A confidential enquiry into certified asthma deaths in the North of England, 1994–1996: influence of co-morbidity and diagnostic inaccuracy

Abstract

To understand more fully the nature of events leading to asthmatic death, we conducted a confidential enquiry prospectively throughout 1994-96 among the surviving relatives and respective general practitioners of subjects whose deaths could be attributed to asthma, whether wholly or partly. We also reviewed relevant hospital records and autopsy reports, and we submitted all the gathered information to an enquiry panel for evaluation. The subjects were identified from death certificates issued in five districts of the Northern Health Region of England (population 1 million) on which asthma was recorded as the primary cause of death. The enquiry panel agreed that asthma had been a critical factor in causing death in only 33 of the 79 certified cases for which there were sufficient data. The level of concordance was substantially greater for subjects aged < 65 years (76%) than for those who were older (17%). In 16 of the 33 cases asthma alone appeared to be responsible for death, but in 17 cases a wide variety of additional, co-morbid, disorders appeared to have contributed. They included, during the 24 h preceding death, gastric aspiration, septicaemia, a single dose of a beta-blocker, the abuse of organic solvents or illicit drugs and possibly, an inadvertent exposure to horse allergen. More chronic causes of co-morbidity included ischaemic heart disease, chronic obstructive pulmonary disease (COPD), thoracic cage deformity and alcohol abuse. There were possible errors of judgement in two cases by the supervising physician (6%) and in three cases by the patient (9%). Poor compliance and psychosocial disruption probably exerted an additional adverse influence in nine cases (27%). We conclude: (1) that asthma death certification in subjects aged 65 years or more is very unreliable, (2) that for approximately half of the deaths in which asthma exerted a critical role there were critical co-morbid disorders and (3) that errors of judgement, poor compliance, or psychosocial disruption are likely to have exerted an additional adverse influence in an important minority of cases.

Systematic review and economic analysis of the comparative effectiveness of different inhaled corticosteroids and their usage with long-acting beta2 agonists for the treatment of chronic asthma in adults and children aged 12 years and over

“…Primary outcome Morning PEF Secondary outcomes Evening PEF Use of rescue medication Day-and night-time asthma symptoms scores % symptom-free days and nights FEV 1 morning PEF for several periods during their 24-week study. The closest data to the end-point that they provided was for weeks [13][14][15][16][17][18][19][20][21][22][23][24]. During this period, the mean ± SD change in the morning PEF from baseline (adjusted by ANCOVA for sex, age and country) was 410 ± 4.49 l/minute for subjects on FP/SAL and 384 ± 4.69 l/minute for subjects on high-dose (1600 µg/day) BUD.…”

“…In the period closest to the end of the study (weeks [13][14][15][16][17][18][19][20][21][22][23][24], the median percentage of symptom-free days was 75% for subjects who received FP/SAL and 40% for subjects who received high-dose (1600 µg/day) BUD (these data were estimated by the reviewers from Figure 3a of Jenkins and colleagues 223 ). The respective median percentages of symptom-free days over the whole study (weeks 1-24) for these drugs were 60 and 34% (95% CI 2 to 11).…”

What do chronic obstructive pulmonary disease patients die from? Amultiple cause coding analysis

“…However, v10% of deaths certified by doctors in England and Wales include information from a post mortem [6] and this may lead to some inaccuracies in the certified cause of death. Studies of death certificates suggest that a label of asthma may be preferentially applied to females with COPD and that some asthma deaths are recorded as COPD and vice versa [16,17]. Because of this and variations in physician preferences for the various COPD codes, the current authors chose to analyse OLD comprising all COPD and asthma codes.…”

Psychological, social and health behaviour risk factors for deaths certified as asthma: a national case-control study

“…1 2 Nevertheless, recent confidential enquiries still suggest that many of these premature deaths may be preventable. [3][4][5][6][7][8] Previous case-control studies and audits of asthma deaths have suggested that risk factors fall into four main categories: (1) severity of the disease; (2) medical care factors (both in terms of the nature of the health care system and the management of the mortal event) 3 5 6 8-12 ; (3) health behaviour (adherence to management) 3 5-8 10 12 ; and (4) adverse psychosocial factors. 3-6 8 10 13 If psychosocial and health behaviour factors are important, this may offer opportunities for prevention, particularly as medical management continues to improve.…”