Clinical decision support systems in the care of hospitalised patients with diabetes

This thesis explored the role of health informatics (decision support systems) in caring for hospitalised patients with diabetes through a systematic review and by analysing data from University Hospital Birmingham, UK. Findings from the thesis: 1) highlight the potential role of computerised physician order entry system in improving guideline based anti-diabetic medication prescription in particular insulin prescription, and their effectiveness in contributing to better glycaemic control; 2) quantify the occurrence of missed discharge diagnostic codes for diabetes using electronic prescription data and suggests 60% of this could be potentially reduced using an algorithm that could be introduced as part of the information system; 3) found that hypoglycaemia and foot disease in hospitalised diabetes patients were independently associated with higher in-hospital mortality rates and longer length of stay; 4) quantify the hypoglycaemia rates in non-diabetic patients and proposes one method of establishing a surveillance system to identify non diabetic hypoglycaemic patients; and 5) introduces a prediction model that may be useful to identify patients with diabetes at risk of poor clinical outcomes during their hospital stay

Comorbidities, complications and mortality in people of South Asian ethnicity with type 1 diabetes compared with other ethnic groups : a systematic review

Objective The aim of this systematic review is to explore the association of South Asian (SA) ethnicity on comorbidities, microvascular and macrovascular complications and mortality compared with other ethnic groups in people with type 1 diabetes mellitus (T1DM). Design Systematic review. Method A systematic literature search strategy was designed and carried out using Medline and Embase for full-text and abstract studies published in English from 1946 to February 2016. The initial search identified 4722 papers. We assessed 305 full-text articles in detail for potential inclusion. Ten papers met the inclusion criteria for review and an additional one paper was included from our secondary search strategy using the bibliography of included studies. In total, 11 studies were included. Eligibility criteria for selecting studies Studies were included if they were published in English, involved SA participants with T1DM and compared them with non- SA participants and assessed one of the outcomes of comorbidities, microvascular complications, macrovascular complications and mortality. Results SA with T1DM have higher mortality compared with white Europeans (WE), mainly contributed to by excess cardiovascular disease. SA have significantly higher glycated haemoglobin (HbA1c), lower high-density lipoprotein (HDL) and lower rates of neuropathy compared with WE. There were no differences in rates of retinopathy and nephropathy. Compared with Africans, SA had lower levels of microalbuminuria, HbA1c and systolic blood pressure and higher HDL levels. There were no significant differences in the remaining outcomes: cardiovascular disease, retinopathy, neuropathy and body mass index. Furthermore, SA have higher HbA1c levels than Malay and Chinese and higher waist hip ratio and lower HDL levels compared with Chinese only. Conclusion Our analysis highlights ethnic disparity in macrovascular outcomes that is so evident for type 2 diabetes mellitus may also be present for SA patients with T1DM. We highlight the need for a large, prospective, cohort study exploring the effect of ethnicity in a uniform healthcare setting

Temporal variation in the diagnosis of resolved atrial fibrillation and the influence of performance targets on clinical coding:cohort study

Objectives To investigate whether the introduction of performance targets for anticoagulation in atrial fibrillation (AF) was associated with a change in use of the ‘resolved AF’ code.Design Retrospective cohort studies.Setting Data from The Health Improvement Network, a UK database of electronic patient records, from 2000 to 2016.Participants 250 788 adult patients aged ≥18 years with a diagnosis of AF, including 14 757 with an incident diagnosis of ‘resolved AF’.Main outcome measures Annual and monthly incidence of ‘resolved AF’ from 2000 to 2016. Among patients with ‘resolved AF’, for each year we calculated median duration of the preceding AF diagnosis and the proportion prescribed anticoagulants prior to ‘resolved AF’.Results Incidence of ‘resolved AF’ increased from 5.7 to 26.3 per 1000 person-years between 2005 and the introduction of AF performance targets in 2006. Compared with the years prior to the introduction of the performance targets, incidence has remained higher in every year since their implementation. Since 2007, monthly incidence has been highest between January and March. Between 2005 and 2006, median duration between AF and ‘resolved AF’ diagnoses increased from 276 days (9 months) to 1343 days (3 years 8 months). Among ‘resolved AF’ patients with CHA2DS2-VASc score ≥1, 81.9% (95% CI 81.1 to 82.6) had no current anticoagulant prescription, and 62.3% (95% CI 61.4 to 63.2) had no record of any anticoagulant prescription.Conclusion The introduction of AF performance targets was followed by a large increase in use of the ‘resolved AF’ code, particularly in the months immediately before practices make their anticoagulant performance target submissions. Although most AF patients are prescribed anticoagulants, few patients diagnosed with ‘resolved AF’ are prescribed anticoagulants and most have never been prescribed them. Untreated patients are much more likely to be coded as having ‘resolved AF’

Trends in the prevalence and pharmacological management of migraine during pregnancy in the UK, 2000–2018

Background: Migraine is common in women of reproductive age. This study aimed to (1) describe the prevalence of migraine in pregnant women in the UK, (2) identify drugs commonly prescribed for migraine during pregnancy and (3) identify characteristics associated with being prescribed medication for migraine during pregnancy. Methods: The Clinical Practice Research Datalink pregnancy register, a database of pregnancy episodes identified in anonymised primary care health records, was used. Crude and age-standardised prevalence of migraine during pregnancy and the proportion of women with migraine prescribed drugs used for migraine management were calculated for each year between 2000 and 2018. Logistic regression was used to describe the relationship between patient characteristics and being prescribed migraine medication during pregnancy. Results: 1 377 053 pregnancies were included, of which 187 328 were in women with a history of migraine. The age-adjusted prevalence increased from 11.4% in 2000 to 17.2% in 2018. There was an increase in the rates of prescription for numerous medications for the management of migraine. Older women (adjusted OR (aOR) 1.41 (1.20 to 1.66)), women of black (aOR 1.40 (1.32 to 1.48)) and South Asian ethnicity (aOR 1.48 (1.38 to 1.59)), those living in the most deprived areas (aOR 1.60 (1.54 to 1.66)), women who were obese (aOR 1.39 (1.35 to 1.43)), smokers (aOR 1.15 (1.12 to 1.18)) and those with comorbid conditions were more likely to receive a prescription during pregnancy. Conclusions: Rates of recorded migraine have increased over the past two decades as well as rates of prescribing in women with migraine. Higher prescribing rates are seen in certain groups, which has the potential to exacerbate health inequalities

The epidemiology of hereditary spastic paraplegia and associated common mental health outcomes in England and Northern Ireland

Background: Hereditary Spastic Paraplegia (HSP) is a rare genetic neurological disorder that causes progressive spasticity and weakness in the lower limbs. This study aims to describe the prevalence and incidence of HSP and examine common mental health outcomes (depression and anxiety) in HSP patients in England and Northern Ireland. Methods: This retrospective cohort study used CPRD Aurum primary care data from 1 January 2000 to 31 December 2021. Annual cross-sectional and cohort studies were conducted for yearly prevalence and incidence of HSP. Common mental health outcomes were examined with a 1:4 matched cohort (age+/−1 year, sex, general practice). Descriptive analysis and logistic regression assessed the characteristics of the HSP cohort and baseline depression and anxiety. Cox regression assessed the hazard of new diagnosis of depression and anxiety. Results: The overall cohort included 31,302,579 patients; the matched cohort included 1455 HSP patients and 5726 control non-HSP patients. Patients who were male (adjusted odds ratio [aOR] 1.45, 95% CI: 1.31–1.61), of White ethnicity (lower odds in all other ethnicity) and from most other geographical areas compared to London had higher odds of a HSP diagnosis, with the highest odds for North East (aOR 3.51, 95% CI: 2.73–4.50) and Northern Ireland (aOR 3.15, 95% CI: 1.62–6.16). HSP prevalence increased from 2.83 per 100,000 population (95% CI: 2.49–3.20) in 2000 to 6.27 per 100,000 population (95% CI: 5.83–6.73) in 2021. HSP incidence remained stable from 0.12 per 100,000 person-years (95% CI: 0.06–0.22) in 2000 to 0.29 per 100,000 person-years (95% CI: 0.20–0.40) in 2021. HSP patients had higher odds of baseline pre-existing depression (aOR: 1.74, 95% CI: 1.47–2.06) and anxiety (aOR: 1.31, 95% CI: 1.08–1.60); and higher hazard for new diagnosis of depression (adjusted hazard ratio [aHR]: 1.57, 95% CI: 1.26–1.96) and anxiety (aHR: 1.41, 95% CI: 1.12–1.76). Conclusion: This first descriptive epidemiological study for HSP in England and Northern Ireland, demonstrated the utility of primary care routine health records for studying rare diseases. The higher rates of common mental health conditions in HSP patients illustrated the importance of access to mental health support

How migraine and its associated treatment impact on pregnancy outcomes:Umbrella Review with Updated Systematic Review and Meta-Analysis

Background: Migraine is common in reproductive aged women. Understanding the impact of migraine and associated treatments on pregnancy outcomes remains very important. An umbrella review of systematic reviews, with or without meta-analyses, examined the link between migraine and pregnancy outcomes. Methods: We systematically searched Medline, Embase and Cochrane to 27th October 2022. Quality appraisal was carried out using the AMSTAR2 tool. An established framework was used to determine whether included reviews were eligible for update. Results: Four studies met review criteria. Migraine was reported to be associated with increased odds ratio (OR) of pre-eclampsia, low birth weight and peripartum mental illness (pooled OR 3.54 (2.24-5.59)). Triptan-exposed women had increased odds of miscarriage compared to women without migraine (pooled OR 3.54 (2.24-5.59)). In updated meta-analyses, migraine was associated with an increased odds of pre-eclampsia and preterm birth (pooled OR 2.05 (1.47-2.84) and 1.26 (1.21-1.32) respectively).Conclusion: Migraine is associated with increased odds of pre-eclampsia, peripartum mental illness and preterm birth. Further investigation of the relationship between migraine and placental abruption, low birth weight and small for gestational age is warranted, as well as the relationship between migraine, triptans and miscarriage risk.Systematic Review Registration: Prospero CRD4202235763

Clinically meaningful and lasting HbA1c improvement rarely occurs after 5 years of type 1 diabetes: an argument for early, targeted and aggressive intervention following diagnosis.

AIMS/HYPOTHESIS: Our objectives were to explore whether the phenomenon of HbA1c 'tracking' occurs in individuals with type 1 diabetes, how long after diagnosis does tracking take to stabilise, and whether there is an effect of sex and age at diagnosis on tracking. METHODS: A total of 4525 individuals diagnosed with type 1 diabetes between 1 January 1995 and 1 May 2015 were identified from The Health Improvement Network (THIN) database. Mixed models were applied to assess the variability of HbA1c levels over time with random effects on general practices (primary care units) and individuals within practices. RESULTS: 4525 individuals diagnosed with type 1 diabetes were identified in THIN over the study period. The greatest difference in mean HbA1c measurement (-7.0 [95% CI -8.0, -6.1] mmol/mol [0.6%]) was seen when comparing measurements made immediately after diagnosis (0-1 year since diagnosis) with those at 10 or more years (the reference category). The mean difference in HbA1c for the successive periods compared with 10 or more years after diagnosis declined and was no longer statistically significant after 5 years. In the stratified analysis using sex and age group there was considerable heterogeneity with adult onset type 1 diabetes appearing to track earlier and at a lower mean HbA1c. CONCLUSIONS/INTERPRETATION: In individuals with type 1 diabetes, glycaemic control measured by HbA1c settles onto a long-term 'track' and this occurs on average by 5 years following diagnosis. Age at diagnosis modifies both the rate at which individuals settle into their track and the absolute HbA1c tracking level for the next 10 years