Mortalitys End

The meaning of mortalityWhen death is not the end. There is growing opposition to the way many countries define dying.
Table of contents

The SMR for alcohol-related death was high when considering the underlying cause of death 5. The cause of death was associated with alcohol in Drug abuse was noted on the death certificate in only two cases. During follow-up, 33 individuals 4. Cumulative incidence of ESRD by years since diagnosis of diabetes was 1. There was no significant difference between men and women Fig.

The Kaplan-Meier estimate and the model handling death as a competing risk gave very similar results data not shown. Incidence of ESRD by years after diagnosis of type 1 diabetes was 2. In B , the dashed line represents men and the solid line, women. This study highlights three important findings.

Result Filters

First, among individuals who were diagnosed with type 1 diabetes in late adolescence and early adulthood and had good access to health care, and who were followed for 30 years, mortality was four to five times that of the general population. Third, there was a relatively low cumulative incidence of ESRD 4. The SMR in the Finnish cohort was lower than that in our cohort 2. This was not the case in Norway; the SMR we report in this study was comparable to or higher than what was recently published in a study of childhood-onset diabetes 3.

The differences between the Norwegian and Finnish data are difficult to explain since both reports are from countries with good access to health care and a high incidence of type 1 diabetes. However, these results are not comparable to those from our cohort because the participants in the DCCT were enrolled in a randomized clinical trial that required adherence to specific treatment and therefore included highly motivated patients.

Also, the selection criteria for DCCT excluded those with hypertension, severe dyslipidemia, or other serious comorbidities and included individuals with diabetes duration of 1—15 years, thereby reducing the potentially high mortality of the first years with diabetes.

We found that SMRs in the younger age bands were higher than those in the older age bands Supplementary Fig. This leads us to speculate about increased risk behavior in young adults with type 1 diabetes. SMRs for violent death and suicide—around 3.

A large Swedish study reported fewer protective factors and more risk behavior among adolescents aged 15—17 years with chronic conditions compared with their healthy peers High risk of violent death in individuals with type 1 diabetes was also demonstrated in a recent review article: However, the review article included studies using an age of 0—30 years at diagnosis. We note that mortality associated with alcohol was about five to seven times higher in the cohort with type 1 diabetes compared with the general population in Norway. It is known that alcohol consumption is underreported on death certificates However, underreporting probably occurs for both people with and people without diabetes, and would therefore not affect the SMR.

A couple of mortality studies have shown abuse of drugs or alcohol among cohorts with type 1 diabetes, but neither provided long-term follow-up nor compared those cohorts with the general population 28 , However, that study reported an SMR for alcohol-related deaths lower than what we found 1. Finland and Norway are appropriate to compare because they share important population and welfare characteristics.

There are, however, significant differences in drinking levels and alcohol-related mortality: The mortality rates for deaths related to alcohol are about three to four times higher in Finland than in Norway The alcohol-related mortality rate for individuals with type 1 diabetes diagnosed between and in Finland is reported to be 9. The markedly higher SMR in our cohort can probably be explained by the lower mortality rates for alcohol-related mortality in the general population.

However, our study shows that people with type 1 diabetes also have a much higher risk of alcohol-related death in a country with substantially lower alcohol consumption and lower mortality related to alcohol. Alcohol consumption impairs cognitive processes such as memory, attention, and planning, which are essential for people with type 1 diabetes It is also a marker for poorer adherence to diabetes self-management and glycemic control 32 , Our study indicates that diabetes is a major hazard for people with a low ability for self-care.

Deaths associated with alcohol may also be a marker for other, nonbeneficial health-related behaviors. This warrants attention from clinicians to people at risk for alcohol abuse. The presence of renal disease is known to be the major predictor of mortality in type 1 diabetes Renal death is low in our study compared with several others, even when including the whole contribution of ESRD 2 , In accordance with this, we report a low cumulative incidence of ESRD 4.

The average incidence of ESRD in Finland among individuals between 20 and 30 years after their diagnosis of type 1 diabetes diagnosed in — was 7. We report lower rates at 4. It has previously been published that the incidence of diabetic nephropathy in Norway is low—7. A major strength of this study is being based on a cohort with type 1 diabetes that is national, is population-based, and has high ascertainment Cohort studies following patients from diagnosis are preferable to studies based on cause of death registries alone because we know that diabetes is underreported on death certificates 40 ; also, differentiation between type 1 and type 2 diabetes is rarely reliable.

We present what is to our knowledge the only study with long-term follow-up of patients diagnosed during late adolescence or young adulthood and using a clinical review committee in addition to registry data; however, short-term mortality has been assessed in similar ways in a few studies 28 , 29 , Registry data are based on death certificates written by physicians, often with limited access to clinical data.

Our study suggests the underestimation of specific causes of death that are of particular importance to individuals with diabetes, such as acute complications and CVD, when using death certificates as the only source of information. Other studies have also underscored the problem with the insufficient reliability of causes of death in type 1 diabetes when only considering death certificates 39 , 42 , An important limitation of this study is that we did not have complete information on HbA 1c or smoking status, among other risk factors.

Another limitation is the relatively small cohort, which might influence the statistical power and give less precise estimates. In conclusion, the high mortality reported in this cohort with an onset of diabetes in late adolescence and young adulthood draws attention to people diagnosed during a vulnerable period of life. Both acute and chronic complications cause substantial premature mortality, implying a continuous need for improved diabetes care.

Our study suggests that increased awareness of alcohol-related death should be encouraged in clinics providing health care to this group of patients. The authors acknowledge Professor Trond G. Berteussen, Department of Forensic Pathology and Clinical Forensic Medicine, Norwegian Institute of Public Health, for sharing their experiences regarding the clinical review committee.

Strategies toward ending preventable maternal mortality (EPMM)

The authors thank all the hospitals in all the Norway Regional Health Authorities that gathered clinical information about the deceased individuals included in this study: The authors also thank the following departments of pathology: The Norwegian Cause of Death Registry contributed data based on death certificates.

The authors thank all the members of the Norwegian Childhood Diabetes Study Group for their contribution and, finally, the patients who contributed their data. No potential conflicts of interest relevant to this article were reported. All authors interpreted the results, contributed to the discussion, and critically reviewed and approved the final version of the manuscript. This article contains Supplementary Data online at http: This study used data from the Norwegian Cause of Death Registry.

You are here

The interpretation and reporting of these data are the sole responsibility of the authors, and no endorsement by the Norwegian Cause of Death Registry is intended nor should be inferred. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.

More information is available at http: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address. Skip to main content. Diabetes Care Jan; 40 1: Introduction Studies assessing causes of death in type 1 diabetes are most frequently conducted in individuals diagnosed during childhood 1 — 7 or without evaluating the effect of age at diagnosis 8 , 9.

The review committee grouped the causes of death as follows: End-Stage Renal Disease To estimate the cumulative incidence of ESRD caused by diabetic nephropathy, we linked to the Norwegian Renal Registry; this registry includes data on all patients in Norway receiving renal replacement therapy for chronic renal failure since and has high degree of ascertainment Results All-Cause Mortality Among the cohort of individuals, View inline View popup.

Table 1 Demographic characteristics of individuals with type 1 diabetes, diagnosed at age 15—29 years, in Norway, — The alternative analysis, however, did not demonstrate these findings, which could be related to the noted differences between analyses. For example, the main analysis specifically evaluated patients discharged soon after transition whereas the alternative analysis measured patients admitted just prior to transition, excluding those patients with longer stays before transition who were likely the most at risk for misinformation transfer.

The transition groups that were consistently associated with increased mortality in-hospital and after discharge involved the transition of interns, whether alone or in combination with residents. The mortality risk increased after the ACGME duty hour restrictions, which primarily affected interns, even though studies have found that duty hour regulations may not be harmful 14 , 27 - 29 and may be associated with benefit. First, interns perform a majority of the day-to-day work of a medical team. They gather, maintain, and transfer the majority of day-to-day information for hospitalized patients, but they are also the most inexperienced residents, increasing the risk for misinformation transfer and potential errors.

Because duty hour regulations primarily limited intern hours, 12 shift-to-shift handoffs have increased noticeably, 13 prompting a prospective trial of medical residencies. This change in day-to-night continuity exposes patients each month to a new team of physicians during the day and at night, when previously they would have only 1 team of physicians taking hour call. Third, interns are now expected to complete the same tasks in less time than in the past, leaving them with limited time to prepare for service change. Although research has shown that medical errors were reduced when interns worked shorter shifts, 33 the present findings suggest that current tools and schedules to standardize end-of-rotation transition may need to evolve, particularly because only 1 of 10 surveyed programs in this study required in-person sign out at the time of rotation-to-rotation transition.

This study has additional limitations. First, VA medical centers include a patient population made up predominantly of older men with multiple comorbidities. Nonetheless, the included programs indicated that end-of-rotation sign out processes were similar at the VA compared with the other hospitals through which house staff rotated. The analysis did not account for other clinicians, such as attending physicians, physician assistants, or nurse practitioners, but only programs in which these clinicians had a different rotation schedule from the house staff were included to minimize potential bias.

Although the number of non—internal medicine house staff that rotated on medical services could not be quantified, end-of-rotation transitions would not be expected to differ. Non—teaching service patients could not be excluded at some of the included hospitals. These patients were covered by nonrotating clinicians without monthly rotating residents. However, this would likely lead to a conservative bias that would be expected to dilute any true effect. Other limitations include the retrospective, observational design; that these compared cohorts may have differed in important ways not accounted for, such as socioeconomic status; and the unavailability of data on specific handoff processes of care, such as the type and amount of education provided at each program.

Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis. Drs Denson and Sherman had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Acquisition, analysis, or interpretation of data: Denson, Jensen, Wang, Fang, Sherman. Critical revision of the manuscript for important intellectual content: Conflict of Interest Disclosures: This material is the result of work supported with resources and the use of facilities at the Veterans Affairs New York Harbor Healthcare System. Role of the Sponsor: The Veterans Affairs New York Harbor Healthcare System had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Between-Group Crossover in the Alternative Analysis. A systematic review of the literature on the evaluation of handoff tools: J Am Med Inform Assoc. PubMed Google Scholar Crossref. Consequences of inadequate sign-out for patient care. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.

Changes in medical errors after implementation of a handoff program. N Engl J Med. Evaluation of an asynchronous physician voicemail sign-out for emergency department admissions. Effects of end-of-month admission on length of stay and quality of care among inpatients with myocardial infarction. Increased mortality rates during resident handoff periods and the effect of ACGME duty hour regulations. The effects of scheduled intern rotation on the cost and quality of teaching hospital care. Effect of short call admission on length of stay and quality of care for acute decompensated heart failure.

The impact of fragmentation of hospitalist care on length of stay. Mortality among patients admitted to hospitals on weekends as compared with weekdays. Accreditation Council for Graduate Medical Education. Accessed November 1, Effect of the vs duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: Association of the ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients.

J Grad Med Educ. Comorbidity measures for use with administrative data. Regression discontinuity for causal effect estimation in epidemiology. The published literature on handoffs in hospitals: Qual Saf Health Care.


  1. Introduction.
  2. Working Together to End Maternal Mortality | CDC Foundation?
  3. Working Together to End Maternal Mortality | CDC Foundation.
  4. Strays.
  5. Maternal mortality at the end of a decade: signs of progress? - PubMed - NCBI.

The effects of patient handoff characteristics on subsequent care: The creating incentives and continuity leading to efficiency staffing model: Post-call transfer of resident responsibility: J Gen Intern Med. Impact of a new electronic handover system in surgery.

You can make a lifesaving difference for people affected by Faces in the Field: Why our Work Matters Lisa Splitlog.

WHO | Strategies toward ending preventable maternal mortality (EPMM)

Do you have a heart for public health? Consider giving to th What are you reading this summer?

View the discussion thread.