Publications
scientifiques

BACKGROUND: Between 1992 and 2001 the UK general practice incidence of post-herpetic neuralgia and trigeminal neuralgia declined, whilst the incidence of painful diabetic neuropathy increased. The most common first line treatments were compound analgesics. As therapeutic options have subsequently changed, this study presents updated data on incidence and prescribing patterns in neuropathic pain. METHODS: A descriptive analysis of the epidemiology and prescription treatment at diagnosis of incident post-herpetic neuralgia (n = 1,923); trigeminal neuralgia (1,862); phantom limb pain (57) and painful diabetic neuropathy (1,444) using computerised UK general practice records (THIN): May 2002 to July 2005. RESULTS: Primary care incidences per 100,000 person years observation of 28 (95% confidence interval (CI) 27-30) for post-herpetic neuralgia, 27 (95%CI 26-29) for trigeminal neuralgia, 0.8 (95%CI 0.6-1.1) for phantom limb pain and 21 (95%CI 20-22) for painful diabetic neuropathy are reported. The most common initial treatments were tricyclic antidepressants (post-herpetic neuralgia) or antiepileptics (trigeminal neuralgia and painful diabetic neuropathy) and opioid analgesics (phantom limb pain). The mean number of changes before a stable drug regimen was 1.2 to 1.5 for trigeminal neuralgia, painful diabetic neuropathy and post-herpetic neuralgia, and 2.4 for phantom limb pain. CONCLUSION: The incidence of phantom limb pain and post-herpetic neuralgia are decreasing whilst painful diabetic neuropathy plateaued and trigeminal neuralgia remained constant. Despite more frequent use of antidepressants and antiepileptics for first line treatment, as opposed to conventional non-opioid analgesics, changes to therapy are common before a stable regimen is reached.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: The 1998 and 2003 Health Survey for England revealed a high prevalence of hypertension and hypercholesterolaemia in the population of England. Major changes in the reimbursement of primary care for the management of both hypertension and hypercholesterolaemia have occurred in the UK. WHAT THIS STUDY ADDS: Using a GP database we have examined the proportion of subjects diagnosed and treated for hypertension and hypercholesterolaemia over time. To examine the true population rates and primary care data we compared the results of the Health survey for England in both 1998 and 2003 with the recorded data on GP computers. Despite current guidelines, many patients with hypertension and/or hypercholesterolaemia are under-treated and, even amongst those who are treated, many do not achieve their blood pressure and/or lipid targets. Although treatment rates in the UK have improved recently, particularly for lipid-lowering therapies, they remain suboptimal. AIMS To determine the prevalence and treatment of hypertension, dyslipidaemia and both together in the UK between 1998 and 2006. METHODS: We used The Health Improvement Network (THIN) a general practice-based database from 1998 to 2006 and we compared the 1998 and 2003 data to that taken from the Health Survey for England (HSE) in 1998 and 2003. RESULTS: The prevalence (treatment) of hypertension was 25.3% (11.4%) in 1998, 27.8% (15.1%) in 2003 and 26.9% (16.2%) in 2006 in THIN. In HSE it was 37.3% (9.6%) in 1998 and 32.9% (13.8%) in 2003. For dyslipidaemia the figures were 8.6% (1.9%), 18.5% (6.5%) and 24.4% (9.8%) for THIN and 67.8% (2.3%) and 74.9% (7.0%) for HSE. Concurrent hypertension and dyslipidaemia in THIN increased from 5.5% (1.1%) in 1998 to 13.5% (4.5%) in 2003 and 17.4% (7.1%) in 2006. The prevalence of both conditions was 30.6% (0.7%) in HSE in 1998 and 28.7% (3.1%) in 2003. CONCLUSIONS: There has been a progressive improvement in the detection and treatment of hypertension, dyslipidaemia and both conditions together between 1998 and 2006. However, much still needs to be done to improve the diagnosis and treatment of hypertension, hypercholesterolaemia and concurrent hypertension and hypercholesterolaemia in the United Kingdom.

BACKGROUND: In England, the impact of increased use of antidepressant medications is unclear. We examine associations between antidepressant use, suicide and antidepressant poisoning mortality, adjusted for important covariates. METHODS: Data on suicide and antidepressant poisoning mortality were provided by the Office for National Statistics. Prescription data were provided by the Department of Health. Age- and sex-specific prescribing rates were estimated from The Health Improvement Network primary care data. We measured the association between prescribing, suicide and poisoning mortality after adjusting for age, sex, calendar year, prescribing rates and use of newer antidepressants drugs. RESULTS: The prevalence of antidepressant treatment increased during the 1990s for all age and sex groups. Treatment prevalence remained constant from 2002 but declined among children and adolescents. Between 1993 and 2004, age-standardized rates for suicide decreased from 98.2 to 81.3 per million populations and for antidepressants from 9.2 to 7.4 per million populations. Before adjustment, increased antidepressant prescribing was associated with a decrease in suicide (r(s) = -0.90, P < 0.001) and antidepressant poisoning mortality rates (r(s) = -0.65, P = 0.023). This association disappeared after adjustment. CONCLUSION: In England, at a population level, there does not appear to be an association between antidepressant prescribing and antidepressant poisoning mortality or suicide.

This study aims to identify the extent of terminal digit bias in routinely recorded blood pressures (BP) across a number of different general practices and report on changes in terminal digit bias over a 10-year period. It also explores the effect this may have had on the mean recorded BP in this population. BP records were taken from The Health Improvement Network database containing anonymized patient records from information entered by UK general practices in the financial years 1996-1997 to 2005-2006. The proportion of measurements ending in zero and the mean BP readings were calculated for each practice and for each year of data.Over this 10-year period the percentage of systolic BPs with zero terminal digits fell from 71.2 to 36.7% and mean recorded BP fell from 152.3 to 145.3 mm Hg. Correcting the BPs to remove terminal digit bias indicates a 2-3 mm Hg underestimation of the mean population systolic BP over this period. The between-practice variation in the percentage of zero terminal digit readings increased from 3.5 to 6.5 s.d. Although it is welcome to see a reduction in terminal digit bias, it is worrying to see the increase in variation between practices. There is evidence that terminal digit bias may lead to potential misclassification and inappropriate treatment of hypertensive patients. The increase in variation observed may therefore lead to an increased variation in the quality of care given to patients.

BACKGROUND: The introduction of the NICE guideline on COPD and the inclusion of COPD in the new Quality and Outcomes Framework (QOF) were designed to improve the care of people with COPD in primary care in the UK. AIM: We have investigated whether these initiatives have had an impact on the prevalence of COPD, the recording of spirometry data and the use of combined inhaled corticosteroid/long-acting beta-agonist inhalers. DESIGN: We analysed data from The Health Improvement Network for the year before and after the introduction of the NICE guideline. METHODS: Data were analysed using logistic regression. RESULTS: The prevalence of COPD in 2003 was 1.27%, and this increased by 14-1.45% in 2005. The risk of COPD was strongly related to age, male gender, socioeconomic disadvantage and living in the North of England, Scotland and Wales. People with COPD had an increased mortality (adjusted rate ratio for 2003 is 2.38, 95% confidence interval 2.30-2.47). The presence of recorded spirometry data in people with COPD increased from 18% in 2003 to 62% in 2005, and FEV1 was consistently a strong predictor of survival. The use of combination inhalers in people with moderate to severe COPD also increased markedly during the study. CONCLUSION: Following the introduction of the NICE guideline for COPD and the new QOF, there has been an increase in the prevalence of COPD in general practice and a large increase in spirometry data and prescriptions for combination inhalers. This represents significant progress for people with COPD.

Although anaemia is recognised as a feature of colorectal cancer, the precise risk is unknown. We performed a case-control study using electronic primary care records from the Health Improvement Network database, UK. A total of 6442 patients had a diagnosis of colorectal cancer, and were matched to 45 066 controls on age, sex, and practice. We calculated likelihood ratios and positive predictive values for colorectal cancer in both sexes across 1 g dl(-1) haemoglobin and 10-year age bands, and examined the features of iron deficiency. In men, 178 (5.2%) of 3421 cases and 47 (0.2%) of 23,928 controls had a haemoglobin <9.0 g dl(-1), giving a likelihood ratio (95% confidence interval) of 27 (19, 36). In women, the corresponding figures were 227 (7.5%) of 3021 cases and 58 (0.3%) of 21,138 controls, a likelihood ratio of 41 (30, 61). Positive predictive values increased with age and for each 1 g dl(-1) reduction in haemoglobin. The risk of cancer for current referral guidance was quantified. For men over 60 years with a haemoglobin <11 g dl(-1) and features of iron deficiency, the positive predictive value was 13.3% (9.7, 18) and for women with a haemoglobin <10 g dl(-1) and iron deficiency, the positive predictive value was 7.7% (5.7, 11). Current guidance for urgent investigation of anaemia misses some patients with a moderate risk of cancer, particularly men.

AIM: To assess the performance of the QRISK score for predicting cardiovascular disease (CVD) in an independent UK sample from general practice and compare with the Framingham score. DESIGN: Prospective open cohort study. SETTING: UK general practices contributing to the THIN and QRESEARCH databases. COHORT: The THIN validation cohort consisted of 1.07 million patients, aged 35-74 years registered at 288 THIN practices between 1 January 1995 and 1 April 2006. The QRESEARCH validation cohort consisted of 0.61 million patients from 160 practices (one-third of the full database) with data until 1 January 2007. Patients receiving statins, those with diabetes or CVD at baseline were excluded. END POINT: First diagnosis of CVD (myocardial infarction, coronary heart disease (CHD), stroke and transient ischaemic attack) recorded on the clinical computer system during the study period. EXPOSURES: Age, sex, smoking status, systolic blood pressure, total/high-density lipoprotein cholesterol ratio, body mass index, family history of premature CHD, deprivation and antihypertensive medication. RESULTS: Characteristics of both cohorts were similar, except that THIN patients were from slightly more affluent areas and had lower recording of family history of CHD. QRISK performed better than Framingham for every discrimination and calibration statistic in both cohorts. Framingham overpredicted risk by 23% in the THIN cohort, while QRISK underpredicted risk by 12%. CONCLUSION: This analysis demonstrated that QRISK is better calibrated to the UK population than Framingham and has better discrimination. The results suggest that QRISK is likely to provide more appropriate risk estimates than Framingham to help identify patients at high risk of CVD in the UK.

OBJECTIVE: To evaluate the effect of antidepressant use on lung cancer risk. METHODS: We conducted a case-control study nested in a cohort of patients 40-84 year-old in 1995-2004, without a prior diagnosis of cancer using The Health Improvement Network (THIN) database in the UK. Cases comprised 4,336 patients with a first diagnosis of primary lung cancer. A sample of 10,000 controls was frequency-matched to the cases for age, sex, and the calendar year of diagnosis. The index date for exposure definition was one year before the diagnosis for cases and one year before a random date for controls. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression models adjusted for potential confounders. RESULTS: Selective serotonin reuptake inhibitor (SSRI) use during the year preceding the index date with treatment duration of at least one year had an OR of 0.59 (95% CI 0.41, 0.86). The corresponding OR was 1.23 (95% CI 0.96, 1.58) for tricyclic antidepressants (TCAs). CONCLUSIONS: SSRI use did not increase the lung cancer risk and might be associated with a reduced risk. However, residual confounding might explain the apparent protective effect found for SSRI use, as well as the marginally elevated risk observed among TCA users.