Do age, period or cohort effects explain circulatory disease mortality trends, Scotland 1974-2015?

Objective: We aimed to explore whether age, period or cohort effects explain the trends and inequalities in ischaemic heart disease (IHD) and cerebrovascular disease (CeVD) mortality in Scotland. Methods: We analysed IHD and CeVD deaths for 1974–2015 by sex, age and area deprivation, visually explored the data using heatmaps and dotplots and built regression models. Results: CeVD mortality improved steadily over time while IHD mortality improved more rapidly from the late 1980s. Age effects were evident; both outcomes showed an exponential relationship with age for all except males for IHD in the 1980s and 1990s. The mortality profiles by age became older, although improvement was slower for those aged <50 years for IHD, especially for males, and faster for CeVD in females aged <65 years. Rates were higher, and inequalities greater, among males, especially for IHD. For IHD, increased risk for males over females reduced with age (incidence rate ratio for 41–50 year old males=4.28 (95% CI 4.12 to 4.44) and 1.17 (95% CI 1.16 to 1.18) for 71–80 year olds). Inequalities in IHD mortality by area deprivation persisted over time, increasing from around 10% to around 25% higher risk in the most deprived areas between 1974 and 1986 before declining in absolute terms from around 2000. Inequalities for CeVD increased after the late 1980s. Conclusions: IHD and CeVD mortality in Scotland exhibit age but not recent distinct period or cohort effects. The improvements in mortality rates have been more sustained for CeVD and inequalities greater for IHD

How bad are life expectancy trends across the UK, and what would it take to get back to previous trends?

Background: Within the UK, there has been debate on whether life expectancy is increasing or decreasing in particular single or 3-year periods, but there has been less thinking whether overall trends have changed. This paper considers the extent to which the trends in life expectancy for the UK and its nations have changed before and after 2011. Methods: We used the Office for National Statistics period life expectancy data for the UK and its nations. We used Lee’s approach to project life expectancy based on repeated sampling of year-to-year change in the baseline periods (1990–2011 and 1980–2011) and applied that to 2012 onwards. Findings: Improvements in period life expectancy were substantially and consistently lower between 2012 and 2018 than predicted from the trends from 1980 and, especially, from 1990. By 2018, life expectancy was lower than projected for females and males, respectively, by 1.22 and 1.52 years (England), 1.44 and 0.95 years (Northern Ireland), 1.30 and 1.44 years (Scotland), 1.53 and 1.63 years (Wales) and 1.24 and 1.49 years (UK overall), based on the 1990–2011 baseline period. Using a longer baseline period, which includes the slower rates of improvement during the 1980s, slightly reduces the gap between the current life expectancies and the projected medians. Interpretation: Future academic and policy focus should be on the deviation of the life expectancy trends from the baseline projection rather than on year-to-year variation. Concerted policy focus to return life expectancy to the projected trends is now urgently required

Impact of a pharmacist-led clinic in optimising lipid therapy for secondary prevention in vascular and diabetic foot patients

Introduction/Aims: Approximately 25-28 % of UK CVD deaths are due to raised cholesterol; every 1.0 mmol/L in LDL-C is associated with a 23% relative risk reduction in major atherosclerotic CVD events. Patients attending vascular or diabetic foot clinics often have atherosclerotic disease and are at increased risk for the recurrence of vascular events. These patients merit high-intensity lipid-modifying therapy to maintain secondary prevention targets to reduce their risk of further disease. In this study we aimed to evaluate the impact of a pharmacist led lipid optimisation clinic for secondary prevention in such patients Method: A baseline audit of 100 consecutive vascular patients was performed to assess lipid management and identify potential areas for pharmacist-led intervention. This resulted in a pharmacist led secondary prevention service covering vascular outpatient clinics (V-OPD) and the weekly regional diabetic foot multidisciplinary team meetings (DFMDT). Two virtual clinics were conducted weekly delivered by a trained clinical pharmacist. Management was according to current national guidelines and patients prioritised according to CVD risk. Patients were offered review in the virtual clinics, optimisation of medication including high intensity statins and new injectable lipid-lowering therapy and post-intervention monitoring. Results: The baseline audit (M:F 61:39, mean age 67.4 (14.3) years) identified 62% were eligible for lipid optimisation and confirmed the potential plan would have a significant impact. Of 216 patients (M:F 144:72 mean age 69.3 (10.7) years, 166 (77%) on statins), 175 (81%) were above target of non-HDL of 2.5 mmol/l (mean 3.51 (2.44) mmol/l) and required optimisation which led to a significant reduction in total cholesterol, triglycerides and non -HDL to a mean of 2.44 (0.91) mmol/l. Post optimisation 92 out of 133 (69%) were at target O.R. 2.95 (1.92 e 4,55], p<.001 of being at target equivalent to an NNT¼2. Calculated LDL levels (Friedewald) show a mean reduction of 0.83 [0.68 e 0.98] mmol/l for vascular patients and 1.39 [0.78 e 2.01] mmol/l for diabetic foot patients due to the intervention. Conclusion: A pharmacist-led service optimising lipid lowering therapy of secondary prevention for vascular and diabetic foot patients achieved significant reductions in LDL and non-HDL cholesterol which will decrease the risk of developing further cardiovascular disease and prevent further life and limb threatening events

Deaths from ‘diseases of despair’ in Britain: comparing suicide, alcohol-related and drug-related mortality for birth cohorts in Scotland, England and Wales, and selected cities

Background: The contribution of increasing numbers of deaths from suicide, alcohol-related and drug-related causes to changes in overall mortality rates has been highlighted in various countries. In Scotland, particular vulnerable cohorts have been shown to be most at risk; however, it is unclear to what extent this applies elsewhere in Britain. The aim here was to compare mortality rates for different birth cohorts between Scotland and England and Wales (E&amp;W), including key cities. Methods: Mortality and population data (1981–2017) for Scotland, E&amp;W and 10 cities were obtained from national statistical agencies. Ten-year birth cohorts and cohort-specific mortality rates (by age of death, sex, cause) were derived and compared between countries and cities. Results: Similarities were observed between countries and cities in terms of peak ages of death, and the cohorts with the highest death rates. However, cohort-specific rates were notably higher in Scotland, particularly for alcohol-related and drug-related deaths. Across countries and cities, those born in 1965–1974 and 1975–1984 had the highest drug-related mortality rates (peak age at death: 30–34 years); the 1965–1974 birth cohort also had the highest male suicide rate (peak age: 40–44 years). For alcohol-related causes, the highest rates were among earlier cohorts (1935–1944, 1945–1954, 1955–1964)—peak age 60–64 years. Conclusions: The overall similarities suggest common underlying influences across Britain; however, their effects have been greatest in Scotland, confirming greater vulnerability among that population. In addressing the socioeconomic drivers of deaths from these causes, the cohorts identified here as being at greatest risk require particular attention

COVID-19-exploring the implications of long-term condition type and extent of multimorbidity on years of life lost : a modelling study

Grant Information: David A. McAllister is wholly supported via an intermediate clinical fellowship from the Wellcome Trust (201492). Peter Hanlon is funded through a Clinical Research Training Fellowship from the Medical Research Council (MR/S021949/1).Background: COVID-19 is responsible for increasing deaths globally. As most people dying with COVID-19 are older with underlying long-term conditions (LTCs), some speculate that YLL are low. We aim to estimate YLL attributable to COVID-19, before and after adjustment for number/type of LTCs, using the limited data available early in the pandemic. Methods: We first estimated YLL from COVID-19 using WHO life tables, based on published age/sex data from COVID-19 deaths in Italy. We then used aggregate data on number/type of LTCs in a Bayesian model to estimate likely combinations of LTCs among people dying with COVID-19. We used routine UK healthcare data from Scotland and Wales to estimate life expectancy based on age/sex/these combinations of LTCs using Gompertz models from which we then estimate YLL. Results: Using the standard WHO life tables, YLL per COVID-19 death was 14 for men and 12 for women. After adjustment for number and type of LTCs, the mean YLL was slightly lower, but remained high (11.6 and 9.4 years for men and women, respectively). The number and type of LTCs led to wide variability in the estimated YLL at a given age (e.g. at ≥80 years, YLL was >10 years for people with 0 LTCs, and <3 years for people with ≥6). Conclusions: Deaths from COVID-19 represent a substantial burden in terms of per-person YLL, more than a decade, even after adjusting for the typical number and type of LTCs found in people dying of COVID-19. The extent of multimorbidity heavily influences the estimated YLL at a given age. More comprehensive and standardised collection of data (including LTC type, severity, and potential confounders such as socioeconomic-deprivation and care-home status) is needed to optimise YLL estimates for specific populations, and to understand the global burden of COVID-19, and guide policy-making and interventions.Peer reviewe

Can changes in spending on health and social care explain the recent mortality trends in Scotland? A protocol for an observational study

Introduction: There have been steady reductions in mortality rates in the majority of high-income countries, including Scotland, since 1945. However, reductions in mortality rates have slowed down since 2012–2014 in these nations; and have reversed in some cases. Deaths among those aged 55+ explain a large amount of these changing mortality trends in Scotland. Increased pressures on health and social care services have been suggested as one factor explaining these changes. This paper outlines a protocol for the approach to testing the extent to which health and social care pressures can explain recent mortality trends in Scotland. Although a slower rate of mortality improvements have affected people of all ages, certain ages have been more negatively affected than the others. The current analyses will be run by age-band to test if the service pressure-mortality link varies across age-group. Methods and analysis: This will be an observational ecological study based on the Scottish population. The exposures of interest will be the absolute (primary outcome) and percentage (secondary outcome) change in real terms per capita spending on social and healthcare services between 2011 and 2017. The outcome of interest will be the absolute (primary outcome) and percentage (secondary outcome) change in age-standardised mortality rate between 2012 and 2018 for men and women separately. The units of analysis will be the 32 local authorities and the 14 territorial health boards. The analyses will be run for both all age-groups combined and for the following age bands: &lt;1, 1–15, 16–44, 45–64, 65–74, 75–84 and 85+. A series of descriptive analyses will summarise the distribution of health and social care expenditure and mortality trends between 2011 and 2018. Linear regression analysis will be used to investigate the direct association between health care spending and mortality rates. Ethics and dissemination: The data used in this study will be publicly available and aggregated and will not be individually identifiable; therefore, ethical committee approval is not needed. This work will not result in the creation of a new data set. On completion, the study will be stored within the National Health Service research governance system. All of the results will be published once they have been shared with partner agencies

Prospectus, September 22, 1982

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How have changes in death by cause and age group contributed to the recent stalling of life expectancy gains in Scotland? Comparative decomposition analysis of mortality data, 2000–2002 to 2015–2017

Objective: Annual gains in life expectancy in Scotland were slower in recent years than in the previous two decades. This analysis investigates how deaths in different age groups and from different causes have contributed to annual average change in life expectancy across two time periods: 2000–2002 to 2012–2014 and 2012–2014 to 2015–2017. Setting Scotland. Methods: Life expectancy at birth was calculated from death and population counts, disaggregated by 5 year age group and by underlying cause of death. Arriaga’s method of life expectancy decomposition was applied to produce estimates of the contribution of different age groups and underlying causes to changes in life expectancy at birth for the two periods. Results: Annualised gains in life expectancy between 2012–2014 and 2015–2017 were markedly smaller than in the earlier period. Almost all age groups saw worsening mortality trends, which deteriorated for most cause of death groups between 2012–2014 and 2015–2017. In particular, the previously observed substantial life expectancy gains due to reductions in mortality from circulatory causes, which most benefited those aged 55–84 years, more than halved. Mortality rates for those aged 30–54 years and 90+ years worsened, due in large part to increases in drug-related deaths, and dementia and Alzheimer’s disease, respectively. Conclusion: Future research should seek to explain the changes in mortality trends for all age groups and causes. More investigation is required to establish to what extent shortcomings in the social security system and public services may be contributing to the adverse trends and preventing mitigation of the impact of other contributing factors, such as influenza outbreaks

Is austerity responsible for the recent change in mortality trends across high-income nations? A protocol for an observational study

Introduction: Mortality rates in many high-income countries have changed from their long-term trends since around 2011. This paper sets out a protocol for testing the extent to which economic austerity can explain the variance in recent mortality trends across high-income countries. Methods and analysis: This is an ecological natural experiment study, which will use regression adjustment to account for differences in exposure, outcomes and confounding. All high-income countries with available data will be included in the sample. The timing of any changes in the trends for four measures of austerity (the Alesina-Ardagna Fiscal Index, real per capita government expenditure, public social spending and the cyclically adjusted primary balance) will be identified and the cumulative difference in exposure to these measures thereafter will be calculated. These will be regressed against the difference in the mean annual change in life expectancy, mortality rates and lifespan variation compared with the previous trends, with an initial lag of 2 years after the identified change point in the exposure measure. The role of underemployment and individual incomes as outcomes in their own right and as mediating any relationship between austerity and mortality will also be considered. Sensitivity analyses varying the lag period to 0 and 5 years, and adjusting for recession, will be undertaken. Ethics and dissemination: All of the data used for this study are publicly available, aggregated datasets with no individuals identifiable. There is, therefore, no requirement for ethical committee approval for the study. The study will be lodged within the National Health Service research governance system. All results of the study will be published following sharing with partner agencies. No new datasets will be created as part of this work for deposition or curation

Digital music libraries - Research and development

A report on the progress of several major research and development projects in digital music libraries is presented. Digital music libraries provide enhanced access and functionality that facilitates scholarly research and education. The issue of integrating digital music library collections with interactive instructional applications is addressed