Towards transforming community eye care: an observational study and time-series analysis of optometrists' prescribing for eye disorders.

OBJECTIVES: This study aimed to provide evidence on the therapeutic prescribing activity by community optometrists in Scotland and to determine its impact on workload in general practice and ophthalmology clinics. STUDY DESIGN: Scottish administrative healthcare data for a 53-month period (November 2013-April 2018) were used to analyse non-medical prescribing practice by optometrists. METHODS: Using interrupted time-series regression (Autoregressive Integrated Moving Average), we assessed the impact of optometrist prescribing on ophthalmology outpatient attendances and general practice prescribing for eye disorders. RESULTS: A total of 54,246 items were prescribed by 205 optometrists over the study period. Since the commencement of data recording, optometrist prescribing activity increased steadily from a baseline of zero to 1.2% of all ophthalmic items prescribed. Neither the monthly number of items prescribed nor the size of optometric workforce were associated with a reduction in ophthalmology outpatient appointments over time. CONCLUSIONS: Optometrists increasingly contribute to community ophthalmic prescribing in Scotland, releasing capacity and lessening general practice, but not secondary care workload. There appears to be an underutilisation of optometrists related to the management of dry eye, which represents an opportunity to release further capacity.

The Mortality After Release from Incarceration Consortium (MARIC): Protocol for a multi-national, individual participant data meta-analysis.

INTRODUCTION: More than 30 million adults are released from incarceration globally each year. Many experience complex physical and mental health problems, and are at markedly increased risk of preventable mortality. Despite this, evidence regarding the global epidemiology of mortality following release from incarceration is insufficient to inform the development of targeted, evidence-based responses. Many previous studies have suffered from inadequate power and poor precision, and even large studies have limited capacity to disaggregate data by specific causes of death, sub-populations or time since release to answer questions of clinical and public health relevance. OBJECTIVES: To comprehensively document the incidence, timing, causes and risk factors for mortality in adults released from prison. METHODS: We created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration representing 29 cohorts of adults who have experienced incarceration from 11 countries. Findings across cohorts will be analysed using a two-step, individual participant data meta-analysis methodology. RESULTS: The combined sample includes 1,337,993 individuals (89% male), with 75,795 deaths recorded over 9,191,393 person-years of follow-up. CONCLUSIONS: The consortium represents an important advancement in the field, bringing international attention to this problem. It will provide internationally relevant evidence to guide policymakers and clinicians in reducing preventable deaths in this marginalized population. KEY WORDS: Mortality; incarceration; prison; release; individual participant data meta-analysis; consortium; cohort.

Incident ischaemic stroke and Type 2 diabetes: trends in incidence and case fatality in Scotland 2004-2013.

AIM: To describe trends in first ischaemic stroke incidence and case fatality in adults with and without a diagnosis of Type 2 diabetes prior to their ischaemic stroke event in Scotland between 2004 and 2013. METHODS: Using population-wide hospital admission, death and diabetes datasets, we conducted a retrospective cohort study. Negative binomial and logistic regression models were used to calculate year-specific incidence and case-fatality rates for people with Type 2 diabetes and for people without diabetes. RESULTS: During 41.0 million person-years of follow-up there were 69 757 ischaemic stroke events. Type 2 diabetes prevalence among patients who experienced ischaemic stroke increased from 13.5% to 20.3% between 2004 and 2013. Stroke incidence rates declined by 2.7% (95% CI 2.4, 3.0) annually for people with and without diabetes [diabetes/year interaction: rate ratio 0.99 (95% CI 0.98, 1.01)]. Type 2 diabetes was associated with an increased risk of ischaemic stroke in men [rate ratio 1.23 (95% CI 1.17, 1.30)] and women [rate ratio 1.41 (95% CI 1.35, 1.48)]. Case-fatality rates were 14.2% and 12.7% in people with Type 2 diabetes and without diabetes, respectively. Case fatality declined by 3.5% (95% CI 2.7, 4.5) annually [diabetes/year interaction: odds ratio 1.01 (95% CI 0.98, 1.02)]. CONCLUSIONS: Ischaemic stroke incidence declined no faster in people with a diagnosis of Type 2 diabetes than in people without diabetes. Increasing prevalence of Type 2 diabetes among stroke patients may mean that declines in case fatality over time will be less marked in the future.

Risk of hospitalization and death following prostate biopsy in Scotland.

OBJECTIVE: To investigate the risk of hospitalization and death following prostate biopsy. STUDY DESIGN: Retrospective cohort study. METHODS: Our study population comprised 10,285 patients with a record of first ever prostate biopsy between 2009 and 2013 on computerized acute hospital discharge or outpatient records covering Scotland. Using the general population as a comparison group, expected numbers of admissions/deaths were derived by applying age-, sex-, deprivation category-, and calendar year-specific rates of hospital admissions/deaths to the study population. Indirectly standardized hospital admission ratios (SHRs) and mortality ratios (SMRs) were calculated by dividing the observed numbers of admissions/deaths by expected numbers. RESULTS: Compared with background rates, patients were more likely to be admitted to hospital within 30 days (SHR 2.7; 95% confidence interval 2.4, 2.9) and 120 days (SHR 4.0; 3.8, 4.1) of biopsy. Patients with prior co-morbidity had higher SHRs. The risk of death within 30 days of biopsy was not increased significantly (SMR 1.6; 0.9, 2.7), but within 120 days, the risk of death was significantly higher than expected (SMR 1.9; 1.5, 2.4). The risk of death increased with age and tended to be higher among patients with prior co-morbidity. Overall risks of hospitalization and of death up to 120 days were increased both in men diagnosed and those not diagnosed with prostate cancer. CONCLUSIONS: Higher rates of adverse events in older patients and patients with prior co-morbidity emphasizes the need for careful patient selection for prostate biopsy and justifies ongoing efforts to minimize the risk of complications.

Patient characteristics associated with risk of first hospital admission and readmission for acute exacerbation of chronic obstructive pulmonary disease (COPD) following primary care COPD diagnosis: a cohort study using linked electronic patient records.

OBJECTIVES: To investigate patient characteristics of an unselected primary care population associated with risk of first hospital admission and readmission for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). DESIGN: Retrospective open cohort using pseudonymised electronic primary care data linked to secondary care data. SETTING: Primary care; Lothian (population approximately 800,000), Scotland. PARTICIPANTS: Data from 7002 patients from 72 general practices with a COPD diagnosis date between 2000 and 2008 recorded in their primary care record. Patients were followed up until 2010, death or they left a participating practice. MAIN OUTCOME MEASURES: First and subsequent admissions for AECOPD (International Classification of Diseases (ICD) 10 codes J44.0, J44.1 in any diagnostic position) after COPD diagnosis in primary care. RESULTS: 1756 (25%) patients had at least 1 AECOPD admission; 794 (11%) had at least 1 readmission and the risk of readmission increased with each admission. Older age at diagnosis, more severe COPD, low body mass index (BMI), current smoking, increasing deprivation, COPD admissions and interventions for COPD prior to diagnosis in primary care, and comorbidities were associated with higher risk of first AECOPD admission in an adjusted Cox proportional hazards regression model. More severe COPD and COPD admission prior to primary care diagnosis were associated with increased risk of AECOPD readmission in an adjusted Prentice-Williams-Peterson model. High BMI was associated with a lower risk of first AECOPD admission and readmission. CONCLUSIONS: Several patient characteristics were associated with first AECOPD admission in a primary care cohort of people with COPD but fewer were associated with readmission. Prompt diagnosis in primary care may reduce the risk of AECOPD admission and readmission. The study highlights the important role of primary care in preventing or delaying a first AECOPD admission.

Factors associated with statin treatment for the primary prevention of cardiovascular disease in people within 2 years following diagnosis of diabetes in Scotland, 2006-2008.

AIM: To describe characteristics associated with statin prescribing for the primary prevention of cardiovascular disease in people with newly diagnosed diabetes. METHODS: Data from the Scottish Care Information-Diabetes Collaboration data set for 2006-2008 were used. This data set contains socio-demographic and prescribing data for over 99% of people with diagnosed diabetes in Scotland. Analyses were conducted on people aged over 40 years diagnosed with Type 1 or Type 2 diabetes between 2006 and 2008 with complete data and no previous history of cardiovascular or statin prescription. Logistic regression was used to calculate odds ratios for statin prescription in the 2 years following diagnosis of diabetes. RESULTS: There were 7157 men and 5601 women who met the inclusion criteria, 68% of whom had a statin prescription recorded in the 2 years following diagnosis of diabetes. The proportions receiving statins were lower above 65 years of age in men and 75 years of age in women. People with Type 1 diabetes had lower odds of receiving statins than people with Type 2 diabetes [odds ratio (95% CI) 0.42 (0.29-0.61) for men and 0.48 (0.28-0.81) for women, after adjustment for age, BMI, smoking status, cholesterol level and deprivation]. Higher total cholesterol, BMI and being a current smoker were associated with greater odds of statin prescription. CONCLUSION: Approximately one third of the study population had no record of statin prescription during the 2 years after diagnosis of diabetes. Cardiovascular disease risk reduction opportunities may be missed in some of these people.

Type 2 diabetes, socioeconomic status and risk of cancer in Scotland 2001-2007.

AIMS/HYPOTHESIS: The objective of this study was to use Scottish national data to assess the influence of type 2 diabetes on the risk of cancer at 16 different sites, while specifically investigating the role of confounding by socioeconomic status in the diabetes-cancer relationship. METHODS: All people in Scotland aged 55-79 years diagnosed with any of the cancers of interest during the period 2001-2007 were identified and classified by the presence/absence of co-morbid type 2 diabetes. The influence of diabetes on cancer risk for each site was assessed via Poisson regression, initially with adjustment for age only, then adjusted for both age and socioeconomic status. RESULTS: There were 4,285 incident cancers in people with type 2 diabetes. RR for any cancers (adjusted for age only) was 1.11 (95% CI 1.05, 1.17) for men and 1.33 (1.28, 1.40) for women. Corresponding values after additional adjustment for socioeconomic status were 1.10 (1.04, 1.15) and 1.31 (1.25, 1.38), respectively. RRs for individual cancer sites varied markedly. CONCLUSIONS/INTERPRETATION: Socioeconomic status was found to have little influence on the association between type 2 diabetes and cancer.

Cause-specific mortality in Scottish patients with colorectal cancer with and without type 2 diabetes (2000-2007).

AIMS/HYPOTHESIS: The objective of this study was to use Scottish national data to assess the influence of type 2 diabetes on (1) survival (overall and cause-specific) in multiple time intervals after diagnosis of colorectal cancer and (2) cause of death. METHODS: Data from the Scottish Cancer Registry were linked to data from a population-based national diabetes register. All people in Scotland diagnosed with non-metastatic cancer of the colon or rectum in 2000-2007 were included. The effect of pre-existing type 2 diabetes on survival over four discrete time intervals (<1, 1-2, 3-5 and >5 years) after cancer diagnosis was assessed by Cox regression. Cumulative incidence functions were calculated representing the respective probabilities of death from the competing causes of colorectal cancer, cardiovascular disease, other cancers and any other cause. RESULTS: Data were available for 19,505 people with colon or rectal cancer (1,957 with pre-existing diabetes). Cause-specific mortality analyses identified a stronger association between diabetes and cardiovascular disease mortality than that between diabetes and cancer mortality. Beyond 5 years after colon cancer diagnosis, diabetes was associated with a detrimental effect on all-cause mortality after adjustment for age, socioeconomic status and cancer stage (HR [95% CI]: 1.57 [1.19, 2.06] in men; 1.84 [1.36, 2.50] in women). For patients with rectal cancer, diabetes was not associated with differential survival in any time interval. CONCLUSIONS/INTERPRETATION: Poorer survival observed for colon cancer associated with type 2 diabetes in Scotland may be explained by higher mortality from causes other than cancer.

Area-based socioeconomic status, type 2 diabetes and cardiovascular mortality in Scotland.

AIMS/HYPOTHESIS: The aim of this study was to explore the relationships between type 2 diabetes mellitus, area-based socioeconomic status (SES) and cardiovascular disease mortality in Scotland. METHODS: We used an area-based measure of SES, Scottish national diabetes register data linked to mortality records, and general population cause-specific mortality data to investigate the relationships between SES, type 2 diabetes and mortality from ischaemic heart disease (IHD) and cerebrovascular disease (CbVD), for 2001-2007. We used negative binomial regression to obtain age-adjusted RRs of mortality (by sex), comparing people with type 2 diabetes with the non-diabetic population. RESULTS: Among 216,652 people aged 40 years or older with type 2 diabetes (980,687 person-years), there were 10,554 IHD deaths and 4,378 CbVD deaths. Age-standardised mortality increased with increasing deprivation, and was higher among men. IHD mortality RRs were highest among the least deprived quintile and lowest in the most deprived quintile (men: least deprived, RR 1.94 [95% CI 1.61, 2.33]; most deprived, RR 1.46 [95% CI 1.23, 1.74]) and were higher in women than men (women: least deprived, RR 2.84 [95% CI 2.12, 3.80]; most deprived, RR 2.04 [95% CI 1.55, 2.69]). A similar, weaker, pattern was observed for cerebrovascular mortality. CONCLUSIONS/INTERPRETATION: Absolute risk of cardiovascular mortality is higher in people with diabetes than in the non-diabetic population and increases with increasing deprivation. The relative impact of diabetes on cardiovascular mortality differs by SES, and further efforts to reduce cardiovascular risk both in deprived groups and people with diabetes are required. Prevention of diabetes may reduce socioeconomic health inequalities.

The effect of deprivation and HbA1c on admission to hospital for diabetic ketoacidosis in type 1 diabetes.

AIMS/HYPOTHESIS: Diabetic ketoacidosis is a potentially life-threatening complication of diabetes and has a strong relationship with HbA(1c). We examined how socioeconomic group affects the likelihood of admission to hospital for diabetic ketoacidosis. METHODS: The Scottish Care Information - Diabetes Collaboration (SCI-DC), a dynamic national register of all cases of diagnosed diabetes in Scotland, was linked to national data on hospital admissions. We identified 24,750 people with type 1 diabetes between January 2005 and December 2007. We assessed the relationship between HbA(1c) and quintiles of deprivation with hospital admissions for diabetic ketoacidosis in people with type 1 diabetes adjusting for patient characteristics. RESULTS: We identified 23,479 people with type 1 diabetes who had complete recording of covariates. Deprivation had a substantial effect on odds of admission to hospital for diabetic ketoacidosis (OR 4.51, 95% CI 3.73, 5.46 in the most deprived quintile compared with the least deprived). This effect persisted after the inclusion of HbA(1c) and other risk factors (OR 2.81, 95% CI 2.32, 3.39). Men had a reduced risk of admission to hospital for diabetic ketoacidosis (OR 0.71, 95% CI 0.63, 0.79) and those with a history of smoking had increased odds of admission to hospital for diabetic ketoacidosis by a factor of 1.55 (95% CI 1.36, 1.78). CONCLUSIONS/INTERPRETATION: Women, smokers, those with high HbA(1c) and those living in more deprived areas have an increased risk of admission to hospital for diabetic ketoacidosis. The effect of deprivation was present even after inclusion of other risk factors. This work highlights that those in poorer areas of the community with high HbA(1c) represent a group who might be usefully supported to try to reduce hospital admissions.

Might infection explain the higher risk of coronary heart disease in South Asians? Systematic review comparing prevalence rates with white populations in developed countries.

OBJECTIVES: South Asians in developed countries such as the UK are at comparatively high risk of coronary heart disease for reasons which are not fully understood. One unexplored hypothesis is more infections in this ethnic group. This study assessed whether the prevalence of infections among South Asians differs from that among White populations of European origin in developed countries. STUDY DESIGN: Systematic review. METHODS: Medline, Web of Science and Google Scholar databases were searched. In addition, reference lists and citations were reviewed. RESULTS: Twenty-one studies reported prevalence rates and mean antibody levels of infection with 17 different pathogens or non-specific markers of infection. Among bacterial infections, higher rates of Escherichia coli and Mycobacterium tuberculosis infection were found in South Asians. No consistent differences were found for periodontal pathogens, Helicobacter pylori, Staphylococcus aureus, Chlamydia pneumoniae and Mycobacterium avium. For viral pathogens, higher rates of hepatitis A, hepatitis B and cytomegalovirus; and lower rates of herpes simplex, hepatitis C, human immunodeficiency virus and varicella zoster virus were found among South Asians. No difference was seen in the prevalence of hepatitis G virus in South Asians. Levels of non-specific markers of infection (total immunoglobulin G, endotoxin) were higher in South Asians. CONCLUSIONS: The number of studies was small. Differences in the prevalence of specific infections were found, but the current evidence is insufficient to support or reject the hypothesis under examination. Further studies are warranted.

Ethnic variations in heart failure: Scottish Health and Ethnicity Linkage Study (SHELS).

OBJECTIVE: Ethnic variations in heart failure are, apparently, large (eg, up to threefold in South Asians compared with White populations in Leicestershire, UK) but data are limited and conflicting. The incidence of first occurrence of heart failure hospitalisation or death by ethnic group in Scotland was studied. DESIGN, SETTING, POPULATIONS AND OUTCOMES: A retrospective cohort study was developed of 4.65 million people using non-disclosive, computerised methods linking the Scottish 2001 census (providing ethnic group) to community death and hospital discharge/deaths data (SMR01). Annual, directly age standardised incidence rates per 100,000, incidence rate ratios (RRs) and risk ratios using Poisson regression were calculated. Ratios were multiplied by 100. Risk ratios were adjusted for age and highest education qualification. Statements of difference imply the 95% CI excludes 100 (reference), otherwise the CI is given. RESULTS: In men, other White British (RR=86.4) and Chinese (RR=54.2) had less heart failure than White Scottish (100) populations while Pakistani men had more (RR=134.9). In women, the pattern was similar to men. Adjustment for highest educational qualification attenuated differences in risk ratios in other White British men (risk ratio=75.8 to 85.4) and women (66.2 to 74.6), made little difference to Pakistani men (146.9 to 142.1) and women (177.4 to 158.1), and augmented them in Indian men (115.4 (95% CI 93.1 to 143.0) to 131.7 (107.4 to 161.5)). CONCLUSIONS: Ethnic variations in heart failure were important in this population setting and not abolished by adjusting for highest education, one important indicator of socioeconomic differences. The ethnic variations were substantial but did not support other studies showing 3-20-fold differences between ethnic groups.

Ethnic variations in the incidence and mortality of stroke in the Scottish Health and Ethnicity Linkage Study of 4.65 million people.

BACKGROUND: Ethnic variations in stroke require more European studies, especially as differences are reportedly large. METHODS: We created a retrospective cohort study of 4.65 million people in Scotland linking ethnicity from the census and stroke incidence and mortality from NHS databases. Rate ratios using direct age standardization and risk ratios were calculated, the latter to model the influence of educational qualification in a Poisson regression model. RESULTS: Age-adjusted rate ratios varied little, compared to the White Scottish group (reference value 100) and the 95% CIs usually included 100, e.g. higher in Pakistani men (120.5, 95% CI 95.2-145.8) and in African men (137.9, 95% CI 91.5-184.4) but not in Pakistani or African women. Stroke rates were low in the Other White British (78.3, 95% CI 75.4-81.2 in men and 84.9, 95% CI 82.0-87.8 in women), Other White (89.8, 95% CI 81.5-98.1 in men and 88.8, 95% CI 80.9-96.7 in women) and Chinese men (70.3, 95% CI 45.7-94.8). Adjusting for highest educational qualification attenuated some and augmented other risk ratios, e.g. in Other White British men, the risk ratio changed from 71.4 to 80.2 (95% CI 74.2-86.6) and in African men from 124.2 to 138.8 (95% CI 107.7-178.8). CONCLUSIONS: Ethnic variations deserve further study, including in White European origin subgroups and the Chinese. Extremely high rates in South Asian and African origin were not corroborated in Scotland. Linkage methods are practical in Europe.

Assessment of the under-reporting of diabetes in hospital admission data: a study from the Scottish Diabetes Research Network Epidemiology Group.

AIMS: Good quality data are required to plan and evaluate diabetes services and to assess progress against targets for reducing hospital admissions and bed days. The aim of this study was to assess the completeness of recording of diabetes in hospital admissions using recent national data for Scotland. METHODS: Data derived from linkage of the Scottish National Diabetes Register and hospital admissions data were analysed to assess the completeness of coding of diabetes in hospital inpatient admissions between 2000 and 2007 for patients identified with diabetes prior to hospital admission. RESULTS: In 2007, only 59% of hospital inpatient admissions for people previously diagnosed with diabetes mentioned diabetes, whereas over 99% of people with a mention of diabetes on hospital records were included in the diabetes register. The completeness of diabetes recording varied from 44 to 82% among mainland National Health Service Boards and from 34 to 89% among large general hospitals. Completeness of recording of diabetes as a co-morbidity also varied by primary diagnosis: 70 and 41% of admissions with coronary heart disease and cancer as the primary diagnosis mentioned co-existing diabetes, respectively. CONCLUSIONS: There is wide variation in the completeness of recording of diabetes in hospital admission data. Hospital data alone considerably underestimate the number of admissions and bed days but overestimate length of stay for people with diabetes. Linkage of diabetes register data to hospital admissions data provides a more accurate source for measuring hospital admissions among people diagnosed with diabetes than hospital admissions data.

Improving the view of Scotland's health: the impact of a public health observatory upon health improvement policy, action and monitoring in a devolved nation.

The Scottish Public Health Observatory (ScotPHO) is a collaboration of the observatory sections/functions of several organizations. It operates within a small country, part of the UK, with devolved legislative and executive powers in health and in many areas relating to wider social determinants of health. The short-term impact of ScotPHO on health improvement action, policy and monitoring is described. A key factor in ScotPHO's impact is the directness of its contact with Scottish government policy and analysis leadership. The context and organization of ScotPHO differentiates it from other PHOs in the UK and Ireland, but many of the health and information challenges faced are similar and the Association of Public Health Observatories enables experience and expertise to be shared.

Epidemiology and disease burden from allergic disease in Scotland: analyses of national databases.

BACKGROUND: There are ongoing concerns about the quality of care provided to patients with allergic disorders in Scotland, but there are relatively few reliable data on the overall disease burden. We sought to: (1) describe the incidence, prevalence and outcome of allergic disorders; (2) estimate healthcare burden and costs; and (3) investigate ethnic variations in the epidemiology and outcomes from allergic disorders in Scotland. DATA SOURCES: national surveys; primary care data; prescribing and medication data; hospital admissions data and mortality data. RESULTS: Allergic disorders are extremely common in Scotland, affecting about one in three of the population at some time in their lives. Incidence was highest for eczema (10.2 per 1000 registered patients). Over 4% of all GP consultations and 1.5% of hospital admissions were for allergic disorders. There were 100 asthma deaths in 2005 (20 per million people). Direct healthcare costs for allergic disorders were an estimated pound130 million per year, the majority of these being incurred in primary care and related to asthma. CONCLUSIONS: Allergic disorders are common in Scotland and given the very high proportion of children now affected, the high disease burden associated with these conditions is likely to persist for many decades.

Secondhand smoke exposure and survival following acute coronary syndrome: prospective cohort study of 1261 consecutive admissions among never-smokers.

OBJECTIVE: To determine whether exposure to secondhand smoke is associated with early prognosis following acute coronary syndrome. DESIGN, SETTING AND PARTICIPANTS: We interviewed consecutive patients admitted to nine Scottish hospitals over 23 months. Information was obtained, via questionnaire, on age, sex, smoking status, postcode of residence and admission serum cotinine concentration was measured. Follow-up data were obtained from routine hospital admission and death databases. RESULTS: Of the 5815 participants, 1261 were never-smokers. Within 30 days, 50 (4%) had died and 35 (3%) had a non-fatal myocardial infarction. All-cause deaths increased from 10 (2.1%) in those with cotinine < or =0.1 ng/ml to 22 (7.5%) in those with cotinine >0.9 ng/ml (chi(2) test for trend p<0.001). This persisted after adjustment for potential confounders (cotinine >0.9 ng/ml: adjusted OR 4.80, 95% CI 1.95 to 11.83, p = 0.003). The same dose response was observed for cardiovascular deaths and death or myocardial infarction. CONCLUSIONS: Secondhand smoke exposure is associated with worse early prognosis following acute coronary syndrome. Non-smokers need to be protected from the harmful effects of secondhand smoke.

Is there equity of service delivery and intermediate outcomes in South Asians with type 2 diabetes? Analysis of DARTS database and summary of UK publications.

BACKGROUND: There are doubts whether diabetes care is equitable across UK ethnic groups. We examined processes and outcomes in South Asians with diabetes and reviewed the UK literature. METHODS: We used name search methods to identify South Asians in a regional diabetes database. We compared prevalence rates, processes and outcomes of care between November 2003 and December 2004. We used standard literature search techniques. RESULTS: The prevalence of diabetes in South Asians was 3-4 times higher than non-South Asians. South Asians were 1.11 times (95% confidence interval 1.06, 1.16) more likely to have a structured review. South Asian women were 1.10 times more likely to have a record of body mass index (95% CI 1.04, 1.16). HbA1c levels were 1.03 times higher (95% CI 1.00, 1.06) among South Asians, retinopathy 1.36 times more common (95% CI 1.03, 1.78) and hypertension 0.71 times as common (95% CI 0.58, 0.87). CONCLUSIONS: We found evidence of equity in many aspects of diabetes care for South Asians in Tayside. The finding of higher HbA1c and more retinopathy among South Asians needs explanation and a service response. These findings from a region with a small non-White population largely support the recent findings from other parts of the UK.

Evaluating the impact of a national pilot screening programme for type 2 diabetes in deprived areas of England.

BACKGROUND: A pilot programme designed to systematically screen for type 2 diabetes was introduced in 24 general practices in England selected for their high levels of socio-economic deprivation and multi-ethnic populations. OBJECTIVE: To evaluate the impact of screening on the prevalence of type 2 diabetes. METHODS: A prospective audit of screening activity in pilot practices and comparison of the change in prevalence of diabetes in pilot and comparison practices were conducted. RESULTS: Of 41,400 individuals invited for screening from a population of 165,828 in pilot practices, 25,356 (61%) were screened. Three hundred and fifty-eight (0.22%) new cases of diabetes were detected among those screened. Only 69% of those with a positive screening test had diagnostic testing recorded and only 19% had a record of an oral glucose tolerance test. The absolute increase in the prevalence of diagnosed diabetes was 0.53% in pilot practices and 0.42% in comparison practices. CONCLUSIONS: The 'real world' nature of the programme and dependence on routine data collection systems makes results more difficult to interpret but also enabled problems with implementation, not evident from previous research, to be identified. It is likely that the low diagnostic yield was largely due to a high level of ad hoc screening activity outside the pilot protocol and inadequate access to diagnostic testing after a positive screening test. In particular, implementation of screening for diabetes in primary care should not be undertaken without robust assessment of the resources required for diagnostic testing and follow-up and adequate clinical audit.