Thyroid disease in ANCA-associated vasculitis: a clinical and epidemiological study.

OBJECTIVES: To describe clinical and laboratory characteristics and outcomes in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and thyroid disease (TD). We also aimed to calculate incidence and identify predictors of TD in two large cohorts of patients with AAV. METHODS: The study comprised 644 patients with AAV in a population-based cohort from southern Sweden (n=325) and a cohort from a specialised vasculitis centre in Cambridge, UK (n=319). Diagnosis and classification of AAV and TD were confirmed by medical record review. Person-years (PY) of follow-up were calculated from AAV diagnosis to the earliest of TD, death or the end of study. Cox-regression analysis was employed to study predictors of TD. RESULTS: At AAV diagnosis, 100 individuals (15.5%, 77 females) had TD, 59 had myeloperoxidase (MPO)-ANCA+ and 34 had proteinase-3 (PR3)-ANCA+. Patients with TD tended to have lower C reactive protein, lower haemoglobin and fewer constitutional symptoms. Survival and renal survival was greater in those patients with AAV with pre-existing TD. During 4522 PY of follow-up, a further 29 subjects developed TD, yielding an incidence rate of 641/100 000 PY. No analysed factor predicted de novo TD in AAV. The prevalence of TD among patients with AAV in southern Sweden was 18%. CONCLUSION: TD is a common comorbidity in AAV, affecting nearly one in five. While TD diagnosis is more common in females and MPO-ANCA+, these factors do not predict de novo TD after initiation of AAV treatment, necessitating monitoring of all patients with AAV with respect to this comorbidity.

Geographic inequalities in need and provision of social prescribing link workers.

BACKGROUND: Long-term health conditions are major challenges for care systems. Social prescribing link workers have been introduced via Primary Care Networks (PCNs) across England since 2019 to address the wider determinants of health by connecting individuals to activities, groups, or services within their local community. AIM: To assess whether the rollout of social prescribing link workers was in areas with the highest need. DESIGN AND SETTING: A retrospective study of social prescribing link workers in England from 2019 to 2023. METHOD: We combined workforce, population, survey, and area-level data at the PCN-level from April 2020 to October 2023. We measured population need prior to the rollout of link workers using reported lack of support from local services in the 2019 GP Patient Survey. To assess if rollout reflected need, we used linear regression to relate provision of link workers (measured by full-time equivalent (FTE) per 10,000 patients) in each quarter to population need for support. RESULTS: Populations in urban, more deprived areas and with higher proportions of minority ethnicities had the highest reported lack of support. Geographically these were in the North West and London. Initially, there was no association between need and provision; then from July 2022, this became negative and significant. By October 2023, a 10-percentage point higher need for support was associated with a 0.035 (95%CI(-0.634 to -0.066)) lower FTE per 10,000 patients. CONCLUSION: Rollout of link workers has not been sufficiently targeted at areas with the highest need. Future deployments should be targeted at those areas.

Age-gender differences in the relationships between physical and mental health.

Previous studies have identified that smoking, exercise and breadth of social interaction mediate the strong associations between physical and mental health. However, these studies have been restricted to older populations, have not explored differences by gender, and have not considered online social interaction. We explore how the effects of four mediators (exercise, smoking, in-person and online social interaction) of the two-way relationships between past and future physical and mental health vary across eight age and gender groups. We use data from a representative sample of the UK population consisting of 175,779 observations on 41,995 adults from Understanding Society (UKHLS) between 2009 and 2019. Within a mediation framework, we estimate the percentage of the total effects that can be explained by the proposed mediating factors. We show that exercise, smoking, in-person and online social interaction are significant mediators of the effect of mental health on future physical health. In-person social interaction is the largest of these, accounting for 2.3% of the total effect. Smoking, in-person and online interaction are significant mediators of the effect of physical health on future mental health. Again, in-person interaction is the largest of these, accounting for 3.0% of the total effect. The percentages of the total effects mediated by each factor differ substantially by age and gender. Seeking to avoid the harmful effects of poor physical health on future mental health should focus on increasing physical activity in older men, and on increasing in-person social interaction in both men and women. Seeking to avoid the harmful effects of poor mental health on future physical health should focus on increasing physical activity and in-person social interaction in older men and women, and on reducing smoking in younger men and women.

Estimating the heterogeneous health and well-being returns to social participation.

Social participation is defined as an individual's involvement in activities that provide connections with others in society. Past research has demonstrated links between social participation, improved health and well-being, and reduced social isolation, but has been restricted to older people and has not investigated heterogeneity. Using cross-sectional data from the UK's Community Life Survey (2013-2019; N = 50,006), we estimated returns to social participation in the adult population. We included availability of community assets as instruments in a marginal treatment effects model, which allows treatment effects to be heterogeneous and examines whether the effects vary by propensity to participate. Social participation was linked to reduced loneliness and improved health (-0.96 and 0.40 points respectively on 1-5 scales) and increased life satisfaction and happiness (2.17 and 2.03 points respectively on 0-10 scales). These effects were larger for those on low income, with lower education attainment, and who live alone or with no children. We also found negative selection, indicating those less likely to participate have higher health and well-being returns. Future interventions could focus on increasing community asset infrastructure and encouraging social participation for those with lower socio-economic status.

Family doctor responses to changes in target stringency under financial incentives.

Healthcare providers may game when faced with targets. We examine how family doctors responded to a temporary but substantial increase in the stringency of targets determining payments for controlling blood pressure amongst younger hypertensive patients. We apply difference-in-differences and bunching techniques to data from electronic health records of 107,148 individuals. Doctors did not alter the volume or composition of lists of their hypertension patients. They did increase treatment intensity, including a 1.2 percentage point increase in prescribing antihypertensive medicines. They also undertook more blood pressure measurements. Multiple testing increased by 1.9 percentage points overall and by 8.8 percentage points when first readings failed more stringent target. Exemption of patients from reported performance increased by 0.8 percentage points. Moreover, the proportion of patients recorded as exactly achieving the more stringent target increased by 3.1 percentage points to 16.6%. Family doctors responded as intended and gamed when set more stringent pay-for-performance targets.

Effects of participating in community assets on quality of life and costs of care: longitudinal cohort study of older people in England.

OBJECTIVES: Improving outcomes for older people with long-term conditions and multimorbidity is a priority. Current policy commits to substantial expansion of social prescribing to community assets, such as charity, voluntary or community groups. We use longitudinal data to add to the limited evidence on whether this is associated with better quality of life or lower costs of care. DESIGN: Prospective 18-month cohort survey of self-reported participation in community assets and quality of life linked to administrative care records. Effects of starting and stopping participation estimated using double-robust estimation. SETTING: Participation in community asset facilities. Costs of primary and secondary care. PARTICIPANTS: 4377 older people with long-term conditions. INTERVENTION: Participation in community assets. PRIMARY AND SECONDARY OUTCOME MEASURES: Quality-adjusted life years (QALYs), healthcare costs and social value estimated using net benefits. RESULTS: Starting to participate in community assets was associated with a 0.017 (95% CI 0.002 to 0.032) gain in QALYs after 6 months, 0.030 (95% CI 0.005 to 0.054) after 12 months and 0.056 (95% CI 0.017 to 0.094) after 18 months. Cumulative effects on care costs were negative in each time period: £-96 (95% CI £-512 to £321) at 6 months; £-283 (95% CI £-926 to £359) at 12 months; and £-453 (95% CI £-1366 to £461) at 18 months. The net benefit of starting to participate was £1956 (95% CI £209 to £3703) per participant at 18 months. Stopping participation was associated with larger negative impacts of -0.102 (95% CI -0.173 to -0.031) QALYs and £1335.33 (95% CI £112.85 to £2557.81) higher costs after 18 months. CONCLUSIONS: Participation in community assets by older people with long-term conditions is associated with improved quality of life and reduced costs of care. Sustaining that participation is important because there are considerable health changes associated with stopping. The results support the inclusion of community assets as part of an integrated care model for older patients.

Life expectancy in hereditary cancer predisposing diseases: an observational study.

BACKGROUND: Neurofibromatosis 1 (NF1), neurofibromatosis 2 (NF2), familial adenomatous polyposis (FAP), von Hippel-Lindau syndrome (VHL), and Gorlin syndrome (GS) are single gene diseases that predispose to early onset tumours. Few studies have assessed the effect of these diseases on life expectancy. This study's aim was to assess this effect, and to test the hypothesis that genetic registers increase survival. METHOD: NF1, NF2, VHL, FAP, and GS patients were identified through the North West Regional Genetic Register Service and the North West Cancer Intelligence Service. Information on benign and malignant tumours, and deaths were obtained. Kaplan-Meier curves were used to show actuarial survival rates for each disease, compared to the local population, and in patients diagnosed pre/post the regional genetic register. Log rank (Mantel-Cox) tests were used to compare survival between groups. RESULTS: Life expectancies were significantly reduced for all diseases investigated compared with the local population (80.0 years) (p=0.05). GS had the longest life expectancy at 73.4 years, followed by NF1 at 71.5 years, NF2 at 69.0 years, FAP at 63.6 years, and VHL at 52.5 years. Patients diagnosed after establishment of the genetic register had an increase in survival compared to those diagnosed pre-1990: NF2 (14.7 years), FAP (13.9 years), VHL (16.3 years), and GS (11.2 years). CONCLUSION: Life expectancy for all five diseases was less than normal, although in recent years this reached the level of the local population in GS. Although there have been improvements in all conditions which may in part be attributable to better targeted care through the genetic register service, more needs to be done to address the very poor life expectancy in VHL.

Mortality in neurofibromatosis 1: in North West England: an assessment of actuarial survival in a region of the UK since 1989.

Neurofibromatosis 1 (NF1) is a comparatively common autosomal dominant disorder. However, relatively few studies have assessed lifetime risk; and information about the effect of NF1 on mortality remains uncertain. NF1 patients were identified using The North West regional family Genetic Register, which covers the 4.1 million people living in North West England, including the regions of Greater Manchester, Cheshire and Cumbria. Data relating to tumours and malignancies were obtained from The North West Cancer Intelligence Service. Death data for the general North West population were obtained from the Office of National Statistics. We identified 1186 individuals with NF1, of whom 1023 lived within the strict regional boundaries (constituting a region of North West England bound by The Pennines to the east and Irish Sea to the west, but excluding the conurbation of Liverpool (Merseyside) and the Wirral peninsula) and 131 had died. MPNST and glioma were found to be the two most common causes of reduced life expectancy among NF1 patients. In Kaplan-Meier analyses the median survival for NF1 patients was shown to be 71.5 years, with women living ∼7.4 years longer than men. On average both men and women lived ∼8 years less than their counterparts in the general population. Reduction in life expectancy for NF1 patients was found to be much lower (8 years) than the previously estimated 15-year decrease. Limitations relating to the underreporting of NF1 on death certificates were once again highlighted and should be considered in future investigations.