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PubMed2005

Some mechanisms linking economic inequality and infant mortality.

We use data from the 1985, 1987 and 1991 United States Vital Statistics Linked Infant Birth and Death Records to assess the relationship between state-level economic inequality and an infant's probability of death. We find that economic inequality is associated with higher neonatal mortality even after we control mother's age and race and state characteristics that are likely to be associated with both inequality and infant death. Inequality is not associated with post-neonatal mortality. We assess three mechanisms that could link income inequality and infant deaths: non-linearity in the relationship between parental income and infant death, economic segregation, and state health care spending. Our evidence suggests that non-linearity in the relationship between family income and infant health accounts for little of the relationship between inequality and infant death. However inequality is associated with greater economic segregation, which in turn is associated with a higher probability of infant death. This effect is partially offset by the fact that inequality is also associated with state spending on health care, which is in turn associated with lower death rates. The increase in economic segregation increased infant deaths more than the increase in health care spending reduces them, so the net effect of economic inequality is to increase infant deaths especially in the first month after birth.

Humans↗

PubMed2005

A European comparative study of marital status and socio-economic inequalities in suicide.

We assess (i) whether being married is a protective factor against socio-economic inequalities in suicide, and (ii) whether any such buffering effect varies between countries. We used the data from a European cross-national comparison project, a prospective follow-up of several European population censuses matched with vital statistics. The data encompass 99.5 million person-years aged 30 and above and 25,476 suicides in Austria, Belgium, Denmark, Finland, Turin, Madrid, Norway and Switzerland. Standardised rates were computed and logistic regressions were used to assess educational inequalities. Among the non-married, the lower educational group had an increased risk of dying of suicide compared to the higher group (Odds Ratio (OR) = 1.45). Inequalities among the married were lower (OR = 1.29). In all countries or regions except Austria, the lower educational group had a higher risk of suicide mortality among the non-married than among the married. The buffering effect of being married was not observed for elderly individuals (65 and over). Among younger individuals, the buffering effect of being married on relative inequalities in suicide was stronger in Madrid, Denmark, Norway and Switzerland (but significant only for Denmark and Norway). There was no indication that countries with stronger welfare policies or lower divorce rate had a lower buffering effect. We conclude that being married protects against inequalities in suicide and that this protective effect is not affected by the level of social capital at the country level.

Adult↗

PubMed2005

Widening ethnic mortality disparities in New Zealand 1981-99.

The aim of this paper is to determine the extent of undercounting of Mäori and Pacific deaths in New Zealand during the 1980s and 1990s, and to calculate corrected ethnic mortality and life expectancy trends. We calculated adjustment ratios for undercounting of Mäori and Pacific deaths (and over-counting of non-Mäori non-Pacific (nMnP) deaths) using the linked census-mortality data. These ratios were then used to calculate corrected mortality rates and life expectancies. Mäori deaths were underestimated by a quarter, and Pacific deaths by a third, during the 1980s and early 1990s. Undercounting was minor in the late 1990s following alignment of ethnicity collection on mortality data to approximate the census. Corrected mortality rates demonstrated 30% (males) and 26% (females) decreases among nMnP from 1980-84 to 1996-99, smaller decreases among Mäori (8% and 7%) and no clear change among Pacific people (9% decrease for males, 4% increase for females). The gap in life expectancy increased from an average of 7.7 years in 1980-84 to 10.8 years in 1996-99 for Mäori, and from 3.3 to 7.7 years for Pacific people, in comparison to nMnP people. Deaths among 45-64 and 65 plus year olds, and cardiovascular disease and cancer deaths, were the main contributors to these disparities. The economic reforms in New Zealand during the 1980s and early 1990s impacted harder upon Mäori and Pacific people in terms of unemployment and income, and are a likely explanation for the diverging mortality trends in this period. Both behavioural factors and health services probably also play a role, but in the absence of trend data by ethnicity, their contribution to diverging mortality trends is unknown. Internationally, our study demonstrates marked undercounting of Mäori and Pacific deaths. We strongly encourage researchers and custodians of vital statistics in other countries to investigate the possibility of undercounting of deaths by ethnicity.

Adolescent↗

PubMed2006

Combining individual and ecological data to determine compositional and contextual socio-economic risk factors for suicide.

The social and economic characteristics of geographic areas are associated with their suicide rates. The extent to which these ecological associations are due to the characteristics of the people living in the areas (compositional effects) or the influence of the areas themselves on risk (contextual effects) is uncertain. Denmark's Medical Register on Vital Statistics and its Integrated Database for Longitudinal Labour Market Research were used to identify suicides and 20 matched controls per case in 25-60-year-old men and women between 1982 and 1997. Individual and area (municipality) measures of income, marital and employment status were obtained. There were 9011 suicides and 180,220 controls. Individual-level associations with these risk factors were little changed when controlling for contextual effects. In contrast, ecological associations of increased suicide risk with declining area levels of employment and income and increasing proportions of people living alone were much attenuated after controlling for compositional effects. We found no consistent evidence that associations with individual-level risk factors differed depending on the areas' characteristics (cross-level interactions). This analysis suggests the ecological associations to be attributed to characteristics of the residents rather than area influences on risk.

Adult↗

PubMed2005

Policy evaluation for the subsidy for influenza vaccination in elderly.

OBJECTIVE: In Japan, the subsidy of influenza vaccination for the elderly was introduced in November 2001. This paper examines its policy evaluation from the viewpoint of cost-benefit analysis. MATERIALS: The data of copayment of influenza vaccination, population and shot rate of the elderly are surveyed by telephone interview to the correspondents in the local governments of Tokyo metropolitan and other 12 big cities in Japan. The mortality due to pneumonia or influenza is obtained from Vital Statistics of Population. METHOD: At first, I examine the impact of amount of copayment, through its effect on shot rate, on the percentage of elderly receiving influenza vaccinations. Using these estimation results, benefit-cost ratio (BCR) is calculated. RESULTS: The estimated coefficient of copayment on shot rate is -0.007 and statistically significant. Shot rate significantly reduces pneumonia and influenza mortality and its magnitude is -0.0028. The obtained net benefit (NB) is 134.9 million yen or US$1.08 billion and benefit-cost ratio is 22.9 and its 95% confidence interval is [2.2, 43.7]. DISCUSSION: If copayment would be cut by a 1000 yen (US$8), it could avoid about 400 deaths in average big city. The benefit-cost ratio is quite high compared with the other countries or other vaccinations. CONCLUSION: We found the strong evidence in a sense of cost-benefit analysis in the subsidy for influenza vaccination in the elderly.

Aged↗

PubMed2006

Influenza-related mortality in the Italian elderly: no decline associated with increasing vaccination coverage.

We investigated trends in influenza-related mortality among the elderly population in Italy associated with increased vaccination coverage. Using Italian vital statistics data, we studied monthly death rates for pneumonia and influenza and all-cause for persons >/=65 years of age by 5-year age groups for 1970-2001. Using a classic seasonal regression modelling approach, we estimated the age-specific seasonal excess mortality rates among Italian elderly as a measure of influenza-related deaths. We studied trends in excess mortality after adjusting for population aging and analyzing separately seasons dominated by the severe A/H3N2 subtype and those dominated by other circulating influenza subtypes. After the late 1980s, no decline in age-adjusted excess mortality was associated with increasing influenza vaccination distribution primarily targeted for the elderly. These findings suggest that either the vaccine failed to protect the elderly against mortality (possibly due to immune senescence), and/or the vaccination efforts did not adequately target the frailest elderly. As in the US, our study challenges current strategies to best protect the elderly against mortality, warranting the need for better controlled trials with alternative vaccination strategies.

Aged↗

PubMed2002

The relationship between liquor outlet density and injury and violence in New Mexico.

This study used an ecologic design based on data from 1990 to 1994 gathered from forensic, vital statistic, census, law enforcement and liquor licensing agencies to assess the relationship between liquor outlet density and alcohol-related health outcomes in New Mexico. Linear regression models show that suicide, alcohol-related crash, and alcohol-related crash fatality (adjusted for age, sex, and minority status) are significantly associated with liquor outlet density. Data also show that, compared with the first tertile, suicide and alcohol-related crash rates increase about 50% and the alcohol-related crash fatality rate two-fold with the third tertile of liquor outlet density. Greater availability of liquor outlets is associated with higher rates of suicide, alcohol-related crash, and alcohol-related crash fatality.

Accidents, Traffic↗

PubMed1994

The morbidity and mortality of pregnancy: still risky business.

Despite impressive gains in safety in recent decades, pregnancy remains risky business. From early in pregnancy until some weeks after its conclusion, pregnant women are at increased risk of morbidity and mortality compared with women who are not pregnant. This review summarizes recent national data from the U.S. Centers for Disease Control and Prevention, including vital statistics from the National Center for Health Statistics. Ectopic pregnancy is substantially more dangerous (38 deaths/100,000 events) than either childbirth (nine) or legal abortion (less than one). The three leading causes of maternal death today are pregnancy-induced hypertension, hemorrhage, and pulmonary embolism. Although comprehensive data on pregnancy-related morbidity are lacking, about 22% of all pregnant women are hospitalized before delivery because of complications. Women of minority races have much higher risks of death than do white women, and the same holds true for older women and those with limited education. For most women, fertility regulation by contraception, sterilization, or legal abortion is substantially safer than childbirth.

Abortion, Induced↗

PubMed2001

[The transition from acute to chronic ischemic heart disease in Spain, 1980-1994].

BACKGROUND AND OBJECTIVES: The remarkable increase in hospital admissions from heart failure in Spain in the last few years may result paradoxical because it coincides with a decrease in ischemic heart disease mortality, the leading cause of heart failure. A plausible explanation is the increase in ischemic heart disease survival, derived from the recent therapeutic advances, which will translate into an increase in the chronic forms of disease. Thus, an analysis was made of mortality and hospital admission trends due to acute and chronic ischemic heart diseases in the 1980-1994 period in Spain. METHODS: Population-based study of temporal trends with data of primary diagnosis of acute (CIE-9: 410-411) and chronic (CIE-9: 412-414) ischemic heart disease obtained from the National Vital Statistics and the National Survey of Hospital Morbidity. RESULTS: The number of deaths due to acute ischemic heart disease has increased by 8.3%, from 18,559 in 1980 to 20,101 in 1994. Deaths due to chronic ischemic heart disease increased by 49.3%, from 4,703 in 1980 to 7,020 in 1994. As a result, chronic forms accounted for 20.2% of all deaths attributable to ischemic heart disease in 1980 and 25.8% in 1994. The age-adjusted acute ischemic heart disease mortality rates decreased by 20.1%, whereas those due to chronic increased by 14.6%. The number and rate of age-adjusted hospital admissions increased remarkably for both acute and chronic ischemic heart disease. Nevertheless, the increase observed with chronic form was higher, from 39.4% of all hospital admissions due to ischemic heart disease in 1980 to 58.4% in 1994. This classification of ischemic heart disease was more notorious among males and younger patients. CONCLUSION: Currently, we are witnessing a transition from acute to chronic ischemic heart disease. That partly explains the increase in hospital care for heart diseases, particularly ischemic heart disease and heart failure.

Adult↗

PubMed1996

Assisted reproductive technologies: estimates of their contribution to multiple births and newborn hospital days in the United States.

OBJECTIVE: Estimate the contribution of assisted reproductive technology (ART) in the United States to multiple gestation births and newborn hospital days. DESIGN: Analysis of successful ART conceptions occurring during 1990 to 1991 compared with vital statistics. Newborn hospital days are estimated from the 1990 National Hospital Discharge Survey. SETTING: The American Fertility Society and the Society for Assisted Reproductive Technology registry. PATIENTS: Infants delivered from ART. INTERVENTIONS: Assisted reproductive technology. MAIN OUTCOME MEASURES: Number of multiple gestation infants and newborn hospital days. RESULTS: Approximately 12,327 live-born infants were delivered from ART conceptions during 1990 to 1991, representing 22.2% of all live-born triplet, 17.3% of quadruplet, and 11.4% of quintuplet infants born in the United States. The number of newborn hospital days attributed to ART infants was 87,135 days. Between the periods 1972 through 1974 and 1990 through 1991, the rate of triplet and higher order multiple gestation infants per 100,000 white live births increased by 191%, with 38% due to ART conceptions and 30% to increased childbearing among older women. CONCLUSIONS: Assisted reproductive technology contributed 22% of U.S. triplet and higher order multiple births during 1990 to 1991.

Female↗

PubMed2000

The impact of colorectal cancer screening on life expectancy.

METHODS: The purpose of this study was to assess the effect of screening for colorectal cancer on life expectancy and estimate the number of colonoscopies needed per life year saved. The declining exponential approximation of life expectancy was used to calculate the effect of colorectal cancer screening on expected remaining lifetime. The annual number of deaths from colorectal cancer and the size of the population were obtained from the vital statistics of the United States. Published reports were consulted to determine the decrease in mortality from colorectal cancer achieved by fecal occult blood testing, screening sigmoidoscopy or colonoscopy. A Markov chain analysis was used to determine the endoscopic resources required to screen and survey the entire population of U.S. residents age 50 years until death or age 85 years. RESULTS: Colorectal cancer decreases the life expectancy of U.S. residents aged 50 to 54 years by 292 days and those aged 70 to 74 years by 70 days. Screening with fecal occult blood tests extends expected lifetime of the 2 age groups by 51 and 12 days, respectively, whereas screening with sigmoidoscopy leads to increases of 86 and 21 days. Colonoscopic screening increases expected lifetime by 170 and 41 days, respectively. The number of colonoscopies needed to save 1 year of expected life ranges from 2.9 to 6.0, depending on the type of screening regimen used. CONCLUSIONS: The extension of life through screening colonoscopy is two or three times longer than the extension achieved through flexible sigmoidoscopy or fecal occult blood test, respectively. Although a large number of colonoscopies are required to screen the U.S. population, relatively few colonoscopies need to be invested per year of life expectancy saved.

Aged↗

PubMed1987

Nonparametric estimation of relative mortality functions.

The standardized mortality ratio (SMR), which is the ratio of the number of deaths from a particular disease observed in a study cohort to the number expected from national vital statistics, has a long history of use in epidemiology. Separate SMRs computed according to discrete intervals of time since initial exposure, time on study, age or calendar year are used to examine effects of these variables on relative mortality. Applying some recent ideas of Andersen et al. (Biometrics 1985; 41: 921-932), we discuss refinements of this procedure that yield a nonparametric estimate of the SMR as a function of one time-varying factor while at the same time adjusting for the effects of other factors in a regression equation. The method is utilized to study relative lung cancer mortality as a function of years since initial employment in cohorts of 8014 Montana smelter workers and 679 Welsh nickel refinery workers. Suggestions are made for approximating the relative mortality function using only data for cases and matched controls sampled from the full cohort.

Epidemiologic Methods↗

PubMed1996

Mortality rates for patients with a history of Kawasaki disease in Japan. Kawasaki Disease Follow-up Group.

OBJECTIVE: To determine whether the mortality rate of patients with a history of Kawasaki disease is higher than that of the general population. DESIGN: In a cohort study, 6585 patients with Kawasaki disease were observed from the first medical encounter because of the disease through the end of 1992, or until death. Standardized mortality ratios (SMRs) with 95% confidence intervals (CI) were calculated with vital statistics data of Japan for the control. RESULTS: Of 6585 patients who met the eligibility criteria, 6550 (99.5%) were followed through either the end of the study or the date of death. Nineteen patients (14 male subjects) died during the study period; an overall SMR of 1.56 (955 CI, 0.94 to 2.43) was calculated for the entire study period. The SMR was 1.78 (95% CI, 0.97 to 2.99) for male subjects and 1.16 (95% CI, 0.38 to 2.71) for female subjects. During the acute phase of the disease (the first 2 months after onset), the SMR was higher, particularly in male subjects (SMR, 10.12; 95% CI, 3.72 to 22.07). After the acute phase, however, both boys and girls had low SMRs. Nine of the 19 deaths were caused by Kawasaki disease; there were 2 deaths as a result of congenital anomalies of the circulatory system and 2 subjects died of malignant neoplasms of lymphatic or hematopoietic tissues. CONCLUSIONS: Although the mortality rate among those with a history of Kawasaki disease was elevated in Japan, many of the deaths that caused the elevation occurred during the acute phase of the disease. The mortality rate was not increased after the acute phase of the disease.

Age Distribution↗

PubMed1999

Living with cerebral palsy and tube feeding: A population-based follow-up study.

OBJECTIVES: To assess the impact of surgically placed feeding tubes on children with severe cerebral palsy (CP) and their families and to determine the survival of these children after initiation of tube feeding (TF). METHODS: Virtually all children from Nova Scotia who had gastrostomy or jejunostomy procedures between the years 1980 and 1998 and who had been diagnosed with CP were identified. Caretakers of those children who had TF initiated in the last 8 years were evaluated by using a semi-structured interview. Names of children who had not had recent follow-up visits were submitted to the provincial Vital Statistics office to determine whether they had died. Data from patients who were tube-fed between 1980 and 1989 were then used in combination with data from the more recent cases to create a survival curve. RESULTS: A total of 61 children were identified; 16 had died. Forty of 45 eligible families were interviewed; 90% were pleased with the effect of TF on their child and family life. Negative reports were associated with increased stress related to feeding. Survival rates after gastrostomy and/or jejunostomy were 83% after 2 years and 75% after 7 years. CONCLUSIONS: In children with severe CF, initiation of TF improved the quality of life for both the child and family in 90% despite frequent minor complications.

Activities of Daily Living↗

PubMed1997

Secular trend and age-period-cohort analysis of prostate cancer mortality in Taiwan.

PURPOSE: We evaluated the secular mortality trend of prostate cancer in Taiwan from 1964 through 1994. MATERIALS AND METHODS: Analyses were based on vital statistics. Relative risks associated with each of the age, period and cohort effects on secular mortality were estimated from a log-linear Poisson model. RESULTS: Age adjusted mortality rates increased more than 2-fold during the last 30 years in Taiwan. Age-period-cohort analysis showed that the age effect was the strongest. CONCLUSIONS: Factors related to aging are the main reason for the increase in prostate cancer mortality in Taiwan during the least 3 decades.

Adult↗

PubMed2000

[Trends in the number of human immunodeficiency virus infected persons and AIDS cases in Spain: 1980-1998].

BACKGROUND: To describe the trend in the number of HIV-infected persons and the number of AIDS cases in Spain between 1980 and 1998. SUBJECTS AND METHODS: The following information was used: annual incidence of AIDS taken from the National Registry, AIDS deaths taken from the same registry and from the Registry of Vital Statistics, HIV seroprevalence in studies in sentinel populations, HIV incidence in cohorts of exposed persons, and reports of HIV infections in the registries existing in the autonomous communities. We considered three events of interest--HIV infection, AIDS and death--which were related using back-projection and compartmental models. RESULTS: HIV spread rapidly in Spain during the years 1980. Transmission subsequently declined by more than 50% to figures that probably do not exceed 6,000 new infections in 1998. The incidence of AIDS increased to more than 7,000 new cases in 1994 and has since declined to some 4,000 cases in 1998. The level of AIDS mortality has always been lower than the incidence; it increased up to 1995 and then dropped to less than half in subsequent years. The number of living persons infected with HIV, including AIDS cases, arose until the early years 1990 and has since remained steady at about 125,000 persons. The number of cases of living persons with AIDS has increased continuously, and is estimated at about 19,000 through the end of 1998. CONCLUSIONS: The recent trend in new infections, AIDS cases and deaths is favourable, while the number of infected living persons remains very high.

Acquired Immunodeficiency Syndrome↗

PubMed2003

The changing epidemiology of multiple births in the United States.

OBJECTIVE: To describe changes in the epidemiology of multiple births in the United States from 1980 to 1999 by race, maternal age, and region; and to examine the impact of these changes on birth weight-specific infant mortality rates for singleton and multiple births. METHODS: Retrospective univariate and multivariable analyses were conducted using vital statistics data from the National Center for Health Statistics. RESULTS: Between 1980 and 1999, the overall multiple birth ratio increased 59% (from 19.3 to 30.7 multiple births per 1000 live births, P <.001), with rates among whites increasing more rapidly than among blacks. Women of advanced maternal age, especially those aged 30-34, 35-39, and 40-44 experienced the greatest increases (62%, 81%, and 110%, respectively). Although all regions of the United States experienced increases in multiple birth ratios between 1991 and 1999, the Northeast had the highest twin (33.9 per 1000 live births) and higher order birth ratios (280.5 per 100,000 live births), even after adjusting for maternal age and race. Between 1989 and 1999, multiple births experienced greater declines in infant mortality than singletons in all birth weight categories. Consequently, very low birth weight and moderately low birth weight infant mortality rates among multiples were lower than among singletons. CONCLUSION: It is important to understand the changing epidemiology of multiple births, especially for women at highest risk (advanced maternal age, white race, Northeast residents). The attribution of infertility management requires further study. The differential birth weight-specific infant mortality for singletons and multiples demonstrates the importance of stratifying by plurality when assessing perinatal outcomes.

Adult↗

PubMed1998

Improved birth outcomes associated with enhanced Medicaid prenatal care in drug-using women infected with the human immunodeficiency virus.

OBJECTIVE: To evaluate the effectiveness of an intervention designed to enhance Medicaid prenatal care in improving birth outcomes of drug-using women infected with the human immunodeficiency virus (HIV). METHODS: Medicaid and vital statistics records were linked for 353 HIV-infected drug-using women delivering in 1993 and 1994 while enrolled in New York State Medicaid. Of these, 68% were treated by providers participating in the Prenatal Care Assistance Program, designed to provide case management, improved continuity, referral services, and behavioral risk reduction counseling. In a series of logistic models, we estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of low birth weight (less than 2500 g) and preterm delivery (before 37 weeks), comparing women using and not using the program. RESULTS: Women using the Prenatal Care Assistance Program were significantly less likely, after adjustments were made for maternal characteristics, to have low birth weight infants and preterm deliveries (OR 0.52, 95% CI 0.31, 0.89; and OR 0.57, 95% CI 0.34, 0.97, respectively). Adding measures of greater adequacy and continuity of prenatal care to the models explained just over 20% of the Prenatal Care Assistance Program's protective effect. The addition of maternal high-risk behavior, HIV-focused care, and drug use treatment variables altered program effect estimates less profoundly (together accounting for 4 and 9% of the program's protection against low birth weight and preterm delivery, respectively). CONCLUSION: The Prenatal Care Assistance Program appeared to be successful in reducing the incidence of low birth weight and preterm delivery in this high-risk population. The program's success can be attributed, in part, to increased adequacy and continuity of prenatal care and, to a lesser extent, to more frequent receipt of special services and reduced maternal high-risk behaviors.

Adult↗