Further follow up of mortality and incidence of cancer in men from the United Kingdom who participated in the United Kingdom's atmospheric nuclear weapon tests and experimental programmes.

OBJECTIVES--To study the long term effects of participation in the United Kingdom''s atmospheric nuclear weapon tests and experimental programmes and to test hypotheses generated by an earlier report, including the possibility that participation in tests caused small hazards of leukaemia and multiple myeloma. DESIGN--Follow up study of mortality and cancer incidence. SUBJECTS--21,358 servicemen and civilians from the United Kingdom who participated in the tests and a control group of 22,333 non-participants. MAIN OUTCOME MEASURES--Numbers of deaths; standardised mortality ratios; relative risks of mortality from all causes and 27 types of cancer. RESULTS--During seven further years of follow up the numbers of deaths observed in participants were fewer than expected from national rates for all causes, all neoplasms, leukaemia, and multiple myeloma (standardised mortality ratios 0.86, 0.85, 0.57, and 0.46); death rates were lower than in controls (relative risks 0.99, 0.96, 0.57, and 0.57; 90% confidence intervals all included 1.00). In the period more than 10 years after the initial participation in tests the relative risk of death in participants compared with controls was near unity for all causes (relative risk 0.99 (0.95 to 1.04) and all neoplasms (0.95 (0.87 to 1.04)); it was raised for bladder cancer (2.69 (1.42 to 5.20)) and reduced for cancers of the mouth, tongue, and pharynx (0.45 (0.22 to 0.93)) and for lung cancer (0.85 (0.73 to 0.99)). For leukaemia mortality was equal to that expected from national rates but greater than in controls for both the whole follow up period (1.75 (1.01 to 3.06)) and the period 2-25 years after the tests (3.38 (1.45 to 8.25)). CONCLUSION--Participation in nuclear weapon tests had no detectable effect on expectation of life or on subsequent risk of developing cancer or other fatal diseases. The excess of leukaemia in participants compared with controls seems to be principally due to a chance deficit in the controls, but the possibility that participation in the tests may have caused a small risk of leukaemia in the early years afterwards cannot be ruled out.     

Mortality of employees of the United Kingdom Atomic Energy Authority, 1946-1979.

An analysis was conducted of 3373 deaths among 39 546 people employed by the United Kingdom Atomic Energy Authority between 1946 and 1979, the population having been followed up for an average of 16 years. Overall the death rates were below those prevailing in England and Wales but consistent with those expected in a normal workforce. At ages 15-74 years the standardised mortality ratios (SMRs) were 74 for deaths from all causes and 79 for deaths from all cancers. Mortality from only four causes was above the national average--namely, testicular cancer (SMR 153; 10 deaths), leukaemia (SMR 123; 35 deaths), thyroid cancer (SMR 122; three deaths), non-Hodgkin''s lymphoma (SMR 107; 20 deaths)--but in none was the increase significant at the 5% level. Half of the authority''s employees were recorded as having been monitored for exposure to radiation, their collective recorded exposure being 660 Sv (65 954 rem). Among these prostatic cancer was the only condition with a clearly increased mortality in relation to exposure. Of the 19 men who had a radiation record and died from prostatic cancer at ages 15-74 years, nine had been monitored for several different sources of exposure to radiation. The standardised mortality ratios were 889 (six deaths) in employees monitored for contamination by tritium, 254 (nine deaths) in those monitored for contamination by other radionuclides, and 385 (nine deaths) in those with dosimeter readings totalling more than 50 mSv (5 rem); but the same nine subjects tended to account for each of these significantly raised ratios. Because multiple exposures were common and other relevant information was not available the reason for the increased mortality from prostatic cancer in this population could not be determined and requires further investigation. Excess mortality rates of 2.2 and 12.5 deaths per million person years per 10 mSv (1 rem) were estimated for leukaemia and all cancers, respectively. The confidence limits around these estimates were wide, included zero, and made it unlikely that the International Commission on Radiological Protection''s cancer risk coefficients were underestimated by more than 15-fold. Thus despite this being the largest British workforce whose mortality has been reported in relation to low level ionising radiation exposure, even larger populations will need to be followed up over longer periods before narrower ranges of risk estimates can be derived.     

Mortality and occupational exposure to radiation: first analysis of the National Registry for Radiation Workers.

OBJECTIVE--To study cause specific mortality of radiation workers with particular reference to associations between fatal neoplasms and level of exposure to radiation. DESIGN--Cohort study. SETTING--United Kingdom. SUBJECTS--95,217 radiation workers at major sites of the nuclear industry. MAIN OUTCOME MEASURE--Cause of death. RESULTS--Most standardised mortality ratios were below 100: 83 unlagged, 85 with a 10 year lag for all causes; 84 unlagged, 86 lagged for all cancers; and 80 for all known other causes, indicating a "healthy worker effect." The deficit of lung cancer (75 unlagged, 76 lagged) was significant at the 0.1% level. Standardised mortality ratios were significantly raised (214 unlagged, 303 lagged) for thyroid cancer, but there was no evidence for any trend with external recorded radiation dose. Dose of external radiation and mortality from all cancers were weakly correlated (p = 0.10), and multiple myeloma was more strongly correlated (p = 0.06); for leukaemia, excluding chronic lymphatic, the trend was significant (p = 0.03; all tests one tailed). The central estimates of lifetime risk derived from these data were 10.0% per Sv (90% confidence interval less than 0 to 24%) for all cancers and 0.76% per Sv (0.07 to 2.4%) for leukaemia (excluding chronic lymphatic leukaemia). These are, respectively, 2.5 times and 1.9 times the risk estimates recommended by the International Commission on Radiological Protection, but 90% confidence intervals are large and the commission''s risk factors fall well within the range. The positive trend with dose for all cancers, from which the risk estimate was derived, was not significant. The positive association between leukaemia (except chronic lymphatic leukaemia) was significant and robust in subsidiary analyses. This study showed no association between radiation exposure and prostatic cancer. CONCLUSION--There is evidence for an association between radiation exposure and mortality from cancer, in particular leukaemia (excluding chronic lymphatic leukaemia) and multiple myeloma, although mortality from these diseases in the study population overall was below that in the general population. The central estimates of risk from this study lie above the most recent estimates of the International Commission on Radiological Protection for leukaemia (excluding chronic lymphatic leukaemia) and for all malignancies. However, the commission''s risk estimates are well within the 90% confidence intervals from this study. Analysis of combined cohorts of radiation workers in the United States indicated lower risk estimates than the commission recommends, and when the American data are combined with our analysis the overall risks are close to those estimated by the commission. This first analysis of the National Registry for Radiation Workers does not provide sufficient evidence to justify a revision in risk estimates for radiological protection purposes.     

Sudden infant death syndrome and postneonatal mortality in immigrants in England and Wales.

To examine ethnic differences in postneonatal mortality and the incidence of sudden infant death in England and Wales during 1982-5 records were analysed, the mother''s country of birth being used to determine ethnic group. Postneonatal mortality was highest in infants of mothers born in Pakistan (6.4/1000 live births) followed by infants of mothers born in the Caribbean (4.5) and the United Kingdom and Republic of Ireland (4.1). Crude rates were lower in infants of mothers born in India (3.9/1000), east and west Africa (3.0), and Bangladesh (2.8) than in infants of mothers born in the United Kingdom despite less favourable birth weights. Mortality ratios standardised separately for maternal age, parity, and social class were significantly higher in infants of mothers born in Pakistan and lower in those of mothers born in Bangladesh. The ratio for infants of Caribbean mothers was significantly higher when adjusted for maternal age. Ratios for infants of Indian and east African mothers did not show significant differences after standardisation. An important finding was a low incidence of sudden infant death in infants of Asian origin. This was paralleled by lower mortality from respiratory causes. During 1975-85 postneonatal mortality in all immigrant groups except Pakistanis fell to a similar or lower rate than that in the United Kingdom group; Pakistanis showed a persistent excess. During 1984-5 several immigrant groups (from the Republic of Ireland, India, west Africa, and the Caribbean) recorded an increase in postneonatal mortality. Surveillance of postneonatal mortality among ethnic communities should be continued, and research is needed to identify the causes underlying the differences.     

Leukaemia and smoking habits among United States veterans.

The relation between leukaemia and smoking habits was examined in data from the veterans'' smoking study, a prospective study of mortality among 248,000 United States veterans, of whom 723 died of leukaemia during 1954-69. A significant increase in mortality from leukaemia among cigarette smokers (relative risk 1.53) was found, together with a dose-response relation with amount smoked (trend p less than 0.001). The relation was strongest (relative risk 1.72) for monocytic and chronic and unspecified myeloid leukaemias (ICD (7th revision) codes 204.1 and 204.2). For these leukaemias the increase was almost twofold (relative risk 1.93) among current smokers of over 20 cigarettes daily. Ex-cigarette smokers also showed an increase of leukaemia (relative risk 1.39; p less than 0.001). These findings are consistent with other studies and relevant to the interpretation of minor increases of leukaemia both in population and in individual based studies. If causal they also imply that smoking is responsible for many more deaths from leukaemia in adults than all other known causes combined.     

Distribution of cancer mortality rates by province in South Africa

IntroductionCancer mortality rates are expected to increase in developing countries. Cancer mortality rates by province remain largely unreported in South Africa. This study described the 2014 age standardised cancer mortality rates by province in South Africa, to provide insight for strategic interventions and advocacy.Methods2014 deaths data were retrieved from Statistics South Africa. Deaths from cancer were extracted using 10th International Classification of Diseases (ICD) codes for cancer (C00-C97). Adjusted 2013 mid-year population estimates were used as a standard population. All rates were calculated per 100 000 individuals.ResultsNearly 38 000 (8%) of the total deaths in South Africa in 2014 were attributed to cancer. Western Cape Province had the highest age standardised cancer mortality rate in South Africa (118, 95% CI: 115–121 deaths per 100 000 individuals), followed by the Northern Cape (113, 95% CI: 107–119 per 100 000 individuals), with the lowest rate in Limpopo Province (47, 95% CI: 45–49 per 100 000). The age standardised cancer mortality rate for men (71, 95% CI: 70–72 per 100 000 individuals) was similar to women (69, 95% CI: 68–70 per 100 000). Lung cancer was a major driver of cancer death in men (13, 95% CI: 12.6–13.4 per 100 000). In women, cervical cancer was the leading cause of cancer death (13, 95% CI: 12.6–13.4 per 100 000 individuals).ConclusionThere is a need to further investigate the factors related to the differences in cancer mortality by province in South Africa. Raising awareness of risk factors and screening for cancer in the population along with improved access and quality of health care are also important.     

Follow up of New Zealand participants in British atmospheric nuclear weapons tests in the Pacific.

OBJECTIVE--To study the health of Royal New Zealand Navy personnel who participated in atmospheric nuclear weapons tests conducted by the United Kingdom at Malden Island and Christmas Island in 1957 and 1958. DESIGN--Blinded, controlled follow up of up to 30 years. SETTING--New Zealand. SUBJECTS--528 Men known to have participated in the tests and a control group of 1504 men who were in the Royal New Zealand Navy during the same period but did not participate in the tests. MAIN OUTCOME MEASURES--Mortality and incidence of cancer. RESULTS--Follow up for the period 1957-87 was 94% complete in test participants and 91% complete in the controls. There were 70 deaths among test participants and 179 deaths among controls, yielding a relative risk of 1.08 (90% confidence interval 0.85 to 1.38, p = 0.29). The relative risk of death from causes other than cancer was 0.96 (0.71 to 1.29, p = 0.59) whereas the relative risk of death from cancer was 1.38 (0.90 to 2.10, p = 0.09) and of the incidence of cancer was 1.12 (0.78 to 1.60, p = 0.29). For cancers other than haematological malignancies the relative risk was 1.14 (0.69 to 1.83, p = 0.31) for mortality and 1.01 (0.67 to 1.50, p = 0.48) for incidence. There were seven deaths from haematological cancers among test participants (relative risk 3.25, 90% confidence interval 1.12 to 9.64, p = 0.02), including four leukaemias (5.58, 1.04 to 41.6, p = 0.03). The relative risk for incidence of haematological cancers was 1.94 (0.74 to 4.84, p = 0.10) and that for leukaemia was 5.51 (1.03 to 41.1, p = 0.03). There were no cases of multiple myeloma in the test participants during the follow up period, but the expected number was only 0.3. CONCLUSIONS--Although the numbers are small, the findings for leukaemia are similar to those for British participants in the nuclear weapons test programme. Some leukaemias, and possibly some other haematological cancers, may have resulted from participation in this programme. There is little evidence of an increased risk for non-haematological cancers, and there is no evidence of an increased risk for causes of death other than cancer.     

Trends in myeloma incidence,mortality and survival in New Zealand (1985–2016)

BackgroundMyeloma, one of the most common haematological malignancies worldwide arises in the bone marrow. Incidence rates vary by age and ethnicity but reasons behind these trends are unknown. Treatment of myeloma has changed significantly over recent decades, resulting in longer survival and decreased mortality.MethodsFrom data supplied by the Ministry of Health, all new registrations of and deaths from myeloma between 1985 and 2016 were extracted. Trends in age-specific rates were assessed using the method of Armitage. Age-standardised rates were calculated, and trends in age-adjusted rates analysed using the Mantel-Haenszel extension chi-square test. Age-adjusted incidence and mortality rate ratios were calculated. Myeloma-specific survival was visualised using Kaplan-Meier curves and multivariable hazard ratios calculated using Cox regression.ResultsBetween 1985 and 2016, 7826 New Zealanders were registered with myeloma. Over this time the age-specific incidence of myeloma increased significantly for men, who had higher rates than women. Myeloma mortality was highest in Maori men. Men had higher mortality rates than women in all time periods. Since 1995–1999, mortality has decreased in women whereas in men it has declined since about 2000–2004. Survival has increased significantly since 1990 but Maori still have a higher risk of death than non-Maori.ConclusionThe patterns of variation in myeloma incidence, mortality and survival, as well as their trends over time may be used to assist research into the causes and management of myeloma in New Zealand.     

Hospital admission for acute pancreatitis in an English population, 1963-98: database study of incidence and mortality

Objectives To investigate trends in the incidence of acute pancreatitis resulting in admission to hospital, and mortality after admission, from 1963 to 1998.Design Analysis of hospital inpatient statistics for acute pancreatitis, linked to data from death certificates.Setting Southern England.Subjects 5312 people admitted to hospital with acute pancreatitis.Main outcome measures Incidence rates for admission to hospital, case fatality rates at 0-29 and 30-364 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission.Results The incidence of acute pancreatitis with admission to hospital increased from 1963-98: age standardised incidence rates were 4.9 per 100 000 population in 1963-74, 7.7 in 1975-86, and 9.8 in 1987-98. Age standardised case fatality rates within 30 days of admission were 14.2% in 1963-74, 7.6% in 1975-86, and 6.7% in 1987-98. From 1975-98, standardised mortality ratios at 30 days were 30 in men and 31 in women (compared with the general population of equivalent age in the same period = 1), and they remained significantly increased until month 5 for men and month 6 for women.Conclusions Incidence rates for acute pancreatitis with admission to hospital rose in both men and women from 1963 to 1998, particularly among younger age groups. This probably reflects, at least in part, an increase in alcoholic pancreatitis. Mortality after admission has not declined since the 1970s. This presumably reflects the fact that no major innovations in the treatment of acute pancreatitis have been introduced. Pancreatitis remains a disease with a poor prognosis during the acute phase.     

Mortality of workers at the Sellafield plant of British Nuclear Fuels.

The mortality of all 14,327 people who were known to have been employed at the Sellafield plant of British Nuclear Fuels at any time between the opening of the site in 1947 and 31 December 1975 was studied up to the end of 1983. The vital state of 96% of the workers was traced satisfactorily and 2277 were found to have died, 572 (25%) from cancer. On average the workers suffered a mortality from all causes that was 2% less than that of the general population of England and Wales and 9% less than that of the population of Cumberland (the area in which the plant is sited). Their mortality from cancers of all kinds was 5% less than that of England and Wales and 3% less than that of Cumberland. In the five years after their first employment Sellafield workers had an overall mortality that was 70% of that of England and Wales, probably due to healthier members of the population being selected for employment. Raised death rates from cancers of several specific sites were found, but only for those of ill defined and secondary sites was the excess statistically significant (30 observed, 19.7 expected). For cancers of the liver and gall bladder there was a significant deficit of deaths (four observed, 10.5 expected). Workers in areas of the plant where radiation exposure was likely were issued with dosimeters to measure their external exposure to ionising radiations. Personal dose records were maintained for workers who entered such areas other than infrequently. Workers with personal dose records ("radiation" workers) had lower death rates from all causes combined than other workers but the death rates from cancer in the two groups were similar. Compared with the general population radiation workers had statistically significant deficits of liver and gall bladder cancer, lung cancer, and Hodgkin''s disease. There were excesses of deaths from myeloma (seven observed, 4.2 expected) and prostatic cancer (19 observed, 15.8 expected) but these were not significant and there was no evidence of an excess of leukaemia (10 deaths observed, 12.2 expected) or cancer of the pancreas (15 observed, 17.8 expected). Non-radiation workers had a significant deficit of leukaemia (one death observed, 5.1 expected) and a significant excess of cancers of ill defined and secondary sites (13 deaths observed, 5.8 expected). For no type of cancer was the ratio of observed to expected deaths significantly different between radiation and non-radiation workers.(ABSTRACT TRUNCATED AT 400 WORDS)     

Causes of Death among Commercially Insured Multiple Sclerosis Patients in the United States

Background

Information on causes of death (CODs) for patients with multiple sclerosis (MS) in the United States is sparse and limited by standard categorizations of underlying and immediate CODs on death certificates. Prior research indicated that excess mortality among MS patients was largely due to greater mortality from infectious, cardiovascular, or pulmonary causes.

Objective

To analyze disease categories in order to gain insight to pathways, which lead directly to death in MS patients.

Methods

Commercially insured MS patients enrolled in the OptumInsight Research database between 1996 and 2009 were matched to non-MS comparators on age/residence at index year and sex. The cause most-directly leading to death from the death certificate, referred to as the “principal” COD, was determined using an algorithm to minimize the selection of either MS or cardiac/pulmonary arrest as the COD. Principal CODs were categorized into MS, cancer, cardiovascular, infectious, suicide, accidental, pulmonary, other, or unknown. Infectious, cardiovascular, and pulmonary CODs were further subcategorized.

Results

30,402 MS patients were matched to 89,818 controls, with mortality rates of 899 and 446 deaths/100,000 person-years, respectively. Excluding MS, differences in mortality rate between MS patients and non-MS comparators were largely attributable to infections, cardiovascular causes, and pulmonary problems. Of the 95 excessive deaths (per 100,000 person-years) related to infectious causes, 41 (43.2%) were due to pulmonary infections and 45 (47.4%) were attributed to sepsis. Of the 46 excessive deaths (per 100,000 person-years) related to pulmonary causes, 27 (58.7%) were due to aspiration. No single diagnostic entity predominated for the 60 excessive deaths (per 100,000 person-years) attributable to cardiac CODs.

Conclusions

The principal COD algorithm improved on other methods of determining COD in MS patients from death certificates. A greater awareness of the common CODs in MS patients will allow physicians to anticipate potential problems and, thereby, improve the care that they provide.     

Socioeconomic Factors and All Cause and Cause-Specific Mortality among Older People in Latin America,India, and China: A Population-Based Cohort Study

Background

Even in low and middle income countries most deaths occur in older adults. In Europe, the effects of better education and home ownership upon mortality seem to persist into old age, but these effects may not generalise to LMICs. Reliable data on causes and determinants of mortality are lacking.

Methods and Findings

The vital status of 12,373 people aged 65 y and over was determined 3–5 y after baseline survey in sites in Latin America, India, and China. We report crude and standardised mortality rates, standardized mortality ratios comparing mortality experience with that in the United States, and estimated associations with socioeconomic factors using Cox''s proportional hazards regression. Cause-specific mortality fractions were estimated using the InterVA algorithm. Crude mortality rates varied from 27.3 to 70.0 per 1,000 person-years, a 3-fold variation persisting after standardisation for demographic and economic factors. Compared with the US, mortality was much higher in urban India and rural China, much lower in Peru, Venezuela, and urban Mexico, and similar in other sites. Mortality rates were higher among men, and increased with age. Adjusting for these effects, it was found that education, occupational attainment, assets, and pension receipt were all inversely associated with mortality, and food insecurity positively associated. Mutually adjusted, only education remained protective (pooled hazard ratio 0.93, 95% CI 0.89–0.98). Most deaths occurred at home, but, except in India, most individuals received medical attention during their final illness. Chronic diseases were the main causes of death, together with tuberculosis and liver disease, with stroke the leading cause in nearly all sites.

Conclusions

Education seems to have an important latent effect on mortality into late life. However, compositional differences in socioeconomic position do not explain differences in mortality between sites. Social protection for older people, and the effectiveness of health systems in preventing and treating chronic disease, may be as important as economic and human development. Please see later in the article for the Editors'' Summary     

Social class differences in years of potential life lost: size,trends, and principal causes.

British social class differences in mortality are examined in terms of years of potential life lost, a measure that gives more weight to deaths that take place at younger ages. It shows wider class differences during the years of working life than those found when mortality is expressed in terms of standardised mortality ratios. Examination of the change in class differences between 1971 and 1981 for all causes of death combined and for the three categories of death which during these ages make a major contribution to total years of potential life lost shows complex changes. Inequalities in years of potential life lost have increased between 1971 and 1981, during which all the principal causes of death have shown stationary or rising rates among the manual classes. The use of years of potential life lost as a measure of population health trends focuses attention on the major contribution of violent death, which occurs mainly in younger men, to widening class differences in mortality.     

Paternal preconceptional radiation exposure in the nuclear industry and leukaemia and non-Hodgkin's lymphoma in young people in Scotland.

OBJECTIVE--To determine if a relation exists between paternal exposure to relatively high levels of radiation in the Scottish nuclear industry and the risk of leukaemia and non-Hodgkin''s lymphoma is subsequently conceived children. DESIGN--Matched case-control study with three controls for each case. SETTING--The whole of Scotland. SUBJECTS--The fathers of 1024 children with leukaemia and 237 children with non-Hodgkin''s lymphoma diagnosed in Scotland below the age of 25 among those born in Scotland since nuclear operations began (in 1958) and the fathers of 3783 randomly chosen controls. The fathers of 80 children with leukaemia and 16 with non-Hodgkin''s lymphoma in north Cumbria were also covered since some workers at one Scottish nuclear site live over the border in that area. Details of all fathers were then matched against records of the nuclear industry. MAIN OUTCOME MEASURES--Paternal preconceptional radiation exposures, particularly relatively high levels, both lifetime and in the six and three months before conception. RESULTS--No significant excess was observed in any subgroup and there was no significant trend: fathers of three controls but no cases were exposed to lifetime preconceptional levels of 100 mSv or greater (Fisher''s exact p value 0.84). In the six months before conception, fathers of two cases and three controls received 10 mSv or more, odds ratio 2.3 (95% confidence interval 0.31 to 17.24). In the three months before conception the fathers of one case and two controls received 5 mSv or more, odds ratio 1.7 (0.10 to 30.76). The results for leukaemia and non-Hodgkin''s lymphoma combined were similar. CONCLUSIONS--No significant excess of leukaemia or of leukaemia and non-Hodgkin''s lymphoma was found at any radiation level in any preconceptional period.     

Impact of using multiple causes of death codes to compute site-specific, death certificate-based cancer mortality statistics in the United States

Background: Cancer mortality statistics, an important indicator for monitoring cancer burden, are traditionally restricted to instances when cancer is determined to be the underlying cause of death (UCD) based on information recorded on standard certificates of death. This study's objective was to determine the impact of using multiple causes of death codes to compute site-specific cancer mortality statistics. Methods: The state cancer registries of California, Colorado and Idaho provided linked cancer registry and death certificate data for individuals who died between 2002 and 2004, had at least one cancer listed on their death certificate and were diagnosed with cancer between 1993 and 2004. These linked data were used to calculate the site-specific proportion of cancers not selected as the UCD (non-UCD) among all cancer-related deaths (any mention on the death certificate). In addition, the retrospective concordance between the death certificate and the population-based cancer registry, measured as confirmations rates, was calculated for deaths with cancer as the UCD, as a non-UCD, and for any mention. Results: Overall, non-UCD deaths comprised 9.5 percent of total deaths; 11 of the 79 cancer sites had proportions greater than 3 standard deviations from 9.5 percent. The confirmation rates for UCD and for any mention did not differ significantly for any of the cancer sites. Conclusion and impact: The site-specific variation in proportions and rates suggests that for a few cancer sites, death rates might be computed for both UCD and any mention of the cancer site on the death certificate. Nevertheless, this study provides evidence that, in general, restricting to UCD deaths will not under report cancer mortality statistics.     

Income distribution and mortality: cross sectional ecological study of the Robin Hood index in the United States.

OBJECTIVE--To determine the effect of income inequality as measured by the Robin Hood index and the Gini coefficient on all cause and cause specific mortality in the United States. DESIGN--Cross sectional ecological study. SETTING--Households in the United States. MAIN OUTCOME MEASURES--Disease specific mortality, income, household size, poverty, and smoking rates for each state. RESULTS--The Robin Hood index was positively correlated with total mortality adjusted for age (r = 0.54; P < 0.05). This association remained after adjustment for poverty (P < 0.007), where each percentage increase in the index was associated with'' an increase in the total mortality of 21.68 deaths per 100,000. Effects of the index were also found for infant mortality (P = 0.013); coronary heart disease (P = 0.004); malignant neoplasms (P = 0.023); and homicide (P < 0.001). Strong associations were also found between the index and causes of death amenable to medical intervention. The Gini coefficient showed very little correlation with any of the causes of death. CONCLUSION--Variations between states in the inequality of income were associated with increased mortality from several causes. The size of the gap between the wealthy and less well off--as distinct from the absolute standard of living enjoyed by the poor--seems to matter in its own right. The findings suggest that policies that deal with the growing inequities in income distribution may have an important impact on the health of the population.     

Explaining differences in English hospital death rates using routinely collected data

ObjectivesTo ascertain hospital inpatient mortality in England and to determine which factors best explain variation in standardised hospital death ratios.DesignWeighted linear regression analysis of routinely collected data over four years, with hospital standardised mortality ratios as the dependent variable.SettingEngland.SubjectsEight million discharges from NHS hospitals when the primary diagnosis was one of the diagnoses accounting for 80% of inpatient deaths.ResultsThe four year crude death rates varied across hospitals from 3.4% to 13.6% (average for England 8.5%), and standardised hospital mortality ratios ranged from 53 to 137 (average for England 100). The percentage of cases that were emergency admissions (60% of total hospital admissions) was the best predictor of this variation in mortality, with the ratio of hospital doctors to beds and general practitioners to head of population the next best predictors. When analyses were restricted to emergency admissions (which covered 93% of all patient deaths analysed) number of doctors per bed was the best predictor.ConclusionAnalysis of hospital episode statistics reveals wide variation in standardised hospital mortality ratios in England. The percentage of total admissions classified as emergencies is the most powerful predictor of variation in mortality. The ratios of doctors to head of population served, both in hospital and in general practice, seem to be critical determinants of standardised hospital death rates; the higher these ratios, the lower the death rates in both cases.

Key messages

• Between 1991-2 and 1994-5 average standardised hospital mortality ratios in English hospitals reduced by 2.6% annually, but the ratios varied more than twofold among the hospitals
• After adjustment for the percentage of emergency cases and for age, sex, and primary diagnosis, the best predictors of standardised hospital death rates were the numbers of hospital doctors per bed and of general practitioners per head of population in the localities from which hospital admissions were drawn
• England has one of the lowest number of physicians per head of population of the OECD countries, being only 59% of the OECD average
• It is now possible to control for factors outside the direct influence of hospital policy and thereby produce a more valid measure of hospital quality of care

     

Mortality in young offenders: retrospective cohort study

Objectives To estimate overall and cause specific standardised mortality ratios in young offenders.Design Comparison of mortality data in cohort of young offenders.Settings State of Victoria, Australia.Subjects Cohort of young offenders aged 10-20 years with a first custodial sentence from 1 January 1988 to 31 December 1999.Main outcome measures Deaths ascertained by matching with the national death index, a database containing records of all deaths in Australia since 1980. Death rates in the reference Victorian population used to calculate standardised mortality ratios.Results The offender cohort comprised 2621 men and 228 women with 11 333 person years of observation. The median age of first detention was 17.9 years for men and 18.4 years for women. Median follow up was 3.3 years for men and 1.4 years for women. Overall standardised mortality ratio adjusted for age (expressed as a ratio) was 9.4 (95% confidence interval 7.4 to 11.9) for men and 41.3 (20.2 to 84.7) for women. Cause specific standardised mortality ratios for men were 25.7 (17.9 to 36.9) for drug related causes, 9.2 (5.8 to 15) for suicide, and 5.7 (3.6 to 9.2) for non-intentional injury. A quarter of drug related deaths in men aged 15-19 years were in offenders.Conclusions Social policies for young offenders should address both the prevalent drug and mental health problems as well the high levels of social disadvantage.     

Child Mortality Estimation: Estimating Sex Differences in Childhood Mortality since the 1970s

Introduction

Producing estimates of infant (under age 1 y), child (age 1–4 y), and under-five (under age 5 y) mortality rates disaggregated by sex is complicated by problems with data quality and availability. Interpretation of sex differences requires nuanced analysis: girls have a biological advantage against many causes of death that may be eroded if they are disadvantaged in access to resources. Earlier studies found that girls in some regions were not experiencing the survival advantage expected at given levels of mortality. In this paper I generate new estimates of sex differences for the 1970s to the 2000s.

Methods and Findings

Simple fitting methods were applied to male-to-female ratios of infant and under-five mortality rates from vital registration, surveys, and censuses. The sex ratio estimates were used to disaggregate published series of both-sexes mortality rates that were based on a larger number of sources. In many developing countries, I found that sex ratios of mortality have changed in the same direction as historically occurred in developed countries, but typically had a lower degree of female advantage for a given level of mortality. Regional average sex ratios weighted by numbers of births were found to be highly influenced by China and India, the only countries where both infant mortality and overall under-five mortality were estimated to be higher for girls than for boys in the 2000s. For the less developed regions (comprising Africa, Asia excluding Japan, Latin America/Caribbean, and Oceania excluding Australia and New Zealand), on average, boys'' under-five mortality in the 2000s was about 2% higher than girls''. A number of countries were found to still experience higher mortality for girls than boys in the 1–4-y age group, with concentrations in southern Asia, northern Africa/western Asia, and western Africa. In the more developed regions (comprising Europe, northern America, Japan, Australia, and New Zealand), I found that the sex ratio of infant mortality peaked in the 1970s or 1980s and declined thereafter.

Conclusions

The methods developed here pinpoint regions and countries where sex differences in mortality merit closer examination to ensure that both sexes are sharing equally in access to health resources. Further study of the distribution of causes of death in different settings will aid the interpretation of differences in survival for boys and girls. Please see later in the article for the Editors'' Summary.     

Home visiting by general practitioners in England and Wales.

OBJECTIVE--To use data from the fourth national survey of morbidity in general practice to investigate the association between home visiting rates and patients'' characteristics. DESIGN--Survey of diagnostic data on all home visits by general practitioners. SETTING--60 general practices in England and Wales. SUBJECTS--502 493 patients visited at home between September 1991 and August 1992. MAIN OUTCOME MEASURES--Home visiting rates per 1000 patient years and home visiting ratios standardised for age and sex. RESULTS--10.1% (139 801/1 378 510) of contacts with general practitioners took place in patients'' homes. The average annual home visiting rate was 299/1000 patient years. Rates showed a J shaped relation with age and were lowest in people aged 16-24 years (103/1000) and highest in people aged > or = 85 years (3009/1000). 1.3% of patients were visited five or more times and received 39% of visits. Age and sex standardised home visiting ratios increased from 69 (95% confidence interval 68 to 70) in social class I to 129 (128 to 130) in social class V. The commonest diagnostic group was diseases of the respiratory system. In older age groups, diseases of the circulatory system was also a common diagnostic group. Standardised home visiting ratios for the 60 practices in the study varied nearly eightfold, from 28 to 218 (interquartile range 67 to 126). CONCLUSIONS--Home visits remain an important component of general practitioners'' workload. As well as the strong associations between home visiting rates and patient characteristics, there were also large differences between practices in home visiting rates. A small number of patients received a disproportionately high number of home visits. Further investigation of patients with high home visiting rates may help to explain the large differences in workload between general practices and help in allocation of resources to practices.