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In this paper, we discuss the impact of some mortality data anomalies on an internal model capturing longevity risk in the Solvency 2 framework. In particular, we are concerned with abnormal cohort effects such as those for generations 1919 and 1920, for which the period tables provided by the Human Mortality Database show particularly low and high mortality rates, respectively. To provide corrected tables for the three countries of interest here (France, Italy and West Germany), we use the approach developed by Boumezoued for countries for which the method applies (France and Italy) and provide an extension of the method for West Germany as monthly fertility histories are not sufficient to cover the generations of interest. These mortality tables are crucial inputs to stochastic mortality models forecasting future scenarios, from which the extreme 0.5% longevity improvement can be extracted, allowing for the calculation of the solvency capital requirement. More precisely, to assess the impact of such anomalies in the Solvency II framework, we use a simplified internal model based on three usual stochastic models to project mortality rates in the future combined with a closure table methodology for older ages. Correcting this bias obviously improves the data quality of the mortality inputs, which is of paramount importance today, and slightly decreases the capital requirement. Overall, the longevity risk assessment remains stable, as well as the selection of the stochastic mortality model. As a collateral gain of this data quality improvement, the more regular estimated parameters allow for new insights and a refined assessment regarding longevity risk.
Chapter 3 is devoted to the demographic impact of the famine in terms of mortality, fertility, and its long-term biological effects. It shows that in the entire crisis period of September 1944-July 1945, the estimated war-related excess deaths among civilians was 35,000 in the three famine-exposed western provinces. Deaths in the large conurbations began to rise sharply after December 1944 and reached a peak in March 1945. It took until the summer of that year before mortality reached normal patterns again. Fertility followed similar patterns, with birth rates in the urban west two to three times lower in the famine’s wake. The long-term effects of the famine are present even today, in adults who were conceived or born during the famine.
To analyse the cost-effectiveness of Baby-Friendly Hospital Initiative (BFHI) in promoting breast-feeding during the first hour of life (BFFHL) and reducing late neonatal mortality.
Cost-effectiveness economic assessment from the health system perspective, preceded by a prospective cohort of mother–baby followed from birth to 6 months of life. The direct costs associated with two health outcomes were analysed: intermediate end point (BFFHL) and final end point (reduction in late neonatal mortality).
Study was carried out in six hospitals in the city of São Paulo (Brazil), three being Baby-Friendly Hospitals (BFH) and three non-BFH.
Mothers with 24 h postpartum, over 18 years old, single fetus and breast-feeding at the time of the interview were included. Poisson regressions adjusted for maternal age and level of education were estimated to identify factors related to BFFHL and late neonatal mortality. Sensitivity analysis was performed to ensure robustness of the economic assessment.
Cost-effectiveness analysis showed that BFHI was highly cost-effective in raising BFFHL by 32·0 % at lower cost in comparison with non-BFHI. In addition, BFHI was cost-effective in reducing late neonatal mortality rate by 13·0 % from all causes and by 13·1 % of infant mortality rate from infections.
The cost-effectiveness of the BFHI in promoting breast-feeding and reducing neonatal mortality rates justifies the investments required for its expansion within the Brazilian health system.
The increase in mortality and total prehospital time (TPT) seen in Qatar appear to be realistic. However, existing reports on the influence of TPT on mortality in trauma patients are conflicting. This study aimed to explore the impact of prehospital time on the in-hospital outcomes.
A retrospective analysis of data on patients transferred alive by Emergency Medical Services (EMS) and admitted to Hamad Trauma Center (HTC) of Hamad General Hospital (HGH; Doha, Qatar) from June 2017 through May 2018 was conducted. This study was centered on the National Trauma Registry database. Patients were categorized based on the trauma triage activation and prehospital intervals, and comparative analysis was performed.
A total of 1,455 patients were included, of which nearly one-quarter of patients required urgent and life-saving care at a trauma center (T1 activations). The overall TPT was 70 minutes and the on-scene time (OST) was 24 minutes. When compared to T2 activations, T1 patients were more likely to have been involved in road traffic injuries (RTIs); experienced head and chest injuries; presented with higher Injury Severity Score (ISS: median = 22); and had prolonged OST (27 minutes) and reduced TPT (65 minutes; P = .001). Prolonged OST was found to be associated with higher mortality in T1 patients, whereas TPT was not associated.
In-hospital mortality was independent of TPT but associated with longer OST in severely injured patients. The survival benefit may extend beyond the golden hour and may depend on the injury characteristics, prehospital, and in-hospital settings.
Little is known about methylphenidate (MPH) use and mortality outcomes.
To investigate the association between MPH use and mortality among children with an attention-deficit hyperactivity disorder (ADHD) diagnosis.
This population-based cohort study analysed data from Taiwan's National Health Insurance Research Database (NHIRD). A total of 68 096 children and adolescents aged 4–17 years with an ADHD diagnosis and prescribed MPH between 2000 and 2010 were compared with 68 096 without an MPH prescription, matched on age, gender and year of first ADHD diagnosis. All participants were followed to death, migration, withdrawal from the National Health Insurance programme or 31 December 2013. MPH prescriptions were measured on a yearly basis during the study period, and the association between MPH use and mortality was analysed using a repeated-measures time-dependent Cox regression model. The outcome measures included all-cause, unnatural-cause (including suicide, accident and homicide) and natural-cause mortality, obtained from linkage to the National Mortality Register in Taiwan.
The MPH group had lower unadjusted all-cause, natural-, unnatural- and accident-cause mortality than the comparison group. After controlling for potential confounders, MPH use was associated with a significantly lower all-cause mortality (adjusted hazard ratio AHR = 0.81, 95% CI 0.67–0.98, P = 0.027), delayed use of MPH was associated with higher mortality (AHR = 1.05, 95% CI 1.01–1.09) and longer MPH use was associated with lower mortality (AHR = 0.83, 95% CI 0.70–0.98).
MPH use is associated with a reduced overall mortality in children with ADHD in this cohort study, but unmeasured confounding cannot be excluded absolutely.
We compare results for 12 multi-population mortality models fitted to 10 distinct socio-economic groups in England, subdivided using the Index of Multiple Deprivation. Using the Bayes Information Criterion to compare models, we find that a special case of the common age effect (CAE) model fits best in a variety of situations, achieving the best balance between goodness of fit and parsimony. We provide a detailed discussion of key models to highlight which features are important. Group-specific period effects are found to be more important than group-specific age effects, and non-parametric age effects deliver significantly better results than parametric (e.g. linear) age effects. We also find that the addition of cohort effects is beneficial in some cases but not all. The preferred CAE model has the additional benefit of being coherent in the sense of Hyndman et al. ((2013) Demography50(1), 261–283); some of the other models considered are not.
We derive optimal portfolio choice patterns in retirement (ages 66–105) for a constant relative risk aversion utility maximising investor facing risky capital market returns, stochastic mortality risk, and income-reducing health shocks. Beyond the usual stocks and bonds, the individual can invest his assets in tontines. Tontines are cost-efficient financial contracts providing age-increasing, but volatile cash flows, generated through the pooling of mortality without guarantees, which can help to match increasing financing needs at old ages. We find that a tontine invested in the risk-free asset dominates stock investments for older investors without a bequest motive. However, with a bequest motive, it is optimal to replace the tontine investment over time with traditional financial assets. Our results indicate that early in retirement, a tontine is only an attractive investment option, if the tontine funds are invested in a risky asset. In this case, they crowd out stocks and risk-free bonds in the optimal portfolios of younger investors. Over time, the average optimal portfolio weight of tontines decreases. Introducing systematic mortality risks noticeably reduces the peak allocation to tontines.
To date, we have only limited evidence of the determinants of earthquake inpatient mortality-related factors. This study is among the first to explore related factors of inpatient deaths using data from multiple hospitals and multiple earthquakes.
We included and retrospectively analyzed data on 32,976 earthquake inpatients in the West China Earthquake Patients Database. Of these, we analyzed the records of 284 patients who died during hospitalization. We collected 12 dichotomous variables with reference to previous reports: patients’ age (both ≤ 15 years and ≥ 65 years), gender, prehospital treatment, intensive care unit (ICU) admission, the presence of severe traumatic brain injury (TBI), trunk injury, severe poly-trauma, crush syndrome, multiple-system organ failure (MSOF), infection, and cardiac/respiratory disease. We performed multivariate logistic regression analysis to explore independent related factors of mortality.
Ultimately, we identified severe TBI, MSOF, old age (≥ 65 years), ICU admission, crush syndrome, and cardiac/respiratory disease as independent mortality-related factors. Severe TBI was the greatest risk factor of inpatient death (ods ratio [OR], 31.913, 95% confidence interval [CI], 20.484-49.720), followed by MSOF (OR 30.905, 95% CI, 21.733-43.947).
To reduce earthquake inpatient mortalities, the related factors analyzed in this study should be prioritized in future inpatient earthquake response strategies.
On March 11, 2011, a magnitude 9 earthquake (the Great East Japan Earthquake) occurred off the east coast of Japan. After the Fukushima Daiichi Nuclear Power Plant accidents, as of 2016, people were not allowed to live in the 6 districts (Tomioka, Okuma, Futaba, Namie, Katsurao, Iidate) in Fukushima Prefecture. In the present study, we aimed to evaluate the long-term effects of displacement on all-cause mortality in Fukushima Prefecture.
Data regarding population and deaths from 2009 to 2016 in Fukushima Prefecture were obtained from the governmental statistics. The age-adjusted all-cause mortality were compared among the 4 areas in Fukushima Prefecture; the Eastern, Middle, Western, and Displacement areas.
The age-adjusted all-cause mortality rates in the Eastern and Displacement areas were higher than in the other 2 areas from 2009 to 2011. During the period from 2012 to 2016, all-cause mortality in the Displacement area decreased to the lowest, while the morality in the Eastern area remained the highest.
Against all expectations, after the earthquake, all-cause mortality in the Displacement area was continuously lower than in the rest of the Fukushima Prefecture. Following disasters, long-term monitoring should be organized to meet local health-care needs.
The relationship between population density and suicide risk remains unclear. While urbanization is associated with greater risk for psychopathology, higher suicide rates have been reported in rural areas. We examined population density and suicide in the Italian population in the last 30 years.
The Italian National Institute of Statistics databases of the Italian population aged 15 years and older (52.4 million in 2016) were used to compute age-adjusted annual total mortality and suicide rates for the years 1985–2016. According to the European Union statistical office (EUROSTAT) criteria, municipalities were classified into densely populated areas, intermediate density areas, or thinly populated areas. Rate ratios (RRs) were computed by sex, age, and geographical area, using densely populated areas as reference.
Total mortality was not associated with population density. In males, suicide rate increased with decreasing population density (RR = 1.17, 95% confidence interval [CI]:1.08–1.28, in intermediate population areas, and RR = 1.32, 95% CI: 1.20–1.45, in thinly populated areas, in 2016). This inverse relationship was found across age, geographical areas, and consecutively over 22 years (1994–2016). In females, no significant difference was detected (RR = 0.96, 95% CI: 0.82–1.13 in intermediate density areas and RR = 1.02, 95% CI: 0.85–1.22 in thinly populated areas). Hanging was the most common suicide method among males, more frequent in thinly (58.8%) than intermediate (53.2%) or densely (41.4%) populated areas.
A consistent and temporally stable inverse relationship between population density and suicide was found in the male, but not female, population. Men may be more vulnerable to adverse social and economic factors associated with lower population density.
CVD is the most common chronic condition and the highest cause of mortality in the USA. The aim of the present work was to investigate diet and sedentary behaviour in relation to mortality in US CVD survivors. The National Health and Nutrition Examination Surveys conducted between 1999 and 2014 linked to the US mortality registry updated to 2015 were investigated. Multivariate adjusted Cox regression was used to derive mortality hazards in relation to sedentary behaviour and nutrient intake. A multiplicative and additive interaction analysis was conducted to evaluate how sedentariness and diet influence mortality in US CVD survivors. A sample of 2473 participants followed for a median period of 5·6 years resulted in 761 deaths, and 199 deaths were due to CVD. A monotone increasing relationship between time spent in sedentary activities and mortality risk was observed for all-cause and CVD mortality (hazard ratio (HR) = 1·20, 95 % CI 1·09, 1·31 and HR = 1·19, 95 % CI 1·00, 1·67, respectively). Inverse mortality risks in the range of 22–34 % were observed when comparing the highest with the lowest tertile of dietary fibre, vitamin A, carotene, riboflavin and vitamin C. Sedentariness below 360 min/d and dietary fibre and vitamin intake above the median interact on an additive scale influencing positively all-cause and CVD mortality risk. Reduced sedentariness in combination with a varied diet rich in dietary fibre and vitamins appears to be a useful strategy to reduce all-cause and CVD mortality in US CVD survivors.
Access to quality healthcare varies across the national territory inside Latin American countries, with some subnational units enjoying higher-quality care than others. Such territorial inequality is consequential, as residents of particular regions face shorter life spans and an increased risk of preventable disease. This article analyzes trajectories of territorial healthcare inequality across time in Argentina, Brazil, and Mexico. The data reveal a large decline in Brazil, a moderate decline in Mexico, and low levels of change followed by a moderate decline in Argentina. The article argues that two factors account for these distinct trajectories: the nature of the coalition that pushed health decentralization forward and the existence of mechanisms for central government oversight and management.
Wavelet theory is known to be a powerful tool for compressing and processing time series or images. It consists in projecting a signal on an orthonormal basis of functions that are chosen in order to provide a sparse representation of the data. The first part of this article focuses on smoothing mortality curves by wavelets shrinkage. A chi-square test and a penalized likelihood approach are applied to determine the optimal degree of smoothing. The second part of this article is devoted to mortality forecasting. Wavelet coefficients exhibit clear trends for the Belgian population from 1965 to 2015, they are easy to forecast resulting in predicted future mortality rates. The wavelet-based approach is then compared with some popular actuarial models of Lee–Carter type estimated fitted to Belgian, UK, and US populations. The wavelet model outperforms all of them.
This study aims to identify the risk factors associated with mortality and survival of COVID-19 cases in a state of the Brazilian Northeast. It is a historical cohort with a secondary database of 2070 people that presented flu-like symptoms, sought health assistance in the state and tested positive to COVID-19 until 14 April 2020, only moderate and severe cases were hospitalised. The main outcome was death as a binary variable (yes/no). It also investigated the main factors related to mortality and survival of the disease. Time since the beginning of symptoms until death/end of the survey (14 April 2020) was the time variable of this study. Mortality was analysed by robust Poisson regression, and survival by Kaplan–Meier and Cox regression. From the 2070 people that tested positive to COVID-19, 131 (6.3%) died and 1939 (93.7%) survived, the overall survival probability was 87.7% from the 24th day of infection. Mortality was enhanced by the variables: elderly (HR 3.6; 95% CI 2.3–5.8; P < 0.001), neurological diseases (HR 3.9; 95% CI 1.9–7.8; P < 0.001), pneumopathies (HR 2.6; 95% CI 1.4–4.7; P < 0.001) and cardiovascular diseases (HR 8.9; 95% CI 5.4–14.5; P < 0.001). In conclusion, mortality by COVID-19 in Ceará is similar to countries with a large number of cases of the disease, although deaths occur later. Elderly people and comorbidities presented a greater risk of death.
While overall neonatal mortality rates are improving in Ghana, the Ashanti Region has the highest mortality rate in the country. The clinical causes of newborn deaths are well known, yet local beliefs about illness aetiology, cause of death and care-seeking are less well understood. This exploratory qualitative study sought to understand how community members perceive and respond to neonatal illness. Researchers worked with public health nurses, community health nurses and opinion leaders in the Ashanti Region of Ghana to identify women who had lost a baby, either during pregnancy or after delivery. In-depth interviews and focus group discussions were conducted about knowledge, attitudes and beliefs regarding neonatal mortality. The transcripts were coded and analysed using NVivo 10.0. A total of 100 participants were interviewed: 24% reported a previous stillbirth; 37% reported a previous miscarriage; and 45% reported losing a baby who was born alive. Nine per cent experienced more than one type of loss. The local illness of asram – an illness with supernatural causes – was cited as a leading cause of death of newborns. Every participant reported hearing of, knowing someone, or having a child who had become ill with asram. While women gave varying information on symptoms, method of contraction and treatment, all participants agreed that asram was common and often fatal. Four overarching themes emerged: 1) asram is not a hospital sickness; 2) there is both a fear of traditional healers as a source of asram, as well as a reliance upon them to cure asram; 3) there are rural/urban differences in perceptions of asram; and 4) asram may serve as a mechanism of social control for pregnant women and new mothers. Local beliefs and practices must be better understood and incorporated into health education campaigns if neonatal mortality is to be reduced in Ghana.
The purpose of this paper is to identify a workhorse mortality model for the adult age range (i.e., excluding the accident hump and younger ages). It applies the “general procedure” (GP) of Hunt & Blake [(2014), North American Actuarial Journal, 18, 116–138] to identify an age-period model that fits the data well before adding in a cohort effect that captures the residual year-of-birth effects arising in the original age-period model. The resulting model is intended to be suitable for a variety of populations, but economises on the number of period effects in comparison with a full implementation of the GP. We estimate the model using two different iterative maximum likelihood (ML) approaches – one Partial ML and the other Full ML – that avoid the need to specify identifiability constraints.
Premature mortality among patients experiencing forensic care is high. This paper examines the morbidity and mortality of all Scottish high secure patients in 1992/1993 and followed up 20 years later through the context of recovery.
To explore morbidity and delineate which patients are at greatest risk of premature mortality. To assess the extent of suicide and unnatural deaths. To establish which factors, if any, appear protective.
Health and mortality data were extracted from national data-sets and death categorised as premature or post-expected age. Standardised mortality ratios were calculated to explore natural, unnatural and suicide deaths with Cox regression conducted to explore baseline demographics and premature death.
During a mean follow-up of 21.1 years, 36.9% (n = 89) died, at an average age of 55.6 years. Of these, 70.8% (n = 63) died prematurely. Men lost on average 14.9 years and women 24.1 years of potential life. Five lives (5.6%) were lost by suicide and three (3.4%) by unnatural means.
In contrast to other mainstream and forensic cohorts, high rates of suicide and accidental deaths were not apparent. Risk of premature mortality is high. A greater focus upon physical health by community and in-patient services is essential.
Obesity is a major public health issue with prevalence increasing worldwide. Obesity is a well-established risk factor for CVD and mortality in adult populations. However, the impact of being overweight or obese in the elderly on CVD and mortality is controversial. Some studies even suggest that overweight and obesity, measured by BMI, are apparently associated with a decreased mortality risk (known as the obesity paradox). Ageing is associated with an increase in visceral fat and a progressive loss of muscle mass. Fat mass is positively associated and lean mass is negatively associated with risk of mortality. Therefore, in older adults BMI is not a good indicator of obesity. Sarcopenia has been defined as the degenerative loss of muscle mass, quality and strength with age and is of major concern in ageing populations. Sarcopenia has previously been associated with increased risks of metabolic impairment, cardiovascular risk factors, physical disability and mortality. It is possible for sarcopenia to co-exist with obesity, and sarcopenic obesity is a new class of obesity in older adults who have high adiposity levels together with low muscle mass, quality or strength. Therefore, sarcopenia with obesity may act together to increase their effect on metabolic disorders, CVD and mortality. This review will discuss the available evidence for the health implications of sarcopenic obesity on CVD and mortality in older adults.
In this paper, we explore the use of an extensive list of Archimedean copulas in general and life insurance modelling. We consider not only the usual choices like the Clayton, Gumbel–Hougaard, and Frank copulas but also several others which have not drawn much attention in previous applications. First, we apply different copula functions to two general insurance data sets, co-modelling losses and allocated loss adjustment expenses, and also losses to building and contents. Second, we adopt these copulas for modelling the mortality trends of two neighbouring countries and calculate the market price of a mortality bond. Our results clearly show that the diversity of Archimedean copula structures gives much flexibility for modelling different kinds of data sets and that the copula and tail dependence assumption can have a significant impact on pricing and valuation. Moreover, we conduct a large simulation exercise to investigate further the caveats in copula selection. Finally, we examine a number of other estimation methods which have not been tested in previous insurance applications.
Colombia is the fourth largest country in South America. It is an upper middle-income country with an estimated population of 49.2 million people, and road traffic collisions (RTCs) are the second most common cause of traumatic death. The United Nations (UN) proclaimed 2011 to 2020 as the “Decade of Action for Road Safety.” In this context, the government of Colombia established the National Road Safety Plan (PNSV) for the period 2011-2021, aiming to reduce RTC-related deaths by 26%. Some road safety laws (RSLs) were implemented before the PNSV, but their impact on deaths and injuries is still not known.
The aim of this study was to evaluate whether these RSLs have had a long-term effect on road safety in the country.
Data on RTC casualties, deaths, and injuries from January 1, 2001 through December 31, 2017 were collated from official Colombian governmental publications. Three different periods were considered for analysis: 2001-2010 to evaluate the Transit Code; 2011-2017 to evaluate the PNSV; and 2001-2017 to evaluate a composite of the full study period. Analyses of trends in deaths and injuries were related to dates of new RSLs.
A total of 102,723 deaths (12.7%) and 707,778 injuries (87.3%) were reported from 2001 through 2017. The Transit Code period (2001-2010) showed a 10.1% decline in deaths, 16.6% decline in injuries, and rates per 100,000 inhabitants and per 10,000 registered vehicles also declined. During the period of the PNSV (2011-2017), there was an increase in the number of deaths by 16.6%, injuries decreased by 1.7%, and death rates per 100,000 inhabitants also increased. During the total study period, a 12.4% reduction in the total number of casualties was achieved, and death and injury rates per 100,000 inhabitants decreased by 12.4% and 27.5%, respectively.
Despite the introduction of the PNSV, RTCs remain the second most common cause of preventable death in Colombia. Overall, while the absolute number of RTCs and deaths has been increasing, the rate of RTCs per 10,000 registered vehicles has been decreasing. This suggests that although the goals of the PNSV may not be realized, some of the laws emanating from it may be having a beneficial effect. Further study is required over a protracted period to determine the longer-term impact of these initiatives.