Ethnic and social inequalities in women's experience of maternity care in England: results of a national survey.

OBJECTIVE: To examine ethnic and social inequalities in women's experience of maternity care in England. DESIGN: A 2007 national survey of women (16 years or over) about their experience of maternity care. Multiple logistic regression analysis, controlling for several maternal characteristics, was used to examine inequalities by ethnicity, partner status and education. SETTING: Sample of records of 149 NHS acute trusts and two primary care trusts (PCTs) providing maternity services in England. RESULTS: A total of 26,325 women responded to the survey (response rate 59%). Ethnic minority women were more likely than White British women to access services late, not have a scan by 20 weeks, and experience complications during pregnancy and birth. They were more likely to initiate breastfeeding and say they were treated with respect and dignity. Single women responded more negatively to almost all questions than women with a husband/partner. They were less likely to access care within 12 weeks of pregnancy (OR 0.45, 95% CI 0.39-0.52), have a scan at 20 weeks (OR 0.49, 95% CI 0.39-0.63), attend NHS antenatal classes (OR 0.56, 95% CI 0.49-0.65), have a postnatal check-up (OR 0.67, 95% CI 0.60-0.75), and initiate breastfeeding (OR 0.57, 95% CI 0.51-0.62), and were more likely to experience complications. Women completing education at 19+ years were more likely to access services early (OR 1.21, 95% CI 1.04-1.40), attend antenatal classes (OR 1.48, 95% CI 1.31-1.67), have a postnatal check-up (OR 1.19, 95% CI 1.07-1.32) and initiate breastfeeding (OR 3.88, 95% CI 3.56-4.22) than those completing education at 16 years or younger, and were less likely to experience complications. CONCLUSIONS: Ethnic minority women, single mothers, and those with an earlier age at completing education access maternity services late, have poorer outcomes, and report poorer experiences across some--though not all--dimensions of maternity care. Ethnic differences were absent or inconsistent between groups for some aspects of care. We recommend these findings are used by commissioners, trusts and healthcare professionals to inform improvements in maternity services for high-risk groups and reduce inequalities.

Do associations between staff and inpatient feedback have the potential for improving patient experience? An analysis of surveys in NHS acute trusts in England.

OBJECTIVE: To examine whether staff feedback on quality, safety and workforce issues is reflected in patient-reported experience. SETTING: 166 NHS acute trusts in England. PARTICIPANTS: Respondents to the 2006 surveys of adult inpatients and staff in 166 NHS acute trusts in England. METHODS: Multiple linear regression was used to model the relationship between responses by "frontline" staff and inpatients at trust level. Staff survey items were the explanatory variables and inpatient responses the dependent variables. Adjustments were made for location (London and non-London) and trust type. RESULTS: 69 500 staff and 81 000 patients responded to the surveys. There were several significant associations between staff and patients' responses, including that staff availability of hand-washing materials was positively associated with patient feedback on cleanliness and hand washing by doctors/nurses (p<0.00). It was a significant predictor of patient experience also in several other models. Other significant predictors of patient experience were managerial support, witnessing and reporting of errors (positively associated with patient experience), working extra hours and stress (negatively associated). London trusts performed worse on patient experience than trusts outside London and specialist trusts performed better than other acute trusts. CONCLUSIONS: Staff feedback was associated with patient-reported experience. Positive staff feedback on availability of hand-washing materials was broadly reflective of positive patient experience. Negative staff experience was reflected in poorer patient experience and vice versa. Although we cannot demonstrate causality, the consistent direction of the findings is indicative of it. Management boards of trusts and clinicians and other staff should monitor and act on the results of their staff surveys. This has the potential for improving quality, safety and patient experience.

Risk of myocardial infarction in men and women with type 2 diabetes in the UK: a cohort study using the General Practice Research Database.

AIMS/HYPOTHESIS: Our primary aim was to establish reliable and generalisable estimates of the risk of myocardial infarction (MI) for men and women with type 2 diabetes in the UK compared with people without diabetes. Our secondary aim was to investigate how the MI risk associated with diabetes differs between men and women. METHODS: A cohort study using the General Practice Research Database (1992-1999) was carried out, selecting 40,727 patients with type 2 diabetes and 194,913 age and sex-matched patients without diabetes. Rates of MI in men and women with and without diabetes were derived, as were hazard ratios for MI adjusted for known risk factors. RESULTS: The rate of MI in men with type 2 diabetes was 19.74 (95% CI 18.83-20.69) per 1,000 person-years compared with 16.18 (95% CI 15.33-17.08) per 1,000 person-years in women with type 2 diabetes. The overall adjusted relative risk of MI in diabetes versus no diabetes was 2.13 (95% CI 2.01-2.26) in men and 2.95 (95% CI 2.75-3.17) in women and decreased with age in both sexes. Women with type 2 diabetes aged 35 to 54 years were at almost five times the risk of MI compared with women of the same age without diabetes (HR 4.86 [95% CI 2.78-8.51]). CONCLUSIONS/INTERPRETATION: This study has demonstrated that women with type 2 diabetes are at a much greater relative risk of MI than men even when adjusted for risk factors.

Risk of stroke in people with type 2 diabetes in the UK: a study using the General Practice Research Database.

AIMS/HYPOTHESIS: Risk estimates for stroke in patients with diabetes vary. We sought to obtain reliable risk estimates for stroke and the association with diabetes, comorbidity and lifestyle in a large cohort of type 2 diabetic patients in the UK. MATERIALS AND METHODS: Using the General Practice Research Database, we identified all patients who had type 2 diabetes and were aged 35 to 89 years on 1 January 1992. We also identified five comparison subjects without diabetes and of the same age and sex. Hazard ratios (HRs) for stroke between January 1992 and October 1999 were calculated, and the association with age, sex, body mass index, smoking, hypertension, atrial fibrillation and duration of diabetes was investigated. RESULTS: The absolute rate of stroke was 11.91 per 1,000 person-years (95% CI 11.41-12.43) in people with diabetes (n = 41,799) and 5.55 per 1,000 person-years (95% CI 5.40-5.70) in the comparison group (n = 202,733). The age-adjusted HR for stroke in type 2 diabetic compared with non-diabetic subjects was 2.19 (95% CI 2.09-2.32) overall, 2.08 (95% CI 1.94-2.24) in men and 2.32 (95% CI 2.16-2.49) in women. The increase in risk attributable to diabetes was highest among young women (HR 8.18; 95% CI 4.31-15.51) and decreased with age. No investigated comorbidity or lifestyle characteristic emerged as a major contributor to risk of stroke. CONCLUSIONS/INTERPRETATION: This study provides risk estimates for stroke for an unselected population from UK general practice. Patients with type 2 diabetes were at an increased risk of stroke, which decreased with age and was higher in women. Additional risk factors for stroke in type 2 diabetic patients included duration of diabetes, smoking, obesity, atrial fibrillation and hypertension.

Mortality in people with type 2 diabetes in the UK.

AIMS: Under-reporting of diabetes on death certificates contributes to the unreliable estimates of mortality as a result of diabetes. The influence of obesity on mortality in Type 2 diabetes is not well documented. We aimed to study mortality from diabetes and the influence of obesity on mortality in Type 2 diabetes in a large cohort selected from the General Practice Research Database (GPRD). Methods A cohort of 44 230 patients aged 35-89 years in 1992 with Type 2 diabetes was identified. A comparison group matched by year of birth and sex with no record of diabetes at any time was identified (219 797). Hazards ratios (HRs) for all-cause mortality during the period January 1992 to October 1999 were calculated using the Cox Proportional Hazards Model. The effects of body mass index (BMI), smoking and duration of diabetes on all-cause mortality amongst people with diabetes was assessed (n = 28 725). Results The HR for all-cause mortality in Type 2 diabetes compared with no diabetes was 1.93 (95% CI 1.89-1.97), in men 1.77 (1.72-1.83) and in women 2.13 (2.06-2.20). The HR decreased with increasing age. In the multivariate analysis in diabetes only, the HR for all-cause mortality amongst smokers was 1.50 (1.41-1.61). Using BMI 20-24 kg/m(2) as the reference range, for those with a BMI 35-54 kg/m(2) the HR was 1.43 (1.28-1.59) and for those with a BMI 15-19 kg/m(2) the HR was 1.38 (1.18-1.61). CONCLUSIONS: Patients with Type 2 diabetes have almost double the mortality rate compared with those without. The relative risk decreases with age. In people with Type 2 diabetes, obesity and smoking both contribute to the risk of all-cause mortality, supporting doctrines to stop smoking and lose weight.

All-cause mortality rates in patients with type 1 diabetes mellitus compared with a non-diabetic population from the UK general practice research database, 1992-1999.

AIMS/HYPOTHESIS: We compiled up to date estimates of the absolute and relative risk of all-cause mortality in patients with type 1 diabetes in the UK. MATERIALS AND METHODS: We selected patients with type 1 diabetes (n=7,713), and for each of these diabetic subjects five age- and sex-matched control subjects without diabetes (n=38,518) from the General Practice Research Database (GPRD). Baseline was 1 January 1992; subjects were followed until 1999. The GPRD is a large primary-care database containing morbidity and mortality data of a large sample representative of the UK population. Deaths occurring in the follow-up period were identified. RESULTS: The study comprised 208,178 person-years of follow-up. The prevalence of type 1 diabetes was 2.15/1,000 subjects in 1992 (mean age 33 years, SD 15). Annual mortality rates were 8.0 per 1,000 person-years (95% CI 7.2-8.9) in type 1 diabetic subjects compared with 2.4 per 1,000 person-years (95% CI 2.2-2.6) in those without diabetes (hazard ratio [HR]=3.7, 95% CI 3.2-4.3). The increased mortality rates in patients with type 1 diabetes were apparent across all age-bands. The HR was higher in women (HR=4.5, 95% CI 3.5-5.6 compared with non-diabetic women) than men (HR=3.3, 95% CI 2.7-4.0), such that the sex difference (p<0.0001) in mortality in the non-diabetic population was abolished (p=0.3) in the type 1 diabetic patients. The predominant cause of death in patients with type 1 diabetes was cardiovascular disease. CONCLUSIONS/INTERPRETATION: Despite advances in care, UK mortality rates in the past decade continue to be much greater in patients with type 1 diabetes than in those without diabetes.

European Union diabetes indicators: fact or fiction?

Diabetes mellitus is one of the major causes of morbidity and mortality in EU/EFTA countries. Monitoring risk factors for diabetes and its complications will offer the possibility to evaluate the development in time as well as the influence of possible interventions. In this investigation a list with core and secondary indicators is proposed. Availability of these indicators and their data sources is discussed. An important variability of data sources is used in EU/EFTA countries, interfering with the comparability of the outcome. Further harmonisation as well as continuous evaluation of data sources will be necessary to provide reliable tools to monitor diabetes mellitus and its outcome on a routine basis.

Trends in world population: how will the millenium compare with the past?

This paper reviews historical and projected trends in world population numbers, and the underlying determinants of those trends. Whereas the world's population has shown little change over most of its one million-year history, the past 200 years have witnessed dramatic changes in fertility, mortality and population growth rates. Recent decades, in particular, have seen unprecedented demographic events, with more people added to the world's population in the past 50 years than in the preceding million. The demographic impact of HIV/AIDS, selective as it is to young adults and infants, is also unprecedented, with life expectancy among some populations reduced by almost 20 years. As we approach the end of the 20th century, further demographic changes are underway with, for the first time in recent human history, a slowing down of world population growth. Nonetheless, world population is projected to grow from 6 billion currently to about 9.4 billion by 2050 (medium fertility assumption), with ageing emerging as the most pressing demographic issue facing humanity in the millenium.

Cirrhosis and primary liver cancer amongst first generation migrants in England and Wales.

OBJECTIVE: To examine mortality from cirrhosis of the liver and primary liver cancer among first generation migrants to England and Wales. DESIGN: Comparison of standardised mortality ratios (SMRs) for cirrhosis of the liver and primary liver cancer in men and women aged 20-69, by country of birth for the five year period 1988-1992. SETTING: England and Wales. RESULTS: There was a statistically significant two-fold excess of mortality from cirrhosis of the liver among male migrants from East Africa (SMR 286), India (SMR 261) and Bangladesh (SMR 254) as well as men born in Scotland (SMR 253) and Ireland (SMR252). Among women, only those born in Scotland (SMR 254) and Ireland (SMR 237) showed significant excess mortality. For liver cancer, significant excess mortality occurred among men born in the Caribbean (SMR 312), Bangladesh (910) and the African Commonwealth other than East Africa (1014), with Scottish and Irish born men showing more moderate excesses (136 and 170, respectively). SMRs were elevated also in all groups of foreign-born women but, probably owing to the small numbers of deaths, none of the findings reached statistical significance. CONCLUSIONS: Of public health concern is the excess mortality from cirrhosis in first generation immigrants to England and Wales from Scotland and Ireland (men and women) and in male migrants from India, Bangladesh and East Africa. Of equal concern is increased mortality from liver cancer in all foreign-born groups of both sexes, particularly among Bangladeshis, and African-Caribbeans. As well as promoting sensible drinking among immigrant men, specific preventive measures for those of Bangladeshi, African-Caribbean origin may include selective screening for hepatitis B and C and other tumour markers. Screening for liver cancer using imaging techniques needs further investigation. The benefit/cost ratio should be assessed by the Screening Committees of the UK Departments of Health. At local level, variation in incidence and prevalence of hepatic disease and feasible prevention programmes should be assessed within developing health improvement programmes.

Abortion rates in England in 1995: comparative study of data from district health authorities.

PIP: Lifetime fertility, abortion rates, and the proportion of pregnancies resulting in induced abortion were investigated in 105 district health authorities in England. In 1995, a total of 147,851 abortions occurred among women living in England, compared with 613,257 live births; a ratio of 1:4. This was equivalent to a total period fertility rate of 1.72 births and a total period abortion rate of 0.44 abortions over a woman's lifetime. Total period fertility rates showed a 1.8-fold variation (1.26-2.32) and total period abortion rates demonstrated a 4.2-fold variation (0.26-1.09) between district health authorities. Extrapolation of the 1995 data suggest that, in England, a woman will have an average of 2.16 pregnancies during her lifetime, of which 0.44 (20.4%) will be aborted. About 20% of abortions occur in women under 20 years of age.^ieng

Patterns of mortality among Bangladeshis in England and Wales.

OBJECTIVES: To investigate the patterns of mortality among Bangladeshis living in England and Wales. METHODS: An analysis of national mortality data, classified by country of birth, for the latest period (1988-1992), using the method of indirect standardization for deriving standardized mortality ratios (SMRs) with the age- and sex-specific rates for England and Wales as the standard (= 100). The SMRs were derived for Bangladeshi-born men and women aged 20-69 years for major disease entities. RESULTS: The mortality among Bangladeshi men was significantly higher (SMR 118 and 95% CI 111-126) than the levels prevalent in England and Wales. In contrast, the mortality among Bangladeshi women was significantly lower (SMR 71 and 95% CI 61-82). The cancer mortality overall was lower than expected in both sexes, with the exception of cancer of the liver and gall bladder. The mortality from breast cancer (SMR 16 and 95% CI 6-34) and cervical cancer (SMR 51 and 95% CI 14-131) was lower than expected. Bangladeshi men experienced high mortality from diabetes (SMR 685 and 95% CI 529-874), coronary heart disease (SMR 148 and 95% CI 134-163) and cerebrovascular disease (SMR 267 and 95% CI 222-319); they also experienced excess deaths from cirrhosis of the liver (SMR 254 and 95% CI 175-357). CONCLUSIONS: The findings establish significant variations in the recent health experiences of Bangladeshi men living in England and Wales, posing a major challenge for purchasers of care. If the Health of the Nation strategy is to ensure that equity in health and health care is to apply to all those living in this country, the Bangladeshi population needs special targeting.

Diabetes and hypertension in Britain's ethnic minorities: implications for the future of renal services.

Diabetes and hypertension are much more prevalent among Britain's 2.5 million Asian and African-Caribbean population than among the white population and are major contributors to end stage renal failure. Asians and African-Caribbeans have threefold to fourfold higher acceptance rates on to renal replacement therapy than white people, and in some districts they comprise up to half of all patients receiving such treatment. Their greater need for renal replacement treatment is accompanied by difficulties of tissue matching in cross racial transplants and a shortage of donor organs. The aging of ethnic minority populations will increase local need for renal services significantly. Measures to control diabetes, hypertension, and secondary complications in Asian and African-Caribbean communities will contribute both to safeguarding health and to economies in spending on renal services. Education about diabetes and hypertension, modification of behavioural risk factors, early diagnosis, effective glycaemic and blood pressure control, and early referral for signs of renal impairment are essential preventive measures. Primary and community health care professionals have a critical role to play here.

Life expectancy in England: variations and trends by gender, health authority, and level of deprivation.

STUDY OBJECTIVES: To investigate variations and trends in life expectancy in English district health authorities in relation to gender and Jarman deprivation level. DESIGN: Mortality data for English health authorities from 1984-94, compiled by the Office for National Statistics, were assessed conventionally and using life table techniques. SETTING: District health authorities in England. MAIN OUTCOME MEASURES: Life expectancies in the 105 DHAs in relation to rank, to gender, and to deprivation category based on the census based Jarman score. CONCLUSIONS: Differences in life expectancy had widened over the decade and prosperous areas with greatest longevity had seen the largest gains. In most deprived areas improvements in life expectancy were negligible. The greatest gender differences in life expectancy were also seen in deprived areas.

The need and demand for renal replacement therapy in ethnic minorities in England.

STUDY OBJECTIVE: The study aimed to determine the relative risk of being accepted for renal replacement treatment of black and Asian populations compared with whites in relation to age, sex, and underlying cause. The implications for population need for renal replacement therapy in these populations and for the development of renal services were also considered. DESIGN/SETTING: This was a cross sectional retrospective survey of all patients accepted for renal replacement treatment in renal units in England in 1991 and 1992. PATIENTS: These comprised all 5901 patients resident in England with end-stage renal failure who had been accepted for renal replacement therapy in renal units in England and whose ethnic category was available from the units. Patients were categorised as white, Asian, black, or other. Population denominators for the ethnic populations were taken from the 1991 census. The census categories Indian, Pakistani, and Bangladeshi were aggregated to form the denominator for Asian patients, and black Caribbeans, black Africans, and black others were aggregated to form the denominator for black patients. MAIN RESULT: Altogether 7.7% of patients accepted were Asian and 4.7% were black; crude relative acceptance rates compared with whites were 3.5 and 3.2 respectively. Age sex specific relative acceptance ratios increased with age in both ethnic populations and were greater in females. Age standardised acceptance ratios were increased 4.2 and 3.7 times in Asian and black people respectively. The most common underlaying cause in both these populations was diabetes; relative rates of acceptance for diabetic end-stage renal failure were 5.8 and 6.5 respectively. The European Dialysis and Transplant Association coding system was inaccurate for disaggregating non-insulin and insulin dependent forms. "Unknown causes" were an important category in Asians with a relative acceptance of rate 5.7. The relative rates were reduced only slightly when the comparison was confined to the district health authorities with large ethnic minority populations, suggesting that geographical access was not a major factor in the high rates for ethnic minorities. CONCLUSION: Acceptance rates for renal replacement treatment are increased significantly in Asian and black populations. Although data inaccuracies and access factors may contribute to these findings, the main reason is probably the higher incidence of end-stage renal failure. This in turn is due to the greater prevalence of underlying diseases such as non-insulin dependent diabetes but possibly also increased susceptibility of developing nethropathy. The main implication is that these populations age demand for renal replacement treatment will increase. This will have an impact nationally but will be particularly apparent in areas with large ethnic minority populations. Future planning must take these factors into account and should include strategies for preventing chronic renal failure, especially that due to non-insulin dependent diabetes and hypertension. The data could not determine the extent to which population need was being met; further studies are required to estimate the incidence of end-stage renal failure in ethnic minority populations.

Suicide patterns and trends in people of Indian subcontinent and Caribbean origin in England and Wales.

OBJECTIVES: To examine suicide rates and trends in people of Indian subcontinent, east African and Caribbean origin using the latest mortality data available for England and Wales. To compare suicide rates in these groups with the baseline and target rates for suicide in the Health of the Nation strategy. METHODS: Suicide data for England and Wales for 1988-1992, classified by the country of birth of the deceased, and population denominators from the 1991 Census were used for the analysis. Standardised mortality ratios (SMRs) for ages 15-64 and age-specific ratios were computed, using the age-sex specific rates for England and Wales as the standard. Trends over the preceding decade and suicide by burning were also analysed. Directly age-standardised suicide rates were derived to facilitate comparison with Health of the Nation baseline and target rates. RESULTS: Suicide ratios were significantly low (SMRs 32, 52 and 55 respectively) in Bangladeshi, Sri Lankan and Pakistani born men at all ages, but raised in young Indian and east African men. Ratios were significantly high in Indian and east African women (143 and 154), with a 2-3 fold excess at ages 15-34 years. Ratios were low in Pakistani and Bangladeshi women overall, but elevated at 15-24 years. For the Caribbean-born, ratios were low overall but raised at ages 25-34. 20% of Asian female suicides were by burning. Indians are a high risk group in terms of the Health of the Nation suicide targets. Suicide trends in the minority ethnic groups reflect national trends. CONCLUSIONS: This study confirms previous findings of high suicide rates in young Asian women. A new finding is the raised suicide rate in young Caribbeans. High suicide risks among young people from some ethnic minority communities are significant in the context of both the Health of the Nation strategy and recent governmental concern about the need to tackle health variations in the UK. Such deaths are indicative of larger numbers of young ethnic minority adults at risk of mental distress and self harm.