Daily variations in deaths in Lithuania: the possible contribution of binge drinking.

BACKGROUND: During the early 1990s the countries of the Former Soviet Union experienced a dramatic rise in mortality, especially from cardiovascular diseases. Although still poorly understood there is evidence, particularly from Russia, that this mortality crisis is partly linked to alcohol consumption. In this paper we use data from Lithuania to explore the daily variations of deaths and the probable relationship with binge drinking. METHODS: Computerized death certificates for those aged 20-59 years were analysed according to the day of death, place of death, and cause of death for the years 1988-1997. RESULTS: There is a marked increase in deaths from accidents, violence, and alcohol poisoning at the weekend, suggesting a pattern of binge drinking in Lithuania. There is also a significant increase in ischaemic heart disease (IHD) deaths on Saturdays, Sundays and Mondays. If the analysis is performed separately according to place of death, the day of the week effect is strengthened for cardiovascular deaths outside of hospital; consistent with the idea of a sudden cardiac death. CONCLUSION: The increase in mortality from cardiovascular diseases observed at the weekend in Lithuania is similar to that observed in Moscow and other populations. The relationship with alcohol consumption is supported by the available physiological evidence. We propose that bingeing can be solely responsible for, or acts as a 'catalyst' for, pathophysiological events by increasing blood pressure, cardiac rhythm and coagulability. The increased IHD mortality observed throughout the weekend and on Monday in Lithuania may reflect the influence of alcohol consumption patterns in a population already subject to high psychosocial stress.

Cancer mortality in Russia and Ukraine: validity, competing risks and cohort effects.

BACKGROUND: The dramatic increase in mortality in Russia and Ukraine in the late 1980s and 1990s has been due to increases in certain causes of death, particularly cardiovascular disease and accidents and violence. In contrast, there has been a slight fall in mortality from cancer. METHODS: This paper presents an analysis of trends and patterns in cancer mortality and examines four possible explanations for its recent fall: changes in data collection; cohort effects; competing mortality from other causes of death; and improvements in health care. RESULTS: All contribute to some extent to the observed changes, with each affecting predominantly different age groups. There is evidence of a significant underrecording of cancer deaths among the elderly especially in rural areas and of significant changes in coding practices in the early 1990s. Competing mortality from cardiovascular diseases and accidents can explain some reduction in male deaths from cancer in middle age. Birth cohort effects can explain some reduction among males after early middle age and among females at all ages. The impact of changes in health care are more difficult to identify with certainty but there is evidence of reduced deaths from childhood leukaemia. IMPLICATIONS: Recent changes in mortality in Russia are complex and their understanding will require a multidisciplinary approach embracing demography, epidemiology and health services research.

Exploring the relationship between alcohol consumption and non-fatal or fatal stroke: a systematic review.

OBJECTIVE: Alcohol consumption has been reported to have both beneficial and harmful effects on stroke occurrence. Several studies have demonstrated a significant association with heavy drinking, but the evidence linking light-to-moderate alcohol consumption still remains unclear. This study, using a systematic review of the published literature, aimed to explore the dose-response relationship between alcohol and stroke, the effect of irregular drinking and the effect of beverage types on the risk of stroke. METHODS: A structured search for English-language published literature since 1966 was made using several electronic databases. This was supplemented using a hand search of references in review articles and additional searches on key authors. From the 153 eligible articles, 41 studies were selected according to study design, categorization of the exposure and outcome measures. FINDINGS: An association between recent alcohol use and stroke was consistently reported. There was also some evidence for a linear positive association for haemorrhagic stroke and alcohol consumption. Inconsistent results emerged on the J-shaped relationship between alcohol and ischaemic stroke, and the association between alcohol and non-fatal or fatal stroke combined. The importance of the pattern of drinking was also demonstrated, indicating a higher risk for irregular drinkers. CONCLUSIONS: There is insufficient evidence to conclude that light-to-moderate alcohol drinking and wine intake have beneficial effects on stroke occurrence. On the contrary, findings from this review suggest the opportunity for a primary prevention regarding heavy drinking and binge drinking. More information regarding the risk of stroke associated with irregular alcohol drinking, and the joint effects of alcohol with other risk factors, would clarify the complex interaction between alcohol and stroke.

Challenges of monitoring use of secondary care at local level: a study based in London, UK.

STUDY OBJECTIVE: To provide those working at district level with practical guidance on using hospital data linked to small geographic areas to explore patterns of care. DESIGN: Examination of the association between age standardised hospital episode rates for the commonest diagnostic categories and deprivation levels (Carstairs index) of the electoral ward of residence. SETTING: An inner London district, Kensington, Chelsea and Westminster, with a population of approximately 325,000. POPULATION: All finished consultant episodes recorded in NHS hospitals for the district population in the year to April 1994. MAIN RESULTS: Many, but not all, disease categories were associated strongly with deprivation, with high episode rates in the most deprived electoral wards. This is partly due to more of those in deprived areas being admitted to hospital and to them being admitted more often. CONCLUSIONS: A wide range of factors needs to be taken into account in interpreting these data. They include the contribution of the private sector and artifacts of both the numerator and denominator. This paper provides a framework for those working at district level to begin to analyse the association between hospitalisation and deprivation locally. It also identifies some of the issues that must be taken into account when seeking to interpret these data.

What happened to life expectancy in Spain in the 1980s?

BACKGROUND: Life expectancy at birth in Spain improved between 1972 and 1982, by 2.5 years for males and 3.2 years for females. This slowed considerably in the following decade, with increases of only 0.5 and 1.7 years respectively. OBJECTIVE: To determine the causes of death that have been responsible for the failure by Spain to maintain in the 1980s and 1990s the rate of improvement in life expectancy seen during the 1970s. DESIGN: Data from WHO mortality tapes grouped in a series of clinically meaningful categories were used to calculate the contribution of each category, in five year age groups, to the changing life expectancy at birth in the two periods. SETTING: Spain. RESULTS: The trend in life expectancy at birth in Spain over this 20 year period can be considered to have two components, both with important consequences for public health policy. Underlying trends include a steady negative contribution from respiratory cancer in men and a reduction in cardiovascular disease. More recent trends include a considerable deterioration in deaths among young adults, most notably from accidents and, possibly, AIDS. CONCLUSION: The failure to maintain the rate of earlier gains in life expectancy in Spain can be attributed largely to a few conditions, although these may indicate less obvious underlying problems. These findings have important consequences for prioritising public health policies.

Changing life expectancy in the 1980s: why was Denmark different from Sweden?

OBJECTIVE: To identify the contribution from specific causes of death to the changes in life expectancy at birth in Denmark relative to Sweden in different age groups during the 1980s and to compare the difference in life expectancy between the two countries in 1990. DESIGN: Mortality data from WHO mortality tapes grouped in smaller series of clinically meaningful categories were used to calculate the contribution of each of these categories at each 10 year age group to the difference in life expectancy at birth in each country between 1979 and 1990 and between the two countries. SETTING: Denmark and Sweden. RESULTS: Between 1979 and 1990 life expectancy increased in both Denmark and Sweden. However, the increase in Sweden was more than two years while that in Denmark was less than one year. In both countries a decrease in cardiovascular disease mortality contributed most to the increase in life expectancy in males as well as females. In both sexes the smaller increase in life expectancy in Denmark was a result of differences in mortality trends in cardiovascular diseases and respiratory and non-respiratory cancers. CONCLUSION: Over a short time two Nordic countries experienced remarkable but different changes in mortality. These findings suggest that mortality rates are sensitive to even minor differences in social and cultural factors across countries and over short time periods.

Alcohol and cardiovascular mortality in Moscow; new evidence of a causal association.

BACKGROUND: In explaining recent trends in Russian mortality, alcohol drinking has often been put forward as a major factor. However, cardiovascular disease remains the major cause of death in Russia and alcohol is currently viewed as having a protective effect on heart disease. This study explores this apparent paradox by examining daily trends in deaths from cardiovascular disease in Moscow. SUBJECTS: Those dying in Moscow in the years 1993-1995. METHODS: Analysis of daily variation in deaths based on data from Moscow City death certificates. RESULTS: There is a significant increase in deaths from alcohol poisoning, accidents, and violence and cardiovascular diseases on Saturdays, Sundays, and Mondays. This is especially marked for sudden deaths. This pattern is consistent with the known pattern of drinking in Russia, which is more likely to take place in binges than is the case in other countries. CONCLUSION: A possible causative role for alcohol in sudden cardiovascular death is suggested as there are no other obvious explanations for this pattern, which cannot be accounted for by daily variations in traditional risk factors such as smoking or lipids. Although this is inconsistent with the prevailing view in the West that alcohol is seen as cardioprotective, there is considerable supporting evidence from a necropsy study and from studies in other places with a similar pattern of drinking. In countries such as Russia, where patterns of drinking differ considerably from that in the West, binge drinking can be an important cause of sudden cardiac death. This has important implications for estimates of the amount of mortality worldwide attributable to specific risk factors and thus for national and international policy.

What has contributed to the change in life expectancy in Italy between 1980 and 1992?

Life expectancy at birth in southern Europe is known to be greater than expected in comparison with levels of economic development. This has been attributed to the 'Mediterranean diet'. There are, however, concerns that this comparative advantage is being lost. This paper examines the factors underlying changing life expectancy in Italy since 1980. The subjects of this analysis are obtained from data on all deaths in Italy between 1980 and 1992. Change in age specific death rates is calculated from selected causes and, using the method developed by Pollard, the contribution of deaths from different causes and at different ages to changing life expectancy at birth is estimated. Between 1980 and 1992, life expectancy at birth increased by 2.70 years for men and 2.75 years for women. Death rates have fallen among children and those over 40. In contrast, death rates have increased among men aged between 20 and 39 and have increased very slightly among women aged 25-29. Falling death rates from ischaemic heart disease are continuing to contribute to increasing life expectancy. Death rates from lung and breast cancer are rising among women but are compensated for by falling death rates from other cancers. Among men, falling death rates from cancer at younger ages are being offset by increases at older ages. The rising death rate among younger men is almost entirely due to AIDS, with accidents also making a small contribution. Life expectancy in Italy has improved throughout the 1980s, largely driven by falling death rates from cardiovascular diseases. Here are, however, some worrying trends, most notably the rising death rate among young men, due almost entirely to AIDS. The changing pattern of mortality has some similarities with Spain, another Mediterranean country, but there are also important differences.

Economic change, crime, and mortality crisis in Russia: regional analysis.

OBJECTIVE: To identify which aspects of socioeconomic change were associated with the steep decline in life expectancy in Russia between 1990 and 1994. DESIGN: Regression analysis of regional data, with percentage fall in male life expectancy as dependent variable and a range of socioeconomic measures reflecting transition, change in income, inequity, and social cohesion as independent variables. Determination of contribution of deaths from major causes and in each age group to changes in both male and female life expectancy at birth in regions with the smallest and largest declines. SETTING: Regions (oblasts) of European Russia (excluding Siberia and those in the Caucasus affected by the Chechen war). SUBJECTS: The population of European Russia. RESULTS: The fall in life expectancy at birth varied widely between regions, with declines for men and women highly correlated. The regions with the largest falls were predominantly urban, with high rates of labour turnover, large increases in recorded crime, and a higher average but unequal distribution of household income. For both men and women increasing rates of death between the ages of 30 and 60 years accounted for most of the fall in life expectancy, with the greatest contributions being from conditions directly or indirectly associated with heavy alcohol consumption. CONCLUSIONS: The decline in life expectancy in Russia in the 1990s cannot be attributed simply to impoverishment. Instead, the impact of social and economic transition, exacerbated by a lack of social cohesion, seems to have played a major part. The evidence that alcohol is an important proximate cause of premature death in Russia is strengthened.

[Changing life expectancy in the 1980's. Why was Denmark different from Sweden?]. / Udviklingen i middellevetid i 1980'erne Hvorfor var Danmark forskellig fra Sverige?

The aim of the present study was to identify the contribution from specific causes of death to the changes in life expectancy at birth in Denmark relative to Sweden in different age groups during the 1980s and to compare the difference in life expectancy between the two countries in 1990. Mortality data from WHO mortality tapes grouped in smaller series of clinically meaningful categories were used to calculate the contribution of each of these categories at each ten year age group to the difference in life expectancy at birth in each country between 1979 and 1990 and between the two countries. During the period from 1979 to 1990 life expectancy increased in both Denmark and Sweden. However, Sweden experienced the greatest increase in life expectancy (more than two years) while it increased less than one year in Denmark. In both countries a decrease in cardiovascular disease mortality contributed most to the increase in life expectancy among males as well as females. Both among males and females the less favourable development in Denmark was mainly caused by differences in mortality trends related to cardio-vascular diseases, respiratory and non-respiratory cancer. Over a short period of time two Nordic countries experienced remarkable, but different changes in mortality. These findings suggest that mortality rates are sensitive to even minor differences in social and cultural factors across countries and over short time periods.

Teenage fertility in the European Union.

PIP: A large proportion of pregnancies which occur among women during their teenage years are unwanted. As such, the abortion rate is high among teenage pregnant women. Teenage women who choose to carry their fetuses to term run an excess risk of delivering premature and low birthweight babies. Teenage mothers often have not finished their studies and will find it difficult to remain in the educational system. There is a high rate of school dropout among teenage mothers. Moreover, they have limited job opportunities, especially in countries like the UK where child care facilities are scarce. Teenage fertility varies widely among the countries of the European Union (EU). In the UK, there are 32 live births per 1000 women aged 15-19, the highest rate in the EU. In the Netherlands, the rate of teenage fertility is only 4 live births per 1000 women aged 15-19 years. In the context of general delayed childbearing throughout the EU, the rate of teenage fertility in the UK has increased in recent years. A more holistic approach to family planning services, improved communication with teenagers, and more appropriate sex education programs are needed if the British government is to succeed in reducing by 50% the conception rate among women younger than age 16 years by the year 2000. An active policy to fight socioeconomic deprivation at the local level should also positively affect teenage fertility.^ieng

Down the road to deregulation.

A recent preliminary ruling by the European Court of Justice, that would have ended the Swedish state retail alcohol monopoly on grounds of European law on free movement of goods, highlights the international pressure on countries to deregulate further their alcohol markets. However, those countries that have recently taken the road to deregulation have not been able to prevent the alcohol industry encouraging people to drink more and they are experiencing increased alcohol-related problems. The international debates about tradeable commodities rarely take account of the consequences for public health. Alcohol is one such commodity that is also an important cause of premature death. It is essential that this is not overlooked in the race to promote free trade.

Informing the market: the strengths and weaknesses of information in the British National Health Service.

Many countries are experimenting with planned (or quasi-) markets to discover if they can efficiently deliver health care in keeping with societal objectives. This paper examines the information requirements of this approach. Information is necessary in order to compare the performance of providers, to support billing, and to monitor access to care. It should be accurate, unambiguous, and resistant to manipulation. We draw on a project to find out how information on hospitalisation could be used in contracting in the British National Health Service. We conclude that the existing British system fails to provide robust measures of how many patients are treated, for what conditions, and with what treatments. We identify some promising remedies, others that are more difficult, and some which may be impossible to implement in any planned market, given the uncertainty of clinical practice.

Health sector reform in the former Soviet Republics of Central Asia.

Health services in the former Soviet Republics of Central Asia face many challenges, not least a rising burden of disease and severe economic constraints. Each government has developed proposals for reform. This paper describes the key elements of the proposals developed in each country. They have many features in common, such as financing based on social insurance, although they also have many differences, reflecting national political, economic and historical circumstances. While most attention so far has concentrated on the design of the proposed systems, it is argued here that there has been inadequate attention to the obstacles to implementation. These stem from the many adverse factors in the context within which reforms are taking place, weaknesses in the process of reform, and failure to involve the groups whose actions will be necessary for success. It is argued that governments and those advising them must place greater emphasis on the challenges of implementation, including the development of a much better understanding of the context within which change must take place.