(Stroke. 1995;26:1159-1165.)
© 1995 American Heart Association, Inc.
Articles |
Geographic Variation in the Decline of Stroke Mortality in the United States
From the Departments of Neurology (D.J.L., P.M.P.), Preventive Medicine and Environmental Health (D.J.L.), and Statistics (P.M.P.), and the Sanders Brown Center on Aging (D.J.L.), University of Kentucky Medical Center, and the Neurology Service (D.J.L.), Veterans Affairs Medical Center, Lexington, Ky.
Correspondence to Douglas J. Lanska, MD, Department of Neurology, Room E124, Kentucky Clinic, University of Kentucky, Lexington, KY 40536-0284. E-mail djlansva@ukcc.uky.edu.
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Abstract |
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Background and Purpose This study examines the geographic variation in the decline of stroke mortality rates in the United States.
Methods National Center for Health Statistics and Bureau of the Census data were used to assess regional and state level temporal trends of stroke mortality in the United States for 1970 to 1989.
Results Underlying- and multiple-cause stroke mortality rates have declined fairly steadily in all regions of the United States and for all race/sex groups, although the rates of decline were greater during 1970 to 1978 than during 1979 to 1989. The declines in underlying-cause rates could not be attributed to a shift toward reporting stroke as a contributing rather than underlying cause of death, since both underlying- and multiple-cause rates declined similarly. There was significant regional variation in the rate of decline, particularly during 1979 to 1989. The South initially had the highest rates, but it experienced the most rapid decline, so that by 1989 the South no longer had the highest rates. States with the most rapid rates of decline were significantly clustered in the South and particularly the Southeast. Most of the decline in overall stroke mortality was due to declines in ischemic stroke mortality.
Conclusions During 1970 to 1989 there was significant geographic variation in the rate of decline of stroke mortality rates, with the most rapid rates of decline concentrated in the high-rate areas of the South and particularly the Southeast. As a result, there has been a decrease in interregional and interstate variation in stroke mortality rates, which is apparently not due to an artifact of changing reporting patterns.
Key Words: cerebrovascular disorders • epidemiology • geography • mortality • racial differences
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Introduction |
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Since at least 1940 there has been a consistent pattern of marked geographic variation in stroke mortality rates within the United States.1 2 3 Very high rates are reported in the southeast coastal plain, while very low rates are reported in the Mountain census division.1 2 3 These general patterns of geographic variation have been observed for both sexes and for whites and nonwhites, although stroke rates have been consistently declining in all geographic areas of the continental United States during this interval.1
Recently there has been some indication that the dense concentration of excess stroke mortality in the southeastern United States is dissipating.1 4 With the overall decline in stroke mortality rates, there has been a convergence (decrease in variability) of age-adjusted state stroke mortality rates overall and within the various race/sex groups.1 In addition, at the level of state economic areas, the dense concentration of excess stroke mortality along the South Atlantic coastal plain has dissipated considerably since the early 1960s.4
Although geographic variation in the decline of stroke mortality rates may be an important contributor to the changing geographic distribution of stroke mortality in the United States, this has not been systematically evaluated. The present study evaluates the geographic variation in the decline of stroke mortality rates at both regional and state levels.
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Methods |
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Data on deaths with cerebrovascular disease listed as an underlying or contributing cause of death were obtained from public-use, multiple-cause-of-death, machine-readable, US mortality data files created by the National Center for Health Statistics (NCHS).5 6 7 Data were analyzed for the period 1970 to 1989. Variables used included the following: age, race, sex, state of residence at death, underlying cause of death, and contributing causes of death. Stroke deaths were defined as those coded to rubrics 430 through 438 according to either the Eighth Revision International Classification of Diseases, Adapted for Use in the United States (ICDA-8) for 1970 to 19788 or the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) for 1979 to 1989.9
For multiple-cause tabulations, "record-axis" codes were used; these codes represent the best person-level description of all conditions listed in the medical certification portion of the death certificate. The NCHS derived record-axis codes from the individual conditions reported by using traditional linkage and modification rules for mortality coding; each individual condition ("entity axis") code was examined and modified as appropriate to create a set of record-axis codes that are free of contradictions and duplications and are the most precise within the constraints of ICD-9-CM and the medical information on the record.10
Population data tabulated by state, race, sex, and age were obtained from published data of the US Bureau of the Census for 1970, based on the population enumerated as of April 1. The racial classification used for data collected in the 1980 and 1990 censuses, however, differs from the racial classification used for vital statistics data and for data from previous censuses. To maintain comparability with the racial designations used in the vital statistics mortality data, we used Census Bureau modified-race estimates of the 1980 and 1990 US population by age, race, and sex.11 12 13 14 15 16
Age-, race-, and sex-specific rates were calculated by state and region for deaths with stroke listed as the underlying cause of death (underlying-cause rates) and for deaths with stroke listed as a cause of death anywhere on the certificate (multiple-cause rates). For the period 1979 to 1989, age-, race-, and sex-specific rates were also calculated by region for different stroke types: subarachnoid hemorrhage (ICD-9-CM rubric 430), other intracranial hemorrhage (ICD-9-CM rubrics 431 and 432), ischemic stroke (ICD-9-CM rubrics 433, 434, and 436), ill-defined cerebrovascular disease (ICD-9-CM rubrics 437.0, 437.1, and 437.9), and late effects of cerebrovascular disease (ICD-9-CM rubric 438). Stroke types were not assessed during the period of ICDA-8, since that was before the widespread availability of CT, and even large stroke categories were not accurately diagnosed during this period. Annual age-adjusted stroke mortality rates (per 100 000 population) by race and race/sex group were computed by the direct method, that is, by applying the age-specific death rates for stroke to the standard population distributed by age. The reference population used was the total US population enumerated on April 1, 1980.
The average annual rate of change in regional or state age-adjusted stroke mortality rates was measured as the slope of the regression of these rates on year. The relationship between stroke rates and year was approximately linear within the period of each revision of the ICD (ICDA-8, 1970 to 1978; ICD-9-CM, 1979 to 1989). Comparison of slopes between regions was achieved by considering an expanded linear model with the mortality rates as a function of both year and region. A significant interaction effect between year and region indicates a significant difference in rate of change of mortality rates across corresponding regions. Ordinary and weighted least-squares regression models were used to assess the association between the rate of decline in state stroke mortality rates and the initial mortality rate for the period of each revision of the ICD.
Spatial autocorrelation of average annual rate of decline in stroke mortality rates was assessed with the use of Moran's I spatial autocorrelation coefficient.17 18 19 The expected value of I for a random arrangement is of small magnitude and negative; positive values of I imply clustering, and extreme negative values imply dispersion. Since the range of possible values of I depends on the spatial structure of a particular study region, significance testing was performed under the randomization hypothesis.19 Given the specific observed values of age-adjusted mortality rates, the probability that they could have been arranged in the observed way by chance is determined by calculating a standard normal deviate from the calculated value, the expected value, and the standard deviation.
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Results |
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Underlying- and multiple-cause stroke mortality rates have declined fairly steadily in all regions of the United States and for all race/sex groups (Fig 1
). The declines in
underlying-cause rates cannot be attributed to a shift toward reporting
stroke as a contributing rather than underlying cause of death, since
both underlying- and multiple-cause rates declined similarly. Across
all regions and for all race/sex groups, the rate of decline was
greater during the period of ICDA-8 than during ICD-9-CM (Fig 1, Tables 1 and 2).
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There was significant regional variation in the rate of decline
particularly during ICD-9-CM (Fig 1
, Tables 1 and 2). Initially, for
all race/sex groups, the South had the highest rates, but the South
also experienced the most rapid decline. Among whites, in fact, there
was a crossover of trend lines so that by 1989 the South no longer had
the highest rates. As a result, during the period 1970 to 1989 there
was a decrease in interregional variation in stroke mortality
rates.
At a state level, there was significant clustering of rates of change
of both underlying- and multiple-cause stroke mortality rates for white
men during the interval 1970 to 1978 and for both white men and white
women during the interval 1979 to 1989 (Figs 2 through 5; the
multiple-cause maps are not shown but are available from the National
Auxiliary Publication Service). For all race/sex groups and for both
periods, states with the most rapid rates of decline in stroke
mortality rates were concentrated in the South and particularly the
Southeast. Because of small population sizes of blacks in many states,
the rates and estimated rates of change of the rates were erratic and
are not shown.
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The rate of decline in state stroke mortality rates for each
race/sex group was strongly and positively associated with the initial
rate for the respective group for each period of the ICD (Table 3). Values were similar for ordinary and weighted
least-squares regression models. The association was strongest for
white men.
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Most of the decline in overall stroke mortality rates during the
ICD-9-CM period was due to declines in ischemic stroke
mortality (Table 4). Rates for subarachnoid
hemorrhage, other intracranial hemorrhage, and
ill-defined cerebrovascular disease also generally declined but
contributed quantitatively little to the large declines in overall
stroke mortality. Rates for late effects of cerebrovascular disease
generally rose a minimal amount. Graphs of underlying- and
multiple-cause rates by stroke type and year are not presented
but are available from the National Auxiliary Publication Service.
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Discussion |
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This study used US national mortality data spanning two decades. The comparability of these statistics may be affected by differences in diagnostic and death certification practices, systems for classifying causes of death, and procedures for selecting the underlying cause of death from among all listed causes. However, analyses by the NCHS indicate that stroke mortality data coded in the interval covered by this report are generally comparable even though such data were coded with the use of two different revisions of the ICD; dual coding of mortality data for ICD transition years produced virtually identical numbers of stroke deaths with the use of the ICDA-8 and ICD-9-CM classification systems.20 Furthermore, compared with other diseases, the accuracy of clinical diagnoses and death certificate reporting of stroke is high because stroke is common, it has a distinctive clinical profile with an acute and often dramatic onset, and it is often rapidly fatal. When all types of stroke are considered collectively, most studies of death certificate diagnoses report positive predictive values greater than 90% compared with either standardized physician diagnoses or autopsy diagnoses.21 22 23 24 25 26 27 The sensitivity of death certificate stroke diagnoses is lower: only 60% to 70% of individuals who have suffered a stroke at any time in life have stroke recorded as a cause of death on their death certificate.24 25 26 27 28 29 However, death certificates are intended to report the cause of death rather than tabulate all medical conditions that individuals had before death. Many "false-negative" certificates (ie, history of stroke but stroke not reported on death certificate) were in fact correctly coded because the individuals died of nonstroke causes. In any case, available data do not indicate significant regional variation in either diagnostic accuracy or death certificate reporting of stroke.29 30
Although the causes of the long-standing regional variation in stroke mortality in the United States are unknown, the nonrandom distribution of stroke mortality across the United States, the large magnitude of the difference between high- and low-rate areas, the persistence of the pattern during more than four decades, the similarity of the distribution for different race/sex groups, and the lack of delimitation by administrative or political boundaries suggest that the pattern of excess stroke mortality is not an artifact of different diagnostic and reporting practices.1 2 In addition, in the 1960s national cooperative studies confirmed the apparent large differences in stroke mortality rates among geographic areas in the United States29 31 ; these large variations in mortality rates could not be explained by differences in certification practices (such as choice of underlying cause of death when multiple causes contributed to death), the frequency with which clinical stroke diagnoses were listed on the certificates, differences in the accuracy of the diagnosis of stroke, or variations in the standards of medical care.29 30 31 32 33
The present results support the previous suggestion4 that the long-standing excess of stroke mortality in the southeastern United States, and particularly the dense concentration of excess stroke mortality along the Atlantic coastal plain, is beginning to dissipate. The South, and particularly the Southeast, experienced the greatest declines in stroke mortality over the 20-year period from 1970 to 1989. Stroke mortality rates in the South now much more closely reflect the national experience than they did in previous decades. Areas of very high stroke mortality rates still persist,1 2 but these are becoming fewer and more isolated,4 especially when examined at a smaller geographic scale, and the magnitudes of the differences between high-rate areas and low-rate areas have lessened dramatically.1
Whether the regional variation in declining stroke mortality rates is due to corresponding variation in declining stroke incidence, case-fatality rate, or a combination of the two34 has not been established, but it seems that variation in declining stroke incidence must play a major role. Although available studies are limited, there are apparently large geographic differences in stroke incidence and in hospitalization rates for stroke,2 35 36 37 which correspond closely to the spatial distribution of stroke mortality rates in the United States.2 35 Unfortunately, despite the existence of longitudinal studies documenting declining stroke incidence in some small communities in the United States38 39 40 41 42 and (with the use of surrogate indicators) across the entire United States,37 no spatial pattern for such changes has been established. Changes in case-fatality rates alone are unlikely to account for the regional variation in the decline of stroke mortality rates, since (1) case-fatality rates show relatively little interstate variation and no clear or consistent spatial pattern,2 43 (2) case-fatality rates are not closely spatially associated with stroke mortality rates,2 and (3) changes in regional case-fatality rates over time44 do not correspond to regional changes in stroke mortality.
Linear models in the analyses presented here were used to estimate
average annual rates of change over periods in which the declines in
stroke mortality rates were approximately linear. Particularly during
the period of ICD-9-CM, there were no marked departures from linearity.
In addition, residual analyses identified no systematic variation in
adequacy of the model fits across geographic areas that could have
biased the results or changed the conclusions reached. Moreover, the
linear models provide a readily interpretable summary of the data for
comparison of temporal changes in stroke mortality rates across
different geographic areas, which supports the graphical presentation
of the various time series. For the purpose for which they were
intended, the models are appropriate and adequate. It should be
emphasized, though, that the linear models used in these analyses were
not used as predictive models for extrapolation purposes or for
estimating stroke rates at end points of the data used to generate the
models. Since alternative modeling procedures (eg, exponential decay
models) could be considered, it is perhaps useful to point out that the
observed data (eg, Fig 1) cannot be simply explained by uniform
percentage declines in rates. With uniform percentage declines, rates
for different areas would asymptotically approach each other, but the
trend lines would not cross. While the South initially had the highest
rates, the rates dropped most quickly in the South and crossed over
other trend lines so that by 1989 the South no longer had the highest
rates for white males or for females of either race.
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Acknowledgments |
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This study was supported in part by a Clinical Investigator Development Award from the National Institutes of Health
(1-K08-NS01549-01) (Dr Lanska), by Research Advisory Group funding from the Office of Research and Development of the Department of Veterans Affairs (Dr Lanska), and by the philanthropic support of Jayne Bolotin (Dr Lanska). Readers can obtain supplemental tables, maps, and figures (31 pages or 1 microfiche) from the National Auxiliary Publications Service, c/o Microfiche Publications, PO Box 3513, Grand Central Station, New York, NY 10163-3513. Request document 05227. Remit with your order (not under separate cover), in US funds only, $11.05 for photocopies or $4.00 for microfiche. Outside the United States and Canada, add postage of $4.50 for the first 20 pages and $1 for each 10 pages of material thereafter, or $1.75 for the first microfiche and $.50 for each fiche thereafter. There is a $15 invoicing fee on all orders filled before payment.
Received February 27, 1995; revision received April 17, 1995; accepted April 17, 1995.
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