Population Index 61(4):527-539. Winter 1995.
Copyright ©1995, Office of Population Research, Princeton University
Abstract: This paper outlines the development of U.S. national vital statistics based on the local registration of vital events in the United States during the twentieth century, including the organization of the National Vital Statistics System. Current data developments and selected publications of the National Center for Health Statistics are presented as they relate to vital statistics. The paper concludes with an overview of ongoing efforts at the local, state, and federal levels to improve the timeliness and quality of vital statistics through the redesign and automation of data collection, processing, and dissemination systems.
As this century of registration-based vital statistics in the United States comes to a close, the local, state, and federal government organizations that comprise the National Vital Statistics System1 (NVSS) are anticipating some significant changes in key aspects of the system. While the inception, development, and maintenance of a system to produce national vital statistics based on the local registration of vital events has been a major accomplishment of the United States during the twentieth century, from data collection to data processing and dissemination, greater efficiency is being sought through redesign and automation. The goal is to improve both the timeliness and quality, but especially the timeliness, of data products. The purpose of this paper is to give an overview of these efforts so that users of U.S. vital statistics will have a better understanding of the capabilities, as well as the limitations, of the data. The paper also discusses the organization of the NVSS and summarizes current data developments and publications.
In the United States, legal authority for the registration of births, deaths, marriages, divorces, fetal deaths, and induced terminations of pregnancy (abortions) resides individually with the states (as well as with cities, in the case of New York City and Washington, D.C.) and with Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Marianas. In effect, the states are the full legal proprietors of the vital statistics records and the information contained therein, and are responsible for maintaining registries according to state law, and issuing copies of birth, marriage, divorce, and death certificates.
As a result of this state authority, the collection of registration-based vital statistics at the national level has always depended on a cooperative relationship between the states and the federal government. Since the late 1970s, that relationship has included a formal arrangement called the Vital Statistics Cooperative Program (VSCP). Under the VSCP, the federal government, acting through its agent, the National Center for Health Statistics (NCHS), partially supports state costs of producing vital statistics through a contract with each state. The Division of Vital Statistics (DVS) within the NCHS administers the VSCP.
The states are collectively represented in their dealings with the federal government by the Association for Public Health Statistics and Information Systems (APHSIS), formerly (until May 1995) the Association for Vital Records and Health Statistics. APHSIS is a professional organization whose members include primarily, but not exclusively, the vital statistics executives and other employees of state registration offices. In addition to providing the states with a common point of contact with the federal government and numerous other professional organizations, APHSIS also facilitates interstate exchanges of ideas, methods, and technology for the registration of vital events and the dissemination of vital and other public health statistics. APHSIS's progenitors date back to 1933, when it was organized as the American Association of Registration Executives.
The registration of births, marriages, and deaths has a long history in the United States, beginning with a registration law enacted by Virginia in 1632 and a modification of this law enacted by Massachusetts in 1639 (National Vital Statistics Division 1954). Later, when the U.S. Constitution was framed, provision was made for a decennial census but not a national vital registration system; this latter function remained with the states. To obtain national data, the decennial censuses in the latter half of the nineteenth century included questions about vital events, but the method was recognized as inefficient and the results as deficient.
Accordingly, in 1902, when the U.S. Bureau of the Census was made a permanent agency of the federal government, the legislation authorized the Director of the Bureau to obtain, annually, copies of records filed in the vital statistics offices of those states and cities having adequate death registration systems and to publish data from these records. A few years earlier, the Bureau had issued a recommended death reporting form (the first "U.S. Standard Certificate of Death") and requested that each independent registration area adopt it as of January 1, 1900. Those areas that adopted the form and whose death registration was 90% complete were to be included in a national death-registration area that had been established in 1880. In 1915, the national birth-registration area was established, and by 1933 all states were registering live births and deaths with acceptable event coverage and providing the required data to the bureau for the production of national birth and death statistics.
In 1946, responsibility for collecting and publishing vital statistics at the federal level was transferred to the U.S. Public Health Service, first in the National Office of Vital Statistics and later (1960) in the NCHS. In 1987, the NCHS became part of the Centers for Disease Control and Prevention (CDC), which in turn is part of the U.S. Department of Health and Human Services.
The continuing improvement of the NVSS depends on extensive cooperation between federal and state governments in a variety of developmental activities. The NCHS often plays a coordinating role in these activities by bringing together representatives of the states and other public and private organizations to focus on specific topics. The following sections present some recent activities, together with related publications and data products.
A prime example of cooperative developmental work is the recently published Model State Vital Statistics Act and Regulations, 1992 Revision (National Center for Health Statistics 1995e). The NCHS facilitated the process of revising the Model Act and Regulations by convening the Revision Working Group and bringing in various experts that have an interest in the registration system. This is the fifth edition of the Model Act (the first was produced in 1907) and the third edition of the Model Regulations (the first was in 1973).
The Model Act and Regulations provide a legal guide to states that are considering refining their laws. The report on the 1992 revision provides a useful reference on terminology, recommended registration practices, disclosure and issuance procedures, and other functional aspects of a state registration system. The latest revision of the Model Act and Regulations contains provisions that allow states that implement the relevant sections of the model to easily incorporate technological advances in records and information management.
A second important area of cooperation with the state vital statistics offices is the revision, generally every ten years, of the U.S. Standard Certificates and Reports. This is a particularly important activity because it brings together various experts--data users, researchers, and policy makers, both public and private--to develop recommendations on the content of the certificates and reports that will be used in the registration of live births, deaths, marriages, divorces, fetal deaths, and induced terminations of pregnancy during the next decade. Although the states do not all adopt the U.S. Standard Certificates and Reports exactly as they are promulgated, the documents are generally employed with only minor changes and thereby succeed in promoting a high degree of uniformity and comparability among the states. In addition, VSCP contracts between the NCHS and the states require collection of certain basic data items from the various certificates and reports; the items for births and deaths are listed in the notes to this paper.2
The latest revision of the U.S. Standard Certificates and Reports was implemented in 1989. A published report describes the procedures followed in developing the revisions and the principal additions, modifications, and deletions of items (Tolson et al. 1991). This report also provides a history of the content of all certificates and reports since 1900. Changes introduced in the 1989 revisions are reflected in statistical reports published by the NCHS for 1989 and later data years (see, for example, Ventura et al. 1995b; Kochanek and Hudson 1995; National Center for Health Statistics 1994a, 1994b, 1995f).
Common to the revised certificates of live birth and death and the reports of fetal death and induced termination of pregnancy was the addition of an item identifying Hispanic origin. For 1995 data, the NCHS obtained from all states and the District of Columbia information on Hispanic origin of the decedent on certificates of death and of the mother and father on the certificates of live birth. All but a few states obtain this information on reports of fetal death.
The 1989 revision of the death certificate had relatively few substantive changes other than addition of an Hispanic identifier. "Decedent's Education" was added as a measure of socioeconomic status.3 To improve reporting of cause of death, some modifications were made to the instructions and format in the section on medical certification and some certification examples were added to the reverse side of the certificate.
On the 1989 U.S. Standard Certificate of Live Birth, there were a number of major changes made in the "Information for Medical and Health Use Only" section. Added to the certificate were items on tobacco and alcohol use, weight gain, obstetric procedures, method of delivery, and abnormal conditions of the newborn (the last three items in checkbox format). Several other items that were retained on the certificate were converted to a checkbox format, including medical risk factors, complications of labor and/or delivery, and congenital anomalies of the child. This format was intended to yield more complete and accurate information. Details can be found in the report by Tolson et al. (1991), which also presents changes made in the other U.S. Standard Certificates and Reports. Further perspectives on the revised certificates and reports are presented by Taffel, Ventura, and Gay (1989) and Freedman et al. (1988).
The Linked Birth and Infant Death File (LBIDF) project is a third major area of cooperation between the NCHS and the state vital statistics offices. For analytical purposes, it is especially useful to combine information from the birth and death certificates for any infant that dies; the additional variables from the birth certificate make a much richer infant mortality database. In addition, with an LBIDF it is possible to use race of mother for both numerator and denominator in an infant mortality rate because race of mother is on the birth certificate linked to the infant death certificate. Because an infant born in one state may die in another, the child's birth and death certificates may be registered in different states. The NCHS facilitates an interstate agreement to exchange infant death and birth certificates. The result is an annual national file containing linked birth and death records for infants in a particular birth cohort that died before the age of one (this requires death information for a two-year period).
An LBIDF is available now as a Public Use tape for each birth cohort from 1983 through 1991. The linked files for the 1985-1988 cohorts are also available on CD-ROM, and the 1989-1991 LBIDFs should be available on CD-ROM in early 1996. Each CD-ROM contains all linked records for a single birth cohort (about 40,000 records), plus information from the birth certificates for all infants in the cohort (about four million births); this arrangement allows infant mortality rates to be calculated using the appropriate birth cohort numbers in the denominator.
In order to produce linked files on a more timely basis, the NCHS will soon start producing LBIDFs on a period basis beginning with data year 1995; that is, the period LBIDF will include all infant deaths in a particular calendar year, linked to the respective birth certificate information. The user will still be able to create a LBIDF based on a birth cohort by combining appropriate infant deaths from two adjacent years on two CD-ROMs. (Due to resource constraints, the NCHS has no plans to produce LBIDFs for the years 1992-1994.)
Two NCHS reports based on analyses of data from linked files may be cited here. Pastore and MacDorman (1995) examined the mortality experience of infants born between 1985 and 1987 to mothers of Hispanic origin who resided in a study area of 20 states and the District of Columbia and compared it with that of non-Hispanic white infants. A report by Prager (1994) presents findings on U.S. infant mortality for the 1985 birth cohort by birthweight, mother's age, prenatal care, and other characteristics.
The NCHS vital statistics training program is another important activity involving interaction with state personnel. The Division of Vital Statistics annually offers one-week courses titled "Vital Statistics: Measurement and Production" and "Vital Statistics Records and Their Administration". The participants in these courses are generally employees of state, county, and city registration offices. Over the past 12 years, almost 800 employees of these offices have taken one of these courses.
The followback surveys conducted by the NCHS depend entirely on the cooperation of state vital statistics offices. A number of such surveys have been conducted since the mid-1950s by the NCHS and its predecessor agency, the National Office of Vital Statistics, usually in collaboration with other federal government agencies. The state offices support the survey by obtaining approval from their own health departments and institutional review boards, as necessary, and by authorizing the use of copies of vital records in the sample.
These surveys typically are based on a sample of vital records in an annual birth or death file. Questionnaires are sent to sources of information identified on the records, for example, to the next-of-kin on the death certificate or to the mother on the birth certificate. The questionnaires elicit additional information about the decedent or the mother and child, and in this way the survey provides a rich supplement to the information on the basic vital record. The sample data are weighted to provide unbiased estimates for the universe of records from which the sample was drawn.
The 1988 National Maternal and Infant Health Survey (NMIHS) is the most recent followback survey focusing on reproductive health; it includes a nationally representative sample of 9,953 live births, 5,332 infant deaths, and 3,309 late fetal deaths. This survey (available from the National Technical Information Service--NTIS) obtained information on socioeconomic and demographic characteristics of mothers, prenatal care,4 pregnancy history, working history, health status of mother and infant, types and sources of medical care received, and lifestyle characteristics, including maternal smoking, drinking, and drug use.
In 1991, the NCHS conducted a Longitudinal Followup (LF) to the 1988 NMIHS by recontacting the mothers in the earlier survey to get information on their children's health during the two or three years after birth. The followup requested data from the child's medical providers as well. The LF (also available from the NTIS) provides information on infant feeding practices, child care, parental employment, and a wide range of information on early childhood health and development.5 A subsample of NMIHS women who had infant or fetal deaths (1,000 of each) was included in the LF survey to obtain data on subsequent reproductive behavior following infant or fetal loss. A CD-ROM containing the entire LF file is currently being prepared for release by the NCHS.
The latest National Mortality Followback Survey (NMFS) has just been completed and data processing and editing will be carried out in 1996. This survey includes special samples of deaths that occurred during 1993 from homicide, suicide, motor vehicle accidents, other accidents, HIV, and certain natural causes. In addition to information on the use of health services in the last year of life, the 1993 NMFS is unique because it includes information obtained from the records of medical examiners and coroners. The NMFS also includes information on socioeconomic and demographic characteristics of deceased persons, use of and payment for hospitals and institutional care during the last year of life, and various aspects of lifestyle and other factors related to health status. The Public Use tape should be available in December 1996, and detailed publications will follow.
Staff at the NCHS have published a number of special reports dealing with reproductive health. Two of these reports present information from several new items on the 1989 U.S. Standard Certificate of Live Birth. A brief article in the Morbidity and Mortality Weekly Report concentrates on maternal weight gain, smoking during pregnancy, and method of delivery (Centers for Disease Control and Prevention 1992). A much more detailed discussion of the demographic and maternal and infant health characteristics associated with cesarean delivery was published in the NCHS's Vital and Health Statistics series (Taffel 1994). Also, Brett, Schoendorf, and Kiely (1994) used new information from the birth certificate to analyze prenatal care technology.
Beginning in 1992, the NCHS contracted with the seven states with the highest Asian or Pacific Islander populations (California, Hawaii, Illinois, New Jersey, New York, Texas, and Washington) to code births 6 to five additional Asian or Pacific Islander subgroups: Vietnamese, Asian Indian, Korean, Samoan, and Guamanian. Births of Chinese, Japanese, Filipino, and Hawaiian origin have been separately identified nationally for many years. Martin's (1995) paper in the Monthly Vital Statistics Report presented demographic and health characteristics of births to these additional Asian or Pacific Islander subgroups.
Out-of-wedlock childbearing is a topic of continuing high interest in the U.S. policy arena. A report by Ventura (1995) presents trends and variations in demographic characteristics of births to unmarried women for 1980-1992, including health aspects of nonmarital childbearing such as prenatal care, smoking, maternal weight gain, and infant birthweight. Ventura's report served as a data source for a special "Report to Congress on Out-of-Wedlock Childbearing" delivered this past September (Department of Health and Human Services 1995) in response to a requirement of the Violent Crime Control and Law Enforcement Act of 1994.
A related topic, pregnancy and childbearing among teenagers, is the subject of continuing surveillance by the CDC. Staff at the NCHS contribute regularly to reports in the Morbidity and Mortality Weekly Report, providing state estimates of pregnancy and birth rates among teenagers (see Spitz et al. 1993; Centers for Disease Control and Prevention 1995). A more general treatise on trends in pregnancies and pregnancy rates has been published by Ventura et al. (1995a).
Beginning with data year 1989, the NCHS started publishing natality data primarily by race of mother rather than race of child (child's race has traditionally been imputed from race of mother and/or father on the birth certificate). A special report by Hoyert (1994) discusses the effect of the change in tabulation from race of child to race of mother on infant, fetal, perinatal, and maternal mortality rates for the years 1970-1989. A related report by Hoyert (1995) presents recent trend data on perinatal mortality by state.
Throughout the twentieth century, U.S. cause-of-death statistics have been classified and disseminated according to the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD). Since 1979, the Ninth Revision of the ICD, published by the World Health Organization (WHO), has been in use (World Health Organization 1977). The Tenth Revision of the ICD was recently published (World Health Organization 1992). The United States plans to implement this latest revision for mortality statistics in 1998.7
Using the selection rules of the ICD, a single cause is selected from among those reported by the physician certifying a particular death. Ideally, this should be the "disease or injury that initiated events resulting in death", and this disease or injury is classified and tabulated as the underlying cause of death. Prior to the advent of automation, this selection process was done manually by experts in disease classification, called nosologists (for examples of this process, see National Center for Health Statistics 1995a).
Beginning with the implementation of the Eighth Revision of the ICD in 1968, the NCHS developed and employed several computer systems to automatically select the underlying cause for each death certificate and to produce multiple cause-of-death data. System automation provides the benefit of greater consistency in the application of classification rules while at the same time requiring less extensive coder training.
Moreover, it has long been recognized that good use could be made of the additional information (multiple causes of death) provided by the certifier if it were properly "cleaned" and reduced, and the computer systems accomplish this.8 Public Use files containing multiple-cause data (plus all demographic information and the underlying cause for each decedent) are available from the NTIS for all data years since 1968. The NCHS is currently preparing the first CD-ROM with multiple-cause data to be issued for the data year 1991.
Several recent government reports on mortality may be cited to indicate areas of recent research at the NCHS. A report by Kochanek, Maurer, and Rosenberg (1994) identifies the major causes of death and age groups that contributed most to the decrease in life expectancy at birth for black males and females and to the increase for white males and females in the United States from 1984 to 1989. Two reports by Lois Fingerhut and others have focused on an area of special public interest, which is firearm mortality among children (Fingerhut 1993; Fingerhut, Jones, and Makuc 1994).
The NCHS staff contribute mortality articles regularly to the CDC's Morbidity and Mortality Weekly Report. Two areas of special interest for surveillance purposes are infant and child mortality and deaths due to HIV infection (Centers for Disease Control and Prevention 1993, 1994; see also Wilcox et al. 1995; Schoendorf et al. 1994; Singh and Yu, in press).
In a collaborative effort with the National Institute for Occupational Safety and Health, the National Cancer Institute, and the state vital statistics offices, the NCHS continues to collect and publish occupation and industry information for decedents (Rosenberg et al. 1993).
The NCHS staff have been active in numerous international projects involving vital statistics. One project produced a report titled "Sister Communities Health Profiles", published by the U.S.-Mexico Border Health Association (1994). The purpose of this report was to help public health workers study and evaluate binational health conditions and to implement joint health activities on the U.S.-Mexico border. A second report compared vital and health statistics of the Russian Federation with those in the United States (National Center for Health Statistics, 1995g). This report was a joint effort of the NCHS and the Public Health Institute MedSocEconInform of the Ministry of Health and Medical Industry of the Russian Federation.
The NCHS has organized several International Collaborative Efforts (ICEs) in recent years, bringing together distinguished international experts from a number of countries, plus experts from a variety of U.S. organizations, to collaborate and present research on specific subjects. Vital statistics figure prominently in these projects. Proceedings have been published on three ICEs: Aging (Feinleib 1991), Perinatal and Infant Mortality (National Center for Health Statistics 1990), and Injury Statistics (National Center for Health Statistics 1995h).
The NCHS staff have also participated in international development efforts for vital statistics such as the African Workshop on Strategies for Accelerating the Improvement of Civil Registration and Vital Statistics Systems, held in Addis Ababa, Ethiopia, in December 1994 (Gay 1994).
A recent mortality chartbook by Zarate (1994) presents country rankings and trends for selected causes of death and variations in patterns of mortality in the United States and 40 industrialized countries for the years 1955-1991.
A number of significant changes are being planned and implemented for the NVSS with the help of computer technology. The primary goal of the effort is to dramatically improve the timeliness of the data produced by the NCHS, especially those needed for surveillance purposes. To fully accomplish this, the entire national vital registration and statistics process will need to move from a "batch mode" of operation to one of "current flow" through the use of automation at several critical junctures (Patterson 1992). Currently, in building the final file for a data year, vital records are processed in batches at most stages. For example, electronic records are sent in monthly batches to the NCHS, where the data are processed and eventually brought together in a single, final file for the data year. No final data are released for a particular data year until the file for that year is complete and all corrections have been made; release of final data typically occurs 20 to 24 months after the end of the data year.9
The vision of a current-flow approach to vital statistics processing provides that records be transmitted, very soon after they originate, from the source to the state office and then on to the NCHS, ideally in a nearly continuous current flow. Through querying, editing, and receipt of additional information, the NCHS file would be constantly updated, so that the data for any given time-period would become progressively more accurate and complete. For some purposes, such as surveillance, timeliness may be much more important than quality and completeness, so taking an early look at the data available for a given time-period may be very useful and reasonable. For some demographic or epidemiological purposes, however, quality and completeness may be more important, and it then would be necessary to wait for the final files to be produced.
Certain methodological problems must be resolved to achieve this vision through full automation. To begin, automation at the data source will be a very important component. The electronic birth certificate (EBC) is a computer system that records information about a birth in a structured format, automatically checks for improbable answers, and produces a file that can be electronically transmitted to the state and/or local vital registration office. Thus an EBC not only facilitates record filing, but it also helps to improve data quality. Even now, an EBC is a reality in more than half the states. By the year 2000, more than 90 percent of U.S. births may be registered electronically. One source has estimated that in 1994, 58 percent of all births were being recorded and communicated to a public agency electronically (Starr and Starr 1995).
An electronic death certificate (EDC) will also be required to make current flow a reality. It will be much harder to achieve, however, because information on the death certificate is generally obtained from both a physician and a funeral director (who questions the next of kin). The purpose of an EDC is to bring together medical and demographic information into one record. 10 For help with this task, the NCHS has recently created a steering committee on re-engineering the death registration system. This committee includes staff from state registration offices and representatives of relevant professional organizations.
To receive electronic records from hospitals and funeral directors, state vital registration offices will need a data-processing system designed to receive and process electronically transmitted data from source locations and to transmit that data electronically to the NCHS. Currently, the NCHS is redesigning its own data-processing system to receive, control, and process data electronically transmitted by the states. This internal NCHS system will provide NCHS staff with online data retrieval for quality control, data tabulation, and report preparation.
In conjunction with the above work, the NCHS is reviewing data dissemination options and planning to release data of a preliminary nature in 1996, well before all electronic components of a current-flow system are fully implemented. As one option, the NCHS expects to receive, under current arrangements with the states, at least 80 percent of the records for a 12-month period within three months after the end of that period. Tabulations of weighted preliminary data for the period could then be published within six months. Successive quarterly reports would include tabulations based on ever more complete files. It is expected that preliminary data will be of considerable use to persons involved in public health surveillance, but the NCHS will be interested in the reactions of all data users to the new approach.
There is little doubt that greater use will be made of electronic media, such as the Internet, for public access to reports and tabulations. As already mentioned, the NCHS is currently producing CD-ROMs of data, although the size of the annual death files (about 2.2 million records) and birth files (almost 4 million records) may require some patience from users of this medium. The NCHS is also considering a reduction in the size and number of printed reports, particularly the size of the print version of Vital Statistics of the United States.
Despite the fact that several of the components are already in place or well along in development, the full realization of the current-flow system will obviously take a number of years. An extensive re-engineering effort will be needed in other components of the NVSS to significantly improve timeliness and quality. However, since the implementation of the steps required to produce a timely surveillance file on a current-flow basis will also contribute to the quality of the final file for a calendar year, these changes will enable the NCHS to better serve all of its data users.
James A. Weed is affiliated with the National Center for Health Statistics, Room 840 Presidential Building, 6525 Belcrest Road, Hyattsville, MD 20782 (e-mail address: firstname.lastname@example.org).
The author gratefully acknowledges the comments and suggestions of many NCHS colleagues in the preparation of this article. Special thanks go to Ronald Chamblee, Mary Anne Freedman, George Gay, Susan Hawk, Robert Heuser, and Harry Rosenberg.
1The NVSS is based on the local registration of vital events. For births and deaths, this typically works, in outline form, as follows: demographic information on the birth certificate is provided by the mother at the time of birth, and medical and health information are based on hospital records. Demographic information on the death certificate is provided by the funeral director based on information supplied by the informant (usually the next of kin). Medical information on cause of death is provided by a physician, medical examiner, or coroner. The completed birth and death certificates are filed with the local registrar by, respectively, the hospital records officer or the funeral director. The local registrar subsequently files the records with the state vital registration office, which codes and keys the data and transmits a copy of the electronic file to the National Center for Health Statistics (NCHS). The state offices are responsible for maintaining archival copies of records and for issuing certificate copies. Upon receipt at the NCHS, the data are edited and assembled into national files for analysis and publication. The NCHS sets uniform standards for data that will be collected and for item coding. For more details, see appendices in National Center for Health Statistics (1994a, 1994b, 1995f).
2For deaths in 1995, the basic items obtained by the NCHS for the decedent include sex, date of death, age, date of birth, birthplace, type of place of death, geographic place of death, marital status, occupation and industry, residence, Hispanic origin, race, education, cause of death, and whether injured at work. For births in 1995, basic items include date of birth, sex, geographic place of birth, type of place of birth, attendant at birth, mother's date of birth, mother's birthplace (state), residence of mother, and father's date of birth; Hispanic origin, race, and education of mother and father; and pregnancy history of mother, date of last live birth, whether mother is married, date last normal menses began, month of pregnancy prenatal care began, prenatal visits, birth weight of infant, clinical estimate of gestation, plurality, apgar score (5 minute), medical risk factors for this pregnancy, other risk factors for this pregnancy, obstetric procedures, complications of labor and/or delivery, method of delivery, abnormal conditions of the newborn, and congenital anomalies.
3Death rates by educational attainment are now available (see National Center for Health Statistics 1995f: Table 36). For a summary of data sources that are available to assess mortality patterns in the United States according to socioeconomic differentials, see Hoyert, Singh, and Rosenberg (1995).
4See, for example, a paper by Kogan, Alexander, Kotelchuck, and Nagey (1994).
5For examples of the use of LF data, see Kogan, Alexander, Teitelbaum, Jack, Kotelchuck, and Pappas (1995); Kogan, Overpeck, and Fingerhut (1995); and Kogan, Pappas, Yu, and Kotelchuck (1994).
6A similar arrangement was made for deaths, and the indicators for these additional five Asian and Pacific Islander racial groups are available on Public Use tapes for mortality as well as for natality.
7 The heads of the WHO Collaborating Centers for the Classification of Diseases met in Canberra, Australia, on October 10-17, 1995. At this meeting, most of the countries reporting indicated that they would be implementing the Tenth Revision of the ICD for mortality between 1995 and 1998.
8 The computer system for automatically selecting the underlying cause of death is called "Automated Classification of Medical Entities" (ACME) (National Center for Health Statistics 1995b, 1995c). The NCHS has also developed the MICAR (Mortality Medical Indexing, Classification, and Retrieval) system, to provide a data-entry system to ACME that would require less coder training than does ACME, yet would still maintain accurate and consistent results (for details, see National Center for Health Statistics 1995d). The program TRANSAX produces multiple cause-of-death data (Chamblee and Evans 1986).
9 On a separate publication track are the provisional data presented each month in the Monthly Vital Statistics Report (MVSR). These data include monthly counts of births, deaths, marriages, divorces, and infant deaths reported by the states, plus cause-of-death statistics from the Current Mortality Sample (CMS). The CMS is a 10 percent sample of death records received in the state registration offices each month. The provisional data are published in the MVSR about 5 or 6 months after the month of occurrence.
10 To create a fully automated EDC, a subsidiary system is needed that accepts all literal entries of the certifying physician and automatically converts the reported medical conditions into special codes for processing through MICAR, TRANSAX, and ACME (see reference note 8). Such a system, referred to as "Super-MICAR" because it produces data-entry to MICAR, already has been developed by the NCHS and is currently being implemented by the NCHS and a few states for coding death certificates in 1995. At present, Super-MICAR handles at least 80 percent of all death certificates. Aside from its potential use in an EDC, Super-MICAR was designed originally to improve efficiency in producing mortality statistics by reducing the training required for cause-of-death coders. Also, Super-MICAR provides a method to retain literal entries in electronic form for quality control and analysis.
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