Optimizing lipid management-impact of the COVID 19 pandemic upon cardiovascular risk in England.

BACKGROUND: We sought to understand the impact of the COVID-19 pandemic on lipid-lowering therapy prescribing as a potential cause of the excess cardiovascular mortality seen post-pandemic in England. We examined temporal changes over 3 years in the prescribing of high-intensity and non-high-intensity statin therapy and ezetimibe. SOURCES OF DATA: We utilized data available via the National Health Service (NHS) Business Services Authority (NHSBSA) Information Services Data Warehouse, extracting 3 monthly data from October 2018 to December 2021 on high- and low-intensity statin and ezetimibe prescribing, (commencement, cessation or continuation) through each time period of study and those before, and after, the period of interest. AREAS OF AGREEMENT: Optimizing lipid management is a key component of the NHS Long Term Plan ambition to reduce deaths from cardiovascular disease, stroke and dementia. AREAS OF CONTROVERSY: The COVID-19 pandemic and associated lockdown have seen a significant reduction in prescribing of lipid-lowering therapies. If cardiovascular risk is not to worsen in the forthcoming years, urgent action is needed to ensure that the impact of the pandemic upon optimization of cholesterol and the historical undertreatment of cholesterol is reversed and improved. AREAS TIMELY FOR DEVELOPING RESEARCH: Prescription data available via NHSBSA can support our understanding of the implications of policy and behaviour and highlight the impact of guidelines in practise. GROWING POINTS: Understanding the impact of the COVID-19 pandemic upon cholesterol management and the opportunities for newer lipid-lowering therapies delivered using a population health approach have the potential to enhance lipid-lowering and improve cardiovascular mortality and morbidity and reduce health inequalities.

Digitally deployed, GP remote consultation video intervention that aims to reduce opioid prescribing in primary care: protocol for a mixed-methods evaluation.

INTRODUCTION: Opioid prescribing rates are disproportionately high in the North of England. In addition to patients' complex health needs, clinician prescribing behaviour is also a key driver. Although strategies have been initiated to reduce opioid prescribing nationally, the COVID-19 pandemic has interrupted service provision and created challenges for the system and health professionals to tackle this complex issue. A pilot intervention using smartphone video messaging has been developed to remotely explain the rationale for opioid reduction and facilitate self-initiation of support. The aim of this study is to evaluate the potential benefits, risks and economic consequences of 'at scale' implementation. METHODS AND ANALYSIS: This will be a mixed-methods study comprising a quasi-experimental non-randomised before-and-after study and qualitative interviews. The intervention arm will comprise 50 General Practitioner (GP) Practices using System 1 (a clinical computer system hosting the intervention) who will deliver the video to their patients via text message. The control arm will comprise 50 practices using EMIS (a different computer system) who will continue usual care. Monthly practice level prescribing and consultation data will be observed for 6 months postintervention. A general linear model will be used to estimate the association between the exposure and the main outcome (opioid prescribing; average daily quantity (ADQ)/1000 specific therapeutic group age-sex related prescribing unit). Semi-structured interviews will be undertaken remotely with purposively selected participants including patients who received the video, and health professionals involved in sending out the videos and providing additional support. Interviews will be audio recorded, transcribed and analysed thematically. ETHICS AND DISSEMINATION: Ethics approval has been granted by the NHS Health Research Authority Research Ethics Committee (22/PR/0296). Findings will be disseminated to the participating sites, participants, and commissioners, and in peer-reviewed journals and academic conferences. TRIAL REGISTRATION NUMBER: NCT05276089.

Cardiovascular-related conditions and risk factors in primary care for deprived communities before and during the COVID-19 pandemic: an observational study in Northern England.

OBJECTIVES: The North East of England, ranked as having the highest poverty levels and the lowest health outcomes, has the highest cardiovascular disease (CVD) premature mortality. This study aimed to compare CVD-related conditions and risk factors for deprived practice populations with other general practice (GP) populations in Northern England to England overall, before and during COVID-19 to identify changes in recorded CVD-related risk factors and conditions and evidence-based lipid prescribing behaviour. DESIGN: A population-based observational study of aggregated practice-level data obtained from publicly accessible data sets. SETTING: 34 practices that fall into the 15% most deprived practice populations in England were identified as the most deprived communities in the North East and North Cumbria (Deep End). PARTICIPANTS: Patients aged ≥16 registered with GP and diagnosed with any form of CVD. PRIMARY AND SECONDARY OUTCOME MEASURES: CVD-related conditions and risk factors, statin prescribing. RESULTS: Deep End (n=263 830) had a smaller, younger and more deprived population with lower levels of employment and full-time education and higher smoking prevalence. They had some higher recorded CVD-related conditions than England but lower than the non-Deep End. Atrial fibrillation (-0.9, -0.5), hypertension (-3.7, -1.3) and stroke and transient ischaemic attack rates (-0.5, -0.1) appeared to be lower in the Deep End than in the non-Deep End but the optimal statin prescribing rate was higher (3.1, 8.2) than in England. CONCLUSION: Recorded CVD-related risk factors and conditions remained comparable before and during COVID-19. These are higher in the Deep End than in England and similar or lower than the non-Deep End, with a higher optimal statin prescribing rate. However, it was not possible to control for age and sex. More work is needed to estimate the consequences of the pandemic on disadvantaged communities and to compare whether the findings are replicated in other areas of deprivation.

Tailoring lipid management interventions to reduce inequalities in cardiovascular disease risk management in primary care for deprived communities in Northern England: a mixed-methods intervention development protocol.

INTRODUCTION: Hyperlipidaemia contributes a significant proportion of modifiable cardiovascular disease (CVD) risk, which is a condition that disproportionally affects disadvantaged socioeconomic communities, with death rates in the most deprived areas being four times higher than those in the least deprived. With the national CVD Prevention programme being delivered to minimise risk factors, no evidence is available on what has been implemented in primary care for deprived populations. This study describes the protocol for the development of a tailored intervention aiming to optimise lipid management in primary care settings to help reduce inequalities in CVD risks and improve outcomes in deprived communities. METHODS AND ANALYSIS: A mixed-methods approach will be employed consisting of four work packages: (1) rapid review and logic model; (2) assessment and comparison of CVD risk management for deprived with non-deprived populations in Northern England to England overall; (3) interviews with health professionals; and (4) intervention development. A systematic search and narrative synthesis will be undertaken to identify evidence-based interventions and targeted outcomes in deprived areas. General practice-level data will be assessed to establish the profile of lipid management, compared with the regional and national levels. Health professionals involved in the organisation and delivery of routine lipid management to deprived populations will be interviewed to understand the implementation and delivery of current lipid management and associated challenges. The prototype intervention will be informed by the evidence generated from workpackages 1-3, which will be reviewed and assessed using the nominal group technique to reach consensus. Training and skills development materials will also be developed as needed. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Faculty of Medical Sciences Research Ethics Committee at Newcastle University, UK. Findings will be disseminated to the participating sites, participants, commissioners, and in peer-reviewed journals and academic conferences.

Cohort study to explore the association between the COVID-19 pandemic lockdown and admissions for violence in North East and North Cumbria.

OBJECTIVES: Explore the association between the first national lockdown associated with the COVID-19 pandemic on admissions for violence and the relationship with deprivation. DESIGN: Population-based longitudinal cohort study. SETTING: North East and North Cumbria (NENC) area of England. PARTICIPANTS: All individuals living in the NENC (total population 3.1 million) admitted 2017/2018, 2018/2019, 2019/2020. MAIN OUTCOME MEASURES: Hospital Episode Statistics were extracted at Lower Layer Super Output Area and the Index of Multiple Deprivation 2019 decile applied. Directly standardised rates were explored for number of accident and emergency (A&E) attendances (per 1000); Alcohol-related admissions using Public Health England (PHE) Fingertips tool (per 100 000, ID 91414) and emergency admissions for violence (including sexual violence) (per 100 000) (ID 11201 classified by International Classification of Diseases (ICD)10 codes X85 to Y09). RESULTS: A&E attendances are higher in NENC compared with England (409.9 per 1000 v 359.2). A&E attendance was 81% higher in 2019/20 in the most deprived compared with the least deprived. Attendances dropped during the first national COVID-19 lockdown and by September 2020 had not returned to 'normal' levels.Admissions related to violence are a third higher in NENC (29% to 34% higher across 3 years) rates 7-10 times higher in most deprived than least deprived areas. Admission rates reduced during the first UK lock down but this bounced back by August higher than any of the previous 12 months. CONCLUSION: Emergency admissions with violence appear to associate with the COVID-19 pandemic being initially higher than before the first national lockdown. This is in the context of overall A&E attendances which are lower post lockdown. Given that emergency admissions with violence have been consistently higher in the NENC compared with England over recent years, we suggest that targeted action is required in NENC to address health inequalities.

Epidemiology of race day injury in young professional jockeys in Great Britain from 2007 to 2018: a retrospective cohort study.

INTRODUCTION: There are limited injury data in professional horse racing, particularly by sex. OBJECTIVES: To describe injury incidence, characteristics and falls in male and female, flat and jump jockeys in Great Britain. DESIGN AND SETTING: Retrospective cohort study of professional jockeys in Britain. PARTICIPANTS: 245 jockeys licensed between 2007 and 2017. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was injury on a race day. Injury incidence (per 1000 rides; per 1000 falls) was derived. Incidence-rate ratios (IRR) were calculated to compare incidence between flat and jump racing, male and female jockeys, and male flat and male jump jockeys for: (i) injury incidence, (ii) fall incidence and (iii) injuries per fall. RESULTS: 234 British professional jockeys were included. Jockeys were on average 19.5±2.0 years old at licence date, 79.9% male and 58.1% flat. The time of follow-up (racing in the study) was 3.7 (SD=2.3) years. There were 278 injuries, occurring in-race (81.7%), in the stalls (10.8%) or parade ring (6.1%). After one injury was removed to preserve anonymity, 57.2% were soft tissue injuries, 25.3% fractures and 10.5% concussion. There were 1634 falls, with 92% in male jump racing. The injury incidence was higher in jump racing (5.1 vs 1.0/1000 jockey rides). The falls incidence was 1.8/1000 rides in flat and 46.2/1000 rides in jump racing (IRR 0.04, 95% CI 0.03 to 0.04). There were over five times higher injuries/1000 falls in flat than jump racing (IRR 5.56, 95% CI 4.05 to 7.53). Male flat jockeys fell less than female flat (IRR 0.57, 95% CI 0.35 to 0.97). CONCLUSION: Most injuries occurred in-race and were soft tissue injuries. Jump jockeys fell more often than flat, and female flat jockeys fell more often than male flat. Flat jockeys injured more frequently when falling. No sex differences were seen for injuries per fall.