Pulmonary embobm and thro is in

the United States, 19fO- 1985

Richard F. Gillum, M.D., Hyattsuille, Md.

Much attention has been given to the primary and embolism or thrombophlebitis diagnoses. The rate
secondary prevention of acute pulmonary embo- of hospital discharges with any diagnosis of pulmo-
lism. Primary prevention rests on prevention or nary embolism was lower in 1978 than in 1975
early detection and treatment of phlebitis and (Table II). Between 1979 and 1985, the rate de-
thrombophlebitis. Secondary prevention aims to creased 45% for persons 15 to 44 years of age, 40%
reduce mortality and morbidity by early detection of for persons 45 to 64 years of age, and 15% for
pulmonary embolism and treatment to prevent persons 65 years and older. The rate of hospital
recurrences. If. these efforts have been successful, a discharges with any diagnosis of phlebitis or throm-
reduction in death rates for pulmonary embolism bophlebitis was lower in 1978 than in 1975 in
and an increase in hospitalizations with any diagno- persons less than 65 years of age. Between 1979 and
sis listed of pulmonary embolism or phlebitis and 1985, the rate of decrease was 39% in persons 15 to
thrombophlebitis might be expected between 1975 44 years old and 22% in persons 45 to 64 years of
and 1985 as suggested by an earlier report covering age, In persons 65 years and older, the rate showed
1971 to 197K2 To test this hypothesis, U.S. vital little change between 1975 and 1978 and between
statistics and data from the National Hospital Dis- 1979 and 1983 but was lower (9%) in 1985 than
charge Survey were examined for this period.3v4 1983.
Among the U.S. white population, the age- Death rates and hospital diagnosis rates for both
adjusted death rate for pulmonary embolism pulmonary embolism and phlebitis and thrombo-
decreased slightly, 12% in men and 20% in women phlebitis increased with age (Tables I and II). Men
between 1970 and 1978 (Table I). Among the non- had consistently higher death rates for pulmonary
white population, the death rate decreased 14% in embolism than women 55 years of age and older
men and 20 % in women. After the change in disease (Table I). In 1981, hospital diagnosis rates for
classification in 1979, further small decreases in pulmonary embolism were only slightly higher in
age-adjusted death rates occurred between 1979 and men than women at 45 years of age and older and
1982 except in black men. Changes were as follows: similar at 15 to 44 years of age. Diagnosis rates for
white men, -11% ; white women, -2% ; black men, phlebitis and thrombophlebitis were higher in
+4% ; and black women, -18%. For all ages in 1982, women than men at all ages, similar to national
pulmonary embolism was listed as the underlying prevalence rates.6 Age-adjusted hospital diagnosis
cause of death in 9933 cases and as a contributing rates for pulmonary embolism in persons 35 to 74
cause in another 21,819.5 years old were higher in blacks (127.7 per 100,000)
Despite a protocol change increasing the number than whites (98.2 per 100,000) in 1981. Hospital
of diagnoses coded from five to seven in 1979, and diagnosis rates for phlebitis and thrombophlebitis
the introduction of prospective payment and diag- did not show consistent racial differences. However,
nosis-related groups from 1983 to 1985, which might data by race must be interpreted with caution
encourage more complete reporting, no increases in because of the relatively large number of cases for
rates were seen from 1979 to 1986 for pulmonary which race was imputed because of missing data. In
1982, the ratio of certified deaths to all-listed hospi-
tal diagnoses of pulmonary embolism was 0.07.
From the O&x of An&&s and Epidemiology Program, National Center Consistent with the initial hypothesis, pulmonary
for Health Statistics.
embolism death rates decreased. However, hospital
Reprint requests: R. F. Gillum, M.D., Office of Analysis and Epidemiology
Program, National Center for H&lth Statistics, Center Building, Room diagnosis rates for pulmonary embolism and phlebi-
2-27, 3700 East-West Highway, Hyattsville, MD 20782. tis/thrombophlebitis did not consistently increase

1262
Volume 114
Number 5 Pulmonary embolism 1263

Table I. Deaths and death rates per million for pulmonary embolism* by race, sex and age, in the United States
1970 1975 1978 1979 198.2
Race, sex, and
age (yr) n Rate n Rate n Rate n Rate n Rate

White
Men
35-44 148 15 139 14 133 13 109 10 114 9
45-54 376 37 357 35 335 33 314 32 259 27
55-64 895 112 896 105 883 99 788 87 647 70
65-74 1284 260 1370 251 1318 225 1210 202 1179 186
75+ 1612 594 1718 586 1732 560 1679 528 1519 445
Age adjusted? 35-74 90 86 79 70 62
Women
35-44 256 25 113 11 129 12 123 11 118 10
45-54 345 32 366 34 300 28 247 24 213 21
55-64 646 73 651 68 590 59 546 53 541 52
65-74 1115 174 1242 174 1121 146 1014 129 1082 132
75+ 1931 446 2445 479 2493 446 2335 404 2411 381
Age adjusted 35-74 66 61 53 47 46
Blackj
Men
35-44 50 41 57 43 46 33 35 29 45 34
45-54 98 89 124 105 111 92 89 87 99 97
55-64 195 236 220 246 207 216 164 194 184 211
65-74 257 497 270 470 246 388 243 431 239 420
75+ 174 722 225 760 203 625 186 641 195 646
Age adjusted 35-74 186 189 160 160 166
Women
35-44 85 57 73 47 56 33 56 38 62 39
45-54 104 82 118 84 99 68 105 84 84 67
55-64 152 161 157 148 178 154 150 144 120 109
65-74 219 347 240 332 212 259 232 303 196 246
75+ 156 476 240 537 246 360 229 494 239 478
Age adjusted 35-74 143 134 114 125 102

*International Classification of Diseases Adapted Eight Revision (ICDA) code 450 (1970-1978); International Classification of Diseases Ninth Revision
(ICD 9) code 415.1 (1979-1982).
Wandard, 1980 U.S. total population.
IData for 1970 through 1978 includes other nonwhites.

between 1975 and 1985. (The total hospital dis- 90% lower extremity). Hence, of diagnoses of pul-
charge rate for all conditions increased steadily from monary embolism substantially less than 5 % in 1979
1972 to 1981, decreasing thereafter. This may indi- and 10% in 1985 and of diagnoses of thrombophle-
cate that primary prevention of venous thromboem- bitis less than 10% in 1979 and less than 40% in
bolic disease has had an effect, especailly in persons 1985 were likely based on invasive test results.
less than 65 years of age.* However, these results However, the number of pulmonary radioisotope
must be interpreted with caution because of possible scans (ICDSCM 92.15),increased from 76,000 in 1979
sources of bias, including the lack of accuracy of to 160,000 in 1985 despite declining diagnosis num-
death certificate and hospital discharge diagnoses of bers and rates of pulmonary embolism.l~ l* This
pulmonary embolism and venous thrombosis.ss lo finding suggests that the declining diagnosis rates
Pulmonary arteriography (ICDSCM 88.43) was per- reflect declining incidence. However, the possibility
formed an estimated 7000 times in 1979 and 12,000 cannot be excluded that more frequent use of these
times in 1985.11*12 Lower extremity phlebography diagnostic tests resulted in more specificity of clini-
(ICDSCM 88.66) was done an estimated 19,000 cal diagnosis and fewer reported cases. Furthermore,
times in 1979 and 73,000 times in 1985. Patients the nearly fourfold increase in the number of phle-
with normal arteriograms would not be discharged bograms supports the hypothesis that declining
with diagnoses of pulmonary embolism, nor would incidence of pulmonary embolism was due to
those with normal phlebograms be discharged with increased vigor in the diagnosis and treatment of
diagnosis of thrombophlebitis (probably more than venous thrombosis.s The association of pulmonary
 November 1987
I 264 Gillum American Heart Journal

Table Ii. Estimated all-listed hospital diagnoses and disg- times in hospital in 1985. Further improvement in
nosis rates per 100,000 populstion for pulmonary embo- the primary and secondary prevention of pulmonary
lism, phlebitis, and thrombophlebitis by age, United embolism and deep venous thrombosis remains a
States challenge for researchers and practitioners. Addi-
Pulmonary Phlebitis and tional studies are needed of the epidemiology of
embolism* thrombophlebitisf pulmonary embolism and deep venous thrombosis.

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