There is currently mixed evidence on the influence of long-term conditions and deprivation on mortality. We aimed to explore whether number of long-term conditions contribute to socioeconomic inequalities in mortality, whether the influence of number of conditions on mortality is consistent across socioeconomic groups and whether these associations vary by working age (18-64 years) and older adults (65 + years). We provide a cross-jurisdiction comparison between England and Ontario, by replicating the analysis using comparable representative datasets.Participants were randomly selected from Clinical Practice Research Datalink in England and health administrative data in Ontario. They were followed from 1 January 2015 to 31 December 2019 or death or deregistration. Number of conditions was counted at baseline. Deprivation was measured according to the participant's area of residence. Cox regression models were used to estimate hazards of mortality by number of conditions, deprivation and their interaction, with adjustment for age and sex and stratified between working age and older adults in England (N = 599,487) and Ontario (N = 594,546).There is a deprivation gradient in mortality between those living in the most deprived areas compared to the least deprived areas in England and Ontario. Number of conditions at baseline was associated with increasing mortality. The association was stronger in working age compared with older adults respectively in England (HR = 1.60, 95% CI 1.56,1.64 and HR = 1.26, 95% CI 1.25,1.27) and Ontario (HR = 1.69, 95% CI 1.66,1.72 and HR = 1.39, 95% CI 1.38,1.40). Number of conditions moderated the socioeconomic gradient in mortality: a shallower gradient was seen for persons with more long-term conditions.Number of conditions contributes to higher mortality rate and socioeconomic inequalities in mortality in England and Ontario. Current health care systems are fragmented and do not compensate for socioeconomic disadvantages, contributing to poor outcomes particularly for those managing multiple long-term conditions. Further work should identify how health systems can better support patients and clinicians who are working to prevent the development and improve the management of multiple long-term conditions, especially for individuals living in socioeconomically deprived areas.
Abstract Background Multiple conditions are more prevalent in some minoritised ethnic groups and are associated with higher mortality rate but studies examining differential mortality once conditions are established is US-based. Our study tested whether the association between multiple conditions and mortality varies across ethnic groups in England. Methods and Findings A random sample of primary care patients from Clinical Practice Research Datalink (CPRD) was followed from 1 st January 2015 until 31 st December 2019. Ethnicity, usually self-ascribed, was obtained from primary care records if present or from hospital records. Cox regression models were used to estimate mortality by number of long-term conditions, ethnicity and their interaction, with adjustment for age and sex for 532,059 patients with complete data. During five years of follow-up, 5.9% of patients died. Each additional long-term condition at baseline was associated with increased mortality. This association differed across ethnic groups. Compared with 50-year-olds of white ethnicity with no conditions, the mortality rate was higher for white 50-year-olds with two conditions (HR 1.77) or four conditions (HR 3.13). Corresponding figures were higher for 50-year-olds of Black Caribbean ethnicity with two conditions (HR=2.22) or four conditions (HR 4.54). The direction of the interaction of number of conditions with ethnicity showed higher mortality associated with long-term conditions in nine out of ten minoritised ethnic groups, attaining statistical significance in four (Pakistani, Black African, Black Caribbean and Black other ethnic groups). Conclusions The raised mortality rate associated with having multiple conditions is greater in minoritised ethnic groups compared with white people. Research is now needed to identify factors that contribute to these inequalities. Within the health care setting, there may be opportunities to target clinical and self-management support for people with multiple conditions from minoritised ethnic groups.
Multiple conditions are more prevalent in some minoritised ethnic groups and are associated with higher mortality rate but studies examining differential mortality once conditions are established is US-based. Our study tested whether the association between multiple conditions and mortality varies across ethnic groups in England.
Objectives Investigate trends in continuity of care with a general practitioner (GP) before and during the COVID-19 pandemic. Identify whether continuity of care is associated with consultation mode, controlling for other patient and practice characteristics. Design Retrospective cross-sectional and longitudinal observational studies. Setting Primary care records from 389 general practices participating in Clinical Practice Research Datalink Aurum in England. Participants In the descriptive analysis, 100 000+ patients were included each month between April 2018 and April 2021. Modelling of the association between continuity of care and consultation mode focused on 153 475 and 125 298 patients in index months of February 2020 (before the pandemic) and February 2021 (during the pandemic) respectively, and 76 281 patients in both index months. Primary and secondary outcomes measures The primary outcome measure was the Usual Provider of Care index. Secondary outcomes included the Bice-Boxerman index and count of consultations with the most frequently seen GP. Results Continuity of care was gradually declining before the pandemic but stabilised during it. There were consistent demographic, socioeconomic and regional differences in continuity of care. An average of 23% of consultations were delivered remotely in the year to February 2020 compared with 76% in February 2021. We found little evidence consultation mode was associated with continuity at the patient level, controlling for a range of covariates. In contrast, patient characteristics and practice-level supply and demand were associated with continuity. Conclusions We set out to examine the association of consultation mode with continuity of care but found that GP supply and patient demand were much more important. To improve continuity for patients, primary care capacity needs to increase. This requires sufficient, long-term investment in clinicians, staff, facilities and digital infrastructure. General practice also needs to transform ways of working to ensure continuity for those that need it, even in a capacity-constrained environment.
Norman L. Christensen is a professor in the Department of Botany, Duke University, Durham, NC 27706. James K. Agee is a professor in the College of Forest Resources, University of Washington, Seattle, WA 98195. Peter F. Brussard is a professor in and the chairman of the Biology Department, University of Nevada, Reno, NV 89557. Jay Hughes is a professor in and dean of the College of Forestry and National Resources, Colorado State University, Fort Collins, CO 80523. Dennis H. Knight is a professor in the Department of Botany, University of Wyoming, Laramie, WY 82071. G. Wayne Minshall is a professor in the Department of Biology, Idaho State University, Pocatello, ID 83209. James M. Peek is a professor in the College of Forest Resources, Wildlife, and Range Science, University of Idaho, Moscow, ID 83843. Stephen J. Pyne is a professor in the Department of History, Arizona State University, West Campus, Phoenix, AZ 85017. Frederick J. Swanson is a senior research scientist in the USDA Forest Ser-
Abstract Background In England, general practitioners voluntarily take part in the Quality and Outcomes Framework, which is a program that seeks to improve care by rewarding good practice. They can make personalized care adjustments (PCAs), e.g. if patients choose not to have the treatment/intervention offered (‘informed dissent’) or because they are considered to be clinically ‘unsuitable’. Methods Using data from the Clinical Practice Research Datalink (Aurum), this study examined patterns of PCA reporting for ‘informed dissent’ and ‘patient unsuitable’, how they vary across ethnic groups and whether ethnic inequities were explained by sociodemographic factors or co-morbidities. Results The odds of having a PCA record for ‘informed dissent’ were lower for 7 of the 10 minoritized ethnic groups studied. Indian patients were less likely than white patients to have a PCA record for ‘patient unsuitable’. The higher likelihood of reporting for ‘patient unsuitable’ among people from Black Caribbean, Black Other, Pakistani and other ethnic groups was explained by co-morbidities and/or area-level deprivation. Conclusions The findings counter narratives that suggest that people from minoritized ethnic groups often refuse medical intervention/treatment. The findings also illustrate ethnic inequities in PCA reporting for ‘patient unsuitable’, which are linked to clinical and social complexity and should be tackled to improve health outcomes for all.
ObjectivesThere is mixed evidence on the influence of number of conditions on inequalities in mortality, we explored the association between number of conditions and deprivation on mortality whilst assessing the difference between working age and older adults. We replicated the analysis in England and Ontario, to provide a cross-jurisdiction comparison. ApproachWe used individual level-linked data from primary care activity, secondary care and mortality data in England and Ontario. For both jurisdictions, we took a random sample of 600,000 adults from 1 January 2015 and followed them up till 31 December 2019. We used cox proportional hazard to test the influence of deprivation (measured using area-level deprivation in deciles) and number of conditions (measured at baseline and capped at six conditions) on survival. Age and sex were also measured at baseline. Analyses were stratified by working age (18-64 years) and older adults (65+ years) and were repeated for England and Ontario. ResultsDeprivation gradient in mortality rate was steeper in working age than older adults in both jurisdictions. Number of conditions was associated with increased mortality rate, this was stronger for working age than older adults, in England (working age HR = 1.60, 95% CI 1.56,1.64 and older adults HR= 1.26, 95% CI 1.25,1.27) and Canada (working age HR=1.69, 95% CI 1.66,1.72 and older adults HR= 1.39, 95% CI 1.38,1.40). After accounting for number of conditions, the mortality rate associated with deprivation decreased but remained significant. The interaction between number of conditions and deprivation showed that adults with more conditions have a higher mortality rate and those living in deprived areas also have a higher mortality rate but having more conditions attenuates the deprivation gradient in mortality. ConclusionNumber of conditions contribute to higher mortality rate and inequalities in morality, this is stronger for working age than older adults in England and Ontario. The fragmented health-care system may be contributing to poorer outcomes, further research should help identify which part of the pathway is driving these inequalities further.
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