Comparability of Patients in Trials of E-Health and Face-To-Face Psychotherapeutic Interventions for Depression: a Meta-Synthesis

Background: Depressive disorders are a public health problem. Face-to-face psychotherapeutic interventions are considered to be a first-line option for their treatment in adults. There is a growing interest in eHealth interventions to maximize accessibility for effective treatments. Thus, the number of randomized controlled trials (RCTs) of eHealth psychotherapeutic interventions has increased, and these interventions are often being offered to patients. However, it is unknown whether patients with depressive disorders differ in internet and face-to-face intervention trials. This information is essential to gain knowledge about the external validity of eHealth trials. Objective: To compare the baseline characteristics of patients with depressive disorder in eHealth and face-to-face psychotherapeutic intervention RCTs. Methods: Meta-epidemiological study. We searched five databases between 1990 and November 2017 (MEDLINE, EMBASE, PsycINFO, Google Scholar, Cuijpers’s database). We included RCTs of psychotherapeutic interventions with a cognitive component (such as cognitive therapy, cognitive–behavioral therapy, or interpersonal therapy) delivered face-to-face or via the internet to adults with a depressive disorder. Each included study had a matching study for predefined criteria to allow a valid comparison of baseline characteristics. Each study was classified as a face-to-face (CBT) or eHealth (iCBT) intervention trial. Two authors selected the studies, extracted data, and resolved disagreements by discussion. We tested whether predefined baseline characteristics differed in face-to-face and internet-based trials by using a mixed-effects model and testing for differences with a Z-test (statistical significance threshold set at 0.05). For continuous outcomes, we also estimated the difference in means between subgroups along with the 95% CI. Results: We included 58 RCTs (29 matching pairs) with 3,655 participants (71.5% females) with a mean age from 20 to 74 years. Caucasian participants were the most frequently reported. Other socioeconomic characteristics were poorly reported. The participants presented different depressive disorders measured with heterogeneous instruments. iCBT trials had a longer mean duration of depression at baseline (7.19 years higher; CI 95% 2.53 to 11.84; 10.0 versus 2.8 years, P=.002), but the proportion of patients with previous depression treatment was lower (24.8% versus 42.0%, P=.035). The subgroup analyses found no evidence of differences for the remaining baseline characteristics: age, gender, education, living area, depression severity, history of depression, actual antidepressant medication, actual physical comorbidity, actual mental comorbidity, study drop-out, quality of life, having children, family status and employment. We could not compare proficiency with computers due to the insufficient number of studies reporting this information. Conclusions: Our study found that the baseline characteristics of patients with depressive disorders included in RCTs of eHealth and face-to-face psychotherapeutic interventions are generally similar. However, patients in eHealth trials had a longer duration of depression, and a lower proportion had received previous depression treatment. This might indicate that eHealth trials attract patients who postpone earlier treatment attempts

European Commission Initiative on Breast Cancer – ECIBC: Organisation of project guiding and support meetings report – 2014

The Joint Research Centre (JRC) coordinates the European Commission's Initiative on Breast Cancer (ECIBC). The ECBIC has two main tasks: 1) the development of a voluntary European quality assurance (QA) scheme for breast cancer services based on an EU legislative framework on accreditation covering all stages and aspects of care and 2) the set-up of the evidence base for such a QA scheme via (i) the development of the new European guidelines for breast cancer screening and diagnosis and (ii) a platform for evidence-based breast cancer guidelines covering stages other than screening and diagnosis (e.g. rehabilitation, follow-up, psychological support and palliative care). Preparation for the ECIBC included literature searches, stakeholder meetings and consensus building workshops and a European-wide survey to gather information on the status and organisation of breast cancer screening and care. This report is a summary of the meetings held in 2014.JRC.I.2-Public Health Policy Suppor

Incidence and prevalence of multiple sclerosis in Spain: a systematic review

[EN] Introduction: Greater understanding of the prevalence and incidence of multiple sclerosis in Spain and their temporal trends is necessary to improve the allocation of healthcare resources and to study aetiological factors. Methods: We performed a systematic search of the MedLine database and reviewed the reference lists of the articles gathered. We collected studies reporting prevalence or incidence rates of multiple sclerosis in any geographical location in Spain, with no time limits. In 70% of cases, data were extracted by 2 researchers (FGL and EAC); any discrepancies were resolved by consensus. Results: We identified 51 prevalence and 33 incidence studies published between 1968 and 2018. In the adjusted analysis, the number of prevalent cases per 100 000 population increased by 26.6 (95% confidence interval [CI], 21.5-31.8) every 10 years. After adjusting for year and latitude, the number of incident cases per 100 000 population increased by 1.34 (95% CI, 0.98-1.69) every 10 years. We observed a trend toward higher prevalence and incidence rates at higher latitudes. Conclusions: The prevalence of multiple sclerosis in Spain has increased in recent decades, although case ascertainment appears to be incomplete in many studies. Incidence rates have also increased, but this may be due to recent improvements in the detection of new cases. [ES] Introducción: El conocimiento de la prevalencia y de la incidencia de la esclerosis múltiple en España y de sus tendencias temporales es necesario para planificar mejor los servicios clínicos y estudiar factores etiológicos. Método: Se efectuó una revisión sistemática, mediante una búsqueda en Medline y en las referencias de cada artículo, de todos los estudios que describieran cifras de prevalencia o de incidencia de la esclerosis múltiple en algún lugar geográfico de España, sin límites temporales. En el 70% de los casos la extracción de datos la hicieron dos observadores (FGL y EAC), que resolvieron las discrepancias por consenso. Resultados: Se identificaron 51 estudios de prevalencia y 33 de incidencia entre 1968 y 2018. En el análisis ajustado, por cada 10 años la prevalencia por 100 000 habitantes aumentó en 26,6 (intervalo de confianza -IC- del 95%, 21,5 a 31,8). Según los datos del análisis ajustado por el año y la latitud, por cada 10 años la incidencia por 100 000 habitantes aumentó en 1,34 (IC 95%, 0,98 a 1,69). Se observó una tendencia de mayores prevalencias e incidencias en latitudes más altas. Conclusiones: La prevalencia de la esclerosis múltiple aumentó en las últimas décadas en España, aunque en muchos estudios la verificación de casos parece haber sido incompleta. La incidencia también aumentó, pero eso puede deberse a una detección de casos nuevos más exhaustiva en los últimos años.This study has received funding from Biogen Idec, S. L.S

GRADE workshop: grading the quality of evidence and strength of recommendations

In December 2013, the Public Health Policy Support Unit at the European Commission's Joint Research Centre organised a two-day workshop on developing evidence-based guidelines and healthcare recommendations using GRADE. GRADE stands for Grading of Recommendations Assessment, Development and Evaluation. It is a method for grading the quality of evidence and going from this evidence to the corresponding healthcare recommendation. The aims of the workshop were: 1) To explain how to develop evidence-based guidelines and health recommendations using the GRADE approach. 2) To build a template for future trainings organised by the JRC on the guideline development process. Twenty participants, without experience using GRADE, attended the workshop—including 14 JRC staff, as well as representatives from the Directorate General for Health and Consumers (DG SANCO), the European Centre for Disease Prevention and Control (ECDC) and various external institutions. The workshop consisted of lectures on the theory behind guidelines development, group work and computer-based exercises. Organisers and participants deemed the training a success and the Public Health Policy Support Unit is planning additional GRADE-oriented workshops in the future.JRC.I.2-Public Health Policy Suppor

Smartphone-RCCT: an online repository of randomized controlled clinical trials of smartphone applications for chronic conditions

Background: Chronic health conditions have a big impact on disability, morbidity, and mortality worldwide. Smart‑ phone health applications (apps) can improve the health of patients with chronic conditions and enhance the quality and efficiency of healthcare. The number of randomized controlled trials (RCTs) of smartphone health apps is increas‑ ing, but a collection of the available evidence into a single database is still missing. The purpose of this study is to describe Smartphone-RCCT, which is an in‑progress database of RCTs of smartphone apps for chronic conditions. Methods: For a study to be included in the database, the following criteria had to be met: (a) RCT published in a peer‑reviewed journal; (b) population: adult study participants with one or several chronic conditions that represent the main health problem addressed by the study intervention; (c) intervention: smartphone health app used by the patient; (d) comparator: any control condition; (e) outcomes: any patient‑reported health outcome (studies exclu‑ sively measuring the patients’ knowledge about the chronic conditions or their satisfaction with the smartphone app were excluded); (f) sample size: at least 15 participants per study arm. We searched in electronic databases and other resources to identify relevant studies. Two reviewers selected the studies and extracted data independently. Annual updates are planned. Results: The proposed database is called Smartphone‑RCCT, an open‑access repository collecting bibliographic references and important characteristics of RCTs of smartphone apps for chronic conditions. The database is available for free in Open Science Framework (OSF): https://osf.io/nxerf/. To date, it includes 70 trials. Their references can be exported to standard reference management software and the extracted data is available in a Microsoft Excel file. Conclusions: Smartphone‑RCCT is the first systematic open‑access database collecting peer‑reviewed publications of RCTs of smartphone apps for patients with chronic conditions. The database accelerates the delivery of evidence‑ based information in a dynamic research field. It represents an essential resource for different stakeholders, such as professionals working in evidence synthesis, meta‑epidemiological studies, or planning an RCT

The ECIBC (European Commission Initiative on Breast Cancer) web hub concept and feasibility study

In December 2012, the Joint Research Centre (JRC) was assigned by the Directorate-General for Health and Consumers (now the Directorate-General for Health and Food Safety - DG SANTE) with the task of coordinating the European Commission Initiative on Breast Cancer henceforth shortened to ECIBC. ECIBC main tasks as defined in the DG SANTE published document are: • To develop a new version of the European guidelines for breast cancer screening and diagnosis based on new knowledge and evidence. • To develop a voluntary European quality assurance (QA) scheme for breast cancer services covering all care processes based on the EU legislative framework on accreditation and underpinned by the evidence provided by the guidelines With regards to guidelines covering processes other than screening and diagnosis (treatment, rehabilitation and follow-up, and all relevant horizontal aspects), a platform for breast cancer guidelines is envisaged to host existing evidence-based, high-quality guidelines. The ECIBC project also includes the definition of a concept for training of professionals in breast cancer screening and the development of a dedicated web hub, to which this report refers. The ECIBC web hub will be the communication interface with stakeholders and the main tool presenting and making available project deliverables (and their updates) over the long-term. The present report is a summary of the process of developing the concept for the ECIBC web hub and of the feasibility study activities: • It provides a list of user requirements along with some sketched ECIBC web hub pages, crafted out of a series of meetings and analysing relevant cancer-related web portals. • It describes the technical platform evaluation process that led to the selection of Liferay Portal. • It presents a high-level initial plan to provide ECIBC web hub functionality needed by the upcoming ECIBC project steps, with a pilot in the second part of 2015 and a fully functional web hub at the end of 2017. In order to develop the ECIBC web hub, the JRC carried out a specific feasibility study with three main objectives: • Analyse user requirements. • Select a technical platform. • Make an initial time and effort estimation.JRC.I.2-Public Health Policy Suppor

Personalized Interpretation and Clinical Translation of Genetic Variants Associated With Cardiomyopathies

Cardiomyopathies are a heterogeneous group of inherited cardiac diseases characterized by progressive myocardium abnormalities associated with mechanical and/or electrical dysfunction. Massive genetic sequencing technologies allow a comprehensive genetic analysis to unravel the cause of disease. However, most identified genetic variants remain of unknown clinical significance due to incomplete penetrance and variable expressivity. Therefore, genetic interpretation of variants and translation into clinical practice remain a current challenge. We performed retrospective comprehensive clinical assessment and genetic analysis in six families, four diagnosed with arrhythmogenic cardiomyopathy, and two diagnosed with hypertrophic cardiomyopathy (HCM). Genetic testing identified three rare variants (two non-sense and one small indel inducing a frameshift), each present in two families. Although each variant is currently classified as pathogenic and the cause of the diagnosed cardiomyopathy, the onset and/or clinical course differed in each patient. New genetic technology allows comprehensive yet cost-effective genetic analysis, although genetic interpretation, and clinical translation of identified variants should be carefully done in each family in a personalized manner

Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. Methods: GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. Findings: Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990–2010 time period, with the greatest annualised rate of decline occurring in the 0–9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10–24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10–24 years were also in the top ten in the 25–49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50–74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. Interpretation: As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and developm nt investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950-2019 : a comprehensive demographic analysis for the Global Burden of Disease Study 2019

Background: Accurate and up-to-date assessment of demographic metrics is crucial for understanding a wide range of social, economic, and public health issues that affect populations worldwide. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 produced updated and comprehensive demographic assessments of the key indicators of fertility, mortality, migration, and population for 204 countries and territories and selected subnational locations from 1950 to 2019. Methods: 8078 country-years of vital registration and sample registration data, 938 surveys, 349 censuses, and 238 other sources were identified and used to estimate age-specific fertility. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate age-specific fertility rates for 5-year age groups between ages 15 and 49 years. With extensions to age groups 10–14 and 50–54 years, the total fertility rate (TFR) was then aggregated using the estimated age-specific fertility between ages 10 and 54 years. 7417 sources were used for under-5 mortality estimation and 7355 for adult mortality. ST-GPR was used to synthesise data sources after correction for known biases. Adult mortality was measured as the probability of death between ages 15 and 60 years based on vital registration, sample registration, and sibling histories, and was also estimated using ST-GPR. HIV-free life tables were then estimated using estimates of under-5 and adult mortality rates using a relational model life table system created for GBD, which closely tracks observed age-specific mortality rates from complete vital registration when available. Independent estimates of HIV-specific mortality generated by an epidemiological analysis of HIV prevalence surveys and antenatal clinic serosurveillance and other sources were incorporated into the estimates in countries with large epidemics. Annual and single-year age estimates of net migration and population for each country and territory were generated using a Bayesian hierarchical cohort component model that analysed estimated age-specific fertility and mortality rates along with 1250 censuses and 747 population registry years. We classified location-years into seven categories on the basis of the natural rate of increase in population (calculated by subtracting the crude death rate from the crude birth rate) and the net migration rate. We computed healthy life expectancy (HALE) using years lived with disability (YLDs) per capita, life tables, and standard demographic methods. Uncertainty was propagated throughout the demographic estimation process, including fertility, mortality, and population, with 1000 draw-level estimates produced for each metric. Findings: The global TFR decreased from 2·72 (95% uncertainty interval [UI] 2·66–2·79) in 2000 to 2·31 (2·17–2·46) in 2019. Global annual livebirths increased from 134·5 million (131·5–137·8) in 2000 to a peak of 139·6 million (133·0–146·9) in 2016. Global livebirths then declined to 135·3 million (127·2–144·1) in 2019. Of the 204 countries and territories included in this study, in 2019, 102 had a TFR lower than 2·1, which is considered a good approximation of replacement-level fertility. All countries in sub-Saharan Africa had TFRs above replacement level in 2019 and accounted for 27·1% (95% UI 26·4–27·8) of global livebirths. Global life expectancy at birth increased from 67·2 years (95% UI 66·8–67·6) in 2000 to 73·5 years (72·8–74·3) in 2019. The total number of deaths increased from 50·7 million (49·5–51·9) in 2000 to 56·5 million (53·7–59·2) in 2019. Under-5 deaths declined from 9·6 million (9·1–10·3) in 2000 to 5·0 million (4·3–6·0) in 2019. Global population increased by 25·7%, from 6·2 billion (6·0–6·3) in 2000 to 7·7 billion (7·5–8·0) in 2019. In 2019, 34 countries had negative natural rates of increase; in 17 of these, the population declined because immigration was not sufficient to counteract the negative rate of decline. Globally, HALE increased from 58·6 years (56·1–60·8) in 2000 to 63·5 years (60·8–66·1) in 2019. HALE increased in 202 of 204 countries and territories between 2000 and 2019

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation