Death Certificate Information Research Articles

A Bayesian spatial–temporal varying coefficients model for estimating excess deaths associated with respiratory infections

Abstract Disease surveillance data are used for monitoring and understanding disease burden, which provides valuable information in allocating health programme resources. Statistical methods play an important role in estimating disease burden since disease surveillance systems are prone to undercounting. This paper is motivated by the challenge of estimating mortality associated with respiratory infections (e.g. influenza and COVID-19) that are not ascertained from death certificates. We propose a Bayesian spatial–temporal model incorporating measures of infection activity to estimate excess deaths. Particularly, the inclusion of time-varying coefficients allows us to better characterize associations between infection activity and mortality counts time series. Software to implement this method is available in the R package NBRegAD. Applying our modelling framework to weekly state-wide COVID-19 data in the US from 8 March 2020 to 3 July 2022, we identified temporal and spatial differences in excess deaths between different age groups. We estimated the total number of COVID-19 deaths in the US to be 1,168,481 (95% CI: 1,148,953 1,187,187) compared to the 1,022,147 from using only death certificate information. The analysis also suggests that the most severe undercounting was in the 18–49 years age group with an estimated underascertainment rate of 0.21 (95% CI: 0.16, 0.25).

The Pleural Mesothelioma Cases and Mortality in Portugal in 2014-2020: A Descriptive Study.

The incidence and mortality of pleural mesothelioma (PM) reflect the production and consumption of asbestos over time. However, despite the current global concern, these data remain to be known. Our aim was to carry out a descriptive analysis of PM cases and mortality from some Portuguese databases between 2014 and 2020. A retrospective observational study was carried out between 2014 and 2020. Data on the number of PM cases were provided by the Portuguese Cancer Registry, and data on mortality were from the Portuguese Death Certificate Information System. Between 2014 and 2020, 315 cases of PM were reported, with 222 (70.5%) men. The average age of patients was 72.1, with the highest number of cases in patients aged >70 years (n = 198; 62.9%). The highest number of cases was reported in 2018 (n = 62; 19.7%). Regarding mortality, 169 deaths were reported, with 126 (74.6%) men and mostly in individuals aged >70 years (n = 109; 64.5%). It is estimated that around 520 years of potential life were lost. The highest number of deaths occurred in 2015 (n = 33; 19.5%). It is mandatory to reinforce the need for surveillance programs that allow us to gather real and reliable data and eliminate asbestos-related diseases.

Abstract 562: Ischemic Heart Disease Mortality And Systemic Lupus Erythematosus

Introduction: Systematic lupus erythematosus (SLE) is associated with significant morbidity and mortality, contributing to accelerated atherosclerotic disease. We sought to quantify ischemic heart disease (IHD) mortality trends in individuals with SLE in the United States (U.S.). Hypothesis: Disparities related to IHD mortality in individuals with SLE exist. Methods: Cross-sectional analyses were conducted using the CDC Wide-ranging Online Data for Epidemiologic Research database to capture all mortality data in the U.S. using death certificate information from 1999 to 2020. We identified individuals with IHD (ICD10: I20-I25) as the underlying cause of death and SLE (ICD10: M32) as the multiple causes of death. Underlying cause of death was defined as the diagnosis that led to mortality and multiple causes of death were defined as the diagnoses that contributed to mortality. Quantified measures included age-adjusted mortality rate (AAMR) per 100,000 population and corresponding 95% confidence intervals. AAMR was adjusted to the U.S. population in the year 2000. Results: We identified 2,733 deaths from 1999 to 2020. AAMR decreased from 0.055 (95% CI, 0.046 - 0.064) in 1999 to 0.027 (95% CI, 0.023 - 0.032) in 2020. Females were disproportionately affected by higher AAMR compared to males (0.054 [95% CI, 0.051 - 0.056] and 0.013 [95% CI, 0.011 - 0.014], respectively). Black populations had the highest AAMR (0.084 [95% CI, 0.077 - 0.090]), with no significant differences among other racial groups such as White (0.029 [95% CI, 0.028 - 0.030], American Indian/Alaska Native (0.041 [95% CI, 0.025 - 0.063]), and Asian/Pacific Islander (0.023 [95% CI, 0.017 - 0.030]) populations. No differences in AAMR were observed between metropolitan and non-metropolitan regions (0.027 [95% CI, 0.026 - 0.029] and 0.029 [95% CI, 0.026 - 0.032], respectively). The West had the highest AAMR (0.036 [95% CI, 0.033 - 0.039]), with no significant differences among the Northeastern (0.027 [95% CI, 0.024 - 0.030]), Midwestern (0.027 [95% CI, 0.025 - 0.030]), and Southern regions (0.029 [95% CI, 0.027 - 0.031]). Conclusion: IHD mortality in individuals with SLE remains disproportionately concentrated in females, Black populations, and Western regions.

Need for Improved Timeliness of Reporting on Drug Overdose Fatalities: The HEALing Communities Study.

Timely data on drug overdose deaths can help identify community needs, evaluate the effectiveness of interventions, and allocate resources. We identified variations in death investigation and reporting systems within and between states that affect the timeliness and accuracy of death certificate information. The HEALing Communities Study (HCS) is a community-engaged, data-driven approach to combating the opioid crisis in 67 communities in 4 states: Kentucky, Massachusetts, New York, and Ohio. HCS conducted a survey of coroners and medical examiners to understand variability in drug overdose death data. We compared survey results in Massachusetts, New York, and Ohio with national data to investigate the completeness of provisional death counts by type of death investigation system. Communities in each HCS state had different ways of collecting and reporting mortality data. Completion of death certificates for drug overdoses ranged from <2 weeks in 23% (7 of 31) of those surveyed to more than 3 months in 10% (3 of 31) of those surveyed. Variabilities in the timeliness of reporting drug overdose deaths were not associated with type of coroner or medical examiner office in each state, urban versus rural setting, or specificity of drug information on the death certificate. Having specific drug information on the death certificate may increase death certificate quality, comparability, and accuracy. We recommend the following: (1) all coroners and medical examiners should be trained on conducting death investigations, interpreting toxicology reports, and completing death certificates; (2) 1 office in each state should oversee all coroners and medical examiners to increase data consistency; and (3) communities should identify and address barriers to timely death certification.

Abstract P354: Trends in Malignancy and Cardiovascular Disease Related Mortality in the United States

Introduction: In the United States (US), malignancy and cardiovascular disease (CVD) make up the majority of the burden of chronic diseases, leading to greater morbidity and mortality. As the general population grows older, the prevalence of these two disease entities are likely to increase. Efforts in cardio-oncology have been focused on disease prevention and treatment, however, little is known about existing disparities in this population. Hypothesis: Unequivocal burden of CVD-related mortality exists among certain gender, racial, and geographic subgroups. Methods: Data was obtained from the CDC Wide-ranging Online Data for Epidemiologic Research database using death certificate information from the National Vital Statistics system. All CVD-related death (I00 - I78) as the underlying cause of death in individuals with malignancy (C00 - C97) as the multiple causes of death were queried from 1999 - 2020. Underlying cause of death was defined as the disease that directly led to death and the multiple causes of death were defined as the diseases that contributed to death. Quantified measures included age-adjusted mortality rate (AAMR) per 100,000 population, 95% confidence intervals, and average annual percentage change (AAPC). Joinpoint regression (National Cancer Institute) was utilized for trend analysis and AAPC calculation. Results: There was a total of 595,446 deaths between 1999 and 2020. The AAMR in 1999 was 24.85 which decreased to 12.811 by 2020 (p &lt;0.05), with an AAPC of -3.1%. Males (23.14) had a higher AAMR compared to females (11.05) (p &lt;0.05), and AAPC for both males and females were -3.4%. AAMR was disproportionately higher in non-Hispanic populations (16.26) compared to Hispanic populations (9.17) (p &lt;0.05), with similar AAPC (-3.1% and -3.0%, respectively [p &gt;0.05]). Black individuals (18.87) had the highest AAMR, followed by White individuals (15.81), American Indian/Alaska Native individuals (9.40), and Asian/Pacific Islander individuals (8.26) (p &lt;0.05). All AAPC for the racial subgroups were similar (-3.3%, -3.1%, -2.7%, and -4.1%, respectively [p &gt;0.05]). Non-metro regions (17.20) had higher AAMR compared to metro regions (15.54) (p &lt;0.05) with an AAPC of -2.4 and -3.3%, respectively (p &gt;0.05). The Northeast (17.93) had the highest AAMR, followed by similar AAMR in the Midwest (16.44) and West (16.30) regions, and then South regions (13.98) (p &lt;0.05). AAPC was similar among all US census regions (-3.6%, -3.3%, -3.4%, and -2.8%, respectively [p &gt;0.05]). Conclusion: Even with decreasing rates of AAMR from 1999 to 2020, there remains a disproportionate burden of AAMR among gender, racial, and geographic subgroups. Continued efforts targeted at mitigating CVD-related mortality in patients with underlying malignancy is warranted.

Abstract P185: Disparities in Cardiovascular Disease and HIV Related Mortality in the United States

Introduction: Great strides have been made in microbiology and infectious diseases regarding HIV, revolutionizing the disease course. In the last forty years, advances in combination antiretroviral therapy (ART) have allowed HIV to become a chronic disease by dramatically decreasing the rates of acquired AIDS-defining illnesses. In contrast, a significant proportion of deaths in individuals infected with HIV due to cardiovascular events have been noted. Hypothesis: Disproportionate trends exist regarding CVD-related death within subpopulations of individuals infected with HIV in the United States (US). Methods: We utilized the CDC Wide-ranging Online Data for Epidemiologic Research database to ascertain mortality data using death certificate information from the National Vital Statistics System. All CVD-related deaths (ICD10 Codes: I00-I78) as the underlying cause of death and HIV (ICD10 Code: B20-B24) as the multiple causes of death from 1999 to 2020 were queried. The underlying cause of death is defined as the disease that directly led to death and multiple causes of death were defined as the diseases that contributed to death. Data were represented as age-adjusted mortality rates (AAMR) per 100,000 population and 95% confidence intervals, stratified by gender, racial, and geographic subgroups. Joinpoint regression (National Cancer Institute) was utilized for trend analysis and average annual percentage change (AAPC) calculation. Results: A total of 8,950 deaths were observed from 1999 to 2020. AAMR increased from 0.10 in 1999 to 0.15 in 2020 (p &lt;0.05). AAMR was more likely to be related to non-ischemic heart disease (0.06) compared to ischemic heart disease (0.05) (p &lt;0.05). AAMR was higher in males (0.20) compared with females (0.05) (p &lt;0.05). AAMR was disproportionately higher in Black populations (0.53) compared to White populations (0.08) (p &lt;0.05). No differences were observed for AAMR between Hispanic (0.12) and non-Hispanic (0.12) populations (p &gt;0.05). AAMR was highest in the Northeast (0.15) and South (0.16) regions, followed by Western (0.11) regions, then finally the Midwest (0.06) regions (p &lt;0.05). Cumulative AAPC from 1999 to 2020 was calculated at +1.7% (p &lt;0.05) with a significant inflection point in 2010. AAPC increased significantly among male subgroups (+1.5%), Black subgroups (+0.8%), White subgroups (+1.6%), metro regions (+1.7%), Midwest regions (+2.3%), and Southern regions (+2.1%) (p &lt;0.05), however, AAPC was not significantly different among female subgroups, Hispanic and non-Hispanic populations, non-metro regions, Northeast regions, and Western regions (p &gt;0.05). Conclusion: Disparities linked to CVD-related death in the population infected with HIV exist among various gender, racial, and geographic subgroups. Research targeted at CVD prevention and management in this population is tantamount to addressing these healthcare disparities.

Leading causes of excess mortality in Mexico during the COVID-19 pandemic 2020–2021: A death certificates study in a middle-income country

SummaryBackgroundThe death toll after SARS-CoV-2 emergence includes deaths directly or indirectly associated with COVID-19. Mexico reported 325,415 excess deaths, 34.4% of them not directly related to COVID-19 in 2020. In this work, we aimed to analyse temporal changes in the distribution of the leading causes of mortality produced by COVID-19 pandemic in Mexico to understand excess mortality not directly related to the virus infection.MethodsWe did a longitudinal retrospective study of the leading causes of mortality and their variation with respect to cause-specific expected deaths in Mexico from January 2020 through December 2021 using death certificate information. We fitted a Poisson regression model to predict cause-specific mortality during the pandemic period, based on the 2015–2019 registered mortality. We estimated excess deaths as a weekly difference between expected and observed deaths and added up for the entire period. We expressed all-cause and cause-specific excess mortality as a percentage change with respect to predicted deaths by our model.FindingsCOVID-19 was the leading cause of death in 2020–2021 (439,582 deaths). All-cause total excess mortality was 600,590 deaths (38⋅2% [95% CI: 36·0 to 40·4] over expected). The largest increases in cause-specific mortality, occurred in diabetes (36·8% over expected), respiratory infections (33·3%), ischaemic heart diseases (32·5%) and hypertensive diseases (25·0%). The cause-groups that experienced significant decreases with respect to the expected pre-pandemic mortality were infectious and parasitic diseases (-20·8%), skin diseases (-17·5%), non-traffic related accidents (-16·7%) and malignant neoplasm (-5·3%).InterpretationMortality from COVID-19 became the first cause of death in 2020–2021, the increase in other causes of death may be explained by changes in the health service utilization patterns caused by hospital conversion or fear of the population using them. Cause-misclassification cannot be ruled out.FundingThis study was funded by Conacyt.

Increase in Massachusetts deaths with ICD-10 codes associated with COVID-19 during the first four months of 2020.

BackgroundPrevious research has suggested that some COVID-19 infections and deaths have gone unrecorded, especially in the early days of the pandemic. Therefore, it is likely that people in Massachusetts were exposed to, infected with, and died from COVID-19 before the first death was recorded and that other deaths in early 2020 may have been due to COVID-19, but were not coded that way. This study sought to determine the number of deaths in the first 4 months of 2020 that may have been due to COVID-19, by comparing deaths with selected ICD-10 codes to the same time frame in 2019 and 2018.MethodsDeath certificate information was obtained for the first 21 weeks of 2018, 2019, and 2020. We calculated and compared the number of deaths for specific ICD-10 codes that may be related to COVID-19 during this time period for each year.ResultsThere was a notable increase in deaths potentially related to COVID-19 between the 11th and 17th weeks of 2020 in comparison with the same time period in 2018 and 2019.ConclusionsEven after Massachusetts began recording deaths as being due to COVID-19, the number of deaths that may have been due to the disease was higher than would have been expected based on data from the two preceding years. These findings may indicate that some COVID-19 deaths were not being recorded or that the pandemic was exacerbating other health issues.

Age and Ageism in the COVID-19 Pandemic: What Does the Data Show?

Gerontologists were quick to call out the resurgence of ageism that was reflected in the paternalistic, overgeneralized, and deficit views of aging that dominated discussions about age-associated risks of the disease and its consequences. One manifestation of the blunt and potentially ageism-promoting use of age in data about the virus is the failure to routinely distinguish the independent role of age alone, separate from its association with comorbidities. A related problem is the use of broad age categories, which can also mask the role of specific comorbidities. To address that gap, this study uses data from Centers for Disease Control and Prevention, as of Feb 21, 2021 to calculate age-specific COVID-19 death rates (ASDR) and compare the extent to which comorbid conditions potentially associated with COVID-19 deaths were listed on death certificates. Findings showed that the ASDR was significantly higher for those 85 years and over (2249.96 per 100,000); the rate was 802.66 for 75-84 and 312.78 per 100,000 for 65-74. Death certificate information revealed that influenza and pneumonia was the major contributing comorbidity to COVID-19 deaths across all three age groups; (listed on 49% of the death certificates for those 65-74 who died with COVID-19, 46% of those 75-84, and 38% of those 85 and over). Future studies should be more precise about the use of age/age groups, about the rationale for those designations, and about the impact of age separate from comorbidities. Broad use of an arbitrary age as a proxy for frailty and illness contributes to ageism.

Infective Endocarditis as the Cause of Death: A Populationbased Study in Portugal, from 2002 to 2018.

Infective endocarditis presents a high rate of morbidity and mortality. Population-based studies addressing mortality caused by infective endocarditis in Portugal are scarce. We aimed to study deaths caused by Infective endocarditis, as well as corresponding demographics and temporal trends. Retrospective cohort study of all patients whose main cause of death was Infective endocarditis in Portugal from 2002 to 2018. The data was obtained from the national death certificate information system. In Portugal, 3634 people died from infective endocarditis throughout the 17-year study period - infective endocarditis specific mortality rate of 2.1 per 100 000 habitants. Of all deceased, 89% were at least 60 years old, and most were women (55%). Overall, 72% died in a healthcare institution. An annual 9% increase in the incidence death rate from Infective endocarditis was observed, with a significant upward trend during the colder months. In Portugal, mortality by infective endocarditis increased, mainly affecting older patients and women, and which can partially be explained by factors such as ageing of the population. The management of older patients with infective endocarditis is challenging as they present a higher number of comorbidities, more valvular heart disease and valve implants, invasive medical procedures and are less likely to undergo cardiac surgery. In addition to data on the evolution of demographics in Portugal, it is crucial to study the incidence of infective endocarditis over time to help explain these findings. The identification of factors that can be used to better model national health policies to improve clinical outcomes of infective endocarditis in Portugal is also required.

Burden and Trends of Severe Rotavirus Infections and Allcause Acute Gastroenteritis Hospital Episodes in Children Under Five Years Old in Mainland Portugal

Introduction: Rotavirus infections are a leading cause of severe acute gastroenteritis in children under five years old. In December 2019, Portugal announced the inclusion of the rotavirus vaccine, already available for private purchase, in the National Immunization Program. We present the first nationwide analysis of the burden and trends of rotavirus and acute gastroenteritis hospital episodes in children under five years old in mainland Portugal (2014 - 2017).Material and Methods: We used the hospital morbidity database and the Death Certificate Information System to identify hospital episodes and deaths of rotavirus and acute gastroenteritis based on the codes of the International Classification of Diseases. We described the number and rates of hospital episodes disaggregated by age group, sex, geographical units, and the seasonality and trends over the study period.Results: On average, during the study period, there were 1985 annual hospital episodes among children under five years old. The annual rate was 48.0/10 000 children (95% CI 46.9 - 49.0). Rates were consistently higher in younger children, and 67.8% episodes occurred in children under 24 months. We found a seasonal pattern with a major peak in the early spring.Discussion: Our results were consistent with the current knowledge on rotavirus and acute gastroenteritis hospital episodes in Europe. Additional studies are needed to identify the risk factors and high-risk groups for hospital attendance.Conclusion: Rotavirus and acute gastroenteritis hospital episodes in children under five years old in mainland Portugal represent an important health and economic burden. In the future, monitoring this burden and these trends in relation with rotavirus vaccine coverage could be useful in order to assess the impact of the vaccination programme on the change in hospital episodes.

Long-term survival after low-dose-rate brachytherapy for prostate cancer: the Royal Surrey experience.

To assess the long-term treatment efficacy of low-dose-rate (LDR) brachytherapy for the treatment of localized prostate cancer. Cause-of-death annotation in our prospective database was supplemented with death certificate information obtained via an internal audit of patients treated from 1999 to 2017 with LDR prostate brachytherapy as monotherapy or as combination with androgen deprivation therapy and/or external beam radiotherapy. Overall and disease-specific survival were the primary outcomes, estimated with Kaplan-Meier and competing risks multi-state models. Clinical variables influencing mortality were assessed with Cox proportional hazards regression in a sub-analysis of men to assess the predictive value of prostate-specific antigen (PSA) level at 48 months post implant. The audit process began in October 2017 and culminated in June 2020 with a curated series of 2936 patients. All-cause and prostate cancer-specific death prevalence were 11% and 2.9%, respectively. The median (range) follow-up time was 10 (3-21) years and the median (range) time to death from any cause was 9 (3-21) years. At 15 years post implant the overall and prostate cancer-specific survival probability were 81% and 95%, respectively. The 15-year cumulative incidence rates of death not due and due to prostate cancer were 14% and 5%, respectively. A greater risk of death due to prostate cancer was conferred by increasing age at therapy (hazard ratio [HR] 1.1, P < 0.001), advanced clinical stages relative to T1a-T2a (HR 1.9, P = 0.048 for T2b; HR 2.7, P = 0.023 for T2c-T3b) and a 48-month PSA level >1.0 ng/mL (HR 6.8, P < 0.001). This study constitutes the largest retrospective analyses of long-term mortality outcomes from prospectively collected prostate brachytherapy data and confirms the excellent treatment efficacy of LDR prostate brachytherapy for localized prostate cancer. T2 clinical stage subdivisions and 48-month PSA level >1.0 ng/mL appear to be strong indicators of prostate cancer-related survival.

The validity of cancer information on death certificates in Norway and the impact of death certificate initiated cases on cancer incidence and survival

BackgroundDeath certificates are an important source of information for cancer registries. The aim of this study was to validate the cancer information on death certificates, and to investigate the effect of including death certificate initiated (DCI) cases in the Cancer Registry of Norway when estimating cancer incidence and survival. MethodsAll deaths in Norway in the period 2011–2015 with cancer mentioned on the death certificates were linked to the cancer registry. Notifications not registered from other sources were labelled death certificate notifications (DCNs), and considered as either cancer or not, based on available information in the registry or from trace-back to another source. ResultsFrom the total of 65 091 cancers mentioned on death certificates in the period 2011–2015, 58,425 (89.8%) were already in the registry. Of the remaining 6 666 notifications, 2 636 (2 129 with cancer as underlying cause) were not regarded to be new cancers, which constitutes 4.0% of all cancers mentioned on death certificates and 39.5% of the DCNs. Inclusion of the DCI cases increased the incidence of all cancers combined by 2.6%, with largest differences for cancers with poorer prognosis and for older age groups. Without validation, including the 2 129 disregarded death certificates would over-estimate the incidence by 1.3%. Including DCI cases decreased the five-year relative survival estimate for all cancer sites combined with 0.5% points. ConclusionIn this study, almost 40% of the DCNs were regarded not to be a new cancer case, indicating unreliability of death certificate information for cancers that are not already registered from other sources. The majority of the DCNs where, however, registered as new cases that would have been missed without death certificates. Both including and excluding the DCI cases will potentially bias the survival estimates, but in different directions. This biases were shown to be small in the Cancer Registry of Norway.

Maternal Mortality in the United States: Recent Trends, Current Status, and Future Considerations.

Rigorous studies carried out by the National Center for Health Statistics show that previously reported increases in maternal mortality rates in the United States were an artifact of changes in surveillance. The pregnancy checkbox, introduced in the revised 2003 death certificate and implemented by the states in a staggered manner, resulted in increased identification of maternal deaths and in reported maternal mortality rates. This Commentary summarizes the findings of the National Center for Health Statistics reports, describes temporal trends and the current status of maternal mortality in the United States, and discusses future concerns. Although the National Center for Health Statistics studies, based on recoding of death certificate information (after excluding information from the pregnancy checkbox), showed that crude maternal mortality rates did not change significantly between 2002 and 2018, age-adjusted analyses show a temporal reduction in the maternal mortality rate (21% decline, 95% CI 13-28). Specific causes of maternal death, which were not affected by the pregnancy checkbox, such as preeclampsia, showed substantial temporal declines. However, large racial disparities continue to exist: Non-Hispanic Black women had a 2.5-fold higher maternal mortality rate compared with non-Hispanic White women in 2018. This overview of maternal mortality underscores the need for better surveillance and more accurate identification of maternal deaths, improved clinical care, and expanded public health initiatives to address social determinants of health. Challenges with ascertaining maternal deaths notwithstanding, several causes of maternal death (unaffected by surveillance artifacts) show significant temporal declines, even though there remains substantial scope for preventing avoidable maternal death and reducing disparities.

Abstract PS7-85: Population based survival of breast cancer in Greater Mumbai, India

Abstract Introduction: Population based survival provides a measure of the efficacy of cancer control in a defined geographical area. The Mumbai Cancer Registry (MCR), India’s oldest population based cancer registry (PBCR), was established by the Indian Cancer Society (ICS) in 1963. It covers 603 sq. km. of Greater Mumbai with a population of 146, 51,584 (2015) and over half a century it has consistently provided cancer statistics from its coverage area. Breast cancer is the commonest cancer in women in Mumbai constituting 30% of all female cancers, and is now the most common cancer in women in India (1, 62,468 in 2018), constituting 27.66% of all female cancers. There have been few reports on breast cancer survival from India, and in this study, we report the survival rate of women diagnosed with breast cancer in Greater Mumbai during the years 2009-13. Patients and Methods: Breast cancer cases registered during the years 2009-13 with the MCR were followed for outcome till 31 Dec 2018. Social investigators visited hospitals, nursing homes, clinics, hospices and laboratory centers for documenting cancer cases. Mortality data was collected from the Vital Statistics Division of the Municipal Corporation. Data and was verified and duplicate cases were deleted. Follow up was conducted with repeated scrutiny of medical records, death certificates issued by the Municipal Corporation, postal and telephone enquiries, house visits and linkage with electoral database. Observed survival was calculated by the Kaplan Meir (1958) method. Expected survival was calculated using the national life-table of India for (Maharashtra) based on Census of India, 2011. Using observed and expected survival, relative survival was calculated by Ederer (1961) method using STATA 12.0. The survival rate was compared to that from other regions of India and with developed countries. Results: Of the 9707 breast cancer cases registered during the period 2009-13, 8031 (83%) cases were included in this study. 1676 (17%) cases were excluded as 469 (5%) had only Death Certificate Information and 1207 (12%) were lost to follow up. The median follow up was 5.1 years (range 8 months - 9 years). The median age was 55 years (range 18 -96 years) with 2725(34%) ≤ 50 years and 5306 (66%) &amp;gt; 50 years. The overall observed survival rates at 1, 3, 5 years were 82.5%, 72.8% and 67.0% respectively and the corresponding figures for relative survival were 83.5%, 75.4%, and 70.9%. Increasing age had an inverse relationship with breast cancer survival. The highest 5-year relative survival was shown by ≤29 age group (74%) and lowest by &amp;gt;70 age group (60%). Those with localised disease at diagnosis had a higher 5-year relative survival rate (84%) compared to 79.7% for direct extension and 20.8% for distant metastasis. The clinical extent of disease and education were significant risk factors affecting survival (p &amp;lt; 0.001). Conclusion:The 5-year population-based survival of patients treated in Greater Mumbai during the period 2009-2013, is 70%. This compares favourably with previously reported 5-year survival from Mumbai (51-55.7%) and other Indian registry data (33-55%), but is inferior to that reported in the developed world (84-88 %). The association of survival with educational status and stage at diagnosis highlights the importance of awareness and early detection. Enhanced awareness and detection coupled with easy access to adequate and affordable treatment could help improve breast cancer outcomes. Citation Format: Vinay Deshmane, Shravani Koyande, Shweta Jadhav. Population based survival of breast cancer in Greater Mumbai, India [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-85.

Abstract PS7-63: Cause of death discordance between death certificates and medical files: Impact on cancer survival assessment in a Belgian case study

Abstract Introduction Accurate information on cause of death is essential for correct breast cancer-specific mortality assessment. However, registration and coding of cause of death is prone to error since determining the exact underlying condition related to the death is challenging. In this study, an expert review of medical files was done to determine the principal cause of death for breast cancer patients of a Belgian tertiary hospital. The retrieved cause of death was compared to death certificate information to assess concordance between both sources. Secondly, the impact of discordant reporting on cause-specific survival (CSS) and other net survival approaches were examined. Methods Breast cancer patients diagnosed and treated at University Hospitals Leuven (UHL) between 2009 and 2014 with follow-up until December 31st, 2016, were included in the study. Information on cause of death was obtained from death certificates (following ICD-10 rules) and medical files. The latter were reviewed by a board of experts at UHL. Agreement was calculated using Cohen’s kappa coefficient, and reasons for discordant reporting were assessed. CSS was calculated based on cause of death information from both sources using the Kaplan-Meier method. These survival estimates were compared to the relative survival probability (RS) using the Ederer II and Pohar Perme method. Results A total of 2,862 patients were included, of whom 354 died after a median follow-up of 54.6 months. We found overall substantial agreement (kappa-value of 0.69 (95% C.I.: 0.62-0.77)) between cause of death reported by death certificates and medical files (Table 1). In 84.8% of cases, there was concordance between both methods. When comparing to medical files, misattribution of breast cancer-specific death in death certificates (4.5% of cases) was linked to the presence of comorbidities (43.7%), metastases (37.5%), or unspecified causes (18.8%). Five-year CSS based on medical files (93.1% (95% C.I.: 91.9-94.1)) was only slightly higher compared to CSS based on death certificates (92.3% (95% C.I.: 91.2-93.4)). RS measures using Ederer II and Pohar Perme were comparable to CSS measures. Conclusions Overall, substantial agreement of cause of death was seen between death certificates and medical files. Attribution of cause death to comorbidities was the most common reason for discordant reporting of breast cancer-specific death. Five-year breast cancer-specific survival was slightly higher based on cause of death information from medical files, compared to death certificates. Periodic reviews and implementation of ICD-10 guidelines for classification of cause of death could improve accuracy in cause of death annotation. Table 1: Discordance for the principal cause of death between medical files and death certificatesmedical filesother causesbreast cancerdeath certificatesother causes136 (38.4%)16 (4.5%)152 (42.9%)breast cancer38 (10.7%)164 (46.3%)202 (57.1%)174 (49.2%)180 (50.9%)354 (100%) Citation Format: Hava Izci, Tim Tambuyzer, Jessica Vandeven, Jérôme Xicluna, Hans Wildiers, Kevin Punie, Nynke Willers, Eva Oldenburger, Els Van Nieuwenhuysen, Patrick Berteloot, Ann Smeets, Ines Nevelsteen, Liesbet Van Eycken, Harlinde De Schutter, Patrick Neven, Geert Silversmit, Freija Verdoodt. Cause of death discordance between death certificates and medical files: Impact on cancer survival assessment in a Belgian case study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-63.

Sensitivity and Specificity of the National Death Index for Multiple Causes of Death in People With HIV.

Inaccuracies in cause-of-death information in death certificates can reduce the validity of national death statistics and result in poor targeting of resources to reduce morbidity and mortality in people with HIV. Our objective was to measure the sensitivity, specificity, and agreement between multiple causes of deaths from death certificates obtained from the National Death Index (NDI) and causes determined by expert physician review. Physician specialists determined the cause of death using information collected from the medical records of 50 randomly selected HIV-infected people who died in San Francisco from July 1, 2016, through May 31, 2017. Using expert review as the gold standard, we measured sensitivity, specificity, and agreement. The NDI had a sensitivity of 53.9% and a specificity of 66.7% for HIV deaths. The NDI had a moderate sensitivity for non-AIDS-related infectious diseases and non-AIDS-related cancers (70.6% and 75.0%, respectively) and high specificity for these causes (100.0% and 94.7%, respectively). The NDI had low sensitivity and high specificity for substance abuse (27.3% and 100.0%, respectively), heart disease (58.3% and 86.8%, respectively), hepatitis B/C (33.3% and 97.7%, respectively), and mental illness (50.0% and 97.8%, respectively). The measure of agreement between expert review and the NDI was lowest for HIV (κ = 0.20); moderate for heart disease (κ = 0.45) and hepatitis B/C (κ = 0.40); high for non-AIDS-related infectious diseases (κ = 0.76) and non-AIDS-related cancers (κ = 0.72); and low for all other causes of death (κ < 0.35). Our findings support education and training of health care providers to improve the accuracy of cause-of-death information on death certificates.

The impact of excluding or including Death Certificate Initiated (DCI) cases on estimated cancer survival: A simulation study

BackgroundPopulation-based cancer registries strive to cover all cancer cases diagnosed within the population, but some cases will always be missed and no register is 100 % complete. Many cancer registries use death certificates to identify additional cases not captured through other routine sources, to hopefully add a large proportion of the missed cases. Cases notified through this route, who would not have been captured without death certificate information, are referred to as Death Certificate Initiated (DCI) cases. Inclusion of DCI cases in cancer registries increases completeness and is important for estimating cancer incidence. However, inclusion of DCI cases will generally lead to biased estimates of cancer survival, but the same is often also true if excluding DCI cases. Missed cases are probably not a random sample of all cancer cases, but rather cases with poor prognosis. Further, DCI cases have poorer prognosis than missed cases in general, since they have all died with cancer mentioned on the death certificates. MethodsWe performed a simulation study to estimate the impact of including or excluding DCI cases on cancer survival estimates, under different scenarios. ResultsWe demonstrated that including DCI cases underestimates survival. The exclusion of DCI cases gives unbiased survival estimates if missed cases are a random sample of all cancer cases, while survival is overestimated if these have poorer prognosis. ConclusionIn our most extreme scenarios, with 25 % of cases initially missed, the usual practice of including DCI cases underestimated 5-year survival by at most 3 percentage points.

Investigating multi-cause mortality in Poland

Progress in life expectancy and the growing number of people living to old age intensify the phenomenon of multi-morbidity, defined as the coexistence of several chronic diseases. By exploiting all the medical information in death certificates, the multiple causes of death (MCoD) approach serves to investigate complex pathological processes that lead eventually to death. This is the first MCoD analysis for Poland and its objective is twofold: to examine the quality of information on contributing causes of death, in particular in the regional dimension, and to assess the scale of multi-morbidity involving conditions that are becoming more and more frequent in ageing populations. The analysis is carried out for all deaths that took place in Poland in 2013. The results show that medical doctors issuing death certificates often define contributing causes of death, but a large part of this information includes unknown or ill-defined conditions. Several conditions favour the certification of well-defined contributing causes: when death occurs in hospital, or is due to underlying causes other than cardiovascular, the number of contributing conditions is higher. Important regional differences are observed in this regard. The analysis highlights the importance of diseases that are rarely certified as the underlying causes, but often contribute to mortal conditions, such as diseases of the blood and the blood-forming organs, diseases of the skin and subcutaneous tissue, diseases of the genitourinary system or mental and behavioural disorders.

Identifying adolescent and young adult patients with sickle cell disease at highest risk of death.

Identifying adolescent and young adult patients with sickle cell disease at highest risk of death.