Demographic and socioeconomic inequalities in the risk of emergency hospital admission for violence: cross-sectional analysis of a national database in Wales

Objectives To investigate the risk of emergency hospital admissions for violence (EHAV) associated with demographic and socioeconomic factors in Wales between 2007/2008 and 2013/2014, and to describe the site of injury causing admission. Design Database analysis of 7 years’ hospital admissions using the Patient Episode Database for Wales (PEDW). Setting and participants Wales, UK, successive annual populations ∼2.8 million aged 0–74 years. Primary outcome The first emergency admission for violence in each year of the study, defined by the International Classification of Diseases V.10 (ICD-10) codes for assaults (X85-X99, Y00-Y09) in any coding position. Results A total of 11 033 admissions for assault. The majority of admissions resulted from head injuries. The overall crude admission rate declined over the study period, from 69.9 per 100 000 to 43.2 per 100 000, with the largest decrease in the most deprived quintile of deprivation. A generalised linear count model with a negative binomial log link, adjusted for year, age group, gender, deprivation quintile and settlement type, showed the relative risk was highest in age group 18–19 years (RR=6.75, 95% CI 5.88 to 7.75) compared with the reference category aged 10–14 years. The risk decreased with age after 25 years. Risk of admission was substantially higher in males (RR=4.55, 95% CI 4.31 to 4.81), for residents of the most deprived areas of Wales (RR=3.60, 95% CI 3.32 to 3.90) compared with the least deprived, and higher in cities (RR=1.37, 95% CI 1.27 to 1.49) and towns (RR=1.32, 95% CI 1.21 to 1.45) compared with villages. Conclusions Despite identifying a narrowing in the gap between prevalence of violence in richer and poorer communities, violence remains strongly associated with young men living in areas of socioeconomic deprivation. There is potential for a greater reduction, given that violence is mostly preventable. Recommendations for reducing inequalities in the risk of admission for violence are discussed

Socioeconomic patterning of excess alcohol consumption and binge drinking: a cross-sectional study of multilevel associations with neighbourhood deprivation

Objectives: The influence of neighbourhood deprivation on the risk of harmful alcohol consumption, measured by the separate categories of excess consumption and binge drinking, has not been studied. The study objective was to investigate the effect of neighbourhood deprivation with age, gender and socioeconomic status (SES) on (1) excess alcohol consumption and (2) binge drinking, in a representative population survey. Design: Cross-sectional study: multilevel analysis. Setting: Wales, UK, adult population ∼2.2 million. Participants: 58 282 respondents aged 18 years and over to four successive annual Welsh Health Surveys (2003/2004–2007), nested within 32 692 households, 1839 census lower super output areas and the 22 unitary authority areas in Wales. Primary outcome measure: Maximal daily alcohol consumption during the past week was categorised using the UK Department of Health definition of 'none/never drinks', 'within guidelines', 'excess consumption but less than binge' and 'binge'. The data were analysed using continuation ratio ordinal multilevel models with multiple imputation for missing covariates. Results: Respondents in the most deprived neighbourhoods were more likely to binge drink than in the least deprived (adjusted estimates: 17.5% vs 10.6%; difference=6.9%, 95% CI 6.0 to 7.8), but were less likely to report excess consumption (17.6% vs 21.3%; difference=3.7%, 95% CI 2.6 to 4.8). The effect of deprivation varied significantly with age and gender, but not with SES. Younger men in deprived neighbourhoods were most likely to binge drink. Men aged 35–64 showed the steepest increase in binge drinking in deprived neighbourhoods, but men aged 18–24 showed a smaller increase with deprivation. Conclusions: This large-scale population study is the first to show that neighbourhood deprivation acts differentially on the risk of binge drinking between men and women at different age groups. Understanding the socioeconomic patterns of harmful alcohol consumption is important for public health policy development

Impact of service redesign on the socioeconomic inequity in revascularisation rates for patients with acute myocardial infarction: a natural experiment and electronic record-linked cohort study

Aim To investigate the impact of service redesign in the provision of revascularisation procedures on the historical socioeconomic inequity in revascularisation rates for patients with acute myocardial infarction (AMI). Design Natural experiment and retrospective cohort study using linked data sets in the Secure Anonymised Information Linkage databank. Non-randomised intervention An increase in the capacity of revascularisation procedures and service redesign in the provision of revascularisation in late 2011 to early 2012. Setting South Wales cardiac network, Census 2011 population 1 359 051 aged 35 years and over. Participants 9128 participants admitted to an NHS hospital with a first AMI between 1 January 2010 and 30 June 2013, with 6-months follow-up. Main outcome measure Hazard ratios (HRs) for the time to revascularisation for deprivation quintiles, age, gender, comorbidities, rural–urban classification and revascularisation facilities of admitting hospital. Results In the preintervention period, there was a statistically significant decreased adjusted risk of revascularisation for participants in the most deprived quintile compared to the least deprived quintile (HR 0.80; 95% CI 0.69 to 0.92, p=0.002). In the postintervention period, the increase in revascularisation rates was statistically significant in all quintiles, and there was no longer any statistically significant difference in the adjusted revascularisation risk between the most and the least deprived quintile (HR 1.04; 95% CI 0.89 to 1.20, p<0.649). However, inequity persisted for those aged 75 years and over (HR 0.40; 95% CI 0.35 to 0.46, p<0.001) and women (HR 0.77; 95% CI 0.70 to 0.86, p<0.001). Conclusions Socioeconomic inequity of access to revascularisation was no longer apparent following redesign of revascularisation services in the south Wales cardiac network, although inequity persisted for women and those aged 75+ years. Increasing the capacity of revascularisation did not differentially benefit participants from the least deprived areas

Common mental disorders, neighbourhood income inequality and income deprivation: small-area multilevel analysis

Background. Common mental disorders are more prevalent in areas of high neighbourhood socioeconomic deprivation but whether the prevalence varies with neighbourhood income inequality is not known. Aims. To investigate the hypothesis that the interaction between small-area income deprivation and income inequality was associated with individual mental health. Method. Multilevel analysis of population data from the Welsh Health Survey, 2003/04–2010. A total of 88 623 respondents aged 18–74 years were nested within 50 587 households within 1887 lower super output areas (neighbourhoods) and 22 unitary authorities (regions), linked to the Gini coefficient (income inequality) and the per cent of households living in poverty (income deprivation). Mental health was measured using the Mental Health Inventory MHI-5 as a discrete variable and as a ‘case’ of common mental disorder. Results. High neighbourhood income inequality was associated with better mental health in low-deprivation neighbourhoods after adjusting for individual and household risk factors (parameter estimate +0.70 (s.e. = 0.33), P = 0.036; odds ratio (OR) for common mental disorder case 0.92, 95% CI 0.88–0.97). Income inequality at regional level was significantly associated with poorer mental health (parameter estimate -1.35 (s.e. = 0.54), P = 0.012; OR = 1.13, 95% CI 1.04–1.22). Conclusions. The associations between common mental disorders, income inequality and income deprivation are complex. Income inequality at neighbourhood level is less important than income deprivation as a risk factor for common mental disorders. The adverse effect of income inequality starts to operate at the larger regional level

Improving mental health through the regeneration of deprived neighbourhoods: a prospective controlled quasi-experimental study

AbstractBACKGROUND Policy makers often target deprived neighbourhoods for regeneration with the expectation that population health will improve, since housing and neighbourhoods of low quality, as well as the social and economic determinants of poor health, are concentrated in the most deprived areas. Our aim was to examine the eff ects of Communities First, a Welsh Assembly Government community-led programme of neighbourhood regeneration targeted at the 100 most deprived electoral wards in Wales on mental health. METHODS Information on Communities First regeneration activities in 35 intervention lower super output areas (LSOAs) (n=4197) and 75 control LSOAs (6695) were linked to data from the eCATALyST study, a prospective cohort study, in 2001 (before regeneration) and 2008 (after regeneration) within the Secure Anonymised Information Linkage (SAIL) databank. Communities First was delivered through multiagency partnership boards in all 22 local authorities. Boards worked with residents to identify and secure funding for regeneration activities. The primary outcome was the change in Mental Health Inventory (MHI) score (a population-based measure of anxiety and depressive symptoms) between 2001 and 2008 recorded in eCATALyST. We examined the changes in mental health in intervention LSOAs compared with control LSOAs using propensity score matching (1:1 ratio) to balance the level of socioeconomic disadvantage across groups. Sensitivity analysis examined the impact of length of residence in an intervention area and six types of regeneration activity. FINDINGS 1500 regeneration projects were funded from 2001 to 2008. Before regeneration, mental health was worse in the intervention than in the control group (mean MHI score 66·6, SD 22·3 vs 71·0, SD 20·8). After propensity score matching, regeneration was associated with an improvement in the mental health of intervention compared with control group residents (β=1·54, 95% CI 0·50–2·59), suggesting that inequalities in mental health narrowed. We found evidence of a dose–response association between length of residence and improvements in mental health (ptrend=0·05). We could not attribute improvements to any one type of regeneration activity. Interpretation Targeted regeneration directed by the residents of deprived urban communities can help reduce inequalities in mental health. FUNDING This study was funded by a grant from the National Institute for Social Care and Health Research (RFS-12-05) and undertaken with the support of the Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (MR/KO232331/1) and the Farr Institute of Health Informatics Research

The Welsh study of mothers and babies: protocol for a population-based cohort study to investigate the clinical significance of defined ultrasound findings of uncertain significance

Background Improvement in ultrasound imaging has led to the identification of subtle non-structural markers during the 18 – 20 week fetal anomaly scan, such as echogenic bowel, mild cerebral ventriculomegaly, renal pelvicalyceal dilatation, and nuchal thickening. These markers are estimated to occur in between 0.6% and 4.3% of pregnancies. Their clinical significance, for pregnancy outcomes or childhood morbidity, is largely unknown. The aim of this study is to estimate the prevalence of seven markers in the general obstetric population and establish a cohort of children for longer terms follow-up to assess the clinical significance of these markers. Methods/Design All women receiving antenatal care within six of seven Welsh Health Boards who had an 18 to 20 week ultrasound scan in Welsh NHS Trusts between July 2008 and March 2011 were eligible for inclusion. Data were collected on seven markers (echogenic bowel, cerebral ventriculomegaly, renal pelvicalyceal dilatation, nuchal thickening, cardiac echogenic foci, choroid plexus cysts, and short femur) at the time of 18 – 20 week fetal anomaly scan. Ultrasound records were linked to routinely collected data on pregnancy outcomes (work completed during 2012 and 2013). Images were stored and reviewed by an expert panel. The prevalence of each marker (reported and validated) will be estimated. A projected sample size of 23,000 will allow the prevalence of each marker to be estimated with the following precision: a marker with 0.50% prevalence to within 0.10%; a marker with 1.00% prevalence to within 0.13%; and a marker with 4.50% prevalence to within 0.27%. The relative risk of major congenital abnormalities, stillbirths, pre-term birth and small for gestational age, given the presence of a validated marker, will be reported. Discussion This is a large, prospective study designed to estimate the prevalence of markers in a population-based cohort of pregnant women and to investigate associations with adverse pregnancy outcomes. The study will also establish a cohort of children that can be followed-up to explore associations between specific markers and longer-term health and social outcomes

Equity of access to tertiary hospitals in Wales: a travel time analysis

BACKGROUND: The objective of the study was to investigate the implications for equity of geographical access for population subgroups arising from hypothetical scenarios of change in configuration of National Health Service tertiary hospital service provision located in Wales. METHODS: For each of three scenarios, the status quo and centralization of services to one of two locations, we used a travel time road length matrix in geographical information software to calculate the proportion of the population living within 30, 60, 90 and 120 min travel of each hospital site and the associated mean, median and 90th percentile travel times. We analysed data for the total resident population of Wales, for residents aged 75 or more years, for residents of the most deprived 10 per cent of enumeration districts, and for residents of rural areas. RESULTS: Centralization of services reduces geographical access for all population subgroups. Access varies between population subgroups, both between and within different scenarios of service configuration. A change in service configuration may improve access for one subgroup but reduce access for another. The interpretation may also vary according to whether the defined cut point for comparing access is based on short or long travel times. Measurements of absolute and relative access are sensitive to the assumed travel speeds. CONCLUSION: Access for the total population does not imply equity of access for subgroups of the population. Comparisons of access between scenarios are dependent on which measure of access is the indicator of choice. Results are sensitive to the road network travel speeds and further local validation may be necessary. This method can provide explicit information to health service planners on the effects on equity of access from a change in service configuration

Assessing the influence of socio-demographic factors and health status on expression of satisfaction with GP services

Abstract: Purpose – Measures of patient satisfaction are used in the assessment of quality of healthcare, but the influence of patient-based factors on reported satisfaction has been little described. This paper aims to quantify associations between reported satisfaction with GP services and measures of socio-demographic and health status and the effect of adjusting for these factors in comparing satisfaction measured at the level of primary care organisations (PCOs). Design/methodology/approach – Cross-sectional analysis of the 1998 Welsh Health Survey, response rate 61 per cent. The 20,380 respondents, aged between 18 and 74 years reporting contact with their GP in the previous 12 months formed the study population. Satisfaction was defined as being “very” or “fairly satisfied” with GP services. Crude odds ratios were calculated(95 per cent confidence intervals) for reported satisfaction for the 22 PCOs in Wales and adjusted odds ratios were calculated for socio-demographic variables and LLTI in logistic regression. Findings – Satisfaction varied with age, gender, employment status, marital status, and reported LLTI. The rank order of reported satisfaction for PCOs changed by up to five places after adjusting for these factors. Research limitations/implications – The generalisability of this study should be assessed through further research on the impact of adjusting for patient based factors when using other validated measures of satisfaction. Practical implications – Comparing measures of satisfaction between organisations to assess relative performance may not be valid unless differences in socio-demographic composition are taken into account. Originality/value – Highlights the importance of caution in using measures of patient satisfaction to assess performance. Keywords General practitioners, Patients, Customer satisfaction, Quality, Demography, Wale

Implementing national guidance on prevention of coronary heart disease: clinical governance and computer simulation modelling

Standing Medical Advisory Committee (SMAC)guidance for the prevention of coronary heart disease (CHD)and the National Service Framework - Coronary Heart Disease both require the identification of patients at high risk of CHD for targeted treatment with statins. Since the best method of identifying these patients is unkown, we compared population screening with opportunistic case finding in a discrete event computer simulation model of the population aged 45-64 in one local health group in Wales. The main outcome measures were numbers of CHD and all-cause deaths and extra patient years of drug treatment. Screening and case finding were of similar effectiveness in identifying high risk individuals to preven CHD and all-cause mortality during the five years simulated. The extra- patient years of drug treatment required by a population screening programme suggests that screening would not be cost effective. Concludes that opportunistic case finding is the method of choice in primary care