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

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

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

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

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

7. Dr. William Farr: 1807-83 Modern Vital Statistics Disease classification Creation of ICD in 1860 Public Health Division

9. Dr. John Snow: 1807-83 Modern Epidemiology Mapping of cholera deaths Public Health Division

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

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

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

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

14. 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

15. 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

16. Public Health Essential Services

17. 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

18. 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

19. Mortality Statistics Public Health Division

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

21. Causes of Death, Oregon 2011

22. Death Rates for Selected Diseases, Oregon, 1980-2005 ICD-9ICD-10

23. Cancer cases and deaths Oregon women, 2010

24. Cancer cases and deaths Oregon men, 2010

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

26. 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

27. Causes of Death/ Premature Death Oregon 2011

28. Mortality by Race/ Ethnicity: Oregon

29. Contributing Factors Public Health Division

30. Modifiable Factors assoc with Deaths U. S. 2000 Number of deaths

31. Behaviors that kill Oregonians Public Health Division

32. Tobacco Public Health Division

33. Cigarette smoking prevalence by year, Oregon 1996 – 2011

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

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

36. Alcohol Public Health Division

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

38. 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

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

40. Pandemic Influenza Public Health Division

41. Influenza Hospitalization Rates by Age & Sex; Oregon, 2009 80 60 40 20 Rates per 100,000 Age (yrs)

42. Influenza Death Rates by Age Oregon, 2009

43. Source: Oregon Immunization Program, Oregon Health Authority Influenza Immunization Rates, Oregon, 2013-2014

44. Birth Statistics Public Health Division

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

46. Teen Pregnancy Rates by Race / Ethnicity, 2010

47. Data on Birth Certificate to Inform Policy Tobacco use during pregnancy: –1990: 22%; 2012: 11% –Unmarried mothers age 20-24 yrs: 25% –Married mothers >40 yrs: 2% Receipt of prenatal care –Early: 76%; inadequate: 24%; no care: 1% Public Health Division

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

49. 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?

50. Oregon DWDA Prescriptions and Deaths Public Health Division

51. Participating Patients’ Underlying Illness: 1998-2013 Cancer591 (79%) ALS 54 (7%) Lung Disease 34 (5%) Heart Disease 14 (2%) Other 56 (7%)

52. DWDA Deaths by Age 0 10 20 30 40 50 60 70 18-3435-4445-5455-6465-7475-8485+ Age group (years) Rate per 10,000 deaths

53. DWDA by Education Rate RR (95% CI) <high school12.2 ref HS graduate22.5 1.9 (1.2-2.8) Some college42.5 3.5 (2.3-5.4) College grad82.0 6.7 (4.3-10.5) Advanced deg 115.6 9.5 (6.1-14.8) Public Health Division

54. 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

55. 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

56. 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

57. 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

58. Questions? Public Health Division