bluuebunny/crossref_metadata_2025 huggingface dataset:
OP27 Marital Status and Ischaemic Heart Disease: The Prospective Million Women Study
Authors: Floud S , Cairns B , Balkwill A , Reeves G , Green J , Beral V
Published: September 2013

Background

Being married is known to decrease the risk of all cause and cardiovascular mortality for men, but it is not clear if marriage confers a similar benefit for women. In addition, few studies have examined marital status in relation to both mortality and disease incidence to determine whether the beneficial effects of marriage influence the aetiology or prognosis of disease.

Methods

A total of 747,532 women (mean age: 59.8, SD 4.9), without previous heart disease, stroke or cancer, were followed prospectively for an average of 6.1 years for hospital admissions and deaths. We used Cox regression models to calculate relative risks for the first ischaemic heart disease (IHD) event and for IHD deaths comparing married women to unmarried women, adjusting for age, region of residence, socio-economic status, health-related behaviours, social support, depression and self-rated health. We also calculated relative risk of subsequent death in participants whose first IHD event was a hospital admission (n = 19,506, mean follow-up 2.7 years).

Results

At baseline, 2000-2003, 81% of the sample was married or living with a partner. Over follow-up, there were 20,458 first IHD events (19,572 non-fatal and 886 fatal), and among those whose first event was a hospital admission there were 407 deaths. Married women had lower rates of smoking and physical inactivity, were less deprived, and less likely to rate their health as poor. In women who had no prior hospital admissions for IHD, married women had a 34% lower risk of IHD death as a first event than unmarried women (p < 0.001), but no significantly decreased risk of non-fatal hospital admission for IHD. Among the women whose first IHD event was a (non-fatal) hospital admission, married women did not have a significant reduction in subsequent mortality.

Conclusion

Being married or living with a partner appears to reduce the risk of death from IHD for women, which is not fully explained by health-related behaviours or by socio-economic status.
OP28 Trends in Mortality from Stroke, and Stroke Subtypes, in the Oxford Region 1979-2011
Authors: Seminog O O , Goldacre R , Goldacre M J
Published: September 2013

Background

A decline in mortality rates from stroke has been observed in many industrialised countries in recent decades. We were interested in whether any of the observed decline in stroke, and its subtypes, might be artefactual rather than real. In particular, we wanted to determine whether any of the trends over time might be attributable to shifts in death certification practice between underlying cause and contributory cause, and/or shifts over time between certification of specific subtypes (haemorrhagic and ischaemic stroke) and stroke without specification of type.

Methods

We analysed mortality data from the former Oxford NHS region 1979–2011. This has a longer run of multiple-cause coded mortality data than all-England mortality (though findings from the latter will also be shown). We calculated age-standardised rates, presented as mortality rates per million population, in each year from 1979–2011 and in grouped years for periods defined by national changes to the rules for selection of underlying cause (the rules changed in 1984, 1992 and 2001).

Results

Mortality rates based on any mention of stroke on the death certificate, and on underlying cause, showed broadly similar trends. Mortality rates for each code for stroke – ischaemic, haemorrhagic and ‘unspecified’ – and for stroke overall fell at a broadly similar rate between 1979–1992. Thereafter, trends diverged. The average annual rate for mortality in men from ischaemic stroke in 2001–2011, at 72.7 per million, was 11% lower than that in 1993–2000 at 84.2. The corresponding rates for haemorrhagic stroke were 93.6 and 92.7, i.e. they did not fall at all. By contrast, the average annual rate for stroke ‘unspecified’ in men was 355.9 in 2001–11 which was 56% lower than the rate of 600.8 in 1993–2000. Stroke mortality, overall, fell from 768.1 to 504.5 between 1993–2000 and 2001–2011. In recent years, when national multiple-cause coding data were available, national trends were similar to those in Oxford in these respects. Rates for women will also be shown (they exhibited the same pattern).

Conclusion

There have been substantial changes in certification practice with a shift in recent years away from specifying stroke type. Studies of trends in mortality from ischaemic stroke alone, or haemorrhagic stroke alone, without being put into the broader context of all stroke, would be seriously misleading. They would suggest a levelling off of the decline in ischaemic and haemorrhagic stroke mortality in recent years which is, in fact, an artefact of certification and coding practice.
OP03 Assessing the Evidence Base of Tobacco Industry Submissions to Public Consultations: The case of ‘plain Packaging’ of Tobacco Products in the UK
Authors: Hatchard J , Fooks G J , Evans-Reeves K A , Gilmore A
Published: September 2013

Background

The UK’s public consultation on ‘plain packaging’ of tobacco products generated an unprecedented volume of responses. Given the track record of the tobacco industry’s misuse of science to oppose policy change, and the fact that plain packaging has only recently been introduced in a single jurisdiction – Australia, December 2012 – how can policymakers weigh up evidence submitted to them? In this paper, the authors deliver an analysis of the relevance and quality of evidence on ‘plain packaging’ submitted to the UK Department of Health by the UK’s four largest tobacco companies to support their argument that plain packaging will not meet associated public health objectives for disease prevention.

Methods

We conducted a case-study based comparative analysis of the quality of evidence cited in tobacco industry submissions consultation with that presented in favour of ‘plain packaging’ in a ‘Systematic Review’ of the literature. We coded each piece of evidence for relevance of subject matter and three quality criteria - funding source, primary or secondary research and peer-review status – and compared the relevance and quality of the two bodies of evidence.

Results

We identified 112 pieces of evidence which present arguments about whether or not plain packaging will influence smoking behaviour – 65 from industry submissions, and 37 from the ‘Systematic Review’. Our preliminary findings are that the tobacco industry cited 10 sources of evidence which critique the evidence for ‘plain packaging’. These were funded by the tobacco companies and were not peer-reviewed. The tobacco companies cited a further 55 sources of new evidence, 34 presenting primary research. Of these 34, 2 related directly to ‘plain packaging’, one of which was funded by the tobacco industry and 14 of the 34 appeared in peer-reviewed journals. In contrast, all of the 37 ‘Systematic Review’ papers were funded independently of the tobacco industry and presented primary research directly related to plain packaging. 22 of these reports appeared in peer-reviewed journals.

Conclusion

Our preliminary findings suggest that evidence cited by the tobacco industry to oppose ‘plain packaging’ is, overall, not as relevant or robust as the growing body of evidence in favour of this regulatory proposal. We propose that an evidence assessment framework, based on four criteria – relevance of research, independence of funding, nature of research and peer-review may offer a structure by which policy-makers can make an assessment of the evidence base of submissions to public consultations, especially where response volumes are high.
OP31 Is Excess Mortality in Glasgow an Artefact of Inadequate Control for Deprivation: A Case-Control Study
Authors: Dundas R , Ralston K , Walsh D , Leyland A H
Published: September 2013

Background

Scotland experiences higher mortality than the rest of Western Europe with Glasgow experiencing higher mortality than the rest of Scotland. This excess persists even when controlling for socio-economic status and levels of deprivation. Moreover, available measures of deprivation have accounted for less of the Glasgow excess over last 30 years. Many theories have been put forward to account for these differences and a recent review identified seventeen hypotheses. One hypothesis, investigated here, was an artefact of inadequate control for deprivation.

Methods

Previous analyses of Glasgow’s ‘excess’ within Scotland have been based on comparison with nationally derived deprivation groupings (e.g. quintiles, deciles). Glasgow’s unique deprivation profile in comparison to the rest of Scotland renders such approaches problematic. Our approach, therefore, is as follows: small area geographies (datazones) were ranked by the Scottish Index of Multiple Deprivation (SIMD) income domain. Using a case control design datazones in Glasgow (cases) were matched with the closest non Glasgow datazone ranked above and below (controls). Geocoded mortality and population data were available for all deaths by age and sex for 2000-2002. Age-standardised all-cause mortality rates were calculated for men and women between the ages of 0–64, and for all ages. Age-standardised mortality rates by sex were compared for cases and matched controls for each quintile of deprivation.

Results

Men in the 3 most deprived quintiles in Glasgow experienced higher levels of mortality compared to both the nearest non-Glasgow datazones and all non-Glasgow datazones within the quintile. Excess mortality was reduced for the 2 most affluent quintiles. The pattern was broadly similar for women, with the excess reduced for the 3 most affluent quintiles. The age-standardised mean mortality rate for men aged 0–64 in Glasgow in the most deprived quintile was 769 per 100,000. The corresponding rate for all non-Glasgow datazones was 582 per 100,000. The mortality rate for the control group was 688 per 100,000, suggesting a substantially smaller excess. Using this case-control approach, the excess is reduced by 57% in the most deprived quintile. In the second most deprived quintile it is reduced by 15%. The corresponding results for women are reductions of 57% (most deprived quintile) and 47% (second most deprived quintile).

Conclusion

Using national population and mortality data, the excess mortality in Glasgow in the most deprived area is halved by means of a closer control for deprivation. Explanations are still required for the remaining excess suggesting it is only partly artefactual.
OP32 Symptoms, Diagnosis and Treatment in Socio-Economic Inequalities of Health
Authors: Hardcastle A C , Steel N , Bachmann M O , Melzer D
Published: September 2013

Background

Ill health and relative poverty are connected. This study aimed to determine first whether the worse health experienced by poorer participants was matched by appropriately greater receipt of healthcare, and second whether any inequalities in receipt occurred at the stage of diagnosis or treatment.

Methods

The English Longitudinal Study of Ageing is a cohort of participants aged 50 years or older. The relative distributions by wealth of symptoms, diagnosis and treatment of five common chronic conditions (angina, diabetes, depression, osteoarthritis, and cataract) were analysed in four waves of data collected from 2002 to 2010. Symptoms were defined for angina using the Rose Angina scale, diabetes using fasting HbA1c level, depression using the Centre for Epidemiologic Studies Depression Scale, osteoarthritis as self-reported pain and disability, and cataract as self-reported poor vision. Doctors’ diagnoses for all conditions were self-reported. Treatment was defined for angina as beta-blocker prescription, osteoarthritis and cataract as surgery, and diabetes and depression as receiving treatment described in quality indicators. Binomial regression models tested variations between the hypothetically poorest and richest individuals for age and sex adjusted symptoms, diagnosis and treatment across the waves, using a slope index of inequality.

Results

Symptoms were commoner in poorer participants in all 5 conditions at all 4 timepoints, with ORs ranging from 2.5 to 7.0. In angina, depression and diabetes, receipt of diagnosis and treatment was similarly higher in poorer participants, with ORs ranging from 1.9 to 5.6. In osteoarthritis and cataract, receipt of diagnosis and treatment did not show substantial matching variations by wealth, with ORs ranging from 0.8 to 1.9. For example, ORs for diabetes in 2008 were broadly similar for symptoms (2.5 [95% CI 1.5, 4.0], diagnosis (3.8 [3.0, 4.9]) and treatment (3.1 [2.4, 4.0]). In contrast, osteoarthritis ORs were substantially larger for symptoms (6.9 [5.2, 9.1]) than for diagnosis (1.4 [1.2, 1.7]) or treatment (0.8 [0.5, 1.3]).

Conclusion

Poorer participants were much more likely to have symptoms of osteoarthritis and cataract, but not much more likely to receive a diagnosis. The block in equitable receipt of healthcare was at the stage of diagnosis rather than treatment, and so interventions to reduce inequalities in osteoarthritis and cataract should focus on the diagnostic process. The same relative inequalities in diagnosis were not seen in angina, depression and diabetes, which have all been the target of multiple quality improvement initiatives. These patterns remained consistent over 8 years.
OP38 A Nationally Representative Study Exploring the Relationship between Sleep and Obesity in the United Kingdom
Authors: Ellison G T H , Scott E M , Al-Naji A , Afif N Al , Barnes M , Law G R
Published: September 2013

Background

This study explored the potential role that sleep, and sleep improvement, might play in the aetiology of obesity, using data from the first wave of the Understanding Society (USoc) cohort – a longitudinal household panel study representative of the UK population.

Methods

The first wave of USoc collected data on seven self-reported sleep-related variables comprising measures of: sleep duration; sleep quality; snoring and/or coughing while asleep; falling asleep within 30 minutes; use of sleep medication; night time waking; and staying awake during the day. Linear (for log-transformed BMI) and multinomial logistic (for BMI categorised as underweight through morbidly obese) regression analyses were conducted using STATA 12.0, before and after adjustment for age, sex, pregnancy, household income per person and household crowding index (bedrooms per person) as potential confounders. Models were specified using a Directed Acyclic Graph.

Results

Complete data were available on 20,956 (41.1%) of the 50,994 cohort participants. Regardless of the sleep-related variable and whether BMI was operationalised as a continuous or multinomial variable, there was a strong, consistent and statistically significant association between sleep and BMI. Shorter, worse quality and more frequently medicated, disturbed and inadequate sleep were all associated with elevated BMI or an increased risk of overweight and obesity before and after adjustment for confounding. The sleep-related variable most strongly associated with BMI was “cough or snore loudly” where participants who reported doing so “most nights” had an adjusted odds of morbid obesity of 11.94 (95% CI 8.35, 17.07). However, even the sleep-related variable with the weakest association with BMI (“medicine for sleep”) was associated with more than twice the odds of obesity and morbid obesity amongst those participants reporting “medicine for sleep” use three or more time per week. Indeed, the overall consistency of the association between sleep and BMI was evident not only across all seven of the different sleep measures but also in the trends observed for those measures with continuous or ordinal scales.

Conclusion

This is the first nationally representative study to demonstrate a powerful association between sleep duration, sleep quality and obesity in the UK. However, the study is limited by: the substantial number of participants with missing data; its cross-sectional design; and potential clustering of sleep and BMI within households. Further research is therefore required to explore whether naturally occurring changes in sleep duration and quality are associated with changes in BMI to strengthen the evidence for a causal link between sleep and obesity.
OP41 Practising Partnership: A Qualitative Analysis of Public Health and Local Authority Co-Implementation of Health and Mental Wellbeing Improvement Interventions
Authors: Johnson R E , Clarke A , Stewart-Brown S
Published: September 2013

Background

The 2010 NHS White Paper Equity and Excellence: Liberating the NHS proposed major changes to how public health services are delivered from 2013. The imminent transition of public health into local authorities will have implications for how services are planned, commissioned and implemented, particularly for wellbeing initiatives. Anticipating this transition, a city-wide initiative brought together Local Authority and NHS Public Health partners to plan, manage and implement a health and mental wellbeing improvement programme over three years (2009-2012). This qualitative study examines the attitudes and views of stakeholders on their involvement in this programme and their experiences of ‘practising partnership’.

Methods

Qualitative thematic analysis (as part of a mix-methods study). Purposive sampling was used to identify potential participants from three groups (programme stakeholders): directorate, programme managers and intervention managers. One-to-one semi-structured interviews were conducted. We used Schutz’s theory of social phenomenology to support the analytical method and the One Sheet of Paper technique was used to identify emerging themes. Creswell’s (2009) strategies for qualitative validity were used to enhance the accuracy of our findings.

Results

Fifteen one-on-one interviews were completed, out of seventeen requests for interview, with five participants from each stakeholder group. Interview times ranged from 45 minutes to 2 hours and were conducted after participants gave informed consent. Three main themes emerged. The first theme, ‘defining, designing and adapting’ represents stakeholders’ challenges using language with culturally different organisational meaning, introducing new concepts (such as mental wellbeing) and designing a programme with implementation and evaluation structures that were both rigid and flexible. The ‘practice of partnership’ theme reflected how partnership was more of a ‘façade’ at the programmes’ commencement and how, by working through stages of conflict and confusion, stakeholders developed an understanding of what the practice of partnership meant and achieved clarity on how it could be done. The third theme ‘knowledge, learning and understanding’ describes how knowledge was created, diffused and utilised. For example ‘evidence’ was used for different strategic ends depending on the stakeholder perspective -- to promote new ideas or interventions or to bolster an existing intervention to prove its merit.

Conclusion

This study demonstrates the challenges and opportunities for partnership working that are likely to be encountered in the transition of Public Health into local authorities. It offers insight into understanding and practising partnership and has implications for planning, managing and implementing public health and wellbeing improvement interventions post-transition.
OP43 Explaining High Parenting Stress in the Growing Up in Scotland Study for Mothers with Both High and Low Educational Levels: The Role of Employment and Social Support for Parenting
Authors: Parkes A , Sweeting H , Wight D
Published: September 2013

Background

Stresses associated with raising a child may lead to less optimal parenting, with consequences for children’s development. Parent’s employment and receipt of social support may impact on stress differently according to family affluence. Affluent parents may be most pressured when balancing employment with child-related commitments. They may also have relocated, restricting informal support. Disadvantaged parents commonly report barriers to accessing formal parenting support and are more likely to have experienced family break-up, also restricting informal support. This study explores how aspects of employment and social support are associated with parenting stress among mothers grouped according to educational level.

Methods

Data were collected from mothers in the Growing up in Scotland study interviewed when their child was 10 months (N = 5870 out of 6127 main carers contacted in 2011/12). Parenting stress was self-reported using an abbreviated version of the Parental Stress Scale. “High stress” was defined as the bottom quartile of stress scores.

Results

33% of mothers were educated to degree level, 59% had lesser qualifications and 7% none. High stress was more likely among both degree-educated mothers (OR 1.15 [95% CI 1.02, 1.30]) and those with no qualifications (1.60 [1.23, 2.08]), compared to mothers with lesser qualifications. More degree-educated mothers worked full-time (36%) compared to those with lesser (13%) or no (6%) qualifications, but work patterns did not explain stress differences. More mothers with degrees (30%) or no qualifications (31%) were born outside Scotland compared to those with lesser qualifications (13%). High stress levels were greater among degree-educated ‘incomers’ (1.60 [1.34, 1.90]) than mothers with lesser qualifications, but did not differ betweennativedegree-educated mothers and those with lesser qualifications. When compared to mothers with lesser qualifications, odds of high stress among degree-educated ‘incomers’ reduced (1.21 [0.90, 1.62]) after adjustment for difficulty arranging childcare and less frequent contact with friends and the child’s grandparents. Incomer status, childcare problems and frequency of informal support did not explain stress among mothers with no qualifications. Low awareness of and/or receptivity to formal support, and feeling less close to family/friends, attenuated odds of stress for this group to 1.30 (0.97, 1.72).

Conclusion

Parenting stress in degree-educated mothers born outside Scotland was related to childcare problems and more generally to less frequent informal support. Among mothers with no qualifications, fewer close informal ties and more perceived barriers to formal support were associated with stress. Findings suggest different approaches to parenting support are appropriate for different social groups.
OP44 Trends in Community Violence in England and Wales 2005-2009
Authors: Sivarajasingam V , Page N A , Morgan P , Matthews K , Moore S , Shepherd J P
Published: September 2013

Background

Recognising the need for clarity in national violence trends, injury records from Emergency Departments (EDs) have been studied over the last decade as part of the work of the National Violence Surveillance Network (NVSN) and provide information about local, regional and national violence levels and trends in England and Wales. The purpose of the current study is to evaluate overall, gender, age-specific and regional trends in community violence in England and Wales from an ED perspective for the period 2005-2009.

Methods

Violence-related injury data were collected prospectively in a stratified sample of 77 EDs (Types 1, 3 and 4) in the nine Government Office Regions in England and in Wales over five years, January 1 2005 to 31st December 2009. Attendance date, age and gender of patients who reported injury in violence were studied. Time series statistical methods were used to detect national trends.

Results

In total 221,673 (163,384 males: 74%) violence-related attendances were identified. Overall estimated annual injury rate was 6.5 per 1000 resident population (9.8 and 3.4 for males and females respectively). Violence affecting males and females decreased significantly in England and Wales over the five year period (p < 0.05), with an overall estimated annual decrease of 2.4%. Attendances for those aged 17 years and under and those aged 31 years and over decreased significantly (p < 0.05), however violence affecting those aged 18-30 years did not change. There were significant regional differences in violence-related ED attendances with decreases in Eastern, North East, North West, South East Regions and Wales and increases in East Midlands, London, South West and West Midlands regions (p < 0.05). Regarding seasonal differences, violence-related ED attendances were highest during the months of May and July and lowest in February.

Conclusion

From this ED perspective overall violence in England and Wales decreased over the period 2005-2009 but increased in the East Midlands, London, South West and West Midlands. Since 2006, overall trends according to the Crime Survey for England and Wales (CSEW), police and ED measures were similar, though CSEW and ED measures reflect far greater numbers of violent incidents than police data. Causes of decreases in some regions need to be identified, shared and solutions implemented within regions where violence increased. Violence prevention efforts should also be extended so that the December drink driving and safety campaigns are implemented in the period May – July.
OP46 Walking to Work: The Contribution to Adult Physical Activity Levels
Authors: Audrey S , Procter S , Cooper A R
Published: September 2013

Background

There is increasing evidence of the link between adult obesity levels and travel behaviour: countries with highest levels of active travel generally have the lowest obesity rates. Walking is a popular, familiar, convenient, and free form of exercise that can be incorporated into everyday life and sustained into old age. Walking at a moderate pace (5 km/hour) expends sufficient energy to meet the definition of moderate intensity physical activity. The study aims to objectively examine the contribution of walking to work on adult physical activity levels.

Methods

Employees (n = 145) at 17 workplaces in Bristol, who lived within 2 miles of the workplace, were asked to wear accelerometers for 7 days from waking in the morning to going to bed at night, and to carry a GPS receiver during the daily commute to and from work. GPS data were matched with accelerometer data to provide a measure of duration of the journey and associated physical activity. Outcome measures included: overall volume of physical activity; moderate to vigorous physical activity (MVPA) levels; temporal pattern of physical activity (to identify when activity has increased and whether there is a compensatory decrease in activity at other times), and; objective measures of routes taken and physical activity associated with journey.

Results

Daily physical activity volume for employees using the car compared to those who walk (Mean (SD)) of 310.5 (149.7) vs 570 (177) (p < 0.001) counts per minute. MVPA in minutes for employees using the car compared to those who walk shows 41.4 (31.7) vs 84.4 (25.4) (p < 0.001). Sedentary time in minutes for employees using the car compared to those who walked was 627.7 (73.8) vs 576.7 (94.8) (p = 0.017). Employees who walked to work showed higher accelerometer counts per minute between 6–9am and 4–7pm which was maintained throughout the day compared to those who used the car. Combined GPS and accelerometer trace showed the journey to work provides employees with more MVPA.

Conclusion

We are not aware of any other study in adults using objective methods to measure the contribution of walking to work on physical activity levels. Our study clearly shows that the daily commute provides an opportunity for adults who live within walking distance of their workplace to meet their daily physical activity requirements and reduces sedentary time.
OP05 From Industries to Services: Occupational Mobility and Health in Scotland
Authors: Kampanellou E
Published: September 2013

Background

The majority of research exploring the impact of deindustrialisation on health is centred on industrial employees. This study explores this association even further. It compares population groups engaged in industries and services and takes into account their occupational transition: unemployment, inactivity and re-employment. The current study assesses the self-rated health and limiting long term illness (LLTI) of industrial and service sector employees who became unemployed and inactive, in comparison to employees still working in similar industries and services, and those reabsorbed in other sectors of the economy.

Methods

The data was derived from the Scottish Longitudinal Study (SLS), a census based study representing 5.3% of the Scottish population in the years between 1991 and 2001. The sample included the employed population in the industrial and services sector aged 20–54 in the year 1991 followed up in the year 2001. The service sector was divided between high-paid and low-paid jobs. Overall health was measured by two indicators, LLTI and self-reported health. Logistic regression models were conducted in order to examine whether industrial employees were more likely to report overall health deterioration compared to the service sector employees through redundancy and re-employment. The analysis was stratified by gender and accounted for socio-economic and demographic circumstances together with pre-existing LLTI.

Results

The main sample comprised of 63,150 individuals (52% males and 48% females). The reference group is the employees who remained in manufacturing/mining sector for both census years. Industrial employees transferred to low-paid service jobs report higher probability of not good health (OR 1.26, 95% CI 0.95, 1.66) compared to individuals who continue in manufacturing. Employees who change jobs within the service sector demonstrate the highest likelihood of LLTI (1.51 [1.29, 1.76]). In contrast individuals who change occupation within the industrial sector illustrate lower probability of LLTI (0.98 [0.74, 1.29]). Unemployed from high-paid service jobs (LLTI: 4.46 [3.36, 5.92], Not good health: 5.15 [3.61, 7.34]) and inactive from the industrial sector show more chances of overall health deterioration (LLTI: 17.99 [15.73, 20.58], Not good health: 21.08 [17.70, 25.09]).

Conclusion

This study shows that there is an association between health and occupational transition. In addition, unemployment and inactivity do not have the same health effect on employees across sectors.
OP50 Socio-Economic Inequalities in Lung Cancer Treatment: The Role of Histological Subtype and Performance Status
Authors: Forrest L F , Adams J M , White M
Published: September 2013

Background

Socio-economic inequalities in receipt of lung cancer treatment have been demonstrated in our recently published systematic review and meta-analysis, in both universal (UHCS) and non-universal healthcare systems. These findings could not be explained by type of healthcare system or stage at diagnosis. However, not all of the included studies reported details of stage and histology, both of which influence treatment type, and very few UHCS studies took co-morbidity into account. Performance status (PS), a measure of general patient wellbeing, might also be an important determinant of lung cancer treatment. The review recommended that the reasons for socio-economic inequalities in treatment be more thoroughly investigated. Cancer registry (NYCRIS), Hospital Episode Statistics (HES) and lung cancer audit (LUCADA) data-sets from the North-east of England were linked in order to examine the influence of stage, histology, PS and co-morbidity on socio-economic inequalities in lung cancer treatment.

Methods

NYCRIS data for 65,210 patients with a primary diagnosis of lung cancer (ICD10 C33 and C34), diagnosed between 1999 and 2010 were analysed. Of these, 18,896 had a linked HES co-morbidity record. Subgroup analysis of the 7773 patients diagnosed between 2006 and 2010, who had stage and PS recorded in LUCADA, was also carried out. Multivariable logistic regression was used to examine the likelihood of receipt of surgery, chemotherapy and radiotherapy by socioeconomic position (SEP), taking into account age, sex, histology, year of diagnosis and co-morbidity, and, for the subgroup, stage and PS.

Results

Socioeconomic inequalities in receipt of surgery and chemotherapy, but not radiotherapy, were found in the full cohort after control for age, sex, histology, year of diagnosis and co-morbidity. The odds of receiving surgery were significantly lower in the lowest compared to the highest SEP group (OR 0.68 [95% CI 0.63, 0.75], p < 0.001) and this remained in the subgroup when stage and PS were additionally controlled for (0.62 [0.46, 0.83], p < 0.001). Inequalities in receipt of surgery were substantially attenuated by histological subtype. Patients in the lowest SEP group were significantly less likely to receive chemotherapy in the full cohort (0.56 [0.52, 0.60], p < 0.001), but not in the subset when stage and PS were included in the model (0.85 [0.70, 1.03], p=0.09).

Conclusion

Socio-economic differences in PS may account for the observed socio-economic differences in receipt of chemotherapy. Socio-economic inequalities in receipt of surgery may be partially explained by socio-economic differences in tumour type.
OP52 Multilevel Latent Class Modelling of Colorectal Cancer Survival Status and Socioeconomic Background
Authors: Harrison W J , Gilthorpe M S , Downing A , Baxter P D
Published: September 2013

Background

Many factors influence survival from colorectal cancer, including stage of diagnosis, treatment centre, and associated risk factors such as age, sex and socioeconomic background (SEB). Previous studies have typically considered stage of disease as a potential confounder. Stage however may lie on the causal path between SEB and survival. Statistical adjustment for stage as a confounder can therefore introduce interpretational difficulties due to the reversal paradox. Classification of stage may also be imprecise and incomplete, leading to bias. Latent Class Analysis (LCA) may minimise these problems by including stage as a ‘class predictor’, accommodating uncertainty associated with stage explicitly via the latent class part of the model.

Methods

We used a dataset of patients in a large UK regional population diagnosed with colorectal cancer between 1998 and 2004. The outcome was death within three years. Diagnostic centre was the NHS Trust where the latest staging took place. Following exclusions, 24,640 records were available for analysis. We constructed multilevel latent class models to allow for the hierarchical data structure: patients nested within NHS Trusts. The optimum number of latent classes at the patient and Trust level was determined with reference to likelihood-based model-fit criteria and classification error.

Results

The three-patient five-Trust class multilevel LCA model was chosen, and provided a better fit to the data than standard multilevel models. Patients were apportioned into either a good, reasonable or poor prognosis class. The patient classes had a graduated survival status analogous to that observed for different stages of disease. More deprived SEB and older age were associated with increased odds of death in all classes (SEB OR 1.33 [95% CI 1.26, 1.41]; age OR 1.46 [1.33, 1.60] per 5-year increase in the good prognosis class, for example). Females had significantly decreased odds of death compared with males in the good prognosis class only (0.59 [0.40, 0.87]).

Discussion

Multilevel LCA improves upon the standard multilevel approach by producing models that are better fitting to the data and provide an enhanced interpretation of the data, while minimising interpretational difficulties due to the reversal paradox and avoiding bias due to incomplete data. Trust classes identified outlying Trusts, indicating that the standard multilevel model would not have been sufficient to model these data. The Trust classes differ only due to patient survival status and the relationship between survival and the covariates, potentially enabling us to highlight differences in patient care that might explain the differences and so be worthy of further investigation.
OP53 Explaining Scottish Coronary Heart Disease Mortality Trends between 2000 and 2010: Socioeconomic Analyses using the Impact Sec Model
Authors: Hotchkiss J W , Dundas R , Davies C A , Hawkins N M , Jhund P S , Scholes S , Bajekal M , O’Flaherty M , Critchley J A , Leyland A H , Capewell S
Published: September 2013

Background

Coronary heart disease (CHD) mortality rates have halved in recent decades. However, CHD remains the largest cause of death in Scotland generating persistent socioeconomic inequalities. A socioeconomic quantification of the prevention and treatment contributions to these mortality reductions might help inform future health policies.

Methods

IMPACTsec, a previously validated policy model, was used to apportion the Scottish CHD mortality decline between 2000 and 2010 to changes in six major CHD risk factors and to 40 treatments in nine patient groups. Analyses were stratified by gender, age and Scottish Index of Multiple Deprivation quintiles. Uncertainties around estimates were explored using probabilistic sensitivity analysis.

Results

There were 5770 fewer CHD deaths in 2010 than would have been expected if 2000 mortality rates had persisted unchanged. This reflected an overall 43% fall in CHD mortality rates (from 262 to 148 deaths per 100,000), but with a slower 37% decline amongst the two most deprived quintiles. The IMPACTsec model explained approximately 83% of the CHD mortality fall. Treatments accounted for approximately 44% of the fall. This benefit was fairly evenly distributed across deprivation quintiles. Three treatments contributed over half of these benefits: statins for primary prevention (13%) and medical therapies for stable angina (9%) and secondary prevention following revascularisation or myocardial infarction (11%). Risk factors accounted for approximately 39% of the mortality fall overall, with the largest contribution in the most deprived quintile (44%) and the least in the most affluent quintile (36%). The decline in systolic blood pressure made the biggest contribution (37%), exceeding that of smoking (4%), total cholesterol (9%) and inactivity (2%); the latter three demonstrating socioeconomic gradients. However, increases in diabetes and obesity negated some of these benefits potentially exacerbating mortality by -8% and -4% respectively. The diabetes contribution to the exacerbation of mortality showed strong socioeconomic patterning (-12% for the most deprived quintile compared to -5% for the most affluent).

Conclusion

This IMPACTsec analysis suggests that NHS medical treatments have made a large and equitable contribution to the recent decline in Scottish CHD mortality. The substantial contribution that improvements in risk factor profiles made on CHD mortality rates was diminished by adverse trends in obesity and diabetes; the latter having an adverse socioeconomic gradient. Population-wide interventions can be powerful, rapid and equitable. However, more radical policies will be required if the CHD mortality decline is to continue in future decades while reducing inequalities.
OP54 Exploring Socioeconomic Inequalities in Coronary Heart Disease Prevention
Authors: Ahmed R , O’Flaherty M , Anwar E , Hawkins N , Wilkinson E , Lucy J , Capewell S
Published: September 2013

Background

Between 2000 and 2007, coronary heart disease (CHD) mortality rates in England plummeted by one third. An important part of this substantial CHD mortality decline was achieved through reductions in major cardiovascular risk factors (primary prevention). However, the relative contributions from medications and from population-wide changes remains unclear, particularly the effects on health inequalities.

Methods

Using a previously validated policy model, the fall in CHD mortality in England was analysed. The contributions from risk factor declines in asymptomatic individuals through medications and through population-wide changes were quantified. Data were stratified using the Index of Multiple Deprivation (IMD). Model outputs were quantified as deaths prevented or postponed (DPPs).

Results

Between 2000 and 2007, approximately 21,900 fewer CHD deaths were attributable to risk factor declines in systolic blood pressure and cholesterol in the English population. Some 7,100 of these 21,900 fewer deaths (DPPs) were attributed to medications (32%) and approximately 14,800 DPPs were attributed to secular changes in asymptomatic individuals (68%). Substantial declines in systolic blood pressure were responsible for approximately 14,300 fewer deaths. This comprised approximately 12,500 DPPs attributable to population-wide changes and some 1,800 DPPs attributable to hypertension medications. The hypertension medications resulted in approximately 350 fewer deaths in the most affluent quintile compared with 270 DPP in the most deprived. In contrast, the population-wide (secular) falls in blood pressure resulted in approximately 2400 fewer deaths in the most deprived quintile compared with only 1900 DPPs in the most affluent. Cholesterol falls resulted in approximately 7,700 fewer deaths. This comprised some 5,300 fewer deaths attributable to statin medications and approximately 2,400 fewer deaths attributable to population-wide changes (mostly diet). Statin medications prevented more deaths in the most affluent quintile (1050 DPPs) compared with the most deprived (770 DPPs). Population-wide changes in cholesterol prevented substantially more deaths in the most deprived quintile (820 DPPs) compared with the most affluent (260 DPPs).

Conclusion

Population-based declines in blood pressure and cholesterol resulted in much greater reductions in CHD deaths than did primary prevention medications. Mortality falls were greatest in the most deprived quintiles, mainly reflecting their bigger initial burden of disease. Future CHD prevention policies should prioritise healthier diets ahead of medications.
OP55 How Many Coronary Heart Disease Deaths in Poland in 2020 might be Prevented by Further Reductions in Population Risk Factor Levels?
Authors: Bandosz P , Guzman-Castillo M , Capewell S , Zdrojewski T , Critchley J , Rutkowski M , O’Flaherty M
Published: September 2013

Background

Poland has experienced one of the most dramatic declines in coronary heart disease (CHD) mortality rates in recent decades. This decline reflects the use of evidence based treatments and, crucially, population wide changes in diet. Our aim is to explore the potential for further gains in Poland by achieving population wide reductions in smoking, dietary salt and saturated fat intake and physical inactivity levels.

Methods

A validated and updated policy model was used to forecast potential decreases in CHD deaths by 2020 as consequence of lifestyle and dietary changes in the population. Data from the most recent Polish risk factor survey was used for the baseline estimates (2011). We modelled two different policy scenarios regarding possible future changes in risk factors: A) conservative scenario: reduction of smoking prevalence and physically inactivity rates by 5% between 2011 and 2020, and reduction of dietary consumption of energy from saturated fats by 1% and of salt by 10%. B) ideal scenario: reduction of smoking and physically inactivity prevalence by 15%, and dietary reduction of energy from saturated fats by 3% and of salt by 30%. We also conducted extensive sensitivity analysis using different counterfactual scenarios of future mortality trends.

Results

Baseline scenarios: by assuming continuing declines in mortality and no future improvements in risk factors the predicted number of CHD deaths in 2020 would be approximately 13,600 (95% CI 9838, 18184) while if mortality rates remain stable, the predicted number of deaths would approximate 22,200 (7792, 26688). Conservative scenario. Assuming continuing declines in mortality, small changes in risk factors could result in approximately 1500 (688, 2490) fewer deaths. This corresponds to an 11% mortality reduction. Under the ideal scenario, our model predicted some 4,600 (2048, 8701) fewer deaths (a 34% mortality reduction). Reduction in smoking prevalence by 5% (conservative scenario) or 15% (ideal scenario) could result in mortality reductions of 4.5% and 13.8% respectively. Decreases in salt intake by 10% or 30% might reduce CHD deaths by 3.0% and 8.6% respectively. Replacing 1% or 3% of dietary saturated fats by poly-unsaturates could reduce CHD deaths by 2.6% or 7.7%. Lowering the prevalence of physically inactive people by 5-15% could decrease CHD deaths by 1.2-3.7%.

Conclusion

Small and eminently feasible population reductions in lifestyle related risk factors could substantially decrease future number of CHD deaths in Poland, thus consolidating the earlier gains.
OP56 Modelling Future Coronary Heart Disease Mortality to 2030 in the British Isles
Authors: Hughes J , Kabir Z , Hotchkiss J W , Bennett K , Kee F , Leyland A H , Davies C A , Bandosz P , Guzman-Castillo M , O’Flaherty M , Capewell S , Critchley J
Published: September 2013

Background

Despite rapidly declining coronary heart disease (CHD) mortality rates over the last two decades, CHD mortality rates in the British Isles are still amongst the highest in Europe. Greater risk factor reductions have been achieved in many other countries in Europe and beyond. This study aimed to use a modelling approach to assess the potential impact of alternative future risk factor scenarios relating to smoking and physical activity levels, dietary salt and saturated fat intakes on future CHD mortality in three countries: Northern Ireland (NI), Republic of Ireland (RoI) and Scotland.

Methods

CHD mortality models previously developed and validated in each country were extended to predict potential reductions in CHD mortality from 2010 (baseline year) to 2030. For each country, using risk factor data from recent surveys as a baseline, we modelled alternative future risk factor scenarios: Absolute decreases in (i) smoking prevalence and (ii) physical inactivity rates of up to 15% by 2030; (iii) relative decreases in dietary salt intake of up to 30% by 2030 & (iv) relative decreases in% energy from dietary saturated fat of up to 6% by 2030 (replacing by polyunsaturated fats). Sensitivity analyses were then conducted.

Results

Projected populations by 2030 (adults aged 25-84) were 1.3, 3.9 and 3.9 million in NI, RoI and Scotland respectively. By 2030: assuming continuing declines in mortality: 15% absolute reductions in smoking could decrease CHD deaths by 6–8% (approximately 40, 130 and 210 fewer deaths In NI, RoI and Scotland respectively). 15% absolute declines in physical inactivity levels might decrease CHD deaths by 4% (approximately 30, 90 and 90 fewer deaths respectively). Relative reductions in salt intake of 30% could decrease CHD deaths by 3–4% (approximately 25, 75 and 110 fewer deaths respectively) and 6% in saturated fat intake might decrease CHD deaths by some 9–10% (approximately 65, 170 and 265 fewer deaths In NI, RoI and Scotland respectively). These projections remained stable under a wide range of sensitivity analyses.

Conclusion

Modest and feasible reductions in four CHD risk factors (which have already been achieved elsewhere) could translate into substantial reductions in future CHD deaths. More aggressive polices are therefore needed in the British Isles to control tobacco, promote healthy food and increase physical activity.