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Background: Alcohol use is associated with breast cancer in many epidemiological studies. Most, however, have measured risk from recent consumption patterns, and only a few include analyses for duration of drinking or age that a woman started to drink. The authors studied the effect of these variables, as well as of recent alcohol consumption patterns, on breast cancer risk.Methods: Data from a large case-control study conducted in Long Island, New York from 1 January 1984 to 31 December 1986 were used. A total of 1214 women aged 20-79 years with incident breast cancer were interviewed. A control was selected for each case from driver's license files, and matched on age and county of residence. Alcohol consumption was measured as: ever versus never, grams of alcohol per day, age started drinking, and total years drinking.Results: After adjustment for breast cancer risk factors, the odds ratio for ever versus never drinking was 1.40 (95% confidence interval [CI] 1.09-1.79); odds ratios for > 0-5 and > or = 5 grams of alcohol use per day, as compared to nondrinkers, were 1.29 (95% CI: 1.00-1.65) and 1.46 (95% CI: 1.13-1.89), respectively. Age when drinking began was not related to breast cancer risk, but the greater the total years of drinking, up to 40 years (odds ratio 1.48, 95% CI: 1.13-1.93), the greater the risk. However, when grams per day and duration of drinking were simultaneously included in the multivariate model, duration was not important as a risk factor. This suggests that intensity of drinking may be the important factor for breast cancer risk. After covariate adjustment, risk from alcohol intake did not differ between pre- and postmenopausal women. [ABSTRACT FROM AUTHOR]

Background: Although mortality from conditions amenable to medical intervention has frequently been shown to be higher in the countries of Central and Eastern Europe (CCEE) than in the countries of Western Europe (CWE), the contribution of these mortality differences to the East-West gap in life expectancy is unknown. We have determined the contribution of mortality from nine amenable causes to differences in temporary life expectancy from birth to age 75 (TLE0-75) between 12 CCEE and the average TLE0-75 for CWE in ca. 1988.Data and Methods: Population and mortality data were extracted from publications of the World Health Organization. Chiang's method was used for constructing abridged life tables, and Arriaga's method was used for decomposition by cause of death of the differences in TLE0-75 between each of the CCEE and the average for CWE.Results: Differences in TLE0-75 between CCEE and the average for CWE ranged between 1.25 and 6.29 years in men, and between 1.09 and 3.44 years in women. After exclusion of early neonatal deaths, for which data were not available in all CCEE, amenable causes accounted for between 11% and 50% of the difference in TLE0-75 in men, and between 24% and 59% in women. The results for countries where data on early neonatal deaths were available show that inclusion of this category generally raises these estimates substantially. The contribution of conditions amenable to medical intervention to the East-West life expectancy gap is of the same order of magnitude as that of cardiovascular diseases, and much larger than that of neoplasms, respiratory diseases or external causes.Conclusion: Although the contribution of conditions amenable to medical intervention should not be taken as a direct estimate of the contribution of medical care to the East-West life expectancy gap, these results suggest that reducing differences in the effectiveness of medical care may be more important for narrowing the life expectancy gap than has hitherto been assumed. [ABSTRACT FROM AUTHOR]

Background: 'Avoidable' mortality is commonly studied as an indicator of the outcome of health care. In this study socioeconomic differences in avoidable mortality in Sweden from 1986 to 1990 are analysed and related methodological issues discussed.Methods: The 1985 Swedish Population and Housing Census was linked to the National Cause of Death Register 1986-1990. Mortality from potentially 'avoidable' causes of death was analysed for the age group 21-64 years. Analyses were performed for different socioeconomic groups, blue-collar workers, white-collar workers and the self-employed as well as for individuals outside the labour market. Standardized Mortality Ratios were calculated using standardization by age and sex.Results: For all indicators studied, the death rates for those not in work were higher than for people at work. The largest differences were found for chronic bronchitis, diabetes, bacterial meningitis, ulcer of the stomach and duodenum, chronic rheumatic heart disease, asthma and hypertensive and cerebrovascular disease. For these causes of death the risk of dying was between 3.1 and 7.5 times greater in the non-working population than in the work-force. The differences in avoidable mortality between blue-collar workers and white-collar workers and the self-employed were, however, much smaller. For most of the indicators no significant differences were found. For ulcers of the stomach and duodenum, however the death rate for blue-collar workers was 2.8 times higher than those for other categories in work.Conclusions: The small difference in mortality outcome for different socioeconomic groups within the work-force indicates an equal quality of care for these groups. The greatly increased risk among the non-working population, however, is a warning sign. These results may be due to a 'healthy worker' effect. The measurement of socioeconomic differences in mortality may be dependent on the time-period chosen between occupational exposure and mortality outcome. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization (WHO) recommended the use of high titre measles vaccine in 1989. Subsequent long term follow-up of several trials yielded results suggesting higher mortality among children inoculated with medium and high titre vaccines compared to standard titre vaccines, although none of the individual trials found significant differences in mortality.Methods: Long term survival after standard, medium and high titre measles vaccines has been investigated in a combined analysis of all West African trials with mortality data. In trials from Guinea-Bissau, The Gambia and Senegal, children received medium or high titre vaccines from 4 months of age and were compared to control groups recruited at the same time later receiving standard titre vaccine from 9 months of age. All children were followed up to at least 3 years old.Results: Combining trials of high titre vaccines showed higher mortality among the high titre group compared to the standard group: mortality ratio (MR) = 1.33 (95% CI : 1.02-1. 73). Mortality among recipients of medium titre vaccines was not different from that in the standard vaccine group, MR = 1.11 (95% CI: 0.54-2.27). In a combined analysis by sex, the adjusted mortality ratios comparing high titre vaccine with standard vaccine were 1.86 (95% CI : 1.28-2.70) for females and 0.91 (95% CI : 0.61-1.35) for males. The trials were not designed to study long term mortality. Adjustments for several possible sources of bias did not alter the results.Conclusions: The combined analysis showed a decreased survival related to high titre measles vaccine compared with standard titre vaccines, though solely among females. As a result of these studies from West Africa and a study from Haiti, WHO has recommended that high titre measles vaccine no longer be used. [ABSTRACT FROM AUTHOR]

Background: Cancer mortality has been stated to be the best single measure of progress in combatting cancer. The variation in total and cause-specific cancer mortality among health administrative areas in Sweden was analysed in order to find out if the mortality outcome has been equally distributed.Methods: Data on underlying causes of death for ages 0-74 years were analyzed for the 26 health administrative areas in Sweden, 1975-1990. Analyses of systematic (non-random) variance were performed and measures chosen in order to make comparisons possible between different malignant neoplasms and different periods of time.Results: The systematic variance for all malignant neoplasms was reduced by about 40% during the study period. The largest systematic variations in mortality were found for cancer of the oesophagus and lung, although the systematic variation for these neoplasms was lower in the 1980s than in the 1970s. Large systematic variation was also found for cancer of the cervix uteri and of the bladder. For these causes the variation remained constant throughout the period.Conclusions: Generally speaking, the outcome of cancer has become more equally distributed across the country. Preventive measures should be possible for the malignant neoplasms with the largest regional variation. [ABSTRACT FROM AUTHOR]

Background: The effect of using multiple causes of death, i.e. all causes of death mentioned on the death certificates, compared to using the underlying cause of death only for analyses of regional variation among small areas in mortality for asthma, diabetes, hypertensive disease and cerebrovascular disease was studied.Methods: Standardized mortality ratios (SMR) were analysed for the different health administrative areas in Sweden using data from the Swedish cause of death register for the period 1987-1991. The SMR were calculated for each of the selected underlying causes of death as well as for multiple causes of death. The correlations between SMR for underlying and multiple causes were analysed.Results: The highest level of correlation of the SMR between multiple and underlying causes of death was found for cerebrovascular disease (0.96) and the lowest for hypertensive disease in the age group 0-64 years (0.51). For hypertensive disease, diabetes and asthma, when using multiple causes of death some further areas were found to have high SMR and the level of significance was higher. Significantly high SMR using underlying causes of death were, however, not shown to be false when multiple causes of death were used. In the case of cerebrovascular disease little additional information was gained.Conclusion: By including multiple causes of death in small-area analysis more statistical outliers can be detected and the risk of false warning signals due to random effect can be limited. Analyses of underlying causes of death and multiple causes of death should preferably be combined. [ABSTRACT FROM AUTHOR]

Background: Relative risk of death from causes amenable to health services' intervention was studied in a case-control design to ascertain regional and social class differences.Methods: The data were 2091 deaths from amenable causes and 8364 randomly drawn living controls in 1980-1986 in the seven health districts in Helsinki, Finland. Logistic regression was used to adjust relative risk estimates for age, sex and marital status.Results: Adjustments decreased the risk ratios. Compared with the Southern District, the Middle District had significantly higher adjusted relative risk (RR = 1.4; 95% confidence interval [CI]: 1.1-1.7). People with no address had even higher relative risk (RR = 3.1; 95% CI: 2.3-4.2). Compared with social group I, increased relative risks were found in social group II (RR = 1.3; 95% CI: 1.1-1.6), group III (RR = 2.0; 95% CI: 1.6-2.4), group IV (RR = 1.9; 95% CI: 1.5-2.5) and group VI (RR = 8.5; 95% CI: 6.9-10.6). Males had higher relative risk than females (RR = 2.4; 95% CI: 2.1-2.8). Of the dead with no address, 29% were pensioners and 41% had been registered unemployed or occupation was unknown; 48% were single and 17% divorced.Conclusions: Our results suggest that regional inequalities in health care between various districts in Helsinki are small. However, to a large extent two overlapping groups, social group VI and people with no address, seem to delineate a deprived group likely to need special help from health care. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate the influence of acute coronary care on the myocardial infarction (MI) case-fatality gradient observed in three French regions. In 1989, a total of 813 hospitalized events of premature MI, occurring in men and women aged 25-64, were registered in three WHO-MONICA sites established in Lille (North of France), Strasbourg (East of France) and Toulouse (South of France). The case-fatality rates observed 28 days after the onset of the MI, were 30.6% in Lille, 17.5% in Strasbourg and 9.9% in Toulouse (P < 0.0001). We compared the management of events and the use of cardiovascular therapies in these centres before admission to hospital, during the stay and on discharge from hospital. Differences were observed between the three centres in the use of medical treatments: in Strasbourg, aspirin and antiplatelet agents were prescribed 15% less frequently, (P < 0.0001) while diuretics were prescribed twice as often as in Toulouse (P < 0.0001). Thrombolytic agents (P < 0.01) and invasive techniques (coronary angiography, coronary angioplasty and coronary bypass surgery) (P < 0.0001) were more widely used in Toulouse compared with the two other centres. Lille might have a higher rate of coronary case fatality than Strasbourg and Toulouse because of a series of cumulative characteristics. The disease presented in a more serious form: more frequent electrocardiographic changes in anterior leads (P < 0.02), higher percentage of use of inotropic drugs in association with diuretic agents (P < 0.04), and longer duration of stay in intensive care units (P < 0.0001). However, when case-fatality rates were adjusted for all these variables in a multivariate model, the rate remained significantly higher in Lille than in the two other centres (P < 0.0001), as suggested by the odds ratio (3.27, 95% confidence interval: 1.69-6.32). In conclusion, the influence of acute coronary care on the MI case-fatality gradient observed between the North and South of France is very weak. [ABSTRACT FROM AUTHOR]

Gapstur S M (Division of Epidemiology, University of Minnesota, School of Public Health, Suite 300 1300 South Second Street, Minneapolis, MN 55454-1015, USA), Potter J D and Folsom A R. Alcohol consumption and colon and rectal cancer in postmenopausal women. International Journal of Epidemiology 1994; 23: 50–57. The associations between alcohol and colon and rectal cancers were examined in the Iowa Women's Health Study. In January 1986, 41 837 postmenopausal women, aged 55–69, completed a questionnaire including usual alcohol intake and other information. Through December 1990, 237 incident colon and 75 rectal cancer cases occurred. Mantel-Haenszel age-adjusted relative risks (RR) and 95% confidence intervals (CD for consumers of <4.0 and ≥4.0 g of alcohol per day compared to abstainers were 1.07 (0.617ndash;1.89) and 1.27 (0.72–2.24) {P for trend=0.46) for rectal cancer. Alcohol intake was inversely associated with distal colon cancer (RR for <4.0 and ≥4.0 g of alcohol per day were 0.64 and 0.69 respectively, Pfor trend=0.04), which was specific to wine; however, no association was observed with proximal colon cancer (P for trend=0.94). This is the only report of an inverse association between alcohol and colon cancer in women. Because gut physiology and alcohol metabolism differ between men and women, more research on the association between alcohol and colon cancer in women only, is warranted. [ABSTRACT FROM PUBLISHER]

Avoidable mortality in Sweden 1974–1985 was analysed using a European Community (EC) Working Group list of ‘avoidable death indicators.’ The list includes causes of death that in certain age groups were defined as indicators of the outcome of medical care intervention or for some conditions, indicators of the national health policies. About 10 Out of 14 medical health care indicators occurred in less than 50 cases per year. Death rates decreased over the 12-year period studied for most avoidable death indicators. For women, however, the death rate for malignant neoplasms of the trachea, bronchus and lung increased significantly. Swedish total mortality for ages 5–64 years was lower than the EC standards 1974–1978 and 1980–1984. Most of the avoidable causes of death had a relatively low standard mortality rate (SMR) when compared to both the EC standard and to the Swedish SMR for total mortality. For asthma, however, the Swedish SMR was higher. The development and implementation of the avoidable death concept and methodology is discussed. [ABSTRACT FROM PUBLISHER]

From May 1982 to June 1985 a hospital-based case-control study of diet and breast cancer (214 cases and 215 controls) was conducted in Milan in northern Italy, an area where wine consumption is widespread. The study used a detailed diet questionnaire to obtain an estimation of total calories as well as major micro- and macro-nutrient intake. The data thus allowed an investigation of the role of alcohol in breast cancer risk, adjusting for other dietary factors, in particular total energy intake. We found positive associations between breast cancer risk and total caloric intake (X=6.05, P=0.014) but no effect for the other nutrients, when adjusted for total caloric intake. The relative risk of breast cancer, for women reporting more than 24.35 g/day of alcohol consumption (highest quintile), was 2.1 (95% confidence interval (Cl): 1.1–3.9) when adjusted for non-dietary risk factors for breast cancer and 1.8 (95% Cl: 1.0–3.3) when adjusted for non-alcohol caloric intake. The relative risks were moderately elevated (50% or less) for low levels of consumption and comparable to those recorded in most American studies. This finding provides further support for a moderate association between alcohol consumption and breast cancer risk, even when allowance is made for potentially relevant nutrients. [ABSTRACT FROM PUBLISHER]

Although maternal mortality is higher in France than in other European countries, hospital data prove that maternal deaths are underestimated. To assess the degree of underestimation and investigate the reasons for it, a retrospective survey was carried out among the certifying doctors of the 3045 deaths that occurred among women aged 15–44 years, form December 1988 to March 1989. Doctors were asked for information on the obstetric condition of the women and their health before death. Some 88.2% of those approached responded. Sociodemographic information was obtained from the French national record of causes of death. Although doctors reported gravid puerperal conditions on 41 death certificates, only 24 deaths were classified in the maternal mortality category of the International Classification of Diseases. The other 17 deaths were classified elsewhere. The present survey permitted the identification of 27 additional deaths of which 16 were considered as having obstetric causes. Of the 68 deaths in pregnant or puerperal women which occurred during the survey period, 54 were classified as having obstetric causes. Of the 68 death in prognant or puerperal women which occurred during the survey period, 54 were classified as having obstetric causes. No sociodemographic differences were found between the deaths registered in the national record and the newly identified maternal deaths. All deaths occurring during or after parturition were reported to the national record, but most of the deaths from abortion were identified from the survey. The discussion deals with the misclassification of maternal deaths and the difficulty of determining the underlying cause of deaths involving complex diseases or uncertain pathogenesis. [ABSTRACT FROM PUBLISHER]

González CA (Unit of Epidemiology, Hospital de Mataró, 08301-Mataró, Barcelona, Spain), Torrent M, Agudo A and Riboli E. Hospital versus neighbourhood controls in the assessment of dietary risk factors. 1990, : 354–361. The selection of the best control group is a major concern in the design of any case-control study, because of its enormous implications on both internal validity and cost. We compare the dietary habits of hospital and neighbourhood control groups which had both been used in a case-control study on bladder cancer. The analysis is based on 485 matched sets. No differences were observed between the two groups in terms of nutrient consumption nor in consumption of specific foods or food groups. Alcohol consumption represents an exception. This may be attributed to the use of incorrect exclusion criteria given that alcohol consumption was not one of the major determinants of the original study. We conclude that, provided correct exclusion criteria are used, hospital controls may be as suitable as neighbourhood controls in the assessment of dietary risk factors in case-control studies in Spain. [ABSTRACT FROM PUBLISHER]

Patel M (Route de Saint-Loup 4, 1290 Versoix, Switzerland), Gutzwiller F, Paccaud F and Marazzi A. A meta-analysis of acupuncture for chronic pain. 1989, : 900–906. Results of 14 randomized controlled trials of acupuncture for chronic pain were pooled in a meta-analysis and analysed in three subgroups according to site of pain; and in two subgroups each according to type to trial, type of treatment, type of control, ‘blindness’ of participating agents, trial size, and type of journal in which results were published. While few individual trials had statistically significant results, pooled results of many subgroups attained statistical significance in favour of acupuncture. Various potential sources of bias, including problems with blindness, precluded a conclusive finding although most results apparently favoured acupuncture. [ABSTRACT FROM PUBLISHER]

Msckenbach J P (Department of Public Health and Social Medicine, Erasmus Universiteit Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands), Looman C W N, Kunst A E, Habbema J D F and van der Maas P J. Regional differences in mortality decline from selected conditions: The Netherlands 1969–1984. 1988, 17: 821–829. In The Netherlands, as in many other industrialized countries, recent mortality developments have been characterized by rapid declines for a number of important causes of death. The results of an analysis of regional variation in mortality decline within The Netherlands are reported, covering the period 1969–1984. The causes of death included in this analysis are Perinatal mortality, Cerebrovascular disease, a more global ‘Amenable’ selection (formed by aggregating a number of causes of death considered to be amenable to medical intervention), Cancer of the stomach, ischaemic heart disease and Traffic accidents. For Perinatal mortality, Cerebrovascular disease, the ‘Amenable’ selection, and ischaemic heart disease,as well as for Total mortality, declines have not been geographically homogeneous. Perinatal mortality had a tendency to decline faster in regions where starting levels were higher, suggesting a certain convergence. For Cerebrovascular disease and the ‘Amenable’ selection, but especially for ischaemic heart disease, the reverse was true. A simple correlation analysis shows that for Perinatal mortality, as well as for the ‘Amenable’ selection, mortality declined faster in less urbanized, more peripherally located, lower income areas. There is no association with the presence of a university hospital. This pattern suggests that faster mortality decline for these conditions is due to factors other than faster diffusion of new medical technologies. For ischaemic heart disease, mortality declined faster in more urbanized, more centrally located, higher income areas. Although this pattern is what one would expect as a result of regional differences in the diffusion of new medical technologies, it may also be due to differences in the diffusion of new lifestyles. The absence of an association with the presence of university hospitals supports the latter view. It is concluded that the monitoring of changes in mortality at the regional level is an important addition to the more usual analyses of mortality variation at one moment in time. [ABSTRACT FROM PUBLISHER]

Gross national product has been found to be negatively associated with age-specific mortality, and the prevalence of. medical doctors positively associated with mortality In younger age groups. We studied the relationship between mortality and its determinants among people aged 64 years or less in 25 developed countries. Age-adjusted mortality rates from causes of death amenable to interventions by health services were calculated for the period 1975–8, and, likewise, rates from partly amenable causes, non-amenable causes, and violent causes of death. In regression analysis, log mortality from amenable causes was significantly negatively associated with gross domestic product (GDP) but not with the numbers of medical doctors, nurses and midwives, hospital beds, alcohol consumption, tobacco consumption, or military expenditure. It is argued that cross-sectional comparisons disguise the effects of hearth services on mortality. [ABSTRACT FROM PUBLISHER]

Several conditions, whose timely and appropriate therapy should decrease case fatality, have been proposed as indicators of medical care quality for the National Health Service. Mortality rates for these diseases vary widely within the UK. To evaluate the contribution of varying incidence rates to these mortality differences, routinely collected morbidity and mortality data for 1974—1978 were analysed for 98 Area Health Authorities (AHAs) in England and Wales. Although differences in morbidity (as measured by hospital discharge and disease registration rates) and socioeconomic factors account for some of the area variation in mortality, significant heterogeneity persists after these factors are taken into account. This finding suggests that morbidity and socioeconomic factors are not the only determinants of mortality variation among areas for these particular diseases. Variation in quality of medical care may account for this result, although regional diagnostic and reporting differences and variation in disease severity among areas must also be considered. [ABSTRACT FROM PUBLISHER]

There is an expanding need for quantitative information to evaluate health and medical care procedures. Existing methods for designing and carrying out evaluation studies need to be improved to provide better techniques for answering questions on efficacy of health and medical procedures, and in providing a more adequate information base on which to set health policy. This paper reviews some of the problems in the design and conduct of evaluation research, and makes a plea for creation of a special discipline to support and develop the field of health and medical care evaluation. [ABSTRACT FROM PUBLISHER]

Background. Although stroke is a major public health issue little is known about the need for stroke services or the most cost-effective methods of treating stroke patients. This paper discusses how stroke registry data can be used to inform and promote health service changes to meet these needs.Methods and Results. Stroke registers were established in three districts of southern England. The initial study findings were that incidence rates reflected mortality rates in these districts, with the higher rates being observed in inner city districts. Hospitalization rates were high with significant use of health service resources but with only 5% being spent on rehabilitation. As a result of these findings a stroke steering group was established in the district with the highest incidence. Standards for care were developed and are currently being audited. A multidisciplinary rehabilitation team was set up in collaboration with the stroke registry. The local purchasers of health care have commissioned an evaluation of a community rehabilitation team to address the problem of low rehabilitation rates in the community.Conclusion. Although it is not possible to control for external influences within a health service this paper illustrates how research findings can influence local health service provision in a tangible way. Epidemiological research can only hope to effect such change if the original studies are undertaken rigorously and the researchers are proactive in the dissemination process, creating opportunities for further research to resolve questions raised by the studies. [ABSTRACT FROM PUBLISHER]

This paper describes the evolution of the concept of rapid epidemiologic assessment (REA) from a series of ideas to a defined area of epidemiologic research. Five broad areas of research are defined: small area survey and sampling methods, surveillance methods, screening and individual risk assessment, community indicators of risk or health status, and case-control methods for evaluation. REA techniques can provide health information more rapidly, simply and at less cost than the standard data collection methods and yet still yield reliable results. The use of these methods is described with examples from both a research programme designed to stimulate the development of REA methods and from other studies in the literature. The further development of REA techniques can lead to better decisions regarding the delivery and allocation of health services in both developing and industrialized countries. [ABSTRACT FROM PUBLISHER]