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Objectives: The addition of fluoride to community drinking water supplies has been a long‐standing public health intervention to improve dental health. However, the evidence of cost‐effectiveness in the UK currently lacks a contemporary focus, being limited to a period with higher incidence of caries. A water fluoridation scheme in West Cumbria, United Kingdom, provided a unique opportunity to study the contemporary impact of water fluoridation. This study evaluates the cost‐effectiveness of water fluoridation over a 5–6 years follow‐up period in two distinct cohorts: children exposed to water fluoridation in utero and those exposed from the age of 5. Methods: Cost‐effectiveness was summarized employing incremental cost‐effectiveness ratios (ICER, cost per quality adjusted life year (QALY) gained). Costs included those from the National Health Service (NHS) and local authority perspective, encompassing capital and running costs of water fluoridation, as well as NHS dental activity. The measure of health benefit was the QALY, with utility determined using the Child Health Utility 9‐Dimension questionnaire. To account for uncertainty, estimates of net cost and outcomes were bootstrapped (10 000 bootstraps) to generate cost‐effectiveness acceptability curves and sensitivity analysis performed with alternative specifications. Results: There were 306 participants in the birth cohort (189 and 117 in the non‐fluoridated and fluoridated groups, respectively) and 271 in the older school cohort (159 and 112, respectively). In both cohorts, there was evidence of small gains in QALYs for the fluoridated group compared to the non‐fluoridated group and reductions in NHS dental service cost that exceeded the cost of fluoridation. For both cohorts and across all sensitivity analyses, there were high probabilities (>62%) of water fluoridation being cost‐effective with a willingness to pay threshold of £20 000 per QALY. Conclusions: This analysis provides current economic evidence that water fluoridation is likely to be cost‐effective. The findings contribute valuable contemporary evidence in support of the economic viability of water fluoridation scheme. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to assess the effectiveness of a Water Fluoridation program on a contemporary population of children. Methods: The study used a longitudinal prospective cohort design. In Cumbria, England, two groups of children were recruited and observed over a period of 5–6 years. The Birth Cohort consisted of families recruited from two hospitals in Cumbria where children were conceived after water fluoridation was reintroduced. The systemic and topical effects of community water fluoridation were evaluated in the Birth Cohort. The Older Cohort were approximately 5 years old and recruited from primary schools in Cumbria, shortly after water fluoridation was reintroduced. The predominantly topical effects of fluoridated water were evaluated in the Older Cohort. The primary outcome was the proportion of children with clinical evidence of caries experience in their primary (Birth Cohort) or permanent teeth (Older Cohort). Unadjusted and adjusted regression models were used for analysis. Results: The final clinical examinations for the Birth Cohort involved 1444 participants (mean age 4.8 years), where 17.4% of children in the intervention group were found to have caries experience, compared to 21.4% in the control group. A beneficial effect of water fluoridation was observed adjusting for deprivation (a socioeconomic measure), sex, and age, (adjusted odds ratio 0.74 95% CI 0.55 to 0.98). The final Older Cohort clinical examinations involved 1192 participants (mean age 10.8 years) where 19.1% of children in the intervention group were found to have caries experience compared to 21.9% in the control group (adjusted odds ratio 0.80, 95% CI 0.58 to 1.09). For both the Birth Cohort and Older Cohort there was evidence of a beneficial effect on dmft/DMFT count (IRR 0.61, 95% CI 0.44, 0.86) and (IRR 0.69, 95% CI 0.52, 0.93) respectively. No conclusive proof was found to indicate that the effectiveness of water fluoridation differed across area deprivation quintiles. Conclusions: In the contemporary context of lower caries levels and widespread use of fluoride toothpaste, the impact of water fluoridation on the prevalence of caries was smaller than previous studies have reported. It is important to consider the clinical importance of the absolute reduction in caries prevalence against the use of other dental caries preventive measures. [ABSTRACT FROM AUTHOR]

Background The NHS Diabetes Prevention Programme (NDPP) is a behaviour change programme for adults who are at risk of developing type 2 diabetes mellitus (T2DM): people with raised blood glucose levels, but not in the diabetic range, diagnosed with nondiabetic hyperglycaemia (NDH). We examined the association between referral to the programme and reducing conversion of NDH to T2DM. Methods and findings Cohort study of patients attending primary care in England using clinical Practice Research Datalink data from 1 April 2016 (NDPP introduction) to 31 March 2020 was used. To minimise confounding, we matched patients referred to the programme in referring practices to patients in nonreferring practices. Patients were matched based on age ([greater than or equal to]3 years), sex, and [greater than or equal to]365 days of NDH diagnosis. Random-effects parametric survival models evaluated the intervention, controlling for numerous covariates. Our primary analysis was selected a priori: complete case analysis, 1-to-1 practice matching, up to 5 controls sampled with replacement. Various sensitivity analyses were conducted, including multiple imputation approaches. Analysis was adjusted for age (at index date), sex, time from NDH diagnosis to index date, BMI, HbA1c, total serum cholesterol, systolic blood pressure, diastolic blood pressure, prescription of metformin, smoking status, socioeconomic status, a diagnosis of depression, and comorbidities. A total of 18,470 patients referred to NDPP were matched to 51,331 patients not referred to NDPP in the main analysis. Mean follow-up from referral was 482.0 (SD = 317.3) and 472.4 (SD = 309.1) days, for referred to NDPP and not referred to NDPP, respectively. Baseline characteristics in the 2 groups were similar, except referred to NDPP were more likely to have higher BMI and be ever-smokers. The adjusted HR for referred to NDPP, compared to not referred to NDPP, was 0.80 (95% CI: 0.73 to 0.87) (p < 0.001). The probability of not converting to T2DM at 36 months since referral was 87.3% (95% CI: 86.5% to 88.2%) for referred to NDPP and 84.6% (95% CI: 83.9% to 85.4%) for not referred to NDPP. Associations were broadly consistent in the sensitivity analyses, but often smaller in magnitude. As this is an observational study, we cannot conclusively address causality. Other limitations include the inclusion of controls from the other 3 UK countries, data not allowing the evaluation of the association between attendance (rather than referral) and conversion. Conclusions The NDPP was associated with reduced conversion rates from NDH to T2DM. Although we observed smaller associations with risk reduction, compared to what has been observed in RCTs, this is unsurprising since we examined the impact of referral, rather than attendance or completion of the intervention., Author(s): Rathi Ravindrarajah 1, Matt Sutton 1,2, David Reeves 1,2, Sarah Cotterill 1, Emma Mcmanus 1,2, Rachel Meacock 1,2, William Whittaker 1, Claudia Soiland-Reyes 3, Simon Heller 4, Peter Bower [...]

Objectives: In 2018, NHS England mandated that all patients in England should be able to access general practice services outside of ordinary hours. While some patients would access additional hours at their own practice, others would need supra-practice level provision – that is, they would be seen in a different location and by a different care team. The policy aim was to enhance patient access to care, with a particular focus on those who work during the day. This study examines (a) how supra-practice level provision of extended access appointments for general medical problems are operationalised and (b) whether the aims of the policy are being met. Methods: This study presents qualitative comparative case studies of two contrasting service providers offering extended access. The data collected included 30 hours of clinician-patient observations, 25 interviews with staff, managers, and commissioners, 20 interviews with patients, organisational protocols/documentation, and routinely collected appointment data. Thematic analysis ran concurrently with data gathering and facilitated the iterative adaptation of data collection. Results: Three cross-cutting themes were identified: extended access is being used to bolster a struggling primary care system, extended access provides a different service to in-hours general practice, and it is difficult for extended access to provide seamless care. Conclusions: Supra-practice access models can provide effective care for most patients with straightforward issues. When ongoing management of complex problems is required, this model of patient care can be problematic. [ABSTRACT FROM AUTHOR]

Background: There is an international trend towards the at-scale provision of primary care services, with such services often provided in different settings by a clinician unfamiliar to the patient. It is often assumed that, in the absence of relational continuity, any competent clinician can deliver joined-up, continuous care if they have access to clinical notes. Aim: To explore the factors that affect the potential for providing joined-up, continuous care in a system where care is delivered away from a patient's regular practice, by a different organisation and set of staff. Design and setting: Case studies of two extended-access providers in the north of England. Method: Case studies were carried out between September 2021 and January 2022 in two sites. Data collected included observations of patient–healthcare professional interactions, interviews with staff and patients, and documentation. Analysis took place using a constant comparison approach. Data were coded. A model of the factors affecting continuity was constructed. Results: The potential for joined-up, continuous care appears dependent on staff, patient, and system factors. This includes diverse elements such as the attitude of clinicians to care coordination and the ability of an organisation to retain staff. Conclusion: Healthcare systems increasingly rely on the assumption that any competent clinician can deliver joined-up, continuous care if they have access to clinical notes. This appears not to be the case. This study presents a model of factors affecting the patient's experience of continuity. The model needs validating in in-hours general practice and other settings. [ABSTRACT FROM AUTHOR]

Background: Equitable access to healthcare is a priority of many healthcare systems, aiming to ensure access is driven by need and not minority groups such as those defined by sexual orientation. However, there are healthcare areas where inequity in access across sexual orientation groups is found that are not justified based on need. Mandated LGBTQ+-specific training of the healthcare workforce may help address some barriers of access for these groups. The study aims to understand the potential economic implications for mandated LGBTQ+-specific healthcare training on the healthcare system in England, UK to inform commissioning of training provision. Methods: Cervical cancer screening was used as an exemplar case where there appears to be inequity in access for different sexual orientation groups. A decision model was developed and analysed that considered the impacts of greater uptake of screening for lesbian and bisexual women due to LGBTQ+ training. Costs took the perspective of the healthcare system and outcomes modelled were cancer cases averted in a timeframe of 5 years. Results: Based on cervical cancer screening alone, where training costs are fully attributed to this service, training would likely result in fewer cancer cases detected in the lesbian and bisexual populations, though this comes at a modest increase in healthcare sector costs, with this increase largely reflecting a greater volume of screens. Training costs do not appear to be a major component of the cost implications. Conclusions: In resource-constrained systems with increasing pressures for efficiency savings, the opportunity cost of delivering training is a realistic component of the commissioning decision. The findings in this paper provide a signal that mandated LGBTQ+ training in healthcare could lead to potentially greater outcomes and in breaking down barriers of access and could also enable the healthcare system to provide more equitable access to healthcare. [ABSTRACT FROM AUTHOR]

A long-term project to map and catalog all precontact Native American burial mounds in Iowa provides information about the number, location, form, survivorship, and rate of loss of mounds. This analysis reveals previously undocumented mound manifestations, including a large cluster of 200 linear mounds along the central Des Moines River valley. Historical records reveal that at least 7,762 mounds were identified at 1,551 sites in Iowa between 1840 and the present. About 47% of the mounds from these sites can be possibly seen in lidar, with 33% of the total clearly seen in lidar. Data show that mound loss over time is linear. Extrapolation of data suggests that at least 15,000–17,000 mounds stood in Iowa in the nineteenth century, but the actual number was likely higher. [ABSTRACT FROM AUTHOR]

This report summarizes the discovery of ca. 200 linear mounds along 40 km of the Des Moines River in central Iowa. Many of these mounds were mapped and recorded piecemeal over a century, but their full extents were not known until recent high-resolution lidar mapping. General insights about the age and significance of the mounds can be inferred from nearby archaeological sites and surface finds, as well as comparisons with regional mounds. Limited archaeological evidence suggests the linear mound concentration may be associated with a long stable Woodland occupation of the region, culminating in the Late Woodland Great Oasis manifestation. [ABSTRACT FROM AUTHOR]

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Analyses of an individual's sexual orientation over time are desirable for policy evaluations and in estimating causal effects. We explore whether accounting for those who change sexual orientation over two time points, to create a measure of fluidity, produces substantially different results compared to sexual orientation measured at one time point and extrapolated to subsequent survey waves. We use seven waves of the UK Household Longitudinal Study which asked sexual orientation identity questions at two time points: waves three (2011–2013) and nine (2017–2019). Using the relationship with sexual orientation and various health outcomes as an empirical example, via a correlated random effects estimation approach, we find that the infrequent reporting of sexual orientation could over‐estimate the negative impact for lesbian, gay and "other" individuals and under‐estimate the negative impact for bisexuals. We further test the feasibility of the fluidity measure by examining attrition by sexual orientation identity and find small but statistically significant probabilities of attrition. Correction for attrition bias through inverse probability weighting makes little difference to the results. These results highlight the importance of accounting for changes in sexual orientation in empirical analysis and that doing so is feasible. [ABSTRACT FROM AUTHOR]

Aims: To estimate how a scheme to pay substance misuse treatment service providers according to treatment outcomes affected hospital admissions. Design A controlled, quasi‐experimental (difference‐in‐differences) observational study using negative binomial regression. Setting: Hospitals in all 149 organisational areas in England for the period 2009–2010 to 2015–2016. Participants: 572 545 patients admitted to hospital with a diagnosis indicating drug misuse, defined based on International Classification of Diseases 10th Revision (ICD‐10) diagnosis codes (37 964 patients in 8 intervention areas and 534 581 in 141 comparison areas). Intervention and comparators: Linkage of provider payments to recovery outcome indicators in 8 intervention organisational areas compared with all 141 comparison organisational areas in England. Outcome indicators included: abstinence from presenting substance, abstinent completion of treatment and non‐re‐presentation to treatment in the 12 months following completion. Measurements Annual counts of hospital admissions, emergency admissions and admissions including a diagnosis indicating drugs misuse. Covariates included age, sex, ethnic origin and deprivation. Findings For 37 245 patients in the intervention areas, annual emergency admissions were 1.073 times higher during the operation of the scheme compared with non‐intervention areas (95% CI = 1.049; 1.097). There were an estimated additional 3 352 emergency admissions in intervention areas during the scheme. These findings were robust to a range of secondary analyses. Conclusion: A programme in England from 2012 to 2014 to pay substance misuse treatment service providers according to treatment outcomes appeared to increase emergency hospital admissions. [ABSTRACT FROM AUTHOR]

Introduction: The World Health Organisation declared a global pandemic in March 2020. The impact of COVID-19 has not been felt equally by all regions and sections of society. The extent to which socio-demographic and deprivation factors have adversely impacted on outcomes is of concern to those looking to 'level-up' and decrease widening health inequalities., Objectives: In this paper we investigate the impact of deprivation on the outcomes for hospitalised COVID-19 patients in Greater Manchester during the first wave of the pandemic in the UK (30/12/19-2/1/21), controlling for proven risk factors from elsewhere in the literature., Methods: We fitted Negative Binomial and logistic regression models to NHS administrative data to investigate death from COVID in hospital and length of stay for surviving patients in a sample of adult patients admitted within Greater Manchester (N = 10,372, spell admission start dates from 30/12/2019 to 02/01/2021 inclusive)., Results: Deprivation was associated with death risk for hospitalised patients but not with length of stay. Male sex, co-morbidities and older age was associated with higher death risk. Male sex and co-morbidities were associated with increased length of stay. Black and other ethnicities stayed longer in hospital than White and Asian patients. Period effects were detected in both models with death risk reducing over time, but the length of stay increasing., Conclusion: Deprivation is important for death risk; however, the picture is complex, and the results of this analysis suggest that the reported COVID related mortality and deprivation linked reductions in life expectancy, may have occurred in the community, rather than in acute settings., Highlights: Older age and male sex are predictive of longer hospital stays and higher death risk for hospitalised cases in this analysis.Deprivation is associated with death risk but not length of stay for hospitalised patients.Ethnicity is associated with length of stay, but not with death risk.There is a social gradient in health, but these data would suggest that once in the care of an NHS hospital in an acute health episode, outcomes are more equal., Competing Interests: Statement on conflicts of interest: The authors have no conflicts of interest to declare.

Background: The NHS Diabetes Prevention Programme (DPP) in England is a behavioural intervention for preventing type 2 diabetes mellitus (T2DM) among people with non-diabetic hyperglycaemia (NDH). How this programme affects inequalities by age, sex, limiting illnesses or disability, ethnicity or deprivation is not known., Methods: We used multinomial and binary logistic regression models to compare whether the population with NDH at different stages of the programme are representative of the population with NDH: stages include (1) prevalence of NDH (using survey data from UK Household Longitudinal Study (n=794) and Health Survey for England (n=1383)); (2) identification in primary care and offer of programme (using administrative data from the National Diabetes Audit (n=1 267 350)) and (3) programme participation (using programme provider records (n=98 024))., Results: Predicted probabilities drawn from the regressions with demographics as each outcome and dataset identifier as predictors showed that younger adults (aged under 40) (4% of the population with NDH (95% CI 2.4% to 6.5%)) and older adults (aged 80 and above) (12% (95% CI 9.5% to 14.2%)) were slightly under-represented among programme participants (2% (95% CI 1.8% to 2.2%) and 8% (95% CI 7.8% to 8.2%) of programme participants, respectively). People living in deprived areas were under-represented in eight sessions (14% (95% CI 13.7% to 14.4%) vs 20% (95% CI 16.4% to 23.6%) in the general population). Ethnic minorities were over-represented among offers (35% (95% CI 35.1% to 35.6%) vs 13% (95% CI 9.1% to 16.4%) in general population), though the proportion dropped at the programme completion stage (19% (95% CI 18.5% to 19.5%))., Conclusion: The DPP has the potential to reduce ethnic inequalities, but may widen socioeconomic, age and limiting illness or disability-related inequalities in T2DM. While ethnic minority groups are over-represented at the identification and offer stages, efforts are required to support completion of the programme. Programme providers should target under-represented groups to ensure equitable access and narrow inequalities in T2DM., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)