The accuracy of the National Death Index when personal identifiers other than Social Security number are used

Use of Immunosuppression and the Risk of Subsequent Overall or Cancer Mortality

PURPOSE

To determine the incidence of all-cause and cancer mortality (CM) in association with immunosuppression.

DESIGN

Retrospective cohort study at ocular inflammatory disease (OID) subspecialty centers. We harvested exposure and covariate data retrospectively from clinic inception (earliest in 1979) through 2010 inclusive. Then we ascertained overall and cancer-specific mortalities by National Death Index linkage. We constructed separate Cox models to evaluate overall and CM for each class of immunosuppressant and for each individual immunosuppressant compared with person-time unexposed to any immunosuppression.

PARTICIPANTS

Patients with noninfectious OID, excluding those with human immunodeficiency infection or preexisting cancer.

METHODS

Tumor necrosis factor (TNF) inhibitors (mostly infliximab, adalimumab, and etanercept); antimetabolites (methotrexate, mycophenolate mofetil, azathioprine); calcineurin inhibitors (cyclosporine); and alkylating agents (cyclophosphamide) were given when clinically indicated in this noninterventional cohort study.

MAIN OUTCOME MEASURES

Overall mortality and CM.

RESULTS

Over 187 151 person-years (median follow-up 10.0 years), during which 15 938 patients were at risk for mortality, we observed 1970 deaths, 435 due to cancer. Both patients unexposed to immunosuppressants (standardized mortality ratio [SMR] = 0.95, 95% confidence interval [CI], 0.90-1.01) and those exposed to immunosuppressants but free of systemic inflammatory diseases (SIDs) (SMR = 1.04, 95% CI, 0.95-1.14) had similar mortality risk to the US population. Comparing patients exposed to TNF inhibitors, antimetabolites, calcineurin inhibitors, and alkylating agents with patients not exposed to any of these, we found that overall mortality (adjusted hazard ratio [aHR] = 0.88, 0.89, 0.90, 1.11) and CM (aHR = 1.25, 0.89, 0.86, 1.23) were not significantly increased. These results were stable in sensitivity analyses whether excluding or including patients with SID, across 0-, 3-, or 5-year lags and across quartiles of immunosuppressant dose and duration.

CONCLUSIONS

Our results, in a cohort where the indication for treatment was proven unassociated with mortality risk, found that commonly used immunosuppressants-especially the antimetabolites methotrexate, mycophenolate mofetil, and azathioprine; the TNF inhibitors adalimumab and infliximab, and cyclosporine-were not associated with increased overall and CM over a median cohort follow-up of 10.0 years. These results suggest the safety of these agents with respect to overall and CM for patients treated with immunosuppression for a wide range of inflammatory diseases.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Mortality after spinal fusion in children with cerebral palsy and cerebral-palsy-like conditions: A 30-year follow-up study

AIM

To report survival probability of a large cohort of children with cerebral palsy (CP) after spinal fusion.

METHOD

All children with CP who had spinal fusion between 1988 and 2018 at the reporting facility were reviewed for survival. Death records of the institutional CP database, institutional electronic medical records, publicly available obituaries, and the National Death Index through the US Centers for Disease Control were searched. Survival probabilities with different surgical eras, comorbidities, ages, and curve severities were compared using Kaplan-Meier curves.

RESULTS

A total of 787 children (402 females, 385 males) had spinal fusion at a mean age of 14 years 1 month (standard deviation 3 years 2 months). The 30-year estimated survival was approximately 30%. Survival decreased for children who had spinal fusion at younger ages, longer postoperative hospital stays, longer postoperative intensive care unit stays, gastrostomy tubes, and pulmonary comorbidities.

INTERPRETATION

Children with CP who required spinal fusions had reduced long-term survival compared with an age-matched typically developing cohort; however, a substantial number survived 20 to 30 years after the surgery. This study had no comparison group of children with CP scoliosis; therefore, we do not know whether correction of scoliosis affected their survival.

Evaluation of California Non-Comprehensive Death File Against National Death Index

The National Death Index (NDI) by the Centers for Disease Control and Prevention and Death Master File (DMF) by Social Security Administration are the two most broadly utilized data files for mortality outcomes in clinical research. NDI's high costs and the elimination of protected death records from California in DMF calls for alternative death files. The recently emerged California Non-Comprehensive Death File (CNDF) serves as an alternative source for vital statistics. This study aims to evaluate the sensitivity and specificity of CNDF compared to NDI. Of 40,724 consented subjects in the Cedars-Sinai Cardiac Imaging Research Registry, 25,836 eligible subjects were queried through the NDI and the CDNF. After exclusion of death records to establish the same temporal and geographic availability of data, NDI identified 5,707 exact matches, while CNDF identified 6,051 death records. CNDF had a sensitivity of 94.3% and specificity of 96.4% compared to NDI exact matches. NDI also produced 581 close matches: all were verified as deaths by CNDF through matching death date and patient identifiers. Combining all NDI death records, CNDF had a sensitivity of 94.8% and specificity of 99.5%. CNDF is a reliable source for obtaining mortality outcomes and providing additional mortality validation. The use of CNDF can aid and replace the use of NDI in the state of California.

An Evaluation of the Effect of the OxyContin Reformulation on Unintentional Fatal and Nonfatal Overdose

OBJECTIVES

OxyContin was reformulated with a polyethylene oxide matrix in August 2010 to reduce the potential for intravenous abuse and for abuse by insufflation. The objective of this study was to evaluate the impact of OxyContin's reformulation on overdose (OD) risk for individuals dispensed OxyContin in comparison to those dispensed other opioids under regular care.

MATERIALS AND METHODS

Three national insurance databases with National Death Index linkage identified OD in individuals with any dispensing of OxyContin or a primary comparator opioid (extended release morphine, transdermal fentanyl, or methadone) between July 2008 through September 2015. A difference-in-differences design was used to compare the pre-post reformulation changes in OD rates for OxyContin versus comparators.

RESULTS

A total of 297,836 individuals were dispensed OxyContin and 659,673 individuals were dispensed a primary comparator across the 3 databases. Overall, there was little or no difference in the temporal change in OD incidence in comparators versus OxyContin (Medicaid: adjusted ratio-of-rate-ratios (aRoRs) ranging from 0.90 to 1.05; MarketScan/HIRD: aRoR ranging from 1.10 to 1.22). However, restriction to person-time without concomitant opioid use revealed a modestly greater reduction in OD incidence over time during OxyContin use, as the aRoRs comparing the primary comparators to OxyContin ranged from 1.06 to 1.30 in Medicaid and from 1.64 to 1.85 in MarketScan/HIRD.

DISCUSSION

This study did not detect an overall effect of the OxyContin reformulation on OD in insured patients under regular medical care. There is a suggestion of a modestly reduced OxyContin-associated OD risk following the reformulation but only in commercially insured individuals receiving single-opioid regimens.

Demographic Correlates of Short-Term Mortality Among Youth and Young Adults With Youth-Onset Diabetes Diagnosed From 2002 to 2015: The SEARCH for Diabetes in Youth Study

OBJECTIVE

To examine short-term mortality and cause of death among youth and young adults (YYAs) with youth-onset diabetes.

RESEARCH DESIGN AND METHODS

We included 19,717 YYAs newly diagnosed with diabetes before 20 years of age from 1 January 2002 to 31 December 2015 enrolled in the SEARCH for Diabetes in Youth Study. Of these, 14,721 had type 1; 4,141 type 2; and 551 secondary and 304 other/unknown diabetes type. Cases were linked with the National Death Index through 31 December 2017. We calculated standardized mortality ratios (SMRs) and 95% CIs based on age, sex, and race/ethnicity for state and county population areas and examined underlying causes of death.

RESULTS

During 170,148 person-years (PY) (median follow-up 8.5 years), 283 individuals died: 133 with type 1 (103.0/100,000 PY), 55 with type 2 (161.5/100,000 PY), 87 with secondary (1,952/100,000 PY), and 8 with other/unknown diabetes type (312.3/100,000 PY). SMRs (95% CI) for the first three groups were 1.5 (1.2-1.8), 2.3 (1.7-3.0), and 28.0 (22.4-34.6), respectively. Diabetes was the underlying cause of death for 42.1%, 9.1%, and 4.6% of deaths, respectively. The SMR was greater for type 2 than for type 1 diabetes (P < 0.001). SMRs were significantly higher for individuals with type 1 diabetes who were <20 years of age, non-Hispanic White and Hispanic, and female and for individuals with type 2 diabetes who were <25 years of age, from all race/ethnic minority groups, and from both sexes.

CONCLUSIONS

Excess mortality was observed among YYAs for each type of diabetes with differences in risk associated with diabetes type, age, race/ethnicity, and sex. The root causes of excess mortality among YYAs with diabetes merit further study.

Long-term risk of hepatocellular carcinoma mortality in 23220 hospitalized patients treated with micafungin or other parenteral antifungals

BACKGROUND

Liver tumours observed in rats exposed to micafungin led to a black box warning upon approval in Europe in 2008. Micafungin's risk for liver carcinogenicity in humans has not been investigated. We sought to describe the risk of fatal hepatocellular carcinoma (HCC) among persons who received micafungin and other parenteral antifungals (PAFs) with up to 12 years of follow-up.

METHODS

We assembled a US multicentre cohort of hospitalized patients who received micafungin or other PAFs between 2005 and 2012. We used propensity score (PS) matching on patient characteristics from electronic medical records to compare rates of HCC mortality identified through the National Death Index though to the end of December 2016. We computed HRs and 95% CIs.

RESULTS

A total of 40110 patients who received a PAF were identified; 6903 micafungin recipients (87% of those identified) were successfully matched to 16317 comparator PAF users. Ten incident HCC deaths, one in the micafungin-exposed group and nine among comparator PAF users, occurred in 71285 person-years of follow-up. The HCC mortality rate was 0.05 per 1000 person-years in micafungin patients and 0.17 per 1000 person-years in comparator PAF patients. The PS-matched HR for micafungin versus comparator PAF was 0.29 (95% CI 0.04-2.24).

CONCLUSIONS

Both micafungin and comparator PAFs were associated with HCC mortality rates of <0.2 per 1000 person-years. Given the very low event rates, any potential risk for HCC should not play a role in clinical decisions regarding treatment with micafungin or other PAFs investigated in this study.

The National Death Index as a Source of Homicide Data: A Methodological Exposition of Promises and Pitfalls for Criminologists

Criminologists largely rely on national de-identified data sources to study homicide in the United States. The National Death Index (NDI), a comprehensive and well-established database compiled by the National Center for Health Statistics, is an untapped source of homicide data that offers identifiable linkages to other data sources while retaining national coverage. This study's five aims follow. First, we review the data sources in articles published in Homicide Studies over the past decade. Second, we describe the NDI, including its origins, procedures, and uses. Third, we outline the procedures for linking a police gang intelligence database to the NDI. Fourth, we introduce the St. Louis Gang Member-Linked Mortality Files database, which is composed of 3,120 police-identified male gang members in the St. Louis area linked to NDI records. Finally, we report on preliminary cause-of-death findings. We conclude by outlining the benefits and drawbacks of the NDI as a source of homicide data for criminologists.

Chronic renal disease among lead-exposed workers

BACKGROUND

Very high exposure to inorganic lead causes serious kidney damage. We have studied workers with occupational exposure and data on blood lead.

METHODS

We extended follow-up for 7 more years, for a previously studied cohort of 58 307 male workers who were part of a surveillance programme in 11 different states. Mortality was assessed using the National Death Index, and end-stage renal disease (ESRD) incidence was assessed using the US Renal Data System. We conducted internal analyses via Cox regression adjusting for age, calendar time and race.

RESULTS

The cohort was followed for a median of 18 years and had 524 cases of ESRD and 6527 deaths. Average maximum blood lead was 26 µg/dL; the mean year of first blood lead test was 1997. No trends by lead level were seen overall or when restricting to those with 15+ years follow-up. Among non-Caucasians with >15 years of follow-up, there was a positive but inconsistent trend (Rate ratios (RRs) 1.00, 2.10, 1.33, 2.20 and 2.76 for maximum blood lead categories of <20 µg/dL, 20-29 µg/dL, 30 to <40 µg/dL, 40 to ≤50 µg/dL and >50 µg/dL, respectively (p for linear trend 0.26). Those with >15 years of follow-up and birth year <1941 showed a positive trend with increased blood lead (RRs 1.00, 1.14, 1.18, 1.46, 1.66, p trend=0.26).

CONCLUSIONS

We found no association between higher lead exposure and ESRD. There were positive but not statistically significant trends of increased risk for non-Caucasians with >15 years of follow-up and for older men with >15 years of follow-up.

Vital Status Ascertainment for a Historic Diverse Cohort of U.S. Women

BACKGROUND

Studies linking large pregnancy cohorts with mortality data can address critical questions about long-term implications of gravid health, yet relevant US data are scant. We examined the feasibility of linking the Collaborative Perinatal Project, a large multiracial U.S. cohort study of pregnant women (n = 48,197; 1959-1966), to death records.

METHODS

We abstracted essential National Death Index (NDI) (1979-2016) (n = 46,428). We performed a linkage to the Social Security Administration Death Master File through 2016 (n = 46,450). Genealogists manually searched vital status in 2016 for a random sample of women (n = 1,249). We conducted agreement analyses for women with abstracted data among the three sources. As proof of concept, we calculated adjusted associations between mortality and smoking and other sociodemographic factors using Cox proportional hazards regression.

RESULTS

We successfully abstracted identifying information for most of the cohort (97%). National Death Index identified the greatest proportion of participants deceased (35%), followed by genealogists (31%) and Death Master File (23%). Estimates of agreement (κ [95% confidence interval]) between National Death Index and Death Master File were lower (0.52 [0.51, 0.53]) than for National Death Index and genealogist (0.66 [0.61, 0.70]). As expected, compared with nonsmokers, smoking ≥1 pack per day was associated with elevated mortality for all vital sources and was strongest for National Death Index.

CONCLUSIONS

Linking this historic cohort with mortality records was feasible and agreed reasonably on vital status when compared with other data sources. Such linkage enables future examination of pregnancy conditions in relation to mortality in a diverse U.S. cohort.

Influence of Prior Coronary Stenting on the Immediate and Mid-term Outcome of Isolated Coronary Artery Bypass Surgery

Background

There has been little emphasis on the possible consequences of prior stent placement on the outcome of coronary bypass surgery (CABG). We compared the results of isolated CABG patients who had prior stents with those who had not with respect to preoperative status, operative procedure, and postoperative immediate and long-term outcome.

Methods

Records of 1471 patients undergoing isolated CABG at our institution between January 1, 2000, and March 31, 2005, were reviewed. Patients were divided into three groups. Group I had no stents (n = 1317). Group II had one to three stents (n = 137). Group III had more than three stents (n = 17). Groups were compared with respect to preoperative risk factors, operative procedures, and postoperative results. Long-term survival data were obtained on 97.6% of patients with a mean follow-up, 4.1 ± 2.3 years.

Results

Stented patients were younger (66.1 ± 10.8 vs. 69.1 ± 10.8 years, P = 0.006), had more unstable angina (68.2% vs. 58.9%, P = 0.02), hypercholesterolemia (83.8% vs. 61.2%, P = 0.00), chronic obstructive pulmonary disease (13.6% vs. 8.4%, P = 0.03), peripheral vascular disease (15.2% vs. 8.4%, P = 0.00), and previous CABG (10.1% vs. 4.2%, P = 0.00), fewer low ejection fractions (1.3% vs. 5.2%, P = 0.02), left main disease (25.3% vs. 32.6%, P = 0.04), diabetes (31.2% vs. 40.8%, P = 0.01), or diffuse disease (19.5 ± 10.5 vs. 22.5 ± 10.9, P = 0.00), had more off pump procedures (53.2% vs. 45.3%, P = 0.03), fewer internal thoracic artery grafts (80.5% vs. 86.6%, P = 0.03), fewer grafts placed (>3: 52.6% vs. 61.8%, P = 0.02), more complications (76.5% vs. 42.6%, P = 0.005), atrial fibrillation (47.1% vs. 19.7%, P = 0.011), longer hospital stays (12.2 vs. 8.3 days, P = 0.019). Percentage survival for groups I, II, and III at 60 months was 82.1%, 84.7%, and 72.6%, respectively.

Conclusions

Stents placed before surgery in isolated CABG patients may be associated with higher preoperative risk, altered operative procedures, more postoperative complications, longer hospitalizations, and more readmissions. Overall, stented patients experienced more preoperative hospitalizations, catheterizations, and percutaneous coronary interventions (PCIs) than nonstented patients. Survival for those with more than three stents may be diminished.

Independent predictors of mortality in adolescents ascertained for conduct disorder and substance use problems, their siblings and community controls

BACKGROUND AND AIMS

Adolescents with conduct and substance use problems are at increased risk for premature mortality, but the extent to which these risk factors reflect family- or individual-level differences and account for shared or unique variance is unknown. This study examined common and independent contributions to mortality hazard in adolescents ascertained for conduct disorder (CD) and substance use disorder (SUD), their siblings and community controls, hypothesizing that individual differences in CD and SUD severity would explain unique variation in mortality risk beyond that due to clinical/control status and demographic factors.

DESIGN

Mortality analysis in a prospective study (Genetics of Antisocial Drug Dependence Study) that began in 1993.

SETTING

Multi-site sample recruited in San Diego, California and Denver, Colorado, USA.

PARTICIPANTS

A total of 1463 clinical probands were recruited through the juvenile correctional system, court-mandated substance abuse treatment programs and correctional schools, along with 1399 of their siblings, and 904 controls.

MEASUREMENTS

Mortality and cause-of-death were assessed via National Death Index search (released October, 2017).

FINDINGS

There were 104 deaths documented among 3766 (1168 female) adolescents and young adults (average age 16.79 years at assessment, 32.69 years at death/censoring). Mortality hazard for clinical probands and their siblings was 4.99 times greater than that of controls (95% confidence interval = 2.40-10.40; P < 0.001). After accounting for demographic characteristics, site, clinical status, familial dependence and shared contributions of CD and SUD, CD independently predicted mortality hazard, whereas SUD severity did not.

CONCLUSIONS

In the United States, youth with conduct and substance use disorders and their siblings face far greater risk of premature death than demographically similar community controls. In contrast to substance use disorder severity, conduct disorder is a robust predictor of unique variance in all-cause mortality hazard beyond other risk factors.

Mortality in youth-onset type 1 and type 2 diabetes: The SEARCH for Diabetes in Youth study

AIMS

To estimate short-term mortality rates for individuals with type 1 or type 2 diabetes diagnosed before age 20 years from the SEARCH for Diabetes in Youth study.

METHODS

We included 8358 individuals newly-diagnosed with type 1 (n = 6840) or type 2 (n = 1518) diabetes from 1/1/2002-12/31/2008. We searched the National Death Index through 12/31/2010. We calculated standardized mortality ratios (SMRs) based on age, sex, and race for the comparable US population in the geographic areas of the SEARCH study.

RESULTS

During 44,893 person-years (PY) of observation (median follow-up = 5.3 years), 41 individuals died (91.3 deaths/100,000 PY); 26 with type 1 (70.6 deaths/100,000 PY) and 15 with type 2 (185.6 deaths/100,000 PY) diabetes. The expected mortality rate was 70.9 deaths/100,000 PY. The overall SMR (95% CI) was 1.3 (1.0, 1.8) and was high among individuals with type 2 diabetes 2.4 (1.3, 3.9), females 2.2 (1.3, 3.3), 15-19 year olds 2.7 (1.7,4.0), and non-Hispanic blacks 2.1 (1.2, 3.4).

CONCLUSIONS

Compared to the state populations of similar age, sex, and race, our results show excess mortality in individuals with type 2 diabetes, females, older youth, and non-Hispanic blacks. We did not observe excess short-term mortality in individuals with type 1 diabetes.

Randomised controlled pragmatic clinical trial evaluating the effectiveness of a discharge follow-up phone call on 30-day hospital readmissions: balancing pragmatic and explanatory design considerations

INTRODUCTION

Hospital readmissions within 30 days are a healthcare quality problem associated with increased costs and poor health outcomes. Identifying interventions to improve patients' successful transition from inpatient to outpatient care is a continued challenge.

METHODS AND ANALYSIS

This is a single-centre pragmatic randomised and controlled clinical trial examining the effectiveness of a discharge follow-up phone call to reduce 30-day inpatient readmissions. Our primary endpoint is inpatient readmission within 30 days of hospital discharge censored for death analysed with an intention-to-treat approach. Secondary endpoints included observation status readmission within 30 days, time to readmission, all-cause emergency department revisits within 30 days, patient satisfaction (measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems scores) and 30-day mortality. Exploratory endpoints include the need for assistance with discharge plan implementation among those randomised to the intervention arm and reached by the study nurse, and the number of call attempts to achieve successful intervention delivery. Consistent with the Learning Healthcare System model for clinical research, timeliness is a critical quality for studies to most effectively inform hospital clinical practice. We are challenged to apply pragmatic design elements in order to maintain a high-quality practicable study providing timely results. This type of prospective pragmatic trial empowers the advancement of hospital-wide evidence-based practice directly affecting patients.

ETHICS AND DISSEMINATION

Study results will inform the structure, objective and function of future iterations of the hospital's discharge follow-up phone call programme and be submitted for publication in the literature.

TRIAL REGISTRATION NUMBER

NCT03050918; Pre-results.

Prognostic importance of anaemia in patients with acute pulmonary embolism

Although associated with adverse outcomes in other cardiopulmonary diseases, limited evidence exists on the prognostic value of anaemia in patients with acute pulmonary embolism (PE). We sought to examine the associations between anaemia and mortality and length of hospital stay in patients with PE. We evaluated 14,276 patients with a primary diagnosis of PE from 186 hospitals in Pennsylvania, USA. We used random-intercept logistic regression to assess the association between anaemia at the time of presentation and 30-day mortality and discretetime logistic hazard models to assess the association between anaemia and time to hospital discharge, adjusting for patient (age, gender, race, insurance type, clinical and laboratory variables) and hospital (region, size, teaching status) factors. Anaemia was present in 38.7% of patients at admission. Patients with anaemia had a higher 30-day mortality (13.7% vs. 6.3%; p <0.001) and a longer length of stay (geometric mean, 6.9 vs. 6.6 days; p <0.001) compared to patients without anaemia. In multivariable analyses, anaemia remained associated with an increased odds of death (OR 1.82, 95% CI: 1.60–2.06) and a decreased odds of discharge (OR 0.85, 95% CI: 0.82–0.89). Anaemia is very common in patients presenting with PE and is independently associated with an increased short-term mortality and length of stay.

Trauma Recidivism Predicts Long-term Mortality: Missed Opportunities for Prevention (Retrospective Cohort Study)

OBJECTIVES

The objectives of this study were to determine the association between recurrent trauma admissions (recidivism) and subsequent long-term mortality, and to identify those in most need for preventive interventions.

BACKGROUND

Patients with a single intentional injury have been shown to have a higher risk of future injury mortality than those with unintentional injury with 5-year mortality rates as high as 20% being reported for recurrent penetrating trauma. Trauma recidivism identifies a high-risk population, but its association with long-term mortality is largely unknown.

METHODS

Patients with 1 or more previous admissions to an urban trauma center (recidivists) were identified and compared with those with single admissions (nonrecidivists) from 1997 to 2008. The trauma registry was linked to the National Death Index to determine both the cause and time to death after hospital discharge. Statistical analysis included chi-square tests, Kaplan-Meier survival curves, and Cox proportional-hazards models.

RESULTS

Trauma recidivists were 7% of the total trauma population from 1997 to 2008, representing 3147 patients. Recidivists were more likely to be male (P < 0.0001), Black (P < 0.0001), have a blood alcohol content above 80 mg/dL (P < 0.0001), and suffer a penetrating injury (P < 0.0001) compared with nonrecidivists. Recidivists with both initial blunt and penetrating injuries had higher rates of long-term mortality after discharge. Recidivists were more likely to die of any cause based on Cox proportional-hazard ratios [hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.57-2.01], injury death (HR 2.02, 95% CI 1.66-2.47), and disease death (HR 1.65, 95% CI 1.41-1.92) than nonrecidivists.

CONCLUSIONS

Male sex, Black race, and elevated blood alcohol content and penetrating injury are associated with trauma recidivism which leads to a higher risk of death. There is a critical public health need to develop interventions to reduce trauma recidivism and preventable death.

Do inferences about mortality rates and disparities vary by source of mortality information?

PURPOSE

Researchers who study mortality among survey participants have multiple options for obtaining information about which participants died (and when and how they died). Some use public record and commercial databases; others use the National Death Index; some use the Social Security Death Master File; and still others triangulate sources and use Internet searches and genealogic methods. We ask how inferences about mortality rates and disparities depend on the choice of source of mortality information.

METHODS

Using data on a large, nationally representative cohort of people who were first interviewed as high school sophomores in 1980 and for whom we have extensive identifying information, we describe mortality rates and disparities through about age 50 using four separate sources of mortality data. We rely on cross-tabular and multivariate logistic regression models.

RESULTS

These sources of mortality information often disagree about which of our panelists died by about age 50 and also about overall mortality rates. However, differences in mortality rates (i.e., by sex, race/ethnicity, education) are similar across of sources of mortality data.

CONCLUSION

Researchers' source of mortality information affects estimates of overall mortality rates but not estimates of differential mortality by sex, race and/or ethnicity, or education.

Outcomes of trauma admission for falls: influence of race and age on inhospital and post-discharge mortality

BACKGROUND

Racial disparities in trauma outcomes occur, but disparities in fall mortality are unknown. The objective of this study was to determine inhospital and 1-year fall mortality among patients discharged from an urban trauma center.

METHODS

We conducted a retrospective analysis of fall patients in our trauma registry (1997 to 2008) linked to the National Death Index to determine postdischarge mortality. Statistical analysis included chi-square tests, multivariable logistic regression, and Cox proportional hazards models.

RESULTS

There were 7,541 fall admissions. There was no clinically significant difference in inhospital mortality between blacks and whites with age stratification. One year after discharge, blacks younger than 65 years were more likely to die of disease (hazard ratio, 1.37; 95% confidence interval, 1.14 to 1.62).

CONCLUSIONS

Although rates of inhospital mortality are similar, blacks younger than 65 years have a higher risk of dying after discharge due to disease when stratified by age highlighting the need for continued medical follow-up and prevention efforts.

Long-Term Mortality in Hypertensive Patients With Coronary Artery Disease: Results From the US Cohort of the International Verapamil (SR)/Trandolapril Study

The dyad of hypertension and coronary artery disease is prevalent; however, data on systolic blood pressure (SBP) control and long-term all-cause mortality are lacking. Using extended follow-up data from the US cohort of the International Verapamil (SR)/Trandolapril Study (mean 11.6 years), subjects were categorized by age at enrollment (50 to <60 and ≥60 years). Cox proportional adjusted hazard ratios (HRs) were constructed for time to all-cause mortality according to achieved mean SBP. In those 50 to <60 years and using a referent SBP of <130 mm Hg, an achieved SBP of 130 to 140 mm Hg was associated with a similar risk of mortality (HR, 1.03; 95% confidence interval [CI], 0.87-1.23), whereas an achieved SBP of ≥140 mm Hg was associated with an increased risk of mortality (HR, 1.80; 95% CI, 1.53-2.11). Among subjects aged ≥60 years and using a referent SBP of <130 mm Hg, an achieved SBP 130 to 140 mm Hg was associated with a lower mortality risk (HR, 0.92; 95% CI, 0.85-0.98). There was an increased risk of mortality with an achieved SBP ≥150 mm Hg (HR, 1.34; 95% CI, 1.23-1.45), but not with an achieved SBP 140 to 150 mm Hg (HR, 1.02; 95% CI, 0.94-1.11). In hypertensive patients with coronary artery disease, achieving a SBP of 130 to 140 mm Hg seems to be associated with lower all-cause mortality after ≈11.6 years of follow-up.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00133692.

In-Hospital Vital Status and Heart Transplants After Intervention for Congenital Heart Disease in the Pediatric Cardiac Care Consortium: Completeness of Ascertainment Using the National Death Index and United Network for Organ Sharing Datasets

BACKGROUND

The long-term outcomes of patients undergoing interventions for congenital heart disease (CHD) remain largely unknown. We linked the Pediatric Cardiac Care Consortium (PCCC) with the National Death Index (NDI) and the United Network for Organ Sharing Dataset (UNOS) registries to study mortality and transplant occurring up to 32 years postintervention. The objective of the current analysis was to determine the sensitivity of this linkage in identifying patients who are known to have died or undergone heart transplant.

METHODS AND RESULTS

We used direct identifiers from 59 324 subjects registered in the PCCC between 1982 and 2003 to test for completeness of case ascertainment of subjects with known vital and heart transplant status by linkage with the NDI and UNOS registries. Of the 4612 in-hospital deaths, 3873 were identified by the NDI as "true" matches for a sensitivity of 84.0% (95% CI, 82.9-85.0). There was no difference in sensitivity across 25 congenital cardiovascular conditions after adjustment for age, sex, race, presence of first name, death year, and residence at death. Of 455 known heart transplants in the PCCC, there were 408 matches in the UNOS registry, for a sensitivity of 89.7% (95% CI, 86.9-92.3). An additional 4851 deaths and 363 transplants that occurred outside the PCCC were identified through 2014.

CONCLUSIONS

The linkage of the PCCC with the NDI and UNOS national registries is feasible with a satisfactory sensitivity. This linkage provides a conservative estimate of the long-term death and heart transplant events in this cohort.

Foot Complications and Mortality: Results from Translating Research Into Action for Diabetes (TRIAD)

BACKGROUND

We sought to study the impact of foot complications on 10-year mortality independent of other demographic and biological risk factors in a racially and socioeconomically diverse managed-care population with access to high-quality medical care.

METHODS

We studied 6,992 patients with diabetes in Translating Research Into Action for Diabetes (TRIAD), a prospective observational study of diabetes care in managed care. Foot complications were assessed using administrative claims data. The National Death Index was searched for deaths across 10 years of follow-up (2000-2009).

RESULTS

Charcot's neuro-osteoarthropathy and diabetic foot ulcer with debridement were associated with an increased risk of mortality; however, the associations were not significant in fully adjusted models. Lower-extremity amputation (LEA) was associated with an increased risk of mortality in unadjusted (hazard ratio [HR], 3.21; 95% confidence interval [CI], 2.50-4.12) and fully adjusted (HR, 1.84; 95% CI, 1.28-2.63) models. When we examined the associations between LEA and mortality stratified by sex and race, risk was increased in men (HR, 1.96; 95% CI, 1.25-3.07), Hispanic individuals (HR, 5.17; 95% CI, 1.48-18.01), and white individuals (HR, 2.18; 95% CI, 1.37-3.47). In sensitivity analyses, minor LEA tended to increase the risk of mortality (HR, 1.48; 95% CI, 0.92-2.40), and major LEA was associated with a significantly higher risk of death at 10 years (HR, 1.89; 95% CI, 1.18-3.01).

CONCLUSIONS

In this managed-care population with access to high-quality medical care, LEA remained a robust independent predictor of mortality. The association was strongest in men and differed by race.

Survival patterns of lead-exposed workers with end-stage renal disease from Adult Blood Lead Epidemiology and Surveillance program

BACKGROUND

One previous study has shown that patients with end-stage renal disease (ESRD) with higher blood lead levels (BLLs) have shorter survival, in a cohort without occupational exposure where follow-up began an average of 5 years after dialysis (a survivor population).

METHODS

The authors studied individuals with at least 1 blood lead test who were part of an occupational lead surveillance program sponsored by the National Institute for Occupational Safety and Health and were diagnosed with ESRD. The authors studied the effect of BLL on survival from time of ESRD diagnosis after adjusting for potential confounders. Cox proportional hazards models were run, in which death was the end point and follow-up time was the time variable.

RESULTS

There were 434 ESRD cases with 82% males, 65% white and 31% African American; 51% had 1 blood test, whereas the remainder had a median of 5 tests. The median years of follow-up were 2.7 years with 219 deaths in the cohort. After adjusting for covariates (eg, transplantation status, age at diagnosis, glomerular filtration rate, comorbidities and ethnicity), the authors found no significant association between highest measured BLL and mortality across categories; 0 to <5 μg/dL (hazard ratio [HR] = 1.00), 5 to <25 μg/dL (HR = 1.09; 95% confidence interval [CI]: 0.70-1.70), 25 to <40 μg/dL (HR = 1.28; 95% CI: 0.81-2.02), 40 to <50 μg/dL (HR = 0.89; 95% CI: 0.48-1.63) and 50+ μg/dL (HR = 1.09; 95% CI: 0.66-1.81).

CONCLUSIONS

The authors found no association between BLL and survival after ESRD diagnosis. The authors' finding differs from earlier findings, possibly because the cohort had higher blood leads (25 versus 10 μg/dL), follow-up began at the time of ESRD diagnosis, and BLLs were measured before ESRD incidence.

Mortality among participants in a lead surveillance program

BACKGROUND

There is evidence that adult lead exposure increases cancer risk. IARC has classified lead as a 'probable' carcinogen, primarily based on stomach and lung cancer associations.

METHODS

We studied mortality among men in a lead surveillance program in 11 states,. categorized by their highest blood lead (BL) test (0-<5 µg/dl, 5-<25 µg/dl, 25-<40 µg/dl and 40+ µg/dl).

RESULTS

There were 58,368 men with a median 12 years of follow-up (6 to 17 years from lowest to higher BL category), and 3337 deaths. Half of the men had only one BL test. There was a strong healthy worker effect (all cause SMR=0.69, 95% CI: 0.66-0.71). The highest BL category had elevated lung and larynx cancer SMRs (1.20, 95% CI: 1.03-1.39, n=174, and 2.11, 95% CI: 1.05-3.77, n=11, respectively); there were no significant excesses of any other cause-specific SMR. Lung cancer RRs by increasing BL category were 1.0, 1.34, 1.88, and 2.79 (test for trend p=<0.0001), unchanged by adjustment for follow-up time. The lung cancer SMR in the highest BL category with 20+ years follow-up was 1.35 (95% CI: 0.92-1.90).

CONCLUSIONS

We found an association of blood lead level with lung cancer mortality. Our data are limited by lack of work history (precluding analyses by duration of exposure), and smoking data, although the strong positive trend in RRs by increasing blood lead category in internal analysis is unlikely to be caused by smoking differences. Other limitations include different lengths of follow-up in different lead categories, reliance on few blood lead tests to characterize exposure, and few deaths for some causes.

Semen quality, infertility and mortality in the USA

STUDY QUESTION

What is the relationship between semen parameters and mortality in men evaluated for infertility?

SUMMARY ANSWER

Among men undergoing an infertility evaluation, those with abnormal semen parameters have a higher risk of death, suggesting a possible common etiology between infertility and mortality.

WHAT IS KNOWN ALREADY

Conflicting data exist that suggest either an inverse relationship or no relationship between semen quality and mortality.

STUDY DESIGN, SIZE, DURATION

A study cohort was identified from two centers, each specializing in infertility care. In California, we identified men with data from 1994 to 2011 in the Stanford Reproductive Endocrinology and Infertility semen database. In Texas, we identified men with data from 1989 to 2009 contained in the andrology database at the Baylor College of Medicine Special Procedures Laboratory who were evaluated for infertility. Mortality was determined by data linkage to the National Death Index or Social Security Death Index. Comorbidity was estimated based on calculation of the Charlson Comorbidity Index or Centers for Medicare & Medicaid Services-Hierarchical Condition Categories Model.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In all, 11,935 men were evaluated for infertility from 1989 to 2011. During 92 104 person years of follow-up, 69 of 11,935 men died (0.58%). The mean age at infertility evaluation was 36.6 years with a mean follow-up of 7.7 years.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared with the general population, men evaluated for infertility had a lower risk of death with 69 deaths observed compared with 176.7 expected (Standardized mortality rate 0.39, 95% CI 0.30-0.49). When stratified by semen parameters, however, men with impaired semen parameters (i.e. male factor infertility) had significantly higher mortality rates compared with men with normal parameters (i.e. no male factor infertility). Low semen volume, sperm concentration, sperm motility, total sperm count and total motile sperm count were all associated with higher risk of death. In contrast, abnormal sperm morphology was not associated with mortality. While adjusting for current health status attenuated the association between semen parameters and mortality, men with two or more abnormal semen parameters still had a 2.3-fold higher risk of death compared with men with normal semen (95% CI 1.12-4.65).

LIMITATIONS, REASONS FOR CAUTION

Our cohort represents infertile men, which may limit generalizability. As comorbidity relied on administrative data, granular information on each man regarding infertility diagnosis and lifestyle factors was unavailable.

WIDER IMPLICATIONS OF THE FINDINGS

Men with impaired semen parameters have an increased mortality rate in the years following an infertility evaluation suggesting semen quality may provide a marker of health.

STUDY FUNDING/COMPETING INTEREST(S)

This study is supported in part by P01HD36289 from the Eunice Kennedy Shriver National Institute for Child Health and Human Development, National Institutes of Health (to D.J.L. and L.I.L.). The project was also partially supported by an NIH CTSA award number UL1 RR025744. None of the authors has any conflict of interest to declare.

Association between intentional injury and long-term survival after trauma

OBJECTIVE

To determine the risk-adjusted mortality of intentionally injured patients within 7 to 9 years postinjury, compared with unintentionally injured patients.

BACKGROUND

Violent injury contributes significantly to trauma mortality in the United States. Homicide is the second leading killer of American youth, aged 15 to 24 years. Long-term survival among intentionally injured patients has not been well studied. It is also unknown whether intentionally injured patients have worse long-term survival compared with unintentionally or accidentally injured patients with equivalent injuries.

METHODS

Adult trauma patients admitted for 24 hours or more and discharged alive from the Johns Hopkins Hospital from January 1, 1998, to December 31, 2000, were included. The primary outcome was mortality within 7 to 9 years postinjury. Long-term patient survival was determined using the National Death Index. The association between injury intentionality and mortality was investigated using a Cox proportional hazard regression model, adjusted for confounders such as injury severity and patient race, socioeconomic status, and comorbid conditions. Overall differences in survival between those with intentional versus unintentional injury were also determined by comparing adjusted Kaplan-Meier survival curves.

RESULTS

A total of 2062 patients met inclusion criteria. Of these, 56.4% were intentionally injured and 43.6% were unintentionally injured. Compared with unintentionally injured patients, intentionally injured patients were younger and more often male and from a zip code with low median household income. Approximately 15% of all patients had died within 7 to 9 years of follow-up. Older age and presence of comorbidities were associated with this outcome; however, intentional injury was not found to be significantly associated with long-term mortality rates. There was also no significant difference in survival curves between groups; intentionally injured patients were much more likely to die of a subsequent injury, whereas those with unintentional injury commonly died of noninjury causes.

CONCLUSIONS

There was no significant difference in mortality between intentionally injured and unintentionally injured patients within 7 to 9 years postinjury. These results confirm the long-term effectiveness of lifesaving trauma care for those with intentional injury. However, given that patients with intentional injuries were more likely to suffer a subsequent violent death, interventions focused on breaking the cycle of violence are needed.

Incident ESRD among participants in a lead surveillance program

BACKGROUND

Very high levels of lead can cause kidney failure; data about renal effects at lower levels are limited.

STUDY DESIGN

Cohort study, external (vs US population) and internal (by exposure level) comparisons.

SETTINGS & PARTICIPANTS

58,307 men in an occupational surveillance system in 11 US states.

PREDICTOR

Blood lead levels.

OUTCOME

Incident end-stage renal disease determined by matching the cohort with the US Renal Data System (n=302).

MEASUREMENTS

Blood lead categories were 0-<5, 5-<25, 25-<40, 40-51, and >51 μg/dL, defined by highest blood lead test result. One analysis for those with data for race (31% of cohort) and another for the whole cohort after imputing race.

RESULTS

Median follow-up was 12 years. Among those with race information, the end-stage renal disease standardized incidence ratio (SIR; US population as referent) was 1.08 (95% CI, 0.89-1.31) overall. The SIR in the highest blood lead category was 1.47 (95% CI, 0.98-2.11), increasing to 1.56 (95% CI, 1.02-2.29) for those followed up for 5 or more years. For the entire cohort (including those with race imputed), the overall SIR was 0.92 (95% CI, 0.82-1.03), increasing to 1.36 (95% CI, 0.99-1.73) in the highest blood lead category (SIR of 1.43 [95% CI, 1.01-1.85] in those with ≥5 years' follow-up). In internal analyses by Cox regression, rate ratios for those with 5 or more years' follow-up in the entire cohort were 1.0 (0-<5 and 5-<25 μg/dL categories combined) and 0.92, 1.08, and 1.96 for the 25-<40, 40-51, and >51 μg/dL categories, respectively (P for trend=0.003). The effect of lead was strongest in nonwhites.

LIMITATIONS

Lack of detailed work history, reliance on only a few blood lead tests per person to estimate level of exposure, lack of clinical data at time of exposure.

CONCLUSIONS

Data suggest that current US occupational limits on blood lead levels may need to be strengthened to avoid kidney disease.

White blood cell count and mortality in patients with acute pulmonary embolism

Although associated with adverse outcomes in other cardiovascular diseases, the prognostic value of an elevated white blood cell (WBC) count, a marker of inflammation and hypercoagulability, is uncertain in patients with pulmonary embolism (PE). We therefore sought to assess the prognostic impact of the WBC in a large, state-wide retrospective cohort of patients with PE. We evaluated 14,228 patient discharges with a primary diagnosis of PE from 186 hospitals in Pennsylvania. We used random-intercept logistic regression to assess the independent association between WBC count levels at the time of presentation and mortality and hospital readmission within 30 days, adjusting for patient and hospital characteristics. Patients with an admission WBC count <5.0, 5.0-7.8, 7.9-9.8, 9.9-12.6, and >12.6 × 10(9) /L had a cumulative 30-day mortality of 10.9%, 6.2%, 5.4%, 8.3%, and 16.3% (P < 0.001), and a readmission rate of 17.6%, 11.9%, 10.9%, 11.5%, and 15.0%, respectively (P < 0.001). Compared with patients with a WBC count 7.9-9.8 × 10(9) /L, adjusted odds of 30-day mortality were significantly greater for patients with a WBC count <5.0 × 10(9) /L (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14-2.03), 9.9-12.6 × 10(9) /L (OR 1.55, 95% CI 1.26-1.91), or >12.6 × 10(9) /L (OR 2.22, 95% CI 1.83-2.69), respectively. The adjusted odds of readmission were also significantly increased for patients with a WBC count <5.0 × 10(9) /L (OR 1.34, 95% CI 1.07-1.68) or >12.6 × 10(9) /L (OR 1.29, 95% CI 1.10-1.51). In patients presenting with PE, WBC count is an independent predictor of short-term mortality and hospital readmission.

Predictors of mortality over 8 years in type 2 diabetic patients: Translating Research Into Action for Diabetes (TRIAD)

OBJECTIVE

To examine demographic, socioeconomic, and biological risk factors for all-cause, cardiovascular, and noncardiovascular mortality in patients with type 2 diabetes over 8 years and to construct mortality prediction equations.

RESEARCH DESIGN AND METHODS

Beginning in 2000, survey and medical record information was obtained from 8,334 participants in Translating Research Into Action for Diabetes (TRIAD), a multicenter prospective observational study of diabetes care in managed care. The National Death Index was searched annually to obtain data on deaths over an 8-year follow-up period (2000-2007). Predictors examined included age, sex, race, education, income, smoking, age at diagnosis of diabetes, duration and treatment of diabetes, BMI, complications, comorbidities, and medication use.

RESULTS

There were 1,616 (19%) deaths over the 8-year period. In the most parsimonious equation, the predictors of all-cause mortality included older age, male sex, white race, lower income, smoking, insulin treatment, nephropathy, history of dyslipidemia, higher LDL cholesterol, angina/myocardial infarction/other coronary disease/coronary angioplasty/bypass, congestive heart failure, aspirin, β-blocker, and diuretic use, and higher Charlson Index.

CONCLUSIONS

Risk of death can be predicted in people with type 2 diabetes using simple demographic, socioeconomic, and biological risk factors with fair reliability. Such prediction equations are essential for computer simulation models of diabetes progression and may, with further validation, be useful for patient management.

Elevated admission glucose and mortality in patients with acute pulmonary embolism

OBJECTIVE

Although associated with adverse outcomes in other cardiopulmonary conditions, the prognostic value of elevated glucose in patients with acute pulmonary embolism (PE) is unknown. We sought to examine the association between glucose levels and mortality and hospital readmission rates for patients with PE.

RESEARCH DESIGN AND METHODS

We evaluated 13,621 patient discharges with a primary diagnosis of PE from 185 acute care hospitals in Pennsylvania (from January 2000 to November 2002). Admission glucose levels were analyzed as a categorical variable (≤110, >110-140, >140-170, >170-240, and >240 mg/dL). The outcomes were 30-day all-cause mortality and hospital readmission. We used random-intercept logistic regression to assess the independent association between admission glucose levels and mortality and hospital readmission, adjusting for patient (age, sex, race, insurance, comorbid conditions, severity of illness, laboratory parameters, and thrombolysis) and hospital (region, size, and teaching status) factors.

RESULTS

Elevated glucose (>110 mg/dL) was present in 8,666 (63.6%) patients. Patients with a glucose level ≤110, >110-140, >140-170, >170-240, and >240 mg/dL had a 30-day mortality of 5.6, 8.4, 12.0, 15.6, and 18.3%, respectively (P < 0.001). Compared with patients with a glucose level ≤110 mg/dL, the adjusted odds of dying were greater for patients with a glucose level >110-140 (odds ratio 1.19 [95% CI 1.00-1.42]), >140-170 (1.44 [1.17-1.77]), >170-240 (1.54 [1.26-1.90]), and >240 mg/dL (1.60 [1.26-2.03]), with no difference in the odds of hospital readmission.

CONCLUSIONS

In patients with acute PE, elevated admission glucose is common and independently associated with short-term mortality.

Prognostic clinicopathologic factors in longitudinally followed patients with metastatic small bowel carcinoid tumors

OBJECTIVES

Neuroendocrine tumors demonstrate heterogeneous behavior based on the site of origin and histology. This study aimed to delineate prognostic clinicopathologic features in patients with metastatic midgut carcinoid.

METHODS

All patients underwent resection of the primary tumor in the setting of metastatic disease. Survival was measured from the date of primary tumor resection and calculated by Kaplan-Meier estimation. Clinical data include age, sex, serum biomarkers, primary tumor size, Ki-67 index, and the performance of hepatic cytoreductive procedure. Serially collected serum biomarkers were considered as mean values within periods relative to primary resection: preoperative, 0 to 1 year postoperative, and years 1 to 5 postoperative. Log-rank comparisons were used to assess the prognostic value of the aforementioned features.

RESULTS

Forty-nine patients (21 men) with metastatic midgut carcinoid who underwent primary tumor resection were identified. Median survival was 121 months. The overall 5-year survival rate was 83%. Age higher than 65 years (P = 0.01) and late postoperative chromogranin A (CgA; P = 0.02) were associated with decreased survival.

CONCLUSIONS

This study highlights the favorable prognosis of patients with metastatic small bowel carcinoid in a multidisciplinary treatment program. Among other factors, elevated postoperative CgA is associated with decreased survival. The significance of increased CgA over time underlies the importance of longitudinal follow-up for these patients.

The general social survey-national death index: an innovative new dataset for the social sciences

Background

Social epidemiology seeks in part to understand how social factors--ideas, beliefs, attitudes, actions, and social connections--influence health. However, national health datasets have not kept up with the evolving needs of this cutting-edge area in public health. Sociological datasets that do contain such information, in turn, provide limited health information.

Findings

Our team has prospectively linked three decades of General Social Survey data to mortality information through 2008 via the National Death Index. In this paper, we describe the sample, the core elements of the dataset, and analytical considerations.

Conclusions

The General Social Survey-National Death Index (GSS-NDI), to be released publicly in October 2011, will help shape the future of social epidemiology and other frontier areas of public health research.

Chronic kidney disease and risk of death from infection

BACKGROUND

Infection, bacteremia and sepsis are major sources of morbidity and mortality in patients with end-stage renal disease. This study sought to determine the association between predialysis chronic kidney disease (CKD) and infection-related mortality.

METHODS

We analyzed participants in the Third National Health and Nutrition Examination Survey (NHANES III). The study included adults ≥45- years-old without end-stage renal disease. Estimated glomerular filtration rate (eGFR) was categorized as ≥60, 45-59.9 and <45 ml/min per 1.73 m(2), and urinary albumin-to-creatinine ratio (ACR) as <30, 30-299.9 and ≥300 mg/g. The study identified infection-related mortality, including septicemia, respiratory, abdominal and gastrointestinal, cardiac, kidney and genitourinary, neurologic, and other infections over a median of 13 years using the National Death Index.

RESULTS

Of 7,400 participants included in the study, 206 died from infections. Compared to individuals with eGFR ≥60 ml/min per 1.73 m(2), infection-related mortality was higher for those with lower eGFR [adjusted HR = 1.36 (95% CI: 0.81, 2.30) and 2.36 (1.04, 5.38) for eGFR of 45-59.9 and <45 ml/min per 1.73 m(2), respectively; p trend = 0.06]. Compared to individuals with ACR <30 mg/g, infection-related mortality was higher for ACR levels of 30-299 and ≥300 mg/g [adjusted HR = 1.68 (95% CI: 0.97, 2.92) and 2.84 (0.92, 8.74), p trend = 0.02].

CONCLUSIONS

Reduced eGFR and albuminuria are associated with increased risk for infection-related mortality. Efforts are needed to reduce its incidence and mitigate the effects of infections among individuals with CKD.

Temporal trends in recording of diabetes on death certificates: results from Translating Research Into Action for Diabetes (TRIAD)

OBJECTIVE

To determine the frequency that diabetes is reported on death certificates of decedents with known diabetes and describe trends in reporting over 8 years.

RESEARCH DESIGN AND METHODS

Data were obtained from 11,927 participants with diabetes who were enrolled in Translating Research into Action for Diabetes, a multicenter prospective observational study of diabetes care in managed care. Data on decedents (N=2,261) were obtained from the National Death Index from 1 January 2000 through 31 December 2007. The primary dependent variables were the presence of the ICD-10 codes for diabetes listed anywhere on the death certificate or as the underlying cause of death.

RESULTS

Diabetes was recorded on 41% of death certificates and as the underlying cause of death for 13% of decedents with diabetes. Diabetes was significantly more likely to be reported on the death certificate of decedents dying of cardiovascular disease than all other causes. There was a statistically significant trend of increased reporting of diabetes as the underlying cause of death over time (P<0.001), which persisted after controlling for duration of diabetes at death. The increase in reporting of diabetes as the underlying cause of death was associated with a decrease in the reporting of cardiovascular disease as the underlying cause of death (P<0.001).

CONCLUSIONS

Death certificates continue to underestimate the prevalence of diabetes among decedents. The increase in reporting of diabetes as the underlying cause of death over the past 8 years will likely impact estimates of the burden of diabetes in the U.S.

A comparison of the original and simplified Pulmonary Embolism Severity Index

The Pulmonary Embolism Severity Index (PESI) is a validated clinical prognostic model for patients with pulmonary embolism (PE). Recently, a simplified version of the PESI was developed. We sought to compare the prognostic performance of the original and simplified PESI. Using data from 15,531 patients with PE, we compared the proportions of patients classified as low versus higher risk between the original and simplified PESI and estimated 30-day mortality within each risk group. To assess the models' accuracy to predict mortality, we calculated sensitivity, specificity, and predictive values and likelihood ratios for low- versus higher-risk patients. We also compared the models' discriminative power by calculating the area under the receiver-operating characteristic curve. The overall 30-day mortality was 9.3%. The original PESI classified a significantly greater proportion of patients as low-risk than the simplified PESI (40.9% vs. 36.8%; p<0.001). Low-risk patients based on the original and simplified PESI had a mortality of 2.3% and 2.7%, respectively. The original and simplified PESI had similar sensitivities (90% vs. 89%), negative predictive values (98% vs. 97%), and negative likelihood ratios (0.23 vs. 0.28) for predicting mortality. The original PESI had a significantly greater discriminatory power than the simplified PESI (area under the ROC curve 0.78 [95% CI: 0.77-0.79] vs. 0.72 [95% CI: 0.71-0.74]; p<0.001). In conclusion, even though the simplified PESI accurately identified patients at low-risk of adverse outcomes, the original PESI classified a higher proportion of patients as low-risk and had a greater discriminatory power than the simplified PESI.

Defining patient-prosthesis mismatch and its effect on survival in patients with impaired ejection fraction

BACKGROUND

How best to define patient-prosthesis mismatch (PPM) continues to be debated. Over time, the indexed effective orifice area has become the most widely used method. However, the clinical relevance of PPM remains controversial.

METHODS

The indexed geometric orifice area and indexed effective orifice area were calculated for 143 patients having undergone aortic valve replacement with a normal left ventricular function 0.45 or less. Using the indexed geometric orifice area method, PPM was defined as nonsignificant if 1.2 cm(2)/m(2) or greater and as significant if less than 1.2 cm(2)/m(2). Using the indexed effective orifice area method, PPM was considered as nonsignificant if greater than 0.85 cm(2)/m(2), as moderate if greater than 0.65 cm(2)/m(2) and less than or equal to 0.85 cm(2)/m(2), and as severe PPM if 0.65 cm(2)/m(2) or less.

RESULTS

The number of patients classified as having PPM differed according to the method used to predict its presence (PPM: Effective orifice area method = 72.7%; geometric method = 19.6%). Regardless of the method used to classify PPM there was no significant effect on mortality (adjusted hazard ratio: 2.65 at 1 year, 0.99 at 5 years, 0.92 at 9 years; p = not significant). The postoperative mean transvalvular gradient (17.1 ± 6.5 mm Hg) and left ventricular function (0.50 ± 0.145) improved significantly compared with the preoperative findings.

CONCLUSIONS

The method used to calculate PPM resulted in significant classification discordance. However, regardless of classification, the presence of PPM did not adversely affect long-term outcome.

Resource utilization in off-pump versus conventional coronary artery bypass grafting in a community hospital: a comparative analysis using propensity scoring

BACKGROUND

At a time when cost containment in health care is under increased scrutiny, coronary artery bypass grafting remains the most widely performed cardiac surgical procedure in the world. This study compares 30-day mortality, morbidity, and resource use for off-pump coronary artery bypass (OPCAB) versus conventional coronary artery bypass (CCAB) revascularization.

METHODS

From January 2000 through December 2008, 1003 patients underwent OPCAB grafting by a single surgeon (S.C.S.). Data were prospectively collected, entered into a Society of Thoracic Surgeons adult cardiac surgery database, and analyzed retrospectively. We used propensity-matching techniques to match this cohort to a group of 1003 patients who underwent CCAB.

RESULTS

The hospital mortality rate was lower for the OPCAB patients than for the CCAB patients: 2.0% (20/1003) versus 2.8% (28/1003). Predictors of hospital mortality for the entire cohort included age (P = .001), cardiogenic shock (P = .001), congestive heart failure (P = .019), history of myocardial infarction (P = .001), and reoperation (P = .007). The overall incidence of morbidity was lower for the OPCAB patients (reoperation for bleeding, P = .011; prolonged ventilation, P = .035; stroke, P = .045; cardiac arrest, P = .004). OPCAB patients experienced significantly reduced procedure times (P = .001), postoperative ventilation times (P = .035), post-operative lengths of stay (P = .035), and blood product use (intraoperative, P = .001; postoperative, P = .001).

CONCLUSION

These outcomes clearly demonstrate that OPCAB is a safe and effective procedure for myocardial revascularization. This retrospective, nonrandomized observational study has shown that the patients who underwent OPCAB had reduced morbidity and mortality, as well as decreased resource use, compared with those who underwent CCAB.

Long-Term Survival after Minimal Invasive Direct Coronary Artery Bypass (MIDCAB) Surgery in Patients with Low Ejection Fraction

Objective

The long-term survival after minimal invasive direct coronary artery bypass (MIDCAB) surgery to any coronary territory in patients with ejection fraction of ≤30% was investigated for the first time in literature.

Methods

Seventy-three patients with primary MIDCAB and 89 patients with reoperative MIDCAB were studied including preoperative risk factors, operative details, early postoperative complications, and survival up to 10 years postoperatively.

Results

Despite the high-risk profile of the patients, the MIDCAB approach for targeted revascularization resulted in excellent short-term results. Ventricular arrhythmia contributed to four of six early deaths. Survival at 5 years postoperatively was 62.5% for primary MIDCAB and 43.2% for reoperative MIDCAB and at 10 years was 36.9% and 29.5%, respectively. Functionally complete vascularization correlates with significantly better long-term survival particularly in primary MIDCAB procedures.

Conclusions

MIDCAB is a valuable option for targeted revascularization in high-risk patients with low ejection fraction and reoperation.

Does volunteering moderate the relation between functional limitations and mortality?

Previous studies have demonstrated that functional limitations increase, and organizational volunteering decreases, the risk of mortality in later life. However, scant attention has been paid to investigating the joint effect of functional limitations and organizational volunteering on mortality. Accordingly, we tested the hypothesis that volunteering moderates the relation between functional limitations and risk of mortality. This prospective study used baseline survey data from a representative sample of 916 non-institutionalized adults 65 years old and older who lived in the continental United States. Data on mortality were extracted six years later from the National Death Index. Survival analyses revealed that functional limitations were associated with an increased risk of dying only among participants who never or almost never volunteered, suggesting that volunteering buffers the association between functional limitations and mortality. We conclude that although it may be more difficult for older adults with functional limitations to volunteer, they may receive important benefits from doing so.

Risk of cardiovascular events and all-cause mortality in patients treated with thiazolidinediones in a managed-care population

BACKGROUND

This study directly compares risk of acute myocardial infarction (AMI), acute heart failure (AHF), or all-cause death among pioglitazone- and rosiglitazone-treated patients in a managed-care population.

METHODS AND RESULTS

Patients ≥18 years of age, newly initiated on rosiglitazone or pioglitazone between January 1, 2001, and December 12, 2005, were included. The date of the first pharmacy claim for rosiglitazone or pioglitazone was defined as index date. Patients were excluded if they had <1 year continuous eligibility preindex or a preindex insulin claim. Primary outcome measure was time to composite event of AMI, AHF or death among pioglitazone- and rosiglitazone-treated patients. The National Death Index database was accessed to obtain date of death for patients who died during the study period. Propensity score matching was used to control for potential confounders. The Cox proportional hazards model was used to evaluate effects of exposure to rosiglitazone and pioglitazone on time to event. A total of 36 628 patients (58% male; mean age, 54 years) were identified. Of the rosiglitazone-treated patients, 602 (4.16%) had an AMI, AHF, or death compared with 599 (4.14%) propensity score-matched pioglitazone-treated patients. No significant difference was observed between matched groups for risk of composite event (hazard ratio, 1.03; 95% confidence interval, 0.91 to 1.15; P=0.666) when patients were followed from index date until end of study period, termination of enrollment status, or diagnosis of AMI/AHF/death.

CONCLUSIONS

In this retrospective cohort study directly comparing rosiglitazone and pioglitazone with a propensity score-matched population that includes mortality data, no significant differences were found in the risk of AMI, AHF or death.

The prognosis of a normal stress-only Tc-99m myocardial perfusion imaging study

BACKGROUND

Stress-only imaging saves time and radiation exposure, but apprehension remains about the reliability, diagnostic, and prognostic accuracy of a normal stress-only study. The objective of this study was to determine the prognosis of stress-only SPECT MPI in routine clinical practice.

METHODS

Patients at lower pre-test risk for CAD presenting for a Tc-99m SPECT MPI over a 2-year period underwent a stress-only protocol. If the stress images were normal (attenuation correction was routinely acquired on all patients), rest imaging was not done. Outcomes of the stress-only group were compared to a full rest-stress protocol cohort. Only patients with normal perfusion and left ventricular function, and no known CAD, were included. All-cause mortality was determined using the Social Security Death Index and specific causes of death were determined using the National Death Index. The difference in all-cause and cardiac mortality between groups in the presence of competing risks was assessed using log-normal survival models.

RESULTS

Out of 10,609 patients studied during the time period, 1,673 had a normal stress-only study and 3,237 had a normal rest-stress study. At one year, there were 20 total and 3 cardiac deaths (1.2% and 0.2% mortality) in the stress-only group, and 40 total and 4 cardiac deaths (1.2% and 0.1% mortality) in the rest-stress cohort. At the end of follow-up (40 +/- 9 months), there were 46 total and 7 cardiac deaths (2.7% and 0.4% mortality) in the stress-only group, and 119 total and 17 cardiac deaths (3.7% and 0.5% mortality) in the rest-stress cohort. No significant difference between the stress-only and rest-stress cohorts was found after controlling for confounding variables for both all-cause mortality (p = .94) and cardiac mortality (p = .82).

CONCLUSIONS

A normal stress-only MPI has an excellent short-term prognosis (both for all-cause and cardiac mortality) comparable to that of a normal rest-stress MPI study.

Early mortality experience in a large military cohort and a comparison of mortality data sources

BACKGROUND

Complete and accurate ascertainment of mortality is critically important in any longitudinal study. Tracking of mortality is particularly essential among US military members because of unique occupational exposures (e.g., worldwide deployments as well as combat experiences). Our study objectives were to describe the early mortality experience of Panel 1 of the Millennium Cohort, consisting of participants in a 21-year prospective study of US military service members, and to assess data sources used to ascertain mortality.

METHODS

A population-based random sample (n = 256,400) of all US military service members on service rosters as of October 1, 2000, was selected for study recruitment. Among this original sample, 214,388 had valid mailing addresses, were not in the pilot study, and comprised the group referred to in this study as the invited sample. Panel 1 participants were enrolled from 2001 to 2003, represented all armed service branches, and included active-duty, Reserve, and National Guard members. Crude death rates, as well as age- and sex-adjusted overall and age-adjusted, category-specific death rates were calculated and compared for participants (n = 77,047) and non-participants (n = 137,341) based on data from the Social Security Administration Death Master File, Department of Veterans Affairs (VA) files, and the Department of Defense Medical Mortality Registry, 2001-2006. Numbers of deaths identified by these three data sources, as well as the National Death Index, were compared for 2001-2004.

RESULTS

There were 341 deaths among the participants for a crude death rate of 80.7 per 100,000 person-years (95% confidence interval [CI]: 72.2,89.3) compared to 820 deaths and a crude death rate of 113.2 per 100,000 person-years (95% CI: 105.4, 120.9) for non-participants. Age-adjusted, category-specific death rates highlighted consistently higher rates among study non-participants. Although there were advantages and disadvantages for each data source, the VA mortality files identified the largest number of deaths (97%).

CONCLUSIONS

The difference in crude and adjusted death rates between Panel 1 participants and non-participants may reflect healthier segments of the military having the opportunity and choosing to participate. In our study population, mortality information was best captured using multiple data sources.

Mortality among frequent consumers of Great Lakes sport fish

Commercial and sport-caught fish provide a healthy source of dietary protein, omega-3 fatty acids, and other micronutrients. Regular fish consumption has been associated with decreased risk of heart disease and health professionals encourage adults to include fish in their weekly diets. However, fish harvested from contaminated waters can contain higher levels of persistent, bioaccumulative chemicals such as methylmercury, PCBs, dieldrin, and DDT. To assess the beneficial effects of fish intake and the adverse effects of contaminant exposure, underlying and contributing causes of death were obtained from the National Death Index for 342 deceased members of a cohort of 2538 Great Lakes charterboat captains, 180 Wisconsin anglers, and 1141 referents who were established in 1993-1995. Multivariate analysis of death rates confirmed a dose-related protective effect of fish intake against all-cause and cardiovascular disease mortality, including coronary heart disease, among the referent group. This effect was not observed among consumers of Great Lakes sport fish, however. Cancer mortality was not associated with fish intake in either exposure group. While the number of deaths among this cohort is currently too small to support rigorous statistical analysis, these preliminary findings are consistent with other studies that have shown a protective effect of commercial fish on human health and longevity and raise concerns regarding the effect of persistent environmental contaminants that continue to be detected in fish from the Great Lakes Basin. It is hoped that continued monitoring of this cohort will improve our understanding of the complex interactions that exist between nutrients and contaminants found in fish harvested from the Great Lakes.

Off-pump Coronary Bypass Surgery in Patients with Low Ejection Fraction

Objective

Long-term survival after off-pump surgery in patients with low ejection fraction was investigated.

Methods

Three hundred forty-six patients with ejection fraction 30% or less with isolated off-pump coronary artery bypass surgery (OPCAB) were compared with a propensity matched historical group operated on-pump (ONCAB) and with data from literature after percutaneous coronary intervention and OPCAB surgery.

Results

The lower invasiveness of OPCAB contributed to a significantly better 30-day survival, shorter postoperative length of stay, and fewer in-hospital complications. Incomplete revascularization of the posterior and lateral territories of the heart correlated with higher 1-year mortality. The probability of survival for 8 years after OPCAB was 50.1% (n = 76) versus 49.7% (n = 82) for ONCAB without comparable data from literature for OPCAB or percutaneous coronary intervention in these high-risk patients.

Conclusions

OPCAB surgery in patients with low ejection fraction is a viable alternative but so far without demonstrable long-term survival advantage to ONCAB.