Total mortality inequality in Scotland: the case for measuring lifespan variation

Lifespan variation captures variation in age at death within a population as opposed to the inequality in average health that exists between populations. Higher lifespan variation equates to greater total inequality and is negatively correlated with life expectancy. Lifespan variation has not previously been measured for Scotland, where life expectancy and mortality rates are the worst in Western Europe. Routinely measuring lifespan variation in Scotland contributes to understanding the extent, and changing nature, of mortality inequalities. Lifespan variation estimates were calculated using data from the Human Mortality Database and from Census population estimates, vital events data and the Carstairs Score. Analyses included joinpoint regression, Age-specific decomposition, Monte Carlo simulation, slope index of inequality, relative index of inequality, and Age-cause specific decomposition. Males in Scotland experience the highest level of lifespan variation in Western Europe, increasing since the 1980s: the longest sustained increasing trend found in Western Europe. Increasing mortality rates across working adult ages account for Scotland’s diverging trend. This age pattern of mortality was not evident in England and Wales. Lifespan variation for males in the most deprived quintile was higher in 2011 than in 1981 and the socioeconomic gradient steepened. Premature deaths from external causes of death accounted for an increasing proportion of lifespan variation inequalities. Without tackling the root causes of social inequality Scotland may struggle to reduce total inequality and improve its lifespan variation ranking within Western Europe

Changing contribution of area-level deprivation to total variance in age at death: a population-based decomposition analysis

Objectives Two processes generate total variance in age at death: heterogeneity (between-group variance) and individual stochasticity (within-group variance). Limited research has evaluated how these two components have changed over time. We quantify the degree to which area-level deprivation contributed to total variance in age at death in Scotland between 1981 and 2011. Design Full population and mortality data for Scotland were obtained and matched with the Carstairs score, a standardised z-score calculated for each part-postcode sector that measures relative area-level deprivation. A z-score above zero indicates that the part-postcode sector experienced higher deprivation than the national average. A z-score below zero indicates lower deprivation. From the aggregated data we constructed 40 lifetables, one for each deprivation quintile in 1981, 1991, 2001 and 2011 stratified by sex. Primary outcome measures Total variance in age at death and the proportion explained by area-level deprivation heterogeneity (between-group variance). Results The most deprived areas experienced stagnating or slightly increasing variance in age at death. The least deprived areas experienced decreasing variance. For males, the most deprived quintile life expectancy was between 7% and 11% lower and the SD is between 6% and 25% higher than the least deprived. This suggests that the effect of deprivation on the SD of longevity is comparable to its effect on life expectancy. Decomposition analysis revealed that contributions from between-group variance doubled between 1981 and 2011 but at most only explained 4% of total variance. Conclusions This study adds to the emerging body of literature demonstrating that socio-economic groups have experienced diverging trends in variance in age at death. The contribution from area-level deprivation to total variance in age at death, which we were able to capture, has doubled since 1981. Area-level deprivation may play an increasingly important role in mortality inequalities

Increasing inequality in age of death at shared levels of life expectancy: A comparative study of Scotland and England and Wales

There is a strong negative correlation between increasing life expectancy and decreasing lifespan variation, a measure of inequality. Previous research suggests that countries achieving a high level of life expectancy later in time generally do so with lower lifespan variation than forerunner countries. This may be because they are able to capitalise on lessons already learnt. However, a few countries achieve a high level of life expectancy later in time with higher inequality. Scotland appears to be such a country and presents an interesting case study because it previously experienced lower inequality when reaching the same level of life expectancy as its closest comparator England and Wales. We calculated life expectancy and lifespan variation for Scotland and England and Wales for the years 1950 to 2012, comparing Scotland to England and Wales when it reached the same level of life expectancy later on in time, and assessed the difference in the level of lifespan variation. The lifespan variation difference between the two countries was then decomposed into age-specific components. Analysis was carried out for males and females separately. Since the 1950s Scotland has achieved the same level of life expectancy at least ten years later in time than England and Wales. Initially it did so with lower lifespan variation. Following the 1980s Scotland has been achieving the same level of life expectancy later in time than England and Wales and with higher inequality, particularly for males. Decomposition revealed that higher inequality is partly explained by lower older age mortality rates but primarily by higher premature adult age mortality rates when life expectancy is the same. Existing studies suggest that premature adult mortality rates are strongly associated with the social determinants of health and may be amenable to social and economic policies. So addressing these policy areas may have benefits for both inequality and population health in Scotland

Gender differences in time to first hospital admission at age 60 in Denmark, 1995–2014

Women have consistently lower mortality rates than men at all ages and with respect to most causes. However, gender differences regarding hospital admission rates are more mixed, varying across ages and causes. A number of intuitive metrics have previously been used to explore changes in hospital admissions over time, but have not explicitly quantified the gender gap or estimated the cumulative contribution from cause-specific admission rates. Using register data for the total Danish population between 1995 and 2014, we estimated the time to first hospital admission for Danish men and women aged 60. This is an intuitive population-level metric with the same interpretive and mathematical properties as period life expectancy. Using a decomposition approach, we were able to quantify the cumulative contributions from eight causes of hospital admission to the gender gap in time to first hospital admission. Between 1995 and 2014, time to first admission increased for both, men (7.6 to 9.4 years) and women (8.3 to 10.3 years). However, the magnitude of gender differences in time to first admission remained relatively stable within this time period (0.7 years in 1995, 0.9 years in 2014). After age 60, Danish men had consistently higher rates of admission for cardiovascular conditions and neoplasms, but lower rates of admission for injuries, musculoskeletal disorders, and sex-specific causes. Although admission rates for both genders have generally declined over the last decades, the same major causes of admission accounted for the gender gap. Persistent gender differences in causes of admission are, therefore, important to consider when planning the delivery of health care in times of population ageing.Output Status: Forthcoming/Available Onlin

The increasing lifespan variation gradient by area-level deprivation: A decomposition analysis of Scotland 1981–2011

Life expectancy inequalities are an established indicator of health inequalities. More recent attention has been given to lifespan variation, which measures the amount of heterogeneity in age at death across all individuals in a population. International studies have documented diverging socioeconomic trends in lifespan variation using individual level measures of income, education and occupation. Despite using different socioeconomic indicators and different indices of lifespan variation, studies reached the same conclusion: the most deprived experience the lowest life expectancy and highest lifespan variation, a double burden of mortality inequality. A finding of even greater concern is that relative differences in lifespan variation between socioeconomic group were growing at a faster rate than life expectancy differences. The magnitude of lifespan variation inequalities by area-level deprivation has received limited attention. Area-level measures of deprivation are actively used by governments for allocating resources to tackle health inequalities. Establishing if the same lifespan variation inequalities emerge for area-level deprivation will help to better inform governments about which dimension of mortality inequality should be targeted. We measure lifespan variation trends (1981–2011) stratified by an area-level measure of socioeconomic deprivation that is applicable to the entire population of Scotland, the country with the highest level of variation and one of the longest, sustained stagnating trends in Western Europe. We measure the gradient in variation using the slope and relative indices of inequality. The deprivation, age and cause specific components driving the increasing gradient are identified by decomposing the change in the slope index between 1981 and 2011. Our results support the finding that the most advantaged are dying within an ever narrower age range while the most deprived are facing greater and increasing uncertainty. The least deprived group show an increasing advantage, over the national average, in terms of deaths from circulatory disease and external causes

How have trends in lifespan variation changed since 1950? A comparative study of 17 Western European countries

Lifespan variation adds to life expectancy by measuring the inequality surrounding age of death that a population faces. Countries that tackle premature mortality generally have decreasing lifespan variation but this is the first study to compare and statistically assess when and to what extent trends in lifespan variation have changed across Western Europe. Lifespan variation was measured using e† and joinpoint regression analysed the timing and rate of change. Trends have been mostly downward with the recent exception of men in Scotland, Northern Ireland, Ireland and Finland where trends have flattened or show slight increases. Future research aimed at identifying the ages and causes of death, driving trends in these countries, is key to preventing increasing inequalities

Rethinking morbidity compression

Studies of morbidity compression routinely report the average number of years spent in an unhealthy state but do not report variation in age at morbidity onset. Variation was highlighted by Fries (1980) as crucial for identifying disease postponement. Using incidence of first hospitalization after age 60, as one working example, we estimate variation in morbidity onset over a 27-year period in Denmark. Annual estimates of first hospitalization and the population at risk for 1987 to 2014 were identified using population-based registers. Sex-specific life tables were constructed, and the average age, the threshold age, and the coefficient of variation in age at first hospitalization were calculated. On average, first admissions lasting two or more days shifted towards older ages between 1987 and 2014. The average age at hospitalization increased from 67.8 years (95% CI 67.7-67.9) to 69.5 years (95% CI 69.4-69.6) in men, and 69.1 (95% CI 69.1-69.2) to 70.5 years (95% CI 70.4-70.6) in women. Variation in age at first admission increased slightly as the coefficient of variation increased from 9.1 (95% CI 9.0-9.1) to 9.9% (95% CI 9.8-10.0) among men, and from 10.3% (95% CI 10.2-10.4) to 10.6% (95% CI 10.5-10.6) among women. Our results suggest populations are ageing with better health today than in the past, but experience increasing diversity in healthy ageing. Pensions, social care, and health services will have to adapt to increasingly heterogeneous ageing populations, a phenomenon that average measures of morbidity do not capture.Peer reviewe

Interrogating the technical, economic and cultural challenges of delivering the PassivHaus standard in the UK.

A peer-reviewed eBook, which is based on a collaborative research project coordinated by Dr. Henrik Schoenefeldt at the Centre for Architecture and Sustainable Environment at the University of Kent between May 2013 and June 2014. This project investigated how architectural practice and the building industry are adapting in order to successfully deliver Passivhaus standard buildings in the UK. Through detailed case studies the project explored the learning process underlying the delivery of fourteen buildings, certified between 2009 and 2013. Largely founded on the study of the original project correspondence and semi-structured interviews with clients, architects, town planners, contractors and manufacturers, these case studies have illuminated the more immediate technical as well as the broader cultural challenges. The peer-reviewers of this book stressed that the findings included in the book are valuable to students, practitioners and academic researchers in the field of low-energy design. It was launched during the PassivHaus Project Conference, held at the Bulb Innovation Centre on the 27th June 2014

Social security cuts and life expectancy: a longitudinal analysis of local authorities in England, Scotland and Wales

Background The UK Government’s ‘welfare reform’ programme included reductions to social security payments, phased in over the financial years 2011/2012–2015/2016. Previous studies of social security cuts and health outcomes have been restricted to analysing single UK countries or single payment types (eg, housing benefit). We examined the association between all social security cuts fully implemented by 2016 and life expectancy, for local authorities in England, Scotland and Wales. Methods Our unit of analysis was 201 upper tier local authorities (unitary authorities and county councils: 147 in England, 32 in Scotland, 22 in Wales). Our exposure was estimated social security loss per head of the working age population per year for each local authority, calculated against the baseline in 2010/2011. The primary outcome was annual life expectancy at birth between the calendar years 2012 and 2016 (year lagged following exposure). We used a panel regression approach with fixed effects. Results Social security cuts implemented by 2016 were estimated to be £475 per head of the working age population in England, £390 in Scotland and £490 in Wales since 2010/2011. During the study period, there was either no improvement or only marginal increases in national life expectancy. Social security loss and life expectancy were significantly associated: an estimated £100 decrease in social security per head of working age population was associated with a 1-month reduction in life expectancy. Conclusions Social security cuts, at the UK local authority level, were associated with lower life expectancy. Further research should examine causality

Bearing the burden of austerity: how do changing mortality rates in the UK compare between men and women?

Background: Mortality rates across the UK stopped improving in the early 2010s, largely attributable to UK Government’s ‘austerity’ policies. Such policies are thought to disproportionately affect women in terms of greater financial impact and loss of services. The aim here was to investigate whether the mortality impact of austerity—in terms of when rates changed and the scale of excess deaths—has also been worse for women. Methods: All-cause mortality data by sex, age, Great Britain (GB) nation and deprivation quintile were obtained from national agencies. Trends in age-standardised mortality rates were calculated, and segmented regression analyses used to identify break points between 1981 and 2019. Excess deaths were calculated for 2012–2019 based on comparison of observed deaths with numbers predicted by the linear trend for 1981–2011. Results: Changes in trends were observed for both men and women, especially for those living in the 20% most deprived areas. In those areas, mortality increased between 2010/2012 and 2017/2019 among women but not men. Break points in trends occurred at similar time points. Approximately 335 000 more deaths occurred between 2012 and 2019 than was expected based on previous trends, with the excess greater among men. Conclusions: It remains unclear whether there are sex differences in UK austerity-related health effects. Nonetheless, this study provides further evidence of adverse trends in the UK and the associated scale of excess deaths. There is a clear need for such policies to be reversed, and for policies to be implemented to protect the most vulnerable in society