Impact of local air quality management policies on emergency hospitalisations for respiratory conditions in the North West Coast region of England: a longitudinal controlled ecological study.

BACKGROUND: Air quality is monitored at a local level in the UK as part of the Local Air Quality Management (LAQM) system. If air quality objectives within an area are not achieved an Air Quality Management Area (AQMA) is declared and action plan developed. The efficacy of this system in reducing air pollution has increasingly come into question, however very little is known about its impact on health or health inequalities. We therefore investigated the effect of declaring an AQMA on emergency hospitalisations for respiratory conditions in the North West Coast region of England, and examined whether the effect differed between more compared to less deprived neighbourhoods. METHODS: This longitudinal controlled ecological study analysed neighbourhoods located within or touching the boundaries of AQMAs declared in the North West Coast region between 2006 and 2016. Each of these intervention neighbourhoods were matched with five control neighbourhoods which had never been located within/touching an AQMA boundary. Difference-in-differences methods were used to compare the change in hospitalisation rates in the intervention neighbourhoods to the change in hospitalisation rates in the matched control neighbourhoods, before and after the declaration of an AQMA. RESULTS: In total, 108 intervention neighbourhoods and 540 control neighbourhoods were analysed over the period 2005-2017, giving a total sample size of 8424 neighbourhood-years. Emergency hospitalisations for respiratory conditions decreased in the intervention neighbourhoods by 158 per 100,000 per year [95% CI 90 to 227] after an AQMA was declared relative to the control neighbourhoods. There was a larger decrease in hospitalisation rates following the declaration of an AQMA in more compared to less income deprived neighbourhoods. CONCLUSIONS: Our results suggest the LAQM system has contributed to a reduction in emergency hospitalisations for respiratory conditions, and may represent an effective strategy to reduce inequalities in health. These findings highlight the importance of measuring the success of air quality policies not just in terms of air pollution but also in terms of population health.

Socioeconomic status and infectious intestinal disease in the community: a longitudinal study (IID2 study).

Background: Infectious intestinal diseases (IID) are common, affecting around 25% of people in UK each year at an estimated annual cost to the economy, individuals and the NHS of £1.5 billion. While there is evidence of higher IID hospital admissions in more disadvantaged groups, the association between socioeconomic status (SES) and risk of IID remains unclear. This study aims to investigate the relationship between SES and IID in a large community cohort. Methods: Longitudinal analysis of a prospective community cohort in the UK following 6836 participants of all ages was undertaken. Hazard ratios for IID by SES were estimated using Cox proportional hazard, adjusting for follow-up time and potential confounding factors. Results: In the fully adjusted analysis, hazard ratio of IID was significantly lower among routine/manual occupations compared with managerial/professional occupations (HR 0.74, 95% CI 0.61-0.90). Conclusion: In this large community cohort, lower SES was associated with lower IID risk. This may be partially explained by the low response rate which varied by SES. However, it may be related to differences in exposure or recognition of IID symptoms by SES. Higher hospital admissions associated with lower SES observed in some studies could relate to more severe consequences, rather than increased infection risk.

Socioeconomic status is associated with symptom severity and sickness absence in people with infectious intestinal disease in the UK.

BACKGROUND: The burden of infectious intestinal disease (IID) in the UK is substantial. Negative consequences including sickness absence are common, but little is known about the social patterning of these outcomes, or the extent to which they relate to disease severity. METHODS: We performed a cross-sectional analysis using IID cases identified from a large population-based survey, to explore the association between socioeconomic status (SES) and symptom severity and sickness absence; and to assess the role of symptom severity on the relationship between SES and absence. Regression modelling was used to investigate these associations, whilst controlling for potential confounders such as age, sex and ethnicity. RESULTS: Among 1164 cases, those of lower SES versus high had twice the odds of experiencing severe symptoms (OR 2.2, 95%CI;1.66-2.87). Lower SES was associated with higher odds of sickness absence (OR 1.8, 95%CI;1.26-2.69), however this association was attenuated after adjusting for symptom severity (OR 1.4, 95%CI;0.92-2.07). CONCLUSIONS: In a large sample of IID cases, those of low SES versus high were more likely to report severe symptoms, and sickness absence; with greater severity largely explaining the higher absence. Public health interventions are needed to address the unequal consequences of IID identified.

The mental health and wellbeing impact of a Community Wealth Building programme in England: a difference-in-differences study.

BACKGROUND: Wide differences in health exist between places in the UK, underscored by economic inequalities. Preston, an economically disadvantaged city in England, implemented a new approach to economic development, known as the Community Wealth Building programme. Public and non-profit organisations modified their procurement policies to support the development of local supply chains, improve employment conditions, and increase socially productive use of wealth and assets. We aimed to investigate the effect of this programme on population mental health and wellbeing. METHODS: Difference-in-differences techniques compared trends in mental health outcomes in Preston, relative to matched control areas before (2011-15) and after (2016-19) the introduction of the programme. Outcomes were antidepressant prescribing, prevalence of depression, and mental health related hospital attendance rates using data provided by National Health Service Digital, the Quality and Outcomes Framework, and the Office for National Statistics. Additional analysis compared local authority measures of life satisfaction, median wages, and employment with synthetic counterfactuals created using Bayesian Structural Time Series. FINDINGS: The introduction of the Community Wealth Building programme was associated with reductions in the prescribing of antidepressants (1·3 average daily quantities per person [95% CI 0·72-1·78) and prevalence of depression (2·4 per 1000 population [0·42-4·46]), relative to the control areas. The local population also experienced a 9% improvement in life satisfaction (95% credible interval 0-19·6%) and 11% increase in median wages (1·8-18·9%), relative to expected trends. Associations with employment and mental health related hospital attendance outcomes did not reach statistical significance. INTERPRETATION: During the period in which the Community Wealth Building programme was introduced, there were fewer mental health problems than would have been expected compared with other similar areas, as life satisfaction and economic measures improved. This approach potentially provides an effective model for economic regeneration potentially leading to substantial health benefits. FUNDING: National Institute for Health Research.

Evaluating the Effectiveness of a Local Primary Care Incentive Scheme: A Difference-in-Differences Study.

National financial incentive schemes for improving the quality of primary care have come under criticism in the United Kingdom, leading to calls for localized alternatives. This study investigated whether a local general practice incentive-based quality improvement scheme launched in 2011 in a city in the North West of England was associated with a reduction in all-cause emergency hospital admissions. Difference-in-differences analysis was used to compare the change in emergency admission rates in the intervention city, to the change in a matched comparison population. Emergency admissions rates fell by 19 per 1,000 people in the years following the intervention (95% confidence interval [17, 21]) in the intervention city, relative to the comparison population. This effect was greater among more disadvantaged populations, narrowing socioeconomic inequalities in emergency admissions. The findings suggest that similar approaches could be an effective component of strategies to reduce unplanned hospital admissions elsewhere.

How does vulnerability to COVID-19 vary between communities in England? Developing a Small Area Vulnerability Index (SAVI).

BACKGROUND: During the initial wave of the COVID-19 epidemic in England, several population characteristics were associated with increased risk of mortality-including, age, ethnicity, income deprivation, care home residence and housing conditions. In order to target control measures and plan for future waves of the epidemic, public health agencies need to understand how these vulnerabilities are distributed across and clustered within communities. METHODS: We performed a cross-sectional ecological analysis across 6789 small areas in England. We assessed the association between COVID-19 mortality in each area and five vulnerability measures relating to ethnicity, poverty, prevalence of long-term health conditions, living in care homes and living in overcrowded housing. Estimates from multivariable Poisson regression models were used to derive a Small Area Vulnerability Index. RESULTS: Four vulnerability measures were independently associated with age-adjusted COVID-19 mortality. Each SD increase in the proportion of the population (1) living in care homes, (2) admitted to hospital in the past 5 years for a long-term health condition, (3) from an ethnic minority background and (4) living in overcrowded housing was associated with a 28%, 19% 8% and 11% increase in age-adjusted COVID-19 mortality rate, respectively. CONCLUSION: Vulnerability to COVID-19 was noticeably higher in the North West, West Midlands and North East regions, with high levels of vulnerability clustered in some communities. Our analysis indicates the communities who will be most at risk from a second wave of the pandemic.

Neighbourhood unemployment and other socio-demographic predictors of emergency hospitalisation for infectious intestinal disease in England: A longitudinal ecological study.

BACKGROUND: Previous studies have observed that infectious intestinal disease (IID) related hospital admissions are higher in more deprived neighbourhoods. These studies have mainly focused on paediatric populations and are cross-sectional in nature. This study examines recent trends in emergency IID admission rates, and uses longitudinal methods to investigate the effects of unemployment (as a time varying measure of neighbourhood deprivation) and other socio-demographic characteristics on IID admissions for adults and children in England. METHODS: A longitudinal ecological analysis was performed using Hospital Episode Statistics on emergency hospitalisations for IID, collected over the time period 2012-17 across England. Analysis was conducted at the neighbourhood (Lower-layer Super Output Area) level for three age groups (0-14; 15-64; 65+ years). Mixed-effect Poisson regression models were used to assess the relationship between trends in neighbourhood unemployment and emergency IID admission rates, whilst controlling for measures of primary and secondary care access, underlying morbidity and the ethnic composition of each neighbourhood. RESULTS: From 2012-17, declining trends in emergency IID admission rates were observed for children and older adults overall, while rates increased for some sub-groups in the population. Each 1 percentage point increase in unemployment was associated with a 6.3, 2.4 and 4% increase in the rate of IID admissions per year for children [IRR=1.06, 95%CI 1.06-1.07], adults [IRR=1.02, 95%CI 1.02-1.03] and older adults [IRR=1.04, 95%CI 1.036-1.043], respectively. Increases in poor primary care access, the percentage of people from a Pakistani ethnic background, and the prevalence of long-term health problems, in a neighbourhood, were also associated with increases in IID admission rates. CONCLUSIONS: Increasing trends in neighbourhood deprivation, as measured by unemployment, were associated with increases in emergency IID admission rates for children and adults in England, despite controlling for measures of healthcare access, underlying morbidity and ethnicity. Research is needed to improve understanding of the mechanisms that explain these inequalities, so that effective policies can be developed to reduce the higher emergency IID admission rates experienced by more disadvantaged communities.

Impact of a community-based cardiovascular disease service intervention in a highly deprived area.

OBJECTIVE: To examine the effects on emergency hospital admissions, length of stay and emergency re-admissions of providing a consultant-led, community-based cardiovascular diagnostic, treatment and rehabilitation service, based in a highly deprived area in the North West of England. METHODS: A longitudinal matched controlled study using difference-in-differences analysis compared the change in outcomes in the intervention population, to the change in outcomes in a matched comparison population that had not received the intervention, 5 years before and after implementation. The outcomes were emergency hospitalisations, length of inpatient stay and re-admission rates for cardiovascular disease (CVD). RESULTS: Findings show that the intervention was associated with 66 fewer emergency CVD admissions per 100 000 population per year (95% CI 22.13 to 108.98) in the post-intervention period, relative to the control group. No significant measurable effects on length of stay or emergency re-admission rates were observed. CONCLUSION: This consultant-led, community-based cardiovascular diagnostic, treatment and rehabilitation service was associated with a lower rate of emergency hospital admissions in a highly disadvantaged population. Similar approaches could be an effective component of strategies to reduce unplanned hospital admissions.

Social patterning of telephone health-advice for diarrhoea and vomiting: analysis of 24 million telehealth calls in England.

OBJECTIVES: Gastrointestinal (GI) infections are common and most people do not see a physician. There is conflicting evidence of the impact of socioeconomic status (SES) on risk of GI infections. We assessed the relationship between SES and GI calls to two National Health Service (NHS) telephone advice services in England. METHODS: Over 24 million calls to NHS Direct (2010-13) and NHS 111 (2013-15) were extracted from Public Health England (PHE) syndromic surveillance systems. The relationship between SES and GI calls was assessed using generalised linear models (GLM). RESULTS: Adjusting for rurality and age-sex interactions, in NHS Direct, children in disadvantaged areas were at lower risk of GI calls; in NHS 111 there was a higher risk of GI calls in disadvantaged areas for all ages (0-4 years RR 1.27, 95% CI 1.25-1.29; 5-9 years RR 1.43, 95% CI 1.36-1.51; 10-14 years RR 1.36, 95% CI 1.26-1.41; 15-19 years RR 1.59, 95% CI 1.52-1.67; 20-59 years RR 1.50, 95% CI 1.47-1.53, 60 years and over RR 1.12, 95% CI 1.09-1.14). CONCLUSIONS: Disadvantaged areas had higher risk of GI calls in NHS 111. This may relate to differences in exposure or vulnerability to GI infections, or propensity to call about GI infections.

Relationship between socioeconomic status and gastrointestinal infections in developed countries: A systematic review and meta-analysis.

BACKGROUND: The association between socioeconomic status (SES) and health is well-documented; however limited evidence on the relationship between SES and gastrointestinal (GI) infections exists, with published studies producing conflicting results. This systematic review aimed to assess the association between SES and GI infection risk, and explore possible sources of heterogeneity in effect estimates reported in the literature. METHODS: MEDLINE, Scopus, Web of Science and grey literature were searched from 1980 to October 2015 for studies reporting an association between GI infections and SES in a representative population sample from a member-country of the Organisation for Economic Co-operation and Development. Harvest plots and meta-regression were used to investigate potential sources of heterogeneity such as age; level of SES variable; GI infection measurement; and predominant mode of transmission. The protocol was registered on PROSPERO: CRD42015027231. RESULTS: In total, 6021 studies were identified; 102 met the inclusion criteria. Age was identified as the only statistically significant potential effect modifier of the association between SES and GI infection risk. For children, GI infection risk was higher for those of lower SES versus high (RR 1.51, 95% CI;1.26-1.83), but there was no association for adults (RR 0.79, 95% CI;0.58-1.06). In univariate analysis, the increased risk comparing low and high SES groups was significantly higher for pathogens spread by person-to-person transmission, but lower for environmental pathogens, as compared to foodborne pathogens. CONCLUSIONS: Disadvantaged children, but not adults, have greater risk of GI infection compared to their more advantaged counterparts. There was high heterogeneity and many studies were of low quality. More high quality studies are needed to investigate the association between SES and GI infection risk, and future research should stratify analyses by age and pathogen type. Gaining further insight into this relationship will help inform policies to reduce inequalities in GI illness in children.

Relationship between socioeconomic status and gastrointestinal infections in developed countries: a systematic review protocol.

BACKGROUND: The association between low socioeconomic status (SES) and poor health is well documented in the existing literature. Nonetheless, evidence on the relationship between SES and gastrointestinal (GI) infections is limited, and the mechanisms underlying this relationship are not well understood with published studies pointing to conflicting results. This review aims to identify studies that investigate the relationship between SES and GI infections in developed countries, in order to assess the direction of the association and explore possible explanations for any differences in the risk, incidence or prevalence of GI infections across socioeconomic groups. METHODS: Three systematic methods will be used to identify relevant literature: electronic database, reference list and grey literature searching. The databases MEDLINE, Scopus and Web of Science Core Collection will be searched using a broad range of search terms. Screening of the results will be performed by two reviewers using pre-defined inclusion and exclusion criteria. The reference lists of included studies will be searched, and Google will be used to identify grey literature. Observational studies reporting quantitative results on the prevalence or incidence of any symptomatic GI infections by SES, in a representative population sample from a member country of the Organisation for Economic Co-operation and Development (OECD), will be included. Data will be extracted using a standardised form. Study quality will be assessed using the Liverpool University Quality Assessment Tools (LQAT). A narrative synthesis will be performed including tabulation of studies for comparison. DISCUSSION: This systematic review will consolidate the existing knowledge on the relationship between SES and GI infections. The results will help to identify gaps in the literature and will therefore provide an evidence base for future empirical studies to deepen the understanding of the relationship, including effective study design and appropriate data analysis methods. Ultimately, gaining insight into this relationship will help to inform policies to reduce any health inequalities identified. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015027231.

Alcohol Consumption and Parkinson's Disease Risk: A Review of Recent Findings.

BACKGROUND: The association between Parkinson's disease and lifestyle exposures such as smoking, coffee and alcohol consumption have been the focus of research for several decades, with varying and often conflicting results. OBJECTIVE: This paper reviews the key features of observational studies investigating the relationship between alcohol drinking and PD risk, to determine potential sources of variability between the results. METHODS: Relevant literature from 2000-2014 was systematically retrieved using three databases. Primary research articles were included if they reported a measure of association between quantity and frequency of alcohol intake and PD risk, and adjusted at least for the potential confounding factors of smoking and age. RESULTS: Sixteen articles were identified. The seven case-control studies were more likely to report a weak protective association by level of alcohol consumption compared to the studies with prospective designs. Two studies reported the relationship between heavy (harmful to health) drinking and PD. There was weak evidence that associations varied by type of alcoholic beverage. Smoking may modify the association between alcohol intake and PD risk, however, the evidence does not support the theory that a confounder (such as an addiction-avoiding personality trait) produced the inverse associations between smoking, coffee and alcohol intake and PD risk. Methodological weaknesses of the studies, including selection and recall bias, residual confounding and lack of statistical power may in part account for their differences. CONCLUSION: The weak association between alcohol drinking and PD risk was found in studies at greater risk of selection and recall bias.

Prevalence and Incidence of Hypoglycaemia in 532,542 People with Type 2 Diabetes on Oral Therapies and Insulin: A Systematic Review and Meta-Analysis of Population Based Studies.

OBJECTIVE: To collate and evaluate the current literature reporting the prevalence and incidence of hypoglycaemia in population based studies of type 2 diabetes. RESEARCH DESIGN AND METHODS: Medline, Embase and Cochrane were searched up to February 2014 to identify population based studies reporting the proportion of people with type 2 diabetes experiencing hypoglycaemia or rate of events experienced. Two reviewers independently screened studies for eligibility and extracted data for included studies. Random effects meta-analyses were carried out to calculate the prevalence and incidence of hypoglycaemia. RESULTS: 46 studies (n = 532,542) met the inclusion criteria. Prevalence of hypoglycaemia was 45% (95%CI 0.34,0.57) for mild/moderate and 6% (95%CI, 0.05,0.07) for severe. Incidence of hypoglycaemic episodes per person-year for mild/moderate and for severe was 19 (95%CI 0.00, 51.08) and 0.80 (95%CI 0.00,2.15), respectively. Hypoglycaemia was prevalent amongst those on insulin; for mild/moderate episodes the prevalence was 50% and incidence 23 events per person-year, and for severe episodes the prevalence was 21% and incidence 1 event per person-year. For treatment regimes that included a sulphonylurea, mild/moderate prevalence was 30% and incidence 2 events per person-year, and severe prevalence was 5% and incidence 0.01 events per person-year. A similar prevalence of 5% was found for treatment regimes that did not include sulphonylureas. CONCLUSIONS: Current evidence shows hypoglycaemia is considerably prevalent amongst people with type 2 diabetes, particularly for those on insulin, yet still fairly common for other treatment regimens. This highlights the subsequent need for educational interventions and individualisation of therapies to reduce the risk of hypoglycaemia.