Joaquín Moncho

Preventable avoidable mortality: Evolution of socioeconomic inequalities in urban areas in Spain, 1996–2003

This study describes the inequalities in preventable avoidable mortality in relation to socioeconomic levels and analyses their evolution during the period 1996-2003 in the cities of Alicante, Castellon and Valencia. Four causes of preventable avoidable mortality were analysed according to sex: malignant tumour of the trachea, bronchus and lung, cirrhosis and other chronic diseases of the liver, motor vehicle accidents and AIDS, which had caused the death of non-institutionalised residents in the three cities during the period 1996-2003. The different census tracts were grouped into three socioeconomic levels. In general, socioeconomic inequalities in preventable avoidable mortality remain constant in time, except the ones caused by AIDS in Valencia, where they increase for men. Some census tracts in the three cities where the study was carried out were found to have significantly higher preventable mortality rates, and therefore require intervention.

Self-rated health and mortality: a follow-up study of a Spanish population

OBJECTIVES Self-rated health (SRH) is known to be a valid indicator for the prediction of health outcomes. The aims of this study were to describe and analyse the associations between SRH and health status, socio-economic and demographic characteristics; and between SRH and mortality in a Spanish population. STUDY DESIGN Longitudinal study. METHODS A sample of 5275 adults (age ≥21 years) residing in the Valencian Community (Spanish Mediterranean region) was surveyed in 2005 and followed for four years. SRH was categorized into good and poor health. The response variable was mortality (dead/alive), obtained from the local mortality register. Logistic regression models were adjusted in order to analyse the associations between SRH and health status, socio-economic and demographic characteristics; odds ratios were calculated to measure the associations. Poisson regression models were adjusted in order to analyse the associations between mortality and explanatory variables; the relative risk of death was calculated to measure the associations. RESULTS Poor SRH was reported by 25.9% of respondents, and the mortality rate after four years of follow-up was 3.6%. An association was found between SRH and the presence of chronic disease and disability in men and women. A perception of poor health vs good health led to a mortality risk of 3.0 in men and 2.7 in women. SRH was predictive of mortality, even after adjusting for all other variables. In men and women, the presence of disability provided additional predictive ability. CONCLUSIONS SRH was predictive of mortality in both men and women, and acted as a mediator between socio-economic, demographic and health conditions and mortality.

Cholelithiasic Disease and Associated Factors in a Spanish Population

In order to analyze the factors associated with cholelithiasic disease, 1268 participants of a population sample were studied. On univariate analysis, 11 of the 23 variables included showed a statistically significant association (P < 0.05). Five of these variables, including obesity, triglyceride level, intake of hypolipidemic drugs, and a diet rich in cholesterol and saturated fats in women, and physical exercise in men, remained significantly associated after controlling for age. On multivariate analysis among women, a positive association was found with age (P < 0.001), obesity, and the use of hypolipidemic agents (P < 0.05) and a negative one with a diet rich in cholesterol and saturated fats (P < 0.05). Among men, the same analysis revealed there was a positive association with age (P < 0.001) and triglycerides (P < 0.05) and a negative one with physical exercise (P < 0.05). In conclusion, obesity and the use of hypolipidemic agents in women and triglycerides in men, were positively associated with cholelithiasic disease, independent of age, while negative associations included the intake of cholesterol and saturated fats in women and physical exercise in men.

Trends in socioeconomic inequalities in preventable mortality in urban areas of 33 Spanish cities, 1996-2007 (MEDEA project)

BackgroundPreventable mortality is a good indicator of possible problems to be investigated in the primary prevention chain, making it also a useful tool with which to evaluate health policies particularly public health policies. This study describes inequalities in preventable avoidable mortality in relation to socioeconomic status in small urban areas of thirty three Spanish cities, and analyses their evolution over the course of the periods 1996–2001 and 2002–2007.MethodsWe analysed census tracts and all deaths occurring in the population residing in these cities from 1996 to 2007 were taken into account. The causes included in the study were lung cancer, cirrhosis, AIDS/HIV, motor vehicle traffic accidents injuries, suicide and homicide. The census tracts were classified into three groups, according their socioeconomic level. To analyse inequalities in mortality risks between the highest and lowest socioeconomic levels and over different periods, for each city and separating by sex, Poisson regression were used.ResultsPreventable avoidable mortality made a significant contribution to general mortality (around 7.5%, higher among men), having decreased over time in men (12.7 in 1996–2001 and 10.9 in 2002–2007), though not so clearly among women (3.3% in 1996–2001 and 2.9% in 2002–2007). It has been observed in men that the risks of death are higher in areas of greater deprivation, and that these excesses have not modified over time. The result in women is different and differences in mortality risks by socioeconomic level could not be established in many cities.ConclusionsPreventable mortality decreased between the 1996–2001 and 2002–2007 periods, more markedly in men than in women. There were socioeconomic inequalities in mortality in most cities analysed, associating a higher risk of death with higher levels of deprivation. Inequalities have remained over the two periods analysed. This study makes it possible to identify those areas where excess preventable mortality was associated with more deprived zones. It is in these deprived zones where actions to reduce and monitor health inequalities should be put into place. Primary healthcare may play an important role in this process.

Análisis de la mortalidad en ciudades: resultados en Valencia y Alicante

Objetivos: Describir los patrones de mortalidad, general y por causas especificas seleccionadas, en Valencia y Alicante; establecer las diferencias internas por distritos, y evaluar los cambios en la magnitud de estas desigualdades en el tiempo. Metodos: Las defunciones ocurridas en residentes en las ciudades de Valencia y Alicante durante los periodos 1990-1992 y 1996-1998 se asignaron a los distritos municipales de residencia. La comparacion entre los periodos de estudio o entre ciudades se ha realizado a traves del riesgo relativo estimado mediante regresion de Poisson. Se calculo la razon comparativa de mortalidad (RCM) segun los 17 grandes grupos de la Clasificacion Internacional de Enfermedades (9.a revision). Por distritos se han calculado en cada periodo de estudio las tasas ajustadas por el metodo directo, la razon de mortalidad estandarizada (RME), la razon de anos potenciales de vida perdida (RAPVP) y la esperanza de vida al nacimiento. Resultados: Los riesgos de muerte por todas las causas disminuyen del primer al segundo periodo tanto en varones, como en mujeres en ambas ciudades. La esperanza de vida aumenta significativamente en ambas ciudades en los varones, y en Valencia en las mujeres. La ciudad de Valencia presenta un mayor riesgo de muerte en ambos periodos. Algunos grupos de causas de muerte aumentan (grupos 5 y 6, que incluyen trastornos mentales y enfermedades del sistema nervioso y organos de los sentidos). Por distritos, se observa una mayor variabilidad en Valencia --donde destacan los distritos 1 y 11 con un elevado riesgo de mortalidad-- que en Alicante. Conclusiones: El proceso de vigilancia de la mortalidad interna, por distritos, es reproducible. En la ciudad de Valencia existen diferencias en la mortalidad que se mantienen en el tiempo. La ciudad de Alicante presenta una menor variabilidad interna en sus indicadores de mortalidad.

Do socioeconomic inequalities in mortality vary between different Spanish cities? a pooled cross-sectional analysis.

BackgroundThe relationship between deprivation and mortality in urban settings is well established. This relationship has been found for several causes of death in Spanish cities in independent analyses (the MEDEA project). However, no joint analysis which pools the strength of this relationship across several cities has ever been undertaken. Such an analysis would determine, if appropriate, a joint relationship by linking the associations found.MethodsA pooled cross-sectional analysis of the data from the MEDEA project has been carried out for each of the causes of death studied. Specifically, a meta-analysis has been carried out to pool the relative risks in eleven Spanish cities. Different deprivation-mortality relationships across the cities are considered in the analysis (fixed and random effects models). The size of the cities is also considered as a possible factor explaining differences between cities.ResultsTwenty studies have been carried out for different combinations of sex and causes of death. For nine of them (men: prostate cancer, diabetes, mental illnesses, Alzheimer’s disease, cerebrovascular disease; women: diabetes, mental illnesses, respiratory diseases, cirrhosis) no differences were found between cities in the effect of deprivation on mortality; in four cases (men: respiratory diseases, all causes of mortality; women: breast cancer, Alzheimer’s disease) differences not associated with the size of the city have been determined; in two cases (men: cirrhosis; women: lung cancer) differences strictly linked to the size of the city have been determined, and in five cases (men: lung cancer, ischaemic heart disease; women: ischaemic heart disease, cerebrovascular diseases, all causes of mortality) both kinds of differences have been found. Except for lung cancer in women, every significant relationship between deprivation and mortality goes in the same direction: deprivation increases mortality. Variability in the relative risks across cities was found for general mortality for both sexes.ConclusionsThis study provides a general overview of the relationship between deprivation and mortality for a sample of large Spanish cities combined. This joint study allows the exploration of and, if appropriate, the quantification of the variability in that relationship for the set of cities considered.

La mortalidad evitable: ¿Cambios en el nuevo siglo?

Objetivos: Estudiar la evolucion temporal y la distribucion geografica de la mortalidad evitable en la Comunidad Valenciana y en sus Departamentos de Salud por sexo, en los periodos 1990-1994, 1995-1999 y 2000-2004. Material y metodo: Se han analizado 21 causas de mortalidad evitable agrupandolas en tratables y prevenibles. Las defunciones analizadas corresponden a residentes en la Comunidad Valenciana durante el periodo 1990-2004. Se han calculado las tasas ajustadas por edad (metodo directo) y las razones de mortalidad comparativas para el estudio de la evolucion temporal en los ambitos geograficos indicados por periodo y sexo. Las razones de mortalidad estandarizadas (metodo indirecto) se han utilizado en el analisis de la distribucion geografica. Resultados: El total de defunciones evitables son 38.061 (un 7,1% de la mortalidad global), el 76,2% corresponden a varones y el 23,8% a mujeres. Por grupos, el 82,4% son prevenibles y el 17,6% tratables. En varones, las prevenibles representan un 86,5%, y en mujeres un 69,4%. En la Comunidad Valenciana se observan descensos significativos de la mortalidad evitable en ambos sexos, mas acusados en las tratables, y en hombres. La mortalidad por cancer de pulmon en mujeres presenta un aumento significativo. En 2000-2004 ningun departamento de salud presenta excesos de mortalidad estadisticamente significativos en las tratables. Conclusiones: La mortalidad evitable desciende mas que la mortalidad general en la Comunidad Valenciana. Cabe destacar el aumento de la mortalidad por cancer de pulmon en las mujeres.

Evolución de los diseños epidemiológicos de la investigación clínica en España (1975-1994)

BACKGROUND: Previous studies have shown a sparing utilization of analytical and experimental designs in Spanish clinical research journals. The study aims are to compare among countries, the use of epidemiologic method in articles published in scientific journals, and to determine the extent to which this research has direct funding. METHODS: Cross-sectional study including all original papers published during 1994 in Medicina Clinica [(Med Clin (Barc)], Revista Clinica Espanola (Rev Clin Esp), The Lancet (Lancet) and New England Journal of Medicine (N Engl J Med). They were classified according to epidemiological design and we verified the financial support mention. RESULTS: 594 papers were included. Epidemiological studies without control group prevailed in Spanish journals. The most common designs were descriptive studies in Med Clin (Barc), with 45.5%, and clinical series in Rev Clin Esp, with 41.7%. The 33.6% of original papers published in Lancet and 28.4% of N England J Med were randomized trials. We found information about financial support in 73.7% of papers published in Lancet, in 77.4 % of N Engl J Med, in 23.1% of Med Clin (Barc) papers and not one in the Rev Clin Esp studies. CONCLUSIONS: In Spanish clinical journals the use of epidemiological methods with control group is limited and direct financial support unusual. Wherefore these studies have a limited applicability.

Trends in socioeconomic inequalities in amenable mortality in urban areas of Spanish cities, 1996-2007.

BackgroundWhile research continues into indicators such as preventable and amenable mortality in order to evaluate quality, access, and equity in the healthcare, it is also necessary to continue identifying the areas of greatest risk owing to these causes of death in urban areas of large cities, where a large part of the population is concentrated, in order to carry out specific actions and reduce inequalities in mortality. This study describes inequalities in amenable mortality in relation to socioeconomic status in small urban areas, and analyses their evolution over the course of the periods 1996–99, 2000–2003 and 2004–2007 in three major cities in the Spanish Mediterranean coast (Alicante, Castellón, and Valencia).MethodsAll deaths attributed to amenable causes were analysed among non-institutionalised residents in the three cities studied over the course of the study periods. Census tracts for the cities were grouped into 3 socioeconomic status levels, from higher to lower levels of deprivation, using 5 indicators obtained from the 2001 Spanish Population Census. For each city, the relative risks of death were estimated between socioeconomic status levels using Poisson’s Regression models, adjusted for age and study period, and distinguishing between genders.ResultsAmenable mortality contributes significantly to general mortality (around 10%, higher among men), having decreased over time in the three cities studied for men and women. In the three cities studied, with a high degree of consistency, it has been seen that the risks of mortality are greater in areas of higher deprivation, and that these excesses have not significantly modified over time.ConclusionsAlthough amenable mortality decreases over the time period studied, the socioeconomic inequalities observed are maintained in the three cities. Areas have been identified that display excesses in amenable mortality, potentially attributable to differences in the healthcare system, associated with areas of greater deprivation. Action must be taken in these areas of greater inequality in order to reduce the health inequalities detected. The causes behind socioeconomic inequalities in amenable mortality must be studied in depth.

Trends in mortality due to motor vehicle traffic accident injuries between 1987 and 2011 in a Spanish region (Comunitat Valenciana)

OBJECTIVE To analyse the time evolution of the rates of mortality due to motor vehicle traffic accidents (MVTA) injuries that occurred among the general population of Comunitat Valenciana between 1987 and 2011, as well as to identify trend changes by sex and age group. METHODS An observational study of annual mortality trends between 1987 and 2011. We studied all deaths due to MVTA injuries that occurred during this period of time among the non-institutionalised population residing in Comunitat Valenciana (a Spanish Mediterranean region that had a population of 5,117,190 inhabitants in 2011). The rates of mortality due to MVTA injuries were calculated for each sex and year studied. These rates were standardised by age for the total population and for specific age groups using the direct method (age-standardised rate - ASR). Joinpoint regression models were used in order to detect significant trend changes. Additionally, the annual percentage change (APC) of the ASRs was calculated for each trend segment, which is reflected in statistically significant joinpoints. RESULTS For all ages, ASRs decrease greatly in both men and women (70% decrease between 1990 and 2011). In 1990 and 2011, men have rates of 36.5 and 5.2 per 100,000 men/year, respectively. In the same years, women have rates of 8.0 and 0.9 per 100,000 women/year, respectively. This decrease reaches up to 90% in the age group 15-34 years in both men and women. ASR ratios for men and women increased over time for all ages: this ratio was 3.9 in 1987; 4.6 in 1990; and 5.8 in 2011. For both men and women, there is a first significant segment (p<0.05) with an increasing trend between 1987 and 1989-1990. After 1990, there are 3 segments with a significant decreasing APC (1990-1993, 1993-2005 and 2005-2011, in the case of men; and 1989-1996, 1999-2007 and 2007-2011, in the case of women). CONCLUSION The risk of death due to motor vehicle traffic accidents injuries has decreased significantly, especially in the case of women, for the last 25 years in Comunitat Valenciana, mainly as of 2006. This may be a consequence of the road-safety measures that have been implemented in Spain and in Comunitat Valenciana since 2004. The economic crisis that this country has undergone since 2008 may have also been a contributing factor to this decrease. Despite the decrease, ASR ratios for men and women increased over time and it is still a high-risk cause of death among young men. It is thus important that the measures that helped decrease the risk of death are maintained and improved over time.