Quality aspects of the Norwegian cause of death statistics

Datakvaliteten i den norske dødsårsaksstatistikken Opplysninger om dødelighet og dødsårsaker i en befolkning regnes som grunnleggende folkehelsedata. De brukes for å overvåke dødsårsaker og se på endringer over tid, gir grunnlag for nasjonal og internasjonal statistikk, brukes i forskning og for planlegging og kvalitetsarbeid i helse- og omsorgstjenestene. Det er den underliggende dødsårsaken (den tilstanden som startet rekken av hendelser som førte til døden) som gir mest informasjon for folkehelseformål. Kvaliteten av den statistikken som produseres og de analysene som blir gjort er ikke bedre enn kvaliteten av dataene som brukes. I denne avhandlingen presenteres studier av noen kvalitetsaspekter i den norske dødsårsaksstatistikken. Datamaterialet til studiene kommer i all hovedsak fra det norske dødsårsaksregisteret. Ved alle dødsfall i Norge blir dødsårsaken registrert ut fra opplysninger på legeerklæring om dødsfall (dødsmelding/dødsattest). Der det er gjort en obduksjon brukes obduksjonsresultatene for å supplere opplysningene på dødsmeldingen. Diagnosene registreres i henhold til det internasjonale kodeverket ICD-10, men ikke alle diagnosene der har like god informasjonsverdi om den underliggende dødsårsaken. Det kan for eksempel være diagnoser som bare sier noe om omstendighetene rundt dødsfallet («plutselig død») eller angir en komplikasjon som kan skyldes mange ulike tilstander («multiorgansvikt»). Slike diagnoser har blitt kalt «skrotkoder» (på engelsk «garbage codes»). Dersom en stor del av dødsfallene har slike diagnoser vil den samlede informasjonsverdien av dødsårsaksstatistikken bli dårlig. Det er nyttig dersom det er mulig å finne ut hvilke dødsårsaker som er skjult bak skrotkodene. Den internasjonale Global Burden of Disease Study (GBD) har utviklet avanserte statistiske metoder for å komme nærmere en mer fullstendig dødsårsaksstatistikk. Denne prosessen kallen redistribusjon. I den første delstudien undersøkte vi forekomsten av skrotkoder i det norske Dødsårsaksregisteret i perioden 1996-2019. Vi fant at 29 % av alle dødsfall hadde fått en skrotkode, 14 % hadde fått en kode i gruppen med minst informasjonsverdi (alvorlige skrotkoder). I løpet av studieperioden var det ikke tegn til at det ble mindre bruk av de alvorligste skrotkodene, men det var en nedgang i bruken av de minst alvorlige kodene. Det var høyere bruk av skrotkoder i de eldste aldersgruppene og ved dødsfall utenfor helseinstitusjon, og lavere der det hadde blitt gjort en obduksjon. Forekomsten er i samme størrelsesorden som i for eksempel Danmark og Sverige, men lavere enn i Finland og Storbritannia. Den høye forekomsten av skrotkoder er den alvorligste kritikken av datakvaliteten i Dødsårsaksregisteret i Norge. I den andre delstudien så vi nærmere på bruken av en enkelt skrotkode i Norge. Koden X59 brukes for dødsfall på grunn av en ytre årsak (skader, forgiftninger) der det ikke er opplysninger om hva som var årsaken til skaden (for eksempel om det var en trafikkulykke eller et fall). I perioden 2005-2014 manglet disse opplysningene i 26 % av alle dødsfall med en ytre årsak. De fleste av disse var hos eldre personer med brudd i hofteregionen. På bakgrunn av de dødsfallene der man hadde fått gode opplysninger utviklet vi en statistisk metode som kunne brukes på dødsfallene som manglet opplysninger. Resultatene tyder på at mer enn 95 % av X59-dødsfallene egentlig var fallulykker, og dette ble støttet av en spørreundersøkelse i 2015 til legene som hadde fylt ut slike dødsmeldinger. Resultatene våre tyder på at den reelle dødeligheten av fallulykker i Norge er mer enn dobbelt så høy som det som fremkommer i den offisielle statistikken. En rettsmedisinsk obduksjon er en del av politiets etterforskning ved mulig unaturlige dødsfall, men obduksjonsresultatene er også viktige bidrag til dødsårsaksstatistikken. Dette gjelder særlig dødsfall på grunn av ytre årsak og plutselige og uventede dødsfall som skjer utenfor helseinstitusjon. I den tredje delstudien undersøkte vi bruken av rettsmedisinske obduksjoner i Norge i perioden 1996-2017. Vi fant at 4,1 % av alle dødsfall hadde blitt rettsmedisinsk undersøkt, men andelen varierte fra 0,9-7,8 % i ulike politidistrikter, og ulikheten ble ikke mindre i løpet av studieperioden. Forskjellene kunne bare delvis forklares med geografiske faktorer, slik som ulikheter i folketall og avstanden fra dødssted til obduksjonssted. Trolig spiller andre faktorer inn, slik som lokale tradisjoner og retningslinjer. Vi konkluderte med at dersom det er ubegrunnede forskjeller i bruk av rettsmedisinske obduksjoner mellom politidistrikt, så øker det risikoen for at unaturlige dødsfall ikke blir godt nok undersøkt, og det kan føre til feil i dødsårsaksstatistikken.Data quality in Norwegian cause of death statistics Information on all-cause and cause-specific mortality in a population are considered fundamental public health indicators. It is used for surveillance of causes of death, production of national and international statistics, for research and quality improvement. It is the underlying cause of death (the condition that started the sequence of events leading to death) that conveys most information for public health purposes. The quality of the produced cause of death statistics and the analyses using these data is no better than the quality of the ingoing data material. This thesis presents some quality aspects of the Norwegian cause of death statistics. The Norwegian Cause of Death Registry is the main data source for the studies. In deaths in Norway, the cause of death is registered based on information on the death certificate. The information is supplemented by the autopsy report, if an autopsy has been performed. The diagnoses are registered according to the international classification system ICD-10, but not all diagnostic codes carry adequate information. Some codes only describe the circumstances, such as “sudden death” or terminal complications that might be the result of a number of different condition (“multi organ failure”). Codes that do not convey sufficient information on the underlying cause of death are called garbage codes. If a large proportion of the deaths is assigned a garbage code, the information value of the cause of death statistics is reduced. The information value increases if it is possible to ascertain which diagnoses that are hidden behind the garbage codes. The international Global Burden of Disease Study has developed advanced statistical methods to come closer to more complete cause of death statistics, a process called redistribution. In the first part of the study, we investigated the use of garbage codes in the Norwegian Cause of Death Registry in the years 1996-2019. We found that 29% of the deaths were assigned a garbage code, 14% in the group with lowest information value (major garbage codes). During the study period, the proportion of deaths assigned a less serious (minor) garbage code decreased, but not the proportion with the most serious garbage codes. The proportion of garbage codes was higher in the oldest age group and in deaths outside health care institutions, and lower where an autopsy had been performed. The garbage code proportions are similar in Denmark and Sweden, but lower in Finland and the United Kingdom. The prevalence of garbage codes is the most important quality issue in the Norwegian cause of death statistics. In the second part of the study, we performed an in-depth analysis of the use of one specific garbage code. The ICD-10 code X59 is used in external cause deaths (injuries, poisonings) where the information on the circumstances is missing (e.g. whether the injury was caused by a traffic accident or a fall). In the study period 2005-2014 this information was lacking in 26% of the deaths with an external cause. Most of these occurred in elderly persons with a fracture in the hip region. Based on the deaths with adequate information, we developed a statistical method that could be applied on the deaths lacking information. The results indicate that more than 95% of the X59 deaths are accidental falls, and a query to the certifying doctors in 2015 supports this view. Our results indicate that the real mortality from accidental falls in Norway is more than twice as high as shown in the official statistics. A forensic autopsy is part of the police investigation in possible unnatural deaths, but the autopsy results are also important supplementary information to the cause of death statistics. This is especially relevant in external cause deaths and unexpected deaths outside health care institutions. In the third part of the study, we investigated the use of forensic autopsies in Norway in the years 1996-2017. We found that a forensic autopsy had been carried out in 4.1% of all deaths, but the proportion varied between police districts, from 0.9-7.8%, and this variation persisted throughout the study period. The differences could only partly be explained by geographical factors, such as the size of the population of the municipality and the distance from the place of death to the autopsy facility. Other factors are probably important, such as local traditions and guidelines. If there are unjustified differences in the use of forensic autopsies between police districts, there is a risk that unnatural deaths will not be adequately investigated, and it might introduce spurious shifts in the cause of death statistics.Doktorgradsavhandlin

Routine Use of Color Doppler in Fetal Heart Scanning in a Low-Risk Population

Objectives. To investigate the detection rate of major fetal heart defects in a low-risk population implementing routine use of color Doppler. Material and Methods. In a prospective observational study, all women undergoing fetal heart scanning (including 6781 routine examinations in the second trimester) during a three-year period were included. First a gray-scale scanning was performed including assessment of the four-chamber view and the great vessels. Thereafter three cross-sectional planes through the fetal thorax were assessed with color Doppler. Results. Thirty-nine fetuses had major heart defects, and 26 (67%) were prenatally detected. In 9/26 (35%) of cases the main ultrasound finding was related to the use of color Doppler. The survival rate of live born children was 91%. Conclusions. Routine use of color Doppler in fetal heart scanning in a low-risk population may be helpful in the detection of major heart defects; however, still severe malformations were missed prenatally

Identification of response signatures for tankyrase inhibitor treatment in tumor cell lines

Small-molecule tankyrase 1 and tankyrase 2 (TNKS1/2) inhibitors are effective antitumor agents in selected tumor cell lines and mouse models. Here, we characterized the response signatures and the in-depth mechanisms for the antiproliferative effect of tankyrase inhibition (TNKSi). The TNKS1/2-specific inhibitor G007-LK was used to screen 537 human tumor cell lines and a panel of particularly TNKSi-sensitive tumor cell lines was identified. Transcriptome, proteome, and bioinformatic analyses revealed the overall TNKSi-induced response signatures in the selected panel. TNKSi-mediated inhibition of wingless-type mammary tumor virus integration site/b-catenin, yes-associated protein 1 (YAP), and phosphatidylinositol-4,5-bisphosphate 3-kinase/AKT signaling was validated and correlated with lost expression of the key oncogene MYC and impaired cell growth. Moreover, we show that TNKSi induces accumulation of TNKS1/2-containing b-catenin degradasomes functioning as core complexes interacting with YAP and angiomotin proteins during attenuation of YAP signaling. These findings provide a contextual and mechanistic framework for using TNKSi in anticancer treatment that warrants further comprehensive preclinical and clinical evaluations.publishedVersio

Changes in life expectancy and disease burden in Norway, 1990–2019: an analysis of the Global Burden of Disease Study 2019

Bill & Melinda Gates FoundationpublishedVersio

Falls in older aged adults in 22 European countries : incidence, mortality and burden of disease from 1990 to 2017

Introduction Falls in older aged adults are an important public health problem. Insight into differences in fall-related injury rates between countries can serve as important input for identifying and evaluating prevention strategies. The objectives of this study were to compare Global Burden of Disease (GBD) 2017 estimates on incidence, mortality and disability-adjusted life years (DALYs) due to fall-related injury in older adults across 22 countries in the Western European region and to examine changes over a 28-year period. Methods We performed a secondary database descriptive study using the GBD 2017 results on age-standardised fall-related injury in older adults aged 70 years and older in 22 countries from 1990 to 2017. Results In 2017, in the Western European region, 13 840 per 100 000 (uncertainty interval (UI) 11 837-16 113) older adults sought medical treatment for fall-related injury, ranging from 7594 per 100 000 (UI 6326-9032) in Greece to 19 796 per 100 000 (UI 15 536-24 233) in Norway. Since 1990, fall-related injury DALY rates showed little change for the whole region, but patterns varied widely between countries. Some countries (eg, Belgium and Netherlands) have lost their favourable positions due to an increasing fall-related injury burden of disease since 1990. Conclusions From 1990 to 2017, there was considerable variation in fall-related injury incidence, mortality, DALY rates and its composites in the 22 countries in the Western European region. It may be useful to assess which fall prevention measures have been taken in countries that showed continuous low or decreasing incidence, death and DALY rates despite ageing of the population.Peer reviewe

Life expectancy and disease burden in the Nordic countries : results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017

Background The Nordic countries have commonalities in gender equality, economy, welfare, and health care, but differ in culture and lifestyle, which might create country-wise health differences. This study compared life expectancy, disease burden, and risk factors in the Nordic region. Methods Life expectancy in years and age-standardised rates of overall, cause-specific, and risk factor-specific estimates of disability-adjusted life-years (DALYs) were analysed in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. Data were extracted for Denmark, Finland, Iceland, Norway, and Sweden (ie, the Nordic countries), and Greenland, an autonomous area of Denmark. Estimates were compared with global, high-income region, and Nordic regional estimates, including Greenland. Findings All Nordic countries exceeded the global life expectancy; in 2017, the highest life expectancy was in Iceland among females (85.9 years [95% uncertainty interval [UI] 85.5-86.4] vs 75.6 years [75.3-75.9] globally) and Sweden among males (80.8 years [80.2-81.4] vs 70.5 years [70.1-70.8] globally). Females (82.7 years [81.9-83.4]) and males (78.8 years [78.1-79.5]) in Denmark and males in Finland (78.6 years [77.8-79.2]) had lower life expectancy than in the other Nordic countries. The lowest life expectancy in the Nordic region was in Greenland (females 77.2 years [76.2-78.0], males 70.8 years [70.3-71.4]). Overall disease burden was lower in the Nordic countries than globally, with the lowest age-standardised DALY rates among Swedish males (18 555.7 DALYs [95% UI 15 968.6-21 426.8] per 100 000 population vs 35 834.3 DALYs [33 218.2-38 740.7] globally) and Icelandic females (16 074.1 DALYs [13 216.4-19 240.8] vs 29 934.6 DALYs [26 981.9-33 211.2] globally). Greenland had substantially higher DALY rates (26 666.6 DALYs [23 478.4-30 218.8] among females, 33 101.3 DALYs [30 182.3-36 218.6] among males) than the Nordic countries. Country variation was primarily due to differences in causes that largely contributed to DALYs through mortality, such as ischaemic heart disease. These causes dominated male disease burden, whereas non-fatal causes such as low back pain were important for female disease burden. Smoking and metabolic risk factors were high-ranking risk factors across all countries. DALYs attributable to alcohol use and smoking were particularly high among the Danes, as was alcohol use among Finnish males. Interpretation Risk factor differences might drive differences in life expectancy and disease burden that merit attention also in high-income settings such as the Nordic countries. Special attention should be given to the high disease burden in Greenland. Copyright (C) 2019 The Author(s). Published by Elsevier Ltd.Peer reviewe

The global burden of falls: Global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017

Background: Falls can lead to severe health loss including death. Past research has shown that falls are an important cause of death and disability worldwide. The Global Burden of Disease Study 2017 (GBD 2017) provides a comprehensive assessment of morbidity and mortality from falls. Methods: Estimates for mortality, years of life lost (YLLs), incidence, prevalence, years lived with disability (YLDs) and disability-adjusted life years (DALYs) were produced for 195 countries and territories from 1990 to 2017 for all ages using the GBD 2017 framework. Distributions of the bodily injury (eg, hip fracture) were estimated using hospital records. Results: Globally, the age-standardised incidence of falls was 2238 (1990-2532) per 100 000 in 2017, representing a decline of 3.7% (7.4 to 0.3) from 1990 to 2017. Age-standardised prevalence w

Burden of injury along the development spectrum : associations between the Socio-demographic Index and disability-adjusted life year estimates from the Global Burden of Disease Study 2017

Background The epidemiological transition of non-communicable diseases replacing infectious diseases as the main contributors to disease burden has been well documented in global health literature. Less focus, however, has been given to the relationship between sociodemographic changes and injury. The aim of this study was to examine the association between disability-adjusted life years (DALYs) from injury for 195 countries and territories at different levels along the development spectrum between 1990 and 2017 based on the Global Burden of Disease (GBD) 2017 estimates. Methods Injury mortality was estimated using the GBD mortality database, corrections for garbage coding and CODEm-the cause of death ensemble modelling tool. Morbidity estimation was based on surveys and inpatient and outpatient data sets for 30 cause-of-injury with 47 nature-of-injury categories each. The Socio-demographic Index (SDI) is a composite indicator that includes lagged income per capita, average educational attainment over age 15 years and total fertility rate. Results For many causes of injury, age-standardised DALY rates declined with increasing SDI, although road injury, interpersonal violence and self-harm did not follow this pattern. Particularly for self-harm opposing patterns were observed in regions with similar SDI levels. For road injuries, this effect was less pronounced. Conclusions The overall global pattern is that of declining injury burden with increasing SDI. However, not all injuries follow this pattern, which suggests multiple underlying mechanisms influencing injury DALYs. There is a need for a detailed understanding of these patterns to help to inform national and global efforts to address injury-related health outcomes across the development spectrum.Peer reviewe

Global injury morbidity and mortality from 1990 to 2017 : results from the Global Burden of Disease Study 2017

Correction:Background Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries. Methods We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs). Findings In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505). Interpretation Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care.Peer reviewe

Estimating global injuries morbidity and mortality : methods and data used in the Global Burden of Disease 2017 study

Background While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria. Methods In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced. Results GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes. Conclusions GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.Peer reviewe