Madhavi Bajekal

Effects of community based nurses specialising in Parkinson's disease on health outcome and costs: randomised controlled trial

Abstract Objective: To determine the effects of community based nurses specialising in Parkinsons disease on health outcomes and healthcare costs. Design: Two year randomised controlled trial. Setting: 438 general practices in nine randomly selected health authority areas of England. Participants: 1859 patients with Parkinsons disease identified by the participating general practices. Main outcome measures: Survival, stand-up test, dot in square test, bone fracture, global health question, PDQ-39, Euroqol, and healthcare costs. Results: After two years 315 (17.3%) patients had died, although mortality did not differ between those who were attended by nurse specialists and those receiving standard care from their general practitioner (hazard ratio for nurse group v control group 0.91, 95% confidence interval 0.73 to 1.13). No significant differences were found between the two groups for the stand-up test (odds ratio 1.15, 0.93 to 1.42) and dot in square score (difference 0.7, 3.25 to 1.84). Scores on the global health question were significantly better in patients attended by nurse specialists than in controls (difference 0.23, 0.4 to 0.06), but no difference was observed in the results of the PDQ-39 or Euroqol questionnaires. Direct costs for patient health care increased by an average of £2658 during the study, although not differentially between groups: the average increase was £266 lower among patients attended by a nurse specialist (£981 to £449). Conclusions: Nurse specialists in Parkinsons disease had little effect on the clinical condition of patients, but they did improve their patients sense of wellbeing, with no increase in patients healthcare costs. What is already known on this topic Most patients with Parkinsons disease have no regular contact with consultants specialising in the condition Contact by nurse specialists of patients attending hospital increases provision of information and is subjectively valued It has not been shown whether nurse specialists improve psychosocial functioning What this study adds Provision of community based nurses specialists in Parkinsons disease does not slow clinical progression of the condition Nurses specialists help to preserve patients sense of wellbeing Healthcare costs are not increased

Persistent socioeconomic inequalities in cardiovascular risk factors in England over 1994-2008: A time-trend analysis of repeated cross-sectional data

BackgroundOur aims were to determine the pace of change in cardiovascular risk factors by age, gender and socioeconomic groups from 1994 to 2008, and quantify the magnitude, direction and change in absolute and relative inequalities.MethodsTime trend analysis was used to measure change in absolute and relative inequalities in risk factors by gender and age (16-54, ≥ 55 years), using repeated cross-sectional data from the Health Survey for England 1994-2008. Seven risk factors were examined: smoking, obesity, diabetes, high blood pressure, raised cholesterol, consumption of five or more daily portions of fruit and vegetables, and physical activity. Socioeconomic group was measured using the Index of Multiple Deprivation 2007.ResultsBetween 1994 and 2008, the prevalence of smoking, high blood pressure and raised cholesterol decreased in most deprivation quintiles. However, obesity and diabetes increased. Increasing absolute inequalities were found in obesity in older men and women (p = 0.044 and p = 0.027 respectively), diabetes in young men and older women (p = 0.036 and p = 0.019 respectively), and physical activity in older women (p = 0.025). Relative inequality increased in high blood pressure in young women (p = 0.005). The prevalence of raised cholesterol showed widening absolute and relative inverse gradients from 1998 onwards in older men (p = 0.004 and p ≤ 0.001 respectively) and women (p ≤ 0.001 and p ≤ 0.001).ConclusionsFavourable trends in smoking, blood pressure and cholesterol are consistent with falling coronary heart disease death rates. However, adverse trends in obesity and diabetes are likely to counteract some of these gains. Furthermore, little progress over the last 15 years has been made towards reducing inequalities. Implementation of known effective population based approaches in combination with interventions targeted at individuals/subgroups with poorer cardiovascular risk profiles are therefore recommended to reduce social inequalities.

Ethnic differences in influences on quality of life at older ages: a quantitative analysis

This article sets out to examine ethnic differences in the key influences on quality of life for older people in the context of the increasing health and wealth of British older people generally and the ageing of the post-1945 migrants. It is based on secondary multivariate analysis of the Fourth National Survey of Ethnic Minorities of England and Wales. Respondents aged 45–74 years belonging to four ethnic groups (1,068 white, 514 Caribbean, 581 Indian and East African Asian, and 199 Pakistani) were included in the analysis, which focuses on differences between ethnic groups by age and gender, using the white population as the reference group. Four dimensions (incorporating seven factors) that influence the quality of life were determined among this age group: quality of neighbourhood (availability of local amenities, and problems with crime and the physical environment); social networks and community participation (strength of family networks, and community participation); material conditions (income, wealth and housing conditions) and health. The relative position of the four ethnic groups on the seven factors illustrated two contrasting patterns. For the factors based on conventional indicators of social inequalities – such as material circumstances, health, participation in formal social networks, and quality of the physical environment – the white group ranked highest, the Pakistanis lowest, and the Indian and Caribbean groups ranked second and third. But factors that capture more immediate and subjective elements, such as frequency of family contact and the desirability of the residential neighbourhood, displayed a diametrically opposite rank-order, with the Pakistani group ranked first and the white group fourth. The study highlights the value of examining separately the various influences on quality of life. Contradictory patterns are revealed in key influences that are hidden by global measures. The study also reveals the difficulty of identifying culturally-neutral measures of quality of locality, with ethnic minority groups having a more positive perception of their area than rated by conventional measures of area deprivation such as the Index of Deprivation.

Measuring disadvantage: changes in the underprivileged area, Townsend, and Carstairs scores 1981-91.

OBJECTIVE--To compare the intercensal change for each of the underprivileged area (UPA), Townsend, and Carstairs scores calculated from 1981 and 1991 census data. SETTING--England and Wales. METHODS--The method described enables comparison of change in composite scores such as the UPA, Townsend, and Carstairs scores which are derived from normalised variables. The national values of equivalent variables derived from the censuses are calculated and normalised on the same baseline of the 1981 electoral ward mean and SD values. The resultant change in composite scores for different censuses can then be compared directly. MAIN OUTCOME MEASURE--Change in the composite score values for the 1991 census when compared with the 1981 census. RESULTS--For England and Wales, the UPA score increased by 5.62 units (0.35 of the SD) but the Townsend and Carstairs scores fell by 2.39 and 1.13 units respectively (0.71 and 0.33 of the SDs). CONCLUSION--The Townsend and Carstairs scores are good measures of material deprivation and show a general improvement as such between 1981 and 1991. The UPA score, however, includes additional factors relating to family structure, social deprivation, and health need and shows a decline in the overall situation.

Unequal Trends in Coronary Heart Disease Mortality by Socioeconomic Circumstances, England 1982-2006: An Analytical Study

Background Coronary heart disease (CHD) remains a major public health burden, causing 80,000 deaths annually in England and Wales, with major inequalities. However, there are no recent analyses of age-specific socioeconomic trends in mortality. We analysed annual trends in inequalities in age-specific CHD mortality rates in small areas in England, grouped into deprivation quintiles. Methods We calculated CHD mortality rates for 10-year age groups (from 35 to ≥85 years) using three year moving averages between 1982 and 2006. We used Joinpoint regression to identify significant turning points in age- sex- and deprivation-specific time trends. We also analysed trends in absolute and relative inequalities in age-standardised rates between the least and most deprived areas. Results Between 1982 and 2006, CHD mortality fell by 62.2% in men and 59.7% in women. Falls were largest for the most deprived areas with the highest initial level of CHD mortality. However, a social gradient in the pace of fall was apparent, being steepest in the least deprived quintile. Thus, while absolute inequalities narrowed over the period, relative inequalities increased. From 2000, declines in mortality rates slowed or levelled off in the youngest groups, notably in women aged 45–54 in the least deprived groups. In contrast, from age 55 years and older, rates of fall in CHD mortality accelerated in the 2000s, likewise falling fastest in the least deprived quintile. Conclusions Age-standardised CHD mortality rates have declined substantially in England, with the steepest falls in the most affluent quintiles. However, this concealed contrasting patterns in underlying age-specific rates. From 2000, mortality rates levelled off in the youngest groups but accelerated in middle aged and older groups. Mortality analyses by small areas could provide potentially valuable insights into possible drivers of inequalities, and thus inform future strategies to reduce CHD mortality across all social groups.

Influences on quality of life: A qualitative investigation of ethnic differences among older people in England

The starting point of this research was the concern that the circumstances, let alone quality of life, of those who migrated to England during the postwar period and who are now progressing into early old age and retirement, have only recently become an issue for research and policy. The study treats quality of life as a phenomenon (comprising the domains control, autonomy, pleasure, and self‐realisation) distinct from its potential influences. Qualitative interviews with respondents from four ethnically homogeneous groups (Jamaican Caribbean, Gujarati Indian Hindu, Punjabi Pakistani, and white English) identified six factors that influenced their quality of life: having a role, support networks, income and wealth, health, having time, and independence. Findings suggest that while both the influences on quality of life and the domains of quality of life were consistent across the ethnic groups, it was the ways in which they played out in peoples lives that revealed ethnic variations.

Recent UK trends in the unequal burden of coronary heart disease

Introduction The burden of coronary heart disease (CHD) in the UK is substantial. However, recent trends and associated socioeconomic inequalities are not well studied. We aim to identify and analyse these trends stratified by age, gender and socioeconomic quintiles. Methods We quantified the CHD burden and analysed trends from 1999 to 2007 in all adults aged over 25u2005years resident in England. Data sources included deaths (from ONS), health surveys, and hospital admissions (from Hospital Episode Statistics), all using ICD9 and ICD10 coding. Socioeconomic inequalities were calculated in both absolute and relative terms. Results In 2007, the CHD burden comprised approximately 205u2008000 hospital admissions (acute and elective), including approximately 110u2008000 admissions with acute coronary syndrome. There were approximately 1.5 million CHD patients with chronic disease living in the community. Approximately 67u2008500 of these were admitted during 2007 for revascularisation. There were approximately 173u2008000 CHD patients living with heart failure, of whom some 14% required hospital admission during 2007. Between 1999 and 2007, age-specific hospital admission rates generally decreased by 20%–35%. Community prevalence decreased by 10%–20%. Strong socioeconomic gradients were apparent in all patient groups, persisting or worsening between 1999 and 2007. Conclusions The burden of CHD is immense, costly and unequal. Hospital admissions attract more attention than the far more numerous patients living with chronic disease in the community. Population-based rates for hospital admissions and CHD prevalence have been declining by 3%–4% per annum. However, marked socioeconomic gradients have persisted or worsened—there is no room for complacency.

The Swedish UPA score An administrative tool for identification of underprivileged areas

The purpose was to construct a Swedish social deprivation index analogous to the underprivileged area (UPA) score, used in the UK to distribute resources to general practice for patients resident in the most underprivileged areas. UPA scores were calculated using 1990 Swedish census data and the 1992 unemployment and migration registers for all 8,502 SAMS (small area market statistics) areas with more than 50 inhabitants. Selection of the eight variables included in the score and weights attached to each were derived from a national survey of general practitioners in the UK representing the degree to which they considered that each factor increased their workload or pressure on services. The UPA score for each area is the sum of the eight normalised (arc sin), standardised (z scores) and weighted variables for that area. The distribution of UPA scores ranged from — 79.13, in the most affluent areas to 46.10 in the most underprivileged areas. It was found that a wide range of social deprivation exists at small area level.

Indices of need and social deprivation for primary health care

This study aimed to examine two indices of need, the underprivileged area (UPA) score and a Swedish Care Need Index (CNI, in Swedish vårdbehovsindex) with weightings from British and Swedish GPs respectively, and an index of material deprivation, Townsend score at SAMS (Small Area Market Statistics) level and at municipality level for the whole of Sweden. One third of primary health care physicians from the whole of Sweden received a questionnaire about their workload. CNI, UPA and Townsend scores were calculated using information from the Swedish census of 1990 and the registers of unemployment and migration for 1992. The Swedish GPs weighted some of the variables quite differently from the GPs in the UK. This may be important, especially at the SAMS level. The GPs in both countries considered that older people living alone contributed most to their workload. However, in Sweden the physicians ranked foreign-born people high compared with the English doctors, and in England the GPs ranked children under five years much higher than the doctors in Sweden. The correlation between the scores was high. Abbreviations: GP=General Practitioner, SAMS=Small Area Market Statistics, UPA=Underprivileged Area, CNI=Care Need Index.

Explaining trends in Scottish coronary heart disease mortality between 2000 and 2010 using IMPACTSEC model: retrospective analysis using routine data

Objective To quantify the contributions of prevention and treatment to the trends in mortality due to coronary heart disease in Scotland. Design Retrospective analysis using IMPACTSEC, a previously validated policy model, to apportion the recent decline in coronary heart disease mortality to changes in major cardiovascular risk factors and to increases in more than 40 treatments in nine non-overlapping groups of patients. Setting Scotland. Participants All adults aged 25 years or over, stratified by sex, age group, and fifths of Scottish Index of Multiple Deprivation. Main outcome measure Deaths prevented or postponed. Results 5770 fewer deaths from coronary heart disease occurred in 2010 than would be expected if the 2000 mortality rates had persisted (8042 rather than 13u2009813). This reflected a 43% fall in coronary heart disease mortality rates (from 262 to 148 deaths per 100u2009000). Improved treatments accounted for approximately 43% (95% confidence interval 33% to 61%) of the fall in mortality, and this benefit was evenly distributed across deprivation fifths. Notable treatment contributions came from primary prevention for hypercholesterolaemia (13%), secondary prevention drugs (11%), and chronic angina treatments (7%). Risk factor improvements accounted for approximately 39% (28% to 49%) of the fall in mortality (44% in the most deprived fifth compared with only 36% in the most affluent fifth). Reductions in systolic blood pressure contributed more than one third (37%) of the decline in mortality, with no socioeconomic patterning. Smaller contributions came from falls in total cholesterol (9%), smoking (4%), and inactivity (2%). However, increases in obesity and diabetes offset some of these benefits, potentially increasing mortality by 4% and 8% respectively. Diabetes showed strong socioeconomic patterning (12% increase in the most deprived fifth compared with 5% for the most affluent fifth). Conclusions Increases in medical treatments accounted for almost half of the large recent decline in mortality due to coronary heart disease in Scotland. Furthermore, the Scottish National Health Service seems to have delivered these benefits equitably. However, the substantial contributions from population falls in blood pressure and other risk factors were diminished by adverse trends in obesity and diabetes. Additional population-wide interventions are urgently needed to reduce coronary heart disease mortality and inequalities in future decades.