Regina Zimmerman

Sickle cell disease incidence among newborns in New York State by maternal race/ethnicity and nativity

Purpose:Sickle cell disease is estimated to occur in 1:300–400 African-American births, with higher rates among immigrants from Africa and the Caribbean, and is less common among Hispanic births. This study determined sickle cell disease incidence among New York State newborns stratified by maternal race/ethnicity and nativity.Methods:Newborns with confirmed sickle cell disease born to New York State residents were identified by the New York State newborn screening program for the years 2000–2008 and matched to birth records to obtain birth and maternal information. Annual incidence rates were computed and bivariate analyses were conducted to examine associations with maternal race/ethnicity and nativity.Results:From 2000 to 2008, 1,911 New York State newborns were diagnosed with sickle cell disease and matched to the birth certificate files. One in every 1,146 live births was diagnosed with sickle cell disease. Newborns of non-Hispanic black mothers accounted for 86% of sickle cell disease cases whereas newborns of Hispanic mothers accounted for 12% of cases. The estimated incidence was 1:230 live births for non-Hispanic black mothers, 1:2,320 births for Hispanic mothers, and 1:41,647 births for non-Hispanic white mothers. Newborns of foreign-born non-Hispanic black mothers had a twofold higher incidence of sickle cell disease than those born to US-born non-Hispanic black mothers (P < 0.001).Conclusion:This study provides the first US estimates of sickle cell disease incidence by maternal nativity. Women born outside the United States account for the majority of children with sickle cell disease born in New York State. Such findings identify at-risk populations and inform outreach activities that promote ongoing, high-quality medical management to affected children.Genet Med 2013:15(3):222–228

An intervention to improve cause-of-death reporting in New York City hospitals, 2009-2010.

Introduction Poor-quality cause-of-death reporting reduces reliability of mortality statistics used to direct public health efforts. Overreporting of heart disease has been documented in New York City (NYC) and nationwide. Our objective was to evaluate the immediate and longer-term effects of a cause-of-death (COD) educational program that NYC’s health department conducted at 8 hospitals on heart disease reporting and on average conditions per certificate, which are indicators of the quality of COD reporting. Methods From June 2009 through January 2010, we intervened at 8 hospitals that overreported heart disease deaths in 2008. We shared hospital-specific data on COD reporting, held conference calls with key hospital staff, and conducted in-service training. For deaths reported from January 2009 through June 2011, we compared the proportion of heart disease deaths and average number of conditions per death certificate before and after the intervention at both intervention and nonintervention hospitals. Results At intervention hospitals, the proportion of death certificates that reported heart disease as the cause of death decreased from 68.8% preintervention to 32.4% postintervention (P < .001). Individual hospital proportions ranged from 58.9% to 79.5% preintervention and 25.9% to 45.0% postintervention. At intervention hospitals the average number of conditions per death certificate increased from 2.4 conditions preintervention to 3.4 conditions postintervention (P < .001) and remained at 3.4 conditions a year later. At nonintervention hospitals, these measures remained relatively consistent across the intervention and postintervention period. Conclusion This NYC health department’s hospital-level intervention led to durable changes in COD reporting.

Trends in Cardiovascular Disease Mortality Among Persons With HIV in New York City, 2001–2012

BACKGROUND Cardiovascular disease (CVD) has become more prominent among human immunodeficiency virus (HIV)-infected individuals. The extent to which CVD mortality rates are changing is unclear. METHODS We analyzed surveillance data for all persons aged ≥13 years with HIV infection between 2001 and 2012 reported to the New York City HIV Surveillance Registry. We examined age-specific and age-standardized mortality rates due to major CVDs. We compared mortality time trends among persons with HIV with the general population, and examined differences among HIV-infected persons by RNA level. RESULTS There were 29 588 deaths reported among 145 845 HIV-infected persons. Ten percent of deaths were attributed to CVD as the underlying cause, including chronic ischemic heart disease (42% of CVD deaths), hypertensive diseases (27%), and cerebrovascular diseases (10%). While proportionate mortality due to CVD among persons with HIV increased (6% in 2001 to 15% in 2012, P < .001), the CVD mortality rate decreased from 5.1 to 2.7 per 1000 person-years. After controlling for sex, race/ethnicity, borough of residence, and year, those with HIV had significantly higher CVD mortality than the general population in all age groups through age 65. The CVD mortality rate was highest among viremic persons (adjusted rate ratio [RR], 3.53 [95% confidence interval {CI}, 3.21-3.87]) but still elevated among virally suppressed (<400 copies/mL) persons (adjusted RR, 1.53 [95% CI, 1.41-1.66]) compared with the general population. CONCLUSIONS Our findings support continued emphasis by HIV care providers on both viremic control and preventive measures including smoking cessation, blood pressure control, and lipid management.

Impact of a hospital-level intervention to reduce heart disease overreporting on leading causes of death.

Introduction The quality of cause-of-death reporting on death certificates affects the usefulness of vital statistics for public health action. Heart disease deaths are overreported in the United States. We evaluated the impact of an intervention to reduce heart disease overreporting on other leading causes of death. Methods A multicomponent intervention comprising training and communication with hospital staff was implemented during July through December 2009 at 8 New York City hospitals reporting excessive heart disease deaths. We compared crude, age-adjusted, and race/ethnicity-adjusted proportions of leading, underlying causes of death reported during death certification by intervention and nonintervention hospitals during preintervention (January–June 2009) and postintervention (January–June 2010) periods. We also examined trends in leading causes of death for 2000 through 2010. Results At intervention hospitals, heart disease deaths declined by 54% postintervention; other leading causes of death (ie, malignant neoplasms, influenza and pneumonia, cerebrovascular disease, and chronic lower respiratory diseases) increased by 48% to 232%. Leading causes of death at nonintervention hospitals changed by 6% or less. In the preintervention period, differences in leading causes of death between intervention and nonintervention hospitals persisted after controlling for race/ethnicity and age; in the postintervention period, age accounted for most differences observed between intervention and nonintervention hospitals. Postintervention, malignant neoplasms became the leading cause of premature death (ie, deaths among patients aged 35–74 y) at intervention hospitals. Conclusion A hospital-level intervention to reduce heart disease overreporting led to substantial changes to other leading causes of death, changing the leading cause of premature death. Heart disease overreporting is likely obscuring the true levels of cause-specific mortality.

Programmatic Impact of 5 Years of Mortality Surveillance of New York City Homeless Populations

A homeless mortality surveillance system identifies emerging trends in the health of the homeless population and provides this information to key stakeholders in a timely and ongoing manner to effect evidence-based, programmatic change. We describe the first 5 years of the New York City homeless mortality surveillance system and, for the first time in peer-reviewed literature, illustrate the impact of key elements of sustained surveillance (i.e., timely dissemination of aggregate mortality data and real-time sharing of information on individual homeless decedents) on the programs of New York Citys Department of Homeless Services. These key elements had a positive impact on the departments programs that target sleep-related infant deaths and hypothermia, drug overdose, and alcohol-related deaths among homeless persons.

Effect of Cause-of-Death Training on Agreement Between Hospital Discharge Diagnoses and Cause of Death Reported, Inpatient Hospital Deaths, New York City, 2008 - 2010

Introduction Accurate cause-of-death reporting is required for mortality data to validly inform public health programming and evaluation. Research demonstrates overreporting of heart disease on New York City death certificates. We describe changes in reported causes of death following a New York City health department training conducted in 2009 to improve accuracy of cause-of-death reporting at 8 hospitals. The objective of our study was to assess the degree to which death certificates citing heart disease as cause of death agreed with hospital discharge data and the degree to which training improved accuracy of reporting. Methods We analyzed 74,373 death certificates for 2008 through 2010 that were linked with hospital discharge records for New York City inpatient deaths and calculated the proportion of discordant deaths, that is, death certificates reporting an underlying cause of heart disease with no corresponding discharge record diagnosis. We also summarized top principal diagnoses among discordant reports and calculated the proportion of inpatient deaths reporting sepsis, a condition underreported in New York City, to assess whether documentation practices changed in response to clarifications made during the intervention. Results Citywide discordance between death certificates and discharge data decreased from 14.9% in 2008 to 9.6% in 2010 (P < .001), driven by a decrease in discordance at intervention hospitals (20.2% in 2008 to 8.9% in 2010; P < .001). At intervention hospitals, reporting of sepsis increased from 3.7% of inpatient deaths in 2008 to 20.6% in 2010 (P < .001). Conclusion Overreporting of heart disease as cause of death declined at intervention hospitals, driving a citywide decline, and sepsis reporting practices changed in accordance with health department training. Researchers should consider the effect of overreporting and data-quality changes when analyzing New York City heart disease mortality trends. Other vital records jurisdictions should employ similar interventions to improve cause-of-death reporting and use linked discharge data to monitor data quality.

A case study of the impact of inaccurate cause-of-death reporting on health disparity tracking: New York City premature cardiovascular mortality.

OBJECTIVES Heart disease death overreporting is problematic in New York City (NYC) and other US jurisdictions. We examined whether overreporting affects the premature (< 65 years) heart disease death rate disparity between non-Hispanic Blacks and non-Hispanic Whites in NYC. METHODS We identified overreporting hospitals and used counts of premature heart disease deaths at reference hospitals to estimate corrected counts. We then corrected citywide, age-adjusted premature heart disease death rates among Blacks and Whites and a White-Black premature heart disease death disparity. RESULTS At overreporting hospitals, 51% of the decedents were White compared with 25% at reference hospitals. Correcting the heart disease death counts at overreporting hospitals decreased the age-adjusted premature heart disease death rate 10.1% (from 41.5 to 37.3 per 100,000) among Whites compared with 4.2% (from 66.2 to 63.4 per 100,000) among Blacks. Correction increased the White-Black disparity 6.1% (from 24.6 to 26.1 per 100,000). CONCLUSIONS In 2008, NYCs White-Black premature heart disease death disparity was underestimated because of overreporting by hospitals serving larger proportions of Whites. Efforts to reduce overreporting may increase the observed disparity, potentially obscuring any programmatic or policy-driven advances.

Mortality of New York children with sickle cell disease identified through newborn screening

Purpose:Long-term follow-up of newborn screening for conditions such as sickle cell disease can be conducted using linkages to population-based data. We sought to estimate childhood sickle cell disease mortality and risk factors among a statewide birth cohort with sickle cell disease identified through newborn screening.Methods:Children with sickle cell disease identified by newborn screening and born to New York residents in 2000–2008 were matched to birth and death certificates. Mortality rates were calculated (using numbers of deaths and observed person-years at risk) and compared with mortality rates for all New York children by maternal race/ethnicity. Stratified analyses were conducted to examine associations between selected factors and mortality.Results:Among 1,911 infants with sickle cell disease matched to birth certificates, 21 deaths were identified. All-cause mortality following diagnosis was 3.8 per 1,000 person-years in the first 2 years of life and 1.0 per 1,000 person-years at ages 2–9 years. The mortality rate was significantly lower among children of foreign-born mothers and was significantly higher among preterm infants with low birth weight. The mortality rates were not significantly higher for infants after 28 days with sickle cell disease than for all New York births, but they were 2.7–8.4 times higher for children 1 through 9 years old with homozygous sickle cell disease than for those of all non-Hispanic black or Hispanic children born to New York residents.Conclusion:Estimated mortality risk in children with homozygous sickle cell disease remains elevated even after adjustment for maternal race/ethnicity. These results provide evidence regarding the current burden of child mortality among children with sickle cell disease despite newborn screening.Genet Med 17 6, 452–459.

Excess Mortality Among Injection Drug Users With AIDS, New York City (1999–2004)

We calculated proportions and trends in contributing causes of death among persons with AIDS (PWA) and a history of injection drug use (IDU) in New York City and compared the proportions with those among PWA with a transmission risk of high-risk heterosexual sex (HRH) and men who have sex with men (MSM). We included all 10,575 injection drug user, HRH, and MSM residents aged 13+ years with AIDS reported by September 30, , who died from 1999 through 2004. Accidental drug overdose was the most frequent contributing cause of death among IDUs (20.5%). Overdose prevention initiatives may greatly and immediately reduce deaths among PWA.

Etiology of Nonspecific Cause of Death Coding in New York City Motor Vehicle Crash–Related Fatalities

Objectives: Nearly 20 percent of New York Citys (NYC) accidental deaths are related to motor vehicles crashes (MVCs). Detailed International Classification of Disease (ICD-10; World Health Organization [WHO] 2007) cause-of-death coding of MVC-related fatalities improves surveillance and resulting identification of prevention strategies. We investigated ICD-10 codes in these fatalities and the potential to make them more specific. Methods: We defined “nonspecific” MVC ICD-10 codes as all globally unspecific codes (V870–V878, V892) and any codes with nonspecific components regarding vehicle involved, decedent position in vehicle, or MVC setting. We calculated nonspecific-code frequency for 1999–2008 MVC deaths. We reviewed a random 10 percent sample of 2007–2008 MVC deaths (N = 61) and medical examiner (ME) records of all nonspecific death certificates (N = 52), including police accident reports (“full PAR”) and summaries prepared by onsite police officers (“brief PAR”) to determine whether MEs had sufficient information available but did not include that information at death certification. Results: Among 1999–2008 NYC MVC deaths, 82.9 percent had nonspecific ICD-10 cause-of-death codes. Similarly, of the 61 recent randomly sampled MVC deaths, 52 (85.2%) had nonspecific codes. Of 52 nonspecific death certificates from the random sample, 38 (73.1%) death certificates had adequate information available on full or brief PAR to be more specific at the time of death certification. Consistent with MEs’ reports of high reliance on the brief PAR, most nonspecific death certificates (76.9%) lacked adequate information in the brief PAR to be more specific. Conclusion: Specific ICD-10 codes for MVC deaths depends on the level of detail provided by the ME in the “How Injury Occurred” and “If Transportation Injury Specify” death certificates sections. We have worked to ensure that key information is available to MEs in the brief PAR and educated MEs on the importance of this information to reduce the frequency of nonspecific codes and enhance injury prevention research.