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Purpose: The purpose of this study was to examine the association between the prevalence of both diabetes-concordant and diabetes-discordant conditions and the quality of diabetes care at the family practice level in England. We hypothesized that the prevalence of concordant (or discordant) conditions would be associated with better (or worse) quality of diabetes care.Methods: We conducted a cross-sectional study using practice-level data (7,884 practices). We estimated the practice-level prevalence of diabetes and 15 other chronic conditions, which were classified as diabetes concordant (ie, with the same pathophysiologic risk profile and therefore more likely to be part of the same management plan) or diabetes discordant (ie, not directly related in either their pathogenesis or management). We measured quality of diabetes care with diabetes-specific indicators (8 processes and 3 intermediate outcomes of care). We used linear regression models to quantify the effect of the prevalence of the conditions on aggregate achievement rate for quality of diabetes care.Results: Consistent with the proposed model, the prevalence rates of 4 of 7 concordant conditions (obesity, chronic kidney disease, atrial fibrillation, heart failure) were positively associated with quality of diabetes care. Similarly, negative associations were observed as predicted for 2 of the 8 discordant conditions (epilepsy, mental health). Observations for other concordant and discordant conditions did not match predictions in the hypothesized model.Conclusions: The quality of diabetes care provided in English family practices is associated with the prevalence of other major chronic conditions at the practice level. The nature and direction of the observed associations cannot be fully explained by the concordant-discordant model. [ABSTRACT FROM AUTHOR]

IgE-mediated allergy to chicken egg affects a large number of children and adults worldwide. The current management strategy for egg allergy is strict avoidance, however this is impractical due to the presence of eggs in a range of foods and pharmaceutical products including vaccines. Strict avoidance also poses nutritional disadvantages due to high nutritional value of eggs. Allergen specific immunotherapy is being pursued as a curative treatment, in which an allergic individual is gradually exposed to the allergen to induce tolerance. Use of recombinant proteins for immunotherapy has been beneficial due to the purity of the recombinant proteins compared to natural proteins. In this study, we produced IgE reactive recombinant egg white proteins that can be used for future immunotherapy. Using E. coli as an expression system, we successfully produced recombinant versions of Gal d 1, 2 and 3, that were IgE reactive when tested against a pool of egg allergic patients’ sera. The IgE reactivity indicates that these recombinant proteins are capable of eliciting an immune response, thus being potential candidates for immunotherapy. We have, for the first time, attempted to produce recombinant versions of all 4 major egg white allergens in E. coli , and successfully produced 3, with only Gal d 4 showing loss of IgE reactivity in the recombinant version. The results suggest that egg allergy in Australian populations may mainly be due to IgE reactivity to Gal d 3 and 4, while Gal d 1 shows higher IgE reactivity. This is the first report of a collective and comparative immunological analysis of all 4 egg white allergens. The significance of this study is the potential use of the IgE reactive recombinant egg white proteins in immunotherapy to treat egg allergic patients. [ABSTRACT FROM AUTHOR]

Aims/hypothesis: We aimed to describe the shape of observed relationships between risk factor levels and clinically important outcomes in type 2 diabetes after adjusting for multiple confounders. Methods: We used retrospective longitudinal data on 246,544 adults with type 2 diabetes from 600 practices in the Clinical Practice Research Datalink, 2006-2012. Proportional hazards regression models quantified the risks of mortality and microvascular or macrovascular events associated with four modifiable biological variables (HbA, systolic BP, diastolic BP and total cholesterol), while controlling for important patient and practice covariates. Results: U-shaped relationships were observed between all-cause mortality and levels of the four biometric risk factors. Lowest risks were associated with HbA 7.25-7.75% (56-61 mmol/mol), total cholesterol 3.5-4.5 mmol/l, systolic BP 135-145 mmHg and diastolic BP 82.5-87.5 mmHg. Coronary and stroke mortality related to the four risk factors in a positive, curvilinear way, with the exception of systolic BP, which related to deaths in a U-shape. Macrovascular events showed a positive and curvilinear relationship with HbA but a U-shaped relationship with total cholesterol and systolic BP. Microvascular events related to the four risk factors in a curvilinear way: positive for HbA and systolic BP but negative for cholesterol and diastolic BP. Conclusions/interpretation: We identified several relationships that support a call for major changes to clinical practice. Most importantly, our results support trial data indicating that normalisation of glucose and BP can lead to poorer outcomes. This makes a strong case for target ranges for these risk factors rather than target levels. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is an important risk factor for ischaemic stroke, and AF incidence is expected to increase. Guidelines recommend using oral anticoagulants (OACs) to prevent the development of stroke. However, studies have reported the frequent underuse of OACs in AF patients. The objective of this study is to describe nonvalvular atrial fibrillation (NVAF) incidence in England and assess the clinical and socioeconomic factors associated with the underprescribing of OACs.Methods and Findings: We conducted a population-based retrospective cohort study using the UK Clinical Practice Research Datalink (CPRD) database to identify patients with NVAF aged ≥18 years and registered in English general practices between 2009 and 2019. Annual incidence rate of NVAF by age, deprivation quintile, and region was estimated. OAC prescribing status was explored for patients at risk for stroke and classified into the following: OAC, aspirin only, or no treatment. We used a multivariable multinomial logistic regression model to estimate relative risk ratios (RRRs) and 95% confidence intervals (CIs) of the factors associated with OAC or aspirin-only prescribing compared to no treatment in patients with NVAF who are recommended to take OAC. The multivariable regression was adjusted for age, sex, comorbidities, socioeconomic status, baseline treatment, frailty, bleeding risk factors, and takes into account clustering by general practice. Between 2009 and 2019, 12,517,191 patients met the criteria for being at risk of developing NVAF. After a median follow-up of 4.6 years, 192,265 patients had an incident NVAF contributing a total of 647,876 person-years (PYR) of follow-up. The overall age-adjusted incidence of NVAF per 10,000 PYR increased from 20.8 (95% CI: 20.4; 21.1) in 2009 to 25.5 (25.1; 25.9) in 2019. Higher incidence rates were observed for older ages and males. Among NVAF patients eligible for anticoagulation, OAC prescribing rose from 59.8% (95% CI: 59.0; 60.6) in 2009 to 83.2% (95% CI: 83.0; 83.4) in 2019. Several conditions were associated with lower risk of OAC prescribing: dementia [RRR 0.52 (0.47; 0.59)], liver disease 0.58 (0.50; 0.67), malignancy 0.74 (0.72; 0.77), and history of falls 0.82 (0.78; 0.85). Compared to white ethnicity, patients from black and other ethnic minorities were less likely to receive OAC; 0.78 (0.65; 0.94) and 0.76 (0.64; 0.91), respectively. Patients living in the most deprived areas were less likely to receive OAC 0.85 (0.79; 0.91) than patients living in the least deprived areas. Practices located in the East of England were associated with higher risk of prescribing aspirin only over no treatment than practices in London (RRR 1.22; 95% CI 1.02 to 1.45). The main limitation of this study is that these findings depends on accurate recording of conditions by health professionals and the inevitable residual confounding due to lack of data on certain factors that could be associated with under-prescribing of OACs.Conclusions: The incidence of NVAF increased between 2009 and 2015, before plateauing. Underprescribing of OACs in NVAF is associated with a range of comorbidities, ethnicity, and socioeconomic factors, demonstrating the need for initiatives to reduce inequalities in the care for AF patients. [ABSTRACT FROM AUTHOR]

Background A range of policy initiatives have addressed inequalities in healthcare and health outcomes. Local pay-for-performance schemes for primary care have been advocated as means of enhancing clinical ownership of the quality agenda and better targeting local need compared with national schemes such as the UK Quality and Outcomes Framework (QOF). We investigated whether professionals' experience of a local scheme in one English National Health Service (NHS) former primary care trust (PCT) differed from that of the national QOF in relation to the goal of reducing inequalities. Methods We conducted retrospective semi-structured interviews with primary care professionals implementing the scheme and those involved in its development. We purposively sampled practices with varying levels of population socio-economic deprivation and achievement. Interviews explored perceptions of the scheme and indicators, likely mechanisms of influence on practice, perceived benefits and harms, and how future schemes could be improved. We used a framework approach to analysis. Results Thirty-eight professionals from 16 general practices and six professionals involved in developing local indicators participated. Our findings cover four themes: ownership, credibility of the indicators, influences on behaviour, and exacerbated tensions. We found little evidence that the scheme engendered any distinctive sense of ownership or experiences different from the national scheme. Although the indicators and their evidence base were seldom actively questioned, doubts were expressed about their focus on health promotion given that eventual benefits relied upon patient action and availability of local resources. Whilst practices serving more affluent populations reported status and patient benefit as motivators for participating in the scheme, those serving more deprived populations highlighted financial reward. The scheme exacerbated tensions between patient and professional consultation agendas, general practitioners benefitting directly from incentives and nurses who did much of the work, and practices serving more and less affluent populations which faced different challenges in achieving targets. Conclusions The contentious nature of pay-for-performance was not necessarily reduced by local adaptation. Those developing future schemes should consider differential rewards and supportive resources for practices serving more deprived populations, and employing a wider range of levers to promote professional understanding and ownership of indicators. [ABSTRACT FROM AUTHOR]

Objective: To test whether receiving a financial bonus for quality in the Premier Hospital Quality Incentive Demonstration (HQID) stimulated subsequent quality improvement.Data: Hospital-level data on process-of-care quality from Hospital Compare for the treatment of acute myocardial infarction (AMI), heart failure, and pneumonia for 260 hospitals participating in the HQID from 2004 to 2006; receipt of quality bonuses in the first 3 years of HQID from the Premier Inc. website; and hospital characteristics from the 2005 American Hospital Association Annual Survey.Study Design: Under the HQID, hospitals received a 1 percent bonus on Medicare payments for scoring between the 80th and 90th percentiles on a composite quality measure, and a 2 percent bonus for scoring at the 90th percentile or above. We used a regression discontinuity design to evaluate whether hospitals with quality scores just above these payment thresholds improved more in the subsequent year than hospitals with quality scores just below the thresholds. In alternative specifications, we examined samples of hospitals scoring within 3, 5, and 10 percentage point "bandwidths" of the thresholds. We used a Generalized Linear Model to estimate whether the relationship between quality and lagged quality was discontinuous at the lagged thresholds required for quality bonuses.Principal Findings: There were no statistically significant associations between receipt of a bonus and subsequent quality performance, with the exception of the 2 percent bonus for AMI in 2006 using the 5 percentage point bandwidth (0.8 percentage point increase, p<.01), and the 1 percent bonus for pneumonia in 2005 using all bandwidths (3.7 percentage point increase using the 3 percentage point bandwidth, p<.05).Conclusions: We found little evidence that hospitals' receipt of quality bonuses was associated with subsequent improvement in performance. This raises questions about whether winning in pay-for-performance programs, such as Hospital Value-Based Purchasing, will lead to subsequent quality improvement. [ABSTRACT FROM AUTHOR]

Pay-for-performance schemes explicitly link provider remuneration to the quality of care provided, with the aims of modifying provider behavior and improving patient outcomes. If successful, pay-for-performance schemes could drive improvements in quality and efficiency of care. However, financial incentives could also erode providers' intrinsic motivation, narrow their focus, promote unethical behavior, and ultimately increase health care inequalities. Evidence from schemes implemented to date suggests that carefully designed pay-for-performance schemes that align sufficient rewards with clinical priorities can produce modest but significant improvements in processes of diabetic care and intermediate outcomes. There is limited evidence, however, on whether improvements in processes of care result in improved outcomes, in terms of patient satisfaction, reduced complications, and greater longevity. The lack of adequate control groups has limited research findings to date, and more robust studies are needed to explore both the potential long-term benefits of pay-for-performance schemes and their unintended consequences. [ABSTRACT FROM AUTHOR]

Background The UK's Quality and Outcomes Framework (QOF) was introduced in 2004/5, linking remuneration for general practices to recorded quality of care for chronic conditions, including diabetes mellitus. We assessed the effect of the incentives on recorded quality of care for diabetes patients and its variation by patient and practice characteristics. Methods Using the General Practice Research Database we selected a stratified sample of 148 English general practices in England, contributing data from 2000/1 to 2006/7, and obtained a random sample of 653 500 patients in which 23 920 diabetes patients identified. We quantified annually recorded quality of care at the patient-level, as measured by the 17 QOF diabetes indicators, in a composite score and analysed it longitudinally using an Interrupted Time Series design. Results Recorded quality of care improved for all subgroups in the pre-incentive period. In the first year of the incentives, composite quality improved over-and-above this pre-incentive trend by 14.2% (13.7-14.6%). By the third year the improvement above trend was smaller, but still statistically significant, at 7.3% (6.7-8.0%). After 3 years of the incentives, recorded levels of care varied significantly for patient gender, age, years of previous care, number of co-morbid conditions and practice diabetes prevalence. Conclusions The introduction of financial incentives was associated with improvements in the recorded quality of diabetes care in the first year. These improvements included some measures of disease control, but most captured only documentation of recommended aspects of clinical assessment, not patient management or outcomes of care. Improvements in subsequent years were more modest. Variation in care between population groups diminished under the incentives, but remained substantial in some cases. [ABSTRACT FROM AUTHOR]

Objective The Medicare and Premier Inc. Hospital Quality Incentive Demonstration ( HQID), a hospital-based pay-for-performance program, changed its incentive design from one rewarding only high performance ( Phase 1) to another rewarding high performance, moderate performance, and improvement ( Phase 2). We tested whether this design change reduced the gap in incentive payments among hospitals treating patients across the gradient of socioeconomic disadvantage. Data To estimate incentive payments in both phases, we used data from the Premier Inc. website and from Medicare Provider Analysis and Review files. We used data from the American Hospital Association Annual Survey and Centers for Medicare and Medicaid Services Impact File to identify hospital characteristics. Study Design Hospitals were divided into quartiles based on their Disproportionate Share Index ( DSH), from lowest disadvantage ( Quartile 1) to highest disadvantage ( Quartile 4). In both phases of the HQID, we tested for differences across the DSH quartiles for three outcomes: (1) receipt of any incentive payments; (2) total incentive payments; and (3) incentive payments per discharge. For each of the study outcomes, we performed a hospital-level difference-in-differences analysis to test whether the gap between Quartile 1 and the other quartiles decreased from Phase 1 to Phase 2. Principal Findings In Phase 1, there were significant gaps across the DSH quartiles for the receipt of any payment and for payment per discharge. In Phase 2, the gap was not significant for the receipt of any payment, but it remained significant for payment per discharge. For the receipt of any incentive payment, difference-in-difference estimates showed significant reductions in the gap between Quartile 1 and the other quartiles ( Quartile 2, 17.5 percentage points [ p < .05]; Quartile 3, 18.1 percentage points [ p < .01]; Quartile 4, 28.3 percentage points [ p < .01]). For payments per discharge, the gap was also significantly reduced between Quartile 1 and the other quartiles ( Quartile 2, $14.92 per discharge [ p < .10]; Quartile 3, $17.34 per discharge [ p < .05]; Quartile 4, $21.31 per discharge [ p < .01]). There were no significant reductions in the gap for total payments. Conclusions The design change in the HQID reduced the disparity in the receipt of any incentive payment and for incentive payments per discharge between hospitals caring for the most and least socioeconomically disadvantaged patient populations. [ABSTRACT FROM AUTHOR]

Objective To analyze the effect of setting higher targets, in a primary care pay-for-performance scheme, on rates of influenza immunization and exception reporting. Study Setting The U.K. Quality and Outcomes Framework links financial rewards for family practices to four separate influenza immunization rates for patients with coronary heart disease ( CHD), chronic obstructive pulmonary disease, diabetes, and stroke. There is no additional payment for immunization rates above an upper threshold. Patients for whom immunization would be inappropriate can be excepted from the practice for the calculation of the practice immunization rate. Data Practice-level information on immunizations and exceptions extracted from electronic records of all practices in England 2004/05 to 2009/10 ( n = 8,212-8,403). Study Design Longitudinal random effect multilevel linear regressions comparing changes in practice immunization and exception rates for the four chronic conditions before and after the increase in the upper threshold immunization rate for CHD patients in 2006/07. Principal Findings The 5 percent increase in the upper payment threshold for CHD was associated with increases in the proportion of immunized CHD patients (0.41 percent, CI: 0.25-0.56 percent), and exception was reported (0.26 percent, CI: 0.12-0.40 percent). Conclusions Making quality targets more demanding can not only lead to improvement in quality of care but can also have other consequences. [ABSTRACT FROM AUTHOR]

The article examines suicide risk in relation to a single physical disease. A total of 873 adult suicide cases and 17,460 living controls matched on age and sex were studied. Among all patients, coronary heart disease, stroke and chronic obstructive pulmonary disease were linked with elevated suicide risk and explained by clinical depression. Overall, heightened risk was confined to physically ill women younger than 50 years and to older women with multiple physical diseases.

Differential gene expression regulates tissue morphogenesis. The embryonic gonad is a good example, where the developmental decision to become an ovary or testis is governed by female- or male-specific gene expression. A number of genes have now been identified that control gonadal sex differentiation. However, the potential role of microRNAs (miRNAs) in ovarian and testicular pathways is unknown. In this review, we summarise our current understanding of gonadal differentiation and the possible involvement of miRNAs, using the chicken embryo as a model system. Chickens and other birds have a ZZ/ZW sex chromosome system, in which the female, ZW, is the heterogametic sex, and the male, ZZ, is homogametic (opposite to mammals). The Z-linked DMRT1 gene is thought to direct testis differentiation during embryonic life via a dosage-based mechanism. The conserved SOX9 gene is also likely to play a key role in testis formation. No master ovary determinant has yet been defined, but the autosomal FOXL2 and Aromatase genes are considered central. No miRNAs have been definitively shown to play a role in embryonic gonadal development in chickens or any other vertebrate species. Using next generation sequencing, we carried out an expression-based screen for miRNAs expressed in embryonic chicken gonads at the time of sexual differentiation. A number of miRNAs were identified, including several that showed sexually dimorphic expression. We validated a subset of miRNAs by qRT-PCR, and prediction algorithms were used to identify potential targets. We discuss the possible roles for these miRNAs in gonadal development and how these roles might be tested in the avian model. [ABSTRACT FROM AUTHOR]

The factors regulating growth of the developing lung are poorly understood, although the degree of fetal lung expansion is critical. The oncogene Trop2 (trophoblast antigen 2) is upregulated during accelerated fetal lung growth, and we hypothesized that it may regulate normal fetal lung growth. We investigated Trop2 expression in the fetal and neonatal sheep lung during accelerated and delayed lung growth induced by alterations in fetal lung expansion, as well as in response to glucocorticoids. Trop2 expression was measured using real-time PCR and localized spatially using in situ hybridization and immunofluorescence. During normal lung development, Trop2 expression was higher at 90 days gestational age (GA; 4.0 ± 0.8) than at 128 days GA (1.0 ± 0.1), decreased to 0.5 ± 0.1 at 142 days GA (full term ∼147 days GA), and was positively correlated to lung cell proliferation rates (r = 0.953, P < 0.005). Trop2 expression was regulated by fetal lung expansion, but not by glucocorticoids. It was increased nearly threefold by 36 h of increased fetal lung expansion (P < 0.05) and was reduced to ∼55% of control levels by reduced fetal lung expansion (P < 0.05). Trop2 expression was associated with lung cell proliferation during normal and altered lung growth, and the TROP2 protein colocalized with Ki-67-positive cells in the fetal lung. TROP2 was predominantly localized to fibroblasts and type II alveolar epithelial cells. Trop2 small interfering RNA decreased Trop2 expression by ∼75% in cultured fetal rat lung fibroblasts and decreased their proliferation by ∼50%. Cell viability was not affected. This study demonstrates that TROP2 regulates lung cell proliferation during development. [ABSTRACT FROM AUTHOR]

To investigate the association between indicators of quality of diabetic management in English family practices and emergency hospital admissions for short-term complications of diabetes. A total of 8,223 English family practices from 2001/2002 to 2006/2007. Multiple regression analyses of associations between admissions and proportions of practice diabetic patients with good (glycated hemoglobin [HbA1c] ≤7.4 percent) and moderate (7.4 percent

This article examines the health outcomes resulting from the financial incentive schemes in Great Britain that measure compensation against the health conditions of a doctor's patients. The relationship between socioeconomic inequality and quality of care in this context is measured. Controls in the incentive scheme to limit the role of health outcomes related more closely to socioeconomic status than quality of patient care are noted. The risk of marginalising patients facing health problems and socioeconomic deprivation in the name of improving quality measurements in clinical practices is addressed.

Background: In the English pay-for-performance program, physicians use a range of criteria to exclude individual patients from the quality calculations that determine their pay. This process, which is called exception reporting, is intended to safeguard patients against inappropriate treatment by physicians seeking to maximize their income. However, exception reporting may allow physicians to inappropriately exclude patients for whom targets have been missed (a practice known as gaming). Methods: We analyzed data extracted automatically from clinical computing systems for 8105 family practices in England (96% of all practices), data from the U.K. Census, and data on practice characteristics from the U.K. Department of Health. We determined the rate of exception reporting for 65 clinical activities and the association between this rate and the characteristics of patients and medical practices. Results: From April 2005 through March 2006, physicians excluded a median of 5.3% of patients (interquartile range, 4.0 to 6.9) from the quality calculations. Physicians were most likely to exclude patients from indicators that were related to providing treatments and achieving target levels of intermediate outcomes; they were least likely to exclude patients from indicators that were related to routine checks and measurements and to offers of treatment. The characteristics of patients and practices explained only 2.7% of the variance in exception reporting. We estimate that exception reporting accounted for approximately 1.5% of the cost of the pay-for-performance program. Conclusions: Exception reporting brings substantial benefits to pay-for-performance programs, providing that the process is used appropriately. In England, rates of exception reporting have generally been low, with little evidence of widespread gaming. N Engl J Med 2008;359:274-84. [ABSTRACT FROM AUTHOR]

Pay-for-performance schemes share the common approach of offering financial incentives to healthcare providers for achieving specified performance targets. Such schemes are becoming increasingly popular with healthcare policy makers and funders worldwide, despite a relative lack of evidence on their long-term effects. This article examines the emerging evidence and its likely consequences for the future development of pay for performance. Successful schemes are likely to be those that use evidence-based targets; focus on aspects of care for which there is a professional consensus on the need for improvement; incentivize practitioners across the range of performance; allow for professional judgment and discretion; offer adequate incentives; adjust for risks outside practitioners’ control; involve patients in the design and implementation stages; make performance data publicly available; have a proper infrastructure in terms of adequate information technology systems and a receptive group of professionals; and are supported by other effective quality improvement initiatives. However, even the most successful schemes carry the risk of unintended effects, such as loss of professionalism, neglect of unincentivized activities, and fraudulent behavior. These risks need to be weighed against the potential benefits of financial incentives, and, in any future pay-for-performance schemes, should be mitigated during development and carefully monitored during implementation. [ABSTRACT FROM AUTHOR]

Pay-for-performance schemes provide financial incentives to health care providers for achieving specified performance targets, and therefore seek to explicitly link physician pay to the quality of care provided for patients. This article provides an overview of the essential elements of pay-for-performance schemes and how these relate to the treatment of hypertension. It also reviews the evidence for the effectiveness of pay-for-performance schemes and analyzes new data from a program in the United Kingdom that provides financial incentives for family practitioners caring for 6 million hypertensive patients. Although several pay-for-performance schemes have proved effective at improving quality of care, few to date have addressed patients with hypertension. Findings from the UK pay-for-performance scheme suggest that generous financial incentives are associated with high levels of achievement for aspects of care for hypertensive patients, but much of this achievement may be attributable to other quality improvement initiatives. [ABSTRACT FROM AUTHOR]

Objective: To identify English local authorities that "overachieve" and "underachieve" in health terms, given their level of deprivation, sociodemographic context, and region. Design: Cross sectional study using data from the 1991 UK census and mortality data from 2000-2. Setting: England. Participants: 354 local authorities (total population 49 558 000). Main outcome measures: Life expectancy. Residual life expectancy after regression analysis. Results: In general, the more materially deprived the population of a local authority was in 1991, the lower its life expectancy a decade later, with men being more sensitive to the effects of deprivation than women. Many local authorities, however, did not follow this general trend, and these shared common characteristics. Mining, Manufacturing and Industry, and Urban Fringe authorities collectively had lower life expectancies than predicted by their level of deprivation, as did authorities located in the north west. Outer London and Education Centres and Inner London authorities had much higher life expectancies than predicted, as did authorities located in the east, south east, and south west. Given their level of deprivation, sociodemographic context, and region, 11 local authorities significantly overachieved for male life expectancy and 10 underachieved, while 12 overachieved for female life expectancy and three underachieved. Conclusions: Life expectancy in English local authorities is strongly associated not only with material deprivation, but with the local sociodemographic context and the region where the authority is located. Some authorities defy their contexts, however, and overachieve in health terms, while others, including some in affluent areas, underachieve. [ABSTRACT FROM AUTHOR]

Objective: To examine the relation between class, gender, and self rated health in adults in Great Britain. Design: Cross sectional study using data from the 2001 national census. Setting: Great Britain. Participants: Adults aged between 25 and 64 in Great Britain, enumerated in the 2001 census (n = 30.3 million). Main outcome measures: Age standardized rates of self rated general health for men and women in different socioeconomic groupings as defined by the National Statistics classification (NS-SeC), rate ratios and the (modified) relative index of inequality. Results: There was a pronounced gradient in rates of "not good" health among people in different social positions. The rate for people in class 7 (routine occupations) was more than double that for people in class 1 (higher managerial and professional occupations): 95 per 1000 and 37 per 1000 respectively. Health inequalities were larger for men than for women-the rate ratio of class 7 to class `I was 2.7 for men and 2.2 for women. The nature and size of the gender differences varied by socioeconomic class, with the greatest gap among people in class 1 (higher managerial and professional occupations), where the rate for women was 25% higher than for men. Conclusions: The NS-SeC shows a pronounced gradient in self rated general health across the population of working age in Great Britain in 2001. It was found that the NS-SeC was a useful measure for women, although it may be better at classifying men. The size of the gender gap in "not good" health varied by NS-SeC class. [ABSTRACT FROM AUTHOR]

Background General practices undertake annual immunization campaigns to protect susceptible patients against influenza. Many practices, however, do not adopt effective approaches and there is great variation in the immunization rates achieved. This study aimed to assess the attitudes of primary care staff to the annual immunization programme, the obstacles they face, and possible reasons for the wide variation in immunization rates. [ABSTRACT FROM PUBLISHER]