Geographic variations in access to cancer services and outcomes along the cancer care pathway

The poorer cancer survival in England in comparison to countries of comparable wealth may be explained by variations in diagnostic and treatment practices, and in disease stage. This highlights the importance of General Practitioners (GPs) in facilitating earlier diagnosis and access to secondary care. Poor access to secondary care has been associated with poorer cancer outcomes. As GPs are the first point of contact with health services for most patients, it is possible that some problems associated with access in secondary care originate from poor GP access. Despite this, there is little evidence describing the relationship between access to GPs and cancer outcomes. This research examines the association between geographical accessibility and cancer outcomes along the cancer care pathway, with a focus on access to the GP. The research begins by reviewing policies on improving access to cancer services, and finds some trade-offs that result when meeting contrasting policy goals. For example, centralisation may improve efficiencies, but may increase inequities in access. One study found that cancer services in England may not be located according to need, but are more likely to be concentrated in urban areas where incidence rates are lower. The other studies examine how geographical access associates with outcomes related to primary care, secondary care and the interface between these two. These studies found that longer travel to primary care has an opposite association on outcomes in rural compared to urban areas, and, has important implications on the mode of cancer diagnosis in secondary care. Additionally, longer travel to both primary and secondary care, and living in an urban area is associated with worse survival, furthermore, times delays and disease stage may be important mediators for these associations. This research generates original evidence showing that geographical access to primary care for diagnosis may have important consequences for cancer outcomes. The findings suggests that rural areas may not necessarily experience poorer outcomes, warranting future research on access issues amongst patients living in urban areas

A Planetary Health Perspective to Decarbonising Public Hospitals in Ireland: A Health Policy Report

Background: Decarbonisation refers to the process by which countries, individuals or other entities aim to achieve zero fossil carbon emissions through reduction of greenhouse gas (GHG) emissions, including procurement, energy and buildings, pharmaceuticals, transport, and waste which impacts public health. Preliminary findings on decarbonisation in healthcare systems suggest that further research is required. Aims: This research was undertaken to explore the opportunities and barriers of decarbonisation of public hospitals within the ‘climate health’ planetary health boundary in the Republic of Ireland. Methodology: A literature review was used in conjunction with semi-structured qualitative interviews to explore barriers and opportunities of decarbonisation of Irish healthcare sector. The purposive sampling for the qualitative interviews resulted in the selection of five key decision-makers within cross-sector fields including environmental, public health, management and transport. Results: Themes emerged which reflected the cross-cutting planetary health principle. Barriers such as financial incentives and the requirement for a transdisciplinary approach were raised. The need for preparing the healthcare sector through adaptation and mitigation of the effects of climate change was also highlighted, as was the importance of leadership within the hospital from all sectors. Recommendations: The findings emerging from this novel research through a planetary health lens can be used to further inform the ‘Climate Action Plan’ in the Republic of Ireland, with adaption to other healthcare sectors internationally, in order to ensure investment within the health sector in preparation for climate change

Variation in Cold-Related Mortality in England Since the Introduction of the Cold Weather Plan: Which Areas Have the Greatest Unmet Needs?

: The Cold Weather Plan (CWP) in England was introduced to prevent the adverse health effects of cold weather; however, its impact is currently unknown. This study characterizes cold-related mortality and fuel poverty at STP (Sustainability and Transformation Partnership) level, and assesses changes in cold risk since the introduction of the CWP. Time series regression was used to estimate mortality risk for up to 28 days following exposure. Area level fuel poverty was used to indicate mitigation against cold exposure and mapped alongside area level risk. We found STP variations in mortality risk, ranging from 1.74, 1.44⁻2.09 (relative risk (RR), 95% CI) in Somerset, to 1.19, 1.01⁻1.40 in Cambridge and Peterborough. Following the introduction of the CWP, national-level mortality risk declined significantly in those aged 0⁻64 (1.34, 1.23⁻1.45, to 1.09, 1.00⁻1.19), but increased significantly among those aged 75+ (1.36, 1.28⁻1.44, to 1.58, 1.47⁻1.70) and for respiratory conditions (1.78, 1.56⁻2.02, to 2.4, 2.10⁻2.79). We show how spatial variation in cold mortality risk has increased since the introduction of the CWP, which may reflect differences in implementation of the plan. Combining risk with fuel poverty information identifies 14 STPs with the greatest need to address the cold effect, and that would gain most from enhanced CWP activity or additional intervention measures

Vitamin A Supplementation and Stunting Levels Among Two Year Olds in Kenya: Evidence from the 2008-09 Kenya Demographic and Health Survey

Background: High levels of undernutrition, particularly stunting, have persisted in Kenya, like in other developing countries. The relationship betweeen vitamin A supplementation and growth of children in Kenya has not been established, while there are context-specific variations on the relationship. This study explores this relationship in the Kenyan context. Methods: The study uses data from the 2008-09 Kenya Demographic and Health Survey, involving children aged 24-35 months, a weighted sample of 1029 children. Descriptive and logistic regression analyses were conducted. The outcome variable of interest is stunting, while the exposure variable of interest is ever receiving a dose of vitamin A supplement. Secondary outcomes include underweight and wasting status. Results: The prevalence of stunting in the study group was 46%; underweight 20%; and wasting 6%. The prevalence of ever receiving vitamin A supplement was 78%. Receiving vitamin A supplement was significantly negatively associated with stunting and underweight status, adjusting for other co-risk factors. The odds of stunting were 50% higher (p=0.038), while for underweight were 75% higher (p=0.013) among children who did not receive Vitamin A supplement compared with those who did. Conclusion: This study demonstrates that receiving vitamin A supplement may be beneficial to growth of young children in Kenya. However, though freely offered through immunization services to children 6-59 months, some children do not receive it, particularly after completing the immunization schedule. There is need to establish innovative and effective ways of maximizing utilization of this intervention, particularly for children who have completed their immunization schedule

Effect of night-time temperatures on cause and age-specific mortality in London.

BACKGROUND: High ambient temperatures are associated with an acute increase in mortality risk. Although heat exposure during the night is anecdotally cited as being important, this has not been rigorously demonstrated in the epidemiological literature. METHODS: We quantified the contribution of nighttime temperatures using time-series quasi-Poisson regression on cause and age-specific daily mortality in London between 1993 and 2015. Daytime and nighttime exposures were characterized by average temperatures between 9 am and 9 pm and between 4 am and 8 am, respectively, lagged by 7 days. We also examined the differential impacts of hot and cool nights preceded by very hot days. All models were adjusted for air quality, season, and day of the week. Nighttime models were additionally adjusted for daytime exposure. RESULTS: Effects from nighttime exposure persisted after adjusting for daytime exposure. This was highest for stroke, RR (relative risk) = 1.65 (95% confidence interval (CI) = 1.27 to 2.14) estimated by comparing mortality risk at the 80th and 99th temperature percentiles. Compared to daytime exposure, nighttime exposure had a higher mortality risk on chronic ischemic and stroke and in the younger age groups. Respiratory mortality was most sensitive to daytime temperatures. Hot days followed by hot nights had a greater mortality risk than hot days followed by cool nights. CONCLUSIONS: Nighttime exposures make an additional important contribution to heat-related mortality. This impact was highest on warm nights that were preceded by a hot day, which justifies the alert criteria in heat-health warning system that is based on hot days followed by hot nights. The highest mortality risk was from stroke; targeted interventions would benefit patients most susceptible to stroke

Geographical access to GPs and modes of cancer diagnosis in England: a cross-sectional study

Background: Poor geographical access to health services and routes to a cancer diagnosis such as emergency presentations have previously been associated with worse cancer outcomes. However, the extent to which access to GPs determines the route that patients take to obtain a cancer diagnosis is unknown. Methods: We used a linked dataset of cancer registry and hospital records of patients with a cancer diagnosis between 2006 and 2010 across eight different cancer sites. Primary outcomes were defined as 'desirable routes to diagnosis' [screen-detected and 2-week wait (TWW) referrals] and 'less desirable routes' [emergency presentations and death certificate only (DCO)]. All other routes (GP referral, inpatient elective and other outpatient) were specified as the reference category. Geographical access was measured as travel time in minutes from patients to their GP, and multinomial logistic regression was used to estimate relative risk ratios (RRR). Results: Longer travel was associated with increased risk of diagnosis via emergency and DCO, but decreased risk of diagnosis via screening and TWW. Patients travelling over 30 minutes had the highest risk of a DCO diagnosis, which was statistically significant for breast, colorectal, lung, prostate, stomach and ovarian cancers (compared with patients with travel times ≤10 minutes: RRR 5.89, 7.02, 2.30, 4.75, 10.41; P < 0.01 and 3.51, P < 0.05). Discussion: Poor access to GPs may discourage early engagement with health services, decreasing the likelihood of screening uptake and increasing the likelihood of emergency presentations. Extra effort is needed to promote early diagnosis in more distant patients

What individual and neighbourhood-level factors increase the risk of heat-related mortality? A case-crossover study of over 185,000 deaths in London using high-resolution climate datasets.

OBJECTIVE: Management of the natural and built environments can help reduce the health impacts of climate change. This is particularly relevant in large cities where urban heat island makes cities warmer than the surrounding areas. We investigate how urban vegetation, housing characteristics and socio-economic factors modify the association between heat exposure and mortality in a large urban area. METHODS: We linked 185,397 death records from the Greater London area during May-Sept 2007-2016 to a high resolution daily temperature dataset. We then applied conditional logistic regression within a case-crossover design to estimate the odds of death from heat exposure by individual (age, sex) and local area factors: land-use type, natural environment (vegetation index, tree cover, domestic garden), built environment (indoor temperature, housing type, lone occupancy) and socio-economic factors (deprivation, English language, level of employment and prevalence of ill-health). RESULTS: Temperatures were higher in neighbourhoods with lower levels of urban vegetation and with higher levels of income deprivation, social-rented housing, and non-native English speakers. Heat-related mortality increased with temperature increase (Odds Ratio (OR), 95% CI?=?1.039, 1.036-1.043 per 1?°C temperature increase). Vegetation cover showed the greatest modification effect, for example the odds of heat-related mortality in quartiles with the highest and lowest tree cover were OR, 95%CI 1.033, 1.026-1.039 and 1.043, 1.037-1.050 respectively. None of the socio-economic variables were a significant modifier of heat-related mortality. CONCLUSIONS: We demonstrate that urban vegetation can modify the mortality risk associated with heat exposure. These findings make an important contribution towards informing city-level climate change adaptation and mitigation policies

From drug discovery to coronaviruses: why restoring natural habitats is good for human health.

Peninah Murage and colleagues argue that biodiversity is the cornerstone of healthy natural habitats. Its preservation is vital to human health and should therefore be embedded into medical and healthcare studies

Impact of travel time and rurality on presentation and outcomes of symptomatic colorectal cancer: a cross-sectional cohort study in primary care

Background: Several studies have reported a survival disadvantage for rural dwellers who develop colorectal cancer, but the underlying mechanisms remain obscure. Delayed presentation to GPs may be a contributory factor, but evidence is lacking. Aim: To examine the association between rurality and travel time on diagnosis and survival of colorectal cancer in a cohort from northeast Scotland. Design and setting: The authors used a database linking GP records to routine data for patients diagnosed between 1997 and 1998, and followed up to 2011. Method: Primary outcomes were alarm symptoms, emergency admissions, stage, and survival. Travel time in minutes from patients to GP was estimated. Logistic and Cox regression were used to model outcomes. Interaction terms were used to determine if travelling time impacted differently on urban versus rural patients. Results: Rural patients and patients travelling farther to the GP had better 3-year survival. When the travel outcome associations were explored using interaction terms, the associations differed between rural and urban areas. Longer travel in urban areas significantly reduced the odds of emergency admissions (odds ratio [OR] 0.62, P<0.05), and increased survival (hazard ratio 0.75, P<0.05). Longer travel also increased the odds of presenting with alarm symptoms in urban areas; this was nearly significant (OR 1.34, P = 0.06). Presence of alarm symptoms reduced the likelihood of emergency admissions (OR 0.36, P<0.01). Conclusion: Living in a rural area, and travelling farther to a GP in urban areas, may reduce the likelihood of emergency admissions and poor survival. This may be related to how patients present with alarm symptoms

A protocol for analysing the effects on health and greenhouse gas emissions of implemented climate change mitigation actions

Background: It is crucial to understand the benefits to human health from decarbonisation to galvanise action among decision makers. Most of our existing evidence comes from modelling studies and little is known about the extent to which the health co-benefits of climate change mitigation actions are realised upon implementation. We aim to analyse evidence from mitigation actions that have been implemented across a range of sectors and scales, to identify those that can improve and sustain health, while accelerating progress towards a zero-carbon economy. Objectives: To understand the implementation process of actions and the role of key actors; explain the contextual elements influencing these actions; summarise what effects, both positive and negative, planned and unplanned they may have on emissions of greenhouse gases and health; and to summarise environmental, social, or economic co-benefits. Data: We will review evidence collected through partnership with existing data holders and an open call for evidence. We will also conduct a hand search of reference lists from systematic reviews and websites of organisations relevant to climate change mitigation. Screening: Screening will be done by two reviewers according to a pre-defined inclusion and exclusion criteria. Analysis: We will identify gaps where implementation or evaluation of implementation of mitigation actions is lacking. We will synthesise the findings to describe how actions were implemented and how they achieved results in different contexts, identifying potential barriers and facilitators to their design, implementation, and uptake. We will also synthesise their effect on health outcomes and other co-benefits. Quantitative synthesis will depend on the heterogeneity of outcomes and metrics. Conclusions: Findings will be used to identify lessons that can be learned from successful and unsuccessful mitigation actions, to make inferences on replicability, scalability, and transferability and will contribute to the development of frameworks that can be used by policy makers.</ns3:p