Exploring ethnicity dynamics in Wales: a longitudinal population-scale linked data study and development of a harmonised ethnicity spine.

OBJECTIVE: This study aims to create a national ethnicity spine based on all available ethnicity records in linkable anonymised electronic health record and administrative data sources. DESIGN: A longitudinal study using anonymised individual-level population-scale ethnicity data from 26 data sources available within the Secure Anonymised Information Linkage Databank. SETTING: The national ethnicity spine is created based on longitudinal national data for the population of Wales-UK over 22 years (between 2000 and 2021). PROCEDURE AND PARTICIPANTS: A total of 46 million ethnicity records for 4 297 694 individuals have been extracted, harmonised, deduplicated and made available within a longitudinal research ready data asset. OUTCOME MEASURES: (1) Comparing the distribution of ethnicity records over time for four different selection approaches (latest, mode, weighted mode and composite) across age bands, sex, deprivation quintiles, health board and residential location and (2) distribution and completeness of records against the ONS census 2011. RESULTS: The distribution of the dominant group (white) is minimally affected based on the four different selection approaches. Across all other ethnic group categorisations, the mixed group was most susceptible to variation in distribution depending on the selection approach used and varied from a 0.6% prevalence across the latest and mode approach to a 1.1% prevalence for the weighted mode, compared with the 3.1% prevalence for the composite approach. Substantial alignment was observed with ONS 2011 census with the Latest group method (kappa=0.68, 95% CI (0.67 to 0.71)) across all subgroups. The record completeness rate was over 95% in 2021. CONCLUSION: In conclusion, our development of the population-scale ethnicity spine provides robust ethnicity measures for healthcare research in Wales and a template which can easily be deployed in other trusted research environments in the UK and beyond.

COVID-19 and influenza vaccine uptake among pregnant women in national cohorts of England and Wales.

Vaccines against COVID-19 and influenza can reduce the adverse outcomes caused by infections during pregnancy, but vaccine uptake among pregnant women has been suboptimal. We examined the COVID-19 and influenza vaccine uptake and disparities in pregnant women during the COVID-19 pandemic to inform vaccination interventions. We used data from the Oxford-Royal College of General Practitioners Research and Surveillance Centre database in England and the Secure Anonymised Information Linkage Databank in Wales. The uptake of at least one dose of vaccine was 40.2% for COVID-19 and 41.8% for influenza among eligible pregnant women. We observed disparities in COVID-19 and influenza vaccine uptake, with socioeconomically deprived and ethnic minority groups showing lower vaccination rates. The suboptimal uptake of COVID-19 and influenza vaccines, especially in those from socioeconomically deprived backgrounds and Black, mixed or other ethnic groups, underscores the necessity for interventions to reduce vaccine hesitancy and enhance acceptance in pregnant women.

Recurrent urinary tract infections and prophylactic antibiotic use in women: cross-sectional study.

BACKGROUND: Despite the considerable morbidity caused by recurrent UTIs (rUTIs), and the wider personal and public health implications from frequent antibiotic use, few studies adequately describe the prevalence and characteristics of women with rUTIs or those who use prophylactic antibiotics. AIM: To describe the prevalence, characteristics, and urine profiles of women with rUTIs with and without prophylactic antibiotic use in Welsh primary care. DESIGN AND SETTING: Retrospective cross-sectional study in Welsh General Practice using the SAIL Databank. METHOD: We describe the characteristics of women aged ≥18 years with rUTIs or using prophylactic antibiotics from 2010-2020, and associated urine culture results from 2015 - 2020. RESULTS: 6.0% of women (n=92,213) had rUTIs, and 1.7% (n=26,862) were prescribed prophylactic antibiotics. Only 49% of prophylactic antibiotic users met the definition of rUTIs before initiation. 81% of women with rUTIs had a urine culture result in the preceding 12 months with high rates of resistance to trimethoprim and amoxicillin. 64% of women taking prophylactic antibiotics had a urine culture result before initiation, and 18% (n=320) of women prescribed trimethoprim had resistance to it on the antecedent sample. CONCLUSION: A substantial proportion of women had rUTIs or incident prophylactic antibiotic use. However, 64% of women had urine cultured before starting prophylaxis. There was a high proportion of cultured bacteria resistant to two antibiotics used for rUTI prevention and evidence of resistance to the prescribed antibiotic. More frequent urine cultures for rUTI diagnosis and before prophylactic antibiotic initiation could better inform antibiotic choices.

Trends in Atherosclerotic Cardiovascular Disease and lipid management. A population-level observational cohort study in Wales.

AIMS: European clinical guidelines recommend that patients with atherosclerotic cardiovascular disease (ASCVD), including ischaemic heart disease (IHD), stroke and peripheral arterial disease (PAD), are prescribed lipid lowering treatment (LLT) and treated to target low-density lipoprotein cholesterol (LDL-C) levels. This study aimed to document trends in ASCVD including treatment, monitoring, and achievement of target LDL-C. METHOD: A retrospective observational population study using linked health-care data (2010-22). RESULTS: Over the study period the number of patients with ASCVD increased from 181,153 to 207,747 (8882 to 9398 per 100,000). The proportion of patients prescribed LLT decreased from 75.3% in 2010 to 67.1% in 2022; high-intensity statin therapy increased from 9.4% to 25.2% and non-high-intensity statin therapy decreased from 59.6% to 38.2%. The prescribing of high-intensity statin therapy was consistently higher amongst patients with IHD (10.9% in 2010 increasing to 28.0% in 2022) than in patients with stroke (4.7% to 21.6%) or PAD (3.9% to 10.6%).The proportion of cases with documented LDL-C decreased from 58.0% in 2010 to 49.3% in 2022. Of those with documented LDL-C in 2022, 44.0% achieved LDL-C <1.8 mmol/L, including 45.2% of those with IHD, 42.0% of those with stroke and only 32.8% of those with PAD. CONCLUSION: Prescribing of LLT, including HI-statin therapy, documentation of LDL-C and achievement of target LDL-C levels was relatively low, especially in PAD patients. Although target achievement in "tested patients" increased over time, the proportion of patients undergoing lipid testing declined. More rigorous lipid management requires prioritisation, especially for PAD and stroke patients.

We analysed trends in the presentation of atherosclerotic cardiovascular disease and lipid management in a population between 2010 to 2022 The number of patients with atherosclerotic cardiovascular disease increased by 14% but the proportion receiving lipid lowering therapy decreased.Patients with ischaemic heart disease were more effectively managed than patients with stroke and patients with peripheral arterial disease were the least effectively managed.

Cohort study of cardiovascular safety of different COVID-19 vaccination doses among 46 million adults in England.

The first dose of COVID-19 vaccines led to an overall reduction in cardiovascular events, and in rare cases, cardiovascular complications. There is less information about the effect of second and booster doses on cardiovascular diseases. Using longitudinal health records from 45.7 million adults in England between December 2020 and January 2022, our study compared the incidence of thrombotic and cardiovascular complications up to 26 weeks after first, second and booster doses of brands and combinations of COVID-19 vaccines used during the UK vaccination program with the incidence before or without the corresponding vaccination. The incidence of common arterial thrombotic events (mainly acute myocardial infarction and ischaemic stroke) was generally lower after each vaccine dose, brand and combination. Similarly, the incidence of common venous thrombotic events, (mainly pulmonary embolism and lower limb deep venous thrombosis) was lower after vaccination. There was a higher incidence of previously reported rare harms after vaccination: vaccine-induced thrombotic thrombocytopenia after first ChAdOx1 vaccination, and myocarditis and pericarditis after first, second and transiently after booster mRNA vaccination (BNT-162b2 and mRNA-1273). These findings support the wide uptake of future COVID-19 vaccination programs.

Risk of cardiovascular events following COVID-19 in people with and without pre-existing chronic respiratory disease.

BACKGROUND: COVID-19 is associated with cardiovascular outcomes in the general population, but it is unknown whether people with chronic respiratory disease (CRD) have a higher risk of cardiovascular events post-COVID-19 compared with the general population and, if so, what respiratory-related factors may modify this risk in these people. METHODS: Primary and secondary care data from the National Health Service England were used to define a population of adults in England with COVID-19 (index date) between 1 January 2020 and 30 November 2021. Adjusted Cox proportional hazard regression was used to quantify the association between CRD, asthma-related factors, chronic obstructive pulmonary disease (COPD)-related factors, and risk of cardiovascular events. Asthma-specific factors included baseline asthma control, exacerbations, and inhaled corticosteroid (ICS) dose. COPD-specific risk factors included baseline ICS and exacerbations. Secondary objectives quantified the impact of COVID-19 hospitalisation and vaccine dose on cardiovascular outcomes. RESULTS: Of 3 670 455 people, those with CRD had a higher risk of cardiovascular events [adjusted hazard ratio (HRadj), 1.08; 95% confidence interval (CI) 1.06-1.11], heart failure (HRadj, 1.17; 95% CI, 1.12-1.22), angina (HRadj, 1.13; 95% CI, 1.06-1.20) and pulmonary emboli (HRadj, 1.24; 95% CI, 1.15-1.33) compared with people without CRD. In people with asthma or COPD, baseline exacerbations were associated with a higher risk of cardiovascular outcomes (HRadj, 1.36; 95% CI, 1.27-1.00 and HRadj, 1.35; 95% CI, 1.24-1.46, respectively). Regardless of CRD, the risk of cardiovascular events was lower with increasing COVID-19 vaccine dose. CONCLUSIONS: Higher risk of cardiovascular events post-COVID-19 might be explained by the underlying severity of the CRD, and COVID-19 vaccines were beneficial to both people with and those without CRD with regards to cardiovascualr events.

10-year multimorbidity patterns among people with and without rheumatic and musculoskeletal diseases: an observational cohort study using linked electronic health records from Wales, UK.

OBJECTIVES: To compare the patterns of multimorbidity between people with and without rheumatic and musculoskeletal diseases (RMDs) and to describe how these patterns change by age and sex over time, between 2010 and 2019. PARTICIPANTS: 103 426 people with RMDs and 2.9 million comparators registered in 395 Wales general practices (GPs). Each patient with an RMD aged 0-100 years between January 2010 and December 2019 registered in Clinical Practice Research Welsh practices was matched with up to five comparators without an RMD, based on age, gender and GP code. PRIMARY OUTCOME MEASURES: The prevalence of 29 Elixhauser-defined comorbidities in people with RMDs and comparators categorised by age, gender and GP practices. Conditional logistic regression models were fitted to calculate differences (OR, 95% CI) in associations with comorbidities between cohorts. RESULTS: The most prevalent comorbidities were cardiovascular risk factors, hypertension and diabetes. Having an RMD diagnosis was associated with a significantly higher odds for many conditions including deficiency anaemia (OR 1.39, 95% CI (1.32 to 1.46)), hypothyroidism (OR 1.34, 95% CI (1.19 to 1.50)), pulmonary circulation disorders (OR 1.39, 95% CI 1.12 to 1.73) diabetes (OR 1.17, 95% CI (1.11 to 1.23)) and fluid and electrolyte disorders (OR 1.27, 95% CI (1.17 to 1.38)). RMDs have a higher proportion of multimorbidity (two or more conditions in addition to the RMD) compared with non-RMD group (81% and 73%, respectively in 2019) and the mean number of comorbidities was higher in women from the age of 25 and 50 in men than in non-RMDs group. CONCLUSION: People with RMDs are approximately 1.5 times as likely to have multimorbidity as the general population and provide a high-risk group for targeted intervention studies. The individuals with RMDs experience a greater load of coexisting health conditions, which tend to manifest at earlier ages. This phenomenon is particularly pronounced among women. Additionally, there is an under-reporting of comorbidities in individuals with RMDs.

All-cause and Infection-attributable Mortality Amongst Adults With Bloodstream Infection-a Population-based Study.

Background: Bloodstream infections (BSIs) are common, life-threatening infections. However, it remains unclear whether deaths following BSIs are primarily from uncontrolled infection or underlying comorbidities. We aimed to determine the overall mortality, infection-attributable mortality, and causes of death for four leading BSI pathogens. Methods: This retrospective cohort study was conducted within the Secure Anonymized Information Linkage Databank, containing anonymized population-scale electronic health record data for Wales, UK. We included adults with Escherichia coli, Klebsiella spp, Pseudomonas aeruginosa, and Staphylococcus aureus BSI between 2010 and 2022 using linked data from Public Health Wales and the Office for National Statistics. Thirty-day all-cause and sepsis-specific mortality, as a proxy for infection-attributable mortality, were compared using Cox proportional hazards and competing risk regression, respectively. Results: We identified 35 691 adults with BSI (59.6% E coli). Adjusted analyses revealed that all organisms had a higher 30-day mortality versus E coli with Pseudomonas aeruginosa the highest (hazard ratio, 1.96 [1.76-2.17], P < .001). Cancer was the leading cause of death following BSIs for all organisms, particularly deaths occurring between 30 and 90 days (35.9%). A total of 25.5% of deaths within 30 days involved sepsis. Methicillin-resistant Staphylococcus aureus was associated with the highest sepsis mortality versus E coli (hazard ratio, 2.56 [2.10-3.12], P < .001). Peak C-reactive protein was positively associated with increased sepsis mortality (P < .001). Conclusions: This population-level study challenges the assumption that most deaths following BSIs are directly attributable to uncontrolled infection, particularly subacutely more than 30 days from BSI. Our findings underscore the need for reevaluating clinical trial design and developing better preventive strategies for BSIs.

Development and external validation of the eFalls tool: a multivariable prediction model for the risk of ED attendance or hospitalisation with a fall or fracture in older adults.

BACKGROUND: Falls are common in older adults and can devastate personal independence through injury such as fracture and fear of future falls. Methods to identify people for falls prevention interventions are currently limited, with high risks of bias in published prediction models. We have developed and externally validated the eFalls prediction model using routinely collected primary care electronic health records (EHR) to predict risk of emergency department attendance/hospitalisation with fall or fracture within 1 year. METHODS: Data comprised two independent, retrospective cohorts of adults aged ≥65 years: the population of Wales, from the Secure Anonymised Information Linkage Databank (model development); the population of Bradford and Airedale, England, from Connected Bradford (external validation). Predictors included electronic frailty index components, supplemented with variables informed by literature reviews and clinical expertise. Fall/fracture risk was modelled using multivariable logistic regression with a Least Absolute Shrinkage and Selection Operator penalty. Predictive performance was assessed through calibration, discrimination and clinical utility. Apparent, internal-external cross-validation and external validation performance were assessed across general practices and in clinically relevant subgroups. RESULTS: The model's discrimination performance (c-statistic) was 0.72 (95% confidence interval, CI: 0.68 to 0.76) on internal-external cross-validation and 0.82 (95% CI: 0.80 to 0.83) on external validation. Calibration was variable across practices, with some over-prediction in the validation population (calibration-in-the-large, -0.87; 95% CI: -0.96 to -0.78). Clinical utility on external validation was improved after recalibration. CONCLUSION: The eFalls prediction model shows good performance and could support proactive stratification for falls prevention services if appropriately embedded into primary care EHR systems.

Health care utilization and mortality for people with epilepsy during COVID-19: A population study.

OBJECTIVE: This study was undertaken to characterize changes in health care utilization and mortality for people with epilepsy (PWE) during the COVID-19 pandemic. METHODS: We performed a retrospective study using linked, individual-level, population-scale anonymized health data from the Secure Anonymised Information Linkage databank. We identified PWE living in Wales during the study "pandemic period" (January 1, 2020-June 30, 2021) and during a "prepandemic" period (January 1, 2016-December 31, 2019). We compared prepandemic health care utilization, status epilepticus, and mortality rates with corresponding pandemic rates for PWE and people without epilepsy (PWOE). We performed subgroup analyses on children (<18 years old), older people (>65 years old), those with intellectual disability, and those living in the most deprived areas. We used Poisson models to calculate adjusted rate ratios (RRs). RESULTS: We identified 27 279 PWE who had significantly higher rates of hospital (50.3 visits/1000 patient months), emergency department (55.7), and outpatient attendance (172.4) when compared to PWOE (corresponding figures: 25.7, 25.2, and 87.0) in the prepandemic period. Hospital and epilepsy-related hospital admissions, and emergency department and outpatient attendances all reduced significantly for PWE (and all subgroups) during the pandemic period. RRs [95% confidence intervals (CIs)] for pandemic versus prepandemic periods were .70 [.69-.72], .77 [.73-.81], .78 [.77-.79], and .80 [.79-.81]. The corresponding rates also reduced for PWOE. New epilepsy diagnosis rates decreased during the pandemic compared with the prepandemic period (2.3/100 000/month cf. 3.1/100 000/month, RR = .73, 95% CI = .68-.78). Both all-cause deaths and deaths with epilepsy recorded on the death certificate increased for PWE during the pandemic (RR = 1.07, 95% CI = .997-1.145 and RR = 2.44, 95% CI = 2.12-2.81). When removing COVID deaths, RRs were .88 (95% CI = .81-.95) and 1.29 (95% CI = 1.08-1.53). Status epilepticus rates did not change significantly during the pandemic (RR = .95, 95% CI = .78-1.15). SIGNIFICANCE: All-cause non-COVID deaths did not increase but non-COVID deaths associated with epilepsy did increase for PWE during the COVID-19 pandemic. The longer term effects of the decrease in new epilepsy diagnoses and health care utilization and increase in deaths associated with epilepsy need further research.

Epilepsy and the risk of COVID-19-related hospitalization and death: A population study.

OBJECTIVE: People with epilepsy (PWE) may be at an increased risk of severe COVID-19. It is important to characterize this risk to inform PWE and for future health and care planning. We assessed whether PWE were at higher risk of being hospitalized with, or dying from, COVID-19. METHODS: We performed a retrospective cohort study using linked, population-scale, anonymized electronic health records from the SAIL (Secure Anonymised Information Linkage) databank. This includes hospital admission and demographic data for the complete Welsh population (3.1 million) and primary care records for 86% of the population. We identified 27 279 PWE living in Wales during the study period (March 1, 2020 to June 30, 2021). Controls were identified using exact 5:1 matching (sex, age, and socioeconomic status). We defined COVID-19 deaths as having International Classification of Diseases, 10th Revision (ICD-10) codes for COVID-19 on death certificates or occurring within 28 days of a positive SARS-CoV-2 polymerase chain reaction (PCR) test. COVID-19 hospitalizations were defined as having a COVID-19 ICD-10 code for the reason for admission or occurring within 28 days of a positive SARS-CoV-2 PCR test. We recorded COVID-19 vaccinations and comorbidities known to increase the risk of COVID-19 hospitalization and death. We used Cox proportional hazard models to calculate hazard ratios. RESULTS: There were 158 (.58%) COVID-19 deaths and 933 (3.4%) COVID-19 hospitalizations in PWE, and 370 (.27%) deaths and 1871 (1.4%) hospitalizations in controls. Hazard ratios for COVID-19 death and hospitalization in PWE compared to controls were 2.15 (95% confidence interval [CI] = 1.78-2.59) and 2.15 (95% CI = 1.94-2.37), respectively. Adjusted hazard ratios (adjusted for comorbidities) for death and hospitalization were 1.32 (95% CI = 1.08-1.62) and 1.60 (95% CI = 1.44-1.78). SIGNIFICANCE: PWE are at increased risk of being hospitalized with, and dying from, COVID-19 when compared to age-, sex-, and deprivation-matched controls, even when adjusting for comorbidities. This may have implications for prioritizing future COVID-19 treatments and vaccinations for PWE.

Uptake of COVID-19 vaccinations amongst 3,433,483 children and young people: meta-analysis of UK prospective cohorts.

SARS-CoV-2 infection in children and young people (CYP) can lead to life-threatening COVID-19, transmission within households and schools, and the development of long COVID. Using linked health and administrative data, we investigated vaccine uptake among 3,433,483 CYP aged 5-17 years across all UK nations between 4th August 2021 and 31st May 2022. We constructed national cohorts and undertook multi-state modelling and meta-analysis to identify associations between demographic variables and vaccine uptake. We found that uptake of the first COVID-19 vaccine among CYP was low across all four nations compared to other age groups and diminished with subsequent doses. Age and vaccination status of adults living in the same household were identified as important risk factors associated with vaccine uptake in CYP. For example, 5-11 year-olds were less likely to receive their first vaccine compared to 16-17 year-olds (adjusted Hazard Ratio [aHR]: 0.10 (95%CI: 0.06-0.19)), and CYP in unvaccinated households were less likely to receive their first vaccine compared to CYP in partially vaccinated households (aHR: 0.19, 95%CI 0.13-0.29).

Adherence to the Atrial fibrillation Better Care pathway and the risk of adverse health outcomes in older care home residents with atrial fibrillation: a retrospective data linkage study 2003-18.

BACKGROUND: The Atrial fibrillation Better Care (ABC) pathway is the gold-standard approach to atrial fibrillation (AF) management, but the effect of implementation on health outcomes in care home residents is unknown. OBJECTIVE: To examine associations between ABC pathway adherence and stroke, transient ischaemic attack, cardiovascular hospitalisation, major bleeding, mortality and a composite of all these outcomes in care home residents. METHODS: A retrospective cohort study of older care home residents (≥65 years) in Wales with AF was conducted between 1 January 2003 and 31 December 2018 using the Secure Anonymised Information Linkage Databank. Adherence to the ABC pathway was assessed at care home entry using pre-specified definitions. Cox proportional hazard and competing risk models were used to estimate the risk of health outcomes according to ABC adherence. RESULTS: From 14,493 residents (median [interquartile range] age 87.0 [82.6-91.2] years, 35.2% male) with AF, 5,531 (38.2%) were ABC pathway adherent. Pathway adherence was not significantly associated with risk of the composite outcome (adjusted hazard ratio, 95% confidence interval [CI]: 1.01 [0.97-1.05]). There was a significant independent association observed between ABC pathway adherence and a reduced risk of myocardial infarction (0.70 [0.50-0.98]), but a higher risk of haemorrhagic stroke (1.59 [1.06-2.39]). ABC pathway adherence was not significantly associated with any other individual health outcomes examined. CONCLUSION: An ABC adherent approach in care home residents was not consistently associated with improved health outcomes. Findings should be interpreted with caution owing to difficulties in defining pathway adherence using routinely collected data and an individualised approach is recommended.

Ethnicity data resource in population-wide health records: completeness, coverage and granularity of diversity.

Intersectional social determinants including ethnicity are vital in health research. We curated a population-wide data resource of self-identified ethnicity data from over 60 million individuals in England primary care, linking it to hospital records. We assessed ethnicity data in terms of completeness, consistency, and granularity and found one in ten individuals do not have ethnicity information recorded in primary care. By linking to hospital records, ethnicity data were completed for 94% of individuals. By reconciling SNOMED-CT concepts and census-level categories into a consistent hierarchy, we organised more than 250 ethnicity sub-groups including and beyond "White", "Black", "Asian", "Mixed" and "Other, and found them to be distributed in proportions similar to the general population. This large observational dataset presents an algorithmic hierarchy to represent self-identified ethnicity data collected across heterogeneous healthcare settings. Accurate and easily accessible ethnicity data can lead to a better understanding of population diversity, which is important to address disparities and influence policy recommendations that can translate into better, fairer health for all.

Cardiac interventions in Wales: A comparison of benefits between NHS Wales specialties.

OBJECTIVES: The study aimed to assess if specialised healthcare service interventions in Wales benefit the population equitably in work commissioned by the Welsh Health Specialised Services Committee (WHSSC). APPROACH: The study utilised anonymised individual-level, population-scale, routinely collected electronic health record (EHR) data held in the Secure Anonymised Information Linkage (SAIL) Databank to identify patients resident in Wales receiving specialist cardiac interventions. Measurement was undertaken of associated patient outcomes 2-years before and after the intervention (minus a 6-month clearance period on either side) by measuring events in primary care, hospital attendance, outpatient and emergency department. The analysis controlled for comorbidity (Charlson) and deprivation (Welsh Index of Multiple Deprivation), stratified by admission type (elective or emergency) and membership of top 5% post-intervention costs. Costs were estimated by multiplying events by mean person cost estimates. RESULTS: We identified 5,999 percutaneous coronary interventions (PCI) and 1,640 coronary artery bypass graft (CABG) between 2014-06-01 to 2020-02-29. The ratio of emergency to elective interventions was 2.85 for PCI and 1.04 for CABG. In multivariate analysis significant associations were identified for comorbidity (OR = 1.52, CI = (1.01-2.27)), deprivation (OR = 1.34, CI = (1.03-1.76)) and rurality (OR = 0.81, CI = (0.70-0.95)) for PCI interventions, and comorbidity (OR = 1.47, CI = (1.10-1.98)) for CABG. Higher costs post-intervention were associated with increased comorbidity for PCI and CABG in the top 5% cost groups, but for PCI this was not seen outside the top 5%. For PCI, moderate cost increase was associated with increased deprivation, but the picture was more mixed following CABG interventions. For both interventions, lower costs post intervention were seen in rural locations. CONCLUSION: We identified and compared health outcomes for selected specialist cardiac interventions amongst patients resident in Wales, with these methods and analyses, providing a template for comparing other cardiac interventions.

The use of Enhanced Vegetation Index for assessing access to different types of green space in epidemiological studies.

BACKGROUND: Exposure to green space can protect against poor health through a variety of mechanisms. However, there is heterogeneity in methodological approaches to exposure assessments which makes creating effective policy recommendations challenging. OBJECTIVE: Critically evaluate the use of a satellite-derived exposure metric, the Enhanced Vegetation Index (EVI), for assessing access to different types of green space in epidemiological studies. METHODS: We used Landsat 5-8 (30 m resolution) to calculate average EVI for a 300 m radius surrounding 1.4 million households in Wales, UK for 2018. We calculated two additional measures using topographic vector data to represent access to green spaces within 300 m of household locations. The two topographic vector-based measures were total green space area stratified by type and average private garden size. We used linear regression models to test whether EVI could discriminate between publicly accessible and private green space and Pearson correlation to test associations between EVI and green space types. RESULTS: Mean EVI for a 300 m radius surrounding households in Wales was 0.28 (IQR = 0.12). Total green space area and average private garden size were significantly positively associated with corresponding EVI measures (ß = < 0.0001, 95% CI: 0.0000, 0.0000; ß = 0.0001, 95% CI: 0.0001, 0.0001 respectively). In urban areas, as average garden size increases by 1 m2, EVI increases by 0.0002. Therefore, in urban areas, to see a 0.1 unit increase in EVI index score, garden size would need to increase by 500 m2. The very small ß values represent no 'measurable real-world' associations. When stratified by type, we observed no strong associations between greenspace and EVI. IMPACT: It is a widely implemented assumption in epidiological studies that an increase in EVI is equivalent to an increase in greenness and/or green space. We used linear regression models to test associations between EVI and potential sources of green reflectance at a neighbourhood level using satellite imagery from 2018. We compared EVI measures with a 'gold standard' vector-based dataset that defines publicly accessible and private green spaces. We found that EVI should be interpreted with care as a greater EVI score does not necessarily mean greater access to publicly available green spaces in the hyperlocal environment.

Risk of severe COVID-19 outcomes after autumn 2022 COVID-19 booster vaccinations: a pooled analysis of national prospective cohort studies involving 7.4 million adults in England, Northern Ireland, Scotland and Wales.

Background: UK COVID-19 vaccination policy has evolved to offering COVID-19 booster doses to individuals at increased risk of severe Illness from COVID-19. Building on our analyses of vaccine effectiveness of first, second and initial booster doses, we aimed to identify individuals at increased risk of severe outcomes (i.e., COVID-19 related hospitalisation or death) post the autumn 2022 booster dose. Methods: We undertook a national population-based cohort analysis across all four UK nations through linked primary care, vaccination, hospitalisation and mortality data. We included individuals who received autumn 2022 booster doses of BNT162b2 (Comirnaty) or mRNA-1273 (Spikevax) during the period September 1, 2022 to December 31, 2022 to investigate the risk of severe COVID-19 outcomes. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CIs) for the association between demographic and clinical factors and severe COVID-19 outcomes after the autumn booster dose. Analyses were adjusted for age, sex, body mass index (BMI), deprivation, urban/rural areas and comorbidities. Stratified analyses were conducted by vaccine type. We then conducted a fixed-effect meta-analysis to combine results across the four UK nations. Findings: Between September 1, 2022 and December 31, 2022, 7,451,890 individuals ≥18 years received an autumn booster dose. 3500 had severe COVID-19 outcomes (2.9 events per 1000 person-years). Being male (male vs female, aHR 1.41 (1.32-1.51)), older adults (≥80 years vs 18-49 years; 10.43 (8.06-13.50)), underweight (BMI <18.5 vs BMI 25.0-29.9; 2.94 (2.51-3.44)), those with comorbidities (≥5 comorbidities vs none; 9.45 (8.15-10.96)) had a higher risk of COVID-19 hospitalisation or death after the autumn booster dose. Those with a larger household size (≥11 people within household vs 2 people; 1.56 (1.23-1.98)) and from more deprived areas (most deprived vs least deprived quintile; 1.35 (1.21-1.51)) had modestly higher risks. We also observed at least a two-fold increase in risk for those with various chronic neurological conditions, including Down's syndrome, immunodeficiency, chronic kidney disease, cancer, chronic respiratory disease, or cardiovascular disease. Interpretation: Males, older individuals, underweight individuals, those with an increasing number of comorbidities, from a larger household or more deprived areas, and those with specific underlying health conditions remained at increased risk of COVID-19 hospitalisation and death after the autumn 2022 vaccine booster dose. There is now a need to focus on these risk groups for investigating immunogenicity and efficacy of further booster doses or therapeutics. Funding: National Core Studies-Immunity, UK Research and Innovation (Medical Research Council and Economic and Social Research Council), Health Data Research UK, the Scottish Government, and the University of Edinburgh.

A scoping review finds a growing trend in studies validating multimorbidity patterns and identifies five broad types of validation methods.

OBJECTIVES: Multimorbidity, the presence of two or more long-term conditions, is a growing public health concern. Many studies use analytical methods to discover multimorbidity patterns from data. We aimed to review approaches used in published literature to validate these patterns. STUDY DESIGN AND SETTING: We systematically searched PubMed and Web of Science for studies published between July 2017 and July 2023 that used analytical methods to discover multimorbidity patterns. RESULTS: Out of 31,617 studies returned by the searches, 172 were included. Of these, 111 studies (64%) conducted validation, the number of studies with validation increased from 53.13% (17 out of 32 studies) to 71.25% (57 out of 80 studies) in 2017-2019 to 2022-2023, respectively. Five types of validation were identified: assessing the association of multimorbidity patterns with clinical outcomes (n = 79), stability across subsamples (n = 26), clinical plausibility (n = 22), stability across methods (n = 7) and exploring common determinants (n = 2). Some studies used multiple types of validation. CONCLUSION: The number of studies conducting a validation of multimorbidity patterns is clearly increasing. The most popular validation approach is assessing the association of multimorbidity patterns with clinical outcomes. Methodological guidance on the validation of multimorbidity patterns is needed.

Using hypergraphs to quantify importance of sets of diseases by healthcare resource utilisation: A retrospective cohort study.

Rates of Multimorbidity (also called Multiple Long Term Conditions, MLTC) are increasing in many developed nations. People with multimorbidity experience poorer outcomes and require more healthcare intervention. Grouping of conditions by health service utilisation is poorly researched. The study population consisted of a cohort of people living in Wales, UK aged 20 years or older in 2000 who were followed up until the end of 2017. Multimorbidity clusters by prevalence and healthcare resource use (HRU) were modelled using hypergraphs, mathematical objects relating diseases via links which can connect any number of diseases, thus capturing information about sets of diseases of any size. The cohort included 2,178,938 people. The most prevalent diseases were hypertension (13.3%), diabetes (6.9%), depression (6.7%) and chronic obstructive pulmonary disease (5.9%). The most important sets of diseases when considering prevalence generally contained a small number of diseases, while the most important sets of diseases when considering HRU were sets containing many diseases. The most important set of diseases taking prevalence and HRU into account was diabetes & hypertension and this combined measure of importance featured hypertension most often in the most important sets of diseases. We have used a single approach to find the most important sets of diseases based on co-occurrence and HRU measures, demonstrating the flexibility of the hypergraph approach. Hypertension, the most important single disease, is silent, underdiagnosed and increases the risk of life threatening co-morbidities. Co-occurrence of endocrine and cardiovascular diseases was common in the most important sets. Combining measures of prevalence with HRU provides insights which would be helpful for those planning and delivering services.

Green-blue space exposure changes and impact on individual-level well-being and mental health: a population-wide dynamic longitudinal panel study with linked survey data.

Background: Cross-sectional evidence suggests that living near green and blue spaces benefits mental health; longitudinal evidence is limited. Objectives: To quantify the impact of changes in green and blue spaces on common mental health disorders, well-being and health service use. Design: A retrospective, dynamic longitudinal panel study. Setting: Wales, UK. Participants: An e-cohort comprising 99,682,902 observations of 2,801,483 adults (≥ 16 years) registered with a general practice in Wales (2008-2019). A 5312-strong 'National Survey for Wales (NSW) subgroup' was surveyed on well-being and visits to green and blue spaces. Main outcome measures: Common mental health disorders, general practice records; subjective well-being, Warwick-Edinburgh Mental Well-being Scale. Data sources: Common mental health disorder and use of general practice services were extracted quarterly from the Welsh Longitudinal General Practice Dataset. Annual ambient greenness exposure, enhanced vegetation index and access to green and blue spaces (2018) from planning and satellite data. Data were linked within the Secure Anonymised Information Linkage Databank. Methods: Multilevel regression models examined associations between exposure to green and blue spaces and common mental health disorders and use of general practice. For the National Survey for Wales subgroup, generalised linear models examined associations between exposure to green and blue spaces and subjective well-being and common mental health disorders. Results and conclusions: Our longitudinal analyses found no evidence that changes in green and blue spaces through time impacted on common mental health disorders. However, time-aggregated exposure to green and blue spaces contrasting differences between people were associated with subsequent common mental health disorders. Similarly, our cross-sectional findings add to growing evidence that residential green and blue spaces and visits are associated with well-being benefits: Greater ambient greenness (+ 1 enhanced vegetation index) was associated with lower likelihood of subsequently seeking care for a common mental health disorder [adjusted odds ratio (AOR) 0.80, 95% confidence interval, (CI) 0.80 to 0.81] and with well-being with a U-shaped relationship [Warwick-Edinburgh Mental Well-being Scale; enhanced vegetation index beta (adjusted) -10.15, 95% CI -17.13 to -3.17; EVI2 beta (quadratic term; adj.) 12.49, 95% CI 3.02 to 21.97]. Those who used green and blue spaces for leisure reported better well-being, with diminishing extra benefit with increasing time (Warwick-Edinburgh Mental Well-being Scale: time outdoors (hours) beta 0.88, 95% CI 0.53 to 1.24, time outdoors2 beta -0.06, 95% CI -0.11 to -0.01) and had 4% lower odds of seeking help for common mental health disorders (AOR 0.96, 95% CI 0.93 to 0.99). Those in urban areas benefited most from greater access to green and blue spaces (AOR 0.89, 95% CI 0.89 to 0.89). Those in material deprivation benefited most from leisure time outdoors (until approximately four hours per week; Warwick-Edinburgh Mental Well-being Scale: time outdoorsâ€…× in material deprivation: 1.41, 95% CI 0.39 to 2.43; time outdoors2 × in material deprivation -0.18, 95% CI -0.33 to -0.04) although well-being remained generally lower. Limitations: Longitudinal analyses were restricted by high baseline levels and limited temporal variation in ambient greenness in Wales. Changes in access to green and blue spaces could not be captured annually due to technical issues with national-level planning datasets. Future work: Further analyses could investigate mental health impacts in population subgroups potentially most sensitive to local changes in access to specific types of green and blue spaces. Deriving green and blue spaces changes from planning data is needed to overcome temporal uncertainties. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (Project number 16/07/07) and will be published in full in Public Health Research; Vol. 11, No. 10. Sarah Rodgers is part-funded by the NIHR Applied Research Collaboration North West Coast.

We investigated whether people who live near or visit green (parks, woodlands) and blue (riversides, beaches) spaces have fewer common mental health disorders (anxiety or depression), and better well-being. We considered whether changes in the amount of green and blue space around the home affected people's mental health. We assessed the availability of local green and blue spaces. Annual exposure and access to local green and blue spaces were extracted from planning and satellite data. We linked these data to anonymised health records of 2,801,483 adults registered with a general practice from 2008 to 2019, and to survey answers about leisure visits to natural environments and well-being. We found: people who lived in greener and bluer areas were less likely to seek help for a common mental health disorder than those in less green or blue areas, with those living in the most deprived areas benefiting the most people who used green and blue spaces for leisure, especially those with the greatest levels of deprivation, had better well-being and were less likely to seek help for common mental health disorders no evidence that changing amounts of green and blue space affected how likely people were to seek help for common mental health disorders; this may be because we found mostly small changes in green and blue space, and we may not have allowed enough time between moving home and recording mental health. We found evidence for relationships between green and blue space and mental health. However, some analyses were restricted due to lack of data on changes in green and blue spaces. An important finding was that people in deprived communities appear to benefit the most. Provision of green and blue spaces could be a strategy to improve the mental health of people living in disadvantaged areas.