The influence of socio-demographic characteristics on consultation for back pain—a review of the literature

Background. There are several assumptions within clinical practice about who is more or less likely to consult a health care practitioner for particular symptoms, most commonly these focus around socio-demographic characteristics. We aimed to assess the evidence for the impact of socio-demographic characteristics on consultation for back pain

Attitudes to depression and its treatment in primary care

Background Undertreatment of depression in primary care is common. Efforts to address this tend to overlook the role of patient attitudes. Our aim was to validate and describe responses to a questionnaire about attitudes to depression and its treatment in a sample with experience of moderate and severe depressive episodes. Method Cross-sectional survey of 866 individuals with a confirmed history of an ICD-10 depressive episode in the 12 months preceding interview, recruited from 7271 consecutive general practitioner (GP) attendees in 36 general practices in England and Wales. Attitudes to and beliefs about depression were assessed using a 19-item self-report questionnaire. Results Factor analysis resulted in a three-factor solution: factor 1, depression as a disabling, permanent state; factor 2, depression as a medical condition responsive to support; and factor 3, antidepressants are addictive and ineffective. Participants who received and adhered to antidepressant medication and disclosed their depression to family and friends had significantly lower scores on factors 1 and 3 but higher scores on factor 2. Conclusions People with moderate or severe depressive episodes have subtle and divergent views about this condition, its outcome, and appropriate help. Such beliefs should be considered in primary care as they may significantly impact on help seeking and adherence to treatment

Gender differences in survival and the use of primary care prior to diagnosis of three cancers:an analysis of routinely collected UK general practice data

Objective To explore whether there are gender differences in the number of GP recorded cases, the probability of survival and consulting pattern prior to diagnosis amongst patients with three non-sex-specific cancers. Design Cross sectional study. Setting UK primary care. Subjects 12,189 patients aged 16 years or over diagnosed with colorectal cancer (CRC), 11,081 patients with lung cancer and 4,352 patients with malignant melanoma, with first record of cancer diagnosis during 1997–2006. Main outcome measures Cancer cases recorded in primary care; probability of survival following diagnosis; and number of GP contacts within the 24 months preceding diagnosis. Results From 1997–2006, overall rates of GP recorded CRC and lung cancer cases recorded were higher in men than in women, but rates of malignant melanoma were higher in women than in men. Gender differences in survival were small; 49% of men and 53% of women survived at least 5 years following CRC diagnosis; 9% of men and 12% of women with lung cancer, and 77% of men and 86% of women with malignant melanoma. The adjusted male to female relative hazard ratio of death in all patients was 1.20 (95%CI 1.13–1.30), 1.24 (95%CI 1.16–1.33) and 1.73 (95%CI 1.51–2.00) for CRC, lung cancer and malignant melanoma respectively. However, gender differences in the relative risk were much smaller amongst those who died during follow-up. For each cancer, there was little evidence of gender difference in the percentage who consulted and the number of GP contacts made within 24 months prior to diagnosis. Conclusions This study found that patterns of consulting prior to cancer diagnosis differed little between two genders, providing no support for the hypothesis that gender differences in survival are explained by gender differences in consultation for more serious illness, and suggests the need for a more critical view of gender and consultation

Landmark models for optimizing the use of repeated measurements of risk factors in electronic health records to predict future disease risk

The benefits of using electronic health records for disease risk screening and personalized heathcare decisions are becoming increasingly recognized. We present a computationally feasible statistical approach to address the methodological challenges in utilizing historical repeat measures of multiple risk factors recorded in electronic health records to systematically identify patients at high risk of future disease. The approach is principally based on a two-stage dynamic landmark model. The first stage estimates current risk factor values from all available historical repeat risk factor measurements by landmark-age-specific multivariate linear mixed-effects models with correlated random-intercepts, which account for sporadically recorded repeat measures, unobserved data and measurements errors. The second stage predicts future disease risk from a sex-stratified Cox proportional hazards model, with estimated current risk factor values from the first stage. Methods are exemplified by developing and validating a dynamic 10-year cardiovascular disease risk prediction model using electronic primary care records for age, diabetes status, hypertension treatment, smoking status, systolic blood pressure, total and high-density lipoprotein cholesterol from 41,373 individuals in 10 primary care practices in England and Wales contributing to The Health Improvement Network (1997-2016). Using cross-validation, the model was well-calibrated (Brier score = 0.041 [95%CI: 0.039, 0.042]) and had good discrimination (C-index = 0.768 [95%CI: 0.759, 0.777]).This work was funded by the Medical Research Council (MRC) (grant MR/K014811/1). J.B. was supported by an MRC fellowship (grant G0902100) and the MRC Unit Program (grant MC_UU_00002/5). R.H.K. was supported by an MRC Methodology Fellowship (grant MR/M014827/1)

Genetically raised serum bilirubin levels and lung cancer: a cohort study and Mendelian randomisation using UK Biobank.

BACKGROUND: Moderately raised serum bilirubin levels are associated with lower rates of lung cancer, particularly among smokers. It is not known whether these relationships reflect antioxidant properties or residual confounding. OBJECTIVE: This study aimed to investigate potential causal relationships between serum total bilirubin and lung cancer incidence using one-sample Mendelian randomisation (MR) and UK Biobank. METHODS: We instrumented serum total bilirubin level using two variants (rs887829 and rs4149056) that together explain ~40% of population-level variability and are linked to mild hereditary hyperbilirubinaemia. Lung cancer events occurring after recruitment were identified from national cancer registries. Observational and genetically instrumented incidence rate ratios (IRRs) and rate differences per 10 000 person-years (PYs) by smoking status were estimated. RESULTS: We included 377 294 participants (median bilirubin 8.1 μmol/L (IQR 6.4-10.4)) and 2002 lung cancer events in the MR analysis. Each 5 μmol/L increase in observed bilirubin levels was associated with 1.2/10 000 PY decrease (95% CI 0.7 to 1.8) in lung cancer incidence. The corresponding MR estimate was a decrease of 0.8/10 000 PY (95% CI 0.1 to 1.4). The strongest associations were in current smokers where a 5 μmol/L increase in observed bilirubin levels was associated with a decrease in lung cancer incidence of 10.2/10 000 PY (95% CI 5.5 to 15.0) and an MR estimate of 6.4/10 000 PY (95% CI 1.4 to 11.5). For heavy smokers (≥20/day), the MR estimate was an incidence decrease of 23.1/10 000 PY (95% CI 7.3 to 38.9). There was no association in never smokers and no mediation by respiratory function. CONCLUSION: Genetically raised serum bilirubin, common across human populations, may protect people exposed to high levels of smoke oxidants against lung cancers

The Value of Blood-Based Measures of Liver Function and Urate in Lung Cancer Risk Prediction: A Cohort Study and Health Economic Analysis

BACKGROUND: Several studies have reported associations between low-cost blood-based measurements and lung cancer but their role in risk prediction is unclear. We examined the value of expanding lung cancer risk models for targeting low-dose computed tomography (LDCT) to include blood measurements of liver function and urate. METHODS: We analysed a cohort of 388,199 UK Biobank participants with 1,873 events and calculated the c-index and fraction of new information (FNI) for models expanded to include combinations of blood measurements, lung function (forced expiratory volume in 1 second - FEV1), alcohol status and waist circumference. We calculated the hypothetical cost per lung cancer case detected by LDCT for different scenarios using a threshold of ≥ 1.51% risk at 6 years. RESULTS: The c-index was 0.805 (95%CI:0.794-0.816) for the model containing conventional predictors. Expanding to include blood measurements increased the c-index to 0.815 (95%CI: 0.804-0.826;p<0.0001;FNI:0.06). Expanding to include FEV1, alcohol status, and waist circumference increased the c-index to 0.811 (95%CI:0.800-0.822;p<0.0001;FNI:0.04). The c-index for the fully expanded model containing all variables was 0.819 (95%CI:0.808-0.830; p<0.0001;FNI:0.09). Model expansion had a greater impact on the c-index and FNI for people with a history of smoking cigarettes relative to the full cohort. Compared with the conventional risk model, the expanded models reduced the number of participants meeting the criteria for LDCT screening by 15-21%, and lung cancer cases detected by 7-8%. The additional cost per lung cancer case detected relative to the conventional model was £1,018 for the addition of blood tests and £9,775 for the fully expanded model. CONCLUSION: Blood measurements of liver function and urate improved lung cancer risk prediction compared with a model containing conventional risk factors. However, there was no evidence that model expansion would improve the cost per lung cancer case detected in UK health care settings

Effectiveness of computer-tailored Smoking Cessation Advice in Primary Care (ESCAPE): a randomised trial.

BACKGROUND: Smoking remains a major public health problem; developing effective interventions to encourage more quit attempts, and to improve the success rate of self-quit attempts, is essential to reduce the numbers of people who smoke. Interventions for smoking cessation can be characterised in two extremes: the intensive face-to face therapy of the clinical approach, and large-scale, public health interventions and policy initiatives. Computer-based systems offer a method for generating highly tailored behavioural feedback letters, and can bridge the gap between these two extremes. Proactive mailing and recruitment can also serve as a prompt to motivate smokers to make quit attempts or to seek more intensive help. The aim of this study is to evaluate the effect of personally tailored feedback reports, sent to smokers identified from general practitioners lists on quit rates and quitting activity. The trial uses a modified version of a computer-based system developed by two of the authors to generate individually tailored feedback reports. METHOD: A random sample of cigarette smokers, aged between 18 and 65, identified from GP records at a representative selection of practices registered with the GPRF are sent a questionnaire. Smokers returning the questionnaire are randomly allocated to a control group to receive usual care and standard information, or to an intervention group to receive usual care and standard information plus tailored feedback reports. Smoking status and cognitive change will be assessed by postal questionnaire at 6-months. DISCUSSION: Computer tailored personal feedback, adapted to reading levels and motivation to quit, is a simple and inexpensive intervention which could be widely replicated and delivered cost effectively to a large proportion of the smoking population. Given its recruitment potential, a modest success rate could have a large effect on public health. The intervention also fits into the broader scope of tobacco control, by prompting more quit attempts, and increasing referrals to specialised services. The provision of this option to smokers in primary care can complement existing services, and work synergistically with other measures to produce more quitters and reduce the prevalence of smoking in the UK. TRIAL REGISTRATION: Current Controlled Trials ISRCTN05385712.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

The value of blood-based measures of liver function and urate in lung cancer risk prediction: A cohort study and health economic analysis

BACKGROUND: Several studies have reported associations between low-cost blood-based measurements and lung cancer but their role in risk prediction is unclear. We examined the value of expanding lung cancer risk models for targeting low-dose computed tomography (LDCT), including blood measurements of liver function and urate. METHODS: We analysed a cohort of 388,199 UK Biobank participants with 1873 events and calculated the c-index and fraction of new information (FNI) for models expanded to include combinations of blood measurements, lung function (forced expiratory volume in 1 s - FEV1), alcohol status and waist circumference. We calculated the hypothetical cost per lung cancer case detected by LDCT for different scenarios using a threshold of ≥ 1.51 % risk at 6 years. RESULTS: The c-index was 0.805 (95 %CI:0.794-0.816) for the model containing conventional predictors. Expanding to include blood measurements increased the c-index to 0.815 (95 %CI: 0.804-0.826;p < 0.0001;FNI:0.06). Expanding to include FEV1, alcohol status, and waist circumference increased the c-index to 0.811 (95 %CI: 0.800-0.822;p < 0.0001;FNI: 0.04). The c-index for the fully expanded model containing all variables was 0.819 (95 %CI:0.808-0.830;p < 0.0001;FNI:0.09). Model expansion had a greater impact on the c-index and FNI for people with a history of smoking cigarettes relative to the full cohort. Compared with the conventional risk model, the expanded models reduced the number of participants meeting the criteria for LDCT screening by 15-21 %, and lung cancer cases detected by 7-8 %. The additional cost per lung cancer case detected relative to the conventional model was £ 1018 for adding blood tests and £ 9775 for the fully expanded model. CONCLUSION: Blood measurements of liver function and urate made a modest improvement to lung cancer risk prediction compared with a model containing conventional risk factors. There was no evidence that model expansion would improve the cost per lung cancer case detected in UK healthcare settings

Suicidal thoughts, suicide attempt and non-suicidal self-harm amongst lesbian, gay and bisexual adults compared with heterosexual adults: analysis of data from two nationally representative English household surveys

PURPOSE: We aimed to compare differences in suicidality and self-harm between specific lesbian, gay and bisexual (LGB) groups, and investigate whether minority stress factors might contribute to any associations, addressing methodological limitations of previous research. METHODS: We analysed data combined from two population-based representative household surveys of English adults (N = 10,443) sampled in 2007 and 2014. Using multivariable logistic regression models adjusted for age, gender, educational attainment, area-level deprivation, and common mental disorder, we tested the association between sexuality and three suicide-related outcomes: past-year suicidal thoughts, past-year suicide attempt, and lifetime non-suicidal self-harm (NSSH). We added bullying and discrimination (separately) to final models to explore whether these variables might mediate the associations. We tested for interactions with gender and survey year. RESULTS: Lesbian/gay people were more likely to report past-year suicidal thoughts [adjusted odds ratio (AOR) = 2.20; 95% CI 1.08-4.50] than heterosexuals. No minority group had an increased probability of suicide attempt. Bisexual (AOR = 3.02; 95% CI = 1.78-5.11) and lesbian/gay (AOR = 3.19; 95% CI = 1.73-5.88) individuals were more likely to report lifetime NSSH than heterosexuals. There was some evidence to support a contribution of bullying in the association between lesbian/gay identity and past-year suicidal thoughts, and of each minority stress variable in the associations with NSSH. There was no interaction with gender or survey year. CONCLUSION: Specific LGB groups are at elevated risk of suicidal thoughts and NSSH, with a possible contribution of lifetime bullying and homophobic discrimination. These disparities show no temporal shift despite apparent increasing societal tolerance towards sexual minorities

Impact of Financial Incentives on Alcohol Consumption Recording in Primary Health Care Among Adults with Schizophrenia and Other Psychoses:A Cross-Sectional and Retrospective Cohort Study

Aims: Lack of financial incentive is a frequently cited barrier to alcohol screening in primary care. The Quality and Outcomes Framework (QOF) pay for performance scheme has reimbursed UK primary care practices for alcohol screening in people with schizophrenia since April 2011. This study aimed to determine the impact of financial incentives on alcohol screening by comparing rates of alcohol recording in people with versus those without schizophrenia between 2000 and 2013. Methods: Cross-sectional and retrospective cohort study. Alcohol data were extracted from The Health Improvement Network (THIN) database of UK primary care records using (a) Read Codes for level of alcohol consumption, (b) continuous measures of drinking (e.g. units a week) and (c) Read Codes for types of screening test. Results: A total of 14,860 individuals (54% (8068) men and 46% (6792) women) from 409 general practices aged 18–99 years with schizophrenia were identified during April 2011–March 2013. Of these, 11,585 (78%) had an alcohol record, of which 99% (8150/8257) of Read Codes for level of consumption were eligible for recompense in the QOF. There was an 839% increase in alcohol recording among people with schizophrenia over the 13-year period (rate ratio per annum increase 1.19 (95% CI 1.18–1.20)) compared with a 62% increase among people without a severe mental illness (rate ratio per annum increase 1.04 (95% CI 1.03–1.05)). Conclusion: Financial incentives offered by the QOF appear to have a substantial impact on alcohol screening among people with schizophrenia in UK primary care. Short summary: Alcohol screening among people with schizophrenia increased dramatically in primary health care following the introduction of the UK pay for performance incentive scheme (Quality and Outcomes Framework) for severe mental illness, with an 839% rise (>8-fold increase) compared with a 62% increase among people without a over the 13-year study period (2000–2013)