Статті в журналах: "Comorbidity – Scotland"

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Baldacchino, A., and I. Crome. "Comorbidity and Comortality." European Psychiatry 24, S1 (January 2009): 1. http://dx.doi.org/10.1016/s0924-9338(09)70262-7.

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Aims:To analyse the nature and extent of data extracted from case files of deceased individuals in contact with health, social care and criminal justice services six months prior to their drug deaths in Scotland during 2003.Methods:A cross-sectional descriptive analysis of 317 case notes of 237 individuals who had drug related deaths, using a data linkage process, was undertaken. All contacts made with services in the six months prior to death were identified. Information on clinical and social circumstances obtained from case records of social care services, specialist drug treatment, mental health and non-statutory services and the Scottish Prison Service and Criminal Records Office were collated using the Centre for Addiction Research and Education Scotland (CARES) Clinical and Social Circumstances Data Collection Form.Findings:More than 50% (n=237) were seen six months prior to their drug death. Sociodemographic details were reported much more frequently than medical problems. While there was information available on ethnicity (49%), living accommodation (66%), education and income (52%), and dependent children (73%), medical and psychiatric history was recorded in only 12%, blood-borne viral status in 17%, and life events in 26%. This paucity of information was also a feature of the treatment plans and progress recorded for these individuals.Conclusions:The 237 drug deaths were not a population unknown to services. Highly relevant data about the six-month period prior to death were missing. Improved training to promote in-depth recording, and effective monitoring may result in better understanding and reduction of drug deaths.

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Boyle, Andrew, Sam Abdulla, Anna Odrowąż-Coates, Jude Tah, Julien Kiss, Rolf Magnus Grung, Margareta Ahlström, and Lynne Marsh. "Supporting the social inclusion of children and young adults with IDD and psychiatric comorbidities: Autobiographical narratives of practitioners and academics from Europe." Society Register 7, no. 2 (June 23, 2023): 33–48. http://dx.doi.org/10.14746/sr.2023.7.2.03.

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The article provides a reflection on the social inclusion of children and young people with IDD and associated psychiatric comorbidity through the eyes of practitioners and academics from Norway, Scotland, Sweden, and Romania. Using an autoethnographic approach to share the first-hand experiences of supporting children and young adults with IDD from the perspective of experienced practitioners, telling their stories (individual case studies) and mapping the challenges and successes (best practice) through these professional narratives. The article also acknowledges psychiatric comorbidity in young people with IDD and how psychiatric disorders can impact social inclusion. The results of the self-reflection of active practitioners involved with complex disabilities may serve as a guide for others in sharing best practices and facing difficulties. It also shows the policy developments on a timeline of their practice. Practice-informed issues clinicians and support staff face may aid the training and share the knowledge with other experts. The value added is the interprofessional exchange created by the international contributors.

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Park, James Hugh, Anniken Fuglestad, Anne Helene Kostner, Antonia K. Roseweir, Joanne Edwards, Campbell SD Roxburgh, Paul G. Horgan, Christian Kersten, and Donald C. McMillan. "Comorbidity and systemic inflammation are independent prognostic factors in patients with colorectal cancer: A ScotScan collaborative study." Journal of Clinical Oncology 37, no. 4_suppl (February 1, 2019): 707. http://dx.doi.org/10.1200/jco.2019.37.4_suppl.707.

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707 Background: Although inextricably linked, both comorbidity and systemic inflammatory responses have been shown to determine survival in patients undergoing surgery for colorectal cancer (CRC). The present study examines the interrelationships between comorbidity (ASA grade) and systemic inflammation (modified Glasgow Prognostic Score (mGPS)) in patients from the ScotScan dataset. Methods: Clinicopathological characteristics and outcome of consecutive patients undergoing potentially curative resection of TNM I-III CRC in Glasgow Royal Infirmary (Scotland) and Sørlandet Hospital (Norway) were prospectively collected. ASA grade and mGPS (0-CRP ≤ 10mg/L, 1-CRP > 10mg/L, 2-CRP > 10mg/L and albumin < 35g/L) prior to surgery was recorded and relationship with overall survival (OS) examined. Results: 2,295 patients (Scotland: n = 1,234 , Norway: n = 1,061) were included. Patients from Norway were more likely to be older, female and have higher ASA grade (all P < 0.001), and more likely to have colon cancer (76% vs. 67%, P < 0.001). Patients from Norway were less likely to be systemically inflamed (mGPS = 0: 72% vs. 65%, P < 0.001), even after propensity score matching ( n = 736, OR 0.36 95%CI0.25-0.51, P < 0.001). ASA grade and mGPS were significantly associated; 21% of ASA 1 patients had mGPS ≥ 1 compared to 41% of ASA four patients ( P < 0.001). In the propensity-matched cohort, both increasing ASA (HR 1.98 95% CI1.57-2.49, P < 0.001) and mGPS (HR 1.20 95% CI1.02-1.41, P = 0.027) were associated with OS independent of age, N stage and adjuvant therapy use; results in the whole cohort were similar. The combination of ASA grade and mGPS was examined with respect to OS in patients with stage II-III CRC (Table 1). In patients with stage II disease, 3-year OS was stratified from 96% (ASA 1, mGPS0) to 67% (ASA 3, mGPS2) ( P < 0.001); in patients with stage II disease, 3-year OS was stratified from 84% to 44% ( P < 0.001). Conclusions: Using a large, prospectively collected dataset of patients undergoing resection of CRC in two countries, the results of the present study confirm the independent prognostic value of measures of comorbidity and systemic inflammation prior to surgery.

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McLean, Gary, and Stewart W. Mercer. "Chronic Migraine, Comorbidity, and Socioeconomic Deprivation: Cross-Sectional Analysis of a Large Nationally Representative Primary Care Database." Journal of Comorbidity 7, no. 1 (January 2017): 89–95. http://dx.doi.org/10.15256/joc.2017.7.114.

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Background: Chronic migraine is common but there is limited knowledge on associated comorbidities. Objectives: To examine mental and physical comorbidities in chronic migraine and the influence of socioeconomic status in a large, nationally representative dataset. Design: Analysis of cross-sectional primary healthcare data from 1,468,404 adults in Scotland. Chronic migraine, 31 other physical conditions, and seven mental health conditions we examined. Prevalence rates were standardized by age groups, sex, and socioeconomic deprivation, and adjusted odds ratio (aOR) and 95% confidence intervals (CI) calculated for those with chronic migraine compared with those without. Results: Chronic migraine patients had more conditions, with the biggest difference found for five or more conditions (chronic migraine 11.7% vs. controls 4.9%; aOR 3.00; 95% CI 2.78–3.22). Twenty-five of the 31 physical conditions were significantly more prevalent in the chronic migraine group. The biggest difference was for chronic pain (aOR 4.33; 95% CI 4.12–4.55). For mental health conditions, the biggest differences were for anxiety (aOR 2.95; 95% CI 2.76–31.5) and depression (aOR 2.94; 95% CI 2.81–3.08). Increasing deprivation was associated with more severe and complex comorbidity (five or more conditions), and with more combined mental and physical comorbidity in the chronic migraine group. Conclusions In a large nationally representative sample in primary care, comorbidity was most common in those with chronic migraine compared with standardized controls, and this was exacerbated by living in areas of higher deprivation.

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Ventre, Chiara, Sian Nowell, Catriona Graham, Doug Kidd, Christos Skouras, and Damian J. Mole. "Survival and new-onset morbidity after critical care admission for acute pancreatitis in Scotland: a national electronic healthcare record linkage cohort study." BMJ Open 8, no. 12 (December 2018): e023853. http://dx.doi.org/10.1136/bmjopen-2018-023853.

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IntroductionSevere acute pancreatitis (AP) requiring critical care admission (ccAP) impacts negatively on long-term survival.ObjectiveTo document organ-specific new morbidity and identify risk factors associated with premature mortality after an episode of ccAP.DesignCohort study.SettingElectronic healthcare registries in Scotland.ParticipantsThe ccAP cohort included 1471 patients admitted to critical care with AP between 1 January 2008 and 31 December 2010 followed up until 31 December 2014. The population cohort included 3450 individuals from the general population of Scotland frequency-matched for age, sex and social deprivation.MethodsRecord linkage of routinely collected electronic health data with population matching.Primary and secondary outcome measuresPatient demographics, comorbidity (Charlson Comorbidity Index), acute physiology, organ support and other critical care data were linked to records of mortality (death certificate data) and new-onset morbidity. Kaplan-Meier and Cox regression analyses were used to identify risk factors associated with mortality.Results310 patients with AP died during the index admission. Outcomes were not ascertained for five patients, and the deprivation quintile was not known for six patients. 340 of 1150 patients in the resulting postdischarge ccAP cohort died during the follow-up period. Greater comorbidity measured by the Charlson score, prior to ccAP, negatively influenced survival in the hospital and after discharge. The odds of developing new-onset diabetes mellitus after ccAP compared with the general population were 10.70 (95% CI 5.74 to 19.94). A new diagnosis of myocardial infarction, stroke, heart failure, liver disease, peptic ulcer, renal failure, cancer, peripheral vascular disease and lung disease was more frequent in the ccAP cohort than in the general population.ConclusionsThe persistent deleterious impact of severe AP on long-term outcome and survival is multifactorial in origin, influenced by pre-existing patient characteristics and acute episode features. Further mechanistic and epidemiological investigation is warranted.

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Walker, J., and S. Wild. "OP77 Socio-economic status, comorbidity, and one-year mortality in patients with diabetes in Scotland 2004–2011." Journal of Epidemiology and Community Health 68, Suppl 1 (September 2014): A38.2—A39. http://dx.doi.org/10.1136/jech-2014-204726.79.

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Rodger, R. S. C., and J. D. Briggs. "Renal Replacement Therapy in the Elderly." Scottish Medical Journal 42, no. 5 (October 1997): 143–44. http://dx.doi.org/10.1177/003693309704200509.

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Before 1980 few patients over the age of 65 started chronic dialysis, despite the fact that the incidence of advanced chronic renal failure was approximately ten times greater in this group compared to young and middle aged adults.1 Since that time the number of elderly patients starting renal replacement has increased markedly and accounted for 38% of new dialysis patients in Scotland in 1995. (Data supplied by the Scottish Renal Registry). In order to meet the needs of older patients with chronic renal failure there has been considerable expansion in renal services and it has been predicted that this will continue to increase in Scotland until 2010.2 The number of older patients receiving dialysis and transplantation is rising steadily and will continue to rise in the future. There is nowadays no justification for a rigid upper age limit in the selection of patients for dialysis although inevitably more elderly patients will be unsuitable on medical grounds than in the younger age groups in particular due to cardiovascular disease. The majority of elderly patients are best managed by haemodialysis but a considerable number can achieve a reasonable quality of health on peritoneal dialysis. Renal transplantation should be seriously considered in the older patient provided that comorbidity is not present, usually in the form of cardiovascular disease, to a degree which would seriously limit life expectation.

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Mullin, Donncha, Danni Gadd, Michelle Luciano, Tom Russ, and Graciela Muniz-Terrera. "TRAJECTORIES OF MOTORIC COGNITIVE RISK SYNDROME AND INCIDENT DEMENTIA IN SCOTLAND." Innovation in Aging 7, Supplement_1 (December 1, 2023): 857. http://dx.doi.org/10.1093/geroni/igad104.2761.

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Abstract Background Motoric cognitive risk syndrome (MCR) - objective slow gait and subjective cognitive complaints - is quick and easy to measure, making it a potentially useful clinical tool for identifying those at high risk of developing dementia. This is the first exploration of MCR syndrome’s predictive ability for incident dementia in a Scottish cohort (Lothian Birth Cohort 1936) and the first examination of the various trajectories of MCR. Method: We classified a total of 680 community-dwelling participants (mean [SD] age 76.3 [0.8] years) free from dementia into non-MCR or MCR groups. We used cox proportional hazard methods to evaluate the risk of developing all-cause dementia in the years following MCR diagnosis, adjusting for age, sex, comorbidity index, apolipoprotein E status, physical activity level, and years of education. We analysed the trajectories for everyone with MCR by tracking their outcomes over 9 years. Result: The prevalence of MCR at baseline was 5.6% (n=38/680). After 9 years of follow-up, 11.6% (n=79/680) of the total cohort developed dementia. The presence of MCR increased the risk of dementia (adjusted hazard ratio 2.37 [95%CI 1.06-5.32; p=0.0359]). The trajectories of those with MCR at baseline were: i) reverted to healthy (n=6/38), ii) ongoing MCR (n=13/38), iii) progressed to dementia (n=9/38), or iv) died (n=10/38). Conclusion MCR could identify a target group for early interventions of modifiable risk factors to prevent incident dementia. Individuals with MCR follow similar trajectories to the related predementia syndrome, Mild Cognitive Impairment.

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Hsieh, P. H., C. Geue, O. Wu, and E. McIntosh. "POS0530 HOW DOES MULTIMORBIDITY IMPACT ON THE DIRECT AND INDIRECT COSTS IN PATIENTS WITH RHEUMATOID ARTHRITIS?" Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 498.3–499. http://dx.doi.org/10.1136/annrheumdis-2021-eular.1817.

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Background:Comorbidities are prevalent in patients with rheumatoid arthritis (RA) and associated with worse outcomes as well as higher economic burden. Little is known about the impact of multimorbidity on the direct and indirect costs of RA. Evidence of the incremental scale of these multimorbidity costs will usefully inform RA interventions and policies.Objectives:The aim of this study was to describe how multimorbidity impacts on the cost-of-illness, including direct and indirect costs, in patients with RA.Methods:The Scottish Early Rheumatoid Arthritis (SERA) is a registry of patients newly presenting with RA since 2011. It contains data on patient characteristics, clinical outcomes, health-related quality of life, and employment status data. These data were linked to routinely recorded hospital admissions and primary care prescribing data. Direct costs were estimated by applying relevant unit costs to healthcare resource use quantities. Indirect cost estimates were obtained from information on employment status and hospital admissions, valued by age and sex specific wages. Two-part models (probit followed by generalized linear model) were used to estimate direct and indirect costs, adjusting for age, gender, and functional disability. The Charlson Comorbidity Index (CCI) score was calculated using patient ICD-10 diagnoses from hospital records. The number of comorbidities was categorized into “RA alone”, “single comorbidity” and “multimorbidity (>1 comorbidity)”.Results:Data were available for 1,150 patients, 65.7% were female and a mean age of 57.5±14 years. The majority of patients only had RA (54.1%), followed by a single comorbidity (23.4%) and multimorbidity (22.5%). Annual total costs were significantly higher for patients with multimorbidity (£6,669 95% CI £4,871-£8,466; OR 11.3 95% CI 8.14-15.87) and for patients with a single comorbidity (£2,075 95% CI £1,559-£2,591; OR 3.52 95% CI 2.61-4.79), when compared with RA alone (£590). The excess costs were mainly driven by direct costs (£6,281 versus £1,875 versus £556). Although the difference in indirect costs between patients with multimorbidity and a single comorbidity were not statistically significant (£1,218 versus £914, p=0.11), patients with multimorbidity were associated with significantly higher costs than those with RA only (£594, p<0.01).Conclusion:The presence of comorbidity contributes significant excess to both direct and indirect costs among RA patients. In particular, patients with multimorbidity incurred substantially higher direct costs than those with a single comorbidity or RA only.Acknowledgements:The study analysed the data from the Scottish Early Rheumatoid Arthritis (SERA) study with a linkage to routinely recorded health data from Information Service Division, National Service Scotland. We would like to thank all the patients, clinical and nursing colleagues who have contributed their time and support to the study, the SERA steering committee for the approval, and Allen Tervit from the Robertson Centre for Biostatistics, University of Glasgow for the timely technical supports.Disclosure of Interests:Ping-Hsuan Hsieh: None declared, Claudia Geue: None declared, Olivia Wu Consultant of: OW has received consultancy fees from Bayer, Lupin and Takeda outside the submitted work., Emma McIntosh: None declared

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Baldacchino, A. "Chronic Non Cancer Pain and Misuse and Dependence of Analgesic Drugs." European Psychiatry 24, S1 (January 2009): 1. http://dx.doi.org/10.1016/s0924-9338(09)70542-5.

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As the chronic disease model is now accepted as the model to treat individuals in the community in the UK, it has become important to recognise that individuals tend to present with more than one concomittant problem (comorbidity). A increasing patient centred approach to treatment and recovery has helped to recognise the dual concept of pain and dependence within the clinical environment. There is an ever increasing prevalence of this dual presentation and this has helped to effectively manage individuals with a substance misuse history and associated chronic pain and others treated for their chronic pain with strong analgesic and subsequently experiencing substance misuse and dependence problems.This presenation aims to provide the literature overview of these populations, clinical characteristics and problems presenting in a pain and dependence clinic in Scotland. Several models of practice will also be presented.

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Walker, Jeremy, Nynke Halbesma, Nazir Lone, David McAllister, Christopher J. Weir, and Sarah H. Wild. "Socioeconomic status, comorbidity and mortality in patients with type 2 diabetes mellitus in Scotland 2004–2011: a cohort study." Journal of Epidemiology and Community Health 70, no. 6 (December 17, 2015): 596–601. http://dx.doi.org/10.1136/jech-2015-206702.

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Papadopoulou, Constantina, Janette Barrie, Mandy Andrew, Janetta Martin, Audrey Birt, FJ Raymond Duffy, and Anne Hendry. "Perceptions, practices and educational needs of community nurses to manage frailty." British Journal of Community Nursing 26, no. 3 (March 2, 2021): 136–42. http://dx.doi.org/10.12968/bjcn.2021.26.3.136.

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Early intervention on frailty can help prevent or delay functional decline and onset of dependency. Community nurses encounter patients with frailty routinely and have opportunities to influence frailty trajectories for individuals and their carers. This study aimed to understand nurses' perceptions of frailty in a community setting and their needs for education on its assessment and management. Using an exploratory qualitative design we conducted focus groups in one Health Board in Scotland. Thematic content analysis of data was facilitated by NVivo© software. A total of 18 nurses described the meaning of frailty as vulnerability, loss and complex comorbidity and identified processes of caring for people with frailty. They identified existing educational needs necessary to support their current efforts to build capability through existing adversities. Our study indicates that current practice is largely reactive, influenced by professional judgement and intuition, with little systematic frailty-specific screening and assessment.

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Diernberger, Katharina, Joanna Bowden, Marie T. Fallon, Xhyljeta Luta, Joanne Droney, Elizabeth Lemmon, Ewan Gray, Holly Ennis, Joachim Marti, and Peter S. Hall. "Patterns and costs of hospital-based cancer care in the last year of life: A national data linkage study in Scotland." Journal of Clinical Oncology 39, no. 15_suppl (May 20, 2021): e18732-e18732. http://dx.doi.org/10.1200/jco.2021.39.15_suppl.e18732.

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e18732 Background: Approximately thirty thousand people in Scotland are diagnosed with cancer each year, of whom 10,000 live less than one year. Hospital is the most common place of death for people with cancer, despite most expressing a preference for community-based care. There is inadequate understanding of the nature and value of hospital-based care for people with advanced cancer. This study aimed to describe patterns of hospital-based healthcare use and associated costs for cancer decedents in their last year of life. Methods: A population-wide administrative data linkage study of hospital-based healthcare use for cancer decedents aged 60+ at death who died between 2012 and 2017 was conducted in Scotland. Linkage was established between the Scottish Morbidity Record, Scottish Cancer Registry and the National Records of Scotland. Hospital admissions, length of stay (LoS), number and nature of outpatient and day case appointments were extracted. Associated costs were estimated using generalised linear models, adjusted for age, gender, primary cause of death, socioeconomic deprivation status, rural-urban (RU) status and comorbidity. Results: The study population included 85,732 decedents with a cancer diagnosis, for whom 64,553 (75.3%) cancer was the underlying cause of death. Mean age at death was 84 years. The mean number of inpatient stays in the last year of life was 5.88 (SD 5.68), with a mean LoS of 7 days. Mean total 1-year inpatient, outpatient and day-case costs per patient were £10,261, £1,275 and £977 respectively. People who died of haematological cancers had the most hospital admissions (mean 11.8). Admission rates rose sharply in the last month of life and were most common in those who died of haematological and lung cancers. One year adjusted and unadjusted costs decreased with increasing age. Unadjusted costs for the youngest group (60-64) were £15,895, double the cost for those aged 90+. People dying of haematological cancers had the highest hospital-based costs (mean £24,772) followed by those with ovarian cancer (mean £17,556). The largest single contributor to hospital-based costs in the last year of life was unscheduled admissions. Conclusions: People in Scotland in their last year of life with cancer use substantial hospital-based care. Unscheduled admission rates are high, particularly in the last month of life when the value of acute intervention may be uncertain. Further research is needed to examine triggers for hospitalisation and to assess the value of hospital-based care to people living with advanced cancer.

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Fleming, Michael, Catherine A. Fitton, Markus F. C. Steiner, James S. McLay, David Clark, Albert King, Daniel F. Mackay, and Jill P. Pell. "Educational and health outcomes of children treated for asthma: Scotland-wide record linkage study of 683 716 children." European Respiratory Journal 54, no. 3 (June 13, 2019): 1802309. http://dx.doi.org/10.1183/13993003.02309-2018.

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BackgroundThe global prevalence of childhood asthma is increasing. The condition impacts physical and psychosocial morbidity; therefore, wide-ranging effects on health and education outcomes are plausible.MethodsLinkage of eight Scotland-wide databases, covering dispensed prescriptions, hospital admissions, maternity records, death certificates, annual pupil census, examinations, school absences/exclusions and unemployment, provided data on 683 716 children attending Scottish schools between 2009 and 2013. We compared schoolchildren on medication for asthma with peers, adjusting for sociodemographic, maternity and comorbidity confounders, and explored effect modifiers and mediators.ResultsThe 45 900 (6.0%) children treated for asthma had an increased risk of hospitalisation, particularly within the first year of treatment (incidence rate ratio 1.98, 95% CI 1.93–2.04), and increased mortality (HR 1.77, 95% CI 1.30–2.40). They were more likely to have special educational need for mental (OR 1.76, 95% CI 1.49–2.08) and physical (OR 2.76, 95% CI 2.57–2.95) health reasons, and performed worse in school exams (OR 1.11, 95% CI 1.06–1.16). Higher absenteeism (incidence rate ratio 1.25, 95% CI 1.24–1.26) partially explained their poorer attainment.ConclusionsChildren with treated asthma have poorer education and health outcomes than their peers. Educational interventions that mitigate the adverse effects of absenteeism should be considered.

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Coid, Jeremy, Min Yang, Peter Tyrer, Amanda Roberts, and Simone Ullrich. "Prevalence and correlates of personality disorder in Great Britain." British Journal of Psychiatry 188, no. 5 (May 2006): 423–31. http://dx.doi.org/10.1192/bjp.188.5.423.

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BackgroundEpidemiological data on personality disorders, comorbidity and associated use of services are essential for health service policy.AimsTo measure the prevalence and correlates of personality disorder in a representative community sample.MethodThe Structured Clinical Interview for DSM-IV Axis II disorders was used to measure personality disorder in 626 persons aged 16-74 years in households in England, Scotland and Wales, in atwo-phase survey.ResultsThe weighted prevalence of personality disorder was 4.4% (95% CI 2.9-6.7). Rates were highest among men, separated and unemployed participants in urban locations. High use of healthcare services was confounded by comorbid mental disorder and substance misuse. Cluster B disorders were associated with early institutional care and criminality.ConclusionsPersonality disorder is common in the community especially in urban areas. Services are normally restricted to symptomatic, help-seeking individuals, but a vulnerable group with cluster B disorders can be identified early are in care during childhood and enter the criminal justice system when young. This suggests the need for preventive interventions at the public mental health level.

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Fagbamigbe, Adeniyi Francis, Utkarsh Agrawal, Amaya Azcoaga-Lorenzo, Briana MacKerron, Eda Bilici Özyiğit, Daniel C. Alexander, Ashley Akbari, et al. "Clustering long-term health conditions among 67728 people with multimorbidity using electronic health records in Scotland." PLOS ONE 18, no. 11 (November 29, 2023): e0294666. http://dx.doi.org/10.1371/journal.pone.0294666.

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There is still limited understanding of how chronic conditions co-occur in patients with multimorbidity and what are the consequences for patients and the health care system. Most reported clusters of conditions have not considered the demographic characteristics of these patients during the clustering process. The study used data for all registered patients that were resident in Fife or Tayside, Scotland and aged 25 years or more on 1st January 2000 and who were followed up until 31st December 2018. We used linked demographic information, and secondary care electronic health records from 1st January 2000. Individuals with at least two of the 31 Elixhauser Comorbidity Index conditions were identified as having multimorbidity. Market basket analysis was used to cluster the conditions for the whole population and then repeatedly stratified by age, sex and deprivation. 318,235 individuals were included in the analysis, with 67,728 (21·3%) having multimorbidity. We identified five distinct clusters of conditions in the population with multimorbidity: alcohol misuse, cancer, obesity, renal failure, and heart failure. Clusters of long-term conditions differed by age, sex and socioeconomic deprivation, with some clusters not present for specific strata and others including additional conditions. These findings highlight the importance of considering demographic factors during both clustering analysis and intervention planning for individuals with multiple long-term conditions. By taking these factors into account, the healthcare system may be better equipped to develop tailored interventions that address the needs of complex patients.

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Bergman, Beverly P., Daniel Mackay, and J. P. Pell. "Type 2 diabetes in Scottish military veterans: a retrospective cohort study." BMJ Open 12, no. 2 (February 2022): e057431. http://dx.doi.org/10.1136/bmjopen-2021-057431.

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ObjectivesType 2 diabetes is an important public health problem but the risk in UK military veterans is unknown. We used data from the Trends in Scottish Veterans' Health study to investigate the risk in comparison with people with no record of service.DesignRetrospective cohort study of a large national sample in Scotland, with up to 37 years follow-up.SettingPseudoanonymised extract of computerised Scottish National Health Service records, including a disease register and national vital records.Participants78 000 veterans and 253 000 people with no record of service matched for age, sex and area of residence.Outcome measuresCox proportional HRs for first record of type 2 diabetes in veterans compared with non-veterans, overall and by sex and birth cohort. Long-term trend, comorbidity with specific mental health outcomes and risk of limb loss.ResultsOverall, 7.2% of veterans were diagnosed with type 2 diabetes, and were at slightly increased risk compared with non-veterans, Cox proportional HR 1.08, 95%CIs 1.04 to 1.11, p<0.001. The increased risk was confined to men, and to veterans born prior to 1960. There has been no change in HR over the last 25 years. Among veterans with post-traumatic stress disorder (PTSD), 12.1% had been diagnosed with type 2 diabetes, compared with 9.4% of non-veterans with PTSD. The difference was statistically significant, OR 1.29, 95% CI 1.04 to 1.59, p=0.021. Risk of limb loss was increased among the oldest veterans.ConclusionsOlder veterans in Scotland have an increased risk of type 2 diabetes in comparison with non-veterans, but there is no difference in respect of younger veterans, and the pattern of risk shows no evidence that it is changing. There is a positive association between type 2 diabetes and PTSD, especially in the presence of comorbid mood disorder, an important finding which should be noted by care providers.

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Fleming, Michael, Catherine A. Fitton, Markus F. C. Steiner, James S. McLay, David Clark, Albert King, Daniel F. Mackay, and Jill P. Pell. "Educational and health outcomes of children and adolescents receiving antidepressant medication: Scotland-wide retrospective record linkage cohort study of 766 237 schoolchildren." International Journal of Epidemiology 49, no. 4 (February 19, 2020): 1380–91. http://dx.doi.org/10.1093/ije/dyaa002.

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Abstract Background Childhood depression is relatively common, under-researched and can impact social and cognitive function and self-esteem. Methods Record linkage of routinely collected Scotland-wide administrative databases covering prescriptions [prescribing information system (PIS)], hospitalizations (Scottish Morbidity Records 01 and 04), maternity records (Scottish Morbidity Records 02), deaths (National Records of Scotland), annual pupil census, school absences/exclusions, special educational needs (Scottish Exchange of Educational Data; ScotXed), examinations (Scottish Qualifications Authority) and (un)employment (ScotXed) provided data on 766 237 children attending Scottish schools between 2009 and 2013 inclusively. We compared educational and health outcomes of children receiving antidepressant medication with their peers, adjusting for confounders (socio-demographic, maternity and comorbidity) and explored effect modifiers and mediators. Results Compared with peers, children receiving antidepressants were more likely to be absent [adjusted incidence rate ratio (IRR) 1.90, 95% confidence interval (CI) 1.85–1.95] or excluded (adjusted IRR 1.48, 95% CI 1.29–1.69) from school, have special educational needs [adjusted odds ratio (OR) 1.77, 95% CI 1.65–1.90], have the lowest level of academic attainment (adjusted OR 3.00, 95% CI 2.51–3.58) and be unemployed after leaving school (adjusted OR 1.88, 95% CI 1.71–2.08). They had increased hospitalization [adjusted hazard ratio (HR) 2.07, 95% CI 1.98–2.18] and mortality (adjusted HR 2.73, 95% CI 1.73–4.29) over 5 years’ follow-up. Higher absenteeism partially explained poorer attainment and unemployment. Treatment with antidepressants was less common among boys than girls (0.5% vs 1.0%) but the associations with special educational need and unemployment were stronger in boys. Conclusions Children receiving antidepressants fare worse than their peers across a wide range of education and health outcomes. Interventions to reduce absenteeism or mitigate its effects should be investigated.

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Ciaccio, Laura, Peter T. Donnan, Benjamin J. Parcell, and Charis A. Marwick. "Community antibiotic prescribing in patients with COVID-19 across three pandemic waves: a population-based study in Scotland, UK." BMJ Open 14, no. 4 (April 2024): e081930. http://dx.doi.org/10.1136/bmjopen-2023-081930.

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ObjectivesThis study aims to examine community antibiotic prescribing across a complete geographical area for people with a positive COVID-19 test across three pandemic waves, and to examine health and demographic factors associated with antibiotic prescribing.DesignA population-based study using administrative data.SettingA complete geographical region within Scotland, UK.ParticipantsResidents of two National Health Service Scotland health boards with SARS-CoV-2 virus test results from 1 February 2020 to 31 March 2022 (n=184 954). Individuals with a positive test result (n=16 025) had data linked to prescription and hospital admission data ±28 days of the test, general practice data for high-risk comorbidities and demographic data.Outcome measuresThe associations between patient factors and the odds of antibiotic prescription in COVID-19 episodes across three pandemic waves from multivariate binary logistic regression.ResultsData included 768 206 tests for 184 954 individuals, identifying 16 240 COVID-19 episodes involving 16 025 individuals. There were 3263 antibiotic prescriptions ±28 days for 2395 episodes. 35.6% of episodes had a prescription only before the test date, 52.3% of episodes after and 12.1% before and after. Antibiotic prescribing reduced over time: 20.4% of episodes in wave 1, 17.7% in wave 2 and 12.0% in wave 3. In multivariate logistic regression, being female (OR 1.31, 95% CI 1.19 to 1.45), older (OR 3.02, 95% CI 2.50 to 3.68 75+ vs <25 years), having a high-risk comorbidity (OR 1.45, 95% CI 1.31 to 1.61), a hospital admission ±28 days of an episode (OR 1.58, 95% CI 1.42 to 1.77) and health board region (OR 1.14, 95% CI 1.03 to 1.25, board B vs A) increased the odds of receiving an antibiotic.ConclusionCommunity antibiotic prescriptions in COVID-19 episodes were uncommon in this population and likelihood was associated with patient factors. The reduction over pandemic waves may represent increased knowledge regarding COVID-19 treatment and/or evolving symptomatology.

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Alfayez, Mohammad, Alexander McDonald, and Vivienne MacLaren. "Primary small cell of esophageal carcinoma (SCEC): Experience of Beatson West of Scotland Cancer Center." Journal of Clinical Oncology 32, no. 3_suppl (January 20, 2014): 38. http://dx.doi.org/10.1200/jco.2014.32.3_suppl.38.

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38 Background: Primary Small Cell of Esophageal Carcinoma (SCEC) is an aggressive tumor with no established treatment guidelines. A treatment strategy was adopted based on small cell carcinoma of the lung, as many clinicopathological features are shared. Methods: We retrospectively collected data from fourteen patients who were treated for small cell of esophageal carcinoma at Beatson West of Scotland Cancer Center between 2005 and 2012. All patients were required to have a histological diagnosis of small cell carcinoma. Data were collected retrospectively by case note review and electronic record on demographic details, performance status (PS), comorbidity, treatment, and response to treatment. Results: The data suggest the median age for SCEC diagnosis is 71 years old. Diagnoses in males predominate (64%). The tumors were mainly located in the lower third of the esophagus (71%). The majority of patients with SCEC were in the limited Disease (LD) at the time of diagnosis (71%). About 50% of the patients received chemotherapy alone and 28% received consolidation radiotherapy. Three patients (21%) only received concomitant chemoradiation. None of the patients have Primary Cranial Irradiation (PCI). The overall survival of patients with limited Disease (LD) vs. Extensive Disease (ES) was 22.2 vs. 4.6 months (P=0.013). None of the patients reviewed developed brain metastasis. Conclusions: There is trend in the data that the combination of radiotherapy and chemotherapy improves local control. Radiotherapy alone is probably inadequate if used alone. It should be combined with adjuvant or neoadjuvant platinum-based chemotherapy. Palliative chemotherapy for patients presenting with extensive disease prolonged survival. PCI should not be a standard treatment for these patients. The data presented are the second largest series from the western world. These data will help establish further guidelines for treatment of the small cell of esophageal carcinoma.

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Ciminata, Giorgio, Claudia Geue, Peter Langhorne, and Olivia Wu. "A two-part model to estimate inpatient, outpatient, prescribing and care home costs associated with atrial fibrillation in Scotland." BMJ Open 10, no. 3 (March 2020): e028575. http://dx.doi.org/10.1136/bmjopen-2018-028575.

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ObjectiveThis study aimed to estimate global inpatient, outpatient, prescribing and care home costs for patients with atrial fibrillation using population-based, individual-level linked data.DesignA two-part model was employed to estimate the probability of resource utilisation and costs conditional on positive utilisation using individual-level linked data.SettingsScotland, 5 years following first hospitalisation for AF between 1997 and 2015.ParticipantsPatients hospitalised with a known diagnosis of AF or atrial flutter.Primary and secondary outcome measuresInpatient, outpatient, prescribing and care home costs.ResultsThe mean annual cost for a patient with AF was estimated at £3785 (95% CI £3767 to £3804). Inpatient admissions and outpatient visits accounted for 79% and 8% of total costs, respectively; prescriptions and care home stay accounted for 7% and 6% of total costs. Inpatient cost was the main driver across all age groups. While inpatient cost contributions (~80%) were constant between 0 and 84 years, they decreased for patients over 85 years. This is offset by increasing care home cost contributions. Mean annual costs associated with AF increased significantly with increasing number of comorbidities.ConclusionThis study used a contemporary and representative cohort, and a comprehensive approach to estimate global costs associated with AF, taking into account resource utilisation beyond hospital care. While overall costs, considerably affected by comorbidity, did not increase with increasing age, care home costs increased proportionally with age. Inpatient admission was the main contributor to the overall financial burden of AF, highlighting the need for improved mechanisms of early diagnosis to prevent hospitalisations.

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Gray, Ewan, Joachim Marti, David H. Brewster, Jeremy C. Wyatt, and Peter S. Hall. "OP447 Feasibility And Validity Of Real-World Data As Evidence Of Effectiveness - Experience From Breast Cancer Care In Scotland." International Journal of Technology Assessment in Health Care 36, S1 (December 2020): 9–10. http://dx.doi.org/10.1017/s0266462320001117.

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IntroductionData from randomized controlled trials (RCTs) are the primary source for health technology assessment (HTA) however these are limited by strict patient inclusion criteria, leading to concerns about whether treatment benefit estimates are accurate for all patients (generalizability). Real-World Data (RWD) have been proposed as a solution however as these are observational data there is additional potential for bias when estimating treatment effectiveness. To maximize the utility of RWD it is useful to consider the whole process of evidence generation and robustly address issues of feasibility and validity.MethodsA series of complementary studies investigated whether population-based routinely collected health data from Scotland are suitable for estimating the effectiveness of chemotherapy for early breast cancer. Firstly, a prognostic score was validated in this population. Secondly, a comparison of RWD and randomized trial effectiveness estimates was made to investigate feasibility and validity of several methods – Propensity Score Matching (PSM), Instrumental variables (IV) and Regression Discontinuity. Finally, effectiveness estimates in trial underrepresented groups were produced.ResultsPSM and IV were feasible and produced results in relatively close agreement with randomized data. Effectiveness estimates in trial underrepresented groups (women over 70 years and women with high comorbidity) were consistent with an approximate one-third reduction in the risk of death from breast cancer. This is equivalent to approximately a 3–4 percentage point difference in all cause mortality over 10 years in these groups.ConclusionsRWD are a feasible for generating estimates of effectiveness of adjuvant chemotherapy in early stage breast cancer. The process of using RWD for this purpose should include careful assessment of data quality and comparison of alternative strategies for causal identification in the context of available randomized data.

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Bansal, Neha, Lindsay Mizen, and Andrew Stanfield. "Does the Presence of Psychiatric Symptoms in Adolescents With Special Educational Needs at Certain Time Points in Earlier Life Predict Functional Outcome Later On?" BJPsych Open 8, S1 (June 2022): S43—S44. http://dx.doi.org/10.1192/bjo.2022.174.

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AimsThis study analyses the progression of psychiatric symptoms over time of young people with special educational needs (SEN). The aims of this study were: 1) To examine whether the presence of psychiatric symptoms in earlier life are more likely to impact functional outcomes in later life in those with SEN; 2) Whether the presence of psychiatric symptoms in adolescence predicts functional outcomes in early adult life.MethodsData were obtained from the Edinburgh Study of Comorbidity (ESC) which was a longitudinal follow-up study of adolescents with SEN. This study had ethical approval from the Multicentre Research Ethics Committee for Scotland. It involved head teachers of 99 schools around Scotland identifying pupils aged 13–22 years whom they would estimate as functioning in the borderline to mild intellectual disability range (estimated IQ between 50–80) and were therefore receiving special educational assistance.Adolescents with SEN were assessed with the Clinical Interview Schedule (CIS) to evaluate the presence of psychiatric symptoms. A total of 247 individuals with SEN were recruited to the study. They completed the CIS at baseline (T1), 1–2 years later (T2) and 6 years later (T3). At T3, the participants also completed the World Health Organisation Disability Assessment Schedule 2.0 (WHO-DAS) to measure the degree of functional impairment. Correlation statistical analyses were carried out to find whether there was a significant relationship between CIS and total WHO-DAS scores.ResultsThere was a statistically significant correlation between total WHO-DAS score with slowness and anxiety symptoms (p values 0.008 and 0.024 respectively) measured on the CIS at T1. None of the symptoms measured on CIS at T2 had a statistically significant correlation with total WHO-DAS score. With the symptoms that were significant, after application of a Bonferroni correction, none of the symptoms measured on CIS had a statistically significant correlation at any time point with total WHO-DAS score.ConclusionOur results show that there is some evidence that anxiety and slowness in adolescence are associated with greater functional impairment in young adulthood. However, further research is required to confirm this relationship. Our data highlight the potential value of identification and treatment of psychiatric symptoms in early adolescence.

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Humphreys, M. S., J. P. Kenney-Herbert, and R. V. Cope. "How to keep up with the Mental Health Act." Advances in Psychiatric Treatment 6, no. 6 (November 2000): 407–11. http://dx.doi.org/10.1192/apt.6.6.407.

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In recent years there has been a marked increase in the proportion of individuals with mental disorders detained in hospital involuntarily, compared to those admitted on an informal basis (Wall et al, 1999). There is also growing concern about legally incompetent patients being treated under the doctrine of necessity (Eastman & Peay, 1998). The rise in the numbers of detained patients may have come about for a variety of reasons. Suggested possible contributory factors include a reduction in psychiatric hospital beds; the move towards community care and the consequent tendency to maintain patients at home for longer; increasing comorbidity and more severely disturbed behaviour on hospital wards; and a greater number of individuals transferred to hospital care from the criminal justice system (Mental Health Act Commission, 1999). Statutory mental health legislation in the UK has remained essentially unchanged, in some cases, for nearly 15 years. There have been additions and amendments during that period, as well as new law. For instance, the Mental Health (Patients in the Community) Act 1995, dealing with the care and treatment of people with mental disorders, and the Criminal Evidence (Amendment) Act 1994, covering specific issues to do with certain groups of those suffering from psychiatric disorders. Despite this there is clear evidence from recent research from various parts of the UK that medical practitioners, most particularly psychiatrists, and even those using the Mental Health Act on a day-to-day basis, do not necessarily possess a detailed knowledge of the law. Among a random sample of Section 12(2) approved medical practitioners in the West Midlands, none of those interviewed was able to define the term mental disorder as used in the Act, and only just over one-third correctly identified the four legal categories of mental illness, mental impairment, severe mental impairment and psychopathic disorder (Bhatti et al, 1999). In similar studies undertaken in Scotland, only one in 10 of a national sample of consultant psychiatrists was able to give the statutory definition of the term mental disorder (Humphreys, 1998) and among a similar non-consultant sample only 28% were able to give the correct title and year of the Mental Health (Scotland) Act 1984 (Humphreys, 1997). It would seem important, therefore, that psychiatrists do not become complacent about their knowledge and use of the Act, even though there has been considerable debate around the issue of how much expertise and precise factual knowledge of specific legislation is actually required.

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Fleming, Michael, James S. McLay, David Clark, Albert King, Daniel F. Mackay, Helen Minnis, and Jill P. Pell. "Educational and health outcomes of schoolchildren in local authority care in Scotland: A retrospective record linkage study." PLOS Medicine 18, no. 11 (November 12, 2021): e1003832. http://dx.doi.org/10.1371/journal.pmed.1003832.

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Background Looked after children are defined as children who are in the care of their local authority. Previous studies have reported that looked after children have poorer mental and physical health, increased behavioural problems, and increased self-harm and mortality compared to peers. They also experience poorer educational outcomes, yet population-wide research into the latter is lacking, particularly in the United Kingdom. Education and health share a bidirectional relationship; therefore, it is important to dually investigate both outcomes. Our study aimed to compare educational and health outcomes for looked after children with peers, adjusting for sociodemographic, maternity, and comorbidity confounders. Methods and findings Linkage of 9 Scotland-wide databases, covering dispensed prescriptions, hospital admissions, maternity records, death certificates, annual pupil census, examinations, school absences/exclusions, unemployment, and looked after children provided retrospective data on 715,111 children attending Scottish schools between 2009 and 2012 (13,898 [1.9%] looked after). Compared to peers, 13,898 (1.9%) looked after children were more likely to be absent (adjusted incidence rate ratio [AIRR] 1.27, 95% confidence interval [CI] 1.24 to 1.30) and excluded (AIRR 4.09, 95% CI 3.86 to 4.33) from school, have special educational need (SEN; adjusted odds ratio [AOR] 3.48, 95% CI 3.35 to 3.62) and neurodevelopmental multimorbidity (AOR 2.45, 95% CI 2.34 to 2.57), achieve the lowest level of academic attainment (AOR 5.92, 95% CI 5.17 to 6.78), and be unemployed after leaving school (AOR 2.12, 95% CI 1.96 to 2.29). They were more likely to require treatment for epilepsy (AOR 1.50, 95% CI 1.27 to 1.78), attention deficit hyperactivity disorder (ADHD; AOR 3.01, 95% CI 2.76 to 3.27), and depression (AOR 1.90, 95% CI 1.62 to 2.22), be hospitalised overall (adjusted hazard ratio [AHR] 1.23, 95% CI 1.19 to 1.28) for injury (AHR 1.80, 95% CI 1.69 to 1.91) and self-harm (AHR 5.19, 95% CI 4.66 to 5.78), and die prematurely (AHR 3.21, 95% CI 2.16 to 4.77). Compared to children looked after at home, children looked after away from home had less absenteeism (AIRR 0.35, 95% CI 0.33 to 0.36), less exclusion (AIRR 0.63, 95% CI 0.56 to 0.71), less unemployment (AOR 0.53, 95% CI 0.46 to 0.62), and better attainment (AIRR 0.31, 95% CI 0.23 to 0.40). Therefore, among those in care, being cared for away from home appeared to be a protective factor resulting in better educational outcomes. The main limitations of this study were lack of data on local authority care preschool or before 2009, total time spent in care, and age of first contact with social care. Conclusions Looked after children had poorer health and educational outcomes than peers independent of increased neurodevelopmental conditions and SEN. Further work is required to understand whether poorer outcomes relate to reasons for entering care, including maltreatment and adverse childhood events, neurodevelopmental vulnerabilities, or characteristics of the care system.

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Chetty, Ula, Gary McLean, Deborah Morrison, Karolina Agur, Bruce Guthrie, and Stewart W. Mercer. "Chronic obstructive pulmonary disease and comorbidities: a large cross-sectional study in primary care." British Journal of General Practice 67, no. 658 (April 27, 2017): e321-e328. http://dx.doi.org/10.3399/bjgp17x690605.

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BackgroundChronic obstructive pulmonary disease (COPD) is common, and a major cause of morbidity and mortality worldwide. Recent studies suggest that comorbidities of COPD increase the risk of hospitalisation, polypharmacy, and mortality, but their estimated prevalence varies widely in the literature.AimTo evaluate the prevalence of 38 physical and mental health comorbidities in people with COPD, and compare findings with those for people without COPD in a large nationally representative dataset.Design and settingA cross-sectional data analysis on 1 272 685 adults in Scotland from 314 primary care practices.MethodData on COPD, along with 31 physical and seven mental health comorbidities, were extracted. The prevalence of comorbidities was compared between people who did, and did not, have COPD, standardised by age, sex, and socioeconomic deprivation.ResultsFrom the total sample, 51 928 patients had COPD (4.1%). Of these, 86.0% had at least one comorbidity, compared with 48.9% of people without COPD. Of those with COPD, 22.3% had ≥5 comorbid conditions compared with 4.9% of those who did not have COPD (adjusted odds ratio 2.63, 95% confidence interval = 2.56 to 2.70). In total, 29 of the 31 physical conditions and six of the seven mental health conditions were statistically significantly more prevalent in people who had COPD than those who did not.ConclusionPatients with COPD have extensive associated comorbidities. There is a real need for guidelines and health care to reflect this complexity, including how to detect those common comorbidities that relate to both physical and mental health, and how best to manage them. Primary care, which is unique in terms of offering expert generalist care, is best placed to provide this integrated approach.

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Lone, Nazir I., Robert Lee, Lisa Salisbury, Eddie Donaghy, Pamela Ramsay, Janice Rattray, and Timothy S. Walsh. "Predicting risk of unplanned hospital readmission in survivors of critical illness: a population-level cohort study." Thorax 74, no. 11 (April 5, 2018): 1046–54. http://dx.doi.org/10.1136/thoraxjnl-2017-210822.

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BackgroundIntensive care unit (ICU) survivors experience high levels of morbidity after hospital discharge and are at high risk of unplanned hospital readmission. Identifying those at highest risk before hospital discharge may allow targeting of novel risk reduction strategies. We aimed to identify risk factors for unplanned 90-day readmission, develop a risk prediction model and assess its performance to screen for ICU survivors at highest readmission risk.MethodsPopulation cohort study linking registry data for patients discharged from general ICUs in Scotland (2005–2013). Independent risk factors for 90-day readmission and discriminant ability (c-index) of groups of variables were identified using multivariable logistic regression. Derivation and validation risk prediction models were constructed using a time-based split.ResultsOf 55 975 ICU survivors, 24.1% (95%CI 23.7% to 24.4%) had unplanned 90-day readmission. Pre-existing health factors were fair discriminators of readmission (c-index 0.63, 95% CI 0.63 to 0.64) but better than acute illness factors (0.60) or demographics (0.54). In a subgroup of those with no comorbidity, acute illness factors (0.62) were better discriminators than pre-existing health factors (0.56). Overall model performance and calibration in the validation cohort was fair (0.65, 95% CI 0.64 to 0.66) but did not perform sufficiently well as a screening tool, demonstrating high false-positive/false-negative rates at clinically relevant thresholds.ConclusionsUnplanned 90-day hospital readmission is common. Pre-existing illness indices are better predictors of readmission than acute illness factors. Identifying additional patient-centred drivers of readmission may improve risk prediction models. Improved understanding of risk factors that are amenable to intervention could improve the clinical and cost-effectiveness of post-ICU care and rehabilitation.

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Spath, Nick B., Kelvin Wang, Sowmya Venkatasumbramanian, Omar Fersia, David E. Newby, Chris CE Lang, Neil R. Grubb, and Marc R. Dweck. "Complications and prognosis of patients undergoing apical or septal right ventricular pacing." Open Heart 6, no. 1 (February 2019): e000962. http://dx.doi.org/10.1136/openhrt-2018-000962.

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ObjectivesOptimal right ventricular lead placement remains controversial. Large studies investigating the safety and long-term prognosis of apical and septal right ventricular lead placement have been lacking.MethodsConsecutive patients undergoing pacemaker insertion for high-degree atrioventricular block at Edinburgh Heart Centre were investigated. Periprocedural 30-day complications were defined (infection/bleeding/pneumothorax/tamponade/lead displacement). Long-term clinical outcomes were obtained from the General Register of Scotland and electronic medical records. The primary endpoint was a composite of all-cause mortality, new heart failure, hospitalisation for a major cardiovascular event, as per the CArdiac REsynchronization in Heart Failure trial. Secondary endpoints were all-cause mortality, new heart failure and their composite.Results820 patients were included, 204 (25%) paced from the septum and 616 (75%) from the apex. All baseline variables were similar with the exception of age (septal: 73.2±1.1 vs apical: 76.9±0.5 years, p<0.001). Procedure duration (58±23 vs 55±25 min, p=0.3), complication rates (18 (8.8) vs 46 (7.5)%, p=0.5) and postimplant QRS duration (152 (23) vs 154 (27) ms, p=0.4) were similar. After 1041 days (IQR 564), 278 patients met the primary endpoint, with no difference between the septal and apical groups in unadjusted (HR 0.86 (95% CIs 0.64 to 1.15)) or multivariable analysis correcting for age, gender and comorbidity (HR 0.97 (95% CI 0.72 to 1.30)). Similarly, no differences were observed in the secondary endpoints.ConclusionsThis large real-world cohort of patients undergoing right ventricular lead placement in the septum or apex demonstrated no difference in procedural complications nor long-term clinical outcomes. Both pacing strategies appear reasonable in routine practice.

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Thyss, Antoine, Esma Saada, Lauris Gastaud, Frédéric Peyrade, and Daniel Ré. "HODGKIN LYMPHOMA IN OLDER PATIENTS: AN ORPHAN DISEASE?" Mediterranean Journal of Hematology and Infectious Diseases 6, no. 1 (July 1, 2014): e2014050. http://dx.doi.org/10.4084/mjhid.2014.050.

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Hodgkin Lymphoma HL ica be cured in the large majority of younger patients, but prognosis for older patients, especially those with advanced-stage disease, has not improved substantially. The percentage of HL patients aged over 60 ranges between 15% and 35%.A minority of them is enrolled into clinical trials. HL in the elderly have some specificities: more frequent male sex, B-symptoms, advanced stage, sub diaphragmatic presentation, higher percentage of mixed cellularity, up to 50% of advanced cases associated to EBV. Very old age (>70) and comorbidities are factor of further worsening prognosis. Like in younger patients, ABVD is the most used protocol, but treatment outcome remains much inferior with more frequent, severe and sometimes specific toxicities. Few prospective studies with specific protocols are available. The main data have been published by the Italian Lymphoma Group with the VEPEMB schedule and the German Hodgkin Study Group with the PVAG regimen. Recently, the Scotland and Newcastle Lymphoma Study Group published the SHIELD program associating a prospective phase 2 trial with VEPEMB and a prospective registration of others patients. Patients over 60y with early-stage disease received three cycles plus radiotherapy and had 81% of 3-year overall survival (OS).Those with advanced-stage disease received six cycles, with 3-year OS of 66%.The role of geriatric and comorbidity assessment in the treatment’s choice for HL in the elderly is a major challenge. The combination of loss of activities of daily living combined with the age stratification more or less 70y has been shown as a simple and effective survival model. Hopes come from promising new agents like brentuximab-vedotin (BV) a novel antibody-drug conjugate. The use of TEP to adapt the combination of chemotherapy and radiotherapy according to the metabolic response could also be way for prospective studies.

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Jackson, Alice M., Ruiqi Zhang, Iain Findlay, Keith Robertson, Mitchell Lindsay, Tamsin Morris, Brian Forbes, et al. "Healthcare disparities for women hospitalized with myocardial infarction and angina." European Heart Journal - Quality of Care and Clinical Outcomes 6, no. 2 (July 25, 2019): 156–65. http://dx.doi.org/10.1093/ehjqcco/qcz040.

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Abstract Aims Ischaemic heart disease persists as the leading cause of death in both men and women in most countries and sex disparities, defined as differences in health outcomes and their determinants, may be relevant. We examined sex disparities in presenting characteristics, treatment and all-cause mortality in patients hospitalized with myocardial infarction (MI) or angina. Methods and results We conducted a cohort study of all patients admitted with MI or angina (01 October 2013 to 30 June 2016) from a secondary care acute coronary syndrome e-Registry in NHS Scotland linked with national registers of community drug dispensation and mortality data. A total of 7878 patients hospitalized for MI or angina were prospectively included; 3161 (40%) were women. Women were older, more deprived, had a greater burden of comorbidity, were more often treated with guideline-recommended therapy preadmission and less frequently received immediate invasive management. Men were more likely to receive coronary angiography [adjusted odds ratio (OR) 1.52, confidence interval (CI) 1.37–1.68] and percutaneous coronary intervention (adjusted OR 1.68, CI 1.52–1.86). Women were less comprehensively treated with evidence-based therapies post-MI. Women had worse crude survival, primarily those with ST-elevation myocardial infarction (14.3% vs. 8.0% at 1 year, P < 0.001), but this finding was explained by differences in baseline factors. Men with non-ST-elevation myocardial infarction had a higher risk of all-cause death at 30 days [adjusted hazard ratio (HR) 1.72, CI 1.16–2.56] and 1 year (adjusted HR 1.38, CI 1.12–1.69). Conclusion After taking account of baseline risk factors, sex differences in treatment pathway, use of invasive management, and secondary prevention therapies indicate disparities in guideline-directed management of women hospitalized with MI or angina.

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McCutchan, Grace, Julia Hiscock, Kerenza Hood, Peter Murchie, Richard D. Neal, Gareth Newton, Sara Thomas, Ann Maria Thomas, and Kate Brain. "Engaging high-risk groups in early lung cancer diagnosis: a qualitative study of symptom presentation and intervention preferences among the UK’s most deprived communities." BMJ Open 9, no. 5 (May 2019): e025902. http://dx.doi.org/10.1136/bmjopen-2018-025902.

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ObjectivesPeople at high-risk for lung cancer—current/former smokers, aged 40+ years, with serious lung comorbidity (ie, chronic obstructive pulmonary disease) and living in highly deprived areas—are more likely to delay symptom presentation. This qualitative study aimed to understand the influences on early presentation with lung cancer symptoms in high-risk individuals and intervention preferences.MethodsSemi-structured qualitative interviews with 37 high-risk individuals (without a cancer diagnosis), identified through seven GP practices in socioeconomically deprived areas of England, Scotland and Wales (most deprived 20%). A symptom attribution task was used to explore lung symptom perception and help seeking, developed using Leventhal’s Common Sense Model. Four focus groups with 16 high-risk individuals and 12 local stakeholders (healthcare professionals and community partners) were conducted to explore preferences for an intervention to promote early lung cancer symptom presentation. Data were synthesised using Framework analysis.ResultsIndividual and area level indicators of deprivation confirmed that interview participants were highly deprived.Interviews.Preoccupation with managing ‘treatable’ short-term conditions (chest infections), led to avoidance of acting on ‘inevitable and incurable’ long-term conditions (lung cancer). Feeling judged and unworthy of medical help because of their perceived social standing or lifestyle deterred medical help seeking, particularly when difficult life circumstances and traumatic events led to tobacco and alcohol addiction.Focus groups. Participants recommended multifaceted interventions in community venues, with information about lung cancer symptoms and the benefits of early diagnosis, led by a trained and non-judgemental facilitator.ConclusionsThis study was novel in engaging a high-risk population to gain an in-depth understanding of the broader contextual influences on lung cancer symptom presentation. Perceived lack of health service entitlement and complex lives facilitated avoidance of recognising and presenting with lung cancer symptoms. Community-based interventions have the potential to empower disadvantaged populations to seek medical help for lung symptoms.

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Houchen-Wollof, L., K. Malhotra, J. Mangwani, and L. Mason. "THE UK FOOT AND ANKLE COVID-19 NATIONAL (FALCON) AUDIT: RATE OF COVID-19 INFECTION AND 30-DAY MORTALITY IN FOOT AND ANKLE SURGERY IN THE UK." Orthopaedic Proceedings 106-B, SUPP_10 (May 23, 2024): 4. http://dx.doi.org/10.1302/1358-992x.2024.10.004.

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ObjectivesThe primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice.DesignMulticentre retrospective national audit.SettingUK-based study on foot and ankle patients who underwent surgery between the 13th January to 31st July 2020 – examining time periods pre- UK national lockdown, during lockdown (23rd March to 11th May 2020) and post-lockdown.ParticipantsAll adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland.Main Outcome MeasuresVariables recorded included demographics, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates.Results6644 patients were included. In total 0.52% of operated patients contracted COVID-19 (n=35). The overall all cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n=9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n=3 deaths). Matching for age, ASA and comorbidities, the OR of mortality with COVID-19 infection was 11.71 (95% CI 1.55 to 88.74, p=0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and amongst patients with and without COVID-19 infection. After lockdown COVID-19 infection rate was 0.15% and no patient died of COVID-19 infection.ConclusionsCOVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and post-operative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions.

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Mangwani, Jitendra, Karan Malhotra, Linzy Houchen-Wolloff, and Lyndon Mason. "The UK Foot and Ankle COVID-19 National (FAlCoN) audit." Bone & Joint Open 2, no. 4 (April 1, 2021): 216–26. http://dx.doi.org/10.1302/2633-1462.24.bjo-2021-0008.r1.

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Aims The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice. Methods This UK-based multicentre retrospective national audit studied foot and ankle patients who underwent surgery between 13 January and 31 July 2020, examining time periods pre-UK national lockdown, during lockdown (23 March to 11 May 2020), and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included. A total of 43 centres in England, Scotland, Wales, and Northern Ireland participated. Variables recorded included demographic data, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates. Results A total of 6,644 patients were included. Of the operated patients, 0.52% (n = 35) contracted COVID-19. The overall all-cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n = 9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n = 3 deaths). Matching for age, American Society of Anesthesiologists (ASA) grade, and comorbidities, the odds ratio of mortality with COVID-19 infection was 11.71 (95% confidence interval 1.55 to 88.74; p = 0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and among patients with and without COVID-19 infection. After lockdown the COVID-19 infection rate was 0.15% and no patient died of COVID-19. Conclusion COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and postoperative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions. Cite this article: Bone Joint Open 2021;2(4):216–226.

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Mason, Lyndon W., Jitendra Mangwani, and Karan Malhotra. "The UK Foot and Ankle COVID-19 National Audit – Rate of COVID-19 Infection and 30 Day Mortality in Foot and Ankle Surgery in the UK." Foot & Ankle Orthopaedics 7, no. 1 (January 2022): 2473011421S0035. http://dx.doi.org/10.1177/2473011421s00355.

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Category: Diabetes; Other Introduction/Purpose: The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice. Methods: Design: Multicentre retrospective national audit. Setting: UK-based study on foot and ankle patients who underwent surgery between the 13th January to 31st July 2020 - examining time periods pre- UK national lockdown, during lockdown (23rd March to 11th May 2020) and post-lockdown. Participants: All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Main Outcome Measures: Variables recorded included demographics, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates. Results: 6644 patients were included. In total 0.52% of operated patients contracted COVID-19 (n=35). The overall all cause 30- day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n=9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n=3 deaths). Matching for age, ASA and comorbidities, the OR of mortality with COVID-19 infection was 11.71 (95% CI 1.55 to 88.74, p=0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and amongst patients with and without COVID-19 infection. After lockdown COVID-19 infection rate was 0.15% and no patient died of COVID-19 infection. Conclusion: COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and post-operative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions.

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Craig, Hannah, Malcolm WG Gordon, and Angela Khan. "1375 An analysis of the certified cause of death within one year of serious injury in the Scottish population." Emergency Medicine Journal 39, no. 12 (November 22, 2022): A973.3—A974. http://dx.doi.org/10.1136/emermed-2022-rcem2.21.

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Aims, Objectives and BackgroundTo date, few studies effectively quantify the long-term incidence of death directly related to injury.The absence of detailed mortality data and underlying cause of death information following trauma results in an inadequate understanding and a potential underestimation of the true consequences of injury on an individual and population level.This study takes a nationwide approach to identify the true one-year mortality in patients due to serious injury in Scotland, evaluating survivorship in relation to other pre-existing co-morbidities and incidental causes of death.Method and DesignThis retrospective cohort study assessed the one-year mortality of adult trauma patients with an Injury Severity Score > 9 during 2020 using the Scottish Trauma Audit Group (STAG) registry linked to inpatient hospital data and death certificate records. Patients were divided into three distinct subgroups: death due to injury, death due to another cause, but injury was a contributory factor, and death due to a separate cause. These were subsequently analysed to determine risk factors linked to death. Kaplan-Meier curves and Cox regression were used for survival analysis to evaluate mortality.Abstract 1375 Figure 1Kaplan-Meier survival curve of the 2020 STAG cohort of traumatically injured adult patients who died within 365 days post-trauma hospitalisation stratified by underlying cause of death subgroup: trauma, trauma-contributed and non-traumaResults and Conclusion4056 patients were analysed with a median age 63 years and male predominance (55.2%). 782 patients died within 365 days (19.3%), with 55% occurring post-discharge. 47.7% of all deaths were attributable to trauma, and 35.3% were a direct consequence of injury. Non-traumatic deaths accounted for 20.3% and 79.4% in-hospital and post-discharge deaths respectively, most frequently due to circulatory, neoplastic and respiratory disease (37.7%, 12.3%, 9.1%, respectively). GCS < 8, modified Charlson Comorbidity score > 5, Injury Severity Score >25, Head AIS >3, Sex, and Age were independent risk factors for mortality at one year. Approximately 20% of patients died within 365 days due to trauma. Although early deaths reflect the bulk of trauma-related mortality, our sample demonstrated a significantly higher post-discharge one-year mortality than previously appreciated.

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Symonds, Joseph D., Sameer M. Zuberi, Kirsty Stewart, Ailsa McLellan, Mary O‘Regan, Stewart MacLeod, Alice Jollands, et al. "Incidence and phenotypes of childhood-onset genetic epilepsies: a prospective population-based national cohort." Brain 142, no. 8 (July 13, 2019): 2303–18. http://dx.doi.org/10.1093/brain/awz195.

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Abstract Epilepsy is common in early childhood. In this age group it is associated with high rates of therapy-resistance, and with cognitive, motor, and behavioural comorbidity. A large number of genes, with wide ranging functions, are implicated in its aetiology, especially in those with therapy-resistant seizures. Identifying the more common single-gene epilepsies will aid in targeting resources, the prioritization of diagnostic testing and development of precision therapy. Previous studies of genetic testing in epilepsy have not been prospective and population-based. Therefore, the population-incidence of common genetic epilepsies remains unknown. The objective of this study was to describe the incidence and phenotypic spectrum of the most common single-gene epilepsies in young children, and to calculate what proportion are amenable to precision therapy. This was a prospective national epidemiological cohort study. All children presenting with epilepsy before 36 months of age were eligible. Children presenting with recurrent prolonged (>10 min) febrile seizures; febrile or afebrile status epilepticus (>30 min); or with clusters of two or more febrile or afebrile seizures within a 24-h period were also eligible. Participants were recruited from all 20 regional paediatric departments and four tertiary children’s hospitals in Scotland over a 3-year period. DNA samples were tested on a custom-designed 104-gene epilepsy panel. Detailed clinical information was systematically gathered at initial presentation and during follow-up. Clinical and genetic data were reviewed by a multidisciplinary team of clinicians and genetic scientists. The pathogenic significance of the genetic variants was assessed in accordance with the guidelines of UK Association of Clinical Genetic Science (ACGS). Of the 343 patients who met inclusion criteria, 333 completed genetic testing, and 80/333 (24%) had a diagnostic genetic finding. The overall estimated annual incidence of single-gene epilepsies in this well-defined population was 1 per 2120 live births (47.2/100 000; 95% confidence interval 36.9–57.5). PRRT2 was the most common single-gene epilepsy with an incidence of 1 per 9970 live births (10.0/100 000; 95% confidence interval 5.26–14.8) followed by SCN1A: 1 per 12 200 (8.26/100 000; 95% confidence interval 3.93–12.6); KCNQ2: 1 per 17 000 (5.89/100 000; 95% confidence interval 2.24–9.56) and SLC2A1: 1 per 24 300 (4.13/100 000; 95% confidence interval 1.07–7.19). Presentation before the age of 6 months, and presentation with afebrile focal seizures were significantly associated with genetic diagnosis. Single-gene disorders accounted for a quarter of the seizure disorders in this cohort. Genetic testing is recommended to identify children who may benefit from precision treatment and should be mainstream practice in early childhood onset epilepsy.

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Brown, Katherine L., Jo Wray, Rachel L. Knowles, Sonya Crowe, Jenifer Tregay, Deborah Ridout, David J. Barron, et al. "Infant deaths in the UK community following successful cardiac surgery: building the evidence base for optimal surveillance, a mixed-methods study." Health Services and Delivery Research 4, no. 19 (May 2016): 1–176. http://dx.doi.org/10.3310/hsdr04190.

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BackgroundWhile early outcomes of paediatric cardiac surgery have improved, less attention has been given to later outcomes including post-discharge mortality and emergency readmissions.ObjectivesOur objectives were to use a mixed-methods approach to build an evidenced-based guideline for postdischarge management of infants undergoing interventions for congenital heart disease (CHD).MethodsSystematic reviews of the literature – databases used: MEDLINE (1980 to 1 February 2013), EMBASE (1980 to 1 February 2013), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1981 to 1 February 2013), The Cochrane Library (1999 to 1 February 2013), Web of Knowledge (1980 to 1 February 2013) and PsycINFO (1980 to 1 February 2013). Analysis of audit data from the National Congenital Heart Disease Audit and Paediatric Intensive Care Audit Network databases pertaining to records of infants undergoing interventions for CHD between 1 January 2005 and 31 December 2010. Qualitative analyses of online discussion posted by 73 parents, interviews with 10 helpline staff based at user groups, interviews with 20 families whose infant either died after discharge or was readmitted urgently to intensive care, and interviews with 25 professionals from tertiary care and 13 professionals from primary and secondary care. Iterative multidisciplinary review and discussion of evidence incorporating the views of parents on suggestions for improvement.ResultsDespite a wide search strategy, the studies identified for inclusion in reviews related only to patients with complex CHD, for whom adverse outcome was linked to non-white ethnicity, lower socioeconomic status, comorbidity, age, complexity and feeding difficulties. There was evidence to suggest that home monitoring programmes (HMPs) are beneficial. Of 7976 included infants, 333 (4.2%) died postoperatively, leaving 7634 infants, of whom 246 (3.2%) experienced outcome 1 (postdischarge death) and 514 (6.7%) experienced outcome 2 (postdischarge death plus emergency intensive care readmissions). Multiple logistic regression models for risk of outcomes 1 and 2 had areas under the receiver operator curve of 0.78 [95% confidence interval (CI) 0.75 to 0.82] and 0.78 (95% CI 0.75 to 0.80), respectively. Six patient groups were identified using classification and regression tree analysis to stratify by outcome 2 (range 3–24%), which were defined in terms of neurodevelopmental conditions, high-risk cardiac diagnosis (hypoplastic left heart, single ventricle or pulmonary atresia), congenital anomalies and length of stay (LOS) > 1 month. Deficiencies and national variability were noted for predischarge training and information, the process of discharge to non-specialist services including documentation, paediatric cardiology follow-up including HMP, psychosocial support post discharge and the processes for accessing help when an infant becomes unwell.ConclusionsNational standardisation may improve discharge documents, training and guidance on ‘what is normal’ and ‘signs and symptoms to look for’, including how to respond. Infants with high-risk cardiac diagnoses, neurodevelopmental conditions or LOS > 1 month may benefit from discharge via their local hospital. HMP is suggested for infants with hypoplastic left heart, single ventricle or pulmonary atresia. Discussion of postdischarge deaths for infant CHD should occur at a network-based multidisciplinary meeting. Audit is required of outcomes for this stage of the patient journey.Future workFurther research may determine the optimal protocol for HMPs, evaluate the use of traffic light tools for monitoring infants post discharge and develop the analytical steps and processes required for audit of postdischarge metrics.Study registrationThis study is registered as PROSPERO CRD42013003483 and CRD42013003484.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The National Congenital Heart Diseases Audit (NCHDA) and Paediatric Intensive Care Audit Network (PICANet) are funded by the National Clinical Audit and Patient Outcomes Programme, administered by the Healthcare Quality Improvement Partnership (HQIP). PICAnet is also funded by Welsh Health Specialised Services Committee; NHS Lothian/National Service Division NHS Scotland, the Royal Belfast Hospital for Sick Children, National Office of Clinical Audit Ireland, and HCA International. The study was supported by the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London. Sonya Crowe was supported by the Health Foundation, an independent charity working to continuously improve the quality of health care in the UK.

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MacRae, Clare Elizabeth, Stewart Mercer, Bruce Guthrie, and David Henderson. "Prevalence of concordant and discordant comorbidity in chronic kidney disease: a large cross-sectional study." British Journal of General Practice, December 9, 2020, bjgp20X714125. http://dx.doi.org/10.3399/bjgp20x714125.

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Abstract Background: Chronic kidney disease (CKD) is commonly comorbid with hypertension, diabetes and cardiovascular disease (CVD). However, the extent of comorbidity in CKD across a wider range of conditions is not well documented. Aim: To ascertain the prevalence of comorbidity (across 39 physical and mental health comorbidities) in adults aged 25 years and over with CKD in a large nationally representative primary care population. Design and Setting: Cross-sectional analysis of a primary care dataset representing 1,274,374 adults in Scotland. Method: Secondary analysis of general practice electronic medical record data. Comparison was made with the entire population without CKD, standardised for age, sex, and socioeconomic status (SES). Results: A total of 98.2% of adults with CKD had at least one comorbidity (vs. 51.8% in controls). After adjustment for age, sex, and deprivation, people with CKD were more likely to have 1-3 conditions (OR 11.2, 95% CI 10.3-12.2), 4-6 conditions (OR 24.9, 95% CI 22.9-27.0), and ≥7 conditions (OR 38.9, 95% CI 35.6-42.6. Furthermore, all concordant (7 out of 7) and the majority of discordant physical health conditions (17 out of 24) and mental health conditions (6 out of 8) had significantly positive associations with CKD after adjustment. Conclusion: CKD is associated with extreme comorbidity, across a wide range of mental and physical conditions. Routine care for people with CKD should include recognition and management of comorbidities and clinical guidelines should support clinicians to do this.

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Diernberger, Katharina, Xhyljeta Luta, Joanna Bowden, Joanne Droney, Elizabeth Lemmon, Giovanni Tramonti, Bethany Shinkins, Ewan Gray, Joachim Marti, and Peter S. Hall. "Variation in hospital cost trajectories at the end of life by age, multimorbidity and cancer type." International Journal of Population Data Science 8, no. 1 (January 16, 2023). http://dx.doi.org/10.23889/ijpds.v8i1.1768.

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BackgroundApproximately thirty thousand people in Scotland are diagnosed with cancer annually, of whom a third live less than one year. The timing, nature and value of hospital-based healthcare for patients with advanced cancer are not well understood. The study's aim was to describe the timing and nature of hospital-based healthcare use and associated costs in the last year of life for patients with a cancer diagnosis. MethodsWe undertook a Scottish population-wide administrative data linkage study of hospital-based healthcare use for individuals with a cancer diagnosis, who died aged 60 and over between 2012 and 2017. Hospital admissions and length of stay (LOS), as well as the number and nature of outpatient and day case appointments were analysed. Generalised linear models were used to adjust costs for age, gender, socioeconomic deprivation status, rural-urban (RU) status and comorbidity. ResultsThe study included 85,732 decedents with a cancer diagnosis. For 64,553 (75.3%) of them, cancer was the primary cause of death. Mean age at death was 80.01 (SD 8.15) years. The mean number of inpatient stays in the last year of life was 5.88 (SD 5.68), with a mean LOS of 7 days. Admission rates rose sharply in the last month of life. One year adjusted and unadjusted costs decreased with increasing age. A higher comorbidity burden was associated with higher costs. Major cost differences were present between cancer types. ConclusionsPeople in Scotland in their last year of life with cancer are high users of secondary care. Hospitalisation accounts for a high proportion of costs, particularly in the last month of life. Further research is needed to examine triggers for hospitalisations and to identify influenceable reasons for unwarranted variation in hospital use among different cancer cohorts.

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Fletcher, Eilidh, Kim Kavanagh, William Malcolm, Camilla Wiuff, Nicholas Reid, and Ashutosh Deshpande. "Data linkage of routinely collected electronic health records to characterise risk factors associated with antibiotic resistance in urinary isolates: an exemplar of NHS Scotland’s Infection Intelligence Platform." International Journal of Population Data Science 1, no. 1 (April 19, 2017). http://dx.doi.org/10.23889/ijpds.v1i1.294.

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ABSTRACT ObjectivesUrinary tract infections (UTIs) are amongst the most common infections treated in community and hospital settings. Initial antibiotic treatment of UTI is usually empirical, that is, where the prescriber has no definitive information on the organism or its antibiotic sensitivity.. Overall the prevalence of antimicrobial resistance is increasing, and specifically so for antibiotics commonly used for UTI. By linking NHS surveillance data to routinely collected administrative health data this study aims to investigate risk factors for antibiotic resistance in urine samples ApproachAll positive urine samples included in the “Surveillance of Antimicrobial Resistance in Urinary Isolates in Scotland” dataset in the period from January 2012 to June 2015 (all NHS Health Boards in Scotland submit susceptibility data for up to eleven antibiotics on 400 positive urinary samples per quarter) were analysed. Cases were assigned a resistance status of Sensitive, Resistant or Multi-drug resistant based on the antibiotic susceptibility data recorded. Using the NHS Scotland Infection Intelligence Platform all cases were linked to national coverage data: (i) hospital discharge data to create the Charlson score for comorbidity and (ii) patient-level community prescribing data to measure cumulative antibiotic exposure (number of defined daily doses) in the 3 months prior to infection. Risk factors associated with the infection susceptibility to antibiotics were assessed using multivariable multinomial logistic regression. Results40,984 positive urine samples were examined. Overall 29.0% were sensitive, 48.1% resistant and 22.9% multi drug resistant. Around a third of the cases (33.9%) had no antibiotic prescribing in the 3 months prior to infection. Age, care home residence and increasing comorbidity were both found to be associated with resistance and multidrug resistance. Cumulative antibiotic exposure had a clear dose-response effect. Those with 1-7DDDs were 1.2 times (95% CI: 1.11-1.29) more likely to have a multidrug resistant infection (compared to a sensitive infection) rising to 7.45 times (95% CI: 95% CI 6.45-8.6) for 29+ DDDs. Similar dose response held for resistant infection but at a lesser scale (1-7DDDs OR=1.36 (95% CI: 1.2-1.5) rising to OR=3.04 (95% CI: 2.38-3.89). ConclusionA clear effect of cumulative antibiotic exposure in the community and multidrug resistance in UTI cases has been demonstrated. Such quantification is key to ensuring and supporting robust antimicrobial stewardship policy and will form the evidence base for development of prescribing decision support tools for more patient centred treatment of UTI.

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Lee, Kuan Ken, Dimitrios Doudesis, Rong Bing, Federica Astengo, Jesus R. Perez, Atul Anand, Shauna McIntyre, et al. "Sex Differences in Oral Anticoagulation Therapy in Patients Hospitalized With Atrial Fibrillation: A Nationwide Cohort Study." Journal of the American Heart Association, March 2, 2023. http://dx.doi.org/10.1161/jaha.122.027211.

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Background Important disparities in the treatment and outcomes of women and men with atrial fibrillation (AF) are well recognized. Whether introduction of direct oral anticoagulants has reduced disparities in treatment is uncertain. Methods and Results All patients who had an incident hospitalization from 2010 to 2019 with nonvalvular AF in Scotland were included in the present cohort study. Community drug dispensing data were used to determine prescribed oral anticoagulation therapy and comorbidity status. Logistic regression modeling was used to evaluate patient factors associated with treatment with vitamin K antagonists and direct oral anticoagulants. A total of 172 989 patients (48% women [82 833 of 172 989]) had an incident hospitalization with nonvalvular AF in Scotland between 2010 and 2019. By 2019, factor Xa inhibitors accounted for 83.6% of all oral anticoagulants prescribed, while treatment with vitamin K antagonists and direct thrombin inhibitors declined to 15.9% and 0.6%, respectively. Women were less likely to be prescribed any oral anticoagulation therapy compared with men (adjusted odds ratio [aOR], 0.68 [95% CI, 0.67–0.70]). This disparity was mainly attributed to vitamin K antagonists (aOR, 0.68 [95% CI, 0.66–0.70]), while there was less disparity in the use of factor Xa inhibitors between women and men (aOR, 0.92 [95% CI, 0.90–0.95]). Conclusions Women with nonvalvular AF were significantly less likely to be prescribed vitamin K antagonists compared with men. Most patients admitted to the hospital in Scotland with incident nonvalvular AF are now treated with factor Xa inhibitors and this is associated with fewer treatment disparities between women and men.

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Walker, J. "One-year mortality in patients with diabetes in Scotland 2004-2011: influence of socioeconomic status and comorbidity." European Journal of Public Health 24, suppl_2 (October 1, 2014). http://dx.doi.org/10.1093/eurpub/cku151.006.

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Mullin, Donncha S. "Trajectories of Motoric Cognitive Risk and Incident Dementia in Scotland." Alzheimer's & Dementia 19, S22 (December 2023). http://dx.doi.org/10.1002/alz.072270.

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AbstractBackgroundMotoric cognitive risk syndrome (MCR) ‐ objective slow gait and subjective cognitive complaints ‐ is quick and easy to measure, making it a potentially useful clinical tool for identifying those at high risk of developing dementia. This is the first exploration of MCR syndrome’s predictive ability for incident dementia in a Scottish cohort (Lothian Birth Cohort 1936) and the first examination of the various trajectories of MCR.MethodWe classified a total of 680 community‐dwelling participants (mean [SD] age 76.3 [0.8] years) free from dementia into non‐MCR or MCR groups. We used cox proportional hazard methods to evaluate the risk of developing all‐cause dementia in the years following MCR diagnosis. Our final model adjusted for age, sex, comorbidity index, apolipoprotein E status, physical activity level, and years of education. We analysed the trajectories for everyone with MCR by tracking their outcomes over 9 years. All analyses were performed in R version 4.0.2.ResultThe prevalence of MCR at baseline was 5.6% (n = 38/680). After 9 years of follow‐up, 11.6% (n = 79/680) of the total cohort developed dementia. The presence of MCR increased the risk of dementia (adjusted hazard ratio 2.37 [95%CI 1.06‐5.32; p = 0.0359]). The trajectories of those with MCR at baseline were: i) reverted to healthy (n = 6/38), ii) ongoing MCR (n = 13/38), iii) progressed to dementia (n = 9/38), or iv) died (n = 10/38).ConclusionMCR showed similar prognostic ability for dementia in a Scottish cohort as for other populations. MCR could identify a target group for early interventions of modifiable risk factors to prevent incident dementia. Individuals with MCR follow similar trajectories to the related predementia syndrome, Mild Cognitive Impairment.

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Cuthbertson, R., K. Ellis, E. Reda, K. Chaplow, M. W. G. Gordon, and E. Capek. "972 EXPLORING THE IMPACT OF FRAILTY FOLLOWING TRAUMA: AN ANALYSIS OF EMERGENCY DEPARTMENT (ED) MANAGEMENT AND LONG TERM OUTCOMES." Age and Ageing 51, Supplement_2 (June 2022). http://dx.doi.org/10.1093/ageing/afac126.029.

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Abstract Introduction Major trauma represents a large number of hospital presentations in Scotland. 1 We aimed to: -Describe the population of ‘major trauma’ patients presenting to the Emergency Department of QEUH, Glasgow -Compare assessment, management and clinical outcomes in frail versus non-frail patients with trauma. Method This was a retrospective, cohort study. Patients were identified using the Scottish Trauma Audit Group (STAG) database. 2 Patients aged over 18, admitted between 01/11/18 and 31/01/19 were included. STAG data was supplemented by individual case note review. Clinical Frailty Scale (CFS) and Charlson Comorbidity Index (CCI) were calculated. Results 203 patients (173 non-frail, 30 frail) were included. Median age was 58 years (range 19–98). Isolated head injuries were the predominant injury type in frail patients (36.7%) versus polytrauma in non-frail cohort (44.5%). Injury Severity Score (ISS) was similar across both groups (median score: 10v9.5). CCI score correlated well with frailty. Frail patients were less likely to: -Have ambulance pre-alert call (10% v 28%, p = 0.041). -Be managed in ‘Resus’ (17% v 54%, p < 0.05). -Have consultant-led care in ED (6.6% v 36.4%, p = 0.001). -Undergo CT within 60 minutes (10% v 34.7%, p = 0.0095). They were more likely to be admitted under a Medical Team (20% v 2.9%, p < 0.05). Frailty was associated with poorer outcomes: -Mortality 30% v 9.8%: significant difference in unadjusted, 1-year survival curves (Log-rank test p = 0.0026). Frailty carried a hazard-ratio of death of 5.02 (CI:2.13–11.79, p = 0.0002) compared to non-frailty through the first year after trauma. -Longer median Length of Stay: 22 v 8 days. Conclusion We identified poorer clinical outcomes in our frail patient cohort. Despite this, and with similar ISS scores across both groups, our data would suggest a tendency to under-recognise significant trauma in Frail patients. References [1] Audit of Trauma Management in Scotland. Public Health Scotland, 2021 [2] Scottish Trauma Audit Group https://www.stag.scot.nhs.uk/

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Shah, A., D. McAllister, F. Astengo, J. Perez, K. K. Lee, P. Gallacher, J. Hall, et al. "3325Incidence, outcomes and microbiology in patients with infective endocarditis." European Heart Journal 40, Supplement_1 (October 1, 2019). http://dx.doi.org/10.1093/eurheartj/ehz745.0077.

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Abstract Introduction Despite recent improvements in management, infective endocarditis remains associated with high morbidity and mortality. Over the last few decades, several factors have impacted on both the incidence and outcomes following infective endocarditis. Purpose Using a national linkage approach, we describe the changing age- and sex-stratified incidence and outcomes of infective endocarditis in Scotland over the last 25 years. Methods We conducted a consecutive retrospective individual patient linkage study across multiple national databases. Using data extracted from the Scottish hospital discharge dataset held by the Information Services Division of NHS National Services Scotland, we extracted episodes for all patients aged 20 years or older who were admitted with infective endocarditis between January 1, 1990, and December 31, 2014 in Scotland, UK. Patient episodes with infective endocarditis were linked to national prescribing and microbiology databases. The primary outcome was 1-year mortality following the index presentation. Generalised additive models were constructed to estimate the crude and age- and sex-stratified incidence rates (using a poison distribution) as well as trends in mortality (using a binomial distribution) adjusted for age, sex and comorbidity. Results Across 12,446 individual patients, there were a total of 12,667 hospitalisations (mean age 68±17 years, 55% females) with infective endocarditis using a 5-year look back period. The estimated crude rate of hospitalisation increased from 7.38 per 100,000 (95% CI 6.58 to 8.28) in 1990 to 15.09 per 100,000 (95% CI 13.90 to 16.39) in 2014 (p<0.001). Over the period of the study, 31% (3,877/12,667) of people admitted to hospital with infective endocarditis died within one year of admission. Case fatality fell markedly in both men and women from 1990 to 2014 (Figure). Microbiology was status was available for 34% of all hospitalisations with staphylococcus cultures associated with worse outcomes. Conclusions Despite the crude incidence of infective endocarditis doubling over the last 25 years and case fatality remaining high, the risk of death has markedly fallen over the last two decades. Staphylococcus cultures remain an independent marker of poor prognosis in this cohort. Acknowledgement/Funding British Heart Foundation

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McGregor, R., G. Couper, P. Lamb, R. Petty, A. MacDonald, and M. Forshaw. "271 OESOPHAGO-GASTRIC CANCER SURVIVAL IN SCOTLAND: LESSONS LEARNT FROM ESTABLISHING A NATIONAL NETWORK." Diseases of the Esophagus 33, Supplement_1 (September 2020). http://dx.doi.org/10.1093/dote/doaa087.55.

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Abstract Oesophageal cancer is the 9th most common cancer in Scotland, with 972 new cases in 2017. It remains the 4th most common cause of cancer death, with an estimated 5 year survival of 12.1%. Scotland’s oesophago-gastric cancer network consists of 3 regional divisions, serving a population of 5.44 million. In 2017, survival data indicated survival differences across the 3 networks. This work analyses these outcomes and provides insight into the challenges faced by national collaboration. Methods Upper GI Cancer Quality Performance Indicators (QPIs) for patients diagnosed between January 1st 2013 and December 2015 were collected by clinical audit staff in each NHS Board and submitted centrally to the Information Services Division (ISD). Twelve QPIs are assessed and include: % discussed at MDT, % undergoing neo-adjuvant chemotherapy/CRT, 30/90 day mortality, length of stay, and R1 resection rates. Quality assurance of the dataset was assessed by analysing 20% of records submitted. Both univariate (log rank testing and Kaplan–Meier survival curves) and multivariate survival analysis (Cox’s proportional hazards model) were then performed on all patients across the networks. Results —Quality assurance of the dataset was high—96% accuracy of those records analysed.—Univariate analysis showed that increased age, higher deprivation scores, poor performance status, high tumour grade, an R1 resection, and a poor Charlson comorbidity index, had worse survival. Gender was not a significant survival factor. There was no difference at either network or health board level for all patients with oesophageal cancer.—multi-variate analysis revealed survival differences across the networks for radical treatment of oesophageal adenocarcinoma. In addition, the survival of patients receiving radical radiotherapy in one network appeared better than chemoradiotherapy for SCC. Conclusion This body of work highlights the challenges and pitfalls of establishing a national clinical network. Importantly, data collection and accuracy are high. Moreover, unlike other national collaboratives, data submission is compulsory. Whilst survival differences were detected across the clinical networks, further in depth analysis revealed confounding factors e.g. 23% of oesophageal cancers were stage “unknown”. The algorithm used at ISD did not capture stage T4a or b accounting for most of these patients.

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Fagbamigbe, Adeniyi, Utkarsh Agrawal, Amaya Azcoaga-Lorenzo, Briana MacKerron, and Colin McCowan. "Clustering of 31 health conditions among multimorbid people in Fife and Tayside, Scotland: E-cohort analysis." International Journal of Population Data Science 7, no. 3 (August 25, 2022). http://dx.doi.org/10.23889/ijpds.v7i3.2036.

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BackgroundA deeper understanding of the clustering of multimorbidity (2+) (MM) conditions by age, sex, and deprivation could help prepare health systems for adequate and effective preventive intervention. We identified the commonest conditions and their clusters contributing to MM stratified age, sex, and deprivation. MethodsRetrospective cohort of 431,772 patients aged >25 years, registered with a general practice in Fife/Tayside, Scotland and alive in January 2000 were followed till December 2019. We developed Multimorbidity e-Cohort for Fife/Tayside (MCFT), Scotland. MCFT combined anonymised Scottish demographic dataset, prescribing information systems records from 2009 and secondary care: hospital admission and day-case records, mental health inpatient and accident and emergency attendances from 2000 from the Scottish Safe Havens Health Informatics Centre. Elixhauser comorbidity classifications were used to identify the presence of 31 conditions. Besides descriptive statistics, dissimilarity algorithm in association rule mining techniques were used for the analysis. Results33.6% and 13.3% had MM and complex MM (4+) respectively, which varied across age, sex and deprivation of the patients. The commonest condition among <50 years with MM are alcohol abuse (32%), chronic pulmonary disease and depression (24% each) compared with uncomplicated hypertension (57%), and cardiac arrhythmia (40%) among those aged 80+ years. We identified four unique clusters among multimorbid individuals (a) liver disease, alcohol, other neurological disorders and depression; (b) weight loss, Rheumatoid Arthritis/collagenm, hypothyroidism, deficiency anemia; (c) solid tumor and metastatic cancer; (4) peripheral vascular disorders, renal failure, fluid & electrolyte disorders, chronic pulmonary disease, uncomplicated hypertension/diabetes, pulmonary circulation disorders, valvular disease, congestive heart failure and cardiac arrhythmias. The clusters varied across sex, age and deprivation. ConclusionClusters of disease conditions in the MM population varied mostly by age. Alcohol misuse contributed to MM among a third of under-50. Almost half of the oldest age group have hypertension and cardiac arrythmia. When considering clustering of conditions, it is important to consider age, sex and deprivation.

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Fleming, Michael. "Educational and health outcomes of schoolchildren in local authority care in Scotland: a retrospective record linkage study." International Journal of Population Data Science 7, no. 3 (August 25, 2022). http://dx.doi.org/10.23889/ijpds.v7i3.2020.

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ObjectivesLooked-after-children are defined as children who are in the care of their local authority. Previous studies have reported that looked-after-children have poorer mental and physical health, increased behavioural problems, and increased self-harm and mortality compared to peers. They also experience poorer educational outcomes yet population wide research into the latter is lacking, particularly in the UK. Education and health share a bidirectional relationship therefore it is important to dually investigate both outcomes. Our study aimed to compare educational and health outcomes for looked-after-children with peers, adjusting for sociodemographic, maternity and comorbidity confounders. ApproachLinkage of nine Scotland-wide databases, covering dispensed prescriptions, hospital admissions, maternity records, death certificates, annual pupil census, examinations, school absences/exclusions, unemployment, and looked-after-children provided retrospective data on 715,111 children attending Scottish schools between 2009 and 2012. ResultsCompared to peers, 13,898 (1.9%) looked-after-children were more likely to be absent and excluded from school, have special educational need and neurodevelopmental multimorbidity, achieve the lowest level of academic attainment, and be unemployed after leaving school. They were more likely to require treatment for epilepsy, attention deficit hyperactivity disorder and depression, be hospitalised overall, for injury and self-harm, and die prematurely. Compared to children looked after at home, children looked after away from home had less absenteeism, less exclusion, less unemployment, and better attainment. Therefore, amongst those in care, being cared for away from home appeared to be a protective factor resulting in better educational outcomes. ConclusionsLooked-after-children had poorer health and educational outcomes than peers independent of increased neurodevelopmental conditions and special educational need. Further work is required to understand whether poorer outcomes relate to reasons for entering care, including maltreatment and adverse childhood events, neurodevelopmental vulnerabilities, or characteristics of the care system.

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Lee, K., D. Doudesis, R. Bing, F. Astengo, J. Perez, A. Anand, S. McIntyre, et al. "Sex-differences in oral anticoagulation therapy in patients hospitalised with atrial fibrillation: a nationwide cohort study." European Heart Journal 43, Supplement_2 (October 1, 2022). http://dx.doi.org/10.1093/eurheartj/ehac544.623.

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Abstract Background Important disparities in the treatment and outcomes of women and men with atrial fibrillation are well recognized. Whether introduction of direct oral anticoagulants has reduced disparities in treatment is uncertain. Methods All patients who had an incident hospitalization from 2010 to 2019 with non-valvular atrial fibrillation in Scotland were included in this cohort study. Community drug dispensing data were used to determine prescribed oral anticoagulation therapy and comorbidity status. Logistic regression modelling was used to evaluate patient factors associated with treatment with vitamin K antagonists and direct oral anticoagulants. Results A total of 172,989 patients (48% women [82,833/172,989]) had an incident hospitalization with non-valvular atrial fibrillation in Scotland between 2010 and 2019. The proportion of patients with thromboembolic risk factors (CHA2DS2VASc score >0 in men and >1 in women) treated with oral anticoagulation therapy increased from 36.8% to 66.3% over this 10-year period. By 2019, factor Xa inhibitors accounted for 83.6% of all oral anticoagulants prescribed, while treatment with vitamin K antagonists and direct thrombin inhibitors declined to 15.9% and 0.6%, respectively. Women were less likely to be prescribed any oral anticoagulation therapy compared to men (adjusted odds ratio, aOR 0.68 [95% CI, CI 0.67–0.70]). This disparity was mainly attributed to vitamin K antagonists (aOR 0.68 [95% CI 0.66–0.70]), whilst there was less disparity in use of factor Xa inhibitors between women and men (aOR 0.92 [95% CI 0.90–0.95]). At 1 year following hospitalization with atrial fibrillation, patients not prescribed oral anticoagulation therapy were more likely to have subsequent major adverse cardiovascular events compared to those prescribed with oral anticoagulation therapy (38.8% [15,380/39,608] versus 17.0% [6,761/39,671] in women and 35.2% [12,977/36,868] versus 16.4% [7,395/45,093] in men). Conclusions Women with non-valvular atrial fibrillation were significantly less likely to be prescribed vitamin K antagonists compared to men. Most patients admitted to hospital in Scotland with incident non-valvular atrial fibrillation are now treated with factor Xa inhibitors and this is associated with less treatment disparities between women and men. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This study was supported by the British Heart Foundation through a Clinical Research Training Fellowship (FS/18/25/33454), Intermediate Clinical Research Fellowship (FS/19/17/34172), Senior Clinical Research Fellowship (FS/16/14/32023) and a Research Excellence Award (RE/18/5/34216), and a research grant to NHS Lothian from Bristol Myers Squibb Pharmaceuticals Ltd and Pfizer UK Ltd.

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Yeung, Alan, Max Wilkinson, Jen Bishop, Bob Taylor, Norah Palmateer, Lee Barnsdale, Jaroslaw Lang, et al. "SARS-CoV-2 vaccine uptake and risks of severe COVID-19 disease among people prescribed opioid agonist therapy in Scotland." Journal of Epidemiology and Community Health, April 9, 2024, jech—2023–221602. http://dx.doi.org/10.1136/jech-2023-221602.

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BackgroundThere is limited evidence quantifying the risk of severe COVID-19 disease among people with opioid dependence. We examined vaccine uptake and severe disease (admission to critical care or death with COVID-19) among individuals prescribed opioid agonist therapy (OAT).MethodA case–control design was used to examine vaccine uptake in those prescribed OAT compared with the general population, and the association between severe disease and OAT. In both analyses, 10 controls from the general population were matched (to each OAT recipient and COVID-19 case, respectively) according to socio-demographic factors. Conditional logistic regression was used to estimate rate ratios (RR) for severe disease.ResultsVaccine uptake was markedly lower in the OAT cohort (dose 1: 67%, dose 2: 53% and dose 3: 31%) compared with matched controls (76%, 72% and 57%, respectively). Those prescribed OAT within the last 5 years, compared with those not prescribed, had increased risk of severe COVID-19 (RR 3.38, 95% CI 2.75 to 4.15), particularly in the fourth wave (RR 6.58, 95% CI 4.20 to 10.32); adjustment for comorbidity and vaccine status attenuated this risk (adjusted RR (aRR) 2.43, 95% CI 1.95 to 3.02; wave 4 aRR 3.78, 95% CI 2.30 to 6.20). Increased risk was also observed for those prescribed OAT previously (>3 months ago) compared with recently (aRR 1.74, 95% CI 1.11 to 2.71).ConclusionsThe widening gap in vaccine coverage for those prescribed OAT, compared with the general population, is likely to have exacerbated the risk of severe COVID-19 in this population over the pandemic. However, continued OAT use may have provided protection from severe COVID-19 among those with opioid dependence.

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