Does a medical home influence the effect of low birthweight on health outcomes?

The objective of this study was to investigate the possible modifying effect of medical home on the association between low birthweight and children's health outcomes. The analytic sample included children 5 years and under from the 2007 National Survey of Children's Health whose mothers were the primary respondents and who had non-missing covariate information (n = 19,356). Controlling for sociodemographic factors, logistic and ordinal regression models estimated the presence of developmental, mental/behavioral or physical health outcomes, condition severity, and health status by birthweight, medical home, and their interaction. Prevalence estimates of physical, developmental, mental/behavioral and severe conditions among those with any conditions as well as fair/poor overall health were 8.9, 6.8, 2.4, 41.6, and 2.5 %, respectively. Overall, low compared to normal birthweight children had a higher prevalence of physical and developmental conditions and fair/poor health (15.2 vs. 8.3 %, 11.1 vs. 6.4 %, 4.5 vs. 2.3 %, respectively). Medical home did not significantly modify the effect of birthweight on health outcomes; however, prevalence of all outcomes was higher for children without a medical home. Adjusted models indicated that low birthweight children were almost twice as likely as normal birthweight children to have a physical or developmental condition and poorer overall health, regardless of having a medical home. Having a medical home was associated with equally improved health outcomes among normal and low birthweight children. Adequacy and frequency of medical home care should be investigated further, especially among low birthweight children.     

Why are the low birthweight rates in Brazil higher in richer than in poorer municipalities? Exploring the epidemiological paradox of low birthweight

Socio-economic disadvantage is usually associated with low birthweight (LBW). However, it has been shown that Mexican Americans, despite being economically less advantaged, present LBW rates that are similar to or lower than those found among white women in the US. This fact has been called 'the epidemiological paradox of low birthweight'. Natality data from Brazil revealed the existence of a similar paradox: LBW rates are higher in more developed than in less developed regions within the country. In this study, data from two population-based cohort studies carried out in the nineties, including 2439 births in Sao Luis, a poor city in north-eastern Brazil, and 2839 births in Ribeirao Preto, a socio-economically well-off city in south-eastern Brazil, were used to explore this paradox. The method proposed by Wilcox and Russell and a graphic analysis of the frequency distribution of birthweight according to gestational age were used to provide indirect information about possible gestational age misclassification. Contrary to expectations, the LBW rate was higher in Ribeirao Preto than in Sao Luis (10.7 vs. 7.6%, P <0.001), while preterm birth (PTB) rate (12.7 vs. 12.1%, P=0.520) and percentage of small-for-gestational-age (SGA) infants (12.5 vs. 13.5%, P=0.290) were similar for the two cities. However, SGA rate among preterm infants was higher in Ribeirao Preto (16.4 vs. 9.8%, P=0.014). A bimodal distribution of birthweight was observed for children with less than 32 weeks in Sao Luis. As estimated by the Wilcox and Russell method, the residual distribution was greater in Ribeirao Preto than in Sao Luis (3.4 vs. 2.4%). Part of the LBW paradox observed for the two cities was due to the higher PTB rate and higher number of preterm SGA infants in Ribeirao Preto. Factors such as greater medical intervention in preterm newborns close to the end of pregnancy in more developed municipalities, artefacts in the determination of gestational age, and the under-registration of livebirths and registration of livebirths as stillbirths in less developed municipalities may explain why LBW rates in Brazil are higher in richer than in poorer municipalities.     

Does the pattern of educational inequalities in smoking in Western Europe depend on the choice of survey?

Objectives

Smoking rates vary according to socioeconomic group. We investigated whether patterns of educational inequalities in smoking prevalence differ across three major European surveys.

Methods

Data on smoking came from National Health Interview Surveys (NHIS), the European Community Household Panel (ECHP) and the Eurobarometer (EB). We calculated prevalence ratios by education. We controlled for sex, country, data source and age. We used likelihood ratio tests to determine whether inequalities in each country differed between surveys and whether the association of education and smoking across countries was the same in different surveys.

Results

Smoking prevalence tended to be lower in the ECHP than in both other surveys, and was highest in the EB. The pattern of inequalities in smoking also differed between surveys. Statistically significant differences between surveys were found mainly in Southern Europe, where EB-based prevalence ratios often deviated from those in the other two surveys.

Conclusions

Relative inequalities in smoking prevalence depend on the survey used. Our results suggest that the NHIS and the ECHP are more reliable sources of information on educational inequalities in smoking than the EB.     

Does the effect of PM10 on mortality depend on PM nickel and vanadium content? A reanalysis of the NMMAPS data

BACKGROUND: Lack of knowledge regarding particulate matter (PM) characteristics associated with toxicity is a crucial research gap. Short-term effects of PM can vary by location, possibly reflecting regional differences in mixtures. A report by Lippmann et al. [Lippmann et al., Environ Health Perspect 114:1662-1669 (2006)] analyzed mortality effect estimates from the National Morbidity, Mortality, and Air Pollution Study (NMMAPS) for 1987-1994. They found that average concentrations of nickel or vanadium in PM2.5 (PM with aerodynamic diameter < 2.5 microm) positively modified the lag-1 day association between PM10 and all-cause mortality. OBJECTIVE: We reestimated the relationship between county-specific lag-1 PM10 (PM with aerodynamic diameter < 10 microm) effects on mortality and county-specific nickel or vanadium PM2.5 average concentrations using 1987-2000 effect estimates. We explored whether such modification is sensitive to outliers. METHODS: We estimated long-term average county-level nickel and vanadium PM2.5 concentrations for 2000-2005 for 72 U.S. counties representing 69 communities. We fitted Bayesian hierarchical regression models to investigate whether county-specific short-term effects of PM10 on mortality are modified by long-term county-specific nickel or vanadium PM2.5 concentrations. We conducted sensitivity analyses by excluding individual communities and considering log-transformed data. RESULTS: Our results were consistent with those of Lippmann et al. However, we found that when counties included in the NMMAPS New York community were excluded from the sensitivity analysis, the evidence of effect modification of nickel or vanadium on the short-term effects of PM10 mortality was much weaker and no longer statistically significant. CONCLUSIONS: Our analysis does not contradict the hypothesis that nickel or vanadium may increase the risk of PM to human health, but it highlights the sensitivity of findings to particularly influential observations.     

Does government provision of healthcare explain the relationship between income inequality and low birthweight?

This paper estimates the relationship between state and county income inequality and low birthweight (LBW) in the U.S. It examines whether more unequal societies are also less healthy because such societies have lower investment in population health. The model includes an extensive list of community and individual controls and community fixed-effects. Results show that unequal states in fact have greater social investments, and absent these investments children born in such states would be more likely to be LBW. Using alternate measures of inequality reveals that income inequality in the upper tail of the income distribution is not related to LBW; but inequality in the lower tail of the income distribution is associated with increased LBW where the supply of healthcare mitigates the effect of income inequality. Consistent with prior findings, county income inequality is not significantly related to LBW.     

How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence

This is an overview of evidence of the effectiveness of antenatal care in relation to maternal mortality and serious morbidity, focused in particular on developing countries. It concentrates on the major causes of maternal mortality, and traces their antecedent morbidities and risk factors in pregnancy. It also includes interventions aimed at preventing, detecting or treating any stage along this pathway during pregnancy. This is an updated and expanded version of a review first published by the World Health Organization (WHO) in 1992. The scientific evidence from randomised controlled trials and other types of intervention or observational study on the effectiveness of these interventions is reviewed critically. The sources and quality of available data, and possible biases in their collection or interpretation are considered. As in other areas of maternal health, good-quality evidence is scarce and, just as in many aspects of health care generally, there are interventions in current practice that have not been subjected to rigorous evaluation. A table of antenatal interventions of proven effectiveness in conditions that can lead to maternal mortality or serious morbidity is presented. Interventions for which there is some promising evidence, short of proof, of effectiveness are explored, and the outstanding questions formulated. These are presented in a series of tables with suggestions about the types of study needed to answer them.     

How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence

This is an overview of evidence of the effectiveness of antenatal care in relation to maternal mortality and serious morbidity, focused in particular on developing countries. It concentrates on the major causes of maternal mortality, and traces their antecedent morbidities and risk factors in pregnancy. It also includes interventions aimed at preventing, detecting or treating any stage along this pathway during pregnancy. This is an updated and expanded version of a review first published by the World Health Organization (WHO) in 1992. The scientific evidence from randomised controlled trials and other types of intervention or observational study on the effectiveness of these interventions is reviewed critically. The sources and quality of available data, and possible biases in their collection or interpretation are considered. As in other areas of maternal health, good-quality evidence is scarce and, just as in many aspects of health care generally, there are interventions in current practice that have not been subjected to rigorous evaluation. A table of antenatal interventions of proven effectiveness in conditions that can lead to maternal mortality or serious morbidity is presented. Interventions for which there is some promising evidence, short of proof, of effectiveness are explored, and the outstanding questions formulated. These are presented in a series of tables with suggestions about the types of study needed to answer them.     

Does the structure of medical services affect the proportion of death in hospitals? An ecological analysis in the mobility regions of Switzerland?

Zusammenfassung Fragestellung Vor dem Hingtergrund der Diskussion über Massnahmen zum Abbau von überkapazit?ten im Gesundheitswesen untersuchten wir die Bedeutung von medizinischen Versorgungsstrukturen und Dienstleistungen für die Inanspruchnahme des Spitals unmittelbar vor dem Tode. Methoden Aufgrund der Angaben zum Sterbeort aus der Sterbefallstatistik ermittelten wir in einem ?kologischen Design für jede der 106 MS-Regionen der Schweiz die Anteile der Sterbef?lle im Spital von Personen ab 65-j?hrig in den Jahren 1979 bis 1980. Ergebnisse Diese Anteile variierten zwischen 27% und 81%. Trotz M?ngeln in den Daten zur station?ren und ambulanten Versorgungsstruktur konnte mittels einer multivariaten Regression mehr als die H?lfte der Varianz erkl?rt werden. Unsere Ergebnisse zeigen, dass der Anteil von Sterbef?llen im Spital umso tiefer ist, je mehr Konsultationen durch Grundversorger durchgeführt wurden, je mehr Alters-oder Pflegeheimbetten und je weniger Spitalbetten in den Regionen vorhanden waren (alle Angaben pro Einwohner gerechnet). Schlussfolgerungen In der Versorgungsplanung sollten solche systematischen Zusammenh?nge zwischen Angebot und Inanspruchnahme der station?ren sowie der ambulanten Versorgung berücksichtigt werden. Wir empfehlen, Unterschiede zwischen den Regionen in Angebot und Ergebnis medizinischer Leistungen regelm?ssig mit den jeweils aktuellsten Daten zu vergleichen.

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Does the structure of medical services affect the proportion of deaths in hospitals? An ecological analysis in the mobility regions of Switzerland

Summary Objectives With the discussion about measures to reduce over-capacities in the health services in mind, we examined the influence of medical supply structures and services on hospital utillisation directly before death. Methods Based on the specification of the place of dying from the death certificates, we determined the proportions of deaths in hospitals in an ecological study. We analysed deaths of persons above age 65 in each of the 106 mobility regions of Switzerland in the years 1979 to 1980. Results The proportion of deaths occuring in hospitals varied between 27% and 81%. Despite missing data regarding stationary and ambulatory care services, more than half of the variance could be explained by means of a multivariate regression analysis. Our results imply an inverse relation between the proportion of deaths in the hospital and the number of consultations provided by primary care physicians, as well as the number of nursing home beds. Further, we observe a direct relation to the number of hospital beds in a region. All indicators are calculated per inhabitant. Conclusions In health care supply planning, such systematic associations should be taken into account. We recommend to analyse regularly interregional differences in supply and outcome of medical performances with the best available data.

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Résumé Objectifs Dans le contexte de la discussion sur la reduction des surcapacités dans les services de santé nous avons examiné l'influence des structures et des services d'approvisionnement médicaux pour le recours à l'h?pital directement avant la mort. Méthodes Sur la base du certificat de décès où l'endroit de mort est enregistré, nous avons déterminé les proportions de décès à l'h?pital des personnes dans une analyse écologique pour chacune des 106 régions MS de la Suisse à partir de 65 ans de 1979 à 1980. Résultats Ces proportions ont varié entre 27% et 81%. Malgré la carence de les données en matière de approvisionnement stationnaire et ambulatoire, plus de la moitié de la variance est expliquée par une analyse de régression multivarie. Nos résultats démontrent que la proportion des décès à l'h?pital dans une région est d'autant plus basseque les consultations ont été exécutées par les médecins de premier recours, que plus de lits de maison de retraite ou le moins les lits d'h?pital étaient disponibles dans la région (tout les indicateurs calculé par habitant). Conclusions Dans la planification des services de santé de telles associations devraient être prises en considération. Nous recommandons de répéter régulièrement des analyses écologiques pour comparer des différences interrégionales entre l'offre et résultat de performances médicales avec des données mises à jour.

     

Is mortality from heart failure increasing in Australia? An analysis of official data on mortality for 1997-2003.

OBJECTIVE: To assess whether trends in mortality from heart failure (HF) in Australia are due to a change in awareness of the condition or real changes in its epidemiology. METHODS: We carried out a retrospective analysis of official data on national mortality data between 1997 and 2003. A death was attributed to HF if the death certificate mentioned HF as either the underlying cause of death (UCD) or among the contributory factors. FINDINGS: From a total of 907 242 deaths, heart failure was coded as the UCD for 29 341 (3.2%) and was mentioned anywhere on the death certificate in 135 268 (14.9%). Between 1997 and 2003, there were decreases in the absolute numbers of deaths and in the age-specific and age-standardized mortality rates for HF either as UCD or mentioned anywhere for both sexes. HF was mentioned for 24.6% and 17.8% of deaths attributed to ischaemic heart disease and circulatory disease, respectively, and these proportions remained unchanged over the period of study. In addition, HF as UCD accounted for 8.3% of deaths attributed to circulatory disease and this did not change materially from 1997 to 2003. CONCLUSION: The decline in mortality from HF measured as either number of deaths or rate probably reflects a real change in the epidemiology of HF. Population-based studies are required to determine accurately the contributions of changes in incidence, survival and demographic factors to the evolving epidemiology of HF.     

What is driving the black–white difference in low birthweight in the US?

This is a first effort to quantify the contribution of different factors in explaining racial difference in low birthweight rate (LBW). Mother's health, child characteristics, prenatal care, socioeconomic status (SES), and the socioeconomic and healthcare environment of mother's community are important inputs into the birthweight production function, and a vast literature has delved into obtaining causal estimates of their effect on infant health. What is unknown is how much of the racial gap in LBW is explained by all these inputs together. We apply a nonlinear extension of the Oaxaca-Blinder method proposed by Fairlie to decompose this gap into the portion explained by differences in observed characteristics and the portion that remains unexplained. Data are obtained from several sources in order to capture as many observables as possible, although the primary data source is the Natality Detail Files. Results show that of the 6.8 percentage point racial gap in LBW, only 0.9-1.9 points are explained by white-black differences in endowments across those measures, and of those endowments, most of the gap in LBW is explained by the differences in SES. The unexplained difference is attributed to racial differences in the returns to or the marginal product of investments in infant health.     

Does the ethical appropriateness of paying donors depend on what body parts they donate?

The idea of paying donors in order to make more human bodily material available for therapy, assisted reproduction, and biomedical research is notoriously controversial. However, while national and international donation policies largely oppose financial incentives they do not treat all parts of the body equally: incentives are allowed in connection to the provision of some parts but not others. Taking off from this observation, I discuss whether body parts differ as regards the ethical legitimacy of incentives and, if so, why. I distinguish two approaches to this issue. On a “principled” approach, some but not all body parts are inherently special in a way that proscribes payment. On a “pragmatic” approach, the appropriateness of payment in relation to a specific part must be determined through an overall assessment of e.g. the implications of payment for the health and welfare of providers, recipients, and third parties, and the quality of providers’ consent. I argue that the first approach raises deep and potentially divisive questions about the good life, whereas the second approach invokes currently unsupported empirical assumptions and requires difficult balancing between different values and the interests of different people. This does not mean that any attempt to distinguish between body parts in regard to the appropriateness of payment necessarily fails. However, I conclude, any plausible such attempt should either articulate and defend a specific view of the good life, or gather relevant empirical evidence and apply defensible principles for weighing goods and interests.     

Does military service damage females? An analysis of medical discharge data in the British armed forces

There is anecdotal and some scientific evidence that females in military service experience an excess of work-related injuries, compared with males. To investigate this more fully, we analysed data collected routinely by the Defence Analytical Services Agency on medical discharges in male and female personnel in the British armed forces. We found that for all disease and injury categories of medical discharge there is a statistically significant excess in females; this disparity is particularly marked for discharges on account of injury [relative risk (RR) = 1.65, 95% confidence interval (95% CI) = 1.30-2.10] and musculoskeletal disease (RR = 3.34, 95% CI = 2.75-4.06). Royal Navy females are eight times more likely (RR = 7.92, 95% CI = 3.03-20.66) and Army females seven times more likely (RR = 6.53, 95% CI = 2.60-16.42) than Royal Air Force females to be medically discharged on account of injury. Over the period 1993-1996, there was a statistically significant increase in the rate of medical discharge for both musculoskeletal disease and injury in female personnel in the British armed forces. During the period 1996-2000, a marked gender differential was maintained, but the rate of increase in females reached a plateau. We concur with previous investigators that mixed-sex training imposes particular ergonomic stresses on females and that it is a major risk factor for overuse injury. We discuss other possible explanations for the marked gender differential in medical discharge rates in the military. Some changes to training programmes are now being introduced to correct this health inequality, but further interventions are needed. Modifications to training programmes must be audited systematically and candidate interventions tested through randomized controlled trials.     

Does reporting behaviour bias the measurement of social inequalities in self-rated health in Indonesia? An anchoring vignette analysis

Purpose

Studies on self-rated health outcomes are fraught with problems when individuals’ reporting behaviour is systematically biased by demographic, socio-economic, or cultural factors. Analysing the data drawn from the Indonesia Family Life Survey 2007, this paper aims to investigate the extent of differential health reporting behaviour by demographic and socio-economic status among Indonesians aged 40 and older (\(N = 3735\)).

Methods

Interpersonal heterogeneity in reporting style is identified by asking respondents to rate a number of vignettes that describe varying levels of health status in targeted health domains (mobility, pain, cognition, sleep, depression, and breathing) using the same ordinal response scale that is applied to the self-report health question. A compound hierarchical ordered probit model is fitted to obtain health differences by demographic and socio-economic status. The obtained regression coefficients are then compared to the standard ordered probit model.

Results

We find that Indonesians with more education tend to rate a given health status in each domain more negatively than their less-educated counterparts. Allowing for such differential reporting behaviour results in relatively stronger positive education effects.

Conclusion

There is a need to correct for differential reporting behaviour using vignettes when analysing self-rated health measures in older adults in Indonesia. Unless such an adjustment is made, the salutary effect of education will be underestimated.

     

Is the self of the infant preserved in the adult?

Medicine, Health Care and Philosophy - What does a confrontation between philosophy and psychoanalysis look like? My task is a philosophical investigation of a psychoanalytic concept. Thus, I offer...     

Variations in infant mortality rates among municipalities in the state of Ceará, Northeast Brazil: an ecological analysis.

BACKGROUND: Infant mortality rates vary substantially among municipalities in the State of Ceará, from 14 to 193 per 1000 live births. Identification of the determinants of these differences can be of particular importance to infant health policy and programmes in Brazil where local governments play a pivotal role in providing primary health care. METHODS: Ecological study across 140 municipalities in the State of Ceará, Brazil. RESULTS: To determine the interrelationships between potential predictors of infant mortality, we classified 11 variables into proximate determinants (adequate weight gain and exclusively breastfeeding), health services variables (prenatal care up-to-date, participation in growth monitoring, immunization up-to-date, and decentralization of health services), and socioeconomic factors (female literacy rate, household income, adequate water supply, adequate sanitation, and per capita gross municipality product), and included the variables in each group simultaneously in linear regression models. In these analyses, only one of the proximate determinants (exclusively breastfeeding (inversely), R2 = 9.3) and one of the health services variables (prenatal care up-to-date (inversely), R2 = 22.8) remained significantly associated with infant mortality. In contrast, female literacy rate (inversely), household income (directly) and per capita GMP (inversely) were independently associated with the infant mortality rate (for the model including the three variables R2 = 25.2). Finally, we considered simultaneously the variables from each group, and selected a model that explained 41% of the variation in infant mortality rates between municipalities. The paradoxical direct association between household income and infant mortality was present only in models including female illiteracy rate, and suggests that among these municipalities, increases in income unaccompanied by improvements in female education may not substantially reduce infant mortality. The lack of independent associations between inadequate sanitation and infant mortality rates may be due to the uniformly poor level of this indicator across municipalities and provides no evidence against its critical role in child survival. CONCLUSIONS: These results suggest that promotion of exclusive breastfeeding and increased prenatal care utilization, as well as investments in female education would have substantial positive effects in further reducing infant mortality rates in the State of Ceará.     

The analysis of trends in induced abortion in Japan—An increasing consequence among adolescents

Objectives  The purpose of this study was to examine trends in induced abortions in Japan. Methods  The Ministry of Health, Labour, and Welfare compiled data on induced abortions, live births, and the population of women aged 15–49 years. These data were provided by 47 prefectures in Japan and were used to examine the number of induced abortions and various characteristics of women who received abortions from 1955 through 2001. We examined abortion numbers, abortion ratios (number of legal abortions per 1,000 live births), and abortion rates (number of legal abortions per 1,000 women aged 15–49). We were particularly interested in examining abortion trends among adolescents. These trends were also compared to those in the United States. Results  A total of 341,588 legal induced abortions were reported in Japan in 2001, representing a 2.5% increase from 1998 to 2001. From 1998 to 2001, the abortion ratio (292) increased by 5.4%; from 1996 through 2001, the abortion rate (11.8) increased by 8.3%. Women less than 20 years old contributed most to these increases. In 1999, the abortion ratio among Japanese adolescents was 5.7 times as high as the ratio among U.S. adolescents, while the abortion rate among U.S. adolescents was 1.8 times as high as the rate among Japanese adolescents. Conclusions  Recent increases in induced abortion among Japanese women may be related to several factors, including changes in sexual behavior among adolescents and a decline in their use of contraceptives. More appropriate educational efforts and interventions are needed to prevent unintended pregnancies.     

Where do pharmaceuticals on the market originate? An analysis of the informal drug supply in Cotonou,Benin

This anthropological study, conducted in Cotonou, Benin between 2005 and 2007, investigates the informal pharmaceuticals market. It was carried out through a long-term participant observation of informal vendors and semi-directive and unstructured interviews. A classification of products sold in the informal market was developed. The fact that a high percentage of them come from Anglophone countries near Benin (Nigeria and Ghana) led to a comparison of the sources of pharmaceutical supply in these three countries as well as their current legislation regarding pharmaceutical distribution. Our study results highlight a new understanding of the phenomenon of the informal market. Nigeria and Ghana rely on a liberal pharmaceutical distribution system with little intervention from public authorities. Conversely, the government maintains considerable influence over pharmaceutical distribution in Benin. Hence, the differences between these three countries in terms of variety of supply sources and flexibility of access to drugs are understood through an investigation of Benin's informal market. Therefore, it appears that beyond issues concerning the quality of the pharmaceuticals, this phenomenon illustrates a kind of liberalization of pharmaceutical distribution and the ensuing public health issues.     

Does the severity of radionuclide-induced skeletal malignancy depend upon radiation dose?

The severity of effect as a function of skeletal radiation dose for induced skeletal malignancy was investigated among a relatively large group of beagle dogs singly injected as young adults with soluble radionuclide. Bone-seeking radionuclides considered were 239Pu, 226Ra, 228Ra, 224Ra, 228Th, and 90Sr. Variables included skeletal radiation dose, tumor growth rate, maximum tumor volume, sex of the animals, growth period of the tumor, degree of calcification of the tumor, skeletal location of the tumor, year of death, and occurrence of metastases. Except for a significant relationship between tumor volume and metastatic process and for growth rate and tumor volume, no significant dependence of any two of these factors could be established. It is concluded from available data on skeletal malignancies among beagles exposed to bone-seeking radionuclides that the severity of the disease is not dependent upon skeletal radiation dose.     

Which is the best deprivation predictor of foetal and infant mortality rates?

This study investigates which, if any, population-based indicator of deprivation best predicts foetal and infant mortality rates in England. For the year 1995, the deprivation levels of 364 English Local Authorities were compared; using the three commonly used indicators, Jarman score, Townsend score and percentage unemployed. The predictive value of these for stillbirth, neonatal and infant mortality rates was then calculated. The three deprivation indicators were highly inter-correlated (r=0.866-0.924). For each mortality rate, the correlation with deprivation did not differ significantly for the three indicators of deprivation. We conclude, when comparing these outcomes in different areas of England, that any of the three deprivation indicators may be used to adjust for deprivation.