BackgroundMany public health interventions cannot be evaluated using randomised controlled trials so they rely on the assessment of observational data. Techniques for evaluating public health interventions using observational data include interrupted time series analysis, panel data regression-based approaches, regression discontinuity and instrumental variable approaches. The inclusion of a counterfactual improves causal inference for approaches based on time series analysis, but the selection of a suitable counterfactual or control area can be problematic. The synthetic control method builds a counterfactual using a weighted combination of potential control units.MethodsWe explain the synthetic control method, summarise its use in health research to date, set out its advantages, assumptions and limitations and describe its implementation through a case study of life expectancy following German reunification.ResultsAdvantages of the synthetic control method are that it offers an approach suitable when there is a small number of treated units and control units and it does not rely on parallel preimplementation trends like difference in difference methods. The credibility of the result relies on achieving a good preimplementation fit for the outcome of interest between treated unit and synthetic control. If a good preimplementation fit is established over an extended period of time, a discrepancy in the outcome variable following the intervention can be interpreted as an intervention effect. It is critical that the synthetic control is built from a pool of potential controls that are similar to the treated unit. There is currently no consensus on what constitutes a ‘good fit’ or how to judge similarity. Traditional statistical inference is not appropriate with this approach, although alternatives are available. From our review, we noted that the synthetic control method has been underused in public health.ConclusionsSynthetic control methods are a valuable addition to the range of approaches for evaluating public health interventions when randomisation is impractical. They deserve to be more widely applied, ideally in combination with other methods so that the dependence of findings on particular assumptions can be assessed.

BackgroundMortality rates are higher in Scotland relative to England and Wales, even after accounting for deprivation. This ‘excess’ mortality is partly due to higher mortality from alcohol-related and drug-related deaths, violence and suicide (particularly in young adults). This study investigated whether cohort effects from exposure to neoliberal politics from the 1980s might explain the recent trends in suicide in Scotland.MethodsWe analysed suicide deaths data from 1974 to 2013 by sex and deprivation using shaded contour plots and intrinsic estimator regression modelling to identify and quantify relative age, period and cohort effects.ResultsSuicide was most common in young adults (aged around 25–40 years) living in deprived areas, with a younger peak in men. The peak age for suicide fell around 1990, especially for men for whom it dropped quickly from around 50 to 30 years. There was evidence of an increased risk of suicide for the cohort born between 1960 and 1980, especially among men living in the most deprived areas (of around 30%). The cohort at highest risk occurred earlier in the most deprived areas, 1965–1969 compared with 1970–1974.ConclusionsThe risk of suicide increased in Scotland for those born between 1960 and 1980, especially for men living in the most deprived areas, which resulted in a rise in age-standardised rates for suicide among young adults during the 1990s. This is consistent with the hypothesis that exposure to neoliberal politics created a delayed negative health impact.

A recent study showed that the Prostate Health Index may avoid unnecessary biopsies in men with prostate specific antigen 4-10ng/ml and normal digital rectal examination in the diagnosis of prostate cancer in Hong Kong. This study aimed to conduct an economic evaluation of the impact of adopting this commercially-available test in the Hong Kong public health service to determine whether further research is justified. A cost-consequence analysis was undertaken comparing the current diagnostic pathway with a proposed diagnostic pathway using the Prostate Health Index. Data for the model was taken from a prospective cohort study recruited at a single-institution and micro-costing studies. Using a cut off PHI score of 35 to avoid biopsy would cost HK$3,000 and save HK$7,988 per patient in biopsy costs and HK$511 from a reduction in biopsy-related adverse events. The net cost impact of the change was estimated to be HK$5,500 under base case assumptions. At the base case sensitivity and specificity for all grades of cancer (61.3% and 77.5% respectively) all grade cancer could be missed in 4.22% of the population and high grade cancer in 0.53%. The introduction of the prostate health index into the diagnostic pathway for prostate cancer in Hong Kong has the potential to reduce biopsies, biopsy costs and biopsy-related adverse events. Policy makers should consider the clinical and economic impact of this proposal.

BackgroundEven after accounting for deprivation, mortality rates are higher in Scotland relative to the rest of Western Europe. Higher mortality from alcohol- and drug-related deaths (DRDs), violence and suicide (particularly in young adults) contribute to this ‘excess’ mortality. Age-period and cohort effects help explain the trends in alcohol-related deaths and suicide, respectively. This study investigated whether age, period or cohort effects might explain recent trends in DRDs in Scotland and relate to exposure to the changing political context from the 1980s.MethodsWe analysed data on DRDs from 1979 to 2013 by sex and deprivation using shaded contour plots and intrinsic estimator regression modelling to identify and quantify relative age, period and cohort effects.ResultsThe peak age for DRDs fell around 1990, especially for males as rates increased for those aged 18 to 45 years. There was evidence of a cohort effect, especially among males living in the most deprived areas; those born between 1960 and 1980 had an increased risk of DRD, highest for those born 1970 to 1975. The cohort effect started around a decade earlier in the most deprived areas compared to the rest of the population.ConclusionAge-standardised rates for DRDs among young adults rose during the 1990s in Scotland due to an increased risk of DRD for the cohort born between 1960 and 1980, especially for males living in the most deprived areas. This cohort effect is consistent with the hypothesis that exposure to the changing social, economic and political contexts of the 1980s created a delayed negative health impact.Electronic supplementary materialThe online version of this article (10.1186/s12889-018-5267-2) contains supplementary material, which is available to authorized users.

The decline in alcohol-related mortality in Scotland since the early 2000s and the differing trend to E&W were partly described by a model predicting the impact of declining incomes. Lagged effects from historical social, economic and political change remain plausible from the available data.

Background and AimsIt has been suggested that distributing naloxone to people who inject drugs (PWID) will lead to fewer attendances by emergency medical services at opioid‐related overdose incidents if peer administration of naloxone was perceived to have resuscitated the overdose victim successfully. This study evaluated the impact of a national naloxone programme (NNP) on ambulance attendance at opioid‐related overdose incidents throughout Scotland. Specifically, we aimed to answer the following research questions: is there evidence of an association between ambulance call‐outs to opioid‐related overdose incidents and the cumulative number of ‘take‐home naloxone’ (THN) kits in issue; and is there evidence of an association between ambulance call‐outs to opioid‐related overdose incidents in early adopter (pilot) or later adopting (non‐pilot) regions and the cumulative number of THN kits issued in those areas?DesignControlled time–series analysis.SettingScotland, UK, 2008–15.ParticipantsPre‐NNP implementation period for the evaluation was defined as 1 April 2008 to 31 March 2011 and the post‐implementation period as 1 April 2011 to 31 March 2015. In total, 3721 ambulance attendances at opioid‐related overdose were recorded for the pre‐NNP implementation period across 158 weeks (mean 23.6 attendances per week) and 5258 attendances across 212 weeks in the post‐implementation period (mean 24.8 attendances per week).InterventionScotland's NNP; formally implemented on 1 April 2011.MeasurementsPrimary outcome measure was weekly incidence (counts) of call‐outs to opioid‐related overdoses at national and regional Health Board level. Data were acquired from the Scottish Ambulance Service (SAS). Models were adjusted for opioid replacement therapy using data acquired from the Information Services Division on monthly sums of all dispensed methadone and buprenorphine in the study period. Models were adjusted further for a control group: weekly incidence (counts) of call‐outs to heroin‐related overdose in the London Borough area acquired from the London Ambulance Service.FindingsThere was no significant association between SAS call‐outs to opioid‐related overdose incidents and THN kits in issue for Scotland as a whole (coefficient 0.009, 95% confidence intervals = −0.01, 0.03, P = 0.39). In addition, the magnitude of association between THN kits and SAS call‐outs did not differ significantly between pilot and non‐pilot regions (interaction test, P = 0.62).ConclusionsThe supply of take‐home naloxone kits through a National Naloxone Programme in Scotland was not associated clearly with a decrease in ambulance attendance at opioid‐related overdose incidents in the 4‐year period after it was implemented in April 2011.

Health technology assessment (HTA) conducted to inform developers of health technologies (development-focused HTA, DF-HTA) has a number of distinct features when compared to HTA conducted to inform usage decisions (use-focused HTA). To conduct effective DF-HTA, it is important that analysts are aware of its distinct features as analyses are often not published. We set out a framework of ten features, drawn from the literature and our own experience: a target audience of developers and investors; an underlying user objective to maximize return on investment; a broad range of decisions to inform; wide decision space; reduced evidence available; earlier timing of analysis; fluid business model; constrained resources for analysis; a positive stance of analysis; and a “consumer”-specific burden of proof. This paper presents a framework of ten features of DF-HTA intended to initiate debate as well as provide an introduction for analysts unfamiliar with the field.

Studies assessing the costs of alcoholic liver disease are lacking. We aimed to calculate the costs of hospitalisations before and after diagnosis compared to population controls matched by age, sex and socio-economic deprivation. We aimed to use population level data to identify a cohort of individuals hospitalised for the first time with alcoholic liver disease in Scotland between 1991 and 2011.Incident cases were classified by disease severity, sex, age group, socio-economic deprivation and year of index admission. 5 matched controls for every incident case were identified from the Scottish population level primary care database. Hospital costs were calculated for both cases and controls using length of stay from morbidity records and hospital-specific daily rates by specialty. Remaining lifetime costs were estimated using parametric survival models and predicted annual costs. 35,208 incident alcoholic liver disease hospitalisations were identified. Mean annual hospital costs for cases were 2.3 times that of controls pre diagnosis (£804 higher) and 10.2 times (£12,774 higher) post diagnosis. Mean incident admission cost was £6,663. Remaining lifetime cost for a male, 50–59 years old, living in the most deprived area diagnosed with acoholic liver disease was estimated to be £65,999 higher than the matched controls (£12,474 for 7.43 years remaining life compared to £1,224 for 21.8 years). In Scotland, alcoholic liver disease diagnosis is associated with significant increases in admissions to hospital both before and after diagnosis. Our results provide robust population level estimates of costs of alcoholic liver disease for the purposes of health-care delivery, planning and future cost-effectiveness analyses.