Summary_Danilova (1136935), страница 3
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For some of the other causes of death the dispersion in mortality levels wasso vast that it is hard to fathom that such a variation is even possible within a singlecountry. Instead it seems that regional differences in mortality from these causes reflectthe different regional approaches to the selection of the underlying cause of death.To perform the mortality analysis, we aggregated some groups of causes of deathinto a larger category, as the studies show that misclassification within ICD-chapters ismore common than between chapters10. Some causes (e.g., endocrine disorders,disorders of the nervous system) had to be excluded from the analysis because thesecauses could not be combined with any others, and the cross-regional dispersion forthese causes was too high.
In the end a list of 23 groups of causes of death wasproposed for further analysis. This list covers 85.2% of the age-standardized death ratein Russia in 2013-2015, and 90% of the death rate for age interval 0-79 years.We also had to exclude ages 80 and over from the analysis by causes of death. Atthese ages, 18.6% of deaths in Russia in 2014-2015 were coded under “Senility” (ICD10 code R54) and this share is wildly different from region to region. In 8 regions fewerthan 1% of all deaths were coded under Senility, whereas in Rostov oblast this code wasused for 55% of deaths at age 80 and older, and this number increased to 57.5% in rep.Bashkortostan and Smolensk Oblast.
The prevalence of senility in cause-of-deathmortality structure also fluctuated significantly in Russia over time. Before 1989, thedeaths of older people were rarely coded as being caused by senility. For the entireperiod of 1965-1989 there were 3.8 times fewer deaths coded as “Senility” than in thesingle year 2015. This increase in the share of deaths coded under “Senility” startedafter 1989, when a special Decree of the Soviet Minister of Health was issued,10Harteloh P.
The reliability of cause-of-death coding in Netherlands // European Journal of Epidemiology. 2010. Vol.25.№ 8. P. 531-538; Winkler V. Reliability of coding causes causes of death with ICD-10 in Germany// Int J Public Health.2010. Vol. 55. № 1. P. 43-48.prescribing all deaths of those aged 80 and over to be coded as caused by senility unlessthere was evidence of an external cause of death or unless the medical records indicatedany other cause.Because the prevalence of senility in cause-of-death mortality structure changessubstantially both across territories and over time, it is not possible to perform thecorrect cause-specific mortality analysis after age 80.Regional trajectories of changes in mortality and life expectancy and theirreflection in inter-regional mortality inequalityRegional trajectories of mortality changes between the turn of the 1960s and1970s and today are examined.
We also compared these with the trend for Russia as awhole and analyzed how the discrepancies in regional trends affected the values ofinterregional inequality.To define whether various regional trends were consistent with the national one,we estimated the changes in life expectancy at the regional level between the followingtime points: 1969/1970-1978/1979; 1978/1979-1989; 1989-2003; and 2003-2015. Thesefour time periods reflect the key milestones of changes in Russian mortality after the1960s: slow deterioration in life expectancy after mid-1960s (which was more of astagnation in females), rapid increase of life expectancy during the anti-alcoholcampaign, life expectancy fluctuations of the 1990s-early 2000s, and the current periodof life expectancy growth after the year 2003.
The analysis of changes in lifeexpectancy at the regional level showed that, even though in the vast majority ofregions the trends of life expectancy coincided with the national one in time, the regionsdisplay enormous differences in the values of life expectancy gains and losses indifferent time periods. This indicates that the regions do not share equal successes andfailures in mortality and life expectancy changes.In 2015, the value of life expectancy at birth in Russia was the highest in thehistorical perspective when calculated for the country as a whole. However, this is nottrue for all regions.
In 2015, life expectancy was lower in 23 regions for males and 3regions for females than in 1989. In 2 regions for males, life expectancy was lower thanin 1969/1970 (in Kemerovo and Bryansk oblasts)11.Most of the regions do follow the national mortality trends when analyzed by agegroups. Compared to 1969-1970 and 1989, infant and child mortality decreasedsubstantially by the year 2015 in all the regions. This is in contrast to mortality at youngand middle ages, which increased in most of the regions.
Compared to the rest of theregions, the city of Moscow and the North Caucasus republics seem to be morefavorable – in these regions, the changes in mortality at young and middle ages wererather positive. Mortality in the elderly declined in the vast majority of the regions. Thedecline in the cities of Moscow and Saint-Petersburg was especially pronounced.Meanwhile, in Amur, Belgorod, Bryansk, Smolensk, Kursk and Orenburg oblasts, themortality of senior men still hasn’t reached its lowest level.
There is a significantincrease in mortality at advanced ages in the republics of North Caucasus. The latter,however, probably reflects the improvement in the quality of mortality statistics in theseregions.The analysis of the changes in life expectancy at the regional level showed thatthe cities of Moscow and Saint-Petersburg and the republics of North Caucasus arequite different from the other regions of Russia, especially in male mortality. However,while the republics of North Caucasus were always somehow peculiar regardingmortality levels: life expectancy in these regions has always been rather high, thefavorable position of Moscow and Saint-Petersburg is a recent achievement which camein force in the second half of the 1990s. The gain in life expectancy between 2003 and11The comparison with life expectancy values for years 1965 and 1987 – the years of the maximum life expectancy inRussia - would probably show that there are even more regions that still haven’t reached the maximum levels of lifeexpectancy.
However, the data for those years were not available for this study.2015 – the current period of mortality improvements in Russia – was also among thehighest in these two cities; although in 2003 life expectancy there was already quitehigh compared to the other regions of Russia. Because the two cities are largelypopulated, the deviation of these two regions from the general trend influences thevalues of weighted by population indicators of mortality inequality significantly.As the tempo and sometimes even the directions of the changes in life expectancyfor specific regions were often different, the changes in inter-regional inequalityfollowed the changes in life expectancy at the national level.
In the current study, twomeasures of inter-regional disparity in life expectancy were examined: standarddeviation (weighted and non-weighted by population size) and the gap in lifeexpectancy at birth between the two 15% groups of the Russian population inhabitingthe regions with the largest and the lowest life expectancy. In 2015, the standarddeviation in life expectancy across regions in Russia was 3.3 years in males and 1.8 andfemales (weighted by the population size of the regions). The gap in life expectancybetween the two 15% groups of the population was 9.2 years in males and 5.1 years infemales.The trends of both measures during the period under study are similar.
Before2007, the changes in inter-regional inequality negatively correlated with the changes inlife expectancy for Russia as a whole. A growth of life expectancy was usually followedby a decline in inter-regional inequality, a reduction in life expectancy – by a growth ofinequality. Since 2007 this correlation has been broken: the continuing increase in lifeexpectancy is no longer followed by the decline in inter-regional disparities. In general,the analysis of trends in inter-regional inequality for the last 50 years shows that theproblem of inequality in life expectancy at the subnational level is much more crucialfor Russia today than it was during the Soviet era. Moreover, it is even more crucialthan it was in the 1990s – the period of mortality crisis in Russia.Using a stepwise replacement decomposition technique12, we decomposed thedifference in life expectancy between the two 15% groups of the population by ages andcauses of death.
This analysis was performed for five broad groups of causes of death:“Infectious and parasitic diseases,” “Neoplasms,” “Circulatory diseases,” “Externalcauses,” and “All other.”The decomposition showed that the largest contribution to the gap in lifeexpectancy between the two 15% groups is made by the same components which areresponsible for the Russian lagging position in life expectancy compared to the otherdeveloped countries. First of all, these are external causes in young and middle ages andcirculatory diseases which make the most substantial contributions at middle and olderages. The contribution of young and middle ages to the life expectancy decreasedetermined the life expectancy fluctuations in Russia in the 1990s – beginning of the2000s – to a large extent. In the recent decade, the contribution of young and middleages to the inter-regional inequality declines.
However, this decline is compensated forby the growing contribution of the older ages, primarily due to growing inequality inmortality from circulatory diseases.We can conclude that the main tendencies of the current period of life expectancyincrease in Russia affect the processes of divergence and convergence differently at theregional level. Those processes which are attributed to the recovery growth of lifeexpectancy in Russia –the decline in “crisis” component of Russian mortality asreflected through the exceptionally high premature mortality in young and middle ages– lead to the convergence in life expectancy at the regional level. On the other hand,those processes in which the researchers tend to see the possible beginning of thecardiovascular revolution in Russia – mortality decline from the circulatory diseases inthe elderly – lead to the regional divergence in life expectancy. These two tendencies12Andreev E.
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