Death Certification Errors and the Effect on Mortality Statistics.

OBJECTIVE: Errors in cause and manner of death on death certificates are common and affect families, mortality statistics, and public health research. The primary objective of this study was to characterize errors in the cause and manner of death on death certificates completed by non-Medical Examiners. A secondary objective was to determine the effects of errors on national mortality statistics. METHODS: We retrospectively compared 601 death certificates completed between July 1, 2015, and January 31, 2016, from the Vermont Electronic Death Registration System with clinical summaries from medical records. Medical Examiners, blinded to original certificates, reviewed summaries, generated mock certificates, and compared mock certificates with original certificates. They then graded errors using a scale from 1 to 4 (higher numbers indicated increased impact on interpretation of the cause) to determine the prevalence of minor and major errors. They also compared International Classification of Diseases, 10th Revision (ICD-10) codes on original certificates with those on mock certificates. RESULTS: Of 601 original death certificates, 319 (53%) had errors; 305 (51%) had major errors; and 59 (10%) had minor errors. We found no significant differences by certifier type (physician vs nonphysician). We did find significant differences in major errors in place of death ( P < .001). Certificates for deaths occurring in hospitals were more likely to have major errors than certificates for deaths occurring at a private residence (59% vs 39%, P < .001). A total of 580 (93%) death certificates had a change in ICD-10 codes between the original and mock certificates, of which 348 (60%) had a change in the underlying cause-of-death code. CONCLUSIONS: Error rates on death certificates in Vermont are high and extend to ICD-10 coding, thereby affecting national mortality statistics. Surveillance and certifier education must expand beyond local and state efforts. Simplifying and standardizing underlying literal text for cause of death may improve accuracy, decrease coding errors, and improve national mortality statistics.

Access to Care in Vermont: Factors Linked With Time to Chemotherapy for Women With Breast Cancer-A Retrospective Cohort Study.

PURPOSE: In the rural United States, there are multiple potential barriers to the timely initiation of chemotherapy. The goal of this study was to identify factors associated with delays in the time from initial diagnosis to first systemic therapy (TTC) among women with breast cancer in Vermont. METHODS: Using data from the Vermont Cancer Registry, we explored TTC for 702 female Vermont residents diagnosed with stage I to III breast cancer between 2006 and 2010 who received adjuvant chemotherapy. Multivariable linear regression was used to evaluate the associations between TTC and patient, tumor, treatment, and geographic variables. RESULTS: Mean TTC was 10.2 weeks. Longer drive time (P < .001), more invasive surgery (P = .01), and breast reconstruction (P < .001) were each associated with longer TTC. Each additional 15 minutes of drive time was associated with a 0.34-week (95% CI, 0.22 to 0.46 weeks) increase in TTC. Participants age younger than 65 years whose primary payer was Medicare (n = 27) had significantly longer average TTC, by 2.37 weeks (P = .001), compared with those with private or military insurance. There was also substantial variation in TTC across hospitals (P < .001). CONCLUSION: Most female patients with stage I to III breast cancer in Vermont are receiving adjuvant chemotherapy within the National Comprehensive Cancer Network-recommended timeframe; however, improvements remain needed for certain subgroups. Novel approaches for women with long drive times need to be developed and evaluated in the community. Variation in TTC by hospital, even after adjusting for patient, tumor, and treatment factors, also suggests opportunities for process improvement.

Changes in the sexual behavior and testosterone levels of male rats in response to daily interactions with estrus females.

Male rat sexual behavior has been intensively studied over the past 100 years, but few studies have examined how sexual behavior changes over the course of several days of interactions. In this experiment, adult male rats in the experimental group (n=12) were given daily access to estrus females for 30 min per day for 15 consecutive days while control males (n=11) did not interact with females. Ovariectomized females were induced into estrus with hormonal injections, and males interacted with a different female each day. The amount of sexual activity (mounts, intromissions, and ejaculations) was found to cycle with a period of approximately 4 days in most male rats. Additionally, blood was collected every other day following sexual interactions to assess serum testosterone levels. Testosterone was found to peak on the first day of interaction and then fell back to near the level of control rats that did not interact with females. Following the initial peak, testosterone concentrations fluctuated less in males exposed to females than in controls. Sexual activity was not found to predict testosterone concentration. We conclude that when male rats have daily sexual interactions, sexual behavior tends to show cyclic changes and testosterone is significantly elevated only on the first day of interactions.