Jonathan Minton

Health, employment, and economic change, 1973-2009: repeated cross sectional study

Objective To see whether adverse relations between social class, health, and economic activity, observed between 1973 and 1993 and previously identified in a 1996 BMJ paper, were still apparent between 1994 and 2009 despite improvements in the general economic climate and overall population health. Design Replication of repeated cross sectional analysis from the original paper, using the same source (the General Household Survey) and occupation coding scheme, but extended from the period 1973-93 to 1973-2009, and including women as well as men. Subjects Men and women aged 20-59 years in each annual survey between 1973 and 2009. Main outcome measures Change over time in class specific rates of employment, unemployment, and economic inactivity within subgroups of respondents. Results Overall employment rates have decreased for men of working age while increasing for working age women. For men in particular, the gradient of these changes seems to depend on occupational group. Over 37 years, the differences in occupational group specific economic inactivity and employment rates between people reporting and those not reporting a limiting long term illness has increased substantially. Conclusion Between 1973 and 2009, the relation between good health and securing and sustaining employment has strengthened for both men and women. For men, this has been due to employment rates decreasing and economic inactivity rates increasing among men with poor health. For women, this has largely been due to a general trend of increased employment and reduced economic inactivity occurring among healthier women but not in women of poorer health. Some evidence suggests that, since 2005, the relation between health, employment, and economic inactivity for women in the top two occupational groups has become more like that for men, with poor health becoming associated with reducing employment rates.

Visualizing Europe’s demographic scars with coplots and contour plots

We present two enhancements to existing methods for visualizing vital statistics data. Data from the Human Mortality Database were used and vital statistics from England and Wales are used for illustration. The simpler of these methods involves coplotting mean age of death with its variance, and the more complex of these methods is to present data as a contour plot. The coplot method shows the effect of the 20th century’s epidemiological transitions. The contour plot method allows more complex and subtle age, period and cohort effects to be seen. The contour plot shows the effects of broad improvements in public health over the 20th century, including vast reductions in rates of childhood mortality, reduced baseline mortality risks during adulthood and the postponement of higher mortality risks to older ages. They also show the effects of the two world wars and the 1918 influenza pandemic on men of fighting age, women and children. The contour plots also show a cohort effect for people born around 1918, suggesting a possible epigenetic effect of parental exposure to the pandemic which shortened the cohort’s lifespan and which has so far received little attention. Although this article focuses on data from England and Wales, the associated online appendices contain equivalent visualizations for almost 50 series of data available on the Human Mortality Database. We expect that further analyses of these visualizations will reveal further insights into global public health.

Accuracy of point-of-care testing for circulatory cathodic antigen in the detection of schistosome infection: Systematic review and meta-analysis

Abstract Objective To assess the accuracy of point-of-care testing for circulatory cathodic antigen in the diagnosis of schistosome infection. Methods We searched MEDLINE, EMBASE, LILACS and other bibliographic databases for studies published until 30 September 2015 that described circulatory cathodic antigen testing compared against one to three Kato–Katz tests per subject – for Schistosoma mansoni – or the filtration of one 10-ml urine sample per subject – for S. haematobium. We extracted the numbers of true positives, false positives, true negatives and false negatives for the antigen testing and performed meta-analyses using a bivariate hierarchical regression model. Findings Twenty-six studies published between 1994 and 2014 met the inclusion criteria. In the detection of S. mansoni, a single antigen test gave a pooled sensitivity of 0.90 (95% confidence interval, CI: 0.84–0.94) and a pooled specificity of 0.56 (95% CI: 0.39–0.71; n = 7) when compared against a single Kato–Katz test. The corresponding values from comparisons with two to three Kato–Katz tests per subject were 0.85 (95% CI: 0.80–0.88) and 0.66 (95% CI: 0.53–0.76; n = 14), respectively. There appeared to be no advantage in using three antigen tests per subject instead of one. When compared against the results of urine filtration, antigen testing for S. haematobium showed poor sensitivity and poor specificity. The performance of antigen testing was better in areas of high endemicity than in settings with low endemicity. Conclusion Antigen testing may represent an effective tool for monitoring programmes for the control of S. mansoni.

Explaining trends in alcohol-related harms in Scotland, 1991–2011 (I): the role of incomes, effects of socio-economic and political adversity and demographic change

OBJECTIVE This paper tests the extent to which differing trends in income, demographic change and the consequences of an earlier period of social, economic and political change might explain differences in the magnitude and trends in alcohol-related mortality between 1991 and 2011 in Scotland compared to England & Wales (E&W). STUDY DESIGN Comparative time trend analyses and arithmetic modelling. METHODS Three approaches were utilised to compare Scotland with E&W: 1. We modelled the impact of changes in income on alcohol-related deaths between 1991-2001 and 2001-2011 by applying plausible assumptions of the effect size through an arithmetic model. 2. We used contour plots, graphical exploration of age-period-cohort interactions and calculation of Intrinsic Estimator coefficients to investigate the effect of earlier exposure to social, economic and political adversity on alcohol-related mortality. 3. We recalculated the trends in alcohol-related deaths using the white population only to make a crude approximation of the maximal impact of changes in ethnic diversity. RESULTS Real incomes increased during the 1990s but declined from around 2004 in the poorest 30% of the population of Great Britain. The decline in incomes for the poorest decile, the proportion of the population in the most deprived decile, and the inequality in alcohol-related deaths, were all greater in Scotland than in E&W. The model predicted less of the observed rise in Scotland (18% of the rise in men and 29% of the rise in women) than that in E&W (where 60% and 68% of the rise in men and women respectively was explained). One-third of the decline observed in alcohol-related mortality in Scottish men between 2001 and 2011 was predicted by the model, and the model was broadly consistent with the observed trends in E&W and amongst women in Scotland. An age-period interaction in alcohol-related mortality was evident for men and women during the 1990s and 2000s who were aged 40-70 years and who experienced rapidly increasing alcohol-related mortality rates. Ethnicity is unlikely to be important in explaining the trends or differences between Scotland and E&W. CONCLUSIONS The decline in alcohol-related mortality in Scotland since the early 2000s and the differing trend to E&W were partly described by a model predicting the impact of declining incomes. Lagged effects from historical social, economic and political change remain plausible from the available data.

Exploring the relationship between baseline physical activity levels and mortality reduction associated with increases in physical activity: a modelling study

Background Increasing physical activity (PA) levels among the general adult population of developed nations is important for reducing premature mortality and the burdens of preventable illness. Assessing how effective PA interventions are as health interventions often involves categorising participants as either ‘active’ or ‘sedentary’ after the interventions. A model was developed showing that doing this could significantly misestimate the health effect of PA interventions. Methods A life table model was constructed combining evidence on baseline PA levels with evidence indicating the non-linear relationship between PA levels and all-cause mortality risks. PA intervention scenarios were modelled which had the same mean increase in PA but different levels of take-up by people who were more active or more sedentary to begin with. Results The model simulations indicated that, compared with a scenario where already-active people did most of the additional PA, a scenario where the least active did the most additional PA was around a third more effective in preventing deaths between the ages of 50 and 60 years. The relationship between distribution of PA take-up and health effect was explored systematically and appeared non-linear. Conclusions As the health gains of a given PA increase are greatest among people who are most sedentary, smaller increases in PA in the least active may have the same health benefits as much larger PA increases in the most active. To help such health effects to be assessed, PA studies should report changes in the distribution of PA level between the start and end of the study.

Could the rise in mortality rates since 2015 be explained by changes in the number of delayed discharges of NHS patients

Background 2015 saw the largest annual spike of mortality rates in England in almost 50 years. We examine whether these changes in mortality rates are associated with an indicator of poor functioning of health and social care: delay in hospital discharges. Methods Office for National Statistics monthly data of death counts and mortality rates for the period August 2010–March 2016 were compared with delays in discharges from National Health Service (NHS) England data on transfers of care for acute and non-acute patients in England. Autoregressive Integrated Moving Average regression models were used in the analysis. Results We estimate that each additional day an acute admission was late being discharged was associated with an increase in 0.394 deaths (95% CIs 0.220 to 0.569). For each additional acute patient delayed being discharged, we found an increase of 7.322 deaths (95% CIs 1.754 to 12.890). Findings for non-acute admissions were mixed. Conclusion The increased prevalence of patients being delayed in discharge from hospital in 2015 was associated with increases in mortality, accounting for up to a fifth of mortality increases. Our study provides evidence that a lower quality of performance of the NHS and adult social care as a result of austerity may be having an adverse impact on population health.

Real geographies and virtual landscapes: exploring the influence on place and space on mortality Lexis surfaces using shaded contour maps.

This paper describes how shaded contour plots, applied to mortality data from the Human Mortality Database, can be used to compare between nations, and start to tease out some of the ways that place and space matters. A number of shaded contour plots are presented, in order to describe the age, period and cohort effects which are apparent within them. They show variations between different subpopulations within the same nation, over time, and between nations. In illustrating these intra- and international variations in the patterns, we hope to encourage the development of hypotheses about the influence of such factors on mortality rates. We conclude with a brief discussion about how such hypotheses might be developed into statistical models, allowing for more rigourous testing of hypotheses and projection across time, place and space.

Echocardiography in newly diagnosed atrial fibrillation patients: a systematic review and economic evaluation

OBJECTIVE To investigate the clinical effectiveness and cost-effectiveness of transthoracic echocardiography (TTE) in all patients who are newly diagnosed with atrial fibrillation (AF). DESIGN Narrative synthesis reviews were conducted on the prognostic and diagnostic accuracy of TTE for, and prevalence of, pathologies in patients with AF. Databases were searched from inception. MEDLINE searches were conducted from March to August 2010, and reference lists of articles checked. There were 44 diagnostic accuracy studies, five prognostic studies, and 16 prevalence studies accepted into the review. Given the complexity of the many pathologies identified by TTE, the variety of potential changes to clinical management, and paucity of data, the model focused on changes to oral anticoagulation (OAC). The mathematical model assessed the cost-effectiveness of TTE for patients with AF who were not routinely given OAC, assuming, if left atrial abnormality was detected, that the higher risk of stroke warranted OAC; this meant that patients with a CHADS2 (cardiac failure, hypertension, age, diabetes, stroke doubled) score of 0 [dabigatran etexilate (Pradaxa, Boehringer Ingelheim)/rivaroxaban (Xarelto, Bayer Schering)] or 0/1 (warfarin) were included. A simplified approach evaluated the additional quality-adjusted life-years (QALYs) required in order for TTE to be perceived as cost-effective at a threshold of £20,000 per QALY. SETTING Transthoracic echocardiography is usually performed in cardiology clinics but may be used in primary or non-specialist secondary care. PARTICIPANTS Patients with newly diagnosed AF. INTERVENTION Transthoracic echocardiography. MAIN OUTCOME MEASURES Prognosis, diagnostic sensitivity or specificity of TTE, prevalence of pathologies in patients with AF, cost-effectiveness and QALYs. RESULTS Prognostic studies indicated that TTE-diagnosed left ventricular dysfunction, increased left atrial diameter and valvular abnormality were significantly associated with an increased risk of stroke, mortality or thromboembolism. There was a high prevalence (around 25-30%) of ischaemic heart disease, valvular heart disease and heart failure in patients with AF. Diagnostic accuracy of TTE was high, with most pathologies having specificity of ≥ 0.8 and sensitivity of ≥ 0.6. The mathematical model predicted that when the CHADS2 tool is used the addition of TTE in identifying patients with left atrial abnormality appears to be cost-effective for informing some OAC decisions. In the simplified approach a threshold of 0.0033 was required for a TTE to be cost-effective. CONCLUSIONS When CHADS2 was used, the addition of TTE in identifying patients with left atrial abnormality was cost-effective for informing some OAC decisions. A simple analysis indicates that the number of QALYs required for TTE to be cost-effective is small, and that if benefits beyond those associated with a reduction in stroke are believed probable then TTE is likely to be cost-effective in all scenarios. Our findings suggest that further research would be useful, following up newly diagnosed patients with AF who have undergone TTE, to study treatments given as a result of TTE diagnoses and subsequent cardiovascular events. This could identify additional benefits of routine testing, beyond stroke prevention. Studies assessing the proportion of people with a CHADS2 score of 0 or 1 that have left atrial abnormality would provide better estimates of the cost-effectiveness of TTE, and allow more accurate estimates of the sensitivity and specificity of TTE for identifying left atrial abnormality in AF to be obtained. STUDY REGISTRATION PROSPERO CRD42011001354. FUNDING The National Institute for Health Research Health Technology Assessment programme.

Explaining trends in alcohol-related harms in Scotland 1991–2011 (II): policy, social norms, the alcohol market, clinical changes and a synthesis

OBJECTIVE To provide a basis for evaluating post-2007 alcohol policy in Scotland, this paper tests the extent to which pre-2007 policy, the alcohol market, culture or clinical changes might explain differences in the magnitude and trends in alcohol-related mortality outcomes in Scotland compared to England & Wales (E&W). STUDY DESIGN Rapid literature reviews, descriptive analysis of routine data and narrative synthesis. METHODS We assessed the impact of pre-2007 Scottish policy and policy in the comparison areas in relation to the literature on effective alcohol policy. Rapid literature reviews were conducted to assess cultural changes and the potential role of substitution effects between alcohol and illicit drugs. The availability of alcohol was assessed by examining the trends in the number of alcohol outlets over time. The impact of clinical changes was assessed in consultation with key informants. The impact of all the identified factors were then summarised and synthesised narratively. RESULTS The companion paper showed that part of the rise and fall in alcohol-related mortality in Scotland, and part of the differing trend to E&W, were predicted by a model linking income trends and alcohol-related mortality. Lagged effects from historical deindustrialisation and socio-economic changes exposures also remain plausible from the available data. This paper shows that policy differences or changes prior to 2007 are unlikely to have been important in explaining the trends. There is some evidence that aspects of alcohol culture in Scotland may be different (more concentrated and home drinking) but it seems unlikely that this has been an important driver of the trends or the differences with E&W other than through interaction with changing incomes and lagged socio-economic effects. Substitution effects with illicit drugs and clinical changes are unlikely to have substantially changed alcohol-related harms: however, the increase in alcohol availability across the UK is likely to partly explain the rise in alcohol-related mortality during the 1990s. CONCLUSIONS Future policy should ensure that alcohol affordability and availability, as well as socio-economic inequality, are reduced, in order to maintain downward trends in alcohol-related mortality in Scotland.

Two cheers for a small giant? Why we need better ways of seeing data: A commentary on: 'Rising morbidity and mortality in midlife among White non-Hispanic Americans in the 21st century'

Two cheers for a small giant? Why we need better ways of seeing data: A commentary on: ‘Rising morbidity and mortality in midlife among White non-Hispanic Americans in the 21st century’ Jonathan Minton,* Mark Green, Gerry McCartney, Richard Shaw, Laura Vanderbloemen, Kate Pickett University of Glasgow College of Social Sciences Room 110, 25 Bute Gardens, Glasgow G12 8RS Email: jonathan.minton@glasgow.ac.uk, University of Liverpool, School of Environmental Sciences, NHS Health Scotland, Public Health Science, University of Glasgow, Medical Research Council/Chief Scientist Office, Social and Public Health Sciences Unit, 5 Imperial College, Faculty of Medicine, Department of Primary Care and Public Health, University of York, Health Sciences