Restructuring and hospital care: Sub-national trends, differentials, and their impacts; New Zealand from 1981

An analysis of the "nation's health" is the central concern of this study. Its genesis was a detailed, technical, time-series research on regional and ethnic differentials in health in New Zealand. But as this work progressed it became increasingly evident that the results of this more narrow analysis could make a wider contribution to the development of a knowledge-base on health trends and on the impacts of policy on these. In a sense, the analysis provides a demographic audit of health trends over the last two decades. The focus here is different from that in most other studies on restructuring of the New Zealand health system as their concern was either to review in detail the rewriting of policy per se, and attendant structural and institutional changes (Fougere 2001), or to identify how these changes relate to changes in mortality (Blakely et al. 2008). The research question reported here was, instead, to analyse the most crucial of health outcomes, „how long we live and how often we end up in hospital‟, identified in the earlier quotation, to report patterns and trends in hospital use nationally and sub-nationally over the period under review, and to determine the degrees to which various sub-populations benefited, or did not benefit, from these changes. The analysis focuses on the hospital sector in the system, but it will also show relations between this and other sectors, formal (e.g. primary health) and less formal (notably the healthcare afforded sickness and invalid beneficiaries). Thus two questions are addressed: 1. whether or not the nation‟s population health improved over the period and; 2. whether or not there was a convergence in patterns of health gain across its constituent sub-populations defined geographically and ethnically. This monograph deals with sub-national differences in health in New Zealand over a period of substantial socio-economic restructuring and associated radical changes in health policy, health systems and their related information systems (see also, Text Appendix A). It complements the recently published analysis of national ethnic trends in mortality (Blakely et al. 2004), but differs in several critical respects. That study reviewed health status by emphasising aetiologies and causes of death. In contrast, the present analysis focuses on actuarial dimensions of both mortality and morbidity and on health as measured by functional capacity rather than the disease orientated „burden of disease‟. It goes beyond health status issues to look at the system itself, to assess whether health policy outcomes were generated more through efficiency-gain (economic or service delivery, such as those resulting in a convergence sub-nationally of supply and demand effects), or through health gains, or ideally, by both. To do this, and as a by-product to analyse changes in health status and the system in an era of restructuring, innovative methodologies and composite time-series indices combining the two dimensions of a „nation‟s health‟, needing hospital care and longevity, have had to be custom-designed. To achieve this objective, the ensuing analysis is often technical, and may introduce concepts that are unfamiliar to some readers. In order to look at possible inequalities of outcome, comparisons were made between regions and ethnic groups, as well as age-groups and genders, and as a result, in places the analysis becomes rather complex

Associations between indicators of screen time and adiposity indices in Portuguese children

Objectives: To examine associations between three types of screen time (TV, electronic games (EG), and personal computer (PC)) and two proxies of adiposity (body mass index (BMI) and sum of skinfolds) in children. Design: The sample comprised 17,509 children aged 2-13. years who participated in the 2009/10 Portuguese Prevalence Study of Obesity in Childhood. Methods: Complex samples generalised linear models, using school as a cluster variable were ran separately for each combination of ST predictor and adiposity-related outcome, adjusting for covariates including age, sex, physical activity, diet, and parental factors. Missing values in predictors and covariates were imputed. Results: Watching TV for >. 2. h/day compared to <. 1. h/day was associated with higher age- and sex-specific BMI standard deviation score (coefficient: 0.06, 95% CI: 0.01 to 0.12, linear trend p. =. 0.008) and sum of skinfolds (logged and back transformed 0.04, 0.02 to 0.07, p. =. <. 0.001). We also found weak evidence for an inverse association between PC and BMI. Conclusions: Associations between ST and adiposity differ by both type of ST and type of adiposity marker. Only TV viewing was consistently associated with adiposity. Studies using a single adiposity marker looking at total screen time or total sedentary behaviour time may miss or confound type-specific associations. © 2013 Elsevier Inc

Physical activity and risk of all-cause and cardiovascular disease mortality in diabetic adults from Great Britain: pooled analysis of 10 population-based cohorts

OBJECTIVE To examine associations between specific types of physical activity and all-cause and cardiovascular disease (CVD) mortality in a large nationally representative sample of adults with diabetes from Great Britain. RESEARCH DESIGN AND METHODS There were a total of 3,038 participants (675 deaths) with diabetes in the Health Survey for England and the Scottish Health Surveys conducted between 1997 and 2008. Participants aged ‡50 years at baseline were followed up for an average of 75.2 months for all-cause and CVD mortality. Data were collected on selfreported frequency, duration, and intensity of participation in sports and exercise, walking, and domestic physical activity, from which the number of MET-hours/ week were derived. Sex-specific medians of time spent in each type of physical activity (for those physically active)were calculated, and Cox proportional hazards regression conducted to examine type-specific associations between the level of physical activity and all-cause and CVD mortality risk. RESULTS Inverse associations with all-cause and CVD mortality were observed for overall physical activity in a dose-response manner after adjusting for covariates. Compared with those who individuals were inactive, participants who reported some activity, but below the recommended amount, or who met the physical activity recommendations had a 26% (95%CI 39–11) and 35%(95% CI 47–21) lower all-cause mortality, respectively. Similar results were found for below/above median physical activity levels. Sports and exercise participation was inversely associated with all-cause (but not CVD)mortality, as were above average levels of walking. Domestic physical activity was not associated with mortality. CONCLUSIONS Moderate physical activity levels were associated with better prognosis in diabetic adults

Seasonality, risk-factors and burden of community-acquired pneumonia in COPD patients: A population database study using linked healthcare records

Community acquired pneumonia (CAP) is more common in patients with chronic obstructive pulmonary disease (COPD) than in the adult general population, with studies of hospitalised CAP consistently reporting COPD as a frequent comorbidity. However, despite an increasing recognition of its importance, large studies evaluating the incidence patterns over time, risk-factors and burden of CAP in COPD are currently lacking.A retrospective observational study using a large UK-based database of linked primary and secondary care records was conducted. Patients with a diagnosis of COPD aged ?40 years were followed for 5 years from the 1st January 2010. CAP and exacerbation episodes were identified from hospital discharge data and primary care coding records, and rates were calculated per month, adjusting for mortality, and displayed over time. In addition, baseline factors predicting future risk of CAP and hospital admission at CAP, were identified. 14513 COPD patients were identified: 13.4% (n=1938) had ?1 CAP episode, of whom 18.8% suffered from recurrent (?2) CAP. Highest rates of both CAP and exacerbations were seen in winter. A greater proportion of frequent, compared to infrequent exacerbators experienced recurrent CAP (5.1% versus 2.0% respectively, p&lt;0.001) 75.6% of CAP episodes were associated with hospital admission compared to 22.1% of exacerbations. Older age and increasing grade of airflow limitation were independently associated with increased odds of CAP and hospital admission at CAP. Other independent predictors of future CAP included lower body mass index, inhaled-corticosteroid use, prior frequent exacerbations and comorbidities including ischaemic heart disease and diabetes. CAP in COPD demonstrates clear seasonal patterns, with patient characteristics predictive of the odds of future CAP and hospital admission at CAP. Highlighting this burden of COPD-associated CAP during the winter period, informs us of the likely triggers and the need for more effective preventive strategies.<br/

Are sitting occupations associated with increased all-cause, cancer, and cardiovascular disease mortality risk? A pooled analysis of seven British population cohorts

Background: There is mounting evidence for associations between sedentary behaviours and adverse health outcomes, although the data on occupational sitting and mortality risk remain equivocal. The aim of this study was to determine the association between occupational sitting and cardiovascular, cancer and all-cause mortality in a pooled sample of seven British general population cohorts. Methods: The sample comprised 5380 women and 5788 men in employment who were drawn from five Health Survey for England and two Scottish Health Survey cohorts. Participants were classified as reporting standing, walking or sitting in their work time and followed up over 12.9 years for mortality. Data were modelled using Cox proportional hazard regression adjusted for age, waist circumference, self-reported general health, frequency of alcohol intake, cigarette smoking, nonoccupational physical activity, prevalent cardiovascular disease and cancer at baseline, psychological health, social class, and education. Results: In total there were 754 all-cause deaths. In women, a standing/walking occupation was associated with lower risk of all-cause (fully adjusted hazard ratio [HR] = 0.68, 95% CI 0.52–0.89) and cancer (HR = 0.60, 95% CI 0.43–0.85) mortality, compared to sitting occupations. There were no associations in men. In analyses with combined occupational type and leisure-time physical activity, the risk of all-cause mortality was lowest in participants with non-sitting occupations and high leisure-time activity. Conclusions: Sitting occupations are linked to increased risk for all-cause and cancer mortality in women only, but no such associations exist for cardiovascular mortality in men or women

Distinct emphysema subtypes defined by quantitative CT analysis are associated with specific pulmonary matrix metalloproteinases

BACKGROUND: Emphysema is characterised by distinct pathological sub-types, but little is known about the divergent underlying aetiology. Matrix-metalloproteinases (MMPs) are proteolytic enzymes that can degrade the extracellular matrix and have been identified as potentially important in the development of emphysema. However, the relationship between MMPs and emphysema sub-type is unknown. We investigated the role of MMPs and their inhibitors in the development of emphysema sub-types by quantifying levels and determining relationships with these sub-types in mild-moderate COPD patients and ex/current smokers with preserved lung function.METHODS: Twenty-four mild-moderate COPD and 8 ex/current smokers with preserved lung function underwent high resolution CT and distinct emphysema sub-types were quantified using novel local histogram-based assessment of lung density. We analysed levels of MMPs and tissue inhibitors of MMPs (TIMPs) in bronchoalveolar lavage (BAL) and assessed their relationship with these emphysema sub-types.RESULTS: The most prevalent emphysema subtypes in COPD subjects were mild and moderate centrilobular (CLE) emphysema, while only small amounts of severe centrilobular emphysema, paraseptal emphysema (PSE) and panlobular emphysema (PLE) were present. MMP-3, and -10 associated with all emphysema sub-types other than mild CLE, while MMP-7 and -8 had associations with moderate and severe CLE and PSE. MMP-9 also had associations with moderate CLE and paraseptal emphysema. Mild CLE occurred in substantial quantities irrespective of whether airflow obstruction was present and did not show any associations with MMPs.CONCLUSION: Multiple MMPs are directly associated with emphysema sub-types identified by CT imaging, apart from mild CLE. This suggests that MMPs play a significant role in the tissue destruction seen in the more severe sub-types of emphysema, whereas early emphysematous change may be driven by a different mechanism.TRIAL REGISTRATION: Trial registration number NCT01701869

Health inequalities in New Zealand: an examination of mortality and hospital utilisation trends, with reference to the compression of morbidity hypothesis

This thesis examines health inequalities by area-level socioeconomic deprivation, and health in later life in New Zealand. It identifies whether expansion or compression of morbidity is occurring at the end of life. It asks if overall morbidity at a population level is likely to increase or decrease in future as life expectancy increases, and if the same trend is seen for more and less deprived areas. The focus of this research is the identification and dissemination of mortality and morbidity patterns present in two large datasets, using powerful but relatively simple techniques. Large administrative datasets on morbidity and public hospital discharges in New Zealand between 1974 and 2006 are used in the analyses.The thesis consists of three papers. Each paper uses the same datasets, but addresses separate research questions using different methods. The first paper is an exploratory analysis of age-specific and age-standardised mortality and hospital bed day rates, which are used as a proxy for morbidity. The second paper explores lifetime morbidity by using period-prevalence life table functions including Hospital Utilisation Expectancies: a variation of health expectancies. The third paper uses individual record linkage between the mortality and hospital datasets to examine hospital use in the last few months of life.Hospital bed day and mortality rates declined over the time period, and convergence was seen between more and less deprived areas. Individuals at the oldest ages (80 years and over) saw little variation in hospital or mortality rates by area deprivation. Strong evidence for compression of morbidity was observed, particularly at older ages. This was in the absence of evidence for rectangularisation of the survival curve, considered by some to be a prerequisite for compression of morbidity. Rectangularisation of the survival curve would be denoted by life expectancy increases slowing, indicating the nearing of a limit to life expectancy. Instead, compression of morbidity was achieved through a decline in the severity of morbidity in the months prior to death. No evidence of a change in the point at onset of morbidity prior to death was observed. There was however some evidence that the decline in hospital utilisation prior to death (particularly for deathsat older ages) may be partly artefactual. Further research using a different measure of morbidity is required to either support or disprove this theory

Children's and adolescents' sedentary behaviour in relation to socioeconomic position

Conclusions: Low SEP is linked with higher television times but with lower total (accelerometer-measured) sedentary time, and non-TV sitting during non-school time in children and adolescents. Associations between sedentary time and SEP differ by type of sedentary behaviour. TV viewing is not a good proxy for total sedentary time in children.