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Abstract |
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Methods Annual age-specific and age-adjusted pulmonary embolism mortality rates for US residents during 19791996 were compiled from the US National Center for Health Statistics web site. These data were analysed for mortality contrasts and trends.
Results For all racial-gender groups, age-adjusted mortality declined throughout the period. The greatest rate of decline was found among black men, followed by (in decreasing order) black women, white men, other men, white women, and other women. In 1996, the previously observed demographic contrasts of blacks experiencing the highest pulmonary embolism mortality, followed by whites and then others, and the male rate being higher than the female one were still present despite this decline. Age-specific mortality from pulmonary embolism in the US during 1996 also mirrored that reported for the 1970s, with mortality increasing during the life span (the risk of death doubling with each decade of life). Specifically, the annual age-adjusted pulmonary embolism mortality rate in 1996 for white men was 2.4 per 100 000 persons; white women, 2.3 per 100 000 persons; black men, 6.0 per 100 000 persons; black women, 4.8 per 100 000 persons; non-black non-white men, 1.0 per 100 000 persons; and non-black non-white women, 0.7 per 100 000 persons.
Conclusions Mortality from pulmonary embolism in the US declined significantly during 19791996. Several demographic contrasts, particularly an excess among men, continue to exist.
Keywords Mortality, pulmonary embolism, cardiovascular disease, pulmonary circulation
Accepted 18 November 1999
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Introduction |
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Methods |
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The annual age-specific mortality rates in the US by gender and race were then generated using the CDCP Wonder System for 1979 and 1996. The number of deaths that each age-specific rate was based upon and the corresponding population were also recorded. The percentage changes from 1979 to 1996 in the age-gender-specific rates among whites were then calculated. Standard z-tests were used to calculate the statistical significance of these percentages.
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Results |
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Discussion |
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The first issue to be considered with regard to these data is their validity. There are little data on the reliability of death certificate statements of cause with regard to pulmonary embolism. This situation has remained unchanged for the past decade. Hence, it is difficult to know whether the mortality patterns observed reflect the occurrence of pulmonary embolism. Indeed, Proctor and Greenfield5 reported in 1997 that a considerable number of pulmonary embolism cases were not properly coded to the correct ICD-9 rubric (415.1). Whether this finding applied to mortality data was not reported. Previous reports of both Lilienfeld et al.2 and Soskolne et al.3 suggested that pulmonary embolism mortality in the US and in Canada from the early 1960s to the middle 1980s increased substantially. This result would be indicative of increased incidence of disease, improved recognition of disease, or both. More recent population-based incidence studies have suggested that the occurrence of the disease has declined.4,6
Population-based data on the incidence of pulmonary embolism in the US have been developed in relatively rural populations (Silverstein et al.6 for Olmsted County, Minnesota and Anderson et al.7 for Worchester, Massachusetts), in specific high-risk populations (Tuttle-Newhall et al.8 in North Carolina trauma patients), and among Medicare beneficiaries (Siddique et al.4,9). Silverstein et al.6 examined pulmonary embolism incidence trends in Olmsted County, Minnesota and found that they had declined between 1976 and 1990. Siddique et al.4,9 observed declines in mortality in the white Medicare population during 19841991, though not among blacks. The other population-based studies did not examine temporal trends in pulmonary embolism incidence. Cohen et al.10 relied upon autopsy data in the UK to conclude that the introduction of prophylactic measures and changes in hospital practice had reduced the prevalence of pulmonary embolism at autopsy in the UK between 1976 and 1990. Our observations of the changes in US pulmonary embolism mortality would be consistent with those of other investigators in the US and elsewhere.
The elevated death rate from pulmonary embolism among blacks was previously observed by Lilienfeld et al.2 This excess has been present in pulmonary embolism mortality in the US since the early 1960s. Kniffen et al.11 reported that among Medicare beneficiaries between 1986 and 1989, blacks were at elevated risk of the disease compared with whites. However, they did not examine any temporal data. Siddique et al.4,9 reported that between 1984 and 1991, white Medicare beneficiaries experienced a 1516% decline in pulmonary embolism mortality. Black beneficiaries did not experience such a decline, in part as a result of decreased survival. These findings appear to be at odds with our own, in which blacks experienced the greatest rate of decline in pulmonary embolism mortality. We do not have an explanation for these differences except to note that Siddique et al. observed their population (a sample of the US elderly population) for a shorter time period. Population-based incidence studies in settings with black populations present might provide insight into the degree to which pulmonary embolism incidence and mortality is changing in the US black population compared with the white one. They would also facilitate our understanding of the lower risk of death experienced by other people. Piccioli et al.12 have noted that the clinical spectrum associated with pulmonary embolism in a registry setting is different from that based on randomized clinical trials. Population-based studies would compliment existing knowledge gained from randomized clinical trials and place these mortality patterns into perspective.
The decline in pulmonary embolism mortality among men was greater (as reflected by the slope in the regression model of the decline) than among women regardless of race. Other investigators (such as Kniffen et al.11 have observed that among Medicare beneficiaries, men experience pulmonary embolism at a greater rate than do women. Assuming no difference in survivorship, men would be expected to have greater mortality from the disease. The reason for men to experience a greater decline in mortality than women is not clear. Given that most of the decline occurred in the elderly, one might focus on differences between elderly men and women in the US during the past two decades. One difference is that elderly women have been increasingly using post-menopausal oestrogens. Although such preparations are thought to reduce the risk of myocardial infarction, it is not known if they have any impact on pulmonary embolism incidence or mortality. The Women's Health Initiative studies now in progress should clarify this issue. There may of course be other reasons for the decline to be greater for men than for women.
In summary, we observed a decline in pulmonary embolism mortality in the US population during 19791996. The decline was greatest among blacks, among men, and among the elderly. The reasons for this decline are not established. In 1996, blacks had an elevated risk of death from pulmonary embolism compared with whites or other individuals. Similarly, men had an elevated risk of mortality compared with women. These data suggest that there may have been favourable changes in the frequency of pulmonary embolism in the population. However, population-based incidence studies are needed to further our understanding of this common clinical condition.
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Notes |
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References |
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2 Lilienfeld DE, Chan E, Ehland J, Godbold JH, Landrigan PJ, Marsh G. Mortality from pulmonary embolism in the United States: 19621984. Chest 1990;98:106772.[Abstract]
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Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ 3rd. Trends in the incidence of deep vein thrombosis and pulmonary embolism: 25-year population-based study. Arch Intern Med 1998;158:58593.
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8 Tuttle-Newhall JE, Rutledge R, Hultman CS, Fakhry SM. Statewide, population-based, time-series analysis of the frequency and outcome of pulmonary embolus in 318 554 trauma patients. J Trauma 1997; 42:9099.[ISI][Medline]
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