In 1989, chronic liver disease,* including cirrhosis, was the
ninth most
frequent cause of death in the United States (1). Periodic analysis
of trends
and factors related to preventable death and hospitalization for
chronic liver
disease may be used to target prevention and control programs. This
report
examines national trends in death and hospitalization rates and
state-specific
death rates for chronic liver disease using data from CDC's
National Center for
Health Statistics' multiple-cause-of-death file and the National
Hospital
Discharge Survey (NHDS).
From 1980 through 1989, the age-adjusted death rate ** for
chronic liver
disease decreased 23%, from 13.5 to 10.4 per 100,000 persons
(Figure 1). During
this period, rates for men were more than two times higher than for
women, and
rates for blacks were more than 50% higher than for whites. ***
Death rates for
each of these groups declined steadily during this period.
In 1989, chronic liver disease was the underlying cause of
death for
26,720 persons (Table 1) and a contributing cause of death for an
additional
14,101 persons. Among deaths for which chronic liver disease was
the underlying
cause, 46.1% were diagnostically associated with alcohol (i.e.,
alcoholic fatty
liver, acute alcoholic hepatitis, alcoholic cirrhosis of the liver,
and
alcoholic liver damage-unspecified); 2.9%, with chronic hepatitis;
1.5%, with
biliary cirrhosis; and 49.5%, with unspecified conditions and no
mention of
alcohol (i.e., cirrhosis of the liver without mention of alcohol,
other chronic
nonalcoholic liver disease, and unspecified chronic liver disease
without
mention of alcohol).
Age-specific death rates increased with age for men in the
35-44-year
through 65-74-year age groups (from 15.2 to 49.0 per 100,000 men)
and for women
in the 35-44-year through 75-84-year age groups (from 4.8 to 26.7
per 100,000
women) (Table 1). State-specific age-adjusted death rates of
chronic liver
disease in 1989 varied more than fivefold, from 6.1 per 100,000
population (for
Idaho) to 31.5 per 100,000 (for the District of Columbia). The
median rate was
9.6 per 100,000.
Chronic liver disease was also an important, although
diminishing, cause
of hospitalizations during 1980-1989. The age-adjusted
hospitalization rate of
chronic liver disease decreased 44% during this period (from 50.6
to 28.2 per
100,000) (Figure 1). Rates for women were generally one third lower
than for
men, and for both, declined steadily throughout the decade. For
most years,
rates for whites were 20%-30% lower than rates for blacks.
Chronic liver disease appeared as the first-listed diagnosis
in an
estimated 72,232 hospitalizations in 1989 (Table 2). Among these
hospitalizations, 49.3% were diagnostically associated with
alcohol, 10.5% with
chronic hepatitis, 1.8% with biliary cirrhosis, and 38.3% with
unspecified
conditions and no mention of alcohol. Chronic liver disease was
also listed as
a diagnosis (other than first-listed) in an additional 218,156
hospitalizations.
Age-adjusted hospitalization rates of chronic liver disease in
1989 were
38% higher for men than for women (33.1 versus 23.9 per 100,000)
and 27% higher
for blacks than for whites (30.1 versus 23.7 per 100,000). Rates
were
successively higher in each age group from 35-44 years through
55-64 years for
both men and women (from 40.9 to 96.5 per 100,000 and from 30.1 to
88.9 per
100,000, respectively) and decreased sharply after this age.
Reported by: Chronic Disease Surveillance Br, Office of
Surveillance and
Analysis, National Center for Chronic Disease Prevention and Health
Promotion,
CDC.
Editorial Note
Editorial Note: Most specific types of chronic liver disease in the
United
States are preventable (2). The findings in this report indicate a
steady
decline in rates of hospitalization and death from chronic liver
disease during
the 1980s. The variation in state-specific age-adjusted death rates
suggests
underlying regional differences in the occurrence of chronic liver
disease and
related risk factors. These findings may be used to target
prevention and
treatment programs and in the design of further epidemiologic
research.
The findings in this report are subject to at least two
limitations.
First, because NHDS data do not distinguish initial from recurrent
hospitalizations for a given person, these results represent the
number of
hospitalizations rather than the number of persons hospitalized for
chronic
liver disease. Thus, the declines might reflect a decline in the
number of
persons with chronic liver disease or in fewer hospitalizations
among those
with chronic liver disease, or some combination of both. Second,
for both
hospitalization and death certificate data, alcohol-related
diagnoses may be
under-reported.
Despite these potential limitations, the declining
hospitalization and
death rates reported here may indicate a true decrease in the
underlying
occurrence of chronic liver disease as a result of decreases in the
prevalences
of major risk factors (e.g., heavy alcohol use). In the United
States, heavy
alcohol use is considered the most important risk factor for
chronic liver
disease; even among deaths coded as chronic liver disease with
unspecified
conditions and no mention of alcohol, approximately 50% are thought
to be due
to alcohol use (3). Thus, decreasing hospitalization and death
rates may
reflect, in part, the decline in per capita alcohol consumption
from 1977
through 1989 (4). These findings also are consistent with data from
CDC's
Behavioral Risk Factor Surveillance System that have shown a
greater proportion
of heavy drinkers among men than women and that alcohol consumption
is
inversely related to age (5). Strategies for reducing per capita
consumption of
alcohol include price controls (e.g., increased taxes on alcohol),
control of
the physical availability of alcohol, changes in legal
accessibility,
information and education programs, health warning labels,
targeted health-promotion programs, and related activities (6).
Hepatitis B and C viruses are also important risk factors for
chronic
liver disease (7), and their relative contribution to chronic liver
disease,
alone and in combination with alcohol, requires further study. A
comprehensive
vaccination strategy for eliminating hepatitis B virus transmission
and its
sequelae in the United States has been recommended (8). Other
potential risk
factors include certain drugs, industrial chemicals, and less
common infectious
agents.
An estimated 90% of deaths attributed to cirrhosis is
preventable (2). The
national health objectives for the year 2000 include reducing
cirrhosis deaths
to no more than six per 100,000 **** (9). The findings in this
report
underscore that efforts to decrease mortality associated with
chronic liver
disease will have to be intensified if this objective is to be met.
References
