Premature Mortality in West Virginia, 1978-1982

From 1978 through 1982, there was an average yearly total of 113,552 years of potential life lost (YPLL) by West Virginians who died before the age of 65*. Unintentional injuries, which accounted for 23.6% of the total, headed the list of causes, and were followed by heart diseases (15.5%), malignant neoplasms (13.8%), suicides/homicides (8.3%), and congenital anomalies (5.5%) (Table 1). Heart diseases, which ranked second in West Virginia, accounted for 12% more YPLL than malignant neoplasms (17,642 as compared with 15,691); whereas, in 1980, heart diseases ranked third nationally and accounted for 8% fewer YPLL than malignant neoplasms (1).

Males accounted for 65.8% of the total YPLL. The annual rate of YPLL among males was 8,783/100,000, in contrast with 4,526/100,000 among females (rate ratio = 1.9). Males had higher rates of YPLL than females for each of the leading causes except diabetes (RR = 1.0). Unintentional injuries (RR = 3.5), suicides/homicides (RR = 3.3), chronic liver diseases (RR = 3.1), heart diseases (RR = 2.7), and pneumonia and influenza (P&I) (RR = 1.8) showed the greatest male/female rate ratios. The rate of YPLL among nonwhites, who constitute only 3.8% of persons under 65 years of age in West Virginia, was 9,141/100,000, in contrast with 6,524/100,000 among whites (RR = 1.4).

Crude county-specific YPLL rates ranged from 4,124 to 10,678/100,000. In an analysis of the distribution of the YPLL rate, the state's 55 counties were ranked by individual YPLL rates and were then aggregated into population quartiles based on the percentage of the population that was under 65 years of age. The 19 counties with the highest YPLL rate contained 25.1% of the state's population under 65 years of age and constituted the upper population quartile. The combined crude YPLL rate for these counties was 8,041/100,000. The 13 counties with the lowest rates contained 24.3% of the state's population under 65 years of age and constituted the lower population quartile. These counties had a combined crude YPLL rate of 5,371/100,000. The remaining 23 counties contained 49.4% of the state's population under 65 years of age and constituted the two intermediate population quartiles; their combined crude YPLL rate was 6,543/100,000. Per capita income in the upper quartile counties was less ($5,376) than in the lower quartile counties and in the combined intermediate quartile counties ($6,339 and $6,422, respectively). Eighty-four percent of the population in the upper quartile were rural inhabitants; whereas, the lower and combined intermediate quartiles had 61% and 55% rural inhabitants respectively (Bureau of the Census, U.S. Department of Commerce, 1980 census of population (public use tapes)).

Standardized to the 1980 age, sex, and racial distribution of the United States, rates of YPLL in West Virginia were substantially above the national level for all causes combined (9%) and for 7 of the 12 leading causes: unintentional injuries (13%), heart diseases (29%), cerebrovascular diseases (7%), chronic liver diseases (5%), P&I (7%), chronic obstructive pulmonary diseases (COPD) (39%), and diabetes (29%) (Table 1). The standardized rate for all causes combined in the upper quartile alone was 32% above the national rate. In the intermediate quartiles, the rate was 6% higher than the national rate, and, in the lower quartile, it was 11% lower.

Standardized cause-specific YPLL rates were generally highest in the upper quartile and lowest in the lower quartile. As shown in Figure 1, these rates in the upper quartile were greater than the corresponding national rates for all leading causes except congenital anomalies and premature birth. YPLL rates in the lower quartile exceeded the national rates for heart diseases (11%), P&I (4%), COPD (24%), and diabetes (12%). The excess/deficit pattern observed for the intermediate quartiles was similar to that for the state as a whole. Reported by R Baron, Acting State Epidemiologist, R Hopkins, E Thoenen, L Haddy, A Holmes, T Leonard, C Bailey, Office of Epidemiology and Health Promotion, D Heydinger, State Health Director, West Virginia Dept of Health; Div of Field Svcs, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: YPLL has become an important means of quantifying premature mortality at the national level (2). The West Virginia Department of Health has prepared these analyses in order to provide statewide and county-specific reference levels for prioritizing health promotion and disease prevention strategies, for identifying counties with the greatest needs, and for tracking future progress.

In light of the national objective to reduce premature mortality by 1990 (3), YPLL rates that are above the national level for all causes of premature mortality combined and that are substantially higher that the national rates for 7 of the 12 leading causes represent an excessive public health burden in West Virginia. Sixty-one percent of West Virginians under the age of 65 live in counties where the crude rate for all causes combined is higher than the national rate. Standardized county-specific rates would have revealed an even greater proportion of the state's population living in counties with rates above the national level, since nonwhites, whose YPLL rates are considerably higher than those of whites, are underrepresented in West Virginia. The populations of most counties, however, are too small for meaningful county-to-county comparisons of directly adjusted rates or even of cause-specific crude rates. Aggregating counties into population quartiles emphasized the magnitude of premature mortality in 19 of the state's 55 counties. Moreover, excesses shown for certain cause-specific YPLL rates among counties constituting the lower quartile underscore how pervasive premature deaths from diabetes and cardiorespiratory conditions are throughout West Virginia.

Measures to reduce premature mortality will entail substantial behavioral, lifestyle, and environmental changes that require committed community and local health department efforts. By identifying individual counties that have high overall rates of YPLL or that belong to population groups with high rates from specific causes, the data can be used to direct and encourage such efforts. While environmental, occupational, and genetic factors also contribute to premature mortality, most causes are linked to one or more modifiable behaviors currently under surveillance in West Virginia: cigarette smoking, sedentary lifestyle, overeating, failure to control high blood pressure, nonuse of seat belts, and alcohol abuse (4). For each of the first five, West Virginia has one of the highest prevalence rates among states that participated in the 1984 and 1985 Behavioral Risk-Factor Surveillance programs (5,6). For alcohol abuse, West Virginia has one of the lower prevalence rates. The West Virginia Department of Health, in support of the 1990 Objectives for the Nation (3), is developing and encouraging programs to reduce these behaviors and lifestyles.

The group of counties with the highest rates of YPLL are the most rural and socioeconomically underpriviledged in the state, and, within these counties, rates for 10 of the 12 leading causes of premature death exceeded the national rates. To the extent that deaths from certain preexisting conditions may be postponed, the findings also raise the question of how much YPLL could be reduced by improved access and utilization of primary and secondary treatment facilities. Although prevention of the underlying conditions and their risk factors will continue to be the ultimate goal, the answer to this question may have important implications regarding allocation of funds for treatment centers and emergency medical services in West Virginia.

References

1. Division of Vital Statistics, National Center for Health Statistics. Vital statistics of the United States, 1980--volume II: mortality statistics for the United States and each state. Hyattsville, Maryland: National Center for Health Statistics, 1985.

2. CDC. Introduction to table V: premature deaths, monthly mortality, and monthly physician contacts--United States. MMWR 1982;31:109-10,117.

3. Public Health Service. Promoting health/preventing disease: objectives for the nation. Washington, DC: US Department of Health and Human Services, Public Health Service, 1980.

4. CDC. Ten leading causes of death in the United States, 1977. Atlanta, Georgia: Public Health Service, 1980.

5. CDC. Behavioral risk-factor surveillance--selected states, 1984. MMWR 1986;35:253-4.

6. CDC. Behavioral risk-factor surveillance in selected states, 1985. MMWR 1986;35:441-4. *Years of potential life lost before age 65 for persons dying in the 5-year period were derived from the number of deaths in each category (as reported by the Vital Registration Unit of the Health Statistics Center, Office of Epidemiology and Health Promotion, West Virginia Department of Health) multiplied by the difference between age 65 years and the age at which each individual death occurred. All infant deaths were considered to have occurred at 6 months of age.

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