Mortality for Alcohol-related Harm by Country of Birth in Scotland, 2000-2004: Potential Lessons for Prevention

Aims: Deaths caused by alcohol have increased in the UK, and Scotland in particular, but the change in the rates of alcohol-related deaths for migrants are uncertain, and could yield insights for the general population. Methods: Alcohol-related mortality in immigrants among Scotland’s residents was assessed using 2001 census data and mortality data from 2000 to 2004. Results: Mortality from direct alcohol-related causes accounted for nearly 1500 deaths per year in Scotland. Age-standardized mortality ratios were comparatively low for people born in Pakistan, other parts of the UK (largely England and Wales) and those from elsewhere in the world. Conclusions: Scotland’s propensity to alcohol-related deaths is not shared by all its residents. Studying such variations in more depth could yield lessons for prevention

Burden of disease scenarios for 204 countries and territories, 2022–2050:a forecasting analysis for the Global Burden of Disease Study 2021

BackgroundFuture trends in disease burden and drivers of health are of great interest to policy makers and the public at large. This information can be used for policy and long-term health investment, planning, and prioritisation. We have expanded and improved upon previous forecasts produced as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) and provide a reference forecast (the most likely future), and alternative scenarios assessing disease burden trajectories if selected sets of risk factors were eliminated from current levels by 2050.MethodsUsing forecasts of major drivers of health such as the Socio-demographic Index (SDI; a composite measure of lag-distributed income per capita, mean years of education, and total fertility under 25 years of age) and the full set of risk factor exposures captured by GBD, we provide cause-specific forecasts of mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) by age and sex from 2022 to 2050 for 204 countries and territories, 21 GBD regions, seven super-regions, and the world. All analyses were done at the cause-specific level so that only risk factors deemed causal by the GBD comparative risk assessment influenced future trajectories of mortality for each disease. Cause-specific mortality was modelled using mixed-effects models with SDI and time as the main covariates, and the combined impact of causal risk factors as an offset in the model. At the all-cause mortality level, we captured unexplained variation by modelling residuals with an autoregressive integrated moving average model with drift attenuation. These all-cause forecasts constrained the cause-specific forecasts at successively deeper levels of the GBD cause hierarchy using cascading mortality models, thus ensuring a robust estimate of cause-specific mortality. For non-fatal measures (eg, low back pain), incidence and prevalence were forecasted from mixed-effects models with SDI as the main covariate, and YLDs were computed from the resulting prevalence forecasts and average disability weights from GBD. Alternative future scenarios were constructed by replacing appropriate reference trajectories for risk factors with hypothetical trajectories of gradual elimination of risk factor exposure from current levels to 2050. The scenarios were constructed from various sets of risk factors: environmental risks (Safer Environment scenario), risks associated with communicable, maternal, neonatal, and nutritional diseases (CMNNs; Improved Childhood Nutrition and Vaccination scenario), risks associated with major non-communicable diseases (NCDs; Improved Behavioural and Metabolic Risks scenario), and the combined effects of these three scenarios. Using the Shared Socioeconomic Pathways climate scenarios SSP2-4.5 as reference and SSP1-1.9 as an optimistic alternative in the Safer Environment scenario, we accounted for climate change impact on health by using the most recent Intergovernmental Panel on Climate Change temperature forecasts and published trajectories of ambient air pollution for the same two scenarios. Life expectancy and healthy life expectancy were computed using standard methods. The forecasting framework includes computing the age-sex-specific future population for each location and separately for each scenario. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline.FindingsIn the reference scenario forecast, global and super-regional life expectancy increased from 2022 to 2050, but improvement was at a slower pace than in the three decades preceding the COVID-19 pandemic (beginning in 2020). Gains in future life expectancy were forecasted to be greatest in super-regions with comparatively low life expectancies (such as sub-Saharan Africa) compared with super-regions with higher life expectancies (such as the high-income super-region), leading to a trend towards convergence in life expectancy across locations between now and 2050. At the super-region level, forecasted healthy life expectancy patterns were similar to those of life expectancies. Forecasts for the reference scenario found that health will improve in the coming decades, with all-cause age-standardised DALY rates decreasing in every GBD super-region. The total DALY burden measured in counts, however, will increase in every super-region, largely a function of population ageing and growth. We also forecasted that both DALY counts and age-standardised DALY rates will continue to shift from CMNNs to NCDs, with the most pronounced shifts occurring in sub-Saharan Africa (60·1% [95% UI 56·8–63·1] of DALYs were from CMNNs in 2022 compared with 35·8% [31·0–45·0] in 2050) and south Asia (31·7% [29·2–34·1] to 15·5% [13·7–17·5]). This shift is reflected in the leading global causes of DALYs, with the top four causes in 2050 being ischaemic heart disease, stroke, diabetes, and chronic obstructive pulmonary disease, compared with 2022, with ischaemic heart disease, neonatal disorders, stroke, and lower respiratory infections at the top. The global proportion of DALYs due to YLDs likewise increased from 33·8% (27·4–40·3) to 41·1% (33·9–48·1) from 2022 to 2050, demonstrating an important shift in overall disease burden towards morbidity and away from premature death. The largest shift of this kind was forecasted for sub-Saharan Africa, from 20·1% (15·6–25·3) of DALYs due to YLDs in 2022 to 35·6% (26·5–43·0) in 2050. In the assessment of alternative future scenarios, the combined effects of the scenarios (Safer Environment, Improved Childhood Nutrition and Vaccination, and Improved Behavioural and Metabolic Risks scenarios) demonstrated an important decrease in the global burden of DALYs in 2050 of 15·4% (13·5–17·5) compared with the reference scenario, with decreases across super-regions ranging from 10·4% (9·7–11·3) in the high-income super-region to 23·9% (20·7–27·3) in north Africa and the Middle East. The Safer Environment scenario had its largest decrease in sub-Saharan Africa (5·2% [3·5–6·8]), the Improved Behavioural and Metabolic Risks scenario in north Africa and the Middle East (23·2% [20·2–26·5]), and the Improved Nutrition and Vaccination scenario in sub-Saharan Africa (2·0% [–0·6 to 3·6]).InterpretationGlobally, life expectancy and age-standardised disease burden were forecasted to improve between 2022 and 2050, with the majority of the burden continuing to shift from CMNNs to NCDs. That said, continued progress on reducing the CMNN disease burden will be dependent on maintaining investment in and policy emphasis on CMNN disease prevention and treatment. Mostly due to growth and ageing of populations, the number of deaths and DALYs due to all causes combined will generally increase. By constructing alternative future scenarios wherein certain risk exposures are eliminated by 2050, we have shown that opportunities exist to substantially improve health outcomes in the future through concerted efforts to prevent exposure to well established risk factors and to expand access to key health interventions.FundingBill & Melinda Gates Foundation

Narrowing the gap in careers in clinical research and academia for healthcare professionals: A scoping review on the role of major funding bodies in the UK

Differential attainment (DA) exists in research and academia, where individuals with protected characteristics face barriers to progression at different stages from selection in training or career pathways through to obtaining funding and getting research published. The causes of DA are multifactorial, however more barriers are associated with an individual’s gender, race, ethnicity, sexual orientation, disability or other social and economic factors rather than academic factors related to research. DA is seen across medicine and healthcare therefore it is likely a manifestation of wider inequalities experienced by these individuals within society. This scoping review takes a first step at exploring DA through the lens of equality, diversity and inclusion in research and academia, specific to healthcare professionals in medicine, in the UK. Given the paucity of published data, benchmarking and investigation of the causes of DA and access in this area, this review seeks to identify what published reports exploring this issue reveal. There has been mixed success in the area of gender equality with the Athena Swan benchmarking exercise; however differences in outcomes exist within gender when other protected characteristics, such as ethnicity, are also explored. The DA observed among women despite the Athena Swan programme demonstrates other factors such as allyship, apprenticeship, sponsorship and mentoring which may be accessible to some individuals, but not others. Furthermore, ethnicity appears to be a barrier to accessing this form of support, and non-Black and Minority Ethnic (BAME) women appear to be more privileged to receiving this type of support. Without more research into the lived experiences of individuals from non-traditional backgrounds at the micro-level, as well as data across the career progression pathway over time at the macro-level, the problem of DA is unlikely to improve. If anything, lack of openness and transparency around such data at an organisational level, may exacerbate the sense of injustice within research and academia among individuals with protected characteristics, especially given that the perceived sense of DA is very real for them. The purpose of this paper is to start the conversation with stakeholders within research and academia, about DA and commence the process of reducing the gap using equality, diversity and inclusion as fundamental concepts for achieving a level playing field for all. This type of accountability is essential for developing trust and in the system. Such open conversations need to happen across every organisation, that is a stakeholder of research and academia in the UK.Peer reviewe

Ethnic variations in five lower gastrointestinal diseases: Scottish Health and Ethnicity Linkage Study

OBJECTIVES: Our objective was to augment the limited evidence mainly from local, clinical studies of ethnic differences in gastrointestinal disorders. Our question was: are there ethnic variations in hospitalisation/death for lower gastrointestinal disorders in Scotland? SETTING: Scotland. POPULATION: This retrospective-cohort linked 4.65 (of 4.9) million people in the 2001 census of Scotland (providing data on ethnicity, country of birth and indicators of socioeconomic deprivation) to 9 years of National Health Service hospitalisation and death records. PRIMARY AND SECONDARY OUTCOME MEASURES AND ANALYSIS: For appendicitis, we studied all ages; for irritable bowel syndrome, ulcerative colitis, Crohn's disease and diverticular disease, we included those ≥20 years. Using Poisson regression (robust variance) we calculated, by ethnic group and sex, first-hospitalisation/death age-adjusted rates per 100 000 person-years, and relative risks (RRs) with 95% CIs multiplied by 100, so the White Scottish reference population had an RR=100. RESULTS: There were ethnic variations; for example, for irritable bowel syndrome, RRs (95% CIs) were comparatively high in Other White British women (128.4 (111.0 to 148.6)), and low in Pakistani women (75.1 (60.6 to 93.1)). For appendicitis, RRs were high in men in Other White British (145.2 (127.8 to 164.9)), and low in most non-White groups, for example, Pakistanis (73.8 (56.9 to 95.6)). For ulcerative colitis, RRs were high in Indian (169.8 (109.7 to 262.7)) and Pakistani (160.8 (104.2 to 248.2)) men. For Crohn's disease, the RR was high in Pakistani men (209.2 (149.6 to 292.6)). For diverticular disease, RRs were high in Irish men (176.0 (156.9 to 197.5)), and any Mixed background women (144.6 (107.4 to 194.8)), and low in most non-White groups, for example, Chinese men (47.1 (31.0 to 71.6) and women (46.0 (30.4 to 69.8)). CONCLUSIONS: Appendicitis and diverticular disease were comparatively low in most non-White groups, while ulcerative colitis and Crohn's disease were mostly higher in South Asians. Describing and understanding such patterns may help clinical practice and research internationally

Information standards for recording alcohol use in electronic health records::Findings from a national consultation

Abstract Background Alcohol misuse is an important cause of premature disability and death. While clinicians are recommended to ask patients about alcohol use and provide brief interventions and specialist referral, this is poorly implemented in routine practice. We undertook a national consultation to ascertain the appropriateness of proposed standards for recording information about alcohol use in electronic health records (EHRs) in the UK and to identify potential barriers and facilitators to their implementation in practice. Methods A wide range of stakeholders in the UK were consulted about the appropriateness of proposed information standards for recording alcohol use in EHRs via a multi-disciplinary stakeholder workshop and online survey. Responses to the survey were thematically analysed using the Consolidated Framework for Implementation Research. Results Thirty-one stakeholders participated in the workshop and 100 in the online survey. This included patients and carers, healthcare professionals, researchers, public health specialists, informaticians, and clinical information system suppliers. There was broad consensus that the Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-Consumption (AUDIT-C) questionnaires were appropriate standards for recording alcohol use in EHRs but that the standards should also address interventions for alcohol misuse. Stakeholders reported a number of factors that might influence implementation of the standards, including having clear care pathways and an implementation guide, sharing information about alcohol use between health service providers, adequately resourcing the implementation process, integrating alcohol screening with existing clinical pathways, having good clinical information systems and IT infrastructure, providing financial incentives, having sufficient training for healthcare workers, and clinical leadership and engagement. Implementation of the standards would need to ensure patients are not stigmatised and that patient confidentiality is robustly maintained. Conclusions A wide range of stakeholders agreed that use of AUDIT-C and AUDIT are appropriate standards for recording alcohol use in EHRs in addition to recording interventions for alcohol misuse. The findings of this consultation will be used to develop an appropriate information model and implementation guide. Further research is needed to pilot the standards in primary and secondary care

Ethnic variations in upper gastrointestinal hospitalizations and deaths:the Scottish Health and Ethnicity Linkage Study

BACKGROUND: Upper gastrointestinal (GI) diseases are common, but there is a paucity of data describing variations by ethnic group and so a lack of understanding of potential health inequalities. We studied the incidence of specific upper GI hospitalization and death by ethnicity in Scotland.METHODS: Using the Scottish Health and Ethnicity Linkage Study, linking NHS hospitalizations and mortality to the Scottish Census 2001, we explored ethnic differences in incidence (2001-10) of oesophagitis, peptic ulcer disease, gallstone disease and pancreatitis. Relative Risks (RRs) and 95% confidence intervals were calculated using Poisson regression, multiplied by 100, stratified by sex and adjusted for age, country of birth (COB) and socio-economic position. The White Scottish population (100) was the reference population.RESULTS: Ethnic variations varied by outcome and sex, e.g. adjusted RRs (95% confidence intervals) for oesophagitis were comparatively higher in Bangladeshi women (209; 124-352) and lower in Chinese men (65; 51-84) and women (69; 55-88). For peptic ulcer disease, RRs were higher in Chinese men (171; 131-223). Pakistani women had higher RRs for gallstone disease (129; 112-148) and pancreatitis (147; 109-199). The risks of upper GI diseases were lower in Other White British and Other White [e.g. for peptic ulcer disease in men, respectively (74; 64-85) and (81; 69-94)].CONCLUSION: Risks of common upper GI diseases were comparatively lower in most White ethnic groups in Scotland. In non-White groups, however, risk varied by disease and ethnic group. These results require consideration in health policy, service planning and future research.</p

Digital health, cardiometabolic disease and ethnicity: an analysis of United Kingdom government policies from 2010 to 2022

Recent health policies in the United Kingdom (UK) and internationally have focussed on digitisation of healthcare. We examined UK policies for evidence of government action addressing health inequalities and digital health, using cardiometabolic disease as an exemplar. Using a systematic search methodology, we identified 87 relevant policy documents published between 2010 and 2022. We found increasing emphasis on digital health, including for prevention, diagnosis and management of cardiometabolic disease. Several policies also focused on tackling health inequalities and improving digital access. The COVID-19 pandemic amplified inequalities. No policies addressed ethnic inequalities in digital health for cardiometabolic disease, despite high prevalence in minority ethnic communities. Our findings suggest that creating opportunities for digital inclusion and reduce longer-term health inequalities, will require future policies to focus on: the heterogeneity of ethnic groups; cross-sectoral disadvantages which contribute to disease burden and digital accessibility; and disease-specific interventions which lend themselves to culturally tailored solutions

Incidence, morbidity and mortality of patients with achalasia in England:findings from a study of nationwide hospital and primary care data

BackgroundAchalasia is an uncommon condition characterised by failed lower oesophageal sphincter relaxation. Data regarding its incidence, prevalence, disease associations and long-term outcomes are very limited.MethodsHospital Episode Statistics (HES) include demographic and diagnostic data for all English hospital attendances. The Health Improvement Network (THIN) includes the primary care records of 4.5 million UK subjects, representative of national demographics. Both were searched for incident cases between 2006 and 2016 and THIN for prevalent cases. Subjects with achalasia in THIN were compared with age, sex, deprivation tand smoking status matched controls for important comorbidities and mortality.ResultsThere were 10 509 and 711 new achalasia diagnoses identified in HES and THIN, respectively. The mean incidence per 100 000 people in HES was 1.99 (95% CI 1.87 to 2.11) and 1.53 (1.42 to 1.64) per 100 000 person-years in THIN. The prevalence in THIN was 27.1 (25.4 to 28.9) per 100 000 population. Incidence rate ratios (IRRs) were significantly higher in subjects with achalasia (n=2369) compared with controls (n=3865) for: oesophageal cancer (IRR 5.22 (95% CI: 1.88 to 14.45), p&lt;0.001), aspiration pneumonia (13.38 (1.66 to 107.79), p=0.015), lower respiratory tract infection (1.33 (1.05 to 1.70), p=0.02) and mortality (1.33 (1.17 to 1.51), p&lt;0.001). The median time from achalasia diagnosis to oesophageal cancer diagnosis was 15.5 (IQR 20.4) years.ConclusionThe incidence of achalasia is 1.99 per 100 000 population in secondary care data and 1.53 per 100 000 person-years in primary care data. Subjects with achalasia have an increased incidence of oesophageal cancer, aspiration pneumonia, lower respiratory tract infections and higher mortality. Clinicians treating patients with achalasia should be made aware of these associated morbidities and its increased mortality.</jats:sec