Disparities in length of life across developed countries: measuring and decomposing changes over time within and between country groups.

BACKGROUND: Over the past half century the global tendency for improvements in longevity has been uneven across countries. This has resulted in widening of inter-country disparities in life expectancy. Moreover, the pattern of divergence appears to be driven in part by processes at the level of country groupings defined in geopolitical terms. A systematic quantitative analysis of this phenomenon has not been possible using demographic decomposition approaches as these have not been suitably adapted for this purpose. In this paper we present an elaboration of conventional decomposition techniques to provide a toolkit for analysis of the inter-country variance, and illustrate its use by analyzing trends in life expectancy in developed countries over a 40-year period. METHODS: We analyze trends in the population-weighted variance of life expectancy at birth across 36 developed countries and three country groups over the period 1970-2010. We have modified existing decomposition approaches using the stepwise replacement algorithm to compute age components of changes in the total variance as well as variance between and within groups of Established Market Economies (EME), Central and Eastern Europe (CEE), and the Former Soviet Union (FSU). The method is generally applicable to the decomposition of temporal changes in any aggregate index based on a set of populations. RESULTS: The divergence in life expectancy between developed countries has generally increased over the study period. This tendency dominated from the beginning of 1970s to the early 2000s, and reversed only after 2005. From 1970 to 2010, the total standard deviation of life expectancy increased from 2.0 to 5.6 years among men and from 1.0 to 3.6 years among women. This was determined by the between-group effects due to polarization between the EME and the FSU. The latter contrast was largely fueled by the long-term health crisis in Russia. With respect to age, the increase in the overall divergence was attributable to between-country differences in mortality changes at ages 15-64 years compared to those aged 65 and older. The within-group variance increased, especially among women. This change was mostly produced by growing mortality differences at ages 65 and older. CONCLUSIONS: From the early 1970s to the mid-2000s, the strong divergence in life expectancy across developed countries was largely determined by the between-group variance and mortality polarization linked to the East-West geopolitical division.

Evidence of large systematic differences between countries in assigning ischaemic heart disease deaths to myocardial infarction: the contrasting examples of Russia and Norway.

BACKGROUND: There is considerable variation in mortality rates from myocardial infarction (MI) across high-income countries, some of which may be artefactual. METHODS: Time trends in mortality rates from ischaemic heart disease (IHD) and MI were analysed for a set of high-income countries from the end of the 1970s. Using individual-level mortality data from Russia (2005-2017) and Norway (2005-2016), we investigated factors associated with the proportion of total IHD deaths certified as due to MI. RESULTS: In most countries, MI mortality rates have dramatically declined from the 1970s. However, the share of MI in total IHD deaths varies substantially across countries. In Russia, only 12% of IHD deaths had MI assigned as the underlying cause vs 63% in Norway. IHD deaths occurring outside of hospital without autopsy were far less likely to be assigned as MI in Russia (2%) than in Norway (59%). CONCLUSIONS: Although established international criteria for MI require specific clinical or post-mortem evidence, it appears that certifying specialists in different countries may interpret these criteria differently. At one extreme, Russian doctors may only assign MI as a cause of death when there is specific pathophysiological evidence. At the other extreme, their counterparts in Norway may be willing to specify MI as the cause even when this evidence is not available. Internationally established criteria for MI diagnosis are challenging to apply for out-of-hospital deaths. Differences between countries in how certifiers interpret these criteria may account for at least some of the international variation in MI mortality rates.

Excess mortality in Russia and its regions compared to high income countries: An analysis of monthly series of 2020.

BACKGROUND: Russia has been portrayed in media as having one of the highest death tolls due to the COVID-19 pandemic in the world. However, the precise scale of excess mortality is still unclear. We provide the first estimates of excess mortality in Russia as a whole and its regions in 2020, placing this in an international context. METHODS: We used monthly death rates for Russia and 83 regions plus the equivalent for 36 comparator countries. Expected mortality was derived in two ways using averages in the same months in preceding years and the same averages adjusted for secular trends. Excess death rates were estimated for the whole year and the last 3 quarters. We also estimated the relationships between excess mortality and reported COVID-19 cases and deaths across countries and Russian regions. RESULTS: Estimating excess deaths rates based on the trend-adjusted average, Russia had the highest excess mortality of any of the 37 countries considered. Using the simple average, Russia had the third highest. Most of the excess deaths were recorded in the 4th quarter of 2020 and the level and trajectory of excess mortality in Russia and most of Eastern European countries differed from that in Western countries. While both the cumulative number of COVID-19 cases and deaths showed positive correlations with excess mortality across countries (r=0.65 and r=0.75, p<0.001), the association across the Russian regions was, surprisingly, negative for cases (r=-0.34, p<0.01) and deaths (r=-0.09, p=0.42). When we replaced reported deaths with final data from death certificates the correlation was positive (r=0.38, p<0.001). CONCLUSION: Russia has one of the largest absolute burden of excess mortality in 2020 but there is a counter-intuitive negative association between excess mortality and cumulative incidence at the regional level. Under-recording of COVID-19 cases seems to be a problem in some regions.

What should be the baseline when calculating excess mortality? New approaches suggest that we have underestimated the impact of the COVID-19 pandemic and previous winter peaks.

Excess mortality has been used to measure the impact of COVID-19 over time and across countries. But what baseline should be chosen? We propose two novel approaches: an alternative retrospective baseline derived from the lowest weekly death rates achieved in previous years and a within-year baseline based on the average of the 13 lowest weekly death rates within the same year. These baselines express normative levels of the lowest feasible target death rates. The excess death rates calculated from these baselines are not distorted by past mortality peaks and do not treat non-pandemic winter mortality excesses as inevitable. We obtained weekly series for 35 industrialized countries from the Human Mortality Database for 2000-2020. Observed, baseline and excess mortalities were measured by age-standardized death rates. We assessed weekly and annual excess death rates driven by the COVID-19 pandemic in 2020 and those related to seasonal respiratory infections in earlier years. There was a distinct geographic pattern with high excess death rates in Eastern Europe followed by parts of the UK, and countries of Southern and Western Europe. Some Asia-Pacific and Scandinavian countries experienced lower excess mortality. In 2020 and earlier years, the alternative retrospective and the within-year excess mortality figures were higher than estimates based on conventional metrics. While the latter were typically negative or close to zero in years without extraordinary epidemics, the alternative estimates were substantial. Cumulation of this "usual" excess over 2-3 years results in human losses comparable to those caused by COVID-19. Challenging the view that non-pandemic seasonal winter mortality is inevitable would focus attention on reducing premature mortality in many countries. As SARS-CoV-2 is unlikely to be the last respiratory pathogen with the potential to cause a pandemic, such measures would also strengthen global resilience in the face of similar threats in the future.

New perspective on geographical mortality divide in Russia: a district-level cross-sectional analysis, 2008-2012.

BACKGROUND: Prior studies on spatial inequalities in mortality in Russia were restricted to the highest level of administrative division, ignoring variations within the regions. Using mortality data for 2239 districts, this study is the first analysis to capture the scale of the mortality divide at a more detailed level. METHODS: Age-standardised death rates are calculated using aggregated deaths for 2008-2012 and population exposures from the 2010 census. Inequality indices and decomposition are applied to quantify both the total mortality disparities across the districts and the contributions of the variations between and within regions. RESULTS: Regional variations in mortality mask one-third (males) and one-half (females) of the inequalities observed at the district level. A comparison of the 5% of individuals residing in the districts with the highest and the lowest mortality shows a gap of 15.5 years for males and 10.3 years for females. The lowest life expectancy levels are in the shrinking areas of the Far East and Northwest of Russia. The highest life expectancy clusters are in the intercity districts of Moscow and Saint Petersburg, and in several science cities. Life expectancy in these best-practice districts is close to the national averages of Poland and Estonia, but is still substantially below the averages in Western countries. CONCLUSION: The large between-regional and within-regional disparities suggest that national-level mortality could be lowered if these disparities are reduced by improving health in the laggard areas. This can be achieved by introducing policies that promote health convergence both within and between the Russian regions.

Spatial patterns of male alcohol-related mortality in Belarus, Lithuania, Poland and Russia.

INTRODUCTION AND AIMS: Eastern Europe is known to suffer from a large burden of alcohol-related mortality. However, persisting unfavourable conditions at the national level mask variation at the sub-national level. We aim to explore spatial patterns of cause-specific mortality across four post-communist countries: Belarus, Lithuania, Poland and Russia (European part). DESIGN AND METHODS: We use official mortality data routinely collected over 1179 districts and cities. The analysis refers to males aged 20-64 years and covers the period 2006-2014. Mortality variation is mainly assessed by means of the standardised mortality ratio. Getis-Ord Gi* statistic is employed to detect hot and cold spots of alcohol-related mortality. RESULTS: Alcohol-related mortality exhibits a gradient from very high levels in northwestern Russia to low levels in southern Poland. Spatial transitions from higher to lower mortality are not explicitly demarcated by national boundaries. Within these countries, hot spots of alcohol-related mortality dominate the territories of northwestern and western Russia, eastern and northwestern Belarus, southeastern Lithuania, and eastern and central Poland. DISCUSSION AND CONCLUSIONS: The observed mortality gradient is likely associated with the spread of alcohol epidemics from the European part of Russia to the other countries, which appears to have started more than a century ago. Contemporary socioeconomic and demographic factors should be taken into account when developing anti-alcohol policies. The same is true for the peculiarities of culture, norms, traditions and behavioural patterns observed in specific geographical areas of the four countries. Reducing alcohol-related harm in the areas identified as hot spots should be prioritised.

Intraurban social risk and mortality patterns during extreme heat events: A case study of Moscow, 2010-2017.

There is currently an increase in the number of heat waves occurring worldwide. Moscow experienced the effects of an extreme heat wave in 2010, which resulted in more than 10,000 extra deaths and significant economic damage. This study conducted a comprehensive assessment of the social risks existing during the occurrence of heat waves and allowed us to identify the spatial heterogeneity of the city in terms of thermal risk and the consequences for public health. Using a detailed simulation of the meteorological regime based on the COSMO-CLM regional climate model and the physiologically equivalent temperature (PET), a spatial assessment of thermal stress in the summer of 2010 was carried out. Based on statistical data, the components of social risk (vulnerabilities and adaptive capacity of the population) were calculated and mapped. We also performed an analysis of their changes in 2010-2017. A significant differentiation of the territory of Moscow has been revealed in terms of the thermal stress and vulnerability of the population to heat waves. The spatial pattern of thermal stress agrees quite well with the excess deaths observed during the period from July to August 2010. The identified negative trend of increasing vulnerability of the population has grown in most districts of Moscow. The adaptive capacity has been reduced in most of Moscow. The growth of adaptive capacity mainly affects the most prosperous areas of the city.

Reducing geographic inequalities in access times for acute treatment of myocardial infarction in a large country: the example of Russia.

Background: Russia has the largest area of any country in the world and has one of the highest cardiovascular mortality rates. Over the past decade, the number of facilities able to perform percutaneous coronary interventions (PCIs) has increased substantially. We quantify the extent to which the constraints of geography make equitable access to this effective technology difficult to achieve. Methods: Hospitals performing PCIs in 2010 and 2015 were identified and combined with data on the population of districts throughout the country. A network analysis tool was used to calculate road-travel times to the nearest PCI facility for those aged 40+ years. Results: The number of PCI facilities increased from 144 to 260 between 2010 and 2015. Overall, the median travel time to the closest PCI facility was 48 minutes in 2015, down from 73 minutes in 2010. Two-thirds of the urban population were within 60 minutes' travel time to a PCI facility in 2015, but only one-fifth of the rural population. Creating 67 new PCI facilities in currently underserved urban districts would increase the population share within 60 minutes' travel to 62% of the population, benefiting an additional 5.7 million people currently lacking adequate access. Conclusions: There have been considerable but uneven improvements in timely access to PCI facilities in Russia between 2010 and 2015. Russia has not achieved the level of access seen in other large countries with dispersed populations, such as Australian and Canada. However, creating a relatively small number of further PCI facilities could improve access substantially, thereby reducing inequality.

Recent Mortality Trend Reversal in Russia: Are Regions Following the Same Tempo?

After several decades of negative trends and short-term fluctuations, life expectancy has been increasing in Russia since 2004. Between 2003 and 2014, the length of life rose by 6.6 years among males and by 4.6 years among females. While positive trends in life expectancy are observed in all regions of Russia, these trends are unfolding differently in different regions. First, regions entered the phase of life expectancy growth at different points in time. Second, the age- and cause-specific components of the gains in life expectancy and the number of years added vary noticeably. In this paper, we apply decomposition techniques-specifically, the stepwise replacement algorithm-to examine the age- and cause-specific components of the changes in inter-regional disparities during the current period of health improvement. The absolute inter-regional disparities in length of life, measured by the population-weighted standard deviation, decreased slightly between 2003 and 2014, from 3.3 to 3.2 years for males, and from 2.0 to 1.8 years for females. The decomposition of these small changes by ages and causes of death shows that these shifts were the result of diverse effects of mortality convergence at young and middle ages, and of mortality divergence at older ages. With respect to causes of death, the convergence is mainly attributable to external causes, while the inter-regional divergence of trends is largely determined by cardiovascular diseases. The two major cities, Moscow and Saint Petersburg, are currently pioneering mortality improvements in Russia and are making the largest contributions to the inter-regional divergence.