Role of Alcohol in Forensic Deaths -- Westchester County, New York, 1989

In the United States, 58% of all adults consume alcohol, and death rates for most injuries and some diseases increase directly in relation to levels of consumption (1-3). Forensic deaths (i.e., deaths certified under the medical examiner system) include a substantial proportion of cases for which alcohol use may have contributed to the death; in many cases, this system provides detailed medical information on causes of death because of autopsies and blood alcohol level testing. To further characterize alcohol-related deaths in Westchester County (4,5), the New York Medical College (NYMC) and the Westchester County Department of Laboratories and Research (WCDLR) estimated the total alcohol-related mortality (ARM) and years of potential life lost before age 65 (YPLL) for all deaths certified by the medical examiner for Westchester County, New York, during 1989. This report summarizes the findings and addresses public health applications for estimating ARM employing this method.

The NYMC and WCDLR used Alcohol-Related Disease Impact (ARDI) software to estimate the overall mortality from both acute injuries and chronic diseases associated with alcohol use or misuse (6). ARDI is based on an established set of diagnoses causally related to alcohol and estimates of alcohol-attributable fractions (AAFs) for each diagnosis (6).

Westchester County (1990 U.S. census population: 874,866), north of New York City, is both urban and suburban and is served by a single medical examiner's office. Of the 7974 persons who died within Westchester County during 1989, 1097 (14%) deaths were reviewed by the Westchester County medical examiner, and 645 (59%) autopsies were performed. The NYMC and WCDLR reviewed each record to obtain data on age, sex, race, place of residence, date and place of injury and death, manner and cause of death, other involved conditions, blood alcohol concentration (BAC), and the presence of other toxicologic substances. To determine estimates of ARM and YPLL by age, sex, and specific diseases, alcohol-related deaths were combined with estimated AAFs.

The Westchester County medical examiner's office obtains a BAC on nearly all persons autopsied; however, autopsies were more likely to be performed when the diagnoses were alcohol related (398 (86%) versus 247 (39%)). Of the 1097 persons, 465 (42%) were determined to have had alcohol-related diagnoses (Table 1). BACs had been determined for 359 (77%) persons with an alcohol-related diagnosis and 229 (36%) persons without an alcohol-related diagnosis.

Persons with an alcohol-related diagnosis were younger and were more likely to be male, race other than white, and noncounty residents, and to have died outside of a hospital or health facility. BAC levels were significantly higher (p=0.001) for the alcohol-related death group.

Of the 1097 deaths reviewed by the medical examiner's office, 165 (15%) were estimated to be attributable to alcohol. Unintentional and intentional injuries, digestive-system diseases, and excess blood alcohol (usually in association with other diseases or drugs) accounted for 95% of all alcohol-attributable deaths. An estimated 119 (17%) deaths among the 699 males and 46 (12%) among the 398 females in this population were attributable to alcohol. The mean YPLL per alcohol-related death was 18.2 years.

Reported by: AB Lowenfels, MD, Depts of Surgery and Community and Preventive Medicine, PE Shein Wynn, MD, Dept of Psychiatry, New York Medical College, Valhalla; CD Smithers Foundation, Mill Nack; MJ Hyland, MD, Medical Examiner's Office, Westchester County Dept of Laboratories and Research, New York. JM Shultz, PhD, Dept of Epidemiology and Public Health, Univ of Miami School of Medicine, Miami.

Editorial Note

Editorial Note: Previous reports based on the use of ARDI have measured the impact of alcohol on mortality in the U.S. and in Wisconsin (7,8). During 1987, 6.3% of deaths among males and 3.4% among females were attributable to alcohol (7). However, because a higher proportion of deaths reviewed by the medical examiner's office in Westchester County were alcohol-related injury deaths, the alcohol-attributable mortality described in this report is higher.

Despite the limitations of studies based on highly selected forensic deaths, the findings described in this report are similar to published total county-specific alcohol-related death rates that are based on diagnostic groups and similar AAFs (9). From 1979 through 1985, in Westchester County, an estimated 220 (range: 161-280) alcohol-attributable deaths occurred annually. The estimate of 165 alcohol-related deaths in forensic cases for 1989 in this report suggests that approximately 75% of all alcohol-attributable deaths occurring within the county were captured using this method. Therefore, this method can provide a measure of the burden of alcohol use and misuse and assist state and local public health professionals and policy makers in better characterizing the public health impact of alcohol use and misuse. Westchester County health-care providers, social agencies, and planning organizations can use these data to estimate the impact of alcohol use locally and to target specific strategies toward this problem.

References

1. Anda RF, Williamson DF, Remington PL. Alcohol and fatal injuries among U.S. adults: findings from the NHANES I epidemiologic follow-up study. JAMA 1988;260:2529-32.

2. Williams GD, Grant BF, Stinson FS, Zobeck TS, Aitken SS, Noble J. Trends in alcohol-related morbidity and mortality. Public Health Rep 1988;103:592-6.

3. Office of the Surgeon General. Surgeon General's Workshop on Drunk Driving. Washington, DC: US Department of Health and Human Services, Public Health Service, 1989.

4. Haddon W Jr, Bradess VA. Alcohol in the single vehicle fatal accident: experience of Westchester County, New York. J Am M Ass 1959;169:1587-93.

5. Hyland MJ, Lowenfels AB, Falvo CE, Chen E. Death takes a ride: alcohol-associated single vehicle fatalities revisited. NY State J Med 1990;90:349-51.

6. Shultz JM, Rice DP, Parker DL, Goodman RA, Stroh G, Chalmers N. Quantifying the disease impact of alcohol with ARDI software. Public Health Rep 1991;106:443-50.

7. CDC. Alcohol-related mortality and years of potential life lost -- United States, 1987. MMWR 1990;39:173-8.

8. CDC. Alcohol-related disease impact -- Wisconsin, 1988. MMWR 1990;39:178-80,185-7.

9. National Institute on Alcohol Abuse and Alcoholism. County alcohol problem indicators, 1979-1985: U.S. alcohol epidemiologic data reference manual. 3rd ed. Vol 3. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, 1991; publication no. (ADM)91-1740.

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