The State Of Us Health, 1990-2016 Burden Of Diseases, Injuries, And Risk Factors Among Us States

Abstract

To use the results of the Global Burden of Disease Study (GBD) to report trends in the burden of diseases, injuries, and risk factors at the state level from 1990 to 2016.

Generated Summary

This study, a systematic analysis of published studies and available data sources, presents a comprehensive report on the burden of disease and its patterns in the United States and the individual 50 states from 1990 to 2016. The research utilized the Global Burden of Disease Study (GBD) methodology to report trends in the burden of diseases, injuries, and risk factors at the state level. The GBD study estimated annually and each round of results is internally consistent. The study analyzed data on mortality, morbidity, and risk factors in 195 locations, including the United States. The GBD 2016 provided updated estimates of mortality, morbidity, and risk factors in 195 locations, including the United States, from 1990 to 2016. The study uses a wide range of updated and standardized analytical procedures and data sources such as the National Health and Nutrition Examination Surveys, state inpatient databases, and the Centers for Disease Control and Prevention Disease Surveillance Reports. The study’s core metric is Disability-Adjusted Life-Years (DALYs), which combines Years of Life Lost (YLLs) due to premature mortality and Years Lived with Disability (YLDs). The study also employed the comparative risk assessment framework to estimate attributable deaths, DALYs, and trends in exposure by age group, sex, year, and geography for risks from 1990 to 2016.

Key Findings & Statistics

• Between 1990 and 2016, overall death rates in the United States declined from 745.2 per 100 000 persons to 578.0 per 100 000 persons.
• The probability of death among adults aged 20 to 55 years declined in 31 states and Washington, DC from 1990 to 2016.
• In 2016, Hawaii had the highest life expectancy at birth (81.3 years) and Mississippi had the lowest (74.7 years), a 6.6-year difference.
• Minnesota had the highest HALE at birth (70.3 years), and West Virginia had the lowest (63.8 years), a 6.5-year difference.
• The leading causes of DALYs in the United States for 1990 and 2016 were ischemic heart disease and lung cancer, while the third leading cause in 1990 was low back pain, and the third leading cause in 2016 was chronic obstructive pulmonary disease.
• Opioid use disorders moved from the 11th leading cause of DALYs in 1990 to the 7th leading cause in 2016, representing a 74.5% change.
• In 2016, each of the following 6 risks individually accounted for more than 5% of risk-attributable DALYs: tobacco consumption, high body mass index (BMI), poor diet, alcohol and drug use, high fasting plasma glucose, and high blood pressure.
• Across all US states, the top risk factors in terms of attributable DALYs were due to 1 of the 3 following causes: tobacco consumption (32 states), high BMI (10 states), or alcohol and drug use (8 states).
• Table 1 lists the 25 leading causes of death and premature mortality from 1990 to 2016. Ischemic heart disease (IHD), cancer of the trachea, bronchus, and lung, chronic obstructive pulmonary disease, Alzheimer disease and other dementias, and cancer of the colon and rectum were the 5 leading causes of death.
• Despite a 50.7% decline in age-standardized mortality and a 50.4% decline in age-standardized YLLs, IHD remained the leading cause of death and premature mortality.
• There was an increase in age-standardized mortality and in age-standardized YLLs from 1990 for chronic obstructive pulmonary disease (13.8% for deaths and 4.6% for YLLs) and for Alzheimer disease and other dementias (11.6% for deaths and 5.5% for YLLs).
• There was a decrease in age-standardized mortality and in age-standardized YLLs for colon and rectal cancer (29.6% for deaths and 27.9% for YLLs) and for breast cancer (32.6% for deaths and 36.0% for YLLs).
• Deaths from endocrine, metabolic, blood, and immune disorders increased by 89.1%, and YLLs increased by 60.3% from 1990 to 2016 (an increase in rank from 37 in 2010 to 22 in 2016).
• Table 2 provides the 25 leading diseases and injuries contributing to YLDs. Low back pain and major depressive disorders remained the first and second causes of YLDs in 2016. Age-standardized rates of low back pain declined by 12.4%, while age-standardized rates of major depressive disorder did not change from 1990.
• Diabetes, which was the third leading cause of YLDs, had a 29.6% increase in age-standardized rates from 1990, and increased in rank from 8 in 1990 to 3 in 2016.
• Figure 1 shows the 25 leading causes of DALYS in 1990 and 2016 with their mean percentage change during the period. IHD and lung cancer were the leading causes of DALYs in both years, but the age-standardized rate declined between 1990 and 2016 by 49.7% for IHD and by 32.5% for lung cancer.
• The age-standardized DALY rate for chronic obstructive pulmonary disease (the third leading cause in 2016) increased by 5.5% between 1990 and 2016, and for diabetes (the fourth leading cause in 2016), it increased by 11%.
• Diabetes increased from the sixth leading cause in 1990 to the fourth in 2016, while low back pain declined from the third leading cause to the fifth.
• Three leading causes of DALYS had declines in age-standardized rates from 1990 to 2016: motor vehicle road injuries (by 35.0%), breast cancer (by 34.3%), and colorectal cancer (by 27.4%).
• Four leading causes of DALYS had increases in age-standardized rates from 1990 to 2016: opioid use disorders (by 47.9%), chronic kidney disease (by 44.3%), self-harm by other means (by 20.3%), and falls (by 19.0%).
• For example, dietary risks accounted for 529 299 deaths in 2016, with 83.9% of these deaths due to cardiovascular diseases, and the remainder due to a combination of neoplasms and diabetes, and to urogenital, blood, and endocrine diseases.
• In 2016, 44.9% of total DALYs in the United States were attributable to risk factors.
• Behavioral risk factors accounted for the largest percentage of the attributable fraction of DALYs due to all causes (43.5%), followed by metabolic (22.7%), and environmental and occupational risks (3.7%).
• Hawaii had the highest life expectancy at birth in 2016 (81.3 years), while Mississippi had the lowest (74.7 years; a 6.6-year difference).
• Minnesota had the highest HALE at birth with 70.3 years, while West Virginia had the lowest at 63.8 years, a 6.5-year difference.
• In terms of life expectancy in 2016, only 9 states had life expectancy values greater than 80.0 years.
• The decomposition of change in the probability of death from birth to age 20 years, ages 20 to 55 years, and ages 55 to 90 years are shown in Figure 3, Figure 4, and Figure 5.
• The age-standardized YLL rates for the United States, all states, and Washington, DC in 2016 for the top 20 causes are grouped by 3 levels of significance.
• The heat map shows a clear pattern of performance ranging from Minnesota to Mississippi, with some clear patterns of exception for some causes.
• For example, Colorado had a YLL rate from self-harm significantly above the mean (760), while Washington, DC had a YLL rate significantly lower than the mean (306).
• Mississippi, West Virginia, Alabama, Oklahoma, Kentucky, Tennessee, South Carolina, Indiana, Missouri, and Ohio had YLLs significantly higher than the mean with a few exceptions of causes that were indistinguishable from the mean.

Other Important Findings

• Between 1990 and 2016, overall death rates in the United States declined from 745.2 per 100 000 persons to 578.0 per 100 000 persons.
• The probability of death among adults aged 20 to 55 years declined in 31 states and Washington, DC from 1990 to 2016.
• In 2016, each of the following 6 risks individually accounted for more than 5% of risk-attributable DALYs: tobacco consumption, high body mass index (BMI), poor diet, alcohol and drug use, high fasting plasma glucose, and high blood pressure.
• Across all US states, the top risk factors in terms of attributable DALYs were due to 1 of the 3 following causes: tobacco consumption (32 states), high BMI (10 states), or alcohol and drug use (8 states).
• Table 1 lists the 25 leading causes of death and premature mortality from 1990 to 2016. Ischemic heart disease (IHD), cancer of the trachea, bronchus, and lung, chronic obstructive pulmonary disease, Alzheimer disease and other dementias, and cancer of the colon and rectum were the 5 leading causes of death.
• Despite a 50.7% decline in age-standardized mortality and a 50.4% decline in age-standardized YLLs, IHD remained the leading cause of death and premature mortality.
• There was an increase in age-standardized mortality and in age-standardized YLLs from 1990 for chronic obstructive pulmonary disease (13.8% for deaths and 4.6% for YLLs) and for Alzheimer disease and other dementias (11.6% for deaths and 5.5% for YLLs).
• There was a decrease in age-standardized mortality and in age-standardized YLLs for colon and rectal cancer (29.6% for deaths and 27.9% for YLLs) and for breast cancer (32.6% for deaths and 36.0% for YLLs).
• Deaths from endocrine, metabolic, blood, and immune disorders increased by 89.1%, and YLLs increased by 60.3% from 1990 to 2016 (an increase in rank from 37 in 2010 to 22 in 2016).
• Table 2 provides the 25 leading diseases and injuries contributing to YLDs. Low back pain and major depressive disorders remained the first and second causes of YLDs in 2016. Age-standardized rates of low back pain declined by 12.4%, while age-standardized rates of major depressive disorder did not change from 1990.
• Diabetes, which was the third leading cause of YLDs, had a 29.6% increase in age-standardized rates from 1990, and increased in rank from 8 in 1990 to 3 in 2016.
• Figure 1 shows the 25 leading causes of DALYS in 1990 and 2016 with their mean percentage change during the period. IHD and lung cancer were the leading causes of DALYs in both years, but the age-standardized rate declined between 1990 and 2016 by 49.7% for IHD and by 32.5% for lung cancer.
• The age-standardized DALY rate for chronic obstructive pulmonary disease (the third leading cause in 2016) increased by 5.5% between 1990 and 2016, and for diabetes (the fourth leading cause in 2016), it increased by 11%.
• Diabetes increased from the sixth leading cause in 1990 to the fourth in 2016, while low back pain declined from the third leading cause to the fifth.
• Three leading causes of DALYS had declines in age-standardized rates from 1990 to 2016: motor vehicle road injuries (by 35.0%), breast cancer (by 34.3%), and colorectal cancer (by 27.4%).
• Four leading causes of DALYS had increases in age-standardized rates from 1990 to 2016: opioid use disorders (by 47.9%), chronic kidney disease (by 44.3%), self-harm by other means (by 20.3%), and falls (by 19.0%).
• For example, dietary risks accounted for 529 299 deaths in 2016, with 83.9% of these deaths due to cardiovascular diseases, and the remainder due to a combination of neoplasms and diabetes, and to urogenital, blood, and endocrine diseases.
• In 2016, 44.9% of total DALYs in the United States were attributable to risk factors.
• Behavioral risk factors accounted for the largest percentage of the attributable fraction of DALYs due to all causes (43.5%), followed by metabolic (22.7%), and environmental and occupational risks (3.7%).
• Hawaii had the highest life expectancy at birth in 2016 (81.3 years), while Mississippi had the lowest (74.7 years; a 6.6-year difference).
• Minnesota had the highest HALE at birth with 70.3 years, while West Virginia had the lowest at 63.8 years, a 6.5-year difference.
• In terms of life expectancy in 2016, only 9 states had life expectancy values greater than 80.0 years.
• The decomposition of change in the probability of death from birth to age 20 years, ages 20 to 55 years, and ages 55 to 90 years are shown in Figure 3, Figure 4, and Figure 5.
• The age-standardized YLL rates for the United States, all states, and Washington, DC in 2016 for the top 20 causes are grouped by 3 levels of significance.
• The heat map shows a clear pattern of performance ranging from Minnesota to Mississippi, with some clear patterns of exception for some causes.
• For example, Colorado had a YLL rate from self-harm significantly above the mean (760), while Washington, DC had a YLL rate significantly lower than the mean (306).
• Mississippi, West Virginia, Alabama, Oklahoma, Kentucky, Tennessee, South Carolina, Indiana, Missouri, and Ohio had YLLs significantly higher than the mean with a few exceptions of causes that were indistinguishable from the mean.

Limitations Noted in the Document

• The overall limitations of the GBD methods, as noted in other publications, apply to the US analysis.
• The accuracy of the estimates depends on the availability of data by time period and state.
• It is challenging to separate measurement error from variation in disease occurrence.
• GBD corrects for known bias from nonreference methods or case definitions, but often has to rely on sparse data at the state level to make those adjustments.
• GBD applies garbage code redistribution for 13% of causes of deaths in the United States; this ranged from 8.4% in South Dakota to 21.3% in Alabama.
• Therefore, the causes of death may not match those in other publications but are more robust because they control for the between-states variation in the prevalence of garbage codes.
• GBD methods adjust for hospital admissions using a large nonrepresentative source of medical claims data. The generalizability of claims data, the use of primary diagnosis only or all diagnostic fields, and the trends of claims data have been questioned.
• There may be considerable interstate variation in how diseases are treated between inpatient and outpatient settings.
• GBD includes risk-outcome pairs that meet the World Cancer Research Fund criteria of causality. However, some risk-outcome pairs might not meet criteria that develop as evidence from new studies is published.
• There is limited information on dietary intake at the state level.
• The Behavioral Risk Factors Surveillance System has 6 dietary questions attempting to capture fruit and vegetable consumption. Therefore, GBD 2016 used commercial sales data to adjust estimates of dietary intake.
• Some of the data used in the analyses have a lower quality and consistency across states and age groups.
• GBD 2016 reports 95% UIs to show the effect of this limitation on the estimates.
• The study reports disparities between states but does not examine the within-state variations of burden, which could be substantial, especially in large states.
• Claims data were only available through 2012 at the time of these analyses.

Conclusion

This study provides a comprehensive assessment of the burden of disease and its patterns in the United States and the individual 50 states from 1990 to 2016, revealing wide disparities in health outcomes at the state level. The findings highlight distinct trends across different age groups and emphasize the need for a more nuanced understanding of mortality and morbidity. While progress has been made in reducing the burden of major causes like IHD and lung cancer, there has been a lack of progress in addressing leading causes of YLDs, particularly mental health disorders and musculoskeletal disorders. The analysis underscores that summary measures such as life expectancy do not fully capture the heterogeneous directions of health status across different age groups and states. The research indicates that mortality reversals in 21 states for adults aged 20 to 55 years are strongly linked to the burden of substance use disorders, cirrhosis, and self-harm, emphasizing the need for targeted interventions. The study suggests that initiatives to address substance abuse, cirrhosis, and self-harm require comprehensive approaches. To address substance abuse, a focus on root causes, socioeconomic factors, and relapse prevention is essential, including physician involvement in addiction control. For cirrhosis, interventions targeting hepatitis C and reducing alcohol consumption are crucial. Regarding self-harm, restricting access to lethal means can reduce suicide rates. It’s crucial to note that these issues have not been comprehensively addressed. The findings also underscore that the key modifiable risks, including diet, tobacco, alcohol, and drug use, and also address social determinants of health. The study also found that occupational risks and air pollution were the 9th and 10th leading causes for DALYs. The United States should prioritize efforts to address key modifiable risks, improve care quality, and address social determinants to make progress in population health and eliminate health disparities. This study reinforces the importance of local experimentation and evidence-based programs to effectively reduce health burdens and achieve these crucial goals. The study calls for a renewed focus on addressing obesity, as it affects health and strains healthcare resources. Comprehensive programs are needed to improve dietary intake, which is a central challenge in the United States. Moreover, the study emphasizes that a need exists for addressing the social determinants of health and the burden of environmental and occupational risks is needed to ensure continued progress in improving health in the United States.

DOI

10.1001/jama.2018.0158