The economic and innovation contribution of universities: a regional perspective

Universities and other higher education institutions (HEIs) have come to be regarded as key sources of knowledge utilisable in the pursuit of economic growth. Although there have been numerous studies assessing the economic and innovation impact of HEIs, there has been little systematic analysis of differences in the relative contribution of HEIs across regions. This paper provides an exploration of some of these differences in the context of the UK’s regions. Significant differences are found in the wealth generated by universities according to regional location and type of institution. Universities in more competitive regions are generally more productive than those located in less competitive regions. Also, traditional universities are generally more productive than their newer counterparts, with university productivity positively related to knowledge commercialisation capabilities. Weaker regions tend to be more dependent on their universities for income and innovation, but often these universities under-perform in comparison to counterpart institutions in more competitive regions. It is argued that uncompetitive regions lack the additional knowledge infrastructure, besides universities, that are more commonly a feature of more competitive regions

Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016:a systematic analysis for the Global Burden of Disease Study 2016

Background As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseasesand injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases,Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence,and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016.Methods We estimated prevalence and incidence for 328 diseases and injuries and 2982 sequelae, their non-fatalconsequences. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuringconsistency between incidence, prevalence, remission, and cause of death rates for each condition. For some causes,we used alternative modelling strategies if incidence or prevalence needed to be derived from other data. YLDs wereestimated as the product of prevalence and a disability weight for all mutually exclusive sequelae, corrected forcomorbidity and aggregated to cause level. We updated the Socio-demographic Index (SDI), a summary indicator ofincome per capita, years of schooling, and total fertility rate. GBD 2016 complies with the Guidelines for Accurate andTransparent Health Estimates Reporting (GATHER).Findings Globally, low back pain, migraine, age-related and other hearing loss, iron-deficiency anaemia, and majordepressive disorder were the five leading causes of YLDs in 2016, contributing 57·6 million (95% uncertainty interval[UI] 40·8–75·9 million [7·2%, 6·0–8·3]), 45·1 million (29·0–62·8 million [5·6%, 4·0–7·2]), 36·3 million(25·3–50·9 million [4·5%, 3·8–5·3]), 34·7 million (23·0–49·6 million [4·3%, 3·5–5·2]), and 34·1 million(23·5–46·0 million [4·2%, 3·2–5·3]) of total YLDs, respectively. Age-standardised rates of YLDs for all causes combineddecreased between 1990 and 2016 by 2·7% (95% UI 2·3–3·1). Despite mostly stagnant age-standardised rates, theabsolute number of YLDs from non-communicable diseases has been growing rapidly across all SDI quintiles, partlybecause of population growth, but also the ageing of populations. The largest absolute increases in total numbers ofYLDs globally were between the ages of 40 and 69 years. Age-standardised YLD rates for all conditions combinedwere 10·4% (95% UI 9·0–11·8) higher in women than in men. Iron-deficiency anaemia, migraine, Alzheimer’s diseaseand other dementias, major depressive disorder, anxiety, and all musculoskeletal disorders apart from gout were themain conditions contributing to higher YLD rates in women. Men had higher age-standardised rates of substance usedisorders, diabetes, cardiovascular diseases, cancers, and all injuries apart from sexual violence. Globally, we notedmuch less geographical variation in disability than has been documented for premature mortality. In 2016, there was aless than two times difference in age-standardised YLD rates for all causes between the location with the lowest rate(China, 9201 YLDs per 100000, 95% UI 6862–11943) and highest rate (Yemen, 14774 YLDs per 100000, 11018–19228).Interpretation The decrease in death rates since 1990 for most causes has not been matched by a similar decline inage-standardised YLD rates. For many large causes, YLD rates have either been stagnant or have increased for somecauses, such as diabetes. As populations are ageing, and the prevalence of disabling disease generally increasessteeply with age, health systems will face increasing demand for services that are generally costlier than theinterventions that have led to declines in mortality in childhood or for the major causes of mortality in adults. Up-todateinformation about the trends of disease and how this varies between countries is essential to plan for an adequatehealth-system response

Shaping innovations in long-term care for stroke survivors with multimorbidity through stakeholder engagement

BACKGROUND:Stroke, like many long-term conditions, tends to be managed in isolation of its associated risk factors and multimorbidity. With increasing access to clinical and research data there is the potential to combine data from a variety of sources to inform interventions to improve healthcare. A 'Learning Health System' (LHS) is an innovative model of care which transforms integrated data into knowledge to improve healthcare. The objective of this study is to develop a process of engaging stakeholders in the use of clinical and research data to co-produce potential solutions, informed by a LHS, to improve long-term care for stroke survivors with multimorbidity. METHODS:We used a stakeholder engagement study design informed by co-production principles to engage stakeholders, including service users, carers, general practitioners and other health and social care professionals, service managers, commissioners of services, policy makers, third sector representatives and researchers. Over a 10 month period we used a range of methods including stakeholder group meetings, focus groups, nominal group techniques (priority setting and consensus building) and interviews. Qualitative data were recorded, transcribed and analysed thematically. RESULTS:37 participants took part in the study. The concept of how data might drive intervention development was difficult to convey and understand. The engagement process led to four priority areas for needs for data and information being identified by stakeholders: 1) improving continuity of care; 2) improving management of mental health consequences; 3) better access to health and social care; and 4) targeting multiple risk factors. These priorities informed preliminary design interventions. The final choice of intervention was agreed by consensus, informed by consideration of the gap in evidence and local service provision, and availability of robust data. This shaped a co-produced decision support tool to improve secondary prevention after stroke for further development. CONCLUSIONS:Stakeholder engagement to identify data-driven solutions is feasible but requires resources. While a number of potential interventions were identified, the final choice rested not just on stakeholder priorities but also on data availability. Further work is required to evaluate the impact and implementation of data-driven interventions for long-term stroke survivors

Utility of electronic patient records in primary care for stroke secondary prevention trials

BACKGROUND: This study aimed to inform the design of a pragmatic trial of stroke prevention in primary care by evaluating data recorded in electronic patient records (EPRs) as potential outcome measures. The study also evaluated achievement of recommended standards of care; variation between family practices; and changes in risk factor values from before to after stroke. METHODS: Data from the UK General Practice Research Database (GPRD) were analysed for 22,730 participants with an index first stroke between 2003 and 2006 from 414 family practices. For each subject, the EPR was evaluated for the 12 months before and after stroke. Measures relevant to stroke secondary prevention were analysed including blood pressure (BP), cholesterol, smoking, alcohol use, body mass index (BMI), atrial fibrillation, utilisation of antihypertensive, antiplatelet and cholesterol lowering drugs. Intraclass correlation coefficients (ICC) were estimated by family practice. Random effects models were fitted to evaluate changes in risk factor values over time. RESULTS: In the 12 months following stroke, BP was recorded for 90%, cholesterol for 70% and body mass index (BMI) for 47%. ICCs by family practice ranged from 0.02 for BP and BMI to 0.05 for LDL and HDL cholesterol. For subjects with records available both before and after stroke, the mean reductions from before to after stroke were: mean systolic BP, 6.02 mm Hg; diastolic BP, 2.78 mm Hg; total cholesterol, 0.60 mmol/l; BMI, 0.34 Kg/m2. There was an absolute reduction in smokers of 5% and heavy drinkers of 4%. The proportion of stroke patients within the recommended guidelines varied from less than a third (29%) for systolic BP, just over half for BMI (54%), and over 90% (92%) on alcohol consumption. CONCLUSIONS: Electronic patient records have potential for evaluation of outcomes in pragmatic trials of stroke secondary prevention. Stroke prevention interventions in primary care remain suboptimal but important reductions in vascular risk factor values were observed following stroke. Better recording of lifestyle factors in the GPRD has the potential to expand the scope of the GPRD for health care research and practice

Age and Ethnic Disparities in Incidence of Stroke Over Time:The South London Stroke Register

BACKGROUND AND PURPOSE: Data on continuous monitoring of stroke risk among different age and ethnic groups are lacking. We aimed to investigate age and ethnic disparities in stroke incidence over time from an inner-city population-based stroke register.METHODS: Trends in stroke incidence and before-stroke risk factors were investigated with the South London Stroke Register, a population-based register covering a multiethnic population of 357 308 inhabitants. Age-, ethnicity-, and sex-specific incidence rates with 95% confidence intervals were calculated, assuming a Poisson distribution and their trends over time tested by the Cochran-Armitage test.RESULTS: Four thousand two hundred forty-five patients with first-ever stroke were registered between 1995 and 2010. Total stroke incidence reduced by 39.5% during the 16-year period from 247 to 149.5 per 100 000 population (P&lt;0.0001). Similar declines in stroke incidence were observed in men, women, white groups, and those aged &gt;45 years, but not in those aged 15 to 44 years (12.6-10.1; P=0.2034) and black groups (310.1-267.5; P=0.3633). The mean age at stroke decreased significantly from 71.7 to 69.6 years (P=0.0001). The reduction in prevalence of before-stroke risk factors was mostly seen in white patients aged &gt;55 years, whereas an increase in diabetes mellitus was observed in younger black patients aged 15 to 54 years.CONCLUSIONS: Total stroke incidence decreased during the 16-year time period. However, this was not seen in younger age groups and black groups. The advances in risk factor reduction observed in white groups aged &gt;55 years failed to be transferred to younger age groups and black groups.<br/

Trends and Survival Between Ethnic Groups After Stroke:The South London Stroke Register

Background and Purpose—To identify trends and differences between ethnic groups in survival after first-ever stroke and examine factors influencing survival.Methods—Population-based stroke register of first in a lifetime strokes between 1995 and 2010. Baseline data were collection of sociodemographic factors, stroke subtype, case mix, risk factors before stroke, and receipt of effective acute stroke processes. Survival curves were estimated with Kaplan-Meier methods, and survival analyses were undertaken using Cox Proportional-hazards models.Results—Survival improved significantly over this 16-year period (P&lt;0.0001). Black Caribbean and black African had a reduced risk of all-cause mortality compared with white patients (hazard ratio, 0.85 [95% confidence interval, 0.74–0.98] and 0.61 [0.49–0.77], respectively) after adjustment for confounders. This survival advantage of black Caribbean/black African over white mainly existed in older patients (over 65). Recent stroke, being black Caribbean/black African, and stroke unit admission were associated with better survival.Conclusions—Survival has improved in a multiethnic population over time. The independent survival advantage of black Caribbean and black African over White group in those aged over 65 may be a healthy migrant effect of first generation migrants. The increase in admission to a stroke unit may contribute to the improvement in survival after stroke.</p

“People like you?”:how people with hypertension make sense of future cardiovascular risk—a qualitative study

Objectives Cardiovascular disease (CVD) prevention guidelines recommend that patients’ future CVD risk (as a percentage) is estimated and used to inform shared treatment decisions. We sought to understand the perspectives of patients with hypertension on their future risk of CVD.Design Qualitative, semi-structured interviews and thematic analysisParticipants People with hypertension, who had not experienced a cardiovascular event recruited from primary careSetting Participants were purposively sampled from two primary care practices in south London. Interviews were transcribed, and a thematic analysis was conducted.Results 24 people participated; participants were diverse in age, sex, ethnicity, and socioeconomic status. Younger working-aged people were underrepresented. Contrasting with probabilistic risk, many participants understood future CVD as binary, and unknowable. Roughly half of participants avoided contemplating future CVD risk; for some, lifestyle change and medication obviated the need to think about CVD risk. Some participants identified with one portion of the probability fraction (“I’d be one of those ones.”). Comparison with peers (typically partners, siblings, and friends of a similar age, including both ‘healthy’ and ‘unhealthy’ people) was most frequently used to describe risk, both among those who engaged with and avoided risk discussion. This contrasts with current risk scores, which describe probabilities in people with similar risk factors; many participants did not identify with such a group, and hence did not find these probabilities meaningful, even where correctly understood.Conclusions Risk as typically calculated and communicated (e.g. the risk of “100 people like you”) may not be meaningful for patients who do not identify with the denominator. Comparing an individual’s risk with their peers could be more meaningful.<br/

Long-term trends in incidence and risk factors for ischaemic stroke subtypes:Prospective population study of the South London Stroke Register

BACKGROUND: As the average life expectancy increases, more people are predicted to have strokes. Recent studies have shown an increasing incidence in certain types of cerebral infarction. We aimed to estimate time trends in incidence, prior risk factors, and use of preventive treatments for ischaemic stroke (IS) aetiological subtypes and to ascertain any demographic disparities.METHODS AND FINDINGS: Population-based data from the South London Stroke Register (SLSR) between 2000 and 2015 were studied. IS was classified, based on the underlying mechanism, into large-artery atherosclerosis (LAA), cardio-embolism (CE), small-vessel occlusion (SVO), other determined aetiologies (OTH), and undetermined aetiologies (UND). After calculation of age-, sex-, and ethnicity-specific incidence rates by subtype for the 16-year period, we analysed trends using Cochran-Armitage tests, Poisson regression models, and locally estimated scatterplot smoothers (loess). A total of 3,088 patients with first IS were registered. Between 2000-2003 and 2012-2015, the age-adjusted incidence of IS decreased by 43% from 137.3 to 78.4/100,000/year (incidence rate ratio [IRR] 0.57, 95% CI 0.5-0.64). Significant declines were observed in all subtypes, particularly in SVO (37.4-18; p &lt; 0.0001) and less in CE (39.3-25; p &lt; 0.0001). Reductions were recorded in males and females, younger (&lt;55 years old) and older (≥55 years old) individuals, and white and black ethnic groups, though not significantly in the latter (144.6-116.2; p = 0.31 for IS). A 4-fold increase in prior-to-stroke use of statins was found (adjusted odds ratio [OR] 4.39, 95% CI 3.29-5.86), and despite the increasing prevalence of hypertension (OR 1.54, 95% CI 1.21-1.96) and atrial fibrillation (OR 1.7, 95% CI 1.22-2.36), preventive use of antihypertensive and antiplatelet drugs was declining. A smaller number of participants in certain subgroup-specific analyses (e.g., black ethnicity and LAA subtype) could have limited the power to identify significant trends.CONCLUSIONS: The incidence of ISs has been declining since 2000 in all age groups but to a lesser extent in the black population. The reported changes in medication use are unlikely to fully explain the reduction in stroke incidence; however, innovative prevention strategies and better management of risk factors may contribute further reduction.</p

Direct oral anticoagulants versus no anticoagulation for the prevention of stroke in survivors of intracerebral haemorrhage with atrial fibrillation (PRESTIGE-AF):a multicentre, open-label, randomised, phase 3 trial

Background: Direct oral anticoagulants (DOACs) reduce the rate of thromboembolism in patients with atrial fibrillation but the benefits and risks in survivors of intracerebral haemorrhage are uncertain. We aimed to determine whether DOACs reduce the risk of ischaemic stroke without substantially increasing the risk of recurrent intracerebral haemorrhage. Methods: PRESTIGE-AF is a multicentre, open-label, randomised, phase 3 trial conducted at 75 hospitals in six European countries. Eligible patients were aged 18 years or older with spontaneous intracerebral haemorrhage, atrial fibrillation, an indication for anticoagulation, and a score of 4 or less on the modified Rankin Scale. Patients were randomly assigned (1:1) to a DOAC or no anticoagulation, stratified by intracerebral haemorrhage location and sex. Only the events adjudication committee was masked to treatment allocation. The coprimary endpoints were first ischaemic stroke and first recurrent intracerebral haemorrhage. Hierarchical testing for superiority and non-inferiority, respectively, was performed in the intention-to-treat population. The margin to establish non-inferiority regarding intracerebral haemorrhage was less than 1·735. The safety analysis was done in the intention-to-treat population. The trial is registered with ClinicalTrials.gov, NCT03996772, and is complete. Findings: Between May 31, 2019, and Nov 30, 2023, 319 participants were enrolled and 158 were randomly assigned to the DOAC group and 161 to the no anticoagulant group. Patients' median age was 79 years (IQR 73–83). 113 (35%) of 319 patients were female and 206 (65%) were male. Median follow-up was 1·4 years (IQR 0·7–2·3). First ischaemic stroke occurred less frequently in the DOAC group than in the no anticoagulant group (hazard ratio [HR] 0·05 [95% CI 0·01–0·36]; log-rank p&lt;0·0001). The rate of all ischaemic stroke events was 0·83 (95% CI 0·14–2·57) per 100 patient-years in the DOAC group versus 8·60 (5·43–12·80) per 100 patient-years in the no anticoagulant group. For first recurrent intracerebral haemorrhage, the DOAC group did not meet the prespecified HR for the non-inferiority margin of less than 1·735 (HR 10·89 [90% CI 1·95–60·72]; p=0·96). The event rate of all intracerebral haemorrhage was 5·00 (95% CI 2·68–8·39) per 100 patient-years in the DOAC group versus 0·82 (0·14–2·53) per 100 patient years in the no anticoagulant group. Serious adverse events occurred in 70 (44%) of 158 patients in the DOAC group and 89 (55%) of 161 patients in the no anticoagulant group. 16 (10%) patients in the DOAC group and 21 (13%) patients in the no anticoagulant group died. Interpretation: DOACs effectively prevent ischaemic strokes in survivors of intracerebral haemorrhage with atrial fibrillation but a part of this benefit is offset by a substantially increased risk of recurrent intracerebral haemorrhage. To optimise stroke prevention in these vulnerable patients, further evidence from ongoing trials and a meta-analysis of randomised data is needed, as well as the evaluation of safer medical or mechanical alternatives for selected patients. Funding: European Commission.</p