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In the United States, maternal mortality, defined as all deaths during pregnancy, childbirth, and up to 365 days after the end of pregnancy, is among the highest of all developed nations. For every 1 maternal death, there are more than 100 life-threatening complications that occur related to pregnancy. However, maternal morbidity and mortality do not affect all mothers equally. Black and indigenous people are at the highest risk for pregnancy-related complications and death-they are up to 5 times as likely to die from childbearing than white women. To understand this nationwide epidemic, cases of maternal death must be thoroughly reviewed, including the medical, social, and societal circumstances surrounding them. The state of Hawai'i formed the Maternal Mortality Review Committee in 2016 to review cases of maternal mortality, collect accurate data, and develop strategies for prevention. Twenty-five maternal deaths occurred in the state of Hawai'i from 2015 to 2017. More than half of these deaths were deemed preventable. Combined data show that mental health disorders played a significant role in maternal mortality, and approximately a quarter of cases involved substance use. Twenty-three percent of maternal deaths occurred in Native Hawaiian and Pacific Islander women, even though they make up a smaller proportion of women in the state. The collection and analysis of these data are the first steps toward understanding and reducing maternal morbidity and mortality in Hawai'i. Most notably, the striking ethnic disparities in maternal deaths and the preventable nature of many cases demand our immediate attention., (©Copyright 2020 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Objective: To evaluate the impact of the Shell Disability Management Program (DMP) on U.S. manufacturing employee absenteeism., Methods: We estimated absence episodes and days lost per employee from 2004 to 2008 compared to pre-program values in 2002, and productivity gains from transitional duty (TD)., Results: Between 2002 and 2008, absence episodes/100 employees decreased from 37.4 to 25.7 among hourly workers but increased from 9.7 to 13.1 among staff employees. Days lost per employee decreased from 7.4 to 5.2 for hourly employees and were virtually unchanged for staff employees. TD resulted in 6042 days saved in 2006 and 11,438 days in 2008, with direct cost savings of more than $4.1 million from 2006 to 2008., Conclusions: The Shell DMP emphasizes absence tracking, timely return-to-work, and facilitation of TD. Absenteeism decreased significantly after DMP implementation, particularly among hourly employees, with an estimated 2.4:1 return-on-investment.

Background: Although obesity is an established risk factor for coronary heart disease and stroke mortality, its role as a risk factor for other causes of death has not been extensively investigated, particularly in an industrial population., Methods: This prospective mortality study included 20 years of follow up of middle-aged industrial workers (n = 7139) at Shell Oil Company's manufacturing and research facilities. Baseline health risk factor data as of December 31, 1983, and mortality data as of December 31, 2003, were extracted from the company's Health Surveillance System. Relative risks (RRs) for selected causes of death by body mass index (BMI) category were calculated using the Cox proportional hazards model adjusted for age, sex, and smoking status as well as other potential risk factors, ie, cholesterol, hypertension, and fasting blood glucose., Results: Compared with employees with BMI between 18.5 and 24.9 kg/m, those with BMI of 30 kg/m or greater had a statistically increased RR (adjusted for age, sex, and smoking status) for all causes (RR, 1.25; 95% confidence interval [CI] = 1.03-1.51), coronary heart diseases (RR, 2.29; 95% CI = 1.50-3.50), cardiovascular diseases (RR, 2.22; 95% CI = 1.51-3.27), diabetes (RR, 16.97; 95% CI = 2.11-136.44), and accidental deaths (RR, 2.64; 95% CI = 1.23-5.66). After adjusting for additional covariates, coronary heart diseases and cardiovascular diseases remained statistically significant., Conclusions: Obesity was associated with increased death rates for all causes, cardiovascular diseases, diabetes, and all accidents. Overweight individuals had a statistically lower cancer rate. Death rates for lung cancer and respiratory disease were lower among overweight/obese employees but did not reach statistical significance. Reductions of employee obesity can be an effective means of reducing these causes of death.

Objective: To assess whether early retirement is associated with better survival., Design: Long term prospective cohort study., Setting: Petroleum and petrochemical industry, United States., Subjects: Past employees of Shell Oil who retired at ages 55, 60, and 65 between 1 January 1973 and 31 December 2003., Main Outcome Measure: Hazard ratio of death adjusted for sex, year of entry to study, and socioeconomic status., Results: Subjects who retired early at 55 and who were still alive at 65 had a significantly higher mortality than those who retired at 65 (hazard ratio 1.37, 95% confidence interval 1.09 to 1.73). Mortality was also significantly higher for subjects in the first 10 years after retirement at 55 compared with those who continued working (1.89, 1.58 to 2.27). After adjustment, mortality was similar between those who retired at 60 and those who retired at 65 (1.06, 0.92 to 1.22). Mortality did not differ for the first five years after retirement at 60 compared with continuing work at 60 (1.04, 0.82 to 1.31)., Conclusions: Retiring early at 55 or 60 was not associated with better survival than retiring at 65 in a cohort of past employees of the petrochemical industry. Mortality was higher in employees who retired at 55 than in those who continued working.

Objectives: The potential gains in life expectancy of the US population by the partial and total elimination of deaths from HIV/AIDS were compared with that of deaths from heart disease and malignant neoplasms., Methods: The data from the 1992 advanced mortality report and detailed information provided by the National Center for Health Statistics were analysed by using the partial multiple decrement life-table technique., Results: For the total population of the United States in 1992, the gains in future life expectancy through the elimination of deaths from HIV/AIDS, heart disease and malignant neoplasms were 0.34, 3.25 and 3.21 years, respectively. The gains in life expectancy in those of working age 15-64 years) through the elimination of deaths from these three causes of deaths were 0.20, 0.40 and 0.55 years, respectively. Race/sex-specific calculations indicate that the total elimination of deaths from HIV/AIDS, heart disease and malignant neoplasms in white men of working age resulted in increased life expectancy of 0.28, 0.54 and 0.53, respectively, whereas the corresponding figures for black men were 0.82, 0.90 and 0.76 years, respectively. Although the impact of the elimination of the other causes remained relatively stable from 1987 to 1992, the potential gains in life expectancy for black men of working age by eliminating HIV/AIDS rose from 0.36 years in 1987 to 0.82 years in 1992. For the total US population of working age, the elimination of HIV/AIDS deaths resulted in increased life expectancy similar to that observed for a 50% reduction of heart disease or malignant neoplasms, whereas among black men of working age, the increased years of life expectancy from the elimination of HIV/AIDS deaths were virtually the same as those observed for the elimination of heart disease or malignant neoplasms., Conclusions: The potential gains in life expectancy by reduction of deaths from heart disease and malignant neoplasms are more heavily influenced by increasing years after the working ages (15-64 years), whereas the potential gains in life expectancy by reducing deaths from HIV/AIDS make a greater contribution to those of working age. Hence, in terms of the economic costs and benefits, these results indicate that in evaluating policy issues regarding allocation of research funds, studies of life expectancy are far more important than the simple approach which allocates funds on the basis of the number of deaths due to various diseases.

A new theoretical relation that does not require the constant age-specific mortality ratio assumption is established between the standardized mortality ratio (SMR) and the life expectancy. A set of regression equations is developed from the theoretical relation to derive estimates of the future expectation of life from estimates of the SMR. Curves are presented showing the changes in life expectancy that are associated with a given SMR for individuals aged 25, 45, and 65 years. These results will provide practical applications in estimating remaining life expectancy in epidemiologic studies in which the SMR is the summary statistic. An application is shown for studies in occupational health to develop and illustrate the method.

A comprehensive initiative utilizing an in-house preferred provider organization, medical case management, and application of ergonomic techniques was implemented in an effort to control the incidence and cost of workplace injuries. The program was evaluated utilizing OSHA 200 Logs to compare the incidence and lost time due to compensable injury and illnesses before and after beginning the program. After the introduction, there was a significant decrease in injuries and illnesses (53/1000 vs 27/1000, P<.01) and average days lost per event (10.4 vs 6.6 days, P<.01). A significant increase in restricted-duty days (.2 vs 1.5 days, P<.01) and an 18% reduction in medical and indemnity costs of the institution's workers' compensation expenditures were observed. This study demonstrates the initial effectiveness of an aggressive ergonomic and managed care approach to reducing the incidence, severity, and cost of occupationally related injury and illness. It also highlights the effectiveness of an outcomes analysis approach, using lost time as an end point, to measure the effectiveness of preventive and management strategies in the workers' compensation setting.

A retrospective mortality analysis and prospective morbidity and haematological analyses were performed for Shell Deer Park Manufacturing Complex (DPMC) male employees who worked in jobs with potential exposure to 1,3-butadiene from 1948 to 1989. 614 employees qualified for the mortality study (1948-89), 438 of those were still employed during the period of the morbidity study (1982-9), and 429 of those had haematological data available for analysis. Industrial hygiene data from 1979 to 1992 showed that most butadiene exposures did not exceed 10 ppm (eight-hour time weighted average (8 hour TWA)), and most were below 1 ppm, with an arithmetic mean of 3.5 ppm. 24 deaths occurred during the mortality study period. For all causes of death, the standardised mortality ratio (SMR) was 48 (95% confidence interval (95% CI) = 31-72), and the all cancer SMR was 34 (95% CI = 9-87). There were only two deaths due to lung cancer (SMR 42, 95% CI = 5-151) and none due to lymphohaematopoietic cancer (expected = 1.2). Morbidity (illness absence) events of six days or more for the 438 butadiene employees were compared with the rest of the complex. No cause of morbidity was in excess for this group; the all cause standardised morbidity ratio (SMbR) was 85 (95% CI = 77-93) and the all neoplasms SMbR was 51 (95% CI = 22-100). Haematological results for the 429 with laboratory data were compared with results for the rest of the complex. No significant differences occurred between the two groups and the distributions of results between butadiene and non-butadiene groups were virtually identical. These results suggest that butadiene exposures at concentrations common at DPMC in the past 10-20 years do not pose a health hazard to employees.

Results for a prospective morbidity study of 14,170 refinery and chemical workers from 1981 through 1988 are presented. Illness/absence data for this study were extracted from the morbidity section of the Shell Health Surveillance System which includes records of all illness/absences in excess of five days. Age adjusted annual morbidity frequency rates and annual durations of absence are presented by age, sex, job, and work status. Generally, rates and durations of absence were highest for older age groups, women, and production workers. Increased risk was associated with the presence of known disease risk factors. Overall, 48% of the employees had at least one illness/absence in excess of five days during the eight year period. Twelve per cent of the employees had four or more absences, which accounted for 54% of the total number of absences and 52% of the total work days lost. Among men, the five most common conditions accounted for 72% of all illness/absences. In descending order they were injuries (25%), respiratory illnesses (17%), musculoskeletal disorders (14%), digestive illnesses (9%), and heart disease (7%). Similar patterns were noted among women. These findings may be useful in setting priorities and directing efforts such as health education programmes and other strategies for the prevention of disease.

This study examined the morbidity experience from 1981 to 1988 of two cohorts (Shell cohort and Enterline cohort) of workers who had potential exposure to epichlorohydrin (ECH). The morbidity prevalence data for this study were extracted from the morbidity section of the Shell health surveillance system which included all illness and absence records in excess of five days. For both cohorts, the standardised morbidity ratios (SMRs) for all causes and all neoplasms were similar to an internal comparison group. There were no increases in heart disease morbidity for the Shell cohort (SMR = 97) or the Enterline cohort (SMR = 90). The SMRs for heart disease in the lower exposure group of the Shell cohort were 101 and 93 for the corresponding Enterline cohort. They were 92 and 87, respectively, in the higher exposure group. The increased risk of heart disease mortality reported by Enterline et al in workers more heavily exposed to ECH was not confirmed in this morbidity study. Morbidity from skin and subcutaneous tissue disorders, however, was found to be increased significantly in the Shell cohort. The SMR was 98 for the lower exposure group and 195 for the higher exposure group. A review of the original morbidity reports for each case suggested that factors unrelated to exposure to ECH such as the physical demands of a particular job, amount of time outside--for example, exposure to poison ivy--and other underlying medical conditions may be of greater importance than exposure to ECH.

As part of Shell's health surveillance program, morbidity frequency and severity by smoking status (current smoker, exsmoker, nonsmoker) were compared for the 3-year period 1985 through 1987. Morbidity data for this study were extracted from the morbidity section of the Shell Health Surveillance System, which included all illness and absence events in excess of 5 days. Statistically significant positive associations were seen between smoking habits and overall morbidity, diseases of the circulatory system, and diseases of the respiratory system for both male and female employees. In addition, a significantly increased association between smoking and both non-motor vehicle accidents and motor vehicle accidents among current smokers was noted. Current smokers had a greater than 60% higher frequency rate (P less than .05) for non-motor vehicle accidents than nonsmokers for both men and women. Male smokers also had a 75% increased (P less than .05) motor vehicle accident rate. These results suggest that it may be possible to reduce overall illness and injury morbidity through implementation of successful smoking cessation programs.

This paper develops a method for adjustment of competing causes of death in the calculation of relative risk. It has identified three factors determining the significance of competing risks: (1) the magnitude of the overall mortality risk of the study population; (2) differential risk (or the adjustment factor) for mortality other than cause of interest between two populations; and (3) age intervals used in the mortality calculation. Thus, the impact of competing risks is increased if the study cohort has a high mortality risk, if the mortality other than the cause of interest has a large differential risk or if the mortality calculation uses wide age intervals. Two examples from a refinery cohort and the US national population show that among certain age groups unadjusted for competing risks the relative risk is overestimated by 9%. The impact of competing risks in these two particular examples is relatively small. Furthermore, if relative risk is expressed in terms of the ratio of mortality rates, competing risks can be ignored.

The "healthy worker effect," perhaps more accurately termed the "active worker effect" has been acknowledged by numerous investigators who have disregarded its significance. The healthy worker effect is expressed by SMRs (standardized mortality ratios) and influenced by the following three factors: (i) selection bias, (ii) improved socioeconomic status, and (iii) the conventional way of calculating SMRs. An examination of these three factors shows that selection for "employability" is probably the most significant factor for the healthy worker effect. For example, the shorter the observation, the smaller the SMR, and the stronger the health worker effect. Secondly, improved socioeconomic status as a result of employment has been shown to lower mortality. Last, although the SMR has the advantage of estimating relative risk in a small sample, it suffers many methodological pitfalls. It is recommended that at least three parameters be used to summarize mortality experience among the employed: (i) relative risk, (ii) attributable risk, and (iii) life expectancy.

Using both occupational (workers' compensation) and non-occupational (group health insurance) data, the nature and magnitude of injuries were determined in a working population of 20,705. Approximately one third of the population sustained an injury in 1986 (the year of study). Men experienced a significantly higher injury rate than women (33.3 per 100 v 24.9 per 100) and hourly employees had significantly higher incidence rates than salaried employees (42.0 per 100 v 22.5 per 100). The majority of nonoccupational injury claims were for low back disorders, whereas most occupational injury claims were related to superficial wounds and contusions. Overall, the incidence of nonoccupational injuries (21.1 per 100) was twofold higher than that of occupational injuries (10.8 per 100). Total costs for occupational and nonoccupational injuries were $4.97 million. The per-capita costs were $120 for both nonoccupational and occupational injuries. However, if only health care expenses are included in this calculation, nonoccupational injury costs would be almost 3 times as high as occupational injury costs ($120 v $46). These findings argue for increasing the share of corporate resources for off-the-job injury prevention programs aimed at reducing injury incidence and resultant health care costs.

This study examines the gains in life expectancy for four race/sex groups of the US population between 1968 and 1975. An increase of 2.3 years in life expectancy at birth and 1.7 years in life expectancy at age 45 years has occurred for all race/sex groups combined. The added years of life for the normal working ages (15-70 years) is only 0.6 years for the total US population, 0.3 years for white females, 0.6 years for white males, 1.5 years for nonwhite males, and 1.7 years for nonwhite females. The relative contribution of the five leading causes of death to this gain varies at different ages. For example, more than 50% of the increase in life expectancy at age 45 years was due to a lower mortality rate in diseases of the heart which is still the leading cause of death among each of the race/sex groups. Other contributions to the increase in life expectancy at age 45 years are: cerebrovascular diseases, 16%; accidents, 6%; influenza and pneumonia, 7%; and all other causes, 16%. The increase in the malignant neoplasms mortality rate had a negative effect, -2%, on the gain of life expectancy.

This article presents the health care experience of 14,162 employees and their families, covered under a private third-party insurance plan of a large multinational corporation for the 1984 policy year. A total of $29.5 million was charged by health care providers to deliver medical care for the studied employees and their families. This amounted to $2,083 per employee and his/her family. Approximately 51% of the employees submitted claims, with females having greater utilization than males. The highest expenditures were for diseases of the circulatory system among adults (3.2 million or 23% for employees, $1.5 million or 14% for spouses). Among employees, neoplasms accounted for $1.4 million or 10% of costs, and musculoskeletal system $1.2 million or 9% of costs. Among spouses, pregnancy and diseases of the female reproductive system accounted for $1.2 million (12%) and $1.1 million (10%), respectively. Among dependents, the top three cost categories were mental disorders ($1.2 million or 24%), accident-related illnesses ($0.7 million or 14%), and diseases of the respiratory system ($0.6 million or 12%). Hospital care expenditures, including room and board, ancillary, and physician services, accounted for approximately 60% of total health care spending. The percentage of health care costs paid for by this insurance plan was 75% for active employees, 34% for retirees, 60% for female spouses, 38% for male spouses, and 64% for dependents. The analyses and parameters measured can be viewed as the first step toward the development of a health care cost containment and disease prevention strategy.

The mortality experience of Taiwan was examined for two time periods (1976 and 1983) to determine the magnitude and direction of change in age-adjusted mortality and to identify deviation from the expected progress by comparison with two industrialized nations, the USA and Japan. Between 1976 and 1983 the overall mortality showed an annual average of nearly 2% decrease, mostly contributed by the marked reduction in the number of young. Significant reductions were also observed for deaths from strokes, rheumatic heart disease, ill-defined conditions, cancer of the stomach, and infectious diseases such as tuberculosis. A disturbing increase in suicide as well as accidents primarily caused by motor vehicles was noted. In general, cancer increased, to an alarming degree for environmentally implicated cancers such as lung, pancreas, nasopharynx, brain and liver in men. When compared to that of the USA or Japan, the mortality experience of Taiwan showed the following increases: overall female mortality, accidental deaths, suicide among elderly women, deaths from strokes, ulcers, asthma, and liver, nasopharyngeal and cervical cancers. However, the overall cancer mortality rate was still much lower than that either in the USA or Japan. Despite marked reductions in infectious disease mortality, deaths from tuberculosis were nearly 40 times those of the USA. Although deaths from ill-defined conditions decreased by half during this study period, they were still high, particularly among elderly women (13% of all deaths and 22 times higher than the USA), which probably reflects inadequate medical services for women. The role of the Taiwanese government in the financing of health services was found to be far smaller than that of the USA or Japan. Expanding health care expenditure by the government is desirable if improvement in the maldistribution of medical services is to be achieved and the untoward health effects of rapid industrialization is to be reduced.

The potential gains in total expectation of life and in the working life ages among the United States population are examined when the three leading causes of death are totally or partially eliminated. The impressive gains theoretically achieved by total elimination do not hold up under the more realistic assumption of partial elimination or reduction. The number of years gained by a new-born child, with a 30 per cent reduction in major cardiovascular diseases would be 1.98 years, for malignant neoplasms 0.71 years, and for motor vehicle accidents 0.21 years. Application of the same reduction to the working ages, 15 to 70 years, results in a gain of 0.43, 0.26, and 0.14 years, respectively for the three leading causes of death. Even with a scientific break-through in combating these causes of death, it appears that future gains in life expectancies for the working ages will not be spectacular. The implication of the results in relation to the current debate on the national health care policy is noted.