Much more medicine for the oldest old: trends in UK electronic clinical records

Melzer, David; Tavakoly, Behrooz; Winder, Rachel; Masoli, Jane; Henley, William; Blé, Alessandro; Richards, Suzanne H

doi:10.1093/ageing/afu113

Cited by 66 publications

(52 citation statements)

References 26 publications

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“…52 The authors further reported an increase in hospital admission rate, which was small and not significant in those aged 65-84 years, but larger in those older than 85 years. They found for both age groups an increase in emergency admission.…”

Section: Discussionmentioning

confidence: 88%

Trend study on the association between hospital admissions and the health of Dutch older adults (1995–2009)

et al. 2016

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ObjectivesAn increase in hospital admission rates in older people may reflect improved access to healthcare, but also declining health trends in the older population. Owing to a lack of individual-level data, the latter possibility has received little attention. The current study examines associations between health status and hospitalisation rates of older adults in the Netherlands.DesignObservational individual-level data linked to hospital register data.SettingData from 1995 to 2009 from the nationally representative Longitudinal Aging Study Amsterdam were linked to the Dutch Hospital Discharge Register.ParticipantsA total of 5681 observations of 2520 respondents across 4 measurement points (each with a follow-up of 36 months; ages 65–88 years).Outcome measuresThe contribution of health, demographic, psychosocial and lifestyle characteristics to time trends in hospitalisation was assessed in multivariate models.ResultsBetween 1995 and 2009, the percentage with 1 or more overnight admissions (planned or acute) increased slightly from 38.1% to 39.7%. This was due to an increase in acute admission only (22.2–27.0%). Increased prevalences of chronic diseases, functional limitations and polypharmacy accounted for part of the observed increase in acute admissions. In addition, a more than doubled prevalence of day admissions over time was observed (12.3–28.3%), a trend that was unrelated to changes in individual characteristics.ConclusionsThis trend study showed a contribution of declines in population health to increases in acute hospital admissions. Since these declines did not provide a full explanation, healthcare reforms and increases in treatment possibilities in this period are likely to have contributed as well.

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Section: Discussionmentioning

confidence: 88%

Trend study on the association between hospital admissions and the health of Dutch older adults (1995–2009)

et al. 2016

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“…This analysis included 39 370 individuals from our main cohort with information available to calculate changes in SBP. Medical conditions included asthma, atrial fibrillation, coronary heart disease, cancer, chronic kidney disease (stage 3-5), chronic obstructive pulmonary disease, dementia, depression, diabetes mellitus, epilepsy, heart failure, hypertension, severe mental conditions (psychoses),23 stroke or transient ischemic attack, and hypothyroidism. We used multivariate regression analysis, adjusted for the same covariates as the main step function model.…”

Section: Methodsmentioning

confidence: 99%

Blood Pressure Trajectories in the 20 Years Before Death

et al. 2018

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IMPORTANCE There is mixed evidence that blood pressure (BP) stabilizes or decreases in later life. It is also unclear whether BP trajectories reflect advancing age, proximity to end of life, or selective survival of persons free from hypertension.OBJECTIVE To estimate individual patient BP for each of the 20 years before death and identify potential mechanisms that may explain trajectories. DESIGN, STUDY, AND PARTICIPANTSWe analyzed population-based Clinical Practice Research Datalink primary care and linked hospitalization electronic medical records from the United Kingdom, using retrospective cohort approaches with generalized linear mixed-effects modeling. Participants were all available individuals with BP measures over 20 years, yielding 46 634 participants dying aged at least 60 years, from 2010 to 2014. We also compared BP slopes from 10 to 3 years before death for 20 207 participants who died, plus 20 207 birth-year and sex-matched participants surviving longer than 9 years. MAIN OUTCOMES AND MEASURES Clinically recorded individual patient repeated systolic BP (SBP) and diastolic BP (DBP).RESULTS In 46 634 participants (51.7% female; mean [SD] age at death, 82.4 [9.0] years), SBPs and DBPs peaked 18 to 14 years before death and then decreased progressively. Mean changes in SBP from peak values ranged from −8.5 mm Hg (95% CI, −9.4 to −7.7) for those dying aged 60 to 69 years to −22.0 mm Hg (95% CI, −22.6 to −21.4) for those dying at 90 years or older; overall, 64.0% of individuals had SBP changes of greater than −10 mm Hg. Decreases in BP appeared linear from 10 to 3 years before death, with steeper decreases in the last 2 years of life. Decreases in SBP from 10 to 3 years before death were present in individuals not treated with antihypertensive medications, but mean yearly changes were steepest in patients with hypertension (−1.58; 95% CI, −1.56 to −1.60 mm Hg vs −0.70; 95% CI, −0.65 to −0.76 mm Hg), dementia (−1.81; 95% CI, −1.77 to −1.87 mm Hg vs −1.41; 95% CI, −1.38 to −1.43 mm Hg), heart failure (−1.66; 95% CI, −1.62 to −1.69 mm Hg vs −1.37; 95% CI, −1.34 to −1.39 mm Hg), and late-life weight loss.CONCLUSIONS AND RELEVANCE Mean SBP and DBP decreased for more than a decade before death in patients dying at 60 years and older. These BP decreases are not simply attributable to age, treatment of hypertension, or better survival without hypertension. Late-life BP decreases may have implications for risk estimation, treatment monitoring, and trial design.

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“…In our literature review, we found only a few studies that quantified overdiagnosis of non-cancer conditions, namely chronic kidney disease, and abdominal aortic aneurysm (AAA). In kidney disease, authors simply reported rising rates of diagnosis and suggested that the rise probably reflected overdiagnosis without quantifying the proportion of actual overdiagnosis 62. The paper on AAA used evidence on the risk of rupture to estimate rates of overdiagnosis for screen detected AAAs of various sizes; the number of AAAs representing overdiagnosis ranged from 11.5% for >54 mm aneurysms to 87% for 26-29 mm aneurysms 63…”

Section: Magnitude Of the Problemmentioning

confidence: 99%

Overdiagnosis in primary care: framing the problem and finding solutions

Kale

Korenstein

2018

BMJ

107

108

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Overdiagnosis, is defined as the diagnosis of a condition that, if unrecognized, would not cause symptoms or harm a patient during his or her lifetime, and it is increasingly acknowledged as a consequence of screening for cancer and other conditions. Because preventive care is a crucial component of primary care, which is delivered to the broad population, overdiagnosis in primary care is an important problem from a public health perspective and has far reaching implications. The scope of overdiagnosis as a result of services delivered in primary care is unclear, though overdiagnosis of indolent breast, prostate, thyroid, and lung cancers is well described and overdiagnosis of chronic kidney disease, depression, and attention-deficit/hyperactivity disorder is also recognized. However, overdiagnosis is a known consequence of all screening and can be assumed to occur in many more clinical contexts. Overdiagnosis can harm patients by leading to overtreatment (with associated potential toxicities), diagnosis related anxiety or depression, and labeling, or through financial burden. Many entrenched factors facilitate overdiagnosis, including the growing use of advanced diagnostic technology, financial incentives, a medical culture that encourages greater use of tests and treatments, limitations in the evidence that obscure the understanding of diagnostic utility, use of non-beneficial screening tests, and the broadening of disease definitions. Efforts to reduce overdiagnosis are hindered by physicians' and patients' lack of awareness of the problem and by confusion about terminology, with overdiagnosis often conflated with related concepts. Clarity of terminology would facilitate physicians' understanding of the problem and the growth in evidence regarding its prevalence and downstream consequences in primary care. It is hoped that international coordination regarding diagnostic standards for disease definitions will also help minimize overdiagnosis in the future.

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Much more medicine for the oldest old: trends in UK electronic clinical records

Cited by 66 publications

References 26 publications

Trend study on the association between hospital admissions and the health of Dutch older adults (1995–2009)

Trend study on the association between hospital admissions and the health of Dutch older adults (1995–2009)

Blood Pressure Trajectories in the 20 Years Before Death

Overdiagnosis in primary care: framing the problem and finding solutions

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