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PubMed2006

The costs of epilepsy misdiagnosis in England and Wales.

BACKGROUND: The management of epilepsy incurs significant costs to the United Kingdom (UK) National Health Service (NHS). Making a diagnosis of epilepsy can, however, be difficult and misdiagnosis frequently occurs when patients are seen by non-specialists. This study estimates the financial costs of epilepsy misdiagnosis in the NHS in England and Wales. METHODS: Standard costing methods were applied to estimate the costs attributable to epilepsy misdiagnosis. The primary data were published in UK studies on the prevalence of epilepsy, epilepsy misdiagnosis and costs identified from Medline, Cinahl and Embase (1996-May 2006). RESULTS: An estimated total of 92,000 people were misdiagnosed with epilepsy in England and Wales in 2002. The average medical cost per patient per year of misdiagnosis was 316 pounds sterling, with the chief economic burdens being inpatient admissions (45%), inappropriate prescribing of antiepileptic drugs (AEDs) (26%), outpatient attendances (16%) and general practitioner (GP) care (8%). The estimated annual medical costs in England and Wales were 29,000,000 pounds sterling, while total costs could reach up to 138,000,000 pounds sterling a year. CONCLUSIONS: Allowing for uncertainty, and considering the analysis exclusively from the NHS/CBS (community based services) perspective the opportunity costs of misdiagnosis are substantial. There is a need for health care commissioners to ensure that misdiagnosis is kept to a minimum by ensuring that individuals with a recent onset suspected seizure are seen as soon as possible by a specialist medical practitioner with training and expertise in epilepsy.

Cost of Illness↗
PubMed2005

Fertility history and health in later life: a record linkage study in England and Wales.

Women born at different periods within the 20th century in England and Wales have followed varying fertility pathways with large changes in, for example, proportions having no children or only one child. Among the consequences of these changes may be effects on women's health later in life. Links between fertility histories and later health and mortality have been investigated in several studies, but in many of these socio-economic characteristics have not been allowed for, even though there are socio-economic differences in both fertility and mortality patterns and results are conflicting. Here we analyse associations between the fertility histories of women born 1911-1940 in England and Wales and their mortality and health status after age 50. We used data from the Office for National Statistics Longitudinal Study; a record linkage study of approximately 1% of the population initially based on those enumerated in the 1971 Census of England and Wales. We used survival analysis to investigate the effects of parity, short birth intervals, and timing of fertility on mortality from age 50 to the end of 2000, controlling for a range of relevant socio-demographic characteristics. For survivors to 1991, we additionally used logistic regression to model probability of having a limiting long-term illness in 1991. We found that nulliparous women and women with five or more children had significantly higher mortality than other women, and that in the oldest groups women with just one child also had raised mortality. Women who had been teenage mothers had higher mortality and higher odds of poor health than other parous women. Mothers with short birth intervals, including mothers of twins, also had elevated risks in some cohorts. Late childbearing (after age 39) was associated with lower mortality. Personal demographic history is an important factor to consider in analyses of health and mortality variations in later life. More research is needed to further elucidate causal pathways.

Birth Intervals↗
PubMed2003

Does car ownership reflect socio-economic disadvantage in rural areas? A cross-sectional geographical study in Wales, UK.

It is widely believed that area-based deprivation indices that include the car ownership census variable are poor indicators of deprivation in rural areas since car ownership is a necessity of rural life. In this cross-sectional geographical study, we assess whether the relation between lack of car ownership and socio-economic deprivation varies between urban and rural enumeration districts of Wales, UK. We classified the 6376 census enumeration districts in Wales into rural (1636, 26%) and urban (4740, 74%), using the Office for National Statistics' classification based on land use. Rank correlation coefficients between the proportion of households with no car and a range of other proxy deprivation census variables were strongly positive in urban and the most densely populated rural enumeration districts. However, these correlations were weaker in sparsely populated rural enumeration districts, with a declining trend across deciles of population density. Exclusion of the car ownership variable from the Townsend index of deprivation re-categorized rural enumeration districts as more deprived and urban enumeration districts as less deprived compared with the standard Townsend index. Our results suggest that lack of car ownership is a poor proxy for social deprivation in the most sparsely populated rural areas of Wales, and therefore, deprivation indices that include the car ownership variable are less valid for use in rural areas.

Automobiles↗
PubMed1984

Contribution of the private sector to elective surgery in England and Wales.

From a sample of 12 959 records of patients treated in 148 of the 153 independent acute hospitals in England and Wales in 1981, it was estimated that 344 008 patients were admitted during that year. Residents of England and Wales admitted for inpatient elective surgery other than termination of pregnancy represented 162 000 of these cases. From 1980 Hospital Inpatient Enquiry data it was estimated that a further 57 000 similar elective treatments were undertaken in National Health Service pay-beds. The 219 000 patients treated in the combined private sector represented 13.2% of the total case-load in domestic inpatient elective surgery. For certain operations this proportion rose to 26%, and for some regions the private sector cases represented more than 20% of the total work-load; therefore when assessing the need for, and provision of, acute health care in England and Wales, the contribution of the private sector cannot be ignored.

Adolescent↗
PubMed2002

The incidence of severe physical child abuse in Wales.

OBJECTIVES: The purposes of this study were: (1) to ascertain the incidence and nature of severe physical child abuse in Wales; (2) to ascertain the incidence of all physical abuse in babies under 1 year of age; and (3) to determine whether child protection registers (CPR) accurately reflect the numbers of children who are physically abused. METHODS: This is a population-based incidence study based in Wales, UK, for 2 years from April 1996 through March 1998. Children studied were under the age of 14 with severe physical abuse consistent with the criminal law level of Grievous Bodily Harm. This included seven categories of injury (death; head injury including subdural hemorrhage; internal abdominal injury; physical injury in Munchausen Syndrome by Proxy including suffocation; fracture; burn or scald; adult bite). Cases were ascertained by a pediatrician surveillance reporting system (WPSU). A criterion for inclusion was multidisciplinary agreement that physical abuse had occurred (at case conference, strategy meeting, or Part 8 Review). The incidence of all babies under 1 year of age with physical abuse was also studied. Ascertainment of babies under the age of 1 year was undertaken from CPR as well as the WPSU. RESULTS: Severe abuse is six times more common in babies [54/100,000/year (95% CI +/- 17.2)] than in children from 1 year to 4 years of age [9.2/100,000 (95% CI +/- 3.6)]. It is 120 times more common than in 5- to 13-year-olds [0.47/100,000 (95% CI +/- 0.47)]. This is mainly because two types of serious abuse (brain injury including subdural hemorrhage and fractures) are more common in babies under the age of 1 year than older children. Using data from two sources (the WPSU and CPRs), the incidence of physical abuse in babies is 114/100,000 (CI 114 +/- 11.8) per year. This equates to 1 baby in 880 being abused in the first year of life. The largely rural Health Authority area in Wales had incidence figures for abuse in babies that were 50% of the three other predominantly urban Health Authority areas. Boys throughout the series were more at risk of being severely abused than girls (p < .025). Only 29% of the babies under 1 year of age on the CPR had actually been injured. Thirty percent of abused babies under the age of 1 year and 73% of severely abused children over the age of 1 year had caused previous concern to health professionals regarding abuse or neglect. CONCLUSIONS: Physical abuse is a significant problem in babies under the age of 1 year. Very young babies (under 6 months old) have the highest risk of suffering damage or death as a result of physical abuse. Severe abuse, in particular subdural hematoma and fracture, is much more common in babies than in older children. There is evidence of failure of secondary prevention of child abuse by health professionals, with a greater need to act on concerns regarding abuse and neglect. Interagency child protection work in partnership with parents should focus more on protecting babies under age 1 year from further abuse than on maintenance of the infant within an abusive home. The CPR is not intended as an accurate measure of children suffering abuse. It is a record of children requiring a child protection plan and must not be used as a measure of numbers of abused children.

Abdominal Injuries↗
PubMed2004

Burden and cost of imported infections admitted to infectious diseases units in England and Wales in 1998 and 1999.

BACKGROUND: International travel from the UK has been rising, and the number of imported infections has increased. This study aimed to describe the number, nature, origin, clinical burden and cost of imported infections treated in infectious disease units (IDU) in England and Wales. METHOD: Information about all admissions in 1998 and 1999 with illnesses considered to have been acquired during their most recent travel abroad was collected retrospectively by IDUs using a pre-piloted questionnaire. RESULTS AND ANALYSIS: Four of the 23 IDUs in England and Wales were able to complete the questionnaires. They reported a total of 421 travel related admissions during the 2-year period. Three hundred and ninety-two of these cases were attributed to infectious causes, and of these a discharge diagnosis was made for 340 cases. The total number of bed days used to treat cases of imported infection was 2918. The most common diagnosis was malaria. The odds ratio that cases of imported infection were malaria was highest following visits to Africa. The average cost per bed day on the IDUs was around pound sterling 100, and on this basis, the total cost of treating imported infections on the four IDUs in 2 years was around pound sterling 289,000. The relative risk of acquiring an imported infection requiring treatment on an IDU was greatest for travellers to Africa. CONCLUSIONS: From this study, the estimate of the total annual cost of IDU treatment for imported infections in England and Wales is in excess of pound sterling 800,000. Many cases may be preventable with prophylactic medication and vaccination and travel advice on risk reduction. Further information about imported infections would be useful to inform travel medicine services, other clinicians and travellers about the health risks associated with travel to specific areas, and help to target and assess the cost effectiveness of preventative measures.

Adult↗
PubMed1999

The effect on morbidity of variability in deprivation and population stability in England and Wales: an investigation at small-area level.

We seek to determine whether variability in deprivation at small area level, and population stability, influence standardised morbidity ratios in England and Wales. A regression analysis was conducted with data from the 1991 British Census, in order to explain variation in morbidity. Both an area deprivation score (for electoral wards) and the within-area variability of deprivation scores were examined as possible determinants of morbidity (self-reported, limiting, long-term illness). Particular attention was focused on a spatially-sensitive measure of the variability of deprivation scores within a wider 'locality'. There was a significant, positive relationship between age-standardised limiting, long-term illness and deprivation. The variation in area deprivation scores within the small areas themselves was also significant and positive. However, the variation in deprivation scores calculated for both an electoral ward and its contiguous neighbours (the locality) was slightly more significant. Areas with higher relative levels of in-migration also had significantly lower standardised morbidity ratios. Multivariate models showed that the deprivation score, the variation in deprivation scores for the broader locality, and the measure of migration, were all significant in combination. Residual analysis showed that many areas in London had lower levels of morbidity than expected, while electoral wards in the coal mining valleys of South Wales had higher levels than expected. We conclude that, for small areas (wards) in England and Wales, morbidity is related to deprivation, variation in deprivation within and surrounding each area, and the proportion of the population that are migrants. Variations in deprivation influence standardised morbidity rates, and policies which widen inequalities will influence health outcomes. Resource allocation based simply on measures of deprivation, which ignore population change within the area and variations in deprivation in the locality, may be inefficient.

Censuses↗
PubMed2001

Reasons for extraction by dental practitioners in England and Wales: a comparison with 1986 and variations between regions.

OBJECTIVES: To compare reasons for extraction in 1997 and 1986, and to consider regional variations for the 1997 data. METHODS: Random samples of general dental practitioners (GDPs) completed questionnaires for all extractions for 4 weeks in 1986 and in 1997. Reasons for extraction by region were compared for the 1997 data. RESULTS: 220 and 562 GDPs participated in 1986 and 1997, respectively, averaging 24 extractions in 1986 and 20 in 1997. 'Caries' remained the commonest reason for < or =50-year-olds (excluding 'ortho'), but peaked a decade later than in 1986. One-third of 'perio' extractions in both studies were for 51-60-year-olds, but in 1997 there were fewer such extractions for < or =40-year-olds and more for >70-year-olds than in 1986. In 1997 'caries' and 'perio' extractions remained equally common for patients >50 years, but there were far more extractions for both reasons for >80-year-olds. Patients < or =30 years in S. England and in the Midlands/E. Anglia had more 'ortho' than 'caries' extractions, whereas 'caries' predominated in N. England and in Wales. 'Caries' exceeded 'perio' for patients >40 years in Wales, whereas in the three English regions the two reasons were equally frequent. CONCLUSIONS: Comparisons of results of two studies conducted a decade apart indicate that there have been some changes in reasons for extraction. Overall, mean number of extractions per dentist has declined, and it appears that the trend is for extractions due to the common dental diseases to be carried out later in life. The 1997 data also suggest that young patients in Wales and N. England are relatively disadvantaged, having more caries and less orthodontic treatment than those in other parts of England.

Adolescent↗
PubMed1990

Trends in perinatal mortality attributed to congenital malformations in England and Wales during 1974-81: a study of the variations among regional health authority areas.

Analysis of perinatal mortality attributed to congenital malformations in England and Wales, using data from birth and death registration over the years 1974-81 showed significant declines in England and Wales as a whole and in the individual Regional Health Authority (RHA) areas. A greater decrease in death rate from congenital malformations, particularly central nervous system malformations, was seen among stillbirths than among early neonatal deaths. There were marked regional differences in perinatal mortality due to central nervous system malformations over the period but not in cardiovascular system malformations or in other malformations. The highest mortality rates due to central nervous system malformations occurred in the North, North-West, West and South-West of England and in Wales, and the lowest rates in the South and South-East. The larger percentage reductions in the mortality rates were found in most of the regions which had had the highest rates. Possible explanations for the decline in regional rates are suggested.

Cause of Death↗
PubMed1986

The epidemiology of hydatid disease in England and Wales.

The epidemiology of hydatid disease in man in England and Wales, based on the data collected between 1981 and 1983 at the Hydatid Reference Laboratory of the Public Health Laboratory Service, is presented. The incidence of hydatid disease was 42 cases per annum, with 2 cases per million population occurring in Wales and 0.2 per million in England. The highest prevalence was in London amongst the immigrant population. The incidence in the indigenous population was 15.5 cases per annum, with 5.6 cases per million occurring in South Powys, parts of South Wales and Herefordshire. The population most at risk is the rural, farming community in that area, but the West Midlands is also an apparent focus of the disease.

Adolescent↗
PubMed2002

Suicide preceded by murder: the epidemiology of homicide-suicide in England and Wales 1988-92.

BACKGROUND: We describe for the first time the epidemiology of homicide-suicide incidents for England and Wales. Previous descriptions have been of incidents in London (1946-62) and Yorkshire and Humberside (1975-1992). METHODS: Death certificates were obtained for all who died in homicide-suicide incidents in England and Wales (1988-1992) that were reported by the police to the Home Office. Incidents were included in the analysis if the interval between death or fatal injury of victim and suspect was 3 or fewer days. RESULTS: Three hundred and twenty-seven people died in 144 incidents (180 victims and 147 suspects). Eighty per cent of incidents had one victim and one suspect. Three incidents were also suicide pacts between two suspects killing their children. Eighty-eight per cent of incidents exclusively involved members of the same family, 9 % acquaintances or strangers, and 3 % both family and acquaintances or strangers. Seventy-five per cent of victims were female, 85% of suspects male. The victims of male suspects were predominantly their womenfolk, past and present, and their children, and of female suspects their young children. Car exhaust and firearms accounted for 40% of victim and 50% of suspect deaths. Of all homicides during 1988-1992, 3 % of male, 11% of female and 19% of child deaths occurred in homicide-suicide incidents. Similarly, of all suicides, 0.8% of male and 0.4% of female deaths occurred in homicide-suicide incidents. CONCLUSIONS: Homicide-suicide in England and Wales is mostly 'a family matter', men of predominantly lower social class killing their kin, and pre-menopausal mothers their young children, before they kill themselves. A few men kill strangers during a crime and then themselves.

Adolescent↗
PubMed1995

A comparison of the investment in hospital-based obstetrical ultrasound in Wales and Washington state.

The purpose of this study was to examine differences in the way Britain and the United States invest in and deploy a new medical technology. We used structured interviews to obtain information on the technical sophistication and approximate replacement value of all hospital-based obstetrical ultrasound machines in every maternity hospital in Washington state and Wales. The supply of hospital-based ultrasound machines--approximately two machines per 1,000 births--was similar in both countries. Wales had fewer advanced ultrasound machines than Washington state, and they were based exclusively in high-volume district general hospitals; there were no obstetric ultrasound machines in the private sector. In Washington state, the majority of advanced machines were in small and medium-sized hospitals, and many private offices had ultrasound machines. The approximate replacement value of hospital-based machines was three times as high per birth in Washington state as in Wales. In the case of obstetrical ultrasound, centralization of facilities, a relatively small private sector, and global budgeting lead to lower expenditures per patient within the National Health Service without compromising access to care.

Birth Rate↗
PubMed2001

Emerging trends in the epidemiology of invasive mycoses in England and Wales (1990-9).

Invasive fungal infections are becoming an increasing public health problem owing to the growth in numbers of susceptible individuals. Despite this, the profile of mycoses remains low and there is no surveillance system specific to fungal infections currently existing in England and Wales. We analysed laboratory reports of deep-seated mycoses made to the Communicable Disease Surveillance Centre between 1990 and 1999 from England and Wales. A substantial rise in candidosis was seen during this period (6.76-13.70 reports per million population/year), particularly in the older age groups. Rates of cryptococcosis in males fluctuated over the decade but fell overall (1.05-0.66 per million population/year), whereas rates of female cases gradually rose up until 1998 (0.04-0.41 per million population/year). Reports of Pneumocystis carinii in men reduced substantially between 1990 and 1999 (2.77-0.42 per million population/year) but showed little change in women. Reports of aspergillosis fluctuated up until 1996, after which reports of male and female cases rose substantially (from 0.08 for both in 1996 to 1.92 and 1.69 per million population/year in 1999 for males and females respectively), largely accounted for by changes in reporting practice from one laboratory. Rates of invasive mycoses were generally higher in males than females, with overall male-to-female rate ratios of 1.32 (95% CI 1.25-1.40) for candidosis, 1.30 (95% CI 1.05-1.60) for aspergillosis, 3.99 (95% CI 2.93-5.53) for cryptococcosis and 4.36 (95% CI 3.47-5.53) for Pneumocystis carinii. The higher male than female rates of reports is likely to be a partial reflection of HIV epidemiology in England and Wales, although this does not fully explain the ratio in infants and older age groups. Lack of information on underlying predisposition prevents further identification of risk groups affected. Whilst substantial under-reporting of Pneumocystis carinii and Cryptococcus species was apparent, considerable numbers of superficial mycoses were misreported indicating a need for clarification of reporting guidelines. Efforts to enhance comprehensive laboratory reporting should be undertaken to maximize the utility of this approach for surveillance of deep-seated fungal infections.

Adolescent↗
PubMed1999

The prevalence of hepatitis B infection in adults in England and Wales.

Cost effectiveness analyses of alternative hepatitis B vaccination programmes in England and Wales require a robust estimate of the lifetime risk of carriage. To this end, we report the prevalence of infection in 3781 anonymized individuals aged 15-44 years whose sera were submitted in 1996 to 16 microbiology laboratories in England and Wales. One hundred and forty-six individuals (3.9%) were confirmed as anti HBc positive, including 14 chronic carriers (0.37%). The prevalence of infection and carriage was higher in samples collected in London and increased with age. No increased risk of infection was seen in sera from genito-urinary (GUM) clinics. Only 15 sera positive for hepatitis B were also positive for hepatitis C. Our results confirm the low prevalence of hepatitis B in England and Wales, are consistent with previous estimates of carriage and suggest that many infections were acquired while resident outside the UK. Future prevalence studies should determine the country of birth and other risk factors for each individual in order to confirm these findings.

Adolescent↗
PubMed1999

Observations on the effect of abolishing analgesic abuse and reducing smoking on cancers of the kidney and bladder in New South Wales, Australia, 1972-1995.

OBJECTIVES: We have assessed the effect on the rates of cancers of the kidney and bladder of measures undertaken by the government in 1979-1983 to limit smoking and analgesic abuse in New South Wales (NSW). Sale of phenacetin-containing analgesics, previously available without restriction and regularly taken by 11-13% of women and 4-9% of men in NSW, was prohibited from 1979. The prevalence of current smokers among adult Australian men had fallen from 72% in 1945 to 43% in 1980 and to 28% in 1992. In women the corresponding figures were 26%, 31% and 24%. METHODS: Incidence and mortality data from the New South Wales Central Cancer Registry for the period 1972 to 1995 were analyzed, by sex and age, for trends over time. Relative survival was calculated for cases diagnosed in the period 1980-94 and followed until the end of 1996. RESULTS: Significant trends evident from these data were: throughout the period of review a rising incidence of, and to a lesser extent mortality from, renal parenchymal cancer for which relative survival has steadily improved; falling mortality from bladder cancer throughout the period of review, but more rapid after 1985; a reversal of the earlier increasing incidence of, and mortality from, cancer of the renal pelvis; and relative survival for bladder and renal pelvic cancers which was worse in women than men. Changes in registration practice in 1985 and 1993 introduced artifacts into the trends in incidence of bladder cancer. CONCLUSIONS: Improvements in the trends of incidence and mortality of cancers of the renal pelvis and bladder in the mid-1980s are interpreted, in the light of registration and clinical practice, to indicate a beneficial effect of regulations which virtually abolished analgesic abuse and, less certainly, a contribution from measures restricting smoking, in New South Wales. However, renal parenchymal cancer continues to increase, although there has been some apparent benefit of earlier detection.

Adult↗
PubMed1981

Recent trends in mortality from prostate cancer in male populations of Australia and England and Wales.

Mortality rates from cancer of the prostate in successive periods from 1908 to 1978 in Australia, and 1911 to 1977 in England and Wales, have been examined for trends with time and birth cohort. Age-specific rates and a proportional hazards model, designed to isolate the effect of birth cohort from those of calendar year and age, were used in the analysis. During the period of study, age-standardized mortality rose more than 5-fold in Australian men compared to just over 3-fold in men in England and Wales. In both countries the increases occurred almost entirely before 1960, with relative stability in age-standardized rates since then. The trends in mortality with year of birth were similar in the two sets of data. The risk of death from prostate cancer increased with successive birth cohorts to reach a peak in men born around 1865-1880 in Australia and men born around 1876-1896 in England and Wales. Males born later experienced a continuing reduction in rates, with the exception of age groups between 50 and 69 in which a further increase has appeared, starting with cohorts born after 1910. On the basis of current knowledge of the aetiology of prostate cancer, possible relationships between changes in sexual practices and prostate-cancer risk in successive generations have been explored. It is suggested that lowered sexual activity during the Great Depression may account for the recent cohort-based increases in mortality in middle-aged men.

Adult↗
PubMed1996

Trends in eye cancer mortality among adults in the USA and England and Wales.

Trends in eye cancer mortality are presented for the USA and England and Wales during the period 1955-89. Mortality rates have fallen by 58% in the USA during this period. The fall in mortality is paralleled by an equal fall in incidence rates in the USA. In England and Wales, mortality rates and incidence rates have remained relatively constant during the last three decades. The explanation for these differences between the USA and England and Wales is unknown.

Age Factors↗
PubMed2005

Carbon losses from all soils across England and Wales 1978-2003.

More than twice as much carbon is held in soils as in vegetation or the atmosphere, and changes in soil carbon content can have a large effect on the global carbon budget. The possibility that climate change is being reinforced by increased carbon dioxide emissions from soils owing to rising temperature is the subject of a continuing debate. But evidence for the suggested feedback mechanism has to date come solely from small-scale laboratory and field experiments and modelling studies. Here we use data from the National Soil Inventory of England and Wales obtained between 1978 and 2003 to show that carbon was lost from soils across England and Wales over the survey period at a mean rate of 0.6% yr(-1) (relative to the existing soil carbon content). We find that the relative rate of carbon loss increased with soil carbon content and was more than 2% yr(-1) in soils with carbon contents greater than 100 g kg(-1). The relationship between rate of carbon loss and carbon content is irrespective of land use, suggesting a link to climate change. Our findings indicate that losses of soil carbon in England and Wales--and by inference in other temperate regions-are likely to have been offsetting absorption of carbon by terrestrial sinks.

Carbon↗