Ashley Akbari

Background: Our aim was to develop and evaluate the electronic frailty index+, a prognostic tool, including four integrated prognostic-decision models, to stratify older people into subgroups for targeting key interventions. Methods: Design: Prognostic model development, internal validation and external validation using large data sets and longitudinal cohort study data, with decision curve and health economic analysis. Population: Patients aged 65+ years. Key outcomes: The 12-month outcomes for prognostic models: new home care package care home admission emergency department attendance/hospitalisation with fall/fracture all-cause mortality. Statistical methods: Prognostic modelling: We developed and internally validated models for our key outcomes in one large data set. We used internal–external cross-validation for the home care model and full external validation for the remaining three models in a second large data set. We used CARE75+ to investigate additional predictive value of clinical measures practical for primary care. Decision curve analysis: We translated the prognostic models into a framework to support clinical decision-making. Health economic evaluation: We integrated the falls prediction models with effect size estimates from network meta-analysis to examine potential cost savings. Results: We used data from 660,417 patients in SAIL, 88,947 in Connected Bradford and 252 CARE75+ participants. New home care package: Model performance was promising in internal–external cross-validation, with average calibration slope 1.00 (95% confidence interval 0.99 to 1.01), average calibration-in-the-large −0.01 (95% confidence interval −0.02 to 0.01), average observed/expected ratio 0.99 (95% confidence interval 0.98 to 1.01) and average C-statistic 0.81 (95% confidence interval 0.81 to 0.81). Emergency department attendance/hospitalisation with fall/fracture: Model performance was promising on internal and external validation, although with some evidence for overprediction of falls risk, with calibration slope 1.25 (95% confidence interval 1.24 to 1.27), calibration-in-the-large −0.931 (95% confidence interval −0.938 to −0.920), observed/expected ratio 0.43 (95% confidence interval 0.42 to 0.44), C-statistic 0.83 (0.82 to 0.83). Care home admission: Model performance was promising on internal validation, but it showed some miscalibration on external validation, with calibration slope 0.75 (95% CI 0.74 to 0.76), calibration-in-the-large −1.60 (−1.62 to −1.58) and observed/expected ratio 0.25 (95% CI 0.24 to 0.25), C-statistic of 0.86 (95% CI 0.86 to 0.86). All-cause mortality: The model showed excellent performance across the full range of predicted risks on external validation, with average calibration slope 1.00 (0.98 to 1.01), average calibration-in-the-large −0.23 (−0.27 to −0.19), average observed/expected ratio 0.77 (0.75 to 0.79) and average C-statistic 0.83 (0.82 to 0.83). Economic modelling: Modelling indicated that provision of multifactorial assessment and treatment for people with an annual falls risk of ≥ 40% has the largest cost reduction per targeted person (£1025). Discussion: All four prediction models have promising predictive performance, although some had evidence of overprediction of risk (miscalibration). Decision curve analysis indicates potential clinical utility, and economic modelling provides novel information for policy-makers and commissioners. Future work: Future research should include model impact studies to evaluate use of the models in routine care. Limitations: We were unable to complete external validation of the home care prediction model. Study registration: This study is registered as ClinicalTrials.gov ID NCT04113174. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 127905) and is published in full in Health Technology Assessment ; Vol. 30, No. 61. See the NIHR Funding and Awards website for further award information.

In Wales, 24.8% of children aged 4–5 years live with overweight/obesity. Obesity is linked to developing multiple long-term conditions. We aimed to predict childhood obesity using healthcare and wider demographic, socioeconomic, and area-level data. The Secure Anonymized Information Linkage (SAIL) Databank in Wales contains routinely collected individual-level anonymized data from health records and administrative data. Two subsamples were created. The first restricted to singleton births between 15 March 2010 and 28 March 2012 to include Census 2011 data. The second included births after 1 January 2014 to include early-life measurements. Age- and sex-adjusted body mass index (BMI) at 4–5 years was used to define outcome of overweight/obesity (≥91st centile). Backward stepwise logistic regression models with multivariable fractional polynomials were used to develop models in stages. Data were available on 53 815 children at 4–5 years in census and 60 990 children in early-life subsample. Maternal BMI, smoking, marital status, birthweight, ethnic group, gender, and breastfeeding at birth were retained in all models. Additional variables were retained on adding census and area-level factors but increase in discrimination (Area Under the Curve, AUC) was marginal (0.66–0.67). In the second subsample, AUC improved from 0.67 to 0.79 as factors up to weight at 27 months were incorporated. Factors from healthcare records were largely consistent with existing literature. Additional insights were provided by including census data, though increase in model discrimination was marginal. Childhood obesity can act as a mediator on the pathway to multiple long-term conditions, and risk identification tools may target early prevention.

Background: Pregnancy‐related complications are linked to increased cardiovascular disease risk, but comprehensive evaluations of diverse complications, particularly multiple or recurrent events, are limited. Methods: A national retrospective cohort study was conducted using the Secure Anonymised Information Linkage (SAIL) Databank in Wales. Exposures were hypertensive disorders of pregnancy, gestational diabetes, placental abruption, stillbirth, small for gestational age, fetal growth restriction, and preterm birth. Multiple complications were defined as >1 complication in the first pregnancy, and recurrent complications as the same complication in both the first and second pregnancies. Outcomes were incident ischemic heart disease, stroke, heart failure, and atrial fibrillation. Cox regression estimated hazard ratios (HRs). Results: A total of 298 515 women (mean age 27.2 years; SD 6.1) were included. Multiple pregnancy‐related complications were associated with increased risk of ischemic heart disease (hazard ratio HR, 2.88 [95% CI, 2.27–3.67]), stroke (HR, 2.03 [95% CI, 1.55–2.65]), heart failure (HR, 3.18 [95% CI, 2.34–4.32]), and atrial fibrillation (HR, 1.80 [95% CI, 1.20–2.72]) compared with no complications. A dose–response relationship was observed, with progressively higher cardiovascular disease risk for multiple compared with single complications and elevated risk for both groups relative to women without complications. Recurrent pregnancy‐related complications increased the risk of ischemic heart disease (HR, 1.93 [95% CI, 1.26–2.95]), stroke (HR, 1.89 [95% CI, 1.25–2.85]), heart failure (HR, 3.61 [95% CI, 2.32–5.60]), and atrial fibrillation (HR, 2.45 [95% CI, 1.38–4.37]) compared with no complication. Conclusions: Women experiencing pregnancy‐related complications encounter higher risks of cardiovascular disease, especially with multiple or recurrent complications. Comprehensive cardiovascular risks assessment and targeted prevention should be prioritized for this group.

Background: To enhance early liver disease detection, a clinical pathway integrating reflex AST testing and automated AAR reporting was implemented. We aim to evaluate the long-term effectiveness of introducing reflex AST testing by assessing its impact after implementation in 2 regions of Wales. Methods: We applied a quasi-experimental, Difference-in-Difference approach to evaluate the introduction of the reflex AST:ALT pathway in Wales (January 2010 to December 2023). Outcomes were the monthly incidence rate of (1) chronic liver disease (including cirrhosis) and (2) cirrhosis in the 2 intervention regions versus the control regions. Results: In total, 78,917 individuals with liver disease were included in the study. A significant increase in cirrhosis diagnoses was observed in both regions (first region: incidence rate ratio=1.24, 95% CI: 1.15–1.34, p p =0.028). The incidence of composite chronic liver disease (including cirrhosis) increased transiently in the second region only (incidence rate ratio=1.35, 95% CI: 1.16–1.56, p <0.001). Conclusions: In this long-term, population-level evaluation, reflex AST:ALT testing increased cirrhosis detection in both regions and produced a short-term rise in chronic liver disease (including cirrhosis) diagnoses one region, strengthening the evidence of the pathway’s effect on cirrhosis detection. Further study is warranted to understand regional variation.

IntroductionAdult social care in the UK faces increasing demand and persistent inequalities in terms of access and care quality, yet national-level understanding remains limited. The CARE Lab study aims to address these gaps using newly available individual-level routine administrative data for the whole of Wales from the Adults Receiving Care and Support (ARCS) census. This study will explore patterns of care provision, transitions from children's to adult services, and socio-demographic disparities, using linked data to inform service planning and policy. Methods and AnalysisThis quantitatively-led mixed-methods study comprises five research questions. Quantitative analysis will use ARCS census data, both standalone and linked to health, education, and social care datasets within the Secure Anonymised Information Linkage (SAIL) Databank. Qualitative interviews with people receiving care and support, carers, and professionals will contextualise findings. Key research questions address care patterns, demographic comparisons, regional variation, transitions from child to adult care, and the feasibility of evaluating care models using linked data. Statistical analyses will include descriptive and inferential statistics, propensity score matching, and there will be thematic analysis of qualitative data. Ethics and DisseminationEthical approval has been obtained from Cardiff University. Data access approvals will be sought from Welsh Government, SAIL, and the Office for National Statistics. Dissemination will occur through peer-reviewed publications, policy briefings, accessible multimedia outputs, and stakeholder engagement via an action group. The study will also produce a research-ready data asset and recommendations for future data infrastructure development across the UK.

PurposeSecondary prevention of stroke requires effective cardiovascular risk factor (RF) management, including blood pressure control, lipid lowering treatment and antithrombotic therapy to reduce the risk of recurrent stroke. Optimal management of risk factors is challenging in older, frailer people, who also have worse outcomes after a stroke. There is limited evidence evaluating secondary prevention quality and outcomes in frail populations. To understand the trends (and factors associated with inequity) in the provision of RF management we developed the `Evaluation of Population Secondary Prevention Quality and Outcomes Post-Stroke (ESP-QOPS) in Wales' e-cohort. The aims of this project include describing (i) the provision of post-stroke evidence-based risk factor management (ii) trends in frailty and outcomes, and (iii) evaluating the impact of suboptimal risk factor provision on adverse outcomes stratified by frailty status. ParticipantsWe identified 71,696 patients with a first recorded stroke diagnosis in primary or secondary care between 2010-2023 in Wales. Findings to DateThe incidence of stroke gradually increased from 4,968 to 5,391 patients per year between 2010-2023, with 70% of diagnoses made in the secondary care setting. Of diagnoses made in primary care, less than 20% were subsequently admitted to secondary care.

Objectives: We developed an efficient Research-Ready Data Asset (RRDA) for the Welsh Longitudinal General Practice (WLGP) data within the Secure Anonymised Information Linkage Databank to standardise curation, enhance reproducibility, and facilitate research on primary care trends. Using this, we investigated primary care activity trends during and after the COVID-19 pandemic. Methods: The RRDA involves cleaning, curation using GP-registration history, and transforming data into a structured, normalised format to support efficient large-scale queries. A comprehensive clinical code look-up was developed, incorporating official, local, and supplementary categories to enhance event classification. To enable patient-practice interaction analysis, a four-layer approach was developed to capture healthcare providers, access mode, interaction type, and event details. We assessed RRDA coverage, defined as the proportion of residents with shared primary care records, stratified by demographic and geographic factors, using longitudinal binomial Generalised Additive Mixed Models (GAMMs). We categorised GP events into key activity types and summarised averaged daily rates per month per 100,000 people (2000–2024), with trends analysed using negative binomial GAMMs. Results: Curating 4.6 billion records for 5.1 million people (1990–2024) revealed significant improvements in data quality and completeness over time, with data retention increased from 40% to 94%, and patient inclusion from 43% to 98%. Use of SNOMED-CT and local codes increased after Read-V2 discontinuation in 2018, while invalid codes declined—reflecting evolving coding practices and improved data quality. WLGP RRDA coverage rose from 35% in 1990 to 86% in 2024, with regional variation but modest demographic differences. From 2000 to 2024, consultation rates rose by 1.9 times, with post-COVID-19 pandemic levels 8% above 2019. Prescription-only activity doubled with little variation associated with the pandemic. Vaccination rates spiked during the pandemic, and remain 1.8 times above pre-pandemic levels. Other less frequent activities were significantly disrupted during the COVID-19 pandemic but recovered to 2019 levels. Conclusions: The WLGP RRDA improves the usability of primary care data, supporting timely, scalable analysis of healthcare delivery and system-level trends.

Aims: In patients with diabetes mellitus (DM) and atherosclerotic cardiovascular disease (ASCVD), or without ASCVD (primary prevention), the prescribing of lipid lowering therapy (LLT) is an established treatment strategy endorsed by clinical guidelines. This study aimed to document (i) trends in presentation of DM, (ii) treatment, monitoring and achievement of target low-density lipoprotein cholesterol (LDL-C) in DM with ASCVD, and (iii) ASCVD risk assessment and lipid treatment according to risk in the DM primary prevention setting. Methods and results: A retrospective observational population study including 282 581 DM patients using linked health-care data (2010–23) in Wales. The prevalence of DM (documented DM diagnosis in record prior to the beginning of the year) increased from 133 439 in 2010 to 183 948 in 2023 (6504 to 8200 per 100 000), along with increasing incidence (new diagnosis of DM documented in record during specific year) with 11 074 cases in 2010 (540 per 100 000 per year), increasing to 14 539 in 2023 (648 per 100 000 per year). The proportion of prevalent patients with established ASCVD prescribed LLT decreased from 87.5% to 81.8% (2010–23), testing of LDL-C decreased from 70.3% to 67.1%, and of those with documented lipids 41.0% achieved an LDL-C 20%, only half were prescribed LLT. Conclusion: Increasing incidence and prevalence of DM, together with decreasing quality of risk factor management has the potential to lead to poorer health outcomes in the population if not addressed more effectively.