Economic inequalities in burden of illness, diagnosis and treatment of five long-term conditions in England: panel study.

OBJECTIVE: We compared the distribution by wealth of self-reported illness burden (estimated from validated scales, biomarker and reported symptoms) for angina, cataract, depression, diabetes and osteoarthritis, with the distribution of self-reported medical diagnosis and treatment. We aimed to determine if the greater illness burden borne by poorer participants was matched by appropriately higher levels of diagnosis and treatment. DESIGN: The English Longitudinal Study of Ageing, a panel study of 12,765 participants aged 50 years and older in four waves from 2004 to 2011, selected using a stratified random sample of households in England. Distribution of illness burden, diagnosis and treatment by wealth was estimated using regression analysis. OUTCOME MEASURES: The main outcome measures were ORs for the illness burden, diagnosis and treatment, respectively, adjusted for age, sex and wealth. We estimated the illness burden for angina with the Rose Angina scale, diabetes with fasting glycosylated haemoglobin, depression with the Centre for Epidemiologic Studies Depression Scale, osteoarthritis with self-reported pain and disability and cataract with self-reported poor vision. Medical diagnoses were self-reported for all conditions. Treatment was defined as ß-blocker prescription for angina, surgery for osteoarthritis and cataract, and receipt of predefined effective interventions for diabetes and depression. RESULTS: Compared with the wealthiest, the least wealthy participant had substantially higher odds for illness burden from any of the five conditions at all four time points, with ORs ranging from 4.2 (95% CI 2.6 to 6.8) for diabetes to 15.1 (11.4 to 20.0) for osteoarthritis. The ORs for diagnosis and treatment were smaller in all five conditions, and ranged from 0.9 (0.5 to 1.4) for diabetes treatment to 4.5 (3.3 to 6.0) for angina diagnosis. CONCLUSIONS: The substantially higher illness burden in less wealthy participants was not matched by appropriately higher levels of diagnosis and treatment.

Neighbourhood deprivation and dental service use: a cross-sectional analysis of older people in England.

BACKGROUND: Appropriate dental care is an important part of maintaining good oral health. We examined the relationship between socioeconomic status, neighbourhood deprivation levels and older people's dental service use. METHODS: We used logistic regression analysis to assess the relationship between self-reported dental service use and neighbourhood deprivation, adjusting for individual socioeconomic and health factors, in individuals aged 65+ in the 2005 Health Survey for England (n = 4240). RESULTS: Among dentulous respondents, 69.9% reported attending for regular check-ups, 6.2% occasional check-ups, 18.4% only saw a dentist when in trouble and 5.6% never went to a dentist. In our adjusted model age, sex, region, education level, occupational social class, self-reported health and smoking status, but not degree of urbanization, were associated with use of dental services. Following adjustment for these other factors those living in the most deprived 20% of neighbourhoods, compared with those in the least deprived, had a relative risk ratio of 2.25 (95% confidence interval 1.59-3.17) of using dental services only when symptomatic, rather than going for regular or occasional check-ups. When alternative outcomes of reporting having recently seen a doctor or been a hospital inpatient were assessed these deprivation-related patterns in service use were not evident. CONCLUSION: Levels of neighbourhood deprivation are associated with the use of dental services by older people. Action is needed to ensure older people in deprived communities access appropriate and comprehensive dental services.

Was John Reid right? Smoking, class, and pleasure: a population-based cohort study in England.

OBJECTIVES: To assess whether there is a relationship between smoking and levels of overall quality of life, or with the pleasure domain of quality of life, in lower socio-economic groups (SES). STUDY DESIGN: Cohort study involving 9176 individuals aged 50 years and over who participated in the Health Survey for England and were followed up in Wave 1 of the English Longitudinal Study of Ageing in 2002. METHODS: We classified smokers as never-smokers, ex-smokers and current smokers, and used household wealth as a marker for socio-economic position. Pleasure was assessed using the pleasure subscale of the CASP-19 instrument, a 19-point measure of quality of life that covers four theoretical domains: control, autonomy, self-realization and pleasure. RESULTS: We found that the odds ratio for experiencing lower than median levels of pleasure for smokers with low SES was 1.42 (95% CI 1.16-1.74), and for all smokers was 1.33 (95% CI 1.17-1.51). The same pattern of associations was found when the outcome was total CASP-19 score or positive GHQ-12 score. CONCLUSIONS: We found no evidence to support a claim that smoking is associated with heightened levels of pleasure, either in people with low SES or in the general population. In fact, our results suggest the opposite: that smoking is associated with lower levels of pleasure and poorer overall quality of life. Policy decisions on smoking should consider its potentially harmful effect on quality of life and pleasure as well as on other aspects of health.

Need for and receipt of hip and knee replacement--a national population survey.

OBJECTIVES: Hip and knee joint replacements are effective, and yet little is known about how closely the need for joint replacement matches supply in different population groups. Our objective was to compare the prevalence of existing joint replacements with that of need in population groups in England. METHODS: A total of 7101 people aged 60 yrs or older, representative of the population of England, were interviewed. Participants were asked about both receipt and need for joint replacement, socio-economic status and co-morbidity. 'Need' classification was based on hip or knee pain and difficulty walking, with adjustment for potential surgical contraindications. Associations between participants' characteristics and both need and receipt were estimated. RESULTS: The prevalence of existing joint replacement (receipt) was 6% [95% confidence intervals (CI) 5, 6], and this was lower in the North than the South [adjusted odds ratio (OR) 0.72, CI 0.53, 0.96]. In contrast, the prevalence of estimated need was higher in the North (OR 1.27, CI 1.03, 1.58). Need was greater in women than men (OR 1.30, CI 1.09, 1.53), and showed an increasing gradient from the wealthiest to poorest quintile (ORs 1.00, 1.52, 2.18, 2.49, 3.23). In contrast, receipt did not differ significantly by sex or socio-economic group. CONCLUSIONS: People living in the North of England, women and the less wealthy experience relatively high levels of need, yet do not receive relatively more hip and knee joint replacements.

Problem behavior in the last year of life: prevalence, risks, and care receipt in older Americans.

OBJECTIVES: To estimate the prevalence of problem behavior in the last year of life in older people and to explore risk factors and assess the effect of behaviors on access to care. DESIGN: Retrospective analysis of data from the 1993 National Mortality Followback Survey, conducted by the National Center for Health Statistics (NCHS). SETTING: Persons who resided and died in the United States (except South Dakota) in 1993. PARTICIPANTS: Seven thousand six hundred and eighty-four deaths in people age 65 and older were included, from which full informant interview data were available for 6,748 decedents (88%). MEASUREMENTS: Informant data were collected on frequency of complaints about behavior from family members, complaints from others in the community, bizarre behavior, destroying property, violent threats or attempts, and temper tantrums. RESULTS: Overall, 20% of decedents were reported as having any of the problem behaviors sometimes or often in the last year of life. Rates differed little by age at death or gender. Risks of having problem behaviors were higher for those with clinically diagnosed dementia, mental illness, alcohol abuse, and bronchitis or emphysema. A diagnosis of dementia had been made in 27% of those with behavior problems. Nursing homes or healthcare facilities were the usual residence of 32% of people with any behavior problems sometimes or often during their last year of life. Informants for decedents who had destroyed property or made violent threats were 2.3 times (95% confidence interval (CI) = 1.2-4.4) more likely to report that the subject had not received the care they had needed during the last year of life. CONCLUSION: Problem behavior is relatively common in older people in the last year of life and is not confined to nursing home residents or people suffering from dementia.

Socioeconomic status and the expectation of disability in old age: estimates for England.

OBJECTIVES: The longer life expectancy in old age of more privileged socioeconomic groups is well established, but less clear is whether the net effect of additional years of life is a lengthened, stable or reduced duration of disability. Estimates of healthy and disabled life expectancy (using definitions including dependency in activities of daily living and cognitive impairment) were made, contrasting occupational classes I and II (professional and managerial) with the rest. DESIGN: Disability prevalence was estimated from the Medical Research Council Cognitive Function and Ageing study. Sullivan's method was used to calculate health expectancy. SUBJECTS: 10,377 people aged 65 years or over in Cambridgeshire, Newcastle, Nottingham and Oxford. Subjects were classified as disabled if they had evidence of dementia (using the Automated Geriatric Examination Computer Assisted Taxonomy) or scored 11 or more on the modified Townsend Disability scale, at baseline screen. RESULTS: The prevalence of disability overall and need for "constant care" was lower in both men and women in social classes I and II compared with the rest. Men aged 65 to 69 in classes I and II can expect nearly 14 years of life free of disability compared with 11.5 years for those in classes III to V: for women the equivalent expectations are 15.5 and 13.8 years. Men aged 65 to 69 in classes I and II can also expect a shorter duration of disability: 1 year compared with 1.6 years for classes III to V. In women expectation of disability is higher overall, but shows little difference by occupational class. CONCLUSIONS: Relatively privileged socioeconomic groups in England, especially men, can expect fewer years of disability despite longer overall life expectancy. These findings lend weight to optimistic scenarios for the future numbers of older people with disability.

Local population differences and the needs of people with cognitive impairment.

INTRODUCTION: Variations in local population age structure have attracted less attention than national population ageing. As moderate and severe cognitive impairment is a major cause of need for long-term care, population-based estimates of the numbers and characteristics of this group were calculated, to explore the effects of local differences. METHOD: The UK Office of Population Census and Surveys (OPCS) study of disability in adults (N > 14000) was reanalysed. A group with moderate or severe cognitive impairments was identified and age-specific estimators of sociodemographic characteristics, household types, disabilities and service use were combined with population estimates for district health authorities in England and Wales. RESULTS: The proportion of the 65 plus population who are 85 plus varies from 8% to 15% across districts, equivalent to national population projections for 1986 and 2031 respectively. The estimated prevalence of the study group varies from 53 to 70 per 1000 population aged 65 plus, with 34-48% of cases aged 85 plus. Curiously, the proportion with severe disabilities varies little across districts. If national norms applied, local rates of institutionalization would vary from 18 to 27 per 1000 aged 65 plus. CONCLUSION: Local differences in population age structure age large compared to national changes over decades. Local differences have substantial effects on overall prevalence and on the proportion of the cognitively impaired who would be institutionalized if national patterns applied. Service design should be influenced by these complex variations, with estimates modified by local surveys.

The outcome of targeting community mental health services: evidence from the West Lambeth schizophrenia cohort.

OBJECTIVES: To report outcome of targeting community mental health services to people with schizophrenia in an inner London district who had been shown, one year after discharge, to have high levels of psychotic symptomatology and social disability but very low levels of supported housing and structured day activity. DESIGN: Repeat interview survey of symptoms, disability, and receipt of care four years after index discharge. SETTING: Inner London health district with considerable social deprivation and a mental hospital in the process of closure. SUBJECTS: 51 patients originally aged 20-65 years who satisfied the research diagnostic criteria for schizophrenia. MAIN OUTCOME MEASURES: Contact with services during the three months before interview, levels of symptoms (from present state examination), global social disability rating. RESULTS: 65% (33/51) of the study group had been readmitted at least once in the three years between surveys. Recent contacts with community psychiatric nurses and rates of hospital admission increased (8 at one year v 24 at four years, p < 0.01; 5 v 13, p < 0.06). Conversely, fewer patients were in contact with social workers (17 v 7, p < 0.03). Proportions in supported housing, day care, or sheltered work did not change. Unemployment rates remained very high. A considerable reduction (almost a halving) in psychiatric symptoms was observed, but there was no significant change in mean levels of social disability. CONCLUSIONS: The policy of targeting the long term mentally ill resulted in significant increases in professional psychiatric input to the cohort but failed to improve access to social workers or suitable accommodation. Improvements in social functioning did not follow from reductions in the proportions of patients with psychotic mental states. Social interventions are likely to be crucial to achieving the Health of the Nation target of improving social functioning for the seriously mentally ill, as improving mental state seems in itself to be insufficient.

Community care for patients with schizophrenia one year after hospital discharge.

OBJECTIVES: To document the circumstances and care of patients with schizophrenia who had recently been discharged from local psychiatric inpatient services, and to establish the extent to which misgivings about community care might be justified. DESIGN: Cross sectional surveys with review of case notes. Follow up interviews with questionnaires administered one year after discharge. SETTING: Two inner London districts (West Lambeth and Lewisham) with high levels of social deprivation and at different stages of developing community services. PATIENTS: 90 and 50 patients in the two services respectively, aged 18 to 65, who satisfied the Research Diagnostic Criteria for schizophrenia and who were discharged from inpatient services. MAIN OUTCOME MEASURES: Diagnosis elicited by present state examination, global social disability rating, use of services during the three months before interview. RESULTS: 89 of the 140 patients (64%) had been ill for five or more years, yet few were former long stay inpatients. 55% (50/91; 95% confidence interval 45% to 65%) of those interviewed had current psychotic mental states and 22% (27/124; 16% to 31%) were functioning socially at very poor or severely maladjusted levels. 86% (107/124) were unemployed. The majority of patients had seen a mental health or social service professional, yet only 16% (20/124) were in specialised accomodation (excluding hospitals) and only 23% (17/73) of those eligible had used day care. Small numbers of people had experienced homelessness (two) or imprisonment (four over six months). CONCLUSIONS: Many schizophrenic patients leaving local psychiatric inpatient care have active symptomatology and profound social disabilities. Community care was characterised by high rates of contact with service professionals but little supported accommodation or day activity. This group of clients may require dedicated provision, which would actively encourage them to use services protected from the demands of those with less severe illness.

An evaluation of a respite care unit for elderly people with dementia: framework and some results.

This paper offers a comprehensive framework for service evaluation relevant to a new respite care unit, and reports some results of its application. On existing evidence the planning assumption of a preventive effect of respite care, in avoiding admission to institutional care, is argued to be unjustifiable. The results indicate that this unit had a high non-attendance and fall-out rate, and no incentives to co-operate with alternative services or to operate efficiently. Broad estimates of cost parities revealed that attenders at the unit sacrificed considerable amounts of alternative forms of care.