Data From North Carolina Out-of-Hospital Deaths Raise Many Questions

A small study of sudden out-of-hospital deaths raises questions about the quality of primary care, especially for women.

The road to measuring healthcare quality is a long one, as researchers from the University of North Carolina at Chapel Hill learn as they study why relatively young people suddenly die, despite being under a doctor’s care.

Led by Zachariah Deyo, PharmD, BCPS, CPP, an adjunct assistant professor at Eschelman School of Pharmacy, the team is examining risk factors for out-of-hospital sudden deaths involving men and women under age 65. So far, results confirm part of their hypothesis: women are prescribed plenty of medication—but it isn’t always evidence-based, and cardiometabolic conditions that need treatment are sometimes missed.

Deyo presented the results during Sunday’s poster session at the 65th Scientific Session of the American College of Cardiology, taking place in Chicago, Illinois.

While their work is far from done, what the UNC team has found raises questions about the quality of primary care that patients with cardiovascular risk factors receive, especially women. Heart disease was the number one killer in the United States in 2013, and diabetes was seventh, according to CDC data. For 2013, the year studied, North Carolina’s death rate from heart disease is 165.3 per 100,000 which is a little better than the US rate of 169.8 per 100,000, according to CDC.

To start, the team examined 187 cases of sudden out-of-hospital death from Wake County, which includes the area around the state capital of Raleigh, not far from UNC. According to the abstract, these cases represent 14% of all natural deaths in persons under age 65.

The cases occurred the year before healthcare coverage was available on the federal exchange under the Affordable Care Act. In an interview with The American Journal of Managed Care, Deyo said insurance status is one of the many data points the team hopes to pull from pharmacy claims, as it moves into its next phase of work.

Among cases from 70 women and 117 men, women were prescribed more medications than men, 5.34 vs. 3.59. (In a sensitivity analysis, the differential between women and men was calculated to be 9.08 medications vs. 5.86; p = 0.0081.) However, consistent use of evidence-based guidelines in prescribing did not differ much for either coronary artery disease (CAD) or diabetes.

Among these patients, use of antiplatelet agents, angiotensin receptor blockers (ARBs), angiotensin-converting enzyme (ACE) inhibitors, and even statins—the mainstay of such care—was low. In fact, only 15.4% of women and 26.9% of men with CAD were taking a statin. Only 56.1% of the persons who had a diagnosis of diabetes were taking a prescription for that disease.

So what kind of medications were these people taking? Women were prescribed antidepressants, opioids, anxiolytics, and more ACE inhibitors than the men.

The team lists 4 areas for further study:

· Gather more data, perhaps from more counties and additional years, to increase the sample size.

· Explore what is behind the high use of antidepressants, antipsychotics, opioids, anxiolytics and antiepileptic medications in women.

· Study the relationship between the available toxicology and medication data.

· Use pharmacy claims to gauge medication adherence.


Deyo Z, Conover M, Pursell I, et al. Use of evidence-based medications for coronary artery disease and diabetes in women and men with out of hospital sudden unexpected death in the Sudden Unexpected Death in North Carolina (SUDDEN) Study. Presented at the 65th Scientific Session of the American College of Cardiology, Chicago, Illinois. April 3, 2016. Abstract 1191-384.