Differences in cancer incidence by broad ethnic group in England, 2013-2017.

BACKGROUND: Cancer incidence variation between population groups can inform public health and cancer services. Previous studies have shown cancer incidence rates vary by ethnic group in England. Since their publication, the completeness of ethnicity recording in cancer data has improved, and relevant inequalities (e.g. risk factor prevalence and healthcare access) may have changed. METHODS: Age-standardised incidence rates were calculated for Asian, Black, Mixed/Multiple and White ethnic groups in England in 2013-2017, using almost 3 million diagnoses across 31 cancer sites. Rate ratios were calculated with the White ethnic group as reference. Sensitivity analyses used imputed ethnicity for cases with missing data and perturbed population estimates. RESULTS: Incidence rates for most cancer sites and ethnic group and sex combinations were lower in non-White minority ethnic groups compared with the corresponding White group, with particularly low rate ratios (below 0.5) for melanoma skin cancer and some smoking-related cancers (lung, bladder and oesophageal cancers). Exceptions included prostate cancer (2.1 times higher in males of Black ethnicity), myeloma (2.7-3.0 times higher in people of Black ethnicity), several gastrointestinal cancers (1.1-1.9 times higher in people of Black ethnicity, 1.4-2.2 times higher in people of Asian ethnicity), Hodgkin lymphoma (1.1 times higher in males of Asian ethnicity, 1.3 times higher in males of Black ethnicity) and thyroid cancers (1.4 times higher in people of Asian ethnicity, 1.2 times higher in people of Black ethnicity). Sensitivity analyses did not materially alter these results (rate ratios changed by a maximum of 12 percentage points, the direction and significance of results were unchanged in all but two cancer site/sex/ethnic group combinations). CONCLUSIONS: People of non-White minority ethnicity in England generally have lower cancer risk than the White population, though there are a number of notable exceptions. These results should galvanise efforts to better understand the reasons for this variation, and the possible impact on cancer services, patient experiences and outcomes.

Identifying inequitable healthcare in older people: systematic review of current research practice.

BACKGROUND: There is growing consensus on the importance of identifying age-related inequities in the receipt of public health and healthcare interventions, but concerns regarding conceptual and methodological rigour in this area of research. Establishing age inequity in receipt requires evidence of a difference that is not an artefact of poor measurement of need or receipt; is not warranted on the grounds of patient preference or clinical safety; and is judged to be unfair. METHOD: A systematic, thematic literature review was undertaken with the objective of characterising recent research approaches. Studies were eligible if the population was in a country within the Organisation for Economic Co-operation and Development and analyses included an explicit focus on age-related patterns of healthcare receipt including those 60 years or older. A structured extraction template was applied. Extracted material was synthesised in thematic memos. A set of categorical codes were then defined and applied to produce summary counts across key dimensions. This process was iterative to allow reconciliation of discrepancies and ensure reliability. RESULTS: Forty nine studies met the eligibility criteria. A wide variety of concepts, terms and methodologies were used across these studies. Thirty five studies employed multivariable techniques to produce adjusted receipt-need ratios, though few clearly articulated their rationale, indicating the need for great conceptual clarity. Eighteen studies made reference to patient preference as a relevant consideration, but just one incorporated any kind of adjustment for this factor. Twenty five studies discussed effectiveness among older adults, with fourteen raising the possibility of differential effectiveness, and one differential cost-effectiveness, by age. Just three studies made explicit reference to the ethical nature of healthcare resource allocation by age. While many authors presented suitably cautious conclusions, some appeared to over-stretch their findings concluding that observed differences were 'inequitable'. Limitations include possible biases in the retrieved material due to inconsistent database indexing and a focus on OECD country populations and studies with English titles. CONCLUSIONS: Caution is needed among clinicians and other evidence-users in accepting claims of healthcare 'ageism' in some published papers. Principles for improved research practice are proposed.

Age-related references in national public health, technology appraisal and clinical guidelines and guidance: documentary analysis.

Background: older people may be less likely to receive interventions than younger people. Age bias in national guidance may influence entire public health and health care systems. We examined how English National Institute for Health & Care Excellence (NICE) guidance and guidelines consider age. Methods: we undertook a documentary analysis of NICE public health (n = 33) and clinical (n = 114) guidelines and technology appraisals (n = 212). We systematically searched for age-related terms, and conducted thematic analysis of the paragraphs in which these occurred ('age-extracts'). Quantitative analysis explored frequency of age-extracts between and within document types. Illustrative quotes were used to elaborate and explain quantitative findings. Results: 2,314 age-extracts were identified within three themes: age documented as an a-priori consideration at scope-setting (518 age-extracts, 22.4%); documentation of differential effectiveness, cost-effectiveness or other outcomes by age (937 age-extracts, 40.5%); and documentation of age-specific recommendations (859 age-extracts, 37.1%). Public health guidelines considered age most comprehensively. There were clear examples of older-age being considered in both evidence searching and in making recommendations, suggesting that this can be achieved within current processes. Conclusions: we found inconsistencies in how age is considered in NICE guidance and guidelines. More effort may be required to ensure age is consistently considered. Future NICE committees should search for and document evidence of age-related differences in receipt of interventions. Where evidence relating to effectiveness and cost-effectiveness in older populations is available, more explicit age-related recommendations should be made. Where there is a lack of evidence, it should be stated what new research is needed.

Using logic model methods in systematic review synthesis: describing complex pathways in referral management interventions.

BACKGROUND: There is increasing interest in innovative methods to carry out systematic reviews of complex interventions. Theory-based approaches, such as logic models, have been suggested as a means of providing additional insights beyond that obtained via conventional review methods. METHODS: This paper reports the use of an innovative method which combines systematic review processes with logic model techniques to synthesise a broad range of literature. The potential value of the model produced was explored with stakeholders. RESULTS: The review identified 295 papers that met the inclusion criteria. The papers consisted of 141 intervention studies and 154 non-intervention quantitative and qualitative articles. A logic model was systematically built from these studies. The model outlines interventions, short term outcomes, moderating and mediating factors and long term demand management outcomes and impacts. Interventions were grouped into typologies of practitioner education, process change, system change, and patient intervention. Short-term outcomes identified that may result from these interventions were changed physician or patient knowledge, beliefs or attitudes and also interventions related to changed doctor-patient interaction. A range of factors which may influence whether these outcomes lead to long term change were detailed. Demand management outcomes and intended impacts included content of referral, rate of referral, and doctor or patient satisfaction. CONCLUSIONS: The logic model details evidence and assumptions underpinning the complex pathway from interventions to demand management impact. The method offers a useful addition to systematic review methodologies. TRIAL REGISTRATION NUMBER: PROSPERO registration number: CRD42013004037.

Systematic review and narrative synthesis of the effectiveness of contraceptive service interventions for young people, delivered in health care settings.

A systematic review and narrative synthesis to determine the effectiveness of contraception service interventions for young people delivered in health care premises was undertaken. We searched 12 key health and medical databases, reference lists of included papers and systematic reviews and cited reference searches on included articles. All retrieved literature was screened at title and abstract levels, and relevant articles were taken through to full paper appraisal. Data relating to study design, outcomes and quality were extracted by one reviewer and independently checked by a second reviewer. We included interventions that consisted of contraceptive service provision for young people, and also interventions to encourage young people to use existing contraceptive services. The searches identified 23 studies that met the inclusion criteria. The papers focused on: new adolescent services, outreach to existing services, advanced provision of emergency contraception, condom/contraceptive provision and advice and repeat pregnancy prevention. The literature in general is not well developed in terms of good quality effectiveness studies and key outcome measures. However, it is possible to make recommendations in terms of outreach versus targeted young people's services in health care settings, advanced provision of emergency contraception and long-acting reversible contraception to prevent repeat adolescent pregnancy.

Socio-economic deprivation and cancer incidence in England: Quantifying the role of smoking.

BACKGROUND: More deprived populations typically experience higher cancer incidence rates and smoking prevalence compared to less deprived populations. We calculated the proportion of cancer cases attributable to smoking by socio-economic deprivation in England and estimated the impact smoking has on the deprivation gap for cancer incidence. METHODS: Data for cancer incidence (2013-2017), smoking prevalence (2003-2007) and population estimates (2013-2017) were split by sex, age-group and deprivation quintile. Relative risk estimates from meta-analyses were used to estimate the population attributable fraction (PAF) for 15 cancer types associated with smoking. The deprivation gap was calculated using age-specific incidence rates by deprivation quintile. RESULTS: Smoking-related cancer PAFs in England are 2.2 times larger in the most deprived quintile compared to the least deprived quintile (from 9.7% to 21.1%). If everyone had the same smoking prevalence as the least deprived quintile, 20% of the deprivation gap in cancer incidence could have been prevented. If nobody smoked, 61% of the deprivation gap could have been prevented. CONCLUSIONS: The majority of the deprivation gap in cancer incidence could have been prevented in England between 2013-2017 if nobody had smoked. Policy makers should ensure that tobacco control policies reduce overall smoking prevalence by tackling smoking inequalities.

A novel household-based patient outreach pilot program to boost late-season influenza vaccination rates during the COVID-19 pandemic.

BACKGROUND: The objective of this study was to test a novel household-based approach to improve late-season influenza vaccine uptake during the 2020-2021 season, using Epic's MyChart patient portal messages and/or interactive voice response telephone calls. METHODS: This study was a non-blinded, quality improvement program using a block randomized design conducted among patients from Reliant Medical Group clinics residing in a traditional household (≥2 individuals clinically active in the Reliant system living at the same address). Households were randomized 1:1:1 into intervention arms: non-tailored communication (messaging based on CDC's seasonal influenza vaccination campaign), tailored communication (comprehensive communication including reinforcement of the importance of influenza vaccination for high-risk individuals), and standard-of-care control. Influenza vaccination during the program was captured via medical records, and the odds of vaccination among communication arms versus the control arm were assessed. A survey assessing influenza vaccination drivers was administered using MyChart. RESULTS: Influenza vaccination increased by 3.3% during the program period, and no significant differences in vaccination were observed in intervention arms relative to the control arm. Study operationalization faced substantial challenges related to the concurrent COVID-19 pandemic. Compared with vaccinated survey respondents, unvaccinated respondents less frequently reported receiving a recommendation for influenza vaccination from their healthcare provider (15.8% vs. 42.3%, p < 0.001) or awareness that vaccination could protect themselves and higher risk contacts (82.3% vs. 92.6%, p < 0.001). CONCLUSIONS: No significant effects of the interventions were observed. Survey results highlighted the importance of healthcare provider recommendations and the need for increased education around the benefits of vaccination.

Views of contraceptive service delivery to young people in the UK: a systematic review and thematic synthesis.

BACKGROUND AND METHODOLOGY: Despite widespread availability of contraceptives and increasing service provision in the UK, rates of teenage pregnancy remain a concern. It has been suggested that young people face particular obstacles in accessing services, leading to a need for specialist provision. This systematic review examined the literature reporting views of service providers and young people. Data were synthesised in order to develop key themes to inform the development of contraceptive services for this population. RESULTS: A total of 59 papers reporting studies carried out within the UK were included. Forty-five of these provided qualitative or mixed method data and 14 reported survey findings. Seven key themes were identified: perceptions of services; accessibility; embarrassment; anonymity and confidentiality; the clinic environment; the consultation; and service organisation. CONCLUSIONS: This review suggests that the most significant concern for young people is the preservation of anonymity and confidentiality. There seems to be a need for young people to be given greater assurances about this, with process and environmental changes suggested. The fear of staff being critical or unfriendly also presents a considerable obstacle to some young people. Issues of service accessibility - such as convenience of location and opening hours - are also highlighted, with lifestyle factors and restrictions on where under-18s can go suggested as important aspects. The review suggests that varying preferences among young people with regard to which service to access requires choice to be preserved and, where possible, extended. This requires services to work effectively together to consider provision across a locality.

Views regarding the use of contraception amongst young people in the UK: a systematic review and thematic synthesis.

OBJECTIVES: The high rate of teenage pregnancy in the United Kingdom continues to be a concern. Factors such as living in a deprived area, poor educational attainment, and living in state-provided care homes have been associated with a greater risk of young motherhood. This study aimed to examine the literature describing perceptions of young people, with a view to gaining a greater understanding of individual contraceptive use and risk factors for young motherhood. METHODS: A systematic review of studies reporting qualitative data was undertaken. Data were synthesised to develop key themes. RESULTS: Thirty-four papers using qualitative or mixed methods were included in the review. Five key themes are reported; they relate to: use or non-use of contraceptives; attitude to pregnancy; views regarding different forms of contraception; influences on views; gender differences. CONCLUSIONS: The review highlights that individual conceptions of risk, differing perceptions of benefits and concerns regarding the forms of contraception, and varying attitudes towards pregnancy, continue to present obstacles to changing behaviour, particularly in high risk groups. There seems to be a need for interventions to further address negative perceptions of contraceptives, and place a greater emphasis on exploring value judgements regarding contraception and young motherhood.

What are older smokers' attitudes to quitting and how are they managed in primary care? An analysis of the cross-sectional English Smoking Toolkit Study.

OBJECTIVES: To investigate whether age is associated with access to smoking cessation services. DESIGN: Data from the Smoking Toolkit Study 2006-2015, a repeated multiwave cross-sectional household survey (n=181 157). SETTING: England. PARTICIPANTS: Past-year smokers who participated in any of the 102 waves stratified into age groups. OUTCOME MEASURES: Amount smoked and nicotine dependency, self-reported quit attempts and use of smoking cessation interventions. Self-report of whether the general practitioner (GP) raised the topic of smoking and made referrals for pharmacological support (prescription of nicotine replacement therapies (NRTs)) or other support (counselling or support groups). RESULTS: Older smokers (75+ years) were less likely to report that they were attempting to quit smoking or seek help from a GP, despite being less nicotine-dependent. GPs raised smoking as a topic equally across all age groups, but smokers aged 70+ were more likely not to be referred for NRT or other support (ORs relative to 16-54 years; 70-74 years 1.27, 95% CI 1.03 to 1.55; 75-79 years 1.87, 95% CI 1.43 to 2.44; 80+ years 3.16, 95% CI 2.20 to 4.55; p value for trend <0.001). CONCLUSIONS: Our findings suggest that there are potential missed opportunities in facilitating smoking cessation in older smokers. In this large population-based study, older smokers appeared less interested in quitting and were less likely to be offered support, despite being less addicted to nicotine than younger smokers. It is unclear whether this constitutes inequitable access to services or reflects informed choices by older smokers and their GPs. Future research is needed to understand why older smokers and GPs do not pursue smoking cessation. Service provision should consider how best to reduce these variations, and a stronger effectiveness evidence base is required to support commissioning for this older population so that, where appropriate, older smokers are not missing out on smoking cessation therapies and the health benefits of cessation at older ages.

Referral interventions from primary to specialist care: a systematic review of international evidence.

BACKGROUND: Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure. AIM: To review the international evidence on interventions to manage referral from primary to specialist care. DESIGN AND SETTING: Systematic review. METHOD: Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions. RESULTS: The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no 'magic bullet' to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts. CONCLUSIONS: To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision.

What are the barriers to primary prevention of type 2 diabetes in black and minority ethnic groups in the UK? A qualitative evidence synthesis.

BACKGROUND: This review aimed to synthesise available qualitative evidence on barriers and facilitators to the implementation of community based lifestyle behaviour interventions to reduce the risk of diabetes in black and minority ethnic (BME) groups in the UK. METHODS: A search of medical and social science databases was carried out and augmented by hand-searching of reference lists and contents of key journals. Qualitative evidence was synthesised thematically. RESULTS: A total of 13 papers varying in design and of mainly good quality were included in the review. A limited number of intervention evaluations highlighted a lack of resources and communication between sites. A lack of understanding by providers of cultural and religious requirements, and issues relating to access to interventions for users was reported. Behaviour change was impeded by cultural and social norms, and resistance to change. There were variations in the way dietary change and physical activity was approached by different groups and contrasting practices between generations. CONCLUSIONS: Qualitative data provided insight into the ways that providers might improve or better design future interventions. Acknowledgement of the way that different groups approach lifestyle behaviours may assist acceptability of interventions.

Systematic review and narrative synthesis of the effectiveness of contraceptive service interventions for young people, delivered in educational settings.

STUDY OBJECTIVE: This review was undertaken to determine the effectiveness of contraception service interventions for young people that were delivered in educational settings. DESIGN: We conducted a systematic review and narrative synthesis. SETTING: Interventions were included where they were delivered in educational institutions, including schools, colleges, and pupil referral units. PARTICIPANTS: Young people aged 19 and under. Studies of wider age groups were included if the majority of participants were aged under 19 years. INTERVENTIONS: We included interventions which consisted of contraceptive service provision, and also interventions to encourage young people to use existing contraceptive services. MAIN OUTCOME MEASURES: The main outcome measures used in the studies were: rate of teenage pregnancy, rate of contraceptive use, and sexual behavior. Many outcome measures were self reported. RESULTS: Twenty-nine papers were included which reported on interventions to prevent adolescent pregnancy (and repeat pregnancy), school-based health centers, contraceptive use in college students, and multicomponent interventions. Intensive case management intervention conducted by a culturally matched school-based social worker (along with other components including peer education) were shown to be effective in preventing repeat adolescent pregnancy, at least for the duration of the intervention. Also, school-based health centers appear to be most effective when contraception provision is made available on site. CONCLUSIONS: The evidence from these papers is limited, in terms of both quality and quantity, along with consistency of findings, but some recommendations in relation to effective interventions can be made.