Telemedicine Use in Children Aged 0–17 Years: United States, July–December 2020

May 10, 2022

Questions for Maria Villarroel, Health Statistician and Lead Author of “Telemedicine Use in Children Aged 0–17 Years: United States, July–December 2020.”

Q: Why did you decide to look at telemedicine among U.S. children during the pandemic?

MV: We know that telemedicine use expanded during the COVID-19 pandemic. Telemedicine became a key practice in health care that supports social distancing and decreases contact between health care staff and other patients for the receipt of health care services and reduce the spread of infection. However, there are limited estimates of telemedicine use, especially in children, and this report aims to address that gap.


Q: How did the data vary by age groups, income level and region?

MV: We examined telemedicine use in two ways: 1) telemedicine use in the past 12 months from the time of interview in July-December 2020, so this included both pre-pandemic and pandemic periods; and 2) telemedicine use because of reasons related to the coronavirus pandemic during the first year of the pandemic – 2020.

We found that telemedicine use in the past 12 months varied by age of the child and family income. Telemedicine use in the past 12 months was highest for younger children (aged 4 years and under) and older children (12 to 17 years), and lowest for children aged 5 to 11 years.  Telemedicine use in the past 12 months was highest for children with family incomes below the federal poverty level and at or above 400% of the federal poverty level, and lowest for children with family incomes at 100%–199% of the federal poverty level.  Although not statistically significant, a similar pattern by age was observed for telemedicine use due the pandemic, while telemedicine use due to the pandemic was highest for children with family income at or above 400% of the federal poverty level.

Telemedicine use in the past 12 months and telemedicine use because of the pandemic varied by region. Children living in the Northeast were more likely to have used telemedicine than children living in the Midwest and South regions, and similarly as likely to have used telemedicine as children living in the West region. 


Q: How did telemedicine use vary between urban and rural areas?

MV: In this study, we used the NCHS Urban–Rural Classification Scheme for Counties to classify urbanization level, and we compared telemedicine use in children living in large metropolitan areas, medium and small metropolitan areas, and nonmetropolitan areas.

We found that both telemedicine use in the past 12 months and telemedicine use because of the pandemic were lower in nonmetropolitan areas compared with metropolitan areas. But we also observed that the percentage point difference between metropolitan and nonmetropolitan areas was wider for the use of telemedicine because of the pandemic than for telemedicine use in the past 12 months. For example, we observed that children residing in metropolitan areas were more than two times as likely to have use of telemedicine because of the pandemic compared with children residing nonmetropolitan areas, but children in metropolitan areas were only about 1.3 to 1.4 more likely than children in nonmetropolitan areas to have used telemedicine in the past 12 months.   


Q: Do you have comparative trend data that goes further back than the second half of 2020?

MV: No. Telemedicine questions were introduced into the NHIS survey in July 2020 as one of the emerging public health topics affecting the United States related to the COVID-19 pandemic, which was declared in March 2020 by the World Health Organization.

Trend data on telemedicine use in children is limited.  Since April 2020, the experimental data system called the Household Pulse Survey, which is a collaboration between multiple federal agencies, began collecting data on telemedicine use in the past 4 weeks in households with at least one child under 18 years of age, among other social and economic impacts of the COVID-19 pandemic. 


Q: What is the main takeaway message here?

MV: Approximately 12.6 million children in the U.S.—corresponding to 17.5% of children aged 0–17 years—used telemedicine in the past 12 months from the time of interview in July-December 2020 (a period that included time before and during the coronavirus pandemic).  

Telemedicine use in the past 12 months varied by age of the child, family income, and region of the country.

Approximately 10.2 million U.S. children—corresponding to 14.1% of children aged 0–17 years—used telemedicine in 2020 because of the pandemic.

Telemedicine use because of the pandemic varied by education of the parents living with the child and region of the country and urbanization level of residence.

Telemedicine use in the past 12 months and because of the pandemic was higher for children with current asthma, a developmental condition, and disability.


PODCAST – 2020 Final Death Statistics: COVID-19 as an Underlying Cause of Death vs. Contributing Cause

January 7, 2022

https://www.cdc.gov/nchs/pressroom/podcasts/2022/20220107/20220107.htm

HOST:  NCHS closed out the year in December with the release of final data on deaths in the United States for 2020.  As in past years, these final death statistics focus on conditions or injuries that are listed as the underlying cause of death on the death certificate, and do not include conditions or injuries listed as a contributing cause on the death certs. 

Many of the 2020 findings had been released previously, in preliminary or provisional form:  The final number on life expectancy showed a decline of 1.8 years in 2020.  The final overall death rate in America rose from 715 deaths per 100,000 in 2019 to 835 per 100,000 in 2020 – a nearly 17 percent increase.  Death rates increased for 6 of the 10 leading causes of death in 2020, including a nearly 17 percent increase in deaths from accidents or unintentional injuries… as well as a nearly 15 percent increase in deaths from diabetes.  Meanwhile, death rates decreased for 2 leading causes of death – cancer and chronic lung disease – and remained unchanged for another cause: kidney disease.  Also, suicide fell out of the top 10 leading causes of death in 2020 after the number and rate of suicide dropped for a 2nd consecutive year.

And of course there was a new entry to the list of 10 leading causes of death in 2020.  COVID-19 was the 3rd leading cause of death in 2020, with nearly 150,000 more deaths than the 4th leading cause of death, accidents, and over 250,000 fewer deaths than the 2nd leading cause of death, cancer.  The final, official tally of COVID-19 deaths in the U.S. for 2020 was 350,831.  CDC had reported a higher number of deaths from its case surveillance reporting system, and NCHS had also posted a higher number on its web site, closer to 385,000 deaths – which included any death mentioning COVID.  The official 350,831 COVID-19 deaths for 2020 reflects deaths in which COVID was the underlying cause of death.

Joining us today to talk about these 2020 numbers for COVID-19 numbers, as well as the difference between tracking underlying causes of death and contributing causes of death, is Mortality Statistics chief Robert Anderson.

HOST:  The final data for 2020 show over 350,000 deaths from COVID-19, meaning the virus was the underlying cause of death.  Can you explain what the underlying cause of death means?

ROBERT ANDERSON: The underlying cause of death is the condition that initiated the chain of events leading to death.  When the death certificate is filled out, the person who’s reporting the cause of death is asked to identify a chain of events, sort of a causal pathway, working from the immediate cause back to the underlying cause.  So an example of a chain of event or pathway would be viral pneumonia due to COVID-19.  That’s a causal pathway – COVID-19 causes viral pneumonia which then would kill the person, so COVID-19 in that instance is considered the underlying cause of death – that condition that started everything forward.  And the reason why we tend to focus on the underlying cause is because that’s the condition that’s considered most amenable to public health prevention, the idea being that if you can prevent the underlying cause then you can prevent the entire chain of events from occurring.

HOST: Now there might be some confusion because the number that had been reported for 2020 was close to 385,000 deaths.  So what about those other (almost) 34,000 deaths that some people thought were COVID-19 deaths but aren’t included in this latest tally?

ROBERT ANDERSON:  Right, so the 385,000 deaths that we would refer to as “involving COVID-19.” The other 34,000 would be deaths in which COVID-19 was a contributing factor but not the underlying cause.  So it may have exacerbated an existing disease or it may have contributed in some way but it wasn’t what initiated the chain of events leading to death.  And the person who is certifying the cause of death – usually it’s a physician, medical examiner, or coroner – has to determine what role COVID-19 played in causing the death, and this is essentially three options: it was the underlying cause and it initiated that chain of events; it was a contributing factor and played some role but it wasn’t the underlying cause; or it wasn’t a factor at all, in which case it shouldn’t be reported on the death certificate.

HOST: OK so it seems like there’s a fine line there and this sort of prompts another question:  In the new 2020 final data, we see significant increases in deaths from diabetes, for example, also from Alzheimer’s disease… heart disease… and those are the underlying cause of death so is it possible that some of those deaths, COVID-19 was listed as a contributing factor?

ROBERT ANDERSON:  Sure it’s likely, actually, that for some of those conditions COVID-19 was listed as a contributing factor, and it may have been a contributing factor in cases in which COVID-19 wasn’t listed as well – particularly in the beginning of the pandemic back when we didn’t know very much about the disease and when there wasn’t widely available testing.  It’s possible that some of those deaths are actually COVID deaths but were attributed to those other causes.  So the increase may be COVID-related.  There is also this other category that’s sort of important to recognize as well, and these are cases in which the death may have been related to the pandemic but not to the virus specifically.  This would be cases where people perhaps didn’t get the care that they needed for whatever reason – either they were afraid to go to the hospital or the doctor or they weren’t able to get into the doctor.  Particularly with a disease like diabetes that requires a fair amount of maintenance and monitoring.  If people are not going to the doctor to get checked out they’re gonna be at higher risk of dying.

HOST: So again, for those who might be confused about this, obviously with COVID-19 you have a very wide spectrum of severity – you’ve got people who may have had it but never knew they had it, or people who have tested positive but never had any symptoms, to the other end where people are severely ill.  How is it determined on the death certificate for COVID to be just a contributing cause?  It would seem like, wouldn’t it be like one or the other?  Either it was an underlying cause or didn’t really play a factor?

ROBERT ANDERSON:  Well it’s a complicated issue.  So you could have for example somebody with COVID who has symptoms, is symptomatic, but the symptoms aren’t particularly severe, but in a case with somebody with like chronic obstructive pulmonary disease or somebody with a heart condition, a serious heart condition, even fairly mild COVID symptoms could sort of push them over the edge and then the certifier has to make a judgment as to what role COVID played in that scenario.   And it’s not not always easy – sometimes it can be quite straightforward, other times not so much, particularly when you have somebody who has multiple serious chronic diseases or people who perhaps are terminally ill. The certifier has to decide what caused that person to die when they did and in some cases it might be that COVID caused them to die when they did, but it might also be a case where COVID just sort of made things worse and they died from the pre-existing condition.  It can be a difficult decision to make.

HOST: I know I’ve asked you this one before but just again to clarify: If someone is admitted to the hospital with an injury – a car accident for example – and they are tested for COVID and test positive, and then they die from their injuries in the crash –COVID would not be a “contributing cause” on the death certificate correct?

ROBERT ANDERSON:   In most cases I think not, but it is possible that COVID could complicate the clinical situation such that it makes survival less likely.  It would depend on the severity of the injuries – maybe the person comes in and they’ve got a very severe injury and they simply test positive for COVID and there are no symptoms that are likely be incidental to death.  But if you had somebody who let’s say had chest trauma from the car accident and they were, they’re struggling to breathe already… They get COVID in the hospital and they’re showing some symptoms… there, it could contribute.  So it’s really – the certifier has to look at the whole clinical picture and then make a judgment as to whether COVID played a role and then what role it played in the death, if they determine that it played a role.

HOST:  In looking at some other examples the one that comes to mind would be influenza –does influenza turn up a lot on death certificates as a contributing but not an underlying cause of death?

ROBERT ANDERSON:  Not very often – influenza is substantially underreported on death certificates to begin with.  It’s a little better now than it used to be with the rapid testing, but very often when people die from the flu they’re dying of the complications of the flu, and often after the point at which it can be determined that they had the flu.  So somebody gets the flu, they’re at home for seven to 10 days with that, they develop a secondary infection, bacterial infection, let’s say bacterial pneumonia, and struggle with that for a few more days and then go to the hospital.  Even if they’re tested for the flu they’re not going to test positive, flu is not gonna show up, so it can be very difficult unless the certifier knows that the person had the flu and understands the chain of events to figure out what happened.  So I think we’d have similar issues with COVID if COVID wasn’t so prevalent.  And if the flu was a lot more prevalent and we did a lot more testing for the flu, I think it would tend to show up on death certificates more often.  Again, it goes to trying to figure out what the chain of events looks like and what initiated that chain of events.  And the certifier needs some sort of evidence that the flu was a factor and if they don’t have it, they’re not likely to report it on the death certificate.  So what we end up with is, we end up with a few thousand deaths a year where the flu is reported on death certificates, where modeling analysis show that it’s more like 30 to 60,000 depending on the severity of the flu season.

HOST:  Are there any other conditions which often turn up as “contributing” but “not underlying?”

ROBERT ANDERSON:  Yeah I mean diabetes is one of those conditions.  If you look at the total number of diabetes deaths where diabetes is the underlying cause, you see, well just take 2020 for example, the number is about 100,000 deaths but if we look at how often it’s actually reported on the death certificate we see a whole lot more.  Something on the order of – I don’t know what the number is for 2020 at this point but in in previous years it’s been somewhere on the order of 250,000 cases.  So diabetes is one of those conditions that frequently shows up as a contributing factor and it certainly does often contribute, it complicates the clinical picture and makes survival a lot less likely in many instances.  It’s also one of those conditions where it’s hard to understand for sure where it fits in the chain of events, unless somebody has sort of a hyper osmolar reaction or something like that, they kinda have to figure out – OK, well, this person had diabetes, it wasn’t well controlled, and they died from stroke, what role did diabetes play if any?  And it likely would have played a role because it tends to make cardiovascular diseases like heart disease and cerebrovascular disease worse. 

HOST: So for the 2020 data then there could be some diabetes deaths where COVID-19 was a contributing factor.  And it could also be the opposite, right?  Where it could be a COVID-19 death where diabetes was maybe a contributing cause?

ROBERT ANDERSON:  Sure yeah, I mean, we do know people with diabetes are very susceptible to severe disease and COVID.  And so it’s likely in many cases that you would see diabetes reported along with COVID on the death certificate, as a contributing factor.

HOST:  Just one more question about the contributing causes.  So then, that section of the death certificate would also be where contributing health behaviors — or unhealthy behaviors more likely  — would that be where, like, smoking, alcoholism, drug abuse… would that be listed as a contributing cause assuming it wasn’t like an overdose or something like that?

ROBERT ANDERSON:  Yeah it could be and we do see that.  It’s not reported very consistently though – a lot of certifiers don’t like to list behaviors on the death certificate.  They want to report clinical conditions, diseases, or injuries, and so they will often leave off sort of behavioral type things.  So while we do see it – you can see smoking reported, for example, and there’s a checkbox item as well that asks the certifier of tobacco played a role or not.  That’s one of the reasons why we added that checkbox was to try to capture that information because it wasn’t reported consistently on the death certificate.  We do see things like drug abuse and alcohol abuse reported on the death certificate but normally if alcohol abuse contributed to, say, cirrhosis of the liver and killed someone, normally the certifier would report alcoholic cirrhosis and so the alcohol abuse would be implied there.

HOST:  Any other points about this you feel are important to note?

ROBERT ANDERSON:  I think it’s important to note – you mentioned the 385,000 deaths that we were reporting in our surveillance website and compared with the 350,000 underlying cause deaths.  And some have asked questions about that and my answer typically is that for surveillance purposes we like to cast a slightly wider net, because we want to get a better sense for the impact of the disease or the pandemic on overall mortality.  But when we start to really boil down the numbers and start comparing causes of death, we need to have a single cause reported for each person and that’s the underlying cause of death.  Because we don’t want to double-count deaths in our in our tabulation so we limit to the underlying cause when we’re ranking leading causes, for example, or when we’re creating a table of various causes of death.  But for surveillance purposes, when we’re trying to capture the impact of the disease we cast a slightly wider net and so we look at both underlying and contributing factors.

HOST:  Thanks for joining us again Dr. Anderson.

ROBERT ANDERSON:  Happy to do it. 

(MUSICAL BRIDGE)

HOST: NCHS capped the year with four more reports released in the final week of 2021.  The first report focused on emergency department visits to people with mental health disorders, featuring data from the National Hospital Ambulatory Medical Care Survey.  A second report looked at pre-pregnancy body mass index and infant outcomes, showing that infants fared better among women who were at normal weight prior to their pregnancy.  A third report also looked at pregnancy – in particular, maternal and infant health outcomes among women who had confirmed or presumed COVID-19 during their pregnancy.  Data from 14 states and DC were examined for this study.  The fourth and final study from NCHS in 2021 featured the final, official numbers of drug overdose deaths in the U.S. for 2020, a report that is updated annually.


PODCAST: Interview with Elizabeth Gregory on Home Births During the Pandemic

December 10, 2021

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20211210/20211210.htm

HOST: Though no historical data are available, it is widely accepted that most births prior to the 20th century occurred in the home.  With the arrival of the 20th century and the advances in modern medicine that came with it, home births became far less common – as low as 0.56% of all births in 2004.  But in 2020, driven at least in part by the pandemic, home births increased 22% from 2019, to 1.26% in 2020 – the highest percentage since at least 1990.

This week NCHS has released a new report documenting the increase in home births during the pandemic.  Joining us to discuss the findings in the report is the lead author of the study, Elizabeth Gregory…

HOST: Are women who give birth at the home – and their babies – more at risk for adverse outcomes?

EG: So, this report doesn’t address the safety of home births – what it does is it examines changes in home births before and during the COVID-19 pandemic by month and by race and Hispanic origin and state of residence of the mother.

HOST: Home births have been higher in recent years than 10-15 years ago, is that correct?

EG: Home births have been increasing for the last 15 years or so.  The pace of increase had slowed from 2014 to 2019, and then there was a large increase in 2020.

HOST: The data suggest the low mark for home births in the United States occurred around 2004, is that correct?

EG: Yes that’s correct, but it’s important to note that we don’t have comparable data on home births prior to the 1989 revision of the US standard certificate of live birth.  But for 1990 through 2020 the lowest percentage of home births which was 0.56% occurred in 2004.

HOST: So even though it’s accepted that back in the 19th century, for example, most births occurred in the home, we don’t really have data prior to 1989, is that correct?

EG: So for vital statistics data, previous to the 1989 revision the question for place of birth – the response could either be in hospital or not in hospital.  We don’t really have the more detailed information about where the birth may have occurred outside the hospital.

HOST: I see.  So the pandemic would help explain the sharp rise in 2020, but what explains the higher rates since 2004?

EG: We didn’t look at what might have caused the increases for those earlier years, but we did look at when and where the increases occurred for 2019 to 2020.  So for example, in 2019 to 2020 the percentage of home births rose 22% for all women, with increases ranging from 21 to 36% for the three largest race and Hispanic origin groups.  And the percentage of home births for all women increased for each month, March through December, peaking in May, and this pattern of home births by month was also generally observed for each of the three largest race and Hispanic origin groups.

HOST: What factors related to the pandemic accounted for the big increase in 2020?

EG: So other researchers have found that some reasons included: increasing number of cases of COVID-19 in the U.S. combined with concerns about contracting COVID-19 while in the hospital… limitations or bans on support persons in the hospital… and the separation of infants from mothers suspected to have COVID-19.

HOST: What were some geographic differences we saw in 2020 as far as home births go?

EG: This report found increases in home births for the vast majority of states from 2019 to 2020.  The percentage of home births increased significantly in 40 states, with non-significant increases seen in an additional nine States and the District of Columbia.

HOST: What about race and ethnicity?  Were there similar increases in home births along those demographic lines?

EG: Historically non-Hispanic white women have been more likely to give birth at home, and this pattern continued into 2020.  However, increases ranging from 21 to 36% were seen for all of the three largest race and Hispanic origin groups from 2019 to 2020.

HOST: Any other topics in your study you’d like to mention?

EG: Yes, the report found that the percentage of home births rose for each month, March through December 2020, compared with the same months in 2019 and peaked in May.  And the timing of increases in home births generally corresponds with the initial surge of COVID-19 cases in the United States in late March and early April 2020.

HOST: Thanks for joining us Elizabeth.

EG: You’re welcome.

MUSICAL BRIDGE

HOST: December got off to a busy start with two reports focusing on children’s health, using 2020 data from the National Health Interview Survey.  The 2020 NHIS included questions on concussion, to measure both symptoms and diagnosis from a health care provider to provide a more complete understanding of the public health burden, as children with mild injuries may not see a doctor or receive a diagnosis.  On Dec. 1, NCHS released a new study on concussions and brain injuries among children in the U.S.  The new study found that nearly 7% of children in the U.S. under the age of 18 have had symptoms of a concussion or brain injury.  And 4% have been diagnosed with these conditions by a health care provider.   Boys are more likely than girls to have had these symptoms, and non-Hispanic White children are more likely than children in other race categories to have had these symptoms. 

While the report on concussions and brain injuries doesn’t have any direct correlation to the pandemic, a second report looked at dental exam visits among children in 2020 compared with 2019. It is known that in 2020, dental practices across the country adjusted their services in response to the COVID-19 pandemic, and access to dental care was disrupted for many Americans. This new study found that there was a decline in visits for dental exams or cleanings from 2019 to 2020, which likely was driven by the pandemic.  The decline was greater among younger children ages 1 to 4, as well as among lower income children and children living in the northeastern United States. 

Capping off the first week of the month was the latest quarterly provisional birth data for the U.S.  This latest release features mid-year 2021 data, and shows that fertility in the U.S. appears to be continuing its steady decline from the past several years, including a sharp decline in the U.S. fertility rate in the one year ending in mid-year 2020 compared to the same point the year before.

MUSICAL BRIDGE

HOST: This week NCHS also released data from its 2019 linked birth and infant death file.  These data are considered to be more comprehensive than infant mortality data from death certificates alone, due to the linking of the two sources of information.  As a result, much more accurate demographic and geographic data on infant mortality are available from this linked file.  However, the general “bottom line” remains the same – infant mortality in the United States continues to decline, as it has for nearly a century.

Finally, today NCHS released a report looking at trends in mortality from the leading cause of death in America, heart disease.  The new study covers most of the past two decades, with a special focus on changes by state.  The report shows that in the first decade of the millennium, 2000 to 2011, heart disease death rates declined in all 50 states and DC.  However, from 2012 through 2019, heart disease death rates fell in only half the states plus DC – and actually increased in one state (Arkansas). 

Later this month, on Dec. 22, NCHS will release its final death data for 2020, which will include the final, official number of COVID-19 deaths for the country in 2020.  Rounding out the last week of the year are several new reports, including one on emergency department visits by adults who have mental health disorders, using data from the National Hospital Ambulatory Medical Care Survey.  Two pregnancy-related reports are slated for release that week as well:  one on pre-pregnancy body mass index and infant outcomes and another on maternal and infant health outcomes among mothers with confirmed or presumed COVID-19 during pregnancy.  And last, the annual final report on drug overdose deaths for 2020 will be released, which comes on the heels of the latest monthly release of provisional overdose death numbers, running through May of 2021.


PODCAST: Design of Survey Questions during the Pandemic

June 25, 2021

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210625/20210625.htm

HOST: The quality of data in any health survey depends on the quality of the questions being asked, as well as the interpretation of those questions by the survey participants.  NCHS has a team in place that directly deals with those issues, the Collaborating Center for Question Design and Evaluation Research, or “CCQDER.”  CCQDER uses cognitive interviewing, a popular method for evaluating survey questions, by offering a detailed depiction of meanings and processes used by respondents to answer questions, which ultimately impact the survey data.  The sample of respondents in these studies is usually small, between 20 and 50 respondents.

This week, the CCQDER team hosted a webinar in which they discussed the design of survey questions about COVID-19, and the administration of those questions during the pandemic.  In addition to cognitive interviewing, the webinar also covered topics such as the Research and Development Survey, or “RANDS.”

As part of the Q and A segment of the webinar, Kristen Miller, the CCQDER Director, was asked whether standardized COVID questions had been developed by NCHS for outside researchers to use in their own studies:

KRISTEN MILLER: So traditionally it hasn’t been in our job scope to come up with standardized questions.  What we have done is – and maybe we want to rethink this for the future – but what we do do is we test these questions…  in these reports you will see specifically what each individual question captures. So what we would like to see people do is to get on, read these reports, see if this question – is this question capturing what I need it to capture – and then you making the decision, “Yes, I’m going to go with this question.”  So again, not anything standardized, but information provided to you so that you can choose the question that is best going to fit your research question.

HOST: The team was also asked what they would recommend in a rapid deployment situation in which there is not enough time to conduct a full evaluation of questions:

KRISTEN MILLER: I fully appreciate the problem.  And at the same time, I think that whenever we’re writing questions we need to have a concerted effort to have a plan how we’re going to go about question evaluation.  So it’s keeping track of the questions that go into the field, having mixed method or having these follow up pro questions that we had on RANDS to be able to see, “OK, this is going to be, there’s going to be error in this question, it’s going to be more error for less educated people, let’s keep that in mind as we interpret the data that’s coming in.”  But then, again, keeping track of what we’re asking so that we can improve our questions.  I mean, we’re so far into this pandemic I’d like to think our questions that we’re asking are much more improved from the questions that we began with when it first started.  So again, it’s just really having a question evaluation plan going forward.

HOST: The reaction to any survey question is highly personal and subjective, and the CCQDER team was asked about whether respondents have been impacted by their fear of COVID-19 when answering the questions.  Dr. Stephanie Willson of the CCQDER team described some of the challenges:

STEPHANIE WILLSON: Right, actually that’s a very astute observation because again the experience that people had – you had people who thought it was a hoax over here to people who were super-afraid of getting it, right?  So that absolutely was filtered through.  One example I didn’t get a chance to talk about was this need — there were questions about, “Did you need medical care for something but not get it because of the pandemic?”  So that kind of fear, the idea of need, was filtered through people’s experience with the pandemic and how afraid they were of catching it.  So certain things were missed, because suddenly now, “I don’t need to get a check-up, I don’t need a well-woman visit, I don’t need a cancer screening because of the pandemic.”  Where in non-pandemic times:  “Yes, I feel like I need those things.”  So that is an element of fear that absolutely did factor into interpretations.

HOST: Dr. Willson also discussed the differences between “remote interviewing” and traditional face-to-face interviews, and whether remote interviewing will continue into the post-pandemic era:

STEPHANIE WILLSON: The interesting thing was, even though I’ve been doing this for a long time, I had never done a virtual interview prior to the pandemic so I went into it kind of skeptical.  But I have to tell you, I’m a convert.  I really feel as though Zoom interviews really gave the same kind of quality cognitive interview data that face-to-face, in-person face-to-face interviews gave, so I think we should continue to use this.  I think that in certain situations, there’s a downside maybe in terms of socioeconomic status, but the upside to this would be geographical diversity that we can now explore that you can’t do… It takes so much more money to, let’s say, go regionally throughout the United States, for example.  And we did have actually geographic diversity in our sample here – not enough to make it count because we were trying to do it quickly but, yeah, I think it should continue to be used.

HOST: All CCQDER studies feature a final report that document the study findings, and are housed on a searchable, publicly accessible database called Q-Bank.

MUSICAL BRIDGE

HOST: Urgent care centers and health clinics located within grocery or retail stores are able to provide acute health care services for non-emergency visits, and they also can provide preventive care services, such as routine vaccinations. The availability and utilization of urgent care has risen dramatically in recent years.

A new report released this week examines urgent care center and retail health clinic visits among adults in the past year by sex and selected characteristics.  The report uses data from the 2019 National Health Interview Survey, and reveal that 1/3 of women and slightly over ¼ of men made one or more visit to an urgent care center or retail health clinic in the past year.

Older adults are less likely to use urgent care centers or retail health clinics than younger adults, and non-Hispanic white adults are more likely to have visited an urgent care center or retail health clinic at least once in the past year compared to Hispanic, non-Hispanic black or NH Asian adults.  In addition, adults with higher education levels are more likely to use urgent care centers or retail health clinics.

A second report came out this week which compares provisional or preliminary 2020 data with final 2019 and 2018 data on changes in the number of births in the United States by month and by state.  The report also includes data on the race and Hispanic origin of the mother, and sheds some light on the impact of the COVID-19 pandemic on fertility in the country.

From 2019 to 2020, the number of births declined for each month.  In comparison, from 2018 to 2019, the number of births declined for only 9 months of the year.  The largest declines in 2020 occurred in December, followed by August, and then October and November.  The number of births in the U.S. declined 8% more in December 2020 than it did the previous year.

In other words, the decline in births between 2019 and 2020 was larger in the second half of the year than in the first half of the year – 6% in the second half of the year vs. only 2% in the first half.   Between 2018 and 2019, the number declined 2% in the first half of the year and 1% in the second half.

Ultimately, more information on fertility during the pandemic won’t be known until 2021 data are available. The first provisional data for 2021 should be available by early Fall.


Latest Mental Health Data from Household Pulse Survey

June 16, 2021

NCHS partnered with the Census Bureau on an experimental data system called the Household Pulse Survey to monitor recent changes in mental health, telemedicine and health care access during the pandemic.

The latest data collected from May 26 through June 7, 2021 shows 3 out of 10 U.S. (28.8%) reported symptoms of an anxiety or a depressive disorder in the past 7 days.  This is the lowest percentage since the start of the Household Pulse Survey more than a year ago.  However, the percentage is almost 60% for those with a disability.

The data also shows that 20.6% of U.S. adults took prescription medication for mental health and 9.5% received counseling or therapy in the last 4 weeks.


PODCAST: The 2020 Increase in Death Rates Were The Highest Ever Recorded

June 11, 2021

STATCAST, JUNE 2021: DISCUSSION WITH FARIDA AHMAD, STATISTICIAN, ABOUT LATEST PROVISIONAL QUARTERLY MORTALITY DATA.

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210611/20210611.htm

podcast-iconHOST:  Each quarter NCHS releases provisional data on mortality from leading causes of death in the U.S. on an interactive web-based dashboard.   This week the dashboard was updated to include Quarter 4 data from 2020 and gives a complete account of provisional death rates in the U.S. for the year.  Joining us to discuss some of the key findings is Farida Ahmad of the Division of Vital Statistics.

HOST: First question: how much did the death rate in the U.S. increase in 2020?

FARIDA AHMAD:  The death rate for the U.S. increased by about 16% in 2020 compared to 2019-

HOST:  Now is it safe to say that almost all of the increase can be attributed to COVID-19.

FARIDA AHMAD:  A large part of it, yes, but we also saw increases in other causes of death like heart disease, Alzheimer’s disease, and diabetes.  Unintentional injuries like drug overdose also increased throughout 2020.  This report only includes drug overdose rates for the first half of the year but you do see very large increases in the second quarter of 2020.

HOST:  Some say that certain causes of death like influenza and pneumonia declined in 2020 due to COVID – is that true?

FARIDA AHMAD:  No, not really – that’s due to influenza and pneumonia were actually higher in 2020 than in 2019.  That’s likely driven by the pneumonia more so than influenza though.

HOST:  Is there any sense whether some of those pneumonia deaths are miscategorized, that maybe they should be in the COVID category?

FARIDA AHMAD:  Yes, you know it’s definitely possible.  We don’t have hard numbers on that and to account for maybe miscategorized COVID deaths we would we would look at excess mortality.  So a different kind of measure to look at that.

HOST:  I guess then the same would be true for other causes of death, particularly those that occur at the very beginning of 2020.  Is there any chance there will be more COVID deaths added to the tally?

FARIDA AHMAD:  It’s certainly possible but we haven’t closed out the 2020 data year.  So we could still get additional changes but we don’t anticipate a significant number of deaths data will change.

HOST:  So the data aren’t final yet is that correct?

FARIDA AHMAD:   Yes that’s correct.

HOST:   So what are some of the more striking changes you saw in the death rates from 2019 to 2020 as far as certain leading causes go?

FARIDA AHMAD:  Diabetes deaths increased by almost 14%… Chronic liver disease increased by 17% … and then hypertension and Parkinson disease those increased by 12% and 11% respectively.

HOST:  So in a normal year those would be considered very large increases is that correct?

FARIDA AHMAD:  Yes, yeah shifts that large would be notable.

HOST: But there’s no way to sort of link that back to the pandemic, either directly or indirectly?

FARIDA AHMAD:   Not with the death certificate data that we have, unless these deaths – you know these deaths which were the underlying cause is what we’re looking at.  For these deaths COVID-19 might also be listed on the death certificate, in which case you could say that COVID-19 played a role in that death but otherwise we wouldn’t necessarily know if it was a direct or indirect cause of the pandemic in terms of disrupted access to healthcare or other contributing factors.  The death certificate data wouldn’t necessarily tell us that.

HOST: So in general 2020 was a very rough year for mortality but were there any declines in leading causes of death in 2020?

FARIDA AHMAD:  There were a few – there were declines in cancer, in chronic lower respiratory diseases, and pneumonitis due to solids and liquids>

HOST: Did the pandemic – did COVID-19 — have any impact on death rates at the state level?  Were there any unusual changes in 2020?

FARIDA AHMAD:  West Virginia and Mississippi had the highest death rates overall, but the largest increases in death rates were actually seen in New York and New Jersey.

HOST:  Is there anything else in this new data that you’d like to note?

FARIDA AHMAD: What this report allows us to look at is not just the deaths due to COVID-19, which have been understandably a huge focus of public health surveillance in last year, but with this report we get to look at some of the other leading causes of death that might not be in the top five, or the top ten, but these are issues of public health importance and concern.  To look at these various diseases and causes of death, so I think that’s really what this report adds is to be able to take a broader look.

MUSICAL BRIDGE:

HOST: Our thanks to Farida Ahmad for joining us on this edition of “Statcast.”

HOST:  On Wednesday of this week, NCHS also released a new report on screening for breast, cervical and colorectal cancer.  The study featured data on women age 45 and over from the National Health Interview Survey, and concluded that regular cancer screening is much more likely among women of higher socio-economic status, as well as women who are married or living with a partner, and women who engage in healthy behaviors — such as not smoking, regularly exercising, and getting a flu shot.


NCHS Releases Latest Quarterly Provisional Mortality Data Through Full-Year 2020

June 8, 2021

NCHS has released the latest quarterly provisional mortality rates for the U.S., through full-year 2020 for most causes of death. 

Estimates are presented for 15 leading causes of death plus estimates for deaths attributed to coronavirus disease 2019 (COVID-19), drug overdose, falls for persons aged 65 and over, firearm-related injuries, human immunodeficiency virus (HIV) disease, and homicide. 

The data is featured on an interactive web site dashboard at: https://www.cdc.gov/nchs/nvss/vsrr/mortality-dashboard.htm.

NCHS has also released state maps showing COVID-19 death rates for provisional quarter 4 mortality data. You can access the 12-month ending map here and quarterly map here.


PODCAST: Effects of the Pandemic on Births in New York City

May 7, 2021

STATCAST, MAY 2021: DISCUSSION WITH ELIZABETH GREGORY, STATISTICIAN, ABOUT HEALTHY PEOPLE INITIATIVE.

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210507/20210507.htm

podcast-iconHOST:  Elizabeth Gregory is a health scientist with the CDC’s National Center for Health Statistics.  Elizabeth has authored a new study examining the effects of the pandemic on births in New York City, one of the hardest-hit areas by COVID-19.  The study looked at changes in the percentage of births to women who are residents of New York City but who gave birth outside the city.  The data covered the period between 2018-2019 and 2019-2020.

HOST:  So this is a different study than what we usually get from NCHS.  Can you explain why you chose this topic?

ELIZABETH GREGORY:  Sure.  Early on during the height of the pandemic in New York City in 2020 there were a lot of news stories about residents leaving the city and busy hospitals with a brief ban on support persons during labor and delivery at some hospitals.  So we decided to take a look at what are these things resulted in women going out of the city to give birth.

HOST: Now a lot of people are anxiously awaiting new data from 2021 to see if there were any major changes in fertility due to the pandemic, but your report is showing really that the pandemic did impact births in New York, at least from a health care utilization, from a delivery perspective, is that correct?

ELIZABETH GREGORY:  So we found that from 2019 to 2020 the percentage of New York City residents giving birth outside the city increased overall for all months from March through November, peaking in April and May.  And the timing of these increases in these out-of-city births correspond with the height of the early pandemic in New York City.

HOST:  is there any indication that these patterns were also true for other cities that were hard hit that in the early stages of the pandemic?

ELIZABETH GREGORY:   We didn’t look at any other cities – but this would be something that would be really interesting to look at.

HOST:  Is there any indication whether these New York City residents were just going across the state line and into New Jersey or Connecticut to have their babies or were they actually traveling further than that? Do you have any information on that?

ELIZABETH GREGORY:   So this is also another thing that be really interesting to look at but for this report we didn’t specifically look at where the out-of-city births were occurring.

HOST:  NCHS of course is also releasing their annual births report on Wednesday and there will be state data and also data for New York City available soon.  Now what happens data-wise in the situation your study focuses on – so for example if a New York City woman goes to New Jersey to give birth does that count as a New Jersey birth or is it still a New York birth?

ELIZABETH GREGORY:  So birth certificates are filed in the state where the birth occurred but are usually looked at by the mother’s state of residence for NCHS reports.  So in this report, a birth to a mother that lived in New York City occurring outside of the city will be considered a birth to a New York City resident.  And in this report it would just be classified as an out-of-city birth.

HOST:   Did we see a surge in births in these neighboring states like New Jersey or Connecticut for 2020?

ELIZABETH GREGORY:  So we didn’t specifically look at where the out-of-city births were occurring but maybe that’s something that could be looked at in the future.

HOST:  So what are some of the conclusions that you’ve drawn from this research?

ELIZABETH GREGORY:  Well from 2019 to 2020 the percent of New York City residents giving birth outside the city increased overall from March through November, peaking in April and May, with the timing of the increases in these out-of-city births corresponding with the height of the early pandemic in New York City.  And additionally, the overall rise in out-of-city births is largely the result of increases among non-Hispanic white women while increases were less pronounced for births to non-Hispanic black and Hispanic residents.

HOST:   Are you planning any other similar geographic studies based on the 2020 data?

ELIZABETH GREGORY:  We currently have a report in the works that will be looking at whether there were any changes between 2019 and 2020 in the percentage of births by whether the mother was born inside or outside the U.S.  I just wanted to mention that we are also working on another report about home births, just to see whether there was a change in the percentage of home births that were occurring in the U.S. from 2019 to 2020.

HOST:  Elizabeth Gregory’s new study was released on the same day that the full-year 2020 birth statistics for the U.S. were released.  These new data were based on over 99% of birth certificates issued in the U.S. during the year, and were featured in a new report that had a number of noteworthy findings:

The nation’s general fertility rate, which is the number of births per 1,000 women age 15-44, reached another record low in 2020, dropping 4% from 2019.  The total number of births in 2020 also fell 4%, to 3,605,201 – the sixth straight year the number of births declined.

The new report also revealed that births in the U.S. continue to be at below replacement levels, based on another decline in the total fertility rate.  Birth rates declined for females of all age groups except two:  adolescents age 10-14 and women age 45-49.

The birth rate for teenagers age 15–19 declined by 8% in 2020 to 15.3 births per 1,000 women in that age group.  The teen birth rate has declined every year going all the way back to 1991 except for two – 2006 and 2007.  The rates in 2020 declined for both younger teens age 15–17 and older teens age 18–19.

Nearly one-third of all births in 2020 were by cesarean delivery, and over one-fourth of births were low-risk cesarean deliveries.  Also, the preterm birth rate in the U.S. declined in 2020 for the first time since 2014, to just over 10% of all births in 2020.


Latest Pulse Survey on Anxiety and Depression during Pandemic

May 6, 2021

The latest Household Pulse Survey shows 1 out of 3 U.S. adults (32.1%) had symptoms of an anxiety or a depressive disorder in the past week.  This is the lowest percentage since the start of the survey a year ago.  Also, more than half of 18-29 year olds experienced the same symptoms.

More Findings:

  • Almost 10% of U.S. adults say they needed counseling or therapy, but did not get it the past month.  This is a 1.2 percentage decrease from more than a year ago.
  • Almost 1 out of 4 U.S. adults (24%)  delayed or did not get needed medical care in the past month due to the pandemic. This estimate is almost 5 percentage points lower than the estimate from March 17-29, 2021.
  • 25% of U.S. adults had an appointment with a health professional over video or phone in the past month.  
  • 2 out of 5 U.S. adults with a disability (40.5%) had an appointment with a health professional over video or phone in the past month.

To rapidly monitor recent changes in mental health, NCHS partnered with the Census Bureau on an experimental data system called the Household Pulse Survey. This 20-minute online survey was designed to complement the ability of the federal statistical system to rapidly respond and provide relevant information about the impact of the coronavirus pandemic in the U.S. The data collection period for Phase 1 of the Household Pulse Survey occurred between April 23, 2020 and July 21, 2020. Phase 2 data collection occurred between August 19, 2020 and October 26, 2020. Phase 3 data collection occurred between October 28, 2020 and March 29, 2021. Data collection for Phase 3.1 of the survey began on April 14, 2021 and will continue through July 5, 2021.


Race and Hispanic-origin Disparities in Underlying Medical Conditions Associated With Severe COVID-19 Illness: U.S. Adults, 2015–2018

April 28, 2021

Figure_02192021A new NCHS report calculates the prevalence of selected conditions by race and Hispanic origin among U.S. adults (aged 20 and over) during 2015–2018.

Data were used from the National Health and Nutrition Examination Survey. Conditions included asthma, chronic obstructive pulmonary disease, and heart disease based on self-report; and obesity, severe obesity, diabetes, chronic kidney disease, smoking, and hypertension based on physical measurements

Findings:

  • An estimated 180.3 million (76.2%) U.S. adults had at least one condition during 2015–2018.
  • Approximately 86.4% of non-Hispanic black adults had at least one condition, 58.5% had at least two conditions, and 29% had at least three conditions; these prevalence estimates were significantly higher than among other race and Hispanic-origin groups.
  • Compared with non-Hispanic white adults, Hispanic adults had higher rates of obesity and diabetes.
  • Non-Hispanic Asian adults had lower rates of at least one condition, but higher rates of diabetes compared with non-Hispanic white adults.
  • Non-Hispanic black women were more likely to have multiple conditions, obesity, severe obesity, diabetes, and hypertension compared with non-Hispanic white women.
  • Non-Hispanic black men were more likely to have one or more conditions and hypertension compared with non-Hispanic white men.
  • Hispanic men were more likely to have diabetes compared with non-Hispanic white men.