Life and Death Matters: Data for Public Health Policy Katrina Hedberg, MD, MPH Oregon State Epidemiologist June 9, 2014

“ The flip side of democracy is bureaucracy: if everyone counts, everyone must be counted.” Kathryn Schulz, New Yorker, April 7, 2014 Public Health Division

Recording Births and Deaths Historically realm of the church Birth: baptism, christening Death: burial and afterlife Public Health Division

Black Death in Europe 1350’s Italy: quarantine to track living England: track the dead Public Health Division

Causes of Death 1500’s: Bill of Mortality periodically published 1600’s: –Weekly –Deaths other than plague Public Health Division

Dr. William Farr: Modern Vital Statistics Disease classification Creation of ICD in 1860 Public Health Division

Dr. John Snow: Modern Epidemiology Mapping of cholera deaths Public Health Division

Deaths from Cholera, London 1850’s Miasma theory Focused around the Broad Street Pump Water intake from the Thames Public Health Division

The Broad Street Pump Removing pump handle decreased cholera cases Public Health Division

Birth Certificates Documentation of birth: Ancient China, Egypt, Greece, Rome, Persia Purpose: taxation, military service Public Health Division

Types of Vital Record Data Birth Death Marriages; divorce Domestic partnership; dissolution Fetal death; induced abortion Other? Surveys… Public Health Division

Vital Records: Dual Purpose Legal documents –Birth: document age, nationality for school, health care, job, marriage, driver’s license, etc –Death: settling the estate after death Health Status of the population –Birth: trends; prenatal care; etc –Death: causes; contributing factors Public Health Division

Vital Records: Competing Issues Legal documents –Privacy; identify theft; access to public services Health Statistics –Complete picture –Accurate data –Timely data Focus on Vital Statistics for Public Health

Public Health Essential Services

Vital Statistics & Public Health Monitor Health: trends in births, deaths Diagnose and Investigate: work with ME’s; data on contributing factors Inform, educate: issue annual reports/ briefs Mobilize partnerships: funeral directors; licensing boards Develop plans, policies: provide data to target appropriate interventions

Vital Statistics & Public Health (2) Enforce laws: Real ID Act; same-sex marriage Link people to service: data for Medicaid; paternity determination Assure competent workforce: vital stats basics for epidemiologists Evaluate effectiveness/ health services quality: prenatal care; tobacco use Research innovative solutions: death with dignity, out-of-hospital births

Mortality Statistics Public Health Division

Leading Causes of Death 2000 heart disease cancer stroke lung disease diabetes 1900 pneumonia influenza tuberculosis Public Health Division

Causes of Death, Oregon 2011

Death Rates for Selected Diseases, Oregon, ICD-9ICD-10

Cancer cases and deaths Oregon women, 2010

Cancer cases and deaths Oregon men, 2010

Motor Vehicle Occupant and Opioid Overdose Deaths Deaths per 100,000 population

Drug Overdose Policies Providers: education; dosing guidelines Patients: screening; monitoring; education; storage Regulatory: Board of Pharmacy, DEA E-prescribing; FDA black box warnings Law Enforcement ( diversion) Drug take-back Public Health Naloxone for overdoses; Prescription Drug Monitoring Programs Public Health Division

Causes of Death/ Premature Death Oregon 2011

Mortality by Race/ Ethnicity: Oregon

Contributing Factors Public Health Division

Modifiable Factors assoc with Deaths U. S Number of deaths

Behaviors that kill Oregonians Public Health Division

Tobacco Public Health Division

Cigarette smoking prevalence by year, Oregon 1996 – 2011

Smoking-Attributable Deaths Oregon Rate per 100,000 Public Health Division

Tobacco Control: Community Interventions Limit access − Vending machines − Placement of cigarettes Cost: taxes Smoke-free air policies Media Public Health Division

Alcohol Public Health Division

Binge Drinking in Adults by Age; Oregon, 2011 Public Health Division

Alcohol-related deaths, by age group, Oregon, 2011Alcohol-related deaths, by age group, Oregon, 2011Alcohol-related deaths, by age group, Oregon, 2011Alcohol-related deaths, by age group, Oregon, 2011

Alcohol Policies Dram shop liability Limiting hours of sale Regulate outlet density Increase price Enhanced enforcement prohibiting sales to minors No privatization of sales

Pandemic Influenza Public Health Division

Influenza Hospitalization Rates by Age & Sex; Oregon, Rates per 100,000 Age (yrs)

Influenza Death Rates by Age Oregon, 2009

Source: Oregon Immunization Program, Oregon Health Authority Influenza Immunization Rates, Oregon,

Birth Statistics Public Health Division

Oregon Teen Pregnancy (15-17 yrs) Rate per 1,000 females Public Health Division

Teen Pregnancy Rates by Race / Ethnicity, 2010

Data on Birth Certificate to Inform Policy Tobacco use during pregnancy: –1990: 22%; 2012: 11% –Unmarried mothers age yrs: 25% –Married mothers >40 yrs: 2% Receipt of prenatal care –Early: 76%; inadequate: 24%; no care: 1% Public Health Division

Objective Data to Inform Societal Debates Death with Dignity Out-of-hospital Births Public Health Division

Oregon’s Death with Dignity Act Citizens' initiative, passed in 1994, 1997 Allows: terminally-ill Oregonians; prescription for lethal dose of meds; self- administered Public Health Division: monitor / report participation Debate: who chooses DWDA? poor? less-educated?

Oregon DWDA Prescriptions and Deaths Public Health Division

Participating Patients’ Underlying Illness: Cancer591 (79%) ALS 54 (7%) Lung Disease 34 (5%) Heart Disease 14 (2%) Other 56 (7%)

DWDA Deaths by Age Age group (years) Rate per 10,000 deaths

DWDA by Education Rate RR (95% CI) <high school12.2 ref HS graduate ( ) Some college ( ) College grad ( ) Advanced deg ( ) Public Health Division

Oregon Out-of Hospital Births 2011 Oregon Law –Amend Birth Certificate to include planned birth place and attendant –Report annually During 2012 –42,011 live term births in Oregon; 2,021 (4.8%) planned OOH –19% of planned OOH delivered in hospital Public Health Division

OOH Birth: Maternal Characteristics Older >30 yrs(57% vs 43%) White, non-Hispanic (88% vs 68%) Married (82% vs 64%) College-educated (46% vs 29%) Self-pay delivery (28% vs 1%) Less overweight(32% vs 49%) Less smoking (2% vs 11%) Public Health Division

Term Fetal & Early Neonatal Deaths 8 late term deaths in planned OOH: –rate 4.0/1,000 pregnancies vs 2.1/1,000 6 of 8 did not meet low-risk criteria: –>42 weeks gestation (4) –Twin gestation (2) –Morbid obesity (1) Public Health Division

Future Directions Electronic birth and death certificates: –Fast data for outbreak detection Health Information Exchange: –Interoperability with electronic health records Flagging rare causes of death: –Automatic notification for preparedness/ epidemiology Public Health Accreditation: –Surveillance/ monitoring health status

Questions? Public Health Division