Changing patterns of teenage pregnancy: population based study of small areas

ObjectivesTo measure the impact of socioeconomic deprivation on rates of teenage pregnancy and the extent of local variation in pregnancy rates in Scotland, and to examine how both have changed over time.Design Population study using routine data from hospital records, aggregated for small areas.Subjects Female teenagers resident in Scotland who were treated for pregnancy in an NHS hospital in either 1981-5 (62 338 teenagers) or 1991-5 (48 514) and who were aged 13-19 at the time of conception.Results From the 1980s to the 1990s pregnancy rates increased differentially according to levels of local deprivation, as measured by the Carstairs index. Among teenagers aged less than 18 the annual pregnancy rate increased in the most deprived areas (from 7.0 to 12.5 pregnancies per 1000 13-15 year olds and from 67.6 to 84.6 per 1000 16-17 year olds), but there was no change, on average, among teenagers in the most affluent areas (3.8 per 1000 13-15 year olds and 28.9 per 1000 16-17 year olds). Among 18-19 year olds the pregnancy rate decreased in the most affluent areas (from 60.0 to 46.3 per 1000) and increased in the most deprived areas (from 112.4 to 116.0 per 1000). The amount of local variation explained by deprivation more than doubled from the 1980s to the 1990s. The proportion of pregnancies resulting in a maternity was positively associated with level of deprivation, but the effect remained similar over time.Conclusion From the 1980s to the 1990s the difference in rates of teenage pregnancy between more affluent and more deprived areas widened. This has implications for allocating resources to achieve government targets and points to important social processes behind the general increase in the number of teenage pregnancies in Scotland.

What is already known on this topic

Rates of teenage pregnancy are considerably higher in the United Kingdom than in other western European countriesIn the United Kingdom rates of teenage pregnancy are known to be higher in areas of greater socioeconomic deprivation, although local variation may also reflect differential access to family planning services

What this study adds

From 1981-5 to 1991-5 rates of teenage pregnancy in Scotland increased more rapidly in areas of greater socioeconomic deprivationIn the 1990s socioeconomic deprivation explained more than 50% of local variation in rates of teenage pregnancy, more than double the amount explained by it in the 1980s     

Teenagers' knowledge of emergency contraception: questionnaire survey in south east Scotland.

OBJECTIVE--To determine the level of knowledge of emergency contraception among 14 and 15 year olds. DESIGN--Confidential questionnaire survey. SETTING--10 secondary schools in Lothian, south east Scotland. SUBJECTS--1206 pupils predominantly (98.7%) aged 14 and 15 in the fourth year of secondary school. MAIN OUTCOME MEASURES--Knowledge of the existence of emergency contraception; of its safety, efficacy, and time limits; and of where to obtain it. RESULTS--1121 (93.0%) fourth year pupils aged 14-16 had heard of emergency contraception. 194 girls (32.7%) and 168 boys (27.5%) had experienced sexual intercourse. Of girls who had experienced sexual intercourse, 61 (31.4%) had used emergency contraception. Knowledge of correct time limits was poor, sexually active girls being the most knowledgeable. Pupils attending schools ranked lower than the national average for academic attainment were less likely to have heard of emergency contraception and more likely to have been sexually active. 861 (76.8%) pupils knew they could obtain emergency contraception from their doctor. 925 (82.5%) pupils believed emergency contraception to be effective but 398 (35.5%) thought it more dangerous than the oral contraceptive pill. CONCLUSIONS--One third of sexually active girls aged under 16 in Lothian have used emergency contraception. This may help explain the fairly constant teenage pregnancy rates despite increasing sexual activity. Scottish teenagers are well informed about the existence of emergency contraception. However, many do not know when and how to access it properly. Health education initiatives should target teenagers from less academic schools as they are more likely to be sexually active at a young age and are less well informed about emergency contraception.     

Fertility trends in Singapore

In 1966, the Singapore National Family Planning and Population Program established the goal of reaching replacement fertility by 1990 and zero population growth by the year 2030. To achieve this goal, the government relied on a series of incentives and disincentives to discourage births above the 3rd birth order, including tax relief for the 1st 3 children only, paid medical leave for women undergoing sterilization after the 3rd or subsequent birth, monetary stipends in some cases where the mother is sterilized after the 1st or 2nd birth, and increasing accouchement charges for increasing birth orders. Also important to demographic planning were liberalization of Singapore's abortion legislation and more aggressive promotion of contraception. As a result of these efforts, Singapore's crude birth rate has declined from 29.5/1000 population in 1965 to 16.6/1000 in 1985. Also observed have been dramatic declines in infant mortality in this same period, from 26.2/1000 live births to 9.3/1000, and in maternal mortality, from 52/100,000 live births to 10/100,000. In 1985, 42% of total births were to women in the 25-29-year age group. The numbers of 4th and later births fell by 90% between 1966 and 1985. The total fertility rate has declined from 4.6/woman in 1965 to 3.1 in 1970 to 1.6 in 1986. Below replacement level fertility was achieved in 1975, in part because of government policy but also as a result of cultural and socioeconomic factors such as increasing female labor force participation rates, a break-up of the extended family system, a rise in the age at 1st marriage, and rises in educational attainment. The drop in fertility was contributed mainly by the higher socioeconomic class, more affluent, and educated Singaporeans. Thus, in 1981, the government introduced certain pronatalist policies and incentives to encourage better educated women to produce more children, e.g., tax relief and the elimination of monetary incentives to sterilization acceptors above a median income level.     

Group B streptococci in the female genital tract.

Vaginal carriage rates of group B streptococci among 250 women attending a clinic for sexually transmitted diseases, 123 attending family planning clinics, and 110 in labour wages were 36.0%, 17-1% and 6.4% respectively. The presence of group B streptococci was not associated with a vaginal discharge or the use of oral contraceptives in the non-pregnant women, or with the isolation of Neisseria gonorrhoeae or Trichomonas vaginalis from the women attending the clinic for sexually transmitted diseases. Serotyping showed a predominance of types II and III in non-pregnant women and an overall incidence of non-typable strains of 14.8%. There was no relationship between serotype and antibacterial susceptibility.     

The return of the pharmaceutical industry to the market of contraception

In the 1980s and 1990s, the litigious climate in the US had a catastrophic effect on sales of many major contraceptives. Although oral contraceptives escaped controversy, the intrauterine device (IUD) and Norplant(R) were two targets of damaging litigation. The IUD was withdrawn from the market in 1985. Since 1994 when the attacks began against Norplant, its US sales have dramatically declined, even though no fault has been found in the method or its development. In general, pharmaceutical companies were extremely hesitant to develop new contraceptives during this period. The bleak outlook, however, began to shift in the late 1990s, as fertility rates began to decrease worldwide and contraceptive users increased. By 2025, 2500 million women will comprise the customer base for contraception. Global pharmaceutical companies are now participating in expanding markets overseas and have launched and continue to develop a range of new long-term reversible, and highly effective, contraceptive products outside the traditional oral contraceptive field. Two new contraceptives on the way to the US market are: Mirena, a levonorgestrel-releasing intrauterine system manufactured by Schering-Leiras; and Implanon, a single implant system manufactured by Organon of the Netherlands. Other birth control methods soon to be launched include: emergency contraceptives, the contraceptive patch, monthly contraceptive injections, mifepristone for medical abortion, and modified oral contraceptives.     

Fertility and legal abortion in England and Wales: performance indicators for family planning services.

The relation between fertility rates and legal abortion rates was investigated in a sample of health authorities in England and Wales to see how these varied. Total period fertility rates and total period legal abortion rates were derived from the average number of live births or legal abortions that would be experienced per woman if women experienced the age specific rates of the year in question throughout their childbearing years. The sample of 30 health authorities was selected by taking the districts with the highest and lowest fertility rates in each English region and in Wales in 1986. Total period fertility rates varied from 1.37 in Riverside to 2.42 in Tower Hamlets, while abortion rates varied from 0.25 in East Yorkshire to 0.99 in Riverside. When the two rates were added to provide a potential fertility rate it became clear that some districts with similar potential fertility rates had very different underlying component rates. Such comparisons can be used for service monitoring, indicating the need for better abortion and family planning services in districts with high fertility rates and for better family planning services in those with high abortion rates.     

Family size and children's education in Matlab, Bangladesh

This study examines the relationship between family size and children's education in Bangladesh for two periods - 1982 with high fertility and 1996 with low fertility - using data from the Matlab Health and Demographic Surveillance System of the ICDDR,B: Centre for Health and Population Research. Children aged 8-17 years (27,448 in 1982 and 32,635 in 1996) were selected from households where the mother was aged 30-49 years and the father was the head of household. Children's education was measured in terms of completed years of schooling: at least class 1 (among 8-17 year olds), at least class 5 (among 12-17 year olds) and at least class 7 (among 15-17 year olds). After controlling for all variables in the multivariate analyses, level of children's education was not found to be associated with family size during the high fertility period. The family size-education relationship became negative during the low fertility period. In both periods children of educated mothers from wealthier households and those who lived close to primary/high schools had more education, but this socioeconomic difference reduced substantially over time. Boys had more education than girls during the high fertility period but this difference disappeared during the low fertility period. As birth rates fall and the proportion of children from small families increases an increase in children's education is to be expected.     

Genotype-Specific Incidence and Clearance of Human Papillomavirus in Oral Mucosa of Women: A Six-Year Follow-Up Study

Background

There are no previous longitudinal studies on genotype-specific natural history of human papillomavirus (HPV) infections in oral mucosa of women.

Methods

In the Finnish Family HPV Study, 329 pregnant women were enrolled and followed up. HPV-genotyping of oral scrapings was performed with nested PCR and Multimetrix® test (Progen, Heidelberg, Germany). Incidence and clearance times and rates for each HPV-genotype identified in oral mucosa were determined. Predictors for incident and cleared HPV infections for species 7/9 genotypes were analyzed using Poisson regression model.

Results

Altogether, 115 baseline HPV-negative women acquired incident oral HPV infection, and 79 women cleared their infection. HPV16 and multiple HPVs most frequently caused incident infections (65% and 12%) in 13.3 and 17.1 months respectively, followed by HPV58, HPV18 and HPV6 (close to 5% each) in 11–24 months. HPV58, HPV18 and HPV66 were the most common to clear. HPV6 and HPV11 had the shortest clearance times, 4.6 months and 2.5 months, and the highest clearance rates, 225.5/1000 wmr and 400/1000 wmr, respectively. The protective factors for incident oral HPV-species 7/9 infections were 1) new pregnancy during follow-up and 2) having the same sexual partner during FU. Increased clearance was related with older age and a history of atopic reactions, whereas previous sexually transmitted disease and new pregnancy were associated with decreased clearance.

Conclusions

HPV16 was the most frequent genotype to cause an incident oral HPV-infection. Low risk HPV genotypes cleared from oral mucosa more quickly than high risk HPV genotypes. Pregnancy affected the outcome of oral HPV infection.     

Mortality among oral contraceptive users: 20 year follow up of women in a cohort study.

OBJECTIVE--To see whether the use of oral contraceptives influences mortality. DESIGN--Non-randomised cohort study of 17,032 women followed up on an annual basis for an average of nearly 16 years. SETTING--17 Family planning clinics in England and Scotland. SUBJECTS--Women recruited during 1968-74. At the time of recruitment each woman was aged 25-39, married, a white British subject, willing to participate, and either a current user of oral contraceptives or a current user of a diaphragm or intrauterine device (without previous exposure to the pill). MAIN OUTCOME MEASURES--Overall mortality and cause specific mortality. RESULTS--238 Deaths occurred during the follow up period. The main analyses concerned women entering the study while using either oral contraceptives or a diaphragm or intrauterine device. The overall relative risk of death in the oral contraceptive users was 0.9 (95% confidence interval 0.7 to 1.2). Though the numbers of deaths were small in most individual disease categories, the trends observed were generally consistent with findings in other reports. Thus the relative risk of death in the oral contraceptive users was 4.9 (95% confidence interval 0.7 to 230) for cancer of the cervix, 3.3 (95% confidence interval 0.9 to 17.9) for ischaemic heart disease, and 0.4 (95% confidence interval 0.1 to 1.2) for ovarian cancer. There was a linear trend in the death rates from cervical cancer and ovarian cancer (in opposite directions) with total duration of oral contraceptive use. Death rates from breast cancer (relative risk 0.9; 95% confidence interval 0.5 to 1.4) and suicide and probable suicide (relative risk 1.1; 95% confidence interval 0.3 to 3.6) were much the same in the two contraceptive groups. In 1981 the relative risk of death in oral contraceptive users from circulatory diseases as a group was reported to be 4.2 (95% confidence interval 2.3 to 7.7) in the Royal College of General Practitioners oral contraception study. The corresponding relative risk in this study was only 1.5 (95% confidence interval 0.7 to 3.0). CONCLUSIONS--These findings contain no significant evidence of any overall effect of oral contraceptive use on mortality. None the less, only small numbers of deaths occurred during the study period and a significant adverse (or beneficial) overall effect might emerge in the future. Interestingly, the mortality from circulatory disease associated with oral contraceptive use was substantially less than that found in the Royal College of General Practitioners study.     

Colonic Crohn's disease and use of oral contraception.

The prevalence of use of oral contraception before the onset of disease was established in 100 consecutive women attending follow up clinics for inflammatory bowel disease. A significant excess of women with Crohn''s disease confined to the colon had taken oral contraceptives in the year before developing symptoms (10/16 (63%] compared with women with small-intestinal Crohn''s disease (12/49 (24%); p less than 0.02) and women with ulcerative colitis (3/35 (9%); p less than 0.0005). When the patient groups were matched for age and year of onset of disease usage of oral contraception before the onset of disease was still more common among women with isolated colonic Crohn''s disease (9/12, 75%) than among those with ulcerative colitis (2/12 (17%); p less than 0.02) and was also more common than would be expected from reported figures for oral contraception in England and Wales (31.4% of women aged under 41; p less than 0.005). A survey of current patient records showed that isolated colonic disease was at least twice as common among women with Crohn''s disease (63/218, 29%) compared with men (25/181, 14%; p less than 0.001). These data support the suggestion made previously that oral contraceptives may predispose to a colitis that resembles colonic Crohn''s disease.     

Recent trends in the incidence of anxiety diagnoses and symptoms in primary care

Background

Anxiety is common, with significant morbidity, but little is known about presentations and recording of anxiety diagnoses and symptoms in primary care. This study aimed to determine trends in incidence and socio-demographic variation in General Practitioner (GP) recorded diagnoses of anxiety, mixed anxiety/depression, panic and anxiety symptoms.

Methodology/Principal Findings

Annual incidence rates of anxiety diagnoses and symptoms were calculated from 361 UK general practices contributing to The Health Improvement Network (THIN) database between 1998 and 2008, adjusted for year of diagnosis, gender, age, and deprivation. Incidence of GP recorded anxiety diagnosis fell from 7.9 to 4.9/1000PYAR from 1998 to 2008, while incidence of anxiety symptoms rose from 3.9 to 5.8/1000PYAR. Incidence of mixed anxiety/depression fell from 4.0 to 2.2/1000PYAR, and incidence of panic disorder fell from 0.9/1000PYAR in 1998 to 0.5/1000PYAR in 2008. All these entries were approximately twice as common in women and more common in deprived areas. GP-recorded anxiety diagnoses, symptoms and mixed anxiety/depression were commonest aged 45–64 years, whilst panic disorder/attacks were more common in those 16–44 years. GPs predominately use broad non-specific codes to record anxiety problems in the UK.

Conclusions/Significance

GP recording of anxiety diagnoses has fallen whilst recording of anxiety symptoms has increased over time. The incidence of GP recorded diagnoses of anxiety diagnoses was lower than in screened populations in primary care. The reasons for this apparent under-recording and whether it represents under-detection in those being seen, a reluctance to report anxiety to their GP, or a reluctance amongst GPs to label people with anxiety requires investigation.     

Sexual behaviour and contraception among unmarried adolescents and young adults in Greater Accra and Eastern regions of Ghana

A fertility survey of unmarried adolescents and young adults (953 males and 829 females) in Greater Accra and Eastern regions of Ghana revealed that a substantial proportion of the respondents were sexually experienced. Overall, 66.8% of the males and 78.4% of the females were sexually experienced. The mean ages (+/- SD) of the males and females were 15.5 +/- 2.5 and 16.2 +/- 2.0 years, respectively. Most respondents claimed to have received adequate information on reproductive health and sexually transmitted diseases (STDs), including AIDS. However, 20% and 30% of the respondents in peri-urban and rural areas, respectively, did not know that a girl could get pregnant the first time she has sexual intercourse. The incidence of pregnancy among the unmarried female respondents was relatively high (37%), and was higher in urban than in rural areas. Approximately 47% of those who had ever been pregnant reported that they had had an abortion. Levels of contraceptive awareness were high (98.2% among males and 95.5% among females) but many still engaged in unprotected sexual relations. The most commonly used methods were the condom and the pill. The main reasons given for non-use were that they did not think about contraception, were concerned about the safety of contraceptives, and partner objection. These findings point to the need for targeting of unmarried adolescents and young adults with information on reproductive health and family planning to increase their awareness of the risks of pregnancy, STDs and HIV infection.     

Nest Record Scheme, 1954

The survival rate of a colour-ringed Common Sandpiper population followed from 1977 to 1989 averaged 0.79 per year, but fluctuated in response to April weather. Late April snowstorms in 1981 and 1989 reduced the apparent survival rates, from the previous years, to 0.39 and 0.50, respectively, and the breeding populations fell from 21 to 14 and from 20 to 12 pairs. Recovery from the reduced population size in 1981 proceeded slowly, at increments of only 1 or 2 pairs per year. There appears to be a low rate of recruitment in this population, sufficient to balance the low mortality rate in average years but inadequate to compensate for the extreme mortality produced by extreme weather.     

Under-age girl as a patient of pediatric and adolescent ginecology outpatient clinic

The research carried out in Poland reflected that sexual initiation before 18 years of age is a common phenomenon and refers to roughly 80% of teenagers. In Poland there is no uniform standing of medical and legal environments with regard to dealing with a juvenile patient who has become sexually active and expects the advice of a gynaecologist, gynaecologic examination and often asks for prescribing contraceptives. The procedures must take into account the fact that in Poland, until 18 years of age, a juvenile functions under the parental or tutelary authority, while a consent for medical service requires beside of the consent of legal guardian also the consent of a juvenile who is 16 years of age and becomes a full-right patient. According to the Act on Health Care Institutions, a patient has the right to self-decisions, the respect of physical and mental integrity and the respect of privacy, while the participation of a statutory representative post 16th year of age refers practically to co-deciding on a medical service provision. Therefore, the information received from such juvenile patient in subjective and objective examination does not have to be passed to the statutory representative, if the juvenile patient requires confidentiality and if this does not affect the patient's health and the planned medical procedures (e.g. the necessity of making an operation). The knowledge of conduct procedures with regard to a juvenile patient as a carrier of rights shall enable doctors to make aware choices of conduct and provide services or, in most cases, only advice, without the necessity to breach the laws of Poland.     

The mortality risk of voluntary surgical contraception

The mortality risk of voluntary surgical contraception (VSC) is compared to the mortality risk of other methods of fertility control, pregnancy and delivery, and selected nonreproductive-related events. After 1 year the rates per 100,000 are .1 for vasectomies, .3 for IUD use, 2.2 for legal abortion, 4.0 for female VSC in developed countries, and 18.7 for pregnancy and delivery. Rates for female VSC, pregnancy and delivery, and legal induced abortion were expressed as deaths per 100,000 procedures or live births and mortality risks for IUD use were presented as deaths per 100,000 women per year, per 5 years, and 10 years. After 10 years the mortality risks remain constant for single-exposure events but increase to 3.0/100,000 for IUD use, to 12/100,000 for the lowest risk category of OC users, and to much higher cumulative totals for higher risk pill users. Risks at 5 and 10 years after abortion and other pregnancy outcomes depend on the reproductive alternatives chosen; risks of barrier methods appear related to unintended pregnancy during use. In developed countries the mortality risks of smoking, driving, power boating, and drinking are higher than those for female VSC and vasectomy at 1 year. Mortality rates for all reproductive strategies in developing countries are estimated to be higher: the rate for female VSC in Bangladesh was recently estimated at 16.2/100,000 and of vasectomy at 19.0/100,000, although vasectomy death rate estimates as low as .1/100,000 have also been made for some developing countries. The risks of VSC in developing countries are considerably lower than those of a single pregnancy or delivery. The risk of VSC is concentrated in the 1st 6 weeks after the procedure and thereafter is related to pregnancy resulting from method failure.     

Inequalities in mortality during and after restructuring of the New Zealand economy: repeated cohort studies

Objectives To determine whether disparities between income and mortality changed during a period of major structural and macroeconomic reform and to estimate the changing contribution of different diseases to these disparities.Design Repeated cohort studies.Data sources 1981, 1986, 1991, 1996, and 2001 censuses linked to mortality data.Population Total New Zealand population, ages 1-74 years.Methods Mortality rates standardised for age and ethnicity were calculated for each census cohort by level of household income. Standardised rate differences and rate ratios, and slope and relative indices of inequality (SII and RII), were calculated to measure disparities on both absolute and relative scales.Results All cause mortality rates declined over the 25 year study period in all groups stratified by sex, age, and income, except for 25-44 year olds of both sexes on low incomes among whom there was little change. In all age groups pooled, relative inequalities increased from 1981-4 to 1996-9 (RIIs increased from 1.85 (95% confidence interval 1.67 to 2.04) to 2.54 (2.29 to 2.82) for males and from 1.54 (1.35 to 1.76) to 2.12 (1.88 to 2.39) for females), then stabilised in 2001-4 (RIIs of 2.60 (2.34 to 2.89) and 2.18 (1.93 to 2.45), respectively). Absolute inequalities were stable over time, with a possible fall from 1996-9 to 2001-4. Cardiovascular disease was the major contributor to the observed disparities between income and mortality but decreased in importance from 45% in 1981-4 to 33% in 2001-4 for males and from 50% to 29% for females. The corresponding contribution of cancer increased from 16% to 22% for males and from 12% to 25% for females.Conclusions During and after restructuring of the economy disparities in mortality between income groups in New Zealand increased in relative terms (but not in absolute terms), but it is difficult to confidently draw a causal link with structural reforms. The contribution of different causes of death to this inequality changed over time, indicating a need to re-prioritise health policy accordingly.     

Serotype distribution of invasive Streptococcus pneumoniae in Canada during the introduction of the 13-valent pneumococcal conjugate vaccine, 2010

A baseline serotype distribution was established by age and region for 2058 invasive Streptococcus pneumoniae isolates collected during the implementation period of the 13-valent pneumococcal conjugate vaccine (PCV13) program in many parts of Canada in 2010. Serotypes 19A, 7F, and 3 were the most prevalent in all age groups, accounting for 57% in <2 year olds, 62% in 2-4 year olds, 45% in 5-14?year olds, 44% in 15-49?year olds, 41% in 50-64?year olds, and 36% in ≥65?year olds. Serotype 19A was most predominant in Western and Central Canada representing 15% and 22%, respectively, of the isolates from those regions, whereas 7F was most common in Eastern Canada with 20% of the isolates. Other prevalent serotypes include 15A, 23B, 12F, 22F, and 6C. PCV13 serotypes represented 65% of the pneumococci isolated from?<2 year olds, 71% of 2-4 year olds, 61% of 5-14 year olds, 60% of 15-49 year olds, 53% of 50-64 year olds, and 49% of the?≥65?year olds. Continued monitoring of invasive pneumococcal serotypes in Canada is important to identify epidemiological trends and assess the impact of the newly introduced PCV13 vaccine on public health.     

Ovarian neoplasms,functional ovarian cysts,and oral contraceptives.

The incidence of ovarian neoplasms and functional ovarian cysts diagnosed at laparotomy or laparoscopy among the 17,000 women taking part in the Oxford Family Planning Association contraceptive study was investigated. Epithelial cancer of the ovary was only 25% as common among those who had ever taken oral contraceptives as those who had never done so (95% confidence interval 8% to 67%). There was little evidence of any important association between use of oral contraceptives and benign teratoma or cystadenoma. Functional cysts of the ovary occurred much less commonly in women who had recently (in the six months preceding diagnosis) taken combined oral contraceptives (but not in those who had taken progestogen only oral contraceptives) than in those who had never taken oral contraceptives or had taken them in the past. This protective effect was more pronounced for corpus luteum cysts (78% reduction; 95% confidence interval 47% to 93%) than for follicular cysts (49% reduction; 95% confidence interval 20% to 70%). It is estimated that about 28 (95% confidence interval 16 to 35) operations for functional ovarian cysts are avoided among every 100,000 women who take oral contraceptives each year.     

Paediatric cardiac surgical mortality in England after Bristol: descriptive analysis of hospital episode statistics 1991-2002

Objective To describe trends in mortality of open cardiac surgery in children in Bristol and England since 1991.Design Retrospective analysis of hospital episode statistics data.Setting All open cardiac surgery of children in England.Population Patients younger than 16 undergoing open cardiac surgical procedures in England between April 1991 and March 2002. Three time periods were defined: epoch 3 (April 1991 to March 1995), epoch 5 (April 1996 to March 1999), epoch 6 (April 1999 to March 2002).Main outcome measure Mortality in hospital within 30 days of a cardiac procedure.Results We identified 5221 open operations between April 1996 and March 2002 in children under 1 year and 6385 in children aged 1-15 years. Mortality for all centres combined fell from 12% in epoch 3 to 4% in epoch 6. Mortality in children under 1 year at Bristol fell from 29% (95% confidence interval 21% to 37%) in epoch 3 to 3% (1% to 6%) in epoch 6, below the national average. The reduction in mortality did not seem to be due to fewer high risk procedures or an increase in the numbers of low risk cases. Oxford had a significantly higher mortality than the national average in all three epochs (11% (5% to 18%) in epoch 6), which was not affected by adjusting for procedure or the inclusion of cases with missing outcomes.Conclusions At Bristol, mortality for open operations in children aged under 1 year has fallen markedly, to below the national average. Nationwide mortality has also fallen. Improved quality of care may account for the drop in mortality, through new technologies or improved perioperative and postoperative care, or both.     

Home visiting by general practitioners in England and Wales.

OBJECTIVE--To use data from the fourth national survey of morbidity in general practice to investigate the association between home visiting rates and patients'' characteristics. DESIGN--Survey of diagnostic data on all home visits by general practitioners. SETTING--60 general practices in England and Wales. SUBJECTS--502 493 patients visited at home between September 1991 and August 1992. MAIN OUTCOME MEASURES--Home visiting rates per 1000 patient years and home visiting ratios standardised for age and sex. RESULTS--10.1% (139 801/1 378 510) of contacts with general practitioners took place in patients'' homes. The average annual home visiting rate was 299/1000 patient years. Rates showed a J shaped relation with age and were lowest in people aged 16-24 years (103/1000) and highest in people aged > or = 85 years (3009/1000). 1.3% of patients were visited five or more times and received 39% of visits. Age and sex standardised home visiting ratios increased from 69 (95% confidence interval 68 to 70) in social class I to 129 (128 to 130) in social class V. The commonest diagnostic group was diseases of the respiratory system. In older age groups, diseases of the circulatory system was also a common diagnostic group. Standardised home visiting ratios for the 60 practices in the study varied nearly eightfold, from 28 to 218 (interquartile range 67 to 126). CONCLUSIONS--Home visits remain an important component of general practitioners'' workload. As well as the strong associations between home visiting rates and patient characteristics, there were also large differences between practices in home visiting rates. A small number of patients received a disproportionately high number of home visits. Further investigation of patients with high home visiting rates may help to explain the large differences in workload between general practices and help in allocation of resources to practices.