The effect of social deprivation on clinical outcomes and the use of treatments in the UK cystic fibrosis population: a longitudinal study

David C Taylor-Robinson, Rosalind L Smyth, Peter J Diggle, Margaret Whitehead, David C Taylor-Robinson, Rosalind L Smyth, Peter J Diggle, Margaret Whitehead

Abstract

Background: Poorer socioeconomic circumstances have been linked with worse outcomes in cystic fibrosis. We assessed whether a relation exists between social deprivation and individual's clinical and health-care outcomes.

Methods: We did a longitudinal registry study of the UK cystic fibrosis population younger than 40 years (8055 people with 49337 observations for weight, the most commonly collected outcome, between Jan 1, 1996, and Dec 31, 2009). We assessed data for weight, height, body-mass index, percent predicted forced expiratory volume in 1 s (%FEV1), risk of Pseudomonas aeruginosa colonisation, and the use of major cystic fibrosis treatment modalities. We used mixed effects models to assess the association between small-area deprivation and clinical and health-care outcomes, adjusting for clinically important covariates. We give continuous outcomes as mean differences, and binary outcomes as odds ratios, comparing extremes of deprivation quintile.

Findings: Compared with the least deprived areas, children from the most deprived areas weighed less (standard deviation [SD] score -0·28, 95% CI -0·38 to -0·18), were shorter (-0·31, -0·40 to -0·21, and had a lower body-mass index (-0·13, -0·22 to -0·04), were more likely to have chronic P aeruginosa infection (odds ratio 1·89, 95% CI 1·34 to 2·66), and have a lower %FEV1 (-4·12 percentage points, 95% CI -5·01 to -3·19). These inequalities were apparent very early in life and did not widen thereafter. On a population level, after adjustment for disease severity, children in the most deprived quintile were more likely to receive intravenous antibiotics (odds ratio 2·52, 95% CI 1·92 to 3·17) and nutritional treatments (1·78, 1·44 to 2·20) compared with individuals in the least deprived quintile. Patients from the most disadvantaged areas were less likely to receive DNase or inhaled antibiotic treatment.

Interpretation: In the UK, children with cystic fibrosis from more disadvantaged areas have worse growth and lung function compared with children from more affluent areas, but these inequalities do not widen with advancing age. Clinicians consider deprivation status, as well as disease status, when making decisions about treatments, and this might mitigate some effects of social disadvantage.

Funding: Medical Research Council (UK).

Copyright © 2013 Elsevier Ltd. All rights reserved.

Figures

Figure 1
Figure 1
Comparison of anthropometric outcomes, by age and socioeconomic status Mean cross-sectional (A) weight, (B) height, and (C) body-mass index (BMI).
Figure 2
Figure 2
Comparison of respiratory outcomes, by age and socioeconomic status Mean cross-sectional (A) FEV1 and (B) Pseudomonas aeruginosa colonisation prevalence.
Figure 3
Figure 3
Comparison of treatment methods, by age and socioeconomic status Proportion of patients who received (A) any intravenous antibiotic treatment, (B) home intravenous antibiotic treatment, (C) hospital intravenous antibiotic treatment, (D) supplemental feeding, (E) DNase, and (F) inhaled antibiotics.

References

    1. Cystic Fibrosis Trust UK CF Registry annual data report 2010. (accessed Sept 28, 2012).
    1. Schechter MS, Shelton BJ, Margolis PA, Fitzsimmons SC. The association of socioeconomic status with outcomes in cystic fibrosis patients in the United States. Am J Respir Crit Care Med. 2001;163:1331–1337.
    1. O'Connor GT, Quinton HB, Kneeland T. Median household income and mortality rate in cystic fibrosis. Pediatrics. 2003;111:e333–e339.
    1. Britton JR. Effects of social class, sex, and region of residence on age at death from cystic fibrosis. BMJ. 1989;298:483–487.
    1. Barr HLSA, Fogarty AW. The association between socioeconomic status and gender with median age at death from cystic fibrosis in England and Wales: 1959 to 2008. BMJ. 2011;343:d4662.
    1. Marmot MJ, Goldblatt P, Boyce T, McNeish D, Grady M, Geddes I. Fair society, healthy lives: strategic review of health inequalities in England post-2010. The Marmot Review; London: 2010.
    1. Ben-Shlomo Y, Kuh D. A life course approach to chronic disease epidemiology: conceptual models, empirical challenges and interdisciplinary perspectives. Int J Epidemiol. 2002;31:285–293.
    1. Stirbu I, Kunst AE, Mielck A, Mackenbach JP. Inequalities in utilisation of general practitioner and specialist services in 9 European countries. BMC Health Serv Res. 2011;11:288.
    1. van Doorslaer E, Masseria C, Koolman X. Inequalities in access to medical care by income in developed countries. CMAJ. 2006;174:177–183.
    1. Hart JT. The inverse care law. Lancet. 1971;1:405–412.
    1. Cystic Fibrosis Trust UK CF Registry. (accessed Jan 15, 2013).
    1. Adler AI, Shine BS, Chamnan P, Haworth CS, Bilton D. Genetic determinants and epidemiology of cystic fibrosis-related diabetes: results from a British cohort of children and adults. Diabetes Care. 2008;31:1789–1794.
    1. Mehta G, Sims EJ, Culross F, McCormick JD, Mehta A. Potential benefits of the UK Cystic Fibrosis Database. J R Soc Med. 2004;97:60–71.
    1. Pan H, Cole T. User's guide to LmsGrowth. Medical Research Council; London: 2005.
    1. Geoconvert Welcome to GeoConvert. (accessed Dec 22, 2012).
    1. Laird NM, Ware JH. Random-effects models for longitudinal data. Biometrics. 1982;38:963–974.
    1. Schechter MS, McColley SA, Silva S, Haselkorn T, Konstan MW, Wagener JS. Association of socioeconomic status with the use of chronic therapies and healthcare utilization in children with cystic fibrosis. J Pediatr. 2009;155:634–639.
    1. Schechter MS, McColley SA, Regelmann W. Socioeconomic status and the likelihood of antibiotic treatment for signs and symptoms of pulmonary exacerbation in children with cystic fibrosis. J Pediatr. 2011;159:819–824.
    1. Krieger N, Waterman P, Chen JT, Soobader MJ, Subramanian SV, Carson R. Zip code caveat: bias due to spatiotemporal mismatches between zip codes and US census-defined geographic areas—the Public Health Disparities Geocoding Project. Am J Public Health. 2002;92:1100–1102.
    1. Taylor-Robinson D, Whitehead M, Diderichsen F. Understanding the natural progression in %FEV1 decline in patients with cystic fibrosis: a longitudinal study. Thorax. 2012;67:860–866.
    1. Howe LD, Tilling K, Galobardes B, Smith GD, Gunnell D, Lawlor DA. Socioeconomic differences in childhood growth trajectories: at what age do height inequalities emerge? J Epidemiol Community Health. 2012;66:143–148.
    1. Howe LD, Tilling K, Galobardes B, Smith GD, Ness AR, Lawlor DA. Socioeconomic disparities in trajectories of adiposity across childhood. Int J Pediatr Obes. 2011;6:e144–e153.
    1. Kinra S, Baumer JH, Davey Smith G. Early growth and childhood obesity: a historical cohort study. Arch Dis Child. 2005;90:1122–1127.
    1. Wijlaars LP, Johnson L, van Jaarsveld CH, Wardle J. Socioeconomic status and weight gain in early infancy. Int J Obes (Lond) 2011;35:963–970.
    1. CSDH Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the commission on social determinants of health. (accessed Jan 15, 2013).
    1. Whitehead M, Dahlgren G. Concepts and principles for tackling social inequities in health: levelling up part 1. WHO; Copenhagen: 2007.
    1. Southern KW, Merelle MM, Dankert-Roelse JE, Nagelkerke AD. Newborn screening for cystic fibrosis. Cochrane Database Syst Rev. 2009;1 CD001402.
    1. Rosenfeld M, Emerson J, McNamara S. Risk factors for age at initial Pseudomonas acquisition in the cystic fibrosis epic observational cohort. J Cyst Fibros. 2012;11:446–453.
    1. Schechter MS. Nongenetic influences on cystic fibrosis outcomes. Curr Opin Pulm Med. 2011;17:448–454.
    1. Hanratty B, Zhang T, Whitehead M. How close have universal health systems come to achieving equity in use of curative services? A systematic review. Int J Health Serv. 2007;37:89–109.
    1. Groholt EK, Stigum H, Nordhagen R, Kohler L. Health service utilization in the Nordic countries in 1996: influence of socio-economic factors among children with and without chronic health conditions. Eur J Public Health. 2003;13:30–37.
    1. Pressler T. Review of recombinant human deoxyribonuclease (rhDNase) in the management of patients with cystic fibrosis. Biologics. 2008;2:611–617.
    1. Mackenbach JP. What would happen to health inequalities if smoking were eliminated? BMJ. 2011;342:d3460.
    1. Taylor-Robinson D, Schechter MS. Health inequalities and cystic fibrosis. BMJ. 2011;343:d4818.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi