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Assessment of relative utility of underlying vs contributory causes of death

Assessment of relative utility of underlying vs contributory causes of death
Assessment of relative utility of underlying vs contributory causes of death

Importance: In etiological research, investigators using death certificate data have traditionally extracted underlying cause of mortality alone. With multimorbidity being increasingly common, more than one condition is often compatible with the manner of death. Using contributory cause plus underlying cause would also have some analytical advantages, but their combined utility is largely untested. 

Objective: To compare the relative utility of cause of death data extracted from the underlying cause field vs any location on the death certificate (underlying and contributing combined). 

Design, Setting, and Participants: This study compares the association of 3 known risk factors (cigarette smoking, low educational attainment, and hypertension) with health outcomes based on where cause of death data appears on the death certificate in 2 prospective cohort study collaborations (UK Biobank [N = 502 655] and the Health Survey for England [15 studies] and the Scottish Health Surveys [3 studies] [HSE-SHS; N = 193 873]). Data were collected in UK Biobank from March 2006 to October 2010 and in HSE-SHS from January 1994 to December 2008. Data analysis began in June 2018 and concluded in June 2019. 

Main Outcomes and Measures: Death from cardiovascular disease, cancer, dementia, and injury. For each risk factor-mortality end point combination, a ratio of hazard ratios (RHR) was computed by dividing the effect estimate for the underlying cause by the effect estimate for any mention. 

Results: In UK Biobank, there were 14 421 deaths (2.9%) during a mean (SD) of 6.99 (1.03) years of follow up; in HSE-SHS, there were 21 314 deaths (11.0%) during a mean (SD) of 9.61 (4.44) years of mortality surveillance. Established associations of risk factors with death outcomes were essentially the same irrespective of placement of cause on the death certificate. Results from each study were mutually supportive. For having ever smoked cigarettes (vs never having smoked) in the UK Biobank, the RHR for cardiovascular disease was 0.98 (95% CI, 0.87-1.10; P value for difference = .69); for cancer, the RHR was 0.99 (95% CI, 0.93-1.05; P value for difference = .69). In the HSE-SHS, the RHR for cardiovascular disease was 0.94 (95% CI, 0.87-1.01; P value for difference = .09); for cancer, it was 1.01 (95% CI, 0.94-1.10; P value for difference = .75). 

Conclusions and Relevance: Risk factor-end point associations were not sensitive to the placement of data on the death certificate. This has implications for the examination of the association of risk factors with causes of death where there may be too few events to compute reliable effect estimates based on the underlying field alone.

1-11
Batty, G. David
894f5dad-375f-40b6-8936-d9143b49f169
Gale, Catharine R.
5bb2abb3-7b53-42d6-8aa7-817e193140c8
Kivimäki, Mika
a5788d83-a59c-477e-9ae9-8b7896ed098a
Bell, Steven
1836243e-c0b8-4b2f-a549-56ae40259806
Batty, G. David
894f5dad-375f-40b6-8936-d9143b49f169
Gale, Catharine R.
5bb2abb3-7b53-42d6-8aa7-817e193140c8
Kivimäki, Mika
a5788d83-a59c-477e-9ae9-8b7896ed098a
Bell, Steven
1836243e-c0b8-4b2f-a549-56ae40259806

Batty, G. David, Gale, Catharine R., Kivimäki, Mika and Bell, Steven (2019) Assessment of relative utility of underlying vs contributory causes of death. JAMA Network Open, 2 (7), 1-11, [e198024]. (doi:10.1001/jamanetworkopen.2019.8024).

Record type: Article

Abstract

Importance: In etiological research, investigators using death certificate data have traditionally extracted underlying cause of mortality alone. With multimorbidity being increasingly common, more than one condition is often compatible with the manner of death. Using contributory cause plus underlying cause would also have some analytical advantages, but their combined utility is largely untested. 

Objective: To compare the relative utility of cause of death data extracted from the underlying cause field vs any location on the death certificate (underlying and contributing combined). 

Design, Setting, and Participants: This study compares the association of 3 known risk factors (cigarette smoking, low educational attainment, and hypertension) with health outcomes based on where cause of death data appears on the death certificate in 2 prospective cohort study collaborations (UK Biobank [N = 502 655] and the Health Survey for England [15 studies] and the Scottish Health Surveys [3 studies] [HSE-SHS; N = 193 873]). Data were collected in UK Biobank from March 2006 to October 2010 and in HSE-SHS from January 1994 to December 2008. Data analysis began in June 2018 and concluded in June 2019. 

Main Outcomes and Measures: Death from cardiovascular disease, cancer, dementia, and injury. For each risk factor-mortality end point combination, a ratio of hazard ratios (RHR) was computed by dividing the effect estimate for the underlying cause by the effect estimate for any mention. 

Results: In UK Biobank, there were 14 421 deaths (2.9%) during a mean (SD) of 6.99 (1.03) years of follow up; in HSE-SHS, there were 21 314 deaths (11.0%) during a mean (SD) of 9.61 (4.44) years of mortality surveillance. Established associations of risk factors with death outcomes were essentially the same irrespective of placement of cause on the death certificate. Results from each study were mutually supportive. For having ever smoked cigarettes (vs never having smoked) in the UK Biobank, the RHR for cardiovascular disease was 0.98 (95% CI, 0.87-1.10; P value for difference = .69); for cancer, the RHR was 0.99 (95% CI, 0.93-1.05; P value for difference = .69). In the HSE-SHS, the RHR for cardiovascular disease was 0.94 (95% CI, 0.87-1.01; P value for difference = .09); for cancer, it was 1.01 (95% CI, 0.94-1.10; P value for difference = .75). 

Conclusions and Relevance: Risk factor-end point associations were not sensitive to the placement of data on the death certificate. This has implications for the examination of the association of risk factors with causes of death where there may be too few events to compute reliable effect estimates based on the underlying field alone.

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More information

Accepted/In Press date: 5 June 2019
e-pub ahead of print date: 31 July 2019

Identifiers

Local EPrints ID: 433733
URI: http://eprints.soton.ac.uk/id/eprint/433733
PURE UUID: 6eceb748-6965-4a4a-ba83-19da8a5846f0
ORCID for Catharine R. Gale: ORCID iD orcid.org/0000-0002-3361-8638

Catalogue record

Date deposited: 03 Sep 2019 16:30
Last modified: 18 Feb 2021 16:45

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