Mortality In England Research Articles

Socioeconomic gradient in mortality of working age and older adults with multiple long-term conditions in England and Ontario, Canada

BackgroundThere is currently mixed evidence on the influence of long-term conditions and deprivation on mortality. We aimed to explore whether number of long-term conditions contribute to socioeconomic inequalities in mortality, whether the influence of number of conditions on mortality is consistent across socioeconomic groups and whether these associations vary by working age (18–64 years) and older adults (65 + years). We provide a cross-jurisdiction comparison between England and Ontario, by replicating the analysis using comparable representative datasets.MethodsParticipants were randomly selected from Clinical Practice Research Datalink in England and health administrative data in Ontario. They were followed from 1 January 2015 to 31 December 2019 or death or deregistration. Number of conditions was counted at baseline. Deprivation was measured according to the participant’s area of residence. Cox regression models were used to estimate hazards of mortality by number of conditions, deprivation and their interaction, with adjustment for age and sex and stratified between working age and older adults in England (N = 599,487) and Ontario (N = 594,546).FindingsThere is a deprivation gradient in mortality between those living in the most deprived areas compared to the least deprived areas in England and Ontario. Number of conditions at baseline was associated with increasing mortality. The association was stronger in working age compared with older adults respectively in England (HR = 1.60, 95% CI 1.56,1.64 and HR = 1.26, 95% CI 1.25,1.27) and Ontario (HR = 1.69, 95% CI 1.66,1.72 and HR = 1.39, 95% CI 1.38,1.40). Number of conditions moderated the socioeconomic gradient in mortality: a shallower gradient was seen for persons with more long-term conditions.ConclusionsNumber of conditions contributes to higher mortality rate and socioeconomic inequalities in mortality in England and Ontario. Current health care systems are fragmented and do not compensate for socioeconomic disadvantages, contributing to poor outcomes particularly for those managing multiple long-term conditions. Further work should identify how health systems can better support patients and clinicians who are working to prevent the development and improve the management of multiple long-term conditions, especially for individuals living in socioeconomically deprived areas.

The association between the proportion of Brexiters and COVID-19 death rates in England

RationaleA cultural divide may exist between a set of people who accept and a set of people who reject the advice of experts. This cultural divide may have important consequences and policy implications, especially in times of severe crisis. ObjectiveEcological study of whether there exists a significant conditional correlation between two variables that appear unrelated except for attitude towards experts: (1) Proportion of people voting in favour of remaining in the European Union in 2016 and (2) COVID-19 outcomes measured by death rates and vaccination rates. A significant conditional correlation would indicate that polarized beliefs have important consequences across a broad spectrum of societal challenges. MethodsThis study uses simple descriptive statistics and multiple linear regression, considering confounders suggested in the related literature, with data at the District level in England. ResultsDistricts where people voted most heavily in favour of remaining in the EU (top quintile) had nearly half the death rate of districts in the bottom quintile. This relationship was stronger after the first wave, which was a time when protective measures were communicated to the public by experts. A similar relationship was observed with the decision to get vaccinated, and results were strongest for the booster dose, which was the dose that was not mandatory, but highly advised by experts. The Brexit vote is the variable most correlated with COVID-19 outcomes among many variables including common proxies for trust and civic capital or differences in industry composition across Districts. ConclusionsOur results suggest a need for designing incentive schemes that take into consideration different belief systems. Scientific prowess – such as finding effective vaccines – may not be sufficient to solve crises.

European Cancer Summit 2022 submission for Special Network: Impact of the Covid-19 Pandemic on CancerImpact of the COVID-19 Pandemic on Cancer Surgery and Cancer Mortality in England

BackgroundDuring the pandemic there has been an impact on the number of patients entering the cancer pathway, because of changes in patients presenting and GP referral behaviours. The aim was to understand whether different groups in our society have been disproportionately affected by the pandemic in terms of the care they have received for their cancer. MethodsThe study looked specifically at elective admissions from the Hospital Episode Statistics data for all cancers combined and separately for breast, bowel, lung, and prostate cancers to investigate the number of patients admitted for cancer surgery over time. The ONS Mortality Dataset was used to investigate the place of death for patients who had died from cancer.Mortality rates were calculated to identify whether there was a rise in in-hospital mortality during the pandemic. Deaths were defined as an in-hospital death for a patient admitted with a primary diagnosis of cancer. Age-standardised mortality rates were created across the last five years, broken down by cancer type, sex and deprivation quintile. ResultsThe analysis shows a decrease in patients undergoing surgery at the start of the pandemic for all demographic groups. At the start of the pandemic, the largest decreases for all cancers combined by ethnicity could be seen in White (42.6%) and Asian or Asian British (44.6%). While by age, the largest decrease was seen in women aged 40-49.For lung cancer surgery, there were differences by deprivation quintile during the recovery period, showing a 42.0% increase in the least deprived compared to a 27.6% increase in the most deprived. However, changes at the beginning of the pandemic were similar across all quintiles.Age standardised mortality rates showed an increase in in-hospital deaths following the start of the pandemic. ConclusionsWhile we know that there are inequalities in access to cancer surgery, particularly by age, for the most part, the results of our analysis indicate that the recovery period of the COVID-19 pandemic has not exacerbated these inequalities. However, it is difficult to understand the extent to which any variation in access to cancer services is unwarranted.

Is England facing an opioid epidemic?

The opioid crisis in the United States (US) is one of the most high-profile public health scandals of the 21st century with millions of people unknowingly becoming dependent on opioids. The United Kingdom (UK) had the world's highest rate of opioid consumption in 2019, and opiate-related drug poisoning deaths have increased by 388% since 1993 in England and Wales. This article explores the epidemiological definitions of public health emergencies and epidemics in the context of opioid use, misuse, and mortality in England, to establish whether England is facing an opioid crisis.

Homelessness and mortality: an extraordinary or unextraordinary phenomenon?

ABSTRACT In this article we explore the vicissitudes of extraordinariness in relation to homelessness and mortality in Britain. Death and its threat are a constant presence in the lives of people experiencing homelessness, but despite the established fact that homeless populations have a far lower life expectancy than the general population, mortality is rarely considered as part of the homelessness plight, nor is it fully acknowledged or understood in official spheres. This article explores the ways in which homelessness and mortality are constructed as an unpreventable phenomenon, not deserving of any meaningful political intervention. Drawing on the conceptual framework of ‘organised abandonment’, we argue that the invisibility of homeless people in death can be linked to their invisibility in life. In so doing, we underline the minimalist policy frameworks and the expansion of anti-homeless campaigns, which, to different extents, result in the exclusion of homeless individuals and families. Since the COVID-19 pandemic, however, the risk of death affecting homeless groups was responded to as an extraordinary social and political problem, requiring maximum political intervention. While remaining cognisant of the limitations of the extraordinary homelessness and housing policy measures brought in during this time, we argue that there are key possibilities to be explored within those policy responses.

Child Mortality in England During the First 2 Years of the COVID-19 Pandemic

During the first year of the COVID-19 pandemic, child mortality in England was the lowest on record, but if this trend will continue, or if unrecognized morbidity during the first year of the pandemic will manifest as increased deaths over the next few years is unclear. To examine the risks and patterns of childhood deaths before and during the COVID-19 pandemic. This population-based cohort study includes all child deaths in England from April 1, 2019, to March 31, 2022. The year of death. The primary outcome measure is risk of death. Of the 9983 child deaths reported during the study period, 9872 (98.8%) were linked to demographic and population data with 3409 deaths (34.5%) between April 2019 and March 2020, 3035 (30.7%) between April 2020 and March 2021, and 3428 (34.7%) between April 2021 and March 2022. Most deaths occurred in children who were younger than 1 year (6257 of 9872 [62.7%]), the majority were male (5534 of 9760 [56.7%]), and lived in an urban area (8766 of 9872 [88.8%]). The risk of death was lower between April 2020 and March 2021 (relative risk [RR], 0.89 [95% CI, 0.84-0.93]), but not between April 2021 and March 2022 (RR, 1.00 [95% CI, 0.95-1.05]) when compared with April 2019 to March 2020. A population attributable risk (PAF) of 4.0% (95% CI, 0.1%-6.8%) suggested fewer deaths occurred during the whole 3-year period than expected. Reductions were seen in risk of dying by infection (PAF, 22.8% [95% CI, 8.2%-37.0%]) and underlying disease (PAF, 13.3% [95% CI, 8.1%-18.8%]), but there was evidence of an increasing risk of death by trauma (PAF, 14.7% [95% CI, 2.9%-25.2%]). Any reduction in the risk of death was greater in rural areas than in urban areas (RR, 0.73 [95% CI, 0.63-0.85] vs RR, 0.91 [95% CI, 0.86-0.95]) and was not seen in children older than 9 years. In this cohort study, there was a significant reduction in all-cause child mortality during the first year of the COVID-19 pandemic (2020-2021), which returned to close to prepandemic levels the following year (2021-2022). However, there was a net reduction in deaths despite this, with 4% fewer deaths during the 3-year period than would have been expected from the 2019 to 2020 risks. The reductions were largest in rural areas and in children younger than 10 years.

Ethnic differences in COVID-19 mortality in the second and third waves of the pandemic in England during the vaccine rollout: a retrospective, population-based cohort study

BackgroundEthnic minority groups in England have been disproportionately affected by the COVID-19 pandemic and have lower vaccination rates than the White British population. We examined whether ethnic differences in COVID-19 mortality in England have continued since the vaccine rollout and to what extent differences in vaccination rates contributed to excess COVID-19 mortality after accounting for other risk factors.MethodsWe conducted a retrospective, population-based cohort study of 28.8 million adults aged 30–100 years in England. Self-reported ethnicity was obtained from the 2011 Census. The outcome was death involving COVID-19 during the second (8 December 2020 to 12 June 2021) and third wave (13 June 2021 to 1 December 2021). We calculated hazard ratios (HRs) for death involving COVID-19, sequentially adjusting for age, residence type, geographical factors, sociodemographic characteristics, pre-pandemic health, and vaccination status.ResultsAge-adjusted HRs of death involving COVID-19 were elevated for most ethnic minority groups during both waves, particularly for groups with lowest vaccination rates (Bangladeshi, Pakistani, Black African, and Black Caribbean). HRs were attenuated after adjusting for geographical factors, sociodemographic characteristics, and pre-pandemic health. Further adjusting for vaccination status substantially reduced residual HRs for Black African, Black Caribbean, and Pakistani groups in the third wave. Fully adjusted HRs only remained elevated for the Bangladeshi group (men: 2.19 [95% CI 1.72–2.78]; women: 2.12 [1.58–2.86]) and Pakistani men (1.24 [1.06–1.46]).ConclusionsLower COVID-19 vaccination uptake in several ethnic minority groups may drive some of the differences in COVID-19 mortality compared to White British. Public health strategies to increase vaccination uptake in ethnic minority groups would help reduce inequalities in COVID-19 mortality, which have remained substantial since the start of the vaccination campaign.

Fatal Places? Contextual Effects on Infant and Child Mortality in Early Twentieth Century England and Wales

AbstractThis paper takes, as its starting point, Preston and Haines’ observation in Fatal Years that social class was the most important influence on infant and child mortality in England and Wales in the early twentieth century. A subsequent study suggested that this could in part be due to the spatial distribution of the different classes across different types of place, and that some of the mortality differences by social class might actually reflect the contextual effects of healthy and unhealthy places. Although this line of argument has received a considerable amount of attention in health geography literature, it has rarely been examined for a specific historic period, and then only within particular urban areas. In this paper, we apply multi-level models to a complete count individual-level dataset of the 1911 census of England and Wales, comparing influences on infant and child mortality at the level of the individual couple and for two spatial levels. We find that although most variation in infant and child mortality operates at the individual level, there is also important variation at the two spatial levels and part of the mortality differences between social classes is better explained by the areas in which people lived rather than by their social class. A consideration of independent variables at all three levels suggests that different spatial scales capture different sorts of influences on early age mortality.

Trends in Thoracic Aortic Aneurysm Hospital Admissions, Interventions, and Mortality in England between 1998 and 2020: An Observational Study

To assess trends in thoracic aortic aneurysm (TAA) hospital admissions, interventions, and aneurysm related mortality (ARM) in England, and examine the impact of endovascular repair on mortality for the years 1998 to 2020.

COVID-19 and deprivation amplification: An ecological study of geographical inequalities in mortality in England.

'Deprivation amplification' is used to understand the relationship between deprivation, scale and COVID-19 mortality rates. We found that more deprived Middle Super Output Areas (MSOAs) in the more deprived northern regions suffered greater COVID-19 mortality rates. Across England, the most deprived 20% of MSOAs had higher mortality than the least deprived (44.1% more COVID-19 deaths/10,000). However, the most deprived MSOAs in the north fared worse than equally deprived areas in the rest of England (14.5% more deaths/10,000, beta=0.136, p<0.01). There was also strong evidence of spatial clustering and spill-overs. We discuss these findings in relation to 'deprivation amplification', the 'syndemic pandemic', and the health and place literature.

The impact of COVID-19 on mortality after hip fracture : a population cohort study from England.

Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England. We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England's SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models. Analysis of 102,900 hip fractures (42,630 occurring during the pandemic) revealed that among those with COVID-19 infection at presentation (n = 1,120) there was a doubling of 90-day mortality; hazard ratio (HR) 2.09 (95% confidence interval (CI) 1.89 to 2.31), while the HR for infections arising between eight and 30 days after presentation (n = 1,644) the figure was greater at 2.51 (95% CI 2.31 to 2.73). Malnutrition (1.45 (95% CI 1.19 to 1.77)) and nonoperative treatment (2.94 (95% CI 2.18 to 3.95)) were the only modifiable risk factors for death in COVID-19-positive patients. Patients who had tested positive for COVID-19 more than two weeks prior to hip fracture initially had better survival compared to those who contracted COVID-19 around the time of their hip fracture; however, survival rapidly declined and by 365 days the combination of hip fracture and COVID-19 infection was associated with a 50% mortality rate. Between 1 January and 30 June 2020, 1,273 (99.7% CI 1,077 to 1,465) excess deaths occurred within 90 days of hip fracture, representing an excess mortality of 23% (99.7% CI 20% to 26%), with most deaths occurring within 30 days. COVID-19 infection more than doubles the rate of early hip fracture mortality. Those contracting infection between 8 and 30 days after initial presentation are at even higher mortality risk, signalling the potential for targeted interventions during this period to improve survival.Cite this article: Bone Joint J2022;104-B(10):1156-1167.

Estimating the Effectiveness of First Dose of COVID-19 Vaccine Against Mortality in England: A Quasi-Experimental Study.

Estimating real-world vaccine effectiveness is vital to assess the COVID-19 vaccination programme and to inform the ongoing policy response. However, estimating vaccine effectiveness using observational data is inherently challenging because of the non-randomised design and potential for unmeasured confounding. We used a Regression Discontinuity Design (RDD) to estimate vaccine effectiveness against COVID-19 mortality in England using. the fact that people aged 80 or over were prioritised for the vaccine roll-out. The prioritisation led to a large discrepancy in vaccination rates in people 80–84 compared to those 75–79 at the beginning of the vaccination campaign. We found a corresponding difference in COVID-19 mortality, but not in non-COVID-19 mortality, suggesting that our approach appropriately addresses the issue of unmeasured confounding factors. Our results suggest that the first vaccine dose reduced the risk of COVID-19 death by 52.6% (95% Cl 26.6–84.2) in those aged 80, supporting existing evidence that a first dose of a COVID-19 vaccine has a strong protective effect against COVID-19 mortality in older adults. The RDD estimate of vaccine effectiveness is only slightly lower to previously published studies using different methods, suggesting that these estimates are unlikely to be substantially affected by unmeasured confounding factors.

Ethnic differences in COVID-19 mortality in the second and third waves of the pandemic in England during the vaccine roll-out.

ObjectivesThis study aims to assess whether ethnic differences in COVID-19 mortality in England have continued into the third wave and to what extent differences in vaccination rates contributed to excess COVID-19 mortality after accounting for other risk factors. ApproachThis Cohort study of 28.8 million adults living in private households or communal establishments in England is based on data from the Office for National Statistics (ONS) Public Health Data Asset (PHDA). The ONS PHDA is a linked dataset combining the 2011 Census, mortality records, the General Practice Extraction Service (GPES) Data for Pandemic Planning and Research (GDPPR), Hospital Episode Statistics (HES) and vaccination data from the National Immunisation Management System (NIMS). We calculated hazard ratios (HRs) for death involving COVID-19 during the second (8 December 2020 to 12 June 2021) and third wave (13 June 2021 to 1 December 2021) of the pandemic separately for males to females to assess the association between ethnic group and death involving COVID-19 in each wave, sequentially adjusting for age, residence type, geographical factors, sociodemographic characteristics, pre-pandemic health, and vaccination status. ResultsAge-adjusted HRs of death involving COVID-19 were higher for most ethnic minority groups than the White British group during both waves, particularly for groups with lowest vaccination rates (Bangladeshi, Pakistani, Black African and Black Caribbean). In both waves, HRs were attenuated after adjusting for geographical factors, sociodemographic characteristics, and pre-pandemic health. Further adjusting for vaccination status substantially reduced residual HRs for Black African, Black Caribbean, and Pakistani groups in the third wave. The only groups where fully-adjusted HRs remained elevated were the Bangladeshi group (men: 2.19, 95% CI 1.72 to 2.78; women: 2.12, 95% CI 1.58 to 2.86) and men from the Pakistani group (1.24, 95% CI 1.06 to 1.46). ConclusionPublic health strategies to increase vaccination uptake in ethnic minority groups could reduce disparities in COVID-19 mortality that cannot be accounted for by pre-existing risk factors.

BMI trajectories, morbidity, and mortality in England: a two-step approach to estimating consequences of changes in BMI.

ObjectiveBMI is known to have an association with morbidities and mortality. Many studies have argued that identifying health risks using single BMI measures has limitations, particularly in older adults, and that changes in BMI can help to identify risks. This study identifies distinct BMI trajectories and their association with the risks of a range of morbidities and mortality.MethodsThe English Longitudinal Study of Aging provides data on BMI, mortality, and morbidities between 1998 and 2015, sampled from adults over 50 years of age. This study uses a growth‐mixture model and discrete‐time survival analysis, combined using a two‐step approach, which is novel in this setting, to the authors' knowledge.ResultsThis study identified four trajectories: “stable overweight,” “elevated BMI,” “increasing BMI,” and “decreasing BMI.” No differences in mortality, cancer, or stroke risk were found between these trajectories. BMI trajectories were significantly associated with the risks of diabetes, asthma, arthritis, and heart problems.ConclusionsThese results emphasize the importance of looking at change in BMI alongside most recent BMI; BMI trajectories should be considered where possible when assessing health risks. The results suggest that established BMI thresholds should not be used in isolation to identify health risks, particularly in older adults.

Debasement and demography in England and France in the Later Middle Ages

AbstractEngland recovered slowly after the Black Death, but countries which debased more saw rising prices and earlier population growth and economic recovery. We examine debasement in England, France, Flanders, and Scotland, emphasising the importance of nominal prices and governments’ role in determining and enforcing monetary policy. Money, as well as demography, strongly influenced the behaviour of prices in later medieval Europe, and price changes had profound economic effects. Population levels depend on mortality and fertility. It is not clear that mortality in England was more severe than elsewhere, but the English economic recession could have affected fertility and nuptiality.

Contributions of event rates, pre-hospital deaths, and deaths following hospitalisation to variations in myocardial infarction mortality in 326 districts in England: a spatial analysis of linked hospitalisation and mortality data

Myocardial infarction mortality varies substantially within high-income countries. There is limited guidance on what interventions-including primary and secondary prevention, or improvement of care pathways and quality-can reduce myocardial infarction mortality. Our aim was to understand the contributions of incidence (event rate), pre-hospital deaths, and hospital case fatality to the variations in myocardial infarction mortality within England. We used linked data from national databases on hospitalisations and deaths with acute myocardial infarction (ICD-10 codes I21 and I22) as a primary hospital diagnosis or underlying cause of death, from Jan 1, 2015, to Dec 31, 2018. We used geographical identifiers to estimate myocardial infarction event rate (number of events per 100 000 population), death rate (number of deaths per 100 000 population), total case fatality (proportion of events that resulted in death), pre-hospital fatality (proportion of events that resulted in pre-hospital death), and hospital case fatality (proportion of admissions due to myocardial infarction that resulted in death within 28 days of admission) for men and women aged 45 years and older across 326 districts in England. Data were analysed in a Bayesian spatial model that accounted for similarities and differences in spatial patterns of fatal and non-fatal myocardial infarction. Age-standardised rates were calculated by weighting age-specific rates by the corresponding national share of the appropriate denominator for each measure. From 2015 to 2018, national age-standardised death rates were 63 per 100 000 population in women and 126 per 100 000 in men, and event rates were 233 per 100 000 in women and 512 per 100 000 in men. After age-standardisation, 15·0% of events in women and 16·9% in men resulted in death before hospitalisation, and hospital case fatality was 10·8% in women and 10·6% in men. Across districts, the 99th-to-1st percentile ratio of age-standardised myocardial infarction death rates was 2·63 (95% credible interval 2·45-2·83) in women and 2·56 (2·37-2·76) in men, with death rates highest in parts of northern England. The main contributor to this variation was myocardial infarction event rate, with a 99th-to-1st percentile ratio of 2·55 (2·39-2·72) in women and 2·17 (2·08-2·27) in men across districts. Pre-hospital fatality was greater than hospital case fatality in every district. Pre-hospital fatality had a 99th-to-1st percentile ratio of 1·60 (1·50-1·70) in women and 1·75 (1·66-1·86) in men across districts, and made a greater contribution to variation in total case fatality than did hospital case fatality (99th-to-1st percentile ratio 1·39 [1·29-1·49] and 1·49 [1·39-1·60]). The contribution of case fatality to variation in deaths across districts was largest in women aged 55-64 and 65-74 years and in men aged 55-64, 65-74, and 75-84 years. Pre-hospital fatality was slightly higher in men than in women in most districts and age groups, whereas hospital case fatality was higher in women in virtually all districts at ages up to and including 65-74 years. Most of the variation in myocardial infarction mortality in England is due to variation in myocardial infarction event rate, with a smaller role for case fatality. Most variation in case fatality occurs before rather than after hospital admission. Reducing subnational variations in myocardial infarction mortality requires interventions that reduce event rate and pre-hospital deaths. Wellcome Trust, British Heart Foundation, Medical Research Council (UK Research and Innovation), and National Institute for Health Research (UK).

Trends in Thoracic Aortic Aneurysm Hospital Admissions, Interventions, and Mortality in England between 1998 and 2020: An Observational Study

To assess trends in thoracic aortic aneurysm (TAA) hospital admissions, interventions, and aneurysm related mortality (ARM) in England, and examine the impact of endovascular repair on mortality for the years 1998 to 2020. Hospital admission and operative approach (thoracic endovascular aortic repair, [TEVAR] or open surgical repair) using Hospital Episodes Statistics, and ARM data from the Office for National Statistics for England standardised to the 2013 European Standard Population were analysed using linear regression and Joinpoint regression analyses. ARM was compared between the pre-endovascular era (1998 - 2008) and the endovascular era (2009 - 2019). A rising trend in hospital admission incidence has been observed, mainly due non-ruptured admissions (4.11 per 100 000 in 1998; 95% confidence interval (CI) 3.71 - 4.50 to 12.61 per 100 000 in 2020; 95% CI 12.00 - 13.21 in 2020; r2= .98; p < .001). Operative interventions increased mainly due to an increase in TEVAR (2.15 per 100 000; 95% CI 1.91 - 2.41 in 2020 vs. 0.26 per 100 000; 95% CI 0.16 - 0.36 in 2006; r2= .90; p < .001). Reductions in ARM from TAA were observed for males and females, irrespective of age and rupture status. The greatest reduction in ARM in the endovascular era was observed in females aged > 80 years with ruptured disease (15.26 deaths per 100 000 vs. 9.50 deaths per 100 000; p < .001). A significant increase in hospital admissions for non-ruptured TAA has been observed in the last 23 years in England, paralleled by a shift towards endovascular repair, and significant declining trends in ARM, irrespective of sex and age. The significant reductions in age standardised death rates from ruptured and non-ruptured TAA in the endovascular era, particularly for females aged > 80 years with ruptured disease, affirm the positive impact of an endovascular approach to TAA.

Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013–20: an observational study of NHS privatisation

The effects of outsourcing health services to for-profit providers are contested, with some arguing that introducing such providers will improve performance through additional competition while others worry that this will lead to cost cutting and poorer outcomes for patients. We aimed to examine this debate by empirically evaluating the impact of outsourced spending to private providers, following the 2012 Health and Social Care Act, on treatable mortality rates and the quality of health-care services in England. For this observational study, we used a novel database composed of parsable procurement contracts between April 1, 2013, and Feb 29, 2020 (n=645 674, value >£25 000, total value £204·1 billion), across 173 clinical commissioning groups (CCGs; regional health boards) in England. Data were compiled from 12 709 heterogenous expenditure files primarily scraped from commissioner websites with supplier names matched to registers identifying them as National Health Service (NHS) organisations, for-profit companies, or charities. We supplemented these data with rates of local mortality from causes that should be treatable by medical intervention, indicating the quality of health-care services. We used multivariate longitudinal regression models with fixed effects at the CCG level to analyse the association of for-profit outsourcing on treatable mortality rates in the following year. We used the average marginal effects to estimate total additional deaths attributable to changes in for-profit outsourcing. We provided alternative model specifications to test the robustness of our findings, match on background characteristics, examine the potential impact of measurement error, and adjust for possible confounding factors such as population demographics, total CCG expenditure, and local authority expenditure. We found that an annual increase of one percentage point of outsourcing to the private for-profit sector corresponded with an annual increase in treatable mortality of 0·38% (95% CI 0·22-0·55; p=0·0016) or 0·29 (95% CI 0·09-0·49; p=0·0041) deaths per 100 000 population in the following year. This finding was robust to matching on background characteristics, adjusting for possible confounding factors, and measurement error in our dataset. Changes to for-profit outsourcing since 2014 were associated with an additional 557 (95% CI 153-961) treatable deaths across the 173 CCGs. The privatisation of the NHS in England, through the outsourcing of services to for-profit companies, consistently increased in 2013-20. Private sector outsourcing corresponded with significantly increased rates of treatable mortality, potentially as a result of a decline in the quality of health-care services. Wellcome Trust.

Continuing inequalities in COVID-19 mortality in England and Wales, and the changing importance of regional, over local, deprivation.

BackgroundObservational studies have highlighted that where individuals live is far more important for risk of dying with COVID-19, than for dying of other causes. Deprivation is commonly proposed as explaining such differences. During the period of localised restrictions in late 2020, areas with higher restrictions tended to be more deprived. We explore how this impacted the relationship between deprivation and mortality and see whether local or regional deprivation matters more for inequalities in COVID-19 mortality.MethodsWe use publicly available population data on deaths due to COVID-19 and all-cause mortality between March 2020 and April 2021 to investigate the scale of spatial inequalities. We use a multiscale approach to simultaneously consider three spatial scales through which processes driving inequalities may act. We go on to explore whether deprivation explains such inequalities.ResultsAdjusting for population age structure and number of care homes, we find highest regional inequality in October 2020, with a COVID-19 mortality rate ratio of 5.86 (95% CI 3.31 to 19.00) for the median between-region comparison. We find spatial context is most important, and spatial inequalities higher, during periods of low mortality. Almost all unexplained spatial inequality in October 2020 is removed by adjusting for deprivation. During October 2020, one standard deviation increase in regional deprivation was associated with 20% higher local mortality (95% CI, 1.10 to 1.30).ConclusionsSpatial inequalities are greatest in periods of lowest overall mortality, implying that as mortality declines it does not do so equally. During the prolonged period of low restrictions and low mortality in summer 2020, spatial inequalities strongly increased. Contrary to previous months, we show that the strong spatial patterning during autumn 2020 is almost entirely explained by deprivation. As overall mortality declines, policymakers must be proactive in detecting areas where this is not happening, or risk worsening already strong health inequalities.

Factors associated with, and variations in, COVID-19 hospital death rates in England’s first two waves: observational study

ObjectivesTo assess patient-level and hospital-level predictors of death and variation in death rates following admission for COVID-19 in England’s first two waves after accounting for random variation. To quantify the...