Determinants of health care costs in the senior elderly: age, comorbidity, impairment, or proximity to death?

Ageing is assumed to be accompanied by greater health care expenditures but the association is also viewed as a ‘red herring’. This study aimed to evaluate whether age is associated with health care costs in the senior elderly, using electronic health records for 98,220 participants aged 80 years and over registered with the UK Clinical Practice Research Datalink and linked Hospital Episode Statistics (2010–2014). Annual costs of health care utilization were estimated from a two-part model; multiple fractional polynomial models were employed to evaluate the non-linear association of age with predicted health care costs while also controlling for comorbidities, impairments, and death proximity. Annual health care costs increased from 80 years (£2972 in men, £2603 in women) to 97 (men; £4721) or 98 years (women; £3963), before declining. Costs were significantly elevated in the last year of life but this effect declined with age, from £10,027 in younger octogenarians to £7021 in centenarians. This decline was steeper in participants with comorbidities or impairments; £14,500 for 80–84-year-olds and £6752 for centenarians with 7+ impairments. At other times, comorbidity and impairments, not age, were main drivers of costs. We conclude that comorbidities, impairments, and proximity to death are key mediators of age-related increases in health care costs. While the costs of comorbidity among survivors are not generally associated with age, additional costs in the last year of life decline with age

The 18 Household Food Security Survey items provide valid food security classifications for adults and children in the Caribbean

BACKGROUND: We tested the properties of the 18 Household Food Security Survey (HFSS) items, and the validity of the resulting food security classifications, in an English-speaking middle-income country. METHODS: Survey of primary school children in Trinidad and Tobago. Parents completed the HFSS. Responses were analysed for the 10 adult-referenced items and the eight child-referenced items. Item response theory models were fitted. Item calibrations and subject scores from a one-parameter logistic (1PL) model were compared with those from either two-parameter logistic model (2PL) or a model for differential item functioning (DIF) by ethnicity. RESULTS: There were 5219 eligible with 3858 (74%) completing at least one food security item. Adult item calibrations (standard error) in the 1PL model ranged from -4.082 (0.019) for the 'worried food would run out' item to 3.023 (0.042) for 'adults often do not eat for a whole day'. Child item calibrations ranged from -3.715 (0.025) for 'relied on a few kinds of low cost food' to 3.088 (0.039) for 'child didn't eat for a whole day'. Fitting either a 2PL model, which allowed discrimination parameters to vary between items, or a differential item functioning model, which allowed item calibrations to vary between ethnic groups, had little influence on interpretation. The classification based on the adult-referenced items showed that there were 19% of respondents who were food insecure without hunger, 10% food insecure with moderate hunger and 6% food insecure with severe hunger. The classification based on the child-referenced items showed that there were 23% of children who were food insecure without hunger and 9% food insecure with hunger. In both children and adults food insecurity showed a strong, graded association with lower monthly household income (P < 0.001). CONCLUSION: These results support the use of 18 HFSS items to classify food security status of adults or children in an English-speaking country where food insecurity and hunger are more frequent overall than in the US

Place of medical qualification and outcomes of UK General Medical Council “fitness to practise” process: cohort study

Objectives To evaluate whether country of medical qualification is associated with “higher impact” decisions at different stages of the UK General Medical Council’s (GMC’s) “fitness to practise” process after allowing for other characteristics of doctors and inquiries

Explaining the Decline in Early Mortality in Men and Women With Type 2 Diabetes: A population-based cohort study

OBJECTIVE—The purpose of this study was to test the hypothesis that changing utilization of lipid-lowering, antihypertensive, and oral hypoglycemic drugs may be associated with trends in all-cause mortality in men and women with type 2 diabetes

Alarm symptoms and identification of non-cancer diagnoses in primary care: cohort study

Objective To evaluate the predictive value of alarm symptoms for specified non-cancer diagnoses and cancer diagnoses in primary care

Declining 1-year case-fatality of stroke and increasing coverage of vascular risk management: population-based cohort study

Background The authors estimated trends in 1-year case-fatality of stroke in relation to changes in vascular risk management from 1997 to 2005.Methods A cohort study was implemented using data for 407 family practices in the UK General Practice Research Database, including subjects with first acute strokes between 1997 and 2005. One-year case-fatality was estimated by year and sex. Rate ratios were estimated using Poisson regression.Results There were 19 143 women and 16 552 men who had first acute strokes between 1997 and 2005. In women, the 1-year case-fatality declined from 41.2% in 1997 to 29.2% in 2005. In men, the decline was from 29.2% in 1997 to 22.2% in 2005. The proportion of general practices that prescribed antihypertensive drugs to two-thirds or more of new patients with stroke increased from 6% in 1997 to 48% in 2005, for statins from 1% to 39% and for antiplatelet drugs from 11% to 39%. The rate ratio for 1-year mortality in 2005, compared with 1997--1998, adjusted for age group, sex, prevalent coronary heart disease, prevalent hypertension and deprivation quintile was 0.79 (0.74 to 0.86, p<0.001). After adjustment for antihypertensive, statin and antiplatelet prescribing, the rate ratio was 1.29 (1.17 to 1.42).Conclusions Reducing 1-year case-fatality after acute stroke may be partly explained by increased prescribing of antihypertensive, statin and antiplatelet drugs to patients with recent strokes. However, these analyses did not include measures of possible changes over time in stroke severity or acute stroke management

Revisiting patient expectations and experiences of antibiotics in an era of antimicrobial resistance: Qualitative study.

OBJECTIVE: To investigate contemporary patient expectations and experiences of antibiotic prescribing in England. BACKGROUND: Primary care providers' compliance with patient influences has been identified as a motivation for antibiotic-prescribing behaviour. Since 2013, there have been concerted efforts to publicize and address the growing threat of antimicrobial resistance. A fresh qualitative insight into patient expectations and experiences is needed. DESIGN: Qualitative study using semi-structured interviews. SETTING AND PARTICIPANTS: Two English regions, one an urban metropolitan area and the other a town in rural England. Patients who recently consulted for infections were recruited. The information power approach was used to determine the number of participants, yielding a sample of 31 participants. MAIN MEASURES: Thematic analysis was carried out to analyse the interview data. RESULTS: Five themes were identified: beliefs, expectations, experiences of taking antibiotic, experience of antimicrobial resistance and side-effects, and experiences of consultations. The accounts reflected improved public knowledge: antibiotics were perceived to be much-needed medicines that should be prescribed when appropriate. The data showed that patients formed expectations of expectations, trying to read the prescribers' intentions and reflect on the dependency between what prescribers and patients wanted. Patient experiences featured as nuanced and detailed with knowledge of AMR and side-effects of antibiotics in the context of positive consultation experiences. CONCLUSIONS: The study highlighted complex interplays between adherence to antibiotics and consuming antibiotics in reflexive, informed ways. Ensuring that present and future patients are informed about potential benefits and harms of antibiotic use will contribute to future antimicrobial stewardship

Family practices' achievement of diabetes quality of care targets and risk of screen-detected diabetic retinopathy

Background: We aimed to determine whether family practices' achievement of diabetes quality of care targets is associated with diabetic retinal disease in registered patients. Methods: Data for achievement of diabetes quality of care targets, including the proportion of patients with HbA1c≤7.5%, for 144 family practices in London UK, for the years 2004/5 to 2007/8, were linked to data from a population-based diabetes eye screening programme collected from September 2007 to February 2009. Analyses were adjusted for age, sex, duration and type of diabetes, unadjusted diabetes prevalence, ethnicity and deprivation category. Results: Data were analysed for 24,458 participants with one or more eye screening results in the period. There were 9,332 (38%) with any diabetic retinopathy and 2,819 (11.5%) with sight threatening diabetic retinopathy (STDR), including 2,654 (10.9%) with maculopathy. Among participants registered at 13 family practices that were in the highest quartile for achievement of the HbA1c quality of care target for all four years of study, the relative odds of any diabetic retinopathy were 0.78 (0.69 to 0.88) P<0.001. For participants at 12 practices consistently in the lowest quartile of HbA1c achievement, the relative odds of any diabetic retinopathy were 1.16 (1.03 to 1.30), P = 0.015. In the highest achieving practices, the relative odds of maculopathy were 0.74 (0.62 to 0.89), P = 0.001 and STDR 0.77 (0.65 to 0.92), P = 0.004. Conclusions: The risk of diabetic retinopathy might be lower at family practices that consistently achieve highly on diabetes quality of care targets for HbA1c