PODCAST: The 2020 Decline in Life Expectancy

July 21, 2021

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210721/20210721.htm

podcast-iconHOST:  In February, we had a discussion with Elizabeth Arias with the NCHS Division of Vital Statistics about life expectancy in the United States during the first half of 2020, right as the pandemic was taking hold.  Americans lost a full year of life expectancy during that first part of 2020.  Today we feature the sequel to that conversation, as this week NCHS is releasing full-year life expectancy estimates for 2020.

HOST:  Can you tell us if life expectancy dropped more in the second half of 2020 than in the first half?

ELIZABETH ARIAS: Yes it did – life expectancy declined an additional amount during the second half of 2020 and it did so more for some groups than for other groups.  For example, for the Hispanic population it declined an additional 1.1 years.  For the non- Hispanic white population it declined an additional .4 years and for the non-Hispanic black population it declined an additional .2 years.

HOST:  So overall what was the total decline in life expectancy for 2020?

ELIZABETH ARIAS: It was 1 1/2 years.

HOST: So it’s another half year of decline from the first half then?

ELIZABETH ARIAS: That’s right.

HOST:  Were you surprised it didn’t drop more than 1.5 years given how bad the pandemic became near the end of 2020?

ELIZABETH ARIAS:  No. I was not surprised because the number of excess deaths would have had to be even larger than they were for the decline to have been greater.  And in addition half a year is a substantial amount – it sounds like a small change, but in terms of the way that mortality changes over time which is rather gradual, and it has been gradual and consistent ever since the 1940s, for example.  We have seen an increase gradually increase in life expectancy year to year, and of course a gradual decrease in mortality year to year.  So a half a year is substantial, so if we would have added another year of decline that would have meant that the number of deaths were even greater than what we saw.

HOST: OK so you mentioned some of the declines among race Hispanic groups- what about declines among men versus women?

ELIZABETH ARIAS:  We have seen the gap in life expectancy between men and women decline over the decades.  It started out rather large at the beginning of the 20th century, with women having higher mortality and lower life expectancy than men – that was mainly due to high rates of maternal mortality.  And then we saw over time men having higher mortality and women having greater advantage in terms of life expectancy.  Over time we’ve seen that this change and particularly during the latter part of the 20th century and early part of the 21st century.  The main reason for the decline in the gap, in the difference between the two, has been that life expectancy has been increasing at a faster pace or rate for men.  In other words, men had been catching up to women, and what happened in 2020 with the pandemic is that men experienced higher mortality than women did, and so they basically lost some of what they had achieved during the previous decades.

HOST: Now are you planning to release mid-year 2021 estimates like you did with 2020?

ELIZABETH ARIAS: That’s a good question and I believe we are. I don’t know definitively.

HOST: With 200,000 plus deaths from COVID-19 so far in 2021, would we expect to see another drop in life expectancy?

ELIZABETH ARIAS: No actually, I think what we would see is a small increase in life expectancy in comparison to what we saw in 2020.  In order for us to see another decline in life expectancy we would have to have a greater number of excess deaths than what we have seen so far.  So I would say that we would probably see life expectancy go up but it won’t return to what it was in 2019.

HOST: Now the drop in life expectancy for 2020 was 1.5 years, and yet way back 100 years ago plus, the Spanish flu pandemic resulted in an 11.8 year decline in 1918.  Why the huge difference?

ELIZABETH ARIAS:  Well, you have to think about number of deaths during the Spanish influenza.  So there were over 600,000 deaths, and also you have to think about the size of the population then.  It was a significantly smaller population than what we have today. So you know in 2020 we had 385,000 deaths and a population of over 330 million and back in 1918 we had over 600,000 deaths and – I don’t remember the number of the population at the time – but it was a lot smaller than it is so that translates into much larger death rates and as a result a greater decline in life expectancy.

HOST:  Are there any plans to down the road look at vaccination and deaths from COVID or vaccination and life expectancy?  Anything planned along those lines?

ELIZABETH ARIAS:  That would be really interesting and I don’t know if we would have the data for that. I think if the National Health Interview Survey asks that question – if people, you know, were vaccinated – or the NHANES… And since we link those surveys to our mortality data, we may be able to look at mortality by vaccination status.  But from our data, from vital statistics – in other words from the death certificate – we would not be able to see that.  We would have to have some sort of data that’s linked to our mortality data.

HOST:  OK well thanks for talking to us again Elizabeth.

ELIZABETH ARIAS:   You’re welcome.  Thank you.

MUSIC BRIDGE

HOST:  Through the week ending on July 14, there have been 213,413 COVID-19 deaths recorded on death certificates in the United States during this year.  Deaths occurring in nursing homes or other long-term care facilities have declined from 22% of all COVID deaths in 2020 to 13% of the total so far in 2021.  81% of deaths in 2020 were among people age 65 and up; that percentage has dropped slightly in 2021 to less than 77%.  Deaths in the 45-64 year age group have risen from 16.6% of all deaths in 2020 to over 20% in 2021.  Total excess deaths in the U.S. since February 1, 2020 have topped 663,000, with approximately 80% or more of those deaths due to COVID-19.


PODCAST: Drowning Deaths Among U.S. Children

July 16, 2021

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210716/20210716.htm

podcast-iconHOST:  We’re joined today by Merianne Spencer, the author of a new study on accidental drowning deaths among children in the United States.

HOST:  So briefly describe to us the scope of the problem.

MERIANNE SPENCER:  Sure.  So unintentional drowning deaths are the second leading cause of injury death among children, those aged zero to 17, and is also the leading cause of unintentional injury deaths for those ages one to four, so for this study we wanted to look at national trends from 1999 to 2019 by demographic characteristics and also by urban-rural status to see what the patterns were over the past two decades among children.

HOST:  So you say that drowning deaths are the second leading cause of unintentional death among kids – what was the leading cause of unintentional injury deaths in that age group?

MERIANNE SPENCER:   The leading cause of death for unintentional injuries is motor vehicle traffic deaths, followed by drowning and then poisoning and then suffocation.  But it’s important to note that motor vehicle traffic deaths are much higher.  In 2019, there were almost 2000 deaths whereas for drowning there were pretty much half the amount.  Motor vehicle traffic deaths is much higher.

HOST:  How has this problem changed over time?

MERIANNE SPENCER:   So over the past two decades drowning deaths have decreased – roughly a 38 percent decline over the past two decades.

HOST:  Do we have any idea why drowning deaths have declined over the past two decades?  Are there any CDC programs that are targeting this problem?

MERIANNE SPENCER:  Looking at prevention programs, the National Center for Injury Prevention and Control – they provide a lot of information about the prevention of drowning, including pool safety, swimming safety tips and other considerations for water safety within the home. I would also look to prevention resources such as “Safe Kids Worldwide” and the “World Safety USA Network” but there are various programs that have been looking at improving safety for drowning among children and targeting that public health issue.

HOST:  Now one would assume that drowning deaths tend to spike during the summer months – is that an accurate assumption?  What did the data tell us about seasonality?

MERIANNE SPENCER:  There’s definitely a seasonality with respect to driving death.  So typically, the number of unintentional drowning deaths are lowest during colder months such as January or December, as well as in the Fall.  The number of deaths tend to rise sometime in April and they peak around June and July and decrease as it goes towards September.  So yes, it is an accurate assumption that there is a spike in around the warmer months when children might be swimming or going to the pool.

HOST: So which groups are more at risk for drowning deaths?

MERIANNE SPENCER:   Our study found that males are definitely at greater risk for unintentional drownings – they had higher rates of unintentional drowning deaths over the past two decades compared to females.  We also saw that those aged one to four had the highest rates of drowning compared to other age groups.  So much higher among those aged one to four years of age.  We also saw that rates were higher among non-Hispanic black children compared to non-Hispanic white children and Hispanics over the study period. And also we saw children were at higher risk for unintentional drownings in rural areas compared to urban areas.

HOST:  And what did the data tell us about places that are most risky for kids in terms of being a potential drowning risk?

MERIANNE SPENCER:  Our study found that death varied by age groups.  So those that were less than a year of age had a higher percentage that died in a bathtub, whereas those that at age 1 to four or five to 13 had the greatest percentage of deaths in swimming pools and those aged 14 to 17 were more likely to die in natural water such as lakes, rivers, streams, or oceans.  So there is definitely a difference by age group in the places where drowning deaths occurred.

HOST:  Are there any plans for further studies on this topic?

MERIANNE SPENCER: We are interested in looking at those places of drowning by looking at the literal text or the written information on the death certificate records to see if we can get a little bit more information.  Currently the study is focused on using the ICD-10 codes to look at places of drowning but maybe we can get some more insight about this finding in a future study.

HOST:  You mentioned the literal text – that’s the same kind of technique that’s been used on some studies looking at the types of drugs involved in overdose deaths is that correct?

MERIANNE SPENCER:  Yes that’s correct.  So by looking at the written information by medical examiners and coroners we might be able to tease out some information beyond the coding on ICD-10 codes or get more specificity on the place of drowning or some context around the drowning deaths so that’s something we might be looking into for a future study for this topic.

MUSICAL BRIDGE

HOST:  This week, NCHS released the first, full-year provisional data from 2020 on drug overdose deaths in America.  The new release shows a nearly 30% increase in deaths, from over 72,000 estimated deaths in 2019 to more than 93,000 deaths in 2020.

Three-quarters of all overdose deaths involve opioids – or nearly 70,000 deaths.  Much of the 2020 spike was the result of increases in deaths from synthetic opioids, primarily fentanyl.  Deaths from psychostimulants such as methamphetamine also continued to increase in 2020, as did deaths from cocaine and from natural and semi-synthetic opioids such as prescription pain medication.

The first 2021 data on overdose deaths will be released in August of this year.


PODCAST: NHANES Updates, Drug Overdose Deaths, and ER Visits From Motor Vehicle Crashes

June 18, 2021

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210618/20210618.htm

podcast-iconHOST:  In March of 2020, field operations for the National Health and Nutrition Examination Survey – or NHANES – were halted due to the COVID-19 pandemic. Field operations are scheduled to restart later this summer.  But the halt in operations presented a problem, since NHANES data traditionally is released in two-year cycles in order to have a large enough sample size to be nationally representative.  Because the data collected in the cycle from 2019 thru March 2020 are ­not nationally representative, NCHS took steps to combine these “partial-cycle” data with previously released 2017–2018 data in order to produce nationally representative estimates.

This effort resulted in a new report this week that explains these “prepandemic NHANES data files,” from the period January 2017 thru March 2020, and outlines recommendations as well as limitations related to using the files.  The new report also presents prevalence estimates for selected health outcomes based on these files.

One of the health topics selected was obesity.  From January 2017 to March 2020, the data show that 1 in 5 children and adolescents in the U.S. were obese, or 19.7% of the age 2-19 population.  The report also shows that nearly half of children and adolescents – or 46% – had untreated or restored cavities in one or more of their primary or permanent teeth.

Among adults age 20 and up, the age-adjusted prevalence of obesity was more than 4 in 10, or 42%, and nearly 1 in 10 were severely obese. In addition to obesity, the new data show that diabetes prevalence among adults was nearly 15% and that nearly half of adults age 18 and over – or 45% — had hypertension.  Also, among older adults age 65 and up, complete tooth loss was present in nearly 14% of that population.

Ultimately, these new estimates are similar to those reported during the 2017-2018 cycle, but the additional year and two plus months-worth of data provide a larger sample size and thus more precise estimates.  And the release of these data mark another important milestone, in that they are the last NHANES data collected before widespread transmission of COVID-19 began in 2020.

(MUSIC BRIDGE)

HOST:  This week, the monthly provisional numbers for drug overdose deaths in the U.S. were released.  The latest round of data cover the one-year period ending in November of 2020, and show that the number of drug overdose deaths increased nearly 30% from the one-year period ending in November 2019.  Over 92,000 Americans died of drug overdoses in the year ending in November 2020, up from less than 72,000 the year before.

Three out of every four of these overdose deaths involved opioids, as the number of opioid-involved deaths topped 69,000 in this one-year period ending in November 2020, a major increase from 50,504 deaths the year before.  It’s important to note that recent trends may still be at least partially due to incomplete data.

A big factor behind the increase in overdose deaths is the continued increase in deaths involving synthetic opioids, primarily fentanyl.  But increases in deaths from other drugs are playing a major role as well.  Overdose deaths from cocaine as well as psychostimulants such as methamphetamine have shown significant increases compared to the previous year.

The next release of provisional numbers will feature full-year 2020 data for the first time.

(MUSIC BRIDGE)

HOST:  An average of 3.4 million emergency department visits occur each year due to injuries from motor vehicle crashes.  Most people who are injured or killed in motor vehicle crashes are occupants.  Studies have shown that medical care costs and productivity losses associated with motor vehicle injuries and deaths exceeded $75 billion in 2017.

Today, NCHS released a new report that presents emergency department visit rates per 1,000 for motor vehicle crashes by age, race and ethnicity, health insurance status, and census region. The data come from the National Hospital Ambulatory Medical Care Survey, an annual, nationally representative survey of nonfederal, general, and short-stay hospitals in the United States.

The report shows that in 2017–2018, the overall ER visit rate for motor vehicle crash injuries was 5.3 visits per 1,000, and was highest among patients between ages 15 and 24.  The ER visit rate for non-Hispanic black patients was several times higher than for non-Hispanic white or Hispanic patients.

Emergency department visit rates were higher for patients who had Medicaid, no insurance, or workers’ compensation insurance as their primary expected source of payment compared with patients who had private insurance or Medicare.  The ER visit rate for motor vehicle crashes at hospitals located in the South was higher than the rates at hospitals in all other census regions of the United States.


PODCAST: Children and Mental Health: Part Two

May 21, 2021

STATCAST, MAY 2021: DISCUSSION WITH BENJAMIN ZABLOTSKY, STATISTICIAN, ABOUT CHILDREN AND MENTAL HEALTH.

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210521/20210521.htm

podcast-iconHOST:  We now continue our conversation with Ben Zablotsky, health statistician with the Division of Health Interview Statistics on children’s mental health in the United States.

HOST:  You mentioned social media and the Internet – what about more traditional environmental issues that might contribute to mental health issues among children, such as family structure.  Does NCHS have any data on how family structure, including maybe divorce, might impact mental health?

BEN ZABLOTSKY:  So in the past, the National Survey of Children’s Health was run out of our center, and we did have some questions about family structure as it relates to whether a parent had divorced or separated.  And we looked at this within kind of the lens of “stressful life event.”  And we do know generally that, yes, children who experience the stressful life events which can include changes to the family structure have been associated with higher rates of mental health conditions.  But other things that we can look at now right within the NHIS have to do with general adversity that a child might be dealing with as it relates to food security or the availability of health resources.  And so those items are also associated with mental health and actually in 2021, we have a longer list of stressful life events that are being asked of parents that can then be looked at in the lens of health.  And that could be something that is worth exploring further.

HOST:  In a general sense, are there any groups of children at higher risk than others at developing mental illness?

BEN ZABLOTSKY:   So I would certainly say again that older children are more likely to experience some of these internalizing mental health disorders that talked about in terms of depression and anxiety.  Certainly there are children who are dealing with a more adverse living situation who have a higher chance of developing a mental health disorder, but some conditions genetically are actually more likely to occur in boys than girls.  So you see that autism spectrum disorder is an example of that, you see higher rates of ADHD among boys versus girls.  And generally when someone has accessibility to services, you might see higher rates of diagnosis because they are able to see someone who can actually say “Oh yes, that is what this child has.  Here’s a treatment plan we can move forward with.”

HOST:  You mentioned autism and ADHD.  Thirty, forty years ago you didn’t really hear about these conditions.  There’s some that might think that this might be over-diagnosed since they’re relatively new conditions.  Do you have any data about that?

BEN ZABLOTSKY:   So the prevalence of autism spectrum disorder has changed over the years because the criteria for defining the condition itself has changed.  So a lot of the increase you saw in some more recent years have actually been just that – that it wasn’t necessarily as difficult to get a diagnosis based on the criteria of the DSM – but I think there’s also a lot to be said about the awareness of these conditions.  And there have been campaigns within the CDC itself to increase awareness of developmental disabilities generally, and I think that also attributes quite a bit to the increased rate that we’ve seen.

HOST:   And we can certainly have a whole separate podcast on those topics alone – maybe we’ll wait till your next publication on that.  Are there any other topics you’d like to discuss before we sign off?

BEN ZABLOTSKY:   When we’re talking about mental health I think it’s certainly worth talking about mental health within the context of COVID-19 and how the NHIS can capture that.  I think one of the challenges of the NHIS is that it is a very large survey, but it’s also cross-sectional so it’s not possible to follow children longitudinally.  But what we can do is look at estimates that come out of 2019 and come out of 2020 and start to get a picture of how things might be changing for children in this age of COVID-19.  And some things we can look at or just access to care and potentially the use of telemedicine to receive services.  You know, I’ve talked a lot about treatment generally – a lot of the treatment in 2019, you know looking at the 2019 data, was face-to-face treatment that these individuals were receiving.  But a lot of times, you know, a lot of treatment is received through the schools and with schools being virtual, it’s quite likely that some children have lost out in some of the care they normally receive.  So I want to certainly look at that avenue of research moving forward because there’s a lot that’s happened obviously and one thing we don’t want to lose sight of is how children’s mental health have been affected.

HOST:  Well you raise a good point, because with the shuttering of schools and the isolation felt by some children and the disadvantages some children have, are you planning to directly look at the correlation between virtual learning and mental health issues that were tied to the pandemic?

BEN ZABLOTSKY:   So that’s one thing that’s tricky to look at within our survey ’cause we don’t have a lot of data on the specific schools the children are attending and the resources they had prior to COVID and receiving.  But I certainly think that understanding various services – and we ask questions about special education-related services – we have to understand how those might have changed and certainly will have changed when we are dealing with something like virtual schooling.

HOST:  Well that also would be a great topic for its own podcast so thanks very much Ben.

BEN ZABLOTSKY:   No problem – my pleasure.


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.


PODCAST: Healthy People Initiative, Part Four

April 30, 2021

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

podcast-iconHOST:  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:  So we can expect more products coming in the future – in the days, weeks, months ahead – from “Healthy People 2020.”  What about any differences between “Healthy People 2030” and “2020” – what are some of the more distinctive differences?

DAVID HUANG:  I think the main difference is that there was really a concerted effort by the Department and its stakeholders to reduce the size of “Healthy People.” “2020” was becoming very large and in some ways unwieldy, and it was felt that the initiative had grown too large to be really useful for its stakeholders.  So as part of these efforts, we went through a process over the past several years where we reduced the size of the initiative itself.  We went from about 1100 objectives with data in “2020” to 355 for “2030.”  In addition to that, there was also an effort to maintain a better balance and structure across the initiative.  So during the development of “2030,” after all of the objectives went through the approval process with the interagency steering committee – the federal interagency work group -there was actually another group that reviewed the objectives, the slate of objectives as a whole, and looked for balance.  And there were actually some objectives that were removed, I think one or two that were added, and that was something that was not part of the “2020” process in terms of looking at the balance of objectives as a whole.  As I mentioned earlier, we made sure that the objectives themselves were aligned with the latest science and that included aligning with the latest recommendations, the latest evidence, and also the latest issues that are important in the field of public health, specifically disease prevention and health promotion.

HOST:  Any other future directions that you like to talk about as far as the Healthy People program?

DAVID HUANG: Well of course we’re wrapping up “Healthy People 2020” with the release of a couple of more components that will comprise the rest of the “Healthy People 2020 Final Review.”  As part of that work, we’re also working on a Statistical Note on the elimination of health disparities, specifically among racial and ethnic groups, as well as a more formal archive site for both “Healthy People 2020” and “Data 2020,” which is the Healthy People 2020 database.  Now for “Healthy People 2030,” of course there is a lot to do over the next decade.  And we’re working on a variety of interactive tools, infographics, and products, working with our federal partners including ODPHP.  And this will start with the launch of our database, “Data 2030,” later this year.  Of note also, our webinars that are related to the leading health indicators and overall health and well-being measures.  And finally I’ll note that we are working on a “Healthy People 2030” disparities tool in collaboration with the HHS Office of Minority Health and ODPHP.

HOST:  One question that comes to mind – for “Healthy People 2030” are there any specific objectives dealing with the pandemic?

DAVID HUANG:  So we don’t have anything that is necessarily directly related to COVID, but certainly as many listeners will be aware there are many risk factors and diseases that are tied to COVID-19, and there’s actually a customized list that the Department has created that has all of the “Healthy People 2030” objectives directly related to COVID and this list is actually available to the public from the “Healthy People 2030” website.

HOST:  Anything else at all that we haven’t covered here that you like to mention?

DAVID HUANG:   Sure.  I actually wanted to mention that in terms of the new decade the branch is actually looking forward to expanding outreach and dissemination efforts throughout the decade, and this is actually possible because we do have a more focused and parsimonious set of objectives in Healthy People 2030.

HOST:  Very good – well, thank you David for joining us.

DAVID HUANG:  You’re welcome.

MUSIC BRIDGE:

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

HOST:  This week NCHS released a new report examining the prevalence of underlying chronic conditions among U.S. adults in the years leading into the pandemic. The analysis helps us understand how many people were at high risk for severe COVID-19 illness going into the pandemic.  Seven risk factors were examined: obesity – in particular severe obesity, diabetes, chronic obstructive pulmonary disease or COPD, serious heart conditions including heart failure, coronary artery disease, and cardiomyopathies, chronic kidney disease or CKD, and smoking.  The data come from the 2015-2018 National Health and Nutrition Examination Survey, and showed that 3/4 of all adults in the U.S. had at least one of these chronic conditions or risk factors that put them at high risk for severe COVID-19 illness, and over 86% of non-Hispanic black adults had one or more of these conditions.


PODCAST: Healthy People Initiative, Part Two

April 16, 2021

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

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20210416/20210416.htm

podcast-iconHOST:  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.

HOST:  So there are obviously – since the beginning of the program – there’ve been hundreds and hundreds of objectives set.  Do you have any sort of gauge of how many objectives or what percent of the objectives of we’ve met over the years or exceeded?

DAVID HUANG:  Sure – so we look at these really decade by decade.  And for Healthy People 2020, which we’re closing out now, there were 985 trackable objectives, which were those with at least a baseline and one or more follow up data points.  And of these 985, 334 of these – which is about a third – had met or exceeded their targets at the end of the decade.  This compares with Healthy People 2010, where 172 of 733 – or about 1/4 of trackable objectives – met or exceeded their targets.  Note that over the decades, the balance and composition of objectives as well as target setting methods themselves do vary, so any of these sorts of comparisons across decades should be taken with a grain of salt.

HOST:  Right, so it’s not a direct apples to apples comparison but your goal is always to increase the proportion that are met?

DAVID HUANG:  Yes and no.  I mean I think certainly we do want to say that we’ve met more and more of our targets, but on the flip side you know some of that is directly related to how the targets are set as well as I mentioned kind of the balance and composition of the objectives themselves, so again not an apples to apples comparison.  It’s certainly something that the Department and Healthy People stakeholders are paying attention to.

HOST:  Now you alluded to COVID-19 – what happens when new health challenges appear on the scene, such as COVID-19?

DAVID HUANG:  One of the hallmarks of the Healthy People initiative is its ability to incorporate new science and innovation as well as emerging health priorities.  For example, Healthy People 2030 includes science-based objectives related to opioids and social determinants of health, which are top priorities for HHS and for the nation.  The initiative itself does allow the flexibility for new objectives to be added or even dropped as the decade progresses.  The new Healthy People 2030 website actually features a resource for building customizable lists of objectives that can be used to curate objectives that are relevant to specific goals.  So even though there isn’t anything necessarily specific on COVID-19 in Healthy People 2030, HHS has used this tool to develop a custom list of 2030 objectives that are directly related to COVID-19 and that list is actually available to the public on the Healthy People website.

HOST:  Before we get into some specifics as far as progress made in these objectives, in looking at the new tables I noticed that in some cases there’s more recent data then what you’re referring to as far as the end point. I’ll use some of the cancer death measures – I think 2017 was used and even though there was great progress made on that there’s obviously more recent data than 2017.  So we’re just curious why you don’t use the latest year of data?

DAVID HUANG:  So what you’re referring to is the set of progress tables that we developed for the Healthy People 2020 final review, which is our end of decade assessment of progress.  And because we were dealing with so many objectives and data sources we had to choose a data cutoff and for the Healthy People 2020 final review, that cutoff was January of 2020.  So yes, we certainly acknowledge we don’t necessarily have the latest available data for this report, but the intention is really to be looking across all objectives which is a broad range of objectives.  And certainly we would encourage folks to look to other sources, such as Healthy People 2030 as well as other indicator projects and programs to find the actual latest available data for each individual indicator.

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

MUSIC BRIDGE:

HOST:  This week the country reached a grim milestone in the fight against drug abuse. NCHS released the latest monthly provisional numbers showing more than 90,000 Americans lost their lives due to drug overdoses in the one-year period ending in September 2020.  This figure was nearly 29% higher than the total observed the year before.  Over 2/3 of those deaths – or nearly 67,000 – involved an opioid of some kind.  As has been the case for the last several years, fentanyl and other synthetic opioids are the drugs driving this increase.  Among the 50 U.S. states and DC, only South Dakota saw a decline in overdose deaths from the previous year.

NCHS also released a new report this week on flu vaccination among U.S. children.  Using data from the 2019 National Health Interview Survey, NCHS determined that just over half of children six months of age up to age 17 received a flu vaccine in the past year, and that older children were less likely to receive a flu vaccine than younger children.


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.