Avoidable mortality among psychiatric patients

Avoidable mortality is a selection of causes of death considered to be amenable to health care and thereby used as an indicator of the quality of health care. In this study avoidable mortality for more than 30,000 psychiatric patients discharged from any hospital of Stockholm County between 1981 and 1985 has been followed up in the Cause of Death Register for the period 1986-1990. Standardised rate ratios were calculated for different groups of psychiatric disorders compared to the general population of Stockholm County for indicators of avoidable mortality, suicide, other mortality ("unavoidable") and causes possibly related to treatment with psychotrophic drugs. As expected, the psychiatric patients had the most pronounced elevated risk for suicide. i.e. 6- to 24-fold compared to the general population, and noticeably more elevated for women. It is also noteworthy that the relative mortality risks for diagnoses amenable to medical interventions and potential side-effects of psychotrophic drugs are higher than for other causes of death ("unavoidable"). The relative risks for avoidable mortality were 4.7 for men and 3.8 for women and for diagnoses possibly related to side-effects of psychotrophic drugs, 7.2. The relative risks for "unavoidable" mortality were 3.4 for men and 3.2 for women. The excess avoidable mortality rates for psychiatric patients and the elevated suicide risk, especially for female patients, are warning signals of shortcomings in psychiatric care that warrants further investigation.     

Mortality of patients with functional psychiatric illnesses during inpatient treatment

Data from 7 psychiatric hospitals with defined catchment areas were analysed. 8927 episodes of treatment in patients with functional psychiatric disorder were recorded within 30 months (mean age 43.4 +/- 16.6 years; 41.2% male patients). During their stay in hospital 51 patients died, 31 from natural causes and 20 by suicide, compared to 12 deaths expected from the mortality rates of the general population. Standardised mortality ratios (SMRs) were calculated for the different diagnostic and age groups. In the whole population mortality from all causes (SMR 4.27, p < 0.001), as well as from natural causes (SMR 2.6 < 0.01) were significantly raised. Risks were highest in patients with schizophrenia (SMR for all causes of death 6.6, p < 0.001). Mortality from natural causes was significantly elevated in schizophrenia and related disorders. Furthermore, a high level of excess mortality mainly due to suicide was established in patients aged under 45 years (SMR 12.2, p < 0.001). Cardiovascular disorders were the most frequent causes of natural death. Our data substantiate a significantly elevated mortality risk due to natural and unnatural death of patients hospitalised for acute mental illness. Although the causative factors have not yet been fully clarified, prophylactic measures with regard to medical care as well as suicide prevention should be intensified in psychiatric hospitals.     

Accuracy of mortality data for interstitial lung diseases in New Mexico, USA

BACKGROUND: The sensitivity and accuracy of death certificates and mortality data as sources of population based data on the occurrence of interstitial lung diseases has received limited attention. To determine the usefulness of these data sources, death certificates and mortality data from patients in New Mexico were examined. METHODS: Patients with an interstitial lung disease were identified from a population based registry. For subjects who had died, diagnostic information from their death certificates and from mortality data was compared with the clinical diagnoses made before death. RESULTS: Of 385 patients with a clinical diagnosis of an interstitial lung disease, 134 died between October 1988 and August 1994. Death certificates were obtained for 96% of these patients. An interstitial lung disease was listed somewhere on the death certificate for only 46% of the patients, and as an immediate cause of death for only 15%. For the patients with an interstitial lung disease listed somewhere on the death certificate the overall concordance between the diagnoses before death and those on the death certificate was 76%. Mortality data for the State of New Mexico showed a diagnosis of interstitial lung disease to be the assigned cause of death for only 22% of the patients. The overall agreement between the diagnoses made before death and those of the state mortality data was only 21%. CONCLUSIONS: These results suggest that death certificates and state mortality data are neither sensitive nor accurate for describing the occurrence of interstitial lung diseases. This finding may partly explain the apparently low mortality rates from idiopathic pulmonary fibrosis in the USA compared with other countries.     

Rising death rate from non-malignant disease of the oesophagus (NMOD) in England and Wales

Between 1968 and 1991, the number of deaths from non-malignant oesophageal disease (NMOD) (International Classification of Diseases code 530), recorded by the Office of Population Censuses and Surveys (OPCS) in England and Wales, trebled in women, from 118 to 340 (5 to 13 per million) and doubled in men, from 131 to 251 (5.5 to 10 per million). Calculation of age specific death rates, shows the increase to result from a rise in mortality in those over 75 years and age standardised mortality confirms a rise in overall frequency from 2.9 to 7.0 deaths per million men and 5.2 to 13.1 per million women. Between 1974 and 1988 when specific diagnoses were coded, deaths from oesophageal ulcer rose from 1.5 to 2.5 per million. In men, the death rate from oesophageal stricture increased from 2.5 to 3 per million and in women from 3.5 to 6 per million. Mortality from oesophageal perforation did not change (1 per million). Some of these changes reflect the increasing age of the population in general, but further explanations are required. Review of 84 sets of case notes from a total of 281 inpatients whose coded diagnoses had included NMOD and who had died suggested that in 28 (33%) death was actually due to NMOD, and in seven of these endoscopic intervention was responsible. The certified underlying cause of death was compared with that suggested from case note review in 62 cases; death from NMOD was substantially underestimated. This study concludes that a rising death rate attributed to NMOD is underestimated on death certificates and that endoscopic intervention explains only a few of the cases.     

A death certificate-based study of occupation and mortality from reproductive cancers among women in 24 US states

We conducted a study of occupation and mortality from reproductive cancers among women, based on death certificates from 24 US states for the period 1984-1993. There were 9,523 cervical cancer deaths, 12,335 endometrial cancer deaths, and 25,212 ovarian cancer deaths. Usual occupation and industry, which were obtained from death certificates, were coded using the 1980 Bureau of Census classification system. Mortality odds ratios (MORs) and 95% confidence intervals (CIs) were calculated, using all non-cancer deaths as the referent disease category. In general, jobs involving professional or administrative occupations were related to increased risk of mortality from endometrial and ovarian cancer, while cervical cancer mortality was increased among women employed in manufacturing, service, farm work, and health care technician and aide occupations. Associations with some occupations involving exposure to chemicals and metals, such as the associations between cervical cancer and employment in printing, typesetting, and machine operating occupations, deserve further attention. Similarly, further investigations should be made into the excess of ovarian cancer observed in several occupations in health care, an industry that has numerous hazardous exposures, including radiation, chemotherapeutic drugs, and viruses. The study results reflect, in part, socioeconomic factors and reproductive patterns but may also indicate a possible etiologic role for occupational chemical exposures.     

Mortality in psychiatric hospital patients: a cohort analysis of prognostic factors

BACKGROUND: This work followed a group of patients living in a psychiatric hospital in Central Italy in 1978 at the time of enforcement of the Italian reform law (No. 180) for closing down mental hospitals. The study had the following aims: a) to compare in terms of mortality patients discharged into the community with patients who did not experience deinstitutionalization; b) to determine the survival of the cohort of patients and to analyse prognostic risk factors for death; c) to analyse differences in mortality rates between psychiatric patients and the general population. METHODS: The study was designed as an historical follow-up investigation. Univariate (product limit) and multivariate (proportional hazards model) methods were used to estimate prognostic variables and related death risks. Mortality was assessed using standardized mortality ratios (SMR) on the entire cohort as well as after stratification according to age, sex, cause of death and discharge status, assuming the Abruzzo Region's population as standard. RESULTS: Length of hospitalization and discharge from hospital are prognostic variables for death risk, with relative risks respectively of 4.22 (95% confidence interval [CI]: 2.41-7.40) for a length of hospitalization of 10-25 years, and 8.13 (95% CI: 4.73-13.88) for non-discharge. The global SMR of the cohort was 2.68 (95% CI: 2.42-3.07). Non-discharged patients showed higher SMR than discharged. Excess mortality was found both in males and females for circulatory, respiratory and undefined diseases. A significantly lower mortality for cancer was observed in male patients. A strong excess mortality was observed in younger patients (20-29 years: SMRmales = 43.57; SMRfemales = 97.52). CONCLUSIONS: Longer periods of hospitalization and non-discharge from hospital are the main risk factors for death in psychiatric patients, who globally experience higher death rates than the general population for a wide spectrum of causes of death, whatever their diagnosis or gender. These findings strongly suggest positive actions in order to overcome the effects of institutionalization.     

Epidemiology of Creutzfeldt-Jakob disease in the United States, 1979-1990: analysis of national mortality data

The trends and current incidence of Creutzfeldt-Jakob disease (CJD) was examined by using a unique and potentially high sensitive source for case ascertainment. We analyzed death certificate information for 1979-1990 from US multiple-cause-of-death mortality data, compiled by the National Center for Health Statistics, Centers for Disease Control and Prevention. We evaluated death certificate data for US residents for whom CJD was listed as one of the multiple causes of death on the death certificate (046.1) from the International Statistical Classification of Diseases, Injuries, and Causes of Death (9th revision). Age-adjusted and age-specific CJD death rates by gender, race, and region were calculated to measure the disease incidence because of the rapidly fatal course of the disease for most patients with CJD. We identified 2,614 deaths with CJD listed on the death certificates. The average annual age-adjusted mortality rate was 0.9 deaths per million persons (range 0.8-1.1). The mean age at death was 67 years. CJD-related deaths were uncommon among persons younger than 50 years of age (4.3% of all deaths). The highest average annual mortality rate was for those persons aged 70-74 years (5.9 deaths per million persons). A slight majority (53.0%) of the deaths was in females, but the age-adjusted mortality rate was 1.2 times higher for males. Most deaths (94.8%) were in whites; the mortality rate for blacks was only 40% of that for whites. The age-adjusted CJD mortality rate in the United States is similar to published estimates of the crude incidence of CJD worldwide.(ABSTRACT TRUNCATED AT 250 WORDS)     

Increased incidence of alcohol-related deaths from accidents and violence in subjects with ankylosing spondylitis

Subjects with ankylosing spondylitis (AS) have an increased incidence of deaths from accidents and violence, which is due in part, but perhaps not entirely, to the vulnerability of the affected spine to fractures. The present study covered all the 71 subjects (58 men and 13 women) who had died in Finland in 1989 and who were entitled under the nationwide sickness insurance scheme to receive specially reimbursed medication for AS. The death certificates of an earlier cohort study dealing with mortality in AS were also re-examined. Sixteen subjects (14 men and two women) in the 1989 mortality series had died of accidents and violence. Nine of the deaths (three accidents, two suicides and four alcohol poisonings) were alcohol related. The relative risk of such deaths in subjects with AS compared to the Finnish population as a whole was 2.64 (95% confidence interval 1.44-4.84). In the cohort study, 16 deaths had been due to accidents and violence, the expected number being 11.4. Eight of the 16 deaths had been alcohol related. Uncontrolled use of alcohol is an important determinant in the surplus of deaths from accidents and violence in Finnish patients with AS.     

A record-linkage study on risk factors for cause-specific infant mortality

Infant death certificates were linked with birth certificates for infants born to residents of Tohoku, Tokai and Kyushu regions in 1989 (n = 409, 679, or about one-third of all births in Japan), to examine the effects of variables, as reported on birth certificates, on cause-specific infant mortality. "Certain conditions originating in the perinatal period" and "congenital anomalies" accounted for nearly 90 percent of neonatal deaths, while "congenital anomalies", "injuries and poisoning" and "sudden infant death" were responsible for about 65 percent of postneonatal deaths. Mortality rates for almost all causes of infant deaths, except injuries and poisonings, increased as birth weight decreased not only in the neonatal period but also in the postneonatal period. This suggests that low birth weight places some infants at higher risk of death, and conditions that lead to low birth weight independently contribute to the risk of infant death. Cox's proportional hazards linear model was used to assess the effects of variables on infant mortalities by causes of death. An extremely strong birth weight effect was noted for "certain conditions originating in the perinatal period" and "congenital anomalies". Being a male infant and late order of birth in multiparity were other risk factors for deaths from "congenital anomalies", while being a male infant, resident of Tohoku region and maternal stillbirth experience related to deaths from "certain conditions originating in the perinatal period". Elevated risks of sudden infant death syndrome (SIDS), of which mortality rate in Japan was considerably lower than those in most developed Western countries, i.e. 0.23 per 1,000 live births in 1989, were associated with low birth weight, being a male infant, low maternal age, late order of birth in multiparity and illegitimacy. Low maternal age, late order of birth in multiparity and illegitimacy, also, related significantly to increased risk of infant deaths for "injuries and poisoning". These results suggest the independent contributions of socioeconomic factors to infant mortality, especially postneonatal mortality, from SIDS, "injuries and poisonings".     

The effect of gender and age at onset of depression on mortality

BACKGROUND: Depression has a marked negative impact on geriatric patient mortality and morbidity. The risk factors and exact reasons for these effects are not well understood. METHOD: Seeking to better define the factors, we retrospectively analyzed the effects of gender and age at onset of affective disorder in a naturalistic study of 192 geriatric patients consecutively admitted to a large midwestern tertiary care center between 1980 and 1987 for the treatment of unipolar depression. RESULTS: After controlling for age at index admission, patients with an onset of depression before age 40 suffered significantly (p < .05) less mortality in follow-up than those with onset after age 40. When effects of gender are examined, the effects of age at onset are most profound in women, with a threefold increase in the rate of death in the cohort with age at onset of depression after 70 years when compared to those with onset before age 40. CONCLUSION: These results and those of others suggest that depressed elderly women with no previous history of affective disorder are at a markedly increased risk compared with elderly women with a history of affective illness for morbidity and mortality and that a significant proportion of elderly depressed patients are admitted to a psychiatric hospital for a depression that is secondary to serious medical illness.     

The role of hormone replacement therapy in the risk for breast cancer and total mortality in women with a family history of breast cancer

BACKGROUND: The risks and benefits of hormone replacement therapy (HRT) are of considerable interest and importance, especially in terms of whether they differ among subsets of women. OBJECTIVE: To determine whether HRT is associated with increased risks for breast cancer and total mortality in women with a family history of breast cancer. DESIGN: Prospective cohort study. SETTING: Population-based sample of midwestern post-menopausal women enrolled in an observational study of risk factors for cancer. PARTICIPANTS: Random sample of 41,837 female Iowa residents 55 to 69 years of age. MEASUREMENTS: Incidence rates of and relative risks for breast cancer (n = 1085) and total mortality (n = 2035) through 8 years of follow-up were calculated by using data from the State Health Registry of Iowa and the National Death Index. RESULTS: A family history of breast cancer was reported by 12.2% of the cohort at risk. Among women with a family history of breast cancer, those who currently used HRT and had done so for at least 5 years developed breast cancer at an age-adjusted annual rate of 61 cases per 10,000 person-years (95% CI, 28 to 94 cases); this rate was not statistically significantly higher than the rate in women who had never used HRT (46 cases per 10,000 person-years [CI, 36 to 55 cases]). Among women with a family history, those who used HRT had a significantly lower risk for total mortality than did women who had never used HRT (relative risk, 0.67 [CI, 0.51 to 0.89]), including total cancer-related mortality (relative risk, 0.75 [CI, 0.50 to 1.12]). The age-adjusted annual mortality rate for women using HRT for at least 5 years was 46 deaths per 10,000 person-years (CI, 19 to 74 deaths); this is roughly half the rate seen in women who had never used HRT (80 deaths per 10,000 person-years [CI, 69 to 92 deaths]). CONCLUSIONS: These data suggest that HRT use in women with a family history of breast cancer is not associated with a significantly increased incidence of breast cancer but is associated with a significantly reduced total mortality rate.     

On changes in psychiatric diagnosis over time.

Examined the factors determining diagnoses of types of mental illness. A survey of the age and diagnosis of 2,134 male psychiatric inpatients discharged from a single treatment facility in 1954, 1964, and 1974 revealed 3 major diagnostic trends: (a) the proportion of patients with affective disorders increased threefold, (b) patients with neuroses went from being the largest group to one of the smallest, and (c) schizophrenia increased significantly. In-depth examination of changes in the psychiatric process revealed that shifts in the patient population and symptomatology could not fully explain these trends. The relative importance of similar symptoms appeared to be interpreted differently at various historical times; diagnosis itself seemed to be relative to historical period. Possible causes include shifts in the patient population, increased treatment of neurotic patients on an outpatient basis, and changes in diagnostic categories due to increased clinical knowledge. It is suggested that the change in treatment emphasis from a psychological/psychoanalytic perspective to a psychopharmacological/medical one may be correlated with an increase in diagnoses more consistent with biological treatment (e.g., affective disorders and schizophrenia) and a decrease in categories less appropriate for this model (e.g., neurosis). (28 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The underreporting of deaths of American Indian children in California, 1979 through 1993

OBJECTIVES: This study linked birth and death certificates to determine misclassification of deaths of American Indian children in California. METHODS: Birth records for 1979 to 1993 were matched with mortality records through a computerized system. RESULTS: The number of deaths to American Indians was estimated to be three to four times greater than that reported on death certificates. Children in urban counties and those who died before 1987 were more likely to be misclassified. CONCLUSIONS: California death certificates identify less than one third of the deaths among American Indian children. Adjusting for racial misclassification provides a more accurate accounting of child mortality among American Indians.     

EMLA prevents pain during local anesthesia for cataract surgery

We developed a method to identify maternal deaths (deaths to women within 365 days of delivery) by linking Tennessee vital records. A computerized algorithm compared personal identifiers from the death certificates of reproductive-aged women to maternal identifiers on birth and fetal death certificates. For each decedent record which met the study criteria, the algorithm calculated a "match score" by comparing common elements in both files. The algorithm awarded full credit for data elements that agree exactly, partial credit for elements in partial agreement, and subtracted credit for information that mismatched. Match scores ranged from 0 to 35 for the 9,009 deaths in women 10-55 years of age during the three study years, with the majority of scores (96.3%) being 0 for "no match." Match scores of 1 to 8 were obtained by 153 (1.7%) of decedent records, while scores greater than 9 were obtained by 184 (2.0%) of decedent records. We used nurse-abstracted hospital, autopsy, and coroner records as our standard to verify the linkages. Manual review of personal identifiers showed that scores of 12 or less were not a match while scores of 13 or more indicated "true" matches. Based on this cutoff, the linkage algorithm yielded 130 maternal deaths. Of these, 32 (25%) were classified as truly pregnancy-related upon medical record review by an obstetrician. The remaining 98 deaths were associated only temporally with pregnancy. During the same time period, 16 individuals were identified to the State Health Department on their death certificates as dying from pregnancy-related causes, including one not identified by the linkage process.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pulmonary function and respiratory symptoms in forest firefighters

As part of a national study of surgical departments is Israel, cardiac surgery patients undergoing open heart surgery between 1987 and 1989 were followed-up prospectively. Of these, 1,046 patients had coronary artery bypass grafting (CABG) and are the subject of this report. The six-months mortality after surgery was 12.9% among 202 women and 4.1% among 844 men. Female gender was an independent predictor of mortality even after controlling for the effect of 14 putative risk factors. The adjusted relative risk for mortality in women compared to men was 2.79 (1.5-5.2). In an attempt to understand this excessive mortality among women, a detailed analysis in one of the participating hospitals revealed differences associated with surgical technique by gender, such as proportion of patients with entirely venous grafting vs internal mammary artery grafts (IMA). Thirty percent of women vs 4.8% of men had entirely venous grafting. Adjusting the data for differences in the proportion of venous grafting has obliterated the difference in mortality between the genders in that hospital. We suggest that interventions to reduce mortality among women should involve a more careful choice of female candidates for CABG surgery, as well as introduction of modifications in the operating technique.     

Performance of a commercial polymerase chain reaction test for endocervical Chlamydia trachomatis infection in a university hospital population

The rate of survival and causes of mortality in a cohort of 2103 psychiatric patients registered on a psychiatric case register and followed up for 7 years are compared with those of a general population sample (n = 2382) randomly extracted from the municipal census in Valencia (Spain). Using multivariate analysis by Cox regression, patients suffering organic psychoses and those diagnosed with drug abuse or dependency exhibited a greater risk of death than the general population for the total causes of death; no interaction was found between sociodemographic variables and psychiatric pathology. In terms of the causes of death, and controlling for the effect of age and sex, organic psychoses involved a greater risk of death due to cardiovascular and respiratory causes, and a greater risk of non-natural deaths than the general population. Schizophrenia and related conditions, the abuse of alcohol/ other drugs, and neurosis/personality disorders all presented a higher risk of death from liver disease. The major affective disorders involved a greater risk of death due to suicide or accidents. The study concludes with a discussion of the possible explanations of these results.     

An analysis of risk factors for withdrawal from dialysis before death

Withdrawal from dialysis has been a significant cause of mortality among dialysis patients, accounting for 6 to 22% of deaths. Since 1990, a new death notification form has allowed more detailed analyses of withdrawal from dialysis separate from causes of death. Using the U.S. Renal Data System data base, this study examined 116,829 deaths in adult patients from 1990 to 1995. Adjusted odds ratios were calculated for the risk of withdrawal using logistic regression. Adjustments included age at death, ethnicity, gender, cause of death, primary cause of end-stage renal disease, time on dialysis, and dialysis modality. In addition, odds ratios of withdrawal were calculated for deaths in patients who started dialysis after age 65. Death was preceded by withdrawal significantly more frequently in women than in men, more than twice as frequently in Caucasians than in African-Americans or Asians, and more frequently in older than in younger age groups. Patients who died of chronic diseases (e.g., dementia, malignancy) were much more likely to withdraw before death, whereas patients who died from more acute causes (e.g., coronary artery disease) were less likely to withdraw before death. It is concluded that patients who are Caucasian, female, older, or die of chronic or progressive diseases are more likely to withdraw from dialysis before death. The ethnic and gender differences in withdrawal do not appear to have a medical explanation from this analysis. Further research along sociologic lines is needed to better explain the differences in withdrawal from chronic dialysis.     

Self-reported long-standing psychiatric illness as a predictor of premature all-cause mortality and violent death: a 14-year follow-up study of native Swedes and foreign-born migrants

The present study focuses on the associations between self-rated long-standing psychiatric illness, ethnicity, all-cause mortality and violent death (accidents and suicide), in a sample of 39,155 Swedish-born and foreign-born individuals. The study was designed as a longitudinal follow-up study, covering the period between 1 January 1979 and 31 December 1996. The data were analysed by a proportional hazard model and the results are given as hazard ratios (HR) with 95% confidence intervals (CI). Self-reported long-standing psychiatric illness was a strong risk factor for total mortality: women had an HR of 2.13 (CI = 1.78-2.54) and men an HR of 1.84 (CI = 1.53-2.21), when adjusted for background factors such as country of birth, civil status and socio-economic factors. Finnish men had an increased risk of all-cause mortality compared to Swedes in the final model, when adjusted for socio-economic factors. Long-standing psychiatric illness was also a strong risk factor for violent death, with an HR of 3.51 (CI = 2.32-5.32). The risk of violent death was 2.4 times higher for men than for women. The conclusions of the present study are that self-reported long-standing psychiatric illness is a strong predictor of an increased all-cause mortality and increased mortality from violent death. The increased age-adjusted mortality risk for foreign-born men could be explained by disadvantaged social and economic conditions. Only Finnish men demonstrated an independent increased all-cause mortality risk.     

Association of secondary and polymicrobial nosocomial bloodstream infections with higher mortality

The objective of this study was to characterize microbiological factors independently associated with higher mortality rates following nosocomial bloodstream infection. All patients admitted to the University of Iowa Hospitals and Clinics between 1 July 1989 and 30 June 1990 who developed a nosocomial bloodstream infection were included. The crude in-house mortality for the 364 patients with nosocomial bloodstream infections was 33%. These deaths accounted for 25% of all in-hospital deaths. Significant risk factors for death from bloodstream infection included diagnoses of cancers and diseases of the cardiovascular and respiratory systems (p < 0.01). Neither previous surgery nor neutropenia was associated with higher mortality rates. Whereas the crude mortality rates associated with gram-negative (33%) and gram-positive (31%) bloodstream infections were similar, that associated with fungemia was higher (54%, p < 0.02). The mortality associated with secondary bloodstream infections (46%) was higher than that associated with primary bloodstream infections (28%, p < 0.001). Furthermore, polymicrobial infections had a worse prognosis than infections from which a single pathogen was isolated (p < 0.05). A multivariate, logistic regression model identified four variables that independently predicted mortality (p = 0.025): age (OR 1.01 per year; CI95 1.00-1.02); cancer (OR 2.35, CI95 1.26-4.37) or diseases of the cardiovascular or respiratory systems (OR 2.20, CI95 1.04-4.67); polymicrobial infection (OR 2.34; CI95 1.21-4.53); and secondary bloodstream infection (OR 2.46; CI95 1.50-4.02). The last variable was the strongest independent predictor. Our study demonstrates the importance of microbiological factors in the outcome of nosocomial bloodstream infections.     

Diagnosis on death certificates of sudden death due to ischemic heart disease

This study was undertaken to evaluate the quality of diagnoses of sudden death (SD) caused by ischemic heart disease (IHD) on death certificates. A random sample of 10% (100 cases) was drawn from all such deaths which occurred in 1970 among Oklahoma City residents. The medical records of each case were reviewed and the quality of the diagnosis was rated, by the use of predetermined standard criteria, as confirmed and valid or unconfirmed and invalid. Among 100 IHD deaths, SD constitute 45%. Of these SDs, 18% were unobserved, without information as to the manifestations of the attack or the interval from onset of symptoms to death. According to criteria of the American Heart Association and WHO Expert Committee, the diagnosis in this 18% was unconfirmed and invalid. Thus there is insufficient quantitative evidence to justify the use of SD, as found on death certificates, as an indication of frequency of ischemic heart disease.