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.

Population need for renal replacement therapy in Thames regions: ethnic dimension.

OBJECTIVES: To determine the use of renal replacement therapy by ethnic origin and to ascertain the variation in provision of such therapy and to relate this to the distribution of ethnic minority populations. DESIGN: Analysis of retrospective and cross sectional data from 19 renal units. SETTING: All four Thames regional health authorities. SUBJECTS: Patients resident in the Thames regions who were accepted as new patients for renal replacement therapy during 1991 and 1992 and the patients who were already undergoing such treatment between December 1992 and April 1993. MAIN OUTCOME MEASURES: Rates of acceptance for and prevalence of renal replacement therapy among white, black, and Asian people. RESULTS: The average annual acceptance rates per million in 1991-2 were 61 for white people, 175 for black people, and 178 for Asians, and the prevalences per million were 351, 918, and 957 respectively. The relative risks increased with age. A threefold increase in the acceptance rate occurred in people aged under 55 in both the black and Asian populations, suggesting that the higher rates are probably not due to factors related to access alone. Treatment rates varied considerably among districts, reflecting both the distribution of ethnic minority populations and access to services. CONCLUSION: Black and Asian people receive and have a greater need for renal replacement therapy, and the need will increase as these populations age. These findings have important implications for the provision of renal services in districts with a high proportion of ethnic minorities and for the management of diabetes mellitus and hypertension, two important causes of end stage renal failure in these populations.

Suicide and self-burning among Indians and West Indians in England and Wales.

Suicide levels in England and Wales during 1979-83 were low among males from the Indian subcontinent (SMR 73) and significantly high in young Indian women (age-specific ratios 273 and 160 at ages 15-24 and 25-34 respectively). Suicide levels were low in Caribbeans (SMRs 81 and 62 in men and women respectively) and high in East Africans (SMRs 128 and 148 in men and women respectively). The excess in East Africans (most of whom are of Indian origin) was largely confined to younger ages. Immigrant groups had significantly higher rates of suicide by burning, with a ninefold excess among women of Indian origin. The pressures leading to higher suicide levels among young women of Indian origin highlight the need for making appropriate forms of support and counselling available to this community.

Hospital care among ethnic minorities in Britain.

This study examined ethnic differences in the levels of inpatient admission and outpatient attendance in Great Britain using the latest national data available from the General Household Surveys of 1983-87. Inpatient admissions in immigrants (Indian, Pakistani and West Indian) did not differ significantly from whites, except for a marked excess in Pakistani women of childbearing ages. The pattern was quite different for outpatient attendance, with immigrant children and young adults having lower attendance rates than whites, and middle-aged immigrant adults showing higher rates. Levels of hospital-based care among immigrant groups may be lower than expected. As monitoring of the health status of ethnic groups, and their use of services, receives increasing recognition, it is important that information on ethnic origin is included in routine health information systems.

Mortality from congenital malformations in England and Wales: variations by mother's country of birth.

Stillbirth and infant mortality from congenital malformations in England and Wales during 1981-5 was investigated according to the mother's country of birth. Significant differences remained after standardising for maternal age and social class. The highest overall mortality was in infants of mothers born in Pakistan (standardised mortality ratio 237), followed by infants of mothers born in India (standardised mortality ratio 134), East Africa (standardised mortality ratio 126), and Bangladesh (standardised mortality ratio 118). Caribbean and West African mothers showed an overall deficit. Mortality was inversely related to social class in all groups except the Afro-Caribbean. Infants of mothers born in Pakistan had the highest mortality in every social class except I, and for most anomalies investigated. Their ratios were particularly high for limb and musculoskeletal anomalies (standardised mortality ratio 362), genitourinary anomalies (standardised mortality ratio 268), and central nervous system anomalies (standardised mortality ratio 239). Our findings highlight the need for further research to identify the causes underlying these differences.

Ethnic differences in general practitioner consultations.

OBJECTIVE: To examine the levels of general practitioner consultations among the different ethnic groups resident in Britain. DESIGN: The study was based on the British general household surveys of 1983-5 and included 63,966 people aged 0-64. Odds ratios were derived for consultation by ethnic group by using logistic regression analysis adjusting for age and socioeconomic group. SETTING: The results relate to people living in private households in England, Scotland, and Wales. RESULTS: After adjustment for age and socioeconomic class, consultation among adults aged 16-64 was highest among people of Pakistani origin with odds ratios of 2.82 (95% confidence interval 1.86 to 4.28) for men and 1.85 (1.22 to 2.81) for women. Significantly higher consultations were also seen for men of West Indian and Indian origin (odds ratios 1.65 and 1.53 respectively). Ethnic differences were greatest at ages 45-64, when consultation rates in people of Pakistani, Indian, and West Indian origin were much higher in both sexes compared with white people. CONCLUSIONS: The ethnic composition of inner cities is likely to influence the workload and case mix of general practitioners working in these areas.

Sudden infant death syndrome and postneonatal mortality in immigrants in England and Wales.

To examine ethnic differences in postneonatal mortality and the incidence of sudden infant death in England and Wales during 1982-5 records were analysed, the mother's country of birth being used to determine ethnic group. Postneonatal mortality was highest in infants of mothers born in Pakistan (6.4/1000 live births) followed by infants of mothers born in the Caribbean (4.5) and the United Kingdom and Republic of Ireland (4.1). Crude rates were lower in infants of mothers born in India (3.9/1000), east and west Africa (3.0), and Bangladesh (2.8) than in infants of mothers born in the United Kingdom despite less favourable birth weights. Mortality ratios standardised separately for maternal age, parity, and social class were significantly higher in infants of mothers born in Pakistan and lower in those of mothers born in Bangladesh. The ratio for infants of Caribbean mothers was significantly higher when adjusted for maternal age. Ratios for infants of Indian and east African mothers did not show significant differences after standardisation. An important finding was a low incidence of sudden infant death in infants of Asian origin. This was paralleled by lower mortality from respiratory causes. During 1975-85 postneonatal mortality in all immigrant groups except Pakistanis fell to a similar or lower rate than that in the United Kingdom group; Pakistanis showed a persistent excess. During 1984-5 several immigrant groups (from the Republic of Ireland, India, west Africa, and the Caribbean) recorded an increase in postneonatal mortality. Surveillance of postneonatal mortality among ethnic communities should be continued, and research is needed to identify the causes underlying the differences.

Sudden infant death syndrome and postneonatal mortality in immigrants in England and Wales

To examine ethnic differences in postnatal mortality and the incidence of sudden infant death in England and Wales during 1982-5 records were analysed, the mother's country of birth being used to determine ethnic group. Postnatal mortality was highest in infants of mothers born in Pakistan (6.4/1000 live births) followed by infants of mothers born in the Caribbean (4.5) and the United Kingdom and Republic of Ireland (4.1). Crude rates were lower in infants of mothers born in India (3.9/1000), east and west Africa (3.0), and Bangladesh (2.8) than in infants of mothers born in the United Kingdom despite less favourable birth weights. Mortality ratios standardised separately for maternal age, parity, and social class were significantly higher in infants of mothers born in Pakistan and lower in those of mothers born in Bangladesh. The ratio for infants of Caribbean mothers was significantly higher when adjusted for maternal age. Ratios for infants of Indian and east African mothers did not show significant differences after standardisation. An important finding was a low incidence of sudden infant death in infants of Asian origin. This was paralleled by lower mortality from respiratory causes. During 1975-85 postnatal mortality in all immigrant groups except Pakistanis fell to a similar or lower rate than that in the United Kingdom group; Pakistanis showed a persistent excess. During 1984-5 several immigrant groups (from the Republic of Ireland, India, west Africa, and the Caribbean) reported an increase in postnatal mortality. Surveillance of postnatal mortality among ethnic communities should be continued, and research is needed to identify the causes underlying the differences (AU)