1.1 Life Expectancy Summary for 2020 - By Race/Ethnicity and Sex

• Life expectancy is a key summary measure of disparity, and succinctly summarizes differences in mortality between groups.
  
  This chart shows Life Expectancy at Birth in 2020 for males and females, for each race/ethnic group. Calculation of life expectancy is complex, and requires use of assumptions applied to high-quality data.

• For all race/ethnic groups, females live longer than males. Among males, the life expectancy for Blacks is 12.4 years less than for Asians; among females the difference is 10.4 years. This difference is caused by a cascade of inequities in social determinants of health, and other factors.

• The red slashes at the bottom of the y-axis indicate that the scale of the y-axis is discontinuous. The y-axis does not start at 0, but rather at age 65, so that the important differences in life expectancy can be seen clearly.

1.2 Life Expectancy by Race/Ethnicity and Sex, by Year, 2000 to 2020

• This chart shows the trends in Life Expectancy at Birth for the past 21 years by sex and race/ethnicity.

• Life expectancy steadily increased for all groups over this period, until 2020. In 2020 there was a sharp drop for all groups due to the impact of COVID-19 (and a 2-year decrease in life expectancy overall).
  
  Black males have had a substantially lower, and Asian females a substantially higher, life expectancy than all other groups in all years.

1.3a All-Cause Mortality Trend by Sex and by Race/Ethnicity (2000-2020), and All-Cause Mortality County Rankings (2020)

• These line charts show the trends in age-adjusted rate for mortality due to all causes, by sex and by race/ethnicity for the past 21 years. In a simple sense, all-cause mortality is the opposite of life expectancy–when all-cause mortality goes down, life expectancy goes up, and vice versa.
  
  The bar chart displays county rates of age-adjusted mortality (and 95% confidence intervals) due to all causes. The counties listed have the highest rates, and a reference line is included for comparison with the state rate.

• The “Trends by Race/Ethnicity” chart demonstrates that all-cause mortality rates decreased substantially (between 18 and 23 percent) among all race-ethnicity groups in California from 2000 to 2019.
  
  Starting around 2013-2015 rates started to level off and even increase for all groups except Whites.
  
  Rates then increased sharply for all groups in 2020, although much less so for Whites.
  
  The very sharp and unprecedented increase among Latinos resulted in the all-cause death rate being higher in 2020 than 20 years earlier in 2000, and, for the first time, higher than the White rate.
  
  The “Trend by Sex” chart shows that all-cause mortality rates decreased for both males and females over the 20 year period, until 2020.

• An arrow at the upper end of the confidence interval (CI) for a county (e.g. Alpine) indicates that that value is beyond the range of the x-axis. The CI is truncated for chart legibility.

1.3b All-Cause Mortality Map - California, Bay Area, and Los Angeles County, 2016-2020

• These maps display all-cause mortality rates by location; statewide and with a regional view for the Bay Area and Los Angeles county. The rates are compared at the subcounty level using Medical Service Study Areas (MSSAs), an aggregation of census tracts, to demonstrate variation between communities within each county.

• In both rural and urban areas, there are concentrations of high all-cause mortality rates within counties and regions.
  
  There is some concentration of higher rates in the central part of the State.

2.1 Multiple Lenses - Top 5 Conditions based on Multiple Measures, 2020

• This multi-chart emphasizes that there are many ways to view the health status of Californians, and that public health looks across multiple measures to identify public health challenges.
  
  The first four charts use measures relating to deaths (number, years of life lost (YLL), increase, and race/ethnicity disparity). The next four charts look at additional lenses of public health burden (hospitalizations, ED visits, reportable diseases, and disability). County-level versions of this same multi-chart and a downloadable document can be found here.

• Many conditions appear on more than one of these ranking measures, even though the measures assess very different levels of burden or impact:
  
  Ischemic heart disease is 1st in terms of numbers of deaths in 2020 and 3rd in terms of Years of Life Lost (YLL).
  
  Drugs overdoses are 1st for YLL, 1st for increases from 2010 to 2020, 5th in terms of a racial/ethnic disparity, and 4th in terms of Years Lived with Disability.
  
  Alcohol-related conditions are 5th for YLL and 2nd in terms of racial/ethnic disparity.
  
  Mental health conditions rank 3rd for numbers of hospitalizations and 2nd for Years Lived with Disability.
  
  Additional detail on key findings for these measures are addressed in later sections.

*Conditions with fewer than 100 deaths in either period are excluded. Such conditions with large percent increases include:
Influenza: 991.1% increase in age-adjusted death rate from 2010 (49 deaths) to 2020 (658 deaths)
Poisonings (non-drug): 75.2% increase in age-adjusted death rate from 2010 (68 deaths) to 2020 (127 deaths)

2.2 Broad Condition Groups (5) - Rankings of Number of Deaths and Years of Life Lost in 2020

• This set of charts compares all causes of death using five broad condition groupings. These broad groupings are important for a very high-level understanding of the burden of death/disease, and these groupings (indicated by color) are used to frame the data in many of the charts that follow.
  
  The top chart ranks the number of deaths in California in 2020 according to the five broad condition groupings. The bottom chart shows the ranking of Years of Life Lost according to the five broad condition groupings. Years of Life Lost weights conditions that impact younger people and is sometimes referred to as “premature death”.

• Cardiovascular Diseases caused the most deaths in 2020, followed closely by Other Chronic Disease . The Cardiovascular Disease broad condition group includes ischemic heart disease, stroke, hypertensive heart disease, and others.
  
  The Other Chronic disease broad condition grouping includes Alzheimer’s disease, cirrhosis (non-alcohol), COPD (Chronic Obstructive Pulmonary Disease), kidney disease, and others.
  
  Injuries caused by far the most years of life lost in 2020. This broad condition group includes drug overdose, alcohol-related conditions (including alcohol-related cirrhosis), suicide, homicide, falls, and road injury.
  
  For detail on the number of deaths due to specific conditions within each broad condition group please see Appendix chart A.5.

2.3 Public Health Condition Groupings - Top 15 Number of Deaths in 2020

• These charts show a more detailed view of causes, disaggregated into what we call the Public Health Level groupings. This grouping is based on programmatic areas of public health and/or clinical aspects of the conditions, to facilitate public health planning and action.
  
  This chart shows the ranking of the top 15 causes based on numbers of deaths.

• At this Public Health Level, the conditions contributing the most deaths are ischemic heart disease, COVID-19 and Alzheimer’s disease. Note that four of the top seven causes of death are in the Cardiovascular broad group.
  
  COVID-19 emerged in 2020 contributing the only ranked cause in the Communicable disease broad condition group.

2.4 Public Health Condition Groups - Top 15 Years of Life Lost in 2020

• This chart shows the ranking of the top 15 Public Health Level causes for years of life lost.

• The top contributors to years of life lost are drug overdose, COVID-19, and ischemic heart disease. Note that five of the top seven causes of years of life lost are in the Injury broad grouping.
  
  In 2019, drug overdose deaths overtook ischemic heart disease as the top cause of years of life lost and remained so in 2020. This was the first time any cause ranked higher than ischemic heart disease for at least two decades. Due to the magnitude of deaths from ischemic heart disease, it has been a leading cause both in terms of numbers and years of life lost for the past 20 years.

2.5 Public Health Condition Groups - Top 15 based on 10-year and 1-year Increases

• This chart shows the ranking of the top 15 Public Health Level causes based on percent increase in rates from 2009 to 2019 and from 2019 to 2020. A detailed data table with these increases is included in Appendix B.1

• Deaths from drug overdoses increased more than any other condition both from 2009 to 2019 and from 2019 to 2020.
  
  Kidney disease ranked 2nd in terms of increases in deaths from 2009 to 2019, and ranked 11th from 2019 to 2020.
  
  From 2019 to 2020, homicide was ranked 2nd in terms of increases in deaths, diabetes 3rd, influenza 4th, alcohol-related conditions 5th, and asthma 6th. Of these five conditions, only alcohol-related ranked in the top 15 increases from 2009 to 2019. These recent increases are concerning and need further exploration, including their relationships to the pandemic.
  
  Other conditions that ranked in the top 15 in both time periods include: Alzheimer’s disease, hypertensive heart disease, road injury and endocrine/blood/immune disorders.

*Conditions with fewer than 100 deaths in any period (2009, 2019, 2020) are excluded. Such conditions with large percent increases include:
Poisonings (non-drug): 31.22% increase in age-adjusted death rate from 2010 (71 deaths) to 2020 (100 deaths)
Sickle cell disorders and trait: 73.08% increase in age-adjusted death rate from 2019 (16 deaths) to 2020 (29 deaths)
Poisonings (non-drug): 25.25% increase in age-adjusted death rate from 2019 (100 deaths) to 2020 (127 deaths)

3.1 TRENDS in Broad Conditions Groups - Age-Adjusted Death Rate, 2000-2020

• This chart shows the age-adjusted death rate trends of the five broad condition groupings in California from 2000-2020.

• Great progress has been made in the past 20 years, through 2019, with decreasing death rates for Cardiovascular Disease, Cancer, and Communicable Disease. In contrast, death rates for Other Chronic Diseases and Injury have increased somewhat over this period. This increase in Other Chronic is due in large part to increases in deaths from Alzheimer’s disease.
  
  In 2020 deaths increased very sharply for Communicable Diseases due to COVID-19, and increased for the other broad conditions groups (except for Cancer), at least in part, due to the many impacts of COVID-19.

3.2 TRENDS In Top Public Health Conditions (by Broad Condition Groups), 2000-2020

• This chart provides a deeper look into the trends in cause of death by showing the age-adjusted death rate trends of the top 5 Public Health conditions within each Broad Condition group.

• The previous chart showed good progress for Cardiovascular and Cancer condition groups. This chart reveals the main drivers for those downward trends, which are ischemic heart disease and lung cancer. (Ischemic heart disease decreased every year from 2000 to 2019, but increased slightly in 2020. The reason for this reversal in trend during the pandemic period is not known, and warrants investigation.) Furthermore, pneumonia deaths from the Communicable group also greatly declined since 2000. In contrast, Alzheimer’s disease in the Other Chronic group and drug overdoses in the Injury group have sharply increased since 2000.
  
  The increase in Alzheimer’s appears to be driving the observed increase in the broader Other Chronic group. In contrast, COPD deaths have decreased substantially (but remain a leading cause of death).
  
  In the Injury broad condition group, drug overdoses have more than tripled, and road injury is increasing after a previous decline. Alcohol-related deaths increased sharply in 2020. Homicides, after many years of decreasing or level rates, increased sharply in 2020.
  
  Note: The y-axis scales for each chart are different.

3.3 Trends in Age-Adjusted Rates for Top 15 Public Health Level Conditions (log-y-axis), 2000-2020

• This chart offers a different angle than the previous chart by looking at trends over past two decades for public health-level conditions overall, regardless of the broader groups. These are the conditions with the top 15 age-adjusted death rates in 2020.

• Age-adjusted death rates from ischemic heart disease and stroke decreased greatly over the past 20 years.
  
  In contrast, Alzheimer’s disease has more than doubled since 2000, resulting in it having the second-highest rate from 2008 onward (and third highest in 2020, after ischemic heart disease and COVID-19).
  
  Also of note are drug overdoses and kidney diseases. While these conditions are lower on the list, their age-adjusted death rates have increased dramatically since 2000.

• A logarithmic scale is used for the y-axis in order to be able to clearly see the trends for all these conditions on one chart. Also, on a logarithmic scale, lines are parallel if the relative changes (i.e. percent change) over a time period are the same.

4.1 2021 PRELIMINARY DATA: All-Cause Mortality, Monthly Trend, 2017-2021

• Due to the urgency of sharing COVID-19 related information, this section includes preliminary 2021 data, which were received in mid-April 2022.
  
  This chart shows monthly all-cause mortality trends for each of the past five years.

• All-cause mortality rates began increasing in April 2020 relative to the same months in the prior four years, and were high throughout 2020 and into the fall of 2021. The decrease in September 2020 reflects decreases in COVID-19 deaths after the first surge. The rate peaked in January of 2021 with the second surge, then decreased in the 2nd quarter of 2021 to pre-covid levels, and began increasing again in the 3rd quarter of 2021, with the surge from “delta variant”.

4.2 2021 PRELIMINARY DATA: Leading Causes of Death, Monthly Trends, 2019-2021

• This chart displays the monthly (adjusted) death rate for all causes of death that were among the leading 4 causes in any month over this period.

• In July of 2020, COVID-19 was the leading cause of death in California, as it was for other months thereafter. In January 2021, it was by far the leading cause (and caused more deaths in that month than any other condition has for any single month in the past decade, and likely many years prior to that). COVID-19 was again the leading cause in August and September of 2021.

• Chart excludes the “Ill-Defined” condition group. This condition may appear to be a leading cause in one or more of the most recent months in these preliminary data, but almost all will eventually be reclassified with final data.

4.3 2021 PRELIMINARY DATA: All-Cause Mortality Quarterly Trend by Race/Ethnicity and Year Group (2017-2019 vs 2020-2021)

• This chart shows, for race/ethnicity groups, all-cause age-adjusted quarterly mortality rates, for 2020 and through Q4 of 2021, and for the 2017-2019 average.

• All-cause death rates for all populations increased compared to prior years in the 2nd, 3rd, and 4th quarters of 2020 and the 1st quarter of 2021.
  
  Rates decreased for all groups in the 2nd quarter of 2021, and increased for all groups in the 3rd quarter of 2021.
  
  
  
  Assessment of these increases in excess mortality are carefully reviewed in Data Brief: 2020 Increases in Deaths in California.

4.4 2021 PRELIMINARY DATA: Top 5 Causes of Death and Years of Life Lost in 2021

• This chart shows leading causes of death and the leading causes of years of life lost in 2021.

• COVID-19 was the leading cause of both deaths and years of life lost in 2021.
  
  These are the same top five ranking conditions as 2020 (shown in section 2.1), and the order is the same, except that COVID-19 is the top ranking condition so far in 2021, whereas it was 2nd in 2020 for both deaths and years of life lost.

5.1 Race/Ethnicity Age-Specific All-Cause Death Rate Ratio with Whites as Referent Group, 2018-2020

• This chart shows the ratio of age-specific American Indian/Alaskan Native (AI/AN), Asian, Black, Latino, and Native Hawaiian/Pacific Islander (NHPI) rates to the corresponding age-specific White rates (Whites are used as the reference group since they have historically been the largest group in the State, and are, on average, relatively advantaged).
  
  A rate ratio of 1.0 means that the rates are the same for both groups.
  
  Appendix Table B.2 shows the numbers of deaths, population sizes, and rates that are the basis for the rate ratios in the chart.

• Of the many observations that can be seen in this chart, one especially important observation is seen in the “Black:White” rate ratio column. In the 0-4 year old age group the death rate is over 3 times higher for Black infants/toddlers than for Whites. For children/teens/early 20’s and 35-44 age group the rates are over 2 times higher for Blacks than Whites. In general, this ratio decreases as age increases and among the oldest age group the rate among Blacks is less than the rate among Whites.
  
  Many complex factors interweave to create these disparities and patterns. The much higher rate of death among Black 0-4 year olds is due to the cascade of social determinants of health and structural inequities.
  
  Among the Latino population, rates are better (lower) than Whites for ages 25 and older, but worse (higher) between ages 0 and 24, with the greatest difference at the youngest (0-4) age level.
  
  Among AI/AN and NHPI, the patterns are similar to the pattern described for Blacks, and important for the same reasons. Because of the much smaller population sizes of these two groups, there is more variability in the numbers.

• The black line at the end of each bar is the 95% confidence interval for the rate ratio, calculated with the rateratio function of the epitools package in R.

*Data are suppressed per the California Health and Human Services Agency Data De-Identification Guidelines

5.2 Change in Race/Ethnicity All-Cause Mortality Rate Disparity, 2000-2020

• This chart shows changes over time in the rate ratio of the other race/ethnic groups compared to White. It shows increasing differences from the White rate for all groups starting in the mid-2010’s, with a sharp acceleration in these disparities in 2020, because of the impact of COVID-19. (The chart in section 1.3a serves as important background for this chart.)

5.3 Ranking of Race/Ethnic Disparities in Death Rate, 2018-2020

• This chart ranks causes of death by racial/ethnic disparities. Disparities are measured using rate ratios, comparing, the rate among the race/ethnic group with the highest rate to the rate among the race/ethnic group with the lowest rate for each cause of death. Data for 2018-2020 are combined for statistical stability.
  
  A rate ratio near one means there is little difference between the groups with the highest and lowest rates.The bar size shows the rate ratio; the labels inside the bar show the group with the highest rate and the lowest rate (highest:lowest) for that cause.

• The two highest ranking disparities in death rates are for homicide and HIV/STDs, both with the Black rate well over 10 times the rate among Asians.
  
  The next highest disparity is for Alcohol-related conditions, with American Indian/Alaska Natives having rates well over 10 times the rate among Asians. The fourth highest disparity is for tuberculosis, with Asians having rates more than 10 times those among Whites. (The high rate among Asians in California is known to be associated with persons born outside of the United States. Report on Tuberculosis in California, 2019).

5.4a Top Ranking Causes of Deaths, Hospitalization, and ED Visits for Californians, Age 15-24

• This set of charts shows the leading causes of Deaths, Hospitalizations and Emergency Department (ED) visits for a selected age group at different stages of the life course using data from 2018 to 2020 combined.
  
  These age groups have been selected to highlight different patterns in causes of death, Hospitalizations, and ED Visits at each stage.
  
  Additional age groups, race/ethnicity and county level views for these same ranked data can be seen in the California Community Burden of Disease Engine (CCB) in the “Ranks” section, in the “DEATH HOSP ED” Tab.

• This first chart is for the 15-24 year old age group, and shows that five of the top six causes of death and many of the top causes of ED visits, are injury-related. The top causes of hospitalization are mental health and perinatal-related. Road injury, drug overdose, homicide, and suicide are by far the leading causes of death in the age group.

5.4b Top Ranking Causes of Deaths, Hospitalization, and ED Visits for Californians, Age 45-54

• This next chart is for the 45-54 year old age group, and shows the leading causes of death include Cardiovascular, Injury (in particular drug overdoses and alcohol-related), Other Chronic (cirrhosis) and COVID-19; septicemia is leading cause of hospitalization in this group (and in many of the older age-groups), and three of the top five causes of hospitalization are mental health related; ED visits are due to a wide range of conditions.

5.4c Top Ranking Causes of Deaths, Hospitalization, and ED Visits for Californians, Age 85+

• This third chart is for the 85+ age group and indicates that in this 2008-2020 time period Alzheimer’s disease is the leading cause of death and that Cardiovascular Diseases are the next five leading causes.
  
  Septicemia is the leading cause of hospitalization; other leading causes include Cardiovascular Diseases, fractures, pneumonia, and urinary tract infections.
  
  Urinary tract infections are also the second leading cause of ED visits; three of the top five causes, including the top cause, are Injuries.

5.5a Top Ranking Causes by Death Rate

• These next three charts look at deaths, hospitalizations, and ED visit data by race/ethnicity; showing all race groups, with the ranks sorted based on one selected race group.
  
  These same charts, and for all age groups, for all California counties are also available in the California Community Burden of Disease Engine (CCB) in the “Ranks” section, in the “AGE RACE FOCUS” Tab.

• This chart is for Deaths, ordered based on rates among American Indian/Alaska Natives, and indicates that the 2nd and 3rd leading causes of deaths among American Indian/Alaska Natives are drug overdoses and alcohol-related conditions. These two causes of death do not rank among even the top six causes of death for any other race/ethnic group
  
  

5.5b Top Ranking Causes by Hospitalization Rate

• This chart is for Hospitalizations, ordered based on rates among Blacks, and indicates that the leading cause of hospitalization for Blacks is septicemia and that the second and fourth leading causes are mental health related.
  
  The chart indicates that this is not the same ordering for all other race/ethnic groups. For example, among both Asians and Latinos “Other Complications of Birth” is the second leading cause of hospitalization, but only the eighth leading cause among Blacks.

5.5c Top Ranking Causes by Emergency Department Rate

• This chart is for Emergency Visits ordered based on rates among Blacks, and indicates that for Blacks, and all race/ethnic groups, abdominal pain, chest pain, and upper respiratory infections are leading causes for ED visits.

6.1 Risk Factors Associated with the Largest Number of YEARS LIVED WITH DISABILITY, 1990 and 2019

• These two charts present information about the risk factors associated with causes of death and disability. They are based on complex model estimates from the Institute for Health Metrics and Evaluation. They provide information for prioritizing public health resources and action based on assessing the prevalence of a wide range of behavioral and environmental risk factors, and the associations of these factors with specific conditions. These associations are modeled based on the three outcomes of deaths, years lived with disability, and disability adjusted life years.
  
  The most recent data available are from 2019.

• This chart shows that in 2019 many of the top 10, including the top two, leading risk factors associated with the greatest number of Years Lived with Disability are related to obesity, healthy eating, and exercise.
  
  Tobacco was the leading cause of Years Lived with Disability in 1990, but has dropped to the third leading risk factor in 2019, due in large part to effective public health programs over the last many years.

6.2 Risk Factors Associated with the Largest Number of DEATHS, 1990 and 2019

• Similarly, the top risk factor, and five of the top six, associated with numbers of deaths are related to heathy eating, exercise, and other factors associated with obesity and high-blood pressure. Again, tobacco has decreased from being the leading risk factor contributing to deaths to the second leading cause.From 1990 to 2019, drug use increased three positions in rank (from 13th to 10th) and Alcohol use increased two (10th to 8th), among risk factors for death. Encouragingly, Unsafe sex dropped four (from 12th to 16th) and Air pollution dropped three (from 8th to 11th).

7.1 Ischemic Heart Disease

7.2 Alzheimer’s Disease

7.3 Kidney Disease

7.4 Drug Overdose

7.5 Suicide/Self-harm

7.6 Homicide/Interpersonal Violence

7.7 Road Injury

7.8 Hepatitis C

7.9 Alcohol-Related Conditions

8.1 Life Expectancy (Mean) by Quartiles of Community Poverty and Community Educational Attainment, 2016-2020

• These charts show the mean community life expectancy based on quartiles of community poverty and educational attainment.

• Average life expectancy increases as poverty decreases and average life expectancy increases at as education increases. Increased life expectancy is associated with lower rates of poverty and higher rates of education.

• The red slashes at the bottom of the y-axis indicate that the scale of the y-axis is discontinuous. The y-axis does not start at 0, but rather at age 65, so that the important differences in life expectancy can be seen clearly.

8.2 Communities with highest and lowest life expectancy, 2016-2020

• This table shows the communities (MSSAs) with the 10 highest and lowest levels of life expectancy in the State. It also presents the mortality rate, percent living in poverty and percent with educational attainment of high school graduation and below, as well as overall population.

• This tabular view of the data highlights the strong community-level associations seen above, and emphasizes some extreme differences in life expectancy. The life expectancy in the “Clearlake /Clearlake Oaks” community in Lake County, with high levels of poverty and lower levels of education at 72.3 is about 16 years less than the life expectancy of 88.1 in the very advantaged community of “Bel Air /Beverly Glen /Beverly Hills /etc.” in Los Angeles County.

8.3 County level social determinants and life expectancy, 2016-2020

• These maps indicate that at the county level poverty, education, and life expectancy are ecologically roughly correlated. The many observed exceptions to this correlation indicate the need for further in-depth analysis.

9.1 Healthy Beginnings

9.2 Living Well

9.3 Healthy Aging

9.4 Redesigning the Health System

9.5 Creating Healthy Communities

9.6 Lowering the Cost of Care

9.7 Overarching Indicators

A - Rankings

B - Tables

C - Exploratory

Data Sources 

A majority of the charts and tables in this module are based on death data: 

• The death data used are from the California Integrated Vital Records (CalIVRS) system, based on death certificates/reports transmitted to the California Department of Public Health, Center for Health Statistics and Informatics (CHSI).  Details of the exact data sets used, aggregation of International Classification of Disease 10th Revision (ICD-10) codes into causes of death, calculation methods, demographic and geographic detail, data de-identification, and a wide range of other particulars are available in the Technical Documentation section of the California Community Burden of Disease Engine (CCB-Tech). 

  • Currently, only the single underlying cause of death ICD-10 code is used–future versions of this Core Module will incorporate “multiple cause of death”  codes for some conditions. 

  • All measures using vital statistics death data are limited based on the accuracy of the coding of cause of death on the death certificate 

Other data used include: 

• Hospital inpatient discharges and Emergency Department encounters, from the California Department of Health Care Access and Information (HCAI). Details of the exact data are in the CCB-TECH. 

• Reportable infectious disease data, from the CDPH Center for Infectious Disease, obtained via the CHHS Open Data Portal. 

• Disability and risk data and charts from the Institute for Health Metrics and Evaluation (IHME),  downloaded or directly extracted as images from their website. 

• Social determinants of health data from the US Census American Community Survey. 

• And, a wide range of Let’s Get Healthy California Progress Indicators, from multiple sources. 

Measures 

Primary measures used with death data include number of deaths, crude death rate, age-adjusted death rate, and life expectancy. 

• Number of deaths (or hospitalizations, etc.) describes the absolute magnitude of deaths, and is a clear and easily understood measure. All other things being equal, the number of deaths will be larger in areas with larger populations. This measure does not take into account the “age distribution” or size of the population.  

• Crude Death Rate takes the size of the population into account by dividing the number of deaths by the number of people in the population (multiplied by 100,000 for interpretability, i.e. number of deaths per 100,000 people).  

• Age-adjusted Death Rate takes into account or “controls” for the age distribution of the population where the rate is being assessed. It is the rate that would have existed if the population had the same age distribution as a reference population. This allows for comparisons between populations with differences in age distributions, accounting for the fact that age itself is generally correlated with higher mortality. 

• Life Expectancy (specifically, “Life Expectancy at Birth”) is a familiar and widely used measure, which summarizes in one number the ‘force of mortality’ in a population, and provides a valuable single measure to compare the overall health status between populations. Its calculation is complex, but is generally interpreted as the number of years people born in a particular year are “likely” to live. 

In addition to these measures, a number of other measures are used, specifically in the “Multiple Lenses” section and other ranking charts. Explanations of these measures are:  

• Premature Deaths: Years of Life Lost (YLL) emphasizes the impact of conditions that cause more deaths among younger people, so YLL is sometimes referred to as “premature deaths”. The number of years of life lost for deaths at each age are determined here using the “Global Burden of Disease” methods from the World Health Organization. Years of Life Lost are expressed here as rates per 100,000 population. 

• Percent Increase measures the change in the death rate between two different years, and shows which conditions are increasing (or decreasing) most rapidly. This is measured by showing the percentage increase in the age-adjusted death rate. “Age-adjusted” death rates are used to account for the impact of the changing age distribution of the California population on the measure. Because this measure focuses on the degree of increase it may sometimes highlight a condition or group for which the absolute number of deaths is relatively small, but the percent increase is great. 

• Disparity Ratio  measures the difference in the death rate between racial/ethnic groups for the same condition using combined data from a three-year period. The measure compares the age-adjusted death rate in the group with the highest rate to the group with the lowest rate. A large ratio between the two rates indicates a large disparity. 

• Years Lived with Disability is based on calculations and modeling done by the Institute for Health Metrics and Evaluation. These models utilize assumptions and multiple data sources to produce reliable California-specific estimates of years lived with disability. (expressed here as rate per 100,000 population, most recent year available 

Data Time Frames  

• This 2022 Core Module generally includes data through the most recent year for which complete data are available, 2020. For some charts data for just 2020 are shown and for others, mainly the trend charts, data for 2000 through 2020 are shown. 

• In some cases, for statistical stability and/or data deidentification purposes, years are aggregated into 3- or 5-year groups. 

• Because of the importance of showing some high-level data for the most recent time period available, especially in this COVID-19 era, data for 2021 are included in the 4th section. These data are preliminary—final death data for a given year are not available until the fall of the following year. 

Additional Notes 

• The data and charts in the Core Module are primarily driven by The California Community Burden of Disease Engine (CCB).  The CCB is a dynamic system of morbidity, mortality, and social determinants of health data;  standard value sets and tools; and modular code,  using R. The CCB provides a detailed interactive visualization platform for discovery and deeper understanding of health outcomes for public health action; and resources to quickly identify and address emerging issues and questions, with rapid deployment of analyses, visualizations, and other data tools and resources, accessible for use by public health practitioners and partners. 

  • The death and hospitalization data in the Core Module use the CCB data processing, measure calculation, and data visualization machinery. Key aspects of the CCB that facilitate insights in the Core Module include the California Community Burden of Disease Condition List, a hierarchical list of about 70 causes of death, that allow for both broad and detailed views mortality burden; hierarchical views of place, including the state, county, community and census tract levels; over 20 years of data; and carefully constructed measures and formulas.  Details of these features are described in the CCB-Tech. 

• The “Medical Service Study Area (MSSA)” geographic unit is used in several places in the report to represent “community”.  MSSAs are aggregations of census tracts, and are constructed by the HCAI with each decennial census. MSSAs are a useful surrogate for “communities” because there are 542 MSSAs for the 2010 census, providing much more geographic granularity than the 58 California counties and much greater numerical/statistical stability than the 8000+ California 2010 census tracts. Further, they are aligned with “communities” in the important sense of geographic, cultural, and sociodemographic similarities (although this is generally more true for urban than rural MSSAs, because of the larger size of MSSAs in rural areas). 

• Grouping of ICD-10 cause of death codes into useful categories is described in detail in the CCB-Tech. Because of their visibility in this Core Module and because their construction may differ from that used in other reports of California death data, we note that:  

  • “Drug overdose” deaths include “accidental poisonings by drugs” codes, “substance use disorder codes” (but not “alcohol use disorder”), and “newborn (suspected to be) affected by maternal use of drugs of addiction” codes. This approach was determined based on discussion with the CDPH Substance and Addition Prevention Branch (SAPB) and on the CDC “Consensus Recommendations for National and State Poisoning Surveillance”. 

  • “Alcohol-related conditions” includes customary causes like “alcohol abuse” and “alcohol dependence disorder”, as well as conditions that may be grouped elsewhere in other systems, especially “Alcoholic liver disease”. This approach was determined based on discussion with the CDPH Injury and Violence Prevention Branch (IVPB) and on the CDC Alcohol-Related Disease Impact (ARDI) ICD-10 codes (using 100% Alcohol-attributable codes only).