Are We Undercounting the True Burden of Mortality Related to Suicide, Alcohol-Related, or Drug Use? An Analysis Using Veteran Colorado Death Certificate Data
Journal article
Study highlights
Life expectancy in the United States has been declining more than 20 years, largely driven by increases in suicide, as well as alcohol and other drug-related deaths. Each of these crises have been the topic for various research studies, but there is less knowledge regarding how they may be overlapping.
During the last two decades alcohol-related deaths in the US have doubled. But how much alcohol contributes to various causes of death is often overlooked, according to the authors of this advance article.
Death certificate data is the primary source used for describing the burden of suicide, alcohol- and other drug-related deaths. In this paper, the researchers have identified notable limitations in this data, possibly leading to an underestimation of the number of deaths.
In death certificates there are two main indicators that can be used when looking at cause of death:
- Underlying cause of death (UCOD)
- Multiple cause of death (MCOD)
For example, alcohol and other drug use disorders can be implicated in both external (e.g., falls and overdoses) and internal (e.g., alcohol-related pancreatitis) causes of death, though only the former may be captured when limiting case definitions to UCOD indicators.
In the first indicators (UCOD), only the direct cause of death is listed. In the broader indicator (MCOD) ”all other intermediate and contributory conditions” are also listed.
Limiting data to UCOD may result in an underestimate of the true burden of deaths. For example, alcohol use disorders can be implicated in both external (e.g. falls and overdoses) and internal (e.g. alcohol-related pancreatitis) causes of death, though only the former may be captured when limiting definitions to UCOD indicators.”
Talia L Spark, Rachel Sayko Adams, Claire A Hoffmire, Jeri E Forster, Lisa A Brenner, Are We Undercounting the True Burden of Mortality Related to Suicide, Alcohol-Related, or Drug Use? An Analysis Using Veteran Colorado Death Certificate Data, American Journal of Epidemiology, 2022
Using data from veterans in Colorado who died between 2009 and 2020, the researchers found that more than 2000 additional deaths (an increase by 41%) was found using the broader MCOD definition.
Most notably, alcohol-related deaths increased more that 100% when using the broader definition. The conclusion is that the case definition frequently used when studying alcohol-related mortality (i.e. UCOD only) is likely too narrow.
Alcohol use disorder codes accounted for 71% of additional alcohol-related deaths captured with the MCOD definition.
Abstract
Knowledge regarding deaths due to suicide, alcohol-related, or other drug-related causes may be limited by inconsistent and/or restrictive case definitions, resulting in concerns regarding validity of findings and underestimates of burden.
In this proof-of-concept study, the researchers assessed varying case definitions (suicide, alcohol-related, other drug-related mortality using underlying cause of death [UCOD] versus multiple cause of death [MCOD]) based on counts and rates among Colorado Veterans who died (2009-2020).
Suicide, alcohol-related, or other drug-related ICD-10 codes were identified, and two case definitions were compared: UCOD; qualifying ICD-10 code listed as the UCOD; and MCOD; qualifying ICD-10 code in any cause of death field.
Of 109,314 decedents, the number and age-adjusted mortality rate (per 100,000 persons) significantly increased when including MCOD:
- UCOD, n=4,930 (110.3/100,000) versus
- MCOD, n= 6,954 (138.4/100,000).
While rates of suicide mortality did not change, alcohol-related mortality doubled with the more inclusive case-definition:
- UCOD 1,752 (27.3/100,000) versus
- MCOD 3,847 (59.8/100,000).
Alcohol use disorder codes accounted for 71% of additional alcohol-related deaths captured with the MCOD definition.
Studies that rely on UCOD codes may be underestimating the burden of deaths, especially alcohol-related deaths. Increased effort is required to reevaluate current classifications of deaths associated with suicide, alcohol-use, or other drug-use.
