Multiple Cause Of Death Analysis Research Articles

Quantifying years of life lost in Australia: a multiple cause of death analysis.

Deaths in Australia and other high-income countries increasingly involve multiple conditions. However, key burden of disease measures typically only use the underlying cause of death (UC). We quantified sex and cause-specific years of life lost (YLL) based on UC compared with a method integrating multiple causes of death. Causes of death for all deaths in Australia (2015-17), mapped to 136 groups based on International Classification of Diseases 10th revision (ICD-10), were ascribed using (1) the UC only and (2) a multiple cause weighting (WT) strategy. Applying the Global Burden of Disease 2010 life table, YLLUC and YLLWT rates were calculated for each sex and cause of death and compared using relative and absolute measures. All-cause YLL rates were 113.4/1000 for males and 79.9/1000 for females. Cancers, cardiovascular diseases, external causes, respiratory diseases and nervous system diseases were the five biggest contributors to YLL for each method. For the top 20 causes combined, YLLWT rates were 10% lower for males (YLLWT = 74.93/1000 vs YLLUC = 67.38/1000) and 7% lower for females (YLLWT = 51.34/1000; YLLUC = 47.90/1000); YLLWT rates were lower for ischaemic heart disease and all cancers, but higher for diabetes and dementia, and for chronic obstructive pulmonary disease in males. With multiple cause weighting, renal failure emerged among the top 20 causes of YLL, as did atrial fibrillation and hypertension among females. YLLWT rates for substance abuse, mood disorders, hypertension and schizophrenia were relatively high compared with YLLUC. The YLLWT metric highlights epidemiologically important conditions that are less often selected as the UC.

Mortality related to different circulatory diseases: a multiple causes of death analysis, 2008-2022

Abstract Background Mortality from circulatory diseases significantly increased in 2020 compared to pre-pandemic years in many countries. However, data were mostly limited to the underlying cause of death and to the first phases of the pandemic. Analyses of any mention of a disease in death certificates (multiple causes of death approach, MCOD) are more robust to changes in coding rules/practices and to the role of COVID-19 as a competing cause of death. Methods Mortality records were extracted from 2008 to 2022 among residents of the Veneto Region (Northeastern Italy, 4.9 million population). Based on MCOD, age-standardized mortality rates (2013 European standard) were computed for ischemic heart diseases (IHD), cerebrovascular diseases (CVD), atrial fibrillation (AF), and hypertensive diseases (HD). The annual percent change (APC) was estimated through the pre-pandemic period (2008-2019), and change in rates during pandemic years were computed compared to 2019. Results Before the pandemic, rates were steeply declining for IHD (APC -5.1%; 95%CI -5.5, -4.6) and CVD (-4.0%; -4.4, -3.5); mortality related to HD reduced at a slower pace (-1.9%; -2.3, -1.4), whereas AF-related mortality was increasing (+1.0%; 0.1, 1.8). During the first year of the pandemic, the growth in mortality compared to 2019 was +26% for HD, +18% for AF, +13% for CVD and +12% for IHD. In 2021-2022, rates for CVD and IHD returned to pre-pandemic levels; rates for HD reduced with respect to 2020 but remained above the baseline; AF-related mortality was still increasing. Conclusions The pandemic differentially impacted mortality associated to different circulatory diseases, depending on pre-existing long-term trends (increasing for AF) and on susceptibility to severe COVID-19 disease (higher for HD). Continuous surveillance based on MCOD is warranted to properly assess changes in mortality associated to specific circulatory diseases after the end of the pandemic. Key messages • Multiple causes of death analyses are warranted to assess how the pandemic affected pre-existing long term trends in cause-specific mortality. • Mortality related to different circulatory diseases increased in 2020, but pre-pandemic trends, the extent of the increase in 2020, and further changes observed in 2021-2022 largely diverged.

Association of multiple-sclerosis-related mortality with COVID-19 and other common infections: a multiple causes of death analysis.

People with multiple sclerosis (MS) suffer from higher infection-related mortality compared to the general population; however, sparse data are available on the increased risk of death associated with coronavirus disease 2019 (COVID-19) and other common types of infections. All mortality records and multiple-cause-of-death data in 2010-2021 of residents in the Veneto region (northeastern Italy) were extracted. Mention of specific infections was compared between death certificates reporting MS or not. Odds ratios (OR) with 95% confidence intervals (95% CI) were estimated by conditional logistic regression matching by age, sex and calendar year. The bimonthly averages of MS-related deaths in 2010-2019 were compared with those registered during the pandemic (2020-2021). Of 580,015 deaths through 2010-2021, MS was mentioned in 850 cases (0.15%), 59.3% women. Influenza and pneumonia were reported in 18.4% of MS-related compared to 11.0% non-MS-related deaths (OR 2.72, 95% CI 2.28-3.25). The odds of mention of urinary tract infections was significantly greater in MS-related deaths of men (OR 8.16, 95% CI 5.23-12.7) than women (OR 3.03, 95% CI 1.82-5.02). Aspiration pneumonia, pressure ulcers/skin infections and sepsis were also significantly associated with MS-related deaths. Reporting of COVID-19 as a cause of death did not significantly differ between deaths with and without mention of MS (approximately 11% of both). However, compared to 2010-2019, peaks in MS-related deaths were observed during the pandemic waves. Infections continue to play a significant role in MS-related deaths, underlying the need to improve prevention and management strategies.

Secular Trends in Systemic Sclerosis Mortality in the United States from 1981 to 2020.

Systemic sclerosis (SSc) has the highest mortality rate among autoimmune disorders. Individuals with SSc frequently die from complications or infections related to SSc. Nonetheless, the sex-age-period interaction of SSc is complex and remains unclear. The study aims to analyze the secular trend of SSc mortality based on data regarding underlying cause of death (UCD) and multiple causes of death (MCD) and clarify the sex-age interaction with time. The multiple-cause mortality statistics provided by the National Center for Health Statistics were used to identify all deaths in the United States from 1981 to 2020 in which SSc was indicated anywhere on the death certificates. The age-standardized mortality rate (ASMR) was determined for both sexes, as well as the variations in these rates. Joinpoint regression analysis was utilized to determine the annual percentage change (APC) of ASMR. A total of 44,672 and 66,259 individuals who died between 1981 and 2020 were identified based on the UCD and MCD data, respectively. According to the UCD data, SSc-related AMSR (SSc-ASMR) of the male and female decedents, respectively, declined from 5.01 and 1.94 in 1981-1990 to 4.77 and 1.32 in 2011-2020, respectively (mortality rate ratio 0.95, 95% confidence interval 0.92-0.98). From 1986 to 1999, the APC of SSc-ASMR in female decedents decreased except for those aged 45-64 years (APC 2.1%, p = 0.002). For MCD analysis, in trend 1, only APC of SSc-ASMR in male decedents aged 45-64 years decreased. The SSc-ASMR of both male and female decedents fell on trend 2 arm. In 2011-2020, the ratio of UCD to MCD increased across all age groups for both sexes compared to 1981-1990. Overall, compared to the male decedents, the SSc-ASMR in female decedents increased significantly before 1999, peaked in 1999, followed by continuous decrease until 2020 according to UCD and MCD statistics. Over the past four decades, the SSc deaths based on the MCD data were 1.48 times more than the UCD data, and the proportion of UCD over MCD increased over time. The SSc-ASMRs in all the sex-age groups significantly decreased over the past two decades. Notably, the mortality rate ratio of women to men with SSc increased in the past four decades.

Abstract 13664: Cardiovascular Mortality in Brazil During the COVID-19 Pandemic: Comparison Between Underlying and Multiple Causes of Death

Introduction: COVID-19 has impacted cardiovascular disease (CVD) mortality worldwide due to avoidance of healthcare, health system collapse, and the direct CV effects, but detailed data from Brazil are still scarce. We aimed to evaluate the impact of COVID-19 pandemic on CVD mortality, stratified by age, sex and region of Brazil, comparing underlying (UC) and multiple causes (MC) of death. Methods: Ecological, time series study analysing CVD age-standardized death rates, from epidemiological weeks (EW) 10/2020 to 11/2021, using data from the Mortality Information System (SIM-SUS). CVD was defined as in ICD-10 Chapter IX, and considered if reported as UC or MC of death (UC + other causes reported in any line of death certificate) in separate analyses. Observed was compared to expected data (mean for the same EW of 2017-2019). Risk ratios (RiR) were analysed and 95% confidence intervals calculated. Results: Age-standardized CVD mortality rate as UC of death in the pandemic was 165.9 (95% CI 165.5 - 166.3)/100,000 inhabitants, similar to the expected: (165.6; 95%CI 165.2 - 166.2)/100,000, with a RiR=1.00; 95% CI 1.00 - 0.93). There was an increase in out-of-hospital mortality (18%) (RiR=1.18; 95% CI 1.17 - 1.19) and in deaths with ill-defined CVD causes (43%) (RiR=1.43; 95%CI 1.42 - 1.44), particularly in the out-of-hospital setting (51%). The increase in out-of-hospital deaths was more pronounced in the North (RiR=1.33; 95% CI 1.30 - 1.36) and Center West (RiR=1.26; 95% CI 1.23 - 1.30), regions with less prepared health systems. Conversely, in MC of death analysis, there was a 10% increase in CVD mortality (observed: 243.2 (95% CI 242.7 - 243.7), expected: 221.6 (95% CI 221.1 - 222.1)/100,000, RiR=1.10 (95% CI 1.09 - 1.10), noticeably in the out-of-hospital setting (19%). Steeper increasing trends also occurred in the North region (RiR=1.16; 95% CI 1.15 - 1.17), and in individuals ≥60 years (RiR=1.11; 95% CI 1.10 - 1.11), and among men (RiR=1.11; 95% CI 1.11 - 1.12) vs. women (RiR=1.08; 95% CI 1.08 - 1.09). Conclusions: During the pandemic, CVD mortality as UC of death remained stable in Brazil, contrasting with an increase when MC were considered. Higher out-of-hospital mortality, exacerbation of existing CVD by COVID-19, and competing causes of death may have contributed.

Distinct Cause of Death Profiles of Hospitalized Non-alcoholic Fatty Liver Disease: A 10 Years' Cross-Sectional Multicenter Study in China.

Background: The clinical burden and natural history of non-alcoholic fatty liver disease (NAFLD) vary globally. We aimed to investigate NAFLD-related mortality profiles in hospitalized patients in southern China.Methods: A multicenter retrospective investigation with a 10-year study period (2009–2018) analyzed 10,071 deaths during hospitalization (NAFLD: 2,015; other liver diseases: 1,140; without liver diseases: 6,916) was performed using a multiple cause of death analysis. Medical histories and biochemistry and imaging findings were extracted from the electronic medical record system. The underlying causes of death were classified by 10th Revision of the International Classification of Diseases (ICD-10) codes.Results: The distribution of death causes in patients with NAFLD has stabilized over time, with cardio- and cerebral vascular disease (CVD) ranked first (35.6%), followed by extrahepatic malignancies (22.6%), infection (11.0%), kidney disease (7.5%), liver-related diseases (5.2%), respiratory diseases (3.9%), digestive diseases (3.5%), endocrine diseases (3.5%), and other diseases (7.2%). NAFLD patients had more deaths attributable to CVD, extrahepatic malignancies, liver-related diseases (all P < 0.001) and multiorgan failure than the deceased controls. The severity of steatosis was independently associated with these relationships (liver-related diseases: OR = 1.37, 95% CI: 1.20–1.59, cardio- and cerebrovascular diseases: OR = 1.23, 95% CI: 1.19–1.31, infectious diseases: OR = 1.14, 95% CI: 1.04–1.26, and renal diseases: OR = 1.21, 95% CI: 1.02–1.47, all P < 0.05) after adjustment for sex, body mass index (BMI), fasting blood glucose, low-density lipoprotein cholesterol, uric acid, metabolic syndromes and fibrosis index based on the 4 factors.Conclusion : NAFLD patients had higher proportions of death due to underlying CVD and liver-related diseases than the general population in China; these proportions positively correlated with steatosis degree.

Animal-Encounter Fatalities, United States, 1999-2016: Cause of Death and Misreporting.

Errors and misreporting on death certificates are common, along with potential inaccuracies in cause-of-death coding. We characterized and compared fatalities by animal-encounter mentions reported as underlying cause of death (UCD) with animal-encounter mentions reported as multiple cause of death (MCD) to determine factors associated with misreporting UCD. We analyzed fatality data from 1999-2016 from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research by UCD and MCD animal-encounter mentions (International Classification of Diseases, 10th Revision codes W53-59, X20-27 and X29, T63.0-63.6, T63.8-63.9, and T78.2-78.4). We examined differences in reporting by age, sex, race, autopsy (yes, no, unknown), allergic reactions, and toxicities. The number of animal-encounter mentions by UCD was 3638 (202 average per year) and by MCD was 4280 (238 average per year), a difference of 18% (n = 642; 36 average per year) by MCD analysis. The number of nonvenomous animal-encounter mentions increased 20% (from 2138 UCD to 2567 MCD), and the number of venomous animal-encounter mentions increased 14% (from 1500 UCD to 1713 MCD). Decedents aged ≥65 had the highest additional number of animal-encounter mentions among all age groups, primarily encounters with other reptiles (n = 113), other mammals (n = 71), and dogs (n = 42). Of 642 MCD additional animal-encounter mentions, heart disease (n = 211, 33%) and infections (n = 146, 23%) represented more than half of the UCD. Of 553 dog-encounter fatalities, 165 (30%) were among children aged ≤4. Animal-encounter fatalities, analyzed by UCD alone, may be underreported. An initiating animal injury, complicated by comorbidities and fatality, may obscure the causal chain, resulting in misreporting UCD. Ongoing training for medical certifiers is recommended, highlighting accurate identification of UCD and contributing causes in the causal chain of death.

Multimorbidity and multiple causes of death in heart failure

Patients with heart failure (HF) usually have multiple comorbid conditions that interact with HF, either leading to its development, aggravating its progression or reducing the effectiveness of treatment. Although the prevalence of HF comorbidities has been studied, more evidence is needed on the strength of their independent association with HF and HF mortality. To examine the strength of association between HF and associated medical conditions. We analysed data from the Baker Biobank, encompassing 6530 adults aged between 18 and 69 years, collected between January 2000 and December 2011. Mortality was determined through linkage to the National Death Index. Medical conditions were self-reported by patients at enrolment to the Biobank. The strength of association between HF and co-occurring medical conditions as a cause of illness and death was assessed using multivariate logistic regression. Hazards of mortality were determined using Cox regression models. Most HF patients (92.2%) had at least one additional medical condition. The most common comorbidities were hypertension, arrhythmia and dyslipidaemia. Coronary artery disease was the most common cause of death co-occurring with HF. HF patients had significantly higher odds of arrhythmia [odds ratio (OR) = 3.3; 95% confidence interval (CI): 2.7, 3.9). Patients with kidney disease had 3 (95% CI: 2.1, 4.4) times higher odds of co-occurring HF as a cause of death compared to those without kidney disease. Patients with a history of HF had 3.6 (95% CI: 2.45, 5.24) times higher hazard of mortality from kidney disease. In multimorbidity analysis, other cardiovascular diseases had a strong association with HF. However, in multiple causes of death analysis, there was a strong association between kidney disease and HF.

Multiple cause of death analysis in multiple sclerosis: A population-based study.

To gain a better understanding of the complex patterns of causes that contribute to death due to multiple sclerosis (MS) by assessing the relationship between MS and other causes of death listed on death certificates. Multiple cause of death data for all adult deaths (aged ≥18 years) in British Columbia, Canada, between 1986 and 2013 were accessed. All causes, as listed on the death certificate, whether underlying or contributing, were considered "any mention" causes. The associations between mention of MS on the death certificate and mention of other causes of death were examined by logistic regression, adjusted for age, sex, and calendar year (Bonferroni-corrected α level = 0.002). Findings were also sex-stratified. Among 771,288 deaths, MS was mentioned on 2,153 certificates. If MS was mentioned (versus not mentioned), there was a greater chance that specific conditions contributed to the death: respiratory infection (adjusted odds ratio [aOR], 3.03 [95% confidence interval (CI), 2.73-3.36]), aspiration pneumonia (aOR, 7.15 [95% CI, 6.23-8.22]), urinary tract infection (UTI) (aOR, 10.2 [95% CI, 8.7-12.0]), other infection including sepsis (aOR, 1.34 [95% CI, 1.15-1.56]), and skin disease (aOR, 5.06 [95% CI, 3.96-6.46]). Sex differences existed for urinary tract infection (men: aOR, 14.9 [95% CI, 11.5-19.3]; women: aOR, 8.00 [95% CI, 6.53-9.81]) and chronic respiratory disease (men = aOR, 1.36 [95% CI, 1.14-1.63]; women = aOR, 0.97 [95% CI, 0.84-1.13]). Deaths attributed to MS were commonly caused by infection (especially respiratory and urinary tract-related); conditions associated with advanced disability and immobility, such as aspiration pneumonia; and chronic respiratory disease in men. All are potentially modifiable; interventions that reduce the frequency or severity of these complications could improve survival in MS.

Asthma-related mortality in the United States, 1999 to 2015: A multiple causes of death analysis

BackgroundAsthma mortality based on the underlying cause of death (UCOD) underestimates disease burden. ObjectiveTo analyze asthma mortality in the United States from 1999 to 2015 and the pattern of reporting of asthma and its comorbidities in death certificates, using multiple cause of death (MCOD) records. MethodsAll 156,517 death certificates with any mention of asthma were analyzed for 1999 to 2015. Asthma was defined by International Classification of Diseases, 10th Revision code J45 based on the UCOD or MCOD. Annual age-adjusted asthma death rates were computed according to age, sex, and race/ethnicity. The 6,304 MCOD coded status asthmaticus cases (J46) were also examined. ResultsFrom 1999 to 2015 a total of 59,067 deaths with a UCOD of asthma occurred; 37,832 deaths occurred in females and 21,235 in males (female-male ratio = 1.78). A total of 156,517 deaths with MCOD of asthma occurred; 101,371 deaths occurred in females and 55,146 in males (female-male ratio = 1.83). Hence, 37.7% of deaths with any mention of asthma had asthma as the UCOD (37.3% in females and 38.45% in males). Of these deaths, 41.7% occurred in non-Hispanic blacks and 36% in non-Hispanic whites. Between 1999 and 2015, age-adjusted MCOD death rates changed as follows: 38.1% in Hispanic white females, 34.1% in non-Hispanic black females, 15.1% in non-Hispanic white females, 28.5% in Hispanic white males, 21.3% in non-Hispanic black males, and 25.0% in non-Hispanic white males. Non-Hispanic black females and males had the highest MCOD and UCOD rates throughout the period. ConclusionAmong deaths with any mention of asthma, asthma was chosen as the UCOD most often in non-Hispanic black males and least often in non-Hispanic white females. Age-adjusted MCOD rates decreased most in non-Hispanic white males and least in non-Hispanic white females.

Mortality Related to Chronic Obstructive Pulmonary Disease and Co-morbidities in the United States, A Multiple Causes of Death Analysis

ABSTRACTChronic obstructive pulmonary disease (COPD) mortality based on the underlying cause of death (UCOD) underestimates disease burden. We aimed to determine the current COPD mortality rate, trends and the distribution of co-morbidities using United States (US) multiple-cause of death (MCOD) records.All 38,905,575 death certificates of decedents aged ≥45 years in the United States were analyzed for 1999–2015. COPD was defined by ICD–10 codes J40–J44 and J47 based either on the UCOD or up to 20 contributing causes coded. Annual age–standardized COPD death rates were computed by age, gender and race/ethnicity for those with any mention of COPD.In 2015, COPD was mentioned in 11.59% (292,572 deaths) in MCOD, compared to 11.13% (243,617 deaths) in 1999, a 4% increase. However, it was reported as the UCOD for only 5.56% and 4.97% in 2015 and 1999 respectively, an 11% increase. The most common UCOD in subjects with any mention of COPD was respiratory disorders in 49% of males and 55% of females. The relative change in death rates differed between MCOD and UCOD. For example, among non-Hispanic white females aged 65–74 years the UCOD rate per 100,000 (95% CI) decreased from 163 (160–166) to 147 (145–150), average annual percent decrease (AAPD) –0.26, while the MCOD rate decreased from 308 (304–311) to 263 (260–267), AAPD –0.87.Statistics based on UCOD understated the burden of COPD in the United States. MCOD rates were twice as high as UCOD rates. The relative change in death percent or rates differed between MCOD and UCOD. MCOD analysis should be repeated periodically to help evaluate the burden of COPD-related mortality.

Distinct mortality profile in systemic sclerosis: a death certificate study in Rio de Janeiro, Brazil (2006-2015) using a multiple causes of death analysis.

The objective of this study was to assess the mortality profile related to SSc in the state of Rio de Janeiro, Brazil. We retrospectively examined all registered deaths in the region (2006-2015 period) in which the diagnosis of SSc was mentioned on any line of the death certificates (underlying cause of death [UCD], n = 223; non-UCD, n = 151). Besides the analysis of gender, age, and the causes of death, we also compared the mortality from UCDs between individuals whose death causes included SSc (cases) and those whose death causes did not include SSc (deceased controls). For the latter comparison, we used the mortality odds ratio to approximate the cause-specific standardized mortality ratio. We identified 1495 death causes among the 374 SSc cases. The mean age at death of the SSc cases (85% women) was significantly lower than that of the controls (n = 1,294,117) (58.7 vs. 65.5years, respectively). The main death causes were circulatory system diseases, infections, and respiratory diseases (36%, 34%, and 21% of SSc cases, respectively). Compared to the deceased controls, there were proportionally more deaths among the SSc cases from pulmonary arterial hypertension, lung fibrosis, septicemia, gastrointestinal hemorrhage, other systemic connective tissue diseases, and heart failure (for death age < 50years). We confirmed the high burden of cardiovascular, respiratory, and infectious causes in thispredominantly non-Caucasian sample of SSc patients. Of interest, the percentage of infection-related deaths in our report was about three times higher than that in SSc studies with predominantly Caucasian populations.

Fracture-related mortality in southern Sweden: A multiple cause of death analysis, 1998–2014

PurposeTo assess fracture-related mortality among adults (aged ≥20years) in southern Sweden using multiple causes of death approach. MethodsAll death certificates (n=201 488) in adults recorded in the region of Skåne from 1998 to 2014 were examined. We identified fracture-related deaths and computed mortality rates by sex, age group, and fracture site. Temporal trends were evaluated using joinpoint regression and associated causes were identified by age- and sex-adjusted observed/expected ratios. ResultsFractures were mentioned on 6 226 (3.1%) death certificates, with majority of these occurred among women (60%) and those aged≥80years (77%). While hip was the most common site overall (61% of all fracture-related deaths), skull was the most common site in people <60years (60% of all fracture-related deaths). Proportion of death certificates mentioning fracture was stable in women but increased by 0.4% (95% CI: 0.1 to 0.6) in men between 1998–2002 and 2010–2014. The mean age at death was higher in death certificates mentioning fracture than those without and this gap widened over time. The mean age-standardized fracture-related mortality rate was 18.8 (14.0) per 100 000 person-year in men (women) and declined by 1.5% (1.3%) per year during 1998–2014. Injuries (84.6%) and cardiovascular disorders (64.6%) were the most common comorbidities on death certificates mentioning fracture. ConclusionsFracture is a contributing cause of death in more than 3% of all deaths in southern Sweden with hip in lead among older and skull fracture among younger people. There was a slight increase in proportion of deaths associated with fracture in men but not women during the study period.

Fall-related mortality in southern Sweden: a multiple cause of death analysis, 1998–2014

ObjectivesTo investigate temporal trend in fall mortality among adults (aged ≥20 years) in southern Sweden using multiple cause of death data.MethodsWe examined all death certificates (DCs, n=2 01 488) in...

Growing burden of sepsis-related mortality in northeastern Italy: a multiple causes of death analysis.

BackgroundFew population-based data are available on mortality due to sepsis. The aim of the study was to estimate sepsis-related mortality rates and to assess the associated comorbidities.MethodsFrom multiple causes of death data (MCOD) of the Veneto Region (northeastern Italy), all deaths with sepsis mentioned anywhere in the death certificate were retrieved for the period 2008–2013. Among these deaths the prevalence of common chronic comorbidities was investigated, as well as the distribution of the underlying cause of death (UCOD), the single disease selected from all condition mentioned in the certificate and usually tabulated in mortality statistics. Age-standardized mortality rates were computed for sepsis selected as the UCOD, and for sepsis mentioned anywhere in the certificate.ResultsOverall 16,906 sepsis-related deaths were tracked. Sepsis was mentioned in 6.3 % of all regional deaths, increasing from 4.9 in 2008 to 7.7 % in 2013. Sepsis was the UCOD in 0.6 % of total deaths in 2008, and in 1.6 % in 2013. Age-standardized mortality rates increased by 45 % for all sepsis-related deaths, and by 140 % for sepsis as the UCOD. Sepsis was often reported in the presence of chronic comorbidities, especially neoplasms, diabetes, circulatory diseases, and dementia. Respiratory tract and intra-abdominal infections were the most frequently associated sites of infection.ConclusionsMCOD analyses provide an estimate of the burden of sepsis-related mortality. MCOD data suggest an increasing importance attributed to sepsis by certifying physicians, but also a real increase in mortality rates, thus confirming trends reported in some other countries by analyses of hospital discharge records.

Multiple causes of death analysis of chronic diseases: the example of diabetes.

BackgroundIdentifying a single disease as the underlying cause of death (UCOD) is an oversimplification of the clinical-pathological process leading to death. The multiple causes of death (MCOD) approach examines any mention of a disease in death certificates. Taking diabetes as an example, the study investigates: patterns of death certification, differences in mortality figures based on the UCOD and on MCOD, factors associated to the mention of diabetes in death certificates, and potential of MCOD in the analysis of the association between chronic diseases.MethodsThe whole mortality archive of the Veneto Region-Italy was extracted from 2008 to 2010. Mortality rates and proportional mortality were computed for diabetes as the UCOD and as MCOD. The position of the death certificate where diabetes was mentioned was analyzed. Conditional logistic regression was applied with chronic liver diseases (CLD) as the outcome and diabetes as the exposure variable. A subset of 19,605 death certificates of known diabetic patients (identified from the archive of exemptions from medical charges) was analyzed, with mention of diabetes as the outcome and characteristics of subjects as well as other diseases reported in the certificate as predictors.ResultsIn the whole mortality archive, diabetes was mentioned in 12.3 % of death certificates, and selected as the UCOD in 2.9 %. The death rate for diabetes as the UCOD was 26.8 × 105 against 112.6 × 105 for MCOD; the UCOD/MCOD ratio was higher in males. The major inconsistencies of certification were entering multiple diseases per line and reporting diabetes as a consequence of circulatory diseases. At logistic regression the mention of diabetes was associated with the mention of CLD (mainly non-alcohol non-viral CLD). In the subset of known diabetic subjects, diabetes was reported in 52.1 %, and selected as the UCOD in 13.4 %. The probability of reporting diabetes was higher with coexisting circulatory diseases and renal failure and with long duration of diabetes, whereas it was lower in the presence of a neoplasm.ConclusionsThe use of MCOD makes the analysis of mortality data more complex, but conveys more information than usual UCOD analyses.

COPD-Related Mortality and Co-morbidities in Northeastern Italy, 2008-2012: A Multiple Causes of Death Analysis

Introduction: Analysis of COPD mortality based only on the underlying cause of death (UCOD) derived from death certificates underestimates disease burden. We analyzed the burden of COPD, as well as the pattern of reporting COPD and its co-morbidities in death certificates, using multiple-cause of death (MCOD) records.Methods: All 220,281 death certificates of decedents aged ≥40 years in the Veneto region (northeastern Italy) were analyzed through 2008–2012. The UCOD was selected by the Automated Classification of Medical Entities software. COPD was defined by ICD-10 codes J40-J44 and J47 based either on the UCOD or on any mention of COPD in death certificates (MCOD). Annual age-standardized COPD death rates were computed for 40–85 year-old subjects.Results: COPD was mentioned in 7.9% (and selected as the UCOD in 2.7%) of death certificates. In about half of these, COPD was mentioned in Part II only. After circulatory and neoplastic diseases, the most frequent chronic diseases reported in certificates with any mention of COPD were diabetes (15.2%) and dementia/Alzheimer (8.9%). Between 2008 and 2012, age-standardized death rates (/100,000/year) decreased from 39.8 to 34.0 in males and from 12.7 to 11.3 in females in the UCOD analyses. These trends were confirmed, although figures were three times greater, in the MCOD analyses.Conclusions: MCOD analysis should be adopted to fully evaluate the burden of COPD-related mortality. Our findings support a decreasing trend in COPD-related mortality in northeastern Italy between 2008 and 2012, in line with other recent studies in Europe and beyond.

Trends in mortality from chronic liver disease

PurposeMortality from liver cirrhosis has sharply declined in most countries in the last few decades, but includes only a fraction of deaths due to chronic liver disease. MethodsMortality records for liver cirrhosis, liver cancer, viral hepatitis, and the three disease categories combined were extracted for the period 1995 to 2010 in the Veneto Region (northeastern Italy). The presence of a birth cohort effect was assessed by fitting Poisson regression models. The alcoholic or viral etiology was retrieved through multiple causes of death analysis for the years 2008 to 2010. ResultsLiver cirrhosis mortality represented only one-third of all liver disease deaths; this proportion was even smaller for deaths with a viral etiology and among elderly people. Through the study period, age-standardized rates declined by 50% for liver cirrhosis, and by 30% (world standard) or by 25% (regional standard) for all liver diseases; the reduction in proportional mortality was limited to 11%. Mortality rates started to decline in subjects born after the early 1920s. ConclusionsThe decline in mortality was smaller than that reported by standard statistics for chronic liver disease; these statistics should routinely include viral hepatitis and liver cancer deaths. When available, multiple causes of death data should be analyzed.

Mortality from rheumatoid arthritis in France, 1970-1990.

The degree to which rheumatoid arthritis (RA) influences life expectancy and mortality remains controversial. There have been few attempts to analyse death certificate data for this condition. Despite limitations, the information derived from detailed death certificate analysis for a large population over a long period allows the examination of aspects of the disease process and its impact. The mortality related to RA in France was investigated for 1970-1990 inclusive. A multiple cause of death analysis was conducted, based on information recorded in death certificates. Death from RA represented 0.22% of all deaths. Mortality due to RA was strongly influenced by sex (female/male ratio of number of deaths = 3.3) and age (proportional mortality ratios higher in the 65-74 and 75-84 year age groups). In women, the mean age at death for RA was slightly lower than the mean age at death from all causes, while the difference was clearly opposite in men. The impact of RA remained relatively constant during the study period, both in terms of proportional mortality and age at death. The analysis of associated causes of death did not yield significant changes in the pattern of death from RA. The study demonstrates the significant and relatively constant impact of RA on mortality in France over the study period. This suggests that the introduction of new treatment regimens or other environmental factors has had little influence on the impact of RA mortality in the community.

A multiple cause of death analysis of hypertension-related mortality in North Carolina, 1968-1977.

In this paper, records of all medical conditions on death certificates are used to evaluate hypertension-related mortality in North Carolina over the decade 1968-1977. Use of both an inclusive hypertension recode category and multiple cause data resulted in gains in information of over 750 per cent in all four race/sex groups compared to the commonly used underlying cause, hypertensive disease category. Race, sex and age specific 10-year trends in death rates for all mentions of hypertension are analyzed, with comparisons to underlying cause mortality from ischemic heart disease and stroke. Age-adjusted declines of 19 to 24 per cent between 1968 and 1977 were observed for all race/sex groups, although non-White declines occurred mainly at younger ages while White declines (especially White males) occurred mainly at older ages. The non-White excess of hypertension mentions (compared to Whites) increased for males and decreased for females. The decline in hypertension mentions, in spite of the increased awareness of hypertension as a public health problem which would make it more likely to be mentioned on death certificates, suggests that there was a real reduction in the contribution of hypertension to total mortality over the period.