The impact of musculoskeletal conditions on outcome of hospital care for acute coronary syndrome and stroke: a linked electronic health record study

Date of ISAC Approval: 
21/02/2019
Lay Summary: 
Many people in hospital for other illnesses, such as a heart attack or stroke, will already suffer from musculoskeletal pain (for example back pain, knee pain, osteoarthritis), which may not be a priority for health professionals. This pain, alongside associated poor function and sleep interference, may reduce effectiveness or receipt of appropriate treatment for other illnesses. This means people with musculoskeletal pain may have extended time in hospital, and increased chance of worse outcomes from hospital stays for other illnesses. The objective of this study is to determine whether having musculoskeletal pain increases time in hospital and leads to worse outcomes after a heart attack or stroke. We will use information collected within the Clinical Practice Research Datalink linked to hospital data. We will analyse data of around 100,000 patients aged 45 years and over newly diagnosed with heart attack or stroke. These conditions are life-threatening, have a major impact on quality of life, are common reasons for going to hospital, and are of high NHS priority. We will determine whether these patients have previously consulted with a doctor for musculoskeletal pain. We will compare length of hospital stay and risk of worse hospital outcomes such as death between those with pre-existing musculoskeletal pain and those without, after taking into account other illnesses. We will investigate links between musculoskeletal pain and likelihood of going back into hospital within 30 days of discharge. We will examine if findings vary by pain type such as osteoarthritis or back pain, or by age.
Technical Summary: 
The NHS is under pressure with increased rates of hospital admission and delayed transfer of care. In people with other long-term conditions, such as vascular disease, musculoskeletal pain is common but often neglected. Musculoskeletal comorbidity can impact on outcomes if pain, and associated restricted functioning and sleep interference, prevent or delay delivery of appropriate treatment or reduce its effectiveness. It may limit patients’ ability to manage another condition at home, extending time to discharge, and worsening outcomes of these other conditions. The extent to which outcomes from vascular disease are worse for people with pre-existing musculoskeletal conditions in the UK is unknown, although there is some international evidence of worse outcomes after stroke. We aim to understand the extent of association between pre-existing musculoskeletal conditions and outcomes for patients hospitalised for acute coronary syndrome (ACS) or stroke. We will analyse data of patients newly diagnosed with ACS or stroke and compare patients with a prior painful musculoskeletal condition requiring health care to patients without such a condition on mortality, length of hospital stay, discharge location, 30-day readmission for any condition, and resource use and costs. Painful musculoskeletal conditions will be identified from primary and secondary care records in the 24-months prior to ACS or stroke. We will compare outcomes of hospitalisation (mortality, discharge location, readmission) between those with and those without musculoskeletal comorbidity using binary logistic regression. Poisson regression will be used to determine differences in length of stay in hospital. We will include in further models proxies for severity (musculoskeletal referral, analgesia prescription). We will use mixed-effects models to account for clustering by practice. Our findings will allow assessment of the potential for existing evidence-based management of musculoskeletal pain and associated disability to be targeted in these patients to make a substantial impact on outcomes of ACS and stroke.
Health Outcomes to be Measured: 
1: Mortality (during hospitalisation, within 30 days of discharge) 2: Length of stay in hospital 3: Discharge location after hospitalisation (home, nursing home) 4: Readmission to hospital for any problem within 30 days of discharge. We will also determine the frequency of recorded musculoskeletal pain during hospitalisation or in primary care within 30 days following discharge.
Collaborators: 

John Edwards - Chief Investigator - Keele University
Dr Alyson Huntley - Collaborator - University of Bristol
Professor Christian Mallen - Collaborator - Keele University
Dr Felix Achana - Collaborator - University of Warwick
Mr James Bailey - Collaborator - Keele University
Dr Kelvin Jordan - Corresponding Applicant - Keele University
Mamas Mamas - Collaborator - Keele University
Mr Stephen Tatton - Collaborator - Keele University
Dr Ying Chen - Collaborator - Keele University

Linkages: 
HES Admitted;ONS;Patient IMD