The Burden of Digestive Diseases in the United States James E. Everhart, M.D., M.P.H., Editor Copyright Information
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_. FOREWORD 2. GASTROINTESTINAL INFECTIONS 7. CANCER OF THE SMALL INTESTINE 8. CANCER OF THE COLON AND RECTUM 13. HEMORRHOIDS 14. GASTROESOPHAGEAL REFLUX DISEASE 16. FUNCTIONAL INTESTINAL DISORDERS 17. APPENDICITIS 19. INFLAMMATORY BOWEL DISEASE 21. LIVER DISEASE 22. GALLSTONES 23. PANCREATITIS 24. INDICATIONS AND OUTCOMES OF GASTROINTESTINAL ENDOSCOPY 25. COSTS OF DIGESTIVE DISEASES _. APPENDICES 2. Summary of Surveys Used in The Burden of Digestive Diseases in the United States 3. Methodology for Tables and Figures _. Index of Tables and Figures Digestive diseases include a wide spectrum of disorders affecting the oropharynx and alimentary canal, liver and biliary system, and pancreas. These disorders have diverse causes, including congenital and genetic anomalies, acute and chronic infections, cancer, adverse effects of drugs and toxins, and, in many cases, unknown causes. Some conditions, such as foodborne diarrheal diseases, are so common as to be considered a universal life experience, while many others are relatively uncommon or rare. The impact of these diseases ranges from the inconvenience of a transient diarrheal disease causing missed time from school or work, to chronic and debilitating illnesses requiring continuous medical care, or, all too frequently, to dreaded conditions such as pancreatic cancer that are usually fatal. During the 20th century, there were dramatic changes in the incidence, prevalence, and overall impact of digestive diseases in the United States that were the result of many factors, including improved sanitation and an improved food supply; numerous research discoveries that led to the development of new drugs, vaccines, diagnostic tests, and minimally invasive procedures; and an economic and health care system capable of providing these advances to the majority of the population. Continued progress in improving the health welfare of the population of the United States requires a continued investment in digestive disease research, public health initiatives, the health care system, and the education of the general public about how to improve their health. Accurate descriptive statistical information is one of the most basic types of information required by those engaged in activities aimed at improving digestive health, including researchers, administrators, public officials, professional and patient-based organizations, and the general public. In 1994, the National Institutes of Health (NIH) sponsored a publication, Digestive diseases in the United States: epidemiology and impact, that has served as a reference to meet these needs; the report had a limited update in 2001.1, 2 Because of continuing changes in the incidence and prevalence of digestive diseases, important changes in health care, such as the emphasis on outpatient care whenever possible, and the availability of new statistical resources, the time is right to generate a new report to capture the impact of digestive diseases in the United States. In addition, congressional report language accompanying the Fiscal Year 2005 appropriations bills in the House and Senate for Labor-Health and Human Services-Education and Related Agencies called for the creation of an advisory committee, the National Commission on Digestive Diseases, and tasked it with addressing the burden of digestive diseases and developing a long-range research plan. The resulting research plan from this charge, Opportunities and challenges in digestive diseases research: recommendations of the National Commission on Digestive Diseases, outlines a broad and ambitious agenda aimed at improving the health of the nation for digestive diseases through research; the research plan can be accessed at http://NCDD.niddk.nih.gov. The NIH sponsored the current report on the burden of digestive diseases to serve not only as a needed statistical reference, but also as a companion volume to inform research goals recommended in the Commission’s research plan. Close examination of this report will reveal many interesting and provocative pieces of statistical information about trends in various digestive diseases. As outlined in the report, for any specific disease condition, there are numerous limitations on the types of data that can be obtained in the diverse and decentralized U.S. health care system. Despite the many limitations of the statistical information, there are several certainties. In spite of a century of progress, the burden of digestive diseases in numerical terms remains staggering in the United States; the numbers, however, convey in only a limited way the suffering of and impact on the millions of individuals affected. In addition, the limitations of the report and the statistical data mandate a strong digestive disease research effort aimed at improving health in the United States through pursuit of the many recommendations of the Commission’s research plan, improving our ability to capture needed statistical and epidemiological information, and spurring fundamental improvements in the health care system. Stephen P. James, M.D. 1 Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447. I wish to thank the following individuals for making this report possible: Danita Byrd-Holt, Constance Ruhl, Bryan Sayer, Sanee Maphungphong, Beny Wu, Laura Fang, Laura Spofford, Polly Gilbert, Julie Kale, and Katherine Merrell of Social & Scientific Systems, Inc., for programming, production of tables and figures, text and cover graphic design, copyediting, and production of the final report; Daniel Westbrook and Douglas Brown of Georgetown University for analysis of the cost of digestive diseases; David Lieberman and Nora Mattek of the Clinical Outcomes Research Initiative (CORI) for the national endoscopy data; Dedun Ingram at the National Center for Health Statistics for advice on age-adjustment; and Robert Kloos at Ohio State University for advice on recovery times from surgery. James E. Everhart, M.D., M.P.H., Editor All Digestive Diseases For systematic coding, mortality and health care statistics rely on disease classification systems, of which the International Classification of Diseases (ICD) is the world standard. The diagnostic codes traditionally used for digestive diseases primarily code for chronic conditions that are neither infectious nor malignant. In the current ICD edition (ICD-10), these include K20 through K93 in chapter “K” (Appendix 1). Other digestive diseases of public health significance and of particular interest to practitioners and researchers are coded in other chapters: Intestinal Infectious and Parasitic Diseases (A00–A09); Viral Hepatitis (B15–B19); Malignant Neoplasms of Digestive Organs (C15–C26); Hemorrhoids (I84); Esophageal and Gastric Varices (I85, I86.4); Maternal Disorders (Digestive) Related to Pregnancy (O21–O22); Conditions (Digestive) Originating in the Perinatal Period (P53, P54, P57, and P59); Digestive System Disorders of Fetus and Newborn (P75–P78, P92); and Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q39–Q45). For some of these groups of conditions, there were enough national data for individual sections in this report. For others, they and many other digestive system disorders were grouped under ”other digestive diseases,” so that a more complete impact of the total burden of digestive diseases could be estimated. ICD-9 codes were used for mortality 1979–1998, and ICD-10 codes have been used subsequently, which has been noted on figures of mortality trends. As of the publication of this report, the United States had yet to switch from ICD-9-CM (Clinical Modification) to ICD-10 codes for coding morbidity, despite the publication of the newer edition in 1992. Therefore, all morbidity information from 1979 through 2005 was from ICD‑9-CM. In 2004, there were an estimated 72 million ambulatory care visits with a first-listed diagnosis of a digestive disease and more than 104 million visits with an all-listed diagnoses, which equated to a rate of 35,684 visits per 100,000 U.S. population (Table 1). In other words, for every 100 U.S. residents, there were 35 ambulatory care visits at which a digestive disease diagnosis was noted. Visits were common for all age groups, with the highest rate among persons age 65 years and older. Age-adjusted rates were comparable for blacks and whites and were 20 percent higher for females than for males. Digestive diseases were common all-listed diagnoses at hospital discharge in 2004 as well as first-listed diagnosis (Table 1). There were approximately 4.6 million discharges of patients with digestive disease as first-listed diagnosis and 13.5 million discharges as all-listed diagnoses. With a rate of all-listed diagnoses of 4,608 per 100,000, there were nearly five overnight hospital stays per 100 U.S. residents that included a discharge diagnosis of at least one digestive disease. These rates were nearly as high among children as among middle-aged adults and were higher in these two age groups than among younger adults. The highest rate was among persons age 65 years and older. In contrast to their ambulatory care visits, blacks had higher rates of hospitalization than did whites. Comparable or lower age-adjusted rates of ambulatory care visits among blacks, yet higher rates of hospitalization, were a common finding for a number of digestive diseases. Women had a 10 percent higher age-adjusted rate than men. The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown in Figure 1 by 3-year periods (except for the first period, which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Age-adjusted rates increased during this period by one-third, from 26.4 per 100 population to 35.3 per 100 population. This trend in increased rates of ambulatory care visits started at least as early as 1985, when there were 22.4 digestive disease diagnoses per 100 population.1 Rates of all-listed hospitalization with a digestive disease diagnosis fell between 1983 and 1988, a pattern that occurred for all hospitalizations in the United States. Hospitalization rates were stable for the next 10 years before rising to a rate in 2004 equal to the previous peak rate in 1982. The age-adjusted percent increase between 1998 and 2004 was 35 percent. This overall increase was the net of diagnoses whose rates increased and diagnoses whose rates decreased. The largest contributor to the increase was “other digestive diseases”—those conditions that do not have separate chapters in this report. The largest individual disease contributions to the increase were made by gastroesophageal reflux disease (GERD), with an increase over this period of 376 per 100,000 population; viral hepatitis C, with 79 per 100,000; chronic constipation, with 62 per 100,000; intestinal infections, with 41 per 100,000; and pancreatitis, with 23 per 100,000. Except for pancreatitis, each of these diagnoses was more likely to be listed as a secondary discharge diagnosis than as the first-listed diagnosis. The recent increase in overnight hospital stays with a diagnosis of digestive disease is surprising for two reasons. A few common conditions were known to have declined as reasons for overnight hospitalizations, notably peptic ulcer disease (due to decreased frequency) and gallstones (due to shift to same-day surgery). Of greater significance was the modest rate of increase of hospital discharges for all diseases (from 11,569 per 100,000 in 1998 to 13,104 per 100,000 in 2004, a 13.3 percent increase) relative to the larger increase for digestive diseases. In 1998, 25.3 percent of all hospital discharges had a diagnosis of digestive diseases; this increased to 30.1 percent in 2004. Thus, rates of hospitalizations with digestive disease diagnoses increased both absolutely and as a proportion of all hospitalizations. In 2004, there were more than 236,000 deaths in the United States with a digestive disease as the underlying cause (Table 2), which represented 9.8 percent of all deaths. A disproportionately lower proportion of deaths from digestive diseases occurred among children (4.1 percent) and a higher proportion occurred among middle-aged adults (15.1 percent). There was no major variation in the distribution of deaths from digestive disease as a proportion of all deaths by race or sex. However, blacks had a 29 percent higher death rate than whites, and men had a 53 percent higher rate than women. There were 2 million years of potential life lost (YPLL) prior to age 75 years due to digestive diseases, representing 8.5 years per death with digestive disease as an underlying cause. Digestive diseases were more frequently listed as underlying cause than as contributing cause, mainly due to the large effect of deaths from cancer, which was usually listed as underlying cause. There was a gradual decline in digestive disease mortality between 1979 and 2004, both as underlying (18.2 percent) and as underlying or other cause (20.3 percent) (Figure 2). There have been many contributions to this decline, but the greatest determinant was the decrease in digestive disease cancer mortality by 19.8 percent as underlying cause and 24.0 percent as underlying or other cause. The 10 costliest prescription drugs from retail pharmacies for digestive diseases, according to the 2004 Verispan database (Appendix 2), are shown in Table 3. Dominating the prescription market at 50.7 percent of total number of prescriptions and 77.3 percent of total cost were five proton pump inhibitors, which were mainly prescribed for GERD. The other costliest medications were mesalamine (for inflammatory bowel disease), ranitidine (another anti-acid agent), tegaserod [for irritable bowel syndrome (IBS) and constipation], and ribavirin and peginterferon alfa_2a (for hepatitis C). A deficiency of the drug data is lack of information on nonprescription medications, complementary and alternative medications, infusions, and drugs administered in the hospital. Summary data for individual digestive diseases are shown in Table 4, ordered by underlying cause of death and type of disease. Five diseases each caused more than 10,000 deaths. These were liver disease and four cancers, led by colorectal cancer. Two common causes of death were transmissible infectious diseases: gastrointestinal (GI) infections and viral hepatitis C. Chronic viral hepatitis is also believed to be a significant contributor to liver and bile duct cancers, which accounted for more than 11,000 deaths. The YPLL prior to age 75 years is the addition of the number of years prior to age 75 at which deaths occur. A death at age 55 years, for example, contributes 20 YPLL, while a death at age 75 years contributes none. Malignancies were responsible for 6 of the top 10 digestive diseases that contributed the most to YPLL (Table 4). Liver disease was the second leading cause of death (after colorectal cancer), but contributed the greatest number of YPLL. Also among the 10 leading causes of YPLL were hepatitis C and pancreatitis. The distribution of burden of medical care for digestive diseases is notably different from mortality from digestive diseases. The six leading diseases with diagnosis noted at ambulatory care visits were GERD, chronic constipation, abdominal wall hernia, hemorrhoids, diverticular disease, and IBS. At least three of these (GERD, constipation, and IBS) are largely caused by disordered function of the GI tract, and diverticular disease also may be in part a consequence of dysfunction. The six most common digestive diseases diagnoses on hospital discharge records were GERD, diverticular disease, liver disease, constipation, gallstones, and peptic ulcer disease. The main difference between the records for hospital discharge diagnoses and ambulatory care diagnoses was the high numbers of diagnoses with liver disease and peptic ulcer disease, which can be life-threatening, and gallstones, which are a common reason for surgery. Because GERD and constipation should rarely lead to hospitalization, it must be assumed that when listed on discharge, they either contributed to the reason for hospitalization or were listed in thousands of discharges simply because they were so common. 1 Everhart JE. Overview. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447 pp. 1–53. Table 1. All Digestive Diseases: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. All Digestive Diseases: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 2. All Digestive Diseases: Number and Age-Adjusted Rates of Deaths, Years of Potential Life Lost (to Age 75), and Digestive Disease as a Percentage of All Deaths by Age, Race, and Sex in the United States, 2004
Figure 2. All Digestive Diseases: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Table 3. All Digestive Diseases: Costliest Prescriptions
Table 4. Burden of Selected Digestive Diseases in the United States, 2004
Gastrointestinal Infections Most GI infections are self-limited and do not come to medical attention, although they are both extremely common and disruptive of daily activities, including school and work. GI infections are caused by viral and bacterial pathogens, but the minority that are most severe and for which causative agents are found are typically bacterial. The ICD-9 and ICD-10 codes match well, except for nonspecified organisms. The most significant differences are that Intestinal Infections Due to Other Organisms (008) and Ill-Defined Intestinal Infections (009) in ICD-9 were replaced by Other Bacterial Intestinal Infections (A04), Other Bacterial Foodborne Intoxications (A05), and Viral and Other Specified Intestinal Infections (A08) in ICD-10. Here is a breakdown of the codes for GI infections:
As shown in Table 1, in 2004, more than half of ambulatory care visits for GI infections occurred in those under the age of 15 years. When first-listed, the rate in this age group (1,930 per 100,000 population), was at least 4 times that of any other age group. Age-adjusted rates were 45.7 percent higher among whites than blacks and 18.1 percent higher among females than males. Relative to the frequency of ambulatory care visits, hospitalizations were uncommon. In contrast to those in ambulatory care, persons over age 65 years had both the highest number and rate of hospitalizations, and blacks had rates similar to those of whites. GI infections were considerably more often a secondary diagnosis (272,000) than first-listed diagnosis (178,000). The rate of age-adjusted hospitalizations with a diagnosis of GI infections increased by 92.8 percent between 1979 (76.1 per 100,000) and 2004 (146.7 per 100,000) and by 43.3 percent between 1992 (102.4 per 100,000) and 2004 (Figure 1). In 2004, there were 4,396 deaths with a GI infection listed as the underlying cause (Table 2). The large majority of these deaths occurred among persons age 65 years and older. The death rate among whites was 50 percent higher than that among blacks, and the rates were similar among females and males. Similar patterns were seen for GI infections as either underlying or contributing cause. Because the majority of deaths occurred in the elderly, the YPLL prior to age 75 years was small, less than 3 years per death. In recent years, there has been a remarkable increase in deaths from GI infections (Figure 2). Over the 20-year period between 1979 and 1999, the age-adjusted underlying cause mortality rate doubled from 0.21 per 100,000 to 0.42 per 100,000. But in the 5 years from 1999 to 2004, the rate more than tripled to 1.44 per 100,000. About two-thirds of the more recent increase is due to one bacterial cause, Clostridium difficile, which is coded under Other Bacterial Intestinal Infections as A04.7. MEDICATIONS The costliest prescriptions filled at retail pharmacies for GI infections in 2004, according to the Verispan database (Appendix 2), are shown in Table 3. Most were antimicrobial agents, such as ciprofloxacin, or they affected GI motility, such as promethazine. An estimated 938,000 outpatient prescriptions were filled. Table 1. Gastrointestinal Infections: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Gastrointestinal Infections: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 2. Gastrointestinal Infections: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Gastrointestinal Infections: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Table 3. Gastrointestinal Infections: Costliest Prescriptions
Viral Hepatitis The primary forms of viral hepatitis in the United States are hepatitis A, B, and C (see ICD codes in Appendix 1). Hepatitis A is common and can be serious or even lethal. It does not have a chronic form. Hepatitis B can cause both acute and chronic disease, whereas acute hepatitis C is often asymptomatic, and its burden is predominantly due to chronic disease. HEPATITIS A Although the infection is common, hepatitis A is infrequently recognized in the ambulatory care or hospital setting. It was too infrequent to appear in the office-based sample of the National Ambulatory Medical Care Survey (Table 1). Hospitalization rates declined by about 75 percent between 1979 and 1993, and remained relatively stable through 2004. An effective vaccine to prevent infection was introduced in the 1990s, but it has not had a noticeable effect on reducing hospitalizations (Figure 1). Mortality from hepatitis A was rare, with fewer than 100 deaths per year (Table 2). Unlike recently stable rates of hospitalizations, the death rate from viral hepatitis A was halved between 1999 and 2004 (Figure 2). HEPATITIS B Viral hepatitis B is a more significant disease than hepatitis A. In the United States, infections were most commonly recognized between ages 15 and 44 years, and hospitalizations with the diagnosis occurred across the age range of adults (Table 3). Rates of both ambulatory care visits and hospitalizations with hepatitis B were higher among blacks than whites and among males than females. Hepatitis B was rarely the first-listed hospital diagnosis. There has been a vaccine available for hepatitis B since the 1980s, but the rates of both ambulatory care and hospitalizations have increased markedly since 1999 (Figure 3). This increase has been attributed to increased rates of immigration of chronic carriers of hepatitis B virus. Although not a common cause of death, viral hepatitis B resulted in about 10 times as many deaths as hepatitis A (Table 4). The majority of deaths with hepatitis B as either underlying or contributing cause occurred in middle age, between age 45 and 64 years. As with other forms of infections, hepatitis B was more often listed as a contributing than as an underlying cause. Deaths from hepatitis B increased between 1979 and 1994, but mortality steadily declined thereafter, in spite of (or perhaps related to) the increased rates of medical care (Figure 4). As an underlying cause, rates in 2004 were similar to those in 1979, but as a contributing cause, rates were considerably higher in 2004 than they had been 25 years earlier. Age-adjusted mortality was higher among blacks than whites. HEPATITIS C The hepatitis C virus was discovered in 1989, and tests for it soon followed. Most prior cases of non-A, non-B hepatitis are believed to have been viral hepatitis C. In both the outpatient and inpatient setting, more than half the cases were in persons ages 45–64 years (Table 5). Rates were at least twice as high among blacks as whites and among males as females. Viral hepatitis C was rarely the first-listed diagnosis at hospital discharge, but was frequently listed as a secondary diagnosis. As a result, only 2.6 percent of hospital discharge diagnoses for hepatitis C listed it as the first-listed diagnosis. Where hepatitis C was not the first-listed diagnosis, the most common underlying (first-listed) causes were chronic liver disease and its sequelae (10.4 percent), mood disorders (4.5 percent), cellulitis (3.8 percent), complications of procedures (2.6 percent), pneumonia (2.5 percent), and HIV (2.4 percent). The majority of hospitalizations, however, appeared to be unrelated to hepatitis C, suggesting that the diagnoses may appear as a result of testing for hepatitis C, rather than as consequences of hepatitis C. Blacks and men had the highest age-adjusted rates. Both outpatient and inpatient diagnoses have greatly increased since hepatitis C received its own ICD code in the early 1990s (Figure 5). The number of hospitalizations prior to 1992 was too small to provide estimates. Much of the increase can be attributed to increasing recognition of the disease. There was also the introduction of antiviral therapy that required frequent patient monitoring. It is not clear how much of the increase can be attributed to the consequences of disease burden due to longstanding infection. In 2004, 85 percent of hepatitis-related deaths were from viral hepatitis C. Hepatitis C was listed as a contributing cause of death more often than as the underlying cause (Table 6). About two-thirds of deaths occurred between the ages of 45 and 64 years. Age-adjusted death rates among blacks were nearly twice those of whites, and males had more than double the death rate of females. Hepatitis C contributed a high number of YPLL before the age of 75 years (87,500), because of the large number of deaths and because few deaths are attributed to the disease after age 75. This number placed hepatitis C as the fifth leading digestive disease cause of YPLL, behind esophageal cancer and ahead of gastric cancer. In keeping with the growing identification and long-term consequences of the disease, mortality rates increased rapidly from 1990 to 2004 (Figure 6). (The few deaths recorded prior to 1990 were for non-A, non-B viral hepatitis.) Of note, the mortality rate for hepatitis C as underlying cause leveled off beginning in 2001 and as underlying or contributing cause in 2002. ALL VIRAL HEPATITIS The burden of all viral hepatitis primarily reflected that of hepatitis B in past years and, more recently, hepatitis C (Tables 7 and 8, Figures 7 and 8). For example, 97.5 percent of the YPLL prior to age 75 years due to viral hepatitis was a result of hepatitis B (11.6 percent) or hepatitis C (85.9 percent). MEDICATIONS The costliest prescriptions filled at retail pharmacies for viral hepatitis in 2004, according to the Verispan database (Appendix 2), are shown in Table 9. An estimated 637,000 outpatient prescriptions were filled, but these were represented by few drugs, which were prescribed exclusively for hepatitis B (adefovir and lamivudine) or hepatitis C (ribavirin and peginterferon). When used to treat hepatitis C, ribavirin was nearly always used with interferon. For a full course of therapy, each of the medications in Table 9 would have required multiple prescriptions. Table 1. Hepatitis A: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Hepatitis A: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 2. Hepatitis A: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Hepatitis A: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Table 3. Hepatitis B: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 3. Hepatitis B: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 4. Hepatitis B: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 4. Hepatitis B: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Table 5. Hepatitis C: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 5. Hepatitis C: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 6. Hepatitis C: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 6. Hepatitis C: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Table 7. All Viral Hepatitis: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 7. All Viral Hepatitis: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 8. All Viral Hepatitis: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 8. All Viral Hepatitis: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Table 9. All Viral Hepatitis: Costliest Prescriptions
Digestive Cancers The Surveillance, Epidemiology, and End Results (SEER) program provides considerable information on cancer burden not available for other digestive diseases. SEER statistics used in this report are number of cases and incidence in 2004, and the time trends for incidence and 5-year survival following diagnosis between 1979 and 2004. The codes used by ICD-9, ICD-10, and SEER are listed in Appendix 1. ALL DIGESTIVE SYSTEM CANCERS In 2004, approximately 233,000 persons were diagnosed with digestive system cancers (Table 1), which represented 18 percent of all cancers and was second only to genital system cancers for the most commonly affected organ system. Two-thirds of digestive system cancers occurred among persons age 65 years and older. The median age of diagnosis was 70 years, compared with 67 years for all cancers (http://seer.cancer.gov/csr/1975_2005/results_merged/topic_med_age.pdf). Age-adjusted rates were highest among non-Hispanic blacks and lowest among American Indians. Males had slightly higher rates than females. Age-adjusted incidence declined by 13.2 percent between 1979 and 2004, with the entire decline coming after 1986 (Figure 1). Survival for all cancers and for individual cancers was calculated as absolute survival. Other reports may calculate survival relative to the general population with the same age and sex distribution, which would result in higher apparent survival. The same trends, however, would be seen for either approach. Five-year survival increased an absolute 6 percent to 34.6 percent; thus, for every 100 persons diagnosed with a digestive system cancer in 1999, 6 more survived at least 5 years longer than did those diagnosed 20 years earlier. There were approximately 3.5 million ambulatory care visits for first-listed digestive system cancer in 2004 and 4.2 million all-listed visits. The elderly, whites, and males had the highest rates of ambulatory care visits (Table 2). Among all hospital discharges with digestive system cancers, about half were first-listed. The main demographic difference between ambulatory care diagnoses and hospital diagnoses was that blacks had a higher age-adjusted rate of hospital diagnoses. Rates of ambulatory care visits for digestive system cancers did not change appreciably over the period 1992–2004, but hospitalizations rates declined by 13.6 percent over that period (Figure 2). In 2004, there were approximately 135,000 deaths due to digestive system cancers (Table 3), which represented 24 percent of all cancers and were second only to respiratory system cancers as cause of death due to cancer. As underlying cause, digestive system cancers constituted 57.2 percent of all digestive disease deaths. Death rates among persons 65 years and older were 5 times that of those aged 45–64 years. Age-adjusted death rates were higher among blacks and men. There were 945,000 YPLL due to digestive system cancer, the large majority occurring among males. Death rates from digestive system cancer declined steadily between 1979 and 2004 by an overall 19.8 percent (Figure 3). MEDICATIONS The costliest prescriptions filled at retail pharmacies for digestive system malignancies in 2004, according to the Verispan database (Appendix 2), are shown in Table 4. An estimated 879,000 outpatient prescriptions were filled. The costliest agents were either anti-neoplastic agents, such as capecitabine, or nonspecific pain and anti-nausea medications, such as fentanyl. Because the prescriptions were filled at retail pharmacies and do not capture all the settings where anti-cancer treatment is prescribed, this table both underestimates the number of prescriptions and likely misses many of the drugs used to treat digestive system malignancies. Medications are not shown for the individual malignancies in the following chapters. Table 1. All Digestive Cancers: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. All Digestive Cancers: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Source: Surveillance, Epidemiology, and End Results (SEER) Program Table 2. All Digestive Cancers: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. All Digestive Cancers: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 3. All Digestive Cancers: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. All Digestive Cancers: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Table 4. All Digestive Cancers: Costliest Prescriptions
Cancer of the Esophagus The two forms of esophageal cancer are squamous cell carcinoma, which occurs in the upper two-thirds of the esophagus, and adenocarcinoma, which occurs in the lower part of the esophagus. Because the epidemiology of the two cancers is quite different, the SEER results are presented separately. Other national data sources do not differentiate as well, and those data therefore are combined. In 2004, the majority (67 percent) of new cases of esophageal squamous cell cancer occurred among persons 65 years and older (Table 1) and occurred most often among non-Hispanic blacks and males (61 percent). The incidence declined over 25 years to 2004, when it was about half the rate of 1979 (Figure 1). Five-year survival remained poor, but improved from about 3 percent to 12 percent over that period. Esophageal adenocarcinoma had a younger age distribution than most other digestive system cancers, but the majority of cases (63 percent) still occurred at age 65 years and older (Table 2). Non-Hispanic whites and males had by far the highest risk. These race and sex differences were greater than for any other common digestive tract cancer. During the 25 years of observation, the incidence of esophageal adenocarcinoma increased more rapidly than any other common malignancy, rising approximately fivefold between 1979 and 2004 (Figure 2). Five-year survival remained poor, but had increased from less than 5 percent to more than 15 percent. Combining the two esophageal cancers (Table 3 and Figure 3) obscures their dynamic differences. For example, incidence of all esophageal cancer increased modestly over the period, but in 1979, adenocarcinoma was about one-eighth as frequent as squamous cell carcinoma, whereas by 2004, adenocarcinoma had the higher incidence. These combined data can, however, be useful for comparison with other national data. In 2004, there were an estimated 372,000 ambulatory care visits and 44,000 hospital diagnoses for esophageal cancer; rates of ambulatory care visits were moderately higher among persons age 65 years and older (Table 4). There were only sufficient numbers of ambulatory care visits for whites and males to show in the table. Hospitalizations occurred predominantly among persons age 65 years and older. During the 25 years of reporting, the rates of hospitalization remained relatively stable, in keeping with the overall incidence figures (Figure 4). Ambulatory care visits were too uncommon to discern a trend. Esophageal cancer was a frequent cause of cancer death, ranking third in 2004 among digestive system cancers (after colorectal and pancreatic cancer) and was responsible for more than 13,000 deaths (Table 5) and 113,000 YPLL prior to age 75 years. Cancers of the gastroesophageal junction and cardia accounted for 4.6 percent of these deaths (see Chapter 6, Cancer of the Stomach). In keeping with the SEER data, death rates were highest among persons age 65 years and older, blacks (modestly more than whites), and males. Death rates increased between 1979 and 2004, but not during the last 6 years of that period. Table 1. Esophageal Squamous Cell Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Esophageal Squamous Cell Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Source: Surveillance, Epidemiology, and End Results (SEER) Program Table 2. Esophageal Adenocarcinoma: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 2. Esophageal Adenocarcinoma: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Source: Surveillance, Epidemiology, and End Results (SEER) Program Table 3. All Esophageal Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 3. All Esophageal Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Source: Surveillance, Epidemiology, and End Results (SEER) Program Table 4. All Esophageal Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 4. All Esophageal Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 5. All Esophageal Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 5. All Esophageal Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Cancer of the Stomach SEER includes cancers of the gastroesophageal junction and gastric cardia with gastric cancer. Over the period 1979 to 2004, the incidence of cancers of the gastroesophageal junction and cardia approximately doubled, resulting in an increase in the proportion of gastric cancer at these sites from 14.9% in 1979 to 30.4% in 2004. However, for medical care and vital statistics, these sites were included with esophageal cancer. In 2004, the stomach was the third most common anatomical site for digestive system cancer, after the colon/rectum and the pancreas. Cancer of the stomach, gastric cancer, had an older age distribution than did other GI cancers, with 68 percent of cases having occurred at age 65 years or older (Table 1). Median age of diagnosis was 71 years (http://seer.cancer.gov/csr/1975_2005/results_merged/topic_med_age.pdf). Asians and Hispanics had the highest age-adjusted incidence rates; non-Hispanic whites had the lowest rate. The incidence of gastric cancer, as reflected by mortality rates, has been declining for more than 70 years in the United States. Between 1979 and 2004, the incidence declined more than one-third (Figure 1). During that period, 5-year survival following diagnosis increased by 50 percent. Ambulatory care visits and hospital discharges with gastric cancer were relatively insubstantial (Table 2). Hospitalization rates declined more rapidly than the incidence rate (Figure 2). Because gastric cancer now has somewhat better survival than other digestive system Table 1. Gastric Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Gastric Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Source: Surveillance, Epidemiology, and End Results (SEER) Program Table 2. Gastric Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Gastric Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 3. Gastric Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Gastric Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Cancer of the Small Intestine Cancer of the small intestine is often considered rare, but in 2004, there were more than 5,000 new cases diagnosed (exclusive of intestinal lymphomas), or about a third the total number of esophageal cancers or primary liver cancers, and more than the number of gallbladder cancers. Slightly more than half of patients were diagnosed at age 65 years or older (Table 1), with a median age of 67 years (http://seer.cancer.gov/csr/1975_2005/results_merged/topic_med_age.pdf), making this the digestive system cancer with the second youngest age of onset (after primary liver cancer). Nevertheless, rates were highest among the elderly and among blacks and males. Age-adjusted incidence for cancer of the small intestine increased by 73 percent between 1979 and 2004 (Figure 1). Lack of awareness of the magnitude of this increase may be a reason for the perception that it remains a rare cancer. Over the same period, 5-year survival improved modestly, from about 33 percent to about 41 percent. National medical care systems do not adequately capture outpatient or inpatient visits (Table 2), although rates of hospital discharges have tended to increase in recent years (Figure 2). The number of hospitalizations prior to 1988 was too small to provide estimates. Because of its relatively high survival rate, there were only 1,115 deaths from cancer of the small intestine in 2004, and fewer than 10,000 YPLL prior to age 75 years (Table 3). The majority of deaths occurred among persons age 65 years and older. Death rates were higher for blacks than whites and for males than females, reflecting the incidence rates. Age-adjusted death rates changed little between 1979 and 2004 (Figure 3). Table 1. Cancer of the Small Intestine: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Cancer of the Small Intestine: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Source: Surveillance, Epidemiology, and End Results (SEER) Program Table 2. Cancer of the Small Intestine: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Cancer of the Small Intestine: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With Any‑L‑Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)
Source: Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 3. Cancer of the Small Intestine: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Cancer of the Small Intestine: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Cancer of the Colon and Rectum For this report, cancers of the colon and rectum were combined (see Appendix 1 for ICD codes). Together, these cancers were responsible for an estimated 55 percent of all digestive system cancers diagnosed in 2004. In 72.5 percent of cases, the colon was the anatomical site. By themselves, colon cancer would be the most common digestive system cancer, and rectal cancer the second most common. Therefore, trends in colorectal cancer largely determine trends in digestive system cancers as a whole. Two-thirds of new cases of colorectal cancer were among those age 65 years or older (Table 1). Among the major racial-ethnic groups, non-Hispanic blacks had the highest rate, followed by non-Hispanic whites. American Indians had the lowest rates, with Hispanics and Asians intermediate. Age-adjusted rates were about one-third higher among males than females. Colorectal cancer incidence has been falling for the past 20 years, declining by 27.1 percent from 1985 to 2004 (Figure 1). The proportion of newly diagnosed patients who survived for at least 5 years has climbed steadily since 1979. Colorectal cancer is the digestive system malignancy with the most reliable data on medical care (Table 2). In 2004, there were an estimated 2.6 million ambulatory care visits for persons with colorectal cancer. Most visits were among persons age 65 years and older and among women. Blacks had two-thirds the age-adjusted rate of whites. Visit rates were similar for males and females. For hospitalizations, colorectal cancer was more often listed as a first-listed diagnosis than as a secondary diagnosis. Hospitalization rates were disproportionately higher among the 65 years and older group. Age-adjusted rates were higher for blacks than for whites and for males than for females. Hospitalization rates declined from the early 1980s through 1995, and subsequently increased slightly (Figure 2). Colorectal cancer was the leading cause of death related to the digestive system, accounting for 22.5 percent of deaths (Table 3). Because the median age of death for colorectal cancer was 75 years (http://seer.cancer.gov/csr/1975_2005/results_merged/topic_med_age.pdf), colorectal cancer accounted for a smaller proportion of YPLL to digestive diseases (16.6 percent), second to liver disease. Because of declining incidence and improved survival, death rates declined 34.8 percent between 1979 and 2004. This decline accelerated during the latter part of that period (Figure 3). Table 1. Colorectal Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Colorectal Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Source: Surveillance, Epidemiology, and End Results (SEER) Program Table 2. Colorectal Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Colorectal Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 3. Colorectal Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Colorectal Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Primary Liver Cancer The major malignant neoplasm of the liver is liver cell cancer (hepatocellular carcinoma). Also included in this category in this report are the rare malignancies of hepatoblastoma and angiosarcoma as well as other primary specified and unspecified liver carcinomas. Intrahepatic bile duct carcinoma is included among bile duct cancers (see Appendix 1 for ICD codes). In 2004, primary liver cancer occurred at an earlier age than any other digestive system cancer, with 50 percent of cases being diagnosed under the age of 65 years (Table 1). Hepatoblastoma, although the most common liver neoplasm among children, had minimal influence on this association because of its rarity. Incidence was lowest among non-Hispanic whites, intermediate among non-Hispanic blacks and Hispanics, and highest among Asians and American Indians. Males had more than 3 times the age-adjusted incidence of females. The incidence of primary liver cancer rose modestly between 1979 and 1988 (14.5 percent) and more rapidly subsequently (90 percent over the period 1988–2004) (Figure 1). Liver cancer was one of the most lethal digestive system cancers, although 5-year survival did increase nearly fourfold during this period, albeit to only 8 percent. Medical care visits and hospitalizations for liver cancer were too infrequent in 2004 to make firm statements about them. Hospitalization discharge rates (Table 2) had a demographic pattern similar to incidence rates (Table 1), with the highest rates among patients age 65 years and older, blacks, and males. Hospitalization rates more than doubled from 1984 to 2004 (Figure 2), also in keeping with the increase in incidence. Death rates increased with age, but not as markedly as in other digestive system cancers (Table 3). Age-adjusted death rates were higher among blacks and males. Because of its increasing incidence and poor survival, primary liver cancer has contributed an increasing number and proportion of deaths, although it accounted for only 4.7 percent of all deaths from digestive system cancers in 2004. Because of the relatively early age of onset, it accounted for a higher proportion of YPLL due to digestive system cancers (7.7 percent). As with incidence, mortality rate increased, although not as quickly. The mortality rate increased 75 percent between 1979 and 2004 (Figure 3). Table 1. Primary Liver Cancer: Number of Cases and Incidence Rate by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Primary Liver Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Source: Surveillance, Epidemiology, and End Results (SEER) Program Table 2. Primary Liver Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Primary Liver Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 3. Primary Liver Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Primary Liver Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Cancer of the Bile Ducts For this report, intrahepatic and extrahepatic bile duct cancers were combined (see Appendix 1 for ICD-9 and ICD-10 codes). Substantial differences between them are noted. In 2004, 22 percent of bile duct cancer was coded intrahepatic and 45 percent extrahepatic; nearly all the remainder did not have a location specified. Rates were much higher in the oldest age group, with 74 percent of cases occurring at age 65 or older. Age-adjusted rates were highest among Hispanics and Asians (Table 1). Males had a higher rate and slightly higher number of cases than females. Incidence increased modestly between 1979 and 2004 (about 22 percent), all of which could be accounted for by an increase in the incidence of intrahepatic bile duct cancer. Five-year survival did not improve and was about 10 percent for the entire period (Figure 1). There were too few outpatient or inpatient diagnoses to draw inferences about medical care (Table 2), but hospitalization rates were relatively constant at about 5 per 100,000 U.S. population (Figure 2). Because of low survival, bile duct cancer mortality was similar to incidence. As underlying cause, there were 4,954 deaths in 2004 and nearly 33,000 YPLL prior to age 75 years (Table 3). Rates were highest in the oldest age group. Age-adjusted mortality rates were slightly higher for whites and for males. Death rates for bile duct cancer rose 39 percent between 1979 and 2004 (Figure 3). Table 1. Bile Duct Cancer: Number of Cases and Incidence Rate by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Bile Duct Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Source: Surveillance, Epidemiology, and End Results (SEER) Program Table 2. Bile Duct Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Bile Duct Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 3. Bile Duct Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Bile Duct Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Cancer of the Gallbladder About 3,000 cases of gallbladder cancer were estimated to have occurred in 2004 (Table 1). Gallbladder cancer was the only digestive system malignancy that occurred predominantly among women (nearly twice the age-adjusted rate of men) and was one of the few nongenital cancers that had a female predominance. It was predominantly a diagnosis of the elderly, with a median age of diagnosis of age 73 years, the highest of any digestive system cancer (http://seer.cancer.gov/csr/1975_2005/results_merged/topic_med_age.pdf). Age-adjusted rates were too low to draw inferences about ethnic differences in risk. Incidence of gallbladder cancer declined by 42.2 percent from 1979 to 1997, and was then stable through 2004 (Figure 1). Five-year survival increased modestly to about 9 percent. Outpatient and inpatient data were too sparse to draw inferences, except that the rate of hospitalization with gallbladder cancer declined substantially until the mid-1990s and has been stable since (Figure 2). Because of low survival, gallbladder cancer mortality was similar to incidence. As underlying cause, there were nearly 2,000 deaths in 2004 and just under 11,000 YPLL prior to age 75 years (Table 3), which reflects the older age at which gallbladder cancer occurred. Rates were 6.8 times as high in the oldest age group (65 years and older) as among those ages 45–64 years. Age-adjusted mortality rates were higher for blacks than whites, and for females than males. The death rate for gallbladder cancer declined by 47 percent between 1979 and 2004 (Figure 3). Because gallstones are the major recognized risk factor for gallbladder cancer, it is of interest that there was a similar decline (56.1 percent) in gallstone disease-related mortality over that period. Table 1. Gallbladder Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Gallbladder Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Source: Surveillance, Epidemiology, and End Results (SEER) Program Table 2. Gallbladder Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Gallbladder Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 3. Gallbladder Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Gallbladder Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Cancer of the Pancreas In 2004, 71 percent of newly diagnosed pancreatic cancers were among persons age 65 years and older (Table 1). Age at diagnosis was higher than for most other digestive system cancers, with the median being 72 years and 40 percent diagnosed at age 75 years or older (http://seer.cancer.gov/csr/1975_2005/results_merged/topic_med_age.pdf). Incidence rates were highest among the elderly, non-Hispanic blacks, and males. Age-adjusted incidence was relatively stable from 1979 to 2004, being essentially the same in the first and last year (Figure 1). Survival from pancreatic cancer is the poorest of any major cancer, digestive system or otherwise. Nevertheless, 5-year survival increased modestly from 2 percent among persons diagnosed in 1979 to 3.8 percent among persons diagnosed in 1999. In 2004, there were an estimated 415,000 ambulatory care visits for pancreatic cancer and 68,000 hospital discharges with a diagnosis of pancreatic cancer (Table 2). Hospitalization rates were highest among the elderly and age-adjusted rates were higher for blacks and males. While ambulatory care visits appear to have increased from 1992 through 2004, hospital discharge rates were stable from 1979 through 2004 (Figure 2). Because of low survival, pancreatic cancer mortality was essentially the same as incidence in 2004. As underlying cause, there were 31,800 deaths in 2004 (third highest of all digestive diseases) and more than 200,000 YPLL prior to age 75 years (also third highest of all digestive diseases) (Table 3). Rates were highest in the oldest age group. Age-adjusted mortality rates were higher for blacks and for males. Death rates for pancreatic cancer remained steady between 1979 and 2004 (Figure 3). Table 1. Pancreatic Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004
Figure 1. Pancreatic Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004
Source: Surveillance, Epidemiology, and End Results (SEER) Program Table 2. Pancreatic Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 2. Pancreatic Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 3. Pancreatic Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 3. Pancreatic Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Hemorrhoids Hemorrhoids are classified as diseases of the circulatory system by ICD-9 and ICD-10 (Appendix 1), but are much more often diagnosed and treated by digestive disease specialists than by those with a primary interest in the circulatory system. Therefore, burden data for hemorrhoids are presented in this report. Hemorrhoids are subclassified by anatomical location (internal or external) and whether they are complicated with bleeding, prolapse, strangulation, or ulceration. Hemorrhoids are common, and their treatment is primarily in the ambulatory care setting. In 2004, there were an estimated 2 million ambulatory care visits with hemorrhoids as first-listed diagnosis and 3.2 million visits at which hemorrhoids were an all-listed diagnoses (Table 1), which made hemorrhoids the fourth or fifth leading outpatient digestive system diagnosis (after GERD, abdominal wall hernia, and functional disorders, and essentially tied with diverticular disease). Visit rates were highest among persons age 65 years and older and among whites. Age-adjusted rates were similar for males and for females. Most hospitalizations for hemorrhoids are for surgery, which is performed most often as same-day surgery; thus, the number of hospitalizations for hemorrhoids was small relative to the number of ambulatory care visits (Table 1). As opposed to rates of ambulatory care visits, age-adjusted hospitalization rates were higher for blacks than whites. Hemorrhoids were most often listed as a secondary diagnosis (87 percent). Age-adjusted ambulatory care visits for hemorrhoids declined slightly between the periods of 1992–1993 and 2003–2005 (Figure 1). The rate of visits in this latter period was about 20 percent lower than in the early 1980s, continuing a trend in declining outpatient visits that began in the 1960s.1 Overnight hospitalizations with hemorrhoids listed as a diagnosis declined by about 60 percent from 1981 to 1994, and were relatively stable for the following 10 years. As a first-listed hospital diagnosis, hemorrhoids declined much more: from about 70 per 100,000 in 1979 to 13 per 100,000 in 2004.2 Death from hemorrhoids has always been exceedingly rare (Table 2 and Figure 2). There was a substantial decline from 1980 through 2004 in hemorrhoids noted as a diagnosis on death certificates. Nearly 2 million prescriptions for hemorrhoids were filled at retail pharmacies in 2004, according to Verispan (Appendix 2), with topical medications such as pramoxine (pramocaine) and hydrocortisone and stool softeners such as psyllium most often prescribed (Table 3). Most persons with hemorrhoids do not seek medical care and are self-treated using nonprescription medications similar to those listed in Table 3; thus the totals in this table were a small portion of the number and cost of medications used to treat hemorrhoids.3 1 Johanson JF. Hemorrhoids. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447 pp. 271–298. 2 Ibid. Table 1. Hemorrhoids: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Hemorrhoids: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 2. Hemorrhoids: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Hemorrhoids: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Table 3. Hemorrhoids: Costliest Prescriptions
Gastroesophageal Reflux Disease In 2004, GERD was by far the most frequently first-listed digestive system condition at ambulatory care visits (Table 1), constituting 17.5 percent of all digestive system diagnoses. There were at least 6 outpatient visits with a GERD diagnosis listed per 100 persons in the United States. GERD was a common diagnosis in all age groups, although the highest rate was for those age 65 years and older. Age-adjusted ambulatory care visit rates were higher among blacks than whites and were similar for females and males. As the first-listed diagnosis, hospitalizations with GERD were not especially common relative to the frequency of outpatient visits. However, GERD was the first-listed diagnosis on only 5 percent of hospital discharges on which it was mentioned. As a result, GERD was the most common digestive system disease noted at hospital discharge and was found on 23.5 percent of hospitalizations at which a digestive system condition was listed at discharge. The pattern by race and sex of rates of hospitalization with a diagnosis of GERD were similar to the rates of ambulatory care visits. About half of all hospital diagnoses were recorded at age 65 years and older. Rates of both all-listed ambulatory care visits and hospital discharges increased several-fold from the early 1990s to 2004 (Figure 1). Among other digestive system diseases, only viral hepatitis C saw a similar increase in medical care, but much of that increase was a result of the fact that hepatitis C was not recognized as a disease with its own ICD code until 1992. The increases in medical care for GERD began at least as early as the mid-1970s.1 Between 1975 and 2004, the rate of all-listed ambulatory care visits for GERD increased approximately 2,000 percent. It was in the mid-1970s that better means to diagnose (flexible endoscopes) and treat (histamine-2 receptor blockers) became available, both of which stimulated recognition of the condition. Nevertheless, it is quite unlikely that all the increases in GERD-related statistics can be attributed solely to increased recognition. Despite not being considered a fatal disease, GERD was listed as the underlying cause of more than 1,000 deaths in 2004 (Table 2), 83 percent of which occurred among persons age 65 years and older. GERD was much more often listed as a contributing cause of death, with the large majority at age 65 years and older. Mortality rates differed little by race and sex. Rates of GERD as a first-listed or contributing cause of death increased by 115 percent from 1979 to 2004, with the majority of the increase occurring during the last 9 years of that period (Figure 2). More than 60 million prescriptions for GERD were estimated to have been filled at retail pharmacies in 2004 (Table 3), representing 48 percent of all prescriptions for digestive system disorders and more than 50 percent of their cost. The large majority of prescriptions and their cost were for proton pump inhibitors, which were the five most commonly prescribed and costliest medications. Because over-the-counter medications were not included in this tabulation, the total medication cost may have been considerably higher. 1 Sonnenberg A. Esophageal diseases. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447 pp. 299–355. Table 1. Gastroesophageal Reflux Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Gastroesophageal Reflux Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 2. Gastroesophageal Reflux Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Gastroesophageal Reflux Disease: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Table 3. Gastroesophageal Reflux Disease: Costliest Prescriptions
Peptic Ulcer Disease Peptic ulcers are coded by anatomical location (stomach, duodenum, gastrojejunum, and unspecified), chronicity, and by complication (hemorrhage or perforation). The ICD codes that cover peptic ulcers are shown in Appendix 1. In 2004, there were about 700,000 ambulatory care visits with peptic ulcer as the first-listed diagnosis and an equal number in which it was a secondary diagnosis (Table 1). Ambulatory care rates increased with increasing age, were higher for blacks than for whites, and were higher among women. When listed at hospital discharge, peptic ulcer was the first-listed diagnosis 37 percent of the time. The frequency of outpatient and inpatient care declined for peptic ulcer disease (Figure 1), which continued a pattern that began in the 1970s, if not before.1 Within 12 years, age-adjusted ambulatory care visit rates with a peptic ulcer diagnosis declined 68 percent, and within 25 years, hospital discharge rates declined 51 percent. Peptic ulcer was coded as the underlying cause among 3,692 deaths in 2004 and other cause among an additional 4,604 deaths (Table 2). Nearly 80 percent of these deaths occurred among persons age 65 years and older. Age-adjusted death rates were similar for blacks and whites and were higher for males than females. Between 1979 and 2004, mortality from peptic ulcer as underlying cause declined 62.6 percent and as underlying or other cause by 68.8 percent (Figure 2). This continued at least a century of decline in peptic ulcer mortality.2 Much of the decline in the medical significance of peptic ulcer has been attributed to the decline of Helicobacter pylori, which is a causative agent. This effect has likely been accelerated by the widespread adoption of acid suppressive medications (Table 3) and eradication of H. pylori infection by antimicrobial agents. Although antimicrobial agents are important for treatment of peptic ulcer disease, they do not appear among the most commonly used drugs, perhaps because of their short-term self-limited use. The high use of acid suppressant therapy does not differentiate indications for treatment from prophylaxis. 1 Sonnenberg A. Peptic ulcer. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447 pp. 357–408. 2 Ibid. Table 1. Peptic Ulcer Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Peptic Ulcer Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 2. Peptic Ulcer Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
Figure 2. Peptic Ulcer Disease: Age-Adjusted Rates of Death in the United States, 1979–2004
Source: Vital Statistics of the United States Table 3. Peptic Ulcer Disease: Costliest Prescriptions
Functional Intestinal Disorders Included in this chapter are separate entries on chronic constipation and irritable bowel syndrome (IBS). Other functional conditions that were either too uncommon or too nonspecific were functional diarrhea, neurogenic bowel and megacolon not elsewhere described, anal spasm, and other specified and unspecified functional intestinal disorders. These are included in the section All Functional Intestinal Disorders. CHRONIC CONSTIPATION In 2004, constipation was frequently noted at ambulatory care visits either as a first-listed diagnosis (3.1 million visits) or all-listed diagnoses (6.3 million visits) (Table 1), which made it the second most common ambulatory care diagnosis, after GERD. Persons under age 15 years had the highest number of visits for chronic constipation and nearly as great a rate as persons age 65 years and older. The number of ambulatory care visits for the younger age group was equal to that of intestinal infections (Chapter 2). Chronic constipation and GI infections were the two most common reasons for ambulatory care visits among children. Rates of visits with a chronic constipation diagnosis were also higher for blacks and for females. Hospitalizations with chronic constipation were uncommon, with first-listed diagnoses only 1–2 percent of ambulatory care visits. All-listed diagnoses of chronic constipation were more common—about one-tenth the rate of all-listed ambulatory care diagnoses. After many years of stable rates of medical care statistics for chronic constipation, there was a surge in both ambulatory medical care visits and hospitalizations between 1992 and 2004 (Figure 1), with more than a doubling of rates of ambulatory care diagnoses and nearly a fourfold increase in rates of hospital discharge diagnoses. The rate of ambulatory visits began to increase at least as early as 1985, when there were approximately 500 per 100,000 population.1 Mortality from chronic constipation is, of course, rare (Table 2). Nevertheless, in keeping with the increase in medical care, there was an increase in constipation as either underlying cause or underlying or other cause between 1989 and 2004 (Figure 2). According to the Verispan database of retail pharmacy prescriptions (Appendix 2), in 2004, nearly half of all medications prescribed for chronic constipation were for the laxative polyethylene glycol (Table 3). Tegaserod (Zelnorm®), a medication for women with irritable bowel syndrome and constipation, was not as commonly prescribed, but was nearly as costly. Other medications were primarily stool softeners or motility agents. These data did not capture the very large number of nonprescription medications purchased for constipation. IRRITABLE BOWEL SYNDROME In 2004, there were 3 million ambulatory care visits with IBS noted as a diagnosis, and slightly more than half were first-listed diagnoses (Table 4). Unlike constipation, which was common among children, rates of visits with IBS increased with age only in later adulthood. Whites had more than twice the age-adjusted rate of visits as blacks. The rate of visits among females was more than 4 times that of males—the largest sex difference for any digestive disease. IBS was rarely noted as first-listed diagnosis on hospital discharge, but was much more commonly coded as a secondary diagnosis. The age, race, and sex patterns for all-listed discharge diagnosis were similar to ambulatory care diagnoses. Age-adjusted rates of ambulatory care visits with an IBS diagnosis fell by about 20 percent between 1992–1993 and 2003–2005 (Figure 3), although the rate in the latest period was similar to rates in 1981, 1982, and 1985.2 In contrast, rates of hospital discharges with a diagnosis of IBS fell in the mid-1980s, leveled off through the mid-1990s, and then increased by 81 percent between 1999 and 2004. IBS as underlying or contributing cause of death was exceedingly rare (Table 5), and trend data were not meaningful (Figure 4). According to the Verispan database of retail pharmacies, in 2004, tegaserod (Zelnorm®) contributed much to the cost of IBS and was the third most widely prescribed drug (Table 6). The anticholinergic drugs hyoscyamine and dicyclomine were the most commonly prescribed drugs. ALL FUNCTIONAL INTESTINAL DISORDERS As a group of conditions, functional disorders were common reasons for outpatient visits, such that there were estimated to be more than 11 million ambulatory care visits noting these diagnoses in 2004 (Table 7), or about 4 visits per every 100 persons in the United States. Eighty percent of these visits were for either chronic constipation or IBS. Hospitalizations for functional disorders were uncommon, but they did commonly appear as an all-listed diagnoses. Recent increases in diagnoses with a mention of functional disorders on ambulatory care visits and hospital discharge were almost entirely due to increased rates of diagnoses of constipation (Figure 5). Chronic constipation and IBS accounted for 73.5 percent of these diagnoses. Functional disorders were coded as an underlying cause of death for 423 persons in 2004, and listed as a contributing cause for 1,766 persons (Table 8). The death rate with mention of functional intestinal conditions was stable from 1979 to 1999, when the change to ICD-10 coding resulted in a 19 percent increase that was likely a coding artifact (Figure 6). According to the Verispan database of retail pharmacies, in 2004, there were estimated to be more than 13 million prescriptions filled at retail pharmacies at a cost of nearly three-quarters of a billion dollars (Table 9). Nearly one-third of this cost was for tegaserod (Zelnorm®). Other agents were primarily for pain, including several acid-blocking agents, or for constipation. 1 Johanson JF. Constipation. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447 pp. 567–593. 2 Sandler RS. Irritable bowel syndrome. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447 pp. 595–612. Table 1. Chronic Constipation: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004
Figure 1. Chronic Constipation: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS) Table 2. Chronic Constipation: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004
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