Context The decrease in overall death rates in the United States may mask changes
in death rates from specific conditions.
Objective To examine temporal trends in the age-standardized death rates and in
the number of deaths from the 6 leading causes of death in the United States.
Design and Setting Analyses of vital statistics data on mortality in the United States
from 1970 to 2002.
Main Outcome Measure The age-standardized death rate and number of deaths (coded as underlying
cause) from each of the 6 leading causes of death: heart disease, stroke,
cancer, chronic obstructive pulmonary disease, accidents (ie, related to transportation
[motor vehicle, other land vehicles, and water, air, and space] and not related
to transportation [falls, fire, and accidental posioning]), and diabetes mellitus.
Results The age-standardized death rate (per 100 000 per year) from all
causes combined decreased from 1242 in 1970 to 845 in 2002. The largest percentage
decreases were in death rates from stroke (63%), heart disease (52%), and
accidents (41%). The largest absolute decreases in death rates were from heart
disease (262 deaths per 100 000), stroke (96 deaths per 100 000),
and accidents (26 deaths per 100 000).The death rate from all types of
cancer combined increased between 1970 and 1990 and then decreased through
2002, yielding a net decline of 2.7%. In contrast, death rates doubled from
chronic obstructive pulmonary disease over the entire time interval and increased
by 45% for diabetes since 1987. Despite decreases in age-standardized death
rates from 4 of the 6 leading causes of death, the absolute number of deaths
from these conditions continues to increase, although these deaths occur at
Conclusions The absolute number of deaths and age at death continue to increase
in the United States. These temporal trends have major implications for health
care and health care costs in an aging population.
Age-standardized death rates from all causes have decreased in the United
States since the 1960s1; however, the overall
trend masks substantial variations in cause-specific rates and in the number
of deaths occurring in different age groups from specific conditions. Understanding
these trends and the relationship between the age-standardized death rates
and the actual number of deaths that occur can provide valuable insight into
the forces that shape the nation’s health. We examined trends in death
rates and number of deaths from the 6 leading causes in the United States
and considered the relationship of these trends to disease prevention and
health care in an aging population.
Cause of death statistics in the United States are based on underlying
cause of death.1 The underlying cause is defined
as the disease or injury that initiated the sequence of events leading directly
to death. It is selected from the conditions entered in the cause of death
section on the death certificate by the certifying physician, coroner, or
medical examiner based on the sequence of morbid events and coding rules specified
by the International Classification of Diseases(ICD).2
Effective with data year 1968, computer software has been used by the
National Center for Health Statistics to determine the underlying cause of
death from information on all causes (multiple causes) listed on the death
For mortality statistics in the interval 1970 through 2002, underlying
causes of death were classified according to the ICD-8, ICD-9, and ICD-10 coding and selection
major causes of death grouped consistently across the ICD codes to facilitate evaluation of long-term trends.6 The ICD-10 codes used for the 6 leading causes of death were
I00-I09, I11, I13, and I20-I51 for heart disease; C00-C97 for cancer; I60-I69
for stroke (cerebrovascular disease); E10-E14 for diabetes mellitus; J40-J47
for chronic obstructive pulmonary disease (COPD); and V01-X59 and Y85-Y86
for accidents (ie, related to transportation [motor vehicle, other land vehicles,
and water, air, and space] and not related to transportation [falls, fire,
and accidental posioning]). The ICD-8 and the ICD-9 codes were 390-398, 402, 404, and 410-429 for heart
disease; 430-438 for stroke; 250 for diabetes mellitus; and 800-949 for accidents.
For cancer, the ICD-8 codes were 140-207 and the ICD-9 codes were 140-208, 238.6. For COPD, the ICD-8 codes were 490-493 and 519.3 and the ICD-9 codes were 490-496.
We calculated the age-standardized death rates (directly adjusted to
the 2000 US standard population) for all causes and the 6 leading causes of
death using SEER*Stat software, developed by the Surveillance, Epidemiology,
and End Results program of the National Cancer Institute.7,8 When
the 2002 death rate for a particular condition was lower than the 1970 rate,
the contribution of this decrease to the overall decrease in all-cause death
rates over the same time interval was expressed as a percentage. Trends in
age-standardized death rates from 1970 through 2002 for each of these conditions
were described using joinpoint regression analysis.9 The
joinpoint regression model fits a series of joined straight lines on a log
scale to the trends in age-adjusted rates. The terms increase or decrease were used when the slope (coefficient)
of the trend was statistically different from zero (2-sided P<.05); otherwise, the terms stable or level were used.
We also examined the leading causes of death in 2002 by age and temporal
trends in age-specific death rates and number of deaths from heart disease
and cancer for individuals aged 40 years or older by 10-year age intervals
from 1970 to 2002.
Between 1970 and 2002, the age-standardized death rate (per 100 000
population) from all causes combined decreased 32% from 1242.2 to 844.6 based
on the year 2000 age standard (Table).
Among the 6 leading causes of death (Table and Figure 1), the largest percentage decreases during
this interval were in the death rates from heart disease (52%), cerebrovascular
disease or stroke (63%), and accidents (41%). The absolute decrease was largest
for heart disease (262 deaths per 100 000) followed by stroke (96 deaths
per 100 000), accidents (26 deaths per 100 000), and cancer (5 deaths
per 100 000). The age-standardized death rate from all types of cancers
combined first increased from 1970 to 1990, and then decreased through 2002,
yielding a net decline of 2.7%. In contrast, death rates doubled since 1970
for COPD and increased by 45% since 1987 for diabetes mellitus (3% net increase
from 1970 to 2002).
When examined by joinpoint regression analysis, the decrease in heart
disease and cancer death rates continues, whereas the decrease in the mortality
rates from stroke and accidents has slowed or stopped since the early 1990s.
In 2002, the leading causes of death were heart disease among persons aged
75 years or older, cancer among persons aged 40 to 74 years, and accidents
among persons younger than age 40 years (Figure
Analysis of temporal trends in age-specific death rates from heart disease
and cancer shows that the decrease in the mortality rate from heart disease
(Figure 3, top panel) affects all age
groups containing individuals aged 40 years or older throughout the entire
time interval, whereas the decrease in age-specific death rates from all types
of cancer begins later and becomes smaller in proportionate terms with increasing
age (Figure 3, bottom panel).
A different perspective on the temporal trends in mortality from heart
disease and cancer is provided by data on the number of deaths that occur
from these conditions (Figure 4). Because
of the aging and growth of the population, the number of deaths attributed
to heart disease among persons aged 80 years or older (Figure 4, top panel) increased 60% from 1970 to 2002, even though
the age-standardized death rate decreased by 40% in this age group over the
same period (Figure 3, top panel). Figure 4 also illustrates the influence of the
baby boomer generation (born after World War II) as reflected in the pattern
of deaths due to heart disease and cancer in individuals aged 50 to 59 years.
A large increase in the number of individuals in this age group began in approximately
1990, resulting in an increase in the number of cancer deaths and flattening
rather than decreasing the number of deaths from heart disease.
This article provides a concise overview of trends in both age-standardized
death rates and numbers of deaths for the 6 leading causes of mortality in
the United States from 1970 to 2002, updating a similar analysis from 1950
to 1986.10 These findings illustrate the substantial
and continuing progress in reducing the age-standardized death rate from heart
disease, the lack of continuing progress for stroke and accidents, and the
increase in the age-standardized rates for COPD and diabetes. The study also
illustrates that the reduction in age-standardized death rates, the best measure
of progress against diseases, is not synonomous with reducing the number of
deaths from these conditions. In fact, the number of deaths continues to increase
because of population growth and aging. It is the number of individuals affected
by various conditions rather than the age-standardized rate that influence
the planning and allocation of preventive and medical services.
Inaccuracies in death certificates and changes in classification of
causes of death are potential limitations in the interpretation of mortality
trends. However, our analyses are restricted to broad disease categories for
which death certificate data are more accurate than for specific diseases.11 Although 2 revisions of the ICD have been implemented in the United States during the study period
(ICD-9 in 1979 and ICD-10 in
1999), there was only 1 significant discontinuity in these broad disease categories.
The ICD-8 codes developed by the World Health Organization
did not have a code for COPD without mention of asthma, bronchitis, or emphysema.
However, in 1970 the National Center for Health Statistics introduced a code
(519.3), used in the United States, for this category of diseases, allowing
comparability in classification of deaths due to COPD under ICD-8, ICD-9, and ICD-10.12 The effect of the changes in ICD rules on the 6 leading causes of death described herein
have been studied by calculating the comparability ratio based on the classification
of 1 year’s mortality data by both the new ICD codes
and the previous ICD codes. All comparability ratios
(the total number of deaths due to a specific cause under the new revision
divided by the total number of deaths under the previous revision) for the
cause of death categories described were between 0.99 and 1.06.12,13
Several important insights are suggested by these temporal trends in
the death rates and number of deaths at various ages. First, the decrease
in the age-standardized death rate for 4 of the 6 leading causes of death
in the United States represents progress toward one of the fundamental goals
of disease prevention by extending the number of years of potentially healthy
life. This progress has been greater for heart disease and for accidental
deaths than for cancer, yet even for cancer the age-standardized death rate
has been decreasing by 1.1% per year since 1993. Less favorable developments
are the slowing of the decline in age-standardized mortality rates from stroke
and accidents since the early 1990s, and the increase in death rates from
COPD and diabetes.
Several other countries have reported similar slowdowns in the decrease
in stroke mortality14; this is striking in
the face of a continuing decrease in age-standardized mortality from heart
disease. Analyses that differentiate subgroups of stroke mortality15 suggest that an increase in hemorrhagic (nonthrombotic,
nonembolic) stroke may be partly offsetting a continuing decrease in thrombotic
stroke. A likely explanation for this is increased use of aspirin and other
antithrombotic agents. The reduction in the death rate from accidents from
1970 through the early 1990s coincided with implementation of a 55-mph speed
limit during the first energy crisis in the 1970s and mandated use of seat
belts in most states16 beginning in 1984.17 The recent flattening of the accident mortality rate
coincides with the relaxation of the maximum interstate speed limits since
1987.18,19 The biphasic trend
in cancer mortality rates reflects both the impact of the tobacco epidemic
on tobacco-related cancers through 1990, followed by reduction in cancer mortality
through tobacco control and advances in early detection, in treatment, or
in both.20 The increase in COPD death rates
results largely from the long-term effects of tobacco smoking in an aging
population,21 whereas the increase in diabetes
mortality since the late 1980s reflects dramatic increases in obesity.22
A consequence of the large decrease in cardiovascular death rates, combined
with the high birth rates that immediately followed World War II, is the growing
importance of health and health care needs in an aging population. While improved
detection and treatment for chronic diseases has resulted in declining mortality
rates, it has also increased the prevalence of “treated disease”
and an associated increase in health care expenditures.23
Corresponding Author: Ahmedin Jemal, DVM,
PhD, Epidemiology and Surveillance Research, American Cancer Society, 1599
Clifton Rd, Atlanta, GA 30329 (firstname.lastname@example.org).
Author Contributions: Dr Jemal had full access
to all of the data in the study and takes responsibility for the integrity
of the data and the accuracy of the data analysis.
Study concept and design: Jemal.
Acquisition of data: Jemal.
Analysis and interpretation of data: Jemal,
Ward, Hao, Thun.
Drafting of the manuscript: Jemal.
Critical revision of the manuscript for important
intellectual content: Ward, Hao, Thun.
Statistical analysis: Jemal, Hao.
Study supervision: Ward, Thun.
Financial Disclosures: None reported.
Funding/Support: The American Cancer Society
funded the analysis, interpretation, compilation of cancer surveillance data.
Role of the Sponsor: Staff in the Epidemiology
and Surveillance Research Department of the American Cancer Society designed
and conducted the study, including analysis, interpretation, and presentation
of the manuscript. No staff at the American Cancer Society, other than the
study investigators, reviewed or approved the manuscript.
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