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Deaths and Hospitalizations from Chronic Liver Disease and Cirrhosis -- United States, 1980-1989

In 1989, chronic liver disease,* including cirrhosis, was the ninth most frequent cause of death in the United States (1). Periodic analysis of trends and factors related to preventable death and hospitalization for chronic liver disease may be used to target prevention and control programs. This report examines national trends in death and hospitalization rates and state-specific death rates for chronic liver disease using data from CDC's National Center for Health Statistics' multiple-cause-of-death file and the National Hospital Discharge Survey (NHDS).

From 1980 through 1989, the age-adjusted death rate ** for chronic liver disease decreased 23%, from 13.5 to 10.4 per 100,000 persons (Figure 1). During this period, rates for men were more than two times higher than for women, and rates for blacks were more than 50% higher than for whites. *** Death rates for each of these groups declined steadily during this period.

In 1989, chronic liver disease was the underlying cause of death for 26,720 persons (Table 1) and a contributing cause of death for an additional 14,101 persons. Among deaths for which chronic liver disease was the underlying cause, 46.1% were diagnostically associated with alcohol (i.e., alcoholic fatty liver, acute alcoholic hepatitis, alcoholic cirrhosis of the liver, and alcoholic liver damage-unspecified); 2.9%, with chronic hepatitis; 1.5%, with biliary cirrhosis; and 49.5%, with unspecified conditions and no mention of alcohol (i.e., cirrhosis of the liver without mention of alcohol, other chronic nonalcoholic liver disease, and unspecified chronic liver disease without mention of alcohol).

Age-specific death rates increased with age for men in the 35-44-year through 65-74-year age groups (from 15.2 to 49.0 per 100,000 men) and for women in the 35-44-year through 75-84-year age groups (from 4.8 to 26.7 per 100,000 women) (Table 1). State-specific age-adjusted death rates of chronic liver disease in 1989 varied more than fivefold, from 6.1 per 100,000 population (for Idaho) to 31.5 per 100,000 (for the District of Columbia). The median rate was 9.6 per 100,000.

Chronic liver disease was also an important, although diminishing, cause of hospitalizations during 1980-1989. The age-adjusted hospitalization rate of chronic liver disease decreased 44% during this period (from 50.6 to 28.2 per 100,000) (Figure 1). Rates for women were generally one third lower than for men, and for both, declined steadily throughout the decade. For most years, rates for whites were 20%-30% lower than rates for blacks.

Chronic liver disease appeared as the first-listed diagnosis in an estimated 72,232 hospitalizations in 1989 (Table 2). Among these hospitalizations, 49.3% were diagnostically associated with alcohol, 10.5% with chronic hepatitis, 1.8% with biliary cirrhosis, and 38.3% with unspecified conditions and no mention of alcohol. Chronic liver disease was also listed as a diagnosis (other than first-listed) in an additional 218,156 hospitalizations.

Age-adjusted hospitalization rates of chronic liver disease in 1989 were 38% higher for men than for women (33.1 versus 23.9 per 100,000) and 27% higher for blacks than for whites (30.1 versus 23.7 per 100,000). Rates were successively higher in each age group from 35-44 years through 55-64 years for both men and women (from 40.9 to 96.5 per 100,000 and from 30.1 to 88.9 per 100,000, respectively) and decreased sharply after this age.

Reported by: Chronic Disease Surveillance Br, Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Most specific types of chronic liver disease in the United States are preventable (2). The findings in this report indicate a steady decline in rates of hospitalization and death from chronic liver disease during the 1980s. The variation in state-specific age-adjusted death rates suggests underlying regional differences in the occurrence of chronic liver disease and related risk factors. These findings may be used to target prevention and treatment programs and in the design of further epidemiologic research.

The findings in this report are subject to at least two limitations. First, because NHDS data do not distinguish initial from recurrent hospitalizations for a given person, these results represent the number of hospitalizations rather than the number of persons hospitalized for chronic liver disease. Thus, the declines might reflect a decline in the number of persons with chronic liver disease or in fewer hospitalizations among those with chronic liver disease, or some combination of both. Second, for both hospitalization and death certificate data, alcohol-related diagnoses may be under-reported.

Despite these potential limitations, the declining hospitalization and death rates reported here may indicate a true decrease in the underlying occurrence of chronic liver disease as a result of decreases in the prevalences of major risk factors (e.g., heavy alcohol use). In the United States, heavy alcohol use is considered the most important risk factor for chronic liver disease; even among deaths coded as chronic liver disease with unspecified conditions and no mention of alcohol, approximately 50% are thought to be due to alcohol use (3). Thus, decreasing hospitalization and death rates may reflect, in part, the decline in per capita alcohol consumption from 1977 through 1989 (4). These findings also are consistent with data from CDC's Behavioral Risk Factor Surveillance System that have shown a greater proportion of heavy drinkers among men than women and that alcohol consumption is inversely related to age (5). Strategies for reducing per capita consumption of alcohol include price controls (e.g., increased taxes on alcohol), control of the physical availability of alcohol, changes in legal accessibility, information and education programs, health warning labels, targeted health-promotion programs, and related activities (6).

Hepatitis B and C viruses are also important risk factors for chronic liver disease (7), and their relative contribution to chronic liver disease, alone and in combination with alcohol, requires further study. A comprehensive vaccination strategy for eliminating hepatitis B virus transmission and its sequelae in the United States has been recommended (8). Other potential risk factors include certain drugs, industrial chemicals, and less common infectious agents.

An estimated 90% of deaths attributed to cirrhosis is preventable (2). The national health objectives for the year 2000 include reducing cirrhosis deaths to no more than six per 100,000 **** (9). The findings in this report underscore that efforts to decrease mortality associated with chronic liver disease will have to be intensified if this objective is to be met.

References

  1. NCHS. Advanced report of final mortality statistics, 1989. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1992. (Monthly vital statistics report; vol 40, no. 8, suppl 2).

  2. Rothenberg RB, Koplan JP. Chronic disease in the 1990s. Ann Rev Public Health 1990;11:267-96.

  3. Shultz JM, Parker DL, Rice DP. ARDI: alcohol-related disease impact software {Software documentation}. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1989.

  4. National Institute on Alcohol Abuse and Alcoholism. Apparent per capita consumption: national, state, and regional trends, 1977-1989. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (ADM)281-89-0001.

  5. Anda RF, Waller MN, Wooten KG, et al. Behavioral risk factor surveillance, 1988. In: CDC surveillance summaries (June). MMWR 1990;39(no. SS-2):1-21.

  6. Rankin JG, Ashley MJ. Alcohol-related health problems. In: Last JM, Wallace RB, eds. Maxcy-Rosenau-Last public health and preventive medicine. 13th ed. East Norwalk, Connecticut: Appleton and Lange, 1992.

  7. Hurwitz ES, Neal JJ, Holman RC, et al. Chronic liver disease deaths associated with viral hepatitis in the United States {Abstract}. In: Program and abstracts of the Seventh National Conference on Chronic Disease Prevention and Control. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992:85.

  8. ACIP. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination -- recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-13).

  9. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

    • International Classification of Diseases, Ninth Revision, code 571. ** Based on the underlying cause of death. Intercensal population estimates were used to calculate age-adjusted rates standardized to the 1980 U.S. population. *** Estimates are presented by race to address the national health objectives for the year 2000 to reduce cirrhosis deaths in special populations. Estimates are not presented for races other than black and white because numbers were too small for analysis. **** Age-adjusted to the 1940 U.S. standard population.




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