Not A \"Pioneer\" But Recognize New Market Requirements? January 2012 CMS recently named 32 Pioneer ACOs and has begun funding Innovation Grants to help prepare for new models of care delivery. Readiness to adapt to expected changes in payment methods varies. Even if you are not participating in these CMS initiatives, you know that change is on the way. You can test the waters and prepare for new payment arrangements or risk loss of the ability to influence your future. Many Healthcare leaders remain legitimately skeptical of pioneer programs in general and ACO certification in particular: \"Pioneers\" take big risks (new frontiers are fraught with risk!). The Medicare ACO payoff is far from clear. Critical capabilities that enable movement from volume based to value based payment systems are missing, i.e. physician alignment, IT infrastructure or scale. Organizational readiness varies among key constituents: physicians, network partners, and payers. Limited capital hinders required investments, and We have forgotten or remember all too clearly our experiences with managed care and physician integration from the 90's. In 2012, smart forward thinking CEOs are repositioning and redesigning their systems to operate successfully in a coordinated care environment, are putting cost reduction programs in place to be prepared for reimbursement cuts beginning in 2013 and are selectively testing bundled payment models. You don't have to create an ACO to be ready for value based payment. How Do Leaders Successfully Navigate Through The Transition? First, let's acknowledge the elephant in the room: the need to maximize income from current payment system complicates the transition to a new system. Leaders face an enormous dilemma. Hospital income for the next few years will continue to be a function of volume, costs and payment rates. Hospital and physicians will get minimal if any direct financial benefit from investing in population health and aggressive disease management which, when successful, decrease demand. No leader can ignore this reality. The challenge is to be able to make the investments which anticipate new payment methodologies while continuing to pay careful attention to revenue production from the current payment system. Leaders Prepare Their Organizations For Success By: 1. Painting a clear picture of their current and desired future states including acknowledgment of what is known and what is simply a best guess, including: Who will be served or targeted: Medicare, exchange patients, commercial groups, Medicaid, the uninsured. The required primary care based care delivery model incorporating needed relationships with specialists and other care providers. The network of hospital, physician (employed and affiliated), and other clinical 1 resources required to provide access to and serve targeted populations. Infrastructure/technology required to deliver care cost effectively with a high degree of consumer satisfaction Integration vehicle(s) needed to align care delivery and economic interests with the desired outcomes, 2. Defining and developing the core competencies required to manage under a value based or populations payment system including: Creating culture of accountability. Establishing new clinical and administrative leadership roles. Robust and real-time integration of clinical and financial information to support performance-based payments and population health. Building strategic community and payer relationships. Building expertise to predict and manage financial risk. Leaders take next steps now, before the transition from volume based payment becomes mandatory: A detailed Gap Analysis to fully understand what's required to successfully operate under this new payment system and through the transition. A detailed design of the elements of the required care delivery system, and A detailed implementation plan. Regular adjustment to the vision, strategy, market conditions as necessary. The Basic Building Blocks For A Coordinated Care System. Multidisciplinary Primary Care Teams that share accountability for a panel of patients supported with an appropriate incentive program, analytic resources and training. Patient-centered and effective processes to manage access, referrals and hand-offs of patients among specialists, ED and primary care providers. Complex Case Management by primary care teams. Disease Management by primary care in collaboration with specialists. Strategic management of populations across the coordinated system through education, prevention and early detection supported by software that provides information to manage. Building competencies in managing care, Create needed administration and management capabilities to manage care. Develop competencies for managing contracts with financial risk for defined populations. Primary Care Teams Coordination of Care Care Management Population Health Management Managing the Coordinated Care System What Gets In The Way? Our experience, re-enforced by our recent engagement in a nearly yearlong \"accountable or coordinated care\" design assignment for a major safety net organization suggest five major challenges leaders must overcome to navigate this transition. 2 1. Timing/Urgency. Your competition and commercial and governmental payers continue to test new approaches and are making inroads in your market. To remain competitive, a comprehensive and simultaneous approach to creating the new systems and initiating the necessary changes in care processes is needed rather than the more comfortable piecemeal and incremental approaches of the past. 2. Mind-Set. Coordinated care systems must incorporate a retail mind set not common among hospital operations leaders. Establishing community based primary care and outpatient support services as a focal point of the new model is very different than the hospital centric focus of the past. Outpatient services can no longer be subordinate to inpatient; in the new environment the two sectors become equal partners in management of the enterprise. Physicians need to be engaged to work in alignment with the new model When patients or consumer have choice, then access, customer service and patient satisfaction become critical to the production of value. We recommend that hospital and health system leaders position their coordinated care initiative at the level of priority and authority needed for success. 3. Leadership Talent. Available physician and executive leadership talent to plan and execute this new model does not meet the demand. We believe this talent needs to be recruited early in the planning process to ensure that an executable plan is developed and implemented. The urgency is real and you want this initiative in the hand of the most experienced people available. So do your competitors. 4. Time. Developing an effective accountable or coordinated care initiative takes time. Many of the \"pioneers\" have been under development for more than ten years. Expect to spend at least six months in design and planning. The focus is on building more effective and efficient processes rather than new cost centers; the distinction is enormous. The changes are about how people work with each other to care for patients, not simply about what tools they use. Making the changes requires perseverance and hard work. 5. Managing the Change. Painting the picture and hoping for the best will not be sufficient. Leaders will have to regularly and consistently make the case for change throughout their organization. Moving from a volume-based system to one that is value-based requires compelling, engaged and dynamic leadership. We Can Help Hindin Healthcare Advisors and its Partners at ZOLO Healthcare Solutions can help you overcome the challenges to establishing a new model of care and help you design and implement your coordinated care system. ZOLO's senior consultants include physicians, nurses and executives with significant experience operating in fully integrated and highly successful delivery systems. We can complete a high level readiness assessment, a comprehensive \"gap\" analysis, design a new delivery model, help you implement your plan, or provide coaching and advise as needed. Call or email me or Deb Lowry @ 925.388.6211 or deb@zolohealthcare.com for additional conversation. Be sure to mention this newsletter! Edward M. Hindin Hindin Healthcare Advisors, LLC 1100 Clinton St. Suite 302, Hoboken NJ 07030 201 656 1004 (O) 201 656 1444 (F) 201 208 7161 (C) email: ehindin@hhadvisors.com Visit us online at: www.hhadvisors.com 3 CHAPTER 3 Population and Disease Patterns and Trends Stephen J. Williams CHAPTER TOPICS Need, Demand, and Utilization W I L S O N , LEARNING OBJECTIVES Upon completing this chapter, the reader should be able to The Underlying Demographic Determinants of Health Services Utilization 1. Trace U.S. demographic trends including births and deaths. Q Fertility Trends in the United States U Mortality Trends in the United States Specic Causes of Death for the U.S. A Population S Incidence of Infectious Diseases H Lifestyle Patterns and Disease Health, Lifestyle, and Social Structure E 2. Understand correlates of mortality, especially with regard to the impact of population trends. 3. Understand disease patterns in the United States. 4. Relate lifestyle, behavior, and social patterns to health. Measuring the Impact of Illness on Society 5. Appreciate cancer survival trends. Access to Health Care Services 6. Understand issues of access to care. 1 9 9 7 B U 41 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 42 Disease patterns throughout history and the underlying social and demographic characteristics of our population provide empirical evidence from which to view the need and demand for health care services in the United States. The principal purposes of this chapter include the review of fundamental demographic, social, and economic trends in our nation, principally throughout the past century, and of patterns of morbidity, mortality, and other aspects of the measurement of the incidence and prevalence of disease. Analytical, epidemiologic measurement of these patterns illuminate the underlying factors that W dene the nature of health care services required for our nation. The chapter also presents quantitative I information that reects the impact of illness and L disease on our longevity and health status. Factoring in the impact of illness and disease further enhances S our appreciation for the challenges and trade-offs O faced by our nation's health care system. An additional purpose of this chapter is to N review population, disease, and illness trends and to , relate these trends to issues of access to health care services. Access to care is a core theme throughout this book and a key health policy issue facing our Q nation. This chapter associates the various social, demographic, and disease patterns experienced U by our nation with measures of access to health care A and interpretation of these measures as a contribuS tor to the national health policy debate. The analysis presented here rst focuses on the H underlying demographic trends in our society durE ing the twentieth century. Social and economic trends that dene the character of our society and relate to the need and demand for health care ser1 vices are also discussed. The next section of the chapter focuses on disease 9 patterns experienced in the past century. Differential 9 mortality and morbidity are presented to emphasize the importance of such variables as age, race, and 7 sex in dening population groups at particular risk B for various diseases. Ultimately, identication of risk U factors and their association with various personal, sociodemographic, and physiological characteristics, and genetic markers will greatly heighten our ability to target health services to individuals in the greatest need for each category of care. PART ONE Overview of the Health Services System All aspects of this chapter are integrally related to virtually every other section of this book. The nature of the delivery system itself, including the settings in which services are provided, the nature of services, the technology of our system, and even the nancing of care are all directly related to the underlying disease patterns that we experience. This chapter sets the stage and forms part of the foundation of knowledge necessary for critically assessing how the health care system is structured. Our ability to measure performance within the system itself, including access to and outcomes of care, and the costs of illness, is related to these fundamental trends as well. Ultimately, the success of the system should be measured against criteria that recognize the true needs of the population with regard to the physiological and psychological manifestations of injury, illness, and disease, and their ability to obtain needed care. In purely quantitative terms the measurable impacts of disease and illness offer enticing avenues for measuring the success and failures of the health care system. Such measures as years of life lost and days of disability attributable to each illness and disease category provide an objective and comparative numerical assessment of the impact of these clinical and psychological problems on us individually and collectively as a society. Increasingly, the utilization of such quantitative measures facilitates the allocation of resources and priorities in decision making at various points within the health care system. As the system moves increasingly to objectively measure clinical care, disease impacts, and other aspects of its own operation, attention to such quantitative measures and objective indicators is paramount. NEED, DEMAND, AND UTILIZATION In discussions of disease patterns and their relation to the utilization of health care services, it is important to differentiate between the concepts of need, demand, and use of health care services. Need for Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 3 Population and Disease Patterns and Trends health care services is dened as an interpretation of an individual's evaluated requirements for obtaining professional care through the health services system. Demand for health services is a function of an individual's actually seeking out, but not necessarily obtaining, health services. Demand may be a reection of professional assessment of an individual's need for services or self-initiated desires for professional services, perhaps triggered by an individual's perceptions of potential illness. Finally, utilization is a measure of actual use of services, as discussed later in this chapter. W The extent to which there is a correlation between need, demand, and utilization is I central the issue in addressing concerns of appropriateness of L care, perceptions of when services should be obtained, and evaluation of access to health care serS vices in our society. Many other issues related to these concepts are addressed throughoutO book. this N Data Sources and Quality , Morbidity, mortality, and other health status-related data are obtained from a variety of sources. Q Information presented throughout this chapter U and elsewhere in this book is based on such sources as national vital statistics data. National A vital statistics data are collected from birth, death, S and marriage certicates. Mandatory data collection requirements in the United States provide the H most consistent and generally highest quality data E available for determining the health status of our population. But even mandated vital statistics data collection 1 produces information of inconsistent quality. All data should be viewed with a skeptical 9 recogeye, nizing the imperfections of the data collection 9 effort. For primary demographic variables such as age, race, and sex, the quality of data recorded on 7 the primary data sourcethe vital event certicate B is generally good. However, for more subjective U data elements such as cause of death, the consistency and quality of data reported can vary appreciably, especially in past years, depending on the judgment of the individual, usually a physician, completing the certicate. Vital statistics data collected at the 43 local level are compiled by the states and the federal government, and efforts are directed toward improving quality at each level. Data on health services utilization, health status, attitudes, and other variables are often collected through national probability surveys conducted by the federal government and some private organizations. The National Health Interview Survey, for example, collects data from a random probability sample of all Americans, asking questions regarding prior health services utilization, perceived health status, mobility, and other, often somewhat subjective, self-reported variables. Recall ability, response judgments, and other complex factors affect the quality of these types of data. Primary data collection by the federal government has even included conducting physical examinations on a random sample of Americans. This research effort, the National Health and Nutrition Examination Survey, provides direct observation data on various health and disease indicators. This type of examination is very expensive to conduct but does provide considerable objective useful information to the extent that those randomly selected for participation reect national patterns in our entire population. A third category of data collection for health services use involves the compilation of data from other sources. An example of this is the National Hospital Discharge and Ambulatory Surgery Survey, conducted by the federal government, which compiles the data from a sampling of hospital discharges in the country. Another example is the National Ambulatory Medical Care Survey, also conducted by the federal government, which is based on a sample of physicians who report on the characteristics, diagnoses, and use of services for all patients seen during a 1-week interval of time. Private data collection includes surveys of health services use, attitudes, and costs. National organizations such as the American Medical Association and the Medical Group Management Association conduct surveys on medical groups, physician practices, and hospital services. Various insurance companies, health care systems, and individual facilities also conduct surveys on patient satisfaction and Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART ONE Overview of the Health Services System 44 other issues. Finally, data are collected by national voluntary accrediting agencies, health services researchers, and other organizations. Health policy data analysis utilizes a variety of databases, producing more complex analyses that go beyond the descriptive nature of many of the surveys. Such analysis, by combining a variety of data and sources, allows for greater insight into the nature of health care services and population needs. For example, combining population data, longevity data, and data on the incidence and prevalence of disease allows for the analysis of the impact of various diseases on our population W as measured by such variables as days lost from work, I years of life lost due to mortality from specic L diseases or behaviors such as smoking, and other analyses that provide a more in-depth reectionS of the impact of illness and disease on our society. O It is important to recognize the sources, quality, and contingencies associated with the data that are N analyzed and presented throughout this book. The , book's analytical perspective on health services is dependent on the assessment of population-based data, and the best available information is utilized Q for discussion purposes. Even the relatively solid U data available in the United States, however, are subject to numerous limitations. Needless to say, A data from many other countries in the world often S lag far behind our own in this regard. THE UNDERLYING DEMOGRAPHIC DETERMINANTS OF HEALTH SERVICES UTILIZATION The dynamics of population are the most fundamental determinants of the need, demand, and use of health care services. The size and age composition of a population have a tremendous impact on total health services use as well as on the distribution of the use of specic services. Therefore, trends in population dynamics, including population size and demographic characteristics as well as births and deaths, are a basic starting point for assessing the need for health services in a population. Population Size and Composition Population size, as reflected in the total number of people in a population, as well as the distribution of population by age group, defined as the population pyramid, is the appropriate starting point. Table 3.1 presents the age-specific distribution of the United States resident population since 1950. These data, obtained from the federal H E Table 3.1. Resident Population: United States, Selected Years Year 1950 1970 1990 2001 2003 Total Resident Population (Population in Under 1-4 Thousands) 1 Year Years 150,697 203,212 248,710 284,797 290,811 3,147 3,485 3,946 4,034 4,004 13,017 13,669 14,812 15,336 15,766 5-14 Years 1 9 Age Group (Population in Thousands) 9 15-24 25-34 35-44 45-54 55-64 Years Years Years Years Years 7 B 22,098 23,759 21,450 17,343 13,370 35,441 24,907 23,088 23,220 18,590 U 37,013 43,161 37,435 25,057 21,113 65-74 75-84 85 Years Years Years and Over 24,319 8,340 3,278 40,746 12,435 6,119 35,095 18,045 10,012 41,065 39,948 39,607 45,019 39,188 25,309 18,313 12,574 40,969 41,206 39,873 44,371 40,805 27,900 18,337 12,869 577 1,511 3,021 4,404 4,713 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 3 Population and Disease Patterns and Trends 45 government, are based on the national census of population data. The federal government is required by the United States Constitution to conduct a census count of the population once every ten years to compile as complete a count as possible of all citizens. The United States Census of Population was most recently completed in 2000. Results of the 2000 census indicated an approximate United States population of 280 million individuals. Complete census results from the 2000 count are available in a variety of forms from the United States Bureau of W the Census. Population data between censuses and for fuI ture periods are determined through intracensual estimates and projections using priorL data and adjusting for estimated population growth and S migration. Intracensual data estimates are facilitated O by using such available statistics as school enrollments, automobile registrations, and utility hookups. N The original purpose of the census, of course, was , to determine representation in the House of Representatives, although these data are now also used for an array of analytical, commercial, and social Q purposes. The accuracy of the actual census count, of intracensual estimates, and of demographic projections into the future is a subject of considerable debate. The mobility of the population, the lack of tracking for internal migration, and illegal migration into the country complicate the picture. The cost of data collection, analysis, adjustment, and reporting has escalated greatly as the population has grown, as well. The United States population has grown tremendously during the period presented in Table 3.1. This growth is a result of two principal factors. The rst of these is the rate of natural increase attributable to the higher number of births as compared to deaths annually in the United States, leading to additions to the total population count. The second factor is the increase in population attributable to net in-migration, which historically has accounted for nearly all of the accumulated population of the country. The current United States population is more than 302,000,000 people, double the count in 1950. A limited selection of the detailed demographic data available from the census is reected in Table 3.2. This table presents age-specic total U A Table 3.2. Resident Population: Age, Sex, Race, United States, 2003 S Total Under 1-4 H 5-14 15-24 25-34 35-44 45-54 Sex and Race Population 1 Year Years Years Years Years Years Years E Male Female White male White female Black or African American male Black or African American female Hispanic or Latino male Hispanic or Latino female 143,037 147,773 116,875 119,474 2,046 1,958 1,594 1,525 8,060 20,977 7,706 119,992 6,296 16,322 5,999 915,488 18,190 336 19,958 323 20,599 442 9 7 3,444 1,260 B 3,337 U 1,682 3,832 19,300 424 1,611 1,301 3,659 Number in thousands 21,183 20,222 22,134 20,024 19,650 22,237 16,726 16,159 18,129 15,658 15,310 17,813 55-64 65-74 75-84 85 Years Years Years Years and Over 20,044 20,761 16,807 17,034 13,424 14,475 11,590 12,263 8,349 9,988 7,308 8,576 5,154 7,714 4,638 6,859 1,445 3,269 1,307 2,950 3,180 2,613 2,705 2,218 1,232 711 355 96 3,140 2,862 3,052 2,579 1,531 999 627 247 3,759 4,016 3,101 1,910 991 542 261 65 3,235 3,363 2,815 1,908 1,097 680 380 128 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 46 population data for the country by sex, and by race and sex for whites, blacks, and Hispanics Careful observation of these data demonstrates, for example, the substantially higher number of individuals alive at age 85 and above who are female as compared to male, while showing a higher population of under 1-year-old males as compared to females. The relative size of the race and sex-specic populations is also illustrated in Table 3.2. Such data are available for numerous subgroups within the population. This type of data is also available for various geographic regions within the country alW though the data presented in these tables are aggregate data for the entire nation. I Comparing data for various time periods L allows for ready assessment of temporal changes. For example, the increasing minority count of popS ulation in comparison to total population over O time is reected in the data. The data present absolute numbers, but many of the numbers presented N in the tables and other data from these sources are , also used in calculating rates and ratios for more extensive analysis of demographic, disease, and other trends. Q The age structure of the population is, as noted U earlier, vitally important for health services purposes. The very young and the older population groups A utilize considerably more health care services than S other age groups. Table 3.1 also presents the age distribution, and hence the structure or pyramid of the H population. E An important current trend is the aging of the population. On average, the typical American is getting older. This trend is the result of increased 1 longevity and relatively lower fertility than was experienced earlier in the last century. The conse9 quences of this trend are reected in Table 3.3. Pro9 jections for the older population groups over the next half century suggest substantial increases 7 in health services utilization, assuming current techB nology, access to care, and patterns of use. The popU ulation aged 65 and above currently uses, on average, approximately twice the health care services as the younger population. This trend in the age structure for the United States is the underlying PART ONE Overview of the Health Services System Table 3.3. Population Age Group Projections, Age 65 and Above Year (Population in Millions) Age Group 2000 2025 2050 2075 65 years and over 75 years and over 85 years and over 35.2 16.7 4.4 60.6 25.0 6.3 73.3 38.9 14.6 83.3 45.7 16.9 SOURCE: U.S. Social Security Administration Ofce of Programs: Ofce of the Actuary, 1993, Baltimore, MD. demographic reason for concerns over the future nancial viability of the Social Security system and the Medicare program. Projections of the aging of the population as reected in Table 3.3 are simple to perform since changes in mortality patterns by age typically do not vary drastically over relatively short periods of time. However, the implications of these fundamental demographic shifts are much more difcult to project. Our aging population of Baby Boomers appears to be healthier and more functional than predecessor generations. Their interest in an active lifestyle, social activities, and cosmetic medicines is clearly greater than that of previous generations. Preferences in housing, entertainment, behaviors, and politics are often difcult to predict. Changes in many of these parameters can have a signicant impact on the scope, use, and nature of the health care system. Many dramatic changes that are now occurring in medicine and biomedical research further complicate any projections. For example, although current demographic trends portend increases in the population of patients with Alzheimer's and related dementias, biomedical research may allow health care providers to prevent these diseases or to repair their damage. Such landmark advances would have a tremendous impact on the need for services and the cost of providing those services to an aging population. Less invasive pharmacologically based interventions for various diseases might be signicantly less Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 3 Population and Disease Patterns and Trends expensive to implement than current alternative surgically based interventions. Then again, the high cost of many pharmacological products may narrow the cost gap. The many longer-term implications of an aging population also extend to numerous economic concerns including labor force participation; the dependency ratio, which is the percentage of the population working to support the nonworking or dependent population; and impacts of economic growth rates from an aging population base. The challenge for the nation and its health care system W is to create an environment that can adapt as the underlying parameters change over time with the I aging of the population. L Parenthetically, many other countries in the world, especially in Europe, face an even more S profound aging of their populations, so that future liabilities for social services, health care,O social and security are even more serious than our N own. Enhanced longevity as a result of biomedical , advances is a two-edged sword leading to longer periods of economic and social dependency, while at the same time enhancing quality of life. As the Q population ages, the burdens on the younger workU ing groups increase. This can have signicant long term impact on social policies, taxes, politics, and A everyday life. S H E FERTILITY TRENDS IN THE UNITED STATES 1 A key determinant of population that affects health 9 services utilization is fertility. Fertility is a key deter9 minant of the population pyramid, as well as of the use of services for mothers, infants, and children. 7 Fertility eventually inuences total population size B and has cohort effects in all age groups as a cohort U ages. Fertility behavior is also a socioeconomic characteristic of population. Developing nations, for example, are typically characterized by relatively 47 high fertility rates, while developed, or postindustrial, societies usually experience low fertility rates. Fertility is a measure of reproduction. Agespecic fertility rates are the primary indicator utilized in measuring this determinant of population. Age-specic fertility rates more accurately reect differences in fertility patterns based on age groups of mothers than do birth rates, which are a cruder measure of reproduction. Birth rates are computed as the total number of births to total population. Age-specic fertility rates are computed as the number of births to women in a specic reproductive age group. The total fertility rate is the sum of all of the age-specic rates. Table 3.4 presents age-specic fertility rates for the United States over the past half century. As for many of the other rates discussed in this chapter, age, race, sex, and other characteristics may be utilized to compute more specic rates than those presented. Fertility, of course, differs greatly by age group, as reected in Table 3.4. Fertility is highest for women in their twenties and generally declines thereafter as the age of the mother increases. Fertility rates drop off appreciably at the higher reproductive ages, with little fertility in the groups above 45 years of age. Historically, and in most societies, the reproductive ages begin with the physiological marker of menarche. A variety of sociological determinants of reproductive behavior, such as marriage, combine with physiology to produce actual behavior. The reproductive ages usually end with menopause. Other physiological factors, such as voluntary sterilization and infertility, and sociological patterns, such as family dissolution, also have a substantial impact on reproduction. The interaction of these dynamics can be quite complex. Technological change has impinged on our traditional concept of fertility behavior. Of course, natural and articial means of birth control have long affected couples' actual fertility behaviors and outcomes. Few societies in history have not been affected by various natural patterns of birth control, mores, and societal behaviors and other inuences Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART ONE Overview of the Health Services System 48 Table 3.4. Live Births and Birth Rates by Age of Mother: United States, Selected Years Year 1950 1960 1970 1980 1990 2001 2003 Age of Mother (Live Births per 1,000 Women) Total Fertility Rate* 10-14 Years 15-19 Years 20-24 Years 25-29 Years 30-34 Years 35-39 Years 40-44 Years 45-54 Years 106.2 118.0 87.9 68.4 70.9 65.3 66.1 1.0 0.8 1.2 1.1 1.4 0.8 0.6 81.6 89.1 68.3 53.0 59.9 45.3 41.6 196.6 258.1 167.8 115.1 116.5 106.2 W 102.6 166.1 197.4 145.1 112.9 120.2 113.4 115.6 103.7 112.7 73.3 61.9 80.8 91.9 95.1 52.9 56.2 31.7 19.8 31.7 40.6 43.8 15.1 15.5 8.1 3.9 5.5 8.1 8.7 1.2 0.9 0.5 0.2 0.2 0.5 0.5 I L S on fertility outcomes. Demographers have searched O for populations such as the Hutterites which strive for maximum fertility to provide a glimpse into N reproduction potential in an uninhibited population. , *The sum of the age-specic rates. Many biological, economic, and social factors impact fertility behavior and outcomes as measured by live births. Q Recent technological advances have also sugU gested the potential for signicant impact on fertility behavior as a result of external interventions. A Such technologies as in vitro fertilization, ovum S freezing and storage, and enhanced infertility treatment have led to increases in birth rates for H population groups, especially older women, and E have also increased the number of multiple births. Although the actual impact of these technologies on total fertility rates has not been great, the 1 longer-term impact of these and other yet to be 9 discovered technologies could be signicant. An increased ability to determine sex, to screen for 9 genetic disorders, and to enhance and prolong 7 fertility could eventually profoundly impact the demographic structure of our society. The cost B and acceptability of many of these interventions, U however, will limit their overall impact. Fertility patterns thus far clearly have not been hugely affected by these new techniques for the population overall. Fertility has declined in most age groups over the past 40 years, as reected in Table 3.4. Reductions in fertility have been rather dramatic in the United States since peak fertility occurred in the mid-1950s. Some uptake in fertility rates at the higher age levels is evident in Table 3.4 for the year 2001. This increase is primarily in the 30-44 age range and minimally so above that point. Further declines in the younger age groups are also evident from this table. Data are available by various social demographic groups as collected on birth certicates. Table 3.5 presents differential fertility rates by age group for whites and blacks. Generally, dramatically higher fertility for most age groups is evident in this table for blacks as compared to whites. Differential fertility patterns combined with demographic trends in migration, population size, and other related information can provide useful data for projecting population trends in local communities and nationwide. The increasing diversity of our population is evident from these and other demographic data. The dramatic decline in fertility that has occurred in the United States over the past 40 years is primarily the result of increases in female labor force participation, marital dissolutions, and other economic and social forces in our society. In recent years, our nation has also witnessed a delayed Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 3 Population and Disease Patterns and Trends 49 Table 3.5. Live Births and Birth Rates by Race of Mother: United States, 2003 Age of Mother Total Fertility Rate 10-14 Years 15-19 Years 66.1 0.5 38.3 66.3 1.6 40-44 Years 45-54 Years Live births per 1,000 women 100.6 119.5 99.3 44.8 8.7 0.5 63.8 126.1 100.4 66.5 33.2 7.7 0.5 82.3 W1.3 I L average age of rst marriage, reduced desired family size, delayed initiation of childbearing due to edS ucation and employment prospects, and a number of other important social and economicO factors, all of which have further reinforced the primary underN lying fertility trends. , Fertility data provide other useful insights into 163.4 144.4 102.0 50.8 12.2 0.7 Race Race of mother: White Race of mother: Black or African American Race of mother: Hispanic or Latino 96.9 population behaviors as reected in Table 3.6. In this table, percentage of women who have not had Q at least one live birth by attained age group is presented for selected years. Since virtuallyU fertility all is complete by age 44, the column for ages 40-44 A reect lifetime childlessness for live births to individual women. Thus about 15 percent ofS women in the population have no lifetime live birth experience. H These data do not specically represent pregnancy E 1 Table 3.6. Women Who Have Not Had at Least One Live Birth, Selected Ages: United 9 States, Selected Years Year 1960 1980 2002 20-24 Years 47.5 66.2 66.5 25-29 Years 30-34 Years Percent of women 20.0 14.2 38.9 19.7 41.3 24.8 9 7 B U 40-44 Years 15.1 9.0 15.8 20-24 Years 25-29 Years 30-34 Years 35-39 Years experience, however. Also evident is the increasing age of the typical mother. The percent of women who have not had at least one live birth has increased substantially from 1960 to the present for the younger age groups in this table. Since a woman's fertility time frame is nite, delays in live childbearing does contribute to reduced total fertility in the population. Indeed, the increasing recognition that fertility capacity, or what is termed fecundability, decreases signicantly with age has been an impetus for much of the reproductive biology research on infertility that has been conducted in recent years. Considerable other insight into reproductive patterns and behaviors is available from the fertility data collected from certicates of live birth. Another interesting component of these behaviors, nonmarital childbearing, is presented in Table 3.7. These data reect live births to unmarried mothers based on birth certicate information. Differential patterns of nonmarital childbearing by race over time are reected in this table. Nonmarital childbearing has increased substantially as a percentage of all live births from 1970 to 2003. Approximately one-third of all live births today are to unmarried mothers. Differential rates reect substantially higher percentages of live births to unmarried mothers for blacks, American Indians or Alaskan Natives, and Hispanic populations, and signicantly lower percentages for Asian populations. The Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART ONE Overview of the Health Services System 50 Table 3.7. Nonmarital Childbearing According to Race of Mother: United States, Selected Years Race of Mother All races White Black or African American American Indian or Alaska Native Asian or Pacic Islander Hispanic or Latino 1970 1990 2003 Percent of live births to unmarried mothers 10.7 28.0 34.6 5.5 20.4 29.4 37.5 66.5 68.2 22.4 53.6 61.3 13.2 36.7 W 15.0 45.0 I L implications of these data relate to family formaS tion, social stability, issues of health insurance covO erage and other economic concerns, and social and behavioral factors in child development. Generally, N the poorest group within our population is single , women with dependent children, so our concerns about the welfare of these mothers and their children are important considerations in the formaQ tion of health and social policies. U Other societies have experienced many of the same general changes in fertility experienced by the A United States in the twentieth century. The change from a high-fertility, high-mortality environment S to a low-fertility, low-mortality environment is typical H of most developing countries. This change is termed E the demographic transition. Countries that achieve low fertility and low mortality combined with relatively afuent economic conditions typically experi1 ence substantial social and economic change that results in permanent reversals of the underlying 9 social factors associated with high fertility. Abortion Trends in the United States 9 7 B U mea- Reproduction may be more appropriately sured in terms of conceptions rather than live births. Conceptions include spontaneous and induced abortions as well as live and dead births. However, the empirical data to accurately count conceptions are considerably weaker than those for live births. National data are available on therapeutically induced abortions. The United States experiences perhaps one million abortions annually at the current time, and an unknown number of conceptions result in spontaneous abortions, primarily in the rst month of gestation. Abortion practices vary considerably from society to society and over time, and the current acceptance of abortion services in the United States dates back nationally to 1973 although some states and foreign nations had less restriction on access to such services before then. National data on the number of medically or therapeutically induced abortions range from a little over 800,000 to approximately 1.2 million abortions per year depending on the source of the data. The availability of legal abortion services in the United States changed dramatically in 1973 with the Supreme Court decision to remove state barriers to access to care. Some erosion in access has occurred since that time, but these services are generally available in most communities. Thus far, the majority of such abortions are performed using suction curettage in the rst trimester of gestation. There is considerable controversy with regard to the availability of abortion services in the United States, although the relative safety of these procedures when performed in medical facilities is excellent. Abortion ratios, that is the number of abortions per 100 live births, is highest for the youngest group of women in the population and for those age 40 and over as well. Abortion ratios are substantially higher for black women than for Hispanic or white women. As might be expected, abortion ratios are substantially higher also for unmarried women as compared to married women. In addition to impacting patterns of fertility, abortion is also believed to affect the percent of births that occur to high-risk women and other aspects of reproductive health. Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 3 Population and Disease Patterns and Trends Technological change has affected the provision of abortion services in the United States and throughout the world. Less invasive pharmacologically based approaches to termination of very early term pregnancies is shifting the locus of abortion services to private physician ofces and clinics without necessarily being associated with surgical procedures. Monitoring these services is extremely difcult. In addition, numerous political, economic, social, and psychological factors will continue to impact the provision of abortion services in the United States regardless of delivery mechanisms. W I L MORTALITY TRENDS IN THE S UNITED STATES O Indicators of mortality are often used toN measure a society's health status. Trends in mortality indicators over time also reect a multitude of , social, economic, health services, and other underlying trends in a society. Reasonably accurate mortality data are Q available for the United States population and for many other nations, although in some U developing countries the quality of data may be limited. A Mortality data are collected at the time of death S through the mechanics of the death certicate, a responsibility of local government. State and federal H agencies compile data collected locally to produce E the vital statistics for the entire country. Because various social and demographic variables are collected on the death certicate in addition to determinants 1 of the cause of death, mortality data can be analyzed by selected characteristics of population. 9 9 Mortality Trends for the 7 United States B This section of the chapter presents quantitative U measures of mortality for the total United States population over time. Mortality data for infants and mothers and an analysis of specic causes of 51 death are presented in later sections of this chapter as well. As for fertility, aggregate mortality data are generally age-adjusted to control for changes in the population age pyramid. Comparisons over time, in particular, require consideration of any substantial changes in the age structure of a population. Life Expectancy A common measure of mortality, particularly popular in the mass media, is life expectancy. Life expectancy is computed from mortality data and reects a cohort effect for estimated years of life remaining. The life table at birth reects the entire expected mortality experience for a population. Life tables use current age-specic mortality experience so that if a population's mortality experience eventually improves or degenerates, the previously computed life table will be inaccurate. For this reason, life tables are periodically updated by insurance companies that use them to compute premiums for life insurance contracts. A life table presents a population's single best reection of mortality expectation for the entire population, although for any one individual, the life table provides only an expectation. Life expectancy can be computed for a population at any specic age, but it is most commonly presented at birth and at age 65. Table 3.8 presents such data for selected countries in the world. Mortality and life expectancy data are typically presented on a sex-specic basis due to the consistent and substantial differences in mortality experienced comparing males and females. International life expectancy comparisons reveal that, for both males and females, life expectancy at birth is greatest in Japan. The United States falls somewhat short in these comparisons, which is a surprising nding for many people. However, the heterogeneity of our population and our complex social problems associated with violence, accidents, and infectious disease account for much of the cross-cultural deciencies reected in our mortality experience. Many Americans are surprised to Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART ONE Overview of the Health Services System 52 Table 3.8. Life Expectancy at Birth and at 65 Years of Age, According to Sex: Selected Countries, 1998 Life Expectancy in Years Life Expectancy in Years Country At Birth At 65 Years Country At Birth At 65 Years Male Canada Chile Cuba Denmark England and Wales France Germany Greece Italy Japan New Zealand Norway Portugal Sweden United States 76.0 72.3 75.8 73.9 75.1 74.8 74.5 75.5 75.9 77.2 75.2 75.5 71.7 76.9 73.8 16.3 15.1 14.8 15.5 16.4 15.3 16.4 16.1 17.1 16.1 15.7 14.3 16.3 16.0 Female Canada Chile Denmark England and Wales France Germany Greece Italy Japan New Zealand Norway Portugal Puerto Rico Sweden United States 81.5 78.3 78.8 80.0 82.4 80.3 80.6 82.2 84.0 80.4 81.3 78.9 79.3 81.9 79.5 20.1 18.4 18.1 18.7 20.9 19.0 18.7 20.4 22.0 19.5 19.6 17.9 20.0 19.2 W I L S O N , Q see that mortality experience measured by life exU pectancy at birth is lower in the United States than in such countries as Greece and France, perhaps A owing a little to the value of red wine, pat, and S olive oil! Life expectancy at age 65 is also presented H in Table 3.8 for selected countries. By age 65, past E the highest-risk periods for mortality attributable to nonphysiological causes, the differences between sexes are much less, as are the differences 1 between countries. Sex mortality differentials drop by about half by age 65, reecting the higher risk 9 from violent accidents and lifestyle causes for indi9 viduals younger than 65. The remaining differential is probably attributable to physiological factors 7 such as hormones and genetics. B International differences are similarly moderated U by age 65, as many of these same causes of mortality in the younger ages have been factored out of the equation. Even at 65, however, life expectancy is greatest in Japan, with females at age 65 expect- ing to live, on average, to about age 86, a truly impressive result. United States Life Expectancy Data Table 3.9 presents life expectancy data for selected subgroups of the United States population. Again, mortality experience differs by sociodemographic characteristics such as sex and race. Dramatic differences appear in these data at birth for males as compared to females and for blacks as compared to whites. As noted previously, data are available for numerous subgroups of the population, and only selected illustrative data are presented here. At birth, females have a substantially higher life expectancy than males, a difference of more than ve years of life. An equally dramatic differential is evident for whites as compared to blacks. These differences have been constant throughout modern Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 3 Population and Disease Patterns and Trends Table 3.9. Life Expectancy at Birth, at 65 Years of Age, and at 75 Years of Age, According to Race and Sex: United States, Selected Years. 53 Table 3.10. Death Rates for All Causes According to Sex: United States, Selected Years. Sex and Age White Age and Year Male Female Black Male 1950 1990 2001 Deaths per 100,000 resident population Female Male All ages, age adjusted All ages, crude Under 1 year 1-4 years 5-14 years 15-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75-84 years 85 years and over 1,674.2 1,106.1 3,728.0 151.7 70.9 167.9 216.5 428.8 1,067.1 2,395.3 4,931.4 10,426.0 21,636.0 1,202.8 918.4 1,082.8 52.4 28.5 147.4 204.3 310.4 610.3 1,553.4 3,491.5 7,888.6 18,056.6 1,029.1 846.4 749.8 37.0 19.8 117.0 143.7 259.6 545.1 1,192.7 2,911.5 6,833.0 16,744.8 United States Mortality Rates Female All ages, age adjusted All ages, crude Under 1 year 1-4 years 5-14 years 15-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75-84 years 85 years and over 1,236.0 823.5 2,854.6 126.7 48.9 89.1 142.7 290.3 641.5 1,404.8 3,333.2 8,399.6 19,194.7 750.9 812.0 855.7 41.0 19.3 49.0 74.2 137.9 342.7 878.8 1,991.2 4,883.1 14,274.3 721.8 850.4 613.9 29.5 14.6 42.6 66.0 148.2 316.8 754.0 1,890.8 4,760.5 14,429.9 the older ages, although notable differentials occur by sex and race. The higher mortality rate for younger black males compared to same-age-group white males is particularly startling; these data are discussed further later in this chapter in the discussion of specic causes of death. Data on differential mortality help to identify problems in society with regard to causes of illness and disease and barriers to access to health care services. Trends over time reect progress, or lack Remaining life expectancy in years At birth 1900 1950 1970 1990 2003 46.6 66.5 68.0 72.7 75.3 48.7 72.2 75.6 79.4 80.5 At 65 years 1950 1970 1990 2003 12.8 13.1 15.2 16.9 15.1 17.1 19.1 19.8 At 75 years 1990 2003 9.4 10.5 12.0 12.6 32.5 59.1 60.0 64.5 69.0 W I L 12.9 S 12.5 13.2 O 14.9 N , 8.6 9.8 33.5 62.9 68.3 73.6 76.1 14.9 15.7 17.2 18.5 11.2 12.4 Q U United States history, as reected in Table 3.9. At A age 65, the differentials continue to exist, but as for S the international comparisons, the differences are much more moderate, indicating that on a biologiH cal basis sex differences may be on the order of two E to three years. Black/white differentials are also quite moderate at this point. 1 9 Table 3.10 presents age-specic mortality rates for 9 the United States by selected demographic characteristics. These data conform to the life expectancy 7 numbers presented earlier. As expected, mortality B rates increase with age. The United States ageU specic mortality rates are relatively moderate until Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 54 thereof, in achieving our goals for a greater quality and quantity of life. Infant and Maternal Mortality An oft-quoted set of data is mortality experience for infants and mothers. Table 3.11 presents international data on infant mortality. Infant mortality is measured as the number of infants who die in the rst year of life per thousand live births. Related measures of mortality for infants include perinatal, postnatal, and other measures, all of which pertain W to the time period before or after delivery in which the fetal or infant death occurs. I Once again, the United States falls short in interL national comparisons of infant mortality. Hong Kong leads all nations in having the lowest infant S mortality rate. The relatively poor performance of the United States population is again a functionO of population heterogeneity and such factors as lack N of access to prenatal care; high fertility among , high-risk young women; poor maternal nutrition; genetic risks; and other complex social, economic, and physiological factors. Differential infant morQ tality among United States population subgroups U indicates that rates are substantially higher for blacks than for whites due to differences in access A to health care, nutrition, social factors, and other S variables that affect infant viability. These differences reect underlying social and economic H concerns faced by our society. Poor gestational E outcomes may result in huge social and economic costs. Implications of inadequate prenatal care, nutrition, and related factors also extend to serious 1 concerns of child intellectual development, social adaptation, and physical maintenance. 9 Maternal mortality, reected in Table 3.12, has 9 declined dramatically in the United States since 1950. In addition to the overall decline in these 7 rates, the reduction in maternal mortality for the B higher age groups is quite notable. Again, a very signicant differential exists U by race. Black women have experienced a signicant decline in maternal mortality since 1950, but they still have rates that are much higher than those of PART ONE Overview of the Health Services System Table 3.11. Infant Mortality Rates and Rankings: Selected Countries, 2002 Country Infant Deaths per 1,000 Live Births Australia Belgium Bulgaria Canada Chile Costa Rica Cuba Denmark England and Wales Finland France Germany Greece Hong Kong Hungary Ireland Israel Italy Japan Netherlands New Zealand Northern Ireland Norway Poland Puerto Rico Romania Russia Singapore Spain Sweden Switzerland United States 5.0 4.9 13.3 5.4 7.8 11.2 6.5 4.4 5.2 3.0 4.1 4.3 5.9 2.3 7.2 5.1 5.4 4.7 3.0 5.0 6.2 4.7 3.5 7.5 9.8 18.6 17.3 2.9 3.4 2.8 4.5 7.0 white women. The reductions in infant and maternal mortality discussed in this chapter represent a real success in our national efforts to improve the quality and quantity of life. But much remains to be done to achieve optimal results for all Americans and to fully invest in the future of our children. Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 3 Population and Disease Patterns and Trends Table 3.12. Maternal Mortality Rates for Complications of Pregnancy, Childbirth, and the Puerperium, According to Race and Age: United States, Selected Years Year (Deaths per 100,000 Live Births) Race and Age White All ages, age adjusted Under 20 years 20-24 years 25-29 years 30-34 years 35 years and over Black All ages, age adjusted Under 20 years 20-24 years 25-29 years 30-34 years 35 years and over 1950 53.1 44.9 35.7 45.0 75.9 174.1 1970 2003 14.4 13.8 8.4W 11.1I 18.7 59.3L S 65.5O 32.3 N 41.9 65.2, 117.8 207.5 Q 6.9 * 5.3 6.9 6.8 23.8 25.5 * 15.8 20.7 46.1 104.1 *Rates based on fewer than 20 deaths are considered unreliable and are not shown. U A S H SPECIFIC CAUSES OF E DEATH FOR THE U.S. POPULATION 1 Age-adjusted death rates for selected 9 causes of death for the U.S. population from 1950 to the 9 present are presented in Table 3.13. Heart disease, cancer, and stroke are, of course, the three leading 7 causes of death in the United States and have B been for quite some time. Interestingly, examinaU tion of equivalent data at the turn of the twentieth century would reveal a much greater prevalence of infectious as opposed to chronic diseases for the leading causes of death. Mortality attributable to 55 such causes as nephritis and tuberculosis, which accounted for many deaths at the turn of the century, is far less common today. Inuenza and pneumonia were also very important causes of death in the early 1900s. A dramatic outbreak of inuenza occurred in 1918, causing considerable mortality. Data on selected causes of death will be presented here in more detail. However, an examination of Table 3.13 reveals striking declines in mortality attributable to diseases of the heart, cerebralal vascular disease, and for some of the other major causes of death since 1950. Results for malignant neoplasms, however, are not comparable and reect the greater challenge faced by biomedical researchers in controlling and curing the ramications of the various types of cancer. Stretching further back into history, among the most important trends in disease patterns and causes of mortality since the early 1900s has been the shift from the predominance of infectious disease to chronic disease. In approximately the early 1920s, mortality from chronic diseases, such as heart disease, cancer, and stroke, overtook mortality from infectious diseases, such as pneumonia and inuenza, as the principal causes of mortality in the United States. Infectious disease mortality continued to decline throughout the remainder of the rst two-thirds of the twentieth century, but the resurgence of some infectious diseases such as AIDS have created an awareness that infectious disease is still an important and challenging arena in mortality. While the control of infectious disease has been one of the most signicant public health successes in the history of mankind, much of that success was attributable to improvements in living conditions and in the workplace as opposed to advances in biomedical research and clinical practice. Although the predominant challenges for mortality are now focused on chronic diseases, our nation must remain vigilant against outbreaks of infectious disease. Morbidity and mortality associated with the epidemic of human immunodeciency virus illustrate the constant threat of infectious disease that we face even today. In many Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART ONE Overview of the Health Services System 56 Table 3.13. Age-Adjusted Death Rates for Selected Causes of Death According to Sex: United States, Selected Years Sex 1950 1980 2003 Age-adjusted death rate per 100,000 population Male All causes Diseases of heart Ischemic heart disease Cerebrovascular diseases Malignant neoplasms Trachea, bronchus, and lung Colon, rectum, and anus Prostate Chronic lower respiratory diseases Inuenza and pneumonia Chronic liver disease and cirrhosis Diabetes mellitus Human immunodeciency virus (HIV) disease Unintentional injuries Motor vehicle-related injuries Suicide Homicide Female All causes Diseases of heart Ischemic heart disease Cerebrovascular diseases Malignant neoplasms Trachea, bronchus, and lung Colon, rectum, and anus Breast Chronic lower respiratory diseases Inuenza and pneumonia Chronic liver disease and cirrhosis Diabetes mellitus Human immunodeciency virus (HIV) disease Unintentional injuries Motor vehicle-related injuries Suicide Homicide W I L S O N , Q U A S H E 1 9 9 7 B U 1,674.2 697.0 186.4 208.1 24.6 28.6 55.0 15.0 18.8 101.8 38.5 21.2 7.9 1,348.1 538.9 459.7 102.2 271.2 85.2 32.8 32.8 49.9 42.1 21.3 18.1 69.0 33.6 19.9 16.6 994.3 286.6 209.9 54.1 233.3 71.7 22.9 26.5 52.3 26.1 13.0 28.9 7.1 51.8 21.6 18.0 9.4 1236.0 484.7 175.8 182.3 5.8 31.9 41.9 7.8 27.0 54.0 11.5 5.6 2.4 817.9 320.8 263.1 91.7 166.7 24.4 23.8 31.9 14.9 25.1 9.9 18.0 26.1 11.8 5.7 4.4 706.2 190.3 127.2 52.3 160.9 41.3 16.2 25.3 37.8 19.4 6.0 22.5 2.4 24.1 9.3 4.2 2.6 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 3 Population and Disease Patterns and Trends 57 Table 3.14. Leading Causes of Death and Numbers of Deaths, Selected Ages: United States, 2003 Age and Rank Order Under 1 year Cause of Death All causes Congenital malformations, deformations and chromosomal abnormalities Disorders related to short gestation and low birth weight, not elsewhere classied Sudden infant death syndrome Newborn affected by maternal complications of pregnancy Newborn affected by complications of placenta, cord, W and membranes Respiratory distress of newborn I Unintentional injuries Bacterial sepsisL newborn of Diseases of circulatory system S Neonatal hemorrhage O 5-14 years 25-44 years All causes N Unintentional injuries , Malignant neoplasms Congenital malformations, deformations, and chromosomal abnormalities Q Homicide Suicide U Diseases of heart A In situ neoplasms, benign neoplasms, and neoplasms of uncertain or unknown behavior S Chronic lower respiratory diseases H Inuenza and pneumonia Septicemia E All causes Unintentional injuries 1 Malignant neoplasms 9 Diseases of heart Suicide 9 Homicide 7 Human immunodeciency virus (HIV) disease Chronic liver disease and cirrhosis B Cerebrovascular diseases U Diabetes mellitus Inuenza and pneumonia Number of Deaths 28,025 5,621 4,849 2,162 1,710 1,099 831 945 772 591 649 6,954 2,618 1,076 386 324 250 264 79 118 147 77 130,761 29,307 19,250 16,850 11,667 7,626 6,928 3,378 3,043 2,706 1,365 (continued ) Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART ONE Overview of the Health Services System 58 Table 3.14. (continued) Age and Rank Order 65 years and over Cause of Death All causes Diseases of heart Malignant neoplasms Cerebrovascular diseases Chronic lower respiratory diseases Inuenza and pneumonia Diabetes mellitus Alzheimer's disease W Nephritis, nephritic syndrome and nephritis Unintentional injuries I Septicemia L S O developing countries, infectious disease remains a principal cause of mortality, particularly among the N very young and the very old. Such diseases as the , Ebola virus and other startlingly virulent infectious diseases could become a threat to developed nations' populations at any time. Increased internaQ tional mobility provides vectors of transmission for U infectious disease that were not common years ago. And, as if the challenges of chronic and infectious A disease were not enough, we now face the added S threat of biological weapons in the war against terror. Fear of biological agents, which we had long H considered conquered in the developed countries, E are with us again. Data for Specic Causes 1 Table 3.14 presents actual numbers of deaths for 9 selected subgroups and causes for the United 9 States population. The leading causes of death for each subgroup are listed. Although much more 7 extensive analysis is available, these data sets draB matically demonstrate the tragic involvement of U economic, social, and lifestyle f