Washington State Death Research Articles

Overdose and substance-related mortality after release from prison in Washington State: 2014–2019

BackgroundPersons released from prison are at an increased risk of mortality compared to the non-incarcerated population, particularly from drug- and opioid-related overdose. Contributors to overdose mortality vary with changing patterns of substance use and updating overdose and mortality statistics may help focus resources for persons released from prison. MethodsIn this retrospective cohort study, records for 33,811 people released from Washington State Department of Corrections prisons between 2014 and 2018 were linked to Washington State death records from 2014 to 2019. We calculated post-release mortality rates by cause of death, including overdose and substance-related mortality. Hazard ratios for risk factors for all-cause, non-overdose, and overdose mortality were estimated using Cox proportional hazards regression. Results862 deaths were identified among persons released from prison. The all-cause mortality rate was 747 per 100,000 person-years (95 % CI: 699–800), and drug overdose was the leading cause of death (216 per 100,000 person-years; 95 % CI: 190–244). Psychostimulant-related mortality (152 per 100,000 person-years; 95 % CI: 131–177) and opioid-related mortality (138 per 100,000 person-years; 95 % CI: 118–161) were the most prevalent among substance-related causes of death, with the greatest mortality risk occurring within two weeks after release. Older age at most recent release, previous incarceration, and drug-related convictions were significant risk factors for all-cause and overdose mortality within six years after release. ConclusionsPsychostimulants were the greatest contributors to substance-related mortality for persons released from Washington State prisons. Greater efforts to prevent psychostimulant- and opioid-related overdose are needed.

Correlates of 90-Day Mortality Among People Who Do and Do Not Inject Drugs With Infective Endocarditis in Seattle, Washington

BackgroundInfective endocarditis (IE) remains highly morbid, but few studies have evaluated factors associated with IE mortality. We examined correlates of 90-day mortality among people who inject drugs (PWID) and people who do not inject drugs (non-PWID).MethodsWe queried the electronic medical record for cases of IE among adults ≥18 years of age at 2 academic medical centers in Seattle, Washington, from 1 January 2014 to 31 July 2019. Cases were reviewed to confirm a diagnosis of IE and drug use status. Deaths were confirmed through the Washington State death index. Descriptive statistics were used to characterize IE in PWID and non-PWID. Kaplan-Meier log-rank tests and Cox proportional hazard models were used to assess correlates of 90-day mortality.ResultsWe identified 507 patients with IE, 213 (42%) of whom were PWID. Sixteen percent of patients died within 90 days of admission, including 14% of PWID and 17% of non-PWID (P = .50). In a multivariable Cox proportional hazard model, injection drug use was associated with a higher mortality within the first 14 days of admission (adjusted hazard ratio [aHR], 2.33 [95% confidence interval {CI}, 1.16–4.65], P = .02); however, there was no association between injection drug use and mortality between 15 and 90 days of admission (aHR, 0.63 [95% CI, .31–1.30], P = .21).ConclusionsOverall 90-day mortality did not differ between PWID and non-PWID with IE, although PWID experienced a higher risk of death within 14 days of admission. These findings suggest that early IE diagnosis and treatment among PWID is critical to improving outcomes.

702. Characteristics of Infective Endocarditis (IE) and Predictors of 90-day Mortality Among People Who Do and Do Not Inject Drugs with IE in Seattle, Washington

BackgroundPeople who inject drugs (PWID) are at high risk for IE and account for a growing proportion of IE cases in the United States. We describe key characteristics of IE and predictors of 90-day mortality among people who do and do not inject drug at two large academic medical centers.MethodsWe used a string-searching and pattern-matching algorithm within all discharge (DC) summaries to query the electronic medical record (EMR) for cases of IE among adults ≥18 years of age at two academic medical centers in Seattle, Washington from December 1, 2013 to July 31, 2019. All cases were chart reviewed by a member of the study team to confirm a clinical diagnosis of IE and verify housing and PWID status, the latter defined as any injection drug use in the 3 months prior to admission. Microbiology and valve involvement were extracted from DC summaries and chart-reviewed where needed. Deaths were obtained from Washington state death index, which links to our EMR. Descriptive statistics were used to compare PWID and non-PWID with IE, and Kaplan-Meier log rank tests and Cox proportional hazard models were used to assess for predictors of 90-day mortality.ResultsWe identified 387 patients with IE, 44% (n=166) of whom were PWID. When compared to non-PWID, PWID were younger (median age 33 vs. 55 years, p< 0.001) and more likely to be female (48% vs. 31%, p=0.001), homeless (41% vs. 9%, p< 0.001), have coagulase-positive Staphylococcal IE (69% vs. 32%, p< 0.001), and have right sided IE (66% vs. 26%, p< 0.001). Seventeen percent (n=64) of patients died within 90 days of admission, including 14% (n=23) of PWID and 19% (n=41) of non-PWID, with no difference in 90-day mortality between these groups (log-rank p=0.3). In univariate analyses, having left sided IE was the only predictor of 90-day mortality (HR 4.79, 95% CI 2.18 – 10.5).ConclusionDespite PWID being significantly younger and having a much higher frequency of right sided IE, they had similar 90-day mortality to non-PWID in this contemporary, urban cohort of hospitalized IE patients.Table 1. Demographic Characteristics of People Who Do and Do Not Inject Drugs with Infective Endocarditis at Two Seattle Hospitals, 2014 – 2019 Disclosures All Authors: No reported disclosures

Type of Intensive Care Unit Matters: Variations in Palliative Care for Critically Ill Patients with Chronic, Life-Limiting Illness.

Background: It is not clear whether use of specialty palliative care consults and "comfort measures only" (CMO) order sets differ by type of intensive care unit (ICU). A better understanding of palliative care provided to these patients may help address heterogeneity of care across ICU types. Objectives: Examine utilization of specialty palliative care consultation and CMO order sets across several different ICU types in a multihospital academic health care system. Design: Retrospective cohort study using Washington State death certificates and data from the electronic health record. Setting/Subjects: Adults with a chronic medical illness who died in an ICU at one of two hospitals from July 2013 through December 2018. Five ICU types were identified by patient population and attending physician specialty. Measurements: Documentation of a specialty palliative care consult during a patient's terminal ICU stay and a CMO order set at time of death. Results: For 2706 eligible decedents, ICU type was significantly associated with odds of palliative care consultation (p < 0.001) as well as presence of CMO order set at time of death (p < 0.001). Compared with medical ICUs, odds of palliative care consultation were highest in the cardiothoracic ICU and trauma ICU. Odds of CMO order set in place at time of death were highest in the neurology/neurosurgical ICU. Conclusion: Utilization of specialty palliative care consultations and CMO order sets varies across types of ICUs. Examining this variability within institutions may provide an opportunity to improve end-of-life care for patients with chronic, life-limiting illnesses who die in the ICU.

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

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

Novel Data Linkages to Characterize Palliative and End-Of-Life Care: Challenges and Considerations

ContextWorking groups have called for linkages of existing and diverse databases to improve quality measurement in palliative and end-of-life (EOL) care, but limited data are available on the challenges of using different data sources to measure such care. ObjectivesTo assess concordance of data obtained from different sources in a novel linkage of death certificates, electronic health records (EHRs), cancer registry data, and insurance claims for patients who died with cancer. MethodsWe joined a database of Washington State death certificates and EHR to a data repository of commercial health plan enrollment and claims files linked to registry records from Puget Sound Cancer Surveillance System. We assessed care in the last month including hospitalizations, intensive care unit (ICU) admissions, emergency department visits, imaging scans, radiation, and hospice, plus chemotherapy in the last 14 days. We used a Chi-squared test to compare differences between health care in EHR and claims. ResultsRecords of hospitalization, ICU use, and emergency department use were 33%, 15%, and 33% lower in EHR versus claims, respectively. Radiation, hospice, and imaging were 6%, 14%, and 28% lower, respectively, in EHR, but chemotherapy was 4% higher than that in claims. These differences were statistically different for hospice (P < 0.02), hospitalization, ICU, ER, and imaging (all P < 0.01) but not radiation (P = 0.12) or chemotherapy (P = 0.29). ConclusionWe found substantial variation between EHR and claims for EOL health-care use. Reliance on EHR will miss some health-care use, while claims will not capture the complex clinical details in EHR that can help define the quality of palliative care and EOL health-care utilization.

The Influence of Multimorbidity on Health Care Utilization at the End of Life for Patients with Chronic Conditions.

Objective: To evaluate the association between the number of chronic conditions and hospital utilization at the end of life. Background: An understanding of the association of multimorbidity with health care utilization at the end of life may inform interventions to improve quality of care for these patients. Methods: A mortality follow-back analysis using Washington State death records and electronic health records. Subject included patients in the UW Medicine system who had at least one chronic condition and died between 2010 and 2015. Utilization was measured by inpatient admissions, emergency department use, and intensive care unit (ICU) admissions in the last 30 days of life. Results: For all utilization types, patients with three or more chronic conditions (n = 5124) had significantly higher utilization (p < 0.001) in the last 30 days of life than those with two (n = 5775) or one condition (n = 11,169). Comparing 3 versus 2 versus 1 conditions, the following percentages of patients had each type of utilization: inpatient admissions (37% vs. 28% vs. 19%), ED admissions (5% vs. 4% vs. 2%), and ICU care (28% vs. 20% vs. 12%). Discussion: Multimorbidity was associated with greater health care utilization at the end of life among patients representing a range of ages and covered by diverse insurers.

Duration of Respiratory Failure After Trauma Is Not Associated With Increased Long-Term Mortality.

Although 1-year survival in medically critically ill patients with prolonged mechanical ventilation is less than 50%, the relationship between respiratory failure after trauma and 1-year mortality is unknown. We hypothesize that respiratory failure duration in trauma patients is associated with decreased 1-year survival. Retrospective cohort of trauma patients. Single center, level 1 trauma center. Trauma patients admitted from 2011 to 2014; respiratory failure is defined as mechanical ventilation greater than or equal to 48 hours, excluded head Abbreviated Injury Score greater than or equal to 4. None. Mortality was calculated from the Washington state death registry. Cohort was divided into short (≤ 14 d) and long (> 14 d) ventilation groups. We compared survival with a Cox proportional hazard model and generated a receiver operator characteristic to describe the respiratory failure and mortality relationship. Data are presented as medians with interquartile ranges and hazard ratios with 95% CIs. We identified 1,503 patients with respiratory failure; median age was 51 years (33-65 yr) and Injury Severity Score was 19 (11-29). Median respiratory failure duration was 3 days (2-6 d) with 10% of patients in the long respiratory failure group. Cohort mortality at 1 year was 16%, and there was no difference in mortality between short and long duration of respiratory failure. Predictions for 1-year mortality based on respiratory failure duration demonstrated an area under the receiver operator characteristic curve of 0.57. We determined that respiratory failure patients greater than or equal to 75 years had an increased hazard of death at 1 year, hazard ratio, 6.7 (4.9-9.1), but that within age cohorts, respiratory failure duration did not influence 1-year mortality. Duration of mechanical ventilation in the critically injured is not associated with 1-year mortality. Duration of ventilation following injury should not be used to predict long-term survival.

Use of Death Certificates to Identify Tuberculosis-Related Deaths in Washington State

Death certificates are routinely used to estimate tuberculosis (TB) mortality rates. The validity of International Classification of Diseases, Tenth Revision (ICD-10) codes and text cause of death data for this purpose is uncertain. To evaluate the accuracy of ICD-10 coded and text cause of death data in identifying TB-related deaths in Washington State. Cross-sectional descriptive study comparing TB-related deaths detected through Washington State death certificates to TB-related deaths identified in the Washington State TB registry during 2009-2010. Sensitivity and positive predictive value of ICD-10 coded and text cause of death definitions in identifying TB-related deaths compared to the TB registry. All methods for identifying TB-related deaths using death certificate data overestimated the number of TB-related deaths compared to the tuberculosis registry. The positive predictive value ranged from 22% for a TB ICD-10 code as an underlying or multiple cause of death to 56% for TB listed in the direct cause of death text field. Seventeen (33%) of 51 subjects assigned with a TB ICD-10 code as an underlying or multiple cause of death had no evidence of TB on the death certificate and were not present in the TB registry. Death certificates were not highly predictive of TB-related deaths. Use of the direct cause of death text field was the most accurate method to identify a TB-related death when using death certificates. Specific ICD-10 coding algorithms may misclassify subjects as having died from TB.

Death with dignity in Washington patients with amyotrophic lateral sclerosis.

To describe the amyotrophic lateral sclerosis (ALS) patients who sought medication under the Washington State Death with Dignity (DWD) Act since its inception in 2009. Chart review at 3 tertiary medical centers in the Seattle/Puget Sound region and comparison to publicly available data of ALS and all-cause DWD cohorts from Washington and Oregon. In Washington State, 39 patients with ALS requested DWD from the University of Washington, Virginia Mason, and Swedish Medical Centers beginning in 2009. The median age at death was 65 years (range 46-86). Seventy-seven percent of the patients used the prescriptions. All of the patients who used the medications passed away without complications. The major reasons for patients to request DWD as reported by participating physicians were loss of autonomy and dignity and decrease in enjoyable activities. Inadequate pain control, financial cost, and loss of bodily control were less commonly indicated. These findings were similar to those of the 92 patients who sought DWD in Oregon. In Washington and Oregon, the percentage of patients with ALS seeking DWD is higher compared to the cancer DWD cohort. Furthermore, compared to the all-cause DWD cohort, patients with ALS are more likely to be non-Hispanic white, married, educated, enrolled in hospice, and to have died at home. Although a small number, ALS represents the disease with the highest proportion of patients seeking to participate in DWD. Patients with ALS who choose DWD are well-educated and have access to palliative or life-prolonging care. The use of the medications appears to be able to achieve the patients' goals without complications.

The Risk of Cancer With the Use of Recombinant Human Bone Morphogenetic Protein in Spine Fusion.

Retrospective cohort study using the Washington State Comprehensive Hospital Abstract Reporting System, the Washington State Cancer Registry, and Washington State death certificates. To study the possible association between recombinant human bone morphogenetic protein (rhBMP) and cancer risk. The use of rhBMP in spine fusion surgery remains controversial with respect to its possible role in tumorigenesis. We compared adults who underwent spine fusion for degenerative disease with and without rhBMP between 2002 and 2010. Patients were matched on the basis of age, sex, and year of treatment. We excluded patients with a diagnosis of cancer before or at the index procedure. The primary outcome was the first diagnosis of cancer as identified in the records of the cancer registry. We included 16,914 patients who had spine fusion, of whom 4246 received rhBMP. During the study period, 449 patients received a diagnosis of cancer: 117 (2.76% of 4246) in the rhBMP group and 332 (2.62% of 12 668) in the no rhBMP group. The incidence rate was similar between the rhBMP and no rhBMP 9.5 and 9.0 per 1000 person years, respectively (hazard ratio, 1.06; 95% confidence interval, 0.86-1.30). There were no differences in the rate of cancer between the two groups in subgroups defined on the basis of site of fusion or surgical method. There was no increase in overall cancer incidence among those receiving rhBMP. An important limitation of this and other studies of rhBMP and cancer that have been conducted to date is their relatively limited duration of follow-up. The examination of cancer incidence following rhBMP administration must continue beyond just the first several years to adequately assess the potential of rhBMP to influence the occurrence of one or more types of malignancy. 3.

Mortality outcomes associated with intake of fast-food items and sugar-sweetened drinks among older adults in the Vitamins and Lifestyle (VITAL) study.

To evaluate associations of fast-food items (FFI) and sugar-sweetened drinks (SSD) with mortality outcomes including deaths due to any cause, CVD and total cancers among a large sample of adults. Using a prospective design, risk of death was compared across baseline dietary exposures. Intakes of FFI and SSD were quantified using a semi-quantitative FFQ (baseline data collected 2000-2002). Deaths (n 4187) were obtained via the Washington State death file through 2008, excluding deaths in the first year of follow-up. Causes of death were categorized as due to CVD (I00-I99) or cancer (C00-D48). Cox models were used to estimated hazard ratios (HR) and 95 % CI. The Vitamins and Lifestyle (VITAL) study among adults living in Western Washington State. Men and women (n 69 582) between 50 and 76 years of age at baseline. Intakes of FFI and SSD were higher among individuals who were younger, female, African-American, American Indian or Alaska Native, Asian-American or Pacific Islander, of lower educational attainment, and of lower income (P<0·0001 for all). Higher risk of total mortality was associated with greater intake of FFI (HR=1·16; 95 % CI 1·04, 1·29; P=0·004; comparing highest v. lowest quartile) and SSD (HR=1·19; 95 % CI 1·08, 1·30; P<0·0001; comparing highest v. lowest quartile). Higher intake of FFI was associated with greater cancer-specific mortality while an association with CVD-specific mortality was suggested. Associations between intake of SSD and cause-specific mortality were less clear. Intake of FFI and SSD has a detrimental effect on future mortality risk. These findings may be salient to socially patterned disparities in mortality.

Long-term neurologic outcomes following paediatric out-of-hospital cardiac arrest

AimEvaluate long-term neurologic outcome for paediatric survivors of OHCA. MethodsSubjects <19 years who experienced OHCA from 1976–2007 and survived to hospital discharge were included. Demographics, neurologic outcomes and years of survival were determined using the King County Emergency Medical Service cardiac arrest database, Seattle Children's Hospital medical records, Washington State Death Database and National Death Index. A Paediatric Cerebral Performance Category (PCPC) score (1–6) was determined for the index hospitalization discharge and all subsequent visits. ResultsFrom 1976–2007, 1683 cases of OHCA resulted in 91 survivors to hospital discharge. 18/91 survivors identified had pre-morbid conditions. 72/91 survivors had follow-up PCPC scores. Patients were: ≤5 years (53%) and 54% female. 33/35 patients with initial favorable neurologic outcomes (PCPC 1–2) maintained favorable neurologic status in long-term follow-up. 14/37 patients with initial unfavorable neurologic outcomes (PCPC 3–5) remained unfavorable over long-term follow-up. Six unfavorable patients showed some improvement, three of whom achieved favorable PCPC scores at last evaluation. One unfavorable patient declined from PCPC 4 to PCPC 5. Twenty patients with an initial unfavorable neurologic outcome died in long-term follow-up. ConclusionsIn this cohort study of neurologic outcomes for paediatric OHCA survivors, a favorable initial PCPC score was highly associated with stable long-term neurological outcomes. Those with poor neurologic status at initial discharge were unlikely to improve and were at greatest risk to die in follow-up. Future studies should focus on improving neurologic outcomes and prospectively evaluating the long-term neurologic course.

Long-term survival in patients with severe acute respiratory distress syndrome and rescue therapies for refractory hypoxemia*.

To describe long-term survival in patients with severe acute respiratory distress syndrome and assess differences in patient characteristics and outcomes among those who receive rescue therapies (prone position ventilation, inhaled nitric oxide, or inhaled epoprostenol) versus conventional treatment. Cohort study of patients with severe hypoxemia. University-affiliated level 1 trauma center. Patients diagnosed with severe acute respiratory distress syndrome within 72 hours of ICU admission between January 1, 2008, and December 31, 2011. None. Data were abstracted from the medical record and included demographic and clinical variables, hospital and ICU length of stay, discharge disposition, and hospital costs. Patient-level data were linked to the Washington State Death Registry. Kaplan-Meier methods and Cox's proportional hazards models were used to estimate survival and hazard ratios. Four hundred twenty-eight patients meeting study inclusion criteria were identified; 62 (14%) were initiated on a rescue therapy. PaO2/FIO2 ratios were comparable at admission between patients treated with a rescue therapy and those treated conventionally but were substantially lower by 72 hours in those who received rescue therapies (54 ± 17 vs 69 ± 17 mm Hg; p < 0.01). For the entire cohort, estimated survival probability at 3 years was 55% (95% CI, 51-61%). Among 280 hospital survivors (65%), 3-year survival was 85% (95% CI, 80-89%). The relative hazard of in-hospital mortality was 68% higher among patients who received rescue therapy compared with patients treated conventionally (95% CI, 8-162%; p = 0.02). For long-term survival, the hazard ratio of death following ICU admission was 1.56 (95% CI, 1.02-2.37; p = 0.04), comparing rescue versus conventional treatment. Despite high hospital mortality, severe acute respiratory distress syndrome patients surviving to hospital discharge have relatively good long-term survival. Worsening hypoxemia was associated with initiation of rescue therapy. Patients on rescue therapy had higher in-hospital mortality; however, survivors to hospital discharge had long-term survival that was comparable to other acute respiratory distress syndrome survivors.

Adherence to the WCRF/AICR cancer prevention recommendations and cancer-specific mortality: results from the Vitamins and Lifestyle (VITAL) Study

In 2007, the World Cancer Research Fund (WCRF) and American Institute for Cancer Research (AICR) released eight recommendations related to body fatness, physical activity, and diet aimed at preventing the most common cancers worldwide. The purpose of this paper is to estimate the association between meeting these recommendations and cancer-specific mortality. We operationalized six recommendations (related to body fatness; physical activity; and consumption of foods that promote weight gain, plant foods, red and processed meat, and alcohol) and examined their association with cancer-specific mortality over 7.7 years of follow-up in the Vitamins and Lifestyle (VITAL) Study cohort. Participants included 57,841 men and women ages 50-76 in 2000-2002 who had not been diagnosed with cancer prior to baseline. Cancer-specific deaths (n = 1,595) were tracked through the Washington State death file. Meeting the recommendations related to plant foods and foods that promote weight gain were most strongly associated with lower cancer-specific mortality [hazard ratio (HR) 0.82, 95 % confidence interval (CI) 0.67, 1.00 and HR 0.82, 95 % CI 0.70, 0.96, respectively]. Cancer-specific mortality was 61 % lower in respondents who met at least five recommendations compared to those who met none (HR 0.39, 95 % CI 0.24, 0.62). Cancer-specific mortality was 10 % lower on an average with each additional recommendation met (per-recommendation HR 0.90, 95 % CI 0.85, 0.94; p trend < 0.001). This association did not differ by sex or age but was stronger in non-smokers (HR 0.84, 95 % CI 0.76, 0.92) than in smokers (HR 0.93, 95 % CI 0.87, 0.98; p interaction = 0.086). Adherence to the WCRF/AICR cancer prevention recommendations developed to reduce incidence of common cancers could substantially reduce cancer-specific mortality in older adults.

Misclassification of veteran status on Washington state death certificates for suicides from 1999 to 2008

To determine the effectiveness and comparative effectiveness of multidisciplinary rehabilitation programs for moderate to severe traumatic brain injury (TBI) in improving participation-related outcomes in adults. This article presents results of select key questions from a recent Agency for Healthcare Quality and Research comparative effectiveness review.MEDLINE, Cochrane Central Register of Controlled Trials, and PsycINFO; hand searches of previous relevant reviews.We included prospective controlled studies that evaluated the effectiveness or comparative effectiveness of multidisciplinary rehabilitation programs delivered to adults with moderate to severe TBI on their participation in life and community.We extracted data, assessed risk of bias, and evaluated strength of evidence. Participation was selected as our primary outcome and included measures of productivity (eg, return to employment or military service) and select scales measuring community integration. Only data from studies with a low or moderate risk of bias were synthesized.Twelve studies met our inclusion criteria; of these, 8 were of low or moderate risk of bias (4 randomized controlled trials of 680 patients and 4 cohort studies of 190 patients, sample size 36–366). Heterogeneous populations, interventions, and outcomes precluded pooled analysis. Evidence was insufficient to draw conclusions about effectiveness. Evidence on comparative effectiveness often demonstrated that improvements were not different between groups; however, this evidence was low strength and may have limited generalizability.Our review used a rigorous systematic review methodology and focused on participation after multidisciplinary rehabilitation programs for impairments from moderate to severe TBI. The available evidence did not demonstrate the superiority of one approach over another. This conclusion is consistent with previous reviews that examined other patient-centered outcomes. While these findings will have little clinical impact, they do point out the limited evidence available to assess effectiveness and comparative effectiveness while highlighting important issues to consider in future comparative effectiveness research on this topic.

Contribution of Health Behaviors to the Association between Area-Level Socioeconomic Status and Cancer Mortality

Abstract Background: Area-level socioeconomic status (SES) is increasingly recognized as an important predictor of health outcomes; however, its association with cancer mortality is not established. Moreover, mediators of the association between area-level factors and health outcomes are not well understood. The purpose of this study is to quantify the association between area-level SES and cancer mortality and to identify whether and to what extent behaviors mediate the association. Methods: We identified the census block groups of participants in the VITamins And Lifestyle (VITAL) Study cohort and constructed an SES index using data from the 2000 U.S. Census. Participants included 54,736 men and women ages 50–76 years with no history of cancer at baseline (2000–2002). Cancer deaths (n = 1,488) were tracked through the Washington State death file over 7.7 years of follow-up. We tested whether eight modifiable risk factors (e.g. body mass index (BMI), physical activity, diet, alcohol, smoking, screening) mediated the association between area-level SES and cancer mortality. Results: Living in the lowest-SES areas was associated with 77% higher cancer mortality than living in the highest-SES areas (hazard ratio (HR): 1.77, 95% confidence interval (CI): 1.50, 2.11). Adding modifiable risk factors into the models explained 45% (95% CI: −68%, −11%) of the association. In models controlling for individual education and income, area-level SES remained associated with cancer mortality (HR highest- vs. lowest-SES areas: 1.37, 95% CI: 1.14, 1.65) and adding modifiable risk factors reduced the association by 37% (95% CI: −99%, 22%). Smoking, physical activity and screening mediated the largest proportion of the association, while diet, alcohol use and BMI had little explanatory effect for the health disparities. Conclusions: Low area-level SES is associated with increased cancer mortality. This association persists after accounting for individual education and income and is partially mediated by smoking, physical activity, and screening.

Erectile Dysfunction Is Not Independently Associated with Cardiovascular Death: Data from the Vitamins and Lifestyle (VITAL) Study

Erectile dysfunction (ED) is a significant problem among aging men. ED is independently associated with cardiovascular (CV) events (angina, myocardial infarction, and stroke). We sought to determine if ED was associated with CV death. Risk of CV death in men with ED. Exactly 31,296 men in Washington aged 50-76 completed a questionnaire in 2000-2002 on supplements, diet, exercise, personal health, and ED. ED was determined by one question: "Have you experienced impotence in the last year?" We excluded patients with a history of coronary artery disease or stroke. Participants linked yearly through 2008 to the Washington State Death Certificate System. CV death was defined by death certificates listing CV-related deaths (International Classification of Diseases 10th Revision [ICD-10] codes: I00-I15, I20-I52, and I60-I99). We performed multivariate Cox proportional hazard regression adjusting for age, marital status, race, education, self-rating of health, body mass index (BMI), antihypertensive/lipid-lowering drug use, diabetes, family history of CV disease, smoking, and exercise. About 7,762 men had ED and there were 486 CV deaths over 7.8-year average follow-up. The typical man who suffered CV death was older, single, reporting poor health, taking antihypertensives, higher BMI, a smoker, a diabetic, and had a family history of CV disease. When adjusting for age, marital status, and education only, men with ED had a 23% increased risk of CV death (hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.01, 1.49). With further adjustment for known risk factors for CV disease (diabetes, treatment for hypertension or hyperlipidemia, family history of myocardial infarction/stroke, BMI, and exercise), ED no longer predicted CV death (HR 0.93, 95% CI 0.76, 1.15). In this community-based cohort, ED was not independently associated with an elevated risk of CV death. These data do not contradict prior data associating ED and CV events but rather suggest that ED may be a manifestation of other known risk factors for CV disease.

959 IMMUNOHISTOCHEMICAL EXPRESSION OF ERG ONCOPROTEIN IS ASSOCIATED WITH DEVELOPMENT OF LOCAL RECURRENCE AND PROSTATE CANCER-SPECIFIC DEATH IN MEN TREATED WITH RADICAL PROSTATECTOMY

INTRODUCTION AND OBJECTIVES: ETS-Related Gene (ERG) encoded protein is present in a significant portion of prostate adenocarcinoma (PCa) and strongly correlates with TMPRSS2-ERG rearrangement. While ERG oncogenic activation is believed to be a causal genomic alteration in a significant portion of PCa, its prognostic value in disease progression remains uncertain. The aim of this study was to evaluate ERG oncoprotein expression levels in men undergoing radical prostatectomy (RP) to determine whether this was predictive of earlier time to relapse or prostate cancer-specific death. METHODS: Between 1954 and 1997, 1004 consecutive patients underwent RP at Virginia Mason Medical Center in Seattle, WA. Local pelvic disease or disease consistent with regional lymph node metastases was defined by tissue diagnosis or by overt radiographic signs of disease. Washington State death certificates were obtained and PCa had to be the first listed cause of death for the patient to be classified as developing PCa-specific death. Paraffin-embedded tissue samples were available for the majority of men. Thirty-four patients were identified with known adverse outcomes of either distant metastasis or PCa-specific death. These patients were matched by age, PSA and time since surgery with 66 patients who had undergone RP and had not developed advanced disease. The tissue was stained with a highly specific anti-ERG monoclonal antibody, clone 9FY (Furustao et al., PCPD, 2010). Each TMA spot was evaluated by a GU pathologist for ERG staining. A proc-mixed analysis with stage as a random effect was performed to assess statistical significance. RESULTS: The mean follow-up was 10.26 years. ERG oncoprotein expression was detected in 11/31 (35.48%) adverse outcome patients and 15/66 (22.39%) favorable outcome patients, however, this was not significant (p 0.59). The mean expression H-score (cancer nuclear staining intensity multiplied by percent of cancer staining) was significantly higher from the group of patients that developed local recurrence 61.46 vs. 16.36 (p 0.0066) and PCa-specific death 31.36 vs. 13.10 (p 0.0181). CONCLUSIONS: ERG oncoprotein expression alone did not have any discriminative ability. However, degree of ERG expression at time of surgery was highly associated with increased risk of developing local recurrence and PCa-specific death. ERG scoring may be a useful metric to identify patients who would benefit from adjuvant treatment or closer follow-up, allowing more accurate individual patient treatment plans.

Washington State Death With Dignity Act

Washington State Death With Dignity Act