Regional Mortality Research Articles

Abstract B103: Racial and geographic disparities in stage of presentation in the colorectal cancer hotspot region of North Carolina

Abstract Background: Despite improvements in colorectal cancer (CRC) screening, treatment, and long-term outcomes, recent epidemiological studies have demonstrated that geographic disparities in CRC persist. Spatial mapping has identified distinct hotspots of increased CRC death rates, including 11 rural counties in eastern North Carolina (NC). The primary aim of this study was to (1) measure CRC incidence by stage in the NC hotspot and non-hotspot regions, and (2) determine if racial disparities exist in stage-stratified incidence and overall mortality rates by geographic region. Methods: CRC diagnosis and death data from 2008-2016 were obtained from the NC Central Cancer Registry and analyzed by hotspot and non-hotspot regions by summary cancer stage at diagnosis and race. The non-hotspot region was defined as 71 NC counties outside of eastern NC. Death rates (95% CI) were expressed per 100,000 person-years and age-adjusted to the 2000 U.S. standard population. Regional rates were calculated for the 8-year interval. Results: Within the hotspot region in eastern NC, the overall incidence rate of CRC is higher than non-hotspot NC [43.7 (95% CI 39.2-48.8) vs 38.4 (95% CI 37.6-39.2)]. Within the hotspot counties, overall incidence rates are higher among African American (AA) compared to White patients [51.1 (95% CI 43.4-59.9) vs. 39.1 (95% CI 33.6-45.4)], and this disparity persists across all stage categories. The incidence among AA and White patients with localized disease is 18.4 and 14.4, respectively; for regional disease, 16.7 vs. 13.9; and for distant disease, 11.4 and 7.8. Similar racial disparities in CRC incidence are also observed within the non-hotspot counties (localized 16.1 vs. 13.5, regional 15.2 vs. 13.5, and distant 11.3 vs. 7.8). CRC mortality rates in the hotspot counties are higher among both AA and White patients (21.7 and 15.5, respectively) compared to non-hotspot NC (19.1 and 12.8, respectively), although the absolute difference by race is similar (6.2 vs. 6.3, respectively). Conclusions: Patients residing within the 11 rural hotspot counties in NC have higher age-adjusted incidence of localized, regional, and distant CRC and higher mortality rates than patients in non-hotspot counties. Noteworthy racial disparities exist in both stage at presentation and mortality rates; however, absolute racial disparities appear similar in both geographic regions. Future work should investigate the underlying etiology for both increased CRC incidence and mortality among AA and White patients in the NC hotspot counties. Citation Format: Tyler Hinshaw, Suzanne Lea, Justin Arcury, Alexander A Parikh, Rebecca A Snyder. Racial and geographic disparities in stage of presentation in the colorectal cancer hotspot region of North Carolina [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B103.

Covid-19: Open-Data Resources for Monitoring, Modeling, and Forecasting the Epidemic

We provide an insight into the open-data resources pertinent to the study of the spread of the Covid-19 pandemic and its control. We identify the variables required to analyze fundamental aspects like seasonal behavior, regional mortality rates, and effectiveness of government measures. Open-data resources, along with data-driven methodologies, provide many opportunities to improve the response of the different administrations to the virus. We describe the present limitations and difficulties encountered in most of the open-data resources. To facilitate the access to the main open-data portals and resources, we identify the most relevant institutions, on a global scale, providing Covid-19 information and/or auxiliary variables (demographics, mobility, etc.). We also describe several open resources to access Covid-19 datasets at a country-wide level (i.e., China, Italy, Spain, France, Germany, US, etc.). To facilitate the rapid response to the study of the seasonal behavior of Covid-19, we enumerate the main open resources in terms of weather and climate variables. We also assess the reusability of some representative open-data sources.

High incidence of sea turtle stranding in the southwestern Atlantic Ocean

AbstractSea turtles are globally threatened due to short- and long-term exposure to anthropogenic activities. Many life-history traits make it difficult to study these species in the wild. Stranding events provide invaluable data to infer key aspects of sea turtle ecology, such as regional occurrence, health status, mortality rates, and potential threats. In this study, we investigate spatial and temporal patterns of sea turtle occurrence and mortality in the southwestern Atlantic Ocean based on a systematic, large-scale survey programme covering 1040 km of coastline during 732 d of two consecutive years. From the 12 571 animals recovered, juvenile green turtles were the most common (90.4%), but four other species were also recorded. A significant non-linear effect of time and space in the number of stranding events was observed. The most parsimonious mixed linear model further indicated that stranding events were influenced by individual (sex, size), health (body condition, pathologies, decomposition), and oceanographic factors (chlorophyll-a, sea surface temperature, salinity, wave height). More than simply describing the spatiotemporal occurrence and aspects of sea turtles’ life history in an otherwise understudied area, this intensive field study provides evidence for relatively high mortality rates—an essential baseline information for guiding conservation efforts.

Proper Disposal of Prescription Opioids in Southwest Virginia: Assessment of Patient, Physician, and Medical Student Beliefs and Practices.

Southwestern Virginia demonstrates the highest regional mortality rate from prescription opioid overdoses. Nationally, 65% of patients misusing opioid medications received them from friends and family, underscoring the need for effective disposal of unused narcotics. (1) To understand patient, provider, and medical student beliefs and misconceptions regarding proper methods of opioid disposal; (2) to characterize discrepancies that exist between patient self-reported habits and medical student/provider perceptions of opioid usage, disposal, and diversion. Descriptive, cross-sectional, observational study. Large, nonprofit health care organization and allopathic medical school in Southwestern Virginia. All ambulatory patients 18 years or older presenting for elective consultation at health system orthopedics department; all institutionally employed physicians with active system e-mail addresses; and all current students at the associated medical school. Patients: The number who had received information regarding proper methods of opioid disposal, intended disposal method, methods of disposal considered appropriate, comfort level with opioid disposal, and demographic data. Physicians and Medical Students: The number who had received instruction regarding proper methods of opioid disposal, acceptable means of opioid disposal, most appropriate disposal method, disposal method most likely to be employed by patients, practice profile/prescribing data, and medical school year. In total, 64% of patients (n = 255/750) had never received instruction from a physician regarding opioid disposal; 56% of physicians (n = 212/732) and 78% (n = 80/171) of medical students indicated that they never received formal instruction regarding methods of disposal. The majority of physicians believed that their patients are most likely to use in-home methods of disposal or store prescription medications for future use; 61% of patients indicated a preference for accessible disposal facilities. The discrepancy between patient and physician responses highlights a lack of communication regarding disposal of unused opioid medications and is a target for future intervention.

FORECASTING MULTIPLE FUNCTIONAL TIME SERIES IN A GROUP STRUCTURE: AN APPLICATION TO MORTALITY

AbstractWhen modelling subnational mortality rates, we should consider three features: (1) how to incorporate any possible correlation among subpopulations to potentially improve forecast accuracy through multi-population joint modelling; (2) how to reconcile subnational mortality forecasts so that they aggregate adequately across various levels of a group structure; (3) among the forecast reconciliation methods, how to combine their forecasts to achieve improved forecast accuracy. To address these issues, we introduce an extension of grouped univariate functional time-series method. We first consider a multivariate functional time-series method to jointly forecast multiple related series. We then evaluate the impact and benefit of using forecast combinations among the forecast reconciliation methods. Using the Japanese regional age-specific mortality rates, we investigate 1–15-step-ahead point and interval forecast accuracies of our proposed extension and make recommendations.

Dynamic principal component regression for forecasting functional time series in a group structure

ABSTRACTWhen generating social policies and pricing annuity at national and subnational levels, it is essential both to forecast mortality accurately and ensure that forecasts at the subnational level add up to the forecasts at the national level. This has motivated recent developments in forecasting functional time series in a group structure, where static principal component analysis is used. In the presence of moderate to strong temporal dependence, static principal component analysis designed for independent and identically distributed functional data may be inadequate. Thus, through using the dynamic functional principal component analysis, we consider a functional time series forecasting method with static and dynamic principal component regression to forecast each series in a group structure. Through using the regional age-specific mortality rates in Japan obtained from the Japanese Mortality Database [(2019). National Institute of Population and Social Security Research. Available at http://www.ipss.go.jp/p-toukei/JMD/index-en.asp (data downloaded on 14 August 2018)], we investigate the point and interval forecast accuracies of our proposed extension, and subsequently make recommendations.

Regional inequalities in benzene exposures across the European petrochemical industry: A Bayesian multilevel modelling approach

BackgroundPollutants released from the petrochemical industry are thought to increase the risk of mortality in fence-line communities, yet the results from previous studies are often inconsistent and lack a global perspective, hampered by the absence of cohesive cross-country research. ObjectivesTo provide the first Pan-European analysis of benzene exposures from the petrochemical industry, connecting polluting practices to pollution episodes and disparities in regional mortality rates, identifying the measures of best environmental practice to mitigate adverse outcomes. MethodsThe activity, classification and location of onshore petrochemical facilities within EU-28 Member States were extracted from the ‘European Pollutant Release and Transfer Register’ (E-PRTR), which holds records on 31,753 industrial operations for the reporting period of 2007–15. Parent company records were collected from the Moody's Analytics Amadeus database of 487,338 active companies across Europe. The EUROSTAT census provided records of income, life expectancy, and the underlying demographics used to calculate standardised health outcomes based on 9,936 sub-populations within the NUTS2 regions. The European Environment Agency provided ambient concentrations of benzene from 579 air quality stations. Bayesian multilevel models were constructed to account for variability caused by spatial hierarchical structures, uncertainty in the estimates, and to incorporate both individual and group-level influences. ResultsHigher levels of benzene emissions from petrochemical operations, both overall and in terms of specific pollution events, were associated with increased mortality rates for nearby residential populations, particularly in areas with socioeconomic deprivation. We identify uneven patterns of polluting practices within the industry, and locations that require epidemiological studies. ConclusionsWhile petrochemical facilities in all European Union regions are regulated to be compliant with the annual average benzene limit of 5 μg/m3, uneven exposures still present regional health inequalities. We recommend extending benzene regulations to an hourly or daily limit, alongside the strengthening of regulation for other toxic petrochemical releases.

Comparing regional neonatal mortality rates: the influence of registration of births as live born for birth weight

ObjectiveTo investigate regional variation in the registration of births (still+live) as live born for birth weight <500 g and the impact on the city/county ranking of neonatal mortality rate (NMR)...

MORTALITY FROM CIRCULATORY SYSTEM DISEASES IN THE KEMEROVO REGION AND THE RUSSIAN FEDERATION IN 2000–2016

Aim. To estimate the trends in mortality from circulatory system diseases, including coronary artery disease and cerebrovascular diseases, in the Kemerovo region in the period from 2000 to 2016 and compare it with the national trends.Methods. Data on national mortality rates, including those among adults of working age (men 16–59 years, women 16–54 years) from circulatory system diseases, coronary artery disease and cerebrovascular diseases in the period from 2000 to 2016 were obtained through the national statistical reports. A linear trend in the regional mortality rate to the national one has been reported.Results. Mortality rate from circulatory system diseases in the period from 2000 to 2016 tends to a decrease in the Kemerovo region and the Russian Federation. The comparative analysis of mortality rates in the Kemerovo region and the Russian Federation reported lower regional mortality rates in the general population. Despite lower mortality rates from coronary artery disease in the general population and working population, there are higher mortality rates from cerebrovascular diseases. Conclusion. The trend in mortality from circulatory system diseases in the Kemerovo region is comparable to that in the Russian Federation. Specific regional features related to the interaction of various factors, including regional healthcare system, have been determined. The trends in mortality from coronary artery disease and cerebrovascular diseases in the period from 2000 to 2016 have been presented.

Trends in regional cancer mortality in Taiwan 1992–2014

BackgroundAlthough the cancer mortality rate in Taiwan has been declining in recent years, no study has yet reported any regional differences in cancer mortality rates in Taiwan. We hypothesized that regional cancer mortality rates in Taiwan, an ethnically homogeneous society, exhibited no significant variations. MethodsWe investigated the trends in Taiwan regional cancer mortality between 1992 and 2014. We analyzed regional age-standardized cancer mortality rates for lung, liver, colon, stomach, oral, breast, and prostate cancers using the Taiwan Longitudinal Health Insurance Database and Demographic Database. Furthermore, we applied Joinpoint regression analysis to evaluate the trends across different regions. ResultsThere are clear regional variations in mortality rates for liver, stomach, and oral cancers, but not for lung, colon, breast, and prostate cancers. The regional death rates of oral cancer, especially for eastern Taiwan, not only elevate the fastest (APC = 14.78% per year, P < 0.001) but also show the largest disparities between men and women. Regional death rates for stomach cancer, which declined most rapidly, are converging in both general and gender groups. Liver cancer is the only one with regional variations whose trends do not all go in the same direction. We also demonstrated that northern Taiwan has significant regional advantages with respect to cancer mortality. ConclusionsSome but not all cancers in Taiwan show regional disparities. Liver, stomach, and oral cancers in Taiwan exhibit clear regional variations in mortality rates. In particular, the regional variations in oral cancer mortality rates are consistent with those in alcohol consumption.

Variability in regional mortality rates

Variability in regional mortality rates

Oral Cancer Treatment: Still an Indication for Elective Neck Dissection?

Introduction: Oral squamous cell carcinoma has a high incidence and, although elective neck dissection is recommended, the removed nodes frequently present without metastasis. This surgical approach causes disabilities and increases possible surgical complications. Objective: To evaluate the possibility of a watchful waiting approach in oral cancer. Methods: We compared 78 patients with clinical and pathological node metastases and their counterparts with pathological node metastases but without evident clinical neck disease. Therefore, we provided a theoretical comparison between the patients who had an elective neck dissection and those who waited until a clinically positive node was evident. Results: The prognostic factor rates were similar between the groups. Their regional recurrence and mortality rates had no statistical differences. Conclusion: A watchful waiting policy could be applied to selected oral cancer patients who can undergo a very close follow-up. This option would be more cost-effective and less harmful than elective neck dissection.

National and regional under-5 mortality rate by economic status for low-income and middle-income countries: a systematic assessment.

SummaryBackgroundThe progress to achieve the fourth Millennium Development Goal in reducing mortality rate in children younger than 5 years since 1990 has been remarkable. However, work remains to be done in the Sustainable Development Goal era. Estimates of under-5 mortality rates at the national level can hide disparities within countries. We assessed disparities in under-5 mortality rates by household economic status in low-income and middle-income countries (LMICs).MethodWe estimated country-year-specific under-5 mortality rates by wealth quintile on the basis of household wealth indices for 137 LMICs from 1990 to 2016, using a Bayesian statistical model. We estimated the association between quintile-specific and national-level under-5 mortality rates. We assessed the levels and trends of absolute and relative disparity in under-5 mortality rate between the poorest and richest quintiles, and among all quintiles.FindingsIn 2016, for all LMICs (excluding China), the aggregated under-5 mortality rate was 64·6 (90% uncertainty interval [UI] 61·1–70·1) deaths per 1000 livebirths in the poorest households (first quintile), 31·3 (29·5–34·2) deaths per 1000 livebirths in the richest households (fifth quintile), and in between those outcomes for the middle quintiles. Between 1990 and 2016, the largest absolute decline in under-5 mortality rate occurred in the two poorest quintiles: 77·6 (90% UI 71·2–82·6) deaths per 1000 livebirths in the poorest quintile and 77·9 (72·0–82·2) deaths per 1000 livebirths in the second poorest quintile. The difference in under-5 mortality rate between the poorest and richest quintiles decreased significantly by 38·8 (90% UI 32·9–43·8) deaths per 1000 livebirths between 1990 and 2016. The poorest to richest under-5 mortality rate ratio, however, remained similar (2·03 [90% UI 1·94–2·11] in 1990, 1·99 [1·91–2·08] in 2000, and 2·06 [1·92–2·20] in 2016). During 1990–2016, around half of the total under-5 deaths occurred in the poorest two quintiles (48·5% in 1990 and 2000, 49·5% in 2016) and less than a third were in the richest two quintiles (30·4% in 1990, 30·5% in 2000, 29·9% in 2016). For all regions, differences in the under-5 mortality rate between the first and fifth quintiles decreased significantly, ranging from 20·6 (90% UI 15·9–25·1) deaths per 1000 livebirths in eastern Europe and central Asia to 59·5 (48·5–70·4) deaths per 1000 livebirths in south Asia. In 2016, the ratios of under-5 mortality rate in the first quintile to under-5 mortality rate in the fifth quintile were significantly above 2·00 in two regions, with 2·49 (90% UI 2·15–2·87) in east Asia and Pacific (excluding China) and 2·41 (2·05–2·80) in south Asia. Eastern and southern Africa had the smallest ratio in 2016 at 1·62 (90% UI 1·48–1·76). Our model suggested that the expected ratio of under-5 mortality rate in the first quintile to under-5 mortality rate in the fifth quintile increases as national-level under-5 mortality rate decreases.InterpretationFor all LMICs (excluding China) combined, the absolute disparities in under-5 mortality rate between the poorest and richest households have narrowed significantly since 1990, whereas the relative differences have remained stable. To further narrow the rich-and-poor gap in under-5 mortality rate on the relative scale, targeted interventions that focus on the poorest populations are needed.FundingNational University of Singapore, UN Children's Fund, United States Agency for International Development, and the Bill & Melinda Gates Foundation.

Mortality from infectious diseases in diabetes

Background and AimsTo investigate the risk of mortality from infections by comparing the underlying causes of death versus the multiple causes of death in known diabetic subjects living in the Veneto region of Northern Italy. Methods and ResultsA total of 185,341 subjects with diabetes aged 30–89 years were identified in the year 2010, and causes of death were assessed from 2010 to 2015. Standardized Mortality Ratios (SMRs) with 95% confidence intervals (CIs) were computed with regional mortality rates as reference. The underlying causes of death and all the diseases reported in the death certificates were scrutinized. At the end of the follow-up, 36,382 subjects had deceased. We observed an increased risk of death from infection-related causes in subjects with diabetes with a SMR of 1.83 (95% CI, 1.71–1.94). The SMR for death from septicemia was 1.91 (95% CI, 1.76–2.06) and from pneumonia was 1.47 (95% CI, 1.36–1.59). The use of the multiple causes of death approach emphasized the association of infectious diseases with mortality. ConclusionThe results of the present study demonstrate an excess mortality due to infection-related diseases in patients with diabetes; more interestingly, by routine mortality analyses, the results show a possible underestimation of the effect of these diseases on mortality.

Wide variation in severe neonatal morbidity among very preterm infants in European regions

ObjectiveTo investigate the variation in severe neonatal morbidity among very preterm (VPT) infants across European regions and whether morbidity rates are higher in regions with low compared with high mortality...

In-depth Analysis of Mortality in Relation to Malnutrition in Children Under-five of Age in the Eastern Mediterranean Region

Background: The Eastern Mediterranean region (EMR) countries are facing many challenges that influence the nutritional status of children under-five years of age (CU5) and increase early mortality rates (MRs). Few studies have considered using global data to analyze the protective effect of breastfeeding on reducing MRs in the EMR. Aim: To analyze regional mortality rates in relation to socio-demographic, nutritional indices and early feeding practices in CU5 in the EMR countries. Methods: Data from the WHO global data bank for nutritional status and MRs in the 22 countries in EMR were analyzed MRs included neonatal mortality rates (NMR), infant mortality rates (IMR), under-five mortality rates (U5MR), maternal mortality ratio (MMR). Data was analyzed by income group and correlated to obesity and underweight, early feeding practices including early initiation of breastfeeding (EIBF), exclusive breastfeeding (EBF), breastfeeding rates at 12 (BR12) and 24 months (BR24) and selected indicators for development included illiteracy rates and total fertility rates (TFR). Results: MRs correlated with global data for country rates EIBF, EBF. Also BF12 and BF24 months correlated with stunting, wasting in the CU5, U5MR and overweight and obesity in adults. MRs correlated highly with stunting and wasting and poorly with overweight or obesity in CU5. Other variables as illiteracy, TFR, obesity and overweight in adults correlated significantly with MRs and with breastfeeding duration. At country level the low trends of shortened breastfeeding duration were associated with the high MRs and rate for obesity and stunting. Conclusions: Suboptimal early feeding practices leading to the double burden of malnutrition influence MR in the under-five mortality rates in children. Improving early initiation rates and prolonging the duration of intense breastfeeding can reduce early mortality. This cannot be attained without improving social indicators of literacy and birth spacing i.e. a comprehensive developmental approach to child survival.

Mortality reductions due to mammography screening: Contemporary population-based data.

Our objective was to compare breast cancer mortality in two regions of the Republic of Ireland that introduced a screening programme eight years apart, and to estimate the steady-state mortality deficits the programme will produce. We carried out age- and year-matched between-region comparison of breast cancer mortality rates, and of incidence rates of stage 2–4 breast cancer, in the eligible cohorts. The regions comprised counties that, beginning in early 2000 (region 1) and late 2007 (region 2), invited women aged 50–64 to biennial mammography screening. The data were supplied by the National Cancer Registry, Central Statistics Office. As impact measures, we used age-and-year-matched mortality (from breast cancers diagnosed from 2000 onwards), rate ratios and incidence rate ratios in the compared regions from 2000 to 2013. Ratios were adjusted for between-region differences in background rates. In cohorts too old to be invited, death rates in regions 1 and 2 were 702 per 0.91 and 727 per 0.90 million women-years respectively (Ratio 0.96). In the eligible cohorts, they were 1027 per 2.9 and 1095 per 2.67 (Ratio 0.88). Thus, rates in cohorts that could have benefitted were 9% lower in region 1 than region 2: (95%CI: -20%, +4%). The incidence rates of stage 2–4 breast cancer were 7% lower in region 2 than region 1 over the entire 14 year period, and 20% lower in 2007, i.e., before the screening in region 2 began to narrow the difference. Since mortality reductions due to screening only manifest after several years, the full impact of screening has not yet been realized in region 1. The lower rate observed in that region is a conservative estimate of the steady state benefit. Additional deaths would have been averted had screening continued beyond age 64.

Mortality of the personnel of an interforce military shooting range in Sardinia, Italy: 1990-2010.

As several media reports suggested an increase in cancer mortality in the surrounding area, we investigated the mortality experience of the military personnel of the Interforce shooting range of Salto di Quirra (PISQ) in Sardinia, Italy. Based on the PISQ registers, we reconstructed the cohort of 6,828 military personnel who had been employed at PISQ for at least six months on January 1, 1990 or entered subsequently up to June 30, 2005. We searched for life status or date, place, and cause of death of each cohort member up to December 31, 2010. Based on job and operating department, we preliminarily assessed exposure of each cohort member to radiofrequencies, solvents, nanoparticles, servicing in shooting ranges, participation to peacekeeping operations abroad, and undergoing vaccination procedures while in service. For each cause of interest, we calculated the standardized mortality ratio (SMR) and its 95% confidence interval, based on the Italian and regional rates specific for age, gender and year of follow-up. Mortality from all causes showed a significant decrease over the expectation, based on the national and regional mortality rates (based on national rates: SMR=78, 95% CI 60-101; based on regional rates: SMR=66, 95% CI 52-84). Deaths from haemolymphatic malignancies matched the expectation from regional rates (7 cases vs 6,3 expected; SMR=111, 95% CI 38-326). We observed two deaths from neoplasms of the haemolymphopoietic system against 0.5 expected among solvent exposed cohort members. We did not observe any significant increase in mortality from all causes or specific causes of death in relation to the exposures we investigated. The study size was too small, and the follow-up not prolonged enough to conclude whether the operational activities at PISQ did result or not in increased risks of specific causes of death, including cancers, among the military personnel. Further follow-up will be needed before final conclusions can be drawn.

With Renewed Calls for Presumed Consent, Letʼs Look at the Donation and Transplant Rates of Opt-In vs Opt-Out Countries

Organ donation rates vary dramatically around the world, even among countries with mature donation programs. Healthcare policy makers, regularly point to the apparent effectiveness of countries with Opt-Out donation laws (also known as Presumed Consent) in contrast to Opt-In donation laws. Unfortunately, the results of moving to Opt-Out have not been shown to substantively increase donation in lower donation rate countries [6] and Opt-In has been demonstrated to perform as well or better than Opt-Out[1]. Further, Wales, the most recent adopter of Opt-Out, showed an intial increase in Donors per Million (DPM) from 19.6 to 20.9 in its first year, but are projected to see a decrease in its second year to 17DPM. While it is intuitive that Opt-Out should result in significant increases in donation, the implementation of the law belies this presumption. Ultimately, even Opt-Out countries prove reluctant to conclude that organs of the deceased are property of the state and family wishes to not donate are routniely followed, despite the law [7]. This is known as "Soft Opt-Out", and is the international standard of practice. Thus, this legal backdrop calls for an analysis of donation rates across countries with mature donation programs and "normalizing" (nDPM) the international standard of Donors per Million population to incorporate widely varying regional death rates between regions.[9]. An analysis of Opt-In vs Opt-Out donation and transplantation rates normalized for death rates illustrates that Spain, continues to lead the world with a nDPM of 41.6. However, when the countries are compared based on transplant rates, the US is the world's leader' (assisted by a high Living Donation rate). The variation identified in this international analysis can also be seen even more dramatically in an analysis of donation and transplantation across the US States. Six US states that are large enough to qualify for the international rankings exceed the best international donation and/or transplant rates including: Pennsylvania, Texas, Arizona, Utah, California, and Minnesota. The data and cited analyses illustrate that the legal framework underlying donation is not a definitive determinant of donation success. That is more likely influenced by national investment in the donation system[10] and cultural factors, such as religion (6 of the leading Opt-Out countries range from 66-94% Catholic), a topic which deserves greater study.

Grouped multivariate and functional time series forecasting:An application to annuity pricing

Age-specific mortality rates are often disaggregated by different attributes, such as sex, state, ethnic group and socioeconomic status. In making social policies and pricing annuity at national and subnational levels, it is important not only to forecast mortality accurately, but also to ensure that forecasts at the subnational level add up to the forecasts at the national level. This motivates recent developments in grouped functional time series methods (Shang and Hyndman, in press) to reconcile age-specific mortality forecasts. We extend these grouped functional time series forecasting methods to multivariate time series, and apply them to produce point forecasts of mortality rates at older ages, from which fixed-term annuities for different ages and maturities can be priced. Using the regional age-specific mortality rates in Japan obtained from the Japanese Mortality Database, we investigate the one-step-ahead to 15-step-ahead point-forecast accuracy between the independent and grouped forecasting methods. The grouped forecasting methods are shown not only to be useful for reconciling forecasts of age-specific mortality rates at national and subnational levels, but they are also shown to allow improved forecast accuracy. The improved forecast accuracy of mortality rates is of great interest to the insurance and pension industries for estimating annuity prices, in particular at the level of population subgroups, defined by key factors such as sex, region, and socioeconomic grouping.