John, Might changes in patterns of foreign travel or related precautions have any effect on the certain infectious and parasitic diseases category? Asking as a layman, not knowing which pathogens are included in this chapter and how many are traditionally encountered overseas vs in the UK.
I would assume so. Over the next couple of weeks I'll be taking each chapter and breaking it down further into code blocks so we get to see the drivers behind the numbers, but I can tell you now that A41 Enterotoxigenic Escherichia coli infection takes first prize at 47% of all deaths, with A09 Cholera, unspecified coming second at 12%.
Thank you for responding John, badly worded by me. But does this mean the team have numbers/data and dates they were used? If so any ideas when can we expect to see publication, (accepting the law moves very slowly)
The Care Quality Commission report into the use of DNACPR was very limited (in my opinion). From memory it considered only a couple of hundred cases, yet over 25,000 died in the first few weeks of Q2 in care homes alone.
It seems to me that the conditions were set to conceal the use and subsequent deaths. Here I’m thinking of, how making Coronavirus a “notifiable disease” whilst almost simultaneously declaring “As of 19 March 2020, COVID-19 is no longer considered to be a high consequence infectious
disease (HCID) in the UK”
Then within a week (26/03/2020) we saw the Chief Coroner issuing guidance that effectively says Covid is a natural cause of death. The effect of which meant, that if it appeared on a death certificate then it wasn’t necessary to refer the death to a coroner’s office. (Unnatural causes are referred). So as Dr John Lee said around this time - “So at a time when accurate death statistics are more important than ever, the rules have been changed in ways that make them less reliable than ever”
They have some truly remarkable detailed data - I've no idea how they managed to wangle it - but it's best if I don't comment further given this is leading to a big legal case.
I expect that if people don't go on holiday and fall off balconies drunk, or drown in swimming pools after taking whacky substances, then this will also reduce stupid deaths.
The study entitled, "Doctors' strikes and mortality: A review," suggests that it's the fact that elective, or non-emergency surgery, tends to stop during a doctors' strike, which seems to be the key factor. It looks like a surprising amount of mortality occurs following this kind of procedure which disappears when elective surgery ceases due to doctors withdrawing their labour. Mortality declined steadily from week one (21 deaths/100,000 population) to weeks six (13) and seven (14), when mortality rates were lower than the averages of the previous five years.
However, as soon as elective surgery resumed, there was a rise in deaths. There were 90 more deaths associated with surgery for the two weeks following the strike in 1976 (ie when doctors went back to work) than there had been during the same period in 1975.
But, unlike Los Angeles, what about the impact of doctors' industrial action where the majority of doctors participate, and the strike lasts several months?
Cunningham and colleagues report on a strike in Jerusalem from 2 March to 26 June 1983 due to a salary dispute between the government and the Israel Medical Association. 8000 of Jerusalem's 11,000 physicians refused to treat patients inside hospitals, though many of them set up separate aid stations where they treated emergency cases for a fee.
Surprisingly, I know someone very well: the mother of a close friend, who went in for hip replacement surgery in June, after many years of declining mobility and pain. Sadly , she didn't make it, a series of medical errors and complications followed, and she eventually died of sepsis in October. Dorothy was a lovely lady, and is survived by her husband, (a retired teacher and councillor), their three daughters and several delightful grandkids.
If it wasn't for that operation, she would probably have lived another ten or more years.
So, how much does the radical drop in elective surgery affect our own mortality rates? Probably quite a lot: how many other Dorothies went untreated over the main pandemic period? How much worse did their condition become due to lengthy waits?
I think we need to examine all cause elective surgery rates since 2019, and then check what happened when the operating theatres got back to speed (I don't even know if they are yet, this has been a shocking winter with some of the worst death rates ever here in Scotland.
Theres a really good new substack here covering Scotland: please join up as Scotland has some really good health statisticians.
Thank you for your important work. The slipperiness of coding may explain some of the synchronous spikes across categories in the ONS data. It perplexes me for instance that Dementia is in a different ICD10 chapter (Mental and behavioural disorders) from Alzheimer’s (Diseases of the nervous system and sense organs).
When a frail elderly person deteriorates and their death is not unexpected, it is a best guess as to what is the underlying cause of death. For example, most people develop a rattly chest at some point in the dying process. Whether we consider that an aspiration pneumonia due to reduced conscious level, a primary or secondary pneumonia, or a sequelae of their dying from frailty, dementia, UTI etc depends on the circumstances, and that can influence the certification. There have been efforts in recent years to improve the consistency of certification to reduce this variability, but it still happens a fair bit.
Do the ONS take the Part 1 underlying cause of death for these statistics? If so then I’m sure there will be similar deaths put under different ICD-10 headings, due to the way the certificate is completed. Examples which I think illustrate this:
1. Person with dementia develops a UTI and subsequently dies:
a. Part 1a Urosepsis 1b UTI 2 Dementia, Type 2 Diabetes = N00-99 XIV. Diseases of the genitourinary system N39 = UTI
b. Part 1a Urosepsis 1b UTI 1c Multi-infarct Dementia 2 Type 2 Diabetes = F00-99 V. Mental and behavioural disorders F01, F03 Dementia
c Part 1a UTI 1b Alzheimer’s = G00-H95 VI-VIII. Diseases of the nervous system and the sense organs G30 Alzheimers Disease
2. Person with Parkinson’s and dementia develops chest symptoms and dies:
a. Part 1a Aspiration pneumonia 1b Severe Parkinson’s Disease and Dementia = G00-H95 VI-VIII. Diseases of the nervous system and the sense organs
b. Part 1a Bronchopneumonia 2 Severe Parkinson’s Disease and dementia = J00-99 X. Diseases of the respiratory system J12-18 Pneumonia
c. Part 1a Influenza 2 Severe Parkinson’s Disease and dementia = J00-99 X. Diseases of the respiratory system J09-11 Influenza
d. Part 1a Covid-19 Part 2 Severe Parkinson’s Disease and dementia = U01-89 XXII. Codes for Special Purposes U07 Covid-19
3. Person with severe frailty gets a flu like illness, then develops cardiac chest pain and dies:
a. Part 1a MI 1b IHD 2 Severe frailty of old age, recent influenza = I00-99 IX. Diseases of the circulatory system I20-25
b. Part 1a MI 1b Covid-19 2 Severe frailty of old age = U01-89 XXII. Codes for Special Purposes U07 Covid-19
c. Part 1a Influenza 1b Severe frailty of old age 2 IHD = Not sure about this one - Severe frailty I think might come under R00-99 XVIII. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.
Many of the Covid-19 deaths would have in previous years been classified under different ICD-10 headings if they had followed Influenza-like illness. However as you have alluded to I suspect there will be other structural/policy reasons to explain the synchronous spikes in wk 15.
A fabulous comment! Coding flips may well explain some of the sync. In an analysis of care home deaths the same spike shows for non-Covid death as well as COVID. I am aware of at least one team meticulously documenting what went on with a view to prosecution.
I heard that old statisticians were broken down by age and sex but I didn’t know they suffered premature tabulation. Looking forward to part 3.
LOL - I couldn't resist putting that in for a giggle. Part 3 was finished a few moments ago and will be published 7am tomorrow!
John, Might changes in patterns of foreign travel or related precautions have any effect on the certain infectious and parasitic diseases category? Asking as a layman, not knowing which pathogens are included in this chapter and how many are traditionally encountered overseas vs in the UK.
I would assume so. Over the next couple of weeks I'll be taking each chapter and breaking it down further into code blocks so we get to see the drivers behind the numbers, but I can tell you now that A41 Enterotoxigenic Escherichia coli infection takes first prize at 47% of all deaths, with A09 Cholera, unspecified coming second at 12%.
If only someone could get hold of the drugs and syringe drivers used in EOL care during this period🤔
That has been meticulously done by a team assessing the legal ramifications.
Thank you for responding John, badly worded by me. But does this mean the team have numbers/data and dates they were used? If so any ideas when can we expect to see publication, (accepting the law moves very slowly)
The Care Quality Commission report into the use of DNACPR was very limited (in my opinion). From memory it considered only a couple of hundred cases, yet over 25,000 died in the first few weeks of Q2 in care homes alone.
It seems to me that the conditions were set to conceal the use and subsequent deaths. Here I’m thinking of, how making Coronavirus a “notifiable disease” whilst almost simultaneously declaring “As of 19 March 2020, COVID-19 is no longer considered to be a high consequence infectious
disease (HCID) in the UK”
Then within a week (26/03/2020) we saw the Chief Coroner issuing guidance that effectively says Covid is a natural cause of death. The effect of which meant, that if it appeared on a death certificate then it wasn’t necessary to refer the death to a coroner’s office. (Unnatural causes are referred). So as Dr John Lee said around this time - “So at a time when accurate death statistics are more important than ever, the rules have been changed in ways that make them less reliable than ever”
Links:
https://www.cqc.org.uk/sites/default/files/20210318_dnacpr_printer-version.pdf
https://www.judiciary.uk/wp-content/uploads/2020/03/Chief-Coroner-Guidance-No.-34-COVID-19_26_March_2020-.pdf
They have some truly remarkable detailed data - I've no idea how they managed to wangle it - but it's best if I don't comment further given this is leading to a big legal case.
Thank you John, I understand.
I recommend reading this to gain further insight
https://architectsforsocialhousing.co.uk/2021/01/27/lies-damned-lies-and-statistics-manufacturing-the-crisis/
Cheers - will take a look after dinner!
Cause #7: External causes of morbidity & mortality
Its a well known fact that doctors bury their mistakes, so if elective surgery falls, then so will deaths.
This also happens when doctors go on strike: deaths fall. https://www.sciencedirect.com/science/article/abs/pii/S0277953608005066#:~:text=The%20general%20expectation%20is%20that%20physician%20strikes%20would,doctors%20go%20on%20strike%2C%20mortality%20rates%20paradoxically%20fall.
I expect that if people don't go on holiday and fall off balconies drunk, or drown in swimming pools after taking whacky substances, then this will also reduce stupid deaths.
The study entitled, "Doctors' strikes and mortality: A review," suggests that it's the fact that elective, or non-emergency surgery, tends to stop during a doctors' strike, which seems to be the key factor. It looks like a surprising amount of mortality occurs following this kind of procedure which disappears when elective surgery ceases due to doctors withdrawing their labour. Mortality declined steadily from week one (21 deaths/100,000 population) to weeks six (13) and seven (14), when mortality rates were lower than the averages of the previous five years.
However, as soon as elective surgery resumed, there was a rise in deaths. There were 90 more deaths associated with surgery for the two weeks following the strike in 1976 (ie when doctors went back to work) than there had been during the same period in 1975.
But, unlike Los Angeles, what about the impact of doctors' industrial action where the majority of doctors participate, and the strike lasts several months?
Cunningham and colleagues report on a strike in Jerusalem from 2 March to 26 June 1983 due to a salary dispute between the government and the Israel Medical Association. 8000 of Jerusalem's 11,000 physicians refused to treat patients inside hospitals, though many of them set up separate aid stations where they treated emergency cases for a fee.
One analysis examined death certificates from several months surrounding the strike period, 16 February-3 September 1983, and from a control period the previous year, 17 February-3 September 1982. Mortality did not increase during or after the strike, even when elective surgery resumed. https://www.psychologytoday.com/us/blog/slightly-blighty/201510/why-do-patients-stop-dying-when-doctors-go-strike
Cracking comments!
Surprisingly, I know someone very well: the mother of a close friend, who went in for hip replacement surgery in June, after many years of declining mobility and pain. Sadly , she didn't make it, a series of medical errors and complications followed, and she eventually died of sepsis in October. Dorothy was a lovely lady, and is survived by her husband, (a retired teacher and councillor), their three daughters and several delightful grandkids.
If it wasn't for that operation, she would probably have lived another ten or more years.
So, how much does the radical drop in elective surgery affect our own mortality rates? Probably quite a lot: how many other Dorothies went untreated over the main pandemic period? How much worse did their condition become due to lengthy waits?
I think we need to examine all cause elective surgery rates since 2019, and then check what happened when the operating theatres got back to speed (I don't even know if they are yet, this has been a shocking winter with some of the worst death rates ever here in Scotland.
Theres a really good new substack here covering Scotland: please join up as Scotland has some really good health statisticians.
https://scottishunityedinburgh.substack.com/p/scotland-mortality-2023-week-2?utm_source=substack&utm_medium=email
Another of the many strands to consider! Here's a fab article by Fenton & Neil...
https://open.substack.com/pub/wherearethenumbers/p/weltanshauung?utm_source=share&utm_medium=android
Thank you for your important work. The slipperiness of coding may explain some of the synchronous spikes across categories in the ONS data. It perplexes me for instance that Dementia is in a different ICD10 chapter (Mental and behavioural disorders) from Alzheimer’s (Diseases of the nervous system and sense organs).
When a frail elderly person deteriorates and their death is not unexpected, it is a best guess as to what is the underlying cause of death. For example, most people develop a rattly chest at some point in the dying process. Whether we consider that an aspiration pneumonia due to reduced conscious level, a primary or secondary pneumonia, or a sequelae of their dying from frailty, dementia, UTI etc depends on the circumstances, and that can influence the certification. There have been efforts in recent years to improve the consistency of certification to reduce this variability, but it still happens a fair bit.
Do the ONS take the Part 1 underlying cause of death for these statistics? If so then I’m sure there will be similar deaths put under different ICD-10 headings, due to the way the certificate is completed. Examples which I think illustrate this:
1. Person with dementia develops a UTI and subsequently dies:
a. Part 1a Urosepsis 1b UTI 2 Dementia, Type 2 Diabetes = N00-99 XIV. Diseases of the genitourinary system N39 = UTI
b. Part 1a Urosepsis 1b UTI 1c Multi-infarct Dementia 2 Type 2 Diabetes = F00-99 V. Mental and behavioural disorders F01, F03 Dementia
c Part 1a UTI 1b Alzheimer’s = G00-H95 VI-VIII. Diseases of the nervous system and the sense organs G30 Alzheimers Disease
2. Person with Parkinson’s and dementia develops chest symptoms and dies:
a. Part 1a Aspiration pneumonia 1b Severe Parkinson’s Disease and Dementia = G00-H95 VI-VIII. Diseases of the nervous system and the sense organs
b. Part 1a Bronchopneumonia 2 Severe Parkinson’s Disease and dementia = J00-99 X. Diseases of the respiratory system J12-18 Pneumonia
c. Part 1a Influenza 2 Severe Parkinson’s Disease and dementia = J00-99 X. Diseases of the respiratory system J09-11 Influenza
d. Part 1a Covid-19 Part 2 Severe Parkinson’s Disease and dementia = U01-89 XXII. Codes for Special Purposes U07 Covid-19
3. Person with severe frailty gets a flu like illness, then develops cardiac chest pain and dies:
a. Part 1a MI 1b IHD 2 Severe frailty of old age, recent influenza = I00-99 IX. Diseases of the circulatory system I20-25
b. Part 1a MI 1b Covid-19 2 Severe frailty of old age = U01-89 XXII. Codes for Special Purposes U07 Covid-19
c. Part 1a Influenza 1b Severe frailty of old age 2 IHD = Not sure about this one - Severe frailty I think might come under R00-99 XVIII. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.
Many of the Covid-19 deaths would have in previous years been classified under different ICD-10 headings if they had followed Influenza-like illness. However as you have alluded to I suspect there will be other structural/policy reasons to explain the synchronous spikes in wk 15.
A fabulous comment! Coding flips may well explain some of the sync. In an analysis of care home deaths the same spike shows for non-Covid death as well as COVID. I am aware of at least one team meticulously documenting what went on with a view to prosecution.