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Background The Global Burden of Disease (GBD) does not produce estimates of heart failure (HF) since this condition is considered the common end to several diseases (i.e., garbage code). This study aims to analyze the interactions between underlying and multiple causes of death related to HF in Brazil and its geographic regions, by sex, from 2006 to 2016. Methods Descriptive study of a historical series of death certificates (DCs) related to deaths that occurred in Brazil between 2006 and 2016, including both sexes and all age groups. To identify HF as the underlying cause of death or as a multiple cause of death, we considered the International Classification of Diseases (ICD) code I50 followed by any digit. We evaluated the deaths and constructed graphs by geographic region to compare with national data. Results We included 1,074,038 DCs issued between 2006 and 2016 that included code I50 in Parts I or II of the certificate. The frequency of HF as the multiple cause of death in both sexes was nearly three times higher than the frequency of HF as an underlying cause of death; this observation remained consistent over the years. The Southeast region had the highest number of deaths in all years (about 40,000 records) and approximately double the number in the Northeast region and more than four times the number in the North region. Codes of diseases clinically unrelated to HF, such as diabetes mellitus, chronic obstructive pulmonary disease, and stroke, were mentioned in 3.11, 2.62, and 1.49% of the DCs, respectively. Conclusions When we consider HF as the underlying cause of death, we observed an important underestimation of its impact on mortality, since when analyzed as a multiple cause of death, HF is present in almost three times more deaths recorded in Brazil from 2006 to 2016. The mentioning of conditions with little association with HF at the time of the death highlights the importance of HF as a complex syndrome with multiple components that must be considered in the analysis of mortality trends for implementation of public health management programs.

Background: International comparisons of mortality largely depend on the quality of data. With more than 20% of deaths annually assigned to ill-defined cardiovascular conditions, the mortality level due to well-defined causes of death is under-registered in Poland. Objective: We aim to reclassify cardiovascular garbage codes (GCs) into well-defined causes based on multiple causes of death (MCoD) data and to approximate mortality levels due to well-defined causes of death in Poland. We examine the usefulness of the MCoD approach for correcting low-quality data on causes of death. Methods: Based on the unique MCoD dataset for Poland, death counts due to cardiovascular GCs were reassigned to well-defined underlying causes in two steps: (1) manually for death records that included MCoD information constituting a logical chain of conditions leading to death and (2) with coarsened exact matching for the remaining death records. Age-specific and age-standardised death rates for large groups of causes were calculated before and after redistribution and compared to those of other Eastern European countries with relatively good data quality. Results: Of deaths originally assigned to cardiovascular GCs, 86,856 were reclassified, mostly to well-defined cardiovascular diseases, cancers, endocrine, nutritional and metabolic diseases, and respiratory diseases. The age-standardised death rate due to well-defined ischaemic heart diseases increased by 43%, and the rate due to cerebrovascular diseases by 22%. Cardiovascular mortality structure by large groups of causes became similar to the structure registered in other Eastern European countries characterised by a low prevalence of GCs. Conclusions: Coarsened exact matching performs relatively well when abundant MCoD information is available and enhances the comparability of cause-of-death data between countries. Contribution: Redistribution of GCs improves the quality of cause-of-death data and enhances their comparability between countries.

Objectives Errors and misreporting on death certificates are common, along with potential inaccuracies in cause-of-death coding. We characterized and compared fatalities by animal-encounter mentions reported as underlying cause of death (UCD) with animal-encounter mentions reported as multiple cause of death (MCD) to determine factors associated with misreporting UCD. Methods We analyzed fatality data from 1999-2016 from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research by UCD and MCD animal-encounter mentions ( International Classification of Diseases, 10th Revision codes W53-59, X20-27 and X29, T63.0-63.6, T63.8-63.9, and T78.2-78.4). We examined differences in reporting by age, sex, race, autopsy (yes, no, unknown), allergic reactions, and toxicities. Results The number of animal-encounter mentions by UCD was 3638 (202 average per year) and by MCD was 4280 (238 average per year), a difference of 18% (n = 642; 36 average per year) by MCD analysis. The number of nonvenomous animal-encounter mentions increased 20% (from 2138 UCD to 2567 MCD), and the number of venomous animal-encounter mentions increased 14% (from 1500 UCD to 1713 MCD). Decedents aged ≥65 had the highest additional number of animal-encounter mentions among all age groups, primarily encounters with other reptiles (n = 113), other mammals (n = 71), and dogs (n = 42). Of 642 MCD additional animal-encounter mentions, heart disease (n = 211, 33%) and infections (n = 146, 23%) represented more than half of the UCD. Of 553 dog-encounter fatalities, 165 (30%) were among children aged ≤4. Conclusions Animal-encounter fatalities, analyzed by UCD alone, may be underreported. An initiating animal injury, complicated by comorbidities and fatality, may obscure the causal chain, resulting in misreporting UCD. Ongoing training for medical certifiers is recommended, highlighting accurate identification of UCD and contributing causes in the causal chain of death.

Background: Atherosclerotic peripheral artery disease (PAD) is an important cause of morbidity in the United States. In this article, we conducted a multiple cause-of-death analysis of PAD to determine patterns and trends in its contribution to mortality. Methods: The Centers for Disease Control and Prevention statistics data were used to determine the number of deaths with the following 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes selected as an underlying cause of death (UCOD) or a contributing cause considering multiple causes of death (MCOD): 170.2, 170.9, 173.9, 174.3, and 174.4. The age-adjusted death rates per 100 000 population by age, gender, race, ethnicity, and region were computed for the United States between the years 1999 and 2017. In these years, there were 47 728 569 deaths from all causes. Results: In 1999 to 2017 combined, there were a total of 311 175 deaths associated with PAD as an UCOD. However, there were 1 361 253 deaths with PAD listed as an UCOD or a contributing cause in MCOD, which is 4.3 times higher than UCOD. Age-adjusted MCOD rates were higher in males (25.6) than in females (19.4). Among non-Hispanics, the rate in African American males and females was 1.2 times higher than in Caucasians. Age-adjusted MCOD rates have declined in African Americans and Caucasians irrespective of gender from 2000 to 2017. Conclusion: Peripheral artery disease is mentioned 4 times as often on death certificates as a contributing cause of death as it is chosen as the UCOD. Overall, age-adjusted MCOD rates were higher in African Americans than Caucasians, males than females, and declined between 2000 and 2017.

OBJECTIVES: To explore temporal trends and geographic variations in mortality from prescription opioids from 1999 to 2016. METHODS: Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research Multiple Cause of Death files were used to calculate age-adjusted rates and 95% confidence intervals (CIs) and create spatial cluster maps. RESULTS: From 1999 to 2016, counties in West Virginia experienced the highest overall mortality rates in the United States from prescription opioids. Specifically, from 1999 to 2004, the highest rate in West Virginia of 24.87/100,000 (95% CI 17.84–33.73) was the fourth highest in the United States. From 2005 to 2009, West Virginia experienced the highest rate in the United States, 60.72/100,000 (95% CI 47.33–76.71). From 2010 to 2016, West Virginia also experienced the highest rate in the United States, which was 90.24/100,000 (95% CI 73.11–107.36). As such, overall, West Virginia experienced the highest rates in the United States and the largest increases overall of ~3.6-fold between 1999 and 2004 and 2010 and 2016. From 1999 to 2004, Florida had no “hot spots,” but from 2006 to 2010 they did appear, and from 2011 to 2016, they disappeared. CONCLUSIONS: These data show markedly divergent temporal trends and geographic variations in mortality rates from prescription opioids, especially in the southern United States. Specifically, although initial rates were high and continued to increase alarmingly in West Virginia, they increased but then decreased in Florida. These descriptive data generate hypotheses requiring testing in analytic epidemiological studies. Understanding the divergent patterns of prescription opioid-related deaths, especially in West Virginia and Florida, may have important clinical and policy implications.

ObjectiveThis study aimed to analyze the chain of events and contributing causes associated with COVID-19 adult mortality (30–69 years old), based on qualified data on CoD from three Brazilian capitals cities, Belo Horizonte, Salvador, and Natal, in 2020.MethodsData of all deaths among residents in the three capitals in 2020 were provided by these municipalities' routine Mortality Information System (SIM). Mentions B34.2 with the markers U07.1 and U07.2 in the death certificate identified COVID-19 deaths. We used a multiple-cause-of-death approach better to understand the complexity of the morbid process of COVID-19. Conditions that appeared more frequently in the same line or above the COVID-19 mentions in the death certificate were considered a chain-of-event. Conditions that occurred more often after the codes for COVID-19 were considered as contributing.ResultsIn 2020, 7,029 records from COVID-19 as the underlying cause of death were registered in SIM in the three capitals. Among these, 2,921 (41.6%) were deceased between 30 and 69 years old, representing 17.0% of deaths in this age group. As chain-of-events, the most frequent conditions mentioned were sepsis (33.4%), SARS (32.0%), acute respiratory failure (31.9%), unspecified lower respiratory infections (unspecified pneumonia) (20.1%), and other specified respiratory disorders (14.1%). Hypertension (33.3%), diabetes unspecified type (21.7%), renal failure (12.7%), obesity (9.8%), other chronic kidney diseases (4.9%), and diabetes mellitus type 2 (4.7%) were the most frequent contributing conditions. On average, 3.04 conditions were mentioned in the death certificate besides COVID-19. This average varied according to age, place of death, and capital.ConclusionThe multiple-cause analysis is a powerful tool to better understand the morbid process due to COVID-19 and highlight the importance of chronic non-communicable diseases as contributing conditions.

In response to the growing concern over diabetes, state-mandated health insurance benefits for diabetes have become popular since the late 1990s. However, little is known about whether these mandates improve the health of people with diabetes. In this paper, I use data from the Vital Statistics Multiple Cause of Death Mortality and the Behavioral Risk Factor Surveillance System to investigate the effects of these mandates on diabetes-related mortality rates, along with underlying mechanisms behind the estimated effects. Using a difference-in-differences framework that leverages variation in the enactment of mandates both across states and over time, I find that about 3.2 fewer diabetes-related deaths per 100,000 occur annually in mandate states than in non-mandate states. The mechanism analysis suggests higher utilization of the mandated medical benefits caused these mortality improvements.

Still’s disease (SD) is often considered a benign disease, with low mortality rates. However, few studies have investigated SD mortality and its causes and most of these have been single-center cohort studies. We sought to examine mortality rates and causes of death among French decedents with SD. We performed a multiple-cause-of-death analysis on data collected between 1979 and 2016 by the French Epidemiological Center for the Medical Causes of Death. SD-related mortality rates were calculated and compared with the general population (observed/expected ratios, O/E). A total of 289 death certificates mentioned SD as the underlying cause of death (UCD) (n = 154) or as a non-underlying causes of death (NUCD) (n = 135). Over the study period, the mean age at death was 55.3 years (vs. 75.5 years in the general population), with differences depending on the period analyzed. The age-standardized mortality rate was 0.13/million person-years and was not different between men and women. When SD was the UCD, the most frequent associated causes were cardiovascular diseases (n = 29, 18.8%), infections (n = 25, 16.2%), and blood disorders (n = 11, 7.1%), including six cases (54%) with macrophage activation syndrome. As compared to the general population, SD decedents aged &lt, 45 years were more likely to die from a cardiovascular event (O/E = 3.41, p &lt, 0.01), decedents at all ages were more likely to die from infection (O/E = 7.96–13.02, p &lt, 0.001).

BackgroundExcess death for Black people compared with White people is a measure of health equity. We sought to determine the excess deaths under the age of 65 (MethodsWe used the Center of Disease Control (CDC) WONDER’s Multiple Cause of Death 1999-2019 dataset to report age-adjusted mortality rates among non-Hispanic Black (Black) and non-Hispanic White (White) people and to calculate annual age-adjusted ResultsFrom 1999 to 2019, the age-adjusted mortality rate for Black men was 1,186 per 100,000 and for White men was 921 per 100,000, for a difference of 265 per 100,000. The age-adjusted mortality rate for Black women was 802 per 100,000 and for White women was 664 per 100,000, for a difference of 138 per 100,000. While the gap for men and women is less than it was in 1999, it has been increasing among men since 2014. These differences have led to many Black people dying before age 65. In 1999, there were 22,945 age-adjusted excess deaths among Black women CommentIn the US, over the recent 20-year period, disparities in mortality rates resulted in between 61,827 excess deaths in 1999 and 40,294 excess deaths in 2019 among

Mortality from idiopathic pulmonary fibrosis (IPF) is increasing in most European countries, but there are no data for Italy. We analysed the registry data from a region in northeastern Italy to assess the trends in IPF-related mortality during 2008–2019, to compare results of underlying vs. multiple cause of death analyses, and to describe the impact of the COVID-19 epidemic in 2020. We identified IPF (ICD-10 code J84.1) among the causes of death registered in 557,932 certificates in the Veneto region. We assessed time trends in annual age-standardized mortality rates by gender and age (40–74, 75–84, and ≥85 years). IPF was the underlying cause of 1310 deaths in the 2251 certificates mentioning IPF. For all age groups combined, the age-standardized mortality rate from IPF identified as the underlying cause of death was close to the European median (males and females: 3.1 and 1.3 per 100,000/year, respectively). During 2008–2019, mortality rates increased in men aged ≥85 years (annual percent change of 6.5%, 95% CI: 2.0, 11.2%), but not among women or for the younger age groups. A 72% excess of IPF-related deaths was registered in March–April 2020 (mortality ratio 1.72, 95% CI: 1.29, 2.24). IPF mortality was increasing among older men in northeastern Italy. The burden of IPF was heavier than assessed by routine statistics, since less than two out of three IPF-related deaths were directly attributed to this condition. COVID-19 was accompanied by a remarkable increase in IPF-related mortality.

To assess gender, race/ethnicity, and geographic disparities in sepsis-associated mortality. The US data for multiple causes of death (MCOD) for years 2013–2016 were used to determine numbers of deaths and age-adjusted rates for sepsis as underlying or contributing cause of death using the International Classification of Diseases–10 (ICD-10) codes for non-Hispanic blacks (NHB) and whites (NHW) aged 15 years and older. There were a total of 746,725 sepsis-associated deaths. Among females, age-adjusted death rate for NHB was 88.6 (95% CI 87.8–89.3) and for NHW, 55.4 (95% CI 55.1–55.6). Among males, age-adjusted death rate for NHB was 115.2 (95% CI 114.1–116.3) and for NHW, 69.5 (95% CI 69.2–69.8). Rates were generally higher in divisions of the south region (West South Central in NHB). Within the South, NHW and NHB who resided in non-metropolitan areas had the highest rates, while the lowest were in suburban metropolitan areas. Sepsis-related MCOD mortality rates were highest in males, in NHB, in the South region, and, within the South, non-metropolitan areas.

Objectives Sepsis is a life-threatening condition and is one of the leading causes of death in the United States. The burden of sepsis-related mortality in the United States in recent years is not well characterized. We sought to describe sepsis-related mortality rates and mortality trends in the United States from 2005 to 2018. Design Retrospective population-based study. Setting We used the Multiple Cause of Death Database available through the Centers for Disease Control and Prevention website. Patients Decedents with sepsis-related deaths were identified using previously validated International Classification of Diseases codes. Interventions None. Measurements and main results From 2005 to 2018, 6.7% of decedents had a diagnosis of sepsis. The overall sepsis-related mortality rates remained stable in both males (57 deaths per 100,000) and females (45.1 deaths per 100,000) during this period. Compared with Whites, the sepsis-related mortality rates were higher in Blacks (rate ratio = 1.78), Native Americans (rate ratio = 1.43), and Hispanics (rate ratio = 1.04) and were lower in Asians (rate ratio = 0.73). Sepsis-related mortality rates declined in Blacks, Hispanics, and Asians but increased in Whites and Native Americans. The majority of sepsis-related deaths occurred in the hospital. The percentage of deaths in the nursing home decreased, whereas deaths occurring at home and hospice increased. Conclusions From 2005 to 2018, the overall sepsis-related mortality rates were stable, but there were significant racial and gender disparities in mortality trends. Further research is needed to evaluate the genetic and environmental contributors to these differences.

The current data on rates and geographic distribution of vasculitis mortality are limited. We aimed to estimate the mortality rates of primary systemic vasculitis and its geographic distribution using recent population data in the United States. The mortality rates of vasculitis from 1999 to 2019 were obtained from the Center for Disease Control (CDC) Wonder Multiple Cause of Death (MCD). The age-adjusted rates per million for vasculitis as MCD and as an underlying cause of death (UCD) were calculated by state using demographics. A joinpoint regression analysis was applied to evaluate trends over time. The age-adjusted mortality rate of vasculitis as MCD was 4.077 (95% CI: 4.029–4.125) and as a UCD was 1.888 per million (95% CI: 1.855–1.921). Since 1999, mortality rates have progressively decreased. The age-adjusted mortality rate was higher in females than in males. The highest mortality rate for vasculitis as MCD was in White patients (4.371, 95% CI: 4.317–4.424). The northern states and areas with lower populations had higher mortality rates. We found a trend of progressive decreases in the mortality rates of vasculitis, as well as gender, racial, and geographic disparities. Further analyses are warranted to better understand the factors associated with these disparities in order to implement targeted public health interventions to decrease them.

Objective: To describe causes of death and mortality data related to cystic fibrosis (CF) using a multiple-cause-of-death methodology. Methods: Annual mortality data for the 1999-2017 period were extracted from the Brazilian National Ministry of Health Mortality Database. All death certificates in which category E84 (CF) of the ICD-10, was listed as an underlying or associated cause of death were selected. Epidemiological and clinical data were described, and standardized mortality rates were calculated per year and for the 2000-2017 period. A joinpoint regression analysis was performed to detect changes in the mortality rates during the study period. Results: Overall, 2,854 CF-related deaths were identified during the study period, ranging from 68 in 1999 to 289 in 2017. CF was the underlying cause of death in 83.5% of the death certificates. A continuous upward trend in the death rates was observed, with a significant annual percent change of 6.84% (5.3-8.4%) among males and 7.50% (6.6-8.4%) among females. The median age at death increased from 7.5 years in 1999 to 56.5 years in 2017. Diseases of the respiratory system accounted for 77% of the associated causes in the death certificates that reported CF as the underlying cause of death. Conclusions: A significant and continuous increase in CF-related death rates was found in Brazil in the last years, as well as a concurrent increase in the median age at death. RESUMO Objetivo: Descrever as causas de morte e dados sobre mortalidade relacionada à fibrose cística (FC) por meio da metodologia de causas múltiplas de morte. Métodos: Dados sobre a mortalidade anual no período de 1999 a 2017 foram extraídos do Sistema de Informações sobre Mortalidade do Ministério da Saúde do Brasil. Foram selecionadas todas as declarações de óbito em que a categoria E84 (FC) da CID-10 foi citada como causa básica ou associada de morte. Foram descritos os dados epidemiológicos e clínicos e calculadas as taxas padronizadas de mortalidade por ano e para o período de 2000 a 2017. Foi realizada a análise de regressão por pontos de inflexão para detectar mudanças nas taxas de mortalidade durante o período estudado. Resultados: No total, foram identificadas 2.854 mortes relacionadas à FC durante o período de estudo: de 68 em 1999 a 289 em 2017. A FC foi a causa básica de morte em 83,5% das declarações de óbito. Observou-se uma tendência contínua de aumento das taxas de mortalidade, com variação percentual anual significativa de 6,84% (5,3-8,4%) nos homens e de 7,50% (6,6-8,4%) nas mulheres. A mediana da idade de óbito aumentou de 7,5 anos em 1999 para 56,5 anos em 2017. As doenças do aparelho respiratório representaram 77% das causas associadas nas declarações de óbito em que a FC foi a causa básica de morte. Conclusões: Observou-se no Brasil um aumento significativo e contínuo das taxas de mortalidade relacionada à FC nos últimos anos, bem como um aumento concomitante da mediana da idade de óbito.

Using electronic health records, we found that hepatitis C virus (HCV) reporting on death certificates of 2901 HCV-infected decedents from 4 US healthcare organizations during 2011–2017 was documented in only 50% of decedents with hepatocellular carcinoma and less than half with decompensated cirrhosis. National figures likely underestimate the US HCV mortality burden.

Purpose To examine and quantify the burden of opioid-related mortality utilizing a serial cross-sectional design of individuals 15 to 64 years of age whose death was related to opioid use from January 1, 1999, to January 31, 2019. Methods Data was obtained from the CDC WONDER Multiple Cause of Death Online Database, which captures mortality and population estimates across the United States stratified by geography, age, sex, race, and ethnicity. The burden of opioid-related deaths in Texas was evaluated as the proportion of all deaths attributable to this underlying cause of death over the study period and years of potential life lost (YPLL). Results Results revealed that between 1999 and 2019, 19,039 opioid-related deaths occurred among persons age 15 to 64, resulting in an increase of 402% over the study period (from 3.8 per 100,000 in 1999 to 8.2 per 100,000 in 2019). In 2019, the number of opioid-related deaths was highest among males (67.1%), non-Hispanic whites (76.0%), and adults aged 25–54 (74.1%). Overall, in Texas in 2019, opioid-related deaths resulted in 51,743 years of potential life lost (3.2 YPLL per 1000) most of which were among males (36,318 YPLL). Additionally, premature mortality due to opioids was highest among adults aged 25 to 34 years (5.1 YPLL per 1000) , and those aged 35 to 44 years (3.8 YPLL per 1000). Conclusions We identified a steady yet significant rise in opioid-related mortality in Texas since 1999 and in particular among demographic groups considered at relatively high risk for midlife mortality. This study is also considered the first of its kind to quantify the burden of premature mortality related to opioid overdoses in Texas.

Highlights • In 2005–2017, US states liberalized statutes on cause of death signature authority. • State variation in signature authority contributes to cause of death inaccuracies. • Logistic regressions suggest certifier type influences death certificate accuracy. • Death certificate training is needed across the array of professional certifiers. • Cause of Death Signature Authority database allows for more robust analysis of certification errors., This study utilized a convergent mixed-methods design to examine whether variation in death certificate certifier type predicts the accuracy of cause of death reporting in the US. We analyzed the content of state statutes, amendments, and policies concerning cause of death signature authority in 2005–2017 to create the Cause of Death Signature Authority (CoDSA) database. After merging the CoDSA data with 2005–2017 National Vital Statistics System Multiple Cause of Death Mortality files for adults with cerebral palsy (CP) (N = 29,996), we employed logistic regression models to determine the likelihood that different certifier groups made one particular type of death certification error – inaccurately reporting CP as the underlying cause of death (UCOD). The content analysis provided evidence of significant liberalization of cause of death signature authority, with 23 states expanding signature authority to include physician extenders. Logistic regression analysis revealed differences in UCOD accuracy based on certifier type. Compared to medical examiners, the likelihood of CP being reported as the UCOD, was: 41% higher (CI 1.12, 1.78) for coroners; 25% higher (1.05, 1.49) for mixed-system death investigators; 24% higher (1.08, 1.42) for physicians; and 16% higher (1.00, 1.34) for physician extenders. Inaccuracies limit public health efforts aimed at improving the health and longevity for disadvantaged populations, such as people with CP. Poor performance among cause of death certifiers may indicate systemic problems with death certification that should be addressed with more robust training for all professional groups with signature authority.

Resumen Justificación: La mortalidad por tuberculosis reúne características para ser estudiada con un enfoque de causa básica y de causa múltiple, debido a que compite frecuentemente con otras patologías como causa básica de muerte. Los objetivos de este estudio son caracterizar las defunciones por tuberculosis en ambas formas, utilizando las variables: tiempo, lugar y persona; cuantificar la concordancia entre las defunciones por tuberculosis registradas por el Programa Institucional, y el certificado de defunción, e identificar la contribución de esta enfermedad en la mortalidad con un enfoque multicausal, en Costa Rica, durante el periodo 2016-2019. Materiales y métodos: Estudio descriptivo. La población de estudio correspondió a todas las defunciones por tuberculosis y con tuberculosis registradas en el libro de registro del programa de de la Caja Costarricense de Seguro Social, ocurridas en 2016 - 2019. Por medio del expediente de salud se depuraron las defunciones registradas y se categorizaron de acuerdo con la Clasificación Internacional de Enfermedades 10 en defunciones por tuberculosis (A15 al A19), tuberculosis / virus de inmunodeficiencia humana (A15 al A19-B24 ), tuberculosis / diabetes mellitus (A15 al A19-E10,E11), tuberculosis / cáncer (A15 al A19-C34,22,18) y tuberculosis / otras (A15 al A19- J44,J45). En el certificado de defunción se revisó la secuencia informada de las causas de muerte y la causa contribuyente, para identificar la tuberculosis como causa básica o múltiple. Se agruparon los resultados por edad y se calculó: porcentajes, tasas, proporción de concordancia observada, proporción de concordancia esperada y el índice de Kappa (va de 0 a 1, y el 1 representa la máxima concordancia). Resultados: Durante el periodo de estudio (4 años), se registró un total de 113 defunciones, lo que corresponde a una tasa de mortalidad de 0,57 / 100 000 hab.; de éstas, el 73% (83) correspondió a personas del sexo masculino y el 27 %, al sexo femenino. El mayor número de defunciones ocurrió principalmente en el grupo de mayores de 65 años, tanto para los hombres como para las mujeres. La proporción de concordancia observada correspondió a un 0,77 %, y la proporción de concordancia esperada a un 26%. Al ser la proporción de concordancia observada mayor que la esperada, y con un índice de Kappa de 0,70, concluimos que la concordancia existente es considerable y se atribuye más a ser causal que al azar. El análisis de mortalidad de tubercolosis por causa múltiple no mostró cambios en la tasa de mortalidad, tomando en cuenta este evento como causa básica de defunción o como causa múltiple. Conclusiones: Con base en los resultados del estudio, se evidencia que existe una concordancia considerable entre el registro de las defunciones por tuberculosis anotadas en el libro del programa institucional y el certificado de defunción. Abstract Background: Tuberculosis mortality has the characteristics to be studied as a basic and multiple cause of death, because it can be compared with other pathologies as a basic cause of death. The goals of this study are to characterize deaths from tuberculosis including basic and multiple cause of death using time, place and person as variables, to measure the concordance of deaths from tuberculosis recorded in the Institutional Program Record Book and death certificate; and to identify the contribution of this disease in mortality with a multicausal approach, in Costa Rica during the period 2016-2019. Methods: Descriptive study. The study population corresponded to all deaths from tuberculosis and tuberculosis recorded in the Program Registration Book of the Social Security Costa Rican entity, that occurred in the period between 2016 and 2019. Using the health files, the deaths registered in the Program Registration Book were purified and categorized according to International Classification of Diseases 10 in deaths due to tuberculosis (A15 through A19), tuberculosis/human immunodeficiency virus (A15 through A19-B24), tuberculosis/diabetes mellitus (A15 through A19-E10, E11), tuberculosis/cancer (A15 through A19 -C34,22,18) and tuberculosis/others (A15 through A19-J44, J45). In the death certificate, the reported sequence of the causes of death and the contributing cause to identify tuberculosis as a basic or multiple cause were reviewed. Percentages, rates, observed concordance ratio, expected concordance ratio and Kappa index were calculated (value from 0 to 1, 1 representing the maximum concordance). Results: During the study period (4 years), a total of 113 deaths were registered, with a mortality rate of 0.57/100,000 inhabitants. Of these, 73% (83) corresponded to the male sex and 27% (30) to the female sex. The highest number of deaths occurred mainly in the group of people over 65 years, for both men and women. The observed concordance ratio corresponded to 0.77% and the expected concordance ratio to 26%. Since the observed concordance ratio is greater than expected concordance ratio and when obtaining a Kappa index of 0.70, it is concluded that the existing concordance is attributed more causally than by chance. The multiple cause tuberculosis mortality analysis did not show changes in the mortality rate, taking this event into account only as a basic cause of death or as a multiple cause. Conclusions: The study made it possible to show that there is a considerable concordance between the register of deaths from tuberculosis recorded in the register of the Institutional Program and the death certificate.

Some subtypes of alcoholic liver disease (ALD) recently had increasing prevalence or mortality. Prevalence of alcoholic fatty liver disease was increased. Mortality of alcoholic hepatitis and cirrhosis also had upward trends. However, trends in ALD- mortality and related factors are unclear. We therefore examined trends in age-standardized ALD-mortality among U.S. adults by factors using multivariable piecewise log-linear models. We collected mortality-data (age-standardized for the 2000 U.S. standard population) from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research database (CDC WONDER), using the Multiple Cause of Death Data to identify all ALD deaths in the United States for 1999-2017. We identified 296,194 deaths of ALD during 1999-2017. Trends in multivariable-adjusted, age-standardized mortality did not differ by sex, race, age or urbanization. The age-standardized mortality ratios of male/female, White/non-White and Metropolitan/Non-Metropolitan were 2.346, 1.657 and 0.851 in 2017, respectively. Strikingly, our multivariable model showed that subjects of 65+ years had the highest and the fastest growing mortality in the 3 age-groups. These findings highlight the continuation of health disparities in ALD, particularly in elderly subjects. Further works are warranted to validate and delineate the associated factors.

Background and objectives Overall mortality among U.S. adults was stable in the past years, while racial disparity was found in 10 leading causes of death or age-specific mortality in Blacks or African Americans. However, the trends in sex- and race-adjusted age-standardized cause-specific mortality are poorly understood. Methods We here aimed at identifying the UCD with sex- and race-adjusted, age-standardized mortality that was changing in recent years. We extracted the data of underlying causes of death (UCD) from the Multiple Cause of Death database of the Centers for Disease Control and Prevention (CDC). Multivariable log-linear regression models were used to estimate trends in sex- and race-adjusted, age-standardized mortality of UCD during 2013-2017. Results A total of 31,029,133 deaths were identified. Among the list of 113 UCD compiled by the CDC, there were 29 UCD with upward trend, 33 UCD with downward trend and 56 UCD with no significant trend-changes. The 2 UCD with largest annual percent change were both nutrition related (annual percent change= 17.73, 95% CI [15.13-20.33] for malnutrition, and annual percent change= 17.49, 95% CI [14.94-20.04] for Nutritional deficiencies), followed by Accidental poisoning and exposure to noxious substances. Conclusions This study thus reported the UCD with changing mortality in recent years, which was sex- and race-adjusted and age-standardized. More efforts and resources should be focused on understanding, prevention and control of the mortality linked to these UCD. Continuous monitoring of mortality trends is recommended.

Autoimmune diseases are not always recognized as urgent health issues, despite a worldwide prevalence of 4%-5%. Most estimates come from high-income countries, as low- and middle-income countries face more issues of under-reporting. Despite this and the lack of recognition under current reporting practices, the role these diseases play in mortality must be acknowledged. In particular, considering multiple causes of death as opposed to a single cause of death results in a 1.5-4.2-fold increase in deaths classified as relating to autoimmune diseases, evidence of their share in overall mortality burden, a factor important for patient care and healthcare policy decision making. However, formulating such policies and programs for timely, appropriate diagnoses and care is stymied in low- and middle-income countries by the shortage of methodologically sound studies on mortality from systemic autoimmune diseases. This limitation exacerbates inequalities and health gaps among patients in different countries and localities. Multiple cause-of-death methodology has been validated for research on other diseases and demonstrates the mortality burden of these illnesses in countries where traditional methodological approaches, primarily based on prospective cohort studies, are not feasible. Studying mortality from systemic autoimmune diseases by analyzing multiple causes of death with data from national mortality registries is a low-cost alternative to traditional mortality analysis. The objective of this paper is to demonstrate and defend the usefulness of this approach to estimate mortality burden.

Purpose Drug overdose mortality remains a public health concern in many countries globally. In the US, overdoses involving synthetic opioids are the primary contributor to overdose mortality. We aimed to assess trends in overdose death due to synthetic opioids among young people and describe key demographic and temporal changes. Methods Data from the US National Vital Statistics System Multiple Cause of Death files for 2009–2018 were analysed to determine age-specific overdose death rates by region (i.e. east versus west of the Mississippi River). Age-adjusted overdose mortality rates were used to compare demographic differences in all drug and synthetic opioid overdose among young people (aged 15–34 years) using a joinpoint regression with Poisson-approximated standard errors. Results Driven by synthetic opioid overdose, the age burden of mortality shifted towards young people in eastern states and remained approximately constant in western states over the study period. The highest increases in drug overdose mortality rates were observed in young Black and Hispanic people and those living in large metropolitan areas. Conclusions Rapid changes in the demographics of overdose demonstrate distinct but overlapping US overdose sub-epidemics, and highlight the need for targeted interventions to reduce overdose risk in young people.

Background: Recent studies of US adult mortality demonstrate a growing disadvantage among southern states. Few studies have examined long-term trends and geographic patterns in US early life (ages 1 to 24) mortality, ages at which key risk factors and causes of death are quite different than among adults. Objective: This article examines trends and variations in early life mortality rates across US states and census divisions. We assess whether those variations have changed over a 50-year time period and which causes of death contribute to contemporary geographic disparities. Methods: We calculate all-cause and cause-specific death rates using death certificate data from the Multiple Cause of Death files, combining public-use files from 1965‒2004 and restricted data with state geographic identifiers from 2005‒2014. State population (denominator) data come from US decennial censuses or intercensal estimates. Results: Results demonstrate a persistent mortality disadvantage for young people (ages 1 to 24) living in southern states over the last 50 years, particularly those located in the East South Central and West South Central divisions. Motor vehicle accidents and homicide by firearm account for most of the contemporary southern disadvantage in US early life mortality. Contribution: Our results illustrate that US children and youth living in the southern United States have long suffered from higher levels of mortality than children and youth living in other parts of the country. Our findings also suggest the contemporary southern disadvantage in US early life mortality could potentially be reduced with state-level policies designed to prevent deaths involving motor vehicles and firearms.

OBJECTIVE Describe southern US homicide rates in whites and blacks between 1999 and 2015. METHODS The Centers for Disease Control and Prevention Multiple Cause of Death Files provided mortality rates and 95% confidence intervals (CIs) for non-Hispanic whites (NHW) as well as non-Hispanic blacks and African Americans (NHB). RESULTS Overall, age-adjusted (1 to ≥85 years) homicide was significantly higher in the South (7.6/100,000, 95% CI 7.6-7.7) than the rest of the United States (4.9/100,000, 95% CI 4.8-4.9) even though the southern rate among NHB (18.7/100,000, 95% CI 18.5-18.8) was lower than the rest of the United States (23.3/100,000, 95% CI 23.1-23.5). The overall southern NHB:NHW mortality rate ratio was 5.1 and 10.6 in the rest of the nation. Homicide rates among NHW men were higher in the South than in each of the other US Census areas, whereas corresponding rates among NHB men were lower. For both men and women the NHB:NHW mortality rate ratio was lower in the South than in any other region. In addition, homicide rates among NHB women in the South were equal to or lower than corresponding rates in the West and Midwest. Finally, higher rates for NHW in metropolitan areas led to overall higher NHW mortality rates and relatively low NHB:NHW rates. Southern NHW had a higher percentage of firearms-related homicides (58.4%) than the corresponding percentage in the rest of the United States (49.8%; P < 0.001). Southern NHB used firearms for 78.8% of homicides compared with 83.9% in the rest of the United States (P < 0.001). CONCLUSIONS The overall high homicide rates in the southern United States were attributable to relatively higher NHW rates than those found in the rest of the country. Further research targeting the role of firearms as well as cultural and other issues could further the understanding of the interrelations of homicide with complex regional and cultural factors.

To assess fracture-related mortality among adults (aged ≥20years) in southern Sweden using multiple causes of death approach.All death certificates (n=201 488) in adults recorded in the region of Skåne from 1998 to 2014 were examined. We identified fracture-related deaths and computed mortality rates by sex, age group, and fracture site. Temporal trends were evaluated using joinpoint regression and associated causes were identified by age- and sex-adjusted observed/expected ratios.Fractures were mentioned on 6 226 (3.1%) death certificates, with majority of these occurred among women (60%) and those aged≥80years (77%). While hip was the most common site overall (61% of all fracture-related deaths), skull was the most common site in people60years (60% of all fracture-related deaths). Proportion of death certificates mentioning fracture was stable in women but increased by 0.4% (95% CI: 0.1 to 0.6) in men between 1998-2002 and 2010-2014. The mean age at death was higher in death certificates mentioning fracture than those without and this gap widened over time. The mean age-standardized fracture-related mortality rate was 18.8 (14.0) per 100 000 person-year in men (women) and declined by 1.5% (1.3%) per year during 1998-2014. Injuries (84.6%) and cardiovascular disorders (64.6%) were the most common comorbidities on death certificates mentioning fracture.Fracture is a contributing cause of death in more than 3% of all deaths in southern Sweden with hip in lead among older and skull fracture among younger people. There was a slight increase in proportion of deaths associated with fracture in men but not women during the study period.

Background: Adults with congenital heart disease (CHD) comprise an increasing proportion of individuals living with CHD in the United States (US). A greater than 20% decrease in adult congenital heart disease (ACHD) related mortality in the US was noted from 1999 to 2006. No recent national data are available evaluating mortality in the ACHD population. Our study aims to estimate US ACHD mortality rates by age and specific CHD lesion over the last two decades. Methods: We conducted a 19-year analysis (1999-2017) of publicly available, de-identified Multiple Cause of Death …

Background Recent studies suggest that the mortality rate of pulmonary fibrosis (PF) in the U.S. is decreasing. However, the mortality trends and demographic differences of PF among the states have not been evaluated. Objective To evaluate PF-related mortality rates and trends in the nine most populated states in the U.S. Methods Population-based study using the Multiple Cause of Death Database available through the Centers for Disease Control and Prevention website. PF-related deaths were identified using ICD codes. Results From 2004 to 2018, average annual mortality rates ranged from being the lowest in New York (110.8 per 1,000,000) to the highest in North Carolina (195.3 per 1,000,000). The mortality rates showed a decline in the majority of the states and were stable in the other states. The most significant declines were in California and Michigan. The average mortality rates in males were higher than females in all the states (rate ratio ranged from 1.56 in Texas to 1.81 in New York) and the decline in the mortality rates was more pronounced compared to males in most states. The mortality rates in Blacks were lower compared to Whites in all the states (rate ratio ranged from 0.47 in New York to 0.69 in Ohio) and the decline in the mortality rates over the period was more significant than in Whites. Conclusions There is substantial variation in mortality rates and mortality trends between states and different demographics. Further studies are needed to evaluate the environmental factors, diagnostic accuracy, and coding practices contributing to these differences.

Background Gout is the most common inflammatory arthritis with a rising prevalence around the globe. While educational inequalities in incidence and prevalence of gout have been reported, no previous study investigated educational inequality in mortality among people with gout. The aim of this study was to assess absolute and relative educational inequalities in all-cause and cause-specific mortality among people with gout in comparison with an age- and sex-matched cohort free of gout in southern Sweden. Methods We identified all residents aged ≥30 years of Skåne region with doctor-diagnosed gout (ICD-10 code M10, n = 24,877) during 1998–2013 and up to 4 randomly selected age- and sex-matched comparators free of gout (reference cohort, n = 99,504). These were followed until death, emigration, or end of 2014. We used additive hazards models and Cox regression adjusted for age, sex, marital status, and country of birth to estimate slope and relative indices of inequality (SII/RII). Three cause-of-death attribution approaches were considered for RII estimation: “underlying cause”, “any mention”, and “weighted multiple-cause”. Results Gout patients with the lowest education had 1547 (95% CI: 1001, 2092) more deaths per 100,000 person-years compared with those with the highest education. These absolute inequalities were larger than in the reference population (1255, 95% CI: 1038, 1472). While the contribution of cardiovascular (cancer) mortality to these absolute inequalities was greater (smaller) in men with gout than those without, the opposite was seen among women. Relative inequality in all-cause mortality was smaller in gout (RII 1.29 [1.18, 1.41]) than in the reference population (1.46 [1.38, 1.53]). The weighted multiple-cause approach generally led to larger RIIs than the underlying cause approach. Conclusions Our register-based matched cohort study showed that low level of education was associated with increased mortality among gout patients. Although the magnitude of relative inequality was smaller in people with gout compared with those without, the absolute inequalities were greater reflecting a major mortality burden among those with lower education.

Background Metanalyses failed to show a decrease of the mortality risk in cohorts of patients with rheumatoid arthritis (RA) between 1950 and 1995. Mortality rates obtained with the analysis of multiple causes of death (MCD) can provide a more complete estimate of the burden of mortality related to RA compared to analysis considering only the underlying cause of death (UCD). Such analyses are available from a limited number of countries, and trends for RA mortality based on MCD were divergent. Objectives The objective of the study was to evaluate trends of rheumatoid arthritis (RA) mortality reported as the underlying cause of death (UCD) and as multiple cause of death (MCD) in Italy between 2003 and 2015. Methods Analyses were carried out on the Italian National Cause of Death Register, managed by the Italian National Institute of Statistics (ISTAT). Diseases mentioned in the death certificate are coded according to the International Classification of Diseases, 10th Edition (ICD-10, 2009 version). Deaths from January 1, 2003 to December 31, 2015 with mention of RA were included. Time trends of age-standardized rates were analyzed for RA both as UCD and MCD; and the annual percent change (APC) was estimated. Results Overall 26,564 deaths with mention of RA were retrieved out of 7,595,214 deaths (0.35% of all certificates). The yearly number of RA-related deaths increased through the study period, meanwhile the probability of selection as the UCD decreased: MCD/UCD ratio was 3.7 in 2003-2006 and 4.8 in 2012-2015 in males; 3.0 and 4.1 in females (Tab.). Mortality rates based on the UCD decreased (males APC -3.1%, CI -3.9, -2.3; females APC -3.3%, CI -4.1, -2.4); while MCD rates for RA-related mortality were stable. Specifically, rates were stable or declined among younger subjects, whereas an increase was registered for the elderly: RA-related deaths in subjects aged ≥80 years raised from 48% in 2003-2006 to 59% in 2012-2015 (Fig.). Conclusion RA is increasingly mentioned among diseases contributing to death in Italy. Rheumatoid arthritis declined as underlying cause of death in the last decades. We observed a shift of RA-related mortality towards the elderly, possibly because of the progress in therapeutic strategies allowing increased survival of RA patients. Disclosure of Interests None declared

Objectives. To examine trends in hip fracture-related mortality among older adults in the United States between 1999 and 2013. Material and Methods. The Wide-Ranging Online Data for Epidemiological Research system was used to identify adults aged 65 years and older with a diagnosis of hip fracture reported in their multiple cause of death record. Joinpoint regression analyses were performed to estimate the average annual percent change in hip fracture-related mortality rates by selected characteristics. Results. A total of 204,254 older decedents listed a diagnosis of hip fracture on their death record. After age adjustment, hip fracture mortality rates decreased by −2.3% (95% CI, −2.7%, and −1.8%) in men and −1.5% (95% CI, −1.9%, and −1.1%) in women. Similarly, the proportion of in-hospital hip fracture deaths decreased annually by −2.1% (95% CI, −2.6%, and −1.5%). Of relevance, the proportion of cardiovascular diseases reported as the underlying cause of death decreased on average by −4.8% (95% CI, −5.5%, and −4.1%). Conclusions. Hip fracture-related mortality decreased among older adults in the United States. Downward trends in hip fracture-related mortality were predominantly attributed to decreased deaths among men and during hospitalization. Moreover, improvements in survival of hip fracture patients with greater number of comorbidities may have accounted for the present findings.

The gains in analyzing death from a multiple cause perspective have been recognized for a very long time. Methods that have been adopted have sought to determine additional gains made by treating death as a multiple cause phenomenon as compared to analysis based on a single under-lying cause. This paper shows how association rules mining methodology can be adapted to determine joint morbid causes with strong and interesting associations. Results show that some causes of death that do not appear among the leading causes show strong associations with other causes that would otherwise remain unknown without the use of association rules methodology. Overall, the study found that the leading joint pair of causes of death in South Africa was metabolic disorders and intestinal infectious diseases which accounted for 18.9 deaths per 1000 in 2008, followed by cerebrovascular and hypertensive diseases which accounted for 18.3 deaths per 1000.