[Mortality, excess mortality, fatalities and the probability of survival].
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Germany, West↗
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Analysis of risk factors for excess mortality after aortic valve replacement.
OBJECTIVES: This study sought to identify risk factors for both late observed and late "excess" mortality after aortic valve replacement and to examine the causes of late mortality. BACKGROUND: Because operative mortality after aortic valve replacement is very low, the timing of surgical intervention should focus on maximizing long-term survival. However, to judge the effect of valve replacement on long-term survival in an elderly population, it is important to separate mortality resulting from extraneous causes (background mortality) from disease-related mortality (excess mortality). Background mortality can be estimated by calculating expected mortality on the basis of age and gender. METHODS: From 1966 to 1986, 643 patients (mean age 59.6 years, 138 [21%] > or = 70 years old) underwent aortic valve replacement, 129 of whom also underwent coronary bypass grafting; 594 patients survived > or = 30 days after the procedure. The overall operative mortality rate for isolated aortic valve replacement decreased over time from 25.5% (1966 to 1972) to 2.6% (1980 to 1986). Cumulative total follow-up after discharge was 3,603 patient-years. Multivariate analysis was performed for both observed and excess mortality. RESULTS: Risk factors for both observed and excess mortality were previous myocardial infarction, coronary artery disease, heart failure and atrial fibrillation. Although age > or = 70 years was a risk factor for observed mortality (hazard rate ratio [HRR] 2.4, 95% confidence interval [CI] 1.6 to 3.7), it was not a risk factor for excess mortality. In contrast, isolated aortic regurgitation was an important risk factor for excess mortality only (HRR 3.8, 95% CI 1.3 to 11.2). Late mortality was valve related in 22% of patients, including sudden death in 7% and cerebral vascular accidents in 7%. Congestive heart failure was an important cause of death (21%) irrespective of the time elapsed since aortic valve replacement. In patients with aortic regurgitation, congestive heart failure was the main cause of death (38%); in patients with aortic regurgitation and preoperative heart failure or severe left ventricular dysfunction, heart failure was the cause of death in 44% and 63%, respectively. CONCLUSIONS: Analysis of excess mortality revealed that older age in itself is not a risk factor for late mortality after aortic valve replacement. Aortic regurgitation carries a high risk, probably associated with left ventricular dysfunction at the time of operation. Earlier operation may be warranted in such patients.
Age Factors↗
Causes of the excess mortality of schizophrenia.
BACKGROUND: The excess mortality of schizophrenia is well recognised, but its precise causes are not well understood. AIMS: To measure the standardised mortality ratio (SMR) and examine the reasons for any excess mortality in a community cohort with schizophrenia. METHOD: We carried out a 13-year follow-up of 370 patients with schizophrenia, identifying those who died and their circumstances. RESULTS: Ninety-six per cent of the cohort was traced. There were 79 deaths. The SMRs for all causes (298), for natural (232) and for unnatural causes (1273), were significantly higher than those to be expected in the general population, as were the SMRs for disease of the circulatory, digestive, endocrine, nervous and respiratory systems, suicide and undetermined death. Smoking-related fatal disease was more prominent than in the general population. CONCLUSIONS: Some of the excess mortality of schizophrenia could be lessened by reducing patients' smoking and exposure to other environmental risk factors and by improving the management of medical disease, mood disturbance and psychosis.
Adolescent↗
Mortality patterns following internal fixation for acute femoral neck fractures in the elderly with special emphasis on potential excess mortality following reoperations.
Mortality patterns and excess mortality have been studied and quantified in 103 patients treated with internal fixation for acute, displaced femoral neck fractures with special emphasis on the potential excess mortality which may follow later operations for capital necrosis, failure of the osteosynthesis, etc. Of 103 patients studied 31 needed one or more reoperations. We have confirmed previously published reports that excess mortality is limited to the first six months after the primary operation. Quantification of the excess mortality which may follow reoperations shows that later operations are not followed by an increased death rate compared with the standard population.
Aged↗
Effect of age on excess mortality in obesity.
CONTEXT: 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. OBJECTIVE: To assess the effect of age on the excess mortality associated with all degrees of obesity. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: 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. MAIN OUTCOME MEASURE: 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. RESULTS: 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. CONCLUSIONS: 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.
Adult↗
Assessment of excess mortality in obesity.
Quantification of the excess mortality from all causes associated with obesity remains controversial. In this paper, 6,193 obese patients, those with a body mass index (weight (kg)/height (m)2 (BMI)) range of 25-74 kg/m2, recruited from 1961 to 1994 in Düsseldorf, Germany, were followed for a mean time of 14 (standard deviation, 8.2) years, yielding 87,179 observed patient-years. During the study period, 1,028 patients (16.6%) died. The entire cohort was grouped into approximate quartiles according to BMI: group 1, BMI from 25 to < 32; group 2, BMI from 32 to < 36; group 3, BMI from 36 to < 40; group 4, BMI > or = 40 kg/m2. The following risk ratios were estimated by means of Cox proportional hazards models using the lowest BMI group as reference category: group 2 for men, 1.02 (95% confidence interval 0.76-1.37); for women, 1.23 (95% confidence interval 0.96-1.58); group 3 for men, 1.50 (95% confidence interval 1.09-2.06); for women, 1.33 (95% confidence interval 1.03-1.73); and group 4 for men, 2.10 (95% confidence interval 1.53-2.88); for women, 2.25 (95% confidence interval 1.78-2.84). The following standardized mortality ratios were calculated by using the respective geographic area (the Federal State of North Rhine Westphalia) as reference population: group 1 for men, 1.26 (95% confidence interval 0.98-1.61); for women, 1.00 (95% confidence interval 0.81-1.23); group 2 for men, 1.31 (95% confidence interval 1.09-1.57); for women, 1.20 (95% confidence interval 1.02-1.40); group 3 for men, 1.92 (95% confidence interval 1.53-2.38); for women, 1.27 (95% confidence interval 1.07-1.50); and group 4 for men, 3.05 (95% confidence interval 2.47-3.73); for women, 2.31 (95% confidence interval 2.04-2.60). In addition to age, sex, and BMI, Cox proportional hazards models revealed systolic blood pressure, glucose intolerance, diabetes, and smoking as significant independent mortality risk factors, whereas cholesterol was not significant. In this prospective study of a large cohort of obese persons, morbid obesity (BMI of > or = 40 kg/m2) was a strong predictor of premature death. Excess mortality risks associated with gross obesity (BMI from 32 to < 40 kg/m2) were considerably lower than hitherto assumed; moderate degrees of obesity (BMI from 25 to < 32 kg/m2) were not significantly associated with excess mortality.
Adult↗
Excess mortality and influenza surveillance in Taiwan.
Excess mortality has proven to be a useful epidemiologic tool for influenza surveillance in the temperate zone. A retrospective analysis of the epidemiology of influenza in Taiwan was undertaken to explore the usefulness of this technique in the tropical--subtropical zone. Excess mortality similar to that observed during influenza epidemics in the temperate zone was noted during periods of previously recognized influenza epidemics in Taiwan. For the very young and the elderly excess mortality was observed to be even higher than in the temperate zone. Virus isolations, increased school absenteeism, and high clinical attack rates were also noted during influenza epidemics. Use of these epidemiologic techniques in Taiwan proved to be a useful approach to describe the impact of influenza.
Absenteeism↗
[Excess mortality from influenza epidemics in Japan, 1980-1994].
In 1973, WHO proposed that "excess mortality" be used for comparative assessment of the severity of influenza epidemics between countries. In this study, analysis of the data for deaths in Japan between 1980-1994 revealed excess mortality, which could be a useful indicator in Japan. There were six influenza epidemics, and statistically significant excess mortality rates were calculated in both deaths from acute respiratory diseases and all causes. The total number of excess deaths from acute respiratory diseases during influenza seasons for the 15 years was 13,931. Statistically significant excess mortality rates were also shown for other diseases, including ischemic heart disease, cerebro-vascular disease, diabetes, nephritis, chronic liver disease, malignant neoplasm, and chronic respiratory disease. Therefore, "excess mortality" is clearly present in recent years in Japan. In analyses of age-specific excess mortality rates, the epidemic was found to be most fatal to the aged. Further, the value of % excess (= excess rate divided by expected rate x 100) suggested that the number of deaths from all causes would be a more useful indicator than that from acute respiratory diseases. It was confirmed that excess mortality was applicable to regional surveillance of epidemic influenza.
Acute Disease↗
Geographic variations in US asthma mortality: small-area analyses of excess mortality, 1981-1985.
US asthma mortality rates have been increasing during the past 10 years. Little is known about the geographic variation of this infrequent health event. Using US vital records for the 1981-1985 period, small-area variation of excess asthma mortality of young adults was studied. Several geopolitical definitions were used to define populations. A total of 22 single counties, 12 metropolitan statistical areas, 11 health service areas, and 29 state economic areas were identified as having mortality significantly in excess of that expected, based on US race/sex-specific rates. Significant variation in asthma mortality was found at several levels of geopolitical classification of the data. Elevated areas included the central plains states and three large urban metropolitan areas--Chicago, Illinois, New York, New York, and Phoenix, Arizona--as well as a few mostly suburban populations. Areas with excess mortality may provide a useful population base for further epidemiologic investigation into the risk factors associated with the more frequent morbid events of this disease, such as emergency room and hospital utilization.
Adolescent↗
Excess mortality and its relation to hypertension and proteinuria in diabetic patients. The world health organization multinational study of vascular disease in diabetes.
OBJECTIVE: To determine the extent that mortality in IDDM and NIDDM patients is in excess of that of the general population and examine its relation to hypertension and proteinuria in diabetic patients. RESEARCH DESIGN AND METHODS: A stratified random sample of 4,714 diabetic patients aged 35-55 years participating in the World Health Organization Multinational Study of Vascular Disease in Diabetes has been followed up from 1975 to 1987. Excess mortality, compared with the background population, was assessed in terms of standardized mortality ratios (SMRs) for each of the 10 international cohorts. The relationship between excess mortality and proteinuria/hypertension was examined by diabetes type and sex. RESULTS: SMRs were in general higher in patients with IDDM (ranging from 188 to 686 for men and from 336 to 790 for women) than with NIDDM (from 138 to 370 for men and from 126 to 435 for women). For both diabetes types and in both sexes, SMRs decreased with increasing age and increased with increasing diabetes duration. Patients with both hypertension and proteinuria experienced a strikingly high mortality risk: 11-fold for men with IDDM and 18-fold for women with IDDM and 5-fold for men with NIDDM and 8-fold for women with NIDDM. Even in the absence of proteinuria and hypertension, SMRs were significantly increased in both IDDM (284 men and 360 women) and NIDDM (192 men and 236 women) patients. CONCLUSIONS: Considerable international differences were found not only in mortality rates for the two types of diabetes but also in the extent of excess mortality among centers. IDDM patients had a high excess mortality in comparison with the general population. The significant excess mortality was demonstrated even in patients without proteinuria and without hypertension for both sexes and diabetes types.
Adult↗
Excess mortality associated with alcohol consumption.
To estimate the excess mortality due to alcohol in England and Wales death rates specific to alcohol consumption that had been derived from five longitudinal studies were applied to the current population divided into categories of alcohol consumption. Because of the J shaped relation between alcohol consumption and death the excess mortality used as a baseline was an alcohol consumption of 1-10 units/week and an adjustment was made for the slight excess mortality of abstainers. The number of excess deaths was obtained by subtracting the number of deaths expected if all the population had the consumption of the lowest risk group; correction for the total observed mortality in the population was made. This resulted in an estimate of 28,000 deaths each year in England and Wales as the excess mortality among people aged 15-74 associated with alcohol consumption.
Adolescent↗
Survival after hip fracture: short- and long-term excess mortality according to age and gender.
The purpose of this study was to analyze the excess mortality after hip fracture and to reveal whether, and eventually when, the excess mortality vanished in different groups of age and gender. A population-based, prospective, matched-pair, cohort study among persons 50 years of age and older was conducted involving 1338 female and 487 male hip fracture patients with 11 086 and 8141 controls respectively. Occurrence of hip fracture and mortality were recorded from 1986 until 1995. We studied the excess mortality of the hip fracture patients versus controls by using Kaplan-Meier curves and extended Cox regression with hip fracture (yes/no) as time-dependent covariate. The male hip fracture patients had higher mortality than the women the first year after the injury, irrespective of age, both in absolute terms (31% and 17% respectively) and relative to their age-matched controls. The relative risk (RR) of dying within 1 year for hip fracture patients versus controls was 3.3 (95% confidence interval (CI) 2.1-5.2) for women and 4.2 (95% CI 2.8-6.4) for men below 75 years of age. The corresponding figures for persons 85 years and older were 1.6 (95% CI 1.2-2.0) for women and 3.1 (95% CI 2.2-4.2) for men. All groups of age and gender, except women 85 years and older, had a large and significant excess mortality lasting for many years after the hip fracture - at least 5-6 years for women below 75 years of age (RR = 3.2, 95% CI 1.9-5.6). The excess mortality after hip fracture for women 85 years and older had vanished after 3 months (RR = 1.0, 95% CI 0.8-1.1). When referring to the excess mortality after hip fracture it is therefore necessary to specify sex, age and time since injury.
Age Factors↗
Dose-response relationship for lifetime excess mortality and temporal pattern of manifestation in mice irradiated neonatally with gamma rays.
The dose-response relationships for the lifetime excess mortality and temporal distribution of excess mortality were analysed using a data set from an experiment on the long-term effects of gamma irradiation in neonatal mice. The excess mortality was calculated based on an assumption that any increase in the mortality rate was attributable to radiation exposure. The dose-response relationship for the lifetime excess mortality was convex upward, whereas the shortening of the mean life span was proportional to the dose. The excess mortality at 1 Gy was estimated to be 35.6%. The relative risk decreased markedly with increasing age. However, the mortality rate in the irradiated group was persistently higher than the background rate of death, and the absolute risk increased with age. A logistic specification was used to analyze the temporal distribution of the excess mortality. The results of the analysis indicated a dose-dependent shortening of the latent period and a broadening of the distribution.
Aging↗
Excess mortality--influenza epidemiological surveillance indicator.
Observations on "excess mortality" from influenza, carried out in the Moldavia area between 1957 and 1973, are presented in the paper. They made it possible to assess in time and space as well as in severity the knowledge on influenza epidemics. "Excess mortality" proved to be a valuable indicator of increase in influenza mortality, especially, on the occurrence of big epidemics the existence of which was closely related to the appearance of new types and variants of influenza viruses. Though "excess mortality" showed the highest values when death from acute pneumopathies recorded in the preepidemic and postepidemic periods was included in the calculation, it also pointed to the strong effect of influenza on all causes of death, especially chronic diseases of the respiratory and cardio-vascular systems.
Disease Outbreaks↗
Maternal mortality in New York City: excess mortality of black women.
To assess maternal mortality in New York City, birth certificates and mortality records for New York City from 1988 through 1994 were linked and examined. During these 7 years, maternal mortality in New York City (defined by the International Classification of Diseases, 9th edition [ICD-9], as 630-676) per 100,000 live births significantly exceeded that of the country as a whole (20.2 vs. 8.2, respectively). Within New York City, an even greater variation of maternal mortality by race/ethnicity was noted, with the mortality ratio of whites, blacks, and Hispanics being 7.1, 39.5, and 14.4 per 100,000 live births, respectively. Socioeconomic characteristics such as educational attainment, marital status, and income influenced maternal mortality more in non-blacks than blacks. Analyses of cause-specific mortality revealed that, overall, ectopic pregnancy, embolism, and hypertension were the leading causes of death. However, the major factors explaining the excess maternal mortality among blacks were hypertension (mortality ratio of blacks to whites 5.57, 95% confidence interval 2.30-13.39), ectopic pregnancy (4.78, 95% confidence interval 2.40-9.51), and abortion (4.58, 95% confidence interval 1.72-12.22). These findings confirm a persisting gap in maternal death between black and white women. Indeed, if all New Yorkers who became pregnant enjoyed the survival of the city's non-Hispanic white residents, the difference in maternal mortality between the city and the nation would be eliminated.
Adolescent↗
[Estimation of excess mortality associated with influenza-epidemics by age and cause specific death in Japan, 1975-1999].
OBJECTIVES: The purpose of this study was to assess the effects of recent influenza epidemics on mortality in Japan. METHODS: We applied a new definition of excess mortality associated with influenza epidemics and a new estimation method (new method) proposed in our previous paper to the national vital statistics for 1975-1999 (ICD8-ICD10 had been adopted) in Japan. This new method has the advantages of removing a source of random variations in excess mortality and of being applicable to shifting trends in mortality rates from different causes of death in response to the revision of ICD. The monthly rates of death from all causes other than accidents (all causes) and some cause-specific deaths such as pneumonia, malignant neoplasm, heart disease, cerebrovascular disease(C.V.D) and diabetes(D.M.) were analyzed by total and by five age groups: 0-4 years, 5-24 years, 25-44 years, 45-64 years, and 65 years old or older. RESULTS: The following findings were noted: 1. For each epidemic in every other year since 1993, large-scale excess mortality of over 10,000 deaths was observed and the effect of those epidemics could be frequently detected in mortality even among young persons, i.e., 0-4 years or 5-25 years. 2. Excess mortality associated with influenza epidemics influenced mortality by some chronic diseases such as pneumonia, heart disease, C.V.D., D.M., etc. For some epidemic years since 1978, excess mortality rates were detected even in mortality by malignant neoplasm. CONCLUSIONS: It has been definitely shown by applying the new method to the national vital statistics for 1975-1999 in Japan that influenza epidemics in recent years exerted an influence on overall mortality, increasing the number of deaths among the elderly and the younger generation. Monitoring of the trends in excess mortality associated with influenza epidemics should be continued.
Age Factors↗
[Liver cirrhosis mortality in Mexico. II. Excess mortality and pulque consumption].
Over the years high cirrhosis mortality rates have been reported in Mexico City and in the surrounding states (Hidalgo, Tlaxcala, Puebla and the State of Mexico); on the contrary, well defined areas, such as the northern states, have shown a considerably lower mortality rate. This situation may indicate that some factors such as the pattern of alcoholic intake and other environmental characteristics could explain this striking difference. To determine the role of alcohol, the availability and consumption of alcohol at regional and state level were compared with cirrhosis mortality rates. A high and statistically significant correlation was found with pulque availability and consumption (r = 72-92%, p less than 0.01) in all periods of time under examination. On the contrary, a statistically significant negative association was observed with beer consumption and a positive, but not significant correlation, with distilled alcoholic beverages. Infectious hepatitis incidence, prevalence of exclusive use of native languages (as an indirect index of ethnic background) and nutritional deficiencies were also studied as possible risk factors. Nutritional deficiencies and the prevalence of exclusive use of náhuatl and otomí languages were positively correlated. These results can be useful to conduct further epidemiological studies still needed to determine the etiologic role of pulque consumption as well as of the other risk factors. Nonetheless, the current data stress the need to implement public health programs to reduce alcohol consumption, especially pulque, and to minimize the impact of these risk factors in high mortality areas.
Alcohol Drinking↗
Differential mortality in New York City (1988-1992). Part One: excess mortality among non-Hispanic blacks.
To determine the distribution of mortality for non-Hispanic blacks and non-Hispanic whites in New York City, death certificates issued in New York City during 1988 through 1992, and the relevant 1990 US census data for New York City, have been examined. Age-adjusted death rates for blacks and whites by gender and cause of death were computed based on the US population in 1940. Also, standard mortality ratios and excess mortality were calculated using the New York City mortality rate as reference. The results showed that New York City blacks had higher age-adjusted death rates than whites regardless of cause, including stroke, AIDS, homicide, and diabetes. The rate for New York City blacks was also higher than the US total for both genders. Using New York City mortality rates as a reference, more than 80% of excess deaths in blacks occurred before age 65. Injury/poisoning was the leading cause of excess death (20.1%) in black males, while in black females, cardiovascular disease was the largest single cause of excess deaths (24.8%). The higher death rates, especially premature death, of blacks in New York City are related to conditions such as violence, substance abuse, and AIDS, for which prevention rather than medical care is the more likely solution, as well as to cardiovascular diseases, where both prevention through behavioral change, and health and medical care, can influence outcome.
Black or African American↗