Area-based Deprivation Measures Research Articles

Does Administrative Data Reflect Individual Experience? Comparing an Index of Poverty with Individually Collected Data on Financial Well-being in a Multi-Ethnic Community

The Income Deprivation Affecting Children Index (IDACI) uses administrative data to count children living in households in receipt of both in-work and out-of-work means-tested benefits and provides small area ranking as an indicator of child poverty in neighbourhoods. Benefit take-up rates within an area will affect its reliability. We aimed to examine benefit take-up rates and compare area ranking by the IDACI with ranking using individually reported data across areas of varying ethnic composition. Mothers living in areas with high minority ethnic density were less likely to report claiming a benefit than those in majority White or mixed areas, despite reporting lower incomes. The correlation between self-reported material difficulties and worsening IDACI rank was much lower in areas characterised by minority ethnic populations. Further investigation into the performance of area-based deprivation measures in areas with high minority ethnic density is needed.

Trends in absolute and relative risk of acute myocardial infarction in people with type 2 diabetes in Scotland: a national retrospective cohort study

BackgroundWhether more rigorous monitoring and evidence-based treatment of type 2 diabetes has led to improvements in cardiovascular outcomes is unclear. We aimed to explore trends in incidence rates of acute myocardial infarction in the Scottish adult population with type 2 diabetes compared with the non-diabetic population. MethodsIncidence rates of acute myocardial infarction (first admissions and deaths in and out of hospital) between Jan 1, 2001, and Dec 31, 2010, for adults aged 35–84 years were derived from Scottish Morbidity Records and linked death records. Diabetes diagnoses were ascertained by linkage to the Scottish diabetes register. Trends were analysed with negative binomial regression adjusted for age and an area-based measure of socioeconomic deprivation, and then expressed as annual percentage change in rates. FindingsOf 118 340 incident acute myocardial infarctions, 15 798 (13%) were in people with type 2 diabetes 1·88 million (4%) of 50·7 million person-years at risk were in people with type 2 diabetes. In men and women with and without type 2 diabetes, incidence of acute myocardial infarction decreased over time. Incidence was higher among people with than without type 2 diabetes, with higher relative risks in women than in men. The mean annual fall in rate of acute myocardial infarction was 3·7% (95% CI 3·2–4·2) and 2·3% (2·0–2·7) in women and men without diabetes, respectively; and 5·6% (4·6–6·7) and 4·4% (3·6–5·2) in women and men with type 2 diabetes. Relative risks for acute myocardial infarction declined for people with type 2 diabetes compared with people without type 2 diabetes from 1·5 (1·4–1·7) to 1·2 (1·1–1·3) for men and 1·8 (1·6–2·1) to 1·5 (1·3–1·6) for women between 2001 and 2010. InterpretationRates of acute myocardial infarction decreased over time in all population groups with more pronounced declines among people with than without type 2 diabetes. Secular trends in risk factors and improved primary and secondary prevention of cardiovascular disease are potential explanations for the observed time trends. FundingData linkage of the Scottish population-based register of people with diagnosed diabetes to national hospital admission and mortality records and data management was funded by the Scottish Government through the Scottish Diabetes Group, which had no role in the writing of the abstract or the decision to submit for publication.

The changing demographics of inpatient hospice death: Population-based cross-sectional study in England, 1993–2012

Background: Studies in the United Kingdom and elsewhere have suggested inequality of hospice provision with respect to factors such as age, diagnosis and socio-economic position. How this has changed over time is unknown. Aim: To describe the factors associated with inpatient hospice death in England and examine how these have changed over time. Design: Population-based study. Multivariable Poisson regression compared 1998–2002, 2003–2007 and 2008–2012, with 1993–1997. Explanatory variables included individual factors (age, gender, marital status, underlying cause of death) and area-based measures of deprivation. Setting: Adults aged 25 years and over who died in inpatient hospice units in England between 1993 and 2002 (n = 446,615). Results: The annual number of hospice deaths increased from 17,440 in 1993 to 26,032 in 2012, accounting for 3.4% of all deaths in 1993 and 6.0% in 2012. A total of 50.6% of hospice decedents were men; the mean age was 69.9 (standard deviation: 12.4) years. The likelihood of hospice decedents being in the oldest age group (>85 years) increased over time (proportion ratio: 1.43, 95% confidence interval: 1.39 to 1.48 for 2008–2012 compared to 1993–1997). Just 5.2% of all hospice decedents had non-cancer diagnoses, though the likelihood of non-cancer conditions increased over time (proportion ratio: 1.41, 95% confidence interval: 1.37 to 1.46 for 2008–2012 compared to 1993–1997). The likelihood of hospice decedents being resident in the least deprived quintile increased over time (proportion ratio: 1.25, 95% confidence interval: 1.22 to 1.29 for 2008–2012 compared to 1993–1997). Conclusion: The increase in non-cancer conditions among hospice decedents is encouraging although absolute numbers remain very small. Deprivation trends are concerning and require further exploration.

Socioeconomic Patterning in the Incidence and Survival of Children and Young People Diagnosed with Malignant Melanoma in Northern England

Previous studies have found marked increases in melanoma incidence. The increase among young people in northern England was especially apparent among females. However, overall 5-year survival has greatly improved. The present study aimed to determine whether socioeconomic factors may be involved in both etiology and survival. All 224 cases of malignant melanoma diagnosed in patients aged 10-24 years during 1968-2003 were extracted from a specialist population-based regional registry. Negative binomial regression was used to examine the relationship between incidence and area-based measures of socioeconomic deprivation and small-area population density. Cox regression was used to analyze the relationship between survival and deprivation and population density. There was significantly decreased risk associated with living in areas of higher unemployment (relative risk per 1% increase in unemployment=0.93; 95% confidence interval (CI) 0.90-0.96, P<0.001). Survival was better in less deprived areas (hazard ratio (HR) per tertile of household overcrowding=1.52; 95% CI 1.05-2.20; P=0.026), but this effect was reduced in the period 1986-2003 (HR=0.61; 95% CI 0.40-0.92; P=0.018). This study found that increased risk of melanoma was linked with some aspects of greater affluence. In contrast, worse survival was associated with living in a more deprived area.

Linking of primary care records to census data to study the association between socioeconomic status and cancer incidence in Southern Europe: a nation-wide ecological study.

BackgroundArea-based measures of economic deprivation are seldom applied to large medical records databases to establish population-scale associations between deprivation and disease.ObjectiveTo study the association between deprivation and incidence of common cancer types in a Southern European region.MethodsRetrospective ecological study using the SIDIAP (Information System for the Development of Research in Primary Care) database of longitudinal electronic medical records for a representative population of Catalonia (Spain) and the MEDEA index based on urban socioeconomic indicators in the Spanish census. Study outcomes were incident cervical, breast, colorectal, prostate, and lung cancer in 2009–2012. The completeness of SIDIAP cancer recording was evaluated through linkage of a geographic data subset to a hospital cancer registry. Associations between MEDEA quintiles and cancer incidence was evaluated using zero-inflated Poisson regression adjusted for sex, age, smoking, alcoholism, obesity, hypertension, and diabetes.ResultsSIDIAP sensitivity was 63% to 92% for the five cancers studied. There was direct association between deprivation and lung, colorectal, and cervical cancer: incidence rate ratios (IRR) 1.82 [1.64–2.01], IRR 1.60 [1.34–1.90], IRR 1.22 [1.07–1.38], respectively, comparing the most deprived to most affluent areas. In wealthy areas, prostate and breast cancers were more common: IRR 0.92 [0.80–1.00], IRR 0.91 [0.78–1.06]. Adjustment for confounders attenuated the association with lung cancer risk (fully adjusted IRR 1.16 [1.08–1.25]), reversed the direction of the association with colorectal cancer (IRR 0.90 [0.84–0.95]), and did not modify the associations with cervical (IRR 1.27 [1.11–1.45]), prostate (0.74 [0.69–0.80]), and breast (0.76 [0.71–0.81]) cancer.ConclusionsDeprivation is associated differently with the occurrence of various cancer types. These results provide evidence that MEDEA is a useful, area-based deprivation index for analyses of the SIDIAP database. This information will be useful to improve screening programs, cancer prevention and management strategies, to reach patients more effectively, particularly in deprived urban areas.

OP49 Socio-Economic Status and Lung Cancer Incidence in Men with type 2 Diabetes in Scotland (2001-2007)

BackgroundDiabetes is a chronic disease which affects c. 5% of Scottish men; lung cancer is the second most common cancer among men in Scotland. While both conditions exhibit marked social...

Increasing Incidence and Sociodemographic Variation in Community-onset Staphylococcus Aureus Skin and Soft Tissue Infections in New Zealand Children

We analyzed all cases of community-onset Staphylococcus aureus skin and soft tissue infection in children presenting to our hospital between 2007 and 2010. A total of 1860 children were included. There was significant sociodemographic disparity, with the incidence disproportionately higher in Maori and Pacific Island children residing in deprived areas.

Area-based socio-economic measures as tools for health disparities research, policy and planning.

This measures es on special the (ABSMs). contemporary issue of the ABSMs, Canadian use as of the Journal area-based name of Public suggests, socio-economic Health are focustools es on the contemporary use of area-based socio-economic mea ures (ABSMs). ABSMs, as the n me uggests, are tool that utilize information (often from the census) selected specifically to characterize the socio-economic profile of geographic areas rather than of individuals. Single-component measures, such as neighbourhood income, are a common example; multiple-component area-based measures of deprivation are another instance of ABSMs. Interest in such devices is not as recent as we may tend to assume. The tools of what was at the time the emerging science of statistics were being used in England by the second half of the nineteenth century to describe the geography of health, particularly by showing differences in mortality between urban and rural areas but also by demonstrating differences between wealthy and poor urban areas.1-2 By the early 20th century in the United States, where statistically-based empirical orientations to social science were taking root, there were numerous attempts to objectively categorize what had come to be called socio-economic status (SES).3 6 Chapin, for example, developed a four-component scale consisting of cultural possessions, effective income, participation in group activities, and material possessions "in order to permit the equating of these factors in experimental study." (ref. 4, p. 99) It is an index that has a familiar ring almost a century later. By the 1930s, again in the United States, this practical interest in statistics and geography saw the first use of census tracts in social analyses;78 and by the late 1950s, Coulter and Guralnick were reporting that census data were being used at census-tract level in conjunction with vital statistics to describe differences in mortality rates between socio-economic groups.9 At the same time, Farber and Osoinach (1959) had developed an index of socio-economic rank of census tracts using census data on occupation, education, income, and non-white population.10 While much of this history may be largely unknown today, there is no doubt that considerable interest in ABSMs has arisen over the

Congenital lower urinary tract obstruction: a population‐based epidemiological study

To determine the prevalence and outcome of lower urinary tract obstruction (LUTO), including the sensitivity of antenatal diagnosis. A retrospective population-based study. Regional population-based congenital anomalies register (WMCAR). Fetuses affected by LUTO delivered between 1995 and 2007 to women resident in the West Midlands. Cases were selected from the WMCAR using codes and keyword terms from the International Classification of Diseases, tenth revision (ICD10). Diagnoses were validated using additional data sets from Regional Fetal Medicine, Perinatal Pathology and Paediatric services. Rates of prevalence, prenatal diagnosis and mortality, with trends. There were 284 LUTO cases in 851 419 births during the study period, representing a total prevalence of 3.34 (2.95-3.72) per 10 000 births, and this prevalence did not change significantly over time. The prevalence of LUTO was significantly higher in Black and minority ethnic groups when compared with white Europeans (OR 2.38; 95% CI 1.87-3.03), and are associated with area-based deprivation measures (P < 0.01). Of all LUTO cases, 221 (77.8%) were isolated, and the remainder were associated with other structural or chromosomal anomalies. The most common subtype was posterior urethral valves (PUVs; n = 179, 63%). In total there were 211 (74.3%) cases of isolated, non-female, singleton fetuses that fitted the referral criteria for in utero vesico-amniotic shunting, giving a prevalence of 2.48 (2.14-2.81) per 10 000 live births. Within this group, the prenatal diagnosis rate was 46.9% (99/211). This is the largest population-based study of LUTO that has been performed to date, and provides accurate estimates for prevalence. The low prevalence and relatively low rate of antenatal detection limit the number of cases amenable to prenatal surgical intervention.

Shipyards and sectarianism: How do mortality and deprivation compare in Glasgow and Belfast?

The extent to which the higher level of mortality seen in Glasgow compared with other UK cities is solely attributable to socio-economic deprivation has been the focus of much discussion recently. Some authors have suggested that poorer health in the city may be influenced by issues related to its history of religious sectarianism. In order to investigate this further, this study compared deprivation and mortality between Glasgow and Belfast, a similar post-industrial city, but one with a considerably more pronounced sectarian divide. To compare the deprivation and mortality profiles of the two cities; to assess the extent to which any differences in mortality can be explained by differences in area-based measures of deprivation; and to examine whether these analyses shed any light on the 'sectarianism' hypothesis for Glasgow's excess mortality relative to elsewhere in the UK. Replicating the methodology of a recent study comparing deprivation and mortality in Glasgow, Liverpool and Manchester, rates of 'income deprivation' for 2005 were calculated for every small area across the two cities (average population size: 1810 in Belfast; 1650 in Glasgow). Standardized mortality ratios were calculated for the period 2003-2007 for Glasgow relative to Belfast, standardizing for age, gender and income deprivation decile. While total levels of deprivation were slightly higher in Glasgow than in Belfast (24.8% of Glasgow's population were income deprived in 2005 compared with 22.4% in Belfast), Belfast was more unequal in terms of its distribution of deprivation across the city. After standardizing for age, sex and deprivation, all-cause mortality in Glasgow was 27% higher for deaths under 65 years of age and 18% higher for deaths at all ages. Higher all-cause mortality in Glasgow was shown in the majority of sub-analyses (i.e. for most age groups, both sexes and across the majority of deprivation deciles). Analyses of particular causes of death showed significantly higher mortality in Glasgow relative to Belfast for all conditions examined except 'external causes'. Notably higher mortality was evident for drug-related poisonings and alcohol-related causes among men in both cities. With a small number of exceptions, the results were very similar to those shown for Glasgow in comparison with Liverpool and Manchester. Area-based deprivation did not explain the higher mortality in Glasgow in comparison with Belfast. Belfast has a more profound history of sectarianism, and similar climatic conditions, to Glasgow. If these factors were to be important in explaining the high mortality in Glasgow, the question arises as to why they have not produced similar effects in Belfast.

Measuring socioeconomic position in New Zealand

Measures of socioeconomic position (SEP) are widely used in health research. To provide future researchers with empirically based guidance about the relative utility of five measures of SEP in predicting health outcomes. Data from 12,488 adults were obtained from the 2006 New Zealand Health Survey. Seven health-related outcome measures with expected variations by SEP are modelled using five measures of SEP: a census-based small-area index of relative socioeconomic deprivation, NZDep2006; a questionnaire-based individual-level index of socioeconomic deprivation, NZiDep; an index of living standards, ELSI; education, measured by highest qualification; and equivalised household income. After including the individual measure of deprivation, the area-based measure of deprivation adds useful explanatory power, and, separately, the broader spectrum provided by the living standards index adds only a small amount of extra explanatory power. The education and household income variables add little extra explanatory power. Both NZiDep and ELSI are useful health-outcome predictors. NZiDep is the cheapest data to obtain and less prone to missing data. The area index, NZDep, is a useful addition to the arsenal of individual SEP indicators, and is a reasonable alternative to them where the use of individual measures is impracticable. Education and household income, using commonly used measurement tools, may be of limited use in research if more proximal indicators of SEP are available. NZDep and NZiDep are cost-effective measures of SEP in health research. Other or additional measures may be useful if costs allow and/or for topic-related hypothesis testing.

Rising premature mortality in the UK’s persistently deprived areas: Only a Scottish phenomenon?

In the international literature, many studies find strong relationships between area-based measures of deprivation and mortality. In the UK, mortality rates have generally fallen in recent decades but the life expectancy gap between the most and least deprived areas has widened, with a number of Scottish studies highlighting increased mortality rates in deprived areas especially in Glasgow. However, these studies relate health outcomes at different time points against period-specific measures of deprivation which may not be comparable over time. Using longitudinal deprivation measures where levels of area deprivation are made comparable over time, a recent study demonstrated how levels of mortality change in relation to changing or persistent levels of (non-) deprivation over time. The results showed that areas which were persistently deprived in Scotland experienced a rise in premature mortality rates by 9.5% between 1981 and 2001. Here, focussing on persistently deprived areas we extended the coverage to the whole of the UK to assess whether, between 1991 and 2001, rising premature mortality rates in persistently deprived areas are a Scottish only phenomenon or whether similar patterns are evident elsewhere and for men and women separately. We found that male premature mortality rates rose by over 14% in Scotland over the 10-year period between the early 1990s and 2000s in persistently deprived areas. We found no significant rise in mortality elsewhere in the UK and that the rise among men in Scotland was driven by results for Glasgow where mortality rates rose by over 15% during the decade. Our analyses demonstrate the importance of identifying areas experiencing persistent poverty. These results justify even more of a public health focus on Glasgow and further work is needed to understand the demographic factors, such as health selective migration, immobility and population residualisation, which may contribute to these findings.

Uptake of the NHS Health Checks programme in a deprived, culturally diverse setting: Cross sectional study

BackgroundThe National Health Service (NHS) Health Checks are an England-wide primary prevention programme designed to lower the national burden of cardiovascular disease. In order to be effective, high risk prevention...

Socio-economic status and mortality from cardiovascular disease among people with Type 2 diabetes in Scotland (2001–2007)

BackgroundIndividuals with type 2 diabetes (T2DM) are known to be at increased risk of death from cardiovascular disease (CVD). However, the influence of socio-economic status (SES) on risk of CVD...

Neighbourhood socio‐economic characteristics and the risk of preterm birth for migrant and non‐migrant women: a study in a French district

Neighbourhood-level deprivation is associated with preterm birth; preterm birth rates are also higher for some, but not all migrant groups. We studied the impact of neighbourhood characteristics (a deprivation score and the proportion of foreign-born residents) on singleton preterm birth in the French district of Seine-Saint-Denis for women born in France, North Africa, sub-Saharan Africa and other countries. Multilevel logistic regression models were adjusted for maternal demographic and health care characteristics. For women born in France, the preterm birth rate rose with neighbourhood deprivation quintile (3.8% in the first to 5.7% in the fifth, adjusted odds ratio: 1.40 [95% confidence interval 1.14, 1.72]) and with increasing proportions of foreign-born residents. Preterm birth rates were not higher in more deprived neighbourhoods for women born outside of France and were lower in neighbourhoods with more foreign-born residents; in multilevel models, the inverse association with deprivation remained significant for women from sub-Saharan Africa. Area-based deprivation measures should be used with caution in populations with large numbers of migrants. These results raise questions about the health benefits of clustering for migrant communities as well as the negative consequences of acculturation.

Socioeconomic status and head and neck cancer

This was a population-based case-control study. CASE-CONTROL SELECTION: Eligible patients were aged between 18 and 80 years and had a primary histopathological diagnosis made between April 2002 and December 2004. Diagnosis included malignant cancers of the oral cavity, oropharynx, hypopharynx or larynx. Incident cases were identified through weekly monitoring of head and neck cancer clinics in hospital departments and were confirmed by pathology department records. Controls matched by age (5-year age band) and sex were randomly selected from the lists of general practitioners. Information about occupation, education, smoking and alcohol consumption was collected at personal interview. Socioeconomic circumstances were measured at an individual level (education, occupational social class, unemployment), and by area-based measures of deprivation. Odds ratios (OR) and corresponding 95% confidence intervals (CI) were computed by unconditional logistic regression and were adjusted for age and sex. This model was repeated to assess for potential independent effects of the range of socioeconomic components after adjusting for smoking and alcohol consumption. Interactions between smoking and consumption of alcohol, and between individual and area-based measures for socioeconomic factors were tested by the likelihood ratio test. In addition, the most important behavioural risk factors and socioeconomic variables were entered into a stepwise multivariate logistic regression model. All statistical analyses were carried out using Statistical Analysis System (SAS; Cary, North Carolina, USA) software. The study population included 103 cancer patients (38 women and 65 men), and 91 controls (39 women and 52 men). Individuals living in the most deprived areas (OR, 4.66; 95% CI, 1.79- 12.18) and those who were unemployed (OR, 2.27; 95% CI, 1.21- 4.26) had a significantly higher risk of cancer than people who had high levels of educational attainment (OR, 0.17; 95% CI, 0.05-0.58). Significance was lost for all measures of social class when adjustments were made for smoking and consumption of alcohol. When the most important behavioural and socioeconomic factors were combined in a fully adjusted multivariate analysis, smoking was the only significant risk factor (OR, 15.53; 95% CI, 5.36-44.99) found to be independently associated with head and neck cancers. A high risk of head and neck cancer was consistently associated with poor socioeconomic circumstances. There were strong links for specific components but smoking dominated the overall profile of risk. More detailed research into the nature of such associations is needed in the future.

Museums, schools and geographies of cultural value

This article explores a paradox and a possibility that have emerged from two pieces of policy-related research concerning educational use of museums within England. The paradox relates to the use of museums which, whilst widely perceived as rather elitist institutions, appear from a postcode analysis of school visits to museums to be visited by large numbers of schools located in areas of social deprivation. The present analysis further explores this paradox, drawing on revised postcode analysis and governmental indices of multiple deprivation and income deprivation affecting children. The analysis supports the contention that museums attracted visits from schools located in areas with some of the highest levels of deprivation, although it suggests that this result needs to be considered in relation to regional differences in areas of social deprivation, the location of museums and the differences between individual and area-based measures of deprivation. Attention is then drawn to the potential of considering museums through a geographical perspective, and specifically through Foucault's notions of primary, secondary and tertiary spatializations. It is argued that primary spatializations encompasses how museums are conceptualized and classified; secondary spatializations concern how various elements of museums are articulated together; and tertiary spatializations relate to the placement of museums in wider societal contexts and processes. It is suggested that the postcode analysis of school visits points both to the significance of considering tertiary spatializations relating to the social circumstances of museum visitors but also raised questions concerning primary spatializations of museums. Attention is drawn to changes in the classification and grouping of museums, and how these often encompass geographically based criteria related to the social reach of museums. The article ends by considering the degree to which museums might seek to further change their primary spatialization to reflect tertiary spatializations relating to cultural value.

Components of socioeconomic risk associated with head and neck cancer: A population-based case–control study in Scotland

The complex associations between socioeconomic circumstances and risk for head and neck cancer are under-explored. We investigated components of social class and their relative influence on the risk of head and neck cancers by studying 103 patients (age range 24–80 years) who had been diagnosed with cancer of the head and neck between April 2002 and December 2004, and 91 controls who were randomly selected from general practitioners’ lists. Information about occupation, education, smoking, and alcohol consumption was collected at personal interview. Socioeconomic circumstances were measured at an individual level (education, occupational social class, unemployment), and by area-based measures of deprivation. Odds ratios (OR) and 95% confidence intervals (CI) were computed using unconditional logistic regression and multivariate analyses. People living in the most deprived areas (OR = 4.66, 95% CI 1.79–12.18); and those who were unemployed (OR = 2.27, 95% CI 1.21–4.26) had a significantly higher risk of cancer than those with high levels of educational attainment (OR = 0.17, 95% CI 0.05–0.58). Significance was lost for all measures of social class when adjustments were made for smoking and consumption of alcohol. Smoking was the only significant risk factor (OR = 15.53, 95% CI 5.36–44.99) in the multivariate analysis. A high risk of head and neck cancer was consistently associated with poor socioeconomic circumstances, and there were strong links for specific components however smoking dominated the overall profile of risk. We propose a framework for future socioeconomic analyses.

Deprivation-based risk scores: the re-emergence of postcode prescribing in the UK?

Socioeconomic gradients exist in the prevalence of cardiovascular disease. This has prompted the development of risk scores such as ASSIGN and QRISK, which incorporate measures of deprivation, to address the issue of underprescribing of primary preventive medicines in the socially disadvantaged. The scores use area-based measures of deprivation rather than the socioeconomic status of the individual. We examined to what extent the decision to treat a patient might be influenced by where that individual lived. On the basis of individual patient risk factor data from the Scottish Health Survey, we compared the theoretical level of deprivation [Scottish Index of Multiple Deprivation (SIMD)] required to give a person an ASSIGN risk of 20% (the treatment cut-off), with the person's actual SIMD quintile. We assumed that patients are more likely to move between areas of similar deprivation (i.e. the same SIMD quintile). If the theoretical SIMD value for that individual fell within their actual SIMD quintile, we assumed that prescribing decisions could be influenced by the area of residence. If the ASSIGN risk score was implemented, the area of residence would affect the decision to initiate statins in the case of 15.7% of the population (aged 30-74 years), and for borderline hypertension, in 3.0%. This corresponds to 407 000 and 15 000 people, respectively, in Scotland and 4.6 million and 169 000 in the entire UK. These findings demonstrate that by using cardiovascular risk scores based on area deprivation, primary prevention treatment decisions will be affected by the area of residence in a large number of individuals.

Practice size, caseload, deprivation and quality of care of patients with coronary heart disease, hypertension and stroke in primary care: national cross-sectional study

BackgroundReports of higher quality care by higher-volume secondary care providers have fuelled a shift of services from smaller provider units to larger hospitals and units. In the United Kingdom, most patients are managed in primary care. Hence if larger practices provide better quality of care; this would have important implications for the future organization of primary care services. We examined the association between quality of primary care for cardiovascular disease achieved by general practices in England and Scotland by general practice caseload, practice size and area based deprivation measures, using data from the New General Practitioner (GP) Contract.MethodsWe analyzed data from 8,970 general practices with a total registered population of 55,522,778 patients in England and Scotland. We measured practice performance against 26 cardiovascular disease (coronary heart disease, left ventricular disease, and stroke) Quality and Outcomes Framework (QOF) indicators for patients on cardiovascular disease registers and linked this with data on practice characteristics and census data.ResultsDespite wide variations in practice list sizes and deprivation, the prevalence of was remarkably consistent, (coronary heart disease, left ventricular dysfunction, hypertension and cerebrovascular disease was 3.7%; 0.45%; 11.4% and 1.5% respectively). Achievement in quality of care for cardiovascular disease, as measured by QOF, was consistently high regardless of caseload or size with a few notable exceptions: practices with larger list sizes, higher cardiovascular disease caseloads and those in affluent areas had higher achievement of indicators requiring referral for further investigation. For example, small practices achieved lower scores 71.4% than large practices 88.6% (P < 0.0001) for referral for exercise testing and specialist assessment of patients with newly diagnosed angina.ConclusionThe volume-outcome relationship found in hospital settings is not seen between practices in the UK in management of cardiovascular disorders in primary care. Further work is warranted to explain apparently poorer quality achievement in some aspects of cardiovascular management relating to initial diagnosis and management among practices in deprived areas, smaller practices and those with a smaller caseload.