Contributions of specific causes of death to lost life expectancy in severe mental illness

The life expectancy gap between people with severe mental illness (SMI) and the general population persists and may even be widening. This study aimed to estimate contributions of specific causes of death to the gap. Age of death and primary cause of death were used to estimate life expectancy at birth for people with SMI from a large mental healthcare case register during 2007-2012. Using data for England and Wales in 2010, death rates in the SMI cohort for each primary cause of death category were replaced with gender- and age-specific norms for that cause. Life expectancy in SMI was then re-calculated and, thus, the contribution of that specific cause of death estimated. Natural causes accounted for 79.2% of lost life-years in women with SMI and 78.6% in men. Deaths from circulatory disorders accounted for more life-years lost in women than men (22.0% versus 17.4%, respectively), as did deaths from cancer (8.1% versus 0%), but the contribution from respiratory disorders was lower in women than men (13.7% versus 16.5%). For women, cancer contributed more in those with non-affective than affective disorders, while suicide, respiratory and digestive disorders contributed more in those with affective disorders. In men, respiratory disorders contributed more in non-affective disorders. Other contributions were similar between gender and affective/non-affective groups. Loss of life expectancy in people with SMI is accounted for by a broad range of causes of death, varying by gender and diagnosis. Interventions focused on multiple rather than individual causes of death should be prioritised accordingly.

Burden of disease due to cancer in England and Wales

BACKGROUND

This study aims to estimate the burden of cancer in England and Wales using disability-adjusted life years (DALYs) and to determine if the ranking of relative importance changes with metric used.

METHODS

DALYs are the sum of years of life lost due to mortality and years lost due to disability. Annual DALYs due to cancer were calculated using cancer registration, mortality, disability weights and World Health Organization methodology.

RESULTS

There were 8 605 362 DALYs due to cancer (3242 DALYs/100 000 population/year). Of the total, 47% corresponded to lung, prostate and colorectal cancers in males and 56% to breast, lung, colorectal and ovarian cancers in females. Mortality (86% of DALYs) contributed predominantly to DALYs. Individuals of 65-75 years contributed to 28% of DALYs. Among females, lung cancer ranked highest by death rates, whereas the highest DALYs were from breast cancer.

CONCLUSIONS

Highest DALYs were due to lung, breast, prostate and colorectal cancers in England and Wales. The addition of the disability component changes the relative position of some of the top cancers. Although metrics based on deaths alone capture most effects of cancer on population health levels, important additional perspectives, relevant to the planning of services, can be gained from burden of disease analyses.

Usefulness of porA sequencing in distinguishing sporadic and linked cases of serogroup B invasive meningococcal disease in Suffolk, United Kingdom, December 2009 to January 2010

A cluster of three fatal cases of invasive meningococcal disease due to Neisseria meningitidis serogroup Bin a town in Suffolk, United Kingdom, during December 2009 to January 2010 was reported to the local Health Protection Unit. This paper describes the investigation undertaken to identify any potential epidemiological links among the cases, to determine if this was an outbreak and to consider whether to implement community-wide interventions and control measures. Case epidemiological information in addition to serogroup and genosubtyping (porA gene sequencing) data of the infecting organism was gathered on all cases in this reported cluster. Genosubtyping was also retrospectively requested for all serogroup B cases confirmed in Suffolk during 2009. Extensive investigation failed to establish an epidemiological link among the cluster of fatal cases of serogroup B invasive meningococcal disease in Suffolk. By demonstrating a number of distinct strains, the genosubtyping of isolates proved to be useful in the public health management of this incident by serving to exclude a community outbreak and preventing unnecessary mass chemoprophylaxis.

Usefulness of porA sequencing in distinguishing sporadic and linked cases of serogroup B invasive meningococcal disease in Suffolk, United Kingdom, December 2009 to January 2010

A cluster of three fatal cases of invasive meningococcal disease due to Neisseria meningitidis serogroup B in a town in Suffolk, United Kingdom, during December 2009 to January 2010 was reported to the local Health Protection Unit. This paper describes the investigation undertaken to identify any potential epidemiological links among the cases, to determine if this was an outbreak and to consider whether to implement community-wide interventions and control measures. Case epidemiological information in addition to serogroup and genosubtyping (porA gene sequencing) data of the infecting organism was gathered on all cases in this reported cluster. Genosubtyping was also retrospectively requested for all serogroup B cases confirmed in Suffolk during 2009. Extensive investigation failed to establish an epidemiological link among the cluster of fatal cases of serogroup B invasive meningococcal disease in Suffolk. By demonstrating a number of distinct strains, the genosubtyping of isolates proved to be useful in the public health management of this incident by serving to exclude a community outbreak and preventing unnecessary mass chemoprophylaxis.

Recognition of skin malignancy by general practitioners: observational study using data from a population-based randomised controlled trial

Skin malignancy is an important cause of mortality in the United Kingdom and is rising in incidence every year. Most skin cancer presents in primary care, and an important determinant of outcome is initial recognition and management of the lesion. Here we present an observational study of interobserver agreement using data from a population-based randomised controlled trial of minor surgery. Trial participants comprised patients presenting in primary care and needing minor surgery in whom recruiting doctors felt to be able to offer treatment themselves or to be able to refer to a colleague in primary care. They are thus relatively unselected. The skin procedures undertaken in the randomised controlled trial generated 491 lesions with a traceable histology report: 36 lesions (7%) from 33 individuals were malignant or pre-malignant. Chance-corrected agreement (κ) between general practitioner (GP) diagnosis of malignancy and histology was 0.45 (0.36–0.54) for lesions and 0.41 (0.32–0.51) for individuals affected with malignancy. Sensitivity of GPs for the detection of malignant lesions was 66.7% (95% confidence interval (CI), 50.3–79.8) for lesions and 63.6% (95% CI, 46.7–77.8) for individuals affected with malignancy. The safety of patients is of paramount importance and it is unsafe to leave the diagnosis and treatment of potential skin malignancy in the hands of doctors who have limited training and experience. However, the capacity to undertake all of the minor surgical demand works demanded in hospitals does not exist. If the capacity to undertake it is present in primary care, then the increased costs associated with enhanced training for general medical practitioners (GPs) must be borne.

A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial

OBJECTIVE

To determine whether there is equivalence in the competence of GPs and hospital doctors to perform a range of elective minor surgical procedures, in terms of the safety, quality and cost of care.

DESIGN

A prospective randomised controlled equivalence trial was undertaken in consenting patients presenting at general practices and needing minor surgery.

SETTING

The study was conducted in the south of England.

PARTICIPANTS

Consenting patients presenting at general practices who needed minor surgery in specified categories for whom the recruiting doctor felt able to offer treatment or to be able to refer to a colleague in primary care.

INTERVENTIONS

On presentation to their GP, patients were randomised to either treatment within primary care or treatment at their local hospital. Evaluation was by assessment of clinical quality and safety of outcome, supplemented by examination of patient satisfaction and cost-effectiveness.

MAIN OUTCOME MEASURES

Two independent observers assessed surgical quality by blinded assessment of wound appearance, between 6 and 8 weeks postsurgery, from photographs of wounds. Other measures included satisfaction with care, safety of surgery in terms of recognition of and appropriate treatment of skin malignancies, and resource use and implications.

RESULTS

The 568 patients recruited (284 primary care, 284 hospital) were randomised by 82 GPs. In total, 637 skin procedures plus 17 ingrowing toenail procedures were performed (313 primary care, 341 hospital) by 65 GPs and 60 hospital doctors. Surgical quality was assessed for 273 (87%) primary care and 316 (93%) hospital lesions. Mean visual analogue scale score in hospital was significantly higher than that in primary care [mean difference=5.46 on 100-point scale; 95% confidence interval (CI) 0.925 to 9.99], but the clinical importance of the difference was uncertain. Hospital doctors were better at achieving complete excision of malignancies, with a difference that approached statistical significance [7/16 GP (44%) versus 15/20 hospital (75%), chi(2)=3.65, p=0.056]. The proportion of patients with post-operative complications was similar in both groups. The mean cost for hospital-based minor surgery was 1222.24 pounds and for primary care 449.74 pounds. Using postoperative complications as an outcome, both effectiveness and costs of the alternative interventions are uncertain. Using completeness of excision of malignancy as an outcome, hospital minor surgery becomes more cost-effective. The 705 skin procedures undertaken in this trial generated 491 lesions with a traceable histology report: 36 lesions (7%) from 33 individuals were malignant or premalignant. Chance-corrected agreement (kappa) between GP diagnosis of malignancy and histology was 0.45 (95% CI 0.36 to 0.54) for lesions and 0.41 (95% CI 0.32 to 0.51) for individuals affected by malignancy. Sensitivity of GPs for detection of malignant lesions was 66.7% (95% CI 50.3 to 79.8) for lesions and 63.6% (95% CI 46.7 to 77.8) for individuals affected by malignancy.

CONCLUSIONS

The quality of minor surgery carried out in general practice is not as high as that carried out in hospital, using surgical quality as the primary outcome, although the difference is not large. Patients are more satisfied if their procedure is performed in primary care, largely because of convenience. However, there are clear deficiencies in GPs' ability to recognise malignant lesions, and there may be differences in completeness of excision when compared with hospital doctors. The safety of patients is of paramount importance and this study does not demonstrate that minor surgery carried out in primary care is safe as it is currently practised. There are several alternative models of minor surgery provision worthy of consideration, including ones based in primary care that require all excised tissue to be sent for histological examination, or that require further training of GPs to undertake the necessary work. The results of this study suggest that a hospital-based service is more cost-effective. It must be concluded that it is unsafe to leave minor surgery in the hands of doctors who have never been trained to do it. Further work is required to determine GPs' management of a range of skin conditions (including potentially life-threatening malignancies), rather than just their recognition of them. Further economic modelling work is required to look at the potential costs of training sufficient numbers of GPs and GPs with special interests to meet the demand for minor surgery safely in primary care, and of the alternative of transferring minor surgery large-scale to the hospital sector. Different models of provision need thorough testing before widespread introduction.