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PubMed1985

National survey of notifications of tuberculosis in England and Wales in 1983. Medical Research Council Tuberculosis and Chest Diseases Unit.

In a survey of all notifications of tuberculosis in England and Wales for the first six months of 1983 56% of the 3002 newly notified patients who had not been treated before were of white and 37% were of Indian subcontinent (Indian, Pakistani, or Bangladeshi) ethnic origin, findings similar to those of a survey in 1978-9. In the four and a quarter years between the surveys the number of patients notified had declined by 26%, the decline being 28% among those of white and 23% among those of Indian subcontinent ethnic origin. The white patients were on average older than the patients of Indian subcontinent ethnic origin, and a higher proportion of them had respiratory disease (82% compared with 66%). The pulmonary lesions were on average larger and more often bacteriologically positive in the white patients. There were considerable differences between the ethnic groups in the estimated yearly rates of notifications per 100 000 population in England in 1983. The highest rates occurred in the Indian (178) and the Pakistani and Bangladeshi (169) populations and were roughly 25 times the rate in the white population (6 X 9). In the Indian subcontinent ethnic groups the highest rates occurred among those who had arrived in the United Kingdom within the previous five years.

Age Factors↗
PubMed1986

Childhood respiratory infection and adult chronic bronchitis in England and Wales.

The high mortality from chronic bronchitis in England and Wales and the excess of urban over rural mortality are unexplained. On dividing England and Wales into 212 local authority areas a strong geographical relation was found between death rates from chronic bronchitis and emphysema in 1959-78 and infant mortality from bronchitis and pneumonia during 1921-5. It was concluded that this relation provided strong evidence of a direct casual link between acute lower respiratory infection in early childhood and chronic bronchitis in adult life. Regression analysis suggested that infection in early childhood had a greater influence than cigarette smoking in determining the geographical distribution of chronic bronchitis. National time trends reflected the influence of both factors. Chronic air pollution in adult life may be less important a cause of chronic bronchitis than previously supposed.

Adult↗
PubMed1986

Asthma mortality: comparison between New Zealand and England.

Causes for the high mortality from asthma in New Zealand were investigated by comparing deaths from asthma in caucasian subjects aged 15-64 in New Zealand with those from asthma in the same age group in two regions in England. There were no significant differences in the accuracy of death certification. The verified asthma mortality in New Zealand (4.2/100,000) was over twice that in England. Many characteristics of patients and management, including poor compliance with treatment and deficiencies in long term and emergency care, were qualitatively similar in the two countries. New Zealand had an apparently higher rate of non-preventable deaths from asthma, suggesting a greater severity of asthma in New Zealand. In both countries, however, most deaths were associated with poor assessment, underestimation of severity and inappropriate treatment (over-reliance on bronchodilators and underuse of systemic corticosteroids), and delays in obtaining help. A greater frequency of some of these deficiencies in management remains a possible additional explanation for part of the excess mortality in New Zealand.

Adolescent↗
PubMed1987

Hospital and community health service costs: England and Scotland compared.

In publications which have compared the health expenditure in the component parts of the United Kingdom by applying the Resource Allocation Working Party (RAWP) formula to the health budget of England, Scotland, Wales, and Northern Ireland it has been previously concluded that Scotland's hospital and community health services expenditure is more than 19% above what would be a fair distribution. It has also been implied that Scotland's allocation should be cut substantially to improve services in England. On the assumption that the purpose of examining the distribution of the health and community health service budget is to ensure "equal opportunity of access to health care for people at equal risk" it is concluded that simple RAWPing of the United Kingdom budget is flawed and a conclusion based on this is therefore untenable.

Community Health Services↗
PubMed1988

Retrospective study of 1000 deaths from injury in England and Wales.

One thousand consecutive deaths from injury in 11 coroner's districts in England and Wales were reviewed by four independent assessors, who studied necropsy reports to identify deaths in hospital that might have been preventable. Of 514 patients admitted to hospital alive, 102 deaths (20%) were judged by all four assessors to have been potentially preventable. When those cases in which three out of four assessors considered that the death was preventable were added the total rose to 170 (33%). Nearly two thirds of all non-central nervous system deaths were judged to have been preventable. The median age of the 170 patients whose deaths were preventable was 41, and the mean Injury Severity Score was 29. Further analysis suggested that the preventable deaths were principally the result of failure to stop bleeding and prevent hypoxia and the absence of, or delay in, surgical treatment. The results closely parallel those from similar studies from the United States and suggest that there are serious deficiencies in the services for managing severe injury in England and Wales. Debate is needed now on how to correct these deficiencies. In particular, the place of trauma centres must be considered.

Adolescent↗
PubMed1989

HIV infection in patients attending clinics for sexually transmitted diseases in England and Wales. Collaborative Study by Consultants in Genitourinary Medicine and the Public Health Laboratory Service.

A national study of the prevalence of HIV antibody designed to monitor sexual spread of HIV infection in England and Wales was made of homosexual and heterosexual patients attending sexually transmitted disease clinics in four districts in 1985, seven in 1986, and 14 in 1987. Patients were invited to participate and were counselled. Among homosexual men in two clinics in south east England, HIV antibody was found in 92 (12.9%) of 711 in 1985, 65 (15.2%) of 428 in 1986, and 81 (14.6%) of 556 in 1987: corresponding findings in the other regions were 16 (5.0%) of 321, 41 (6.3%) of 654, and 21 (3.1%) of 678. The prevalence of HIV antibody was higher in homosexual than bisexual men, in patients aged 25 years or more, or with one or more specified minor complaints. Among heterosexual patients in the south east in 1986, HIV antibody was found in seven (3.0%) of 230 men and three (1.3%) of 233 women and in 1987 in 10 (1.0%) of 962 men and seven (0.7%) of 949 women. In other areas corresponding findings in 1986 were two (0.2%) of 950 men and three (0.4%) of 752 women and in 1987 were three (0.06%) of 5312 men and one (0.02%) of 4778 women. All but one of the heterosexual patients with the antibody were intravenous drug abusers or had had sexual contacts in or were from an area abroad with a high prevalence of AIDS. Failure to identify a heterosexual patient with HIV antibody not in a risk group (other than that of being an attender at the clinic) or who did not have a sexual partner in a risk group suggests that their prevalence in the patient population of the clinics in the south east is less than one in 700 and in the other regions less than one in 3000. Refusals to participate increased during the study but comparisons of patients who agreed and refused in terms of age, the presence of symptoms suggesting AIDS, travel abroad, and number of sexual partners a month showed little evidence of selective bias.

Adult↗
PubMed1989

Prevalence of HIV antibody in high and low risk groups in England. Public Health Laboratory Service Working Group.

Most studies of the spread of HIV infection have centred on homosexuals and intravenous drug users. To estimate the extent of infection in different groups, including heterosexuals, the prevalence of HIV antibody was studied in 34,222 subjects tested with consent between October 1986 and December 1987 in England. These included subjects in high risk groups for HIV infection, heterosexuals with partners in the high risk groups and heterosexuals with multiple partners or with no identifiable risk factors. The prevalence was highest in homosexual or bisexual men in London (15.1%; 213/1412), being 4.0% (146/3607) outside London. The yearly incidence of infection in 632 homosexual or bisexual men without HIV antibody when retested during the study period was 3%. Among intravenous drug users the prevalence of HIV antibody was 5.7% (36/633) in London and 1.5% (39/2562) outside. Of 3272 heterosexual subjects tested, whose partner was in a risk group, eight of 515 (1.6%) in London and six of 2757 (0.2%) outside were positive for the antibody. Among 20,455 heterosexuals with a history of multiple partners or with no declared risk, only six subjects with HIV antibody were identified, two of whom had been infected abroad. Heterosexual spread of infection in England is evidently still largely confined to subjects whose partner has an identifiable risk.

Cross-Sectional Studies↗
PubMed1989

Incidence of insulin dependent diabetes in England: a study in the Oxford region, 1985-6.

OBJECTIVE: To determine the incidence of insulin dependent diabetes mellitus up to the age of 21 in a geographically defined population in England with independent validation of completeness of case ascertainment. DESIGN: Prospective registration of newly diagnosed cases supplemented by centralised hospital discharge records and death certificates. Validation of ascertainment from general practitioners. SETTING: Oxford Regional Health Authority area (population 2.4 million). PATIENTS: All patients with insulin dependent diabetes diagnosed below age 21 during 1985-6 and resident in the region at the time of diagnosis. INTERVENTIONS: None. END POINT: Validation of a method of case ascertainment for assessing temporal variation in incidence of insulin dependent diabetes. MEASUREMENTS AND MAIN RESULTS: The overall yearly incidence of newly diagnosed insulin dependent diabetes mellitus in people under 21 was 15.6 cases/100,000 (95% confidence interval 13.6 to 17.6). Among males the incidence was 16.8 cases (14.0 to 19.7)/100,000 and among females 14.3 cases (11.6 to 17.1)/100,000. The highest incidence, in the 10-14 year age group, was 26.4 (20.9 to 31.8) new cases/100,000 population yearly. Case ascertainment was greater than 95%. CONCLUSIONS: The incidence of insulin dependent diabetes in England is considerably higher than reported from large scale studies. It is consistent with described patterns of geographical variation. The figures provide a baseline for assessing temporal change.

Adolescent↗
PubMed1989

Deprivation: explaining differences in mortality between Scotland and England and Wales.

To detect reasons for the difference in mortality between Scotland and England and Wales a measure of deprivation was studied, comprising overcrowding, unemployment of men, low social class, and not having a car. Data for Scotland for 1980-2 showed this measure to be strongly associated with mortality, with gradients being particularly steep in young adults. Deprivation was much severe in Scotland than in England and Wales. These findings suggest that much excess mortality may be ascribed to more adverse conditions. Standardising the mortality ratios to take account of the relative affluence and deprivation of the two populations led to the differentials observed being radically adjusted, while standardising for social class had little effect. Deprivation measures based on areas overcome many of the limitations associated with social class analysis and also show much greater discrimination between populations. Measures of deprivation apparently provide a powerful basis for explanation of health differences. Such measures should therefore form part of the 1991 census output to facilitate their use on a consistent basis.

Automobiles↗
PubMed1989

Organ donation from intensive care units in England.

OBJECTIVE: To audit all deaths in intensive care units (excepting coronary care only and neonatal intensive care units) in England to assess potential for organ procurement. DESIGN: An audit in which 14 regional health authorities and London special health authorities each designated a regional liaison officer to identify intensive care units and liaise with Department of Health and the Medical Research Council's biostatistics unit in distribution, return, and checking of audit forms. Audit took place from 1 January to 31 March 1989 and will continue to 31 December 1990. SETTING: 278 Intensive care units in England. PARTICIPANTS: Colleagues in intensive care units (doctors, nurses, coordinators, and others), who completed serially numbered audit forms for all patients who died in intensive care. RESULTS: The estimated number of deaths in intensive care units was 3085, and validated audit forms were received for 2853 deaths (92%). Brain stem death was a possible diagnosis in only 407 (14%) patients (about 1700 cases a year) and was confirmed in 282 (10%) patients (an estimated 1200 cases a year). Half the patients (95% confidence interval 45% to 57%) in whom brain stem death was confirmed became actual donors of solid organs. Tests for brain stem death were not performed in 106 (26%) of 407 patients with brain stem death as a possible diagnosis, and general medical contraindication to organ donation was recorded for 48 (17%) of 282 patients who fulfilled brain stem death criteria before cessation of heart beat. The criteria were fulfilled before cessation of heart beat and in the absence of any general medical contraindication to organ donation in 234 patients, 8% of those dying in intensive care (an estimated 1000 cases a year). Consent for organ donation was given in 152 (70%) of 218 cases (64% to 76%) when the possibility of organ donation was suggested to relatives. In only 14 out of 232 families (6%; 3% to 9%) was there no discussion of organ donation with relatives. Corneal suitability was recorded as "not known" in a high proportion (1271; 45%) of all deaths and intensive care units reported only 123 corneal donors (4% of all audited deaths). CONCLUSION: When brain stem death is a possible diagnosis tests should always be carried out for confirmation. Early referral to the transplant team or coordinator should occur in all cases of brain stem death to check contraindications to organ donation. There should be increased use of asystolic kidney donation, and patients should be routinely assessed for suitability for corneal donation. Finally, more publicity and education are necessary to promote consent.

Aged↗
PubMed1991

Insulin dependent diabetes in childhood and material deprivation in northern England, 1977-86.

OBJECTIVE: To determine the incidence of insulin dependent diabetes in the Northern region of England in children less than 16 years old in the period 1977 to 1986 and to relate the incidence data to an index of deprivation. DESIGN: Retrospective analysis of hospital case records identified from the regional health authority's computer; validation of the primary source with hospital clinic registers and community paediatric registers. SETTING: Northern region, excluding South Cumbria District Health Authority (659,300 children under 16 in 1981). PATIENTS: All children diagnosed with insulin dependent diabetes before the age of 16 and resident in the region at time of diagnosis. MAIN OUTCOME MEASURES: Incidence rates for the 10 year period and analysis of incidence rates within categories of deprivation. RESULTS: 919 incident cases were identified. The validation procedure covered 54% of all cases identified and gave 95% completeness of ascertainment. The average annual incidence over the 10 year period was 14.8/100,000 for girls and 13.4/100,000 for boys. The annual incidence for the most and least deprived areas of the region was 18.7/100,000 (95% confidence interval 16.2 to 21.5) for boys and 7/100,000 (5.6 to 8.8) for girls. There was a highly significant trend (p less than 0.001) of decreasing incidence with decreasing level of deprivation. CONCLUSIONS: In the north of England the incidence of childhood diabetes is related to material deprivation.

Adolescent↗
PubMed1991

Results of first year (1989) of a national register of Down's syndrome in England and Wales.

OBJECTIVE: To examine the feasibility of a national register of Down's syndrome and its effectiveness in evaluating prenatal screening for the syndrome. DESIGN: Information for the register was obtained from all eligible cytogenetic laboratories on relevant cytogenetic diagnoses, including date and place of birth or termination, maternal age, indication for karyotyping, and type of diagnostic test used. SETTING: Cytogenetic laboratories in England and Wales. SUBJECTS: All fetuses with trisomy 21 diagnosed prenatally and live births with Down's syndrome diagnosed at birth. MAIN OUTCOME MEASURES: Number of prenatal and postnatal diagnoses of Down's syndrome. National and maternal age specific prevalence of Down's syndrome. RESULTS: For 1989 there were 1060 registrations--323 prenatal diagnoses and 737 postnatal diagnoses--after exclusion of postnatally diagnosed miscarriages and stillbirths. The estimated national rate of affected births for mothers resident in England and Wales was 1.4/1000 live births, assuming no terminations of affected pregnancies and after correction for natural losses which would have occurred in the absence of termination. The corrected maternal age specific rates were close to those found in previous population based studies. The proportion of affected pregnancies diagnosed prenatally in mothers aged 35 to 39 was 44%, and for those aged 40 or more it was 71%. Abnormal findings on ultrasonography played an unexpectedly important part in initiating cytogenetic investigation (13% of the prenatal diagnoses). CONCLUSIONS: The findings establish the feasibility of a national Down's syndrome register and its use in evaluating prenatal screening services. Together with information held by the Office of Population Censuses and Surveys on congenital malformations, data from the register will permit studies of environmental variables affecting the prevalence of the syndrome.

Down Syndrome↗
PubMed1992

Prescribing at the hospital-general practice interface. I: Hospital outpatient dispensing policies in England.

OBJECTIVE: To describe the outpatient dispensing policies of major acute hospitals in England. DESIGN: Postal questionnaire survey in November 1990. SETTING: All (278) major acute hospitals in England with more than 250 beds, excluding maternity, paediatric, or psychiatric hospitals; nine hospitals declined. PARTICIPANTS: Hospital chief pharmacists. MAIN OUTCOME MEASURES: Current dispensing policy and exceptions to it; when the policy was formed; and who was involved in its formation. RESULTS: Completed questionnaires were received from 200 (72%) of the hospitals approached. The quantities of drugs dispensed to outpatients ranged from zero in 12 hospitals to unlimited amounts in nine; nearly half (92) dispensed a 14 days' supply of drugs. The greater the restriction on outpatient dispensing, the more recently the policy had been introduced (chi 2 for trend = 7.15; df = 1; p less than 0.01). Permissible exceptions to the policy included the consultant's specific request (134 hospitals), difficulty in obtaining drugs in the community (102), urgent need for start of treatment (49), and certain types of patients (41) or drugs or their regimens (104). Groups who were neither represented on the hospital committee concerned with policy formation nor consulted before policy changes included regional health authorities in 122 hospitals, district health authorities in 101 hospitals, and general practitioners in 32 hospitals. CONCLUSIONS: Outpatient dispensing policies varied considerably among the hospitals surveyed, but they seemed to be moving towards greater restrictions on the supply of drugs given to outpatients.

Drug Prescriptions↗
PubMed1992

Prescribing at the hospital-general practice interface. II: Impact of hospital outpatient dispensing policies in England on general practitioners and hospital consultants.

OBJECTIVE: To assess the impact on general practitioners and hospital consultants of hospital outpatient dispensing policies in England. DESIGN: Postal questionnaire and telephone interview survey of general practitioners and hospital consultants in January 1991. SETTING: 94 selected major acute hospitals in England. PARTICIPANTS: 20 general practitioners in the vicinity of each of 94 selected hospitals and eight consultants from each, selected by chief pharmacists. MAIN OUTCOME MEASURES: Proportions of general practitioners unable to assume responsibility for specialist drugs and of consultants wishing to retain responsibility; association between dispensing restrictions and the frequency of general practitioners being asked to prescribe hospital initiated treatments. RESULTS: Completed questionnaires were obtained from 1207 (64%) of 1887 general practitioners and 457 (63%) of 729 consultants. 570 (46%) general practitioners felt unable to take responsibility for certain treatments, principally because of difficulty in detecting side effects (367, 30%), uncertainty about explaining treatment to patients (332, 28%), and difficulty monitoring dosage (294, 24%). Among consultants 328 (72%) wished to retain responsibility, principally because of specialist need for monitoring (93, 20%), urgent need to commence treatment (64, 14%), and specialist need to initiate or stabilise treatment (63, 14%). The more restricted the drug supply to outpatients, the more frequently consultants asked general practitioners to prescribe (p less than 0.01) and complete a short course of treatment initiated by the hospital (p less than 0.001). CONCLUSIONS: Restrictive hospital outpatient dispensing shifts clinical responsibility on to general practitioners. Hospital doctors should be able to retain responsibility for prescribing when the general practitioner is unfamiliar with the drug or there is a specialist need to initiate, stabilise, or monitor treatment.

Attitude of Health Personnel↗
PubMed1992

Childhood deaths from intussusception in England and Wales, 1984-9.

OBJECTIVE: To assess the incidence of potentially avoidable factors contributing to death of children with intussusception. DESIGN: Review of children who died with intussusception in England and Wales between 1984 and 1989 from data of the Office of Population Censuses and Surveys, case notes, coroners' records, and necropsy reports. MAIN OUTCOME MEASURES: Unambiguous objective criteria such as failure to diagnose intussusception within 24 hours of admission. RESULTS: 33 children died of acute intussusception in England and Wales between 1984 and 1989 compared with 67 in the previous six years. Their median age was 7 months (range 2 months to 12 years), and two thirds were boys. Half of the deaths occurred at home or soon after arrival at hospital but 15 patients had surgery. Potentially avoidable factors contributing to death were identified in 20 (61%) children, all but three of whom had ileocolic intussusception. These factors were excessive delay in diagnosis, inadequate intravenous fluid and antibiotic therapy, delay in recognising recurrent or residual intussusception after hydrostatic reduction, and surgical complications. Of the 13 patients in whom no avoidable factors were identified, there were nine of 11 children with isolated small bowel intussusception, who tended to have atypical presentations. CONCLUSION: Although the mortality from intussusception has declined, there remains ample opportunity for improved management.

Child↗
PubMed1992

BCG immunisation in England and Wales: a survey of policy and practice in schoolchildren and neonates.

OBJECTIVE: To determine the policy and practice of district health authorities in England and Wales for BCG immunisation in schoolchildren and neonates. DESIGN: Self completion postal questionnaire survey. PARTICIPANTS: District immunisation coordinators. SETTING: 199 district health authorities in England and Wales. RESULTS: Questionnaires were received from 186 districts, a response rate of 94%. Considerable uniformity was observed in many aspects of BCG immunisation policy and practice but some important variations were found. 15 districts no longer carry out a routine schools programme. 148 districts offer BCG to selected groups of neonates and five to all neonates, but 31 districts do not offer BCG to this age group. The recommended action in response to different levels of tuberculin sensitivity in schoolchildren and neonates varied among districts. CONCLUSIONS: Despite the recommendations of the Joint Committee on Vaccination and Immunisation some districts do not offer BCG immunisation to neonates at high risk of tuberculosis and there are important variations in other aspects of BCG policy.

BCG Vaccine↗
PubMed1993

Social deprivation and premature mortality: regional comparison across England.

OBJECTIVE: To investigate the pattern and size of the relationship between social deprivation in electoral wards and premature mortality for each health region in England. DESIGN: Ecological study using 1981 census variables and data on mortality for 1981-5. SETTING: 14 regional health authorities in England. MAIN OUTCOME MEASURE: Mortality under the age of 65 years from all causes, coronary heart disease, and smoking related diseases in men and women. RESULTS: Increasing deprivation was significantly associated with mortality from all causes, coronary heart disease, and smoking related diseases. The relationship was linear with no apparent threshold. Correlation coefficients were generally greater for deaths from all causes and smoking related diseases and for men compared with women. The slope of the relationship between deprivation and mortality varied among regions. Variations in mortality still existed between regions for equal levels of deprivation. CONCLUSION: Deprivation of an area and premature mortality are strongly linked. The effects of deprivation can be seen throughout the range of affluence and are not limited to the poorest areas. Current targets for reducing coronary heart disease mortality may be achievable if the mortality in poor areas can be reduced to the rates in affluent areas.

Adult↗
PubMed1994

Patient characteristics and clinical caseload of short stay independent hospitals in England and Wales, 1992-3.

OBJECTIVE: To describe and quantify the patients and clinical activities of independent short stay hospitals. DESIGN: Retrospective survey of hospital records for sampled periods of one financial year and comparison with data from 1981 to 1986. SETTING: 217 independent hospitals in England and Wales, 1992-3. MAIN OUTCOME MEASURES: Distributions of sex, age groups, and areas of residence of patients, clinical procedures, financial provision. RESULTS: Data were obtained from 201 (93%) hospitals. An estimated 429,172 inpatients (7% more than 1986) and 249,531 day cases (an increase of 154%) from 1986 were treated in the year. The number of overseas patients was half that in 1986. Clinical case mix remained similar to 1986. Abortion remained the commonest procedure (13% v 19% in 1986). Lens operations, heart operations, endoscopies, and non-surgical cases showed the largest increases from 1986. Proportionately more overseas patients had abortions (30% v 12% for England and Wales residents) and they received 41% of coronary artery bypass grafting. Three quarters of the patients were aged 15-64. The proportion of patients aged over 65 had changed little (19% v 17% in 1986). Estimated average bed occupancy was only 48%. Only one in 20 patients was treated under NHS contract; 90% of episodes were funded through private health insurance. CONCLUSIONS: The demand for treatment in private hospitals continues to increase despite additional investment in the NHS, but the overseas market is falling. Overall, the range of clinical activity has changed little.

Adolescent↗