A common error in the ecological regression of cancer incidence on the deprivation index.

OBJECTIVE: To determine if introducing age as another explanatory variable in an ecological regression model relating crude rates of cancer incidence and a deprivation index provides better results than the usual practice of using the standard incidence ratio (SIR) as the response variable, introducing the non-standardized index, and not including age in the model. METHODS: Relative risks associated with the deprivation index for some locations of cancer in Spain's Girona Health Region were estimated using two different models. Model 1 estimated relative risks with the indirect method, using the SIR as the response variable. Model 2 estimated relative risks using age as an explanatory variable and crude cancer rates as the response variable. Two scenarios and two sub-scenarios were simulated to test the properties of the estimators and the goodness of fit of the two models. RESULTS: The results obtained from Model 2's estimates were slightly better (less biased) than those from Model 1. The results of the simulation showed that in all cases (two scenarios and two sub-scenarios) Model 2 had a better fit than Model 1. The probability density for the parameter of interest provided evidence that Model 1 leads to biased estimates. CONCLUSIONS: When attempting to explain the relative risk of incidence of cancer using ecological models that control geographic variability, introducing age as another explanatory variable and crude rates as a response variable provides less biased results.

The ERA Registry Annual Report 2020: a summary.

Background: The European Renal Association (ERA) Registry collects data on kidney replacement therapy (KRT) in patients with ESKD. This paper is a summary of the ERA Registry Annual Report 2020, also including comparisons among primary renal disease (PRD) groups. Methods: Data were collected from 52 national and regional registries from 34 European countries and countries bordering the Mediterranean Sea: 35 registries from 18 countries providing individual level data and 17 registries from 17 countries providing aggregated data. Using this data, KRT incidence and prevalence, kidney transplantation rates, expected remaining lifetimes and survival probabilities were calculated. Results: A general population of 654.9 million people was covered by the ERA Registry in 2020. The overall incidence of KRT was 128 per million population (p.m.p.). In incident KRT patients, 54% were older than 65 years, 63% were men and the most common PRD was diabetes mellitus (21%). Regarding initial treatment modality in incident patients, 85% received haemodialysis (HD), 11% received peritoneal dialysis (PD) and 4% received a pre-emptive kidney transplant. On 31 December 2020, the prevalence of KRT was 931 p.m.p. In prevalent patients, 45% were older than 65 years, 60% were men and glomerulonephritis was the most common PRD (18%). Of these patients, 58% were on HD, 5% on PD and 37% were living with a kidney transplant. The overall kidney transplantation rate in 2020 was 28 p.m.p., with a majority of kidney grafts from deceased donors (71%). The unadjusted 5-year survival, based on incident dialysis patient from 2011-15, was 41.8%. For patients having received a deceased donor transplant, the unadjusted 5-year survival probability was 86.2% and for patients having received a living donor transplant it was 94.4%. When comparing data by PRD group, differences were found regarding the distribution of age groups, sex and treatment modality received.

The ERA-EDTA Registry Annual Report 2018: a summary.

BACKGROUND: The European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) Registry collects data on kidney replacement therapy (KRT) via national and regional renal registries in Europe and countries bordering the Mediterranean Sea. This article summarizes the 2018 ERA-EDTA Registry Annual Report, and describes the epidemiology of KRT for kidney failure in 34 countries. METHODS: Individual patient data on patients undergoing KRT in 2018 were provided by 34 national or regional renal registries and aggregated data by 17 registries. The incidence and prevalence of KRT, the kidney transplantation activity and the survival probabilities of these patients were calculated. RESULTS: In 2018, the ERA-EDTA Registry covered a general population of 636 million people. Overall, the incidence of KRT for kidney failure was 129 per million population (p.m.p.), 62% of patients were men, 51% were ≥65 years of age and 20% had diabetes mellitus as cause of kidney failure. Treatment modality at the onset of KRT was haemodialysis (HD) for 84%, peritoneal dialysis (PD) for 11% and pre-emptive kidney transplantation for 5% of patients. On 31 December 2018, the prevalence of KRT was 897 p.m.p., with 57% of patients on HD, 5% on PD and 38% living with a kidney transplant. The transplant rate in 2018 was 35 p.m.p.: 68% received a kidney from a deceased donor, 30% from a living donor and for 2% the donor source was unknown. For patients commencing dialysis during 2009-13, the unadjusted 5-year survival probability was 42.6%. For patients receiving a kidney transplant within this period, the unadjusted 5-year survival probability was 86.6% for recipients of deceased donor grafts and 93.9% for recipients of living donor grafts.

Factors Associated with the Prescribing of High-Intensity Statins.

In this study, we investigated the relationship between sociodemographic, clinical, anthropometric, and lifestyle characteristics and the type of statin prescribed for primary prevention of cardiovascular disease (CVD). We conducted an observational study in workers who began statin treatment. Statin therapy was categorized as "high-intensity" or "low-moderate-intensity". Workers were classified according to the alignment of their statin therapy with the recommended management practices. Logistic regression models were used to evaluate the association between the different variables studied and the probability of being prescribed high-intensity statins. The only variables associated with a higher probability of being treated with high-intensity statins were increased physical activity (>40 versus <20 METs (metabolic equivalent of task) h/wk; odds ratio (OR), 1.65; 95%CI, 1.08-2.50) and, in diabetics, higher low-density lipoprotein cholesterol (LDL-C) levels (≥155 mg/dL versus <155 mg/dL; OR, 4.96; 95%CI, 1.29-19.10). The model that best predicted treatment intensity included LDL-C, diabetes, hypertension, smoking, and age (area under the Receiver Operating Characteristic curve (AUC), 0.620; 95%CI, 0.574-0.666). The prescribing and type of statin used in primary CVD prevention did not correspond with the indications in current guidelines. The probability of receiving high-intensity statins was higher in diabetics with high LDL-C levels and in more physically active individuals. These findings underscore the great variability and uncertainty in the prescribing of statins.

[The EMECAS Project: Spanish multicentre study on short-term health effects of air pollution]. / El proyecto EMECAS: protocolo del estudio multicéntrico en España de los efectos a corto plazo de la contaminación atmosférica sobre la salud.

UNLABELLED: The EMECAM Project demonstrated the short-term effect of air pollution on the death rate in 14 cities in Spain throughout the 1990-1995 period. The Spanish Multicentre Study on Health Effects of Air Pollution (EMECAS) is broadening these objectives by incorporating more recent data, information on hospital disease admissions and totaling 16 Spanish cities. This is an ecological time series study in which the response variables are the daily deaths and the emergency hospitalizations due to circulatory system diseases and respiratory diseases among the residents in each city. Pollutants analyses: suspended particles, SO2, NO2, CO and O3. Control variables: meteorological, calendar, seasonality and influenza trend and incidence. STATISTICAL ANALYSIS: estimate of the association in each city by means of the construction of generalized additive Poisson regression models and metanalysis for obtaining combined estimators. The EMECAS Project began with the creation of three working groups (Exposure, Epidemiology and Analysis Methodology) which defined the protocol. The average levels of pollutants were below those established under the current regulations for sulfur dioxide, carbon monoxide and ozone. The NO2 and PM10 values were around those established under the regulations (40 mg/m3). This is the first study of the relationship between air pollution and disease rate among one group of Spanish cities. The pollution levels studied are moderate for some pollutants, although for others, especially NO2 and particles, these levels could entail a problem with regard to complying with the regulations in force.

A combined analysis of the short-term effects of photochemical air pollutants on mortality within the EMECAM project.

In recent years, some epidemiologic studies have attributed adverse effects of air pollutants on health not only to particles and sulfur dioxide but also to photochemical air pollutants (nitrogen dioxide and ozone). The effects are usually small, leading to some inconsistencies in the results of the studies. Furthermore, the different methodologic approaches of the studies used has made it difficult to derive generic conclusions. We provide here a quantitative summary of the short-term effects of photochemical air pollutants on mortality in seven Spanish cities involved in the EMECAM project, using generalized additive models from analyses of single and multiple pollutants. Nitrogen dioxide and ozone data were provided by seven EMECAM cities (Barcelona, Gijón, Huelva, Madrid, Oviedo, Seville, and Valencia). Mortality indicators included daily total mortality from all causes excluding external causes, daily cardiovascular mortality, and daily respiratory mortality. Individual estimates, obtained from city-specific generalized additive Poisson autoregressive models, were combined by means of fixed effects models and, if significant heterogeneity among local estimates was found, also by random effects models. Significant positive associations were found between daily mortality (all causes and cardiovascular) and NO(2), once the rest of air pollutants were taken into account. A 10 microg/m(3) increase in the 24-hr average 1-day NO(2)level was associated with an increase in the daily number of deaths of 0.43% [95% confidence interval (CI), -0.003-0.86%] for all causes excluding external. In the case of significant relationships, relative risks for cause-specific mortality were nearly twice as much as that for total mortality for all the photochemical pollutants. Ozone was independently related only to cardiovascular daily mortality. No independent statistically significant relationship between photochemical air pollutants and respiratory mortality was found. The results in this study suggest that, given the present levels of photochemical pollutants, people living in Spanish cities are exposed to health risks derived from air pollution.

[Short-term relationship between air pollution and mortality in 13 Spanish cities]. / Relación a corto plazo de la contaminación atmosférica y la mortalidad en 13 ciudades españolas.

BACKGROUND AND OBJECTIVE: EMECAM is a collaborative project that seeks to evaluate the short-term effects of air pollution on mortality in Spain. MATERIAL AND METHOD: We collected data for air pollutants (particles and gases), daily mortality (total except external, cardiovascular and respiratory causes) and co-variables (temperature, humidity, influenza and calendar variables) in 13 Spanish cities. The magnitude of the association in every city was estimated using GAM under a Poisson distribution. Combined estimates for each cause and pollutant were obtained under 'fixed effects' and 'random effects'models. RESULTS: An increase of 10 (g/m3 in the levels of the average of the concurrent and one day lag for black smoke was associated with a 0.8% (CI: 0.4-1.1) increase in mortality. The same increase in the concentration of SO2 was associated with a 0.5% (CI: 0.1-1.0) increase in daily deaths, and a 0.6% (CI: 0.3-0.8) increase in the case of NO2. An increase of 1 mg/m3 in the levels of CO was associated with an increase of 1.5% (CI: 0.5-2.6) in daily deaths. CONCLUSIONS: There is a short-term association between increases of daily levels of air pollutants and the number of daily deaths in Spanish cities.

[Public hospital utilization by the foreign population in Aragon, Spain (2004-2007)]. / Utilización de los hospitales públicos por la población extranjera en Aragón (2004-2007).

OBJECTIVES: To describe hospitalization rates and hospital morbidity among the foreign population residing in Aragon (Spain) by country of birth, between 2004 and 2007, and to compare these rates with those in the autochthonous population. METHODS: A retrospective longitudinal study was carried out of hospital discharges of the foreign population in public hospitals in Aragon. Utilization rates were estimated by sex, age, country of birth and main diagnosis. Poisson regression was used to estimate the utilization rate ratios and their 95% confidence intervals. RESULTS: Hospitalization rates were lower in the foreign population (adjusted RR: 0.52; 95% CI: 0.51-0.56), except in women aged between 15 and 24 years (RR: 2.9; 95% CI: 2.8-3.0) and among those born in the Maghreb (RR: 1.8; 95% CI: 1.7; 1.9), sub-Saharan Africa (RR: 2.0; 95% CI: 1.9-2.1) and Asia (RR=1.4; 95% CI: 1.3-1.6). When hospital discharges related to obstetrics and gynecology were excluded, only women born in sub-Saharan Africa continued to have adjusted RR greater than 1. These women had higher hospitalization rates in groups of infectious and parasitic diseases (RR: 2.5) and blood and blood-forming organs (RR: 2.8). CONCLUSIONS: In Aragon (Spain), public hospital utilization is lower in foreigners than in the autochthonous population. The diseases treated varied by country of birth. The diseases prevalent in these countries, together with hereditary diseases, can increase hospital utilization rates.

A common error in the ecological regression of cancer incidence on the deprivation index / Un error frecuente en los modelos de regresión ecológica de la incidencia de cáncer con respecto al índice de carencia

OBJECTIVE: To determine if introducing age as another explanatory variable in an ecological regression model relating crude rates of cancer incidence and a deprivation index provides better results than the usual practice of using the standard incidence ratio (SIR) as the response variable, introducing the non-standardized index, and not including age in the model. METHODS: Relative risks associated with the deprivation index for some locations of cancer in Spain's Girona Health Region were estimated using two different models. Model 1 estimated relative risks with the indirect method, using the SIR as the response variable. Model 2 estimated relative risks using age as an explanatory variable and crude cancer rates as the response variable. Two scenarios and two sub-scenarios were simulated to test the properties of the estimators and the goodness of fit of the two models. RESULTS: The results obtained from Model 2's estimates were slightly better (less biased) than those from Model 1. The results of the simulation showed that in all cases (two scenarios and two sub-scenarios) Model 2 had a better fit than Model 1. The probability density for the parameter of interest provided evidence that Model 1 leads to biased estimates. CONCLUSIONS: When attempting to explain the relative risk of incidence of cancer using ecological models that control geographic variability, introducing age as another explanatory variable and crude rates as a response variable provides less biased results.

OBJETIVO: Determinar si la introducción de la edad como otra variable independiente en un modelo de regresión ecológica que relaciona las tasas brutas de incidencia de cáncer con un índice de carencia, ofrece mejores resultados que la práctica corriente del uso de la razón de incidencia normalizada como criterio de valoración, con introducción del índice sin normalización y sin incluir la edad en el modelo. MÉTODOS:Se calcularon los riesgos relativos asociados con el índice de carencia de algunos tipos de cáncer en la Región Sanitaria de Girona en España, mediante dos modelos diferentes. En el modelo 1 se calcularon los riesgos relativos con el método indirecto, usando la razón de incidencia normalizada como criterio de valoración. En el modelo 2 se calcularon los riesgos relativos introduciendo la edad como una variable independiente y las tasas brutas de cáncer como criterio de valoración. Se simularon dos hipótesis y dos subhipótesis con el fin de verificar las propiedades de los estimadores y la bondad del ajuste de ambos modelos. RESULTADOS: Los resultados obtenidos a partir de las estimaciones con el modelo 2 fueron un poco mejores (menos sesgados) que los resultados obtenidos con el modelo 1. Los resultados de la simulación indicaron que en todos los casos (las dos hipótesis y las dos subhipótesis) el modelo 2 exhibió un mejor ajuste que el modelo 1. La función de densidad del parámetro de interés puso en evidencia que el modelo 1 da lugar a estimaciones sesgadas. CONCLUSIONES: Cuando se intenta explicar el riesgo relativo de incidencia de cáncer mediante modelos de regresión ecológica que tienen en cuenta la variabilidad geográfica, se obtienen resultados menos sesgados cuando se introduce la edad como una de las variables independientes y se utilizan las tasas brutas de incidencia como criterio de valoración.

El Proyecto EMECAS: protocolo del estudio multicéntrico en España de los efectos a corto plazo de la contaminación atmosférica sobre la salud / The EMECAS project: spanish multicentre study on short-term health effects of air pollution

El proyecto EMECAM constató el efecto a corto plazo de la contaminación atmosférica sobre la mortalidad en 14 ciudades españolasentre 1990 y 1995. El Estudio Multicéntrico Español de Contaminación Atmosférica y Salud (EMECAS) amplía estos objetivosincorporando al análisis datos de morbilidad hospitalaria, utilizainformación más reciente y suma un total de 16 ciudades. Se trata deun estudio ecológico de series temporales, siendo las variables respuestalas defunciones diarias y los ingresos hospitalarios urgentespor enfermedades del aparato circulatorio y enfermedades respiratoriasen los residentes de cada ciudad. Contaminantes analizados: partículas en suspensión, SO2, NO2, CO y O3. Variables de control:meteorológicas, de calendario, estacionalidad y tendencia e incidenciade gripe. Análisis estadístico: estimación de la asociación en cadaciudad mediante la construcción de modelos de regresión de Poissonaditivos generalizados, y meta-análisis para la obtención de estimadoresconjuntos. Los niveles medios de contaminantes se situaronpor debajo de los establecidos por la normativa actual para el dióxidode azufre, el monóxido de carbono y el ozono. Los valores de NO2y PM10 se situaron alrededor de los establecidos en la normativa (40mg/m3). Se trata del primer estudio de la relación entre contaminación atmosférica y morbilidad en un conjunto de ciudades españolas.Los niveles de contaminantes estudiados son moderados para algunoscontaminantes, aunque en otros, especialmente NO2 y partículas,podrían representar un problema para el cumplimiento de la normativavigente

The EMECAM Project demonstrated the short-term effect of airpollution on the death rate in 14 cities in Spain throughout the 1990-1995 period. The Spanish Multicentre Study on Health Effects of AirPollution (EMECAS) is broadening these objectives by incorporatingmore recent data, information on hospital disease admissionsand totaling 16 Spanish cities. This is an ecological time series studyin which the response variables are the daily deaths and the emergencyhospitalizations due to circulatory system diseases and respiratorydiseases among the residents in each city. Pollutants analyses:suspended particles, SO2, NO2, CO and O3. Control variables:meteorological, calendar, seasonality and influenza trend and incidence.Statistical analysis: estimate of the association in each city bymeans of the construction of generalized additive Poisson regressionmodels and metanalysis for obtaining combined estimators. TheEMECAS Project began with the creation of three working groups(Exposure, Epidemiology and Analysis Methodology) which definedthe protocol. The average levels of pollutants were below thoseestablished under the current regulations for sulfur dioxide, carbonmonoxide and ozone. The NO2 and PM10 values were around thoseestablished under the regulations (40 mg/m3). This is the first studyof the relationship between air pollution and disease rate among onegroup of Spanish cities. The pollution levels studied are moderate forsome pollutants, although for others, especially NO2 and particles,these levels could entail a problem with regard to complying with theregulations in force

Relación a corto plazo de la contaminación atmosférica y la mortalidad en 13 ciudades españolas / Short-term relationship between air pollution and mortality in 13 Spanish cities

FUNDAMENTO Y OBJETIVO: EMECAM es un proyecto multicéntrico cuyo objetivo es evaluar la asociación a corto plazo de la contaminación sobre la salud en España. MATERIAL Y MÉTODO: Se obtuvieron los datos sobre contaminación atmosférica (partículas en suspensión y gases), mortalidad (todas las causas excluidas las externas, causas respiratorias y causas del aparato circulatorio) y de covariables para el control de la confusión (temperatura, humedad, gripe, variables de calendario) en 13 ciudades españolas. Los estimadores locales de los efectos de los contaminantes, obtenidos a partir de modelos autorregresivos generalizados aditivos de Poisson, se combinaron mediante modelos de efectos fijos y, cuando existía heterogeneidad, modelos de efectos aleatorios. Se construyeron todos los modelos con uno y con dos contaminantes simultáneamente. RESULTADOS: Un aumento de 10 µg/m3 en el promedio de las concentraciones del día simultáneo y el día anterior de humos negros se asoció con un incremento del 0,8 por ciento (intervalo de confianza [IC] del 95 por ciento, 0,4-1,1) de la mortalidad total. El mismo incremento de dióxido de azufre y de dióxido de nitrógeno se asoció con incrementos del 0,5 por ciento (IC del 95 por ciento, 0,1-1,0) y del 0,6 por ciento (IC del 95 por ciento: 0,3-0,8) de la mortalidad, respectivamente. Un aumento de 1 mg/m3 en los valores de monóxido de carbono se asoció con un incremento del 1,5 por ciento (IC del 95 por ciento, 0,5-2,6) en las defunciones diarias. Los coeficientes obtenidos para los grupos de causas específicas fueron, en general, de mayor magnitud. En los modelos de dos contaminantes las partículas y el monóxido de carbono fueron los contaminantes que mostraron mayor robustez en los estimadores. CONCLUSIONES: Los incrementos diarios en las concentraciones de contaminantes atmosféricos se asocian, a corto plazo, con un aumento en el número de defunciones en las ciudades españolas (AU)