Seasonal Variation in Mortality, Medical Care Expenditure and Institutionalization in Older People: Evidence from a Dutch Cohort of Older Health Insurance Clients

Excess winter mortality in Finland, 1971-2019: a register-based study on long-term trends and effect modification by sociodemographic characteristics and pre-existing health conditions

OBJECTIVES

Excess winter mortality is a well-established phenomenon across the developed world. However, whether individual-level factors increase vulnerability to the effects of winter remains inadequately examined. Our aim was to assess long-term trends in excess winter mortality in Finland and estimate the modifying effect of sociodemographic and health characteristics on the risk of winter death.

DESIGN

Nationwide register study.

SETTING

Finland.

PARTICIPANTS

Population aged 60 years and over, resident in Finland, 1971-2019.

OUTCOME MEASURES

Age-adjusted winter and non-winter death rates, and winter-to-non-winter rate ratios and relative risks (multiplicative interaction effects between winter and modifying characteristics).

RESULTS

We found a decreasing trend in the relative winter excess mortality over five decades and a drop in the series around 2000. During 2000-2019, winter mortality rates for men and women were 11% and 14% higher than expected based on non-winter rates. The relative risk of winter death increased with age but did not vary by income. Compared with those living with at least one other person, individuals in institutions had a higher relative risk (1.07, 95% CI 1.05 to 1.08). Most pre-existing health conditions did not predict winter death, but persons with dementia emerged at greater relative risk (1.06, 95% CI 1.04 to 1.07).

CONCLUSIONS

Although winter mortality seems to affect frail people more strongly-those of advanced age, living in institutions and with dementia-there is an increased risk even beyond the more vulnerable groups. Protection of high-risk groups should be complemented with population-level preventive measures.

Seasonality of mortality under climate change: a multicountry projection study

BACKGROUND

Climate change can directly impact temperature-related excess deaths and might subsequently change the seasonal variation in mortality. In this study, we aimed to provide a systematic and comprehensive assessment of potential future changes in the seasonal variation, or seasonality, of mortality across different climate zones.

METHODS

In this modelling study, we collected daily time series of mean temperature and mortality (all causes or non-external causes only) via the Multi-Country Multi-City Collaborative (MCC) Research Network. These data were collected during overlapping periods, spanning from Jan 1, 1969 to Dec 31, 2020. We projected daily mortality from Jan 1, 2000 to Dec 31, 2099, under four climate change scenarios corresponding to increasing emissions (Shared Socioeconomic Pathways [SSP] scenarios SSP1-2.6, SSP2-4.5, SSP3-7.0, and SSP5-8.5). We compared the seasonality in projected mortality between decades by its shape, timings (the day-of-year) of minimum (trough) and maximum (peak) mortality, and sizes (peak-to-trough ratio and attributable fraction). Attributable fraction was used to measure the burden of seasonality of mortality. The results were summarised by climate zones.

FINDINGS

The MCC dataset included 126 809 537 deaths from 707 locations within 43 countries or areas. After excluding the only two polar locations (both high-altitude locations in Peru) from climatic zone assessments, we analysed 126 766 164 deaths in 705 locations aggregated in four climate zones (tropical, arid, temperate, and continental). From the 2000s to the 2090s, our projections showed an increase in mortality during the warm seasons and a decrease in mortality during the cold seasons, albeit with mortality remaining high during the cold seasons, under all four SSP scenarios in the arid, temperate, and continental zones. The magnitude of this changing pattern was more pronounced under the high-emission scenarios (SSP3-7.0 and SSP5-8.5), substantially altering the shape of seasonality of mortality and, under the highest emission scenario (SSP5-8.5), shifting the mortality peak from cold seasons to warm seasons in arid, temperate, and continental zones, and increasing the size of seasonality in all zones except the arid zone by the end of the century. In the 2090s compared with the 2000s, the change in peak-to-trough ratio (relative scale) ranged from 0·96 to 1·11, and the change in attributable fraction ranged from 0·002% to 0·06% under the SSP5-8.5 (highest emission) scenario.

INTERPRETATION

A warming climate can substantially change the seasonality of mortality in the future. Our projections suggest that health-care systems should consider preparing for a potentially increased demand during warm seasons and sustained high demand during cold seasons, particularly in regions characterised by arid, temperate, and continental climates.

FUNDING

The Environment Research and Technology Development Fund of the Environmental Restoration and Conservation Agency, provided by the Ministry of the Environment of Japan.

The Impact of Winter Months on Venous Thromboembolism (VTE) Patients: A Retrospective Analysis of Hospital Outcomes in the United States

Objective: We aimed to analyze the Health Care Utilization Project’s (HCUP) Nationwide Inpatient Sample (NIS) and compare mortality rates in hospitals by month to determine if there is seasonal variability in outcomes associated with venous thromboembolism (VTE).

Methods: The Nationwide Inpatient Sample database was queried from 1998 to 2011. Inclusion criteria were a diagnosis of deep vein thrombosis (DVT) (ICD-9 {International Classification of Diseases, Ninth Revision, Clinical Modification} 453.4, 453.8) and/or VTE (ICD-9 415.1) in patients aged 18 years or more. Admission data was then analyzed to compare mortality rates in teaching and non-teaching hospitals over that time and by month. Demographics, Charlson Comorbidity Index, length of stay (LOS), hospital region, and admission types (emergent/urgent versus elective admissions) were assessed. Linear and logistic models were generated for complex survey design to analyze predictors of mortality and LOS.

Results: A total of 1,449,113 DVT/VTE cases were identified in the Nationwide Inpatient Sample (weighted n= 7,150,613), 54.7% female, 56.38% white, 49% in teaching hospitals. Higher mortality was found in the months of November 6.52%, December 6.9%, January 6.94%, and February 6.93% versus overall mortality of 6.4% over 12 months. Higher mortality was noted in these winter months in all regions, along with a significantly increased LOS. Mortality in the total cohort was found to be higher in January, with odds ratio (OR) 1.11 (1.08-1.15), p<0.0001; February, OR 1.11 (1.07-1.15), p<0.0001; and December, OR 1.10 (1.06-1.14), p<0.0001 compared to June. Mortality was significantly lower in the Midwest or North Central regions (OR 0.78 {0.72-0.83}, p<0.0001) and West (OR 0.80 {0.73-0.87}, p<0.0001) compared to the Northeast. Mortality was also significantly higher in teaching hospitals than in non-teaching hospitals (OR 1.16 {1.10-1.22}, p<0.0001), with mortality trending higher in teaching hospitals each month. Emergent/urgent admission, larger hospital size, female sex, age, and urban location were also significantly associated with increased mortality.

Conclusions: This national study identified an increased risk of mortality associated with hospitalizations for DVT/VTE in the winter months, independent of hospital teaching status or region.

Variability of Mortality: Additional Information on Mortality and Morbidity Curves under Normal and Pathological Conditions [Commentary on the Article by A. G. Malygin “Programmed Risks of Death in Male Patients with Diabetes” Published in Biochemistry (Moscow), vol. 86, pp. 1553-1562 (2021)]

Analysis of demographic data indicates uneven distribution of mortality within a year, month, and even week time period. This is of great practical importance for the operation of medical institutions, including intensive care units, and makes it possible to calculate economic and labor requirements of medical institutions. All the above is especially relevant during the era of the COVID-19 pandemic. Malygin showed the presence of one to two fluctuations per week in the mortality of male patients with type 2 diabetes. The height of the peaks of such fluctuations is determined, as expected, by the regular parameter indicating their position on the axis of lifespan and random parameter reflecting adverse effects of external environmental factors on the body, as well as the extent of the periodically occurring sharp decrease in the nonspecific resistance. This article discusses results of recent research in the field of small (semi-weekly, weekly, monthly, and seasonal) fluctuations of mortality. Based on a large array of accumulated data, it can be concluded that the decrease in seasonal variability of mortality accompanies an increase in the life expectancy. Studying characteristics of mortality fluctuations makes it possible to move from investigating the impact of biorhythms (Master Clock) on the development of acute and chronic phenoptotic processes directly to studying the patterns of mortality rhythms themselves (rhythms of phenoptosis).

Seasonal Variation in Generic and Disease-Specific Health-Related Quality of Life in Rhinologic Patients in Southern Finland

Background: Seasonal variation in exacerbations, hospitalisations, and mortality statistics has been reported for some diseases. To our knowledge, however, no published studies exist on the seasonality of health-related quality of life (HRQoL) amongst rhinologic patients. Aims/Objectives: This study, therefore, aimed to investigate the possible seasonal variation in rhinologic patients’ HRQoL using the rhinologic disease-specific Sino-Nasal Outcome Test-22 (SNOT-22) and the generic 15D HRQoL instrument. Material and Methods: We enrolled unselected adult rhinologic patients requiring specialist care at the Helsinki University Hospital in this cross-sectional, questionnaire-based prospective study during four seasons: February (winter), May (spring), August (summer), and November (autumn). Patients received SNOT-22 and 15D questionnaires via post. The Finnish Meteorological Institute supplied climate data from these months. Results: SNOT-22 and 15D data were available for 301 and 298 patients, respectively. We found no statistically significant differences (p = 0.948) between the mean monthly 15D scores or mean SNOT-22 scales. Furthermore, the mean SNOT-22 subscales did not differ between the monthly study periods. Conclusions and Significance: Our study shows that seasonality did not impact rhinologic patients’ SNOT-22 or 15D HRQoL scores. Thus, these questionnaires can be used for follow-up amongst rhinologic patients regardless of season.

Aging Affects the Capacity of Photoperiodic Adaptation Downstream from the Central Molecular Clock

Aging impairs circadian clock function, leading to disrupted sleep-wake patterns and a reduced capability to adapt to changes in environmental light conditions. This makes shift work or the changing of time zones challenging for the elderly and, importantly, is associated with the development of age-related diseases. However, it is unclear what levels of the clock machinery are affected by aging, which is relevant for the development of targeted interventions. We found that naturally aged mice of >24 months had a reduced rhythm amplitude in behavior compared with young controls (3-6 months). Moreover, the old animals had a strongly reduced ability to adapt to short photoperiods. Recording PER2::LUC protein expression in the suprachiasmatic nucleus revealed no impairment of the rhythms in PER2 protein under the 3 different photoperiods tested (LD: 8:16, 12:12, and 16:8). Thus, we observed a discrepancy between the behavioral phenotype and the molecular clock, and we conclude that the aging-related deficits emerge downstream of the core molecular clock. Since it is known that aging affects several intracellular and membrane components of the central clock cells, it is likely that an impairment of the interaction between the molecular clock and these components is contributing to the deficits in photoperiod adaptation.

The effect of bariatric surgery on health care costs: A synthetic control approach using Bayesian structural time series

Surgical measures to combat obesity are very effective in terms of weight loss, recovery from diabetes, and improvement in cardiovascular risk factors. However, previous studies found both positive and negative results regarding the effect of bariatric surgery on health care utilization. Using claims data from the largest health insurance provider in Germany, we estimated the causal effect of bariatric surgery on health care costs in a time period ranging from 2 years before to 3 years after bariatric intervention. Owing to the absence of a control group, we employed a Bayesian structural forecasting model to construct a synthetic control. We observed a decrease in medication and physician expenditures after bariatric surgery, whereas hospital expenditures increased in the post-intervention period. Overall, we found a slight increase in total costs after bariatric surgery, but our estimates include a high degree of uncertainty.

Seasonal Variation in Acute Cholecystitis: An Analysis of Cholecystectomies Spanning Three Decades

BACKGROUND

Seasonal variation in the occurrence of medical illnesses reflects the effect of the environment, provides insight into pathogenesis, and can assist health care administrators in allocating resources accordingly. Seasonal variation has been reported in various infectious and surgical diseases, but has been rarely studied in acute cholecystitis. Our objective was to study seasonal variation in acute cholecystitis at our institution.

METHODS

We performed a retrospective analysis of patients who underwent cholecystectomy for acute cholecystitis from January 1988 to December 2018. Chi-square goodness-of-fit test was used to analyze seasonality of acute cholecystitis adjusting for variation in number of days between seasons. The number of days for seasons were taken as 92, 92, 91, and 90.25 for spring, summer, fall, and winter, respectively.

RESULTS

Overall, 3924 patients underwent cholecystectomy for acute cholecystitis during the study period. The frequency of cholecystectomies performed varied between months (minimum February n = 259, maximum July n = 372, P < 0.001) and seasons (minimum winter n = 789, maximum summer n = 1101 P < 0.001). Age and gender distribution across months and seasons was similar (P > 0.05).

CONCLUSIONS

Our findings confirm seasonal variation in occurrence of acute cholecystitis with summer season witnessing the most and the winter season encountering the least patients with acute cholecystitis. Validation of our findings through prospectively collected data at national level is the way forward.

Monthly variance in UK renal transplantation activity: a national retrospective cohort study

OBJECTIVE

To identify whether renal transplant activity varies in a reproducible manner across the year.

DESIGN

Retrospective cohort study using NHS Blood and Transplant data.

SETTING

All renal transplant centres in the UK.

PARTICIPANTS

A total of 24 270 patients who underwent renal transplantation between 2005 and 2014.

PRIMARY OUTCOME

Monthly transplant activity was analysed to see if transplant activity showed variation during the year.

SECONDARY OUTCOME

The number of organs rejected due to healthcare capacity was analysed to see if this affected transplantation rates.

RESULTS

Analysis of national transplant data revealed a reproducible yearly variance in transplant activity. This activity increased in late autumn and early winter (p=0.05) and could be attributed to increased rates of living (October and November) and deceased organ donation (November and December). An increase in deceased donation was attributed to a rise in donors following cerebrovascular accidents and hypoxic brain injury. Other causes of death (infections and road traffic accidents) were more seasonal in nature peaking in the winter or summer, respectively. Only 1.4% of transplants to intended recipients were redirected due to a lack of healthcare capacity, suggesting that capacity pressures in the National Health Service did not significantly affect transplant activity.

CONCLUSION

UK renal transplant activity peaks in late autumn/winter in contrast to other countries. Currently, healthcare capacity, though under strain, does not affect transplant activity; however, this may change if transplantation activity increases in line with national strategies as the spike in transplant activity coincides with peak activity in the national healthcare system.

Healthcare costs for the elderly in Japan: Analysis of medical care and long-term care claim records

BACKGROUND

The population is aging rapidly in many developed countries. Such countries need to respond to the growing demand and expanding costs of healthcare (HC) for the elderly. Therefore, it is important to investigate the factors correlating such HC costs. In Japan, HC is composed of two sections, namely medical care (MC) and long-term care (LTC). While many studies have examined MC and LTC costs on their own, few studies have conducted comprehensive investigations of HC costs. The aim of this study is to examine the risk factors that influence HC costs for the elderly who enroll in the LTC insurance system in Japan.

METHODS

The inclusion criteria in the present study are as follows: being 65 years of age, or older; certified eligibility for, and use of services offered by the LTC insurance system at home or in an institutional setting in December 2009; and being covered by the National Health Insurance (NHI) system. MC and LTC insurance data were obtained from claim records for the elderly in July and December of 2007, 2008, and 2009 (i.e., a total of six survey points). Panel data, per subject, were constructed using MC and LTC claim records. The sample included 810 subjects and 4029 observations.

RESULTS

We estimated a regression equation with a censored dependent variable using a Tobit model. Significant associations between MC or LTC costs and interaction terms (household composition × seasonal effects) were investigated. MC costs significantly decreased and LTC costs significantly increased among subjects living alone during winter. Income level was also a positive determinant of MC costs, while eligibility level was a positive determinant of LTC costs.

CONCLUSIONS

We recommend that the health policy for the elderly focus more on seasonal effects, household composition, and income level, as well as on eligibility level.

Potentially inappropriate prescribing to older patients in primary care in the Netherlands: a retrospective longitudinal study

Background

potentially inappropriate prescribing (PIP) is associated with adverse health effects in older patients. PIP comprises prescription of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs).

Objective

to estimate the prevalence of PIMs and PPOs among older patients in primary care.

Design

retrospective longitudinal study.

Setting

routinely collected data of 182,000 patients of 49 general practitioners (GPs) gathered in the GPs' database of the Academic Medical Center of Amsterdam, the Netherlands.

Subjects

in each studied year, all patients who were aged 65 years and older at 1st January.

Methods

the prevalence of patients with at least one PIM and patients with at least one PPO was measured in 8 subsequent years (2007-14) by application of the Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP)/Screening Tool to Alert doctors to Right Treatment (START) criteria. Multivariate logistic regression was used to evaluate trends in the prevalence of PIMs and PPOs over the years.

Results

on average, 4,537 patients were included per investigated year. The mean prevalence of ≥1 PIM was 34.7% (range 34.0-35.6%) and of ≥1 PPO 84.8% (range 77.4-90.6%). Examples were the prescription of salicylates without a proper indication and the absence of a therapeutically indicated vitamin D prescription. The prevalence of ≥1 PPOs showed a statistically significant decrease over the investigated years (OR 0.87, P < 0.001), whereas the prevalence of PIMs did not change significantly.

Conclusions

this study underscores the need for more attention to medication prescribing to older patients. The prevalence of PIP among older patients in primary care is substantial and the prevalence of PIMs did not decrease over time.