Ethnic inequalities in age-related patterns of multiple long-term conditions in England: Analysis of primary care and nationally representative survey data.

Little is known about the patterning of multiple long-term conditions (MLTCs) by age, ethnicity and across conceptualisations of MLTCs (e.g. MLTCs with/without mental health conditions [MHCs]). We examined ethnic inequalities in age-related patterns of MLTCs, and combinations of physical and MHCs using the English GP Patient Survey and Clinical Practice Research Datalink. We described the association between MLTCs and age using multilevel regression models adjusting for sex and area-level deprivation with patients nested within GP practices. Similar analyses were repeated for MLTCs that include MHCs. We observed ethnic inequalities from middle-age onwards such as older Pakistani, Indian, Black Caribbean and Other ethnic people had increased risk of MLTCs compared to white British people, even after adjusting for area-level deprivation. Compared to white British people, Gypsy and Irish Travellers had higher levels of MLTCs across the age groups, and Chinese people had lower levels. Pakistani and Bangladeshi people aged 50-74 years were more likely than white people to report MLTCs that included MHCs. We find clear evidence of ethnic inequalities in MLTCs. The lower prevalence of MLTCs that include MHCs among some minoritised ethnic groups may be an underestimation due to underdiagnosis and/or inadequate primary care and requires further scrutiny.

Demographic characteristics, long-term health conditions and healthcare experiences of 6333 trans and non-binary adults in England: nationally representative evidence from the 2021 GP Patient Survey.

OBJECTIVE: In order to address the lack of data on the health and healthcare needs of trans and non-binary adults, NHS England includes questions asking about both gender and trans status in its surveys to support quality improvement programmes.We used self-reported data from the GP Patient Survey to answer the research question: what are the demographic characteristics, health conditions and healthcare experiences of trans and non-binary adults in England? DESIGN/SETTING: Nationally representative, population-based cross-sectional survey in England with survey data collection from January to March 2021. PARTICIPANTS: 840 691 survey respondents including 6333 trans and non-binary adults. OUTCOMES: We calculated weighted descriptive statistics, and using logistic regression explored 15 long-term physical and mental health conditions, and 18 patient experience items, covering overall experience, access, communication and continuity. RESULTS: Trans and non-binary adults were younger, more likely to be from Asian, black, mixed or other ethnic groups and more likely to live in more deprived parts of the country. Age-specific patterns of long-term conditions were broadly similar among trans and non-binary adults compared with all other survey respondents, with some variation by condition. Overall, inequalities in long-term health conditions were largest for autism: OR (95% CI), 5.8 (5.0 to 6.6), dementia: 3.1 (2.5 to 3.9), learning disabilities: 2.8 (2.4 to 3.2) and mental health: 2.0 (1.9 to 2.2), with variation by age. In healthcare experience, disparities are much greater for interpersonal communication (OR for reporting a positive experience, range 0.4 to 0.7 across items) than access (OR range 0.8 to 1.2). Additionally, trans and non-binary adults report much higher preference for continuity 1.7 (1.6 to 1.8), with no evidence of any differences in being able to see or speak to a preferred general practitioner. CONCLUSION: This research adds up to date evidence about population demographics, health and healthcare needs to support healthcare improvement for trans and non-binary adults.

Sexual Minority Adults in England Have Greater Odds of Chronic Mental Health Problems: Variation by Sexual Orientation, Age, Ethnicity, and Socioeconomic Status.

Purpose: Sexual minority adults report worse mental health than heterosexual peers, although few empirical studies are large enough to measure variation in these disparities by sexual orientation, age, ethnicity, and socioeconomic status (SES). We investigate chronic mental health problems among sexual minority adults. Methods: Sex-disaggregated logistic regressions examined associations between self-reported chronic mental health problems and sexual orientation, age, ethnicity, and SES in a 2015-2017 dataset from the nationally representative English General Practice Patient Survey data (n = 1,341,339). Results: Bisexual adults, especially young bisexual females, reported the highest rates of chronic mental health problems. Sexual minority females 18-24 years of age had five times the odds of reporting chronic mental health problems of their heterosexual peers, with 32% of sexual minority females 18-24 years of age reporting the outcome. Sexual minority identity was also strongly associated with chronic mental health problems for adults who were White and lived in more affluent areas. Conclusion: The very high odds of chronic mental health problems among bisexual adults, especially younger bisexual females, may reflect simultaneous isolation from sexual minority and heterosexual communities. Elevated odds at younger ages may reflect disproportionate social media use and bullying. It is plausible that those who are subject to minority stress associated with SES and ethnicity may develop resilience strategies that they then apply to sexual minority stress. The results suggest that sexual minority identity is a source of minority stress, even for those who are affluent. Clinicians should be alert to the need to support the specific mental health concerns of their sexual minority patients.

Long-term conditions among sexual minority adults in England: evidence from a cross-sectional analysis of responses to the English GP Patient Survey.

BACKGROUND: Epidemiological evidence for specific long-term conditions is required to inform best practices regarding the substantial health inequalities experienced by sexual minority individuals compared with heterosexual peers. AIM: To describe inequalities in long-term conditions among sexual minority (lesbian, gay, and bisexual [LGB]) adults. DESIGN & SETTING: Cross-sectional analysis of 1 341 339 nationally representative survey responses from the English GP Patient Survey (GPPS). METHOD: Stratifying by sex, the weighted prevalence and covariate-adjusted association of 15 long-term conditions were calculated, comparing sexual minority and heterosexual adults, considering variation by sexual orientation and variation in sexual orientation inequalities by deprivation, ethnic group, region, and age. RESULTS: After adjusting for deprivation, ethnic group, region, and age, 13 long-term conditions (all except cancer and hypertension) were more prevalent among sexual minority women than their heterosexual peers, with the largest inequalities for mental health problems (odds ratio [OR] 2.8, 95% confidence interval [CI] = 2.7 to 3.0), neurological conditions (OR 1.7, 95% CI = 1.5 to 1.8), dementia (OR 1.6, 95% CI = 1.3 to 1.9), and back problems (OR 1.4, 95% CI = 1.3 to 1.5). It was found that nine long-term conditions were also more prevalent among sexual minority men including mental health problems (OR 2.3, 95% CI = 2.2 to 2.4), 'all other conditions' (OR 1.8, 95% CI = 1.7 to 1.8), neurological conditions (OR 1.5, 95% CI = 1.4 to 1.6), and kidney or liver disease (OR 1.4, 95% CI = 1.3 to 1.5); inequalities were often largest for bisexual adults. Inequalities did not vary significantly by deprivation, ethnic group, or region except for mental health problems. Inequalities in multimorbidity were highest at younger ages; for example, LGB women aged 18-24 years had multimorbidity at the same level (approximately 20%) as heterosexual women aged 45-54 years. CONCLUSION: Sexual minority adults, especially bisexual adults, are at elevated risk for many long-term conditions and multimorbidity; this risk spans socioeconomic status and ethnic group, representing a significant healthcare challenge.

Using UK Biobank for sexual minority health research.

Aim: Despite poorer health and healthcare outcomes experienced by lesbian, gay and bisexual adults, data for research to characterize and address these disparities remain limited. Patients & methods: We describe sexual history information from 502,543 UK Biobank participants recruited between 2006 and 2010, as sexual identity was not collected from the cohort at baseline, and compare this with sexual history and sexual identity responses to the third National Survey of Sexual Attitudes and Lifestyles (NATSAL-3), collected between 2010 and 2012. Results: After exclusions, 700 (0.3%) women and 2112 (1.2%) men in UK Biobank reported a history of exclusively same-sex sex and 5162 (2.3%) women and 4275 (2.3%) men reported a history of sex with both women and men; estimates were consistent with, although slightly lower those from NATSAL-3. Conclusion: UK Biobank is an important resource for sexual minority health research.

Lay abstract Although lesbian, gay and bisexual adults experience poorer health and healthcare outcomes, data for researchers to use to understand and address these disparities remain limited. UK Biobank is a research study which recruited, and is now following up, over half a million adults aged between 40 and 70. When participants were recruited they were not asked about sexual identity but they were asked about their history of sex with both women and men. In this research, we compared the responses to this question in UK Biobank to responses from another survey, the third National Survey of Sexual Attitudes and Lifestyles, and found the estimates were broadly comparable. We also provide some advice to researchers on how to use UK Biobank in future research to explore disparities in health outcomes experienced by lesbian, gay and bisexual adults.

The Costs and Benefits of Risk Stratification for Colorectal Cancer Screening Based On Phenotypic and Genetic Risk: A Health Economic Analysis.

Population-based screening for colorectal cancer is an effective and cost-effective way of reducing colorectal cancer incidence and mortality. Many genetic and phenotypic risk factors for colorectal cancer have been identified, leading to development of colorectal cancer risk scores with varying discrimination. However, these are not currently used by population screening programs. We performed an economic analysis to assess the cost-effectiveness, clinical outcomes, and resource impact of using risk-stratification based on phenotypic and genetic risk, taking a UK National Health Service perspective. Biennial fecal immunochemical test (FIT), starting at an age determined through risk-assessment at age 40, was compared with FIT screening starting at a fixed age for all individuals. Compared with inviting everyone from age 60, using a risk score with area under the receiver operating characteristic curve of 0.721 to determine FIT screening start age, produces 418 QALYs, costs £247,000, and results in 218 fewer colorectal cancer cases and 156 fewer colorectal cancer deaths per 100,000 people, with similar FIT screening invites. There is 96% probability that risk-stratification is cost-effective, with net monetary benefit (based on £20,000 per QALY threshold) estimated at £8.1 million per 100,000 people. The maximum that could be spent on risk-assessment and still be cost-effective is £114 per person. Lower benefits are produced with lower discrimination risk scores, lower mean screening start age, or higher FIT thresholds. Risk-stratified screening benefits men more than women. Using risk to determine FIT screening start age could improve the clinical outcomes and cost effectiveness of colorectal cancer screening without using significant additional screening resources. PREVENTION RELEVANCE: Colorectal cancer screening is essential for early detection and prevention of colorectal cancer, but implementation is often limited by resource constraints. This work shows that risk-stratification using genetic and phenotypic risk could improve the effectiveness and cost-effectiveness of screening programs, without using substantially more screening resources than are currently available.

Should colorectal cancer screening start at different ages for men and women? Cost-effectiveness analysis for a resource-constrained service.

BACKGROUND: Men have a greater risk of colorectal cancer (CRC) than women, but population screening currently starts at the same age for both sexes. AIM: This analysis investigates whether, in a resource-constrained setting, it would be more effective and cost-effective for men and women to start screening for CRC at different ages. METHODS AND RESULTS: An economic modeling analysis was carried out using the Microsimulation Model in Cancer of the Bowel to compare sex-stratification against screening everyone from the same age, taking an English National Health Service perspective. Screening men from age 56 and women from age 60, rather than screening everyone from age 58 using a Fecal Immunochemical Test (FIT) threshold of 120 µg/g is expected to produce an additional 0.0004 QALYs for a cost of £0.55 per person at model start (Incremental Cost-effectiveness Ratio = £1392), and to reduce CRC cases and mortality by 25 and 19 per 100 000 people respectively, while using a similar amount of screening resources. Probabilistic sensitivity analysis indicates a 61% probability that sex-stratification is more cost-effective than screening everyone at age 58. Similar benefits of sex-stratification are found at other FIT thresholds, but become negligible if mean screening start age is reduced to 50. CONCLUSION: Where resources are constrained and it is not feasible to screen everyone from the age of 50, starting screening earlier in men than women is likely to be more cost-effective and gain more health benefits overall than strategies where men and women start screening at the same age.

Sociodemographic inequalities in patients' experiences of primary care: an analysis of the General Practice Patient Survey in England between 2011 and 2017.

OBJECTIVE: Younger people, minority ethnic groups, sexual minorities and people of lower socioeconomic status report poorer experiences of primary care. In light of NHS ambitions to reduce unwarranted variations in care, we aimed to investigate whether inequalities in patient experience of primary care changed between 2011 and 2017, using data from the General Practice Patient Survey in England. METHODS: We considered inequalities in relation to age, sex, deprivation, ethnicity, sexual orientation and geographical region across five dimensions of patient experience: overall experience, doctor communication, nurse communication, access and continuity of care. We used linear regression to explore whether the magnitude of inequalities changed between 2011 and 2017, using mixed models to assess changes within practices and models without accounting for practice to assess national trends. RESULTS: We included 5,241,408 responses over 11 survey waves from 2011-2017. There was evidence that inequalities changed over time (p < 0.05 for 27/30 models), but the direction and magnitude of changes varied. Changes in gaps in experience ranged from a 1.6 percentage point increase for experience of access among sexual minorities, to a 5.6 percentage point decrease for continuity, where experience worsened for older ages. Inequalities in access in relation to socio-economic status remained reasonably stable for individuals attending the same GP practice; nationally inequalities in access increased 2.1 percentage points (p < 0.0001) between respondents living in more/less deprived areas, suggesting access is declining fastest in practices in more deprived areas. CONCLUSIONS: There have been few substantial changes in inequalities in patient experience of primary care between 2011 and 2017.

The impact of information about different absolute benefits and harms on intention to participate in colorectal cancer screening: A think-aloud study and online randomised experiment.

BACKGROUND: There is considerable heterogeneity in individuals' risk of disease and thus the absolute benefits and harms of population-wide screening programmes. Using colorectal cancer (CRC) screening as an exemplar, we explored how people make decisions about screening when presented with information about absolute benefits and harms, and how those preferences vary with baseline risk, between screening tests and between individuals. METHOD: We conducted two linked studies with members of the public: a think-aloud study exploring decision making in-depth and an online randomised experiment quantifying preferences. In both, participants completed a web-based survey including information about three screening tests (colonoscopy, sigmoidoscopy, and faecal immunochemical testing) and then up to nine scenarios comparing screening to no screening for three levels of baseline risk (1%, 3% and 5% over 15 years) and the three screening tests. Participants reported, after each scenario, whether they would opt for screening (yes/no). RESULTS: Of the 20 participants in the think-aloud study 13 did not consider absolute benefits or harms when making decisions concerning CRC screening. In the online experiment (n = 978), 60% expressed intention to attend at 1% risk of CRC, 70% at 3% and 77% at 5%, with no differences between screening tests. At an individual level, 535 (54.7%) would attend at all three risk levels and 178 (18.2%) at none. The 27% whose intention varied by baseline risk were more likely to be younger, without a family history of CRC, and without a prior history of screening. CONCLUSIONS: Most people in our population were not influenced by the range of absolute benefits and harms associated with CRC screening presented. For an appreciable minority, however, magnitude of benefit was important.

Increased Reporting of Sexual Minority Orientation from 2009 to 2017 in England and Implications for Measuring Sexual Minority Health Disparities.

Purpose: Sexual minority adults experience considerable mental and physical health disparities compared to their heterosexual counterparts, but changes in these disparities over time may, in part, reflect changes in how the same people self-identify their sexual orientation. Therefore, we estimated between-cohort and within-person changes in self-identified sexual orientation to better understand changes in sexual orientation-based health disparities over the life course. Methods: We examined 2009 to 2015 changes among 5712 adults 19-25 years of age from the Longitudinal Study of Young People in England (LSYPE) to validate a synthetic cohort approach applied to cross-sectional data on 1,168,346 adults 18-74 years of age (n = 29,677 sexual minority adults) from the General Practice Patient Survey (GPPS), estimating 2009 to 2017 changes in sexual orientation identification. Results: Heterosexual identification for adults 18-24 years of age fell three percentage points from 2009 to 2017. Approximately half of those 26-32 years of age, who identified as sexual minority adults in 2017, may not have identified as such 8 years earlier. LSYPE and GPPS results were similar, validating the synthetic cohort application. Within-cohort analyses estimated that 2.1% and 2.7% of heterosexual-identified women and men 18-24 years of age in 2009, respectively, changed identification by 2017. Smaller changes occurred for adults 25-34 years of age (1.0% and 1.2%, respectively), with still smaller differences at older ages. Conclusion: Changes in health disparities may reflect people newly identifying as a sexual minority as well as longitudinal changes in those long identifying as sexual minority adults. Future research should measure the health of both early- and late-identifying sexual minority adults, as their health care and policy needs may differ.

Using Ancillary Sociodemographic Data to Identify Sexual Minority Adults Among Those Responding "Something Else" or "Don't Know" to Sexual Orientation Questions.

BACKGROUND: General population surveys are increasingly offering broader response options for questions on sexual orientation-for example, not only gay or lesbian, but also "something else" (SE) and "don't know" (DK). However, these additional response options are potentially confusing for those who may not know what the terms mean. Researchers studying sexual orientation-based disparities face difficult methodological trade-offs regarding how best to classify respondents identifying with the SE and DK categories. OBJECTIVES: Develop respondent-level probabilities of sexual minority orientation without excluding or misclassifying the potentially ambiguous SE and DK responses. Compare 3 increasingly inclusive analytic approaches for estimating health disparities using a single item: (a) omitting SE and DK respondents; (b) classifying SE as sexual minority and omitting DK; and (c) a new approach classifying only SE and DK respondents with >50% predicted probabilities of being sexual minorities as sexual minority. MATERIALS AND METHODS: We used the sociodemographic information and follow-up questions for SE and DK respondents in the 2013-2014 National Health Interview Survey to generate predicted probabilities of identifying as a sexual minority adult. RESULTS: About 94% of the 144 SE respondents and 20% of the 310 DK respondents were predicted to identify as a sexual minority adult, with higher probabilities for younger, wealthier, non-Hispanic white, and urban-dwelling respondents. Using a more specific definition of sexual minority orientation improved the precision of health and health care disparity estimates. CONCLUSIONS: Predicted probabilities of sexual minority orientation may be used in this and other surveys to improve representation and categorization of those who identify as a sexual minority adult.

Delivery and impact of the NHS Health Check in the first 8 years: a systematic review.

BACKGROUND: Since 2009, all eligible persons in England have been entitled to an NHS Health Check. Uncertainty remains about who attends, and the health-related impacts. AIM: To review quantitative evidence on coverage (the proportion of eligible individuals who attend), uptake (proportion of invitees who attend), and impact of NHS Health Checks. DESIGN AND SETTING: A systematic review and quantitative data synthesis. Included were studies or data reporting coverage or uptake and studies reporting any health-related impact that used an appropriate comparison group or before- and-after study design. METHOD: Eleven databases and additional internet sources were searched to November 2016. RESULTS: Twenty-six observational studies and one additional dataset were included. Since 2013, 45.6% of eligible individuals have received a health check. Coverage is higher among older people, those with a family history of coronary heart disease, those living in the most deprived areas, and some ethnic minority groups. Just under half (48.2%) of those invited have taken up the invitation. Data on uptake and impact (especially regarding health-related behaviours) are limited. Uptake is higher in older people and females, but lower in those living in the most deprived areas. Attendance is associated with small increases in disease detection, decreases in modelled cardiovascular disease risk, and increased statin and antihypertensive prescribing. CONCLUSION: Published attendance, uptake, and prescribing rates are all lower than originally anticipated, and data on impact are limited, with very few studies reporting the effect of attendance on health-related behaviours. High-quality studies comparing matched attendees and non-attendees and health economic analyses are required.

Current and future cardiovascular disease risk assessment in the European Union: an international comparative study.

Background: Risk assessment is central to primary prevention of cardiovascular disease (CVD), but there remains a need to better understand the use of evidence-based interventions in practice. This study examines: (i) the policies and guidelines for risk assessment in Europe, (ii) the use of risk assessment tools in clinical practice and (iii) the barriers to, and facilitators of, risk assessment. Methods: Data were collected from academics, clinicians and policymakers in an online questionnaire targeted at experts from all European Union member states, and in 8 in-depth country case studies that were developed from a targeted literature review and 36 interviews. Results: The European Society of Cardiology (ESC) produces European guidelines for CVD risk assessment and recommends the Systematic COronary Risk Evaluation tool, which is the most widely used risk assessment tool in Europe. The use of risk assessment tools is variable. Lack of time and resources are important barriers. Integrating risk assessment tools into clinical systems and providing financial incentives to carry out risk assessments could increase implementation. Novel biomarkers would need to be supported by evidence of their clinical effectiveness and cost-effectiveness to be introduced in clinical practice. These findings were consistent across Europe. Conclusions: Efforts to improve the assessment of CVD risk in clinical practice should be carried out by or in collaboration with, the ESC. Increasing the use of existing risk assessment tools is likely to offer greater gains in primary prevention than the development of novel biomarkers.

Reasons why people do not attend NHS Health Checks: a systematic review and qualitative synthesis.

BACKGROUND: The NHS Health Check programme is a prevention initiative offering cardiovascular risk assessment and management advice to adults aged 40-74 years across England. Its effectiveness depends on uptake. When it was introduced in 2009, it was anticipated that all those eligible would be invited over a 5-year cycle and 75% of those invited would attend. So far in the current cycle from 2013 to 2018, 33.8% of those eligible have attended, which is equal to 48.5% of those invited to attend. Understanding the reasons why some people do not attend is important to maximise the impact of the programmes. AIM: To review why people do not attend NHS Health Checks. DESIGN AND SETTING: A systematic review and thematic synthesis of qualitative studies. METHOD: An electronic literature search was carried out of MEDLINE, Embase, Health Management Information Consortium, Cumulative Index to Nursing and Allied Health Literature, Global Health, PsycINFO, Web of Science, OpenGrey, the Cochrane Library, NHS Evidence, Google Scholar, Google, ClinicalTrials.gov, and the ISRCTN registry from 1 January 1996 to 9 November 2016, and the reference lists of all included papers were also screened manually. Inclusion criteria were primary research studies that reported the views of people who were eligible for but had not attended an NHS Health Check. RESULTS: Nine studies met the inclusion criteria. Reasons for not attending included lack of awareness or knowledge, misunderstanding the purpose of the NHS Health Check, aversion to preventive medicine, time constraints, difficulties with access to general practices, and doubts regarding pharmacies as appropriate settings. CONCLUSION: The findings particularly highlight the need for improved communication and publicity around the purpose of the NHS Health Check programme and the personal health benefits of risk factor detection.

Views of commissioners, managers and healthcare professionals on the NHS Health Check programme: a systematic review.

OBJECTIVE: To synthesise data concerning the views of commissioners, managers and healthcare professionals towards the National Health Service (NHS) Health Check programme in general and the challenges faced when implementing it in practice. DESIGN: A systematic review of surveys and interview studies with a descriptive analysis of quantitative data and thematic synthesis of qualitative data. DATA SOURCES: An electronic literature search of MEDLINE, Embase, Health Management Information Consortium, Cumulative Index of Nursing and Allied Health Literature, Global Health, PsycInfo, Web of Science, OpenGrey, the Cochrane Library, NHS Evidence, Google Scholar, Google, ClinicalTrials.gov and the International Standard Randomised Controlled Trial Number registry from 1 January 1996 to 9 November 2016 with no language restriction and manual screening of reference lists of all included papers. INCLUSION CRITERIA: Primary research reporting views of commissioners, managers or healthcare professionals on the NHS Health Check programme and its implementation in practice. RESULTS: Of 18 524 citations, 15 articles met the inclusion criteria. There was evidence from both quantitative and qualitative studies that some commissioners and general practice (GP) healthcare professionals were enthusiastic about the programme, whereas others raised concerns around inequality of uptake, the evidence base and cost-effectiveness. In contrast, those working in pharmacies were all positive about programme benefits, citing opportunities for their business and staff. The main challenges to implementation were: difficulties with information technology and computer software, resistance to the programme from some GPs, the impact on workload and staffing, funding and training needs. Inadequate privacy was also a challenge in pharmacy and community settings, along with difficulty recruiting people eligible for Health Checks and poor public access to some venues. CONCLUSIONS: The success of the NHS Health Check Programme relies on engagement by those responsible for its commissioning, management and delivery. Recognising and addressing the challenges identified in this review, in particular the concerns of GPs, are important for the future of the programme.

Patient experience of NHS health checks: a systematic review and qualitative synthesis.

OBJECTIVE: To review the experiences of patients attending NHS Health Checks in England. DESIGN: A systematic review of quantitative and qualitative studies with a thematic synthesis of qualitative studies. DATA SOURCES: An electronic literature search of Medline, Embase, Health Management Information Consortium, Cumulative Index of Nursing and Allied Health Literature, Global Health, PsycInfo, Web of Science, OpenGrey, the Cochrane Library, National Health Service (NHS) Evidence, Google Scholar, Google, Clinical Trials.gov and the ISRCTN registry to 09/11/16 with no language restriction and manual screening of reference lists of all included papers. INCLUSION CRITERIA: Primary research reporting experiences of patients who have attended NHS Health Checks. RESULTS: 20 studies met the inclusion criteria, 9 reporting quantitative data and 15 qualitative data. There were consistently high levels of reported satisfaction in surveys, with over 80% feeling that they had benefited from an NHS Health Check. Data from qualitative studies showed that the NHS Health Check had been perceived to act as a wake-up call for many who reported having gone on to make substantial lifestyle changes which they attributed to the NHS Health Check. However, some had been left with a feeling of unmet expectations, were confused about or unable to remember their risk scores, found the lifestyle advice too simplistic and non-personalised or were confused about follow-up. CONCLUSIONS: While participants were generally very supportive of the NHS Health Check programme and examples of behaviour change were reported, there are a number of areas where improvements could be made. These include greater clarity around the aims of the programme within the promotional material, more proactive support for lifestyle change and greater appreciation of the challenges of communicating risk and the limitations of relying on the risk score alone as a trigger for facilitating behaviour change.

Informal carers' health-related quality of life and patient experience in primary care: evidence from 195,364 carers in England responding to a national survey.

BACKGROUND: We aim to describe the health-related quality of life of informal carers and their experiences of primary care. METHODS: Responses from the 2011-12 English General Practice Patient Survey, including 195,364 informal carers, were analysed using mixed effect logistic regressions controlling for age, gender, ethnicity and social deprivation to describe carer health-related quality of life (mobility, self-care, usual activities, pain, and anxiety/depression, measured using EQ-5D) and primary care experience (access, continuity and communication). RESULTS: Informal carers reported poorer health-related quality of life than non-carers of similar age, gender, ethnicity and social deprivation. Increasing caring commitment was associated with worse EQ-5D scores, with carers of 50+ hours a week scoring 0.05 points lower than non-carers (95 % CI 0.05 to 0.04), equivalent to 18 fewer days of full health annually. Considering each domain of EQ-5D separately, carers of 50+ hours/week were more likely to report pain OR = 1.53 (1.50-1.57), p < 0.0001, and anxiety/depression OR = 1.69 (1.66-1.73), p < 0.0001, than non-carers. Younger carers scored lower on EQ-5D than non-carer peers but the converse was true among over-85s. In the most deprived areas carers reported the equivalent of 37 fewer days of full health annually than carers in the most affluent areas. On average, carers reported poorer patient experiences in all areas of primary care than non-carers (odds ratios 0.84-0.97), with this difference being most marked in the domain of access. CONCLUSIONS: Informal carers experience a double disadvantage of poorer health-related quality of life and poorer patient experience in primary care. We find no evidence for health benefits of caregiving. We recommend physicians identify and treat carer health problems, including pain and anxiety/depression, particularly among young, deprived and high time-commitment carers. Improving patient experience for carers, including access to primary care, should be a priority.

Why do patients with multimorbidity in England report worse experiences in primary care? Evidence from the General Practice Patient Survey.

OBJECTIVES: To describe and explain the primary care experiences of people with multiple long-term conditions in England. DESIGN AND METHODS: Using questionnaire data from 906,578 responders to the English 2012 General Practice Patient Survey, we describe the primary care experiences of patients with long-term conditions, including 583,143 patients who reported one or more long-term conditions. We employed mixed effect logistic regressions to analyse data on six items covering three care domains (access, continuity and communication) and a single item on overall primary care experience. We controlled for sociodemographic characteristics, and for general practice using a random effect, and further, controlled for, and explored the importance of, health-related quality of life measured using the EuroQoL (EQ-5D) scale. RESULTS: Most patients with long-term conditions report a positive experience of care at their general practice (after adjusting for sociodemographic characteristics and general practice, range 74.0-93.1% reporting positive experience of care across seven questions) with only modest variation by type of condition. For all three domains of patient experience, an increasing number of comorbid conditions is associated with a reducing percentage of patients reporting a positive experience of care. For example, compared with respondents with no long-term condition, the OR for reporting a positive experience is 0.83 (95% CI 0.80 to 0.87) for respondents with four or more long-term conditions. However, this relationship is no longer observed after adjusting for health-related quality of life (OR (95% CI) single condition=1.23 (1.21 to 1.26); four or more conditions=1.31 (1.25 to 1.37)), with pain making the greatest difference among five quality of life variables included in the analysis. CONCLUSIONS: Patients with multiple long-term conditions more frequently report worse experiences in primary care. However, patient-centred measures of health-related quality of life, especially pain, are more important than the number of conditions in explaining why patients with multiple long-term conditions report worse experiences of care.

Assessment of head size adjusted for height: an anthropometric tool for clinical use based on Argentinian data.

BACKGROUND: Relative macrocephaly describes a large head in relation to stature, and this indicator could be helpful in depicting syndromes with large heads and short stature, providing the existence of some relationship between both measurements in normal children. OBJECTIVE: The aims of this study were (1) to evaluate the existence of a relationship between head circumference (HC), height and weight, (2) to build an instrument for evaluating it and validate its clinical utility. SUBJECTS AND METHODS: Relationship between HC, height and weight was explored in a national sample of 3571 healthy, well nourished boys and girls aged 0-5.99 years. Age-adjusted correlation coefficients calculated were: HC and height, 0.30; HC and weight, 0.37; and height and weight, 0.60. A growth standard of HC to height ratio was constructed using the LMS method with both sexes pooled, and selected centiles and SD scores of HC to height ratio for each age were estimated. Z-scores of HC for age, and HC to height ratio were calculated for 13 children with hypochondroplasia, and 90 with achondroplasia, both conditions associated with macrocephaly. RESULTS: Only four children with hypochondroplasia had HC for age above 2.00 SD, whereas all of them showed SD scores above 2.00 when the HC to height ratio was evaluated. Results suggest that the prepared standard may be of clinical utility. CONCLUSIONS: A new standard is proposed, capable of pinpointing children with relative macrocephaly.