Areas Of England Research Articles

A service evaluation of the implementation of a novel digital intervention for hypertension self-monitoring and management system in primary care (SHIP): protocol for a mixed methods study

Abstract Background Hypertension is a key risk factor for death and disability, and blood pressure reduction is associated with significant reductions in cardiovascular risk. Large trials have shown that interventions including self-monitoring of blood pressure can reduce blood pressure but real-world data from wider implementation are lacking. Aim The self-monitoring and management service evaluation in primary care (SHIP) study will evaluate a novel digital intervention for hypertension management and medication titration platform (“Hypertension-Plus”) that is currently undergoing initial implementation into primary care in several parts of the UK. Methods and analyses The study will use a mixed methods approach including both quantitative analysis of anonymised electronic health record data and qualitative analyses of interview and customer support log data. Pseudonymised data will be extracted from electronic health records and outcomes compared between those using the digital intervention and their own historical data, as well as to those not registered to the system. The primary outcome will be difference in systolic blood pressure in the 12 months before and after implementation. A further analysis will utilise self-monitored blood pressure data from the Hypertension-Plus system itself. Semi-structured qualitative interviews will be completed with implementation and clinical leads, staff and patients in six general practices located in two different geographical areas in England. Informed by the non-adoption, abandonment, scale-up, spread, and sustainability (NASSS) framework, our analysis will identify the challenges to successful implementation and sustainability of the digital intervention in routine clinical practice and in patients’ homes. Ethics and dissemination The analyses of pseudonymised data were assessed by the sponsor (The University of Oxford) as service evaluation not requiring individual consent and hence did not require ethical approval. Ethics approval for the qualitative analyses was provided by Wales REC 4 (21/WA/0280) and individual written informed consent will be gained for all participants. Results will be published in peer-reviewed journals, presented at national and international conferences and disseminated via patient and health service organisations. Discussion This study will provide an in-depth analysis of the impact and acceptance of initial implementation of a novel digital intervention, enhancing our understanding and supporting more effective implementation of telemonitoring based hypertension management systems for blood pressure control in England.

Variation in attendance at emergency departments in England across local areas: A system under unequal pressure

BackgroundCrowding in Accident and Emergency Departments (AEDs) and long waiting times are critical issues contributing to adverse patient outcomes and system inefficiencies. These challenges are exacerbated by varying levels of AED attendance across different local areas, which may reflect underlying disparities in primary care provision and population characteristics. MethodWe used regression analysis to determine how much variation across local areas in England of attendance at emergency departments remained after controlling for population risk factors and alternative urgent care provision. FindingsThere is substantial residual variation of the order of 3 to 1 (highest to lowest) in per person attendance rate across different areas. This is not related to in-hospital capacity as proxied by the per person number of hospital emergency doctors in an area. ConclusionSome areas in England have emergency departments that are under much greater pressure than others, and this cannot be explained in terms of their population characteristics or the availability of alternative treatment options. It is imperative to better understand the drivers of this variation so that effective interventions to address utilisation can be designed.

Diabetes specialist nurse support, training and 'virtual' advice reduces district nurse visits and improves outcomes for people with diabetes requiring visits for insulin administration.

We evaluated the effectiveness of a community diabetes specialist nurse (cDSN) working with district nurses (DNs) to optimise insulin therapy on DN workload and patient outcomes. This was an observational clinical improvement study of outcomes pre- and post-introduction of an intervention within a community diabetes service in an areas of England. Patients were followed up for 6 months. The intervention was a cDSN providing advice and support to DNs in safe diabetes management, with a particular focus on insulin use. in total, 148 of 224 patients were reviewed; 130 (87.8 %) were available for follow up 6 months after their first review. Comparing pre- to post-intervention outcomes, number of patients with a hypoglycaemic event reduced from 21/129 to 1/128 (X2 = 19.71, p < 0.001) as did the number with a hyperglycaemic event; 53/129 to 23/128 (X2 = 16.48, p < 0.001). Number of DN visits and use of acute hospital services also improved significantly. Estimated cost savings through reduced DN visits, insulin usage, and hospital service use totalled £1.9 million. Significant financial savings and reduced patient harms were identified following our intervention in this cohort. Roll-out to other sites in England is a next step.

Parent carer and disabled young people’s perspectives on the impacts of changes to service provision for children and young people in England during the COVID-19 pandemic: a qualitative study

ObjectivesIn England, the delivery of health, education and social care services changed substantially during COVID-19. Some services closed, some had reduced capacity and there was a shift to the use...

‘We were persistently othering them out’: Reconceptualising ‘safeguarding’ for young people experiencing extra-familial risks and harms during transition to adulthood

Background: The transition to adulthood may involve experiences of risk and harm – including, for some young people, abuse, violence or exploitation in peer and community contexts. In the UK, such extra-familial risks and harms have prompted safeguarding responses in policy and practice. However, safeguarding conceptualisations are significantly different for young people under 18 than for those over 18, leading to service and system gaps in transition. The concept of Transitional Safeguarding seeks to address this, advocating for more integrated approaches that centre the needs, voices and lived experiences of young people. Objectives: Based on findings from a study on early-stage innovation developments aligned with Transitional Safeguarding, this paper considers issues and dilemmas linked to reconceptualising ‘safeguarding’ so as to better protect young people experiencing extra-familial risks and harms during transition to adulthood. Methods: A 4-year study followed safeguarding innovation developments in selected local areas in England, based on a qualitative case study approach that involved ethnography, interviews and documentary analysis. Findings: The paper highlights gaps in safeguarding services and systems for young people around age 18, when support may either significantly decrease or stop altogether. The intersecting dynamics of risks, harms and unmet needs point to the importance of multi-agency collaboration, beyond service-centric threshold definitions. The need to systemically and systematically involve young people in support and innovation development is also emphasised. Conclusions: The boundary-spanning change which the Transitional Safeguarding approach advocates requires significant shifts to create conditions capable of addressing risks and harms during transition to adulthood, as well as their structural drivers. Navigating these shifts remains a key challenge for local services and systems engaged in Transitional Safeguarding innovation, and their efforts need to be supported by policy frameworks and adequate funding.

The perceptions of secondary school students regarding the learning of computer programming at Key Stage 4 in the revised curriculum in England: problems and solutions.

Programming is becoming progressively important for many societies in the world today. It is also required in educational institutions and is especially important for students who will be graduating and looking for employment opportunities in the future. However, the teaching of a programming is not well developed in many secondary schools in different areas in England. Today, teaching programming is considered to be of the priority domain of several countries in the twenty-first century. Interest in this domain is wide and the amount of research conducted in the field is numerous. This study was designed to investigate and to aid a critical students’ understanding of the learning of programming in the revised Key Stage 4 (KS4) Computer Science (CS) curriculum. It seeks to understand the impact of learning programming on student’s perceptions toward programming and how to improve the teaching and learning of programming. The study found that the issues faced by students learning programming include a lack of time, the perception that it is a ‘difficult’ subject and students’ insufficient understanding of programming. The findings also suggest that schools have made efforts to overcome these challenges and are willing to adopt programming as a subject and to help, encourage, develop and improve students’ ability to learn programming.

Sexual experiences and behaviours of the parents in the Avon Longitudinal Study of Parents and Childhood (ALSPAC)

The aim of this data note is to describe the sexual experiences, functioning and behaviour data collected from the parent cohorts of the Avon Longitudinal Study of Parents and Children (ALSPAC) occurring during their childhoods and up to 19 years after the birth of the index child. ALSPAC is an ongoing birth cohort which enrolled 14,541 pregnant women living in Avon, an area of southwest England, with expected dates of delivery between April 1991 and December 1992 inclusive. It continues collecting data on these mothers (age range at delivery &lt;16–41 years), their partners (age range at delivery &lt;16–65), and their offspring, so far resulting in 100,000+ phenotype variables. During the index pregnancy the mothers were asked (and at 8 months post-delivery for partners) about their early sexual experiences to identify sexual abuse, the age at which an event first occurred, along with the type of perpetrator (e.g. stranger, relatives, boy/girlfriend). There are also data on these parents’ experiences of sexual assault as adults. Both parents were asked also about sexual abuse within a battery of questions identifying Adverse Childhood Events (ACEs). Further longitudinal data described here includes satisfaction with sexual and non-sexual sides of their relationship; sexual functioning; and at seven years post-delivery, both parents were asked to describe their sexual orientation as well as the sex of their partners. These data provide the ability to compare generational differences between parental sexual experiences and behaviours with those of their offspring, as well as allowing comparisons with other longitudinal surveys where similar (or identical) information has been collected such as the National Survey of Sexual Attitudes and Lifestyles (NATSAL-3). This paper forms a companion to a further data note describing similar data collected on the offspring cohort.

JUE Insight: The labor market effects of place-based policies: Evidence from England’s Neighbourhood Renewal Fund

Neighbourhood renewal programs are a type of place-based policy that aim to revive underperforming localities. The literature on place-based policies has found mixed results regarding their effects on local labor market outcomes, but there are relatively few studies of policies that aim to improve local labor supply. In this paper we examine the labor market effects of the Neighbourhood Renewal Fund, which targeted 88 of the most deprived areas in England during the early 2000s as part of the Labour government’s National Strategy for Neighbourhood Renewal. The fund disbursed almost £3 billion for spending on community safety, education, healthcare and worklessness, with supply-side interventions making up the bulk of the program’s spending on worklessness. Using a difference-in-differences approach, we find statistically significant impacts on local employment. Our results suggest that policy interventions to improve local labor supply can be a successful strategy for neighborhood renewal.

Risk factors and vulnerabilities amongst people who died whilst homeless or with a housing support need: a mixed-methods analysis of client case histories in a UK local authority area

BackgroundOver the last decade, deaths amongst homeless people in England and Wales have doubled, with the average age of death several decades younger than the general population. Due to limited availability, aggregating data on this cohort to understand compounding needs is difficult. Using a novel approach, we worked in partnership with homelessness and housing support services in a local authority area in southern England to review a sample of case histories of deceased clients known to these services, aiming to better understand risk factors driving this early mortality. MethodsA mixed-methods analysis was conducted using case histories, provided by homelessness services, of a cross-sectional sample of clients who died within a three-year period (2020/21–2022/23). Included were single people and childless couples in contact with services and either rough-sleeping, sofa-surfing, in temporary accommodation, or in ‘move-on’/permanent accommodation. Quantitative data were collected for circumstances of death, health issues, substance misuse, engagement with services, and risk factors, including histories of self-neglect, suicide and offending. Descriptive statistics were produced, as were narrative summaries describing each case history, which were thematically analysed. Findings60 individuals were included, with varying volumes and quality of data available for each client. Most deaths with a suspected cause recorded involved physical health issues/illnesses, with chronic conditions commonly identified. Despite a high prevalence of mental health and substance misuse issues, relatively few individuals were recorded as engaging with relevant specialist services. Self-neglecting behaviours, including failing to access/refusing assistance from services, were common. Themes identified included multiple compounding needs, difficulties living independently, poor engagement with services, and unstable lifestyles. InterpretationMultiple compounding needs were evident across this cohort; however, fluctuating circumstances, needs, and ability/willingness to engage with services presented challenges in providing support. Despite challenges in data collection, this methodology is replicable and provides valuable insights into compounding needs in a vulnerable population. FundingNo funding received.

Future patterns of health inequalities in the population of England to 2040: a microsimulation study

Abstract Introduction The existence of wide inequalities in health across England is well-documented. Our research adds to this evidence on inequalities in self-reported health by describing current patterns and projecting future patterns of inequality in diagnosed illness across multiple conditions by deprivation. Methods We used the IMPACTNCD microsimulation model that simulates a close-to-reality synthetic population of adults in England from 2019 to 2040. This model combines individual-level data on demographics, health and mortality from linked administrative data for primary and secondary care with survey responses on individual-level risk factors and epidemiological evidence on the associations between risk factors and chronic illness. This model can be adapted for other countries based on data availability. We used the Cambridge Multimorbidity Score (CMS) as our multimorbidity measure. This assigns a weight to 20 common long-term conditions based on individuals’ healthcare use and their likelihood of death. We further focus on “major illness” which corresponds to a CMS greater than 1.5. Results In preliminary results, we project that health inequalities are not projected to improve between 2019 and 2040. In 2019, the difference in the average time spent without major illness between the most and least deprived 10% of areas in England was 10.4 years. This is projected to remain largely unchanged at 10.7 years (8.8, 11.7). We also find that in 2019, the share of working age people living with major illness in the most deprived 10% of areas in England (14.6%) was more than double the rate seen in the least deprived 10% of areas (6.3%). In 2040, we project these rates to remain largely unchanged at 15.2% (13.0%, 17.6%) and 6.8% (5.4%, 9.1%) respectively. Discussion On current trends, health inequalities are projected to persist into the future. This has significant implications not just for population health but for labour supply and wider economic growth. Key messages • If current trends in risk factors continue into the future, existing wide inequalities in diagnosed illness in England are projected to persist onto 2040. • With significant disparities in major illness among the working-age population, this has implications not just for population health but for labour supply and wider economic growth.

Syndemic geographic patterns of cancer risk in a health-deprived area of England

ObjectivesThis study aims to analyse the geographical co-occurrence of cancers and their individual and shared risk factors in a highly deprived area of the North West of England to aid the identification of potential interventions. Study designAn ecological study design was employed and applied at postcode sector level in the Morecambe Bay region. MethodsA novel spatial joint modelling framework designed to account for large frequencies of left-censored cancer data was employed. Nine cancer types (breast, colorectal, gynaecology, haematology, head and neck, lung, skin, upper gastrointestinal, urology) alongside demographic, behavioural factors and socio-economic variables were included in the model. Explanatory factors were selected by employing an accelerated failure model with lognormal distribution. Post-processing included principal components analysis and hierarchical clustering to delineate geographic areas with similar spatial risk patterns of different cancer types. Results15,506 cancers were diagnosed from 2017 to 2022, with the highest incidence in skin, breast and urology cancers. Factors such as age, ethnicity, frailty and comorbidities were associated with cancer risk for most of the cancer types. A positive geographical association was found mostly between the colorectal, haematology, upper GI, urology and head and neck cancer types. That is, these cancers had their largest risk in the same areas, similarly to their lowest risk values. The spatial distribution of the risk and cumulative risk of the cancer types revealed regional variations, with five clusters identified based on cancer type risk, demographic and socio-economic characteristics. Rural areas were the least affected by cancer and the urban area of Barrow-in-Furness was the area with the highest cancer risk, three times greater than the risk in the surrounding rural areas. ConclusionsThis study emphasizes the utility of joint disease mapping by geographically identifying common or shared factors that, if targeted, could lead to reduced risk of multiple cancers simultaneously. The findings suggest the need for tailored public health interventions, considering specific risk factors and socio-economic disparities. Policymakers can utilize the spatial patterns identified to allocate resources effectively and implement targeted cancer prevention programmes.

The long-term effect of the coronavirus pandemic on parkrun participation: an interrupted time series analysis

BackgroundThe growth of parkrun between 2004 and 2019 has been heralded as a success story for public health as a result of its physical activity and wellbeing benefits for participants. However, parkrun was not immune from the COVID-19 pandemic - with events in mainland England cancelled from March 2020 to July 2021. This study explores the lasting impact of the pandemic on parkrun participation to February 2023, and its implications across the socioeconomic spectrum.MethodsThe study combines aggregated parkrun weekly finisher data from 32,470 Lower Layer Super Output Areas (LSOA) in England from January 2015 to February 2023 with Office of National Statistics (ONS) data on population and deprivation. Interrupted time series analysis using segmented Poisson regression models was used to estimate the immediate change in parkrun participation and the change in the rate of growth following the pandemic. Models were fitted for each Index of Multiple Deprivation (IMD) quintile separately to assess whether this effect differed by socioeconomic deprivation.ResultsVisualisation and interrupted time series analysis showed a significant and long-term decrease in parkrun participation following the reopening of parkrun events. This was consistent across all IMD quintiles, indicating that the inequalities in parkrun participation according to IMD observed prior to the pandemic remained after the pandemic. Between March 2020 and February 2023, almost 13 million fewer parkrun finishes are estimated to have occurred relative to what would have occurred in the absence of the pandemic.ConclusionThe reduction in parkrun participation during the pandemic and following the reopening of events is likely to have negatively impacted wellbeing in would-be participants. Going forwards, policymakers must make the difficult trade-off between the long-term health and social implications of restricting outdoor physical activity events against the benefits associated with a reduction in infectious disease transmission.

From marine plans to marine licences: a weak link in the English system?

ABSTRACT As marine spatial planning becomes established, attention is turning to the influence of plans on coastal and marine decisions. A study of marine licencing in the East Marine Plan Areas in England, UK, revealed that little reference is being made to plans. A technical approach to licencing has persisted despite the broader perspectives that spatial planning can offer. Also, plans may not be sufficiently specific and tested to guide licencing. Reforms to integrate planning and decision-making are needed, including plans designed to help with setting conditions and spatially allocating marine uses. Increased dialogue between planners and decision-makers is also needed.

Health optimisation for patients with obesity before elective orthopaedic surgery: a qualitative study of professionals’ views on restrictive approaches and future practice

BackgroundPreoperative health optimisation for elective surgery entails supporting patients to improve their health in preparation for their treatment and recovery. While there is consensus that this process should address obesity, approaches vary across England. Despite guidance from the National Institute for Health and Care Excellence to the contrary, restrictive approaches with body mass index thresholds for referral to arthroplasty are in use. This qualitative study aimed to investigate the views of professionals on the current use and future implications of these policies.MethodsSemi-structured interviews were conducted with 20 professionals including clinicians, commissioners, policymakers, and health service managers, with experience of developing and/or implementing health optimisation policies for elective arthroplasty. Participants were sampled from areas in England with and without restrictive policies. We undertook thematic analysis of the interview data.ResultsParticipants described pre-surgical health optimisation as an important trigger for health improvement but identified current resourcing and inadequacies in provision of weight management support as significant barriers to success. Participants expressed concerns about the appropriateness and fairness of including obesity as a determinant to restrict access to surgery. They described short-term financial pressures underlying the use of restrictive body mass index thresholds and a lack of an evidence base, such that policies amounted to rationing and risked exacerbations of health inequalities. The study identified four priorities for improvements to future health optimisation practices: developing and implementing national guidance with flexibility for local variation, initiating patient engagement in primary care with onward integration across all services, improving resourcing to support effective equitable impact, and addressing wider determinants of obesity through societal change.ConclusionsOverall, participants had limited expectations of the impact of health optimisation policies on obesity without additional support, investment, and national guideline implementation. They raised strong concerns over current restrictive approaches. We conclude that addressing concerns around weight management support service availability and impacts on health inequalities is essential for shaping effective health optimisation policies. Future policy direction should support health optimisation to be offered early (ideally in primary care). Health optimisation interventions should be non-restrictive, inclusive, and well-monitored, particularly around equality impact.

Molecular characterization of reassortant infectious bursal disease virus (IBDV) strains of genogroup A3B1 detected in some areas of Britain between 2020 and 2021

Infectious bursal disease virus (IBDV) causes a major immunosuppressive disease of chickens. As part of ongoing epidemiological surveillance for IBDV, the hypervariable region (HVR) of the VP2 capsid gene encoded by segment A, and a region of the VP1 polymerase gene, encoded by segment B, were sequenced from 20 IBDV-positive bursal samples obtained in 2020 and 2021, from 16 commercial British broiler farms. Birds had received a live IBDV vaccine at 17–22 days of age, and samples were obtained at 25–55 days of age. Of the 16 farms, none contained very virulent (vv) strains, one contained a classical virulent strain, two contained vaccine strains, and five contained sequences of reassortant strains with a vv segment A and a non-vv segment B belonging to genogroup A3B1. In eight of the farms, we identified the sequences of both genogroup A3B1 reassortant strains and vaccine strains in the same samples. Therefore, the majority of the farms (13/16 (81%)) contained genogroup A3B1 reassortant viruses. Of the flocks containing reassortant strains, 5/13 (38%) had HVR mutations Q219L, G254D, D279N, and N280T, consistent with a recently described Western European clade, but the rest had other mutations or no mutations, demonstrating that multiple clades were present in the samples. Taken together, vv strains were not detected, but reassortant strains predominated in the farms, which belonged to different clades, and were frequently found together with vaccine strains.

Predicting pharmaceutical concentrations and assessing risks in the aquatic environment using PERK: A case study of a catchment area in South-West England

The aim of this study was to introduce a model to predict pharmaceuticals concentrations in the aquatic environment and their environmental impacts using the Risk Quotient (RQ) approach. The model was trained using: (i) high resolution dataset on pharmaceuticals’ concentration in wastewater and receiving environment in a river catchment, (ii) understanding of pharmaceuticals’ discharge points in the catchment, (iii) fate of pharmaceuticals during wastewater treatment and in the receiving environment, (iv) high resolution per-postcode pharmaceutical prescription data. A total of 41 pharmaceuticals were evaluated, with successful predictions achieved for concentrations falling within the range of 0.7 (influent: 37 %, effluent: 39 %, river: 29 %) to 1 % (influent: 56 %, effluent: 58 %, river: 48 %) of the measured values. Importantly, our risk assessment demonstrates significant environmental risks associated with specific pharmaceuticals, with strong alignment (86 %) between assessments based on predicted and measured data, underscoring the reliability of our model in assessing environmental risks. The observed variability in predicted and measured concentrations underscores the necessity for ongoing model refinement, particularly in regions with notable discrepancies such as wastewater treatment plant (WWTP) C. Overall, our study illustrates the intricate dynamics of pharmaceutical contamination in aquatic ecosystems, emphasizing the crucial need for continued research in this field.

Attitudes towards being offered a choice of self-sampling or clinician sampling for cervical screening: A cross-sectional survey of women taking part in a clinical validation of HPV self-collection devices.

Primary human papillomavirus (HPV) testing in cervical screening offers the opportunity for women to be given a choice between HPV self-sampling and traditional clinician screening. This study assessed attitudes towards a choice and anticipated future preference among women who had collected a vaginal self-sample alongside their usual cervical screen. Thirty-eight general practices across five areas in England. Overall, 2323 women (24-65 years; response rate: 48%) completed a survey after collecting a self-sample and having a clinician screen at their GP practice. We asked which test they preferred and assessed attitudes to being offered a choice. We explored age, education, ethnicity and screening experience as predictors of attitudes towards a choice and anticipated future choice. Most participants felt they would like a choice between self-sampling and clinician screening (85%) and thought this would improve screening for them (72%). However, 23% felt it would be difficult to choose, 15% would worry about making a choice, and nearly half would prefer a recommendation (48%). Compared with women with degree-level education, those with fewer qualifications were more likely to say they would worry about having a choice or would not want a choice (p < 0.001). The majority said they would choose to self-sample at home if offered a choice in the future (69%; n = 1602/2320). Self-sampling is likely to be popular, but offering a choice could cause worry for some people and many would prefer a recommendation. Supporting people to make a choice will be important, particularly for those with lower levels of education.

Inequality in green space distribution and its association with preventable deaths across urban neighbourhoods in the UK, stratified by Index of Multiple Deprivation

BackgroundThis study investigated inequalities in the distribution of green space (GS) and the association between inequalities in amounts of GS and preventable deaths across urban neighbourhoods with different Index of...

Using the Recommended Summary Plan for Emergency Care and Treatment in Primary Care: a mixed methods study.

Emergency care treatment plans provide recommendations about treatment, including cardiopulmonary resuscitation, to be considered in emergency medical situations. In 2016, the Resuscitation Council United Kingdom developed a standardised emergency care treatment plan, the recommended summary plan for emergency care and treatment, known as ReSPECT. There are advantages and potential difficulties in initiating the ReSPECT process in primary care. Hospital doctors and general practitioners may use the process differently and recommendations do not always translate between settings. There are no large studies of the use of ReSPECT in the community. To evaluate how, when and why ReSPECT is used in primary care and what effect it has on patient treatment and care. A mixed-methods approach using interviews, focus groups, surveys and evaluation of ReSPECT forms within an analytical framework of normalisation process theory. A total of 13 general practices and 13 care homes across 3 areas of England. General practitioners, senior primary care nurses, senior care home staff, patients and their relatives, community and emergency department clinicians and home care workers, people with learning disability and their carers. National surveys of (1) the public and (2) general practitioners. Members of the public are supportive of emergency care treatment plans. Respondents recognised benefits of plans but also potential risks if the recommendations become out of date. The ReSPECT plans were used by 345/842 (41%) of general practitioner survey respondents. Those who used ReSPECT were more likely to be comfortable having emergency care treatment conversations than respondents who used standalone 'do not attempt cardiopulmonary resuscitation' forms. The recommended summary plan for emergency care and treatment was conceptualised by all participants as person centred, enabling patients to have some say over future treatment decisions. Including families in the discussion is seen as important so they know the patient's wishes, which facilitates decision-making in an emergency. Writing recommendations is challenging because of uncertainty around future clinical events and treatment options. Care home staff described conflict over treatment decisions with clinicians attending in an emergency, with treatment decisions not always reflecting recommendations. People with a ReSPECT plan and their relatives trusted that recommendations would be followed in an emergency, but carers of people with a learning disability had less confidence that this would be the case. The ReSPECT form evaluation showed 87% (122/141) recorded free-text treatment recommendations other than cardiopulmonary resuscitation. Patient preferences were recorded in 57% (81/141). Where a patient lacked capacity the presence of a relative or lasting power of attorney was recorded in two-thirds of forms. Recruitment for patient/relative interviews was less than anticipated so caution is required in interpreting these data. Minority ethnic groups were under-represented across our studies. The aims of ReSPECT are supported by health and social care professionals, patients, and the public. Uncertainty around illness trajectory and treatment options for a patient in a community setting cannot be easily translated into specific recommendations. This can lead to conflict and variation in how recommendations are interpreted. Future research should explore how best to integrate patient values into treatment decision-making in an emergency. This study is registered as NCT05046197. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131316) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 42. See the NIHR Funding and Awards website for further award information.

Effect modification of air pollution on the association between heat and mortality in five European countries

BackgroundEvidence suggests that air pollution modifies the association between heat and mortality. However, most studies have been conducted in cities without rural data. This time-series study examined potential effect modification of particulate matter (PM) and ozone (O3) on heat-related mortality using small-area data from five European countries, and explored the influence of area characteristics. MethodsWe obtained daily non-accidental death counts from both urban and rural areas in Norway, England and Wales, Germany, Italy, and the Attica region of Greece during the warm season (2000–2018). Daily mean temperatures and air pollutant concentrations were estimated by spatial-temporal models. Heat effect modification by air pollution was assessed in each small area by over-dispersed Poisson regression models with a tensor smoother between temperature and air pollution. We extracted temperature-mortality relationships at the 5th (low), 50th (medium), and 95th (high) percentiles of pollutant distributions. At each air pollution level, we estimated heat-related mortality for a temperature increase from the 75th to the 99th percentile. We applied random-effects meta-analysis to derive the country-specific and overall associations, and mixed-effects meta-regression to examine the influence of urban-rural and coastal typologies and greenness on the heat effect modification by air pollution. ResultsHeat-related mortality risks increased with higher PM levels, rising by 6.4% (95% CI: −2.0%–15.7%), 10.7% (2.6%–19.5%), and 14.1% (4.4%–24.6%) at low, medium, and high PM levels, respectively. This effect modification was consistent in urban and rural regions but more pronounced in non-coastal regions. In addition, heat-mortality associations were slightly stronger at high O3 levels, particularly in regions with low greenness. ConclusionOur analyses of both urban and rural data indicate that air pollution may intensify heat-related mortality, particularly in non-coastal and less green regions. The synergistic effect of heat and air pollution implies a potential pathway of reducing heat-related health impacts by improving air quality.