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1.  Development of an algorithm for determining smoking status and behaviour over the life course from UK electronic primary care records 
Background
Patients’ smoking status is routinely collected by General Practitioners (GP) in UK primary health care. There is an abundance of Read codes pertaining to smoking, including those relating to smoking cessation therapy, prescription, and administration codes, in addition to the more regularly employed smoking status codes. Large databases of primary care data are increasingly used for epidemiological analysis; smoking status is an important covariate in many such analyses. However, the variable definition is rarely documented in the literature.
Methods
The Secure Anonymised Information Linkage (SAIL) databank is a repository for a national collection of person-based anonymised health and socio-economic administrative data in Wales, UK. An exploration of GP smoking status data from the SAIL databank was carried out to explore the range of codes available and how they could be used in the identification of different categories of smokers, ex-smokers and never smokers. An algorithm was developed which addresses inconsistencies and changes in smoking status recording across the life course and compared with recorded smoking status as recorded in the Welsh Health Survey (WHS), 2013 and 2014 at individual level. However, the WHS could not be regarded as a “gold standard” for validation.
Results
There were 6836 individuals in the linked dataset. Missing data were more common in GP records (6%) than in WHS (1.1%). Our algorithm assigns ex-smoker status to 34% of never-smokers, and detects 30% more smokers than are declared in the WHS data. When distinguishing between current smokers and non-smokers, the similarity between the WHS and GP data using the nearest date of comparison was κ = 0.78. When temporal conflicts had been accounted for, the similarity was κ = 0.64, showing the importance of addressing conflicts.
Conclusions
We present an algorithm for the identification of a patient’s smoking status using GP self-reported data. We have included sufficient details to allow others to replicate this work, thus increasing the standards of documentation within this research area and assessment of smoking status in routine data.
Electronic supplementary material
The online version of this article (doi:10.1186/s12911-016-0400-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s12911-016-0400-6
PMCID: PMC5217540  PMID: 28056955
Smoking status; Smoking cessation; Data linkage; SAIL databank
2.  Update to a protocol for a feasibility cluster randomised controlled trial of a peer-led school-based intervention to increase the physical activity of adolescent girls (PLAN-A) 
Background
Physical activity levels are low amongst adolescent girls, and this population faces specific barriers to being active. Peer influences on health behaviours are important in adolescence, and peer-led interventions might hold promise to change behaviour. This paper describes the protocol for a feasibility cluster randomised controlled trial of Peer-Led physical Activity iNtervention for Adolescent girls (PLAN-A), a peer-led intervention aimed at increasing adolescent girls’ physical activity levels. In addition, this paper describes an update that has been made to the protocol for the PLAN-A feasibility cluster randomised controlled trial.
Methods/design
A two-arm cluster randomised feasibility trial will be conducted in six secondary schools (intervention n = 4; control n = 2) with year 8 (12–13 years old) girls. The intervention will operate at a year group level and consist of year 8 girls nominating influential peers within their year group to become peer supporters. Approximately 15% of the cohort will receive 3 days of training about physical activity and interpersonal communication skills. Peer supporters will then informally diffuse messages about physical activity amongst their friends for 10 weeks. Data will be collected at baseline (time 0 (T0)), immediately after the intervention (time 1 (T1)) and 12 months after baseline measures (time 2 (T2)). In this feasibility trial, the primary interest is in the recruitment of schools and participants (both year 8 girls and peer supporters), delivery and receipt of the intervention, data provision rates and identifying the cost categories for future economic analysis. Physical activity will be assessed using 7-day accelerometry, with the likely primary outcome in a fully powered trial being daily minutes of moderate-to-vigorous physical activity. Participants will also complete psychosocial questionnaires at each time point: assessing motivation, self-esteem and peer physical activity norms. Data analysis will be largely descriptive and focus on recruitment, attendance and data provision rates. The findings will inform the sample size required for a definitive trial. A detailed process evaluation using qualitative and quantitative methods will be conducted with a variety of stakeholders (i.e. pupils, parents, teachers and peer-supporter trainers) to identify areas of success and necessary improvements prior to proceeding to a definitive trial.
Discussion
The study will provide the information necessary to design a fully powered trial should PLAN-A demonstrate evidence of promise. This paper describes an update to the protocol for the PLAN-A feasibility cluster randomised controlled trial related to the data-linkage component.
Trial registration
ISRCTN12543546
doi:10.1186/s40814-016-0110-y
PMCID: PMC5154093  PMID: 27965883
Physical activity; Peers; Adolescent girls; Intervention; School
3.  Disability weights based on patient-reported data from a multinational injury cohort 
Abstract
Objective
To create patient-based disability weights for individual injury diagnosis codes and nature-of-injury classifications, for use, as an alternative to panel-based weights, in studies on the burden of disease.
Methods
Self-reported data based on the EQ-5D standardized measure of health status were collected from 29 770 participants in the Injury-VIBES injury cohort study, which covered Australia, the Netherlands, New Zealand, the United Kingdom of Great Britain and Northern Ireland and the United States of America. The data were combined to calculate new disability weights for each common injury classification and for each type of diagnosis covered by the 10th revision of the International statistical classification of diseases and related health problems. Weights were calculated separately for hospital admissions and presentations confined to emergency departments.
Findings
There were 29 770 injury cases with at least one EQ-5D score. The mean age of the participants providing data was 51 years. Most participants were male and almost a third had road traffic injuries. The new disability weights were higher for admitted cases than for cases confined to emergency departments and higher than the corresponding weights used by the Global Burden of Disease 2013 study. Long-term disability was common in most categories of injuries.
Conclusion
Injury is often a chronic disorder and burden of disease estimates should reflect this. Application of the new weights to burden studies would substantially increase estimates of disability-adjusted life-years and provide a more accurate reflection of the impact of injuries on peoples’ lives.
doi:10.2471/BLT.16.172155
PMCID: PMC5096353  PMID: 27821883
4.  The epidemiology, healthcare and societal burden and costs of asthma in the UK and its member nations: analyses of standalone and linked national databases 
BMC Medicine  2016;14(1):113.
Background
There are a lack of reliable data on the epidemiology and associated burden and costs of asthma. We sought to provide the first UK-wide estimates of the epidemiology, healthcare utilisation and costs of asthma.
Methods
We obtained and analysed asthma-relevant data from 27 datasets: these comprised national health surveys for 2010–11, and routine administrative, health and social care datasets for 2011–12; 2011–12 costs were estimated in pounds sterling using economic modelling.
Results
The prevalence of asthma depended on the definition and data source used. The UK lifetime prevalence of patient-reported symptoms suggestive of asthma was 29.5 % (95 % CI, 27.7–31.3; n = 18.5 million (m) people) and 15.6 % (14.3–16.9, n = 9.8 m) for patient-reported clinician-diagnosed asthma. The annual prevalence of patient-reported clinician-diagnosed-and-treated asthma was 9.6 % (8.9–10.3, n = 6.0 m) and of clinician-reported, diagnosed-and-treated asthma 5.7 % (5.7–5.7; n = 3.6 m). Asthma resulted in at least 6.3 m primary care consultations, 93,000 hospital in-patient episodes, 1800 intensive-care unit episodes and 36,800 disability living allowance claims. The costs of asthma were estimated at least £1.1 billion: 74 % of these costs were for provision of primary care services (60 % prescribing, 14 % consultations), 13 % for disability claims, and 12 % for hospital care. There were 1160 asthma deaths.
Conclusions
Asthma is very common and is responsible for considerable morbidity, healthcare utilisation and financial costs to the UK public sector. Greater policy focus on primary care provision is needed to reduce the risk of asthma exacerbations, hospitalisations and deaths, and reduce costs.
Electronic supplementary material
The online version of this article (doi:10.1186/s12916-016-0657-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s12916-016-0657-8
PMCID: PMC5002970  PMID: 27568881
Asthma; Epidemiology; Burden; Cost; UK
5.  Association between breakfast consumption and educational outcomes in 9–11-year-old children 
Public Health Nutrition  2015;19(9):1575-1582.
Objective
Breakfast consumption has been consistently associated with health outcomes and cognitive functioning in schoolchildren. Evidence of direct links with educational outcomes remains equivocal. We aimed to examine the link between breakfast consumption in 9–11-year-old children and educational outcomes obtained 6–18 months later.
Design
Data on individual-level free school meal entitlement and educational outcomes (Statutory Assessment Tests (SATs) at Key Stage 2) were obtained via the SAIL databank and linked to earlier data collected on breakfast consumption. Multilevel modelling assessed associations between breakfast consumption and SATs.
Setting
Trial of the Primary School Free Breakfast Initiative in Wales.
Subjects
Year 5 and 6 students, n 3093 (baseline) and n 3055 (follow-up).
Results
Significant associations were found between all dietary behaviours and better performance in SATs, adjusted for gender and individual- and school-level free school meal entitlement (OR=1·95; CI 1·58, 2·40 for breakfast, OR=1·08; CI 1·04, 1·13 for healthy breakfast items). No association was observed between number of unhealthy breakfast items consumed and educational performance. Association of breakfast consumption with educational performance was stronger where the measure of breakfast consumption was more proximal to SATs tests (OR=2·02 measured 6 months prior to SATs, OR=1·61 measured 18 months prior).
Conclusions
Significant positive associations between self-reported breakfast consumption and educational outcomes were observed. Future research should aim to explore the mechanisms by which breakfast consumption and educational outcomes are linked, and understand how to promote breakfast consumption among schoolchildren. Communicating findings of educational benefits to schools may help to enhance buy-in to efforts to improve health behaviours of pupils.
doi:10.1017/S1368980015002669
PMCID: PMC4873891  PMID: 26411331
Breakfast consumption; Educational outcomes; Socio-economic inequalities; Free school breakfast
6.  ‘Breakfast: how important is it really?’ A response 
Public Health Nutrition  2016;19(9):1720-1721.
doi:10.1017/S1368980016000380
PMCID: PMC4873892  PMID: 26976743
7.  All Wales Injury Surveillance System revised: development of a population-based system to evaluate single-level and multilevel interventions 
Injury Prevention  2015;22(Suppl 1):i50-i55.
Background
Injury surveillance has been established since the 1990s, but is still largely based upon single-source data from sentinel sites. The growth of electronic health records and developments in privacy protecting linkage technologies provide an opportunity for more sophisticated surveillance systems.
Objective
To describe the evolution of an injury surveillance system to support the evaluation of interventions, both simple and complex in terms of organisation.
Methods
The paper describes the evolution of the system from one that relied upon data only from emergency departments to one that include multisource data and are now embedded in a total population privacy protecting data linkage system. Injury incidence estimates are compared by source and data linkage used to aid understanding of data quality issues. Examples of applications, challenges and solutions are described.
Results
The age profile and estimated incidence of injuries recorded in general practice, emergency departments and hospital admissions differ considerably. Data linkage has enabled the evaluation of complex interventions and measurement of longer-term impact of a wide range of exposures.
Conclusions
Embedding injury surveillance within privacy protecting data linkage environment can transform the utility of a traditional single-source surveillance system to a multisource system. It also facilitates greater involvement in the evaluation of simple and complex healthcare and non-healthcare interventions and contributes to the growing evidence basis underlying the science of injury prevention and control.
doi:10.1136/injuryprev-2015-041814
PMCID: PMC4853534  PMID: 26658339
Interventions
8.  Understanding flucloxacillin prescribing trends and treatment non-response in UK primary care: a Clinical Practice Research Datalink (CPRD) study 
Objectives
The volume of prescribed antibiotics is associated with antimicrobial resistance and, unlike most other antibiotic classes, flucloxacillin prescribing has increased. We aimed to describe UK primary care flucloxacillin prescribing and factors associated with subsequent antibiotic prescribing as a proxy for non-response.
Patients and methods
Clinical Practice Research Datalink patients with acute prescriptions for oral flucloxacillin between January 2004 and December 2013, prescription details, associated Read codes and patient demographics were identified. Monthly prescribing rates were plotted and logistic regression identified factors associated with having a subsequent antibiotic prescription within 28 days.
Results
3 031 179 acute prescriptions for 1 667 431 patients were included. Average monthly prescription rates increased from 4.74 prescriptions per 1000 patient-months in 2004 to 5.74 (increase of 21.1%) in 2013. The highest prescribing rates and the largest increases in rates were seen in older adults (70+ years), but the overall increase in prescribing was not accounted for by an ageing population. Prescribing 500 mg tablets/capsules rather than 250 mg became more common. Children were frequently prescribed low doses and small volumes (5 day course) and prescribing declined for children, including for impetigo. Only 4.2% of new prescriptions involved co-prescription of another antibiotic. Age (<5 and ≥60 years), diagnosis of ‘cellulitis or abscess’ or no associated code, and 500 mg dose were associated with a subsequent antibiotic prescription, which occurred after 17.6% of first prescriptions.
Conclusions
There is a need to understand better the reasons for increased prescribing of flucloxacillin in primary care, optimal dosing (and the need to co-prescribe other antibiotics) and the reasons why one in five patients are prescribed a further antibiotic within 4 weeks.
doi:10.1093/jac/dkw084
PMCID: PMC4896409  PMID: 27090629
9.  Does frequent residential mobility in early years affect the uptake and timeliness of routine immunisations? An anonymised cohort study 
Vaccine  2016;34(15):1773-1777.
Background
There are conflicting findings regarding the impact of residential mobility on immunisation status. Our aim was to determine whether there was any association between residential mobility and take up of immunisations and whether they were delayed in administration.
Methods
We carried out a cohort analysis of children born in Wales, UK. Uptake and time of immunisation were collected electronically. We defined frequent movers as those who had moved: 2 or more times in the period prior to the final scheduled on-time date (4 months) for 5 in 1 vaccinations; and 3 or more times in the period prior to the final scheduled on-time date (12 months) for MMR, pneumococcal and meningitis C vaccinations. We defined immunisations due at 2–4 months delayed if they had not been given by age 1; and those due at 12–13 months as delayed if they had not been given by age 2.
Results
Uptake rates of routine immunisations and whether they were given within the specified timeframe were high for both groups. There was no increased risk (odds ratios (95% confidence intervals) between frequent movers compared to non-movers for the uptake of: primary MMR 1.08 (0.88–1.32); booster Meningitis C 1.65 (0.93–2.92); booster pneumococcal 1.60 (0.59–4.31); primary 5 in 1 1.28 (0.92–1.78); and timeliness: primary MMR 0.92 (0.79–1.07); booster Meningitis C 1.26 (0.77–2.07); booster pneumococcal 1.69 (0.23–12.14); and primary 5 in 1 1.04 (0.88–1.23).
Discussion
Findings suggest that children who move home frequently are not adversely affected in terms of the uptake of immunisations and whether they were given within a specified timeframe. Both were high and may reflect proactive behaviour in the primary healthcare setting to meet Government coverage rates for immunisation.
doi:10.1016/j.vaccine.2016.02.049
PMCID: PMC4820086  PMID: 26923454
Residential mobility; Children; Cohort; Immunisation status
10.  Case-finding for common mental disorders of anxiety and depression in primary care: an external validation of routinely collected data 
Background
The robustness of epidemiological research using routinely collected primary care electronic data to support policy and practice for common mental disorders (CMD) anxiety and depression would be greatly enhanced by appropriate validation of diagnostic codes and algorithms for data extraction. We aimed to create a robust research platform for CMD using population-based, routinely collected primary care electronic data.
Methods
We developed a set of Read code lists (diagnosis, symptoms, treatments) for the identification of anxiety and depression in the General Practice Database (GPD) within the Secure Anonymised Information Linkage Databank at Swansea University, and assessed 12 algorithms for Read codes to define cases according to various criteria. Annual incidence rates were calculated per 1000 person years at risk (PYAR) to assess recording practice for these CMD between January 1st 2000 and December 31st 2009. We anonymously linked the 2799 MHI-5 Caerphilly Health and Social Needs Survey (CHSNS) respondents aged 18 to 74 years to their routinely collected GP data in SAIL. We estimated the sensitivity, specificity and positive predictive value of the various algorithms using the MHI-5 as the gold standard.
Results
The incidence of combined depression/anxiety diagnoses remained stable over the ten-year period in a population of over 500,000 but symptoms increased from 6.5 to 20.7 per 1000 PYAR. A ‘historical’ GP diagnosis for depression/anxiety currently treated plus a current diagnosis (treated or untreated) resulted in a specificity of 0.96, sensitivity 0.29 and PPV 0.76. Adding current symptom codes improved sensitivity (0.32) with a marginal effect on specificity (0.95) and PPV (0.74).
Conclusions
We have developed an algorithm with a high specificity and PPV of detecting cases of anxiety and depression from routine GP data that incorporates symptom codes to reflect GP coding behaviour. We have demonstrated that using diagnosis and current treatment alone to identify cases for depression and anxiety using routinely collected primary care data will miss a number of true cases given changes in GP recording behaviour. The Read code lists plus the developed algorithms will be applicable to other routinely collected primary care datasets, creating a platform for future e-cohort research into these conditions.
Electronic supplementary material
The online version of this article (doi:10.1186/s12911-016-0274-7) contains supplementary material, which is available to authorized users.
doi:10.1186/s12911-016-0274-7
PMCID: PMC4791907  PMID: 26979325
Anxiety; Depression; Electronic health records; Validation
11.  The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013 
Haagsma, Juanita A | Graetz, Nicholas | Bolliger, Ian | Naghavi, Mohsen | Higashi, Hideki | Mullany, Erin C | Abera, Semaw Ferede | Abraham, Jerry Puthenpurakal | Adofo, Koranteng | Alsharif, Ubai | Ameh, Emmanuel A | Ammar, Walid | Antonio, Carl Abelardo T | Barrero, Lope H | Bekele, Tolesa | Bose, Dipan | Brazinova, Alexandra | Catalá-López, Ferrán | Dandona, Lalit | Dandona, Rakhi | Dargan, Paul I | De Leo, Diego | Degenhardt, Louisa | Derrett, Sarah | Dharmaratne, Samath D | Driscoll, Tim R | Duan, Leilei | Petrovich Ermakov, Sergey | Farzadfar, Farshad | Feigin, Valery L | Franklin, Richard C | Gabbe, Belinda | Gosselin, Richard A | Hafezi-Nejad, Nima | Hamadeh, Randah Ribhi | Hijar, Martha | Hu, Guoqing | Jayaraman, Sudha P | Jiang, Guohong | Khader, Yousef Saleh | Khan, Ejaz Ahmad | Krishnaswami, Sanjay | Kulkarni, Chanda | Lecky, Fiona E | Leung, Ricky | Lunevicius, Raimundas | Lyons, Ronan Anthony | Majdan, Marek | Mason-Jones, Amanda J | Matzopoulos, Richard | Meaney, Peter A | Mekonnen, Wubegzier | Miller, Ted R | Mock, Charles N | Norman, Rosana E | Orozco, Ricardo | Polinder, Suzanne | Pourmalek, Farshad | Rahimi-Movaghar, Vafa | Refaat, Amany | Rojas-Rueda, David | Roy, Nobhojit | Schwebel, David C | Shaheen, Amira | Shahraz, Saeid | Skirbekk, Vegard | Søreide, Kjetil | Soshnikov, Sergey | Stein, Dan J | Sykes, Bryan L | Tabb, Karen M | Temesgen, Awoke Misganaw | Tenkorang, Eric Yeboah | Theadom, Alice M | Tran, Bach Xuan | Vasankari, Tommi J | Vavilala, Monica S | Vlassov, Vasiliy Victorovich | Woldeyohannes, Solomon Meseret | Yip, Paul | Yonemoto, Naohiro | Younis, Mustafa Z | Yu, Chuanhua | Murray, Christopher J L | Vos, Theo
Injury Prevention  2015;22(1):3-18.
Background
The Global Burden of Diseases (GBD), Injuries, and Risk Factors study used the disability-adjusted life year (DALY) to quantify the burden of diseases, injuries, and risk factors. This paper provides an overview of injury estimates from the 2013 update of GBD, with detailed information on incidence, mortality, DALYs and rates of change from 1990 to 2013 for 26 causes of injury, globally, by region and by country.
Methods
Injury mortality was estimated using the extensive GBD mortality database, corrections for ill-defined cause of death and the cause of death ensemble modelling tool. Morbidity estimation was based on inpatient and outpatient data sets, 26 cause-of-injury and 47 nature-of-injury categories, and seven follow-up studies with patient-reported long-term outcome measures.
Results
In 2013, 973 million (uncertainty interval (UI) 942 to 993) people sustained injuries that warranted some type of healthcare and 4.8 million (UI 4.5 to 5.1) people died from injuries. Between 1990 and 2013 the global age-standardised injury DALY rate decreased by 31% (UI 26% to 35%). The rate of decline in DALY rates was significant for 22 cause-of-injury categories, including all the major injuries.
Conclusions
Injuries continue to be an important cause of morbidity and mortality in the developed and developing world. The decline in rates for almost all injuries is so prominent that it warrants a general statement that the world is becoming a safer place to live in. However, the patterns vary widely by cause, age, sex, region and time and there are still large improvements that need to be made.
doi:10.1136/injuryprev-2015-041616
PMCID: PMC4752630  PMID: 26635210
12.  Protocol for a feasibility cluster randomised controlled trial of a peer-led school-based intervention to increase the physical activity of adolescent girls (PLAN-A) 
Background
Physical activity levels are low amongst adolescent girls, and this population faces specific barriers to being active. Peer influences on health behaviours are important in adolescence and peer-led interventions might hold promise to change behaviour. This paper describes the protocol for a feasibility cluster randomised controlled trial of Peer-Led physical Activity iNtervention for Adolescent girls (PLAN-A), a peer-led intervention aimed at increasing adolescent girls’ physical activity levels.
Methods/design
A two-arm cluster randomised feasibility trial will be conducted in six secondary schools (intervention n = 4; control n = 2) with year 8 (12–13 years old) girls. The intervention will operate at a year group level and consist of year 8 girls nominating influential peers within their year group to become peer-supporters. Approximately 15 % of the cohort will receive 3 days of training about physical activity and interpersonal communication skills. Peer-supporters will then informally diffuse messages about physical activity amongst their friends for 10 weeks. Data will be collected at baseline (time 0 (T0)), immediately after the intervention (time 1 (T1)) and 12 months after baseline measures (time 2 (T2)). In this feasibility trial, the primary interest is in the recruitment of schools and participants (both year 8 girls and peer-supporters), delivery and receipt of the intervention, data provision rates and identifying the cost categories for future economic analysis. Physical activity will be assessed using 7-day accelerometry, with the likely primary outcome in a fully-powered trial being daily minutes of moderate-to-vigorous physical activity. Participants will also complete psychosocial questionnaires at each time point: assessing motivation, self-esteem and peer physical activity norms. Data analysis will be largely descriptive and focus on recruitment, attendance and data provision rates. The findings will inform the sample size required for a definitive trial. A detailed process evaluation using qualitative and quantitative methods will be conducted with a variety of stakeholders (i.e. pupils, parents, teachers and peer-supporter trainers) to identify areas of success and necessary improvements prior to proceeding to a definitive trial.
Discussion
This paper describes the protocol for the PLAN-A feasibility cluster randomised controlled trial which will provide the information necessary to design a fully-powered trial should PLAN-A demonstrate evidence of promise.
Trial Registration
ISRCTN12543546
doi:10.1186/s40814-015-0045-8
PMCID: PMC4770840  PMID: 27966675
Physical activity; Peers; Adolescent girls; Intervention; School
13.  Changes in health in England, with analysis by English regions and areas of deprivation, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013 
Newton, John N | Briggs, Adam D M | Murray, Christopher J L | Dicker, Daniel | Foreman, Kyle J | Wang, Haidong | Naghavi, Mohsen | Forouzanfar, Mohammad H | Ohno, Summer Lockett | Barber, Ryan M | Vos, Theo | Stanaway, Jeffrey D | Schmidt, Jürgen C | Hughes, Andrew J | Fay, Derek F J | Ecob, Russell | Gresser, Charis | McKee, Martin | Rutter, Harry | Abubakar, Ibrahim | Ali, Raghib | Anderson, H Ross | Banerjee, Amitava | Bennett, Derrick A | Bernabé, Eduardo | Bhui, Kamaldeep S | Biryukov, Stanley M | Bourne, Rupert R | Brayne, Carol E G | Bruce, Nigel G | Brugha, Traolach S | Burch, Michael | Capewell, Simon | Casey, Daniel | Chowdhury, Rajiv | Coates, Matthew M | Cooper, Cyrus | Critchley, Julia A | Dargan, Paul I | Dherani, Mukesh K | Elliott, Paul | Ezzati, Majid | Fenton, Kevin A | Fraser, Maya S | Fürst, Thomas | Greaves, Felix | Green, Mark A | Gunnell, David J | Hannigan, Bernadette M | Hay, Roderick J | Hay, Simon I | Hemingway, Harry | Larson, Heidi J | Looker, Katharine J | Lunevicius, Raimundas | Lyons, Ronan A | Marcenes, Wagner | Mason-Jones, Amanda J | Matthews, Fiona E | Moller, Henrik | Murdoch, Michele E | Newton, Charles R | Pearce, Neil | Piel, Frédéric B | Pope, Daniel | Rahimi, Kazem | Rodriguez, Alina | Scarborough, Peter | Schumacher, Austin E | Shiue, Ivy | Smeeth, Liam | Tedstone, Alison | Valabhji, Jonathan | Williams, Hywel C | Wolfe, Charles D A | Woolf, Anthony D | Davis, Adrian C J
Lancet (London, England)  2015;386(10010):2257-2274.
Summary
Background
In the Global Burden of Disease Study 2013 (GBD 2013), knowledge about health and its determinants has been integrated into a comparable framework to inform health policy. Outputs of this analysis are relevant to current policy questions in England and elsewhere, particularly on health inequalities. We use GBD 2013 data on mortality and causes of death, and disease and injury incidence and prevalence to analyse the burden of disease and injury in England as a whole, in English regions, and within each English region by deprivation quintile. We also assess disease and injury burden in England attributable to potentially preventable risk factors. England and the English regions are compared with the remaining constituent countries of the UK and with comparable countries in the European Union (EU) and beyond.
Methods
We extracted data from the GBD 2013 to compare mortality, causes of death, years of life lost (YLLs), years lived with a disability (YLDs), and disability-adjusted life-years (DALYs) in England, the UK, and 18 other countries (the first 15 EU members [apart from the UK] and Australia, Canada, Norway, and the USA [EU15+]). We extended elements of the analysis to English regions, and subregional areas defined by deprivation quintile (deprivation areas). We used data split by the nine English regions (corresponding to the European boundaries of the Nomenclature for Territorial Statistics level 1 [NUTS 1] regions), and by quintile groups within each English region according to deprivation, thereby making 45 regional deprivation areas. Deprivation quintiles were defined by area of residence ranked at national level by Index of Multiple Deprivation score, 2010. Burden due to various risk factors is described for England using new GBD methodology to estimate independent and overlapping attributable risk for five tiers of behavioural, metabolic, and environmental risk factors. We present results for 306 causes and 2337 sequelae, and 79 risks or risk clusters.
Findings
Between 1990 and 2013, life expectancy from birth in England increased by 5·4 years (95% uncertainty interval 5·0–5·8) from 75·9 years (75·9–76·0) to 81·3 years (80·9–81·7); gains were greater for men than for women. Rates of age-standardised YLLs reduced by 41·1% (38·3–43·6), whereas DALYs were reduced by 23·8% (20·9–27·1), and YLDs by 1·4% (0·1–2·8). For these measures, England ranked better than the UK and the EU15+ means. Between 1990 and 2013, the range in life expectancy among 45 regional deprivation areas remained 8·2 years for men and decreased from 7·2 years in 1990 to 6·9 years in 2013 for women. In 2013, the leading cause of YLLs was ischaemic heart disease, and the leading cause of DALYs was low back and neck pain. Known risk factors accounted for 39·6% (37·7–41·7) of DALYs; leading behavioural risk factors were suboptimal diet (10·8% [9·1–12·7]) and tobacco (10·7% [9·4–12·0]).
Interpretation
Health in England is improving although substantial opportunities exist for further reductions in the burden of preventable disease. The gap in mortality rates between men and women has reduced, but marked health inequalities between the least deprived and most deprived areas remain. Declines in mortality have not been matched by similar declines in morbidity, resulting in people living longer with diseases. Health policies must therefore address the causes of ill health as well as those of premature mortality. Systematic action locally and nationally is needed to reduce risk exposures, support healthy behaviours, alleviate the severity of chronic disabling disorders, and mitigate the effects of socioeconomic deprivation.
Funding
Bill & Melinda Gates Foundation and Public Health England.
doi:10.1016/S0140-6736(15)00195-6
PMCID: PMC4672153  PMID: 26382241
14.  Obesity in pregnancy: infant health service utilisation and costs on the NHS 
BMJ Open  2015;5(11):e008357.
Objective
To estimate the direct healthcare cost of infants born to overweight or obese mothers to the National Health Service in the UK.
Design
Retrospective prevalence-based study.
Setting
Combined linked anonymised electronic data sets on a cohort of mother–child pairs enrolled on the Growing Up in Wales: Environments for Healthy Living (EHL) study. Infants were categorised according to maternal early-pregnancy body mass index (BMI): healthy weight mother (18.5≤BMI<25 kg/m2; n=342), overweight mother (25≤BMI≤29.9 kg/m2; n=157) and obese mother (BMI≥30; n=110).
Participants
609 singleton pregnancies with available health service records and an antenatal maternal BMI.
Primary outcome measure
Total health service utilisation and direct healthcare costs for providing these services in the year 2012–2013. Costs are calculated as cost of the infant (no maternal costs considered) and are related to health service usage from birth to age 1 year.
Results
A strong association existed between healthcare usage cost and BMI (p<0.001). Mean total costs were 72% higher among children born to obese mothers (rate ratio (RR) 1.72, 95% CI 1.71 to 1.73) compared with infants born to healthy weight mothers. Higher costings were attributed to a significantly greater number (RR 1.39, 95% CI 1.04 to 1.84) and duration (RR 1.55, 95% CI 1.37 to 1.74) of inpatient visits and a higher number of general practitioner visits (RR 1.10, 95% CI 1.03 to 1.16). Total mean additional resource cost was estimated at £65.13 for infants born to overweight mothers and £1138.11 for infants born to obese mothers, when compared with infants of healthy weight mothers.
Conclusions
Increasingly infants born to mothers with high BMIs consume additional health service resources in the first year of life; this was apparent across inpatient and general practitioner services. Considering both maternal and infant health service use, interventions that cost less than £2310 per person in reducing obesity early pregnancy could be cost-effective.
doi:10.1136/bmjopen-2015-008357
PMCID: PMC4663437  PMID: 26610756
HEALTH ECONOMICS; PUBLIC HEALTH; PAEDIATRICS
15.  Understanding burn injuries in Aboriginal and Torres Strait Islander children: protocol for a prospective cohort study 
BMJ Open  2015;5(10):e009826.
Introduction
Although Aboriginal and Torres Strait Islander children in Australia have higher risk of burns compared with non-Aboriginal children, their access to burn care, particularly postdischarge care, is poorly understood, including the impact of care on functional outcomes. The objective of this study is to describe the burden of burns, access to care and functional outcomes in Aboriginal and Torres Strait Islander children in Australia, and develop appropriate models of care.
Methods and analysis
All Aboriginal and Torres Strait Islander children aged under 16 years of age (and their families) presenting with a burn to a tertiary paediatric burn unit in 4 Australian States (New South Wales (NSW), Queensland, Northern Territory (NT), South Australia (SA)) will be invited to participate. Participants and carers will complete a baseline questionnaire; follow-ups will be completed at 3, 6, 12 and 24 months. Data collected will include sociodemographic information; out of pocket costs; functional outcome; and measures of pain, itch and scarring. Health-related quality of life will be measured using the PedsQL, and impact of injury using the family impact scale. Clinical data and treatment will also be recorded. Around 225 participants will be recruited allowing complete data on around 130 children. Qualitative data collected by in-depth interviews with families, healthcare providers and policymakers will explore the impact of burn injury and outcomes on family life, needs of patients and barriers to healthcare; interviews with families will be conducted by experienced Aboriginal research staff using Indigenous methodologies. Health systems mapping will describe the provision of care.
Ethics and dissemination
The study has been approved by ethics committees in NSW, SA, NT and Queensland. Study results will be distributed to community members by study newsletters, meetings and via the website; to policymakers and clinicians via policy fora, presentations and publication in peer-reviewed journals.
doi:10.1136/bmjopen-2015-009826
PMCID: PMC4606434  PMID: 26463225
ACCIDENT & EMERGENCY MEDICINE; PLASTIC & RECONSTRUCTIVE SURGERY
17.  Level of agreement between patient-reported EQ-5D responses and EQ-5D responses mapped from the SF-12 in an injury population 
Background
Comparing health-related quality of life (HRQL) outcomes between studies is difficult due to the wide variety of instruments used. Comparing study outcomes and facilitating pooled data analyses requires valid “crosswalks” between HRQL instruments. Algorithms exist to map 12-item Short Form Health Survey (SF-12) responses to EQ-5D item responses and preference weights, but none have been validated in populations where disability is prevalent, such as injury.
Methods
Data were extracted from the Validating and Improving injury Burden Estimates Study (Injury-VIBES) for 10,166 adult, hospitalized trauma patients, with both the three-level EQ-5D (EQ-5D-3L) and SF-12 data responses at six and 12-months postinjury. Agreement between actual (patient-reported) and estimated (mapped from SF-12) EQ-5D-3L item responses and preference weights was assessed using Kappa, Prevalence-Adjusted Bias-Adjusted Kappa statistics and Bland-Altman plots.
Results
Moderate agreement was observed for usual activities, pain/discomfort, and anxiety/depression. Agreement was substantial for mobility and self-care items. The mean differences in preference weights were -0.024 and -0.012 at six and 12 months (p < 0.001), respectively. The Bland-Altman plot limits of agreement were large compared to the range of valid preference weight values (-0.56 to 1.00). Estimated EQ-5D-3L responses under-reported disability for all items except pain/discomfort.
Conclusions
Caution should be taken when using EQ-5D-3L responses mapped from the SF-12 to describe patient outcomes or when undertaking economic evaluation, due to the underestimation of disability associated with mapped values. The findings from this study could be used to adjust expected EQ-5D-3L preference weights when estimated from SF-12 item responses when combining data from studies that use either instrument.
Electronic supplementary material
The online version of this article (doi:10.1186/s12963-015-0047-z) contains supplementary material, which is available to authorized users.
doi:10.1186/s12963-015-0047-z
PMCID: PMC4474565  PMID: 26097435
Injury; Agreement; SF-12; EQ-5D; Quality of life
18.  Parental recommendations for population level interventions to support infant and family dietary choices: a qualitative study from the Growing Up in Wales, Environments for Healthy Living (EHL) study 
BMC Public Health  2015;15:234.
Background
Childhood obesity presents a challenge to public health. This qualitative study explored the main barriers to dietary choices faced by parents with infants, and the types of interventions and policy level recommendations they would like to see put in place, to promote a healthier food environment.
Methods
61 semi-structured interviews with prospective parents and parents of infants (61 mothers and 35 fathers) were conducted. Families were selected according to community deprivation levels using the Townsend Deprivation Index to ensure a representative sample from deprived and affluent neighbourhoods. Inductive thematic analysis was used to analyse the data.
Results
Parents identified triggers which led to unhealthy dietary choices such as reliance on fast food outlets due to; shift work, lack of access to personal transport, inability to cook, their own childhood dietary experiences, peer pressure and familial relationships. Parents who made healthy dietary choices reported learning cooking skills while at university, attending community cooking classes, having access to quality food provided by church and community organisations or access to Healthy Start vouchers. They called for a reduction in supermarket promotion of unhealthy food and improved access to affordable and high-quality fresh produce in the local area and in supermarkets. There was a strong message to policy makers to work with commercial companies (food manufactures) as they have resources to lower costs and target messages at a diverse population. Provision of targeted advice to fathers, minority ethnic parents, and tailored and practical advice and information on how to purchase, prepare, store and cook food was requested, along with community cookery classes and improved school cookery lessons.
Conclusions
There is a need for parent directed community/population level interventions that aims to reduce socio-ecological barriers to making healthy dietary choices. Parents desired improvements in meals provided in workplaces, schools and hospitals, as well as increased access to healthy foods by increasing local healthy food outlets and reducing unhealthy, fast food outlets. Knowledge and skills could then be enhanced in line with these improvements, with confidence gained around cooking and storing food appropriately.
doi:10.1186/s12889-015-1561-4
PMCID: PMC4364488  PMID: 25881187
19.  Reduced Population Burden of Road Transport–related Major Trauma After Introduction of an Inclusive Trauma System 
Annals of Surgery  2015;261(3):565-572.
This population-based study found that since the introduction of an inclusive, regionalized trauma system in Victoria, Australia, the burden of road transport–related serious injury has decreased. Hospitalized major trauma cases increased, but disability burden per case declined. Increased survival did not result in an overall increase in nonfatal injury burden.
Objective:
To describe the burden of road transport–related serious injury in Victoria, Australia, over a 10-year period, after the introduction of an integrated trauma system.
Background:
Road traffic injury is a leading cause of death and disability worldwide. Efforts to improve care of the injured are important for reducing burden, but the impact of trauma care systems on burden and cost of road traffic injury has not been evaluated.
Methods:
All road transport–related deaths and major trauma (injury severity score >12) cases were extracted from population-based coroner and trauma registry data sets for July 2001 to June 2011. Modeling was used to assess changes in population incidence rates and odds of in-hospital mortality. Disability-adjusted life years, combining years of life lost and years lived with disability, were calculated. Cost of health loss was calculated from estimates of the value of a disability-adjusted life year.
Results:
Incidence of road transport–related deaths decreased (incidence rate ratio 0.95, 95% confidence interval: 0.94–0.96), whereas the incidence of hospitalized major trauma increased (incidence rate ratio 1.03, 95% confidence interval: 1.02–1.04). Years of life lost decreased by 43%, and years lived with disability increased by 32%, with an overall 28% reduction in disability-adjusted life years over the decade. There was a cost saving per case of A$633,446 in 2010–2011 compared with the 2001–2002 financial year.
Conclusions:
Since introduction of the trauma system in Victoria, Australia, the burden of road transport–related serious injury has decreased. Hospitalized major trauma cases increased, whereas disability burden per case declined. Increased survival does not necessarily result in an overall increase in nonfatal injury burden.
doi:10.1097/SLA.0000000000000522
PMCID: PMC4337622  PMID: 24424142
burden of injury; costs; disability-adjusted life years; outcomes; trauma
20.  Association between the Number of Injuries Sustained and 12-Month Disability Outcomes: Evidence from the Injury-VIBES Study 
PLoS ONE  2014;9(12):e113467.
Objective
To determine associations between the number of injuries sustained and three measures of disability 12-months post-injury for hospitalised patients.
Methods
Data from 27,840 adult (18+ years) participants, hospitalised for injury, were extracted for analysis from the Validating and Improving injury Burden Estimates (Injury-VIBES) Study. Modified Poisson and linear regression analyses were used to estimate relative risks and mean differences, respectively, for a range of outcomes (Glasgow Outcome Scale-Extended, GOS-E; EQ-5D and 12-item Short Form health survey physical and mental component summary scores, PCS-12 and MCS-12) according to the number of injuries sustained, adjusted for age, sex and contributing study.
Findings
More than half (54%) of patients had an injury to more than one ICD-10 body region and 62% had sustained more than one Global Burden of Disease injury type. The adjusted relative risk of a poor functional recovery (GOS-E<7) and of reporting problems on each of the items of the EQ-5D increased by 5–10% for each additional injury type, or body region, injured. Adjusted mean PCS-12 and MCS-12 scores worsened with each additional injury type, or body region, injured by 1.3–1.5 points and 0.5 points, respectively.
Conclusions
Consistent and strong relationships exist between the number of injury types and body regions injured and 12-month functional and health status outcomes. Existing composite measures of anatomical injury severity such as the NISS or ISS, which use up to three diagnoses only, may be insufficient for characterising or accounting for multiple injuries in disability studies. Future studies should consider the impact of multiple injuries to avoid under-estimation of injury burden.
doi:10.1371/journal.pone.0113467
PMCID: PMC4263479  PMID: 25501651
21.  Local Modelling Techniques for Assessing Micro-Level Impacts of Risk Factors in Complex Data: Understanding Health and Socioeconomic Inequalities in Childhood Educational Attainments 
PLoS ONE  2014;9(11):e113592.
Although inequalities in health and socioeconomic status have an important influence on childhood educational performance, the interactions between these multiple factors relating to variation in educational outcomes at micro-level is unknown, and how to evaluate the many possible interactions of these factors is not well established. This paper aims to examine multi-dimensional deprivation factors and their impact on childhood educational outcomes at micro-level, focusing on geographic areas having widely different disparity patterns, in which each area is characterised by six deprivation domains (Income, Health, Geographical Access to Services, Housing, Physical Environment, and Community Safety). Traditional health statistical studies tend to use one global model to describe the whole population for macro-analysis. In this paper, we combine linked educational and deprivation data across small areas (median population of 1500), then use a local modelling technique, the Takagi-Sugeno fuzzy system, to predict area educational outcomes at ages 7 and 11. We define two new metrics, “Micro-impact of Domain” and “Contribution of Domain”, to quantify the variations of local impacts of multidimensional factors on educational outcomes across small areas. The two metrics highlight differing priorities. Our study reveals complex multi-way interactions between the deprivation domains, which could not be provided by traditional health statistical methods based on single global model. We demonstrate that although Income has an expected central role, all domains contribute, and in some areas Health, Environment, Access to Services, Housing and Community Safety each could be the dominant factor. Thus the relative importance of health and socioeconomic factors varies considerably for different areas, depending on the levels of each of the other factors, and therefore each component of deprivation must be considered as part of a wider system. Childhood educational achievement could benefit from policies and intervention strategies that are tailored to the local geographic areas' profiles.
doi:10.1371/journal.pone.0113592
PMCID: PMC4237439  PMID: 25409038
22.  The Communities First (ComFi) study: protocol for a prospective controlled quasi-experimental study to evaluate the impact of area-wide regeneration on mental health and social cohesion in deprived communities 
BMJ Open  2014;4(10):e006530.
Introduction
Recent systematic reviews have highlighted the dearth of evidence on the effectiveness of regeneration on health and health inequalities. ‘Communities First’ is an area-wide regeneration scheme to improve the lives of people living in the most deprived areas in Wales (UK). This study will evaluate the impact of Communities First on residents’ mental health and social cohesion.
Methods and analysis
A prospective controlled quasi-experimental study of the association between residence in Communities First regeneration areas in Caerphilly county borough and change in mental health and social cohesion. The study population is the 4226 residents aged 18–74 years who responded to the Caerphilly Health and Social Needs Study in 2001 (before delivery) and 2008 (after delivery of Communities First). Data on the location, type and cost of Communities First interventions will be extracted from records collected by Caerphilly county borough council. The primary outcome is the change in mental health between 2001 and 2008. Secondary outcomes are changes: in common mental disorder case status (using survey and general practice data), social cohesion and mental health inequalities. Multilevel models will examine change in mental health and social cohesion between Communities First and control areas, adjusting for individual and household level confounding factors. Further models will examine the effects of (1) different types of intervention, (2) contamination across areas, (3) length of residence in a Communities First area, and (4) population migration. We will carry out a cost-consequences analysis to summarise the outcomes generated for participants, as well as service utilisation and utility gains.
Ethics and dissemination
This study has had approval from the Information Governance Review Panel at Swansea University (Ref: 0266 CF). Findings will be disseminated through peer-review publications, international conferences, policy and practice partners in local and national government, and updates on our study website (http://medicine.cardiff.ac.uk/clinical-study/communities-first-regeneration-programme/).
doi:10.1136/bmjopen-2014-006530
PMCID: PMC4202000  PMID: 25314962
MENTAL HEALTH; PUBLIC HEALTH; EPIDEMIOLOGY
23.  Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013 
Wang, Haidong | Liddell, Chelsea A | Coates, Matthew M | Mooney, Meghan D | Levitz, Carly E | Schumacher, Austin E | Apfel, Henry | Iannarone, Marissa | Phillips, Bryan | Lofgren, Katherine T | Sandar, Logan | Dorrington, Rob E | Rakovac, Ivo | Jacobs, Troy A | Liang, Xiaofeng | Zhou, Maigeng | Zhu, Jun | Yang, Gonghuan | Wang, Yanping | Liu, Shiwei | Li, Yichong | Ozgoren, Ayse Abbasoglu | Abera, Semaw Ferede | Abubakar, Ibrahim | Achoki, Tom | Adelekan, Ademola | Ademi, Zanfina | Alemu, Zewdie Aderaw | Allen, Peter J | AlMazroa, Mohammad AbdulAziz | Alvarez, Elena | Amankwaa, Adansi A | Amare, Azmeraw T | Ammar, Walid | Anwari, Palwasha | Cunningham, Solveig Argeseanu | Asad, Majed Masoud | Assadi, Reza | Banerjee, Amitava | Basu, Sanjay | Bedi, Neeraj | Bekele, Tolesa | Bell, Michelle L | Bhutta, Zulfiqar | Blore, Jed | Basara, Berrak Bora | Boufous, Soufiane | Breitborde, Nicholas | Bruce, Nigel G | Bui, Linh Ngoc | Carapetis, Jonathan R | Cárdenas, Rosario | Carpenter, David O | Caso, Valeria | Castro, Ruben Estanislao | Catalá-Lopéz, Ferrán | Cavlin, Alanur | Che, Xuan | Chiang, Peggy Pei-Chia | Chowdhury, Rajiv | Christophi, Costas A | Chuang, Ting-Wu | Cirillo, Massimo | Leite, Iuri da Costa | Courville, Karen J | Dandona, Lalit | Dandona, Rakhi | Davis, Adrian | Dayama, Anand | Deribe, Kebede | Dharmaratne, Samath D | Dherani, Mukesh K | Dilmen, Uğur | Ding, Eric L | Edmond, Karen M | Ermakov, Sergei Petrovich | Farzadfar, Farshad | Fereshtehnejad, Seyed-Mohammad | Fijabi, Daniel Obadare | Foigt, Nataliya | Forouzanfar, Mohammad H | Garcia, Ana C | Geleijnse, Johanna M | Gessner, Bradford D | Goginashvili, Ketevan | Gona, Philimon | Goto, Atsushi | Gouda, Hebe N | Green, Mark A | Greenwell, Karen Fern | Gugnani, Harish Chander | Gupta, Rahul | Hamadeh, Randah Ribhi | Hammami, Mouhanad | Harb, Hilda L | Hay, Simon | Hedayati, Mohammad T | Hosgood, H Dean | Hoy, Damian G | Idrisov, Bulat T | Islami, Farhad | Ismayilova, Samaya | Jha, Vivekanand | Jiang, Guohong | Jonas, Jost B | Juel, Knud | Kabagambe, Edmond Kato | Kazi, Dhruv S | Kengne, Andre Pascal | Kereselidze, Maia | Khader, Yousef Saleh | Khalifa, Shams Eldin Ali Hassan | Khang, Young-Ho | Kim, Daniel | Kinfu, Yohannes | Kinge, Jonas M | Kokubo, Yoshihiro | Kosen, Soewarta | Defo, Barthelemy Kuate | Kumar, G Anil | Kumar, Kaushalendra | Kumar, Ravi B | Lai, Taavi | Lan, Qing | Larsson, Anders | Lee, Jong-Tae | Leinsalu, Mall | Lim, Stephen S | Lipshultz, Steven E | Logroscino, Giancarlo | Lotufo, Paulo A | Lunevicius, Raimundas | Lyons, Ronan Anthony | Ma, Stefan | Mahdi, Abbas Ali | Marzan, Melvin Barrientos | Mashal, Mohammad Taufiq | Mazorodze, Tasara T | McGrath, John J | Memish, Ziad A | Mendoza, Walter | Mensah, George A | Meretoja, Atte | Miller, Ted R | Mills, Edward J | Mohammad, Karzan Abdulmuhsin | Mokdad, Ali H | Monasta, Lorenzo | Montico, Marcella | Moore, Ami R | Moschandreas, Joanna | Msemburi, William T | Mueller, Ulrich O | Muszynska, Magdalena M | Naghavi, Mohsen | Naidoo, Kovin S | Narayan, KM Venkat | Nejjari, Chakib | Ng, Marie | Ngirabega, Jean de Dieu | Nieuwenhuijsen, Mark J | Nyakarahuka, Luke | Ohkubo, Takayoshi | Omer, Saad B | Caicedo, Angel J Paternina | Wyk, Victoria Pillay-van | Pope, Dan | Prabhakaran, Dorairaj | Rahman, Sajjad UR | Rana, Saleem M | Reilly, Robert Quentin | Rojas-Rueda, David | Ronfani, Luca | Rushton, Lesley | Saeedi, Mohammad Yahya | Salomon, Joshua | Sampson, Uchechukwu | Santos, Itamar S | Sawhney, Monika | Schmidt, Jürgen C | Nazarova, Marina Shakh | She, Jun | Sheikhbahaei, Sara | Shibuya, Kenji | Shin, Hwashin Hyun | Shishani, Kawkab | Shiue, Ivy | Sigfusdottir, Inga Dora | Singh, Jasvinder A | Skirbekk, Vegard | Sliwa, Karen | Soshnikov, Sergey S | Sposato, Luciano A | Stathopoulou, Vasiliki Kalliopi | Stroumpoulis, Konstantinos | Tabb, Karen M | Talongwa, Roberto Tchio | Teixeira, Carolina Maria | Terkawi, Abdullah Sulieman | Thomson, Alan J | Lyman, Andrew L Thorne | Toyoshima, Hideaki | Dimbuene, Zacharie Tsala | Uwaliraye, Parfait | Uzun, Selen Begüm | Vasankari, Tommi J | Vasconcelos, Ana Maria Nogales | Vlassov, Vasiliy Victorovich | Vollset, Stein Emil | Vos, Theo | Waller, Stephen | Wan, Xia | Weichenthal, Scott | Weiderpass, Elisabete | Weintraub, Robert G | Westerman, Ronny | Wilkinson, James D | Williams, Hywel C | Yang, Yang C | Yentur, Gokalp Kadri | Yip, Paul | Yonemoto, Naohiro | Younis, Mustafa | Yu, Chuanhua | Jin, Kim Yun | Zaki, Maysaa El Sayed | Zhu, Shankuan | Lopez, Alan D | Murray, Christopher J L
Lancet  2014;384(9947):957-979.
Summary
Background
Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success.
Methods
We generated updated estimates of child mortality in early neonatal (age 0–6 days), late neonatal (7–28 days), postneonatal (29–364 days), childhood (1–4 years), and under-5 (0–4 years) age groups for 188 countries from 1970 to 2013, with more than 29 000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030.
Findings
We estimated that 6·3 million (95% UI 6·0–6·6) children under-5 died in 2013, a 64% reduction from 17·6 million (17·1–18·1) in 1970. In 2013, child mortality rates ranged from 152·5 per 1000 livebirths (130·6–177·4) in Guinea-Bissau to 2·3 (1·8–2·9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from −6·8% to 0·1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000–13 than during 1990–2000. In 2013, neonatal deaths accounted for 41·6% of under-5 deaths compared with 37·4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1·4 million more child deaths, and rising income per person and maternal education led to 0·9 million and 2·2 million fewer deaths, respectively. Changes in secular trends led to 4·2 million fewer deaths. Unexplained factors accounted for only −1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone.
Interpretation
Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030.
Funding
Bill & Melinda Gates Foundation, US Agency for International Development.
doi:10.1016/S0140-6736(14)60497-9
PMCID: PMC4165626  PMID: 24797572
24.  Support and Assessment for Fall Emergency Referrals (SAFER 1): Cluster Randomised Trial of Computerised Clinical Decision Support for Paramedics 
PLoS ONE  2014;9(9):e106436.
Objective
To evaluate effectiveness, safety and cost-effectiveness of Computerised Clinical Decision Support (CCDS) for paramedics attending older people who fall.
Design
Cluster trial randomised by paramedic; modelling.
Setting
13 ambulance stations in two UK emergency ambulance services.
Participants
42 of 409 eligible paramedics, who attended 779 older patients for a reported fall.
Interventions
Intervention paramedics received CCDS on Tablet computers to guide patient care. Control paramedics provided care as usual. One service had already installed electronic data capture.
Main Outcome Measures
Effectiveness: patients referred to falls service, patient reported quality of life and satisfaction, processes of care.
Safety
Further emergency contacts or death within one month.
Cost-Effectiveness
Costs and quality of life. We used findings from published Community Falls Prevention Trial to model cost-effectiveness.
Results
17 intervention paramedics used CCDS for 54 (12.4%) of 436 participants. They referred 42 (9.6%) to falls services, compared with 17 (5.0%) of 343 participants seen by 19 control paramedics [Odds ratio (OR) 2.04, 95% CI 1.12 to 3.72]. No adverse events were related to the intervention. Non-significant differences between groups included: subsequent emergency contacts (34.6% versus 29.1%; OR 1.27, 95% CI 0.93 to 1.72); quality of life (mean SF12 differences: MCS −0.74, 95% CI −2.83 to +1.28; PCS −0.13, 95% CI −1.65 to +1.39) and non-conveyance (42.0% versus 36.7%; OR 1.13, 95% CI 0.84 to 1.52). However ambulance job cycle time was 8.9 minutes longer for intervention patients (95% CI 2.3 to 15.3). Average net cost of implementing CCDS was £208 per patient with existing electronic data capture, and £308 without. Modelling estimated cost per quality-adjusted life-year at £15,000 with existing electronic data capture; and £22,200 without.
Conclusions
Intervention paramedics referred twice as many participants to falls services with no difference in safety. CCDS is potentially cost-effective, especially with existing electronic data capture.
Trial Registration
ISRCTN Register ISRCTN10538608
doi:10.1371/journal.pone.0106436
PMCID: PMC4162545  PMID: 25216281
25.  Physical Disability, Anxiety and Depression in People with MS: An Internet-Based Survey via the UK MS Register 
PLoS ONE  2014;9(8):e104604.
Introduction
People with Multiple Sclerosis are known to have a relatively high prevalence of both anxiety and depression. Studies of the relationship between physical disability and mental health in people with MS have reported mixed results, showing the need for further work.
Methods
Between May 2011 and April 2012, 4516 people completed the MSIS-29 (v.1) and HADS scales via the dedicated internet site of the UK MS Register within a 7 day time window. These responses were linked with basic demographic and descriptive data and analysed in SPSS (v.20).
Results
The proportions of people experiencing anxiety or depression increased with physical disability such that 38.0% of respondents with low, and 66.7% with high disability reported at least mild anxiety, and 17.1% of people with low, and 71.7% with high disability experienced at least mild depression. The multiple regression model explained 18.4% of the variance in anxiety with MSIS-29-PHYS score being the strongest predictor of anxiety. The model for depression explained 37.8% of the variance with MSIS-29-PHYS score being the strongest predictor. Some of the other variables included showed negative associations with anxiety and depression, indicating that the influence of physical disability on mental wellbeing could be underestimated.
Conclusions
This study indicates that there is a positive relationship between physical disability and anxiety and depression, that physical disability impacts on anxiety and depression to differing extents, and that the effects vary with gender, age, disease course and disease duration. We have shown that physical disability is a predictor of anxiety and depression, and that other factors may mask the extent of this effect. Whether the causes of anxiety and depression are reactive, organic or a combination, it is essential that mental wellbeing is given due attention in caring for people with MS so that all their health needs can be met.
doi:10.1371/journal.pone.0104604
PMCID: PMC4143231  PMID: 25153835

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