Predictors of admission and readmission to hospital for major depression: A community cohort study of 52,990 individuals.

Background Our current knowledge about predictors of admission and re-admission to hospital as a result of major depressive disorder (MDD) is limited. Here we present a descriptive analysis of factors which are associated with MDD hospitalisations within a large population cohort. Methods We linked participants of the Scottish Health Survey (SHS) to historical and prospective hospital admission data. We combined information from the SHS baseline interview and historical hospitalisations to define a range of exposure variables. The main outcomes of interest were: (1) first time admission for MDD occurring after the SHS interview; and (2) readmission for MDD. We used Cox regression to determine the association between each predictor and each outcome, after adjusting for age, gender and deprivation quintile. Results 52,990 adult SHS participants were included. During a median follow-up of 4.5 years per participant, we observed 530 first-time admissions for MDD. A relatively wide range of factors – encompassing social, individual health status, and lifestyle-related exposures – were associated with this outcome (p&#60;0.05). Among the 530 participants exhibiting a de novo admission for MDD during follow-up, 118 were later re-admitted. Only older age (over 70) and a prior non-depression related psychiatric admission were associated with readmission for MDD. Limtations MDD was defined using records of International Classification of Disease hospital discharge codes rather than formal diagnostic assessments. Conclusion These findings have implications for mental health service organisation and delivery and should stimulate future research on predictive factors for admission and readmission in MDD.</p

Alcohol consumption, wealth and health - Authors' reply

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Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised clinical trials

&lt;b&gt;Objectives&lt;/b&gt; To determine if video assisted thoracic surgery is associated with better clinical outcomes than thoracotomy for three common procedures: surgery for pneumothorax, minor resections, and lobectomy. &lt;b&gt;Design&lt;/b&gt; Systematic review of randomised clinical trials. &lt;b&gt;Data sources&lt;/b&gt; Medline, Embase, Cochrane database of systematic reviews, Cochrane controlled trials register. Reference lists of relevant articles and reviews. &lt;b&gt;Methods&lt;/b&gt; Criteria for inclusion were random allocation of patients and no concurrent use of another experimental medication or device. At least two authors performed and confirmed data abstraction and analyses. Information on quality of trials, demographics, frequency of the events, and numbers randomised were collected. &lt;b&gt;Results&lt;/b&gt; 12 trials randomised 670 patients. Video assisted thoracic surgery was associated with shorter length of stay (reduction ranged from 1.0 to 4.2 days) and less pain or use of pain medication than thoracotomy in the five out of seven trials in which the technique was used for pneumothorax or minor lung resection. In the treatment of pneumothorax, video assisted thoracic surgery was associated with substantially fewer recurrences than pleural drainage in two trials (from 20 to 53 events prevented per 100 treated patients). No substantial advantages were observed for video assisted thoracic surgery in lobectomies. &lt;b&gt;Conclusions&lt;/b&gt; Video assisted thoracic surgery is associated with better outcomes and seems to have a complication profile comparable with that of thoracotomy for the treatment of pneumothorax and minor resections. As for lobectomy, further studies are needed to determine how it compares with thoracotomy

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.&lt;p&gt;&lt;/p&gt; 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.&lt;p&gt;&lt;/p&gt; Results: As individuals approach death costs increase. This effect is highly significant (p&lt;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.&lt;p&gt;&lt;/p&gt; 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.&lt;p&gt;&lt;/p&gt

Socioeconomic status as an effect modifier of alcohol consumption and harm: an analysis of linked cohort data

Background: Alcohol-related mortality and morbidity are higher in socioeconomically disadvantaged populations. It is unclear if elevated harm reflects differences in consumption, reverse causation or greater risk of harm following similar consumption. We investigated whether the harmful effects differed by socioeconomic status accounting for alcohol consumption and other health-related factors. Methods: Alcohol consumption (weekly units and binge drinking) data (n=50,236; 429,986 person-years of follow-up) were linked to deaths, hospitalisations and prescriptions. The primary outcome was alcohol-attributable hospitalisation/death. The relationship between alcohol attributable harm and socioeconomic status was investigated for four measures (education level, social class, household income and area-based deprivation) using Cox proportional hazards models. The potential for alcohol consumption and other risk factors mediating the social patterning was explored. Downward social selection for high-risk drinkers (reverse causation) was tested by comparing change in area deprivation over time. Findings: Low socioeconomic status was consistently associated with markedly elevated alcohol-attributable harms, including after adjustment for weekly consumption, binge drinking, body mass index and smoking. There was evidence of effect modification: for example, relative to light drinkers living in advantaged areas, the hazard ratio for excessive drinkers was 6.75 (95% CI 5.09-8.93) in advantaged and 11.06 (95% CI 8.53-14.35) in deprived areas. We found little support for downward social selection. Interpretation: Disadvantaged social groups experience greater alcohol-attributable harms compared to the advantaged for given levels of alcohol consumption, even after accounting for different drinking patterns, obesity and smoking status at the individual level

Cost-effectiveness analysis in R using a multi-state modelling survival analysis framework: a tutorial

This tutorial provides a step-by-step guide to performing cost-effectiveness analysis using a multi-state modelling approach. Alongside the tutorial we provide easy-to-use functions in the statistics package R. We argue this multi-state modelling approach using a package such as R has advantages over approaches where models are built in a spreadsheet package. In particular, using a syntax-based approach means there is a written record of what was done and the calculations are transparent. Reproducing the analysis is straightforward as the syntax just needs to be run again. The approach can be thought of as an alternative way to build a Markov decision analytic model, which also has the option to use a state-arrival extended approach if the Markov property does not hold. In the state-arrival extended multi-state model a covariate that represents patients’ history is included allowing the Markov property to be tested. We illustrate the building of multi-state survival models, making predictions from the models and assessing fits. We then proceed to perform a cost-effectiveness analysis including deterministic and probabilistic sensitivity analyses. Finally, we show how to create two common methods of visualising the results, namely cost-effectiveness planes and cost-effectiveness acceptability curves. The analysis is implemented entirely within R. It is based on adaptions to functions in the existing R package mstate, to accommodate parametric multi-state modelling which facilitates extrapolation of survival curves

Survival after liver transplantation in the United Kingdom and Ireland compared with the United States

&lt;b&gt;Background and Aim&lt;/b&gt;: Surgical mortality in the US is widely perceived to be superior to that in the UK. However, previous comparisons of surgical outcome in the two countries have often failed to take sufficient account of case-mix or examine long-term outcome. The standardised nature of liver transplantation practice makes it uniquely placed for undertaking reliable international comparisons of surgical outcome. The objective of this study is to undertake a risk-adjusted disease-specific comparison of both short- and long-term survival of liver transplant recipients in the UK and Ireland with that in the US. &lt;b&gt;Design, setting and participants&lt;/b&gt;: Multi-centre cohort study using two high quality national databases including all adults who underwent a first single organ liver transplant in the UK and Ireland (n=5,925) and the US (n=41,866) between March 1994 and March 2005. &lt;b&gt;Main outcome measures&lt;/b&gt;: Post-transplant mortality during the first 90 days, 90 days-1 year and beyond the first year, adjusted for donor and recipient characteristics. &lt;b&gt;Results&lt;/b&gt;: Risk-adjusted mortality in the UK and Ireland was generally higher than in the US during the first 90 days (hazard ratio 1.17 95%CI 1.07-1.29), both for patients transplanted for acute liver failure (hazard ratio 1.27 95%CI 1.01-1.60) as well as those transplanted for chronic liver disease (hazard ratio 1.18 95% CI 1.07- 1.31). Between 90 days and 1 year post-transplantation, no statistically significant differences in overall risk- adjusted mortality were noted between the two cohorts. Survivors of the first post-transplant year in the UK and Ireland had lower overall risk-adjusted mortality than those transplanted in the US (hazard ratio 0.88 95% CI 0.81- 0.96). This difference was observed among patients transplanted for chronic liver disease (hazard ratio 0.88 95%CI 0.81-0.96) but not those transplanted for acute liver failure (hazard ratio 1.02 95%CI 0.70- 1.50). &lt;b&gt;Conclusions&lt;/b&gt;: Whilst risk adjusted mortality is higher in the UK and Ireland during the first 90 days following liver transplantation, it is higher in the US among those liver transplant recipients who survived the first post- transplant year. Our results are consistent with the notion that the US has superior acute peri-operative care whereas the UK appears to provide better quality chronic care following liver transplantation surgery

Do patients who die from an alcohol-related condition ‘drift’ into areas of greater deprivation? Alcohol-related mortality and health selection theory in Scotland

Background: Health selection has been proposed to explain the patterning of alcohol-related mortality by area deprivation. This study investigated whether persons who die from alcohol-related conditions are more likely to experience social drift than those who die from other causes. Methods: Deaths recorded in Scotland (2013, &gt;21 years) were coded as ‘alcohol-related’ or ‘other’ and by deprivation decile of residence at death. Acute hospital admissions data from 1996 to 2012 were used to provide premortality deprivation data. χ² tests estimated the difference between observed and expected alcohol-related deaths by first Scottish Index of Multiple Deprivation (SIMD) decile and type of death. Logistic regression models were fitted using type of death as the outcome of interest and change in SIMD decile as the exposure of interest. Results: Of 47 012 deaths, 1458 were alcohol-related. Upward and downward mobility was observed for both types of death. An estimated 31 more deaths than expected were classified ‘alcohol-related’ among cases whose deprivation score decreased, while 204 more deaths than expected were classified ‘alcohol-related’ among cases whose initial deprivation ranking was in the four most deprived deciles. Becoming more deprived and first deprivation category were both associated with increased odds of type of death being alcohol-related after adjusting for confounders. Conclusion: This study suggests that health selection appears to contribute less to the deprivation gradient in alcohol-related mortality in Scotland than an individual’s initial area deprivation category

Is there overutilisation of cataract surgery in England?

&lt;b&gt;Objectives:&lt;/b&gt; Following a 3.7-fold increase in the rate of cataract surgery in the UK between 1989 and 2004, concern has been raised as to whether this has been accompanied by an excessive decline in the threshold such that some operations are inappropriate. The objective was to measure the impact of surgery on a representative sample of patients so as to determine whether or not overutilisation of surgery is occurring. &lt;b&gt;Design:&lt;/b&gt; Prospective cohort assessed before and 3 months after surgery. &lt;b&gt;Setting:&lt;/b&gt; Ten providers (four NHS hospitals, three NHS treatment centres, three independent sector treatment centres) from across England. &lt;b&gt;Participants:&lt;/b&gt; 861 patients undergoing first eye (569) or second eye (292) cataract surgery provided preoperative data of whom 745 (87%) completed postoperative questionnaires. &lt;b&gt;Main outcome measures:&lt;/b&gt; Patient-reported visual function (VF-14); general health status and quality of life (EQ5D); postoperative complications; overall view of the operation and its impact. &lt;b&gt;Results:&lt;/b&gt; Overall, visual function improved (mean VF-14 score increased from 83.2 (SD 17.3) to 93.7 (SD 13.2)). Self-reported general health status deteriorated (20.3% fair or poor before surgery compared with 25% afterwards) which was reflected in the mean EQ5D score (0.82 vs 0.79; p = 0.003). At least one complication was reported by 66 (8.9%) patients, though this probably overestimated the true incidence. If the appropriateness of surgery is based on an increase in VF-14 score of 5.5 (that corresponds to patients’ reporting being "a little better"), 30% of operations would be deemed inappropriate. If an increase of 12.2 (patients’ reports of being "much better") is adopted, the proportion inappropriate is 49%. Using a different approach to determining a minimally important difference, the proportion inappropriate would be closer to 20%. Although visual function (VF-14) scores were unchanged or deteriorated in 25% of patients, 93.1% rated the results of the operation as "good," "very good" or "excellent," and 93.5% felt their eye problem was "better." This partly reflects inadequacies in the validity of the VF-14. &lt;b&gt;Conclusions:&lt;/b&gt; Improvement in the provision of cataract surgery has been accompanied by a reduction in the visual function threshold. However, methodological difficulties in measuring the impact of cataract surgery on visual function and quality of life mean it is impossible to determine whether or not overutilisation of cataract surgery is occurring. N Black1, J Browne1, J van der Meulen1, L Jamieson2, L Copley2 and J Lewsey