State-specific mortality from stroke and distribution of place of death--United States, 1999

In the United States, stroke is the third leading cause of death and one of the major causes of serious, long-term disability among adults. Each year, approximately 500,000 persons suffer a first-time stroke, and approximately 167,000 deaths are stroke-related. This report presents national and state-specific death rates for stroke in 1999, which indicate state-by-state variations in both stroke-related death rates and the proportions of stroke decedents who die before transport to an emergency department (ED). Prevention through public and medical education remains a key strategy for reducing stroke-related deaths and disability.     

Prehospital and hospital delays after stroke onset--United States, 2005-2006

Each year approximately 700,000 persons in the United States have a new or recurrent stroke; of these persons, 15%-30% become permanently disabled, and 20% require institutionalization during the first 3 months after the stroke. The severity of stroke-related disability can be reduced if timely and appropriate treatment is received. Patients with ischemic stroke may be eligible for treatment with intravenous thrombolytic (i.e., tissue plasminogen activator [t-PA]) therapy within 3 hours of symptom onset. Receipt of this treatment usually requires patients to recognize stroke symptoms and receive prompt transport to a hospital emergency department (ED), where timely evaluation and brain imaging (i.e., computed tomography or magnetic resonance imaging) can take place. For patients eligible for t-PA, evidence suggests that the earlier patients are treated after the onset of symptoms the greater the likelihood of a more favorable outcome. In 2001, Congress established the Paul Coverdell National Acute Stroke Registry to measure and track the quality of care provided to acute stroke patients. To assess prehospital delays from onset of stroke symptoms to ED arrival and hospital delays from ED arrival to receipt of brain imaging, CDC analyzed data from the four states participating in the national stroke registry. The results of that analysis indicated that fewer than half (48.0%) of stroke patients for whom onset data were available arrived at the ED within 2 hours of symptom onset, and prehospital delays were shorter for persons transported to the ED by ambulance (i.e., emergency medical services) than for persons who did not receive ambulance transport. The interval between ED arrival and brain imaging also was significantly reduced for those arriving by ambulance. More extensive public education is needed regarding early recognition of stroke and the urgency of telephoning 9-1-1 to receive ambulance transport. Shortening prehospital and hospital delays will increase the proportion of ischemic stroke patients who are eligible to receive t-PA therapy and reduce their risk for severe disability from stroke.     

Impact of a Japanese Incentivization Program to Increase End-of-Life Care Outside of Hospitals

ObjectivesTo analyze the association of an incentivization program to promote death outside of hospitals with changes in place of death.DesignA longitudinal observational study using national databases.Setting and ParticipantsParticipants comprised Japanese decedents (≥65 years) who had used long-term care insurance services and died between April 2007 and March 2014.MethodsUsing a database of Japanese long-term care insurance service claims, subjects were divided into community-dwelling and residential aged care (RAC) facility groups. Based on national death records, change in place of death after the Japanese government initiated incentivization program was observed using logistic regression.ResultsHospital deaths decreased by 8.7% over time, mainly due to an increase in RAC facility deaths. The incentivization program was more associated with decreased in-hospital deaths for older adults in RAC facilities than community-dwelling older adults.Conclusions and ImplicationsIn Japan, the proportion of in-hospital deaths of frail older adults decreased since the health services system introduced the incentivization program for end-of-life care outside of hospitals. The shift of place of death from hospitals to different locations was more prominent among residents of RAC facilities, where informal care from laymen was required less, than among community residents.     

Disparities in deaths from stroke among persons aged <75 years--United States, 2002

Despite declines in deaths from stroke, stroke remained the third leading cause of death in the United States in 2002, and age-adjusted death rates for stroke remained higher among blacks than whites. In 1997, excess deaths from stroke occurred among persons aged <65 years in most racial/ethnic minority groups, compared with whites. A younger age distribution among Hispanics and other racial/ethnic groups compared with whites might partly explain the disproportionate burden in deaths at younger ages. To examine disparities in stroke mortality among persons aged <75 years, CDC assessed several characteristics of mortality at younger ages by using death certificate data for 2002. This report summarizes the results of that assessment. Overall, 11.9% of all stroke deaths in 2002 occurred among persons aged <65 years; the proportion of stroke decedents who were aged <65 years was higher among blacks, American Indians/Alaska Natives, and Asians/Pacific Islanders, compared with whites. In addition, the mean ages of stroke decedents were statistically significantly lower in these racial groups than among whites. Blacks had more than twice the age-specific death rates from stroke than whites aged <75 years. Approximately 3,400 excess stroke deaths would not have occurred among blacks in 2002 if blacks had had the same death rates for stroke as whites aged <65 years. Moreover, age-adjusted estimates of years of potential life lost (YPLL) before age 75 years from stroke were more than twice as high for blacks than for all other racial groups. Reducing premature death from stroke in these groups will require early prevention, detection, treatment, and control of risk factors for stroke in young and middle-aged adults.     

Place, time and certified cause of death in people who die after hospital admission for myocardial infarction or stroke

BACKGROUND: Two areas of uncertainty about routine statistics for mortality after hospital admission for myocardial infarction (MI) or stroke are i) whether most deaths occur in the admission episode itself rather than after discharge, and ii) whether most deaths are certified on death certificates as, respectively, MI or stroke. METHODS: Use of linked hospital and mortality statistics to analyse the time, place and certified cause of death in people aged 35-74 after admission for MI or stroke. RESULTS: Of 7,964 deaths within a year of admission for MI, 5,686 (71.4%) occurred within 30 days of admission. Of these, 4,856 (85.4%) occurred during the initial hospital admission. Of 7,070 deaths within a year of admission for stroke, 4,905 (69.4%) were within 30 days, and 4,509 (91.9%) of these occurred during the initial admission. As expected, deaths at longer intervals than 30 days occurred mainly after discharge. Of deaths within 30 days of MI and stroke, 85.2% and 80.0%, respectively, were certified with MI or stroke as the underlying cause of death. CONCLUSION: In-hospital death rates alone, calculated without record linkage to death certificates, would have identified most deaths that occurred within 30 days of admission. Nonetheless, linkage added to completeness of ascertainment even within this time period. Data without linkage are unreliable in identifying deaths at longer time intervals. Routine mortality statistics for MI and stroke, as the underlying cause, reliably included most deaths that occurred within 30 days of admission for each respective disease.     

Likelihood of residential aged care use in later life: a simple approach to estimation with international comparison

Objectives: In New Zealand (NZ), place of death among decedents aged 65+ years has been reported as residential aged care (RAC, 38%), acute hospital (34%) or elsewhere (28%). However, lifetime risk of use of RAC (or nursing homes) is unknown. A simple method of estimation is demonstrated for NZ and Australia, with comparisons to other countries. Methods: Deaths of RAC residents in acute hospitals were estimated for NZ from four separate studies and added to deaths occurring in RAC, to derive the likelihood of using RAC after age 65 years. Academic and other sources were searched for comparative reports. Results: An estimated 18% of RAC residents died in acute hospital in NZ. When added to those who died in RAC, the proportion using RAC for late‐life care was estimated at over 47% (66% if aged 85+ years). Of 12 US reports, the median report was 41%. Elsewhere, Finland was 47%, UK 28%, Australia 34% to 53%, and Germany 22% & 26%. Conclusions: Simple estimation using existing data demonstrates that RAC in late life is common. Implications: Late‐life care services will continue to evolve. Monitoring RAC utilisation is necessary for informed debate about palliative care provision in RAC, use of hospital by RAC residents and for planning and policy setting.     

威海市急性脑梗死院前延迟的原因分析与对策

目的研究威海市区2家医院脑梗死患者到达医院前时间（院前延迟）的影响因素及对策。方法回顾性研究了进入医院急诊就诊的急性脑梗死病人的院前延迟影响因素，并制定相应对策。对所有资料分别采用KruskalWal—lis检验方法和logistic回归进行单变量和多变量分析。统计学软件采用SPSS12．0和SAS6．0。结果患者平均到达医院急诊时间为312min，27．27％于发病2h内到达医院急诊，42．08％于发病5h内到达医院急诊。单因素分析显示：女性、非独居、有医疗保险、首发症状为传统症状、病人能识别卒中症状、病人或救助者能认识脑梗死治疗紧迫性、由120救护车或110警车进行运送有利于及早到达医院急诊。多因素回归模型显示：影响及早到达医院急诊最重要因素是运送方式和首发症状，使用120救护车或110警车运送病人而非使用其他运送方式和卒中表现为传统症状能缩短入院时间。结论57．92％急性脑梗死患者不能在发病后5h内到达医院。为了缩短到达医院急诊时间，应加强对民众急性脑梗死知识的宣传教育；提高社区医生脑梗死诊治水平；进一步完善城镇基本医疗保险制度和新型农村合作医疗制度建设，扩大参保、参合率；重视敬老院、老年公寓建设，减少独居老年人比例。     

Awareness of stroke warning signs--17 states and the U.S. Virgin Islands, 2001

Stroke is the third leading cause of death in the United States and a major cause of disabilities among adults. Since 1900, the number of stroke deaths has declined, and substantial advances have been made in the diagnosis and treatment of ischemic stroke during the previous decade; however, the proportion of deaths that occur before patients are transported to hospitals has increased to nearly half of all stroke deaths. One of the national health objectives for 2010 is to increase the proportion of persons who are aware of the early warning symptoms and signs of stroke (objective no. 12.8). To assess public awareness and knowledge of the proper emergency response, CDC analyzed 2001 data from the Behavioral Risk Factor Surveillance System (BRFSS) in 17 states and the U.S. Virgin Islands (USVI). This report summarizes the results of that analysis, which indicated that public awareness of several stroke signs is high, but the ability to recognize the five major warning signs is low. Education campaigns are needed to increase public awareness of stroke signs and the necessity of calling 911 when persons are suffering a possible stroke.     

The preventability of 'premature mortality': an investigation of early diabetes deaths.

Certifying physicians were surveyed regarding the 40 diabetic deaths under 45 years of age occurring in Washington State between July 1 and December 31, 1984. At most, it is estimated that three deaths may have been prevented by more accessible, timely or careful medical management immediately prior to death. Over 50 per cent of decedents were reported to be financially disadvantaged and 81 per cent had significant psychological problems. The role of these psychosocial factors needs further delineation.     

Health care utilization among homeless adults prior to death

This study characterizes health care utilization prior to death in a group of 558 homeless adults in Boston. In the year before death, 27 percent of decedents had no outpatient visits, emergency department visits, or hospitalizations except those during which death occurred. However, 21 percent of homeless decedents had a health care contact within one month of death, and 21 percent had six or more outpatient visits in the year before death. Injection drug users and persons with HIV infection were more likely to have had contact with the health care system. This study concludes that homeless persons may be underusing health care services even when they are at high risk of death. Because a subset of homeless persons had extensive health care contacts prior to death, opportunities to prevent deaths may have been missed, and some deaths may not have been preventable through medical intervention.     

深圳市2002年急诊住院死亡病例调查

目的　查找急救各环节存在的问题 ,降低急救死亡率和伤残率 ,为进一步建设和完善急救网络提供客观依据。方法　对照 2 0 0 2年全市 6 0个急救网络医院急诊入院急救的 14 4 6份死亡病历填写调查表 ,用Profox6 0建立数据库 ,用SPSS 11 0统计分析。结果　各项急救处置用时中位数 :下达首次医嘱、执行首次医嘱和上级医师到场均为 5min ,二线医师到场 10min ;病情讨论和院内会诊时间分别为入院后 12 0min和 180min ;开始输血时间为入院后 6 0min。调查中发现一些医师对急救技术和程序掌握不到位 ,医疗文书时间因素记录不详细 ,存在制度不落实的现象 ;急诊住院死亡和院前死亡的死因谱有差别。结论　急诊住院急救在时间因素、技术因素和质量因素等方面需进一步提高 ,要提高对急救工作的重视程度     

Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics

Objective

Place of death, specifically the percentage who die in hospital or residential aged care, is largely unreported. This paper presents a cross-national comparison of location of death information from published reports and available data.

Methods

Reports of deaths occurring in hospitals, residential aged care facilities, and other locations for periods since 2001 were compiled.

Results

Over 16 million deaths are reported in 45 populations. Half reported 54 % or more of all deaths occurred in hospitals, ranging from Japan (78 %) to China (20 %). Of 21 populations reporting deaths of older people, a median of 18 % died in residential aged care, with percentages doubling with each 10-year increase in age, and 40 % higher among women.

Conclusions

This place of death study includes more populations than any other known. In many populations, residential aged care was an important site of death for older people, indicating the need to optimise models of end-of-life care in this setting. For many countries, more standardised reporting of place of death would inform policies and planning of services to support end-of-life care.     

Adolescent profile: hospital record based study

A discharge case record (ICD-10) based retrospective study for a calendar year was carried out in one of the biggest tertiary care hospitals of Delhi, India. Of 5856 adolescent admissions, 53.77% were males and 46.22% were females. The respective proportion of adolescent admission and death recorded was 7.5% and 5.2%. The average monthly adolescent admissions were 488 (range: 304-648), and 47% of admissions happened through the emergency department. The outcome was 5499 (93.9%) adolescents were discharged alive, and 353 (6.02%) died during hospital stay. The average loss for adolescents was 6.8 days. The top three causes of morbidity were injuries (12.70%), burns (6.18%), or nonspecific signs and symptoms (5.51%), With regard to mortality, of 353 adolescent deaths recorded, the leading causes were 123 (34.84%) burns, 29 (8.21%) injuries, and 22 (6.23%) tuberculosis.     

Evaluation of hospital care in one trauma care system

To evaluate the effectiveness of the trauma care system in the Hudson Valley Emergency Medical Services (EMS) Region, (with no designated regional trauma care center) 421 consecutive trauma autopsy reports for 1979-80 were analyzed. Of the 421 trauma patients, 194 died at the scene (DAS), most from vehicular accidents. The remaining 227 patients were triaged into the EMS system. Ninety-five were dead on arrival (DOA) at medical facilities; of 132 (31 per cent) who arrived alive at hospitals, 35 died in emergency rooms and 97 died later as inpatients. Nearly 60 per cent of the deaths involved brain injuries. A panel of five physician-evaluators examined the pathologist's analysis of those deaths considered to have been possibly preventable and concluded that 10 deaths (7.6 per cent) of in-hospital cases were preventable. The study showed the need for primary prevention of accidents to decrease the number of victims (46 per cent) who died at the scene and those (23 per cent) who were dead on arrival at hospitals.     

Modifiable determinants of delayed hospital admission following a cerebrovascular accident

OBJECTIVE: To identify the modifiable determinants of delayed hospital admission of stroke patients. DESIGN: Multicentre observational study. METHOD: In the period from 1 October 1998 to 31 May 1999, before thrombolysis was an accepted treatment for ischaemic stroke in the Netherlands, we interviewed 252 consecutively admitted patients with stroke upon admission. The patients were asked to describe their symptoms and personal reaction to the stroke event in everyday language. The study was carried out in 14 regional hospitals and one university hospital in the Netherlands. The determinants of delay were calculated by means of multiple linear regression analysis. RESULTS: A total of 252 patients took part in the study: 136 men and 116 women, of whom 130 (52%) were 75 years of age or older. The median time from onset of symptoms to calling in any professional assistance was 60 minutes. The median time from onset of symptoms to arrival at the hospital was 5 hours and 10 minutes. One-third (n = 87; 34%) of the patients reached the hospital within 2.5 hours. Nearly half of the patients (46%) recognised their symptoms as a stroke. Patients who had not recognised their symptoms as a stroke (54%) and patients who had waited until their symptoms had worsened (20%) waited longer before calling in professional assistance than those who did not. Hospital admission was delayed in patients who had waited until their symptoms had worsened, and in those who had first called a family physician (87%). On the other hand, a more rapid admission was achieved in case of referral by the family physician by telephone and also after transportation by ambulance (77%). CONCLUSION: The modifiable determinants of delayed calling for professional help by stroke patients were the fact that they did not recognise the symptoms as a stroke, and the circumstance that they waited until the symptoms would disappear or become worse. This latter circumstance, referral by the family physician by telephone and transportation by ambulance, were modifiable determinants of delayed hospital admission.     

Risk factors for fatal diarrhea: a case-control study of African children

Few studies have determined risk factors for diarrheal deaths in developing areas. The Ministry of Health of Lesotho, southern Africa, reported that 9.5% of children under five years of age who were hospitalized for diarrhea in 1984 died. Of 104 children under five years of age who died during hospitalization for diarrhea, 85% were aged 24 months or younger and had nonbloody diarrhea during the warm season. We conducted two retrospective case-control studies of children aged 24 months or younger admitted for diarrhea at two hospitals in 1983 and 1984, comparing 44 who died with 89 who survived. Eight factors were significantly associated (p less than 0.05) with death at one or both hospitals by univariate analysis: diagnosis of a major infection, age under six months, illness for seven days or more before admission, thrush or stomatitis on admission, severe dehydration, history of vomiting, dehydration that had not improved after 12 hours in the hospital, and fever or subnormal temperature. Multivariate analysis of data from one hospital showed the first three factors to be significantly associated with death. Cases and controls were similar in sex and in degree of malnutrition. This study identified children at high risk for death from diarrhea.     

The rapidly changing location of death in Canada, 1994–2004

This 2008 study assessed location-of-death changes in Canada during 1994–2004, after previous research had identified a continuing increase to 1994 in hospital deaths. The most recent (1994–2004) complete population and individual-level Statistics Canada mortality data were analyzed, involving 1,806,318 decedents of all Canadian provinces and territories except Quebec. A substantial and continuing decline in hospitalized deaths was found (77.7%–60.6%). This decline was universal among decedents regardless of age, gender, marital status, whether they were born in Canada or not, across urban and rural provinces, and for all but two (infrequent) causes of death. This shift occurred in the absence of policy or purposive healthcare planning to shift death or dying out of hospital. In the developed world, recent changing patterns in the place of death, as well as the location and type of care provided near death appear to be occurring, making location-of-death trends an important topic of investigation. Canada is an important case study for highlighting the significance of location-of-death trends, and suggesting important underlying causal relationships and implications for end-of-life policies and practices.