subgroups with genetic and environmental heterogeneity.

Type 2 diabetes (T2D) is a heterogeneous illness caused by genetic and environmental factors. Previous genome-wide association studies (GWAS) have identified many genetic variants associated with T2D and found evidence of differing genetic profiles by age-at-onset. This study seeks to explore further the genetic and environmental drivers of T2D by analyzing subgroups on the basis of age-at-onset of diabetes and body mass index (BMI). In the UK Biobank, 36 494 T2D cases were stratified into three subgroups, and GWAS was performed for all T2D cases and for each subgroup relative to 421 021 controls. Altogether, 18 single nucleotide polymorphisms were significantly associated with T2D genome-wide in one or more subgroups and also showed evidence of heterogeneity between the subgroups (Cochrane's Q P < 0.01), with two SNPs remaining significant after multiple testing (in CDKN2B and CYTIP). Combined risk scores, on the basis of genetic profile, BMI and age, resulted in excellent diabetes prediction [area under the ROC curve (AUC) = 0.92]. A modest improvement in prediction (AUC = 0.93) was seen when the contribution of genetic and environmental factors was evaluated separately for each subgroup. Increasing sample sizes of genetic studies enables us to stratify disease cases into subgroups, which have sufficient power to highlight areas of genetic heterogeneity. Despite some evidence that optimizing combined risk scores by subgroup improves prediction, larger sample sizes are likely needed for prediction when using a stratification approach.

Exploring the Use of Monoclonal Antibodies and Antiviral Therapies for Early Treatment of COVID-19 Outpatients in a Real-World Setting: A Nationwide Study from England and Italy.

BACKGROUND: Real-world data on early treatment of coronavirus disease 2019 (COVID-19) outpatients with newly approved therapies are sparse. AIM: To explore the pattern of use of monoclonal antibodies (mAbs)/antiviral therapies approved for early COVID-19 treatment in non-hospitalized patients from England and Italy from December 2021 to October 2022. METHODS: Public national dashboards on weekly mAb/antiviral use and/or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection diagnoses from the Italian Medicines Agency, the Italian National Institute of Health, National Health Service in England and the UK Government were explored. Prevalence of antiviral use in outpatients during the entire study period and every two weeks was calculated, as a whole and by class and compounds. An interrupted time-series (ITS) analysis was carried out to assess the impact of predominant SARS-CoV-2 variants over time on the prevalence of use of mAbs/antivirals in England and Italy. RESULTS: Overall, 77,469 and 195,604 doses of mAbs/antivirals were respectively administered to a total of 10,630,903 (7.3 per 1000) and 18,168,365 (10.8 per 1000) patients diagnosed with SARS-CoV-2 infection in England and Italy. Prevalence of use every two weeks increased from 0.07% to 3.1% in England and 0.9% to 2.3% in Italy during the study period. Regarding individual compounds, sotrovimab (prevalence of use, 1.6%) and nirmatrelvir/ritonavir (1.6%) in England, and nirmatrelvir/ritonavir (1.7%) and molnupiravir (0.5%) in Italy, reported the highest prevalence during a 2-week period. In the ITS analysis, the transition from Delta to Omicron variant predominance was associated with a significant increase in the use of sotrovimab, molnupiravir, remdesivir and nirmatrelvir/ritonavir in both England and Italy, with a reduction of other marketed mAbs. The extent of the increase was higher in England than in Italy for all these drugs except for nirmatrelvir/ritonavir. CONCLUSIONS: In this dual nationwide study, the prevalence of use of mAbs/antivirals against SARS-CoV-2 for early outpatients' treatment increased slowly up to 2.0-3.0% of all patients diagnosed with SARS-CoV-2 infection in both England and Italy from December 2021 to October 2022. The trend of individual drug use varied in relation to predominant SARS-CoV-2 variants with some differences across countries. In line with scientific societies' guidelines, nirmatrelvir/ritonavir was the most frequently prescribed antiviral in both countries in the most recent period.

What factors influence differential uptake of NHS Health Checks, diabetes and hypertension reviews among women in ethnically diverse South London? Cross-sectional analysis of 63,000 primary care records.

Background: Uptake of health checks among women has not been examined in relation to patient and General Practitioner (GP) practice level factors. We investigated patient and practice level factors associated with differential uptake of health checks. Methods: Primary care records from 44 practices in Lambeth for women aged 40-74 years old (N = 62,967) from 2000-2018 were analysed using multi-level logistic regression models. An odds ratio (OR) >1 indicates increased occurrence of no health check. Findings: The mean age (IQR) of the included female sample (aged 40-74 years) was 52.9 years (45.0-59.0). Adjusted for patient-level factors (age, ethnicity, English as first language, overweight/obesity, smoking, attendance to GP practices, and co-morbidity), the odds of non-uptake of health checks were higher for Other White (OR 1.24, 95% confidence interval 1.17-1.33), and Other ethnicity (1.20, 1.07-1.35) vs. White British. It was also higher for 50-69 year olds (1.55, 1.47-1.62), 70-74 year olds (1.60, 1.49-1.72) vs. 40-49 year olds. These ORs did not change on adjustments for practice level factors (proportion of patients living in deprived areas, proportion of patients with ≥1 chronic condition, ≥3 emergency diabetes admissions annually, GP density/1000 patients, quality outcome framework score of ≥ 95%, and patient satisfaction scores of ≥80%). Non-uptake was lower for Black Caribbeans, Bangladeshis, overweight/obese patients, frequent practice attenders and comorbid patients. Interpretation: Differential uptake in health checks remained after adjustment for patient and practice level factors. Better measures of social determinants of health and of practice context are needed. Funding: NIHR Research for Patient Benefit Programme (NIHR202769).

Digital health RCT interventions for cardiovascular disease risk reduction: a systematic review and meta-analysis.

Heart disease is a leading cause of UK mortality. Evidence suggests digital health interventions (DHIs), such as smartphone applications, may reduce cardiovascular risk, but no recent reviews are available. This review examined the effect of DHIs on cardiovascular disease (CVD) risk scores in patients with increased CVD risk, compared to usual care alone. PubMed, Cochrane Database, Medline, and Google Scholar were searched for eligible trials published after 01/01/2010, involving populations with at least one CVD risk factor. Primary outcome was change in CVD risk score (e.g. QRISK3) between baseline and follow-up. Meta-analysis was undertaken using Revman5/STATA using random-effects modelling. Cochrane RoB-2 tool determined risk-of-bias. 6 randomised controlled trials from 36 retrieved articles (16.7%) met inclusion criteria, involving 1,157 patients treated with DHIs alongside usual care, and 1,127 patients offered usual care only (control group). Meta-analysis using random-effects model in STATA showed an inconclusive effect for DHIs as effective compared to usual care (Mean Difference, MD -0.76, 95% CI -1.72, 0.20), with moderate certainty (GRADEpro). Sensitivity analysis by DHI modality suggested automated email messaging was the most effective DHI (MD -1.09, 95% Cl -2.15, -0.03), with moderate certainty (GRADEpro). However, substantial study heterogeneity was noted in main and sensitivity analyses (I2 = 66% and 64% respectively). Quality assessment identified risk-of-bias concerns, particularly for outcome measurement. Findings suggest specific DHIs such as automated email messaging may improve CVD risk outcomes, but were inconclusive for DHIs overall. Further research into specific DHI modalities is required, with longer follow-up. Supplementary Information: The online version contains supplementary material available at 10.1007/s12553-022-00651-0.

Digital Education for Health Professionals: An Evidence Map, Conceptual Framework, and Research Agenda.

BACKGROUND: Health professions education has undergone major changes with the advent and adoption of digital technologies worldwide. OBJECTIVE: This study aims to map the existing evidence and identify gaps and research priorities to enable robust and relevant research in digital health professions education. METHODS: We searched for systematic reviews on the digital education of practicing and student health care professionals. We searched MEDLINE, Embase, Cochrane Library, Educational Research Information Center, CINAHL, and gray literature sources from January 2014 to July 2020. A total of 2 authors independently screened the studies, extracted the data, and synthesized the findings. We outlined the key characteristics of the included reviews, the quality of the evidence they synthesized, and recommendations for future research. We mapped the empirical findings and research recommendations against the newly developed conceptual framework. RESULTS: We identified 77 eligible systematic reviews. All of them included experimental studies and evaluated the effectiveness of digital education interventions in different health care disciplines or different digital education modalities. Most reviews included studies on various digital education modalities (22/77, 29%), virtual reality (19/77, 25%), and online education (10/77, 13%). Most reviews focused on health professions education in general (36/77, 47%), surgery (13/77, 17%), and nursing (11/77, 14%). The reviews mainly assessed participants' skills (51/77, 66%) and knowledge (49/77, 64%) and included data from high-income countries (53/77, 69%). Our novel conceptual framework of digital health professions education comprises 6 key domains (context, infrastructure, education, learners, research, and quality improvement) and 16 subdomains. Finally, we identified 61 unique questions for future research in these reviews; these mapped to framework domains of education (29/61, 47% recommendations), context (17/61, 28% recommendations), infrastructure (9/61, 15% recommendations), learners (3/61, 5% recommendations), and research (3/61, 5% recommendations). CONCLUSIONS: We identified a large number of research questions regarding digital education, which collectively reflect a diverse and comprehensive research agenda. Our conceptual framework will help educators and researchers plan, develop, and study digital education. More evidence from low- and middle-income countries is needed.

Rare Variation in Drug Metabolism and Long QT Genes and the Genetic Susceptibility to Acquired Long QT Syndrome.

BACKGROUND: Acquired long QT syndrome (aLQTS) is a serious unpredictable adverse drug reaction. Pharmacogenomic markers may predict risk. METHODS: Among 153 aLQTS patients (mean age 58 years [range, 14-88], 98.7% White, 85.6% symptomatic), computational methods identified proteins interacting most significantly with 216 QT-prolonging drugs. All cases underwent sequencing of 31 candidate genes arising from this analysis or associating with congenital LQTS. Variants were filtered using a minor allele frequency <1% and classified for susceptibility for aLQTS. Gene-burden analyses were then performed comparing the primary cohort to control exomes (n=452) and an independent replication aLQTS exome sequencing cohort. RESULTS: In 25.5% of cases, at least one rare variant was identified: 22.2% of cases carried a rare variant in a gene associated with congenital LQTS, and in 4% of cases that variant was known to be pathogenic or likely pathogenic for congenital LQTS; 7.8% cases carried a cytochrome-P450 (CYP) gene variant. Of 12 identified CYP variants, 11 (92%) were in an enzyme known to metabolize at least one culprit drug to which the subject had been exposed. Drug-drug interactions that affected culprit drug metabolism were found in 19% of cases. More than one congenital LQTS variant, CYP gene variant, or drug interaction was present in 7.8% of cases. Gene-burden analyses of the primary cohort compared to control exomes (n=452), and an independent replication aLQTS exome sequencing cohort (n=67) and drug-tolerant controls (n=148) demonstrated an increased burden of rare (minor allele frequency<0.01) variants in CYP genes but not LQTS genes. CONCLUSIONS: Rare susceptibility variants in CYP genes are emerging as potentially important pharmacogenomic risk markers for aLQTS and could form part of personalized medicine approaches in the future.

Determinants of long-term opioid prescribing in an urban population: A cross-sectional study.

BACKGROUND: Opioid prescribing has more than doubled in the UK between 1998 and 2016. Potential adverse health implications include dependency, falls and increased health expenditure. AIM: To describe the predictors of long-term opioid prescribing (LTOP) (≥3 opioid prescriptions in a 90-day period). DESIGN AND SETTING: A retrospective cross-sectional study in 41 general practices in South London. METHOD: Multi-level multivariable logistic regression to investigate the determinants of LTOP. RESULTS: Out of 320 639 registered patients ≥18 years, 2679 (0.8%) were identified as having LTOP. Patients were most likely to have LTOP if they had ≥5 long-term conditions (LTCs) (adjusted odds ratio [AOR] 36.5, 95% confidence interval [CI] 30.4-43.8) or 2-4 LTCs (AOR 13.8, CI 11.9-16.1) in comparison to no LTCs, were ≥75 years compared to 18-24 years (AOR 12.31, CI 7.1-21.5), were smokers compared to nonsmokers (AOR 2.2, CI 2.0-2.5), were female rather than male (AOR 1.9, CI 1.7-2.0) and in the most deprived deprivation quintile (AOR 1.6, CI 1.4-1.8) compared to the least deprived. In a separate model examining individual LTCs, the strongest associations for LTOP were noted for sickle cell disease (SCD) (AOR 18.4, CI 12.8-26.4), osteoarthritis (AOR 3.0, CI 2.8-3.3), rheumatoid arthritis (AOR 2.8, CI 2.2-3.4), depression (AOR 2.6, CI 2.3-2.8) and multiple sclerosis (OR 2.5, CI 1.4-4.4). CONCLUSION: LTOP was significantly higher in those aged ≥75 years, with multimorbidity or specific LTCs: SCD, osteoarthritis, rheumatoid arthritis, depression and multiple sclerosis. These characteristics may enable the design of targeted interventions to reduce LTOP.

Hypertension and cardiovascular risk factor management in a multi-ethnic cohort of adults with CKD: a cross sectional study in general practice.

BACKGROUND: Hypertension, especially if poorly controlled, is a key determinant of chronic kidney disease (CKD) development and progression to end stage renal disease (ESRD). AIM: To assess hypertension and risk factor management, and determinants of systolic blood pressure control in individuals with CKD and hypertension. DESIGN AND SETTING: Cross-sectional survey using primary care electronic health records from 47/49 general practice clinics in South London. METHODS: Known effective interventions, management of hypertension and cardiovascular disease (CVD) risk in patients with CKD Stages 3-5 were investigated. Multivariable logistic regression analysis examined the association of demographic factors, comorbidities, deprivation, and CKD coding, with systolic blood pressure control status as outcome. Individuals with diabetes were excluded. RESULTS: Adults with CKD Stages 3-5 and hypertension represented 4131/286,162 (1.4%) of the total population; 1984 (48%) of these individuals had undiagnosed CKD without a recorded CKD clinical code. Hypertension was undiagnosed in 25% of the total Lambeth population, and in patients with CKD without diagnosed hypertension, 23.0% had systolic blood pressure > 140 mmHg compared with 39.8% hypertensives, p < 0.001. Multivariable logistic regression revealed that factors associated with improved systolic blood pressure control in CKD included diastolic blood pressure control, serious mental illness, history of cardiovascular co-morbidities, CKD diagnostic coding, and age < 60 years. African ethnicity and obesity were associated with poorer systolic blood pressure control. CONCLUSION: We found both underdiagnosed CKD and underdiagnosed hypertension in patients with CKD. The poor systolic blood pressure control in older age groups ≥ 60 years and in Black African or obese individuals is clinically important as these groups are at increased risk of mortality for cardiovascular diseases.

Risk of COVID-19 in shielded and nursing care home patients: a cohort study in general practice.

BACKGROUND: COVID-19 cases were first detected in the UK in January 2020 and vulnerable patients were asked to shield from March to reduce their risk of COVID-19 infection. AIM: To determine the risk and determinants of COVID-19 diagnosis in shielded versus non-shielded groups, adjusted for key comorbidities not explained by shielding. DESIGN & SETTING: Retrospective cohort study of adults with COVID-19 infection between 1 February 2020 and 15 May 2020 in west London. METHOD: Individuals diagnosed with COVID-19 were identified in SystmOne records using clinical codes. Infection risks were adjusted for sociodemographic factors, nursing home status, and comorbidities. RESULTS: Of 57 713 adults, 573 (1%) individuals were identified as shielded and 1074 adults had documented COVID-19 infections (1.9%). COVID-19 infection rate in the shielded group individuals compared with non-shielded adult individuals was 6.5% (n = 37/573) versus 1.8% (n = 1037/57 140), P<0.001. A multivariable fully adjusted Cox proportional hazards (CPH) regression identified that COVID-19 infection was increased with shielding status (adjusted hazard ratio [aHR] 1.52; 95% confidence interval [CI] = 1.00 to 2.30; P = 0.048). Other determinants of COVID-19 infection included nursing home residency (aHR 7.05; 95% CI = 4.22 to 11.77; P<0.001); Black African (aHR 2.52; 95% CI = 1.99 to 3.18; P<0.001), Other (aHR 1.74; 95% CI = 1.42 to 2.13; P<0.001), Non-stated (aHR 1.70; 95% CI = 1.02 to 2.84; P = 0.04), or South Asian ethnic group (aHR 1.46; 95% CI = 1.10 to 1.93; P = 0.01); history of respiratory disease (aHR 1.51; 95% CI = 1.06 to 2.16; P = 0.02); deprivation (third versus least deprived Index of Multiple Deprivation [IMD] quintile) (aHR 1.25 ; 95% CI = 1.01 to 1.56; P = 0.05); obesity (body mass index [BMI] >30 kg/m2) (aHR 1.39; 95% CI = 1.18 to 1.63; P<0.001); and age (aHR 1.02; 95% CI = 1.01 to 1.02; P<0.001. Male sex was associated with lower risk of COVID-19 infection (aHR 0.71; 95% CI = 0.62 to 0.82; P<0.001). CONCLUSION: Shielded individuals had a higher COVID-19 infection rate compared with non-shielded individuals, after adjusting for sociodemographic factors, nursing home status, and comorbidities.

What gets recorded, counts: dementia recording in primary care compared with a specialist database.

BACKGROUND: databases of electronic health records are powerful tools for dementia research, but data can be influenced by incomplete recording. We examined whether people with dementia recorded in a specialist database (from a mental health and dementia care service) differ from those recorded in primary care. METHODS: a retrospective cohort study of the population covered by Lambeth DataNet (primary care electronic records) between 2007 and 2019. Documentation of dementia diagnosis in primary care coded data and linked records in a specialist database (Clinical Records Interactive Search) were compared. RESULTS: 3,859 people had dementia documented in primary care codes and 4,266 in the specialist database, with 2,886/5,239 (55%) documented in both sources. Overall, 55% were labelled as having Alzheimer's dementia and 29% were prescribed dementia medication, but these proportions were significantly higher in those documented in both sources. The cohort identified from the specialist database were less likely to live in a care home (prevalence ratio 0.73, 95% confidence interval 0.63-0.85), have multimorbidity (0.87, 0.77-0.98) or consult frequently (0.91, 0.88-0.95) than those identified through primary care codes, although mortality did not differ (0.98, 0.91-1.06). DISCUSSION: there is under-recording of dementia diagnoses in both primary care and specialist databases. This has implications for clinical care and for generalizability of research. Our results suggest that using a mental health database may under-represent those patients who have more frailty, reflecting differential referral to mental health services, and demonstrating how the patient pathways are an important consideration when undertaking database studies.

Associations between attainment of incentivised primary care indicators and emergency hospital admissions among type 2 diabetes patients: a population-based historical cohort study.

OBJECTIVES: England has invested considerably in diabetes care over recent years through programmes such as the Quality and Outcomes Framework and National Diabetes Audit. However, associations between specific programme indicators and key clinical endpoints, such as emergency hospital admissions, remain unclear. We aimed to examine whether attainment of Quality and Outcomes Framework and National Diabetes Audit primary care diabetes indicators is associated with diabetes-related, cardiovascular, and all-cause emergency hospital admissions. DESIGN: Historical cohort study. SETTING: A total of 330 English primary care practices, 2010-2017, using UK Clinical Practice Research Datalink. PARTICIPANTS: A total of 84,441 adults with type 2 diabetes. MAIN OUTCOME MEASURES: The primary outcome was emergency hospital admission for any cause. Secondary outcomes were (1) diabetes-related and (2) cardiovascular-related emergency admission. RESULTS: There were 130,709 all-cause emergency admissions, 115,425 diabetes-related admissions and 105,191 cardiovascular admissions, corresponding to unplanned admission rates of 402, 355 and 323 per 1000 patient-years, respectively. All-cause hospital admission rates were lower among those who met HbA1c and cholesterol indicators (incidence rate ratio = 0.91; 95% CI 0.89-0.92; p < 0.001 and 0.87; 95% CI 0.86-0.89; p < 0.001), respectively), with similar findings for diabetes and cardiovascular admissions. Patients who achieved the Quality and Outcomes Framework blood pressure target had lower cardiovascular admission rates (incidence rate ratio = 0.98; 95% CI 0.96-0.99; p = 0.001). Strong associations were found between completing 7-9 (vs. either 4-6 or 0-3) National Diabetes Audit processes and lower rates of all admission outcomes (p-values < 0.001), and meeting all nine National Diabetes Audit processes had significant associations with reductions in all types of emergency admissions by 22% to 26%. Meeting the HbA1c or cholesterol Quality and Outcomes Framework indicators, or completing 7-9 National Diabetes Audit processes, was also associated with longer time-to-unplanned all-cause, diabetes and cardiovascular admissions. CONCLUSIONS: Attaining Quality and Outcomes Framework-defined diabetes intermediate outcome thresholds, and comprehensive completion of care processes, may translate into considerable reductions in emergency hospital admissions. Out-of-hospital diabetes care optimisation is needed to improve implementation of core interventions and reduce unplanned admissions.

Associations between attainment of incentivised primary care diabetes indicators and mortality in an English cohort.

AIMS: To describe associations between incentivised primary care clinical and process indicators and mortality, among patients with type 2 diabetes in England. METHODS: A historical 2010-2017 cohort (n = 84,441 adults) was derived from the UK CPRD. Exposures included English Quality and Outcomes Framework glycated haemoglobin (HbA1c; 7.5%, 59 mmol/mol), blood pressure (140/80 mmHg), and cholesterol (5 mmol/L) indicator attainment; and number of National Diabetes Audit care processes completed, in 2010-11. The primary outcome was all-cause mortality. RESULTS: Over median 3.9 (SD 2.0) years follow-up, 10,711 deaths occurred. Adjusted hazard ratios (aHR) indicated 12% (95% CI 8-16%; p < 0.0001) and 16% (11-20%; p < 0.0001) lower mortality rates among those who attained the HbA1c and cholesterol indicators, respectively. Rates were also lower among those who completed 7-9 vs. 0-3 or 4-6 care processes (aHRs 0.76 (0.71-0.82), p < 0.0001 and 0.61 (0.53-0.71), p < 0.0001, respectively), but did not obviously vary by blood pressure indicator attainment (aHR 1.04, 1.00-1.08; p = 0.0811). CONCLUSIONS: Cholesterol, HbA1c and comprehensive process indicator attainment, was associated with enhanced survival. Review of community-based care provision could help reduce the gap between indicator standards and current outcomes, and in turn enhance life expectancy.