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Verburg I.W.M.,University of Amsterdam | De Keizer N.F.,University of Amsterdam | Holman R.,University of Amsterdam | Dongelmans D.,University of Amsterdam | And 2 more authors.
Critical Care Medicine | Year: 2016

Objectives: The performance of ICUs can be compared by ranking them into a league table according to their risk-adjusted mortality rate. The statistical quality of a league table can be expressed as its rankability, the percentage of variation between ICUs attributable to unexplained differences. We examine whether we can improve the rankability of our league table by using data from a longer period or by grouping ICUs with similar performance constructing a league table of clusters rather than individual ICUs. Design: We developed a league table for risk-adjusted mortality rate with its rankability. The effect of assessment period was determined using a resampling procedure. Hierarchical clustering was used to obtain clusters of similar ICUs. Patients: We used data from ICUs participating in the Dutch National Intensive Care Evaluation registry between 2011 and 2013. Measurements and Main Results: We constructed league tables using 157,394 admissions from 78 ICUs with risk-adjusted mortality rate between 5.9% and 13.9% per ICU over the inclusion period. The rankability was 73% for 2013 and 89% for the whole period 2011-2013. Rankability over the year 2013 increased till 98% when clustering ICUs, reaching an optimum at a league table of seven clusters. Conclusions: We conclude that, when using data from a single year, the rankability of a league table of Dutch ICUs based on risk-adjusted mortality rate was unacceptably low. We could improve the rankability of this league table by increasing the period of data collection or by grouping similar ICUs into clusters and constructing a league table of clusters of ICUs rather than individual ICUs. Ranking clusters of ICUs could be useful for identifying possible differences in performance between clusters of ICUs. Source

Gulliford M.C.,Kings College London | Dregan A.,Kings College London | Moore M.V.,University of Southampton | Ashworth M.,Kings College London | And 7 more authors.
BMJ Open | Year: 2014

Objectives: Overutilisation of antibiotics may contribute to the emergence of antimicrobial drug resistance, a growing international concern. This study aimed to analyse the performance of UK general practices with respect to antibiotic prescribing for respiratory tract infections (RTIs) among young and middle-aged adults. Setting: Data are reported for 568 UK general practices contributing to the Clinical Practice Research Datalink. Participants: Participants were adults aged 18-59 years. Consultations were identified for acute upper RTIs including colds, cough, otitis-media, rhino-sinusitis and sore throat. Primary and secondary outcome measures: For each consultation, we identified whether an antibiotic was prescribed. The proportion of RTI consultations with antibiotics prescribed was estimated. Results: There were 568 general practices analysed. The median general practice prescribed antibiotics at 54% of RTI consultations. At the highest prescribing 10% of practices, antibiotics were prescribed at 69% of RTI consultations. At the lowest prescribing 10% of practices, antibiotics were prescribed at 39% RTI consultations. The median practice prescribed antibiotics at 38% of consultations for 'colds and upper RTIs', 48% for 'cough and bronchitis', 60% for 'sore throat', 60% for 'otitis-media' and 91% for 'rhinosinusitis'. The highest prescribing 10% of practices issued antibiotic prescriptions at 72% of consultations for 'colds', 67% for 'cough', 78% for 'sore throat', 90% for 'otitis-media' and 100% for 'rhino-sinusitis'. Conclusions: Most UK general practices prescribe antibiotics to young and middle-aged adults with respiratory infections at rates that are considerably in excess of what is clinically justified. This will fuel antibiotic resistance. Source

BACKGROUND:: Carotid–femoral pulse wave velocity (cfPWV) adds significantly to traditional cardiovascular risk prediction, but is not widely available. Therefore, it would be helpful if cfPWV could be replaced by an estimated carotid–femoral pulse wave velocity (ePWV) using age and mean blood pressure, and previously published equations. The aim of this study was to investigate whether ePWV could predict cardiovascular events independently of traditional cardiovascular risk factors and/or cfPWV. METHOD:: cfPWV was measured and ePWV was calculated in 2366 patients from four age groups of the Danish MONICA10 cohort. Additionally, the patients were divided into four cardiovascular risk groups based on Systematic COronary Risk Evaluation (SCORE) or Framingham risk score (FRS). In 2006, the combined cardiovascular endpoint of cardiovascular death, nonfatal myocardial infarction, stroke and hospitalization for ischemic heart disease was registered. RESULTS:: Most results were retested in 1045 hypertensive patients from a Paris cohort. Bland–Altman plot demonstrated a relative difference of −0.3% [95% confidence interval (CI) −15 to 17%] between ePWV and cfPWV. In Cox regression models in apparently healthy patients, ePWV and cfPWV (per SD) added independently to SCORE in prediction of combined endpoint [hazard ratio (95%CI)?=?1.38(1.09–1.76) and hazard ratio (95%CI)?=?1.18(1.01–1.38)] and to FRS [hazard ratio (95%CI)?=?1.33(1.06–1.66) and hazard ratio (95%CI)?=?1.16(0.99–1.37)]. If healthy patients with ePWV and/or cfPWV at least 10?m/s were reclassified to a higher SCORE risk category, net reclassification index was 10.8%, P less than 0.01. These results were reproduced in the Paris cohort. CONCLUSION:: ePWV predicted major cardiovascular events independently of SCORE, FRS and cfPWV indicating that these traditional risk scores have underestimated the complicated impact of age and blood pressure on arterial stiffness and cardiovascular risk. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Source

Kraal J.J.,University of Amsterdam | Peek N.,Health eResearch Centre | | Van den Akker-Van Marle M.E.,Leiden University | Kemps H.M.,University of Amsterdam
European journal of preventive cardiology | Year: 2014

BACKGROUND: Home-based exercise training in cardiac rehabilitation (CR) has the potential to improve CR uptake, decrease costs and increase self-management skills. The FIT@Home study evaluates home-based CR with telemonitoring guidance using coaching interventions including strategies for behavioural changes with the aim to maintain adherence to a healthy lifestyle and to improve long-term effects. In this interim analysis we provide short-term results on exercise capacity, quality of life and training adherence of the first 50 patients included in the FIT@Home study.DESIGN: The study design was a randomised controlled trial.METHODS: Low to moderate risk CR patients were randomised to a 12-week home-based training (HT) programme or a 12-week centre-based training (CT) programme. In both groups, training was performed at 70-85% of maximal heart rate (HRmax) for 45-60 min, 2-3 times per week. The HT group received three supervised training sessions, before commencing training with a heart rate monitor in their home environment. These patients received individual coaching by telephone weekly, based on training data uploaded on the Internet. The CT programme was performed under the direct supervision of a physical therapist. Exercise capacity and health-related quality of life were assessed at baseline and at 12 weeks.RESULTS: CT (n = 25) and HT (n = 25) both showed a significant improvement in peak oxygen uptake (peak VO2) (10% and 14% respectively) and quality of life after 12 weeks of training, without significant between-group differences. The average training intensity of the HT group was 73.3 ± 3.5% of HRmax. Training adherence was similar between groups.CONCLUSION: This analysis shows that HT with telemonitoring guidance has similar short-term effects on exercise capacity and quality of life as CT in CR patients. © Authors 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav. Source

Herrett E.,London School of Hygiene and Tropical Medicine | Gallagher A.M.,Datalink | Gallagher A.M.,University Utrecht | Bhaskaran K.,London School of Hygiene and Tropical Medicine | And 6 more authors.
International Journal of Epidemiology | Year: 2015

The Clinical Practice Research Datalink (CPRD) is an ongoing primary care database of anonymised medical records from general practitioners, with coverage of over 11.3 million patients from 674 practices in the UK. With 4.4 million active (alive, currently registered) patients meeting quality criteria, approximately 6.9% of the UK population are included and patients are broadly representative of the UK general population in terms of age, sex and ethnicity. General practitioners are the gatekeepers of primary care and specialist referrals in the UK. The CPRD primary care database is therefore a rich source of health data for research, including data on demographics, symptoms, tests, diagnoses, therapies, health-related behaviours and referrals to secondary care. For over half of patients, linkage with datasets from secondary care, disease-specific cohorts and mortality records enhance the range of data available for research. The CPRD is very widely used internationally for epidemiological research and has been used to produce over 1000 research studies, published in peer-reviewed journals across a broad range of health outcomes. However, researchers must be aware of the complexity of routinely collected electronic health records, including ways to manage variable completeness, misclassification and development of disease definitions for research. © The Author 2015. Published by Oxford University Press on behalf of the International Epidemiological Association. Source

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