Differential mortality in New York City (1988-1992). Part Two: excess mortality in the south Bronx.
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To display the extent of variations in mortality according to geographic regions in New York City, we have compared mortality in New York City as a whole with that of the South Bronx. Mortality records for 1988 to 1992 and 1990 US census data for New York City were linked. The 471,000 residents of the South Bronx were younger, less educated, and more likely to lack health insurance than other New Yorkers. Using age- and gender-stratified populations and mortality in New York City as standards, age-adjusted death rates and excess mortality in the South Bronx were determined. All-cause mortality in the South Bronx was 26% higher than the city as a whole. Mortality for AIDS, injury and poisoning, drug and alcohol abuse, and cardiovascular diseases were 50% to 100% higher in the South Bronx than in New York City; years of potential life lost before age 65 in the South Bronx were 41.6% and 44.2% higher for men and women, respectively, than in New York City; AIDS accounted for the largest single share of excess premature deaths (21.8%). In summary, inequalities in health status, reflected by higher mortality rates in the South Bronx, are consistent with, and perhaps caused by, lower socioeconomic status and deficient medical care among residents of this inner-city community. (+info)
Audit of deaths in general practice: pilot study of the critical incident technique.
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OBJECTIVE: To develop and pilot a method for conducting an audit of deaths in general practice by the critical incident technique. DESIGN: Prospective use of the technique within a primary health care team, with the aid of a facilitator, to analyse the events surrounding patients' deaths. SETTING: One inner city academic general practice. PARTICIPANTS: Practice team, comprising general practitioners, trainee, practice manager, practice nurse, and attached health visitor and district nurses. MAIN MEASURES: Identification and classification of critical incidents associated with the case studies of eight recently decreased patients in the practice and subsequent impact on the practice. RESULTS: Among the eight case studies, 57 critical incidents were identified (mean 7.1 per case, range 2 to 15). A failure of communication was the most common factor identified in incidents giving rise to concern, but positive factors in patient care were also identified. Changes in practice included developing protocols for follow up of bereaved relatives and carers and a checklist to ensure completion of administrative follow up tasks resulting from the patient's death; cases of recent deaths and terminally ill patients were reviewed monthly. The practice team found the method acceptable and felt that the discussions had provided useful opportunities for reflecting on their role in patient care. CONCLUSIONS: The critical incident technique fulfils the needs of an audit of deaths in general practice; however, further evaluation based on more cases from different practices is now required. (+info)
Studies of avoidable factors influencing death: a call for explicit criteria.
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OBJECTIVE: To analyse studies evaluating cases of potentially "avoidable" death. DESIGN: The definitions, sources of information, and methods were reviewed with a structured protocol. The different types of avoidable factors,--that is, deficiencies in medical care that may have contributed to death--were categorised. The presence of explicit classifications and standards was examined. basic criteria for quality of the studies were defined and the numbers of studies fulfilling these criteria were assessed. SETTING AND PARTICIPANTS: 65 studies, published during 1988-93 in peer reviewed medical journal for which the title, or abstract, or both indicated that they had analysed potentially avoidable factors influencing death. Studies analysing aggregated data only, were not included. RESULTS: Only one third of the studies fulfilled basic quality criteria,--namely, that the avoidable factors examined should be defined and the sources of information and people responsible for the judgements presented. The definitions used comprised two levels, one stating that there had been errors in management (process) and the other that the errors may have contributed to the deaths (outcome). Only 15% of the studies explicitly defined what type of factors they had looked for and 8% referred to specified standards of care. CONCLUSIONS: Studies of avoidable factors influencing death may have considerable potential as part of a system of improving medical care and reducing avoidable mortality. At present, however, the results from different studies are not comparable, due to differences in materials and methods. There is a need to improve the quality of the studies and to define standardised explicit definitions and classifications. (+info)
Health status during the transition in Central and Eastern Europe: development in reverse?
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This paper reports on a study of the cross-national trends in health status during the economic transition and associated health sector reforms in Central and Eastern Europe (CEE). The central premise is that before long-run gains in health status are realized, the transition towards a market economy and adoption of democratic forms of government should lead to short-run deterioration as a result of: (i) reduction in real income and widening income disparities; (ii) stress and stress-related behaviour; (iii) lax regulation of environmental and occupational risks; and (iv) breakdown in basic health services. Analysis focused on three broad indicators of health status: life expectancy at birth, infant mortality rate and the probability of dying between the ages of 15 and 65 years, shown by the notation '50q15'. The study revealed significant new information about health status and the health sector which could not have been obtained without a proper cross-national study. Infant mortality rates in former socialist economies (FSE) follow the global trend, declining as per capita income rises. However, rates are lower than would be predicted given their income levels. Despite declining infant mortality, life expectancy at birth in the former socialist economies decreases as per capita income rises, in marked contrast to global trends. This is because rising income level is associated with greater probability of death between the ages of 15 and 65: the wealthier the society, the less healthy is its population, particularly for its males. Causes of death in the FSE follow global trends: higher death rates due to infectious and parasitic diseases in poorer countries, and higher death rates due to chronic diseases in wealthier countries. However, age-standardized death rates for chronic diseases generally associated with unhealthy lifestyles and environmental risk factors are very high when compared with wealthier established market economies (EME). Policies and procedures which alter the effectiveness of health services have had a demonstrable but mixed impact on health status during the early phase of transition. Effective preventive health strategies must be formulated and implemented to reverse the adverse trends observed in Central and Eastern Europe. (+info)
Explaining educational differences in mortality: the role of behavioral and material factors.
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OBJECTIVES: This study examined the role of behavioral and material factors in explaining educational differences in all-cause mortality, taking into account the overlap between both types of factors. METHODS: Prospective data were used on 15,451 participants in a Dutch longitudinal study. Relative hazards of all-cause mortality by educational level were calculated before and after adjustment for behavioral factors (alcohol intake, smoking, body mass index, physical activity, dietary habits) and material factors (financial problems, neighborhood conditions, housing conditions, crowding, employment status, a proxy of income). RESULTS: Mortality was higher in lower educational groups. Four behavioral factors (alcohol, smoking, body mass index, physical activity) and 3 material factors (financial problems, employment status, income proxy) explained part of the educational differences in mortality. With the overlap between both types of factors accounted for, material factors were more important than behavioral factors in explaining mortality differences by educational level. CONCLUSIONS: The association between educational level and mortality can be largely explained by material factors. Thus, improving the material situation of people might substantially reduce educational differences in mortality. (+info)
Aging successfully until death in old age: opportunities for increasing active life expectancy.
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The purpose of this study was to estimate the prevalence of having no disability in the year prior to death in very old age and to examine factors associated with this outcome. Participants were men and women aged 65 years and older who were followed prospectively between 1981 and 1991 from three communities: New Haven, Connecticut; Iowa and Washington counties, Iowa; and East Boston, Massachusetts. Persons who died in late old age with known disability status within 15 months of death (n = 1,097) were studied for predictors of dying without disability at the last follow-up interview prior to death. The probability of a nondisabled 65-year-old man's surviving to age 80 and then being nondisabled prior to death was 26% and, for a 65-year-old woman, the probability of surviving to age 85 and being nondisabled before death was 18%. Physical activity was a key factor predicting nondisability before death. There was nearly a twofold increased likelihood of dying without disability among the most physically active group compared with sedentary adults (adjusted odds ratio = 1.86, 95% confidence interval 1.24-2.79). These findings provide encouraging evidence that disability prior to death is not an inevitable part of a long life but may be prevented by moderate physical activity. (+info)
Relation between mode of pacing and long-term survival in the very elderly.
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OBJECTIVES: This study analyzes the relationship between pacing mode and long-term survival in a large group of very elderly patients (> or = 80 years old). BACKGROUND: The relationship between pacing mode and long-term survival is not clear. Because the number of very elderly who are candidates for pacing is increasing, issues related to pacemaker (PM) use in the elderly have important clinical and economic implications. METHODS: We retrospectively reviewed 432 patients (mean age, 84.5+/-3.9 years) who received their initial PM (ventricular in 310 and dual chamber in 122) between 1980 and 1992. Follow-up was complete (3.5+/-2.6 years). Observed survival was estimated by the Kaplan-Meier method. Age- and gender-matched cohorts from the Minnesota population were used for expected survival. Log-rank test and Cox regression hazard model were used for univariate and multivariate analyses. RESULTS: Patients with ventricular PMs appeared to have poor overall survival compared with those with dual-chamber PMs. Observed survival after PM implantation in high grade atrioventricular block (AVB) patients was significantly worse than expected survival of the age- and gender-matched population (p < 0.0001), whereas observed survival of patients with sinus node dysfunction was not significantly different from expected survival of the matched population (p = 0.413). By univariate analysis, ventricular pacing in patients with AVB appeared to be associated with poor survival compared with dual-chamber pacing (hazard ratio [HR] 2.08; 95% confidence interval [CI] 1.33 to 3.33). After multivariate analysis, this difference was no longer significant (HR 1.41; 95% CI 0.88 to 2.27). Independent predictors of all-cause mortality were number of comorbid illnesses, New York Heart Association functional class, left ventricular depression and older age at implant. Pacing mode was not an independent predictor of overall survival. Older age at implantation, diabetes mellitus, dementia, history of paroxysmal atrial fibrillation and earlier year of implantation were independent predictors of ventricular pacemaker selection. CONCLUSIONS: After PM implantation, long-term survival among very elderly patients was not affected by pacing mode after correction of baseline differences. Selection bias was present in pacing mode in the very elderly, with ventricular pacing selected for sicker and older patients, perhaps partly explaining the apparent "beneficial impact on survival" observed with dual-chamber pacing. (+info)
Inequalities in mortality according to educational level in two large Southern European cities.
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BACKGROUND: In Spain, studies on social inequalities in mortality based on individuals are few due to the poor quality of information on occupation in death certificates. This study looks at the differences in mortality according to educational level, using individual information obtained through the linkage between the Death Register and the Municipal Census, in the cities of Madrid and Barcelona, Spain. METHODS: The study populations were residents of Madrid and Barcelona aged >24 years, who died in 1993 and 1994. Indicators obtained for each city and educational level were: age- and sex-specific mortality rates, and life expectancy at 25 years. Poisson regression models were fitted to obtain the relative risk (RR) of death for each educational level with respect to the reference level (higher education completed), adjusted for age. RESULTS: The mortality rate was lower among individuals with higher educational levels, while life expectancy at 25 years was higher. In both cities men and women with no education showed the highest mortality in all age groups, with very high RR in the youngest age group (RR for men aged 25-34 years = 7.08 in Madrid and 6.02 in Barcelona, whereas in women these RR were 6.33 and 5.63 respectively). In Barcelona the greater part of the overall mortality difference for the group aged 25-34 years was due to AIDS (acquired deficiency syndrome, 33.4% in men and 59.3% in women). CONCLUSION: The present study has found higher mortality (mainly from AIDS) among individuals with no academic qualifications thus drawing attention to the need to implement policies aimed at reducing these inequalities. (+info)