Peritoneal dialysis (PD) preserves kidney function and offers flexibility; however, few young adults have it compared with hemodialysis (HD). This study aimed to understand factors influencing the change from PD to HD.

This was a sequential explanatory mixed-methods study.

Quantitative data were collected from 470 participants (50% male participants, 85% White, mean age: 16 years) who received dialysis between 1987 and 2015. Cox proportional hazards analysis was used to examine psychosocial factors associated with transitions from PD to HD. Qualitative data were gathered from 13 young adults (aged 14-29 years) who received dialysis between 2013 and 2015, with retrospective interviews conducted in 2020.

25% of participants experienced multiple episodes of PD. Survival rates for PD at 1 and 5 years were 71% and 37%, respectively. Risk factors for transitioning to HD included young adulthood (age: 15-30 years), with higher transition risks in older age groups (age: 15-19 years, HR: 2.41; age: 20-24 years, HR: 3.39; age: 25-30 years, HR: 3.14; P < 0.005). Other factors included primary kidney disease type (systemic diseases vs tubulointerstitial diseases). Leading causes for transition were infection (50%), noncompliance (21%), and mechanical issues (18%). Qualitative analysis revealed the key themes around communicating treatment options, life impact, and support structures. Resilience was an additional theme among those who continued PD.

The study was based on cross-sectional psychosocial data, lacked detailed parental involvement, and may have suffered recall bias.

Young adults are at higher risk of transitioning to HD owing to both transplant failure and complications with PD. Challenges of PD have been underestimated, and there is a need to educate young adults well on all dialysis options. Additional support including mental health support, peer support, and support during life changes, such as moving out of their family home, is recommended.

The Welsh Index of Multiple Deprivation (WIMD) is an area-based deprivation measure comprising eight domains, produced by the Welsh Government to rank Lower Layer Super Output Areas (LSOAs) in Wales. Researchers use the WIMD to account for deprivation, however, as one domain contains health indicators, there is a risk of endogeneity bias when using the WIMD in research on health outcomes. This study evaluated the effect on study results of removing the health domain from the overall WIMD or using only the income domain as deprivation measures.

WIMD 2019 scores were linked to 2,760,731 individuals in the SAIL Databank. Original WIMD scores including decile and quintile rankings for each LSOA 2011 were obtained from Welsh Government. The first alternative method removed the health domain from the original WIMD scores. In the second alternative method, WIMD scores were based on only the income domain. Spearman's correlation and Cohen's kappa were used to assess the agreement of ranks, deciles, and quintiles between each method. To quantify the change in association between WIMD quintile and diabetes mellitus prevalence for each alternative method, binary logistic regression obtained age-adjusted odds ratios and 95% confidence intervals.

Removing the health domain from the original WIMD scores resulted in 17.28% of LSOAs changing decile (8.64% to a more deprived group and 8.64% to a less deprived group) and 9.00% changing quintile (4.50% more deprived, 4.50% less deprived). The income-domain-only method caused 50.49% of LSOAs to change decile (26.87% more deprived, 23.62% less deprived) as compared with the original WIMD, and 29.65% changed quintile (15.14% more deprived, 14.51% less deprived). There was a significant association between each of the three methods and diabetes prevalence, with odds ratios increasing with more deprived quintiles, but the 95% confidence intervals for each method showed little or no overlap with each other.

To avoid biased estimates, researchers using WIMD in studies on health, education, housing, physical environment, income, employment, community safety, and access to services should consider how these domains are related to their outcomes. We describe a methodology for researchers to quantify any bias in their own studies.

Community pharmacies in England and Wales are taking on a broader range of primary care responsibilities in order to ease pressure on other health services. 'Pharmacy First', launched in 2024, allows patients to access treatment for a range of common conditions directly from a pharmacy without the need to consult a GP. However, funding and workforce pressures have resulted in a number of pharmacy closures in recent years. This study assesses the geographical accessibility of community pharmacies in England and Wales and identifies the impact of these recent closures.

Using open data on pharmacy locations and opening hours this study calculates a Spatial Accessibility Index (SPAI) for access to pharmacies by car in 2022 and 2024. We use a Modified Huff Variable Three Step Floating Catchment Area (MHV3SFCA), a variant of the Floating Catchment Area (FCA) technique.

Suburban and rural neighbourhoods tend to have poorer access to community pharmacies, whilst more deprived neighbourhoods generally have comparatively better access. We identify neighbourhoods which could be classed as 'pharmacy deserts', which are primarily located in rural areas. We identify that all neighbourhood area types witness a reduction in overall accessibility to community pharmacies between 2022 and 2024. In total these result in a 10% reduction in the SPAI.

The MHV3SFCA applied here is novel in its application to community pharmacy accessibility in a UK context. We demonstrate its utility as a tool to identify the impact of changes to the community pharmacy network on accessibility as experienced by different neighbourhoods. We find evidence of a 'positive pharmacy care law' and also the existence of some 'pharmacy deserts'.

The psychological impact of surviving an admission to an intensive care unit (ICU) with COVID-19 is uncertain. The objective of the study was to assess the prevalence of anxiety, depression and post-traumatic stress disorder (PTSD) symptoms in ICU survivors treated for COVID-19 infection, and identify risk factors for psychological distress.

This observational study was conducted at 52 ICUs in the United Kingdom. Participants, treated for COVID-19 infection during an ICU admission of ⩾24 h, were recruited post-ICU discharge. Self-report questionnaires were completed at 3, 6 and/or 12 months. Symptoms of anxiety and depression were identified using the Hospital Anxiety and Depression Scale. PTSD was assessed using the Impact of Events Scale-6. Demographic, clinical, physical and psychosocial factors were considered as putative predictors of psychological distress.

1620 patients provided consent and 1258 (77.7%) responded to at least one questionnaire, with responses at 3 months (N = 426), 6 months (N = 656) and 12 months (N = 1050) following ICU admission. The following prevalence rates were found at 3, 6 and 12 months, respectively: anxiety in 28.8% (95% CI 24.6-33.1), 30.4% (95% CI 27.0-33.8) and 29.3% (95% CI 26.5-32.1); depression in 25.1% (21.0-29.3), 25.9% (22.7-29.3) and 24.0% (21.5-26.6); and PTSD in 43.5% (38.8-48.2), 44.3% (40.6-48.0) and 43.2% (40.2-46.1) of patients. Risk factors for psychological distress included a previous mental health diagnosis, unemployment or being on sick leave, and a history of asthma or COPD.

Clinically significant symptoms of anxiety, depression and PTSD were common and persisted up to 12 months post-ICU discharge.

Important changes in symptom profiles occur early in the course of severe mental illness (SMI) after its clinical presentation. The emergence of negative symptoms is of particular concern for later function, and these may well have strong links with loneliness and poor social support which are also recognised to be common. However, the impact of loneliness and social isolation on symptoms and treatment outcomes remains unclear. To explore this, we conducted a retrospective observational analysis using data from electronic health records of a large mental health provider in London. Loneliness, living alone and symptoms of SMI were extracted using bespoke natural language processing algorithms. Symptoms were grouped into five domains: positive, negative, disorganised, manic, and catatonic, and were measured at diagnosis and 12 months following the initial SMI diagnosis. Loneliness and living alone were operationalised as binary variables, based on any recording during the follow-up period. A total of 8237 records were analysed. The prevalence of loneliness was 20.4 % and living alone 19.9 %, with only 6.8 % recorded with both. Recorded loneliness was associated with an increase in negative symptoms over the follow-up period, in models adjusted by sociodemographic variables and pharmacological treatment [OR 1.28 (1.11-1.48), p = 0.001], as was living alone to a weaker extent [OR 1.18 (1.02-1.36), p = 0.030]. No associations were found between either exposure variable and changes in symptoms from other domains. Given that negative symptoms are disabling and challenging to treat, these results highlight the importance of effective interventions to enhance social support in SMI over the early post-diagnostic period.

The effectiveness of tax increases in reducing tobacco consumption relies on the tobacco retailers and producers passing on increases to consumers (tax pass-through). Previous UK research on supermarkets found heterogeneous levels of tax pass-through across the market segments and price distribution of tobacco products. This study uses data from small retailers across the UK to assess whether recent tax changes have been passed on to consumers and if this varies across the price distribution, between countries of the UK and by neighbourhood deprivation.

We use panel data quantile regression analysis of tobacco sales in small retailers in the UK from March 2017 to December 2021 combined with UK tax rates and store-level index of multiple deprivation (IMD). We calculated the rate of tax pass-through for factory-made cigarettes (FM) and roll-your-own tobacco (RYO).

Following increases in the duty payable on tobacco, we find evidence of overshifting across the entire price distribution for FM and RYO. For England, Scotland and Wales, the rate of the overshift in tax increased with product price. For Scotland, we find that stores in the least deprived IMD pass-through taxes at a higher rate.

Our evidence shows heterogeneous levels of tax pass-through by price, region and level of deprivation. The findings emphasise the importance of understanding the pricing strategies of the tobacco industry (TI) and how these vary across the UK to develop robust approaches to mitigate the pricing strategies of the TI.

Disparities in health and healthcare between more and less socially advantaged groups are pervasive, multidimensional, and far-reaching. The material and social conditions in which people are born, grow, work, live, and age are systematically associated with their health and with the volume, quality, and outcomes of care received by the vast majority of the general population, as well as by specific marginalized populations. The field of health economics and outcomes research (HEOR) has an important role in supporting health equity goals. This publication aimed to act as a "primer" for conducting health equity research within the field of HEOR, establishing foundational understanding of key concepts.

The ISPOR Special Interest Group on Health Equity Research was established in 2021 to advance equity-informative methods and data to better enable researchers to empirically investigate-and ultimately reduce-unfair social differences in health. This publication was developed by the ISPOR Special Interest Group leadership team with input from the group membership.

The resultant publication provides an overview of health equity research methods and data considerations as they relate to HEOR-relevant topics including clinical trials, real-world evidence and economic evaluation. Reflecting the current body of research on health equity in HEOR, particular focus is given to the latter. It also brings together a list of core reference material to support future learning.

This report provides the HEOR community with a tailored "state of play" overview of health equity, to support development of foundational understanding and inspire increased engagement.

Around one in three pregnant women undergoes induction of labour in the United Kingdom, usually preceded by in-hospital cervical ripening to soften and open the cervix.

This study set out to determine whether cervical ripening at home is within an acceptable safety margin of cervical ripening in hospital, is effective, acceptable and cost-effective from both National Health Service and service user perspectives.

The CHOICE study comprised a prospective multicentre observational cohort study using routinely collected data (CHOICE cohort), a process evaluation comprising a survey and nested case studies (qCHOICE) and a cost-effectiveness analysis. The CHOICE cohort set out to compare outcomes of cervical ripening using dinoprostone (a prostaglandin) at home with in-hospital cervical ripening from 39 weeks of gestation. Electronic maternity record data were collected from 26 maternity units. Following pilot analysis, the primary comparison was changed to ensure feasibility and to reflect current practice, comparing home cervical ripening using a balloon catheter with in-hospital cervical ripening using any prostaglandin from 37 weeks of gestation. Analysis involved multiple logistic regression for the primary outcome and descriptive statistics for all other outcomes. The qCHOICE study reported descriptive statistics of quantitative survey data and thematic analysis of focus group and interview data. The economic analysis involved a decision-analytic model from a National Health Service and Personal Social Services perspective, populated with CHOICE cohort and published data. Secondary analysis explored the patient perspective utilising cost estimates from qCHOICE data.

Twenty-six United Kingdom maternity units.

Women with singleton pregnancies at or beyond 37 weeks of gestation having induction with details of cervical ripening method and location recorded.

Neonatal unit admission within 48 hours of birth for 48 hours or more.

Maternal and staff experience of cervical ripening.

Incremental cost per neonatal unit admission within 48 hours of birth avoided.

Electronic maternity records from 26 maternity units; survey and interviews with service users/maternity staff; focus groups with maternity staff; published literature on economic aspects.

CHOICE cohort: A total of 515 women underwent balloon cervical ripening at home and 4332 underwent in-hospital cervical ripening using prostaglandin in hospitals that did not offer home cervical ripening. Neonatal unit admission within 48 hours of birth for 48 hours or more following home cervical ripening with balloon was not increased compared with in-hospital cervical ripening with prostaglandin. However, there was substantial uncertainty with the adjusted analysis consistent with a 74% decrease in the risk through to an 81% increase.

Important aspects of service users' experience of home cervical ripening were quality of information provided, support and perception of genuine choice.

Home cervical ripening with balloon led to cost savings of £993 (-£1198, -£783) per woman and can be considered the dominant strategy.

Circumstances relating to the COVID-19 pandemic limited the number of participating maternity units and the duration for which units participated. Low numbers of women having at-home cervical ripening limited the power to detect differences in safety, effectiveness, cost and acceptability between study groups.

Home cervical ripening using balloon catheter may be as safe for babies as using prostaglandins in hospital in low and moderate-risk groups, but there is substantial uncertainty. Home cervical ripening with balloon is likely to be cost saving. Impacts on workload, service user and staff experiences were complex.

Future research should focus on optimising experience and logistics of home cervical ripening within busy maternity services.

Current Controlled Trials ISRCTN32652461.

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127569) and is published in full in Health Technology Assessment; Vol. 28, No. 81. See the NIHR Funding and Awards website for further award information.

Living in socioeconomically deprived areas is associated with shorter lives and worse health. GPs working in these areas face additional challenges compared with those in more affluent locations.

To establish GPs' motivation for working in these areas, to discover the challenges that GPs face, and to gain insights from GPs on potential improvements and changes.

An interpretative phenomenological analysis was undertaken of GPs' lived experiences of working in the most socioeconomically deprived practices in Northern Ireland (NI), which is the most deprived country within the UK.

Interviews were carried out with nine GPs to find out the challenges facing them, why they work in a Deep End area, and what suggestions, ideas, and solutions they have to improve patient care and GP experience at NI's Deep End.

The challenges related to wider health service failures including the increased demand on GPs and feelings of powerlessness. Patient population challenges included 'missingness', late or crisis presentations, alongside the clinical difficulties of a highly 'medicalised' patient population, as well as the high prevalence of mental health problems. However, GPs choose to work in Deep End areas because the environments were seen as clinically stimulating and rewarding, as well as giving them feelings of belonging and fulfilling a duty to 'their' area. Improvements focused on providing more flexible access, increased mental health provision, and future training and recruitment, particularly around widening participation in medical school.

Improving the environmental conditions, empowering individuals, and investing in communities are essential factors to achieving health. The current model of providing reactionary acute care is leading to GPs experiencing powerlessness and feelings of helplessness at the Deep End.

ANA-associated rheumatic and musculoskeletal (MSK) diseases (RMDs) [SLE, primary SS (pSS), scleroderma, inflammatory myositis, MCTD and UCTD] make up a disease spectrum with overlapping clinical and immunological features. MSK inflammation is common and impactful across ANA-associated RMDs. The objectives of this study were to evaluate MSK inflammation (ANA-associated arthritis) prevalence in a multidisease ANA-associated RMD study, assess its clinical impact across ANA-associated RMD diagnoses, propose new basket groupings of patients, and evaluate immunological profiles in legacy and new basket contexts.

An observational study enrolled patients with ANA-associated RMDs. Demographic variables, comorbidities, therapies, disease activity instruments [BILAG, SLEDAI, the EULAR SS disease activity index (ESSDAI), physician visual analogue scale (VAS)], patient-reported outcomes [SF36, FACIT-Fatigue, EQ5D, ICECAP-A, Work Productivity and Activity impairment (WPAI), patient VAS] and the biomarker profile (six-gene expression scores, flow cytometry, autoantibody profile) were analysed. Reclustering utilized Gaussian mixture modelling (GMM). The clinical and immune features of new and legacy clusters were compared.

Inflammatory MSK symptoms were prevalent across ANA-associated RMDs, in 213/294 patients. In ANA-associated arthritis patients, most variables did not differ between diagnoses, with the exception of the EQ5D-5L index and mobility domains (lower in MCTD/pSS, both P < 0.05). FM and OA prevalence were similar across diagnoses. Therapy use differed significantly, the use of biologics being greatest in SLE (P < 0.05). GMM yielded two multidisease clusters: High MSK disease activity (n = 89) and low MSK disease activity (n = 124). The high MSK disease activity cluster included all patients with active joint swelling, and they had significantly higher prednisolone usage, physician global assessment (PGA), Sm/RNP/SmRNP/chromatin positivity, Tetherin mean fluorescence intensity (MFI), and IFN Score-A activity, along with numerically lower FM and OA prevalence.

We defined ANA-associated arthritis, a more clinically and immunologically homogeneous population than existing RMD populations for trials, and a more prevalent population for therapies in the clinic.

Socioeconomic deprivation - defined as a lack of social, economic and material resources - is associated with poor health outcomes and health disparities between population groups. The All of Us Research Program is a longitudinal cohort study of diverse participants from the United States, with demographic and social determinants of health data gleaned from participant surveys and health outcome data derived from electronic health records. We developed a composite index of socioeconomic deprivation (iSDI) using a cohort of 202,919 All of Us participants - based on education, employment, health insurance, housing, and income data - and we associated iSDI with health outcomes and disparities. iSDI is significantly associated with 970 out of 1,755 (55.3%) health conditions modeled here, with 661 positive and 309 negative associations. Mental disorders and circulatory diseases show the highest proportion of positive associations with iSDI, whereas neoplasms and congenital anomalies show the highest proportion of negative associations. Black (0.55) and Hispanic (0.52) All of Us participants show higher average iSDI values compared to White (0.29) and Asian (0.24) participants; although the majority of iSDI variation is found within (76.8%) rather than between (23.2%) groups. iSDI mediates 213 out of 399 (53.5%) Black health disparity conditions and 173 out of 297 (58.2%) Hispanic health disparity conditions. The composite socioeconomic deprivation index (iSDI) developed here is associated with a wide variety of health outcomes and disparities in the All of Us cohort, and we make participant iSDI values available on the Researcher Workbench to support future studies on social determinants of health.

Sagittal synostosis is the most common craniosynostosis. The aim of surgery is to preserve cognitive function and to correct the morphologic changes. In our unit, the authors offer strip craniectomy and microbarrel staving (SMB) performed at 16 to 22 weeks. This study aims to ascertain the 7-year outcome of scaphocephaly correction by SMB. The authors investigate whether the improvement in cranial index (CI) is sustained over time, and report speech and language and neurodevelopmental outcomes.

All nonsyndromic patients with sagittal synostosis who underwent SMB between 2009 and 2012 were identified from a prospectively created database that recorded anthropometric measurements, quality metrics, and neurodevelopmental outcomes.

A total of 27 patients were analyzed. The mean CI preoperatively was 67.5% (±3.5), and at 7 years 78% (±4.8). Regarding neurodevelopmental outcomes at 7 years, SDQ responses did not highlight any concerns for social, emotional, or behavioral outcomes. The vast majority of those who completed a WASI-II assessment performed within the average ranges in terms of cognitive ability. In terms of speech and language 70% of subjects demonstrated receptive language within normal level (WNL). Seventy-seven percent of subjects demonstrated expressive language WNL.

In conclusion, after 7 years of follow-up, early open extended SMB is a safe and effective method for correction of isolated nonsyndromic isolated sagittal synostosis. Across the neurodevelopmental measures and assessments, the children in the current study appeared to perform within expected ranges. Speech and language problems are more prevalent than in the general population.

Hip fracture incidence is rising globally, making it crucial to understand the demographic factors that influence their occurrence for targeted healthcare interventions. This study focuses on examining the determinants of hip fracture incidence, particularly socioeconomic status, body mass index (BMI), and gender.

The study utilised data from 570 patients recorded in the 2023 National Hip Fracture Database Audit tool. Socioeconomic status was assessed through the Index of Multiple Deprivation (IMD), based on patient postcodes. The analysis aimed to explore correlations between socioeconomic status, BMI, gender, and the incidence and types of hip fractures.

The findings indicate that the majority of hip fractures occurred in individuals from the lowest socioeconomic deciles, with a statistically significant correlation (p < 0.05) between lower socioeconomic status and higher fracture incidence. Gender-specific disparities were observed, with males experiencing fractures at younger ages and presenting with different fracture types compared to females. Additionally, lower BMI was significantly associated with a higher likelihood of certain fracture types (p < 0.05).

The study highlights the substantial influence of socioeconomic status, gender, and BMI on hip fracture incidence and typology. These results indicate the need for targeted prevention strategies and health policies aimed at mitigating hip fracture risks in socioeconomically disadvantaged populations. Understanding these factors can enable healthcare providers to allocate resources and interventions more effectively, reducing the incidence and impact of hip fractures in deprived areas.

There is no standardised approach to screening adults for social risk factors. The goal of this study was to develop mortality risk prediction models based on the social determinants of health (SDoH) for clinical risk stratification.

Data were used from REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a national, population-based, longitudinal cohort of black and white Americans aged ≥45 recruited between 2003 and 2007. Analysis was limited to participants with available SDoH and mortality data (n=20 843). All-cause mortality, available through 31 December 2018, was modelled using Cox proportional hazards with baseline individual, area-level and business-level SDoH as predictors. The area-level Social Vulnerability Index (SVI) was included for comparison. All models were adjusted for age, sex and sampling region and underwent internal split-sample validation.

The baseline prediction model including only age, sex and REGARDS sampling region had a c-statistic of 0.699. An individual-level SDoH model (Model 1) had a higher c-statistic than the SVI (0.723 vs 0.708, p<0.001) in the testing set. Sequentially adding area-level SDoH (c-statistic 0.723) and business-level SDoH (c-statistics 0.723) to Model 1 had minimal improvement in model discrimination. Structural racism variables were associated with all-cause mortality for black participants but did not improve model discrimination compared with Model 1 (p=0.175).

In conclusion, SDoH can improve mortality prediction over 10 years relative to a baseline model and have the potential to identify high-risk patients for further evaluation or intervention if validated externally.

Depression is one of the most significant public health issues, but evidence of geographic patterns and trends of depression is limited. We aimed to examine the spatio-temporal patterns and trends of depression prevalence among adults in a nationwide longitudinal spatial study in England and evaluate the influence of neighbourhood socioeconomic deprivation in explaining patterns.

Information on recorded depression prevalence was obtained from the indicator Quality and Outcomes Framework: Depression prevalence that measured the annual percentage of adults diagnosed with depression for Lower Super Output Areas (LSOA) from 2011 to 2022. We applied Cluster and Outlier Analysis using the Local Moran's I algorithm. Local effects of deprivation on depression in 2020 examined with Geographically Weighted Regression (GWR). Inequalities in recorded prevalence were presented using Prevalence Rate Ratios (PRR).

The North West Region of England had the highest concentration of High-High clusters of depression, with 17.4% of the area having high values surrounded by high values in both space and time and the greatest percentage of areas with a high rate of increase (43.1%). Inequalities widened among areas with a high rate of increase in prevalence compared to those with a lower rate of increase, with the PRR increasing from 1.66 (99% CI 1.61-1.70) in 2011 to 1.81 (99% CI 1.76-1.85) by 2022. Deprivation explained 3%-39% of the variance in depression in 2020 across the country.

It is crucial to monitor depression's spatial patterns and trends and investigate mechanisms of mental health inequalities. Our findings can help identify priority areas and target prevention and intervention strategies in England. Evaluating mental health interventions in different geographic contexts can provide valuable insights to policymakers on the most effective and context-sensitive strategies, enabling them to allocate resources towards preventing the worsening of mental health inequalities.

This retrospective population-based analysis assessed variations in urgent healthcare use by children and young people (CYP) across UK nations (England, Scotland and Wales) between 2007 and 2017. The study focused on urgent hospital admissions, short stay urgent admissions (SSUA) and Emergency Department (ED) attendances among CYP aged <25 years, stratified by age groups and Index of Multiple Deprivation (IMD) quintile groups. A linear mixed model was used to assess trends in healthcare activity over time and across deprivation quintiles. Urgent admissions, SSUA and ED attendances increased across all deprivation quintiles in all studied nations. Increasing deprivation was consistently associated with higher urgent healthcare utilisation. In England, the rise in urgent admissions and SSUA for CYP was slower for CYP from the quintile of greatest deprivation compared those from the least deprived quintile (respective mean differences 0.69/1000/y [95% CI 0.53, 0.85] and 0.25/1000/y [0.07, 0.42]), leading to a narrowing in health inequality. Conversely, in Scotland, urgent admissions and SSUA increased more rapidly for CYP from all deprivation quintiles, widening health inequality. Understanding the differences we describe here could inform changes to NHS pathways of care across the UK which slow the rise in urgent healthcare use for CYP.

To evaluate trust-level performance in time to initiation of DMARD therapy in patients with early inflammatory arthritis (EIA), with identification of the change in performance trajectories over time and investigation of trust characteristics associated with this change.

We included 130 trusts from the UK contributing to the National Early Inflammatory Arthritis Audit (NEIAA) from 2018 to 2020. The primary outcome was days from referral to initiation of DMARD therapy in patients with EIA. Latent class growth mixture models were applied to identify distinct groups of trusts with similar trajectories of performance change over time. We used mixed effects linear and multinomial logistic regression models to evaluate the association between delay in treatment and trust-level characteristics.

The mean time to DMARD initiation was 53 days (s.d. 18), with an average 0.3-day decrease with each month over time. Four latent trajectories were identified in our cohort, with >77% of individual trusts showing ongoing improvements in decreasing treatment waiting times. Prior to separating by latent class, time to DMARD initiation was shorter in trusts with higher rheumatology staffing, a local EIA treatment pathway and those with access to musculoskeletal ultrasound. Trusts with more nurses in the rheumatology department were less likely to be in the worst performance group [odds ratio 0.69 (95% CI 0.49, 0.93)].

In this cohort study, we observed a reduction in treatment waiting time over time. Trusts with better staffed and improved EIA clinical structure are likely to initiate definitive treatment earlier in patients with EIA.

People under the care of mental health services are at increased risk of suicide. Existing studies are small in scale and lack comparisons.

To identify opportunities for suicide prevention and underpinning data enhancement in people with recent contact with mental health services.

This population-based study includes people who died by suicide in the year following a mental health services contact in Wales, 2001-2015 (cases), paired with similar patients who did not die by suicide (controls). We linked the National Confidential Inquiry into Suicide and Safety in Mental Health and the Suicide Information Database - Cymru with primary and secondary healthcare records. We present results of conditional logistic regression.

We matched 1031 cases with 5155 controls. In the year before their death, 98.3% of cases were in contact with healthcare services, and 28.5% presented with self-harm. Cases had more emergency department contacts (odds ratio 2.4, 95% CI 2.1-2.7) and emergency hospital admissions (odds ratio 1.5, 95% CI 1.4-1.7), but fewer primary care contacts (odds ratio 0.7, 95% CI 0.6-0.9) and out-patient appointments (odds ratio 0.2, 95% CI 0.2-0.3) than controls. Odds ratios were larger in females than males for injury and poisoning (odds ratio: 3.3 (95% CI 2.5-4.5) v. 2.6 (95% CI 2.1-3.1)).

We may be missing existing opportunities to intervene, particularly in emergency departments and hospital admissions with self-harm presentations and with unattributed self-harm, especially in females. Prevention efforts should focus on strengthening routine care contacts, responding to emergency contacts and better self-harm care. There are benefits to enhancing clinical audit systems with routinely collected data.

There is a large body of literature demonstrating a social gradient in health and increasing evidence of an association between social deprivation and diabetes complications. Diabetic kidney disease (DKD) increases mortality in people with diabetes. Socioeconomic deprivation is increasingly recognized as a modifier of risk factors for kidney disease but also an independent risk factor itself for kidney disease. This may not be truly appreciated by clinicians and warrants further attention and exploration. In this review we explore the literature to date from Europe on the relationship between social deprivation and DKD. The majority of the studies showed at least an association with microalbuminuria, an early marker of DKD, while many showed an association with overt nephropathy. This was seen across many countries in Europe using a variety of different measures of deprivation. We reviewed and considered the mechanisms by which deprivation may lead to DKD. Health related behaviors such as smoking and suboptimal control of risk factors such as hypertension, hyperglycemia and elevated body mass index (BMI) accounts for some but not all of the association. Poorer access to healthcare, health literacy, and stress are also discussed as potential mediators of the association. Addressing deprivation is difficult but starting points include targeted interventions for people living in deprived circumstances, equitable roll out of diabetes technology, and flexible outpatient clinic arrangements including virtual and community-based care.

This study explores whether people who have recently moved to an area differ from longer-term residents in their health, travel behaviour, and perceptions of the environment. Using a large, representative sample from the UKHLS, Newcomers demonstrate significantly lower mental and physical health, reduced car commuting, and a higher likelihood of liking their neighbourhood. Area deprivation, urbanicity, household income, and age emerge as influential moderators with i.e. Newcomers in affluent areas experiencing lower physical health than Settled Residents, and rural Newcomers expressing less neighbourhood satisfaction. Our findings highlight that Newcomers' perceptions of their environment diverge and environmental influences vary among population segments, potentially impacting related health behaviours such as active travel. Furthermore, residential relocation introduces Newcomers with distinct characteristics into areas, affecting the context in which potential population health interventions aiming to influence health behaviours operate. This necessitates a deeper understanding of what influences reactions to the environment as well as ongoing adaptation of environmental interventions to respond to changing contexts within the same location over time.

To analyse the effectiveness of rapid diagnostic clinics (RDCs) as an alternative pathway for patients with concerning symptoms and a faecal immunochemical test (FIT) result <10. Our primary endpoint was rate of colorectal cancer (CRC) detection. Second endpoints were rates of other cancers and gastrointestinal (GI) serious benign conditions. Finally, we analysed the specific pathway followed by FIT <10 patients with cancer at Guy's and St Thomas NHS Foundation Trust (GSTT) RDC.

A retrospective and prospective cohort study.

GSTT RDC, one of England's largest single-centre RDCs. Sociodemographic and clinical characteristics of FIT <10 patients were analysed descriptively.

Patients with an FIT result <10, seen at GSTT RDC between 1 January 2020 and 5 May 2023.

A total of 1299 patients with an FIT<10 were seen at GSTT RDC between January 2020 and May 2023. Of these, 66% (n=861) reported weight loss, 62% (n=805) pain, 37% (n=481) fatigue, 34% (n=444) were anaemic and 23% (n=301) had nausea and vomiting. Among these patients, 7% (n=88) received a cancer diagnosis, 36% (n=462) were identified as having a serious benign condition. Within the patients with cancer, 9% (n=8) were diagnosed with CRC. Among patients with serious benign conditions, 7% (n=31) were referred to colorectal, hepatopancreatobiliary, or upper GI specialists.

This study demonstrates the effectiveness of RDCs as an alternate pathway for FIT <10 patients with ongoing clinical concerns. These results contribute to enhancing patient care and optimising resource allocation within the healthcare system.

Patients with severe-to-profound hearing loss may benefit from management with cochlear implants. These patients need a referral to a cochlear implant team for further assessment and possible surgery. The referral pathway may result in varied access to hearing healthcare. This study aimed to explore referral patterns and whether there were any socioeconomic or ethnic associations with the likelihood of referral. The primary outcome was to determine factors influencing referral for implant assessment. The secondary outcome was to identify factors impacting whether healthcare professionals had discussed the option of referral.

A multicentre multidisciplinary observational study was conducted in secondary care Otolaryngology and Audiology units in Great Britain. Adults fulfilling NICE (2019) audiometric criteria for implant assessment were identified over a 6-month period between 1 July and 31 December 2021. Patient- and site-specific characteristics were extracted. Multivariable binary logistic regression was employed to compare a range of factors influencing the likelihood of implant discussion and referral including patient-specific (demographics, past medical history, and degree of hearing loss) and site-specific factors (cochlear implant champion and whether the hospital performed implants). Hospitals across all 4 devolved nations of the UK were invited to participate, with data submitted from 36 urban hospitals across England, Scotland, and Wales. Nine hospitals (25%) conducted cochlear implant assessments. The majority of patients lived in England (n = 5,587, 86.2%); the rest lived in Wales (n = 419, 6.5%) and Scotland (n = 233, 3.6%). The mean patient age was 72 ± 19 years (mean ± standard deviation); 54% were male, and 75·3% of participants were white, 6·3% were Asian, 1·5% were black, 0·05% were mixed, and 4·6% were self-defined as a different ethnicity. Of 6,482 submitted patients meeting pure tone audiometric thresholds for cochlear implantation, 311 already had a cochlear implant. Of the remaining 6,171, 35.7% were informed they were eligible for an implant, but only 9.7% were referred for assessment. When adjusted for site- and patient-specific factors, stand-out findings included that adults were less likely to be referred if they lived in more deprived area decile within Indices of Multiple Deprivation (4th (odds ratio (OR): 2·19; 95% confidence interval (CI): [1·31, 3·66]; p = 0·002), 5th (2·02; [1·21, 3·38]; p = 0·05), 6th (2·32; [1·41, 3·83]; p = 0.05), and 8th (2·07; [1·25, 3·42]; p = 0·004)), lived in London (0·40; [0·29, 0·57]; p < 0·001), were male (females 1·52; [1·27, 1·81]; p < 0·001), or were older (0·97; [0·96, 0·97]; p < 0·001). They were less likely to be informed of their potential eligibility if they lived in more deprived areas (4th (1·99; [1·49, 2·66]; p < 0·001), 5th (1·75; [1·31, 2·33], p < 0·001), 6th (1·85; [1·39, 2·45]; p < 0·001), 7th (1·66; [1·25, 2·21]; p < 0·001), and 8th (1·74; [1·31, 2·31]; p < 0·001) deciles), the North of England or London (North 0·74; [0·62, 0·89]; p = 0·001; London 0·44; [0·35, 0·56]; p < 0·001), were of Asian or black ethnic backgrounds compared to white patients (Asian 0·58; [0·43, 0·79]; p < 0·001; black 0·56; [0·34, 0·92]; p = 0·021), were male (females 1·46; [1·31, 1·62]; p < 0·001), or were older (0·98; [0·98, 0·98]; p < 0·001). The study methodology was limited by its observational nature, reliance on accurate documentation of the referring service, and potential underrepresentation of certain demographic groups.

The majority of adults meeting pure tone audiometric threshold criteria for cochlear implantation are currently not appropriately referred for assessment. There is scope to target underrepresented patient groups to improve referral rates. Future research should engage stakeholders to explore the reasons behind the disparities. Implementing straightforward measures, such as educational initiatives and automated pop-up tools for immediate identification, can help streamline the referral process.

The aim of this study was to examine the extent to which neighborhood-level socioeconomic factors (objective and perceived) are associated with poor oral health in older adults over time, independent of individual socioeconomic position. Data for this cross-sectional and longitudinal observation study came from a socially and geographically representative cohort of men aged 71 to 92 y in 2010-12 (n = 1,622), drawn from British general practices, which was followed up in 2018-19 (aged 78-98 y; N = 667). Dental measures at both times included number of teeth, periodontal pocket depth, self-rated oral health, and dry mouth. Neighborhood deprivation was based on Index of Multiple Deprivation (IMD) and a cumulative index measuring perceptions about local environment. Individual-level socioeconomic position was based on longest-held occupation. Multilevel and multivariate logistic regressions, adjusted for relevant sociodemographic, behavioral, and health-related factors, were performed to examine the relationships of dental measures with IMD and perceived neighborhood quality index, respectively. Cross-sectionally, risks of tooth loss, periodontal pockets, and dry mouth increased from IMD quintiles 1 to 5 (least to most deprived); odds ratios (ORs) for quintile 5 were 2.22 (95% confidence interval [CI], 1.41-3.51), 2.82 (95% CI, 1.72-4.64), and 1.51 (95% CI, 1.08-2.09), respectively, after adjusting for sociodemographic, behavioral, and health-related factors. Risks of increased pocket depth and dry mouth were significantly greater in quintile 5 (highest problems) of perceived neighborhood quality index compared to quintile 1. Over the 8-y follow-up, deterioration of dentition (tooth loss) was significantly higher in the most deprived IMD quintiles after full adjustment (OR for quintile 5 = 2.32; 95% CI, 1.09-4.89). Deterioration of dentition and dry mouth were significantly greater in quintile 5 of perceived neighborhood quality index. Neighborhood-level factors were associated with poor oral health in older age, both cross-sectionally and longitudinally, particularly with tooth loss, and dry mouth, independent of individual-level socioeconomic position.

This systematic review aimed to assess if women living in deprived areas have worse perinatal outcomes than those residing in high-income areas.

Datasets of PubMed, ScienceDirect, CENTRAL, Embase, and Google Scholar were searched for studies comparing perinatal outcomes (preterm birth, small-for-gestational age, and stillbirth) in deprived and non-deprive areas.

A total of 46 studies were included. The systematic review of the literature revealed a higher risk for adverse perinatal outcomes such as preterm birth, small for gestational age, and stillbirth in deprived areas.

Deprived areas are associated with adverse perinatal outcomes. More multifactorial studies are needed to assess the weight of each factor that composes the socioeconomic gradient of health in adverse perinatal outcomes.

Multimorbidity is common in patients with stroke and is associated with increased medium- to long-term mortality, but its value for clinical decision-making and case-mix adjustment will depend on other factors, such as age, stroke severity, etiological subtype, prior disability, and vascular risk factors.

In the absence of previous studies, we related multimorbidity to long-term post-stroke mortality with stratification by these factors.

In patients ascertained in a population-based stroke incidence study (Oxford Vascular Study; 2002-2017), we related pre-stroke multimorbidity (weighted/unweighted Charlson comorbidity index (CCI)) to all-cause/vascular/non-vascular mortality (1/5/10 years) using regression models adjusted/stratified by age, sex, predicted early outcome (THRIVE score), stroke severity (NIH stroke scale (NIHSS)), etiology (Trial of Org 10172 in Acute Stroke Treatment (TOAST)), premorbid disability (modified Rankin Scale (mRS)), and non-CCI risk factors (hypertension, hyperlipidemia, atrial fibrillation, smoking, deprivation, anxiety/depression).

Among 2454 stroke patients (M/SD age: 74.1/13.9 years; 48.9% male; M/SD NIHSS: 5.7/7.0), 1375/56.0% had ⩾ 1 CCI comorbidity and 685/27.9% had ⩾ 2. After age/sex adjustment, multimorbidity (unweighted CCI ⩾ 2 vs 0) predicted (all ps < 0.001) mortality at 1 year (aHR = 1.57, 95% CI = 1.38-1.78), 5 years (aHR = 1.73, 95% CI = 1.53-1.96), and 10 years (aHR = 1.79, 95% CI = 1.58-2.03). Although multimorbidity was independently associated with premorbid disability (mRS > 2: aOR = 2.76, 2.13-3.60) and non-CCI risk factors (hypertension: 1.56, 1.25-1.95; hyperlipidemia: 2.58, 2.03-3.28; atrial fibrillation: 2.31; 1.78-2.98; smoking: 1.37, 1.01-1.86), it predicted death after adjustment for all measured confounders (10-year-aHR = 1.56, 1.37-1.78, p < 0.001), driven mainly by non-vascular death (aHR = 1.89, 1.55-2.29). Predictive value for 10-year all-cause death was greatest in patients with lower expected early mortality: lower THRIVE score (pint < 0.001), age < 75 years (aHR = 2.27, 1.71-3.00), NIHSS < 5 (1.84, 1.53-2.21), and lacunar stroke (3.56, 2.14-5.91). Results were similar using the weighted CCI.

Pre-stroke multimorbidity is highly prevalent and is an independent predictor of death after stroke, supporting its inclusion in case-mix adjustment models and in informing decision-making by patients, families, and carers. Prediction in younger patients and after minor stroke, particularly for non-vascular death, suggests potential clinical utility in targeting interventions that require survival for 5-10 years to achieve a favorable risk/benefit ratio.

Data requests will be considered by the Oxford Vascular Study (OXVASC) Study Director (P.M.R.-peter.rothwell@ndcn.ox.ac.uk).

Brain dynamic functional connectivity characterises transient connections between brain regions. Features of brain dynamics have been linked to emotion and cognition in adult individuals, and atypical patterns have been associated with neurodevelopmental conditions such as autism. Although reliable functional brain networks have been consistently identified in neonates, little is known about the early development of dynamic functional connectivity. In this study we characterise dynamic functional connectivity with functional magnetic resonance imaging (fMRI) in the first few weeks of postnatal life in term-born (n = 324) and preterm-born (n = 66) individuals. We show that a dynamic landscape of brain connectivity is already established by the time of birth in the human brain, characterised by six transient states of neonatal functional connectivity with changing dynamics through the neonatal period. The pattern of dynamic connectivity is atypical in preterm-born infants, and associated with atypical social, sensory, and repetitive behaviours measured by the Quantitative Checklist for Autism in Toddlers (Q-CHAT) scores at 18 months of age.

Many non-modifiable factors are associated with poorer health-related quality of life (HRQoL) experienced by people with chronic kidney disease (CKD). We hypothesize that potentially modifiable factors for poor HRQoL can be identified among CKD patients, providing potential targets for intervention.

The National Unified Renal Translational Research Enterprise Chronic Kidney Disease (NURTuRE-CKD) cohort study recruited 2996 participants from nephrology centres with all stages of non-dialysis-dependent CKD. Baseline data collection for sociodemographic, anthropometric, biochemical and clinical information, including Integrated Palliative care Outcome Scale renal, Hospital Anxiety and Depression score (HADS) and the 5-level EuroQol-5D (EQ-5D-5L) as HRQoL measure, took place between 2017 and 2019. EQ-5D-5L dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) were mapped to an EQ-5D-3L value set to derive index value. Multivariable mixed effects regression models, adjusted for known factors affecting HRQoL with recruitment region as a random effect, were fit to assess potentially modifiable factors associated with index value (linear) and within each dimension (logistic).

Among the 2958/2996 (98.7%) participants with complete EQ-5D data, 2201 (74.4%) reported problems in at least one EQ-5D-5L dimension. Multivariable linear regression identified independent associations between poorer HRQoL (EQ-5D-3L index value) and obesity (body mass index ≥30.0 kg/m2, β -0.037, 95% CI -0.058 to -0.016, P = .001), HADS depression score ≥8 (β -0.159, -0.182 to -0.137, P < .001), anxiety score ≥8 (β -0.090, -0.110 to -0.069, P < .001), taking ≥10 medications (β -0.065, -0.085 to -0.046, P < .001), sarcopenia (β -0.062, -0.080 to -0.043, P < .001) haemoglobin <100 g/L (β -0.047, -0.085 to -0.010, P = .012) and pain (β -0.134, -0.152 to -0.117, P < .001). Smoking and prescription of prednisolone independently associated with problems in self-care and usual activities respectively. Renin-angiotensin system inhibitor (RASi) prescription associated with fewer problems with mobility and usual activities.

Potentially modifiable factors including obesity, pain, depression, anxiety, anaemia, polypharmacy, smoking, steroid use and sarcopenia associated with poorer HRQoL in this cohort, whilst RASi use was associated with better HRQoL in two dimensions.

Socioeconomic status (SES) is associated with late disease presentation and poorer outcomes. We evaluate the effect of SES on treatment outcomes and report the correlation between SES and baseline characteristics of participants in the Treatment of Advanced Glaucoma Study.

Pragmatic multicentre randomised controlled trial. Four hundred and fifty-three patients presenting with advanced open-angle glaucoma in at least one eye (Hodapp-Parrish-Anderson classification). Participants were randomised to either glaucoma drops (medical arm) or trabeculectomy (surgery arm). Clinical characteristics, Quality of life measurement (QoL) and SES defined by the Index of Multiple Deprivation are reported. Subgroup analysis explored treatment effect modifications of SES at 24 months. Correlation between SES and baseline characteristics was tested with the χ2 test of association for dichotomous variables and pairwise Pearson's correlation for continuous variables.

The mean visual field mean deviation was -17.2 (6.7)dB for the most deprived quintile of participants and -13.0 (5.5) for the least deprived quintile in the index eye. At diagnosis, there was a strong correlation between SES and ethnicity, age, extent of visual field loss and number of visits to opticians prior to diagnosis. At 24 months, there was no evidence that the treatment effect was moderated by SES.

In patients presenting with advanced glaucoma. SES at baseline is correlated with poorer visual function, poorer Visual Function Questionnaire-25 QoL, ethnicity, age and number visits to an optician in the years preceding diagnosis. SES at baseline does not have an effect of the success of treatment at 24 months.

ISRCTN56878850.

The Rose hypothesis predicts that since genetic variation is greater within than between populations, genetic risk factors will be associated with individuals' risk of disease but not population disparities, and since socioenvironmental variation is greater between than within populations, socioenvironmental risk factors will be associated with population disparities but not individuals' disease risk.

We used the UK Biobank to test the Rose hypothesis for type 2 diabetes (T2D) ethnic disparities in the UK. Our cohort consists of 26 912 participants from Asian, black and white ethnic groups. Participants were characterised as T2D cases or controls based on the presence or absence of T2D diagnosis codes in electronic health records. T2D genetic risk was measured using a polygenic risk score (PRS), and socioeconomic deprivation was measured with the Townsend Index (TI). The variation of genetic (PRS) and socioeconomic (TI) risk factors within and between ethnic groups was calculated using analysis of variance. Multivariable logistic regression was used to associate PRS and TI with T2D cases, and mediation analysis was used to analyse the effect of PRS and TI on T2D ethnic group disparities.

T2D prevalence differs for Asian 23.34% (OR=5.14, CI=4.68 to 5.65), black 16.64% (OR=3.81, CI=3.44 to 4.22) and white 7.35% (reference) ethnic groups in the UK. Both genetic and socioenvironmental T2D risk factors show greater within (w) than between (b) ethnic group variation: PRS w=64.60%, b=35.40%; TI w=71.18%, b=28.19%. Nevertheless, both genetic risk (PRS OR=1.96, CI=1.87 to 2.07) and socioeconomic deprivation (TI OR=1.09, CI=1.08 to 1.10) are associated with T2D individual risk and mediate T2D ethnic disparities (Asian PRS=22.5%, TI=9.8%; black PRS=32.0%, TI=25.3%).

A relative excess of within-group versus between-group variation does not preclude T2D risk factors from contributing to T2D ethnic disparities. Our results support an integrative approach to health disparities research that includes both genetic and socioenvironmental risk factors.

Approximately 20-30% of patients with a cardiac disease suffer from anxiety and/or depression, leading to poor health outcomes. To identify this subgroup, clinical guidelines recommend screening for anxiety and depression in cardiac rehabilitation (CR). It is unknown how screening practice is delivered post-COVID.

This observational study used data from the National Audit of Cardiac Rehabilitation from April 2018-March 2022. Descriptive statistics were used to assess screening rates and prevalence, while a multivariate logistic regression model was performed to analyse determinants for screening for anxiety and depression among patients participating in cardiac rehabilitation.

The population consisted of 245,705 patients, where 128,643 (52.4%) were screened and 117,062 (47.6%) were not. Patients attending CR during first year of COVID-19 were less likely to be screened. Patients with female gender, living alone, non-white ethnicity, living in the most deprived areas, current smoking, and physical inactivity were less likely to be screened, while patients who were revascularized, having an objective physical fitness test, and attending a certified CR center were more likely to be screened. For patients attending CR during COVID-19, the prevalence of anxiety and depression decreased significantly. For anxiety the prevalence dropped from 34.4% to 15.8%, for depression the prevalence dropped from 33.5% to 16.5%.

CR service provision was negatively impacted during COVID-19, leading to much lower screening for anxiety and depression in the CR setting. Prevalence of anxiety and depression decreased during COVID-19 for this population, possibly because psychologically affected patients refrained from attending CR.

Recent studies have established the key individual-level risk factors of COVID-19 mortality such as age, gender, ethnicity, and socio-economic status. However, the spread of infectious diseases is a spatial and temporal process implying that COVID-19 mortality and its determinants may vary sub-nationally and over time. We investigate the spatial patterns of age-standardised death rates due to COVID-19 and their correlates across local authority districts in England, Wales, and Scotland across three waves of infection. Using a Spatial Durbin model, we explore within- and between-country variation and account for spatial dependency. Areas with a higher share of ethnic minorities and higher levels of deprivation had higher rates of COVID-19 mortality. However, the share of ethnic minorities and population density in an area were more important predictors of COVID-19 mortality in earlier waves of the pandemic than in later waves, whereas area-level deprivation has become a more important predictor over time. Second, during the first wave of the pandemic, population density had a significant spillover effect on COVID-19 mortality, indicating that the pandemic spread from big cities to neighbouring areas. Third, after accounting for differences in ethnic composition, deprivation, and population density, initial cross-country differences in COVID-19 mortality almost disappeared. COVID-19 mortality remained higher in Scotland than in England and Wales in the third wave when COVID-19 mortality was relatively low in all three countries. Interpreting these results in the context of higher overall (long-term) non-COVID-19 mortality in Scotland suggests that Scotland may have performed better than expected during the first two waves. Our study highlights that accounting for both spatial and temporal factors is essential for understanding social and demographic risk factors of mortality during pandemics.

Air pollution is associated with poor health. Yet, more research is needed to reveal the association of long-term exposure to outdoor air pollution with less studied health outcomes like hospital admissions and general-practitioner (GP) visits and whether this association is stronger for ethnic minorities compared to the rest of population. This study investigates the association between air pollution and all-cause GP visits and hospital admissions by ethnicity in the United-Kingdom (UK).

We used individual-level longitudinal data from the "UK Household Longitudinal Study" including 46,442 adult individuals who provided 140,466 responses across five years (2015-2019). This data was linked to yearly concentrations of NO2, SO2, and particulate-matter (PM10, PM2.5) outdoor pollution using the Lower Super Output Area (LSOA) of residence for each individual. Multilevel mixed-effects ordered logistic models were used to assess the association between air pollution and all-cause GP visits and hospital admissions.

We found higher odds of hospital admissions per 1 μg/m3 increase in annual concentrations of NO2 (OR = 1.008; 95%CI = 1.004-1.012), SO2 (OR = 1.048; 95%CI = 1.014-1.083), PM10 (OR = 1.011; 95%CI = 1.003-1.018), and PM2.5 (OR = 1.018; 95%CI = 1.007-1.029) pollutants. Higher odds of GP visits were also observed with increased exposure to NO2 (OR = 1.010; 95%CI = 1.006-1.014) and SO2 (OR = 1.114; 95%CI = 1.077-1.152) pollutants. The observed associations did not differ across ethnic groups, but by country of birth, they were more pronounced in individuals born outside UK than those born in UK.

This study supports an association between higher exposure to outdoor air pollution and increased all-cause hospital admissions and GP visits. Further longitudinal studies with longer follow-up time periods may be able to reveal more definite conclusions on the influence of ethnicity on the association between long-term outdoor air pollution and both hospital admissions and GP visits.

Health inequities exist within and between societies at different hierarchical levels. Despite overall improvements in health status in European Union countries, disparities persist among socially, economically, and societally disadvantaged individuals. This study aims to develop a holistic model of health determinants, examining the complex relationship between various determinants of health inequalities and their association with health condition.

Health inequalities and conditions were assessed at the territorial level of Local Administrative Units (LAU1) in the Czech Republic. A dataset of 57 indicators was created, categorized into seven determinants of health and one health condition category. The necessary data were obtained from publicly available databases. Comparisons were made between 2001-2003 and 2016-2019. Various methods were employed, including composite indicator creation, correlation analysis, the Wilcoxon test, aggregate index calculation, cluster analysis, and data visualization using the LISA method.

The correlation matrix revealed strong relationships between health inequality categories in both periods. The most significant associations were observed between Economic status and social protection and Education in the first period. However, dependencies weakened in the later period, approaching values of approximately 0.50. The Wilcoxon test confirmed variations in determinant values over time, except for three specific determinants. Data visualization identified persistently adverse or worsening health inequalities in specific LAU1, focusing on categories such as Economic status and social protection, Education, Demographic situation, Environmental status, Individual living status, and Road safety and crime. The health condition indices showed no significant change over time, while the aggregate index of health inequalities improved with widened differences.

Spatial inequalities in health persist in the Czech Republic, influenced by economic, social, demographic, and environmental factors, as well as local healthcare accessibility. Both inner and outer peripheries exhibit poor health outcomes, challenging the assumption that urban areas fare better. The combination of poverty and vulnerabilities exacerbates these inequalities. Despite the low rates of social exclusion and poverty, regional health inequalities persist in the long term. Effectively addressing health inequalities requires interdisciplinary collaboration and evidence-based policy interventions. Efforts should focus on creating supportive social and physical environments, strengthening the healthcare system, and fostering cooperation with non-medical disciplines.

Increasing the GP workforce will not necessarily level up healthcare provision. Instead, increasing GP training numbers could worsen health inequity and inequalities. This is especially true if there are fewer opportunities to learn, train, and build confidence in underserved, socioeconomically deprived areas.

To investigate the representation of socioeconomic deprivation in postgraduate GP training practices in Northern Ireland (NI).

An analysis of socioeconomic deprivation indices and scores of GP practices in NI involved in postgraudate GP training.

The socioeconomic deprivation indices and scores of GP postgraduate training practices were compared against general practice in NI by examining the representation of practices whose patients live in areas of blanket deprivation, higher deprivation, and higher affluence.

Of 319 practices in NI, 195 (61%) were registered as postgraduate training practices and had a statistically significantly lower deprivation score (3.02±0.21) compared with non-training practices (3.2±0.32), t(255) -2.02, P = 0.041. The proportion of training practices with blanket deprivation and higher levels of deprivation was underrepresented, with the current postgraduate GP training practices having more affluent populations.

Postgraduate training practices had a statistically significant lower deprivation score and did not fully reflect the socioeconomic make-up of wider NI general practice. The results, however, are more favourable than in other areas of the UK and better than undergraduate teaching opportunities in general practice. Health inequalities will worsen if the representation of general practice training in areas of greater socioeconomic deprivation is not increased.

Chest pain (CP) is one of the most frequent presentations to the emergency department (ED), a large proportion of which is non-cardiac chest pain (NCCP). Repeat attendances to ED are common and impose considerable burden to overstretched departments.

Our aim was to determine drivers for repeat ED presentations using NCCP as the primary cause of index presentation.

This was a retrospective cohort study of 1066 consecutive presentations with NCCP to a major urban hospital ED in North England. Index of Multiple Deprivation (IMD), a postcode-derived validated index of deprivation, was computed. Charlson comorbidity index (CCI) was determined by reference to known comorbidity variables. Repeat presentation to ED to any national hospital was determined by a national linked database (population 53.5 million). Independent predictors of ED representation were computed using logistic regression analysis.

Median age was 43 (IQR 28-59), and 50.8% were male. Furthermore, 27.8%, 8.1% and 3.8% suffered from chronic obstructive pulmonary disease (COPD), hypertension and diabetes mellitus, respectively. The most frequent diagnoses, using ICD-10 coding, were non-cardiac chest pain (55.1%), followed by respiratory conditions (14.7%). One-year incidence of adjudicated myocardial infarction, urgent or emergency coronary revascularisation and all-cause death was 0.6%, 2% and 5.3%, respectively. There was a total of 4770 ED repeat presentations 1 year prior to or following index presentation with NCCP in this cohort. Independent (multivariate) predictors for frequent re-presentation (defined as ≥2 representations) were a history of COPD (OR [odds ratio] 2.06, p = 0.001), previous MI (OR3.6, p = 0.020) and a Charlson comorbidity index ≥1 (OR 1.51, p = 0.030). The frequency of previous MI was low as only 3% had sustained a previous MI.

This analysis indicates that COPD and complex health care needs (represented by high CCI), but not socio-economic deprivation, should be health policy targets for lessening repeat ED presentations. What is already known on this topic: Repeat presentations with non-ischaemic chest pain are common, placing a considerable burden on emergency departments.

COPD and complex health care needs, denoted by Charlson comorbidity index, are implicated as drivers for repeat presentation to accident and emergency department. Socio-economic deprivation was not an independent predictor of re-presentation. How might this study affect research, practice, or policy: Community-based support for COPD and complex health care needs may reduce frequency of ED attendance.

Few studies describe the epidemiology of childhood acute kidney injury (AKI) nationally. Laboratories in England are required to issue electronic (e-)alerts for AKI based on serum creatinine changes. This study describes a national cohort of children who received an AKI alert and their clinical course.

A cross-section of AKI episodes from 2017 are described. Hospital record linkage enabled description of AKI-associated hospitalizations including length of stay (LOS) and critical care requirement. Risk associations with critical care (hospitalized cohort) and 30-day mortality (total cohort) were examined using multivariable logistic regression.

In 2017, 7788 children (52% male, median age 4.4 years, interquartile range 0.9-11.5 years) experienced 8927 AKI episodes; 8% occurred during birth admissions. Of 5582 children with hospitalized AKI, 25% required critical care. In children experiencing an AKI episode unrelated to their birth admission, Asian ethnicity, young (<1 year) or old (16-<18 years) age (reference 1-<5 years), and high peak AKI stage had higher odds of critical care. LOS was higher with peak AKI stage, irrespective of critical care admission. Overall, 30-day mortality rate was 3% (n = 251); youngest and oldest age groups, hospital-acquired AKI, higher peak stage and critical care requirement had higher odds of death. For children experiencing AKI alerts during their birth admission, no association was seen between higher peak AKI stage and critical care admission.

Risk associations for adverse AKI outcomes differed among children according to AKI type and whether hospitalization was related to birth. Understanding the factors driving AKI development and progression may help inform interventions to minimize morbidity.

To describe and compare the association between suicidality and subsequent readmission for patients hospitalized for eating disorder treatment, within 2 years of discharge, at two large academic medical centers in two different countries.

Over an 8-year study window from January 2009 to March 2017, we identified all inpatient eating disorder admissions at Weill Cornell Medicine, New York, USA (WCM) and South London and Maudsley Foundation NHS Trust, London, UK (SLaM). To establish each patient's-suicidality profile, we applied two natural language processing (NLP) algorithms, independently developed at the two institutions, and detected suicidality in clinical notes documented in the first week of admission. We calculated the odds ratios (OR) for any subsequent readmission within 2 years postdischarge and determined whether this was to another eating disorder unit, other psychiatric unit, a general medical hospital admission or emergency room attendance.

We identified 1126 and 420 eating disorder inpatient admissions at WCM and SLaM, respectively. In the WCM cohort, evidence of above average suicidality during the first week of admission was significantly associated with an increased risk of noneating disorder-related psychiatric readmission (OR 3.48 95% CI = 2.03-5.99, p-value < .001), but a similar pattern was not observed in the SLaM cohort (OR 1.34, 95% CI = 0.75-2.37, p = .32), there was no significant increase in risk of admission. In both cohorts, personality disorder increased the risk of any psychiatric readmission within 2 years.

Patterns of increased risk of psychiatric readmission from above average suicidality detected via NLP during inpatient eating disorder admissions differed in our two patient cohorts. However, comorbid diagnoses such as personality disorder increased the risk of any psychiatric readmission across both cohorts.

Suicidality amongst is eating disorders is an extremely common presentation and it is important we further our understanding of identifying those most at risk. This research also provides a novel study design, comparing two NLP algorithms on electronic health record data based in the United States and United Kingdom on eating disorder inpatients. Studies researching both UK and US mental health patients are sparse therefore this study provides novel data.

Patients with bladder and kidney cancer may experience diagnostic delays.

To identify patterns of suboptimal care and contributors of potential missed diagnostic opportunities (MDOs).

Prospective, mixed-methods study recruiting participants from nine general practices in Eastern England between June 2018 and October 2019.

Patients with possible bladder and kidney cancer were identified using eligibility criteria based on National Institute for Health and Care Excellence (NICE) guidelines for suspected cancer. Primary care records were reviewed at recruitment and at 1 year for data on symptoms, tests, referrals, and diagnosis. Referral predictors were examined using logistic regression. Semi-structured interviews were undertaken with 15 patients to explore their experiences of the diagnostic process, and these were analysed thematically.

Participants (n = 940) were mostly female (n = 657, 69.9%), with a median age of 71 years (interquartile range 64-77 years). In total, 268 (28.5%) received a referral and 465 (48.5%) had a final diagnosis of urinary tract infection (UTI). There were 33 (3.5%) patients who were diagnosed with cancer, including prostate (n = 17), bladder (n = 7), and upper urothelial tract (n = 1) cancers. Among referred patients, those who had a final diagnosis of UTI had the longest time to referral (median 81.5 days). Only one-third of patients with recurrent UTIs were referred despite meeting NICE referral guidelines. Qualitative findings revealed barriers during the diagnostic process, including inadequate clinical examination, female patients given repeated antibiotics without clinical reviews, and suboptimal communication of test results to patients.

Older females with UTIs might be at increased risk of MDOs for cancer. Targeting barriers during the initial diagnostic assessment and follow-up might improve quality of diagnosis.