Heart Disease Mortality Data Trends, California 2000-2008
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At a Glance
- Heart disease was California’s number one leading cause of death every year from 2000 through 2008. Heart disease deaths accounted for more than one quarter (28.1 percent) of all California deaths during the same period.
- The age-adjusted heart disease death rate was lower in California than the United States every year from 2000 through 2007. National-level data is not available for 2008.
- There was a statistically significant downward trend in the California heart disease mortality rate. California’s age-adjusted heart disease death rate dropped from 237.6 in 2000 to 169.5 in 2008, a 28.7 percent decrease.
- More than two-thirds of all heart disease deaths during this time occurred to persons aged 75 and older. However, the proportions of deaths under age 75 varied considerably by sex and race/ethnicity.
- Men had consistently higher age-adjusted heart disease death rates than women, but both men and women exhibited statistically significant decreasing trends.
- Blacks had the highest age-adjusted mortality rates among race/ethnic groups.
- All race/ethnic groups had statistically significant decreasing trends with the exception of Two or More Races, which showed a statistically significant increase, possibly due to improved race reporting on the death certificate.
- Statistically significant decreasing trends were seen in 40 of California’s 58 counties. Sutter County demonstrated the greatest numerical and percentage decreases when comparing 2000 to 2008 data.
- For the study period, the lowest average age-adjusted heart disease death rate occurred in Marin County. The highest average age-adjusted heart disease death rate occurred in Kern County.
This report was authored by Loran Sheley, MA, Research Program Specialist. Please contact PDATrends@cdph.ca.gov for further information.
Heart disease has historically been the leading cause of death in the United States (U.S.) and in California. Heart disease accounted for more than one quarter of all California deaths between 2000 and 2008. Health care services, medications, and lost productivity due to heart disease will cost the U.S. $316.4 billion in 2010.1
Some disparities have been identified in heart disease mortality. The heart disease death rate has historically been higher in males than in females and higher in the Black population than in the White population.2
According to the Centers for Disease Control and Prevention, there are several factors that can increase the risk of heart disease. These include high cholesterol, high blood pressure, diabetes, cigarette smoking, overweight and obesity, poor diet, physical inactivity, and alcohol use.1
The definition of heart disease used in this report is based on the International Classification of Diseases, Tenth Revision (ICD-10) codes I00-I09, I11, I13, and I20-I51 currently presented in National Center for Health Statistics (NCHS) reports.3 The national health objective for heart disease as defined by the Healthy People 2010 initiative2 pertains only to coronary heart disease, which is a subset of heart disease. Therefore, California’s progress in meeting this objective is not discussed in this report. However, it is presented in other Health Information and Strategic Planning reports.4
This report examines heart disease mortality trends for the years 2000 though 2008 and presents data in five major sections. The first section discusses heart disease mortality for the total California resident population. The second section analyzes male and female populations separately. The third section describes differences in heart disease 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 heart disease deaths and mortality trends over time. The final section reviews trends in heart disease mortality by county of residence and includes trend charts for each county.
California Total Population
Heart disease was California’s leading cause of death from 2000 through 2008 and the number one leading cause of death nationally from 2000 through 2007, the most recent year for which national data is available.
The age-adjusted heart disease death rate was lower in California than the United States each year from 2000 through 2007. 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 heart disease death rate decreased every year during the study period, and the decline over time became statistically significant. The rate dropped from 237.6 in 2000 to 169.5 in 2008, a 28.7 percent decrease. A similar pattern can be observed in the national-level data. Annual age-adjusted death rates are shown in Table 3 (PDF).
There were 592,235 heart disease deaths in California from 2000 through 2008. This represented more than one quarter (28.1 percent) of all California deaths during the same period.
The average age of death due to heart disease was 78.1 years. More than two-thirds of all California heart disease deaths during this time occurred to persons aged 75 and older. The chart below shows the age distribution of heart disease deaths for all California residents.
The risk of dying from heart disease increases with age, with the exception of infants under 1 year of age, whose rates are higher than all ages through the age of 24. The minimum and maximum annual age specific death rates per 100,000 population for 2000 through 2008 and age groups that had reliable rates during each study year were as follows:
• Under 1 year (4.8, 12.8)
• 15-24 years (1.5, 2.1)
• 25-34 years (5.1, 6.3)
• 35-44 years (16.3, 22.9)
• 45-54 years (61.8, 76.5)
• 55-64 years (157.2, 218.5)
• 65-74 years (380.8, 583.8)
• 75-84 years (1,167.8, 1,646.8)
• 85+ years (4,263.3, 5,903.5)
* Please Note: Age groups 1-4 years and 5-14 years were not shown due to unreliable rates.
All age groups for ages 35 and older displayed statistically significant downward trends during the period. There were no statistically significant trends in groups under age 35.
During the study period, the actual risk of dying (or crude death rate) from heart disease ranged from 158.8 to 200.9 per 100,000 population. Annual heart disease 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
Heart disease was the number one leading cause of death for both men and women during all years studied in this report.
The chart below presents 2000 through 2008 age-adjusted death rates for California residents by sex.
The age-adjusted heart disease death rate was lower for women than men throughout the study period, but both males and females experienced statistically significant rate decreases. For males, the age-adjusted rate fell from 291.1 in 2000 to 208.7 in 2008, a 28.3 percent decrease. The female rate dropped from 195.9 in 2000 to 138.1 in 2008, a 29.5 percent decrease. Annual heart disease age-adjusted death rates are shown in Table 3 (PDF).
Of California’s 592,235 total heart disease deaths from 2000 through 2008, the proportions were about equal between males and females (296,957 deaths in males; 295,278 deaths in females).
The average age of death due to heart disease during this time was 74.4 years for men and 81.9 years for women. This means that, on average, men died more than seven years earlier from heart disease than women.
Although most heart disease deaths occurred to persons over age 75 in both sexes, the proportion of deaths that occurred to people under age 75 was larger for males. Approximately 42.0 percent of male heart disease deaths occurred to men under age 75 compared to 21.1 percent of female heart disease deaths in that age group.
The chart below shows the age distribution of heart disease deaths by sex.
The risk of dying from heart disease increases with age for both sexes. Age-specific death rates for both males and females were higher in older age groups. Annual age-specific heart disease death rates are displayed in Table 2b (PDF)for males and Table 2c (PDF)for females.
During the study period, the actual risk of dying (or crude death rate) from heart disease ranged from 199.7 to 163.0 deaths per 100,000 population for males. The female rate ranged from 202.2 to 154.7. Both males and females experienced consistent decreases in crude heart disease death rates during the study period. Annual 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
Heart disease was the leading cause of death for all race/ethnic groups in all years from 2000 through 2008 with the following exceptions:
• For Asians, heart disease was second to cancer in all years except 2002.
• For Hispanics, heart disease was the leading cause from 2000 through 2006 and was second to cancer in 2007 and 2008.
• For Two or More Races, heart disease was second to cancer in 2006 and 2007.
The chart below presents 2000 through 2008 age-adjusted death rates for California residents by race/ethnicity.
Blacks had the highest age-adjusted heart disease death rates throughout the study period. All race/ethnic groups experienced statistically significant rate decreases except Two or More Races, which had a statistically significant increase, possibly due to improved race reporting on the death certificate. Rate changes between 2000 and 2008 varied among race/ethnic groups:
• The age-adjusted death heart disease rate for Blacks decreased by 25.3 percent.
• The rate for Whites decreased by 25.6 percent.
• The rate for Asians decreased by 30.8 percent.
• The Pacific Islander rate decreased by 31.0 percent.
• The Hispanic rate decreased by 31.1 percent.
• The American Indian rate decreased by 51.3 percent.
• The Two or More Races rate increased by 93.0 percent.
Annual heart disease age-adjusted death rates and 95 percent confidence intervals are shown in Table 3(PDF).
The average age of death due to heart disease during the study period varied among the race/ethnic groups. Pacific Islanders had the lowest average age of 65.3 years and Whites had the highest average of 79.8 years. This means on the average Pacific Islanders died more than 14 years earlier from heart disease when compared to Whites. The average age of death from heart disease between 2000 and 2008 was:
• 65.3 years for Pacific Islanders.
• 70.7 years for American Indians and Two or More Races.
• 71.3 years for Blacks.
• 73.4 years for Hispanics.
• 77.6 years for Asians.
• 79.8 years for Whites.
While the majority of all heart disease deaths occurred to people over age 75, the proportions that occurred to people under age 75 varied considerably among race/ethnic groups. Specifically, the proportion of heart disease deaths before age 75 was:
• More than 60 percent among Pacific Islanders.
• Between 50 and 60 percent for American Indians and Blacks.
• Between 40 and 50 percent for Hispanics and Two or More Races.
• Less than 40 percent among Whites and Asians.
The chart below shows the age distribution of heart disease deaths by race/ethnicity.
Age-specific death rates for all race/ethnic groups were generally higher in older age groups. Annual age-specific heart disease death rates are displayed in Table 2a (PDF).
During the study period, the actual risk of dying per 100,000 population, or crude death rate, for race/ethnic groups ranged as follows:
• American Indian, 88.6 to 113.4
• Asian, 93.7 to 103.8
• Black, 207.2 to 241.5
• Hispanic, 56.7 to 63.1
• Pacific Islander, 130.4 to 154.6
• Two or More Races, 10.6 to 38.3
• White, 261.7 to 323.8
Annual heart disease 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
Heart disease was the leading cause of death for most race/ethnic groups regardless of sex during the study period with the following exceptions where cancer death rates exceeded those for heart disease:
• For American Indian females in 2002 and 2007.
• For Asian males from 2004 through 2008.
• For Asian females in all study years.
• For Hispanic females from 2006 through 2008.
• Heart disease and cancer alternated as the leading cause of death for Pacific Islander females and females of Two or More Races during the study period.
• For males of Two or More Races in 2007.
The chart below displays age-adjusted heart disease death rates by sex and race/ethnicity for the years 2000 through 2008.
Age-adjusted heart disease 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. Males and Females of Two or More Races had the lowest age-adjusted heart disease death rates over the period.
Both sexes within all race/ethnic groups with the exception of Two or More Races demonstrated statistically significant downward trends during the study period. Males of Two or More Races showed a statistically significant increase and females of Two or More Races did not exhibit a statistically significant trend.
Annual age-adjusted heart disease death rates by sex and race/ethnicity are shown in Table 3 (PDF).
On average, men died earlier from heart disease than women in all race/ethnic groups. Pacific Islander males had the lowest average age of heart disease death and died an average of more than 20 years earlier than White women, the longest surviving group. The average ages of heart disease death by sex and race/ethnicity for 2000 through 2008 were as follows:
• American Indian: males 67.1 years, females 74.8 years.
• Asian: males 74.6 years, females 80.9 years.
• Black: males 67.5 years, females 75.1 years.
• Hispanic: males 69.6 years, females 77.8 years.
• Pacific Islander: males 62.6 years, females 69.2 years.
• Two or More Races: males 66.9 years, females 75.3 years.
• White: males 76.0 years, females 83.4 years.
The percentage of deaths that occurred to people under age 75 varied by sex and race/ethnicity, and some groups experienced more deaths at younger ages than other groups. Specifically, the proportion of heart disease deaths before age 75 was:
• More than 75 percent among Pacific Islander males.
• Between 50 and 75 percent among American Indian males, Black males, Hispanic males, males of Two or More Races, and Pacific Islander females.
• Between 25 and 50 percent among Asian males, White males, American Indian females, Black females, Hispanic females, and females of Two or More Races.
• Less than 25 percent among Asian females and White females.
The charts below show the age distribution of heart disease deaths by sex and race/ethnicity.
The risk of dying from heart disease increases with age. Age-specific death rates for all race/ethnic categories grouped by sex were generally higher in older age groups. Annual age specific heart disease death rates by sex and race/ethnic group are displayed in Table 2b (PDF) for males and Table 2c (PDF) for females.
Annual heart disease 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
Fifty-four of California’s fifty-eight counties had reliable age-adjusted heart disease death rates every year from 2000 through 2008. Kern County had the highest average age-adjusted death rate, and Marin County had the lowest average rate during the nine-year 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 heart disease death rates by county are accessible through the links provided below.
Statistically significant decreasing trends in heart disease death rates were seen in 40 counties. The largest numerical and percentage decreases occurred in Sutter County, which showed a drop of 46.1 percent from 2000 to 2008.
Fourteen counties exhibited rates that were reliable each year but did not show statistically significant trends.
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.5
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.5 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.6
To control for the effect of age on death rates and provide a single measure, age-adjusted death rates are used.5 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)5 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 California 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.5 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, 2009.7
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-10.8 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 California 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 was determined first and includes decedents of any race group or groups. Non-Hispanic decedents who were reported with two or more races were 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.9 This would contribute to artificially low rates for these groups and the Two or More Races group. Multiple races identification experienced improved reporting of Two or More Races on the death certificate in 2000, which might have resulted in an increase in their death rates. 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 Centers for Disease Control and Prevention. Heart Disease Fact Sheet. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta, GA. 2010. URL http://www.cdc.gov/dhdsp/library/pdfs/fs_heart_disease.pdf (PDF). Accessed September 16, 2010.
2 U.S. Department of Health and Human Services. Healthy People 2010, 2nd edition. Washington, DC. 2000. URL http://www.healthypeople.gov/Document/tableofcontents.htm#volume1. Accessed September 16, 2010.
3 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 September 16, 2010.
4 Shippen, S. County Health Status Profiles 2010. State of California, Department of Public Health, Center for Health Statistics. Sacramento, CA. 2010. URL http://www.cdph.ca.gov/pubsforms/Pubs/OHIRProfiles2010.pdf (PDF 12.6MB). Accessed September 16, 2010.
5 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.
6 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.
7 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.
8 World Health Organization. International Statistical Classification of Diseases and Related Health Problems. Tenth Revision. Geneva: World Health Organization. 1992.
9 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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