Cardiovascular Diseases (CVD) are the largest burden of disease in the National Health Service (NHS) and one of the commonest causes of death among homeless individuals. CVD are a group of conditions affecting the blood vessels and heart, both acutely (e.g. heart attacks, stroke) and chronically (e.g. angina). There have been great advances in the last forty years in both treatment and prevention of CVD. However, recent policy initiatives to tackle CVD fail to mention homeless populations, and the majority of health programmes targeting homeless individuals focus on communicable diseases, ignoring CVD. Homeless people are at a risk of developing illness earlier in their lives and with homelessness rising, the impact of CVD is likely to increase. The national burden of CVD among homeless people and current use of CVD services is unknown.
Our research will initially investigate the potential to study CVD in homeless individuals in UK electronic health records in primary care. If data are available and of sufficient quality, burden and range of CVD together with current management and service use within the NHS will be studied in homeless individuals using routinely collected health data. We will identify existing strategies for CVD and their impact on the health of homeless populations. Our research can inform policymakers, general practitioners (GPs) and hospital doctors in the detection, prevention and treatment of CVD in homeless individuals in the NHS.
Cardiovascular disease (CVD) is likely to be a major cause of morbidity and mortality in homeless people, but few data exist to describe the burden of disease or the health care management of patients for CVD. This study aims to describe the epidemiology and healthcare resource use and the care pathway of CVD in homeless populations and to understand the changes which may be necessary to improve treatment and prevention of CVD.
Codes for homelessness in primary care data linked with secondary care data will be assessed and evaluated. The completeness and quality of data regarding CVD will be evaluated. If quality and completeness of data permit,incidence, prevalence and outcomes will be estimated for CVD in homeless individuals. Prevalence will be measured as a proportion of the homeless population. Incidence and service utilisation (e.g. rates of coronary artery bypass surgery) will be measured as a rate with person-years as the denominator. We will develop a prediction model to predict future burden using regression methods including negative binomial regression modelling.
Data visualisation tools will be used to describe patient care pathways and service use within 1 year after a CVD initial patient care pathway/healthcare utilisation (6 and 12 months).
The effectiveness of different health care management experienced by patients will be measured through the evaluation of patients prognosis. Survival analysis models, Kaplan-Meier plots and Poisson regression will be used to assess the prognosis of patients will be used to evaluate their effectiveness.
Existing cardiovascular risk prediction models (e.g. QRISK2) will be validated and calibrated in homelessness people. The need for and feasibility of new risk prediction tools in this specific population will be explored using regression.
The primary outcomes will be a three composites of cardiovascular and cerebrovascular
conditions/syndromes;
composite of acute vascular conditions/syndromes
composite of chronic vascular conditions/syndromes
composite of the acute and chronic conditions/syndromes
Acute vascular condition/syndromes will be defined as Coronary artery disease (unstable angina, myocardial infarction, acute coronary syndromes); Peripheral arterial disease (claudication, acute limb ischaemia, lower limb amputation); Cerebrovascular disease (stroke/TIA); Heart failure; Atrial fibrillation; Aortic disease (e.g. aortic aneurysm, aortic dissection); Cardiac arrest; Sudden cardiac death; Mortality (all-cause, cardiovascular).
Chronic vascular condition/syndromes will be defined as Coronary artery disease (stable angina); Peripheral arterial disease (chronic limb ischaemia); Aortic disease (e.g. hypertension, atherosclerosis).
Secondary outcomes include each of the chronic and acute vascular conditions/syndromes listed above in turn as well as the following; healthcare resource utilisation; cardiovascular-related and non-cardiovascular primary care consultations, emergency and elective inpatient admissions, outpatient attendances, A&E attendances procedures; Missed elective inpatient appointments; Missed emergency inpatient appointments; missed outpatient appointments; missed GP appointments; prescriptions of cardiometabolic drug prescriptions (antiplatelets [e.g. aspirin], lipid-lowering therapies [e.g. statins]; antihypertensives [e.g. ACE inhibitors]; CABG; Angioplasty/PCI [percutaneous coronary intervention]; Pacemaker.
Amitava Banerjee - Chief Investigator - University College London ( UCL )
Amitava Banerjee - Corresponding Applicant - University College London ( UCL )
Atsunori Nanjo - Collaborator - University College London ( UCL )
Hannah Evans - Collaborator - University College London ( UCL )
John Robson - Collaborator - Queen Mary University of London
Neha Pathak - Collaborator - University College London ( UCL )
Robert Aldridge - Collaborator - University College London ( UCL )
Serena Luchenski - Collaborator - University College London ( UCL )
Spiros Denaxas - Collaborator - University College London ( UCL )
2011 Rural-Urban Classification at LSOA level;HES Accident and Emergency;HES Admitted Patient Care;HES Outpatient;ONS Death Registration Data;Patient Level Index of Multiple Deprivation