Well-being, physical activity and long-term conditions: cross-sectional analysis of Health Survey for England 2016.

OBJECTIVES: We investigated whether physical activity is associated with greater well-being in people with multiple long-term conditions or limiting long-term illness (LLI). STUDY DESIGN: Cross-sectional analysis of data from the Health Survey for England 2016. METHODS: The Warwick-Edinburgh mental well-being score (WEMWBS) was evaluated according to number of days per week with >30 min moderate or vigorous activity. LLI and number of long-term conditions were evaluated as effect modifiers, adjusting for age, sex, smoking, body mass index and education. Marginal effects were estimated for female non-smokers, aged 45-54 years. RESULTS: Data were analyzed for 5952 adults (female, 3275; male, 2677) including 1104 (19%) with non-limiting long-term illness and 1486 (25%) with LLI. There were 2065 (35%) with 1-2 long-term conditions, 461 (8%) with 3-4 and 58 (1%) with 5-6 long-term conditions. Participants with LLI were less likely to engage in physical activity on 5 or more days per week (LLI, 24%; No LLI, 47%) and more likely to be inactive (LLI, 41%; No LLI 13%). The adjusted marginal mean WEMWBS for inactive participants with no long-term illness was 49.0 (95% confidence interval 48.1 to 50.0), compared with 51.1 (50.4-51.8) if active on 5+ days per week. In LLI, the adjusted marginal mean WEMWBS was 41.6 (40.7-42.5) if inactive but 47.6 (46.6-48.6) if active on 5+ days per week. Similar associations were observed for the number of long-term conditions. CONCLUSIONS: Physical activity may be associated with greater increments in well-being among people with multiple long-term conditions or LLI than those without.

Tuberculosis screening for prospective migrants to high-income countries: systematic review of policies.

OBJECTIVE: To compare predeparture tuberculosis (TB) screening policies, including screening criteria and screening tests, and visa requirements for prospective migrants to high-income countries that have low to intermediate TB incidence and high immigration. STUDY DESIGN: Systematic review of policy documents. METHODS: We systematically identified high-income, high net-migration countries with an estimated TB incidence of <30 per 100,000. After initial selection, this yielded 15 countries which potentially had TB screening policies. We performed a systematic search of governmental and official visa services' websites for these countries to identify visa information and policy documents for prospective migrants. Results were summarized, tabulated, and compared. RESULTS: Programs to screen for active TB were identified in all 15 countries, but screening criteria and screening tests varied substantially between countries. Prospective migrants' country of origin represented an initial assessment criterion which generally focused on elevated TB incidence based on World Health Organization data but also focused on the countries of origin that sent the most migrants, and this varied between destination countries. Specific categories of migrants represented a second assessment criterion that focused on duration of stay and reasons for migration; the focus of which showed variation between the destination countries. Specific screening tests including medical examination and chest X-rays were used as the final stage of assessment, and there were differences between which tests were used between the destination countries. CONCLUSIONS: Current approaches to migrant TB screening are inconsistent in their approach and implementation. While this variation might reflect adaptation to local public health situations, it could also indicate uncertainty concerning optimal strategies. Comparative research studies are needed to define the most effective and efficient methods for TB screening of migrants.

Cardiovascular risk assessment and treatment in chronic inflammatory disorders in primary care.

OBJECTIVE: To compare differences in cardiovascular (CV) risk factors assessment and management among patients with rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) with that of matched controls. METHODS: A matched cohort study was conducted using primary care electronic health records for one London borough. All patients diagnosed with RA or IBD, and matched controls registered with local general practices on 12th of January 2014 were identified. The study compared assessment and treatment of CV risk factors (blood pressure, body mass index, cholesterol and smoking) in the year before, the year after, and 5 years after RA and IBD diagnosis. RESULTS: A total of 1121 patients with RA and 1875 patients with IBD were identified and matched with 4282 and, respectively, 7803 controls. Patients with RA were 25% (incidence rate ratio, 1.25, 95% CI 1.12 to 1.35) more likely to have a CV risk factor measured compared with matched controls. The difference declined to 8% (1.08, 1.04 to 1.14) over 5 years of follow-up. The corresponding figures for IBD were 26% (1.26, 1.16 to 1.38) and 10% (1.10, 1.05 to 1.15). Patients with RA showed higher antihypertensive prescription rates during 5 years of follow-up (OR, 1.37, 95% CI 1.14 to 1.65) and patients with IBD showed higher statin prescription rates in the year preceding diagnosis (2.30, 1.20 to 4.42). Incomplete CV risk assessment meant that QRISK scores could be calculated for less than a fifth (17%) and clinical recording of CV disease (CVD) risk scores among patients with RA and IBD was 11% and 6%, respectively. CONCLUSIONS: The assessment and treatment of vascular risk in patients with RA and IBD in primary care is suboptimal, particularly with reference to CVD risk score calculation.

Are healthcare costs from obesity associated with body mass index, comorbidity or depression? Cohort study using electronic health records.

The objective of this study was to evaluate the association between body mass index (BMI) and healthcare costs in relation to obesity-related comorbidity and depression. A population-based cohort study was undertaken in the UK Clinical Practice Research Datalink (CPRD). A stratified random sample was taken of participants registered with general practices in England in 2008 and 2013. Person time was classified by BMI category and morbidity status using first diagnosis of diabetes (T2DM), coronary heart disease (CHD), stroke or malignant neoplasms. Participants were classified annually as depressed or not depressed. Costs of healthcare utilization were calculated from primary care records with linked hospital episode statistics. A two-part model estimated predicted mean annual costs by age, gender and morbidity status. Linear regression was used to estimate the effects of BMI category, comorbidity and depression on healthcare costs. The analysis included 873 809 person-years (62% female) from 250 046 participants. Annual healthcare costs increased with BMI, to a mean of £456 (95% CI 344-568) higher for BMI ≥40 kg m(-2) than for normal weight based on a general linear model. After adjusting for BMI, the additional cost of comorbidity was £1366 (£1269-£1463) and depression £1044 (£973-£1115). There was evidence of interaction so that as the BMI category increased, additional costs of comorbidity (£199, £74-£325) or depression (£116, £16-£216) were greater. High healthcare costs in obesity may be driven by the presence of comorbidity and depression. Prioritizing primary prevention of cardiovascular disease and diabetes in the obese population may contribute to reducing obesity-related healthcare costs.

Severity of obesity and management of hypertension, hypercholesterolaemia and smoking in primary care: population-based cohort study.

Obesity and obesity-associated cardiovascular risk are increasing worldwide. This study aimed to determine how different levels of obesity are associated with the management of smoking, hypertension and hypercholesterolaemia in primary care. We conducted a cohort study of adults aged 30-100 years in England, sampled from the primary care electronic health records in the Clinical Practice Research Datalink. Prevalence, treatment and control were estimated for each risk factor by body mass index (BMI) category. Adjusted odds ratios (AOR) were estimated, allowing for age, gender, comorbidity and socioeconomic status, with normal weight as reference category. Data were analysed for 247,653 patients including 153,308 (62%) with BMI recorded, of whom 46,149 (30%) were obese. Participants were classified into simple (29,257), severe (11,059) and morbid obesity (5833) categories. Smoking declined with the increasing BMI category, but smoking cessation treatment increased. Age-standardised hypertension prevalence was twice as high in morbid obesity (men 78.6%; women 66.0%) compared with normal weight (men 37.3%; women 29.4%). Hypertension treatment was more frequent (AOR 1.75, 1.59-1.92) but hypertension control less frequent (AOR 0.63, 0.59-0.69) in morbid obesity, with similar findings for severe obesity. Hypercholesterolaemia was more frequent in morbid obesity (men 48.2%; women 36.3%) than normal weight (men 25.0%; women 20.0%). Lipid lowering therapy was more frequent in morbid obesity (AOR 1.83, 1.61-2.07) as was cholesterol control (AOR 1.19, 1.06-1.34). Increasing obesity category is associated with elevated risks from hypertension and hypercholesterolaemia. Inadequate hypertension control in obesity emerges as an important target for future interventions.

Leisure-time physical activity over the life course and cognitive functioning in late mid-adult years: a cohort-based investigation.

BACKGROUND: The objective of the present study was to estimate the association between different leisure-time physical activity (LTPA) parameters from 11 to 50 years and cognitive functioning in late mid-adulthood. METHOD: The study used a prospective birth cohort study including participants in the UK National Child Development Study (NCDS) from age 11 to 50 years. Standardized z scores for cognitive, memory and executive functioning at age 50 represented the primary outcome measures. Exposures included self-reported LTPA at ages 11, 16, 33, 42, 46 and 50 years. Analyses were adjusted for important confounders including educational attainment and long-standing illness. RESULTS: The adjusted difference in cognition score between women who reported LTPA for at least 4 days/week in five surveys or more and those who never reported LTPA for at least 4 days/week was 0.28 [95% confidence interval (CI) 0.20-0.35], 0.10 (95% CI 0.01-0.19) for memory score and 0.30 (95% CI 0.23-0.38) for executive functioning score. For men, the equivalent differences were: cognition 0.12 (95% CI 0.05-0.18), memory 0.06 (95% CI -0.02 to 0.14) and executive functioning 0.16 (95% CI 0.10-0.23). CONCLUSIONS: This study provides novel evidence about the lifelong association between LTPA and memory and executive functioning in mid-adult years. Participation in low-frequency and low-intensity LTPA was positively associated with cognitive functioning in late mid-adult years for men and women. The greatest benefit emerged from participating in lifelong intensive LTPA.

Prevalence of depression and utilization of health care in single and multiple morbidity: a population-based cohort study.

BACKGROUND: This study aimed to determine whether depression in patients with long-term conditions is associated with the number of morbidities or the type of co-morbidity. Method A cohort study of 299 912 participants aged 30-100 years. The prevalence of depression, rates of health-care utilization and costs were evaluated in relation to diagnoses of diabetes mellitus (DM), coronary heart disease (CHD), stroke and colorectal cancer. RESULTS: The age-standardized prevalence of depression was 7% in men and 14% in women with no morbidity. The frequency of depression increased in single morbidities including DM (men 13%, women 22%), CHD (men 15%, women 24%), stroke (men 14%, women 26%) or colorectal cancer (men 10%, women 21%). Participants with concurrent diabetes, CHD and stroke had a very high prevalence of depression (men 23%, women 49%). The relative rate of depression for one morbidity was 1.63 [95% confidence interval (CI) 1.59-1.66], two morbidities 1.96 (95% CI 1.89-2.03) and three morbidities 2.35 (95% CI 2.03-2.59). Compared to those with no morbidity, depression was associated with higher rates of health-care utilization and increased costs at any level of morbidity. In women aged 55 to 64 years without morbidity, the mean annual health-care cost was £513 without depression and £1074 with depression; when three morbidities were present, the cost was £1495 without depression and £2878 with depression. CONCLUSIONS: Depression prevalence and health-care costs are more strongly associated with the number of morbidities than the nature of the co-morbid diagnosis.

Validity of cancer diagnosis in a primary care database compared with linked cancer registrations in England. Population-based cohort study.

AIMS: The present study aimed to evaluate the validity of cancer diagnoses and death recording in a primary care database compared with cancer registry (CR) data in England. METHODS: The eligible cohort comprised 42,556 participants, registered with English general practices in the General Practice Research Database (GPRD) that consented to CR linkage. CR and primary care records were compared for cancer diagnosis, date of cancer diagnosis and death. Read and ICD cancer code sets were reviewed and agreed by two authors. RESULTS: There were 5216 (91% of CR total) cancer events diagnosed in both sources. There were 494 (9%) diagnosed in CR only and 213 (4%) that were diagnosed in GPRD only. The predictive value of a GPRD cancer diagnosis was 96% for lung cancer, 92% for urinary tract cancer, 96% for gastro-oesophageal cancer and 98% for colorectal cancer. 'False negative' primary care records were sometimes accounted for by registration end dates being shortly before cancer diagnosis dates. The date of cancer diagnosis was median 11 (interquartile range -6 to 30) days later in GPRD compared with CR. Death records were consistent for the two sources for 3337/3397 (99%) of cases. CONCLUSION: Recording of cancer diagnosis and mortality in primary care electronic records is generally consistent with CR in England. Linkage studies must pay careful attention to selection of codes to define eligibility and timing of diagnoses in relation to beginning and end of record.

Foster care, residential care and public care placement patterns are associated with adult life trajectories: population-based cohort study.

OBJECTIVES: Childhood experiences of public care may be associated with adult psychosocial outcomes. This study aimed to evaluate the associations of four public care exposures: type of placement, length of placement, age at admission to care and number of placements, as well as the reasons for admission to public care with emotional and behavioural traits at age 30 years. METHODS: Participants included 10,895 respondents at the age 30 survey of the 1970 British Cohort Study (BCS70) who were not adopted and whose care history was known. Analyses were adjusted for individual, parental and family characteristics in childhood. RESULTS: Cohort members with a public care experience presented lower childhood family socio-economic status compared with those in the no public care group. After adjusting for confounding, exposure to both foster and residential care, longer placements and multiple placements were associated with more extensive adult emotional and behavioural difficulties. Specifically, residential care was associated with increased risk of adult criminal convictions (OR = 3.09, 95% CI: 2.10-4.55) and depression (1.81, 1.23-2.68). Multiple placements were associated with low self-efficacy in adulthood (OR = 3.57, 95% CI: 2.29, 5.56). Admission to care after the age of 10 was associated with increased adult criminal convictions (OR = 6.03, 95% CI: 3.34-10.90) and smoking (OR = 3.32, 95% CI: 1.97-5.58). CONCLUSION: Adult outcomes of childhood public care reflect differences in children's experience of public care. Older age at admission, multiple care placements and residential care may be associated with worse outcomes.

Trends in Type 1 diabetes incidence in the UK in 0- to 14-year-olds and in 15- to 34-year-olds, 1991-2008.

AIM: To describe Type 1 diabetes incidence trends in the UK between 1991 and 2008 in children aged 0-14 years and in young adults aged 15-34 years. METHODS: Data from the UK General Practice Research Database were analysed, including 3002 individuals (1565 aged 0-14 years and 1437 aged 15-34 years) newly diagnosed with Type 1 diabetes. Poisson regression was used to model annual incidence increases and seasonality effects. RESULTS: Type 1 diabetes incidence increased from 11 to 24/100,000 person-years in boys and from 15 to 20/100,000 person-years in girls. In adults, the incidence rate increased from 13 to 20/100,000 person-years (men) and from 7 to 10/100,000 person-years (women). Annual incidence increases tended to be greater in children (4.1%, 95% CI 3.0-5.2%) compared with 15- to 34-year-olds (2.8%, 95% CI 1.6-3.9%). There was evidence of higher incidence rates during autumn and winter in children, but not in adults. CONCLUSIONS: A continuing increase in Type 1 diabetes incidence was shown that was greater in children than in young adults. Seasonal variation was observed in children only.

Multiple morbidity is associated with increased problems of food access in hospital: a cross-sectional survey utilising the Cumulative Illness Rating Scale.

BACKGROUND: Problems of undernutrition are common in hospital in-patients. Multiple morbidity increases with age and may contribute to nutritional risks. This research aimed to determine whether increased burden of long-term conditions is associated with patients' difficulties gaining access to food in hospital. METHODS: A survey was implemented in 29 wards at four hospitals using a questionnaire measure of patients' experiences of food access and the Cumulative Illness Rating Scale (CIRS) to evaluate the burden of long-term illness in each patient. Experiences of food access were evaluated in relation to CIRS score category using random effects logistic regression to adjust for age group, sex and clustering by ward. RESULTS: Data were analysed for 764/1154 (66%) eligible participants, including 384 women. The median age was 60 years (range 18-96 years). CIRS scores were analysed using the categories 0 (104 patients), 1-3 (197), 4-6 (285), 7-9 (144) and ≥10 (34). When the CIRS was zero, 10% of patients experienced physical problems with food access, whereas, when the CIRS was ≥10, 41% experienced physical barriers to food access, adjusted odds ratio 3.65 (1.14-11.7, P = 0.029). Problems with food quality were experienced by 13% with CIRS = 0 and 32% with CIRS ≥ 10 (adjusted odds ratio 3.97, 1.35-11.6, P = 0.012). Participants with greater morbidity were more likely to report that depression, breathing difficulties or chewing and swallowing difficulties affected the amount of food that they ate at mealtimes. CONCLUSIONS: Patients with multiple morbidities are more vulnerable to experiencing physical barriers to accessing food and increased concerns with food quality. Assessing barriers to food access is particularly important in multiple morbidity.

Socio-economic and ethnic inequalities in diabetes retinal screening.

OBJECTIVE: We aimed to quantify socio-economic and ethnic inequalities in diabetes retinal screening. METHODS: Data were analysed for the retinal screening programme for three South London boroughs for the 18-month period to February 2009. Sight-threatening diabetic retinopathy (STDR) was defined as the occurrence of diabetic maculopathy, severe non-proliferative or proliferative diabetic retinopathy. Odds ratios were adjusted for sex, age group, duration and type of diabetes, self-reported ethnicity and deprivation quintile by participant postal code. RESULTS: There were 76 351 records obtained but, after excluding duplicate and ineligible records, data were analysed for 59 495 records from 31 484 subjects. There were 7026 (22%) subjects called for appointments who were not screened in the period, with 24 458 (78%) having one or more screening episodes. Non-attendance for screening was highest in young adults aged 18-34 years (32%) and in those aged 85 years or greater (28%). In the most deprived quintile, non-attendance was 23% compared with 21% in the least deprived quintile [odds ratio (OR) 1.37, 95% confidence interval (CI) 1.16-1.61, P < 0.001]. There were 2819 (11.5%) participants with STDR, including 10.8% in the least deprived quintile and 12.2% in the most deprived quintile (OR 1.10, 95% CI 0.95-1.16, P = 0.196). Compared with white Europeans (9.4%), STDR was higher in Africans (15.2%) and African Caribbeans (14.7%), resulting from a higher frequency of diabetic maculopathy. CONCLUSION: Socio-economic inequality in diabetes retinal screening may be smaller than reported in earlier studies. This study suggested an increased frequency of diabetic maculopathy among participants of African origins.

Antenatal screening for haemoglobinopathies in primary care: a cohort study and cluster randomised trial to inform a simulation model. The Screening for Haemoglobinopathies in First Trimester (SHIFT) trial.

OBJECTIVES: To assess the effectiveness, cost-effectiveness, acceptability and feasibility of offering universal antenatal sickle cell and thalassaemia (SCT) screening in primary care when pregnancy is first confirmed and to model the cost-effectiveness of early screening in primary care versus standard care. DESIGN: A population-based cohort study, cluster randomised trial and refinement of a published decision model. SETTING: Twenty-five general practices from two UK primary care trusts (PCTs) in two inner city boroughs with a high proportion of residents from minority ethnic groups. PARTICIPANTS: Practices were considered eligible if they agreed to be randomised and they were able to provide anonymous data on all eligible pregnant women. Participants were at least 18 years old and consented to take part in the evaluation. INTERVENTIONS: Practices were allocated to intervention, using minimisation and stratifying for PCT and number of partners at the practice, as follows: screening in primary care with parallel father testing (test offered to mother and father simultaneously; n = 8 clusters, 1010 participants); screening in primary care with sequential father testing (test offered to father only if mother identified as carrier; n = 9 clusters, 792 participants); and screening in secondary care with sequential father testing (standard care; n = 8 clusters, 619 participants). MAIN OUTCOME MEASURES: Data on gestational age at pregnancy confirmation and screening date were collected from trial practices for 6 months before randomisation in the cohort phase. The primary outcome measure was timing of SCT screening, measured as the proportion of women screened before 70 days' (10 weeks') gestation. Other outcomes included: offer of screening, rates of informed choice and proportion of women who knew the carrier status of their baby's father by 77 days (11 weeks). RESULTS: For 1441 eligible women in the cohort phase, the median [interquartile range (IQR)] gestational age at pregnancy confirmation was 7.6 weeks (6.0 to 10.7 weeks) and 74% presented in primary care before 10 weeks. The median gestational age at screening was 15.3 weeks (IQR 12.6 to 18.0 weeks). Only 4.4% were screened before 10 weeks. The median delay between pregnancy confirmation and screening was 6.9 weeks (4.7 to 9.3 weeks). In the intervention phase, 1708 pregnancies from 25 practices were assessed for the primary outcome measure. Completed questionnaires were obtained from 464 women who met eligibility criteria for the main analysis. The proportion of women screened by 10 weeks (70 days) was 9/441 (2%) in standard care, compared with 161/677 (24%) in primary care with parallel testing, and 167/590 (28%) in primary care with sequential testing. The proportion of women offered screening by 10 weeks (70 days) was 3/90 (3%) in standard care (note offer of test ascertained for questionnaire respondents only), compared with 321/677 (47%) in primary care with parallel testing, and 281/590 (48%) in primary care with sequential testing. The proportion of women screened by 26 weeks (182 days) was similar across the three groups: 324/441 (73%) in standard care, 571/677 (84%, 0.09) in primary care with parallel testing, and 481/590 (82%, 0.148) in primary care with sequential testing. The screening uptake of fathers was 51/677 (8%) in primary care with parallel testing, and 16/590 (3%) in primary care with sequential testing, and 13/441 (3%) in standard care. The predicted average total cost per pregnancy of offering antenatal SCT screening was estimated to be 13 pounds in standard care, 18.50 pounds in primary care with parallel testing, and 16.40 pounds in primary care with sequential testing. The incremental cost-effectiveness ratio (ICER) was 23 pounds in primary care with parallel testing and 12 pounds in primary care with sequential testing when compared with standard care. Women offered testing in primary care were as likely to make an informed choice as those offered screening by midwives later in pregnancy, but less than one-third of women overall made an informed choice about screening. CONCLUSIONS: Offering antenatal SCT screening as part of pregnancy-confirmation consultations significantly increased the proportion of women screened before 10 weeks (70 days), from 2% in standard care to between 16% and 27% in primary care, but additional resources may be required to implement this. There was no evidence to support offering fathers screening at the same time as women. TRIAL REGISTRATION: Current Controlled Trials ISRCTN00677850.

Achievement of metabolic targets for diabetes by English primary care practices under a new system of incentives.

OBJECTIVE: To analyse achievement of metabolic targets by English general practices following the introduction of a new system of incentives. METHODS: Clinical data were abstracted from the records of 2099 patients at 26 general practices in South London. Cross-sectional data for 2005 were obtained for all general practices in England, including characteristics of registered populations, practice organizational characteristics and 'Quality and Outcomes Framework' (QOF) metabolic targets. RESULTS: Among 26 practices in South London, the median practice-specific proportion of patients achieving HbA(1c) < or = 7.4% each year increased: 2000, 22%; 2001, 32%; 2002, 37%; 2003, 38% and in 2005 from QOF, 57%. In 8484 general practices in England in 2005, the median proportion of diabetic patients with HbA(1c) < or = 7.4% was 59.0%; the highest and lowest centiles ranged from 27.7 to 89.8% among general practices, from 46.9 to 71.0% among 303 primary care trusts and from 49.9 to 67.1.% among 28 health authorities. Comparing the highest and lowest tertiles of deprivation, the per cent achieving HbA(1c) < or = 7.4% was 2.96% (95% confidence interval 2.23-3.69%) lower in the most deprived areas. In areas with the highest proportion of ethnic minorities, the per cent achieving HbA(1c) < or = 7.4% was 2.73% (1.85-3.61%) lower than where there were few ethnic minorities. Practices with the highest total QOF organization scores had more patients achieving the HbA(1c) target (difference 5.03%, 4.43-5.64%). CONCLUSIONS: Intermediate outcomes are improving but deprived areas with less organized services achieve worse glycaemic control. Financial incentives may contribute to improved services and better clinical outcomes.

Incidence of common compressive neuropathies in primary care.

Apart from carpal tunnel syndrome, there are no population based studies of the epidemiology of compressive neuropathies. To provide this information, new presentations of compressive neuropathies among patients registered with 253 general practices in the UK General Practice Research Database with 1.83 million patient years at risk in 2000 were analysed. The study revealed that in 2000 the annual age standardised rates per 100 000 of new presentations in primary care were: carpal tunnel syndrome, men 87.8/women 192.8; Morton's metatarsalgia, men 50.2/women 87.5; ulnar neuropathy, men 25.2/women 18.9; meralgia paraesthetica, men 10.7/women 13.2; and radial neuropathy, men 2.97/women 1.42. New presentations were most frequent at ages 55-64 years except for carpal tunnel syndrome, which was most frequent in women aged 45-54 years, and radial nerve palsy, which was most frequent in men aged 75-84 years. In 2000, operative treatment was undertaken for 31% of new presentations of carpal tunnel syndrome, 3% of Morton's metatarsalgia, and 30% of ulnar neuropathy.

Changing patterns of primary care for diabetes in Trinidad and Tobago over 10 years.

OBJECTIVE: To evaluate standards of preventive medical care for Type 2 diabetes in the context of high prevalence and limited resources. METHODS: Surveys of records for diabetic subjects attending 23 government primary care health centres in Trinidad and Tobago in 2003 and 1998 and nine health centres in 1993. Records were compared by study year for blood glucose and blood pressure, surveillance for complications, appropriate management advice and drug prescriptions. Relevant interventions included new clinical guidelines, training workshops for clinical staff and reports to the Ministry of Health. During this time, investment in primary care increased in the context of health sector reform policies and a favourable macroeconomic environment. RESULTS: Comparing 1993 with 2003, the proportion with a blood glucose test in the past 12 months increased from 33% to 91%, urea or creatinine ever recorded increased from 14% to 61%, diet advice recorded in the first 12 months of follow-up from 35% to 67%, exercise advice from 3% to 61%. The proportion prescribed metformin increased from 25% to 65%, while chlorpropamide decreased from 48% to 0%. The proportion of all subjects treated with antihypertensive drugs increased from 49% to 70%, and the proportion of treated patients prescribed angiotensin-converting enzyme inhibitors increased from 8% to 72%. Most recent ever records of blood glucose, blood pressure and body weight showed no decrease. CONCLUSIONS: Repeated surveillance of processes of care provided information to stimulate and plan change. Process changes were associated with intervention at several levels and increased availability of resources.

Intraclass correlation coefficient and outcome prevalence are associated in clustered binary data.

BACKGROUND AND OBJECTIVE: To describe the association between values for a proportion and the intraclass correlation coefficient (ICC). METHODS: Analysis of data obtained from the General Practice Research Database (GPRD) for variation between United Kingdom general practices and results from a Health Technology Assessment (HTA) review for a range of outcomes in community and health services settings. RESULTS: There were 188 ICCs from the GPRD, the median prevalence was 13.1% (interquartile range IQR 3.5 to 28.4%) and median ICC 0.051 (IQR 0.011 to 0.094). There were 136 ICCs from the HTA review, with median prevalence 6.5% (IQR 0.4 to 20.7%) and median ICC 0.006 (IQR 0.0003 to 0.036). There was a linear association of log ICC with log prevalence in both datasets (GPRD, regression coefficient 0.61, 95% confidence interval 0.53 to 0.69, P < 0.001; HTA, 0.91, 0.81 to 1.01, P < 0.001). When the prevalence was 1% the predicted ICC was 0.008 from the GPRD or 0.002 from the HTA, but when the prevalence was 40% the predicted ICC was 0.075 (GPRD) or 0.046 (HTA). CONCLUSION: The prevalence of an outcome may be used to make an informed assumption about the magnitude of the intraclass correlation coefficient.

Trends in antihypertensive and lipid-lowering therapy in subjects with type II diabetes: clinical effectiveness or clinical discretion?

Hypertension and lipid disorders in type II diabetes contribute to increased coronary risk, but optimal drug therapy has not been defined. We investigated primary care physicians choices of antihypertensive and lipid-lowering therapy for subjects with type II diabetes diagnosed with hypertension. Subjects were registered with 105 UK general practices in the General Practice Research Database and prescribed oral hypoglycaemic drugs for the first time between January 1993 and December 2001. We evaluated prescriptions for antihypertensive drugs in subjects with secondary diagnoses of hypertension in the first year following initiation of oral hypoglycaemic therapy. Data were analysed for 4519 diabetic subjects with diagnosed hypertension. Between 1993 and 2001, the proportion prescribed thiazide diuretics increased from 20 to 30%; angiotensin-converting enzyme (ACE) inhibitors from 35 to 45% and angiotensin receptor blockers from 0 to 8%. The proportion of subjects prescribed lipid-lowering therapy increased from 8% in 1993 to 33% in 2001, with the proportion prescribed statins increasing from 1 to 30%. At different general practices, the proportion prescribed thiazide diuretics ranged from 0 to 52%, beta-blockers from 5 to 60%, ACE inhibitors from 15 to 81%, and statins from 0 to 50%. Variation between practices was not explained by adjusting for age, sex, prevalent coronary heart disease or study year. Trends in drug utilisation were consistent with the evolving evidence base but there were wide variations in drug utilisation between practices. A more consistent approach to drug selection might be associated with improved patient outcomes.

Diabetes-related inequalities in health status and financial barriers to health care access in a population-based study.

AIMS: We evaluated the relationship between diabetes, health status, household income and expenditure on health care in the general population in Trinidad. METHODS: Multistage sampling of 300 households was used to select a sample of 548 adults aged > or = 25 years. There were 64 (12%) who reported a diagnosis of diabetes. Comparison was made with 128 non-diabetic controls who were frequency matched for age and sex. RESULTS: Subjects with diabetes had lower income levels than non-diabetic controls [income < or = US dollars 533 per month for 66% diabetes cases and 48% controls, test for trend P = 0.007]. Compared with controls, subjects with diabetes were less likely to have good or very good self-rated health (diabetes 32%, controls 67%; P < 0.001), and more frequently reported long-standing illness, limitation of activities, visual impairment, or self-reported history of high blood pressure, angina or heart attack. Subjects with diabetes (11%) were less likely than controls (30%) to have private health insurance (P = 0.005). Diabetic subjects (35%) were more likely than controls (16%) to have incurred expenditure on doctors' services in the last 4 weeks (P = 0.021). CONCLUSIONS: Diabetes is associated with worse health status and more frequent expenditure on medical services but greater financial barriers to access in terms of low income and lack of health insurance. Policies for diabetes should specifically address the problem of income-related variations in risk of diabetes, health care needs and barriers to uptake of preventive and treatment services, otherwise inequalities in health from this condition may increase.

Socioeconomic inequality in blood pressure and its determinants: cross-sectional data from Trinidad and Tobago.

We evaluated income- and education-related inequalities in blood pressure, hypertension and hypertension treatment in the general population of Trinidad and Tobago. The design included survey of 300 households in north central Trinidad, including 631 adults in 2001. Measurements of blood pressure, weight, height, waist and hip circumferences, and educational attainment, household income and alcohol intake by questionnaire. The slope index of inequality (SII) was used to estimate the difference in blood pressure between those with highest, as compared to lowest, socioeconomic status. Complete measurements and questionnaires were obtained for 461 (73%) including 202 men and 259 women. In women, after adjusting for age and ethnicity, the SII for systolic blood pressure by income was -12.6, 95% confidence interval -22.6 to -2.6 mmHg (P=0.013); and -10.8 (-21.4 to -0.2) mmHg (P=0.045) by educational attainment. After additionally adjusting for body mass index, waist-hip circumference ratio and self-reported diabetes, the SII for income was -7.3 (-16.5 to 1.9) mmHg (P=0.120) and for educational attainment was -3.0 (-13.0 to 6.9) mmHg (P=0.551). In men, after adjusting for age and ethnicity, the SII for systolic blood pressure by income was -4.3 (-15.4 to 6.8) mmHg (P=0.447) and for education -8.1 (-19.0 to 2.8) (P=0.145). There is a negative association of systolic blood pressure with increasing income or education in women. This is associated with body mass index, abdominal obesity and diabetes. There is no consistent association between education or income and blood pressure in men.