About the Office for National Statistics The Office for National Statistics (ONS) is the Government Agency responsible for compiling, analysing and disseminating many of the United Kingdom’s economic, social and demographic statistics, including the retail prices index, trade figures and labour market data, as well as the periodic census of the population and health statistics.The Director of ONS is also Head of the Government Statistical Service (GSS) and Registrar General in England and Wales and the agency carries out all statutory registration of births, marriages and deaths there.
About Health Statistics Quarterly and Population Trends Health Statistics Quarterly and Population Trends are journals of the Office for National Statistics. Each is published four times a year in February, May, August and November and March, June, September and December, respectively. In addition to bringing together articles on a wide range of population and health topics, Health Statistics Quarterly and Population Trends contain regular series of tables on a wide range of subjects for which ONS is responsible, including the most recently available statistics. Subscription Annual subscription, including postage, is £75; single issues are £20. Annual subscription for both Health Statistics Quarterly and Population Trends, including postage, is £135.
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Peter Goldblatt (editor) David Pearce (editor) Angela Dale Paul Hyatt Graham C Jones Azeem Majeed Jil Matheson Ian R Scott Judith Walton
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© Crown copyright 1999. Published with permission of the Office for National Statistics on behalf of the Controller of Her Majesty’s Stationery Office. For permission to reproduce material in this publication please contact: Copyright enquiries Office for National Statistics B1/09 1 Drummond Gate London SW1V 2QQ Tel: 020 7533 5674 Fax: 020 7533 5685 ISBN 0 11 621122 9 ISSN 1465-1645
Health
statistics 04 Winter 1999
Quarterly
IN THIS ISSUE
Page
In brief
2
Health indicators
4
Prevalence and management of heart failure in general practice in England and Wales 1994–96 Examines the prevalence and management of heart failure in England and Wales Azeem Majeed and Kath Moser
5
Health of older people: disease prevalence, prescription and referral rates, England and Wales 1996 Studies the prevalence of five treated diseases, rates of prescribing and out-patient rates by speciality in 1996 in people aged 65 and over Mark Carter, Kath Moser and Sue Kelly
9
16
Occupational Cancer: the role of routine cancer registration Describes occupational information collected at routine cancer registration for men and women aged 20–74 years living in England and Wales Graham R Law, Eve Roman and Jill Simpson Tables List of tables Notes to tables Tables 1.1–6.3
22 23 24
Annual Updates: Congenital anomalies statistics: notifications 1998 (England and Wales) 1997 Mortality statistics: general (England and Wales) Legal Abortions in England and Wales, 1998
46 51 54
Reports: Cancer Incidence 1993–96 Infant and perinatal mortality by social and biological factors 1998 (England and Wales)
59 71
Recent ONS publications
76
London: The Stationery Office
A publication of the Government Statistical Service
Health Statistics Quar terl y 04
Winter 1999
in brief People
average of 65 cigarettes in the previous week, compared with 49 for girls.
Peter Goldblatt has joined ONS as the Chief Medical Statistician and Director of Demography and Health Division. He will chair the editorial board of Health Statistics Quarterly and Population Trends. He began his career in Government Service when he joined OPCS’s Medical Statistics Division in 1977. Since then he has worked in the Social Statistics Research Unit at City University, the Statistics Division of the Department of Health and the Research and Development Directorate of the Home Office. His main research interests have covered the medical aspects of the Longitudinal Study, social and demographic variations in health and the targeting of resources, particularly in the areas of health gain, social care and crime reduction.
Smoking, drinking and drug use among young teenagers in 1998 Volume 1: England1, Volume 2: Scotland1 Two new surveys on smoking, drinking and drug use among teenagers in England and Scotland were produced by the Social Survey Division of ONS in October 1999.
Office for National Statistics
2
In 1998 as in previous years most smokers bought their cigarettes from shops, with newsagents or tobacconists (65%) and garage shops (35%) being the most common type of retail outlets used. Sixty-one per cent of current smokers were given cigarettes by their friends while over a quarter (28%) bought them from friends and relatives: almost a quarter (24%) said that they bought cigarettes from a machine. Drinking
Peter Goldblatt The main purpose of these latest surveys in a biennial series was to continue to monitor smoking and drinking among secondary school children aged 11–15 (12–15 in Scotland), and for the first time to obtain estimates of the prevalence of drug use among this age group. Some of the key results for England are given below. Smoking In 1998, the overall proportion of 11–15 year olds who were regular smokers (smoking at least one cigarette a week, on average) was 11%, compared with 13% in 1996. Continuing the pattern first established in the mid-1980s, prevalence was significantly higher among girls (12%) than among boys (9%). Although the fall in prevalence between 1996 and 1998 is statistically significant, it may just represent a short term fluctuation, rather than the start of a downward trend. Although girls are more likely than boys to be regular smokers, among those who do smoke, boys smoke more cigarettes. In 1998, boys who were regular smokers had smoked an
The average weekly amount drunk per pupil aged 11–15 in 1998 was 1.6 units (somewhat less than a pint of beer, or its equivalent). This was less than the estimate of 1.8 units in 1996, but still double the figure of 0.8 units in 1990. The overwhelming majority had drunk little or nothing in the previous seven days, and most of the remainder had drunk only modest amounts. However, at the other end of the scale, 4% of boys and 2% of girls had drunk 15 or more units in the previous week. It is against the law for anyone under 18 to buy alcohol in a pub, off-licence, shop or other outlet, but almost half of those who drink (28% of all children aged 11–15) said they did buy alcohol. By far the most common place of purchase was the off-licence, mentioned by 20% of drinkers. Drug use Although one third of pupils had been offered drugs, a much smaller proportion, 13%, had ever used drugs. Boys were more likely to have used drugs than were girls (14% compared with 12%). Over half (52%) of those who had ever taken drugs had only ever used cannabis, 40% had used cannabis and other drugs, and 9% had used other drugs only.
Health Statistics Quar terly 04
Of the 13% of pupils who had ever used drugs, about half - 7% of all pupils - had done so in the last month, and a further 4% of pupils had done so in the last year, though not in the last month. Two per cent of pupils had last used drugs more than a year ago. The likelihood of having ever used drugs is strongly related to both smoking experience and usual drinking frequency. When the different combinations of smoking and drinking behaviour are considered, the association with drug use is striking. Virtually no children who had never smoked or drunk alcohol had ever used drugs, but as many as 75% of regular smokers who drank at least once a week had done so. 1
Smoking, drinking and drug use among young teenagers in 1998 Volume 1: England, ISBN 0 11 621263 2, price £27.00 and Smoking, drinking and drug use among young teenagers in 1998 Volume 2: Scotland, ISBN 0 11 621281 0, price £27.00 are both available from The Stationery Office.
BINOCAR heads for Birmingham The British Isles Network of Congenital Anomaly Registers (BINOCAR) was set up jointly, in 1996, by ONS and Dr David Stone at the Glasgow Register of Congenital Anomalies. The purpose of the network is to bring together all those working in the field of monitoring and reporting on congenital anomalies. It includes the National Congenital Anomaly System at ONS and registers set up in some regions. Some of these focus on prenatal diagnosis and counselling, others on epidemiological studies or specific anomalies such as Down’s Syndrome and facial clefts. The second annual BINOCAR meeting took place in February 1999 at the new Swallow Hotel in Liverpool. It was co-hosted by ONS staff from London and Titchfield and the Merseyside and Cheshire Congenital Anomaly Survey. One hundred people attended the twoday meeting, which provided an opportunity to share information and achievements, and to plan to work together on collaborative projects. Those present included, doctors, research midwives, academics, computer programmers and statisticians. The meeting included a session where research papers on birth defects and their prevention were presented.
The event gave ONS an opportunity to celebrate the culmination of 2 years work with two regional registers, the Trent register CAR and the Welsh register CARIS, on electronic data transfer to the National Congenital Anomaly System. The ONS system has been modified to accept both paper and electronic data transfer. Local NHS Trusts in these regions previously filled in congenital anomaly notification forms, which they then submitted to ONS. They will now only have to notify cases to their local register who will send the data on to ONS. Regional registers collect information about congenital anomalies from many sources, and this development is now providing ONS with more comprehensive data on congenital anomalies in Wales and the Trent region. ONS published a new guide for the National Congenital Anomaly System to coincide with the BINOCAR meeting. The guide provides a comprehensive overview of the system for both data users and suppliers. It includes changes which have been made to incorporate the NHS number and for year 2000 compliance. It also explains the surveillance procedures and how data for England and Wales contribute to world-wide monitoring programmes. Copies of the guide can be obtained from Lyn Watmore (01329 813618). The 3rd annual BINOCAR meeting will be held in Birmingham on 2nd and 3 rd March 2000. For more details contact Lorraine Streater (020 7533 5209).
Figure 1
Winter 1999
Recent trends in deaths from homicide in England and Wales Since the publication of Health Statistics Quarterly 03, an error has been discovered in the text for the above article. The 4th bullet point in the Key findings box on page 13 should read ●
In younger men death rates have risen by about 35% on average
Infant and perinatal mortality 1998: health areas, England and Wales An error has been discovered in Health Statistics Quarterly 03 in Figure 1 of the above report on page 63. The correct Figure 1 now appears below.
Infant mortality rates, 1973–98, England and Wales
Infant deaths per 1,000 live births 20 Postneonatal deaths Neonatal deaths 15
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Health Statistics Quar terly 04
Winter 1999
Health indicators Figure A
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Figure B
Age-standardised mortality rate
Rate per million population 20,000 15,000 10,000 5,000 0 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 Year
Figure C
Infant mortality (under 1 year)
Rate per 1,000 live births 20 15 10 5 0 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998* Year * Provisional data.
Figure D
Quarterly abortion rates – residents
Rate per 1,000 women 14–49 15 14 13 12 11 10
Abortion rate
9 8
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1982
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Office for National Statistics
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Moving average rate 1991
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Prevalence and management of heart failure in general practice in England and Wales 1994 – 96 Azeem Majeed and Kath Moser, ONS
This study examines the prevalence and management of heart failure in England and Wales.The data come from 288 general practices, and 2.1 million patients, in the General Practice Research Database. In 1996, the age-adjusted prevalence of heart failure was 9.7 per 1,000 males and 8.2 per 1,000 females. Between 1994 and 1996, the percentage of heart failure patients prescribed ACE-inhibitors increased from 40 per cent to 51 per cent of men and 28 per cent to 36 per cent of women. The findings suggest that management of heart failure in primary care is changing to reflect current guidelines, with an increase in the percentage of patients who are being prescribed ACE-inhibitors.
I NTRODUCTION Heart failure is very common, increases in prevalence with age, and results in high levels of ill-health and mortality (see Box One). The number of hospital admissions for heart failure has increased substantially over the last 20 years and it is now one of the most common reasons for admission to hospitals in developed countries. Even in milder cases detected through community screening programmes, five-year survival rates are around 50 per cent and are worse than for many forms of cancer. Furthermore, in studies of the major chronic illnesses, heart failure reduced quality of life more than illnesses such as diabetes and hypertension. 1 Heart failure has been traditionally treated with drugs such as diuretics and digoxin but there have been several recent developments in management.2 Because of these developments, and the burden of illhealth it causes, the management of heart failure is becoming an increasingly important area for the National Health Service. 3 There is some evidence that in the past many patients with heart failure were inadequately investigated and treated both in hospitals and in primary care. 4,5 Moreover, several studies have shown that the use of Angiotensin Converting Enzyme (ACE) inhibitors in patients with heart failure can lead to a substantially improved prognosis and a better quality of life.6 However, relatively little is known about the prevalence of heart failure in primary care or how heart failure is currently being managed by general practitioners. Many previous studies of heart failure have either used selected groups of patients, such as those attending hospital clinics, who may not be typical of all patients with heart failure, or data from only a small number of general practices.7,8 The objectives of this study were to determine the prevalence of heart failure in primary care, based on
5
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Health Statistics Quar terly 04
Winter 1999
Box one Heart failure Hear t failure arises when the heart is unable to pump enough blood to meet the demands of the body. Some people with mild heart failure may have very few symptoms. Patients with moderate or severe hear t failure suffer from a number of problems including shortness of breath (particularly when lying flat); waking up suddenly at night with a feeling of breathlessness; general tiredness or weakness; swelling of the feet, ankles and legs; rapid weight gain; and chronic cough. Heart failure is a serious condition with a poor prognosis and one which can markedly reduce quality of life. Hear t failure has many causes. The most common causes are ischaemic heart disease, problems with the heart muscle (cardiomyopathy); high blood pressure (hypertension); problems with any of the heart valves; abnormal heart rhythms (arrhythmias); and toxic substances (such as alcohol abuse). The diagnosis is sometimes clear from the histor y and examination but usually has to be confirmed by investigations such as chest x-ray or echocardiography. Hear t failure is treated in several different ways. The aims of treatment are to reduce progression of the disease, reduce hospitalisation, and extend life . A ver y impor tant aspect of treatment is dealing with any underlying problems such as high blood pressure . The main groups of drugs used to treat heart failure are: • ACE-inhibitors. ACE-inhibitors help open (dilate) arteries and lower blood pressure , thus improving blood flow. • Diuretics. Diuretics are often called ‘water pills’ because they help keep fluid from building up in the body. They can also decrease the amount of fluid that collects in the lungs, which helps breathing. • Beta-blockers. Beta-blockers can improve blood flow and may help prevent some heart rhythm problems. • Digoxin. Digoxin can help the heart pump better.
Health. The Medicines Control Agency has been responsible for its overall management and financial control since April 1999. The Office for National Statistics (formerly the Office of Population Censuses and Surveys) operated the database from 1994–99. General practices participating in the GPRD follow agreed guidelines for the recording of clinical and prescribing data, and submit anonymised patient-based clinical records for inclusion in the database at regular intervals. Consequently, the database contains longitudinal information on diagnoses, prescriptions and hospital referrals.9 The accuracy and comprehensiveness of the data recorded in the GPRD has been documented previously. 10,11,12 All 288 practices included in this analysis contributed data throughout the period 1994–96 and passed regular quality checks. The combined population of the practices had a very similar age-sex composition to the population of England and Wales.13,14
Definition of heart failure We defined patients with heart failure as those who had ever had a diagnosis of heart failure recorded on their computer record and who had been prescribed either a diuretic or ACE-inhibitor during the study year. For example, the prevalence of heart failure in 1994 was based on a previous diagnosis of heart failure and a prescription for a diuretic or ACE-inhibitor during 1994. We did this to help ensure that only active cases of heart failure were included in the analysis and to exclude cases where the original diagnosis of heart failure had been incorrect. We then determined what percentage of patients with heart failure had been prescribed an ACE-inhibitor during the study year.
Inter-practice variation Four practices with list sizes of less than 1,000 patients were excluded from the analysis of inter-practice variation. For each of the remaining 284 practices, we calculated the prevalence of heart failure in 1996 using the same method as described above. We then calculated the percentage of patients with heart failure who had been prescribed an ACE-inhibitor during 1996 to determine the interpractice variation in prescribing.
RESULTS
diagnoses recorded in general practice, and to examine the use in primary care of diuretics and ACE-inhibitors in patients with heart failure during the period 1994–96. We used data from a large general practice database to carry out our study, and hence it is among the largest studies ever to examine the prevalence and management of heart failure in the United Kingdom.
The crude overall prevalence of heart failure in 1996 was 11.5 per 1,000 in men and 15.5 per 1,000 in women. Age-standardised prevalences, calculated using the European standard population, were 9.7 per 1,000 in men and 8.2 per 1,000 in women. Prevalence rates increased with age from less than 1 per 1,000 in people aged under 45 years to 176 per 1,000 in men and 186 per 1,000 in women aged 85 years and over. Although the crude overall prevalence of heart failure was higher in women than men, age-specific prevalence rates were higher in men than in women except for the most elderly group, patients aged 85 years and over (Table 1). The prevalence of heart failure was similar in 1996 and 1994 but the percentage of patients with heart failure prescribed ACE-inhibitors increased substantially during this period, from 40 per cent to 51 per cent in men and from 28 per cent to 36 per cent in women (Table 2). Younger patients with heart failure were more likely to be prescribed ACEinhibitors than older patients. This was particularly true for men; among women there was substantially less variation in the percentage of patients prescribed ACE-inhibitors.
METHODS
Inter-practice variation
The data for this study came from 288 general practices in England and Wales, total list size 2.1 million, contributing data to the United Kingdom General Practice Research Database (GPRD). The GPRD was originally set up in 1987 by VAMP Ltd and was subsequently acquired by Reuters who donated it in 1994 to the Department of
Both the recorded prevalence of heart failure and the percentage of patients with heart failure prescribed ACE-inhibitors varied widely in the 284 practices included in the examination of inter-practice differences in prescribing (Table 3). The unadjusted prevalence of heart failure varied from 0.7 to 30.4 per 1,000 in men (median 11.0)
Office for National Statistics
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Health Statistics Quar terly 04
Table 1
Number of patients with heart failure and prevalence of heart failure per 1,000 in 288 general practices in England and Wales in 1996
Males
Age group (years)
0–34 35–44 45–54 55–64 65–74 75–84 85+
Number of patients with heart failure
Prevalence per 1,000
Number of patients with heart failure
Prevalence per 1,000
0.1 0.4 2.5 13.7 42.4 103.5 175.5
35 40 187 784 2,891 5,814 4,463
0.1 0.3 1.5 8.7 34.6 95.6 186.0
All ages (crude rate) 10,212 All ages (age standardised) -
11.5 9.7
14,214 -
15.5 8.2
Percentage of patients with heart failure prescribed ACE-inhibitors in England and Wales in 288 general practices in England and Wales in 1994 and 1996
Percentage of patients prescribed ACE-inhibitors Males Age group (years)
Inter-practice variation in prevalence and management of heart failure in 284 practices in England and Wales in 1996.
Median
Range
10th Centile
90th Centile
Prevalence per 1,000 in men
11.0
0.7 to 30.4
6.0
17.3
Prevalence per 1,000 in women
15.0
0 to 40.4
8.9
23.8
Percentage of men prescribed ACE-inhibitors
51.5
0 to 100
36.8
66.7
Percentage of women prescribed ACE-inhibitors
36.6
0.7 to 66.7
22.0
50.0
Females
25 54 318 1,240 3,064 3,965 1,546
Table 2
Table 3
Females
1994
1996
1994
1996
0–34 35–44 45–54 55–64 65–74 75–84 85+
43.6 75.6 64.3 58.6 47.1 34.0 21.4
56.0 83.3 73.3 68.0 58.4 45.9 28.4
44.4 35.1 43.3 37.8 38.0 28.6 17.7
42.9 42.5 56.1 44.5 45.0 37.8 24.5
All ages
40.3
50.8
27.9
35.7
and from 0 to 40.4 per 1,000 in women (median 15.0). Even after excluding the top and bottom 10 per cent of practices, there was still a more than two-fold variation in the prevalence of heart failure. The percentage of patients with heart failure prescribed ACEinhibitors varied from 0 per cent to 100 per cent in men (median 52 per cent) and from 0.7 per cent to 67 per cent in women (median 37 per cent). There was a strong association between the reported prevalence of heart failure in men and women in the 288 practices (r=0.70, P
