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Article History

Received: 8 May 2025

Accepted: 22 August 2025

First Online: 25 September 2025

Declarations

:

: AS reports grants from NIHR Birmingham BRC during the conduct of the study and grants from Astra Zeneca outside the submitted work; REJ reports grants from NIHR, outside the submitted work and membership of Boehringer Ingelheim primary care advisory board; PA reports grants from NIHR Programme Grant, during the conduct of the study; and is Chair of the NIHR PHR Funding committee; FMEF has received grants and personal fees from AstraZeneca, Chiesi, Boehringer Ingelheim, Glaxosmithkline, Novartis and MSD outside the submitted work. All other authors declare no conflicts of interest in relation to the present study.

: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

: The Health Improvement Network (THIN) is a longitudinal, clinical primary care database that contains anonymised and validated data on diagnoses, symptoms, hospital referrals, discharge summaries, lifestyle, mortality, prescribing, and clinical and laboratory tests captured by general practitioners using Vision medical software (Vision, London, UK). The NHS South East Multi-centre Research Ethics Committee (MREC) approved the use of THIN data for research purposes in 2003, subject to independent scientific review, which we obtained (approval 16THIN039) on May 23, 2016. The need for individual informed consent was waived by the NHS MREC because the study used de-identified data collected during routine primary care. This waiver is consistent with national regulations governing the secondary use of anonymized health data in the UK. The study adhered to the principles of the Declaration of Helsinki.

: Not applicable.