South West Public Health Observatory

Bristol, United Kingdom

South West Public Health Observatory

Bristol, United Kingdom
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Murtagh F.E.M.,King's College London | Bausewein C.,Ludwig Maximilians University of Munich | Verne J.,South West Public Health Observatory | Iris Groeneveld E.,King's College London | And 2 more authors.
Palliative Medicine | Year: 2014

Background: Understanding the need for palliative care is essential in planning services. Aim: To refine existing methods of estimating population-based need for palliative care and to compare these methods to better inform their use. Design: (1) Refinement of existing population-based methods, based on the views of an expert panel, and (2) application/comparison of existing and refined approaches in an example dataset. Existing methods vary in approach and in data sources. (a) Higginson used cause of death/symptom prevalence, and using pain prevalence, estimates that 60.28% (95% confidence interval = 60.20%-60.36%) of all deaths need palliative care, (b) Rosenwax used the International Statistical Classification of Diseases and Related Health Problems-10th Revision (ICD-10) causes of death/hospital-use data, and estimates that 37.01% (95% confidence interval = 36.94%-37.07%) to 96.61% (95% confidence interval = 96.58%-96.64%) of deaths need palliative care, and (c) Gómez-Batiste used percentage of deaths plus chronic disease data, and estimates that 75% of deaths need palliative care. Setting/participants: All deaths in England, January 2006-December 2008, using linked mortality and hospital episode data. Results: Expert panel review identified changing practice (e.g. extension of palliative care to more non-cancer conditions), changing patterns of hospital/home care and multiple, rather than single, causes of death as important. We therefore refined methods (using updated ICD-10 causes of death, underlying/contributory causes, and hospital use) to estimate a minimum of 63.03% (95% confidence interval = 62.95%-63.11%) of all deaths needing palliative care, with lower and upper mid-range estimates between 69.10% (95% confidence interval = 69.02%-69.17%) and 81.87% (95% confidence interval = 81.81%-81.93%). Conclusions: Death registration data using both underlying and contributory causes can give reliable estimates of the populationbasedneed for palliative care, without needing symptom or hospital activity data. In high-income countries, 69%-82% of those who die need palliative care. © 2013 The Author(s).

Gao W.,King's College London | Ho Y.K.,King's College London | Verne J.,South West Public Health Observatory | Glickman M.,Office for National Statistics - ONS | Higginson I.J.,King's College London
PLoS Medicine | Year: 2013

Background: Most patients with cancer prefer to die at home or in a hospice, but hospitals remain the most common place of death (PoD).This study aims to explore the changing time trends of PoD and the associated factors, which are essential for end-of-life care improvement. Methods and Findings: The study analysed all cancer deaths in England collected by the Office for National Statistics during 1993-2010 (n = 2,281,223). Time trends of age- and gender-standardised proportion of deaths in individual PoDs were evaluated using weighted piecewise linear regression. Variables associated with PoD (home or hospice versus hospital) were determined using proportion ratio (PR) derived from the log-binomial regression, adjusting for clustering effects. Hospital remained the most common PoD throughout the study period (48.0%; 95% CI 47.9%-48.0%), followed by home (24.5%; 95% CI 24.4%-24.5%), and hospice (16.4%; 95% CI 16.3%-16.4%). Home and hospice deaths increased since 2005 (0.87%; 95% CI 0.74%-0.99%/year, 0.24%; 95% CI 0.17%-0.32%/year, respectively, p<0.001), while hospital deaths declined (-1.20%; 95% CI -1.41 to -0.99/year, p<0.001). Patients who died from haematological cancer (PRs 0.46-0.52), who were single, widowed, or divorced (PRs 0.75-0.88), and aged over 75 (PRs 0.81-0.84 for 75-84; 0.66-0.72 for 85+) were less likely to die in home or hospice (p<0.001; reference groups: colorectal cancer, married, age 25-54). There was little improvement in patients with lung cancer of dying in home or hospice (PRs 0.87-0.88). Marital status became the second most important factor associated with PoD, after cancer type. Patients from less deprived areas (higher quintile of the deprivation index) were more likely to die at home or in a hospice than those from more deprived areas (lower quintile of the deprivation index; PRs 1.02-1.12). The analysis is limited by a lack of data on individual patients' preferences for PoD or a clinical indication of the most appropriate PoD. Conclusions: More efforts are needed to reduce hospital deaths. Health care facilities should be improved and enhanced to support the increased home and hospice deaths. People who are single, widowed, or divorced should be a focus for end-of-life care improvement, along with known at risk groups such as haematological cancer, lung cancer, older age, and deprivation. Please see later in the article for the Editors' Summary. © 2013 Gao et al.

Sleeman K.E.,King's College London | Ho Y.K.,King's College London | Verne J.,South West Public Health Observatory | Glickman M.,Office for National Statistics - ONS | And 3 more authors.
Palliative Medicine | Year: 2013

Background: Little is known about place of death in chronic neurological diseases. Mortality statistics are ideal for examining trends in place of death, but analyses are limited by coding rule changes. Aim: To examine the relationship between place of death and underlying cause of death in Parkinson's disease, multiple sclerosis and motor neurone disease and the impact of coding rule changes on analysis of place of death. Design: Population-based study. Proportion ratios for death in hospice, home, care home and hospital were calculated according to underlying cause of death, using multivariable Poisson regression. Participants: Deaths in England (1993-2010) with any mention of Parkinson's disease, multiple sclerosis or motor neurone disease as a cause of death, identified from national mortality data. Results: In this study, 125,242 patients with Parkinson's disease, 23,501 with multiple sclerosis, and 27,030 with motor neurone disease were included. Home deaths ranged from 9.7% (Parkinson's disease) to 27.1% (motor neurone disease), hospice deaths ranged from 0.6% (Parkinson's disease) to 11.2% (motor neurone disease) and hospital deaths ranged from 43.4% (Parkinson's disease) to 55.8% (multiple sclerosis). In Parkinson's disease and multiple sclerosis, cancer as underlying cause of death increased likelihood of hospice death (proportion ratio (PR): 18.8, 95% confidence interval (CI) = 16.1-22.0; 8.88, 95% CI = 7.49-10.5) and home death (PR: 1.91, 95% CI = 1.80-2.04; 1.71, 95% CI = 1.56-1.88). Dementia as underlying cause of death increased likelihood of care home death in Parkinson's disease (PR: 1.25, 95% CI = 1.19-1.32), multiple sclerosis (PR: 1.73, 95% CI = 1.22-2.45) and motor neurone disease (PR: 2.36, 95% CI = 1.31-4.27). Conclusions: Underlying cause of death has a marked effect on place of death. The effects of coding rule changes are an essential consideration for all research using underlying cause of death to study place of death. © The Author(s) 2013.

Vesey S.G.,University of Liverpool | McCabe J.E.,University of Liverpool | Hounsome L.,South West Public Health Observatory | Fowler S.,British Association of Urological Surgeons
BJU International | Year: 2012

OBJECTIVE To undertake a detailed analysis of the British Association of Urological Surgeons (BAUS) Section of Oncology Complex Operations Database to report UK outcomes of radical prostatectomy (RP) with particular reference to the case volume of the operating surgeon. MATERIALS AND METHODS All RP entries on the BAUS complex operations database were extracted from its commencement in January 2004 to September 2009. Patient age, prostate-specific antigen (PSA) levels, clinical tumour stage and biopsy Gleason score were analyzed together with operative variables, including the surgical approach, lymphadenectomy status, blood loss, hospital length of stay and individual surgeon case volume. The postoperative variables assessed included surgical specimen Gleason score and pathological tumour stage, prostate weight and the presence of positive surgical margins (PSM), as well as evidence of biochemical recurrence. RESULTS A total of 8032 RP cases were entered on the database and Follow-up data was available on 4206 cases. Mean patient age was 61.8 years and the mean presenting PSA was 8.3 ng/mL. Open RP procedures were performed on 5429 patients and laparoscopic RP on 2219. The positive surgical margin (PSM) rate for the entire series was 38%. Analysis of PSM by pathological stage revealed a pT2 PSM rate of 24%. Multivariate analysis of variables which might affect PSM revealed pre-operative clinical TNM stage, surgeon case volume, RP specimen Gleason score and pathological TNM stage were significant parameters (P < 0.01). When prostate weight and PSM status were analysed, these was a significant association between smaller prostate weight and PSM status. Interestingly, 45% of high grade Gleason 8-10 needle biopsy cancers were downgraded to Gleason scores 7 or less on RP analysis. Analysis of annual surgeon caseload revealed that 54% of surgeons performed an average of less than 10 procedures per annum and 6% of surgeons performed an average of 30 or more procedures per annum. When individual outcome variables where examined against surgeon case activity it was demonstrated that outcomes are clearly improved beyond 20 cases and there is a trend to continued improvement up to the series maximum of 40 cases per annum. CONCLUSIONS High volume surgeons have less peri-operative and postoperative complications and better surgical and disease-free outcomes than low volume surgeons. In the UK, raising the current minimum Improving Outcomes Guidance threshold from five RP cases per surgeon per annum to no less than 20 (and ideally to 35 or more cases per annum) could potentially improve overall outcomes. © 2011 BJU International.

Boustead G.B.,Lister Hospital Hertfordshire | Fowler S.,BAUS Section of Oncology | Swamy R.,Lister Hospital Hertfordshire | Kocklebergh R.,Leicester General Hospital | Hounsome L.,South West Public Health Observatory
BJU International | Year: 2014

Objective To investigate Tumour-Node-Metastasis (TNM) stage and demographics at presentation in a very large, contemporary UK cohort of patients with bladder cancer and compare them with other published series, as little published data exists on the pathological characteristics of bladder cancer at presentation. Patients and Methods The British Association of Urological Surgeons (BAUS) Section of Oncology started a new urological tumour registry in 1998. We performed a data analysis of all bladder cancer cases between 1999 and 2008. Tumour TNM stage, grade and histopathological diagnosis were reviewed along with standard epidemiological data. Results In all, 69=712 bladder cancer registrations were recorded. Complete T, N and M stage and grade was available for 32=240 patients. The male to female ratio of the study population was 3:1 and the overall median (sd, range) age at presentation was 73 (11.6, 6-108) years. Final pathological T staging showed that non-muscle-invasive bladder cancer accounted for 75% of cases with the remaining 25% being muscle-invasive disease. Of these patients, 8% had nodal disease and 4% other metastatic sites at presentation. The tumour grade was G1-2 in 65% and G3 in 35% of cases. Transitional cell carcinoma (TCC) accounted for 92%, squamous cell carcinoma and adenocarcinomas 1.5% each, with 5% other histological variants. Conclusions Non-muscle-invasive TCC accounted for 75% of bladder cancer cases in the UK. The 1973 World Health Organization classification remains in widespread use amongst pathologists in the UK. Obtaining complete and standardised staging and pathology reporting systems in bladder cancer remains a challenge. © 2013 The Authors. BJU International © 2013 BJU International.

Kemp G.A.,University of the West of England | Eagle L.,University of the West of England | Verne J.,South West Public Health Observatory
Health Promotion International | Year: 2011

The role of the mass media in communicating health-related information to the wider population is the focus of this paper. Using the example of sun protection within the UK, we highlight some of the major challenges to raising awareness of steadily increasing melanoma rates and of effective sun protection strategies. The implications of potential barriers to official sun protection messages via conflicting messages in the media are discussed in terms of editorial on sun protection and in the way in which television programme content portrays the issues. Implications for public policy and future research conclude the paper. © The Author (2010).

McKenzie F.,Massey University | Ives A.,South West Public Health Observatory | Jeffreys M.,University of Bristol
European Journal of Public Health | Year: 2012

Background: Socio-economic inequalities in breast cancer survival have been reported worldwide, but whether these exist in screen detected as well as symptomatic women has not been established. Making this distinction will allow inferences about the relative contributions of pre-and post-diagnostic delay to these inequalities. Methods: Screening-eligible women diagnosed with breast cancer in South West England (2002-06) were followed-up to 2007. Five-year relative survival ratios (RSRs) were calculated for each deprivation quintile, using deprivation-specific life-tables and a period approach. The 'deprivation gap' in survival was calculated as the slope index of inequality between least and most deprived women. Results: The study included 11018 women, of whom 1176 died during follow-up. Screening status of 54 of women was missing. A clear gradient in survival across deprivation groups ranged from 83.6 [95 confidence interval (CI) 80.0, 86.6] in the most deprived to 90.8 (95 CI 89.0, 92.3) in the least deprived group. Comparing the most deprived to least deprived women, the estimated deprivation gap was -9.42 (95 CI -12.80, -6.04, P=0.003). Among screen-detected women, inequalities were attenuated, but persisted, ranging from 95.6 (95 CI 90.6, 98.0) in the most deprived to 98.2 (95 CI 95.9, 99.2) in least deprived; the estimated deprivation gap was -3.03 (95 CI -5.75, -0.85, P=0.023). Conclusion: The deprivation gap in survival does not appear as marked with screen-detected breast cancer as the other groups, though still apparent. Efforts to eliminate inequalities should consider both increasing breast screening participation and ensuring equal access through secondary care systems for women of lower socio-economic position. © The Author 2011. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

Elliss-Brookes L.,Avon | McPhail S.,Network Intelligence | Ives A.,South West Public Health Observatory | Greenslade M.,South West Public Health Observatory | And 3 more authors.
British Journal of Cancer | Year: 2012

Background: Cancer survival in England is lower than the European average, which has been at least partly attributed to later stage at diagnosis in English patients. There are substantial regional and demographic variations in cancer survival across England. The majority of patients are diagnosed following symptomatic or incidental presentation. This study defines a methodology by which the route the patient follows to the point of diagnosis can be categorised to examine demographic, organisational, service and personal reasons for delayed diagnosis. Methods: Administrative Hospital Episode Statistics data are linked with Cancer Waiting Times data, data from the cancer screening programmes and cancer registration data. Using these data sets, every case of cancer registered in England, which was diagnosed in 2006-2008, is categorised into one of eight Routes to Diagnosis. Results: Different cancer types show substantial differences between the proportion of cases that present by each route, in reasonable agreement with previous clinical studies. Patients presenting via Emergency routes have substantially lower 1-year relative survival. Conclusion: Linked cancer registration and administrative data can be used to robustly categorise the route to a cancer diagnosis for all patients. These categories can be used to enhance understanding of and explore possible reasons for delayed diagnosis. © 2012 Cancer Research UK.

Abel J.,Weston Area Health Trust and Weston Hospicecare | Pring A.,South West Public Health Observatory | Rich A.,Weston Area Health Trust and Weston Hospicecare | Malik T.,South West Public Health Observatory | Verne J.,South West Public Health Observatory
BMJ Supportive and Palliative Care | Year: 2013

Objectives: There is limited evidence of the impact of advance care planning (ACP) on outcomes. We conducted a retrospective cohort study on deaths of all patients known to a hospice in a 2.5-year period to see if use of ACP affected actual place of death, hospital use and cost of hospital care in the last year. Results: 969 patients were included. 550 (57%) people completed ACP. 414 (75%) achieved their choice of place of death. For those who chose home, 34 (11.3%) died in hospital; a care home 2 (1.7%) died in hospital; a hospice 14 (11.2%) died in hospital and 6 (86%) who chose to die in hospital did so. 112 (26.5%) of people without ACP died in hospital. Mean number of days in hospital in the last year of life was 18.1 in the ACP group and 26.5 in the non-ACP group (p<0.001). Mean cost of hospital treatment during the last year of life for those who died in hospital was £11,299, those dying outside of hospital £7,730 (p<0.001). Mean number of emergency admissions for those who died in hospital was 2.2 and who died elsewhere was 1.7 (p<0.001). Conclusions: ACP can be used routinely in a hospice setting. Those who used ACP spent less time in hospital in their last year. ACP is associated with a reduction in the number of days in hospital in the last year of life with less hospital costs, supporting the assumptions made in the End of Life Care Strategy 2008.

Sims M.,University of Bath | Maxwell R.,South West Public Health Observatory | Gilmore A.,University of Bath
Thorax | Year: 2013

Background Comprehensive smokefree laws have now been introduced in several jurisdictions. Few studies have examined the association between smokefree laws and asthma in adults and these have limitations, such as lacking appropriate adjustment for long-term trends or having limited statistical power due to small study populations. This study addresses these limitations and evaluates the short-term impact of smokefree legislation in England. It aims to investigate whether the introduction of smokefree legislation on 1 July 2007 was associated with an immediate reduction in emergency hospital admissions for asthma in the adult population, and whether any association differs across regions. Methods We identified monthly numbers of emergency admissions for asthma ( primary diagnosis, 10th revision of the International Classification of Diseases code J45 and J46) in the nine Government Office Regions from April 1997 to December 2010 in the population aged 16 and over. A generalised additive model was fitted that adjusted for seasonality, variation in population size and region-specific, non-linear, long-term trends. Results Smokefree legislation was associated with an immediate 4.9% (95% CI 0.6% to 9.0%) reduction in emergency admissions for asthma in the adult population. This implies that approximately 1900 emergency admissions for asthma were prevented in each of the first 3 years after legislation was introduced. The reduction in admissions did not vary significantly across regions. Conclusions Our findings add to the expanding body of evidence that smokefree policies are associated with positive health outcomes. Further research evaluating the impact of legislation in other jurisdictions is needed to support these findings.

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