Age and Ageing Advance Access originally published online on May 16, 2008
Age and Ageing 2008 37(5):572-575; doi:10.1093/ageing/afn111
Recent changes in general practice morbidity in older people
SIR—Chronic illness and multiple morbidity are more common in older people and are associated with a greater use of primary and secondary care services [1–4]. The demand for health services is expected to rise and priorities change, as the proportion and diversity of older people increase [5].The National Health Service (NHS) plan 2000 [6], and subsequent National Service Frameworks (NSF) and changes to the general practitioners' contract in 2004, outlined NHS strategies that focus on priority areas, and promote the provision of equitable and individualised care, appropriate multi-disciplinary health and social care and health promotion. Improving care in priority areas and reducing risk factors for disease in the population should reduce the prevalence of modifiable diseases.
Examining general practice morbidity provides an indirect monitor of disease prevalence by estimating illness rates presented for health care and indicating future consultation patterns [7]. We have investigated changes in morbidity and comorbidity prevalence in older people in North Staffordshire, UK, as recorded in general practice.
Analysis was carried out using routinely collected general practice consultation data from nine out of the ten general practices in North Staffordshire that contribute to a local computerised database, Consultations in Primary Care Archive (CiPCA). The 10th practice used a different version of the morbidity coding system and was therefore excluded. The localities in which the practices are situated are slightly more deprived than the average for England and Wales, and approximately 97% of the population of the localities are white. Morbidity data is entered by practice staff using Read codes that provide a hierarchical classification based on disease, clinical features and procedures. Diagnostic codes within the Read code system are grouped into chapters (e.g. musculoskeletal, mental health). The practices are part of the Keele GP Research Partnership that achieves high levels of coding quality through a system of assessment, feedback and training [8]. CiPCA gave comparable prevalence rates to national general practice databases [9].
Annual prevalence of recorded consultation of disease was defined as the number of patients aged 65 and over, who had at least one recorded consultation in a year for a condition or group of conditions, divided by the total population registered at the end of the year. Rates were expressed per 10,000 population at risk. Contacts with a primary care professional were included if these occurred during a surgery, home visit or by telephone. A consultation was defined as a problem addressed during a patient–professional contact. More than one problem could be addressed and recorded during any contact. Recorded morbidities were identified using electronic searches based on the relevant Read codes.
Actual and percentage change in recorded disease prevalence between 2000 and 2004 was determined. Additional data from 2003 was used to examine whether change was progressive or sudden. Comparisons were made across Read code chapters and for selected common conditions based on a clearly identifiable Read code.
Comorbidity count was calculated for each individual on the basis of the number of individual Read code chapters (disease chapters and preventative procedures chapter) for which a patient had a record during a 12-month period. Changes in the prevalence of recorded comorbidity were examined by comparing 2000 and 2004.
The CiPCA database and its research activity have ethical permission from North Staffordshire Local Research Ethics Committee. CiPCA is funded by the North Staffordshire Primary Care Research Consortium and the National Coordinating Centre for Research Capacity Development.
The registered adult population of the practices was stable between 2000 (55,078) and 2004 (55,614). The study population of age 65 and over remained stable at 12,690 (23.0% of the adult population) in 2000 and 13,013 (23.4%) in 2004, although this was a slightly higher proportion of the adult population than that for England and Wales (20.6%) [10]. The proportion of the study population who consulted at least once was 12,445 (96%) in 2004 and 12,043 (95%) in 2000.
The change in primary care recorded morbidity prevalence showed substantial variation across Read code chapters (Table 1). Examination of trends suggested that recorded morbidity prevalence was continuing to increase for circulatory system diseases (20% increase on the 2000 prevalence rate in 2004), and endocrine, nutritional and metabolic disorders (43%).
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In some disease chapters recorded prevalence rose between 2000 and 2003, and had stabilised by 2004. These included preventative procedures (47%), blood disorders (41%), neoplasms (13%), skin and subcutaneous tissue disorders (10%) and musculoskeletal disorders (9%).
Rise in ‘symptoms, signs and ill-defined conditions’ (34%) and ‘unspecified conditions’ (48%), were somewhat offset by falls in consultations in the ‘history and symptoms’ chapter (31%), but recorded prevalence for undifferentiated disease still rose overall, and suggested high levels of activity in general practice in these areas.
Changes in primary care recorded prevalence of selected, specific morbidities in older people demonstrating variation during the period 2000–2004 (Table 2). Increases were seen in lipid disorders (73%), epilepsy (67%), diabetes (54%), hypothyroidism (41%), hypertension (34%) and asthma (14%). The prevalence of stroke remained stable and transient ischaemic attacks (TIA) fell slightly. There was an increase of 38% in unspecified back disorders, but the prevalence of osteoarthritis and allied disorders remained stable.
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The proportion of patients aged 65 years and over who had a recorded consultation in four or more disease chapters rose from 31% in 2000 to 38% in 2004. In 2004, 5.6% of patients had a recorded consultation for seven or more Read code chapters compared to 3.3% in 2000.
Primary care recorded morbidity prevalence in older people had increased in 2004 compared with 2000 substantially for cardiovascular disease overall, as well as for endocrine, nutritional and metabolic disorders. Specific increases were observed in the recorded prevalence of hypertension, diabetes, lipid disorders and hypothyroidism. By contrast, stroke and osteoarthritis rates remained stable. Comorbidity, estimated from consultations across multiple disease chapters, also increased over the study period.
The study was based on the analysis of routinely collected data from nine general practices in North Staffordshire. Analysis focussed on common conditions and disease groups with easily identified, distinct Read codes across a variety of disease chapters. The method of estimation of comorbidity by Read chapter was crude and does not reflect comorbidity occurring within the same Read chapter. However recorded morbidity prevalence across Read chapters will reflect the wide range of coexisting morbidities with which patients present in primary care.
An increase in recorded morbidity prevalence in older people in general practice is anticipated with an increased life expectancy and higher levels of chronic disease [11], and our study findings are consistent with this. The results also suggest an improvement in systematic recording, case finding and management. In the United Kingdom, changes to the general practitioners’ contract for 2004 specifically introduced systems and incentives which encourage the systematic collection and consistent recording of data for a number of prioritised conditions, through its Quality and Outcomes Framework (QOF). We found that areas included in the QOF, such as diabetes, hypothyroidism, asthma, epilepsy, cardiovascular disorders and preventative procedures showed greater increase in recorded prevalence among persons aged 65 years and over than areas not included, such as musculoskeletal disorders, osteoarthritis and nervous system disease. Another study found that 1 year following the introduction of the NSF for coronary heart disease, there were increases in coding for coronary heart disease, blood pressure and cholesterol measurement [12].
A better management of chronic disease and underlying risk factors would have the potential to reduce subsequent morbidity through secondary prevention. For example, a fall in stroke incidence has been linked with a lower level of risk in the population due to reduction in smoking, cholesterol and blood pressure; and improved management of individuals’ predisposing risk factors [13]. In our study, substantial increases in the prevalence of circulatory disease and endocrine disorders suggest an accelerated rise in chronic disease management in these areas between 2000 and 2004, with no clear evidence that preventive activity is yet resulting in a decline in the rate of these problems in the population, with the continued exception of stroke. A similar increase in recorded prevalence in older people of coronary artery disease, anxiety and depression, diabetes and asthma, but a fall in stroke prevalence was observed between 1994 and 1998 [14].
While an increases in the recorded consultation prevalence of chronic illness may be a measure of the current lack of impact of preventive activity, and a genuine rise in the population of chronic disease and risk factors, it may also represent improved quality of care for older people with these problems. For example, the rise in prevalence of coded lipid disorders is likely to reflect increased screening and treatment of blood cholesterol levels. A greater awareness of chronic illnesses and their risk factors leads to better recognition and management. This results in apparently increased prevalence but not yet in clear reductions in incidence of these conditions.
By contrast, a modest reduction in recorded morbidity related to upper respiratory tract infections and urine infections seen in this study is consistent with previous studies [15, 16].
In older people, multiple morbidities are now the norm, rather than an exception [2]. Increasing levels of recorded comorbidity in general practice suggest that more problems are being addressed. It also supports the perception that general practitioners are dealing with a greater complexity of cases and greater levels of ill health [17]. Although the systematic treatment of chronic conditions improves care, individual practice guidelines may be of limited value when applied to patients with multiple morbidities [18, 19].
This study demonstrated a continuing rise in the level of primary care recorded morbidity and complexity presented by older people in general practice. Recent health service priorities and incentives focussing on better management of chronic disease appear to be influencing general practice activity and recorded morbidity prevalence. Morbidity patterns are changing and multiple morbidities are common in older people, presenting challenges in optimising patient care.
- This study shows that the prevalence of morbidity and comorbidity in older people estimated from general practice records increased from 2000 to 2004.
- This is consistent with increasing demand and complexity in the care of older people in general practice.
- Recorded morbidity was greater around areas prioritised in NSF and QOF of the NHS GP contract.
- Changes in health service priorities are influencing general practice activity and patient management. However long-term benefits of such activity in reducing incidence and prevalence of illness in older people are not yet apparent from such routine clinical data with the possible exception of stroke.
The authors thank the Informatics team in the Primary Care Musculoskeletal Research Centre for collecting the data and all the general practices who contributed to CiPCA.
None.
1 Primary Care Musculoskeletal Research Centre, Keele University, Keele, Staffs ST5 5BG, UK
2 Stoke-on-Trent PCT, Stoke-on-Trent, Staffs, UK
* To whom correspondence should be addressed E-mail: k.p.jordan{at}cphc.keele.ac.uk
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