Suchergebnisse

ABSTRACT
ObjectivesPatients with atrial fibrillation (AF) have an increased risk of developing stroke, and oral anticoagulants (OACs) are commonly used in stroke prevention. The CHA2DS2-VASc score has been proved to be a simple and effective tool for stroke risk assessment which guides the selection of treatment with OACs. This score is calculated using disease diagnoses; however, a range of different versions exist, making comparability questionable.
The aim of this study was to compare CHA2DS2-VASc scores in OAC treated patients with a hospital-confirmed diagnosis of AF in Scotland using different subsets of ICD-10 codes.
Approach This is a retrospective study, covering AF patients in Scotland who received at least one prescription for any OAC between January 2009 and June 2014. The Prescribing Information System (PIS) was used to identify patients with OAC prescriptions, while the Scottish Morbidity Records (SMR) provided patients' diagnoses. Different sets of ICD-10 codes, using varying definitions, were used to classify the stroke risk in AF patients in order to account for heterogenous definitions applied in previously published studies. The main differences in codes used were the inclusion or exclusion of unclassified stroke (ICD-10 code I64), and the inclusion of pulmonary embolism (PE) (I26) as either "prior thromboembolic event" or "vascular disease".
ResultsIn our study, a cohort of 71012 AF patients with OAC prescription were analysed. Using narrow disease definitions, 18.15% of patients were categorised as being at low risk of stroke (score 0-1), 74.80% at medium risk (score 2-5), and 7.04% at high risk (score 6-9). With an extended disease definition, including PE in "prior thromboembolic event", 14.81% of patients were at low risk (score 0-1), 72.60% at medium risk (score 2-5), and 12.59% at high risk (score 6-9); while including PE in "vascular disease", 14.99% of the patients had a score 0-1, 73.54% a score 2-5, and 11.48% a score 6-9.
Conclusion The change in score definitions makes a difference mainly in the number of patients categorised as very low risk or high risk. Standardisation in ICD-10 code definition of risk diseases could be useful in order to make the results comparable from different studies and further evaluate OAC choice according to risk group.

ABSTRACTObjectivesThere have been a number of key changes in the clinical definition and diagnostic threshold of acute coronary syndromes in the last 10 years. We have characterised temporal and geographic changes in the incidence and outcomes following Acute Coronary Syndrome (ACS: Unstable Angina (UA), Non ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI)) between 2009 and 2013.
Approach65,137 hospitals stays were identified involving ACS (ICD-10: I20.0, I21 and I22) relating to 55,369 individuals identified through secondary care primary diagnosis records during 2009-2013. All prior and subsequent secondary care diagnoses from 1981-2014 were sourced for these patients and records were deterministically matched on a pseudo patient identifier to obtain the cause and date of death for purposes of follow-up. An incident ACS case was defined as such if the patient had not suffered an ACS in the five years prior to the hospital admission and all co-morbidities were derived from hospital diagnostic codes accompanying the ACS codes.
ResultsFor the entire cohort, patients with an incident ACS were predominantly male (61.5%) with mean age 68 (SD=13.7 years). Co-morbidities included: 65.5% Other Ischaemic Heart Disease; 5.2% Stroke; 7.5% Peripheral Artery Disease; 14.8% Atrial Fibrillation; 42.0% Hypertension; 18.0% Diabetes Mellitus and 8.4% Chronic Kidney Disease.
The overall incidence of ACS in 2009 was 204/100,000 and fell by 8.1% to 188/100,000 in 2013. Subtypes of ACS comprised 9.4% UA, 50.9% NSTEMI, 29.0% STEMI and 10.8% MI unspecified in 2013.
In-hospital mortality following an incident ACS was 9.7% (95% CI: 9.2-10.3%) in 2009 and varied from 7.9 to 19.0% across the NHS boards. In 2013, in-hospital mortality was 8.5% (95% CI: 7.9-9.0%) ranging from 4.5 to 10.5% across the NHS boards. One-year mortality following an incident ACS in 2009 was 18.6% (95% CI: 17.9-19.4%) falling to 16.8% (95% CI: 16.1-17.5%) in 2013. Stratified by NHS board, the one-year mortality rate in 2009 varied from 16.9 to 28.0% and in 2013 ranged from 11.9 to 20.0% across the NHS boards.
ConclusionThese findings highlight the importance of a cohort based record linkage approach to routine healthcare datasets. While there appears to be changes in incidence of ACS and its subtypes and changes in mortality over time, these findings reflect significant changes in clinical practice with respect to definition and diagnosis. Cautious interpretation is needed combined with further research to fully understand the epidemiological implications of our findings.

ABSTRACTObjectivesBiologics are a class of medicines recommended by UK and international guidelines for treatment of patients with rheumatoid arthritis (RA) who are unresponsive, intolerant or who have contraindications to conventional therapies. Biologics are often supplied in the UK to patients in their home by external healthcare providers commissioned by the National Health Service (NHS). Patient adherence and persistence to biologics has not been assessed within NHS Scotland.The aim of this study was to evaluate adherence and persistence patterns of subcutaneous biologics delivered by homecare services to patients with rheumatoid arthritis in a Scottish NHS Board.
ApproachA population-based cohort study was conducted using records from patients receiving medication through healthcare delivery companies in the NHS Greater Glasgow and Clyde health board. RA patients with deliveries between 2012- 2015 were linked via their Community Health Index number to their prescriptions in primary care, hospital admissions and death records. For this study those with at least two deliveries of biologics and who did not switch biologic treatment were included. Length of therapy was determined from first delivery to last day treatment was covered. Adherence rate referring to the supply received for the whole study period was evaluated through Medication Refill Adherence (MRA). Persistence from first delivery to discontinuation was estimated using survival analysis and a drug–free interval of 90 days.
ResultsA total of 434 patients with RA received a subcutaneous biologic. The mean age at first delivery was 54.7 (SD 13.4) years and 78% were female. From this cohort, 322 had at least 2 deliveries of the same biologic. The overall median length of treatment was 387.5 days (IQR 544.5); the longest for certolizumab pegol users with a median of 511.5 days (IQR 629.2) and the shortest for tocilizumab (median of 187 days, IQR 90.5). The adherence throughout the study had a mean MRA 79.73% (SD 29.95) and was similar across the different biologics. Persistence at follow-up decreased with time from 81% of the patients receiving a biologic at 6 months, to 67% after 1 year and 65% after two years. Adalimumab, certolizumab pegol, etanercept and golimumab users had higher persistence rates.
ConclusionLength of treatment and persistence, but not adherence, are influenced by the type of subcutaneous biologic received by the RA patients in this cohort.Future research will gain a better insight into the factors influencing adherence and persistence to these medicines.