Anthony A. Laverty

Hospital Admissions for Childhood Asthma After Smoke-Free Legislation in England

OBJECTIVE: To assess whether the implementation of English smoke-free legislation in July 2007 was associated with a reduction in hospital admissions for childhood asthma. METHODS: Interrupted time series study using Hospital Episodes Statistics data from April 2002 to November 2010. Sample consisted of all children (aged ≤14 years) having an emergency hospital admission with a principle diagnosis of asthma. RESULTS: Before the implementation of the legislation, the admission rate for childhood asthma was increasing by 2.2% per year (adjusted rate ratio 1.02; 95% confidence interval [CI]: 1.02–1.03). After implementation of the legislation, there was a significant immediate change in the admission rate of −8.9% (adjusted rate ratio 0.91; 95% CI: 0.89–0.93) and change in time trend of −3.4% per year (adjusted rate ratio 0.97; 95% CI: 0.96–0.98). This change was equivalent to 6802 fewer hospital admissions in the first 3 years after implementation. There were similar reductions in asthma admission rates among children from different age, gender, and socioeconomic status groups and among those residing in urban and rural locations. CONCLUSIONS: These findings confirm those from a small number of previous studies suggesting that the well-documented population health benefits of comprehensive smoke-free legislation appear to extend to reducing hospital admissions for childhood asthma.

Designing and implementing a COPD discharge care bundle

National surveys have revealed significant differences in patient outcomes following admission to hospital with acute exacerbation of COPD which are likely to be due to variations in care. We developed a care bundle, comprising a short list of evidence-based practices to be implemented prior to discharge for all patients admitted with this condition, based on a review of national guidelines and other relevant literature, expert opinion and patient consultation. Implementation was then piloted using action research methodologies with patient input. Actively involving staff was vital to ensure that the changes introduced were understood and the process followed. Implementation of a care bundle has the potential to produce a dramatic improvement in compliance with optimum health care practice.

Impacts of a national strategy to reduce population salt intake in England: serial cross sectional study.

Background The UK introduced an ambitious national strategy to reduce population levels of salt intake in 2003. The aim of this study was to evaluate the impact of this strategy on salt intake in England, including potential effects on health inequalities. Methods Secondary analysis of data from the Health Survey for England. Our main outcome measure was trends in estimated daily salt intake from 2003–2007, as measured by spot urine. Secondary outcome measures were knowledge of government guidance and voluntary use of salt in food preparation over this time period. Results There were significant reductions in salt intake between 2003 and 2007 (−0.175grams per day per year, p<0.001). Intake decreased uniformly across all other groups but remained significantly higher in younger persons, men, ethnic minorities and lower social class groups and those without hypertension in 2007. Awareness of government guidance on salt use was lowest in those groups with the highest intake (semi-skilled manual v professional; 64.9% v 71.0% AOR 0.76 95% CI 0.58–0.99). Self reported use of salt added at the table reduced significantly during the study period (56.5% to 40.2% p<0.001). Respondents from ethnic minority groups remained significantly more likely to add salt during cooking (white 42.8%, black 74.1%, south Asian 88.3%) and those from lower social class groups (unskilled manual 46.6%, professional 35.2%) were more likely to add salt at the table. Conclusions The introduction a national salt reduction strategy was associated with uniform but modest reductions in salt intake in England, although it is not clear precisely which aspects of the strategy contributed to this. Knowledge of government guidance was lower and voluntary salt use and total salt intake was higher among occupational and ethnic groups at greatest risk of cardiovascular disease.

Two-year trends and predictors of e-cigarette use in 27 European Union member states

Objective This study assessed changes in levels of ever use, perceptions of harm from e-cigarettes and sociodemographic correlates of use among European Union (EU) adults during 2012–2014, as well as determinants of current use in 2014. Methods We analysed data from the 2012 (n=26 751) and 2014 (n=26 792) waves of the adult Special Eurobarometer for Tobacco survey. Point prevalence of current and ever use was calculated and logistic regression assessed correlates of current use and changes in ever use, and perception of harm. Correlates examined included age, gender, tobacco smoking, education, area of residence, difficulties in paying bills and reasons for trying an e-cigarette. Results The prevalence of ever use of e-cigarettes increased from 7.2% in 2012 to 11.6% in 2014 (adjusted OR (aOR)=1.91). EU-wide coefficient of variation in ever e-cigarette use was 42.1% in 2012 and 33.4% in 2014. The perception that e-cigarettes are harmful increased from 27.1% in 2012 to 51.6% in 2014 (aOR=2.99), but there were major differences in prevalence and trends between member states. Among those who reported that they had ever tried an e-cigarette in the 2014 survey, 15.3% defined themselves as current users. Those who tried an e-cigarette to quit smoking were more likely to be current users (aOR=2.82). Conclusions Ever use of e-cigarettes increased during 2012–2014. People who started using e-cigarettes to quit smoking tobacco were more likely to be current users, but the trends vary by country. These findings underscore the need for more research into factors influencing e-cigarette use and its potential benefits and harms.

Consultant input in acute medical admissions and patient outcomes in hospitals in England: a multivariate analysis.

Recent recommendations for physicians in the UK outline key aspects of care that should improve patient outcomes and experience in acute hospital care. Included in these recommendations are Consultant patterns of work to improve timeliness of clinical review and improve continuity of care. This study used a contemporaneous validated survey compared with clinical outcomes derived from Hospital Episode Statistics, between April 2009 and March 2010 from 91 acute hospital sites in England to evaluate systems of consultant cover for acute medical admissions. Clinical outcomes studied included adjusted case fatality rates (aCFR), including the ratio of weekend to weekday mortality, length of stay and readmission rates. Hospitals that had an admitting Consultant presence within the Acute Medicine Unit (AMU, or equivalent) for a minimum of 4 hours per day (65% of study group) had a lower aCFR compared with hospitals that had Consultant presence for less than 4 hours per day (p<0.01) and also had a lower 28 day re-admission rate (p<0.01). An ‘all inclusive’ pattern of Consultant working, incorporating all the guideline recommendations and which included the minimum Consultant presence of 4 hours per day (29%) was associated with reduced excess weekend mortality (p<0.05). Hospitals with >40 acute medical admissions per day had a lower aCFR compared to hospitals with fewer than 40 admissions per day (p<0.03) and had a lower 7 day re-admission rate (p<0.02). This study is the first large study to explore the potential relationships between systems of providing acute medical care and clinical outcomes. The results show an association between well-designed systems of Consultant working practices, which promote increased patient contact, and improved patient outcomes in the acute hospital setting.

Eligibility for bariatric surgery among adults in England: analysis of a national cross-sectional survey.

Summary Objectives: This study aimed to determine the number eligible for bariatric surgery and their sociodemographic characteristics. Design: We used Health Survey for England 2006 data, representative of the non-institutionalized English population. Setting: The number of people eligible for bariatric surgery in England based on national guidance is unknown. The UK National Institute for Health and Clinical Excellence criteria for eligibility are those with body mass index (BMI) 35–40 kg/m2 with at least one comorbidity potentially improved by losing weight or a BMI > 40 kg/m2. Participants: Of 13,742 adult respondents (≥18 years), we excluded participants with invalid BMI (n = 2103), comorbidities (n = 2187) or sociodemographic variables (n = 27) data, for a final study sample of 9425 participants. Main outcome measures: The comorbidities examined were hypertension, type 2 diabetes, stroke, coronary heart disease and osteoarthritis. Sociodemographic variables assessed included age, sex, employment status, highest educational qualification, social class and smoking status. Results: 5.4% (95% CI 5.0–5.9) of the non-institutionalized adult population in England could meet criteria for having bariatric surgery after accounting for survey weights. Those eligible were more likely than the general population to be women (60.1% vs. 39.9%, p<0.01), retired (22.4% vs. 12.8% p<0.01), and have no formal educational qualifications (35.7% vs. 21.3%, p<0.01). Conclusions: The number of adults potentially eligible for bariatric surgery in England (2,147,683 people based on these results and 2006 population estimates) far exceeds previous estimates of eligibility. In view of the sociodemographic characteristics of this group, careful resource allocation is required to ensure equitable access on the basis of need.

Rural, urban and migrant differences in non-communicable disease risk-factors in middle income countries : a cross-sectional study of WHO-SAGE data

Background Understanding how urbanisation and rural-urban migration influence risk-factors for non-communicable disease (NCD) is crucial for developing effective preventative strategies globally. This study compares NCD risk-factor prevalence in urban, rural and migrant populations in China, Ghana, India, Mexico, Russia and South Africa. Methods Study participants were 39,436 adults within the WHO Study on global AGEing and adult health (SAGE), surveyed 2007–2010. Risk ratios (RR) for each risk-factor were calculated using logistic regression in country-specific and all country pooled analyses, adjusted for age, sex and survey design. Fully adjusted models included income quintile, marital status and education. Results Regular alcohol consumption was lower in migrant and urban groups than in rural groups (pooled RR and 95%CI: 0.47 (0.31–0.68); 0.58, (0.46–0.72), respectively). Occupational physical activity was lower (0.86 (0.72–0.98); 0.76 (0.65–0.85)) while active travel and recreational physical activity were higher (pooled RRs for urban groups; 1.05 (1.00–1.09), 2.36 (1.95–2.83), respectively; for migrant groups: 1.07 (1.0 -1.12), 1.71 (1.11–2.53), respectively). Overweight, raised waist circumference and diagnosed diabetes were higher in urban groups (1.19 (1.04–1.35), 1.24 (1.07–1.42), 1.69 (1.15–2.47), respectively). Exceptions to these trends exist: obesity indicators were higher in rural Russia; active travel was lower in urban groups in Ghana and India; and in South Africa, urban groups had the highest alcohol consumption. Conclusion Migrants and urban dwellers had similar NCD risk-factor profiles. These were not consistently worse than those seen in rural dwellers. The variable impact of urbanisation on NCD risk must be considered in the design and evaluation of strategies to reduce the growing burden of NCDs globally.

Effect of financial incentives on delivery of alcohol screening and brief intervention (ASBI) in primary care: longitudinal study

INTRODUCTION Alcohol screening and brief intervention (ASBI) is effective but underprovided in primary care. Financial incentives may help address this. This study assesses the impact of a local pay-for-performance programme on delivery of ASBI in UK primary care. METHODS Longitudinal study using data from 30 general practices in north-west London from 2008 to 2011 with logistic regression to examine disparities in ASBI delivery. RESULTS Of 211 834 registered patients, 45 040 were targeted by the incentive (cardiovascular conditions or high risk; mental health conditions), of whom 65.7% were screened (up from a baseline of 4.8%, P < 0.001), compared with 14.7% of non-targeted patients (P < 0.001). Screening rates were lower after adjustment in younger patients, White patients, less deprived areas and in patients with mental health conditions (P < 0.05). Of those screened, 11.5% were positive and 88.6% received BI. Men and White patients were significantly more likely to screen positive. Women and younger patients were less likely to receive BI. 30.1% of patients re-screened were now negative. However, patients with mental health conditions were less likely to re-screen negative than those with cardiovascular conditions. CONCLUSION Financial incentives appear to be effective in increasing delivery of ASBI in primary care and may reduce hazardous and harmful drinking in some patients. The findings support universal rather than targeted screening.

Trends in hospital admissions for sickle cell disease in England, 2001/02–2009/10

BACKGROUND Sickle cell disease (SCD) is a rising cause of mortality and morbidity in England and consequently an important policy issue for the National Health Service. There has been no previous study that has examined SCD admission rates in England. METHODS Data from Hospital Episode Statistics were analysed for all hospital episodes (2001/10) in England with a primary diagnosis of sickle cell anaemia with crisis (D57.0) or without crisis (D57.1). Secondary and tertiary diagnoses were examined among those patients admitted with either of these codes as their primary diagnosis. RESULTS The overall SCD admission rate per 100 000 has risen from 21.2 in 2001/02 to 33.5 in 2009/10, a rise of over 50%. London accounts for 74.9% of all SCD admissions in England. 57.9% of patients admitted are discharged within 24 h. The largest rise in admission rates was seen among males aged 40-49 years where admission rates per 100 000 increased from 7.6 to 26.8 over the study period. CONCLUSIONS Our data show that SCD admissions are rising in England, particularly in London. Over half of patients admitted with SCD were discharged within 24 h, suggesting that some of these admissions could be prevented through better ambulatory care of patients.

Blood pressure monitoring and control by cardiovascular disease status in UK primary care: 10 year retrospective cohort study 1998–2007

BACKGROUND Strategies to reduce the burden of cardiovascular disease (CVD) in the UK have emphasized improved management of high-risk individuals rather than population-based approaches. METHODS This 10-year retrospective cohort study examined blood pressure (BP) monitoring and control among patients with and without CVD in general practices in Wandsworth, London between 1998 and 2007. Logistic regression was used to assess associations among age, gender, ethnicity, deprivation and BP control. RESULTS The percentage of patients with elevated BP (>140/90 mm Hg) decreased at a slower rate in patients without CVD (31.0-25.3%) compared with those with CVD (56.8-36.0%) (P < 0.001). Mean systolic BP decreased from 146.1 to 136.4 mm Hg in patients with CVD and from 133.7 to 130.1 in patients without CVD. Mean diastolic BP decreased from 84.2 to 78.4 mm Hg in patients with CVD and from 80.5 to 79.0 in patients without CVD. Inequalities in BP control decreased among age, ethnic and deprivation groups but increased between men and women without CVD. CONCLUSIONS Measurement and control of BP among those with CVD has improved much more rapidly compared with those without CVD. Inequalities in BP control appeared to increase between men and women without CVD, but decreased among age, ethnicity and deprivation groups.