Board of Scientific Counselors Program Review

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Vital Statistics What is Our Future?
Centers for Disease Control and
Prevention National Center for Health Statistics
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Before we get to the future lets revisit the
past
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Early History Egypt, Greece, and Rome

• Gathered through a census for revenue and
  military purposes

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Early History

• Ecclesiastical registration
• With the advent of the modern nation state came -
  Civil registration

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English and Colonial History

• 1632Grand assembly of Virginia required clergy
  to keep records of christenings, marriages, and
  burials
• 1639Massachusetts Bay Colony General Court
  required town officers to register town officers
  to register births, marriages, and deaths

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English and Colonial HistoryMortality
Surveillance

• 1662The Bills of Mortality (John Graunt)
• 1721Use of burial records by Cotton Mather to
  demonstrate effects of smallpox

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Examples of Diseases Listed in Graunts Bills of
Mortality

• Bloody Flux-dysentery
• Bursten-hernia/rupture
• Falling Sickness-Epilepsy
• French Pox-Venereal Disease
• Horseshoehead-inflammation of brain
• Livergrown-Cirrhosis of the liver
• Planet Struck-Paralytic/confounded
• Tissick-Consumption/TB
• Tympany-obstructed flatulence

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English and U.S. History

• 1789Edward Wigglesworth developed first U.S.
  life table
• 1836English Act creates central registry of
  births, marriages, and deaths by cause
• 1839Vital statistics used to initiate sanitary
  reform (William Farr)

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English and U.S. History

• 1842Massachusetts first state to require
  State-wide registration of vital
  events--(Secretary of States office!!)
• 1855 John Snow demonstrates connection between
  water supply and deaths from cholera in England.
  Florence Nightingale mortality rates in
  hospitals

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U.S. History

• 1850-90 - Birth and death data - collected on
  census
• 1850 Collection of national mortality data
  through the Census
• 1900 Death registration areas established (10
  States and D.C.)
• 1915 Birth registration areas established (10
  states and DC)
• 1933 Birth and Death Registration areas are
  complete

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Leading Causes

• 1900
• Influenza Pneumonia
• Tuberculosis
• Diarrhea
• Heart disease
• Stroke
• Population approx 76 million

• 2004
• Heart disease
• Cancer
• Stroke
• Chronic lower respiratory diseases
• Accidents (unintentional injuries)
• Diabetes
• Alzheimers Disease
• Influenza Pneumonia (61k)
• Population approx 290 million

NOTE Prior to 1933, data are for
death-registration States only. 2004 -Preliminary
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Life Expectancy and Age-Adjusted Death Rates

Deaths per 100,000 standard population
Age in years

Life expectancy
Age-adjusted death rates
2004
NOTE Prior to 1933, data are for
death-registration States only.
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Death Rates for Infectious Diseases and
Accidents, Ages 1-19, Selected Years
Rate per 100,000 population

Infectious diseases
Accidents
With HIV infection
2004
SOURCE CDC/NCHS National Vital Statistics
System, 1900-2004
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Age-Adjusted Death Rates for Heart Disease and
Influenza and Pneumonia
Rate per 100,000 standard population
Heart disease
Influenza and pneumonia
2004
NOTE Data prior to 1933 contain
death-registration States only.
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Childhood Death Rates by Age at Death

Deaths per 100,000 population
2000
1-4 years
15-19 years
10-14 years
5-9 years
2004
SOURCE CDC/NCHS National Vital Statistics
System, 1900-2004
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Do we believe that Vital Statistics continues to
provide the

• Core of our health data system?
• Baseline for public health, social science, and
  related programs?
• Ability to monitor key indicators of health
  world-wide and at the local, state and national
  level ?
• Ability to track progress to health goals?
• Ability to identify disparities in outcomes?
• Ability to alert to emerging problems?

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How can we build on our past successes for a new
beginning?To measure what is and not just what
was?
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Some things that should not change

• States Register all events correctly and quickly
• States Efficiently issue certified copies of
  certificates
• States Maintain historical records
• NCHS and States Provide high quality annual
  reports/data files of vital events for trend
  analysis and for measuring the attainment of
  health objectives

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The futureIs it really all about EDRs and
EBRs?Yes but What about how we currently
do business internally?
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It certainly begins with EBRs and EDRs

• From a statistical perspective EBRs and EDRs
  give us the potential for higher quality and more
  timely data
• If EBRs and EDRs meet appropriate data
  standards, they provide the potential to tie in
  with electronic medical records
• With quicker receipt and better quality both
  States and NCHS can provide end of year reports
  and data soon after the end of the year.

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But is this all we can get out of the investment?

• Even if we could make an end of year file and
  report available a week after the end of year
  some events will be 6--12 months old and most
  will be of no better quality than when they came
  in!
• Why not get Vitals back into surveillance? A
  Back to the Future movement.
• We need a Use it now or Lose it mentality or we
  will be at best public health historians.

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What are some things to consider if we get back
into the surveillance game? How do we get ready?
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How do we process our data into statistical
files?

• Do we now examine the data carefully upon receipt
  or do we wait until we close the end of year
  file?
• Do we ever utilize our demographic mortality data
  before we code cause of death information?
• Have we thought of modeling current demographic
  mortality data with past complete mortality
  reporting for public health surveillance
  purposes?
• Do we strive to match our cause of death
  information immediately with demographic
  mortality and do edits for improbable events?

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How do we process our data into statistical
files?

• Could we release data files on a YTD basis or
  just at the end of the year?
• Are our systems capable to do YTD release?
• Do we have staff ready to interact with a YTD
  data release system? Do we need staff with
  different interests or is that the role of
  partner organizations?
• Are we comfortable with releasing incomplete but
  useful data files ?
• What type of edits are needed for even incomplete
  data to be released?

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How do we process our data into statistical files?

• Do we have systems that would allow updating of
  YTD files as updates and corrections are
  received?
• Should denominator data be provided with YTD
  files?
• Is the YTD file just for in-state occurrences or
  should a national data transfer system be in
  place to handle out of state events? What should
  be NCHSs role?

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What is NCHS planning?

• We need to take advantage of improved timeliness
  of States using EBRs and EDRs
• Through funding from Pan Flu, DVS is
  re-engineering its internal mortality systems and
  processes to be able to support a YTD
  surveillance system
• We will be doing edits sooner and linking
  mortality demographic and medical records on an
  ongoing basis
• Although we plan to release YTD data for
  surveillance purposes the how is yet unknown.
  

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What is NCHS planning?

• We are planning to provide for surveillance
  purposes demographic mortality data with what
  might be expected from past years complete
  mortality files.
• I believe the release of surveillance files can
  be accommodated through our existing data
  release agreement with a little tweaking but
  further study with NAPHSIS is needed before that
  takes place

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Many Unknowns

• Impact on internal staff in dealing with YTD
  processing
• Scheduling of updating of YTD files for external
  surveillance use
• Methods of data access for surveillance
• Impact on States with NCHS doing earlier edits
• Reporting of NCHS back to States on surveillance
  estimates How What?

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Many Unknowns

• Data transfer STEVE or SOS (Son of Steve) or
  even DOS?
• How to handle YTD files with current States while
  dealing with old data from other States
• We currently do provisional (record count) and
  preliminary data (mostly complete) reports how
  should they change?

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Many Possibilities

• As you send us your files if addresses are
  provided we could geo-code your records at no
  cost and send those records and associated files
  back to you for State surveillance purposes
• New surveillance partnerships - adding to
  reporting
• New interest and use of vitals could mean support
  from different programs

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How are we perceived may relate to our funding
future Are we seen as

• Careful and inflexible?
• Careful, responsive and inflexible?
• Careful, responsive, and flexible?
• Inventive, careful, responsive, and flexible?

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Is this really the time?

• Dont we have problems funding what we currently
  provide?
• Perhaps just perhaps there is a reason for our
  situation
• Perhaps we need to be relevant to the doers not
  just those interested in the past