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  • Accuracy of Asthma Mortality in France

We read with great interest the study by Jackson et al on the trends in asthma mortality in 14 different countries. As stated by these authors, “it is clearly of considerable importance to ascertain in countries with increasing reported asthma mortality rates, whether these trends are real or due to changes in accuracy of certification or in diagnosis fashions”. We wish to add some comments about the accuracy of methodology used in these epidemiologic studies reporting asthma mortality data, ie, the accuracy of death certificates. We wish to report a discrepancy between the French statistics concerning asthma deaths and our own experience, which was previously reported in this journal.

We compared the age distribution of asthmatic patients who died from asthma during the same period (1983 to 1984) as reported in the two following studies: 1) the report of asthma mortality in France given by Bousquet et al using the data of the Institut National de la Sante et de la Recherche MÑ‘dicale (data also used by Jackson et al) and 2) the report of asthmatic deaths observed in a prehospital mobile emergency care unit in Paris, France.

Obviously, this comparison must be made with caution. As a matter of fact, our study was not an epidemiologic study and we failed to report all asthma deaths in Paris during this period: patients who used the other Mobile Emergency Care Unit available in Paris (SAMU), and patients who died without calling anyone were not considered in our study. Moreover, we have compared the data obtained in the whole country with the data obtained in one town only of this country. However, our observation was so striking we think this comparison must be reported.
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Figure. Age distribution of asthmatic patients at death in France and in Paris during the same period. Data from France were obtained from Bousquet et al; data from Paris were obtained from Barriot and Riou.

As shown in the Figure, age distribution of asthmatic patients at death was totally different in the two studies of the same period. The most important result was that patients below 55 years accounted for 15 percent in the national study, whereas they accounted for 83 percent in our study. Incidence of asthma death in the national study was 2.85 per 100,000, whereas it was 1.05 per 100,000 in our study. The lower incidence in our study was not surprising since we did not consider all asthma deaths which occurred in the Paris area. However, these data allow us to calculate the incidence of asthma deaths in patients who were under 55: 0.43 per 100,000 in the national study vs 0.87 per 100,000 in our study. Thus, in spite of the fact that we only considered part of asthma deaths which occurred in the Paris area, we observed a mortality twice that of the national rate.

There was a great difference in the way data were collected in the two studies. In the national study, data were obtained using death certificates, and accuracy of these certificates was not verified. Many authors have previously emphasized the poor accuracy of death certificates, especially in asthma. In our study, accuracy might be considered to be the highest possible in such a study; a detailed data-sheet was completed by the emergency physician at the scene soon after death, and the agreement of two physicians who independently examined this data-sheet was necessary for inclusion of the patients. We suggest that the main reason why few young patients died from asthma in the national study may be the inaccuracy of death certificates.
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To our opinion, in France any epidemiologic study on asthma deaths which is only based on death certificates and does not verily the validity of the data collected is questionable. The problem is probably not a French problem but might be encountered in all countries. Therefore, two questions arise: first, can we trust mortality data obtained from death certificates? Second, if not, what can we do to accurately evaluate asthma mortality? Our response to the first question is no, but we have no answer to the second question. Finding a response to this question is probably one of the most important challenges concerning fatal asthma.

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