Deprivation and general practitioner workload.

OBJECTIVES--To examine general practitioner consultations by demographic and socioeconomic variables and to derive a method of measuring the impact of relative deprivation on general practitioner workload. DESIGN--The study was based on general practitioner consultations reported in the general household surveys of 1983-7, covering a sample of 129,987 individuals in Great Britain. Odds ratios for general practitioner consultations were obtained for selected variables among children (0-15 years), men (16-64), women (16-64), and elderly people (greater than or equal to 65). These were then used to derive deprivation indices specific to electoral wards for use in general practice. SETTING--Great Britain, with particular findings illustrated by English electoral wards and the conurbations of London, Manchester, Merseyside, and the West Midlands. RESULTS--Council tenure increased the likelihood of consultation significantly in all four groups. Odds ratios were raised in children, men, and women with no access to a car. Birth in the New Commonwealth or Pakistan yielded high odds ratios in men, women, and elderly people but not in children. Marginally increased consultation rates were evident in the manual socioeconomic groups in women, elderly people, and children with a single parent mother. The deprivation indices for general practice derived using these odds ratios varied substantially among English electoral wards with, for example, anticipated general practitioner consultations in the electoral ward of Hulme, Manchester, being 24% higher than the average ward in England as a result of local attributes, and consultations in the Cheam South ward of Sutton, London, 11% lower than average. CONCLUSION--This deprivation index for general practice overcomes several shortcomings expressed about the underprivileged area score, which has been adopted in the 1990 contract as a basis for allocating deprivation supplements to general practitioners. The proposed index can be applied nationwide.     

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.     

Higher mortality in deprived areas: community or personal disadvantage?

OBJECTIVE--To investigate the association between level of social deprivation in electoral wards and premature mortality among residents, before and after allowing for levels of personal deprivation. DESIGN--Longitudinal study of the Office of Population Censuses and Surveys. SETTING--England. SUBJECTS--Random sample of nearly 300,000 people aged between 16 and 65 at the 1981 census and followed up for nearly nine years. MAIN OUTCOME MEASURE--Death from all causes between ages of 16 and 70. RESULTS--Without allowance for personal disadvantage, both sexes showed a clear, significant, and roughly linear positive relation between degree of deprivation of the ward of residence in 1981 and premature death before 1990. For men, this association was effectively explained away once allowance was made for individual socioeconomic circumstances. For women living in wards of above average deprivation, the association was also effectively removed, but the situation for other women was less clear. CONCLUSION--The excess mortality associated with residence in areas designated as deprived by census based indicators is wholly explained by the concentration in those areas of people with adverse personal or household socioeconomic factors. Health policy needs to target people as well as places.     

Breast Cancer Biology and Ethnic Disparities in Breast Cancer Mortality in New Zealand: A Cohort Study

Introduction

Indigenous Māori women have a 60% higher breast cancer mortality rate compared with European women in New Zealand. We investigated differences in cancer biological characteristics and their impact on breast cancer mortality disparity between Māori and NZ European women.

Materials and Methods

Data on 2849 women with primary invasive breast cancers diagnosed between 1999 and 2012 were extracted from the Waikato Breast Cancer Register. Differences in distribution of cancer biological characteristics between Māori and NZ European women were explored adjusting for age and socioeconomic deprivation in logistic regression models. Impacts of socioeconomic deprivation, stage and cancer biological characteristics on breast cancer mortality disparity between Māori and NZ European women were explored in Cox regression models.

Results

Compared with NZ European women (n=2304), Māori women (n=429) had significantly higher rates of advanced and higher grade cancers. Māori women also had non-significantly higher rates of ER/PR negative and HER-2 positive breast cancers. Higher odds of advanced stage and higher grade remained significant for Māori after adjusting for age and deprivation. Māori women had almost a 100% higher age and deprivation adjusted breast cancer mortality hazard compared with NZ European women (HR=1.98, 1.55-2.54). Advanced stage and lower proportion of screen detected cancer in Māori explained a greater portion of the excess breast cancer mortality (HR reduction from 1.98 to 1.38), while the additional contribution through biological differences were minimal (HR reduction from 1.38 to 1.35).

Conclusions

More advanced cancer stage at diagnosis has the greatest impact while differences in biological characteristics appear to be a minor contributor for inequities in breast cancer mortality between Māori and NZ European women. Strategies aimed at reducing breast cancer mortality in Māori should focus on earlier diagnosis, which will likely have a greater impact on reducing breast cancer mortality inequity between Māori and NZ European women.     

Is the ratio of inhaled corticosteroid to bronchodilator a good indicator of the quality of asthma prescribing? Cross sectional study linking prescribing data to data on admissions.

OBJECTIVE: To investigate the ratio of inhaled corticosteroid to bronchodilator as a measure of the quality of asthma prescribing by general practitioners. DESIGN: Ecological cross sectional study linking general practitioner asthma prescribing with hospital admission data and a measure of deprivation. SUBJECTS: 11 family health services authorities in the West Midlands region and 99 general practices in North Staffordshire. MAIN OUTCOME MEASURES: Hospital admission rates for asthma; the ratio of inhaled corticosteroid to bronchodilator; and Townsend deprivation scores. RESULTS: No overall significant correlation was found between admission rates for asthma and corticosteroid:bronchodilator ratios for family health services authorities (Spearman''s rs = -0.109, P = 0.750) or general practices (rs = -0.084, P = 0.407). In deprived family health services authority areas and general practices an inverse non-significant correlation existed between admission rates for asthma and corticosteroid:bronchodilator ratios (rs = -0.300, P = 0.624; rs = -0.218, P = 0.136). In contrast, in more affluent areas and general practices a positive non-significant correlation existed between admission rates and corticosteroid:bronchodilator ratios (rs = 0.371, P = 0.468; rs = 0.038, P = 0.792). CONCLUSION: Although the corticosteroid:bronchodilator ratio may be a valid indicator of the quality of prescribing for individual patients with asthma, caution should be applied in interpreting aggregated ratios. Differences in the severity of asthma or the prevalence of chronic obstructive pulmonary disease may explain inconsistent associations between admission rates for asthma and corticosteroid:bronchodilator ratios in family health services authorities and general practices with different deprivation scores.     

Neighborhood socioeconomic deprivation and mortality: NIH-AARP diet and health study

Purpose

Residing in deprived areas may increase risk of mortality beyond that explained by a person''s own SES-related factors and lifestyle. The aim of this study was to examine the relation between neighborhood socioeconomic deprivation and all-cause, cancer- and cardiovascular disease (CVD)-specific mortality for men and women after accounting for education and other important person-level risk factors.

Methods

In the longitudinal NIH-AARP Study, we analyzed data from healthy participants, ages 50–71 years at study baseline (1995–1996). Deaths (n = 33831) were identified through December 2005. Information on census tracts was obtained from the 2000 US Census. Cox models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for quintiles of neighborhood deprivation.

Results

Participants in the highest quintile of deprivation had elevated risks for overall mortality (HR_men = 1.17, 95% CI: 1.10, 1.24; HR_women = 1.13, 95% CI: 1.05, 1.22) and marginally increased risk for cancer deaths (HR_men = 1.09, 95% CI: 1.00, 1.20; HR_women = 1.09, 95% CI: 0.99, 1.22). CVD mortality associations appeared stronger in men (HR = 1.33, 95% CI: 1.19, 1.49) than women (HR = 1.18, 95% CI: 1.01, 1.38). There was no evidence of an effect modification by education.

Conclusion

Higher neighborhood deprivation was associated with modest increases in all-cause, cancer- and CVD-mortality after accounting for many established risk factors.     

Neighborhood Deprivation and Risk of Cancer Incidence,Mortality and Survival: Results from a Population-Based Cohort Study in Japan

Background

In many developed countries, socioeconomic status is associated with cancer incidence and survival. However, research in Japan is sparse. We examined the association between neighborhood deprivation based on the Japanese Deprivation Index and the risk of incidence, mortality and survival from total and major cancers in the Japan Public Health Center-based Prospective Study.

Methods

86,112 participants were followed through the end of 2009. A total of 10,416 incident cases and 5,510 deaths from cancer were identified among 1,348,437 person-years of follow-up (mean follow-up: 15.7 years). The Japanese deprivation index was used to access neighborhood deprivation. Hazard ratios and 95% confidence intervals were calculated by Cox regression analysis.

Results

We found no associations between neighborhood deprivation index and the incidence of total and major cancers. In some cancer risks or deaths, however, we found positive or inverse associations with a higher deprivation index, such as a decreased risk of colorectal cancer incidence and an increased risk of liver cancer incidence and deaths in women.

Conclusion

Although some positive or inverse associations were detected for specific sites, the neighborhood deprivation index has no substantial overall association with the risk of incidence, mortality and survival from cancer in the Japanese population.     

The effect of deprivation on variations in general practitioners' referral rates: a cross sectional study of computerised data on new medical and surgical outpatient referrals in Nottinghamshire.

OBJECTIVE: To determine the effect of deprivation on variations in general practitioners'' referral rates using the Jarman underprivileged area (UPA(8)) score as a proxy measure. DESIGN: Cross sectional survey of new medical and surgical referrals from general practices to hospitals (determined from hospital activity data). SETTING: All of the 183 general practices in Nottinghamshire and all of the 19 hospitals in Trent region. MAIN OUTCOME MEASURES: The relation between the referral rates per 1000 registered patients and the practice population''s UPA(8) score (calculated on the basis of electoral ward), with adjustment for the number of partners, percentage of patients aged over 65 years, and fundholding status of each practice. RESULTS: There was a significant independent association between deprivation, as measured by the UPA(8) score, and high total referral rates and high medical referral rates (P < 0.0001). The UPA(8) score alone explained 23% of the total variation in total referral rates and 32% of the variation in medical referral rates. On multivariate analysis, where partnership size, fundholding status, and percentage of men and women aged over 65 years were included, the UPA(8) score explained 29% and 35% of the variation in total and medical referral rates respectively. CONCLUSION: Of the variables studied, the UPA(8) score was the strongest predictor of variations in referral rates. This association is most likely to be through a link with morbidity, although it could reflect differences in patients'' perceptions, doctors'' behaviour, or the use and provision of services.     

Widening inequality of health in northern England, 1981-91.

OBJECTIVE--To identify relative and absolute changes in mortality in the Northern region of England between 1981 and 1991. DESIGN--1981 and 1991 census data were used to rank 678 wards on an index of material deprivation composed of four variables (unemployment, car ownership, housing tenure, household overcrowding). Standardised mortality ratios (all causes) were calculated for various periods between 1981 and 1991 and for different age categories. SETTING--Counties of Cleveland, Cumbria, Durham, Northumberland, and Tyne and Wear. RESULTS--During 1981-91 mortality differentials widened between the most affluent and deprived fifths of wards in all age categories under 75 years. The decline in the relative position of the poorest areas was particularly great, and there was no narrowing of inequalities across the remainder of the socioeconomic spectrum. In absolute terms, there were improvements in mortality in all age categories in the most affluent areas. In the poorest areas improvements in the 55-64 age group were balanced by increased mortality among men aged 15-44, a slight rise among women aged 65-74, and static rates among men aged 45-54. CONCLUSIONS--These results re-emphasise the case for linking mortality patterns with material conditions rather than individual behaviour.     

Deprivation: explaining differences in mortality between Scotland and England and Wales.

To detect reasons for the difference in mortality between Scotland and England and Wales a measure of deprivation was studied, comprising overcrowding, unemployment of men, low social class, and not having a car. Data for Scotland for 1980-2 showed this measure to be strongly associated with mortality, with gradients being particularly steep in young adults. Deprivation was much severe in Scotland than in England and Wales. These findings suggest that much excess mortality may be ascribed to more adverse conditions. Standardising the mortality ratios to take account of the relative affluence and deprivation of the two populations led to the differentials observed being radically adjusted, while standardising for social class had little effect. Deprivation measures based on areas overcome many of the limitations associated with social class analysis and also show much greater discrimination between populations. Measures of deprivation apparently provide a powerful basis for explanation of health differences. Such measures should therefore form part of the 1991 census output to facilitate their use on a consistent basis.     

The ghost of Christmas past: health effects of poverty in London in 1896 and 1991

ObjectivesTo compare the extent to which late 20th century patterns of mortality in London are predicted by contemporary patterns of poverty and by late 19th century patterns of poverty. To test the hypothesis that the pattern of mortality from causes known to be related to deprivation in early life can be better predicted by the distribution of poverty in the late 19th century than by that in the late 20th century.DesignData from Charles Booth''s survey of inner London in 1896 were digitised and matched to contemporary local government wards. Ward level indices of relative poverty were derived from Booth''s survey and the 1991 UK census of population. All deaths which took place within the surveyed area between 1991 and 1995 were identified and assigned to contemporary local government wards. Standardised mortality ratios for various causes of death were calculated for each ward for all ages, under age 65, and over age 65. Simple correlation and partial correlation analysis were used to estimate the contribution of the indices of poverty from 1896 and 1991 in predicting ward level mortality ratios in the early 1990s.SettingInner London.ResultsFor many causes of death in London, measures of deprivation made around 1896 and 1991 both contributed strongly to predicting the current spatial distribution. Contemporary mortality from diseases which are known to be related to deprivation in early life (stomach cancer, stroke, lung cancer) is predicted more strongly by the distribution of poverty in 1896 than that in 1991. In addition, all cause mortality among people aged over 65 was slightly more strongly related to the geography of poverty in the late 19th century than to its contemporary distribution.ConclusionsContemporary patterns of some diseases have their roots in the past. The fundamental relation between spatial patterns of social deprivation and spatial patterns of mortality is so robust that a century of change in inner London has failed to disrupt it.     

Socioeconomic determinants of rates of consultation in general practice based on fourth national morbidity survey of general practices.

OBJECTIVE--To identify the socioeconomic determinants of consultation rates in general practice. DESIGN--Analysis of data from the fourth national morbidity survey of general practices (MSGP4) including sociodemographic details of individual patients and small area statistics from the 1991 census. Multilevel modelling techniques were used to take account of both individual patient data and small area statistics to relate socioeconomic and health status factors directly to a measure of general practitioner workload. RESULTS--Higher rates of consultations were found in patients who were classified as permanently sick, unemployed (especially those who became unemployed during the study year), living in rented accommodation, from the Indian subcontinent, living with a spouse or partner (women only), children living with two parents (girls only), and living in urban areas, especially those living relatively near the practice. When characteristics of individual patients are known and controlled for the role of "indices of deprivation" is considerably reduced. The effect of individual sociodemographic characteristics were shown to vary between different areas. CONCLUSIONS--Demographic and socioeconomic factors can act as powerful predictors of consultation patterns. Though it will always be necessary to retain some local planning discretion, the sets of coefficients estimated for individual level factors, area level characteristics, and for practice groupings may be sufficient to provide an indicative level of demand for general medical services. Although the problems in using socioeconomic data from individual patients would be substantial, these results are relevant to the development of a resource allocation formula for general practice.     

Social deprivation and premature mortality: regional comparison across England.

OBJECTIVE--To investigate the pattern and size of the relationship between social deprivation in electoral wards and premature mortality for each health region in England. DESIGN--Ecological study using 1981 census variables and data on mortality for 1981-5. SETTING--14 regional health authorities in England. MAIN OUTCOME MEASURE--Mortality under the age of 65 years from all causes, coronary heart disease, and smoking related diseases in men and women. RESULTS--Increasing deprivation was significantly associated with mortality from all causes, coronary heart disease, and smoking related diseases. The relationship was linear with no apparent threshold. Correlation coefficients were generally greater for deaths from all causes and smoking related diseases and for men compared with women. The slope of the relationship between deprivation and mortality varied among regions. Variations in mortality still existed between regions for equal levels of deprivation. CONCLUSION--Deprivation of an area and premature mortality are strongly linked. The effects of deprivation can be seen throughout the range of affluence and are not limited to the poorest areas. Current targets for reducing coronary heart disease mortality may be achievable if the mortality in poor areas can be reduced to the rates in affluent areas.     

Influence of primary care physician availability and socioeconomic deprivation on breast cancer from 1988 to 2008: a spatio-temporal analysis

Background

Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States. It is unclear how county-level primary care physician (PCP) availability and socioeconomic deprivation affect the spatial and temporal variation of breast cancer incidence and mortality.

Methods

We used the 1988–2008 public-use county-based data from nine Surveillance, Epidemiology, and End Results (SEER) programs to analyze the temporal and spatial disparity of PCP availability and socioeconomic deprivation on early-stage incidence, advanced-stage incidence and breast cancer mortality. The spatio-temporal analysis was implemented by a novel structural additive modeling approach.

Results

Greater PCP availability was significantly associated with higher early-stage incidence, advanced-stage incidence and mortality during the entire study period while socioeconomic deprivation was significantly negatively associated with early-stage incidence, advanced-stage incidence, and mortality up to 1992. However, the observed influence of PCP availability and socioeconomic deprivation varied by county.

Conclusions

We showed important associations of PCP availability and socioeconomic deprivation with the three breast cancer indicators. However, the effect of these associations varied over time and across counties. The association of PCP availability and socioeconomic deprivation was stronger in selected counties.     

Patterns of mortality in second generation Irish living in England and Wales: longitudinal study.

OBJECTIVE--To examine the mortality of second generation Irish living in England and Wales. DESIGN--Longitudinal study of 1% of the population of England and Wales (longitudinal study by the Office of Population Censuses and Surveys (now the Office for National Statistics)) followed up from 1971 to 1989. SUBJECTS--3075 men and 3233 women aged 15 and over in 1971. MAIN OUTCOME MEASURES--Age and sex specific standardised mortality ratios for all causes, cancers, coronary heart disease, cerebrovascular diseases, respiratory diseases, and injuries and poisonings. Deaths were also analysed by socioeconomic indicators. RESULTS--786 deaths were traced to men and 762 to women. At working ages (men, aged 15-64; women, 15-59) the mortality of men (standardised mortality ratio 126) and women (129) was significantly higher than that of all men and all women. At ages 15-44, relative disadvantages were even greater both for men (145) and for women (164). Mortality was raised for most major causes of death. Significant excess mortality from cancers was seen for men of working age (132) and for women aged 60 and over (122). At working ages mortality of the second generation Irish in every social class and in the categories of car access and housing tenure was higher than that of all men and all women in the corresponding categories. Adjusting for these socioeconomic indicators did not explain the excess mortality. CONCLUSION--Mortality of second generation Irish men and women was higher than that of all men and all women and for most major causes of death. While socioeconomic factors remain important, cultural and lifestyle factors are likely to contribute to this adverse mortality.     

Relation between socioeconomic deprivation and pathological prognostic factors in women with breast cancer.

OBJECTIVE--To investigate the relation between socioeconomic deprivation and pathological prognostic factors in women with breast cancer as a possible explanation for socioeconomic differences in survival. DESIGN--Retrospective analysis of data from cancer registry and from pathology and biochemistry records. SETTING--Catchment areas of two large teaching hospitals in Glasgow. SUBJECTS--1361 women aged under 75 who had breast cancer diagnosed between 1980 and 1987. MAIN OUTCOME MEASURES--Tumour size, axillary lymph node status, histological grade, and oestrogen receptor concentration in relation to deprivation category of area of residence. RESULTS--There was no significant relation between socioeconomic deprivation and four pathological prognostic factors: 93 (32%) women in the most affluent group presented with tumours less than 20 mm in size compared with 91 (31%) women in the most deprived group; 152 (48%) of the most affluent group presented with negative nodes compared with 129 (46%) of the most deprived group; 23 (22%) of the most affluent group presented with grade I tumours compared with 12 (17%) of the most deprived group; and 142 (51%) of the most affluent group had a low oestrogen receptor concentration at presentation compared with 148 (52%) of the most deprived group. None of these differences was statistically significant. CONCLUSIONS--Differences in survival from breast cancer by socioeconomic deprivation category could not be accounted for by differences in tumour stage or biology. Other possible explanations, such as differences in treatment or in host response, should be investigated.     

Cognitive impairment and mortality in a cohort of elderly people.

OBJECTIVES--To investigate the relation between cognitive function and cause specific mortality in people aged 65 and over. DESIGN-A 20 year follow up study of a cohort of randomly selected elderly people living in the community who in 1973-4 had taken part in a nutritional survey funded by the Department of Health and Social Security. SETTING--Eight areas in Britain (five in England, two in Scotland, and one in Wales). SUBJECTS--921 men and women whose cognitive function was assessed by a geriatrician in 1973-4 and for whom data on health, socioeconomic circumstances, and diet had been recorded. RESULTS--Cognitive impairment was associated with increased mortality, in particular death from ischaemic stroke. Those who scored 7 or less on the Hodkinson mental test had a relative risk of dying from stroke of 2.8 (95% confidence interval 1.4 to 5.5), compared with those who gained the maximum score (10), after adjustment for age, sex, blood pressure, serum cholesterol concentration, and vitamin C intake. These associations were independent of illness or social class. At the time of the nutritional survey, cognitive function was poorest in those with the lowest vitamin C status, whether measured by dietary intake or plasma ascorbic acid concentration. The relation between vitamin C status and cognitive function was independent of age, illness, social class, or other dietary variables. CONCLUSION--The relation between cognitive function and risk of death from stroke suggests that cerebrovascular disease is an important cause of declining cognitive function. Vitamin C status may be a determinant of cognitive function in elderly people through its effect on atherogenesis. A high vitamin C intake may protect against both cognitive impairment and cerebrovascular disease.     

Some recent trends in infant mortality in the province of Marrakech,morocco: A demographic transition in process

Abstract

Two surveys designed to appraise fecundity and mortality were carried out In Morocco in 1983 and 1984, on samples of 3,000 and 5,000 women, respectively, In the city and in the province of Marrakech. Infant mortality was studied using the biometric method of J. Bourgeois‐Pichat. The first results presented in this article highlight the absence of excess exogenous mortality among women under thirty years of age living in a provincial urban environment and among women from the city of Marrakech whose husbands are employed in service activities. These results are discussed in relation to the socioeconomic backgrounds of the sample families.     

A methodological note on the relationship between infant mortality and socioeconomic status with evidence from San Antonio, Texas.

A number of previous studies have concluded from social area analyses of medium-size cities that there is no longer a significant correlation between socioeconomic status (SES) and infant mortality in the U.S. To determine if these findings were an artifact of too small samples, the total, neonatal, and postneonatal infant mortality rates were analyzed for 115 census tracts of San Antonio, Texas. The SES of each tract was measured by a score reflecting equally the variables of income, education, and occupation, and allowed assignment of the tracts to 1 of 4 socioeconomic rankings. All 3 infant mortality rates rose as SES decreased, with the most marked relationship being between SES and postneonatal rates. It was also found that of the 3 variables used to measure SES, income bore the strongest relationship to infant mortality. In general it should be noted that social area analysis of infant mortality is limited by the extreme reductions of sample size when additional variables are induced.