Signs of Maturity

Lifestyle changes and improvements in healthcare mean that deaths owing to heart disease continue to fall. Yet relative inequalities have widened. Dr Madhavi Bajekal investigates what growing old means for different social group

Analysing recent socioeconomic trends in coronary heart disease mortality in England, 2000–2007: a population modelling study

Background Coronary heart disease (CHD) mortality in England fell by approximately 6% every year between 2000 and 2007. However, rates fell differentially between social groups with inequalities actually widening. We sought to describe the extent to which this reduction in CHD mortality was attributable to changes in either levels of risk factors or treatment uptake, both across and within socioeconomic groups. Methods and Findings A widely used and replicated epidemiological model was used to synthesise estimates stratified by age, gender, and area deprivation quintiles for the English population aged 25 and older between 2000 and 2007. Mortality rates fell, with approximately 38,000 fewer CHD deaths in 2007. The model explained about 86% (95% uncertainty interval: 65%–107%) of this mortality fall. Decreases in major cardiovascular risk factors contributed approximately 34% (21%–47%) to the overall decline in CHD mortality: ranging from about 44% (31%–61%) in the most deprived to 29% (16%–42%) in the most affluent quintile. The biggest contribution came from a substantial fall in systolic blood pressure in the population not on hypertension medication (29%; 18%–40%); more so in deprived (37%) than in affluent (25%) areas. Other risk factor contributions were relatively modest across all social groups: total cholesterol (6%), smoking (3%), and physical activity (2%). Furthermore, these benefits were partly negated by mortality increases attributable to rises in body mass index and diabetes (−9%; −17% to −3%), particularly in more deprived quintiles. Treatments accounted for approximately 52% (40%–70%) of the mortality decline, equitably distributed across all social groups. Lipid reduction (14%), chronic angina treatment (13%), and secondary prevention (11%) made the largest medical contributions. Conclusions The model suggests that approximately half the recent CHD mortality fall in England was attributable to improved treatment uptake. This benefit occurred evenly across all social groups. However, opposing trends in major risk factors meant that their net contribution amounted to just over a third of the CHD deaths averted; these also varied substantially by socioeconomic group. Powerful and equitable evidence-based population-wide policy interventions exist; these should now be urgently implemented to effectively tackle persistent inequalities

Review of Disability Estimates and Definitions: A study carried out on behalf of the Department for Work and Pensions

This report presents findings of a review of survey estimates of the prevalence of disability in Britain and the definitions of disability used in government social surveys. The study examines the relative merits and methodological robustness of a variety of estimates of the prevalence of disability produced by surveys. The review involved: A technical review of the existing surveys and estimates; A consultation exercise involving key stakeholders and users of disability estimates to explore their views on measurement and definitional issues of disability; An exploration of what might be done to ensure consistency over time of estimates and definitions of disability in Great Britain

Agricultural production in six selected qasbas of eastern Rajasthan (c.1700-1780).

This study is an attempt to examine agrarian production in eighteenth century eastern Rajasthan at two levels. First, we attempt to establish the chronology of the trends in major indices of agricultural production using the annual revenue records of six representative qasbas or townships. The wealth of varied data available in the revenue and related records of the eighteenth century Jaipur state made it possible to estimate trends in the size of the agricultural product, the variations in cropping patterns and the secular movements of foodgrain prices. Second, a primary concern of the thesis has been to locate the secular trends in production within the context of the interaction between the state and the agrarian production system. A discussion of the environmental context of agriculture in the region leads to an analysis of the logic of the system of taxation that these realities predicated. The complexities of the functioning of the socio-economic system have been analysed by an examination of the mechanism of redistribution of the surplus, the marketing of foodgrains and the provision of rural credit that underpinned the agrarian production system. We argue that the policies of the state in these spheres were interlocked elements of a coherent agrarian policy that sought to actively promote private investment and raise productivity in agriculture. The effective implementation of the policy however was crucially dependent upon the ability of the state to maintain effective control over each element. The analysis of the changing interaction between the state and rural society in a phase of agrarian expansion and a period of recession provides a perspective on the nature of the linkage between political stability and agrarian production and the impetus towards institutional changes in the mechanism of revenue collection during the eighteenth century

Spatial mapping of hepatitis C prevalence in recent injecting drug users in contact with services.

In developed countries the majority of hepatitis C virus (HCV) infections occur in injecting drug users (IDUs) with prevalence in IDUs often high, but with wide geographical differences within countries. Estimates of local prevalence are needed for planning services for IDUs, but it is not practical to conduct HCV seroprevalence surveys in all areas. In this study survey data from IDUs attending specialist services were collected in 52/149 sites in England between 2006 and 2008. Spatially correlated random-effects models were used to estimate HCV prevalence for all sites, using auxiliary data to aid prediction. Estimates ranged from 14% to 82%, with larger cities, London and the North West having the highest HCV prevalence. The methods used generated robust estimates for each area, with a well-identified spatial pattern that improved predictions. Such models may be of use in other areas of study where surveillance data are sparse

Trajectories of Disease Accumulation Using Electronic Health Records

Multimorbidity is a major problem for patients and health services. However, we still do not know much about the common trajectories of disease accumulation that patients follow. We apply a data-driven method to an electronic health record dataset (CPRD) to analyse and condense the main trajectories to multimorbidity into simple networks. This analysis has never been done specifically for multimorbidity trajectories and using primary care based electronic health records. We start the analysis by evaluating temporal correlations between diseases to determine which pairs of disease appear significantly in sequence. Then, we use patient trajectories together with the temporal correlations to build networks of disease accumulation. These networks are able to represent the main pathways that patients follow to acquire multiple chronic conditions. The first network that we find contains the common diseases that multimorbid patients suffer from and shows how diseases like diabetes, COPD, cancer and osteoporosis are crucial in the disease trajectories. The results we present can help better characterize multimorbid patients and highlight common combinations helping to focus treatment to prevent or delay multimorbidity progression

Analysing Recent Socioeconomic Trends in Coronary Heart Disease Mortality in England, 2000–2007: A Population Modelling Study

A modeling study conducted by Madhavi Bajekal and colleagues estimates the extent to which specific risk factors and changes in uptake of treatment contributed to the declines in coronary heart disease mortality in England between 2000 and 2007, across and within socioeconomic groups

Az Év Hala, 2017: a harcsa

<p>Notes:</p><p>APC = annual percentage change (for each period segment).</p><p>AAPC = annual average percentage change (weighted average of annual percentage changes over all period segments).</p><p>‘*’ Indicates statistically significant change compared to no change (in AAPC) or relative to the previous segment (in APC).</p

The slowdown in mortality improvement rates 2011–2017: a multi-country analysis

Mortality rates have been falling or ‘improving’ in many demographically developed countries since the 1950s. However, there has been a slowdown since 2010 in the speed of improvement and this phenomenon has been particularly marked at ages over 50. To understand better this mortality slowdown, we have analysed long-run mortality trends of a group of developed countries using data up to 2017 from the Human Mortality Database. Specifically, we have used statistical models to parametrise the historical mortality trends of 21 countries between 1965 and 2010 and then forecast trends beyond 2011. We find that many countries have experienced lower mortality improvement rates in 2011–2017 than in the previous decade and also experienced lower improvement rates in 2011–2017 than would have been forecast based on the models fitted to data prior to 2011. Some of the Scandinavian populations have bucked the stalling mortality improvement trend, experiencing higher mortality improvement rates than the forecasts. We conclude that part of the slowdown in mortality improvement rates of the over 1950s since 2011 would have been expected from historical trends in many countries, especially among men. However, there has been a notable slowdown since 2011, compared with the model forecasts, in many countries especially among women. A few countries had higher mortality improvement rates than forecast. A better understanding of the drivers behind these complex trends would help decision makers in insurance companies and pension funds and also inform public policy