Ultra-Processed Food Consumption and Chronic Non-Communicable Diseases-Related Dietary Nutrient Profile in the UK (2008⁻2014)

We described the contribution of ultra-processed foods in the U.K. diet and its association with the overall dietary content of nutrients known to affect the risk of chronic non-communicable diseases (NCDs). Cross-sectional data from the U.K. National Diet and Nutrition Survey (2008⁻2014) were analysed. Food items collected using a four-day food diary were classified according to the NOVA system. The average energy intake was 1764 kcal/day, with 30.1% of calories coming from unprocessed or minimally processed foods, 4.2% from culinary ingredients, 8.8% from processed foods, and 56.8% from ultra-processed foods. As the ultra-processed food consumption increased, the dietary content of carbohydrates, free sugars, total fats, saturated fats, and sodium increased significantly while the content of protein, fibre, and potassium decreased. Increased ultra-processed food consumption had a remarkable effect on average content of free sugars, which increased from 9.9% to 15.4% of total energy from the first to the last quintile. The prevalence of people exceeding the upper limits recommended for free sugars and sodium increased by 85% and 55%, respectively, from the lowest to the highest ultra-processed food quintile. Decreasing the dietary share of ultra-processed foods may substantially improve the nutritional quality of diets and contribute to the prevention of diet-related NCDs.

Associations between multimorbidity, healthcare utilisation and health status: evidence from 16 European countries

BACKGROUND

with ageing populations and increasing exposure to risk factors for chronic diseases, the prevalence of chronic disease multimorbidity is rising globally. There is little evidence on the determinants of multimorbidity and its impact on healthcare utilisation and health status in Europe.

METHODS

we used cross-sectional data from the Survey of Health, Ageing and Retirement in Europe (SHARE) in 2011-12, which included nationally representative samples of persons aged 50 and older from 16 European nations. Negative binomial and logistic regression models were used to assess the association between number of chronic diseases and healthcare utilisation, self-perceived health, depression and reduction of functional capacity.

RESULTS

overall, 37.3% of participants reported multimorbidity; the lowest prevalence was in Switzerland (24.7%), the highest in Hungary (51.0%). The likelihood of having multimorbidity increased substantially with age. Number of chronic conditions was associated with greater healthcare utilisation in both primary (regression coefficient for medical doctor visits = 0.29, 95% CI = 0.27-0.30) and secondary setting (adjusted odds ratio (AOR) for having any hospitalisation in the last year = 1.49, 95% CI = 1.42-1.55) in all countries analysed. Number of chronic diseases was associated with fair/poor health status (AOR 2.13, 95% CI = 2.03-2.24), being depressed (AOR 1.48, 95% CI = 1.42-1.54) and reduced functional capacity (AOR 2.12, 95% CI = 2.02-2.22).

CONCLUSION

multimorbidity is associated with greater healthcare utilisation, worse self-reported health status, depression and reduced functional capacity in European countries. European health systems should prioritise improving the management of patients with multimorbidity to improve their health status and increase healthcare efficiency.

Social epidemiology of hypertension in middle-income countries: determinants of prevalence, diagnosis, treatment, and control in the WHO SAGE study

Large-scale hypertension screening campaigns have been recommended for middle-income countries. We sought to identify sociodemographic predictors of hypertension prevalence, diagnosis, treatment, and control among middle-income countries. We analyzed data from 47 443 adults in all 6 middle-income countries (China, Ghana, India, Mexico, Russia, and South Africa) sampled in nationally representative household assessments from 2007 to 2010 as part of the World Health Organization Study on Global Aging and Adult Health. We estimated regression models accounting for age, sex, urban/rural location, nutrition, and obesity, as well as hypothesized covariates of healthcare access, such as income and insurance. Hypertension prevalence varied from 23% (India) to 52% (Russia), with between 30% (Russia) and 83% (Ghana) of hypertensives undiagnosed before the survey and between 35% (Russia) and 87% (Ghana) untreated. Although the risk of hypertension significantly increased with age (odds ratio, 4.6; 95% confidence interval, 3.0-7.1; among aged, 60-79 versus <40 years), the risk of being undiagnosed or untreated fell significantly with age. Obesity was a significant correlate to hypertension (odds ratio, 3.7; 95% confidence interval, 2.1-6.8 for obese versus normal weight), and was prevalent even among the lowest income quintile (13% obesity). Insurance status and income also emerged as significant correlates to diagnosis and treatment probability, respectively. More than 90% of hypertension cases were uncontrolled, with men having 3 times the odds as women of being uncontrolled. Overall, the social epidemiology of hypertension in middle-income countries seems to be correlated to increasing obesity prevalence, and hypertension control rates are particularly low for adult men across distinct cultures.

Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals?

The Sustainable Development Goals (SDGs) are now steering the global health and development agendas. Notably, the SDGs contain no mention of primary health care, reflecting the disappointing implementation of the Alma-Ata declaration of 1978 over the past four decades. The draft Astana declaration (Alma-Ata 2·0), released in June, 2018, restates the key principles of primary health care and renews these as driving forces for achieving the SDGs, emphasising universal health coverage. We use accumulating evidence to show that countries that reoriente their health systems towards primary care are better placed to achieve the SDGs than those with hospital-focused systems or low investment in health. We then argue that an even bolder approach, which fully embraces the Alma-Ata vision of primary health care, could deliver substantially greater SDG progress, by addressing the wider determinants of health, promoting equity and social justice throughout society, empowering communities, and being a catalyst for advancing and amplifying universal health coverage and synergies among SDGs.

Impact of Noncommunicable Disease Multimorbidity on Healthcare Utilisation and Out-Of-Pocket Expenditures in Middle-Income Countries: Cross Sectional Analysis

Background

The burden of non-communicable disease (NCDs) has grown rapidly in low- and middle-income countries (LMICs), where populations are ageing, with rising prevalence of multimorbidity (more than two co-existing chronic conditions) that will significantly increase pressure on already stretched health systems. We assess the impact of NCD multimorbidity on healthcare utilisation and out-of-pocket expenditures in six middle-income countries: China, Ghana, India, Mexico, Russia and South Africa.

Methods

Secondary analyses of cross-sectional data from adult participants (>18 years) in the WHO Study on Global Ageing and Adult Health (SAGE) 2007–2010. We used multiple logistic regression to determine socio-demographic correlates of multimorbidity. Association between the number of NCDs and healthcare utilisation as well as out-of-pocket spending was assessed using logistic, negative binominal and log-linear models.

Results

The prevalence of multimorbidity in the adult population varied from 3∙9% in Ghana to 33∙6% in Russia. Number of visits to doctors in primary and secondary care rose substantially for persons with increasing numbers of co-existing NCDs. Multimorbidity was associated with more outpatient visits in China (coefficient for number of NCD = 0∙56, 95% CI = 0∙46, 0∙66), a higher likelihood of being hospitalised in India (AOR = 1∙59, 95% CI = 1∙45, 1∙75), higher out-of-pocket expenditures for outpatient visits in India and China, and higher expenditures for hospital visits in Russia. Medicines constituted the largest proportion of out-of-pocket expenditures in persons with multimorbidity (88∙3% for outpatient, 55∙9% for inpatient visit in China) in most countries.

Conclusion

Multimorbidity is associated with higher levels of healthcare utilisation and greater financial burden for individuals in middle-income countries. Our study supports the WHO call for universal health insurance and health service coverage in LMICs, particularly for vulnerable groups such as the elderly with multimorbidity.

Harnessing the cloud of patient experience: using social media to detect poor quality healthcare

Recent years have seen increasing interest in patient-centred care and calls to focus on improving the patient experience. At the same time, a growing number of patients are using the internet to describe their experiences of healthcare. We believe the increasing availability of patients' accounts of their care on blogs, social networks, Twitter and hospital review sites presents an intriguing opportunity to advance the patient-centred care agenda and provide novel quality of care data. We describe this concept as a 'cloud of patient experience'. In this commentary, we outline the ways in which the collection and aggregation of patients' descriptions of their experiences on the internet could be used to detect poor clinical care. Over time, such an approach could also identify excellence and allow it to be built on. We suggest using the techniques of natural language processing and sentiment analysis to transform unstructured descriptions of patient experience on the internet into usable measures of healthcare performance. We consider the various sources of information that could be used, the limitations of the approach and discuss whether these new techniques could detect poor performance before conventional measures of healthcare quality.

Use of sentiment analysis for capturing patient experience from free-text comments posted online

BACKGROUND

There are large amounts of unstructured, free-text information about quality of health care available on the Internet in blogs, social networks, and on physician rating websites that are not captured in a systematic way. New analytical techniques, such as sentiment analysis, may allow us to understand and use this information more effectively to improve the quality of health care.

OBJECTIVE

We attempted to use machine learning to understand patients' unstructured comments about their care. We used sentiment analysis techniques to categorize online free-text comments by patients as either positive or negative descriptions of their health care. We tried to automatically predict whether a patient would recommend a hospital, whether the hospital was clean, and whether they were treated with dignity from their free-text description, compared to the patient's own quantitative rating of their care.

METHODS

We applied machine learning techniques to all 6412 online comments about hospitals on the English National Health Service website in 2010 using Weka data-mining software. We also compared the results obtained from sentiment analysis with the paper-based national inpatient survey results at the hospital level using Spearman rank correlation for all 161 acute adult hospital trusts in England.

RESULTS

There was 81%, 84%, and 89% agreement between quantitative ratings of care and those derived from free-text comments using sentiment analysis for cleanliness, being treated with dignity, and overall recommendation of hospital respectively (kappa scores: .40-.74, P<.001 for all). We observed mild to moderate associations between our machine learning predictions and responses to the large patient survey for the three categories examined (Spearman rho 0.37-0.51, P<.001 for all).

CONCLUSIONS

The prediction accuracy that we have achieved using this machine learning process suggests that we are able to predict, from free-text, a reasonably accurate assessment of patients' opinion about different performance aspects of a hospital and that these machine learning predictions are associated with results of more conventional surveys.

Socioeconomic inequalities in non-communicable diseases prevalence in India: disparities between self-reported diagnoses and standardized measures

BACKGROUND

Whether non-communicable diseases (NCDs) are diseases of poverty or affluence in low-and-middle income countries has been vigorously debated. Most analyses of NCDs have used self-reported data, which is biased by differential access to healthcare services between groups of different socioeconomic status (SES). We sought to compare self-reported diagnoses versus standardised measures of NCD prevalence across SES groups in India.

METHODS

We calculated age-adjusted prevalence rates of common NCDs from the Study on Global Ageing and Adult Health, a nationally representative cross-sectional survey. We compared self-reported diagnoses to standardized measures of disease for five NCDs. We calculated wealth-related and education-related disparities in NCD prevalence by calculating concentration index (C), which ranges from -1 to +1 (concentration of disease among lower and higher SES groups, respectively).

FINDINGS

NCD prevalence was higher (range 5.2 to 19.1%) for standardised measures than self-reported diagnoses (range 3.1 to 9.4%). Several NCDs were particularly concentrated among higher SES groups according to self-reported diagnoses (Csrd) but were concentrated either among lower SES groups or showed no strong socioeconomic gradient using standardized measures (Csm): age-standardised wealth-related C: angina Csrd 0.02 vs. Csm -0.17; asthma and lung diseases Csrd -0.05 vs. Csm -0.04 (age-standardised education-related Csrd 0.04 vs. Csm -0.05); vision problems Csrd 0.07 vs. Csm -0.05; depression Csrd 0.07 vs. Csm -0.13. Indicating similar trends of standardized measures detecting more cases among low SES, concentration of hypertension declined among higher SES (Csrd 0.19 vs. Csm 0.03).

CONCLUSIONS

The socio-economic patterning of NCD prevalence differs markedly when assessed by standardized criteria versus self-reported diagnoses. NCDs in India are not necessarily diseases of affluence but also of poverty, indicating likely under-diagnosis and under-reporting of diseases among the poor. Standardized measures should be used, wherever feasible, to estimate the true prevalence of NCDs.

Effect of tobacco control policies on perinatal and child health: a systematic review and meta-analysis

BACKGROUND

Tobacco smoking and smoke exposure during pregnancy and childhood cause considerable childhood morbidity and mortality. We did a systematic review and meta-analysis to investigate whether implementation of WHO's recommended tobacco control policies (MPOWER) was of benefit to perinatal and child health.

METHODS

We searched 19 electronic databases, hand-searched references and citations, and consulted experts to identify studies assessing the association between implementation of MPOWER policies and child health. We did not apply any language restrictions, and searched the full time period available for each database, up to June 22, 2017. Our primary outcomes of interest were perinatal mortality, preterm birth, hospital attendance for asthma exacerbations, and hospital attendance for respiratory tract infections. Where possible and appropriate, we combined data from different studies in random-effects meta-analyses. This study is registered with PROSPERO, number CRD42015023448.

FINDINGS

We identified 41 eligible studies (24 from North America, 16 from Europe, and one from China) that assessed combinations of the following MPOWER policies: smoke-free legislation (n=35), tobacco taxation (n=11), and smoking cessation services (n=3). Risk of bias was low in 23 studies, moderate in 16, and high in two. Implementation of smoke-free legislation was associated with reductions in rates of preterm birth (-3·77% [95% CI -6·37 to -1·16]; ten studies, 27 530 183 individuals), rates of hospital attendance for asthma exacerbations (-9·83% [-16·62 to -3·04]; five studies, 684 826 events), and rates of hospital attendance for all respiratory tract infections (-3·45% [-4·64 to -2·25]; two studies, 1 681 020 events) and for lower respiratory tract infections (-18·48% [-32·79 to -4·17]; three studies, 887 414 events). Associations appeared to be stronger when comprehensive smoke-free laws were implemented than when partial smoke-free laws were implemented. Among two studies assessing the association between smoke-free legislation and perinatal mortality, one showed significant reductions in stillbirth and neonatal mortality but did not report the overall effect on perinatal mortality, while the other showed no change in perinatal mortality. Meta-analysis of studies on other MPOWER policies was not possible; all four studies on increasing tobacco taxation and one of two on offering disadvantaged pregnant women help to quit smoking that reported on our primary outcomes had positive findings. Assessment of publication bias was only possible for studies assessing the association between smoke-free legislation and preterm birth, showing some degree of bias.

INTERPRETATION

Smoke-free legislation is associated with substantial benefits to child health. The majority of studies on other MPOWER policies also indicated a positive effect. These findings provide strong support for implementation of such policies comprehensively across the world.

FUNDING

Chief Scientist Office Scotland, Farr Institute, Netherlands Lung Foundation, Erasmus MC.

Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study

BACKGROUND

Since 2015, a major economic crisis in Brazil has led to increasing poverty and the implementation of long-term fiscal austerity measures that will substantially reduce expenditure on social welfare programmes as a percentage of the country's GDP over the next 20 years. The Bolsa Família Programme (BFP)-one of the largest conditional cash transfer programmes in the world-and the nationwide primary healthcare strategy (Estratégia Saúde da Família [ESF]) are affected by fiscal austerity, despite being among the policy interventions with the strongest estimated impact on child mortality in the country. We investigated how reduced coverage of the BFP and ESF-compared to an alternative scenario where the level of social protection under these programmes is maintained-may affect the under-five mortality rate (U5MR) and socioeconomic inequalities in child health in the country until 2030, the end date of the Sustainable Development Goals.

METHODS AND FINDINGS

We developed and validated a microsimulation model, creating a synthetic cohort of all 5,507 Brazilian municipalities for the period 2017-2030. This model was based on the longitudinal dataset and effect estimates from a previously published study that evaluated the effects of poverty, the BFP, and the ESF on child health. We forecast the economic crisis and the effect of reductions in BFP and ESF coverage due to current fiscal austerity on the U5MR, and compared this scenario with a scenario where these programmes maintain the levels of social protection by increasing or decreasing with the size of Brazil's vulnerable populations (policy response scenarios). We used fixed effects multivariate regression models including BFP and ESF coverage and accounting for secular trends, demographic and socioeconomic changes, and programme duration effects. With the maintenance of the levels of social protection provided by the BFP and ESF, in the most likely economic crisis scenario the U5MR is expected to be 8.57% (95% CI: 6.88%-10.24%) lower in 2030 than under fiscal austerity-a cumulative 19,732 (95% CI: 10,207-29,285) averted under-five deaths between 2017 and 2030. U5MRs from diarrhoea, malnutrition, and lower respiratory tract infections are projected to be 39.3% (95% CI: 36.9%-41.8%), 35.8% (95% CI: 31.5%-39.9%), and 8.5% (95% CI: 4.1%-12.0%) lower, respectively, in 2030 under the maintenance of BFP and ESF coverage, with 123,549 fewer under-five hospitalisations from all causes over the study period. Reduced coverage of the BFP and ESF will also disproportionately affect U5MR in the most vulnerable areas, with the U5MR in the poorest quintile of municipalities expected to be 11.0% (95% CI: 8.0%-13.8%) lower in 2030 under the maintenance of BFP and ESF levels of social protection than under fiscal austerity, compared to no difference in the richest quintile. Declines in health inequalities over the last decade will also stop under a fiscal austerity scenario: the U5MR concentration index is expected to remain stable over the period 2017-2030, compared to a 13.3% (95% CI: 5.6%-21.8%) reduction under the maintenance of BFP and ESF levels of protection. Limitations of our analysis are the ecological nature of the study, uncertainty around future macroeconomic scenarios, and potential changes in other factors affecting child health. A wide range of sensitivity analyses were conducted to minimise these limitations.

CONCLUSIONS

The implementation of fiscal austerity measures in Brazil can be responsible for substantively higher childhood morbidity and mortality than expected under maintenance of social protection-threatening attainment of Sustainable Development Goals for child health and reducing inequality.

Ultra-processed food consumption and risk of obesity: a prospective cohort study of UK Biobank

Objective

The objective of this study was to examine the associations between ultra-processed food consumption and risk of obesity among UK adults.

Methods

Participants aged 40–69 years at recruitment in the UK Biobank (2006–2019) with dietary intakes collected using 24-h recall and repeated measures of adiposity––body mass index (BMI), waist circumference (WC) and percentage of body fat (% BF)––were included (N = 22,659; median follow-up: 5 years). Ultra-processed foods were identified using the NOVA classification and their consumption was expressed as a percentage of total energy intake. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HR) of several indicators of obesity according to ultra-processed food consumption. Models were adjusted for sociodemographic and lifestyle characteristics.

Results

947 incident cases of overall obesity (BMI ≥ 30 kg/m²) and 1900 incident cases of abdominal obesity (men: WC ≥ 102 cm, women: WC ≥ 88 cm) were identified during follow-up. Participants in the highest quartile of ultra-processed food consumption had significantly higher risk of developing overall obesity (HR 1.79; 95% CI 1.06─3.03) and abdominal obesity (HR 1.30; 95% CI 1.14─1.48). They had higher risk of experiencing a ≥ 5% increase in BMI (HR 1.31; 95% CI 1.20─1.43), WC (HR 1.35; 95% CI 1.25─1.45) and %BF (HR 1.14; 95% CI 1.03─1.25), than those in the lowest quartile of consumption.

Conclusions

Our findings provide evidence that higher consumption of ultra-processed food is strongly associated with a higher risk of multiple indicators of obesity in the UK adult population. Policy makers should consider actions that promote consumption of fresh or minimally processed foods and reduce consumption of ultra-processed foods.

Electronic supplementary material

The online version of this article (10.1007/s00394-020-02367-1) contains supplementary material, which is available to authorized users.

Non communicable disease multimorbidity and associated health care utilization and expenditures in India: cross-sectional study

BACKGROUND

Non communicable disease (NCD) multimorbidity is increasingly becoming common in high income settings but little is known about its epidemiology and associated impacts on citizens and health systems in low and middle-income countries (LMICs). We aim to examine the socio-demographic distribution of NCD multimorbidity (≥2 diseases) and its implications for health care utilization and out-of-pocket expenditure (OOPE) in India.

METHODS

We analyzed cross-sectional nationally representative data from the World Health Organisaion Study on Global Ageing and Adult Health (WHO-SAGE), conducted in India during 2007. Multiple logistic regression was used to determine socio-demographic predictors of self-reported multimorbidity. A two part model was used to assess the relationship between number of NCDs and health care utilization including OOPE.

RESULTS

28.5% of the sample population had at least one NCD and 8.9% had NCD multimorbidity. The prevalence of multimorbidity increased from 1.3% in 18-29 year olds to 30.6% in those aged 70 years and above. Mean outpatient visits in the preceding 12 months increased from 2.2 to 6.2 and the percentage reporting an overnight hospital stay in the past 3 years increased from 9% to 29% in those with no NCD and ≥2 NCDs respectively (p <0.001).OOPE incurred during the last outpatient visit increased from INR 272.1 (95% CI = 249.0-295.2) in respondents with no NCDs to INR 454.1 (95% CI = 407.8-500.4) in respondents with ≥2 NCDs. However, we did not find an increase in OOPE during the last inpatient visit with number of NCDs (7865.9 INR for those with zero NCDs compared with 7301.3 for those with ≥2 NCDs). For both outpatient and inpatient OOPE, medicine constitutes the largest proportion of spending (70.7% for outpatient, 53.6% for inpatient visit), followed by spending for health care provider (14.0% for outpatient, 12.2% for inpatient visit).

CONCLUSION

NCD multimorbidity is common in the Indian adult population and is associated with substantially higher healthcare utilization and OOPE. Strategies to address the growing burden of NCDs in LMICs should include efforts to improve the management of patients with multimorbidity and reduce associated financial burden to individuals and households.

Ultra-processed food consumption and indicators of obesity in the United Kingdom population (2008-2016)

We examined the association between the consumption of ultra-processed foods and adiposity in a nationally representative sample of the UK adult population. We studied 6,143 participants (19 to 96 years, 51.6% female) sampled by the UK National Diet and Nutrition Survey (2008-16). Food items reported in four-day food diary were classified according to the NOVA system. Multiple linear and logistic regressions were used to evaluate associations between the dietary contribution of ultra-processed foods (sex-specific quartile and continuous) and Body Mass Index (BMI), Waist Circumference (WC) and obesity (BMI>30kg/m2) and abdominal obesity (men: WC≥102cm, women: WC≥88cm) status. Models were adjusted for sociodemographic and lifestyle characteristics. In multivariable analyses, the highest consumption of ultra-processed food was associated with 1.66 kg/m2 higher BMI (95%CI 0.96-2.36), 3.56 cm greater WC (95%CI 1.79-5.33) and 90% higher odds for being obese (OR = 1.90, 95%CI 1.39-2.61), compared with the lowest consumption. A 10% increase in the consumption of ultra-processed foods was associated with an increase of 0.38 kg/m2 in BMI (95%CI 0.20-0.55), 0.87 cm in WC (95%CI 0.40-1.33) and 18% higher odds of being obese (OR = 1.18, 95%CI 1.08-1.28). The consumption of ultra-processed food was associated with an increase in BMI, WC and prevalence of obesity in both sexes. A dose response relationship was observed in both sexes, with a 10% increase in the consumption of ultra-processed foods being associated with a 18% increase in the prevalence of obesity in men and a 17% increase in women. Higher consumption of ultra-processed food is associated with greater adiposity in the UK adult population. Policy makers should consider actions that promote consumption of unprocessed or minimally processed foods and reduce consumption of ultra-processed foods.

Uptake of the NHS Health Checks programme in a deprived, culturally diverse setting: cross-sectional study

BACKGROUND

The UK is embarking on a national cardiovascular risk assessment programme called NHS Health Checks; in order to be effective, high and equitable uptake is paramount.

METHODS

A cross-sectional study, using data extracted from electronic medical records of persons aged 35-74 years estimated to be at a high risk of developing cardiovascular disease, to examine the uptake of the Health Checks using logistic regression and statin prescribing.

RESULTS

A total of 44.8% of high risk patients invited for a Health Check attended. Uptake was lower among younger men but higher among patients from south Asian (AOR = 1.71 [1.29-2.27] compared with white) or mixed ethnic backgrounds (AOR = 2.42 [1.50-3.89]), and patients registered with smaller practices (AOR = 2.53 [1.09-5.84] <3000 patients compared with 3000-5999). The percentage of patients confirmed to be at high risk of CVD prescribed a statin increased from 24.7 to 44.8%.

CONCLUSIONS

Uptake of cardiovascular risk assessment and prescribing of statins in high risk patients was considerably lower than projected in the first year of NHS Health Checks programme. Targeting efforts to increase uptake and adherence to interventions in high risk populations and reinvesting resources into population wide strategies to reduce obesity, smoking and salt intake may prove more cost-effective in reducing the burden of cardiovascular disease in the UK.

Diabetes in the Middle-East and North Africa: an update

In recent decades, the prevalence of diabetes has risen dramatically in many countries of the International Diabetes Federation's (IDF) Middle-East and North Africa (MENA) Region. This increase has been driven by a range of factors that include rapid economic development and urbanisation; changes in lifestyle that have led to reduced levels of physical activity, increased intake of refined carbohydrates, and a rise in obesity. These changes have resulted in the countries of MENA Region now having among the highest rates of diabetes prevalence in the world. The current prevalence of diabetes in adults in the Region is estimated to be around 9.2%. Of the 34 million people affected by diabetes, nearly 17 million were undiagnosed and therefore at considerable risk of diabetes complications and poor health outcomes. Enhanced research on the epidemiology of diabetes in the MENA Region needs to be combined with more effective primary prevention of diabetes; and early detection and improved management of patients with established diabetes, including an increased focus on self-management and management in primary care and community settings.

Changes in the incidence of lower extremity amputations in individuals with and without diabetes in England between 2004 and 2008

OBJECTIVE

To describe recent trends in the incidence of nontraumatic amputations among individuals with and without diabetes and estimate the relative risk of amputations among individuals with diabetes in England.

RESEARCH DESIGN AND METHODS

We identified all patients aged >16 years who underwent any nontraumatic amputation in England between 2004 and 2008 using national hospital activity data from all National Health Service hospitals. Age- and sex-specific incidence rates were calculated using the total diabetes population in England every year. To test for time trend, we fitted Poisson regression models.

RESULTS

The absolute number of diabetes-related amputations increased by 14.7%, and the incidence decreased by 9.1%, from 27.5 to 25.0 per 10,000 people with diabetes, during the study period (P > 0.2 for both). The incidence of minor and major amputations did not significantly change (15.7-14.9 and 11.8-10.2 per 10,000 people with diabetes; P = 0.66 and P = 0.29, respectively). Poisson regression analysis showed no statistically significant change in diabetes-related amputation incidence over time (0.98 decrease per year [95% CI 0.93-1.02]; P = 0.12). Nondiabetes-related amputation incidence decreased from 13.6 to 11.9 per 100,000 people without diabetes (0.97 decrease by year [0.93-1.00]; P = 0.059). The relative risk of an individual with diabetes undergoing a lower extremity amputation was 20.3 in 2004 and 21.2 in 2008, compared with that of individuals without diabetes.

CONCLUSIONS

This national study suggests that the overall population burden of amputations increased in people with diabetes at a time when the number and incidence of amputations decreased in the aging nondiabetic population.

Ethnic disparities in diabetes management and pay-for-performance in the UK: the Wandsworth Prospective Diabetes Study

BACKGROUND

Pay-for-performance rewards health-care providers by paying them more if they succeed in meeting performance targets. A new contract for general practitioners in the United Kingdom represents the most radical shift towards pay-for-performance seen in any health-care system. The contract provides an important opportunity to address disparities in chronic disease management between ethnic and socioeconomic groups. We examined disparities in management of people with diabetes and intermediate clinical outcomes within a multiethnic population in primary care before and after the introduction of the new contract in April 2004.

METHODS AND FINDINGS

We conducted a population-based longitudinal survey, using electronic general practice records, in an ethnically diverse part of southwest London. Outcome measures were prescribing levels and achievement of national treatment targets (HbA1c < or = 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol < or = 5 mmol/l or 193 mg/dl). The proportion of patients reaching treatment targets for HbA1c, BP, and total cholesterol increased significantly after the implementation of the new contract. The extents of these increases were broadly uniform across ethnic groups, with the exception of the black Caribbean patient group, which had a significantly lower improvement in HbA1c (adjusted odds ratio [AOR] 0.75, 95% confidence interval [CI] 0.57-0.97) and BP control (AOR 0.65, 95% CI 0.53-0.81) relative to the white British patient group. Variations in prescribing and achievement of treatment targets between ethnic groups present in 2003 were not attenuated in 2005.

CONCLUSIONS

Pay-for-performance incentives have not addressed disparities in the management and control of diabetes between ethnic groups. Quality improvement initiatives must place greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes.

Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study

BACKGROUND

The number of visits to hospital emergency departments (EDs) in England has increased by 20% since 2007-08, placing unsustainable pressure on the National Health Service (NHS). Some patients attend EDs because they are unable to access primary care services. This study examined the association between access to primary care and ED visits in England.

METHODS

A cross-sectional, population-based analysis of patients registered with 7,856 general practices in England was conducted, for the time period April 2010 to March 2011. The outcome measure was the number of self-referred discharged ED visits by the registered population of a general practice. The predictor variables were measures of patient-reported access to general practice services; these were entered into a negative binomial regression model with variables to control for the characteristics of patient populations, supply of general practitioners and travel times to health services. MAIN RESULT AND CONCLUSION: General practices providing more timely access to primary care had fewer self-referred discharged ED visits per registered patient (for the most accessible quintile of practices, RR = 0.898; P<0.001). Policy makers should consider improving timely access to primary care when developing plans to reduce ED utilisation.

Waterpipe Tobacco Smoking Prevalence and Correlates in 25 Eastern Mediterranean and Eastern European Countries: Cross-Sectional Analysis of the Global Youth Tobacco Survey

INTRODUCTION

Waterpipe tobacco smoking is highly prevalent among young people in some settings. There is an absence of nationally representative prevalence studies of waterpipe tobacco use and dual use with other tobacco products in young people.

METHODS

We conducted a secondary analysis of the Global Youth Tobacco Survey, a nationally representative cross-sectional study of students aged 13-15 years. Of 180 participating countries, 25 included optional waterpipe tobacco smoking questions: 15 Eastern Mediterranean and 10 Eastern European countries. We calculated the prevalence of current (past 30-day) waterpipe tobacco use, including dual waterpipe and other tobacco use, and used logistic regression models to identify sociodemographic correlates of waterpipe tobacco smoking. Individual country results were combined in a random effects meta-analysis.

RESULTS

Waterpipe tobacco smoking prevalence was highest in Lebanon (36.9%), the West Bank (32.7%) and parts of Eastern Europe (Latvia 22.7%, the Czech Republic 22.1%, Estonia 21.9%). These countries also recorded greater than 10% prevalence of dual waterpipe and cigarette use. In a meta-analysis, higher odds of waterpipe tobacco smoking were found among males (Adjusted odds ratio [AOR] = 1.37, 95% confidence interval [CI] = 1.18% to 1.59%), cigarette users (AOR = 6.95, 95% CI = 5.74% to 8.42%), those whose parents (AOR = 1.54, 95% CI = 1.31% to 1.82%) or peers smoked (AOR = 3.53, 95% CI = 2.97% to 4.20%) and those whose parents had higher educational attainment (Father, AOR = 1.47, 95% CI = 1.14% to 1.89%; Mother, AOR = 1.62, 95% CI = 1.07% to 2.46%). We report on regional- and country income-level differences.

CONCLUSIONS

Waterpipe tobacco smoking, including dual waterpipe and cigarette use, is alarmingly high in several Eastern Mediterranean and Eastern European countries. Ongoing waterpipe tobacco smoking surveillance is warranted.

Multimorbidity and out-of-pocket expenditure on medicines: a systematic review

Background

Multimorbidity, the presence of two or more non-communicable diseases (NCD), is a costly and complex challenge for health systems globally. Patients with NCDs incur high levels of out-of-pocket expenditure (OOPE), often on medicines, but the literature on the association between OOPE on medicines and multimorbidity has not been examined systematically.

Methods

A systematic review was conducted via searching medical and economics databases including Ovid Medline, EMBASE, EconLit, Cochrane Library and the WHO Global Health Library from year 2000 to 2016. Study quality was assessed using Newcastle-Ottawa Scale. PROSPERO: CRD42016053538.

Findings

14 articles met inclusion criteria. Findings indicated that multimorbidity was associated with higher OOPE on medicines. When number of NCDs increased from 0 to 1, 2 and ≥3, annual OOPE on medicines increased by an average of 2.7 times, 5.2 times and 10.1 times, respectively. When number of NCDs increased from 0 to 1, 2, ≥2 and ≥3, individuals spent a median of 0.36% (IQR 0.15%–0.51%), 1.15% (IQR 0.62%–1.64%), 1.41% (IQR 0.86%–2.15%), 2.42% (IQR 2.05%–2.64%) and 2.63% (IQR 1.56%–4.13%) of mean annual household net adjusted disposable income per capita, respectively, on annual OOPE on medicines. More multimorbidities were associated with higher OOPE on medicines as a proportion of total healthcare expenditures by patients. Some evidence suggested that the elderly and low-income groups were most vulnerable to higher OOPE on medicines. With the same number of NCDs, certain combinations of NCDs yielded higher medicine OOPE. Non-adherence to medicines was a coping strategy for OOPE on medicines.

Conclusion

Multimorbidity of NCDs is increasingly costly to healthcare systems and OOPE on medicines can severely compromise financial protection and universal health coverage. It is crucial to recognise the need for better equity and financial protection, and policymakers should consider health system financial options, cost sharing policies and service patterns for those with NCD multimorbidities.

Hospital admissions for childhood asthma after smoke-free legislation in England

OBJECTIVE

To assess whether the implementation of English smoke-free legislation in July 2007 was associated with a reduction in hospital admissions for childhood asthma.

METHODS

Interrupted time series study using Hospital Episodes Statistics data from April 2002 to November 2010. Sample consisted of all children (aged ≤14 years) having an emergency hospital admission with a principle diagnosis of asthma.

RESULTS

Before the implementation of the legislation, the admission rate for childhood asthma was increasing by 2.2% per year (adjusted rate ratio 1.02; 95% confidence interval [CI]: 1.02-1.03). After implementation of the legislation, there was a significant immediate change in the admission rate of -8.9% (adjusted rate ratio 0.91; 95% CI: 0.89-0.93) and change in time trend of -3.4% per year (adjusted rate ratio 0.97; 95% CI: 0.96-0.98). This change was equivalent to 6802 fewer hospital admissions in the first 3 years after implementation. There were similar reductions in asthma admission rates among children from different age, gender, and socioeconomic status groups and among those residing in urban and rural locations.

CONCLUSIONS

These findings confirm those from a small number of previous studies suggesting that the well-documented population health benefits of comprehensive smoke-free legislation appear to extend to reducing hospital admissions for childhood asthma.

A method of identifying and correcting miscoding, misclassification and misdiagnosis in diabetes: a pilot and validation study of routinely collected data

AIMS

Incorrect classification, diagnosis and coding of the type of diabetes may have implications for patient management and limit our ability to measure quality. The aim of the study was to measure the accuracy of diabetes diagnostic data and explore the scope for identifying errors.

METHOD

We used two sets of anonymized routinely collected computer data: the pilot used Cutting out Needless Deaths Using Information Technology (CONDUIT) study data (n = 221 958), which we then validated using 100 practices from the Quality Improvement in Chronic Kidney Disease (QICKD) study (n = 760,588). We searched for contradictory diagnostic codes and also compatibility with prescription, demographic and laboratory test data. We classified errors as: misclassified-incorrect type of diabetes; misdiagnosed-where there was no evidence of diabetes; or miscoded-cases where it was difficult to infer the type of diabetes.

RESULTS

The standardized prevalence of diabetes was 5.0 and 4.0% in the CONDUIT and the QICKD data, respectively: 13.1% (n = 930) of CONDUIT and 14.8% (n = 4363) QICKD are incorrectly coded; 10.3% (n = 96) in CONDUIT and 26.2% (n = 1143) in QICKD are misclassified; nearly all of these cases are people classified with Type 1 diabetes who should be classified as Type 2. Approximately 5% of T2DM in both samples have no objective evidence to support a diagnosis of diabetes. Miscoding was present in approximately 7.8% of the CONDUIT and 6.1% of QICKD diabetes records.

CONCLUSIONS

The prevalence of miscoding, misclassification and misdiagnosis of diabetes is high and there is substantial scope for further improvement in diagnosis and data quality. Algorithms which identify likely misdiagnosis, misclassification and miscoding could be used to flag cases for review.

Quality of diabetes care in the UK: comparison of published quality-of-care reports with results of the Quality and Outcomes Framework for Diabetes

AIMS

To conduct a systematic review of published observational studies of quality of diabetes care in primary care in the UK and to compare the results with the quality of care data from the Quality and Outcomes Framework (QOF) of the new General Practice Contract in the UK.

METHODS

medline and embase were searched for articles published from 1999 to June 2006. We also searched for reference lists of studies that fitted our inclusion criteria. All members of the Primary Care Diabetes Europe were contacted and asked to send lists of any relevant published articles. Abstracts were reviewed and data were collected independently by two authors.

RESULTS

Abstracts of 742 papers were identified, of which six papers fulfilled the final selection criteria. The total number of people included in the six published studies was 83 098 (a range of 504 to 54 180 people) compared with the UK QOF data of 1.8 million people with diabetes. The quality indicators for assessment of care varied between different published studies, making comparisons more difficult. Overall, there was a trend towards improvement in both process and outcome of care in the published studies. The quality of care achieved as a result of QOF was greater than that found in published studies.

CONCLUSIONS

There have been improvements in both process and outcome measures recorded in publications of quality of diabetes care in the UK between 2000 and 2004. Modest financial incentives in primary care are a successful method of improving care for people with diabetes.

Associations between Internet-based patient ratings and conventional surveys of patient experience in the English NHS: an observational study

OBJECTIVE

Unsolicited web-based comments by patients regarding their healthcare are increasing, but controversial. The relationship between such online patient reports and conventional measures of patient experience (obtained via survey) is not known. The authors examined hospital level associations between web-based patient ratings on the National Health Service (NHS) Choices website, introduced in England during 2008, and paper-based survey measures of patient experience. The authors also aimed to compare these two methods of measuring patient experience.

DESIGN

The authors performed a cross-sectional observational study of all (n=146) acute general NHS hospital trusts in England using data from 9997 patient web-based ratings posted on the NHS Choices website during 2009/2010. Hospital trust level indicators of patient experience from a paper-based survey (five measures) were compared with web-based patient ratings using Spearman's rank correlation coefficient. The authors compared the strength of associations among clinical outcomes, patient experience survey results and NHS Choices ratings.

RESULTS

Web-based ratings of patient experience were associated with ratings derived from a national paper-based patient survey (Spearman ρ=0.31-0.49, p<0.001 for all). Associations with clinical outcomes were at least as strong for online ratings as for traditional survey measures of patient experience.

CONCLUSIONS

Unsolicited web-based patient ratings of their care, though potentially prone to many biases, are correlated with survey measures of patient experience. They may be useful tools for patients when choosing healthcare providers and for clinicians to improve the quality of their services.

Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis

BACKGROUND

Universal health coverage (UHC) can play an important role in achieving Sustainable Development Goal (SDG) 10, which addresses reducing inequalities, but little supporting evidence is available from low- and middle-income countries. Brazil's Estratégia de Saúde da Família (ESF) (family health strategy) is a community-based primary healthcare (PHC) programme that has been expanding since the 1990s and is the main platform for delivering UHC in the country. We evaluated whether expansion of the ESF was associated with differential reductions in mortality amenable to PHC between racial groups.

METHODS AND FINDINGS

Municipality-level longitudinal fixed-effects panel regressions were used to examine associations between ESF coverage and mortality from ambulatory-care-sensitive conditions (ACSCs) in black/pardo (mixed race) and white individuals over the period 2000-2013. Models were adjusted for socio-economic development and wider health system variables. Over the period 2000-2013, there were 281,877 and 318,030 ACSC deaths (after age standardisation) in the black/pardo and white groups, respectively, in the 1,622 municipalities studied. Age-standardised ACSC mortality fell from 93.3 to 57.9 per 100,000 population in the black/pardo group and from 75.7 to 49.2 per 100,000 population in the white group. ESF expansion (from 0% to 100%) was associated with a 15.4% (rate ratio [RR]: 0.846; 95% CI: 0.796-0.899) reduction in ACSC mortality in the black/pardo group compared with a 6.8% (RR: 0.932; 95% CI: 0.892-0.974) reduction in the white group (coefficients significantly different, p = 0.012). These differential benefits were driven by greater reductions in mortality from infectious diseases, nutritional deficiencies and anaemia, diabetes, and cardiovascular disease in the black/pardo group. Although the analysis is ecological, sensitivity analyses suggest that over 30% of black/pardo deaths would have to be incorrectly coded for the results to be invalid. This study is limited by the use of municipal-aggregate data, which precludes individual-level inference. Omitted variable bias, where factors associated with ESF expansion are also associated with changes in mortality rates, may have influenced our findings, although sensitivity analyses show the robustness of the findings to pre-ESF trends and the inclusion of other municipal-level factors that could be associated with coverage.

CONCLUSIONS

PHC expansion is associated with reductions in racial group inequalities in mortality in Brazil. These findings highlight the importance of investment in PHC to achieve the SDGs aimed at improving health and reducing inequalities.