Regional Variation In Mortality Research Articles

Gender, nutritional disparities, and child survival in Nepal

BackgroundThis paper examines seemingly contradictory evidence from extant research that son preference is high, but male disadvantage in mortality is increasing in Nepal. To do so, we documented the timing, geographic patterning, and extent of gendered patterns in mortality and feeding practices for children under-five.MethodsWe applied pooled multilevel regression models and survival analysis to five rounds of data from Nepal’s nationally representative Demographic and Health Surveys (1996–2016). We controlled for potential sociodemographic confounders, including child, maternal, household, and regional correlates, and disaggregated findings by birth order and sibling gender.ResultsWe found evidence of regional variation in mortality, with girls in wealthy urban areas faring the worst in terms of mortality rates. Girls’ comparative mortality advantage compared to boys in the neonatal period masks their mortality disadvantage in later periods. Mortality has fallen at a faster rate for boys than girls in most cases, leading to widening of gender inequalities. We also found evidence of female disadvantage in breastfeeding duration, which was linked to higher mortality risks, but no gender disparities in the consumption of other food items. Sibling gender and birth order also mattered for breastfeeding duration: Young girls with older sisters but with no brothers were most disadvantaged.ConclusionWhile we did not find evidence of postnatal discrimination in access to solid and semi-solid foods, girls in Nepal face a disadvantage in breastfeeding duration. Girls with older sisters but no older brothers facing the greatest disadvantage, with risks being particularly concentrated for girls aged 1–4 years. This disadvantage is linked to an increased risk of mortality. To address this, community-based health programs could be expanded to continue targeted healthcare for children beyond 12 months of age, with particular focus on nutrition monitoring and health service provision for girls.

Regional Differences in the Ratio of Observed and Expected In-hospital Mortality for Acute Coronary Syndrome Patients in China: The Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project Analysis

Previous studies reported regional variations in in-hospital acute coronary syndrome (ACS) mortality, but the reasons for that were not clearly defined. We explored whether differences in patient characteristics could explain regional variation. The Improving Care for Cardiovascular Disease in China (CCC)-ACS project is an ongoing national registry and quality improvement project, involving 150 tertiary hospitals from 30 provinces across China. We applied a prediction model that included patient-specific variables to calculate the expected in-hospital mortality. For each province, we reported the observed, expected in-hospital mortality and the risk-adjusted ratio which is based on the observed divided by the expected mortality. From 2014 to 2018, 79585 ACS patients were enrolled. The average in-hospital mortality was 1.8%. There was a wide variation in the in-hospital mortality among different provinces (0.2-3.9%). Patient characteristics explained part of this variation because of differences in the expected in-hospital mortality (0.7-2.8%). There was a substantial variation in the risk-adjusted ratio among provinces (0.2-3.5), which suggests that the variations in the mortality cannot be completely explained by the differences in patient characteristics. In conclusion, we observed a wide regional variation in mortality for ACS, part of which could be explained by the difference in patient characteristics.

Regionales Monitoring von Infektionen mittels standardisierter Fallfatalit\xe4tsraten am Beispiel von SARS-CoV-2 in Bayern

ZusammenfassungHintergrundKarten zur zeitlichen Entwicklung der regionalen Verteilung einer gesundheitsbezogenen Maßzahl ermöglichen public-health-relevante Bewertungen des Gesundheitsgeschehens.Ziel der ArbeitDie Arbeit führt das Konzept der standardisierten Fallfatalitätsrate (sFFR) ein. Sie beschreibt das Verhältnis der regionalen Abweichung in der Mortalität zur regionalen Abweichung im dokumentierten Infektionsprozess. Die regionalen sFFR-Werte werden in Karten dargestellt und die darin beobachtete zeitlich variierende regionale Heterogenität interpretiert.Materialien und MethodenDie regionale sFFR ist der Quotient der regionalen standardisierten Mortalitäts- und Fallrate. Sie wird mittels eines bivariaten Modells geschätzt. Die in Karten dargestellten sFFR-Werte basieren auf den SARS-CoV-2-Meldedaten aus Bayern seit Anfang April 2020 bis Ende März 2021. Es werden 4 Quartale (Q2/20, Q3/20, Q4/20, Q1/21) betrachtet.ErgebnisseIn den betrachteten Quartalen liegen die bayerischen naiven FFR-Werte bei 5,0 %, 0,5 %, 2,5 % und 2,8 %. In Q2/20 sind die regionalen sFFR-Werte unregelmäßig über das Bundesland verteilt. Diese Heterogenität schwächt sich in der zweiten Welle der Epidemie ab. In Q1/21 zeigen sich in Südbayern nur vereinzelt Regionen mit erhöhter sFFR (> 1,25). Im Norden Bayerns bilden sich Cluster von Regionen mit einer sFFR > 1,25. Das Oberallgäu ist die Region mit dem niedrigsten sFFR-Wert (0,39, 95 % Kredibilitätsintervall: 0,25–0,55).DiskussionIn Bayern zeigen sich heterogene regionale SARS-CoV-2-spezifische sFFR-Werte, die sich über die Zeit verändern. Sie schätzen das relative Risiko, als dokumentierter Infektionsfall an/mit COVID-19 zu versterben. Eine starke kleinräumige Variabilität der sFFR legt nahe, regionale gegenüber übergeordneten Maßnahmen zur Steuerung des Infektionsgeschehens vorzuziehen.

The impact of regionality and hospital status on mortality associated with non-accidental trauma

IntroductionNon-accidental trauma (NAT) affects 2 per 100,000 children annually in the US and may go unrecognized. The aim of this study to quantify the burden of NAT and to evaluate regional variations in mortality. MethodsThe Kids Inpatient Database (2000–2012) was queried for pediatric patients presenting with a diagnosis of NAT. Data was obtained on demographic, clinical and hospital-level characteristics. Primary outcome measure was mortality. Multivariable logistic regression models for age, sex, race/ethnicity, insurance status, income quartile, hospital volume, region (Northeast, South, West and Midwest), teaching status, and injury severity scores. ResultsNAT represented 1.92% (n = 15,999) of all trauma patients. Mortality rates were 3.98% for patients presenting with NAT. African American children had a higher likelihood of mortality compared to White children (OR[95%CI]:1.35[1.03–1.79]), however, this effect was not statistically significant for patients being treated at designated children's hospitals (OR[95%CI]:1.23(0.78–1.95) and urban facilities (OR[95%CI]:1.30[0.99–1.72]). Statistically significant regional variations in mortality, lost significance for patients treated at designated children's hospitals (p > 0.05). ConclusionNAT has devastating consequences and is associated with a high mortality rate. Treatment at designated children's hospitals results in the loss of variation in mortality, resulting in diminished disparities and improved outcomes. These findings align with current trends towards the “regionalization of pediatric health care” and reflects the value of regional transfer centers that are.

Changes in regional variation in mortality over five decades – The contribution of age and socioeconomic population composition

Existing evidence suggests that within-country area variation in mortality has increased in several high-income countries. Little is known about the role of changes in the population composition of areas in these trends. In this study, we look at mortality variation across Finnish municipalities over five decades. We examine trends by sex, age categories and two broad cause of death groups and assess the role of individual-level compositional factors. Analyses rely on individual-level register data on the total Finnish population aged 30 years and over. We estimated two-level Weibull survival-models with individuals nested in areas for 10 periods between 1972 and 2018 to assess municipal-level variation in mortality. Median hazard ratio (MHR) was used as our summary measure and analyses were adjusted for age and socioeconomic characteristics. The results show a clear overall growth in area variation in mortality with MHR increasing from 1.14 (95% CI 1.12–1.15) to 1.28 (CI 1.26–1.30) among men and 1.17 (CI 1.15–1.18) to 1.30 (CI 1.27–1.32) among women. This growth, however, was fully attenuated by adjustment for age. Area differentials were largest and increased most among men at ages 30–49, and particularly for external causes. This increase was largely due to increasing differentiation in the socioeconomic composition of municipalities. In conclusion, our study shows increases in mortality differentials across municipalities that are mostly attributable to increasing differentiation between municipalities in terms of individual compositional factors.

Regional Variation of Mortality in Heart Failure With Reduced and Preserved Ejection Fraction Across Asia: Outcomes in the ASIAN-HF Registry.

Regional Variation of Mortality in Heart Failure With Reduced and Preserved Ejection Fraction Across Asia: Outcomes in the ASIAN-HF Registry.

Trends and risk factors of mortality and disability adjusted life years for chronic respiratory diseases from 1990 to 2017: systematic analysis for the Global Burden of Disease Study 2017

ObjectiveTo describe the temporal and spatial trends of mortality and disability adjusted life years (DALYs) due to chronic respiratory diseases, by age and sex, across the world during 1990-2017 using...

Decreased trend in hospital mortality from pancreatic cancer despite increase in number of hospital admissions.

Background and aimPancreatic cancer is one of the common cancers in US and is associated with high mortality and morbidity. The objectives of our study were to look at the recent trends in the number of hospitalizations with pancreatic cancer.MethodsWe identified patients with a discharge diagnosis of pancreatic cancer in the National Inpatient Sample from 2007 to 2011 using International Classification of Diseases—Clinical Modification, 9th revision (ICD-9-CM) codes. We looked at the yearly trend in the hospitalizations with pancreatic cancer and the outcomes which included length of stay (LOS), hospital charges and in-hospital mortality. We also performed multivariate analysis to look for the predictors of mortality.ResultsThere were 450, 414 patients with discharge diagnosis of pancreatic cancer. There was 18% increase in hospitalizations with pancreatic cancer in 2011 compared to 2007. Most of the patients were Caucasian (63%) with the mean age of 68 ± 0.14 years, had Medicare (57%) as primary insurance, were from Southern region (35%) and had higher Charlson Comorbidity Index (CCI) (87% with CCI > = 5). 6% underwent Whipple’s procedure in the index hospitalization. After the adjustment for inflation, the mean hospital charges increased from $ 47,331 in 20007 to $ 53, 854 in 2011 (p = 0.01). LOS decreased from 7.31 ± 0.11 days in 2007 to 6.70 ± 0.09 days in 2011 (<0.001). Despite the increase in the number of hospitalizations of patients with pancreatic cancer, mortality decreased from 9.8% in 2007 to 8.1% in 2011 (p<0.001). On multivariate analysis, the independent factors associated with higher mortality were older age, male sex African-American race, insurance status other than Medicare, higher CCI and enrollment in palliative care. There was regional variation in mortality. Whipple’s procedure conferred lower mortality.ConclusionsOur study showed downward trends in LOS and in-hospital mortality despite increasing hospitalizations with pancreatic cancer.

Regional Variation in Mortality, Major Complications, and Cost After Left Ventricular Assist Device Implantation in the United States (2009 to 2014)

The objective of this analysis was to provide evidence on regional differences in outcomes, cost and disposition among patients who undergo continuous-flow LVAD implantation. Using data from the National Inpatient Sample and US Census Bureau, annual national estimates in utilization, in-hospital mortality, major complications, cost, length of stay (LOS), and disposition were estimated for years 2009 to 2014. Main outcomes and complications were identified using patient safety indicators and International Classification of Diseases-Ninth Revision, Clinical Modification codes. We analyzed a total of 3,572 (weighted = 17,552) patients with LVAD implants among the 4 Census regions of the United States. The patient population in the Southern region was younger with higher percentage of African-Americans. Overall, the comorbidity burden was higher in the Midwest. The risk-adjusted rate of in-hospital mortality did not differ significantly among the geographical regions (p = 0.8). With the exception of cardiac tamponade rates which were higher in the Northeast and West, all other post-operative complications did not differ between regions. LOS was higher in the Northeast (median 32 days) and lower in the South (median 27 days). The cost analysis suggested higher median cost in the West (median $246,292) and lowest in the Northeast region (median $192,604). Finally, higher percentages of patients were transferred to an extended care facility in the Northeast, whereas more patients were discharged to home in the Western region. We identified region disparities in LOS, cost and disposition but not in-hospital mortality and complications, among patients who underwent LVAD implantation between 2009 and 2014.

Regional variation in patient outcomes in carotid artery disease treatment in the Vascular Quality Initiative

ObjectiveQuality metrics were developed to improve outcomes after carotid artery revascularization; however, few studies have evaluated regional differences in perioperative outcomes. This study aimed to evaluate regional variation in mortality and perioperative outcomes after carotid endarterectomy (CEA) and carotid artery stenting (CAS). MethodsWe identified all patients who underwent CEA or CAS from 2009 to 2016 in the Vascular Quality Initiative. Patients were analyzed on the basis of their symptom status. We assessed variation in perioperative outcomes using χ2 analysis, Fisher exact test, and t-test, where appropriate. ResultsA total of 78,467 carotid interventions were identified; 85% were CEAs, with 69% of those asymptomatic. Within CAS, 39% were asymptomatic. Perioperative stroke/death varied across regions within both CAS groups (asymptomatic, 0%-5.8% [P = .03]; symptomatic, 2.4%-8.1% [P = .1]), and several regions did not meet the American Heart Association (AHA) guidelines of 3% for asymptomatic patients and 6% for symptomatic patients, which persisted after risk adjustment. For CEA, the stroke/death rates fell within the standards set by the AHA guidelines in all regions for both the unadjusted and risk-adjusted models; however, there was significant regional variation in the cohorts (asymptomatic, 0.9%-3.1% [P < .01]; symptomatic, 1.3%-4.9% [P < .01]). Variation in 30-day mortality was significant in symptomatic patients (asymptomatic: CEA, 0%-1.3% [P = .2], CAS, 0%-2.4% [P = .2]; symptomatic: CEA, 0%-1.8% [P < .01], CAS, 0%-4.6% [P = .01]). Rates of in-hospital stroke, postoperative myocardial infarction, prolonged length of stay (>2 days), and use of intravenous blood pressure medications all varied significantly across the regions. After CEA, there was significant variation in the rates of cranial nerve injuries (asymptomatic, 0.9%-4.9% [P < .01]; symptomatic, 1.5%-7.7% [P < .01]), return to the operating room (asymptomatic, 0.9%-3.4% [P < .01]; symptomatic, 0.6%-3.4% [P = .02]), and discharge on antiplatelet and statin (asymptomatic, 75%-87% [P < .01]; symptomatic, 78%-91% [P < .01]). After CAS, significant variation was found in the rates of access site complications (asymptomatic, 2.3%-18.2% [P < .01]; symptomatic, 1.4%-16.9% [P < .01]) and discharge on dual antiplatelet therapy (asymptomatic, 79%-94% [P < .01]; symptomatic, 83%-93% [P < .01]). ConclusionsUnwarranted regional variation exists in outcomes after carotid artery revascularization across the regions of the VQI. Significant variation was seen in a number of outcomes for which quality metrics currently exist, such as length of stay and discharge medications. In addition, after CAS, several regions failed to meet the AHA guidelines for stroke and death. Given these results, quality improvement projects should be targeted to improve adherence to current guidelines to promote best practices.

Regional variations in mortality and causes of death in Israel, 2009\u20132013

BackgroundRegional variations in mortality can be used to study and assess differences in disease prevalence and factors leading to disease and mortality from different causes. To enable this comparison, it is important to standardize the mortality data to adjust for the effects of regional population differences in age, nationality and country of origin.MethodsStandardized mortality ratios (SMR) were calculated for the districts and sub-districts in Israel, for total mortality by gender as well as for leading causes of death and selected specific causes. Correlations were assessed between these SMRs, regional disease risk factors and socio-economic characteristics. Implications for health policy were then examined.ResultsTotal mortality in the Northern District of Israel was not significantly different from the national average; but the Haifa, Tel Aviv, and Southern districts were significantly higher and the Jerusalem, Central, Judea and Samaria districts were lower.Cancer SMR was significantly lower in Jerusalem and not significantly higher in any region. Heart disease and diabetes SMRs were significantly higher in many sub-districts in the north of the country and lower in the south. SMRs for septicemia, influenza/pneumonia, and for cerebrovascular disease were higher in the south. Septicemia was also significantly higher in Tel Aviv and lower in the North, Haifa and Jerusalem districts. SMRs for accidents, particularly for motor vehicle accidents were significantly higher in the peripheral Zefat and Be’er Sheva sub-districts.ConclusionThe SMR, adjusted for age and ethnicity, is a good method for identifying districts that differ significantly from the national average. Some of the regional differences may be attributed to differences in the completion of death certificates. This needs to be addressed by efforts to improve reporting of causes of death, by educating physicians.The relatively low differences found after adjustment, show that factors associated with ethnicity may affect mortality more than regional factors. Recommendations include encouraging good eating habits, exercise, cancer screening, control of hypertension, reduction of smoking and improving road infrastructure and emergency care access in the periphery.

Global geographical variations in ST-segment elevation myocardial infarction management and post-discharge mortality

BackgroundThere is a shortage of information on regional variations in ST-segment elevation myocardial infarction (STEMI) management and prognosis at a global level. We aimed to compare patient profiles, in-hospital management and post-discharge mortality across several world regions. MethodsIn total, 11,559 patients with STEMI were enrolled in two prospective studies of acute coronary syndrome survivors: EPICOR (4943 patients from 555 hospitals in 20 countries in Europe and Latin America recruited between September 2010 and March 2011) and EPICOR Asia (6616 patients from 218 hospitals in eight Asian countries recruited between June 2011 and May 2012). Comparisons were performed by eight pre-defined regions: Northern Europe (NE), Southern Europe (SE), Eastern Europe (EE), Latin America (LA), China (CN), India (IN), Southeast Asia (SA), and South Korea/Hong Kong/Singapore (KS). ResultsReperfusion therapy rates ranged between 53.9% (IN) and 81.2% (SE), primary percutaneous coronary intervention (PCI) between 24.8% (IN) and 65.6% (NE) and fibrinolysis between 8.1% (CN) and 34.2% (SA). Median time to primary PCI (h) ranged from 3.9 (NE) to 20.9 (IN) and to fibrinolysis from 2.4 (SE) to 6.3 (IN). Two-year mortality ranged between 2.5% in NE and 7.4% in LA. Regional variations in mortality persisted after adjustment for reperfusion therapy and known prognostic factors. ConclusionsAmong patients with STEMI, there is a wide regional variation in clinical profiles, hospital care and mortality. Substantial room for improvement remains at a global level for increasing reperfusion rates, reducing delays and post-discharge mortality in patients with STEMI.

Regional Variation in Mortality, Length of Stay, Cost, and Discharge Disposition Among Patients Admitted for Heart Failure in the United States

The objective of the study was to provide contemporary evidence on regional variation in hospitalization outcomes in patients with heart failure (HF) in the United States. Using the National Inpatient Sample, we compared hospitalization outcomes among primary HF admissions (2013 to 2014) among the 4 Census regions of the United States. Overall, an estimated 1.9 million HF hospitalizations occurred in the United States over the study period. Mortality rate was 3%, the mean length of stay was 5.3 days, the median cost of hospitalization was US$7,248, and the rate of routine home discharge was 51%. There was a significant regional variation for all end points (p <0.001); for example, compared with other regions of the country, the risk-adjusted rate of in-hospital mortality was highest in the Northeast (3.2%) and lowest in the Midwest (2.7%); and within each region, these mortalities were higher in the rural locations (range: 3.0% to 3.8%) than in the urban locations (range: 2.7% to 3.1%). In addition, the Northeast region had the longest length of stay (mean: 5.9 days) and the lowest risk-adjusted rate of routine home discharge (42%). However, the cost of hospitalization was highest in the West (median: US$8,898) and lowest in the South (US$6,366). A similar pattern of variation was found in subgroup analysis except that the risk-adjusted rate of in-hospital mortality was highest in the West among patients <65 years (1.7% vs 1.2% [lowest] in the Midwest), male gender (3.2% vs 2.8% in the Midwest), and rural location (3.8% vs 3% in the Midwest). In conclusion, HF hospitalization outcomes tend to be worse in the Northeast compared with other regions of the country. In addition, the in-hospital mortality rate was higher in rural locations than in urban locations.

Estimating regional variations in adult mortality in Zambia

Background: A dearth of regional level adult mortality estimates exists in Zambia. Regional adult mortality rates reflect inequalities in socioeconomic conditions and health service provision. Adult mortality rates are useful indicators for monitoring effectiveness and impact of health interventions (HIV/AIDS antiretroviral therapy (ART), tuberculosis (TB) and malaria) at regional level. Previous studies have not produced adult mortality rates at regional level. Data Source and Methods: Using data from the 2010 census, this study estimated adult mortality rates at regional level for age group 15-59 years. Age-specific mortality rates (ASMRs), cause-specific mortality rates (CSMRs), standardised mortality rates (SMRS) and probabilities of dying between age 15 and 60 years ( 45 q 15 ) were computed. Correlations with HIV prevalence and literacy rates, and mortality rates were also computed. Findings: Adult mortality rates varied across all provinces. The 45 q 15 was highest for males in Western province, 59 % and lowest in North-western province, 36.7 %. For females, 45 q 15 was highest in Copperbelt province, 47.9 % and lowest in North-western province, 34.8 %. Conclusion: HIV prevalence and literacy rates were positively correlated with regional adult mortality rates. Health policies and programmes aimed at reducing adult mortality should, therefore, be tailored to recognise the regional variations in mortality rates

Significant regional variation exists in morbidity and mortality after repair of abdominal aortic aneurysm

ObjectiveLimited data exist comparing perioperative morbidity and mortality after open and endovascular abdominal aortic aneurysm (AAA) repair (EVAR) among regions of the United States. This study evaluated the regional variation in mortality and perioperative outcomes after repair of AAAs. MethodsThe Vascular Quality Initiative (VQI) was used to identify patients undergoing open AAA repair and EVAR between 2009 and 2014. Ruptured and intact aneurysms were evaluated separately, and the analysis of intact aneurysms was limited to infrarenal AAAs. All 16 regions of the VQI were deidentified, and those with <100 open repairs were combined to eliminate the effect of low-volume regions. Regional variation was evaluated using χ2 and Fisher exact tests. Regional rates were compared against current quality benchmarks. ResultsPerioperative outcomes from 14 regions were compared. After open repair of intact aneurysms, no significant variation was seen in 30-day or in-hospital mortality; however, multiple regions exceeded the Society for Vascular Surgery benchmark for in-hospital mortality after open repair of intact aneurysms of <5% (range, 0%-7%; P = .55). After EVAR, all regions met the Society for Vascular Surgery benchmark of <3% (range, 0%-1%; P = .75). Significant variation in in-hospital mortality existed after open (14%-63%; P = .03) and endovascular (3%-32%; P = .03) repair of ruptured aneurysms across the VQI regional groups. After repair of intact aneurysms, wide variation was seen in prolonged length of stay (>7 days for open repair: 32%-53%, P = .54; >2 days for EVAR: 16-43%, P < .01), transfusion (open: 10%-35%, P < .01; EVAR: 7%-18%, P < .01), use of vasopressors (open: 19%-37%, P < .01; EVAR: 3%-7%, P < .01), and postoperative myocardial infarction (open: 0%-13%, P < .01; EVAR: 0%-3%, P < .01). After open repair, worsening renal function (6%-18%; P = .04) and respiratory complications (6%-20%; P = .20) were variable across regions. The frequency of endoleak at completion of EVAR also had considerable variation (15%-38%; P < .01). ConclusionsDespite limited variation, multiple regions do not meet current benchmarks for in-hospital mortality after open AAA repair for intact aneurysms. Significant regional variation exists in perioperative outcomes and length of stay, and mortality is widely variable after repair for rupture. These data identify important areas for quality improvement initiatives and clinical practice guidelines.

Trends and Regional Variation in Hospital Mortality, Length of Stay and Cost in Hospital of Ischemic Stroke Patients in Alberta Accompanying the Provincial Reorganization of Stroke Care

This study aimed to evaluate the trends and regional variation of stroke hospital care in 30-day in-hospital mortality, hospital length of stay (LOS), and 1-year total hospitalization cost after implementation of the Alberta Provincial Stroke Strategy. New ischemic stroke patients (N = 7632) admitted to Alberta acute care hospitals between 2006 and 2011 were followed for 1 year. We analyzed in-hospital mortality with logistic regression, LOS with negative binomial regression, and the hospital costs with generalized gamma model (log link). The risk-adjusted results were compared over years and between zones using observed/expected results. The risk-adjusted mortality rates decreased from 12.6% in 2006/2007 to 9.9% in 2010/2011. The regional variations in mortality decreased from 8.3% units in 2008/2009 to 5.6 in 2010/2011. The LOS of the first episode dropped significantly in 2010/2011 after a 4-year slight increase. The regional variation in LOS was 15.5 days in 2006/2007 and decreased to 10.9 days in 2010/2011. The 1-year hospitalization cost increased initially, and then kept on declining during the last 3 years. The South and Calgary zones had the lowest costs over the study period. However, this gap was diminishing. After implementation of the Alberta Provincial Stroke Strategy, both mortality and hospital costs demonstrated a decreasing trend during the later years of study. The LOS increased slightly during the first 4 years but had a significant drop at the last year. In general, the regional variations in all 3 indicators had a diminishing trend.

Health Shocks and Human Capital Accumulation: The Case of Spanish Flu in Italian Regions

Percoco M. Health shocks and human capital accumulation: the case of Spanish flu in Italian regions, Regional Studies. The impact of health on economic development is a hotly debated issue in the economics literature, with most scholars supporting the idea that the diffusion of diseases is detrimental to development. In this context, pandemics are an important case study given their exogenous nature, which makes identification of the impact of diseases on development clearer than in other cases such as malaria or smallpox. This paper focuses on Spanish flu in Italy, one of the countries with the highest mortality rate due to the pandemic. By exploiting the regional variation in mortality and focusing on the hypothesis of the foetal origins of cognitive abilities, the long-run consequences of influenza exposure in terms of human capital accumulation are estimated. An average reduction of 0.3–0.4 years of schooling for the cohort born in 1918–20 is found. This result points to a small but persisting effect of health shocks on regional productivity through a variation in the rate of accumulation of human capital.

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.

A country divided? Regional variation in mortality in Ukraine

We set out to identify the contribution of various causes of death to regional differences in life expectancy in Ukraine. Mortality data by oblast (province) were obtained from the State Statistical Committee of Ukraine. The contribution of various causes of death to differences in life expectancy between East, West and South Ukraine was estimated using decomposition. In 2008, life expectancy for men in South (61.8 years) and East Ukraine (61.2 years) was lower than for men in West Ukraine (64.0 years). A similar pattern was observed among women. This was mostly due to deaths from infectious disease and external causes among young adults, and cardio- and cerebro-vascular deaths among older adults. Deaths from TB among young adults contribute most to differences in life expectancy. Deaths due to infectious disease, especially TB, play an important role in the gap in life expectancy between regions in Ukraine. These deaths are entirely preventable--further research is needed to identify what has 'protected' individuals in Western Ukraine from the burden of deaths experienced by their Southern and Eastern counterparts.