Islay Gemmell

The population effect of crime and neighbourhood on physical activity: an analysis of 15 461 adults

Area-based interventions offer the potential to increase physical activity for many sedentary people in countries such as the UK. Evidence on the effect of individual and area/neighbourhood influences on physical activity is in its infancy, and despite its value to policy makers a population focus is rarely used. Data from a population-based health and lifestyle survey of adults in northwest England were used to analyse associations between individual and neighbourhood perceptions and physical activity. The population effect of eliminating a risk factor was expressed as a likely effect on population levels of physical activity. Of the 15 461 responders, 21 923 (27.1%) were physically active. Neighbourhood perceptions of leisure facilities were associated with physical activity, but no association was found for sense of belonging, public transport or shopping facilities. People who felt safe in their neighbourhood were more likely to be physically active, but no associations were found for vandalism, assaults, muggings or experience of crime. The number of physically active people would increase by 3290 if feelings of “unsafe” during the day were removed, and by 11 237 if feelings of “unsafe” during the night were removed. An additional 8342 people would be physically active if everyone believed that they were “very well placed for leisure facilities”. Feeling safe had the potential largest effect on population levels of physical activity. Strategies to increase physical activity in the population need to consider the wider determinants of health-related behaviour, including fear of crime and safety.

Factors influencing emergency medical readmission risk in a UK district general hospital: A prospective study

BackgroundOver recent years increased emphasis has been given to performance monitoring of NHS hospitals, including overall number of hospital readmissions, which however are often sub-optimally adjusted for case-mix. We therefore conducted a study to examine the effect of various patient and disease factors on the risk of emergency medical readmission.MethodsThe study setting was a District General Hospital in Greater Manchester and the study period was 4.5-years. All index emergency medical admission during the study period leading to a live discharge were included in the study (n = 20,209). A multivariable proportional hazards modelling was used, based on Hospital Episodes Statistics data, to examine the influence of various baseline factors on readmission risk. Deprivation status was measured with the Townsend deprivation index score. Hazard ratios (HR) and associated 95% confidence intervals (CI) of unplanned emergency medical admission by sex, age group, admission method, diagnostic group, number of coded co-morbidities, length of stay and patients deprivation status quartile, were calculated.ResultsSignificant independent predictors of readmission risk at 12 months were male sex (HR 1.13, CI: 1.07–1.2), age (age >75 (HR 1.57, CI 1.45–1.7), number of coded co-morbidities (HR for >4 coded co-morbidities: 1.49 CI: 1.26–1.76), admission via GP referral (HR 0.93, CI 0.88–0.99) and primary diagnosis of heart failure (HR 1.33, CI: 1.16–1.53) and chronic obstructive pulmonary disease/asthma (HR 1.34, CI: 1.21–1.48). Higher level of deprivation was also significantly and independently associated and with increased emergency medical readmission risk at three (HR for the most deprived quartile 1.21, CI: 1.08–1.35), six (HR 1.21, CI: 1.1–1.33) and twelve months (HR 1.25, CI: 1.16–1.36).ConclusionsThere is a potential for improving health and reducing demand for emergency medical admissions with more effective management of patients with heart failure and chronic obstructive airways disease/asthma. There is also a potential for improving health and reducing demand if reasons for increased readmission risk in more deprived patients are understood. The potential influence of deprivation status on readmission risk should be acknowledged, and NHS performance indicators adjustment for deprivation case-mix would be prudent.

Potential population impact of the UK government strategy for reducing the burden of coronary heart disease in England: comparing primary and secondary prevention strategies

Objective: To use population impact measures to help prioritise the National Service Framework (NSF) strategies recommended by the UK government for reducing the population burden of coronary heart disease (CHD). Design: Modelling study. Setting: Primary care. Data sources: Published data on incidence, baseline risk and prevalence of risk factors for CHD and the proportion treated, eligible for treatment, and adhering to the different interventions. Data from meta-analyses and systematic reviews for relative risk and relative risk reduction associated with different risk factors and interventions. Main outcome measures: Population impact measures for the decline in the prevalence of a risk factor and the increased uptake of interventions expressed as number of CHD events prevented in the population. Results: If lifestyle targets for primary prevention are met, 73 522 (95% CI 54 117 to 95 826) CHD events would be prevented per year, with the greatest gain coming from reduced cholesterol and blood pressure levels. In those at high risk of developing CHD, achieving target levels for lifestyle interventions would prevent 4410 (95% CI 1 993 to 8014) CHD events and for pharmacological treatments 2008 (95% CI 790 to 3627) CHD events. For patients with established CHD, achieving NSF targets will result in the prevention of 3067 (95% CI 1572 to 5878) CHD events through improved drug treatment and 1103 (95% CI 179 to 2097) events through lifestyle interventions. Conclusion: Current strategies focus largely on secondary prevention, but many more cardiovascular events would be prevented by meeting the government’s public health and primary prevention targets than targeting people at high risk or those with established heart disease.

Capture-recapture estimates of problem drug use and the use of simulation based confidence intervals in a stratified analysis.

STUDY OBJECTIVE To establish the prevalence of problem drug use in the 10 local authorities within the Metropolitan County of Greater Manchester between April 2000 and March 2001. SETTING AND PARTICIPANTS Problem drug users aged 16-54 resident within Greater Manchester who attended community based statutory drug treatment agencies, were in contact with general practitioners, were assessed by arrest referral workers, were in contact with the probation service, or arrested under the Misuse of Drugs Act for offences involving possession of opioids, cocaine, or benzodiazepines. DESIGN Multi-sample stratified capture-recapture analysis. Patterns of overlaps between data sources were modelled in a log-linear regression to estimate the hidden number of drug users within each of 60 area, age group, and gender strata. Simulation methods were used to generate 95% confidence intervals for the sums of the stratified estimates. MAIN RESULTS The total number of problem drug users in Greater Manchester was estimated to be 19 255 giving a prevalence of problem drug use of 13.7 (95% CI 13.4 to 15.7) per 1000 population aged 16-54. The ratio of men to women was 3.5:1. The distribution of problem drug users varied across three age groups (16-24, 25-34, and 35-54) and varied between the 10 areas. CONCLUSIONS Areas in close geographical proximity display different patterns of drug use in terms of prevalence rates and age and gender patterns. This has important implications, both for future planning of service provision and for the way in which the impact of drug misuse interventions are evaluated.

Moving specialist care into the community: an initial evaluation

Objectives: To assess the likely impact on patients and local health economies of shifting specialist care from hospitals to the community in 30 demonstration sites in England. Methods: The evaluation comprised: interviews with service providers at 30 sites, supplemented by interviews with commissioners, GPs and hospital doctors at 12 sites; economic case studies in six sites; and patient surveys at 30 sites plus at nine conventional outpatient services. Outcomes comprised: staff views of service organization and development, impact on primary and secondary care, and benefits for patients; cost per consultation and cost per patient in new services compared to estimates of the price of services if undertaken by hospitals; patients’ views of waiting time, access, quality (technical and interpersonal), coordination and satisfaction. Results: New services required high initial investment in staff, premises and equipment, and the support of hospital consultants. Most new services were added to existing hospital services so expanded capacity. Patient reported waiting times (6.7 versus 10.1 weeks; p = 0.001); technical quality of care (96.2 versus 94.5; p < 0.001), overall satisfaction (88.2 versus 85.4; p = 0.04); and access (72.2 versus 65.8; p = 0.001) were significantly better for new compared to conventional services but there was no significant difference in coordination or interpersonal quality of care. Some service providers expressed concerns about service quality. New services dealt with less complex conditions and undercut the price tariff applied to hospitals thus providing a cost saving to commissioners. There was some concern that expansion of new services might destabilize hospitals. Conclusions: Moving specialist care into the community can improve patient access, particularly when new services are added to existing hospital services. Wider impacts on health care quality, capacity and cost merit closer scrutiny before rollout.

Small Vessel Remodeling and Impaired Endothelial-Dependent Dilatation in Subcutaneous Resistance Arteries from Patients with Acromegaly

CONTEXT Patients with acromegaly have increased morbidity and mortality, predominantly from cardiovascular disease. Hypertension and diabetes are more prevalent, and both cause small vessel remodeling and endothelial dysfunction. OBJECTIVE To understand the structure and function of small arteries in acromegaly, sc blood vessels from gluteal fat biopsies were harvested from 18 patients with active disease (AD; age, 56 +/- 15 yr; 14 males), 23 patients in remission (CD; age, 55 +/- 12 yr; 15 males), and 20 healthy controls (age, 55 +/- 11 yr; 10 males) and examined in vitro using pressure myography. DESIGN Contractile responses to cumulative noradrenaline concentrations were recorded and followed by dose-dependent dilator responses to acetylcholine. The acetylcholine protocol was repeated after incubation with a nitric oxide synthase inhibitor (N-nitro-L-arginine methyl ester) and cyclooxygenase inhibitor (indomethacin). After perfusion with Ca(2+)-free physiological saline solution, structural measurements were recorded at varying intraluminal pressures (3-180 mm Hg). RESULTS Wall thickness and wall:lumen ratio were increased in AD, reduced with treatment but remained greater in CD than controls. Wall cross-sectional area was increased in AD vs. controls (P < 0.001), decreased with treatment (AD vs. CD, P < 0.001), but remained higher than controls (CD vs. controls, P = 0.015). Growth index was increased in AD (20%) compared to controls (CD, 9%). Contractility was similar in all groups. Endothelial-dependent dysfunction was evident in AD compared with CD (P < 0.001) and controls (P < 0.01). Dilation did not change after N-nitro-L-arginine methyl ester but was impaired after indomethacin incubation. CONCLUSION Active acromegaly is associated with hypertrophic remodeling of the vascular wall and embarrassed endothelial function due to reduced nitric oxide and endothelium-derived hyperpolarizing factor bioavailability, both of which may contribute to the early mortality from cardiovascular disease.

General practice factors and MMR vaccine uptake: structure, process and demography

BACKGROUND Despite the fall in MMR uptake between 1998 and 2004, some general practices managed to sustain remarkably high MMR coverage. METHODS The aim of the study was to identify general practice factors associated with high MMR vaccine coverage. The study population included 257 general practices in Cumbria and Lancashire in 2005. Practice level MMR coverage data for 2002-04 were obtained from the child health information systems of eight Primary Care Trusts (PCTs) and linked to information on practice structure, census indicators for deprivation and ethnicity data at lower level super output area and information from a questionnaire survey of practice nurses. RESULTS Mean MMR uptake was 86.4% with a range from 59 to 98%. Twenty-eight per cent (74/257) practices achieved the Department of Health higher target payment level of 90%. The uptake was not associated with practice size, the number of general practitioners (GPs) or practice nurses. There was no correlation between uptake and deprivation or the percentage of non-white population. There was a strong negative association between MMR uptake and barriers to housing and services (r = -0.230, P < 0.001). On the basis of a questionnaire response rate of 75.9%, having a strategic approach to MMR with clear objectives was associated with MMR uptake of 90% or above (odds ratio, 3.76, 1.26-12.04). There was no association between immunization by GP, practice nurse or health visitor. CONCLUSIONS There are no easily identifiable characteristics of high-uptake MMR practices although having a strategic approach to MMR is important. Practices in rural areas should endeavour to ensure easy access to child vaccination. High uptake can be achieved by practices in deprived areas. Further research is needed to identify practice system factors associated with high MMR uptake.

Prioritising between direct observation of therapy and case-finding interventions for tuberculosis: use of population impact measures.

BackgroundPopulation impact measures (PIMs) have been developed as tools to help policy-makers with locally relevant decisions over health risks and benefits. This involves estimating and prioritising potential benefits of interventions in specific populations. Using tuberculosis (TB) in India as an example, we examined the population impact of two interventions: direct observation of therapy and increasing case-finding.MethodsPIMs were calculated using published literature and national data for India, and applied to a notional population of 100 000 people. Data included the incidence or prevalence of smear-positive TB and the relative risk reduction from increasing case finding and the use of direct observation of therapy (applied to the baseline risks over the next year), and the incremental proportion of the population eligible for the proposed interventions.ResultsIn a population of 100 000 people in India, the directly observed component of the Directly Observed Treatment, Short-course (DOTS) programme may prevent 0.188 deaths from TB in the next year compared with 1.79 deaths by increasing TB case finding. The costs of direct observation are (in international dollars) I

Using economic analyses for local priority setting: The population cost-impact approach

5960 and of case finding are I

Population impact of stricter adherence to recommendations for pharmacological and lifestyle interventions over one year in patients with coronary heart disease

4839 or I