The Impact of demographic, socio-economic and geographic factors on mortality risk among people living with dementia in England (2002–2016)
Open accessAbstract
Increasing numbers of people living with dementia (PLWD), and a pressured health and social care system, will exacerbate inequalities in mortality for PLWD. There is a dearth of research examining multiple factors in mortality risk among PLWD, including application of large administrative datasets to investigate these issues. This study explored variation mortality risk variation among people diagnosed with dementia between 2002–2016, based on: age, sex, ethnicity, deprivation, geography and general practice (GP) contacts. Data were derived from electronic health records from a cohort of Clinical Practice Research Datalink GP patients in England (n = 142,340). Cox proportional hazards regression modelled mortality risk separately for people with early- and later- onset dementia. Few social inequalities were observed in early-onset dementia; men had greater risk of mortality. For early- and later-onset, higher rates of GP observations—and for later-onset only dementia medications—are associated with increased mortality risk. Social inequalities were evident in later-onset dementia. Accounting for other explanatory factors, Black and Mixed/Other ethnicity groups had lower mortality risk, more deprived areas had greater mortality risk, and higher mortality was observed in North East, South Central and South West GP regions. This study provides novel evidence of the extent of mortality risk inequalities among PLWD. Variance in mortality risk was observed by social, demographic and geographic factors, and frequency of GP contact. Findings illustrate need for greater person-centred care discussions, prioritising tackling inequalities among PLWD. Future research should explore more outcomes for PLWD, and more explanatory factors of health outcomes.
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Written from the paper’s full text.
TL;DR
Using Clinical Practice Research Datalink electronic health records for 142,340 people diagnosed with dementia in England (2002–2016), this study found mortality risk varied by demographic, socio-economic, geographic and GP-contact factors, with more inequalities in later-onset dementia. Men, older people, more deprived groups, and those in certain GP regions had higher mortality risk, while Black and Mixed/Other ethnic groups had lower risk than White people.
Key findings
- In later-onset dementia, each additional year of age was associated with 4% greater mortality risk (HR: 1.04; CI: 1.04–1.05); men had significantly greater mortality risk than women in both early- and later-onset dementia.
- For later-onset dementia, Black (HR: 0.71; 0.64–0.79) and Mixed/Other (HR: 0.75; 0.65–0.86) ethnic groups had lower mortality risk than White people; the most deprived quintile had a 20% increased mortality risk compared with the least deprived (HR: 1.20; 1.15–1.24), with a dose-response relationship across deprivation quintiles.
- Geographic variation was observed for later-onset dementia: compared with South East Coast, mortality risk was greater in South Central (HR: 1.23; 1.17–1.29), South West (HR: 1.17; 1.11–1.23), and North East (HR: 1.10; 1.03–1.16). Descriptive mortality was highest in the North East (57.2%) and lowest in London (44.3%); by ethnicity, White 51.5%, Asian 43.6%, Black 40.0%, Mixed/Other 41.9%.
- Higher rates of GP observations were associated with greater mortality risk in early- and later-onset dementia; for later-onset only, higher rates of dementia medications were also associated with greater mortality risk. Few social inequalities were observed in early-onset dementia.
Methods
- Retrospective cohort using CPRD Aurum electronic health records; analytical sample was 142,340 patients registered at GPs in England, diagnosed with dementia between 2002–2016, with at least two years of GP follow-up data.
- Mortality was a binary outcome based on presence of date of death in CPRD. Explanatory variables included age at diagnosis, sex, ethnicity, 2019 Indices of Multiple Deprivation quintile, urban/rural GP classification, GP region, and rates of GP observations, dementia medications, and non-dementia medications.
- Cox proportional hazards regression modelled mortality risk separately for early- and later-onset dementia, with Bonferroni correction applied to p-values. Missing ethnicity (7,421; 5.2%) and missing IMD (276; 0.2%) were excluded from regression models.
Limitations
- Stated: CPRD lacks potential explanatory factors; representativeness issues exist, especially over/under-representation of GP regions, which may introduce selection bias and limit generalisability; CPRD only includes GPs who have registered to share practice data.
- Stated: date of dementia diagnosis is difficult to define and relies on clinical judgement/first dementia-specific observation; lack of GP confidence or knowledge may affect diagnosis; minority ethnic groups and deprived areas may be under-represented, and dementia medication records are few (~2.5% of all patient-GP records; fewer than 2.4 and 2.9 dementia medication records per patient year for early- and later-onset), yielding wider confidence intervals.
- Evident from text: the observational design cannot establish causality; missing data were excluded under an assumption of missing completely at random; ethnicity came from secondary healthcare records and diagnosis date was a proxy based on first dementia-specific observation.
Model-written summary. Check it against the paper before relying on it.
Integrity signals
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Cites
Statistics
Claims the paper makes
0 of 37 cited sources checked · 0 supported · 0 flagged
- Findingown data
Few social inequalities were observed in early-onset dementia.
“Few social inequalities were observed in early-onset dementia”
- Also stated in: § 3.2. Mortality Inequalities in Early-Onset Dementia · plain
“Regression analyses found few factors had a significant impact on mortality risk among those with early-onset dementia (Table 4).”
Quote in the paperSubstantial claim - Also stated in: § 3.2. Mortality Inequalities in Early-Onset Dementia · plain
- Findingown data
Men had greater risk of mortality in early-onset dementia.
“men had greater risk of mortality”
- Also stated in: § 3.2. Mortality Inequalities in Early-Onset Dementia · plain
“men had significantly greater mortality risk than women”
Quote in the paperSubstantial claim - Also stated in: § 3.2. Mortality Inequalities in Early-Onset Dementia · plain
- Findingown data
In later-onset dementia, rates of dementia medications were associated with significantly greater risk of mortality.
“Rates of GP observations and dementia medications were also associated with significantly greater risk of mortality among people living with late-onset dementia.”
Quote in the paperNot a substantial claim - Findingown data
In later-onset dementia, compared to the South East Coast region, mortality risk was greater in the South West region (HR: 1.17; 1.11-1.23).
“Compared to the South East Coast region, mortality risk was greater in the South Central (HR: 1.23; 1.17–1.29), South West (HR: 1.17; 1.11–1.23), North East (HR: 1.10; 1.03–1.16).”
Quote in the paperSubstantial claim - Findingown data
For later-onset dementia only, dementia medications are associated with increased mortality risk.
“higher rates of GP observations—and for later-onset only dementia medications—are associated with increased mortality risk.”
Quote in the paperSubstantial claim
- Findingown data
Accounting for covariates, men had significantly greater mortality risk than women in early-onset dementia.
“Accounting for covariates (age at diagnosis, ethnicity, IMD 2015 deprivation quintile, urban-rural GP classification, GP region and patient-GP contact rates), men had significantly greater mortality risk than women”
Quote in the paperSubstantial claim - Findingown data
In later-onset dementia, compared to the South East Coast region, mortality risk was greater in the North East region (HR: 1.10; 1.03-1.16).
“Compared to the South East Coast region, mortality risk was greater in the South Central (HR: 1.23; 1.17–1.29), South West (HR: 1.17; 1.11–1.23), North East (HR: 1.10; 1.03–1.16).”
Quote in the paperSubstantial claim - Findingown data
Regression analyses found few factors had a significant impact on mortality risk among those with early-onset dementia.
“Regression analyses found few factors had a significant impact on mortality risk among those with early-onset dementia (Table 4).”
Quote in the paperNot a substantial claim - Findingown data
In later-onset dementia, age was significantly, positively associated with mortality risk, with each year of age associated with 4% greater likelihood of dying in the study (HR: 1.04; CI: 1.04-1.05).
“Age was significantly, positively associated with mortality risk, with each year of age associated with 4% (hazard risk (HR): 1.04; confidence Intervals: 1.04–1.05) greater likelihood of dying in the study.”
Quote in the paperSubstantial claim - Findingown data
Black and Mixed/Other ethnicity groups had lower mortality risk.
“Black and Mixed/Other ethnicity groups had lower mortality risk”
Quote in the paperSubstantial claim - Findingown data
In later-onset dementia, rates of GP observations were associated with significantly greater risk of mortality.
“Rates of GP observations and dementia medications were also associated with significantly greater risk of mortality among people living with late-onset dementia.”
Quote in the paperSubstantial claim - Findingown data
In later-onset dementia, compared to the South East Coast region, mortality risk was greater in the South Central region (HR: 1.23; 1.17-1.29).
“Compared to the South East Coast region, mortality risk was greater in the South Central (HR: 1.23; 1.17–1.29), South West (HR: 1.17; 1.11–1.23), North East (HR: 1.10; 1.03–1.16).”
Quote in the paperSubstantial claim - Findingown data
Accounting for covariates, higher rates of GP observations were significantly associated with greater mortality risk in early-onset dementia.
“higher rates of GP observations were significantly associated with greater mortality risk.”
Quote in the paperSubstantial claim - Findingown data
For early- and later-onset dementia, higher rates of GP observations are associated with increased mortality risk.
“higher rates of GP observations—and for later-onset only dementia medications—are associated with increased mortality risk.”
Quote in the paperSubstantial claim - Findingown data
In later-onset dementia, Black people had lower mortality risk than White people (HR: 0.71; 0.64-0.79).
“Black (HR: 0.71; 0.64–0.79) and Mixed/Other (HR: 0.75; 0.65–0.86) people having lower mortality risk than White people.”
Quote in the paperSubstantial claim - Findingown data
Variance in mortality risk was observed by social, demographic and geographic factors, and frequency of GP contact.
“Variance in mortality risk was observed by social, demographic and geographic factors, and frequency of GP contact.”
Quote in the paperSubstantial claim - Findingown data
Social inequalities were evident in later-onset dementia.
“Social inequalities were evident in later-onset dementia.”
Quote in the paperSubstantial claim - Findingreasoning
People registered with North East, South Central and South East GPs had greater mortality risk.
“People registered with North East, South Central and South East GPs had greater mortality risk.”
Quote in the paperSubstantial claim - Findingown data
Higher mortality was observed in North East, South Central and South West GP regions.
“higher mortality was observed in North East, South Central and South West GP regions.”
Quote in the paperSubstantial claim - Findingown data
In later-onset dementia, Mixed/Other people had lower mortality risk than White people (HR: 0.75; 0.65-0.86).
“Black (HR: 0.71; 0.64–0.79) and Mixed/Other (HR: 0.75; 0.65–0.86) people having lower mortality risk than White people.”
Quote in the paperSubstantial claim - Findingown data
In later-onset dementia, men had significantly greater mortality risk than women.
“When accounting for covariates (Table 4), men had significantly greater mortality risk than women.”
Quote in the paperSubstantial claim - Findingown data
More deprived areas had greater mortality risk.
“more deprived areas had greater mortality risk”
Quote in the paperSubstantial claim - Findingown data
In early-onset dementia there are fewer than 2.4 dementia medication records per patient year.
“In early- and later-onset dementia there are fewer than 2.4 and 2.9 dementia medication records per patient year respectively.”
Quote in the paperNot a substantial claim - Findingown data
For the sample population, there are fewer dementia medication records (~2.5% of all recorded patient-GP) than GP observation or non-dementia medication records.
“For the sample population, there are fewer dementia medication records (~2.5% of all recorded patient-GP) than GP observation or non-dementia medication records.”
Quote in the paperSubstantial claim - Findingown data
In later-onset dementia there are fewer than 2.9 dementia medication records per patient year.
“In early- and later-onset dementia there are fewer than 2.4 and 2.9 dementia medication records per patient year respectively.”
Quote in the paperSubstantial claim - Study design and conductown data
The analytical sample size was 142,340 people.
“Our analytical sample size was 142,340 people (Figure 1).”
Quote in the paperNot a substantial claim - Premisecitation
Effective treatment and management of dementia and comorbidities has been illustrated to impact survival rates among people living with dementia.
“Effective treatment and management of dementia and comorbidities has been illustrated to impact survival rates among PLWD [16,17].”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [16] Vaartjes, 2019, Increased mortality and hospital readmission risk in patients with dementia and a history of cardiovascular disease: Results from a nationwide registry linkage study, Int. J. Geriatr. Psychiatry source
Not checked in the free run.
- cites [17] Watson, 2021, Use of routine and cohort data globally in exploring dementia care pathways and inequalities: A systematic review, Int. J. Geriatr. Psychiatry source
Not checked in the free run.
- Interpretationreasoning
Greater dementia mortality risk in South Central and South East regions is reflective of demographic and systemic factors.
“Greater dementia mortality risk in South Central and South East regions is reflective of demographic and systemic factors.”
Quote in the paperSubstantial claim - Interpretationreasoning
With increased mortality risk observed in GP regions with varied levels of deprivation, mortality risk may be more likely a result of the regions' population composition, rather than the geographic region itself.
“With increased mortality risk observed in GP regions with varied levels of deprivation, mortality risk may be more likely a result of the regions’ population composition, rather than the geographic region itself.”
Quote in the paperSubstantial claim - Premisecitation
There are inequalities in mortality for people living with dementia by various socio-economic and geographic factors.
“There are inequalities in mortality for people living with dementia (PLWD) by various socio-economic and geographic factors [1,2].”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [1] Koek, 2016, Socioeconomic Disparities and Mortality after a Diagnosis of Dementia: Results From a Nationwide Registry Linkage Study, Am. J. Epidemiol. source
Not checked in the free run.
- cites [2] Korhonen, 2020, Midlife socioeconomic position and old-age dementia mortality: A large prospective register-based study from Finland, BMJ Open source
Not checked in the free run.
- Premisecitation
Inequalities in dementia and dementia outcomes have been illustrated across spatial contexts-including where somebody lives, the levels of deprivation in the area they live, and where their GP is based.
“Inequalities in dementia and dementia outcomes have been illustrated across spatial contexts—including where somebody lives, the levels of deprivation in the area they live, and where their GP is based [17,32,33].”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [17] Watson, 2021, Use of routine and cohort data globally in exploring dementia care pathways and inequalities: A systematic review, Int. J. Geriatr. Psychiatry source
Not checked in the free run.
- cites [32] Russ, 2012, Geographical variation in dementia: Systematic review with meta-analysis, Int. J. Epidemiol. source
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- cites [33] Russ, 2016, Geographical Variation in Dementia Mortality in Italy, New Zealand, and Chile: The Impact of Latitude, Vitamin D, and Air Pollution, Dement. Geriatr. Cogn. Disord. source
Not checked in the free run.
- Premisecitation
Existing research examines the impact of few social, demographic or geographic factors in mortality risk among people living with dementia.
“Existing research examines the impact of few social, demographic or geographic factors in mortality risk among PLWD [1,2,40].”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [1] Koek, 2016, Socioeconomic Disparities and Mortality after a Diagnosis of Dementia: Results From a Nationwide Registry Linkage Study, Am. J. Epidemiol. source
Not checked in the free run.
- cites [2] Korhonen, 2020, Midlife socioeconomic position and old-age dementia mortality: A large prospective register-based study from Finland, BMJ Open source
Not checked in the free run.
- cites [40] Co, 2021, Differences in survival and mortality in minority ethnic groups with dementia: A systematic review and meta-analysis, Int. J. Geriatr. Psychiatry source
Not checked in the free run.
- Interpretationown data
This study provides novel evidence of the extent of mortality risk inequalities among people living with dementia.
“This study provides novel evidence of the extent of mortality risk inequalities among PLWD.”
Quote in the paperSubstantial claim - Premisecitation
Electronic health records can be employed to identify healthcare use and outcomes among specified, large patient groups, which may not be possible through other means.
“Electronic health records (EHR) can be employed to identify healthcare use and outcomes among specified, large patient groups, which may not be possible through other means [25,26].”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [25] Casey, 2016, Using Electronic Health Records for Population Health Research: A Review of Methods and Applications, Annu. Rev. Public Health source
Not checked in the free run.
- cites [26] Manca, 2015, Rebuttal: Do electronic medical records improve quality of care? Yes, Can. Fam. Physician Med. Fam. Can.
Not checked in the free run.
- Premisecitation
There is a reliance on clinical judgement during healthcare interactions to indicate dementia symptomology.
“Though screening and testing can indicate dementia symptomology, there is a reliance on clinical judgement during healthcare interactions [65].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [65] Brodaty, 1994, General practice and dementia, Med. J. Aust. source
Not checked in the free run.
- Study design and conductown data
The sample population in the study is relatively representative of the UK dementia population for most social and demographic variables.
“Although the population in our study is relatively representative of the UK dementia population for most social and demographic variables—as seen in Table 2 and Table 3—there are differences between the GP region of the sample population compared to the UK dementia population.”
Quote in the paperNot a substantial claim - Interpretationreasoning
True prevalence among certain population groups may not be discovered.
“Furthermore, less reliance on formal care for PLWD among some communities [69], inadequate collection of socio-economic and demographic information and historic under-representation in EHRs and research among some communities [70], means true prevalence among certain population groups may not be discovered [71].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [71] Klinger, 2015, Accuracy of Race, Ethnicity, and Language Preference in an Electronic Health Record, J. Gen. Intern. Med. source
Not checked in the free run.
- Study design and conductnone given
The GP region of the sample population differs from the UK dementia population.
“Although the population in our study is relatively representative of the UK dementia population for most social and demographic variables—as seen in Table 2 and Table 3—there are differences between the GP region of the sample population compared to the UK dementia population.”
Quote in the paperNot a substantial claim - Premisecitation
There is less reliance on formal care for PLWD among some communities.
“Furthermore, less reliance on formal care for PLWD among some communities [69], inadequate collection of socio-economic and demographic information and historic under-representation in EHRs and research among some communities [70], means true prevalence among certain population groups may not be discovered [71].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [69] Williams, D.R., and Cooper, L.A. (2019). Reducing Racial Inequities in Health: Using What We Already Know to Take Action. Int. J. Environ. Res. Public Health, 16. source
Not checked in the free run.
- Interpretationown data
The low number of dementia medication records may help explain wider confidence intervals for dementia medication contacts as an explanatory factor for mortality risk in the sample population.
“This may help explain wider confidence intervals for dementia medication contacts as an explanatory factor for mortality risk in the sample population.”
Quote in the paperNot a substantial claim
- May combine two claims. 19
- Classified as probably not a substantial claim. 25
May combine two claims.
Findingown dataThere were differences in mortality by geographic region; greatest mortality was in the North East (57.2%), and lowest in London (44.3%).
“There were differences in mortality by geographic region; greatest mortality was in the North East (57.2%), and lowest in London (44.3%).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataOlder age groups and areas with increased levels of deprivation had the highest rates of mortality.
“Older age groups and areas with increased levels of deprivation had the highest rates of mortality (Table 3).”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataIn later-onset dementia, compared to the least deprived quintile, each quintile had significantly increased mortality risk with a dose-response relationship; the most deprived quintile had a 20% increased risk of mortality (HR: 1.20; 1.15-1.24).
“Compared to the least deprived quintile (Quintile 1), each quintile had significantly increased mortality risk with a dose-response relationship; the most deprived quintile (Quintile 5) had a 20% increased risk of mortality (HR: 1.20; 1.15–1.24) compared to the least deprived.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataAsian (43.6%), Black (40.0%) and Mixed/Other (41.9%) groups had lower mortality than White (51.5%).
“Asian (43.6%), Black (40.0%) and Mixed/Other (41.9%) groups had lower mortality than White (51.5%).”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Premisenone givenThere is a dearth of research examining multiple factors in mortality risk among people living with dementia, including application of large administrative datasets.
“There is a dearth of research examining multiple factors in mortality risk among PLWD, including application of large administrative datasets to investigate these issues.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductown dataEthnicity was missing for 7421 (5.2%) people, and 276 (0.2%) people had no available IMD 2015 deprivation.
“Ethnicity was missing for 7421 (5.2%) people, and 276 (0.2%) people had no available IMD 2015 deprivation (Table 1).”
Quote in the paperNot a substantial claim- The authors state this as an assumption: Data are missing completely at random.
Classified as probably not a substantial claim. May combine two claims.
Study design and conductreasoningUsing this date as date of diagnosis will both standardise diagnosis date across the sample population, and define the first date at which a dementia-specific event was observable within an individuals' GP records.
“Using this date as date of diagnosis will both standardise diagnosis date across the sample population, and define the first date at which a dementia-specific event was observable within an individuals’ GP records.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing), S4 (based).
Interpretationnone givenThis study presents one of the first to apply large EHRs in exploring numerous causes of inequalities in dementia-related mortality.
“This study presents one of the first to apply large EHRs in exploring numerous causes of inequalities in dementia-related mortality.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationCPRD has been employed previously to investigate socio-economic and demographic factors in variation in care of physical and mental health conditions.
“CPRD has been employed previously to investigate socio-economic and demographic factors in variation in care of physical and mental health conditions [27,28].”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [27] Chan, 2019, Socio-economic inequalities in life expectancy of older adults with and without multimorbidity: A record linkage study of 1.1 million people in England, Int. J. Epidemiol. source
Not checked in the free run.
- cites [28] Hawkins, 2012, Community Care in England: Reducing Socioeconomic Inequalities in Heart Failure, Circulation source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationAs dementia progresses, people living with dementia are likely to need greater levels of healthcare involvement.
“As dementia progresses, and health deteriorates, PLWD are likely to need greater levels of healthcare involvement, both in relation to dementia, and comorbidities [16].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [16] Vaartjes, 2019, Increased mortality and hospital readmission risk in patients with dementia and a history of cardiovascular disease: Results from a nationwide registry linkage study, Int. J. Geriatr. Psychiatry source
Not checked in the free run.
May combine two claims.
PremisecitationThough electronic health records have evidenced mortality risk among people living with dementia, there is limited use in evidencing social, demographic and geographic inequalities.
“Though EHRs have evidenced mortality risk among PLWD, there is limited use in evidencing social, demographic and geographic inequalities [17].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [17] Watson, 2021, Use of routine and cohort data globally in exploring dementia care pathways and inequalities: A systematic review, Int. J. Geriatr. Psychiatry source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationCPRD Aurum contains three primary datasets for patients' contacts with their GP: consultations, observations and drug issue records.
“CPRD Aurum contains three primary datasets for patients’ contacts with their GP: consultations, observations and drug issue (medication) records [29].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [29] CPRD (2021, September 08). CPRD Aurum Data Specification: Version 2.5: Date: 21 January 2021. Available online: https://www.cprd.com/sites/default/files/CPRD%20Aurum%20Data%20Specification%20v2.6.pdf.
Not checked in the free run.
Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.
PremisecitationMortality is a definitive outcome, which can illustrate both ill-health and effectiveness of care and symptom management throughout the trajectory of an illness.
“Mortality is a definitive outcome, which can illustrate both ill-health and effectiveness of care and symptom management throughout the trajectory of an illness [16,23].”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [16] Vaartjes, 2019, Increased mortality and hospital readmission risk in patients with dementia and a history of cardiovascular disease: Results from a nationwide registry linkage study, Int. J. Geriatr. Psychiatry source
Not checked in the free run.
- cites [23] Rait, 2010, Survival of people with clinical diagnosis of dementia in primary care: Cohort study, BMJ source
Not checked in the free run.
Classified as probably not a substantial claim.
PremisecitationPrevious research using CPRD calculated date of diagnosis as the first GP observation record with the condition under investigation specified.
“Previous research using CPRD calculated date of diagnosis as the first GP observation record with the condition under investigation specified [31].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [31] Kuan, 2019, A chronological map of 308 physical and mental health conditions from 4 million individuals in the English National Health Service, Lancet Digit. Health source
Not checked in the free run.
May combine two claims.
PremisecitationPeople from the most disadvantaged socio-economic groups are most likely to have unmet care needs and experience poorer health outcomes.
“People from the most disadvantaged socio-economic groups are most likely to have unmet care needs and experience poorer health outcomes [3].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [3] Wu, 2018, Inequalities in living well with dementia-The impact of deprivation on well-being, quality of life and life satisfaction: Results from the improving the experience of dementia and enhancing active life study, Int. J. Geriatr. Psychiatry source
Not checked in the free run.
Classified as probably not a substantial claim.
Study design and conductreasoningBonferroni correction was applied to derived p-values to account for the potential for Type I errors when calculating multiple, simultaneous statistical tests.
“Inequalities in mortality risk were examined using Cox Proportional Hazards (CPH) regression models, with Bonferroni correction applied to derived p-values to account for the potential for Type I errors when calculating multiple, simultaneous statistical tests.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Interpretationnone givenPockets of deprivation may be hidden in regional analyses.
“However, pockets of deprivation may be hidden in regional analyses.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductreasoningGPs apply to CPRD to register for their data to be collected, resulting in potential uneven geographic coverage.
“GPs apply to CPRD to register for their data to be collected, resulting in potential uneven geographic coverage.”
Quote in the paperNot a substantial claimMay combine two claims.
Premisenone givenNone focus on multiple risk factors or investigate healthcare contacts as explanatory factors in health outcomes for people living with dementia.
“Yet none focus on multiple risk factors or investigate healthcare contacts as explanatory factors in health outcomes for PLWD.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationcitationThe North East contains some of the most socio-economically deprived areas in England, likely contributing to higher mortality risk.
“The North East—along with higher prevalence of poor health [44] and lowest life expectancy in England [45]—contains some of the most socio-economically deprived areas in England [46], likely contributing to higher mortality risk for.”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites [44] UK Parliament (2021, September 08). Dementia: Age and Deprivation Differences. Available online: https://commonslibrary.parliament.uk/dementia-age-and-deprivation-differences/.
Not checked in the free run.
- cites [45] Corris, 2020, Health inequalities are worsening in the North East of England, Br. Med. Bull. source
Not checked in the free run.
- cites [46] Ministry of Housing, Communities & Local Government (2021, September 08). The English Indices of Deprivation 2019 (IoD2019), Available online: https://www.gov.uk/government/statistics/english-indices-of-deprivation-2019.
Not checked in the free run.
Classified as probably not a substantial claim.
Premisenone givenDate of diagnosis is not specified in CPRD.
“Date of diagnosis is not specified in CPRD.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationDementia-specific medications include prescriptions for four drugs advised for use by the NHS for people living with dementia: Donepezil, Galantamine, Rivastigmine and Memantine.
“Dementia-specific medications include prescriptions for four drugs advised for use by the NHS for PLWD [30]: Donepezil, Galantamine, Rivastigmine and Memantine.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [30] NHS (2021, December 16). What Are the Treatments for Dementia?. Available online: https://www.nhs.uk/conditions/dementia/treatment/.
Not checked in the free run.
Classified as probably not a substantial claim. May combine two claims.
PremisecitationSuch variations can exist due to the social gradient in wider determinants of health, differences in local funding and service equity, the make-up of local healthcare systems and regional differences in population composition.
“Such variations can exist due to the social gradient in wider determinants of health, differences in local funding and service equity, the make-up of local healthcare systems and regional differences in population composition [34,35,36,37].”
Quote in the paperSubstantial claim0 of 4 sources checked- cites [34] Whitehead, 2006, Concepts and principles for tackling social inequities in health: Levelling up Part 1, World Health Organ. Stud. Soc. Econ. Determ. Popul. Health
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- cites [35] Goddard, 2001, Equity of access to health care services: Theory and evidence from the UK, Soc. Sci. Med. source
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- cites [36] Kerpershoek, 2020, Is there equity in initial access to formal dementia care in Europe? The Andersen Model applied to the Actifcare cohort, Int. J. Geriatr. Psychiatry source
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- cites [37] Marmot, M., Allen, J., Boyce, T., Goldblatt, P., and Morrison, J. Health Equity in England: The Marmot Review 10 Years on, Institute of Health Equity. Available online: https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on.
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
InterpretationreasoningDifferences in mortality risk by ethnicity are associated with demographic, systemic and cultural factors.
“Differences in mortality risk by ethnicity are associated with demographic, systemic and cultural factors.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
InterpretationreasoningHigh observations may also act as a proxy for health status, since individuals who require more observations may have greater needs.
“High observations may also act as a proxy for health status, since individuals who require more observations may have greater needs (rather than only reflecting effective treatment).”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationreasoningOur findings progress previous research, highlighting social, demographic, geographic and healthcare inequalities in mortality risk, accounting for a greater range of explanatory factors.
“Our findings progress previous research, highlighting social, demographic, geographic and healthcare inequalities in mortality risk, accounting for a greater range of explanatory factors.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).
PremisecitationDate of dementia diagnosis is difficult to define.
“Given the nature of the condition, date of dementia diagnosis is difficult to define.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [65] Brodaty, 1994, General practice and dementia, Med. J. Aust. source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
InterpretationreasoningIf GPs engaging with data sharing are not random and socially/geographically patterned, this may contribute to bias in the data.
“If those GPs engaging with data sharing are not random and socially/geographically patterned, this may contribute to the bias in our data.”
Quote in the paperNot a substantial claim- Rests on an assumption: CPRD holds only data from GPs who have registered to send their practice data to CPRD.
May combine two claims.
PremisecitationThere is inadequate collection of socio-economic and demographic information and historic under-representation in EHRs and research among some communities.
“Furthermore, less reliance on formal care for PLWD among some communities [69], inadequate collection of socio-economic and demographic information and historic under-representation in EHRs and research among some communities [70], means true prevalence among certain population groups may not be discovered [71].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [70] Hindorff, 2018, Enhancing diversity to reduce health information disparities and build an evidence base for genomic medicine, Pers. Med. source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationGreater prevalence of diagnosed and undiagnosed dementia exists in areas of greatest deprivation.
“Evidence points to greater prevalence of diagnosed and undiagnosed dementia among some minority ethnic groups [67], and in areas of greatest deprivation [68].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [68] Connolly, 2011, Underdiagnosis of dementia in primary care: Variations in the observed prevalence and comparisons to the expected prevalence, Aging Ment. Health source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
InterpretationreasoningPotential lack of representation in CPRD may impact potential findings and conclusions.
“Potential lack of representation in CPRD may impact potential findings and conclusions.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationLack of GP confidence in diagnosing, or lack of knowledge of dementia in primary care may result in issues around dementia diagnosis, resulting in issues with defining dementia date of diagnosis.
“Lack of GP confidence in diagnosing, or lack of knowledge of dementia in primary care may result in issues around dementia diagnosis, resulting in issues with defining dementia date of diagnosis [66].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [66] Phillips, 2012, Difficulties in disclosing the diagnosis of dementia: A qualitative study in general practice, Br. J. Gen. Pract. J. R. Coll. Gen. Pract. source
Not checked in the free run.
May combine two claims.
Interpretationown dataFindings from this study suggest substantial differential mortality risk among PLWD, due to demographic, social and geographic factors, and use of primary healthcare.
“Findings from this study suggest substantial differential mortality risk among PLWD, due to demographic, social and geographic factors, and use of primary healthcare.”
Quote in the paperSubstantial claimMay combine two claims.
InterpretationreasoningOver/under-representation of certain regions may introduce selection bias into the analyses, which may limit the generalisability of the findings, especially the inequalities by region identified.
“Over/under-representation of certain regions may introduce selection bias into our analyses, which may limit the generalisability of our findings (especially the inequalities by region we identify).”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S2 (checkable). May combine two claims.
InterpretationreasoningThis study illustrates the potential and importance of using existing EHRs to explore health inequalities.
“This study illustrates the potential and importance of using existing EHRs to explore health inequalities.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).
Study design and conductreasoningStandardising date of diagnosis in the sample population adds a greater degree of precision.
“There is currently no way to negate this, however in standardising date of diagnosis in the sample population, adds a greater degree of precision.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationGreater prevalence of diagnosed and undiagnosed dementia exists among some minority ethnic groups.
“Evidence points to greater prevalence of diagnosed and undiagnosed dementia among some minority ethnic groups [67], and in areas of greatest deprivation [68].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [67] Pham, 2018, Trends in dementia diagnosis rates in UK ethnic groups: Analysis of UK primary care data, Clin. Epidemiol. source
Not checked in the free run.
The authors state this as an assumption.
Data are missing completely at random.
“Individuals with missing ethnicity or IMD quintile were not included regression models, with data assumed missing completely at random.”
The paper relies on this without support.
CPRD holds only data from GPs who have registered to send their practice data to CPRD.
“CPRD holds only data from GPs who have registered to send their practice data to CPRD.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Benefits of these models appear unevenly distributed, with continued inequities linked to geography, socioeconomic status, and service availability.
“Unfortunately, these benefits appear unevenly distributed, with continued inequities linked to geography, socioeconomic status, and service availability (Giebel et al., 2025; Watson et al., 2021).”
From Mind the gap: a systematic review of barriers, facilitators, and experiences of care transitions for people living with dementia and their informal caregivers. (2026) · cites this paper as Watson et al., 2021
The Discussion (§4.2) and Conclusions (§5; page unavailable) report inequalities in mortality risk among people living with dementia associated with socioeconomic and geographic factors and primary healthcare use. The Introduction (§1) also links restricted service availability to widening inequalities. The paper does not assess whether the benefits of the citing sentence’s unspecified models are unevenly distributed, so that part is unsupported. (LLM, conf=0.86)
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Discussion substitutes South East for South West
MinorThe Results identify South West, South Central and North East as having greater mortality risk than the South East Coast reference region. The Discussion instead names South East alongside North East and South Central.
“People registered with North East, South Central and South East GPs had greater mortality risk.”
“Compared to the South East Coast region, mortality risk was greater in the South Central (HR: 1.23; 1.17–1.29), South West (HR: 1.17; 1.11–1.23), North East (HR: 1.10; 1.03–1.16).”
Deprivation index year differs across Methods
MinorThe Methods say the linked deprivation quintile is from the 2019 index, but the missing-data section identifies it as IMD 2015. The text does not consistently identify which index was used.
“The 2011 GP urban/rural classification and 2019 Indices of Multiple Deprivation (IMD) quintile were available through data linkage.”
“Ethnicity was missing for 7421 (5.2%) people, and 276 (0.2%) people had no available IMD 2015 deprivation (Table 1).”
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Rebuttal: Do electronic medical records improve quality of care? Yes.
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Cited by
Sorted by citations
Geographical inequalities in dementia diagnosis and care: A systematic review
Giebel, C., Readman, M. R., Godfrey, A., Gray, A., Carton, J., & Polden, M. (2025) · International Psychogeriatrics · doi:10.1016/j.inpsyc.2025.100051 · Cited by 44 · see citing works
Self-citationWatson, J. B., Green, M. A., Giebel, C. M., Darlington‐Pollock, F., & Akpan, A. (2022) · Aging & Mental Health · doi:10.1080/13607863.2022.2107176 · Cited by 32 · see citing works
Self-citationRecent research advances in young-onset dementia
Loi, S. M., Pijnenburg, Y. A. L., & Velakoulis, D. (2022) · Current Opinion in Psychiatry · doi:10.1097/yco.0000000000000843 · Cited by 28 · see citing works
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Survival rates in frontotemporal dementia and Alzheimer’s disease
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Emerging directions in tauopathy research
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Self-citationNeighborhood deprivation and mortality among people with Alzheimer’s disease and related dementia
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Watson, J. B., Green, M. A., Giebel, C. M., & Akpan, A. (2024) · Figshare · doi:10.6084/m9.figshare.26680637
Self-citationWatson, J. B., Green, M. A., Giebel, C. M., & Akpan, A. (2024) · Figshare · doi:10.6084/m9.figshare.26680634
Self-citationWatson, J. B., Green, M. A., Giebel, C. M., & Akpan, A. (2024) · Figshare · doi:10.6084/m9.figshare.26680619
Self-citationWatson, J. B., Green, M. A., Giebel, C. M., & Akpan, A. (2024) · Figshare · doi:10.6084/m9.figshare.26680628
Self-citationWatson, J. B., Green, M. A., Giebel, C. M., & Akpan, A. (2024) · Figshare · doi:10.6084/m9.figshare.26680622
Self-citationWatson, J. B., Green, M. A., Giebel, C. M., & Akpan, A. (2024) · Figshare · doi:10.6084/m9.figshare.26680631
Self-citationWatson, J. B., Green, M. A., Giebel, C. M., & Akpan, A. (2024) · Figshare · doi:10.6084/m9.figshare.26680625
Self-citationEmergency conditions in home care as part of ambulatory health care
Gavrilović, N. (2026) · ABC - časopis urgentne medicine · doi:10.5937/abc2601039g
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- Authors
- Watson, J., Darlington-Pollock, F., Green, M., Giebel, C., & Akpan, A.
- Affiliations
- University of Liverpool (GB)
- School of Environmental Sciences, The University of Liverpool, Liverpool L69 7ZT, UK
- Liverpool University Hospitals NHS Foundation Trust (GB)
- Corresponding author
- Watson, James
- Venue
- International Journal of Environmental Research and Public Health
- Publisher
- MDPI AG
- Published
- 2021-12-20
- Volume
- 18
- Issue
- 24
- Pages
- 13405
- ISSN
- 1660-4601 (ISSN-L)
- PMC
- PMC8708637
- OpenAlex
- W4200407288
- Semantic Scholar
- 75fd80f2f506010dd0cd03f2e532836d57600ec5
- Cited by
- 21
- References
- 51
- Citations by year
- 2026: 3 · 2025: 7 · 2024: 9 · 2022: 2
- FWCI
- 1.97
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- International Journal of Environmental Research and Public Health (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- UK Research and Innovation
- National Institute for Health and Care Research
- Department of Health and Social Care
- Engineering and Physical Sciences Research Council
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Social Sciences › Health › Health disparities and outcomes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Keywords
- dementia, mortality risk, health disparities, social deprivation, ethnicity, regional variation, early-onset dementia, late-onset dementia, sex differences, dementia medications, person-centred care, England
- MeSH terms
- Dementia, Demography, Geography, Humans, Male, Socioeconomic Factors, Cohort Studies
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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