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Home » Publications » Surveillance Reports » Surveillance Report #111

National Institute on Alcohol Abuse and Alcoholism
Division of Epidemiology and Prevention Research
Alcohol Epidemiologic Data System

SURVEILLANCE REPORT #111

LIVER CIRRHOSIS MORTALITY IN THE UNITED STATES:
NATIONAL, STATE, AND REGIONAL TRENDS, 2000–2015

Young-Hee Yoon, Ph.D.
Chiung M. Chen, M.A.

CSR, Incorporated1
Suite 500
4250 N. Fairfax Drive
Arlington, VA 22203

April 2018


U.S. Department of Health and Human Services
Public Health Service
National Institutes of Health

1 CSR, Incorporated, operates the Alcohol Epidemiologic Data System (AEDS) under Contract No. HHSN275201300016C for the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Dr. Rosalind A. Breslow (Division of Epidemiology and Prevention Research) serves as the NIAAA Contracting Officer’s Representative on the contract.

HIGHLIGHTS

This surveillance report, prepared biennially by the Alcohol Epidemiologic Data System (AEDS), National Institute on Alcohol Abuse and Alcoholism (NIAAA), presents trends in liver cirrhosis mortality in the United States. Data on the underlying cause of death were compiled from public use data tapes and files published annually by the National Center for Health Statistics (NCHS). Population data from the U.S. Census Bureau and NCHS are used as denominators to calculate mortality rates.

The age-adjusted death rate from liver cirrhosis in the United States increased steadily from 11.9 deaths per 100,000 population at the end of Prohibition in 1933 to a peak of 18.1 deaths per 100,000 population in 1973, and then steadily declined for three decades until 2006, when the long-term downward trend shifted its course. The following are highlights of liver cirrhosis mortality in 2015 and its trends from 2000 through 2015.

Cirrhosis Mortality in 2015

  • In 2015, liver cirrhosis was the 12th leading cause of death in the United States, with a total of 42,443 deaths—2,494 more than in 2014. The crude death rate from all cirrhosis was 13.2 deaths per 100,000 population, and the rate from alcohol-related cirrhosis was 6.6, representing an increase of 5.6 percent and 8.2 percent from 2014, respectively.
  • Among all cirrhosis deaths in 2015, 49.5 percent were alcohol related. The proportion of alcohol-related cirrhosis was highest (76.8 percent) among decedents ages 25 to 34, followed by decedents ages 35 to 44, at 72.7 percent.
  • The age-adjusted death rate from all cirrhosis for Hispanic White males was 1.5 times the rate for non-Hispanic White males and 2.2 times the rate for non-Hispanic Black males. The rate for Hispanic White females was 1.3 times the rate for non-Hispanic White females and 1.9 times the rate for non-Hispanic Black females.
  • Wide variations existed across Hispanic subgroups. The 5-year annual average of age-adjusted death rates from all cirrhosis was highest for Mexicans and Puerto Ricans and lowest for Cubans, among both males and females.

Cirrhosis Mortality Trends

  • While the age-adjusted all-cause mortality rate declined by 15.6 percent from 2000 to 2015, the age-adjusted death rate from all liver cirrhosis increased for the same period by 17.5 percent, from 9.7 to 11.4 deaths per 100,000 population. Rates for White males and females increased by 17.5 percent and 41.9 percent, respectively, whereas rates for Black males and females declined by 26.3 percent and 14.1 percent, respectively.
  • The age-adjusted death rate from all liver cirrhosis for males was consistently about twice the rate for females, regardless of race.
  • The age-adjusted death rate from alcohol-related liver cirrhosis increased by 34.9 percent, from 4.3 deaths per 100,000 population in 2000 to 5.8 deaths per 100,000 population in 2015. Rates for White males and females increased by 32.4 percent and 85.0 percent, respectively, whereas rates for Black males and females declined by 27.5 percent and 10.7 percent, respectively.
  • From 2000 to 2015, the age-specific death rates from all liver cirrhosis increased for ages 25–34 (81.8 percent), 45–54 (18.5 percent), 55–64 (41.8 percent), 65–74 (9.9 percent), 75–84 (11.9 percent), and 85 or older (14.6 percent), but decreased for ages 35–44 (5.2 percent).
  • Between 2000 and 2015, changes in the age-adjusted death rate from all liver cirrhosis included increases in 41 States, decreases in 8 States and the District of Columbia, and no change in 1 State (Georgia).

Healthy People 2020 Objectives

  • One of the objectives of Healthy People 2020 is to reduce the age-adjusted liver cirrhosis mortality to no more than 8.2 deaths per 100,000 population. To achieve this goal, the age-adjusted cirrhosis death rate must decrease by 6.4 percent per year from 2015 through 2020.

INTRODUCTION

This surveillance report on liver cirrhosis mortality is one of a series of five reports published annually or biennially to monitor trends in alcohol consumption and alcohol-related morbidity and mortality in the United States. These surveillance reports are prepared by the Alcohol Epidemiologic Data System (AEDS), Division of Epidemiology and Prevention Research, National Institute on Alcohol Abuse and Alcoholism (NIAAA), and are intended to be useful to researchers, policymakers, and other professionals interested in alcohol misuse and its long-term effects. The data also are essential in assessing progress toward meeting the Nation’s health promotion and disease prevention objective of reducing liver cirrhosis mortality, as stated in Healthy People 2020 (Department of Health and Human Services [HHS] 2014).

Cirrhosis of the liver is an outcome with a variety of causes, including alcohol consumption, exposure to various drugs and toxic chemicals, viral hepatitis, and other viral and infectious diseases (Dufour et al. 1993; Scaglione et al. 2015; Wahlang et al. 2013). It has been well established that alcohol consumption is a major contributor to deaths from cirrhosis and the related condition of alcoholic hepatitis (Mann et al. 2003; Rehm et al. 2013; Szabo and Mandrekar 2010).

The level and duration of alcohol consumption are important determinants in the development of liver pathology. As the primary site for detoxification of alcohol by oxidation of its metabolites, the liver can undergo three pathologies: fatty liver, alcoholic hepatitis, and cirrhosis. The prognosis for patients with cirrhosis is highly unpredictable. Although some patients can benefit from a liver transplant, at present, no method exists for repairing liver damage associated with cirrhosis. However, the consequences of this disease can be treated and life can be prolonged if patients with cirrhosis resulting from alcohol consumption abstain from further alcohol use. Thus, early detection and prevention of further damage are important in prolonging life.

The coding scheme used in the United States to classify cause of death is the International Classification of Diseases (ICD), a statistical classification of disease and injury widely used by countries supporting mortality reporting systems. ICD codes classify the cause of death from cirrhosis as either related to alcohol or not related to alcohol. Because of the stigma associated with excessive alcohol use, physicians and other officials who certify causes of death may not identify alcohol in the case of a death from cirrhosis in an effort to protect family members. Furthermore, it is difficult to determine the alcohol-relatedness of a cirrhosis death without knowing the decedent’s history of alcohol consumption. As a result, alcohol-related cirrhosis mortality can be significantly underreported. For instance, from 2000 to 2015, the proportion of all cirrhosis deaths coded as alcohol related ranged from 44 to 50 percent (depending on year). However, some researchers believe alcohol might have contributed to a substantially higher proportion of all deaths from cirrhosis (Haberman and Weinbaum 1990; Powell and Klatskin 1968; Puffer and Griffith 1967; Ramstedt 2003; Stein et al. 2016). Therefore, this surveillance report examines all cirrhosis deaths as well as those that are explicitly coded as alcohol related.

This report has been presenting national data since its first issue published in 1986. Beginning with its 2014 issue, the report added data for States and Census Regions. Because of this addition, the report focuses on data in the 2000s and onward to closely monitor the emerging trends and patterns in cirrhosis mortality. Consequently, the title of the report has been revised to reflect these changes. To provide readers a quick reference of the historical trend, the report keeps one table and one figure on national total cirrhosis mortality from 1910 to the present. Detailed national data for 1970–1999 are available online in the 2012 issue of this report (http://pubs.niaaa.nih.gov/publications/Surveillance93/Cirr09.pdf).

DATA SOURCES

Death counts and rates in this report are based on a single underlying cause of each death, defined as “the disease or injury which initiated the train of morbid events leading directly or indirectly to death or circumstances of the accident or violence which produced the fatal injury” (National Center for Health Statistics [NCHS] 1982). This approach is consistent with other mortality statistics reported by NCHS.

Cirrhosis death records for national trends for 1970–2015 were extracted from public use mortality data files produced by NCHS. These data files contained individual records of each death occurring in the United States, with the exception of data files for 1972, which contained only a 50-percent sample of all U.S. deaths. The deaths counted in this report are for U.S. residents only. Deaths of foreign residents in the United States are not counted. Cirrhosis death data for States and Census Regions for 2000–2015 were obtained from the CDC WONDER online mortality database using its query system (http://wonder.cdc.gov/).

Historical cirrhosis mortality rates for 1910–1969 (presented in Figure 1 and Table 1) were calculated based on historical government documents that NCHS made available on the Internet (http://www.cdc.gov/nchs/products/vsus.htm). For 1910–1919, the data sources included the National Office of Vital Statistics special report (1956) and intercensal resident population estimates in death registration States developed by the Bureau of the Census and presented in Linder and Grove (1943). For 1920–1969, the data sources included the annual reports of the Mortality Statistics (Bureau of the Census 1922–1938) and Vital Statistics in the United States (Bureau of the Census 1939–1946; National Center for Health Statistics, 1961–1974; National Office of Vital Statistics 1947–1951, 1953–1960). Note that all historical mortality statistics were based on numbers obtained through State death registration offices. Before 1933, not all States collected death registration information. The changing number of death registration States impedes the process of obtaining comparable mortality data for the United States before 1933.

Population data from various estimates provided by the U.S. Census Bureau were used as denominators for calculating mortality rates in this report. The detailed data sources for population estimates at the national and State level and for Hispanic subgroups are listed in Appendix A.

METHODS

Definitions and Subclassifications of Liver Cirrhosis

This report presents data for three major subcategories of liver cirrhosis: alcohol-related liver cirrhosis, specified liver cirrhosis without mention of alcohol, and unspecified liver cirrhosis without mention of alcohol (see the last column of the table “Crosswalk of ICD-10 codes to ICD-9 codes and ICDA-8 codes” below). When the case numbers are small, the latter two subcategories are combined into one and labeled as “all other cirrhosis without mention of alcohol.”

During the long period (1910–2015) for which historical mortality statistics are shown in this report, cause of death was classified according to nine revisions of the ICD. The ICD has been revised periodically to reflect progress in medical knowledge, with later revisions generally providing greater specificity of coding.

The eighth (NCHS 1968), ninth (World Health Organization [WHO] 1978), and tenth (WHO 1992) revisions of the ICD (ICDA-8, ICD-9, and ICD-10, implemented in 1968, 1979, and 1999, respectively) provide for coding categories of cirrhosis with and without mention of alcohol. ICD-9 uses different categories for cirrhosis than did ICDA-8. ICD-10 uses twice as many categories for cirrhosis as did ICD-9. To examine trends for comparable diseases over time, ICD-9 and ICD-10 categories must be matched and recoded to those consistent with ICDA-8 categories. The relevant crosswalk of the three ICD revisions, developed by AEDS staff in collaboration with NIAAA’s former Division of Biometry and Epidemiology (DBE), is shown in the table “Crosswalk of ICD-10 codes to ICD-9 codes and ICDA-8 codes.” As can be seen under ICD-10, this report includes portal hypertension (ICD code K76.6) and fatty (change of) liver not elsewhere classified (n.e.c.) (ICD code K76.0) among cirrhosis categories. Because NCHS counts only ICD codes K70, K73, and K74 as liver cirrhosis, numbers presented in this report are slightly larger than those reported by NCHS.

.

1 Not defined as liver cirrhosis by NCHS.

Race or Hispanic Origin of Decedent

Data are presented in this report by White and Black race categories, with other races such as American Indian/Alaska Native and Asian/Pacific Islander included in the “all races” category but not shown separately. Beginning in 2003, multiple race reporting was implemented in 7 States (California, Idaho, Montana, New York, Hawaii, Maine, and Wisconsin), and the remaining 43 States and the District of Columbia allowed only a single race to be reported. To make the data uniform and comparable, NCHS began to “bridge” multiple races to a single race. In this effort, multiracial decedents were imputed with a single race according to the combination of races, Hispanic origin, sex, and age indicated on their death certificates. The imputation procedure is described in detail at: http://www.cdc.gov/nchs/data/dvs/Multiple_race_docu_5-10-04.pdf.

Vital statistics data also provide information on the Hispanic origin (also known as ethnicity) of decedents. From 2000 through 2015, the percentage of cirrhosis deaths with unknown Hispanic origin was less than 1 percent for both Black and White decedents. In 2015, only 0.4 percent of cirrhosis decedents had an “unknown” classification for Hispanic origin. The tables and figures showing data based on Hispanic origin excluded decedents for whom Hispanic origin could not be determined. Readers are cautioned that rates calculated for Black Hispanics are unreliable because of the small number of cirrhosis deaths in this population subgroup.

After a continuous, rapid population growth over the past few decades, Hispanics became the largest minority group in the United States in 2001 (U.S. Census Bureau 2011). Although Hispanics often are considered one ethnic group, they are well known for heterogeneity by country of origin in terms of socioeconomic status and drinking patterns, which may well affect cirrhosis mortality. To provide information on Hispanic subgroup differences, this report presents additional data on cirrhosis death rates for four major Hispanic subgroups, namely Mexicans, Puerto Ricans, Cubans, and Other Hispanics.

Mortality Measures

For epidemiologic purposes, death rates are used to compare the frequency of death from a disease or condition. The following measures are used in this report to assess trends in liver cirrhosis mortality:

  • Unadjusted (or crude) death rates—These are summary measures calculated by dividing the total number of deaths due to cirrhosis (or subcategories) in the population in a certain year by the total number of individuals in that population in that year (i.e., population at risk). Problems can arise when comparing crude rates between various years to assess any change in mortality over time, because the populations at risk may differ with respect to an underlying characteristic such as age, race, or sex. For example, an older population tends to have a higher rate of death for a target disease than a younger population, because death from disease is more common in an aging population. In this case, rates in different populations should be assessed by comparing age-specific rates and age-adjusted rates.
  • Age-specific death rates—These rates for any year refer to the number of deaths due to liver cirrhosis (or subcategories) in a defined age interval, divided by the total number of persons in that age interval. For a given age interval, examining age-specific rates for various years allows comparison of mortality rates among subgroups of the population that do not differ in their age distribution. Age-specific rates also provide a basis for detailed study of the variation of mortality rates among different age intervals in any single year.
  • Age-adjusted death rates—These are statistically constructed summary rates that account for differences in mortality, regardless of any difference in the age distribution between populations. Age adjustment assumes that populations have the same age distribution and applies a standard age distribution to calculate age-adjusted rates for various populations. Therefore, when comparing age-adjusted rates of two populations, any differences between the rates can no longer be due to the difference in the age distribution between the two populations. Age adjustment is crucial for standardizing rates over many years because the U.S. population has grown progressively older in recent decades. Without age adjustment, any apparent increases in unadjusted mortality rates for cirrhosis (or any other disease) could be caused by the fact that older people are more likely to die from disease.

According to the requirement of the U.S. Department of Health and Human Services (1998), this report applies the year 2000 standard population in calculations of all age-adjusted death rates (replacing the 1940 standard population used in issues published before 2002).1

1 Standard population age distribution:

 

Age-adjusted death rates presented in this report were computed by using 10-year age intervals of the enumerated population of the United States in 2000 as the standard population. Results from the age adjustment allow for meaningful comparison of similar rates over long periods of time or from different subpopulations. The basic procedure involves finding the expected number of deaths that would have existed if the age-specific rates for a particular year prevailed in a population whose age distribution was like that of the United States in 2000. This was accomplished by multiplying the specific rates for each age group by the population for the corresponding age group in the standard population. The age-adjusted death rate was then calculated by adding the expected deaths for each age group and dividing this sum by the total population taken as the standard.

Rates for Hispanic subgroups are based on 5-year annual moving averages to increase the reliability of these estimates. Readers are cautioned that the rates are subject to sampling variability of the population data (denominator) drawn from the Current Population Survey as well as random variations of the death counts (numerator) drawn from the mortality data.

Rates for States and Census Regions are based on 3-year annual moving averages to increase the reliability of these estimates.

Limitations

There is no standard definition of liver cirrhosis deaths. This report is based on the NIAAA definition (Stinson et al. 2001), which includes more ICD codes than the NCHS definition but fewer than the WHO Global Burden of Disease definition (Mokdad et al. 2014). The NIAAA definition does not include those deaths with an underlying cause of viral hepatitis, other liver diseases, and some other complications of liver diseases. Death numbers and the corresponding mortality trends over time can be different when estimated based on different definitions (Asrani et al. 2013; Manos et al. 2008; Vong and Bell 2004).

The introduction of ICD-10 for 1999 data brought changes in rules for selecting the underlying cause of death and new categories. These new rules and categories may contribute to observed changes in the number of deaths from liver cirrhosis. Anderson and colleagues (2001) conducted a comparability study that estimated that the use of ICD-10 would classify an additional 3.67 percent of deaths as due to cirrhosis when compared with ICD-9. Readers should keep this in mind when examining trends involving data from 1999 and later years. In addition, NCHS implemented coding changes in data for 2007 that resulted in more deaths being assigned to alcoholic liver disease (ICD-10 code K70). Therefore, the unusually big increase in cirrhosis deaths observed from 2006 to 2007 may be largely due to the coding changes (Xu et al. 2010).

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Xu, J.; Kochanek, K.D.; Murphy, S.L.; and Tejada-Vera, B. Deaths: Final Data for 2007. National Vital Statistics Reports, Vol. 58, No. 19. Hyattsville, MD: National Center for Health Statistics, 2010.

Xu, J.; Murphy, S.L.; Kochanek, K.D.; and Bastian, B.A. Deaths: Final Data for 2013. National Vital Statistics Reports, Vol. 64, No. 2. Hyattsville, MD: National Center for Health Statistics, 2016.

List of Figures

Figure 1. Age-adjusted death rates of liver cirrhosis by sex (death registration States, 1910–1932, and United States, 1933–2015).

Figure 2. Age-adjusted death rates of liver cirrhosis by sex and race, United States, 2000–2015.

Figure 3. Age-specific death rates of liver cirrhosis, United States, 2000–2015.

Figure 4. Age-specific death rates of liver cirrhosis by race and sex, United States, 2000–2015.

Figure 5. Age-adjusted death rates of liver cirrhosis by sex, race, and Hispanic origin, United States, 2000–2015.

Figure 6. Age-adjusted death rates of liver cirrhosis reported with and without mention of alcohol, United States, 2000–2015.

Figure 7. Percent of all cirrhosis deaths coded as alcohol-related by age, United States, 2000–2015.

Figure 8. Age-adjusted death rates of alcohol-related liver cirrhosis by sex, race, and Hispanic origin, United States, 2000–2015.

Figure 9. Age-adjusted death rates of specified liver cirrhosis without mention of alcohol by sex, race, and Hispanic origin, United States, 2000–2015.

Figure 10. Age-adjusted death rates of unspecified liver cirrhosis without mention of alcohol by sex, race, and Hispanic origin, United States, 2000–2015.

Figure 11. Five-year annual average of age-adjusted death rates of liver cirrhosis with and without mention of alcohol by Hispanic subgroup and sex, United States, 2011–2015.

Figure 12. Three-year annual average of age-adjusted death rates of all liver cirrhosis, by State, 2013–2015.

Figure 13. Three-year annual average of age-adjusted death rates of alcohol-related liver cirrhosis, by State, 2013–2015.

Figure 14. Three-year annual average of age-adjusted death rates of all other liver cirrhosis without mention of alcohol, by State, 2013–2015.

 

List of Tables

Table 1. Age-adjusted death rates from liver cirrhosis by sex (death registration States, 1910–1932, and United States, 1933–2015).

Table 2. Age-specific number of deaths, age-specific death rates, and age-adjusted death rates from all liver cirrhosis by race, Hispanic origin, and sex, United States, 2000–2015.

Table 3. Age-specific number of deaths, age-specific death rates, and age-adjusted death rates from liver cirrhosis with and without mention of alcohol, United States, 2000–2015.

Table 4. Age-adjusted death rates from liver cirrhosis with and without mention of alcohol by sex, race, and Hispanic origin, United States, 2000–2015.

Table 5. Age-specific number of deaths, 5-year annual moving average of age-specific death rates, and age-adjusted death rates from all liver cirrhosis by Hispanic subgroup and sex, United States, 2000–2015.

Table 6. Age-specific number of deaths, 5-year annual moving average of age-specific death rates, and age-adjusted death rates from liver cirrhosis with and without mention of alcohol by Hispanic subgroup and sex, United States, 2000–2015.

Table 7. Number of deaths and 3-year annual moving average of age-adjusted death rates from liver cirrhosis with and without mention of alcohol, States, Census Regions, and the United States, 2000–2015.

Appendix A. Data sources of population estimates at the national and State level and for Hispanic subgroups.



Figure 1. Age-adjusted death rates of liver cirrhosis by sex (death registration States, 1910–1932, and United States, 1933–2015).

figure 1
Data for Figure 1 are presented in Table 1.

Figure 2. Age-adjusted death rates of liver cirrhosis by sex and race, United States, 2000–2015.

figure 2
Data for Figure 2 are presented in Table 2.

 

Figure 3. Age-specific death rates of liver cirrhosis, United States, 2000–2015.

figure 3
Data for Figure 3 are presented in Table 2.

 

Data for Figure 4 are presented in Table 2.

 

Figure 5. Age-adjusted death rates of liver cirrhosis by sex, race, and Hispanic origin, United States, 2000–2015.

figure 5
Data for Figure 5 are presented in Table 2.

 

Figure 6. Age-adjusted death rates of liver cirrhosis reported with and without mention of alcohol, United States, 2000–2015.

figure 6
Data for Figure 6 are presented in Table 3.

 

Figure 7. Percent of all cirrhosis deaths coded as alcohol-related by age, United States, 2000–2015.

figure 7
Data for Figure 7 are presented on this page.

 

Figure 8. Age-adjusted death rates of alcohol-related liver cirrhosis by sex, race, and Hispanic origin, United States, 2000–2015.

figure 8
Data for Figure 8 are presented in Table 4.

 

Figure 9. Age-adjusted death rates of specified liver cirrhosis without mention of alcohol by sex, race, and Hispanic origin, United States, 2000–2015.

figure 9
Data for Figure 9 are presented in Table 4.

 

Figure 10. Age-adjusted death rates of unspecified liver cirrhosis without mention of alcohol by sex, race, and Hispanic origin, United States, 2000–2015.

figure 10
Data for Figure 10 are presented in Table 4.

 

Figure 11. Five-year annual average of age-adjusted death rates of liver cirrhosis with and without mention of alcohol by
Hispanic subgroup and sex, United States, 2011–2015.

figure 11
Data for Figure 11 are presented in Table 6.

 

Figure 12. Three-year annual average of age-adjusted death rates of all liver cirrhosis, by State, 2013–2015.

figure 12

Data for Figure 12 are presented in Table 7.

Figure 13. Three-year annual average of age-adjusted death rates of alcohol-related liver cirrhosis, by State, 2013–2015.

figure 13

Data for Figure 13 are presented in Table 7.


Figure 14. Three-year annual average of age-adjusted death rates of all other liver cirrhosis without mention of alcohol, by State, 2013–2015.

figure 14

Data for Figure 14 are presented in Table 7.


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