Small area mortality patterns

Little information on the health of populations living in small geographic areas of Ireland is available and it is therefore difficult to clearly identify small communities whose health is significantly below average. The aim of this study was to identify areas within Dublin having above average death rates by application of the technique of small area analysis. By using mortality and census data and by calculating standardised mortality ratios, a number of electoral wards/district electoral divisions in Dublin with significantly elevated mortality rates from all causes and from specific disease groups were identified. In general these were in inner city areas and new suburbs to the north and west of the city. A considerable proportion of the excess mortality can be attributed to conditions amenable to preventive measures. Before specific intervention is attempted, local investigation by Directors of Community Care/Medical Officers of Health will be necessary in order to confirm the findings and to identify factors which may be amenable to prevention. If intervention is attempted it should be carefully planned and should be implemented on a pilot basis initially.     

General practice in Gloucestershire, Avon and Somerset: explaining variations in standards.

Variations in standards are found in all health services. The method and amount of funding are thought to be important reasons for these variations. A cross sectional survey of all general practices in three counties in south west England was undertaken in order to explain variations in the level of development. A development score for each practice was calculated. There was wide variation in standards as described by the level of development. Multiple regression analysis showed that being a training practice, having a practice manager, the partners having a younger mean age, a larger total number of patients registered with the practice and a lower Jarman underprivileged area score were all independently related to a higher level of practice development. In addition, the responsible family health services authority was also related to the level of development. A combination of professional factors such as the decision to become a training practice, environmental factors such as the family health services authority or the underprivileged area score and economic factors reflected in the total list size determine the level of practice development. The most easily corrected factor is the employment of a practice manager. It is suggested that differences in standards in general practice may be increased rather than decreased by the fundholding scheme.     

AIDS and the future general practitioner

Teaching by example is an essential component of vocational training in general practice and trainers should be expected to exhibit a high standard of practice. A postal questionnaire about knowledge of, attitudes to and response to the epidemic of the acquired immune deficiency syndrome (AIDS) was completed by 114 general practitioner trainers in the south west Thames region. The findings were compared with those of an identical survey of 155 non-trainer general practitioner principals in south west London. There were no appreciable differences between trainers and nontrainers in knowledge and attitudes, although trainers were significantly more likely to have discussed the problem of AIDS with their practice staff. The problems encountered in both groups included: lack of knowledge about AIDS, inability to offer AIDS counselling and advice, and reluctance to care for intravenous drug abusers. These findings suggest that trainers need to improve their practice in areas concerned with the AIDS problem in order to provide a better learning model for their trainees.     

The carrot,the stick and the general practitioner: how have changes in financial incentives affected health promotion activity in general practice?

BACKGROUND: Financial incentives for increasing health promotion activity in primary care, introduced with the 1990 contract for general practitioners, were amended in 1993 and are now focused on cardiovascular disease. Payments for health promotion clinics were abolished and target payments were introduced. AIM: The study aimed to evaluate the effect of the change, in June 1993, in financial incentives for health promotion activity in primary care on the distribution of health promotion payments in two family health services authorities. METHOD: A retrospective study was undertaken in which data from two family health services authorities were used to determine the annual level of health promotion payments per 1000 practice population before and after the contractual amendment. Health promotion clinic payment data were analysed for 78 practices in Bedfordshire Family Health Services Authority and 85 practices in Kensington, Chelsea and Westminster Family Health Services Authority. Changes in health promotion payments were calculated and related to two measures of relative need: all cause standardized mortality ratios, for patients aged 74 years or less, of the electoral ward in which the practice is located; and the Jarman underprivileged area score. High relative need was defined as a standardized mortality ratio of over 100 or more than 25% of the practice population living in electoral wards with a Jarman score of over 30. RESULTS: Health promotion payments were more evenly distributed after the change in June 1993 than before between the two family health services authorities and between general practices. Single-handed practices were carrying out more clinics in 1992 than multi-partner practices and consequently were one of the greatest financial losers as a result of the change. In addition, practices located in electoral wards with high relative needs lost proportionally more than those in electoral wards with lower needs. CONCLUSION: Changes in the general practitioner health promotion contract have created new financial winners and losers. It now appears that health promotion payments are more evenly distributed but that the distribution is unrelated to need or treatment given. More evidence on the effectiveness of health promotion interventions is required before policies aimed at promoting better health through primary care can be fully evaluated.     

Predicting admission rates to secure forensic psychiatry services

BACKGROUND: The planning and development of secure forensic psychiatry services for mentally disordered offenders in England and Wales has proceeded independently within different regional areas. However, certain mental disorders, offenders, and offending behaviour are all more prevalent in geographical areas characterized by socio-economic deprivation and social disorganization. Failure to consider these factors has led to inadequate service provision in some areas and inequity in funding. A new model is required to predict admissions to these services as an aid to resource allocation. METHOD: Actual admissions (N = 3155) to high and medium secure psychiatric services for seven of 14 (pre-reorganization) Regional Health Authorities, 1988-94. Expected admissions were calculated for each district using 1991 census data adjusted for under-enumeration. Standardized psychiatric admission ratios were calculated and a range of social, health status, and service provision data were used as explanatory variables in a regression analysis to determine variation between districts. RESULTS: Actual psychiatric admissions varied from 160% above to 62% below expected for age, sex, and marital status, according to patients' catchment area of origin, measured according to deciles of the distribution of underprivileged area scores at ward level. The most powerful explanatory variables included a composite measure of social deprivation, ethnicity and availability of low secure beds at regional level. CONCLUSION: Admission rates to secure forensic psychiatry services demonstrate a linear correlation with measures of socio-economic deprivation in patients catchment area of origin. A model was developed to predict admissions from District Health Authorities and is recommended for future use in resource allocation. Identification of factors that explain higher admission rates of serious offenders with mental disorder from deprived areas is a priority for future research.     

Demographic profile of the elderly population in Dublin accident and emergency hospital catchment areas

The Dublin metropolitan area is now divided into a number of clearly defined accident and emergency (A & E) catchment areas since the closing of the smaller inner city hospitals and the opening of newer hospitals on the periphery of the city. We examined the demographic profile of the elderly population in Dublin city and county served by each of the new catchment areas. Whilst the elderly population make up 9.9% (105,188) of the Dublin population (1996 census) they make up over 20% of the A & E attendances and up to over 40% of the A & E admissions in major Dublin hospitals. There is a wide variation in the percentage elderly population in each hospital catchment area with inner more settled city areas having a much higher percentage elderly population over those hospital catchment areas that serve newer housing areas. We also looked at the level of deprivation. Combining the two most deprived levels St James's Hospital had the largest absolute number and the highest percentage of deprived elderly 12,736 (51.1%) followed by the Mater 6,919 (32.9%), Beaumont 5371 (31.5%), James Connolly 2,983 (38.1%), Tallaght 2012 (22.3%) and St Vincent's Hospital 1987 (7.7%). Hospitals with high numbers of elderly and serving deprived catchment areas face particular resource problems in meeting the needs of the population that they serve. A significant increase in the provision of publicly funded community facilities and long stay accommodation is required to meet the needs of the large number of deprived elderly in the inner city area. Failure to respond to these demographic challenges will have a profound effect on the ability of hospital emergency services to meet the increasing pressures posed by the high volume of acutely sick economically deprived elderly presenting to hospital accident and emergency departments.     

From the surgery to the surgeon: does deprivation influence consultation and operation rates?

BACKGROUND: Concern about equity of access to health care has increased since the health care reforms implemented in the 1990s. Access to specialist health care is controlled by general practitioners; assessing and ensuring equity should therefore begin in general practice. AIM: This study set out to determine whether there are socioeconomic differences in the relationship between expressed need for possible surgical intervention (consulting a general practitioner) and surgical provision. METHOD: Information on the social class distribution of expressed need was obtained from the third national morbidity survey (1981-82) for 140,049 patients consulting a general practitioner. The conditions examined were: inguinal hernia, gallstones, tonsillitis, varicose veins, cataract and osteoarthritis. This expressed need was compared with the appropriate operation for all residents of North East Thames Regional Health Authority from January 1991 to July 1992 classified, according to area of residence, by the Townsend deprivation score. RESULTS: The relationship between expressed need and provision by deprivation was concordant for some conditions, but discordant for others. For cataract and tonsillitis, there was an inverse U pattern between increasing deprivation and both patient consultation and operation ratios. For varicose veins, deprivation was associated with higher patient consultation and operation ratios. For hernia, gallstones and osteoarthritis, consultations increased with deprivation, but operation ratios were either unrelated to deprivation scores (hernia and gallstones) or decreased by deprivation score (hip operations). CONCLUSION: There are marked socioeconomic differences in consultation ratios for these common conditions which may not be matched by operation ratios. For discordant comparisons, people in the most deprived quartiles were generally least likely to receive surgery despite being most likely to consult a general practitioner with symptoms. If validated, these findings have important implications for general practice and service providers.     

Calculation of the underprivileged area score for a practice in inner London.

A study was undertaken in a London inner city practice to determine an underprivileged area score for the practice based on information derived from questionnaires completed by 773 patients. The practice studied was new, had a highly mobile population and operated an 'open door' policy to new registrations--factors which were all considered to be contributing to a high level of workload. This was confirmed by the practice underprivileged area score which at 60.37 was considerably higher than the comparative score of 17.22 obtained for the same patients based on 1981 census information. This method highlights the differing workloads of practices in the same area and provides a means by which to make comparisons between practices.     

Providing census data for general practice. 2. Usefulness

Computerized census data are described in relation to a general practice population. The previously published methods for scoring deprivation – underprivileged areas score and material deprivation score – are applied to the data. Wards and enumeration districts within a single practice area are ranked by both methods and examples show the wide variation in deprivation scores for enumeration districts within single wards. The value of these data to a general practice is discussed with particular reference to developing a profile of the practice and to planning prevention and anticipatory care.     

Inequalities in treated heart disease and mental illness in England and Wales, 1994-1998.

BACKGROUND: Current government policy is directed towards reducing inequalities in health. General practice is increasingly the focus for health care provision in the United Kingdom and it is therefore important to understand the relationship between socioeconomic factors and health at the general practice level. A deprivation measure was used for the area in which the practice is located and two key priority areas were focused upon: mental health and heart disease. AIM: To explore the relationship between area deprivation and the prevalence of treated heart disease and mental illness in England and Wales. DESIGN OF STUDY: Analysis of data from medical records from practices contributing to the General Practice Research Database. SETTING: A total of 211 practices located in England and Wales. METHOD: The data from the practices were used to examine deprivation differentials in treated disease prevalence rates. RESULTS: There are strong deprivation gradients (highest prevalence in the most deprived category) for treated depression, anxiety, schizophrenia, coronary heart disease and non-insulin-treated diabetes. In general the deprivation differentials are wider in the middle of the age range. Women aged 35 to 64 years in the most deprived areas had rates of treated coronary heart disease two to three times those in the least deprived areas. Men aged 25 to 44 years in the most deprived areas had rates of treated depression 50% higher than those in the least deprived areas. CONCLUSIONS: This study has identified wide deprivation differentials in the prevalence of treated mental illness and heart disease. If all of England and Wales experienced the rates of the least deprived fifth of the population then the number of people being treated for depression, anxiety, and coronary heart disease would fall by 10%, 16%, and 11% respectively.     

Excess mortality in Harlem

In recent decades mortality rates have declined for both white and nonwhite Americans, but national averages obscure the extremely high mortality rates in many inner-city communities. Using data from the 1980 census and from death certificates in 1979, 1980, and 1981, we examined mortality rates in New York City's Central Harlem health district, where 96 percent of the inhabitants are black and 41 percent live below the poverty line. For Harlem, the age-adjusted rate of mortality from all causes was the highest in New York City, more than double that of U.S. whites and 50 percent higher than that of U.S. blacks. Almost all the excess mortality was among those less than 65 years old. With rates for the white population as the basis for comparison, the standardized (adjusted for age) mortality ratios (SMRs) for deaths under the age of 65 in Harlem were 2.91 for male residents and 2.70 for female residents. The highest ratios were for women 25 to 34 years old (SMR, 6.13) and men 35 to 44 years old (SMR, 5.98). The chief causes of this excess mortality were cardiovascular disease (23.5 percent of the excess deaths; SMR, 2.23), cirrhosis (17.9 percent; SMR, 10.5), homicide (14.9 percent; SMR, 14.2), and neoplasms (12.6 percent; SMR, 1.77). Survival analysis showed that black men in Harlem were less likely to reach the age of 65 than men in Bangladesh. Of the 353 health areas in New York, 54 (with a total population of 650,000) had mortality rates for persons under 65 years old that were at lest twice the expected rate. All but one of these areas of high mortality were predominantly black or Hispanic. We conclude that Harlem and probably other inner-city areas with largely black populations have extremely high mortality rates that justify special consideration analogous to that given to natural-disaster areas.     

Evaluation of the use of general practice age-sex registers in epidemiological research.

AIM. This study set out to show how well samples from general practice registers compare with census data, to describe those characteristics of the population and of the register that influence the response to postal surveys, and to demonstrate how general practice records can be used to assess non-response bias. METHOD. The data for this study were obtained from a large postal survey about low back pain among the general adult population aged 20-59 years in eight areas of the United Kingdom, using general practice age-sex registers as the sampling frame. RESULTS. The overall response rate was 59%. In the areas chosen, general practice registers yielded samples of size and age-sex composition close to that predicted from national census data. Responses were more likely to be obtained from women, from older age groups and from practices where the sample lists had been inspected for errors. The use of computerized registers and a letter of recommendation from the general practitioner had no effect on the response rate. Inspection of the general practice records of subsamples of respondents and non-respondents to determine consultation rates suggested that there was little response bias in respect of the subject of the survey. CONCLUSION. General practice registers can provide a suitable sampling frame for epidemiological purposes. Inaccuracies in the register can be reduced to some extent by careful inspection, but an irreducible minimum remain. Information held in general practice records can be useful in assessing response bias in health surveys.     

Patient satisfaction surveys as a market research tool for general practices.

BACKGROUND. Recent policy developments, embracing the notions of consumer choice, quality of care, and increased general practitioner control over practice budgets have resulted in a new competitive environment in primary care. General practitioners must now be more aware of how their patients feel about the services they receive, and patient satisfaction surveys can be an effective tool for general practices. AIM. A survey was undertaken to investigate the use of a patient satisfaction survey and whether aspects of patient satisfaction varied according to sociodemographic characteristics such as age, sex, social class, housing tenure and length of time in education. METHOD. A sample of 2173 adults living in Medway District Health Authority were surveyed by postal questionnaire in September 1991 in order to elicit their views on general practice services. RESULTS. Levels of satisfaction varied with age, with younger people being consistently less satisfied with general practice services than older people. Women, those in social classes 1-3N, home owners and those who left school aged 17 years or older were more critical of primary care services than men, those in social classes 3M-5, tenants and those who left school before the age of 17 years. CONCLUSION. Surveys and analyses of this kind, if conducted for a single practice, can form the basis of a marketing strategy aimed at optimizing list size, list composition, and service quality. Satisfaction surveys can be readily incorporated into medical audit and financial management.     

Overall Quality of Outcomes Framework scores lower in practices in deprived areas

BACKGROUND: There has been much debate as to whether quality points allocated through the new general medical services contract are more difficult to achieve for practices in deprived and rural areas. We used multiple regression to assess the relationships between deprivation, rurality and the number of overall quality points achieved by each practice. Multiple deprivation was significantly inversely related to quality points achieved. Practices in villages and towns gained 2% more quality points than urban areas and hamlets.     

Are specialist mental health services being targeted on the most needy patients? The effects of setting up special services in general practice.

BACKGROUND: Around 25% of patients with psychoses lose contact with specialist psychiatric services, despite the government's policy to focus the efforts of community teams on this group. AIM: To identify patient and practice factors associated with continuing contact and loss of contact with specialist services. METHOD: Cross-sectional comparison was made of patients in and out of specialist contact, through detailed interviews with 102 patients among 26 south west London practices. Associations were sought between contact with specialist services and patient factors (illness severity, social functioning, quality of life, needs for care, and satisfaction with general practitioner [GP] services) and practice factors (size, location, fundholding status, training status, and the presence of mental health professionals on site). RESULTS: Thirty-one (30%) patients were currently out of specialist contact. No significant differences were found between those in and out of contact on any measures of diagnosis or psychiatric history. Those in contact had significantly more symptoms, poorer social functioning, poorer quality of life, and more needs for care. The proportion out of contact was significantly higher in two practices that had employed their own mental health professionals to provides services on site for severe mental illnesses. Two factors remained significant predictors of contact in a logistic regression model: whether or not the patient's practice offered a special service on site, and greater patient needs for care. CONCLUSIONS: Secondary mental health services are being targeted towards the more needy patients. The provision of special services in practices can shift care further away from secondary care while still meeting patients' needs.     

Effect of practice and patient population characteristics on the uptake of childhood immunizations.

BACKGROUND. The target-linked payments introduced by the 1990 general practitioners' contact were intended to reflect a close association between payments and performance in general practice. However, a straightforward direct relationship between service uptake in primary care and financial incentives should not be assumed. AIM. This study set out to examine the relationship between the factors which provide a broad profile of practices and general practitioners' performance in terms of primary childhood immunization targets. METHOD. Anonymized data on primary immunization uptake rates in 208 practices in Greater Glasgow Health Board and selected characteristics of the practices and their patient populations were analysed. RESULTS. Seventy five per cent of the practices in the study qualified for a high-target payment in the last quarter of the 1991-92 financial year, but only 53% managed to do so in all four quarters of the year. Tests of differences between means showed that the provision of child health surveillance, the notional' mortality ratio for each practice's patient population and the percentage of patients attracting deprivation payments were significant differentiating factors among the practices grouped according to immunization target achieved at 1 October 1991--high target, low target and neither. There was no evidence that the target achieved was significantly affected by the activity or clinical staffing levels of the practices--number of patients per general practitioner, number of practice nurses or being single handed. A disproportionate number of practices reaching the high target were located in the more affluent areas, whereas a higher than expected proportion of those which either achieved the low target or missed both targets was located in the more deprived areas. Similar results were obtained when the performance of the practices in achieving the high target over four consecutive quarters was considered. CONCLUSION. Practice serving populations living in socially deprived areas and with poorer health were less likely to achieve the high target for childhood immunizations. Evidence of repetition of performance in immunization uptake among the practices leads to concern over increased risk of infectious diseases among children from socially deprived populations who fail to be immunized. This seems to be yet another example of the inverse care law.     

Mortality by deprivation and cause of death in England and Wales, 1999-2003

The relationship between deprivation and mortality is long established and many studies report higher death rates in more deprived areas. This article examines recent patterns of mortality and deprivation and illustrates these for leading causes of death. Results are considered by age group, sex and region. Mortality rates increased with deprivation for both sexes but the relationship was generally stronger for males. The strongest positive relationships with deprivation were mostly found for smoking-related causes. Those living in the least deprived areas had similar mortality rates, independent of region. There was more geographical variation in mortality for those in the most deprived areas with highest rates generally in the north.     

Attitudes to community psychiatry among urban and rural general practitioners.

General practitioners' requirements for community psychiatric services may differ according to the area in which they practise. A questionnaire survey of general practitioners' attitudes to community psychiatric services is reported from three contrasting areas: an inner city urban area, a new town and a rural area. General practitioners in all areas wanted more consultation with psychiatrists, and 53-68% wanted regular psychiatric outpatient clinics in their surgeries. There was enthusiasm for community psychiatric nurses and for help with psychotherapy. In the rural area general practitioners favoured surgery based psychiatric outpatient clinics and arranging emergency hospital admissions themselves; in urban areas domiciliary visits from psychiatrists to help with emergencies were favoured. These results appear to reflect the greater geographical distance between primary and hospital based secondary care in rural as opposed to urban areas. Overall, general practitioners wanted more support from community psychiatric services in carrying out their primary therapeutic role especially in rural areas far from hospital-based psychiatric services.     

Holidaymakers in a seaside town

A general practice in a holiday area has problems in dealing with the demands for general medical services by holidaymakers. A survey was devised to study these demands and their effect on the work of the practice. Throughout the summer months every eighth patient seen in the surgery was a visitor and at the peak period every fifth patient was a temporary resident. Temporary residents requested proportionately more home visits late in the day and those staying more than 15 days had a higher doctor contact rate.     

Psychiatrists' attitudes,knowledge, and experience regarding genetics: a preliminary study

PurposeThis study is the first survey of a random national sample of US psychiatrists to assess attitudes, knowledge, and clinical experience regarding genetics. We hypothesized that clinicians with more recent genetics training would demonstrate more positive attitudes and greater genetics knowledge and experience than those with less recent training.MethodsA probability sample of US psychiatrists (n = 93) was invited to participate in a mail survey regarding genetic medicine.ResultsForty-five psychiatrists completed the survey (response rate = 48%). All believed that genetics strongly or moderately influenced a person's mental health. Respondents expressed positive attitudes toward incorporating genetics into psychiatric practice, but most did not have recent genetics training or experience in referring patients to genetic counselors or ordering genetic tests. Psychiatrists who had genetics training within the previous 5 years had more experience in providing genetic services.ConclusionsThis survey identified areas of strength (positive attitudes about providing genetic services, belief in the heritability of mental illness) and future targets for educational intervention (general genetics, information about testing and counseling resources). The association between recent training and a greater level of clinical genetics experience suggests that educational efforts may be successful in preparing psychiatrists to provide genetic services in the future.