Specific Standardised Mortality Ratios Research Articles

Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data.

Background: International and UK data suggest that Black, Asian and Minority Ethnic (BAME) groups are at increased risk of infection and death from COVID-19. We aimed to explore the risk of death in minority ethnic groups in England using data reported by NHS England. Methods: We used NHS data on patients with a positive COVID-19 test who died in hospitals in England published on 28th April, with deaths by ethnicity available from 1st March 2020 up to 5pm on 21 April 2020. We undertook indirect standardisation of these data (using the whole population of England as the reference) to produce ethnic specific standardised mortality ratios (SMRs) adjusted for age and geographical region. Results: The largest total number of deaths in minority ethnic groups were Indian (492 deaths) and Black Caribbean (460 deaths)groups. Adjusting for region we found a lower risk of death for White Irish (SMR 0.52; 95%CIs 0.45-0.60) and White British ethnic groups (0.88; 95%CIs 0.86-0.0.89), but increased risk of death for Black African (3.24; 95%CIs 2.90-3.62), Black Caribbean (2.21; 95%CIs 2.02-2.41), Pakistani (3.29; 95%CIs 2.96-3.64), Bangladeshi (2.41; 95%CIs 1.98-2.91) and Indian (1.70; 95%CIs 1.56-1.85) minority ethnic groups. Conclusion: Our analysis adds to the evidence that BAME people are at increased risk of death from COVID-19 even after adjusting for geographical region, but was limited by the lack of data on deaths outside of NHS settings and ethnicity denominator data being based on the 2011 census. Despite these limitations, we believe there is an urgent need to take action to reduce the risk of death for BAME groups and better understand why some ethnic groups experience greater risk. Actions that are likely to reduce these inequities include ensuring adequate income protection, reducing occupational risks, reducing barriers in accessing healthcare and providing culturally and linguistically appropriate public health communications.

Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data

Background: International and UK data suggest that Black, Asian and Minority Ethnic (BAME) groups are at increased risk of infection and death from COVID-19. We aimed to explore the risk of death in minority ethnic groups in England using data reported by NHS England. Methods: We used NHS data on patients with a positive COVID-19 test who died in hospitals in England published on 28th April, with deaths by ethnicity available from 1st March 2020 up to 5pm on 21 April 2020. We undertook indirect standardisation of these data (using the whole population of England as the reference) to produce ethnic specific standardised mortality ratios (SMRs) adjusted for age and geographical region. Results: The largest total number of deaths in minority ethnic groups were Indian (492 deaths) and Black Caribbean (460 deaths) groups. Adjusting for region we found a lower risk of death for White Irish (SMR 0.52; 95%CIs 0.45-0.60) and White British ethnic groups (0.88; 95%CIs 0.86-0.0.89), but increased risk of death for Black African (3.24; 95%CIs 2.90-3.62), Black Caribbean (2.21; 95%CIs 2.02-2.41), Pakistani (3.29; 95%CIs 2.96-3.64), Bangladeshi (2.41; 95%CIs 1.98-2.91) and Indian (1.70; 95%CIs 1.56-1.85) minority ethnic groups. Conclusion: Our analysis adds to the evidence that BAME people are at increased risk of death from COVID-19 even after adjusting for geographical region, but was limited by the lack of data on deaths outside of NHS settings and ethnicity denominator data being based on the 2011 census. Despite these limitations, we believe there is an urgent need to take action to reduce the risk of death for BAME groups and better understand why some ethnic groups experience greater risk. Actions that are likely to reduce these inequities include ensuring adequate income protection, reducing occupational risks, reducing barriers in accessing healthcare and providing culturally and linguistically appropriate public health communications.

Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data

Background: International and UK data suggest that Black, Asian and Minority Ethnic (BAME) groups are at increased risk of infection and death from COVID-19. We aimed to explore the risk of death in minority ethnic groups in England using data reported by NHS England. Methods: We used NHS data on patients with a positive COVID-19 test who died in hospitals in England published on 28th April, with deaths by ethnicity available from 1st March 2020 up to 5pm on 21 April 2020. We undertook indirect standardisation of these data (using the whole population of England as the reference) to produce ethnic specific standardised mortality ratios (SMRs) adjusted for age and geographical region. Results: The largest total number of deaths in minority ethnic groups were Indian (492 deaths) and Black Caribbean (460 deaths)groups. Adjusting for region we found a lower risk of death for White Irish (SMR 0.52; 95%CIs 0.45-0.60) and White British ethnic groups (0.88; 95%CIs 0.86-0.0.89), but increased risk of death for Black African (3.24; 95%CIs 2.90-3.62), Black Caribbean (2.21; 95%CIs 2.02-2.41), Pakistani (3.29; 95%CIs 2.96-3.64), Bangladeshi (2.41; 95%CIs 1.98-2.91) and Indian (1.70; 95%CIs 1.56-1.85) minority ethnic groups. Conclusion: Our analysis adds to the evidence that BAME people are at increased risk of death from COVID-19 even after adjusting for geographical region. We believe there is an urgent need to take action to reduce the risk of death for BAME groups and better understand why some ethnic groups experience greater risk. Actions that are likely to reduce these inequities include ensuring adequate income protection (so that low paid and zero-hours contract workers can afford to follow social distancing recommendations), reducing occupational risks (such as ensuring adequate personal protective equipment), reducing barriers in accessing healthcare and providing culturally and linguistically appropriate public health communications.

Causes of death among women with epithelial ovarian cancer by length of survival post-diagnosis: a population-based study in British Columbia, Canada.

Little is known regarding the health of women who survive more than 5 years following their ovarian cancer diagnosis. To bridge an important gap in our knowledge about long term health of ovarian cancer survivors, we examined the causes of death among women diagnosed with epithelial ovarian cancer between 1990 and 2014 in British Columbia. These causes were stratified by years since diagnosis, and compared with age- standardized causes of death among women who have not been diagnosed with ovarian cancer. We examined all women with epithelial ovarian cancer in British Columbia 1990-2014 using population- based administrative datasets. We stratified women into three groups: all epithelial ovarian cancer patients; women surviving 5 to 9 years post-diagnosis, and women surviving 10 or more years since diagnosis. All- cause and cause specific standardized mortality ratios (SMRs) were calculated. There were 4246 deaths among 6427 women with epithelial ovarian cancer. About 55.9% of deaths were from ovarian cancer. When compared with the general population, the highest SMRs (SMR of 5 or higher) were for deaths from other cancers and external causes (44.4% from falls) among women surviving 5-9 years and 10 or more years post-diagnosis. Mortality from other cancers can largely be explained by deaths from breast cancer (15.8%), lung cancer (12.3%), and colorectal cancer (11%). While the majority of epithelial ovarian cancer patients continue to die from their ovarian cancer, our results suggest that long term ovarian cancer survivors are particularly vulnerable to deaths from other cancers and from falls in elderly survivors. These data could indicate closer surveillance for breast, lung, and colorectal cancer, and closer attention to bone health is warranted among women surviving for 5 or more years following their epithelial ovarian cancer diagnosis.

Premature Mortality among People with Severe Mental Illness – New Evidence from Linked Primary Care Data

IntroductionStudies assessing premature mortality in people with severe mental illness (SMI) are often based in one setting, hospital (secondary care inpatients and/or outpatients) or community (primary care). This may lead to ascertainment bias.
 Objectives and ApproachThis study aimed to estimate standardised mortality ratios (SMRs) for all-cause and cause-specific mortality in people with SMI drawn from linked primary and secondary care populations compared to the general population. Standardised mortality ratios (SMRs) were calculated using the indirect method for a United Kingdom population of almost four million between 2004-2013.
 ResultsThe all-cause SMR was higher in the cohort identified from secondary care hospital admissions (SMR: 2.9; 95% CI: 2.8-3.0) than from primary care (SMR: 2.2; 95% CI: 2.1-2.3) when compared to the general population. The SMR for the combined cohort was 2.6 (95% CI: 2.5-2.6). Solely hospital admission based studies may somewhat over-estimate premature mortality in those with SMI. However, there is no doubt this remains a major health inequality. Cause specific SMRs in the combined cohort were particularly elevated in those with SMI relative to the general population for ill-defined and unknown causes, suicide, and substance abuse, as well as a number of other causes.
 Conclusion/ImplicationsThe ability to combine cohorts electronically from primary and secondary care is more representative of the whole population. Comprehensive characterisation of mortality is important to inform policy and practice and to discriminate settings to allow for proportionate interventions to address this health injustice.

Premature mortality among people with severe mental illness — New evidence from linked primary care data

Studies assessing premature mortality in people with severe mental illness (SMI) are usually based in one setting, hospital (secondary care inpatients and/or outpatients) or community (primary care). This may lead to ascertainment bias. This study aimed to estimate standardised mortality ratios (SMRs) for all-cause and cause-specific mortality in people with SMI drawn from linked primary and secondary care populations compared to the general population. SMRs were calculated using the indirect method for a United Kingdom population of almost four million between 2004 and 2013. The all-cause SMR was higher in the cohort identified from secondary care hospital admissions (SMR: 2.9; 95% CI: 2.8–3.0) than from primary care (SMR: 2.2; 95% CI: 2.1–2.3) when compared to the general population. The SMR for the combined cohort was 2.6 (95% CI: 2.5–2.6). Cause specific SMRs in the combined cohort were particularly elevated in those with SMI relative to the general population for ill-defined and unknown causes, suicide, substance abuse, Parkinson's disease, accidents, dementia, infections and respiratory disorders (particularly pneumonia), and Alzheimer's disease. Solely hospital admission based studies, which have dominated the literature hitherto, somewhat over-estimate premature mortality in those with SMI. People with SMI are more likely to die by ill-defined and unknown causes, suicide and other less common and often under-reported causes. Comprehensive characterisation of mortality is important to inform policy and practice and to discriminate settings to allow for proportionate interventions to address this health injustice.

Long term cause specific mortality among 34 489 five year survivors of childhood cancer in Great Britain: population based cohort study

Objective To determine whether modern treatments for cancer are associated with a net increased or decreased risk of death from neoplastic and non-neoplastic causes among survivors of childhood cancer.Design Population...

Mortality of French participants in the Tour de France (1947-2012)

In the context of recent concerns regarding performance enhancing techniques and potential negative health effects of high-level physical activity, data on the long-term outcomes and causes of death in elite endurance cyclists are of particular interest. Characteristics and vital status of all French participants in the Tour de France were collected for the 1947-2012 period. Causes of death were obtained from 1968. Overall and disease-specific mortalities were compared with the French male population using overall and specific standardized mortality ratios (SMRs) with their 95% confidence intervals (CIs). Among the 786 French cyclists who participated at least once between 1947 and 2012, 208 (26%) died by 1 September 2012. Neoplasms and cardiovascular diseases accounted for 61% of deaths. We observed a 41% lower mortality in French cyclists (SMR: 0.59, 95% CI: 0.51-0.68, P < 0.0001), which did not change over time (P = 0.70). It was observed for main mortality causes: for neoplasms (SMR: 0.56; 95% CI: 0.42-0.72, P < 0.0001) and for cardiovascular death (SMR: 0.67; 95% CI: 0.50-0.88, P = 0.004), except mortality related to external causes (SMR: 1.06, 95% CI: 0.71-1.53, P = 0.80). We observed a substantially and significantly lower mortality in participants in the Tour de France, compared with the general male population. However, our results do not allow us to assess in detail the balance between positive effects of high-level sports activity and selection of healthy elite athletes, vs. any potential deleterious effects of excessive physical exercise or alleged doping.

Mortality from sudden unexpected death in epilepsy (SUDEP) in a cohort of adults with intellectual disability

People with intellectual disability (ID) and epilepsy are more likely to die prematurely than the general population. A significant number of deaths in people with epilepsy may be potentially preventable through better seizure control, regular monitoring and raising awareness among patients and carers. The aim of this project was to study mortality from sudden unexpected death in epilepsy (SUDEP) in adults with ID. All adults (≥20 years old) living in Leicester city, Leicestershire and Rutland, UK, with ID between 1993 and 2010 were identified using the Leicestershire Intellectual Disability Register database. People with and without ID who died during the same period were identified using death certificate data from the Office for National Statistics (ONS). Deaths from probable and definite SUDEP were identified. Additional information on adults with ID who had died from probable or definite SUDEP was obtained from case notes and post-mortem reports, where available. Cases of probable and definite SUDEP in adults with ID were compared with the general population using standardised mortality ratios (SMRs). A total of 898 adults with ID had died over the 18-year study period. Of these, 244 deaths (27%) occurred in people with ID who had a diagnosis of epilepsy. Twenty-six people with ID died from probable or definite SUDEP, which was the second most common cause of death among adults with ID and epilepsy. All-cause specific SMRs were 2.2 [95% confidence interval (CI): 2.0-2.4] and 2.8 (95% CI: 2.5-3.1) for men and women with ID respectively. SMRs were 3.2 (95% CI: 2.7-3.8) and 5.6 (95% CI: 4.6-6.7) for men and women with epilepsy and ID respectively. During the same study period, 83 adults without ID had died of probable or definite SUDEP. The SMRs for SUDEP in patients with ID were 37.6 for men (95% CI: 21.9-60.2) and 52.0 for women (95% CI: 23.8-98.8). We found that in the majority of ID cases there was little detailed documentation on the circumstances surrounding deaths, no communication with patients/carers about risk of SUDEP and an absence of post-mortem reports or carers' referral for bereavement counselling. The authors believe that a comprehensive risk management under a multiagency/multidisciplinary framework should be undertaken for all adults with ID and epilepsy in day-to-day clinical practice to reduce mortality in people with ID.

Long-Term Prospective Study of 6104 Survivors of Arsenic Poisoning During Infancy Due to Contaminated Milk Powder in 1955

BackgroundIn 1955, an outbreak of arsenic poisoning caused by ingestion of arsenic-contaminated dry milk occurred in western Japan. We assessed the excess mortality among Japanese who were poisoned during this episode as infants.MethodsWe identified and enrolled 6104 survivors (mean age at enrollment, 27.4 years) who had ingested contaminated milk when they were age 2 years or younger; they were followed until 2006 (mean duration of follow-up, 24.3 years). Death certificates of subjects who died between 1982 and 2006 were examined to calculate cause-specific standardized mortality ratios (SMRs) using the mortality rate among Osaka residents as the standard.ResultsThere was no significant excess overall mortality (SMR: 1.1, 95% confidence interval: 1.0–1.2). However, significant excess mortality in both sexes was observed from diseases of the nervous system (3.7, 1.9–6.2). Excess mortality from all causes of death decreased to unity beyond 10 years after study enrollment. The 408 men who were unemployed at the time of enrollment in the study had a significantly elevated risk of death from diseases of the nervous system (25.3, 10.8–58.8), respiratory diseases (8.6, 3.1–16.8), circulatory diseases (3.2, 1.6–5.2), and external causes (2.6, 1.4–4.1).ConclusionsAs compared with the general population, survivors of arsenic poisoning during infancy had a significantly higher mortality risk from diseases of the nervous system.

Mortality after traumatic spinal cord injury: 50 years of follow-up

ObjectiveTo study mortality and causes of death in an unselected geographically defined cohort of patients with traumatic spinal cord injury (TSCI), 1952–2001.MethodsPatients were identified from hospital records. The date of...

Mortality Study Update of Ethylene Oxide Workers in Chemical Manufacturing: A 15 Year Update

To investigate the long-term mortality patterns of workers with past exposure to ethylene oxide (EO). We redefined and updated a cohort of male workers employed in industrial facilities where EO was produced or used. All 2063 men were employed between 1940 and the end of 1988 and were observed for mortality through 2003. Cause specific Standardized Mortality Ratios were calculated. Internal analyses were made by applying Cox proportional hazards models to the data. No indications were found for excess cancer risks from EO exposures, including the lymphohematopoietic malignancies. There were 11 leukemia deaths and 11.8 expected and 12 non-Hodgkin lymphoma deaths and 11.5 expected. Proportional hazards modeling for all cause, leukemia and lymphoid malignancies mortality revealed no trends or associations with cumulative exposure. Despite the relatively high EO exposures in the past and extensive mortality follow-up, the cause specific mortality rates are comparable with those of the general US population. The Standardized Mortality Ratio analyses and the proportional hazards modeling for all cause mortality, leukemia and lymphoid malignancies mortality do not indicate exposure related effects in this cohort.

Ranking USRDS provider specific SMRs from 1998–2001

Provider profiling (ranking/percentiling) is prevalent in health services research. Bayesian models coupled with optimizing a loss function provide an effective framework for computing non-standard inferences such as ranks. Inferences depend on the posterior distribution and should be guided by inferential goals. However, even optimal methods might not lead to definitive results and ranks should be accompanied by valid uncertainty assessments. We outline the Bayesian approach and use estimated Standardized Mortality Ratios (SMRs) in 1998-2001 from the United States Renal Data System (USRDS) as a platform to identify issues and demonstrate approaches. Our analyses extend Liu et al. (2004) by computing estimates developed by Lin et al. (2006) that minimize errors in classifying providers above or below a percentile cut-point, by combining evidence over multiple years via a first-order, autoregressive model on log(SMR), and by use of a nonparametric prior. Results show that ranks/percentiles based on maximum likelihood estimates of the SMRs and those based on testing whether an SMR = 1 substantially under-perform the optimal estimates. Combining evidence over the four years using the autoregressive model reduces uncertainty, improving performance over percentiles based on only one year. Furthermore, percentiles based on posterior probabilities of exceeding a properly chosen SMR threshold are essentially identical to those produced by minimizing classification loss. Uncertainty measures effectively calibrate performance, showing that considerable uncertainty remains even when using optimal methods. Findings highlight the importance of using loss function guided percentiles and the necessity of accompanying estimates with uncertainty assessments.

Mortalité urbaine et rurale en Bretagne

Relative differences in environment, behaviour, social composition as well as access to health care tend to suggest that levels of health may vary between urban and rural areas. The aim of this study was to identify rural-urban variations in mortality risks in the region of Brittany for the period from 1988 to 1992. The definition of urban and rural areas used adhered to that of the zoning of urban areas established by the INSEE (the National Statistical Office). The amalgamation of all causes of standardised mortality ratios (SMR) show only a moderately increased risk in the rural areas compared with the overall regional level (+4% in men, +5-7% in women). The analysis of cause specific SMRs display higher rural mortality for cardiovascular diseases and external causes of death, road traffic accidents in particular (+24% in men). Among all specific causes investigated, only lung cancer mortality risk appears to be higher in urban areas.

Mortality in young offenders: retrospective cohort study

Objectives To estimate overall and cause specific standardised mortality ratios in young offenders.Design Comparison of mortality data in cohort of young offenders.Settings State of Victoria, Australia.Subjects Cohort of young offenders...

Pedestrian injuries in Mexico: a multi-method approach

Studies of road traffic injuries should identify social determinants amenable to intervention, and should attend to the problems of individual drivers and pedestrians. This is especially true in developing nations like Mexico, where traffic fatality rates are high and interventions ineffective. Objective: Combine qualitative and quantitative methods to analyze pedestrian injuries from motor vehicles in Mexico City, and identify their social, contextual and environmental determinants. Methods included (1) a cross-sectional analysis of mortality, producing crude and specific mortality rates and standardized mortality ratios (95% CI) by region; (2) Spatial analysis using a geographic information system to generate maps at different aggregation levels; (3) Observation with cameras to identify traffic patterns, spaces, behaviors, and patterned violations of regulations; and 4) Semi-structured in-depth interviews of pedestrians and drivers involved in an accident. Results: The overall crude mortality rate was 7.14/100,000, (CI 6.85–7.42), with differences by sex and region. The highest concentration of deaths was observed in 10 neighborhoods, at specific types of street environments. The high-risk environments have wide avenues with abundant vehicular traffic, where spaces supposedly reserved for pedestrians are invaded by cars and vendors. Many pedestrians have never driven a motor vehicle, few know the traffic signs, and almost all events were “hit and run” cases. Conclusions: The combination of quantitative and qualitative methods allows us to see the specific importance of some determinants of pedestrian injuries. Spatial, epidemiological, and social perspectives help point out the local accident characteristics which must be considered before defining preventive interventions.

Excess mortality in a population with diabetes and the impact of material deprivation: longitudinal, population based study

Objectives: To establish the age and sex specific mortality for people with diabetes in comparison with local and national background populations; to investigate the relationship between mortality and material deprivation...

Cohort mortality study of rubber and plastics product makers in Italy.

A retrospective cohort mortality study was carried out in 20 industrial factories in the Local Health Unit Bologna Sud (Emilia Romagna, Italy), where different rubber and plastics products were manufactured. The cohort consisted of 925 subjects (578 males and 347 females) employed for at least six months continuously; follow-up was between the beginning of operation of each factory, ranging between mid fifties and mid seventies, and 31 December 1989. For those exposed more than one year cause specific Standardized Mortality Ratios (SMRs) were computed using regional rates for comparison, 90% confidence intervals (CI) were calculated assuming the Poisson distribution. Among the 748 subjects employed for more than one year (457 males and 291 females) there were no lost to follow-up, 54 individuals were dead (41 males and 13 females) and for three subjects the cause of death was unknown. The results showed that all causes mortality was above expectancy in the total cohort (SMR = 123; 54 Obs; 90% CI = 97-154), among males (SMR = 117; 41 Obs; 90% CI = 89-152) and females (SMR = 143; 13 Obs; 90% CI = 85-228). Increased mortality for all malignant tumours was observed in the total cohort (SMR = 150; 25 Obs; 90% CI = 104-209) and for both genders. All nine lung cancer cases were observed among males, the SMR was equal to 218 and was statistically significant; seven cases occurred at duration of exposure less than 10 years and six at latency up to 20 years. The interpretation in terms of causality of the present investigation is limited by the small number of observations and by exposure definition solely in terms of employment in the study factories; nonetheless the results are indicating the existence, in this group of rubber and plastics product makers, of an adverse health effect which deserve further investigation.

"I'm all right, John": voting patterns and mortality in England and Wales, 1981-92.

To investigate the association between voting patterns, deprivation, and mortality across England and Wales. Ecological study. All the electoral constituencies of England and Wales. Combined and sex specific standardised mortality ratios. For the years surrounding the three elections of 1983, 1987, and 1992 overall standardised mortality ratios showed substantial negative correlations of -0.74 to -0.76 with Conservative voting and substantial positive correlations of 0.73 to 0.77 with Labour voting (all P < 0.0001). Correlations were higher for male than female mortality. Conservative voting was strongly negatively correlated (r = -0.84) with the Townsend deprivation score, while Labour voting was positively correlated (r = 0.74) with this. Labour and Conservative voting explained more of the variance in mortality than did the Townsend score. In multiple regression analyses for the 1992 election Labour voting (P < 0.0001), Conservative voting (P < 0.0001), the Townsend score (P = 0.016), and abstentions (P = 0.032) were all associated with mortality. Labour and conservative voting explained 61% of the variance in mortality between constituencies; when Townsend score and abstentions were added this increased to 63%. Conservative and Labour voting are at least as strongly associated with mortality as is a standard deprivation index. Voting patterns may add information above that provided by indicators of material deprivation. People living in better circumstances and who have better health, who are least likely to require unemployment benefit and free school meals or to rely on a state pension in old age, and who are most able to opt out of state subsidised provision of transport, education, and the NHS, vote for the party that is most likely to dismantle the welfare state.

Patterns of mortality in second generation Irish living in England and Wales: longitudinal study

To examine the mortality of second generation Irish living in England and Wales. Longitudinal study of 1% of the population of England and Wales (longitudinal study by the Office of Population Censuses and Surveys (now the Office for National Statistics)) followed up from 1971 to 1989. 3075 men and 3233 women aged 15 and over in 1971. Age and sex specific standardised mortality ratios for all causes, cancers, coronary heart disease, cerebrovascular diseases, respiratory diseases, and injuries and poisonings. Deaths were also analysed by socioeconomic indicators. 786 deaths were traced to men and 762 to women. At working ages (men, aged 15-64; women, 15-59) the mortality of men (standardised mortality ratio 126) and women (129) was significantly higher than that of all men and all women. At ages 15-44, relative disadvantages were even greater both for men (145) and for women (164). Mortality was raised for most major causes of death. Significant excess mortality from cancers was seen for men of working age (132) and for women aged 60 and over (122). At working ages mortality of the second generation Irish in every social class and in the categories of car access and housing tenure was higher than that of all men and all women in the corresponding categories. Adjusting for these socioeconomic indicators did not explain the excess mortality. Mortality of second generation Irish men and women was higher than that of all men and all women and for most major causes of death. While socioeconomic factors remain important, cultural and lifestyle factors are likely to contribute to this adverse mortality.