Multiple Cause of Death Data

1. Multiple Cause of Death Data A Resource for Mortality Study

2. Multiple Cause of Death Data

3. Introduction | Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A US Cause of Death Mortality Trends

4. Introduction | Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Major Shifts in U.S. Cause of Death During Last Century • At beginning of 20th century • Infectious diseases were a major contributor • Acute illness often progressing to death • Clear underlying cause of death • Even non-infectious diseases • e.g. cancers, heart disease • Tended to strike suddenly, progress rapidly • Clear underlying cause of death

5. Introduction | Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Major Shifts in U.S. Cause of Death During Last Century • At end of 20th century • Infectious diseases no longer a major contributor • Chronic illness, may progress to death • Less clear as an underlying cause of death • Non-infectious diseases • Primarily chronic illnesses • Unclear underlying cause of death • Comortality • Multiple Cause of Death data

6. Introduction | Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A The National Vital Statistics System • In the United States, legal authority for the registration of births, deaths, marriages, divorces, fetal deaths, and induced terminations of pregnancy (abortions) resides individually with the states (as well as with cities, in the case of New York City and Washington, D.C.). • In effect, the states are the full legal proprietors of the vital statistics records and the information contained therein, and are responsible for maintaining registries according to state law, and issuing copies of birth, marriage, divorce, and death certificates. • Under the Vital Statistics Cooperative Program (VSCP), the federal government, acting through its agent, the National Center for Health Statistics (NCHS), partially supports state costs of producing vital statistics through a contract with each state. The Division of Vital Statistics (DVS) within the NCHS administers the VSCP. Weed JA; Population Index 61(4):527-539. Winter 1995.

7. Introduction | Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Developments in Mortality Statistics • Throughout the twentieth century, U.S. cause-of-death statistics have been classified and disseminated according to the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD). • Using the selection rules of the ICD, a single cause is selected from among those reported by the physician certifying a particular death. Ideally, this should be the "disease or injury that initiated events resulting in death", and this disease or injury is classified and tabulated as the underlying cause of death. Prior to automation, this selection process was done manually by experts in disease classification, called nosologists. • Beginning in 1968, the NCHS developed computer systems to automatically select the underlying cause for each death certificate and to produce multiple cause-of-death data. • Moreover, it has long been recognized that good use could be made of the multiple causes of death if it were properly "cleaned" and reduced. The computer systems accomplish this. • Public Use files containing multiple-cause data (plus all demographic information and the underlying cause for each decedent) are available from the NTIS for all data years since 1968. Weed JA; Population Index 61(4):527-539. Winter 1995.

8. Introduction | Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A NCHS Computer Systems • Automated Classification of Medical Entities (ACME) • automatically selects the underlying cause of death • MICAR (Mortality Medical Indexing, Classification, and Retrieval) • a data-entry system to ACME that requires less coder training • maintains accurate and consistent results • Super-MICAR – for electronic death certificates • TRANSAX • produces multiple cause-of-death data

9. Multiple Cause of Death Data

10. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Death Certificates: WHO => NCHS => States

11. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Death Certificates

12. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Death Certificates

13. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Death Certificates

14. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Death Certificates

15. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Death Certificates

16. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Death Certificates

17. Multiple Cause of Death Data

18. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A MCOD Public Release Data • Annual datasets • Currently running @ ~ 2.5 million deaths per annum • All deaths within U.S. with the exception of years 1972, 1981, and 1982 • Wide format with many empty fields • Not designed with longitudinal studies in mind! • Cause of death coding • 1968 thru 1978: ICDA (modified version of ICD-8) • 1979 thru 1998: ICD-9 (with substitutions for traumatic causes) • 34-, 61-, 72-, and 282-bin cause of death recodes • 1999 thru 2009 (most recent release): ICD-10 • 39-, 113-, 130-, and 358-bin cause of death recodes • Other fields • Actual date of death thru 1988 • Constants: age, sex, month of death, marital status • 12-, 22-, 27-, 52-bin age recodes • Variable: education level • Variable to non-existent: geography codes

19. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A MCOD Public Release Data - 2003 First 15 of 2,452,154 rows First 90 of 488 columns ··················11AK999AK9AK··AK9999999992AK00009900OR··OR14·001··F1079·412110··4W4····· ··················11AK999AK9AK··AK9999999992AK00009900NY··NY17·001··F1088·432311··1W6····· ··················11AK999AK9AK··AK9999999992AK00009900WA··WA15·001··F1059·371708··6D7····· ··················11AK999AK9AK··AK9999999992AK00009900TX··TX16·001··F1084·422210··4W7····· ··················11AK999AK9AK··AK9999999992AK00009900AK··AK12·001··M1039·331306··4S1····· ··················11AK999AK9AK··AK9999999992AK00009900AK··AK12·001··M1082·422210··4M6····· ··················11AK999AK9AK··AK9999999992AK00009900AK··AK16·001··M1086·432311··1M4····· ··················11AK999AK9AK··AK9999999992AK00009900ID··ID09·001··M1072·402009··4M4····· ··················11AK999AK9AK··AK9999999992AK00009900AK··AK00·001··M2004·150201152S1····· ··················11AK020AK2AK··AK0200300021AK03802100MI··MI12·001··F1075·412110··4M3····· ··················11AK020AK2AK··AK0200300021AK03802100AK··AK12·001··F1062·381808··1M4····· ··················11AK020AK2AK··AK0200300021AK03802100OH··OH12·001··F1079·412110··1W3····· ··················11AK020AK2AK··AK0200300021AK03802100CA··CA15·001··F1058·371708··1M6····· ··················11AK020AK2AK··AK0200300021AK03802100AK··AK00·001··F2002·130201132S2····· ··················11AK020AK2AK··AK0200300021AK03802100HI··HI12·001··F1022·301004··7S6····· State of birth recode Age Marital status Sex State of birth Expanded state of occurrence blank State of residence State of residence recode Expanded state of residence State of occurrence

20. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A MCOD Public Release Data - 2003 ··············································01··11·································280·5 ··············································02··32·································100·7 ··············································01··11·································280·5 ··············································01··11·································100·6 ··············································02··32·································100·7 ··············································02··32·································100·7 ··············································01··11·································998·9 ··············································01··11·································260·2 ··············································01··11·································260·2 ··············································02··32·································100·7 ··············································02··32·································998·9 ··············································02··32·································100·7 ··············································01··11·································280·5 ··············································02··32·································998·9 ··············································01··11·································100·6 ··············································01·111·································280·5 Race Last 15 of 2,452,154 rows Last 90 of 488 columns

21. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Death Certificate I233 I21 I240 I250 E14 J449 Z720 Entity axis: 11I233 21I21 31I240 41I250 61E14 62J449 63Z720 Record axis: E14 I21 I250 J449 Z720

22. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A MCOD Public Release Data - 2003 1911T179·12W80··13J189·21K319·22E119·31G309·41I64··42N390·43I500·44I48··45I454·61I64··62L89 0611C349·12C793·13C795·61N19··62E46··63F179················································ 0111I250··················································································· 0211C349·21C349············································································ 0711A419·21C61··61E889·62E872·63N19··64N390·65I251········································· 0811J189·21J690·61C444·62C795·63I48··64R000·65T455·66X44··································· 0211N19··21I500············································································ 0611C793·21C349·61G309·62C509·63C189·64F179················································ 0111C259··················································································· 0611I219·21I251·31E149·61I802·62I500·63F179················································ 0511I64··12I678·21I48··61I500·62F03························································ 0111C20···················································································· 0311I269·21I802·31J449····································································· 0411F03··21G20··22G049·61I10······························································· 0211C109·61F179············································································ Entity Axis Columns 163 - 253 Rows 1,057,500 – 1,057,514

23. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A MCOD Public Release Data - 2003 13·A419·D649·E115·G309·I454·I48··I500·I64··J189·K319·N390·T179·W80···· 06·C349·C793·C795·E46··F179·N19······································· 01·I250······························································· 01·C349······························································· 06·A419·C61··E872·I251·N19··N390······································ 08·C444·C795·I48··J189·J690·R000·T455·X44····························· 02·I500·N19··························································· 06·C189·C349·C509·C793·F179·G309······································ 01·C259······························································· 06·E149·F179·I219·I251·I500·I802······································ 05·F03··I48··I500·I64··I678··········································· 01·C20································································ 03·I269·I802·J449····················································· 04·F03··G049·G20··I10················································· 02·C109·F179·························································· Record Axis Columns 341 - 410 Rows 1,057,500 – 1,057,514

24. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Relational Data Storage

25. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A MCOD Public Release Data

26. Multiple Cause of Death Data

27. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Redelings MD, Sorvillo F, Simon P. A comparison of underlying cause and multiple causes of death: US vital statistics, 2000-2001. Epidemiology. 2006 Jan;17(1):100-3.

28. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Redelings MD, Sorvillo F, Simon P. A comparison of underlying cause and multiple causes of death: US vital statistics, 2000-2001. Epidemiology. 2006 Jan;17(1):100-3.

29. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Paula H, Asrani SK, Boetticher NC, Pedersen R, Shah VH, Kim WR. Alcoholic liver disease-related mortality in the United States: 1980-2003. Am J Gastroenterol. 2010 Aug;105(8):1782-7. Epub 2010 Feb 23. OBJECTIVES: Data on temporal changes in alcoholic liver disease (ALD)-related mortality in the United States are lacking. This longitudinal assessment is important, given the divergent data on trends in worldwide ALD-related mortality, concerns for underestimation of mortality attributed to ALD in previous investigations, and shifting attention to hepatitis C virus (HCV)-related mortality. METHODS: We analyzed mortality data compiled in the multiple cause-of-death public-use data file from the National Vital Statistics System from 1980 to 2003 using categorization by both International Classification of Diseases (ICD)-9 and ICD-10 systems. The main outcome measure was age- and sex-adjusted death rates attributable to ALD, HCV, or both (ALD/HCV) listed as immediate or underlying cause of death. The standard death certificates were extracted for information in part I of the certificate, which records the “immediate” or “underlying” causes of death. Information from part II, which includes information on other “significant conditions contributing to death but not resulting in the underlying cause given in Part I,” was not extracted...

30. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Paula H, Asrani SK, Boetticher NC, Pedersen R, Shah VH, Kim WR. Alcoholic liver disease-related mortality in the United States: 1980-2003. Am J Gastroenterol. 2010 Aug;105(8):1782-7. Epub 2010 Feb 23. When hepatitis C serology testing was introduced in the early 1990s, a rapid increase in HCV-related deaths was observed. Therefore, it is possible that alcohol-related mortality may have remained at a constant rate throughout the 1980s and 1990s, but HCV-related deaths may have been mistakenly classified as alcohol related, leading to the apparent decline. RESULTS: A total of 287,365 deaths were observed over the 24-year period. Age- and sex- adjusted incidence rates of ALD-related deaths decreased from 6.9/100,000 persons in 1980 to 4.4/100,000 persons by 2003. After introduction of HCV diagnostic testing, HCV-related liver mortality increased to 2.9/100,000 persons by 2003. Death rates for subjects with concomitant ALD/HCV rose to 0.2/100,000 persons by 1999 and then remained unchanged through 2003… CONCLUSIONS: Despite a decline in ALD-related mortality, the proportion of alcohol-related liver deaths is still considerably large and comparable in scope to that of HCV.

31. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I Mortality Improvement I Q & A Redelings MD, Wise M, Sorvillo F. Using multiple cause-of-death data to investigate associations and causality between conditions listed on the death certificate. Am J Epidemiol. 2007 Jul 1;166(1):104-8. …analysis of the 114,380 deaths reported in the United States from 1990 to 2001 in which pressure ulcers were listed as a cause of death…septicemia is also reported on 45,374 (39.7 percent) of these death certificates…this percentage is far higher than we would expect to see among decedents without pressure ulcers..

32. Multiple Cause of Death Data

33. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I MortalityImprovementI Q & A Extrapolation: e.g. life expectancy

34. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I MortalityImprovementI Q & A Components of Mortality Change IDMOA: Males ages 50+

35. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I MortalityImprovementI Q & A U.S. Males Ages 75-84: Underlying Cause of Death

36. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I MortalityImprovementI Q & A Mortality rate mx by Cause-of-Death Male 75-84

37. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I MortalityImprovementI Q & A Diabetes Mellitus: Market Share Analysis

38. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I MortalityImprovementI Q & A Diabetes Mellitus: Mortality Rates

39. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I MortalityImprovementI Q & A Diabetes Mellitus: Overall Mortality Rates

40. Multiple Cause of Death Data

41. Introduction| Death Certificates | Nuts & Bolts | Medical Literature I MortalityImprovementI Q & A Typical Questions • Aren’t the certifying physicians’ opinions as to cause of death highly subjective and inaccurate? • Yes, and no. For any particular death certificate the ucod (and other cod’s) could be way off. However, MICAR and TRANSAX software do a good job of eliminating most errors and converting DC entries into usable data. At the very least, the MCOD data is a good survey of what is killing Americans. • Don’t the changes in field types and values make it difficult to do longitudinal studies? • Yes. As with many datasets, one is limited to certain well-conserved fields for longitudinal study. Other studies can provide shapshots of mortality phenomena using data fields that are available for a few years only. • What is the significance of the lack of geography codes for the years 2005 to present? • Geography fields can help distinguish phenomena on the basis of socioeconomics. Fortunately, education is an excellent proxy for socioeconomic status and the educational level fields are well-conserved in the MCOD data. • How can you use comortality rates when they “don’t add up?” • I would never use any comortality statistic alone. Instead, always in combination with ucod or other more straightforward statistic. • I would always keep in mind that there is no “conservation of mortality.” • There are other measures of comortality besides mortality rate.