Sentinel Health Event Research Articles

Using Continuous Passive Assessment Technology to Describe Health and Behavior Patterns Preceding and Following a Cancer Diagnosis in Older Adults: Proof-of-Concept Case Series Study.

Describing changes in health and behavior that precede and follow a sentinel health event, such as a cancer diagnosis, is challenging because of the lack of longitudinal, objective measurements that are collected frequently enough to capture varying trajectories of change leading up to and following the event. A continuous passive assessment system that continuously monitors older adults' physical activity, weight, medication-taking behavior, pain, health events, and mood could enable the identification of more specific health and behavior patterns leading up to a cancer diagnosis and whether and how patterns change thereafter. In this study, we conducted a proof-of-concept retrospective analysis, in which we identified new cancer diagnoses in older adults and compared trajectories of change in health and behaviors before and after cancer diagnosis. Participants were 10 older adults (mean age 71.8, SD 4.9 years; 3/10, 30% female) with various self-reported cancer types from a larger prospective cohort study of older adults. A technology-agnostic assessment platform using multiple devices provided continuous data on daily physical activity via wearable sensors (actigraphy); weight via a Wi-Fi-enabled digital scale; daily medication-taking behavior using electronic Bluetooth-enabled pillboxes; and weekly pain, health events, and mood with online, self-report surveys. Longitudinal linear mixed-effects models revealed significant differences in the pre- and postcancer trajectories of step counts (P<.001), step count variability (P=.004), weight (P<.001), pain severity (P<.001), hospitalization or emergency room visits (P=.03), days away from home overnight (P=.01), and the number of pillbox door openings (P<.001). Over the year preceding a cancer diagnosis, there were gradual reductions in step counts and weight and gradual increases in pain severity, step count variability, hospitalization or emergency room visits, and days away from home overnight compared with 1 year after the cancer diagnosis. Across the year after the cancer diagnosis, there was a gradual increase in the number of pillbox door openings compared with 1 year before the cancer diagnosis. There was no significant trajectory change from the pre- to post-cancer diagnosis period in terms of low mood (P=.60) and loneliness (P=.22). A home-based, technology-agnostic, and multidomain assessment platform could provide a unique approach to monitoring different types of behavior and health markers in parallel before and after a life-changing health event. Continuous passive monitoring that is ecologically valid, less prone to bias, and limits participant burden could greatly enhance research that aims to improve early detection efforts, clinical care, and outcomes for people with cancer.

An updated review of diffuse mesothelioma of the pleura – A sentinel health event of potential elongate mineral particle pathogenicity

There are approximately 400 inorganic minerals in the Earth's crust, some of which can be encountered as elongate mineral particles [EMPs] with dimensional characteristics similar to the six minerals known as asbestos and other asbestiform amphiboles with established human pathogenicity. In addition, the rapidly developing field of nanotechnology is producing an ever-increasing array of high aspect ratio engineered nanomaterials [HARNs] with physical dimensions and biodurability similar to the asbestos fiber types with recognized pathogenic potential. Many of these non-asbestos/non-asbestiform EMPs and HARNs with the potential for aerosolization into the breathing zones of workers and in individuals in non-occupational environments have not yet been thoroughly studied with respect to their potential human pathogenicity, a fact which obviously poses concerns for both occupational health and public health professionals. On the basis of dose-response considerations it seems reasonable to infer that if any of these non-regulated EMPs or HARNs actually are pathogenic, then those mineral fiber exposure-induced disorders associated with the lowest cumulative exposure doses of the commercial amphibole types of asbestos, that is, diffuse mesothelioma of the pleura, and its non-malignant correlate of benign parietal pleural plaques, are those which are most likely to occur following inhalational exposures to any of the non-regulated EMPs and HARNs. Because of that observation, this paper reviews certain aspects of diffuse mesothelioma, including a summary of recent changes in the nomenclature of diffuse mesothelioma of the pleura; of both the descriptive and the analytical epidemiology of the disease; of the etiologies of mesothelioma, both “exposure” related and endogenous in nature; and of the asbestos population attributable fraction for diffuse mesotheliomas in the USA, both historically and in the future.

Long-term health outcomes in survivors after chronic subdural haematoma

Chronic subdural haematoma (CSDH) is the most common neurosurgical presentation among the elderly. Although initially considered a non-threatening event, recent studies have highlighted poor long-term survival post-CSDH. Currently, there is a paucity of information regarding long-term health outcome in survivors after CSDH post-intervention. The objective of this research was to assess long-term functional, cognitive, and mental health outcome after CSDH. CSDH patients were administered a telephone-based assessment including a Demographic Questionnaire, Functional Activities Questionnaire (FAQ), Cognitive Telephone Screening Instrument (COGTEL), Mental Health Continuum-Short Form (MHC-SF), and the Geriatric Depression Scale (GDS). Results were obtained in n = 51 patients. CSDH patients were assessed at 5.5 + 2.1 years after CSDH and results were compared to age/gender matched controls (n = 52). Comorbidities were significantly greater in CSDH patients at the time of assessment (χ2 = 35.47, P < .01). CSDH patients demonstrated a significant reduction in functional independence (FAQ, P < .001) and Verbal Short-Term Memory (COGTEL, P = .048). Potential negative trends were observed for Verbal Long-Term Memory (P = .06) and Inductive Reasoning (P = .07). CSDH patients also demonstrated significantly poorer emotional, psychological and social well-being (MHC-SF: Emotional, P = .003; Psychological, P = .001; and Social, P < .001), with increased depressive symptomatology (GDS, P < .001). In addition to known decreased long-term survival, CSDH survivors demonstrated poorer long-term functional, cognitive and mental health outcomes than controls. Pre-existent comorbidities were also more prevalent. CSDH is therefore a sentinel health event: survivors represent a vulnerable group who require long-term, comprehensive, person-centred care. This is the first study of long term CSDH health outcomes.

Cognitive and affective predictors of smoking after a sentinel health event

Objective: This study examined how smoking-related causal attributions, perceived illness severity, and event-related emotions relate to both intentions to quit and subsequent smoking behavior after an acute medical problem (sentinel event). Methods: Three hundred and seventy-five patients were enrolled from 10 emergency departments (EDs) across the USA and followed for six months. Two saturated, manifest structural equation models were performed: one predicting quit attempts and the other predicting seven-day point prevalence abstinence at 14 days, three months, and six months after the index ED visit. Stage of change was regressed onto each of the other predictor variables (causal attribution, perceived illness severity, event-related emotions) and covariates, and tobacco cessation outcomes were regressed on all of the predictor variables and covariates. Results: Non-White race, baseline stage of change, and an interaction between causal attribution and event-related fear were the strongest predictors of quit attempt. In contrast, abstinence at six months was most strongly predicted by baseline stage of change and nicotine dependence. Conclusion: Predictors of smoking behavior after an acute medical illness are complex and dynamic. The relations vary depending on the outcome examined (quit attempts vs. abstinence), differ based on the time that has progressed since the event, and include significant interactions.

PB10 Safe Elderly Emergency Discharge (SEED) project: determining best practice for safe discharge of the older emergency patient

Background and ObjectivesIncreasing numbers of older patients presenting for emergency hospital care is a major worldwide concern. The fastest growth is in people aged ≥65 years representing 18% of all...

2,4,6-Trinitrotoluene (TNT) air concentrations, hemoglobin changes, and anemia cases in respirator protected TNT munitions demilitarization workers

2,4,6-Trinitrotoluene (TNT) is an explosive used in munitions production that is known to cause both aplastic and hemolytic anemia in exposed workers. Anemia in a TNT worker is considered a sentinel health event (occupational) (SHE(O)) in the United States (US). Deaths have been reported secondary to aplastic anemia. Studies have shown that TNT systemic absorption is significant by both the respiratory and dermal routes. No studies encountered looked at hemoglobin change or anemia cases in respiratory protected workers. It is hypothesized that respiratory protection is insufficient to protect TNT workers from the risk of anemia development and hemoglobin concentration drop. A records review of eight groups of respiratory protected TNT workers' pre-exposure hemoglobin levels were compared with their during-exposure hemoglobin levels for statistically significant (alpha level 0.05) hemoglobin level changes, and anemia cases were recorded. A curve estimation analysis was performed between mean TNT air concentrations and mean hemoglobin change values. Statistically significant hemoglobin level drops and anemia cases were apparent at TNT air concentrations about the REL and PEL in respiratory protected workers. There were no anemia cases or statistically significant hemoglobin level drops at concentrations about the TLV, however. A statistically significant inverse non-linear regression model was found to be the best fit for regressing hemoglobin change on TNT air concentration. Respiratory protection may be inadequate to prevent workers who are at risk for TNT skin absorption from developing anemia. This study contributes evidence that the TLV should be considered for adoption as the new PEL.

Update on successes and challenges regarding mother-to-child transmission of HIV

There is an unprecedented global commitment to reverse the pediatric HIV epidemic by making prevention of mother-to-child transmission (PMTCT) services accessible in all countries. This review outlines the successes made and the challenges that remain. In resource-rich countries, mother-to-child transmission rates of HIV as low as 1% have been achieved. The efficacy of short-course antiretrovirals for PMTCT in Africa is estimated at 50%. Coinfections with herpes simplex virus type 2, other sexually transmitted infections resulting in genital ulcers, and endemic infectious diseases (e.g., malaria) may increase the risk of mother-to-child transmission of HIV. Vertical transmission of drug-resistant viruses has been reported; the prevalence and effect of transmitted resistant virus on treatment outcomes are under investigation. Obstacles facing PMTCT in resource-limited countries include the lack of healthcare infrastructure, limited manpower, and competing public health priorities with the limited healthcare budget. Although the birth of an HIV-infected child in a resource-rich country is now a sentinel health event, in most resource-limited countries the birth of an HIV-infected child continues to be the status quo. Comprehensive PMTCT, including antiretroviral treatment for HIV-infected women and children, should be paramount in resource-limited countries.

Changes in smoking associated with an acute health event: Theoretical and practical implications

Experiencing a serious adverse behavior-related consequence may motivate behavior change. To examine how a sentinel health event is associated with changes in smoking. We used a prospective cohort design. Adult emergency department (ED) patients provided demographic data, a smoking history, ratings of quit intentions, and endorsement of self-identified smoking-related health problems. A chart review collected data on acuity, ED disposition, and medical diagnoses. Smoking was reassessed 1 month postvisit. Hierarchical regression analyses were conducted to predict (a) intention to quit, (b) any quit attempt of 24 hr or more, and (3) 7-day abstinence. Of 717 smokers enrolled, 189 (26%) intended to quit within the next month. Of the 253 participants reached 1 month postvisit, 126 (50%) reported they had attempted to quit, with 44 (19%) reporting 7-day abstinence. After controlling for other predictors, several event-related variables, such as having a smoking-related ED visit and being admitted to the hospital, were strong predictors of outcomes. Compared to community-based estimates, many more smokers in our sample attempted to quit and achieved 7-day abstinence. This was especially true among smokers who attributed their ED visit to a smoking-related health problem and who were admitted to the hospital. We discuss the implications for tobacco intervention design in medical settings.

Spatial and space-time scan statistics to detect low rate clusters of sex ratio

Whether general environmental exposures to endocrine disrupting chemicals (including pesticides and dioxin) might induce decreased sex ratios (male/female ratio at birth) is discussed. To address this issue, the authors looked for a space-time clustering test which could detect local areas of significantly low risk, assuming a Bernoulli distribution. As a matter of fact, if the endocrine disruptor hypothesis holds true, and if the sex ratio is a sentinel health event indicative of new reproductive hazards ascribed to environmental factors, then in a given region, either a cluster of low male/female ratio among newborn babies would be expected in the vicinity of polluting municipal solid waste incinerators (MSWIs) (supporting the dioxin hypothesis), or local clusters would be expected in some rural areas where large amounts of pesticides are sprayed.

Hypersensitivity Pneumonitis Associated with Environmental Mycobacteria

A previously healthy man working as a machine operator in an automotive factory developed respiratory symptoms. Medical evaluation showed abnormal pulmonary function tests, a lung biopsy showed hypersensitivity pneumonitis, and his illness was traced to his work environment. His physician asked the employer to remove him from exposure to metalworking fluids. Symptoms reoccurred when he was later reexposed to metalworking fluids, and further permanent decrement in his lung function occurred. Investigation of his workplace showed that five of six large reservoirs of metalworking fluids (cutting oils) grew Mycobacterium chelonae (or Mycobacterium immunogenum), an organism previously associated with outbreaks of hypersensitivity pneumonitis in automaking factories. His lung function remained stable after complete removal from exposure. The employer, metalworking fluid supplier, union, and the National Institute for Occupational Safety and Health were notified of this sentinel health event. No further cases have been documented in this workplace.

Asthma clinical pathways: toward what end?

Clinical pathways are increasingly guiding the care of hospitalized patients. A clinical, or critical, pathway is an operational version of a clinical guideline that designates the timing and sequence of desired care.1 Clinical pathways are typically developed for inpatient diagnoses for which care is relatively predictable and depends on multidisciplinary inputs. Clinical pathways may pursue several goals: reduction of unintended variation in care delivery, improved patient education, reduction in resource utilization, and improvement in the quality of care.1 A particular clinical pathway may emphasize some or all of these goals. Only limited evidence supports the efficacy of clinical pathways in achieving these goals despite their growing adoption by hospitals. Because asthma is a major cause of hospitalization in children, clinical pathways have been developed to guide inpatient management. A growing published literature examines these asthma clinical pathways. The focus of these studies indicates that asthma clinical pathways are being developed primarily to reduce costs rather than improve care and outcomes. We believe this represents an important missed opportunity. A pediatric asthma hospitalization is a sentinel health event in a child's life that both flags unmet chronic illness needs and provides a teachable moment to address these needs. Kwan-Gett et al2 evaluated the impact of an asthma clinical pathway in a academic children's hospital. The pathway included the recommendation to “continue or add maintenance anti-inflammatory medication.”2 Yet the only clinical outcomes reported were the use of systemic steroids, which was near universal in the preintervention and postintervention groups, and the provision of peak flow meters.2 Readmission beyond 2 weeks postdischarge or the percentage of children prescribed a controller medication on discharge also were not evaluated. The pathway did not reduce length of stay or cost.2 Johnson et al3 conducted a randomized trial of an …

Reduced ratio of male to female births in several industrial countries: a sentinel health indicator?

The sex ratio of 1.06:1, the ratio of male to female births, has declined over the past decades. Recent reports from a number of industrialized countries indicate that the proportion of males born has significantly decreased, while some male reproductive tract disorders have increased. To examine the evidence for declines in the male proportion at birth and suspected causes for this decline, and to determine whether altered sex ratio can be considered a sentinel health event. Birth records were analyzed from national statistical agencies. Published analyses of trends in ratio of males to females at birth and studies of sex determinants evaluating epidemiological and endocrinological factors. Proportion of males born: 1950-1994 in Denmark; 1950-1994 in the Netherlands; 1970-1990 in Canada; and 1970-1990 in the United States. Since 1950, significant declines in the proportion of males born have been reported in Denmark and the Netherlands. Similar declines have been reported for Canada and the United States since 1970 and parallel declines also have occurred in Sweden, Germany, Norway, and Finland. In Denmark, the proportion of males declined from 0.515 in 1950 to 0.513 in 1994. In the Netherlands, the proportion of males declined from 0.516 in 1950 to 0.513 in 1994. Similar declines in the proportion of males born in Canada and the United States are equivalent to a shift from male to female births of 8600 and 38000 births, respectively. Known and hypothesized risk factors for reduced sex ratio at birth cannot fully account for recent trends. Patterns of reduced sex ratio need to be carefully assessed to determine whether they are occurring more generally, whether temporal or spatial variations are evident, and whether they constitute a sentinel health event.

The Union Health Center: A working model of clinical care linked to preventive occupational health services

As health care provision in the United States shifts to primary care settings, it is vital that new models of occupational health services be developed that link clinical care to prevention. The model program described in this paper was developed at the Union Health Center (UHC), a comprehensive health care center supported by the International Ladies Garment Workers Union (now the Union of Needletrades, Industrial and Textile Employees) serving a population of approximately 50,000 primarily minority, female garment workers in New York City. The objective of this paper is to describe a model occupational medicine program in a union-based comprehensive health center linking accessible clinical care with primary and secondary disease prevention efforts. To assess the presence of symptoms suggestive of occupational disease, a health status questionnaire was administered to female workers attending the UHC for routine health maintenance. Based on the results of this survey, an occupational medicine clinic was developed that integrated direct clinical care with worker and employer education and workplace hazard abatement. To assess the success of this new approach, selected cases of sentinel health events were tracked and a chart review was conducted after 3 years of clinic operation. Prior to initiation of the occupational medicine clinic, 64% (648) of the workers surveyed reported symptoms indicative of occupational illnesses. However, only 42 (4%) reported having been told by a physician that they had an occupational illness and only 4 (.4%) reported having field a workers' compensation claim for an occupational disease. In the occupational medicine clinic established at the UHC, a health and safety specialist acts as a case manager, coordinating worker and employer education as well as workplace hazard abatement focused on disease prevention, ensuring that every case of occupational disease is treated as a potential sentinel health event. As examples of the success of this approach, index cases of rotator cuff tendonitis, lead poisoning, and formaldehyde overexposure in three patients and their preventative workplace follow-up, affecting approximately 150 workers at three worksites, are described. Work-related conditions diagnosed during the first 3 years of clinic operation included cumulative trauma disorders (141 cases), carpal tunnel syndrome (47 cases), low back disorders (33 cases), lead poisoning (20 cases), and respiratory disease (9 cases). This pilot project represents a new model for effective integration of clinical care and occupational disease prevention efforts within a primary care center. It could serve as a prototype for development of such services in other managed and primary care settings.

The Union Health Center: A working model of clinical care linked to preventive occupational health services

As health care provision in the United States shifts to primary care settings, it is vital that new models of occupational health services be developed that link clinical care to prevention. The model program described in this paper was developed at the Union Health Center (UHC), a comprehensive health care center supported by the International Ladies Garment Workers Union (now the Union of Needletrades, Industrial and Textile Employees) serving a population of approximately 50,000 primarily minority, female garment workers in New York City. The objective of this paper is to describe a model occupational medicine program in a union-based comprehensive health center linking accessible clinical care with primary and secondary disease prevention efforts. To assess the presence of symptoms suggestive of occupational disease, a health status questionnaire was administered to female workers attending the UHC for routine health maintenance. Based on the results of this survey, an occupational medicine clinic was developed that integrated direct clinical care with worker and employer education and workplace hazard abatement. To assess the success of this new approach, selected cases of sentinel health events were tracked and a chart review was conducted after 3 years of clinic operation. Prior to initiation of the occupational medicine clinic, 64% (648) of the workers surveyed reported symptoms indicative of occupational illnesses. However, only 42 (4%) reported having been told by a physician that they had an occupational illness and only 4 (.4%) reported having filed a workers' compensation claim for an occupational disease. In the occupational medicine clinic established at the UHC, a health and safety specialist acts as a case manager, coordinating worker and employer education as well as workplace hazard abatement focused on disease prevention, ensuring that every case of occupational disease is treated as a potential sentinel health event. As examples of the success of this approach, index cases of rotator cuff tendonitis, lead poisoning, and formaldehyde overexposure in three patients and their preventative workplace follow-up, affecting approximately 150 workers at three worksites, are described. Work-related conditions diagnosed during the first 3 years of clinic operation included cumulative trauma disorders (141 cases), carpal tunnel syndrome (47 cases), low back disorders (33 cases), lead poisoning (20 cases), and respiratory disease (9 cases). This pilot project represents a new model for effective integration of clinical care and occupational disease prevention efforts within a primary care center. It could serve as a prototype for development of such services in other managed and primary care settings. Am. J. Ind. Med. 31:263–273, 1997. © 1997 Wiley-Liss, Inc.

Los registros de mortalidad como fuente para, la detección de alteraciones de salud de, probable etiología laboral

Study aim was to assess Andalucian death certificate records to find potential occupational disease problems. Methodology proposed by Rutstein (1983) has been adapted. We had checked Seville City Council Mortality Registry (1987-89) and Andalucian Mortality Registry (1975-85). In the former 8.1% of diagnoses and in the latter 8.6% of diagnoses have one included in the Sentinel Health Event (occupational) List. Accurate occupation data in the Seville City Council Mortality provides appropRiate information about occupational diseases. Limitations of the occupational data in the Andalucian Mortality Registries make it impossible to find the majority of potential occupational diseases, and occupation data were even worse during the second period of study (1980-85).

Pesticide poisoning surveillance through regional poison control centers.

The purpose of this study is to describe pesticide exposure in the population of callers to Minnesota Regional Poison Centers. Case files from 1988 reporting pesticide exposure to humans were identified in cooperation with the Minnesota Center for Health Statistics. Data analysis was conducted by computer using SAS statistical package. Of the 1,428 case files indicating pesticide as the primary substance of exposure to Minnesota residents, a mean age of 5 years (range, one month to 85 years) was identified; 50 percent of all cases were below age 3 years. Males accounted for 1.3 times as many cases as females. Insecticide was identified in the largest percentage of case files (74 percent) followed by herbicide (12 percent), rodenticide (11 percent) and fungicide-nonmedicinal (3 percent). Ingestion was the most common route of exposure; 85 percent of all calls originated from a residence. While insecticides are still the most common types of pesticide call, herbicide has surpassed insecticide in production and sales in the US. In this study, herbicide type exposure calls present a much different picture than other pesticide types. The usefulness of poison control centers for examination of pesticide poisoning is explored. Since reporting occurs coincidental with the exposure and its associated symptoms, each pesticide poisoning report could potentially serve as a true sentinel health event.

Occupational sentinel health events: An up‐dated list for physician recognition and public health surveillance

An occupational sentinel health event (SHE[O]) is a disease, disability, or untimely death, which is occupationally related and whose occurrence may: 1) provide the impetus for epidemiologic or industrial hygiene studies; or 2) serve as a warning signal that materials substitution, engineering control, personal protection, or medical care may be required. Following survey of scientific literature, a list of 50 disease conditions linked to the workplace was presented in 1983; these were codable within the framework of the International Classification of Diseases system (ICD-9). Three criteria were used for inclusion: documentation of associated agent(s), of involved industries, and of involved occupations. The up-dated list contains 64 diseases or conditions and a bibliography of literature citations. The list is useful for the practicing physician in occupational disease recognition, for occupational morbidity and mortality surveillance, and as a periodically up-dated database of occupationally related diseases.

Fatal Occupational Electrical Injuries in Virginia

Work-related electrical injuries and fatalities in Virginia were reviewed for the period 1977 to 1985. Of 196 workers electrocuted (0.9/100,000/year), 65% (127) died between May and September. Death rates were highest for male workers in utility companies (10.0/100,000), mining (5.9/100,000), and construction industries (3.9/100,000), but these high risk groups accounted for only 50% of the deaths. Most accidental electrocutions resulted from power line contact (53%) and machine or tool usage or repair (22%). Only 1.5% (2/101) of the workers who died within 6 hours of injury and had blood alcohol concentration tested were legally intoxicated. All workers need safety education on active measures to prevent hazardous electrical exposures, not just those at high risk for electrical injury. Every work-related electrical injury represents a sentinel health event--an opportunity for preventive intervention in the workplace.

Sentinel health event surveillance: skin cancer of the scrotum in New York State.

Skin cancer of the scrotum is a disease that has been identified as a sentinel health event (occupational) (SHE(O] that is necessarily occupationally related. The present paper examines the feasibility of using this disease in active cancer surveillance in New York State. After consulting cancer case reports, hospital records, death certificates, and city directories, we obtained occupational data for 17 of 22 cases of nonmelanoma skin cancer of the scrotum diagnosed between 1979 and 1984. Only three cases had occupations previously linked to scrotal cancer, while 11 of 19 cases had one or more possibly contributory medical conditions. The probable under-reporting of scrotal cancer cases and incompleteness of occupational data may limit the usefulness of scrotal cancer as a sentinel health event (occupational) unless additional steps are taken.

Geographic distribution of deaths due to sentinel health event (occupational) causes.

This report describes the Compressed Mortality File available from the National Center for Health Statistics that can be used to easily and efficiently generate annual mortality rates for geographic areas as small as counties for any period from 1968 to 1985. Several ways of presenting geographic variation in mortality rates due to potentially work-related deaths and changes in these rates over time are discussed for the 15-year period from 1969 through 1983. Causes of death that are potentially work-related were identified using the sentinel health events (occupational) [SHE(O)] concept. Data are given for nine diagnostic groups of occupationally related disorders, and maps are presented for bladder cancer, acute myeloid leukemia, and pneumoconioses. Significant changes in age-adjusted mortality rates were noted for pneumoconioses and acute myeloid leukemia that could not be due to changes in the disease coding of death certificates. Racial differences in mortality rates due to pneumoconioses may be due to differences in employment patterns. The use of SHE(O) codes to search the Compressed Mortality File may be helpful in identifying areas for public health concern, even if only as a monitoring signal for subsequent time periods. This file also provides an easy way to generate reference population mortality rates for epidemiologic studies.