Diabetes Mortality Data Trends, California 2000-2008
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At a Glance
- Diabetes was California’s seventh leading cause of death for each year from 2000 through 2008.
- The age-adjusted diabetes death rate was lower in California than the United States for every year from 2000 through 2007.
- The age-adjusted diabetes death rate for California ranged from 20.6 to 23.0 during this period. The 2008 rate of 20.6 was the lowest in the nine years studied in this report.
- Decreasing trends were seen in Hispanics overall and Hispanic females specifically. These two groups were the only sex or race/ethnic groups that demonstrated statistically significant trends.
- Decreasing diabetes death trends were observed in San Francisco, Shasta, and Ventura counties.
- Increasing trends occurred in Santa Clara, and Solano counties.
- Higher age-adjusted diabetes mortality rates were seen in men than women throughout the study period.
- The highest age-adjusted mortality rates among race/ethnic groups were observed in Blacks.
- Half of all diabetes deaths during this time occurred to persons aged 75 and older.
This report was authored by Loran Sheley, MA, Research Program Specialist. Please contact PDATrends@cdph.ca.gov for further information.
Diabetes was California’s seventh leading cause of death for the years 2000 through 2008 and the seventh leading cause of death nationally in 20071, the most recent year for which national data is available.
Diabetes disproportionately affects minority populations and the elderly, and its incidence is likely to increase as minority populations grow and the U.S. population becomes older.2 The burden of disease and economic cost of diabetes to society is significant. Diabetes can have a harmful effect on most of the body’s organ systems. Most non-traumatic lower-extremity amputations occur in persons with diabetes. Diabetes is the leading cause of kidney failure and onset of blindness in adults aged 20-74 years. Persons with diabetes are at increased risk for heart disease and stroke, and their overall risk of death is approximately twice that of similarly aged people without diabetes. In economic terms, the direct medical expenditures attributable to diabetes in 2007 have been estimated at $116 billion, or about 2.3 times higher on average than the estimated costs for people without diabetes.3
This report examines mortality trends for the California resident population over the period 2000 through 2008, and presents data in five major sections. The first section discusses diabetes mortality for the total California resident population. The second section analyzes male and female populations separately. The third section describes differences in diabetes mortality by race/ethnic groups. Sex differences within race/ethnic groups are discussed in the fourth section. Each of these sections includes information about the numbers and age distributions for diabetes deaths and mortality trends over time. The final section reviews trends in diabetes mortality by county of residence and includes trend charts for each county.
Detailed tables are also provided. Table 1a (PDF), Table 1b (PDF), and Table 1c (PDF) show 2000 to 2008 California resident diabetes deaths by age and race/ethnicity for both sexes combined, males, and females, respectively. Table 2a (PDF), Table 2b (PDF), and Table 2c (PDF) display diabetes death rates for the same period. Table 3 (PDF) provides age-adjusted death rates and 95% confidence intervals. Table 4 (PDF), Table 5 (PDF), and Table 6 (PDF) provide diabetes deaths, age-adjusted death rates, and 95% confidence intervals by county of residence.
Information about rate calculation and trend analysis is located in the Technical Notes.
Use of Underlying Cause of Death and Limitations
The definition of diabetes used in this report is based on the International Classification of Diseases, Tenth Revision (ICD-10) codes E10-E14. For the purposes of this report, deaths are coded to E10-E14 only when diabetes is identified as the underlying cause of death. More information about cause of death is located in the technical notes. The U.S. Department of Health and Human Services has established a number of health objectives pertaining to diabetes. However, these objectives are based on both underlying and contributing causes of diabetes deaths rather than underlying cause only.4 Therefore, California’s progress in meeting the HP 2010 national objectives for diabetes is not addressed in this report.
There are some limitations to using underlying cause to tabulate diabetes deaths. When analysis is based on deaths with any mention of diabetes on the death certificate, the number of diabetes-related deaths increases greatly. Diabetes has been found to be about three times more likely to be reported as a contributing rather than underlying cause of death in California.
On the other hand, heart disease and cerebrovascular disease were slightly more likely to be listed as the underlying cause than as contributing causes, and cancer was about six times more likely to be listed as the underlying cause than as a contributing cause of death.5 In 2008, there were 7,349 deaths in California with diabetes listed as the underlying cause on the death certificate, but there were 21,362 deaths with diabetes listed elsewhere on the certificate.
California Total Population
Diabetes was California’s seventh leading cause of death from 2000 through 2008 and the seventh leading cause of death nationally in 2007, the most recent year for which national data is available.
The age-adjusted diabetes death rate was lower in California than the United States each year from 2000 through 2007. National-level data is not available for 2008. The chart below displays California’s age-adjusted death rates for 2000 through 2008, compared with the available United States rates.
California’s age-adjusted diabetes death rate ranged from 20.6 to 23.0 between 2000 and 2008 and has decreased for the last three consecutive years. The 2008 rate of 20.6 was the lowest during the nine years studied. There was no statistically significant trend over the entire period. Annual age-adjusted death rates are shown in Table 3 (PDF).
There were 63,440 diabetes deaths in California from 2000 through 2008. This represented 3.0 percent of all California deaths during the same period. The average age of death due to diabetes for the California population was 72.1 years.
Diabetes primarily affects older people. Fifty percent of diabetes deaths during this time occurred to people aged 75 and older, and when people aged 65 to 74 were included it rose to over 70 percent.
The chart below shows the age distribution of diabetes deaths for all California residents.
The risk of dying from diabetes increases with age. The minimum and maximum annual age specific death rates for 2000 through 2008 and age groups that had reliable rates during each study year were as follows:
• 25-34 years (0.9, 1.4)
• 35-44 years (3.1, 3.9)
• 45-54 years (10.3, 12.8)
• 55-64 years (30.1, 34.0)
• 65-74 years (70.7, 84.1)
• 75-84 years (153.3, 168.4)
• 85+ years (238.2, 285.6)
Annual age-specific diabetes death rates for the California population are displayed in Table 2a (PDF).
During this period, the actual risk of dying (or crude death rate) from diabetes ranged from 18.2 to 20.8 per 100,000 population. Annual diabetes crude death rates for the California population are displayed in Table 2a (PDF) under the “All Ages” column.
See the Technical Notes for information about rate calculation and trend analysis.
Male and Female Populations
Although diabetes was the seventh leading cause of death for the California population as a whole in 2008, it was the sixth leading cause for males and females when these groups were examined separately.
The chart below presents 2000 through 2008 age-adjusted death rates for California residents by sex.
The diabetes age-adjusted death rate was lower for women than men during every year over the study period. The age-adjusted diabetes death rate for men ranged from 23.8 to 26.9, and the rate for women ranged from 17.7 to 19.9. The age-adjusted rates for both males and females have decreased for the last three consecutive years. There was no statistically significant trend over the entire study period for either males or females. Annual diabetes age-adjusted death rates are shown in Table 3 (PDF).
Of California’s 63,440 total diabetes deaths from 2000 through 2008, the proportion was about half between males and females (31,692 deaths in males; 31,748 deaths in females).
The average age of death due to diabetes during this time was 70.1 years for men and 74.0 years for women. This means that, on average, men died almost four years earlier from diabetes than women.
Although most diabetes deaths occurred to persons over age 65 in both sexes, the proportion of deaths that occurred to people under age 65 was larger for males. Approximately 31.9 percent of male diabetes deaths occurred to men under age 65 compared to 22.5 percent of female diabetes deaths in that age group.
The chart below shows the age distribution of diabetes deaths by sex.
The risk of dying from diabetes increases with age. Age-specific death rates for both males and females were higher in older age groups. Annual age-specific diabetes death rates are displayed in Table 2b (PDF) for males and Table 2c (PDF) for females.
During the period, the actual risk of dying (or crude death rate) from diabetes ranged from 17.7 to 21.1 deaths per 100,000 population for males. The female rate ranged from 18.6 to 20.5. Annual diabetes crude death rates are displayed in Table 2b (PDF) for males and Table 2c (PDF) for females under the “All Ages” column.
See the Technical Notes for information about rate calculation and trend analysis.
Race/Ethnic Group Differences
Diabetes affects race/ethnic groups differently, and the rank of diabetes as a leading cause of death varied among groups. In 2008, diabetes was the:
• Fourth leading cause of death among Asians, Blacks, and Pacific Islanders.
• Fifth leading cause of death among Hispanics.
• Sixth leading cause of death for Two or More Races.
• Seventh leading cause of death among American Indians.
• Eighth leading cause of death for Whites.
The chart below displays age-adjusted death rates by race/ethnicity for the years 2000 to 2008.
The diabetes age-adjusted death rate was consistently higher for Blacks than all other race/ethnic groups. Whites and Asians had the lowest age-adjusted death rates for diabetes over the period, while the rates for American Indians and Hispanics were in the middle. Between 2000 and 2008, the age-adjusted diabetes death rates ranged from 22.0 to 37.1 for American Indians, 16.6 to 19.0 for Asians, 44.1 to 49.9 for Blacks, 30.1 to 36.5 for Hispanics, and 16.7 to 18.6 for Whites.
Hispanics were the only race/ethnic group that exhibited a statistically significant trend during the period, a slight downward trend.
Annual diabetes age-adjusted death rates are shown in Table 3 (PDF). Rates for Pacific Islanders and Two or More Races were unreliable during one or more years in the study, so their rates are not discussed here. However, the rates are displayed in Table 3 (PDF).
There were differences in the average age of diabetes death among race/ethnic groups. For example, Pacific Islanders died an average of more than 10 years earlier from diabetes than Asians. The average age of death due to diabetes between 2000 and 2008 was:
• 64.6 years for Pacific Islanders.
• 65.1 years for Two or More Races.
• 67.1 years for American Indians.
• 68.2 years for Blacks.
• 69.6 years for Hispanics.
• 73.8 years for Whites.
• 74.7 years for Asians.
More than half of diabetes deaths between 2000 and 2008 occurred to persons over age 65 in all race/ethnic groups. However, the percentage of deaths that occurred to people under age 65 varied by race/ethnicity, and some groups experienced more deaths at younger ages than other groups. Specifically, the proportion of diabetes deaths before age 65 was:
• More than 40 percent among Pacific Islanders and Two or More Races.
• Between 30 and 40 percent among American Indians, Blacks, and Hispanics.
• Less than 30 percent among Asians and Whites.
The chart below shows the age distribution of diabetes deaths by race/ethnicity.
The risk of dying from diabetes increases with age. Age-specific death rates for all race/ethnic groups were higher in older age groups. Annual age-specific diabetes death rates by race/ethnic group are displayed in Table 2a (PDF).
During the period, the actual risk of dying per 100,000 population, or crude death rate, ranged for race/ethnic/groups were as follows:
• American Indians, 18.9 to 29.4
• Asians, 12.0 to 16.6
• Blacks, 31.5 to 38.6
• Hispanics, 13.1 to 15.7
• Whites, 21.7 to 24.2
Pacific Islanders and Two or More Races had unreliable crude death rates during one or more years of the study period and, therefore, are not included above. Annual diabetes crude death rates by race/ethnic group are displayed in Table 2a (PDF) under the “All Ages” column.
See the Technical Notes for information about rate calculation and trend analysis.
Sex Differences Within Race/Ethnic Groups
There are sex differences in diabetes mortality within race/ethnic groups, as is the case with the population overall. In 2008, diabetes was the:
• Seventh leading cause of death for American Indian men and the fifth leading cause for American Indian women.
• Sixth leading cause for Asian males and the fifth leading cause for Asian females.
• Sixth leading cause for Black males and the fourth leading cause for Black females.
• Sixth leading cause for Hispanic males and the fourth leading cause for Hispanic females.
• Fourth leading cause for Pacific Islander males and females.
• Ninth leading cause for males of Two or More Races and the sixth leading cause for females of Two or More Races.
• Ninth leading cause for White males and the eighth leading cause for White females.
The chart below displays age-adjusted death rates by sex and race/ethnicity for the years 2000 through 2008.
The diabetes age-adjusted death rates were generally higher for females than males within the same race/ethnic group. Black males had the highest age-adjusted rates among males, and Black females had the highest rates among females. Whites and Asians had the lowest age-adjusted diabetes death rates over the period for both males and females.
Hispanic females demonstrated a downward trend and were the only sex and race/ethnic group to exhibit a statistically significant trend during the study.
Annual diabetes age-adjusted death rates by sex and race/ethnicity are shown in Table 3 (PDF). Rates for Pacific Islanders, Two or More Races and American Indian males were unreliable during one or more years in the study and, therefore, their rates are not discussed. However, the rates are displayed in Table 3 (PDF).
On average, men died earlier from diabetes than women in all race/ethnic groups. Men of Two or More Races had the lowest average age of diabetes death and died an average of nearly 15 years earlier than Asian women, the longest surviving group. The average ages of diabetes death by sex and race/ethnicity for 2000 through 2008 were as follows:
• American Indian: males 65.1 years, females 68.9 years
• Asian: males 72.1 years, females 77.1 years
• Black: males 65.8 years, females 70.2 years
• Hispanic: males 67.5 years, females 71.8 years
• Pacific Islander: males 63.0 years, females 66.3 years
• Two or More Races: males 62.5 years, females 67.2 years
• White: males 72.0 years, females 75.7 years
The percentage of deaths that occurred to people under age 65 varied, and some groups experienced more deaths at younger ages than other groups. Specifically, the proportion of diabetes deaths before age 65 was:
• More than 50 percent among Pacific Islander males and males of Two or More Races.
• Between 40 and 50 percent among Black males, American Indian males, Pacific Islander females, and females of Two or More Races.
• Between 30 and 40 percent among Hispanic males, American Indian females, and Black females.
• Less than 30 percent among Asian males and females, White males and females, and Hispanic females.
The charts below show the age distribution of diabetes deaths by sex and race/ethnicity.
The risk of dying from diabetes increases with age. Age-specific death rates for all race/ethnic categories grouped by sex were higher in older age groups. Annual age-specific diabetes death rates by sex and race/ethnic group are displayed in Table 2b (PDF) for males and Table 2c (PDF) for females.
Annual diabetes crude death rates by sex and race/ethnic group are also presented in Table 2b (PDF) for males and Table 2c (PDF) for females under the “All Ages” column.
See the Technical Notes for information about rate calculation and trend analysis.
County of Residence Populations
Thirty-four California counties had reliable age-adjusted diabetes death rates every year from 2000 through 2008. Kings County had the highest average diabetes death rate during the nine-year period, and Marin County had the lowest average rate over the entire period.
Refer to Table 4 (PDF), Table 5 (PDF), and Table 6 (PDF) for detailed counts of deaths, age-adjusted rates, and 95 percent confidence intervals by county of residence. Trend charts showing age-adjusted diabetes death rates by county are accessible through the links provided below.
Of the counties that had reliable rates for every year during the study period, six had statistically significant trends in the diabetes death rate over time. San Francisco, Shasta, and Ventura counties showed significant decreasing trends, and Kern, Santa Clara, and Solano had significant increasing trends.
Twenty-eight counties exhibited rates that were reliable each year but did not show statistically significant trends.
Twenty-four counties had rates that were unreliable or no events during one or more of the years studied. Graphs are provided for these counties, but no trend analysis was conducted. This information should be interpreted with caution.
See the Technical Notes for information about rate calculation and trend analysis. A map of California is located here.
Number of Events – The number of events provides a description of how a disease affects a population, but it is not useful for examining trends or comparison across groups because the number of events largely depends on population size.6
Crude Rates, Age-Specific Rates, and Age-Adjusted Rates – The crude death rate (number of deaths per population size) is a widely used mortality measure.6 This rate represents the average chance of dying during a specified period for persons in the entire population. However, crude death rates are influenced by the age distribution of the population. As such, crude death rate comparisons over time or between groups may be misleading if the populations being compared differ in age composition.
The age specific death rate is defined as the number of deaths occurring in a specified age group divided by the population for the specified age group, usually expressed per 100,000 population. Age-specific death rates allow one to compare mortality risks of a particular age group over time or between age groups at a particular point in time. Although effective in eliminating the effect of differences in age composition, age-specific comparisons can be cumbersome, because they require a relatively large number of comparisons, one for each age group.7
To control for the effect of age on death rates and provide a single measure, age-adjusted death rates are used.6 Age-adjusted rates are computed by separating deaths into their respective age groups based on the age of the decedent, and computing age-specific rates. These age-specific rates are then weighted according to the 2000 U.S. Standard Population, and are summed to produce the age-adjusted rate. Age-adjusted death rates are highly effective for making comparisons among population groups and among geographical areas because they remove the effects of dissimilar age distributions.
Three important caveats apply when using age-adjusted rates. First, the age-adjusted death rate does not reflect the mortality risk of a “real” population. The actual risk of mortality is represented by the crude death rate. The numerical value of an age-adjusted death rate depends on the standard used and, as a result, is not meaningful by itself. Age-adjusted death rates are appropriate only when comparing groups or examining trends across multiple time periods. A comparison of age-adjusted death rates among groups or periods over time will reflect differences in the average risk of mortality.
Second, age adjusting may mask important information if the age-specific rates between comparison groups do not have a consistent relationship. As an example, Anderson and Rosenberg (1998)6 demonstrate that the trend in the age-adjusted death rate for cancer does not reflect the complexities in the underlying age-specific rates. As averages, age-adjusted rates, like other averages, may be misleading, especially when age-specific rates reflect divergent trends over time. However, usually age-specific rates move roughly in parallel. Thus, age-adjusted death rates are a widely accepted and useful convention for analyzing trends.
Finally, because age-adjusted death rates are averages, they represent merely the beginning of an analytical strategy that should proceed to age-specific analyses, and then to an examination of additional sociodemographic, temporal, and geographic variables.
Data Sources – Numerator data are taken from California Department of Public Health death records, and denominator population data are obtained from the Department of Finance “Race/Ethnic Population Estimates with Age and Sex Detail, July 2007”. The 2000 U.S. Standard Population was used for calculating age-adjustments in accordance with statistical policy implemented by NCHS.6 Age-adjusted death rates are not comparable when rates are calculated with different population standards, e.g., the 1940 U.S. Standard Population.
Variability of Rates – Rates are sensitive to size variations in both the numerator (the number of vital events that occurred) and the denominator (the estimated population at risk). For example, in small counties a numerator variation of only a few cases might cause a relatively large shift in a rate, while in a large county could cause no difference in the rate. Likewise, a minor revision in a small county population estimate may cause a relatively major change in a county’s vital event rate. Therefore, caution needs to be exercised when analyzing small numbers, including the rates derived from them.
Rates that are calculated from fewer than 20 deaths are considered unreliable (Tables 2a-2c). These rates are not shown, and are indicated with an asterisk (*). Unreliable age-adjusted rates by race/ethnicity and sex (Table 3) and county of residence (Table 5), are displayed with an asterisk (*) and are provided only as a point of information for further investigation. Rates based on no events are denoted with a dash (-).
Sampling Error and Vital Statistics – Vital events are essentially a complete count, because more than 99 percent of all vital events are registered. Although these numbers are not subject to sampling error, they may be affected by nonsampling errors in the registration process.
The number of vital events is subject to random variation and a probable range of values can be estimated from the actual figures, according to certain statistical assumptions. This is because the number of vital events that actually occurred can be thought of as one outcome in a large series of possible results that could have occurred under the same (or similar) circumstances.
A 95 percent confidence interval is the range of values for a measurement that would be expected in 95 out of 100 cases. The confidence intervals are the highest and lowest values of the range. Confidence intervals tell you how much a measurement could vary under the same (or similar) circumstances.
Confidence intervals based on 100 deaths or more – When there were 100 deaths or more, a normal approximation was used to calculate confidence intervals.
Confidence intervals based on fewer than 100 deaths – When there were fewer than 100 deaths, a gamma distribution was used to calculate confidence intervals.
Detailed procedures and examples for each type of calculation are given in Technical Notes of Deaths: Final Data for 2006; National Vital Statistics Reports; National Center for Health Statistics, 2009.8
Cause of Death – One of the most important uses for vital statistics data is the study of trends by cause of death. Vital statistics trend research yields valuable information about population health status, emerging public health problems, and at-risk populations, and can be used to develop strategies and allocate resources to improve public health.
Cause-of-death statistics are derived from the medical information reported on the
death certificate by the certifying physician or coroner. The medical portion of the death certificate has fields for up to four causes of death (immediate, two intervening, and underlying) plus additional fields for recording contributing causes of death. Up to 20 causes can be entered onto a single death certificate. The cause-of-death field selected for coding and tabulation in this report is the "underlying cause of death." This is generally defined as the disease, injury, or complication that initiated the morbid events sequence leading directly to death.
Deaths by Place of Residence – Mortality data analysis in this report are based on records for all California resident deaths occurring in the fifty states, the District of Columbia, US territories, and Canada; all other worldwide resident deaths are excluded. Deaths to non-California residents were excluded from analysis.
Age Groups – The following age groups were used to compute age-specific and age-adjusted rates: under 1 year, 1-4 years, 5-14 years, 15-24 years, 25-34 years, 35-44 years, 45-54 years, 55-64 years, 65-74 years, 75-84 years, and 85 and older.
International Classification of Diseases, Tenth Revision (ICD-10) – Beginning in 1999, cause of death has been coded using ICD-10.9 For more information, see the National Center for Health Statistics ICD-10 page.
Race/Ethnicity – Beginning in 2000, the federal race/ethnicity reporting guidelines changed to allow more than one race to be recorded on death certificates. California initiated use of the new guidelines on January 1, 2000, and collects up to three races per certificate. To be consistent with population data, current reports tabulate race of decedent using all races identified on the certificate.
To meet the U.S. Office of Management and Budget minimum standards for race and ethnicity data collection and reporting, and to be consistent with the population data obtained from the Department of Finance, this report presents Hispanic and the following non-Hispanic race/ethnic groups: American Indian, Asian, Black, Pacific Islander, White, and Two or More Races. Hispanic origin of decedents is determined first and includes decedents of any race group or groups. Non-Hispanic decedents who were reported with two or more races are subsequently placed in the Two or More Races group. Single non-Hispanic race groups are defined as follows: the “American Indian” race group includes Aleut, American Indian, and Eskimo; the “Asian” race group includes Asian Indian, Asian (specified/unspecified), Cambodian, Chinese, Filipino, Hmong, Japanese, Korean, Laotian, Thai, and Vietnamese; the “Pacific Islander” race group includes Guamanian, Hawaiian, Samoan, and Other Pacific Islander; the “White” race group includes White, Other (specified), Not Stated, and Unknown.
Caution should be exercised in the interpretation of mortality data by race/ethnicity. Misclassification of race/ethnicity on death certificates may contribute to underreporting of deaths in American Indians, Asians, Hispanics, and Pacific Islanders.10 This could contribute to artificially low rates for these groups and the Two or More Races group. Race groups’ data that are not individually displayed on the tables or figures due to unreliable rates are collectively included the state data totals.
Trend Analysis – In this report, linear regression was performed to establish the presence of statistically significant trends over the period examined. The trends identified in the report as statistically significant are those for which an F test yielded a p-value less than or equal to 0.05 and had R-square values greater than 0.50 unless otherwise specified. Trend analyses were not performed in cases where rates for one or more years examined were unreliable.
1 Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. Deaths: Final Data for 2007 web release. National Vital Statistics Reports; Vol. 58, No.19. National Center for Health Statistics. Hyattsville, Maryland. 2010. URL http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf (PDF 3.4MB). Accessed May 24, 2010.
2 U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. U.S. Government Printing Office. Washington, DC. URL http://www.healthypeople.gov/2010/Document/tableofcontents.htm#under. Accessed June 28, 2010.
3 Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2007. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta, GA. 2008. URL http://www.cdc.gov/diabetes/pubs/factsheet07.htm. Accessed May 24, 2010.
4 U.S. Department of Health and Human Services. Tracking Healthy People 2010. U.S. Government Printing Office. Washington, D.C. 2000. URL http://www.healthypeople.gov/2010/Document/tableofcontents.htm#tracking. Accessed May 24, 2010.
5 Fujitani, L. Multiple Cause of Death in California, 1995. Report Register No. DM98-06000. California Department of Public Health, Center for Health Statistics. June 1998. URL http://www.cdph.ca.gov/pubsforms/Pubs/OHIRmultiplecause1995.pdf (PDF 5.6MB). Accessed May 24, 2010.
6 Anderson RN, Rosenberg HM. Age Standardization of Death Rates: Implementation of the Year 2000 Standard. National Vital Statistics Reports; Vol. 47, No. 3. National Center for Health Statistics. Hyattsville, Maryland. 1998.
7 Curtin, L. and Klein, R. Direct Standardization (Age-Adjusted Death Rates). Healthy People 2000 Statistical Notes; No. 6 - Revised. National Center for Health Statistics. Hyattsville, Maryland. 1995. URL http://www.cdc.gov/nchs/data/statnt/statnt06rv.pdf (PDF). Accessed August 19, 2009.
8 Heron MP, Hoyert DL, Murphy SL, Xu JQ, Kochanek KD, Tejada-Vera B. Deaths: Final Data for 2006. National Vital Statistics Reports; Vol 57, No. 14. National Center for Health Statistics. Hyattsville, Maryland. 2009. URL: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf (PDF). Accessed May 28, 2010.
9 World Health Organization. International Statistical Classification of Diseases and Related Health Problems. Tenth Revision. Geneva: World Health Organization. 1992.
10 Rosenberg HM, et al. Quality of Death Rates by Race and Hispanic Origin: A Summary of Current Research, 1999. Vital and Health Statistics, Series 2, No. 128. National Center for Health Statistics. September 1999.
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