Regional Differences In Mortality Research Articles

Determinants of within-country variation in traffic accident mortality in Italy: a geographical analysis

ObjectiveTo identify determinants of regional differences in traffic accident mortality in Italy.Data and methodsMultiple linear regression models were conducted assessing the associations between regional differences in traffic mortality, case fatality and accident rates (dependent variables) with socio-demographic factors, and variables describing road behaviour, vehicles, infrastructure and medical care (independent variables). Data were derived from the National Institute of Statistics, the National Institute of Health and the Italian Automobile Club. In addition to analyses for the whole country of Italy, separate models were conducted for Northern and southern regions.ResultsIn Italy large regional differences in traffic mortality rates can be observed, ranging from 5.5 to 20 per 100.000 person-years. There is a North-South gradient with higher mortality rates in the Northern part of Italy. Strong predictors of regional differences in both traffic mortality and accident rates are the employment rate (directly associated) and alcohol use (directly associated). This is observed in the whole of Italy, and separately in Northern and southern regions.ConclusionOur study has shown the need for regional policies to improve road behaviour to reduce traffic accident and mortality rates in identified high-risk areas.

No Improvement in Outcome of Nationwide Extremely Low Birth Weight Infant Populations Between 1996–1997 and 1999–2000

Our goal was to investigate whether outcome in extremely low birth weight infants changes over time in Finland. All infants with a birth weight <1000 g born in Finland in 1996-1997 and 1999-2000 were included in the study. Perinatal and follow-up data were collected in a national extremely low birth weight infant research register. Data concerning cerebral palsy and visual impairment were obtained from hospitals, the national discharge, and visual impairment registers. A total of 529 and 511 extremely low birth weight infants were born during 1996-1997 and 1999-2000. No changes were detected in prenatal, perinatal, neonatal, and postneonatal mortality rates between the periods. The survival rates including stillborn infants were 40% and 44%. The incidence of respiratory distress syndrome and septicemia increased from 1996-1997 to 1999-2000 (75% vs 83% and 23% vs 31%). The overall incidence of intraventricular hemorrhage increased (29% vs 37%), but the incidence of intraventricular hemorrhage grades 3 through 4 did not (16% vs 17%). The rates of oxygen dependency at the age corresponding with 36 gestational weeks, retinopathy of prematurity stages 3 to 5, cerebral palsy, and severe visual impairment did not change. Mortality remained higher in 1 university hospital area during both periods compared with the other 4 areas, but no regional differences in morbidity were detected during the later period. No significant changes were detected in birth or mortality rate in extremely low birth weight infants born in Finland during the late 1990s, but some neonatal morbidities seemed to increase. Regional differences in mortality were detected in both cohorts. Repeated long-term follow-up studies on geographically defined very preterm infant cohorts are needed for establishing reliable outcome data of current perinatal care. Regional differences warrant thorough audits to assess causalities.

Regional mortality differences in end-stage renal disease: How far can observational studies take us?

The survival of patients with ESRD living in various geographic regions is strikingly different. Efforts to determine the reasons behind this observation have been hampered by difficulties in adjusting for many characteristics that are inherently different in patient populations living on different continents. The mortality rate for the general population in a given region could be used to adjust for risk factors that would be otherwise difficult to quantify.

Avoidable mortality across Canada from 1975 to 1999.

BackgroundThe concept of 'avoidable' mortality (AM) has been proposed as a performance measure of health care systems. In this study we examined mortality in five geographic regions of Canada from 1975 to 1999 for previously defined avoidable disease groups that are amenable to medical care and public health. These trends were compared to mortality from other causes.MethodsNational and regional age-standardized mortality rates for ages less than 65 years were estimated for avoidable and other causes of death for consecutive periods (1975–1979, 1980–1985, 1985–1989, 1990–1994, and 1995–1999). The proportion of all-cause mortality attributable to avoidable causes was also determined.ResultsFrom 1975–1979 to 1995–1999, the AM decrease (46.9%) was more pronounced compared to mortality from other causes (24.9%). There were persistent regional AM differences, with consistently lower AM in Ontario and British Columbia compared to the Atlantic, Quebec, and Prairies regions. This trend was not apparent when mortality from other causes was examined. Injuries, ischaemic heart disease, and lung cancer strongly influenced the overall AM trends.ConclusionThe regional differences in mortality for ages less than 65 years was attributable to causes of death amenable to medical care and public health, especially from causes responsive to public health.

Regionale Sterblichkeitsunterschiede in Bayern

In completion of a decision of the Bavarian Parliament we examined the regional mortality differences within Bavaria. The analysis was based on the number of deaths in Bavaria in the years of 2000-2002. Data on regional demographic and socioeconomic indicators were used to identify potential associations. Deaths were analysed by cause of death and region. Crude and age standardised mortality rates were calculated. Additionally, we assessed the potential years of life lost in order to obtain some indication of the potential effects of preventive action. The association with likely explanatory factors was investigated on an ecological level. The regional mortality differences in Bavaria show a northeast-southwest gradient favouring the southwest, which reflects the socioeconomic situation within Bavaria. This may be due to the economic disadvantage northeast Bavaria had to endure as a result of its marginal location within a divided Europe. We found strong bivariate correlations of the mortality rate with individual socioeconomic factors (e. g. with available income: -0.582; with unemployment: +0.416; with the immigration rate: -0.473). Exploratory analysis suggest that about 50 % of the regional variation in mortality could be explained by socioeconomic factors. The results for cause of death indicate that behavioural factors in relation to socioeconomic aspects may well play a role in the mortality gradient. This will be the focus of a future piece of research of our unit.

Applicability of clinical prediction models in acute myocardial infarction: A comparison of traditional and empirical Bayes adjustment methods

Several clinical prediction models have been developed to predict outcome after acute myocardial infarction. Updating to local circumstances may be required to make such models better applicable. We aimed to compare traditional and empirical Bayes (EB) methods to perform such updating. We focused on 16 geographical regions within the GUSTO-I trial, which included 40,830 patients with acute myocardial infarction; of whom, 2851 (7.0%) had died by 30 days. Differences in mortality between regions were studied with traditional adjustment for case mix in logistic regression models and with EB methods. These methods updated predictions for new patients while accounting for the uncertainty in the traditionally estimated mortality differences. The case mix in the regions differed with respect to important predictive characteristics such as age, presence of shock, and anterior infarct location (all P < .001). These differences did not explain regional differences in 30-day mortality, which varied between 80% and 120% with traditional analyses (P < .01). The EB estimates for regional differences were much smaller (between 93% and 107%). Statistically significant differences in case mix and 30-day mortality were noted between geographical regions. The practical implications of this heterogeneity were, however, limited when model predictions were updated with EB methods.

Determinants of traffic accident mortality in Italy, 1997-1999

Traffic accidents represent an important public health issue in Italy. In order to explore the relationship between traffic accident mortality and factors such as road behaviour, vehicles and road characteristics, four different linear regression models were performed using data from the end of the 1990’s provided by the National Institute of Statistics (ISTAT) and from the Automobile Club Italia (ACI). In Italy regional differences in traffic mortality and injury rates can be observed. Strong predictors are the number of motor vehicles circulating and road length (inversely associated) and the number of new vehicles circulating and suspended driving licenses (directly associated).

Heat wave 2003 and mortality in Switzerland.

During June to August 2003, high temperatures were reported across Europe including Switzerland. In many European countries, particularly in France the heat wave was associated with an increase in mortality. This is the first analysis investigating whether the high temperatures during summer 2003 in Switzerland had a measurable impact on mortality. Daily data on all-cause mortality for the period January 1990 to December 2003, and meteorological data from 20 different stations for the same period were analysed. Excess mortality for different age groups, gender and geographic regions was calculated. Daily mortality and temperature in 2003 was correlated with lags of temperature up to 7 days. An estimated 7% increase in all cause mortality occurred during June to August 2003. Excess mortality was limited to the region north of the Alps, to inhabitants of cities and suburban areas and was more pronounced among the elderly and the inhabitants of Basel, Geneva and Lausanne. North of the Alps, deviations in daily mortality were significantly correlated with deviations in maximum daily temperatures and night temperatures. The combination of day temperature above 35 degrees C and night temperatures above 20 degrees C predominantly occurred in Basel and Geneva and might in part explain the regional differences in excess mortality. As the number of elderly people in Switzerland continues to rise and the occurrence of heat waves is predicted to increase as a consequence of global warming, preventive programmes targeting susceptible populations during heat waves are warranted.

Mortality among hemodialysis patients in Europe, Japan, and the United States: Case-mix effects

Mortality among hemodialysis patients in Europe, Japan, and the United States: Case-mix effects

Mortality among hemodialysis patients in Europe, Japan, and the United States: Case-mix effects

The Dialysis Outcomes and Practice Patterns Study is well suited to identify case-mix effects, given its extensive data set. The data set was used to examine the influence of case-mix variables on mortality and the extent to which these variables account for differences in mortality across regions, as well as the prevalence and incidence of hepatitis B and hepatitis C. Demographic and comorbid disease features were determined for 8,615 patients internationally; mortality was recorded for this cohort, plus replacement patients (total n = 16,720), from 1996 to 2002. Mortality was associated with increasing age, nonblack race, coronary artery disease, congestive heart failure, other cardiac disease, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, absence of hypertension, lung disease, cancer, human immunodeficiency virus infection, gastrointestinal bleeding, neurologic disease, psychiatric disease, cellulitis/gangrene, hepatitis C, and smoking. US patients were slightly older than those in Europe or Japan and had the highest prevalence of diabetes, coronary artery disease, congestive heart failure, peripheral vascular disease, and cerebrovascular disease. Upon adjusting for case-mix to assess mortality across facilities, it was found that regional differences in mortality (highest in the United States and lowest in Japan) and differences across facilities within nations remain after such corrections. It is likely that practice patterns account for some of this variation. Prevalence of hepatitis B virus (HBV) across facilities increased as the number of dialyzing patients per facility increased; risk of HBV seroconversion decreased among facilities using protocols for treatment of patients with HBV infection. Greater employment of staff with at least 2 years of formal nursing training was associated with lower prevalence of hepatitis C virus infection and lower seroconversion risk.

Regional differences in perinatal mortality rates in Japan--an investigation based on vital statistics

This study investigated whether regional differences in perinatal mortality rates are related to distances to medical resources for perinatal care, such as the Neonatal Intensive Care Unit (NICU). Using the census for Japan in 2000, all municipalities in Japan were classified into four groups based on population size: municipalities of 1,000,000 people or more (Group 1), municipalities between 350,000 and 1,000,000 people (Group 2), municipalities between 10,000 and 350,000 people (Group 3), and municipalities of less than 10,000 people (Group 4). Then, using the vital statistics, perinatal mortality rates for all groups were calculated. In addition, setting the perinatal mortality rate in Group 1 as a referent, we calculated the differences in the rates to detect regional differences in perinatal mortality in Japan. Finally, we compared the distances between the municipality center and the closest NICU among the four groups by one-way ANOVA. The perinatal mortality rates of Groups 1, 2, 3 and 4 were 5.38, 5.58, 5.88 and 6.31, respectively. The perinatal mortality rate ratios (95%CI) were 1.04 (0.96-1.12), 1.09 (1.03-1.16), and 1.17 (1.05-1.31), respectively. The perinatal mortality rate differences (95%CI) were 0.20 (-0.24-0.64), 0.50 (0.15-0.84), and 0.93 (0.23-1.62), respectively. The distances (95%CI) between the center of the municipalities and the closest NICU for Groups 1, 2, 3 and 4 were 2.61 (1.56-3.66) km, 4.23 (2.74-5.72) km, 20.79 (17.68-23.90) km and 38.07 (31.65-44.48) km, respectively. All of the differences among the groups were significant (p < 0.001), except for the difference between Group 1 and Group 2. There are regional differences in perinatal mortality rates in Japan. This study suggests that the difference is associated with the uneven distribution of NICUs.

Krill population dynamics in the Scotia Sea: variability in growth and mortality within a single population

Understanding the demographics of Antarctic krill over large scales may be complicated by regional differences in the processes that govern population structure. The influence of regional differences in growth and mortality on population size structure was examined using data on the length–frequency distribution of krill in the Scotia Sea using samples from the South Shetland Islands and South Georgia collected annually from 1991 to 2000. A correction function, which took account of the higher growth rate at South Georgia, produced a consistent similarity in the position of the modal size classes that was not present in the raw data. Optimising the mortality rate, to minimise the differences in the growth corrected length–frequency distribution, suggested a higher mortality rate at South Georgia that the South Shetlands. The intra-specific variations in growth and mortality rates are consistent with published values and with other Euphausiids species. Having accounted for the demographic plasticity, it is apparent that strong recruitment of the smallest size class of krill is represented in both populations simultaneously. It appears that first-year krill are advected into different regions of the Scotia Sea where the resultant population size structure is determined by regional differences in growth and mortality. The majority of the commercial harvest of krill in the Antarctic occurs in a relatively small number of regional fisheries within the Scotia Sea and is managed using population models based on a single set of demographic parameters. Where substantial differences in these parameters exist between fishing areas, the calculation of catch limits should take these differences into account.

Potential impact of socioeconomic differences on clinical outcomes in international clinical trials

Despite advances in therapy, global mortality due to acute myocardial infarction remains high. The international Hirulog and Early Reperfusion or Occlusion (HERO-2) trial of 17,073 patients with ST-segment elevation myocardial infarction provided the opportunity to explore international differences in outcomes.Patient characteristics, treatment, and outcomes were compared across 5 diverse regions: Western countries, Latin America, Eastern Europe, Russia, and Asia. In addition, a representative sample of 1,743 screened patients was compared with enrolled patients.Larger percentages of eligible patients were randomized in Eastern Europe, Russia, and Asia than Western countries. These regions enrolled more patients with anterior myocardial infarction, Killip class III or IV, and late presentation (>4 hours). More patients aged >75 years were enrolled from Western countries. Overall risk levels were similar. Eastern Europe and Russia had lower rates than Western countries of coronary revascularization (2% vs 18%) and longer hospital stays (median 18 vs 7 days). Thirty-day mortality was lower in Western countries; 6.7% versus 10.2% to 13.2% elsewhere, whereas reinfarction was more frequent (3.2% vs 1.5% to 3.0%; each, P < .001). Regional mortality differences persisted after adjustment for baseline risk factors, treatments, or national health and economic statistics (each P < .001).The variation in mortality and other clinical outcomes across geographic regions was not adequately explained by risk factors, patterns of care, or national health statistics. Nevertheless, large international trials are a better way to assess potential new treatments across many countries than the alternative of separate smaller trials in each region.

Variations in 'avoidable' mortality: a reflection of variations in incidence?

Variations in 'avoidable' mortality may reflect variations in the quality of care, but they may also be due to variations in incidence or severity of diseases. We studied the association between regional variations in 'avoidable' mortality and variations in disease incidence. For a selection of conditions we also analysed whether the proportion of in-hospital deaths can explain the regional variations in incidence-adjusted mortality. Relative risks for mortality, incidence, incidence-adjusted mortality and in-hospital mortality (1984-1994) were calculated by log-linear regression. Linear regression was used to examine the relationship between mortality and incidence on the one hand, and between incidence-adjusted mortality and in-hospital mortality on the other. Significant regional mortality variations were found for cervical cancer, cancer of the testis, hypertensive and cerebrovascular disease, influenza/pneumonia, cholecystitis/lithiasis, perinatal causes and congenital cardiovascular anomalies. Regional mortality differences in general were only partly accounted for by incidence variations. The only exception was cervical cancer, which no longer showed significant variations after adjustment for incidence. The contribution of inhospital mortality variations to total cause-specific mortality variations varied between conditions: the highest percentage of explained variance was found for mortality from CVA (60.1%) and appendicitis (29.2%). Incidence data are a worthy addition to studies on 'avoidable' mortality. It is to be expected that the incidence-adjusted mortality rates are more sensitive for quality-of-care variations than the 'crude' mortality variations. Nevertheless, further research at the individual level is needed to identify possible deficiencies in health care delivery.

1.P.339 Are regional differences in coronary mortality in France related to case-fatality or to incidence of events?

1.P.339 Are regional differences in coronary mortality in France related to case-fatality or to incidence of events?

760 Air pollution, temperature and regional differences in lung cancer mortality in Japan

760 Air pollution, temperature and regional differences in lung cancer mortality in Japan

Cirrhosis of the liver in Brazil: mortality and productive years of life lost prematurely

This descriptive study was done using official data on mortality from cirrhosis of the liver for the year 1989. Its objectives are: (a) to describe mortality from cirrhosis of the liver in Brazilian adults; (b) to estimate the productive years of life lost (PYLL) prematurely (between 20 and 59 years of age) from this cause; and (c) to show any regional differences in cirrhosis mortality or PYLL. The raw data were adjusted by age and sex, using the 1980 population of Brazil as the standard. Calculation of PYLL was based on the formula of Romeder and McWhinnie for years of potential life lost, modified by the author to express productive years of life lost. The crude death rates from cirrhosis were higher in the Southeast and North, and in all regions they were higher in males, the countrywide male/female ratio being 4.5. Cirrhosis mortality among males ranged from a low of 14.37 deaths per 100 000 in the Center-West to a high of 35.86 per 100 000 in the Southeast; for females the rates ranged from 3.49 deaths per 100 000 in the Center-West to 8.5 deaths per 100 000 in the North. The cirrhosis mortality curves by age for men showed a leveling off or decline after age 60, except in the North where the curve continued to rise. Like this latter curve, the cirrhosis mortality curves for women also kept rising progressively with increasing age, most markedly in the North and Northeast. Overall, mortality from cirrhosis of the liver accounted for 48.7% of the deaths from digestive system disorders among men and for 24.1% of such deaths among women. Of the 138 860 PYLL from cirrhosis of the liver in 1989, 83.2% were lost by males; but the average loss per person dying of cirrhosis nationwide, around 15.5 years, was similar for both sexes. Regionally, the average PYLL per affected person was higher for men and women in the North and for women in the Center-West than it was in the other regions. The data suggest that cirrhosis of the liver among men in all the regions, except the North, is probably attributable largely to alcoholism. Among males from the North, there is strong evidence that cirrhosis with a viral etiology (hepatitis B and C viruses) is also important. For women, the evidence suggests that cirrhosis of viral etiology predominates.

Origins of Regional Differences in Mortality from Ischaemic Heart Disease in Finland

Origins of Regional Differences in Mortality from Ischaemic Heart Disease in Finland

Regional differences in consumption of 103 fat products in Belgium: a supermarket-chain sales approach.

In Belgium, important regional differences in mortality exist which have been linked to differences in dietary consumption patterns. To study regional food consumption in Belgium, sales data of 103 spreading and cooking fat products in 110 branch stores of a major supermarket chain (Colruyt) for 12 months (1991-92) were analyzed. Sale of more ordinary and polyunsaturated spreading margarine and of more polyunsaturated low-fat spread in the north in combination with a greater sale of butter and dairy low-fat spread in the south resulted in a P/S-ratio of 0.99 in the north vs. 0.40 in the south (p < 0.001) and a U/S-ratio of 1.93 vs. 1.10 (p < 0.001) for spreading fats. The P/S- and U/S-ratios of cooking fats were lower in the north (ns). Mortality data correlated positively with the sale of butter and dairy low-fat spread and negatively with sales data of spreading margarine, polyunsaturated spreading margarine, and polyunsaturated low-fat spread (all p < 0.001). Sales data from supermarket chains provide useful information on regional fat consumption and offer interesting perspectives of trends over time.

Regional differences in cardiovascular risk factor prevalence in Tasmania: are they consistent with the increased cardiovascular mortality?

The death rate from cardiovascular disease in Tasmania has been among the highest in Australian States for a number of years. The North-West (NW) and Northern regions of Tasmania account for most of the increased mortality. To determine the prevalence of cardiovascular risk factors in the North and NW regions of Tasmania and to ascertain whether any differences are consistent with the regional patterns of mortality for ischaemic heart disease (IHD) within the State. The design of the study was almost identical to the previous National Heart Foundation (NHF) Risk Factor Prevalence Survey conducted in 1989. The subjects, aged 20-69 years, were randomly selected from the Electoral Roll with 1146 subjects participating in the North and 1219 in the NW. Subjects answered a detailed questionnaire and then underwent a brief physical examination with venipuncture for blood lipids. Hobart data from the NHF Risk Factor Prevalence Survey in 1989 were used as an estimate of risk factor prevalence in the Southern region. In both males and females, mean systolic blood pressure was significantly higher in the NW than the South which was in turn higher than the North. Mean serum cholesterol levels in males were higher in the NW than the North. Smoking behaviour was similar in males and females in all regions. Males and females in the NW and North were more inactive than those in the South. Similar proportions in all regions were on either 'no specific' or 'fat modified' diets. Body mass index in males and females was higher in the NW and North but waist to hip ratios failed to show a consistent trend. While the NW has an unfavourable risk factor profile compared with the South, the North does not. The risk factor data are broadly consistent with, but unlikely to be sufficient to explain fully, the regional differences in mortality from IHD.