A critical reflection on the use of improvement science approaches in public health.

OBJECTIVE: 'Improvement science' is used to describe specific quality improvement methods (including tests of change and statistical process control). The approach is spreading from clinical settings to population-wide interventions and is being extended from supporting the adoption of proven interventions to making generalisable claims about new interventions. The objective of this narrative review is to evaluate the strengths and risks of current improvement science practice, particularly in relation to how they might be used in population health. METHODS: A purposive sampling of published studies to identify how improvement science methods are being used and for what purpose. The setting was Scotland and studies that focused on health and wellbeing outcomes. RESULTS: We have identified a range of improvement science approaches which provide practitioners with accessible tools to assess small-scale changes in policy and practice. The strengths of such approaches are that they facilitate consistent implementation of interventions already known to be effective and motivate and empower staff to make local improvements. However, we also identified a number of potential risks. In particular, their use to assess the effectiveness of new interventions often seems to pay insufficient attention to random variation, measurement bias, confounding and ethical issues. CONCLUSIONS: The use of current improvement science methods to generate evidence of effectiveness for population-wide interventions is problematic and risks unjustified claims of effectiveness, inefficient resource use and harm to those not offered alternative effective interventions. Newer methodological approaches offer alternatives and should be more widely considered.

Trends in incidence and case fatality of acute myocardial infarction, angina and coronary revascularisation in people with and without type 2 diabetes in Scotland between 2006 and 2015.

AIMS/HYPOTHESIS: The aim of the study was to examine trends in the incidence and case fatality of acute myocardial infarction (AMI) and in hospital admissions for angina and coronary revascularisation procedures in people with type 2 diabetes and in people without diabetes in Scotland between 2006 and 2015. METHODS: In this retrospective cohort study, AMI, angina and revascularisation event data were obtained for adults from hospital admissions and death records linked to a population-based diabetes register. Incidence by diabetes status was estimated using negative binomial models with adjustment or stratification by age, sex, deprivation and calendar year. Logistic regression was used to estimate AMI case fatality by diabetes status. RESULTS: There were 129,926 incident AMI events, 41,263 angina admissions and 69,875 coronary revascularisation procedures carried out during 34.9 million person-years of follow-up. The adjusted incidence of AMI, angina and revascularisation procedures declined by 2.0% (95% CI 1.73%, 2.26%), 9.62% (95% CI 9.22%, 10.01%) and 0.35% (95% CI -0.09%, 0.79%) per year, respectively. The rate of decline did not differ materially by diabetes status. RRs of AMI for type 2 diabetes were 1.86 (95% CI 1.74, 1.98) for men and 2.32 (95% CI 2.15, 2.51) for women. Of the 77,211 people admitted to hospital with a first AMI, 7842 (10.2%) died within 30 days of admission. Case fatality was higher in people with type 2 diabetes than in people without diabetes and declined in both groups by 7.93% (95% CI 7.03%, 8.82%) per year. CONCLUSIONS/INTERPRETATION: The incidence of AMI, angina, revascularisation and AMI case fatality has declined over time, but the increased risk associated with type 2 diabetes has remained approximately constant.

Adverse events after first, single, mesh and non-mesh surgical procedures for stress urinary incontinence and pelvic organ prolapse in Scotland, 1997-2016: a population-based cohort study.

BACKGROUND: Concerns have been raised about the safety of surgery for stress urinary incontinence and pelvic organ prolapse using transvaginal mesh. We assessed adverse outcomes after first, single mesh procedures and comparable non-mesh procedures. METHODS: We did a cohort study of women in Scotland aged 20 years or older undergoing a first, single incontinence procedure or prolapse procedure during 1997-98 to 2015-16 identified from a national hospital admission database. Primary outcomes were immediate postoperative complications and subsequent (within 5 years) readmissions for later postoperative complications, further incontinence surgery, or further prolapse surgery. Poisson regression models were used to compare outcomes after procedures carried out with and without mesh. FINDINGS: Between April 1, 1997, and March 31, 2016, 16 660 women underwent a first, single incontinence procedure, 13 133 (79%) of which used mesh. Compared with non-mesh open surgery (colposuspension), mesh procedures had a lower risk of immediate complications (adjusted relative risk [aRR] 0·44 [95% CI 0·36-0·55]) and subsequent prolapse surgery (adjusted incidence rate ratio [aIRR] 0·30 [0·24-0·39]), and a similar risk of further incontinence surgery (0·90 [0·73-1·11]) and later complications (1·12 [0·98-1·27]); all ratios are for retropubic mesh. During the same time period, 18 986 women underwent a first, single prolapse procedure, 1279 (7%) of which used mesh. Compared with non-mesh repair, mesh repair of anterior compartment prolapse was associated with a similar risk of immediate complications (aRR 0·93 [95% CI 0·49-1·79]); an increased risk of further incontinence (aIRR 3·20 [2·06-4·96]) and prolapse surgery (1·69 [1·29-2·20]); and a substantially increased risk of later complications (3·15 [2·46-4·04]). Compared with non-mesh repair, mesh repair of posterior compartment prolapse was associated with a similarly increased risk of repeat prolapse surgery and later complications. No difference in any outcome was observed between vaginal and, separately, abdominal mesh repair of vaginal vault prolapse compared with vaginal non-mesh repair. INTERPRETATION: Our results support the use of mesh procedures for incontinence, although further research on longer term outcomes would be beneficial. Mesh procedures for anterior and posterior compartment prolapse cannot be recommended for primary prolapse repair. Both vaginal and abdominal mesh procedures for vaginal vault prolapse repair are associated with similar effectiveness and complication rates to non-mesh vaginal repair. These results therefore do not clearly favour any particular vault repair procedure. FUNDING: None.

Trends in type 2 diabetes incidence and mortality in Scotland between 2004 and 2013.

AIMS/HYPOTHESIS: The relative contribution of increasing incidence and declining mortality to increasing prevalence of type 2 diabetes in Scotland is unclear. Trends in incidence and mortality rates are described for type 2 diabetes in Scotland between 2004 and 2013 by age, sex and socioeconomic deprivation. METHODS: Data for incident and prevalent cases of type 2 diabetes were obtained from the Scottish national diabetes register with number of deaths identified from linkage to mortality records. Population size and death data for Scotland by age, sex and socioeconomic deprivation were obtained from National Records of Scotland. Age- and sex-specific incidence and mortality rates stratified by year and deciles of socioeconomic status were calculated using Poisson models. RESULTS: There were 180,290 incident cases of type 2 diabetes in Scotland between 2004 and 2013. Overall, incidence of type 2 diabetes remained stable over time and was 4.88 (95% CI 4.84, 4.90) and 3.33 (3.28, 3.32) per 1000 in men and women, respectively. However, incidence increased among young men, remained stable in young women, and declined in older men and women. Incidence rates declined in all socioeconomic groups but increased after 2008 in the most deprived groups. Standardised mortality ratios associated with diabetes, adjusted for age and socioeconomic group, were 1.38 (1.36, 1.41) in men and 1.49 (1.45, 1.52) in women, and remained constant over time. CONCLUSIONS/INTERPRETATION: Incidence of type 2 diabetes has stabilised in recent years suggesting that increasing prevalence may be primarily attributed to declining mortality. Prevention of type 2 diabetes remains important, particularly among socioeconomically deprived populations.

Understanding extreme mortality among prisoners: a national cohort study in Scotland using data linkage.

BACKGROUND: Mortality is known to be extremely high among people who have been imprisoned, but there is limited information about the factors that explain this increased risk. METHODS: Standard record linkage methods were used to link Scottish prison records and mortality data for all individuals imprisoned in Scotland for the first time between 1 January 1996 and 31 December 2007. RESULTS: Among 76 627 individuals there were 4414 deaths (3982 in men). When compared with the general population, the age-standardized mortality rate ratio for those imprisoned was 3.3 (95% CI: 3.2, 3.4) for men and 7.6 (6.9, 8.3) for women. Further adjustment for an area measure of deprivation accounted for part but not all of this excess risk [adjusted rate ratio 2.3 (2.2, 2.4) and 5.7 (5.1, 6.2) for men and women, respectively]. Relative risks were highest for drug and alcohol related causes, suicide and homicide and were markedly higher among women than men. Out of prison deaths were most frequent in the first 2 weeks after release from prison. Mortality rates were lower in those with longer total duration in prison and higher in those with multiple short episodes in prison. CONCLUSION: People who have been imprisoned in Scotland experience substantial excess mortality from a range of causes that is only partly explained by deprivation. The association of increased mortality with multiple periods in prison and the concentration of deaths in the early period after prison release both have implications for policy and practice.

Ethnicity and first birth: age, smoking, delivery, gestation, weight and feeding: Scottish Health and Ethnicity Linkage Study.

BACKGROUND: We linked census and health service data sets to address the shortage of information comparing maternal characteristics and pregnancy outcomes by ethnic group in Scotland. METHODS: Retrospective cohort study linking the 2001 National Census for Scotland and hospital obstetric data (2001-08), comparing maternal age, smoking status, gestational age, caesarean section rates, birthweight, preterm birth and breastfeeding rates by ethnic group. RESULTS: In all, 144 344 women were identified as having had a first birth between 1 May 2001 and 30 April 2008. White Scottish mothers were younger [mean age 27.3 years; 95% confidence interval (CI): 27.3, 27.4] than other white groups and most non-white groups. They had the highest smoking rates (25.8%; CI: 25.5, 26.0) and the lowest rates of breastfeeding at 6-8 weeks (23.4%; CI: 23.1, 23.6), with most of the other groups being around 40%. Women from non-white minority ethnic groups in Scotland tended to have babies of lower birthweight (e.g. Pakistani mean birthweight-3105 g, white Scottish-3356 g), even after adjustment for gestational age, maternal age, education, smoking and housing tenure. This effect was more noticeable for women born in the UK. White English, Irish and other white babies tended to have higher birthweights. There was little variation between groups in caesarean section rates. CONCLUSIONS: Pregnant women from ethnic minority populations in Scotland have more favourable health behaviour than the white Scottish, although the non-white groups tend to have lower birthweight. Further exploration of the reasons for these differences has potential to benefit women from the majority population.

Socioeconomic deprivation increases the effect of winter on admissions to hospital with COPD: retrospective analysis of 10 years of national hospitalisation data.

BACKGROUND: Admission to hospital with chronic obstructive pulmonary disease (COPD) is associated with deprivation and season. However, it is not known whether deprivation and seasonality act synergistically to influence the risk of hospital admission with COPD. AIMS: To investigate whether the relationship between season/temperature and admission to hospital with COPD differs with deprivation. METHODS: All COPD admissions (ICD10 codes J40-J44 and J47) were obtained for the decade 2001-2010 for all Scottish residents by month of admission and 2009 Scottish Index of Multiple Deprivation (SIMD) quintile. Confidence intervals for rates and absolute differences in rates were calculated and the proportion of risk during winter attributable to main effects and interactions were estimated. Monthly rates of admission by average daily minimum temperatures were plotted for each quintile of SIMD. RESULTS: Absolute differences in admission rates between winter and summer increased with greater deprivation. In the most deprived quintile, in winter 19.4% (95% CI 17.3% to 21.4%) of admissions were attributable to season/deprivation interaction, 61.2% (95% CI 59.5% to 63.0%) to deprivation alone, and 5.2% (95% CI 4.3% to 6.0%) to winter alone. Lower average daily minimum temperatures over a month were associated with higher admission rates, with stronger associations evident in the more deprived quintiles. CONCLUSIONS: Winter and socioeconomic deprivation-related factors appear to act synergistically, increasing the rate of COPD admissions to hospital more among deprived people than among affluent people in winter than in the summer months. Similar associations were observed for admission rates and temperatures. Interventions effective at reducing winter admissions for COPD may have potential for greater benefit if delivered to more deprived groups.

Cardiovascular disease and air pollution in Scotland: no association or insufficient data and study design?

BACKGROUND: Coronary heart disease and stroke are leading causes of mortality and ill health in Scotland, and clear associations have been found in previous studies between air pollution and cardiovascular disease. This study aimed to use routinely available data to examine whether there is any evidence of an association between short-term exposure to particulate matter (measured as PM10, particles less than 10 micrograms per cubic metre) and hospital admissions due to cardiovascular disease, in the two largest cities in Scotland during the years 2000 to 2006. METHODS: The study utilised an ecological time series design, and the analysis was based on overdispersed Poisson log-linear models. RESULTS: No consistent associations were found between PM10 concentrations and cardiovascular hospital admissions in either of the cities studied, as all of the estimated relative risks were close to one, and all but one of the associated 95% confidence intervals contained the null risk of one. CONCLUSIONS: This study suggests that in small cities, where air quality is relatively good, then either PM10 concentrations have no effect on cardiovascular ill health, or that the routinely available data and the corresponding study design are not sufficient to detect an association.

Clinical burden, risk factor impact and outcomes following myocardial infarction and stroke: A 25-year individual patient level linkage study.

BACKGROUND: Understanding trends in the incidence and outcomes of myocardial infarction and stroke, and how these are influenced by changes in cardiovascular risk factors can inform health policy and healthcare provision. METHODS: We identified all patients 30 years or older with myocardial infarction or stroke in Scotland. Risk factor levels were determined from national health surveys. Incidence, potential impact fractions and burden attributable to risk factor changes were calculated. Risk of subsequent fatal and non-fatal events (myocardial infarction, stroke, bleeding and heart failure hospitalization) were calculated with multi-state models. FINDINGS: From 1990 to 2014, there were 372,873 (71±13 years) myocardial infarctions and 290,927 (74±13 years) ischemic or hemorrhagic strokes. Age-standardized incidence per 100,000 fell from 1,069 (95% confidence interval, 1,024-1,116) to 276 (263-290) for myocardial infarction and from 608 (581-636) to 188 (178-197) for ischemic stroke. Systolic blood pressure, smoking and cholesterol decreased, but body-mass index increased, and diabetes prevalence doubled. Changes in risk factors accounted for a 74% (57-91%) reduction in myocardial infarction and 68% (55-83%) reduction in ischemic stroke. Following myocardial infarction, the risk of death decreased (30% to 20%), but non-fatal events increased (20% to 24%) whereas the risk of both death (47% to 34%) and non-fatal events (22% to 17%) decreased following stroke. INTERPRETATION: Over the last 25 years, substantial reductions in myocardial infarction and ischemic stroke incidence are attributable to major shifts in risk factor levels. Deaths following the index event decreased for both myocardial infarction and stroke, but rates remained substantially higher for stroke. FUNDING: British heart foundation.

Trends in disease incidence and survival and their effect on mortality in Scotland: nationwide cohort study of linked hospital admission and death records 2001-2016.

OBJECTIVES: Identify causes and future trends underpinning Scottish mortality improvements and quantify the relative contributions of disease incidence and survival. DESIGN: Population-based study. SETTING: Linked secondary care and mortality records across Scotland. PARTICIPANTS: 1 967 130 individuals born between 1905 and 1965 and resident in Scotland from 2001 to 2016. MAIN OUTCOME MEASURES: Hospital admission rates and survival within 5 years postadmission for 28 diseases, stratified by sex and socioeconomic status. RESULTS: 'Influenza and pneumonia', 'Symptoms and signs involving circulatory and respiratory systems' and 'Malignant neoplasm of respiratory and intrathoracic organs' were the hospital diagnosis groupings associated with most excess deaths, being both common and linked to high postadmission mortality. Using disease trends, we modelled a mean mortality HR of 0.737 (95% CI 0.730 to 0.745) from one decade of birth to the next, equivalent to a life extension of ~3 years per decade. This improvement was 61% (30%-93%) accounted for by improved disease survival after hospitalisation (principally cancer) with the remainder accounted for by lowered hospitalisation incidence (principally heart disease and cancer). In contrast, deteriorations in infectious disease incidence and survival increased mortality by 9% (~3.3 months per decade). Disease-driven mortality improvements were slightly greater for men than women (due to greater falls in disease incidence), and generally similar across socioeconomic deciles. We project mortality improvements will continue over the next decade but slow by 21% because much progress in disease survival has already been achieved. CONCLUSION: Morbidity improvements broadly explain observed mortality improvements, with progress on prevention and treatment of heart disease and cancer contributing the most. The male-female health gaps are closing, but those between socioeconomic groups are not. Slowing improvements in morbidity may explain recent stalling in improvements of UK period life expectancies. However, these could be offset if we accelerate improvements in the diseases accounting for most deaths and counteract recent deteriorations in infectious disease.

Enhanced detection services for developmental dysplasia of the hip in Scottish children, 1997-2013.

BACKGROUND: Developmental dysplasia of the hip (DDH) remains common. If detected early, DDH can usually be corrected with conservative management. Late presentations often require surgery and have worse outcomes. OBJECTIVE: We estimated the risk of undergoing surgery for DDH by age 3 years before and after the introduction of enhanced DDH detection services. DESIGN: Retrospective cohort study. SETTING: Scotland, 1997/98-2010/11. PATIENTS: All children. METHODS: Using routinely collected national hospital discharge records, we examined rates of first surgery for DDH by age 3 by March 2014. Using a difference in difference analysis, we compared rates in two areas of Scotland before (to April 2002) and after (from April 2005) implementation of enhanced DDH detection services to those seen in the rest of Scotland. RESULTS: For children born in the study period, the risk of first surgery for DDH by age 3 was 1.18 (95% CI 1.11 to 1.26) per 1000 live births (918/777 375).Prior to April 2002, the risk of surgery was 1.13 (95% CI 0.88 to 1.42) and 1.31 (95% CI 1.16 to 1.46) per 1000 live births in the intervention and non-intervention areas, respectively. In the intervention areas, from April 2005, this risk halved (RR 0.47; 95% CI 0.32 to 0.68). The risk remained unchanged in other areas (RR 1.01; 95% CI 0.86 to 1.18). The ratio for the difference in change of risk was 0.46 (95% CI 0.31 to 0.70). CONCLUSIONS: The implementation of enhanced DDH detection services can produce substantial reductions in the number of children having surgical correction for DDH.

Trends and inequalities in the burden of mortality in Scotland 2000-2015.

BACKGROUND: Cause-specific mortality trends are routinely reported for Scotland. However, ill-defined deaths are not routinely redistributed to more precise and internationally comparable categories nor is the mortality reported in terms of years of life lost to facilitate the calculation of the burden of disease. This study describes trends in Years of Life Lost (YLL) for specific causes of death in Scotland from 2000 to 2015. METHODS: We obtained records of all deaths in Scotland by age, sex, area and underlying cause of death between 2000 and 2015. We redistributed Ill-Defined Deaths (IDDs) to more exact and meaningful causes using internationally accepted methods. Years of Life Lost (YLL) using remaining life expectancy by sex and single year of age from the 2013 Scottish life table were calculated for each death. These data were then used to calculate the crude and age-standardised trends in YLL by age, sex, cause, health board area, and area deprivation decile. RESULTS: Between 2000 and 2015, the annual percentage of deaths that were ill-defined varied between 10% and 12%. The proportion of deaths that were IDDs increased over time and were more common: in women; amongst those aged 1-4 years, 25-34 years and >80 years; in more deprived areas; and in the island health boards. The total YLL fell from around 17,800 years per 100,000 population in 2000 to around 13,500 years by 2015. The largest individual contributors to YLL were Ischaemic Heart Disease (IHD), respiratory cancers, Chronic Obstructive Pulmonary Disease (COPD), cerebrovascular disease and Alzheimer's/dementia. The proportion of total YLL due to IHD and stroke declined over time, but increased for Alzheimer's/dementia and drug use disorders. There were marked absolute inequalities in YLL by area deprivation, with a mean Slope Index of Inequality (SII) for all causes of 15,344 YLL between 2001 and 2015, with IHD and COPD the greatest contributors. The Relative Index of Inequality (RII) for YLL was highest for self-harm and lower respiratory infections. CONCLUSION: The total YLL per 100,000 population in Scotland has declined over time. The YLL in Scotland is predominantly due to a wide range of chronic diseases, substance misuse, self-harm and increasingly Alzheimer's disease and dementia. Inequalities in YLL, in both relative and absolute terms, are stark.

Scottish Keep Well health check programme: an interrupted time series analysis.

BACKGROUND: Effective interventions are available to reduce cardiovascular risk. Recently, health check programmes have been implemented to target those at high risk of cardiovascular disease (CVD), but there is much debate whether these are likely to be effective at population level. This paper evaluates the impact of wave 1 of Keep Well, a Scottish health check programme, on cardiovascular outcomes. METHODS: Interrupted time series analyses were employed, comparing trends in outcomes in participating and non-participating practices before and after the introduction of health checks. Health outcomes are defined as CVD mortality, incident hospitalisations and prescribing of cardiovascular drugs. RESULTS: After accounting for secular trends and seasonal variation, coronary heart disease mortality and hospitalisations changed by 0.4% (95% CI -5.2% to 6.3%) and -1.1% (-3.4% to 1.3%) in Keep Well practices and by -0.3% (-2.7% to 2.2%) and -0.1% (-1.8% to 1.7%) in non-Keep Well practices, respectively, following the intervention. Adjusted changes in prescribing in Keep Well and non-Keep Well practices were 0.4% (-10.4% to 12.5%) and -1.5% (-9.4% to 7.2%) for statins; -2.5% (-12.3% to 8.4%) and -1.6% (-7.1% to 4.3%) for antihypertensive drugs; and -0.9% (-6.5% to 5.0%) and -2.4% (-10.1% to 6.0%) for antiplatelet drugs. CONCLUSIONS: Any impact of the Keep Well health check intervention on CVD outcomes and prescribing in Scotland was very small. Findings do not support the use of the screening approach used by current health check programmes to address CVD. We used an interrupted time series method, but evaluation methods based on randomisation are feasible and preferable and would have allowed more reliable conclusions. These should be considered more often by policymakers at an early stage in programme design when there is uncertainty regarding programme effectiveness.

Impact of opioid substitution therapy for Scotland's prisoners on drug-related deaths soon after prisoner release.

AIM: To assess whether the introduction of a prison-based opioid substitution therapy (OST) policy was associated with a reduction in drug-related deaths (DRD) within 14 days after prison release. DESIGN: Linkage of Scotland's prisoner database with death registrations to compare periods before (1996-2002) and after (2003-07) prison-based OST was introduced. SETTING: All Scottish prisons. PARTICIPANTS: People released from prison between 1 January 1996 and 8 October 2007 following an imprisonment of at least 14 days and at least 14 weeks after the preceding qualifying release. MEASUREMENTS: Risk of DRD in the 12 weeks following release; percentage of these DRDs which occurred during the first 14 days. FINDINGS: Before prison-based OST (1996-2002), 305 DRDs occurred in the 12 weeks after 80 200 qualifying releases, 3.8 per 1000 releases [95% confidence interval (CI) = 3.4-4.2]; of these, 175 (57%) occurred in the first 14 days. After the introduction of prison-based OST (2003-07), 154 DRDs occurred in the 12 weeks after 70 317 qualifying releases, a significantly reduced rate of 2.2 per 1000 releases (95% CI = 1.8-2.5). However, there was no change in the proportion which occurred in the first 14 days, either for all DRDs (87: 56%) or for opioid-related DRDs. CONCLUSIONS: Following the introduction of a prison-based opioid substitution therapy (OST) policy in Scotland, the rate of drug-related deaths in the 12 weeks following release fell by two-fifths. However, the proportion of deaths that occurred in the first 14 days did not change appreciably, suggesting that in-prison OST does not reduce early deaths after release.

Measures of socioeconomic position are not consistently associated with ethnic differences in cardiovascular disease in Scotland: methods from the Scottish Health and Ethnicity Linkage Study (SHELS).

BACKGROUND: Ethnic health inequalities are substantial. One explanation relates to socioeconomic differences between groups. However, socioeconomic variables need to be comparable across ethnic groups as measures of socioeconomic position (SEP) and indicators of health outcomes. METHODS: We linked self-reported SEP and ethnicity data on 4.65 million individuals from the 2001 Scottish Census to hospital admission and mortality data for cardiovascular disease (CVD). We examined the direction, strength and linearity of association between eight individual, household and area socioeconomic measures and CVD in 10 ethnic groups and the impact of SEP adjustment. RESULTS: There was wide socioeconomic variation between groups. All eight measures showed consistent, positive associations with CVD in White populations, as did educational qualification in non-White ethnic groups. For other SEP measures, associations tended to be consistent with those of White groups though there were one or two exceptions in each non-White group. Multiple SEP adjustment had little effect on relative risk of CVD for most groups. Where it did, the effect varied in direction and magnitude (for example increasing adjusted risk by 23% in Indian men but attenuating it by 11% among Pakistani women). CONCLUSIONS: Across groups, SEP measures were inconsistently associated with CVD hospitalization or death, with effect size and direction of effect after adjustment varying across ethnic groups. We recommend that researchers systematically explore the effect of their choice of SEP indicators, using standard multivariate methods where appropriate, to demonstrate their cross-ethnic group validity as potential confounding variables for the specific groups and outcomes of interest.

Changes in cardiovascular risk factors in relation to increasing ethnic inequalities in cardiovascular mortality: comparison of cross-sectional data in the Health Surveys for England 1999 and 2004.

OBJECTIVES: Reducing disease inequalities requires risk factors to decline quickest in the most disadvantaged populations. Our objective was to assess whether this happened across the UK's ethnic groups. DESIGN: Secondary analysis of repeated but independent cross-sectional studies focusing on Health Surveys for England 1999 and 2004. SETTING: Community-based population level surveys in England. PARTICIPANTS: Seven populations from the major ethnic groups in England (2004 sample sizes): predominantly White general (6704), Irish (1153), Chinese (723), Indian (1184), Pakistani (941), Bangladeshi (899) and Black Caribbean (1067) populations. The numbers were smaller for specific variables, especially blood tests. OUTCOME MEASURES: Data on 10 established cardiovascular risk factors were extracted from published reports. Differences between 1999 and 2004 were defined a priori as occurring when the 95% CI excluded 0 (for prevalence differences), or 1 (for risk ratios) or when there was a 5% or more change (independent of CIs). RESULTS: Generally, there were reductions in smoking and blood pressure and increases in the waist-hip ratio, body mass index and diabetes. Changes between 1999 and 2004 indicated inconsistent progress and increasing inequalities. For example, total cholesterol increased in Pakistani (0.3 mmol/L) and Bangladeshi men (0.3 mmol/L), and in Pakistani (0.3 mmol/L), Bangladeshi (0.4 mmol/L) and Black Caribbean women (0.3 mmol/L). Increases in absolute risk factor levels were common, for example, in Pakistani (five risk factors), Bangladeshi (four factors) and general population women (four factors). For men, Black Caribbeans had the most (five factor) increases. The changes relative to the general population were also adverse for three risk factors in Pakistani and Black Caribbean men, four in Bangladeshi women and three in Pakistani women. CONCLUSIONS: Changes in populations with the most cardiovascular disease and diabetes did not decline the quickest. Cardiovascular screening programmes need more targeting.

Myocardial infarction incidence and survival by ethnic group: Scottish Health and Ethnicity Linkage retrospective cohort study.

OBJECTIVE: Inequalities in coronary heart disease mortality by country of birth are large and poorly understood. However, these data misclassify UK-born minority ethnic groups and provide little detail on whether excess risk is due to increased incidence, poorer survival or both. DESIGN: Retrospective cohort study. SETTING: General resident population of Scotland. PARTICIPANTS: All those residing in Scotland during the 2001 Census were eligible for inclusion: 2 972 120 people were included in the analysis. The number still residing in Scotland at the end of the study in 2008 is not known. PRIMARY AND SECONDARY OUTCOME MEASURES: As specified in the analysis plan, the primary outcome measures were first occurrence of admission or death due to myocardial infarction and time to event. There were no secondary outcome measures. RESULTS: Acute myocardial infarction (AMI) incidence risk ratios (95% CIs) relative to white Scottish populations (100) were highest among Pakistani men (164.1 (142.2 to 189.2)) and women (153.7 (120.5, 196.1)) and lowest for men and women of Chinese (39.5 (27.1 to 57.6) and 59.1 (38.6 to 90.7)), other white British (77 (74.2 to 79.8) and 72.2 (69.0 to 75.5)) and other white (83.1 (75.9 to 91.0) and 79.9 (71.5 to 89.3)) ethnic groups. Adjustment for educational qualification did not eliminate these differences. Cardiac intervention uptake was similar across most ethnic groups. Compared to white Scottish, 28-day survival did not differ by ethnicity, except in Pakistanis where it was better, particularly in women (0.44 (0.25 to 0.78)), a difference not removed by adjustment for education, travel time to hospital or cardiac intervention uptake. CONCLUSIONS: Pakistanis have the highest incidence of AMI in Scotland, a country renowned for internationally high cardiovascular disease rates. In contrast, survival is similar or better in minority ethnic groups. Clinical care and policy should focus on reducing incidence among Pakistanis through more aggressive prevention.