Regional Disparities In Mortality Research Articles

Spatial-temporal analysis of cerebral infarction mortality in Hokkaido, Japan: an ecological study using a conditional autoregressive model

Background:Accessibility to stroke treatments is a challenge that depends on the place of residence. However, recent advances in medical technology have improved health outcomes. Nevertheless, the geographic heterogeneity of medical resources may increase regional disparities. Therefore, evaluating spatial and temporal influences of the medical system on regional outcomes and advanced treatment of cerebral infarction are important from a health policy perspective. This spatial and temporal study aims to identify factors associated with mortality and to clarify regional disparities in cerebral infarction mortality at municipality level.Methods:This ecological study used public data between 2010 and 2020 from municipalities in Hokkaido, Japan. We applied spatial and temporal condition autoregression analysis in a Bayesian setting, with inference based on the Markov chain Monte Carlo simulation. The response variable was the number of deaths due to cerebral infarction (ICD-10 code: I63). The explanatory variables were healthcare accessibility and socioeconomic status.Results:The large number of emergency hospitals per 10,000 people (relative risk (RR) = 0.906, credible interval (Cr) = 0.861 to 0.954) was associated with low mortality. On the other hand, the large number of general hospitals per 10,000 people (RR = 1.123, Cr = 1.068 to 1.178) and longer distance to primary stroke centers (RR = 1.064, Cr = 1.014 to 1.110) were associated with high mortality. The standardized mortality ratio decreased from 2010 to 2020 in Hokkaido by approximately 44%. Regional disparity in mortality remained at the same level from 2010 to 2015, after which it narrowed by approximately 5% to 2020. After mapping, we identified municipalities with high mortality rates that emerged in Hokkaido’s central and northeastern parts.Conclusion:Cerebral infarction mortality rates and the disparity in Hokkaido improved during the study period (2010–2020). This study emphasized that healthcare accessibility through places such as emergency hospitals and primary stroke centers was important in determining cerebral infarction mortality at the municipality level. In addition, this study identified municipalities with high mortality rates that require healthcare policy changes. The impact of socioeconomic factors on stroke is a global challenge, and improving access to healthcare may reduce disparities in outcomes.

Quantifying the contribution of smoking to regional mortality disparities in Germany: a cross-sectional study.

ObjectivesSubstantial regional variation in smoking behaviour in Germany has been well documented. However, little is known about how these regional differences in smoking affect regional mortality disparities. We aim to assess the contribution of smoking to regional mortality differentials in Germany over the last four decades.DesignA cross-sectional study using official cause-specific mortality data by German Federal State aggregated into five macro-regions: East, North, South, West-I and West-II.ParticipantsThe entire population of Germany stratified by sex, age and region during 1980–2019.Main outcome measuresSmoking-attributable fraction estimated using the Preston-Glei-Wilmoth method; life expectancy at birth before and after the elimination of smoking-attributable deaths.ResultsIn all macro-regions, the burden of past smoking has been declining among men but growing rapidly among women. The hypothetical removal of smoking-attributable deaths would eliminate roughly half of the contemporary advantage in life expectancy of the vanguard region South over the other macro-regions, apart from the East. In the latter, smoking only explains around a quarter (0.5 years) of the 2-year difference in male life expectancy compared with the South observed in 2019. Among women, eliminating smoking-attributable deaths would put the East in a more disadvantageous position compared with the South as well as the other macro-regions.ConclusionWhile regional differences in smoking histories explain large parts of the regional disparities in male mortality, they are playing an increasingly important role for female mortality trends and differentials. Health policies aiming at reducing regional inequalities should account for regional differences in past smoking behaviour.

Urban–rural disparities in old-age mortality vary systematically with age: evidence from Germany and England & Wales

ObjectivesPopulation aging — which tends to be more pronounced in rural than in urban areas — poses important challenges for facilitating equal opportunities for aging well and ‘aging in place.’ Unmet health care needs among the older rural population may result in poorer health and higher mortality, but the scientific evidence of a systematic rural mortality disadvantage at older ages is scarce. We argue that systematic urban–rural mortality differences by age may be found if the confounding effect of life expectancy is considered. Study designNationwide population-based study. MethodsWe draw on age- and sex-specific data for the population aged 60+ years in NUTS-3 regions in Germany (2016–2018) and LAU-1 regions in England & Wales (2017–2019). To account for the confounding effect of life expectancy, we compare age-specific mortality only across urban and rural regions with similar life expectancy levels. We quantify statistical uncertainty with bootstrapping. ResultsThe results show a remarkable shift from higher mortality in urban regions to higher mortality in rural regions with increasing age, when controlling for the confounding effect of life expectancy. That is, the urban mortality disadvantage is strongest for the population aged 60–79 years, whereas the pattern shifts toward a rural mortality disadvantage for the population aged 80 years and older. This pattern is present at all levels of life expectancy, for both sexes and in both countries. ConclusionThe shift from urban to rural excess mortality over age suggests that regions may vary in their capability to respond to arising health issues across older ages. This systematic mortality disadvantage is of high public health relevance and should be considered in designing policies to reduce regional mortality disparities.

Gram-negative neonatal sepsis in low- and lower-middle-income countries and WHO empirical antibiotic recommendations: A systematic review and meta-analysis.

BackgroundNeonatal sepsis is a significant global health issue associated with marked regional disparities in mortality. Antimicrobial resistance (AMR) is a growing concern in Gram-negative organisms, which increasingly predominate in neonatal sepsis, and existing WHO empirical antibiotic recommendations may no longer be appropriate. Previous systematic reviews have been limited to specific low- and middle-income countries. We therefore completed a systematic review and meta-analysis of available data from all low- and lower-middle-income countries (LLMICs) since 2010, with a focus on regional differences in Gram-negative infections and AMR.Methods and findingsAll studies published from 1 January 2010 to 21 April 2021 about microbiologically confirmed bloodstream infections or meningitis in neonates and AMR in LLMICs were assessed for eligibility. Small case series, studies with a small number of Gram-negative isolates (<10), and studies with a majority of isolates prior to 2010 were excluded. Main outcomes were pooled proportions of Escherichia coli, Klebsiella, Enterobacter, Pseudomonas, Acinetobacter and AMR. We included 88 studies (4 cohort studies, 3 randomised controlled studies, and 81 cross-sectional studies) comprising 10,458 Gram-negative isolates from 19 LLMICs. No studies were identified outside of Africa and Asia. The estimated pooled proportion of neonatal sepsis caused by Gram-negative organisms was 60% (95% CI 55% to 65%). Klebsiella spp. was the most common, with a pooled proportion of 38% of Gram-negative sepsis (95% CI 33% to 43%). Regional differences were observed, with higher proportions of Acinetobacter spp. in Asia and Klebsiella spp. in Africa. Resistance to aminoglycosides and third-generation cephalosporins ranged from 42% to 69% and from 59% to 84%, respectively. Study limitations include significant heterogeneity among included studies, exclusion of upper-middle-income countries, and potential sampling bias, with the majority of studies from tertiary hospital settings, which may overestimate the burden caused by Gram-negative bacteria.ConclusionsGram-negative bacteria are an important cause of neonatal sepsis in LLMICs and are associated with significant rates of resistance to WHO-recommended first- and second-line empirical antibiotics. AMR surveillance should underpin region-specific empirical treatment recommendations. Meanwhile, a significant global commitment to accessible and effective antimicrobials for neonates is required.

Assessments of provincial mortality in China’s 2010 population census based on the Developing Countries Mortality Database model life table

The provincial mortality data of China’s 2010 population census sustains the study of regional mortality disparities, but the data suffer from the disadvantage of underestimation. Due to the deficiency of relevant information, little research on the quality of province-specific mortality data has been published with respect to the 2010 census. We estimated provincial underestimation of infant and old-age mortality, analysed regional disparities using the Developing Countries Mortality Database model life table and re-calculated sex-specific life expectancy at birth and at age 60 for the 2010 census. Results show that in most provinces the infant mortality rate is underestimated by at least 70% and that the related data for the eastern and southwestern provinces show better quality than that of other areas. Old-age mortality underestimate rates vary among provinces: the eastern, south-central and northern provinces present less severe underestimations than the southwest, northwest and northeast provinces. After adjustments, the province gap in e0 ranged from 0 to 14.8 years for boys and 0 to 15.9 years for girls, that in e60 ranged from 0 to 8.8 years for men and 0 to 9.9 years for women. Sex differences in life expectancy increased compared to the reported values of the 2010 census.

Gram-Negative Neonatal Sepsis in Low- and Middle- Income Countries: How Appropriate are the WHO Recommended Empirical Sepsis Antibiotic Regimens? A Systematic Review and Meta-Analysis

Background: Neonatal sepsis is a significant global health issue associated with marked regional disparities in mortality. Antimicrobial resistance (AMR) is a growing concern in Gram-negative organisms which increasingly predominate in neonatal sepsis, and existing WHO empirical antibiotic recommendations may no longer be appropriate. Previous systematic reviews have been limited to specific low- and middle-income countries (LMICs). We therefore completed a systematic review and meta-analysis of available data from all LMICs since 2010, with a focus on regional differences in Gram-negative infections and AMR. Methods: All studies published from 2010 with microbiologically confirmed bloodstream infections or meningitis in neonates and AMR from LMICs were assessed for eligibility. Small case series or number of Gram-negative isolates (<10), and studies with a majority of isolates prior to 2010 were excluded. Main outcomes were pooled proportions of E.coli, Klebsiella, Enterobacter, Pseudomonas, Acinetobacter and AMR. Findings: We included 75 studies comprising 17,066 positive blood cultures from 16 LMICs. No studies were identified outside of Africa and Asia. The estimated pooled proportion of neonatal sepsis caused by Gram-negative organisms was 60% (95% CI 54-65%). Klebsiella spp was the most common, with a pooled proportion of 37% of Gram-negative sepsis (95% CI 32-43%). Resistance to aminoglycosides and 3rd generation cephalosporins ranged from 42-69% and 59-84%, respectively. Interpretation: Gram-negative bacteria are an important cause of neonatal sepsis in LMICs and associated with significant rates of resistance to WHO recommended first and second line empirical antibiotics. AMR surveillance should underpin region-specific empirical treatment recommendations. Meanwhile, a significant global commitment to accessible and effective antimicrobials for neonates is required. Funding Statement: Sophie CH Wen is supported by a Queensland Health Clinical Research Fellowship. Geoff Spurling, David L Paterson, Adam D Irwin, and Colleen L Lau are supported by National Health and Medical Research Council (NHMRC) Investigator Grants. Declaration of Interests: None to declare.

Erratum to: Declining regional disparities in mortality in the context of persisting large inequalities in economic conditions: the case of Germany.

BACKGROUND Subnational regional mortality inequalities are large and appear to be mostly increasing within industrialized countries, although comparative studies across high-income countries are scarce. Germany is an important country to examine because it continues to experience considerable economic disparities between its federal states, in part resulting from its former division. METHODS We analyse state-level mortality in Germany utilizing data from a newly constructed regional database based on the methodology of the Human Mortality Database. We compare time trends (1991-2015) in the German state-level standard deviation in life expectancy to that of other large, wealthy countries and examine the association between mortality and economic inequalities at the regional level. Finally, using contour-decomposition methods, we investigate the degree to which age patterns of mortality are converging across German federal states. RESULTS Regional inequalities in life expectancy in Germany are comparatively low internationally, particularly among women, despite high state-level inequalities in economic conditions. These low regional mortality inequalities emerged 5-10 years after reunification. Mortality is converging over most ages between the longest- and shortest-living German state populations and across the former East-West political border, with the exception of an emerging East-West divergence in mortality among working-aged men. CONCLUSIONS The German example shows that large regional economic inequalities are not necessarily paralleled with large regional mortality disparities. Future research should investigate the factors that fostered the emergence of this unusual pattern in Germany.

Declining regional disparities in mortality in the context of persisting large inequalities in economic conditions: the case of Germany.

BackgroundSubnational regional mortality inequalities are large and appear to be mostly increasing within industrialized countries, although comparative studies across high-income countries are scarce. Germany is an important country to examine because it continues to experience considerable economic disparities between its federal states, in part resulting from its former division.MethodsWe analyse state-level mortality in Germany utilizing data from a newly constructed regional database based on the methodology of the Human Mortality Database. We compare time trends (1991–2015) in the German state-level standard deviation in life expectancy to that of other large, wealthy countries and examine the association between mortality and economic inequalities at the regional level. Finally, using contour-decomposition methods, we investigate the degree to which age patterns of mortality are converging across German federal states.ResultsRegional inequalities in life expectancy in Germany are comparatively low internationally, particularly among women, despite high state-level inequalities in economic conditions. These low regional mortality inequalities emerged 5–10 years after reunification. Mortality is converging over most ages between the longest- and shortest-living German state populations and across the former East–West political border, with the exception of an emerging East–West divergence in mortality among working-aged men.ConclusionsThe German example shows that large regional economic inequalities are not necessarily paralleled with large regional mortality disparities. Future research should investigate the factors that fostered the emergence of this unusual pattern in Germany.

The effect of community socioeconomic status on sepsis-attributable mortality

PurposeCommunity factors may play a role in determining individual risk for sepsis, as well as sepsis-related morbidity and mortality. We sought to define the relationship between community socioeconomic status and mortality due to sepsis in an urban locale. MethodsUsing community statistical areas of Baltimore City, we dichotomized neighborhoods at median household income, and compared distribution of outcomes of interest within the two income categories. We performed multivariable regression analyses to determine the relationship between socioeconomic variables and sepsis-attributable mortality. ResultsThe collective median household income was $38,660 (IQR $32,530, 54,480), family poverty rate was 28.4% (IQR 13.5, 38.8%), and rate of death from sepsis was 3.1 per 10,000 persons (IQR 2.60, 4.10). Lower household income communities demonstrated higher rates of death from sepsis (3.65 (IQR 2.78, 4.40)) than higher household income communities (2.80 (IQR 2.05, 3.55)) (p = .02). In regression models, household income (β = −8.42, p = .006) and percentage of poverty in communities (β = 2.71, p = .01) demonstrated associations with sepsis-attributable mortality. DiscussionOur findings suggest that socioeconomic variables play significant role in sepsis-attributable mortality. Such confirmation of regional disparities in mortality due to sepsis warrants further consideration, as well as integration, for future national sepsis policies.

Regional Mortality Disparities in Germany: Long-Term Dynamics and Possible Determinants.

While regional mortality inequalities in Germany tend to be relatively stable in the short run, over the course of the past century marked changes have occurred in the country’s regional mortality patterns. These changes include not only the re-emergence of stark differences between eastern and western Germany after 1970, which have almost disappeared again in the decades after the reunification of Germany in 1990; but also substantial changes in the disparities between northern and southern Germany. At the beginning of the twentieth century, the northern regions in Germany had the highest life expectancy levels, while the southern regions had the lowest. Today, this mortality pattern is reversed. In this paper, we study these long-term trends in spatial mortality disparities in Germany since 1910, and link them with theoretical considerations and existing research on the possible determinants of these patterns. Our findings support the view that the factors which contributed to shape spatial mortality variation have changed substantially over time, and suggest that the link between regional socioeconomic conditions and recorded mortality levels strengthened over the last 100 years.

Regional variation in mortality from ischaemic heart disease in Poland, 2006-2010.

Spatial differences in mortality in Poland are large and remain unexplained to a large extent. Ischaemic heart disease (IHD) is a good candidate for explaining regional inequalities in mortality in Poland due to the high level of mortality from this cause and the large spatial differences. We describe the contribution of IHD to all-cause mortality in Poland in 2006-2010 on a powiat (Polish district) level and explain the differences in mortality by selected socio-economic factors. We use mortality data from the population registry at the NUTS-4 level for 2006-2010. We map age-standardised all-cause and IHD mortality rates. The contribution of IHD mortality to all-cause mortality was also assessed through variance decomposition. Correlation coefficients between age-standardised mortality rates and selected socio-economic variables were estimated for all powiats and for a group excluding large cities. We demonstrated that regional differences between powiats in IHD mortality do not constitute a major factor behind regional mortality disparities in Poland. However, the spatial patterns for all-cause and IHD mortality in Polish powiats were both related to the level of urbanisation, with group of powiats characterised by the lowest IHD mortality comprising only large cities. The negative effect of large cities on the level of all-cause and IHD mortality was confirmed by the significant correlation between the socio-economic contextual variables, standing for the level of urbanisation, and IHD mortality. Ease of access to medical care in large cities and in particular to cardiology units is an important factor behind the levels of all-cause and IHD mortality in Poland.

Role of smoking in regional variation in mortality in Poland.

We assess the effect of smoking on regional disparities in mortality in Poland and its contribution to the change in regional disparities during the last two decades. We used population-level mortality data from the population registry for 379 Nomenclature of Territorial Units for Statistics (NUTS)-4 Polish regions for 1991-93 and 2008-10. The importance of smoking was assessed by smoking-attributable mortality (SAM) derived using a simplified indirect Peto-Lopez method. Regional differences in age-standardized all-cause, smoking- and non-smoking-attributable mortality (NSAM) rates at ages 35 years and over were mapped, and spatial clustering (Moran's I) and coefficients of variation (CV) were estimated. The contribution of SAM to variation in all-cause mortality was assessed by variance decomposition and compared over time. In 2008-10, all-cause and SAM rates were characterized by a similar pattern of spatial clustering (Moran's I > 0.44, P < 0.0001). For NSAM, a more random pattern with less regional clustering showed (Moran's I = 0.34, P < 0.0001). The contribution of smoking to regional variation was substantial [54%, 95% confidence interval (CI) = 44.9, 62.5 among men; 24.9%, 95% CI = 20.9, 29.1 among women], and compared with 1991-93, 27.5 percentage points lower for men and 6.3 percentage points higher for women. Smoking contributed to the divergence between the regions in all-cause mortality between 1991-93 and 2008-10 for men [increase in CV of SAM by 2% (0, 4%)], but not for women [decrease in CV of SAM by 15% (22, 10%)]. Differences in past smoking behaviour may largely explain the regional differences in all-cause mortality existing in 2008-10 in Poland, and its trends since 1991-1993.

Regional Disparities in Mortality after Ischemic Heart Disease in a Brazilian State from 2006 to 2010

BackgroundHigh technology in the field of interventional cardiology applied in tertiary hospitals has brought enormous benefits in the treatment of ischemic heart disease (IHD). However, IHD mortality rates remain high. We analyzed the relationship between IHD mortality rate and the socioeconomic, demographic, and geographic conditions in 399 cities in Parana state, Brazil, from 2006 to 2010.Methods and ResultsData were obtained from the Mortality Information System and the Brazilian Institute of Geography and Statistics and evaluated through Exploratory Spatial Data Analysis. GeoDa™ was used to analyze 29.351 deaths across 399 cities. We found a positive spatial autocorrelation regarding IHD mortality (I = 0.5913, p = 0.001). There was a significant positive association between each of three socioeconomic and demographic indicators and IHD mortality rate: Population Elderly Index (I = 0.3436), Illiteracy Rate (I = 0.1873) and City Development Index (I = 0.0900). In addition, two indicators presented significant negative association with IHD mortality rate: Adjusted Population Size (I = −0.1216) and Gross Domestic Product (I = −0.0864). We also found a positive association between IHD mortality rates and the geographic distances between patients’ city of residence and their corresponding regional referral centers in interventional cardiology (I = 0.3368). Cities located within Regional Health Units with Reference Interventional Cardiology Center presented a significantly lower average specific mortality rate by IHD. The high mortality rate by IHD within the Regional Health Units was not restricted to socioeconomic and demographic variables, but dependent on the distance between each city and their reference interventional cardiology center.ConclusionsWe conclude that geographic factors play a significant role in IHD mortality within cities. These findings have important policy implications regarding the geographic distribution of cardiac health care networks in Latin America and in other emerging countries.

Spatial disparities in hospital performance

Using a French exhaustive dataset, this article studies the determinants of regional disparities in mortality for patients admitted to hospitals for a heart attack. These disparities are large, with an 80% difference in the propensity to die within 15 days between extreme regions. They may reflect spatial differences in patient characteristics, treatments, hospital characteristics and local healthcare market structure. To distinguish between these factors, we estimate a flexible duration model. The estimated model is aggregated at the regional level and a spatial variance analysis is conducted. We find that spatial differences in the use of innovative treatments play a major role whereas the local composition of hospitals by ownership does not have any noticeable effect. Moreover, the higher the local concentration of patients in a few large hospitals rather than many small ones, the lower the mortality. Regional unobserved effects account for around 20% of spatial disparities.

Social and Economic Disparities under Canadian Health Care

Central to the objectives of Canadian national health insurance were the principles that health is a basic right that should be open to all and that all Canadians, regardless of their ability to pay, would be provided with publicly financed comprehensive hospital and medical services. During the two decades that this program has been in place, substantial gains have been realized in making insured services more accessible to all Canadians, in the reduction of regional mortality disparities, and in a leveling out of earlier sharp differences in the supply of health resources across Canada. These changes have not been matched by any significant realignment of the health status of Canadians relative to their economic circumstances, nor as yet by the full removal of economic constraints affecting accessibility to health services. The Canadian experience raises the fundamental concern of whether a reasonable level of equity can be achieved in nations having distinctive regional priorities, a federal structure linking people of different cultural identities, and where a sharp gradient of economic opportunities is entrenched.

Regional disparities in mortality : the case of North Rhine- Westphalia and Rhineland-Palatinate

Disparités régionales de la mortalité : le cas de la Rhénanie-Nord-Westphalie et de la Rhénanie-Palatinat. Cet article examine les disparités interrégionales de la mortalité en 1979-1981 en Rhénanie du Nord-Westphalie et en Rhénanie-Palatinat, deux Etats de la République Fédérale Allemande. Il a pour objectif la présentation et l'analyse des répartitions régionales de la mortalité par sexe, âge et cause de décès. On a examiné la migration interrégionale en tant que biais pour l'étude des différentiels régionaux de la mortalité. Les relations statistiques entre la densité de population, considérée comme un indicateur socio- économique général, et différents taux de mortalité spécifiques selon le sexe et l'âge ont été étudiées. On a constaté qu'elles varient considérablement selon les causes de décès, ici accidents de la route et cancer du poumon.