Do influenza and pneumococcal vaccines prevent community-acquired respiratory infections among older people with diabetes and does this vary by chronic kidney disease? A cohort study using electronic health records

Objective: We aimed to estimate the effectiveness of influenza and 23-valent pneumococcal polysaccharide vaccination on reducing the burden of community-acquired lower respiratory tract infection (LRTI) among older people with diabetes, and whether this varied by chronic kidney disease status. Research design and methods: We used linked UK electronic health records for a retrospective cohort study of 190,492 patients ≥65 years with diabetes mellitus and no history of renal replacement therapy, 1997–2011. We included community-acquired LRTIs managed in primary or secondary care. Infection incidence rate ratios were estimated using Poisson regression. Pneumococcal vaccine effectiveness (VE) was calculated as (1 – effect measure). To estimate influenza VE a ratio-of-ratios analysis (winter effectiveness/summer effectiveness) was used to address confounding by indication. Final VE estimates were stratified according to estimated glomerular filtration rate and proteinuria status. Results: Neither influenza nor pneumococcal vaccine uptake varied according to CKD status. Pneumococcal VE was 22% (95%CI: 11–31) against community-acquired pneumonia for the first year after vaccination, but was negligible after five years. In the ratio-of-ratios analysis, current influenza vaccination had 7% effectiveness for preventing community-acquired LRTI (95%CI: 3–12). Pneumococcal vaccine effectiveness was lower among patients with a history of proteinuria than among patients without proteinuria (p=0.04), but otherwise this study did not identify variation in pneumococcal or influenza VE by markers of CKD. Conclusions: The public health benefits of influenza vaccine may be modest among older people with diabetes. Pneumococcal vaccination protection against community-acquired pneumonia declines swiftly: alternative vaccination schedules should be investigated

The use of a bayesian hierarchy to develop and validate a co-morbidity score to predict mortality for linked primary and secondary care data from the NHS in England

Background: We have assessed whether the linkage between routine primary and secondary care records provided an opportunity to develop an improved population based co-morbidity score with the combined information on co-morbidities from both health care settings. Methods: We extracted all people older than 20 years at the start of 2005 within the linkage between the Hospital Episodes Statistics, Clinical Practice Research Datalink, and Office for National Statistics death register in England. A random 50% sample was used to identify relevant diagnostic codes using a Bayesian hierarchy to share information between similar Read and ICD 10 code groupings. Internal validation of the score was performed in the remaining 50% and discrimination was assessed using Harrell’s C statistic. Comparisons were made over time, age, and consultation rate with the Charlson and Elixhauser indexes. Results: 657,264 people were followed up from the 1st January 2005. 98 groupings of codes were derived from the Bayesian hierarchy, and 37 had an adjusted weighting of greater than zero in the Cox proportional hazards model. 11 of these groupings had a different weighting dependent on whether they were coded from hospital or primary care. The C statistic reduced from 0.88 (95% confidence interval 0.88–0.88) in the first year of follow up, to 0.85 (0.85–0.85) including all 5 years. When we stratified the linked score by consultation rate the association with mortality remained consistent, but there was a significant interaction with age, with improved discrimination and fit in those under 50 years old (C=0.85, 0.83–0.87) compared to the Charlson (C=0.79, 0.77–0.82) or Elixhauser index (C=0.81, 0.79–0.83). Conclusions: The use of linked population based primary and secondary care data developed a co-morbidity score that had improved discrimination, particularly in younger age groups, and had a greater effect when adjusting for co-morbidity than existing scores

New estimates of the burden of acute community-acquired infections among older people with diabetes mellitus: a retrospective cohort study using linked electronic health records.

AIM: To describe the incidence of acute community-acquired infections (lower respiratory tract infections, urinary tract infections and sepsis) among the UK population aged ≥65 years with diabetes mellitus, and all-cause 28-day hospital admission rates and mortality. METHODS: We used electronic primary care records from the Clinical Practice Research Datalink, linked to death certificates and Hospital Episode Statistics admission data, to conduct a retrospective cohort study from 1997 to 2011. RESULTS: Among the 218 805 older people with diabetes there was a high burden of community-acquired infection, lower respiratory tract infections having the highest incidence (crude rate: 152.7/1000 person-years) followed by urinary tract infections (crude rates 51.4 and 147.9/1000 person-years for men and women, respectively). The incidence of all infections increased over time, which appeared to be driven by the population's changing age structure. Most patients diagnosed with pneumonia and sepsis were hospitalized on the same day (77.8 and 75.1%, respectively). For lower respiratory tract infections and urinary tract infections, a large proportion of 28-day hospitalizations were after the day of diagnosis (39.1 and 44.3%, respectively), and a notable proportion of patients (7.1 and 5.1%, respectively) were admitted for a cardiovascular condition. In the 4 weeks after onset, all-cause mortality was 32.1% for pneumonia (3115/9697), 31.7% for sepsis (780/2461), 4.1% for lower respiratory tract infections (5685/139 301) and 1.6% for urinary tract infections (1472/91 574). CONCLUSIONS: The present large cohort study provides up-to-date detailed infection incidence estimates among older people with diabetes in the community, with variation by age, sex and region and over time. This should be of use for patient communication of risk and future healthcare planning

Factors associated with being lost to follow-up before completing tuberculosis treatment: analysis of surveillance data.

Completion of treatment is key to tuberculosis control. Using national surveillance data we assessed factors associated with tuberculosis patients being lost to follow-up before completing treatment ('lost'). Patients reported in England, Wales and Northern Ireland between 2001 and 2007 who were lost 12 months after beginning treatment were compared to those who completed, or were still on treatment, using univariable and multivariable logistic regression. Of 41 120 patients, men [adjusted odds ratio (aOR) 1·29; 95% confidence interval (CI) 1·23-1·35], 15- to 44-year-olds (P<0·001), and patients with pulmonary sputum smear-positive disease (aOR 1·25, 95% CI 1·12-1·45) were at higher risk of being lost. Those recently arrived in the UK were also at increased risk, particularly those of the White ethnic group (aOR 6·39, 95% CI 4·46-9·14). Finally, lost patients had a higher risk of drug resistance (aOR 1·41, 95% CI 1·17-1·69). Patients at risk of being lost require enhanced case management and novel case retention methods are needed to prevent this group contributing towards onward transmission

Sex differences in risk factors for myocardial infarction: cohort study of UK Biobank participants

Objectives To investigate sex differences in risk factor associations with incident myocardial infarction (MI) and whether these vary by age. Design Prospective population based study. Setting UK Biobank Participants 471,998 participants, (56% women; mean age 56.2 years) with no history of cardiovascular disease. Main outcome measures Incident (fatal and non-fatal) MI. Results 5,081 participants (29% women) experienced MI over seven years mean follow-up, resulting in incidence rates of 7.76/10,000 person years (95% CI 7.37 to 8.16) among women and 24.35/10,000 (23.57 to 25.16) among men. In both sexes, higher blood pressure (BP) indices, smoking intensity, and body mass index, and the presence of diabetes were associated with an increased risk of MI, but associations were attenuated with age. Compared with men, women had an excess HR of MI for systolic BP and hypertension, smoking status and intensity, and diabetes: ratio of HRs (95% CIs) were 1.09 (1.02 to 1.16) for systolic BP, 1.55 (1.32 to 1.83) for current smoking, and 2.91 (1.56 to 5.45) for type I and 1.47 (1.16 to 1.87) for type II diabetes. There was no evidence of attenuation of any of these RHRs with age (p&gt;0.2). With the exception of type I diabetes, for all risk factors, and for every category of those risk factors, men had higher rates of MI than women. Conclusions Rates of MI are higher among men than women. However, several major risk factors for MI confer an excess relative risk of MI among women compared with men. With ageing, sex-specific associations decline but, where it occurs, the female disadvantage in relative risk persists. Over time, population ageing, coupled with the increasing prevalence of lifestyle-associated risk factors, is likely to result in women having a more similar rate of MI to men.</p

Sex differences in risk factors for myocardial infarction: cohort study of UK Biobank participants

Objectives To investigate sex differences in risk factor associations with incident myocardial infarction (MI) and whether these vary by age. Design Prospective population based study. Setting UK Biobank Participants 471,998 participants, (56% women; mean age 56.2 years) with no history of cardiovascular disease. Main outcome measures Incident (fatal and non-fatal) MI. Results 5,081 participants (29% women) experienced MI over seven years mean follow-up, resulting in incidence rates of 7.76/10,000 person years (95% CI 7.37 to 8.16) among women and 24.35/10,000 (23.57 to 25.16) among men. In both sexes, higher blood pressure (BP) indices, smoking intensity, and body mass index, and the presence of diabetes were associated with an increased risk of MI, but associations were attenuated with age. Compared with men, women had an excess HR of MI for systolic BP and hypertension, smoking status and intensity, and diabetes: ratio of HRs (95% CIs) were 1.09 (1.02 to 1.16) for systolic BP, 1.55 (1.32 to 1.83) for current smoking, and 2.91 (1.56 to 5.45) for type I and 1.47 (1.16 to 1.87) for type II diabetes. There was no evidence of attenuation of any of these RHRs with age (p>0.2). With the exception of type I diabetes, for all risk factors, and for every category of those risk factors, men had higher rates of MI than women. Conclusions Rates of MI are higher among men than women. However, several major risk factors for MI confer an excess relative risk of MI among women compared with men. With ageing, sex-specific associations decline but, where it occurs, the female disadvantage in relative risk persists. Over time, population ageing, coupled with the increasing prevalence of lifestyle-associated risk factors, is likely to result in women having a more similar rate of MI to men.</p

Temporal trends and patterns in mortality after incident heart failure: a longitudinal analysis of 86,000 individuals

Importance Despite considerable improvements in heart failure care, mortality rates among patients in high-income countries have changed little since the early 2000s. Understanding the reasons underlying these trends may provide valuable clues for developing more targeted therapies and public health strategies. Objective To investigate mortality rates following a new diagnosis of heart failure and examine changes over time and by cause of death and important patient features. Design, Setting, and Participants This population-based retrospective cohort study analyzed anonymized electronic health records of individuals who received a new diagnosis of heart failure between January 2002 and December 2013 who were followed up until December 2014 from the Clinical Practice Research Datalink, which links information from primary care, secondary care, and the national death registry from a subset of the UK population. The data were analyzed from January 2018 to February 2019. Main Outcomes and Measures All-cause and cause-specific mortality rates at 1 year following diagnosis. Poisson regression models were used to calculate rate ratios (RRs) and 95% confidence intervals comparing 2013 with 2002, adjusting for age, sex, region, socioeconomic status, and 17 major comorbidities. Results Of 86 833 participants, 42 581 (49%) were women, 51 215 (88%) were white, and the mean (SD) age was 76.6 (12.6) years. While all-cause mortality rates declined only modestly over time (RR comparing 2013 with 2002, 0.94; 95% CI, 0.88-1.00), underlying patterns presented explicit trends. A decline in cardiovascular mortality (RR, 0.73; 95% CI, 0.67-0.80) was offset by an increase in noncardiovascular deaths (RR, 1.22; 95% CI, 1.11-1.33). Subgroup analyses further showed that overall mortality rates declined among patients younger than 80 years (RR, 0.79; 95% CI, 0.71-0.88) but not among those older than 80 years (RR, 0.97; 95% CI, 0.90-1.06). After cardiovascular causes (898 [43%]), the major causes of death in 2013 were neoplasms (311 [15%]), respiratory conditions (243 [12%]), and infections (13%), the latter 2 explaining most of the observed increase in noncardiovascular mortality. Conclusions and Relevance Among patients with a new heart failure diagnosis, considerable progress has been achieved in reducing mortality in young and middle-aged patients and cardiovascular mortality across all age groups. Improvements to overall mortality are hindered by high and increasing rates of noncardiovascular events. These findings challenge current research priorities and management strategies and call for a greater emphasis on associated comorbidities. Specifically, infection prevention presents as a major opportunity to improve prognosis.</p