Alan Craft

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International comparisonsof care for children
Alan Craft
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Children have never been healthier

• An international perspective
• London
• Nov 2007

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Children have never been healthier ?
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Probably true but are they as healthy as they
could be?

• How do we compare internationally?

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21 countries in Europe and North America
2007
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• The true measure of a nations standing is how
  well it attends to its children-their health and
  safety, their material security, their education
  and socialisation, and their sense of being
  loved, valued and included in the families and
  societies into which they are born

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Out of 21 nations UK ranks

• 18 for Material wellbeing
• 12 for Health and safety
• 17 for Educational wellbeing
• 21 for Family and peer relationships
• 21 for Behaviours and risks
• 20 for Subjective wellbeing

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Health and safety

• Number of infants dying before 1 year
• LBW infants
• 12 to 23 months immunised against measles,DPT
  and polio
• Deaths from accidents and injuries 0-19

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For accidental death UK ranks second to Sweden
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How easy is it to compare health outcomes across
countries?
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CHILD

• Child Health Indicators of Life and Development
• Report to European Commision 2002

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Monitoring Indicators

• ECHI framework
• Demography and socio economic situation
• Health status
• Determinants of health
• Health systems

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Not easy to compare but what information is
available?
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Perinatal/Neonatal mortality

• England is 15th in European league table

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Possible reasons for poor IMR

• High rate of preterm and LBW
• High rate of teenage pregnancy
• SIDS are down but not in LSEG
• High rate of congenital abnormalities in some
  communities
• Maternal smoking

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Childhood Cancer
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Geographical comparisons of childhood cancer
survival across Europe 1988-1997, ACCIS project
(Sankila et al, EJC, 2006, 421972-1980).
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Possible explanations for poorer cancer survival

• Completeness of ascertainment
• Definitions of what is included eg benign brain
  tumours and spontaneously regressing
  neuroblastoma
• Organisation of care
• Access to treatment and protocols used
• Delay in diagnosis

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Geographical comparisons of 5 yr observed
survival, ACCIS, 1988-97
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Wilms tumour

• Incidence 110000
• No spontaneous regression
• Comprehensive ascertainment

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WILMS TUMOUR DIAGNOSIS The GPOH Experience
Introduction Results Discussion
Question Did the diagnostic workup start
because of tumour related
symptoms or because of a preventive medical
examination (U1 U10) or because of casual
findings ?
Norbert Graf 2007
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WILMS TUMOUR DIAGNOSIS The GPOH Experience
Introduction Results Discussion
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WILMS TUMOUR DIAGNOSIS The GPOH Experience
Preventive medical examinations in childhood
Introduction Results Discussion
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WILMS TUMOUR DIAGNOSIS The GPOH Experience
Introduction Results Discussion
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Mode of presentation among 97 renal tumours at
Royal Marsden Hospital, 1992-2006
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Northern Region Registry

• 4 patients with Wilms tumour diagnosed without
  symptoms

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Physical examination

• Routine Reviews
• We recommend the continuation of the neonatal and
  6-8 week physical examination of every child
• Routine medical examinations at school entry
  should be discontinued

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Duchenne Muscular Dystrophy

• The best centres in the UK are as good as
  anywhere in the world
• But..

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Duchenne muscular dystrophyMean age at death

• Large geographical variation
• NE England 28 years
• SW England 18 years

Kate Bushby
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DMD diagnosed earlier in Germany

• May be due to screening or more intensive
  developmental surveillance

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Diabetes

• One of the highest incidences and one of the
  worst records for control

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• Persistent differences among centres over 3 years
  in glycemic control..Danne et al
• Diabetes Care 2001
• Making every young person with diabetes
  matter.DH.2007

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Possible reasons for poor diabetic control

• Life style factors
• Diet
• Family
• Services
• Occasional practice with lack of access to
  specialist care

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Asthma and CF
John Price
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Childhood asthma in the UK

• UK has the highest prevalence in the world
• - 1.4 million children with diagnosed asthma
• - 3 times as many as in the 1970s
• More school lost than any other chronic illness
• Annual cost to the NHS - 254 million
• Hospital admission rates have fallen
• - 37,000 in 1995-96 26,000 in 2005-06
• Hospital admission rates show regional variation
• Asthma attacks in primary care have fallen but
  are still 3 times the level in the 1970s

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The UK has the highest prevalence of childhood
asthma in the world
Self-reported prevalence of asthma symptoms in
13-14 year olds
Masoli M, Fabian D et al. GINA. Global Burden of
Asthma, 2004
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Worldwide trends in prevalence of childhood
asthma change past 5-10yrs
6-7yrs
13-14yrs
Global
W Europe
Oceania
N E Europe
North America
Latin America
Indian sc
E Mediterranean
Asia-Pacific
Africa
ISAAC Phase 3 Study Group Thorax 200762758
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Hospital admission rate for asthma per head of
population. Standardised for regional
differences in age and sex. The average for
England is assigned a rate of 100
The Asthma Divide Asthma UK May 2007
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Childhood asthma worldwide is often poorly
controlled
Europe (AIRE, 2000), Asia-Pacific (AIRAP 2002)
Latin America (AIRLA 2005)
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Cystic Fibrosis in the UK

• The estimated CF population in the UK in 2003 was
  8,284 with just over 50 gt16 years of age
• Rates of chronic infection with Pseudomonas in
  the UK are lower than the USA but higher than
  Denmark
• UK 25 year survival 1978-2003
• - 55 males 49 females
• Comparison of survival rates between countries is
  difficult because of varying methodology

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Persistent colonisation with pseudomonas
aeroginosa reduces life expectancy in CF by 10
years
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Prevalence of Chronic infection with Pseudomonas
aeruginosa
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Possible reasons for less than optimal care
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• Underinvestment in childrens services
• Complacency
• Lack of central direction-not allowed
• Occasional practice
• Difficulties in reconfiguring services
• Perverse incentives of PBR

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Possible solutions
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• Centralisation of care for very specialist
  conditions
• Networks of care from primary care to all levels
  of specialist care
• Commissioning of whole pathway of care
• Improving primary care

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Centralisation of care

• A case study of liver surgery in infants

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Surgery for Biliary Atresia

• 2 year prospective study (BPSU)-
• - New cases of biliary atresia
• - Evaluate outcome at 1, 2 and 8 years
• 93 cases of biliary atresia
• - 15 centres in the UK
• - Biliary drainage - 55
• - Survival was dependent on centre experience

McKiernan et al, Lancet 2000
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The BPSU study of biliary atresiaOutcome after
median 3.5 years (n93)
Centres with gt 5 cases yearly
Centres with lt 5 cases yearly
McKiernan, Kelly et al , Lancet 2000
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The BPSU study of biliary atresiaoutcome at 8
yearsSurvival without liver transplantation
Successful Kasai (n50)
Failed Kasai (n41)
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Government Reaction

• Designation of 3 Centres
• Birmingham
• Leeds
• London
• Diagnosis and management
• of biliary atresia
• Kasai portoenterostomy
• Liver Transplantation

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Then and Now

• 1993 95 1999 2002
• 15 centres 3 centres
• 55 Clearance of Jaundice 57
• 30 Native Liver Survival 51
• 44 Transplanted 38
• 85 Survival 89
• 54 days Median age at Kasai 54 days
• Davenport, Kelly et al , Lancet 2004

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Neonatal care
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Establishing neonatal networksthe reality

• Marlow and Gill
• Arch Dis Child
• 2007
• F137-142

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Neonatal networks

• Established 2004
• Structure and effectiveness vary widely
• Lack of coordinated approach to capacity building
• Structural changes to NHS pose a challenge
• Lack of commisioning knowledge

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Teenage pregnancy

• Often a cause and consequence of social exclusion
• 90,000 conceptions a year to teenagers
• teenage parents tend to have poor ante-natal
  health/late booking, higher rates of smoking
• 25 more likely than average to have a low
  birthweight baby
• infant mortality rate is 60 higher than for
  older mothers

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Fertility rates in women aged 15-19 in
comparable countries
 
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Primary care
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Should we adopt the Primary care Paediatrician
model?
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Health care in Germany

• System allows free access to GP or specialist
  care
• To prevent doctor hopping an access fee of 40
  per annum introduced
• Children exempt from this
• Virtually all health care for children provided
  by PCP

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Court 1976
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General Practitioner Paediatricians

• A primary care physician with special
  responsibility for children in his practice and
  the community of which it is a part
• They would provide general medical services to an
  appropriate number of adult patients

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Primary care paediatricians

• Paediatricians who work in primary care
• Not GPWSI

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Conclusion

• The best in England is amongst the best in the
  world
• But there are significant variations in outcomes
  .
• These variations are both across the country and
  beyond

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Leadership