Radiation Reveal: Moving from research engagement to involvement.

Here, we report on the process of a highly impactful and successful creative, collaborative, and multi-partner public engagement project, Radiation Reveal. It brought together ten young adults aged 17-25-year-olds with experience of radiotherapy with researchers at Cancer Research UK RadNet City of London across three 2-hour online workshops. Our aims were to 1) initiate discussions between young adults and radiation researchers, and 2) identify what people wish they had known about radiotherapy before or during treatment. These aims were surpassed; other benefits included peer support, participants' continued involvement in subsequent engagement projects, lasting friendships, creation of support groups for others, and creation and national dissemination of top ten tips for medical professionals and social media resources. A key learning was that this project required a dedicated and (com)passionate person with connections to national cancer charities. When designing the project, constant feedback is also needed from charities and young adults with and without radiotherapy experience. Finally, visually capturing discussions and keeping the door open beyond workshops further enhanced impact. Here, we hope to inform and inspire people to help project the patient voice in all we do.

Tobacco control interventions for populations living in subsidised, low-income housing: a scoping review.

OBJECTIVES: People living in subsidised low-income housing are more likely to smoke and experience secondhand smoke exposure compared to the general population. While tobacco control interventions have yielded substantial population health benefits, people living in subsidised housing experience a greater burden of tobacco-related harms. We synthesised existing peer-reviewed and grey literature to determine tobacco control interventions that have been implemented in subsidised housing globally, and to understand their impact on smoking and secondhand smoke exposure. METHODS: We searched five databases for peer-reviewed research, and Google Advanced for grey literature. We adhered to the JBI Scoping Review Methodology and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. RESULTS: Fifty-seven sources met the eligibility criteria. The most common type of intervention was mandatory smoking bans covering all indoor spaces (n = 32), followed by cessation-focused interventions (n = 19). Interventions that indirectly addressed smoking were the least common (n = 6). Our findings suggest smoking bans can increase smoking cessation and reduce secondhand smoke exposure, especially if implemented alongside cessation support strategies. CONCLUSION: Tobacco control interventions targeting subsidised housing demonstrate positive effects on tobacco-related outcomes for residents and provide an important opportunity to address health disparities. Future research should examine the long-term impacts of the interventions, including potential unintended consequences, in varied subsidised housing contexts.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Epidemiology of IBD.

Inflammatory bowel disease (IBD), consisting of Crohn's disease and ulcerative colitis, is recognized across the world, though Canada has among the highest burdens of IBD in the world. The Canadian Gastro-Intestinal Epidemiology Consortium (CanGIEC) led a six-province study that demonstrated the compounding prevalence of IBD in Canada from 400 per 100,000 in 2002 to 636 per 100,000 in 2014. The prevalence in 2023 is estimated at 825 per 100,000, meaning that over 320,000 people in Canada are living with IBD. Prevalence is forecasted to rise by 2.44% per year such that 1.1% of the population, 470,000 Canadians, will live with IBD by 2035. The overall incidence of IBD in 2023 is 30 per 100,000 person-years, indicating that over 11,000 Canadians will be newly diagnosed with IBD in 2023. Incidence is forecasted to rise by 0.58% per year up to 32.1 per 100,000 by 2035. The rising incidence of IBD is propelled by pediatric-onset IBD, which is rising by 1.23% per year from 15.6 per 100,000 in 2023 to 18.0 per 100,000 in 2035. In contrast, incidence rates among adults and seniors are relatively stable. Understanding the determinates of IBD has expanded through prospective cohort studies such as the Crohn's and Colitis Canada Genetic, Environmental, Microbial (CCC-GEM) project. Consensus recommendations towards diet, lifestyle, behavioural and environmental modifications have been proposed by international organizations with the goal of optimizing disease control and ultimately preventing the development of IBD. Despite these efforts, Canadian healthcare systems will need to prepare for the rising number of people living with IBD.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Direct Health System and Medication Costs.

Healthcare utilization among people living with inflammatory bowel disease (IBD) in Canada has shifted from inpatient management to outpatient management; fewer people with IBD are admitted to hospitals or undergo surgery, but outpatient visits have become more frequent. Although the frequency of emergency department (ED) visits among adults and seniors with IBD decreased, the frequency of ED visits among children with IBD increased. Additionally, there is variation in the utilization of IBD health services within and between provinces and across ethnocultural and sociodemographic groups. For example, First Nations individuals with IBD are more likely to be hospitalized than the general IBD population. South Asian children with Crohn's disease are hospitalized more often than their Caucasian peers at diagnosis, but not during follow-up. Immigrants to Canada who develop IBD have higher health services utilization, but a lower risk of surgery compared to individuals born in Canada. The total direct healthcare costs of IBD, including the cost of hospitalizations, ED visits, outpatient visits, endoscopy, cross-sectional imaging, and medications are rising rapidly. The direct health system and medication costs of IBD in Canada are estimated to be $3.33 billion in 2023, potentially ranging from $2.19 billion to $4.47 billion. This is an increase from an estimated $1.28 billion in 2018, likely due to sharp increases in the use of biologic therapy over the past two decades. In 2017, 50% of total direct healthcare costs can be attributed to biologic therapies; the proportion of total direct healthcare costs attributed to biologic therapies today is likely even greater.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Indirect (Individual and Societal) and Direct Out-of-Pocket Costs.

People living with inflammatory bowel disease (IBD) and their caregivers are faced with indirect and out-of-pocket costs that they would not otherwise experience. These costs impact one's ability to contribute to the economy to their fullest potential. The indirect costs of IBD in Canada are estimated to be at least $1.51 billion in 2023 and include costs associated with lost productivity resulting from a combination of missed work (absenteeism), decreased workplace productivity (presenteeism), unemployment, premature mortality, and caregiving costs. Unemployment is the largest contributor to indirect costs ($1.14 billion), followed by costs of absenteeism and presenteeism ($285 million). Caregiving costs for children with IBD are estimated to be nearly $58 million. Canadians with IBD also pay $536 million every year for care that is not covered by universal or supplemental private health insurance; this includes allied healthcare (e.g., care provided by psychologists), medication, and other supportive therapy. Combined, the indirect and out-of-pocket costs of IBD in Canada are estimated at more than $2 billion CAD in 2023. This is substantially higher than the estimate of $1.29 billion in Crohn's and Colitis Canada's 2018 Impact of IBD report with differences attributable to a combination of rising prevalence, inflation, and the addition of presenteeism and caregiving costs to the total indirect costs.

Outcome of an elective readmission policy in patients receiving acute myeloid leukaemia consolidation therapy and implications for an outpatient management programme.

Safe outpatient management of acute leukaemia consolidation cycles may enable substantial savings in admission costs. Safety involves the prompt administration of antibiotics in patients with neutropenic fever. Our unit in a metropolitan tertiary referral hospital analysed a cohort of patients spanning a 10-year period, with two key observations: (i) a high proportion of patients living a substantial distance from hospital and (ii) the high incidence and generally prompt onset of fever after severe neutropenia, suggesting this broad applicability of this approach is unfeasible without addressing travel issues and potentially reducing and/or delaying neutropenic fever with prophylactic antibiotics.

Natural experiments for the evaluation of place-based public health interventions: a methodology scoping review.

Introduction: Place-based public health evaluations are increasingly making use of natural experiments. This scoping review aimed to provide an overview of the design and use of natural experiment evaluations (NEEs), and an assessment of the plausibility of the as-if randomization assumption. Methods: A systematic search of three bibliographic databases (Pubmed, Web of Science and Ovid-Medline) was conducted in January 2020 to capture publications that reported a natural experiment of a place-based public health intervention or outcome. For each, study design elements were extracted. An additional evaluation of as-if randomization was conducted by 12 of this paper's authors who evaluated the same set of 20 randomly selected studies and assessed 'as-if ' randomization for each. Results: 366 NEE studies of place-based public health interventions were identified. The most commonly used NEE approach was a Difference-in-Differences study design (25%), followed by before-after studies (23%) and regression analysis studies. 42% of NEEs had likely or probable as-if randomization of exposure (the intervention), while for 25% this was implausible. An inter-rater agreement exercise indicated poor reliability of as-if randomization assignment. Only about half of NEEs reported some form of sensitivity or falsification analysis to support inferences. Conclusion: NEEs are conducted using many different designs and statistical methods and encompass various definitions of a natural experiment, while it is questionable whether all evaluations reported as natural experiments should be considered as such. The likelihood of as-if randomization should be specifically reported, and primary analyses should be supported by sensitivity analyses and/or falsification tests. Transparent reporting of NEE designs and evaluation methods will contribute to the optimum use of place-based NEEs.

Mental health impact of cuts to local government spending on cultural, environmental and planning services in England: a longitudinal ecological study.

BACKGROUND: Over the past decade, there have been significant and unequal cuts to local authority (LA) budgets, across England. Cultural, environmental and planning (CEP) budgets have been cut by 17% between 2011 and 2019. This funding supports services such as parks, leisure centres, community development and libraries, all of which have potential to influence population mental health. We therefore investigated whether cuts to CEP services have affected mental health outcomes and the extent to which they have contributed to mental health inequalities between areas. METHODS: Using fixed effects regression applied to longitudinal LA-level panel data in England, we assessed whether trends in CEP spend were associated with trends in mental health outcomes, between 2011 and 2019. The exposure was CEP spend and the primary outcome was the LA-average Small Area Mental Health Index (SAMHI). Additionally, we considered subcategories of CEP spend as secondary exposures, and antidepressant prescription rate and self-reported anxiety levels as secondary outcomes, both aggregated to LA-level. We adjusted all models for confounders and conducted subgroup analysis to examine differential mental health effects of spending cuts based on the level of area deprivation. RESULTS: The average decrease in CEP spend of 15% over the period was associated with a 0.036 (95% CI: 0.005, 0.067) increase in SAMHI score, indicating worsening mental health. Amongst subcategories of CEP spending, cuts to planning and development services impacted mental health trends the most, with a 15% reduction in spend associated with a 0.018 (95% CI: 0.005, 0.031) increase in the SAMHI score. The association between cuts in CEP and deteriorating mental health was greater in more affluent areas. CONCLUSION: Cuts to spending on cultural, environmental, planning and development services were associated with worsening population mental health in England. Impacts were driven by cuts to planning and development services in particular. Reinvesting in these services may contribute to improved public mental health.

Evaluating an Integrated Local System Response to the COVID-19 Pandemic: Case Study of East Toronto Health Partners.

Introduction: East Toronto Health Partners (ETHP) is a network of organizations that serve residents of East Toronto, Ontario, Canada. ETHP is a newly formed integrated model of care in which hospital, primary care, community providers and patients/families work together to improve population health. We describe and evaluate the evolution of this emerging integrated care system as it responded to a global health crisis. Description: This paper begins by describing ETHP's pandemic response mapping out over two years of data. To evaluate the response, semi-structured interviews were conducted with 30 decision makers, clinicians, staff, and volunteers who were part of the response. The interviews were thematically analyzed, and emergent themes mapped onto the nine pillars of integrated care. Discussion: The ETHP pandemic response evolved rapidly. Early siloed responses gave way to collaborative efforts and equity emerged as a central priority. New alliances formed, resources were shared, leaders emerged, and community members stepped forward to contribute. Interviewees identified positives as well as many opportunities for improvement post-pandemic. Conclusion: The pandemic was a catalyst for change in East Toronto that accelerated existing initiatives to achieve integrated care. The East Toronto experience may serve as a useful guide for other emerging integrated care systems.

Rapid hepatitis C virus point-of-care RNA testing and treatment at an integrated supervised consumption service in Toronto, Canada: a prospective, observational cohort study.

Background: Despite high burden of Hepatitis C (HCV) among people who inject drugs, significant barriers to care persist. The aim of this study was to evaluate the provision of rapid, low-barrier point-of-care (POC) HCV RNA testing and linkage to care among clients of a supervised consumption service (SCS) located within a community health centre in Toronto, Canada. Secondary aims included measuring HCV RNA prevalence at baseline, HCV incidence during follow-up and exploring factors associated with HCV RNA positivity and treatment uptake. Methods: Participants were enrolled in a prospective, observational cohort from August 13, 2018 to September 30, 2021. Those with positive HCV RNA tests were offered immediate referral to onsite treatment. Those with negative results were offered repeat testing every three months for up to four visits. HCV incidence was estimated as the number of incident HCV infections per 100 person-years at risk, among those HCV RNA negative at baseline who returned for ≥1 follow-up visit. Missing data were reported when present. Findings: 128 participants were enrolled with four later removed due to ineligibility. At baseline, 54 of 124 eligible participants (43.5%) tested HCV RNA positive. HCV incidence was 35.1 cases per 100 person-years (95% CI: 18.9-65.3) with a cumulative incidence of 38.3% at 15 months of follow-up. Among participants HCV RNA positive at baseline or follow-up (n = 64), 67.2% (n = 43) were linked to HCV care and treatment was initiated among 67.4% (n = 29/43). Interpretation: High HCV RNA prevalence and incidence demonstrate that the SCS serves a high-risk population for HCV. Testing acceptance was high, as was treatment engagement. POC HCV RNA testing positions SCSs as an important point of HCV care access. Funding: HCV Micro-Elimination Grant, Gilead Sciences Canada; in-kind support from Cepheid.

Inequalities in local government spending on cultural, environmental and planning services: a time-trend analysis in England, Scotland, and Wales.

BACKGROUND: Local government provides Cultural, Environmental, and Planning (CEP) services, such as parks, libraries, and waste collection, that are vital for promoting health and wellbeing. There have been significant changes to the funding of these services over the past decade, most notably due to the UK government's austerity programme. These changes have not affected all places equally. To understand potential impacts on health inequalities, we investigated geographical patterning of recent CEP spending trends. METHODS: We conducted a time trend analysis using routinely available data on local government expenditure. We used generalised estimating equations to determine how expenditure trends varied across 378 local authorities (LAs) in Great Britain between 2009/10 and 2018/19 on the basis of country, deprivation, rurality, and local government structure. We investigated the gross expenditure per capita on CEP services, and the CEP expenditure as a proportion of total local authority budgets. We present the estimated annual percentage change in these spend measures. RESULTS: Expenditure per capita for CEP services reduced by 36% between 2009/10 and 2018/19. In England, the reduction in per capita spending was steepest in the most deprived quintile of areas, falling by 7.5% [95% CI: 6.0, 8.9] per year, compared to 4.5% [95% CI: 3.3, 5.6] per year in the least deprived quintile. Budget cuts in Scotland and Wales have been more equitable, with similar trends in the most and least deprived areas. Welsh LAs have reduced the proportion of total LA budget spent on CEP services the most (-4.0% per year, 95% CI: -5.0 to -2.9), followed by Scotland (-3.0% per year, 95% CI: -4.2 to -1.7) then England (-1.4% per year, 95% CI: -2.2 to -0.6). In England, rural and unitary LAs reduced their share of spending allocated to CEP more than urban and two-tier structured LAs, respectively. CONCLUSION: Funding for cultural, environmental and planning services provided by local government in the UK has been cut dramatically over the last decade, with clear geographical inequalities. Local areas worst affected have been those with a higher baseline level of deprivation, those with a single-tier local government structure, and English rural local authorities. The inequalities in cuts to these services risk widening geographical inequalities in health and wellbeing.

Incidence of Sinusoidal Obstruction Syndrome/Veno-Occlusive Disease and Treatment with Defibrotide in Allogeneic Transplantation: A Multicenter Australasian Registry Study.

Sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD) is an established complication in patients undergoing allogeneic hemopoietic stem cell transplantation (HSCT). Defibrotide is an effective and safe pharmacologic option for treating diagnosed SOS/VOD. By exploring data provided to the Australasian Bone Marrow Transplant Recipient Registry (ABMTRR) by centers in Australia and New Zealand, this study aimed to describe the incidence of SOS/VOD and patterns of defibrotide use from 2016 to 2020. Patients who underwent allogeneic hemopoietic stem cell transplantation between 2016 and 2020 were identified from the ABMTRR. Data were extracted for a total of 3346 patients, 2692 from adult centers and 654 from pediatric centers, with a median follow-up of 21.5 months and 33.3 months, respectively. Descriptive statistics were used to describe the patient population, including the incidence of SOS/VOD and defibrotide use. Comparisons were made between patients without SOS/VOD and those with SOS/VOD, divided into defibrotide and no defibrotide cohorts. Associations with overall survival (OS) and day 100 survival with such variables as sex, age, disease at transplantation, stem cell source, conditioning agents, SOS/VOD diagnosis, and use of defibrotide, were determined. The reported incidence of SOS/VOD was 4.1% in adult centers and 11.5% in pediatric centers. Defibrotide was administered to 74.8% of adult patients and 97.3% of pediatric patients with SOS/VOD. Significant variability in the use, dosage, and duration of defibrotide was seen across the adult centers. The day 100 survival rate and median OS for patients managed with defibrotide was 51.8% and 103 days, respectively, for adult patients and 90.4% and not reached, respectively, for pediatric patients. In adults, older age at transplantation, an HLA-matched nonsibling relative donor, and a diagnosis of SOS/VOD treated with defibrotide were associated with reduced OS. In pediatric patients, the patient and transplantation characteristics associated with reduced OS were a diagnosis of SOS/VOD and a ≥2 HLA-mismatched related donor. A collaborative approach across Australasia to diagnosing and managing SOS/VOD, particularly with respect to consistent defibrotide use, is recommended.

Disparities in health utilities among hepatitis C patients receiving care in different settings.

BACKGROUND: Although chronic hepatitis C (CHC) disproportionately affects marginalized individuals, most health utility studies are conducted in hospital settings which are difficult for marginalized patients to access. We compared health utilities in CHC patients receiving care at hospital-based clinics and socio-economically marginalized CHC patients receiving care through a community-based program. METHODS: We recruited CHC patients from hospital-based clinics at the University Health Network and community-based sites of the Toronto Community Hep C Program, which provides treatment, support, and education to patients who have difficulty accessing mainstream health care. We elicited utilities using six standardized instruments (EuroQol-5D-3L [EQ-5D], Health Utilities Index Mark 2/Mark 3 [HUI2/HUI3], Short Form-6D [SF-6D], time trade-off [TTO], and Visual Analogue Scale [VAS]). Multivariable regression analysis was performed to examine factors associated with differences in health utility. RESULTS: Compared with patients recruited from the hospital setting (n = 190), patients recruited from the community setting (n = 101) had higher unemployment (87% versus 67%), history of injection drug use (88% versus 42%), and history of mental health issue(s) (79% versus 46%). Unadjusted health utilities were lower in community than hospital patients (e.g., EQ-5D: 0.722 [SD 0.209] versus 0.806 [SD 0.195]). Unemployment and a history of mental health issue(s) were significant predictors of low health utility. CONCLUSIONS: Socio-economically marginalized CHC patients have lower health utilities than patients typically represented in the CHC utility literature. Their utilities should be incorporated into future cost-utility analyses to better represent the population living with CHC in health policy decisions.

Impact of cuts to local authority spending on cultural, environmental and planning services on inequalities in childhood obesity in England: A longitudinal ecological study.

BACKGROUND: Almost 20% of children in England are living with obesity by the end of primary school, with marked and growing inequalities driven by increasing prevalence in more deprived areas. Neighbourhood environments are upstream determinants of childhood weight status. Cultural, Environmental and Planning (CEP) services delivered by local authorities (LAs) in England include various services that contribute to these local environments, e.g. leisure centres, parks, playgrounds, libraries, community safety and environmental protection. Children in deprived areas potentially benefit most from the provision of these universal services. Spending on CEP services has been cut dramatically over the past decade, especially in more deprived areas. Given the potential link between these services and childhood obesity, we examined whether recent cuts in LA spending on CEP services are associated with trends and inequalities in obesity. METHODS: We compiled annual data (2009-2017) on CEP spending in 324 LAs in England, from Ministry of Housing, Communities and Local Government reports. Obesity prevalence data for Year 6 children were obtained from the National Child Measurement Programme, for LAs and Middle-layer Super Output Areas (MSOAs). Following descriptive and pooled OLS analyses, we used fixed effects panel regression to estimate associations between CEP spending and obesity prevalence, within LAs over time, adjusting for potential confounding by local economic conditions and spending on other public services. Final models included an interaction term between area deprivation (2015 IMD) and year to account for differential background trends in obesity across deprivation levels. We tested for effect modification by deprivation and, using MSOA-level obesity data, explored associations between spending and within-LA obesity inequalities. RESULTS: In unadjusted pooled OLS analyses, areas with higher CEP spending had higher prevalence of obesity, reflecting the strong social gradient in childhood obesity and the higher levels of central government funding allocated to more deprived areas. Deprivation, other spend, and local economic conditions explained this relationship. In the fixed effects analysis, designed to isolate average within-area change in obesity associated with changing spend, we observed a 0.10 percentage point increase in obesity prevalence for each 10% reduction in spend (95%CI: 0.04,0.15; p < 0.001), but this disappeared after accounting for differential background trends in obesity across deprivation levels (-0.02; 95%CI: 0.07,0.03; p = 0.39). Similar results were observed for obesity inequalities, although sensitivity analyses suggest spending on Environmental Services in particular may affect inequalities in urban local authorities. CONCLUSIONS: CEP spending levels may influence local childhood obesity risk, but the increasing prevalence and widening inequalities in obesity of the past decade seem to have been driven mainly by factors other than CEP spending cuts, that are also unevenly distributed across deprivation levels. The influence of specific services might be obscured by grouping CEP services for analysis.

Impact of direct-acting antiviral treatment on health utility in patients with chronic hepatitis C in hospital and community settings.

BACKGROUND: Direct-acting antiviral agents (DAAs) have transformed chronic hepatitis C (CHC) treatment. Continued affordable access to DAAs requires updated cost-effectiveness analyses (CEA). Utility is a preference-based measure of health-related quality of life (HRQoL) used in CEA. This study evaluated the impact of DAAs on utilities for patients with CHC in two clinical settings. METHODS: This prospective longitudinal study included patients aged ≥18 years, diagnosed with CHC and scheduled to begin DAA treatment, from two tertiary care hospital clinics and four community clinics in Toronto, Calgary, and Montreal. Patients completed two utility instruments (EQ-5D-5L and Health Utilities Index 2/3 (HUI2/3)) before treatment, 6 weeks after treatment initiation, and 12 weeks and 1 year after treatment completion. We measured utilities for all patients, and for hospital-based and community-based groups. RESULTS: Between 2017 and 2020, 209 patients (126 hospital-based, 83 community-based; average age 53 years; 65% male) were recruited, and 143 completed the 1-year post-treatment assessment. Pre-treatment, utilities were (mean ± standard deviation) 0.77 ± 0.21 (EQ-5D-5L), 0.69 ± 0.24 (HUI2) and 0.58 ± 0.34 (HUI3). The mean changes at 1-year post-treatment were 0.035, 0.038 and 0.071, respectively. While utilities for hospital-based patients steadily improved, utilities for the community-based cohort improved between baseline and 12-weeks post-treatment, but decreased thereafter. DISCUSSION: This study suggests that utilities improve after DAA treatment in patients with CHC in a variety of settings. However, community-based patients may face challenges related to comorbid health and social conditions that are not meaningfully addressed by treatment. Our study is essential for valuing health outcomes in CHC-related CEA.

Integrated supervised consumption services and hepatitis C testing and treatment among people who inject drugs in Toronto, Canada: A cross-sectional analysis.

Despite the availability of publicly funded hepatitis C (HCV) treatment in Canada, treatment gaps persist, particularly among people who inject drugs. We estimate correlates of HCV care cascade engagement (testing, diagnosis, and treatment) among people who inject drugs in Toronto, Canada and examine the effect of accessing differing supervised consumption service (SCS) models on self-reported HCV testing and treatment. This is a cross-sectional baseline analysis of 701 people who inject drugs surveyed in the Toronto, Ontario integrated Supervised Injection Services (OiSIS-Toronto) study between November 2018 and March 2020. We examine correlates of self-reported HCV care cascade outcomes including SCS model, demographic, socio-structural, drug use, and harm reduction characteristics. Overall, 647 participants (92%) reported ever receiving HCV testing, of whom 336 (52%) had been diagnosed with HCV. Among participants who reported ever being diagnosed with HCV, 281 (84%) reported chronic HCV, of whom 130 (46%) reported HCV treatment uptake and 151 (54%) remained untreated. Compared to those with no SCS use, participants who had ever injected at an integrated SCS model with co-located HCV care had greater prevalence of both ever receiving HCV testing (adjusted prevalence ratio [aPR]: 1.12, 95% confidence interval [CI]: 1.02-1.24) and ever receiving HCV treatment (aPR: 1.67, 95% CI: 1.04-2.69). Over half of participants diagnosed with chronic HCV reported remaining untreated. Our findings suggest that integrated SCS models with co-located HCV care represent key strategies for linkage to HCV care, but that more is needed to support scale-up.

Predictors and outcomes of dose reduction of methotrexate and cyclosporin graft-versus-host disease prophylaxis following allogeneic haemopoietic cell transplantation.

BACKGROUND: Concern regarding dose-related toxicities of methotrexate (MTX) and cyclosporin (CYA) graft-versus-host disease (GVHD) prophylaxis occasionally leads to dose alterations post allogeneic haemopoietic cell transplant (alloHCT). AIMS: To clarify causes of MTX and CYA dose alteration and assess impact on patient outcomes, including GVHD, relapse, non-relapse mortality (NRM) and overall survival (OS). METHODS: Analysis of retrospective data was performed in a single tertiary centre of patients who underwent alloHCT for any indication and who received GVHD prophylaxis with CYA and MTX between the years 2011 and 2015. Univariate analysis was conducted using the log-rank test for OS and using competing risk regression for NRM, relapse and GVHD. Fisher exact tests were used to determine if an association existed between each of the pre-transplant variables and MTX alteration. Multivariate models for OS and NRM were constructed using Cox proportional hazards modelling and competing risk regression respectively. RESULTS: Fifty-four (28%) of 196 had MTX alterations and 61/187 (33%) had CYA alterations. Reasons for MTX alteration included mucositis, renal or liver impairment, fluid overload and sepsis. Causes of CYA alteration were numerous, but most commonly due to acute kidney impairment. MTX alteration was associated with inferior OS (hazard ratio 2.4; P = <0.001) and higher NRM (odds ratio (OR) 4.6; P < 0.001) at 6 years post-landmark. CYA alteration was associated with greater NRM (OR 2.7; P = 0.0137) at 6 years. GVHD rates were unaffected by dose alteration. CONCLUSIONS: Our findings suggest dose alteration in MTX and CYA GVHD prophylaxis is associated with adverse survival outcomes in alloHCT, without a significant impact on GVHD rates.

Neighborhood environment and socioeconomic inequalities in cancer admissions: a prospective study using UK Biobank and linked hospital records.

PURPOSE: Neighborhood environments may influence cancer risk. Average population effect estimates might mask differential effects by socioeconomic position. Improving neighborhood environments could inadvertently widen health inequalities if important differences are overlooked. METHODS: Using linked records of hospital admissions in UK Biobank, we assessed associations between admission with a primary diagnosis of cancer (any/breast/colorectal), and exposure to neighborhood greenspace, physical activity facilities, and takeaway food stores, and whether household income and area deprivation modify these associations. We used adjusted Cox proportional hazards models, and estimated relative excess risks due to interaction (RERI) to assess effect modification. RESULTS: Associations between neighborhood exposures and cancer-related hospitalizations were weak to null overall, but with some evidence of effect modification. Most notably, more greenspace near home was associated with 16% lower hazard of cancer-related hospital admission in deprived areas (95% CI 2-29%). This was further pronounced for people in low-income households in deprived areas, and for breast cancer. CONCLUSION: In deprived neighborhoods, increasing the amount of greenspace may help reduce cancer-related hospitalizations. Examining effect modification by multiple socioeconomic indicators can yield greater insight into how social and environmental factors interact to influence cancer incidence. This may help avoid perpetuating cancer inequalities when designing neighborhood environment interventions.

Local area public sector spending and nutritional anaemia hospital admissions in England: a longitudinal ecological study.

INTRODUCTION: Reductions in local government spending may have impacts on diets and health which increase the risk of hospital admissions for nutritional anaemias. Mechanisms include potential impacts of changes to local authority (LA) services (eg, housing services) on personal resources and food access, availability and provision. We therefore investigated the association between changes in LA spending and nutritional anaemia-related hospital admissions. Specifically, we address whether greater cuts to LA spending were linked to increased hospital admissions for nutritional anaemias. DESIGN: Longitudinal analysis of LA panel data using Poisson fixed effects regression models. SETTING: 312 LAs in England (2005-2018). MAIN EXPOSURE: Total LA service expenditure per capita per year. MAIN OUTCOME: Principal and total nutritional anaemia hospital admissions, for all ages and stratified by age (0-14, 15-64, 65+ years). RESULTS: LA service expenditure increased by 9% between 2005 and 2009 then decreased by 20% between 2010 and 2018. Total nutritional anaemia hospital admissions increased between 2005 and 2018 from 173 to 633 admissions per 100 000 population. A £100 higher LA service spending was associated with a 1.9% decrease in total nutritional anaemia hospital admissions (adjusted incidence rate ratio (aIRR): 0.98, 95% CI: 0.96 to 0.99). When stratified by age, this was seen only in adults. A £100 higher LA service spending was associated with a 2.6% decrease in total nutritional anaemia hospital admissions in the most deprived LAs (aIRR: 0.97, 95% CI: 0.95 to 1.0). CONCLUSION: Increased LA spending was associated with reduced hospital admissions for nutritional anaemia. Austerity-related reductions had the opposite effect, increasing admissions, with greater impacts in more deprived areas. This adds further evidence to the potential negative impacts of austerity policies on health and health inequalities. Among other impacts, re-investing in LA services may prevent hospital admissions associated with nutritional anaemias.

Changes to local area public sector spending and food purchasing in England: a longitudinal ecological study.

Objectives: Changes in public sector service spending may influence food consumption. We make use of changing local authority (LA) expenditure in England to assess impacts on food purchasing. We examine total LA service spending and explore two potential pathways: highways and transport spending which may affect access to food; and housing service expenditure which may affect household resources available to purchase foods. Design: Longitudinal panel survey at the LA level (2008-2015) using fixed effects linear regression. Setting: 324 LAs in England. Main exposure: Expenditure per capita on total LA services, highways and transport services, and housing services. Main outcome measures: LA area estimates of purchasing of fresh fruits and vegetables, high in fat, sugar and salt (HFSS) foods, and takeaways at home, expressed as a percentage of total food and drink expenditure. Results: Total LA service spending decreased by 17% on average between 2008 and 2015. A 10% decrease in total LA spending was associated with a 0.071 percentage point decrease in HFSS (95% CI -0.093 to -0.050) and a 0.015 percentage point increase in takeaways (95% CI 0.006 to 0.024). A 10% decrease in highways and transport expenditure was associated with a 0.006 percentage point decrease in fruit and vegetable purchasing (95% CI -0.009 to -0.002) and a 0.006 percentage point increase in takeaway purchasing (95% CI 0.001 to 0.010). These associations were seen in urban areas only when analyses were stratified by rural/urban area status. A 0.006 percentage point decrease in HFSS purchasing was also seen with a 10% decrease in housing expenditure (95% CI -0.010 to -0.002). Conclusion: Changes in LA spending may have impacts on food purchasing which are evident at the area level. This suggests that in addition to more prominent impacts such as foodbank use, austerity measures may have mixed impacts on food purchasing behaviours among the wider population. Individual-level research is needed to further elucidate these relationships.