Trends In All-cause Mortality Research Articles

Worldwide trends in all-cause mortality of auto-immune systemic diseases between 2001 and 2014.

To describe changes in the 2001-2014 mortality of 6 autoimmune systemic diseases (AISDs), namely Systemic Lupus Erythematosus (SLE), Systemic Sclerosis (SSc), Idiopathic Inflammatory Myopathies (IIM), Sjögren's Syndrome (SS), Mixed Connective Tissue Disease (MCTD) and ANCA-associated vasculitis (AAV) at the country-, continent-, and world-levels. Mortality data were retrieved from the World Health Organization (WHO) mortality database for each disease, based on ICD-10 codes. We computed age-standardized mortality rate (ASMR) as the estimated number of deaths per million inhabitants and its 95% confidence interval (95%CI). The association between gender, geographical areas and disease-specific mortality was analyzed using multivariate Poisson regression. The 2001-2014 temporal trends were analyzed using Jointpoint software. In 2014, the worldwide ASMR for SLE was 2.68 (95%CI: 2.62-2.75) deaths/millions inhabitants, 1.46 (1.42-1.51) for SSc, 0.47 (0.44-0.49) for IIM, 0.17 (0.15-0.18) for SS, 0.11 (0.10-0.13) for MCTD and 0.53 (0.50-0.56) for AAV, with ASMRs generally lower in Europe than in North America, Latin America and Asia. Between 2001 and 2014, the worldwide ASMR decreased significantly for SSc (-0.71%/year), IIM (-1.65%/year) and AAV (-1.01%/year; p<.001 for all) and increased for SS (+1.53%/year, p=.01). The worldwide ASMR of SLE decreased significantly between 2001 and 2003 (-6.37%, p<.05) before increasing slightly between 2004 and 2014 (+0.58%, p<.01). We observed a strong heterogeneity of standardized mortality rates across all countries analyzed for 6 autoimmune diseases. Those results further highlight the impact of world-wide inequities and major gaps in access to care and strategies for diagnosis and management of rare diseases, a crucial finding for world-wide physicians, patient associations and policy makers.

One-year mortality after implantable cardioverter-defibrillator placement within the Veterans Affairs Health System.

Implantable cardioverter-defibrillator (ICD) therapy reduces mortality in patients with heart failure and current guidelines advise implantation of ICDs in patients with a life expectancy of >1year. We examined trends in all-cause mortality in patients who underwent primary or secondary prevention ICD placement in the Veterans Affairs (VA) Health System. US veterans receiving a new ICD placement for primary or secondary prevention of sudden cardiac death between January 2007 and January 2015, who had heart failure with reduced ejection fraction (HFrEF) were included in the analysis. We assessed all-cause mortality 1 year post-ICD implantation. ICD implantation and HFrEF diagnosis were established with associated ICD-9 codes. The VA death registry was utilized to identify mortality rates following ICD placement. Results were subsequently age-stratified. There were 17 901 veterans with HFrEF with ICD placement nationwide. There was no statistically significant difference in 1-year mortality from 2007 (13.1%) to 2014 (13.4%, P> 0.05). There was a significant increase in 1-year mortality in patients in the oldest age quartile (81.6 years, 32.3% mortality) compared to the youngest quartile (55.5 years, 7% mortality). The finding of diverging clinical outcomes extended to the 30-day but also 8-year mark. Our data suggest there is a high 1-year mortality in aging HFrEF patients undergoing primary and secondary prevention ICD placement. This highlights the importance of developing better predictive models for mortality in our ICD eligible patient population.

Change in the Mortality Trend of Hospitalized Patients with Clostridium difficile Infection: A Nation-wide Study.

BackgroundAccording to the Healthcare Cost and Utilization Project (HCUP), mortality in Clostridium difficile infection (CDI) has been rising since 2009, and an upward trend in mortality has been noted. Although there have been studies exploring the incidence of CDI and mortality in the national database, those studies were limited to one particular year. With the advent of newer modalities of diagnosis and treatment for CDI, the recent multiyear trend in disease-specific outcomes from large administrative databases is unknown.ObjectiveTo study the recent trend in nationwide hospital admissions and mortality along with hospital outcomes.MethodsWe queried the identified National Inpatient Sample from 2007 to 2011 to identify patients of age >18 years, with a discharge diagnosis of CDI identified by the International Classification of Diseases, 9th edition (ICD-9), clinical modification codes 008.45, respectively.ResultsWe identified a decline in CDI mortality to 2.67% in 2011 as compared to 3.83% in 2007 (P<0.0001) with CDI as the primary discharge diagnosis and a downward trend in all-cause mortality from 9.2% in 2007 to 7.9% in 2011 (P<0.0001). We identified an upward trend in CDI-related hospital discharges from 2007 (N=325,022) to 2011 (N=333498). Hospital discharges with CDI as a primary discharge diagnosis also increased from 2007 (N=104,123) to 2011 (123,898). The mean length of stay decreased from 7.16 days in 2007 to 6.40 days in 2011 (P 0.0001). CDI was noted to be more common in the elderly (61-80), with a mean age of 68 years. Patients were of Caucasian descent (67%), female (64%), and primarily a Medicare payer (69%). Mean hospital charges increased from $31,551 to 35,654$ (P .04). Of interest, CDI was noted to be more common in large bed-sized non-teaching hospitals (57%) than large bed-sized teaching hospitals (42%). In terms of the geographical distribution of CDI, the southern states of the US had an increased incidence of CDI (36%) and the west coast (16%) had the least incidence.Conclusion Our study shows an improved trend in-hospital mortality outcomes and a decreased length of stay likely related to the advancement in CDI treatments. Hospital charges were increased from 2007 to 2011 in spite of a decrease in hospital length of stay.

Rising Trends in Medication Non-compliance and Associated Worsening Cardiovascular and Cerebrovascular Outcomes Among Hospitalized Adults Across the United States.

IntroductionSmall-scale studies have described concerning rates of non-compliance/nonadherence towards groups of medications for primary and secondary prevention. Trends in cardiovascular and cerebrovascular events (CCE) among hospitalized patients with a non-compliant behavior towards medication, on the whole, remains unexplored on a large scale.MethodsUsing the National Inpatient Sample databases (2007-2014), we sought to assess the prevalence and trends in all-cause mortality and CCE in adult patients hospitalized with medication non-compliance. We compared baseline characteristics and comorbidities in the non-compliant patients with and without concomitant in-hospital CCE.ResultsWe identified 7,453,831 adult hospitalizations with medication non-compliance from 2007 to 2014, of which 867,997 (11.6%) patients demonstrated in-hospital CCE. Non-compliant patients with CCE consisted of a higher number of older, white, male patients having greater comorbid risk factors. Non-compliant patients with CCE had higher all-cause in-hospital mortality (3% vs. 0.7%), frequent transfers [4.4% vs. 1.8% transfers to short-term hospitals, and 17.6% vs. 11.6% other transfers (skilled nursing or intermediate care facilities)], lower routine discharges (59.4% vs. 71.1%), and higher mean hospital charges ($52,740 vs. $30,748) compared to non-compliant patients without CCE. Remarkably, this study demonstrates the rising trend in medication non-compliance across all age, sex, and race groups, and related in-hospital mortality, CCE, transfers to other facilities, and the health care cost from 2007 to 2014.ConclusionsWe observed rising trends in the prevalence of medication non-compliance and subsequent in-hospital mortality in hospitalizations among adults from 2007 to 2014. Non-compliant patients with inpatient CCE demonstrated rising trends in all-cause mortality, complications, health care utilization, and cost from 2007 to 2014.

1659-P: A Systematic Review of Trends in All-Cause Mortality among People with Diabetes

Some studies have reported falling mortality among populations with diabetes, but the consistency of this trend is unclear. We systematically reviewed studies published from 1980-2017 reporting all-cause mortality across 2 time-periods in people with diabetes. A total of 35 studies were found, providing data on 56 sex-specific or total populations with diabetes or type 2 diabetes. All studies were from high-income countries. Mortality declined in 80% of populations with diabetes in the 1980s, 53% in the 1990s, and 85% from 2000 onwards (Table). Falling mortality in diabetes occurred in 87% of Europid populations and in 10% of non-Europid populations. Of 25 populations with age-specific data, mortality declined in 29% of populations aged &amp;lt;40 years and in &amp;gt;60% of populations aged &amp;gt;55 years. Of 37 populations that reported on those with and without diabetes, greater or similar mortality reduction was observed among those with diabetes than without diabetes in 70% of populations. In conclusion, mortality has declined in the majority of Europid populations with diabetes since 1980. However, most non-Europid and most younger populations show no such declines. Disclosure L. Chen: None. R.M. Islam: None. J. Wang: None. T.R. Hird: None. M.E. Pavkov: None. E.W. Gregg: None. M. Tabesh: None. D. Koye: None. J.L. Harding: None. J.W. Sacre: None. E.L. Barr: None. D.J. Magliano: None. J.E. Shaw: Advisory Panel; Self; Abbott, Merck Sharp &amp; Dohme Corp. Speaker's Bureau; Self; AstraZeneca, Mylan, Roche Diabetes Care, Sanofi-Aventis. Funding Centers for Disease Control and Prevention

Early cardiovascular risk and all-cause mortality following an incident of severe hypoglycaemia: A population-based cohort study.

Severe hypoglycaemia is associated with a high risk of cardiovascular events in patient with diabetes. The aim of this study was to clarify the temporal relationship between hypoglycaemia and cardiovascular events. This observational cohort study was conducted using Taiwan's Longitudinal Cohort of Diabetes Patients Database, which included 360 000 patients with newly diagnosed diabetes during the period 1999 to 2001. Patients with the first severe hypoglycaemia after 2002 served as the study cohort. Each patient in the study cohort was matched with two control patients without severe hypoglycaemia, based on a propensity score. A joinpoint regression model was used to determine trends in all-cause mortality and incidence of cardiovascular disease (CVD) events in both cohorts. A total of 10 157 patients with severe hypoglycaemia and 20 314 matched controls were recruited. Patients with severe hypoglycaemia had a significantly higher risk of CVD (HR, 7.28; 95% CI, 5.19-10.20) and all-cause mortality (HR, 19.92; 95% CI, 13.42-29.56) during the first month compared with those without. In patients with severe hypoglycaemia, the incidence of CVDs dropped by 17.29% monthly during the first 4 months and slowly decreased (-0.67%) during subsequent months. All-cause mortality decreased by 16.55% and 3.24% monthly during months 0-6 and months 6-17, respectively. Severe hypoglycaemia is associated with a greater risk of cardiovascular events and death, especially during the first month following a hypoglycaemic episode. Patients prone to severe hypoglycaemia should be made aware of the elevated risk of subsequent cardiovascular events.

378 Trends of All-Cause Mortality by Severity of Hyponatremia Among Hospitalized Patients in a Tertiary Referral Hospital over a Five-Year Period

378 Trends of All-Cause Mortality by Severity of Hyponatremia Among Hospitalized Patients in a Tertiary Referral Hospital over a Five-Year Period

All-Cause and Cause-Specific Mortality Trends of End-Stage Renal Disease Due to Lupus Nephritis From 1995 to 2014.

A prior study showed that premature mortality among patients with end-stage renal disease (ESRD) due to lupus nephritis (LN) persisted in the US between 1995 and 2006. The present study was undertaken to extend this analysis through 2014 to examine more recent trends, including key cause-specific mortality trends. Using the national registry of patients with ESRD, we identified all patients with incident ESRD due to LN between January 1, 1995 and December 31, 2014, divided into four 5-year cohorts of ESRD onset by calendar year (1995-1999, 2000-2004, 2005-2009, 2010-2014). We assessed mortality within each cohort. Temporal trends in all-cause mortality and cause-specific mortality were examined, adjusting for covariates. We identified 20,974 individuals with incident ESRD due to LN from 1995 through 2014. The mortality rate per 100 patient-years declined from 11.1 (95% confidence interval [95% CI] 10.4-11.8) in 1995-1999 to 6.7 (95% CI 6.2-7.2) in 2010-2014 (P for trend < 0.01). Adjusted mortality hazard ratios in 2010-2014, compared with 1995-1999, were 0.68 (95% CI 0.58-0.78) for white patients, 0.67 (95% CI 0.57-0.78) for African American patients, and 0.51 (95% CI 0.38-0.69) for Hispanic patients. Deaths from cardiovascular disease (CVD) and infection declined by 44% and 63%, respectively, from 1995-1999 to 2010-2014 (P for trend < 0.01 for both). In the more recent years of the period 1995-2014, there was a considerable reduction in all-cause mortality among white, African American, and Hispanic patients, with reduced risk of death from CVD and infection. Collectively, these trends provide an important benchmark of improving care in this high-risk population.

The effect of radial pulse spectrum on the risk of major adverse cardiovascular events in patients with type 2 diabetes

Radial pulse spectrum has been shown to correlate with coronary stenosis in patients with type 2 diabetes mellitus (T2DM). In academia, it has not been demonstrated that the radial artery pulse spectrum is an independent risk factor for major adverse cardiovascular events (MACE), including myocardial infarction, stroke, and all-cause mortality. The primary objective of this study is to assess the risk of MACE, in patients with T2DM and to determine if an increase in MACE would be associated with a first harmonic (C1) increase in the radial artery pulse. 1972 consecutive patients with T2DM were enrolled. All subjects received measurements of radial pulse waves at baseline. Harmonic analysis of radial pressure wave was performed. The hazard ratios for MACE and its 95% confident interval were estimated using Cox proportional hazard model. The follow-up period lasted for one year. MACE was detected in 232 (11.8%) of those with T2DM. The log-rank test demonstrated that the cumulative incidence of patients with C1 above 0.96 was greater than those with C1 bellow 0.96. Comparing the patients with C1 smaller than first quartile to the patients with C1 greater than third quartile, higher C1 increased the cardiovascular risks as follows: MACE (Hazard ratio,1.93; 95% CI,1.31–2.86), stroke (Hazard ratio, 1.61; 95% CI, 0.90–2.90), myocardial infarction (Hazard ratio, 2.23; 95% CI, 1.33–3.74). The risk for the composite MACE increased continuously as C1 increased (P < 0.001 for trend). The hazard ratio and trend for all-cause mortality were not significant. Increased C1 resulted in increased risk for nonfatal stroke, and nonfatal myocardial infarction among patients with T2DM. Our results indicate that the degree of C1 is a risk factor for nonfatal MACE. Therefore, the radial pulse spectrum could identify patients with T2DM at high risk of nonfatal MACE.

Secular trends in all cause mortality among children under the age of 15 years in Germany, 1980–2015

Introduction In the last century infant mortality in Germany has decreased substantially. Hundred years ago, one in six children in Germany died under the age of one year, while the corresponding rate today is about 3 in 1000 children. Similar reports on secular trends of the age-specific mortality among children of other age groups in the last decades are rather rare. Therefore, the aim of this study was an overview of secular trends in the age-specific mortality rates of children under the age of 15 years in Germany for the time from 1980 to 2015. Methods The analyses of secular trends were based on the German age- and sex-specific mortality data of the following age groups: Results The time series of the infant mortality ( Conclusions The analysis of age- and sex-specific mortality rates in time series allows an overview of the mortality development in different age groups and comparisons between both sexes over a longer period in time. The detection and comparison of secular trends is supported by visualization of the data in time series. Mortality rates decreased between 1980 and 2015 in all age groups considered and the differences in the mortality of boys and girls diminished.

Trends in all-cause five-year mortality after head and neck cancers diagnosed over a period of 33 years. Focus on estimated degree of association with human papillomavirus

Background: Factors influencing survival after head and neck cancer (HNC) include among others stage, age, and sex. More recently, human papillomavirus (HPV) positivity has been described as a favorable prognostic factor in relation to some HNCs.Material and methods: In this nationwide register-based cohort study of all 20 925 individuals diagnosed with squamous cell carcinoma of the head and neck (HNSCC) in Denmark 1978–2010, we investigate secular trends in all-cause five-year mortality after HNSCC according to the anticipated degree of association with HPV using a Cox proportional hazards model. Furthermore, we examine whether any trend over time differed according to sex, stage, and age at diagnosis.Results: All-cause five-year mortality after HNSCC has decreased over time. The greatest decrease was seen in the last decade (2000–2010) among patients with HNSCC at sites estimated to be strongly associated with HPV, i.e. the base of the tongue and the tonsils, where a 28% decrease per five years (e.g. HRbase of tongue/tonsils=0.72; 95% CI 0.64–0.81) was observed. When examining sex- and age-specific time trends, the decrease in mortality was most pronounced among male patients and patients below 60 years at diagnosis. In contrast, no clear pattern was observed when examining five-year all-cause mortality trends according to stage.Conclusion: All-cause five-year mortality after HNSCC has decreased significantly in Denmark from 1978 to 2010, especially for HNSCCs at sites anticipated to be strongly associated with HPV, possibly due to an increasing proportion of HPV-positive HNSCCs.

An association between time-varying serum albumin level and the mortality rate in maintenance haemodialysis patients: a five-year clinical cohort study.

BackgroundUntil now, no long-term studies relating serum albumin level to mortality rate in prevalent haemodialysis (HD) patients have been conducted. We aimed to examine the association between serum albumin level and mortality over a 5-year period.MethodsThis study included 781 patients who received maintenance HD in a large, hospital-facilitated HD centre. Five-year medical records (2009–2013) were retrospectively reviewed, and the cut-off level for serum albumin level was set at 3.5 g/dL. The analysed albumin levels were expressed as time-averaged levels (first 24-month data) and albumin target reach rate over the first 2-year interval. Univariate and multivariate Cox proportional hazard regression models were used to examine the hazard function of the all-cause and cardiovascular mortality of the study participants in the subsequent 3-year period (2011–2013).ResultsCompared to those with a 100 % albumin reach rate (3.5 g/dL), the participants with 75– < 100, 50– < 75, and 1– < 50 % albumin reach rates exhibited significantly increased risk for all-cause mortality (HR 1.72, 95 % CI 1.19–2.47; HR 3.14, 95 % CI 1.91–5.16; HR 3.66, 95 % CI 2.18–6.16, respectively). A similar trend for all-cause mortality was demonstrated in participants with time-averaged albumin levels <4 g/dL (HR 1.57, 95 % CI 1.00–2.46 for 3.5–4.0 g/dL; HR 3.66, 95 % CI 2.11–6.32 for <3.5 g/dL). Compared to a 100 % albumin reach rate, the 50– < 75 and 1– < 50 % groups (HR 4.28, 95 % CI 1.82–10.01; HR 3.23, 95 % CI 1.22–8.54 respectively) showed significantly higher cardiovascular mortality rates. Similarly, participants with a time-averaged serum albumin level <3.5 g/dL exhibited a higher risk for cardiovascular mortality (HR 3.24, 95 % CI: 1.23–8.56).ConclusionsThis long-term study demonstrated that higher reach rates of serum albumin levels and higher time-averaged serum albumin levels are associated with a lower mortality rate in patients undergoing maintenance HD.

Mortality trends among Japanese dialysis patients, 1988-2013: a joinpoint regression analysis.

Evaluation of mortality trends in dialysis patients is important for improving their prognoses. The present study aimed to examine temporal trends in deaths (all-cause, cardiovascular, noncardiovascular and the five leading causes) among Japanese dialysis patients. Mortality data were extracted from the Japanese Society of Dialysis Therapy registry. Age-standardized mortality rates were calculated by direct standardization against the 2013 dialysis population. The average annual percentage of change (APC) and the corresponding 95% confidence interval (CI) were computed for trends using joinpoint regression analysis. A total of 469 324 deaths occurred, of which 25.9% were from cardiac failure, 17.5% from infectious disease, 10.2% from cerebrovascular disorders, 8.6% from malignant tumors and 5.6% from cardiac infarction. The joinpoint trend for all-cause mortality decreased significantly, by -3.7% (95% CI -4.2 to -3.2) per year from 1988 through 2000, then decreased more gradually, by -1.4% (95% CI -1.7 to -1.2) per year during 2000-13. The improved mortality rates were mainly due to decreased deaths from cardiovascular disease, with mortality rates due to noncardiovascular disease outnumbering those of cardiovascular disease in the last decade. Among the top five causes of death, cardiac failure has shown a marked decrease in mortality rate. However, the rates due to infectious disease have remained stable during the study period [APC 0.1 (95% CI -0.2-0.3)]. Significant progress has been made, particularly with regard to the decrease in age-standardized mortality rates. The risk of cardiovascular death has decreased, while the risk of death from infection has remained unchanged for 25 years.

Temporal trends in all-cause mortality according to smoking status: Insights from the Global Registry of Acute Coronary Events

ObjectiveSmoking has been shown to be a risk factor for heart disease. However, it was recently reported that despite the evolution in therapy for acute coronary syndrome (ACS), smokers have not demonstrated improved outcomes.The aim of the present study was to evaluate the temporal trends in the treatments and outcomes across a broad spectrum of ACS patients (STEMI and non-ST-elevation ACS [NSTEACS]) according to smoking status on presentation in the Global Registry of Acute Coronary Events (GRACE). MethodsOur cohort was stratified into 3 groups: current smokers, former smokers and never smokers. We evaluated trends in demographics, treatment modalities and outcomes in these 3 groups from 1999 to 2007. ResultsThe study population comprised a total of 63,015 patients admitted to hospital with an ACS and with identifiable baseline smoking status. Smokers presented with STEMI more often than non-smokers. There was an unadjusted decline in 30-day mortality in all 3 groups. However, the adjusted decline was not statistically significant among current smokers (HR=0.98 per study year, 95% CI 0.94–1.01, p=0.20). A subgroup analysis of 22,894 STEMI patients demonstrated no reduction in annual adjusted 30-day mortality rates among smokers (HR=1.01, 95% CI 0.96–1.06 (Table 5), whereas former and never smokers' mortality declined. ConclusionsOver the years 1999–2007, 30-day mortality declined in patients presenting with acute coronary syndrome. However, smokers presenting with STEMI did not demonstrate a reduction in mortality.

Cancer incidence and all-cause mortality in HIV-positive patients in Northeastern Algeria before and during the era of highly active antiretroviral therapy.

To assess cancer incidence and all-cause mortality trends in HIV-positive patients in Algeria before and during the highly active antiretroviral therapy (HAART) era. Cross-sectional study. We used hospital-based data of patients with HIV/AIDS between January 1988 and December 2010. Cancer incidence, standardized mortality ratios (SMRs), risk of death, and proportion of HIV-positive patients treated before and during the HAART era were calculated. The joinpoint model was used to assess the magnitude of changes in SMRs. In 1988-2010, 156 patients were diagnosed as HIV-positive. During pre-HAART era, Kaposi sarcoma (KS) incidence was 5%. After the introduction of HAART, KS incidence decreased to 2%. No other AIDS-related cancer was diagnosed during the study. One-third died (52/156), of which 83.6% died in the same year as or in the year after HIV diagnosis; median age at death (interquartile range) was 34.5 (11.8) years. Yearly risk of death declined from 100% in 1998 to 8% in 2010; percentage of patients treated with HAART increased from 13% in 1998 to >80% after 2002. Overall SMR decreased from 200.2 (95% confidence interval [95% CI], 123.2-325.2) before the HAART era to 91.4 (95% CI, 66.0-126.6) thereafter. From 2003, yearly SMRs decreased significantly by 66.1% (P < 0.05) until 2006 but not thereafter. Since 1998, the proportion of HIV-positive patients treated with HAART increased, reaching 84% in 2010, all-cause mortality decreased, and cancer remained rare. However, almost all patients who died during the study seemed to be diagnosed at a late stage of the disease, emphasizing the need for earlier diagnosis of HIV in Algeria.

Trends in All-Cause Mortality across Gestational Age in Days for Children Born at Term.

BackgroundTerm birth is a gestational age from 259 days to 293 days. However trends in mortality according to gestational ages in days have not yet been described in this time period.Methods and FindingsBased on nation-wide registries, we conducted a population-based cohort study among all children born at term in Denmark from 1997 to 2004 to estimate differences in mortality across gestational ages in days among singletons born at term. We studied early-neonatal mortality, neonatal mortality, infant mortality, and five-year mortality. Children were followed from birth up to the last day of the defined mortality period or December 31, 2009. A total of 360,375 singletons born between 259 and 293 days of gestation were included in the study. Mortality decreased with increasing gestational age in days and the highest mortality was observed among children born at 37 week of gestation. A similar pattern was observed when analyses were restricted to children born to by mothers without pregnancy complications.ConclusionsThis study demonstrates heterogeneity in mortality rates even among singletons born at term. The highest mortality was observed among children born 37 weeks of gestation, which call for cautions when inducing labor in term pregnancies just reaching 37 weeks of gestation. The findings support that 37 weeks of gestation should be defined as early term.

Mortality Trends in Cardiovascular Disease: a New Model to Visualise the Contribution of Specific Diseases, Cohort Effects and Coding Changes to Overall Mortality Improvement

Identifying the drivers of trends in mortality for disease classes is challenging. We used the Requiem model to visualise trends by gender and age in 3-D format to identify cohort effects, impacts of interventions and mortality coding changes in specific cardiovascular diseases (CVD). The Requiem model analysed and smoothed ONS mortality statistics for England and Wales from 1970 to 2013 by single year of age and gender. Disease codes were mapped at 4-digit level from ICD-8 to ICD-10 by medical modellers. An analysis was run for all CVD and individual diseases within that category. Outputs were displayed in multiple formats, including 3-D images of central mortality and deaths by age over time, and heat maps of absolute mortality improvement per disease and the component each disease contributed to all-cause mortality trends. CVD mortality has declined by up to 8% per year in England and Wales, especially in the “golden cohort” born in the 1930s, as shown clearly in the heat maps. Mortality rates from ischaemic stroke have fallen precipitously by up to 10% per year in both genders, especially in the 80+ age group, as shown in the 3-D charts. This contributed up to 0.4% absolute improvement in all-cause mortality prior to 1990. Mortality improvement from myocardial infarction was up to 20% per year in both genders aged 40 to 80, especially in the mid-1980s to 1990s, contributing up to 2% in absolute improvement in all-cause mortality in men in the mid-1980s and 1% in women in the early 1990s. The Requiem model 3-D visualisation shows the substantial improvement in mortality from CVD and all causes was largely driven by improvements in ischaemic stroke and MI in the golden cohort. In future years, as this cohort eventually dies, mortality improvement rates in CVD are likely to decline.

Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013

China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China. Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013. All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4.0 years in Hebei province to 14.2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0-14, 15-49, and 50-74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990. Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems. China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation.

Is There a Gradient of Mortality Risk among Men with Low Cardiorespiratory Fitness?

A low level of cardiorespiratory fitness (CRF) is a strong and independent predictor of all-cause mortality in men; however, it is unknown whether a gradient of mortality risk exists within the lowest CRF category. A total of 6251 apparently healthy men (mean age, 48.7 ± 6.3 yr) completed a comprehensive baseline clinical examination, including a maximal treadmill exercise test at Cooper Clinic between 1971 and 2006. In accord with previous studies using this cohort, low CRF was defined as a treadmill time in the first quintile within each age category of 40-49, 50-59, and 60-69 yr. The low CRF cohort was then grouped by tertiles (low/low, LL; mid/low, ML; and high/low, HL) using the same age categories. After a mean follow-up period of 19.1 ± 10.4 yr, 1259 deaths occurred. Adjusted all-cause mortality rates were 57.0, 31.1, and 34.4 deaths per 10,000 man-years across LL, ML, and HL CRF categories for the 40- to 49-yr-old age group (P trend = 0.007). Similar trends were seen across low CRF categories for the 50- to 59-yr-old and 60- to 69-yr-old age groups (P trend = 0.02 and 0.09, respectively). When using treadmill time as a continuous variable, each 1-min increment in treadmill time was associated with a 9%, 11%, and 15% reduction in risk of all-cause mortality among low-CRF men in the 40-49, 50-59, and 60-69 age groups, respectively. An inverse trend in all-cause mortality exists among men across LL, ML, and HL CRF groups. Although all low-fit men should be targeted for physical activity intervention, it is especially important to target the LL CRF group.

Mortality, Hospitalizations, and Expenditures for the Medicare Population Aged 65 Years or Older, 1999-2013.

In a period of dynamic change in health care technology, delivery, and behaviors, tracking trends in health and health care can provide a perspective on what is being achieved. To comprehensively describe national trends in mortality, hospitalizations, and expenditures in the Medicare fee-for-service population between 1999 and 2013. Serial cross-sectional analysis of Medicare beneficiaries aged 65 years or older between 1999 and 2013 using Medicare denominator and inpatient files. For all Medicare beneficiaries, trends in all-cause mortality; for fee-for-service beneficiaries, trends in all-cause hospitalization and hospitalization-associated outcomes and expenditures. Geographic variation, stratified by key demographic groups, and changes in the intensity of care for fee-for-service beneficiaries in the last 1, 3, and 6 months of life were also assessed. The sample consisted of 68,374,904 unique Medicare beneficiaries (fee-for-service and Medicare Advantage). All-cause mortality for all Medicare beneficiaries declined from 5.30% in 1999 to 4.45% in 2013 (difference, 0.85 percentage points; 95% CI, 0.83-0.87). Among fee-for-service beneficiaries (n = 60,056,069), the total number of hospitalizations per 100,000 person-years decreased from 35,274 to 26,930 (difference, 8344; 95% CI, 8315-8374). Mean inflation-adjusted inpatient expenditures per Medicare fee-for-service beneficiary declined from $3290 to $2801 (difference, $489; 95% CI, $487-$490). Among fee-for-service beneficiaries in the last 6 months of life, the number of hospitalizations decreased from 131.1 to 102.9 per 100 deaths (difference, 28.2; 95% CI, 27.9-28.4). The percentage of beneficiaries with 1 or more hospitalizations decreased from 70.5 to 56.8 per 100 deaths (difference, 13.7; 95% CI, 13.5-13.8), while the inflation-adjusted inpatient expenditure per death increased from $15,312 in 1999 to $17,423 in 2009 and then decreased to $13,388 in 2013. Findings were consistent across geographic and demographic groups. Among Medicare fee-for-service beneficiaries aged 65 years or older, all-cause mortality rates, hospitalization rates, and expenditures per beneficiary decreased from 1999 to 2013. In the last 6 months of life, total hospitalizations and inpatient expenditures decreased in recent years.