Max Oscar Bachmann

Objectives: Local public health organisations require information about local variations in healthy life expectancy (HLE) and associated risks to inform decisions about how and where to intervene to improve HLE, a key indicator of population health. We aimed to estimate both HLE and levels of risk in small areas and quantify associations between them. Design: Cross-sectional population-based study. Setting: Norfolk and Waveney Integrated Care System. Population: 128 Middle Layer Super Output Areas and eight Lower Tier Local Authority Areas. Outcome measures: HLE (estimated using self-reported health status from the 2021 UK Census) in each Middle layer Super Output Area and levels of 10 risk factors (selected based on existing evidence of association with lower life expectancy or self-reported health and availability of local risk information): index of multiple deprivation; weekly net income; urban area; diet not meeting five portions of fruit and vegetables on a usual day; physical inactivity; older person living alone; falls admissions rate; alcohol mortality rate; road casualties and air pollution. Main results: HLE in 2021 was 66.5 years for men (range 52–73) and 67.5 years for women (range 56–74). The difference between areas was 21 years for men and 18 years for women. Higher income was strongly associated with all healthy life expectancies: £100 higher weekly income was associated with 4.4 (95% confidence limits 3.5 to 5.2) and 4.6 (3.8 to 5.4) years greater HLE at birth in males and females respectively and with 1.7 (1.3 to 2.2) and 2.0 (1.5 to 2.5) greater HLE at age 65. Higher percentage of older adults living alone was associated with lower HLE at birth in males and females. Physical inactivity was associated with lower HLE at 65 in males and at birth in females. Conclusions: This approach uses standard methods and publicly available data to estimate both HLE and risk exposures in small areas to find areas with low life expectancy and high risks, where local organisations may prioritise the implementation of cost-effective interventions. It could be replicated in other areas to target interventions and inequalities. More accurate data on risk exposures in small areas would allow a broader range of risk factors, including smoking, to be considered.

Background: Improving Access to Psychological Therapies (IAPT), an NHS England service providing talking therapies, is meeting its target recovery rate of 50%. However, engagement in treatment, as well as recovery rates, may be lower for some groups. Aims: To assess variation in treatment completion and recovery rates by demographic and socioeconomic group and to describe rates of further referrals for patients to IAPT and secondary mental health services. Method: Using 121 548 administrative records for 2019–2020 and 2022–2023 for the Norfolk and Waveney area, we estimated associations of age, gender, ethnicity and deprivation with the likelihood of treatment completion and recovery using logistic regression modelling. We also described rates of further referrals. Results: Younger people and those living in deprived areas were less likely to recover or complete treatment, with those aged 16–17 years (n = 735) having the lowest adjusted odds for recovery (adjusted odds ratio = 0.5, 95% CI: 0.5–0.6) compared with those aged 36–70 years, and those aged 18–24 years (n = 23 563) having the lowest rate of completion (adjusted odds ratio = 0.5, 95% CI: 0.5–0.6). Further referrals before April 2022 were recorded for 45.4% of 6513 patients who had completed treatment and 68.8% of 9469 who had not completed treatment, and for 39.4% of 2007 recovered patients in 2019–2020 and 53.1% of 1586 who had not recovered. Non-completers had relatively more further referrals to secondary mental health services compared with completers (43.6% v. 22.8%; P < 0.01). Conclusions: Younger people and those living in deprived areas have lower recovery and completion rates. Those who have completed treatment and not recovered have higher rates of further referrals.

Objective This study explored the attributes of asthma care coordination from the perspective of healthcare professionals at different levels of care in Ecuador. Design Qualitative descriptive study. The Integrated Health Networks Model was the theoretical framework of reference. Narrative analysis was used to identify significant phrases from the interviews. Setting Healthcare professionals involved in the care of patients with asthma in primary care, specialists, emergency and management in three Ecuadorian cities between 2019 and 2021. Participants 25 healthcare professionals participated in semistructured in-depth interviews. Convenience sampling was used. Results Participants highlighted the scarce use of institutional documents for the referral of asthma patients from the first level to specialists and vice versa, duplication of tests and medical prescriptions, and lack of appointment availability that limits access to specialised care. From the first level, they considered that specialists do not return patients and specialists stressed that the first level does not have enough training to follow asthma patients. Managers highlighted the system’s inability to assign appointments on time and failures in administrative processes for follow-up. Emergency professionals did not have access to the medical records of patients suffering from asthma attacks. Conclusions The lack of shared objectives and effective communication between different levels of care for the follow-up of asthma patients were attributes of asthma care coordination perceived by healthcare professionals at different levels of care in Ecuador. The Ecuadorian health system should consider these to improve its performance.

Background: Access to and use of urgent and emergency care in the United Kingdom’s National Health Service reduced during COVID-19 related lockdowns but demand reportedly increased since then. We investigated the impact of COVID-19 on urgent and emergency health care services activity in an eastern England population of 1.1 million. Methods: We used health care activity data from a municipal health department, recorded at the level of discrete events (such as visits to hospital or ambulance calls) to compare system activity between 2018–2020 (pre-COVID), 2020–2021 (lockdown) and 2021–2023 (post-lockdown), carrying out interrupted time series analyses to describe changes in activity. Results: Daily emergency department (ED) attendances were 10% (95% confidence interval 9–12%) lower during the lockdown period, and 7% (6–8%) higher in the post-lockdown period than pre-COVID. Attendances arriving by ambulance were 13% (12–14%) lower post-lockdown than pre-COVID, while attendances of arrivals by other means were 17% (16–19%) higher. Post-lockdown, overall attendances were continually reducing. ED waiting times were 45% (44–47%) longer in the post-lockdown period compared to the pre-COVID period and continued to increase post-lockdown. There was a 15% (14–16%) reduction in daily ambulance dispatches post-lockdown versus pre-COVID. Ambulance arrivals with delayed handover to hospital care exceeding 60 minutes increased by 17% (16–18%) post-lockdown versus pre-COVID, and probability of delay showed a continuously upward trend post-lockdown of 20% (19–21%) per year. Conclusion: Patients are facing long waits in EDs to be admitted to hospital, discharged or transferred. This results in delays in ambulances handing over patients and attending to other calls, which may explain decreasing rates of ambulance dispatches. Potential solutions are likely to involve enhancing the flow through and discharge of patients from hospital, and a whole systems approach which considers the capacity of the local health and care infrastructure, including intermediate care and social care.

Background Training primary care doctors and nurses to use Practical Approach to Care Kit (PACK) improved management of asthma and chronic obstructive pulmonary disease (COPD) in a previous randomised trial. The present study examined the training effects including a second year of follow-up with expanded coverage of repeated training sessions. Methods Using a stepped-wedge cluster randomised trial design, 48 clinics were randomly allocated either to sequence A: (1) no intervention, (2) no intervention, (3) intervention or sequence B: (1) no intervention, (2) intervention, (3) intervention, during three 12-month periods. Primary outcomes were change in treatment and spirometry ordering. Effects of any exposure to the training, and of exposure to the first and second years of training, were estimated with mixed effect logistic regression models. Results Any exposure to training was associated with increased changes in treatment (OR adjusted for calendar time (OR) 1.29, 95% CI 1.02 to 1.64) and more spirometry ordering (OR 1.55, (95% CI 1.22 to 1.97)) in asthma patients, and with more spirometry ordering (OR 1.50 (95% CI 1.15 to 1.96)) in patients with COPD. Change in asthma treatment was more likely during the first and second year of exposure to training compared with no exposure (ORs 1.43 (95% CI 1.09 to 1.87); 1.91 (95% CI 1.21 to 3.02)), respectively. Spirometry was more likely during the first and second year of exposure in asthma patients (ORs 1.76 (95% CI 1.34 to 2.30); 2.05 (95% CI 1.32 to 3.19)) and in patients with COPD (ORs 1.57 (95% CI 1.18 to 2.10)); 1.71 (95% CI 1.08 to 2.70)). Conclusion Extended follow-up suggested that PACK training continued to be effective in improving chronic respiratory care and that effective intervention delivery was sustainable for 2 years. Trial registration number NCT02786030.

Demand for urgent and emergency health care in England has grown over the last decade, for reasons that are not clear. Changes in population demographics may be a cause. This study investigated associations between individuals’ characteristics (including socioeconomic deprivation and long term health conditions (LTC)) and the frequency of emergency department (ED) attendances, in the Norfolk and Waveney subregion of the East of England. The study population was people who were registered with 91 of 106 Norfolk and Waveney general practices during one year from 1 April 2022 to 31 March 2023. Linked primary and secondary care and geographical data included each individual’s sociodemographic characteristics, and number of ED attendances during the same year and, for some individuals, LTCs and number of general practice (GP) appointments. Associations between these factors and ED attendances were estimated using Poisson regression models. 1,027,422 individuals were included of whom 57.4% had GP data on the presence or absence of LTC, and 43.1% had both LTC and general practitioner appointment data. In the total population ED attendances were more frequent in individuals aged under five years, (adjusted Incidence Rate Ratio (IRR) 1.25, 95% confidence interval 1.23 to 1.28) compared to 15–35 years); living in more socioeconomically deprived areas (IRR 0.61 (0.60 to 0.63)) for least deprived compared to most deprived,and living closer to the nearest ED. Among individuals with LTC data, each additional LTC was also associated with increased ED attendances (IRR 1.16 (1.15 to 1.16)). Among individuals with LTC and GP appointment data, each additional GP appointment was also associated with increased ED attendances (IRR 1.03 (1.026 to 1.027)). In the Norfolk and Waveney population, ED attendance rates were higher for young children and individuals living in more deprived areas and closer to EDs. In individuals with LTC and GP appointment data, both factors were also associated with higher ED attendance.

Background The development of strategies to better detect and manage patients with multiple long-term conditions requires estimates of the most prevalent condition combinations. However, standard meta-analysis tools are not well suited to synthesising heterogeneous multimorbidity data. Methods We developed a statistical model to synthesise data on associations between diseases and nationally representative prevalence estimates and applied the model to South Africa. Published and unpublished data were reviewed, and meta-regression analysis was conducted to assess pairwise associations between 10 conditions: arthritis, asthma, chronic obstructive pulmonary disease (COPD), depression, diabetes, HIV, hypertension, ischaemic heart disease (IHD), stroke and tuberculosis. The national prevalence of each condition in individuals aged 15 and older was then independently estimated, and these estimates were integrated with the ORs from the meta-regressions in a statistical model, to estimate the national prevalence of each condition combination. Results The strongest disease associations in South Africa are between COPD and asthma (OR 14.6, 95% CI 10.3 to 19.9), COPD and IHD (OR 9.2, 95% CI 8.3 to 10.2) and IHD and stroke (OR 7.2, 95% CI 5.9 to 8.4). The most prevalent condition combinations in individuals aged 15+ are hypertension and arthritis (7.6%, 95% CI 5.8% to 9.5%), hypertension and diabetes (7.5%, 95% CI 6.4% to 8.6%) and hypertension and HIV (4.8%, 95% CI 3.3% to 6.6%). The average numbers of comorbidities are greatest in the case of COPD (2.3, 95% CI 2.1 to 2.6), stroke (2.1, 95% CI 1.8 to 2.4) and IHD (1.9, 95% CI 1.6 to 2.2). Conclusion South Africa has high levels of HIV, hypertension, diabetes and arthritis, by international standards, and these are reflected in the most prevalent condition combinations. However, less prevalent conditions such as COPD, stroke and IHD contribute disproportionately to the multimorbidity burden, with high rates of comorbidity. This modelling approach can be used in other settings to characterise the most important disease combinations and levels of comorbidity.

Background: The rising prevalence of non-communicable diseases (NCDs) alongside the continuing high burden of HIV poses a serious challenge to middle- and low-income countries’ healthcare systems. Pilot studies of integrated models of service delivery for HIV, hypertension and diabetes have demonstrated that they are feasible and acceptable among patients and care providers. This study assessed multi-stakeholders’ perspectives of the delivery and receipt of integrated care in Tanzania.Methods: A qualitative process evaluation was conducted in Dar es Salaam region of Tanzania where the integrated service delivery model was implemented from July to November 2021. In-depth interviews were held with seven key informants at the national, regional and district levels, eight healthcare providers, two researchers working at the integrated clinic and forty patients benefiting from integrated services at a large hospital. Three focus group discussions were held with community leaders and residents of the hospital’s catchment area, and clinic level observations were conducted. Thematic analysis was conducted followed by the use of Bronfenbrenner’s ecological model to identify factors pertinent to sustaining and scaling up of the integrated model.Results: Participants of the study at all levels were aware of the increased prevalence of NCDs specifically for hypertension and diabetes and were concerned about the trend of increasing co-morbid conditions among people living with HIV (PLHIV). The integrated service delivery model was positively perceived by stakeholders because of its multiple benefits for both patients and the healthcare system. These include stigma and discrimination reduction, improved quality of care, efficient use of limited resources, cost and time saving, reduced duplication of services and fostering of early detection for undiagnosed conditions. The organisation of the clinic was critical in increased satisfaction. Several challenges were observed, which included costs for NCD services relative to free care for HIV and inconsistent availability of NCD medications.Conclusion: Stakeholders reported numerous benefits of the integrated service delivery model that are fundamental in improving the health of many Tanzanians living with NCDs and HIV. These benefits highlight the need for policy and decision-makers to sustain and expand the integrated service delivery model as a solution to many challenges facing the health system especially at the primary care level.

Aims: England's Diabetic Eye Disease Screening Programme offers screening to every resident over age 12 with diabetes, starting as soon as possible after diagnosis and repeated annually. People first diagnosed with diabetes at older ages have shorter life expectancy and therefore may be less likely to benefit from screening and treatment. To inform decisions about whether diabetic eye screening policy should be stratified by age, we investigated the probability of receiving treatment according to age at first screening episode.Methods: This was a cohort study of participants in the Norfolk Diabetic Retinopathy Screening Programme from 2006 to 2017, with individuals' programme data linked to hospital treatment and death data recorded up to 2021. We estimated and compared the probability, annual incidence and screening costs of receiving retinal laser photocoagulation or intravitreal injection and of death, in age groups defined by age at first screening episode.Results: The probability of death increased with increasing age at diagnosis, while the probability of receiving either treatment decreased with increasing age. The estimated cost of screening per person who received either or both treatments was £18,608 among all participants, increasing with age up to £21,721 in those aged 70–79 and £26,214 in those aged 80–89.Conclusions: Diabetic retinopathy screening is less effective and less cost‐effective with increasing age at diagnosis of diabetes, because of the increasing probability of death before participants develop sight‐threatening diabetic retinopathy and can benefit from treatment. Upper age limits on entry into screening programmes or risk stratification in older age groups may, therefore, be justifiable.