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Progress in Chronic Disease Prevention Chronic Disease Reports: Mortality Trends -- United States, 1979-1986

CDC's National Center for Health Statistics (NCHS) has developed the system by which deaths are reported, coded, and tabulated to produce official U.S. mortality statistics (1). Crude and adjusted mortality rates as reported by NCHS are the standard for reporting mortality statistics. Some alternative approaches may be useful to focus on particular events of epidemiologic importance (2). This report describes U.S. mortality trends from 1979 to 1986 using two departures from standard mortality reporting: the data were age-adjusted to the 1980 total U.S. population, and in some cases, different International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) groupings were used to form diagnostic categories (e.g., chronic obstructive pulmonary disease (OPD) included only cases likely to be associated with smoking).

Between 1979 and 1986, the total age-standardized mortality rate in the United States declined by 8%. However, this "average" change obscures considerable diversity in changing mortality rates for specific diseases: nine major chronic disease groupings demonstrated differing trends over this period (Figure 1). The largest decreases occurred for stroke (ICD-9-CM 430-434, 436-438)*, coronary heart disease (CHD) (ICD-9-CM 410-414, 429.2), and cirrhosis (ICD-9-CM 571) (Figure 1). In contrast, the portion of OPD likely to be related to smoking (ICD-9-CM 491, 492, 496) increased by 33% and lung cancer (ICD-9-CM 162), by 15%. Three cancers showed diverse trends: female breast cancer (ICD-9-CM 174) increased by 5%; colorectal cancer (ICD-9-CM 153, 154) declined by 7%, and cervical cancer (ICD-9-CM 180) declined by 18%. Diabetes mellitus (ICD-9-CM 250) decreased moderately (3%) as an underlying cause of death. Reported by: Office of the Director, Center for Chronic Disease Prevention and Health Promotion; Epidemiology and Surveillance Br, Div of Surveillance and Epidemiologic Studies, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The diverse trends in mortality for these nine diseases suggest that shared risk factors may have different effects. For example, the overall national prevalence of smoking declined by 13% (from 33.5% to 29.1%) during 1979-1987 (3). During the same period, stoke and CHD mortality decreased substantially; in contrast, smoking-related OPD and lung cancer mortality markedly increased. This diversity in the trends for smoking-related disorders may result from a combination of epidemiologic circumstances. Smoking is a stronger risk factor (i.e., is associated with greater relative risks) for lung cancer and this grouping of OPD than for stroke or heart disease (4). In addition, the latency between initiation of smoking and subsequent death is much longer for persons with pulmonary sequelae; recent mortality trends are thus less likely to be associated with recent trends in the risk factor. Finally, smoking may be the primary causative agent in lung cancer and this grouping of OPD, whereas smoking is only one of several interrelated risks for stroke and heart disease. Prevalences of these risks, which include hypertension, hypercholesterolemia, physical inactivity, and obesity, may have changed among the population in recent years (5).

The divergent trends in breast and cervical cancer mortality may also result from a variety of risk factors (4,6), of which few are amenable to direct intervention. Effective screening tests are available for both cancers. The Pap smear for cervical cancer is a well-established clinical tool, and its use may account for some of the decline in cervical cancer mortality. However, efficacy of the Pap smear has never been directly tested nor a systematic national program for its application conducted. The screening mammogram, a more recent development, was effective in a controlled setting (7), but no systematic national program exists for the widespread dissemination of mammographic services. The lack of such a program may not directly contribute to the increase in mortality but could be important in the failure to demonstrate desired decreases. Finally, the age, race, and socioeconomic differences in survival patterns exhibited by persons with cervical or breast cancer, as well as by those with colorectal cancer (8), may also play an important role in current mortality trends.

Death attributed to a chronic disease results from a series of intertwined biologic and epidemiologic events, including interactions among risk factors, diseases, and coding practices. Although cause-specific mortality trends using nonstandard rubrics are a useful measure of overall effect, they must be interpreted cautiously. Nonstandard use of diagnostic categories provides opportunities for special epidemiologic focus, but care should be taken to make such use explicit.


  1. CDC. Mortality data from the National Vital Statistics System. MMWR 1989;38:118-23. 2.CDC. Chronic disease reports in the Morbidity and Mortality Weekly Report (MMWR). MMWR 1989;38(suppl S-1). 3.CDC. Reducing the health consequences of smoking: 25 years of progress--a report of the Surgeon General, 1989. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1989; DHHS publication no. (CDC)89-8411. 4.Rothenberg R, Nasca P, Mikl J, Burnett W, Reynolds B. Cancer. In: Amler RW, Dull HB, eds. Closing the gap: the burden of unnecessary illness. New York: Oxford University Press, 1987:30-42. 5.CDC. Behavioral Risk Factor Survey data, 1981-1987. Atlanta: US Department of Health and Human Services, Public Health Service, 1988. 6.Thomas DB. Epidemiologic and related studies of breast cancer etiology. In: Lilienfeld AM, ed. Reviews in cancer epidemiology. Vol 1. New York: Elsevier/North-Holland, 1980:153-217. 7.Shapiro S, Venet W, Strax P, Venet L, Roeser R. Ten- to fourteen-year effect of screening on breast cancer mortality. JNCI 1982;69:349-55. 8.National Cancer Institute. Annual cancer statistics review, 1987. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1988; NIH publication no. 88-2789. *See Chronic Disease Reports: Stroke figure and tables following this article.

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