Tag Archives: mortality

45,000 Unnecessary Deaths Per Year

Posted on by

According to a recent editorial (NEJM 2013; 369: 1180-81), 45,000 American adults die each year because they have no medical coverage (Am J Public Health 2009; 99: 2289-95).

The editorial which describes a late diagnosis of colon cancer in an adult who had been chronically uninsured despite working full-time makes a couple of key points:

  • Lack of insurance can be lethal
  • Underinsured also have higher mortality rates  One example: insurance status, not race, was associated with mortality after an acute cardiovascular event in Maryland (J Gen Intern Med 2012; 27: 1368)

While the rollout for the Affordable Care Act (ACA) has been bad, the underlying reason for it remains sound.  In addition, though the ACA expands coverage, I am skeptical that it will control problems with skyrocketing costs.  As such, many other difficult changes in medical care delivery will ultimately be needed.

Related blog post:

Life in the balance (book) | gutsandgrowth

Liver Biopsy -Risks and Benefits

Posted on by

Even in the ‘old USA,’ there is a mortality risk from liver biopsy in the pediatric population.  A recent study from Los Angeles confirms this (JPGN 2013; 57: 644-48).

This retrospective review of all children (n=213 children & 328 biopsies) who underwent a percutaneous liver biopsy between 2008-2011 were examined.  These biopsies were completed by radiology with ultrasound or CT.  Gel foam was injected in cases of multiple biopsies.

Results:

  • 9 (4.2%) dropped hemoglobin > 2 /dL.
  • 7 (3.3%) needed a transfusion.
  • 1 (0.5%) died.  This was a 2.6 kg infant seen for transplant evaluation.
  • 63 (19%) had insufficient samples for definitive histologic evaluation.
  • In 81% of initial biopsies, “a definitive pathologic diagnosis was obtained.”
  • Biopsies for unexplained elevation of liver function tests were nondiagnostic in 34.9%.

The authors take: “our data demonstrate that percutaneous liver biopsy is generally safe; yet, finite risk remains, with bleeding-related complications occurring 5.2% of children.”

Bottomline: make sure you need the information from the liver biopsy enough to justify the risk, particularly in small children and in those at increased risk for bleeding.

Related blog post (with annotated references):

Liver biopsy risk in children | gutsandgrowth

Don’t Go Nuts over Nuts

Posted on by

A recent study (NEJM 2013; 369: 2001-11) showed that nut consumption was associated with a lower mortality rate among more than 115,000 people in two large independent cohorts.  Nut consumption had significant inverse associations with deaths due to cancer, heart disease, and respiratory disease.  Those who ate nuts most frequently (7 or more times per week) had a 20% lower hazard ratio for death. However, the individuals who consumed nuts may have been more likely to have other healthy habits, though this was not identified in the study.

This study is explained more fully in the following video (less than 3 minutes):  nej.md/1aSbuY4 

Life Cut Short by Obesity

Posted on by

When someone is too heavy, everyone knows that this is associated with numerous health risks.  A recent estimate on the amount of life lost due to obesity has been published (Obesity 2013; 21: 405-12).

Using data from the National Health and Nutrition Examination Survey (NHANES) I (1971-75), II (1976-80), and III (1988-94), the author was able to follow-up for 15 years and prospectively analyzed the data to calculate the relative risk of death and the “advancement period” of death due to obesity.  Stratification of death was adjusted for covariates including pre-existing illness, smoking, and older age.

The study focused on otherwise healthy nonsmokers to isolate the effects of obesity on mortality.  The averages of the cohorts was 46-48 years of age. While the author studied only 37,632 patients who had 8,791 deaths during the study, these results are relevant to about one-third of American adults.

Key finding: Compared to reference weight (BMI 23-25 kg/meter-squared), mortality was likely to occur 9.44 years earlier for those who were obese (BMI ≥ 30).

When the data was divided by weight, overweight (BMI 25-30 kg/meter-squared), mild obesity (BMI 30-35 kg/meter-squared), and obesity grades 2-3 (BMI >35 kg/meter-squared), the results were 4.40 years, 6.69 years, and 14.16 years respectively. The effect on advancement period mortality was less in older age groups (>55 years).

The main limitation of the study was its reliance on statistical analysis.  For those without a statistical background, Figure 2 which describes the mortality risk advancement period formula could as easily be written in Chinese.  Nevertheless, in the discussion the author underscores that these estimates are consistent with prior studies.

Related blog posts:

Mortality from IBD

Posted on by

A large Danish cohort provides useful information on the mortality effects of having inflammatory bowel disease (IBD) and how this has changed over the last three decades (Clin Gastroenterol Hepatol 2013; 11: 43-48).

Using a national cohort of all individuals living in Denmark between 1982-2010 (on average 5.3 million), the authors studied 36,080 patients with ulcerative colitis (UC) and 15,361 with Crohn’s disease (CD) in comparison to data from 2,858,096 matched controls (50 controls from each IBD patient) from the general population.  For UC, the median age was 45.2 years and for CD 36.3 years.

Findings:

  • With UC, the first year of diagnosis carried a higher risk of dying (HR 2.43) then rapidly declined to around HR 1.1 after 2 years.  Overall, long-term mortality was increased 10% among UC patients.  Mortality from UC decreased from 1982 to 2010 due to decreased mortalities from gastrointestinal disorders, including colorectal cancer.
  • Mortality was higher among patients diagnosed at younger ages.  Patients diagnosed with UC in childhood or adolescence had a 2.15-fold higher relative mortality than patients diagnosed with UC at 60-79 years.
  • Cause-Specific Mortality: during the first year after UC diagnosis, the HR ratio was increased markedly for gastrointestinal disease (HR 13.3) and infection (HR 9.17).  These areas were most prominent at 10+ years, but the HR ratios had decreased to 1.95 and 1.64 respectively at that time.
  • For CD, mortality was markedly increased in the first year with HR 3.69 and declined to HR 1.53 during years 2-4; HR was 1.49 at 10+ years following diagnosis.  Overall, long-term mortality was increased 50% among CD patients.  Unlike UC, no improvement in mortality rate occurred during the study.
  • Cause-Specific Mortality: during the first year after CD diagnosis, the HR ratio was increased markedly for gastrointestinal disease (HR 23.02) and infection (HR 10.19). These areas were most prominent at 10+ years, but the HR ratios had decreased to 3.67 and 2.70 respectively at that time.  Infections were not increased in the most recent decade, indicating that thiopurines and biologics have not increased the overall risk of fatal infections.
  • While the relative risk of cardiovascular disease was only slightly increased (HR 1.11 for both CD and UC), this is important given the overall frequency of cardiovascular disease in the population.  Presumably, systemic inflammation contributes to the formation of atherosclerosis.
  • Suicide was also increased, especially in the first year after diagnosis (HR 2.05 for UC and HR 1.37 for CD)

Strengths of study: since Denmark has free access to health care and all citizens have a unique 10-digit personal identification, this enables capture of virtually all patients with IBD.  Previous studies have validated the database to be accurate and that the IBD diagnoses have been validated.

Related blog entries:

Live longer -drink more coffee

Posted on by

In a previous post, I was impressed with some of the benefits of coffee (Drink Up!).  More good news for coffee drinkers: drinking coffee is associated with decreased mortality (NEJM 2012; 366: 1891-1904).  Full disclosure –I don’t even drink coffee & I am not being paid by industry!

This study examined a huge population, 5,148,760 person-years (1995-2008) among 229,119 men and 173,141 women in the NIH-AARP Diet and Health Study with participants aged 50-71 at baseline.  With age-adjusted models, if adjusted for smoking, an inverse association between coffee consumption and mortality was noted.  With 6 cups per day, the hazard ratio (HR) was 0.90 for men and 0.85 for women.  For 2-3 cups, the HRs were 0.94 and 0.95 respectively.

Declines in mortality were noted for heart disease, respiratory disease, stroke, injuries/accidents, diabetes and infections, but not for deaths from cancer.  However, while coffee is associated with improved mortality data, a causal role for coffee consumption in reducing mortality cannot be established with this study.

Related link:

http://www.cnn.com/2012/05/16/health/coffee-drinking-longer-life/index.html?hpt=hp_t2

HCV now more deadly than HIV

Posted on by

Hepatitis C virus (HCV) now kills more people in the United States than HIV (Ann Intern Med 2012; 156: 271-78).  Data from the CDC followed the mortality burden of Hepatitis B (HBV), HCV, and HIV from 1999 to 2007.    The data were derived from death certificates & a limitation was that these are often completed by individuals other than the primary physician.  Sometimes the exact cause is difficult to discern.  However, this is more likely to result in underreports of deaths from viral hepatitis compared with those from HIV.

In total, 21.8 million death certificates were analyzed.

  • HBV death rate stayed relatively constant –in 2007: 1815 deaths*
  • HCV death rate increased steadily –in 2007: 15106 deaths*
  • HIV death rate improved –in 2007: 12734 deaths*

*When infection was cause or underlying contributor of death

One in 33 baby boomers are infected with HCV; most do not know they are infected.  Three-fourths of the deaths for HCV are in this age group as well.  In addition, it is expected that mortality from HCV will grow over the next 10-15 years without a major intervention. http://www.ajc.com/health/hepatitis-c-deaths-up-1356460.html

Given the increasing HCV disease burden, this strengthens the rationale for more aggressive case finding and the use of more effective & more expensive therapies (see previous blog: The cost of progress in treating Hepatitis C.  Among patients with HCV with advanced disease/cirrhosis, monitoring for HCC is important (Looking for trouble).

Additional references:

  • -Hepatology 2011; 54: 1547. Excess mortality (6x gen population) in those who achieve SVR
  • -Gastroenterology 2010; 138: 513. Predicts peak cirrhosis due to HCV in year 2020; peak HCV prevalence was year 2000.
  • -Clin Gastro Hep 2010; 8: 924. Epidemiology 2010.
  • -Hepatology 2010; 52: 1543. Visceral adiposity is associated with increased histological findings and higher viral loads.
  • -Gastroenterology 2010; 138: 136. Predicting clinical outcomes: plt<99, Alb <3.5, AST/ALT ratio >1.2, & TB>2 all assoc with 40-50% risk of developing ‘clinical outcome’ in next 3.5yrs. Outcomes: ascites, variceal hemorrhage, decompensation according to CTP (66%), peritonitis, death (2%), encephalopathy
  • -Hepatology 2009; 49: 729. 5-yr f/u after successful HCV RX, n=150. 2 developed HCC.
  • -Gastroenterology 2009; 136: 138, 39(ed). HCC occurring c HCV ~1%/yr in HALT-C study. prolonged Rx -not helpful. n=1005
  • -Hepatology 2008; 47: 1128. Increasing mortality of HCV between 1995-2004. Due to aging of infected individuals.
  • -Hepatology 2008; 47: 1371. Genotype 4 review.
  • -Hepatology 2008; 47: 836. 2/121 bx of children had cirrhosis.
  • -J Pediatr 2007; 150: 168. n=60. Looked at two populations: look back after transfusion and referrals. mean age at infection 7 months, mean time with infection 13yrs. 12% developed significant fibrosis.
  • -Hepatology 2007; 45: 1076. Large study: Lancet 2006; 368: 938. 39,109 c HBV, 75,834 c HCV, 2,604 c both. death rate: 3.2%, 5.3%, 7.1% respecively. Increased rate of dying c HCV due to drug use rather than liver dz.
  • -Clin Gastro & Hep 2006; 4: 1190-1191, 1271-78, 1278-1282. slow progression of HCV in 184 untreated women infected in 1977 (mean 27 years) — 2.1% developed cirrhosis. genotype 1B ALT values correlated with change in histology.
  • -JPGN 2006; 43: 209. Review of 91 cases; 7 c cirrhosis at presentation (mean 11.7yrs)
  • -Clin Gastro & Hep 2005; 3: 910. cirrhosis in 71% after 60 years in Asian patients; 25% in Caucasian pts 61-80 who presumably had disease for shorter interval.
  • -Gastroenterology 2003; 125: 1695. obesity/insulin resistance worsens fibrosis in HCV
  • -Gastroenterology 2002; 123: 483-491. IFN Rx improved survival; n=2889. retrospective study.
  • -JPGN 2001;33: 22A. spontaneous clearance in 30% during short f/u; n=145.
  • -Hepatology 2000; 32: 91-96. Low likelihood of progression in cohort followed for 20yrs.