Global burden, risk factors, and temporal trends of ureteral cancer: a comprehensive analysis of cancer registries.

BACKGROUND: Ureteral cancer is a rare cancer. This study aimed to provide an up-to-date and comprehensive analysis on the global trends of ureteral cancer incidence and its association with lifestyle and metabolic risk factors. METHODS: The incidence of ureteral cancer was estimated from the Cancer Incidence in Five Continents Plus and Global Cancer Observatory databases. We analyzed the (1) global incidence of ureteral cancer by region, country, sex, and age group by age-standardized rates (ASR); (2) associated risk factors on a population level by univariable linear regression with logarithm transformation; and (3) incidence trend of ureteral cancer by sex and age group in different countries by Average Annual Percentage Change (AAPC). RESULTS: The global age-standardized rate of ureteral cancer incidence in 2022 was 22.3 per 10,000,000 people. Regions with higher human development index (HDI), such as Europe, Northern America, and East Asia, were found to have a higher incidence of ureteral cancer. Higher HDI and gross domestic product (GDP) and a higher prevalence of smoking, alcohol drinking, physical inactivity, unhealthy dietary, obesity, hypertension, diabetes, and lipid disorder were associated with higher incidence of ureteral cancer. An overall increasing trend of ureteral cancer incidence was observed for the past decade, especially among the female population. CONCLUSIONS: Although ureteral cancer was relatively rare, the number of cases reported was rising over the world. The rising trends among females were more evident compared with the other subgroups, especially in European countries. Further studies could be conducted to examine the reasons behind these epidemiological changes and confirm the relationship with the risk factors identified.

Burden of liver cancer attributable to high fasting plasma glucose: a global analysis based on the global burden of disease study 2019.

OBJECTIVE: Liver cancer is the world's sixth most prevalent cancer and the third most frequent cause of cancer-related mortality. Glucose metabolic disorders, indicated by a high fasting plasma glucose (HFPG) concentration, is a contributor to the etiology of liver cancer. With the rising prevalence of glucose metabolic disorders, an assessment of the global burden of liver cancer attributable to HFPG is warranted to inform global liver cancer prevention and control strategies. METHODS AND ANALYSIS: We evaluated the global death and disability-adjusted life years (DALYs) of liver cancer and its subtypes attributable to HFPG at global, regional, and country level. The temporal trend and disparity across geographic regions, social development level, age groups and sex were assessed. RESULTS: In 2019, HFPG-attributable liver cancer was estimated to have caused 4,729.49 deaths and to be responsible for 99,302.25 DALYs. The age-standardized mortality and DALY rate were 0.06 and 1.20 per 100,000 population, and displayed a significantly increasing temporal trend from 1990 to 2019. The age-standardized mortality rate of patients with liver cancer that was attributable to HFPG was higher in men than women. Sex-based disparity narrowed after the women reached menopause, but increased between 1990 and 2019. CONCLUSION: The burden of liver cancer that are attributable to HFPG has been influenced by longitudinal changes in lifestyle, the etiology of liver disease, age demographics, and hormonal status in women. These findings suggest that comprehensive strategies could be implemented, especially for patients with NASH and hyperglycemia, to prevent liver cancer.

Health policy competencies in regional organizations: a retrospective analysis for 76 regional organizations from 1945 to 2015.

BACKGROUND: Health policy competencies of regional organizations include mandates to create regional health laws and policies, as well as authorities that allow member states to undertake collective actions in the health field. The examination of the health policy competencies of regional organizations is essential, as it constitutes an important prerequisite for regional organizations to govern regional health. This study aims to map the development trajectory of health policy competencies in regional organizations worldwide and investigate their potential correlates. This will contribute to the enhanced promotion of both existing and new regional health cooperation. METHODS: This retrospective analysis utilized the health policy competencies of the 76 regional organizations worldwide from 1945 to 2015, as investigated in the Regional Organizations Competencies Database. By aggregating member state data from various sources such as the IHME Global Burden of Disease 2019, the World Bank, and the World Trade Organization, we extracted the mean values and coefficients of variation for the covariates in regional organization characteristics, socioeconomic and demographic factors, health status and health-system capacity. The correlation between changes in the health policy scope of regional organizations and independent variables was analyzed using Poisson pseudo-likelihood regression with multiple levels of fixed effects. RESULTS: From 1945 to 2015, the number of regional organizations with health policy competencies experienced a slow growth stage before 1991 and an explosive growth stage post-1991. By 2015, 48 out of the 71 existing regional organizations had developed their health policy competencies, yet 26 (54.2%) of these organizations possessed only 1-2 health policy competencies. An enhancement in the health policy scope of a regional organization correlated with its founding year, a greater number of policy fields, higher under-five mortality, and larger disparities in trade and healthcare access and quality indexes among member states. In contrast, larger disparities in population, under-five mortality and health worker density among member states, along with more hospital beds per capita, were negatively correlated with the expansion of a regional organization's health policy scope. CONCLUSION: Since 1991, there has been a surge of interest in health among regional organizations, although health remains a secondary priority for them. The health policy competencies of regional organizations are pivotal for promoting social equity within regional communities. Its establishment is also closely linked to the level and disparities among member states in aspects such as trade, population, child mortality rates, and health system capacity.

Disease burden, risk factors, and temporal trends of eye cancer: A global analysis of cancer registries.

BACKGROUND: This study aims to investigate the global disease burden, risk factors, and temporal trends of eye cancer by sex and age group. METHODS: Databases including Cancer Incidence in Five Continents volumes I-XI, the Nordic Cancer Registries, the Surveillance, Epidemiology, and End Results Program and the WHO IARC mortality database were accessed to extract incidence and mortality data. Joinpoint regression analyses were conducted to evaluate the Average Annual Percentage Change of the incidence and mortality. RESULTS: The age-standardised rates of eye cancer incidence and mortality were 0.49 and 0.08 globally in 2020. Higher incidence rates were observed in Sub-Saharan Africa (ASR = 4.06), Western Europe (ASR = 0.89), and Northern Europe (ASR = 0.84), but higher mortality was observed only in Sub-Saharan Africa (ASR = 1.59). Lower HDI, higher prevalence of UV exposure and lower prevalence of several lifestyle habits and metabolic syndromes were associated with higher incidence and mortality. There was an overall stable incidence trend and a decreasing mortality trend. Notably, all countries reporting decreasing trend in mortality were in the Asian or European region. CONCLUSIONS: Although higher incidence was observed in both African and European regions, only the Sub-Saharan Africa region reported high mortality, indicating inequity in the access of healthcare and treatment resource. Higher prevalence of UV exposure was associated with both higher incidence and mortality. Education should be provided to increase the awareness of eye protection. An overall declining mortality trend was found, but it was limited to only Asian and European countries.

The association of cervical cancer screening and quality of care: A systematic analysis of the Global Burden of Disease Study 2019.

Background: Improving the quality of care is vital to enhance outcomes for cervical cancer patients. However, the inequality of cervical cancer care was seldomly assessed. Methods: We collected the data of cervical cancer burden from the Global Burden of Disease 2019 database, and constructed the Quality of Care Index (QCI) using principle component analysis. Then the disparity of QCI across regions and populations were evaluated. The association between cervical cancer screening coverage and QCI weas also explored. Results: Quality of cervical cancer care was of disparity across regions with different development levels, with a widening gap between low-income regions and others. Cervical cancer QCI dropped rapidly after the age of 35. Cervical cancer screening coverage was positively associated with QCI, and this association was stronger in countries with low- and middle-development levels. Conclusions: Regions with a low development level and the middle-aged women were vulnerable in QCI improvement. Higher screening coverage was associated with better cervical cancer QCI, implying that expanding cervical cancer screening coverage may be an effective strategy to improve the quality of cervical cancer care.

Inequity of maternal-child health services in ASEAN member states from 1993 to 2021.

INTRODUCTION: Inequity in maternal-child health services is a challenge to global health as it hinders the achievement of Sustainable Development Goals (SDGs) and Universal Health Coverage. Though the Association of Southeast Asian Nations (ASEAN) has made remarkable achievements in maternal-child health, there remain gaps in reaching global goals. This study aimed to compare and investigate the inequity in maternal-child health (MCH) services in ASEAN member states to help guide policy decisions to improve equitable health services in the SDG era and beyond. METHODS: Using the WHO Health Inequality Monitor, we identified inequity summary measures for five MCH services in ASEAN member states from 1993 to 2021: antenatal care, births attended by skilled health personnel, diphtheria, tetanus and pertussis (DTP3) immunization, measles immunization, and polio immunization. We divided the analysis dimension of inequity into urban-rural inequity, economic status inequity, and sub-regional inequity. Trends of absolute and relative inequity in every dimension of MCH services in ASEAN member states were examined with the principal component analysis (PCA). RESULTS: The mean coverages of MCH services are 98.80% (Thailand), 86.72% (Cambodia), 84.54% (Viet Nam), 78.52 (Indonesia), 76.94% (Timor-Leste), 72.40% (Lao PDR), 68.10% (Philippines) and 48.52% (Myanmar) in 2021. Thailand have the lowest MCH services absolute inequity indexes of -1.945, followed by Vietnam (-1.449). Lao PDR and Myanmar have relatively higher MCH services absolute inequity indexes of 0.852 and 0.054 respectively. The service in Cambodia, Indonesia, and the Philippines is pro-specific regions (with subnational region absolute inequity indexes of -0.02, 0.01, and 1.01 respectively). The service in Myanmar is pro-rich (with economic status absolute inequity index of 0.43). The service in Lao PDR and Timor-Leste is pro-urban areas, pro-rich, and pro-specific regions. CONCLUSION: The inequity of MCH services in ASEAN persists but is in a declining trend. Thailand and Vietnam have performed well in ensuring MCH services equity, while Laos and Myanmar are still facing serious inequity dilemmas. The progress of MCH service equity in Myanmar, Cambodia, the Philippines, and Indonesia is uneven. It is acceptable to learn from the successful experiences of Thailand and Vietnam to improve the equities in other ASEAN countries. Policies should be developed according to the specific types of MCH inequity in member states to improve equity levels.

Disease burden, risk factors, and trends of lip, oral cavity, pharyngeal cancers: A global analysis.

BACKGROUND: Lip, oral and pharyngeal cancers make up a small percentage of total cancer cases worldwide and have reported lower rates of cancer-related deaths globally in 2020, but their 5-year survival rate in either early or advanced stages is different. The study evaluated the global incidence, mortality, risk factors, and temporal trends by age, gender, and geographical locations of lip, oral cavity, and pharyngeal cancer. METHODS: Incidence and mortality rates were extracted from Cancer Incidence in Five Continents (CI5) volumes I-XI, the Nordic Cancer Registries (NORDCAN), the Surveillance, Epidemiology, and End Results (SEER) Program, and the WHO IARC mortality database. Joinpoint regression was used to calculate the Average Annual Percentage Change to examine trends. RESULTS: The highest incidence rates were found in Melanesia and South-Central Asia and mortality rates were 8.2 and 7.5. Risk factors associated with incidence and mortality included HDI, tobacco use, alcohol consumption, poor diet, and chronic health conditions such as hypertension. Increasing trends of incidence and mortality were observed in females from Malta; males aged 50 and above from the United Kingdom, and females aged 50 and above from Slovakia reporting the largest increase. CONCLUSIONS: Although global incidence and mortality trends reported an overall decrease, significant increases were found for older age groups and female subjects. Incidence increase may be due to the growing prevalence of lifestyle, metabolic risk factors, and HPV infections, especially in developed countries.

Global incidence and mortality trends of corpus uteri cancer and associations with gross domestic product, human development index, lifestyle, and metabolic risk factors.

OBJECTIVE: To evaluate the worldwide distribution, risk factors, and temporal trends of corpus uteri cancer for different countries and age groups. METHOD: Data relating to corpus uteri cancer in 2020 were retrieved from the Global Cancer Observatory database. Data from Cancer Incidence in Five Continents and the WHO mortality database were used for trend analysis. Age-standardized rates (ASR, per 100 000 persons) were calculated for incidence and mortality. Joinpoint regression analysis was used to estimate the 10-year annual average percent change (AAPC). RESULTS: A total of 417 367 new cases and 97 370 new deaths of corpus uteri cancer were reported globally in 2020. The highest incidence was observed in high-income countries. Higher ASR of mortality of corpus uteri cancer was associated with a higher gross domestic product per capita, higher Human Development Index, and higher prevalence of smoking, alcohol drinking, physical inactivity, obesity, hypertension, diabetes, and lipid disorders. There was a substantial increasing trend of corpus uteri cancer, with the largest AAPC in incidence found in Japan, followed by India, Chile, Korea, and Thailand. CONCLUSION: The incidence and mortality of corpus uteri cancer have been increasing substantially for the past 10 years. Intensive lifestyle modifications are needed, especially among younger women.

Global burden of hepatitis B attributable to modifiable risk factors from 1990 to 2019: a growing contribution and its association with socioeconomic status.

BACKGROUND: Hepatitis B is a global public health concern, and modifiable risk factors can accelerate progression of this disease. The burden of hepatitis B attributable to modifiable risk factors has not been well evaluated. We aimed to estimate the disease burden of hepatitis B attributable to tobacco, alcohol use, and a high body mass index (BMI) to guide lifestyle interventions in the management of patients with hepatitis B virus (HBV) infection. RESULTS: In 2019, 33.73% of hepatitis B age-standardized deaths and 34.52% of disability-adjusted life-years (DALYs) were attributable to tobacco, alcohol use, and a high BMI. The proportion showed an increasing trend that 28.23% of deaths and 27.56% of DALYs were attributable to the three modifiable risk factors in 1990. The hepatitis B burden attributable to modifiable risk factors was disparate across regions and countries. Countries with a low socioeconomic status have a high burden of hepatitis B owing to modifiable risk factors. Countries with a high-level sociodemographic index also had an increasing burden of hepatitis B attributable to a high BMI. CONCLUSIONS: Lifestyle interventions are warranted in hepatitis prevention strategies and plans of action. Countries with low and middle socioeconomic development should be prioritized, and countries with high socioeconomic development should be aware of the novel challenge of a high BMI-related disease burden.

Global Trends of Prostate Cancer by Age, and Their Associations With Gross Domestic Product (GDP), Human Development Index (HDI), Smoking, and Alcohol Drinking.

BACKGROUND: We aimed to examine the global disease burden and trends of prostate cancer incidence and mortality by age, and their associations with gross domestic product (GDP), human development index (HDI), smoking, and alcohol drinking. MATERIALS AND METHODS: We retrieved the Global Cancer Observatory (GLOBOCAN) database for the incidence and mortality of prostate cancer in 2020; the World Bank for GDP per capita; the United Nations for HDI; the WHO Global Health Observatory for prevalence of smoking and alcohol drinking; the Cancer Incidence in 5 Continents (CI5), WHO mortality database, for trend analysis. We presented the prostate cancer incidence and mortality using age-standardized rates. We examined their associations with GDP, HDI, smoking, and alcohol drinking by Spearman's correlations and multivariable regression. We estimated the 10-year trend of incidence and mortality by joinpoint regression analysis with average annual percent change with 95% confidence intervals in different age groups. RESULTS: A wide variation in the burden of prostate cancer with the highest mortality found in low-income countries while the highest incidence was observed in high-income countries. We found moderate to high positive correlations for GDP, HDI, and alcohol drinking with prostate cancer incidence, whilst a low negative correlation was observed for smoking. Globally, there was an increasing incidence but decreasing mortality of prostate cancer, and such trends were particularly prominent in Europe. Notably, the incidence increase was also found in the younger population aged <50 years. CONCLUSIONS: There was a global variation in the burden of prostate cancer associated with GDP, HDI, smoking, and alcohol drinking.

Disease burden, risk factors, and trends of primary central nervous system (CNS) cancer: A global study of registries data.

BACKGROUND: This study aimed to evaluate the global incidence, mortality, associated risk factors, and temporal trends of central nervous system (CNS) cancer by sex, age, and country. METHODS: We extracted incidence and mortality of CNS cancer from the GLOBOCAN (2020), Cancer Incidence in Five Continents series I-X, WHO mortality database, the Nordic Cancer Registries, and the Surveillance, Epidemiology, and End Results Program. We searched the Global Health data exchanges for the prevalence of its associated risk factors. We tested the trends by Average Annual Percentage Change (AAPC) from Joinpoint regression analysis with 95% confidence intervals in different age groups. RESULTS: The age-standardized rates (ASRs) of CNS cancer incidence and mortality were 3.5 and 2.8 per 100,000 globally. Southern Europe (ASR = 6.0) and Western Asia (ASR = 4.2) had the highest incidence and mortality, respectively. The incidence was associated with Human Development Index, Gross Domestics Products per capita, prevalence of traumatic brain injuries, occupational carcinogens exposure, and mobile phone use at the country level. There was an overall stable and mixed trend in the CNS cancer burden. However, increasing incidence was observed in younger male population from five countries, with Slovakia (AAPC = 5.40; 95% CI 1.88, 9.04; P = .007) reporting the largest increase. CONCLUSIONS: While the overall global trends of cancer have been largely stable, significant increasing trends were found in the younger male population. The presence of some higher-HDI countries with increasing mortality suggested an ample scope for further research and exploration of the reasons behind these epidemiological trends.

Factors Associated with Vaccination Intention against the COVID-19 Pandemic: A Global Population-Based Study.

Several vaccines have been developed for COVID-19 since the pandemic began. This study aimed to evaluate the factors associated with COVID-19 vaccination intention. A global survey was conducted across 26 countries from October, 2020 to December, 2021 using an online self-administered questionnaire. Demographic information, socio-economic status, and clinical information were collected. A logistic regression examined the associations between vaccine intention and factors such as perceptions and the presence of chronic physical and mental conditions. The sample included 2459 participants, with 384 participants (15.7%) expressing lower COVID-19 vaccination intent. Individuals who identified as female; belonged to an older age group; had a higher level of education; were students; had full health insurance coverage; or had a previous history of influenza vaccination were more willing to receive vaccination. Conversely, those who were working part-time, were self-employed, or were receiving social welfare were less likely to report an intention to get vaccinated. Participants with mental or physical health conditions were more unwilling to receive vaccination, especially those with sickle cell disease, cancer history within the past five years, or mental illness. Stronger vaccination intent was associated with recommendations from the government or family doctors. The presence of chronic conditions was associated with lower vaccine intention. Individuals with health conditions are especially vulnerable to health complications and may experience an increased severity of COVID-19 symptoms. Future research should evaluate the effectiveness of interventions targeting the vaccine perceptions and behaviours of at-risk groups. As such, public awareness campaigns conducted by the government and proactive endorsement from health physicians may help improve COVID-19 vaccination intention.

The epidemiological landscape of multiple myeloma: a global cancer registry estimate of disease burden, risk factors, and temporal trends.

BACKGROUND: Multiple myeloma accounted for 176 404 (14%) of 1 278 362 the incidence cases leukaemia, lymphoma, and multiple myeloma in 2020. Identifying its geographical distribution, risk factors, and epidemiological trends could help identify high-risk population groups. We aimed to examine the worldwide incidence, mortality, associated risk factors, and temporal trends of multiple myeloma by sex, age, and geographical region. METHODS: The incidence and mortality of multiple myeloma were extracted from Global Cancer Observatory (2020), Cancer Incidence in Five Continents, WHO mortality database, Nordic Cancer Registries, and Surveillance, Epidemiology, and End Results Program (1980-2019). The WHO Global Health Observatory data repository was searched for the age-standardised prevalence of lifestyle and metabolic risk factors (2010). Associations with risk factors were examined by multivariable regression. The temporal trends were evaluated by average annual percentage change (AAPC) using joinpoint regression. FINDINGS: The age-standardised rate (ASR) of multiple myeloma incidence was 1·78 (95% UI 1·69-1·87) per 100 000 people globally and mortality was 1·14 (95% UI 1·07-1·21) per 100 000 people globally in 2020. Increased incidence and mortality were associated with higher human development index, gross domestics product, prevalence of physical inactivity, overweight, obesity, and diabetes. Australia and New Zealand (ASR 4·86 [4·66-5·07]), northern America (4·74 [4·69-4·79]), and northern Europe (3·82 [3·71-3·93]) reported the highest incidence. The lowest incidences were observed in western Africa (0·81 [0·39-1·66]), Melanesia (0·87 [0·55-1·37]), and southeastern Asia (0·96 [0·73-1·27]). Overall, more countries had an increase in incidence, especially in men aged 50 years or older. The countries with the highest incidence increase in men older than 50 years were Germany (AAPC 6·71 [95% CI 0·75-13·02] p=0·027), Denmark (3·93 [2·44-5·45] p=0·00027), and South Korea (3·25 [0·69-5·88] p=0·019). For women aged 50 years or older, Faroe Islands (21·01 [2·15-43·34] p=0·032), Denmark (4·70 [1·68-7·82], p=0·0068), and Israel (2·57 [0·74-4·43] p=0·012) reported the greatest increases. Overall, there was a decreasing trend for multiple myeloma mortality. The highest mortality was observed in Polynesia (ASR 2·69 [0·74-9·81]), followed by Australia and New Zealand (1·84 [1·73-1·96]) and northern Europe (1·80 [1·73-1·88]). The lowest mortalities were reported in southeastern Asia (ASR 0·82 [0·62-1·09]), eastern Asia (0·76 [0·71-0·81]), and Melanesia (0·73 [0·61-0·87]). Men (1·41 [1·29-1·53]) were found to have mortality higher than women (0·93 [0·85-1·02]). INTERPRETATION: There was an increasing trend of multiple myeloma incidence globally, particularly in men, people aged 50 years or older, and those from high-income countries. The overall decreasing global trend of multiple myeloma mortality was more evident in women. Lifestyle habits, diagnosis capacity, and treatment availability should be improved to control the increasing trends of multiple myeloma in high-risk populations. Future studies should explore the reasons behind these epidemiological transitions. FUNDING: None.

Socioeconomic status and depressive symptoms in older people with the mediation role of social support: A population-based longitudinal study.

BACKGROUND: Depressive symptoms has become an increasingly important public health issue, contributing to disability and disease burden around the world. Higher socioeconomic status (SES) has been found to be associated with lower prevalence of depression, but there are few studies about the older Chinese adults with long-term follow up and rigorous prospective design. Meanwhile, there is little conclusive evidence about the mechanisms through which SES influences the onset of depressive symptoms. OBJECTIVE: To prospectively examine the association of baseline socioeconomic factors with the risks of developing depressive symptoms during 7-year follow up in older Chinese population, and to study the mechanism by which SES impacts the prevalence of depressive symptoms. METHODS: A total of 5677 individuals over 45 years who participated in an ongoing nationally representative prospective cohort study, China Health and Retirement Longitudinal Study, were free from depressive symptoms at baseline, and completed 7-year follow-up were included. Depressive symptoms were assessed using the 10-item Center for Epidemiological Studies Depression Scale score. Cox proportional hazards regression models were used to examine the association of SES and the incidence of depressive symptoms in 2011 to 2018. Generalized structural equation model was used to analyze the mediation effects of social support on the relation between SES and depressive symptoms. RESULTS: During the 7-year follow-up, 2398 (42.2%) cases were identified as depressive symptoms. Compared with the lowest level of household income, participants with the highest level of household income had a 20% reduction in risk (95% CI, 0.70-0.92, P < 0.001). Participants who had junior high school or above education had a 41% lower risk of depressive disorders compared with illiterate participants (95% CI, 0.52-0.69, P < 0.001). The relationship between SES and depressive symptoms was partially mediated by the social support, where higher social support was negatively associated with depressive symptoms. The proportion of mediation effect was even larger for women compared with men. CONCLUSION: Socioeconomic factors were independently associated with the development of depressive symptoms, and the relationship was partially mediated by social support. Social support could be an effective intervention to alleviate the negative effects of lower SES on mental health. Multiple-level policies should precisely target low-SES groups, and timely intervention to promote social support for this group should be used to reduce the influence of depression on individuals, family as well as the whole society.

Economic burden of comorbid chronic conditions among survivors of stroke in China: 10-year longitudinal study.

BACKGROUND: The coexistence of chronic diseases among people with stroke is common. However, little is known about the extent of incremental healthcare expenditures associated with having physically and psychologically chronic conditions among stroke survivors. METHODS: We used the nationally representative data from the China Health and Nutrition Survey, including 36,076 participants enrolled as our analytic cohort of ten years of follow-up visits (2006, 2009, 2011, 2015). Chronic conditions include hypertension, diabetes, obesity, and impaired cognitive function. Two-part models were used to estimate the effect of comorbid chronic conditions on total annual healthcare expenditure, out-of-pocket (OOP) healthcare expenditure, and incidence of catastrophic healthcare expenditure (CHE). RESULTS: Among survivors of stroke during 2006 to 2015, the prevalence rates of hypertension, diabetes, obesity and impaired cognitive function were 75.5, 9.8, 12.7 and 65.1%, significantly higher than those among adults without stroke history (27.9, 2.7, 10.0 and 41.2%). Having hypertension ($794.5, p = 0.004), diabetes ($3978.5, p < 0.001) were associated with the largest incremental total healthcare expenditures. Stroke survivors with diagnosed hypertension and diabetes had additional 5.7 (p < 0.001) and 10.4 (p < 0.001) percentage point of CHE rate, respectively. Total healthcare expenditures were $2413.0 (P < 0.001) and $5151.7 (P < 0.001) higher among patients with 2, and ≥ 3 chronic conditions, respectively, than those individuals with no chronic conditions. CONCLUSIONS: Excess expenditures associated with chronic diseases were substantial among stroke survivors. These results highlight the needs for both prevention and better management of multimorbidity among stroke survivors, which in turn may lower the financial burden of treating these concurrent comorbidities.

Disparities in COVID-19 Vaccination among Low-, Middle-, and High-Income Countries: The Mediating Role of Vaccination Policy.

Inequity in the access to and deployment of the coronavirus disease 2019 (COVID-19) vaccines has brought about great challenges in terms of resolving the pandemic. Aiming to analyze the association between country income level and COVID-19 vaccination coverage and explore the mediating role of vaccination policy, we conducted a cross-sectional ecological study. The dependent variable was COVID-19 vaccination coverage in 138 countries as of May 31, 2021. A single-mediator model based on structural equation modeling was developed to analyze mediation effects in different country income groups. Compared with high-income countries, upper-middle- (ß = -1.44, 95% CI: -1.86--1.02, p < 0.001), lower-middle- (ß = -2.24, 95% CI: -2.67--1.82, p < 0.001), and low- (ß = -4.05, 95% CI: -4.59--3.51, p < 0.001) income countries had lower vaccination coverage. Vaccination policies mediated 14.6% and 15.6% of the effect in upper-middle- (ß = -0.21, 95% CI: -0.39--0.03, p = 0.020) and lower-middle- (ß = -0.35, 95% CI: -0.56--0.13, p = 0.002) income countries, respectively, whereas the mediation effect was not significant in low-income countries (ß = -0.21, 95% CI: -0.43-0.01, p = 0.062). The results were similar after adjusting for demographic structure and underlying health conditions. Income disparity remains an important cause of vaccine inequity, and the tendency toward "vaccine nationalism" restricts the functioning of the global vaccine allocation framework. Stronger mechanisms are needed to foster countries' political will to promote vaccine equity.

Evaluation of Between-County Disparities in Premature Mortality Due to Stroke in the US.

Importance: Identifying the factors associated with premature stroke mortality and measuring between-county disparities may provide insight into how to reduce variations and achieve more equitable health outcomes. Objective: To examine the between-county disparities in premature stroke mortality in the US, investigate county-level factors associated with mortality, and describe differences in mortality disparities by place of death and stroke subtype. Design, Setting, and Participants: This retrospective cross-sectional study linked the mortality and demographic data of US counties from the Centers for Disease Control and Prevention WONDER database to county-level characteristics from multiple databases. The outcome measure was county-level age-adjusted stroke mortality among adults aged 25 to 64 years in 2637 US counties from 1999 to 2018. This study was conducted from April 1, 2019, to October 31, 2020. Generalized linear Poisson regressions were fitted to investigate 4 sets of factors associated with county-level mortality: demographic composition, socioeconomic status, health care and environmental features, and population health. The Theil index score was calculated to assess the mortality disparities. Main Outcomes and Measures: Stroke mortality was measured as the number of deaths attributed to stroke in the data set. Out-of-stroke-unit death was defined as any death occurring in outpatient or emergency departments or at the pretransport location. Five stroke subtypes were included in the analysis. Results: Although mortality did not change substantially from 1999 to 2018 (from 12.62 to 11.81 per 100 000 population), the proportion of deaths occurring out of the stroke unit increased from 23.56% (4328 of 18 369) to 34.57% (6978 of 20 188). A large percentage of stroke of an uncertain cause was reported, with most deaths (55.20%) occurring out of the stroke unit. In the county with the highest premature stroke mortality, the incidence was 20.78 times as high as that in the county with the lowest mortality (65.04 vs 3.13 deaths per 100 000 population). The highest between-county disparities were found for stroke of uncertain cause. For out-of-stroke-unit death, county-level mortality was largely associated with demographic composition (31.6%) and health care and environmental features (25.8%). For in-hospital death, 29.8% of county-level mortality was associated with population health and 28.7% was associated with demographic composition. Conclusions and Relevance: These findings suggest that strategies addressing specific factors that underlie the mortality disparities among US counties, especially for out-of-stroke-unit death and stroke of uncertain cause, may be useful when tailored to the county-level context before implementing interventions for the neediest counties.

Socioeconomic Inequalities in Premature Cancer Mortality Among U.S. Counties During 1999 to 2018.

BACKGROUND: This study investigated socioeconomic inequalities in premature cancer mortality by cancer types, and evaluated the associations between socioeconomic status (SES) and premature cancer mortality by cancer types. METHODS: Using multiple databases, cancer mortality was linked to SES and other county characteristics. The outcome measure was cancer mortality among adults ages 25-64 years in 3,028 U.S. counties, from 1999 to 2018. Socioeconomic inequalities in mortality were calculated as a concentration index (CI) by income (annual median household income), educational attainment (% with bachelor's degree or higher), and unemployment rate. A hierarchical linear mixed model and dominance analyses were used to investigate SES associated with county-level mortality. The analyses were also conducted by cancer types. RESULTS: CIs of SES factors varied by cancer types. Low-SES counties showed increasing trends in mortality, while high-SES counties showed decreasing trends. Socioeconomic inequalities in mortality among high-SES counties were larger than those among low-SES counties. SES explained 25.73% of the mortality. County-level cancer mortality was associated with income, educational attainment, and unemployment rate, at -0.24 [95% (CI): -0.36 to -0.12], -0.68 (95% CI: -0.87 to -0.50), and 1.50 (95% CI: 0.92-2.07) deaths per 100,000 population with one-unit SES factors increase, respectively, after controlling for health care environment and population health. CONCLUSIONS: SES acts as a key driver of premature cancer mortality, and socioeconomic inequalities differ by cancer types. IMPACT: Focused efforts that target socioeconomic drivers of mortalities and inequalities are warranted for designing cancer-prevention implementation strategies and control programs and policies for socioeconomically underprivileged groups.

When dispatcher assistance is not saving lives: assessment of process compliance, barriers and outcomes in out-of-hospital cardiac arrest in a metropolitan city in China.

BACKGROUND: Several Chinese cities have implemented dispatcher-assisted cardiopulmonary resuscitation (DA-CPR), although out-of-hospital cardiac arrest (OHCA) survival rates remain low. We aimed to assess the process compliance, barriers and outcomes of OHCA in one of the earliest implemented (DA-CPR) programmes in China. METHODS: We retrospectively reviewed OHCA emergency dispatch records of Suzhou emergency medical service from 2014 to 2015 and included adult OHCA victims (>18 years) with a bystander-witnessed atraumatic OHCA that was subsequently confirmed by on-site emergency physician. The circumstances and DA-CPR process related to the OHCA event were analysed. Dispatch audio records were reviewed to identify potential barriers to implementation during the DA-CPR process. RESULTS: Of the 151 OHCA victims, none survived. The median time from patient collapse to call for emergency services and that from call to provision of cardiopulmonary resuscitation instructions was 30 (IQR 20-60) min and 115 (IQR 90-153) s, respectively. Only 110 (80.3%) bystanders/rescuers followed the dispatcher instructions; of these, 51 (46.3%) undertook persistent chest compressions. Major barriers to following the DA-CPR instructions were present in 104 (68.9%) cases, including caller disconnection of the call, distraught mood or refusal to carry out either compressions or ventilations. CONCLUSIONS: The OHCA survival rate and the DA-CPR process were far from optimal. The zero survival rate is disproportionally low compared with survival statistics in high-income countries. The prolonged delay in calling the emergency services negated and rendered futile any DA-CPR efforts. Thus, efforts targeted at developing public awareness of OHCA, calling for help and competency in DA-CPR should be increased.

Worldwide Burden of, Risk Factors for, and Trends in Pancreatic Cancer.

BACKGROUND & AIMS: We evaluated global and regional burdens of, risk factors for, and epidemiologic trends in pancreatic cancer among groups of different sexes and ages. METHODS: We used data from the GLOBOCAN database to estimate pancreatic cancer incidence and mortality in 184 countries. We examined the association between lifestyle and metabolic risk factors, extracted from the World Health Organization Global Health Observatory database, and pancreatic cancer incidence and mortality by univariable and multivariable linear regression. We retrieved country-specific age-standardized rates (ASRs) of incidence and mortalities from cancer registries from 48 countries through 2017 for trend analysis by joinpoint regression analysis. RESULTS: The highest incidence and mortality of pancreatic cancer were in regions with very high (ASRs, 7.7 and 4.9) and high human development indexes (ASRs, 6.9 and 4.6) in 2018. Countries with higher incidence and mortality were more likely to have higher prevalence of smoking, alcohol drinking, physical inactivity, obesity, hypertension, and high cholesterol. From 2008 to 2017, 2007 to 2016, or 2003 to 2012, depending on the availability of the data, there were increases in incidence among men and women in 14 (average annual percent changes [AAPCs], 8.85 to 0.41) and 17 (AAPCs, 6.04 to 0.87) countries, respectively. For mortality, the increase was observed in 8 (AAPCs, 4.20 to 0.55) countries among men and 14 (AAPCs, 5.83 to 0.78) countries among women. Although the incidence increased in 18 countries (AAPCs, 7.83 to 0.91) among individuals 50 years or older, an increasing trend in pancreatic cancer was also identified among individuals younger than 50 years and 40 years in 8 (AAPCs, 8.75 to 2.82) and 4 (AAPCs, 11.07 to 8.31) countries, respectively. CONCLUSIONS: In an analysis of data from 48 countries, we found increasing incidence and mortality trends in pancreatic cancer, especially among women and populations 50 years or older, but also among younger individuals. More preventive efforts are recommended for these populations.