Vital Statistics: What is Our Future?

1. Vital Statistics: What is Our Future? Centers for Disease Control and Prevention National Center for Health Statistics

2. Before we get to the future let’s revisit the past

3. Early History– Egypt, Greece, and Rome Gathered through a census for revenue and military purposes

4. Early History • Ecclesiastical registration • With the advent of the modern nation state came - Civil registration

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

6. English and Colonial HistoryMortality Surveillance • 1662–The Bills of Mortality (John Graunt) • 1721–Use of burial records by Cotton Mather to demonstrate effects of smallpox

7. Examples of Diseases Listed in Graunt’s 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

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

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

10. 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

11. 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 Alzheimer’s Disease Influenza & Pneumonia (61k) Population approx 290 million Leading Causes NOTE: Prior to 1933, data are for death-registration States only. 2004 -Preliminary

12. 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.

13. 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

14. 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.

15. 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

16. 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?

17. How can we build on our past successes for a new beginning?To measure what is and not just what was?

18. 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

19. The futureIs it really all about EDR’s and EBR’s?Yes … but …What about how we currently do business internally?

20. It certainly begins with EBR’s and EDR’s • From a statistical perspective EBR’s and EDR’s give us the potential for higher quality and more timely data • If EBR’s and EDR’s 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.

21. 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.

22. What are some things to consider if we get back into the surveillance game?How do we get ready?

23. 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?

24. 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?

25. 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 NCHS’s role?

26. What is NCHS planning? • We need to take advantage of improved timeliness of States using EBR’s and EDR’s • 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.

27. 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

28. 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?

29. 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?

30. 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

31. 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?

32. Is this really the time? • Don’t 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