The Health Impact of Waiting for Elective Procedures in the NHS in England: A Modeling Framework Applied to Coronary Artery Bypass Graft and Total Hip Replacement.

INTRODUCTION: The aim of this study is to demonstrate a practical framework that can be applied to estimate the health impact of changes in waiting times across a range of elective procedures in the National Health Service (NHS) in England. We apply this framework by modeling 2 procedures: coronary artery bypass graft (CABG) and total hip replacement (THR). METHODS: We built a Markov model capturing health pre- and postprocedure, including the possibility of exiting preprocedure to acute NHS care or self-funded private care. We estimate the change in quality-adjusted life-years (QALYs) over a lifetime horizon for 10 subgroups defined by sex and Index of Multiple Deprivation quintile groups and for 7 alternative scenarios. We include 18 wk as a baseline waiting time consistent with current NHS policy. The model was populated with data from routinely collected data sets where possible (Hospital Episode Statistics, Patient-Reported Outcome Measures, and Office for National Statistics Mortality records), supplemented by the academic literature. RESULTS: Compared with 18 wk, increasing the wait time to 36 wk resulted in a mean discounted QALY loss in the range of 0.034 to 0.043 for CABG and 0.193 to 0.291 for THR. The QALY impact of longer NHS waits was greater for those living in more deprived areas, partly as fewer patients switch to private care. DISCUSSION/CONCLUSION: The proposed framework was applied to 2 different procedures and patient populations. If applied to an expanded group of procedures, it could provide decision makers with information to inform prioritization of waiting lists. There are a number of limitations in routine data on waiting for elective procedures, primarily the lack of information on people still waiting. HIGHLIGHTS: We present a modeling framework that allows for an estimation of the health impact (measured in quality-adjusted life-years) of waiting for elective procedures in the NHS in England.We apply our model to waiting for coronary artery bypass graft (CABG) and total hip replacement (THR). Increasing the wait for THR results in a larger health loss than an equivalent increase in wait for CABG.This model could potentially be used to estimate the impact across an expanded group of procedures to inform prioritization of activities to reduce waiting times.

The impact of COVID-19 on mental health service utilisation in England.

The COVID-19 pandemic has had a significant impact on population mental health and the need for mental health services in many countries, while also disrupting critical mental health services and capacity, as a response to the pandemic. Mental health providers were asked to reconfigure wards to accommodate patients with COVID-19, thereby reducing capacity to provide mental health services. This is likely to have widened the existing mismatch between demand and supply of mental health care in the English NHS. We quantify the impact of these rapid service reconfigurations on activity levels for mental health providers in England during the first thirteen months (March 2020-March 2021) of the COVID-19 pandemic. We use monthly mental health service utilisation data for a large subset of mental health providers in England from January 1, 2015 to March 31, 2021. We use multivariate regression to estimate the difference between observed and expected utilisation from the start of the pandemic in March 2020. Expected utilisation levels (i.e. the counterfactual) are estimated from trends in utilisation observed during the pre-pandemic period January 1, 2015 to February 31, 2020. We measure utilisation as the monthly number of inpatient admissions, discharges, net admissions (admissions less discharges), length of stay, bed days, number of occupied beds, patients with outpatient appointments, and total outpatient appointments. We also calculate the accumulated difference in utilisation from the start of the pandemic period. There was a sharp reduction in total inpatient admissions and net admissions at the beginning of the pandemic, followed by a return to pre-pandemic levels from September 2020. Shorter inpatient stays are observed over the whole period and bed days and occupied bed counts had not recovered to pre-pandemic levels by March 2021. There is also evidence of greater use of outpatient appointments, potentially as a substitute for inpatient care.

Economic inequality and depressive symptoms: an individual versus aggregate-level analysis using Mexican survey data.

BACKGROUND: There is a lack of consensus on the relationship between economic inequality and mental health, which may be due to the measures of inequality used in empirical studies. We studied this relationship using individual and aggregate measures of economic inequality, and tested whether there is an interaction between the individual and the aggregate levels. METHODS: We used data from a nationally representative Mexican health survey (Encuesta Nacional de Salud y Nutrición, n=44 324) where depressive symptoms were measured through a validated 7-item version of the Centre for Epidemiologic Studies Depression Scale. We estimated multilevel models employing aggregate inequality measures (Gini coefficient) and the individual-level framework of advantageous and disadvantageous inequality, where economic status comprised absolute wealth, relative deprivation and relative affluence. RESULTS: The three facets of economic status were independently associated with depressive symptoms, while Gini coefficients showed no associations. Absolute wealth and relative affluence were associated with lower depressive symptoms while relative deprivation was associated with higher depressive symptoms. However, interaction models indicated an interplay between the Gini and relative affluence: higher status became a risk factor at high levels of aggregate economic inequality. For those at the top of the economic hierarchy, being in a context of high inequality more than doubles our measure of depressive symptoms-from 2.08 (95% CI 1.28 to 2.87) to 6.29 (95% CI 4.1 to 8.5) for state inequality and from 2.40 (95% CI 1.64 to 3.16) to 6.24 (95% CI 3.87 to 8.62) for municipal inequality. CONCLUSION: We provided a novel perspective on the economic gradient in mental health, and on how high aggregate economic inequality may harm also the better off. Policymakers need to consider the consequences of economic inequalities, which can harm the mental health of both those at the bottom and the top of the socioeconomic ladder.

The economic gradient of obesity in Mexico: Independent predictive roles of absolute and relative wealth by gender.

Despite the vast literature on the economic gradient of obesity, no study investigates the independent predictive roles of absolute and relative standards of living using a large nationally representative adult sample. This gap limits our ability to discern 'material' and 'psychosocial' pathways to obesity as well as our understanding of the role played by economic inequality in the growing obesity epidemic. Using a large and nationally representative Mexican dataset, we find that absolute wealth and relative deprivation are independently related to obesity, and that such relationships are patterned by sex. Absolute wealth predicts body mass index as well as abdominal obesity according to an inverted-U shape for both sexes, and more markedly so for females. Relative deprivation predicts higher body mass index for females and higher waist circumference for both sexes, with highly relatively deprived females being 24.29% (95% CI [24.26, 24.31]) more likely to be obese and 34.46% (95% CI [34.40,34.53]) more likely to be abdominal obese, and highly relatively deprived males being 14.91% (95% CI [14.88,14.93] more likely to be abdominal obese. Our results offer a new perspective on the economic gradient of obesity and highlight the potential impact of economic inequality, especially for women. Greater awareness of the independent and sex-specific roles of the absolute and relative facets of economic status is needed to better understand and address the obesity epidemic.

Depression and economic status: evidence for non-linear patterns in women from Mexico.

BACKGROUND: While social determinants of health perspective might lead to the hypothesis that higher economic achievements should be associated with better mental health, the evidence for adults is mixed and inconclusive. AIM: We test the role of wealth as a predictor of depressive symptoms controlling for a number of socio-demographic covariates, with a specific interest in gender-specific patterns. METHODS: Using a nationally representative survey from Mexico (N = 44,618), we carry out multivariate regression analysis where we jointly model linear and quadratic measures of wealth to detect non-linear relations between depression and wealth. RESULTS: The paper reports clear evidence of an inverted-U relationship between depressive symptoms and wealth for females, whereas the relationship for males tends to be linear and decreasing with wealth as expected (though weak and significant only in the upper part of the wealth distribution). Our findings are robust to alternative empirical strategies and we discuss potential explanations for this novel finding. CONCLUSION: The paper confirms that the association between standards of living and depression is complex, due to the mediating role of socio-demographic characteristics and the existence of non-linearities not fully explored in the literature.

Relative deprivation: Measurement issues and predictive role for body image dissatisfaction.

The study of how relative standing in the socioeconomic hierarchy affects health outcomes faces a number of challenges. Two critical issues are the choice of the indicator quantifying relative standard of living and the collinearity which typically arises when absolute standard of living is controlled for. We address these issues by taking into examination linear and concave measures of relative deprivation and by showing that collinearity can be lessened through manipulations of the measures' formulae. Importantly, we argue that the two issues are intertwined and should be jointly considered by researchers. We illustrate the points above using nationally representative data from Mexico (N = 44,214) and studying relative deprivation as a predictor of body image dissatisfaction - a growing public health concern whose effects go well beyond eating disorders. Controlling for several individual characteristics, binary and multinomial logit regressions indicate relative deprivation as a risk factor for body image dissatisfaction. By conducting subsample analyses and by introducing an interaction term between gender and relative deprivation, we show evidence of a gender-based heterogeneity in the role of relative deprivation - which predicts feeling smaller than desired for both females and males and feeling larger than desired for females but not for males. This heterogeneity is discussed in the light of the different social pressures females and males face for slenderness and muscularity. Our evidence enriches the literature on socioeconomic gradients in health, pointing to an additional domain in which a low position in the socioeconomic ladder translates into greater likelihood of developing health problems and adopting health-compromising behaviors.