Mercè Gotsens

Inequalities in mortality in small areas of eleven Spanish cities (the multicenter MEDEA project).

The objectives of this study are to identify inequalities in mortality among census tracts of 11 Spanish cities in the period 1996-2003 and to analyse the relationship between these geographical inequalities and socioeconomic deprivation. It is a cross-sectional ecological study where the units of analysis are census tracts. We obtained an index of socioeconomic deprivation and estimated SMR by each census tract using hierarchical Bayesian models which take into account the spatial structure. In the majority of the cities geographical patterns in total mortality were found in both sexes, which were similar to those for the index of socioeconomic deprivation. Among men, four specific causes of death (lung cancer, ischemic heart diseases, respiratory diseases and cirrhosis) were positively associated with deprivation in the majority of cities. Among women the specific causes diabetes and cirrhosis were positively associated, while lung cancer was negatively associated with deprivation. The excess of mortality related with deprivation was 59,445 deaths among men and 23,292 among women. These results highlight the importance of intra-urban inequalities in health.

Validación de la causa básica de defunción en las muertes que requieren intervención medicolegal

Background: Deaths due to external causes require additional medical tests in order to determine the cause of death. If these results are not incorporated into the death register these causes may be misclassified. The objective of this study is to validate the underlying cause of death of the Mortality Register with information obtained from forensic sources in Barcelona between 2004 and 2006. Methods: Cross-sectional design. The study population consisted of deceased residents in Barcelona with a medicolegal intervention between 2004 and 2006. The sources of information are the Mortality Registry and the forensic pathology file filled in by Institute of Legal Medicine of Catalonia (ILMC) (gold standard). The study variables are the cause of death, sex and age. Sensitivity and percentage of confirmation (PC) with 95% confidence intervals (95% CI) are calculated. Results: The sensitivity of external causes is 59.7% (95% CI:56.5-62.9) and PC is 96.7% (95% CI:94.8-98.0). Traffic injuries, poisonings and suicides are under-reported in the Mortality Register with a sensitivity lower than 45% and a PC higher than 80%. Symptoms, signs and ill-defined conditions are over-reported with a sensitivity of 89.2% (95% CI:83.4-93.4) and a PC of 28.0% (95% CI:24.2-32.1). There are no differences by sex and age. Conclusions: The validity of the external causes in the Mortality Register is low due to under-reporting and the high proportion of symptoms signs and ill-defined causes. According to the results, incorporating information from forensic sources to the Mortality Register increases the quality of mortality statistics.BACKGROUND Deaths due to external causes require additional medical tests in order to determine the cause of death. If these results are not incorporated into the death register these causes may be misclassified. The objective of this study is to validate the underlying cause of death of the Mortality Register with information obtained from forensic sources in Barcelona between 2004 and 2006. METHODS Cross-sectional design. The study population consisted of deceased residents in Barcelona with a medicolegal intervention between 2004 and 2006. The sources of information are the Mortality Registry and the forensic pathology file filled in by Institute of Legal Medicine of Catalonia (ILMC) (gold standard). The study variables are the cause of death, sex and age. Sensitivity and percentage of confirmation (PC) with 95% confidence intervals (95% CI) are calculated. RESULTS The sensitivity of external causes is 59.7% (95% CI:56.5-62.9) and PC is 96.7% (95% CI:94.8-98.0). Traffic injuries, poisonings and suicides are under-reported in the Mortality Register with a sensitivity lower than 45% and a PC higher than 80%. Symptoms, signs and ill-defined conditions are over-reported with a sensitivity of 89.2% (95% CI:83.4-93.4) and a PC of 28.0% (95% CI:24.2-32.1). There are no differences by sex and age. CONCLUSIONS The validity of the external causes in the Mortality Register is low due to under-reporting and the high proportion of symptoms signs and ill-defined causes. According to the results, incorporating information from forensic sources to the Mortality Register increases the quality of mortality statistics.

Cancer mortality inequalities in urban areas: a Bayesian small area analysis in Spanish cities

BackgroundIntra-urban inequalities in mortality have been infrequently analysed in European contexts. The aim of the present study was to analyse patterns of cancer mortality and their relationship with socioeconomic deprivation in small areas in 11 Spanish cities.MethodsIt is a cross-sectional ecological design using mortality data (years 1996-2003). Units of analysis were the census tracts. A deprivation index was calculated for each census tract. In order to control the variability in estimating the risk of dying we used Bayesian models. We present the RR of the census tract with the highest deprivation vs. the census tract with the lowest deprivation.ResultsIn the case of men, socioeconomic inequalities are observed in total cancer mortality in all cities, except in Castellon, Cordoba and Vigo, while Barcelona (RR = 1.53 95%CI 1.42-1.67), Madrid (RR = 1.57 95%CI 1.49-1.65) and Seville (RR = 1.53 95%CI 1.36-1.74) present the greatest inequalities. In general Barcelona and Madrid, present inequalities for most types of cancer. Among women for total cancer mortality, inequalities have only been found in Barcelona and Zaragoza. The excess number of cancer deaths due to socioeconomic deprivation was 16,413 for men and 1,142 for women.ConclusionThis study has analysed inequalities in cancer mortality in small areas of cities in Spain, not only relating this mortality with socioeconomic deprivation, but also calculating the excess mortality which may be attributed to such deprivation. This knowledge is particularly useful to determine which geographical areas in each city need intersectorial policies in order to promote a healthy environment.

Socioeconomic inequalities in cause-specific mortality in 15 European cities

Background Socioeconomic inequalities are increasingly recognised as an important public health issue, although their role in the leading causes of mortality in urban areas in Europe has not been fully evaluated. In this study, we used data from the INEQ-CITIES study to analyse inequalities in cause-specific mortality in 15 European cities at the beginning of the 21st century. Methods A cross-sectional ecological study was carried out to analyse 9 of the leading specific causes of death in small areas from 15 European cities. Using a hierarchical Bayesian spatial model, we estimated smoothed Standardized Mortality Ratios, relative risks and 95% credible intervals for cause-specific mortality in relation to a socioeconomic deprivation index, separately for men and women. Results We detected spatial socioeconomic inequalities for most causes of mortality studied, although these inequalities differed markedly between cities, being more pronounced in Northern and Central-Eastern Europe. In the majority of cities, most of these causes of death were positively associated with deprivation among men, with the exception of prostatic cancer. Among women, diabetes, ischaemic heart disease, chronic liver diseases and respiratory diseases were also positively associated with deprivation in most cities. Lung cancer mortality was positively associated with deprivation in Northern European cities and in Kosice, but this association was non-existent or even negative in Southern European cities. Finally, breast cancer risk was inversely associated with deprivation in three Southern European cities. Conclusions The results confirm the existence of socioeconomic inequalities in many of the main causes of mortality, and reveal variations in their magnitude between different European cities.

Socioeconomic inequalities in mortality in 16 European cities

Aims: To explore inequalities in total mortality between small areas of 16 European cities for men and women, as well as to analyse the relationship between these geographical inequalities and their socioeconomic indicators. Methods: A cross-sectional ecological design was used to analyse small areas in 16 European cities (26,229,104 inhabitants). Most cities had mortality data for a period between 2000 and 2008 and population size data for the same period. Socioeconomic indicators included an index of socioeconomic deprivation, unemployment, and educational level. We estimated standardised mortality ratios and controlled for their variability using Bayesian models. We estimated relative risk of mortality and excess number of deaths according to socioeconomic indicators. Results: We observed a consistent pattern of inequality in mortality in almost all cities, with mortality increasing in parallel with socioeconomic deprivation. Socioeconomic inequalities in mortality were more pronounced for men than women, and relative inequalities were greater in Eastern and Northern European cities, and lower in some Western (men) and Southern (women) European cities. The pattern of excess number of deaths was slightly different, with greater inequality in some Western and Northern European cities and also in Budapest, and lower among women in Madrid and Barcelona. Conclusions: In this study, we report a consistent pattern of socioeconomic inequalities in mortality in 16 European cities. Future studies should further explore specific causes of death, in order to determine whether the general pattern observed is consistent for each cause of death.

Socio-economic inequalities in mortality due to injuries in small areas of ten cities in Spain (MEDEA Project)

OBJECTIVES To analyse socio-economic inequalities in mortality due to injuries among census tracts of ten Spanish cities by sex and age in the period 1996-2003. METHODS This is a cross-sectional ecological study where the units of analysis are census tracts. The study population consisted of people residing in the cities during the period 1996-2003. For each census tract we obtained an index of socio-economic deprivation, and estimated standardized mortality ratios using hierarchical Bayesian models which take into account the spatial structure of the data. RESULTS In the majority of the cities, the geographical pattern of total mortality from injuries is similar to that of the socio-economic deprivation index. There is an association between mortality due to injuries and the deprivation index in the majority of the cities which is more important among men and among those younger than 45 years. In these groups, traffic injuries and overdoses are the causes most often associated with deprivation in the cities. The percentage of excess mortality from injuries related to socio-economic deprivation is higher than 20% in the majority of the cities, the cause with the highest percentage being drug overdose. CONCLUSIONS In most cities, there are socio-economic inequalities in mortality due to overdose and traffic injuries. In contrast, few cities have found association between suicide mortality and deprivation. Finally, no association was found between deprivation and deaths due to falls. Inequalities are higher in men and those under 45 years of age. These results highlight the importance of intra-urban inequalities in mortality due to injuries.

Social differences in avoidable mortality between small areas of 15 European cities: an ecological study

BackgroundHealth and inequalities in health among inhabitants of European cities are of major importance for European public health and there is great interest in how different health care systems in Europe perform in the reduction of health inequalities. However, evidence on the spatial distribution of cause-specific mortality across neighbourhoods of European cities is scarce. This study presents maps of avoidable mortality in European cities and analyses differences in avoidable mortality between neighbourhoods with different levels of deprivation.MethodsWe determined the level of mortality from 14 avoidable causes of death for each neighbourhood of 15 large cities in different European regions. To address the problems associated with Standardised Mortality Ratios for small areas we smooth them using the Bayesian model proposed by Besag, York and Mollié. Ecological regression analysis was used to assess the association between social deprivation and mortality.ResultsMortality from avoidable causes of death is higher in deprived neighbourhoods and mortality rate ratios between areas with different levels of deprivation differ between gender and cities. In most cases rate ratios are lower among women. While Eastern and Southern European cities show higher levels of avoidable mortality, the association of mortality with social deprivation tends to be higher in Northern and lower in Southern Europe.ConclusionsThere are marked differences in the level of avoidable mortality between neighbourhoods of European cities and the level of avoidable mortality is associated with social deprivation. There is no systematic difference in the magnitude of this association between European cities or regions. Spatial patterns of avoidable mortality across small city areas can point to possible local problems and specific strategies to reduce health inequality which is important for the development of urban areas and the well-being of their inhabitants.

Socioeconomic inequalities in injury mortality in small areas of 15 European cities.

This study analysed socioeconomic inequalities in mortality due to injuries in small areas of 15 European cities, by sex, at the beginning of this century. A cross-sectional ecological study with units of analysis being small areas within 15 European cities was conducted. Relative risks of injury mortality associated with the socioeconomic deprivation index were estimated using hierarchical Bayesian model. The number of small areas varies from 17 in Bratislava to 2666 in Turin. The median population per small area varies by city (e.g. Turin had 274 inhabitants per area while Budapest had 76,970). Socioeconomic inequalities in all injury mortality are observed in the majority of cities and are more pronounced in men. In the cities of northern and western Europe, socioeconomic inequalities in injury mortality are found for most types of injuries. These inequalities are not significant in the majority of cities in southern Europe among women and in the majority of central eastern European cities for both sexes. The results confirm the existence of socioeconomic inequalities in injury related mortality and reveal variations in their magnitude between different European cities.

Assessment of primary care in health surveys: a population perspective

BACKGROUND The objective of this study was to evaluate the metric properties of a selection of items of the Primary Care Assessment Tool (PCAT) included into 2006 Catalonia Health Survey and adapted to evaluate experiences of primary care (PC) under population perspective. METHODS This was a cross-sectional study. The study population was composed of non-institutionalized residents of Catalonia over 15 years of age (n = 12,933). The instrument used was a 10-item selection of the adult users version of the PCAT (PCAT10-AE). We assessed internal consistency, correlation between items and performed exploratory factor analysis and external validity analysis. RESULTS The instrument presented adequate internal consistency (0.72). All items showed acceptable correlation with other items that constitute the scale. The single extracted factor explained 64% of the common variance in the responses, allowing the construction of a global index for evaluation of PC. We observed an association between better evaluation of PC and more satisfaction with the health system. CONCLUSIONS Metric analysis supported the integrity and general adequacy of this very short tool included in a population health survey. The global index proposed could be a good measure for assessing and monitoring the adequacy of part of the PC experiences in first-contact care and person-focused care over time, under population perspective. On the other hand, the loss of content as a consequence of the selection of items, suggesting use of the expanded versions of the PCAT-AE whenever a global evaluation of PC is desired and it is possible.

Trends in socio-economic inequalities in injury mortality among men in small areas of 26 Spanish cities, 1996-2007.

OBJECTIVE To analyse trends in socio-economic inequalities in mortality due to all injuries, as well as, suicide and motor vehicle injuries, in men in the census tracts of 26 Spanish cities for the periods 1996-2001 and 2002-2007. METHODS Ecological study of trends based on two periods (1996-2001 and 2002-2007). The study population consisted of male residents in each city during the period 1996-2007. We fitted a hierarchical Bayesian model which takes into account the spatial structure of the data in order to obtain relative risks (RRs), and their 95% credible intervals (CIs), between mortality and a socio-economic deprivation index, in each period. RESULTS In most of the cities, mortality due to total injuries presents the same geographical pattern as the deprivation index in the two periods. Moreover, inequalities remained stable. In contrast, socio-economic inequalities in mortality due to motor vehicle injuries tended to diminish in the second period in the majority of the cities, particularly Castellón (first period: RR(1)=2.56; 95%CI: 1.19-4.84; second period: RR(2)=1.06; 95%CI: 0.45-2.12), whereas in the case of suicides, the inequalities remain stable but are only significant in large cities. CONCLUSION This study has demonstrated that socio-economic inequalities in mortality due to all injuries in small areas of 26 Spanish cities remain stable over time. These results highlight the importance of intra-urban inequalities in mortality due to injuries and their evolution over time.