Sustainable Development Goals' health-related indicators for Brazil and Ecuador: an analysis for the period of 1990-2019.

OBJECTIVE: This article aims to analyse the evolution of 40 Sustainable Development Goals' (SDGs) health-related indicators in Brazil and Ecuador from 1990 to 2019. STUDY DESIGN: Epidemiological study of long-term trends in 40 SDGs' health-related indicators for Brazil and Ecuador from 1990 to 2019, using estimates from the Global Burden of Disease Study. METHODS: Forty SDGs' health-related indicators and an index from 1990 to 2017 for Brazil and Ecuador, and their projections up to 2030 were extracted from the Institute for Health Metrics and Evaluation's Global Burden of Disease website and analysed. The percent annual change (PC) between 1990 and 2019 was calculated for both countries. RESULTS: Both countries have made progress on child stunting (Brazil: PC = -38%; Ecuador: PC = -43%) and child wasting prevalences (Brazil: PC = -42%; Ecuador: PC = -41%), percent of vaccine coverage (Brazil: PC = +215%; Ecuador: PC = +175%), under-5 (Brazil: PC = -75%; Ecuador: PC = -60%) and neonatal mortality rates (Brazil: PC = -69%; Ecuador: PC = -51%), health worker density per 1000 population (Brazil: PC = +153%; Ecuador: PC = +175%), reduction of neglected diseases prevalences (Brazil: PC = -40%; Ecuador: PC = -58%), tuberculosis (Brazil: PC = -27%; Ecuador: PC = -55%) and malaria incidences (Brazil: PC = -97%; Ecuador: PC = -100%), water, sanitation and hygiene mortality rates (Brazil and Ecuador: PC = -89%). However, both countries did not show sufficient improvement in maternal mortality ratio to meet SDGs targets (Brazil: PC = -37%; Ecuador: PC = -40%). Worsening of indicators were found for violence, such as non-intimate partner violence for both countries (Brazil: PC = +26%; Ecuador: PC = +18%) and suicide mortality rate for Ecuador (PC = +66%), child overweight indicator for Brazil (PC = -67%), disaster mortality rates (Brazil: PC = +100%; Ecuador: PC = +325%) and alcohol consumption (Brazil: PC = +46%; Ecuador: PC = +35%). CONCLUSIONS: Significant improvements are necessary in both countries requiring the strengthening of health and other policies, particularly concerning the prevention and management of violence and alcohol consumption, and preparedness for dealing with environmental disasters.

Loneliness in young people: a multilevel exploration of social ecological influences and geographic variation.

BACKGROUND: Loneliness is a growing public health concern, yet little is known about loneliness in young people. The current study aimed to identify social ecological factors related to loneliness and examine the extent to which geographic region may account for differences in loneliness. METHODS: The data come from a cross-sectional sample of 6503 young people living in the UK. Loneliness was measured using the UCLA 3-item scale. Bivariate analyses were used to test associations between each predictor and loneliness. Multilevel models were used to identify key social ecological factors related to loneliness, and the extent to which loneliness may vary across geographic regions (local authority districts). RESULTS: Sociodemographic, social, health and well-being, and community factors were found to be associated with loneliness. Geographic region was associated with 5-8% of the variation in loneliness. The effect of gender, sexual orientation and minority ethnic background on loneliness differed across regions. CONCLUSIONS: This is the first study to highlight modifiable social and community factors related to youth loneliness, and individual vulnerabilities, such as poor mental well-being. Results related to geographic differences suggest that local-level initiatives may be most appropriate in tackling loneliness, rather than wider, less contextualized national efforts.

Hospital re-admission after critical care survival: a systematic review and meta-analysis.

Survivors of critical illness frequently require increased healthcare resources after hospital discharge. We undertook a systematic review and meta-analysis to assess hospital re-admission rates following critical care admission and to explore potential re-admission risk factors. We searched the MEDLINE, Embase and CINAHL databases on 05 March 2020. Our search strategy incorporated controlled vocabulary and text words for hospital re-admission and critical illness, limited to the English language. Two reviewers independently applied eligibility criteria and assessed quality using the Newcastle Ottawa Score checklist and extracted data. The primary outcome was acute hospital re-admission in the year after critical care discharge. Of the 8851 studies screened, 87 met inclusion criteria and 41 were used within the meta-analysis. The analysis incorporated data from 3,897,597 patients and 741,664 re-admission episodes. Pooled estimates for hospital re-admission after critical illness were 16.9% (95%CI: 13.3-21.2%) at 30 days; 31.0% (95%CI: 24.3-38.6%) at 90 days; 29.6% (95%CI: 24.5-35.2%) at six months; and 53.3% (95%CI: 44.4-62.0%) at 12 months. Significant heterogeneity was observed across included studies. Three risk factors were associated with excess acute care rehospitalisation one year after discharge: the presence of comorbidities; events during initial hospitalisation (e.g. the presence of delirium and duration of mechanical ventilation); and subsequent infection after hospital discharge. Hospital re-admission is common in survivors of critical illness. Careful attention to the management of pre-existing comorbidities during transitions of care may help reduce healthcare utilisation after critical care discharge. Future research should determine if targeted interventions for at-risk critical care survivors can reduce the risk of subsequent rehospitalisation.

How have trends in lifespan variation changed since 1950? A comparative study of 17 Western European countries.

Lifespan variation adds to life expectancy by measuring the inequality surrounding age of death that a population faces. Countries that tackle premature mortality generally have decreasing lifespan variation but this is the first study to compare and statistically assess when and to what extent trends in lifespan variation have changed across Western Europe. Lifespan variation was measured using e† and joinpoint regression analysed the timing and rate of change. Trends have been mostly downward with the recent exception of men in Scotland, Northern Ireland, Ireland and Finland where trends have flattened or show slight increases. Future research aimed at identifying the ages and causes of death, driving trends in these countries, is key to preventing increasing inequalities.

How much of the difference in life expectancy between Scottish cities does deprivation explain?

BACKGROUND: Glasgow's low life expectancy and high levels of deprivation are well documented. Studies comparing Glasgow to similarly deprived cities in England suggest an excess of deaths in Glasgow that cannot be accounted for by deprivation. Within Scotland comparisons are more equivocal suggesting deprivation could explain Glasgow's excess mortality. Few studies have used life expectancy, an intuitive measure that quantifies the between-city difference in years. This study aimed to use the most up-to-date data to compare Glasgow to other Scottish cities and to (i) evaluate whether deprivation could account for lower life expectancy in Glasgow and (ii) explore whether the age distribution of mortality in Glasgow could explain its lower life expectancy. METHODS: Sex specific life expectancy was calculated for 2007-2011 for the population in Glasgow and the combined population of Aberdeen, Dundee and Edinburgh. Life expectancy was calculated for deciles of income deprivation, based on the national ranking of datazones, using the Scottish Index of Multiple Deprivation. Life expectancy in Glasgow overall, and by deprivation decile, was compared to that in Aberdeen, Dundee and Edinburgh combined, and the life expectancy difference decomposed by age using Arriaga's discrete method. RESULTS: Life expectancy for the whole Glasgow population was lower than the population of Aberdeen, Dundee and Edinburgh combined. When life expectancy was compared by national income deprivation decile, Glasgow's life expectancy was not systematically lower, and deprivation accounted for over 90 % of the difference. This was reduced to 70 % of the difference when carrying out sensitivity analysis using city-specific income deprivation deciles. In both analyses life expectancy was not systematically lower in Glasgow when stratified by deprivation. Decomposing the differences in life expectancy also showed that the age distribution of mortality was not systematically different in Glasgow after accounting for deprivation. CONCLUSIONS: Life expectancy is not systematically lower across the Glasgow population compared to Aberdeen, Dundee and Edinburgh combined, once deprivation is accounted for. This provides further evidence that tackling deprivation in Glasgow would probably reduce the health inequalities that exist between Scottish cities. The change in the amount of unexplained difference when carrying out sensitivity analysis demonstrates the difficulties in comparing socioeconomic deprivation between populations, even within the same country and when applying an established ecological measure. Although the majority of health inequality between Glasgow and other Scottish cities is explained by deprivation, the difference in the amount of unexplained inequality depending on the relative context of deprivation used demonstrates the challenges associated with attributing mortality inequalities to an independent 'place effect'.

Exploring disparities in acute myocardial infarction events between Aboriginal and non-Aboriginal Australians: roles of age, gender, geography and area-level disadvantage.

We investigated disparities in rates of acute myocardial infarction (AMI) between Aboriginal and non-Aboriginal people in the 199 Statistical Local Areas (SLAs) in New South Wales, Australia. Using routinely collected and linked hospital and mortality data from 2002 to 2007, we developed multilevel Poisson regression models to estimate the relative rates of first AMI events in the study period accounting for area of residence. Rates of AMI in Aboriginal people were more than two times that in non-Aboriginal people, with the disparity greatest in more disadvantaged and remote areas. AMI rates in Aboriginal people varied significantly by SLA, as did the Aboriginal to non-Aboriginal rate ratio. We identified almost 30 priority areas for universal and targeted preventive interventions that had both high rates of AMI for Aboriginal people and large disparities in rates.

Adiposity has differing associations with incident coronary heart disease and mortality in the Scottish population: cross-sectional surveys with follow-up.

OBJECTIVE: Investigation of the association of excess adiposity with three different outcomes: all-cause mortality, coronary heart disease (CHD) mortality and incident CHD. DESIGN: Cross-sectional surveys linked to hospital admissions and death records. SUBJECTS: 19 329 adults (aged 18-86 years) from a representative sample of the Scottish population. MEASUREMENTS: Gender-stratified Cox proportional hazards models were used to estimate hazard ratios (HRs) for all-cause mortality, CHD mortality and incident CHD. Separate models incorporating the anthropometric measurements body mass index (BMI), waist circumference (WC) or waist-hip ratio (WHR) were created adjusted for age, year of survey, smoking status and alcohol consumption. RESULTS: For both genders, BMI-defined obesity (30 kg m(-2)) was not associated with either an increased risk of all-cause mortality or CHD mortality. However, there was an increased risk of incident CHD among the obese men (hazard ratio (HR)=1.78; 95% confidence interval=1.37-2.31) and obese women (HR=1.93; 95% confidence interval=1.44-2.59). There was a similar pattern for WC with regard to the three outcomes; for incident CHD, the HR=1.70 (1.35-2.14) for men and 1.71 (1.28-2.29) for women in the highest WC category (men 102 cm, women 88 cm), synonymous with abdominal obesity. For men, the highest category of WHR (1.0) was associated with an increased risk of all-cause mortality (1.29; 1.04-1.60) and incident CHD (1.55; 1.19-2.01). Among women with a high WHR (0.85) there was an increased risk of all outcomes: all-cause mortality (1.56; 1.26-1.94), CHD mortality (2.49; 1.36-4.56) and incident CHD (1.76; 1.31-2.38). CONCLUSIONS: In this study excess adiposity was associated with an increased risk of incident CHD but not necessarily death. One possibility is that modern medical intervention has contributed to improved survival of first CHD events. The future health burden of increased obesity levels may manifest as an increase in the prevalence of individuals living with CHD and its consequences.

Childhood residential mobility and health in late adolescence and adulthood: findings from the West of Scotland Twenty-07 Study.

BACKGROUND: The relationship between childhood residential mobility and health in the UK is not well established; however, research elsewhere suggests that frequent childhood moves may be associated with poorer health outcomes and behaviours. The aim of this paper was to compare people in the West of Scotland who were residentially stable in childhood with those who had moved in terms of a range of health measures. METHODS: A total of 850 respondents, followed-up for a period of 20 years, were included in this analysis. Childhood residential mobility was derived from the number of addresses lived at between birth and age 18. Multilevel regression was used to investigate the relationship between childhood residential mobility and health in late adolescence (age 18) and adulthood (age 36), accounting for socio-demographic characteristics and frequency of school moves. The authors examined physical health measures, overall health, psychological distress and health behaviours. RESULTS: Twenty per cent of respondents remained stable during childhood, 59% moved one to two times and 21% moved at least three times. For most health measures (except physical health), there was an increased risk of poor health that remained elevated for frequent movers after adjustment for socio-demographic characteristics and school moves (but was only significant for illegal drug use). CONCLUSIONS: Risk of poor health was elevated in adolescence and adulthood with increased residential mobility in childhood, after adjusting for socio-demographic characteristics and school moves. This was true for overall health, psychological distress and health behaviours, but physical health measures were not associated with childhood mobility.

Socio-demographic and health characteristics of individuals left behind in deprived and declining areas in Scotland.

Deprived and declining areas in Scotland have poorer health than other areas in the rest of Scotland. Using data from the Scottish Longitudinal Study, this paper examines whether differential migration over a one year period can explain these differences. Compared with migrants to and from deprived and declining areas, stable residents in those areas were generally older, less well educated and less affluent. Continued disproportionate loss of more affluent and better educated individuals could result in deprived and declining areas becoming even more deprived over time. Migrants appeared to be in better health; however, this finding was reversed on adjustment for age. It may be that while the relationship between migration and socio-economic status is immediately apparent, the relationship between migration and health could take longer to develop.

The relationship between body size and mortality in the linked Scottish Health Surveys: cross-sectional surveys with follow-up.

OBJECTIVE: To investigate the relationship between body mass index (BMI), waist circumference (WC) or waist-hip ratio (WHR) and all-cause mortality or cause-specific mortality. DESIGN: Cross-sectional surveys linked to hospital admissions and death records. SUBJECTS: In total, 20,117 adults (aged 18-86 years) from a nationally representative sample of the Scottish population. MEASUREMENTS: Cox proportional hazards models were used to estimate hazard ratios (HRs) for all-cause, or cause-specific, mortality. The three anthropometric measurements BMI, WC and WHR were the main variables of interest. The following were adjustment variables: age, gender, smoking status, alcohol consumption, survey year, social class and area of deprivation. RESULTS: BMI-defined obesity (≥ 30 kg m(-2)) was not associated with increased risk of mortality (HR = 0.93; 95% confidence interval = 0.80-1.08), whereas the overweight category (25-<30 kg m(-2)) was associated with a decreased risk (0.80; 0.70-0.91). In contrast, the HR for a high WC (men ≥ 102 cm, women ≥ 88 cm) was 1.17 (1.02-1.34) and a high WHR (men ≥ 1, women ≥ 0.85) was 1.34 (1.16-1.55). There was an increased risk of cardiovascular disease (CVD) mortality associated with BMI-defined obesity, a high WC and a high WHR categories; the HR estimates for these were 1.36 (1.05-1.77), 1.41 (1.11-1.79) and 1.44 (1.12-1.85), respectively. A low BMI (<18.5 kg m(-2)) was associated with elevated HR for all-cause mortality (2.66; 1.97-3.60), for chronic respiratory disease mortality (3.17; 1.39-7.21) and for acute respiratory disease mortality (11.68; 5.01-27.21). This pattern was repeated for WC but not for WHR. CONCLUSIONS: It might be prudent not to use BMI as the sole measure to summarize body size. The alternatives WC and WHR may more clearly define the health risks associated with excess body fat accumulation. The lack of association between elevated BMI and mortality may reflect the secular decline in CVD mortality.

The social patterning of deaths due to assault in Scotland, 1980-2005: population-based study.

OBJECTIVES: The objectives of this study were to explore the extent of the social gradient for deaths due to assault and its impact on overall inequalities in mortality and to investigate the contribution to assault mortality of knives and other sharp weapons. DESIGN: An analysis of death records and contemporaneous population estimates was conducted. SETTING: The authors investigated the social patterning of homicide in Scotland. PARTICIPANTS: This study included deaths between 1980 and 2005 due to assault. MAIN MEASUREMENTS: Death rates were standardised to the European standard population. Time trends were analysed and inequalities were assessed, using rate ratios and the slope index of inequality, along axes defined by individual occupational socioeconomic status and area deprivation. RESULTS: An increase in mortality due to assault was most pronounced at ages 15-44 and was steeper among assaults involving knives. The death rate among men in routine occupations aged 20-59 was nearly 12 times that of those in higher managerial and professional occupations. Men under 65 living in the most deprived quintile of areas had a death rate due to assault 31.9 times (95% CI 13.1 to 77.9) that of those living in the least deprived quintile; for women, this ratio was 35.0 (4.8 to 256.2). Despite comprising just 3.2% of all male deaths between 15 and 44 years, assault accounted for 6.4% of the inequalities in mortality. CONCLUSIONS: Inequalities in mortality due to assault in Scotland exceed those in other countries and are greater than for other causes of death in Scotland. Reducing mortality and inequalities depends on addressing the problems of deprivation as well as targeting known contributors, such as alcohol use, the carrying of knives and gang culture.

Life course influence of residential area on cause-specific mortality.

OBJECTIVE: To examine the relative influence of area of residence on mortality risk along the life course in different age groups and to see if this differs for causes known to be related differently to various models of the life course. METHODS: Individual data from the Censuses in 1960, 1970, 1980 and 1990 from Oslo, Norway, were linked to the death register 1990-1998. All male inhabitants living in Oslo in 1990 aged 30-69 years who had lived in Oslo at the three previous Censuses were included. RESULTS: In the youngest age group, area of residence closest to the time of death is most important for violent and psychiatric causes. In older age groups, area of residence at all time points in the period studied seemed to have a similar influence. Cardiovascular deaths were related to earlier as well as later area of residence in both young and old age groups. For violent and psychiatric causes, the most recent area may be the most important. CONCLUSION: This paper explores a research strategy to investigate how the area of residence through the life course influences mortality. The associations seem to vary according to age at, and cause of, death.

Social class inequalities in perinatal outcomes: Scotland 1980-2000.

OBJECTIVE: To examine social class inequalities in adverse perinatal events in Scotland between 1980 and 2000 and how these were influenced by other maternal risk factors. DESIGN: Population based study using routine maternity discharge data. SETTING: Scotland. PARTICIPANTS: All women who gave birth to a live singleton baby in Scottish hospitals between 1980 and 2000 (n=1,282,172). MAIN OUTCOME MEASURES: Low birth weight (LBW), preterm birth, and small for gestational age (SGA). RESULTS: The distribution of social class changed over time, with the proportion of mothers with undetermined social class increasing from 3.9% in 1980-84 to 14.8% in 1995-2000. The relative index of inequality (RII) decreased during the 1980s for all outcomes. The RII then increased between the early and late 1990s (LBW from 2.09 (95%CI 1.97, 2.22) to 2.43 (2.29, 2.58), preterm from 1.52 (1.44, 1.61) to 1.75 (1.65, 1.86), and SGA from 2.28 (2.14, 2.42) to 2.49 (2.34, 2.66) respectively). Inequalities were greatest in married mothers, mothers aged over 35, mothers taller than 164 cm, and mothers with a parity of one or more. Inequalities were also greater by the end of the 1990s than at the start of the 1980s for women of parity one or more and for mothers who were not married. CONCLUSION: Despite decreasing during the 1980s, inequalities in adverse perinatal outcomes increased during the 1990s in all strata defined by maternal characteristics.

Increasing inequalities in premature mortality in Great Britain.

STUDY OBJECTIVE: To describe inequalities in all cause premature mortality between and within regions of Great Britain and how these inequalities have changed between 1979 and 1998. DESIGN: Retrospective study using routine population and death data aggregated into five year age and sex groups for each of 20 years. SETTING: All 459 local authority districts (England and Wales) and local government districts (Scotland). PARTICIPANTS: Estimated population and registered deaths aged 0-64. MAIN OUTCOME MEASURES: Indirectly standardised mortality ratios for all cause mortality; percentages of deaths that would be avoided if there were no inequalities between and within regions. RESULTS: The decrease in premature mortality of 36% seen in Great Britain ranged from 42% in Wales to 33% in Scotland and 31% in London. Differences between regions led to excess mortality of about 25% in Scotland, the North East, and the North West. In London excess mortality increased from 14% to 19%. Inequalities within regions increased in most parts of Great Britain, the exceptions being Wales, London, and the South West. The largest increase was seen in Scotland where the percentage of excess deaths increased from 23% to 33%. CONCLUSIONS: A decrease in premature mortality in Great Britain was seen in all regions, although less pronounced in London, but the gap between regions remained. Inequalities between districts within regions vary from one region to another and have increased in nearly every part of Great Britain.

How did the recent increase in the supply of coronary operations in Finland affect socioeconomic and gender equity in their use?

STUDY OBJECTIVE: To explore how the increased supply of coronary bypass operations and angioplasties from 1988 to 1996 influenced socioeconomic and gender equity in their use. DESIGN: Register based linkage study; information on coronary procedures from the Finnish Hospital Discharge Register in 1988 and 1996 was individually linked to national population censuses in 1970-1995 to obtain patients' socioeconomic data. Data on both hospitalisations and mortality attributable to coronary heart disease obtained from similar linkage schemes were used to approximate the relative need of procedures in socioeconomic groups. SETTING: Finland, 2,094,846 inhabitants in 1988 and 2,401,027 in 1996 aged 40 years and older, and Discharge Register data from all Finnish hospitals offering coronary procedures in 1988 and 1996. MAIN RESULTS: The overall rate of coronary revascularisations in Finland increased by about 140% for men and 250% for women from 1988 to 1996. Over the same period, socioeconomic and gender disparities in operation rates diminished, as did the influence of regional supply of procedures on the extent of these differences. However, men, and better off groups in terms of occupation, education, and family income, continued to receive more operations than women and the worse off with the same level of need. CONCLUSIONS: Although revascularisations in Finland increased 2.5-fold overall, some socioeconomic and gender inequities persisted in the use of cardiac operations relative to need. To improve equity, a further increase of resources may be needed, and practices taking socioeconomic and gender equity into account should be developed for the referral of coronary heart disease patients to hospital investigations.

Using routine data to complement and enhance the results of randomised controlled trials.

BACKGROUND: Randomised controlled trials (RCTs) are widely accepted as the best way to assess the outcomes and safety of medical interventions, but are sometimes not ethical, not feasible, or limited in the generalisability of their results. In such circumstances, routinely available data could help in several ways. Routine data could be used, for example, to conduct 'pseudo-trials', to estimate likely outcomes and required sample size to help design and conduct trials, or to examine whether the expected outcomes observed in an RCT will be realised in the general population. OBJECTIVES: The project was undertaken to explore how routinely assembled hospital data might complement or supplement RCTs to evaluate medical interventions: in contexts where RCTs are not feasible for defining the context and design of an RCT for assessing whether the benefits indicated by RCTs are achieved in wider clinical practice. METHODS: The project was based on the system of linked Scottish morbidity records, which cover 100% of acute hospital care episodes and statutory death records from 1981 to 1995. Three case studies were undertaken as a way of investigating the utility of these records in different applications. First, an attempt was made to analyse the link between the timing of surgery for subarachnoid haemorrhage (SAH) and subsequent outcomes (a question not easily susceptible to RCT design). A subsample was derived by excluding patients for which a diagnosis of SAH may not have been established or that may not have been admitted to a neurosurgical unit, and the data were assessed to attempt to inform the design of a trial of early versus late surgery. Transurethral prostatectomy (TURP), the second case study, has become the surgery of choice for benign prostatic hyperplasia without systematic assessment of its effectiveness and safety, and an RCT would now be considered unethical. However, there is a need to investigate long-term effects and the influence of co-morbidities on outcomes. A retrospective comparison of mortality and re-operation following either open prostatectomy (OPEN) or TURP was, therefore, undertaken. Patients for whom it was not possible to establish the initial procedure were excluded. The third case study compared coronary artery bypass grafting (CABG) with percutaneous transluminal angioplasty (PTCA) for coronary revascularisation. RCTs have been conducted in limited patient subgroups with short follow-up periods. A meta-analysis of RCTs could be augmented by routine data, which are available for large populations. This would allow assessment of subgroup effects, and outcomes over a long period. A subgroup of patients was therefore constructed for whom relevant routine data were available and who reflected the entry criteria for major RCTs, thus enabling a comparison between the results expected from this subgroup and those of the general population. RESULTS AND CONCLUSIONS: The uses of routine data in these contexts had strengths and weaknesses. The SAH study suggested a means of assessing outcomes and survival rates following haemorrhage, which could have value in informing the design of more precise trials and in evaluating changes in outcome following the introduction of new treatments such as embolisation. However, the potential of the data was not realised because their scope and content were insufficient. For example, lack of data on the time of onset of symptoms and patients' conditions at hospital admission made it difficult to establish the link between timing of surgery and the outcome, and there was insufficient information on patients' conditions at discharge to enable a comparison of outcomes. The prostatectomy study was able to address questions not answered by RCT literature because the large number of cases it included allowed exploration of subgroup effects. (ABSTRACT TRUNCATED)

Multivariate spatial models for event data.

This paper describes how estimates made for event rates in small areas may be enhanced through spatial modelling of the data - taking the geographical location of each area into account - and through the addition of further information from each area. In particular we consider the use of spatial models to predict more than one outcome simultaneously. This is done by writing the spatial model as a multi-level model and subsequently enhancing this to encompass a multivariate data structure; estimates are obtained using iterative generalized least squares in the software package MLwiN. The example given considers mortality due to two causes--neoplasms and circulatory disease--in 143 postcode sectors in Greater Glasgow Health Board, Scotland. In addition, a measure of socio-economic deprivation is available for each area. Correlations between causes within areas, between areas within causes and between areas and causes are quantified, as are the relative contributions of the heterogeneous and spatial parts of the model. The results suggest a tendency for there to be pockets with high mortality rates due to neoplasms, whilst mortality due to circulatory disease follows a much smoother pattern. After taking deprivation into account, the spatial component accounts for just 19 per cent of the variation in the mortality due to neoplasms in Greater Glasgow but 66 per cent of the mortality due to circulatory disease.

Comparing outcomes of percutaneous transluminal coronary angioplasty with coronary artery bypass grafting; can routine health service data complement and enhance randomized controlled trials?

AIM: To compare outcomes of percutaneous transluminal coronary angioplasty (PTCA) with coronary artery bypass graft surgery (CABG) for a population stemming from routinely collected data, in order to assess the merits of such data sources as a complement, and possible enhancement, to randomized controlled trial results. METHODS AND RESULTS: A population of Scottish patients were taken from a routine discharge summary and from this data source patients comparable to those from randomized controlled trial settings were identified. Between 1989 and 1995, 12 238 pseudo randomized controlled trial patients were identified from the routine data set, of which 3714 (30.3%) received PTCA and 8524 (69.7%) received CABG. The baseline characteristics of the pseudo randomized controlled trial and randomized controlled trial patients were similar. The evidence from both the randomized controlled trials and routine data indicate that for 1 year follow-up the risk of cardiac death and/or non-fatal myocardial infarction is not significantly different between the two treatment groups. CONCLUSION: The outcomes expected of PTCA and CABG following trial evidence have been realized in the routine data which are representative of a complete, non-selective population. Due to the size of the routine data set it would be possible to set up hypotheses for potential subgroup effects at the outset.

Multilevel modelling of the geographical distributions of diseases.

"Multilevel modelling is used on problems arising from the analysis of spatially distributed health data. We use three applications to demonstrate the use of multilevel modelling in this area. The first concerns small area all-cause mortality rates from Glasgow where spatial autocorrelation between residuals is examined. The second analysis is of prostate cancer cases in Scottish counties where we use a range of models to examine whether the incidence is higher in more rural areas. The third develops a multiple-cause model in which deaths from cancer and cardiovascular disease in Glasgow are examined simultaneously in a spatial model. We discuss some of the issues surrounding the use of complex spatial models and the potential for future developments."

League tables and acute myocardial infarction.

BACKGROUND: Comparison of the outcomes of care provided by hospitals is a growing trend. Outcomes need to be distinguished into those attributable to the practice of hospitals and those that arise from differences in the characteristics of patients and the underlying morbidity of the populations for whom hospitals provide care. We explored these issues for deaths in hospital or within 30 days of discharge after acute myocardial infarction in Scotland, UK. METHODS: We used records from December, 1992, to November, 1993, for 14,359 episodes of acute myocardial infarction, the death records of those who died, and 9391 death records for individuals who died after acute myocardial infarction but who had not been in hospital in the 30 days before death. Hospital discharge records were taken from the Scottish Morbidity Records. The outcomes we investigated were all-cause mortality within 30 days of discharge from hospital, and death from acute myocardial infarction at any time during the study period. We estimated separately effects attributable to patients' characteristics, hospitals, and areas of residence with multilevel modelling. FINDINGS: We found significant differences between hospitals by age, sex, and medical history. The odds ratios for death ranged from 0.62 (95% CI 0.50-0.80) to 1.28 (1.07-1.59), relative to the average performance for Scotland as a whole. Analysis including area of residence, deaths occurring out of hospital, and more detailed information about patients showed no significant differences between hospitals for patients aged 70 years. By postcode area, there was a strong association between out-of-hospital deaths and deaths in hospital or shortly after discharge. INTERPRETATION: Hospital outcomes may vary from one subgroup of patients to another and should be assessed independently of patients' areas of residence. Measures of performance that do not provide valid comparisons could diminish public confidence in hospital services.