1013How has change in gestational diabetes diagnosis affected pregnancy outcomes?

Background Gestational diabetes mellitus (GDM) incidence is increasing in Australia, influenced by new diagnostic criteria gradually implemented from 2011. We aimed to identify whether the change was associated with increased obstetric intervention and/or improved outcomes. Methods Linked perinatal, hospital and deaths data from New South Wales identified singleton births, 33-41 weeks, 2006-2015. Adjusted Poisson modelling predicted the GDM incidence trajectory post-2011 without the diagnostic change and estimated the post-2011 “additional GDM” cases. Actual rates of interventions and outcomes for GDM-diagnosed pregnancies were compared with predicted scenarios where the “additional GDM” group was assumed to have the same rate as (ie clinically same as): (A) the “previous GDM” group <2011; (B) the “non-GDM” group <2011; or (C) the “non-GDM” group ≥2011. Results GDM incidence more than doubled over the study period. Actual planned birth, Caesarean and macrosomia rates were consistent with Scenario A, ie higher intervention rates, but lower macrosomia than B and C. Neonatal hypoglycaemia was lower than Scenario A, closer to B and C. Actual perinatal deaths were lower than predicted by all scenarios, showing improvement for all with GDM, not only “additional” cases. Maternal and neonatal morbidity rates were within the confidence bounds for all three predicted scenarios. Conclusions Our study suggests that the widely adopted new diagnostic criteria for GDM are associated with increased obstetric intervention rates and lower macrosomia rates but with no clear impacts on maternal or neonatal morbidity. Key messages A diagnostic criteria change has identified more GDM pregnancies without clear benefit for outcomes.

Dyadic approach to post-stroke hospitalizations: role of caregiver and patient characteristics

Aim To study the association of caregiver factors and stroke patient factors with rehospitalizations over the first 3 months and subsequent 3–12 months post-stroke in Singapore. Methods Patients with stroke and their caregivers were recruited in the Singapore Stroke Study, a prospective yearlong cohort. While caregiver and patient variables were taken from this study, hospitalization data were extracted from the national claims database. We used Poisson modelling to perform bivariate and multivariable analysis with counts of hospitalization as the outcome. Results Two hundred and fifty-six patient with stroke and caregiver dyads (N = 512) were analysed, with patients having spouse (60%), child (29%), sibling (4%) and other (7%) as their caregivers. Among all participants, 89% of index strokes were ischemic, 57% were mild in severity and more than half (59%) of the patients had moderate or severe disability post-stroke as measured on the Modified Rankin Scale. Having social support in the form of a foreign domestic worker for general help of caregiver reduced the hospitalization rate over 3 months post-stroke by 66% (IRR: 0.342; 95% CI: 0.180, 0.651). Compared to having a spousal caregiver, those with a child caregiver had an almost three times greater rate of hospitalizations over 3–12 months post-stroke (IRR: 2.896; 95% CI: 1.399, 5.992). Higher reported caregiving burden at the 3-month point was associated with the higher subsequent rate of hospitalization. Conclusion Recommendations include the adoption of a dyadic or holistic approach to post-stroke care provision by healthcare practitioners, giving due importance to both patients with stroke and their caregivers, integrating caregivers in the healthcare system to extend the care continuum to include informal care in the community and provision of timely support for caregivers.

Sex, age and socioeconomic inequalities in older people’s unscheduled care

Background In Scotland, unscheduled care is usually received at hospital accident and emergency (A&E) departments or referral by GPs to medical assessment units (MAU). Almost a quarter attendances are for those aged 65 years+. Demand for unscheduled care will increase as the population ages. This study measures inequalities in unscheduled care presentations among those aged 65 years+. Methods A&E and MAU attendance data between April 2017 and March 2018 for Glasgow residents were analysed. Data were modelled using poisson modelling for outcome measures attendances, rate of attendance and length of stay, adjusting for agegroup, sex and deprivation. A second set of models also adjusted for time of day, month and referral source, including interaction terms. Results While there was a higher number of attendances among females (RR and 95% CI = 0.30 (0.28, 0.32)), and among those aged 65-69 years compared with older ages (RR = 0.03 (0.01, 0.06)), modelling rates showed that males were significantly more likely to attend (RR = 0.14 (0.13, 0.16)) and that likelihood rose with age, eg RR for 85+ years significantly greater than 80-84 years, significantly greater than for 75-79 years etc. There was no gender difference in length of stay but this increased with increasing age. Attendance was significantly more likely for those living in the most deprived quintile of deprivation (RR = 0.30 (0.27, 0.34) compared with the most affluent quintile). SES inequalities in attendance and length of stay became less pronounced with increasing age. Referrals via 999 emergency services increased with age while referrals by GP and NHS24 reduced with age. Attendance was more likely in December (RR = 0.15 (0.11, 0.18)) and likelihood of a morning attendance reduced significantly with increasing age and deprivation. Conclusions Inequalities in attendance, length of stay and methods of referral are observed which should be considered when planning to meet the demand for unscheduled care. Key messages Age, sex and socioeconomic inequalities in unscheduled care exist even at the oldest ages. When planning to meet the demand of future unscheduled care, patterns of current use and population projections should be considered in tandem.

Structured additive distributional hurdle Poisson modelling of individual fertility levels in Nigeria

Fertility is one of the dynamic components of population and has been modelled through children ever born per woman, which is a count variable that can be characterized with excessive zeros origination from women without any births. In order to examine the spatial variation across states of Nigeria, we proposed the use of hurdle models that classifies the data into a truncated count and point mass of zeros. We adopt distributional regression model that allows all parameters of the hurdle model to be linked to covariates of different types so as to allow for accessing the spatial variations and nonlinear forms of metrical covariates on the level of fertility and in the likelihood of having no child. Data was sourced from the 2013 Nigeria Demographic and Health Survey. Findings reveal the existence of north-south divide in the average level of fertility and in the likelihood of a woman not giving birth to any child. Women with higher level of education and those from richer or richest households have higher likelihood of having no child, but this is not the case for women with primary or secondary education, users of traditional or modern contraceptive, ever-married women and those working. There is therefore the need to strengthen family planning policies so that investment in contraceptive would yield the expected results in Nigeria.

Handwashing with soap after potential faecal contact: global, regional and country estimates

Background Limited data have been available on the global practice of handwashing with soap (HWWS). To better appreciate global HWWS frequency, which plays a role in disease transmission, our objectives were to: (i) quantify the presence of designated handwashing facilities; (ii) assess the association between handwashing facility presence and observed HWWS; and (iii) derive country, regional and global HWWS estimates after potential faecal contact. Methods First, using data from national surveys, we applied multilevel linear modelling to estimate national handwashing facility presence. Second, using multilevel Poisson modelling on datasets including both handwashing facility presence and observed HWWS after potential faecal contact, we estimated HWWS prevalence conditional on handwashing facility presence by region. For high-income countries, we used meta-analysis to pool handwashing prevalence of studies identified through a systematic review. Third, from the modelled handwashing facility presence and estimated HWWS prevalence conditional on the presence of a handwashing facility, we estimated handwashing practice at country, regional and global levels. Results First, approximately one in four persons did not have a designated handwashing facility in 2015, based on 115 data points for 77 countries. Second the prevalence ratio between HWWS when a designated facility was present compared with when it was absent was 1.99 (1.66, 2.39) P <0.001 for low- and middle-income countries, based on nine datasets. Third, we estimate that in 2015, 26.2% (23.1%, 29.6%) of potential faecal contacts were followed by HWWS. Conclusions Many people lack a designated handwashing facility, but even among those with access, HWWS is poorly practised. People with access to designated handwashing facilities are about twice as likely to wash their hands with soap after potential faecal contact as people who lack a facility. Estimates are based on limited data.

Venous Thromboembolism (VTE) Incidence and VTE-Associated Survival among Olmsted County Residents of Local Nursing Homes

Nursing home (NH) residency is an independent risk factor for venous thromboembolism (VTE), but the VTE burden within the NH population is uncertain. This study estimates VTE incidence and VTE-associated mortality among NH residents. We identified all NH residents in any NH in Olmsted County, Minnesota, United States, 1 October 1998 to 31 December 2005 and all first lifetime VTE among county residents to estimate VTE incidence while resident of local NHs (NHVTE), using Centers for Medicare and Medicaid Services Minimum Data Set and Rochester Epidemiology Project resources. We tested associations between NHVTE and age, sex and time since each NH admission using Poisson modelling. Additionally, we tested incident NHVTE as a potential predictor of survival using Cox proportional hazards, adjusting for age, sex and NH residency. Between 1 October 1998 and 31 December 2005, 3,465 Olmsted County residents with ≥1 admission to a local NH, contributed 4,762 NH stays. Of the 3,465 NH residents, 111 experienced incident NHVTE (2.3% of all eligible stays), for an overall rate of 3,653/100,000 NH person-years (NH-PY). VTE incidence was inversely associated with time since each NH admission, and was highest in the first 7 days after each NH admission (18,764/100,000 NH-PY). The adjusted hazard of death for incident NHVTE was 1.90 (95% confidence interval [CI]: 1.38–2.62). In conclusion, VTE incidence among NH residents was nearly 30-fold higher than published incidence rates for the general Olmsted County population. VTE incidence was highest within 7 days after NH admission, and NHVTE was associated with significantly reduced survival. These data can inform future research and construction of clinical trials regarding short-term prophylaxis.

Explaining international footballer selection through Poisson modelling

Purpose Growing evidence suggests regional economic factors impact on individual outcomes, such as life expectancy and well-being. The purpose of this paper is to investigate the impact that player-specific and regional differences have on the number of senior international appearances football players accumulate over the course of their careers, for six UEFA member countries, from 1993 to 2014. Design/methodology/approach The research employs a Poisson regression model to analyse the impact of individual and regional factors on the number of senior international caps a footballer receives over the course of their career. Findings The results indicate that both individual and regional variables can explain the number of caps a player receives over the course of their career. The authors find that an individual’s career length positively influences the number of international caps accrued. Players born in wealthier and more populous regions accumulate a greater number of international appearances. Distance from the capital has no effect, however, the number of youth academies in the player’s region of birth has a significant positive effect. Research limitations/implications The analysis is limited to regional variations within economically developed states. It would be interesting to test whether the correlation between relative regional development and international success exists in less developed countries. The authors only address mens international football in this study and cannot comment on the generality of the findings across genders or sports. Practical implications The results can provide insights for local football authorities and policy makers concerned with regional characteristics and those interested in the development of elite talent. Originality/value This is the first study to analyse a pan-European data set, using an increasingly adopted econometric method to understanding regional economic development – Poisson modelling.

An application of compound Poisson modelling to biological dosimetry

In this paper, the r th-order univariate Hermite distributions are proposed to model the number of dicentrics in biological dosimetry. These families of distributions are introduced from compound Poisson process modelling. Regression models appropriate for analysing the number of dicentrics as a function of doses of radiation are presented, and an example of application is also given.