Inaccuracies in certification of nonmelanoma skin cancer deaths

Widespread pain is a risk factor for cardiovascular mortality: results from the Framingham Heart Study

AIMS

With the introduction of widespread pain (WSP) as a separate diagnostic code in the ICD-11, WSP has now become an own clinical diagnosis independent of the underlying pathophysiology. Research has reported aetiological associations of WSP and cardiovascular diseases. However, studies on mortality risk in individuals with WSP have reported inconsistent results. This study investigates whether there is increased mortality in WSP individuals and establish potential determinants of mortality risk. Therefore, we evaluates the population-based prospective cohort of the Framingham Heart Study (FHS).

METHODS AND RESULTS

The FHS is a longitudinal multi-generational study. Pain status was assessed uniquely between 1990 and 1994. Cox proportional hazards modelling was used to estimate hazard ratios (HRs) of WSP on all-cause mortality controlling for sex and age, cardiovascular risk factors, cancer history, lifestyle factors and current medication. WSP examination was carried out in 4746 participants of the FHS (60.3 ± 13.5 years, 55.1% women). A total of 678 (14.5%) subjects fulfilled the criteria for WSP, whereas 4011 (85.5%) subjects did not. The follow-up time was 15 years, during which 202 persons died in the WSP group and 1144 in the no-WSP group. When adjusting for age and sex, all-cause mortality was increased by about 16% in WSP subjects. Individuals with WSP had an increased HR particularly for cardiovascular cause of death (HR adjusted by age and sex = 1.46, 95% confidence interval 1.10-1.94).

CONCLUSION

Our data show that in a large population-based cohort, WSP is associated with increased HR for cardiovascular cause of death, underlining the need for pain assessments in cardiovascular practice.

Misclassification of the actual causes of death and its impact on analysis: A case study in non-small cell lung cancer

OBJECTIVES

Cumulative incidence of lung cancer deaths (LC-CID) is an important metric to understand cancer prognosis and to determine treatment options. However, credible estimates of LC-CID rely on accurate cause-of-death coding in death certificates. Results from lung cancer screening trials estimated 15% under-reporting and 1% over-reporting of lung cancer deaths due to misclassification. This study investigated the impact of cause-of-death misclassification on the estimation of LC-CID.

MATERIALS AND METHODS

Patients with stage I/II non-small cell lung cancer (NSCLC) from the Surveillance, Epidemiology, and End Results registry were included. LC-CID was estimated using the competing-risk approach in two ways: (1) reporting observed estimates that ignore potential cause-of-death misclassification and (2) correcting for plausible misclassification rates reported in the literature (15% under-reporting and 1% over-reporting). Bias was quantified as the difference between observed and corrected 10-year LC-CIDs: positive values indicated that observed LC-CID overestimated true LC-CID, whereas negative values indicated the opposite.

RESULTS

Among 66,179 patients, the impact of over-reporting on 10-year LC-CID was negligible across all age groups. In contrast, under-reporting resulted in substantial underestimation of 10-year LC-CID. The biases increased as age increased due to higher LC-CIDs: 10-year LC-CIDs among stage I patients 18-44, 45-59, 60-74 and ≥75 years were 25%, 32%, 41%, and 50%, respectively, and the corresponding biases given the plausible misclassification rates were -4.4%, -5.6%, -7.1%, and -8.6%. Because the observed LC-CIDs among patients with stage II disease were higher than those with stage I disease, the biases were greater among stage II patients, up to -12.5% in the oldest age group.

CONCLUSIONS

In lung cancer, LC-CID may be severely underestimated due to under-reporting of lung cancer deaths, particularly among older patients or those with late-stage disease. Future studies that involve such subpopulations should present the corrected LC-CIDs based on plausible misclassification rates alongside the observed LC-CIDs.

A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease

Background

Skin diseases are very common and can have a large impact on the quality of life of patients and caregivers. This programme addressed four diseases: (1) eczema, (2) vitiligo, (3) squamous cell skin cancer (SCC) and (4) pyoderma gangrenosum (PG).

Objective

To set priorities and reduce uncertainties for the treatment and prevention of skin disease in our four chosen diseases.

Design

Mixed methods including eight systematic reviews, three prioritisation exercises, two pilot randomised controlled trials (RCTs), three feasibility studies, two core outcome initiatives, four funding proposals for national RCTs and one completed national RCT.

Setting

Secondary care, primary care and the general population.

Participants

Patients (and their caregivers) with eczema, vitiligo, SCC and PG, plus health-care professionals with an interest in skin disease.

Interventions

Our three intervention studies included (1) barrier enhancement using emollients from birth to prevent eczema (pilot RCT); (2) handheld narrowband ultraviolet light B therapy for treating vitiligo (pilot RCT); and (3) oral ciclosporin (Neoral®, Novartis Pharmaceuticals) compared with oral prednisolone for managing PG (pragmatic national RCT).

Results

Systematic reviews included two overarching systematic reviews of RCTs of treatments for eczema and vitiligo, an umbrella review of systematic reviews of interventions for the prevention of eczema, two reviews of treatments for SCC (one included RCTs and the second included observational studies), and three reviews of outcome measures and outcome reporting. Three prioritisation partnership exercises identified 26 priority areas for future research in eczema, vitiligo and SCC. Two international consensus initiatives identified four core domains for future eczema trials and seven core domains for vitiligo trials. Two pilot RCTs and three feasibility studies critically informed development of four trial proposals for external funding, three of which are now funded and one is pending consideration by funders. Our pragmatic RCT tested the two commonly used systemic treatments for PG (prednisolone vs. ciclosporin) and found no difference in their clinical effectiveness or cost-effectiveness. Both drugs showed limited benefit. Only half of the participants’ ulcers had healed by 6 months. For those with healed ulcers, recurrence was common (30%). Different side effect profiles were noted for each drug, which can inform clinical decisions on an individual patient basis. Three researchers were trained to PhD level and a dermatology patient panel was established to ensure patient involvement in all aspects of the programme.

Conclusions

Findings from this programme of work have already informed clinical guidelines and patient information resources. Feasibility studies have ensured that large national pragmatic trials will now be conducted on important areas of treatment uncertainty that address the needs of patients and the NHS. There is scope for considerable improvement in terms of trial design, conduct and reporting for RCTs of skin disease, which can be improved through wider collaboration, registration of trial protocols and complete reporting and international consensus over core outcome sets. Three national trials have now been funded as a result of this work. Two international initiatives to establish how best to measure the core outcome domains for eczema and vitiligo are ongoing.

Trial registration

Current Controlled Trials Barrier Enhancement for Eczema Prevention (BEEP) (ISRCTN84854178 and NCT01142999), Study of Treatments fOr Pyoderma GAngrenosum Patients (STOP GAP) (ISRCTN35898459) and Hand Held NB-UVB for Early or Focal Vitiligo at Home (HI-Light Pilot Trial) (NCT01478945).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 18. See the NIHR Journals Library website for further project information.

Co-morbidities of persons dying of Parkinson's disease

Introduction

Disease interactions can alter functional decline near the end of life (EOL). Parkinson's disease (PD) is characterized by frequent occurrences of co-morbidities but data challenges have limited studies investigating co-morbidities across a broad range of diseases. The goal of this study was to describe disease associations with PD.

Methods

We conducted an analysis of death certificate data from 1998 to 2005 in Nova Scotia. All death causes were utilized to select individuals dying of PD and compare with the general population and an age–sex-matched sample without PD. We calculated the mean number of death causes and frequency of disease co-occurrence. To account for the chance occurrence of co-morbidities and measure the strength of association, observed to expected ratios were calculated.

Results

PD decedents had a higher mean number of death causes (3.37) than the general population (2.77) and age–sex-matched sample (2.88). Cancer was the most common cause in the population and matched sample but fifth for those with PD. Cancer was one of nine diseases that occurred less often than what would be expected by chance while four were not correlated with PD. Dementia and pneumonia occurred with PD 2.53 ([CI] 2.21–2.85) and 1.83 (CI 1.58–2.08) times more often than expected. The strength of association for both is reduced but remains statistically significant when controlling for age and sex.

Discussion

Those with PD have a higher number of co-morbidities even after controlling for age and sex. Individuals dying with PD are more likely to have dementia and pneumonia, which has implications for the provision of care at EOL.

Human fatalities resulting from dog attacks in the United States, 1979-2005

INTRODUCTION

Dog attacks are a major public health concern worldwide. Dogs bite over 4 million people resulting in the hospitalization of 6000 to 13,000 people each year in the United States. Rarely deaths may occur after an attack.

METHODS

This study utilized the compressed mortality files from CDC WONDER to evaluate deaths from dog attacks over the 27-year period 1979-2005.

RESULTS

An average of approximately 19 deaths was reported annually from dog attacks during this time period. Males and children less than 10 years of age had the highest rate of death from dog attacks. Deaths have been reported in 49 states with Alaska reporting the highest death rate from dog attacks. The number of deaths and death rate from dog attacks appear to be increasing.

CONCLUSIONS

Deaths from dog attacks appear to be increasing as the population of both humans and dogs has increased during this time period. Children have the greatest risk of death. There is a need for a national reporting system on dog bites to fully capture the extent of fatalities and look at risk factors surrounding the attack. The development of effective prevention practices is dependent upon examination of these risk factors.

Prognostic significance of the number of lymph node metastases in esophageal cancer

BACKGROUND

Regional lymph node (LN) involvement is one of the most important predictors of survival for patients with esophageal cancer. The current staging classification differentiates only between the presence and absence of LN metastasis. In this study, we examined whether involvement of a higher number of LNs is associated with worse survival among esophageal cancer patients.

STUDY DESIGN

We identified all patients who underwent operations for node-positive esophageal cancer between 1988 and 2003 from the Surveillance, Epidemiology and End Results cancer registry. Because the number of positive LNs is confounded by the total number of LNs removed, patients were classified into three groups by the ratio of positive-to-total number of LNs removed (LN ratio [LNR]): <or= 0.2, 0.21 to 0.5, and>0.5. Esophageal cancer-specific survival was compared among these groups using Kaplan-Meier curves. Stratified and Cox regression analyses were used to evaluate the relationship between the LNR and survival after adjusting for potential confounders.

RESULTS

The study cohort included 838 esophageal cancer patients. Disease-specific survival rates decreased with higher LNR. Five-year disease-specific survival was 30% among patients with an LNR<or=0.2, compared with 16% and 13% for those with LNs of 0.21 to 0.5 and>0.5, respectively (p < 0.001). In stratified and multivariable analyses controlling for age, race, gender, histology, tumor-status, and postoperative radiotherapy, a higher LNR was independently associated with worse disease-specific survival.

CONCLUSIONS

These data suggest that a higher LNR among patients with node-positive esophageal cancer is associated with worse survival. If validated, this prognostic criterion may be included in staging classifications.

Trends in nonmelanoma skin cancer mortality rates in the United States, 1969 through 2000

The purpose of this population-based study was to assess trends in mortality rates for nonmelanoma skin cancer (NMSC) in the United States. Particular emphasis was placed on the subgroup of malignancies arising on genital skin. Nearly 75,000 deaths in the United States were attributed to NMSC from 1969 to 2000. The age-adjusted US mortality rate for NMSC arising on nongenital skin from 1969 to 2000 was 0.69/10(5)/year; the rate among men was twice that among women. Mortality rates among white men exceeded that of black men by a factor of two; the same was observed among women, but by a smaller multiple. Corresponding mortality rates for malignancies arising from genital skin (penis, scrotum, vulva) were higher in women (0.54) than in men (0.30). In contrast to nongenital NMSC, mortality rates among black men were twice that of white men; however, rates for white and black women were similar. These results suggest that greater emphasis could be placed on reducing mortality from genital NMSC while continuing to stress reduction of excess sun exposure.

Issues in the epidemiology of melanoma

Malignant melanoma imposes a considerable public health burden. Both incidence and mortality have increased many fold over the past several decades, although current trends suggest possible change in the prior patterns. Etiologic factors have been established, of which the most important is intense sun exposure. Primary prevention and early detection are both potentially critical in reducing the burden of melanoma. Much remains to be clarified in our management of this disorder on a population basis, and methodologic difficulties are plentiful. The potential for substantial reductions in melanoma mortality requires that we address the difficulties so that maximally effective public health initiatives may be undertaken.

Accuracy of ICD-9-CM codes in hospital morbidity data, Victoria: implications for public health research

Hospital morbidity data in the form of International classification of diseases, 9th revision, clinical modification codes are often used for epidemiological studies and disease surveillance. We aimed to evaluate the reliability of the Victorian In-patient Minimum Database for use in epidemiological studies and disease surveillance. Data from 1993-94 were collected, as part of a coding audit of public hospitals in Victoria, from 7052 randomly selected records. The frequency of discrepancy in any coding field was 53 per cent, and of discrepancy in the principal diagnosis, 22 per cent. New Australian national diagnosis-related group (ANDRG) codes were assigned as a result of discrepancy in 13.6 per cent of cases. Discrepancy rates increased with increasing rarity of ANDRG, from 50 per cent to 56 per cent. Predictors of change in ANDRG assignment were discrepancy in the principal diagnosis, ANDRG frequency of over 0.6 per cent, more than three diagnoses, medical ANDRGs, length of stay over five days and rural hospitals. Rates of any discrepancy increased from 36 per cent in patients with one diagnosis to 94 per cent in patients with 12 diagnoses. The discrepancy rates were consistent with those of other studies. Coding discrepancy is likely to be caused by universal difficulties associated with the coding of hospital records, rather than any unique local problems. The predictors of discrepancy suggest that more complex cases are more prone to coding discrepancy. In areas where the database is less reliable, use of a supplementary data source, such as link-age studies, would improve reliability.

Deaths due to squamous cell carcinoma in Australia: is there a case for a public health intervention?

The death certificates of all people who died from cancer in Victoria for the years 1988-1990 were examined looking for deaths due primarily to squamous cell carcinoma (SCC) of the skin. The findings were compared with the Australian Bureau of Statistics (ABS) published data on the number of deaths due to non melanoma skin cancer (NMSC) for the same period. One hundred and fifteen deaths due to SCC were identified. The mean age of death for the 74 males (64%) was 74.2 (s.d. 11.7) years and the 41 females (36%) was 81.3 (s.d. 10.3) years. Seventy (80%) of the 91 people where satisfactory information was able to be extracted had one or more major illnesses which were likely to have contributed substantially to the death. Only 3.5% of the total tumours were on the trunk in the covered areas, the remainder were on exposed areas of the body easily seen during a consultation. Seventeen cases of AIDS (Kaposi's Sarcoma) were incorrectly classified by the ABS as primary NMSC deaths. Seventeen other misclassifications included seven deaths from melanoma, eight deaths from cancers which were not skin tumours and two non-cancer deaths. Thirty-one deaths due to SCC were identified from death certificates and careful medical follow up which were not recorded in ABS data. The results suggest that there is likely to be little, if any, reduction in the number of deaths due to SCC as a result of an early detection programme directed at those people currently developing lethal tumours. A professional education programme directed at doctors who are seeing these elderly people with tumours on easily examined sites is more likely to be fruitful. The results also suggest the need for further education about the correct filling out of death certificates by medical practitioners and the careful supervision of those who extract data from these records at the ABS.

Epidemiologic investigation of nonmelanoma skin cancer mortality: the Rhode Island Follow-Back Study

The Rhode Island Follow-Back Study was initiated to elucidate the magnitude and characteristics of nonmelanoma skin cancer mortality. All deaths reported among Rhode Island residents during 1979 through 1987 and attributed to nonmelanoma skin cancer were investigated and medical records sought. Most were misclassified, primarily due to squamous cell carcinoma of mucosal surfaces in the head and neck. In Rhode Island and nationally, this source of misclassification is increasingly frequent. Appropriate adjustment of national statistics for misclassification reveals a consistent decline in nonmelanoma skin cancer mortality rates from 1969 through 1988, although the actual numbers of deaths are increasing due to growth and aging of the population. Examination of the records of those Rhode Island residents who did die from nonmelanoma skin cancer demonstrated that most had squamous cell carcinoma, and many of those arose from the ear. These analyses suggest that particular emphasis should be placed on the ear in public health campaigns geared toward the prevention and early detection of nonmelanoma skin cancer.