Grief and causal attribution are two of the most commonly observed reactions to early miscarriage, yet little is known about these reactions or whether a relationship exists between them. This exploratory and descriptive correlational study examined the maternal grief intensities, the causal attributions, and the relationship between them in a convenience sample of 15 women who spontaneously aborted at 16 weeks' or less gestation. Women responded to both a written questionnaire and a semi-structured Interview at 6 to 10 weeks post-miscarriage. Their responses Indicated both current and retrospective reactions to their miscarriages. Responses were analysed using nonparametric statistics and content analysis. Maternal grief Intensities were found to vary widely at the time of the miscarriage, but all decreased significantly 6 to 10 weeks later. All women reacted to their miscarriage with attribution-seeking behaviors. The explanations most women formed were comprised of more than one causal attribution. Attributions were observed to have four distinct characteristics. Causal attributions were found to be either philosophical or physically oriented; to be organic, non-specific or maternal/self-blaming In origin; to be either dominant or non-dominant, and/or to refer to causalities immediate or prior to the physical event. At the time of the miscarriage a positive correlation between grief Intensity and maternal/self-blaming attributions and between grief Intensity and philosophical attributions was found. These relationships were not observed 6 to 10 weeks later. A positive correlation was found between grief intensity and attributions to maternal emotions at both the time of the miscarriage and 6 to 10 weeks later. / Applied Science, Faculty of / Nursing, School of / Graduate

Development of mortality from malignant neoplasm of bronchus and lung in the Czech Republic Abstract Malignant neoplasm of bronchus and lung is one of the most common causes of death in the Czech Republic and this diploma thesis aims to evaluate and describe the development of mortality from this disease since the mid-nineties to the present time in the Czech Republic compared to other European countries and on district level. The main goal of this thesis is to analyze the indicators evaluating the structure and intensity of mortality on this common cause of death. The theoretical part describes the selected disease, all the important risk factors, possibilities of prevention, diagnosis, treatment and prognosis of the disease. There are some other theoretical concepts described especially the tobacco epidemic, as smoking is without a doubt the most important risk factor for this disease. Throughout the study period, mortality rates have been converging in the Czech Republic and other selected European countries for malignant neoplasm of bronchus and lung by sex when mortality has decreased significantly for men population, while for women it is slightly increasing. Keywords: mortality, cause of death, malignant neoplasm, bronchus, lung, Czech Republic

Rationale Epilepsy is a common, chronic, neurological condition that disproportionately affects individuals living in low- and middle- income countries, including much of sub-Saharan Africa. Epilepsy is treatable, with the majority of individuals who take anti-epileptic drugs experiencing a reduction, or elimination, of seizures. Yet the number of individuals taking and adhering to medication in Africa is low and interventions aimed at improving treatment are lacking. Aims To define the epidemiology of convulsive epilepsy in rural South Africa in terms of incidence, mortality and disability-adjusted life years; to determine outpatient, out-of-pocket costs resulting from epilepsy treatment; to establish the level of adherence to anti-epileptic drugs amongst people with epilepsy; and, to determine whether the introduction of routine visits to people with epilepsy by community health workers is a cost-effective intervention for improving adherence to anti-epileptic drugs. Methods Nested within the Agincourt Health and Demographic Surveillance System, this work utilized a cohort of individuals diagnosed with convulsive epilepsy in 2008 to determine health care utilization and out-of-pocket costs due to care sought for epilepsy. Additionally, using blood samples from the cohort, anti-epileptic drug adherence was measured and, following the cohort, mortality rates were determined. Using these collected epidemiological parameters, disability-adjusted life years due to convulsive epilepsy were determined. Finally, combining the epidemiological and cost parameters, a community health worker intervention was modeled to determine its incremental cost-effectiveness ratio. Key Findings The burden of convulsive epilepsy is lower in rural South Africa than other parts of Africa, likely due to lower levels of known risk factors. Yet the burden, especially in terms of mortality, remains high, as does the treatment gap and health care utilization. Findings from the economic evaluation found the introduction of a community health worker to be highly cost-effective and would likely lower the burden of epilepsy in rural South Africa. Implications Epilepsy contributes to the burden of disease in rural South Africa, with high levels of mortality and a substantial treatment gap. The introduction of a community-health worker is likely to be one cost-effective, community based intervention that would lower the burden of epilepsy by improving adherence to anti-epileptic drugs. Implementing this intervention, based on these findings, is a justified and important next step.

La mortalité aux jeunes âges devenant de plus en plus faible, l’augmentation de l’espérance de vie est de plus en plus dépendante des progrès en mortalité aux âges avancés. L’espérance de vie à 65 ans et à 85 ans n’a cependant pas connu un rythme de progression continu depuis les trois dernières décennies. Ces changements dans l’évolution de l’espérance de vie proviennent de changements dans les tendances de certaines causes de décès et de leurs interactions. Ce mémoire analyse la contribution des causes de décès aux changements qu’a connus l’espérance de vie, mais aussi l’évolution spécifique des taux de mortalité liés aux principales causes de décès au Canada entre 1979 et 2007. Finalement, une analyse de l’implication de ces changements dans un contexte de transition épidémiologique sera réalisée, par un questionnement sur le fait que l’on assiste ou non au passage de certaines pathologies dominantes à d’autres. La réponse à ce questionnement se trouve dans l’étude de l’évolution par âge et dans le temps des causes de décès. Les résultats montrent que les progrès en espérance de vie à 65 ans et à 85 ans sont encore majoritairement dus à la diminution de la mortalité par maladies cardiovasculaires. Toutefois, ces dernières causes de décès ne sont pas les seules à contribuer aux progrès en espérance de vie, puisque les taux de mortalité dus aux dix principales causes de décès au Canada ont connu une diminution, bien qu’elles n’aient pas toutes évolué de la même manière depuis 1979. On ne semble ainsi pas passer d’un type de pathologies dominantes à un autre, mais à une diminution générale de la mortalité par maladies chroniques et à une diversification plus importante des causes de décès à des âges de plus en plus avancés, notamment par la diminution des «grandes» causes de décès. / With the decrease of mortality at younger ages, gain in life expectancy is heavily dependent on the progress in old age mortality. However, over the last three decades, life expectancies at 65 and 85 years old have not experienced a constant rate of progress. Changes in life expectancy progress come from changes in specific causes of death trends and their interactions. The present thesis studies the contribution of causes of death on the changes in life expectancies and the trends in death rates of specific causes of death in Canada between 1979 and 2007. An analysis of those changes in an epidemiological transition context has also been done by questioning whether or not we are witnessing a shift from certain dominant diseases to others. This questioning will be answered by studying variation in the causes of death by age and over time. The results of this study show that progress in life expectancies at 65 and 85 years old are still mainly due to the decrease in cardiovascular mortality. However, cardiovascular diseases are not the only causes of death to contribute to the progress in life expectancy. Since 1979, mortality rates from the ten leading causes of death in Canada have all declined but in different ways. Thus, there does not seem to be a shift in the dominant causes of death towards others in Canada, but there is a general mortality decline from chronic diseases and a greater diversification of causes of death at older ages.

La progression de l’espérance de vie au Québec reflète l’amélioration de la santé de la population. Toutefois, des décès continuent à survenir prématurément avant l’âge de 75 ans. Une part de cette mortalité prématurée est potentiellement évitable. L'objectif de ce mémoire est d’estimer la mortalité évitable au Québec de 1981-1985 à 2005-2009. Pour cela, la méthode de Tobias et Jackson (2001) a été appliquée sur des données de décès, fournies par l’Institut national de santé publique du Québec, pour estimer les taux de mortalité évitable totale et pour chacun des sexes. Cette approche nous a, par ailleurs, permis d’estimer des taux de mortalité évitable selon trois paliers de prévention : primaire, secondaire et tertiaire. Nos résultats démontrent une tendance à la baisse de la mortalité évitable à travers le temps. Cette baisse a été enregistrée chez les deux sexes, mais des disparités de mortalité évitable existent entre les hommes et les femmes. En effet, la mortalité évitable des hommes est plus élevée que celle des femmes et cet écart de mortalité est principalement dû à la mortalité évitable associée à la prévention primaire. L’analyse de la mortalité évitable par cause de décès fait ressortir que le cancer du poumon est la principale cause de décès évitable tant chez les hommes que chez les femmes en 2005-2009. Durant cette même période, le cancer du sein et les cardiopathies ischémiques étaient la deuxième cause de décès évitable respectivement chez les femmes et chez les hommes. / The upward trend observed in Quebec’s life expectancy in past years suggests that population health has continued to improve. However, a number of deaths continue to occur prematurely before the age of 75 years. A part of this premature mortality is potentially avoidable. The objective of this paper is to estimate avoidable mortality rates in Quebec from 1981-1985 to 2005-2009. Avoidable mortality rates were obtained by applying the method of Tobias and Jackson (2001) to mortality data made available to us by the Institut national de santé publique du Québec. Furthermore, this approach allowed us to evaluate avoidable mortality rates by three levels of prevention: primary, secondary and tertiary. Our results show a downward trend in avoidable mortality from 1981-1985 to 2005-2009. This decline was observed for the whole population and also for both sexes. Differences in male’s and female’s avoidable mortality trends are however noticed. Indeed, avoidable mortality is higher for men than women and a large part of this difference is associated to primary prevention. The analysis by cause of death revealed that lung cancer was the leading cause of avoidable death in both men and women in 2005-2009. During this same period, the second leading cause of avoidable mortality is breast cancer and ischemic heart diseases in females and males respectively.

Introdução - Uma das formas de se aumentar a qualidade das informações sobre causas de morte é automatizar o processo de sua elaboração. O software Iris é um dos mecanismos disponíveis para esse fim. Suas principais características é que ele segue as regras internacionais de mortalidade e ele é independente de idioma. Objetivo - Elaborar para o Iris um dicionário na língua portuguesa e avaliar a sua completitude para a codificação das causas de morte. Método - O dicionário criado com dados do arquivo eletrônico do volume 1 da CID-10 e com o Tesauro da Classificação Internacional de Atenção Primária. Foi utilizado o Iris V4.0.34 e, como codificação manual, o que o Programa de Aprimoramento das Informações de Mortalidade no Município de São Paulo (PRO-AIM) da Secretaria Municipal de Saúde de São Paulo escreveu nas declarações de óbito. Caso o Iris não codificasse as causas de morte, ajustes eram feitos no dicionário ou na tabela de padronização. Resultado - O Iris é capaz de codificar as causas de morte e selecionar a causa básica de morte, ambas automaticamente, é um software recente que está em constantes adequações, é independente de idioma e para usá-lo em cada país é necessário realizar somente um dicionário de causas de morte. No teste para avaliação da primeira versão do dicionário em português, o Iris apresentou um desempenho satisfatório. Foi capaz de codificar diretamente 50,6 por cento das declarações de óbito e, após ajustes e acréscimos no dicionário e na tabela de padronização, o software codificou todas as linhas em 94,44 por cento das declarações. Das declarações não codificadas completamente 89,19 por cento delas tinham algum diagnóstico contido no capítulo XX da CID-10. O Iris apresentou 63,1 por cento de concordância nas declarações de óbito pareadas considerando todas as causas de morte com códigos completos de 4 caracteres da CID-10. Conclusão - A realização dos ajustes no dicionário ou na padronização faz parte do processo de desenvolvimento do dicionário e que esse processo é continuo. Com as novas versões do Iris e atualizações e aprimoramento da codificação das causas externas, avanços serão feitos para que ele seja mais compatível com a realidade brasileira. Somado a isso, as futuras versões do Iris com um dicionário mais desenvolvido podem satisfazer as necessidades de codificação automática e melhorar a precisão dos dados de causa morte paras estudos de saúde pública. / Introduction - One way to increase the quality of causes-of-death statistics is to use computers for applying the rules systematically. Iris software is an available system for this purpose. Its main characteristics are that it follows international rules of mortality and it is language independent. Objective - Produce a Portuguese dictionary for Iris and assess its completeness of coding of causes of death. Methods - The creation of the dictionary used two sources: the electronic file of volume 1 of ICD-10 and Thesaurus of Classificação Internacional de Atenção Primária. Was used Iris V4.0.34 and for manual coding the codes at the Programa de Aprimoramento das Informações de Mortalidade no Município de São Paulo (PRO-AIM) of Secretaria Municipal de Saúde of São Paulo has written on death certificates. If Iris couldnt codify the causes of death, adjustments were made in the dictionary or standardization table. Results - Iris is able to encode causes of death and select the underlying cause of death, either automatically; is a recent software that is in constant adjustments; is a language independent software and to use it in your country you need only dictionary of causes of death. In the test for evaluation the first version of the Portuguese dictionary Iris showed satisfactory performance. He was able to code directly for 50.6 per cent of death certificates and, after adjustments and additions in the dictionary and standardization table, the software coded all lines in 94.44 per cent of death certificate. The statements do not fully coded 89.19 per cent had a diagnosis contained in Chapter XX of ICD-10. Iris presented 63,1 per cent agreement on paired death certificates considering all causes of death and 4-digit ICD-10 code level. Conclusion - making adjustments in the dictionary or the standardization is part of the development process of the dictionary and that this process is ongoing. With new Iris versions and updates in the management of the coding external causes, progress will be made to make it more compatible with the Brazilian reality. Added to this, future versions of Iris with a dictionary more developed can meet the needs of auto-tagging and improve the accuracy of data causes death to public health studies.

O presente trabalho teve como objetivo, estudar as variações da mortalidade por câncer, no Distrito de São Paulo, ocorridas no período de doze anos, compreendido entre 1962-1963 e 1974-1975. Foram utilizados dados de mortal idade originados da \" lnvestigação lnteramericana de Mortalidade\" , realizada em 1962-1963, e do \"Estudo dos Transtor Mentais como causa básica e associada na mortalidade de adultos de 15-74 anos no Distrito de São Paulo e Município de Botucatú e São Manuel em 1974-1975\". A escolha desses dados de mortalidade deu-se porque esses referidos estudos utilizaram uma mesma metodologia de pesquisa, baseada fundamentalmente na correçao da causa básica de óbito assinalada no atestado de óbito, através de entrevistas domiciliares e junto aos médicos, hospitais,etc. Desse modo, os 811 óbitos por tumores malígnos apresentados nesse trabalho, do período de 1962-1963, e os 452 do período de 1974-75, são mais fidedígnos que os oficiais. As variações da mortalidade foram descritas, tanto por corte transversal do tempo, quanto por coortes. Em relação ao sexo masculino, o risco morte por todas as localizações de câncer, aumentou de 1962-1963 à 1974-1975 em todos os grupos etários, exceto no de 15-24 anos.Para o sexo feminino, o risco de morte por todos os tumores malígnos, aumentou de 1962-1963 à 1974-1975 nos grupos etários de 15-24 anos de 35-44 anos e de 45-54 anos. As coortes mais jovens foram as que apresentaram maior incremento da mortal idade por câncer. / The objective of this dissertation was to study the variations of cancer mortality, in the District of São Paulo, during the período of twelve years, between 1962-1963 and 1974-1975- The baseline data used were those from the studies \"Investigação lnteramericana de Mortalidade\", done in 1962-1963, and \"Estudos dos Transtornos Mentais como Causa Básica e Associada na Mortalidade de Adultos de 15-74 anos no Distrito de São Paulo e Município de Botucatu e São Manuel em 1974-1975\'\'. These data were chosen because both studies used the same methods of research, based in the underlying cause of death registered in the death certiffcate and corrected by means of home interviews and interviews whith physicians, in hospitals and other sources of informations. So, the 811 deaths by malignant neoplasms for the period 1962-1963 and the 452 for the period 1974- 1975, studied in the present dissertation are figures more reliable than the official ones. The variations of mortality were described both under the views of a cross-section in the time and as the aspect of cohort. For males, the risk of death for all sites became greater from 1962-1963 to 1974-1975 in all age groups, except 15-24. For females, the risk became greater from 1962-1963 to 1974-1975 in the age groups: 15-24, 35-44 and 45-54. The youngest cohorts presented the greatest increment in cancer mortality.

A mortalidade neonatal, em sua maioria, ocorre por causas que poderiam ser evitadas se houvesse oferta de serviços qualificados durante o pré-natal, parto e puerpério. De modo geral, estão associadas às condições biológicas, às disparidades socioeconômicas e de acesso aos serviços de saúde. Assim, mesmo em municípios com melhores índices de desenvolvimento econômico, a elucidação dos elementos que compõem a trama de causalidade dos óbitos neonatais é fundamental. Dessa forma, o objetivo do estudo foi analisar os fatores associados aos óbitos neonatais no Município de Londrina-PR, no período de 2000 a 2009. Foram investigados os óbitos neonatais, segundo características maternas, do recém-nascido e relativas ao uso do sistema municipal de saúde, por meio de estudo retrospectivo descritivo do tipo ecológico. Os dados foram extraídos da Declaração de Nascido Vivo, da Declaração de Óbito e das Fichas de Investigação do Óbito Infantil do Comitê Municipal de Prevenção de Mortalidade Materno-Infantil do Núcleo de Informação de Mortalidade (NIM) da Secretaria de Saúde Municipal. No que se refere à caracterização materna, mais de 60,0% das mães eram jovens adultas (12 a 27 anos) e a média de idade 25,8 anos. Ao longo dos 10 anos, o número de mães adolescentes diminuiu de 22,9% para 8,5%. Do total, 83,5% tinham companheiro, 73,9% de oito a onze anos de estudo e 52,7% não trabalhavam. Tiveram acompanhamento no pré-natal 91,4% das mulheres, 55,1% das quais se consultaram de uma a seis vezes. Quase a totalidade apresentou algum tipo de afecção durante a gestação: 82,7% trabalho de parto prematuro e 36,7% doenças renais e de vias urinárias. Pouco mais de 51,0% evoluiu para o parto vaginal. Ao longo dos anos, o parto cirúrgico aumentou de 35,4% para 61,5%. Quanto às características dos recém-nascidos que foram a óbito, 56,9% eram do sexo masculino e 86,0% da raça branca. Aproximadamente 60,0% nasceram entre 22 e 31 semanas de gestação e 60,7% tinham peso inferior a 1.500 gramas e 73,0% apresentaram asfixia no 1º minuto de vida. Ao longo dos anos, a prematuridade se manteve elevada. A média de idade do óbito foi de 4,9 dias. A maioria das mortes ocorreu no período neonatal precoce (73,9%) e o Coeficiente de Mortalidade Neonatal passou de 21,2 para 14,8, entre 2000 e 2009. A causa básica foram, predominantemente, afecções perinatais (77,6%), seguidas das anomalias congênitas (20,0%). Do total das mortes evitáveis, 77,1% ocorreram por causas redutíveis por adequado controle na gravidez e atenção ao parto. Quanto ao uso do sistema municipal de saúde pelas mães dos neonatos observou-se que 62,3% realizaram o pré-natal no serviço público de saúde. A quase totalidade dos partos ocorreu no hospital (96,5%), sendo 63,7% em hospitais que ofereciam atendimento obstétrico e de unidade de terapia intensiva neonatal (UTIN). Ao longo dos 10 anos de estudo, o uso do serviço hospitalar com maternidade e UTIN, aumentou de 39,2% para 66,6%. O período do óbito neonatal apresentou associação estatisticamente significativa com: trabalho de parto prematuro (p<0,01), infecção do trato urinário (p<0,05), hipertensão arterial/pré-eclâmpsia (p<0,01), peso ao nascer (p<0,01), idade gestacional (p<0,01), Apgar no 1º e 5º minuto (p<0,01), local do parto (p<0,01) e local do óbito (p<0,05). Por outro lado, não houve associação estatística com as características demográficas e socioeconômicas maternas. Ainda que as mortes neonatais tenham sido reduzidas, ao longo dos anos, no Município de Londrina, a sua ocorrência requer atenção para a reorganização do sistema de saúde, particularmente no que se refere à qualificação da assistência pré-natal e parto. Conclui-se ser necessária a operacionalização da integralidade de forma a abordar as necessidades materno-infantis que recorrerem ao serviço municipal de saúde. / Neonatal mortality mostly occurs due to avoidable causes which could be prevented if quality health services were available at prenatal, delivery and postnatal periods. In general, these causes are related to biological conditions, socioeconomic disparities and health services accessibility. Hence, even in cities where the economic development is high, it is fundamental to elucidate factors that contribute to the causality of neonatal deaths. The aim of this study was to analyze the factors associated to neonatal deaths in Londrina - PR, from 2000 to 2009. Neonatal deaths were investigated according to characteristics of mothers, newborns and health system city services through an ecological study with a retrospective and descriptive approach. Data were obtained from Birth Certificates, Death Certificates and Infant Death Investigation Forms provided by the Municipal Committee for Prevention of Maternal and Infant Death obtained from the Mortality Information Center assigned under the City Health Department. Regarding maternal characteristics, more than 60.0% were young adults (aged from 12 to 27), mean age of 25.8. Over this ten-year period, the number of teenager mothers decreased from 22.9% to 8.5%. Out of the total, 83.5% were married, 73.9% had 8-11 schooling years and 52.7% did not have a job. Most women (91.4%) received prenatal care and 55.1% of them attended to 1-6 prenatal care appointments. Almost all mothers had some sort of health problems during pregnancy: 82.7% presented with premature labor and 36.7% had renal and urinary conditions. Slightly more than 51,0% led to natural deliveries. Over the years, surgical deliveries increased from 35.4% to 61.5%. As for characteristics of newborns who died, 56.9% were male and 86.0% were caucasian. About 60.0% were born with 22-31 weeks of gestational age and 60.7% weighted under 1500 grams and 73.0% presented with asfixiation at the first minute. Over the studied period, prematurity rates remained elevated. Mean death age was 4.9 days. Most deaths occured at early neonatal period (73.9%) and the Neonatal Mortality Rate decreased from 21.2 to 14.8 between 2000 to 2009. The leading death causes were perinatal conditions (77.6%) followed by congenital anomalies (20.0%). Out of all avoidable deaths, 77.1% occured due to causes that could be prevented if adequate control over pregnancy and labor care were available. As for the city health services attended by the newborns\' mothers, 62.3% used the public health system. Almost all labors took place in hospitals (96.5%), and 63.7% of these facilities provided obstetric and neonatal intensive care. In the studied period, the use of hospital facilities with maternity/nursery and neonatal intensive care wards increased from 39.2% to 66.6%. The neonatal death period was statistically associated to premature labor (p<0.01), urinary tract infeccion (p<0.05), arterial hypertension/pre-eclampsia (p<0.01), birth weight (p<0.01), gestational age (p<0.01), Apgar score at 1st and 5th minutes (p<0.01), place of delivery (p<0.01) and place of death (p<0.05). On the other hand, there was no statistical association between maternal demographic and socioeconomical characteristics. Even though neonatal deaths have decreased over the years, in Londrina, this number still requires attention in order to reorganize the health system, specifically regarding qualified assitance for prenatal care and delivery. In conclusion, it is necessary to implement integrative care as to address the maternal-infant needs of the population who attends the city health services.

O presente trabalho teve como objetivo, estudar as variações da mortalidade por câncer, no Distrito de São Paulo, ocorridas no período de doze anos, compreendido entre 1962-1963 e 1974-1975. Foram utilizados dados de mortal idade originados da \" lnvestigação lnteramericana de Mortalidade\" , realizada em 1962-1963, e do \"Estudo dos Transtor Mentais como causa básica e associada na mortalidade de adultos de 15-74 anos no Distrito de São Paulo e Município de Botucatú e São Manuel em 1974-1975\". A escolha desses dados de mortalidade deu-se porque esses referidos estudos utilizaram uma mesma metodologia de pesquisa, baseada fundamentalmente na correçao da causa básica de óbito assinalada no atestado de óbito, através de entrevistas domiciliares e junto aos médicos, hospitais,etc. Desse modo, os 811 óbitos por tumores malígnos apresentados nesse trabalho, do período de 1962-1963, e os 452 do período de 1974-75, são mais fidedígnos que os oficiais. As variações da mortalidade foram descritas, tanto por corte transversal do tempo, quanto por coortes. Em relação ao sexo masculino, o risco morte por todas as localizações de câncer, aumentou de 1962-1963 à 1974-1975 em todos os grupos etários, exceto no de 15-24 anos.Para o sexo feminino, o risco de morte por todos os tumores malígnos, aumentou de 1962-1963 à 1974-1975 nos grupos etários de 15-24 anos de 35-44 anos e de 45-54 anos. As coortes mais jovens foram as que apresentaram maior incremento da mortal idade por câncer. / The objective of this dissertation was to study the variations of cancer mortality, in the District of São Paulo, during the período of twelve years, between 1962-1963 and 1974-1975- The baseline data used were those from the studies \"Investigação lnteramericana de Mortalidade\", done in 1962-1963, and \"Estudos dos Transtornos Mentais como Causa Básica e Associada na Mortalidade de Adultos de 15-74 anos no Distrito de São Paulo e Município de Botucatu e São Manuel em 1974-1975\'\'. These data were chosen because both studies used the same methods of research, based in the underlying cause of death registered in the death certiffcate and corrected by means of home interviews and interviews whith physicians, in hospitals and other sources of informations. So, the 811 deaths by malignant neoplasms for the period 1962-1963 and the 452 for the period 1974- 1975, studied in the present dissertation are figures more reliable than the official ones. The variations of mortality were described both under the views of a cross-section in the time and as the aspect of cohort. For males, the risk of death for all sites became greater from 1962-1963 to 1974-1975 in all age groups, except 15-24. For females, the risk became greater from 1962-1963 to 1974-1975 in the age groups: 15-24, 35-44 and 45-54. The youngest cohorts presented the greatest increment in cancer mortality.

L’objectif de cette thèse était d’investiguer différents choix méthodologiques, en particulier le choix du délai et la prise en compte des causes médicales de décès, dans l’élaboration des indicateurs de mortalité post-hospitalière visant à refléter la qualité des soins.Dans une première phase, les données médico-administratives hospitalières des bénéficiaires du Régime Général (RG) de l’Assurance Maladie décédés dans l'année suivant une hospitalisation en 2008 ou 2009 ont été appariées aux causes de décès (base du CépiDc). Le taux d’appariement était de 96,4%.Dans une deuxième phase les séjours pour lesquels la cause initiale de décès pouvait être qualifiée d'indépendante du diagnostic principal du séjour ont été repérés à l'aide d'un algorithme et d'un logiciel s'appuyant sur des standards internationaux. Dans une troisième phase, le modèle le plus souvent utilisé à l'international pour évaluer la mortalité intra-hospitalière (modèle « de Jarman ») a été reproduit et utilisé pour construire des indicateurs de mortalité par établissement à 30, 60, 90, 180 et 365 jours post-admission, pour l'année 2009 (12 322 831 séjours PMSI-MCO des bénéficiaires du RG).L’indicateur de mortalité intra-hospitalière s’est révélé biaisé par les pratiques de sortie des établissements (caractérisées par la durée moyenne de séjour et le taux de transfert vers d’autres établissements). Les indicateurs à 60 ou 90 jours post-admission doivent être préférés à l’indicateur à 30 jours car ils ont l’avantage d’inclure presque tous les décès intra-hospitaliers, limitant notamment les incitations à maintenir les patients en vie jusqu’à la fin de la période de suivi et/ou à cesser de leur dédier des ressources une fois ce terme atteint. L’utilisation des causes de décès en supprimant les décès indépendants change de façon négligeable les indicateurs de mortalité globale par établissement, toutefois elle pourrait être utile pour des indicateurs spécifiques, limités à certaines pathologies ou procédures.Des réserves quant à la pertinence de ces indicateurs ont été décrites (limites du modèle et des variables d'ajustement, hétérogénéité de la qualité du codage entre les établissements), mettant en évidence la nécessité de recherches complémentaires, en particulier sur leur capacité à refléter la qualité des soins et sur l’impact de leur diffusion publique. A ce jour, l’interprétation des indicateurs de mortalité par établissement nécessite la plus grande prudence. / The main objective of this PhD work was to investigate different methodological options for the elaboration of post hospital mortality indicators aiming at reflecting quality of care, in particular to identify the most relevant timeframes and to assess the contribution of the causes of death information.In a first phase, the hospital discharge data of the French General health insurance scheme beneficiaries who died during the year following an hospital stay in 2008 or 2009 were linked to the cause of death register. The matching rate was 96.4%.In a second phase, the hospital stays for which the underlying cause of death could be qualified as independent from the main diagnosis were identified with an algorithm and a software relying on international standards.In a third phase, the method most widely used to assess in-hospital mortality (Dr Foster Unit method) was reproduced and used to construct hospital mortality indicators at 30, 60, 90, 180 et 365 days post-admission, on year 2009 (12 322 831 acute-care stays)..As in other countries, in-hospital mortality revealed biased by discharge patterns in the French data: hospitals : short length-of-stay or high transfer-out rates for comparable casemix tend to have lower in-hospital mortality. The 60-day and 90-day indicators should be preferred to the 30-day indicator, because they reflect a larger part of in-hospital mortality, and are less subject to the incentives either to maintain patients alive until the end of the follow-up window or to shift resources away when this length of stay is reached. The contribution of the causes of death seems negligible in the context of hospital-wide indicators, but it could prove its utility in future health services research about specific indicators limited to selected conditions or procedures.However, reservations about the relevance of hospital-wide mortality indicators aiming at assessing quality of care are described (limits of the statistical model and adjustment variables available, heterogeneity of the coding quality between hospitals). Further research is needed, in particular on the capacity of these indicators to reflect quality of care and on the impact of their public reporting. To date, the use of hospital-wide mortality indicators needs to be extremely cautious.