Descriptive study of causes of death and COVID-19-associated morbidities from the New York City electronic death record: first wave of the pandemic March-July 2020

OBJECTIVE

Assessing excess deaths from benchmarks across causes of death during the first wave of the COVID-19 pandemic and identifying morbidities most frequently mentioned alongside COVID-19 deaths in the death record.

METHODS

Descriptive study of death records between 11 March 2020 and 27 July 2020, from the New York City Bureau of Vital Statistics. Mortality counts and percentages were compared with the average for the same calendar period of the previous 2 years. Distributions of morbidities from among forty categories of conditions were generated citywide and by sex, race/ethnicity and four age groups. Causes of death were assumed to follow Poisson processes for Z-score construction.

RESULTS

Within the study period, 46 563 all-cause deaths were reported; 132.9% higher than the average for the same period of the previous 2 years (19 989). Of those 46 563 records, 19 789 (42.5%) report COVID-19 as underlying cause of death. COVID-19 was the most prevalent cause across all demographics, with respiratory conditions (prominently pneumonia), hypertension and diabetes frequently mentioned morbidities. Black non-Hispanics had greater proportions of mentions of pneumonia, hypertension, and diabetes. Hispanics had the largest proportion of COVID-19 deaths (52.9%). Non-COVID-19 excess deaths relative to the previous 2-year averages were widely reported.

CONCLUSION

Mortality directly due to COVID-19 was accompanied by significant increases across most other causes from their reference averages, potentially suggesting a sizable COVID-19 death undercount. Indirect effects due to COVID-19 may partially account for some increases, but findings are hardly dispositive. Unavailability of vaccines for the time period precludes any impact over excess deaths. Respiratory and cardiometabolic-related conditions were most frequently reported among COVID-19 deaths across demographic characteristics.

Structural Racism, Historical Redlining, and Risk of Preterm Birth in New York City, 2013-2017

Objectives. To assess if historical redlining, the US government's 1930s racially discriminatory grading of neighborhoods' mortgage credit-worthiness, implemented via the federally sponsored Home Owners' Loan Corporation (HOLC) color-coded maps, is associated with contemporary risk of preterm birth (< 37 weeks gestation).Methods. We analyzed 2013-2017 birth certificate data for all singleton births in New York City (n = 528 096) linked by maternal residence at time of birth to (1) HOLC grade and (2) current census tract social characteristics.Results. The proportion of preterm births ranged from 5.0% in grade A ("best"-green) to 7.3% in grade D ("hazardous"-red). The odds ratio for HOLC grade D versus A equaled 1.6 and remained significant (1.2; P < .05) in multilevel models adjusted for maternal sociodemographic characteristics and current census tract poverty, but was 1.07 (95% confidence interval = 0.92, 1.20) after adjustment for current census tract racialized economic segregation.Conclusions. Historical redlining may be a structural determinant of present-day risk of preterm birth.Public Health Implications. Policies for fair housing, economic development, and health equity should consider historical redlining's impacts on present-day residential segregation and health outcomes.

Deaths From Pneumonia-New York City, 1999-2015

Background

"Pneumonia and influenza" are the third leading cause of death in New York City. Since 2012, pneumonia and influenza have been the only infectious diseases listed among the 10 leading causes of death in NYC. Most pneumonia and influenza deaths in NYC list pneumonia as the underlying cause of death, not influenza. We therefore analyzed death certificate data for pneumonia in NYC during 1999-2015.

Methods

We calculated annualized pneumonia death rates (overall and by sociodemographic subgroup) and examined the etiologic agent listed.

Results

There were 41 400 pneumonia deaths during the study period, corresponding to an annualized age-adjusted death rate of 29.7 per 100 000 population. Approximately 17.5% of pneumonia deaths specified an etiologic agent. Age-adjusted pneumonia death rate declined over the study period and across each borough. Males had an annualized age-adjusted pneumonia death rate 1.5 (95% confidence interval [CI], 1.5-1.5) times that of females. Non-Hispanic blacks had an annualized age-adjusted pneumonia death rate 1.2 (95% CI, 1.2-1.2) times that of non-Hispanic whites. The annualized pneumonia death rate increased with age group above 5-24 years and neighborhood-level poverty. Staten Island had an annualized age-adjusted pneumonia death rate 1.3 (95% CI, 1.2-1.3) times that of Manhattan. In the multivariable analysis, pneumonia deaths were more likely to occur among males, non-Hispanic blacks, persons aged ≥65 years, residents of neighborhoods with higher poverty levels, and in Staten Island.

Conclusions

While the accuracy of death certificates is unknown, investigation is needed to understand why certain populations are disproportionately recorded as dying from pneumonia in NYC.

Neighborhood Inequalities in Hepatitis C Mortality: Spatial and Temporal Patterns and Associated Factors

Deaths attributable to hepatitis C (HCV) infection are increasing in the USA even as highly effective treatments become available. Neighborhood-level inequalities create barriers to care and treatment for many vulnerable populations. We seek to characterize citywide trends in HCV mortality rates over time and identify and describe neighborhoods in New York City (NYC) with disproportionately high rates and associated factors. We used a multiple cause of death (MCOD) definition for HCV mortality. Cases identified between January 1, 2006, and December 31, 2014, were geocoded to NYC census tracts (CT). We calculated age-adjusted HCV mortality rates and identified spatial clustering using a local Moran's I test. Temporal trends were analyzed using joinpoint regression. A multistep global and local Poisson modeling approach was used to test for neighborhood associations with sociodemographic indicators. During the study period, 3697 HCV-related deaths occurred in NYC, with an average annual percent increase of 2.6% (p = 0.02). The HCV mortality rates ranged from 0 to 373.6 per 100,000 by CT, and cluster analysis identified significant clustering of HCV mortality (I = 0.23). Regression identified positive associations between HCV mortality and the proportion of non-Hispanic black or Hispanic residents, neighborhood poverty, education, and non-English-speaking households. Local regression estimates identified spatially varying patterns in these associations. The rates of HCV mortality in NYC are increasing and vary by neighborhood. HCV mortality is associated with many indicators of geographic inequality. Results identified neighborhoods in greatest need for place-based interventions to address social determinants that may perpetuate inequalities in HCV mortality.

Spatial social polarization and birth outcomes: preterm birth and infant mortality - New York City, 2010-14

AIMS

This study assessed the relationship between spatial social polarization measured by the index of the concentration of the extremes (ICE) and preterm birth (PTB) and infant mortality (IM) in New York City. A secondary aim was to examine the ICE measure in comparison to neighborhood poverty.

METHODS

The sample included singleton births to adult women in New York City, 2010-2014 ( n=532,806). Three ICE measures were employed at the census tract level: ICE - Income (persons in households in the bottom vs top 20th percentile of US annual household income), ICE -Race/Ethnicity (black non-Hispanic vs white non-Hispanic populations), and ICE - Income + Race/Ethnicity combined. Preterm birth was defined as birth before 37 weeks' gestation. Infant mortality was defined as a death before one year of age. A two-level generalized linear model with random intercept was utilized adjusting for individual-level covariates.

RESULTS

Preterm birth prevalence was 7.1% and infant mortality rate was 3.4 per 1000 live births. Women who lived in areas with the least privilege were more likely to have a preterm birth or infant mortality as compared to women living in areas with the most privilege. After adjusting for covariates, this association remained for preterm birth (ICE - Income: Adjusted Odds Ratio (AOR) 1.16 (1.10-1.21); ICE - Race/Ethnicity: AOR 1.41 (1.34-1.49); ICE - Income + Race/Ethnicity: AOR 1.36 (1.29-1.43)) and IM (ICE - Race/Ethnicity (AOR 1.80 (1.43-2.28) and ICE - Income + Race/Ethnicity (AOR 1.54 (1.23-1.94)). High neighborhood poverty was associated with PTB only (AOR 1.09 (1.04-1.14).

CONCLUSIONS

These results provide preliminary evidence for the use of the ICE measure in examining structural barriers to healthy birth outcomes.

Infant Deaths Due To Herpes Simplex Virus, Congenital Syphilis, and HIV in New York City

BACKGROUND

Neonatal infection with herpes simplex virus (HSV) is not a nationally reportable disease; there have been few population-based measures of HSV-related infant mortality. We describe infant death rates due to neonatal HSV as compared with congenital syphilis (CS) and HIV, 2 reportable, perinatally transmitted diseases, in New York City from 1981 to 2013.

METHODS

We identified neonatal HSV-, CS-, and HIV-related deaths using International Classification of Diseases (ICD) codes listed on certificates of death or stillbirth issued in New York City. Deaths were classified as HSV-related if certificates listed (1) any HSV ICD-9/ICD-10 codes for deaths ≤42 days of age, (2) any HSV ICD-9/ICD-10 codes and an ICD code for perinatal infection for deaths at 43 to 365 days of age, or (3) an ICD-10 code for congenital HSV. CS- and HIV-related deaths were those listing any ICD code for syphilis or HIV.

RESULTS

There were 34 deaths due to neonatal HSV (0.82 deaths per 100 000 live births), 38 from CS (0.92 per 100 000), and 262 from HIV (6.33 per 100 000). There were no CS-related deaths after 1996, and only 1 HIV-related infant death after 2004. The neonatal HSV-related death rate during the most recent decade (2004-2013) was significantly higher than in previous years.

CONCLUSIONS

The increasing neonatal HSV-related death rate may reflect increases in neonatal herpes incidence; an increasing number of pregnant women have never had HSV type 1 and are therefore at risk of acquiring infection during pregnancy and transmitting to their infant.

Public Health Monitoring of Privilege and Deprivation With the Index of Concentration at the Extremes

OBJECTIVES

We evaluated use of the Index of Concentration at the Extremes (ICE) for public health monitoring.

METHODS

We used New York City data centered around 2010 to assess cross-sectional associations at the census tract and community district levels, for (1) diverse ICE measures plus the US poverty rate, with (2) infant mortality, premature mortality (before age 65 years), and diabetes mortality.

RESULTS

Point estimates for rate ratios were consistently greatest for the novel ICE that jointly measured extreme concentrations of income and race/ethnicity. For example, the census tract-level rate ratio for infant mortality comparing the bottom versus top quintile for an ICE contrasting low-income Black versus high-income White equaled 2.93 (95% confidence interval [CI] = 2.11, 4.09), but was 2.19 (95% CI = 1.59, 3.02) for low versus high income, 2.77 (95% CI = 2.02, 3.81) for Black versus White, and 1.56 (95% CI = 1.19, 2.04) for census tracts with greater than or equal to 30% versus less than 10% below poverty.

CONCLUSIONS

The ICE may be a useful metric for public health monitoring, as it simultaneously captures extremes of privilege and deprivation and can jointly measure economic and racial/ethnic segregation.

Public Health Monitoring of Privilege and Deprivation With the Index of Concentration at the Extremes

OBJECTIVES

We evaluated use of the Index of Concentration at the Extremes (ICE) for public health monitoring.

METHODS

We used New York City data centered around 2010 to assess cross-sectional associations at the census tract and community district levels, for (1) diverse ICE measures plus the US poverty rate, with (2) infant mortality, premature mortality (before age 65 years), and diabetes mortality.

RESULTS

Point estimates for rate ratios were consistently greatest for the novel ICE that jointly measured extreme concentrations of income and race/ethnicity. For example, the census tract-level rate ratio for infant mortality comparing the bottom versus top quintile for an ICE contrasting low-income Black versus high-income White equaled 2.93 (95% confidence interval [CI] = 2.11, 4.09), but was 2.19 (95% CI = 1.59, 3.02) for low versus high income, 2.77 (95% CI = 2.02, 3.81) for Black versus White, and 1.56 (95% CI = 1.19, 2.04) for census tracts with greater than or equal to 30% versus less than 10% below poverty.

CONCLUSIONS

The ICE may be a useful metric for public health monitoring, as it simultaneously captures extremes of privilege and deprivation and can jointly measure economic and racial/ethnic segregation.

Impact of a hospital-level intervention to reduce heart disease overreporting on leading causes of death

INTRODUCTION

The quality of cause-of-death reporting on death certificates affects the usefulness of vital statistics for public health action. Heart disease deaths are overreported in the United States. We evaluated the impact of an intervention to reduce heart disease overreporting on other leading causes of death.

METHODS

A multicomponent intervention comprising training and communication with hospital staff was implemented during July through December 2009 at 8 New York City hospitals reporting excessive heart disease deaths. We compared crude, age-adjusted, and race/ethnicity-adjusted proportions of leading, underlying causes of death reported during death certification by intervention and nonintervention hospitals during preintervention (January-June 2009) and postintervention (January-June 2010) periods. We also examined trends in leading causes of death for 2000 through 2010.

RESULTS

At intervention hospitals, heart disease deaths declined by 54% postintervention; other leading causes of death (ie, malignant neoplasms, influenza and pneumonia, cerebrovascular disease, and chronic lower respiratory diseases) increased by 48% to 232%. Leading causes of death at nonintervention hospitals changed by 6% or less. In the preintervention period, differences in leading causes of death between intervention and nonintervention hospitals persisted after controlling for race/ethnicity and age; in the postintervention period, age accounted for most differences observed between intervention and nonintervention hospitals. Postintervention, malignant neoplasms became the leading cause of premature death (ie, deaths among patients aged 35-74 y) at intervention hospitals.

CONCLUSION

A hospital-level intervention to reduce heart disease overreporting led to substantial changes to other leading causes of death, changing the leading cause of premature death. Heart disease overreporting is likely obscuring the true levels of cause-specific mortality.

A case study of the impact of inaccurate cause-of-death reporting on health disparity tracking: New York City premature cardiovascular mortality

OBJECTIVES

Heart disease death overreporting is problematic in New York City (NYC) and other US jurisdictions. We examined whether overreporting affects the premature (< 65 years) heart disease death rate disparity between non-Hispanic Blacks and non-Hispanic Whites in NYC.

METHODS

We identified overreporting hospitals and used counts of premature heart disease deaths at reference hospitals to estimate corrected counts. We then corrected citywide, age-adjusted premature heart disease death rates among Blacks and Whites and a White-Black premature heart disease death disparity.

RESULTS

At overreporting hospitals, 51% of the decedents were White compared with 25% at reference hospitals. Correcting the heart disease death counts at overreporting hospitals decreased the age-adjusted premature heart disease death rate 10.1% (from 41.5 to 37.3 per 100,000) among Whites compared with 4.2% (from 66.2 to 63.4 per 100,000) among Blacks. Correction increased the White-Black disparity 6.1% (from 24.6 to 26.1 per 100,000).

CONCLUSIONS

In 2008, NYC's White-Black premature heart disease death disparity was underestimated because of overreporting by hospitals serving larger proportions of Whites. Efforts to reduce overreporting may increase the observed disparity, potentially obscuring any programmatic or policy-driven advances.

An intervention to improve cause-of-death reporting in New York City hospitals, 2009-2010

Introduction

Poor-quality cause-of-death reporting reduces reliability of mortality statistics used to direct public health efforts. Overreporting of heart disease has been documented in New York City (NYC) and nationwide. Our objective was to evaluate the immediate and longer-term effects of a cause-of-death (COD) educational program that NYC’s health department conducted at 8 hospitals on heart disease reporting and on average conditions per certificate, which are indicators of the quality of COD reporting.

Methods

From June 2009 through January 2010, we intervened at 8 hospitals that overreported heart disease deaths in 2008. We shared hospital-specific data on COD reporting, held conference calls with key hospital staff, and conducted in-service training. For deaths reported from January 2009 through June 2011, we compared the proportion of heart disease deaths and average number of conditions per death certificate before and after the intervention at both intervention and nonintervention hospitals.

Results

At intervention hospitals, the proportion of death certificates that reported heart disease as the cause of death decreased from 68.8% preintervention to 32.4% postintervention (P < .001). Individual hospital proportions ranged from 58.9% to 79.5% preintervention and 25.9% to 45.0% postintervention. At intervention hospitals the average number of conditions per death certificate increased from 2.4 conditions preintervention to 3.4 conditions postintervention (P < .001) and remained at 3.4 conditions a year later. At nonintervention hospitals, these measures remained relatively consistent across the intervention and postintervention period.

Conclusion

This NYC health department’s hospital-level intervention led to durable changes in COD reporting.

Risk adjustment and public reporting on home health care

Risk adjustment is a critical tool in public reporting of quality measures. Its aim is to level the playing field so that providers serving different patients can be meaningfully compared. We used a theory and evidence-based approach to develop risk-adjustment models for the 10 publicly reported home health quality measures and compared their performance with current models developed using a data-driven stepwise approach. Overall, the quality ratings for most agencies were similar regardless of approach. Theory and evidence-based models have the potential to simplify risk adjustment, and thereby improve provider and consumer understanding and confidence in public reporting.