Technical Appendix for 1991 SOURCES OF DATA Death and fetal death statistics Mortality statistics for 1991 are, as for all previous years except 1972, based on information from records of all deaths occurring in the United States. Fetal-death statistics for every year are based on all reports of fetal death received by the National Center for Health Statistics (NCHS). The death-registration system and the fetal-death reporting system of the United States encompass the 50 States, the District of Columbia, New York City (which is independent of New York State for the purpose of death registration), Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Marianas. In the statistical tabulations of this publication, United States refers only to the aggregate of the 50 States (including New York City) and the District of Columbia. Tabulations for Guam, Puerto Rico, and the Virgin Islands are shown separately in this volume. No data have ever been included for American Samoa or the Trust Territory of the Pacific Islands. The Virgin Islands was admitted to the registration area for deaths in 1924; Puerto Rico, in 1932; and Guam, in 1970. Tabulations of death statistics for Puerto Rico and the Virgin Islands were shown regularly in the annual volumes of Vital Statistics of the United States from the year of their admission through 1971 except for the years 1967-69, and tabulations for Guam were included for 1970 and 1971. Death statistics for Puerto Rico, the Virgin Islands, and Guam were not included in the 1972 volume but have been included in section 8 of the volumes for each of the years 1973-78 and in section 9 beginning with 1979. Information for 1972 for these three areas was published in the respective annual vital statistics reports of the Department of Health of the Commonwealth of Puerto Rico, the Department of Health of the Virgin Islands, and the Department of Public Health and Social Services of the Government of Guam. Procedures used by NCHS to collect death statistics have changed over the years. Before 1971, tabulations of deaths and fetal deaths were based solely on information obtained by NCHS from copies of the original certificates. The information from these copies was edited, coded, and tabulated. For 1960-70, all mortality information taken from these records was transferred by NCHS to magnetic tape for computer processing. Beginning with 1971, an increasing number of States provided NCHS, via the Vital Statistics Cooperative Program (VSCP), computer tapes of data coded according to NCHS specifications. The year State-coded demographic data were first transmitted on computer tape to NCHS is shown below for each of the States, New York City, Puerto Rico, and the District of Columbia, all of which now furnish demographic or nonmedical data on tape. 197l 1977 Florida Alaska Idaho Massachusetts New York City Ohio Puerto Rico - 1 - 1972 1978 Maine Indiana Missouri Utah New Hampshire Washington Rhode Island Vermont 1973 1979 Colorado Connecticut Michigan Hawaii New York (except) Mississippi New York City) New Jersey Pennsylvania Wyoming 1974 1980 Illinois Arkansas Iowa New Mexico Kansas South Dakota Montana Nebraska Oregon South Carolina 1975 1982 Louisiana North Dakota Maryland North Carolina Oklahoma Tennessee Virginia Wisconsin 1976 1985 Alabama Arizona Kentucky California Minnesota Delaware Nevada Georgia Texas District of West Virginia Columbia For the Virgin Islands and Guam, mortality statistics for 1991 are based on information obtained directly by NCHS from copies of the original certificates received from the registration offices. In 1974 States began coding medical (cause-of-death) data on computer tapes according to NCHS specifications. The year State-coded medical data were first transmitted to NCHS is shown below for the 30 States now furnishing such data. NCHS contracted with Colorado, Kansas, and Mississippi to precode medical data for all deaths on computer tape for the five States added in 1988. Vermont subcontracted with Pennsylvania to code its medical data. - 2 - 1974 1984 Iowa Maryland Michigan New York State (except New York City) 1975 Vermont Louisiana 1986 Nebraska California North Carolina Florida Virginia Texas Wisconsin 1980 1988 Colorado Alaska Kansas Delaware Massachusetts Idaho Mississippi North Dakota New Hampshire Wyoming Pennsylvania South Carolina 1981 1989 Maine Georgia Indiana Washington 1983 1991 Minnesota Arkansas For 1991 and previous years except 1972, NCHS coded the medical information from copies of the original certificates received from the registration offices for all deaths occurring in those States that were not furnishing NCHS with medical data coded according to NCHS specifications. For 1981 and 1982, these procedures were modified because of a coding and processing backlog resulting from personnel and budgetary restrictions. To produce the mortality files on a timely basis with reduced resources, NCHS used State-coded underlying cause-of-death information supplied by 19 States for 50 percent of the records; for the other 50 percent of the records for these States as well as for 100 percent of the records for the remaining 21 registration areas, NCHS coded the medical information. Mortality statistics for 1972 were based on information obtained from a 50-percent sample of death records instead of from all records as in other years. The sampling resulted from personnel and budgetary restrictions. Sampling variation associated with the 50-percent sample is described in "Estimates of errors arising from 50-percent sample for 1972." Fetal death data are obtained directly from copies of original reports of fetal deaths received by NCHS, except New York State (excluding New York City), which submitted State-coded data in 1991. For 1991 approximately 26 percent (573,416) of the Nations's death records were multiple cause coded using Mortality Medical Indexing, Classification, and Retrieval System (MICAR). Arkansas, Florida, Indiana, and Washington implemented MICAR on at least a portion of their 1991 data. NCHS expanded the use of MICAR to code at least a portion of the records from the following states: Alabama, Connecticut, Hawaii, Kentucky, Missouri, Montana, Nevada, New Mexico, Ohio, Oregon, Rhode Island, South Dakota, Tennessee, Utah, and West Virginia as well as the District of Columbia and - 3 - New York City. The remainder of the national file was processed by either NCHS or the State using only the Automated Classification of Medical Entities system. (See sections "Automated selection of underlying cause of death" and "Medical items on the death certificate.") Standard certificates and reports For many years, the U.S. Standard Certificate of Death and the U.S. Standard Report of Fetal Death, issued by the Public Health Service, have been used as the principle means to attain uniformity in the contents of documents used to collect information on these events. They have been modified in each State to the extent required by the particular needs of the State or by special provisions of the State vital statistics law. However, the certificates or reports of most States conform closely in content and arrangement to the standards. The first issue of the U.S. Standard Certificate of Death appeared in 1900. Since then, it has been revised periodically by the national vital statistics agency through consultation with State health officers and registrars; Federal agencies concerned with vital statistics; national, State, and county medical societies; and others working in such fields as public health, social welfare, demography, and insurance. This revision procedure has ensured careful evaluation of each item in terms of its current and future usefulness for legal, medical and health, demographic, and research purposes. New items have been added when necessary, and old items have been modified to ensure better reporting; or in some cases, items have been dropped when their usefulness appeared to be limited. New revisions of the U.S. Standard Certificate of Death and the U.S. Standard Report of Fetal Death were recommended for State use beginning January 1, 1989 (1). Among the major changes made were the addition of a new item on educational attainment and changes to improve the medical certification of cause of death. Additional lines to report causes of death were added as well as more complete instructions with examples for properly completing the cause of death. Also, for the first time, the U.S. Standard Certificate of Death includes a question on the Hispanic origin of the decedent. A number of States had included an Hispanic-origin identifier on their certificates, resulting in data shown in this volume for years before 1989. To obtain information on type of place of death, the format of the item was changed from an open-ended question to a checkbox. - 4 -