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Epilepsy by the Numbers
Epilepsy & Behavior 69 (2017) 28–30
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Epilepsy by the Numbers☆,☆☆ Epilepsy deaths by age, race/ethnicity, and gender in the United States significantly increased from 2005 to 2014 Sujay F. Greenlund a, Janet B. Croft b, Rosemarie Kobau c,⁎ a
Georgia State University, Atlanta, GA, USA Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, Epidemiology and Surveillance Branch, 4770 Buford Highway NE, MS F-78, Atlanta, GA 30341, USA c Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, Epilepsy Program, 4770 Buford Highway NE, MS F-78, Atlanta, GA 30341, USA b
a r t i c l e
i n f o
Available online xxxx Keywords: Epilepsy Mortality Deaths Rates Epidemiology
a b s t r a c t To inform public health efforts to prevent epilepsy-related deaths, we used the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER; Wonder.cdc.gov) to examine any-listed epilepsy deaths for the period 2005–2014 by age groups (≤24, 25–44, 45–64, 65–84, ≥85 years), sex, and race/ethnicity (non-Hispanic White, non-Hispanic African American, Hispanic, Asian/Pacific Islander, or American Indian/Alaska Native). Epilepsy deaths were defined by the International Classification of Diseases, Tenth Revision (ICD-10) codes G40.0–G40.9. The total number of deaths per year with epilepsy as any listed cause ranged from 1760 in 2005 to 2962 in 2014. Epilepsy was listed as the underlying cause of death for about 54% of all deaths with any mention of epilepsy in 2005 and for 43% of such deaths in 2014. Age-adjusted epilepsy mortality rates (as any-listed cause of death) per 100,000 significantly increased from 0.58 in 2005 to 0.85 in 2014 (47% increase). In 2014, deaths among the non-Hispanic Black population (1.42 deaths per 100,000) were higher than among non-Hispanic White (0.86 deaths per 100,000) and Hispanic populations (0.70 deaths per 100,000). Males had a higher mortality rate than females (1.01 per 100,000 versus 0.74 per 100,000 in 2014), and those aged 85 years or older had the highest mortality among age groups. Results highlight the need for heightened action to prevent and monitor epilepsy-associated mortality. Published by Elsevier Inc.
1. Introduction
2. Methods
Studies have noted that people with epilepsy have a higher risk of mortality from seizure-related causes (e.g., status epilepticus, seizure control), underlying etiology (congenital conditions, cerebrovascular disease), comorbidity (psychiatric disorder), and unrelated causes [1–4]. Despite recognized population burden [5], no recent study has examined trends in mortality associated with epilepsy in the United States. To inform public health measures to prevent epilepsy-related deaths, we examined trends in mortality with epilepsy as a listed cause of death overall, and by age, sex, and race and ethnicity.
Using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER; http://wonder.cdc. gov) multiple cause of death database, epilepsy deaths for the years 2005–2014 were examined by age group (≤24, 25–44, 45–64, 65–84, ≥85 years), sex, and race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, Asian/Pacific Islander, or American Indian/Alaska Native). Mortality data in WONDER are based on death certificates for U.S. residents. Each death certificate contains a single underlying cause of death and up to twenty additional multiple causes. We used the multiple cause of death data to determine epilepsy as any listed cause of death defined by the International Classification of Diseases, Tenth Revision (ICD-10) codes G40.0–G40.9. We also compared the proportion of deaths for epilepsy as the underlying cause of death compared to total epilepsy deaths. We calculated age-specific rates overall and agestandardized (to the year 2000 US population [6]) rates overall, by sex, and by race/ethnicity for the years 2005 through 2014 and calculated the percent change in 2014 relative to 2005. Differences between
☆ Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. ☆☆ The authors have no conflicts of interest to report. ⁎ Corresponding author at: Division of Population Health, 4770 Buford Highway NE, MS F-78, Atlanta, GA 30341, USA. E-mail address: [email protected] (R. Kobau).
http://dx.doi.org/10.1016/j.yebeh.2017.01.016 1525-5050/Published by Elsevier Inc.
S.F. Greenlund et al. / Epilepsy & Behavior 69 (2017) 28–30
two rates were considered statistically significant at p b 0.05 via the z-test.
29
underlying cause of death. These findings supplement recommendations from the Institute of Medicine [7] and others for heightened efforts to prevent epilepsy-associated mortality [1–4]. Complex, myriad factors interact to cause increased mortality risk [3]. Health care providers can discuss elevated mortality risk with their patients, and they can promote evidenced based programs to decrease known risk factors (e.g., smoking, physical inactivity, psychological distress), improve epilepsy self-management, and refer patients with uncontrolled seizures to specialty care [7]. At least two caveats should be pointed out. First, these data only include those for which epilepsy was listed as a contributing cause of death. Epilepsy likely was not listed on death certificates for all people who had epilepsy. Second, we examined only ICD-10 codes G40 which includes probable epilepsy as a cause of death. We did not include other ICD-10 codes such as status epilepticus (G41) which may include some epilepsy deaths [8], but also include other conditions. CDC WONDER data can be used to examine trends in epilepsyassociated mortality and help to assess the effectiveness of prevention efforts implemented by health care providers and public health practitioners to reduce the burden of epilepsy-related deaths.
3. Results The total number of deaths with epilepsy as any listed cause was 1760 in 2005 and 2962 in 2014 (Supplemental Tables 1 and 2). Epilepsy was listed as the underlying cause of death for about 54% of all deaths with any mention of epilepsy in 2005 and for 43% of such deaths in 2014. In both 2005 and 2014, age-specific death rates with any-listed epilepsy increased for each successive age group. Age-standardized rates were higher in males than females and were highest among non-Hispanic blacks. Asian or Pacific Islanders had the lowest rates in 2014. Fig. 1 illustrates annual age-adjusted death rates from 2005 to 2014 for any-listed epilepsy overall, by sex, and by selected race/ethnicity groups. Overall, age-adjusted mortality rates per 100,000 population for epilepsy as any-listed cause of death significantly increased from 0.58 in 2005 to 0.85 in 2014 (47% increase). Age-adjusted rates increased from 2005 to 2014 for both males and females and for nonHispanic whites, non-Hispanic blacks, and Hispanics. Rates were considered unstable for Asian/Pacific Islanders and for American Indian/Alaska Natives for most of the 10-year period. The significantly higher rate among non-Hispanic blacks compared to other race and ethnic groups remained so throughout the 10-year period. Overall, age-adjusted mortality rates per 100,000 population for epilepsy as the underlying cause of death showed a corresponding increase from 2005 to 2014 (Supplemental Table 2). Significant increases were observed among those aged ≤24 and ≥85 years, among both males and females, and among non-Hispanic whites (Supplemental Table 2).
Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.yebeh.2017.01.016.
References [1] Nevalainen O, Ansakorpi H, Simola M, Raitanen J, Isojärvi J, Artama M, et al. Epilepsyrelated clinical characteristics and mortality. A systematic review and meta-analysis. Neurology 2014;83:1968–77. [2] Fazel S, Wolf A, Langstrom N, Newton CR, Lichtenstein P. Premature mortality in epilepsy and the role of psychiatric comorbidity: a total population study. Lancet 2013;382:1646–54. [3] Neligan A, Sander JW. Premature mortality in epilepsy: is it preventable? Expert Rev Neurother 2011;11:767–70. [4] Keezer MR, Bell GS, Neligan A, Novy J, Sander JW. Cause of death and predictors of mortality in a community-based cohort of people with epilepsy. Neurology 2016; 86:704–12.
4. Conclusions Although not a leading cause of death in the United States, deaths with epilepsy as a listed cause of death significantly increased among the general population since 2005. Our analyses suggest that about 40–50% of deaths with epilepsy listed included epilepsy as the 1.50 1.40 1.30
Rate per 100,000 population*
1.20 1.10 1.00 0.90
Male
0.80
Female
0.70
NH-White NH-Black
0.60
Hispanic
0.50
Total
0.40 0.30 0.20 0.10 0.00
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Year
*Age-adjusted to the year 2000 US standard population Fig. 1. Age-adjusted* death rate (per 100,000 population) with epilepsy as any-listed cause reported on death certificate, by sex and race/ethnicity: United States, 2005–2014.
30
S.F. Greenlund et al. / Epilepsy & Behavior 69 (2017) 28–30
[5] Koh HK, Kobau R, Whittemore VH, Mann MY, Johnson JG, Hutter JD, et al. Toward an integrated public health approach for epilepsy in the 21st century. Prev Chronic Dis 2014;11:E146. http://dx.doi.org/10.5888/pcd11.14027. [6] Klein RJ, Schoenborn CA. Age adjustment using the 2000 projected U.S. population. Healthy People statistical notes, no. 20. Hyattsville, Maryland: National Center for Health Statistics; January 2001.
[7] Institute of Medicine. Epilepsy across the spectrum: promoting health and understanding. Washington (DC): National Academies Press; 2012. [8] Jette N, Beghi E, Hesdorffer D, Moshé SL, Zuberi SM, Medina MT, et al. ICD coding for epilepsy: past, present, and future—a report by the International League Against Epilepsy Task Force on ICD codes in epilepsy. Epilepsia 2015;56:348–55.
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Epilepsy by the Numbers☆,☆☆ Epilepsy deaths by age, race/ethnicity, and gender in the United States significantly increased from 2005 to 2014 Sujay F. Greenlund a, Janet B. Croft b, Rosemarie Kobau c,⁎ a
Georgia State University, Atlanta, GA, USA Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, Epidemiology and Surveillance Branch, 4770 Buford Highway NE, MS F-78, Atlanta, GA 30341, USA c Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, Epilepsy Program, 4770 Buford Highway NE, MS F-78, Atlanta, GA 30341, USA b
a r t i c l e
i n f o
Available online xxxx Keywords: Epilepsy Mortality Deaths Rates Epidemiology
a b s t r a c t To inform public health efforts to prevent epilepsy-related deaths, we used the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER; Wonder.cdc.gov) to examine any-listed epilepsy deaths for the period 2005–2014 by age groups (≤24, 25–44, 45–64, 65–84, ≥85 years), sex, and race/ethnicity (non-Hispanic White, non-Hispanic African American, Hispanic, Asian/Pacific Islander, or American Indian/Alaska Native). Epilepsy deaths were defined by the International Classification of Diseases, Tenth Revision (ICD-10) codes G40.0–G40.9. The total number of deaths per year with epilepsy as any listed cause ranged from 1760 in 2005 to 2962 in 2014. Epilepsy was listed as the underlying cause of death for about 54% of all deaths with any mention of epilepsy in 2005 and for 43% of such deaths in 2014. Age-adjusted epilepsy mortality rates (as any-listed cause of death) per 100,000 significantly increased from 0.58 in 2005 to 0.85 in 2014 (47% increase). In 2014, deaths among the non-Hispanic Black population (1.42 deaths per 100,000) were higher than among non-Hispanic White (0.86 deaths per 100,000) and Hispanic populations (0.70 deaths per 100,000). Males had a higher mortality rate than females (1.01 per 100,000 versus 0.74 per 100,000 in 2014), and those aged 85 years or older had the highest mortality among age groups. Results highlight the need for heightened action to prevent and monitor epilepsy-associated mortality. Published by Elsevier Inc.
1. Introduction
2. Methods
Studies have noted that people with epilepsy have a higher risk of mortality from seizure-related causes (e.g., status epilepticus, seizure control), underlying etiology (congenital conditions, cerebrovascular disease), comorbidity (psychiatric disorder), and unrelated causes [1–4]. Despite recognized population burden [5], no recent study has examined trends in mortality associated with epilepsy in the United States. To inform public health measures to prevent epilepsy-related deaths, we examined trends in mortality with epilepsy as a listed cause of death overall, and by age, sex, and race and ethnicity.
Using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER; http://wonder.cdc. gov) multiple cause of death database, epilepsy deaths for the years 2005–2014 were examined by age group (≤24, 25–44, 45–64, 65–84, ≥85 years), sex, and race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, Asian/Pacific Islander, or American Indian/Alaska Native). Mortality data in WONDER are based on death certificates for U.S. residents. Each death certificate contains a single underlying cause of death and up to twenty additional multiple causes. We used the multiple cause of death data to determine epilepsy as any listed cause of death defined by the International Classification of Diseases, Tenth Revision (ICD-10) codes G40.0–G40.9. We also compared the proportion of deaths for epilepsy as the underlying cause of death compared to total epilepsy deaths. We calculated age-specific rates overall and agestandardized (to the year 2000 US population [6]) rates overall, by sex, and by race/ethnicity for the years 2005 through 2014 and calculated the percent change in 2014 relative to 2005. Differences between
☆ Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. ☆☆ The authors have no conflicts of interest to report. ⁎ Corresponding author at: Division of Population Health, 4770 Buford Highway NE, MS F-78, Atlanta, GA 30341, USA. E-mail address: [email protected] (R. Kobau).
http://dx.doi.org/10.1016/j.yebeh.2017.01.016 1525-5050/Published by Elsevier Inc.
S.F. Greenlund et al. / Epilepsy & Behavior 69 (2017) 28–30
two rates were considered statistically significant at p b 0.05 via the z-test.
29
underlying cause of death. These findings supplement recommendations from the Institute of Medicine [7] and others for heightened efforts to prevent epilepsy-associated mortality [1–4]. Complex, myriad factors interact to cause increased mortality risk [3]. Health care providers can discuss elevated mortality risk with their patients, and they can promote evidenced based programs to decrease known risk factors (e.g., smoking, physical inactivity, psychological distress), improve epilepsy self-management, and refer patients with uncontrolled seizures to specialty care [7]. At least two caveats should be pointed out. First, these data only include those for which epilepsy was listed as a contributing cause of death. Epilepsy likely was not listed on death certificates for all people who had epilepsy. Second, we examined only ICD-10 codes G40 which includes probable epilepsy as a cause of death. We did not include other ICD-10 codes such as status epilepticus (G41) which may include some epilepsy deaths [8], but also include other conditions. CDC WONDER data can be used to examine trends in epilepsyassociated mortality and help to assess the effectiveness of prevention efforts implemented by health care providers and public health practitioners to reduce the burden of epilepsy-related deaths.
3. Results The total number of deaths with epilepsy as any listed cause was 1760 in 2005 and 2962 in 2014 (Supplemental Tables 1 and 2). Epilepsy was listed as the underlying cause of death for about 54% of all deaths with any mention of epilepsy in 2005 and for 43% of such deaths in 2014. In both 2005 and 2014, age-specific death rates with any-listed epilepsy increased for each successive age group. Age-standardized rates were higher in males than females and were highest among non-Hispanic blacks. Asian or Pacific Islanders had the lowest rates in 2014. Fig. 1 illustrates annual age-adjusted death rates from 2005 to 2014 for any-listed epilepsy overall, by sex, and by selected race/ethnicity groups. Overall, age-adjusted mortality rates per 100,000 population for epilepsy as any-listed cause of death significantly increased from 0.58 in 2005 to 0.85 in 2014 (47% increase). Age-adjusted rates increased from 2005 to 2014 for both males and females and for nonHispanic whites, non-Hispanic blacks, and Hispanics. Rates were considered unstable for Asian/Pacific Islanders and for American Indian/Alaska Natives for most of the 10-year period. The significantly higher rate among non-Hispanic blacks compared to other race and ethnic groups remained so throughout the 10-year period. Overall, age-adjusted mortality rates per 100,000 population for epilepsy as the underlying cause of death showed a corresponding increase from 2005 to 2014 (Supplemental Table 2). Significant increases were observed among those aged ≤24 and ≥85 years, among both males and females, and among non-Hispanic whites (Supplemental Table 2).
Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.yebeh.2017.01.016.
References [1] Nevalainen O, Ansakorpi H, Simola M, Raitanen J, Isojärvi J, Artama M, et al. Epilepsyrelated clinical characteristics and mortality. A systematic review and meta-analysis. Neurology 2014;83:1968–77. [2] Fazel S, Wolf A, Langstrom N, Newton CR, Lichtenstein P. Premature mortality in epilepsy and the role of psychiatric comorbidity: a total population study. Lancet 2013;382:1646–54. [3] Neligan A, Sander JW. Premature mortality in epilepsy: is it preventable? Expert Rev Neurother 2011;11:767–70. [4] Keezer MR, Bell GS, Neligan A, Novy J, Sander JW. Cause of death and predictors of mortality in a community-based cohort of people with epilepsy. Neurology 2016; 86:704–12.
4. Conclusions Although not a leading cause of death in the United States, deaths with epilepsy as a listed cause of death significantly increased among the general population since 2005. Our analyses suggest that about 40–50% of deaths with epilepsy listed included epilepsy as the 1.50 1.40 1.30
Rate per 100,000 population*
1.20 1.10 1.00 0.90
Male
0.80
Female
0.70
NH-White NH-Black
0.60
Hispanic
0.50
Total
0.40 0.30 0.20 0.10 0.00
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Year
*Age-adjusted to the year 2000 US standard population Fig. 1. Age-adjusted* death rate (per 100,000 population) with epilepsy as any-listed cause reported on death certificate, by sex and race/ethnicity: United States, 2005–2014.
30
S.F. Greenlund et al. / Epilepsy & Behavior 69 (2017) 28–30
[5] Koh HK, Kobau R, Whittemore VH, Mann MY, Johnson JG, Hutter JD, et al. Toward an integrated public health approach for epilepsy in the 21st century. Prev Chronic Dis 2014;11:E146. http://dx.doi.org/10.5888/pcd11.14027. [6] Klein RJ, Schoenborn CA. Age adjustment using the 2000 projected U.S. population. Healthy People statistical notes, no. 20. Hyattsville, Maryland: National Center for Health Statistics; January 2001.
[7] Institute of Medicine. Epilepsy across the spectrum: promoting health and understanding. Washington (DC): National Academies Press; 2012. [8] Jette N, Beghi E, Hesdorffer D, Moshé SL, Zuberi SM, Medina MT, et al. ICD coding for epilepsy: past, present, and future—a report by the International League Against Epilepsy Task Force on ICD codes in epilepsy. Epilepsia 2015;56:348–55.