NUR 603 Module 3 Milestone One Example

Milestone One: Defining the Problem, the Case and the Data for Alcohol-Induced Deaths Among Women Aged 45 to 64 in Ridgeline County

[Student Name]

Southern New Hampshire University

NUR 603: Epidemiology

Milestone One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone One: Defining the Problem, the Case and the Data for Alcohol-Induced Deaths Among Women Aged 45 to 64 in Ridgeline County

Deaths caused directly by alcohol have risen in the United States for two decades, and in recent years they have risen fastest among women. Public attention to substance-related deaths has centered on opioids, which makes alcohol an easy problem to overlook at the county level. This milestone begins a population health analysis of alcohol-induced deaths among women aged 45 to 64 in Ridgeline County, a composite county used for this project. It argues that the problem is large enough and changing fast enough to warrant local analysis, sets a case definition that can be applied consistently and identifies the data sources, with their limits, on which later milestones will depend.

Why This Problem and This Population

National data make the case for attention. Across 1999 through 2020, 605,948 deaths in the United States were attributed to alcohol. The male rate was 2.88 times the female rate over the whole period, but from 2018 to 2020 the age-adjusted rate rose by an estimated 14.7% per year among women compared with 12.5% per year among men (Karaye et al., 2023). Then came the pandemic, and with it a sharp jump: alcohol-related deaths rose by about a quarter between 2019 and 2020 (White et al., 2022). Deaths directly caused by alcohol are only part of the burden. Counting both fully and partly attributable causes, an estimated 12.9% of all deaths among adults aged 20 to 64 in 2015 through 2019 were due to excessive drinking, about 1 in 8 (Esser et al., 2022).

Behavior points the same way. Between 2001 to 2002 and 2012 to 2013, national surveys found that high-risk drinking and alcohol use disorder increased across most groups, with some of the largest increases among women and adults in middle and older age (Grant et al., 2017). Women aged 45 to 64 are a sensible focus because deaths from alcoholic liver disease, the largest single cause of alcohol-induced death, accumulate after years of heavy drinking and peak in midlife, and because women develop liver injury at lower levels of consumption than men. They are also a group primary care sees regularly, which matters for the prevention milestone that follows.

Case Definition

A case is a death of a Ridgeline County resident who was female and aged 45 to 64 at death, occurring in 2018 through 2022, with an underlying cause of death coded to the National Center for Health Statistics list of alcohol-induced causes. That list includes alcoholic liver disease (K70), mental and behavioral disorders due to alcohol use (F10), accidental and intentional alcohol poisoning (X45, X65 and Y15), alcohol-induced pancreatitis (K85.2 and K86.0), alcoholic cardiomyopathy (I42.6), alcoholic gastritis (K29.2), alcoholic polyneuropathy and myopathy (G62.1 and G72.1), degeneration of the nervous system due to alcohol (G31.2), alcohol-induced pseudo-Cushing syndrome (E24.4) and excess alcohol in blood (R78.0).

This definition is deliberately narrow. It counts only deaths caused wholly by alcohol and excludes deaths in which alcohol contributed, such as motor vehicle crashes, falls, many cancers and some suicides. The narrow definition has two advantages: it can be applied the same way to county, state and national data, and it matches the published national series, so comparisons are fair. Its cost is that it understates the full toll, which Esser et al. (2022) show is several times larger. Residence, not place of death, determines county assignment, so county residents who die in a hospital in another county are still counted.

Data Sources

Three sources will be used, each for a different purpose. The first is death certificate data, accessed through the CDC WONDER multiple cause of death files for county, state and national comparisons and, for exact small counts, through a data request to the state vital records office. The second is the county population estimates published by the Census Bureau, which supply the denominators for women aged 45 to 54 and 55 to 64 in each year. The third is the Behavioral Risk Factor Surveillance System, which provides estimates of binge and heavy drinking among adult women in the state and, through small-area estimates, the county. Table 1 summarizes each source.

Table 1. Data Sources for the Analysis

Note. Ridgeline County is a composite. Source descriptions apply to the real national systems.

Small Numbers and Pooling

In a county of this size, the number of alcohol-induced deaths among women aged 45 to 64 in any single year will be small, likely under 20. CDC WONDER suppresses counts from 1 to 9 to protect privacy and flags rates based on fewer than 20 deaths as unreliable, because a change of two or three deaths moves the rate substantially. For that reason, the analysis will pool five years, 2018 through 2022, for its main rates and will present single-year counts only as a trend, with that caution stated. Pooling also means that the rate will describe the period as a whole and cannot show exactly when a change occurred.

Known Threats to the Numbers

The most important threat is undercounting. Alcohol involvement is often left off death certificates; an analysis of fatal crashes found wide state variation in how often certifiers recorded alcohol when toxicology showed it was present (Castle et al., 2014). Stigma may make certifiers less likely to record alcohol for some decedents, including women, which would bias the count downward in the very group this project studies. A second threat is misclassification between codes, such as liver disease recorded without specifying alcohol. A third is that self-reported drinking in the BRFSS is known to capture much less alcohol than sales data show, so drinking prevalence will be treated as a lower bound.

Conclusion

Alcohol-induced deaths among midlife women are rising nationally, and the county deserves a local picture. This milestone has set a case definition that matches national reporting, identified three data sources with their coverage and gaps, chosen to pool five years because of small numbers and named the biases most likely to affect the count. Milestone Two will use these decisions to calculate age-adjusted rates and compare them by person, place and time.

References

Castle, I.-J. P., Yi, H.-Y., Hingson, R. W., & White, A. M. (2014). State variation in underreporting of alcohol involvement on death certificates: Motor vehicle traffic crash fatalities as an example. Journal of Studies on Alcohol and Drugs, 75(2), 299-311. https://doi.org/10.15288/jsad.2014.75.299

Esser, M. B., Leung, G., Sherk, A., Bohm, M. K., Liu, Y., Lu, H., & Naimi, T. S. (2022). Estimated deaths attributable to excessive alcohol use among US adults aged 20 to 64 years, 2015 to 2019. JAMA Network Open, 5(11), Article e2239485. https://doi.org/10.1001/jamanetworkopen.2022.39485

Grant, B. F., Chou, S. P., Saha, T. D., Pickering, R. P., Kerridge, B. T., Ruan, W. J., Huang, B., Jung, J., Zhang, H., Fan, A., & Hasin, D. S. (2017). Prevalence of 12-month alcohol use, high-risk drinking, and DSM-IV alcohol use disorder in the United States, 2001-2002 to 2012-2013: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry, 74(9), 911-923. https://doi.org/10.1001/jamapsychiatry.2017.2161

Karaye, I. M., Maleki, N., Hassan, N., & Yunusa, I. (2023). Trends in alcohol-related deaths by sex in the US, 1999-2020. JAMA Network Open, 6(7), Article e2326346. https://doi.org/10.1001/jamanetworkopen.2023.26346

White, A. M., Castle, I.-J. P., Powell, P. A., Hingson, R. W., & Koob, G. F. (2022). Alcohol-related deaths during the COVID-19 pandemic. JAMA, 327(17), 1704-1706. https://doi.org/10.1001/jama.2022.4308