Upper gastrointestinal haemorrhage and deprivation: a nationwide cohort study of health inequality in hospital admissions

Abstract

Objective: Inequalities in health are well recognized in cardiovascular disease and cancer, but in comparison, we have minimal understanding for upper gastrointestinal bleeding. Since furthering our understanding of such inequality signposts preventable disease, we investigated in detail the association between upper gastrointestinal bleeding and socioeconomic status.

Design: Population-based cohort study.

Setting: All English National Health Service hospitals.

Population: English adult population, 1 January 2001 to 31 December 2007.

Exposure measures: Deprivation scores defined according to quintiles of neighbourhood areas ranked by the Indices of Multiple Deprivation for England 2007.

Outcome measures: Rates of all adult admissions coded with a primary diagnosis of upper gastrointestinal bleed were analysed by deprivation quintile and adjusted for age, sex, region and year using Poisson regression.

Results: The annual hospitalization rate for non-variceal haemorrhage was 84.6 per 100,000 population (95% CI 83.5 to 84.1; n=237,145), and for variceal haemorrhage, it was 2.83 per 100,000 population (95% CI 2.87 to 2.99; n=8291). There was a twofold increase in the hospitalization rate ratio for non-variceal haemorrhage from the most deprived areas compared to the least deprived (2.00, 95% CI 1.98 to 2.03). The ratio for variceal haemorrhage was even more pronounced (2.49, 95% CI 2.32 to 2.67). Inequality increased over the study period (non-variceal p<0.0001, variceal p=0.0068), and adjusting for age and sex increased the disparity between deprived and affluent areas. Case fatality did not have a similar socioeconomic gradient.

Conclusion: Both variceal and non-variceal haemorrhage hospitalization rates increased with deprivation, and there was a similar gradient in all areas of the country and in all age bands. The existence of such a steep gradient suggests that there are opportunities to reduce hospitalizations down to the low rates seen in the most affluent, and thus, there is the potential to prevent almost 10,000 admissions and over 1000 deaths a year.

Figure 1

Flow chart of exclusions from study.

Figure 2

Hospitalization rates of upper gastrointestinal haemorrhage by Regional Government Office. (A) Non-variceal haemorrhage. (B) Variceal haemorrhage.

Figure 3

Average annual non-variceal hospitalization rate by quintiles of the Indices of Multiple Deprivation 2007 for each government office.

Figure 4

Average annual non-variceal hospitalization rate by quintiles of the Indices of Multiple Deprivation 2007 for each age band.

Figure 5

Age- and sex-adjusted hospitalization RRs for non-variceal haemorrhage by year for each quintile of deprivation compared to the least deprived quintile.