Standardized Mortality Ratios For Women Research Articles

Socioeconomic Predictors of Diabetes Mortality in Japan: An Ecological Study Using Municipality-specific Data.

ObjectivesThe aim of this study was to examine the geographic distribution of diabetes mortality in Japan and identify socioeconomic factors affecting differences in municipality-specific diabetes mortality.MethodsDiabetes mortality data by year and municipality from 2013 to 2017 were extracted from Japanese Vital Statistics, and the socioeconomic characteristics of municipalities were obtained from government statistics. We calculated the standardized mortality ratio (SMR) of diabetes for each municipality using the empirical Bayes method and represented geographic differences in SMRs in a map of Japan. Multiple linear regression was conducted to identify the socioeconomic factors affecting differences in SMR. Statistically significant socioeconomic factors were further assessed by calculating the relative risk of mortality of quintiles of municipalities classified according to the degree of each socioeconomic factor using Poisson regression analysis.ResultsThe geographic distribution of diabetes mortality differed by gender. Of the municipality-specific socioeconomic factors, high rates of single-person households and unemployment and a high number of hospital beds were associated with a high SMR for men. High rates of fatherless households and blue-collar workers were associated with a high SMR for women, while high taxable income per-capita income and total population were associated with low SMR for women. Quintile analysis revealed a complex relationship between taxable income and mortality for women. The mortality risk of quintiles with the highest and lowest taxable per-capita income was significantly lower than that of the middle-income quintile.ConclusionsSocioeconomic factors of municipalities in Japan were found to affect geographic differences in diabetes mortality.

Multi-scalar influences on mortality change over time in 274 European cities

Understanding determinants of urban health is of growing importance. Factors at multiple scales intertwine to influence health in cities but, with the growing autonomy of some cities from their countries, city population health may be becoming more a matter for city-level rather than national-level policy and action. We assess the importance of city, country, and macroregional (Western and East-Central Europe) scales to mortality change over time for 274 cities (population 80 million) from 27 European countries. We then investigate whether mortality changes over time are related to changes in city-level affluence. Using Urban Audit data, all-age all-cause standardised mortality ratios (SMRs) for males and females were calculated at three time points (wave one 1999–2002, wave two 2003–2006, and wave three 2007–2009) for each city. Multilevel regression was used to model the SMRs as a function of survey wave and city region gross domestic product (GDP) per 1000 capita. SMRs declined over time and the substantial East-West gap narrowed slightly. Variation at macroregion and country scales characterised SMRs for women in Western and East-Central European cities, and SMRs for men in East-Central European cities. Between-city variation was evident for male SMRs in Western Europe. Changes in city-region GDP per capita were not associated with changes in mortality over the study period. Our results show how geographical scales differentially impact urban mortality. We conclude that changes in urban health should be seen in both city and wider national and macroregional contexts.

P08 People with diabetes have a higher risk of death from liver disease compared to the general population

IntroductionThe association between liver disease and diabetes has been described, but less information is available regarding mortality from liver disease among people with diabetes from a population perspective.AimTo compare mortality...

Morbidity and mortality in patients with craniopharyngioma after surgery

Craniopharyngioma (CP) is a benign tumour of the suprasellar region that is associated with increased morbidity and mortality in comparison with other causes of hypopituitarism. We aimed to establish the rate and causes of mortality and morbidity in patients with CP who attended our centre. We performed a retrospective case note audit of patients with CP who were managed by our service. We established the standardized mortality ratio (SMR) for patients with CP. We compared obesity prevalence with two other hypopituitary groups who are managed by our service. We identified 70 patients with CP, 97% of whom had undergone surgery and 42% radiotherapy. We compared the prevalence of obesity with that of 89 patients with hypopituitarism secondary to surgery for nonfunctioning pituitary adenoma and 29 patients with post-traumatic hypopituitarism (PTHP). Standardized mortality ratio for patients with CP was 8.75 (95% CI of 5.4-13.3); SMR for women was 10.51 (95% CI 5.04-19.3) and 7.55 (95% CI 3.77-13.52) for men. The rates of growth hormone (GH), gonadotrophin, adrenocorticotrophic hormone (ACTH) and TSH deficiencies were 91%, 93.5%, 92% and 86%, respectively. The rate of diabetes insipidus (DI) was 81%; 7.1% had adipsic DI. Dyslipidaemia was present in 46.9% and diabetes mellitus in 11.5%. Obesity affected 66% of patients with CP, 47% of patients with nonfunctioning adenoma and 31% of those with PTHP (P < 0.001). Patients with CP suffer from high rates of mortality and morbidity. The underlying causes for mortality and for obesity in this population remain poorly understood.

Suicide in cancer patients in South East England from 1996 to 2005: a population-based study

BACKGROUND: Studies from around the world have shown that suicide risk is increased in cancer patients, but no previous detailed analysis has been carried out in England.METHODS: We calculated standardised mortality ratios (SMRs) for suicide in 206 129 men and 211 443 women diagnosed with cancer in South East England between 1996 and 2005, relative to suicide rates in the general population.RESULTS: We found a significantly increased risk of suicide in men (SMR 1.45, 95% confidence interval (CI) 1.20–1.73) and a moderately increased risk in women (SMR 1.19, 95% CI 0.88–1.57). In both sexes, relative risk of suicide was greatest in the first year after cancer diagnosis (SMR for men 2.42, 95% CI 1.84–3.13; SMR for women 1.44, 95% CI 0.82–2.33), and was also greater in individuals diagnosed with types of cancer with high fatality (SMR for men 2.67, 95% CI 1.71–3.97; SMR for women 2.17, 95% CI 0.80–4.73).CONCLUSION: There is a critical period immediately after the diagnosis of cancer during which the excess risk of suicide is particularly high. Carers need to be aware of the importance of attending to both the physical and emotional needs of cancer patients and cancer survivors.

Stomach cancer mortality in two large cohorts of migrants from the Former Soviet Union to Israel and Germany: are there implications for prevention?

Prevention and early detection are key elements for the reduction of stomach cancer mortality. To apply pertinent measures effectively, high-risk groups need to be identified. With this aim, we assessed stomach cancer mortality among migrants from the Former Soviet Union (FSU), a high-risk area, to Germany and Israel. We calculated standardized mortality ratios (SMRs) comparing stomach cancer mortality in two retrospective migrant cohorts from the FSU to Germany (n=34,393) and Israel (n=589,388) to that in the FSU and the host country. The study period ranges from 1990 to 2005 in Germany and from 1990 to 2003 in Israel. Vital status and cause of death were retrieved from municipal and state registries. To assess secular mortality trends, we calculated annual age-standardized mortality rates in the cohorts, the FSU, and the two host countries and conducted Poisson regression modeling. SMRs (95% confidence intervals) for men in the German migrant cohort were 0.51 (0.36-0.70) compared with the FSU population and 1.44 (1.04-1.99) compared with the German population, respectively. For women, SMRs were 0.73 (0.49-1.03) compared with the FSU population and 1.40 (0.98-1.99) compared with the German population. SMRs for men in the Israeli migrant cohort were 0.49 (0.45-0.53) compared with the FSU population and 1.79 (1.65-1.94) compared with the Israeli population. SMRs for women in the Israeli cohort were 0.65 (0.59-0.72) compared with the FSU population and 1.82 (1.66-1.99) compared with the Israeli population. Poisson modeling showed a secular decrease in all populations with a time lag of 4-5 years between migrants and 'natives' in Germany and converging rates between migrants and the general population in Israel. Stomach cancer mortality in migrants from the FSU remains elevated after migration to Germany and Israel but is much lower than in the FSU. Due to a secular decline, it can be expected that mortality among migrants from the FSU reaches within a few years levels similar to those of the host countries today. Therefore, migrant-specific prevention and early detection measures cannot be recommended. Detailed risk factor profiles, however, need to be obtained through further studies.

Death by homicide, suicide, and other unnatural causes in people with mental illness: a population-based study

People with mental illness are at great risk of suicide, but little is known about their risk of death from other unnatural causes. No study has commented on their risk of being victims of homicide; public concern is pre-occupied with their role as perpetrators. We aimed to calculate standardised mortality ratios (SMRs) and directly standardised rate ratios for death by homicide, suicide, and accident in people admitted to hospital because of mental illness. We did a population-based study in which we linked the data for 72208 individuals listed in the Danish Psychiatric Case Register between 1973 and 1993, and who died before Dec 31, 1993, with data in the Danish National Register of Causes of Death. 17892 (25%) patients died from unnatural causes. Our results show raised SMRs for homicide, suicide, and accident for most psychiatric diagnoses irrespective of sex. The all-diagnosis SMRs for women and men, respectively, were: 632 (95% CI 517-773) and 609 (493-753) for homicide, 1356 (1322-1391) and 1212 (1184-1241) for suicide, and 318 (305-332) and 466 (448-484) for accident. We recorded an increased risk of dying by homicide in men with schizophrenia and in individuals with affective psychosis. The highest risks of death by homicide and accident were in alcoholism and drug use, whereas the highest risks of suicide were in drug use. People with mental disorders, including severe mental illness, are at increased risk of death by homicide. Strategies to reduce mortality in the mentally ill are correct to emphasise the high risk of suicide, but they should also focus on other unnatural causes of death.

Female homicide offenders have greatly increased mortality from unnatural deaths

The mortality of female homicidal offenders has scarcely been studied. Our aim was to examine the mortality of homicidal women in Finland using a representative nation-wide material. The data consisted of all 132 women who underwent forensic psychiatric examinations after committing homicide or attempted homicide in 1982–1992. We analysed their rate and cause of death during follow-up using standardised mortality ratios (SMRs) and the official classification of death. The mean follow-up time for dead subjects was 7 years (S.D. 4), and for the rest 11 years (S.D. 3). There were 22 observed deaths, the expected value being 1.3 (SMR 17.4). The SMR for unnatural deaths was 226 and for suicides 425. The SMRs for women below 40 years were over 220. In conclusion, homicidal women have an over 200-fold risk of unnatural death, rising to over 400-fold for suicide. This should be taken into consideration in planning discharge programmes for homicidal offenders.

Prognosis of persons with type 1 diabetes on intensified insulin therapy in relation to nephropathy.

To study the prognosis of persons with type 1 diabetes in relation to the degree of nephropathy at initiation of intensified insulin therapy. Ten years follow-up of a cohort of 3674 patients who had participated in a 5-day group treatment and teaching programme for intensification of insulin therapy between September 1978 and December 1994. Ten diabetes centres in Germany. A total of 3674 patients (insulin treatment before age 31), age at baseline 27 +/- 10 years, with a diabetes duration of 11 +/- 9 years. Patients were divided into three groups according to baseline renal parameters (group I, normal proteinuria, n = 1829; group II, microproteinuria, n = 1257; group III, at least macroproteinuria, n = 367). End-stage diabetic complications (blindness, amputations, renal replacement therapy, standardized mortality ratios (SMR) and causes of death. Outcome measures were documented for 97% of patients; 251 (7%) had died. During follow-up, 1% of patients in group I, 4% in group II and 47% in group III had at least one end-stage diabetic complication. SMR for men: nephropathy group I, 2.2 (95% CI = 1.5-3); group II, 3.2 (2.3-4.3); group III, 11.5 (8.8-14.7). SMR for women: group I, 2.5 (1.5-3.8); group II, 3.5 (2.2-5.3); group III, 27 (19.8-35.9). Causes of death for men and women combined: group I (total 58 deaths)--cardiovascular, 21 (36%); hypoglycaemia, 1; ketoacidosis, 3; violent deaths, 17 (29%); others, 16; group II (66 deaths)--cardiovascular, 25 (38%); hypoglycaemia, 2; ketoacidosis, 2; violent deaths, 14 (21%); others, 23; group III (114 deaths)--cardiovascular, 68 (60%); hypoglycaemia, 2; ketoacidosis, 5; infections, 15 (13%); violent deaths, 5 (4%); others, 19. Patients with microproteinuria have only a slightly worse prognosis than patients with normal proteinuria during the first 10 years after initiation of intensified insulin therapy. Excess mortality amongst patients who started intensified insulin therapy is mainly due to those with manifest clinical nephropathy.

Pituitary adenomas in Sweden between 1958 and 1991: incidence, survival, and mortality.

The objective of the present study was to determine the incidence of pituitary adenomas (PAs) and the associated rates and causes of mortality in a large population. The study population comprised 2279 patients (1010 women and 1269 men) of all individuals (n = 3321) with pituitary tumors included in the Swedish Cancer Registry between 1958 and 1991. The mean age (+/-SD) at diagnosis was 52.3 +/-15.7 yr. The age-standardized incidence of PA increased significantly from approximately 6 cases/million inhabitants in 1958 to 11 cases/ million in 1991. The age-specific incidence peaked between 60-70 yr of age in both sexes. Excess mortality was found in the study population. The total number of deaths was 842. The standardized mortality ratio (SMR) for the study population was 2.0. The SMR for women (2.3) was significantly (P < 0.01) higher than that for men (1.9). Cardiovascular diseases were the most common cause of mortality among patients, accounting for 346 deaths (SMR, 1.6). The difference between the sexes was significant (men, 1.4; women, 1.8; P < 0.05). Cerebrovascular death occurred in 97 patients (SMR, 2.4), with no significant difference between men (SMR, 2.5) and women (SMR, 2.2). Excess mortality was also observed for tumors, endocrine diseases, and gastrointestinal diseases. These findings suggest that the annual incidence of PA is increasing. Possible explanations are improved diagnostic skill and/or increased awareness of pituitary diseases among physicians. However, a real increase in the incidence of PA cannot be ruled out.

Effect of age on excess mortality in obesity.

The effect of age on excess mortality from all causes associated with obesity is controversial. Few studies have investigated the association between body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), age, and mortality, with sufficient numbers of subjects at all levels of obesity. To assess the effect of age on the excess mortality associated with all degrees of obesity. Prospective cohort study. A total of 6193 obese patients with mean (SD) BMI of 36.6 (6.1) kg/m2 and mean (SD) age of 40.4 (12.9) years who had been referred to the obesity clinic of Heinrich-Heine University, Düsseldorf, Germany, between 1961 and 1994. Median follow-up time was 14.8 years. All-cause mortality through 1994 among 6053 patients for whom follow-up data were available (1028 deaths) analyzed as standardized mortality ratios (SMRs) using the male-female population of the geographic region (North Rhine Westphalia) as reference. The cohort was grouped into approximate quartiles according to age (18-29, 30-39, 40-49, and 50-74 years) and BMI (25 to <32, 32 to <36, 36 to <40, and > or =40 kg/m2) at baseline. The SMRs showed a significant excess mortality with an SMR for men of 1.67 (95% confidence interval, 1.51-1.85; P<.001) and an SMR for women of 1.45 (95% confidence interval, 1.34-1.57; P<.001). The excess mortality associated with obesity declined with age. For men, the SMRs of the 4 age groups were 2.46, 2.30, 1.99, and 1.31, respectively; for women, they were 1.81, 2.10, 1.70, and 1.26, respectively (Poisson trend test, P<.001). The SMRs increased with BMI but, within each BMI group, the SMRs decreased with age. The lowest SMRs (for men, 1.01; for women, 0.91) were obtained for patients older than 50 years with BMIs of 25 to less than 32 kg/m2. Thus, older men and women at a BMI range of 25 to less than 32 kg/m2 had no excess mortality. The highest SMRs (for men, 4.22; for women, 3.79) were calculated for the patients aged 18 to 29 years with a BMI of 40 kg/m2 or higher. In this large cohort of obese persons, risk of death increased with body weight, but obesity-related excess mortality declined with age at all levels of obesity.

Coronary artery bypass surgery in women and in men; early and long-term results. A study of the Norwegian population adjusted by age and sex.

We wished to analyse early mortality, postoperative low-output syndrome needing intra-aortic balloon pumping support (IABP), total mortality, recurrent angina pectoris and total non-fatal myocardial infarction in women compared with men. Also, the standard mortality ratio (SMR) was estimated to compare the mortality data to the general Norwegian population of comparable sex and age. A total of 1025 patients; 113 women and 912 men, were submitted to coronary artery bypass surgery at Rikshospitalet, Oslo between August 1982 and December 1986. The patients were followed up until the 1st of January 1993, representing a mean follow-up time of 7.4 years. An exposed/non-exposed cohort study design was used. A power study was carried out. The standardized mortality ratios for women and men were calculated after adjusting for age and sex. Crude odds ratio (ORC) of early mortality was 2.0 with a 95% confidence limit (CL95%) of 0.7-5.4. Odds ratio of low output syndrome needing intra-aortic balloon support was 1.7 (CL95% = 0.8-4.2). Statistical significance was not achieved for these end-points. Women did not run an increased hazard of total mortality (ORC = 0.9; CL95% = 0.5-1.5), recurrent angina pectoris (ORC = 1.4; CL95% = 0.8-2.4) or of total non-fatal myocardial infarction (ORC = 0.8; CL95% = 0.4-1.6) when compared with men. Adjusting for confounders did not significantly alter the results. When matched on sex and age and compared to the normal Norwegian population, we found an increased SMR in both men (2.5; CL95% = 2.2-2.9) and women (4.1; CL95% = 2.2-4.9). The risk of early mortality and low-output syndrome needing intra-aortic balloon support tended to be higher in women compared with men. Women did not run an increased risk of total mortality, recurrent angina or of total non-fatal myocardial infarction. The standard mortality ratio was increased in both men and women, but in particular higher in women, suggesting a more aggressive course of coronary artery disease in operated women than in operated men. However, this difference did not show in the long term follow-up, due to the beneficial effect of coronary artery bypass surgery in both men and women.

Lower risk of suicide during pregnancy.

The authors determined the risk of suicide during pregnancy. The autopsy reports of all female residents of New York City, 10-44 years old, who committed suicide from 1990 to 1993 were assessed for pregnancy. These data were compared with age-adjusted and race-adjusted standardized mortality ratios for women, which were calculated by using population data from the 1990 U.S. Census as well as data obtained from the New York City Health Department on the number of live births, spontaneous abortions, and induced abortions. The standardized mortality ratio for suicide during pregnancy was 0.33; that is, the number of suicides of pregnant women was only one-third of that expected. Despite the mood swings and stresses associated with pregnancy and impending childbirth, pregnant women have a significantly lower risk of suicide than women of childbearing age who are not pregnant.

Insulin treated diabetes mellitus: causes of death determined from record linkage of population based registers in Leicestershire, UK.

Analyses of causes of mortality in people with diabetes using data form death certificates mentioning diabetes provide unreliable estimates of mortality. Under-recording of diabetes as a cause on death certificates has been widely reported, ranging from 15-60%. Using a population based register on people with diabetes and linking data from another source is a viable alternative. Data from the Office of Population Censuses and Surveys (OPCS) are the most acceptable mortality data available for such an exercise, as direct comparison with other published mortality rates is then possible. A locally maintained population-based mortality register and all insulin-treated diabetes mellitus cases notified to the Leicestershire diabetes register (n = 4680) were linked using record linkage software developed in-house (Lynx). This software has been extensively used in a maintenance and update cycle designed to maximise accuracy and minimise duplication and false registration on the diabetes register. Deaths identified were initially coded locally to the International Classification of Diseases, 9th revision (ICD9), and later a linkage was performed to use official OPCS coding. Mortality data identified by the linkage was indirectly standardised using population data for Leicestershire for 1991. Standardised mortality ratios (SMR) were estimated, with 95% confidence intervals. Insulin dependent diabetes (IDDM) was defined as diabetes diagnosed before age 30 years with insulin therapy begun within one year of diagnosis. All other types were considered non-insulin dependent diabetes (NIDDM). Analyses were performed for the whole sample and then for the NIDDM subgroup. Results from these analyses were similar and therefore only whole group analyses are presented. A total of 370 deaths were identified for the period of 1990-92 inclusive - 56% were in men and 44% in women, median age (range) 71 years (12-94). Approximately 90% of deaths were subjects with NIDDM. Diabetes was mentioned on 215 (58%) death certificates. The all causes SMRs were significantly raised for men and women for all ages less than 75 years. Ischaemic heart disease (ICD9) rubrics 410-414) accounted for 146 (40%) deaths - 41% of male and 38% of female deaths. Male and female SMRs were significantly raised for the age groups 45-64, 65-74, and 75-84 years. Cerebrovascular disease (ICD9 rubrics 430-438) accounted for 39 (10%) deaths and the SMR for women the external causes of death (ICD9 rubrics E800-E999) were also significantly raised overall and in age groups 15-44 and 45-64 years. This was not true for men, although numbers of deaths in this category were small for both men (4) and women (9). Record linkage has been used successfully to link two local, population based registers. This has enabled an analysis of mortality in people with diabetes to be performed which overcomes the problems associated with using as a sample, death certificates where diabetes is mentioned. The mortality rates and SMRs estimated should more accurately reflect the true rates than would be possible using other methods. The persisting excess mortality identified for people with diabetes is of a similar magnitude and attributable to similar causes as has been reported elsewhere in population based studies.