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Cerebrovascular Disease Mortality and Medicare Hospitalization -- United States, 1980 - 1990

Cerebrovascular disease, the third leading cause of death in the United States, disproportionately affects older adults. In 1988, 87% of all deaths from and 74% of all hospitalizations for cerebrovascular disease occurred among persons aged greater than or equal to 65 years. This report presents temporal trends and geographic patterns in mortality and Medicare hospitalizations resulting from cerebrovascular disease among persons aged greater than or equal to 65 years.

Public-use mortality data from CDC's National Center for Health Statistics were used to determine the annual number of cerebrovascular disease deaths listed as the underlying cause of death (International Classification of Diseases, Ninth Revision (ICD-9) codes 430-434 and 436-438 (1)) from 1980 through 1988, by decedent's age, sex, and race. Age-adjusted death rates for persons aged greater than or equal to 65 years were calculated using postcensal population estimates (2); the 1980 U.S. population aged greater than or equal to 65 years was used as the standard. The number of persons hospitalized each year with a principal diagnosis of cerebrovascular disease (ICD-9 codes 430-434, 436-437 (1)) was obtained for 1985-1990 from computerized Medicare Part A (hospitalization) discharge records. Age-adjusted rates for persons hospitalized were calculated using as denominators the annual number of Medicare enrollees (persons aged greater than or equal to 65 years) listed in the Medicare denominator file. Race-specific rates are not reported for races other than black and white because sufficient denominators were not available.

Age-adjusted cerebrovascular disease death rates among persons aged greater than or equal to 65 years declined 27.6% from 568.9 per 100,000 in 1980 to 411.8 per 100,000 in 1988 (Figure 1). Overall declines in cerebrovascular disease death rates occurred for white women (27.1%, from 525.8 to 383.3 per 100,000), white men (28.8%, from 602.6 to 428.8 per 100,000), black women (23.1%, from 664.4 to 511.1 per 100,000), and black men (27.6%, from 781.0 to 565.8 per 100,000). However, from 1987 to 1988, the death rates increased for both black men and black women. In addition, death rates for blacks were consistently higher than rates for whites.

Among Medicare recipients, the rate of persons hospitalized for cerebrovascular disease declined 8.5%, from 1436.3 per 100,000 in 1985 to 1314.4 per 100,000 in 1990 (Figure 2). The decrease was greatest for whites. For blacks, increases from 1985 to 1986 were followed by decreases for black men and a stabilization for black women.

In 1988, age-adjusted rates for cerebrovascular disease mortality and hospitalization among persons aged greater than or equal to 65 years were greatest primarily in the southeastern United States (Figures 3 and 4). Reported by: Disease Surveillance Br, Office of Surveillance and Analysis, and Cardiovascular Health Br, Div of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Despite the declines in cerebrovascular disease mortality among older adults during the 1980s, these declines may be less prominent than declines that occurred during the 1970s (3). In addition, cerebrovascular disease death rates for blacks increased from 1987 to 1988 and were higher in 1988 than were rates for whites in 1980. Changes in treatment of hypertension, prevalence of cigarette smoking, dietary patterns, living conditions, and educational resources may have influenced trends in cerebrovascular disease mortality.

Trends in hospital discharge rates for cerebrovascular disease are difficult to interpret because they may reflect changes in factors such as natural history of the disease, availability of and access to hospital care, management of acute stroke, and case-fatality rates. The trends described in this report suggest that changes in the factors that influence hospitalization rates for Medicare recipients occur differentially for blacks and whites. Whether the Medicare hospitalization rates reflect a differential in race-specific incidence rates is not known; the only study of stroke incidence among whites during this time period reported an increase from 1980 to 1984 (4), and there have been no studies of incidence among blacks.

High rates of death and hospitalization for cerebrovascular disease in the Southeast (i.e., the "stroke belt") have been reported previously (5,6). Although specific factors contributing to this pattern are unclear, this pattern has been documented for both blacks and whites (CDC, unpublished data, 1992) and, therefore, cannot be attributed to the higher concentration of blacks living in the Southeast. The continued clustering of high rates of death and Medicare hospitalization in the Southeast suggests a persistence in geographic inequalities in the distribution of factors associated with cerebrovascular disease.

The continued development of effective public health interventions to reduce cerebrovascular disease morbidity and mortality, particularly among blacks and persons living in the Southeast, requires additional understanding of the distribution of a variety of factors, including socioeconomic resources (e.g., employment patterns, income, and educational opportunities), cigarette smoking prevalence, treatment of hypertension, dietary patterns, and delivery of health-care services.

References

  1. Hahn RA, Teutsch SM. Chronic disease reports in the Morbidity and Mortality Weekly Report (MMWR). MMWR 1989;38(no. S-1):1-8.

  2. Irwin R. 1980-1988 Intercensal population estimates by race, sex, and age (machine-readable data tape). Alexandria, Virginia: Demo-Detail, 1989.

  3. Cooper R, Sempos C, Hsieh SC, Kovar MG. Slowdown in the decline of stroke mortality in the United States, 1978-1986. Stroke 1990;21:1274-9.

  4. Broderick JP, Phillips SJ, Whisnant JP, O'Fallon WM, Bergstrahl EJ. Incidence rates of stroke in the `80s: the end of the decline in stroke? Stroke 1989;20:577-82.

  5. Borhani NO. Changes and geographic distribution of mortality from cerebrovascular disease. Am J Public Health 1965;55:673-81.

  6. Wing SB, Casper ML, Davis WB, Pellom A, Riggan W, Tyroler HA. Stroke mortality maps: United States, whites aged 35-74 years, 1962-1982. Stroke 1988;19:1501-13.

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