BACKGROUND: It is generally acknowledged that conventional estimates of the potential number of life years to be gained by elimination of causes of death are too generous. This is because these estimates fail to take into account the fact that those who are saved from the cause are likely to have one or more other conditions ("competing" causes of death), which may increase their risks of dying. It is unknown to what extent this introduces bias in comparisons of life years to be gained between underlying causes of death. The purpose of the study was to assess this bias. DATA AND METHODS: A sample of 5975 death certificates from the Netherlands, 1990, was coded for the presence of diseases that, according to a set of explicit rules, could be regarded as potential causes of death "competing" with the underlying cause. Logistic regression analysis was used to quantify age and sex adjusted differences between four main underlying causes of death (neoplasms, cardiovascular diseases, respiratory diseases, all other diseases) in prevalence of the six most frequent competing causes of death (neoplasms, ischaemic heart disease, cerebrovascular disease, other cardiovascular diseases, chronic obstructive lung disease, all other diseases). These prevalence differences were then used to revise conventional calculations of gains in life expectancy, by taking them to indicate differences in risk of dying from these competing causes after the underlying cause has been eliminated. RESULTS: The prevalence of competing causes of death is relatively low among persons dying from neoplasms as the underlying cause, about average among persons dying from cardiovascular diseases, and relatively high among persons dying from respiratory diseases. Taking this into account results in substantial decreases of potential life years to be gained by elimination of cardiovascular diseases and respiratory diseases, relative to the number of years to be gained by elimination of neoplasms. Specifically, while according to the conventional calculations the gain in life expectancy by elimination of cardiovascular diseases exceeds that for neoplasms by more than one year, in the revised calculations the number of life years to be gained is approximately equal. CONCLUSIONS: Despite its limitations, mainly relating to reliance on death certificate data, this study suggests that conventional estimates of differences between underlying causes of death in life years to be gained by elimination are seriously biased by ignoring the effects of competing causes. Specifically, the relative impacts of eliminating cardiovascular diseases and respiratory diseases, as compared with eliminating neoplasms, seem to be overestimated. The implications are discussed.
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