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THE LIBRARY OF THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL THE COLLECTION OF NORTH CAROLINIANA C614.1 N87v5 1988 UNIVERSITY OF N C AT CHAPEL HILL 00034018777 FOR USE ONLY IN THE NORTH CAROLINA COLLECTION For.71 No, A-368 Digitized by the Internet Arcinive in 2009 with funding from Ensuring Democracy through Digital Access (NC-LSTA) http://www.archive.org/details/northcarolinavit198802nort LEADING CAUSES OF MORTALITY North Carolina Vital Statistics 1988—Volume 2 LEADING CAUSES OF MORTALITY North Carolina Vital Statistics 1988—Volume 2 Center for Health and Environmental Statistics N.C. Department of Environment, Health, and Natural Resources Division of Statistics and Information Services STATE OF NORTH CAROLINA James G. Martin, Governor DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES William W. Cobey, Jr., Secretary DIVISION OF STATISTICS AND INFORMATION SERVICES Delton Atkinson, M.S.P.H., M.P.H., Director June 1990 800 copies of this public document were printed at a cost of $3,310.44 or $4.14 per copy. ins TABLE OF CONTENTS Page PREFACE vii I. INTRODUCTION 1-1 Purpose and Organization 1-3 Overview of Mortality in North Carolina 1-9 II. TECHNICAL NOTES 2-1 North Carolina Population Bases 2-3 Mortality Rates 2-4 Computation of Mortality Rates 2-4 Interpretation of Mortality Rates 2-6 Flagging Biased Rates 2-9 Procedure for Geographic Clustering of Counties . . .2-12 III. GENERAL MORTALITY IN NORTH CAROLINA 3-1 IV. MAJOR CARDIOVASCULAR DISEASE MORTALITY 4-1 Heart Disease 4-3 Cerebrovascular Disease 4-9 Atherosclerosis 4-15 Page V. CANCER MORTALITY 5-1 Cancer 5-3 Cancer of the Colon, Rectum, and Anus 5-13 Cancer of the Trachea, Bronchus, and Lung 5-19 Cancer of the Female Breast 5-25 Cancer of the Prostate 5-31 Cancer in Special Populations 5-37 VI. OTHER LEADING CAUSES OF MORTALITY 6-1 Septicemia 6-3 Diabetes Mellitus 6-8 Pneumonia and Influenza 6-13 Chronic Obstructive Pulmonary Disease 6-19 Chronic Liver Disease and Cirrhosis 6-26 Nephritis, Nephrosis, and Nephrotic Syndrome . . . .6-31 VII. MAJOR EXTERNAL CAUSES OF MORTALITY 7-1 Injuries 7-3 - Unintended Motor Vehicle Injuries 7-5 Unintended Injuries Excluding Motor Vehicles . . .7-12 Suicide 7-20 Homicide 7-27 VIII. INFANT MORTALITY 8-1 IX. MULTIPLE CONDITIONS PRESENT AT DEATH 9-1 HI D m lij cr DO PREFACE The Center for Health and Environmental Statistics produces a major publication annually, describing in tabular and map form North Carolina's mortality experience over the most recent five-year period. Periodically, an expanded volume is produced that includes a narrative analysis for each cause of death. The expanded format is resumed in this 1988 edition, which includes statistical tables, maps, and graphs, as well as discussions of cause-specific trends, geographic patterns, risk factors, multiple conditions present at death, and pertinent research. An overview of the mortality experience in North Carolina is also presented. The tables in this report provide selected 1988 mortality statistics for counties. Department of Human Resources regions. Health Service Areas, and the state (see maps on preceding pages) . More than a dozen of the leading causes of mortality in North Carolina are tabulated; in addition, various cancer sites and total infant mortality are included. Comparisons with national statistics are usually based on 1987 data, which is the most recent year of final data available from the National Center for Health Statistics. As with previous editions, multiple conditions present at death are discussed in a separate section. Five diseases in particular—septicemia, diabetes, hypertension, atherosclerosis, and nephritis/nephrosis—are considered associated conditions far more often than underlying causes. Hence, Figures 18. A through 22. B display 1984-88 county rates for deaths associated with a Vll PURPOSE AND ORGANIZATION Although North Carolina has traditionally experienced low crude death rates, our status among states has worsened. In 1960, only seven of the 50 states had death rates lower than North Carolina's; this had increased to 14 by 1970 (1); 19 by 1980 (2); and 21 by 1987 (3). Furthermore, while many of the state's cause-specific rates are consistently below United States levels, some of North Carolina's age-adjusted rates are substan-tially higher. For example, cerebrovascular disease, motor vehicle injuries, other injuries, and septicemia are causes for which North Carolina's 1987 adjusted rates were 23 to 35 percent above the corresponding United States rates. For all causes, the 1987 North Carolina unadjusted rate was less than one percent lower than the United States rate, while the age-adjusted rate was six percent greater. Finally, four years of successive decreases in the infant death rate for North Carolina ended in 1987 with a 4.3% increase over 1986, followed by an increase of 4.1% in 1988. These facts pose a serious challenge to health officials throughout the state to (i) isolate those determinants of mor-tality that permit intervention, and (ii) identify high-risk areas in order to strategically utilize limited medical and health resources. The data in this volume should aid in these areas of investigation by providing information against which North Carolina's county and regional mortality may be assessed in the present and evaluated in the future. Nine sections comprise this edition of Leading Causes of Mortality . This section presents an overview of mortality 1-3 experience in North Carolina as well as the purpose and organiza-tion of the document. Section II provides technical information concerning the calculation, interpretation, and appropriate use of adjusted and unadjusted rates. As in past editions of this volume, readers are cautioned about using rates based on a small number of deaths, and the most problematic of the adjusted rates are "flagged" in the tables with an asterisk. The procedures used to determine which rates to flag are described in Section II. Also, the procedure used to analyze geographic clustering of counties is described. Sections III through IX consist of maps, tabular data, and narrative material which describe North Carolina's recent experi-ence with respect to general mortality, cause-specific mortality (underlying cause) , infant mortality, and multiple conditions present at death. For most causes, risk factors, geographic clustering, differences by race and sex, and trends over time are considered. Table 1 describes the selected cause-of-death categories in terms of codes from the ninth revision of the International Classification of Diseases (4) . Altogether, the 14 major causes selected for examination in this report accounted for 85 percent of all North Carolina deaths during 1988. Some of the cancer sites listed in Table 1 are not discussed separately in this report. However, the considerable interest in cancer justified presentation of rates for these sites. DESCRIPTION OF TABLES Sections III-IX contain tables that summarize the recent mortality experience of the state, four Department of Human Resources regions, six Health Service Areas, and the counties. Except in the case of infant deaths (Section VIII) , a table corresponding to each cause-of-death category includes the 1-4 following items of information: 1. the number of resident deaths occurring during 1988; 2. the 1988 death rate; 3. the number of resident deaths occurring during 1984-88; 4. the 1984-88 average annual death rate; 5. the 1984-88 average annual age-race-sex-adjusted death rate computed by the direct method (5). The formulas for calculating single- and five-year rates are described in Section II. In this report, general mortality rates (all causes combined) are expressed as deaths per 1,000 popula-tion, whereas cause-specific rates are expressed as deaths per 100,000 population. The infant death rates of Table 21, Section VIII, are computed as the number of infant deaths per 1,000 live births. DESCRIPTION OF MAPS This volume contains 64 computer-produced maps which depict data for the state's 100 counties. The maps on pages v and vi identify the four regions of the Department of Human Resources (DHR) and the state's six Health Service Areas (HSA's). In Sections III-IX, maps depicting geographical patterns in mortality should aid in the determination of specific types of health care needs. Up to four maps are shown for each cause-of -death category. Two maps depict the 1984-88 unadjusted death rate and the 1984-88 age-race-sex-adjusted death rate for each of the 100 counties. These maps show six levels of death rates, where level one is the highest rate interval, represented by solid black on the maps, and level six the lowest, depicted by solid white. The interval values (levels) indicated by the map legends are not necessarily continuous, but reflect the actual range of values for each interval. These maps must be viewed 1-5 with extreme caution for causes where the number of deaths per county is small, since in these cases rates can be very unstable. A clustering routine from the Statistical Analysis System (SAS) was used to group counties that are "most like each other" with respect to their unadjusted and then their adjusted rates (6) . This procedure may result in very large or very small groups, depending upon how county rates differ from one another. The other two maps for a particular cause depict "spatial" clustering of two or more adjacent counties with high unadjusted and/or adjusted rates, using a procedure described in Section II. These maps are presented for a given cause only when a statisti-cally significant spatial cluster was found to exist. Unlike the maps described above, these maps are presented in reduced form as part of the narrative and show up to three interval levels of death rates, depending on the number of significant spatial clusters found, along with the significance level (i.e., p-val-ue) . MULTIPLE CONDITIONS PRESENT AT DEATH Since 1975, multiple conditions present at death have been coded, and statistics are available for all conditions reported by the certifier. Five diseases--septicemia, diabetes, hyper-tension, atherosclerosis, and nephritis--are considered associ-ated conditions far more often than they are reported as under-lying causes. The importance of multiple conditions and the geographic patterns of these five diseases are discussed in Section IX, while the etiology and risk factors associated with septicemia, diabetes, atherosclerosis, and nephritis are dis-cussed separately in Sections IV and VI. County rate tables for these diseases as underlying causes are likewise available in Sections IV and VI. Neither separate discussion nor a county rate table for hypertension is warranted, since it was reported 1-6 as the underlying cause for only 283 deaths in 1988. Tables included in Section IX show deaths cross-tabulated by underlying cause and associated mentioned conditions, death frequencies for selected pairs of mentioned conditions, and death rates based on mentioned conditions rather than underlying causes. Rates are deaths with the condition mentioned per 100,000 population. In addition, ratios of the 14 major causes (plus hypertension and four site-specific cancers) as mentioned conditions versus underlying causes are tabulated. 1-7 00 00 I 00 On QZ< 00 00 o ^ WD H o 4) « On o 2 Bi Z 3 u — Q S vi_, O o s U^ o6'^r4o6'^i^-^CT\rsic>-^---rg^Tt^<X3-^rnTfinNdoduSr-^odoo6'^r<Sr4os ^^ rst csl '— ON'^r--T^oqvqpu-;oqrnrrivo-^ir;rsjpOsrop'^prg'^QqrOoqMvqO;'--;0\ odc><^NOu-irouSor40'-J^r*Sr4Tt-ONvd'*Sirisbr^o6oONr4ot^-<J-Tt-rvi 0^0't•0^<J-^m^^CT^•^<^^^^<t0^^r^r^OO^sl^vOOCX3^0^00^•^00 mcNOO—'OrOrsimoOt^OO^OOON-^-Orn—irsiCT\inr<->(Nn-iONO\OON'-iOOr-vC-^ r^'^r^fNmrO'-'VO \0r~40—'"-i00r-ir<-)rn-^mr<->O\Or--<*-irivor^m oo oo ON f<~) 6 6 ON rn 00 ON o -^ in (N QO (N O O rsl (N rsi oo On On in 00 (N in oo OOO—'f»~)inr^--r^rjTt-OfOinoO — O"<J-Q0OOO^OO <t--^^ininininNONOt^i^oOQOooooONOOr<NinooONr-oo— I ,j-^rt^_<^^^^^^^rt^^^(v4rsjorNi-<j--^ininoo [^ ON oo O in r- (6 <Z) c> O in NO 00 ON ON ^Q -1 !^ O tn « "^ 2 = .2 S-£ <QO< E o -S "3 JS Dd J; 'J - Si - c ^ u 3 C II •; -£ cat 2i 2-TD - c ca n c .2 a OVERVIEW OF MORTALITY IN NORTH CAROLINA Mortality in North Carolina has exhibited a general downward trend in this century, but an upward trend since 1982, rising from a low of 8.1 deaths per 1,000 population in 1982 to a high of 8.9 in 1988. Probably the major factor contributing to this increase is aging of the state's population. Other factors that affect mortality include changes in lifestyle (e.g., reduction in smoking) , environment, risk factors, and the medical care system. In sections III through IX of this report, these factors and others are considered in discussing each cause of death. This overview summarizes four general determinants of mortality as well as some of the risk factors which are associated with a number of different causes. Next, some of the major mortality findings are highlighted, and finally, premature mortality in North Carolina is examined via the concept of "years of life lost," which emphasizes the impact of mortality in the younger age groups (7) . DETERMINANTS OF MORTALITY A broad view of mortality determinants shows that problems "arise from causes embedded in the social fabric of the nation as a whole" (8) , and that medical care is only one aspect of health maintenance. Accordingly, environment, lifestyle, biology and genetics, and medical care must all be considered as determinants of health. Over the past decade, environmental factors, both natural and man-made, have been increasingly recognized as having a signifi- 1-9 cant impact on health. For example, naturally occurring varia-tions such as water mineral content and elevation have been cited as influencing the incidence of cardiovascular disease (9) . A more important problem may be the natural occurrence of radon gas in some homes. However, most serious environmental problems are consequences of man-made pollution of air, water, and food sour-ces. Recent examples include atmospheric pollution from lead and ozone, ground water contamination from toxic wastes, and occupa-tional exposures to hazardous substances. Children are especial-ly at risk from pollutants such as ozone (10) and lead (11). While pollution is a by-product of a high-technology, growth-oriented society, concomitants of economic growth also include jobs, income, health insurance, and improved access to medical care. Unemployment, poverty, and their social accompani-ments are generally associated with less adequate mental and physical health. The poor, having fewer economic and social resources, experience higher levels of stress and are more vulnerable to infectious agents, economic problems, and hazards in the home and workplace. These problems are typified by farming. The prolonged decline of economic conditions for many farmers has increased stress. Pollution from agricultural chemicals (fertilizers and pesticides) and injuries are relative-ly common: among all industrial groups, farmers rank near the top on rates for poisoning, skin diseases, and injuries (12). Also, rural populations are less likely to have medical insurance and/or quick access to medical care. In short, economic condi-tions and environmental factors may interact in complex ways to affect health status. Lifestyle refers to behaviors that affect health and over which individuals have varying degrees of control. There are substantial data showing that certain health habits (e.g., never having smoked, moderate or no alcohol consumption, regular exercise, sleeping 7-8 hours per night, and maintaining appropri- 1-10 ate weight) are associated with improved health and reduced mortality (13). Individuals' lifestyle decisions regarding these variables are associated with their socioeconomic status, race, and sex: men are more likely than women to smoke and drink excessively and to exercise; younger women are more likely to smoke than older women; blacks are more likely to be sedentary and to smoke than whites; and black women are substantially overweight almost twice as often as white women. Persons with fewer than 12 years of education are more likely to smoke, sleep excessively, not exercise, and be substantially overweight. (13) In short, individuals' decisions are conditioned to a large extent by their socioeconomic status. "Blaming the victim" by keeping the problem at the individual level may obscure the origins of disease in the socioeconomic environment. However, policies to educate individuals about their health behaviors are much less complex and easier to sell politically than those aimed at modifying the underlying social and economic determinants of lifestyle and health. This is not meant to suggest that health education is without impact. Certain population groups are more likely to have lifestyles associated with increased mortality, and education programs are effective (although short-run) complements to policies oriented toward the environmental factors that condition lifestyle. For example, nutrition education can have a substan-tial health payoff among the poor, but only if they are provided sufficient money to buy proper foods and facilities for prepara-tion. Sex education for prevention of sexually transmitted diseases and unwanted pregnancies is another area where education may be very effective in altering specific high-risk behaviors that are or may be associated with lifestyle. Variables such as income, education, and residence (urban versus rural) may be important indicators and determinants of lifestyle (14) , and effective education programs must consider variations along such dimensions. In short, targeting specific groups is likely to be 1-11 more successful than generalized education or media campaigns. Biological factors are relatively powerful determinants of mortality. The age, race, and sex of an individual are biologi-cally determined, and mortality rates vary consistently along these dimensions: health is strongly tied to aging and the life cycle. Some diseases that vary by race are thought to be geneti-cally linked, and biological factors account for some of the differences in incidence rates between males and females for some diseases, with females living longer on the average. However, there are health consequences of age, race, and sex that are not biological in origin. Social stratification is partly based on these variables, with the elderly, nonwhites, and females gener-ally being accorded lower socioeconomic status. Some of the elevated male mortality may result from the aggressive, achieve-ment- oriented lifestyle that accompanies higher status positions (15), while higher nonwhite mortality is due in part to a lower position in the economic hierarchy (16) . Many causes of diseases are directly or indirectly genetic in origin. In North Carolina, an estimated 320,375 persons are afflicted with serious genetic disorders, resulting in physical defects, mental retardation, and other health problems, and approximately 80 percent of birth defects are genetic in origin (17). Forty percent of the children admitted to inpatient pediatric care are there because of genetic disorders (18), and about 50 percent of all childhood blindness is linked to genetic factors (19). In North Carolina, congenital malformations are now the leading cause of mortality among infants under one year, and second only to injuries among children ages one through four (20). Overall, the 1988 congenital anomalies death rate was 5.3 deaths per 100,000 population. In addition, some persons have a genetically linked susceptibility to certain diseases. Some types of cancer, for example, may result from genetic weaknesses of the immunological system in combination with specific external 1-12 agents (carcinogens) . The medical care system is another important determinant of mortality levels. This complex system is primarily reactive, in that it responds to health problems by attempting to restore the individual to a full and productive life. Disease prevention is also within the purview of the medical care system, as exempli-fied by vaccination to prevent infectious diseases and by patient education concerning specific health consequences of certain behaviors. Medical care personnel may occasionally be involved in attacking certain environmental and biological causes of disease, though this type of activity has traditionally been carried out by the public sector. McKeown and Brown (21) present evidence suggesting that medical practice in the first half of the 19th century had little to do with the large decline in mortality that took place in Western societies, but rather that transportation improvements, changes in the economic system that assured a more continuous and nutritious food supply, and improved sanitation practices urged on by reformers in the cities were responsible. After the practice of antisepsis became widespread late in the 19th centu-ry, medical care became a much more positive factor in reducing mortality. During the first half of this century, the health and average life span of Americans improved considerably, due sub-stantially to efforts in the medical sector to reduce infections and acute nutritional diseases. Major gains were also observed in infant and maternal mortality, probably due to improvements in nutrition, sanitation, and the development of vaccines (22) . However, McKeown (23) notes that a significant reduction in mortality from the introduction of antibiotics cannot be demon-strated. Medical care may sometimes have negative health consequences. It has been estimated that nosocomial infections (acquired inside 1-13 the hospital) strike five percent of Americans hospitalized each year, adding to hospital costs by increasing lengths of stay (24). Inappropriate or unnecessary treatment may also increase mortality as well as health care costs. Probably less than 20 percent of the procedures used by health professionals have been demonstrated to be helpful in clinical trials (25) . In short, risks are always present, even in proper medical treatment, but in most cases they are far outweighed by the potential benefits. In summary , a complete program to improve health status and reduce mortality must include environmental, lifestyle, biologi-cal, and medical care strategies. Too much emphasis in one area may involve substantial opportunity costs due to neglect of other areas. For example, expenditures for basic research, for envi-ronmental protection, to improve substandard housing, or for public education regarding specific risk behaviors could have higher long-term health payoffs than would the same amount expended just for medical care. The status of heart disease and cancer as major killers is closely linked to environmental and lifestyle factors, and medical treatment or attempts to modify individual behaviors are unlikely to substantially reduce mor-tality from these diseases. Increased per capita consumption of foods high in animal fats along with the increase in sedentary occupations, and drinking and smoking associated with stresses on the individual and family unit all underlie both heart disease and cancer. In addition, the spiral of post-WWII economic production, technological achievements, and personal affluence have led to chronic exposure of large segments of the population to increasing numbers of carcinogens in the air, water, and food supplies. Cancer control is such a difficult policy area pre-cisely because cancer prevention will require fundamental changes in the physical--and therefore economic--environment , as well as modification of behaviors and lifestyle. Policies aimed at improving the medical treatment of cancer patients, while often costly, are probably easier to implement, but they do not con- 1-14 front the basic problems. In brief, strategies to deal with cancer, heart disease, and other leading causes of mortality must deal with factors that exist in the fabric of contemporary society. RISK FACTORS Risk factors particular to each cause of death are discussed in separate sections of this volume. In addition, information about several factors that are common to a number of different causes of death is summarized here. Two of the most pervasive factors contributing to U.S. mortality from various diseases are high blood pressure and cigarette smoking . Elevated blood pressure is associated with death from all cardiovascular diseases, diabetes mellitus, cirrhosis of the liver (26, 27) and renal failure (28) . While most causes of hypertension are amenable to treatment, many people either are unaware of having the condition or do not modify behaviors (e.g., maintain proper weight, diet, and medica-tion regimen) necessary to control it. Use of tobacco products contributes to death from a large number of causes (26, 27, 29-32). According to data compiled by the U.S. Surgeon General (32), cigarette smoking is a major cause of lung cancer as well as cancers of the larynx, oral cavity, and esophagus; it is a contributory factor in the development of cancers of the bladder, pancreas, and kidney; and approximately 30 percent of all cancer deaths are attributable to cigarette smoking. There is evidence that it is a contributor in the development of chronic bronchitis and emphysema, pulmonary heart disease, myocardial infarction, aortic aneurysm, and a wide variety of other vascular diseases. It may be a risk factor for Alzheimer's Disease (33). In addition, smoking seems to interact synergistically with other risk factors, such as asbestos, ioniz- 1-15 ing radiation, oral contraceptives, and certain dietary factors, to produce a variety of cancers and vascular diseases. While the low tar, low nicotine cigarette may be less likely to cause lung cancer or chronic bronchitis, its carbon monoxide content—which is associated with vascular disease—remains unchanged. The in-creased use of smokeless tobacco (snuff, chewing tobacco, and similar products) is disturbing, since these products are associ-ated with tongue cancer mortality and oral cancers in general (34, 35). Finally, the impact of tobacco use on mortality is such that nearly 50 percent of the difference by sex in total mortality over the adult age span is likely attributable to smoking (36). The data indicate that a considerable reduction in morbidity and mortality related to tobacco usage is likely to come about only with a substantial reduction in usage of tobacco products (29) . Diet also has an important impact on certain causes of mortality. Overeating may lead to obesity, which is associated with high blood pressure, diabetes, and cardiovascular disease. In turn, diabetes is a risk factor for stroke and other cardiovascular diseases. In addition, the content of the modern diet has important consequences for mortality. The contemporary diet "... is higher in intake of energy, of protein (especial-ly animal protein) , and of fat (especially animal fat) , but lower in intake of fiber-containing cereal foods; this diet is associ-ated with high rates of morbidity and mortality from degenerative diseases" (37). Based on findings such as these, decreased intake of animal fat and protein, cholesterol, salt, sugar, and alcohol are often--but not unanimously--recommended. Excessive alcohol consumption is the third largest health problem in America (38) and is associated with a risk of prema-ture death greatly exceeding normal expectancy from a variety of diseases (39-41). "While the lifestyle typical of many heavy drinkers contributes to this risk, the effects of alcohol per se 1-16 account for a substantial part of the excess mortality" (39) . In two Chicago studies, heavy drinkers had higher mortality from all causes, cardiovascular diseases, coronary heart disease, and sudden death than could be entirely explained by other risk factors such as blood pressure, smoking, and weight (40) . Heavy alcohol use by pregnant women leads to birth anomalies, including fetal alcohol syndrome and subsequent mental retardation (38). In contrast to findings for excessive alcohol consumption, the mortality experience of moderate drinkers does not seem to differ notably from that of life-long abstainers (39) . Social class has a very strong impact on mortality (16, 30, 42). "Social class gradients of mortality and life expectancy have been observed for centuries, and a vast body of evidence has shown consistently that those in the lower classes have higher mortality, morbidity, and disability rates" (16) . The higher morbidity rates typically found in lower socioeconomic status groups indicate that the excess mortality is not simply attribut-able to a higher case fatality rate, since it is accompanied by a higher prevalence of morbidity. Differences between white and nonwhite mortality rates can be attributed largely to social class differences: persons in lower socioeconomic groups, who are substantially nonwhite, live in a more toxic, hazardous, and non-hygienic environment resulting in a broad array of disease consequences. Low education contributes to poor health practic-es, and low income affects many aspects of health, including nutrition. Higher stress levels and ineffective responses to stress also contribute to higher mortality among the poor (16). Lower class persons generally receive less adequate medical care, though this probably does not account for a major portion of the social class differences in morbidity and mortality (16) . In fact, the association between excess mortality and low socioeco-nomic status persists independent of individual behaviors or at-tributes such as smoking, alcohol consumption, body mass index, physical activity, martial status, race, and sex; hence the " ... 1-17 properties of the sociophysical environment may be important contributors to the . . . excess mortality" (43) . Sex is another important variable associated with mortality. Females have lower mortality rates and greater life expectancies than males in all developed countries (36) . The differential in death rates is present at conception and continues for every age group. At birth, the ratio of males to females is 104:100, but by age 70 females outnumber males by approximately 3:2. In the United States, the 1987 age-adjusted death rate for males exceed-ed that of females by 73 percent (3) . A substantial amount of excess male mortality is related to sex differences in behavior, such as cigarette smoking, drinking alcohol, aggressive competitiveness, and occupational exposure to environmental and physical hazards (15). For 15-44-year-olds, more than 90 percent of the excess male mortality may be attrib-utable to violence and smoking (36) . Biological factors also contribute to higher male mortality. "Thus, even among nonsmokers, men have higher mortality than women for certain types of cancer, and this implies that there must be other factors, in addition to smoking, that contribute to higher cancer among men" (36) . To the extent that the sex difference in mortality is not due to biological factors, substantial reductions in male excess mortality may be possible through lifestyle and behavioral changes. With the transition earlier in this century from infectious to degenerative diseases as the major causes of death, lifestyle became more important in affecting mortality experi-ence, and the difference between male and female mortality rates increased steadily. More recently, female mortality relative to male mortality has actually worsened for several age groups and for several leading causes (44) . This may be associated with increased smoking (29) and the adoption of other "male" behaviors 1-1? by women as job participation and mobility increase and tradi-tional roles are modified. Thus, social and lifestyle changes may also help to reduce female mortality. A number of risk factors have been reviewed that bear on many causes of death, and efforts to reduce excess mortality must involve consideration of these important precursors. NORTH CAROLINA MORTALITY HIGHLIGHTS o As shown in Table 1, a total of 57,630 North Carolinians died in 1988, for a rate of 8.9 deaths per 1,000 population. The 1988 crude rate was three percent above the 1987 rate. The five-year (1984-88) crude rate was 8.6, which was four percent over the rate for the 1979-83 period. The median age at death in 1988 increased to 72.9 years, up from 72.6 in 1987 and consistent with a generally steady increase in the median over the last three decades. o The number of deaths per 1,000 population was slightly (under 2%) higher for nonwhites than for whites, and substantially higher for males than for females (by 21%) . A much younger age structure for nonwhites accounts for the fact that their crude mortality rate is not higher in comparison for whites. Age-adjusted mortality is much higher for nonwhites. o Age-adjusted mortality rates for the 1984-88 period show wide gaps in the overall risk of mortality by race and sex. In the 1984-88 period, the male rate for both races was approxi-mately 90 percent greater than the female rate, and the nonwhite rate for both sexes remained more than 4 5 percent above the white rate. o Comparisons of the 1987 N.C. age-race-sex-specific mortality rates with corresponding rates for the U.S. (3) reveal the 1-19 following major excesses* in North Carolina: White males: Under 1 and ages 65-74 (11% above the U.S. rate) ; White females: Under 1 (17% above U.S. rate) ; Nonwhite males: Ages 1-4 (50%), 5-14 (36%), 45-54 (29%), 55-64 (26%), 65-74 (27%), 75-84 (16%); Nonwhite females: Ages 45-54 (18%) Even after adjusting for age, race, and sex, the eastern counties, especially the northeastern counties, seem to have consistently higher mortality rates. Based on the 1984-88 adjusted rates, statistically significant spatial clusters exist in the eastern third of North Carolina for total mortality, chronic obstructive pulmonary disease, total cancer, colon cancer, and cerebrovascular disease. For the 1984-88 period, the highest overall adjusted death rate was in DHR Region IV (the Eastern region) . The ten leading causes of deaths in 1988 were (in descending order) heart disease, cancer, cerebrovascular disease, unintentional injuries, chronic obstructive pulmonary disease, pneumonia/influenza, diabetes, suicide, chronic liver disease/cirrhosis, and homicide. However, based on the number of years of life lost prematurely for each cause, the order of the ten leading causes shifts to cancer, heart disease, unintentional injuries, suicide, homicide, cerebrovascular disease, chronic obstructive pulmonary *North Carolina excesses for nonwhites reflect to some extent the fact that the proportion of blacks in the N.C. nonwhite population is greater than for the U.S., and mortality rates for black males and females in each age group generally exceed the corresponding nonwhite rates. 1-20 disease, chronic liver disease/cirrhosis, diabetes, and pneumonia/ influenza . Nonwhite males have a greater risk of death from uninten-tional injuries at every age interval except 15-24 and 85 and older where white males have the highest rates. The 1988 age-adjusted nonwhite male rates for motor vehicle and all other unintentional injuries exceeded rates for white males by 47 and 124 percent respectively. Comparing the U.S. and N.C. 1987 unadjusted rates, mortality in N.C. was more than 23 percent greater for unintentional injuries and septicemia, 14 percent greater for cerebrovas-cular disease, and five percent greater for homicide. However, for most remaining leading causes including cancer and diseases of the heart, the N.C. unadjusted rates were two to 2 percent lower than the corresponding U.S. rates. Total mortality for N.C. was one percent lower than for the U.S. After adjusting for the state's more youthful age structure, mortality conditions in N.C. appear less favorable, especially for cerebrovascular disease, unintentional injuries, and septicemia. The adjusted total mortality rate for N.C. was nearly six percent greater than for the U.S. The 1988 total cancer rate was three percent above the rate for 1987. Site-specific cancers showing large percentage increases in rates for 1988 were leukemia (+10%) and cancer of the pancreas (+8%). Of the four major cancers, rates for three (trachea/bronchus/lung; breast; and prostate) each increased by about six percent while cancer of the colon/rectum/anus increased approximately two percent. Cancer of the cervix uteri and stomach cancer each decreased by about three percent. However, some of these increases 1-21 reflect aging of the state's population. After adjusting for age, the increase in the total cancer rate between 1987 and 1988 dropped to one percent; the rate for cancer of the colon/rectum/anus decreased by three percent; the rate for breast cancer was essentially unchanged; and rates for cancer of the trachea/bronchus/ lung and prostrate cancer showed four percent increases. By race and sex, the 1988 age-adjusted rates for males were substantially higher than those for females, and rates for nonwhites were higher than those for whites. Total cancer mortality (the unadjusted rate) increased steadily (by 19 percent in total) between 1980 and 1988 and rose 10 percent during the 1984-88 five-year period in comparison to the 1979-83 period. Further comparisons of the five-year periods show that unadjusted rates for cancer of the trachea/bronchus/ lung and breast cancer each in-creased by about 2 percent, and prostrate cancer and cancer of the ovary and other uterine adnexa both increased by 13 percent. The rate for cancer of the cervix uteri decreased by 10 percent, while leukemia and stomach cancer rates decreased by two percent. Comparisons based on age-adjusted rates show that total cancer increased by two percent, while cancer of the trachea/bronchus/ lung and breast increased by 12 percent and 11 percent respectively. Between the 1979-83 and 1984-88 five-year periods, the pneumonia/ influenza and chronic obstructive pulmonary disease (COPD) crude death rates in N.C. increased 26 and 28 percent respectively. For both causes, large crude rate in-creases over the last five years occurred between 1987 and 1988. After adjusting for age, the mortality rate for pneumonia/ influenza shows c relatively moderate increase of eight percent between the 1979-83 and 1984-88 periods, whereas the corresponding increase for COPD was more 1-22 substantial (about 15 percent) . Based on 1987 age-adjusted rates, North Carolina's rates for COPD and pneumonia/ influenza are about six percent and one percent respectively less than corresponding U.S. rates (3). Race-sex-specific age-adjusted rates show that males of both races die from each of these causes substantially more often than females. COPD mortality rates for whites are higher than for nonwhites, while nonwhites have higher rates from pneumonia/ influenza. The suicide crude death rate decreased slightly in four of the last five years. In 1988, the rate fell by less than two percent, to slightly below the 1987 U.S. rate. Between the 1979-83 and 1984-88 periods, the age-adjusted suicide rate remained essentially stable. Based on 1984-88 age-ad-justed data, the rate for white males is approximately twice that of nonwhite males and nearly three times that of white females, while nonwhite females have an age-adjusted rate less than half that of white females. The homicide crude death rate increased from 1984 to 1986, then decreased in 1987 and 1988. For the five-year period 1984-88, the rate was 16 percent lower than for the preced-ing five years (1979-83), although it was above the U.S. rate for 9 of the 10 years between 1979 and 1988. Between 1987 and 1988, the age-adjusted homicide rate declined about 11 percent for whites and increased five percent for nonwhites of both sexes. In 1988 about 40 percent of all homicide victims were nonwhite males; yet nonwhite males represent only 11 percent of the total population. The age-adjusted homicide rate for nonwhite males exceeded that for white males by 327 percent. 1-23 PREMATURE MORTALITY IN NORTH CAROLINA Since 1914, when deaths were first centrally recorded in North Carolina, the leading causes of mortality have been ranked according to number of deaths. North Carolina deaths in 1988 have been ranked in Table A for each race-sex group based on this traditional method. As shown, heart disease and cancer are the leading causes of death for each group, unintentional injuries are the third leading cause for white and nonwhite males, and stroke (cerebrovascular disease) is the third leading cause for white and nonwhite females. The rankings of most causes, as well as the sizes of the rates for the same cause, vary among the four groups. Rankings based only on number of deaths (or rate per 100,000 population), however, do not necessarily indicate where medical and public health intervention strategies can be most effectively employed. Since death is postponable but not preventable, age at death is a key factor to consider. Prevention of a death that would otherwise occur early in life could be assigned higher priority than prevention of a death later in life. A convenient method of ranking causes of death that incorporates age at death is by "years of life lost" (7) . If the average life expectancy at birth for white males, for example, is 70 years, a death at age 65 would mean five years of life lost (on the average) , while a death at age 40 would mean 30 life-years lost. A white male infant death results in 70 years of life lost, whereas deaths at ages 70 and over do not contribute to "life-years lost" for white males. Based on the 1990 life tables for North Carolina (43) , the life expectancies used here to calculate years of life lost were 72 for white males, 80 for white females, 67 for nonwhite males, and 76 for nonwhite females. For each death in a given cause group, age at death was subtracted from the appropriate life expectancy and all of these life-years lost were then summed for that race-sex group. Deaths over the specified life 1-24 expectancies were not counted. A rate of years-of-life-lost per 100,000 population was then computed tor ranking the causes of death, so that comparisons can be made across race-sex groups. These rates are given in Table B. A more accurate determination of years of life lost is based on an average expected remaining years of life for each age of death rather than an average life expectancy at birth. This procedure was considered too complicated for the present applica-tion, and probably would not produce rankings substantially different from those in Table B. It v/ould place somewhat less emphasis on infant mortality, since more years of life lost would be generated for the causes listed in Table B. Table B displays the leading causes of death ranked accord-ing to years of life lost per 100,000 population. Heart disease and cancer are still very important causes of death from this perspective, but other causes become much more prominent than before. Unintentional injuries (motor vehicle injuries and other injuries combined) account for more than twice as many years of life lost for nonwhite males than any other cause except heart disease, and were also the top-ranked cause for white males. The general seriousness of injuries as a life and health hazard is clearly shown in this table. Unintentional injuries become a much more important cause of death relative to heart disease from this perspective, since injury decedents (who died prior to normal life expectancy) are on average about 28 years younger than heart disease decedents. Likewise, cancer decedents who die prior to normal life expectancy are on average more than two years younger than heart disease decedents. Cancer accounts for the most years of life lost among white women and in total, in part because the life expectancy for white women is substantially longer than for any other race-sex group. 1-25 O u~i ^ O — - vd <> in r-- O 00 —' a\ 00 m r>-| O r~r-)OOOr^r~rM .2, c g ^ c -^ ^ Ci 1 =1 1 s fc eg u O U ii c g o 4j s £ 3 O c C £ 5 «i t a T) o D £ U c^ S K < U t^ s -go ^ C O r- vo o p Tj^ \d t^ "S .a Q OOirivqr-ip-HU-;-- 00 Z Q I I I 9. —' O O vO r-l c^ r^ r<-i so - in o i/^ ^ r^ in ^ sO —^ O so —' O O QO — • (V) rsj ^ ^ — BO-tj .j, <^ 2 :3 -2 U en 5 tn < Z c -2 Z = Q J. s0QOO^\O^ONf'n^am0v—O'OO\OOV^OO'^- t'l m rsi (N -^ — O X U X 2 5 .C CO -5 3 S „ -^ 2 « ^ 5 I III g -^ I -§ -R pa < 5 REFERENCES FOR SECTION I United States Department of Health, Education, and Welfare. Public Health Service, National Vital Statistics Division. Vital Statistics of the United States. Volume II-Mortality (Part A) . Washington, 1960, 1970. U.S. Department of Health and Human Services. Public Health Service, National Center for Health Statistics. Vital Statistics of the United States, Volume II-Mortality (Part A) . Washington, 1980. U.S. Department of Health and Human Services. Public Health Service, Centers for Disease Control, National Center for Health Statistics. Vital Statistics of the United States. Volume II-Mortality (Part A) . Washington, 1987, International Classification of Diseases. 9th Revision. Volume 1. Diseases; Tabular List . Commission on Professional and Hospital Activities, Ann Arbor, MI, 1980. Grove, R.D.; Hetzel, A.M. Vital Statistics Rates in the United States: 1940-1960 . Public Health Service Publication Number 1677, U.S. Government Printing Office, Washington, 1968. SAS Institute Inc. SAS User's Guide; Statistics. 1982 Edition . Cluster Procedure. Cary, N.C. 1-2! 7. Kleinman, J.C. Statistical Notes for Health Planners; Mor-tality . Public Health Service Publication Number 1677, U.S. Government Printing Office, Washington, 1968. 8. Lalonde, M.A. A New Perspective on the Health of Canadians . Government of Canada, Ottawa, 1974. 9. North Carolina Department of Human Resources, Division of Health Services, Public Health Statistics Branch. "Associa-tions Between Mortality and Various Social, Economic, and Environmental Factors in North Carolina," PHSB Studies . No. 3, Raleigh, April 1977. 10. Landrigan, P.J. "Comment: The Effects of Ozone Pollution on Our Children." The Nation's Health . Vol. XIX, No. 4, April, 1989, pg. 9. 11. Gannon, I.R., "President's Column," The Nation's Health , Vol. XIX, No. 7, July, 1989, pg. 2. 12. Gannon, I.R., "President's Column," The Nation's Health . Vol. XIX, No. 4, July 1989, pg. 2. 13. Schoenborn, C.A. "Health Habits of U.S. Adults, 1985: the "Alameda 7" Revisited," Public Health Reports . Nov-Dec; Vol 101, No. 6, 1986, pp. 571-580. 14. North Carolina Department of Human Resources, Division of Health Services, Public Health Statistics Branch. "Health Characteristics of Adults in North Carolina," PHSB Studies . No. 11, Raleigh, NC, July 1978. 15. Waldron, I, "Why Do Women Live Longer Than Men?," Social Science and Medicine . Vol. 10, 1976, pp. 349-362. 1-29 16. Syme, S.L.; Berkman, L.F. "Social Class, Susceptibility, and Sickness," American Journal of Epidemiology . Vol. 104, No. 1, 1976, pp. 1-8. 17. What Are The Facts about Genetic Disease ? The National Institute of General Medical Sciences, The National Insti-tutes of Health, Bethesda, MD, 1980. 18. North Carolina Department of Human Resources, Division of Health Services, Public Health Statistics, North Carolina Vital Statistics ; Quarterly Provisional Report . Raleigh, January-March, 1978. 19. Robinson, C.G. "Causes, Occular Disorders, Associated Handicaps, and Incidence and Prevention of Blindness in Childhood," in Visual Impairments in Children and Adoles-cents , eds. Jan, S.E.; Freeman, R.D.; and Scott, E.P.; Grune & Stratton, New York, 1977. 20. N.C. Department of Human Resources, Division of Health Services, State Center for Health Statistics, "North Caroli-na Surveillance of Birth Defects." SCHS Studies . No. 52, Raleigh, September 1989. 21. McKeown, T. ; Brown, R.G. "Medical Evidence Related to English Population Changes in the Eighteenth Century," Population Studies . No. 9, 1955, pp. 119-141. 22. Jonas, S. Health Care Delivery in the United States . Third Edition, Springer Publishing Company, New York, 1986, pp. 24-25. 23. McKeown, T. The Role of Medicine: Dream. Mirage, or Nemesis . London: The Nuffield Provincial Hospitals Trust, 1976. 1-30 24. Cassel, E. Human EcoIocty and Public Health . Kilbourne and Smillie, Editors, 1969, pg. 353. 25. White, K. Personal communication. 1982, in Jonas, S. Health Care Delivery in the United States . Third Edition, Springer Publishing Company, New York, 1986, pg. 25. 26. Paf fenbarger, R.S.; Brand, R.J.; Sholtz, R.I.; Jung, D.L. "Energy Expenditure, Cigarette Smoking, and Blood Pressure Level as Related to Death from Specific Diseases," American Journal of Epidemiology . Vol. 198, No. 1, 1978, pp. 12-18. 27. Eyer, J. "A Diet/Stress Interaction Hypothesis of Coronary Heart Disease Epidemiology," International Journal of Health Services . Vol. 9, No. 1, 1979, pp. 161-168. 28. Manton, K.G.; Patrick, C.H. ; and Johnson, K.W. "Health Differences between Blacks and Whites: Recent Trends in Mortality and Morbidity," The Milbank Quarterly . Vol. 65, Suppl. 1, 1987, pp. 129-199. 29. Doll, R. "The Smoking Induced Epidemic," Canadian Journal of Public Health . Vol. 72, November-December, 1981, pp. 372. 30. Curtiss, J.; Grahn, R.B.; Grahn, D. "Population Characteris-tics and Environmental Factors That Influence Level and Cause of Mortality: A Review," Journal of Environmental Pathology and Toxicology . Vol. 4, No. 2, 1980, pp. 471-511. 31. Doll, R. ; Peto, R. "The Causes of Cancer: Quantitative Estimates of Avoidable Risks of Cancer in the U.S. Today," Journal of the National Cancer Institute . 1981. 1-31 32. US Department of Health and Human Services, Office on Smoking and Health. The Health Consequences of Smoking; Cancer, A Report of the Surgeon General . Rockville, Md., 1982. 33. Shalat, S.L; B.; Pidcock, C. , et. al. "Risk Factors for Alzheimer's Disease: A Case-Control Study," Neurology . Vol. 37 No. 10, October, 1987 pp. 1630-1633. 34. Davis, S.; Severson, R.K. "Increasing Incidence of Cancer of the Tongue in the United States Among Young Adults". (Let-ter), Lancet 2 (8564), pp. 910-911, October 17, 1987. 35. Connoly, G.N.; Blum, A; Richards, J.W. Smoke Screen Around Oral Snuff. (Letter), Lancet 2 (8551), pg. 160, July 18, 1987. 36. Waldron, I. "The Contribution of Smoking to Sex Differences in Mortality", Public Health Reports . 101(2), March-April 1986, pp. 163-173. 37. Walker, A.R. "Dietary Goals, Sensible Eating, and Nutrition in the Future," South African Medical Journal . Vol 57, No. 4, 1980, pp. 471-511. 38. West, L.J.; Maxwell, D.S.; Noble, E.P.; Solomon, D.H., "Alcoholism." Annals of Internal Medicine . Vol. 100, 1984, pp. 405-416. 39. Schmidt, W. ; Popham, R.E. "Heavy Alcohol Consumption and Physician Health Problems: A Review of Epidemiological Evidence," Drug and Alcohol Dependence , Vol. 1, No. 1, 1975, pp. 27-50. 1-32 40. Dyer, A.R. ; et al. "Alcohol Consumption, Cardiovascular Risk Factors, and Mortality in Two Chicago Epidemiologic Stud-ies," Circulation . Vol. 56, No. 6, December, 1977, pp. 1067-1074. 41. Buescher, P. A.; Patetta , M.J., "Alcohol-Related Morbidity and Mortality in North Carolina." SCHS Studies . N.C. Department of Human Resources, Division of Health Services, State Center for Health Statistics, No. 41, July, 1986. 42. Egbuonu, L. "Child Health and Social Status," Pediatrics . Vol. 69, No. 5, 1982, pp. 550-557. 43. Haan, M. ; Kaplan, G.A.; Camacho, T. "Poverty and Health: Prospective Evidence from the Alameda County Study." Ameri-can Journal of Epidemiology . Vol. 125, No. 5, June, 1987, pp. 989-998. 44. Verbrugge, L.M. "Recent Trends in Sex Mortality Differen-tials in the United States," Women and Health , Vol. 5, No. 3, 1980, pp. 17-37. 1-33 11. TECHNICAL NOTES NORTH CAROLINA POPULATION BASES Every ten years (years ending in zero) the United States Bureau of the Census has conducted a count of the United States population, which includes a profile of the population's charac-teristics such as age, race, and sex. After a census year, estimates of population size and composition are based on knowl-edge of the population in the census year plus subsequent events such as births, deaths, and migration. In the later years of a decade, these estimates may depart considerably from the "true" population values if the assumptions about population changes differ significantly from what actually occurred. Since almost all mortality rates in CHES publications are based on population counts in the denominator, changes in estimates of population such as might result from a new census could cause substantial changes in the trend of rates over time. State and county population bases are obtained from the North Carolina Office of State Budget and Management, and incor-porate assumptions about births, deaths, net migration, and institutional populations (1) . In this volume the reader should note that pre-1988 rates have been corrected for changes in population bases in order to interpret trends. These corrected rates may differ slightly from the rates shown in previous CHES publications. 2-3 MORTALITY RATES COMPUTATION OF MORTALITY RATES In this report, total death rates are expressed as resident deaths per 1,000 population while all cause-specific mortality rates are expressed as resident deaths per 100,000 population. All rates in Tables 1-20 use total population in the denominator, except rates for the sex-specific cancer sites, which use male or female population in the denominator. Population bases for these rates were provided by the Office of State Budget and Management in the Governor's Office. The infant mortality rates of Table 21 and Figure 17 are computed as the number of resident deaths under one year of age per 1,000 resident live births. Vital events in this report are allocated to place of residence. For deaths of inmates of long-term institutions (mental, penal, old age, orphan, nursing home, rest home, etc.), the institution is considered the usual residence provided the decedent had resided in the institution at least one year. College students and military personnel are considered residents of the college or military community. The following definitions apply to the rates of Tables 2-20. Unadjusted Annual Death Rate: the annual death rate computed as resident deaths per 1,000 or 100,000 population. These rates permit the user knowledge of an area's status with respect to the observed incidence of mortality during the given year. 2-4 Unadjusted 5-year Death Rate: the average annual death rate computed as average resident deaths per 1,000 or 100,000 average population. These rates permit the user knowledge of an area's status with respect to the observed incidence of mortality during the 5-year period. These rates are depicted in the Series A maps (e.g.. Figures 2. A, 3. A, etc.). Adjusted 5-Year Death Rate: the average annual age-race- sex-adjusted rates computed by the direct method. Also expressed as deaths per 1,000 or 100,000 popula-tion, these rates are those which would be expected if the average annual age, race, and sex composition of each county's population were the same as that estimat-ed for the state. These rates are free of differing effects of age, race, and sex and thus permit the user knowledge of an area's status with respect to other determinants of mortality during the 5-year period. Adjusted rates for different time periods cannot be directly compared unless they were adjusted by the same standard population. The adjusted rates are depicted in the Series B maps (e.g., Figures 2.B, 3.B, etc). [Note: For the two sex-specific cancer sites (female breast and prostate) , rates are adjusted for age and race and denominators are sex-specific] Except as noted in the text of this report, the age-adjusted death rates cited in the narrative (not the age-race-sex adjusted rate in tables 2-20) use the 1940 U.S. Census as the standard for direct age-adjustment, following the convention of the National Center for Health Statistics. The use of this standard is necessary for comparison of N.C. and U.S. age-adjusted rates. 2-5 For the maps, a clustering routine* from the Statistical Analysis System (SAS) was used to group counties that are "most like each other" with respect to their unadjusted rates and then their adjusted rates (2). These maps show six levels of death rates, where level one is the lowest rate interval and level six the highest. INTERPRETATION OF MORTALITY RATES To assess an area's relative mortality conditions during a five-year period, both the unadjusted rate and the adjusted rate can be compared to the state rate for a particular cause of death. Then, provided the area's unadjusted rate represents a relatively stable situation, viz., the rate has not fluctuated widely in recent years, the following alternative diagnoses will apply: Relative Status Of Unadjusted Adjusted Rate Rate Diagnosis Low Low Low mortality is not due to age, race, and sex factors; other mortality condi-tions are favorable. *In 1983 the CHES conducted an evaluation of several clustering methods. It was found that one method, called "Average Linkage Method," produced tighter clusters (i.e., clusters with smaller within-cluster variances) than the other methods examined. Consequently, we have used this method henceforth to cluster county rates in all CHES publica-tions. 2-6 Relative Status Of Unadjusted Adjusted Rate Rate Diagnosis Low High Low mortality is due to favorable age, race, and sex factors; other mortality conditions are unfavorable. High Low High mortality is due to unfavorable age, race, and sex factors; other mor-tality conditions are favorable. High High High mortality is not due to age, race, and sex factors; other mortality condi-tions are unfavorable. In using adjusted rates, it is important that the user understand the reason for adjustment. The following hypothetical example illustrates. Here, A and B stand for population sub-groups, e.g., whites and nonwhites, males and females, etc. COUNTY STATE DEATH DEATH POPULATION DEATHS RATE* POPULATION DEATHS RATE* Population A Population B Total 300, 000 10,000 310, 000 1,000 333.3 10 100.0 1,010 325.8 500, 000 800, 000 1,300,000 2,500 500.0 1,000 125.0 3,500 269.2 Deaths per 100,000 population. Compared to the state, county subgroups A and B both have lower rates, but the county as a whole (A and B combined) has a higher rate. This seemingly paradoxical situation results from two factors: different proportions of A and B in the county vs. 2-7 the state population and wide differences between the rates for A vs. B. In this example, it is true that the county has a higher total rate—BUT ONLY BECAUSE THE POPULATION CONTAINS A HIGH PROPORTION OF SUBGROUP A. Certainly, it is important for program planners to know that the county has a high rate relative to the state rate; this information is needed in determining manpower and facility needs, etc. But in assessing "risk," the researcher needs to adjust for confounding factors such as age or race. To do this, one multi-plies each population-specific county rate by the corresponding "standard" population, sums these results, and divides by the total "standard." In the above example, using the state popula-tion as the standard, the computation is: (1,000/300,000 X 500,000) + (10/10,000 X 800,000) = 0.001897 or 189.7 per 1,300,000 100,000 population Thus, as rates specific for A and B imply, the county's rate is lower than the state's rate after adjustment for the factor represented by A and B. CAUTION! In assessing the relative mortality conditions of a county, one should be particularly aware of rates based on small numbers of deaths since, in such cases, random fluctuation in the rate may render rate comparisons risky. The reader should read very carefully the next section entitled "Flagging Biased Rates." 2-8 FLAGGING BIASED RATES This section discusses the problem of unstable mortality rates and then describes a method of flagging rates with a large bias in a given year. The reason for flagging an unstable or possibly biased rate is to provide the reader with a criterion for placing confidence in statements, tables, maps, and other interpretative displays of the mortality data. Not all calcu-lated rates are an accurate portrayal of the "true" force of mortality, and the intent of this section is to caution the reader against uncritically using the rates in this volume. Especially in the maps, the reader should be alert to unusually high rates that may result from very small numerators or from the type of bias described below. Any rate with a small number of events (deaths) in the numerator will be unstable, with possibly large random fluctua-tions from year to year that do not comprise a significant trend. Such a rate is said to have a large standard error . A useful rule is that any rate based on fewer than 20 events in the numerator may have a 95 percent confidence interval that is wider than the rate itself (3). For example, in an area with 20 deaths out of 20,000 population, the measured rate, stated as deaths per 100,000 population, would be 100. But due to variability over time in rates based on small numerators, one could say with 95 percent certainty that the underlying or "true" rate (of which the sample rate of 100 is the best estimate) is between approxi-mately 50 and 150 deaths per 100,000. The width of the interval (100) is relatively large because rates based on small numerators may differ considerably from the actual or "true" rate. Many of the rates in this volume have numerators smaller than 20 and thus a large standard error, and any conclusions about trends based on these rates should be made very cautiously, if at all. The age-race-sex-adjusted rates in this volume, described in 2-9 the previous section, are likewise subject to random variability over time, and those rates involving a small number of deaths will be the most unstable. For example, one death out of an estimated population of 5 would produce a death rate of 20,000 per 100,000 population. If this rate were applied to the appro-priate age-race-sex group of the standard population, a very large number of expected deaths would result and the adjusted rate would be biased. Counties with a small number of persons in one or more of the 40 age-race-sex groups are most likely to have adjusted rates with a large standard error, and these rates therefore show substantial random fluctuation over time. In this volume an adjusted rate is flagged if: a) applying the age-race-sex-specif-ic rates of a county for a given cause to the standard population results in more than 25 percent of the total expected deaths being generated by one cell, and b) the denominator of the rate is also less than 50 (an average of 10 per year) . These criteria will catch only the worst problems. Only 21 out of a total of 1900 county adjusted rates in this volume are flagged by this method . In addition to putting asterisks by those 1984-88 adjusted rates with a large bias due to an extremely high age-race-sex-specific rate, the rates have been recomputed by substituting the appropriate North Carolina age-race-sex-cause-specific rate in the problem cell. Table C on the next page compares the flagged rates with the rates where the state rate has been substituted. The reader who must use one of these flagged rates is advised to use the rate in this table with the substitution instead. If the latter rate is clearly out of line with the North Carolina rate in the last column, the rate should be treated as missing data. 2-10 u PROCEDURE FOR GEOGRAPHIC CLUSTERING OF COUNTIES In all editions of this report, county rates for each leading cause of mortality have been mapped. As described in the Introduction of this volume, these maps show counties grouped together (in six groups) based on similar rates—in other words, a numerical clustering of rates. From these maps, one might imply "spatial" clustering if counties with high rates happen to be contiguous to each other. However, under this procedure there is no way to know whether this clustering is a statistically significant geographic cluster or an artifact of the SAS cluster-ing procedure (2) . In 1980 the CHES in conjunction with the UNO Department of Biostatistics developed a new statistical procedure for detecting and characterizing spatial clusters. This procedure determines whether apparent geographic clustering of counties with high rates is statistically significant. Only a brief summary of the mechanics of the procedure is presented in this section. For a detailed description, readers should consult the appropriate reference (4) or contact the Center for Health and Environmental Statistics. Briefly the mechanics of this procedure are as follows: 1. Counties are listed in rank order of their unadjusted or adjusted rates (highest rates first) for each cause of death. 2-12 For each county listed, cumulative counts are obtained of the number of counties and the number of adjacencies in-volved between the county and other counties with higher rates. Two counties are considered adjacent if they have a common nonsalt-water boundary. For some "pairs" of counties (in particular, counties which seem to touch only at one point on a map) , it was difficult to decide whether these counties are adjacent. These "troublesome pairs of coun-ties" in North Carolina are discussed in the paper refer-enced above as are the decisions made with regard to these pairs. Finally, a reference table is used to obtain for the cumula-tive number of high-rate counties a significance level based on the number of adjacencies observed. While a few adjacen-cies might be expected to occur randomly, a relatively large number of adjacencies will have a low probability of random occurrence. In this report, the high-rate counties are said to cluster geographically if the probability of such random occurrence is .05 or less; maps for a given disease are included in the text only if statistically significant geographic clusters were found to exist. This procedure can result in one or more groups of contigu-ous high-rate counties. For some diseases, no clusters of this type exist. For some others, one, two or more clusters exist. In the latter case, a disease may cluster with high rates in one part of the state and with other tiers or levels of high rates in other parts of the state. In this report each map shows the multi-tiers or levels via differ-erent shading schemes to represent the relative levels of the high death rates. This method is a simple and inexpensive approach for recog-nizing mortality patterns of varying intensity in geographi-cal areas and for testing for clusters. 2-13 REFERENCES FOR SECTION II 1. North Carolina Office of State Budget and Management, Management and Information Services. North Carolina Popula-tion Projections; 1988-2010 , Raleigh, 1988. 2. SAS Institute Inc. SAS User's Guide: Statistics, 1982 Edition . Cluster Procedure. Cary, N.C. 1982. 3. Kleinman, J.C. "Infant Mortality," Statistical Notes for Health Planners . No. 2, National Center for Health Statis-tics, Rockville, Md, July, 1976. 4. Crimson, R.C.; Wank, K.C.; & Johnson, P.W.C. "Searching for Hierarchical Clusters of Diseases: Spatial Patterns of Sudden Infant Death Syndrome," Social Science Medicine , Vol. 15D, pp. 287-293, 1981. 2-14 GENERAL MORTALITY IN NORTH CAROLINA GENERAL MORTALITY IN NORTH CAROLINA During 1988 a total of 57,630 North Carolinians died. This number represents an annual death rate of 8.9 resident deaths per 1,000 population, three percent above the rate of 8.6 for 1987, and is the highest rate over the past 10 years. The 1987 rate for the United States (the most recent year for which data are available) was higher at 8.7 (1). The N.C. unadjusted rate rose in six of the last 10 years. The greatest increases occurred during the 1984-88 period, when the overall rate was five percent greater than in the preceding (1979-83) five-year period. One confounding factor in making comparisons of mortality rates is that age structure of a population, which has an impor-tant impact on mortality, may vary among geographic areas and over time. Compared to the nation. North Carolina has a younger but more rapidly aging population. Thus, adjusting the North Carolina and United States mortality rates for age, a higher mortality rate is obtained for N.C. than for the U.S. The 1987 age-adjusted North Carolina rate (5.7) was nearly six percent higher than the age-adjusted United States rate (5.4), illustrat-ing that N.C.'s lower unadjusted rate (in comparison to the U.S.) is due to its favorable age structure (i.e., more people at the young low-risk ages) . While the N.C. trend for unadjusted rates indicates some increase in mortality, examination of age-adjusted rates shows a different pattern. From 1979-83 to 1984-88 the risk of death for North Carolinians actually declined by five percent, from 6.0 to 5.7 per 1,000 population. Over the longer span since 1974-78, 3-3 the state's age-adjusted rate declined by 15 percent. Age. Race, and Sex Groups Within the general comparisons of mortality noted above, significant subgroup differences are concealed, especially between N.C. and the U.S. For example, while the 1987 unadjusted U.S. rate was higher than that for North Carolina, mortality rates for infants and for age groups 1-4, 5-14, and 45-54 were each more than 10 percent greater than corresponding United States rates. In fact, only two age groups (15-24 and 85 and over) had rates lower than the U.S. rates. As observed with age, general comparisons can mask varia-tions by race and sex. Looking at North Carolina deaths in the 1984-88 period, the male rate (9.5) exceeded the female rate (7.7) by 23 percent. For the previous five-year period (1979- 83) , the male rate was 3 4 percent greater than the female rate; hence differences in mortality by sex have diminished over time. Differences in unadjusted death rates by race were relatively minor and have also decreased: the white and nonwhite rates were each 8.6 during the 1984-88 period, while the nonwhite rate exceeded the white rate (8.4 to 8.2) during the 1979-83 period. (2, 3) Nonwhites have a younger age structure than whites and this accounts for their similar unadjusted death rates. These comparisons mask the exceedingly high overall mortality rate for nonwhite males. Adjusting the race-sex-spe-cific rates for age using the 1940 U.S. population as the stan-dard, the 1984-88 adjusted rate was lower than the unadjusted rate for each race-sex group except nonwhite males, who had a higher rate after adjustment. This finding implies that nonwhite males are dying at younger ages than any other race-sex group, a fact also revealed by the age-specific rates. With the exception of the 85+ age group (based on 1988 data) , nonwhite males had the highest age-specific mortality rates of the four race-sex groups. 3-4 In each of the ten-year age groups between ages 2 5 and 54, the rates for nonwhite males were at least twice the rates for white males (the next highest group). However, after age 54, differ-ences between white and nonwhite males are much smaller, and the rate for nonwhite males older than 84 is lower than that for white males. In Sections IV through IX, important differences in risks of mortality by age, race, and sex groups will be described for each cause. Underlying Causes of Death A statistically complex study conducted by the CDC (4,5) shows that only 11 states ranked worse than North Carolina on a composite index based on 1986 age-adjusted mortality rates for nine causes* (i.e., stroke, coronary heart disease, cirrhosis, obstructive pulmonary disease, lung cancer, breast cancer, colorectal cancer, cervical cancer, and diabetes mellitus) . These causes accounted for 52 percent of deaths nationally and in North Carolina during 1986. Four major causes of mortality—heart disease, cerebrovascu-lar disease, cancer, and cancer other than lung-- have exhibited interesting patterns of change in North Carolina over the past 38 years. The following figures depict cumulative percent changes in death rates for these causes as well as total mortality over seven successive time periods since 1950-59. Results are shown for four race-sex groups. The first figure represents decedents *Groupings of ICD codes for these diseases differ from the groupings used by CHES in this volume. These nine diseases were selected based on diversity in their mortality rates between 1979 and 1986. 3-5 45-64 years old at death. The cumulative percent increase in lung cancer rates for each race-sex group is striking: it exceeds 100 percent earliest (by the 1965-69 period) for nonwhite men and white women and latest (by the 1975-79 period) for nonwhite women. However, after the 1960-64 period, the rate of increase for nonwhite women appears to accelerate. CUMULATIVE PERCENT CHANGE IN DEATH ElATES — SELECTED CAUSES OF DEATH BY RACE AND SEX, AGE 45-M, SINCE TIME PERIOD 1950-1959 NORTH CAROLINA WHIIT MHN WlilTE WOMtN NONWHITE MEN Nt)NWHlTE WOMEN CUMULATIVE PERCENT CHANGE 2 3 4 5 6 7 ToLal Morulity TIME PERIODS —K Heart OiseaK -^ Cerchrovascular Dis<:aM-Cancer other than Lung ^ Lung Cancer 1950-1959 1960-1964 1965-1969 1970-1974 1975-1979 1980-1984 1985-1988 For nonwhite men, the cumulative percent change for cancer other than lung increases sharply through the 1975-79 period, after which a modest decline appears. The pattern for white men is similar, but the cumulative percent increase is smaller and the decline occurs later. Cumulative percent changes for white 3-6 women are relatively small with no clear trend, while the cumu-lative changes for nonwhite women show a decreasing trend over most of the time intervals. The patterns and magnitudes of changes for total mortality . heart disease . and cerebrovascular disease are essentially similar among the race-sex groups: after the 1970-74 period, all cumulative percent changes are negative, reflecting decreasing mortality rates. Total mortality for white women declined the least, while total mortality for nonwhite women showed the greatest cumulative percent decrease. The cumulative percent decrease for white men was greater than for nonwhite men. The following figure presents the same information for decedents in the 65-74 age group. While the lung cancer rate for nonwhite women showed a slight decrease in the 1975-79 period, the cumulative percent increase still exceeded 100 percent by the 1980-84 period. For the remaining causes, the pattern and magnitude of changes in cumulative percentages are similar to the preceding figure with one notable exception: for each race-sex group except white women, the cumulative percent change for cancer other than lung is clearly positive by the 1985-88 period. Taken together, these figures show that the rates for total mortality, heart disease, and cerebrovascular disease have decreased for each race-sex group, while lung cancer rates have increased. Cumulative percent changes for cancer other than lung show clear increases for nonwhites and white males in the 65-74 age group, but only for nonwhite males in the 45-64 age group. These trends are especially noteworthy because of the relatively long time periods involved. 3-7 CUMULAllVE PERCENT CHANGE IN DEATH RATE^ — SELECTED CAUSES OF DEATH BY RACE AND SEX, AGE 65-74, SINCE TIME PERIOD 1950-1959 NORTH CAROLINA WHITE WOMEN NONWHITE MEN NONWHITE WOMEN CUMULATIVE PERCENT CHANGE 12 3*567 12 3 4 5 8 7 2 3 4 5 6 7 TIME PERIODS X X K K e e 6 e Total Mortality ¥. Hean Dueaic ^ Cerebrova*cular Di^ea&e Cancer other than Lung Lung Cancer Time Period 1 1950-1959 1960-1964 1965-1969 1970-1974 1975-1979 1980-1984 1985-1988 GEOGRAPHIC PATTERNS The 1984-88 unadjusted total mortality rates for counties (Figure 2. A) ranged from 4.3 in Onslow County to 12.9 in Swain County, with a state rate of 8.9 per 1,000 population. Figure 2. A shows several scattered groups of high-rate counties, with the northeast seemingly having the largest cluster. In some cases, these high rates reflect unfavorable mortality conditions other than age, race, and sex, since among the 33 counties in the two highest rate levels (Figure 2. A), 16 were in the top three levels after adjustment for age, race, and sex (Figure 2.B). In addition, Figure 2.B shows a large band of contiguous, high-rate 3-8 counties extending from Virginia to South Carolina in the eastern third of North Carolina. Based on procedures described in Section II of this volume, the clustering of 13 northeastern counties with high unadjusted death rates was found to be statistically significant (see map below) . In fact, eight of the ten highest-rate counties are in the northeastern cluster. A smaller cluster of seven counties appears in the southwest. Together, these clusters include 2 of the 25 counties with the highest mortality rates in the 1984-88 period. GENERAL MORTALITY MORTALITY RATES PER 100,000 POPULATION 11.1310 12.87 (P<-05) 10.32 to 10.97 (p<-.05) D 4.30 to 10.32 NORTH CAROLINA RESIDENT DATA 1984-1988 The cluster of high adjusted rates forming a north-south band of 19 eastern counties was also found to be statistically significant (see next map) . Unlike the unadjusted rates, only a single two-county adjacency appears in the west. Thus, eastern North Carolina is experiencing high levels of mortality that cannot be explained on the basis of age, race, and sex factors. In this case, high mortality may be due to socioeconomic and health resource factors, or to some other set of local conditions that invite intervention. A similar north-south cluster appeared in the 1981 version of this volume (6) ; hence this grouping of counties with high rates of total mortality persists. 3-9 The cause-specific data in the sections to follow will aid counties in identifying their particular kinds of mortality proneness. GENERAL MORTALITY AGE - RACE - SEX ADJUSTED MORTALITY RATES PER 100,000 POPULATION 9.44 to 10.93 (P<-05) 9.35 to 9.42 (fX-05) H 9.28 to 9.35 (P<-01) D 7.07 to 9.20 NORTH CAROLINA RESIDENT DATA 1984-19B8 3-10 r A b L c - 2 murtality statistics hjr 19b& -^ortm Carolina klSiocuTs total deathi,(ptr 10 jo population; GcOORaPHICAL ARfcA NORTH CAROLINA REGIONS DHR I wcSTcRN OUR II N. CENTRAL 0^R III S. CtNTRAL OHR IV tASTtRN riSA HSA III HSA HSA riSA I MfcSTcRN II PIcD^UNT S. PIbDIUNT IV CAPITAL V CARDINAL VI EAST CRN NOMbER MOKTALITy STATISTICS FOK I9a8. l^^OKTH CAROLINA RESIDENTS T3TAL UEATHSCt-ER 1000 POPULATIO-^) CONT'D. GENERAL MORTALITY MORTALITY RATES PER 100,000 POPULATION n 12.75 to 12.87 10.05 to 11.97 8.55 to 9.97 7.69 to 8.44 5.82 to 7.30 4.30 to 4.30 NORTH CAROLINA RESIDENT DATA 1984-1988 FIGURE 2.A GENERAL MORTALITY AGE - RACE - SEX ADJUSTED MORTALITY RATES PER 100,000 POPULATION 10.93 to 10.93 9.75 to 10.30 9.02 to 9.59 8.33 to 8.92 7.80 to 8.26 7.07 to 7.67 NORTH CAROLINA RESIDENT DATA 1984-1988 FIGURE 2.B 3-13 REFERENCES FOR SECTION III 1. U.S. Department of Health and Human Services. Public Health Service, Centers for Disease Control, National Center for Health Statistics. Vital Statistics of the United States. Volume II-Mortalitv (Part A) . Washington, 1987. 2. N.C. Department of Environment, Health, and Natural Resourc-es, Center for Health and Environmental Statistics. North Carolina Vital Statistics 1988. Volume 1; Births. Deaths. Population. Marriages. Divorces . Raleigh, November 1989. 3. North Carolina Department of Human Resources, State Center for Health Statistics. North Carolina Vital Statistics 1983. Volume 1: Births. Deaths. Population. Marriages. Divorces. Raleigh, March 1983. 4. Thacker. S.B.; Koplan, J. P.; Letter to State Epidemiologists and Chronic Disease Program Directors. Centers for Disease Control, Atlanta, GA, November 1989. 5. "Chronic Disease Reports: Mortality Trends - United States, 1979-1986." Morbidity and Mortality Weekly Report . Massa-chusetts Medical Society, Waltham, MA, March 31, 1989. 6. North Carolina Department of Human Resources, State Center for Health Statistics. Leading Causes of Mortality: North Carolina Vital Statistics. Volume 2. 1981 . Raleigh, Septem-ber 1983. 3-14 IV. MAJOR CARDIOVASCULAR DISEASE MORTALITY HEART DISEASE Nearly 34 percent of deaths among North Carolina residents in 1988 resulted from heart disease, which has been the leading cause of death for the state and the nation for more than 50 years (1). Heart disease ranks second behind cancer in potential years of life lost by all North Carolinians. It ranks first among nonwhite females. Diseases of the heart accounted for 19,421 North Carolina deaths in 1988, a rate of 299.4 per 100,000 population. While the 1987 rate for the United States was higher at 312.4, North Carolina's 1987 age-adjusted rate was 6.2 percent higher than the nation's (2). In 1986, N.C.'s age-adjusted coronary heart disease death rate was the tenth highest among the 50 states (3). The risk of death from heart disease has declined in North Carolina, with the 1984-88 age-adjusted rate representing an 11 percent decrease since 1979-83. The largest decrease was among white males for whom the 1984-88 age-adjusted rate was down about 15 percent. Age-adjusted rates for the other race-sex groups also declined, for white females by 9 percent and for each of nonwhite males and females by 4 percent. RISK FACTORS A number of alterable risk factors for heart disease exist. Among these are smoking, hypertension, elevated cholesterol, 4-3 obesity, and sedentary lifestyle (3) . Cigarette smoking is the single factor responsible for the most preventable deaths in our society, the largest numbers of those excess deaths being due to coronary heart disease, lung cancer, and chronic obstructive lung disease (4) . The smoking behavior of the U.S. population has changed dramatically, from 52 percent of men and 34 percent of women in 1965 to 33 percent of men and 28 percent of women in 1985, In 1985, however, the North Carolina age-adjusted percentage of current smokers among men ranked in the top quartile among the 50 states. North Carolina women did better, ranking in the second lowest quartile. (4) North Carolina's decrease in heart disease death rates is consistent with a decline nationwide. Possible reasons for the decline include smoking cessation, increased control of hyper-tension, dietary changes, reduced serum cholesterol levels, and improvements in medical care (4). In recent years, the ability of aspirin to prevent the occurrence or recurrence of vaso-oc-clusion has been studied extensively. Taken together, the results of these studies are highly suggestive of a beneficial effect of aspirin. (5) GEOGRAPHIC PATTERNS Unadjusted and age-race-sex-adjusted heart disease death rates for 1984-88 are depicted in Figures 3. A and 3.B respec-tively. After adjustment, a number of contiguous high-rate counties are found to exist, almost exclusively in the east. Based on the procedures described in Section II of this report, the following map reveals that, of the 25 counties with the highest unadjusted death rates, statistically significant 4-4 geographic clusters exist in the east-northeast and west-southwest . the DISEASES OF THE HEART MORTALITY RATES PER 100,000 POPULATION 391.55 to 533.67 (p<-.01) 385.69 to 390.73 (fX-01) M 381.00 to 383.02 (P<--01) D 116.71 to 380.37 NORTH CAROLINA RESIDENT DATA 1984 1988 After adjustment for age, race, and sex, clusters of high-rate counties are no longer statistically significant. The interpretation here is that no significant clusters of counties are experiencing higher levels of heart disease mortality than can be explained on the basis of age, race, and sex. This is in sharp contrast to a significant spatial grouping of 15 counties observed in 1979-81 (6) . 4-5 T A B L E - 3 MORTALITY STATISTICS FDR 1988 NORTH CAROLINA RESIDENTS DISEASES OF THE HEART ceOiiRAPHICAL AREA NORTH CAROLINA REGIONS OHR I WESTERN OHR II N. CENTRAL OHR III S. CENTRAL DHR IV EASTERN NUMOER OF DEATHS 1968 19t2 1 MORTALITY STATISTICS FOR 1988. NORTH CAROLINA RESIDENTS DISEASES OF THE HEART CONT'D. COUNTIES (CONT'D) hZ HALIFAX ifi HARi\ETT ^'t HAYwOOD ^b HENDERSON hb HERTFORD VT hOKE -ta HYDE «t9 IREUcLL 50 JACKSON b\ JOHNSTON 52 JONES 53 LEE S-t LENOIR 55 LINCOLN 56 MCDOWELL 57 MACON 56 MADISON 59 MARTIN 60 MtCKLENbURl. 61 MITCHELL 62 MONTGOMERY 63 MOORE b^ NASH 65 NEW HANOVER 66 NORTHAMPTON 67 UNSLUn 68 ORANbE 69 PAMLICO 70 PASjUOTANK 71 PENDER 72 PERJUIMANS 73 PERSON Ih PITT 75 POLK 76 RANDOLPH 77 RICHMOND 78 ROBESON 79 ROCKINGHAM 80 ROWAN 81 RUTHERFORD &Z SAMPSON 83 SCOTLAND a't STANLY, 85 STOKES 86 SURRY 87 SWAIN 88 TRANSYL\/ANIA 39 TYRRELL 90 UNION 91 VANCE 92 WAKE 93 WARREN 9^ WASHINGTON 95 WATAUGA 96 WAYNE 97 wILKES 98 WILSON 99 YADKIN 100 YANCEY NUMBER DISEASES OF THE HEART MORTALITY RATES PER 100,000 POPULATION HD D 533.67 to 533.67 434.26 to471. 86 317.99 to415.08 261.60 to310. 69 175.11 to 245.89 116.71 to 116.71 NORTH CAROLINA RESIDENT DATA 1984-1988 FIGURE 3.A DISEASES OF THE HEART AGE - RACE - SEX ADJUSTED MORTALITY RATES PER 100.000 POPULATION 446.96 to 446.96 350.06 to 396.55 M 315.38 to 344.64 El 274.73 to 31 0.77 D 244.84 to 269.50 D 210.17 to 232.97 FIGURE 3.B NORTH CAROLINA RESIDENT DATA 1984-1988 4-8 CEREBROVASCULAR DISEASE Cerebrovascular disease, or stroke, claimed the lives of 4,780 North Carolinians during 1988. It was the third leading cause of death in North Carolina with an overall rate of 73.7 deaths per 100,000 population. The North Carolina unadjusted rate was 15 percent higher than the 1987 U.S. rate, and the state's 1987 age-adjusted rate was 24 percent higher than the nation's (2). In 1986, North Carolina's age-adjusted stroke death rate was the third highest in the nation, exceeded only by rates for South Carolina and Georgia (7) . The state's age-adjusted cerebrovascular mortality rate dropped a dramatic 19 percent between 1979-83 and 1984-88. By race and sex, the reductions ranged from 14 percent for nonwhite females to 21 percent for white males. The age-adjusted rates for nonwhite males and females remain considerably higher than those for whites. RISK FACTORS The risk factors associated with cerebrovascular disease are essentially the same as those for heart disease: hypertension, diabetes, cardiac impairment, elevated blood lipids, obesity, and cigarette smoking. The large racial differential is at least partially explained by the higher prevalence of hypertension and diabetes among the black population. (4) 4-9 In addition to lifestyle changes, other factors possibly associated with reduced cerebrovascular and other cardiovascular mortality are improved patient and physician education and increased availability of medical services including rescue squads, coronary care units, and physician supply (8) . Improvements in hypertension detection and control have probably contributed to the observed declines (4) . There is convincing evidence from several studies for the efficacy of aspirin in the prevention of stroke (5) . GEOGRAPHIC PATTERNS Figure 4. A shows a scattering of counties with relatively high unadjusted rates and several pockets of high-rate counties, primarily in the east. After adjusting for age, race, and sex (Figure 4.B), even more counties appear in the high-rate groups, and nearly all are contiguous to other high-rate counties. Based on procedures described in Section II, the eastern pockets of high unadjusted county rates were found to cluster significantly (see first map on next page) . Spatial clustering continues to prevail in the east after adjusting for age, race, and sex (see second map on next page) . Thus, it is clear that some eastern North Carolina counties are experiencing inordi-nately high cerebrovascular mortality that cannot be explained by age, race, and sex factors. Both the unadjusted and adjusted cerebrovascular death rates of 1979-81 exhibited similar clus-tering properties (6) . 4-10 CEREBROVASCULAR DISEASE MORTALITY RATES PER 100,000 POPULATION 111.32 to 136.37 (p<-.05) 100.71 to 109.52 (p<-.01) El 96.34 to 100.50 (p<-.01) D 28.77 to 96.20 NORTH CAROLINA RESIDENT DATA 1984-1988 CEREBROVASCULAR DISEASE AGE - RACE - SEX ADJUSTED MORTALITY RATES PER 100,000 POPULATION 84.57 to 105.88 (p<-.05) D 33.47 to 84.37 NORTH CAROLINA RESIDENT DATA 1984-1988 4-11 T A B L E - ^ MORTALITY STATISTICS FOR 1936 NORTH CAROLINA RESIDENTS CEREBROVASCULAR NUMBER MORTALITY STATISTICS FOR 1983. NORTH CAROLINA RESIDENTS CEREBkOVASCULAR CJNT'U. COUNTIES (CONT'D) •*2 HALIFAX ^3 HARNETT hk HAYWOOD ^tS HENDERSON 46 HERTFORD 47 HOKE 4b HYDE 49 IREDELL 50 JACKSON 51 JOHNSTON 52 JONES 53 LEE 54 LENOIR 55 LINCOLN 5b MCDOWELL 57 MACON 58 MADISON 59 MARTIN oO MECKLENtJURb 61 MITCHELL t)2 MONTGOMERY b3 MOOKE 64 NASH t>5 NEW HANOVER 66 NORTHAMPTON 67 ONSLOW 68 ORANGE 69 PAMLICO 70 PASQUOTANK 71 PENDER 72 PERQUIMANS 73 PERSON 74 PITT 75 POLK 76 RANDOLPH 77 RICHMOND 78 kOoESON 79 ROCKINGHAM 80 ROwAN 81 RUTHERFORD 82 SAMPSON 83 SCOTLAND 84 STANLY 85 STOKES 86 SURRY 87 SwAIN 88 TRANSYLVANIA 69 TYRRELL 90 UNION 91 VANCE 92 WAKE 93 WARREN 94 WASHINGTON 95 WATAUGA 96 WAYNE 97 WILKES 98 WILSON 99 YADKIN 100 YANCEY * SEE SECTION II; RATES BASED ON SMALL NUMBERS MAY BE UNRELIABLE. DIVISION OF STATISTICS AND INFORMATION SERVICES DEPARTMENT OF ENVIRONMENT. HEALTH AND NATURAL RESOURCES 4-13 NUMbER CEREBROVASCULAR DISEASE MORTALITY RATES PER 100.000 POPULATION 124.94 to 136.37 99.49 10 114.81 M 87.38 to 97.48 M 66.94 to 84.77 D 42.35 to 63.90 D 28.77 to 28.77 NORTH CAROLINA RESIDENT DATA 1984-1988 FIGURE 4.A CEREBROVASCULAR DISEASE AGE - RACE - SEX ADJUSTED MORTALITY RATES PER 100,000 POPULATION 92.42 to 105.88 73.61 to 89.32 62.48 to 72.72 51.21 to 61.01 42.51 to 46.67 33.47 to 36.98 NORTH CAROLINA RESIDENT DATA 1984-1988 FIGURE 4.B 4-14 ATHEROSCLEROSIS Atherosclerosis is a general term covering a number of diseases of the blood vessels and is often called "hardening of the arteries." Like hypertension, atherosclerosis is listed as a contributing cause on the death certificate far more often than it is considered the underlying cause of death. In particular, atherosclerosis contributes to deaths from heart disease, stroke, and diabetes. It was estimated that in 1970, 87 percent of the more than 1 million deaths in the United States due to heart and blood vessel diseases were attributable to atherosclerosis and its sequelae (1). As the underlying cause of death, atherosclerosis accounted for 414 North Carolina deaths in 1988, a rate of 6.4 deaths per 100,000 population. The 1987 U.S. rate was considerably higher at 9.2. However, after adjustment for age, the 1987 N.C. and U.S. rates were virtually the same at 3.4 and 3.6 respectively. (2) The recent decline in North Carolina's age-adjusted atherosclerosis mortality far exceeded the declines observed for heart disease and stroke, and the decline was virtually the same for all race-sex groups at an average 28 percent between 1979-83 and 1984-88. Noteworthy are the race and sex differentials. The 1984-88 white male rate was about a third higher than that for white females, and the nonwhite male rate exceeded that for nonwhite females by 58 percent. Nonwhite rates were considerably higher 4-15 than the white rates, 54 percent higher for males and 31 percent higher for females. Compared to 414 deaths with atherosclerosis as the underly-ing cause, a total of 12,329 death certificates had a mention of atherosclerosis. This suggests that 21 percent of all North Carolina deaths in 1988 involved atherosclerosis, though it is not known just how completely this condition is recorded on the death certificate. Of these 12,329 deaths with mention of atherosclerosis, 66 percent had heart disease as the underlying cause of death and 12 percent had cerebrovascular disease as the underlying cause. Around 40 percent of the deaths with heart disease and 30 percent of those with cerebrovascular disease as the underlying cause had a mention of atherosclerosis, and about 35 percent of the deaths with a mention of heart or cerebrovascular disease had a mention of atherosclerosis. These data are from Tables 23 and 24 of this report. RISK FACTORS Three major treatable risk factors contributing to atherosclerosis have been identified: elevated blood cholesterol levels, high blood pressure, and cigarette smoking. A number of additional factors are also recognized: diabetes, physical inactivity, obesity, age, male sex, and certain personality types, that is, "type A" or coronary-prone behavior. (1) Increasing epidemiological evidence supports the hypothesis that higher concentrations of high-density lipoproteins (HDLs) may be a protective factor in the development of atherosclerosis. "Levels of HDL have been correlated positively with exercise and moderate ingestion of alcohol and inversely related to obesity, smoking, poor control of diabetes, and the use of progestin-containing contraceptives" (1). However, the cause and effect of the inverse relationship between HDL and atherosclerosis remain unclear. 4-16 GEOGRAPHIC PATTERNS The clustering procedures described in Section II of this report revealed no statistically significant clusters of counties with high unadjusted or adjusted atherosclerosis death rates. Although a cluster of six southcentral counties was identified by the adjusted rates of 1979-81, it was noted that the pattern should be considered cautiously due to very small numerators in the six counties' rates (6). Due to this problem in most counties of the state, the two maps on atherosclerosis use mentioned conditions rather than underlying cause data. These maps, along with an associated analysis, are presented in the Multiple Conditions Section (Section IX) and show 1988 atherosclerosis mentions per 100,000 population. 4-17 T A B L E - 5 MORTALITY jTATISTlLS HOH 1988 NORTH CAROLINA RESIOc.NTS ATHEROSCLEROSIS NUMbER DEATH f»iJMbbR DEATH AUJUSTED GtOijRAPHICAL OF DEATHS RATE^> OF OEATHS RATE=:' JbATH RATE< AREA 198B 1988 igS^t-Sa 1984-88 198'>-88 NORTH CAROLINA 'tl'* 6.38 Z^ifb 8.05 8.05 KEUIONS UHR MORTALITY STATISTICS FOR 19a8, NOkTH CAROLINA RESIDENTS ATHtROSCLEROSIS CJNT'O. REFERENCES FOR SECTION IV 1. Levy, R.I.; Moskowitz, J. "Cardiovascular Research: Decades of Progress, A Decade of Promise," Science . Volume 217, July 9, 1982, pp. 121-129. 2. National Center for Health Statistics. "Advance Report of Final Mortality Statistics, 1987," Monthly Vital Statistics Report . Volume 38, Number 5 supp. , Hyattsville, Maryland: Public Health Service, September 26, 1989. 3. Centers for Disease Control. "Chronic Disease Reports: Coronary Heart Disease Mortality - United States, 1986," Morbidity and Mortality Weekly Report . Vol. 38, Massachu-setts Medical Society, Waltham, Ma. 1989, pp. 285-286. 4. National Center for Health Statistics. Health. United States. 1988 . DHHS Pub. No. (PHS) 89-1232. Public Health Service. Washington, U.S. Government Printing Office, March 1989. 5. Reilly, I. A.; Fitzgerald, G.A. "Aspirin in Cardiovascular Disease," Drugs . Vol. 35, No. 2. February 1988, pp. 154-76. 6. North Carolina Department of Human Resources, State Center for Health Statistics. Leading Causes of Mortality: North Carolina Vital Statistics. Volume 2. 1981 . Raleigh, Septem-ber 1983. 4-2 7. Centers for Disease Control. "Chronic Disease Reports: Stroke - United States, 1986," Morbidity and Mortality Weekly Report . Vol. 38, Massachusetts Medical Society, Waltham, Ma. 1989, pg . 193. 8. Tyroler, H.A.; Haynes, S. "Community Cardiovascular Surveil-lance Program: Phase Il-Protocol," Unpublished Paper. Department of Epidemiology, School of Public Health, UNC-Chapel Hill, N.C., April 1982. 4-21 V. CANCER MORTALITY ACKNOWLEDGEMENTS We are indebted to the following people who contributed to the cancer sections: Cancer -Donald Lannin, M.D. Associate Professor, East Carolina University Medical School Chief of Surgical Oncology, Pitt Memorial Hospital, Greenville Cancer of the -Robert Sandler, M.D., Ph.D. Colon, Rectum Associate Professor, Department of Medicine University of North Carolina at Chapel Hill Cancer of the -Electra Paskett, Ph.D. Lung Assistant Professor, Department of Public Health Services Bowman Gray School of Medicine, Winston-Salem Cancer of the Female Breast -Sara Ephross, M.S.P.H. Research Assistant, Department of Epidemiology School of Public Health, University of North Carolina at Chapel Hill Cancer of the Prostate -Dexter Morris, M.D., Ph.D. Assistant Professor, Department of Epidemiology School of Public Health, University of North Carolina at Chapel Hill Cancer in -Paul Godley, M.D., M.P.P. Special Research Fellow, Department of Medical Oncology Populations University of North Carolina at Chapel Hill 5-2 CANCER A recent article in the New England Journal of Medicine (1) asserted that, despite years of work and millions of dollars for research, there has been little progress against cancer. The main evidence in favor of this viewpoint is that cancer is still the second leading cause of mortality in the United States, and it is the only major illness which causes more deaths today than it did in 1950. The article stimulated quite a bit of debate in the scientific and lay press, and most observers concluded that it is a complex issue which cannot be reduced to generalizations. However, at least these considerations should be kept in mind as one evaluates the viewpoint of the referenced article: 1) For lung cancer, which is the most frequently occurring type of cancer in men and now the leading cause of cancer death in American women, the survival picture is dismal. The large proportion of cancer victims experiencing poor surviv-al creates the statistical "evidence" that no progress is being made. 2) Other leading causes of death are declining in the United States, e.g., heart disease and cerebrovascular disease (1). As these causes of death claim fewer and fewer lives, per-sons survive longer, leaving a substantially larger pool of individuals at higher risk for cancer than previously exist-ed. This phenomenon of "competing causes of death" is one reason for the absence of a decline in U.S. cancer mortality since 1950. 5-3 It is also apparent that progress with one form of cancer or in one geographic location is easily hidden by worsening results elsewhere. Furthermore, to really answer the question, the incidence trends for different cancers and survival figures after treatment as well as mortality data must be examined. However, mortality is still the bottom line. In 1986, the National Cancer Institute set a goal to reduce cancer mortality by 50 percent before the year 2 000 (1) . The data in this volume can be used to measure how far we must go to achieve this goal. In addition to measuring progress, the data presented here may suggest strategies which could be used to reduce cancer mortality. There are two possible ways to make progress against cancer: to make new discoveries or develop new technology and to apply current knowledge and technology more effectively. Where the data show a marked difference in mortality between two geographical areas for a certain cancer, attempts should be made to identify reasons for the discrepancy. It is likely that methods may be found to better apply existing knowledge to lower the mortality in the higher area. Thus, the data in the follow-ing pages not only measure our progress toward the goal of reducing cancer mortality, but also provide clues as to how this goal may be achieved. In 1988, a total of 12,700 North Carolinians died from cancer. These deaths represent 2 2 percent of the state's deaths, the same proportion observed in the U.S. (2). The 1988 cancer death rate was 195.8 deaths per 100,000 population, an increase of 3.5 percent over the 1987 rate. However, the state's age-ad-justed cancer death rate rose less than 1.1 percent in 1988. The state's 1984-88 age-adjusted cancer death rate was two percent higher than that for the five-year period 1979 -83. Comparisons of the age-adjusted rate changes for race-sex groups reveal increases of about five percent for all but white males whose rate declined slightly. 5-4 The number of cancer deaths in North Carolina begins to increase at ages 35-44 and peaks at ages 75-84. The death rate peaks in the 8 5 and older category except among nonwhite males whose rate is highest at ages 75-84. A recent study concerning the health of the elderly in North Carolina found an increase in cancer rates for all age, race, and sex groups over 65, especial-ly nonwhite males, between 1968-72 and 1983-87 (3). In 1987, the state's age-adjusted cancer death rate was 0.3 percent higher than that for the United States. The rate for N.C. white females was 9.5 percent lower while rates for the other race-sex groups were all higher. The rate for N.C. non-white males was more than 16 percent higher than the corre-sponding U.S. rate. (4) An interesting criterion for evaluating the impact of cause-specific mortality is the measure "years-of-life-lost, " i.e., the loss in years of expected survival due to "early" death. Years-of-life-lost (YLL) cancer rates in North Carolina in 1988 reveal that for white females cancer had the highest overall YLL due largely to the fact that white females have the highest life expectancy of all the race-sex groups. Cancer ranked second or third in YLL for each of the other race-sex groups . GEOGRAPHIC PATTERNS Unadjusted and age-race-sex-adjusted county death rates for 1984-88 are mapped in Figures 5. A and 5.B respectively. For this five-year period, as in the past, high unadjusted rates were more prevalent among western and eastern counties with relatively low rates occurring in the southcentral portion of the state. However, these differences are due largely to age-race-sex differences since adjustment for these factors considerably changes the mortality picture. The western counties' rates are 5-5 generally lower while the high rates, although diminished, remain in the eastern counties. Based on procedures described in Section II, the following map reveals several statistically significant clusters of coun-ties with high unadjusted rates. These clusters are located in northeastern and western North Carolina, and are similar to clusters of unadjusted county rates observed in 1979-81 (5) . After adjustment for age, race, and sex, there were no statisti-cally significant clusters of high-rate counties. Hence, clus-tering of high-rate counties reflects variations in age, race, and/or sex among the populations of these counties. In contrast, in the 1979-81 period there were two small clusters of three and four counties (based on adjusted rates) in the eastern part of the state (5) . CANCER -ALL SITES MORTALITY RATES PER 100.000 POPULATION 225.88 to 292.23 (P<-.01) D 96.83 to 224.73 NORTH CAROLINA RESIDENT DATA 1984 • 1986 SITE-SPECIFIC CANCER This report is designed to address mortality patterns for several cancers that are leading causes of death (lung, colorectal, breast, and prostate). Other cancers previously reported in this volume are not included this year due to growing concern about instability of the county death rates (due to the relatively small numbers of deaths involved) . A separate report will be forthcoming on these more rare cancers. 5-6 T A B L E - 6 MORTALITY STATISTICS FOR 1V68 NORTH CAROLINA RESIDENTS CANCER - ALL SITES btOURAPHICAL AREA NORTH LAKOLINA NUMbEk MORTALITY STATISTICS FOR 19a8i CANCeR - ALL SITtS CONT'D. NORTH CAROLINA keSIOfcNTS COUNTIES CANCER -ALL SITES MORTALITY RATES PER 100,000 POPULATION 277.05 to 292.23 223.00 to 258.78 M 182.59 to 217.41 O 156.93 to 179.78 D 125.58 to 148.49 D 96.83 to 113.39 NORTH CAROLINA RESIDENT DATA 1984-1988 FIGURE 5.A CANCER - ALL SITES AGE - RACE - SEX ADJUSTED MORTALITY RATES PER 100,000 POPULATION 231.98 to 231.98 213.36 to 225.15 194.32 to 207.69 176.01 to 192.27 164.72 to 173.95 141.80 to 160.55 NORTH CAROLINA RESIDENT DATA 1984-1988 FIGURE 5.B 5-9 Meanwhile, because of their substantial public health interest, a brief narrative follows for three of these "rare" cancers: pancreas, uterine cervix, and leukemia. PANCREAS (ICD 157) This cancer has been increasing in frequency in the United States for the last two decades (2) . Debate continues over whether the increase is due to better detection and reporting, or whether it is a real trend (1) . The 1988 North Carolina rate of 10.3 deaths per 100,000 population represented an eight percent increase over the 1987 rate, while the age-adjusted rate increase was 5.5 percent. Between the five-year periods 1979-83 and 1984-88, there was virtually no change in the state's age-adjusted death rate although nonwhite males and females experienced small increases. During 1984-88, the age-adjusted death rates for nonwhite males and females were approximately 50 percent higher than the corresponding rates for whites. This race differential warrants close public health attention and surveillance; unfortunately, clear-cut options for prevention are not established. CERVIX UTERI (ICD 180) Cervical cancer is still a common diagnosis in the United States; yet increasingly, it is not life-threatening because of early detection and the availability of excellent treatment capabilities. Between 1987 and 1988, the North Carolina death rate for cervical cancer declined 2.8 percent to 4.2 deaths per 100,000 population. The age-adjusted rate declined 3.5 percent. Between 5-10 1979-83 and 1984-88, the age-adjusted rate declined approximately 12 percent; the decline was approximately 20 percent for non-whites compared to 10 percent for whites. During 1984-88, the age-adjusted nonwhite female death rate was about three times that for white females. This wide differ-ential probably involves late access to health care and perhaps socioeconomic and sexual activity factors often associated with the disease. LEUKEMIA (ICD 204-208) Leukemia is second only to injuries as a leading cause of death among children. Childhood leukemia presents as a very aggressive disease, while for adults leukemias are often quite indolent processes. Risk factors for leukemia are generally environmental and occupational. Leukemia is managed primarily with chemotherapy; today the prognosis is quite good for early diagnoses. North Carolina's leukemia death rate in 1988 was 7.0, which was 11 percent above the 1987 rate. However, the age-adjusted rate increase was half that at 5.5 percent. Between 1979-83 and 1984-88, the state's age-adjusted leukemia death rate declined about nine percent with most of the decrease occurring among whites. During 1984-88, the age-adjust-ed rates for white and nonwhite males were approximately the same, each being more than 50 percent higher than the correspond-ing female rate. In 1987, the state's age-adjusted leukemia death rate was eight percent below the nation's. However, the rate for North Carolina's nonwhite males was 15 percent higher than the corre-sponding U.S. rate. (4) 5-11 NOTE: Due to ready availability, the 1979-83 and 1984-88 age-adjusted death rates examined for the above site-specific cancers used the 1970 U.S. Census population as the standard for direct age-adjustment. Other age-adjusted rates examined in this report use the 1940 U.S. Census as the standard, following the convention of the National Center for Health Statistics. In terms of percent differences over time and between race-sex groups, the two standards yield generally similar results. 5-12 CANCER OF THE COLON AND RECTUM Colorectal cancer is the second leading cause of cancer death in North Carolina, exceeded only by lung cancer. The marked geographic differences in incidence for this cancer, and the fact that incidence rates change with migration, suggest that there may be important environmental determinants. It might be possible to prevent a substantial proportion of colorectal cancer if these factors could be identified and modified. A variety of risk factors for the disease have been examined. Many studies have explored the relationship between diet and colorectal cancer. A high-fiber, low-fat diet is thought by some to protect against large bowel cancer, although studies have had somewhat contradictory results (6,7). Other dietary factors that may be protective include calcium, cruciferous vegetables (broccoli, cabbage, Brussels sprouts), vitamin A, beta carotene, garlic and onions (8,9). There is no consistent association with occupation apart from above-average risk among professional and administrative workers. There have been reports of increased rates in woodwork-ers, pattern makers, synthetic fiber workers, and asbestos workers. Physical activity, both avocational and occupational, may decrease risk. (10) Individuals with a first-degree relative with colon cancer appear to be three times more likely to develop the disease themselves. Recent molecular studies have identified specific genetic abnormalities in some colon cancers. (11) 5-13 Colon cancers that are discovered early are more amenable to surgical cure. Although there are techniques available to screen for colon cancer, they have not been convincingly demonstrated to confer a survival advantage to those screened. Because screening programs are expensive, our best hope to decrease the burden of suffering from colon cancer is through prevention. The data available from epidemiologic studies suggest that such prevention may be feasible. Based on data collected between 1979 and 1984, the five-year survival rates for colon cancer were 54 percent for whites, 49 percent for blacks, and 53 percent overall (2). In 1988, a total of 1,331 North Carolinians died of colorectal cancer. This accounted for 10.5 percent of the state's cancer deaths and 2.3 percent of all deaths. The mor-tality rate in 1988 was 20.5 deaths per 100,000 population. This was a 2.5 percent increase over the 1987 mortality rate of 20.0. However, after adjustment for age, there was a three percent decrease between 1987 and 1988. The five-year age-adjusted mortality rate (1984-88) was the same as that of the preceding five-year period (1979-83) . There was a slight decrease for whites (males and females) and increas-es of 5.4 and 12.5 percent respectively for nonwhite males and females. In 1986 North Carolina had the thirty-second highest age-adjusted mortality rate in the nation (12) . In North Carolina colon cancer deaths are not often found prior to age 45, and the death rate is highest at ages 85 and older (3). This holds true for both sexes and races. The age-adjusted colorectal cancer death rate for race-sex groups reveal higher rates among nonwhites, but the race differentials are relatively small. This suggests that environmental determinants are largely non-occupational. 5-14 GEOGRAPHIC PATTERNS More than any other site-specific cancer mortality rates examined in this report, North Carolina's higher county-level colon/rectum cancer rates tend to cluster to a statistically significant degree, following the procedures described in Section II. When mapped, the high unadjusted rates reveal northeastern, central, and southwestern clusters as shown in the first text map ^^^°'^ ' CANCER COLON, RECTUM AND ANUS MORTALITY RATES PER 100.000 POPULATION 27.28 lo 40.30 (P<-.01 24.14 to 26.39 (P<-05) D 9.86 10 23.89 NORTH CAROLINA RESIDENT DATA 1984-1988 As shown in the age-race-sex-adjusted text map below, significant clusters of high-rate counties are found in the east-northeast and central portions of the state. Health offi-cials should be particularly aware of these areas with high colon/rectum cancer mortality over and above that due to age, race, and sex factors. Counties not identified in the text maps should consult Figures 6. A and 6.B to ascertain their relative levels of mortality from colorectal cancer. CANCER - COLON, RECTUM AND ANUS AGE - RACE - SEX ADJUSTED MORTALITY RATES PER 100.000 POPULATION 23.77 to 49.03 (p<..05) n 8.42 to 23.49 NORTH CAROLINA RESIDENT DATA 1984-1988 5-15 T A tJ L E - 7 MORTALITY STATISTICS FOR 1988 NORTH CAROLINA RESIDENTS CANCER - COLON, RECTUM AND ANUS MORTALITY STATISTICS FOR 1988. NORTH CAROLINA RESIDENTS CANCER - COLONf RECTUM AND ANUS CONT'D. COUNTIES (CONT'D) ^2 HALIFAX hi HARNETT kt HAYWOOD <*5 HENDERSON hb HERTFORD 't? HJKE 1*6 HYOE 'f9 IREDELL 50 JACK.SON 51 JOHNSTON 52 JONES 53 LEE 5^ LENOIR 55 LINCOLN 56 MCDOWELL 57 MACJN 58 MADISON 59 MARTIN 60 MECKLENBURG 61 MITCHELL 62 MONTGOMERY 63 MOORE 6^ NASH 65 NEW HANOVER 6b NORTHAMPTON 67 ONSLOw 68 ORANGE 69 PAMLICO 70 PASJUOTaNK. 71 PENDER 72 PERWUIMANS 73 PERSON 7^* PITT 75 POLK 76 RANDOLPH 77 RICHMOND 78 ROtJESON 79 ROCKINGHAM 80 ROWAN 81 RUTHERFORD 82 SAMPSON 83 SCOTLAND S'f STANLY 85 STOKES 66 SURRY 87 SWAIN 88 TRANSYLVANIA 89 TYRRELL 90 UNION 91 VANCE 92 WAKE 93 WARREN 9'f WASHINGTON 95 WATAUGA 96 WAYNE 97 WILKES 98 WILSON 99 YADKIN 100 YANCEY * SEE SECTION II; RATES BASED ON SMALL NUMBERS MAY BE UNRELIABLE. DIVISION OF STATISTICS AND INFORMATION SERVICES DEPARTMENT OF ENVIRONMENT. HEALTH AND NATURAL RESOURCES 5-17 NUMBER CANCER COLON, RECTUM AND ANUS MORTALITY RATES PER 100.000 POPULATION 38.95 to 40.30 33.46 to 35.76 28.47 to 30.97 22.40 to 27.41 13.92 to 21.85 9.86 to 12.82 NORTH CAROLINA RESIDENT DATA 1984-1988 FIGURE 6.A CANCER COLON, RECTUM AND ANUS AGE - RACE - SEX ADJUSTED MORTALITY RATES PER 100,000 POPULATION 40.03 to 49.03 29.77 to 31.95 26.43 to 27.29 17.79 to 24.74 12.73 to 17.46 8.42 to 11.89 NORTH CAROLINA RESIDENT DATA 1984-1988 FIGURE 6.B 5-18 CANCER OF THE TRACHEA, BRONCHUS, AND LUNG Lung cancer is the leading cause of cancer death in both men and women in the United States (13) . The incidence rate for this cancer continues to increase nationwide in both males and fe-males, black and white. Lung cancer deaths among American women have now surpassed the number of breast cancer deaths. (2) Among North Carolina residents in 1988 there were 1,058 female deaths due to lung cancer while 1,093 women died of breast cancer. Thus, lung cancer deaths among women are rapidly approaching the number due to breast cancer. This increase in deaths is larger than for any other cancer site. There have been increases in both incidence and death for every group with women increasing more rapidly. (14) In 1988, a total of 3,669 North Carolinians died from lung cancer. This accounted for 28.9 percent of the state's cancer deaths and 6.4 percent of all deaths. The mortality rate in 1988 was 56.6 deaths per 100,000 population. This was a six percent increase over the 1987 mortality rate; however, the age-adjusted rate increase was a third lower at 3.9 percent. The five-year age-adjusted mortality rate (1984-88) was 12.2 percent higher than that for the preceding five-year period (1979-83) . All race-sex groups experienced increases over this time period, with the greatest increase in white females whose rate rose by one-third. In 1986, North Carolina had the 27th highest age-adjusted mortality rate in the nation (15) . This North Carolina rate was 0.6% less than that for the U. S. 5-19 During 1984-88, North Carolina's age-adjusted death rates were over three times higher for white males than for white females and almost six times higher for nonwhite males than for nonwhite females. Thus, there is a wide sex differential in mortality risk. The 1984-88 nonwhite male rate was 23 percent higher than that for white males, while the nonwhite female rate was 31 percent below that for white females. In North Carolina, lung cancer deaths are not generally found prior to age 4 5 with the number of deaths peaking at ages 65-74. The death rate also peaks at ages 65-74 except among white males whose peak occurs at ages 75-84 (3) . Lung cancer is very difficult to detect early since symptoms often don't appear until the disease has advanced considerably. Only 24 percent of lung cancer cases are detected at the early (localized) stage. For this reason, only 13 percent of lung cancer patients (all stages, whites and blacks) live five or more years after diagnosis. (13) The major risk factor for the development of lung cancer is cigarette smoking. Tobacco is responsible for 83 percent of lung cancer cases overall, 85 percent among men and 75 percent among women (16) . To date, 4 3 chemicals in tobacco smoke have been determined to be carcinogenic (13) . Certain industrial substances such as asbestos, radon decay products, and other risk factors for lung cancer have been found to interact with smoking to produce even higher risk estimates (17) . Air pollution has been estimated to be the cause of 1 to 2 percent of lung cancer cases (18) . Indoor air pollution, mainly in the form of tobacco smoke and radon, have been linked causally to lung cancer (6) . Diet has recently been considered as poten-tially influencing the risk of lung cancer in smokers, in partic-ular deficiencies in vitamin A, carotene, vitamin E, and vitamin 5-20 C (19) . Clinical trials on vitamin A and lung cancer risk are now in progress. Finally, exposure to radiation and familial factors have been suggested to affect lung cancer risk (18). GEOGRAPHIC PATTERNS During 1984-88 residents of eastern North Carolina experi-enced higher lung cancer mortality prior to and after adjustment for age, race and sex distribution (Figures 7. A and 7.B, respec-tively) . However, there were no statistically significant clustering patterns. This contrasts sharply with significant clustering of the unadjusted and adjusted rates during 1979-81 (5). 5-21 T A B L fc - 3 MOrtTALITV STATISTICS FOR 19Ba NORTH CAROLINA RESIDENTS CANCER - TRAChEAf BRONCHUS AND LUNG NUMBER MJkTALITY STATISTICS FOR 1968t NORTH CAROLINA RESIDENTS CANCER - TRACHEA. BRONCHUS AND LUNi CONT'D. COUNTIES (CONT'D) hZ HALIFAX hi HARNETT if^ HAYhUOD <*5 HENDERSON kb HERTFORD ^7 HOkE 'td HYOE t9 IREDELL 50 JACKSON 51 JOHNSTON 52 JONES 53 LEE bk LENOIR 55 LINCOLN 5b MCDOWELL 57 MACON 58 MADISON 59 MARTIN bO MEC<LENoURt, bl MITCHELL bZ MONTbOMERY b3 MOORE bk NASh b5 NEW HANOVER bb NORTHAMPTON b7 ONSLOW b8 ORANCiE b9 PAMLICO 70 PASOUOTANK. 71 PENDER 72 PERQUIMANS 73 PERSON Tt PITT 75 P3LK 76 RANDOLPH 77 RICHMOND 7 8 RObtSON 79 kOCKIN&HAM tiO ROWAN 81 RUTHERFORD 32 SAMPSON b3 SCOTLAND 8^ STANLY 65 STOKES 86 SURRY 87 SWAIN 88 TRANSYLVANIA 89 TYRRELL 90 UNION 91 VANCE 92 WAKE 93 WARREN 9't wASHlNliTON 95 WATAU&A 96 WAYNE 97 WIL<ES 98 WILSON 99 YADKIN 100 YANCEY <= SEE SECTION II; RATES BASED ON SMALL NUMBERS MAY BE UNRELIABLE. DIVISION Of STATISTICS AND INFORMATION SERVICES DEPARTMENT OF ENVIRONMENT, HEALTH AND NATURAL RESOURCES 5-23 NUMBER CANCER TRACHEA, BRONCHUS AND LUNG MORTALITY RATES PER 100,000 POPULATION 87.56 to 89.59 66.25 to 78.51 54.02 to 64.88 45.93 to 53.20 36.65 to 44.38 29.10 to 34.78 NORTH CAROLINA RESIDENT DATA 1984 -U FIGURE 7.A CANCER TRACHEA, BRONCHUS AND LUNG AGE - RACE - SEX ADJUSTED MORTALITY RATES PER 100.000 POPULATION CANCER OF THE FEMALE BREAST Breast cancer is the second leading cause of cancer death in American women (2). It is estimated that there will be 142,900 new breast cancer cases and more than 453,300 deaths in the United States in 1989 (20) . According to the American Cancer Society, one in 10 American women will develop the disease in her lifetime (2) . Several risk factors for breast cancer have been consistent-ly identified. They include: older age, upper socioeconomic class, never having been married, urban residence, residence in the Northern U.S., white race, late age at first full-term pregnancy, early menarche, late menopause, family history of a primary cancer of the ovary or endometrium. Artificial menopause has been shown to exert a protective effect. Additional research into breast cancer etiology is needed as only 2 5 percent of the current breast cancer burden can be explained by known risk factors. Current areas of research include alcohol consumption, oral contraceptive use, mammographic parenchymal patterns, hormone replacement therapy, and high-fat diet. (21) Between 1975 and 1985, there was a 17 percent increase in the incidence of breast cancer in the National Cancer Institute's population-based Surveillance, Epidemiology and End Results (SEER) program (4) . The 1985 age-adjusted incidence rate for white women was 19 percent higher than that for black women. Mortality rates over the same period remained essentially stable for white women while increasing at an average annual rate of less than one percent for black women (14). 5-25 Survival rates for breast cancer in the SEER areas improved slightly between 1975 and 1985. Overall five-year relative survival rates for all stages of breast cancer for the period 1979-84 were 75 percent and 62 percent for white and black women, respectively. (14) For localized breast cancer, there was a less radical difference in survival. For white women, the five-year survival rate was 90 percent and for black women, 87 percent (21) . An improved survival rate has stabilized the mortality rate, despite the increased incidence (2) . In 1988, a total of 1,093 North Carolina women died of breast cancer, still the leading cause of cancer deaths in N.C. females. This accounted for 8.6 percent of the state's cancer deaths. The 1988 mortality rate was 32.5 deaths per 100,000 female population which represents a 6.1 percent increase over 1987. However, there was virtually no change in the age-adjusted death rate. The five-year (1984-88) age-adjusted rate was 11.2 percent higher than in 1979-83. The rate for whites increased 8.4 percent while that for nonwhites rose 23.3 percent. In 1986, North Carolina had the 25th highest age-adjusted mortality in the nation (22). This rate was 2.4 percent less than that for the U.S. In North Carolina, breast cancer deaths rarely occur prior to age 3 5 in both white and nonwhite women, and the number peaks at ages 55-64 for both race groups. For both races, the death rate is highest at ages 85 and older (3). GEOGRAPHIC PATTERNS During the period 1984-88, no statistically significant clusters of high rates were observed, although moderate rates did occur in some contiguous counties (Figures 8. A and 8.B). Users 5-26 should consult these maps to ascertain a county's relative level of unadjusted and age-race-sex-adjusted mortality from female breast cancer. 5-27 T A b L E - 9 MORTALITY STATISTICS FOR 1988 "^URTH CAROLINA RESIOtNTS R - B R E ST - FEMALE :0>,KAPHILAL AREA NUMBER MORTALITY STATISTICS FOk 1988f NORTH CAROLINA RESIDENTS CANCER - BREAST - FEMALE CONT'D. COUNTIES (CONT'U) <tZ HALIFAX '»3 HARNETT 't'f HAYwOOO ^tS HENDERSON hb HERTFORD V7 HOKE ka HYDE '»9 IREDELL 50 JAC<.SON 51 JOHNSTON 52 JONES 53 LEE 5<t LENOIR 55 LINCOLN 56 MCDOWELL 57 MACON 53 MADISON 59 MARTIN bO MECKLENBURC 61 MITCHELL bZ MONTCOMERY 63 MOORE bit NASm 65 NEW HANOVER 66 NORTHAMPTON 67 ONSLOW t>8 ORANH,E 69 PAMLICO 70 PASUUOTaNK 71 PENDER 72 PERgUIMANS 73 PERSON Ik PITT 75 POLK 76 RANDOLPH 77 RICHMOND 78 RObtSON 79 ROCKINGHAM 80 ROWAN 81 RUTHERFORD 82 SAMPSON 83 SCOTLAND ak STANLY 85 STOKES 86 SURRY 87 SwAlN 38 TRANSYLVANIA 89 TYRRELL 90 UNION 91 VANCE 92 WAKE 93 WARREN 9't WASHIN&TON 95 WATAUGA 96 WAYNE 97 WILKES 93 WILSON 99 YADKIN 100 YANCEY =:= SEE SECTION II DIVISION OF STATISTICS AND INFORMATION SERVICES DEPARTMENT OF ENVlRONMENTt HEALTH AND NATURAL RESOURCES 5-29 NUMBER CANCER FEMALE BREAST MORTALITY RATES PER 100,000 FEMALE POP. 48.47 to 54.87 42.13 to 47.24 28.40 to 38.36 20.59 to 27.70 14.00 to 18.42 11.11 to 11.11 NORTH CAROLINA RESIDENT DATA 1984-1988 FIGURE 8.A CANCER FEMALE BREAST AGE - RACE - SEX ADJUSTED MORTALITY RATES PER 100.000 FEMALE POP. 61.84 to 61.84 45.78 to 51.92 37.59 to 43.01 26.08 to 36.42 18.55 to 25.60 8.21 to 14.55 NORTH CAROLINA RESIDENT DATA 1984-1988 FIGURE 8.B 5-30 CANCER OF THE PROSTATE Prostate cancer is a major cause of morbidity and mortality among males in the United States, with almost one out of 11 men developing the disease during his lifetime. In North Carolina during 1989 alone, an estimated 2,700 new cases will be diag-nosed. (2) The death rate for this disease changes dramatically with age, increasing over one-hundred fold between ages 50 and 80. It is also much higher in blacks than whites. In fact, blacks in certain regions of North Carolina have some of the highest prostate cancer mortality rates in the world. The high rate among blacks may be related to genetic or environmental factors as well as to health care access or quality issues. (23) Despite the importance of this disease, little is known about its cause. Studies examining hormonal, social, and sexual factors have yielded uniformly unimpressive results. Certain occupations, such as farming, have been associated with an increased risk of developing prostate cancer as has exposure to cadmium. The roles of dietary factors, sunlight, and farming
Object Description
Description
Title | North Carolina vital statistics, vol 2 |
Other Title | Leading causes of mortality |
Contributor | North Carolina. |
Date | 1988 |
Subjects |
Mortality--North Carolina Vital Statistics--North Carolina North Carolina--Statistics, Vital--Periodicals North Carolina--Statistics Public health--North Carolina Women African American Women Education Mental health |
Place |
Raleigh, Wake County, North Carolina, United States North Carolina, United States |
Time Period |
(1945-1989) Post War/Cold War period |
Description | Vols. for <1971>- issued in 2 vols.: vol. 1: Population, births, deaths, marriages, divorces (changed to: Births, deaths, population, marriages, divorces, 1974- ); vol. 2: Leading causes of mortality (changed to: Leading causes of death, 1994- ).; Vol. for 1972 issued by the N.C. Dept. of Human Resources, Public Health Statistics Services; 1973-1978 by the N.C. Dept. of Human Resources, Public Health Statistics Branch; 1979-1987 by the State Center for Health Statistics; 1988-1989 by the Center for Health and Environmental Statistics; 1990-1994 by the State Center for Health and Environmental Statistics; 1995- by the State Center for Health Statistics. |
Publisher | Raleigh, N.C. :State Board of Health, Public Health Statistics Section,1965- |
Agency-Current | North Carolina Department of Health and Human Services |
Rights | State Document see http://digital.ncdcr.gov/u?/p249901coll22,63754 |
Physical Characteristics | v. ;28 cm. |
Collection | Health Sciences Library. University of North Carolina at Chapel Hill |
Type | text |
Language |
English |
Format |
Annual reports Statistics Periodicals |
Digital Characteristics-A | 10189 KB; 270 p. |
Digital Collection |
Ensuring Democracy through Digital Access, a North Carolina LSTA-funded grant project North Carolina Digital State Documents Collection |
Digital Format | application/pdf |
Related Items | Vol. for 1972 issued by the N.C. Dept. of Human Resources, Public Health Statistics Services; 1973-1978 by the N.C. Dept. of Human Resources, Public Health Statistics Branch; 1979-1987 by the State Center for Health Statistics; 1988-1989 by the Center for Health and Environmental Statistics; 1990-1994 by the State Center for Health and Environmental Statistics; 1995- by the State Center for Health Statistics. |
Title Replaces | North Carolina. Public Health Statistics Section..Annual report of Public Health Statistics Section |
Audience | All |
Pres File Name-M | pubs_edp_ncvitalstatistics1988v2.pdf |
Pres Local File Path-M | \Preservation_content\StatePubs\pubs_edp\images_master\ |
Full Text |
THE LIBRARY OF THE
UNIVERSITY OF
NORTH CAROLINA
AT CHAPEL HILL
THE COLLECTION OF
NORTH CAROLINIANA
C614.1
N87v5
1988
UNIVERSITY OF N C AT CHAPEL HILL
00034018777
FOR USE ONLY IN
THE NORTH CAROLINA COLLECTION
For.71 No, A-368
Digitized by the Internet Arcinive
in 2009 with funding from
Ensuring Democracy through Digital Access (NC-LSTA)
http://www.archive.org/details/northcarolinavit198802nort
LEADING CAUSES
OF MORTALITY
North Carolina
Vital Statistics
1988—Volume 2
LEADING CAUSES
OF MORTALITY
North Carolina
Vital Statistics
1988—Volume 2
Center for Health and Environmental Statistics
N.C. Department of Environment, Health, and Natural Resources
Division of Statistics and Information Services
STATE OF NORTH CAROLINA
James G. Martin, Governor
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
William W. Cobey, Jr., Secretary
DIVISION OF STATISTICS AND INFORMATION SERVICES
Delton Atkinson, M.S.P.H., M.P.H., Director
June 1990
800 copies of this public document were
printed at a cost of $3,310.44 or $4.14 per copy.
ins
TABLE OF CONTENTS
Page
PREFACE vii
I. INTRODUCTION 1-1
Purpose and Organization 1-3
Overview of Mortality in North Carolina 1-9
II. TECHNICAL NOTES 2-1
North Carolina Population Bases 2-3
Mortality Rates 2-4
Computation of Mortality Rates 2-4
Interpretation of Mortality Rates 2-6
Flagging Biased Rates 2-9
Procedure for Geographic Clustering of Counties . . .2-12
III. GENERAL MORTALITY IN NORTH CAROLINA 3-1
IV. MAJOR CARDIOVASCULAR DISEASE MORTALITY 4-1
Heart Disease 4-3
Cerebrovascular Disease 4-9
Atherosclerosis 4-15
Page
V. CANCER MORTALITY 5-1
Cancer 5-3
Cancer of the Colon, Rectum, and Anus 5-13
Cancer of the Trachea, Bronchus, and Lung 5-19
Cancer of the Female Breast 5-25
Cancer of the Prostate 5-31
Cancer in Special Populations 5-37
VI. OTHER LEADING CAUSES OF MORTALITY 6-1
Septicemia 6-3
Diabetes Mellitus 6-8
Pneumonia and Influenza 6-13
Chronic Obstructive Pulmonary Disease 6-19
Chronic Liver Disease and Cirrhosis 6-26
Nephritis, Nephrosis, and Nephrotic Syndrome . . . .6-31
VII. MAJOR EXTERNAL CAUSES OF MORTALITY 7-1
Injuries 7-3
- Unintended Motor Vehicle Injuries 7-5
Unintended Injuries Excluding Motor Vehicles . . .7-12
Suicide 7-20
Homicide 7-27
VIII. INFANT MORTALITY 8-1
IX. MULTIPLE CONDITIONS PRESENT AT DEATH 9-1
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PREFACE
The Center for Health and Environmental Statistics produces
a major publication annually, describing in tabular and map form
North Carolina's mortality experience over the most recent
five-year period. Periodically, an expanded volume is produced
that includes a narrative analysis for each cause of death. The
expanded format is resumed in this 1988 edition, which includes
statistical tables, maps, and graphs, as well as discussions of
cause-specific trends, geographic patterns, risk factors,
multiple conditions present at death, and pertinent research. An
overview of the mortality experience in North Carolina is also
presented.
The tables in this report provide selected 1988 mortality
statistics for counties. Department of Human Resources regions.
Health Service Areas, and the state (see maps on preceding
pages) . More than a dozen of the leading causes of mortality in
North Carolina are tabulated; in addition, various cancer sites
and total infant mortality are included. Comparisons with
national statistics are usually based on 1987 data, which is the
most recent year of final data available from the National Center
for Health Statistics.
As with previous editions, multiple conditions present at
death are discussed in a separate section. Five diseases in
particular—septicemia, diabetes, hypertension, atherosclerosis,
and nephritis/nephrosis—are considered associated conditions far
more often than underlying causes. Hence, Figures 18. A through
22. B display 1984-88 county rates for deaths associated with a
Vll
PURPOSE AND ORGANIZATION
Although North Carolina has traditionally experienced low
crude death rates, our status among states has worsened. In
1960, only seven of the 50 states had death rates lower than
North Carolina's; this had increased to 14 by 1970 (1); 19 by
1980 (2); and 21 by 1987 (3). Furthermore, while many of the
state's cause-specific rates are consistently below United States
levels, some of North Carolina's age-adjusted rates are substan-tially
higher. For example, cerebrovascular disease, motor
vehicle injuries, other injuries, and septicemia are causes for
which North Carolina's 1987 adjusted rates were 23 to 35 percent
above the corresponding United States rates. For all causes, the
1987 North Carolina unadjusted rate was less than one percent
lower than the United States rate, while the age-adjusted rate
was six percent greater. Finally, four years of successive
decreases in the infant death rate for North Carolina ended in
1987 with a 4.3% increase over 1986, followed by an increase of
4.1% in 1988.
These facts pose a serious challenge to health officials
throughout the state to (i) isolate those determinants of mor-tality
that permit intervention, and (ii) identify high-risk
areas in order to strategically utilize limited medical and
health resources. The data in this volume should aid in these
areas of investigation by providing information against which
North Carolina's county and regional mortality may be assessed in
the present and evaluated in the future.
Nine sections comprise this edition of Leading Causes of
Mortality . This section presents an overview of mortality
1-3
experience in North Carolina as well as the purpose and organiza-tion
of the document. Section II provides technical information
concerning the calculation, interpretation, and appropriate use
of adjusted and unadjusted rates. As in past editions of this
volume, readers are cautioned about using rates based on a small
number of deaths, and the most problematic of the adjusted rates
are "flagged" in the tables with an asterisk. The procedures
used to determine which rates to flag are described in Section
II. Also, the procedure used to analyze geographic clustering of
counties is described.
Sections III through IX consist of maps, tabular data, and
narrative material which describe North Carolina's recent experi-ence
with respect to general mortality, cause-specific mortality
(underlying cause) , infant mortality, and multiple conditions
present at death. For most causes, risk factors, geographic
clustering, differences by race and sex, and trends over time are
considered.
Table 1 describes the selected cause-of-death categories in
terms of codes from the ninth revision of the International
Classification of Diseases (4) . Altogether, the 14 major causes
selected for examination in this report accounted for 85 percent
of all North Carolina deaths during 1988. Some of the cancer
sites listed in Table 1 are not discussed separately in this
report. However, the considerable interest in cancer justified
presentation of rates for these sites.
DESCRIPTION OF TABLES
Sections III-IX contain tables that summarize the recent
mortality experience of the state, four Department of Human
Resources regions, six Health Service Areas, and the counties.
Except in the case of infant deaths (Section VIII) , a table
corresponding to each cause-of-death category includes the
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following items of information:
1. the number of resident deaths occurring during 1988;
2. the 1988 death rate;
3. the number of resident deaths occurring during 1984-88;
4. the 1984-88 average annual death rate;
5. the 1984-88 average annual age-race-sex-adjusted death
rate computed by the direct method (5).
The formulas for calculating single- and five-year rates are
described in Section II. In this report, general mortality rates
(all causes combined) are expressed as deaths per 1,000 popula-tion,
whereas cause-specific rates are expressed as deaths per
100,000 population. The infant death rates of Table 21, Section
VIII, are computed as the number of infant deaths per 1,000 live
births.
DESCRIPTION OF MAPS
This volume contains 64 computer-produced maps which depict
data for the state's 100 counties. The maps on pages v and vi
identify the four regions of the Department of Human Resources
(DHR) and the state's six Health Service Areas (HSA's).
In Sections III-IX, maps depicting geographical patterns in
mortality should aid in the determination of specific types of
health care needs. Up to four maps are shown for each cause-of
-death category. Two maps depict the 1984-88 unadjusted death
rate and the 1984-88 age-race-sex-adjusted death rate for each of
the 100 counties. These maps show six levels of death rates,
where level one is the highest rate interval, represented by
solid black on the maps, and level six the lowest, depicted by
solid white. The interval values (levels) indicated by the map
legends are not necessarily continuous, but reflect the actual
range of values for each interval. These maps must be viewed
1-5
with extreme caution for causes where the number of deaths per
county is small, since in these cases rates can be very unstable.
A clustering routine from the Statistical Analysis System
(SAS) was used to group counties that are "most like each other"
with respect to their unadjusted and then their adjusted rates
(6) . This procedure may result in very large or very small
groups, depending upon how county rates differ from one another.
The other two maps for a particular cause depict "spatial"
clustering of two or more adjacent counties with high unadjusted
and/or adjusted rates, using a procedure described in Section II.
These maps are presented for a given cause only when a statisti-cally
significant spatial cluster was found to exist. Unlike the
maps described above, these maps are presented in reduced form as
part of the narrative and show up to three interval levels of
death rates, depending on the number of significant spatial
clusters found, along with the significance level (i.e., p-val-ue)
.
MULTIPLE CONDITIONS PRESENT AT DEATH
Since 1975, multiple conditions present at death have been
coded, and statistics are available for all conditions reported
by the certifier. Five diseases--septicemia, diabetes, hyper-tension,
atherosclerosis, and nephritis--are considered associ-ated
conditions far more often than they are reported as under-lying
causes. The importance of multiple conditions and the
geographic patterns of these five diseases are discussed in
Section IX, while the etiology and risk factors associated with
septicemia, diabetes, atherosclerosis, and nephritis are dis-cussed
separately in Sections IV and VI. County rate tables for
these diseases as underlying causes are likewise available in
Sections IV and VI. Neither separate discussion nor a county
rate table for hypertension is warranted, since it was reported
1-6
as the underlying cause for only 283 deaths in 1988.
Tables included in Section IX show deaths cross-tabulated by
underlying cause and associated mentioned conditions, death
frequencies for selected pairs of mentioned conditions, and death
rates based on mentioned conditions rather than underlying
causes. Rates are deaths with the condition mentioned per
100,000 population. In addition, ratios of the 14 major causes
(plus hypertension and four site-specific cancers) as mentioned
conditions versus underlying causes are tabulated.
1-7
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