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We thank Dr Jones for his comment on our paper but do not believe that changes in patterns of deaths would alter our conclusions. Absolute numbers of deaths are essentially driven by three factors; the size of a population, the demographic makeup of the population (i.e. age and sex distribution) and life expectancy. Changes in any of these factors can lead to a change in the absolute number of deaths in a given time period. Our analytical approach explicitly accounts for two of these three factors. We accounted for changes in population size (through the offset term in the Poisson regression) such that we were modelling the effect on admission rates rather than crude admission number. Our regression framework adjusted for age and gender, thus accounted for changes in population demographics and furthermore was restricted only to patients aged 65 and over. Given that changes in life expectancy have been minimal in recent years we are confident that the issue raised does not threaten the validity of our results.
This is an interesting study which may have omitted to correct for a hidden cost driver. The nearness to death effect implies that around half of a person's lifetime acute admissions and bed occupancy occurs in the last year of life. After a 35 year decline deaths in England reached a minimum in the 12-month period ending January 2012 and then proceeded to show a large and ongoing increase. However, the trend for England is the composite of local area trends. For example, Office for National Statistics monthly data for Southwark shows that deaths reached a maximum of 1,441 in the 12-months ending Sep-10, declined to a minimum of 1,249 for the 12-months ending Mar-13 and then rose to another maximum of 1,412 for the 12-months ending May-16. Hence the intervention period is marked by rising deaths and rising costs due to persons in the last year of life. May I suggest that you recalculate the utilization and costs with an emphasis on those who were and those who were not in the last year of life. Hope this helps.