Contributions of diseases and injuries to widening life expectancy inequalities in England from 2001 to 2016: a population-based analysis of vital registration data.
ABSTRACT: BACKGROUND:Life expectancy inequalities in England have increased steadily since the 1980s. Our aim was to investigate how much deaths from different diseases and injuries and at different ages have contributed to this rise to inform policies that aim to reduce health inequalities. METHODS:We used vital registration data from the Office for National Statistics on population and deaths in England, by underlying cause of death, from 2001 to 2016, stratified by sex, 5-year age group, and decile of the Index of Multiple Deprivation (based on the ranked scores of Lower Super Output Areas in England in 2015). We grouped the 7·65 million deaths by their assigned International Classification of Diseases (10th revision) codes to create categories of public health and clinical relevance. We used a Bayesian hierarchical model to obtain robust estimates of cause-specific death rates by sex, age group, year, and deprivation decile. We calculated life expectancy at birth by decile of deprivation and year using life-table methods. We calculated the contributions of deaths from each disease and injury, in each 5-year age group, to the life expectancy gap between the most deprived and affluent deciles using Arriaga's method. FINDINGS:The life expectancy gap between the most affluent and most deprived deciles increased from 6·1 years (95% credible interval 5·9-6·2) in 2001 to 7·9 years (7·7-8·1) in 2016 in females and from 9·0 years (8·8-9·2) to 9·7 years (9·6-9·9) in males. Since 2011, the rise in female life expectancy has stalled in the third, fourth, and fifth most deprived deciles and has reversed in the two most deprived deciles, declining by 0·24 years (0·10-0·37) in the most deprived and 0·16 years (0·02-0·29) in the second-most deprived by 2016. Death rates from every disease and at every age were higher in deprived areas than in affluent ones in 2016. The largest contributors to life expectancy inequalities were deaths in children younger than 5 years (mostly neonatal deaths), respiratory diseases, ischaemic heart disease, and lung and digestive cancers in working ages, and dementias in older ages. From 2001 to 2016, the contributions to inequalities declined for deaths in children younger than 5 years, ischaemic heart disease (for both sexes), and stroke and intentional injuries (for men), but increased for most other causes. INTERPRETATION:Recent trends in life expectancy in England have not only resulted in widened inequalities but the most deprived communities are now seeing no life expectancy gain. These inequalities are driven by a diverse group of diseases that can be effectively prevented and treated. Adoption of the principle of proportionate universalism to prevention and health and social care can postpone deaths into older ages for all communities and reduce life expectancy inequalities. FUNDING:Wellcome Trust.
Project description:To investigate whether the policy of increasing National Health Service funding to a greater extent in deprived areas in England compared with more affluent areas led to a reduction in geographical inequalities in mortality amenable to healthcare.Longitudinal ecological study.324 lower tier local authorities in England, classified by their baseline level of deprivation.Differential trends in NHS funds allocated to local areas resulting from the NHS resource allocation policy in England between 2001 and 2011.Trends in mortality from causes considered amenable to healthcare in local authority areas in England. Using multivariate regression, we estimated the reduction in mortality that was associated with the allocation of additional NHS resources in these areas.Between 2001 and 2011 the increase in NHS resources to deprived areas accounted for a reduction in the gap between deprived and affluent areas in male mortality amenable to healthcare of 35 deaths per 100,000 population (95% confidence interval 27 to 42) and female mortality of 16 deaths per 100,000 (10 to 21). This explained 85% of the total reduction of absolute inequality in mortality amenable to healthcare during this time. Each additional £10 m of resources allocated to deprived areas was associated with a reduction in 4 deaths in males per 100,000 (3.1 to 4.9) and 1.8 deaths in females per 100,000 (1.1 to 2.4). The association between absolute increases in NHS resources and improvements in mortality amenable to healthcare in more affluent areas was not significant.Between 2001 and 2011, the NHS health inequalities policy of increasing the proportion of resources allocated to deprived areas compared with more affluent areas was associated with a reduction in absolute health inequalities from causes amenable to healthcare. Dropping this policy may widen inequalities.
Project description:To investigate whether the uneven rise in prosperity between 1999 and 2008 accounted for differential increases in life expectancy in English local authorities.Longitudinal ecological study.324 local authorities in England, classified by their baseline level of deprivation. M: ain outcome measures Multivariable regression was used to investigate the association between trends in prosperity between 1998 and 2007 and trends in life expectancy. Trends in health inequalities were assessed by comparing the experience of Spearhead local authorities (the 70 most deprived in 1998) with the average for all English local authorities.Those local authorities that experienced the greatest improvement in prosperity experienced greater increases in life expectancy. With each 1% absolute decline in unemployment, life expectancy increased by 2.2 (95% confidence interval 0.5 to 3.8) months in men and by 1.7 (0.4 to 3.1) months in women. With each £1000 increase in average household income in a local authority, life expectancy increased by 1.4 (0.3 to 2.5) months in men and by 1.1 (0.2 to 1.9) months in women. The more deprived a local authority was in 1998, the lower the rate at which life expectancy improved.Decreases in unemployment and increases in average income in an area explained, to a large extent, why some local authorities "performed" better than others. Health inequalities between Spearhead and all local authorities widened during the period of rising prosperity, but they would have widened to an even greater extent had unemployment not fallen at a faster rate in more deprived areas. With worsening economic trends over the next 10 years, this research suggests that increases in life expectancy are likely to be smaller and health inequalities may widen at a faster rate than in the previous decade. Allocating resources to local authorities on the basis of their "performance" at increasing life expectancy is likely to reward more affluent areas rather than disadvantaged areas with greater needs, exacerbating the problem.
Project description:Objective To investigate whether the English health inequalities strategy was associated with a decline in geographical health inequalities, compared with trends before and after the strategy.Design Time trend analysis.Setting Two groups of lower tier local authorities in England. The most deprived, bottom fifth and the rest of England.Intervention The English health inequalities strategy-a cross government strategy implemented between 1997 and 2010 to reduce health inequalities in England. Trends in geographical health inequalities were assessed before (1983-2003), during (2004-12), and after (2013-15) the strategy using segmented linear regression.Main outcome measure Geographical health inequalities measured as the relative and absolute differences in male and female life expectancy at birth between the most deprived local authorities in England and the rest of the country.Results Before the strategy the gap in male and female life expectancy between the most deprived local authorities in England and the rest of the country increased at a rate of 0.57 months each year (95% confidence interval 0.40 to 0.74 months) and 0.30 months each year (0.12 to 0.48 months). During the strategy period this trend reversed and the gap in life expectancy for men reduced by 0.91 months each year (0.54 to 1.27 months) and for women by 0.50 months each year (0.15 to 0.86 months). Since the end of the strategy period the inequality gap has increased again at a rate of 0.68 months each year (-0.20 to 1.56 months) for men and 0.31 months each year (-0.26 to 0.88) for women. By 2012 the gap in male life expectancy was 1.2 years smaller (95% confidence interval 0.8 to 1.5 years smaller) and the gap in female life expectancy was 0.6 years smaller (0.3 to 1.0 years smaller) than it would have been if the trends in inequalities before the strategy had continued.Conclusion The English health inequalities strategy was associated with a decline in geographical inequalities in life expectancy, reversing a previously increasing trend. Since the strategy ended, inequalities have started to increase again. The strategy may have reduced geographical health inequalities in life expectancy, and future approaches should learn from this experience. The concerns are that current policies are reversing the achievements of the strategy.
Project description:BACKGROUND:Low socioeconomic position is consistently associated with increased risk of premature death. The aim of this study is to measure the aggregate scale of inequality in premature mortality for the whole population of England. METHODS:We used mortality records from the UK Office for National Statistics to study all 2?465?285 premature deaths (defined as those before age 75 years) in England between Jan 1, 2003, and Dec 31, 2018. Socioeconomic position was defined using deciles of the Index of Multiple Deprivation: a measure of neighbourhood income, employment, education levels, crime, health, availability of services, and local environment. We calculated the number of expected deaths by applying mortality in the least deprived decile to other deciles, within the strata of age, sex, and time. The mortality attributable to socioeconomic inequality was defined as the difference between the observed and expected deaths. We also used life table modelling to estimate years-of-life lost attributable to socioeconomic inequality. FINDINGS:35·6% (95% CI 35·3-35·9) of premature deaths were attributable to socioeconomic inequality, equating to 877?082 deaths, or one every 10 min. The biggest contributors were ischaemic heart disease (152?171 excess deaths), respiratory cancers (111?083) and chronic obstructive pulmonary disease (83?593). The most unequal causes of death were tuberculosis, opioid use, HIV, psychoactive drugs use, viral hepatitis, and obesity, each with more than two-thirds attributable to inequality. Inequality was greater among men and peaked in early childhood and at age 40-49 years. The proportion of deaths attributable to inequality increased during the study period, particularly for women, because mortality rates among the most deprived women (excluding cardiovascular diseases) plateaued, and for some diseases increased. A mean of 14·4 months of life before age 75 years are lost due to socioeconomic inequality. INTERPRETATION:One in three premature deaths are attributable to socioeconomic inequality, making this our most important public health challenge. Interventions that address upstream determinants of health should be prioritised. FUNDING:National Institute of Health Research; Wellcome Trust.
Project description:BACKGROUND:Average life expectancy has stopped increasing for many countries. This has been attributed to causes such as influenza, austerity policies and deaths of despair (drugs, alcohol and suicide). Less is known on the inequality of life expectancy over time using reliable, whole population, data. This work examines all-cause and cause-specific mortality rates in Scotland to assess the patterning of relative and absolute inequalities across three decades. METHODS:Using routinely collected Scottish mortality and population records we calculate directly age-standardized mortality rates by age group, sex and deprivation fifths for all-cause and cause-specific deaths around each census 1981-2011. RESULTS:All-cause mortality rates in the most deprived areas in 2011 (472 per 100 000 population) remained higher than in the least deprived in 1981 (422 per 100 000 population). For those aged 0-64, deaths from circulatory causes more than halved between 1981 and 2011 and cancer mortality decreased by a third (with greater relative declines in the least deprived areas). Over the same period, alcohol- and drug-related causes and male suicide increased (with greater absolute and relative increases in more deprived areas). There was also a significant increase in deaths from dementia and Alzheimer's disease for those aged 75+. CONCLUSIONS:Despite reductions in mortality, relative (but not absolute) inequalities widened between 1981 and 2011 for all-cause mortality and for several causes of death. Reducing relative inequalities in Scotland requires faster mortality declines in deprived areas while countering increases in mortality from causes such as drug- and alcohol-related harm and male suicide.
Project description:BACKGROUND:Coronary heart disease (CHD) remains a major public health burden, causing 80,000 deaths annually in England and Wales, with major inequalities. However, there are no recent analyses of age-specific socioeconomic trends in mortality. We analysed annual trends in inequalities in age-specific CHD mortality rates in small areas in England, grouped into deprivation quintiles. METHODS:We calculated CHD mortality rates for 10-year age groups (from 35 to ? 85 years) using three year moving averages between 1982 and 2006. We used Joinpoint regression to identify significant turning points in age- sex- and deprivation-specific time trends. We also analysed trends in absolute and relative inequalities in age-standardised rates between the least and most deprived areas. RESULTS:Between 1982 and 2006, CHD mortality fell by 62.2% in men and 59.7% in women. Falls were largest for the most deprived areas with the highest initial level of CHD mortality. However, a social gradient in the pace of fall was apparent, being steepest in the least deprived quintile. Thus, while absolute inequalities narrowed over the period, relative inequalities increased. From 2000, declines in mortality rates slowed or levelled off in the youngest groups, notably in women aged 45-54 in the least deprived groups. In contrast, from age 55 years and older, rates of fall in CHD mortality accelerated in the 2000s, likewise falling fastest in the least deprived quintile. CONCLUSIONS:Age-standardised CHD mortality rates have declined substantially in England, with the steepest falls in the most affluent quintiles. However, this concealed contrasting patterns in underlying age-specific rates. From 2000, mortality rates levelled off in the youngest groups but accelerated in middle aged and older groups. Mortality analyses by small areas could provide potentially valuable insights into possible drivers of inequalities, and thus inform future strategies to reduce CHD mortality across all social groups.
Project description:OBJECTIVE:To analyse the falls in coronary heart disease (CHD) mortality in England between 2000 and 2007 and quantify the relative contributions from preventive medications and population-wide changes in blood pressure (BP) and cholesterol levels, particularly by exploring socioeconomic inequalities. DESIGN:A modelling study. SETTING:Sources of data included controlled trials and meta-analyses, national surveys and official statistics. PARTICIPANTS:English population aged 25+ in 2000-2007. MAIN OUTCOME MEASURES:Number of deaths prevented or postponed (DPPs) in 2007 by socioeconomic status. We used the IMPACTSEC model which applies the relative risk reduction quantified in previous randomised controlled trials and meta-analyses to partition the mortality reduction among specific treatments and risk factor changes. RESULTS:Between 2000 and 2007, approximately 20?400 DPPs were attributable to reductions in BP and cholesterol in the English population. The substantial decline in BP was responsible for approximately 13?000 DPPs. Approximately 1800 DPPs came from medications and some 11?200 DPPs from population-wide changes. Reduction in population BP prevented almost twofold more deaths in the most deprived quintile compared with the most affluent. Reduction in cholesterol resulted in approximately 7400 DPPs; approximately 5300 DPPs were attributable to statin use and approximately 2100 DPPs to population-wide changes. Statins prevented almost 50% more deaths in the most affluent quintile compared with the most deprived. Conversely, population-wide changes in cholesterol prevented threefold more deaths in the most deprived quintile compared with the most affluent. CONCLUSIONS:Population-wide secular changes in systolic blood pressure (SBP) and cholesterol levels helped to substantially reduce CHD mortality and the associated socioeconomic disparities. Mortality reductions were, in absolute terms, greatest in the most deprived quintiles, mainly reflecting their bigger initial burden of disease. Statins for high-risk individuals also made an important contribution but maintained socioeconomic inequalities. Our results strengthen the case for greater emphasis on preventive approaches, particularly population-based policies to reduce SBP and cholesterol.
Project description:Coronary Heart Disease (CHD) remains a leading cause of UK mortality, generating a large and unequal burden of disease. Dietary trans fatty acids (TFA) represent a powerful CHD risk factor, yet to be addressed in the UK (approximately 1% daily energy) as successfully as in other nations. Potential outcomes of such measures, including effects upon health inequalities, have not been well quantified. We modelled the potential effects of specific reductions in TFA intake on CHD mortality, CHD related admissions, and effects upon socioeconomic inequalities.We extended the previously validated IMPACTsec model, to estimate the potential effects of reductions (0.5% & 1% reductions in daily energy) in TFA intake in England and Wales, stratified by age, sex and socioeconomic circumstances. We estimated reductions in expected CHD deaths in 2030 attributable to these two specific reductions. Output measures were deaths prevented or postponed, life years gained and hospital admissions. A 1% reduction in TFA intake energy intake would generate approximately 3,900 (95% confidence interval (CI) 3,300-4,500) fewer deaths, 10,000 (8,800-10,300) (7% total) fewer hospital admissions and 37,000 (30,100-44,700) life years gained. This would also reduce health inequalities, preventing five times as many deaths and gaining six times as many life years in the most deprived quintile compared with the most affluent. A more modest reduction (0.5%) would still yield substantial health gains.Reducing intake of industrial TFA could substantially decrease CHD mortality and hospital admissions, and gain tens of thousands of life years. Crucially, this policy could also reduce health inequalities. UK strategies should therefore aim to minimise industrial TFA intake.
Project description:BACKGROUND: Growing mortality differences between socioeconomic groups have been reported in both Finland and elsewhere. While health behaviours and other lifestyle factors are important in contributing to health differences, some researchers have suggested that some of the mortality differences attributable to lifestyle factors could be preventable by health policy measures and that health care may play a role. It has also been suggested that its role is increasing due to better results in disease prevention, improved diagnostic tools and treatment methods. This study aimed to assess the impact of mortality amenable to health policy and health care on increasing income disparities in life expectancy in 1996-2007 in Finland. METHODS: The study data were based on an 11% random sample of Finnish residents in 1988-2007 obtained from individually linked cause of death and population registries and an oversample of deaths. We examined differences in life expectancy at age 35 (e35) in Finland. We calculated e35 for periods 1996-97 and 2006-07 by income decile and gender. Differences in life expectancies and change in them between the richest and the poorest deciles were decomposed by cause of death group. RESULTS: Overall, the difference in e35 between the extreme income deciles was 11.6 years among men and 4.2 years among women in 2006-07. Together, mortality amenable to health policy and care and ischaemic heart disease mortality contributed up to two thirds to socioeconomic differences. Socioeconomic differences increased from 1996-97 by 3.4 years among men and 1.7 years among women. The main contributor to changes was mortality amenable through health policy measures, mainly alcohol related mortality, but also conditions amenable through health care, ischaemic heart disease among men and other diseases contributed to the increase of the differences. CONCLUSIONS: The results underline the importance of active health policy and health care measures in tackling socioeconomic health inequalities.
Project description:Health professionals, policy-makers and researchers need to be able to explore potential associations between prevalence rates and quality of care with a range of possible determinants including socio-economic deprivation and morbidity levels to determine the impact of commissioning and service delivery. In the UK, data in England are only available nationally at practice postcode level. In Scotland, such data are available based on an aggregate of the practices population's postcodes. The use of data assigned to the practice postcode may underestimate the association between ill health and income deprivation. Here, we report on the impact of using data assigned to the practice population by comparing analyses using English and Scottish data.Income deprivation based on data assigned to the practice postcode under-estimated deprivation compared to using income deprivation data assigned to the practice population for the five least deprived deciles, and over-estimated deprivation for the five most deprived deciles. The biggest differences were found for the most deprived decile. A similar trend was found for limiting long-term illness (LLTI). Differences between the QOF prevalence rates of the least and most deprived deciles using practice postcode data were similar (0.2% points or less) in England and Scotland for 8 out of 10 clinical domains. Using practice population assigned deprivation, differences in the prevalence rate between the least and most deprived deciles increase for all clinical domains. A similar trend was again found for LLTI. Using practice population assigned deprivation, differences for population achievement increase for all CHD quality indicators with the exception of beta-blockers (CHD10). With practice postcode assigned deprivation, significant differences between the least and most deprived deciles were found for 2 out 8 indicators, compared to 5 using practice population assigned deprivation. For LLTI differences between the lowest and most deprived deciles increased for all indicators when ill health assigned to the practice population was used.We have found, through comparing deprivation and ill health data assigned to either the practice postcode or the practice population postcode in Scotland, that analyses based on practice postcode assigned data under-estimated the relationship between deprivation and ill health for both prevalence and quality care. Given the importance of understanding the effect of deprivation and ill health on a range of determinants related to health care, policy makers should ensure that practice population data are available and used at national level in England and elsewhere where possible.