The Use of ICD-9-CM Coding to Identify COVID-19 Diagnoses and Determine Risk Factors for 30-Day Death Rate in Hospitalized Patients in Italy: Retrospective Study.

BACKGROUND: In Italy, it has been difficult to accurately quantify hospital admissions of patients with a COVID-19 diagnosis using the Hospital Information System (HIS), mainly due to the heterogeneity of codes used in the hospital discharge records during different waves of the COVID-19 pandemic. OBJECTIVE: The objective of this study was to define a specific combination of codes to identify the COVID-19 hospitalizations within the HIS and to investigate the risk factors associated with mortality due to COVID-19 among patients admitted to Italian hospitals in 2020. METHODS: A retrospective study was conducted using the hospital discharge records, provided by more than 1300 public and private Italian hospitals. Inpatient hospitalizations were detected by implementing an algorithm based on specific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code combinations. Hospitalizations were analyzed by different clinical presentations associated with COVID-19 diagnoses. In addition, 2 multivariable Cox regression models were performed among patients hospitalized "due to COVID-19" from January 1 to December 31, 2020, to investigate potential risk factors associated with 30-day death and the temporal changes over the course of the pandemic; in particular, the 30-day death rates during the first and the second waves were analyzed across 3 main geographical areas (North, Center, and South and Islands) and by discharge wards (ordinary and intensive care). RESULTS: We identified a total of 325,810 hospitalizations with COVID-19-related diagnosis codes. Among these, 73.4% (n=239,114) were classified as "due to COVID-19," 14.5% (n=47,416) as "SARS-CoV-2 positive, but not due to COVID-19," and 12.1% (n=39,280) as "suspected COVID-19" hospitalizations. The cohort of patients hospitalized "due to COVID-19" included 205,048 patients, with a median age of 72 years and a higher prevalence of male patients (n=124,181, 60.6%). The overall 30-day death rate among hospitalized patients due to COVID-19 was 9.9 per 1000 person-days. Mortality was lower for women (hazard ratio [HR]=0.83; P<.001) and for patients coming from high migration pressure countries, especially Northern Africans (HR=0.65; P<.001) and Central and Eastern Europeans (HR=0.66; P<.001), compared to patients coming from Italy and high-income countries. In the southern regions and the Islands, mortality was higher compared to the northern regions (HR=1.17; P<.001), especially during the second wave of COVID-19 among patients with a transfer to intensive care units (HR=2.52; P<.001). CONCLUSIONS: To our knowledge, the algorithm is the first attempt to define, at a national level, selection criteria for identifying COVID-19 hospitalizations within the HIS. The implemented algorithm will be used to monitor the pandemic over time, and the patients selected in 2020 will be followed up in the next years to assess the long-term effects of COVID-19.

Suicide mortality in Italy during the first year of the COVID-19 pandemic.

BACKGROUND: Italy was severely hit by COVID-19 during 2020 and great concern about the possible increase of suicide rates in the population has arisen since early pandemic phases. Analyses limited to March-April have shown a drop in suicides in both sexes. This study aims to analyze suicide mortality in Italy during the whole 2020 making comparisons with the pre-pandemic period 2015-19, by sex, age and geographic area. METHODS: Official cause-of-death data with national coverage were used to analyze suicide mortality by sex, month, age class and geographic area in the population aged ≥10 years (54,595,179). The monthly number of suicide deaths in 2020 was compared to the average number in 2015-19. Age-specific and age-adjusted suicide rates in 2020 and in 2015-19 were compared using rate-ratios with 95 % confidence intervals. RESULTS: Compared to 2015-19 a non-significant reduction of the overall suicide rate was observed during 2020, both in males (-3 %) and females (-7 %). Suicide rates non-significantly decreased in most age groups; an increase, although not statistically significant, was found among males aged ≥75 years and females aged ≥85 years. Suicide deaths reduced mainly in Central-Southern areas and the Islands, while they slightly increased in the North especially among males. LIMITATIONS: Study limitations include accuracy of death certification and the relatively brief observation period. CONCLUSIONS: The study contributes to the analysis of early effects of the COVID-19 pandemic on suicide mortality in the whole population highlighting sex, age and territorial differences and suggesting to monitor possible increases in a longer observation period.

Epidemiologic transition of lung cancer mortality in Italy by sex, province of residence and birth cohort (1920-1929 to 1960-1969).

Space-time analysis of mortality risk is useful to evaluate the epidemiologic transitions at the subnational level. In our study, we analysed the death certificate records for lung cancer in Italy in 1995-2016, obtained from the Italian National Institute of Statistics. Our objective was to investigate the spatial-temporal evolution of lung cancer mortality by sex and province of residence (n = 107) using the birth cohort as relevant time axis. We built Bayesian space-time models with space-time interactions. Among males (n = 554 829), mortality peaked in the 1920-1929 cohort, followed by a generalised decline. Among females (n = 158 619), we found novel original evidence for a peak in the 1955-1964 cohort, equivalent to a 35-year delay, with a downward trend being observed thereafter. Over time, the documented north-south decreasing mortality gradient has been replaced by a west-east decreasing gradient. Naples has become the province at highest risk in Italy, both among males and females. This pattern is consistent with an epidemiologic transition of risk factors for lung cancer to the south-west of the country and raises concern, because 5-year age-standardised net survival from the disease in this geographic area is lower than in northern and central Italy. The variability of mortality rates among provinces has changed over time, with an increasing homogeneity for males and an opposite trend for females in the more recent birth cohorts. These unprecedented observations provide evidence for a profound spatio-temporal transition of lung cancer mortality in Italy.

Frailty at death: An examination of multiple causes of death in four low mortality countries in 2017.

BACKGROUND: The increasing prevalence of frailty in aging populations represents a major social and public health challenge which warrants a better understanding of the contribution of frailty to the morbid process. OBJECTIVE: To examine frailty-related mortality as reported on the death certificate in France, Italy, Spain and the United States in 2017. METHODS: We identify frailty at death for the population aged 50 years and over in France, Italy, Spain and the United States. We estimate the proportions of deaths by sex, age group and country with specific frailty-related ICD-codes on the death certificate 1) as the underlying cause of death (UC), 2) elsewhere in Part I (sequence of diseases or conditions or events leading directly to death), and 3) anywhere in Part II (conditions that do not belong in Part I but whose presence contributed to death). RESULTS: The age-standardized proportion of deaths with frailty at ages 50 and over is highest in Italy (25.0%), then in France (24.1%) and Spain (17.3%), and lowest in the United States (14.0%). Cross-country differences are smaller when frailty-related codes are either the underlying cause of the death or reported in Part II. Frailty-related mortality increases with age and is higher among females than males. Dementia is the most frequently reported frailty-related code. CONCLUSIONS: Notable cross-country differences were found in the prevalence and the type of frailty-related symptoms at death even after adjusting for differential age distributions.

Mortality rates from asbestos-related diseases in Italy during the first year of the COVID-19 pandemic.

Background and aim: Patients with interstitial lung diseases, including asbestosis, showed high susceptibility to the SARS-CoV-2 virus and a high risk of severe COVID-19 symptoms. Italy, highly impacted by asbestos-related diseases, in 2020 was among the European countries with the highest number of COVID-19 cases. The mortality related to malignant mesotheliomas and asbestosis in 2020 and its relationship with COVID-19 in Italy are investigated. Methods: All death certificates involving malignant mesotheliomas or asbestosis in 2010-2020 and those involving COVID-19 in 2020 were retrieved from the National Registry of Causes of Death. Annual mortality rates and rate ratios (RRs) of 2020 and 2010-2014 compared to 2015-2019 were calculated. The association between malignant pleural mesothelioma (MPM) and asbestosis with COVID-19 in deceased adults ≥80 years old was evaluated through a logistic regression analysis (odds ratios: ORs), using MPM and asbestosis deaths COVID-19-free as the reference group. The hospitalization for asbestosis in 2010-2020, based on National Hospital Discharge Database, was analyzed. Results: In 2020, 746,343 people died; out of them, 1,348 involved MPM and 286 involved asbestosis. Compared to the period 2015-2019, the mortality involving the two diseases decreased in age groups below 80 years; meanwhile, an increasing trend was observed in subjects aged 80 years and older, with a relative mortality risks of 1.10 for MPM and 1.17 for asbestosis. In subjects aged ≥80 years, deaths with COVID-19 were less likely to have MPM in both genders (men: OR = 0.22; women: OR = 0.44), while no departure was observed for asbestosis. A decrease in hospitalization in 2020 with respect to those in 2010-2019 in all age groups, both considering asbestosis as the primary or secondary diagnosis, was observed. Conclusions: The increasing mortality involving asbestosis and, even if of slight entity, MPM, observed in people aged over 80 years during the 1st year of the COVID-19 pandemic, aligned in part with the previous temporal trend, could be due to several factors. Although no positive association with COVID-19 mortality was observed, the decrease in hospitalizations for asbestosis among individuals aged over 80 years, coupled with the increase in deaths, highlights the importance of enhancing home-based assistance during the pandemic periods for vulnerable patients with asbestos-related conditions.

Increased kidney disease mortality among people with AIDS versus the general population: a population-based cohort study in Italy, 2006-2018.

OBJECTIVES: This study aimed to assess whether an excess mortality related to kidney and other urinary tract diseases exists among Italian people with AIDS (PWA), as compared with the general population without AIDS (non-PWA). DESIGN: Population-based, retrospective cohort study. SETTING AND PARTICIPANTS: We conducted a nationwide study including 9481 Italian PWA, aged 15-74 years, reported to the National AIDS Registry between 2006 and 2018. METHODS: Vital status and causes of death were retrieved by record linkage with the National Register of Causes of Death up to 2018. Excess mortality for PWA versus non-PWA was estimated through sex-standardised and age-standardised mortality ratios (SMRs) with corresponding 95% CIs. RESULTS: Among 2613 deceased PWA, 262 (10.0%) reported at least one urinary tract disease at death, including 254 (9.7%) non-cancer diseases-mostly renal failures (225 cases, 8.6%)-and 9 cancers (0.3%). The overall SMR for non-cancer urinary tract diseases was 15.3 (95% CI 13.4 to 17.3) with statistically significant SMRs for acute (SMR=22.3, 95% CI 18.0 to 27.4), chronic (SMR=8.4, 95% CI 6.0 to 11.3), and unspecified renal failure (SMR=13.8, 95% CI 11.2 to 16.8). No statistically significant excess mortality was detected for urinary tract cancers (SMR=1.7, 95% CI 0.8 to 3.3). The SMRs were particularly elevated among PWA aged <50 years, injecting drug users, or those with the first HIV-positive test >6 months before AIDS diagnosis. CONCLUSIONS: The excess mortality related to non-cancer kidney and other urinary tract diseases reported among PWA highlights the importance of implementing the recommendation for screening, diagnosis and management of such conditions among this population.

Mortality Related to Chronic Obstructive Pulmonary Disease during the COVID-19 Pandemic: An Analysis of Multiple Causes of Death through Different Epidemic Waves in Veneto, Italy.

Mortality related to chronic obstructive pulmonary disease (COPD) during the COVID-19 pandemic is possibly underestimated by sparse available data. The study aimed to assess the impact of the pandemic on COPD-related mortality by means of time series analyses of causes of death data. We analyzed the death certificates of residents in Veneto (Italy) aged ≥40 years from 2008 to 2020. The age-standardized rates were computed for COPD as the underlying cause of death (UCOD) and as any mention in death certificates (multiple cause of death-MCOD). The annual percent change (APC) in the rates was estimated for the pre-pandemic period. Excess COPD-related mortality in 2020 was estimated by means of Seasonal Autoregressive Integrated Moving Average models. Overall, COPD was mentioned in 7.2% (43,780) of all deaths. From 2008 to 2019, the APC for COPD-related mortality was -4.9% (95% CI -5.5%, -4.2%) in men and -3.1% in women (95% CI -3.8%, -2.5%). In 2020 compared to the 2018-2019 average, the number of deaths from COPD (UCOD) declined by 8%, while COPD-related deaths (MCOD) increased by 14% (95% CI 10-18%), with peaks corresponding to the COVID-19 epidemic waves. Time series analyses confirmed that in 2020, COPD-related mortality increased by 16%. Patients with COPD experienced significant excess mortality during the first year of the pandemic. The decline in COPD mortality as the UCOD is explained by COVID-19 acting as a competing cause, highlighting how an MCOD approach is needed.

Mortality of people with AIDS in Italy: comparison of AIDS surveillance and multiple cause-of-death registries.

AIMS: To assess whether the use of multiple cause-of-death data could improve reporting of AIDS mortality in Italy. METHOD: Population-based, record-linkage study, on 3,975,431 deaths recorded in the National Registry of Causes of Death (RCoD) and 4,530 deaths recorded in the National AIDS Registry (RAIDS), during 2006-2012. RESULTS: The record-linkage identified 3,646 AIDS-related deaths present in both registries, 884 deaths in the RAIDS without mention of HIV/AIDS in the RCoD, and 3,796 deaths in the RCoD with mention of HIV/AIDS that were not present in the RAIDS. In the latter, in-depth analysis of multiple cause-of-death allowed the identification of 1,484 deaths that were AIDS-related. On these results, we estimated 6,014 deceased people with AIDS. Of them, 14.7% (884) were not present in the RCoD and 24.7% (1,484) derived from the RCoD only. CONCLUSIONS: The integration of different nationwide registries allowed a more comprehensive estimate of the impact of AIDS-associated mortality in Italy.

Variation in Cause-Specific Mortality Rates in Italy during the First Wave of the COVID-19 Pandemic: A Study Based on Nationwide Data.

Italy was a country severely hit by the first coronavirus disease 2019 (COVID-19) pandemic wave in early 2020. Mortality studies have focused on the overall excess mortality observed during the pandemic. This paper investigates the cause-specific mortality in Italy from March 2020 to April 2020 and the variation in mortality rates compared with those in 2015-2019 regarding sex, age, and epidemic area. Causes of death were derived from the national cause-of-death register. COVID-19 was the leading cause of death among males and the second leading cause among females. Chronic diseases, such as diabetes and hypertensive, ischemic heart, and cerebrovascular diseases, with decreasing or stable mortality rates in 2015-2019, showed a reversal in the mortality trend. Moreover, mortality due to pneumonia and influenza increased. No increase in neoplasm mortality was observed. Among external causes of death, mortality increased for accidental falls but reduced for transport accidents and suicide. Mortality from causes other than COVID-19 increased similarly in both genders and more at ages 65 years or above. Compared with other areas in Italy, the Lombardy region showed the largest excess in mortality for all leading causes. Underdiagnosis of COVID-19 at the beginning of the pandemic may, to some extent, explain the mortality increase for some causes of death, especially pneumonia and other respiratory diseases.

Evolution of Pathology Patterns in Persons Who Died From COVID-19 in Italy: A National Study Based on Death Certificates.

Background: In Italy, during the first epidemic wave of 2020, the peak of coronavirus disease 2019 (COVID-19) mortality was reached at the end of March. Afterward, a progressive reduction was observed until much lower figures were reached during the summer, resulting from the contained circulation of SARS-CoV-2. This study aimed to determine if and how the pathological patterns of the individuals deceased from COVID-19 changed during the phases of epidemic waves in terms of: (i) main cause of death, (ii) comorbidities, and (iii) complications related to death. Methods: Death certificates of persons who died and tested positive for SARS-CoV-2, provided by the National Surveillance system, were coded according to ICD rev10. Deaths due to COVID-19 were defined as those in which COVID-19 was the underlying cause of death. Results: The percentage of COVID-19 deaths varied over time. It decreased in the downward phase of the epidemic curve (76.6 vs. 88.7%). In February-April 2020, hypertensive heart disease was mentioned as a comorbidity in 18.5% of death certificates, followed by diabetes (15.9% of cases), ischemic heart disease (13.1%), and neoplasms (12.1%). In May-September, the most frequent comorbidity was neoplasms (17.3% of cases), followed by hypertensive heart disease (14.9%), diabetes (14.8%), and dementia/Alzheimer's disease (11.9%). The most mentioned complications in both periods were pneumonia and respiratory failure with a frequency far higher than any other condition (78.4% in February-April 2020 and 63.7% in May-September 2020). Discussion: The age of patients dying from COVID-19 and their disease burden increased in the May-September 2020 period. A more serious disease burden was observed in this period, with a significantly higher frequency of chronic pathologies. Our study suggests better control of the virus' lethality in the second phase of the epidemic, when the health system was less burdened. Moreover, COVID-19 care protocols had been created in hospitals, and knowledge about the diagnosis and treatment of COVID-19 had improved, potentially leading to more accurate diagnosis and better treatment. All these factors may have improved survival in patients with COVID-19 and led to a shift in mortality to older, more vulnerable, and complex patients.

Multi-morbidity and frailty at death: A new classification of death records for an ageing world.

Mortality statistics based on underlying cause of death are challenged by increased life expectancy and the growing share of population reaching ages associated with frequent multi-morbidity (with death likely resulting from interactions between multiple diseases). We provide a novel way of analysing causes of death: accounting for all causes mentioned on death certificates and summarizing this information along two dimensions emblematic of ageing populations-multi-morbidity and frailty. We implement this classification for all deaths at ages 50+ in Italy in 2014. Multi-morbid processes represent the majority of deaths, rising from 43 per cent at ages 50-54 to 63 per cent at ages 85-89. Multi-morbidity at death is more frequent among males, although age patterns are identical for both sexes. About one in four deaths involves frailty symptoms, rising to 45 per cent at ages 95+. Mortality rates involving frailty are very similar for both sexes. Supplementary material is available for this article at: https://doi.org/10.1080/00324728.2020.1820558.

The Role of COVID-19 in the Death of SARS-CoV-2-Positive Patients: A Study Based on Death Certificates.

Background: Death certificates are considered the most reliable source of information to compare cause-specific mortality across countries. The aim of the present study was to examine death certificates of persons who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to (a) quantify the number of deaths directly caused by coronavirus 2019 (COVID-19); (b) estimate the most common complications leading to death; and (c) identify the most common comorbidities. Methods: Death certificates of persons who tested positive for SARS-CoV-2 provided to the National Surveillance system were coded according to the 10th edition of the International Classification of Diseases. Deaths due to COVID-19 were defined as those in which COVID-19 was the underlying cause of death. Complications were defined as those conditions reported as originating from COVID-19, and comorbidities were conditions independent of COVID-19. Results: A total of 5311 death certificates of persons dying in March through May 2020 were analysed (16.7% of total deaths). COVID-19 was the underlying cause of death in 88% of cases. Pneumonia and respiratory failure were the most common complications, being identified in 78% and 54% of certificates, respectively. Other complications, including shock, respiratory distress and pulmonary oedema, and heart complications demonstrated a low prevalence, but they were more commonly observed in the 30-59 years age group. Comorbidities were reported in 72% of certificates, with little variation by age and gender. The most common comorbidities were hypertensive heart disease, diabetes, ischaemic heart disease, and neoplasms. Neoplasms and obesity were the main comorbidities among younger people. Discussion: In most persons dying after testing positive for SARS-CoV-2, COVID-19 was the cause directly leading to death. In a large proportion of death certificates, no comorbidities were reported, suggesting that this condition can be fatal in healthy persons. Respiratory complications were common, but non-respiratory complications were also observed.

Logical Rules and a Preliminary Prototype for Translating Mortality Coding Rules from ICD-10 to ICD-11.

Iris is a system for coding multiple causes of death in ICD-10 and for the selection of the underlying cause of death, based on a knowledge base composed by a large number of rules. With the adoption of ICD-11, those rules need translation to ICD-11. A pre-project has been carried out to evaluate feasibility of transition to ICD-11, which included the analysis of the logical meta-rules needed for rule translation and development of a prototype support system for the expert that will translate the coding rules.

Fatal anaphylaxis in Italy: Analysis of cause-of-death national data, 2004-2016.

BACKGROUND: Epidemiological data on fatal anaphylaxis are underestimated worldwide. Few Italian data do exist. The aims of the study are to determine the anaphylaxis mortality rate in Italy and its associations with demographic characteristics (gender, age, and geographical distribution), and to investigate which are the most common triggers of fatal anaphylaxis. MATERIAL AND METHODS: This is a descriptive study analyzing data reported to the National Register of Causes of Death database and managed by the Italian National Institute of Statistics for the years 2004-2016. An analytical method was developed to identify all the ICD-10 codes related to anaphylaxis deaths, which were divided into two classes: "Definite anaphylaxis deaths" and "Possible anaphylaxis deaths." RESULTS: From 2004 through 2016, 392 definite anaphylaxis deaths and 220 possible anaphylaxis deaths were recorded. The average mortality rate for definite anaphylaxis, from 2004 to 2016, was 0.51 per million population per year. Definite fatal anaphylaxis was mostly due to the use of medications (73.7%), followed by unspecified causes (20.7%) and hymenoptera stings (5.6%). Concerning possible anaphylaxis deaths, the most common cause was venom-stinging insect (51.4%). We did not find any data on food fatal anaphylaxis. Unspecified anaphylaxis accounted for 21%-28% of all cases, underlining the difficulty in accurately ascertaining the causes of fatal anaphylaxis and therefore in assigning the proper ICD-10 code. CONCLUSION: This is the first study of anaphylaxis-related mortality coming from an official database of the whole Italian population. However, the actual number of deaths by anaphylaxis, and their related triggers, is probably underreported, mostly due to limitations of the current recording system, and to a poor allergy education. Corrective actions should be undertaken for the benefit of the Health System.

[Impact of the implementation of ICD-10 2016 version and Iris software on mortality statistics in Italy]. / Impatto dell'implementazione della versione 2016 dell'ICD-10 e del software Iris sulle statistiche di mortalità in Italia.

OBJECTIVES: to assess the impact of coding causes of death with the ICD-10 2016 version and the software Iris on Italian official statistics on mortality. DESIGN: coding of a sample of death certificates with two different coding systems (bridge coding). SETTING AND PARTICIPANTS: a sample of 63,525 deaths occurred throughout 2015 among people aged over one year, already coded using the ICD-10 2009 version and the Mortality Medical Data System (MMDS) software, was re-coded through the ICD-10 2016 version and the Iris software. MAIN OUTCOME MEASURES: the transition matrix between the two coding systems was realized and the agreement percentages between the two coding systems, the comparability ratios, and the relative 95% confidence intervals were calculated. Comparability ratios have been calculated for both the underlying cause of death and the multiple causes. RESULTS: overall, 79% of deaths showed exactly the same underlying cause of death (ICD-10 code, 4 digits) in the two coding systems. On the three-digit level, the agreement was 89%; on ICD-10 chapter level, the agreement was 95%. At the chapter level, the most important changes were observed for: • certain infectious and parasitic diseases (-18% in ICD-10 2016/Iris); • diseases of the genitourinary system (-17%); • diseases of the respiratory system (+7%); • diseases of the nervous system and sense organs (+5%); • external causes of morbidity and mortality (+5%). Analyzing the multiple causes, the most important changes were observed for: • certain infectious and parasitic diseases (-19% in ICD-10 2016/Iris); • external causes of morbidity and mortality (+28%); • symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (+7%). CONCLUSION: the results are very useful to explain any change in the Italian statistics on mortality comparing 2015 with the following years.

The increase of sepsis-related mortality in Italy: a nationwide study, 2003-2015.

The true burden of sepsis is largely unknown. Conventional underlying cause of death (UCoD) statistics largely underestimates sepsis-related mortality. This study aims to analyze all the conditions mentioned in the death certificates (multiple causes of death-MCoD) to estimate the nationwide burden of sepsis-related mortality in Italy, to investigate time trends and main comorbidities in sepsis-related deaths. All death certificates mentioning sepsis from 2003 to 2015 were analyzed. Age-standardized mortality rates were calculated for sepsis as both UCoD and MCoD, by gender and broad age groups. The ratio of the age-standardized proportions of any mention of sepsis in the presence/absence of associated chronic diseases (ASPR) was computed. The number of certificates reporting sepsis increased from 18,939 in 2003 to 49,010 in 2015 (from 3 to 8% of all deaths). The increase in sepsis mortality rates was larger for UCoD (males, + 200%; females, + 175%) than for MCoD-based figures (+ 100%; + 90%); MCoD rates remained noticeably higher than UCoD rates (2015, 87.3 per 100,000 vs. 16.3 for males; 54.9 vs. 11.8 for females). The largest increase was observed among the very elderly. The association between sepsis and chronic diseases was stronger for subjects aged less than 75 years. The increased awareness within the medical community in addition to the growing susceptible elderly population and the spread of antimicrobial resistance could have contributed to the sepsis-related mortality increase. MCoD statistics could help in recognizing sepsis not only as a clinical challenge, but also as a major public health issue.

Excess mortality related to circulatory system diseases and diabetes mellitus among Italian AIDS patients vs. non-AIDS population: a population-based cohort study using the multiple causes-of-death approach.

BACKGROUND: Chronic diseases, chiefly cancers and circulatory system diseases (CSDs), have become the leading non-AIDS-related causes of death among HIV-infected people, as in the general population. After our previous report of an excess mortality for several non-AIDS-defining cancers, we now aim to assess whether people with AIDS (PWA) experience also an increased mortality for CSDs and diabetes mellitus (DM), as compared to the non-AIDS general population (non-PWA). METHODS: A nationwide, population-based, retrospective cohort study was conducted including 5285 Italians, aged 15-74 years, who were diagnosed with AIDS between 2006 and 2011. Multiple cause-of-death (MCoD) data, i.e. all conditions reported in death certificates, were retrieved through record-linkage with the National Register of Causes of Death up to 2011. Using MCoD data, sex- and age-standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated by dividing the observed number of PWA reporting a specific disease among MCoD to the expected number, estimated on the basis of mortality rates (based on MCoD) of non-PWA. RESULTS: Among 1229 deceased PWA, CSDs were mentioned in 201 (16.4%) certificates and DM in 46 (3.7%) certificates among the various causes of death. These values corresponded to a 13-fold higher mortality related to CSDs (95% CI 10.8-14.4) and DM (95% CI: 9.5-17.4) as compared to 952,019 deceased non-PWA. Among CSDs, statistically significant excess mortality emerged for hypertension (23 deaths, SMR = 6.3, 95% CI: 4.0-9.4), ischemic heart diseases (39 deaths, SMR = 6.1, 95% CI: 4.4-8.4), other forms of heart diseases (88 deaths, SMR = 13.4, 95% CI: 10.8-16.5), and cerebrovascular diseases (42 deaths, SMR = 13.4, 95% CI: 9.7-18.2). The SMRs were particularly elevated among PWA aged < 50 years and those infected through drug injection. CONCLUSIONS: The use of MCoD data disclosed the fairly high mortality excess related to several CSDs and DM among Italian PWA as compared to non-PWA. Study findings also indicate to start preventive strategies for such diseases at a younger age among AIDS patients than in the general population and with focus on drug users.

Multiple cause-of-death data among people with AIDS in Italy: a nationwide cross-sectional study.

BACKGROUND: Multiple cause-of-death (MCOD) data allow analyzing the contribution to mortality of conditions reported on the death certificate that are not selected as the underlying cause of death. Using MCOD data, this study aimed to fully describe the cause-specific mortality of people with AIDS (PWA) compared to people without AIDS. METHODS: We conducted a nationwide investigation based on death certificates of 2,515 Italian PWA and 123,224 people without AIDS who had died between 2006 and 2010. The conditions most frequently associated with PWA mortality, compared to people without AIDS, were identified using an age-standardized proportion ratio (ASPR) calculated as the ratio between the age-standardized proportion of a specific cause among PWA and the same proportion among people without AIDS. RESULTS: The most frequently reported conditions at death among PWA were infectious/parasitic diseases (52%), digestive (36%), respiratory (33%), and circulatory (32%) system diseases, and neoplasms (29%). All AIDS-defining conditions resulted highly associated (ASPR significantly greater than unity) with PWA deaths. Significant associations also emerged for leishmaniasis (ASPR = 188.0), encephalitis/myelitis/encephalomyelitis (ASPR = 14.3), dementia (ASPR = 13.1), chronic viral hepatitis (ASPR = 13.1), liver fibrosis/cirrhosis (ASPR = 4.4), pneumonia (ASPR = 4.4), anal (ASPR = 12.1) and liver (ASPR = 1.9) cancers, and Hodgkin's disease (ASPR = 3.1). CONCLUSIONS: Study findings identified the contribution of several non-AIDS-defining conditions on PWA mortality, emphasizing the need of preventive public health interventions targeting this population.