Murray Christopher J L, Kulkarni Sandeep C, Ezzati Majid
Harvard School of Public Health, Boston, MA 02115, USA.
Circulation. 2006 May 2;113(17):2071-81. doi: 10.1161/CIRCULATIONAHA.105.595777. Epub 2006 Apr 24.
Coronary heart disease (CHD) represents the largest share of cardiovascular disease in the United States, but there are conspicuous discrepancies between CHD and total cardiovascular death rates across the states, possibly due in part to variations in physician assignment of causes of death. Our aim was to identify exogenous individual- and community-level predictors of cause-of-death assignment and variability and to use these predictors to improve the comparability of CHD mortality estimates across states.
We performed a multinomial logistic regression analysis to estimate the effect of individual- and community-level factors on the likelihood of a death being certified as 1 of 3 ill-defined clusters (general atherosclerosis and unspecified heart disease, heart failure, and cardiac arrest) relative to being certified as CHD. The individual-level variables were the decedent's race, sex, age, education, and place of death; the community-level variable was the number of cardiologists per capita. We used the model to estimate state-level CHD rates that are standardized with regard to the levels of individual- and community-level determinants of cause-of-death assignment. Decedents who died in hospitals and in counties with more cardiologists per capita were more likely to be assigned to CHD than to the ill-defined categories, as were white males relative to other race-sex combinations. Adjustment for these factors resulted in substantially improved correlation between death rates for CHD and all cardiovascular causes. Increases in CHD death rates across states after adjustment for external predictors of cause-of-death assignment ranged from 2% (North Dakota) to 72% (Washington, DC); New York had a decrease (1%) in CHD death rates after adjustment. Nationally, CHD death rates increased 10% for males and 15% for females. The total number of deaths in 2001 attributed to CHD in patients over 30 years of age rose from 433,625 to 489,836 after adjustment.
Greater presence of medical knowledge at the time of death, reflected by place of death and cardiologists per capita, reduces the use of the ill-defined cardiovascular clusters. Racial and gender effects on CHD assignment may reflect disparities in access to care and quality of care. By adjusting for differentials in these parameters, a comparable and consistent set of CHD mortality estimates can be created. The role of the exogenous predictors in validity and comparability of cause-of-death statistics should be confirmed in carefully designed validation autopsy studies.
冠心病（CHD）在美国心血管疾病中占比最大，但各州冠心病死亡率与总体心血管疾病死亡率之间存在显著差异，部分原因可能是医生对死亡原因的判定存在差异。我们的目的是确定个体和社区层面导致死亡原因判定及差异的外部预测因素，并利用这些预测因素提高各州冠心病死亡率估计的可比性。
我们进行了多项逻辑回归分析，以估计个体和社区层面因素对死亡被判定为3个定义不明确的类别（一般动脉粥样硬化和未指定的心脏病、心力衰竭和心脏骤停）之一相对于被判定为冠心病的可能性的影响。个体层面的变量包括死者的种族、性别、年龄、教育程度和死亡地点；社区层面的变量是人均心脏病专家数量。我们使用该模型来估计在个体和社区层面死亡原因判定决定因素水平上进行标准化的州级冠心病发病率。在医院死亡以及所在县人均心脏病专家数量较多的死者，相对于其他种族 - 性别组合，白人男性更有可能被判定为冠心病而非定义不明确的类别。对这些因素进行调整后，冠心病死亡率与所有心血管疾病原因死亡率之间的相关性显著提高。在对死亡原因判定的外部预测因素进行调整后，各州冠心病死亡率的增幅从2%（北达科他州）到72%（华盛顿特区）不等；纽约州调整后冠心病死亡率下降了1%（1%）。在全国范围内，男性冠心病死亡率上升了10%，女性上升了15%。2001年30岁以上患者归因于冠心病的死亡总数在调整后从433,625例增加到489,836例。
死亡时医学知识的更多存在，以死亡地点和人均心脏病专家数量为体现，减少了对定义不明确的心血管类别判定的使用。种族和性别对冠心病判定的影响可能反映了医疗服务可及性和医疗质量的差异。通过对这些参数差异进行调整，可以创建一组可比且一致的冠心病死亡率估计值。在精心设计的验证尸检研究中应确认外部预测因素在死亡原因统计的有效性和可比性中的作用。
