Bias in the Standardized Mortality Ratio when Using General Population Rates to Estimate Expected Number of Deaths

Background and Purpose— People with end-stage kidney disease (ESKD) are at greater risk of stroke. We aimed to compare stroke mortality between the ESKD population and the general population. Methods— We included all patients with incident ESKD in Australia, 1980 to 2013, and New Zealand, 1988 to 2012. The primary cause of death was ascertained using data linkage with national death registers. We produced standardized mortality ratios for stroke deaths, by age, sex, and calendar year. Results— We included 60 823 patients with ESKD, where 941 stroke deaths occurred during 381 874 person-years. Patients with ESKD had >3× the stroke deaths compared with the general population (standardized mortality ratio, 3.4; 95% CI, 3.2–3.6), markedly higher in younger people and women. The greatest excess was in intracerebral hemorrhages (standardized mortality ratio, 5.2; 95% CI, 4.5–5.9). Excess stroke deaths in patients with ESKD decreased over time, although were still double in 2013 (2013 standardized mortality ratio, 2.1; 95% CI, 1.5–2.9). Conclusions— People with ESKD experience much greater stroke mortality with the greatest difference for women and younger people. However, mortality has improved over time.

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Disparities in COVID-19 Related Mortality in U.S. Prisons and the General Population

10.1101/2020.09.17.20183392 ◽

2020 ◽

Author(s):

Kathryn M Nowotny ◽

David Cloud ◽

Alysse G. Wurcel ◽

Lauren Brinkley-Rubinstein

Keyword(s):

General Population ◽

Single Case ◽

Prison Population ◽

State Level ◽

Mortality Data ◽

Standardized Mortality Ratio ◽

Mortality Ratio ◽

Prison Systems ◽

Related Mortality

We provide an analysis of COVID-19 mortality data to assess the potential magnitude of COVID-19 among prison residents. Data were pooled from Covid Prison Project and multiple publicly available national and state level sources. Data analyses consisted of standard epidemiologic and demographic estimates. A single case study was included to generate a more in-depth and multi-faceted understanding of COVID-19 mortality in prisons. The increase in crude COVID-19 mortality rates for the prison population has outpaced the rates for the general population. People in prison experienced a significantly higher mortality burden compared to the general population (standardized mortality ratio (SMR) = 2.75; 95% confidence interval = 2.54, 2.96). For a handful of states (n = 5), these disparities were more extreme, with SMRs ranging from 5.55 to 10.56. Four states reported COVID-19 related death counts that are more than 50% of expected deaths from all-causes in a calendar year. The case study suggested there was also variation in mortality among units within prison systems, with geriatric facilities potentially at highest risk. Understanding the dynamic trends in COVID-19 mortality in prisons as they move in and out of hotspot status is critical.

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Incidence of Suicide in Persons With Cancer

Journal of Clinical Oncology ◽

10.1200/jco.2007.13.8941 ◽

2008 ◽

Vol 26 (29) ◽

pp. 4731-4738 ◽

Cited By ~ 303

Author(s):

Stephanie Misono ◽

Noel S. Weiss ◽

Jesse R. Fann ◽

Mary Redman ◽

Bevan Yueh

Keyword(s):

United States ◽

General Population ◽

The United States ◽

Mortality Data ◽

Standardized Mortality Ratio ◽

Patients With Cancer ◽

Suicide Rates ◽

Increased Risk ◽

Mortality Ratio ◽

Adjusted Rate

Purpose The purpose of this study was to characterize suicide rates among patients with cancer in the United States and identify patient and disease characteristics associated with higher suicide rates. Prior studies, mostly in Europe, have suggested that patients with cancer may be at increased risk for suicide, but large cohort studies comparing patients with cancer with the general population have not been performed in the United States. Methods Patients in the study were residents of geographic areas served by the Surveillance, Epidemiology, and End Results (SEER) program who were diagnosed with cancer from 1973 to 2002. Comparisons with the general US population were based on mortality data collected by the National Center for Health Statistics. This was a retrospective cohort study of suicide in persons with cancer. Results Among 3,594,750 SEER registry patients observed for 18,604,308 person-years, 5,838 suicides were identified, for an age-, sex-, and race-adjusted rate of 31.4/100,000 person-years. In contrast, the suicide rate in the general US population was 16.7/100,000 person-years. Higher suicide rates were associated with male sex, white race, and older age at diagnosis. The highest suicide risks were observed in patients with cancers of the lung and bronchus (standardized mortality ratio [SMR] = 5.74; 95% CI, 5.30 to 6.22), stomach (SMR = 4.68; 95% CI, 3.81 to 5.70), oral cavity and pharynx (SMR = 3.66; 95% CI, 3.16 to 4.22), and larynx (SMR = 2.83; 95% CI, 2.31 to 3.44). SMRs were highest in the first 5 years after diagnosis with cancer. Conclusion Patients with cancer in the United States have nearly twice the incidence of suicide of the general population, and suicide rates vary among patients with cancers of different anatomic sites. Further examination of the psychological experience of patients with cancer, particularly that of patients with certain types of cancer, is warranted.

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Suicide among Swedish Dentists

Scandinavian Journal of Social Medicine ◽

10.1177/140349488701500407 ◽

1987 ◽

Vol 15 (4) ◽

pp. 243-246 ◽

Cited By ~ 10

Author(s):

Bengt B. Arnetz ◽

Lars-Gunnar Hörte ◽

Anders Hedberg ◽

Hans Malker

Keyword(s):

High School ◽

General Population ◽

Socioeconomic Factors ◽

High School Education ◽

Standardized Mortality Ratio ◽

Etiologic Role ◽

Increased Risk ◽

National Cohort ◽

Mortality Ratio

In the present study, we have followed a national cohort of dentists, academics, i.e. people with three or more years of post-high school education, and the general population for a period of ten years, and identified all cases of recognized suicide during the period 1961 to 1970. The aim of the study was to assess whether suicide rates are higher among dentists even after adjustment for socioeconomic factors. Results show an elevated standardized mortality ratio (SMR) for male dentists compared to other male academics. Female dentists did not exhibit any increased risk. It is suggested that enhanced interest should be given to the possible etiologic role of not only psychosocial factors but also to psychoorganic consequences of mercury exposure among dentists.

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Multiple sclerosis and suicide

Multiple Sclerosis Journal ◽

10.1177/1352458517702553 ◽

2017 ◽

Vol 23 (7) ◽

pp. 923-927 ◽

Cited By ~ 26

Author(s):

Anthony Feinstein ◽

Bennis Pavisian

Keyword(s):

Multiple Sclerosis ◽

General Population ◽

Epidemiological Data ◽

Standardized Mortality Ratio ◽

Full Disclosure ◽

Suicidal Intent ◽

Destructive Behavior ◽

Mortality Ratio ◽

Risk Patients ◽

Severity Of Depression

Mortality rates are elevated in people with multiple sclerosis (MS) relative to the general population. There is, however, some uncertainty whether suicide contributes to this. Epidemiological data suggest that the standardized mortality ratio (SMR) for suicide in MS is approximately twice that of the general population with younger males in the first few years following diagnosis most at risk. Rates of suicidal intent, a potential harbinger of more self-destructive behavior, are also elevated, but the frequency with which intent is followed by suicide is not known. Depression, severity of depression, social isolation, and alcohol abuse are associated with thoughts of suicide. The variables linked with suicide and suicidal intent are therefore well defined and should be readily available from routine clinical inquiry. While vigilance on the part of clinicians is required, particularly in the context of high-risk patients, it is also recognized that prevention is dependent on full disclosure of intent.

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Mortality in first-contact psychosis patients in the UK: a cohort study

Psychological Medicine ◽

10.1017/s0033291711002807 ◽

2011 ◽

Vol 42 (8) ◽

pp. 1649-1661 ◽

Cited By ~ 32

Author(s):

R. Dutta ◽

R. M. Murray ◽

J. Allardyce ◽

P. B. Jones ◽

J. E. Boydell

Keyword(s):

General Population ◽

Causes Of Death ◽

Circulatory System ◽

Standardized Mortality Ratio ◽

Risk Of Death ◽

Weak Evidence ◽

Catchment Areas ◽

Mortality Ratio ◽

The Uk ◽

First Contact

BackgroundThe excess mortality following first-contact psychosis is well recognized. However, the causes of death in a complete incidence cohort and mortality patterns over time compared with the general population are unknown.MethodAll 2723 patients who presented for the first time with psychosis in three defined catchment areas of the UK in London (1965–2004, n=2056), Nottingham (1997–1999, n=203) and Dumfries and Galloway (1979–1998, n=464) were traced after a mean of 11.5 years follow-up and death certificates were obtained. Data analysis was by indirect standardization.ResultsThe overall standardized mortality ratio (SMR) for first-contact psychosis was 184 [95% confidence interval (CI) 167–202]. Most deaths (84.2%, 374/444) were from natural causes, although suicide had the highest SMR (1165, 95% CI 873–1524). Diseases of the respiratory system and infectious diseases had the highest SMR of the natural causes of death (232, 95% CI 183–291). The risk of death from diseases of the circulatory system was also elevated compared with the general population (SMR 139, 95% CI 117–164) whereas there was no such difference for neoplasms (SMR 111, 95% CI 86–141). There was strong evidence that the mortality gap compared with the general population for all causes of death (p<0.001) and all natural causes (p=0.01) increased over the four decades of the study. There was weak evidence that cardiovascular deaths may be increasing relative to the general population (p=0.07).ConclusionsPeople with first-contact psychosis have an overall mortality risk that is nearly double that of the general population. Most excess deaths are from natural causes. The widening of the mortality gap over the last four decades should be of concern to all clinicians involved in delivering healthcare.

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Risk and timing of cardiovascular death among patients with myelodysplastic syndromes

Blood Advances ◽

10.1182/bloodadvances.2017010165 ◽

2017 ◽

Vol 1 (23) ◽

pp. 2032-2040 ◽

Cited By ~ 26

Author(s):

Andrew M. Brunner ◽

Traci M. Blonquist ◽

Gabriela S. Hobbs ◽

Philip C. Amrein ◽

Donna S. Neuberg ◽

...

Keyword(s):

General Population ◽

Myelodysplastic Syndromes ◽

Lower Risk ◽

Clinical Care ◽

Cardiovascular Death ◽

Standardized Mortality Ratio ◽

Hematopoietic Stem ◽

Clonal Hematopoiesis ◽

Increased Risk ◽

Mortality Ratio

Abstract Myelodysplastic syndromes (MDS) are clonal hematopoietic stem cell disorders associated with progression to leukemia and poor survival. Clonal hematopoiesis in people without an MDS diagnosis carries an increased risk of cardiovascular death. Many clonally restricted mutations are shared between patients with MDS and those with non-MDS clonal hematopoiesis; therefore, we evaluated the risk of cardiovascular death among patients with MDS. We evaluated adults with MDS in the Surveillance, Epidemiology, and End Results database of the National Cancer Institute and compared them with the general population living in the same states. We grouped histological subtypes of MDS into lower-, intermediate-, and higher-risk disease. The primary outcomes were overall survival and primary cause of death (COD) as reported to state registries. A total of 21 372 patients with MDS between 2001 and 2011 died during follow-up with a known COD. The rate of death due to cardiovascular disease (CVD) was 4613 per 100 000 person-years, compared with 2091 in the age- and-sex-adjusted US population (standardized mortality ratio, 2.21). At 24 months, the cumulative incidence of death attributed to MDS or leukemia was 23% vs 8% for CVD. Among those alive at 60 months, 27% eventually died of CVD compared with 29% from MDS or leukemia; those with lower-risk disease who survived >60 months had more deaths attributed to cardiovascular causes (30%; 95% confidence interval [CI], 26.7-33.2%) than MDS itself (24%; 95% CI, 21.4-27.5%). Patients with MDS are more likely to die of cardiovascular causes than the general population. Modifying cardiovascular risk factors, especially among those with lower-risk disease, may be warranted for MDS-related clinical care.

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A Population-Based Study of Cardiovascular Disease Mortality in Italian Cancer Patients

Cancers ◽

10.3390/cancers13235903 ◽

2021 ◽

Vol 13 (23) ◽

pp. 5903

Author(s):

Lucia Mangone ◽

Pamela Mancuso ◽

Luigi Tarantini ◽

Mario Larocca ◽

Isabella Bisceglia ◽

...

Keyword(s):

Cardiovascular Disease ◽

General Population ◽

Cancer Patients ◽

Cardiovascular Mortality ◽

Interdisciplinary Approach ◽

Population Based ◽

Standardized Mortality Ratio ◽

Disease Mortality ◽

Mortality Ratio ◽

Melanoma Patients

The present research describes 25 years of cardiovascular mortality in a cohort of patients in Northern Italy. The study included patients with malignant cancer enrolled in the period of 1996–2019, and describes cardiovascular and cancer mortality in relation to sex, age, year of diagnosis, months of survivorship, tumor site, and standardized mortality ratio (SMR). Out of 67,173 patients, 38,272 deaths (57.7%) were recorded: 4466 from cardiovascular disease (CVD) (6.6%), and 28,579 (42.6%) from cancer. The proportion of CVD death increased from 4.5% in the first two years after diagnosis, to 7.3% after more than 10 years, while the proportion of deaths from cancer decreased from 70.5% to 9.4%. The CVD SMR comparing cancer patients with the general population was 0.87 (95% CI: 0.82–0.92) in 1996–1999, rising to 0.95 (95% CI: 0.84–1.08) in 2015–2019, without differences in terms of sex or age. The risk of dying from CVD was higher compared with the general population (SMR 1.31; 95% CI: 1.24–1.39) only in the first two years after diagnosis. The trend over time underscored that CVD deaths increased in patients with breast, bladder, prostate, and colorectal cancers, and, in the more recent period, for kidney cancer and melanoma patients. Our data confirmed that cardiovascular mortality is an important issue in the modern management of cancer patients, suggesting the need for an extensive interdisciplinary approach.

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Measures of disease occurrence

Epidemiology with R ◽

10.1093/oso/9780198841326.003.0003 ◽

2020 ◽

pp. 41-46

Author(s):

Bendix Carstensen

Keyword(s):

Mortality Rate ◽

General Population ◽

Incidence Rate ◽

Mortality Rates ◽

Incidence Rates ◽

Standardized Mortality Ratio ◽

Newly Diagnosed ◽

Disease Occurrence ◽

Mortality Ratio ◽

Incident Cases

This chapter provides a brief introduction to some of the most common measures of disease occurrence used in epidemiology, both the empirical and theoretical versions of the measures. It begins with the prevalence of a disease in a population, which is the fraction of the population that has the disease at a given date. The chapter then considers mortality rate, incidence rate, standardized mortality ratio (SMR), and survival. Mortality is typically reported as a number of people that have died in a population of a certain size. Incidence rates are defined exactly as mortality rates, where one just counts incident cases, that is, newly diagnosed cases of a particular disease. Meanwhile, the SMR is a measure of the mortality in a group of persons as compared to the general population. Finally, the survival after diagnosis of a disease is defined as the fraction of diagnosed individuals alive at a given time after diagnosis.

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Mortality in patients with psychogenic nonepileptic seizures

Neurology ◽

10.1212/wnl.0000000000009855 ◽

2020 ◽

Vol 95 (6) ◽

pp. e643-e652 ◽

Cited By ~ 6

Author(s):

Russell Nightscales ◽

Lara McCartney ◽

Clarissa Auvrez ◽

Gerard Tao ◽

Sarah Barnard ◽

...

Keyword(s):

General Population ◽

Standardized Mortality Ratio ◽

Psychogenic Nonepileptic Seizures ◽

Risk Of Death ◽

Significant Difference ◽

Tertiary Hospitals ◽

Mortality Ratio ◽

Nonepileptic Seizures ◽

External Causes ◽

Drug Resistant Epilepsy

ObjectiveTo investigate the hypothesis that patients diagnosed with psychogenic nonepileptic seizures (PNES) on video-EEG monitoring (VEM) have increased mortality by comparison to the general population.MethodsThis retrospective cohort study included patients evaluated in VEM units of 3 tertiary hospitals in Melbourne, Australia, between January 1, 1995, and December 31, 2015. Diagnosis was based on consensus opinion of experienced epileptologists and neuropsychiatrists at each hospital. Mortality was determined in patients diagnosed with PNES, epilepsy, or both conditions by linkage to the Australian National Death Index. Lifetime history of psychiatric disorders in PNES was determined from formal neuropsychiatric reports.ResultsA total of 5,508 patients underwent VEM. A total of 674 (12.2%) were diagnosed with PNES, 3064 (55.6%) with epilepsy, 175 (3.2%) with both conditions, and 1,595 (29.0%) received other diagnoses or had no diagnosis made. The standardized mortality ratio (SMR) of patients diagnosed with PNES was 2.5 (95% confidence interval [CI] 2.0–3.3). Those younger than 30 had an 8-fold higher risk of death (95% CI 3.4–19.8). Direct comparison revealed no significant difference in mortality rate between diagnostic groups. Among deaths in patients diagnosed with PNES (n = 55), external causes contributed 18%, with 20% of deaths in those younger than 50 years attributed to suicide, and “epilepsy” was recorded as the cause of death in 24%.ConclusionsPatients diagnosed with PNES have a SMR 2.5 times above the general population, dying at a rate comparable to those with drug-resistant epilepsy. This emphasizes the importance of prompt diagnosis, identification of risk factors, and implementation of appropriate strategies to prevent potential avoidable deaths.

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