Atrial fibrillation as a cause of death increased steeply in England between 1995 and 2010.

AIMS: To report trends in mortality rates for atrial fibrillation/flutter (AF), using all the certified causes of death mentioned on death certificates (conventionally known as 'mentions') as well as the underlying cause of death, in the national population of England (1995-2010) and in a regional population with longer coverage of all-mentions mortality (1979-2010). METHODS AND RESULTS: Analysis of death registration data in England and in the Oxford record linkage study. In England between 1995 and 2010, AF was mentioned as a cause of death (either as an underlying cause or as a contributory cause) in 192 770 registered deaths in people aged 45 years of age and over (representing 0.254% of all registered deaths in this age group). Atrial fibrillation was given as the underlying cause of death in 21.4% of all deaths in which it was mentioned (41 298 of 192 770). In England, age-standardized death rates for mentions of AF increased almost three-fold between 1995 and 2010, from 202.5 deaths per million (1995) to 554.1 deaths per million (2010), with an average annual percentage change of 6.6% (95% confidence interval: 6.3, 7.0). Mortality rates for AF did not increase substantially until the mid-1990s: rates in Oxford were 145.4 deaths per million in 1979, 178.1 in 1995, and 505.1 in 2010. CONCLUSION: Atrial fibrillation has become much more common as a certified cause of death. The reasons for this are likely to be multifactorial, with changes in demographics, lifestyle, advances in therapeutics, and altered perception of the importance of the condition by certifying doctors all likely to be contributing factors.

Certification of deaths from diabetes mellitus and obesity in England: trends into the twenty-first century.

BACKGROUND: Most cases of Type 2 diabetes are attributable to excess weight and physical inactivity. We investigated trends in mortality based on doctors' certification of diabetes and obesity. METHODS: Analysis of a national data set of all certified causes of death, i.e. underlying cause and contributing causes ('mentions'), in England 1995-2010. RESULTS: Diabetes exhibited divergent trends for mortality based on underlying cause and mentions. Underlying cause rates were 107.2 per million population [95% confidence interval (CI): 105.7-108.6] in 1995, but only 68.9/10(6) (CI: 67.9-69.9) in 2010. Mortality rates for mentions of diabetes were 403.1/10(6) (CI: 400.4-405.8) in 1995, increasing to 478.4/10(6) (CI: 475.7-481.0) in 2010. Underlying cause mortality for obesity was 3.7/10(6) (CI: 3.2-4.1) in 1995 and 7.5 (CI: 7.0-8.0) in 2010. The corresponding rates for mentions of obesity were 13.2/10(6) (CI: 12.6-13.9) and 34.5/10(6) (CI: 33.6-35.4), respectively. 24.0% of death certificates with a mention of obesity also had diabetes recorded on the same certificate. CONCLUSIONS: Multiple-cause mortality statistics provide a more accurate picture than underlying cause of the total mortality burden attributed on death certificates to diabetes and obesity. Rates for both increased substantially: analysis by underlying cause alone would have missed this for diabetes.

Trends in mortality from appendicitis and from gallstone disease in English populations, 1979-2006: study of multiple-cause coding of deaths.

OBJECTIVE: To report on trends in mortality from appendicitis and from gallstone disease. DESIGN AND SETTING: Analysis of data from death certificates including all certified causes of death, termed 'mentions', not just the underlying cause, using data from Oxford ('mentions' available from 1979 to 2006) and all England ('mentions' available from 1995 to 2006). OUTCOME MEASURES: Mortality rates across all years studied, and in periods defined by changes to national rules in selecting the underlying cause of death. RESULTS: In the Oxford region, mortality rates for appendicitis based on underlying cause fluctuated between periods defined by coding rule changes. Those based on mentions were more stable: they were 3.3 per million population in 1979-83 and 3.5 in 2001-6. Nationally, mentions-based rates fell from 3.4 per million in 1995-2000 to 3.1 in 2001-2006, a small but statistically significant decline. For gallstone disease in Oxford, rates fell in the early years but then levelled off. Mortality rates for gallstones in England actually rose slightly between 1995-2000 (15.0 deaths per million) and 2001-6 (15.6 per million). The majority of deaths from appendicitis and gallstone disease were in the elderly. CONCLUSIONS: Appendicitis and gallstones are considered to be avoidable causes of death. Mortality rates for each cause have not shown any substantial falls in the recent periods covered by this study. It is possible that deaths were not, in fact, avoidable, but audits into the circumstances of deaths from these diseases may be warranted. Mortality data based on underlying cause alone substantially underestimate deaths from these two conditions.

Mortality trends for benign prostatic hyperplasia and prostate cancer in English populations 1979-2006.

OBJECTIVE To determine mortality trends for benign prostatic hyperplasia (BPH) and prostate cancer in English populations, between 1979 and 2006. SUBJECTS AND METHODS Analysis of datasets that include both the underlying cause and all other mentioned causes on death certificates (together, termed 'mentions'): the Oxford Record Linkage Study, 1979-2006, and English national data, 1995-2006. RESULTS In the Oxford region, underlying-cause mortality from BPH fell from 45 deaths per million in 1979 to 2.4 in 2006. For mentions, the respective rates were 93 and 7.1. In England, underlying-cause mortality reduced from 9.2 deaths per million in 1995 to 4.5 deaths per million in 2006. For mentions, the rates were 20 and 9.9 deaths per million. When BPH was certified on death certificates, it was selected as the underlying cause of death on fewer than half. Underlying-cause mortality for prostate cancer in Oxford increased from 213 deaths per million in 1979 to 335 by 1991, and thereafter declined to 253 deaths per million in 2006. Mentions-mortality in Oxford followed a similar pattern. In later years, when there were comparable data for Oxford and England, the pattern of decline in England was similar to that in Oxford. Where mentioned, prostate cancer was coded as the underlying cause of death on three-quarters of death certificates. CONCLUSIONS The fall in BPH mortality, evident in statistics on underlying cause, was confirmed by statistics on all certified causes of death. The fall is dramatic in scale, likely to be attributable to clinical care, and could be regarded as an indicator of improving standards of care. Mortality for prostate cancer increased, peaking in the 1990s, then decreased in recent years in rates as measured both by underlying cause and by mentions.

Psychiatric disorders certified on death certificates in an English population.

BACKGROUND: Psychiatric disorders are sometimes certified on death certificates, but seldom selected as the underlying cause of death. The majority of deaths with a certified psychiatric cause are usually omitted from official mortality statistics, which are typically based on the underlying cause alone. AIM: To report on death rates for psychiatric disorders, as certified on death certificates, including all mentioned causes as well as the underlying cause of death. METHOD: Analysis of database including all certified causes of death in 1979-1999, in three time periods defined by coding rule changes. RESULTS: Statistics on the underlying cause of death grossly under-estimated certified psychiatric disorders. For example, in the first period of our study they missed 88% of deaths in which schizophrenia was a certified cause, 98% of affective psychosis, and 96% of depression. Over time, considering all certified causes, age-standardised death rates for schizophrenia declined, those for affective psychosis showed no change, and those for depression and dementia increased. CONCLUSION: The decline in mortality rates for schizophrenia, and the increase for depression and dementia, may reflect real changes over time in disease prevalence at death, although other explanations are possible and are discussed.

Trends in mortality rates comparing underlying-cause and multiple-cause coding in an English population 1979-1998.

Until recently, national coding and analysis of routine mortality statistics in most countries included only underlying cause of death. There were changes in the rules for selection and coding of underlying cause in England in 1984 and 1993. We report on trends in mortality rates in an English region from 1979 to 1998, comparing multiple-cause and underlying-cause coded rates, for individual diseases that were affected by coding changes. Among many others, these include pneumonia, venous thromboembolism, heart failure, respiratory distress syndrome, tuberculosis, diabetes, dementia, alcohol and drug abuse, epilepsy, multiple sclerosis, stroke, asthma, peptic ulcer, appendicitis, and cancers of the breast, colon and prostate. Comparisons over time of mortality rates based on underlying cause alone will be misleading when the time-period crosses years in which rules changed for selecting underlying cause.