The impact of the COVID-19 pandemic on non-COVID-associated mortality : a descriptive longitudinal study of UK data

It has been previously reported in the literature that the COVID-19 pandemic resulted in overall excess deaths and an increase in non-COVID deaths during the pandemic period.Specifically, our research elucidates the impact of the COVID-19 pandemic on non-COVID associated mortality. To compare mortality rates in non-COVID conditions before and after the onset of the COVID-19 pandemic in England and Wales. Annual mortality data for the years 2011-2019 (pre-pandemic) and 2020 (pandemic) in England and Wales were retrieved from the Office for National Statistics (ONS). These data were filtered by ICD-10 codes for nine conditions with high associated mortality. We calculated mortality numbers - overall and age stratified (20-64 and 65+ years) and rates per 100 000, using annual mid-year population estimates. Interrupted time series analyses were conducted using segmented quasi-Poisson regression to identify whether there was a statistically significant change (p < 0.05) in condition-specific death rates following the pandemic onset. Eight of the nine conditions investigated in this study had significant changes in mortality rate during the pandemic period (2020). All-age mortality rate was significantly increased in: 'Symptoms Signs and Ill-defined conditions', 'Cirrhosis and Other Diseases of the Liver', and 'Malignant Neoplasm of the Breast', whereas 'Chronic Lower Respiratory Disorders' saw a significant decrease. Age-stratified analyses also revealed significant increases in the 20-64 age-group in: 'Cerebrovascular Disorders', 'Dementia and Alzheimer's Disease', and 'Ischaemic Heart Diseases'. Trends in non-COVID condition-specific mortality rates from 2011 to 2020 revealed that some non-COVID conditions were disproportionately affected during the pandemic. This may be due to the direct impact COVID-19 had on these conditions or the effect the public health response had on non-COVID risk factor development and condition-related management. Further work is required to understand the reasons behind these disproportionate changes. [Abstract copyright: © 2024 The Authors.

Does a bursary scheme for students in low- to middle-income countries influence outcomes in a master’s programme in Public Health?

Introduction The People’s Open Access Education Initiative (Peoples-uni) provides online education for health professionals in Public Health at the master’s level. Although fees are low due to the use of volunteers and Open Educational Resources, a bursary scheme is provided to waive all or some of the fees. This study tests the hypothesis that student outcomes of completing and passing modules are higher among those given a bursary than others. Methods Data were retrieved for all students enrolling between 2009-2017, including demographics and module outcomes, where available. Multivariable logistic regression was used to identify factors associated with a successful bursary application, as well as to elicit whether a successful bursary application was associated with ever completing, or ever passing, a module. Results Data were obtained from 1499 students. Of these, 624 (42%) had ever completed a module, and 513 (34%) had ever passed a module. 503 students (34%) had applied for a bursary, of whom 285 (57%) were successful. After adjusting for demographic variables, employment status and education level, students who were given a bursary were more likely to ever pass a module (adjusted odds ratio [aOR] 2.3, 95% CI 1.7,3.3), as were those who applied for a bursary but were unsuccessful (aOR 1.9, 95% CI 1.3,2.8), compared with students who had not applied for a bursary. Similar results were obtained for the outcome of completing a module. Conclusions Students who were successful in gaining a bursary, as well as those who were not but still able to enroll, were more likely to complete or pass a module than those who did not apply. These results point to the success of the bursary scheme and give us confidence to continue to offer bursaries, in order to sustain the mission of improving population health through capacity building in low resource settings

The relationship between quality and outcomes framework scores and socioeconomic deprivation : a longitudinal study

Background: The Quality Outcomes Framework (QOF) is a pay incentive scheme in England designed to improve and standardise general practice. QOF attainment has been used as a proxy for primary care quality in previous research. Aim: To investigate whether there is a relationship between socioeconomic deprivation and QOF attainment in primary care in England. Design & setting: Retrospective longitudinal study of primary care providers in England. Method: QOF scores were obtained for individual general practices in England from between 2007–2019 and linked to practice-level Indices of Multiple Deprivation (IMD) scores derived from census data. Beta regression analyses were used to analyse the relationship with either percentage of total QOF attainment, or of domain-specific attainment, with multivariate analyses adjusting for additional practice-level demographics. QOF attainment in the most affluent quintile was used as the reference group. Results: General practices in less deprived areas have consistently outperformed those in more deprived areas in terms of QOF achievement. Initially, the gap between least and most deprived practices decreased, however since 2015 there has been relatively little change in comparative performance. The magnitude of inequality was reduced after adjusting for demographic factors. Of the independent variables analysed, the proportion of over 65 seconds had the strongest relationship with QOF attainment. Conclusion: There remains an inequality in primary care quality by socioeconomic deprivation in England, even after accounting for demographic differences

Guidance impact on primary care prescribing rates of simple analgesia: an interrupted time series analysis in England

Background: In March 2018, NHS England published guidance for Clinical Commissioning Groups (CCGs; NHS bodies that commission health services for local areas) to encourage implementation of policy to reduce primary care prescriptions of over-the-counter medications, including simple analgesia. Aims: To investigate: the impact of guidance publication on prescribing rates of simple analgesia (oral paracetamol, oral ibuprofen and topical non-steroidal anti-inflammatory drugs [NSAIDS]) in primary care; CCG implementation intentions; and whether it has created a health inequality based on socioeconomic status. Design and Setting: Interrupted time series analysis of primary care prescribing data in England. Methods: Practice-level prescribing data from January 2015 to March 2019 were obtained from NHS Digital. Interrupted time series analyses assessed the association of guidance publication with prescribing rates. The association between practice-level prescribing rates and Index of Multiple Deprivation score (a marker of socioeconomic deprivation) before and after publication was quantified using multivariable Poisson regression. Freedom of information requests were submitted to all CCGs. Results: There was a 4% reduction in prescribing of simple analgesia following guidance publication (adjusted incidence rate ratio [aIRR] 0.96, 95% CI 0.92-0.99, p=0.027), adjusting for underlying time trend and seasonality. Practice-level prescribing rates were greater in more deprived areas. There was considerable diversity across CCGs in whether or how they chose to implement the guidance. Conclusion: Guidance publication was associated with a small reduction in the prescribing rates of simple analgesia across England, without evidence of creating an additional health inequality. Careful implementation by CCGs would be required to optimise cost-saving to the NHS

Socioeconomic status and benzodiazepine and Z-drug prescribing : a cross-sectional study of practice-level data in England

Background Benzodiazepines and Z-drugs (such as zopiclone) are widely prescribed in primary care. Given their association with addiction and dependence, understanding where and for whom these medications are being prescribed is a necessary step in addressing potentially harmful prescribing. Objective To determine whether there is an association between primary care practice benzodiazepine and Z-drug prescribing and practice population socioeconomic status in England. Methods This was a cross-sectional study. An aggregated data set was created to include primary care prescribing data for 2017, practice age and sex profiles and practice Index of Multiple Deprivation (IMD) scores—a marker of socioeconomic status. Drug doses were converted to their milligram-equivalent of diazepam to allow comparison. Multiple linear regression was used to examine the association between IMD and prescribing (for all benzodiazepines and Z-drugs in total, and individually), adjusting for practice sex (% male) and older age (>65 years) distribution (%). Results Benzodiazepine and Z-drug prescribing overall was positively associated with practice-level IMD score, with more prescribing in practices with more underserved patients, after adjusting for age and sex (P < 0.001), although the strength of the association varied by individual drug. Overall, however, IMD score, age and sex only explained a small proportion of the overall variation in prescribing across GP practices. Conclusion Our findings may, in part, be a reflection of an underlying association between the indications for benzodiazepine and Z-drug prescribing and socioeconomic status. Further work is required to more accurately define the major contributors of prescribing variation

Socioeconomic status and HRT prescribing : a study of practice-level data in England

Background Concerns have been raised that women from deprived backgrounds are less likely to be receiving hormone replacement therapy (HRT) treatment and its benefits, although evidence in support of this is lacking. Aim To investigate general practice HRT prescription trends and their association with markers of socioeconomic deprivation. Design Cross-sectional study of primary care prescribing data in England in 2018. Method Practice-level prescribing rate was defined as the number of items of HRT prescribed per 1000 registered female patients over the age of 40 years. The association between Index of Multiple Deprivation (IMD) score and HRT prescribing rate was tested using multivariate Poisson regression, adjusting for practice proportions of obesity, smoking, hypertension, diabetes, coronary heart disease and cerebrovascular disease and practice list size. Results The overall prescribing rate of HRT was 29% lower in practices from the most deprived quintile compared with the most affluent (incidence rate ratio [IRR] 0.71, 95% CI 0.68-0.73). After adjusting for all cardiovascular disease outcomes and risk factors, the prescribing rate in the most deprived quintile was still 18% lower than in the least deprived quintile (adjusted IRR 0.82, 95% CI 0.77-0.86). In more deprived practices, there was a significantly higher tendency to prescribe oral HRT than transdermal preparations (p < 0.001). Conclusion This study has highlighted inequalities associated with HRT prescription. This may reflect a large unmet need in terms of menopause care in areas of deprivation. Further research is needed to identify the factors from patient and GP perspectives that may explain this

Potential excess spend in primary care due to NHS drug tariff variability in vitamin D preparations

Objectives Vitamin D is commonly prescribed in primary care for the prevention and treatment of deficiency and for maintenance after treatment (although supplementation for maintenance and prevention can be bought over-the-counter). There is wide variation in the costs to the NHS in England of oral preparations of vitamin D, even for a single-specific dose and route.1 It is possible that the availability of multiple options for the same intended medicine, the costs of which are unlikely to be known by the prescriber, could result in an inadvertent excess spend. We aimed to estimate the annual cost-saving if only the cheapest vitamin D preparations were prescribed. Design Primary care prescribing data for 2018 were downloaded from NHS Digital (https://digital.nhs.uk).2 Monthly datasets include the number of items, quantity and cost of each drug prescribed and dispensed. Private prescriptions are not recorded. All prescription items relating to the vitamin D preparations colecalciferol and ergocalciferol, regardless of dose, route or manufacturer, were extracted. Data for each specific preparation were aggregated across all practices and all months to give the annual number of items and their cost across England. All liquid and injectable preparations were assumed to be appropriately prescribed and therefore excluded from the analysis. Combined preparations – such as calcium/vitamin D, calcium/alendronate and multivitamins – were also excluded. For each defined dose range of vitamin D, the lowest cost preparation was identified, and the potential cost-savings if only these preparations were prescribed was calculated. Setting Primary care in England. Participants All patients registered with a general practitioner in England in 2018. Main Outcome Measure The difference between actual and potential spend on vitamin D prescriptions, if only the lowest priced preparation were available. Results In 2018, over 4 million vitamin D items were prescribed in primary care, at a cost of over £21 million. If only the cheapest options were prescribed for non-liquid preparations across all dose ranges, and assuming all prescriptions were appropriate, it would have resulted in an approximate £15 million (>70%) cost-saving to the NHS. Maintenance doses of vitamin D (designated as 800 to 2000 international units per day as per NICE guidelines3) accounted for more than half of the spend (∼£12 million). It was noted that all the cheapest options available are suitable for vegetarians. Conclusion The prescribing of more expensive vitamin D preparations in primary care may have significant financial consequences, although our results relate to a single year of prescribing within NHS primary care. Since choice of preparation may intentionally be based on factors other than cost (e.g. dietary requirements, bioavailability, what was initially prescribed by a hospital), work is needed nationally to rationalise available prescribing options. If national guidance were produced, the difficulties of implementation within individual Clinical Commissioning Groups might limit economic benefit. National efficient procurement strategies are an alternative approach, but require careful consideration of legislative frameworks (such as the Public Contract Regulations 20154) with safeguards to prevent horizontal cooperation between suppliers

Knowledge about E-Cigarettes and tobacco harm reduction among public health residents in Europe

Introduction: Although electronic cigarettes (e-cigarettes) and other tobacco-related products are becoming widely popular as alternatives to tobacco, little has been published on the knowledge of healthcare workers about their use. Thus, the aim of this study was to elicit the current knowledge and perceptions about e-cigarettes and tobacco harm reduction (THR) among medical residents in public health (MRPH). Material and Methods: A Europe-wide cross-sectional study was carried out amongst MRPH from the countries associated with the European Network of MRPH from April to October 2018 using an online questionnaire. Results: 256 MRPHs agreed to participate in the survey. Approximately half the participants were women (57.4%), with a median age of 30 years, and were mainly Italian (26.7%), Spanish (16.9%) and Portuguese (16.5%). Smoking prevalence was 12.9%. Overall, risk scores significantly differed for each investigated smoking product when compared with e-cigarettes; with tobacco cigarettes and snus perceived as more risky, and nicotine replacement therapy (NRT) and non-NRT oral medications seen as less risky (p 0.01 for all). Regarding the effects of nicotine on health, the vast majority of MRPHs associated nicotine with all smoking-related diseases. Knowledge of THR was low throughout the whole sample. Conclusions: European MRPH showed a suboptimal level of knowledge about e-cigarettes and THR. Training programs for public health and preventive medicine trainees should address this gap

A systematic review of the burden of hypertension, access to services and patient views of hypertension in humanitarian crisis settings

Introduction Globally, a record number of people are affected by humanitarian crises caused by conflict and natural disasters. Many such populations live in settings where epidemiological transition is underway. Following the United Nations high level meeting on non-communicable diseases, the global commitment to Universal Health Coverage and needs expressed by humanitarian agencies, there is increasing effort to develop guidelines for the management of hypertension in humanitarian settings. The objective was to investigate the prevalence and incidence of hypertension in populations directly affected by humanitarian crises; the cascade of care in these populations and patient knowledge of and attitude to hypertension. Methods A literature search was carried out in five databases. Grey literature was searched. The population of interest was adult, non-pregnant, civilians living in any country who were directly exposed to a crisis since 1999. Eligibility assessment, data extraction and quality appraisal were carried out in duplicate. Results Sixty-one studies were included in the narrative synthesis. They reported on a range of crises including the wars in Syria and Iraq, the Great East Japan Earthquake, Hurricane Katrina and Palestinian refugees. There were few studies from Africa or Asia (excluding Japan). The studies predominantly assessed prevalence of hypertension. This varied with geography and age of the population. Access to care, patient understanding and patient views on hypertension were poorly examined. Most of the studies had a high risk of bias due to methods used in the diagnosis of hypertension and in the selection of study populations. Conclusion Hypertension is seen in a range of humanitarian settings and the burden can be considerable. Further studies are needed to accurately estimate prevalence of hypertension in crisis-affected populations throughout the world. An appreciation of patient knowledge and understanding of hypertension as well as the cascade of care would be invaluable in informing service provision