Suicide After Partner's Death in the Elderly Population: Results From a Nationwide Cohort Study in Italy.

OBJECTIVE: This study aims to investigate the effect of partner loss on suicide mortality for surviving partners in the elderly Italian population and to explore differences according to sex and time elapsed since the loss. DESIGN: This was a historical cohort study. SETTING: All Italian residents registered by the 15th Italian Population Census (9 October 2011) were linked to emigration records and death certificates for 2012-2017 to track migration, vital status, and cause of death. PARTICIPANTS: 5,068,414 individuals living as a couple, as registered in the census, and aged ≥69 years on January 1, 2012. MEASUREMENTS: Mortality rate ratios (MRR) estimated through Poisson regression models were used to compare suicide mortality at age ≥75 years between subjects who experienced partner loss and those who did not. RESULTS: Among people who experienced partner loss, there were 383 suicide deaths in men and 90 in women. Suicide mortality was higher in older men and women who experienced the loss compared to those who did not, and the impact of the spouse loss on mortality was stronger in men (age-adjusted MRR=2.83) than in women (1.41). Among men the excess risk was particularly high during the first year following the loss; in women, no substantial differences in the excess risk were observed over the follow-up period. CONCLUSION: Study findings provide evidence of the sex differences in the impact of spouse loss based on data from a large national cohort and reinforce the need for monitoring suicide risk in recently widowed older people.

Socioeconomic inequalities in avoidable mortality in Italy: results from a nationwide longitudinal cohort.

BACKGROUND: Disparities in avoidable mortality have never been evaluated in Italy at the national level. The present study aimed to assess the association between socioeconomic status and avoidable mortality. METHODS: The nationwide closed cohort of the 2011 Census of Population and Housing was followed up for 2012-2019 mortality. Outcomes of preventable and of treatable mortality were separately evaluated among people aged 30-74. Education level (elementary school or less, middle school, high school diploma, university degree or more) and residence macro area (North-West, North-East, Center, South-Islands) were the exposures, for which adjusted mortality rate ratios (MRRs) were calculated through multivariate quasi-Poisson regression models, adjusted for age at death. Relative index of inequalities was estimated for preventable, treatable, and non-avoidable mortality and for some specific causes. RESULTS: The cohort consisted of 35,708,459 residents (48.8% men, 17.5% aged 65-74), 34% with a high school diploma, 33.5% living in the South-Islands; 1,127,760 deaths were observed, of which 65.2% for avoidable causes (40.4% preventable and 24.9% treatable). Inverse trends between education level and mortality were observed for all causes; comparing the least with the most educated groups, a strong association was observed for preventable (males MRR = 2.39; females MRR = 1.65) and for treatable causes of death (males MRR = 1.93; females MRR = 1.45). The greatest inequalities were observed for HIV/AIDS and alcohol-related diseases (both sexes), drug-related diseases and tuberculosis (males), and diabetes mellitus, cardiovascular diseases, and renal failure (females). Excess risk of preventable and of treatable mortality were observed for the South-Islands. CONCLUSIONS: Socioeconomic inequalities in mortality persist in Italy, with an extremely varied response to policies at the regional level, representing a possible missed gain in health and suggesting a reassessment of priorities and definition of health targets.

Epidemiologic transition of lung cancer mortality in Italy by sex, province of residence and birth cohort (1920-1929 to 1960-1969).

Space-time analysis of mortality risk is useful to evaluate the epidemiologic transitions at the subnational level. In our study, we analysed the death certificate records for lung cancer in Italy in 1995-2016, obtained from the Italian National Institute of Statistics. Our objective was to investigate the spatial-temporal evolution of lung cancer mortality by sex and province of residence (n = 107) using the birth cohort as relevant time axis. We built Bayesian space-time models with space-time interactions. Among males (n = 554 829), mortality peaked in the 1920-1929 cohort, followed by a generalised decline. Among females (n = 158 619), we found novel original evidence for a peak in the 1955-1964 cohort, equivalent to a 35-year delay, with a downward trend being observed thereafter. Over time, the documented north-south decreasing mortality gradient has been replaced by a west-east decreasing gradient. Naples has become the province at highest risk in Italy, both among males and females. This pattern is consistent with an epidemiologic transition of risk factors for lung cancer to the south-west of the country and raises concern, because 5-year age-standardised net survival from the disease in this geographic area is lower than in northern and central Italy. The variability of mortality rates among provinces has changed over time, with an increasing homogeneity for males and an opposite trend for females in the more recent birth cohorts. These unprecedented observations provide evidence for a profound spatio-temporal transition of lung cancer mortality in Italy.

Frailty at death: An examination of multiple causes of death in four low mortality countries in 2017.

BACKGROUND: The increasing prevalence of frailty in aging populations represents a major social and public health challenge which warrants a better understanding of the contribution of frailty to the morbid process. OBJECTIVE: To examine frailty-related mortality as reported on the death certificate in France, Italy, Spain and the United States in 2017. METHODS: We identify frailty at death for the population aged 50 years and over in France, Italy, Spain and the United States. We estimate the proportions of deaths by sex, age group and country with specific frailty-related ICD-codes on the death certificate 1) as the underlying cause of death (UC), 2) elsewhere in Part I (sequence of diseases or conditions or events leading directly to death), and 3) anywhere in Part II (conditions that do not belong in Part I but whose presence contributed to death). RESULTS: The age-standardized proportion of deaths with frailty at ages 50 and over is highest in Italy (25.0%), then in France (24.1%) and Spain (17.3%), and lowest in the United States (14.0%). Cross-country differences are smaller when frailty-related codes are either the underlying cause of the death or reported in Part II. Frailty-related mortality increases with age and is higher among females than males. Dementia is the most frequently reported frailty-related code. CONCLUSIONS: Notable cross-country differences were found in the prevalence and the type of frailty-related symptoms at death even after adjusting for differential age distributions.

Suicide mortality among the elderly population in Italy: A nationwide cohort study on gender differences in sociodemographic risk factors, method of suicide, and associated comorbidity.

OBJECTIVES: This study aimed at investigating gender differences in the relationship between sociodemographic factors and suicide mortality, as well as in the method used for suicide and the presence of comorbidities in an older population in Italy. METHODS/DESIGN: We conducted a historical cohort study based on individual record linkage across the 15th Italian Population Census, the Italian Population Register, and the National Register of Causes of Death. Suicides among people aged 75 years or older from 2012 to 2017 were analyzed. Crude mortality rates were computed, and cause-specific mortality rate ratios were estimated using negative binomial regression models. Chi-square tests were used to evaluate significant gender differences in suicide methods and comorbidities associated with suicide. RESULTS: The study included 9,686,698 individuals (41% men, 59% women). Compared to living alone, living with children or partners reduced suicide mortality, especially among men. Having high or medium educational levels was associated with lower mortality than low educational levels among men. Foreign citizens had lower mortality among men, but not among women. Living in urban areas was associated with lower suicide rates in men and higher rates in women. Methods of suicide significantly differed by gender: leading methods were hanging, strangulation, and suffocation in men, and falling from height in women. Mental comorbidity was significantly more frequent among women, especially at ages 75-84 years. CONCLUSIONS: We believe that our findings might help to promote public health strategies taking gender differences in old age into account to improve social support and quality of life of older men and women.

[Effects of the COVID-19 pandemic on the inequalities in total mortality by country of birth]. / Gli effetti della pandemia di COVID-19 sulle disuguaglianze nella mortalità totale per Paese di nascita.

OBJECTIVES: to evaluate the impact on total mortality of the COVID-19 pandemic in Italy, by country of birth. DESIGN: historic cohort study based on administrative databases. SETTING AND PARTICIPANTS: the study is based on subjects included in the Base Register of Individuals of the Italian National Institute of Statistics on 01.01.2019, aged 35-64 years, and followed-up until 31.07.2021. MAIN OUTCOME MEASURES: age-standardized mortality rates were computed to analyse trends in overall mortality by country of birth grouped in three categories: 1. Italy and other high developed countries; 2. European countries with strong migratory pressure (EU-SMP); 3, non-European countries with strong migratory pressure (non-EU-SMP). Variations in mortality rates during the pandemic (March 2020-July 2021) with respect to the pre-pandemic period (January 2019-February 2020) were measured and compared across groups using mortality rate ratios (MRR) estimated by Poisson regression models, separately for men and women. RESULTS: the cohort includes 26,199,241 individuals, of whom 172,847 died during the follow-up. Over the whole period, mortality was consistently lower in individuals born in non-EU-SMP countries as compared to those born in Italy and other high developed countries. During the first pandemic wave (March-April 2020), individuals born in non-EU-SMP countries had higher excesses as compared to those born in Italy or other high developed countries (MRRs: 1.42 vs 1.28 in men and 1.30 vs 1.11 in women). Similar results were observed during the pandemic period October 2020-April 2021, when the MRRs were 1.37 vs 1.20 in men and 1.30 vs 1.11 in women. In the same period, the excess mortality among individuals born in EU-SMP did not significantly differ from that observed among those born in Italy and other high developed countries. CONCLUSIONS: in Italy, excess mortality during the COVID-19 pandemic was higher among immigrants born in non-EU-SMP countries as compared to the native population and immigrants born in high developed countries.

Mortality from suicide among agricultural, fishery, forestry and hunting workers in Italy and the contribution of work-related factors.

OBJECTIVES: Excess risk of suicide has been reported among workers in agriculture, fishery, forestry and hunting (AFFH). However, there is still uncertainty in the quantification of the risk and in the contribution of work-related factors. We aimed to quantify the suicide mortality risk among these workers in Italy. METHODS: We carried out a historical cohort study based on record linkage between the 2011 Italian census and the mortality archives for years 2012-2017. The mortality rate ratio (MRR) was used as a measure of risk. MRR was estimated through quasi-Poisson regression models using workers in other sectors as reference category. Models were adjusted for age, citizenship, marital status, area of residence, education, employment status and hours worked per week. RESULTS: The cohort included 1 004 655 workers employed in the AFFH sector and 15 269 181 workers in other sectors. During the 6-year follow-up, 559 deaths from suicide (500 men and 59 women) occurred among AFFH workers and 5917 (4935 men and 982 women) among workers in other sectors. The MRR for suicide was 1.36 (95% CI 1.19 to 1.55) among men and 1.18 (95% CI 0.87 to 1.60) among women. The excess risk was remarkably high for casual and fixed-term contract workers (3.01, 95% CI 1.50 to 6.04). CONCLUSIONS: Male workers in AFFH are at high risk of suicide mortality, and casual and fixed-term contract workers are at exceedingly high risk. Our study also suggests a higher risk among single, highly educated and long-hours workers. Female workers in AFFH do not have an appreciably increased risk.

Suicide among adolescents in Italy: a nationwide cohort study of the role of family characteristics.

Suicide is a leading cause of death among adolescents and is recognized as a serious public health problem. This study aimed to investigate the relationship between family characteristics and the risk of suicide among adolescents in Italy using nationwide official data. We carried out a cohort study based on the record linkage between the 15th Italian Population Census, the Italian Population Register, and the National Register of Causes of Death. Suicides in adolescents aged 10-19 years from 2012 to 2016 were analyzed. Hazard ratios of mortality from suicide were estimated through a multivariable Cox regression model using time-on-study as the time scale. We included 8,284,359 children and adolescents (51% males, 49% females). Over the 5-year follow-up, we registered 330 deaths from suicides (74% males), mostly occurred in the age class 15-19 years (86%). The suicide rate was 1.71 per 100,000 person-years among males and 0.65 among females. We found some familial characteristics associated with a higher risk of dying by suicide, including: living in single-parent or reconstructed families (among boys), a 40-year or more age gap between mother and child (among girls), having highly educated parents, an age difference between parents greater than 5 years. Furthermore, the study showed a lower risk for boys living in urban areas and for both boys and girls living in South Italy. Our results could help in identifying adolescents at high risk of suicide who could benefit from the planning of targeted intervention strategies.

Education inequalities in overall mortality during the first wave of the COVID-19 pandemic in Italy.

BACKGROUND: there is increasing concern that the COVID-19 pandemic has disproportionately affected the most vulnerable individuals. OBJECTIVES: to determine whether education inequalities have widened during the first wave of the COVID-19 pandemic in Italy. DESIGN: historic cohort study based on administrative databases. SETTING AND PARTICIPANTS: the study was based on subjects registered in the Base Register of Individuals on 01.01.2019, aged >=35 years, and followed-up until 30.06.2020. MAIN OUTCOME MEASURES: education inequalities in mortality before, during the first phase (March-April), and during the second phase (May-June) of the first pandemic wave in Italy were measured through the mortality rate ratios (MRRs). MMRs were estimated through negative binomial models. The interaction term between period and education was tested through the likelihood ratio test. RESULTS: the cohort included 37,976,670 individuals, and 719,665 of them died over the follow-up. In high pandemic areas, the MRR among less educated men were: 1.48 (95%CI 1.42-1.55) in the pre-pandemic period, 1.45 (95%CI 1.36-1.55) in the first phase and 1.42 (95%CI 1.30-1.56) in the second phase of the pandemic (p-value: 0.92). Corresponding figures among women were: 1.26 (95%CI 1.21-1.32), 1.39 (95%CI 1.30-1.49), and 1.35 (95%CI 1.23-1.48); p-value: 0.03. The MRRs substantially increased in the first pandemic phase among women aged 35-64 years (from 1.48 to 1.98; p-value; 0.011) and 65-79 years (from 1.22 to 1.51; p-value: 0.017). During the second phase, the MRRs returned to the values observed before the pandemic. CONCLUSIONS: in Italy, education inequality in mortality widened during the COVID-19 pandemic among working-age women and those aged 65-79 years.

Parental education and cancer mortality in children, adolescents, and young adults: A case-cohort study within the 2011 Italian census cohort.

BACKGROUND: Progress in the treatment of juvenile cancers has led to remarkable improvements in survival. However, not all families have the resources to cope with the burden that such diseases require. This study was aimed at evaluating the association between parental education and cancer mortality in children, adolescents, and young adults. METHODS: This was a case-cohort study based on 1889 cancer cases and 108,387 noncases sampled from the 2011 Italian census cohort of 10,964,837 individuals younger than 20 years and followed for 6 years. Mortality rate ratios (MRRs) were estimated for individuals with parents with high and intermediate levels of education (International Standard Classification of Education [ISCED] levels 5-8 and 3-4, respectively) in comparison with individuals with less educated parents (ISCED levels < 3) through multiple Poisson regression models. RESULTS: Over the follow-up, 684, 858, and 347 cancer cases with parents with the lowest, intermediate, and highest levels of education, respectively, were registered. In comparison with the individuals with parents with the lowest level of education, the MRR from all neoplasms was 0.92 (95% confidence interval [CI], 0.83-1.03) for those with parents with an intermediate level of education and 0.83 (95% CI, 0.72-0.95) for those with parents with the highest level of education. The MRRs from all neoplasms for individuals with parents with the highest level of education were 0.88 (95% CI, 0.69-1.11) among children, 0.87 (95% CI, 0.70-1.06) among adolescents, and 0.64 (95% CI, 0.50-0.83) among young adults. CONCLUSIONS: Children, adolescents, and young adults with highly educated parents have reduced mortality from cancer. This calls for further efforts to optimize treatment for children of less educated parents.

Mortality among Italian male workers in the construction industry: a census-based cohort study.

BACKGROUND: Advances in technologies, occupational hygiene and increased surveillance have reduced the excess mortality previously found in the construction industry. This study is aimed to evaluate cause-specific mortality in a recent cohort of construction workers. METHODS: We carried out a record-linkage cohort study based on the 2011 Italian census and the mortality archives (2012-2015), including 1 068 653 construction workers. We estimated mortality rate ratios (MRR) using Poisson regression models including terms for age and geographic area. RESULTS: Compared with non-manual workers, construction workers showed an excess mortality from all causes (MRR: 1.34), all neoplasms (MRR: 1.30), head and neck (MRR: 2.05), stomach (MRR: 1.56), liver (MRR: 1.62), lung (MRR: 1.80), prostate (MRR: 1.24) and bladder (MRR: 1.60) cancers, respiratory (MRR: 1.41) and liver (MRR: 1.79) diseases, all external causes (MRR: 1.87), falls (MRR: 2.87) and suicide (MRR: 1.58). Compared with manual workers in other industries, construction workers showed excess mortality from prostate (MRR: 1.27) and non-melanoma skin cancers (MRR: 1.95), all external causes (MRR: 1.14), falls (MRR: 1.94) and suicide (MRR: 1.18). Most of this excess mortality disappeared after adjusting for education, with the exception of prostate and non-melanoma skin cancers, all external causes, falls and suicide. CONCLUSIONS: Construction workers are at high risk of dying from external causes, while the excess mortality found for several cancers, liver and respiratory diseases may be at least partially due to the high prevalence of low education and unfavorable lifestyle factors. The excess mortality from prostate cancer requires further evaluations.

Multi-morbidity and frailty at death: A new classification of death records for an ageing world.

Mortality statistics based on underlying cause of death are challenged by increased life expectancy and the growing share of population reaching ages associated with frequent multi-morbidity (with death likely resulting from interactions between multiple diseases). We provide a novel way of analysing causes of death: accounting for all causes mentioned on death certificates and summarizing this information along two dimensions emblematic of ageing populations-multi-morbidity and frailty. We implement this classification for all deaths at ages 50+ in Italy in 2014. Multi-morbid processes represent the majority of deaths, rising from 43 per cent at ages 50-54 to 63 per cent at ages 85-89. Multi-morbidity at death is more frequent among males, although age patterns are identical for both sexes. About one in four deaths involves frailty symptoms, rising to 45 per cent at ages 95+. Mortality rates involving frailty are very similar for both sexes. Supplementary material is available for this article at: https://doi.org/10.1080/00324728.2020.1820558.

The increase of sepsis-related mortality in Italy: a nationwide study, 2003-2015.

The true burden of sepsis is largely unknown. Conventional underlying cause of death (UCoD) statistics largely underestimates sepsis-related mortality. This study aims to analyze all the conditions mentioned in the death certificates (multiple causes of death-MCoD) to estimate the nationwide burden of sepsis-related mortality in Italy, to investigate time trends and main comorbidities in sepsis-related deaths. All death certificates mentioning sepsis from 2003 to 2015 were analyzed. Age-standardized mortality rates were calculated for sepsis as both UCoD and MCoD, by gender and broad age groups. The ratio of the age-standardized proportions of any mention of sepsis in the presence/absence of associated chronic diseases (ASPR) was computed. The number of certificates reporting sepsis increased from 18,939 in 2003 to 49,010 in 2015 (from 3 to 8% of all deaths). The increase in sepsis mortality rates was larger for UCoD (males, + 200%; females, + 175%) than for MCoD-based figures (+ 100%; + 90%); MCoD rates remained noticeably higher than UCoD rates (2015, 87.3 per 100,000 vs. 16.3 for males; 54.9 vs. 11.8 for females). The largest increase was observed among the very elderly. The association between sepsis and chronic diseases was stronger for subjects aged less than 75 years. The increased awareness within the medical community in addition to the growing susceptible elderly population and the spread of antimicrobial resistance could have contributed to the sepsis-related mortality increase. MCoD statistics could help in recognizing sepsis not only as a clinical challenge, but also as a major public health issue.

[Impact of the implementation of ICD-10 2016 version and Iris software on mortality statistics in Italy]. / Impatto dell'implementazione della versione 2016 dell'ICD-10 e del software Iris sulle statistiche di mortalità in Italia.

OBJECTIVES: to assess the impact of coding causes of death with the ICD-10 2016 version and the software Iris on Italian official statistics on mortality. DESIGN: coding of a sample of death certificates with two different coding systems (bridge coding). SETTING AND PARTICIPANTS: a sample of 63,525 deaths occurred throughout 2015 among people aged over one year, already coded using the ICD-10 2009 version and the Mortality Medical Data System (MMDS) software, was re-coded through the ICD-10 2016 version and the Iris software. MAIN OUTCOME MEASURES: the transition matrix between the two coding systems was realized and the agreement percentages between the two coding systems, the comparability ratios, and the relative 95% confidence intervals were calculated. Comparability ratios have been calculated for both the underlying cause of death and the multiple causes. RESULTS: overall, 79% of deaths showed exactly the same underlying cause of death (ICD-10 code, 4 digits) in the two coding systems. On the three-digit level, the agreement was 89%; on ICD-10 chapter level, the agreement was 95%. At the chapter level, the most important changes were observed for: • certain infectious and parasitic diseases (-18% in ICD-10 2016/Iris); • diseases of the genitourinary system (-17%); • diseases of the respiratory system (+7%); • diseases of the nervous system and sense organs (+5%); • external causes of morbidity and mortality (+5%). Analyzing the multiple causes, the most important changes were observed for: • certain infectious and parasitic diseases (-19% in ICD-10 2016/Iris); • external causes of morbidity and mortality (+28%); • symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (+7%). CONCLUSION: the results are very useful to explain any change in the Italian statistics on mortality comparing 2015 with the following years.

Italian Atlas of mortality inequalities by education level. / Atlante italiano delle disuguaglianze di mortalità per livello di istruzione.

OBJECTIVES: To evaluate the geographical and socioeconomic differences in mortality and in life expectancy in Italy; to evaluate the proportion of mortality in the population attributable to a medium-low education level through the use of maps and indicators. DESIGN: Longitudinal design of the population enrolled in the 2011 Italian Census, following the population over time and registering any exit due to death or emigration. SETTING AND PARTICIPANTS: The study used the database of the Italian National Institute of Statistics (Istat) developed by linking the 2011 Census with the Italian National Register of Causes of Death (2012-2014) for 35 groups of causes of death. Age, sex, residence, and education level information were collected from the Census. MAIN OUTCOME MEASURES: Life expectancy at birth was calculated by sex, Italian region, and education level. For the population aged 30-89 years, the following items were developed by sex: 1. provincial maps showing, for each cause of death, the distribution in quintiles of smoothed standardized mortality ratio (SMR), adjusted for age and education level and estimated with Bayesian models for small areas (spatial conditional autoregressive model); 2. regional maps of population attributable fraction (PAF) for low and medium education levels, calculated starting from age-standardized mortality ratios; 3. tables illustrating for each region standardized mortality rates and standardized years of life lost rate by age (standardized YLL rate), and mortality rate ratios standardized by age (MMRs). RESULTS: Males with a lower education level throughout Italy show a life expectancy at birth that is 3 years less than those with higher education; residents in Southern Italy lose an additional year in life expectancy, regardless of education level. Social inequalities in mortality are present in all regions, but are more marked in the poorer regions of Southern Italy. Geographical differences, taking into account the different population distributions in terms of age and education level, produce mortality differences for all causes: from -15% to +30% in women and from -13% to +26% in men, compared to the national average. Among the main groups of causes, the geographical differences are greater for cardiovascular diseases, respiratory diseases, and accidents, and lower for many tumour sites. A clear mortality gradient with an excess in Southern Italy can be seen for cardiovascular diseases: there are some areas where mortality for people with higher education level is higher than that for residents in Northern Italy with low education level. The gradient for "All tumours", instead, is from South to North, as it is for most single tumour sites. Population attributable fraction for low education level in Italy, taking into account the population distribution by age, is 13.4% in women and 18.3% in men. CONCLUSIONS: The study highlighted important geographical differences in mortality, regardless of age and socioeconomic level, with a more significant impact in the poorer Southern regions, revealing a never-before-seen health advantage in the regions along the Adriatic coast. A lower education level explains a considerable proportion of mortality risk, although with differing effects by geographical area and cause of death. There are still mortality inequalities in Italy, therefore, representing a possible missed gain in health in our Country; these inequalities suggest a reassessment of priorities and definition of health targets. Forty years after the Italian National Health Service was instituted, the goal of health equity has not yet been fully achieved.

Excess mortality related to circulatory system diseases and diabetes mellitus among Italian AIDS patients vs. non-AIDS population: a population-based cohort study using the multiple causes-of-death approach.

BACKGROUND: Chronic diseases, chiefly cancers and circulatory system diseases (CSDs), have become the leading non-AIDS-related causes of death among HIV-infected people, as in the general population. After our previous report of an excess mortality for several non-AIDS-defining cancers, we now aim to assess whether people with AIDS (PWA) experience also an increased mortality for CSDs and diabetes mellitus (DM), as compared to the non-AIDS general population (non-PWA). METHODS: A nationwide, population-based, retrospective cohort study was conducted including 5285 Italians, aged 15-74 years, who were diagnosed with AIDS between 2006 and 2011. Multiple cause-of-death (MCoD) data, i.e. all conditions reported in death certificates, were retrieved through record-linkage with the National Register of Causes of Death up to 2011. Using MCoD data, sex- and age-standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated by dividing the observed number of PWA reporting a specific disease among MCoD to the expected number, estimated on the basis of mortality rates (based on MCoD) of non-PWA. RESULTS: Among 1229 deceased PWA, CSDs were mentioned in 201 (16.4%) certificates and DM in 46 (3.7%) certificates among the various causes of death. These values corresponded to a 13-fold higher mortality related to CSDs (95% CI 10.8-14.4) and DM (95% CI: 9.5-17.4) as compared to 952,019 deceased non-PWA. Among CSDs, statistically significant excess mortality emerged for hypertension (23 deaths, SMR = 6.3, 95% CI: 4.0-9.4), ischemic heart diseases (39 deaths, SMR = 6.1, 95% CI: 4.4-8.4), other forms of heart diseases (88 deaths, SMR = 13.4, 95% CI: 10.8-16.5), and cerebrovascular diseases (42 deaths, SMR = 13.4, 95% CI: 9.7-18.2). The SMRs were particularly elevated among PWA aged < 50 years and those infected through drug injection. CONCLUSIONS: The use of MCoD data disclosed the fairly high mortality excess related to several CSDs and DM among Italian PWA as compared to non-PWA. Study findings also indicate to start preventive strategies for such diseases at a younger age among AIDS patients than in the general population and with focus on drug users.

Differences in education and premature mortality: a record linkage study of over 35 million Italians.

Background: Large, representative studies are needed to evaluate cause-specific aspects of socio-economic inequalities in mortality. Methods: We conducted a census-based retrospective cohort study to quantify differences in cause-specific premature mortality by educational level in Italy. We linked the 2011 Italian census with 2012 and 2013 death registries. We used the mortality rate ratio (MRR) as a measure of relative inequality. Results: Overall, 305 043 deaths (190 061 men-114 982 women) were registered from a population of 35 708 445 subjects aged 30-74. The age-standardized mortality rate for all educational levels was 57.68 deaths per 10 000 person-years among men and 31.41 among women. MRR from all causes was 0.51 (95% CI: 0.49; 0.52) in men and 0.63 (95% CI: 0.61; 0.65) in women for the highest (university) compared to the lowest level of education (none or primary school). The association was stronger in single than in married individuals: MRRs were 0.36 (95% CI: 0.34; 0.39) in single men, 0.57 (95% CI: 0.55; 0.59) in married men, 0.44 (95% CI: 0.40; 0.47) in single women and 0.69 (95% CI: 0.66; 0.72) in married women. High education was associated with lower mortality from liver, circulatory, chronic respiratory and genitourinary diseases in both sexes. Highly educated men had a lower mortality from lung cancer than less educated men, whereas highly educated women did not have a reduced mortality from lung and breast cancers. Conclusion: Level of education is a strong indicator of premature mortality. The magnitude of the association between educational level and mortality differs across sexes, marital status and causes of death.

[Differences in mortality by educational level in Italy (2012-2014)]. / Differenze nella mortalità per livello di istruzione in Italia (2012-2014).

OBJECTIVES: to evaluate socioeconomic inequalities in mortality by educational level in Italy. DESIGN: cohort study based on the record linkage between the 2012-2014 archives of mortality and the 2011 Italian population Census. SETTING AND PARTICIPANTS: Italian population registered in the 2011 Census. MAIN OUTCOME MEASURES: life expectancy by educational level, age-standardized mortality rates, mortality rate ratios (MRRs) for overall mortality, and 12 groups of causes of death. RESULTS: life expectancy at birth was 80.3 years among men and 84.9 among women. High-educated men were expected to live 3 years longer than lower educated men, while the gap was narrower in women (1.5 years). Lower educated men had a higher mortality from any cause (MRR: 1.34; 95%CI 1.33-1.35) with larger differentials for lung, upper aerodigestive, and liver cancers, respiratory system diseases, AIDS and accidents. Socioeconomic inequalities were larger in the North-West of the Country for lung and liver cancer. Educational inequalities were smaller among women for all-cause mortality, but remarkably larger for circulatory system diseases (MRR: 1.40; 95%CI 1.38-1.42), particularly in the South (MRR: 1.46; 95%CI 1.42-1.50). CONCLUSIONS: this study documented socioeconomic inequalities in mortality in Italy for many causes of death; some of them resulted heterogeneous by area of residence. Most of the inequalities can be counteracted with specific measures aimed to improve behavioural risk factors among less educated people.

Educational inequality in cancer mortality: a record linkage study of over 35 million Italians.

PURPOSE: Large studies are needed to evaluate socioeconomic inequality for site-specific cancer mortality. We conducted a longitudinal census-based national study to quantify the relative inequality in cancer mortality among educational levels in Italy. METHODS: We linked the 2011 Italian census with the 2012 and 2013 death registries. Educational inequality in overall cancer and site-specific cancer mortality were evaluated by computing the mortality rate ratio (MRR). RESULTS: A total of 35,708,445 subjects aged 30-74 years and 147,981 cancer deaths were registered. Compared to the lowest level of education (none or primary school), the MRR for all cancers in the highest level (university) was 0.57 (95% CI 0.55; 0.58) in men and 0.84 (95% CI 0.81; 0.87) in women. Higher education was associated with reduced risk of mortality from lip, oral cavity, pharynx, oesophagus, stomach, colon and liver in both sexes. Higher education (university) was associated with decreased risk of lung cancer in men (MRR: 0.43, 95% CI 0.41; 0.46), but not in women (MRR: 1.00, 95% CI 0.92; 1.10). Highly educated women had a reduced risk of mortality from cervical cancer than lower educated women (MRR: 0.39, 95% CI 0.27; 0.56), but they had a similar risk for breast cancer (MRR: 1.01, 95% CI 0.94; 1.09). CONCLUSIONS: Education is inversely associated with total cancer mortality, and the association was stronger in men. Different patterns and trends in tobacco smoking in men and women account for at least most of the gender differences.

Multiple cause-of-death data among people with AIDS in Italy: a nationwide cross-sectional study.

BACKGROUND: Multiple cause-of-death (MCOD) data allow analyzing the contribution to mortality of conditions reported on the death certificate that are not selected as the underlying cause of death. Using MCOD data, this study aimed to fully describe the cause-specific mortality of people with AIDS (PWA) compared to people without AIDS. METHODS: We conducted a nationwide investigation based on death certificates of 2,515 Italian PWA and 123,224 people without AIDS who had died between 2006 and 2010. The conditions most frequently associated with PWA mortality, compared to people without AIDS, were identified using an age-standardized proportion ratio (ASPR) calculated as the ratio between the age-standardized proportion of a specific cause among PWA and the same proportion among people without AIDS. RESULTS: The most frequently reported conditions at death among PWA were infectious/parasitic diseases (52%), digestive (36%), respiratory (33%), and circulatory (32%) system diseases, and neoplasms (29%). All AIDS-defining conditions resulted highly associated (ASPR significantly greater than unity) with PWA deaths. Significant associations also emerged for leishmaniasis (ASPR = 188.0), encephalitis/myelitis/encephalomyelitis (ASPR = 14.3), dementia (ASPR = 13.1), chronic viral hepatitis (ASPR = 13.1), liver fibrosis/cirrhosis (ASPR = 4.4), pneumonia (ASPR = 4.4), anal (ASPR = 12.1) and liver (ASPR = 1.9) cancers, and Hodgkin's disease (ASPR = 3.1). CONCLUSIONS: Study findings identified the contribution of several non-AIDS-defining conditions on PWA mortality, emphasizing the need of preventive public health interventions targeting this population.