Asthma deaths in Cardiff 1963-74: 90 deaths outside hospital.

In a detailed study of factors associated with death from bronchial asthma outside hospital 90 patients were investigated. The fatal attack was typically short and was most likely to occur in patients with a long history. Deaths often occurred before effective medical help was obtainable, but occasionally the patient or the doctor underestimated the severity of the attack. Patients especially at risk were those recently discharged from hospital after a previous attack. These deaths might be prevented by better patient education, a self-admission service for selected asthmatics, and by doctors using objective measurements of severity of asthma for the control of treatment. The underuse of corticosteroids is an important factor associated with death.     

Controlled investigation of deaths from asthma in hospitals in the North East Thames region.

One hundred and thirty deaths definitely or potentially due to asthma occurring in hospitals in the North East Thames region over one year were identified from death certificates and Hospital Activity Analysis records. Thirty five of these deaths were considered after independent assessment to have been directly due to asthma. Control patients who left hospital alive after acute asthma attacks were selected and matched with cases for sex, age, and hospital. Management was compared in the two groups. Inadequate monitoring, including failure to monitor arterial blood gas values, and inadequate use of nebulised beta agonists occurred significantly more often in fatal cases. Use of sedation, inadequate treatment with steroids, exposure to potentially toxic doses of aminophylline, and inadequate clinical assessment were more common in cases than controls, but not significantly so. Failure to institute artificial ventilation contributed to seven deaths. Assessors considered important defects in management to have occurred in 83% (29/35) of the cases and 40% (14/35) of the controls. Nevertheless, most of the hospital deaths (19/35) were considered not to have been preventable. Eight other deaths in the region were attributed to the complications of asthma or its treatment. Three of these were associated with gastrointestinal bleeding and one with perforation of a duodenal ulcer. Before considering policies aimed at speeding admission to hospital of patients with acute attacks of asthma it is crucial that the general standard of hospital care offered to all patients with asthma should be improved.     

Edinburgh Emergency Asthma Admission Service: report on 10 years' experience.

In December 1968 an emergency service was begun in Edinburgh to expedite admission to hospital of patients with severe acute asthma. During the first 10 years requests were made to admit 112 patients to a respiratory unit with provision for intensive care on 360 occasions. Four of the patients died of their disease, one in hospital and three before admission. It was thought that the death rate would have been much higher had conventional admission procedures been observed. Owing to ethical objections to a controlled trial it was not possible to obtain substantive proof that the service reduced deaths from asthma. Nevertheless, there was strong circumstantial evidence that organised facilities for the immediate admission to hospital of patients with a history of life-threatening attacks would result in fewer deaths at home. Earlier admission also apparently reduced hospital mortality and the number of patients requiring tracheal intubation and mechanical ventilation. It is concluded that there is a prima facie case for an emergency asthma admission serivce similar to that operating in Edinburgh to be established in all cities and large towns.     

Circumstances of death from asthma.

Mortality from asthma in England and Wales has remained unchanged for at least 20 years, even in the age group 15-44. Yet in those 20 years "modern" drugs have been introduced for the treatment of asthma, such as beta 2 agonist bronchodilators and corticosteroids. Why do patients still die? Detailed review of the circumstances of 90 deaths from asthma showed that a few were inevitable but that in the remainder four main sets of circumstances in the fatal attack contributed to the death. These were, firstly, the patient''s failure to recognise the severity of the asthma; secondly, very rapid progress in the severity of the attack; thirdly, misjudgment in the management of the attack; and, fourthly, delay from many causes. Patients admitted to hospital with severe acute asthma usually survive. Those at risk of a life threatening attack should be identified and taught to monitor the severity and progress of their asthma objectively. Their direct admission to hospital should be facilitated.     

Death from asthma in two regions of England

The British Thoracic Association has conducted a confidential inquiry into death from asthma of adults aged 15 to 64 years resident in the West Midland and Mersey regions in 1979. Information concerning the patients, their asthma, and death was obtained by questionnaire, interview with the general medical practitioner and a relative, and from patient records. A panel of three physicians, helped by a pathologist, identified 90 patients as dying of asthma and assessed management and treatment in the last year, last month of life, and the fatal attack. They were generally chronic asthmatics, but unstable, most having suffered severe attacks previously. Corticosteroids and bronchodilator drugs were in general underprescribed or not given in sufficiently large doses. Inhaled corticosteroids and cromoglycate had frequently not been tried. The patient''s co-operation with the management of the asthma was satisfactory for only 42 of the 90 patients. For 71 of the patients the fatal attack lasted under 24 hours; of the 77 who died at home or at work, 50 did not receive any medical attention in the fatal attack. Failure to recognise the severity of the asthma by patients, relatives, and doctor often caused delay in starting appropriate treatment. The interaction of several of these adverse factors often contributed to the patient''s death. The panel considered that there were potentially preventable factors contributory to the death of 77 (86%) of the 90 patients. Within the limits of retrospective judgment the panel considered that the routine management of the asthma was often unsatisfactory as patients known to suffer severe acute attacks were often not adequately supervised or instructed in the management and treatment of their asthma. From this retrospective inquiry we concluded that closer overall supervision, including careful attention to patient education, earlier and more intensive treatment, and pre-arranged immediate admission to hospital for asthma emergencies is desirable.     

Asthma mortality in Birmingham 1975-7: 53 deaths.

Out of 83 patients studied 72 were certified as dying from asthma, and 11 aged under 45 as dying from chronic bronchitis and pneumonia. Fifty-three deaths were thought to be due to asthma. There were avoidable factors associated with several of these deaths from asthma. Recent discharge from hospital (16%), non-availability of aerosol bronchodilators (45%), underuse of corticosteroids (66%), and lack of objective measurements of airflow obstruction (100%) were found in deaths outside hospital. Inadequate initial assessment including baseline spirometry and blood gases (50%), significant underusage of corticosteroids (93%) and intravenous and nebulised bronchodilators (100%), and failure to monitor treatment objectively (100%) were found in deaths in hospital. "False-positive" and "false-negative" certifications of asthma were studied, and the findings suggest that these may lead to appreciable inaccuracy in the reporting of deaths from asthma.     

Death from asthma.

The factors associated with the deaths of 31 asthma patients were examined. The subjects, whose deaths occurred in the period 1967 through 1979, had all received some care at the Hospital for Sick Children in Toronto, but only nine died there. The greatest single cause of death was the inappropriate use of beta-agonists, with or without the concurrent use of epinephrine. In seven patients an asthma attack that occurred outside hospital progressed so rapidly that there was insufficient time for them to obtain adequate therapy. In five cases the assessment of the patient''s condition or the therapy recommended by the attending physician appeared to have been inadequate. Two patients suffered an acute attack in hopital and did not respond to treatment that appeared to have been adequate. In six cases the available information was insufficient to indicate the cause of death. Over half (18) of the deaths occurred in teenagers. Various ways of preventing death from asthma are discussed, including better education of physicians and patients, adequate management of factors that provoke bronchospasm, sufficient follow-up -- especially in teenagers -- and the use of approaches with teenagers that encourage better compliance.     

Trends in the hospital care of acute childhood asthma 1970-8: a regional study.

In the South-west Thames Region over the period 1970-8 the number of admissions for asthma in children aged 5-14 years increased from 256 to 684, an increase of 167%. Factors associated with this trend were investigated by an analysis of routine hospital statistics and examination of case notes for 1970 and 1978 from every hospital in the region. The trend was caused partly by an increase in readmission rates. There was a more than fivefold increase in self-referrals; these patients had less severe asthma on admission and a higher readmission rate than patients referred by general practitioners. Drug management before and after admission changed considerably over the nine years, as did hospital investigations. Overall, there was little change in the level of severity on admission. The increase in admissions was not associated with a reduction in deaths from asthma in the region and occurred in spite of major advances in the drug control of asthma; this indicates an inadequacy of ambulatory care. The shift in the balance of care towards the hospital and the increasing adoption of a primary care function by the hospital indicate a need for hospitals and general practice to agree jointly on management policies for acute asthma.     

Asthma: analysis of sudden deaths and ventilatory arrests in hospital.

The incidence of episodes of unexpected ventilatory arrest, some of which led to sudden death, was studied in 1169 consecutive hospital admissions for asthma. Of the most acute cases, 458 were initially managed in a special care unit where only one ventilatory arrest occurred. A further nine cases of arrest, three of which proved fatal, happened on general wards. Accepted clinical criteria of a severe attack were not present in those episodes occurring outside the unit, which were apparently mild attacks. The risk of sudden death could not be related to the severity of the attack but it did correlate with the presence of excessive diurnal variation in peak expiratory flow rate (PEFR). Special treatment of patients with this sign might reduce mortality.     

Illness in the family

OBJECTIVE: To update reports of increases in the rates of admission to hospital and death from asthma among children and young adults in Canada during the 1970s by examining data for the 1980s. DESIGN: Age-standardized rates were calculated from data for people less than 35 years of age at the time of death from asthma, bronchitis or other respiratory conditions (from 1980 through 1989) and at the time of admission to hospital for treatment of these diseases (from 1980 through 1988). Standardized mortality ratios were calculated with the death rate for Canada as the expected rate. SETTING: Data for all of Canada were examined by sex, age group and province. RESULTS: In contrast to sharp increases in the rate of death from asthma observed from 1970 through the early 1980s among Canadians less than 35 years of age, the rate showed no net change between 1980 and 1989; on average, there were 58 deaths in this age group annually. During the decade, the rates of death from asthma were three times higher in Saskatchewan and Alberta than in Newfoundland. The national rate of hospital admission/separation for asthma, however, increased greatly, though changes in the rate varied by province. Increases of over 90% were observed in Prince Edward Island and New Brunswick, whereas little overall change occurred in Newfoundland, Manitoba and Saskatchewan. The rate of hospital admission/separation for asthma was highest in Prince Edward Island and lowest in Manitoba and British Columbia. Although the rates of hospital admission/separation for asthma among boys aged less than 15 years of age were consistently 50% higher than those among girls of that age, the rate among people aged 15 through 34 years was twice as high among females as males. A slight decrease in the rates of death from respiratory conditions other than asthma was observed, together with a steady, fairly substantial decline in the rates of hospital admission/separation for these conditions. CONCLUSIONS: Whether there is any relation between increases in rates of admission to hospital for asthma and trends in the rates of death from asthma during the decade will require further study.     

Fatal opioid overdoses during and shortly after hospital admissions in England: A case-crossover study

BackgroundHospital patients who use illicit opioids such as heroin may use drugs during an admission or leave the hospital in order to use drugs. There have been reports of patients found dead from drug poisoning on the hospital premises or shortly after leaving the hospital. This study examines whether hospital admission and discharge are associated with increased risk of opioid-related death.Methods and findingsWe conducted a case-crossover study of opioid-related deaths in England. Our study included 13,609 deaths between January 1, 2010 and December 31, 2019 among individuals aged 18 to 64. For each death, we sampled 5 control days from the period 730 to 28 days before death. We used data from the national Hospital Episode Statistics database to determine the time proximity of deaths and control days to hospital admissions. We estimated the association between hospital admission and opioid-related death using conditional logistic regression, with a reference category of time neither admitted to the hospital nor within 14 days of discharge. A total of 236/13,609 deaths (1.7%) occurred following drug use while admitted to the hospital. The risk during hospital admissions was similar or lower than periods neither admitted to the hospital nor recently discharged, with odds ratios 1.03 (95% CI 0.87 to 1.21; p = 0.75) for the first 14 days of an admission and 0.41 (95% CI 0.30 to 0.56; p < 0.001) for days 15 onwards. 1,088/13,609 deaths (8.0%) occurred in the 14 days after discharge. The risk of opioid-related death increased in this period, with odds ratios of 4.39 (95% CI 3.75 to 5.14; p < 0.001) on days 1 to 2 after discharge and 2.09 (95% CI 1.92 to 2.28; p < 0.001) on days 3 to 14. 11,629/13,609 deaths (85.5%) did not occur close to a hospital admission, and the remaining 656/13,609 deaths (4.8%) occurred in hospital following admission due to drug poisoning. Risk was greater for patients discharged from psychiatric admissions, those who left the hospital against medical advice, and those leaving the hospital after admissions of 7 days or more. The main limitation of the method is that it does not control for time-varying health or drug use within individuals; therefore, hospital admissions coinciding with high-risk periods may in part explain the results.ConclusionsDischarge from the hospital is associated with an acute increase in the risk of opioid-related death, and 1 in 14 opioid-related deaths in England happens in the 2 weeks after the hospital discharge. This supports interventions that prevent early discharge and improve linkage with community drug treatment and harm reduction services.

In a case-crossover study, Dan Lewer and coauthors investigate factors associated with fatal opioid overdoses during and shortly after hospital admissions in England.     

75 deaths in asthmatics prescribed home nebulisers.

The circumstances surrounding the deaths of 75 asthmatic patients who had been prescribed a domiciliary nebuliser driven by an air compressor pump for administration of high dose beta sympathomimetic drugs were investigated as part of the New Zealand national asthma mortality study. Death was judged unavoidable in 19 patients who seemed to have precipitous attacks despite apparently good long term management. Delays in seeking medical help because of overreliance on beta agonist delivered by nebuliser were evident in 12 cases and possible in a further 11, but these represented only 8% of the 271 verified deaths from asthma in New Zealanders aged under 70 during the period. Evidence for direct toxicity of high dose beta agonist was not found. Nevertheless, the absence of serum potassium and theophylline concentrations and of electrocardiographic monitoring in the period immediately preceding death precluded firm conclusions whether arrhythmias might have occurred due to these factors rather than to hypoxia alone. In most patients prescribed domiciliary nebulisers death was associated with deficiencies in long term and short term care similar to those seen in patients without nebulisers. Discretion in prescribing home nebulisers, greater use of other appropriate drugs, including adequate corticosteroids, and careful supervision and instruction of patients taking beta agonist by nebuliser should help to reduce the mortality from asthma.     

Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study

ObjectiveTo explore reasons for increased risk of hospital admission among south Asian patients with asthma.DesignQualitative interview study using modified critical incident technique and framework analysis.SettingNewham, east London, a deprived area with a large mixed south Asian population.Participants58 south Asian and white adults with asthma (49 admitted to hospital with asthma, 9 not admitted); 17 general practitioners; 5 accident and emergency doctors; 2 out of hours general practitioners; 1 asthma specialist nurse.ResultsSouth Asian and white patients admitted to hospital coped differently with asthma. South Asians described less confidence in controlling their asthma, were unfamiliar with the concept of preventive medication, and often expressed less confidence in their general practitioner. South Asians managed asthma exacerbations with family advocacy, without systematic changes in prophylaxis, and without systemic corticosteroids. Patients describing difficulty accessing primary care during asthma exacerbations were registered with practices with weak strategies for asthma care and were often south Asian. Patients with easy access described care suggesting partnerships with their general practitioner, had better confidence to control asthma, and were registered with practices with well developed asthma strategies that included policies for avoiding hospital admission.ConclusionsThe different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission in south Asian patients. Interventions that increase confidence to control asthma, confidence in the general practitioner, understanding of preventive treatment, and use of systemic corticosteroids in exacerbations may reduce hospital admissions. Development of more sophisticated asthma strategies by practices with better access and partnerships with patients may also achieve this.

What is already known on this topic

South Asian patients with asthma are at increased risk of hospital admission with asthma compared with white patientsNo consistent differences in severity or prevalence of asthma, prescribed drugs, or asthma education have been described, and interventions to reduce admission rates in Asian patients have met with variable success

What this study adds

Compared with white patients, south Asian patients admitted to hospital with asthma had less confidence to control asthma, were unfamiliar with the concept of preventive medication, and had less confidence in their general practitionersSouth Asian patients managed asthma attacks through family advocacy and without systematic changes in prophylaxis and without systemic corticosteroidsPatients reporting difficulty in accessing primary care during attacks were often south Asian     

Mortality in elderly patients admitted for respite care.

OBJECTIVE--To determine whether admitting elderly patients to hospital to give temporary relief to their carers is associated with increased mortality. DESIGN--Prospective multicentre study comparing the mortality of patients admitted on a one off or rotational basis with that experienced while they were awaiting admission. SETTING--A wide range of urban and rural district general, geriatric or long stay, and general practitioner hospitals. PATIENTS--474 Patients aged 70 or over who had 601 admissions. MAIN OUTCOME MEASURE--Death. RESULTS--16 (3.4%) Of the 474 patients (2.7% of all 601 admissions) died while in hospital during an average stay of 15.7 days whereas 23 (4.9%) patients died while awaiting admission (average waiting time was 34.2 days). The 16 deaths in hospital and the 23 deaths during the longer waiting period correspond to death rates of 19.9 and 12.5 per 10,000 person days respectively. The difference between these of 7.4 is not statistically significant (95% confidence interval -3.6 to 18.3). The estimated relative risk of dying in hospital is 1.59 but the 95% confidence interval is wide (0.84 to 3.01). CONCLUSION--Although the death rates are slightly higher in those admitted to hospital for relief care than in those awaiting admission, the difference was not significant, and the death rate in both groups was reassuringly small.     

Factors associated with physician agreement on verbal autopsy of over 11,500 injury deaths in India

INTRODUCTION: Worldwide, injuries account for 9.8% of all deaths. The majority of these deaths occur in low- and middle-income countries where vital registration systems are often inadequate. Verbal autopsy (VA) is a tool used to ascertain cause of death in such settings. Validation studies for VA using hospital diagnosed causes of death as comparisons have shown that injury deaths can be reliably diagnosed by VA. However, no study has assessed the factors that may affect physicians' abilities to code specific causes of injury death using VA. METHOD/PRINCIPAL FINDINGS: This study used data from over 11,500 verbal autopsies of injury deaths from the Million Death Study (MDS) in which 6.3 million people in India were monitored from 2001-2003 for vital events. Deaths that occurred in the MDS were coded by two independent physicians. This study focused on whether physician agreement on the classification of injury deaths was affected by characteristics of the deceased and respondent. Agreement was analyzed using three primary methods: 1) kappa statistic; 2) sensitivity and specificity analysis using the final VA diagnosed category of injury death as gold standard; and 3) multivariate logistic regression using a conceptual hierarchical model. The overall agreement for all injury deaths was 77.9% with a kappa of 0.74 (99% CI 0.74-0.75). Deaths in the injury categories of "transport", "falls", "drowning" and "other unintentional injury" occurring outside the home were associated with greater physician agreement than those occurring at home. In contrast, self-inflicted injury deaths that occurred outside the home were associated with lower physician agreement. CONCLUSIONS/SIGNIFICANCE: With few exceptions, most characteristics of the deceased and the respondent did not influence physician agreement on the classification of injury deaths. Physician training and continued adaptation of the VA tool should focus on the reasons these factors influenced physician agreement.     

Operating room deaths; an analysis of mortality in a Veterans Administration hospital over a ten-year period

A study of operating room and recovery room deaths which occurred during a ten-year period from 1948 through 1957 at one hospital revealed that there were 59 deaths associated with 57,132 surgical procedures. Factors which directly influenced the rate of operating room and recovery room death were the age of the patient and the length of operating time. Seventy-five per cent of the deaths occurred in cases in which the operation took longer than one hour. Combined anesthesia techniques may have indirectly contributed to death in some cases. Complications of operation requiring another surgical procedure sometimes occur. In this series, reoperation proved to be more hazardous in terms of mortality rate than did single operations. This is not surprising for most complications occur in the poorer risk patients. The operating room death rate steadily increased during the ten-year period studied. This increasing death rate can largely be attributed to the more intricate operations which are being done on poorer risk patients. The use of the curariform drugs had no influence on the increasing death rate.     

Retrospective study of 1000 deaths from injury in England and Wales

One thousand consecutive deaths from injury in 11 coroner''s districts in England and Wales were reviewed by four independent assessors, who studied necropsy reports to identify deaths in hospital that might have been preventable. Of 514 patients admitted to hospital alive, 102 deaths (20%) were judged by all four assessors to have been potentially preventable. When those cases in which three out of four assessors considered that the death was preventable were added the total rose to 170 (33%). Nearly two thirds of all non-central nervous system deaths were judged to have been preventable. The median age of the 170 patients whose deaths were preventable was 41, and the mean Injury Severity Score was 29. Further analysis suggested that the preventable deaths were principally the result of failure to stop bleeding and prevent hypoxia and the absence of, or delay in, surgical treatment.The results closely parallel those from similar studies from the United States and suggest that there are serious deficiencies in the services for managing severe injury in England and Wales. Debate is needed now on how to correct these deficiencies. In particular, the place of trauma centres must be considered.     

Increased rates of illness and death from asthma in Canada.

Recent rates of illness and death from asthma in Canada and rates of hospital admission/separation for asthma were examined by age group and region. The death rates were higher in 1982-84 than in 1970-72, especially among those aged 15 to 34 years. Increases were also noted in hospital admission/separation rates, especially among those less than 15 years of age. Hospital admission/separation rates were highest in the Maritime provinces and Saskatchewan, whereas death rates were highest in Alberta and Saskatchewan. Examination of death certificates for coding errors and recoding of certificates to a single (8th) revision of the International Classification of Diseases indicated that changes in disease coding and errors in coding did not account for the significant increase in rates of death from asthma for those aged 15 to 34 years. These increases in rates of illness and death from asthma are unexplained and warrant further investigation.     

Nationwide study of decisions concerning the end of life in general practice in The Netherlands.

OBJECTIVE--To gain insight into decisions made in general practice about the end of life. DESIGN--Study I: interviews with 405 physicians. Study II: analysis of death certificates with data obtained on 5197 cases in which decisions about the end of life may have been made. Study III: prospective study with doctors from study I: questionnaires used to collect information about 2257 deaths. The information was representative for all deaths in the Netherlands. RESULTS--Over two fifths of all patients in the Netherlands die at home. General practitioners took fewer decisions about the end of life than hospital doctors and doctors in nursing homes (34%, 40%, and 56% of all dying patients, respectively). Specifically, decisions to withhold or withdraw treatment to prolong life were taken less often. Euthanasia or assisted suicide, however, was performed in 3.2% of all deaths in general practice compared with 1.4% in hospital practice. In over half of the cases concerning pain relief or non-treatment general practitioners did not discuss the decision with the patient, mostly because of incapacity of the patient, but in 20% of cases for "paternalistic" reasons. Older general practitioners discussed such decisions less often with their patients. Colleagues were consulted more often if the general practitioner worked in group practice. CONCLUSION--Differences in work situation between general practitioners and hospital doctors and differences between the group of general practitioners contribute to differences in the number and type of decisions about the end of life as well as in the decision making process.