Geographical variation mortality from ischaemic heart disease in England and Wales

Analysis ofthe proportional mortality attributed to ischaemic heart disease, adjusted for age, reminds us that many of the well known geographical, environmental, social, and economic variations within England and Wales are not disease specific.     

Seasonal congestive heart failure mortality and hospitalisation trends, Quebec 1990-1998

STUDY OBJECTIVE: To describe seasonal congestive heart failure (CHF) mortality and hospitalisations in Quebec, Canada between 1990-1998 and compare trends in CHF mortality and morbidity with those in France. DESIGN: Population cohort study. SETTING: Province of Quebec, Canada. PATIENTS: Mortality data were obtained from the Quebec Death Certificate Registry and hospitalisation from the Quebec Med-Echo hospital discharge database. Cases with primary ICD-9 code 428 were considered cases of CHF. RESULTS: Monthly CHF mortality was higher in January, declined until September and then rose steadily (p<0.05). Hospital admissions for CHF declined from May until September (moving averages analysis p<0.0001). Seasonal mortality patterns observed in Quebec were similar to those observed in France. CONCLUSION: CHF mortality in Quebec is highest during the winter and declines in the summer, similar to observations in France and Scotland. This suggests that absolute temperatures may not necessarily be that important but increased CHF mortality is observed once environmental temperatures fall below a certain "threshold" temperature. Alternatively better internal heating and warmer clothing required for survival in Quebec may ameliorate mortality patterns despite colder external environments.     

Geographical variation mortality from ischaemic heart disease in England and Wales.

Analysis ofthe proportional mortality attributed to ischaemic heart disease, adjusted for age, reminds us that many of the well known geographical, environmental, social, and economic variations within England and Wales are not disease specific.     

Regional variation in health care utilization and mortality

Geographic variation in health care utilization has raised concerns of possible inefficiencies in health care supply, as differences are often not reflected in health outcomes. Using comprehensive Norwegian microdata, we exploit cross-region migration to analyze regional variation in health care utilization. Our results indicate that place factors account for half of the difference in utilization between high and low utilization regions, while the rest reflects patient demand. We further document heterogeneous impacts of place across socioeconomic groups. Place factors account for 75% of the regional utilization difference for high school dropouts, and 40% for high school graduates; for patients with a college degree, the impact of place is negligible. We find no statistically significant association between the estimated place effects and overall mortality. However, we document a negative association between place effects and utilization-intensive causes of death such as cancer, suggesting high-supply regions may achieve modestly improved health outcomes.     

Simultaneous modelling of time trends and regional variation in mortality rates

BACKGROUND: We seek to model the regional component of the variance in the mortality rates in the UK and to ascertain if there is evidence that this regional variance is increasing in recent periods. METHODS: Age Period Cohort (APC) models, based on the local 'curvatures', are used in each region to describe the changes in the trends in the mortality rates. This is extended to a multilevel model to estimate the regional component of the variance in the rates and to estimate the effect of regional differences in the trends in the rates. We show how the use of a multilevel APC model can help to distinguish the cohort and period trends in the mortality rates from the cohort and period effects on the regional variance in these rates. RESULTS: For both sexes, but particularly for females, a reduction in the rate of decrease in mortality was found around 1960. In addition, particularly for females, cohorts born after 1930 appear to show reductions in mortality at an increased rate. It is demonstrated that there is evidence that the between-region variation in the rates has not remained constant and that it is much less now than it was at the beginning of the data series. Further, there is evidence that the trends in the rates are not the same in all regions and that while there is a convergence of the rates in many regions, Scotland, in particular, stands out as a region which contributes most to the regional variation in mortality rates. CONCLUSION: Evidence of regional variation in mortality rates has been found with a suggestion of a decrease over the period of the study though with some stability since 1951.     

Regional variation and time trends in mortality from ischaemic heart disease: East and West Germany 10 years after reunification

STUDY OBJECTIVE: Within Europe, a pronounced geographical gradient of mortality from ischaemic heart disease has been observed with the highest burden in the north east and the lowest in the south west. The study objective was to compare mortality from ischaemic heart disease between former East and West Germany since reunification. DESIGN: Analyses of age standardised mortality rates from ischaemic heart disease (ICD-9 410-414, ICD-10 I20-I25) between 1990-1991 and 2000. SETTING: Former East and West Germany. MAIN RESULTS: After a peak in the early 1990s, mortality from ischaemic heart disease has substantially declined in both parts of Germany (from 222 to 169 per 100 000 in the East and from 150 to 116 per 100 000 in the West). The regional difference, however, remained rather constant: the rate ratio between the pooled mortality in the East compared with the West was 1.51 (95% CI 1.46 to 1.56) in 1991 and 1.45 (95% CI 1.39 to 1.50) in 2000. These rate ratios were higher in women (1.63 in 1991 and 1.52 in 2000) compared with men (1.45 and 1.44, respectively). CONCLUSIONS: Within Germany, there has been a pronounced east-west gradient of mortality from ischaemic heart disease since reunification. Further insight into possible underlying reasons may lead to improved preventive strategies.     

Short-term mortality in end-stage heart failure patients

ObjectivesThis study is aimed at analyzing the impact of the main factors contributing to short and long-term mortality in patients at final stages of heart failure (HF).SettingPatients attended at any of the 279 primary health care centers belonging to the Institut Català de la Salut, in Catalonia (Spain).ParticipantsPatients with Advanced HF.DesignMulticenter cohort study including 1148 HF patients followed for one-year after reaching New York Heart Association (NYHA) IV.Main measurementsThe primary outcome was all-cause mortality. Multivariate logistic regression models were performed to assess the outcomes at 1, 3, 6, and 12 months.ResultsMean age of patients was 82 (SD 9) years and women represented 61.7%. A total of 135 (11.8%) and 397 (34.6%) patients died three months and one year after inclusion, respectively. Male gender, age, and decreased body mass index were associated with higher mortality at three, six and twelve months. In addition, low systolic blood pressure levels, severe reduction in glomerular filtration, malignancy, and higher doses of loop diuretics were related to higher mortality from 6 to 12 months.The most important risk factor over the whole period was presenting a body mass index lower than 20 kg/m² (three months OR 3.06, 95% CI: 1.58–5.92; six months OR 4.42, 95% CI: 2.08–9.38; and 12 months OR 3.68, 95% CI: 1.76–7.69).ConclusionsWe may conclude that male, age, and decreased body mass index determined higher short-term mortality in NYHA IV. In addition, low systolic blood pressure, reduced glomerular filtration, malignancy, and higher doses of loop diuretics contribute to increasing the risk of mortality at medium and long-term. Such variables are easily measurable and can help to decide the best way to face the most advances stages of the disease.     

Regional differences in mortality from ischemic heart disease

The geographical distribution of mortality from ischaemic heart disease in the Netherlands has changed dramatically since 1950. In 1950-1954 mortality was highest in high-income, urbanized areas, in 1980-1984 the reverse was true. This development resembles the one observed in the United States of America. The changes in geographical distribution cannot be attributed to differences in cause-of-death certification. The change in the association with income and the association between mortality and a number of ischaemic heart disease risk factors found in 1970-1974, suggest that at least part of the explanation is a change in the geographical distribution of risk factors.     

Regional variation in ischemic heart disease incidence.

This study examines the relationship between cardiovascular risk factors and regional variation in IHD incidence among white males 55-74 years of age from the NHANES I Epidemiologic Followup Study. The age-adjusted IHD incidence rate was lowest in the west (31.3 per 1000 persons years of followup). The rates in the northeast, midwest, and south were similar and so they were combined into one region, the non-west, with a rate of 42.4. Differences in risk factors (smoking, educational level, hypertension, serum cholesterol, diabetes mellitus, and body mass index) did not explain the regional differences in IHD incidence. After adjusting for baseline risk factors using proportional hazards model, the risk of IHD incidence was still 38% higher in the non-west compared to the west. However, the effect of hypertension, diabetes, and body mass index on IHD incidence varied by region.     

Racial and geographic variation in coronary heart disease mortality trends

ABSTRACT: BACKGROUND: Magnitudes, geographic and racial variation in trends in coronary heart disease (CHD) mortality within the US require updating for health services and health disparities research. Therefore the aim of this study is to present data on these trends through 2007. METHODS: Data for CHD were analyzed using the US mortality files for 1999-2007 obtained from the US Centers for Disease Control and Prevention. Age-adjusted annual death rates were computed for non-Hispanic African Americans (AA) and European Americans (EA) aged 35-84 years. The direct method was used to standardize rates by age, using the 2000 US standard population. Joinpoint regression models were used to evaluate trends, expressed as annual percent change (APC). RESULTS: For both AA men and women the magnitude in CHD mortality is higher compared to EA men and women, respectively. Between 1999 and 2007 the rate declined both in AA and in EA of both sexes in every geographic division; however, relative declines varied. For example, among men, relative average annual declines ranged from 3.2% to 4.7% in AA and from 4.4% to 5.5% in EA among geographic divisions. In women, rates declined more in later years of the decade and in women over 54 years. In 2007, age-adjusted death rate per 100,000 for CHD ranged from 93 in EA women in New England to 345 in AA men in the East North Central division. In EA, areas near the Ohio and lower Mississippi Rivers had above average rates. Disparities in trends by urbanization level were also found. For AA in the East North Central division, the APC was similar in large central metro (-4.2), large fringe metro (-4.3), medium metro urbanization strata (-4.4), and small metro (-3.9). The somewhat higher APC in the micropolitan/non-metro (-5.3), and especially the non-core/non-metro (-6.5). For EA in the East South Central division, the APC was higher in large central metro (-5.3), large fringe metro (-4.3) and medium metro urbanization strata (-5.1) than in small metro (-3.8), micropolitan/non-metro (-4.0), and non-core/non-metro (-3.3) urbanization strata. CONCLUSIONS: Between 1999 and 2007, the level and rate of decline in CHD mortality displayed persistent disparities. Declines were greater in EA than AA racial groups. Rates were greater in the Ohio and Mississippi River than other geographic regions.     

Intermittent observation of time-dependent explanatory variables: a multistate modelling approach

Motivated by investigations of factors related to various patient-reported outcome measures in psoriatic arthritis patients, after controlling for the effect of disease activity on these outcomes, we outline an approach for dealing with a rapidly fluctuating explanatory variable in a multistate model. On the basis of a representation of this variable as an ordinal classification, we suggest the use of an expanded multistate model. We examine the bias in estimating effects associated with other variables via simulation for different modelling choices. We present an analysis of a motivating data set on physical functional disability in psoriatic arthritis patients.     

Analysing geographic variations in mortality using Poisson regression: the example of ischaemic heart disease in England and Wales 1969-1973

This paper describes how Poisson regression techniques can be used to examine the relationship between mortality and possible explanatory variables over a series of areas in cases where the number of deaths involved is relatively low. As an example an analysis is carried out on deaths from ischaemic heart disease among young adults in the county boroughs of England and Wales during 1969-1973. The results of the study indicate that the number of deaths was higher for males than females and was positively related to age, the size of the 'at risk' population and crowding, but negatively associated with water hardness and the size of the New Commonwealth population. A comparison of the Poisson and log-normal regression models clearly shows that the latter provides an inferior goodness of fit and unreliable results. It is therefore concluded that when the number of deaths is small there are both theoretical and practical advantages in using Poisson regression to analyse mortality data.     

Survival after initial hospitalisation for heart failure: a multilevel analysis of patients in Swedish acute care hospitals

STUDY OBJECTIVE: Although national variation in short-term prognosis (that is, 30 day mortality) after a patient's first hospitalisation for heart failure may depend on individual differences between patients, dissimilarities in hospital practices may also influence prognosis. This study, therefore, sought to disentangle patient determinants from institutional factors that might explain such variation. DESIGN: A multilevel logistic regression modelling was performed with patients (1st level) nested in hospitals (2nd level). Institutional effects (that is, 2nd level variance and intra-hospital correlation) were calculated unadjusted and adjusted for specific patient (that is, age and previous diseases) and institutional (that is, size of hospital) characteristics. Patients were followed up until death or 30 days from hospital admission. SETTING: Hospitals in Sweden. PATIENTS: The study identified all the 20420 men and 17923 women (ages 65 to 85) admitted to the 90 acute care hospitals in Sweden during the period 1992-1995 for their first hospitalisation attributable to heart failure. MAIN RESULTS: Patient age and previous diseases (particularly senile dementia) were major determinants of impaired prognosis. Institutional factors explained only 1.6% and 2.3% of the total variation in 30 day mortality in men and women, respectively. These modest institutional effects remained after adjusting for patient age and previous diseases, but were in part explained by hospital size. CONCLUSIONS: National variation in short-term prognosis after an initial hospitalisation for heart failure was mainly explained by differences between patients, with hospital factors playing a minor part. Of the latter, hospital size seemed to emerge as one determinant (that is, the greater the number of patients, the better the individual prognosis).     

Deaths from ischaemic heart disease and infant mortality in England and Wales.

Death rates from ischaemic heart disease (IHD) in English and Welsh counties are correlated, in both men and women, with the infant mortality rates of those counties when the individuals whose deaths are considered were young, thus confirming previous findings in Norway. In England and Wales, however, there is an equally good correlation between deaths from IHD and infant mortality patterns up to and including that for the same time period as the IHD deaths. The British data provide no grounds for concluding from these relationships that living conditions during early life per se bear a causal relationship to deaths from IHD.     

Sedentary lifestyle and state variation in coronary heart disease mortality.

Using linear regression, the authors demonstrated a strong association between State-specific coronary heart disease mortality rates and State prevalence of sedentary lifestyle (r2 = 0.34; P = 0.0002) that remained significant after controlling for the prevalence of diagnosed hypertension, smoking, and overweight among the State''s population. This ecologic analysis suggests that sedentary lifestyle may explain State variation in coronary heart disease mortality and reinforces the need to include physical activity promotion as a part of programs in the States to prevent heart disease.