Population ageing in Scotland - implications for healthcare expenditure

POPULATION AGEING IN SCOTLAND - IMPLICATIONS FOR HEALTHCARE EXPENDITURE Population ageing is a major concern for developed countries in terms of public expenditure required to pay for health care (HC). The broad aim of this thesis is to contribute to and expand the debate on the independent effects that population ageing and the time immediately before death (TTD) have on HC expenditure in Scotland. This study analyses, for the first time in Scotland, how HC expenditure projections are influenced through the application of two approaches; the first only accounting for an increasing proportion of the elderly population, and the second also implementing a TTD component. Several issues that are under-researched or have not been addressed in TTD studies previously, are explored and alternative approaches are presented. Utilising two large linked datasets this thesis addresses important methodological issues. Alternative methods to cost inpatient hospital stays are examined as this has pivotal implications for any analysis undertaken to estimate the independent effect of TTD and age on HC expenditure. Explanatory variables that have previously not been considered, such as health risk and health status measures at baseline, are included in these analyses. The issue of sample selection, arising through the inclusion/exclusion of survivors in a TTD study is investigated and the impact of individuals’ socio-economic status on costs is examined. The analysis of alternative costing methods clearly showed that any inference that can be made from econometric modelling of costs, where the marginal effect of explanatory variables is assessed, is substantially influenced by the chosen costing method. The application of a Healthcare Resource Group (HRG) costing method was recommended. This study found that TTD, age and the interactions between these two factors were significant predictors for HC expenditure. The analysis further identified some of the health status and health risk measures to be important predictors of future HC expenditure. An examination of how sample selection impacts on estimated costs at the end of life showed that if survivors were excluded from the analysis, costs might be overestimated. Drawing on a representative sample of the Scottish population, the investigation of the association that the socio-economic status had with HC costs suggested that less is spent on individuals from more deprived areas. This might partly be explained through the decreased probability of accessing hospital services for individuals from more deprived areas. Furthermore, results showed that projected HC expenditure for acute inpatient care for the year 2028 was overestimated by ~7% when an approach that only accounts for the higher proportion of elderly people in a population in the future is being used as compared to an approach that also accounts for the effect that remaining TTD has on costs

Hospital expenditure at the end-of-life: what are the impacts of health status and health risks?

Background: It is important for health policy and expenditure projections to understand the relationship between age, death and expenditure on health care (HC). Research has shown that older age groups incur lower hospital costs than previously anticipated and that remaining time to death (TTD) was a much stronger indicator for expenditure than age. How health behaviour or risk factors impact on HC utilisation and costs at the end of life is relatively unknown. Smoking and Body Mass Index (BMI) have featured most prominently and mixed findings exist as to the exact nature of this association.<p></p> Methods: This paper considers the relationship between TTD, age and expenditure for inpatient care in the last 12 quarters of life; and introduces measures of health status and risks. A longitudinal dataset covering 35 years is utilised, including baseline survey data linked to hospital and death records. The effect of age, TTD and health indicators on expenditure for inpatient care is estimated using a two-part model.<p></p> Results: As individuals approach death costs increase. This effect is highly significant (p<0.01) from the last until the 8th quarter before death and influenced by age. Statistically significant effects on costs were found for: smoking status, systolic blood pressure and lung function (FEV1). On average, smokers incurred lower quarterly costs in their last 12 quarters of life than non-smokers (~7%). Participants’ BMI at baseline did show a negative association with probability of HC utilisation however this effect disappeared when costs were estimated.<p></p> Conclusions: Health risk measures obtained at baseline provide a good indication of individuals’ probability of needing medical attention later in life and incurring costs, despite the small size of the effect. Utilising a linked dataset, where such measures are available can add substantially to our ability to explain the relationship between TTD and costs.<p></p&gt

The loser leaves (Rome's loss) : Umbricius’ wishful exile in Juvenal, Satire 3

Juvenal's third satire is a privileged piece of verbal diarrhoea. As the longest satire in Juvenal's well-attended Book 1, as the centre of this book, and as the one Juvenalian jewel that sparkles ‘non-rhetorically’, it has always been the critics’ darling. Its protagonist, on the other hand, has not always been so popular. Recently, reader sympathy for old Umbricius (the poem's main speaker) has shifted to laughter in his face; the old sense of ‘pathetic’ has ceded to the new. One of the central strategies of the ‘Umbricius-as-caricature’ camp has been to point to the overtime worked by ‘mock-epic’ in this poem: Umbricius self-inflates to become another Aeneas, fleeing a crumbling Troy (Rome). But an oppositio is wedged in imitando. Umbricius makes his lengthy verbal preparations to depart from Rome for Cumae; Aeneas had come to Rome through Cumae. Umbricius withdraws to set up shop in the meagre countryside; Aeneas had escaped to cap his exile teleologically with the (pre-foundation of the) Greatest City That Will Ever Be. Still, Virgil's paradigm tale of displacement, drift and re-establishment underlies Umbricius' self-definition as an exile. Indeed exile, with a large and ever-increasing stock of mythical and historical examples, was a situation ripe for self-mythologizing. Umbricius stands in Aeneas' shadow then, standing it on its head. His recession also makes him into a Iustitia/Dikē figure, the final trace of the golden age, off to alloy himself elsewhere. In his mind, exile is rationalized by distinguished past examples; in ours, we laugh at how disparate example and man really are. That side of Umbricius has been done to death; or at least, for present purposes, to exile.PostprintPeer reviewe

Embracing ligands. A synthetic strategy towards new nitrogen-thioether multidentate ligands and characterization of the cobalt(III) complexes

The synthesis of the hexadentate ligand 2,2,9,9-tetra(methyleneamine)-4,7-dithiadecane (EtN(4)S(2)amp) is reported. The ligand is of a type in which bifurcations of the chain occur at atoms other than donor atoms. The cobalt(III) complex [Co(EtN(4)S(2)amp)](3+) (1) was isolated and characterized. The synthetic methodology also results in a number of by-products, notably 2,9,9-tris(methyleneamine)-9-methylenehydroxy-4,7-dithiadecane (Et(HO)N(3)S(2)amp) and an eleven-membered pendant arm macrocyclic ligand 6,10-dimethyl-6,10-bis(methyleneamine)-1,4-dithia-8-azaacycloundec-7- ene (dmatue). The complexes [Co(Et(HO)N(3)S(2)amp)](3+) (2), in which the alcohol is coordinated to the metal ion, and [Co(dmatue)Cl](2+) (4) were isolated and characterized. Et(HO)N(3)S(2)amp also undergoes complexation with cobalt(III) to produce two isomers endo-[Co(Et(HO) N(3)S(2)amp)Cl](2+) (endo-3) and exo-[Co(Et(HO) N(3)S(2)amp)Cl](2+) (exo-3), both with an uncoordinated alcohol group. endo- 3 has the alcohol positioned cis, and exo-3 trans, to the sixth metal coordination site. Reaction of 1 with isobutyraldehyde, paraformaldehyde and base in dimethylformamide results in the encapsulated complex [Co(1,5,5,9,13,13-hexamethyl-18,21-dithia-3,7,11,15-tetraazabicyclo[7.7.6]docosa- 3,14-diene)](ClO4)(3) . 2H(2)O ([Co(Me(6)docosadieneN(4)S(2))](3+) ( 5). All complexes have been characterized by single crystal X-ray study. The low-temperature (11 K) absorption spectrum of 1 has been measured in Nafion films with spin-allowed (1)A(1g) --> T-1(1g) and (1)A(1g) --> T-1(2g) and spin forbidden (1)A(1g) --> T-3(1g) and (1)A(1g) --> T-3(2g) bands observed. The octahedral ligand-field parameters were determined (10Dq = 22570 cm(-1), B = 551 cm(-1); C = 3500 cm(-1)). For 5 10Dq and B were determined (20580 cm(-1); 516 cm(-1), respectively) and compared with those for similar expanded cavity complexes [Co(Me(8)tricosatrieneN(6))](3+) and [Co(Me(5)tricosatrieneN(6))](3+)

Glass transition in Ultrathin Polymer Films : A Thermal Expansion Study

Glass transition process gets affected in ultrathin films having thickness comparable to the size of the molecules. We observe systematic broadening of glass transition temperature (Tg) as the thickness of the polymer film reduces below the radius of gyration but the change in the average Tg was found to be very small. Existence of reversible negative and positive thermal expansion below and above Tg increased the sensitivity of our thickness measurements performed using energy dispersive x-ray reflectivity. A simple model of Tg variation as a function of depth expected from sliding motion could explain the results. We observe clear glass transition even for 4 nm polystyrene film that was predicted to be absent from ellipsometry measurements of thicker films.Comment: 11 pages, 5 figure

Evaluating the impact of the Alcohol Act on off-trade alcohol sales: a natural experiment in Scotland

<b>Background and aims</b> A ban on multi-buy discounts of off-trade alcohol was introduced as part of the Alcohol Act in Scotland in October 2011. The aim of this study was to assess the impact of this legislation on alcohol sales, which provide the best indicator of population consumption.<p></p> <b>Design Setting and Participants</b> Interrupted time-series regression was used to assess the impact of the Alcohol Act on alcohol sales among off-trade retailers in Scotland. Models accounted for underlying seasonal and secular trends and were adjusted for disposable income, alcohol prices and substitution effects. Data for off-trade retailers in England and Wales combined (EW) provided a control group.<p></p> <b>Measurements</b> Weekly data on the volume of pure alcohol sold by off-trade retailers in Scotland and EW between January 2009 and September 2012.<p></p> <b>Findings</b> The introduction of the legislation was associated with a 2.6% (95% CI -5.3 to 0.2%, P = 0.07) decrease in off-trade alcohol sales in Scotland, but not in EW (-0.5%, -4.6 to 3.9%, P = 0.83). A statistically significant reduction was observed in Scotland when EW sales were adjusted for in the analysis (-1.7%, -3.1 to -0.3%, P = 0.02). The decline in Scotland was driven by reduced off-trade sales of wine (-4.0%, -5.4 to -2.6%, P < 0.001) and pre-mixed beverages (-8.5%, -12.7 to -4.1%, P < 0.001). There were no associated changes in other drink types in Scotland, or in sales of any drink type in EW.<p></p> <b>Conclusions</b> The introduction of the Alcohol Act in Scotland in 2011 was associated with a decrease in total off-trade alcohol sales in Scotland, largely driven by reduced off-trade wine sales

An expanded cavity hexaamine cage for copper(II)

The crystal structure of the bicyclic hexaamine complex [Cu(fac-Me-5-tricosane-N-6)](ClO4)(2) center dot H2O (fac-Me-5-tricosane-N-6 = facial-1,5,9,13,20-pentamethyl-3,7,11,15,18,22-hexaazabicyclo[7.7.7] tricosane) at 100 K defines an apparently tetragonally compressed octahedral geometry, which is attributed to a combination of dynamic interconversion and static disorder between two tetragonally elongated structures sharing a common short axis. This structure is fluxional at 60 K and above as shown by EPR spectroscopy. Aqueous cyclic voltammetry reveals that a remarkably stable Cu-I form of the complex is stabilised by the encapsulating nature of the expanded cage ligand

Elena Ferrante as the classics

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A two-part model to estimate inpatient, outpatient, prescribing and care home costs associated with atrial fibrillation in Scotland

Objective:This study aimed to estimate global inpatient, outpatient, prescribing and care home costs for patients with atrial fibrillation using population-based, individual-level linked data. Design:A two-part model was employed to estimate the probability of resource utilisation and costs conditional on positive utilisation using individual-level linked data. Settings:Scotland, 5 years following first hospitalisation for AF between 1997 and 2015. Participants: Patients hospitalised with a known diagnosis of AF or atrial flutter. Primary and secondary outcome measures: Inpatient, outpatient, prescribing and care home costs. Results: The mean annual cost for a patient with AF was estimated at £3785 (95% CI £3767 to £3804). Inpatient admissions and outpatient visits accounted for 79% and 8% of total costs, respectively; prescriptions and care home stay accounted for 7% and 6% of total costs. Inpatient cost was the main driver across all age groups. While inpatient cost contributions (~80%) were constant between 0 and 84 years, they decreased for patients over 85 years. This is offset by increasing care home cost contributions. Mean annual costs associated with AF increased significantly with increasing number of comorbidities. Conclusion: This study used a contemporary and representative cohort, and a comprehensive approach to estimate global costs associated with AF, taking into account resource utilisation beyond hospital care. While overall costs, considerably affected by comorbidity, did not increase with increasing age, care home costs increased proportionally with age. Inpatient admission was the main contributor to the overall financial burden of AF, highlighting the need for improved mechanisms of early diagnosis to prevent hospitalisations