Mortality among homeless people in France, 2008-10.

BACKGROUND: Studies in various countries have shown that homeless people have high mortality levels. The aims of this study concerning the French population were to investigate mortality among the homeless and to study their causes of death in comparison to those of the general population. METHODS: A representative sample of 1145 homeless deaths registered by an association was matched to the national database of medical causes of death using common descriptive variables. Log-binomial regression was used to compare mortality among the homeless to that of the general population. Multiple imputation was used to manage missing causes of deaths. RESULTS: Out of the 1145 registered homeless deaths, 693 were matched to the causes of death database. Homeless deaths were young (average age: 49). Overall, homeless deaths were slightly more frequent during winter. Among all deaths, the probability of being homeless was higher when dying from hypothermia (RR = 6.4), alcohol-related deaths (RR = 1.7), mental disorders, diseases of the digestive and circulatory systems, and undetermined causes (RR from 1.5 to 3.7). CONCLUSION: The homeless died at 49 years old on average compared with 77 in the general population in 2008-10. The health of homeless people should be considered not only in winter periods or in terms of alcohol- or cold-related conditions. This study also highlights the need for more precise data to estimate the mortality risks of the homeless in France.

Quality comparison of electronic versus paper death certificates in France, 2010.

BACKGROUND: Electronic death certification was established in France in 2007. A methodology based on intrinsic characteristics of death certificates was designed to compare the quality of electronic versus paper death certificates. METHODS: All death certificates from the 2010 French mortality database were included. Three specific quality indicators were considered: (i) amount of information, measured by the number of causes of death coded on the death certificate; (ii) intrinsic consistency, explored by application of the International Classification of Disease (ICD) General Principle, using an international automatic coding system (Iris); (iii) imprecision, measured by proportion of death certificates where the selected underlying cause of death was imprecise. Multivariate models were considered: a truncated Poisson model for indicator (i) and binomial models for indicators (ii) and (iii). Adjustment variables were age, gender, and cause, place, and region of death. RESULTS: 533,977death certificates were analyzed. After adjustment, electronic death certificates contained 19% [17%-20%] more codes than paper death certificates for people deceased under 65 years, and 12% [11%-13%] more codes for people deceased over 65 years. Regarding deceased under and over 65 respectively, the ICD General Principle could be applied 2% [0%-4%] and 6% [5%-7%] more to electronic than to paper death certificates. The proportion of imprecise death certificates was 51% [46%-56%] lower for electronic than for paper death certificates. CONCLUSION: The method proposed to evaluate the quality of death certificates is easily reproducible in countries using an automatic coding system. According to our criteria, electronic death certificates are better completed than paper death certificates. The transition to electronic death certificates is positive in many aspects and should be promoted.

Estimating the number of homeless deaths in France, 2008-2010.

BACKGROUND: The homeless population of France has increased by 50% over the last 10 years. Studies have shown that homelessness is associated with a high risk of premature death. The aim of this study was to estimate the number of homeless deaths in France between 2008 and 2010, using a reproducible method. METHODS: We used the capture-recapture method to estimate the number of homeless deaths in France using two independent sources. An associative register of homeless deaths was matched with the national exhaustive database of the medical causes of death, using several matching approaches based on various combinations of the following variables: gender, age, place of death, date of death. RESULTS: The estimated number of homeless deaths between 2008 and 2010 was 6730 (95% CI: [4381-9079]), a number greatly underestimated by the two sources considered separately (less than 20%). CONCLUSIONS: In the absence of a register of the homeless deaths, the capture-recapture method provides an order of magnitude for evaluation of the resources that may be allocated by policy makers to manage the issue. Based on common and routinely produced databases, this estimate may therefore be used to monitor the mortality of the homeless population. Further studies about homeless mortality, particularly on the lead causes of deaths, are needed to manage this issue and to implement strategy to decrease the number of homeless deaths.

Automated comparison of last hospital main diagnosis and underlying cause of death ICD10 codes, France, 2008-2009.

BACKGROUND: In the age of big data in healthcare, automated comparison of medical diagnoses in large scale databases is a key issue. Our objectives were: 1) to formally define and identify cases of independence between last hospitalization main diagnosis (MD) and death registry underlying cause of death (UCD) for deceased subjects hospitalized in their last year of life; 2) to study their distribution according to socio-demographic and medico-administrative variables; 3) to discuss the interest of this method in the specific context of hospital quality of care assessment. METHODS: 1) Elaboration of an algorithm comparing MD and UCD, relying on Iris, a coding system based on international standards. 2) Application to 421,460 beneficiaries of the general health insurance regime (which covers 70% of French population) hospitalized and deceased in 2008-2009. RESULTS: 1) Independence, was defined as MD and UCD belonging to different trains of events leading to death 2) Among the deaths analyzed automatically (91.7%), 8.5% of in-hospital deaths and 19.5% of out-of-hospital deaths were classified as independent. Independence was more frequent in elder patients, as well as when the discharge-death time interval grew (14.3% when death occurred within 30 days after discharge and 27.7% within 6 to 12 months) and for UCDs other than neoplasms. CONCLUSION: Our algorithm can identify cases where death can be considered independent from the pathology treated in hospital. Excluding these deaths from the ones allocated to the hospitalization process could contribute to improve post-hospital mortality indicators. More generally, this method has the potential of being developed and used for other diagnoses comparisons across time periods or databases.

Empirical comparison study of approximate methods for structure selection in binary graphical models.

Looking for associations among multiple variables is a topical issue in statistics due to the increasing amount of data encountered in biology, medicine, and many other domains involving statistical applications. Graphical models have recently gained popularity for this purpose in the statistical literature. In the binary case, however, exact inference is generally very slow or even intractable because of the form of the so-called log-partition function. In this paper, we review various approximate methods for structure selection in binary graphical models that have recently been proposed in the literature and compare them through an extensive simulation study. We also propose a modification of one existing method, that is shown to achieve good performance and to be generally very fast. We conclude with an application in which we search for associations among causes of death recorded on French death certificates.

Diverging trends in educational inequalities in cancer mortality between men and women in the 2000s in France.

BACKGROUND: Socioeconomic inequalities in cancer mortality have been observed in different European countries and the US until the end of the 1990s, with changes over time in the magnitude of these inequalities and contrasted situations between countries. The aim of this study is to estimate relative and absolute educational differences in cancer mortality in France between 1999 and 2007, and to compare these inequalities with those reported during the 1990s. METHODS: Data from a representative sample including 1% of the French population were analysed. Educational differences among people aged 30-74 were quantified with hazard ratios and relative indices of inequality (RII) computed using Cox regression models as well as mortality rate difference and population attributable fraction. RESULTS: In the period 1999-2007, large relative inequalities were found among men for total cancer and smoking and/or alcohol related cancers mortality (lung, head and neck, oesophagus). Among women, educational differences were reported for total cancer, head and neck and uterus cancer mortality. No association was found between education and breast cancer mortality. Slight educational differences in colorectal cancer mortality were observed in men and women. For most frequent cancers, no change was observed in the magnitude of relative inequalities in mortality between the 1990s and the 2000s, although the RII for lung cancer increased both in men and women. Among women, a large increase in absolute inequalities in mortality was observed for all cancers combined, lung, head and neck and colorectal cancer. In contrast, among men, absolute inequalities in mortality decreased for all smoking and/or alcohol related cancers. CONCLUSION: Although social inequalities in cancer mortality are still high among men, an encouraging trend is observed. Among women though, the situation regarding social inequalities is less favourable, mainly due to a health improvement limited to higher educated women. These inequalities may be expected to further increase in future years.

Trends in geographic mortality inequalities and their association with population changes in France, 1975-2006.

BACKGROUND: Although some studies have reported that population change is associated with spatial mortality inequalities, few of them have tried to take a dynamic approach to the association. The aim of this study was to explore and interpret the ecological association between the change in cause-specific mortality inequalities and population change over a 30-year period in areas exhibiting different deprivation and urbanization levels in France. METHODS: The French communes were classified by category of demographic change during the period 1962-2006. The changes in standardized mortality ratios were analysed by category over 5 inter-censal periods, taking into account degree of urbanization and deprivation quintile. The magnitude and significance of the associations for various causes of death were estimated using a Generalised Estimating Equation Poisson model. RESULTS: Overall, the change in relative mortality was negatively associated with population growth. For a compound annual population growth rate of 1% in 1990-99, the standardized mortality ratios decreased, on average, by 2.1% (95% confidence interval: -1.45 to -2.72). The association was stronger in urban areas, and reversed in the least deprived areas. The association was stronger and more significant for men, subjects aged less than 65 years and alcohol-related and violent deaths. CONCLUSION: This study highlights the significance of dynamic approaches. Population growth was associated with a decrease in relative mortality level; the direction and strength of the association varied depending on the socio-territorial characteristics. As is the case for English-speaking countries, in France, population growth may be considered a component of current social dynamics that are not measured by usual indicators.

Innovations in medical care and mortality trends from four circulatory diseases between 1970 and 2005.

BACKGROUND: Governments have identified innovation in pharmaceuticals and medical technology as a priority for health policy. Although the contribution of medical care to health has been studied extensively in clinical settings, much less is known about its contribution to population health. We examine how innovations in the management of four circulatory disorders have influenced trends in cause-specific mortality at the population level. METHODS: Based on literature reviews, we selected six medical innovations with proven effectiveness against hypertension, ischaemic heart disease, heart failure and cerebrovascular disease. We combined data on the timing of these innovations and cause-specific mortality trends (1970-2005) from seven European countries. We sought to identify associations between the introduction of innovations and favourable changes in mortality, using Joinpoint-models based on linear spline regression. RESULTS: For both ischaemic heart disease and cerebrovascular disease, the timing of medical innovations was associated with improved mortality in four out of five countries and five out of seven countries, respectively, depending on the innovation. This suggests that innovation has impacted positively on mortality at the population level. For hypertension and heart failure, such associations could not be identified. CONCLUSION: Although improvements in cause-specific mortality coincide with the introduction of some innovations, this is not invariably true. This is likely to reflect the incremental effects of many interventions, the time taken for them to be adopted fully and the presence of contemporaneous changes in disease incidence. Research on the impact of medical innovations on population health is limited by unreliable data on their introduction.

Mortality among active-duty male French Armed Forces, 2006-10.

BACKGROUND: In the Armed Forces, knowledge about the causes of deaths is required in order to develop prevention strategies. This study presents the main characteristics of causes of deaths among male active-duty personnel in the French Armed Forces during the 2006-10 period and compares them with the general French male population. METHODS: The data are provided by military public health surveillance. Comparisons of the specific mortality rates (MR) were performed using a Poisson regression. Standardized mortality ratios (SMRs) were calculated to compare mortality with the general French male population. RESULTS: There were 1455 deaths among male active-duty personnel during the study period [MR: 100.9 per 100,000 person-years (PY); 95% confidence interval 95.7-106.1]. The 17-24 age group was characterized by violent deaths: transport accident (MR: 45.9 per 100,000 PY) and suicide (18.8 per 100 000 PY). Overall SMRs show significantly lower MR compared with the French national MR with the exception of SMR for transport accident and suicide in the 17-24 age group. CONCLUSIONS: There is a significantly lower deficit of mortality compared with the French male general population, reflecting a strong healthy worker effect. However, health promotion programmes should continue to put emphasis on transport accident especially among the 17-24 age group.

Spatiotemporal association between deprivation and mortality: trends in France during the nineties.

BACKGROUND: Monitoring the time course of socio-economic inequalities in mortality is a key public health issue. The aim of this study is to analyse this trend at an ecological level, in mainland France, over the 1990s, using a deprivation index enabling time comparisons. METHODS: Deprivation indexes (FDep) were built using the 1990 and 1999 data and the same methodology. The indices were defined as the first component of a principal component analysis including four specific socio-economic variables. The time course of the association between mortality and deprivation was evaluated on the 'commune' geographic scale (36 000 U in mainland France), without considering spatial autocorrelation and on the larger 'canton' scale (3700 U), considering spatial autocorrelation. The analysis was carried out by gender, age and degree of urbanicity and applied to general mortality and a specific subcategory: 'avoidable' deaths. RESULTS: Area-level socio-economic inequalities in mortality tended to increase during the 1990s. For the period 1997-2001, the standard mortality ratio (SMR) was 24% higher for the communes in the most deprived quintile than for those in the least deprived quintile, while this differential was of 20% for the period 1988-92. This increase in the differentials concerned especially males and people in the age group of <65 years. For both men and women, it was stronger for the 'avoidable' mortality subcategory. CONCLUSION: As observed at the individual level in previous studies, area-level socio-economic inequalities in health increased during the nineties, while general health improved.

Anaphylaxis during anesthesia in France: an 8-year national survey.

BACKGROUND: More attention should be paid to rare serious adverse events such as anaphylaxis to increase the safety of anesthesia. OBJECTIVE: To report the results of an 8-year survey of anaphylaxis during anesthesia in France. METHODS: Data from patients who experienced anaphylaxis between January 1, 1997, and December 31, 2004, were analyzed. Estimated incidences were obtained by combining this database with data from the French pharmacovigilance system by using a capture-recapture method. The number of patients exposed to the offending agents was obtained from data collected during the national survey of anesthesia practice. RESULTS: A total of 2516 patients was included. A diagnosis of IgE-mediated reaction was established in 1816 cases (72.18%). The most common causes were neuromuscular blocking agents ([NMBAs]; n = 1067; 58.08%), latex (n = 361; 19.65%), and antibiotics (n = 236; 12.85%). The median annual incidence per million procedures was higher for females 154.9 (5th-95th percentile, 117.2-193.1) than for males 55.4 (5th-95th percentile, 42.0-68.0). It reached 250.9 (5th-95th percentile, 189.8-312.9) for women in cases of allergic reactions to NMBAs. In children, a diagnosis of IgE-mediated reactions was obtained in 122 cases (45.9%). The most common causes were latex (n = 51; 41.8%), NMBAs (n = 39; 31.97%), and antibiotics (n = 11; 9.02%). In contrast with adults, no female predominance was observed. CONCLUSION: The incidence of allergic reactions during anesthesia, estimated on a national basis, is higher than previously estimated. These results should be taken into account in the evaluation of the benefit-to-risk ratio of the various anesthetic techniques in individuals. The similar incidence of reactions according to sex before adolescence suggests a role for sex hormones in the increase of anaphylaxis observed in women.

Cause-specific mortality time series analysis: a general method to detect and correct for abrupt data production changes.

BACKGROUND: Monitoring the time course of mortality by cause is a key public health issue. However, several mortality data production changes may affect cause-specific time trends, thus altering the interpretation. This paper proposes a statistical method that detects abrupt changes ("jumps") and estimates correction factors that may be used for further analysis. METHODS: The method was applied to a subset of the AMIEHS (Avoidable Mortality in the European Union, toward better Indicators for the Effectiveness of Health Systems) project mortality database and considered for six European countries and 13 selected causes of deaths. For each country and cause of death, an automated jump detection method called Polydect was applied to the log mortality rate time series. The plausibility of a data production change associated with each detected jump was evaluated through literature search or feedback obtained from the national data producers.For each plausible jump position, the statistical significance of the between-age and between-gender jump amplitude heterogeneity was evaluated by means of a generalized additive regression model, and correction factors were deduced from the results. RESULTS: Forty-nine jumps were detected by the Polydect method from 1970 to 2005. Most of the detected jumps were found to be plausible. The age- and gender-specific amplitudes of the jumps were estimated when they were statistically heterogeneous, and they showed greater by-age heterogeneity than by-gender heterogeneity. CONCLUSION: The method presented in this paper was successfully applied to a large set of causes of death and countries. The method appears to be an alternative to bridge coding methods when the latter are not systematically implemented because they are time- and resource-consuming.

Population-level impact of osteoporotic fractures on mortality and trends over time: a nationwide analysis of vital statistics for France, 1968-2004.

Osteoporotic fractures are one of the leading causes of death in the elderly population, but mortality may have been reduced by the advances in management and prevention during recent decades. The authors analyzed the population-level impact of these fractures on mortality in France from 1968 to 2004. About 20 million death certificates registered in metropolitan France from 1968 to 2004 were analyzed. Osteoporotic fractures were identified by using a previously developed methodology. Age-specific and standardized mortality rates were calculated by site of fracture and sex, and time trends were evaluated. Associated causes of death were compared between the extreme periods of the study by the observed/expected pairs method; 440,890 (2.2%) death certificates reported an osteoporotic fracture. Osteoporotic fractures overall, particularly hip and skull fractures, declined by half during the study period, exceeding the decline in general mortality and resulting in fracture-deceased subjects being older. However, pelvis, vertebral, and rib fractures became more frequent. Associated causes of death increased with time, except for decubitus ulcers, indicating a change in the pattern of the death process. Despite a 50% decline, osteoporotic fractures still have a significant impact on mortality. The pattern of the death process has changed, with an increased role for comorbidities.

Time trends in hospital-referred stroke and transient ischemic attack: results of a 7-year nationwide survey in France.

BACKGROUND: Nationwide evaluations of the burden of stroke are scarce. We aimed to evaluate trends in stroke and transient ischemic attack (TIA) hospitalization, in-hospital case fatality rates (CFRs) and mortality rates in France during 2000-2006. METHODS: Hospitalizations for stroke and TIA were determined from National Hospital Discharge Diagnosis Records that used the International Classification of Disease, 10th revision, codes I60, I61, I63, I64, G45, G46. CFRs and mortality rates were estimated from the national death certificates database. RESULTS: The total number of stays for stroke increased between 2000 and 2006 (88,371 vs. 92,118) contrasting with a decrease in that for TIA. The age-standardized (European population) hospitalization rates for TIA decreased in men (52.2 vs. 44.5/100,000/year, p = 0.002), whereas they remained stable in women (32.4 vs. 31.0/ 100,000/year). Concerning stroke, a decrease in hospitalization rates was observed in both men (from 135.3 to 123.4/ 100,000/year, p < 0.001) and women (from 85.1 to 80.7, p < 0.001). Whatever the age group and the sex, a sharp decrease in in-hospital stroke CFRs was noted. In addition, a 23% decrease in mortality rates was observed. This decrease was greater in patients >65 years. CONCLUSION: Our results demonstrate a decline in hospitalization rates for stroke, and in both stroke CFRs and mortality rates between 2000 and 2006. Improvements in stroke prevention and acute stroke care may have contributed to these results, and may have been initiated by recent advances in health policy with regard to this disease in France.

Mortality trends in systemic sclerosis in France and USA, 1980-1998: an age-period-cohort analysis.

We compared trends of Systemic Sclerosis (SS) mortality in France and the USA over the period 1980-1998 and used an Age-Period-Cohort (APC) model to adjust on the age at death of SS patients. All deaths coded with SS as an underlying primary or secondary cause in the national French and US mortality databases from 1980 to 1998 were included in the analysis. SS age-standardized mortality rates increased from 7.2 to 10.3/million in US women (+43%), and from 3 to 3.9/million in French women (+22%). Most of the increase occurred in senior women. In contrast, SS age-standardized death rates remained stable among US men (around 3/million) and French men (around 2/million). In US women, the APC analysis shows a growing cohort effect between 1900 and 1940, tending to stabilize for following cohorts. Similar findings were obtained to a lesser extent in French women. In conclusion, SS mortality rates increased by more than 40% between 1980 and 1998 in the USA, mostly in women born between 1900 and 1940. Whether these trends reflect rising incidence of SS need to be documented. The observed dissimilarity between genders and countries underline that environmental exposure and gender-related factors likely play a major etiological role. Stabilization in the following birth cohorts suggests that the increase of mortality observed since 1980 may slow down in the near future.

Changes in cancer mortality among HIV-infected patients: the Mortalité 2005 Survey.

BACKGROUND: The goal of the current study was to describe the distribution and characteristics of malignancy related deaths among human immunodeficiency virus (HIV)-infected patients with use of data obtained from a national survey conducted in France in 2005 and to compare with results obtained from a similar survey conducted in 2000. METHOD: The underlying cause of death was documented using a standardized questionnaire fulfilled in French hospital wards and networks that were involved in the treatment of HIV-infected patients. RESULTS: Among the 1042 deaths reported in 2005 (964 were reported in 2000), 344 were cancer related (34%), which represented a significant increase from 2000 (29% of deaths were cancer related) (P=.02); 134 of the cancer-related deaths were AIDS related and 210 were not AIDS related. Among the cancer-related causes of death, the proportion of hepatitis-related cancers (6% in 2000 vs. 11% in 2005) and non-AIDS/hepatitis-related cancers (38% in 2000 vs 50% in 2005) significantly increased from 2000 to 2005 (P=.03 and P=.01, respectively), compared with the proportion of cancer that was AIDS related and adjusting for age and sex. Among cases involving AIDS, the proportion of non-Hodgkin lymphoma-associated deaths did not change statistically significantly between 2000 and 2005 (11% and 10% of deaths, respectively). CONCLUSIONS: In this study, an increasing proportion of lethal non-AIDS-related cancers was demonstrated from 2000 to 2005; meanwhile, the proportion of lethal AIDS-related cancers remained stable among HIV-infected patients. Thus, cancer prophylaxis, early diagnosis, and improved management should be included in the routine long-term follow-up of HIV-infected patients.

Emerging role of hepatocellular carcinoma among liver-related causes of deaths in HIV-infected patients: The French national Mortalité 2005 study.

BACKGROUND/AIMS: Longer exposure to hepatitis C (HCV) or B virus (HBV) and the increased use of hepatitis treatment might have an impact on liver-related deaths in patients co-infected with the Human Immunodeficiency Virus (HIV). We describe the proportion of liver-related deaths among HIV-infected patients in 2005 compared with 2000. METHODS: In a nationwide survey (341 hospital departments involved in HIV management), all deaths of HIV-infected patients were prospectively reported. Deaths from either cirrhosis, hepatocellular carcinoma or fulminant hepatitis were defined as liver-related deaths. RESULTS: Of the 898 deaths reported in 2005, liver-related causes accounted for 15.4%; this is compared to 13.4% in 2000. Among liver-related deaths, hepatocellular carcinoma increased from 15% to 25% (p=0.04). Among hepatocellular carcinoma-related deaths: in 2000, 10% were HCV-infected; in 2005, 25% were HCV-infected (p=0.03). Half of the HCV-related deaths had been treated for HCV but 98% remained HCV-RNA positive at time of death. The proportion of HBV-related deaths remained stable between 2000 and 2005. CONCLUSIONS: Liver-related deaths, mainly liver cancers, have increased in HIV-infected patients in France despite wide access to HCV treatment. The stability of HBV-related deaths might be explained by the use of dually active antiretroviral drugs in co-infected patients.

Heat exposure and socio-economic vulnerability as synergistic factors in heat-wave-related mortality.

Heat waves may become a serious threat to the health and safety of people who currently live in temperate climates. It was therefore of interest to investigate whether more deprived populations are more vulnerable to heat waves. In order to address the question on a fine geographical scale, the spatial heterogeneity of the excess mortality in France associated with the European heat wave of August 2003 was analysed. A deprivation index and a heat exposure index were used jointly to describe the heterogeneity on the Canton scale (3,706 spatial units). During the heat wave period, the heat exposure index explained 68% of the extra-Poisson spatial variability of the heat wave mortality ratios. The heat exposure index was greater in the most urbanized areas. For the three upper quintiles of heat exposure in the densely populated Paris area, excess mortality rates were twofold higher in the most deprived Cantons (about 20 excess deaths/100,000 people/day) than in the least deprived Cantons (about 10 excess deaths/100,000 people/day). No such interaction was observed for the rest of France, which was less exposed to heat and less heterogeneous in terms of deprivation. Although a marked increase in mortality was associated with heat wave exposure for all degrees of deprivation, deprivation appears to be a vulnerability factor with respect to heat-wave-associated mortality.

Do we really know the cause of death of the very old? Comparison between official mortality statistics and cohort study classification.

Causes of death of 625 subjects who died during the 4-year follow-up of a large population-based elderly cohort (Three-City study) were independently classified by the study adjudication committee and the national mortality register. The former used all available data about the cause of death (hospital records, medical data obtained from family physicians or specialists, and proxy interviews) and the latter used internationally standardized recommendations for processing death certificate data. Comparison showed a moderate overall agreement for underlying cause of death between the study adjudication committee and the national register (kappa = 0.51). Differences were found especially for cardiovascular diseases (20.6% of deaths from the study committee vs. 32.5% from the national register) and ill-defined causes of death (22.7 vs. 4%). The proportion of disagreement increased in participants dying at age >85 compared to those dying at age < or =70 (adjusted odds ratio = 2.46, 95% confidence interval = 1.10-5.49). It was also higher when the study committee used hospital record data for defining cause of death, compared to adjudication based on data obtained from proxy (adjusted odds ratio = 1.85, 95% CI = 1.09-3.14). These findings raise questions about the validity of national mortality registers in very old persons. Disease-specific causes of death, especially vascular diseases, could be overestimated in this age group.

Deaths with asthma in France, 2000-2005: a multiple-cause analysis.

Mortality from asthma has decreased in many countries since the 1990s. Mortality statistics are usually based only on the underlying cause of death. The objectives of this study were to describe the characteristics of deaths and the trends in asthma-related mortality using multiple-cause analysis. Data were obtained from the French Centre of Epidemiology on Medical Causes of Death. Because ICD-10 was implemented in 2000, the analysis covers the period 2000-2005. In 2004-2005, asthma was the underlying cause of 42% of deaths with certificates mentioning asthma. The age-standardised rates of death from asthma decreased from 2000 through 2005 (-12% and -11%/year in the 1-44 and 45-64 age groups, respectively). The decline for all deaths with asthma was less pronounced (-9%/year in the 1-44 age group and -8%/year in the 45-64). Among adults aged 65 or older, the decrease in asthma-related mortality was higher in men (-12%/year for underlying cause, -9% for multiple-cause) than women (-5% and -3%, respectively). Since 2002, age-standardised rates of asthma-related mortality have been higher in women than men. In people aged 1-44 years, in-hospital deaths have declined between 2000 and 2005 while the proportion of non-hospital deaths increased from 53% to 67%. Regardless of the definition used, the age-standardised rate of asthma-related deaths decreased from 2000 to 2005, and the faster decline for underlying cause than for multiple-cause mortality argues for a real decline in mortality attributable to asthma. Using multiple cause-of-death analysis provides additional information for asthma mortality surveillance.