Gopalakrishnan Netuveli

Examining Resilience of Quality of Life in the Face of Health-Related and Psychosocial Adversity at Older Ages: What is “Right” About the Way We Age?

PURPOSE This article examines resilience at older ages, focusing on the relationships between quality of life (qol) and adversity. Our objectives are to identify (a) the basis of adversity, (b) the characteristics of resilient individuals, and (c) the attributes that attenuate the full impact of adversity. DESIGN AND METHODS Resilience is defined as flourishing despite adversity. Analysis is carried out in a subsample of the Boyd Orr cohort (aged between 68 and 82 years) using questionnaire data. Adversity was identified as circumstances that produce a significant average decrease in qol (CASP-19 scores). Participants were classified into resilient and vulnerable groups based on high or low qol (CASP-19 scores dichotomized at the median) in the face of significant adversity. Shared characteristics that define these outcomes are reported. Attributes that attenuate the negative impact of adversity were analyzed using stratified logistic regression. RESULTS Adversity was typified by functional limitation; life getting worse in the domains of health, stress, and general living circumstances; and experiencing a negative life event. The resilient tended to report fewer multiple adversities. Indicators of protective attributes, which also characterized resilient outcomes relative to qol, included good quality relationships (5.105, confidence interval [CI] 95% 1.323-19.699), integration in the community (10.800, 95% CI 1.227-95.014), developmental coping (3.397, 95% CI 1.079-10.690), and adaptive coping styles (3.211, 95% CI 1.041-9.910). IMPLICATION Overall results indicate that policies that offer access to protection and help minimize adversity exposure where possible will promote resilience.

Impact of Pay for Performance on Ethnic Disparities in Intermediate Outcomes for Diabetes: A Longitudinal Study

OBJECTIVE—The purpose of this study was to examine the impact of a major pay for performance incentive on trends in the quality of diabetes care in white, black, and South Asian ethnic groups in an urban setting in the U.K. RESEARCH DESIGN AND METHODS—We developed longitudinal models examining the quality of diabetes care in a cohort of ethnically diverse patients in Southwest London using electronic family practice records. Outcome measures were mean blood pressure and A1C values between 2000 and 2005. RESULTS—The introduction of pay for performance was associated with reductions in mean systolic and diastolic blood pressure, which were significantly greater than those predicted by the underlying trend in the white (−5.8 and −4.2 mmHg), black (−2.5 and −2.4 mmHg), and South Asian (−5.5 and −3.3 mmHg) groups. Reductions in A1C levels were significantly greater than those predicted by the underlying trend in the white group (−0.5%) but not in the black (−0.3%) or South Asian (−0.4%) groups. Ethnic group disparities in annual measurement of blood pressure and A1C were abolished before the introduction of pay for performance. CONCLUSIONS—The introduction of a pay for performance incentive in U.K. primary care was associated with improvements in the intermediate outcomes of diabetes care for all ethnic groups. However, the magnitude of improvement appeared to differ between ethnic groups, thus potentially widening existing disparities in care. Policy makers should consider the potential impacts of pay for performance incentives on health disparities when designing and evaluating such programs.

Free bus passes, use of public transport and obesity among older people in England

Background All residents of England aged 60 years and older became entitled to free travel on local buses on 1 April 2006. This study examines the impact of this policy on public transport use, a mode of active transport and levels of obesity. Methods Logistic regression analyses using three waves of data (2004, 2006 and 2008) from the English Longitudinal Study of Ageing. Our main outcome measures were changes in self-reported public transport use, body mass index, waist circumference and obesity. Results Eligibility for free bus travel was associated with increased use (adjusted odds ratio (AOR) 1.51, 95% CI 1.14 to 2.00) of public transport among older people. Older people who used public transport had reduced odds of being obese in 2008 compared with those who did not (AOR 0.75, 95% CI 0.65 to 0.86), as did those who were eligible for free local bus travel (AOR 0.75, 95% CI 0.59 to 0.97). Older people who used public transport had reduced odds of becoming obese between 2004 and 2008 (AOR 0.79, 95% CI 0.63 to 0.98). Conclusion The introduction of free bus travel for older residents of England appears to have increased public transport use and may have conferred a protective effect against obesity.

Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma

Aziz Sheikh and colleagues report on a qualitative study in the US and the UK to investigate ways to bolster recruitment of South Asians into asthma studies, including making inclusion of diverse populations mandatory.

Effect of psychological stress on blood pressure increase: a meta-analysis of cohort studies

Studies have suggested that chronic exposure to stress may have an influence on increased blood pressure. A systematic review followed by a meta-analysis was conducted aiming to assess the effect of psychological stress on blood pressure increase. Research was mainly conducted in Ingenta, Psycinfo, PubMed, Scopus and Web of Science. Inclusion criteria were: published in any language; from January 1970 to December 2006; prospective cohort design; adults; main exposure psychological/emotional stress; outcome arterial hypertension or blood pressure increase > 3.5mmHg. A total of 2,043 studies were found, of which 110 were cohort studies. Of these, six were eligible and yielded 23 comparison groups and 34,556 subjects. Median follow-up time and loss to follow-up were 11.5 years and 21%. Results showed individuals who had stronger responses to stressor tasks were 21% more likely to develop blood pressure increase when compared to those with less strong responses (OR: 1.21; 95%CI: 1.14-1.28; p < 0.001). Although the magnitude of effect was relatively small, results suggest the relevance of the control of psychological stress to the non-therapeutic management of high blood pressure.

Proximal predictors of change in quality of life at older ages

Objective To investigate whether changes in health, social and economic circumstances predict change in quality of life (QoL) at older ages. Design Secondary analysis, using multiple regression analyses, of waves 1 and 3 of the English Longitudinal Study of Ageing. Setting England, 2002–6. Participants A nationally representative sample of non-institutionalised adults aged over 50 years living in England with non-missing data for the variables of interest (N=4848). Main Outcome Measure QoL in 2006, with reference to QoL in 2002, both measured using the CASP-19 score. Results Mean QoL decreased over the 4 years, with becoming depressed (β −0.12) and developing difficulties with activities of daily living (β −0.08) contributing to this decrease. Improvements in family relationships (β 0.10), the neighbourhood (β 0.08) and perceived financial position (β 0.07) each counteracted the decline in QoL. Initial QoL strongly predicted QoL at follow-up (β 0.46). Regression models explained 59% of variation in QoL, and there were small differences between age and gender groups. Conclusions The maintenance of good QoL in older aged people is enabled by the avoidance of depression, maintenance of physical function, good neighbourhood standards, family relationships and financial circumstances.

Genome-wide association study reveals multiple loci associated with primary tooth development during infancy.

Tooth development is a highly heritable process which relates to other growth and developmental processes, and which interacts with the development of the entire craniofacial complex. Abnormalities of tooth development are common, with tooth agenesis being the most common developmental anomaly in humans. We performed a genome-wide association study of time to first tooth eruption and number of teeth at one year in 4,564 individuals from the 1966 Northern Finland Birth Cohort (NFBC1966) and 1,518 individuals from the Avon Longitudinal Study of Parents and Children (ALSPAC). We identified 5 loci at P<5×10−8, and 5 with suggestive association (P<5×10−6). The loci included several genes with links to tooth and other organ development (KCNJ2, EDA, HOXB2, RAD51L1, IGF2BP1, HMGA2, MSRB3). Genes at four of the identified loci are implicated in the development of cancer. A variant within the HOXB gene cluster associated with occlusion defects requiring orthodontic treatment by age 31 years.

Welfare State Regime Life Courses: The Development of Western European Welfare State Regimes and Age-Related Patterns of Educational Inequalities in Self-Reported Health

This article uses data from three waves of the European Social Survey (2002, 2004, 2006) to compare educational inequalities in self-reported health (good vs. bad) and limiting longstanding illness in six age groups based on decade of birth (1930s–1980s) in 17 countries, categorized into four welfare state regimes (Anglo-Saxon, Bismarckian, Scandinavian, Southern). The authors hypothesized that health inequalities in these age groups would vary because of their different welfare state experiences—welfare state regime life courses—both temporally, in terms of different phases of welfare state development (inequalities smaller among older people), and spatially, in terms of welfare state regime type (inequalities smaller among older Scandinavians). The findings are that inequalities in health tended to increase, not decrease, with age. Similarly, inequalities in health were not smallest in the Scandinavian regime or among the older Scandinavian cohorts. In keeping with the rest of the literature, the Bismarckian and Southern regimes had smaller educational inequalities in health. Longitudinal analysis that integrates wider public health factors or makes smaller comparisons may be a more productive way of analyzing cross-national variations in health inequalities and their relationship to welfare state life courses.

Effect of a UK Pay-for-Performance Program on Ethnic Disparities in Diabetes Outcomes: Interrupted Time Series Analysis

PURPOSE We wanted to examine the long-term effects of the Quality and Outcomes Framework (QOF), a major pay-for-performance program in the United Kingdom, on ethnic disparities in diabetes outcomes. METHODS We undertook an interrupted time series analysis of electronic medical record data of diabetes patients registered with 29 family practices in South West London, United Kingdom. Main outcome measures were mean hemoglobin A1c (HbA1c), total cholesterol, and blood pressure. RESULTS The introduction of QOF was associated with initial accelerated improvements in systolic blood pressure in white and black patients, but these improvements were sustained only in black patients (annual decrease: −1.68 mm Hg; 95% CI, −2.41 to −0.95 mm Hg). Initial improvements in diastolic blood pressure in white patients (−1.01 mm Hg; 95% CI, −1.79 to −0.24 mm Hg) and in cholesterol in white (−0.13 mmol/L; 95% CI, −0.21 to −0.05 mmol/L) and black (−0.10 mmol/L; 95% CI, −0.20 to −0.01 mmol/L) patients were not sustained in the post-QOF period. There was no beneficial impact of QOF on HbA1c in any ethnic group. Existing disparities in risk factor control remained largely intact (for example; mean HbA1c: white 7.5%, black 7.8%, south Asian 7.8%; P <.05) at the end of the study period. CONCLUSION A universal pay-for-performance scheme did not appear to address important disparities in chronic disease management over time. Targeted quality improvement strategies may be required to improve health care in vulnerable populations.

The Effects of Pay for Performance on Disparities in Stroke, Hypertension, and Coronary Heart Disease Management: Interrupted Time Series Study

Background The Quality and Outcomes Framework (QOF), a major pay-for-performance programme, was introduced into United Kingdom primary care in April 2004. The impact of this programme on disparities in health care remains unclear. This study examines the following questions: has this pay for performance programme improved the quality of care for coronary heart disease, stroke and hypertension in white, black and south Asian patients? Has this programme reduced disparities in the quality of care between these ethnic groups? Did general practices with different baseline performance respond differently to this programme? Methodology/Principal Findings Retrospective cohort study of patients registered with family practices in Wandsworth, London during 2007. Segmented regression analysis of interrupted time series was used to take into account the previous time trend. Primary outcome measures were mean systolic and diastolic blood pressure, and cholesterol levels. Our findings suggest that the implementation of QOF resulted in significant short term improvements in blood pressure control. The magnitude of benefit varied between ethnic groups with a statistically significant short term reduction in systolic BP in white and black but not in south Asian patients with hypertension. Disparities in risk factor control were attenuated only on few measures and largely remained intact at the end of the study period. Conclusions/Significance Pay for performance programmes such as the QOF in the UK should set challenging but achievable targets. Specific targets aimed at reducing ethnic disparities in health care may also be needed.