PODCAST: Healthy People Initiative

April 9, 2021

STATCAST, APRIL 2021: DISCUSSION WITH DAVID HUANG, CHIEF, STATISTICIAN, ABOUT HEALTHY PEOPLE INITIATIVE.

HOST:  David Huang is the chief of the health promotion statistics branch at NCHS, and serves as the center’s primary statistical advisor on the Healthy People initiative. Healthy People for decades now has been identifying science-based objectives with targets to monitor progress and motivate and focus action aimed at improving the health of the nation.

David joined us to discuss the history of the program, what is going on presently, and what the future directions are.

HOST: David can you start by telling us a little bit about the history of the Healthy People program?

DAVID HUANG:  Sure.  Established in 1979, Healthy People is a science-based 10-year national initiative for improving the health of all Americans based on the latest available scientific evidence.  And at its core Healthy People provides a strategic framework for a national prevention agenda that communicates a vision for improving health and achieving health equity but at the heart of the initiative are the science-based measurable objectives with targets to be achieved by the end of each decade.  With the recent release of Healthy People 2030 last August, we’re actually now in our fifth decade of the initiative and while the Department of Health and Human Services or HHS leads the initiative through the Office of the Assistant Secretary for Health Office of Disease Prevention and Health Promotion or ODPHP, NCHS has served as the statistical advisor to the initiative since the first iteration of Healthy People.

HOST:  This program has been going on for quite a while – now how important is it in public health to have specific goals to work towards?

DAVID HUANG:  Well there are many federal health indicator projects, but the inclusion of a quantifiable target for each objective is a unique feature that distinguishes Healthy People from other broad federal prevention initiatives.  The use of targets was inspired by the “Management by Objectives” movement which emphasize setting of organizational goals and objectives and was outlined by Peter Drucker in his 1954 book called “The Practice of Management.”  Targets have been an integral part of Healthy People since its inception in 1979.  The examination of data relative to targets is considered critical to the usefulness of Healthy People as targets do communicate policy expectations and expert or evidence based recommendations to a wide range of stakeholders.  Moreover, targets offer a marker for assessing progress for each objective and for the initiative as a whole.

HOST:  How do you decide what the target is – is there any way of gauging whether it might be too lofty of a goal or too easy of a goal.  How is that process?

DAVID HUANG:  Targets are actually set by subject matter experts that are on topic area work groups and these are folks from across the Department.  Some from actually outside of HHS who provide subject matter expertise and at the end of the day these are the folks who are responsible for determining targets.  As policy constructs, NCHS does not advise one way or the other but we do provide statistical support as needed because there are certainly many cases where statistical methods are used to calculate targets.

HOST:  So there’s a lot of folks involved in this, is that correct?

DAVID HUANG:  Yes I would say probably hundreds from across the Department and certainly if you look at the stakeholder base of Healthy People, there are folks outside of government at the sub-national level, nonprofits… and really the intention is for Healthy People to reach the individual level.  In an ideal world that’s how I think the Department would like to see it.

HOST:  I wanted to then ask you what generally happens when you achieve one of these goals?  What happens to that health issue or condition as far as Healthy People goes?

DAVID HUANG:  Sure that’s definitely an interesting question and certainly one that has come up historically, particularly when targets are met or exceeded early in the decade.  In the last decade, for example, there was an objective in the Immunization and Infectious Diseases topic area.  They reached out to us in 2014 and actually asked to increase the Healthy People 2020 target for a specific objective IID 14 – that was one that tracked that percentage of adults 60 years and older who are vaccinated against zoster or shingles.  Ultimately, we decided for consistency and simplicity not to officially set new in Healthy People when targets are met, but to continue tracking and reporting data throughout the decade.  The work groups that as I mentioned manage Healthy People objectives have also been given the option to set unofficial secondary targets if desired.  Sometimes targets are adjusted for other reasons.  For example, some targets are set to be aligned with national policies, programs or laws and if there is some sort of change to that underlying policy program or law we do have the flexibility to make the same change to the corresponding Healthy People target.  Another example is if an objective baseline changes due to a change in science or data collection.  In those cases, targets are generally adjusted using the same target-setting method if possible.  And finally I’ll just note that there are certainly opportunities for further progress even after targets have been met.  So for example we continued to track the further reduction in overall cancer death rates, which is objective C1 for Healthy People 2020, even though the target for that objective was met in the year 2014.   Moreover, most population-based objectives continue to have underlying health disparities by various sociodemographic factors such as race, ethnicity or family income whether they have met their targets or not.  One of the overarching goals for Healthy People is actually to eliminate health disparities and achieve health equity.  And of course this is a topic that has been further highlighted by COVID-19.

HOST:  So you’re saying the official policy is not to make any adjustments if you’ve already met an objective.  Is that also true on the flip side – if there’s no progress being made and it might become apparent that maybe the goal is a little too ambitious?  Is it the same sort of approach on that side?

DAVID HUANG:  Yeah it is a similar approach for… consistency and simplicity, not to change targets. I think in those situations where an objective is moving in the wrong direction… these certainly highlight opportunities for further work in disease prevention and health promotion.  In addition, this could be a consideration for the target-setting for the following decade if that objective happens to be carried over from one 10-year iteration to the next.

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


PODCAST: Death Certificate Data & COVID-19, Part 3

March 26, 2021

STATCAST, MARCH 2021: DISCUSSION WITH ROBERT ANDERSON, A STATISTICIAN, ABOUT DEATH CERTIFICATE DATA & COVID-19.

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210326/20210326.htm

HOST:  In Part Three of our conversation with Dr. Robert Anderson, the chief of mortality statistics at NCHS, we discussed the subject of excess deaths in the United States during the pandemic, and also the differences between when COVID-19 is listed as the underlying cause of death on the death certificate and those occasions when it is listed as a contributing cause but not the primary cause of death.

HOST:  So now you mentioned excess deaths – what are excess deaths, how has COVID-19 contributed to these excess deaths?

ROBERT ANDERSON:  So excess deaths are defined as the difference between the observed number of deaths in a specific time period and the expected or normal number of deaths in the same time period. So with the pandemic we’re looking at the total number of weekly deaths that occurred in 2020 and so far in 2021, and we’re comparing it with what we would expect in a comparable time period, essentially based on average weekly data from previous years.  The advantage of looking at excess deaths is that it’s not dependent on the accuracy of cause of death reporting – the focus is just on the total deaths, not deaths by cause.  Now at this point COVID-19 explains about 3/4 of total excess deaths and the other quarter likely includes three components: there are deaths that should have been attributed to COVID-19 but were instead attributed to some other cause for whatever reason.  Second, indirect deaths.  And these are deaths that can be attributed to the circumstances of the pandemic but not directly to the virus.  And this may be things like people not able to get health care during a crisis not related to the virus.  Or perhaps they’re afraid to seek care because the hospitals are full of people with COVID.  And then, three: a third component is other causes of excess deaths.  So you know there may be some excess deaths not associated with pandemic.  This could include things like deaths due to natural disasters.  This is generally going to be relatively small in comparison to what we’re dealing with the pandemic but these are sort of another category of excess deaths.

HOST:  There was some other speculation out there – rumors or what have you – that 2020 might have been actually a normal year in terms of total mortality in comparison to past years despite COVID-19.  How were people getting confused about that?

ROBERT ANDERSON:   Yeah the problem was that some folks were comparing incomplete counts for 2020 with complete counts for earlier years.  And so it did look like there were about a normal number of deaths.  The problem was that they weren’t including all of the deaths that occurred for 2020.  So we’ve made some changes to our website to try to make it more clear what the total number of deaths were for 2020.

HOST:  So NCHS ranks leading causes of death according to the underlying cause of death, and you mentioned earlier that in 92%, approximately, of COVID-19 related deaths, COVID-19 was listed as the underlying cause of death. And in roughly the other 8% of COVID-19 related deaths COVID-19 was not listed as the underlying cause of death.  Could you talk about that a little bit?

ROBERT ANDERSON:  Sure.  Let me start by saying that leading causes are ranked by the total number of deaths, and it’s based on a standard cause of death tabulation list that we typically used.  And if folks are interested in that we have a publication called “Deaths: Leading Causes for… insert the year – I think the most recent one that we have published right now is for 2018 -but you get the idea of exactly how NCHS does the rankings and how all of that came about.  Now when tabulating and comparing causes of death it’s important that we assign a single cause to each death so that we don’t double count.  We don’t want to have deaths falling into multiple categories, so we select a single cause.  And as we discussed earlier, certifiers typically report more than one condition on death certificates.  Now fortunately, as we also discussed, the death certificate is designed to elicit the single underlying cause, and that’s defined as the disease or injury that initiated that sequence of events leading to death.  That sequence gets reported in Part One on the certificate, and if completed correctly the underlying cause will be at the beginning of the sequence on the lowest use line in Part One.  So as I mentioned before you could have a sequence like respiratory distress due to viral pneumonia due to COVID-19.  That’s a logical sequence starting with the immediate cause – which is respiratory distress – and then working backwards through viral pneumonia, back to COVID-19, which is the underlying cause.  So that is the condition then that we would select for tabulation when comparing causes of death.  Now if the certificate is not completed correctly – and this does happen – we actually have a set of standardized selection rules to choose the best underlying cause for among those conditions listed.  These rules are part of ICD-10, which we used to code mortality, and they’re an international standard.  So the all those rules get applied regardless of the cause of death in the same way and as a result we would select an underlying cause from among those conditions, assuming that the certificate is not completed correctly.  Now with regard to the other 8 or 9 percent – I think it’s something on the order of 91 point-something percent, underlying cause and then about 8 point-something percent not underlying cause.  In cases where COVID-19 is not the underlying cause, we’re typically seeing it reported in Part Two as a significant contributing factor.  So if reported in Part Two, it may not be the underlying cause. It should be considered a significant factor that contributed to death.  And this is an important distinction – if COVID-19 is not a factor it’s not supposed to be reported on the death certificate.

MUSIC BRIDGE

HOST:  Still to come next week in our discussion with Dr. Robert Anderson:  How COVID-19 will be categorized among the other leading causes of death in the country, as well as more complicated scenarios facing certifiers on how to list COVID-19 on the death certificate.

MUSIC BRIDGE

HOST:  The rate of multiple births in the United states declined in 2019, according to the latest final birth data released this week by NCHS.  The new report also shows that more than 3 in 4 women began prenatal care during the first trimester of pregnancy.  The percentage of women who smoke during pregnancy declined in 2019 – to 6% of all women who gave birth. Medicaid was the source of payment for over 4 in 10 births that occurred in 2019.

Another report published this week by NCHS looks at drug overdose death rates in the U.S. on a state by state basis.  The report documents that the highest death rates from overdoses in 2019 were concentrated in jurisdictions that are in fairly close geographical proximity to one another: West Virginia, Delaware, DC, Ohio, Maryland and Pennsylvania.  Nebraska had the lowest overdose death rate in the nation in 2019.


PODCAST: COVID-19 Death Tracking Questions

March 12, 2021

STATCAST, MARCH 2021: DISCUSSION WITH ROBERT ANDERSON, A STATISTICIAN, ABOUT HOW COVID-19 DEATHS ARE TRACKED AND ENTERED ONTO THE DEATH CERTIFICATE .

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210312/20210312.htm

TRANSCRIPT

HOST: Since the beginning of the pandemic, there have been a lot of questions about how COVID-19 deaths are tracked and how they are entered onto the death certificate.  Joining us to talk about those topics is Robert Anderson, Chief of Mortality Statistics at NCHS.

HOST:  There are two CDC sources of COVID-19 deaths.  Could you talk a little bit about each source – what they are and what role they play in providing key information about the pandemic?

ROBERT ANDERSON:  Sure – there are two main sources for COVID-19 deaths.  The first piece is the case surveillance system which is built on the national notifiable diseases surveillance system.  So anytime that there’s what’s called a reportable disease – these are things like measles or mumps or things that are of significant public health import – a case report has to be filed.  And of course at the beginning of the COVID-19 pandemic it was decided that COVID-19 would be a reportable disease as well.  So anytime any health care provider comes across a COVID-19 case they’re supposed to file a case report with the state health Department, with the County Health Department – it varies from state to state – so on that form there is a line that asks did the patient die from this disease.  It is capturing the fact of death from that particular disease.  So the case surveillance system then collects these reports and then aggregates them – they also do some, for those states that are really slow in sending reports, they also scrape websites in order to get numbers that they can report in a timely fashion.  The second source is from vital statistics and these data are based on death certificates. And the death certificate is filled out typically by a funeral director who provides demographic personal information and then physician/ medical examiner/coroner provides the cause of death information.  And these are permanent legal records of the fact of death and the cause of death, and so they take a little bit more time to complete.  These have to be done in a certain, specific way and they have to be done correctly.  And so it takes a little bit longer.  In general the death certificates lag the case reports by about two weeks on average, although that does vary quite a bit from state to state.

HOST: For the death certificate, NCHS issued a guidance report – a guidance document – for certifiers on how to include COVID-19 on the death certificate.  That came out about a year ago.  Can you talk about that a little bit?

ROBERT ANDERSON:  Sure.  At the beginning of the pandemic, we realized that we had an opportunity to reach out to physicians to help them understand how to complete the death certificate – in general, not just with regard to COVID-19.  And so we created this document that was specific to COVID-19 that showed them how to fill out the death certificate properly in general, and then once they determined that COVID-19 was either the cause of death or a contributing factor, how to report it on the death certificate.  This guidance just sort of builds on guidance that we issued several years earlier –  I think the last time we issued guidance, general guidance, was in 2003.  This guidance is essentially the same – it’s just specific to COVID-19. This builds on the guidance that we issued before.

HOST:  Turning to another topic here: comorbidities, other conditions contributing or involved with COVID-19 deaths.  There was some confusion about the note on Table 3 on the website on COVID-19 deaths by contributing condition.  The note says “For 6% of these deaths COVID-19 was the only cause mentioned on the death certificate.”  And this has led to some wild and inaccurate speculation that the other 94% of the deaths may have been really some other cause of death and not COVID-19.  Could you talk about that a little bit?

ROBERT ANDERSON:  Yeah sure.  I can provide a little bit of background here.  The cause of death section on the death certificate is designed in a specific way and it’s designed to elicit a sequence of events leading to death.  And then also to gather any significant conditions that contributed to death.  So you have Part One about “cause of death” section which asks the certifier to provide the causal sequence.  And so you would start on the top line and you would put the immediate cause of death.  To use a COVID-19 example, you might have “respiratory distress syndrome” which is a common complication of COVID-19.  And then you would work backwards from that immediate cause of death. And let’s suppose that respiratory distress was brought on by pneumonia, viral pneumonia, and so you would put on the second line “viral pneumonia.” And then on the third line – because we want to know what the cause of viral pneumonia was – if it was COVID-19, then you would write COVID-19 on the third line.  So you’d have respiratory distress due to viral pneumonia due to COVID-19.  That’s a logical causal sequence from the immediate cause working back to the underlying cause.  And then in Part Two, you could put any other conditions that might have contributed to death but weren’t part of that causal pathway in Part One.  Now with a disease like COVID-19, it should be fairly unusual to see only COVID-19 reported –  I mean normally we should at least see the complications caused by the disease, such as pneumonia or respiratory distress.  In cases where only COVID-19 is reported, the certifier is indicating that COVID-19 was the cause of death, but really they left it – the cause of death statement – somewhat incomplete.  They neglected to provide the entire causal pathway.  Now with regard to the other 94% which mentioned other diseases or conditions, it’s important to understand that in the overwhelming majority of these cases the additional diseases or conditions are either complications of COVID-19 – they are in the causal pathway, like pneumonia or respiratory distress – or they’re reported in Part Two as contributing conditions. So for about 92% of the deaths involving COVID-19 that mention other conditions –  91 or 92% – the certifiers indicated that COVID-19 is the primary or underlying cause.  This is not a situation where the certifier is writing all of the diseases that the person had equally; they’re actually reporting it in this causal sequence.  And in the overwhelming majority of cases, COVID-19 has been indicated as the cause of the death.  It’s the cause that started that causal pathway, that causal sequence leading to death.

HOST:  So to summarize, in some cases COVID-19 leads to complications such as pneumonia which can lead to death, and then in other cases a person already has a pre-existing condition – maybe diabetes or COPD – and in those cases COVID-19 can then cause serious illness and death in those individuals.  Is that correct?

ROBERT ANDERSON:  That’s essentially correct.  In almost all cases COVID-19 leads to some other complications, even if there are pre-existing chronic diseases.  So for those that die from COVID-19, COVID almost always initiates a sequence of conditions and those can include respiratory, cardiovascular, neurological complications.  And then the pre-existing chronic diseases seem to make things much worse and do seem to make people more prone to having a serious illness or death.

(MUSIC BRIDGE)

HOST: Join us next time for a further discussion with Robert Anderson about how COVID-19 is documented on death certificates.

HOST:  A few weeks ago NCHS released a provisional report on how the pandemic impacted life expectancy in 2020.  Each year NCHS releases national life tables for the country.  This week for the first time in several years NCHS released state estimates on life expectancy.  These life tables were based on final data for 2018, and showed that Hawaii had the highest life expectancy of any state – 81 years at birth. West Virginia had the lowest life expectancy in 2018 at 74.4 years.

This week NCHS also released its latest summary of visits to hospital emergency departments, using data from the National Hospital Ambulatory Medical Care survey.  The report showed ER visit rates were higher for infants than other age groups, and were also higher for females than for males.

in, specific way and they have to be done correctly.  And so it takes a little bit longer.  So in general the death certificates lag the case reports by about two weeks on average, although that does vary quite a bit from from state to state.

HOST: For the death certificate, NCHS issued a guidance report – a guidance document – for certifiers on how to include COVID-19 on the death certificate.  That came out about a year ago.  Can you talk about that a little bit?

ROBERT ANDERSON:  Sure.  At the beginning of the pandemic, we realized that we had an opportunity to reach out to physicians to help them understand how to complete the death certificate – in general, not just with regard to COVID-19.  And so we created this document that was specific to COVID-19 that showed them how to fill out the death certificate properly in general, and then once they determined that COVID-19 was either the cause of death or a contributing factor, how to report it on the death certificate.  This guidance just sort of builds on guidance that we issued several years –  I think the last time we issued guidance, general guidance, was in 2003.  This guidance is essentially the same – it’s just specific to COVID-19. This builds on the guidance that we issued before.

HOST:  Turning to another topic here: comorbidities, other conditions contributing or involved with COVID-19 deaths.  There was some confusion about the note on Table 3 on the website and COVID-19 deaths by contributing condition.  The note says “For 6% of these deaths COVID-19 was the only cause mentioned on the death certificate.”  And this has led to some wild and inaccurate speculation that the other 94% of the deaths may have been really some other cause of death and not COVID-19.  Could you talk about that a little bit?

ROBERT ANDERSON:  Yeah sure.  So I can provide a little bit of background here.  So the cause of death section on the death certificate is designed in a specific way and it’s designed to elicit a sequence of events leading to death.  And then also to gather any significant conditions that contributed to death.  So you have Part One about “cause of death” section which asks the certifier to provide the causal sequence.  And so you would start on the top line and you would put the immediate cause of death.  So to use a COVID-19 example, you might have “respiratory distress syndrome” which is a common complication of COVID-19.  And then you would work backwards from that immediate cause of death and let’s suppose that respiratory distress was brought on by pneumonia, viral pneumonia, and so you would put on the second line “viral pneumonia.” And then on the third line – because we want to know what the cause of viral pneumonia was – if it was COVID-19 then you would write COVID-19 on the third line.  So you’d have respiratory distress due to viral pneumonia due to COVID-19.  That’s a logical causal sequence from the immediate cause working back to the underlying cause.  And then in Part Two, you could put any other conditions that might have contributed to death but weren’t part of that causal pathway in Part One.  Now with a disease like COVID-19 it should be fairly unusual to see only COVID-19 reported –  I mean normally we should at least see the complications caused by the disease, such as pneumonia or respiratory distress.  In cases where only COVID-19 is reported, the certifier is indicating that COVID-19 was the cause of death, but really they left it – the cause of death statement – somewhat incomplete.  They neglected to provide the entire causal pathway.  Now with regard to the other 94% which mentioned other diseases or conditions, it’s important to understand that in the overwhelming majority of these cases the additional diseases or conditions are either complications of COVID-19 – they are in the causal pathway, like pneumonia or respiratory distress – or they’re reported in Part Two as contributing conditions. So for about 92% of the deaths involving COVID-19 that mention other conditions –  91 or 92% – the certifiers indicated that COVID-19 is the primary or underlying cause.  So this is not a situation where the certifier is writing all of the diseases that the person had equally; they’re actually reporting it in this causal sequence.  And in the overwhelming majority of cases, COVID-19 has been indicated as the cause of the death.  It’s the cause that started that causal pathway, that causal sequence leading to death.

HOST:  So to summarize, in some cases COVID-19 leads to complications such as pneumonia which can lead to death, and then in other cases a person already has a pre-existing condition – maybe diabetes or COPD – and in those cases COVID-19 can then cause serious illness and death in those individuals.  Is that correct?

ROBERT ANDERSON:  That’s essentially correct.  In almost all cases COVID-19 leads to some other complications, even if there are pre-existing chronic diseases.  So for those that die from COVID-19, COVID almost always initiates a sequence of conditions and those can include respiratory, cardiovascular, neurological complications.  And then the pre-existing chronic diseases seem to make things much worse and do seem to make people more prone to having a serious illness or death.

(MUSIC BRIDGE)

HOST: Join us next time for a further discussion with Robert Anderson about how COVID-19 is documented on death certificates.

HOST:  A few weeks ago NCHS released a provisional report on how the pandemic impacted life expectancy in 2020.  Each year NCHS releases national life tables for the country.  This week for the first time in several years NCHS released state estimates on life expectancy.  These life tables were based on final data for 2018, and showed that Hawaii had the highest life expectancy of any state – 81 years at birth. West Virginia had the lowest life expectancy in 2018 at 74.4 years.

This week NCHS also released its latest summary of visits to hospital emergency departments, using data from the National Hospital Ambulatory Medical Care survey.  The report showed ER visit rates were higher for infants than other age groups, and were also higher for females than for males.


PODCAST: Latest Edition of Health, United States

March 5, 2021

STATCAST, MARCH 2021: DISCUSSION WITH RENEE GINDI, A STATISTICIAN, ABOUT LATEST EDITION OF HEALTH, UNITED STATES.

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210226/2021022

TRANSCRIPT

HOST:  This week marked the release of “Health, United States,” a compilation of data on a wide range of topics, from birth to death – and everything in-between – including: health care, disease prevalence, and other risk factors facing the population.  “Health, United States” is unique because it features not only data from NCHS, but also from sources outside of NCHS, including other federal health agencies. In compliance with the Public Health Service Act, the report is ultimately submitted from the Secretary of Health and Human Services, to Congress and the President.  This latest report is the 43rd edition, and to put that into further perspective, the very first edition of “Health, United States” was published in 1976, when Gerald Ford was president.  That report looked much different from the current edition.  For example, the first report did not contain any data on HIV/AIDS – because the disease was still unknown at the time.  Through the years, the content in the report has evolved to meet emerging public health needs.

Joining us today is Dr. Renee Gindi, who leads the NCHS team that produces the report.

HOST: Turning to this latest edition that came out this week, what are some of the significant highlights in this report?

RENEE GINDI: For the most part, I’ve been talking about three different narratives or stories that line up throughout the chart book.  The first is on leading causes of death and trends in those leading causes of death.  The second is thinking about continuing disparities by race and Hispanic origin.  And the third one is changes in health insurance and access.  The two leading causes of death are heart disease and cancer, and together they accounted for 44% of deaths.  When we look at the trends in mortality due to cancer and heart disease, we find that for the most part between 2008 and 2018 the death rates for cancer had a pretty stable drop.  But that wasn’t the case for heart disease.  We found that when we looked between 2008 and 2018 that while there was a decline certainly over that entire period, actually the rate of that decline was lower between 2011 and 2018.  It just means that while the rate of deaths due to heart disease was falling, it didn’t fall quite as quickly in the second part of that decade.  One of the things that we’re able to do with Health U.S. is t pull together multiple data sources to help understand the topic, so the next thing we did is we also follow this up with a look at trends in heart disease among adults age 18 and older as well as trends in reported history of cancer.  And we saw results that seem to correspond pretty well with those changes in the mortality rate.  For heart disease, we saw a decrease in prevalence between 2008 and 2018 among men and women age 65 and older, and then also among women aged 45 to 64. Results for the reported history of cancer were a little bit more mixed, where when we looked at the reported history of cancer over that time period we did see decreases in the percentage of women age 18 to 44 who reported history of cancer but increases among women aged 65 and over. So when we are able to look not only at mortality and also prevalence of heart disease and cancer, we can also look at prevention.  And so the Health U.S. team also focused on cancer screening trends, this year looking 1st at the use of colorectal cancer testing among adults age 50 to 75.  One of the things we saw we looked at this particular set of trends broken down by race and Hispanic origin and while we certainly saw increases in the percentage of adults who had reported having colorectal cancer testing between 2008 and 2018 in all of the racial in Hispanic origin groups that we studied, we still saw differences by racial and Hispanic origin group by 2018.  We had a little bit of a similar story with the use of mammogram in the past two years.  So while we didn’t see any increases or decreases in the percentage of women who reported having a mammogram in the past two years, by 2018 we still saw some differences by race and Hispanic origin.  So picking up on those differences in race and Hispanic origin, we were able to explore those kinds of differences and disparities across the chart book and across the figures.

HOST:  I want to sort of zero in on the topic of vital statistics, because during the pandemic what we’ve now seen is data coming out very rapidly to meet the needs of the pandemic.  How do you see Health U.S. in the future utilizing vital statistics now that there’s been this surge in speed of data release?

RENEE GINDI:  I think that’s a really great question and I think that can be a really broad question, thinking about the statistical community in general.  There’s a real tension between the desire to get out the most accurate, triple-checked final data, but also the need to get actionable evidence out to the public and the public health community as quickly as possible.  And I think Health U.S. is a good example of that issue.  Partially because we have a compendium of so many different data sources, we have a real tension in our annual report of having all of the data line up so that we’ve got all the same data leading to the same most current point versus getting the report out before we need to update it with new data. I think that you’ve really identified, both with vital statistics and with the National Health Interview Survey Early Release program, some real challenges for us as we figure out how to – and whether to – incorporate these earlier sources of data into what has traditionally been a report that focuses on the final sources.

HOST:  So now that we’ve transitioned to a more web-based electronic environment in terms of publishing, how is Health U.S. adapted to those changes?

RENEE GINDI:  We have been a product since 1975, and we’ve been keeping up with the times since then.  We started sending our trend tables out on floppy disk in 1990, and we had our first publication on the World Wide Web in Y2K.  So we have a really long tradition of trying to make sure that we provide high quality data in a timely way to the broadest possible audience.  In service of that, in the past few years we’ve actually introduced something called the “Data Finder” page which has become the most popular way to access the Health U.S. tables and figures.  Using the Data Finder, people can search for different kinds of health topics or choose from different population or geographic subgroups that they’re interested in.  They can download individual printable PDF tables for reference.  Or they can download an Excel table to be able to get more data years, more statistical information, or to work with the data themselves.  Our future really, I think, brings that same commitment to timeliness, quality, and utility.  We’re trying to phase in improved access.  So we want more people to be able to access our data more quickly.  We want to bring in topical web pages to allow people to search for topics that they are interested in.  And we want to have more timely trend table updates, to be able to update those data tables, those trend tables, in a way that’s a little bit closer to when those data become available.  We really want to focus our analysis on those cornerstone detailed trend tables, and one of the things that will help us do is to report on more trends in a broader variety of topics, rather than the smaller selection that we’ve needed to focus on when we are working on the chart books.  And we want to really also look towards a more streamlined annual summary, and that will allow us to report on this year’s-worth of updates across the topical pages in a slightly smaller format to make it more accessible to our policymaker audience.

(Music bridge)

HOST:  Our thanks to Dr. Renee Gindi for joining us on this edition of “Statcast.”

HOST:  The National Household Pulse Survey, which tracks mental health and health care access issues during the pandemic, released its latest data last week, covering the period February 3 thru the 15th.   Nearly 2 out of 5 adults reported anxiety or depression-like symptoms in the previous week.  This 39% figure was the lowest number reported since October.  Nearly a quarter of adults with anxiety or depression-related symptoms over the past four weeks did not get needed mental health care during this time.  Over a third of adults delayed or did not get necessary medical care in the past four weeks due to the pandemic.

Today, NCHS also released the latest quarterly provisional data on infant mortality in the United States.  The infant mortality rate remained stable during the first quarter of 2020, at nearly 5.6 infant deaths per 1,000 live births.  The rate has remained quite stable over the past several years.


PODCAST: Suicide Trends in the U.S. and Weekly NCHS Updates

February 26, 2021

STATCAST, FEBRUARY 2021: DISCUSSION WITH HOLLY HEDEGAARD, A STATISTICIAN, ABOUT SUICIDE TRENDS IN THE UNITED STATES.

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210226/20210226.htm

HOST:  Last week NCHS released the latest trend report on suicide rates in the nation.  Joining us today is Holly Hedegaard, the lead author of this new report.

Holly, so what do the latest final numbers tell us?

HOLLY HEDEGAARD:  Well the report that was just released from the National Center for Health Statistics looked at suicide rates over the last 20 years and what we saw was that from 1999 through 2018 there’s been a steady increase in the suicide rate – it increased about 35% over that time period. But what’s interesting is that in 2019 the rate is lower than it was in 2018 and that’s the first significant drop in suicide rates we’ve seen in the past 20 years.  While that’s an encouraging sign, I think it’s important to remember that a single year drop doesn’t necessarily say that’s a meaningful change in the overall trend is just that within a single year we saw a decrease in the suicide rates in 2019 compared to 2018

HOST:  Youth suicide in particular is a major concern.  What do the trends show among young people?

HOLLY HEDEGAARD:  So for young people suicide rates are actually lower than for other age groups – so that’s a good thing that the rates are lower – but what’s concerning is that these are the age groups where we’ve seen quite a bit of an increase in the suicide rates in recent years.  And so for example for girls who are age 10 to 14, their rates have increased about four-fold in the past 20 years, but their rates are still among the lowest of all the age and sex groups.  Rates have also increased for boys and for young men but not to the same extent as for girls.  And so again, for both boys and girls and for age 10 to 14 and ages 15 to 24, the rates are low but they are increasing – and I think that’s the reason of concern about suicide rates in young people.

HOST:  What groups have the highest suicide rates in the country?

HOLLY HEDEGAARD:  This report focuses on rates by sex and by age group, so the report looks at those particular characteristics, and the suicide rates are highest for men age 75 and older and that’s been true for a long period of time so the highest rates among men aged 75 and older.  For females the highest rates are for women ages 45 to 64 so it’s more of the middle-aged female when you look for high suicide rates among females.

HOST:  There aren’t full-year data available yet for 2020, but mental health professionals worry that the stress and isolation from the pandemic will result in a spike in suicide rates.  Do you have any insight at all about 2020 at this point?

HOLLY HEDEGAARD:  As you mentioned, we don’t have any of the final data for 2020 yet so we can’t give a definitive answer but NCHS has been generating from provisional estimates to try to get a sense of what has been happening during 2020.  And NCHS has posted some provisional estimates for the first quarter of 2020 – which it goes through March of 2020 – and as of the beginning of last year the rate, the suicide rate, was slightly higher than the rate during the comparable time period in 2019.  So a slight increase in the first quarter.  NCHS has been developing some additional modeling techniques to look at the trends in a variety of different types of deaths including drug overdose, suicide, and transportation related deaths during the early months of 2020, and based on that modeling technique the predicted weekly numbers of suicide deaths early 2020 were similar to historic levels, and then declined a little bit between March and June, and then again was pretty much no different than historic levels from July through October.  So based on these model estimates, that suggested there hasn’t really been a spike in suicide mortality, at least in the first half of 2020.  But it’s important to recognize that these are modeled estimates – these are not final numbers, they aren’t the final rates – and we’ll continue to be refining and confirming these estimates as NCHS receives more data for the deaths that occurred in 2020.  So as of now, we don’t have anything that looks like there’s been a huge increase in suicide during 2020 but that’s again based on modeled estimates.

HOST:  Your report looks at the different mechanisms used in suicides in the U.S.  What do those numbers tell us?

HOLLY HEDEGAARD:  The means of suicide varies by males compared to females, and for males about little over half of the suicides involve use of a firearm and about 28% involve hanging or suffocation… A much smaller proportion involved poisoning or other means. We’ve seen a slight increase in the rates for firearm-related suicides among men over the past 20 years but where there’s been a rather large increase has been in the rate for suicide by hanging or suffocation.  That rate among men has doubled over the last 20 years.  The picture for women is a little bit different.  From about 2001 through 2015, poisoning was the leading means of suicide among women.  But Interestingly in the last few years, since about 2016, we’ve actually seen a decline in the rate of suicide by poisoning among women and an increase in the rate of suicides that involve firearms or suffocation.  And so in the most recent years, the rates of suicide by firearm and by suffocation are slightly higher than the rate of suicide by poisoning.  The rate of suicide by suffocation among females has actually tripled in the past 20 years.

HOST:  Now by poisoning are you referring to drug overdoses?

HOLLY HEDEGAARD:  No, poisoning is actually a broader terminology that includes drug poisoning, but it also includes other types of poisons like carbon monoxide or chemicals or a variety of other things that sometimes people ingest or take. But they aren’t drugs there are used for other purposes.

HOST:  So your data then show that drug overdoses are really not a significant method used in suicides?

HOLLY HEDEGAARD:  It’s different – again, as I mentioned – for men or for women.  For men, only about 5% of suicide actually involve a drug overdose.  For women, it’s about 27% of their suicides involve a drug overdose.  So they’re not the, drug overdoses are not the leading means of suicide for either men or women.  For both men and women, rates of firearm-related suicide or suicide by hanging and suffocation are higher than the rates of suicide by drug overdose.

HOST:  This report doesn’t look at geographical differences but what areas of the country are having a tougher time with this problem?

HOLLY HEDEGAARD:  So the higher suicide rates are found in the Rocky Mountain states such as Wyoming, Montana, New Mexico, Colorado, Utah, as well as Alaska.  So these are states that have historically been high and they continue to remain high.  In the most current years or recent years, we’ve seen increase in the rates in some of the other states in the Midwest and in the New England states, up in Maine and Vermont and New Hampshire.  They aren’t the highest rates but they are increasing, so it’s important to sort of recognize that there are states in addition to the Rocky Mountain stage that also are seeing higher suicide rates.

HOST:   The National Health Interview Survey issued two new reports, on Tuesday and Wednesday of this week.  On Tuesday, NCHS teamed with the VA on a report that examined multiple chronic conditions among veterans and non-veterans.  Based on data from the 2015-2018 NHIS, the study authors found that about one-half of male veterans and over one-third of female veterans had two or more chronic conditions, compared with less than one-fourth of male nonveterans and less than one-fifth of female nonveterans.  Hypertension and arthritis were the most prevalent chronic conditions among all veterans age 25 and over.  Diabetes was also prevalent among male veterans ages 25 to 64 and asthma was also prevalent among female veterans in this age group.  Cancer was also prevalent among all veterans age 65 and older.

On Wednesday, NCHS released another study looking at health care utilization among those afflicted with inflammatory bowel disease, or IBD.  The study used NHIS data and found that adults with IBD were more likely than those without IBD to have visited any doctor or mental health provider in the past year, and were also more likely to have been prescribed medication or to have received acute care services such as ER visits, overnight hospital stays, or surgeries.

On Thursday, NCHS released a third study – on dietary supplement use among American adults age 20 and over.  The report used data from the 2017-2018 National Health and Nutrition Examination Survey, and found that over half of adults used a dietary supplement in the past month – nearly two-thirds /3 of women and just over half of men.  Eight out of ten women age 60 and over used dietary supplements, and older Americans are more likely to use more than one dietary supplement.   The most common dietary supplement used was multivitamin-mineral supplements.  Vitamin D and omega-3 fatty acid supplements were also commonly used.

Finally, today NCHS is releasing the latest quarterly provisional data on birth rates in the United States, through the third quarter of 2020, showing that fertility rates in the country continued to drop compared to the same point in 2019.  Teen birth rates and pre-term rates also declined in Quarter 3 of 2020 compared with Quarter 3 of 2019, while cesarean delivery rates increased over this period.

 


PODCAST: Quarterly NHIS Early Release Key Health Indicator Estimates

February 12, 2021

STATCAST, FEBRUARY 2021: DISCUSSION WITH TAINYA CLARKE, A STATISTICIAN WITH NHIS, ABOUT LATEST QUARTERLY NHIS EARLY RELEASE KEY HEALTH INDICATOR ESTIMATES.

HOST:  This week NCHS released its latest quarterly estimates on a number of key health indicators from the National Health Interview Survey, one of the oldest health surveys in US history dating back to 1957. This latest quarterly release covers the period up to the midpoint of 2020.  Health data from NHIS have always been driven by the types of questions asked in this traditionally in-person survey and in order to improve the quality of data the survey has been redesigned on occasion over the years, most recently in 2019. Tainya Clarke, an epidemiologist with the survey, elaborates:

TAINYA CLARKE:   The NHIS underwent a survey redesign to better meet the needs of data users.  Some questions were dropped from the survey, new questions were added, and some question text or the order they appear changed.  All these changes mean that the NHIS survey for 2019 going forward is quite distinct from the past survey.  In addition to the questionnaire design, changes made to the weighting approach have the potential to impact direct comparisons between the estimates for 2019 to June 2020 and earlier years.  Because of this we have not examined trends prior to 2019 in this release.

HOST:  The last time the NHIS was redesigned was in 1997.  That redesign laid the foundation for the creation of the early release program, which features quarterly preliminary estimates on a number of high profile health topics.  The 2019 redesign introduced several new topics to the survey.  However, the arrival of the pandemic in 2020 forced more changes to the way the survey operates, which in turn has had an impact on response rates:

TAINYA CLARKE:    Due to the current pandemic and the need for physical distancing, in quarter two we switched to a telephone-only approach, and in quarter three and four a telephone-first approach and followed up in person for households with no response or without a listed telephone contact.   We may have some new questions on COVID-19 and related health behaviors added in the future early releases.  So we’re not quite sure what those questions will be – only time will tell.

HOST:  In recent years this release has switched from a publication-based format to an interactive web-based data visualization format.  But there remains a gold mine of important data topics in this quarterly release.  For example, hypertension among adults is now being tracked, which is important particularly now during the pandemic with high blood pressure being a major risk factor for people with COVID-19.

TAINYA CLARKE:   The early release data in 2019 and the first half of 2020 showed that about 1/4 of US adults have been diagnosed with hypertension in the past 12 months, and the prevalence is highest among non-Hispanic Blacks, with more than one in three having hypertension in the past 12 months.

HOST:  The NHIS has tracked cigarette smoking among adults since the 1960s, and has documented along running decline in the percentage of adults who smoke.  Cigarette smoking is also one of the topics featured in this week’s new quarterly release showing that an all-time low of 12.2% of American adults were current cigarette smokers in Quarter Two of 2020.  And recently, the NHIS has added E-cigarette use to this quarterly release.

TAINYA CLARKE:   In 2019 we had approximately 4.4% of adults using E-cigarettes.  The percentage is even lower in January to June 2020 at 3.6%.

HOST:  Some of these second quarter estimates from 2020 may indeed reflect the impact of the pandemic on the country.  However, many of the survey questions are based on the past 12 months, so any direct connection to the pandemic is inconclusive.  This includes the second quarter 2020 finding that a higher percentage of adults are seeking mental health counseling, as well as the fact that a lower percentage of adults visited the emergency Department during this period. Another important measure featured in this quarterly release is flu vaccination.  Nearly half of adults reported they received a flu vaccine, according to data from the second quarter of 2020.  But Tainya Clarke says some context is needed when interpreting those immunization numbers.

TAINYA CLARKE:   I think I want to point out that even though this is almost 50% – and to some people that may seem like a large percentage – the target for vaccinating adults against influenza is much higher.  It’s closer to 70% for HP 2020 – that’s a Healthy People 2020 initiative.  And although that initiative is targeted at seasonal flu, we really hope to see a larger percentage of the U.S. adult population receiving more flu vaccines going forward.

HOST:  The latest quarterly release of data from the NHIS also includes new data on health insurance coverage in America.  During the first half of 2020, over 30 million Americans – or 9.4% – were uninsured at the time they were interviewed as part of the survey.  This proportion of the population who had no insurance includes over 13% of those ages 18 to 64.  In this age group, a little more than one in five had public health insurance and a little more than 2/3 had private insurance.  The poor or near poor in this age group were more likely to be uninsured than those who are not poor. Hispanic adults in this 18 to 64 age group were twice as likely to be uninsured as non-Hispanic black adults and nearly three times as likely as non-Hispanic white or non-Hispanic Asian adults.  Among children under age 18, less than 5% were uninsured, and among those who did have insurance over 41% had public coverage and over 56% had private coverage.

HOST:  Our thanks to Tainya Clarke of the National Health Interview Survey for joining us on this edition of “Statcast.”  Join us next week for a special segment on data related to the pandemic’s impact on life expectancy.


PODCAST: Secondhand Smoke Exposure among U.S. Adults

February 5, 2021

STATCAST, FEBRUARY 2021: DISCUSSION WITH DEBRA BRODY, AN EPIDEMIOLOGIST WITH NHANES, ABOUT SECONDHAND SMOKE EXPOSURE AMONG ADULTS.

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210205/20210205.htm

TRANSCRIPT

HOST:  Today we welcome Debra Brody, an epidemiologist with NCHS’s National Health and Nutrition Examination Survey, or NHANES.  Debra has been studying trends and exposure to secondhand smoke in America and has just authored a new study focusing on secondhand smoke exposure among adults in the U.S.

HOST:  First off, what are some of the reasons why secondhand smoke is a public health threat and what did you set out to accomplish with this new study?

DEBRA BRODY:  Well, I want to begin by defining secondhand smoke and that is the smoke that is breathed in involuntarily from the burning tobacco of smokers.  And because it contains toxic chemicals, it has many of the same harmful health risks to non-smokers as tobacco smoke has to active smokers.  And this would include increased risks of respiratory diseases, heart disease, stroke, and lung cancer.  So the bottom line is that no amount of exposure to secondhand smoke is safe. And while we can not determine the exact source of exposure, our goal was to assess the current proportion of the non-smoking adult population in the U.S. who are exposed to the burning smoke of others.

HOST:  So how does NHANES measure secondhand smoke?

DEBRA BRODY:   So NHANES is a national survey that assesses the health and nutritional status of adults and children in the U.S., and the survey is unique in that it combines interviews with physical exams and laboratory testing. So as part of the laboratory component, we draw blood from our participants and measure cotinine levels.  Cotinine is a metabolite of the chemical nicotine that’s found in tobacco smoke.  And cotinine provides a good measurement of the amount of nicotine a person has in his or her body due to tobacco inhalation.  So persons who don’t smoke should not have any cotinine in their system unless they breathe in smoke from other people’s tobacco.  In this report, secondhand smoke is based on having a certain level of cotinine in the blood, indicating current exposure to tobacco smoke.

HOST:  With the growth of E-cigarettes, is there a way to measure secondhand smoke with that?

DEBRA BRODY:   That’s a good question.  So we can’t distinguish from the cotinine level the source of the tobacco product.  So we don’t know whether it’s based on cigarette smoking or cigar, pipe, or hookas or possibly even from the vapor from E-cigarettes.

HOST:  I see.  So how many folks participated in this study?

DEBRA BRODY:  Our report focuses on data from non-smoking adults during the period of 2015 to 2018, and in this four-year period there were about 7,600 non-smoking adults who were 18 years and older who had blood drawn during the examination and answered questions about their smoking status and their current tobacco use.  But I want to mention NHANES is a population-based survey and is nationally representative of all adults in the U.S.

HOST:  So what’s the bottom line here?  How prevalent is secondhand exposure in the adult population?

DEBRA BRODY:  So we found that 20.8% or about one in five non-smoking adults 18 years and older were exposed to secondhand smoke.  Overall, we found the percentage of secondhand smoke exposure was similar for men and women.

HOST:  So how has this changed over time?

DEBRA BRODY:   If we look back to when we first measured cotinine in the survey – and that was in the late 80’s – and at that time close to 90% of all Americans were exposed to secondhand smoke.  Now, in this report we examine the change in exposure prevalences over a 10-year period. So that would be since 2009-2010.  Across the 10-year timeframe we observed a downward trend overall.

HOST:  So this isn’t part of your study of course but you mentioned that when you originally started measuring this back in the late 80’s, ninety percent of adults were exposed. I trust that what has happened is we’ve seen the results since then of all the smoke-free establishments?

DEBRA BRODY:    Yeah that’s really a good question.  So exposure has steadily decreased in the U.S. obviously with increases in regulatory oversight concerning smoke-free indoor air quality.  And then individual policies regarding smoking in homes and cars, and then declines in smoking, particularly cigarette smoking overall.

HOST:  So are your findings consistent with other studies on secondhand smoke?

DEBRA BRODY:   As I mentioned, NHANES is a national survey representing the U.S. population and has been measuring secondhand smoke exposure using a biomarker – that is cotinine – for more than 40 years.  While there are some other surveys focused on tobacco smoke, there really isn’t any other survey that has measured exposure like this among non-tobacco users over so many years.

HOST:  And what groups of people are more likely to be exposed to secondhand smoke?

DEBRA BRODY:    We saw that exposure was disproportionately more prevalent among non-Hispanic blacks compared to non-Hispanic whites, non-Hispanic Asians, and Hispanic adults.  There are other findings from this report that highlight what we might say is a “health equity” concern as well.  We found that the prevalence of secondhand smoke exposure increased with decreasing level of family income and that the percentage of exposure also increased with decreasing education levels.

HOST:  Now are children more likely to be exposed to secondhand smoke than adults? Do we know about that?

DEBRA BRODY:    We did not include children for this short report but we have focused on youths in other reports.  We do know the percentage of secondhand smoke exposure in children exceeds adult prevalences, and it may be because of the involuntary nature of exposure.  Children may not be able to protect themselves from possible sources whereas adults can protect themselves and may be able to stay away from others who are smoking cigarettes or using other tobacco products.

HOST:  One more question:  Are there plans for any pains to continue to track secondhand smoke exposure in the population?

DEBRA BRODY:    Yes.  Our measurements of the cotinine levels will continue to be collected in future NHANES studies in order to track progress in reducing all secondhand smoke exposure.

HOST:  Our thanks to Debra Brody for joining us to discuss her new research on secondhand smoke exposure among American adults.  The new report was released yesterday, on February 4th.

HOST:  Today, there is another new report from NHANES – this one on fruit and vegetable consumption among American adults.  The new report features 2015-2018 data, and shows that 2/3 of adults age 20 and up consume fruit on a given day and over 9 in 10 consume vegetables.  The study shows that more women consume fruit than men, whereas an equal percentage of women and men consume vegetables.  Income level seems to play a key role here.  As the level of income rises among adults, so does fruit and vegetable consumption.  While vegetable consumption among adults has remained essentially unchanged over the past two decades, fruit consumption has decreased since 1999-2000, when over three quarters of adults consumed fruit on a given day.

This has been another edition… of “Statcast.”  Next week we’ll be discussing the latest quarterly health indicators from the National Health Interview Survey.


NCHS Podcast Series

February 1, 2021

CDC’s National Center for Health Statistics (NCHS) produces a short podcast series, “Statcast,” which posts on the NCHS web site every Friday morning.  The podcasts are 5-10 minutes in length and feature an interview with an NCHS subject matter expert on a specific health topic along with a summary of that week’s NCHS data releases.

Last Friday, we wrapped up a four-part series on death certificate data in the U.S. with NCHS Mortality Statistics Chief Robert Anderson.  The full four-part interview (and transcript) can be found at the following link.

If you are interested in learning more about the podcasts, in general or on specific topics, please let the NCHS Press Office know at paoquery@cdc.gov.


Q & A Podcast with Author of Special Diets Among Adults Report

November 6, 2020

NCHS has a new podcast interview with Bryan Stierman, an epidemic intelligence officer with the CDC’s National Center for Health Statistics. Dr. Stierman works with the NCHS National Health and Nutrition Examination Survey, or NHANES, and he is the lead author on a  study on Special Diets among American adults that was released on November 3, 2020.

https://www.cdc.gov/nchs/pressroom/podcasts/20201106/20201106.htm


CDC’s Abortion Surveillance Report

August 16, 2007

podcast.pngThe National Center for Health Statistics does not track the number of abortions. Abortions are tracked through CDC’s Abortion Surveillance System and reported annually in the Morbidity and Mortality Weekly Report.

Reports covering 1979 through the most current report are located at the above link. Typically, these reports are published in the last week of November and lag three years.

Click the icon for a CDC podcast on the abortion surveillance system