Evaluating the impacts on health outcomes of Welsh Government funded schemes designed to improve the energy efficiency of the homes of low income households: A comparison of individual level and area based schemes.

Introduction Living in a cold and/or damp house can damage health. To reduce fuel poverty in Wales, the Welsh Government developed domestic energy efficiency schemes - an individual-level scheme, Warm Homes Nest and an area-based scheme, Warm Homes Arbed. Both schemes provide improvements to those most likely affected by fuel poverty. Objectives and Approach Overall aim: to evaluate the health impacts of Welsh Government funded schemes designed to reduce fuel poverty. Presented objective: to investigate the relative impact of the individual-level and area-based schemes on the health of recipients. A longitudinal dataset was created using the anonymised residence that received improvements linked to residents’ health measures (hospital admissions, GP prescriptions and clinical diagnoses) using routine health records held in the SAIL Databank at Swansea University. We used difference-in-difference (DID) estimations to compare any changes in recipient health before and after intervention with any concurrent change in health in those yet to receive the intervention. Results An analysis of the Warm Homes Nest Scheme, published in 2017 and presented at the IPDLN 2017 conference found a positive impact of the scheme on the health of recipients. This presentation will describe the further analysis (concluding shortly) comparing the area-based Arbed scheme with both the recipients of the individual-level Nest scheme and groups in comparable need that had not yet received the intervention. We will present results focussing on the relative impacts of the two schemes on cardiovascular, respiratory and general health. Conclusion/Implications Providing home energy efficiency interventions has the potential to benefit population health; however, there is a scarcity of evidence comparing different methods of implementing schemes. Our findings will inform more effectively-focussed home energy efficiency schemes and potentially thus improve the health of people living in Wales

A policy impact case study using real world data from Welsh government fuel poverty schemes to inform scheme design

Objectives To reduce fuel poverty in Wales: the Welsh Government developed schemes to provide energy efficiency improvements to lower income households. To inform scheme design: investigate health impacts by linking scheme data to health records. Presented objective: to demonstrate how research findings using real world data can impact policy focus. Approach The research was conducted by an independent researcher at Swansea University who co-produced research questions with the Welsh Government Fuel Poverty Policy Team. A longitudinal dataset was created linking anonymised ‘Warm Homes: Nest’ improvements data to residents’ routine health records in the SAIL Databank at Swansea University. We examined recipient health before and after intervention compared with controls. A high-level policy briefing and research report were published in the Welsh Government Social Research – Analysis for Policy series. Findings were used to design and pilot new eligibility criteria to capture low-income individuals with a respiratory, circulatory or mental health condition. Results This presentation will describe the policy impact pathway from initial discussions with policymakers to real world change, including: • securing ESRC funding for a Knowledge Transfer Fellowship, which included a 2013 data linking demonstration project… • …which allowed funding to be secured for a 2015-18 research project on the impact of improvements on recipient health… • …which published emerging findings in 2016… • …and substantive findings in 2017, showing a significant positive impact of improvements on recipient health… • …which policymakers used to design a pilot to test ways to widen eligibility criteria to include individuals on a low income with a respiratory, circulatory or mental health condition… • …which led to scheme criteria being widened in 2019. By 2021, 25% of recipients entered the scheme via the ‘health route’. Conclusion By delivering research findings generated using linked real world data, and focused on questions co-produced with policymakers, researchers can successfully impact the design and implementation of government policy, thereby improving the lives of people in the real world - in this case, the health of the citizens of Wales

Evaluating the impacts on health outcomes ofWelsh Government funded schemes designed to improve the energy efficiency of the homes of low income households: A comparison of individual level and area based schemes.

Background To reduce fuel poverty and its adverse health effects in Wales the Welsh Government developed programmes to improve the energy efficiency of homes. This includes the fuel poverty scheme: ‘Warm Homes Nest‘. The scheme was available to low income and vulnerable households in Wales from 2011 to 2015, and provided energy efficiency measures e.g. insulation and heating upgrades such as a more efficient boiler, aimed to maintain warmer homes. Objectives The overall aim was to evaluate the health impacts of Welsh Government funded schemes designed to reduce fuel poverty through the use of existing data linked to the routine health records held in the SAIL Databank at Swansea University. Method We created a longitudinal dataset of individuals living in residential dwellings in receipt of home energy efficiency improvements, then linked to their health records to create a summary of their health utilization measures. We used difference-in-difference (DID) estimations to compare any changes in recipient health before and after intervention against any concurrent change in health in those yet to receive the intervention. Findings We have built upon our previous work presented at the ADRN 2017 conference where we reported a positive impact of the Nest scheme on the respiratory health of recipients. We will show a significant impact on respiratory conditions leading to a change to the eligibility criteria for the successor scheme. We will discuss our ongoing work analysing the impacts of the Nest scheme on mental health outcomes. This will include the findings from the literature search demonstrating the need for more evidence using objective outcome measures, and on selecting and utilizing validated codes developed for administrative data to investigate any changes in common mental health issues such as depression and anxiety. Conclusions Providing home energy efficiency interventions has the potential to benefit population health. Our findings will inform more effectively-focussed home energy efficiency schemes and potentially thus improve the health of people living in Wales

AD|ARC (Administrative Data | Agricultural Research Collection): Linking individual, household and farm business data for agricultural research – Challenges of linking agricultural datasets with individual-level records

Objectives To create an anonymised research-ready data resource of farm households in the UK to generate evidence to support policy development, implementation and evaluation; improve understanding of farm family socio-economic characteristics; and assist stakeholders interested in understanding the health and well-being, resilience and prosperity and spatial properties of farming communities. Methods The ADARC research-ready data resource is being created in each nation of the UK. Each core dataset links agricultural datasets with individual- and household-level population data from the Census 2011. The farm business data is drawn from a number of sources (the Inter Departmental Business Register, EU Farm Structure Survey 2010 and Rural Payments data), which presented many data preparation challenges when linking to the Census of Population. Each core dataset will be linked to the health and education data available for that nation. Where possible, the ADARC datasets have been harmonised to allow federated querying across the UK. Results The ADARC core datasets are complete in Wales and near completion in England and Scotland. Work is also well advanced in Northern Ireland. To the best of our knowledge, these are the first datasets linking agricultural data to individual- and household-level data at a population level. We will report the challenges experienced in linking farm business data with data at the household and individual level. This will include a description of the data preparation steps, the challenges encountered and solutions utilised at each stage of building this complex dataset from numerous, very different ‘parent’ datasets. The structure and content of the core datasets will be presented as well as the potential benefits to researchers investigating the individual, household and community dimensions of agricultural research. Conclusion Agriculture is currently facing a range of challenges with little known about the impact on farmers and farming households. ADARC introduces a new, powerful and versatile resource that will help inform debate and potentially lead to better outcomes on a range of issues relevant to farmers and farming communities

Establishment of a National Homelessness Prevention Programme dataset to enable an anonymised longitudinal dynamic cohort based study

Introduction Welsh Government invests over £120m annually in housing related support to help prevent and tackle homelessness under the ‘Supporting People Programme’. A 2016 data-linkage Feasibility Study indicated health-service utilisation reductions post-intervention, and led to a four year project to create a national, all-Wales dataset to provide robust statistical results. Objectives and Approach Establish data sharing agreements, acquire and import anonymised individual-level data into the SAIL Databank. Create a research ready dataset, designed to permit annual administrative data updates to form dynamic cohort and control groups. Create several control group methods: 1) Internal Programme Data; 2) Matched controls; 3) Healthcare-Utilisation Patterns; 4) External Data Sources. Link to routine health data, obtain and link to other public service data to gain a deeper understanding of the Programme; how it affects use of other public services, and whether it helps people live independently. Complete statistical analysis using a Generalised Linear Mixed Modelling approach. Results Data sharing agreements, data acquisition and standardisation complete for nineteen of twenty-two Unitary Authorities in Wales. Temporal coverage varies by Unitary Authority (2003-2017). 2016 data measures: match rates >85%; 57% female; lead reason for support (top 5) : ‘General’ 20%, ‘Mental Health’ 15%, ‘Older People’ 14%, ‘Domestic Abuse’ 9%, ‘Young People’ 7%. Various control group methods employed: 1) Internal ‘Programme’ Data – no support taken up; 2) Matched controls; 3) Healthcare-Utilisation Patterns – rejected due to sparse outcome data; 4) External Data Sources being further explored. Health data-linkage (emergency admissions, emergency department attendance and primary care events) complete. Ongoing discussions to obtain sample social care, and police call data during 2018. Statistical analysis underway with results planned to be published during the summer of 2018. Conclusion/Implications Despite many challenges, creation of a national linked dataset for people at risk of homelessness is possible with collaborative working between central government, academic and local government bodies. This ‘Administrative Data Research Centre Wales’ project has created a rich research resource enabling statistical analysis to answer research questions around homelessness

AD|ARC: Construction of a research ready dataset to better understand farmers and farming households.

Objectives The AD|ARC Administrative Data: Agriculture Research Collection is an ambitious and original linkage project, bringing together information about farmers and farming households from several sources. When complete, this research-ready dataset will assist in addressing three broad themes: health and well-being, prosperity and resilience, and engagement with agri-environment. Approach The dataset is being constructed from information drawn from survey, census, and administrative sources. Necessarily, this includes working across government departments to ensure comprehensive coverage of farm, business, education, and health data. Similarly, data owners, processors, and researchers are working closely to ensure the resultant dataset meets expectations. Alongside this cross-sectoral aspect, the work is also cross-jurisdictional, with the intention being for the data to capture information about farms, farmers and farming households from across the UK. Results Rather than focus on the detail of the substantive research that AD|ARC will enable, this paper discusses some of the challenges and successes of this linkage project to date. Drawing on the experience of the teams from across the UK (England, Northern Ireland, Scotland, and Wales), the first part will discuss challenges faced in linkage of this multi-faceted project, alongside how the population census is being utilised to better understand farming communities, through the identification of both farming households and workers. Secondly, a broader discussion of the challenges and sensitivities of working across government departments and administrations will be presented, alongside ways of working developed to recognise and overcome these. Conclusion The AD|ARC project will result in an invaluable resource to better understand the farming community, which in turn will help to better inform policy debate and decision making. Alongside this, the process of creating the dataset has offered opportunities for learning and insight across a range of issues

Significant benefits of AIP testing and clinical screening in familial isolated and young-onset pituitary tumors

Context Germline mutations in the aryl hydrocarbon receptor-interacting protein (AIP) gene are responsible for a subset of familial isolated pituitary adenoma (FIPA) cases and sporadic pituitary neuroendocrine tumors (PitNETs). Objective To compare prospectively diagnosed AIP mutation-positive (AIPmut) PitNET patients with clinically presenting patients and to compare the clinical characteristics of AIPmut and AIPneg PitNET patients. Design 12-year prospective, observational study. Participants & Setting We studied probands and family members of FIPA kindreds and sporadic patients with disease onset ≤18 years or macroadenomas with onset ≤30 years (n = 1477). This was a collaborative study conducted at referral centers for pituitary diseases. Interventions & Outcome AIP testing and clinical screening for pituitary disease. Comparison of characteristics of prospectively diagnosed (n = 22) vs clinically presenting AIPmut PitNET patients (n = 145), and AIPmut (n = 167) vs AIPneg PitNET patients (n = 1310). Results Prospectively diagnosed AIPmut PitNET patients had smaller lesions with less suprasellar extension or cavernous sinus invasion and required fewer treatments with fewer operations and no radiotherapy compared with clinically presenting cases; there were fewer cases with active disease and hypopituitarism at last follow-up. When comparing AIPmut and AIPneg cases, AIPmut patients were more often males, younger, more often had GH excess, pituitary apoplexy, suprasellar extension, and more patients required multimodal therapy, including radiotherapy. AIPmut patients (n = 136) with GH excess were taller than AIPneg counterparts (n = 650). Conclusions Prospectively diagnosed AIPmut patients show better outcomes than clinically presenting cases, demonstrating the benefits of genetic and clinical screening. AIP-related pituitary disease has a wide spectrum ranging from aggressively growing lesions to stable or indolent disease course

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570