LAC 48:I.10309. Health Status

A. Death, disease and disability patterns in a population provide insight into the health of that population. There is no single indicator through which to make totally valid observations about health status, but rather a number of indicators through which a composite picture is sketched of the health of the populace. B. Mortality Statistics 1. Introduction a. Statistics on death are essential tools for understanding the impact of disease, evaluating health programs, allocating health resources and establishing priorities for health improvement efforts. Death statistics are the most widely used group of health status indicators because of their availability, uniformity, reliability and low cost. b. In the following sections of this document, a variety of mortality statistics is presented, including age-specific and age-adjusted rates, race and sex adjusted rates, disease-specific rates and infant mortality rates. 2. Age-Adjusted Mortality Rates a. The concept of an age adjustment when analyzing mortality rates is an important one since crude mortality rates have little meaning. Adjusting mortality statistics by age means factoring the death rate within a specific age group by the percentage which that age group represents in a standard population. Thus, populations which are heavily weighted with persons 45 and over are not seen as more "unhealthy" because of having higher death rates than predominantly younger population groups. b. In Table 3.14, the age-adjusted, 1984 death rates for Louisiana as compared to the United States are presented, both for the leading causes of death and for all causes. The Louisiana age-adjusted death rate in 1975 was 725.67 per 100,000 population. This decreased to 618.22 in 1984. However, Louisiana continues to have a significantly higher rate than the nation as a whole. The state's death rates exceed those of the nation in each category of leading causes of death, with the exception of influenza/pneumonia and liver disease. The most significant differences are in the categories of diseases of the heart and malignant neoplasms which are the two leading causes of death in the U.S. as well as in Louisiana. (See Chapter IX sections on Open Heart Surgery, Cardiac Catheterization and Radiation Therapy for more information about the incidence of heart disease and malignant neoplasm.) c. It is significant to note that in the period between 1975 and 1984, the state showed a decrease in death rates in each category of leading causes of death with the exception of suicide and malignant neoplasm which showed slight increases. Table 3.14 Age Adjusted Death Rates * of Louisiana and the U.S. for Major Diseases, 1984 Disease | Age Specific Death Rate: Louisiana Age Adjusted Rate 11 | 1-14 | 15-24 | 25-34 | 35-44 | 45-54 | 55-64 | 65-74 | 75-84 | 85+ | LA | USA Disease of Heart | 34.8 | 1.4 | 5.5 | 10.1 | 50.6 | 203.2 | 573.1 | 1269.4 | 2932.5 | 6989.9 | 212.42 | 183.3 Malignant Neoplasm | 2.5 | 3.2 | 5.4 | 12.5 | 57.3 | 182.4 | 497.4 | 882.2 | 1383.4 | 1692.3 | 144.55 | 133.1 Cerebrovascular | 5.0 | .5 | 1.0 | 3.2 | 11.6 | 36.3 | 69.6 | 216.5 | 674.5 | 1801.2 | 39..61 | 33.9 Motor Vehicle Accidents | 7.5 | 7.9 | 41.8 | 26.1 | 19.2 | 17.3 | 16.2 | 13.0 | 30.0 | 11.5 | 21.22 | 19.2 Suicide | 0.0 | 0.1 | 12.9 | 20.4 | 15.9 | 16.8 | 22.6 | 21.0 | 20.2 | 22.9 | 13.10 | 11.6 Homicide & Legal | 9.9 | 1.5 | 16.1 | 26.2 | 20.1 | 13.5 | 9.1 | 7.1 | 9.0 | 14.3 | 13.34 | 8.2 Prtherosclerosis | 0.0 | 1.1 | 1.0 | 5.5 | 24.4 | 113.9 | 578.4 | 5.51 | 4.1 Influenza, Pneumonia | 27.3 | 1.1 | 0.4 | 3.1 | 2.8 | 6.1 | 19.5 | 53.7 | 201.6 | 715.9 | 12.01 | 12.2 Chronic Liver Disease | 3.7 | 0.1 | 2.2 | 7.6 | 20.6 | 31.4 | 35.6 | 28.5 | 11.5 | 8.70 | 9.8 All Causes | 618.22 | 547.7 * Rates per 100,000 population ** Source: Monthly Vital Statistics Report, Vol. 33, No. 13, September 26, 1986 d. Table 3.14 allows us to compare age adjusted death rates in specific age categories. An important factor to consider is that, while heart disease and malignant neoplasms are the leading causes of death in most age categories, motor vehicle accidents and homicide are the leading causes of death for persons 1 year of age through 34 years of age (Vital Statistics Report 1985). 3. Crude Mortality Rates—a comparison of neighboring states and planning districts within the state a. A comparison of Louisiana to the neighboring states of Mississippi, Arkansas and Texas is seen in table 3.15. Louisiana's death rates for specified leading causes of death are lower than those of Mississippi and Arkansas from diseases of the heart, malignant neoplasms, and cerebrovascular disease and is lower than each of its neighboring states in deaths from motor vehicle accidents. Table 3.15 Death and Death Rates for Specified Leading Causes of Death - 1983* Disease of Heart | Malignant Neoplasms | Cerebrovascular Dis. | Motor Vehicle Accidents Number | Rate | Number | Rate | Number | Rate | Number | Rate U.S. | 770,432 | 329.8 | 442,986 | 189.3 | 155,598 | 66.5 | 44,452 | 19.0 Louisiana | 13,266 | 298.8 | 7,670 | 172.7 | 2,115 | 47.6 | 980 | 22.1 Mississippi | 8,425 | 326.4 | 4,592 | 177.9 | 2,076 | 80.4 | 716 | 27.7 Arkansas | 8,617 | 370.6 | 4,902 | 210.8 | 1,162 | 50.0 | 565 | 24.3 Texas | 39,973 | 253.3 | 23,282 | 147.6 | 7,253 | 46.0 | 3,868 | 24.5 SOURCE: NCHS. Monthly Vital Statistics. Advance Report of Final Mortality Statistics, 1983 V34, No.6, Supp (2) September 26, 1985. b. Another comparison of death rates may be made within the state. Table 3.16 provides data on principal causes of deaths by planning district. The Northwest district has the highest death rate from diseases of the heart and malignant neoplasms and the second highest from pneumonia/influenza, homicide and suicide. The New Orleans district has the highest death rates from homicide, suicide and chronic liver diseases. The Northeast district has the highest death rates from cerebrovascular diseases and pnemonia/influenza and the second highest from disease of the heart. Although these death rates are not adjusted for age, the statistics indicate the need for improved health care initiatives in the New Orleans, Northeast, and Northwest districts. Table 3.16 Principal Causes of Deaths by Planning Districts Louisiana/U.S. 1984 Disease of Heart | Malignant Neoplasms | Cerebrovascular Arterios Disease | Cronic Pnemonia and Influenza | Accidents and Adverse Effects Homicide Suicide Number | Rate | Number | Rate | Number | Rate | Number | Rate | Number | Rate 1. New Orleans | 3,509 | 283.9 | 2,338 | 189.2 | 677 | 54.8 | 510 | 41.3 | 203 | 16.4 2. Capital | 1,403 | 218.2 | 846 | 131.6 | 273 | 42.5 | 229 | 35.6 | 100 | 15.6 3. Bayou | 711 | 234.6 | 463 | 152.7 | 131 | 43.2 | 194 | 64.0 | 33 | 10.9 4. Acadiana | 1,419 | 281.2 | 946 | 187.5 | 276 | 54.7 | 258 | 51.1 | 91 | 18.0 5. Southwest | 808 | 295.0 | 474 | 173.0 | 195 | 71.2 | 137 | 50.0 | 48 | 17.5 6. Cenla | 1,283 | 345.2 | 609 | 163.9 | 237 | 63.8 | 179 | 48.2 | 79 | 21.3 7. Northwest | 1,815 | 366.4 | 1,015 | 204.9 | 352 | 71.1 | 213 | 46.6 | 112 | 22.6 8. Northeast | 1,341 | 360.6 | 691 | 185.8 | 290 | 78.0 | 145 | 39.0 | 120 | 32.3 9. Northshore | 769 | 291.4 | 416 | 157.6 | 175 | 66.3 | 157 | 59.5 | 40 | 15.2 SOURCE: Louisiana Vital Statistics. 1984 Advance Final Data. PHS. 1984 Series c. The Capital district has fewer deaths per 100,000 from diseases of the heart malignant neoplasms, cerebrovascular diseases, accidents and adverse effects, and suicide than other areas of the state. The Bayou district has the lowest death rate from pnemonia/influenza and chronic liver disease. 4. Age, Race, Sex and Disease—Specific Mortality a. Another way of looking at mortality statistics is the examination of disease-specific causes of death by age group. Table 3.17 presents such statistics for Louisiana according to 1984 mortality data. These data reveal that perinatal diseases are the leading cause of death of persons under one year of age. Congenital anomalies constitute the second leading cause of death in this age group. This group of diseases remains among the top five leading causes of death in the 1 year to 4 year age group, but is not found among the top five causes of death in age groups above four years. Motor vehicle accidents appears as a leading cause of death in the 1-4 year age group and remains ranked among the top five until the 55-64 year age group. In this age group chronic pulmonary disease and diabetes mellitus are introduced among the five leading causes of death. Pneumonia and influenza appear as a leading cause in the 75-84 year age group and atherosclerosis appears in the 85 and over age group. b. An interesting analysis of death rates is provided by a breakdown of the death rate by sex, race and age. Such a statistical analysis is given in Table 3.18. The significance in such a comparison lies in premature deaths, that is in age groups below 75 but especially in the 15-64 age groups. The variation by race and sex is quite substantial. Table 3.17 Rank Order of 5 Leading Calms of Death Stage Group and Miser of Deaths—Louisiana, 1984 Age Group | Rank 1 | Rank 2 | Rank3 | Rank4 | Rank5 | Total Deaths Under1 | Perinatal Diseases 481 | Congenital Anomalies 202 | Cardiovascular Dis. 34 | Pneumonia and Influenza 22 | All Other Accidents 15 | 979 1-4 | All Other Accidents 63 | Motor Vehicle Accidents 40 | Congenital Diseases 14 | Malignant Neoplasm 14 | Pneumonia and Influenza 10 | 212 5-14 | All Other Accidents 56 | Motor Vehicle Accidents 43 | Malignant Neoplasm 19 | Homicide 13 | Cardiovascular Disease 11 | 191 15-24 | Motor Vehicle Accidents 343 | All Other Accidents 178 | Homicide 132 | Suicide 106 | Cardiovascular Disease 54 | 947 25-34 | All Other Accidents 210 | Homicide 206 | Motor Vehicle Accidents 206 | Suicide 160 | Cardiovascular Disease 111 | 1,144 35-44 | Cardiovascular Disease 353 | Malignant Neoplasm 310 | All Other Accidents 124 | Homicide 109 | Motor Vehicle Accidents 104 | 1,367 45-54 | Cardiovascular Disease 968 | Malignant Neoplasm 718 | Cerebrovascular 143 | All Other Accidents 112 | Motor Vehicle Accidents 68 | 2,459 55-64 | Cardiovascular Disease 2,418 | Malignant Neoplasm 1,807 | Cerebrovascular 253 | Chronic Pulmonary 151 | Diabetes Mellitus 135 | 5,576 65-74 | Cardiovascular Disease 4,172 | Malignant Neoplasm 2,351 | Cerebrovascular 577 | Chronic Pulmonary 303 | Diabetes Mellitus 237 | 8,477 75-84 | Cardiovascular Disease 5,073 | Malignant Neoplasm 1,846 | Cerebrovascular 900 | Chronic Pulmonary 304 | Pneumonia and Influenza 269 | 9,110 85 and Over | Cardiovascular Disease 3,337 | Cerebrovascular Disease 629 | Malignant Neoplasm 591 | Pneumonia and Influenza 250 | Arteriosclerosis 202 | 5,191 Source: Louisiana Vital Statistics Report, 1984 advance Final Report, PHS-1984 Series No. 2, Nov, 1985 Table 3.18 Age Race Sex Specific Death Rates - All Causes - of LA Residents Over 14 Years 1984 Age at Death 15-24 | 25-34 | 35-44 | 45-54 | 55-64 | 65 and over Louisiana | 115.4 | 145.7 | 252.5 | 624.7 | 1535.0 | 5251.3 WM | 117.3 | 108.7 | 191.5 | 497.1 | 1410.8 | 6360.3 WF | 108.9 | 124.6 | 203.6 | 511.7 | 1269.0 | 4208.2 NWM | 117.5 | 255.7 | 473.9 | 1153.6 | 2539.7 | 6994.0 NWF | 122.0 | 199.1 | 380.7 | 884.1 | 1939.7 | 4954.0 SOURCE: La. Vital Statistics Report, Public Health Statistics, 1984, series: No. #2, November, 1985 c. Premature death rates are strongly correlated with non-whites as a group. As the above chart indicates, non-white males are at substantially greater risk of premature death than others in all age ranges over 24. The death rate for non-white females is substantially greater than whites in all age ranges and greater than that for non-white males in the age group 15-24. It is significant to note, that in the past the death rate among white females was consistently below that of the population in general by as much as 50 percent. However, according to 1984 vital statistics data, in the age range 25-54 the white female death rate now exceeds the white male rate. d. Planning districts do not show significant variations in the numbers of males and females in specific age groups within the population. Therefore, the correlation of higher premature death rates with males does not, in itself, have implications in the identification of special local and regional health care needs. However, racial correlations with higher death rates are significant for local planning, since there is some variation in the racial composition of regional populations. e. Of interest in comparing race and sex differentials in the death rates is a parallel comparison of utilization patterns of health care services and facilities. Current data are not available for Louisiana on the race/sex variations in utilization; however, several studies at the national level provide data which permit extrapolation. A National Ambulatory Medical Care Survey (NAMCS) conducted by the Department of Health Education and Welfare (DHEW) in 1975 provided statistics on the numbers of persons in the U.S. who visited general and family practitioners during the survey years. Female patients accounted for 59.2 percent of the total number of reported visits in 1975, while representing 51.3 percent of the population. (Pregnancy exams accounted for 2.4 percent of the visits.) Whites accounted for 88.5 percent of the patients making the physician visits, nonwhites 11.5 percent. The population ratio of whites to non-whites in the surveyed population was 85.5 to 14.5. From these statistics it could be observed that the female utilization rate for these general outpatient health services was 31.1 percent higher than for males, with pregnancy-related examinations accounting for only 4.1 percent of this differential and the difference in the male-female ratio in the population accounting for 5.19 percent. The utilization rate for whites was 87 percent higher than for the non-white population, with 83 percent of this difference being accounted for by population differences of the races. f. A local study which seems to support these statistics regarding sex and race variables in health services utilization is the Mid-Louisiana HSA Hospital Patient Abstract Study. A random 5 percent sample of hospital discharges during 1977-78 was taken. Almost 60 percent of all discharges in the study were female, while 51.2 percent of the population was female. Here a 35 percent higher utilization rate was seen for women, with 20 percent of their discharges being for services related to obstetrical care. Whites accounted for 75 percent of the discharges, while representing 72.2 percent of the area population; non-whites comprised 25 percent of the discharges, with a 27.8 percent representation in the area. Thus, non-whites were 14 percent less likely than whites to use general hospital facilities. g. Excluding obstetrical services, females in these studies were about 25 percent more likely to receive general outpatient care than males and about 15 percent more likely to receive general inpatient care. The same approximate variables applied to whites versus non-whites, that is whites were about 25 percent more likely than non-whites to receive general outpatient care and about 15 percent more likely to receive general inpatient care. Similarly, the observation can be made that white females are over 40 percent more likely than white males and non-white females to receive general outpatient services and over 80 percent more likely to receive such services than non-white males. White females are over 20 percent more likely to receive non-OB-related general hospital care than white males and non-white females and over 40 percent more likely to receive such services than non-white males. It can be observed that there are close parallels between this health service utilization pattern and death rates when analyzed by sex and race variables. There is not sufficient data to draw definite conclusions; however, it may be postulated that higher utilization of some health care services correlates with lower premature death rates and that differentials in sex and race variables in the death rate may not be related to sexual or racial characteristics but rather to patterns and attitudes toward health care. Such observations underline the need for health planners and health care service providers to focus on activities related to health promotion, prevention and early detection of disease, and primary care. h. In a 1974 NAMCS survey (U.S.), respondents with no regular place of care stated more frequently (54.2 percent) that the main reason for not having a regular source of medical care was that, as far as they could determine, they did not need one. People in lower income groups confronted cost, transportation and knowledge barriers to care disproportionately more often than in higher income family groups. The most frequently identified reason that people felt they were not getting all the medical care they needed was the high cost of care. Implications again revolve around a need to emphasize health education, prevention and promotion and to target such efforts in poverty areas. A lack of Medicaid coverage for preventive health care for adults makes screening and preventive personal health care services a commodity which a large segment of the population in Louisiana may not be able to afford. 5. Percent of years of life lost between ages one and 65. a. Another method of examining mortality statistics is through percent of years of life lost. In this method, the number of years between 1 and 65 lost as a result of each cause of death is computed and compared to the number of years of life between one and 65 for the population as a whole. Breaking this information down to a cause specific analysis permits a better understanding of the impact that the various causes of death have on the population in terms of percent of productive years of life lost. b. Table 3.19 presents such data for Louisiana residents based on 1984 deaths. Louisianians exceeded national percentages of productive years of life lost in several cause-specific categories. Louisiana exceeds the U.S. average by the greatest amount in non-motor vehicular accidents and homicides. In deaths due to malignant neoplasm, Louisiana is significantly lower than the nation as a whole, inspite of higher age adjusted death rates. One possible explanation for this is that cancer mortality tends to be lower in Louisiana among the very young who have many years of life to lose and higher in the more advanced age groups with fewer years of life to lose. For most other causes of death, there is little deviation between U.S. and Louisiana statistics in terms of percentage of years of life lost. Table 3.19 Percent of All Years of Life Lost Between Ages 1 and 65 for Selected Causes of Death, Louisiana and U.S., 1984 LA | US Malignant Neoplasms | 17.0 | 19.5 Diabetes Mellitus | 1.2 | 1.3 Heart Disease | 17.1 | 16.5 Cerebrovascular Disease | 3.2 | 2.8 Arteriosclerosis | 0.2 | 0.1 Diseases of Arteries | 0.3 | NR Influenza and Pneumonia | 1.3 Bronchitis, Emphysema | 1.1 | 1.3 Cirrhosis of Liver | 1.7 | 2.5 Congenital Anomalies | 1.2 | 1.5 Accidents | 11.7 | 9.4 Motor Vehicle Accidents | 15.3 | 15.0 Suicide | 6.8 | 7.1 Homicide | 8.7 | 6.2 Hypertension | 0.2 | NR All Other Causes | 13.1 | 15.7 SOURCE: Louisiana Department of Health and Human Resources, Louisiana Vital Statistics Report, Provisional Statistics, January-December, 1984 National Center for Health Statistics Monthly Vital Statistics Report: V33, No. 13, September 26, 1985 6. Infant Mortality Rates a. The rate of infant deaths per 1,000 live births provides insight into the relative health status of pregnant women and their newborns, as well as into the relative responsiveness of the health care system in meeting the needs of pregnant women and newborns. b. Figure 3.3 depicts the relationship between the U.S. and Louisiana infant mortality over the period 1950-1984. There is a significantly higher infant mortality rate among non-whites than whites. There is a noted trend of decreasing infant mortality in the U.S., as Figure 3.3 indicates. It also shows that Louisiana follows the national trend closely. The decrease is most pronounced for non-whites. However, in Louisiana the nonwhite infant mortality rate remains far above that of whites. c. Table 3.20 presents infant mortality data by planning district. The 1984 infant mortality rates are highest in the Cenla district, for both whites and non-whites. The non-white infant mortality rate for the Cenla district is 21.3 per 1,000, which compares to 15 per 1,000 for whites. In comparing white and non-white infant mortality, the greatest range exists in the southwest district where the white mortality rate is 10.7 and the nonwhite rate is 19.9. Table 3.20 Infant Deaths and Mortality Rates by Race and Planning Districts Louisiana - 1984 Total | White | Non-White Infant Deaths | Rate/ 1000 | Infant Death | Rate/ 1000 | Infant Deaths | Rate/1000 Louisiana | 977 | 12.0 | 466 | 9.1 | 531 | 16.5 1. New Orleans | 277 | 12.8 | 98 | 8.8 | 179 | 16.9 2. Capital | 138 | 11.5 | 56 | 7.6 | 82 | 17.6 3. Bayou | 54 | 9.2 | 30 | 7 5 | 24 | 12.6 4. Acadiana | 111 | 11.0 | 65 | 9.4 | 46 | 14.4 5. Southwest | 52 | 10.7 | 27 | 7.5 | 25 | 19.9 6. Cenla | 102 | 15.0 | 51 | 11.6 | 51 | 21.3 7. Northwest | 101 | 11.2 | 50 | 9.9 | 51 | 12.9 8. Northeast | 80 | 12.9 | 34 | 10.3 | 46 | 16.0 9. Northshore | 62 | 12.7 | 35 | 10.0 | 27 | 19.4 C. Morbidity Statistics 1. Issues in Obtaining Morbidity Statistics a. Information on the distribution and types of diseases and disabilities afflicting the population is an essential health planning tool. Unfortunately, information on the incidence of disease within the state is incomplete and for the most part unavailable since there is no single indicator of morbidity and no uniform system through which such statistics are reported. The only exception is in the area of certain highly communicable diseases which are required to be reported to the Office of Preventive and Public Health Services. b. Several indicators may be analyzed to estimate the effect of disease, illness and disability in a population. Hospital discharge diagnoses and diagnoses given by physicians on health insurance claims are the only diagnoses (other than communicable diseases) which flow into the general "information system" and which are presumably supported by clinical evidence of disease. Statistical analysis of such reported diagnoses provides some insights, but is made difficult by several factors. c. First, clinical diagnosis nomenclature systems contain thousands of diagnoses, the use of which by clinicians is by no means uniform and often inexact. Many patients have multiple symptoms or diseases, and the reporting and sequence of primary, secondary, or tertiary diagnoses is often left to the discretion of a medical records clerk. Additionally, the existence of multiple diagnoses for a single patient's single medical service complicates and distorts the proper evaluation of such statistics. d. Another problem in analyzing clinical diagnoses from hospital and physician service insurance claims is the fact that the population being measured is in fact not a random sample. The exercise is actually a comparison of the relative frequency of one diagnosis over another among a population of people who have sought medical care. Thus, there is no representation whatsoever of those in the population who are ill but may have not sought medical care or who may have been treated on an outpatient basis without the submittal of an insurance claim. e. This problem ties in with another, that is the actual availability to health planners of the diagnostic information that has, in fact, been reported. At this time, there are no available data in Louisiana on the frequency of the various clinical diagnoses on insurance claims for physician services. This is because there is a reluctance on the part of third party payors to share such information, in part based on their need to preserve the confidentiality of medical records information and, in part, based on the expense of extracting diagnostic data from claims and sharing it with other entities in a way that permits comparisons. There are impediments in that various third party payors use different nomenclature systems for the classification of medical services or procedures. In some cases there are also different classification systems for diseases since there have not been timely or uniform changeovers to the use of updated disease classification systems (i.e. from ICDA-8 to ICD-9-CM). f. At present, the only physician service claim information from which the State Health Planning and Development Agency might obtain information is that extracted from state Medicaid claims. As previously noted, such information will have the bias of the Medicaid eligible population, compounded by specialty and geographic variations in provider participation. g. The only statistical information on diagnoses (other than communicable disease) which is available to this agency is: i. that obtained by the Mid-Louisiana Health Systems Agency in their 1978-79 Hospital Patient Abstract Study; and ii. that released by the federal Health Care Financing Administration (HCFA) in an analysis of the most frequently submitted diagnoses on Medicare hospital claims in 1977-78. h. Both of these studies are biased in that only patients obtaining hospital care are included in the surveyed population. The Mid-Louisiana study is limited to the 24 parishes of that area. Though the HCFA study is statewide, the bias of the Medicare population is that all of the beneficiaries were age 65 + . So, with an understanding of the inherent limitations of the data, we present it and make some observations. i. Mid-Louisiana Hospital Patient Abstract Study (a). Data in this survey were provided by almost every hospital in the area and described a five percent sample of discharges. Analysis of raw data provided the following information. (b). The most frequent discharge diagnoses were: (i). Obstetrical and related diagnoses, including delivery, complications of pregnancy, live-born infant, perinatal morbidity and mortality, fetal deaths and abortions-20.67 percent; (ii). Digestive System Diseases-11.55 percent; (iii). Respiratory Disease, including respiratory system disease, flu and pneumonia-9.95 percent; (iv). Genitourinary Diseases-9.32 percent; (v). Circulatory System Diseases, including hypertension, ischemic heart and cerebro-vascular diseases and diseases of the arteries-8.78 percent; (vi). External Causes of Injuries, including accidents, burns and violence-8.49 percent; (vii). Symptoms and ill-defined conditions-4.95 percent; (viii). Musculoskeletal System Diseases, includes bone joint diseases, arthritis and rheumatism-3.55 percent; (ix). Infections-3.47 percent; (x). Mental Diagnoses, includes mental disorders and retardation-3.09 percent; (xi). Cancer (malignant neoplasms)-2.75 percent; All Other-11.81 Percent; (xii). Total-100.00 percent. (c). Those diagnoses accounting for the most patient days, (number of discharges times the length of stay,) were circulatory diseases, obstetrical and related diagnoses, digestive system diseases, external causes of injury, respiratory diseases, and genitourinary diseases. During 1978, the 24 parish area experienced a rate of 985.5 patient days per 1,000 population. (d). Of interest in the analysis of morbidity is the high percentage of hospital discharges for reason of digestive, respiratory and genitourinary diseases. These disease categories do not appear in statistics depicting the leading five causes of mortality, but they were the leading disease-related causes for hospitalization in the mid-Louisiana area. This would seem to underscore the need for health planners to develop a methodology for measuring morbidity so that initiatives in the health care field may be directed more precisely toward treatment of illness and disease. ii. HCFA Medicare Hospital Abstract (a). Data in the HCFA study were obtained from a 20% sample of all Medicare ( + 65) inpatient hospital bills submitted during 197778. The 25 most frequently reported diagnoses were analyzed for participating hospitals in Louisiana. (b). The most frequent discharge diagnoses were: Number discharges reported in 20 percent sample. (i). Circulatory System Diseases-13,750 Respiratory Diseases-3,046; (ii). Digestive System Diseases-2,694 Eye Disease (cataract surgery)-1,641; (iii). Endocrine Disease (diabetes)-1,505; (iv). Genitourinary Disease (prostate surgery and other diseases of the urinary tract)-1,493; (v). Musculoskeletal System Diseases (osteoarthritis and allied conditions; fracture of necks or femur) 1,124; (c). The number of discharges with diagnoses other than the most frequent ones was not included in the HCFA report and thus relative percentages could not be included. Again, the high incidence of respiratory and digestive disease discharges is of note, and the incidence of circulatory and related diseases is, as would be expected among the 65 + population, quite pronounced. 2. Health Index a. One of the most valuable tools for evaluating the incidence of morbidity in a population is a random survey of the residents. While clinical diagnoses cannot be obtained from the general population with any accuracy or validity, behavioral indicators of general health status can be obtained. Loss of functioning, days of restricted activity, special personal care requirements and use of health care services are all health status indicators which may be obtained from a survey of an area's households. These indicators are of particular importance in our current chronic disease-oriented environment in which concern is increasingly directed toward nonfatal illnesses and injuries which disable or, at the least, cause inconvenience and economic loss. Sampling the same population regularly, on an annual or biannual basis, provides the basis for a comparative health status index. b. Such health status indicators are obtained on a national level in an annual survey performed under the auspices of the National Center for Health Statistics. The sampling of individual states is too small to permit a statistically reliable projection of the indicators for the state as an entity in itself. c. The Louisiana State Health Planning and Development Agency has recommended that an annual sample of 2,400 Louisiana households be undertaken to obtain reliable behavioral indicators of health status within the state. The State Health Planning Agency has not had sufficient funds to perform the survey (estimated 1982 cost to initiate survey: $25-30,000; cost in future years: $10,000 + ). At such time as funds become available, the State Health Planning Agency would see this type of survey as a priority. Data that would be obtained could be used to develop a hierarchy of goals for forming governmental policies and in providing health care services. 3. Developmental Disability a. It is important to identify the segment of the population with developmental disabilities (DD) since persons with these chronic conditions require special medical and social services if they are to function at as high a level as possible. The term "developmental disability" means a severe, chronic disability which: i is attributable to a mental or physical impairment or combination of mental and physical impairments; ii. is manifested before the person attains age 22; iii. is likely to continue indefinitely; iv. results in substantial functional limitations in three or more of the following areas of major life activity: (a). self-care; (b). receptive and expressive language; (c). learning; (d). mobility; (e). self-direction (f). capacity for independent living; and (g). economic sufficiency; and v. reflects the person's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services which are of lifelong or extended duration and are individually planned and coordinated. b. The definition of developmental disability, as amended by P.L. 95-602, is a functional rather than a categorical definition. Specific disability categories are not cited; however, individuals with the following types of conditions originating in childhood could be included if the above criteria in the definition of developmental disabilities are met: i. moderate, severe and profound levels of mental retardation; ii. cerebral palsy; iii. severe cases of epilepsy; iv. autism; v. severe emotional disturbances, particularly childhood psychosis and childhood schizophrenia; vi. severe physical impairments associated with such disorders as spina bifida, muscular dystrophy, tuberous sclerosis, and osteogenesis imperfect; vii. multiple handicaps such as deaf-blindness; viii. severe learning disabilities. c. It is estimated that at least 50 percent of the developmentally disabled persons have a major intellectual deficit. d. The Louisiana State Planning Council on Developmental Disabilities has adopted the prevalence rate of 1.1 percent for developmental disabilities. This estimate has been developed nationally and does not reflect high risk factors in Louisiana, which may contribute to a higher prevalence of developmental disabilities in this state. Using the 1.1 percent prevalence rate, it is estimated that there are 46,244 persons with developmental disabilities in Louisiana, based on 1980 census figures. e. Persons with developmental disabilities require a comprehensive coordinated system of services to participate as fully as possible in the community. Because of the developmentally disabled individual's need for continuing services, long term care services in the least restrictive and most cost effective settings are needed. Support of the family to maintain a developmentally disabled family member at home is critical. Residential programs are also needed, such as community homes, supervised apartment programs, independent living services and specialized adoptive and foster care. Finally, a range of community support services are required. 4. Mental Health and Substance Abuse a. Problems related to mental health and substance abuse are serious impediments to good health and are a major cause of ill health in the U.S. as well as in Louisiana. b. The National Institute of Mental Health estimates that 20 percent of Americans have a mild to severe psychiatric disorder and that 2 percent of the population will be hospitalized for mental illness at some point in their lives. Applying these percentages to 1980 Louisiana census data, it is estimated that 840,794 Louisianians suffer from mental health disorders, with over 84,000 persons hospitalized for mental illness. Survey data compiled by the Louisiana Office of Mental Health and Substance Abuse was the basis for an estimated prevalence rate of 6 percent for problems related to alcohol. Alcohol and drug abuse are recognized as serious primary illnesses which often overlap with each other and with other diseases and aggravate many other health and social problems. Health-related problems which are exacerbated or caused by alcohol and drug abuse are heart and liver disease, accidental death and injury, severe psychiatric impairment, fetal and infant morbidity and mortality, homicide and other violence. c. The incidence of significant mental health and substance abuse problems in the Louisiana population is at least 15 percent, or about 630,600 persons based on 1980 census data. With so large a segment of the population affected by these problems, it is critical that services directed toward ameliorating these health problems be given substantial attention. (See Chapter 115, sections on Chemical Dependency and Psychiatric Beds for further information.) d. Statistical information provided by the Office of Prevention and Recovery of Alcohol and Drug Abuse, which highlights the health and social problems caused by alcohol and drug abuse is as follows: i. the effects of alcoholism on members of the alcoholic's family is such that it is classified as a family illness. One out of eight Americans alive today (28.6 million) have been reared by a parent or parents who were alcoholics. Currently 6.6 million children under eighteen years of age live with an alcoholic parent; ii. alcohol is estimated to be involved in 53 percent to 58 percent of fatal accidents resulting in approximately 22,500 traffic deaths in 1983. Louisiana ranks 11th in the nation in deaths from motor vehicle accidents; iii. in the United States, cocaine use has increased fivefold in just ten years. Recent surveys show an estimated 22 million Americans have used cocaine and 4.2 million are considered current users; iv. fifty-four percent of inmates had been drinking prior to committing the crimes for which they were convicted. Sixty-eight percent of those convicted of manslaughter, 62 percent of those convicted of assault, and 49 percent of those convicted of murder or attempted murder were drinking prior to committing the offense; v. one fourth of all suicides are alcohol related; vi. current research shows that one out of every 16 employees has or is developing a serious alcohol or drug problem. These employees yield a 25-50 percent loss in productivity; vii. the estimated economic costs of alcohol and drug abuse to the state of Louisiana for 1980 was $2.5 billion; viii. in 1984, Louisiana ranked 26th among states in alcohol consumption; ix. an estimated 32 million Americans use marijuana each year; x. marijuana and cocaine users are concentrated among our youth; 18-25 year olds have the highest drug use rates and 12 to 17 years olds have the second highest. There has been a 200 percent increase in cocaine-related deaths in the past 5 years, and a 500 percent increase in cocaine-related treatment admissions. 5. Physically Handicapped a. Prevalence rates for the physical handicaps are inexact. The "Ridge Method" of calculating the prevalence of physical handicap in a state population was applied to Louisiana population characteristics and a prevalence rate of 18.53 percent among persons aged 18-64 was found. b. 1970 census data indicated a prevalence rate for physical handicap of 10.6 percent of the population age 16-64, which is a significantly lower estimation than produced by the "Ridge Method". c. Because 1980 census data do not have the age 18 as the bottom of an age range, it is not possible to calculate precisely the numbers of people age 18-64. Of the 1980 population 64.7 percent or 2,722,230 persons were age 15-64. We have used 12 percent of this population group as a prevalence indicator and estimate that 326,667 of the state's 1980 population age 15-64 are physically handicapped. This prevalence indicator does not include handicapped persons younger than 15 or older than 64. d. See Chapter 115, section on Comprehensive Physical Rehabilitation Services for more information. 6. Communicable Disease and other Reportable Health Conditions a. There are 32 health conditions which are to be reported by treating physicians. The incidence of most of these is minimal. For 1980 and 1984, statistics released by the Office of Preventive and Public Health Services revealed the following disease incidence in the state. Table 3.21 Reportable Diseases 1984 | 1980 Asceptic Meningitis | 85 | 93 Diptheria | 0 Encephalitis, Other and Unspecified | 14 | 24 Encephalitis Arthropod Bone | 0 | N/A Hepatitis A | 322 | - Hepatitis, Unspecified | 93 | - Hepatitis, NON A, NON B | 31 | - Hepatitis B | 336 | 313 Tuberculosis, Pulmonary | 337 | 478 Tuberculosis, Other | 40 | N/A AIDS | 53 | N/A Pertussis | 12 | 38 Rabies in Animals | 63 | 19 Rubella | 0 | 13 Severe Undernutrition | 21 | 7 Shigellosis | 113 | 233 Typhoid Fever | 2 Other Salmonellosis | 225 | 213 Tetanus | 3 | 5 Measles | 8 | 15 Gonorrhea | 25,469 | 22,605 Syphilis, including primary and secondary | 2,854 | 1,421 Brucellosis | 3 | N/A H-Blue Meningitis | 96 | N/A Legionellosis | 4 | N/A Leprosy | 4 | N/A Malaria | 12 | N/A Mycobactoeriosis, Atypical | 86 | N/A Botulism, Infant | 3 | N/A Botulism | 1 | N/A Food Poisoning | 11 | N/A Leptospirosis | 2 | N/A Source: La. Vital. Statistics Office b. Venereal disease is the most prevalent of the communicable diseases and is a serious problem in the state. Rates of gonorrhea in Louisiana decreased during the 1950's and early 1960's after the widespread use of penicillin. However, the incidence level began rising in 1965. In 1974 the incidence well exceeded pre-penicillin levels. In 1980 there were 22,605 reported cases of gonorrhea. In 1984 the number of reported cases increased to 25,469. AIDS has recently been added to the reportable diseases list because of widespread concerns. In 1984 there were 53 reported cases of AIDS in the state. c. Syphilis rates per 100,000 dropped from a 1950 high of 348.4 to 17.1 in 1977. There has been a sharp increase since 1977 in the syphilis incidence rate, with 72.6/100,000 noted in 1980. In 1984 the number of reported cases of syphilis was more than double the reported cases in 1980 or 2,854 reported cases. D. Summary 1. Mortality statistics are the most reliable indicators of health status currently available for use. Using prevalence rates to estimate the incidence of some conditions is helpful in determining health service needs for certain well-defined segments of the population, such as the developmentally disabled and physically handicapped. On the other hand, morbidity statistics are quite limited in Louisiana and should be further explored. The use of hospital discharge diagnoses as a measure of morbidity is accurate only as a measure of the relative frequency of one discharge diagnosis over another discharge diagnosis. Such "relative frequency" data available in Louisiana hospital discharges indicates a higher frequency of hospital utilization for patients with digestive, respiratory and genitourinary disease than might be expected based on mortality indicators. 2. External causes of injury (non-motor vehicular and motor vehicular accidents, burns and violence) account for a substantial number of hospital discharges (8.5 percent, according to a Mid-Louisiana patient abstract study conducted in 1978-1979) and account for a significant number of productive years lost because of premature death. There is a correlation between injuries and death from accidents and violence and the incidence of alcohol and substance abuse. These problems are significant in evaluating the health status of Louisianians. 3. Perhaps the most distinct "risk factors" which can be identified are noted in examining race and sex variables in health status. The premature death rate for non-whites is substantially greater than whites. Nonwhite males have the highest level of premature death. The observation is made, on the basis of available information, that the utilization of medical care services is inversely proportional to the likelihood of premature death. The observation can also be made that treatment appears to be most often obtained for diseases not significantly related to mortality. These correlations suggest that much illness and premature death is preventable with improved access for regular primary health care. The target population for health system initiatives in this area should be non-whites. 4. The age-adjusted death rate in Louisiana suggests that Louisiana's population is in relatively poorer health than the national average and is particularly affected by higher incidences of circulatory diseases and cancer. Louisiana's higher incidence of disease-related deaths can be attributed, at least in part, to the state's higher percentage of non-whites. (Non-whites have a significantly higher age-adjusted death rate than whites). 5. The observation can be made that rural people have a higher crude death rate and more frequent and longer hospitalizations than urban residents. This correlation is primarily due to rural areas having higher percentages of persons over 65 years of age, non-whites and persons below poverty level. Thus ruralness in itself is not seen as a health risk factor but rather the location of high percentages of persons at risk because of other factors. 6. A health status indicator which seems particularly urgent is the rate of malignant neoplasm, or cancer, in the state. The age-adjusted mortality rate for cancer is increasing rather than decreasing. The state has an age-adjusted death rate from cancer which exceeds the national rate. The death rate for cancer is greatest in the northwest district, New Orleans district and Acadiana district. Risk factors which are generally associated with poor health care are age, low income, and accessibility and availability of health care resources. However, these factors do not explain the high incidence of cancer in some areas of the state. Identification of the risk factors involved in the increasing incidence of cancer in some districts of the state, warrants study by health care professionals. 7. Louisiana's overall health status does not fare well in comparison with the U.S. as a whole. Much can be done through initiatives and changes in the health care system to improve the health status of the citizens. Much which needs to be done is also in the province of those outside the health care system, that is, those concerned with safety and accident control, homicides and violence, control of narcotics and other addictive substances, environmental quality and health education in schools. Improvement of the health of Louisianians will require a mutual effort by all, including the participation and assumption of responsibility by every citizen for his or her own personal health habits.