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Summary Background The Apgar score has been used worldwide as an index of early neonatal condition for more than 60 years. With advances in health-care service provision, neonatal resuscitation, and infant care, its present relevance is unclear. The aim of the study was to establish the strength of the relation between Apgar score at 5 min and the risk of neonatal and infant mortality, subdivided by specific causes. Methods We linked routine discharge and mortality data for all births in Scotland, UK between 1992 and 2010. We restricted our analyses to singleton livebirths, in women aged over 10 years, with a gestational age at delivery between 22 and 44 weeks, and excluded deaths due to congenital anomalies or isoimmunisation. We calculated the relative risks (RRs) of neonatal and infant death of neonates with low (0–3) and intermediate (4–6) Apgar scores at 5 min referent to neonates with normal Apgar score (7–10) using binomial log-linear modelling with adjustment for confounders. Analyses were stratified by gestational age at birth because it was a significant effect modifier. Missing covariate data were imputed. Findings Complete data were available for 1 029 207 eligible livebirths. Across all gestational strata, low Apgar score at 5 min was associated with an increased risk of neonatal and infant death. However, the strength of the association (adjusted RR, 95% CI referent to Apgar 7–10) was strongest at term (p Interpretation Low Apgar score at 5 min was strongly associated with the risk of neonatal and infant death. Our findings support its continued usefulness in contemporary practice. Funding None.

Background Chronic ill health can affect children's educational and health outcomes. Previous studies have reported poorer school outcomes among children with diabetes, asthma, epilepsy, attention deficit hyperactivity disorder (ADHD), and depression; however, many have limitations, very few have analysed multiple outcomes or population-wide data, and literature in Scotland and the UK is scarce. We aimed to identify children prescribed medication for these chronic medical conditions and investigate their educational and health outcomes compared with their peers. Methods We retrospectively linked Scotland-wide education records for children attending primary and secondary schools in Scotland between 2009 and 2013 to prescribing data, acute and psychiatric hospital admissions, maternity records, and deaths. School absenteeism, exclusion, and special educational need were analysed annually using generalised estimating equations. Academic attainment was analysed using generalised ordinal logistic regression and unemployment with binomial logistic regression. All-cause hospitalisation and mortality were analysed using Cox proportional hazards or Poisson piecewise regression. Analyses were restricted to singleton children born in Scotland and adjusted for sociodemographic or maternity factors and comorbid conditions Findings 766 244 schoolchildren were included in the analyses. All conditions were associated with increased school absenteeism (diabetes incidence rate ratio [IRR] 1·34, asthma 1·25, epilepsy 1·50, ADHD 1·18, depression 1·95), special educational need (diabetes odds ratio [OR] 2·45, asthma 1·28, epilepsy 10·11, ADHD 8·77, depression 2·24], and all-cause hospitalisation (diabetes hazard ratio [HR] 3·97, asthma 1·69, epilepsy 3·72, ADHD 1·33, depression 2·56). All, excluding diabetes, were associated with poorer academic attainment (asthma OR 1·11, epilepsy 4·07, ADHD 3·64, depression 3·44] and all, excluding ADHD, were associated with increased all-cause mortality [diabetes HR 3·84, asthma 1·77, epilepsy 24·77, depression 6·21]. ADHD (IRR 5·82) and depression (1·65) were associated with increased exclusion from school, whereas epilepsy (OR 1·99), ADHD (1.42), and depression (1·98) were associated with subsequent unemployment. Interpretation In addition to poorer health outcomes, schoolchildren with these chronic medical conditions have significant educational disadvantage compared with their peers. Interventions and further understanding of the relationships between health and education among children with these conditions is required. Funding Health Data Research UK

Background The Alcohol etc (Scotland) Act 2010 was implemented in Scotland on Oct 1, 2011, and included a ban on multi-buy discounts of alcohol in Scotland's supermarkets and off licences (ie, off trade). The main aim of the legislation was to remove the price incentive for consumers to purchase more alcohol than they may otherwise have intended and, in turn, to reduce population levels of alcohol consumption. Alcohol sales data provide the best estimate of population alcohol consumption. We have investigated the effect of the introduction of the Alcohol Act on off-trade alcohol sales in Scotland. Methods We obtained data for the volume of pure alcohol sold off trade in Scotland and in England and Wales from market research specialists Nielsen (Oxford, UK) for individual weeks between January, 2009, and September, 2012 (appendix). Sales estimates were produced from electronic sales records from most large multiple retailers and a weighted stratified random sample of smaller retailers. We have previously shown that alcohol retail sales data offer a robust source of data for measurement and monitoring of alcohol consumption in Scotland and England and Wales. We used interrupted autoregressive integrated moving average time-series models to test for any change in off-trade alcohol sales (all alcohol and by drink type) after the introduction of the Alcohol Act in Scotland. Models accounted for underlying seasonal and secular trends and were adjusted for changes in other potential confounding factors including disposable income, alcohol prices, and on-trade alcohol sales. Data for these covariates were obtained from the Scottish Government and Office for National Statistics; Nielsen and Office for National Statistics; and CGA Strategy (Stockport, UK), respectively. To provide a concurrent control group, we did the same analyses using data for England and Wales, where the Alcohol Act does not apply. Findings The introduction of the Alcohol Act was associated with a 2·6% decrease in per-adult off-trade alcohol sales in Scotland (95% CI −5·3 to 0·2). This decline was driven by changes in off-trade wine sales, which decreased by 4·0% after the Act was introduced (95% CI −5·4 to −2·6). The Act was also associated with reduced sales of pre-mixed alcohol beverages (–8·5%, 95% CI −12·7 to −4·1), although these account for a very small proportion of total off-trade sales (1%). The Act was not associated with changes in sales of spirits, beer, or cider or perry in Scotland. There was no evidence to support an association between off-trade alcohol sales and the dummy Alcohol Act variable in England and Wales. Interpretation The introduction of the Alcohol Act was associated with reduced off-trade alcohol sales in Scotland, largely attributable to a decline in wine sales. Key strengths of our study include the use of objective data for alcohol sales rather than subjective data on self-reported consumption, and the adjustment of our time-series models for underlying trends and potential confounders. Limitations include the exclusion of alcohol sales by certain retailers, the inability to disaggregate population sales estimates by different subgroups, and the short period after implementation of the Act. However, similar changes were not noted in England and Wales, where the Act does not apply, which lends weight to the hypothesis that the changes witnessed in Scotland were as a result of the Act rather than other unmeasured factors or biases. Thus, legislation to ban alcohol discounting seems an important policy in the mix to reduce population alcohol consumption levels. Funding Purchase of the sales data was funded by the Scottish Government as part of the wider Monitoring and Evaluating Scotland's Alcohol Strategy portfolio of studies.

Background Analysis of routine data provides an efficient way of exploring health risks and outcomes. We aimed to undertake the first Scotland-wide linkage of children's health and education data to show the feasibility of such cross-sectoral linkage for research. Methods We undertook a data linkage study of children in Scottish schools between 2006–07 and 2011–12. The main datasets were the annual Scottish Government pupil census, which contains Scottish candidate numbers (SCNs; unique identifier used on education records) and personal identifiers for children in publicly funded schools; and the Community Health Index (CHI) database held by NHS National Services Scotland (NSS), which contains CHI numbers (unique identifier used on health records) and identifiers for patients registered with a GP. Restricted pupil identifiers available for linkage in the pupil census (date of birth, sex, home postcode) were matched against patient identifiers held on the CHI database by a bespoke version of NSS's in-house medical record linkage software (previously validated). A best match CHI and additional possible (rival) CHIs were identified for each pupil and assigned probabilistic scores suggesting the amount of agreement between identifiers. Links were then partitioned into categories depending on scores. Links within specified categories (best match CHI with exact agreement on all identifiers or with postcode differing by one character only, and nearest rival CHI with lower score) were regarded as secure, and best match CHIs were accepted. Two methods of linkage were explored: linking identifiers from each year's pupil census separately (A) and combining all the available pupil identifier data from each census into one record per pupil and then linking the combined records (B). Two quality checks were undertaken to assess whether accepted CHIs were correct. Pupil names are available in pupil census records, but the government is unable to share these for linkage purposes. NSS therefore returned SCNs and full names from the best matching CHI records to the government. The government then used name-matching algorithms to compare these with the names in the pupil census. The Scottish Qualifications Agency provided SCNs and full pupil identifiers (including names) for the subset of children registered for Scottish examinations. NSS ran these data through their established probabilistic matching algorithms and the CHI numbers obtained were compared with those from the pupil census linkage. The SCN–CHI key resulting from the linkage was used to construct an anonymised analysis dataset including children's delivery records and their educational attendance, needs, and attainment records. This dataset was used to explore educational outcomes for children with different birth presentations and delivery modes to assess its utility in answering research questions. The results are reported elsewhere. Findings Using linkage method A, an acceptable CHI number could be found for 607 115 (86·3%) of 703 500 children in the 2006–07 census, increasing to 623 396 (92·9%) of 671 264 in 2011–12. Comparable figures using method B were 655 429 of 703 500 (93·2%) in 2006–07 and 638 011 of 671 264 (95·0%) in 2011–12. Linkage method B was therefore regarded as preferable. Using linkage method B, both quality checks suggested that over 99% of the accepted CHIs were indeed correct for children in the 2006–07 and 2011–12 censuses. Interpretation Routine health and education data in Scotland can be linked to an acceptable quality for public health research purposes, despite the absence of names available for linkage within education datasets. This finding opens up the potential for a range of policy-relevant life-course research drawing on routine data from different sectors. Funding Scottish Collaboration for Public Health Research and Policy (https://www.scphrp.ac.uk/node/264).