Methods to examine the prognosis of people with angina in primary care (Doctorate of Medicine MD)

Abstract Angina is an important condition associated with significant mortality and morbidity. The condition has largely been managed in primary care, and there have recently been substantial changes in its management. The aim of this thesis is to synthesize existing knowledge about the prognosis of angina in primary care and report on the pilot of a new cohort study. Methods This thesis applies multiple methods including: i) a systematic review of prognosis in a primary care population of people with angina; ii) a cross sectional study measuring equity of access to angina treatments; iii) a review of the literature on the ethics of searching patients’ records; iv) a randomized controlled trial of recruitment methods (‘opt-in’ and ‘opt-out’); and v) a qualitative study to explore patients’ symptoms. Results from a pilot testing the feasibility and viability of a cohort study, recruiting from a primary care population of people with angina, is then reported. Based on the findings of the pilot, new methods for obtaining longitudinal data about angina in primary care are discussed. Results The systematic review revealed yearly angina mortality rates of 2.8% to 6.6%. In the equity of access study, practices with a higher proportion of south Asians, but not those with increased deprivation, had higher rates of angiography. The trial showed that the opt-in methodology was associated with a lower response rate, and a bias towards healthier patients. The feasibility study, on the other hand, indicated that although recruiting a cohort of people with angina would be feasible, it would probably be non-viable. I use preliminary data from trials to examine prognosis. Conclusion This investigation has been undertaken during a period of great change in the management of angina within primary care. The key finding is that a new cohort study of those with angina in primary care is probably not viable. However, I report other findings that will inform the design of new research on the prognosis of angina in primary care