Análise da mortalidade por causas mal definidas e por diagnósticos incompletos na região do Médio Paraíba, Estado do Rio de Janeiro, de 2005 a 2009

A elevada frequência de óbitos por causas mal definidas e por diagnósticos incompletos compromete a validade de indicadores de mortalidade por causas, constituindo obstáculo para a alocação racional dos recursos de saúde com base em perfil epidemiológico. O presente trabalho avalia a qualidade da informação da causa básica de morte na região do Médio Paraíba, estado do Rio de Janeiro, Brasil, nos anos de 2005 a 2009 para toda a população. Os dados provieram do Sistema de Informações sobre Mortalidade (SIM) disponibilizados pelo DATASUS/MS. A análise baseou-se em dois indicadores de mortalidade proporcional, por causas mal definidas (CMD - todos os óbitos cuja causa básica esteja incluída no capítulo XVIII da CID-10) e por diagnósticos incompletos (DI), segundo classificação apresentada no Projeto Carga de Doença do Brasil, 2002. As associações entre a qualidade da informação e variáveis demográficas, socioeconômicas e relacionadas à ocorrência do óbito foram investigadas por meio do cálculo das razões de chances de mortes por CMD e por DI, em relação às demais causas de morte. Observou-se na região do Médio Paraíba uma proporção de CMD de 4,54% no período de 2005 a 2009. A proporção de diagnósticos incompletos na região do Médio Paraíba no mesmo período mostrou-se elevada (20,59%). Somados os óbitos por CMD e DI na região do Médio Paraíba no quinquênio avaliado, chega-se a uma proporção de causas inadequadamente definidas (25,13%) bem acima do valor mediano de 12% estimado para a população mundial. As chances de CMD e DI decrescem quanto maior o grau de instrução. Quanto à variável raça, os óbitos de indivíduos da raça negra apresentaram maiores chances de ter CMD. Entre os óbitos de indivíduos de cor branca observaram-se maiores chances de constar um DI como causa básica. Nos óbitos sem assistência médica as chances de CMD e DI foram superiores em relação aos óbitos com assistência. Os óbitos em unidade hospitalar apresentaram menores chances de CMD e maiores chances de DI. As variáveis ignoradas ou não informadas apresentaram-se associadas a maiores chances de CMD e DI. Os resultados sugerem que na região do Médio Paraíba a qualidade dos dados de mortalidade no que concerne CMD está bem superior à nacional, assemelhando-se aos valores dos países desenvolvidos. Ainda assim, a proporção de causas residuais encontra-se bastante elevada, evidenciando que não obstante a expressiva melhora do SIM, persistem limitações que restringem a utilização mais ampla do sistema e impedem que os avanços nas políticas e programas na área da saúde sejam maiores.

Anos de vida perdidos por morte prematura por causas externas: análise da tendência e uma proposta metodológica para redistribuição dos códigos-lixo

A violência é considerada uma questão social, ou ainda, um fenômeno social e histórico, que ocorre nas diversas formas de relações humanas e que pode se manifestar em atos individuais ou institucionais, ou seja, realizados por pessoas, grupos, nações, com o objetivo de provocar algum dano físico ou psicológico em outrem. O termo violência, no presente trabalho, refere-se às mortes por causas externas, que incluem as mortes intencionais e as mortes não intencionais, ou seja, agressões, suicídios e acidentes em geral. O objetivo é analisar a evolução da carga de mortalidade no estado do Rio de Janeiro e propor a realocação dos óbitos cuja intenção é indeterminada através de uma nova metodologia. Os dados utilizados são provenientes do Sistema de Informações sobre Mortalidade. Neste estudo, foi utilizado o indicador YLL (Years of Life Lost Anos de Vida Perdidos) na avaliação do comportamento das causas violentas ao longo do tempo, no período de 1996 a 2009, para as macrorregionais de saúde do estado do Rio de Janeiro, através de modelos de efeitos mistos. Foi aplicada a regressão logística multinomial nos óbitos com causa básica conhecida, utilizando as informações como lesões e características individuais das vítimas, para prever qual seria a causa básica de morte nos registros indeterminados com características semelhantes aos óbitos com causas conhecidas. Os resultados encontrados mostram que a violência aumentou em regiões do interior do estado, com destaque para a macrorregional Norte. Na capital e nas regiões metropolitanas, houve uma estabilização das taxas, com exceção para as mortes por agressão que sofreram queda, porém as taxas de YLL permaneceram elevadas. As duas metodologias de realocação, da Carga de Doença e desta nova proposta, aumentam todas as taxas de mortalidade por grupo de causas, porém o grupo que sofreu maior impacto foi o de quedas. Os resultados encontrados, apesar das limitações, apontam para uma proposta de combinação das duas metodologias. Para os óbitos com causa básica de Y10 (Envenenamento [intoxicação] por e exposição a analgésicos, antipiréticos e anti-reumáticos nãoopiáceos, intenção não determinada) a Y33 (Outros fatos ou eventos especificados, intenção não determinada), seria utilizada a metodologia da Carga de Doenças e, para os óbitos de Y34 (Fatos ou eventos não especificados e intenção não determinada), seria utilizado o método proposto.

Causes of injuries resulting in hospitalisation in Australia : assessing coder agreement on external causes

Objective: To assess extent of coder agreement for external causes of injury using ICD-10-AM for injury-related hospitalisations in Australian public hospitals. Methods: A random sample of 4850 discharges from 2002 to 2004 was obtained from a stratified random sample of 50 hospitals across four states in Australia. On-site medical record reviews were conducted and external cause codes were assigned blinded to the original coded data. Code agreement levels were grouped into the following agreement categories: block level, 3-character level, 4-character level, 5th-character level, and complete code level. Results: At a broad block level, code agreement was found in over 90% of cases for most mechanisms (eg, transport, fall). Percentage disagreement was 26.0% at the 3-character level; agreement for the complete external cause code was 67.6%. For activity codes, the percentage of disagreement at the 3-character level was 7.3% and agreement for the complete activity code was 68.0%. For place of occurrence codes, the percentage of disagreement at the 4-character level was 22.0%; agreement for the complete place code was 75.4%. Conclusions: With 68% agreement for complete codes and 74% agreement for 3-character codes, as well as variability in agreement levels across different code blocks, place and activity codes, researchers need to be aware of the reliability of their specific data of interest when they wish to undertake trend analyses or case selection for specific causes of interest.

Global, regional, and national age–sex specifi c all-cause and cause-specifi c mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background Up-to-date evidence on levels and trends for age-sex-specific all-cause and cause-specific mortality is essential for the formation of global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013) we estimated yearly deaths for 188 countries between 1990, and 2013. We used the results to assess whether there is epidemiological convergence across countries. Methods We estimated age-sex-specific all-cause mortality using the GBD 2010 methods with some refinements to improve accuracy applied to an updated database of vital registration, survey, and census data. We generally estimated cause of death as in the GBD 2010. Key improvements included the addition of more recent vital registration data for 72 countries, an updated verbal autopsy literature review, two new and detailed data systems for China, and more detail for Mexico, UK, Turkey, and Russia. We improved statistical models for garbage code redistribution. We used six different modelling strategies across the 240 causes; cause of death ensemble modelling (CODEm) was the dominant strategy for causes with sufficient information. Trends for Alzheimer's disease and other dementias were informed by meta-regression of prevalence studies. For pathogen-specific causes of diarrhoea and lower respiratory infections we used a counterfactual approach. We computed two measures of convergence (inequality) across countries: the average relative difference across all pairs of countries (Gini coefficient) and the average absolute difference across countries. To summarise broad findings, we used multiple decrement life-tables to decompose probabilities of death from birth to exact age 15 years, from exact age 15 years to exact age 50 years, and from exact age 50 years to exact age 75 years, and life expectancy at birth into major causes. For all quantities reported, we computed 95% uncertainty intervals (UIs). We constrained cause-specific fractions within each age-sex-country-year group to sum to all-cause mortality based on draws from the uncertainty distributions. Findings Global life expectancy for both sexes increased from 65·3 years (UI 65·0–65·6) in 1990, to 71·5 years (UI 71·0–71·9) in 2013, while the number of deaths increased from 47·5 million (UI 46·8–48·2) to 54·9 million (UI 53·6–56·3) over the same interval. Global progress masked variation by age and sex: for children, average absolute differences between countries decreased but relative differences increased. For women aged 25–39 years and older than 75 years and for men aged 20–49 years and 65 years and older, both absolute and relative differences increased. Decomposition of global and regional life expectancy showed the prominent role of reductions in age-standardised death rates for cardiovascular diseases and cancers in high-income regions, and reductions in child deaths from diarrhoea, lower respiratory infections, and neonatal causes in low-income regions. HIV/AIDS reduced life expectancy in southern sub-Saharan Africa. For most communicable causes of death both numbers of deaths and age-standardised death rates fell whereas for most non-communicable causes, demographic shifts have increased numbers of deaths but decreased age-standardised death rates. Global deaths from injury increased by 10·7%, from 4·3 million deaths in 1990 to 4·8 million in 2013; but age-standardised rates declined over the same period by 21%. For some causes of more than 100 000 deaths per year in 2013, age-standardised death rates increased between 1990 and 2013, including HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anaemias. Diarrhoeal diseases, lower respiratory infections, neonatal causes, and malaria are still in the top five causes of death in children younger than 5 years. The most important pathogens are rotavirus for diarrhoea and pneumococcus for lower respiratory infections. Country-specific probabilities of death over three phases of life were substantially varied between and within regions. Interpretation For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries. Important gaps exist in the empirical data for cause of death estimates for some countries; for example, no national data for India are available for the past decade.

Stratospheric water vapor and climate: sensitivity to the representation in radiation codes

There has been considerable interest in the climate impact of trends in stratospheric water vapor (SWV). However, the representation of the radiative properties of water vapor under stratospheric conditions remains poorly constrained across different radiation codes. This study examines the sensitivity of a detailed line-by-line (LBL) code, a Malkmus narrow-band model and two broadband GCM radiation codes to a uniform perturbation in SWV in the longwave spectral region. The choice of sampling rate in wave number space (Δν) in the LBL code is shown to be important for calculations of the instantaneous change in heating rate (ΔQ) and the instantaneous longwave radiative forcing (ΔFtrop). ΔQ varies by up to 50% for values of Δν spanning 5 orders of magnitude, and ΔFtrop varies by up to 10%. In the three less detailed codes, ΔQ differs by up to 45% at 100 hPa and 50% at 1 hPa compared to a LBL calculation. This causes differences of up to 70% in the equilibrium fixed dynamical heating temperature change due to the SWV perturbation. The stratosphere-adjusted radiative forcing differs by up to 96% across the less detailed codes. The results highlight an important source of uncertainty in quantifying and modeling the links between SWV trends and climate.

A question of continuing control -balancing building quality of housing and building codes

The Building Code of Australia seeks to establish “nationally consistent, minimum necessary standards of relevant, health, safety (including structural safety and safety from fire), amenity and sustainability objectives efficiently”. These goals are laudable – but where are the goals of quality and maintenance, which are also an essential part of achieving adequate and continuing health and safety for the built environment?

Defects such as dampness, settlement and cracking, staining, wood rot, termite damage, rusting, and roof leakage are common enough to suggest that there are still issues with building quality in housing. They are caused by a combination of initial poor workmanship and poor quality materials and latterly by poorly executed or inadequate maintenance.

Local architecture, developed over many years of trial and error, produce buildings linked to their climate and local materials (think of the typical “Queenslander” house). Today’s architecture imports technologies and materials from many differing countries and climates – that are not necessarily suitable for the location, nor is there necessarily the same quality control over the material quality and production. Inappropriate use and inadequate understanding of new materials and techniques can lead to the generation of further defects.

Whilst the building code contains provisions for initial-build material quality and workmanship, there is no continuing control over a house over its life span. Reliance is placed on advertising the need, for example, to employ qualified tradespeople; replace batteries in smoke detectors; and other good advice to help maintain housing to a minimum standard. Is this sufficient?

Mechanisms to make the transfer of knowledge to those who need to use it – be it the workforce or the houseowner – need to be improved. Should the building code be more visual and accessible in it’s content? Should the building code include provisions for maintenance? Should the building code require every house to have a “users manual” – much like a car? An extensive review of literature identifies the scale of the problem of poor quality housing and highlights some suggested causes – inadequate knowledge of the BCA by general housebuilders being one. However little work has been done to investigate what could be done to improve the situation. This work suggests that improvements to knowledge transfer would improve the quality of housing and a model of the knowledge transfer process is proposed, identifying those areas where the knowledge flows need to occur that would impact both the builders and users of housing.

Mutated MESP2 causes spondylocostal dysostosis in humans

Spondylocostal dysostosis (SCD) is a term given to a heterogeneous group of disorders characterized by abnormal vertebral segmentation (AVS). We have previously identified mutations in the Delta-like 3 (DLL3) gene as a major cause of autosomal recessive spondylocostal dysostosis. DLL3 encodes a ligand for the Notch receptor and, when mutated, defective somitogenesis occurs resulting in a consistent and distinctive pattern of AVS affecting the entire spine. From our study cohort of cases of AVS, we have identified individuals and families with abnormal segmentation of the entire spine but no mutations in DLL3, and, in some of these, linkage to the DLL3 locus at 19q13.1 has been excluded. Within this group, the radiological phenotype differs mildly from that of DLL3 mutation–positive SCD and is variable, suggesting further heterogeneity. Using a genomewide scanning strategy in one consanguineous family with two affected children, we demonstrated linkage to 15q21.3-15q26.1 and furthermore identified a 4-bp duplication mutation in the human MESP2 gene that codes for a basic helix-loop-helix transcription factor. No MESP2 mutations were found in a further 7 patients with related radiological phenotypes in whom abnormal segmentation affected all vertebrae, nor in a further 12 patients with diverse phenotypes.

Accuracy of national mortality codes in identifying adjudicated cardiovascular deaths

Objective: This study investigated the sensitivity and specificity of the national mortality codes in identifying cardiovascular disease (CVD) deaths and documents methods of verification.

Methods: A 12-year retrospective case ascertainment of all ICD-coded CVD deaths was performed for deaths between 1990 and 2002 in the Melbourne Collaborative Cohort Study, comprising 41,528 subjects. Categories of non-CVD codes were also examined. Stratified samples of 750 deaths were adjudicated from a total of 2,230 deaths. Expert panels of cardiologists and neurologists adjudicated deaths.

Results: Of the 750 deaths adjudicated, 582 were verified as CVD [392 coronary heart disease (CHD) and 92 stroke] and 168 non-CVD. Estimated sensitivity and specificity of national mortality codes for identifying specific causes of death were: CHD 74.2% (95% CI: 69.8–78.5%) and 97.6% (96.0–99.2%), respectively; myocardial infarction 59.9% (50.9–69.0%) and 94.2% (92.4–96.0%), respectively; haemorrhagic stroke 58.9% (46.0–71.7%) and 99.8% (99.4–100.0%), respectively and; ischaemic stroke 38.7% (20.5–56.9%) and 99.9% (99.6–100.0%), respectively. Misclassification was most common for deaths with primary ICD codes for endocrine-metabolic and genito-urinary diseases.

Conclusions: National mortality coding under-estimated the true proportion of CHD and stroke deaths in the cohort by 13.6% and 50.8%, respectively.

Exploring in-hospital adverse drug events using ICD-10 codes

 Abstract
Objective Adverse drug events (ADEs) during hospital admissions are a widespread problem associated with adverse patient outcomes. The ‘external cause’ codes in the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) provide opportunities for identifying the incidence of ADEs acquired during hospital stays that may assist in targeting interventions to decrease their occurrence. The aim of the present study was to use routine administrative data to identify ADEs acquired during hospital admissions in a suburban healthcare network in Melbourne, Australia.

Methods Thirty-nine secondary diagnosis fields of hospital discharge data for a 1-year period were reviewed for ‘diagnoses not present on admission’ and assigned to the Classification of Hospital Acquired Diagnoses (CHADx) subclasses. Discharges with one or more ADE subclass were extracted for retrospective analysis.

Results From 57 205 hospital discharges, 7891 discharges (13.8%) had at least one CHADx, and 402 discharges (0.7%) had an ADE recorded. The highest proportion of ADEs was due to administration of analgesics (27%) and systemic antibiotics (23%). Other major contributors were anticoagulation (13%), anaesthesia (9%) and medications with cardiovascular side-effects (9%).

Conclusion Hospital data coded in ICD-10 can be used to identify ADEs that occur during hospital stays and also clinical conditions, therapeutic drug classes and treating units where these occur. Using the CHADx algorithm on administrative datasets provides a consistent and economical method for such ADE monitoring.

What is known about the topic? Adverse drug events (ADEs) can result in several different physical consequences, ranging from allergic reactions to death, thereby posing a significant burden on patients and the health system. Numerous studies have compared manual, written incident reporting systems used by hospital staff with computerised automated systems to identify ADEs acquired during hospital admissions. Despite various approaches aimed at improving the detection of ADEs, they remain under-reported, as a result of which interventions to mitigate the effect of ADEs cannot be initiated effectively.

What does this paper add? This research article demonstrates major methodological advances over comparable published studies looking at the effectiveness of using routine administrative data to monitor rates of ADEs that occur during a hospital stay and reviews the type of ADEs and their frequency patterns during patient admission. It also provides an insight into the effect of ADEs that occur within different hospital treating units. The method implemented in this study is unique because it uses a grouping algorithm developed for the Australian Commission on Safety and Quality in Health Care (ACSQHC) to identify ADEs not present on admission from patient data coded in ICD-10. This algorithm links the coded external causes of ADEs with their consequences or manifestations. ADEs identified through the use of programmed code based on this algorithm have not been studied in the past and therefore this paper adds to previous knowledge in this subject area.

What are the implications for health professionals? Although not all ADEs can be prevented with current medical knowledge, this study can assist health professionals in targeting interventions that can efficiently reduce the rate of ADEs that occur during a hospital stay, and improve information available for future medication management decisions.

OCCUPATIONAL CAUSES OF LUNG CANCER IN NEW MEXICO'S ANGLOS AND HISPANICS

Although, elevated risk for lung cancer has been associated with certain industries and occupations in previous studies, the lack of cigarette smoking information in many of these investigations resulted in estimates that could not be adjusted for the effects of smoking. To determine lung cancer risk due to occupation and smoking, for New Mexico's Anglos and Hispanics, a population-based case-control study was conducted. Incident cases diagnosed 1980-1982, and controls from the general population, were interviewed for lifetime occupational and smoking histories. Specific high risk industries and occupations were identified in advance and linked with industrial and occupational codes for hypotheses-testings. Significantly elevated risks were found for welders (RR = 3.5) and underground miners (RR = 2.0) with adjustment for smoking. Because shipbuilding was the industry of employment for only five of the 18 cases who were welders, exposures other than asbestos could be causal agents. Among the underground for only five of the 18 cases who were welders, exposures other than asbestos could be causal agents. Among the underground miners, uranium, copper, lead and zinc, coal, and potash mining industries were represented. Low prevalence of employment in some of the industries and occupations of interest resulted in inconclusive results. ^

The crash outcome data evaluation system (CODES).

National Highway Traffic Safety Administration, Office of Research and Development, Washington, D.C.

Report to Congress: benefits of safety belts and motorcycle helmets. Based on data from the Crash Outcome Data Evaluation System (CODES).

Mode of access: Internet.

Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

Background: Up-to-date evidence on levels and trends for age-sex-specific all-cause and cause-specific mortality is essential for the formation of global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013) we estimated yearly deaths for 188 countries between 1990, and 2013. We used the results to assess whether there is epidemiological convergence across countries. Methods We estimated age-sex-specific all-cause mortality using the GBD 2010 methods with some refinements to improve accuracy applied to an updated database of vital registration, survey, and census data. We generally estimated cause of death as in the GBD 2010. Key improvements included the addition of more recent vital registration data for 72 countries, an updated verbal autopsy literature review, two new and detailed data systems for China, and more detail for Mexico, UK, Turkey, and Russia. We improved statistical models for garbage code redistribution. We used six different modelling strategies across the 240 causes; cause of death ensemble modelling (CODEm) was the dominant strategy for causes with sufficient information. Trends for Alzheimer's disease and other dementias were informed by meta-regression of prevalence studies. For pathogen-specific causes of diarrhoea and lower respiratory infections we used a counterfactual approach. We computed two measures of convergence (inequality) across countries: the average relative difference across all pairs of countries (Gini coefficient) and the average absolute difference across countries. To summarise broad findings, we used multiple decrement life-tables to decompose probabilities of death from birth to exact age 15 years, from exact age 15 years to exact age 50 years, and from exact age 50 years to exact age 75 years, and life expectancy at birth into major causes. For all quantities reported, we computed 95% uncertainty intervals (UIs). We constrained cause-specific fractions within each age-sex-country-year group to sum to all-cause mortality based on draws from the uncertainty distributions. Findings Global life expectancy for both sexes increased from 65·3 years (UI 65·0-65·6) in 1990, to 71·5 years (UI 71·0-71·9) in 2013, while the number of deaths increased from 47·5 million (UI 46·8-48·2) to 54·9 million (UI 53·6-56·3) over the same interval. Global progress masked variation by age and sex: for children, average absolute differences between countries decreased but relative differences increased.For women aged 25-39 years and older than 75 years and for men aged 20-49 years and 65 years and older, both absolute and relative differences increased. Decomposition of global and regional life expectancy showed the prominent role of reductions in age-standardised death rates for cardiovascular diseases and cancers in high-income regions, and reductions in child deaths from diarrhoea, lower respiratory infections, and neonatal causes in low-income regions. HIV/AIDS reduced life expectancy in southern sub-Saharan Africa. For most communicable causes of death both numbers of deaths and age-standardised death rates fell whereas for most non-communicable causes, demographic shifts have increased numbers of deaths but decreased age-standardised death rates. Global deaths from injury increased by 10·7%, from 4·3 million deaths in 1990 to 4·8 million in 2013; but age-standardised rates declined over the same period by 21%. For some causes of more than 100 000 deaths per year in 2013, age-standardised death rates increased between 1990 and 2013, including HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anaemias. Diarrhoeal diseases, lower respiratory infections, neonatal causes, and malaria are still in the top five causes of death in children younger than 5 years. The most important pathogens are rotavirus for diarrhoea and pneumococcus for lower respiratory infections. Country-specific probabilities of death over three phases of life were substantially varied between and within regions. Interpretation For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries. Important gaps exist in the empirical data for cause of death estimates for some countries; for example, no national data for India are available for the past decade.