Widening educational inequalities in mortality in more recent birth cohorts: a study of 14 European countries.

BACKGROUND: Studies of period changes in educational inequalities in mortality have shown important changes over time. It is unknown whether a birth cohort perspective paints the same picture. We compared changes in inequalities in mortality between a period and cohort perspective and explored mortality trends among low-educated and high-educated birth cohorts. DATA AND METHODS: In 14 European countries, we collected and harmonised all-cause and cause-specific mortality data by education for adults aged 30-79 years in the period 1971-2015. Data reordered by birth cohort cover persons born between 1902 and 1976. Using direct standardisation, we calculated comparative mortality figures and resulting absolute and relative inequalities in mortality between low educated and high educated by birth cohort, sex and period. RESULTS: Using a period perspective, absolute educational inequalities in mortality were generally stable or declining, and relative inequalities were mostly increasing. Using a cohort perspective, both absolute and relative inequalities increased in recent birth cohorts in several countries, especially among women. Mortality generally decreased across successive birth cohorts among the high educated, driven by mortality decreases from all causes, with the strongest reductions for cardiovascular disease mortality. Among the low educated, mortality stabilised or increased in cohorts born since the 1930s in particular for mortality from cardiovascular diseases, lung cancer, chronic obstructive pulmonary disease and alcohol-related causes. CONCLUSIONS: Trends in mortality inequalities by birth cohort are less favourable than by calendar period. In many European countries, trends among more recently born generations are worrying. If current trends among younger birth cohorts persist, educational inequalities in mortality may further widen.

Socioeconomic inequalities in cancer mortality between and within countries in Europe: a population-based study.

Background: Reducing socioeconomic inequalities in cancer is a priority for the public health agenda. A systematic assessment and benchmarking of socioeconomic inequalities in cancer across many countries and over time in Europe is not yet available. Methods: Census-linked, whole-of-population cancer-specific mortality data by socioeconomic position, as measured by education level, and sex were collected, harmonized, analysed, and compared across 18 countries during 1990-2015, in adults aged 40-79. We computed absolute and relative educational inequalities; temporal trends using estimated-annual-percentage-changes; the share of cancer mortality linked to educational inequalities. Findings: Everywhere in Europe, lower-educated individuals have higher mortality rates for nearly all cancer-types relative to their more highly-educated counterparts, particularly for tobacco/infection-related cancers [relative risk of lung cancer mortality for lower- versus higher-educated = 2.4 (95% confidence intervals: 2.1-2.8) among men; = 1.8 (95% confidence intervals: 1.5-2.1) among women]. However, the magnitude of inequalities varies greatly by country and over time, predominantly due to differences in cancer mortality among lower-educated groups, as for many cancer-types higher-educated have more similar (and lower) rates, irrespective of the country. Inequalities were generally greater in Baltic/Central/East-Europe and smaller in South-Europe, although among women large and rising inequalities were found in North-Europe (relative risk of all cancer mortality for lower- versus higher-educated ≥1.4 in Denmark, Norway, Sweden, Finland and the England/Wales). Among men, rate differences (per 100,000 person-years) in total-cancer mortality for lower-vs-higher-educated groups ranged from 110 (Sweden) to 559 (Czech Republic); among women from approximately null (Slovenia, Italy, Spain) to 176 (Denmark). Lung cancer was the largest contributor to inequalities in total-cancer mortality (between-country range: men, 29-61%; women, 10-56%). 32% of cancer deaths in men and 16% in women (but up to 46% and 24%, respectively in Baltic/Central/East-Europe) were associated with educational inequalities. Interpretation: Cancer mortality in Europe is largely driven by levels and trends of cancer mortality rates in lower-education groups. Even Nordic-countries, with a long-established tradition of equitable welfare and social justice policies, witness increases in cancer inequalities among women. These results call for a systematic measurement, monitoring and action upon the remarkable socioeconomic inequalities in cancer existing in Europe. Funding: This study was done as part of the LIFEPATH project, which has received financial support from the European Commission (Horizon 2020 grant number 633666), and the DEMETRIQ project, which received support from the European Commission (grant numbers FP7-CP-FP and 278511). SV and WN were supported by the French Institut National du Cancer (INCa) (Grant number 2018-116). PM was supported by the Academy of Finland (#308247, # 345219) and the European Research Council under the European Union's Horizon 2020 research and innovation programme (grant agreement No 101019329). The work by Mall Leinsalu was supported by the Estonian Research Council (grant PRG722).

Occupations and geographical distribution of mesothelioma in Switzerland 1989-2018 - record linkage of an asbestos-exposed population with the Swiss National Cohort.

OBJECTIVE: We investigated the possibility of linking the data of the Swiss Laboratory for Particle Analysis (Silag), a valuable but incomplete data source in the field of asbestos-related diseases, to the Swiss National Cohort (SNC). With the resulting comprehensive dataset, we intended to provide a source for further research in the field. We also conducted preliminary analyses of data focusing on occupations and regional distribution of malignant pleural mesothelioma cases. METHODS: Data of asbestos-exposed individuals available from the Silag were anonymously linked with the SNC by means of deterministic record linkage. From this linkage, data on occupation classified according to the international standard classification of occupations (ISCO) as well as the canton of residence in Switzerland could be retrieved. RESULTS: Of 838 eligible individuals from the Silag data, 788 (94.0%) could be linked to the SNC database, including 476 mesothelioma cases. In 340 cases of the latter, data on occupation and industries were available. Although the majority of them were blue-collar workers, a significant proportion (n = 44, 12.9%) had executive professions. The Canton of residence in 1990 was established in 430 of subjects with mesothelioma. A cluster could be identified in eastern Switzerland, especially in the canton of Glarus. CONCLUSIONS: It was possible to link the datasets to a large extent thereby creating a data source for further research. Of note, the linkage provided data on occupation of a selection of mesothelioma cases in Switzerland.

Does diet map with mortality? Ecological association of dietary patterns with chronic disease mortality and its spatial dependence in Switzerland.

We investigated the associations between dietary patterns and chronic disease mortality in Switzerland using an ecological design and explored their spatial dependence, i.e. the tendency of near locations to present more similar and distant locations to present more different values than randomly expected. Data of the National Nutrition Survey menuCH (n 2057) were used to compute hypothesis- (Alternate Healthy Eating Index (AHEI)) and data-driven dietary patterns. District-level standardised mortality ratios (SMR) were calculated using the Swiss Federal Statistical Office mortality data and linked to dietary data geographically. Quasipoisson regression models were fitted to investigate the associations between dietary patterns and chronic disease mortality; Moran's I statistics were used to explore spatial dependence. Compared with the first, the fifth AHEI quintile (highest diet quality) was associated with district-level SMR of 0·95 (95 % CI 0·93, 0·97) for CVD, 0·91 (95 % CI 0·88, 0·95) for ischaemic heart disease (IHD), 0·97 (95 % CI 0·95, 0·99) for stroke, 0·99 (95 % CI 0·98, 1·00) for all-cancer, 0·98 (95 % CI 0·96, 0·99) for colorectal cancer and 0·93 (95 % CI 0·89, 0·96) for diabetes. The Swiss traditional and Western-like patterns were associated with significantly higher district-level SMR for CVD, IHD, stroke and diabetes (ranging from 1·02 to 1·08) compared with the Prudent pattern. Significant global and local spatial dependence was identified, with similar results across hypothesis- and data-driven dietary patterns. Our study suggests that dietary patterns partly contribute to the explanation of geographic disparities in chronic disease mortality in Switzerland. Further analyses including spatial components in regression models would allow identifying regions where nutritional interventions are particularly needed.

Assessing relative COVID-19 mortality during the second wave: a prospective Swiss population-based study.

OBJECTIVE: During the first COVID-19 wave in Switzerland, relative mortality was at least eight times higher compared with the uninfected general population. We aimed to assess sex-specific and age-specific relative mortality associated with a SARS-CoV-2 diagnosis during the second wave. DESIGN: Prospective population-based study. SETTING: Individuals testing positive for SARS-CoV-2 after the start of the second wave on 1 October 2020 were followed up until death or administrative censoring on 31 December 2020. PARTICIPANTS: 5 179 740 inhabitants of Switzerland in fall 2018 aged 35-95 years (without COVID-19) and 257 288 persons tested positive for SARS-CoV-2 by PCR or antigen testing during the second wave. PRIMARY AND SECONDARY OUTCOME MEASURES: The planned outcome measure was time to death from any cause, measured from the date of a SARS-CoV-2 diagnosis or 1 October in the general population. Information on confirmed SARS-CoV-2 diagnoses and deaths was matched by calendar time with the all-cause mortality of the general Swiss population of 2018. Proportional hazards models were used to estimate sex-specific and age-specific mortality rates and probabilities of death within 60 days. RESULTS: The risk of death for individuals tested positive for SARS-CoV-2 in the second wave in Switzerland increased at least sixfold compared with the general population. HRs, reflecting the risk attributable to a SARS-CoV-2 infection, were higher for men (1.40, 95% CI 1.29 to 1.52) and increased for each additional year of age (1.01, 95% CI 1.01 to 1.02). COVID-19 mortality was reduced by at least 20% compared with the first wave in spring 2020. CONCLUSION: General mortality patterns, increased for men and older persons, were similar in spring and in fall. Absolute and relative COVID-19 mortality was smaller in fall. TRIAL REGISTRATION: The protocol for this study was registered on 3 December 2020 at https://osf.io/gbd6r.

Assessing relative COVID-19 mortality: a Swiss population-based study.

OBJECTIVE: Severity of the COVID-19 has been previously reported in terms of absolute mortality in SARS-CoV-2 positive cohorts. An assessment of mortality relative to mortality in the general population is presented. DESIGN: Retrospective population-based study. SETTING: Individual information on symptomatic confirmed SARS-CoV-2 patients and subsequent deaths from any cause were compared with the all-cause mortality in the Swiss population of 2018. Starting 23 February 2020, mortality in COVID-19 patients was monitored for 80 days and compared with the population mortality observed in the same time of year starting 23 February 2018. PARTICIPANTS: 5 102 300 inhabitants of Switzerland aged 35-95 without COVID-19 (general population in spring 2018) and 20 769 persons tested positively for COVID-19 during the first wave in spring 2020. MEASUREMENTS: Sex-specific and age-specific mortality rates were estimated using Cox proportional hazards models. Absolute probabilities of death were predicted and risk was assessed in terms of relative mortality by taking the ratio between the sex-specific and age-specific absolute mortality in COVID-19 patients and the corresponding mortality in the 2018 general population. RESULTS: Absolute mortalities increased with age and were higher for males compared with females, both in the general population and in positively tested persons. A confirmed SARS-CoV-2 infection substantially increased the probability of death across all patient groups at least eightfold. The highest relative mortality risks were observed among males and younger patients. Male COVID-19 patients exceeded the population hazard for males (HR 1.21, 95% CI 1.02 to 1.44). An additional year of age increased the population hazard in COVID-19 patients only marginally (HR 1.00, 95% CI 1.00 to 1.01). CONCLUSIONS: Healthcare professionals, decision-makers and societies are provided with an additional population-adjusted assessment of COVID-19 mortality risk. In combination with absolute measures of risk, the relative risks presented here help to develop a more comprehensive understanding of the actual impact of COVID-19.

Identification of socio-demographic, occupational, and societal factors for guiding suicide prevention: A cohort study of Swiss male workers (2000-2014).

INTRODUCTION: We modeled suicidal rate among Swiss working-age males, considering three groups of factors at socio-demographic, occupational, and societal levels jointly. Our goal was twofold: to verify the effect of occupation after adjustment for non-occupational factors and to identify protective and risk factors relevant for suicide prevention in working male adults. METHODS: The study population included all men aged [18-65] years at the 2000 population census and followed up within the Swiss National Cohort (SNC). The risk of suicide was modeled using Poisson regression. RESULTS: The cohort comprised 1,534,564 men and 4371 deaths by suicide. Suicide rate varied significantly according to age, civil status, nationality, highest education achieved, and socio-professional category at socio-demographic level; occupation, occupational activity branch, weekly working hours, and home-to-work commute time at occupational level; calendar period of death, region, religious affiliation, and volunteering activity at societal level. After adjustment for non-occupational factors, agricultural and fishery laborers, military and civil security workers, and health and social workers were identified as high-risk groups with respect to suicide. CONCLUSION: This study evidenced a complex web of factors at socio-demographic, occupational, and societal levels behind the suicide in Swiss male workers and identified the most at-risk groups, deserving targeted prevention efforts.

Higher educational level in patients with eosinophilic esophagitis: a comparative analysis.

BACKGROUND: Eosinophilic esophagitis is a chronic inflammatory gastrointestinal disease with a high prevalence in younger, atopic males. In our clinical practice, we observed a striking preponderance of patients having a high educational background. The purposes of this study were first to assess the level of education of eosinophilic esophagitis patients and second to compare the findings to patients with inflammatory bowel disease, another chronic immune-mediated condition of the gastrointestinal tract, and with the Swiss general population. METHODS: Using a questionnaire, we assessed the educational level of adult patients who have attended Swiss Eosinophilic Esophagitis Clinics in the past. In addition, the educational level of the parents was assessed as well. We calculated the proportions of patients and parents who have obtained a higher educational level. Data from the Swiss Inflammatory Bowel Disease Cohort Study and from the Swiss general population served as confirmation and as comparison, respectively. RESULTS: A total of 277 successfully contacted patients (response rate 69.1%; mean age 51.1 years, 73% male) participated. A significantly higher proportion of surveyed eosinophilic esophagitis patients had a high International Standard Classification of Education level (66.8%, P < 0.001) compared with inflammatory bowel disease patients (n = 2534; 34.2%, P < 0.001) and to the Swiss general population (n = 6,066,907; 30.5% P < 0.001). CONCLUSION: Our analysis confirms the clinical observation that eosinophilic esophagitis patients have a significantly higher educational level compared with the general population and to patients with other chronic inflammatory diseases of the gastrointestinal tract. As a limitation, this impressive finding remains on a purely descriptive level.

Determinants of educational inequalities in disability-free life expectancy between ages 35 and 80 in Europe.

Socioeconomic inequalities in disability-free life expectancy (DFLE) exist across all European countries, yet the driving determinants of these differences are not completely known. We calculated the impact on educational inequalities in DFLE of equalizing the distribution of eight risk factors for mortality and disability using register-based mortality data and survey data from 15 European countries for individuals between 35 and 80 years old. From the selected risk factors, the ones that contribute the most to the educational inequalities in DFLE are low income, high body-weight, smoking (for men), and manual occupation of the father. Potentially large reductions in inequalities can be achieved in Eastern European countries, where educational inequalities in DFLE are also the largest.

Smoking and inequalities in mortality in 11 European countries: a birth cohort analysis.

PURPOSE: To study the trends of smoking-attributable mortality among the low and high educated in consecutive birth cohorts in 11 European countries. METHODS: Register-based mortality data were collected among adults aged 30 to 79 years in 11 European countries between 1971 and 2012. Smoking-attributable deaths were estimated indirectly from lung cancer mortality rates using the Preston-Glei-Wilmoth method. Rate ratios and rate differences among the low and high-educated were estimated and used to estimate the contribution of inequality in smoking-attributable mortality to inequality in total mortality. RESULTS: In most countries, smoking-attributable mortality decreased in consecutive birth cohorts born between 1906 and 1961 among low- and high-educated men and high-educated women, but not among low-educated women among whom it increased. Relative educational inequalities in smoking-attributable mortality increased among both men and women with no signs of turning points. Absolute inequalities were stable among men but slightly increased among women. The contribution of inequality in smoking-attributable mortality to inequality in total mortality decreased in consecutive generations among men but increased among women. CONCLUSIONS: Smoking might become less important as a driver of inequalities in total mortality among men in the future. However, among women, smoking threatens to further widen inequalities in total mortality.

NO2 and PM2.5 Exposures and Lung Function in Swiss Adults: Estimated Effects of Short-Term Exposures and Long-Term Exposures with and without Adjustment for Short-Term Deviations.

BACKGROUND: The impact of nitrogen dioxide (NO2) and particulate matter with an aerodynamic diameter of less than or equal to 2.5. microns (PM2.5) exposures on lung function has been investigated mainly in children and less in adults. Furthermore, it is unclear whether short-term deviations of air pollutant concentration need to be considered in long-term exposure models. OBJECTIVES: The aims of this study were to investigate the association between short-term air pollution exposure and lung function and to assess whether short-term deviations of air pollutant concentration should be integrated into long-term exposure models. METHODS: Short-term (daily averages 0-7 d prior) and long-term (1- and 4-y means) NO2 and PM2.5 concentrations were modeled using satellite, land use, and meteorological data calibrated on ground measurements. Forced expiratory volume within the first second (FEV1) of forced exhalation and forced vital capacity (FVC) were measured during a LuftiBus assessment (2003-2012) and linked to exposure information from the Swiss National Cohort for 36,085 adults (ages 18-95 y). We used multiple linear regression to estimate adjusted associations, and additionally adjusted models of long-term exposures for short-term deviations in air pollutant concentrations. RESULTS: A 10µg/m3 increase in NO2 and PM2.5 on the day of the pulmonary function test was associated with lower FEV1 and FVC (NO2: FEV1 -8.0 ml [95% confidence interval: -13.4, -2.7], FVC -16.7 ml [-23.4, -10.0]; PM2.5: FEV1 -15.3 ml [-21.9, -8.7], FVC -18.5 ml [-26.5, -10.5]). A 10µg/m3 increase in 1-y mean NO2 was also associated with lower FEV1 (-7.7 ml; -15.9, 0.5) and FVC (-21.6 ml; -31.9, -11.4), as was a 10µg/m3 increase in 1-y mean PM2.5 (FEV1: -42.2 ml; -56.9, -27.5; FVC: -82.0 ml; -100.1, -63.9). These associations were robust to adjustment for short-term deviations in the concentration of each air pollutant. CONCLUSIONS: Short- and long-term air pollution exposures were negatively associated with lung function, in particular long-term PM2.5 exposure with FVC. Our findings contribute substantially to the evidence of adverse associations between air pollution and lung function in adults. https://doi.org/10.1289/EHP7529.

Determinants of inequalities in years with disability: an international-comparative study.

BACKGROUND: Persons with a lower socioeconomic position spend more years with disability, despite their shorter life expectancy, but it is unknown what the important determinants are. This study aimed to quantify the contribution to educational inequalities in years with disability of eight risk factors: father's manual occupation, low income, few social contacts, smoking, high alcohol consumption, high body-weight, low physical exercise and low fruit and vegetable consumption. METHODS: We collected register-based mortality and survey-based disability and risk factor data from 15 European countries covering the period 2010-14 for most countries. We calculated years with disability between the ages of 35 and 80 by education and gender using the Sullivan method, and determined the hypothetical effect of changing the prevalence of each risk factor to the prevalence observed among high educated ('upward levelling scenario'), using Population Attributable Fractions. RESULTS: Years with disability among low educated were higher than among high educated, with a difference of 4.9 years among men and 5.5 years among women for all countries combined. Most risk factors were more prevalent among low educated. We found the largest contributions to inequalities in years with disability for low income (men: 1.0 year; women: 1.4 year), high body-weight (men: 0.6 year; women: 1.2 year) and father's manual occupation (men: 0.7 year; women: 0.9 year), but contributions differed by country. The contribution of smoking was relatively small. CONCLUSIONS: Disadvantages in material circumstances (low income), circumstances during childhood (father's manual occupation) and high body-weight contribute to inequalities in years with disability.

Educational inequalities in mortality amenable to healthcare. A comparison of European healthcare systems.

BACKGROUND: Educational inequalities in health and mortality in European countries have often been studied in the context of welfare regimes or political systems. We argue that the healthcare system is the national level feature most directly linkable to mortality amenable to healthcare. In this article, we ask to what extent the strength of educational differences in mortality amenable to healthcare vary among European countries and between European healthcare system types. METHODS: This study uses data on mortality amenable to healthcare for 21 European populations, covering ages 35-79 and spanning from 1998 to 2006. ISCED education categories are used to calculate relative (RII) and absolute inequalities (SII) between the highest and lowest educated. The healthcare system typology is based on the latest available classification. Meta-analysis and ANOVA tests are used to see if and how they can explain between-country differences in inequalities and whether any healthcare system types have higher inequalities. RESULTS: All countries and healthcare system types exhibited relative and absolute educational inequalities in mortality amenable to healthcare. The low-supply and low performance mixed healthcare system type had the highest inequality point estimate for the male (RII = 3.57; SII = 414) and female (RII = 3.18; SII = 209) population, while the regulation-oriented public healthcare systems had the overall lowest (male RII = 1.78; male SII = 123; female RII = 1.86; female SII = 78.5). Due to data limitations, results were not robust enough to make substantial claims about typology differences. CONCLUSIONS: This article aims at discussing possible mechanisms connecting healthcare systems, social position, and health. Results indicate that factors located within the healthcare system are relevant for health inequalities, as inequalities in mortality amenable to medical care are present in all healthcare systems. Future research should aim at examining the role of specific characteristics of healthcare systems in more detail.

Occupational exposure and the risk of airway obstruction and mortality.

OBJECTIVES: To identify occupational groups at high risk of airway obstruction (AO) and mortality and potential interactions with smoking. METHODS: Lung function data from the LuftiBus project were enriched with occupational and follow-up information from the Swiss National Cohort, resulting in a cohort of 10582 adults between 2000 and 2015. We assigned professions to occupational groups and estimated the risk of AO and mortality using adjusted logistic and Cox regression model. Additionally, we assessed multiplicative and additive interactions between occupational exposure and smoking. RESULTS: Chimney sweeps and male workers from the agriculture, construction and food industries had an increased risk of AO (odds ratios ranging from 1.43 to 2.21). The risk of mortality was increased among male workers from the food industry (hazard ratio 1.57, 95% CI 1.10-2.23). Interactions with smoking were present in most associations, but smoking had no effect on the increased risk of mortality in the food industry. CONCLUSIONS: Some occupational groups have a considerable risk of AO and mortality. The identification of the most affected occupations is of great importance enabling targeted risk reduction strategies.

Time trend of suicide in Swiss male farmers and comparison with other men: a cohort study.

OBJECTIVE: The ongoing agricultural reforms present serious challenges for Swiss farmers. Pressure is growing with difficult economic situations and the increasing demands for environmental protection, animal welfare and food safety. The aim of this study was to determine whether the strain is associated with higher risk of suicide in farmers than in men in other professions. We also wanted to analyse any changes in trends over time. METHODS: Using the Swiss National Cohort, a population-based longitudinal study (1991–2014), we investigated suicide rates for Swiss men aged 35 to 74 years who lived in small communities. We calculated crude rates of suicide and standardised mortality ratios (SMRs) for both calendar periods of four years, and overall. We estimated hazard ratios using Cox proportional hazard regression models of increasing complexity to examine associations with profession (farmer, non-farmer), calendar period, marital status, type of household, religion and language region. RESULTS: We identified 9006 suicides among 1,796,379 men in the total study population, of which 447 occurred in 89,303 farmers. Age-standardised rates of suicide per 100,000 person-years were higher (38.1, 95% CI 34.6–41.8) in farmers than in men with other professions (32.6, 95% CI 31.9–33.3). Although the age-standardised rates decreased for the whole study population until 2006, the declining trend continued afterwards only in non-farmers. The widening gap between farmers and non-farmers also showed in the SMR, which increased from 1.06 (95% CI 0.88–1.27) in the period 1991–1994 to 1.37 (95% CI 1.05–1.79) in 2011-2014. The Cox regression model analyses also revealed a higher risk of suicide for farmers, with hazard ratios ranging from 1.10 (95% CI 1.00–1.22) to 1.17 (95% CI 1.07–1.29). Usage of firearms was the most common method in the overall population (36.5%). In farmers, however, almost 60% committed suicide by hanging. CONCLUSION: The study shows a higher rate of suicide in farmers compared to non-farmers in Switzerland, with the gap widening increasingly after 2006. It underlines the importance of identifying the difficulties and concerns of male farmers at an early stage in order to make appropriate structural adjustments and to offer low-threshold assistance tailored to their needs and preferences.

Increase in Airway Obstruction between 1993 and 2012 in Switzerland. An Observational Study.

Rationale: Most studies determining the prevalence of airway obstruction are limited to short time periods.Objectives: Because temporal trends of obstruction in populations are largely unknown, we determined the prevalence of airway obstruction over 20 years in yearly general population samples in Switzerland between 1993 and 2012.Methods: We analyzed data of 85,789 participants aged 35 years and older who provided spirometric measurements as part of the LuftiBus lung function campaign. We linked data from the 2003-2012 period to the Swiss National Cohort to adjust for annual population differences. Spirometry was performed without bronchodilation, according to American Thoracic Society guidelines. We used Global Lung Initiative (GLI) and Hankinson reference equations to identify obstruction.Results: Obstruction prevalence increased between 1993 and 2012 from 6.1% (95% confidence interval [CI], 5.5 to 6.7) to 15.6% (95% CI, 13.8 to 17.3) based on GLI estimates and from 5.3% (95% CI, 4.7 to 5.9) to 15.4% (95% CI, 13.6 to 17.1) based on Hankinson estimates. When adjusted for participant demographics, air pollutant and occupational exposures, altitude, and season, the prevalence ratios of obstruction were 1.54 (95% CI, 1.22 to 1.93) and 1.65 (95% CI, 1.33 to 2.04) for GLI- and Hankinson-defined airway obstruction, respectively, for 2012 compared with 2003.Conclusions: Though prebronchodilator measurements likely overestimate the prevalence of airway obstruction in absolute terms compared with post-bronchodilator measurements, we found an increase in airway obstruction prevalence. Even with adjustment for several well-known risk factors for obstruction to make the populations across the years more comparable, we still saw a statistically significant increase in prevalence over this time period.

Medical end-of-life decisions in the oldest old in Switzerland.

AIMS OF THE STUDY: To analyse medical end-of-life decision making among the oldest old (80+ years) in Switzerland, focusing not only on treatments withheld or withdrawn but also on those continued until death. METHODS: This was a retrospective follow-up study of deaths registered in Switzerland between August 2013 and January 2014 using a standardised questionnaire completed by the attending physician. All individuals aged 65 years and older who did not die suddenly and completely unexpectedly, and who had met the responding physician prior to death were included (n = 2842). We examined three age groups: 65–79, 80–89, and 90+ years. Logistic regression analysis was used to identify age-related differences, controlled for place of death and sociodemographic characteristics. RESULTS: In 83.8% of the study population at least one medical end-of-life decision was made, and for 39.4% the use of a potentially life-sustaining treatment was documented. Alleviation of pain and other symptoms with a possible life-shortening effect was performed with 29% higher odds among the 90+-year-olds (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.01–1.66) than in the youngest age group. Withholding or withdrawing potentially life-sustaining treatment with or without the explicit intention to hasten death did not differ with age. However, when the frequency of withholding a potentially life-sustaining treatment was compared with the frequency of using this treatment (either continued until death or withdrawn later on), the former was more common in old age (80–89 years), and particularly in very old age (90+ years) for most of the treatments studied. This applied especially for ventilator therapy (80–89 years: OR 2.83, 95% CI 1.82–4.41; 90+ years: OR 6.17, 95% CI 2.89–13.17, compared with 65–79 years), artificial nutrition (ORs 2.33, 95% CI 1.46–3.71 and 4.44, 95% CI 2.28–8.65, respectively), and antibiotics (ORs 1.53, 95% CI 1.11–2.09 and 1.57, 95% CI 1.05–2.35, respectively). Age had no independent impact on artificial hydration. CONCLUSIONS: The use of some potentially life-sustaining treatments decreased with older age and, in relation, the relative frequency of withholding such treatments increased. There may be various reasons for this finding: less benefit of a particular treatment in older patients for instance due to comorbidities, higher burden of treatment, and finally a tacit consensus of physicians and patients that death is nearing.

Progress in reducing inequalities in cardiovascular disease mortality in Europe.

OBJECTIVE: To assess whether recent declines in cardiovascular mortality have benefited all socioeconomic groups equally and whether these declines have narrowed or widened inequalities in cardiovascular mortality in Europe. METHODS: In this prospective registry-based study, we determined changes in cardiovascular mortality between the 1990s and the early 2010s in 12 European populations by gender, educational level and occupational class. In order to quantify changes in the magnitude of differences in mortality, we calculated both ratio measures of relative inequalities and difference measures of absolute inequalities. RESULTS: Cardiovascular mortality has declined rapidly among lower and higher socioeconomic groups. Relative declines (%) were faster among higher socioeconomic groups; absolute declines (deaths per 100 000 person-years) were almost uniformly larger among lower socioeconomic groups. Therefore, although relative inequalities increased over time, absolute inequalities often declined substantially on all measures used. Similar trends were seen for ischaemic heart disease and cerebrovascular disease mortality separately. Best performer was England and Wales, which combined large declines in cardiovascular mortality with large reductions in absolute inequalities and stability in relative inequalities in both genders. In the early 2010s, inequalities in cardiovascular mortality were smallest in Southern Europe, of intermediate magnitude in Northern and Western Europe and largest in Central-Eastern European and Baltic countries. CONCLUSIONS: Lower socioeconomic groups have experienced remarkable declines in cardiovascular mortality rates over the last 25 years, and trends in inequalities can be qualified as favourable overall. Nevertheless, further reducing inequalities remains an important challenge for European health systems and policies.

Continuing, Withdrawing, and Withholding Medical Treatment at the End of Life and Associated Characteristics: a Mortality Follow-back Study.

BACKGROUND: Studies on forgoing treatment often ignore treatments that are continued until death. OBJECTIVE: To investigate how often specific treatments are withdrawn or withheld before death and to describe the associated patient, physician, and care characteristics. DESIGN: National mortality follow-back study in Switzerland in 2013/2014 using a standardized survey to collect information on the patient's end of life and demographics on the physician. PARTICIPANTS: A random sample of adults who died non-suddenly without an external cause and who had met the physician completing the survey (N = 3051). MAIN MEASURES: Any of nine specific treatments was continued until death, withdrawn, or withheld. KEY RESULTS: In 2242 cases (84%), at least one treatment was either continued until death or withheld or withdrawn. The most common treatment was artificial hydration, which was continued in 23%, withdrawn in 4%, and withheld in 22% of all cases. The other eight treatments were withdrawn or withheld in 70-94% of applicable cases. The impact of physician characteristics was limited, but artificial hydration, antibiotics, artificial nutrition, and ventilator therapy were more likely to be withheld at home and in nursing homes than in the hospitals. CONCLUSIONS: Large differences exist between care settings in whether treatments are continued, withdrawn, or withheld, indicating the different availability of treatment options or different philosophies of care. While certain patient groups are more likely to have treatment withheld rather than attempted, neither patient nor physician characteristics impact the decision to continue or withdraw treatment.