John Tayu Lee

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.

Access to Primary Care and Visits to Emergency Departments in England: A Cross-Sectional, Population-Based Study

Background The number of visits to hospital emergency departments (EDs) in England has increased by 20% since 2007-08, placing unsustainable pressure on the National Health Service (NHS). Some patients attend EDs because they are unable to access primary care services. This study examined the association between access to primary care and ED visits in England. Methods A cross-sectional, population-based analysis of patients registered with 7,856 general practices in England was conducted, for the time period April 2010 to March 2011. The outcome measure was the number of self-referred discharged ED visits by the registered population of a general practice. The predictor variables were measures of patient-reported access to general practice services; these were entered into a negative binomial regression model with variables to control for the characteristics of patient populations, supply of general practitioners and travel times to health services. Main Result and Conclusion General practices providing more timely access to primary care had fewer self-referred discharged ED visits per registered patient (for the most accessible quintile of practices, RR = 0.898; P<0.001). Policy makers should consider improving timely access to primary care when developing plans to reduce ED utilisation.

Prevalence and predictors of water pipe and cigarette smoking among secondary school students in london

INTRODUCTION Water pipe tobacco smoking appears to be an increasing public health concern, with anecdotal reports of higher prevalence than cigarette smoking among young people in some high-income countries. We examined the prevalence and predictors of water pipe and cigarette smoking among students attending secondary schools in a deprived, ethnically diverse part of inner London. METHODS We conducted a 96-item, validated smoking habits questionnaire with 2,399 students from Years 8, 10, and 12/13 from 15 secondary schools in Brent, northwest London. Multilevel logistic regression models were used to examine predictors of current and ever cigarette and water pipe smoking. RESULTS Current water pipe smoking prevalence was more than double that of cigarette smoking prevalence (7.6% vs. 3.4%, p < .001). One in 4 students had tried water pipe compared with 1 in 6 who had tried cigarette smoking (24.0% vs. 15.8%, p < .001). Significant predictors of ever water pipe use include being in a higher age group, South Asian or Middle Eastern ethnicity, and personal, family, or friends tobacco use. Significant predictors of ever cigarette use include being in a higher age group, White ethnicity, and personal, family, or friends tobacco use. Students attending schools with more water pipe cafes within 0.5 miles were more likely to be current water pipe users (AOR = 2.43, 95% CI = 1.33-4.42). CONCLUSIONS Water pipe smoking may be more prevalent than cigarette smoking among young people in some high-income countries. Improved surveillance and dedicated tobacco control interventions are required to better understand the epidemiology of water pipe use and address its growing use.

Waterpipe Tobacco Smoking Prevalence and Correlates in 25 Eastern Mediterranean and Eastern European Countries: Cross-Sectional Analysis of the Global Youth Tobacco Survey

INTRODUCTION Waterpipe tobacco smoking is highly prevalent among young people in some settings. There is an absence of nationally representative prevalence studies of waterpipe tobacco use and dual use with other tobacco products in young people. METHODS We conducted a secondary analysis of the Global Youth Tobacco Survey, a nationally representative cross-sectional study of students aged 13-15 years. Of 180 participating countries, 25 included optional waterpipe tobacco smoking questions: 15 Eastern Mediterranean and 10 Eastern European countries. We calculated the prevalence of current (past 30-day) waterpipe tobacco use, including dual waterpipe and other tobacco use, and used logistic regression models to identify sociodemographic correlates of waterpipe tobacco smoking. Individual country results were combined in a random effects meta-analysis. RESULTS Waterpipe tobacco smoking prevalence was highest in Lebanon (36.9%), the West Bank (32.7%) and parts of Eastern Europe (Latvia 22.7%, the Czech Republic 22.1%, Estonia 21.9%). These countries also recorded greater than 10% prevalence of dual waterpipe and cigarette use. In a meta-analysis, higher odds of waterpipe tobacco smoking were found among males (Adjusted odds ratio [AOR] = 1.37, 95% confidence interval [CI] = 1.18% to 1.59%), cigarette users (AOR = 6.95, 95% CI = 5.74% to 8.42%), those whose parents (AOR = 1.54, 95% CI = 1.31% to 1.82%) or peers smoked (AOR = 3.53, 95% CI = 2.97% to 4.20%) and those whose parents had higher educational attainment (Father, AOR = 1.47, 95% CI = 1.14% to 1.89%; Mother, AOR = 1.62, 95% CI = 1.07% to 2.46%). We report on regional- and country income-level differences. CONCLUSIONS Waterpipe tobacco smoking, including dual waterpipe and cigarette use, is alarmingly high in several Eastern Mediterranean and Eastern European countries. Ongoing waterpipe tobacco smoking surveillance is warranted.

Effect of smoke-free legislation on adult smoking behaviour in England in the 18 months following implementation.

Background Comprehensive smoke-free legislation covering all enclosed public places and workplaces was implemented in England on 1 July 2007. This study examines the impact of this legislation on smoking prevalence, number of cigarettes smoked and location of smoking, controlling for secular trends through the end of 2008. Method and Findings Repeat cross sectional survey using nationally representative data from the Health Survey for England (HSE). In total there are 54,333 respondents from 2003–2008. Logit and linear regression models were used to examine the effect of the legislation on smoking prevalence and the number of cigarettes smoked daily among continuing smokers which took the underlying trend into account. Our finding suggest that smoking prevalence (current smoker) decreased from 25% in 2003 to 21% in 2008 (AOR = 0.96 per year, 95% CI = 0.95–0.98, P<0.01) and the mean number of cigarettes consumed daily by smokers decreased from 14.1 in 2003 to 13.1 in 2008 (coefficient for time trend = −0.28±0.06 SE cig/day per year, P<0.01). After adjusting for these trends the introduction of smoke-free legislation was not associated with additional reductions in smoking prevalence (AOR = 1.02, 95% CI = 0.94–1.11, P = 0.596) or daily cigarette use in smokers (0.42±0.28 SE; P = 0.142). The percentage of respondents reporting smoking ‘at work’ and ‘inside pubs or bars’ decreased significantly from 14% to 2% (p<0.001) and from 34% to 2% (p<0.001), respectively, after the legislation. The percentage reporting smoking ‘inside restaurants, cafes, or canteens’ decreased significantly from 9% to 1% (p<0.001) and ‘inside their home’ decreased significantly from 65% to 55% (p<0.01). Conclusion There is widespread compliance with the smoke-free legislation in England, which has led to large drops in indoor smoking in all venues, including at home. Declines in smoking prevalence and consumption continued along existing trends; they did not accelerate during the 18 months immediately following implementation.

Impact of Noncommunicable Disease Multimorbidity on Healthcare Utilisation and Out-Of-Pocket Expenditures in Middle- Income Countries: Cross Sectional Analysis

Background The burden of non-communicable disease (NCDs) has grown rapidly in low- and middle-income countries (LMICs), where populations are ageing, with rising prevalence of multimorbidity (more than two co-existing chronic conditions) that will significantly increase pressure on already stretched health systems. We assess the impact of NCD multimorbidity on healthcare utilisation and out-of-pocket expenditures in six middle-income countries: China, Ghana, India, Mexico, Russia and South Africa. Methods Secondary analyses of cross-sectional data from adult participants (>18 years) in the WHO Study on Global Ageing and Adult Health (SAGE) 2007–2010. We used multiple logistic regression to determine socio-demographic correlates of multimorbidity. Association between the number of NCDs and healthcare utilisation as well as out-of-pocket spending was assessed using logistic, negative binominal and log-linear models. Results The prevalence of multimorbidity in the adult population varied from 3∙9% in Ghana to 33∙6% in Russia. Number of visits to doctors in primary and secondary care rose substantially for persons with increasing numbers of co-existing NCDs. Multimorbidity was associated with more outpatient visits in China (coefficient for number of NCD = 0∙56, 95% CI = 0∙46, 0∙66), a higher likelihood of being hospitalised in India (AOR = 1∙59, 95% CI = 1∙45, 1∙75), higher out-of-pocket expenditures for outpatient visits in India and China, and higher expenditures for hospital visits in Russia. Medicines constituted the largest proportion of out-of-pocket expenditures in persons with multimorbidity (88∙3% for outpatient, 55∙9% for inpatient visit in China) in most countries. Conclusion Multimorbidity is associated with higher levels of healthcare utilisation and greater financial burden for individuals in middle-income countries. Our study supports the WHO call for universal health insurance and health service coverage in LMICs, particularly for vulnerable groups such as the elderly with multimorbidity.

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.

Smoke-free legislation and childhood hospitalisations for respiratory tract infections

Second-hand smoke exposure is a major risk factor for respiratory tract infections (RTIs). Although evidence suggests important early-life health benefits of smoke-free public environments, the impact on childhood RTIs is unclear. We investigated the association between Englands smoke-free legislation and childhood RTI hospitalisations. We used the Hospital Episode Statistics database to obtain nationwide data on hospital admissions for acute RTIs among children (<15 years of age) from 2001 to 2012. Hospitalisation counts were disaggregated by month, age group, sex and small-area level, and linked to urbanisation, region, deprivation index and corresponding population estimates. Negative binomial regression analyses were adjusted for confounders, seasonal variation, temporal autocorrelation, population-size changes and underlying incidence trends. Models allowed for sudden and gradual changes following the smoke-free legislation. We performed sensitivity and subgroup analyses, and estimated number of events prevented. We analysed 1 651 675 hospital admissions. Introduction of smoke-free legislation was followed by an immediate reduction in RTI admissions (−3.5%, 95% CI −4.7– −2.3%), this mainly being attributable to a decrease in lower RTI admissions (−13.8%, 95% CI −15.6– −12.0%). The reductions in admissions for upper RTI were more incremental. The introduction of national smoke-free legislation in England was associated with ∼11 000 fewer hospital admissions per year for RTIs in children. Smoke-free legislation in England was associated with a drop in paediatric respiratory infection admissions http://ow.ly/L4XCL

Association between being employed in a smoke-free workplace and living in a smoke-free home: Evidence from 15 low and middle income countries

Objective To assess whether being employed in a smoke-free workplace is associated with living in a smoke-free home in 15 low and middle income countries (LMICs). Methods Country-specific individual level analyses of cross-sectional Global Adult Tobacco Survey data (2008–2011) from 15 LMICs was conducted using multiple logistic regression. The dependent variable was living in a smoke-free home; the independent variable was being employed in a smoke-free workplace. Analyses were adjusted for age, gender, residence, region, education, occupation, current smoking, current smokeless tobacco use and number of household members. Individual country results were combined in a random effects meta-analysis. Results In each country, the percentage of participants employed in a smoke-free workplace who reported living in a smoke-free home was higher than those employed in a workplace not smoke-free. The adjusted odds ratios (AORs) of living in a smoke-free home among participants employed in a smoke-free workplace (vs. those employed where smoking occurred) were statistically significant in 13 of the 15 countries, ranging from 1.12 [95% CI 0.79–1.58] in Uruguay to 2.29 [1.37–3.83] in China. The pooled AOR was 1.61 [1.46–1.79]. Conclusion In LMICs, employment in a smoke-free workplace is associated with living in a smoke-free home. Accelerated implementation of comprehensive smoke-free policies is likely to result in substantial population health benefits in these settings.