Ethnic variation in maternity care: a comparison of Polish and Scottish women delivering in Scotland 2004-2009.

OBJECTIVES: Birth outcomes in migrants vary, but the relative explanatory influence of obstetric practice in origin and destination countries has been under-investigated. To explore this, birth outcomes of Scots and Polish migrants to Scotland were compared with Polish obstetric data. Poles are the largest group of migrants to Scotland, and Poland has significantly more medicalized maternity care than Scotland. STUDY DESIGN: A population-based epidemiological study of linked maternal country of birth, maternity and birth outcomes. METHODS: Scottish maternity and neonatal records linked to birth registrations were analysed for differences in modes of delivery and pregnancy outcomes between Polish migrants and Scots, and compared with Polish Health Fund and survey data. RESULTS: 119,698 Scottish and 3105 Polish births to primiparous women in Scotland 2004-9 were analysed. Poles were less likely than Scots to have a Caesarean section and more likely to have a spontaneous vaginal or instrumental delivery. The Caesarean section rate in Poland is significantly higher and instrumental delivery rate lower than for either group of women in Scotland. CONCLUSIONS: Methodologically, comparing a large group of migrants from one country with the host population has advantages over grouping migrants from several countries into a single category, and allows more informed analysis of the effect of health services. Polish mothers' being slightly healthier explains some of their lower Caesarean section rate compared to Scots in Scotland. However, dominant models of obstetrics in the two countries seem likely to influence the differences between Poles delivering in Poland and Scotland. Further investigation of both is required.

Evidence of improving prognosis in heart failure: trends in case fatality in 66 547 patients hospitalized between 1986 and 1995.

BACKGROUND: Contemporary survival in unselected patients with heart failure and the population impact of newer therapies have not been widely studied. Therefore, we have documented case-fatality rates (CFRs) over a recent 10-year period. METHODS AND RESULTS: In Scotland, all hospitalizations and deaths are captured on a single database. We have studied case fatality in all patients admitted with a principal diagnosis of heart failure from 1986 to 1995. A total of 66 547 patients (47% male) were studied. Median age was 72 years in men and 78 years in women. Crude CFRs at 30 days and at 1, 5, and 10 years were 19.9%, 44.5%, 76.5%, and 87.6%, respectively. Median survival was 1.47 years in men and 1.39 years in women (2.47 and 2. 36 years, respectively, in those surviving 30 days). Age had a powerful effect on survival, and sex, comorbidity, and deprivation had modest effects. One-year CF was 24.2% in those aged <55 years and 58.1% in those aged >84 years. After adjustment, 30-day CFRs fell between 1986 and 1995, by 26% (95% CI 15 to 35, P<0.0001) in men and 17% (95% CI 6 to 26, P<0.0001) in women. Longer term CFRs fell by 18% (95% CI 13 to 24, P<0.0001) in men and 15% (95% CI 10 to 20, P<0.0001) in women. Median survival increased from 1.23 to 1. 64 years. CONCLUSIONS: Heart failure CF is much higher in the general population than in clinical trials, especially in the elderly. Although survival has increased significantly over the last decade, there is still much room for improvement.

Gender and survival: a population-based study of 201,114 men and women following a first acute myocardial infarction.

OBJECTIVES: We tested the hypotheses that the effect of gender on short-term case fatality following a first admission for acute myocardial infarction (AMI) varies with age, and that this effect is offset by differences in the proportion of men and women who survive to reach hospital. BACKGROUND: Evidence is conflicting regarding the effect of gender on prognosis after AMI. METHODS: All 201,114 first AMIs between 1986 and 1995 were studied. Both 30-day and 1-year case fatality were analyzed for the 117,749 patients hospitalized and for all first AMIs, including deaths before hospitalization. The effect of gender and its interaction with age on survival was examined using multivariate modeling. RESULTS: Gender-based differences in survival varied according to age in hospitalized patients, with younger women having higher 30-day case fatality than men (e.g., <55 years, women 6.5% vs. 4.8% men, p < 0.0001). When deaths from first AMI before hospitalization were included in 30-day case fatality, women were less likely to die (adjusted odds ratio 0.9, confidence interval 0.89 to 0.93). Gender was not an independent predictor of one-year survival (p = 0.16). CONCLUSIONS: Female gender increases the probability of surviving to reach hospital, and this outweighs the excess risk of death occurring in younger women following hospitalization. Overall, men have a higher 30-day case fatality than women. Women do not fare worse than men after AMI when age and other factors are taken into account. However, men are more likely to die before hospitalization.

Trends in case-fatality in 22968 patients admitted for the first time with atrial fibrillation in Scotland, 1986-1995.

BACKGROUND: Although atrial fibrillation (AF) is an important cause of cardiovascular morbidity and mortality there is a paucity of data describing hospitalisation rates and case-fatality associated with this common arrhythmia. This study examines recent trends in first-ever hospitalisations for AF in Scotland. METHODS: Using the linked Scottish Morbidity Record Scheme, we identified all 22968 patients admitted to Scottish hospitals for the first time with a principal diagnosis of AF between 1986 and 1995. For each calendar year we calculated short (30-day) and medium (31 day to 2 years) case-fatality rates. Adjusting for each patient's age, sex, deprivation status, concurrent diagnoses and prior hospitalisation status, we examined whether case-fatality rates had significantly improved during this 10-year period. RESULTS: Between 1986 and 1995 the number of men hospitalised for the first time with AF increased by 926 (125%) to 1730 per annum and the number of women and by 875 (105%) to 1712 (both P<0.001). Hospitalisation rates increased from 0.31 to 0.70/1000 men and from 0.32 to 0.65/1000 women (both P<0.001). By the end of this period the proportion of men had increased from 48 to 50%. In both sexes, the median age of patients rose--in men from 66 to 68 years and in women from 74 to 75 years (both P<0.01). Despite the increasing age of patients and greater comorbidity, short-term (30-day) case-fatality declined from 4.0 to 3.1% in men (P<0.001) and 4.1 to 3.8% (P<0.01) in women. Similarly, medium-term (31-day to 2-year) case-fatality fell from 25 to 22% in men and 27 to 25% (both P<0.001) in women. Adjusting for the age, sex, extent of deprivation, secondary diagnoses and prior hospitalisation of hospitalised patients, we found that the risk of short-term case-fatality in the 1995 male and female cohort significantly declined by 21% (P<0.05) and 24% (P<0.05), respectively, in comparison to the 1986 cohort. The adjusted risk of case-fatality in the medium term also declined significantly in men by 30% (P<0.05) over this period and by 20% (P<0.05) in women relative to 1986. CONCLUSION: The number of first-ever hospitalisations for AF has increased twofold during the 10-year period 1986-1995. Although the age of patients has progressively increased during this period, short and medium case-fatality rates have declined, especially in men. This may partly reflect better treatment of AF. However, changing admission thresholds and other factors could also have led to an apparent improvement in prognosis. Nevertheless, medium-term case fatality remains substantial after a first ever admission to hospital with AF.

Variations in breast feeding advice, a telephone survey of community midwives and health visitors.

Although 65% of mothers start breast feeding their baby, at six weeks after birth this proportion has dropped to 40%. It is postulated that one of the causes of this decrease might be that women receive conflicting advice from professionals. To examine this hypothesis, a telephone survey was designed to compare a random sample of community midwives (CMs) and a random sample of health visitors (HVs), in regard to the advice they would offer to breast feeding women, and the resources available to help them. On many topics, the advice likely to be offered by the two groups was markedly different. The CMs tended to be more uniform in their advice, which generally followed the Royal College of Midwives' booklet entitled Present Day Practice in Infant Feeding. Both groups recognised the value of lay breast-feeding counsellors, and there was much support for collaboration in the production of a guidance document on breast feeding.

Short-term and long-term outcomes in 133,429 emergency patients admitted with angina or myocardial infarction in Scotland, 1990-2000: population-based cohort study.

OBJECTIVE: To analyse short- and long-term outcomes and prognostic factors in a large population-based cohort of unselected patients with a first emergency admission for suspected acute coronary syndrome between 1990 and 2000 in Scotland. METHODS: All first emergency admissions for acute myocardial infarction (AMI) and all first emergency admissions for angina (the proxy for unstable angina) between 1990 and 2000 in Scotland (population 5.1 million) were identified. Survival to five years was examined by Cox multivariate modelling to examine the independent prognostic effects of diagnosis, age, sex, year of admission, socioeconomic deprivation and co-morbidity. RESULTS: In Scotland between 1990 and 2000, 133,429 individual patients had a first emergency admission for suspected acute coronary syndrome: 96 026 with AMI and 37,403 with angina. After exclusion of deaths within 30 days, crude five-year case fatality was similarly poor for patients with angina and those with AMI (23.9% v 21.6% in men and 23.5% v 26.0% in women). The longer-term risk of a subsequent fatal or non-fatal event in the five years after first hospital admission was high: 54% in men after AMI (53% in women) and 56% after angina (49% in women). Event rates increased threefold with increasing age and 20-60% with different co-morbidities, but were 11-34% lower in women. CONCLUSIONS: Longer-term case fatality was similarly high in patients with angina and in survivors of AMI, about 5% a year. Furthermore, half the patients experienced a fatal or non-fatal event within five years. These data may strengthen the case for aggressive secondary prevention in all patients presenting with acute coronary syndrome.

Edinburgh's community drug problem service--a pilot evaluation of methadone substitution.

The intravenous drug abusers of Edinburgh are known to have a high prevalence of infection with the Human Immunodeficiency Virus (HIV). A new service for the treatment of drug abusers in Edinburgh was commenced in April 1988. In this service, oral methadone substitution is frequently used to try to reduce the level of behaviour known to increase the risk of transmission of HIV. A questionnaire-based pilot study of the outcomes of oral methadone substitution therapy in 24 clients is described. The results indicate that the therapy is acceptable and may have a significant effect in reducing risk behaviour.

An outbreak of viral gastroenteritis associated with adequately prepared oysters.

Over Christmas 1993, an outbreak of food poisoning occurred among guests in a hotel in South West Scotland. Evidence from a cohort study strongly suggested that raw oysters were the vehicle for infection, probably due to a Small Round Structured Virus (SRSV). Detailed enquiry about the source and preparation of the oysters revealed no evidence of any unsafe handling at any stage in the food chain, nor any evidence of bacterial contamination. It is suggested that the present standards of preparation and monitoring are inadequate to protect the consumer, and that bacteriophage monitoring may be a useful method of screening for viral contamination in future.

An outbreak of bovine tuberculosis in two herds in south west Scotland--veterinary and human public health response.

BACKGROUND: Although the incidence of bovine tuberculosis in UK cattle has declined markedly, outbreaks still occur. There is often confusion as to how veterinary and human public health agencies should interact in such circumstances. We report an outbreak of bovine tuberculosis which occurred in South West Scotland in 1992. METHODS: The outbreak, which affected two cattle herds, and potentially involved 17 humans, was discovered when visible tuberculous lesions were found at routine post mortem examination of a calf. Investigation of animals and humans, exchange of information between human and veterinary public health agencies, and subsequent control measures followed the guidance of a recently produced protocol. RESULTS: Tuberculin testing of other animals in the index herd revealed 11 reactors. Testing of the herd of origin of these animals revealed 84 reactors out of 261 animals. Movement restrictions were placed on the index herd, and all the animals in the herd of origin were slaughtered. The humans were screened primarily by history and tuberculin skin testing. Eleven of them required chest X-rays (all were normal) and six were given prophylactic chemotherapy with isoniazid. Nobody developed clinical illness. CONCLUSION: The use of an agreed protocol proved to be very helpful to both human and veterinary public health agencies in the investigation and control of an outbreak of bovine tuberculosis. There is a clear need for better human screening tests.

Coping with your coronary heart disease target.

The Scottish targets for coronary heart disease are examined in detail from the point of view of a Health Board. It is suggested that even though the target refers to the under 65 age group, further age/sex standardisation is needed for fair comparison. A least-squares regression technique is also recommended as a means of reducing the effect of atypical rates in baseline or target years. The targets adopted do not make it clear whether Health Boards should aim for a target in terms of the percentage fall, or should aim to be below an absolute level by the target year. The specific targets imply that resources will have to be concentrated in people of late middle age, particularly males, to the detriment of preventive activities in younger age groups. It seems necessary to emphasise that targets are not an end in themselves but merely an indicator of progress. Monitoring progress towards achieving the target could be achieved by assuming a linear fall in rate between baseline and target years, to produce annual intermediate targets. A health board's progress towards the final target can then be annually monitored by comparison of its regressed age-sex standardised rate with the intermediate target.

Routinely collected data in national and regional databases--an under-used resource.

Regional and national databases of routinely collected data contain large quantities of health information, usually covering whole populations and often spanning prolonged time periods. Using routine data involves identifying useful sources, assessing the quality of the data and deciding whether what is available is 'fit for purpose'. As long as adequate care is taken, these data may be used in a number of different ways beyond their traditional uses for population health assessments and health service planning.

Audit of major gastrointestinal surgery in patients aged 80 years or over.

The value of preoperative assessment in relation to outcome and long-term survival was studied in 171 octogenarians undergoing major gastrointestinal surgery at Dumfries and Galloway Royal Infirmary between 1985 and 1990. The 30-day mortality rates for elective and emergency operations were 11% and 25% respectively. The American Society of Anesthesiologists (ASA) physical status scale was found to be a useful predictor of morbidity and mortality. ASA class 2 patients had a postoperative complication rate of 36% and a mortality rate of 13% while the figures for ASA class 4 patients were 85% and 54% respectively. Cox proportional hazards survival analysis using the variables age group, sex, ASA class, and type of surgery showed that the only statistically significant differences were between ASA classes. The relative 5-year survival of 63% indicates that these patients compare favourably with a population of the same age and sex not undergoing an operation. These data suggest that in the absence of severe concomitant medical disease, gastrointestinal surgery can be carried out reasonably safely in the elderly.

Trends in case-fatality in 117 718 patients admitted with acute myocardial infarction in Scotland.

OBJECTIVES: To analyse short- and long-term case-fatality trends following admission to hospital with a first acute myocardial infarction, in men and women between 1986 and 1995, after adjusting for risk factors known to influence survival. DESIGN: A Scottish-wide retrospective cohort study. SETTING: The Linked Scottish Morbidity Record Database was analysed. This contains accurate data on all hospital admissions since 1981, for the Scottish population of 5.1 million. It is linked to the Registrar General's death certificate data. SUBJECTS: All 117 718 patients admitted to Scottish hospitals with a principal diagnosis of first acute myocardial infarction (ICD-9 code 410) between 1986 and 1995. MAIN OUTCOME MEASURES: The outcome was death, both in and out of hospital, from any cause, at 30 days, 1 year, 5 and 10 years. RESULTS: Overall case-fatality following hospital admission with acute myocardial infarction was 22. 2%, 31.4%, 51.1% and 64.0% at 1 month, 1 year, 5 and 10 years, respectively. Multivariate analyses identified statistically significant independent prognostic factors. Thirty day mortality increased twofold for each decade of increasing age, and increased with any prior admission to hospital. When comparing the most deprived category to that of the most affluent, men had a 10% increased mortality (P<0.01), whilst women had an increased mortality of 4% (not significant). After adjustment for age, sex, deprivation and prior admission to hospital, case-fatality rates fell significantly between 1986 and 1995. Short-term case-fatality fell by 46% in men (27% in women) and long-term by 34% in men (30% in women) (both P<0.001). CONCLUSIONS: Population-based case-fatality rates in Scotland have fallen dramatically since 1986, particularly in men. The increasing survival in patients admitted to hospital suggests that the trial-based efficacy of modern therapies is now translating into population-based effectiveness. However, an individual's life expectancy still halves after a diagnosis of acute myocardial infarction. Of the variables that we could examine, age was the most powerful predictor of prognosis.

Age, sex, and social trends in out-of-hospital cardiac deaths in Scotland 1986-95: a retrospective cohort study.

BACKGROUND: Most deaths from coronary heart disease occur out of hospital. Hospital patients face social, age, and sex inequalities. Our aim was to examine inequalities and trends in out-of-hospital cardiac deaths. METHODS: We used the Scottish record linked database to identify all deaths from acute myocardial infarction that occurred in Scotland (population 5.1 million), in 1986-95. We have compared population-based death rates for men and women across age and social groups. FINDINGS: Between 1986 and 1995, 83365 people died from acute myocardial infarction, out of hospital and without previous hospital admission (44655 men, 38710 women); and 117749 were admitted with a first acute myocardial infarction, of whom 37020 died within 1 year. Thus, out-of-hospital deaths accounted for 69.2% (95% CI 69.0-69.5) of all 120385 deaths. Out-of-hospital deaths, measured as a proportion of all acute myocardial infarction events (deaths plus first hospital admissions), increased with age, from 20.1% (19.2-21.0) in people younger than 55 years, to 62.1% (61.3-62.9) in those older than 85 years. Population-based out-of-hospital mortality rates fell by a third in men and by a quarter in women. Mean yearly falls were larger in people aged 55-64 years (5.6% per year in men, 3.7% in women), than in those older than 85 years (2.5% in men and women). Mortality rates were substantially higher in deprived socioeconomic groups than in affluent groups, especially in people younger than 65 years. INTERPRETATION: These inequalities in age, sex, and socioeconomic class should be actively addressed by prevention strategies for coronary heart disease.