Burden of mortality associated with autoimmune diseases among females in the United Kingdom.

OBJECTIVES: We estimated the collective burden of mortality from autoimmune diseases among females in the United Kingdom and the effects of death certificate coding changes on this estimate. METHODS: We analyzed 1993-2003 England and Wales death certificate data for 3,150,267 females aged 1 year or older. We identified death certificates that listed autoimmune conditions as underlying or contributory causes of death. The percentages of all female deaths attributed to autoimmune disorders and to UK official mortality categories were ranked to determine the leading causes of death. RESULTS: In 2003, autoimmune diseases were the sixth or seventh most frequent underlying cause of death among females in all age groups below 75 years. Results were similar when both underlying and contributory causes of death were considered. The proportion of females dying with an autoimmune disorder remained relatively constant from 1993 to 2003. Analyses indicated that death counts for specific autoimmune diseases had been underestimated. CONCLUSIONS: Autoimmune diseases are a leading cause of death among females in England and Wales, but their collective impact remains hidden in current disease classification systems. Grouping these disorders together may help promote research needed to identify common determinants and future prevention strategies.

Alcohol-related and hepatocellular cancer deaths by country of birth in England and Wales: analysis of mortality and census data.

BACKGROUND: The incidence of and mortality from alcohol-related conditions, liver disease and hepatocellular cancer (HCC) are increasing in the UK. We compared mortality rates by country of birth to explore potential inequalities and inform clinical and preventive care. DESIGN: Analysis of mortality for people aged 20 years and over using the 2001 Census data and death data from 1999 and 2001-2003. SETTING: England and Wales. MAIN OUTCOME MEASURES: Standardized mortality ratios (SMRs) for alcohol-related deaths and HCC. RESULTS: Mortality from alcohol-related deaths (23 502 deaths) was particularly high for people born in Ireland (SMR for men [M]: 236, 95% confidence interval [CI]: 219-254; SMR for women [F]: 212, 95% CI: 191-235) and Scotland (SMR-M: 187, CI: 173-213; SMR-F 182, CI: 163-205) and men born in India (SMR-M: 161, CI: 144-181). Low alcohol-related mortality was found in women born in other countries and men born in Bangladesh, Middle East, West Africa, Pakistan, China and Hong Kong, and the West Indies. Similar mortality patterns were observed by country of birth for alcoholic liver disease and other liver diseases. Mortality from HCC (8266 deaths) was particularly high for people born in Bangladesh (SMR-M: 523, CI: 380-701; SMR-F: 319, CI: 146-605), China and Hong Kong (SMR-M: 492, CI: 168-667; SMR-F: 323, CI: 184-524), West Africa (SMR-M: 440, CI, 308-609; SMR-F: 319, CI: 165-557) and Pakistan (SMR-M: 216, CI: 113-287; SMR-F: 215, CI: 133-319). CONCLUSIONS: These findings show persistent differences in mortality by country of birth for both alcohol-related and HCC deaths and have important clinical and public health implications. New policy, research and practical action are required to address these differences.

Death certification following MRSA bacteraemia, England, 2004-05.

This study examined factors affecting whether or not meticillin resistant Staphylococcus aureus(MRSA) is recorded on the death certificate of individuals who died following a laboratory confirmed MRSA bacteraemia and compared this with another organism, Streptococcus pneumoniae. The study included all patients with a positive MRSA or S. pneumoniae bacteraemia reported to the Health Protection Agency between 1 January 2004 and 31 December 2005 and linked to a death registered up to 31 March 2006. It was an opportunistic analysis of infection surveillance records and death registrations that had been linked for other purposes Certifiers are most likely to record MRSA on the death certificate if they believe that a large number of conditions contributed to the patient's death, and if the patient dies between 2 and 15 days following a positive blood culture. Certifiers do not appear to be deliberately omitting MRSA from death certificates; rather they report the clinical manifestation of infection or disease the patient died from, not the microbiological diagnosis. Certifiers were significantly less likely to mention S. pneumoniae than MRSA.

Burden of suicide presented as one of the leading causes of death: uncover facts or misrepresent statistics?

BACKGROUND: Suicide is a relatively rare incident. Nevertheless, parts of the literature on intentional self-harm behaviour state that suicide is one of the leading causes of death. We aimed to assess the evidence behind the statement that suicide is a leading cause of death across all ages, with reference to the methods of ranking causes of death. METHODS: Two sets of data were used: For the European Union (EU) we used cause specific mortality statistics from the European Statistical Office (Eurostat) for the data-year 2014, and globally and for the WHO European Region we used data from Global Health Estimates (GHE) 2015. We used different sets of rules to select mutually exclusive leading underlying causes of mortality for Europe (EU28). We also present lists with estimates of leading causes of death globally, and for the WHO European Region based on the GHE 2015. RESULTS: In 2014, 1.2% of all reported deaths in the Europe Union (EU28) were due to suicide, and 1.4% globally (2015) according to the WHO estimates. In Europe, suicide was ranked as number 11 and 15 in the two different ranking lists we used, and according to GHE-2015, suicide was ranked as the 17th leading cause globally, and number 14 in the WHO European Region. Looking at the differences by sex, suicide for males was ranked as the ninth and the tenth leading cause of death in two ranking lists for the European Union. For females, suicide was number 13 in the first and 23 in the second list, respectively. CONCLUSIONS: Different cause lists and rules for ranking produce different leading causes of mortality. The quality of data can also affect the ranking. Our rankings suggested that suicide was not among the ten leading causes of death in Europe or globally. To ensure that ranking causes of death is not driven by political motives and funding considerations, standard methods and official tabulation lists should be used. The rankings do not necessarily present the causes of mortality of greatest public health importance.

Antidepressant prescribing and changes in antidepressant poisoning mortality and suicide in England, 1993-2004.

BACKGROUND: In England, the impact of increased use of antidepressant medications is unclear. We examine associations between antidepressant use, suicide and antidepressant poisoning mortality, adjusted for important covariates. METHODS: Data on suicide and antidepressant poisoning mortality were provided by the Office for National Statistics. Prescription data were provided by the Department of Health. Age- and sex-specific prescribing rates were estimated from The Health Improvement Network primary care data. We measured the association between prescribing, suicide and poisoning mortality after adjusting for age, sex, calendar year, prescribing rates and use of newer antidepressants drugs. RESULTS: The prevalence of antidepressant treatment increased during the 1990s for all age and sex groups. Treatment prevalence remained constant from 2002 but declined among children and adolescents. Between 1993 and 2004, age-standardized rates for suicide decreased from 98.2 to 81.3 per million populations and for antidepressants from 9.2 to 7.4 per million populations. Before adjustment, increased antidepressant prescribing was associated with a decrease in suicide (r(s) = -0.90, P < 0.001) and antidepressant poisoning mortality rates (r(s) = -0.65, P = 0.023). This association disappeared after adjustment. CONCLUSION: In England, at a population level, there does not appear to be an association between antidepressant prescribing and antidepressant poisoning mortality or suicide.

Standardised mortality ratios--the effect of smoothing ward-level results.

Geographical indicators of mortality provide one of the most important means of assessing the health of populations and are particularly effective in identifying inequalities in health. Geographical mortality indicators have regularly been produced by the Office for National Statistics, but not normally for areas smaller than local authorities. In order to allow variations in mortality within local authorities to be examined, in 2006 ONS published Standardised Mortality Ratios (SMRs) for wards in England and Wales, based on deaths in 1999-2003. For mortality indicators for small populations, based on small numbers of deaths, there is however a risk that results will be unstable, making geographical patterns hard to interpret. To examine whether this problem could be overcome, methods for smoothing SMRs in time and space were considered, with conclusions published in a methodology report in 2007. This article presents results from that work, illustrating the geographical patterns in mortality that emerge following smoothing of the ward-level SMRs.

Geographical variations in deaths related to drug misuse in England and Wales, 1993-2006.

Drug misuse is a significant public health issue in England and Wales. This article examines geographical variations in drug misuse mortality in England and Wales over the period 1993 t 2006. Geographical variations in deaths related to drug misuse have generally persisted over this period, one of substantial change in these deaths (with a peak in 2001 and numbers in 2006 being almost double those in 1993), although there were some significant changes to the regional level pattern. The regions with the highest mortality rates aggregated over the whole time period were the North West, Yorkshire and The Humber, and London, although by 2004/06 the rate in London was among the lowest and the rate in the North East was higher than the North West. Three Drug Action Teams (DATs), Brighton and Hove, Blackpool, and Camden, consistently had the highest drug misuse mortality rates. Urban areas tended to have the highest rates, but the rate in the most sparsely populated areas was similar to those of towns. The mortality rate in the most deprived parts of England and Wales was five times the rate in the least deprived areas. Areas with low rates were generally large, mostly rural areas, as well as areas in outer London and the south east of England.

Trends in suicide by marital status in England and Wales, 1982-2005.

This article examines trends in suicide by marital status in England and Wales over the period 1982 to 2005. A protective effect of marriage has been observed in a number of previous studies and this article updates figures up to 2005. The article shows that despite changes in marriage patterns over the last 25 years, those who are married still have the lowest risk of suicide, and there has generally been no obvious decline in the difference in suicide rates between those who are married and those who are not.

Interrupted time-series analysis of regulations to reduce paracetamol (acetaminophen) poisoning.

BACKGROUND: Paracetamol (acetaminophen) poisoning is the leading cause of acute liver failure in Great Britain and the United States. Successful interventions to reduced harm from paracetamol poisoning are needed. To achieve this, the government of the United Kingdom introduced legislation in 1998 limiting the pack size of paracetamol sold in shops. Several studies have reported recent decreases in fatal poisonings involving paracetamol. We use interrupted time-series analysis to evaluate whether the recent fall in the number of paracetamol deaths is different to trends in fatal poisoning involving aspirin, paracetamol compounds, antidepressants, or nondrug poisoning suicide. METHODS AND FINDINGS: We calculated directly age-standardised mortality rates for paracetamol poisoning in England and Wales from 1993 to 2004. We used an ordinary least-squares regression model divided into pre- and postintervention segments at 1999. The model included a term for autocorrelation within the time series. We tested for changes in the level and slope between the pre- and postintervention segments. To assess whether observed changes in the time series were unique to paracetamol, we compared against poisoning deaths involving compound paracetamol (not covered by the regulations), aspirin, antidepressants, and nonpoisoning suicide deaths. We did this comparison by calculating a ratio of each comparison series with paracetamol and applying a segmented regression model to the ratios. No change in the ratio level or slope indicated no difference compared to the control series. There were about 2,200 deaths involving paracetamol. The age-standardised mortality rate rose from 8.1 per million in 1993 to 8.8 per million in 1997, subsequently falling to about 5.3 per million in 2004. After the regulations were introduced, deaths dropped by 2.69 per million (p = 0.003). Trends in the age-standardised mortality rate for paracetamol compounds, aspirin, and antidepressants were broadly similar to paracetamol, increasing until 1997 and then declining. Nondrug poisoning suicide also declined during the study period, but was highest in 1993. The segmented regression models showed that the age-standardised mortality rate for compound paracetamol dropped less after the regulations (p = 0.012) but declined more rapidly afterward (p = 0.031). However, age-standardised rates for aspirin and antidepressants fell in a similar way to paracetamol after the regulations. Nondrug poisoning suicide declined at a similar rate to paracetamol after the regulations were introduced. CONCLUSIONS: Introduction of regulations to limit availability of paracetamol coincided with a decrease in paracetamol-poisoning mortality. However, fatal poisoning involving aspirin, antidepressants, and to a lesser degree, paracetamol compounds, also showed similar trends. This raises the question whether the decline in paracetamol deaths was due to the regulations or was part of a wider trend in decreasing drug-poisoning mortality. We found little evidence to support the hypothesis that the 1998 regulations limiting pack size resulted in a greater reduction in poisoning deaths involving paracetamol than occurred for other drugs or nondrug poisoning suicide.

Alcohol-related deaths by occupation, England and Wales, 2001-05.

This article continues a long tradition of examining alcohol-related deaths by occupation in England and Wales. Results are presented for men and women which show those occupations with the highest and lowest indicators of alcohol-related mortality in 2001-05. For both sexes, many of the occupations with the highest alcohol-related mortality were found among those working in the drinks industry, including publicans and bar staff. Low indicators of alcohol-related deaths were found for men who worked as farmers and drivers, and women who worked with children.

Tends in avoidable mortality in England and Wales, 1993-2005.

Avoidable mortality is a major public health concern but there has been little consensus among researchers on how it should be defined and reported. In this article two definitions of avoidable mortality are considered. These are used to present trends in avoidable deaths in England and Wales from 1993 to 2005, using two statistical indicators of mortality. Analysis of both definitions shows a substantial decline in causes of mortality that are considered amenable to medical intervention over this period. This article discusses which mortality indicator is most appropriate for measuring avoidable deaths, and highlights key issues in developing a National Statistics definition of avoidable mortality.

Trends and geographical variations in alcohol-related deaths in the United Kingdom, 1991-2004.

Alcohol-related deaths in the UK increased substantially between 1991 and 2004, from 4144 to 8221. Overall rates increased in all parts of the UK. There were, however, large differences in rates between countries and regions. This article presents these differences and also looks at patterns of alcohol-related mortality by deprivation within England and Wales. The article considers changes over time for males and females and for different age groups.

Association between availability of heroin and methadone and fatal poisoning in England and Wales 1993-2004.

BACKGROUND: The UK heroin market is the biggest in Europe and approximately 70% of heroin deaths are due to fatal poisoning. Methadone treatment for heroin addiction in the UK, the 'British system', is unique as it is largely provided by General Practitioners. METHODS: The Office for National Statistics provided data on deaths, the Home Office provided law enforcement data on drug seizures and the Department of Health data on prescriptions. For methadone treatment we calculated the death rate per 1000 patient years. We used Spearman's rank correlation to assess the association between illicit drug seizures for heroin and methadone and deaths. RESULTS: Between 1993 and 2004 there were 7072 deaths involving heroin/morphine (86% males) and 3298 deaths involving methadone (83% male). From 1993-1997, directly age-standardized mortality rates for males were similar for both drugs, increasing from approximately 5 to 15 per million. Mortality rates for heroin continued to increase until 2000, subsequently decreasing from 30 to 20 per million by 2003, and rising again to 24 per million in 2004. In contrast, mortality rates for methadone decreased between 1997 and 2004 to just above 1993 levels. Among females the mortality rate for both drugs was lower than for males throughout the study period, remaining relatively stable. Methadone deaths per 1000 patient years remained similar between 1993 and 1997, after which they fell by three quarters. For both heroin/morphine and methadone, deaths were strongly associated with seizures (Spearmans' coefficient for males: heroin, P = 0.95, P < 0.001 and methadone, P = 0.83, P = 0.0013). CONCLUSIONS: Our study suggests the 'British System' can deliver substantial expansion of treatment without increased mortality risk. The fall in heroin/morphine deaths since 2000 may also be an indication of success of increasing methadone treatment. Data on mortality risk is needed to determine whether increased methadone treatment has reduced drug-related deaths.

Trends in mortality from Alzheimer's disease, Parkinson's disease and dementia, England and Wales, 1979-2004.

In this article we present trends in mortality from Alzheimer's disease, Parkinson's disease and dementia in England and Wales from 1979 to 2004. We describe the impact of mortality coding changes on the underlying cause of death, particularly the introduction of ICD-10 in 2001. We present rates for all mentions of the conditions on death certificates to interpret trends better. Mortality rates for the three conditions showed varying trends over the time period examined. Between 1985 and 2004, Alzheimer's disease showed a dramatic increase. Trends in mentions of dementia differed between males and females, with rates being relatively stable among males, but increasing among females. Rates for Parkinson's disease declined over this period.

Trends in injury and poisoning mortality using the ICE on injury statistics matrix, England and Wales, 1979-2004.

This article shows trends in injury and poisoning mortality in England and Wales using a matrix of mechanism (e.g. fall, fire) by intent (e.g. accident, suicide) developed by the International Collaborative Effort (ICE) on injury statistics. Overall injury and poisoning mortality rates have declined for both males and females. Declines were greatest during the 1980s and early 1990s, with rates falling only slightly since. Rates were generally higher for males and were highest in the elderly. Transport death rates declined substantially. Death rates from falls declined to the mid 1990s but then increased. There were increases in death rates from drug abuse/dependence in both sexes and in homicide rates among males.

Mortality by deprivation and cause of death in England and Wales, 1999-2003.

The relationship between deprivation and mortality is long established and many studies report higher death rates in more deprived areas. This article examines recent patterns of mortality and deprivation and illustrates these for leading causes of death. Results are considered by age group, sex and region. Mortality rates increased with deprivation for both sexes but the relationship was generally stronger for males. The strongest positive relationships with deprivation were mostly found for smoking-related causes. Those living in the least deprived areas had similar mortality rates, independent of region. There was more geographical variation in mortality for those in the most deprived areas with highest rates generally in the north.

Trends in premature mortality in England and Wales, 1950-2004.

Premature mortality is a major public health concern but there has been little consensus among researchers on how it should be defined and reported. In this article four means of measuring early deaths are considered using four different age thresholds to define prematurity. Using these four indicators, trends in premature mortality are reported for England and Wales from 1950 to 2004. All measures show that, however 'premature' is defined, levels of premature mortality have decreased markedly over time. This article discusses which mortality indicator and age threshold would be most appropriate for a measure of premature mortality for use in national mortality statistics for England and Wales.

The impact of introducing ICD-10 on analysis of respiratory mortality trends in England and Wales.

This article examines the impact of the introduction of ICD-10 on respiratory disease mortality statistics in England and Wales, specifically focussing on pneumonia, chronic lower respiratory diseases, and influenza. The main changes are highlighted and the article explains how figures can be adjusted to take account of these changes so that trends over time can be analysed. The number of deaths assigned to the respiratory disease chapter of the ICD as a whole decreased by 22 per cent as a result of the introduction of ICD-10. Although it is not usually recommended that comparability ratios from the CD-10 bridge-coding study are used to adjust rates prior to 1993, our analysis shows that unadjusted data for 1984 to 1992 can be used to examine longer time trends for respiratory diseases as a whole.

Trends in deaths related to drug misuse in England and Wales, 1993-2004.

In this article we report trends in deaths related to drug misuse in England and Wales from 1993 to 2004, looking particularly at the period between 1999 and 2004, for which there was a Government target to reduce these deaths by 20 per cent. Although there was an overall decline in deaths related to drug misuse between 1999 and 2004, the percentage reduction, at 9 per cent, was less than the Government target. There was an increase in deaths between 2003 and 2004, largely accounted for by deaths involving heroin/methadone and morphine. Mortality rates were highest in young adults and an increase in mortality rates within this group appears to have been the driver behind rising mortality trends during the 1990s.