Marie Duncan

Mortality Rates for Stroke in England From 1979 to 2004. Trends, Diagnostic Precision, and Artifacts

Background and Purpose— Stroke mortality appears to be declining more rapidly in the UK than in many other Western countries. To understand this apparent decline better, we studied trends in mortality in the UK using more detailed data than are routinely available. Methods— Analysis of datasets that include both the underlying cause and all other mentioned causes of death (together, termed “all mentions”): the Oxford Record Linkage Study from 1979 to 2004 and English national data from 1996 to 2004. Results— Mortality rates based on underlying cause and based on all mentions showed similar downward trends. Mortality based on underlying cause alone misses about one quarter of all stroke-related deaths. Changes during the period in the national rules for selecting the underlying cause of death had a significant but fairly small effect on the trend. Overall, mortality fell by an average annual rate of 2.3% (95% confidence interval 2.1% to 2.5%) for stroke excluding subarachnoid hemorrhage; and by 2.1% (1.7% to 2.6%) per annum for subarachnoid hemorrhage. Coding of stroke as hemorrhagic, occlusive, or unspecified varied substantially across the study period. As a result, rates for hemorrhagic and occlusive stroke, affected by artifact, seemed to fall substantially in the first part of the study period and then leveled off. Conclusion— Studies of stroke mortality should include all mentions as well as the certified underlying cause, otherwise the burden of stroke will be underestimated. Studies of stroke mortality that include strokes specified as hemorrhagic or occlusive, without also considering stroke overall, are likely to be misleading. Stroke mortality in the Oxford region halved between 1979 and 2004.

Trends in death certification for multiple sclerosis, motor neuron disease, Parkinson’s disease and epilepsy in English populations 1979–2006

The objective of this study is to report trends in mortality, as certified on death certificates, from multiple sclerosis (MS), motor neuron disease (MND), primary Parkinson’s disease (PD), and epilepsy, analysing not only the underlying cause of death but also all certified causes for each disease. Death records in the Oxford region, 1979–2006, and England, 1996–2006, were analysed for ascertaining the trends in mortality. The percentage of deaths coded as the underlying cause changed over time, coinciding with changes to the rules for selecting the underlying cause of death. Changes over time to coding rules had a large impact on apparent trends in death rates for PD when studied by underlying cause alone. They also had significant, though smaller, effects on trends in death rates for MS, MND and epilepsy. Nationally, in the last period of the study, underlying cause mortality identified 64% of deaths with a mention of MS, 88% of MND, 56% of PD, and 48% of epilepsy. In the longstanding Oxford data from 1979 to 2006, death rates based on all certified causes of death showed no significant change for MS; an upward trend for MND (notably in women over 75), though only in the last few years of the study; a significant but small decline for PD; and no significant change for epilepsy. When mortality statistics are analysed by underlying cause only, their value is reduced. A substantial percentage of neurological deaths are missed. Time trends may be misleading. All certified causes for each disease, as well as the underlying cause, should be analysed.

Trends in mortality rates for death-certificate-coded diabetes mellitus in an English population 1979-99.

Aims  Mortality statistics have customarily been coded and analysed using only one underlying cause of death. Rules for selecting the underlying cause, when more than one cause is certified on a death certificate, have changed twice in England over the past 20 years. We used data from death certificates for 1979–99 to compare mortality rates for diabetes mellitus certified anywhere on death certificates with those certified as the underlying cause.

Mortality from heart failure, acute myocardial infarction and other ischaemic heart disease in England and Oxford: a trend study of multiple-cause-coded death certification

Background Age-standardised death rates from acute myocardial infarction (AMI) and ischaemic heart disease (IHD) have been declining in most developed countries. However, the magnitude of such reductions and how they impact on death from heart failure are less certain. We sought to assess and compare temporal trends in mortality from heart failure, AMI and non-AMI IHD over a 30-year period in England. Methods We analysed death registration data for multiple-cause-coded mortality for all deaths in people aged 35 years and over in England from 1995 to 2010, population 52 million, and in a regional population (Oxford region) from 1981 to 2010, population 2.5 million, for which data on all causes of death were available. Results Considering all ages and both sexes combined, during the 30-year observation period, age-standardised and sex-standardised mortality rates based on all certified causes of death declined by 60% for heart failure, 80% for AMI and 46% for non-AMI IHD. These longer term trends observed in the Oxford region were consistent with those for the whole of England from 1995 to 2010, with no evidence of a plateau in recent years. Although proportional reductions in rates differed by age and sex, even in those aged 85 years or more, there were substantial reductions in mortality rates in the all-England data set (50%, 66% and 20% for heart failure, AMI and non-AMI IHD, respectively). Conclusions This study shows large and sustained reductions in age-specific and sex-specific and standardised death rates from heart failure, as well as from AMI and non-AMI IHD, over a 30-year period in England.

Psychiatric disorders certified on death certificates in an English population

BackgroundPsychiatric disorders are sometimes certified on death certificates, but seldom selected as the underlying cause of death. The majority of deaths with a certified psychiatric cause are usually omitted from official mortality statistics, which are typically based on the underlying cause alone.AimTo report on death rates for psychiatric disorders, as certified on death certificates, including all mentioned causes as well as the underlying cause of death.MethodAnalysis of database including all certified causes of death in 1979–1999, in three time periods defined by coding rule changes.ResultsStatistics on the underlying cause of death grossly under-estimated certified psychiatric disorders. For example, in the first period of our study they missed 88% of deaths in which schizophrenia was a certified cause, 98% of affective psychosis, and 96% of depression. Over time, considering all certified causes, age-standardised death rates for schizophrenia declined, those for affective psychosis showed no change, and those for depression and dementia increased.ConclusionThe decline in mortality rates for schizophrenia, and the increase for depression and dementia, may reflect real changes over time in disease prevalence at death, although other explanations are possible and are discussed.

Cancer of the body of the uterus: trends in mortality and incidence in England, 1985–2008

Please cite this paper as: Duncan M, Seagroatt V, Goldacre M. Cancer of the body of the uterus: trends in mortality and incidence in England, 1985–2008. BJOG 2011; 10.1111/j.1471‐0528.2011.03201.x.

Mortality trends for benign prostatic hyperplasia and prostate cancer in English populations 1979-2006.

Study Type – Prevalence (retrospective cohort)
Level of Evidence 2b

Trends in mortality from appendicitis and from gallstone disease in English populations, 1979–2006: study of multiple-cause coding of deaths

Objective To report on trends in mortality from appendicitis and from gallstone disease. Design and setting Analysis of data from death certificates including all certified causes of death, termed ‘mentions’, not just the underlying cause, using data from Oxford (‘mentions’ available from 1979 to 2006) and all England (‘mentions’ available from 1995 to 2006). Outcome measures Mortality rates across all years studied, and in periods defined by changes to national rules in selecting the underlying cause of death. Results In the Oxford region, mortality rates for appendicitis based on underlying cause fluctuated between periods defined by coding rule changes. Those based on mentions were more stable: they were 3.3 per million population in 1979–83 and 3.5 in 2001–6. Nationally, mentions-based rates fell from 3.4 per million in 1995–2000 to 3.1 in 2001–2006, a small but statistically significant decline. For gallstone disease in Oxford, rates fell in the early years but then levelled off. Mortality rates for gallstones in England actually rose slightly between 1995–2000 (15.0 deaths per million) and 2001–6 (15.6 per million). The majority of deaths from appendicitis and gallstone disease were in the elderly. Conclusions Appendicitis and gallstones are considered to be avoidable causes of death. Mortality rates for each cause have not shown any substantial falls in the recent periods covered by this study. It is possible that deaths were not, in fact, avoidable, but audits into the circumstances of deaths from these diseases may be warranted. Mortality data based on underlying cause alone substantially underestimate deaths from these two conditions.

Inflammatory bowel disease, peptic ulcer and diverticular disease as certified causes of death in an English population 1979-2003.

Background When gastrointestinal diseases are certified as causes of death, they are often not selected as the underlying cause. Until recently, only one underlying cause of death has been coded and analysed in official national statistics in England and many other countries. Aims To report on the total ‘burden of mortality’ from some common gastrointestinal diseases, and whether it has changed over time, including all certified causes of death as well as underlying causes, (i) in the Oxford region from 1979 to 2003, (ii) in England from 1996 to 2003; and to quantify the under-ascertainment of cause-specific mortality when based on underlying cause alone. Methods We searched death certificate data from the Oxford Record Linkage Study database, and from English national data, for specified gastrointestinal diseases certified as underlying or contributory causes of death. Results For all the conditions studied, underlying-cause-coded mortality missed a substantial percentage of all certified deaths. The extent of underestimation varied according to the periods in which different criteria were used for the selection of the underlying cause. For example, in Oxford, in the latest period 1993–2003, underlying-cause-coded mortality identified only 37% of all death certificates with ulcerative colitis, 47% of Crohns disease, between 62 and 68% for the different types of peptic ulcer and 66% of diverticular disease. Conclusions Studies of mortality for these diseases should take account of all certified causes as well as underlying-cause mortality. This is particularly important for analyses that go across periods of change to the rules for selecting the underlying cause of death.

Trends in mortality for agranulocytosis in English populations, 1979-2010 and associations with cancer

and we speculate that romiplostim may have contributed to this outcome, leading to a reduction of haemorrhagic complications. Hence, we significantly modified our protocol in four patients, who were treated with one injection of 4 lg/kg romiplostim 1 week before transplantation and at days +2 and +8 post-transplant. For these patients, of whom two were treated by BEAM, the mean period of severe thrombocytopenia was 1 (range, 0–4) day. The last patient received 4 lg/kg romiplostim before melphalan on days 15 and 8; the nadir platelet count was 34 9 10/l. Further studies may help to determine a more accurate dosage and schedule for romiplostim administration during ASCT, based on ongoing studies with TPO-R agonists as a supporting intervention after chemotherapy (Stasi et al, 2010). Overall, our current study confirms the feasibility of ASCT without transfusion and emphasizes the benefit of using haematopoiesis-stimulating agents in this setting.