bluuebunny/crossref_metadata_2025_split huggingface dataset:
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

BackgroundMany 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.MethodsWe 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.ResultsThe 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]).DiscussionMultilevel 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

BackgroundCoronary 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.MethodsIMPACTsec, 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.ResultsThere 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).ConclusionThis 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

BackgroundBetween 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.MethodsUsing 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).ResultsBetween 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).ConclusionPopulation-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

BackgroundPoland 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.MethodsA 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.ResultsBaseline 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%.ConclusionSmall 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

BackgroundDespite 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.MethodsCHD 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.ResultsProjected 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.ConclusionModest 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.
OP61 The Future Health and Economic Consequences of Recent Obesity Trends in Ireland
Authors: Keaver L M , Webber L , Dee A , Marsh T , Balanda K , Perry I J 
Published: September 2013

BackgroundGiven the scale of the current obesity epidemic and its consequences for health there has been increasing concern about the economic burden placed on society in terms of direct healthcare costs and indirect societal costs. In the Republic of Ireland obesity related costs (direct and indirect) have been estimated at 1.13 billion for 2009. The total direct healthcare costs for six major obesity related conditions (coronary heart disease & stroke, cancer, hypertension, type 2 diabetes and knee osteoarthritis) in the same year were estimated at 2.55 billion. The aim of this research is to project disease burden and direct healthcare costs for major obesity related conditions in Ireland to 2030 using the established model developed by the National Heart Forum (UK) for the Foresight: Tackling Obesities project.MethodsRoutine data sources were used to derive incidence, prevalence, mortality and survival for coronary heart disease, stroke, cancer, hypertension, type 2 diabetes and knee osteoarthritis as inputs for the model. The model utilises a two stage modelling process to predict future BMI rates, disease prevalence and costs. Stage 1 employs a non-linear multivariate regression model to project BMI trends; stage 2 employs a microsimulation approach to produce longitudinal projections and test the impact of interventions upon future incidence of obesity-related disease.ResultsOverweight and obesity are projected to reach levels of 89% and 85% in males and females respectively by 2030. This will result in an increase in the obesity related prevalence of CHD and stroke by 97%, cancers by 61% and type 2 diabetes by 21%. Prevalence of hypertension and knee osteoarthritis is also projected to increase but to a lesser degree. The direct healthcare costs for the six conditions, associated with the projected increase in obesity will amount to €5.4 billion by 2030. A 5% fall in population BMI levels by 2030 is projected to decrease the incidence of CHD & stroke and type 2 diabetes by 35 984 and 37 788 cases respectively, resulting in savings of €495 million in direct healthcare costs.DiscussionThese findings have significant implications for policy, highlighting the need for effective strategies to prevent this avoidable health and economic burden.Keywords Foresight; Obesity; Co-morbidities; Burden of disease; Healthcare costs
OP64 More than Obesity Prevention? Defining Outcomes in the Healthy Towns Programme in England
Authors: Sautkina E , Cummins S , Petticrew M , Goodwin D , Jones A , Ogilvie D , White M 
Published: September 2013

BackgroundIn 2008, £30 million was invested by UK Government in the Healthy Towns (HT) Programme in England. Nine urban areas were selected to develop and implement interventions to tackle the obesogenic environment. These involved multi-sector approaches to promoting physical activity and improve diet through the use of environmental interventions. In this paper, we explore how stakeholders conceptualised and defined programme outcomes in relation to national and local priorities, and across multiple policy sectors.MethodsWe undertook semi-structured, face-to-face interviews with 65 HT staff (programme leads, intervention managers and staff) in 2010–2011. Interviews lasted 50 to 110 minutes and were digitally recorded, anonymised and transcribed verbatim. Participants were asked about: the main outcomes and benefits of the HT programme, and links and synergies with other policy areas. Thematic analysis was undertaken; three authors developed and discussed the coding framework, coding outputs and agreed the resultant main themes.ResultsProgramme staff conceptualised outcomes as extending beyond obesity-related behaviours and identified multiple, complementary policy areas that they were attempting to address through the initiative. Four broad categories of outcomes were articulated: [1] direct obesity-related outcomes (healthy diet, physical activity); [2] indirect obesity-related outcomes (obesity awareness, infrastructure provision); [3] wider health-related outcomes (air quality, social capital); [4] non-health outcomes (environmental sustainability, monetary savings). Stakeholders emphasised the interrelatedness of these four categories of outcomes. For example, tackling obesity, improving transport planning and air quality could all be addressed using active travel interventions; tackling obesity, enhancing social capital and promoting environmental sustainability could be addressed using ‘growing food’ interventions. Furthermore, obesity and non-obesity agendas were seen as complementary in terms of delivery of their respective outcomes.DiscussionThe range and number of outcomes identified may have been both a consequence of the multi-sector, holistic approach taken by HT programme and the ‘on the ground’ reality of implementing complex interventions, whose components touch a wide variety of policy sectors. When planning programmes and their evaluation, consideration of the impact on outcomes that extend beyond the focus of a particular programme could also be beneficial. In the HT programme, policy makers and practitioners believed that delivered interventions could address a range of complementary policy areas, which were all equally important. Taking such a ‘joined-up’ perspective could help increase the efficiency and acceptability of social, environmental, and health policies and interventions.
OP65 What’s Best for Mental Health: No Job or Any Job at All?
Authors: McManus S , Butterworth P , Leach L , Stansfeld S 
Published: September 2013

BackgroundIn terms of mental health, employment is generally better for people than joblessness. But is that still the case when the choice is between unemployment and a demanding job with low levels of control, security and reward? The prevalence of psychiatric disorders among people who are unemployed has rarely been compared with those in jobs of differing psychosocial quality.MethodsThe Adult Psychiatric Morbidity Survey (APMS) was commissioned by the NHS Information Centre, with funds from the Department of Health. It is a probability sample general population survey, from which the rates of treated and untreated mental illness in England are derived. Participants’ mental health is assessed using the Clinical Interview Schedule (CIS-R), a validated assessment tool operationalising criteria for anxiety and depressive disorders, as specified in the International Classification of Diseases 10. In the 2007 survey, we included a module covering the Job Strain and Effort-Reward Imbalance models of work-related stress. Quality of work was assessed by the number of adverse psychosocial job conditions reported (high demands, and low control, security and esteem). We examined prevalence and risk of common mental disorders (CMDs) among the 2603 participants aged 21 to 54 years who were either (i) unemployed and looking for work at the time of interview, or (ii) employed (in jobs banded by their psychosocial quality).ResultsA logistic regression model adjusted for age, sex, partnership status, debt and housing conditions was run to produce ORs for CMD. They were 0.16 ([95% CI 0.10, 0.26], p < 0.001) for people employed the highest quality jobs and 0.79 ([0.41, 1.54], p = -0.492) among unemployed people, compared with employees in the poorest quality jobs.ConclusionWhile people who are unemployed or in low quality work have worse mental health than those in high quality work, jobs of poor psychosocial quality may be no better for mental health than being unemployed. Getting the jobless back into work is, of course, a priority for recession-hit Britain. But so are the Government’s plans to improve national wellbeing. These results highlight the relevance of what goes on in the workplace for the wellbeing agenda, and show that policies aimed at increasing the employment rate should not be at the expense of job quality.