Costs of healthy living for older adults: the need for dynamic measures of health-related poverty to support evidence-informed policy-making and real-time decision-making

OBJECTIVES

This study aimed to examine the dynamic properties of the costs of healthy living for older adults and to compare these costs to the timing and levels of Pension Credit for older adults on low incomes.

STUDY DESIGN

This was a longitudinal descriptive study.

METHODS

We used monthly inflation data and the concept of a 'Minimum Income for Healthy Living' (MIHL) to estimate the dynamic changes in MIHL from 2003 to 2022 and compared these costs with Pension Credit levels for older adults on low incomes.

RESULTS

Progress in closing the gap between the MIHL and Pension Credit has been reversed by recent sharp increases in costs. From April 2021 to April 2022, the MIHL for single older adults rose from £5.57 per week below to £8.29 per week above Pension Credit levels.

CONCLUSIONS

There is a need for dynamic measures of health-related poverty to support evidence-informed policy-making and real-time decision-making to mitigate the health impacts on older adults.

The ORNATE India Project: United Kingdom-India Research Collaboration to tackle visual impairment due to diabetic retinopathy

INTRODUCTION

The ORNATE India project is funded by the UK Research and Innovation (UKRI) through the Global Challenges Research Fund. The aim is to build research capacity and capability in India and the UK to tackle global burden of diabetes-related visual impairment. As there are over 77 million people with diabetes in India, it is challenging to screen every person with diabetes annually for sight-threatening diabetic retinopathy (DR). Therefore, alternate safe approaches need to be developed so that those at-risk of visual impairment due to DR is identified promptly and treated.

METHODS

The project team utilised diverse global health strategies and research methods to co-design work packages to build research capacity and capability to ensure effective, affordable and efficient DR services are made available for the population. The strategies and methods employed included health system strengthening; implementation science; establishing care pathways; co-designing collaborative studies on affordable technologies, developing quality standards and guidelines to decrease variations in care; economic analysis; risk modelling and stratification. Five integrated work packages have been developed to deal with all aspects of DR care. These included implementation of a DR screening programme in the public health system in a district in Kerala, evaluating regional prevalence of diabetes and DR and assessing ideal tests for holistic screening for diabetes and its complications in 20 areas in India, utilising artificial intelligence on retinal images to facilitate DR screening, exploring biomarker and biosensor research to detect people at risk of diabetes complications, estimating cost of blindness in India and risk modelling to develop risk-based screening models for diabetes and its complications. A large collaborative network will be formed to propagate research, promote shared learning and bilateral exchanges between high- and middle-income countries to tackle diabetes-related blindness.

Allergen immunotherapy for allergic asthma: A systematic review and meta-analysis

BACKGROUND

To inform the development of the European Academy of Allergy and Clinical Immunology's (EAACI) Guidelines on Allergen Immunotherapy (AIT) for allergic asthma, we assessed the evidence on the effectiveness, cost-effectiveness and safety of AIT.

METHODS

We performed a systematic review, which involved searching nine databases. Studies were screened against predefined eligibility criteria and critically appraised using established instruments. Data were synthesized using random-effects meta-analyses.

RESULTS

98 studies satisfied the inclusion criteria. Short-term symptom scores were reduced with a standardized mean difference (SMD) of -1.11 (95% CI -1.66, -0.56). This was robust to a prespecified sensitivity analyses, but there was evidence suggestive of publication bias. Short-term medication scores were reduced SMD -1.21 (95% CI -1.87, -0.54), again with evidence of potential publication bias. There was no reduction in short-term combined medication and symptom scores SMD 0.17 (95% CI -0.23, 0.58), but one study showed a beneficial long-term effect. For secondary outcomes, subcutaneous immunotherapy (SCIT) improved quality of life and decreased allergen-specific airway hyperreactivity (AHR), but this was not the case for sublingual immunotherapy (SLIT). There were no consistent effects on asthma control, exacerbations, lung function, and nonspecific AHR. AIT resulted in a modest increased risk of adverse events (AEs). Although relatively uncommon, systemic AEs were more frequent with SCIT; however no fatalities were reported. The limited evidence on cost-effectiveness was mainly available for sublingual immunotherapy (SLIT) and this suggested that SLIT is likely to be cost-effective.

CONCLUSIONS

AIT can achieve substantial reductions in short-term symptom and medication scores in allergic asthma. It was however associated with a modest increased risk of systemic and local AEs. More data are needed in relation to secondary outcomes, longer-term effectiveness and cost-effectiveness.

Allergen immunotherapy for allergic rhinoconjunctivitis: A systematic review and meta-analysis

BACKGROUND

The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing Guidelines on Allergen Immunotherapy (AIT) for Allergic Rhinoconjunctivitis. To inform the development of clinical recommendations, we undertook a systematic review to assess the effectiveness, cost-effectiveness, and safety of AIT in the management of allergic rhinoconjunctivitis.

METHODS

We searched nine international biomedical databases for published, in-progress, and unpublished evidence. Studies were independently screened by two reviewers against predefined eligibility criteria and critically appraised using established instruments. Our primary outcomes of interest were symptom, medication, and combined symptom and medication scores. Secondary outcomes of interest included cost-effectiveness and safety. Data were descriptively summarized and then quantitatively synthesized using random-effects meta-analyses.

RESULTS

We identified 5960 studies of which 160 studies satisfied our eligibility criteria. There was a substantial body of evidence demonstrating significant reductions in standardized mean differences (SMD) of symptom (SMD -0.53, 95% CI -0.63, -0.42), medication (SMD -0.37, 95% CI -0.49, -0.26), and combined symptom and medication (SMD -0.49, 95% CI -0.69, -0.30) scores while on treatment that were robust to prespecified sensitivity analyses. There was in comparison a more modest body of evidence on effectiveness post-discontinuation of AIT, suggesting a benefit in relation to symptom scores.

CONCLUSIONS

AIT is effective in improving symptom, medication, and combined symptom and medication scores in patients with allergic rhinoconjunctivitis while on treatment, and there is some evidence suggesting that these benefits are maintained in relation to symptom scores after discontinuation of therapy.

Allergen immunotherapy for insect venom allergy: a systematic review and meta-analysis

BACKGROUND

The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing the EAACI Guidelines on Allergen Immunotherapy (AIT) for the management of insect venom allergy. To inform this process, we sought to assess the effectiveness, cost-effectiveness and safety of AIT in the management of insect venom allergy.

METHODS

We undertook a systematic review, which involved searching 15 international biomedical databases for published and unpublished evidence. Studies were independently screened and critically appraised using established instruments. Data were descriptively summarized and, where possible, meta-analysed.

RESULTS

Our searches identified a total of 16 950 potentially eligible studies; of which, 17 satisfied our inclusion criteria. The available evidence was limited both in volume and in quality, but suggested that venom immunotherapy (VIT) could substantially reduce the risk of subsequent severe systemic sting reactions (OR = 0.08, 95% CI 0.03-0.26); meta-analysis showed that it also improved disease-specific quality of life (risk difference = 1.41, 95% CI 1.04-1.79). Adverse effects were experienced in both the build-up and maintenance phases, but most were mild with no fatalities being reported. The very limited evidence found on modelling cost-effectiveness suggested that VIT was likely to be cost-effective in those at high risk of repeated systemic sting reactions and/or impaired quality of life.

CONCLUSIONS

The limited available evidence suggested that VIT is effective in reducing severe subsequent systemic sting reactions and in improving disease-specific quality of life. VIT proved to be safe and no fatalities were recorded in the studies included in this review. The cost-effectiveness of VIT needs to be established.

Can sleep disturbance influence changes in mental health status? Longitudinal research evidence from ageing studies in England and Japan

BACKGROUND

Little is known about the role of sleep disturbance in relation to changes in depressive states. We used data obtained from the participants aged 65 and over in the English Longitudinal Study of Ageing (ELSA, waves four and five, N = 3108) and the Japan Gerontological Evaluation Study (JAGES, 2010 and 2013 sweeps, N = 7527) to examine whether sleep disturbance is longitudinally associated with older adults' patterns of depressive states.

METHODS

We created four patterns of depressive states (non-case, recovered, onset, repeatedly depressive) by combining responses to the measures (scoring four or more on seven items from the Center for Epidemiological Studies Depression Scale for the ELSA participants and scoring five or more for the Geriatric Depression Scale-15 for the JAGES participants) obtained at the baseline and follow-up. Sleep disturbance was assessed through responses to three questions on sleep problems. Age, sex, partnership status, household equivalised income, alcohol and cigarette use, and physical function were treated as confounders in this study. Additionally, information on sleep medication was available in JAGES and was included in the statistical models.

RESULTS

More ELSA participants were non-depressive cases and reported no sleep disturbances compared with the JAGES participants. Findings from multinomial logistic regression analysis showed that more sleep disturbance was associated with the onset group in ELSA (RRR = 2.37, 95% CI = 1.44-3.90) and JAGES (RRR = 2.41, 95% CI = 1.79-3.25) as well as the recovery (RRR = 3.42, 95% CI = 1.98-5.90, RRR = 2.71, 95% CI = 1.95-3.75) and repeatedly depressed group (RRR = 7.24, 95% CI = 3.91-13.40, RRR = 5.16, 95% CI = 3.82-6.98).

CONCLUSIONS

Findings suggest that the association between sleep disturbance and depression in older adults is complex.

Remarriage after divorce and depression risk

As marriage is associated with lower depression rates compared with being single in men, we aimed to examine if remarriage compared with remaining divorced is also associated with a reduced depression risk. Swedish register data were used to define a cohort of men who were born between 1952 and 1956 and underwent a compulsory military conscription assessment in adolescence. This study population comprised men who were divorced in 1985 (n = 72,246). The risk of pharmaceutically treated depression from 2005 to 2009 was compared for those who remarried or remained divorced between 1986 and 2004. Cox proportional hazards analysis was used to estimate hazard ratios for the risk of depression identified by pharmaceutical treatment, with adjustment for a range of potential confounding factors including childhood and adulthood socioeconomic circumstances, cognitive, physical, psychological and medical characteristics at the conscription assessment. The results showed that, even though divorced men who remarried had markers of lower depression risk in earlier life such as higher cognitive and physical function, higher stress resilience and socioeconomic advantages than men who remained divorced, remarriage was associated with a statistically significant elevated risk of depression with an adjusted hazard ratio (and 95% confidence interval) of 1.27(1.03 1.55), compared with men who remained divorced. Remarriage following divorce is not associated with a reduced risk of depression identified by pharmaceutical treatment, compared with remaining divorced. Interpersonal or financial difficulties resulting from remarriage may outweigh the benefits of marriage in terms of depression risk.

Clustering of lifestyle risk behaviours among residents of forty deprived neighbourhoods in London: lessons for targeting public health interventions

BACKGROUND

Clustering of lifestyle risk behaviours is very important in predicting premature mortality. Understanding the extent to which risk behaviours are clustered in deprived communities is vital to most effectively target public health interventions.

METHODS

We examined co-occurrence and associations between risk behaviours (smoking, alcohol consumption, poor diet, low physical activity and high sedentary time) reported by adults living in deprived London neighbourhoods. Associations between sociodemographic characteristics and clustered risk behaviours were examined. Latent class analysis was used to identify underlying clustering of behaviours.

RESULTS

Over 90% of respondents reported at least one risk behaviour. Reporting specific risk behaviours predicted reporting of further risk behaviours. Latent class analyses revealed four underlying classes. Membership of a maximal risk behaviour class was more likely for young, white males who were unable to work.

CONCLUSIONS

Compared with recent national level analysis, there was a weaker relationship between education and clustering of behaviours and a very high prevalence of clustering of risk behaviours in those unable to work. Young, white men who report difficulty managing on income were at high risk of reporting multiple risk behaviours. These groups may be an important target for interventions to reduce premature mortality caused by multiple risk behaviours.

Development of a social morbidity score in patients with chronic ulcerative colitis as a potential guide to treatment

AIM

Present quality of life instruments for inflammatory bowel disease do not evaluate many social aspects of patients' lives that are potentially important in clinical decision making. We have developed a new Social Impact of Chronic Conditions - Inflammatory Bowel Disease (SICC-IBD) questionnaire to assess these areas.

METHOD

A 34-item questionnaire was piloted to determine quality of life relating to education, personal relationships, employment, independence and finance. It was compared with the Short Form 36-Item version 2 (SF-36v2) and the Inflammatory Bowel Disease Questionnaire (IBDQ) in 150 patients with chronic ulcerative colitis on an endoscopic surveillance register who had never had surgery.

RESULTS

Reliability and validity testing enabled the questionnaire to be shortened to only eight items. There was a high level of reliability (Cronbach's α=0.72). The questionnaire correlated well with the social functioning domain of the SF-36 (rs=0.56) and was able to distinguish clinical severity of disease.

CONCLUSION

The SICC-IBD is a new tool for assessment of patients with ulcerative colitis, which has identified new aspects of social disability for further study and for potential use as an additional tool in therapy decisions.

Obesity and intermediate clinical outcomes in diabetes: evidence of a differential relationship across ethnic groups

AIM

To examine associations between obesity, ethnicity and intermediate clinical outcomes in diabetes.

METHODS

Population-based, cross-sectional study using electronic primary care medical records of 7300 people with diabetes from White, Black and south Asian ethnic groups.

RESULTS

The pattern of obesity differed within ethnic groups, with rates significantly higher in younger when compared to older Black (women, 63% vs. 44%, P = 0.002; men, 37% vs. 20%, P = 0.005) and south Asian (women, 47% vs. 27%, P = 0.01; men, 21% vs. 13%, P = 0.05) people. Obese people with diabetes were significantly less likely to achieve an established target for blood pressure control (adjusted odds ratio 0.50, 95% confidence interval 0.42, 0.59). Differences in mean systolic blood pressure in obese and normal weight persons were significant in the White group but not in the Black groups or south Asian groups (6.9 mmHg, 1.9 mmHg and 2.7 mmHg, respectively). Differences in mean diastolic blood pressure between obese and normal weight persons were 4.8 mmHg, 3.6 mmHg and 3.4 mmHg in the White, Black and south Asian groups. Mean HbA(1c) and achievement of an established treatment target did not differ significantly with obesity in any ethnic group.

CONCLUSIONS

Obesity is more prevalent amongst younger people than older people with diabetes in ethnic minority groups. The relationship between obesity and blood pressure control in diabetes differs markedly across ethnic groups. Major efforts must be implemented, especially in young people, to reduce levels of obesity in diabetes and improve long-term outcomes.

The development of life course epidemiology

The present paper reviews the development of life course epidemiology since its origins during the 1990s from biological programming, birth cohort research and the study of health inequalities. Methods of studying the life course are examined, including birth cohort studies, linked register datasets and epidemiological archaeology. Three models of life course epidemiology are described: critical periods, accumulation, and pathways. Their conceptual and empirical differentiation can be difficult, but it is argued that accumulation is the underlying social process driving life course trajectories, while the critical period and pathway models are distinguished by their concern with specific types of aetiological process. Among the advantages of the accumulation model are predictive power, aetiological insights, contributions to health inequality debates and social policy implications. It is emphasised that the life course approach is not opposed to, or an alternative to, a concern with cross-sectional and current effects; major social disruption can have a large and immediate impact on health. Other limitations of the life course approach include a spectrum of impact (life course effects can be strong in relation to physiology, but often are weaker in relation to behaviour and psychological reactions to everyday life) and, more speculatively, the possibility that life course effects are diluted in the older age groups where morbidity and mortality are highest. Three issues for the future of life course epidemiology are identified. Many life course data are collected retrospectively. We need to know which items of information are recalled with what degree of accuracy over how many decades; and what methods of collecting these retrospective data maximise accuracy and duration. Second, the two partners in life course research need to take more seriously each other's disciplines. Social scientists need to be more critical of such measures as self-assessed health, which lacks an aetiology and hence biological plausibility. Natural scientists need to be more critical of such concepts as socio-economic status, which lacks social plausibility because it fails to distinguish between social location and social prestige. Finally, European comparative studies can play an important part in the future development of life course epidemiology if they build on the emerging infrastructure of European comparative research.

Is opportunistic oral cancer screening by dentists feasible? An analysis of the patterns of dental attendance of a nationally representative sample over 10 years

OBJECTIVES

To assess whether or not opportunistic oral cancer screening by dentists to detect pre-malignant or early cancer lesions is feasible. The objective was to analyse the patterns of dental attendance of a national representative sample over a period of 10 years to ascertain whether individuals at high-risk of oral cancer would be accessible for opportunistic oral cancer screening.

METHODS

Secondary analysis of data extracted from the British Household Panel Survey, a national longitudinal survey (n=5547). Analysis to ascertain whether patterns of attendance for dental check-ups for a period of 10 years (1991-2001) were associated with risk factors for oral cancer such as age, sex, education, social class, smoking status and smoking intensity.

RESULTS

Males, aged over 40 years, less educated manual workers and smokers were significantly less likely to attend for dental check-ups compared with females and younger, higher educated, higher socio-economic class non-smokers (p < 0.05). Throughout the 10-year period, young people, more than older people, had progressively lower odds ratios of attending. Those with more education used dental services more. Heavy smokers were infrequent attendees.

CONCLUSIONS

This study suggests that opportunistic oral cancer screening by dentists is not feasible to include high-risk groups as they are not regular attendees over 10 years. Those who would be screened would be the low-risk groups. However, dentists should continue screening all patients as oral precancers are also found in regular attendees. More should be done to encourage the high-risk groups to visit their dentists.