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Kerr S, Bedston S, Cezard G, Sampri A, Murphy S, Bradley DT, Morrison K, Akbari A, Whiteley W, Sullivan C, Patterson L, Khunti K, Denaxas S, Bolton T, Khan S, Keys A, Weatherill D, Mooney K, Davies J, Ritchie L, McMenamin J, Kee F, Wood A, Lyons RA, Sudlow C, Robertson C, Sheikh A. Undervaccination and severe COVID-19 outcomes: meta-analysis of national cohort studies in England, Northern Ireland, Scotland, and Wales. Lancet 2024; 403:554-566. [PMID: 38237625 DOI: 10.1016/s0140-6736(23)02467-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Undervaccination (receiving fewer than the recommended number of SARS-CoV-2 vaccine doses) could be associated with increased risk of severe COVID-19 outcomes-ie, COVID-19 hospitalisation or death-compared with full vaccination (receiving the recommended number of SARS-CoV-2 vaccine doses). We sought to determine the factors associated with undervaccination, and to investigate the risk of severe COVID-19 outcomes in people who were undervaccinated in each UK nation and across the UK. METHODS We used anonymised, harmonised electronic health record data with whole population coverage to carry out cohort studies in England, Northern Ireland, Scotland, and Wales. Participants were required to be at least 5 years of age to be included in the cohorts. We estimated adjusted odds ratios for undervaccination as of June 1, 2022. We also estimated adjusted hazard ratios (aHRs) for severe COVID-19 outcomes during the period June 1 to Sept 30, 2022, with undervaccination as a time-dependent exposure. We combined results from nation-specific analyses in a UK-wide fixed-effect meta-analysis. We estimated the reduction in severe COVID-19 outcomes associated with a counterfactual scenario in which everyone in the UK was fully vaccinated on June 1, 2022. FINDINGS The numbers of people undervaccinated on June 1, 2022 were 26 985 570 (45·8%) of 58 967 360 in England, 938 420 (49·8%) of 1 885 670 in Northern Ireland, 1 709 786 (34·2%) of 4 992 498 in Scotland, and 773 850 (32·8%) of 2 358 740 in Wales. People who were younger, from more deprived backgrounds, of non-White ethnicity, or had a lower number of comorbidities were less likely to be fully vaccinated. There was a total of 40 393 severe COVID-19 outcomes in the cohorts, with 14 156 of these in undervaccinated participants. We estimated the reduction in severe COVID-19 outcomes in the UK over 4 months of follow-up associated with a counterfactual scenario in which everyone was fully vaccinated on June 1, 2022 as 210 (95% CI 94-326) in the 5-15 years age group, 1544 (1399-1689) in those aged 16-74 years, and 5426 (5340-5512) in those aged 75 years or older. aHRs for severe COVID-19 outcomes in the meta-analysis for the age group of 75 years or older were 2·70 (2·61-2·78) for one dose fewer than recommended, 3·13 (2·93-3·34) for two fewer, 3·61 (3·13-4·17) for three fewer, and 3·08 (2·89-3·29) for four fewer. INTERPRETATION Rates of undervaccination against COVID-19 ranged from 32·8% to 49·8% across the four UK nations in summer, 2022. Undervaccination was associated with an elevated risk of severe COVID-19 outcomes. FUNDING UK Research and Innovation National Core Studies: Data and Connectivity.
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Cezard G, McHale CT, Sullivan F, Bowles JKF, Keenan K. Studying trajectories of multimorbidity: a systematic scoping review of longitudinal approaches and evidence. BMJ Open 2021; 11:e048485. [PMID: 34810182 PMCID: PMC8609933 DOI: 10.1136/bmjopen-2020-048485] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 10/20/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Multimorbidity-the co-occurrence of at least two chronic diseases in an individual-is an important public health challenge in ageing societies. The vast majority of multimorbidity research takes a cross-sectional approach, but longitudinal approaches to understanding multimorbidity are an emerging research area, being encouraged by multiple funders. To support development in this research area, the aim of this study is to scope the methodological approaches and substantive findings of studies that have investigated longitudinal multimorbidity trajectories. DESIGN We conducted a systematic search for relevant studies in four online databases (Medline, Scopus, Web of Science and Embase) in May 2020 using predefined search terms and inclusion and exclusion criteria. The search was complemented by searching reference lists of relevant papers. From the selected studies, we systematically extracted data on study methodology and findings and summarised them in a narrative synthesis. RESULTS We identified 35 studies investigating multimorbidity longitudinally, all published in the last decade, and predominantly in high-income countries from the Global North. Longitudinal approaches employed included constructing change variables, multilevel regression analysis (eg, growth curve modelling), longitudinal group-based methodologies (eg, latent class modelling), analysing disease transitions and visualisation techniques. Commonly identified risk factors for multimorbidity onset and progression were older age, higher socioeconomic and area-level deprivation, overweight and poorer health behaviours. CONCLUSION The nascent research area employs a diverse range of longitudinal approaches that characterise accumulation and disease combinations and to a lesser extent disease sequencing and progression. Gaps include understanding the long-term, life course determinants of different multimorbidity trajectories, and doing so across diverse populations, including those from low-income and middle-income countries. This can provide a detailed picture of morbidity development, with important implications from a clinical and intervention perspective.
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Affiliation(s)
- Genevieve Cezard
- School of Geography and Sustainable Development, University of St Andrews, St Andrews, UK
| | | | - Frank Sullivan
- School of Medicine, University of St Andrews, St Andrews, UK
| | | | - Katherine Keenan
- School of Geography and Sustainable Development, University of St Andrews, St Andrews, UK
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Bhopal R, Douglas A, Sheikh A, Wild SH, Gill JMR, Sattar N, Lean MEJ, McKnight J, Tuomilehto J, Wallia S, Cezard G. Diabetes incidence in a high-risk UK population at 7 years: linkage of the Prevention of Diabetes and Obesity in South Asians (PODOSA) trial to the Scottish Diabetes Register. Diabet Med 2021; 38:e14369. [PMID: 32738831 DOI: 10.1111/dme.14369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/18/2020] [Indexed: 11/29/2022]
Affiliation(s)
- R Bhopal
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - A Douglas
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - A Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - S H Wild
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - J M R Gill
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - N Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - M E J Lean
- School of Medicine, Dentistry and Nursing, University of Glasgow Royal Infirmary, Glasgow, UK
| | - J McKnight
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Metabolic Unit, NHS Lothian, Edinburgh, UK
| | - J Tuomilehto
- Public Health Promotion Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
- Diabetes Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
| | - S Wallia
- NHS Greater Glasgow & Clyde, Glasgow, UK
| | - G Cezard
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Population and Health Research Group, School of Geography and Sustainable Development, University of St Andrews, UK
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Jenum AK, Brekke I, Mdala I, Muilwijk M, Ramachandran A, Kjøllesdal M, Andersen E, Richardsen KR, Douglas A, Cezard G, Sheikh A, Celis-Morales CA, Gill JMR, Sattar N, Bhopal RS, Beune E, Stronks K, Vandvik PO, van Valkengoed IGM. Effects of dietary and physical activity interventions on the risk of type 2 diabetes in South Asians: meta-analysis of individual participant data from randomised controlled trials. Diabetologia 2019; 62:1337-1348. [PMID: 31201437 DOI: 10.1007/s00125-019-4905-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/15/2019] [Indexed: 10/26/2022]
Abstract
AIMS/HYPOTHESIS Individuals of South Asian origin have a high risk of type 2 diabetes and of dying from a diabetes-attributable cause. Lifestyle modification intervention trials to prevent type 2 diabetes in high-risk South Asian adults have suggested more modest effects than in European-origin populations. The strength of the evidence of individual studies is limited, however. We performed an individual participant data meta-analysis of available RCTs to assess the effectiveness of lifestyle modification in South Asian populations worldwide. METHODS We searched PubMed, EMBASE, Cochrane Library and Web of Science (to 24 September 2018) for RCTs on lifestyle modification interventions incorporating diet and/or physical activity in South Asian adults. Reviewers identified eligible studies and assessed the quality of the evidence. We obtained individual participant data on 1816 participants from all six eligible trials (four from Europe and two from India). We generated HR estimates for incident diabetes (primary outcome) and mean differences for fasting glucose, 2 h glucose, weight and waist circumference (secondary outcomes) using mixed-effect meta-analysis overall and by pre-specified subgroups. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system to rate the quality of evidence of the estimates. The study is registered with the International Prospective Register of Systematic Reviews ([PROSPERO] CRD42017078003). RESULTS Incident diabetes was observed in 12.6% of participants in the intervention groups and in 20.0% of participants in the control groups. The pooled HR for diabetes incidence was 0.65 (95% CI 0.51, 0.81; I2 = 0%) in intervention compared with control groups. The absolute risk reduction was 7.4% (95% CI 4.0, 10.2), with no interactions for the pre-specified subgroups (sex, BMI, age, study duration and region where studies were performed). The quality of evidence was rated as moderate. Mean difference for lifestyle modification vs control groups for 2 h glucose was -0.34 mmol/l (95% CI -0.62, -0.07; I2 = 50%); for weight -0.75 kg (95% CI -1.34, -0.17; I2 = 71%) and for waist -1.16 cm (95% CI -2.16, -0.16; I2 = 75%). No effect was found for fasting glucose. Findings were similar across subgroups, except for weight for European vs Indian studies (-1.10 kg vs -0.08 kg, p = 0.02 for interaction). CONCLUSIONS/INTERPRETATION Despite modest changes for adiposity, lifestyle modification interventions in high-risk South Asian populations resulted in a clinically important 35% relative reduction in diabetes incidence, consistent across subgroups. If implemented on a large scale, lifestyle modification interventions in high-risk South Asian populations in Europe would reduce the incidence of diabetes in these populations.
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Affiliation(s)
- Anne Karen Jenum
- General Practice Research Unit (AFE), Department of General Practice, Institute of Health and Society, Faculty of Medicine, University of Oslo, Post Box 1130 Blindern, 0318, Oslo, Norway.
| | - Idunn Brekke
- Centre for Welfare and Labour Research, Norwegian Social Research, OsloMet - Oslo Metropolitan University, Oslo, Norway
- Faculty of Health Sciences, Department of Nursing and Health Promotion, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Ibrahimu Mdala
- General Practice Research Unit (AFE), Department of General Practice, Institute of Health and Society, Faculty of Medicine, University of Oslo, Post Box 1130 Blindern, 0318, Oslo, Norway
| | - Mirthe Muilwijk
- Department of Public Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands
| | - Ambady Ramachandran
- India Diabetes Research Foundation, Chennai, India
- Dr. A. Ramachandran's Diabetes Hospitals, Chennai, India
| | - Marte Kjøllesdal
- Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Eivind Andersen
- Faculty of Humanities, Sports and Educational Science, University of South-Eastern Norway, Borre, Norway
| | - Kåre R Richardsen
- Department of Physiotherapy, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Anne Douglas
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Genevieve Cezard
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
- Population and Health Research Group, School of Geography and Sustainable Development, University of St Andrews, Fife, Scotland, UK
| | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | | | - Jason M R Gill
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Raj S Bhopal
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Erik Beune
- Department of Public Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands
| | - Karien Stronks
- Department of Public Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands
| | - Per Olav Vandvik
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Irene G M van Valkengoed
- Department of Public Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands
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Crawford F, Cezard G, Chappell FM. The development and validation of a multivariable prognostic model to predict foot ulceration in diabetes using a systematic review and individual patient data meta-analyses. Diabet Med 2018; 35:1480-1493. [PMID: 30102422 DOI: 10.1111/dme.13797] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2018] [Indexed: 12/14/2022]
Abstract
AIMS Diabetes guidelines recommend screening for the risk of foot ulceration but vary substantially in the underlying evidence base. Our purpose was to derive and validate a prognostic model of independent risk factors for foot ulceration in diabetes using all available individual patient data from cohort studies conducted worldwide. METHODS We conducted a systematic review and meta-analysis of individual patient data from 10 cohort studies of risk factors in the prediction of foot ulceration in diabetes. Predictors were selected for plausibility, availability and low heterogeneity. Logistic regression produced adjusted odds ratios (ORs) for foot ulceration by ulceration history, monofilament insensitivity, any absent pedal pulse, age, sex and diabetes duration. RESULTS The 10 studies contained data from 16 385 participants. A history of foot ulceration produced the largest OR [6.59 (95% CI 2.49 to 17.45)], insensitivity to a 10 g monofilament [3.18 (95% CI 2.65 to 3.82)] and any absent pedal pulse [1.97 (95% CI 1.62 to 2.39)] were consistently, independently predictive. Combining three predictors produced sensitivities between 90.0% (95% CI 69.9% to 97.2%) and 95.3% (95% CI 84.5% to 98.7%); the corresponding specificities were between 12.1% (95% CI 8.2% to 17.3%) and 63.9% (95% CI 61.1% to 66.6%). CONCLUSIONS This prognostic model of only three risk factors, a history of foot ulceration, an inability to feel a 10 g monofilament and the absence of any pedal pulse, compares favourably with more complex approaches to foot risk assessment recommended in clinical diabetes guidelines.
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Affiliation(s)
- F Crawford
- Research and Development, NHS Fife, Queen Margaret Hospital, Dunfermline, Scotland
| | - G Cezard
- Population and Health Research Group (PHRG), School of Geography and Sustainable Development (SGSD), Irvine Building, University of St Andrews, St Andrews, UK
- The Centre for Population Health Sciences, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - F M Chappell
- The Centre for Clinical Brain Sciences, the University of Edinburgh, Edinburgh, UK
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Cezard G, Smith L, Petherick E, Cameron N, West J, Lawlor D, Bhopal R. 1.11-P19Ethnic differences in early life adiposity trajectories between White British and Pakistani children: results from the Born in Bradford cohort study in the UK. Eur J Public Health 2018. [DOI: 10.1093/eurpub/cky048.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- G Cezard
- University of St Andrews, Scotland
| | - L Smith
- University of Leeds, United Kingdom
| | | | - N Cameron
- Loughborough University, United Kingdom
| | - J West
- Bradford Institute for Health Research, United Kingdom
| | - D Lawlor
- University of Bristol, United Kingdom
| | - R Bhopal
- University of Edinburgh, United Kingdom
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Gruer L, Cezard G, Wallace L, Hutchinson S, Douglas A, Buchanan D, Katikireddi S, Millard A, Goldberg D, Sheikh A, Bhopal R. 4.10-P2Comparing rates of serious infections in ethnic groups: a retrospective cohort study of 4.62 million people in Scotland. Eur J Public Health 2018. [DOI: 10.1093/eurpub/cky048.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- L Gruer
- University of Edinburgh, United Kingdom
| | - G Cezard
- University of Edinburgh, United Kingdom
| | - L Wallace
- Health Protection Scotland, United Kingdom
| | | | - A Douglas
- University of Edinburgh, United Kingdom
| | - D Buchanan
- Information Services Division, United Kingdom
| | - S Katikireddi
- MRC/CSO Social and Public Health Sciences Unit, United Kingdom
| | - A Millard
- NHS Health Scotland, Edinburgh, United Kingdom
| | - D Goldberg
- Health Protection Scotland, United Kingdom
| | - A Sheikh
- University of Edinburgh, United Kingdom
| | - R Bhopal
- University of Edinburgh, United Kingdom
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Douglas A, Wild S, Cezard G, Gill J, Lean M, McKnight J, Sattar N, Sheikh A, Tuomilehto J, Wallia S, Bhopal R. 1.4-O8Progression to diabetes in Indian and Pakistani adults with impaired glycaemia in central Scotland: follow-up by record linkage in the PODOSA trial (Prevention of Diabetes & Obesity in South Asians). Eur J Public Health 2018. [DOI: 10.1093/eurpub/cky047.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A Douglas
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | - S Wild
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | - G Cezard
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | - J Gill
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - M Lean
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - J McKnight
- Metabolic Unit, NHS Lothian, Edinburgh, United Kingdom
| | - N Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - A Sheikh
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | | | - S Wallia
- NHS Greater Glasgow & Clyde, United Kingdom
| | - R Bhopal
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
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Gruer L, Millard A, Williams L, Bhopal R, Katikireddi S, Cezard G, Buchanan D, Douglas A, Steiner M, Sheikh A. 3.10-P23All-cause hospitalisation of different ethnic groups: a data linkage cohort study of 4.62 million people in Scotland. Eur J Public Health 2018. [DOI: 10.1093/eurpub/cky048.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- L Gruer
- University of Edinburgh, United Kingdom
| | | | | | - R Bhopal
- University of Edinburgh, United Kingdom
| | | | - G Cezard
- University of Edinburgh, United Kingdom
| | - D Buchanan
- Information Services Division, United Kingdom
| | - A Douglas
- University of Edinburgh, United Kingdom
| | - M Steiner
- University of Aberdeen, United Kingdom
| | - A Sheikh
- University of Edinburgh, United Kingdom
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Katikireddi S, Cezard G, Bhopal R, Williams L, Douglas A, Millard A, Steiner M, Buchanan D, Sheikh A, Gruer L. 4.1-O1Assessing ethnic equity of health policy by studying avoidable mortality, hospitalisations and unplanned readmissions in linked Scottish data. Eur J Public Health 2018. [DOI: 10.1093/eurpub/cky047.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- S Katikireddi
- MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, United Kingdom
| | - G Cezard
- Department of Geography and Sustainable Development (DGSD), Irvine Building, University of St Andrews, Edinburgh, United Kingdom
| | - R Bhopal
- Edinburgh Migration, Ethnicity and Health Research Group (EMEHRG), Centre for Population Health Sciences, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | - L Williams
- Edinburgh Migration, Ethnicity and Health Research Group (EMEHRG), Centre for Population Health Sciences, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | - A Douglas
- Edinburgh Migration, Ethnicity and Health Research Group (EMEHRG), Centre for Population Health Sciences, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | | | - M Steiner
- Environmental & Occupational Medicine, Section of Population Health, University of Aberdeen, United Kingdom
| | - D Buchanan
- Information Services Division (ISD), NHS National Services Scotland, United Kingdom
| | - A Sheikh
- Edinburgh Migration, Ethnicity and Health Research Group (EMEHRG), Centre for Population Health Sciences, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | - L Gruer
- Edinburgh Migration, Ethnicity and Health Research Group (EMEHRG), Centre for Population Health Sciences, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
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Bhopal RS, Gruer L, Cezard G, Douglas A, Steiner MFC, Millard A, Buchanan D, Katikireddi SV, Sheikh A. Mortality, ethnicity, and country of birth on a national scale, 2001-2013: A retrospective cohort (Scottish Health and Ethnicity Linkage Study). PLoS Med 2018; 15:e1002515. [PMID: 29494587 PMCID: PMC5832197 DOI: 10.1371/journal.pmed.1002515] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 01/24/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Migrant and ethnic minority groups are often assumed to have poor health relative to the majority population. Few countries have the capacity to study a key indicator, mortality, by ethnicity and country of birth. We hypothesized at least 10% differences in mortality by ethnic group in Scotland that would not be wholly attenuated by adjustment for socio-economic factors or country of birth. METHODS AND FINDINGS We linked the Scottish 2001 Census to mortality data (2001-2013) in 4.62 million people (91% of estimated population), calculating age-adjusted mortality rate ratios (RRs; multiplied by 100 as percentages) with 95% confidence intervals (CIs) for 13 ethnic groups, with the White Scottish group as reference (ethnic group classification follows the Scottish 2001 Census). The Scottish Index of Multiple Deprivation, education status, and household tenure were socio-economic status (SES) confounding variables and born in the UK or Republic of Ireland (UK/RoI) an interacting and confounding variable. Smoking and diabetes data were from a primary care sub-sample (about 53,000 people). Males and females in most minority groups had lower age-adjusted mortality RRs than the White Scottish group. The 95% CIs provided good evidence that the RR was more than 10% lower in the following ethnic groups: Other White British (72.3 [95% CI 64.2, 81.3] in males and 75.2 [68.0, 83.2] in females); Other White (80.8 [72.8, 89.8] in males and 76.2 [68.6, 84.7] in females); Indian (62.6 [51.6, 76.0] in males and 60.7 [50.4, 73.1] in females); Pakistani (66.1 [57.4, 76.2] in males and 73.8 [63.7, 85.5] in females); Bangladeshi males (50.7 [32.5, 79.1]); Caribbean females (57.5 [38.5, 85.9]); and Chinese (52.2 [43.7, 62.5] in males and 65.8 [55.3, 78.2] in females). The differences were diminished but not eliminated after adjusting for UK/RoI birth and SES variables. A mortality advantage was evident in all 12 minority groups for those born abroad, but in only 6/12 male groups and 5/12 female groups of those born in the UK/RoI. In the primary care sub-sample, after adjustment for age, UK/RoI born, SES, smoking, and diabetes, the RR was not lower in Indian males (114.7 [95% CI 78.3, 167.9]) and Pakistani females (103.9 [73.9, 145.9]) than in White Scottish males and females, respectively. The main limitations were the inability to include deaths abroad and the small number of deaths in some ethnic minority groups, especially for people born in the UK/RoI. CONCLUSIONS There was relatively low mortality for many ethnic minority groups compared to the White Scottish majority. The mortality advantage was less clear in UK/RoI-born minority group offspring than in immigrants. These differences need explaining, and health-related behaviours seem important. Similar analyses are required internationally to fulfil agreed goals for monitoring, understanding, and improving health in ethnically diverse societies and to apply to health policy, especially on health inequalities and inequities.
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Affiliation(s)
- Raj S. Bhopal
- Edinburgh Migration, Ethnicity and Health Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Laurence Gruer
- Edinburgh Migration, Ethnicity and Health Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Genevieve Cezard
- Edinburgh Migration, Ethnicity and Health Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Anne Douglas
- Edinburgh Migration, Ethnicity and Health Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Markus F. C. Steiner
- Environmental & Occupational Medicine, Section of Population Health, University of Aberdeen, Aberdeen, United Kingdom
- NHS Grampian, Aberdeen, United Kingdom
| | | | - Duncan Buchanan
- Information Services Division, NHS National Services Scotland, Edinburgh, United Kingdom
| | - S. Vittal Katikireddi
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, United Kingdom
| | - Aziz Sheikh
- Edinburgh Migration, Ethnicity and Health Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
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Cezard G, Douglas A, Gill JMR, McKnight J, Sheikh A, Wallia S, Bhopal R. Did the weight loss in the Prevention of Diabetes and Obesity in South Asians (PODOSA) trial differ by sex? An exploratory analysis. Public Health 2017; 145:67-69. [PMID: 28359393 DOI: 10.1016/j.puhe.2016.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/23/2016] [Accepted: 12/07/2016] [Indexed: 12/17/2022]
Affiliation(s)
- G Cezard
- Edinburgh Migration, Ethnicity and Health Research Group (EMEHRG), Centre for Population Health Sciences, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Teviot Place, Edinburgh, UK.
| | - A Douglas
- Edinburgh Migration, Ethnicity and Health Research Group (EMEHRG), Centre for Population Health Sciences, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Teviot Place, Edinburgh, UK
| | - J M R Gill
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - J McKnight
- Metabolic Unit, Western General Hospital, Edinburgh, UK
| | - A Sheikh
- Edinburgh Migration, Ethnicity and Health Research Group (EMEHRG), Centre for Population Health Sciences, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Teviot Place, Edinburgh, UK
| | - S Wallia
- Edinburgh Migration, Ethnicity and Health Research Group (EMEHRG), Centre for Population Health Sciences, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Teviot Place, Edinburgh, UK
| | - R Bhopal
- Edinburgh Migration, Ethnicity and Health Research Group (EMEHRG), Centre for Population Health Sciences, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Teviot Place, Edinburgh, UK
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Ward HJT, Douglas A, Cezard G, Simpson C, Fischbacher C, Steiner MFC, Sheikh A, Bhopal R. Developing health information by ethnic status in Europe: a pilot data linkage study in Scotland. Eur J Public Health 2016. [DOI: 10.1093/eurpub/ckw167.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Crawford F, Cezard G, Chappell FM, Murray GD, Price JF, Sheikh A, Simpson CR, Stansby GP, Young MJ. A systematic review and individual patient data meta-analysis of prognostic factors for foot ulceration in people with diabetes: the international research collaboration for the prediction of diabetic foot ulcerations (PODUS). Health Technol Assess 2016. [PMID: 26211920 DOI: 10.3310/hta19570] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Annual foot risk assessment of people with diabetes is recommended in national and international clinical guidelines. At present, these are consensus based and use only a proportion of the available evidence. OBJECTIVES We undertook a systematic review of individual patient data (IPD) to identify the most highly prognostic factors for foot ulceration (i.e. symptoms, signs, diagnostic tests) in people with diabetes. DATA SOURCES Studies were identified from searches of MEDLINE and EMBASE. REVIEW METHODS The electronic search strategies for MEDLINE and EMBASE databases created during an aggregate systematic review of predictive factors for foot ulceration in diabetes were updated and rerun to January 2013. One reviewer applied the IPD review eligibility criteria to the full-text articles of the studies identified in our literature search and also to all studies excluded from our aggregate systematic review to ensure that we did not miss eligible IPD. A second reviewer applied the eligibility criteria to a 10% random sample of the abstract search yield to check that no relevant material was missed. This review includes exposure variables (risk factors) only from individuals who were free of foot ulceration at the time of study entry and who had a diagnosis of diabetes mellitus (either type 1 or type 2). The outcome variable was incident ulceration. RESULTS Our search identified 16 cohort studies and we obtained anonymised IPD for 10. These data were collected from more than 16,000 people with diabetes worldwide and reanalysed by us. One data set was kept for independent validation. The data sets contributing IPD covered a range of temporal, geographical and clinical settings. We therefore selected random-effects meta-analysis, which assumes not that all the estimates from each study are estimates of the same underlying true value, but rather that the estimates belong to the same distribution. We selected candidate variables for meta-analysis using specific criteria. After univariate meta-analyses, the most clinically important predictors were identified by an international steering committee for inclusion in the primary, multivariable meta-analysis. Age, sex, duration of diabetes, monofilaments and pulses were considered most prognostically important. Meta-analyses based on data from the entire IPD population found that an inability to feel a 10-g monofilament [odds ratio (OR) 3.184, 95% confidence interval (CI) 2.654 to 3.82], at least one absent pedal pulse (OR 1.968, 95% CI 1.624 to 2.386), a longer duration of a diagnosis of diabetes (OR 1.024, 95% CI 1.011 to 1.036) and a previous history of ulceration (OR 6.589, 95% CI 2.488 to 17.45) were all predictive of risk. Female sex was protective (OR 0.743, 95% CI 0.598 to 0.922). LIMITATIONS It was not possible to perform a meta-analysis using a one-step approach because we were unable to procure copies of one of the data sets and instead accessed data via Safe Haven. CONCLUSIONS The findings from this review identify risk assessment procedures that can reliably inform national and international diabetes clinical guideline foot risk assessment procedures. The evidence from a large sample of patients in worldwide settings show that the use of a 10-g monofilament or one absent pedal pulse will identify those at moderate or intermediate risk of foot ulceration, and a history of foot ulcers or lower-extremity amputation is sufficient to identify those at high risk. We propose the development of a clinical prediction rule (CPR) from our existing model using the following predictor variables: insensitivity to a 10-g monofilament, absent pedal pulses and a history of ulceration or lower-extremities amputations. This CPR could replace the many tests, signs and symptoms that patients currently have measured using equipment that is either costly or difficult to use. STUDY REGISTRATION This study is registered as PROSPERO CRD42011001841. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Fay Crawford
- Department of Vascular Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Genevieve Cezard
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Francesca M Chappell
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Gordon D Murray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Jacqueline F Price
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Colin R Simpson
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Gerard P Stansby
- Department of Vascular Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Matthew J Young
- Department of Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
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Simpson CR, Steiner MF, Cezard G, Bansal N, Fischbacher C, Douglas A, Bhopal R, Sheikh A. Ethnic variations in morbidity and mortality from lower respiratory tract infections: a retrospective cohort study. J R Soc Med 2015; 108:406-17. [PMID: 26152675 DOI: 10.1177/0141076815588321] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE There is evidence of substantial ethnic variations in asthma morbidity and the risk of hospitalisation, but the picture in relation to lower respiratory tract infections is unclear. We carried out an observational study to identify ethnic group differences for lower respiratory tract infections. DESIGN A retrospective, cohort study. SETTING Scotland. PARTICIPANTS 4.65 million people on whom information was available from the 2001 census, followed from May 2001 to April 2010. MAIN OUTCOME MEASURES Hospitalisations and deaths (any time following first hospitalisation) from lower respiratory tract infections, adjusted risk ratios and hazard ratios by ethnicity and sex were calculated. We multiplied ratios and confidence intervals by 100, so the reference Scottish White population's risk ratio and hazard ratio was 100. RESULTS Among men, adjusted risk ratios for lower respiratory tract infection hospitalisation were lower in Other White British (80, 95% confidence interval 73-86) and Chinese (69, 95% confidence interval 56-84) populations and higher in Pakistani groups (152, 95% confidence interval 136-169). In women, results were mostly similar to those in men (e.g. Chinese 68, 95% confidence interval 56-82), although higher adjusted risk ratios were found among women of the Other South Asians group (145, 95% confidence interval 120-175). Survival (adjusted hazard ratio) following lower respiratory tract infection for Pakistani men (54, 95% confidence interval 39-74) and women (31, 95% confidence interval 18-53) was better than the reference population. CONCLUSIONS Substantial differences in the rates of lower respiratory tract infections amongst different ethnic groups in Scotland were found. Pakistani men and women had particularly high rates of lower respiratory tract infection hospitalisation. The reasons behind the high rates of lower respiratory tract infection in the Pakistani community are now required.
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Affiliation(s)
- Colin R Simpson
- Edinburgh Ethnicity and Health Research Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | - Markus Fc Steiner
- Department of Child Health, School of Medicine, University of Aberdeen, Aberdeen, UK
| | - Genevieve Cezard
- Edinburgh Ethnicity and Health Research Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | - Narinder Bansal
- Cardiovascular Epidemiology Unit, The Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Anne Douglas
- Edinburgh Ethnicity and Health Research Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | - Raj Bhopal
- Edinburgh Ethnicity and Health Research Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Edinburgh Ethnicity and Health Research Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital/Harvard Medical School, Boston MA, USA
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Bhopal R, Steiner MF, Cezard G, Bansal N, Fischbacher C, Simpson CR, Douglas A, Sheikh A. Risk of respiratory hospitalization and death, readmission and subsequent mortality: scottish health and ethnicity linkage study. Eur J Public Health 2015; 25:769-74. [DOI: 10.1093/eurpub/ckv064] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
OBJECTIVES Our objective was to augment the limited evidence mainly from local, clinical studies of ethnic differences in gastrointestinal disorders. Our question was: are there ethnic variations in hospitalisation/death for lower gastrointestinal disorders in Scotland? SETTING Scotland. POPULATION This retrospective-cohort linked 4.65 (of 4.9) million people in the 2001 census of Scotland (providing data on ethnicity, country of birth and indicators of socioeconomic deprivation) to 9 years of National Health Service hospitalisation and death records. PRIMARY AND SECONDARY OUTCOME MEASURES AND ANALYSIS For appendicitis, we studied all ages; for irritable bowel syndrome, ulcerative colitis, Crohn's disease and diverticular disease, we included those ≥20 years. Using Poisson regression (robust variance) we calculated, by ethnic group and sex, first-hospitalisation/death age-adjusted rates per 100,000 person-years, and relative risks (RRs) with 95% CIs multiplied by 100, so the White Scottish reference population had an RR=100. RESULTS There were ethnic variations; for example, for irritable bowel syndrome, RRs (95% CIs) were comparatively high in Other White British women (128.4 (111.0 to 148.6)), and low in Pakistani women (75.1 (60.6 to 93.1)). For appendicitis, RRs were high in men in Other White British (145.2 (127.8 to 164.9)), and low in most non-White groups, for example, Pakistanis (73.8 (56.9 to 95.6)). For ulcerative colitis, RRs were high in Indian (169.8 (109.7 to 262.7)) and Pakistani (160.8 (104.2 to 248.2)) men. For Crohn's disease, the RR was high in Pakistani men (209.2 (149.6 to 292.6)). For diverticular disease, RRs were high in Irish men (176.0 (156.9 to 197.5)), and any Mixed background women (144.6 (107.4 to 194.8)), and low in most non-White groups, for example, Chinese men (47.1 (31.0 to 71.6) and women (46.0 (30.4 to 69.8)). CONCLUSIONS Appendicitis and diverticular disease were comparatively low in most non-White groups, while ulcerative colitis and Crohn's disease were mostly higher in South Asians. Describing and understanding such patterns may help clinical practice and research internationally.
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Affiliation(s)
- Raj S Bhopal
- Edinburgh Ethnicity and Health Research Group (EEHRG), Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Genevieve Cezard
- Edinburgh Ethnicity and Health Research Group (EEHRG), Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Narinder Bansal
- Edinburgh Ethnicity and Health Research Group (EEHRG), Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
- Cardiovascular Epidemiology Unit, Department of Public Health & Primary Care, Strangeways Research Laboratory, University of Cambridge, Wort's Causeway, Cambridge, UK
| | - Hester J T Ward
- Edinburgh Ethnicity and Health Research Group (EEHRG), Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
- Public Health and Intelligence, NHS National Services Scotland, Gyle Crescent, Edinburgh, UK
| | - Neeraj Bhala
- Gastroenterology and Liver Units, University of Birmingham, Queen Elizabeth Hospital, Birmingham, UK
- Department of Gastroenterology, Wellington Regional Hospital, Capital and Coast District Health Board, Newtown, Wellington, New Zealand
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Cezard G, Bhopal R, Douglas A, Bansal N, Steiner M, Simpson C, Fischbacher C, Sheikh A. Ethnic variations in respiratory disorders in Scotland: asthma, COPD and infections. Eur J Public Health 2014. [DOI: 10.1093/eurpub/cku165.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sharpe KH, Cezard G, Bansal N, Bhopal RS, Brewster DH. Policy for home or hospice as the preferred place of death from cancer: Scottish Health and Ethnicity Linkage Study population cohort shows challenges across all ethnic groups in Scotland. BMJ Support Palliat Care 2013; 5:443-51. [PMID: 24644191 DOI: 10.1136/bmjspcare-2013-000485] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 09/24/2013] [Indexed: 11/03/2022]
Abstract
BACKGROUND Place of cancer death varies ethnically and internationally. Palliative care reviews highlight limited ability to demonstrate equal access due to incomplete or unreliable ethnicity data. AIM To establish place of cancer death by ethnicity and describe patient characteristics. DESIGN We linked census, hospital episode and mortality data for 117 467 persons dying of cancer, 2001-2009. With White Scottish population as reference, prevalence ratios (PR), 95% CIs and p values of death in hospital, home or hospice adjusted for sex and age were calculated by ethnic group. RESULTS White Scottish group and minority ethnic groups combined constituted 91% and 0.4% of cancer deaths, respectively. South Asian, Chinese and African Origin patients were youngest at death (66, 66 and 65.9 years). Compared with the Scottish White reference, the White Irish (1.15 (1.10 to 1.22), p<0.0001) and Other White British (1.07 (1.02 to 1.12), p=0.003) groups were more likely to die at home. Generally, affluent Scottish White patients were less likely to die in hospital and more likely to die at home or in a hospice regardless of socioeconomic indicator used. CONCLUSIONS Cancer deaths occur most often in hospital (52.3%) for all ethnic groups. Regardless of the socioeconomic indicator used, more affluent Scottish White patients were less likely to die in hospital; existing socioeconomic indicators detected no clear trend for the non-White population. Regardless of ethnic group, significant work is required to achieve more people dying at home or the setting of their choice.
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Affiliation(s)
- Katharine H Sharpe
- Information Services Division, NHS National Services Scotland, Edinburgh, UK
| | - Genevieve Cezard
- Centre for Population Health Sciences Edinburgh University Medical School, Edinburgh, UK
| | - Narinder Bansal
- Centre for Population Health Sciences Edinburgh University Medical School, Edinburgh, UK
| | - Raj S Bhopal
- Centre for Population Health Sciences Edinburgh University Medical School, Edinburgh, UK
| | - David H Brewster
- Information Services Division, NHS National Services Scotland, Edinburgh, UK Centre for Population Health Sciences Edinburgh University Medical School, Edinburgh, UK
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