US Vital Statistics Research Articles

A Nationwide Population-Based Study Identifying Health Disparities Between American Indians/Alaska Natives and the General Populations Living in Select Urban Counties

Despite their increasing numbers, little is known about the health of American Indians/Alaska Natives living in urban areas. We examined the health status of American Indian/Alaska Native populations served by 34 federally funded urban Indian health organizations. We analyzed US census data and vital statistics data for the period 1990 to 2000. Disparities were revealed in socioeconomic, maternal and child health, and mortality indicators between American Indians/Alaska Natives and the general populations in urban Indian health organization service areas and nationwide. American Indians/Alaska Natives were approximately twice as likely as these general populations to be poor, to be unemployed, and to not have a college degree. Similar differences were observed in births among mothers who received late or no prenatal care or consumed alcohol and in mortality attributed to sudden infant death syndrome, chronic liver disease, and alcohol consumption. We found health disparities between American Indians/Alaska Natives and the general populations living in selected urban areas and nationwide. Such disparities can be addressed through improvements in health care access, high-quality data collection, and policy initiatives designed to provide sufficient resources and a more unified vision of the health of urban American Indians/Alaska Natives.

The widening black/white gap in asthma hospitalizations and mortality

Large racial differences in asthma morbidity and mortality have prompted research on new interventions, public awareness, and health policy efforts in the past decade. We sought to characterize recent trends in US asthma hospitalization and mortality for black and white children and adults during the period from 1980 through 2002. We conducted a successive representative national cohort study of US residents ages 5 to 34 years using data from the National Hospital Discharge Survey and the US vital statistics system. Outcome measures included black/white (B/W) asthma hospitalization and mortality rates, rate ratios, and rate differences. For asthma hospitalizations from 1980 through 2002, children ages 5 to 18 years had a 50% increase in the B/W rate ratio, and the rate difference increased from 22.8 to 28.3 hospitalizations per 10,000 population. For young adults ages 19 to 34 years, the B/W rate ratio increased from 2.3 to 2.8, and the rate difference decreased from 9.6 to 7.9 hospitalizations per 10,000 population. For asthma mortality from 1980 through 2001, children ages 5 to 19 years had a large increase in the B/W rate ratio from 4.5 to 5.6 and in the rate difference from 5.6 to 8.1 deaths per 1,000,000 population. There did not appear to be a significant change in the B/W differences for adults ages 20 to 34 years. For children, there have been notable increases in asthma B/W differences in hospitalizations and mortality since 1980, whereas for adults the increase has been smaller. National efforts to improve asthma care over the past decade do not appear to have reduced this B/W gap. When treating children with asthma, it is important to consider the racial-ethnic factors that might lead to avoidable hospitalizations and premature mortality.

Post-operative radiotherapy (PORT) or chemoradiotherapy (CPORT) following resection of stages II and IIIA non-small cell lung cancer (NSCLC) does not increase the expected risk of death from intercurrent disease (DID) in Eastern Cooperative Oncology Group (ECOG) trial E3590

To determine the influence of adjuvant therapy on the risk of DID following resection of NSCLC, we compared the actuarial rate of non-cancer related deaths of patients who had been entered in Eastern Cooperative Oncology Group E3590 (a phase III trial of adjuvant therapy in patients with completely resected stages II and IIIA NSCLC) to the actuarial death rate of age and gender matched controls. Following surgery, patients were randomized to receive either PORT (5040 cGy in 28 daily fractions) or CPORT (PORT plus four cycles of cisplatin (60 mg/m2, day 1) and etoposide (120 mg/m2, days 1-3) administered concurrently). The study accrued 488 patients, 242 to the PORT only arm and 246 to the CPORT arm. The overall 4 years actuarial rate of DID for the two arms combined, with a median follow-up of 82 months, was 12.9%, not significantly different from the 10.1% expected rate of DID, based on mortality rates for age and gender matched controls derived from US vital statistics and corrected for smoking status (p=0.16). Survival distributions with regard to DID did not differ between the two treatment arms (p=0.96). DID increased with age (treated as a continuous variable, p<0.01), but was not affected by histology, side of chest irradiated, type of surgery, FEV1 or weight loss in the previous 6 months. The risk of DID following resection of stages II and IIIA NSCLC is not increased in patients who received PORT or CPORT.

Cost-effectiveness of a single colonoscopy in screening for colorectal cancer.

A single colonoscopy at the age of 65 years has been recommended as a potential option to screen for colorectal cancer. This study compares the cost-effectiveness of 2 screening programs based on a single or repeated colonoscopy. The cost-effectiveness of screening is analyzed with a computer model of a Markov process. A hypothetical population of 100 000 subjects aged 50 years undergoes a single colonoscopy at the age of 65 years or repeated colonoscopy every 10 years starting at the age of 50. Transition rates are estimated from US vital statistics and cancer statistics and published data on polyp incidence, patient compliance, and efficacy of colonoscopy plus polypectomy in cancer prevention. Costs of screening and cancer care are estimated from the 1998 Medicare reimbursement data using the perspective of a third-party payer. Compared with no screening, the incremental cost-effectiveness ratio of a single or repeated colonoscopy amounts to $2981 or to $10 983 per life year saved, respectively. A single colonoscopy saves most life years if done at the age of 60, but becomes most cost-effective after the age of 70. Depending on the level of compliance, repeated colonoscopies save 2 to 3 times more lives than a screening program based on a single colonoscopy. A repeated colonoscopy every 10 years offers better prevention against colorectal cancer and represents a medically more desirable screening option. If high costs or low patient compliance renders this option not feasible, a single colonoscopy at the age of 65 would represent a highly cost-effective alternative.

Occupational mortality from squamous cell carcinoma of the esophagus in the United States during 1991-1996.

The epidemiology of esophageal squamous cell cancer has remained poorly understood. The occupational distribution of this cancer may provide clues about its yet unknown etiology. Data files from the National Center for Health Statistics (NCHS) of the United States offer a unique source to study causes of death, broken down by occupation and industry. The number of deaths from esophageal cancer was retrieved from the computerized US vital statistics. Mortality by occupation or industry was expressed as standardized proportional mortality ratio (PMR), adjusted by age, gender, and ethnicity. Between 1991 and 1996, 63,717 subjects died from esophageal squamous cell carcinoma. Mortality was particularly high among nonwhites and men. The industrial and the occupational distributions shared a similar pattern. Mortality from esophageal squamous cell carcinoma occurred more frequently among subjects exposed to silica dust, such as brickmasons and stonemasons, concrete and terrazzo finishers, roofers, and construction laborers. It was also high in such industries as unspecified machinery or manufacturing and such occupations as unspecified material handlers, janitors, or cleaners. It was low in industries and occupations associated with agriculture, clergy, work in religious organizations, and textiles. In conclusion, mortality from esophageal squamous cell carcinoma appeared to be low in occupations associated with less consumption of alcohol and tobacco. It was high among occupations potentially associated with exposure to silica dust and chemical solvents or detergents.

Website of the week: Men's health

As I searched for men's health related websites, it seemed to me that men were mainly concerned with hair growth, penis enlargement, smart eating, and better weightlifting. We are concerned with things that do not matter but not enough with those that do. Are men's obsessions with genital size and body shape a symptom of our image dominated culture? adbusters.org/spoofads/fashion/obsession-m, which is one of a clever collection of spoof ads, offers a witty reflection on this. The US based Men's Health Network (www.menshealthnetwork.org) says that men's health and wellbeing are deteriorating steadily because of a lack of awareness, poor health education, and culturally induced behaviour patterns. Even though we'd rather ignore it, violence is a male problem. Men are responsible for most of the structural and individual violence in society. Those who suffer as a result are women, children, and, not surprisingly, men. The Men's Health Network also provides links to US vital statistics. In 1998, the age adjusted death rate for males of all races was 1.6 times that for females. In 1995 drowning was the seventh leading cause among injury related deaths in the US and males drowned four times as often as females in every age group (blacks twice as often as whites). Deaths from fires among males are 1.5 times higher than among females. For more recent, UK based data, visit www.menshealthforum.org.uk The Centers for Disease Control, always an invaluable source for those who love numbers, also devotes a slot to men's health issues (www.cdc.gov/health/mensmenu.htm). I found the mortality maps fascinating, but you would need speedy internet access, or something to do on the side while waiting for the maps to download, because these files are rather large. Worldwide there is an increasing number of serious men's health related organisations carrying out important work in the community, and a good way to find them is via the web. Gay Men's Health (www.gmhp.demon.co.uk) particularly emphasises local projects and networking, and people from the Men's Health Forum visit pubs and betting shops to screen the most vulnerable men in their normal settings.

The comorbid occurrence of other diagnoses in patients with ulcerative colitis and Crohn's disease.

The comorbidity between inflammatory bowel disease (IBD) and other diagnoses may help to shed light on the etiology and pathophysiology of IBD. The US Vital Statistics offer the opportunity to study causes of death broken down by comorbid disease associations. The aim of this study was to analyze the presence of comorbid conditions in persons who died from ulcerative colitis or Crohn's disease. The numbers of deaths from ulcerative colitis and Crohn's disease were retrieved from the computerized 1991-1996 data files of the National Center for Health Statistics. Comorbid associations between other diagnosis and ulcerative colitis or Crohn's disease were expressed as age-, gender-, and race-standardized proportional mortality ratios. Ulcerative colitis and Crohn's disease showed, in general, similar patterns of comorbidity. Both diseases were associated with similar sets of GI complications, such as intestinal obstruction and stasis, mucosal inflammation and infection, vascular complications, and complications related to fistula and abscess formation. Extraintestinal complications of both IBD involved disorders of the hepatobiliary system, urinary system, and various coagulopathies. Ulcerative colitis alone was found to be associated with Hirschsprung's disease and schizophrenia, whereas Crohn's disease alone was found to be related with osteoporosis and amyloidosis. No completely unexplained or hitherto undescribed association was revealed. The numerous intestinal and extraintestinal complications associated with IBD serve as a reminder of the systemic nature and the resultant clinical severity of both ulcerative colitis and Crohn's disease.

The comorbid occurrence of other diagnoses in patients with ulcerative colitis and Crohn’s disease

OBJECTIVES: The comorbidity between inflammatory bowel disease (IBD) and other diagnoses may help to shed light on the etiology and pathophysiology of IBD. The US Vital Statistics offer the opportunity to study causes of death broken down by comorbid disease associations. The aim of this study was to analyze the presence of comorbid conditions in persons who died from ulcerative colitis or Crohn’s disease. METHODS: The numbers of deaths from ulcerative colitis and Crohn’s disease were retrieved from the computerized 1991–1996 data files of the National Center for Health Statistics. Comorbid associations between other diagnosis and ulcerative colitis or Crohn’s disease were expressed as age-, gender-, and race-standardized proportional mortality ratios. RESULTS: Ulcerative colitis and Crohn’s disease showed, in general, similar patterns of comorbidity. Both diseases were associated with similar sets of GI complications, such as intestinal obstruction and stasis, mucosal inflammation and infection, vascular complications, and complications related to fistula and abscess formation. Extraintestinal complications of both IBD involved disorders of the hepatobiliary system, urinary system, and various coagulopathies. Ulcerative colitis alone was found to be associated with Hirschsprung’s disease and schizophrenia, whereas Crohn’s disease alone was found to be related with osteoporosis and amyloidosis. CONCLUSIONS: No completely unexplained or hitherto undescribed association was revealed. The numerous intestinal and extraintestinal complications associated with IBD serve as a reminder of the systemic nature and the resultant clinical severity of both ulcerative colitis and Crohn’s disease.

Costs of Poisoning in the United States and Savings From Poison Control Centers: A Benefit-Cost Analysis

See related editorial, p 246. Data on incidence, medical spending, and payment sources for poisoning were taken from the 1987 National Medical Expenditure Survey, 1991 US Vital Statistics, the 1992 National Hospital Discharge Survey, and 1992 poison control center surveillance data. Benefits, measured as percentage reductions in medical spending attributable to use of poison control centers, were calculated from analyses of published and unpublished studies of jurisdictions in which services became unavailable. Medical spending (payments) for poisoning treatment totaled $3 billion in 1992. Spending averaged $925 per case. Poison control center services were available for 86% of poisonings. As used, they reduced the number of patients who were medically treated but not hospitalized for poisoning by an estimated 350,000 (24%) and the number of hospitalizations by 40,000 (12%) in 1992. The average public call to a poison control center for aid prevented $175 in other medical spending. Poison control centers offer a large return on investment. Despite their proven benefits, many poison control centers are unstably funded and financially strapped, in part because the federal government pays far less than its fair share of center costs. [Miller TR, Lestina DC: Costs of poisoning in the United States and savings from poison control centers: A benefit-cost analysis. Ann Emerg Med February 1997;29:239-245.]

Racial opportunity structures and black fertility

This paper develops and tests hypotheses about the impact of opportunity structures on black fertility across local labor markets. US Vital Statistics and Census of Population data are combined and then examined with regression techniques to estimate the effect of both race-specific and relative measures of opportunity structure on black fertility in the United States. The results show that relative female opportunity structure has a negative relationship with black total fertility rates as well as with birth rates for specific points along the reproductive age structure. However, the hypothesized relationship between relative male opportunity structures and black fertility is not supported. We discuss these results as they relate to minority fertility theory and as they relate to public policy concerns.

Changes in neuroendocrine elements in bronchial mucosa in chronic lung disease in adults.

It is not clear whether there is any association between metaplasia of the bronchial epithelium and changes in the distribution of neuroendocrine cells. This study examined, by immunohistological techniques, the distribution of neuroendocrine cells and juxtamucoscal nerve fibres in bronchial biopsies showing metaplastic changes. Bronchial biopsies from 12 subjects with epithelial metaplasia associated with bronchiectasis and diffuse pulmonary fibrosis were examined by conventional light microscopy and immunohistological techniques for protein gene product 9.5 (PGP), chromogranin A and B (CAB), serotonin, vasoactive intestinal peptide (VIP), substance P (SP), calcitonin gene-related peptide (CGRP), calcitonin (CT), and gastrin releasing peptide (GRP). Regions of non-metaplastic epithelium contained numerous PGP and serotonin immunoreactive cells. Sub-populations of these cells displayed CAB, CGRP, CT, and GRP immunoreactivity. Metaplastic epithelium contained only a few weakly stained PGP, serotonin, CAB, GRP, CT and CGRP immunoreactive cells in six cases. Metaplastic epithelium was characterised by a high number of CAB-containing cells in six cases and in these biopsies prominent PGP-containing nerve bundles were seen in the subepithelial layer beneath the metaplastic epithelium. The distribution patterns of neuroendocrine cells and neuronal elements vary between areas of normal and metaplastic epithelium and within areas of metaplastic epithelium. Neuronal hyperplasia was associated with an increase in the number of CAB-containing cells within the metaplastic epithelium.

The epidemiology of stroke in Native Americans.

Because of the paucity of published information, this report seeks to better characterize the pattern of stroke occurrence and risk factors among Native Americans in the United States. Data from the US Vital Statistics System and two National Health and Nutrition Examination Surveys were analyzed. Stroke was a leading cause of death among US Native Americans in 1990. In persons aged 45 and over, stroke was the cause of 6% of deaths in Native Americans and 7% of deaths in whites. The percentage of stroke deaths due to hemorrhagic stroke was higher in Native Americans than whites. In 1988 through 1990, stroke death rates were similar in Native Americans and whites under age 65 but lower in Native Americans at ages 65 years and over. High prevalence of diabetes, smoking, and obesity may contribute to stroke mortality in Native Americans. Targeted research, innovative analyses of existing data, and use of ongoing surveys and the Census should be considered in the study of the epidemiology of stroke, other leading causes of death, and risk factors in Native Americans. Continued hypertension detection and treatment efforts are needed for Native Americans as for other groups. Smoking cessation and prevention should receive high priority in Native American populations.

Why infant very low birthweight rates have failed to decline in the United States vital statistics.

Very low birthweight (VLBW) rates, i.e. births of < 1500 g, have been long established as the major determinant of outcome for infants. Nevertheless, despite much medical, political and social effort, these rates have not declined during the past 40 years in the US Vital Statistics. To explore the causes of this disturbing finding, trends in low birthweight distribution at a community hospital and the Vital Statistics data were investigated. The weights of livebirths and foetal deaths (27,944 births) at a community hospital during three 5-year periods, 1973-1987, were examined for trends in low birthweight (LBW) distribution, and they were contrasted with the US Vital Statistics. For white infants weighing 500-999 g the livebirth rates declined from 3.7 per 1000 births in period one to 1.1 per 1000 in period three (70.2%); for white infants 1000-1499 g, livebirths declined from 4.2 to 3.2 per 1000. Hospital white livebirths < 2500 g declined 18.7% from the first to the third period. Among black livebirths the LBW rate also declined from 126.4 per 1000 in period one to 85.4 per 1000 in the third period. Foetal deaths declined from 8.2 per 1000 births to 6.2 per 1000 in period three, a 24.4% decline. However, foetal deaths < 500 g increased 411%, from 3.6% of the total foetal deaths in period one to 18.4% in the third period. Increasing registration of births in the US may have hidden a marked improvement in the VLBW problem. More complete registration of births and changes in the perception of viability appear responsible for the artefact.

Melanoma: linked temporal and latitude changes in the United States.

The rise in the incidence and mortality from melanoma of the skin is slowing down in younger age groups in the United States. In many White populations, including that of the US, melanoma incidence and mortality rates increase according to proximity of residence to the Equator. Variations with age in this gradient do not seem to have been examined. We examined how the influence of latitude on melanoma rates varied with age. Estimates of age-specific trends by time and by latitude for natural logarithm (Ln) melanoma incidence-rates from the Surveillance, Epidemiology and End Results (SEER) programs, and Ln melanoma mortality rates from the US Vital Statistics were derived from fitted regression equations. Unexpectedly, a decline from old age to youth in the influence of latitude was found for both incidence and mortality from melanoma of the skin in males, and for mortality in females. Further, these changes in the relationship to latitude with age correlated with the changes in time trends with age. The link with exposure suggests that the time trends in melanoma are driven by variations in damage to melanocytes in early life that increases sensitivity to sunlight. This has implications for the general understanding of melanoma etiology and for health education.

The costs of multiple pregnancy

This paper reviews US vital statistics to describe the increase in multiple births in the United States between 1977 and 1987 and clarify the participation of differing maternal ethnic and age groups to this trend. The projected needs for NICU beds and costs of handicaps are estimated based on the distribution of low birthweights in multiple gestations. The potential methods of changing the distribution of low birthweight infants in multiple pregnancies are discussed.

Infectious Disease-Related Deaths of Low Birth Weight Infants, United States, 1968 to 1982

Infant mortality rates in the United States are higher than in any other developed country. Low birth weight (LBW) is the primary determinant of infant mortality. Despite city, state, and federal programs to prevent LBW, decreases in infant mortality in the 1980s appear to be largely secondary to improved survival of LBW infants rather than to a decline in the rate of LBW births. Because prevention of mortality due to infectious disease is feasible, it was of interest to examine the role of infectious diseases in LBW infant mortality. US vital statistics mortality data for 1968 through 1982 were analyzed in terms of LBW infant mortality associated with infectious and noninfectious diseases. These analyses indicated that the rates of infectious disease-associated early neonatal and postneonatal LBW mortality increased during this time; late neonatal rates did not decline appreciably. Infectious diseases were associated with 4% of all LBW infant deaths in 1968; this had increased to 10% by 1982. Although LBW infant mortality rates associated with noninfectious diseases did not differ for white and black populations, infectious disease-associated mortality rates were consistently higher for blacks than whites in both metropolitan and nonmetropolitan areas. Chorioamnionitis was involved in 28% of infectious disease-associated early neonatal LBW deaths. Sepsis was an increasingly listed cause of death in all infant age periods, whereas respiratory tract infections were decreasingly listed. Necrotizing enterocolitis increased as a cause of late neonatal mortality. These data suggest that infectious diseases are an increasing cause of LBW infant mortality and these deaths occur more frequently in the black population targeted by prevention programs.(ABSTRACT TRUNCATED AT 250 WORDS)

Decline in US stroke mortality. Demographic trends and antihypertensive treatment.

Stroke mortality has been falling rapidly in this country since 1973. To investigate age-race-sex effects on stroke mortality, we studied US vital statistics during 1950-1972 and 1973-1981 in 55-64-, 65-74-, and 75-84-year-old race-sex groups. The accelerated rate of decline in stroke mortality since 1973 has had a substantial public health impact, with greater than 200,000 fewer stroke deaths than would otherwise have occurred. For all groups, stroke mortality declined at a greater rate (p less than 0.05) in 1973-1981 than during 1950-1972. The rates of decline during 1973-1981 were greater with increasing age (p less than 0.05) and were more substantial for younger blacks. There were no consistent differences in the rate of decline by sex. The greater rate of decline in absolute stroke mortality in the older age groups and blacks was explained by higher baseline mortality in these groups. Overall, stroke mortality decreased by approximately 2%/yr in 1950-1972 and by approximately 7%/yr after 1973. Rank order of average annual percent decline after 1973 by age-race-sex groups did not correspond to rates of change in treatment or control of hypertension obtained from three national surveys. The accelerated rate of decline after 1973 may have resulted from improved antihypertensive therapy, but our findings fail to confirm this hypothesis and suggest that treatment of hypertension may not be the principal reason for the decline in stroke mortality.

Trends in gastric cancer sex ratio in the United States.

Recent reports have suggested that the male/female ratio for gastric cancer has decreased over time and that the mean age of cases has increased. The authors calculated age- and sex-specific mortality rates for gastric cancer from 1950 through 1979 for whites using data from US Vital Statistics and population estimates from the US Census Bureau. Whereas sex ratios based on crude mortality rates showed a decrease over time from 1.7 in 1950 to 1.5 in 1979, similar ratios based on age-adjusted mortality rates showed an increase from 1.8 to 2.1. An increase in mean age at death over time was consistent with the increase in age of the population. The authors conclude that factors responsible for the decrease in gastric cancer mortality in the United States appear to have affected males and females equally. The overall data do not support the emergence of a new form of gastric cancer with a sex ratio or age pattern different from that found in the past.

Editorial: The prevalence and malignancy of Alzheimer disease. A major killer.

An accompanying letter to the editor (p 304) provides another illustration of the malignancy of Alzheimer disease, a phenomenon well known to neurologists. Katzman and Karasu 1 estimate that the senile form of Alzheimer disease may rank as the fourth or fifth most common cause of death in the United States. Yet the US vital statistics tables do not list "Alzheimer disease," "senile dementia," or "senility" as a cause of death, even in the extended list of 263 causes of death. The argument that Alzheimer disease is a major killer rests on the assumption that Alzheimer disease and senile dementia are a single process and should, therefore, be considered a single disease. Both Alzheimer disease and senile dementia are progressive dementias with similar changes in mental and neurological status that are indistinguishable by careful clinical analyses. 2,3 The pathological findings are identical—atrophy of the brain, marked loss of neurons