Steven Michael Macey

Measuring the Population Burden of Injuries—Implications for Global and National Estimates: A Multi-centre Prospective UK Longitudinal Study

Ronan Lyons and colleagues compared the population burden of injuries using different approaches from the UK Burden of Injury and Global Burden of Disease studies and find that the absolute UK burden of injury is higher than previously estimated.

The costs of traumatic brain injury: a literature review

Objective The purpose of this study was to review the literature relating to the psychosocial costs associated with traumatic brain injury (TBI). Methods Nine online journal databases, including MEDLINE, CINAHL, PsychINFO, and PUBMED, were queried for studies between July 2010 and May 2012 pertaining to the economic burden of head injuries. Additional studies were identified through searching bibliographies of related publications and using Google internet search engine. Results One hundred and eight potentially relevant abstracts were identified from the journal databases. Ten papers were chosen for discussion in this review. All but two of the chosen papers were US studies. The studies included a cost-benefit analysis of the implementation of treatment guidelines from the US brain trauma foundation and a cost-effectiveness analysis of post-acute traumatic brain injury rehabilitation. Conclusion Very little research has been published on the economic burden that mild and moderate traumatic brain injury patients pose to their families, careers, and society as a whole. Further research is needed to estimate the economic burden of these patients on healthcare providers and social services and how this can impact current health policies and practices.

No Increased Rate of Acute Myocardial Infarction or Stroke Among Patients with Ankylosing Spondylitis—A Retrospective Cohort Study Using Routine Data

OBJECTIVES To examine if people with ankylosing spondylitis (AS) are at higher risk of acute myocardial infarction (MI) or stroke compared to those without AS. METHODS Primary care records were linked with all hospital admissions and deaths caused by MI or stroke in Wales for the years 1999-2010. The linked data were then stratified by AS diagnosis and survival analysis was used to obtain the incidence rate of MI and separately cerebrovascular disease (CVD)/stroke. Cox regression was used to adjust for gender and age. Logistic regression was used to examine prevalence of diabetes, hypertension, or hyperlipidemia for those with AS compared to those without. RESULTS There were 1686 AS patients (75.9% male, average age 46.1 years) compared to 1,206,621 controls (48.9% male, average age 35.9 years). Age- and gender-adjusted hazard ratios for MI were 1.28 (95% CI: 0.93 to 1.74) P = 0.12, and for CVD/stroke 1.0 (95% CI: 0.73 to 1.39) P = 0.9, in AS compared to controls. The prevalence of diabetes and hypertension, but not hyperlipidemia/hypercholesterolemia, was higher in AS. CONCLUSIONS There is no increase in the MI or CVD/stroke rates in patients with AS compared to those without AS, despite higher rates of hypertension, which may be related to nonsteroidal anti-inflammatory drug use.

The Injury List Of All deficits (LOAD) Framework - conceptualising the full range of deficits and adverse outcomes following injury and violence

Over recent years, there has been increasing recognition that the burden of injuries and violence includes more than just the direct and indirect monetary costs associated with their medical outcomes. However, quantification of the total burden has been seriously hampered by lack of a framework for considering the range of outcomes which comprise the burden, poor identification of the outcomes and their imprecise measurement. This article proposes a new conceptual framework, the List of All Deficits (or LOAD) Framework, that has been developed from extensive expert discussion and consensus meetings to facilitate the measurement of the full burden of injuries and violence. The LOAD Framework recognises the multidimensional nature of injury burden across individual, family and societal domains. This classification of potential consequences of injury was built on the International Classification of Functioning concept of disability. Examples of empirical support for each consequence were obtained from the scientific literature. Determining the multidimensional injury burden requires the assessment and combination of 20 domains of potential consequences. The resulting LOAD Framework classification and concept diagram describes 12 groups of injury consequences for individuals, three for family and close friends and five for wider society. Understanding the extent of the negative implications (or deficits) of injury, through application of the LOAD Framework, is needed to put existing burden of injury studies into context and to highlight the inter-relationship between the direct and indirect burden of injury relative to other conditions.

Using multiple datasets to understand trends in serious road traffic casualties

Accurate information on the incidence of serious road traffic casualties is needed to plan and evaluate prevention strategies. Traditionally police reported collisions are the only data used. This study investigate the extent to which understanding of trends in serious road traffic injuries is aided by the use of multiple datasets. Health and police datasets covering all or part of Great Britain from 1996-2003 were analysed. There was a significantly decreasing trend in police reported serious casualties but not in the other datasets. Multiple data sources provide a more complete picture of road traffic casualty trends than any single dataset. Increasing availability of electronic health data with developments in anonymised data linkage should provide a better platform for monitoring trends in serious road traffic casualties.

Estimating the costs associated with the management of patients with chronic wounds using linked routine data

Chronic wounds are known to represent a significant burden to patients and National Health Service (NHS) alike. However, previous attempts to estimate the costs associated with the management of chronic wounds have been based on literature studies or broad estimates derived from incidence rates and extrapolations from relatively small‐scale studies. The aim of this study is therefore to determine the extent of resource utilisation by patients classed as having chronic wounds within Wales using linked routine data – available through the Secure Anonymised Information Linkage (SAIL) database – to estimate the costs associated with the management of these patients by the NHS in Wales. The SAIL database brings together, and anonymously links, a wide range of person‐based data from general practitioner (GP) practices within Wales, which includes primary and secondary care consultations to create an encrypted anonymised linking field for each individual. This linkage allows the patient pathway to be tracked through the NHS system both retrospectively and prospectively from a specific reference date. The estimated costs were derived by extrapolating to an all‐Wales level from the results gleaned from the SAIL database using the respective READ codes to capture relevant patients with chronic wounds. The number of patients identified as having chronic wounds within the SAIL database was 78 090, which equates to 190 463 across Wales as a whole and a prevalence of 6% of the Welsh population. The total cost of managing patients with chronic wounds in Wales amounted to £328·8 million – an average cost of £1727 per patient and 5·5% of total expenditure on the health service in Wales. A relatively few READ codes represented a significant proportion of expenditure, with diabetic foot ulcers, leg ulcers, foot ulcers, varicose eczema, bed sores and postoperative wound care constituting 93% of total expenditure. When a more conservative perspective was used in relation to classification of chronic wounds, the total cost amounted to £303 million. However, these are likely to be underestimates because of the lack of information for patients with treatments lasting over 6 months and not including patients who might have entered the health care system of wound management elsewhere – such as patients contracting pressure ulcers in hospitals and having surgical wound infections.

Obesity in pregnancy: a retrospective prevalence-based study on health service utilisation and costs on the NHS.

Objective To estimate the direct healthcare cost of being overweight or obese throughout pregnancy to the National Health Service in Wales. Design Retrospective prevalence-based study. Setting Combined linked anonymised electronic datasets gathered on a cohort of women enrolled on the Growing Up in Wales: Environments for Healthy Living (EHL) study. Women were categorised into two groups: normal body mass index (BMI; n=260) and overweight/obese (BMI>25; n=224). Participants 484 singleton pregnancies with available health service records and an antenatal BMI. Primary outcome measure Total health service utilisation (comprising all general practitioner visits and prescribed medications, inpatient admissions and outpatient visits) and direct healthcare costs for providing these services in the year 2011–2012. Costs are calculated as cost of mother (no infant costs are included) and are related to health service usage throughout pregnancy and 2 months following delivery. Results There was a strong association between healthcare usage cost and BMI (p<0.001). Adjusting for maternal age, parity, ethnicity and comorbidity, mean total costs were 23% higher among overweight women (rate ratios (RR) 1.23, 95% CI 1.230 to 1.233) and 37% higher among obese women (RR 1.39, 95% CI 1.38 to 1.39) compared with women with normal weight. Adjusting for smoking, consumption of alcohol, or the presence of any comorbidities did not materially affect the results. The total mean cost estimates were £3546.3 for normal weight, £4244.4 for overweight and £4717.64 for obese women. Conclusions Increased health service usage and healthcare costs during pregnancy are associated with increasing maternal BMI; this was apparent across all health services considered within this study. Interventions costing less than £1171.34 per person could be cost-effective if they reduce healthcare usage among obese pregnant women to levels equivalent to that of normal weight women.

Population based absolute and relative survival to 1 year of people with diabetes following a myocardial infarction: a cohort study using hospital admissions data.

BackgroundPeople with diabetes who experience an acute myocardial infarction (AMI) have a higher risk of death and recurrence of AMI. This study was commissioned by the Department for Transport to develop survival tables for people with diabetes following an AMI in order to inform vehicle licensing.MethodsA cohort study using data obtained from national hospital admission datasets for England and Wales was carried out selecting all patients attending hospital with an MI for 2003-2006 (inclusion criteria: aged 30+ years, hospital admission for MI (defined using ICD 10 code I21-I22). STATA was used to create survival tables and factors associated with survival were examined using Cox regression.ResultsOf 157,142 people with an MI in England and Wales between 2003-2006, the relative risk of death or recurrence of MI for those with diabetes (n = 30,407) in the first 90 days was 1.3 (95%CI: 1.26-1.33) crude rates and 1.16 (95%CI: 1.1-1.2) when controlling for age, gender, heart failure and surgery for MI) compared with those without diabetes (n = 129,960). At 91-365 days post AMI the risk was 1.7 (95% CI 1.6-1.8) crude and 1.50 (95%CI: 1.4-1.6) adjusted. The relative risk of death or re-infarction was higher at younger ages for those with diabetes and directly after the AMI (Relative risk; RR: 62.1 for those with diabetes and 28.2 for those without diabetes aged 40-49 [compared with population risk]).ConclusionsThis is the first study to provide population based tables of age stratified risk of re-infarction or death for people with diabetes compared with those without diabetes. These tables can be used for giving advice to patients, developing a baseline to compare intervention studies or developing license or health insurance guidelines.

The Advocacy in Action Study a cluster randomized controlled trial to reduce pedestrian injuries in deprived communities

Background Road trafficrelated injury is a major global public health problem. In most countries, pedestrian injuries occur predominantly to the poorest in society. A number of evaluated interventions are effective in reducing these injuries. Very little research has been carried out into the distribution and determinants of the uptake of these interventions. Previous research has shown an association between local political influence and the distribution of traffic calming after adjustment for historical crash patterns. This led to the hypothesis that advocacy could be used to increase local politicians knowledge of pedestrian injury risk and effective interventions, ultimately resulting in improved pedestrian safety. Objective To design an intervention to improve the uptake of pedestrian safety measures in deprived communities. Setting Electoral wards in deprived areas of England and Wales with a poor record of pedestrian safety for children and older adults. Methods Design mixedmethods study, incorporating a cluster randomized controlled trial. Data mixture of Geographical Information Systems data collision locations, road safety interventions, telephone interviews, and questionnaires. Randomization 239 electoral wards clustered within 57 local authorities. Participants 615 politicians representing intervention and control wards. Intervention a package of tailored information including maps of pedestrian injuries was designed for intervention politicians, and a general information pack for controls. Outcome measures Primary outcome number of road safety interventions 25months after randomization. Secondary outcomes politicians interest and involvement in injury prevention cost of interventions. Process evaluation use of advocacy pack, facilitators and barriers to involvement, and success.

The association between hospitalisation for childhood head injury and academic performance: evidence from a population e-cohort study

Background Childhood head injury has the potential for lifelong disability and burden. This study aimed to establish the association between admission to hospital for childhood head injury and early academic performance. Methods The Wales Electronic Cohort for Children (WECC) study is comprised of record-linked routinely collected data, on all children born or residing in Wales. Anonymous linking fields are used to link child and maternal health, environment and education records. Data from WECC were extracted for children born between September 1998 and August 2001. A Generalised Estimating Equation model, adjusted for clustering based on the maternal identifier as well as other key confounders, was used to establish the association between childhood head injury and performance on the Key Stage 1 (KS1) National Curriculum assessment administered to children aged 5–7 years. Head injury was defined as an emergency admission for >24 h for concussion, skull fracture or intracranial injury prior to KS1 assessment. Results Of the 101 892 eligible children, KS1 results were available for 90 661 (89%), and 290 had sustained a head injury. Children who sustained an intracranial injury demonstrated significantly lower adjusted odds of achieving a satisfactory KS1 result than children who had not been admitted to hospital for head injury (adjusted OR 0.46, 95% CI 0.30 to 0.72). Conclusions The findings of this population e-cohort study quantify the impact of head injury on academic performance, highlighting the need for enhanced head injury prevention strategies. The results have implications for the care and rehabilitation of children admitted to hospital with head injury.