Journals Watch - COPD, sick days and retirement

Too busy to read the research? Let Dr Jonathan Holliday brief you on the best of this week's journals.

Epidemiology of allergic rhinitis - J R Soc Med 2008; 101: 466-72
Using QRESEARCH, one of the world's largest national aggregated health databases with access to over nine million patients, researchers extracted data on all patients with a recorded diagnosis of allergic rhinitis to obtain annual prevalence rates for each year between 2001 and 2005, as well as analysing prescribing trends and the drugs used in treating allergic rhinitis.

Allergic rhinitis

The results showed that the incidence increased over that period from 5.57 per 1,000 to 7.41 per 1,000 person-years, a rise of 33 per cent.

Over the same period the lifetime prevalence increased from 46 to 66 per 1,000 - a 43 per cent rise. Not surprising then that the prescriptions went up as well, and by a similar figure of 42 per cent.

Slightly worrying for GPs is that the consultation rate for any cause for people with this diagnosis is higher than predicted - a double whammy for the consultation figures.

Effect of tiotropium in COPD - New Engl J Med 2008: (10.1056/NEJMoa0805800)
This study considered long-term use of tiotropium in COPD. Researchers recruited almost 6,000 patients to the trial with FEV1 <70 per cent after bronchodilation. Patients were randomly allocated to tiotropium and placebo groups. They were allowed to have any respiratory treatment other than inhaled anticholinergic drugs.

The end points declined in FEV1 before and after bronchodilation with secondary end points of measures of FVC, changes on St Georges Respiratory Questionnaire (SGRQ), exacerbations of COPD and mortality.

A higher proportion of participants did not complete at least 45 monthsin the placebo group (45 per cent) than in the tiotropium group (36 per cent), which must say something about tolerability. Indeed, significant differences in favour of tiotropium were found for health-related quality of life (SGRQ scores).

The time to the first exacerbation was also significantly delayed (mean 16 months versus 12 for placebo) and similarly there was a significant delay in the time to hospital admission with the exacerbation. There was also a reduction in the mean number of exacerbations.

Adverse events were reported in 92 per cent of both groups, and a similar level of serious adverse events occurred in each group. Fatal events occurred in 381 (12.8 per cent) of the tiotropium group and in 411 (13.7 per cent) of the placebo group.

Although there did not appear to be any benefit in terms of the rate of decline of the FEV1, there were definite benefits in how the patient felt and in terms of respiratory and cardiac morbidity, frequency of exacerbations and frequency of admissions.

Treatment preferences for psychological distress - Br J Gen Pract 2008; 578: 694-8
There is pressure to offer non-pharmaceutical treatment for patients presenting with psychological distress and, of course, difficulty supplying enough of it. So this paper seeking to understand what it is that patients want is a useful contribution to the debate.

Patients with mild-to-moderate distress appear to prefer the informal sources such as friends/family support, relaxation/yoga, exercise/sport or massage, with general advice from their GP.

Those with moderate-to-severe distress were more likely to require some help and while more of them would consider medication as an option, talking to someone was still the most popular form of help identified.

The more distressed a patient was, the more likely they were to value professional talking therapies, and less likely to want to talk to friends and family. Even then, 43 per cent preferred to deal with things on their own or were not sure that they would want any help.

Formal interventions such as 'bibliotherapy' or internet-based interventions involving people administering their own treatment were not so popular, particularly among those with mild-to-moderate distress, who might have been expected to be the target group for such interventions.

Sick days as a predictor of mortality - BMJ 2008; 337: a1,469
The epidemiology and public health department of University College Hospital picked the civil servants of London for this fascinating research.

Using the sick certificate of seven consecutive days as the discriminating tool (one or more in a three-year period) they aimed to discover any link between risk of death and diagnosis on the certificate.

It appeared to be a good cohort study with 6,478 patients aged between 35 and 55 years enrolled between 1985 and 1988. Main outcome measures were all-cause, cardiovascular and cancer mortality up to 2004 with an average follow-up of 13 years.

A diagnosis of circulatory disease gave a hazard ratio for mortality of 4.7, for surgical operations it was 2.2 and for psychiatric diagnoses the ratio was 1.9. As worrying, psychiatric diagnoses were also predictive of cancer mortality (HR 2.5).

Reassuringly for those on extended 'sickies', associations of infectious, respiratory and injury absences were less closely associated with overall mortality (HR 1.5-1.7), while there was no association between musculoskeletal absences and overall mortality.

Health, psychosocial factors and retirement - Occup Med 2008; 58: 406-12
Those of us over 45 are all thinking of retirement, and yet there is a worldwide shortage of doctors, so this piece of work aimed to find out if there were factors - among our Finnish counterparts - that were amenable to change.

They looked at retirement intention with a score based on the responses to two questions asking about willingness to continue working or retiring and about pension-applying considerations.

Health indicators were self-rated health, work ability and sickness absence in the past 12 months.

Low work ability, sickness absence, self-reports of poor health and organisational injustice all independently increased the likelihood of retirement intentions, while low job control strengthened the associations of poor health and low work ability with retirement intentions.

The authors rightly suggested promoting control opportunities and organisational justice might help to decrease early retirement amongst physicians, and that brought me back to that RCGP thrust for encouraging partnership.

  • Dr Holliday is a GP in Windsor, Buckingshire and a member of our panel who regularly review the journals

The Quick Study

  • Allergic rhinitis consultations and prescriptions increased between 2001 and 2005.
  • COPD patients taking tiotropium experienced fewer exacerbations than those on placebo.
  • Distressed patients are more likely to require talking therapies if the distress is severe.
  • Sickness absence diagnosis has some correlation with mortality.
  • Retirement intention in doctors was related to factors including job control.

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