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Upper gastrointestinal haemorrhage and deprivation: a nationwide cohort study of health inequality in hospital admissions
  1. Colin J Crooks1,2,
  2. Joe West1,2,
  3. Tim R Card1,2,3
  1. 1Division of Epidemiology and Public Health, The University of Nottingham, Nottingham City Hospital, Nottingham, UK
  2. 2Nottingham Digestive Diseases Centre National, Institute for Health Research Biomedical Research Unit, Queen's Medical Centre, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
  3. 3Sherwood Forest Hospitals National Health Service Trust, Mansfield, UK
  1. Correspondence to Colin J Crooks, Division of Epidemiology and Public Health, The University of Nottingham, Clinical Sciences Building 2, Nottingham City Hospital, NG5 1PB, UK; colin.crooks{at}


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.

  • Haemorrhage
  • mortality
  • hospitalization
  • incidence
  • socioeconomic factors
  • epidemiology
  • coeliac disease
  • clinical trials
  • medical statistics
  • IBD
  • inflammatory bowel disease
  • Helicobacter pylori
  • gastric cancer
  • gastritis
  • acid-related diseases
  • non-ulcer dyspepsia
  • genetic polymorphisms
  • gastric neoplasia
  • bleeding peptic ulcer
  • bleeding
  • gastrointestinal bleeding
  • oesophageal varices

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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  • Funding Colin Crooks is a research fellow supported by a Medical Research Council fellowship. Tim Card is a clinical associate professor and a consultant gastroenterologist supported by a Walport senior lectureship. Joe West is a clinical associate professor and a consultant gastroenterologist supported by an National Institute for Health Research (NIHR) clinician scientist fellowship. These funding bodies had no role in the collection, analysis or interpretation of data.

  • Competing interests The only competing interest is that Tim R Card is married to an employee of AstraZeneca. Otherwise, there are no potential competing interests to declare.

  • Ethical approval Ethical approval was obtained through the Database Monitoring Subgroup and the Office of National Statistics Microdata Release Panel as part of the standard Hospitals Episode Statistics approval process.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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