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Potentially Preventable Deaths from the Five Leading Causes of Death — United States, 2008–2010

Paula W. Yoon, ScD1, Brigham Bastian2, Robert N. Anderson, PhD2, Janet L. Collins, PhD3, Harold W. Jaffe, MD4 (Author affiliations at end of text)

In 2010, the top five causes of death in the United States were 1) diseases of the heart, 2) cancer, 3) chronic lower respiratory diseases, 4) cerebrovascular diseases (stroke), and 5) unintentional injuries (1). The rates of death from each cause vary greatly across the 50 states and the District of Columbia (2). An understanding of state differences in death rates for the leading causes might help state health officials establish disease prevention goals, priorities, and strategies. States with lower death rates can be used as benchmarks for setting achievable goals and calculating the number of deaths that might be prevented in states with higher rates. To determine the number of premature annual deaths for the five leading causes of death that potentially could be prevented ("potentially preventable deaths"), CDC analyzed National Vital Statistics System mortality data from 2008–2010. The number of annual potentially preventable deaths per state before age 80 years was determined by comparing the number of expected deaths (based on average death rates for the three states with the lowest rates for each cause) with the number of observed deaths. The results of this analysis indicate that, when considered separately, 91,757 deaths from diseases of the heart, 84,443 from cancer, 28,831 from chronic lower respiratory diseases, 16,973 from cerebrovascular diseases (stroke), and 36,836 from unintentional injuries potentially could be prevented each year. In addition, states in the Southeast had the highest number of potentially preventable deaths for each of the five leading causes. The findings provide disease-specific targets that states can use to measure their progress in preventing the leading causes of deaths in their populations.

Mortality data from the National Vital Statistics System for the period 2008–2010 were analyzed. Population estimates for the period 2008–2010 were produced by the U.S. Census Bureau in collaboration with the National Center for Health Statistics. The calculations of potentially preventable deaths were restricted to U.S. residents and to deaths that occurred to persons aged <80 years. The age restriction is consistent with average life expectancy for the total U.S. population, which was nearly 79 years in 2010 (2). Analysis was restricted to deaths with an underlying cause of death among the five leading causes, based on International Classification of Diseases, 10th Revision (ICD-10) codes: diseases of the heart codes (I00–I09, I11, I13, I20–I51), cancer (C00–C97), chronic lower respiratory diseases (J40–J47), cerebrovascular diseases (stroke) (I60–I69), and unintentional injuries (V01–X59, Y85–Y86). The five leading causes of death represented 63% of all deaths in 2010; the next five most frequent causes accounted for only about 12% of deaths (2).

The annual number of potentially preventable deaths for each of the five leading causes of death by state was calculated in three steps. The first step was to calculate and rank state disease-specific death rates by age group. Ages were initially grouped by 10-year increments, from 0–9 years through 70–79 years. However, these 10-year age groups, especially at the younger ages, frequently did not have enough deaths reported to be statistically reliable. Therefore, adjacent 10 year-age groups with small numbers of deaths were combined until enough deaths were aggregated to achieve reliability. For chronic lower respiratory diseases, for example, the age groupings were 0–49, 50–59, 60–69, and 70–79 years. The three states with the lowest observed death rates for each age group-specific cause of death category were then selected and their death rates averaged to calculate a lowest average age-specific death rate for each cause of death. The average of the lowest three states was chosen to minimize the effect of any extreme outlier and to represent the low end of the distribution of death rates among the states. The second step was to calculate expected deaths for each age group and state by multiplying the age-specific state populations by the lowest three-state average age-specific death rate for each cause. Total expected deaths for each cause per state were then calculated by summing expected deaths over all age groups up to age 79 years. Finally, the potentially preventable deaths were calculated by subtracting expected deaths from observed deaths. In instances where the result would be a negative number of potentially preventable deaths because the existing state rate was lower than the average of the three lowest states, the state's potentially preventable deaths were set to zero. Results are presented by state and by the 10 U.S. Department of Health and Human Services regions.*

During the period from 2008 to 2010, the average number of annual deaths from the five leading causes of death in persons aged <80 years was 895,317. This number represents 66% of annual deaths from all causes. The estimated average number of potentially preventable deaths for the five leading causes of death in persons aged <80 years were 91,757 for diseases of the heart, 84,443 for cancer, 28,831 for chronic lower respiratory diseases, 16,973 for cerebrovascular diseases (stroke), and 36,836 for unintentional injuries (Table 1). The Southeast (Region IV) had the highest number of potentially preventable deaths for all five leading causes of death (Table 2). The proportion of potentially preventable deaths among observed deaths for each of the five causes of death were 34% for diseases of the heart, 21% for cancer, 39% for chronic lower respiratory diseases, 33% for cerebrovascular diseases (stroke), and 39% for unintentional injuries (Figure).

Discussion

Death rates are population health outcome measures that reflect the combined influences of multiple biological and social health determinants, public health efforts, and medical care. Examining which diseases and injuries result in the greatest number of deaths in populations, particularly for deaths that occur earlier than expected, allows health officials to establish disease prevention goals, priorities, and strategies. In the United States, the largest number of deaths during 2008–2010 occurred from diseases of the heart, cancer, chronic lower respiratory diseases, cerebrovascular diseases (stroke), and unintentional injuries (1). The results of this study demonstrate that if all states achieved the lowest observed mortality levels for the five leading causes, when considered separately, as many as 91,757 premature heart disease deaths, 84,443 cancer deaths, 28,831 chronic lower respiratory disease deaths, 16,973 stroke deaths, and 36,836 unintentional injury deaths might be prevented each year. These calculations translate to approximately one in three premature heart disease deaths, one in five premature cancer deaths, two out of five chronic lower respiratory disease deaths, one out of every three stroke deaths, and two out of every five unintentional injury deaths that could be prevented.

Reducing the number of earlier than expected deaths from the leading causes of death requires risk factor reduction, screening, early intervention, and successful treatment of the disease or injury. For the five leading causes of death, the major modifiable risk factors include 1) diseases of the heart: tobacco use, high blood pressure, high blood cholesterol, type 2 diabetes, poor diet, being overweight, and lack of physical activity (3); 2) cancer: tobacco use, poor diet, lack of physical activity, being overweight, sun exposure, certain hormones, alcohol, some viruses and bacteria, ionizing radiation, and certain chemicals and other substances (4); 3) chronic lower respiratory diseases: tobacco smoke, second hand smoke exposure, other indoor air pollutants, outdoor air pollutants, allergens, and occupational agents (5); 4) cerebrovascular diseases (stroke): high blood pressure, high blood cholesterol, heart disease, diabetes, being overweight, tobacco use, alcohol use, and lack of physical activity (6); and 5) unintentional injuries: lack of vehicle restraint use, lack of motorcycle helmet use, unsafe consumer products, drug and alcohol use (including prescription drug misuse), exposure to occupational hazards, and unsafe home and community environments (7).

The majority of these risk factors do not occur randomly in populations; they are closely aligned with the social, demographic, environmental, economic, and geographic attributes of the neighborhoods in which people live and work (8). However, the calculation of potentially preventable deaths in this study did not account for differences in the attributes of states that might influence risk factors and ultimately death rates, such as proportion of the population below the poverty level. If health disparities were eliminated, as is called for by Healthy People 2020 (9), all states should be closer to achieving the lowest possible death rates for the five leading causes of death.

The findings in this report are subject to at least four limitations. First, uncertainty and error in the diagnosis and reporting of cause of death might result in errors in death rate estimations for some causes of death. Second, state affiliation is based on the person's residency at the time of death. With the exception of unintentional injuries, the factors that led to the resulting cause of death for some persons might have accumulated over a lifetime spent in different geographic locations. Third, the potentially preventable deaths are based on existing levels of state performance for the three states with the lowest death rates for each condition and might underestimate the benefit if these three states made full use of optimal health promotion and disease prevention strategies. Finally, to the extent that natural (i.e., random) variability in state death rates from year to year is responsible for the selection of the three states with the lowest death rates, there will be a tendency to regress to the mean. The method used tends to slightly overestimate the number of potentially preventable deaths. Nevertheless, the random component of the variation in state death rates is minimal and any bias is also minimal.

As a further note of caution, potentially preventable deaths cannot be added across causes of death by state or for the nation as a whole because of competing risks. For example, for a state that has been able to reduce its heart disease mortality, some premature deaths will be prevented altogether, but others will be pushed to different causes of death. A person who avoids death from heart disease might then be exposed to a higher risk for dying from injury or cancer. The result is that there is less variation by state in the death rate for all causes combined than for any particular cause of death.

States can use the disease-specific aspirational goals for potentially preventable deaths presented in this report in several ways. They can identify other states with similar populations but better outcomes and examine what those are doing differently to address the leading causes of death. Although each state has a unique set of factors that determine health outcomes, states might find neighboring states or states within their region as good sources of information on effective policies, programs, and services. The goals can also be used to educate state policymakers and leaders about what is achievable if they were able to match the best state outcomes.

1Division of Epidemiology, Analysis, and Library Services, Center for Surveillance, Epidemiology, and Laboratory Services; 2Division of Vital Statistics, National Center for Health Statistics; 3Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion; 4Office of the Associate Director for Science, CDC (Corresponding author: Paula W. Yoon, pyoon@cdc.gov, 404-498-6298)

References

  1. Hoyert DL, Xu JQ. Deaths: preliminary data for 2011. Natl Vital Stat Rep 2012;61(6).
  2. Murphy SL, Xu JQ, Kochanek KD. Deaths: final data for 2010. Natl Vital Stat Rep 2013;61(4).
  3. National Heart Lung and Blood Institute. What are the risk factors for heart disease? Washington, DC: National Institutes of Health; 2012. Available at http://www.nhlbi.nih.gov/educational/hearttruth/lower-risk/risk-factors.htm.
  4. National Cancer Institute. Prevention, genetics, causes. Washington, DC: National Institutes of Health; 2013. Available at http://www.cancer.gov/cancertopics/prevention-genetics-causes.
  5. World Health Organization. Risk factors for chronic respiratory diseases. In: Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach. Geneva, Switzerland: World Health Organization; 2007:37–55. Available at http://www.who.int/gard/publications/GARD%20Book%202007.pdf.
  6. CDC. Stroke risk factors. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. Available at http://www.cdc.gov/stroke/risk_factors.htm.
  7. Doll LS, Bonzo SE, Mercy JA, Sleet DA, eds. Handbook of injury and violence prevention. New York, NY: Springer; 2007.
  8. CDC. CDC health disparities and inequalities report—United States, 2013. MMWR 2013;62(Suppl No. 3).
  9. US Department of Health and Human Services. Healthy people 2020. Washington, DC: US Department of Health and Human Service; 2013. Available at http://www.healthypeople.gov/2020.

* Region 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. Region 2: New Jersey, New York, Puerto Rico, and the U.S. Virgin Islands. Region 3: Delaware, the District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia. Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee. Region 5: Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. Region 6: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas. Region 7: Iowa, Kansas, Missouri, and Nebraska. Region 8: Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming. Region 9: Arizona, California, Hawaii, Nevada, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Marshall Islands, and Republic of Palau. Region 10: Alaska, Idaho, Oregon, and Washington. Additional information available at http://www.hhs.gov/about/regionmap.html.


What is already known on this topic?

The top five causes of death in the United States are diseases of the heart, cancer, chronic lower respiratory diseases, cerebrovascular diseases (stroke), and unintentional injuries. Death rates for these diseases vary widely across the states because of the distribution of health determinants, access and use of health services, and public health efforts.

What is added by this report?

This report demonstrates that if all states could achieve the lowest observed death rates for the five leading causes, when considered separately, as many as 91,757 premature heart disease deaths, 84,443 cancer deaths, 28,831 chronic lower respiratory disease deaths, 16,973 stroke deaths, and 36,836 unintentional injury deaths might be prevented in the United States each year.

What are the implications for public health practice?

State health officials can use the lower death rates as benchmarks to establish disease prevention goals, priorities, and strategies. Reducing the number of earlier than expected deaths from the leading causes of death requires the joint effort of public health and heath-care organizations and personnel to support risk factor prevention and reduction, screening, early intervention, and successful treatment of diseases or injuries.


TABLE 1. Annual number of deaths expected,* observed, and potentially preventable for the five leading cause of death for persons aged <80 years, by state/area — United States, 2008–2010

State/Area

Diseases of the heart

Cancer

Chronic lower respiratory diseases

Cerebrovascular diseases (stroke)

Unintentional injuries

Deaths observed

Deaths expected

Potentially preventable deaths

Deaths observed

Deaths expected

Potentially preventable deaths

Deaths observed

Deaths expected

Potentially preventable deaths

Deaths observed

Deaths expected

Potentially preventable deaths

Deaths observed

Deaths expected

Potentially preventable deaths

Alabama

6,604

2,993

3,611

7,595

5,227

2,368

1,778

765

1,013

1,277

588

689

2,036

910

1,126

Alaska

463

331

132

703

588

115

112

77

35

91

62

29

331

131

200

Arizona

4,735

3,885

850

7,460

6,775

685

1,558

1,004

554

848

771

77

2,341

1,191

1,150

Arkansas

3,808

1,845

1,963

4,720

3,219

1,501

1,101

476

625

718

365

353

1,221

551

670

California

24,707

19,742

4,965

38,226

34,454

3,772

6,047

4,904

1,143

5,366

3,839

1,527

8,627

6,886

1,741

Colorado

2,815

2,707

108

4,944

4,752

192

1,141

665

476

604

520

84

1,525

940

585

Connecticut

2,569

2,176

393

4,367

3,805

562

509

544

0

425

420

5

905

679

226

Delaware

857

575

282

1,352

1,006

346

224

147

77

170

113

57

296

172

124

DC

729

310

419

742

543

199

73

78

0

107

61

46

169

117

52

Florida

17,586

13,352

4,234

28,249

23,195

5,054

5,327

3,501

1,826

3,481

2,655

826

6,927

3,675

3,252

Georgia

9,103

5,120

3,983

11,820

8,967

2,853

2,413

1,263

1,150

1,965

989

976

3,133

1,791

1,342

Hawaii

1,007

836

171

1,555

1,467

88

141

212

0

244

163

81

344

259

85

Idaho

1,080

883

197

1,753

1,546

207

409

224

185

234

174

60

516

285

231

Illinois

11,424

7,249

4,175

16,558

12,654

3,904

2,740

1,815

925

2,047

1,412

635

3,093

2,395

698

Indiana

6,421

3,783

2,638

9,385

6,612

2,773

2,154

954

1,200

1,240

739

501

2,064

1,209

855

Iowa

2,716

1,892

824

4,127

3,295

832

859

485

374

462

373

89

892

571

321

Kansas

2,248

1,636

612

3,624

2,854

770

826

414

412

485

321

164

1,010

525

485

Kentucky

5,332

2,662

2,670

7,499

4,655

2,844

1,792

675

1,117

934

520

414

2,240

826

1,414

Louisiana

5,784

2,609

3,175

6,909

4,562

2,347

1,106

658

448

1,003

510

493

1,771

850

921

Maine

1,083

928

155

2,259

1,627

632

443

237

206

229

180

49

390

262

128

Maryland

5,321

3,303

2,018

7,218

5,788

1,430

1,035

818

217

935

636

299

1,065

1,093

0

Massachusetts

4,416

3,926

490

8,319

6,865

1,454

1,115

984

131

807

761

46

1,507

1,252

255

Michigan

10,327

6,056

4,271

14,394

10,600

3,794

2,721

1,527

1,194

1,743

1,178

565

2,923

1,869

1,054

Minnesota

2,720

3,050

0

6,273

5,328

945

960

762

198

662

592

70

1,342

993

349

Mississippi

4,183

1,750

2,433

4,731

3,055

1,676

1,016

446

570

827

344

483

1,395

553

842

Missouri

6,553

3,691

2,862

9,023

6,442

2,581

2,090

941

1,149

1,164

724

440

2,328

1,133

1,195

Montana

826

650

176

1,304

1,143

161

341

166

175

162

127

35

416

190

226

Nebraska

1,252

1,063

189

2,254

1,852

402

543

270

273

294

209

85

490

337

153

Nevada

2,903

1,566

1,337

3,370

2,743

627

701

395

306

446

305

141

952

510

442

New Hampshire

916

828

88

1,772

1,455

317

315

206

109

163

158

5

381

255

126

New Jersey

7,106

5,243

1,863

10,948

9,147

1,801

1,436

1,312

124

1,319

1,015

304

1,888

1,665

223

New Mexico

1,510

1,253

257

2,393

2,194

199

535

320

215

310

246

64

1,013

386

627

New York

17,371

11,522

5,849

23,787

20,112

3,675

3,358

2,906

452

2,423

2,246

177

3,804

3,692

112

North Carolina

9,021

5,679

3,342

13,297

9,931

3,366

2,698

1,436

1,262

1,894

1,108

786

3,268

1,802

1,466

North Dakota

512

406

106

780

708

72

170

104

66

127

80

47

193

127

66

Ohio

11,875

7,164

4,711

17,413

12,514

4,899

3,729

1,818

1,911

2,271

1,400

871

4,016

2,184

1,832

Oklahoma

4,857

2,267

2,590

5,787

3,957

1,830

1,736

581

1,155

889

448

441

1,870

703

1,167

Oregon

2,421

2,364

57

5,212

4,153

1,059

1,110

599

511

635

461

174

1,068

730

338

Pennsylvania

12,668

8,221

4,447

19,114

14,340

4,774

3,051

2,101

950

2,194

1,611

583

4,319

2,435

1,884

Rhode Island

820

636

184

1,423

1,112

311

225

160

65

148

123

25

339

200

139

South Carolina

5,413

2,896

2,517

7,063

5,079

1,984

1,391

740

651

1,119

567

552

1,910

883

1,027

South Dakota

590

491

99

1,054

856

198

226

126

100

126

97

29

284

151

133

Tennessee

7,956

3,916

4,040

10,185

6,853

3,332

2,197

995

1,202

1,463

765

698

2,895

1,209

1,686

Texas

19,939

12,683

7,256

27,141

22,143

4,998

5,061

3,139

1,922

4,254

2,471

1,783

7,612

4,551

3,061

Utah

1,229

1,194

35

1,931

2,080

0

383

298

85

282

238

44

765

470

295

Vermont

482

411

71

921

723

198

167

103

64

91

79

12

181

122

59

Virginia

6,588

4,609

1,979

10,162

8,073

2,089

1,647

1,148

499

1,369

891

478

1,889

1,521

368

Washington

4,437

3,844

593

8,193

6,754

1,439

1,451

956

495

907

743

164

1,925

1,269

656

West Virginia

2,400

1,308

1,092

3,415

2,289

1,126

921

338

583

464

257

207

1,031

364

667

Wisconsin

4,513

3,424

1,089

7,530

5,978

1,552

1,190

862

328

869

667

202

1,666

1,074

592

Wyoming

492

333

159

695

585

110

186

83

103

73

65

8

296

106

190

Total

272,688

181,261

91,757

400,949

316,652

84,443

74,458

45,738

28,831

52,360

35,390

16,973

94,862

58,055

36,836

Abbreviation: DC = District of Columbia.

* Expected deaths are the lowest three-state average age-specific death rate times the age-specific state population rounded to the nearest whole number.

Potentially preventable deaths are observed deaths minus expected deaths rounded to the nearest whole number.


TABLE 2. Annual number of deaths expected,* observed, and potentially preventable for the five leading cause of death for persons aged <80 years, by U.S. Department of Health and Human Services region§ — United States, 2008–2010

Region

Diseases of the heart

Cancer

Chronic lower respiratory diseases

Cerebrovascular diseases (stroke)

Unintentional injuries

Deaths observed

Deaths expected

Potentially preventable deaths

Deaths observed

Deaths expected

Potentially preventable deaths

Deaths observed

Deaths expected

Potentially preventable deaths

Deaths observed

Deaths expected

Potentially preventable deaths

Deaths observed

Deaths expected

Potentially preventable deaths

1

10,286

8,904

1,382

19,061

15,587

3,474

2,774

2,234

540

1,863

1,722

141

3,703

2,771

932

2

24,477

16,765

7,712

34,735

29,259

5,476

4,794

4,218

576

3,742

3,261

481

5,692

5,357

335

3

28,563

18,327

10,236

42,003

32,039

9,964

6,951

4,630

2,321

5,239

3,568

1,671

8,769

5,703

3,066

4

65,198

38,367

26,831

90,439

66,962

23,477

18,612

9,820

8,792

12,960

7,538

5,422

23,804

11,650

12,154

5

47,280

30,726

16,554

71,553

53,686

17,867

13,494

7,740

5,754

8,832

5,988

2,844

15,104

9,724

5,380

6

35,898

20,656

15,242

46,950

36,074

10,876

9,539

5,174

4,365

7,174

4,040

3,134

13,487

7,040

6,447

7

12,769

8,281

4,488

19,028

14,443

4,585

4,318

2,111

2,207

2,405

1,628

777

4,720

2,566

2,154

8

6,464

5,782

682

10,708

10,123

585

2,447

1,442

1,005

1,374

1,128

246

3,479

1,985

1,494

9

33,352

26,030

7,322

50,611

45,439

5,172

8,447

6,514

1,933

6,904

5,078

1,826

12,264

8,845

3,419

10

8,401

7,422

979

15,861

13,041

2,820

3,082

1,857

1,225

1,867

1,439

428

3,840

2,414

1,426

Total

272,688

181,261

91,428

400,949

316,652

84,296

74,458

45,738

28,718

52,360

35,390

16,970

94,862

58,055

36,807

* Expected deaths are the lowest three-state average age-specific death rate times the age-specific state population rounded to the nearest whole number. Differences between Table 1 and Table 2 are the result of rounding error when calculating states individually or by region.

Potentially preventable deaths are observed deaths minus expected deaths rounded to the nearest whole number.

§ Region 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. Region 2: New Jersey, New York, Puerto Rico, and the U.S. Virgin Islands. Region 3: Delaware, the District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia. Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee. Region 5: Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. Region 6: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas. Region 7: Iowa, Kansas, Missouri, and Nebraska. Region 8: Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming. Region 9: Arizona, California, Hawaii, Nevada, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Marshall Islands, and Republic of Palau. Region 10: Alaska, Idaho, Oregon, and Washington. Additional information available at http://www.hhs.gov/about/regionmap.html.


FIGURE. Annual number of deaths observed and potentially preventable* for the five leading cause of death for persons aged <80 years — United States, 2008–2010


The figure above shows the annual number of deaths observed and potentially preventable for the five leading cause of death for persons aged <80 years in the United States during 2008-2010. The proportion of potentially preventable deaths among observed deaths for each of the five causes of death were 34% for diseases of the heart, 21% for cancer, 39% for chronic lower respiratory diseases, 33% for cerebrovascular diseases (stroke), and 39% for unintentional injuries.

* Potentially preventable deaths are observed deaths minus expected deaths (the lowest three-state average age-specific death rate times the age-specific state population) rounded to the nearest whole number.

Alternate Text: The figure above shows the annual number of deaths observed and potentially preventable for the five leading cause of death for persons aged <80 years in the United States during 2008-2010. The proportion of potentially preventable deaths among observed deaths for each of the five causes of death were 34% for diseases of the heart, 21% for cancer, 39% for chronic lower respiratory diseases, 33% for cerebrovascular diseases (stroke), and 39% for unintentional injuries.



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