Twenty-Year Observational Study Shows Rising Alcohol-Attributable Death Profiles in the U.S. and Delaware

The U.S. alcohol-attributable mortality burden makes it the third-leading cause of preventable deaths. This 1999-2018 observational study used the Tenth Revision of the International Classification of Diseases codes and the alcohol-related disease impact (ARDI) causes of death records to track alcohol’s mortality burden. The Centers for Disease Control and Prevention keeps Wide-Ranging Online Data for Epidemiologic Research (WONDER) death certificates for the U.S. community. Evidence indicates that the U.S. ARDI mortality rates progressively trended upward (53.73%). Men were three times as likely as women to die, but female mortality rate changes (90.03%) advanced more rapidly than males. The study also revealed that the changes in alcohol-related death rate percentages for middle-age groups increased faster. In contrast, the African American/Black (AA/B) community’s age-adjusted mortality rate change patterns first declined and then increased. The alcohol-attributable mortality rate (1999 to 2018) difference for AA/B was -6.35%. Delaware’s population is around one million, and about 23% is African American/Black. The subgroup analysis for Delaware’s population was robust and showed alcohol-attributable mortality rates above national averages. This trend was apparent for both gender and race. www.scholink.org/ojs/index.php/rhs Research in Health Science Vol. 5, No. 4, 2020 47 Published by SCHOLINK INC. In conclusion, for both the U.S. and Delaware, alcohol use disorder is a risk factor for mortality, especially for males.


Introduction
. Typically in such discovery projects, students uncover ways to cross-reference and probe the WONDER's menu-driven files to look for associations between incidences of chronic health conditions and mortality (D'Souza, Wentzien et al., 2017;D'Souza, Li, Gannon et al., 2019).
Under the Wesley College STEM UR-CATS umbrella and within course-embedded research projects (Neff & D'Souza, 2019), students use publicly available, interactable, and searchable databases. For their research projects, students probe the databases' annual records for population, demographic, housing, social, and economic characteristics for all U.S. states, as well as for the State of Delaware (D'Souza et al., 2018;D'Souza, Kashmar et al., 2015;D'Souza, Wentzien, Bautista et al., 2017;D'Souza, Li, Gannon et al. 2019;Neff & D'Souza, 2019). Furthermore, undergraduates completed epidemiologic methods in study design, data analysis, and statistical interpretations for the adverse human health effects observed from persistent health complications arising from obesity, diabetes, cardiovascular diseases, and cancer (D'Souza et al., 2018;D'Souza, Kashmar et al., 2015;D'Souza, Li, Gannon et al., 2019;D'Souza, Walls et al., 2015;D'Souza, Wentzien et al., 2017;. Results reveal that the listed chronic conditions do (indeed) impact all segments of the U.S. population and that the African American/Black (AA/B) population has been disproportionately affected. Also, project data showed that the AA/B community invariably experienced higher age-adjusted mortality rate averages correlated to low socioeconomic status and lack of adequate healthcare (D'Souza et al., 2018;D'Souza, Kashmar et al., 2015;D'Souza, Li, Gannon et al., 2019).
Delaware's population is close to one million, about 0.33% of the U.S. total (U.S. Census Bureau, www.scholink.org/ojs/index.php/rhs Research in Health Science Vol. 5, No. 4, 2020 48 All U.S. death records for alcohol-related disease impacts (ARDI) are public and can be accessed through the national CDC WONDER repository (Case & Deaton, 2017;CDC, 2012;Mokdad et al., 2018). Alcohol dependence is found to be a U.S. public health challenge, as substantial increases are observed in the associations of alcohol-induced mortality (Rehm et al., 2013;Spillane et al., 2020).
Chronic alcohol use and its addiction effects on health, social outcomes, and mortality at both the U.S.

Methods
We obtained this study's data from the Centers for Disease Control and Prevention (CDC), Wide-ranging Online Data for Epidemiologic Research (CDC, 2017). CDC collects and compiles the data from the death certificates reported from all 50 states and the District of Columbia. The CDC calculates age-adjusted mortality rates and confidence interval limits to permit comparisons between demographic groups over time (CDC, 2017;Friede et al.,1993). We downloaded the data into an M.S.
Excel dataset utilizing the query menu-driven access tools and line graphs generated using the SAS software.
CDC WONDER provides a menu-driven system made available to public health professionals and the public. It provides access to a wide array of public health information, including mortality rates, age-adjusted mortality rates, and 95% confidence interval limits by several demographic factors such as race and gender. The age-adjusted rates were determined using the year 2000 population distributions as the reference population (Hoyert & Anderson, 1998). The effect of a change in mortality rates due to a change in the age distribution of a population is minimized using the age-adjusted rates, thereby permitting a more effective analysis of mortality rates over time (Anderson & Rosenberg, 2001; www.scholink.org/ojs/index.php/rhs Research in Health Science Vol. 5, No. 4, 2020 49 Published by SCHOLINK INC. Anderson & Arias, 2003). Mortality rates and age-adjusted mortality rates for alcohol attributed deaths according to alcohol-related impact (ARDI) ICD-10 codes between 1999 and 2018 were obtained and analyzed.
The CDC's alcohol-related disease impact (ARDI) online application uses more ICD-10 codes for alcohol-attributable deaths than the database category "Alcohol-Induced Causes" under the CDC WONDER database. Even though some of the codings are for fetal deaths, we selected age-groups older than 15 years to exclude fetal deaths from the final calculation when searching the database.
There were similarities between the ARDI codes and the "Alcohol-Induced Causes" category under the database. For the inclusion category under mortality, we selected as the single underlying cause, "all causes of death." For multiple causes of death, we selected all the ICD-10 codes under Table 1. or inconsistent reporting on death certificates. Line graphs displaying the age-adjusted mortality rates between 1999 and 2018 were constructed to compare the Delaware and U.S. rates by gender and race.
Mortality rates between 1999 and 2018 were constructed to compare the Delaware and U.S. rates by age.

Results and Discussion
The alcohol-related disease impact (ARDI) mortality is the third leading preventable cause of U.S.
death (Norström & Skog, 2001;Rehm et al., 2013;Spillane et al., 2020;White et al., 2020 Table 2. The twenty years of study (Figure 1) show that the national ARDI age-adjusted mortality rates steadily trended higher and accelerated to 53.73% in 2018. For Delaware, the ARDI age-adjusted mortality rate trend line (Figure 1) shows that the underlying relationship is not linear, and its final mortality rate increased by 15.87%.

Age-adjusted Mortality Rates
Also exhibited in Figure 1 are the 95% CI bands for Delaware's ARDI age-adjusted mortality rates that generally trended higher than the national mortality rate averages but saw periodic annual overlays.
Close ascending patterns were also observed in prior comparison studies of Delaware's obesity-related mortality rates with their corresponding national obesity-related mortality rate averages ( The 1999 and 2018 U.S. and DE gender-based ARDI age-adjusted mortality rates and their corresponding 95% CI values are shown in Table 3. Illustrated in Figure 2 are the similar gender-based,

Alcohol-attributable Age-Adjusted Mortality Rates
When the computed gender-based population mortality rate ratio values that were obtained from death certificate data that listed alcohol as a contributory and/or induced cause of death are coupled with the 1999-2018 ARDI age-adjusted mortality rate information provided in Table 3    The Figure 3 race-based data for the U.S. and Delaware bare the fact that the AA/B individuals had substantially higher 1999 ARDI age-adjusted mortality rates whose gradient veered noticeably downwards and then in 2013, rose upwards. As a result, the 1999 to 2018 ARDI age-adjusted mortality rate differences for Whites in the U.S. and Delaware were very positive, at 70.68% and 20.34%, respectively. Comparatively, for the U.S. and Delaware AA/B population, the alcohol-attributable death rates ended in 2018 at -6.35% and -20.34%, respectively. Due to lower available ARDI death record numbers for the age-groups, 35-44, 44-54, 55-64, and 65-74, crude mortality rates were utilized for both the U.S. and Delaware residents. For each listed age-group,  (1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018) crude-adjusted mortality rate trends for the U.S. are shown in Figure 4, and likewise, the Delaware graphs are in Figure 5.
No significant Pearson correlations were found between the county mortality rates and per-capita income levels, except for Sussex County, which was very close to a 5% threshold (p = .0513).
The Figure 6 Delaware County trends for the alcohol-attributable crude mortality rates feature large 1999 to 2018 crude mortality rate changes of 48.19% for Kent County and 42.39% for Sussex County.
The Kent and Sussex County percentages are much lower than the comparable 1999 to 2018 crude mortality rate change of 72.09% for the U.S. national average. They are in line with the general epidemiological patterns for the prevalence rates for alcohol use (Norström & Skog, 2001;Rehm et al., 2013;Spillane et al., 2020;White et al., 2020)

Conclusions
The alcohol-related disease impact application was useful in tracking the estimates of alcohol-attributable deaths in the U.S. and Delaware. In the twenty-year (1999-2018) period, deaths registered show that there were 1,016,445 US deaths and 3,724 Delaware deaths known to be a consequence of alcohol. Overall, the U.S. alcohol-attributable mortality rates increased by 53.73%, and