Deprivation and poor health in rural areas: inequalities hidden by averages

Poor health and social deprivation scores in 570 wards in East Anglia, UK, were much less associated in rural than in urban areas. The deprivation measure most closely related to poor health in the least accessible rural wards was male unemployment, but use of this measure did not remove the urban-rural gradient of association strength. Neither did replacing wards by smaller enumeration districts as the units of analysis. The differences between urban and rural correlations were removed by restricting the comparison to wards with the same unemployment range and combining pairs of rural wards with similar deprivation values. Apparent differences between rural and urban associations are therefore not due to the choice of deprivation indices or census areas but are artifacts of the greater internal variability, smaller average deprivation range and smaller population size of rural small areas. Deprived people with poor health in rural areas are hidden by favourable averages of health and deprivation measures and do not benefit from resource allocations based on area values.     

Isolation, car ownership, and small area variation in incidence of acute lymphoblastic leukaemia in children

Summary. .To determine whether increased rates of childhood acute lymphoblastic leukaemia (ALL) which had been reported in isolated areas could be attributed to higher proportions of households owning cars, ecological analysis was performed with electoral wards as area units. Previous data were re-analysed using the proportion of households having no car, taken from the 1981 census of England and Wales, as an additional explanatory factor. A specialist registry of haematopoietic malignancies covering one-third of England and Wales (3270 electoral wards) recorded 438 cases of ALL in children diagnosed 1984-89, including 304 in the childhood peak (at ages 1–7 years). Relative risks were derived by Poisson regression of total childhood ALL and at ages 1–7 years for groups of electoral wards classified by isolation and car ownership. Multivariable analyses included adjustment for socio-economic status. No evidence of increased risk of childhood ALL in areas where more households own cars was found. ALL at ages 1–7 years was inversely associated with car ownership (risk in wards with least cars relative to those with most cars = 2.28,95% CI: 1.12-4.64). The associations with geographic isolation persisted after allowing for car ownership (risks for ALL in young children in isolated relative to built-up areas = 2.19,95% CI: 1.44-3.33). Levels of car ownership cannot explain the increased rates of childhood ALL which have been observed in isolated areas. No support has been found for a hypothesis relating these excesses to benzene exposure of children transported in cars. The previous explanation for the small area variation of childhood ALL in terms of geographical isolation and interpretation in terms of exposure to common infections continues to be justified.     

Mortality, long-term illness and deprivation in rural and metropolitan wards of England and Wales

The relationships between mortality, limiting long-term illness and indicators of social deprivation were investigated using regression analysis on data for rural wards, metropolitan wards and the remaining wards in England and Wales. Regional differences were controlled. In rural wards, people had better health than average and slightly better health than would be expected from their deprivation scores. Average levels of health in rural areas were only weakly related to deprivation, which was partly but not fully due to the restricted range of average deprivation values in rural wards. In metropolitan areas, relatively poor levels of health were largely explained by social deprivation, but people in Inner London were healthier than might be expected from measures of deprivation. The relationship between health and social deprivation is therefore not uniform over England and Wales, but varies between geographical types of area. One consequence is that resource allocation on the basis of social deprivation would put the populations of rural areas and Inner London at an advantage.     

医院SARS重症监护病区空气传播途径的研究

目的对SARS重症监护(ICU)病区患者及周围空气等进行研究,为SARS的传播途径提供帮助和证据支持.方法用日本产安德森空气采样器对SARSICU病区重复2次,对5个病房的空气和病区空调的过滤网、冷凝水取样,分别用RT-PCR和病毒分离培养方法检测.结果SARSICU病房空气样本中查出SARS病毒,并发现病毒既存在大的生物颗粒上,也存在较小的生物颗粒和病房外空调机过滤网上,表明在ICU病区SARS病毒可能存在近距离飞沫,也存在小的气溶胶的生物颗粒上,随空气在一定范围、一定的时间内传播.结论在SARSICU病房、病区空气中可能存在SARS病毒,所以加强病区的空气通风与ICU医务人员的呼吸道、黏膜等个人防护是防止SARS传播的关键.     

Discharge planning. Armchair fan

The establishment of a discharge lounge is believed to have reduced pressure on beds in the wards. All adult wards refer patients to the lounge, where the average wait is two hours. The establishment of the lounge has reduced delays for ambulance crews who no longer have to collect patients from several areas of the hospital. Running costs for the first year were 30,000 Pounds. An agreement with the hospital pharmacy has been pivotal to the success of the scheme.     

呼叫器在医院病房合理配置的研究

目的：呼叫器是医院基础设备,在医护人员的监护过程中占有重要地位,为提高医院病区医护人员的护理水平,本文研究如何针对不同病房特点配置呼叫器。方法通过对当前呼叫器性能以及医院病区病房规模和应用特点的分析,对呼叫器和病区进行系统分类,研究如何科学合理地针对医院病房结构以及功能特点安置呼叫器。结果根据对呼叫器在病区的应用特点的分析,医院病区可分为具有较大流动性、稳定型和包含监护特殊环节三类,呼叫器可分为包含附加功能和移动便携式两种类型,为呼叫器的配置提供了一定的依据。结论为提高医院病房的监护能力,需要详细分析医院病区的特点,并且结合病房类型和呼叫器特点进行科学合理的安排。     

Use of homogeneous social areas for ecological analyses: A study of accident rates in pre school children

Background: The results of ecological analyses are sensitiveto the geographical areas used and census areas are not necessarilythe most suitable units. This study compares the effects ofusing specially constructed areas with similar social characteristicsrather than standard census areas as basic units in a smallarea ecological study. Methods: The study used ecological regressionanalyses of accident rates in pre-school children on socialand demographic predictors using census enumeration districts,wards and specially constructed social areas as the units. Thesetting was the city of Norwich, UK and adjacent suburbs, consistingof 349 census enumeration districts nested within 30 wards or21 social areas. Results: Analyses at different geographicalscales produced similar estimates of the effects of materialdeprivation, presence of lone parent households and young populationage structures on child accident rates, but the r² values variedconsiderably, the weakest relationships being found for enumerationdistricts and the best fitting for social areas. Adjusted r²values between log accident rates and material deprivation scores,for example, were 10.5% for enumeration districts, 52.7% forwards and 63.3% for social areas. Conclusions: Specially constructedareas were preferable to enumeration districts and wards asunits for identifying ecological relationships between accidentrates in pre-school children and social conditions. Homogeneoussocial areas are potentially useful units of analysis for ecologicalstudies in epidemiology.     

A cross-sectional prospective study of seclusion,restraint and involuntary medication in acute psychiatric wards: patient,staff and ward characteristics

Background  

Previous research on mental health care has shown considerable differences in use of seclusion, restraint and involuntary medication among different wards and geographical areas. This study investigates to what extent use of seclusion, restraint and involuntary medication for involuntary admitted patients in Norwegian acute psychiatric wards is associated with patient, staff and ward characteristics. The study includes data from 32 acute psychiatric wards.     

某肿瘤医院癌痛治疗药物使用情况动态分析

目的 分析某肿瘤医院癌痛治疗药品的使用情况,为临床合理用药提供参考。 方法 通过医院HIS系统查询2018年1—3月肿瘤相关病房癌痛治疗药物使用信息,以药品名称、规格、药品消耗数量(支或片)、同期相关病房癌痛治疗药物消耗总量等为基础进行分析;同时对各个肿瘤相关科室随机抽查住院癌痛患者10例,对阶梯用药情况进行分析。 结果 癌痛病房所使用的止痛药以口服(包括外用贴剂)药为主(占总消耗量的86.64%),与世界卫生组织(WHO)推荐的口服给药为缓解癌痛的最佳给药途径相符。3个阶梯消耗量构成比分别为5.58%、31.67%、62.75%,其中治疗重度疼痛的第三阶梯药物占很大比例。 结论 该院癌痛患者止痛治疗基本合理、用药安全、有效,但对于癌痛治疗中辅助用药的使用不够重视,仍需要进一步加强监管。     

Do social factors affect where patients die: an analysis of 10 years of cancer deaths in England.

BACKGROUND: This study investigated whether indices of social deprivation were related to the proportion of cancer patients who died at home. METHODS: Data were derived from death registrations for all cancer deaths 1985-1994 in England. Two indices of deprivation (Underprivileged Area Score (UPA), or Jarman, and Townsend scores) were calculated for each electoral ward; 1991 Census data were used. The scores use combinations of variables, including the percentage in overcrowded homes, the percentage of elderly people living alone, the percentage of one-parent families, etc. A high score indicates more deprivation. The main outcome measures were the proportion (in five and ten year averages) of cancer deaths which occurred at home, calculated for every electoral ward (with populations usually ranging from 5000 to 11,000). Spearman rho was used to test for correlations between the proportion of cancer deaths at home and deprivation score. Electoral wards were categorized by deprivation score into three groups of equal size and analysed over 10 years. Multivariate analysis was used to determine the relative association of different patient based and electoral ward variables with cancer death at home. p < 0.05 (two-tailed) was taken as significant. RESULTS: There were over 1.3 million death registrations from cancer in the 10 years. The proportion who died at home was 0.27, in hospital 0.47, and other setting 0.26. There were wide variations (0.05-0.75) in the proportion of people who died at home in different electoral wards. Small inverse correlations were found between the percentage who died at home and the UPA (-0.35; p < 0.001) and Townsend (-0.26; p < 0.001) scores. The correlations were greatest in North Thames (-0.63, UPA) and smallest in West Midlands (-0.20, UPA). The proportion of home deaths for the different bands of deprivation were: 0.30 (low deprivation), 0.27 (middle deprivation) and 0.24 (high deprivation). Plotting the trends over 10 years suggests no change in this relationship. Multiple regression analysis predicted several ward and patient characteristics and accounted for 30 per cent of the variation. Increased age (patient variable), Jarman score and ethnic minorities (both ward variables) were associated with fewer patients dying at home. Being male and having cancer of the digestive organs were associated with home death. CONCLUSION: There are wide variations in the percentage of cancer deaths at home in different electoral wards. Social factors are inversely correlated with home cancer death, and may explain part of this variation. Home care in deprived areas may be especially difficult to achieve.     

Impact of nursing home deaths on life expectancy calculations in small areas

STUDY OBJECTIVE: The drive to tackle health inequalities at the local level has increased interest in mortality data for small populations. There is some concern that nursing homes may affect measures of mortality for small populations, but there has been little in depth analysis of this. DESIGN AND SETTING: Deaths between 1997 and 2001 and population figures from the GP register (Exeter) database and census 2001 were used to produce life expectancy (LE) figures for all electoral wards in West Sussex. The proportion of those dying within each ward that had been residents of nursing homes was calculated and the relation between these variables and deprivation investigated. RESULTS: There was a significant linear relation between nursing home deaths and LE (p<0.0001), which explained 36% of variation in LE between wards. Deprivation accounted for around 35% of the variation in LE (p<0.0001) but was not correlated with nursing home deaths (p> or =0.0982). Multiple linear regression shows that over 60% of the variation in LE at ward level can be explained by both nursing home deaths and deprivation (p<0.0001) and that the two variables explain similar proportions of this variation. The relation between LE and nursing home deaths within wards grouped by deprivation suggests that the impact of nursing homes is strongest in deprived wards. CONCLUSIONS: This finding has important implications for LE calculations in small populations. Further investigation is now needed to examine the impact of nursing homes in other areas, on other mortality measures, and in larger populations.     

'Clustering'--real or apparent? Probability maps of childhood cancer in the West Midlands Health Authority region

The West Midlands Regional Children's Tumour Registry collects detailed information on all cases of childhood cancer in the West Midlands Health Authority Region (WMHAR). The distribution by electoral ward of all cases diagnosed in the WMHAR between 1980 and 1984 has been determined. Analysis has also been performed for leukaemias/non-Hodgkin's lymphomas alone. We suggest that this latter grouping should be universally employed, owing to the difficulty of accurately separating out cases of leukaemia. Both spatial analyses showed several wards with significantly excessive rates on the basis of their cumulative Poison probability. Observed/expected ratios of 3-35 were seen for cases in significant wards, which are similar to the ratios seen in analysis of incidence around nuclear installations. However, further detailed consideration of these individual significance levels in the light of the number of statistically significant wards which would occur by chance alone, due to the multiple use of the test, accounted completely for the number of wards obtained in each of the groups considered. Thus, apparent 'clustering' of cases could be mere statistical artefact. In the WMHAR, therefore, using the technique of probability mapping, no true spatial pattern of incidence was found, other than that which would occur by chance alone. This, in a large area without nuclear installations and an even mix of rural and industrialised regions, could be seen as control data for those studies which have considered cases of childhood leukaemia around nuclear facilities, where the observation of single point clusters associated with suspected sites restricts assessments of spatial pattern in the rest of the area.(ABSTRACT TRUNCATED AT 250 WORDS)     

Is the Jarman score better than social class at assessing the need for prevention and primary care?

This paper reports an analysis by small areas of various measures of disease and the use of cervical smear services in the city of Sheffield. The correlation of these with social class and the Jarman underprivileged area score were compared. Wide variations in mortality rates between electoral wards in Sheffield were demonstrated, particularly for deaths from diseases with a large preventable component. Social class correlated more strongly with all-cause mortality (r = 0.69) and preventable mortality (r = 0.91) than did the Jarman score. There was no significant correlation between routine cervical smear rate and either social class or the Jarman score among women under the age of 35 years. Among older women, however, there was a high degree of correlation with fewest smears being taken in the most deprived wards. Social class was more strongly correlated with the invasive cervical cancer rate in electoral wards than was the Jarman score, and was thus a better indicator of the need for cervical screening. However, the Jarman score showed a greater degree of (negative) correlation with the uptake of cervical screening than did social class with disproportionately fewer smears being taken by general practitioners in areas of highest need. Social class may be better than the Jarman score as an indicator of both ill-health and the need for preventive health services in Sheffield. Information is routinely collected decenially on social class and needs little further computation, unlike the Jarman score. Furthermore, much is already known about the relationships between social class and both ill-health and the need for preventive services.     

The Tuscany longitudinal study: mortality among selected causes in inner city of Florence and Leghorn

The analysis of mortality in urban settings for the Cities of Florence (1991-95) and Leghorn (1987-95), based on data from the Tuscany Longitudinal Study, is reported in the present paper. The data came from a census-based cohort study, all residents at the census day 1981 (Leghorn) or 1991 (Florence) being enrolled and followed-up by automated procedures of record-linkage. The cause of death certificate had been eventually collected by the Regional Mortality Register. For each city, internally standardized mortality ratios (SMR) had been calculated by sub-urban areas (city sectors or wards). The analysis was restricted to age groups > 15 years to have interpretable results on socio-economic variables derived from census questionnaires. Bayesian estimates (Besag, York e Mollié) of mortality relative risks had been calculated to overcome extra-variability of SMRs. In the city of Florence two wards showed about 10% excess risk for overall mortality. In the city of Leghorn one sector was at higher risk while one showed a significant lower mortality. For both cities such risk gradients were still present after adjustment for deprivation index at individual level.     

A rural advantage? Urban-rural health differences in northern England.

Rural health inequalities have been relatively neglected in recent years. The data assembled for a large study of health and deprivation in the Northern Region of England have been reanalysed to examine three questions. How wide are rural health inequalities compared with those in urban areas? Is health intrinsically better in rural areas, given comparable deprivation or affluence? Is the association between health and wealth weaker in rural than in urban areas? It is shown that, although health inequalities are wider in urban areas, this corresponds to wider socio-economic divisions: at equivalent levels of wealth, health measures are similar. This relationship breaks down, however, when the most remote rural areas are compared with matching localities in conurbations, for in this case rural areas have a clear advantage. We go on to show that the apparent weakness of the association between health and wealth in rural areas is largely an artefact; the association becomes stronger when the units of population (electoral wards) are enlarged to resemble more closely those in urban contexts. The comparability of rural and urban forms of deprivation is discussed in the light of these results.     

Factors influencing the distribution of tuberculosis cases in an inner London borough

The incidence of tuberculosis (TB) has increased throughout London, especially in inner city boroughs. Ethnicity, poverty, and the success of TB control measures all affect the distribution of cases between boroughs. This study was conducted to see which factors affect the distribution of cases between electoral wards within an inner London borough. The Borough of Newham in the East End of London is made up of 24 electoral wards and has one of the highest notification rates in the United Kingdom. Our analysis showed that the percentage of the population who were non-white made a strong contribution to the variance in TB rates between wards (p < 0.0001), but the age distribution of the population and Jarman scores for poverty did not, the latter because the entire borough is deprived. Measures to control TB should be targeted at those areas where members of the community are most at risk.     

肝胆外科病房深部真菌感染调查及其危险因素分析

目的 探讨肝胆外科病房真菌感染的临床特点与危险因素.方法 收集2005年1月-2010年6月肝胆外科病房深部真菌感染63例患者的临床资料,回顾性分析深部真菌感染的临床特点及危险因素.结果 63例患者留样标本共分离出76株真菌,深部真菌感染以白色假丝酵母菌为主,占47.4％,＞2种真菌混合感染者为13.1％;深部真菌感染的疾病主要有重症急性胰腺炎、肝胆胰恶性肿瘤、急性梗阻性胆管炎;长期广谱抗菌药物及皮质类固醇激素的使用、机械通气、中心静脉置管、静脉高营养的使用、肝功能障碍、高龄(≥60岁)等是肝胆外科病房深部真菌感染的高危因素.结论 深部真菌感染是肝胆外科病房常见的并发症;合理使用抗菌药物、减少侵入性操作、加强无菌观念和增强机体抵抗力是防止深部真菌感染的有效措施.     

Impact of patients' socioeconomic status on the distance travelled for hospital admission in the English National Health Service

OBJECTIVES: To compare the distances travelled for inpatient treatment in England between electoral wards prior to the introduction of a policy to extend patient choice and to consider the impact of patients' socio-economic status. METHODS: Using Hospital Episode Statistics for 2003-04, the distance from a patient's residence to a National Health Service hospital was calculated for each admission. Distances were summed to electoral ward level to give the distribution of distances travelled at ward level. These were analysed to show the distance travelled for different admission types, ages of patient, rural/urban location, and the socioeconomic deprivation of the population of the ward. RESULTS: There is considerable variation in the distances travelled for hospital admission between electoral wards. Some of this is explained by geographical location: individuals living in more rural areas travel further for elective (median 27.2 versus 15.0 km), emergency (25.3 versus 13.9 km) and maternity (25.0 versus 13.9 km) admissions. But individuals located in highly deprived wards travel less far, and this shorter distance is not explained simply by the closer location of hospitals to these wards. CONCLUSIONS: Before the introduction of more patient choice, there were considerable differences between individuals in the distances they travelled for hospital care. An increase in patient choice may disproportionately benefit people from less deprived areas.     

Widening social inequalities in mortality: the case of Barcelona, a southern European city.

OBJECTIVE: To analyse trends in mortality inequalities in Barcelona between 1983 and 1994 by comparing rates in those electoral wards with a low socioeconomic level and rates in the remaining wards. DESIGN: Mortality trends study. SETTING: The city of Barcelona (Spain). SUBJECTS: The study included all deaths among residents of the two groups of city wards. Details were obtained from death certificates. MAIN OUTCOME MEASURES: Age standardised mortality rates, age standardised rates of years of potential life lost, and age specific mortality rates in relation to cause of death, sex, and year were computed as well as the comparative mortality figure and the ratio of standardised rates of years of potential life lost. RESULTS: Rates of premature mortality increased from 5691.2 years of potential life lost per 100,000 inhabitants aged 1 to 70 years in 1983 to 7606.2 in 1994 in the low socioeconomic level wards, and from 3731.2 to 4236.9 in the other wards, showing an increase in inequalities over the 12 years, mostly due to AIDS and drug overdose as causes of death. Conversely, cerebrovascular disease showed a reduction in inequality over the same period. Overall mortality in the 15-44 age group widened the gap between both groups of wards. CONCLUSION: AIDS and drug overdose are emerging as the causes of death that are contributing to a substantial increase in social inequality in terms of premature mortality, an unreported observation in European urban areas.