Many people who have a stroke or heart attack will already suffer from musculoskeletal pain (for example, back pain). This pain, alongside poor function and sleep interference resulting from the pain, may reduce effectiveness or receipt of appropriate treatment for their stroke or heart attack. We previously showed, using CPRD GOLD, that people with musculoskeletal pain have longer hospital stays for heart attack and are more likely to be readmitted within 30 days of discharge. The objectives of this study are to assess if we get similar findings using CPRD Aurum, whether in-hospital management and longer-term outcomes are different if people have musculoskeletal pain, and whether any differences are higher in certain groups of patients (e.g., by age).
We will analyse data of patients aged 45 years and over newly diagnosed with a heart attack or stroke. We will first assess consistency of findings with GOLD on the relationship between pre-existing musculoskeletal pain and length of hospital stay, readmission, and in-hospital outcomes such as death. We will then follow patients after discharge through their records to investigate links between musculoskeletal pain and longer term outcomes including having a further stroke or heart attack, and early mortality. We will compare management of stroke and heart attack in-hospital between those with musculoskeletal pain and those without such pain as a possible explanation for differences in outcome. We will examine if findings vary by type of painful condition (such as back pain or knee pain), or by age, gender, ethnicity, and deprivation.
In people with long-term conditions such as stroke or acute coronary syndrome (ACS), comorbid musculoskeletal pain is common but often neglected. Musculoskeletal comorbidity could adversely impact outcomes if pain, and associated restricted functioning and sleep interference, prevent or delay delivery of appropriate treatment or reduce its effectiveness, and extend time in hospital. Our previous analysis of CPRD GOLD (ISAC 19_025) suggested patients with recent musculoskeletal health care had a longer hospital stay for ACS and increased rates of readmission within 30 days. We will validate these findings in Aurum and extend analyses to assess the relationship of musculoskeletal pain with management and longer-term outcomes of ACS/stroke. Using CPRD Aurum, we will analyse data of patients newly diagnosed with ACS/stroke and compare patients with a prior painful musculoskeletal condition requiring health care to patients without on in-hospital intervention (thrombolysis or thrombectomy for stroke, coronary angiography, percutaneous coronary intervention or coronary artery bypass graft for ACS), pharmacological management, length of hospital stay, 30 day readmission, and long term outcomes including further ACS or stroke, mortality, and resource use. Painful musculoskeletal conditions will be identified from primary care records in the 24-months prior to admission for ACS/stroke. Poisson regression will be used to determine differences in hospital length of stay. Flexible parametric survival models will be used for time to event outcomes (e.g. mortality). We will assess if impact varies by time of most recent musculoskeletal consultation or pain severity (proxy measures of musculoskeletal referral, analgesia prescription). We will determine if inequalities exist in these relationships by socioeconomic characteristics (age, ethnicity, deprivation, geographical region), and if relationships differ by type of painful musculoskeletal condition. Our findings will allow assessment of potential for existing evidence-based management of musculoskeletal pain and associated disability to be targeted at patients to improve outcomes following admission with ACS/stroke.
i) Length of stay in hospital based on admission and discharge dates recorded in HES;
ii) Readmission to hospital within 30 days of discharge for the same reason as initial hospitalisation;
iii) Readmission to hospital within 30 days of discharge for different reason to initial hospitalisation;
iv) (time to) Mortality based on recorded information in linked ONS data;
v) Progression of disease defined as a further ACS/stroke;
vi) Management of index condition based on procedures recorded in HES during the hospital stay and prescriptions recorded in primary care in the three months following index date. This will include angiography, percutaneous coronary intervention and coronary artery bypass graft, and prescription of dual antiplatelet therapy, beta blockers and ACE inhibiters and angiotensin receptor blockers for ACS; thrombolysis or thrombectomy, and prescription of antiplatelets or anticoagulants for stroke;
vii) Cumulative health care use and costs over 5 years after index date. Primary care data will include number, type and length of consultations with each health care professional, prescriptions, tests and investigations. Secondary care utilisation includes referral, type of admission, length of stay, diagnosis, and procedures undertaken.
Kelvin Jordan - Chief Investigator - Keele University
Kelvin Jordan - Corresponding Applicant - Keele University
Alyson Huntley - Collaborator - University of Bristol
Christian Mallen - Collaborator - Keele University
Felix Achana - Collaborator - University of Oxford
Felix Achana - Collaborator - University of Oxford
James Bailey - Collaborator - Keele University
John Edwards - Collaborator - Keele University
Kayleigh Mason - Collaborator - Keele University
Mamas Mamas - Collaborator - Keele University
Martin Frisher - Collaborator - Keele University
May Ee Png - Collaborator - University of Oxford
Michelle Marshall - Collaborator - Keele University
Neil Heron - Collaborator - Keele University
Simon White - Collaborator - Keele University
HES Admitted Patient Care;ONS Death Registration Data;Patient Level Index of Multiple Deprivation