The longitudinal NIHR ARC North West Coast Household Health Survey: exploring health inequalities in disadvantaged communities.

BACKGROUND: The Household Health Survey (HHS) was developed to understand the socioeconomic determinants of mental and physical health, and health inequalities in health and social care. This paper aims to provide a detailed rationale of the development and implementation of the survey and explore socio-economic variations in physical and mental health and health care. METHODS: This comprehensive longitudinal public health survey was designed and piloted in a disadvantaged area of England, comprising questions on housing, physical health, mental health, lifestyle, social issues, environment, work, and finances. After piloting, the HHS was implemented across 28 neighbourhoods - 10 disadvantaged neighbourhoods for learning (NfLs), 10 disadvantaged comparator sites, and eight relatively advantaged areas, in 2015 and 2018. Participants were recruited via random sampling of households in pre-selected neighbourhoods based on their areas of deprivation. RESULTS: 7731 residents participated in Wave 1 (N = 4319) and 2 (n = 3412) of the survey, with 871 residents having participated in both. Mental health, physical health, employment, and housing quality were poorer in disadvantaged neighbourhoods than in relatively advantaged areas. CONCLUSIONS: This survey provides important insights into socio-economic variations in physical and mental health, with findings having implications for improved care provision to enable residents from any geographical or socio-economic background to access suitable care.

Implementation of genotype-guided dosing of warfarin with point-of-care genetic testing in three UK clinics: a matched cohort study.

BACKGROUND: Warfarin is a widely used oral anticoagulant. Determining the correct dose required to maintain the international normalised ratio (INR) within a therapeutic range can be challenging. In a previous trial, we showed that a dosing algorithm incorporating point-of-care genotyping information ('POCT-GGD' approach) led to improved anticoagulation control. To determine whether this approach could translate into clinical practice, we undertook an implementation project using a matched cohort design. METHODS: At three clinics (implementation group; n = 119), initial doses were calculated using the POCT-GGD approach; at another three matched clinics (control group; n = 93), patients were dosed according to the clinic's routine practice. We also utilised data on 640 patients obtained from routinely collected data at comparable clinics. Primary outcome was percentage time in target INR range. Patients and staff from the implementation group also provided questionnaire feedback on POCT-GGD. RESULTS: Mean percentage time in INR target range was 55.25% in the control group and 62.74% in the implementation group; therefore, 7.49% (95% CI 3.41-11.57%) higher in the implementation group (p = 0.0004). Overall, patients and staff viewed POCT-GGD positively, suggesting minor adjustments to allow smooth implementation into practice. CONCLUSIONS: In the first demonstration of the implementation of genotype-guided dosing, we show that warfarin dosing determined using an algorithm incorporating genetic and clinical factors can be implemented smoothly into clinic, to ensure target INR range is reached sooner and maintained. The findings are like our previous randomised controlled trial, providing an alternative method for improving the risk-benefit of warfarin use in daily practice.

Public involvement in the dissemination of the North West Coast Household Health Survey: Experiences and lessons of co-producing research together.

BACKGROUND: Engaging with the public is a key element of health research; however, little work has examined experiences of public involvement in research dissemination. The aim of this paper was to assess the extent of public involvement, experiences of public advisers and resulting changes in the dissemination of the North West Coast Household Health Survey (HHS). METHODS: Three writing groups allowed public advisers to contribute to the dissemination of the HHS. A public workshop was set up to aid the co-production of the research evidence and discuss the experiences of public advisers involved with the survey in March 2018. A focus group with public advisers was conducted in August 2018 to understand their experiences of involvement. Data were analysed using thematic analysis and coded by two researchers. Writing groups are still on-going. RESULTS: Fourteen public advisers contributed via three face-to-face writing groups, by actively interpreting findings and helping in the write-up of research articles and by presenting talks at the public workshop. At the workshop, seven public advisors contributed to setting priorities for data analysis from the HHS. Five public advisers took part in the focus group, which highlighted that whilst public advisers were generally satisfied with their involvement, they would like to be involved in more activities. CONCLUSIONS: Members of the public shaped the dissemination of evidence and provided guidance for future steps. Public advisers were mostly positive about their involvement in the dissemination of the HHS, but highlighted the need for more transparency and support from researchers.

The development of morphological representations in young readers: a cross-modal priming study.

The way children organize words in their memory has intrigued many researchers in the past 20 years. Given the large number of morphologically complex words in many languages, the influence of morphemes on this organization is being increasingly examined. The aim of this study was to understand how morphemic information influences English-speaking children's word recognition. Children in grades 3 and 5 were asked to complete a lexical decision priming task. Prime-target pairs varied in semantic similarity, with low (e.g., belly-bell), moderate (e.g., lately-late), and high similarity relations (e.g., boldly-bold). There were also word pairs similar in form only (e.g., spinach-spin) and in semantics only (e.g., garbage-trash). Primes were auditory and targets were presented visually. Analyses of children's lexical decision times revealed graded priming effects as a function of the convergence of form and meaning. These results indicate that developing readers do not necessarily need to lexicalize morphological units to facilitate word recognition. Their ability to process the morphological structure of words depends on their ability to develop connections between form and meaning.

Acceptability of virtual psychiatric consultations for routine follow-ups post COVID-19 pandemic for people with intellectual disabilities: cross-sectional study.

BACKGROUND: After the rapid implementation of digital health services during the COVID-19 pandemic, a paucity of research exists about the suitability of remote consulting in people with intellectual disabilities and their carers, particularly for neuropsychiatric reviews. AIM: This study examines when remote neuropsychiatric routine consulting is suitable for this population. METHOD: A survey was conducted of people with intellectual disabilities and their carers, examining their preference between face-to-face and video consultations for ongoing neuropsychiatric reviews within a rural countywide intellectual disability service in Cornwall, England (population: 538 000). The survey was sent to all adults with intellectual disabilities open to the service on 30 July 2022, closing on 30 September 2022. Participants were asked to provide responses on 11 items predesigned and co-produced between clinicians and experts by experience. The entire service caseload of people had White ethnicity, reflecting the ethnic demographics of Cornwall. Responses received without consent were excluded from the study dataset. RESULTS: Of 271 eligible participants, 119 responses were received, 104 of whom consented to having their anonymised data used for research analysis. There were no significant differences between preferences and age and gender variables. There was no statistically significant difference regarding preference for the reintroduction of face-to-face appointments (52.0%) compared with video consultations (48.0%). Travel distance (>10 miles) to the clinical setting was important but did not outweigh benefits for those preferring a face-to-face appointment. CONCLUSIONS: This study offers insights into the factors that influence preferences about what type of neuropsychiatric appointment is most suitable for people with intellectual disabilities.

Transition in endocrinology: the challenge of maintaining continuity.

OBJECTIVE: Transition from child to adult status is a crucial stage in young people's lives. It is important that young people continue to receive appropriate endocrine care throughout and following transfer from paediatric to adult services. This study examined indicators of patient loss to follow-up at initial transfer from paediatric care to identify implications for transitional care practice and research. METHODS: A retrospective analysis of patient data following transfer from paediatric services to a young person's transition clinic was conducted. Attendance data from 103 patients transferred to the Young Person's Clinic were analysed to determine the factors affecting nonattendance 1-year post-transfer. RESULTS: We found that overall one quarter of patients did not attend the young person's clinic in the first year after transfer. Those with poor attendance prior to transfer were likely to be poor attenders post-transfer. Further, those without an appointment scheduled in the first 6 months of their final paediatric transfer appointment were less likely to attend in the first year. CONCLUSIONS: Young people are at risk of losing contact during the transfer from paediatric to the young person's clinic. Measures that promote continuity of contact could reduce the risk of long-term disengagement with care. Further development and research is required to identify the best ways to help young people with endocrine conditions in the transition from child to adult status.

Investigating the impact of undiagnosed anxiety and depression on health and social care costs and quality of life: cross-sectional study using household health survey data.

BACKGROUND: There is uncertainty around the costs and health impacts of undiagnosed mental health problems. AIMS: Using survey data, we aim to understand the costs and health-related quality-of-life decrements from undiagnosed anxiety/depression. METHOD: We analysed survey data from two waves of the North West Coast Household Health Survey, which included questions on disease, medications, and Patient Health Questionnaire 9 (PHQ-9) and Generalised Anxiety Disorder 7 (GAD-7) scores (depression and anxiety scales). People were judged as having undiagnosed anxiety/depression problems if they scored ≥5 on the PHQ-9 or GAD-7, and did not declare a mental health issue or antidepressant prescription. Linear regression for EuroQol 5-Dimension 3-Level (EQ-5D-3L) index scores, and Tweedie regression for health and social care costs, were used to estimate the impact of undiagnosed mental health problems, controlling for age, gender, deprivation and other health conditions. RESULTS: Around 26.5% of participants had undiagnosed anxiety/depression. The presence of undiagnosed anxiety/depression was associated with reduced EQ-5D-3L index scores (0.040 lower on average) and increased costs (£250 ($310) per year on average). Using a higher cut-off score of 10 on the PHQ-9 and GAD-7 for undiagnosed anxiety/depression had similar increased costs but a greater reduction in EQ-5D-3L index scores (0.076 on average), indicating a larger impact on health-related quality of life. CONCLUSIONS: Having undiagnosed anxiety or depression increases costs and reduces health-related quality of life. Reducing stigma and increasing access to cost-effective treatments will have population health benefits.

The impact of an integrated care intervention on mortality and unplanned hospital admissions in a disadvantaged community in England: A difference-in-differences study.

BACKGROUND: Many health systems are experimenting with integrated care models to improve outcomes and reduce healthcare demand. Evidence for effects on health service utilisation is variable, with few studies investigating impacts on mortality or differences by socioeconomic group. OBJECTIVE: To examine the impact of a multidisciplinary, integrated care team intervention on emergency admissions and mortality, and whether effects differed by deprivation group. DESIGN: A longitudinal matched controlled study using difference-in-differences analysis comparing the change in unplanned emergency admissions twelve months before and after the intervention, and inverse probability of treatment-weighted survival analysis comparing mortality, between intervention and matched control groups. SETTING: A relatively deprived city in England, U.K. INTERVENTION: A case-management integrated care programme delivered through multidisciplinary teams and aimed at complex needs and/or high hospitalisation risk patients. RESULTS: The intervention was associated with a small increase in emergency admissions of 15 per 1,000 patients per month (95% CI 5 to 24, p = 0.003) after the intervention relative to the control group and no significant change in survival between intervention and control groups (HR 0.9, 95% CI 0.84 to 1.13, p = 0.7). Effects were similar across age and deprivation groups. CONCLUSIONS: It is unlikely that similar interventions lead to reduced emergency admissions or increased survival. Further studies should use experimental methods and assess impacts on quality of life.

Factors Affecting Patient and Physician Engagement in Remote Health Care for Heart Failure: Systematic Review.

BACKGROUND: Adult chronic heart failure mainly affects an elderly population with multiple comorbidities that often require frequent medical visits to prevent poor health outcomes. However, the heart failure disease process reduces their independence by reducing mobility, exercise tolerance, and cognitive decline. Remote care technologies can bridge the gap in care for these patients by allowing them to be followed up within the comfort of their home and encourage their self-care. However, patients, carers, and health care professionals need to engage with the technology for it to be useful. OBJECTIVE: This systematic review explores qualitative primary studies of remote care technologies used in heart failure, to determine the factors that affect user engagement with the technology. This is explored from the perspective of patients, carers, and health care professionals. METHODS: Relevant studies published between January 1, 1990, and September 19, 2020, were identified from EMBASE, Ovid MEDLINE, PubMed, Cochrane Library, and Scopus. These studies were then synthesized using thematic analysis. Relevant user experiences with remote care were extracted using line-by-line coding. These codes were summarized into secondary codes and core concepts, which were further merged into overarching themes that encapsulate user experience with remote care. RESULTS: The review included 47 studies, which led to the generation of 5 overarching themes that affect engagement: (1) "Convenience" relates to time saved by the intervention; (2) "Clinical Care" relates to perceived quality of care and health outcomes; (3) "Communication" involves feedback and interaction between patients, staff, and carers; (4) "Education" concerns the tailored information provided; and (5) "Ease of Use" relates to accessibility and technical barriers to engagement. Each theme was applied to each user base of patient, carer, and health care professional in a different manner. CONCLUSIONS: The 5 themes identified highlight aspects of remote care that facilitate engagement, and should be considered in both future design and trials evaluating these technologies.

Low vitamin D levels do not predict risk of autoimmune disease following alemtuzumab treatment for multiple sclerosis.

Alemtuzumab is a highly effective treatment for multiple sclerosis (MS) and the treatment strategy of two cycles 12 months apart has a lot of appeal to patients. Widespread use of alemtuzumab has been tempered by treatment emergent autoimmunity which is seen in approximately one-third of patients in the 5 years after treatment. It has been postulated that relative vitamin D deficiency may be a causative factor in this setting. We have conducted a retrospective case-control study looking at the association of vitamin D and other potentially relevant clinical factors on the likelihood of treatment emergent autoimmune disease following alemtuzumab. Occurrence of autoimmunity was monitored for clinically and through the Bloodwatch® monitoring program. Clinical data and vitamin D levels obtained as part of routine clinical practice were recorded. Vitamin D levels were seasonally adjusted. Only cases with complete data were included. Univariable and multivariable Cox proportional hazards analyses were performed. There were 113 patients treated with alemtuzumab for whom there was complete data. Median follow up was 4.4 years. Risk of autoimmune disease was not associated with lower vitamin D levels. Risk of autoimmune disease was associated with female sex (HR 3.5) and with higher EDSS score at treatment. The association with EDSS was lost when analysis was restricted to those with 4 or more years of follow up. These data do not support a role for vitamin D supplementation in the prevention of autoimmune disease following alemtuzumab. Males have a lower risk of autoimmunity following alemtuzumab.

Socioeconomic and health factors related to polypharmacy and medication management: analysis of a Household Health Survey in North West Coast England.

OBJECTIVES: To examine the socioeconomic and demographic drivers associated with polypharmacy (5-9 medicines), extreme polypharmacy (9-20 medicines) and increased medication count. DESIGN, SETTING AND PARTICIPANTS: A total of 5509 participants, from two waves of the English North West Coast, Household Health Survey were analysed OUTCOME MEASURES: Logistic regression modelling was used to find associations with polypharmacy and extreme polypharmacy. A negative binomial regression identified associations with increased medication count. Descriptive statistics explored associations with medication management. RESULTS: Age and number of health conditions account for the greatest odds of polypharmacy. ORs (95% CI) were greatest for those aged 65+ (3.87, 2.45 to 6.13) and for those with ≥5 health conditions (10.87, 5.94 to 19.88). Smaller odds were seen, for example, in those prescribed cardiovascular medications (3.08, 2.36 to 4.03), or reporting >3 emergency attendances (1.97, 1.23 to 3.17). Extreme polypharmacy was associated with living in a deprived neighbourhood (1.54, 1.06 to 2.26). The greatest risk of increased medication count was associated with age, number of health conditions and use of primary care services. Relative risks (95% CI) were greatest for those aged 65+ (2.51, 2.23 to 2.82), those with ≥5 conditions (10.26, 8.86 to 11.88) or those reporting >18 primary care visits (2.53, 2.18 to 2.93). Smaller risks were seen in, for example, respondents with higher levels of income deprivation (1.35, 1.03 to 1.77). Polypharmic respondents were more likely to report medication management difficulties associated with taking more than one medicine at a time (p<0.001). Furthermore, individuals reporting a mental health condition, were significantly more likely to consistently report difficulties managing their medication (p<0.001). CONCLUSION: Age and number of health conditions are most associated with polypharmacy. Thus, delaying or preventing the onset of long-term conditions may help to reduce polypharmacy. Interventions to reduce income inequalities and health inequalities generally could support a reduction in polypharmacy, however, more research is needed in this area. Furthermore, increased prevention and support, particularly with medication management, for those with mental health conditions may reduce adverse medication effects.

Characteristics of mental health stability during COVID-19: An online survey with people residing in a city region of the North West of England.

BACKGROUND AND AIM: Despite the significant mental health challenges the COVID-19 pandemic and its associated government measures have presented, research has shown that the majority of people have adapted and coped well. The aim of this study was i) to determine the proportion of people with mental stability and volatility during the pandemic in a North West England city region sample and ii) to establish group differences in psychosocial variables. Mental stability and volatility refer to the extent to which individuals reported change in levels of common mental health symptoms over the course of 12 weeks. No change in mental health over the 12 weeks reflected mental stability whilst change in mental health reflected mental volatility. METHOD: A two-wave-online survey (N = 163) was used to explore the psychological and social impact of the pandemic on relatively disadvantaged neighbourhoods within the region. The data collected represents 12 weeks of individual pandemic experience between mid-June and mid-December 2020. A three-level composite common mental health change variable was created combining self-reported anxiety and depression to group stable, volatile, and very volatile individuals in terms of the changeability of their mental health. Kruskal-Wallis with post-hoc tests were used to determine how people with mental stability and volatility differed on factors categorised within an ecological framework of resilience (individual, community, societal, and COVID-19 specific). RESULTS: Individuals categorised as 'stable' in terms of mental health symptoms (63.6%) had better mental and physical health; were more tolerant of uncertainty; and reported higher levels of resilience and wellbeing compared to 'very volatile' people (19.8%). These individuals also reported feeling less socially isolated, experienced a greater sense of belonging to their community which was more likely to fulfil their needs, and were more likely to have access to green space nearby for their recommended daily exercise. 'Stable' individuals did not report worrying any more during the pandemic than usual and tolerated uncertainty better compared to those in the 'volatile' group. IMPLICATIONS: The majority of participants in this sample were mentally stable and coping well with the challenges presented by the pandemic. The resilience of these individuals was related to key place-based factors such as a strong sense of community and useable local assets. The data showcase the role of place-based social determinants in supporting resilience and thereby highlight key preventative measures for public mental health during times of international crisis.

Factors associated with risky sexual behaviour: a comparison of British, Spanish and German holidaymakers to the Balearics.

BACKGROUND: Previous studies exploring risk-taking behaviour on holiday are typically limited to single nationalities, confounding comparisons among countries. Here we examine the sexual behaviour of holidaymakers of three nationalities visiting Ibiza and Majorca. METHODS: A comparative cross-sectional study design was used focusing on British, Spanish and German holidaymakers in the age range of 16-35 years. Overall, 3003 questionnaires were gathered at airports in Majorca and Ibiza from holidaymakers returning home. RESULTS: Of those surveyed, 71.1% were single (travelling without a current sexual partner) (Majorca, 74.3%; Ibiza, 68.0%). Overall, 34.1% of single holidaymakers had sex on holiday. Amongst single participants, factors associated with having sex on holiday were high levels of drunkenness, being Spanish and holidaying for over 2 weeks. Of those single and having sex on holiday, factors associated with multiple sexual partners were being male and age ≤19 years. Unprotected sex was predicted by being German and holidaying in Majorca, holidaying with members of the opposite sex and using four or more drugs on holiday. All sexual behaviours were predicted by a high number of sexual partners in the previous 12 months. Furthermore, single holidaymakers having sex abroad were more likely to prefer night-time venues facilitating casual sex and excessive alcohol consumption. CONCLUSIONS: Casual sex encounters in youth holiday resorts may be commonplace and mediated through substance use. Further focused public health efforts, including in bars/nightclubs, are needed to prevent sexual risk-taking which can increase the likelihood of poor sexual health outcomes and associated factors such as regretted sex.

A systematic review of parent and family-based intervention effectiveness on sexual outcomes in young people.

Limited evidence exists about the effectiveness of parent/family-based interventions for preventing poor sexual health outcomes, thus a systematic review was conducted as part of a wider review of community-based sex and relationships and alcohol education. Method guidance from the UK's National Institute for Health and Clinical Excellence was adhered to. Overall, 18 databases were searched. In total, 12 108 references were identified, of which 440 were retrieved and screened. Overall, 17 studies met the inclusion criteria. Findings showed that parent-based interventions were inconsistently effective at reducing young people's sexual risk behaviours. Parent-based interventions had greater impact on parent/child communication than family-based interventions, which showed no evidence of effectiveness. However, increasing parent/child communication showed no effect on sexual risk behaviours. Preliminary evidence suggests that effectiveness was greater in those studies aiming to affect multiple risk behaviours. However, this may be due to longer programme delivery and follow-up times; further evidence is required. Sexual health communication was sensitive to intervention. Studies addressing multiple risk behaviours may be as effective as targeted interventions at affecting sexual risk behaviours. Longitudinal controlled studies, examining broader sexual activity outcomes, are needed in countries such as the United Kingdom to inform the evidence base, which is primarily US based, and contribute to related policies and practices.

A qualitative study of phlebotomy device selection.

Limited research exists comparing Vacutainer versus butterfly phlebotomy devices. The purpose of this study was to examine decision processes staff use when choosing a device. A qualitative, purposive sampling was used and determined a gap between correct device use and reported practice. Applied findings can enhance employee safety.

Examining the uptake of predictive BRCA testing in the UK; findings and implications.

Predictive BRCA testing is offered to asymptomatic individuals to predict future risk where a variant has been identified in a relative. It is uncertain whether all eligible relatives access testing, and whether this is related to health care inequalities. Our aim was to analyse trends and inequalities in uptake of testing, and identify predictors of testing and time-to-receipt of testing. A database from April 2010 to March 2017 was collated. Multivariate analysis explored individual associations with testing. Predictor variables included gender, BRCA test type, cancer history, Index of Multiple Deprivation (IMD) and education status. To evaluate factors associated with time-to-testing, a Cox proportional-hazards (CP) model was used. Of 779 tests undertaken, 336 (43.1%) were identified with a BRCA variant. A total of 537 (68.9%) were female and in 83.4% (387/464) of probands, predictive testing was received by relatives. Analysis identified inequalities since decreased testing was found when the proband was unaffected by cancer (OR 0.14, 95% CI 0.06-0.33). Median time-to-testing was 390 days (range, 0-7090 days) and the CP model also identified inequalities in the hazard ratio (HR) for testing for people aged >40 was higher than for aged <40 (HR 1.41, 95% CI 1.20-1.67) and BRCA2 testing was higher than for BRCA1 testing (HR 1.39, 95% CI 1.18-1.64). Reduced testing was found when probands were unaffected by cancer and time-to-testing was found to vary by age and BRCA1/2 test. Given limited study sample size, further research is recommended to examine inequalities in predictive BRCA testing.

Management of cases testing positive for gonococcal infection in a community-based chlamydia screening programme.

BACKGROUND: The National Chlamydia Screening Programme in Greater Manchester (NCSP-GM) commissioned an evaluation of the management of gonorrhoea cases identified using the Gen-Probe APTIMA Combo 2 assay (AC2). METHODS: NCSP-GM provided data on gonorrhoea cases from a 6-month period (September 2007-February 2008). Data were collected from patient referral pathways to genitourinary medicine (GUM) clinics, including confirmatory testing, antibiotic resistance patterns and contact tracing. The AC2 positive predictive value (PPV) was calculated. RESULTS: 111 individuals tested positive for gonococcal infection using AC2 (0.7% of 16,028 individuals tested). Of these, 96 (0.6% of all tested) known index cases were seen at Greater Manchester GUM clinics. 78/96 (14 men, 64 women) underwent confirmatory microscopy and gonococcal culture. Confirmatory tests were positive in 14 men (100%) but only 40 women (63%). Thus the PPV of AC2 was 69% (54/78). Sensitivity in women may have been reduced by limited partner information and sample-taking (only 28% had a full gonorrhoea screen). CONCLUSION: Gonorrhoea screening in an NCSP-targeted population identified gonorrhoea in a low-risk population. Subsequent management in GUM clinics was variable and limited sample-taking may have decreased the sensitivity of confirmatory testing in women. Appropriate antibiotic sensitivity tests or, in their absence, a test of cure may be needed to ensure effective treatment.

A cross-sectional survey of compliance with national guidance for alcohol consumption by children: measuring risk factors, protective factors and social norms for excessive and unsupervised drinking.

BACKGROUND: The Chief Medical Officer for England has developed the first guidance in England and some of the first internationally on alcohol consumption by children. Using the most recent iteration of a large biennial survey of schoolchildren we measure the extent to which young people's drinking fell within the guidelines just prior to their introduction and the characteristics of individuals whose drinking does not; how alcohol related harms relate to compliance; and risk factors associated with behaving outside of the guidance. METHODS: A cross-sectional survey was conducted utilising a self-completed questionnaire with closed questions. A total of 11,879 schoolchildren, aged 15-16 years, from secondary schools in North West England participated in the study. Data were analysed using chi square and conditional logistic regression. RESULTS: Alcohol consumption is an established norm by age 15 years (81.3%). Acute alcohol related violence, regretted sex and forgetfulness were experienced by significantly fewer children drinking within the guidance (than outside of it). Over half of drinkers (54.7%) reported routinely drinking more heavily than guidance suggests (here ≥ 5 drinks/session ≥ 1 month), or typically drinking unsupervised at home or at a friend's home when parents were absent (57.4%). Both behaviours were common across all deprivation strata. Children with greater expendable incomes were less likely to consume within guidance and reported higher measures for unsupervised, frequent and heavy drinking. Although drinking due to peer pressure was associated with some measures of unsupervised drinking, those reporting that they drank out of boredom were more likely to report risk-related drinking behaviours outside of the guidance. CONCLUSIONS: Successful implementation of guidance on alcohol consumption for children could result in substantial reductions in existing levels of alcohol related harms to young people. However, prolonged social marketing, educational and parental interventions will be required to challenge established social norms in heavy and unsupervised child drinking across all social strata. Policy measures to establish a minimum price for alcohol and provide children with entertaining alternatives to alcohol should also increase compliance with guidance.

Has the introduction of direct oral anticoagulants (DOACs) in England increased emergency admissions for bleeding conditions? A longitudinal ecological study.

OBJECTIVE: There is concern about long-term safety of direct oral coagulants (DOACs) in clinical practice. Our aim was to investigate whether the introduction of DOACs compared with vitamin-K antagonists in England was associated with a change in admissions for bleeding or thromboembolic complications. SETTING: 5508 General practitioner (GP) practices in England between 2011 and 2016. PARTICIPANTS: All GP practices in England with a registered population size of greater than 1000 that had data for all 6 years. MAIN OUTCOME MEASURE: The rate of emergency admissions to hospital for bleeding or thromboembolism, per 100 000 population for each GP practice in England. MAIN EXPOSURE MEASURE: The annual number of DOAC items prescribed for each GP practice population as a proportion of all anticoagulant items prescribed. DESIGN: This longitudinal ecological study used panel regression models to investigate the association between trends in DOAC prescribing within GP practice populations and trends in emergency admission rates for bleeding and thromboembolic conditions, while controlling for confounders. RESULTS: For each additional 10% of DOACs prescribed as a proportion of all anticoagulants, there was a 0.9% increase in bleeding complications (rate ratio 1.008 95% CI 1.003 to 1.013). The introduction of DOACs between 2011 and 2016 was associated with additional 4929 (95% CI 2489 to 7370) emergency admissions for bleeding complications. Increased DOAC prescribing was associated with a slight decline in admission for thromboembolic conditions. CONCLUSION: Our data show that the rapid increase in prescribing of DOACs after changes in National Institute for Health and Care Excellence guidelines in 2014 may have been associated with a higher rate of emergency admissions for bleeding conditions. These consequences need to be considered in assessing the benefits and costs of the widespread use of DOACs.

Impact of community-based chronic obstructive pulmonary disease service, a multidisciplinary intervention in an area of high deprivation: a longitudinal matched controlled study.

OBJECTIVE: To examine the effects of a consultant-led, community-based chronic obstructive pulmonary disease (COPD) service, based in a highly deprived area on emergency hospital admissions. DESIGN: A longitudinal matched controlled study using difference-in-differences analysis to compare the change in outcomes in the intervention population to a matched comparison population, 5 years before and after implementation. SETTING: A deprived district in the North West of England between 2005 and 2016. INTERVENTION: A community-based, consultant-led COPD service providing diagnostics, treatment and rehabilitation from 2011 to 2016. MAIN OUTCOME MEASURES: Emergency hospital admissions, length of stay per emergency admission and emergency readmissions for COPD. RESULTS: The intervention was associated with 24 fewer emergency COPD admissions per 100 000 population per year (95% CI -10.6 to 58.8, p=0.17) in the postintervention period, relative to the control group. There were significantly fewer emergency admissions in populations with medium levels of deprivation (64 per 100 000 per year; 95% CI 1.8 to 126.9) and among men (60 per 100 000 per year; 95% CI 12.3 to 107.3). CONCLUSION: We found limited evidence that the service reduced emergency hospital admissions, after an initial decline the effect was not sustained. The service, however, may have been more effective in some subgroups.