Judith Green

Deaths from injury in children and employment status in family: analysis of trends in class specific death rates

Abstract Objective To examine socioeconomic inequalities in rates of death from injury in children in England and Wales. Design Analysis of rates of death from injury in children by the eight class version of the National Statistics Socio-Economic Classification (NS-SEC) and by the registrar generals social classification. Setting England and Wales during periods of four years around the 1981, 1991, and 2001 censuses. Subjects Children aged 0-15 years. Main outcome measures Death rates from injury and poisoning. Results Rates of death from injury in children fell from 11.1 deaths (95% confidence interval 10.8 to 11.5 deaths) per 100 000 children per year around the 1981 census to 4.0 deaths (3.8 to 4.2 deaths) per 100 000 children per year around the 2001 census. Socioeconomic inequalities remain: the death rate from all external causes for children of parents classified as never having worked or as long term unemployed (NS-SEC 8) was 13.1 (10.3 to 16.5) times that for children in NS-SEC 1(higher managerial/professional occupations). For deaths as pedestrians the rate in NS-SEC 8 was 20.6 (10.6 to 39.9) times higher than in NS-SEC 1; for deaths as cyclists it was 27.5 (6.4 to 118.2) times higher; for deaths due to fires it was 37.7 (11.6 to 121.9) times higher; and for deaths of undetermined intent it was 32.6 (15.8 to 67.2) times higher. Conclusions Overall rates of death from injury and poisoning in children have fallen in England and Wales over the past 20 years, except for rates in children in families in which no adult is in paid employment. Serious inequalities in injury death rates remain, particularly for pedestrians, cyclists, house fires, and deaths of undetermined intent.

Primary care in the accident and emergency department: I. Prospective identification of patients

Abstract Objective:To compare patient characteristics and consultation activities for attenders at accident and emergency departments assessed by nurse triage as presenting with “primary care” or “accident and emergency” type problems. Design:One year prospective study. Setting:A busy, inner city accident and emergency department in south London. Subjects:Of the 5658 patients treated for new problems during a stratified random sample of 204 three hour sessions between 10 am and 9 pm during June 1989 to May 1990, all “primary care” (2065 patients) and a 10% random sample of “accident and emergency” (291 patients) were included in the analysis. Main outcome measures:Patients age, sex, duration of presenting problem, diagnosis, laboratory and radiographic investigations, treatments, and referrals. Results:40.9% of attenders with new problems were classified by triage as presenting with “primary care” problems (95% confidence interval 39.6% to 42.2%). Primary care attenders were more likely than accident and emergency patients to be young adults, to have symptoms with a duration of longer than 24 hours, and to present problems not related to injury (all P<0.001). Accident and emergency patients were considerably more likely to be referred to on call teams and to be admitted. Even so, 9.7% of primary care patients were referred to on call teams and a further 8.9% were referred to the fracture clinic or advised to return to the accident and emergency department for follow up. Conclusion:Accident and emergency triage can be developed to identify patients with problems that are more likely to be of a primary care type, and these patients are less likely to receive an investigation, minor surgical procedure, or referral. Many patients in this category, however, receive interventions likely to support their decision to attend accident and emergency rather than general practice. This may reflect limitations in the sensitivity of triage practice or a clinical approach of junior medical staff that includes a propensity to intervene.

What are the health benefits of active travel? A systematic review of trials and cohort studies.

Background Increasing active travel (primarily walking and cycling) has been widely advocated for reducing obesity levels and achieving other population health benefits. However, the strength of evidence underpinning this strategy is unclear. This study aimed to assess the evidence that active travel has significant health benefits. Methods The study design was a systematic review of (i) non-randomised and randomised controlled trials, and (ii) prospective observational studies examining either (a) the effects of interventions to promote active travel or (b) the association between active travel and health outcomes. Reports of studies were identified by searching 11 electronic databases, websites, reference lists and papers identified by experts in the field. Prospective observational and intervention studies measuring any health outcome of active travel in the general population were included. Studies of patient groups were excluded. Results Twenty-four studies from 12 countries were included, of which six were studies conducted with children. Five studies evaluated active travel interventions. Nineteen were prospective cohort studies which did not evaluate the impact of a specific intervention. No studies were identified with obesity as an outcome in adults; one of five prospective cohort studies in children found an association between obesity and active travel. Small positive effects on other health outcomes were found in five intervention studies, but these were all at risk of selection bias. Modest benefits for other health outcomes were identified in five prospective studies. There is suggestive evidence that active travel may have a positive effect on diabetes prevention, which may be an important area for future research. Conclusions Active travel may have positive effects on health outcomes, but there is little robust evidence to date of the effectiveness of active transport interventions for reducing obesity. Future evaluations of such interventions should include an assessment of their impacts on obesity and other health outcomes.

Effect of 20 mph traffic speed zones on road injuries in London, 1986-2006: controlled interrupted time series analysis

Objective To quantify the effect of the introduction of 20 mph (32 km an hour) traffic speed zones on road collisions, injuries, and fatalities in London. Design Observational study based on analysis of geographically coded police data on road casualties, 1986-2006. Analyses were made of longitudinal changes in counts of road injuries within each of 119 029 road segments with at least one casualty with conditional fixed effects Poisson models. Estimates of the effect of introducing 20 mph zones on casualties within those zones and in adjacent areas were adjusted for the underlying downward trend in traffic casualties. Setting London. Main outcome measures All casualties from road collisions; those killed and seriously injured (KSI). Results The introduction of 20 mph zones was associated with a 41.9% (95% confidence interval 36.0% to 47.8%) reduction in road casualties, after adjustment for underlying time trends. The percentage reduction was greatest in younger children and greater for the category of killed or seriously injured casualties than for minor injuries. There was no evidence of casualty migration to areas adjacent to 20 mph zones, where casualties also fell slightly by an average of 8.0% (4.4% to 11.5%). Conclusions 20 mph zones are effective measures for reducing road injuries and deaths.

Understanding resolution of deliberate self harm: qualitative interview study of patients' experiences

Abstract ObjectiveTo explore the accounts of those with a history of deliberate self harm but who no longer do so, to understand how they perceive this resolution and to identify potential implications for provision of health services. Design Qualitative in-depth interview study. Setting Interviews in a community setting. Participants 20 participants selected from a representative cohort identified in 1997 after an episode of deliberate self poisoning that resulted in hospital treatment. Participants were included if they had no further episodes for at least two years before interview. Results We identified three recurrent themes: the resolution of adolescent distress; the recognition of the role of alcohol as a precipitating and maintaining factor in self harm; and the understanding of deliberate self harm as a symptom of untreated or unrecognised illness. Conclusion Patients with a history of deliberate self harm who no longer harm themselves talk about their experiences in terms of lack of control over their lives, either through alcohol dependence, untreated depression, or, in adolescents, uncertainty within their family relationships. Hospital management of deliberate self harm has a role in the identification and treatment of depression and alcohol misuse, although in adolescents such interventions may be less appropriate.

Primary care in the accident and emergency department: II. comparison of general practitioners and hospital doctors

Abstract Objective:To compare the process and outcome of “primary care” consultations undertaken by senior house officers, registrars, and general practitioners in an accident and emergency department. Design:Prospective, controlled intervention study. Setting:A busy, inner city accident and emergency department in south London. Subjects:Patients treated during a stratified random sample of 419 three hour sessions between June 1989 and May 1990 assessed at nurse triage as presenting with problems that could be treated in a primary care setting. 1702 of these patients were treated by sessionally employed local general practitioners, 2382 by senior house officers, and 557 by registrars. Main outcome measures:Process variables: laboratory and radiographic investigations, prescriptions, and referrals; outcome variables: results of investigations. Results:Primary care consultations made by accident and emergency medical staff resulted in greater utilisation of investigative, outpatient, and specialist services than those made by general practitioners. For example, the odds ratios for patients receiving radiography were 2.78 (95% confidence interval 2.32 to 3.34) for senior house officer v general practitioner consultations and 2.37 (1.84 to 3.06) for registrars v general practitioners. For referral to hospital specialist on call teams or outpatient departments v discharge to the community the odds ratios were 2.88 (2.39 to 3.47) for senior house officers v general practitioners and 2.57 (1.98 to 3.35) for registrars v general practitioners. Conclusion:Employing general practitioners in accident and emergency departments to manage patients with primary care needs seems to result in reduced rates of investigations, prescriptions, and referrals. This suggests important benefits in terms of resource utilisation, but the impact on patient outcome and satisfaction needs to be considered further.

The WHO Commission on Social Determinants of Health

The World Health Organizations (WHO) Commission on the Social Determinants of Health (CSDH) published its final report on health equity in 2008, with the titled aspiration of ‘closing the gap in a...

Evaluation of modernisation of adult critical care services in England: time series and cost effectiveness analysis

Objective To evaluate the impact and cost effectiveness of a programme to transform adult critical care throughout England initiated in late 2000. Design Evaluation of trends in inputs, processes, and outcomes during 1998-2000 compared with last quarter of 2000-6. Setting 96 critical care units in England. Participants 349 817 admissions to critical care units. Interventions Adoption of key elements of modernisation and increases in capacity. Units were categorised according to when they adopted key elements of modernisation and increases in capacity. Main outcome measures Trends in inputs (beds, costs), processes (transfers between units, discharge practices, length of stay, readmissions), and outcomes (unit and hospital mortality), with adjustment for case mix. Differences in annual costs and quality adjusted life years (QALYs) adjusted for case mix were used to calculate net monetary benefits (valuing a QALY gain at £20 000 (

Is it time for the sociology of health to abandon ‘risk’?

33 170, €22 100)). The incremental net monetary benefits were reported as the difference in net monetary benefits after versus before 2000. Results In the six years after 2000, the risk of unit mortality adjusted for case mix fell by 11.3% and hospital mortality by 13.4% compared with the steady state in the three preceding years. This was accompanied by substantial reductions both in transfers between units and in unplanned night discharges. The mean annual net monetary benefit increased significantly after 2000 (from £402 (

Why consider patients' preferences? A discourse analysis of clinical practice guideline developers.

667, €445) to £1096 (