National Death Index Data Research Articles

Food Insecurity is Associated With Mortality Among U.S. Adults With Nonalcoholic Fatty Liver Disease and Advanced Fibrosis

Food insecurity is a growing public health challenge in the United States (U.S.) and has been linked to nonalcoholic fatty liver disease (NAFLD) and advanced fibrosis. However, little is known of how food insecurity impacts mortality risk and health care utilization in chronic liver disease. Using a population-based cohort study of U.S. adults (≥20 years) in the National Health and Nutrition Examination Survey, 1999 to 2014, with NAFLD (estimated by the U.S. Fatty LiverIndex) and advanced fibrosis (estimated by the NAFLD fibrosis score, aspartate aminotransferase-to-platelet ratio index, or Fibrosis-4 Index), food security was measured using the Department of Agriculture Food Security Survey Module. The primary outcome was all-cause mortality from National Death Index data and the secondary outcome was health care utilization, defined as ≥2 inpatient and ≥4 outpatient visits, with Cox and logistic regression, respectively, estimating associations between food insecurity and outcomes. Of 34,134 eligible participants (mean age, 47 years; 51% women; 14% in poverty), 4816 had NAFLD and 1654 had advanced fibrosis, with food insecurity present in 28% and 21%, respectively. All-cause age-adjusted mortality was 12 per 1000 person-years among participants with NAFLD (food-secure, 11; food-insecure, 15) and 32 per 1000 person-years among advanced fibrosis participants (food-secure, 28; food-insecure, 50). In multivariable analyses, food insecurity was independently associated with higher mortality among participants with NAFLD (hazard ratio, 1.46; 95% confidence interval [CI], 1.08-1.97) and advanced fibrosis (hazard ratio, 1.37; 95% CI, 1.01-1.86) and greater outpatient health care utilization in participants with NAFLD (odds ratio, 1.32; 95% CI, 1.05-1.67). Food insecurity is significantly associated with greater all-cause mortality in adults with NAFLD and advanced fibrosis. Interventions that address food insecurity among adults with liver disease should be prioritized to improve health outcomes in this population.

Effects of Posttrial Antihypertensive Drugs on Morbidity and Mortality: Findings from 15-Year Passive Follow-Up after ALLHAT Ended.

Background Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) ended in 2002, but it is important to study its long-term outcomes during the posttrial period by incorporating posttrial antihypertensive medication uses in the analysis. Purposes The primary aim is to explore the patterns of antihypertensive medication use during the posttrial period from Medicare Part-D data over the 11-year period from 2007 to 2017. The secondary aim is to examine the potential effects of these posttrial antihypertensive medications on the observed mortality and morbidity benefits. Methods This is a posttrial passive follow-up study of ALLHAT participants in 567 US centers in 1994–1998 with the last date of active in-trial follow-up on March 31, 2002, by linking with their Medicare and National Death Index data through 2017 among 8,007 subjects receiving antihypertensive drugs (3,637 for chlorthalidone, 2,189 for amlodipine, and 2,181 for lisinopril). Outcomes included posttrial antihypertensive drug use, all-cause mortality, and cardiovascular disease (CVD) mortality. Results Of 8007 subjects, 3,637 participants were initially randomized to diuretic (chlorthalidone). The majority (67.9%) of them still received diuretics in 2007, and 52.7%, 47.2%, and 44.0% received β-blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers (CCBs), respectively. Compared to participants who received diuretic-based antihypertensives, those who received CCB had a nonsignificantly higher risk of all-cause mortality (1.17, 0.99–1.37), whereas those who received ACE/ARB (angiotensin receptor blockers) had a significantly higher risk of all-cause mortality (1.26, 1.09–1.45). For the combined fatal or nonfatal hospitalized events, the risk of CVD was significantly higher in patients receiving CCB (1.30, 1.04–1.61) and ACE/ARB (1.49, 1.22–1.81) as compared to patients receiving diuretics. Conclusion After the conclusion of the ALLHAT, almost all patients switched to combination antihypertensive therapies, independently by the original drug class, and the combination therapies (mostly based on diuretics) reduced the incidence of major cardiovascular outcomes and mortality.

Onset and progression of chronic disease and disability in a large cohort of older Australian women

ObjectiveTo estimate the probability of onset and progression of disease and disability, length of life with or without disease and/or disability, and incidence of mortality, and to identify factors associated with transitioning to disease and/or disability over time. Study designA prospective cohort study. Data were provided by 12,432 participants (born 1921–26) of the Australian Longitudinal Study of Women's Health linked with National Death Index data from 1996 (age: 70–75) to 2016 (age: 90–95). Main outcome measuresA five-state Markov model was fitted to estimate the transition probability, length of life with or without disease and/or disability, and the association between baseline characteristics and disease/disability/mortality risk. ResultsOver two-thirds of women had died by age 90–95, and only 3.8% of these had died with no chronic disease and disability. Those reporting chronic disease were more likely to have experienced disability (Transition Rate Ratio: 2•72, 95%CI= 2•52–2•93) than those who died without disability. At age 70–75, the expected life without chronic disease and disability was 7•68 (95%CI: 7•52–7•80) years, life with chronic disease but no disability was 4•39 (95%CI=4•23–4•49) years, and life with disability was 3.76 (95%CI=3•66–3•92) years. The factors difficulties managing on available income (HR=1•18, 95%CI=1•02–1•38), did not complete secondary school (HR=1•19, 95%CI=1•03–1•37), and overweight/obese (HR=1•36, 95%CI=1•20–1•55) were associated with an increased risk of disability. ConclusionsOur findings provide important insights on the onset and progression of disease and disability in older women, underscoring the importance of addressing mid-/early old-life risk factors, managing chronic conditions, and delaying disability onset and progression through targeted intervention programs.

Alcohol-involved overdose deaths in US veterans

BackgroundAlcohol-involved overdose deaths are increasing and often occur with other substances but have been minimally studied compared to other causes of overdose. MethodsWe used national Veterans Health Administration (VHA) records linked to National Death Index data from 2012 to 2018 to examine trends in alcohol-related overdose mortality. Patient characteristics and treatment receipt were compared across categories of alcohol overdose deaths (alcohol-only, alcohol+opioids which may include additional substances, and alcohol+other substances without opioids). ResultsFrom 2012–2018, 2421 Veterans died from an alcohol-involved overdose (alcohol-only: 868, alcohol+opioids: 1269, alcohol+other substances: 284). The alcohol-involved overdose rate increased 57% during this period. Compared to those who died of an alcohol-only overdose, Veterans who died from alcohol+opioids and alcohol+other substances were more likely Black or Hispanic, and to have an opioid use disorder, but less likely to live in rural areas or to be diagnosed with alcohol use disorder (AUD). Only 32.5% of those who died from alcohol-involved overdose received treatment in a substance use disorder clinic in the year preceding death, compared to 65.1% seen in mental health and 85.7% in primary care. Only 9.5% of Veterans who died from alcohol overdose received medication treatment for AUD and 24.8% received psychotherapy for AUD in the year preceding death. ConclusionsAlcohol overdose is increasing primarily related to overdoses involving opioids and other substances. Most patients did not receive any effective medication or psychotherapy treatments for AUD, suggesting further need to identify those at risk and to target treatment for this vulnerable group in healthcare settings.

Suicide Risk Among Adults With Mental Health Emergency Department Visits With and Without Suicidal Symptoms.

Objective: To describe risk factors and suicide rates during the year following discharge from mental health emergency department (ED) visits by adults with suicide attempts, suicidal ideation, or neither.Methods: National cohorts of patients with mental health ED visits for suicide attempts or self-harm (n = 55,323), suicidal ideation (n = 435,464), or other mental health visits (n = 9,144,807) from 2008 to 2012 Medicaid data were followed for suicide for 1 year after discharge. Suicide rates per 100,000 person-years were determined from National Death Index data. Poisson regression models, adjusted for age, sex, and race/ethnicity, estimated suicide rate ratios (RRs). Suicide standardized mortality ratios (SMRs) were estimated from National Vital Statistics System data.Results: Suicide rates per 100,000 person-years were 325.4 for suicide attempt or self-harm visits (RR = 5.51, 95% CI, 4.64-6.55), 156.6 for suicidal ideation visits (RR = 2.59, 95% CI, 2.34-2.87), and 57.0 for the other mental health ED visits (1.0, reference). Compared to expected suicide general population rates, SMRs were 18.2 (95% CI, 13.0-23.4) for suicide attempt or self-harm patients, 10.6 (95% CI, 9.0-12.2) for suicidal ideation patients, and 3.2 (95% CI, 3.1-3.4) for other ED mental health patients. Among patients with suicide attempt ED visits in the 180 days before their index mental health ED visit, suicide rates per 100,000 person-years were 687.2 (95% CI, 396.5-978.0) for attempt or self-harm visits, 397.4 (95% CI, 230.6-564.3) for ideation visits, and 328.4 (95% CI, 241.5-415.4) for other mental health visits.Conclusions: In the year following discharge, emergency department patients with suicide attempts or self-harm, especially repeated attempts, have a high risk of suicide.

Aortic valve endocarditis in patients with bicuspid and tricuspid aortic valves

ObjectiveTo determine the long-term survival and rate of reoperation after surgical treatment of infective endocarditis (IE) in patients with a bicuspid aortic valve (BAV) and patients with a tricuspid aortic valve (TAV). MethodsBetween 1997 and 2017, 210 patients underwent surgical treatment for native aortic valve endocarditis, including 51 patients with BAV (24%) and 159 patients with TAV (76%). Data were obtained from the Society of Thoracic Surgeons data warehouse and hospital medical record review, supplemented with surveys and national death index data for more complete follow-up. ResultsCompared with the TAV IE group, the BAV IE group was significantly younger (42 years vs 54 years) and had lower incidence rates of hypertension, coronary artery disease, and congestive heart failure (CHF). There were no significant between-group differences in postoperative stroke, sepsis, pacemaker requirement, or in-hospital mortality (2.0% vs 4.4%). Liver disease was a risk factor for operative mortality (odds ratio [OR], 13; 95% CI, 3.3-30; P = .0002). The 10-year survival rate was 64% for the BAV group versus 46% for the TAV group (P = .0191). Significant risk factors for long-term mortality were intravenous drug use (hazard ratio [HR], 4.5; P < .0001), preoperative renal failure requiring dialysis (HR, 4.13; P < .0001), CHF (HR, 1.7; P = .04), and liver disease (HR, 2.6; P = .02). The HR for BAV was 0.67 (95% confidence interval [CI], 0.3-1.4). The 10-year postoperative cumulative incidence of reoperation was significantly higher in the BAV patients compared with the TAV patients (5.7% vs 4.5%; P = .045) with an HR of 2.4 (95% CI, 0.8-7.1; P = .11) for BAV. ConclusionsBAV patients develop IE requiring surgery at a younger age than TAV patients, but have significantly better long-term survival. Early detection of BAV is important to prevent IE and provide aggressive surgical treatment should IE occur.

Maternal and Child Mortality: Analysis of Nurse Home Visiting in 3 RCTs

The impact of intensive prenatal and infant/toddler nurse home visiting on low-income mothers' and children's survival was examined in 3 RCTs following participants over 2-decade periods after trial registration during pregnancy (data gathered between 1978 and 2015 and analyzed between 2016 and 2020). All-cause and external-cause maternal mortality and preventable-cause child mortality were examined using National Death Index data. Survival rates were calculated for all the 1,138 mothers randomized and 1,076 live-born children in the second RCT (conducted in Memphis, TN) and for all the 1,135 mothers randomized and 1,087 live-born children in the first and third RCTs combined (conducted in Elmira, NY and Denver, CO). There were no significant nurse home visiting-control differences in maternal mortality in Memphis or Elmira and Denver. Posthoc analysis, combining all 3 trials, suggested a reduction in external-cause maternal mortality among nurse-visited mothers (p=0.054). There was a marginally significant nurse home visiting-control difference in preventable-cause child mortality (p=0.09) in Memphis. These results support examining maternal and child mortality in additional nurse home visiting trials with larger samples living in disadvantaged contexts. Intensive prenatal and infant/toddler home visiting by nurses for mothers and children living in poverty may decrease premature death.

Combined Effect of Lead Exposure and Allostatic Load on Cardiovascular Disease Mortality-A Preliminary Study.

This study explores the combined effect of lead (Pb) exposure and an index of chronic physiological stress on cardiovascular disease mortality using data from the National Health and Nutrition Examination Survey (NHANES) 1999–2008 linked to 1999–2014 National Death Index data. Chronic physiological stress was measured using the allostatic load (AL) index, which was formed by analyzing markers from the cardiovascular, inflammatory, and metabolic systems, with Pb levels, assessed using blood lead levels (BLL). The dataset was analyzed with statistical techniques to explore (a) the relationship between Pb exposure and AL, and (b) the combined role of Pb and AL on cardiovascular disease mortality. Results indicated that AL was more elevated in those with BLLs above the 50th percentile in the US population and that those with elevated AL were more likely to have high BLL. Finally, the interaction of AL and BLL significantly increased the likelihood of cardiovascular disease mortality. These findings highlight the need for considering the totality of exposures experienced by populations to build holistic programs to prevent Pb exposure and reduce stressors to promote optimal health outcomes and reduce cardiovascular mortality risk.

No Association between Age of Transfused Red Cells and 30-Day Mortality in Massively Transfused Patients: Results from the Australian and New Zealand Massive Transfusion Registry

BackgroundClinical trials studying age of transfused red blood cells (RBCs) have found no evidence of benefit from transfusion of fresher RBCs. However, these studies have not included patients requiring massive transfusion for major bleeding, a patient population that may be more susceptible to adverse effects of the RBC storage lesion. Further, no clinical trials have specifically evaluated the safety of transfusing RBCs approaching expiry (30-42 days). We investigated the association between RBC storage time and 30-day mortality in a large cohort of massively transfused patients (5 RBCs within 4 hours, from any bleeding context).MethodsUsing 2007-2015 Australian/NZ Massive Transfusion Registry data from 25 hospitals linked with Australian and New Zealand National Death Index data, we modelled the association between storage time and 30-day mortality in massively transfused patients. Our logistic regression model adjusted for Charlson co-morbidity score, patient age, patient sex, number of RBC units transfused, and bleeding category (cardiothoracic, gastrointestinal, obstetric, surgical, trauma, vascular surgery, or other) with treating hospital as a random-effects grouping variable. Storage time was quantified as the mean storage time of all units each patient received for our primary analysis, and as a binary predictor indicating patients receiving only RBCs older than 30 days for our secondary analysis. As sensitivity analyses, we stratified patients by number of RBC units received and ran our model individually on each stratum containing more than 50 patients receiving equivalent numbers of RBCs in order to eliminate any confounding introduced by comparing patients receiving differing numbers of RBCs. In our stratified sensitivity analyses, in addition to mean storage time of RBC units received by each patient, we tested minimum and maximum storage times of transfused RBC units as predictors.Results4127 patients meeting the massive transfusion definition during the study period had RBC age available. Stratifying on number of RBC units transfused resulted in 19 strata containing more than 50 patients (those receiving 5,6,7,...23 RBC units), comprising 3641 patients (88% of study population). In the analysis of the entire cohort together, we found no significant association between mean storage duration and 30-day mortality (ORST=0.99 [95%CI: 0.98 to 1.01]; p=0.42) or patients transfused with only RBCs >30days old and 30-day mortality (ORST>30d=0.85 [95%CI: 0.52 to 1.37]; p=0.49). In our stratified sensitivity analyses, we found no association between mean storage time and 30-day mortality (OR for a 1-day increase in mean storage time [ORmeanST] range = 0.95 to 1.08 with p>0.05 for entire range). We likewise found no associations between maximum and minimum storage times and 30-day mortality (ORmaxST range = 0.93 to 1.05 with p>0.05 for all but one stratum; ORminST range = 0.94 to 1.04 with p>0.05 for all strata). For all three stratified sensitivity analyses, we observed no trend in ORST across the strata of patients receiving equivalent numbers of RBCs (figure 1 shows the stratified analysis with mean storage time as the predictor).ConclusionsWe found no association between storage time of transfused RBCs and 30-day mortality in a large cohort of massively transfused patients. Our findings were consistent both for the cohort as a whole and within strata of patients receiving equivalent numbers of RBC transfusions. Additionally, we observed no association when we modelled storage duration as maximum RBC age, minimum RBC age, or when we considered patients receiving only RBCs >30 days old. Our conclusions are consistent with recent large randomised trials which have not demonstrated mortality benefit from transfusing fresher RBCs. Differences in our findings and those of previous observational studies reporting correlations between storage time and mortality may be due to methodological differences: specifically, our stratified analysis eliminated the potential confounding effect of number of RBCs transfused, and we more accurately modelled the storage lesion as a continuous function by using mean storage age rather than comparing patients who received only RBCs above or below arbitrary storage time thresholds. In conclusion, we find no evidence that fresher blood leads to better clinical outcomes in massively transfused patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Outcomes in Patients With Chronic Renal Failure on Hemodialysis After Aortic Valve or Root Replacement

The long-term survival and reoperation rate in chronic renal failure (CRF) on hemodialysis (HD) patients after aortic valve/root replacement (AVR/ARR) with a stentless bioprosthesis is unknown. From 1992-2015, 1941 patients underwent AVR/ARR with stentless valve for primary indications of aortic stenosis/insufficiency, root aneurysm, and acute type A aortic dissection, including 93 CRF-HD (64 new-onset postoperative HD, and 29 preoperative HD) and 1848 non-CRF-HD. Data was obtained from the STS database, retrospective chart review, administered surveys and national death index data. Compared to the non-CRF-HD group, the CRF-HD group had significantly higher incidence of diabetes mellitus (28 vs 18%), CAD (49 vs 38%), COPD (31 vs 16%), NYHA class IV (12 vs 4%), atrial fibrillation (24 vs 12%), and previous cardiac surgery (27 vs 16%). Postoperatively, CRF-HD group had a higher reoperation for bleeding (10 vs 4%), length of hospital stays (20 vs 7 days), and operative mortality (23 vs 2.3%), all p < 0.01. The odds ratio of CRF-HD for operative mortality was 8.97. The long-term survival was worse in CRF-HD group than that in non-CRF-HD group [8-year survival: 31% vs 70%, p < 0.0001]. The hazard ratio of CRF-HD for long-term mortality was 2.4. The 10-year cumulative reoperation rate for structural valve deterioration in the CRF-HD group was 6.0% vs 5.0% in the non-CRF-HD group, p=0.74. Surgeons should consider poor short- and long-term outcomes of patients with high risk of being on dialysis when offering aortic valve/root replacement. Bioprosthesis could be a good option in this patient population.

Predicting Chronic Disease, Disability and Mortality in a Large Cohort of Older Australian Women: A Markov Multi-State Modelling Approach

Background: Many older people, particularly women, spend a substantial proportion of later life with chronic disease and/or disability. This study aimed to estimate the transition probability, length of life with or without disease and/or disability, and identify factors associated with transitioning to declining health states over time. Methods: Data were provided by 12,432 participants (born: 1921-26) of the Australian Longitudinal Study of Women’s Health linked with National Death Index data from 1996 (age: 70-75) to 2016 (age: 90-95). A five-state Markov model was fitted to estimate the transition probability, length of life with or without disease and/or disability, and the association between baseline characteristics and disease/disability/mortality risk. Findings: Over two-thirds of women died by age 90-95, with only 326 (3.8%) of these dying with no reported chronic disease and disability. Those reporting chronic disease were more likely to experience disability (Transition Rate Ratio: 2·72, 95%CI= 2·52-2·93) than die without disability. At age 70-75, the predicted length of life without disease and disability: 7·68 (CI: 7·52-7·80) years, life with chronic disease but no disability: 4·39 (CI=4·23-4·49) years, and life with disability: 3.76 (CI=3·66-3·92) years. Difficulties managing on available income (HR=1·18, 95%CI=1·02-1·38), did not completed secondary school (HR=1·19, 95%CI=1·03-1·37), and overweight/obese (HR=1·36, 95%CI=1·20-1·55) were associated with an increased risk of disability. Interpretation: Our findings provide important insights on the onset and progression of disease and disability in older women, underscoring the importance of addressing mid-/early old-life risk factors, managing chronic conditions, and delaying disability onset and progression through targeted intervention programs. Funding Information: Australian Research Council. Declaration of Interests: The authors have no conflicts. Ethics Approval Statement: The ethical approval was obtained from the Human Resources Ethics Committee of The University of Newcastle.

Changes in the severity and lethality of age-related health deficit accumulation in the USA between 1999 and 2018: a population-based cohort study

With an ageing population, the number of people with frailty is increasing. Despite this trend, the extent to which the severity and lethality of frailty have changed over time is not well understood. We aimed to investigate how frailty severity and lethality have changed over an 18-year period in the USA. In this population-based observational study, we used data from the National Health and Nutrition Examination Survey (NHANES) to identify community-dwelling individuals (aged ≥20 years) in the USA between 1999 and 2018. We analysed data from a series of ten 2-year, nationally representative, cross-sectional, prospective studies (from 1999-2000 to 2017-18) from the NHANES. Frailty was measured by use of the deficit accumulation approach (ie, a 46-item frailty index). The proportion of individuals categorised as non-frail, or living with very mild frailty, mild frailty, moderate frailty, and severe frailty were compared across cohorts. Random-effects models were used to examine the association between frailty index score and sex, age, and cohort. Mortality status as of Dec 31, 2015, was ascertained by use of National Death Index data, and 5-year mortality was available in the first six cohorts (1999-2010). Cox regression models and Kaplan-Meier curves were used to estimate the association between frailty index scores and mortality. In total, 49 004 individuals were included in our study. Associations were mainly non-linear (quadratic), with frailty increasing at a faster rate in more recent cohorts. Between 1999 and 2018, the proportion of non-frail individuals decreased by 10·4% (from 2747 [63·8%; 95% CI 61·9-65·6] of 4307 to 2884 [53·4%; 51·3-55·5] of 5399), whereas the proportion of individuals with very mild frailty increased by 2·4% (from 987 [22·9%; 21·3-24·6] to 1365 [25·3%; 23·5-27·2]), by 2·7% (from 370 [8·6%; 7·7-9·6] to 609 [11·3%; 10·1-12·5]) in those with mild frailty, by 3·1% (from 140 [3·3%; 2·7-3·9] to 347 [6·4%; 5·6-7·4]) in those with moderate frailty, and by 2·1% (from 63 [1·5%; 1·1-1·9] to 195 [3·6%; 3·0-4·3]) in those with severe frailty. Being a woman, older, and from a more recent cohort were associated with higher frailty index scores (all p<0·0001). In more recent cohorts, mean frailty index scores increased more quickly with age (p<0·0001), and sex differences in mean frailty index scores decreased (p<0·0001). In men of all ages and in women aged 35 years or older, mean frailty index scores were higher in more recent cohorts, with larger increases in frailty in older age groups. In 28 692 individuals from the first six cohorts (1999-2000 to 2009-10) with linked mortality data, frailty index scores were significantly associated with mortality (hazard ratio 1·053 [95% CI 1·050-1·057] per 0·01 increase in frailty index score). The absence of an interaction between cohort and frailty index score (p=0·58) suggested that the association between frailty and mortality was similar for all cohorts. Increasing frailty levels in more recent cohorts of middle-aged and older adults combined with stable frailty lethality between 1999 and 2018, suggest a challenge to healthy longevity, with the proportion of individuals with a high degree of frailty continuing to increase. Supported in part by the Canadian Institutes of Health Research.

Depression Screening and Rates of Mood Disorder Diagnosis and Suicide in Younger and Older Adults

Rates of suicide are elevated among older adults in the U.S. and around the world, with the highest rates in older men (CDC, 2019; WHO, 2014). More than half of older adults who die by suicide were in contact with a primary care physician within the month prior to death, and almost one-third within the prior week (Luoma et al., 2002; Stene-Larsen & Reneflot, 2019), demonstrating the importance of better identification and treatment of mental health issues among older adults across healthcare systems. Depression, a well-established risk factor for suicide, goes under-diagnosed and under-treated, especially among older adults (Bryant, 2010). The University of Rochester Medical Center has led integration of patient-reported outcomes assessment via large-scale implementation of PROMIS measures across multiple departments. We compared results of PROMIS depression screening from 1/1/2015 to 8/31/2019 with mood disorder diagnoses within the year prior and year following screening. Twenty-six percent (39491/154669) of adults under age 65 and 23% (11694/51702) of those age 65 and older screened positive for mild, moderate, or severe depression. Whereas 29.0% of younger adults who screened positive received mood disorder diagnoses, 22.1% of older adults received a diagnosis (χ2(1)=214.69, p<.001). Suicide outcomes using National Death Index data will also be reported. Results confirm depression is underdiagnosed (and, by extension, likely undertreated) at all ages, but show a distinct disparity for older adults, which may put them at greater risk for negative outcomes such as suicide.

Design and Creation of Multi-Source Enduring Linked Assets

IntroductionThe Australian Institute of Health and Welfare is collaborating with a range of government and other institutions to build enduring data assets for improving analysis and informed policy outcomes. There were lessons learnt that can be shared, in addition to the architecture and linkage techniques.&#x0D; The enduring assets were created by linking States’ and Territories’ health or welfare data to Commonwealth datasets such as Medicare Consumer Directory (MCD), Residential Aged Care (RAC) and National Death Index (NDI) data. The linkage was carried out by the Australian Institute of Health and Welfare (AIHW) Data Integration Services Centre (DISC).&#x0D; Objectives and ApproachTo create the integrated asset, the linkage spine was assembled by de-duplicating and linking MCD and NDI data. The states’ datasets and other commonwealth datasets involved in the project were linked to this spine. Each unique individual in the spine was assigned Personal Project Number (PPN) which was added to each record linked to the individual. The unlinked individuals from these datasets were de-duplicated and assigned different PPNs.&#x0D; Names, dates of birth and addresses were used in probabilistic linkage process.&#x0D; To enable investigators to interrogate the sequences of the events without releasing the exact dates, the central events file was created. It contains date differences for every event in the asset, calculated as the difference (in days) between event and not released “date zero”, different for each individual.&#x0D; ResultsBetween 96% and 99% of records in the supplied datasets were linked to the spine with linkage accuracy at least 98.5%. The linkage rates depends on the data completeness and the nature of the datasets as not all individuals accessing states’ servicers are eligible for Medicare.&#x0D; Conclusion / ImplicationsThe person-focused de-identified analytical assets allow to study journeys of the individual through Australian health and welfare systems which transcends jurisdictional boundaries.

Periodontal pathogens and their association with incident all‐cause and Alzheimer’s disease dementia in a large national survey

AbstractBackgroundInfectious agents including periodontal pathogens have recently appeared as important actors in Alzheimer’s Disease (AD) pathology. We examined associations of serum immunoglobulin G (IgG) against periodontal pathogens and Pd markers with incident all‐cause and AD dementia as well as AD mortality among U.S. middle‐aged and older adults.MethodPeriodontal disease (Pd) markers [Clinical Attachment Loss (CAL); probing depth and periodontal pathogen immunoglobulin G (IgG)] were investigated in relation to AD and all‐cause dementia incidence and to AD mortality, using data from the third National Health and Nutrition Examination Surveys (NHANES III, 1988‐1994) linked longitudinally with National Death Index and Medicare data through January 1st, 2014, with up to 26y of follow‐up. Sex‐ and age group‐specific multivariable‐adjusted Cox proportional hazards models were conducted.ResultAmong those ≥65y, AD incidence and mortality were consistently associated with probing depth, two factors and one cluster comprised of IgG titers against Porphyromonas gingivalis (Pg), Prevotella melaninogenica (Pm) and Campylobacter rectus (Cr) among others. Specifically, AD incidence was linked to a composite of Cr and Pg titers (per SD, aHR=1.22; 95% CI, 1.04‐1.43, P=0.012), while AD mortality risk was increased with another composite (per SD, aHR=1.46; 95% CI, 1.09‐1.96, P=0.017) loading highly on Pg, Prevotella intermedia, Prevotella nigrescens, Fusobacterium nucleatum, Cr, Streptococcus intermedius, Capnocylophaga Ochracea and Pm.ConclusionThis study provides evidence for an association between periodontal pathogens and AD, which was stronger for older adults. Effectiveness of periodontal pathogen treatment on reducing sequelae of neurodegeneration should be tested in randomized controlled trials.

The impact of socioeconomic status on secondary prevention of the acute coronary syndrome

Abstract Background Although socioeconomic status (SES) has been reported to be associated with health inequities, there are limited studies exploring the association between SES and secondary prevention of acute coronary syndrome (ACS) in countries with universal health cover. Purpose The aim is to examine whether SES has an impact on the secondary prevention of ACS in Australia. Methods Australian SNAPSHOT ACS data (2012) and its 18-month follow-up data were linked to admissions data from 6 jurisdictions covering all states and territories, national death index and Medicare Pharmaceutical Benefits Scheme data covering up to 3 years post-discharge. The five SES groups (lowest in Group 1 and highest in Group 5) were derived from the Australian Bureau of Statistics Socio-Economic Indexes for Areas (SEIFA) using the residential postcode at baseline. Outcomes were cardiac rehabilitation (CR) participation and smoking rate at 18 months post discharge as well as the use of ≥3 of the 4 indicated medications, all-cause death and cardiovascular disease (CVD) rates by 36 months of discharge. Outcomes were compared between the groups using the multilevel logistic regression with covariates of SES (5 groups), sex, GRACE risk score (4 groups), ACS diagnosis (STEMI/NSTEMI/UA) and the jurisdictions where the admissions data were linked. Results Of 1655 patients with ACS (mean age 68±13.5 yrs, 65% were male), who were discharged from hospital alive and had linked data available, 353 (21%) were in SES Group 1 (lowest SES), 369 (22%) in Group 2, 382 (23%) in Group 3, 296 (18%) in Group 4 and 255 (15%) in Group 5 (highest SES). Baseline clinical characteristics were comparable across the five SES groups. At 18-month after discharge, 1014 (61%) patients were followed-up with comparable loss to follow-up in each group. After adjustment, fewer patients in the lower SES groups (Groups 1 and 2) had participated in CR than those in the highest SES group (Group 5) (OR (95% CI): 0.60 (0.36, 0.99) and 0.56 (0.35, 0.91), respectively). Moreover, the odds of smoking was greater in Group 3 than Group 5 (2.60 (1.15, 5.89)) but no trend was found across the groups. By 36 months of discharge after adjustment, there was no difference in the odds of using ≥3 out of 4 medications between the SES groups. Despite this, patients in Groups 1 and 2 were significantly more likely to die than those in the highest SES group (1.96 (1.19, 3.21) and 1.91 (1.19, 3.07), respectively). The odds of CVD readmission did not differ across SES groups. Conclusion This study suggests that patients with low SES were less likely to participate in CR programs and more likely to die than those with high SES. Smoking rates varied between patients with intermediate and high SES but no trend was found across the groups. Despite the universal health cover available, inequity between the SES groups still exist. Future research is needed to further explore strategies to help close the evidence-practice gaps. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Australian National Heart Foundation Postdoctoral Fellowship

Analysis of the association between serum PFAS levels measured in NHANES and subsequent development of stroke or myocardial infarction as assessed through linked Medicare claims data

Background/Aim: Per- and polyfluoroalkyl substances (PFAS) are persistent chemicals used in many products and manufacturing processes. Human exposure to some PFAS has been associated with serum cholesterol concentrations, but observed cardiovascular disease (CVD) associations have been inconsistent. Previous cross-sectional analyses of PFAS-CVD associations used U.S. National Health and Nutrition Examination Survey (NHANES) data. We prospectively examined associations between NHANES serum PFAS concentrations and subsequent myocardial infarction (MI), ischemic stroke (IS) or any stroke (AS), using linked National Death Index and Medicare claims data, for participants aged ≥65 years with PFAS measurements and Medicare fee-for-service enrollment (study population).Methods: NHANES (1999-2000, 2003-2012) serum PFAS concentrations [perfluorooctane sulfonate, perfluorooctanoic acid (PFOA), perfluorononanoic acid, perfluorohexane sulfonate] were analyzed using quartile (among cases) indicator variables and the natural log of quartile geometric means (continuous variable, trend test). CVD outcomes occurring after serum collection were identified, among participants reporting no prior history of the outcome, using linked (through 2013) Medicare claims ICD-9-CM codes and underlying cause-of-death ICD-10 codes. Survival analysis models with an age time scale; weighted to account for survey design and Medicare matching; and stratified on body mass index; controlled for survey cycle, age, gender, race/ethnicity, smoking, alcohol consumption, physical activity, education, and income-to-poverty ratio.Results: Among 1248 in the study population, 1078 reported no prior MI (72 developed MI) and 1102 reported no prior stroke (67 developed IS; 78 developed AS). Quartile-specific hazard ratios (HRs) and trends for all PFAS-outcome combinations were not statistically significant, but some elevated HRs were observed [e.g., IS HRs (95% confidence intervals) for PFOA quartiles 2-4 vs. 1: 2.04 (0.79-5.28), 1.98 (0.75-5.19), 1.63 (0.61-4.36)].Conclusions: This analysis did not provide clear evidence of an association between serum PFAS concentrations and MI, IS, or AS. Results should be interpreted considering study limitations (e.g., limited power, single exposure measurement).

Assessing the relationship between institutional cancer and diabetes mortality rates using National Death Index data.

Aim:To evaluate overall survival (OS), glycemic control in cancer patients with and without diabetes mellitus (DM).Patients & methods:Patients (2010–2015) with newly diagnosed prostate, breast, lung, colorectal and pancreatic cancers were identified in institutional cancer registry. Data linked to National Death Index for vital status. 5-year OS estimated; glucose and hemoglobin A1c assessed during year postdiagnosis.Results:We identified 1404 patients (non-DM, n = 936; DM, n = 468). DM cohort had 168 deaths (36%); non-DM, 267 (29%). 5-year OS estimated at 58% (95% CI: 53–64%) for DM and 67% (95% CI: 64–71%) for controls; for matched pairs, hazard ratio: 1.35 (95% CI: 1.02–1.79). Cancer did not harm glycemic control.Conclusion:OS among cancer patients with DM was lower than without DM.

Causes of death among Federal Black Lung Benefits Program beneficiaries enrolled in Medicare, 1999-2016.

Coal miners with totally disabling pneumoconiosis are eligible for benefits through the Federal Black Lung Benefits Program (FBLP). We identify the causes of death among Medicare beneficiaries with a claim for which the FBLP was the primary payer and compare these causes of death to all deceased Medicare beneficiaries to better understand elevated death and disease among miners with occupational respiratory exposures. From 1999 to 2016 Medicare data, we extracted beneficiary and National Death Index data for 28,003 beneficiaries with an FBLP primary payer claim. We summarized the International Classification of Diseases, Clinical Modification 10th revision-coded underlying causes of death and entity-axis multiple causes of death for 22,242 deceased Medicare beneficiaries with an FBLP primary payer Medicare claim and compared their causes of death to the deceased Medicare beneficiary population. Among deceased FBLP beneficiaries, the three leading underlying causes of death were chronic obstructive pulmonary disease, unspecified (J44.9, 10.1%), atherosclerotic heart disease (I25.1, 9.3%), and coal workers' pneumoconiosis (CWP) (J60, 9.2%). All diseases of the respiratory system combined (J00-J99) were the underlying cause of death for 29.1% of all beneficiaries, with pneumoconioses (J60-J64) as the underlying cause for 11.0% of all beneficiaries. Coal miners enrolled in Medicare with an FBLP primary payer claim were more likely to have specific respiratory and cardiovascular diseases listed as a cause of death than deceased Medicare beneficiaries overall, and were also more likely to die from CWP or any pneumoconioses.

Treatment of aortic valve endocarditis with stented or stentless valve.

The study objective was to provide evidence for choosing a bioprosthesis in treating patients with active aortic valve endocarditis. From 1998 to 2017, 265 patients with active aortic valve endocarditis underwent aortic valve replacement with a stented valve (n=97, 37%) or a stentless valve (n=168, 63%) with further breakdown into inclusion technique (n=142, 85%) or total root replacement (n=26, 15%). Data were obtained from the Society of Thoracic Surgeons database aided with chart review, surveys, and National Death Index data. The median age of patients was 53years (43-56) in the stented group and 57years (44-66) in the stentless group. The stented and stentless groups had high rates of heart failure (54% and 40%), liver disease (16% and 7.7%), prosthetic valve endocarditis (14% and 48%), root abscess (38% and 70%), and concomitant ascending aorta procedures (6.2% and 22%), respectively. The stentless group required permanent pacemakers in 11% of cases. Operative mortality was similar between groups (6.2% and 7.1%). The 5-year survival was 52% and 63% in the stented and stentless groups, respectively. Significant risk factors for long-term mortality included liver disease (hazard ratio, 2.38), previous myocardial infarction (hazard ratio, 1.64), congestive heart failure (hazard ratio, 1.63), and renal failure requiring dialysis (hazard ratio, 4.37). The 10-year cumulative incidence of reoperation was 12% and 3.4% for the stented and stentless groups, respectively. The 10-year freedom from reoccurrence of aortic valve endocarditis was 88% for the stented and 98% for the stentless groups. Both stented and stentless aortic valves are appropriate conduits for replacement of active aortic valve endocarditis for select patients.