Actual and Preferred Place of Death of Home-Dwelling Patients in Four European Countries: Making Sense of Quality Indicators

Background

Dying at home and dying at the preferred place of death are advocated to be desirable outcomes of palliative care. More insight is needed in their usefulness as quality indicators. Our objective is to describe whether “the percentage of patients dying at home” and “the percentage of patients who died in their place of preference” are feasible and informative quality indicators.

Methods and Findings

A mortality follow-back study was conducted, based on data recorded by representative GP networks regarding home-dwelling patients who died non-suddenly in Belgium (n = 1036), the Netherlands (n = 512), Italy (n = 1639) or Spain (n = 565). “The percentage of patients dying at home” ranged between 35.3% (Belgium) and 50.6% (the Netherlands) in the four countries, while “the percentage of patients dying at their preferred place of death” ranged between 67.8% (Italy) and 86.0% (Spain). Both indicators were strongly associated with palliative care provision by the GP (odds ratios of 1.55–13.23 and 2.30–6.63, respectively). The quality indicator concerning the preferred place of death offers a broader view than the indicator concerning home deaths, as it takes into account all preferences met in all locations. However, GPs did not know the preferences for place of death in 39.6% (the Netherlands) to 70.3% (Italy), whereas the actual place of death was known in almost all cases.

Conclusion

GPs know their patients’ actual place of death, making the percentage of home deaths a feasible indicator for collection by GPs. However, patients’ preferred place of death was often unknown to the GP. We therefore recommend using information from relatives as long as information from GPs on the preferred place of death is lacking. Timely communication about the place where patients want to be cared for at the end of life remains a challenge for GPs.     

“Unwarranted survivals” and “anomalous deaths” from coronary heart disease: prospective survey of general population

ObjectivesTo assess survival in people who are at apparent high risk who do not develop coronary heart disease (“unwarranted survivals”) and mortality in people at low risk who die from the disease (“anomalous deaths”) and the extent to which these outcomes are explained by other, less visible, risk factors.DesignProspective general population survey.SettingRenfrew and Paisley, Scotland.Participants6068 men aged 45-64 years at screening in 1972-6, allocated to “visible” risk groups on the basis of body mass index and smoking.ResultsVisible risk was a good predictor of mortality: 13% (45) of men at low risk and 45% (86) of men at high risk had died by age 70 years. Of these deaths, 12 (4%) and 44 (23%), respectively, were from coronary heart disease. In the group at low visible risk other less visible risk factors accounted for increased risk in 83% (10/12) of men who died from coronary heart disease and 29% (84/292) of men who survived. In the high risk group 81/107 who survived (76%) and 19/44 (43%) who died from coronary heart disease had lower risk after other factors were considered. Different risk factors modified risk (beyond smoking and body mass index) in the two groups. Among men at low visible risk, poor respiratory function, diabetes, previous coronary heart disease, and socioeconomic deprivation modified risk. Among men at high visible risk, height and cholesterol concentration modified risk.ConclusionsDifferences in survival between these extreme risk groups are dramatic. Health promotion messages would be more credible if they discussed anomalies and the limits of prediction of coronary disease at an individual level.

What is already known on this topic

People pay attention to visible risk factors, such as smoking and weight, in explaining or predicting coronary events but are aware that these behavioural risk factors fail to explain some early deaths from coronary heart disease (in those with “low risk” lifestyles) and long survival (in those with “high risk” lifestyles)Such violations to notions of coronary candidacy undermine people''s belief in the worth of modifying behavioural risk factors for coronary heart disease

What this study adds

Visible risk status was a good marker for other coronary risk factors at the extremes of the risk distributionMost men at low visible risk (slim, never smoked) who died prematurely from coronary heart disease had poorer risk profiles on other less visible risk factors; similarly, men at high visible risk (obese, heavy smokers) who survived often had more favourable profiles on other risk factors     

Place and Cause of Death in Centenarians: A Population-Based Observational Study in England, 2001 to 2010

Background

Centenarians are a rapidly growing demographic group worldwide, yet their health and social care needs are seldom considered. This study aims to examine trends in place of death and associations for centenarians in England over 10 years to consider policy implications of extreme longevity.

Methods and Findings

This is a population-based observational study using death registration data linked with area-level indices of multiple deprivations for people aged ≥100 years who died 2001 to 2010 in England, compared with those dying at ages 80-99. We used linear regression to examine the time trends in number of deaths and place of death, and Poisson regression to evaluate factors associated with centenarians’ place of death. The cohort totalled 35,867 people with a median age at death of 101 years (range: 100–115 years). Centenarian deaths increased 56% (95% CI 53.8%–57.4%) in 10 years. Most died in a care home with (26.7%, 95% CI 26.3%–27.2%) or without nursing (34.5%, 95% CI 34.0%–35.0%) or in hospital (27.2%, 95% CI 26.7%–27.6%). The proportion of deaths in nursing homes decreased over 10 years (−0.36% annually, 95% CI −0.63% to −0.09%, p = 0.014), while hospital deaths changed little (0.25% annually, 95% CI −0.06% to 0.57%, p = 0.09). Dying with frailty was common with “old age” stated in 75.6% of death certifications. Centenarians were more likely to die of pneumonia (e.g., 17.7% [95% CI 17.3%–18.1%] versus 6.0% [5.9%–6.0%] for those aged 80–84 years) and old age/frailty (28.1% [27.6%–28.5%] versus 0.9% [0.9%–0.9%] for those aged 80–84 years) and less likely to die of cancer (4.4% [4.2%–4.6%] versus 24.5% [24.6%–25.4%] for those aged 80–84 years) and ischemic heart disease (8.6% [8.3%–8.9%] versus 19.0% [18.9%–19.0%] for those aged 80–84 years) than were younger elderly patients. More care home beds available per 1,000 population were associated with fewer deaths in hospital (PR 0.98, 95% CI 0.98–0.99, p<0.001).

Conclusions

Centenarians are more likely to have causes of death certified as pneumonia and frailty and less likely to have causes of death of cancer or ischemic heart disease, compared with younger elderly patients. To reduce reliance on hospital care at the end of life requires recognition of centenarians’ increased likelihood to “acute” decline, notably from pneumonia, and wider provision of anticipatory care to enable people to remain in their usual residence, and increasing care home bed capacity. Please see later in the article for the Editors'' Summary     

Vagotomy and Pyloroplasty for Gastric Ulcer

In a series of 68 patients with gastric ulcer who were treated by vagotomy and pyloroplasty there were no operative deaths, though one patient who received massive transfusions died 14 weeks later from hepatic necrosis probably associated with serum hepatitis. Four patients developed recurrent peptic ulceration requiring further surgical treatment. The clinical condition of all but three of the remainder was satisfactory after an average follow-up period of three years and two months. Of the 14 patients who presented with an acutely bleeding gastric ulcer, one subsequently required gastrectomy for continued bleeding; in all the others the immediate and long-term results were satisfactory. Of 21 patients with a “high” ulcer and 29 with combined gastric and duodenal ulceration one (4·8%) and three (10%) respectively suffered recurrences. We conclude that vagotomy and pyloroplasty is a satisfactory form of treatment for a high or bleeding gastric ulcer, but that for all other gastric ulcers some form of gastric resection is preferable.     

Mothers' experiences of induction

Mothers of a random sample of 2182 legitimate live births were interviewed about their experiences of pregnancy, labour, and delivery. Of these, 24% reported that their labours were induced, and data about this from a subsample of mothers tallied with information obtained through the doctors in charge in 88% of cases. All but 3% of the mothers who were induced perceived some medical reason for the induction. The proportion of inductions in the 24 study areas ranged from 6% to 39%. A relatively small proportion of labours in “teaching” hospitals, small hospitals with less than 100 beds, and GP maternity hospitals were induced, but a comparatively high proportion of private patients had an induction. There was no clear association between induction and the mother''s age or parity. Despite being given more pain relief, those who were induced reported similar intensities of pain during the first and second stages of labour to those whose labour started spontaneously; they also reported that they had “bad pains” for a similar period. The period they had contractions was shorter for the induced than for those starting spontaneously, and the intensity of pain at delivery was rated somewhat less by those who were induced.There was no difference between induced babies and others in the proportion who were held by their mothers immediately after their birth. Two-fifths of the mothers who were induced would have liked more information about induction; and a similar proportion said they had not discussed induction with a doctor, midwife, or nurse during their pregnancy. Only 17% of the mothers who had an induction said they would prefer to be induced if they had another baby. This contrasts with 63% of those who had epidural analgesia who would opt for the same procedure next time, while 83% of those who had had a baby in hospital, and 91% of those having had a home birth, would want their next baby in the same type of place.     

The Probability of Death Following a Fracture of the Hip

All patients 45 years of age and over admitted with fractures of the hip to hospitals in the Atlantic Health Region of Nova Scotia were followed up over a two-year period. Actuarial methods were used to estimate survivorship from the date of fracture in 202 patients.Over-all, it was estimated that only 63.8% would be alive by one year post-fracture. This is 70% of the survival rate expected in the general population of corresponding age and sex. The period of greatest mortality was within the first 12 weeks. Patients surviving to one year could be considered “cured”, for after that their survivorship was at least as favourable as that of the “normal” population.Mortality was greatest in males in those 75 years of age and over and especially in patients who were relatively immobilized prior to their fracture. In this “dependent” group the relative survival ratio at one year was only 38%.     

Non-Tuberculous Chest Disease Found in a Mass X-Ray Survey in Vancouver,B.C

In 1964, 219,085 persons were examined during a tuberculosis survey in Vancouver, B.C. One hundred and fifteen new cases of tuberculosis and 929 cases of significant non-tuberculous lung disease were found. In a four-month follow-up of the non-tuberculous cases it was found that of the 742 patients who had named a physician when examined 26.6% had not made contact with him. Of those who did contact the physician, the follow-up was considered “poor” in only 30 patients (2.1%). Seventeen patients had died in the four-month interval and 81 who could not be located after the initial survey were considered “lost”. Rates were determined for 37 diagnoses per 1000 patients screened. The most common diagnosis was localized pulmonary fibrosis (1.69/1000). Carcinoma was found in 0.30/1000 and solitary lung density in 0.17/1000 population screened.     

Acute Myocardial Infarction in Doncaster. II—Delays in Admission and Survival

The speed of admission of patients with suspected acute myocardial infarction was observed over a period of 12 months during which a “no refusal” coronary care scheme was functioning, with emphasis on minimizing delay. During the same period the duration of survival of cases diagnosed as coronary thrombosis by the coroner''s pathologist was measured. Comparison of the two series shows that 75% to 80% of the coroner''s cases had died before the median time of notification of the general practitioner by those patients referred to hospital.We argue that the provision of mobile coronary care on request from general practitioners is unlikely to have an appreciable effect in preventing deaths from acute myocardial infarction outside hospital.     

Can Serum Levels of Alkaline Phosphatase and Phosphate Predict Cardiovascular Diseases and Total Mortality in Individuals with Preserved Renal Function? A Systemic Review and Meta-Analysis

Background

It is demonstrated that elevated serum levels of alkaline phosphatase (ALP) and phosphate indicate a higher risks of cardiovascular disease (CVD) and total mortality in population with chronic kidney disease (CKD), but it remains unclear whether this association exists in people with normal or preserved renal function.

Method

Clinical trials were searched from Embase and PubMed from inception to 2013 December using the keywords “ALP”, “phosphate”, “CVD”, “mortality” and so on, and finally 24 trials with a total of 147634 patients were included in this study. Dose-response and semi-parametric meta-analyses were performed.

Results

A linear association of serum levels of ALP and phosphate with risks of coronary heart disease (CHD) events, CVD events and deaths was identified. The relative risk(RR)of ALP for CVD deaths was 1.02 (95% confidence interval [CI], 1.01–1.04). The RR of phosphate for CVD deaths and events was 1.05 (95% CI, 1.02–1.09) and 1.04 (95% CI: 1.03–1.06), respectively. A non-linear association of ALP and phosphate with total mortality was identified. Compared with the reference category of ALP and phosphate, the pooled RR of ALP for total mortality was 1.57 (95% CI, 1.27–1.95) for the high ALP group, while the RR of phosphate for total mortality was 1.33 (95% CI, 1.21–1.46) for the high phosphate group. It was observed in subgroup analysis that higher levels of serum ALP and phosphate seemed to indicate a higher mortality rate in diabetic patients and those having previous CVD. The higher total mortality rate was more obvious in the men and Asians with high ALP.

Conclusion

A non-linear relationship exists between serum levels of ALP and phosphate and risk of total mortality. There appears to be a positive association of serum levels of ALP/phosphate with total mortality in people with normal or preserved renal function, while the relationship between ALP and CVD is still ambiguous.     

Revascularization of the Entire Heart by Internal Mammary Artery Implantation,Epicardiectomy and Free Omental Graft

The indications for and the contraindications to total cardiac revascularization are described on the basis of the author''s experience. The combined operation of internal mammary artery implant, epicardiectomy and free omental graft was performed on 62 patients. Of 45 who did not have angina at rest without exciting cause (Grade I) 39 showed improvement; 32 returned to full-time work, 18 of whom had been unable to work before operation. There were two operative deaths. Among the 17 patients who were “bed-chair cripples” (angina at rest without cause-Grade II), there was a 24% operative mortality (four deaths), but 76% of the survivors had marked improvement. Only one of this group had been working full-time preoperatively; now nine are working full-time.     

Effect of Immunotherapy on Seizure Outcome in Patients with Autoimmune Encephalitis: A Prospective Observational Registry Study

Objective

To evaluate the seizure characteristics and outcome after immunotherapy in adult patients with autoimmune encephalitis (AE) and new-onset seizure.

Methods

Adult (age ≥18 years) patients with AE and new-onset seizure who underwent immunotherapy and were followed-up for at least 6 months were included. Seizure frequency was evaluated at 2–4 weeks and 6 months after the onset of the initial immunotherapy and was categorized as “seizure remission”, “> 50% seizure reduction”, or “no change” based on the degree of its decrease.

Results

Forty-one AE patients who presented with new-onset seizure were analysed. At 2–4 weeks after the initial immunotherapy, 51.2% of the patients were seizure free, and 24.4% had significant seizure reduction. At 6 months, seizure remission was observed in 73.2% of the patients, although four patients died during hospitalization. Rituximab was used as a second-line immunotherapy in 12 patients who continued to have seizures despite the initial immunotherapy, and additional seizure remission was achieved in 66.6% of them. In particular, those who exhibited partial response to the initial immunotherapy had a better seizure outcome after rituximab, with low adverse events.

Conclusion

AE frequently presented as seizure, but only 18.9% of the living patients suffered from seizure at 6 months after immunotherapy. Aggressive immunotherapy can improve seizure outcome in patients with AE.     

Canadian Applicants to Medical Schools in Canada for 1965-66

An examination of applicants to Canadian medical schools for 1965-66 revealed that 4660 applications were received by the 12 schools for approximately 900 places available; 2852 of these were from Canadians, but because many applicants applied to more than one school, these 2852 applications represented only 1767 individuals. Evaluations made by the schools concerning the acceptability of these applicants showed that only 36 persons rated as “acceptable” by one or more schools failed to gain admission to any Canadian school for 1965-66. Furthermore, 66 “marginal” applicants were accepted, as were 130 multiple applicants who were rated as “acceptable” by one school but “marginal” and/or “unacceptable” by one or more other schools. Of the 464 multiple applicants, only 40% received the same evaluation from all schools to which they applied. If those multiple applicants who were rated as acceptable by all schools to which they applied are added to single applicants rated as acceptable, the pool of these clearly acceptable candidates (40% of all Canadian applicants) is sufficient only to fill 78% of places available. It was thus concluded that it is erroneous to speak of a surplus of well-qualified Canadian applicants at the present time.     

Comparison of avalanche survival patterns in Canada and Switzerland

Background

Current recommendations for rescue and resuscitation of people buried in avalanches are based on Swiss avalanche survival data. We analyzed Canadian survival patterns and compared them with those from Switzerland.

Methods

We extracted relevant data for survivors and nonsurvivors of complete avalanche burials from Oct. 1, 1980, to Sept. 30, 2005, from Canadian and Swiss databases. We calculated survival curves for Canada with and without trauma-related deaths as well as for different outdoor activities and snow climates. We compared these curves with the Swiss survival curve.

Results

A total of 301 people in the Canadian database and 946 in the Swiss database met the inclusion criteria. The overall proportion of people who survived did not differ significantly between the two countries (46.2% [139/301] v. 46.9% [444/946]; p = 0.87). Significant differences were observed between the overall survival curves for the two countries (p = 0.001): compared with the Swiss curve, the Canadian curve showed a quicker drop at the early stages of burial and poorer survival associated with prolonged burial. The probability of survival fell quicker with trauma-related deaths and in denser snow climates. Poorer survival probabilities in the Canadian sample were offset by significantly quicker extrication (median duration of burial 18 minutes v. 35 minutes in the Swiss sample; p < 0.001).

Interpretation

Observed differences in avalanche survival curves between the Canadian and Swiss samples were associated with the prevalence of trauma and differences in snow climate. Although avoidance of avalanches remains paramount for survival, the earlier onset of asphyxia, especially in maritime snow climates, emphasizes the importance of prompt extrication, ideally within 10 minutes. Protective devices against trauma and better clinical skills in organized rescue may further improve survival.A valanches make winter outdoor travel in mountainous terrain a hazardous activity. A total of 881 people died from avalanches in open terrain in Europe and North America over the six winters from 2003/04 to 2008/09.¹ The survival pattern of complete avalanche burials (coverage of the person’s head and chest, impairing breathing) in open terrain in Europe has been depicted in the avalanche survival curve,^2,3 which displays probability of survival as a function of burial time. The curve exhibits a characteristic shape, with four distinct phases. The probability of survival remains above 91% during the first 18 minutes of burial (“survival phase”). This phase is followed by a precipitous drop to 34% between 19 and 35 minutes because of asphyxiation of most people (“asphyxia phase”). Between 35 and 90 minutes, the survival curve levels out (“latent phase”) because of the survival of people with patent airways.⁴ Thereafter, survival drops again as those buried eventually succumb to lethal hypothermia complicated by progressive hypoxia and hypercapnia.⁵This avalanche survival model forms the foundation for current international recommendations for rescue and resuscitation^3,4 as well as the rationale for safety and rescue devices.⁶ However, the existing survival curve was calculated solely from Swiss data. Therefore, the universal validity of the survival curve and recommendations derived from it remains unknown.We analyzed survival curves for Canada and compared them with the survival curve in Switzerland. A better understanding of the factors affecting survival during an avalanche burial will provide important background for improvements in rescue, resuscitation and avalanche safety measures in Canada and elsewhere.     

Which Is More Useful in Predicting Hospital Mortality -Dichotomised Blood Test Results or Actual Test Values? A Retrospective Study in Two Hospitals

Background

Routine blood tests are an integral part of clinical medicine and in interpreting blood test results clinicians have two broad options. (1) Dichotomise the blood tests into normal/abnormal or (2) use the actual values and overlook the reference values. We refer to these as the “binary” and the “non-binary” strategy respectively. We investigate which strategy is better at predicting the risk of death in hospital based on seven routinely undertaken blood tests (albumin, creatinine, haemoglobin, potassium, sodium, urea, and white blood cell count) using tree models to implement the two strategies.

Methodology

A retrospective database study of emergency admissions to an acute hospital during April 2009 to March 2010, involving 10,050 emergency admissions with routine blood tests undertaken within 24 hours of admission. We compared the area under the Receiver Operating Characteristics (ROC) curve for predicting in-hospital mortality using the binary and non-binary strategy.

Results

The mortality rate was 6.98% (701/10050). The mean predicted risk of death in those who died was significantly (p-value <0.0001) lower using the binary strategy (risk = 0.181 95%CI: 0.193 to 0.210) versus the non-binary strategy (risk = 0.222 95%CI: 0.194 to 0.251), representing a risk difference of 28.74 deaths in the deceased patients (n = 701). The binary strategy had a significantly (p-value <0.0001) lower area under the ROC curve of 0.832 (95% CI: 0.819 to 0.845) versus the non-binary strategy (0.853 95% CI: 0.840 to 0.867). Similar results were obtained using data from another hospital.

Conclusions

Dichotomising routine blood test results is less accurate in predicting in-hospital mortality than using actual test values because it underestimates the risk of death in patients who died. Further research into the use of actual blood test values in clinical decision making is required especially as the infrastructure to implement this potentially promising strategy already exists in most hospitals.     

Non-Employment Histories of Middle-Aged Men and Women Who Died from Alcohol-Related Causes: A Longitudinal Retrospective Study

Background

Long-term patterning of non-employment among problem drinkers is poorly understood. We determined the level and timing of non-employment, and the relative contribution of various types of non-employment among middle-aged persons who died of alcohol-related causes.

Methods

We conducted a longitudinal retrospective register-based study of Finnish men and women aged 45–64 years who died of alcohol-related causes (n = 15 552) or other causes (n = 39 166) in the period 2000–07, or who survived (n = 204 422) until the end of 2007. We traced back the number of days in employment and non-employment for up to 17 years before death or before the end of the study period for the survivors.

Results

The majority (≥56%) of persons who died of alcohol-related causes were in employment up to ten years before death. Over the 17-year period before death, those who died of alcohol-related causes were in employment on average two years less (mean 6.3 years, 95%CI 6.2–6.4) than those dying of other causes (8.2, 8.1–8.3), and five years less than survivors (11.6, 11.5–11.7), when sex and age were adjusted for. The relative role of various types of non-employment differed markedly across the two mortality groups. Among those who died of alcohol-related causes, unemployment accounted for 54% of the total burden of non-employment, in comparison with 29% among those who died of other causes. In contrast, disability pension accounted for 41% of the total burden of non-employment among those who died of alcohol-related causes, but 65% among those who died of other causes.

Conclusions

The results indicate the feasibility of preventing movement out of employment among middle-aged men and women with severe alcohol-related harm, provided that they are identified early on during their working careers and offered effective interventions.     

DORMANCY AND GERMINATION IN SEEDS OF COMMON RAGWEED WITH REFERENCE TO BEAL'S BURIED SEED EXPERIMENT

Common ragweed (Ambrosia artemisiifolia L.) was one of 19 herbaceous weedy species used by Beal in his buried viable seed experiment started in 1879. No seeds germinated during the first 35 years of the experiment when germination tests were performed in late spring, summer or early autumn. Germination did occur in seeds buried for 40 years when seeds were exhumed and tested for germination in early spring. Data obtained in more recent research provide the probable explanation for these results. Seeds of common ragweed that do not germinate in spring enter secondary dormancy by mid to late spring and will not germinate until dormancy is broken the following late autumn and winter. Thus, during the first 35 years of the experiment seeds were dormant when tested for germination, whereas seeds buried for 40 years were nondormant. Seeds buried 50 years or longer did not germinate when tested in spring, probably because they had lost viability and/or seeds germinated during burial and seedlings died.     

USE OF THE ARTIFICIAL KIDNEY—Its Place in the Treatment of Acute Renal Failure

Of 57 patients with severe, but potentially reversible, acute renal failure who were observed during a recent four-year period, some had dialysis with an artificial kidney and some did not.Twenty survived with the standard “conservative” management alone; 19 survived with a combination of “conservative” and “intensive” (that is, artificial kidney) treatment; 18 patients died.One error that was made in the management of all 18 patients who died, was excessive delay in the use of the artificial kidney.Hemodialysis should be used whenever serious electrolyte abnormality exists, whenever the blood urea nitrogen exceeds 150 mg. per 100 cc. or whenever clinical signs of uremia first appear. One or more of these indications will usually, but not always, become evident between the fifth and the eighth day of virtual anuria.     

Blood Pressure in a Scottish Town

As part of a general health screening survey in the Burgh of Renfrew blood pressure was measured in 3,001 subjects (78·8% of those eligible) aged 45 to 64. In 468 (15·6%) diastolic blood pressure was 100 mm Hg or more. A year later the mean blood pressure for those of the population re-examined showed no change, there being an equal number of subjects with increased and decreased pressures. The prognostic significance of those showing the larger fluctuations remains to be determined through medical-record linkage.Examination of the general practitioners'' medical records of 422 of the 468 subjects with diastolic blood pressure of 100 mm Hg or more showed that 255 had no previous documented hypertension. Of the remainder 73 were receiving antihypertensive therapy. Examination of the records of subjects whose blood pressure was under 100 mm Hg showed that 55 were receiving antihypertensive treatment and that another 113 had previously been recorded as having a diastolic blood pressure of 100 mm Hg or more by their general practitioner. Altogether at least 636 (21·2%) of those who were examined had been considered at some time to have evidence of hypertension.The prevalence of undetected hypertension in the general population has important implications for the resources of the National Health Service if current trials show benefit to the health of the community from treating “mild” as well as “moderate” hypertension.