Study objective -To assess the nature of the relation between health and social factors at both the aggregated scale of geographical areas and the individual scale. Design and setting -The individual data are derived from the sample of anonymised records (SAR) from the census of 1991 in Great Britain, and are combined' with area data from this census. The ecological setting (context) was defined using multivariate methods to classify the 278 districts of residence identifiable in the SAR. The outcome health variable is the 1991 census long-term limiting illness question. Health variations were analysed by multilevel logistic regression to examine the compositional variation (at the level of the individual) and the contextual variation (variability operating at the level of districts) in reported illness. Participants -10 per cent randomised subsample of the SAR who are aged 16 + and are resident in households. Main results -The multi-level modelling revealed that area factors have a significant association with individual health outcome but their effect is smaller than that of individual attributes. The results show evidence for both compositional and contextual effects in the pattern of variation in propensity to report illness. Conclusions -The results suggest generally higher levels of ill health for individuals who are older, not married, in a semi/unskilled manual social class, and socioeconomically deprived (as measured by a composite deprivation score). All individuals living in areas with high levels of illness (which tend to be more deprived areas) show greater morbidity, even after allowing for their individual characteristics. However, within affluent areas, where morbidity was generally lower, the health inequality (health gradient) between rich and poor individuals was particularly strong. We consider the implications of these findings for health and resource allocation policy.(JT Epidemiol Community Health 1996;50:366-376) This paper examines some aspects of health inequalities and their associations with socioeconomic conditions in the British population. While most measures of population health demonstrate inequalities in health status, the patterns observed depend on the type of indicator used and the aspect of health it measures.The measure of health considered here comes from the 1991 census question on longterm limiting illness, which is a self assessed measure of health status. It may be more affected by subjectivity and imprecision than other health measures such as mortality and physiological measures. However, premature mortality can be the result of chronic ill health, and perceived health status is a good predictor of mortality.' Moreover, chronic illness encompasses disabling conditions not usually associated with mortality, and provides a more comprehensive health status measure. Self reported health is also associated with physiological health2 and general practitioner and hospital utilisation.3 The 1991 census measure has been shown to be ecologically associated with mort...
Background:Clinical uncertainty is emotionally challenging for patients and carers and creates additional pressures for those clinicians in acute hospitals. The AMBER care bundle was designed to improve care for patients identified as clinically unstable, deteriorating, with limited reversibility and at risk of dying in the next 1–2 months.Aim:To examine the experience of care supported by the AMBER care bundle compared to standard care in the context of clinical uncertainty, deterioration and limited reversibility.Design:A comparative observational mixed-methods study using semi-structured qualitative interviews and a followback survey.Setting/participants:Three large London acute tertiary National Health Service hospitals. Nineteen interviews with 23 patients and carers (10 supported by AMBER care bundle and 9 standard care). Surveys completed by next of kin of 95 deceased patients (59 AMBER care bundle and 36 standard care).Results:The AMBER care bundle was associated with increased frequency of discussions about prognosis between clinicians and patients (χ2 = 4.09, p = 0.04), higher awareness of their prognosis by patients (χ2 = 4.29, p = 0.04) and lower clarity in the information received about their condition (χ2 = 6.26, p = 0.04). Although the consistency and quality of communication were not different between the two groups, those supported by the AMBER care bundle described more unresolved concerns about caring for someone at home.Conclusion:Awareness of prognosis appears to be higher among patients supported by the AMBER care bundle, but in this small study this was not translated into higher quality communication, and information was judged less easy to understand. Adequately powered comparative evaluation is urgently needed.
IntroductionDespite preferences to the contrary, 53% of deaths in England occur in hospital. Difficulties in managing clinical uncertainty can result in delayed recognition that a person may be approaching the end of life, and a failure to address his/her preferences. Planning and shared decision-making for hospital patients need to improve where an underlying condition responds poorly to acute medical treatment and there is a risk of dying in the next 1–2 months. This paper suggests an approach to improve this care.InterventionA care bundle (the AMBER care bundle) was designed by a multiprofessional development team, which included service users, utilising the model for improvement following an initial scoping exercise. The care bundle includes two identification questions, four subsequent time restricted actions and systematic daily follow-up.Clinical impactThis paper describes the development and implementation of a care bundle. From August 2011 to July 2012, 638 patients received care supported by the AMBER care bundle. In total 42.8% died in hospital and a further 14.5% were readmitted as emergencies within 30 days of discharge. Clinical outcome measures are in development.ConclusionsIt has been possible to develop a care bundle addressing a complex area of care which can be a lever for cultural change. The implementation of the AMBER care bundle has the potential to improve care of clinically uncertain hospital patients who may be approaching the end of life by supporting their recognition and prompting discussion of their preferences. Outcomes associated with its use are currently being formally evaluated.
Main results-The socioeconomic conditions of lone mothers deteriorated during the period 1979-1995, with increasing unemployment and poverty rates. Lone mothers had worse health status than couple mothers throughout the period. In comparison with the first two periods, the prevalence of less than good health increased among both lone and couple mothers from the late 1980s onwards. For lone and couple mothers who were poor, their rates of less than good health were similar in the early 1980s, but in 1992-95 poor lone mothers were significantly more likely to report less than good health than poor couple mothers. Unemployed lone mothers had particularly high rates of ill health throughout the study period. Conclusions-As in other European countries, lone mothers are emerging as a vulnerable group in society in Sweden, especially in the economic climate of the 1990s. While they had very low rates of poverty and high employment rates in the 1980s, their situation has deteriorated with the economic recession of the 1990s. The health status of lone mothers, particularly those who are unemployed or poor, appears worse than that of couple mothers and in some circumstances may be deteriorating. Further study is needed to elucidate the mechanisms mediating their health disadvantage compared with couple mothers. (J Epidemiol Community Health 1999;53:750-756)
Understanding differing interpretations of complex interventions is essential. Consideration of ward composition, casemix and potential exposure to the intervention is critical for their successful implementation.
It has been possible to develop a care bundle addressing a complex area of care which can be a lever for cultural change. The implementation of the AMBER care bundle has the potential to improve care of clinically uncertain hospital patients who may be approaching the end of life by supporting their recognition and prompting discussion of their preferences. Outcomes associated with its use are currently being formally evaluated.
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