Widening inequality of health in northern England, 1981-91.

OBJECTIVE--To identify relative and absolute changes in mortality in the Northern region of England between 1981 and 1991. DESIGN--1981 and 1991 census data were used to rank 678 wards on an index of material deprivation composed of four variables (unemployment, car ownership, housing tenure, household overcrowding). Standardised mortality ratios (all causes) were calculated for various periods between 1981 and 1991 and for different age categories. SETTING--Counties of Cleveland, Cumbria, Durham, Northumberland, and Tyne and Wear. RESULTS--During 1981-91 mortality differentials widened between the most affluent and deprived fifths of wards in all age categories under 75 years. The decline in the relative position of the poorest areas was particularly great, and there was no narrowing of inequalities across the remainder of the socioeconomic spectrum. In absolute terms, there were improvements in mortality in all age categories in the most affluent areas. In the poorest areas improvements in the 55-64 age group were balanced by increased mortality among men aged 15-44, a slight rise among women aged 65-74, and static rates among men aged 45-54. CONCLUSIONS--These results re-emphasise the case for linking mortality patterns with material conditions rather than individual behaviour.     

Changing patterns of teenage pregnancy: population based study of small areas

ObjectivesTo measure the impact of socioeconomic deprivation on rates of teenage pregnancy and the extent of local variation in pregnancy rates in Scotland, and to examine how both have changed over time.Design Population study using routine data from hospital records, aggregated for small areas.Subjects Female teenagers resident in Scotland who were treated for pregnancy in an NHS hospital in either 1981-5 (62 338 teenagers) or 1991-5 (48 514) and who were aged 13-19 at the time of conception.Results From the 1980s to the 1990s pregnancy rates increased differentially according to levels of local deprivation, as measured by the Carstairs index. Among teenagers aged less than 18 the annual pregnancy rate increased in the most deprived areas (from 7.0 to 12.5 pregnancies per 1000 13-15 year olds and from 67.6 to 84.6 per 1000 16-17 year olds), but there was no change, on average, among teenagers in the most affluent areas (3.8 per 1000 13-15 year olds and 28.9 per 1000 16-17 year olds). Among 18-19 year olds the pregnancy rate decreased in the most affluent areas (from 60.0 to 46.3 per 1000) and increased in the most deprived areas (from 112.4 to 116.0 per 1000). The amount of local variation explained by deprivation more than doubled from the 1980s to the 1990s. The proportion of pregnancies resulting in a maternity was positively associated with level of deprivation, but the effect remained similar over time.Conclusion From the 1980s to the 1990s the difference in rates of teenage pregnancy between more affluent and more deprived areas widened. This has implications for allocating resources to achieve government targets and points to important social processes behind the general increase in the number of teenage pregnancies in Scotland.

What is already known on this topic

Rates of teenage pregnancy are considerably higher in the United Kingdom than in other western European countriesIn the United Kingdom rates of teenage pregnancy are known to be higher in areas of greater socioeconomic deprivation, although local variation may also reflect differential access to family planning services

What this study adds

From 1981-5 to 1991-5 rates of teenage pregnancy in Scotland increased more rapidly in areas of greater socioeconomic deprivationIn the 1990s socioeconomic deprivation explained more than 50% of local variation in rates of teenage pregnancy, more than double the amount explained by it in the 1980s     

Grommets,tonsillectomies, and deprivation in Scotland.

OBJECTIVE--To see whether there is a relation between grommet insertion operation and tonsillectomy rates, otolaryngology services, and deprivation scores in Scotland. DESIGN--Analysis of routine 1990 NHS data on grommet insertions and tonsillectomies in Scottish children aged 0-15 years compared with data on general practitioner and otolaryngology services and Carstairs deprivation scores. SETTING--All 15 Scottish health boards. SUBJECTS--All children aged 0-15 (1,021,933). RESULTS--Tonsillectomy was more common than grommet insertion operations in Scotland (6182:4850). Health boards with high grommet insertion rates were more likely to have low tonsillectomy rates (Spearman''s rank correlation -0.59; 95% confidence interval -0.87 to -0.03). Grommet insertion rates varied fourfold (from 2.4/1000 to 9.2/1000) and tonsillectomy rates twofold (from 3.6/1000 to 8.0/1000) across Scottish health boards. Variation between health boards had changed over the 15 years 1975-90. Variation in grommet insertion rates did not reflect variation in the supply of otolaryngology consultants (Spearman''s rank correlation -0.25). There was a non-significant tendency for high general practitioner referral rates to be associated with high grommet insertion rates, low tonsillectomy rates, and less deprived areas (Spearman''s rank correlation coefficients 0.50, -0.53, and -0.43). Deprivation (measured by Carstairs scoring for each health board) was associated with higher tonsillectomy rates (Spearman''s rank correlation 0.41; 95% confidence interval -0.22 to 0.80) and significantly lower grommet insertion rates (-0.73; -0.92 to -0.28). CONCLUSION--Social factors as well as differences in disease prevalence and medical practice need to be considered when studying variation in childhood grommet insertion and tonsillectomy rates.     

Relation between socioeconomic deprivation and pathological prognostic factors in women with breast cancer.

OBJECTIVE--To investigate the relation between socioeconomic deprivation and pathological prognostic factors in women with breast cancer as a possible explanation for socioeconomic differences in survival. DESIGN--Retrospective analysis of data from cancer registry and from pathology and biochemistry records. SETTING--Catchment areas of two large teaching hospitals in Glasgow. SUBJECTS--1361 women aged under 75 who had breast cancer diagnosed between 1980 and 1987. MAIN OUTCOME MEASURES--Tumour size, axillary lymph node status, histological grade, and oestrogen receptor concentration in relation to deprivation category of area of residence. RESULTS--There was no significant relation between socioeconomic deprivation and four pathological prognostic factors: 93 (32%) women in the most affluent group presented with tumours less than 20 mm in size compared with 91 (31%) women in the most deprived group; 152 (48%) of the most affluent group presented with negative nodes compared with 129 (46%) of the most deprived group; 23 (22%) of the most affluent group presented with grade I tumours compared with 12 (17%) of the most deprived group; and 142 (51%) of the most affluent group had a low oestrogen receptor concentration at presentation compared with 148 (52%) of the most deprived group. None of these differences was statistically significant. CONCLUSIONS--Differences in survival from breast cancer by socioeconomic deprivation category could not be accounted for by differences in tumour stage or biology. Other possible explanations, such as differences in treatment or in host response, should be investigated.     

Socioeconomic deprivation and notification rates for tuberculosis in London during 1982-91.

OBJECTIVES--To investigate the association between four sociodemographic measures (unemployment, overcrowding, low social class, and the proportion of migrants from areas of high prevalence of tuberculosis) and average level and rate of change of notification rates for tuberculosis. DESIGN--Ecological analysis of both the average and the rate of change of standardised annual notification rates for tuberculosis from 1982-91 and sociodemographic measures from the 1981 and 1991 censuses. SETTING--32 London boroughs. SUBJECTS AND DATA--Sociodemographic measures from the 1981 and 1991 censuses and tuberculosis notification rates for 1982-91. MAIN OUTCOME MEASURES--A measure of the association between average levels and rate of change in tuberculosis notification rates and four sociodemographic measures in 1981 and between the rate of change in tuberculosis notification rates between 1981 and 1991 and changes in sociodemographic measures between 1981 and 1991. RESULTS--The average level of notifications was correlated with overcrowding and the proportion of migrants but not with unemployment or social class. No significant association was found between the rate of change in notification rates and sociodemographic measures in 1981. An association was found between increases in unemployment and the rate of change in notification rates, but the effect was small. Changes in the levels of unemployment explained 23% of the variation between boroughs in the rate of change in their notification rates. CONCLUSION--The average tuberculosis notification rates were related to overcrowding and the proportion of migrants in 1981. Only increases in unemployment from 1981 to 1991, however, were significantly associated with the rate of change in notifications over the same period.     

Incidence and thickness of primary tumours and survival of patients with cutaneous malignant melanoma in relation to socioeconomic status.

OBJECTIVE--To study incidence of and survival from cutaneous malignant melanoma in relation to socioeconomic status. DESIGN--Application of Carstairs deprivation score to all malignant melanoma patients diagnosed in a geographically defined area over a 15 year period. SETTING--West of Scotland (area population 2,716,900). SUBJECTS--3142 patients first diagnosed with malignant melanoma in the period 1979-93. INTERVENTIONS--Surgical excision of primary malignant melanoma with additional treatment as appropriate and follow up until December 1994. MAIN OUTCOME MEASURES--Malignant melanoma incidence, primary tumour thickness and five year survival by socioeconomic status. RESULTS--From 1979 to 1993, the age standardised incidence rate for cutaneous malignant melanoma was 9.1/100,000 for the most affluent men and 2.4/100,000 for the least affluent men and 16.1/100,000 and 5.0/100,000 respectively for most and least affluent women (P < 0.001 for trend in both). The incidence increased steadily over time in both sexes in all socioeconomic groups. Good prognosis tumours ( < 1.5 mm thick) were most common in the most affluent men and women, and over the study period the proportion of such tumours increased most in the intermediate affluence group (both sexes) and in the least affluent women. Five year disease free survival from melanoma for the sexes combined was 81% for most affluent, 77% for intermediate, and 73% for least affluent groups. Even after adjustment for known prognostic factors of tumour thickness, ulceration, age, and body site of primary melanoma, the more affluent the group, the better the survival. CONCLUSION--Although the incidence of cutaneous malignant melanoma is higher among more affluent people, the prognosis is better in this group than for less affluent individuals. Early diagnosis campaigns should be targeted particularly to less affluent men and primary prevention campaigns should emphasise the greater risk in more affluent women.     

Socio-Economic Inequalities in Survival of Patients with Prostate Cancer: Role of Age and Gleason Grade at Diagnosis

In the United Kingdom, survival of prostate cancer patients has improved since the 1990s. A deprivation gap in survival (better survival for the least deprived compared with the most deprived) has been reported but it is not known if differential distribution of earlier age or lower grade disease at diagnosis might explain such patterns. We therefore investigated the impact of age and Gleason grade at diagnosis on the deprivation gap in survival of prostate cancer patients over time. Incident cases of prostate cancer (ICD-10 C61) from the West of Scotland were extracted from the Scottish Cancer Registry from 1991 to 2007. Socio-economic circumstances were measured using the Scottish Index for Multiple Deprivation 2004 (SIMD). Age and deprivation specific mortality rates were obtained from the General Registrar Office for Scotland (GRO(S)). The survival gradient across the five deprivation categories was estimated with linear regression, weighted by the variance of the relative survival estimate. We examined the data for 15,292 adults diagnosed with prostate cancer between 1991 and 2007. Despite substantial improvements in survival of prostate cancer patients, a deprivation gap persists throughout the three periods of diagnoses. The deprivation gap in five year relative survival widened from −4.76 in 1991–1996 to −10.08 in 2003–2007. On age and grade-specific analyses, a significant deprivation gap in five year survival existed between all age groups except among patients'' age ≥75 and both low and high grade disease. On multivariate analyses, deprivation was significantly associated with increased excess risk of death (RER 1.48, 95% CI 1.31–1.68, p-value<0.001) independent of age, Gleason grade and period of diagnosis. The deprivation gap in survival from prostate cancer cannot be wholly explained by socio-economic differentials in early detection of disease. Further research is needed to understand whether differences in comorbidities or treatment explain inequalities in prostate cancer outcomes.     

Socioeconomic variations in responses to chest pain: qualitative study

ObjectiveTo explore and explain socioeconomic variations in perceptions of and behavioural responses to chest pain.DesignQualitative interviews.SettingCommunity based study in Glasgow, Scotland.Participants30 respondents (15 men and 15 women) from a socioeconomically deprived area of Glasgow and 30 respondents (15 men and 15 women) from an affluent area of Glasgow.ResultsResidents of the deprived area reported greater perceived vulnerability to heart disease, stemming from greater exposure to heart disease in family members and greater identification with high risk groups and stereotypes of cardiac patients. This greater perceived vulnerability was not associated with more frequent reporting of presenting to a general practitioner. People from the deprived area reported greater exposure to ill health, which allowed them to normalise their chest pain, led to confusion with other conditions, and gave rise to a belief that they were overusing medical services. These factors were associated with a reported tendency not to present with chest pain. Anxiety about presenting among respondents in the deprived area was heightened by self blame and fear that they would be chastised by their general practitioner for their risk behaviours.ConclusionsImportant socioeconomic variations in responses to chest pain may contribute to the known inequities in uptake of secondary cardiology services. Primary care professionals and health promoters should be aware of the ways in which perceptions of symptoms and illness behaviour are shaped by social and cultural factors.

What is already known on this topic

Socioeconomic variations in rates of angiography and revascularisation existAmong socioeconomically deprived patients with a diagnosis of angina, barriers to accessing services include fear, denial, low expectations, and diagnostic confusion

What this study adds

Perceived vulnerability to heart disease is associated with socioeconomic deprivation and is underpinned by positive family history and identification with high risk groups and stereotypesGreater perceived vulnerability to heart disease does not lead to reported presentation in deprived patientsIllness behaviour is influenced by normalisation of chest pain, comorbidity, and poor experience and low expectations of health care, which are more prominent in deprived patients     

Social deprivation and premature mortality: regional comparison across England.

OBJECTIVE--To investigate the pattern and size of the relationship between social deprivation in electoral wards and premature mortality for each health region in England. DESIGN--Ecological study using 1981 census variables and data on mortality for 1981-5. SETTING--14 regional health authorities in England. MAIN OUTCOME MEASURE--Mortality under the age of 65 years from all causes, coronary heart disease, and smoking related diseases in men and women. RESULTS--Increasing deprivation was significantly associated with mortality from all causes, coronary heart disease, and smoking related diseases. The relationship was linear with no apparent threshold. Correlation coefficients were generally greater for deaths from all causes and smoking related diseases and for men compared with women. The slope of the relationship between deprivation and mortality varied among regions. Variations in mortality still existed between regions for equal levels of deprivation. CONCLUSION--Deprivation of an area and premature mortality are strongly linked. The effects of deprivation can be seen throughout the range of affluence and are not limited to the poorest areas. Current targets for reducing coronary heart disease mortality may be achievable if the mortality in poor areas can be reduced to the rates in affluent areas.     

Ecological study of social fragmentation,poverty, and suicide

ObjectivesTo investigate the association between suicide and area based measures of deprivation and social fragmentation.DesignEcological study.Setting633 parliamentary constituencies of Great Britain as defined in 1991.ResultsMortality from suicide and all other causes increased with increasing Townsend deprivation score, social fragmentation score, and abstention from voting in all age and sex groups. Suicide mortality was most strongly related to social fragmentation, whereas deaths from other causes were more closely associated with Townsend score. Constituencies with absolute increases in social fragmentation and Townsend scores between 1981 and 1991 tended to have greater increases in suicide rates over the same period. The relation between change in social fragmentation and suicide was largely independent of Townsend score, whereas the association with Townsend score was generally reduced after adjustment for social fragmentation.ConclusionsSuicide rates are more strongly associated with measures of social fragmentation than with poverty at a constituency level.

Key messages

• Place of residence may affect health, and mortality from most common diseases tends to be higher in areas characterised by low socioeconomic position
• Research dating back over 100 years suggests that social fragmentation may influencesuicide
• In the 1980s and 1990s, parliamentary constituencies with high levels of social fragmentation had high rates of suicide, independent of deprivation
• Constituencies with the greatest increases in social fragmentation between 1981 and 1991 also had the greatest increases in suicide rates over the same period
• Any targeting of suicide prevention may be more effective if aimed at socially fragmented rather than deprived areas

     

Do interventions that improve immunisation uptake also reduce social inequalities in uptake?

OBJECTIVE--To investigate whether an intervention designed to improve overall immunisation uptake affected social inequalities in uptake. DESIGN--Cross-sectional small area analyses measuring immunisation uptake in cohorts of children before and after intervention. Small areas classified into five groups, from most deprived to most affluent, with Townsend deprivation score of census enumeration districts. SETTING--County of Northumberland. SUBJECTS--All children born in country in four birth cohorts (1981-2, 1985-6, 1987-8, and 1990-1) and still resident at time of analysis. MAIN OUTCOME MEASURES--Overall uptake in each cohort of pertussis, diphtheria, and measles immunisation, difference in uptake between most deprived and most affluent areas, and odds ratio of uptake between deprived and affluent areas. RESULTS--Coverage for pertussis immunisation rose from 53.4% in first cohort to 91.1% in final cohort. Coverage in the most deprived areas was lower than in the most affluent areas by 4.7%, 8.7%, 10.2%, and 7.0% respectively in successive cohorts, corresponding to an increase in odds ratio of uptake between deprived and affluent areas from 1.2 to 1.6 to 1.9 to 2.3. Coverage for diphtheria immunisation rose from 70.0% to 93.8%; differences between deprived and affluent areas changed from 8.6% to 8.3% to 9.0% to 5.5%, corresponding to odds ratios of 1.5, 2.0, 2.5, and 2.6. Coverage for measles immunisation rose from 52.5% to 91.4%; differences between deprived and affluent areas changed from 9.1% to 5.7% to 8.2% to 3.6%, corresponding to odds ratios of 1.4, 1.4, 1.7, and 1.5. CONCLUSION--Despite substantial increase in immunisation uptake, inequalities between deprived and affluent areas persisted or became wider. Any reduction in inequality occurred only after uptake in affluent areas approached 95%. Interventions that improve overall uptake of preventive measures are unlikely to reduce social inequalities in uptake.     

Asbestos and lung cancer in Glasgow and the west of Scotland.

OBJECTIVE--To quantify the relation between lung cancer and exposure to asbestos in men in west Scotland and to estimate the proportion of lung cancer which may be attributed to exposure to asbestos. DESIGN--An ecological correlation study of the incidence of lung cancer in men and past asbestos exposure. The unit of analysis was the postcode sector. Correction was made for past cigarette smoking, air pollution, and deprivation. SETTING--The region covered by the west of Scotland cancer registry, containing 2.72 million people and including Glasgow and the lower reaches of the River Clyde, where shipbuilding was once a major industry. SUBJECTS--All men diagnosed with lung cancer between 1975 and 1984 whose residence at the time of registration was within the west of Scotland. MAIN OUTCOME MEASURE--The population attributable risk for asbestos related lung cancer. RESULTS--An estimated 5.7% (95% confidence interval 2.3 to 9.1%) of all lung cancers in men registered in the west of Scotland during the period 1975-84 were asbestos related, amounting to 1081 cases. CONCLUSIONS--A considerable proportion of cases of lung cancer in men in Glasgow and the west of Scotland from 1975 to 1984 were asbestos related. Most of these may not have been considered for compensation by the Department of Social Security. Given the very small annual number of recorded cases of asbestosis this condition is probably not a prerequisite for the development of asbestos related lung cancer. A heightened awareness of the increasing incidence of asbestos related neoplasms and their more thorough investigation are recommended.     

Inequalities in mortality during and after restructuring of the New Zealand economy: repeated cohort studies

Objectives To determine whether disparities between income and mortality changed during a period of major structural and macroeconomic reform and to estimate the changing contribution of different diseases to these disparities.Design Repeated cohort studies.Data sources 1981, 1986, 1991, 1996, and 2001 censuses linked to mortality data.Population Total New Zealand population, ages 1-74 years.Methods Mortality rates standardised for age and ethnicity were calculated for each census cohort by level of household income. Standardised rate differences and rate ratios, and slope and relative indices of inequality (SII and RII), were calculated to measure disparities on both absolute and relative scales.Results All cause mortality rates declined over the 25 year study period in all groups stratified by sex, age, and income, except for 25-44 year olds of both sexes on low incomes among whom there was little change. In all age groups pooled, relative inequalities increased from 1981-4 to 1996-9 (RIIs increased from 1.85 (95% confidence interval 1.67 to 2.04) to 2.54 (2.29 to 2.82) for males and from 1.54 (1.35 to 1.76) to 2.12 (1.88 to 2.39) for females), then stabilised in 2001-4 (RIIs of 2.60 (2.34 to 2.89) and 2.18 (1.93 to 2.45), respectively). Absolute inequalities were stable over time, with a possible fall from 1996-9 to 2001-4. Cardiovascular disease was the major contributor to the observed disparities between income and mortality but decreased in importance from 45% in 1981-4 to 33% in 2001-4 for males and from 50% to 29% for females. The corresponding contribution of cancer increased from 16% to 22% for males and from 12% to 25% for females.Conclusions During and after restructuring of the economy disparities in mortality between income groups in New Zealand increased in relative terms (but not in absolute terms), but it is difficult to confidently draw a causal link with structural reforms. The contribution of different causes of death to this inequality changed over time, indicating a need to re-prioritise health policy accordingly.     

Rural population mixing and childhood leukaemia: effects of the North Sea oil industry in Scotland,including the area near Dounreay nuclear site.

OBJECTIVE--To determine if any excess of childhood leukaemia and non-Hodgkin''s lymphoma was associated with certain striking examples of population mixing in rural Scotland produced by the North Sea oil industry. DESIGN--Details were traced for over 30,000 workers involved in the construction of the large oil terminals in the Shetland and Orkney islands in northern Scotland or employed offshore. Home addresses of the 17,160 Scottish residents were postcoded, integrated with census data, and then classified as urban or rural. Rural postcode sectors, ranked by proportion of oil workers, were grouped into three categories with similar numbers of children but contrasting densities of oil workers. The incidence of leukaemia and non-Hodgkin''s lymphoma was examined in these rural (and also in urban) categories in the periods 1974-8, 1979-83 and 1984-8. SETTING--Scotland. SUBJECTS--Young people below age 25. RESULTS--A significant excess of leukaemia and non-Hodgkin''s lymphoma was found in 1979-83 in the group of rural home areas with the largest proportion of oil workers, following closely on large increases in the workforce. The area near the Dounreay nuclear installation, where an excess of leukaemia is already well known, was within the rural high oil category. CONCLUSION--The findings support the infection hypothesis that population mixing can increase the incidence of childhood leukaemia in rural areas. They also suggest that the recent excess in the Dounreay-Thurso area is due to population mixing linked to the oil industry, promoted by certain unusual local demographic factors.     

Deprivation: explaining differences in mortality between Scotland and England and Wales.

To detect reasons for the difference in mortality between Scotland and England and Wales a measure of deprivation was studied, comprising overcrowding, unemployment of men, low social class, and not having a car. Data for Scotland for 1980-2 showed this measure to be strongly associated with mortality, with gradients being particularly steep in young adults. Deprivation was much severe in Scotland than in England and Wales. These findings suggest that much excess mortality may be ascribed to more adverse conditions. Standardising the mortality ratios to take account of the relative affluence and deprivation of the two populations led to the differentials observed being radically adjusted, while standardising for social class had little effect. Deprivation measures based on areas overcome many of the limitations associated with social class analysis and also show much greater discrimination between populations. Measures of deprivation apparently provide a powerful basis for explanation of health differences. Such measures should therefore form part of the 1991 census output to facilitate their use on a consistent basis.     

Socioeconomic variation in incidence of epilepsy: prospective community based study in south east England

ObjectiveTo determine the incidence of epilepsy in a general practice population and its variation with socioeconomic deprivation.DesignProspective surveillance for new cases over an 18 or 24 month period.ParticipantsAll patients on practice registers categorised for deprivation with the Carstairs score of their postcode.Setting20 general practices in London and south east England.Results190 new cases of epilepsy were identified during 369 283 person years of observation (crude incidence 51.5 (95% confidence interval 44.4 to 59.3) per 100 000 per year). The incidence was 190 (138 to 262) per 100 000 in children aged 0-4 years, 30.8 (21.3 to 44.6) in those aged 45-64 years, and 58.7 (42.5 to 81.0) in those aged ⩾65 years. There was no apparent difference in incidence between males and females. The incidence showed a strong association with socioeconomic deprivation, the age and sex adjusted incidence in the most deprived fifth of the study population being 2.33 (1.46 to 3.72) times that in the least deprived fifth (P=0.001 for trend across fifths). Adjustment for area (London v outside London) weakened the association with deprivation (rate ratio 1.62 (0.91 to 2.88), P=0.12 for trend).ConclusionsThe incidence of epilepsy seems to increase with socioeconomic deprivation, though the association may be confounded by other factors.

What is already known on this topic

Epilepsy is associated with a wide range of markers of social and economic disadvantageA small number of epidemiological studies have confirmed this association but have not established the direction of causality

What this study adds

The incidence of epilepsy, adjusted for age and sex, in the most deprived fifth of the study population was 2.3 times that in the least deprived fifthSocioeconomic deprivation is an important risk factor for the development of epilepsy, though the results may partly reflect differences in incidence within and outside London     

Deprivation and emergency admissions for cancers of colorectum,lung, and breast in south east England: ecological study

Objectives: To examine the relation between deprivation and acute emergency admissions for cancers of the colon, rectum, lung, and breast in south east England. Design: Ecological analysis with data from hospital episode statistics and 1991 census. Setting: North and South Thames Regional Health Authorities (population about 14 million), divided into 10 aggregations of 31 470 census enumeration districts (median population 462). Subjects: 146 639 admissions relating to 76 552 patients aged <100 years on admission, resident in the Thames regions, admitted between 1 April 1992 and 31 March 1995. Results: Residents living in deprived areas were more likely to be admitted as emergencies and has ordinary inpatient admissions and less likely to be admitted as day cases. Adjusted odds of ordinary admissions from the most deprived tenth occurring as emergencies (relative to admissions from the most affluent tenth) were 2.29 (95% confidence interval 2.09 to 2.52) for colorectal cancer, 2.20 (1.99 to 2.43) for lung cancer, and 2.41 (2.17 to 2.67) for female breast cancer; adjusted odds of admissions as day cases were 0.70 (0.64 to 0.76), 0.50 (0.44 to 0.56), and 0.56 (0.50 to 0.62), respectively. Patients from deprived areas with lung or breast cancers were less likely to be recorded as having surgical interventions. Adjusted odds of patients from the most deprived tenth receiving surgery were 0.88 (0.78 to 1.00), 0.58 (0.48 to 0.70), and 0.63 (0.56 to 0.71), respectively. Admissions for colorectal cancer from the most deprived areas were less likely to be to hospitals admitting 100 or more new patients a year; the opposite held true for breast cancer admissions. No association was found for lung cancer admissions. Conclusions: Earlier diagnostic and referral procedures in primary care in deprived areas are required if there are to be significant reductions in mortality from these cancers. A national information strategy is required to ensure the continued availability of population based data on NHS patients and to mandate standardised datasets from the private sector. Rationalisation of acute services, hospital mergers, and plans for bed closures must take into account the increased healthcare needs and inequities in access to treatment and care of residents in areas with high levels of deprivation. Health authorities and primary care groups should re-examine their purchasing intentions, service reviews, and monitoring arrangements in the light of these findings.

Key messages

• A major reorganisation of cancer services is under way in England and Wales with the aim of improving access to and quality of treatment
• Residents with cancers of the bowel, lung, or breast in deprived areas in the Thames region were more likely to be admitted as emergencies and ordinary inpatients than their counterparts from more affluent areas, and patients with lung or breast cancers from deprived areas were less likely to receive surgical treatment
• Patients with colorectal cancer from the most deprived areas were less likely to be seen at hospitals with a large caseload than were patients from affluent areas; the opposite held true for patients with breast cancer, but no association was found for admissions for lung cancer
• More effective early diagnostic and referral procedures in primary care in deprived areas are required if reductions in mortality are to be achieved
• Hospital mergers and plans for service reconfiguration and bed closures must take into account inequities in access to treatment among residents in deprived areas

     

Cancer mortality 1981–2016 and contribution of specific cancers to current socioeconomic inequalities in all cancer mortality: A population-based study

BackgroundIn many high-income countries cancer mortality rates have declined, however, socioeconomic inequalities in cancer mortality have widened over time with those in the most deprived areas bearing the greatest burden. Less is known about the contribution of specific cancers to inequalities in total cancer mortality.MethodsUsing high-quality routinely collected population and mortality records we examine long-term trends in cancer mortality rates in Scotland by age group, sex, and area deprivation. We use the decomposed slope and relative indices of inequality to identify the specific cancers that contribute most to absolute and relative inequalities, respectively, in total cancer mortality.ResultsCancer mortality rates fell by 24 % for males and 10 % for females over the last 35 years; declining across all age groups except females aged 75+ where rates rose by 14 %. Lung cancer remains the most common cause of cancer death. Mortality rates of lung cancer have more than halved for males since 1981, while rates among females have almost doubled over the same period.ConclusionCurrent relative inequalities in total cancer mortality are dominated by inequalities in lung cancer mortality, but with contributions from other cancer sites including liver, and head and neck (males); and breast (females), stomach and cervical (younger females). An understanding of which cancer sites contribute most to inequalities in total cancer mortality is crucial for improving cancer health and care, and for reducing preventable cancer deaths.     

Access to coronary catheterisation: fair shares for all?

OBJECTIVE--To determine the effects of patient''s sex and area''s material deprivation on utilisation rates of coronary catheterisation and angiography in the investigation of ischaemic heart disease. DESIGN--Retrospective analysis of routinely collected hospital statistics. SETTING--Acute hospitals throughout Northern Ireland. SUBJECTS--24,179 episodes of patients discharged from hospital with a primary diagnosis of ischaemic heart disease and 1270 episodes relating to patients with an underlying diagnosis of ischaemic heart disease who had either coronary catheterisation or angiography. MAIN OUTCOME MEASURES--Age standardised admission rates for heart disease and age standardised utilisation rates for catheterisation or angiography, or both, for 566 electoral wards ranked by Townsend "deprivation" scores. RESULTS--Catheterisation-angiography rates in men were over fivefold those of women, ranging from 85.5/100,000 v 16/100,000 in patients from "well off" areas to 123/100,000 v 22/100,000 for patients from deprived areas. After admission rates for heart disease were controlled for, the overall rate ratio for women was 0.48 (95% confidence interval 0.38 to 0.60). After differential admission rates for heart disease and other potential clinical confounders were controlled for, the investigation rates of patients from the least and most "deprived" areas were not significantly different (rate ratio 1.04 (0.87 to 1.25)). CONCLUSION--Although investigation rates were significantly lower in women than in men, further clinical data would be required before labelling this underutilisation as evidence of bias. There was no significant difference in invasive investigation rates for heart disease in areas of varying deprivation or affluence.     

Investigating reasons for socioeconomic inequalities in breast cancer survival in New Zealand

Background: This study investigated the role that demographic and tumour factors play in explaining socioeconomic inequalities in breast cancer survival. Methods: Breast cancer cases notified to the New Zealand Cancer Registry (NZCR) from April 2005 to April 2007 were followed up to April 2009. The New Zealand area-based deprivation index (NZDep) was used as a measure of socioeconomic position. Relative survival rates were estimated using sex-, deprivation- and ethnic-specific life tables. Multiple imputation was used to impute missing data. Excess mortality modelling was used to estimate the contribution of demographic and tumour factors to inequalities in survival. Results: There were 2968 breast cancer cases included and 433 recorded deaths. Relative survival rates at 4 years varied across deprivation groups. Using NZDep deciles 1–4 (least deprived) as the reference group, the age- and ethnicity-adjusted hazard ratio (HR) for NZDep deciles 7–8 was 2.03 (CI 1.36–3.04) and for NZDep deciles 9–10 was 1.93 (CI 1.28–2.92). In the fully adjusted model there remained 50% excess mortality for the two most deprived groups compared to the most affluent. Variables which measured timely access to care (extent/size) accounted for more of the survival disparity than breast cancer subtype variables (ER/PR/HER2). Conclusion: Women from deprived areas in New Zealand who are diagnosed with breast cancer are less likely to survive as long as those from affluent areas. A substantial proportion of these socioeconomic disparities can be attributed to differential access to health care although other factors, currently unknown, are also likely to play an important role.