Death Certificate Data Research Articles

TRENDS IN ANTINEUTROPHIL CYTOPLASMIC AUTOANTIBODY-ASSOCIATED VASCULITIS-RELATED MORTALITY IN THE UNITED STATES, 1999-2017

SESSION TITLE: Monday Electronic Posters 3 SESSION TYPE: Original Inv Poster Discussion PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: Estimates of the national mortality rate related to antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA) are largely unknown. We sought to describe trends in mortality related to ANCA-associated vasculitides from 1999 to 2017. METHODS: Using death certificate data from the Centers for Disease Control and Prevention Wide-ranging OnLine Data for Epidemiologic Research database, we computed standardized mortality rates to the 2000 U.S. population across gender, age, race, and geographic region, and used Joinpoint regression analysis to calculate the average annual percent change in mortality for patients with an ANCA-associated vasculitis. RESULTS: From 1999 to 2017, there were 11,316 ANCA-associated vasculitis-realted deaths in the United States. GPA accounted for 85% of cases. During the study period, the age-adjusted mortality rate was 1.86 (95% CI, 1.83 to 1.90) per 1,000,000 population. Mortality rates had an equal gender distribution and were highest in non-Hispanic whites (2.2 per 1,000,000 population), in the Midwestern United States (2.0 per 1,000,000 population) and increased with age (from 0.54 per 1,000,000 in decedents <65 years-old to 13.0 per 1,000,000 population in decedents aged 75). The age-adjusted mortality decreased from 1999 to 2017 by an average of 1.6% (95% CI, -2.6% to -0.7%) per year. CONCLUSIONS: The national age-adjusted ANCA-associated vasculitides-related mortality rate decreased from 1999 to 2017. Non-Hispanic whites, in particular adults 65 years-old have the highest mortality rates. CLINICAL IMPLICATIONS: Further work needs to be done to determine how steroid-sparing agents, new targeted immunotherapies, and other factors have contributed to the decline in ANCA-associated vasculitis-related mortality in recent years. This information can be used to develop interventions aimed at further decreasing the disease burden. DISCLOSURES: no disclosure on file for Evans Fernández Pérez; No relevant relationships by Alex Steinberg, source=Web Response

Identification of American Indians and Alaska Natives in Public Health Data Sets: A Comparison Using Linkage-Corrected Washington State Death Certificates.

Efforts to address disparities experienced by American Indians/Alaska Natives (AI/ANs) have been hampered by a lack of accurate and timely health data. One challenge to obtaining accurate data is determining who "counts" as AI/AN in health and administrative data sets. To compare the effects of definition and misclassification of AI/AN on estimates of all-cause and cause-specific mortality for AI/AN in Washington during 2015-2016. Secondary analysis of death certificate data from Washington State. Data were corrected for AI/AN racial misclassification through probabilistic linkage with the Northwest Tribal Registry. Counts and age-adjusted rates were calculated and compared for 6 definitions of AI/AN. Comparisons were made with the non-Hispanic white population to identify disparities. Washington State. AI/AN and non-Hispanic white residents of Washington State who died in 2015 and 2016. Counts and age-adjusted rates for all-cause mortality and mortality from cardiovascular diseases, cancer, and unintentional injuries. The most conservative single-race definition of AI/AN identified 1502 AI/AN deaths in Washington State during 2015-2016. The least conservative multiple-race definition of AI/AN identified 2473 AI/AN deaths, with an age-adjusted mortality rate that was 48% higher than the most conservative definition. Correcting misclassified AI/AN records through probabilistic linkage significantly increased mortality rate estimates by 11%. Regardless of definition used, AI/AN in Washington had significantly higher all-cause mortality rates than non-Hispanic whites in the state. Reporting single-race versus multiple-race AI/AN had the most consequential effect on mortality counts and rates. Correction of misclassified AI/AN records resulted in small but statistically significant increases in AI/AN mortality rates. Researchers and practitioners should consult with AI/AN communities on the complex issues surrounding AI/AN identity to obtain the best method for identifying AI/AN in health data sets.

Avoidable, amenable, and preventable mortalities in South Korea, 2000–2017: Age-period-cohort trends and impact on life expectancy at birth

This study aimed to estimate age-period-cohort effects on avoidable mortality and quantify the impact of avoidable mortality changes on life expectancy (LE) at birth in the South Korean population aged 0–74 years. Using death certificate and resident population data from 2000 to 2017, trends in age-standardized avoidable mortality rates were analyzed with joinpoint regression. Intrinsic estimator regression analysis was conducted to estimate age-period-cohort effects on avoidable mortality. Arriaga's method was used to measure the contributions of avoidable causes to changes in LE gaps between adjacent three-year periods by age and avoidable cause of death groups. Avoidable mortality decreased annually by 4.6% between 2000 and 2017. There were strong age and cohort effects and a weak period effect on avoidable mortality. In the overall decreasing trend, avoidable mortality declined less in cohorts born after the 1950–1953 Korean War and economic recession in the 1970s, with further reductions in cohorts born after the 1987 democratic reform and 1997–1998 economic crisis. Avoidable mortality was reduced after implementation of major health policies, but the decrease stagnated during the 2008–2009 financial crisis. Avoidable mortality reduction resulted in LE gains of 3.1 years, which accounted for 80% of total LE gains. Contribution to LE gains by causes of death was the largest for cerebrovascular disease. Major social changes and health policies influenced the avoidable mortality trend through cohort and period effects. Health care and public health policies implemented since the 2000s might have contributed substantially to gains in LE.

Place of death by region and urbanization among gynecologic cancer patients: 2006–2016

ObjectiveTo evaluate associations between US region of residence and urbanization and the place of death among women with gynecologic malignancies in the United States. MethodsA retrospective cross-sectional study was performed using publicly available death certificate data from the National Center for Health Statistics. All gynecologic cancer deaths were included from 2006 to 2016. Comparisons among categories were performed with a two-tailed chi-square test, with p-values <0.05 considered significant. ResultsFrom 2006 to 2016, 328,026 women died from gynecologic malignancies in the US. Of these deaths, 40.1% (n = 134,333) occurred in the patient's home, 24.9%(n = 81,823) in the hospital, and 11.3% (37,188) in an inpatient hospice facility. Place of death varied by geographic region. The Northeast had the largest percentage of gynecologic cancer patients (31.3%) die as a hospital inpatient. The West had the highest percentage of deaths (49.3%) at home. Deaths in a hospice facility were the highest (14.1%) in the South. Place of death varied by urbanization; patients residing in large central metro or rural counties were the most likely to die during hospital admission (28.7% and 27.1%, respectively). Patients living in medium-sized metro areas were the least likely to die in hospitals (21.8%) and most likely to die in a hospice facility (14.3%). All comparisons were significant by study definition. ConclusionThe place of death for patients with gynecologic malignancies varies by US region and urbanization. These disparities are multifactorial in nature, likely influenced by both sociodemographic factors and regional resource availability. In this study, however, rural and central metro areas are identified as regions that may benefit from further hospice development and advocacy.

Assessment of Relative Utility of Underlying vs Contributory Causes of Death

In etiological research, investigators using death certificate data have traditionally extracted underlying cause of mortality alone. With multimorbidity being increasingly common, more than one condition is often compatible with the manner of death. Using contributory cause plus underlying cause would also have some analytical advantages, but their combined utility is largely untested. To compare the relative utility of cause of death data extracted from the underlying cause field vs any location on the death certificate (underlying and contributing combined). This study compares the association of 3 known risk factors (cigarette smoking, low educational attainment, and hypertension) with health outcomes based on where cause of death data appears on the death certificate in 2 prospective cohort study collaborations (UK Biobank [N = 502 655] and the Health Survey for England [15 studies] and the Scottish Health Surveys [3 studies] [HSE-SHS; N = 193 873]). Data were collected in UK Biobank from March 2006 to October 2010 and in HSE-SHS from January 1994 to December 2008. Data analysis began in June 2018 and concluded in June 2019. Death from cardiovascular disease, cancer, dementia, and injury. For each risk factor-mortality end point combination, a ratio of hazard ratios (RHR) was computed by dividing the effect estimate for the underlying cause by the effect estimate for any mention. In UK Biobank, there were 14 421 deaths (2.9%) during a mean (SD) of 6.99 (1.03) years of follow up; in HSE-SHS, there were 21 314 deaths (11.0%) during a mean (SD) of 9.61 (4.44) years of mortality surveillance. Established associations of risk factors with death outcomes were essentially the same irrespective of placement of cause on the death certificate. Results from each study were mutually supportive. For having ever smoked cigarettes (vs never having smoked) in the UK Biobank, the RHR for cardiovascular disease was 0.98 (95% CI, 0.87-1.10; P value for difference = .69); for cancer, the RHR was 0.99 (95% CI, 0.93-1.05; P value for difference = .69). In the HSE-SHS, the RHR for cardiovascular disease was 0.94 (95% CI, 0.87-1.01; P value for difference = .09); for cancer, it was 1.01 (95% CI, 0.94-1.10; P value for difference = .75). Risk factor-end point associations were not sensitive to the placement of data on the death certificate. This has implications for the examination of the association of risk factors with causes of death where there may be too few events to compute reliable effect estimates based on the underlying field alone.

Overdose Deaths and Acute Hepatitis Infections among American Indians in North Carolina.

BACKGROUND Like the rest of the nation, North Carolina is experiencing the worst drug crisis in United States history, as deaths related to medication and drug overdoses are at an all-time high. Although the absolute numbers of deaths are highest among white populations, American Indians (AIs) experience disproportionally high rates.METHOD Using death certificate data, death rates due to unintentional medication and drug overdose were calculated for various races and ethnicities. Acute hepatitis B (HBV) and acute hepatitis C (HCV) rates were also calculated across racial and ethnic groups using data from the North Carolina Electronic Disease Surveillance System.RESULTS After adjusting for population size, AIs have as high or higher overdose death rates for all types of drugs except heroin, compared to other racial and ethnic groups. During the most recent 5 years of data (2012-2016), the highest rate of acute HCV infection occurred among AIs.LIMITATIONS Race/ethnicity data recorded on death certificates is often provided by family members and is difficult to verify independently. Another potential limitation is use of small numbers to calculate rates. Additionally, HBV and HCV are thought to be underreported.CONCLUSION Overdose death rates and rates of communicable diseases associated with injection drug use among AIs residing in North Carolina are as high as or higher than the overall North Carolina population. It is important to recognize and address these differences and provide prevention, harm reduction, and treatment services to all groups being impacted by the overdose epidemic.

Trends in Mortality Due to Cancer in the United States by Age and County-Level Income, 1999-2015.

Disparities in cancer mortality by county-level income have increased. It is unclear whether these widening disparities have affected older and younger adults equally. National death certificate data were utilized to ascertain cancer deaths during 1999-2015. Average annual percent changes in mortality rates and mortality rate ratios (RRs) were estimated by county-level income quintile and age (25-64 vs ≥65 years). Among 25- to 64-year-olds, cancer mortality rates were 30% higher (RR = 1.30, 95% confidence interval [CI] = 1.29 to 1.31) in the lowest-vs the highest-income counties in 1999-2001 and 56% higher (RR = 1.56, 95% CI = 1.55 to 1.57) in 2013-2015; the disparities among those 65 years and older were smaller but also widened over time (RR1999-2001 = 1.04, 95% CI = 1.03 to 1.05; RR2013-2015 = 1.14, 95% CI = 1.13 to 1.14). Widening disparities occurred across cancer sites. If all counties had the mortality rates of the highest-income counties, 21.5% of cancer deaths among 25- to 64-year-olds and 7.3% of cancer deaths in those 65 years and older would have been avoided in 2015. These results highlight an ongoing need for equity-focused interventions, particularly among younger adults.

How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study

Background: The high burden of disease-oriented drugs among older adults with limited life expectancy raises important questions about the potential futility of care. Aim: To describe the use of drugs of questionable clinical benefit during the last 3 months of life of older adults who died from life-limiting conditions. Design: Longitudinal, retrospective cohort study of decedents. Death certificate data were linked to administrative and healthcare registries with national coverage in Sweden. Setting: Older adults (≥75 years) who died from conditions potentially amenable to palliative care between 1 January and 31 December 2015 in Sweden. We identified drugs of questionable clinical benefit from a set of consensus-based criteria. Results: A total of 58,415 decedents were included (mean age, 87.0 years). During their last 3 months of life, they received on average 8.9 different drugs. Overall, 32.0% of older adults continued and 14.0% initiated at least one drug of questionable clinical benefit (e.g. statins, calcium supplements, vitamin D, bisphosphonates, antidementia drugs). These proportions were highest among younger individuals (i.e. aged 75–84 years), among people who died from organ failure and among those with a large number of coexisting chronic conditions. Excluding people who died from acute and potentially unpredictable fatal events had little influence on the results. Conclusion: A substantial share of older persons with life-limiting diseases receive drugs of questionable clinical benefit during their last months of life. Adequate training, guidance and resources are needed to rationalize and deprescribe drug treatments for older adults near the end of life.

The epidemiology of amyloidosis in Queensland, Australia

Published studies on the epidemiology of amyloidosis have relied on death certificate data for case ascertainment. We estimated the incidence and mortality burden of amyloidosis among residents of the Australian state, Queensland, aged ≥20years for the years 1999-2013 based on case ascertainment from histopathology reports. Information systems for participating laboratories were scrutinised to identify histopathology reports that documented a diagnosis of amyloidosis. Case mortality status was determined via linkage to the National Death Index. A total of 447 cases of amyloidosis were identified, with a median age at diagnosis of 66years. A plasma cell dyscrasia was identified in 72% of patients who had paraprotein studies performed. The estimated incidence for Queenslanders aged ≥20years was 12·1 cases per million person years. The median survival was 2·45years. Age at diagnosis, presence of a paraprotein, earlier year of diagnosis, and inner regional location of residence (compared with residence in a major city) were independently associated with reduced survival. Our data confirms previously reported incidence data for amyloidosis of approximately 10 cases per million patient years and indicates that survival for Queensland patients with amyloidosis is improving, though it remains poor for the elderly and patients with AL amyloidosis.

An Assessment of the EMS Drug Overdose to Death Pathway from 2011 to 2017

An Assessment of the EMS Drug Overdose to Death Pathway from 2011 to 2017

Incidence of comorbidities on death certificate data in women with gynecological cancers.

e17127 Background: Risk factors for the development of gynecological cancers are known to vary; however, the effect on mortality is uncertain. Methods: Using CDC Wonder Database, death certificate data, all women who died of cancer in the United States from 2003-2016 were included if a cancer diagnosis was listed as a primary or contributing cause. Cases were then divided into gynecological (GYN) cancer or not, and thereafter characterized as cervical, ovarian, uterine, or other. Other causes contributing to death (comorbidities were then captured via ICD10 codes listed on death certificates and grouped into similar disease states. Chi-squared and Mann-Whitney U tests were performed for statistical significance. Results: Of 35,324,091 death certificates, 4,177,823 deaths were women with cancer listed as a cause of death. 440,792 were gynecological cancer, with cervical cancer in 62,807; uterine cancer in 134,420; ovarian cancer in 221,119; and other gynecological cancers in 25,946. Women with GYN cancers were more likely to have intestinal obstruction (2.7% vs 0.7%, OR 4.05), ascites (0.7% vs 0.2%, OR 3.30), HIV (0.1% vs 0.05%, OR 1.53), kidney disease (4.7% vs 3.6%, OR 1.33), and thrombo-embolic disorders (4.3% vs 3.5%, OR 1.25) when compared to non-GYN cancers (all p &lt; 0.00001). Uterine cancer was more likely to have diabetes-related comorbidities (6.4% vs 3.8%, OR 1.75), metabolic syndrome (9.5% vs 6.1%, OR 1.60), thrombo-embolic disorders (5.5% vs 3.8%, OR 1.48), ischemic heart disease (5.0% vs 3.6%, OR 1.43), than other GYN cancers (all p &lt; 0.00001). Cervical cancer was more associated with HIV (0.3% vs 0.03%, OR 10.73) and tobacco-related disorders (4.7% vs 1.9%, OR 2.56). Ovarian cancer was more associated with ascites (1.1% vs 0.4%, OR 2.93), intestinal obstruction (3.5% vs 1.8%, OR 2.04), and pleural effusion (1.1% vs 0.6%, OR 1.92) (all p &lt; 0.00001). Conclusions: Comorbidities contributing to death significantly differ amongst gynecological cancers and non-gynecological cancers, which has relevance to strategies that can be differentially employed to reduce mortality. In particular, women with uterine cancer may benefit from reduction in risk of diabetes, ischemic heart disease, and embolic disorders; those with cervical cancer may benefit from smoking cessation and optimal HIV management.

Racial Disparities in Mortality Associated with Systemic Lupus Erythematosus - Fulton and DeKalb Counties, Georgia, 2002-2016.

Systemic lupus erythematosus (SLE) is a chronic, systemic autoimmune disease with often nonspecific symptoms that can lead to a delay in diagnosis. The disease disproportionately affects women and minorities. Blacks with SLE also have more severe disease and develop it at an earlier age (1). Despite an increase in the 5-year survival rate from 50% in 1955 to approximately 90% in the 2000s, attributed largely to advances in management of SLE (2), premature mortality among SLE patients persists, often as a result of disease severity, infections, and cardiovascular disease. Because existing SLE mortality estimates based on death certificate data are known to underestimate SLE deaths (3), SLE mortality was analyzed using 2002-2004 data from the population-based Georgia Lupus Registry (1). Incident and prevalent SLE cases matched to the National Death Index through 2016 identified 97 and 401 deaths, respectively. Standardized mortality ratios adjusted for age group, sex, and race were two to three times higher among persons with SLE relative to expected deaths in the general population. Blacks had significantly higher cumulative mortality than did whites, and blacks with both incident and prevalent cases were significantly younger at death (mean age 51.8 and 52.3 years, respectively) than were whites (mean age 64.4 and 65.0 years, respectively). Whites had lower mortality after diagnosis than did blacks; among incident cases, mortality among whites did not occur until 5 years after SLE diagnosis, whereas blacks had significantly and persistently higher mortality from the time of diagnosis. There were no significant differences by sex. Current CDC-supported efforts encourage early detection, diagnosis, and treatment, and enhanced self-management skills to mitigate racial disparities and improve outcomes overall among persons with SLE.

The Impact of Suicide Prevention Act (2006) on Suicides in Japan.

Background: The Suicide Prevention Act was implemented in 2006 in Japan to promote various suicide prevention strategies. Aims: The present study examined the impact of the Suicide Prevention Act on recent suicide mortality rates in Japan. Method: Using an interrupted time-series design, we analyzed monthly mortality rates between January 1996 and December 2016. Death certificate data from vital statistics were obtained. Results: A total of 597,007 suicides (99.3% of all suicides) were analyzed. At the onset of the economic recession in 1998, a significant increase was observed in overall age-standardized mortality rates and sex-/age-specific populations, except for those aged 60 or older. The difference in trend between before and after implementation of the Suicide Prevention Act was not significant for overall or for any stratified populations. After the onset of the Tōhoku earthquake and tsunami of 2011, mortality rates declined for overall and for sex-/age-specific populations. Limitations: No information was available on what could have led to each suicide. Conclusion: The decline in mortality rates may be due to a significant and recent natural disaster. Further studies are needed to clarify plausible mechanisms for the decline in suicide rates following the Tōhoku disaster.

Global trends in mortality from intrahepatic and extrahepatic cholangiocarcinoma

Intrahepatic (ICC) and extrahepatic cholangiocarcinoma (ECC) have rarely been studied individually, probably due to difficulties in their diagnosis and certification. Mortality trends from these 2 neoplasms have been inconsistent over the last decades. The aim of this study was to analyze worldwide trends in mortality from ICC and ECC in selected countries. We extracted death certification data for ICC and ECC, and population estimates from the World Health Organization and Pan American Health Organization databases for 32 selected countries from Europe, the Americas, and Australasia from 1995 to 2016. We computed age-standardized (world population) mortality rates from ICC and ECC, and performed joinpoint regression analysis. Mortality rates from ICC increased in all countries considered, with a levelling off over recent years in Germany (women), Italy (men), Argentina (men), the USA (men), Hong Kong (men), and Japan (both sexes). The highest rates in 2010-2014 (1.5-2.5/100,000 in men and 1.2-1.7/100,000 in women) were registered in Hong Kong, France, Austria, Spain, the UK, and Australia. The lowest rates (0.2-0.6/100,000 in both sexes) were registered in Latin American and eastern European countries. Mortality from ECC decreased in most of the countries considered, with rates below 1/100,000 in both sexes between 2010 and 2014, with the only exception being Japan (2.8/100,000 in men and 1.4/100,000 in women). Increasing mortality from ICC was observed globally, due to trends in risk factors and possibly, in part, due to better disease classification. Mortality from ECC levelled off or decreased, most likely following the increased use of laparoscopic cholecystectomy. Biliary tract cancers include intrahepatic cholangiocarcinoma (ICC) and extrahepatic cholangiocarcinoma (ECC), however there are some differences in their risk factors. Consequently, the distinction between ICC and ECC is important. Over the last few decades, mortality from ICC has tended to rise in several areas of the world, following the increased prevalence of its major risk factors. In contrast, mortality from ECC tended to decrease in most countries, following the increased use of laparoscopic cholecystectomy.

Descriptive Epidemiology of New Zealand\u2019s Highest Mortality Earthquake: Hawke\u2019s Bay in 1931

In this study we aimed to produce the first detailed analysis of the epidemiology of the severe injury and mortality impacts of the 1931 Hawke’s Bay earthquake in New Zealand (NZ). This involved the compilation and analysis of archival data (hospitalisations and deaths) including the examination of 324 death certificates. We found that there were 662 people for whom some hospitalisation data were available at four weeks post-earthquake: 54% were still in hospital, 4% were still classified as “serious”, and 5% had died (n = 28). Our classification of death certificate data indicated 256 earthquake-attributable deaths and for another five deaths the earthquake was estimated to have played an indirect role. There were 15 buildings associated with three or more deaths each (accounting for 58% of deaths with a known location). Many of these buildings were multi-storey and involved unreinforced masonry – with some of this falling into the street and killing people there (19% of deaths). In contrast, deaths in homes, which were typically of wood construction and single stories, comprised only 3% of deaths. In conclusion, this earthquake had a relatively high injury impact that appears partly related to the lack of regulations for building construction that would mitigate earthquake-related risk. Such regulations continue to be of relevance for New Zealand and for other countries in earthquake zones.

Abstract P421: Cardiovascular Death Trends in Minnesota From 2000-2017

Background: The decline in cardiovascular disease (CVD) mortality in the United States noted since the mid 1970s has recently leveled off. This has generated concern and a need for further analyses to understand geographic variation, cause-specific deaths, location of death, and age-specific trends. Methods: Death certificate data obtained from the Minnesota Department of Health were used for analysis. The American Heart Association (AHA) classification was applied to the underlying cause of death to generate the following CVD categories: coronary heart disease (CHD), non-CHD diseases of the heart, and non-cardiac circulatory diseases. Temporal trends in death rates were explored by negative binomial regression, which enables estimates of age- and sex-adjusted average annual percentage changes (AAPCs). Differences in AAPCs between 2000-2009 and 2010-2017 were tested overall and across demographic, CVD, and location of death categories. Results: CVD mortality rates, which were declining in 2000-2009, have leveled off in 2010-2017 (Table). These trends were observed across all subgroups. After adjusting for sex, the age group that drove the decline in rates from 2000-2009 was the 65-84 year old group, which experienced no change in rates from 2010-2017. Across CVD categories, after adjusting for age and sex, the decline in rates from 2000-2009 was largely attributable to steep reductions in CHD and non-cardiac circulatory diseases, with lesser reduction in non-CHD diseases of the heart. In 2010-2017, CHD and non-cardiac circulatory diseases rates showed no change, whereas the rate of non-CHD diseases of the heart increased. The rates for in- and out-of-hospital deaths improved in 2000-2009 with no further improvement observed in 2010-2017. Conclusions: CVD mortality rates are no longer declining in Minnesota, paralleling national trends. These trends are particularly concerning for non-CHD diseases of the heart.

ETS-related gene (ERG) expression as a predictor of oncological outcomes in patients with high-grade prostate cancer treated with primary androgen deprivation therapy: a cohort study

ObjectivesTo determine whether ETS-related gene (ERG) expression can be used as a biomarker to predict biochemical recurrence and prostate cancer-specific death in patients with high Gleason grade prostate cancer treated...

Relative sarcopenia and mortality and the modifying effects of chronic kidney disease and adiposity.

BackgroundConventional definitions of sarcopenia based on lean mass may fail to capture low lean mass relative to higher fat mass, that is, relative sarcopenia. The objective of this study is to determine the associations of sarcopenia and relative sarcopenia with mortality independent of co‐morbidities, and whether chronic kidney disease (CKD) and adiposity alter these associations.MethodsDual energy X‐ray absorptiometry‐derived appendicular lean mass index (ALMI, kg/m2) and fat mass index (FMI, kg/m2) were assessed in 14 850 National Health and Nutrition Examination Survey participants from 1999 to 2006 and were linked to death certificate data in the National Death Index with follow‐up through 2011. Sarcopenia was defined using sex‐specific and race/ethnicity‐specific standard deviation scores compared with young adults (T‐scores) as an ALMI T‐score < −2 and relative sarcopenia as fat‐adjusted ALMI (ALMIFMI) T‐score < −2. Glomerular filtration rate (GFR) was estimated using creatinine‐based (eGFRCr) and cystatin C‐based (eGFRCys) regression equations.ResultsThree (3.0) per cent of National Health and Nutrition Examination Survey participants met criteria for sarcopenia and 8.7% met criteria for relative sarcopenia. Sarcopenia and relative sarcopenia were independently associated with mortality (HR sarcopenia 2.20, 95% CI 1.69 to 2.86; HR relative sarcopenia 1.60, 95% CI 1.31 to 1.96). The corresponding population attributable risks were 5.2% (95% CI 3.4% to 6.4%) and 8.4% (95% CI 4.8% to 11.2%), respectively. Relative sarcopenia remained significantly associated with mortality (HR 1.32, 95% CI 1.08 to 1.61) when limited to the subset who did not meet the criteria for sarcopenia. The risk of mortality associated with relative sarcopenia was attenuated among persons with higher FMI (P for interaction <0.01) and was not affected by CKD status for either sarcopenia or relative sarcopenia.ConclusionsSarcopenia and relative sarcopenia are significantly associated with mortality regardless of CKD status. Relative sarcopenia is nearly three‐fold more prevalent amplifying its associated mortality risk at the population level. The association between relative sarcopenia and mortality is attenuated in persons with higher FMI.

Age‐specific distributed lag models for heat ‐ related mortality

AbstractDistributed lag (DL) models have been consistently used throughout the years to assess the cumulative impact of multiple days of high heat on public health. DL models, however, are often used on an aggregate level (e.g., city or census tracts) in spite of the fact that the effect of heat on health is individual specific, leading to possible ecological fallacies. To capture more individualized effects of heat on health, we propose a negative binomial regression model where the effect of lagged temperatures is age specific. Utilizing principles of predictive process models, we place appropriate smoothness and decay constraints on the associated DL surfaces. Furthermore, we borrow strength across ages to facilitate the estimation of the age‐specific DL function. Using death certificate data from the Texas Department of State Health Services, we show how different ages are impacted by consecutive days of high heat.

Disparities in place of death for patients with hematological malignancies, 1999 to 2015

AbstractPatients with hematologic malignancies (HMs) often receive aggressive end-of-life care and less frequently use hospice. Comprehensive longitudinal reporting on place of death, a key quality indicator, is lacking. Deidentified death certificate data were obtained via the National Center for Health Statistics for all HM deaths from 1999 to 2015. Multivariate regression analysis (MVA) was used to test for disparities in place of death associated with sociodemographic variables. During the study period, there were 951 435 HM deaths. Hospital deaths decreased from 54.6% in 1999 to 38.2% in 2015, whereas home (25.9% to 32.7%) and hospice facility deaths (0% to 12.1%) increased (all P < .001). On MVA of all cancers, HM patients had the lowest odds of home or hospice facility death (odds ratio [OR], 0.55; 95% confidence interval, 0.54-0.55). Older age (40-64 years: OR, 1.34; ≥65 years: OR, 1.89), being married (OR, 1.62), and having myeloma (OR, 1.34) were associated with home or hospice facility death, whereas being black or African American (OR, 0.68), Asian (OR, 0.58), or Hispanic (OR, 0.84) or having chronic leukemia (OR, 0.83) had decreased odds of dying at home or hospice (all P < .001). In conclusion, despite hospital deaths decreasing over time, patients with HMs remained more likely to die in the hospital than at home.