Kansas City Data Collective Technical Report, June 2015

Kansas City Data Collective Technical Report, June 2015 Top 10 leading causes of death, Kansas City Metro Area, 2007-2011 Background Kansas City Data Collective (KCDC) is a group of epidemiologists and data analysts based in the Kansas City Metro Area (KCMA). The group formed in the summer of 2012 to leverage resources and combine skills in order to produce a broader picture of the health of individuals in the KCMA. Because the metro area falls in two states, with multiple county health departments and two city health departments, this combination of resources and skills was especially desirable and needed. Staff from the Missouri Department of Health and Senior Services, the Kansas Department of Health, and the Mid-America Regional Council (MARC) were also involved with this project, most specifically to support the findings and address data-related concerns. The mission of KCDC is to use available data to provide regional and local health information to the community, identify gaps in existing data sources, and work to fill these gaps by producing (collecting, analyzing, and interpreting) missing/necessary population-based data for the Kansas City Metropolitan Area. KCDC data includes Leavenworth, Wyandotte, and Johnson counties in Kansas; Platte, Clay, Cass, Jackson, and Ray counties in Missouri; and the cities of Independence and Kansas City, Missouri. Due to staff shortages, it was not possible for representatives from Cass and Ray Counties in Missouri and Leavenworth County in Kansas to attend meetings, but data for those counties is included in the analysis. Douglas County, Kansas, joined the group and was included in analyses because of its strong social and economic ties to the KCMA. KCDC s vision is to become a regional leader in disseminating health data that is easy to use and translatable into improved health at both the local and regional levels. KCDC will seek to be involved in improvement processes for current data use systems, advocating for data consistency and functionality for the user. KCDC will provide information on data use, interpretation, and quality to users of KCDC data. KCDC will collaborate on data use projects with other local and regional organizations. Additionally, KCDC will assess training needs for workforce development. As its first group effort, KCDC launched an analysis of the top 10 causes of death in the KCMA. Members were specifically interested in determining the death rates for the top 10 causes of death in each jurisdiction, both overall and by gender, and reporting data by jurisdiction and for the entire KCMA. Years of potential life lost (YPLL) was also estimated for each of the 10 top causes of death. This work ensured that KCDC members had the appropriate skills and resources to complete epidemiological analyses and to collaborate on a necessary and useful report for the metro area. 1

Methods Beginning in early 2013, individual epidemiologists and data analysts from KCDC began compiling data on the top 10 causes of death in their respective jurisdictions for the combined years between 2007 and 2011. Jurisdictions from Missouri used data from the Missouri Information for Community Assessment system (MICA) while Kansas jurisdictions used data from Kansas Information for Communities (KIC). Age-adjusted rates, confidence intervals and YPLL were calculated for both the overall population and by gender. After each jurisdiction completed its unique analysis, the data were compiled into one document. This document included overall state data for both Kansas and Missouri for comparison, as well as for the KCMA. KCDC then created graphs to better display the data, completed a population pyramid, obtained demographic information for each jurisdiction, and drew conclusions concerning the provided data. Results The states of Kansas and Missouri used the same ICD-10 codes when categorizing cause of death data. Thus, differences seen between Kansas and Missouri overall and specific Kansas and Missouri counties were true differences, not artifacts of the disease definitions. All-cause mortality rates were higher in Missouri than in Kansas (Table 1 and 5, Figure 1). This was true for the total population as well as for women and men separately (Tables 2, 3, and 5, Figure 1). Wyandotte County, Kansas, exhibited the highest overall death rate of any jurisdiction. Douglas and Johnson counties in Kansas had the lowest overall death rates of any jurisdiction. Missouri had higher death rates compared to Kansas for each of the diseases listed except for diabetes. In Missouri, lowest disease-specific death rates were generally seen in Platte County while highest death rates were seen in Ray County. In Kansas, lowest disease-specific death rates were observed in Douglas and Johnson Counties. The top three leading causes of death in the area were heart disease, cancer, and chronic lower respiratory disease. In Kansas, atherosclerosis was the third leading cause of death in Johnson County. Variation was seen in the top 10 leading causes of death by jurisdiction and by gender. Unique causes of death included homicide in Kansas City, Missouri; atherosclerosis in Johnson County, Kansas; and pneumonitis due to solids and liquids in Platte County and Ray County, Missouri. Among women, atherosclerosis was a leading cause of death in Wyandotte and Johnson counties in Kansas. Table 4 depicts the YPLL due to each cause of death for each jurisdiction and the KCMA overall. YPLL is based on a 75-year life expectancy. The highest rate of years of potential life lost occurred in Independence, Missouri. Kansas City, Missouri, and Ray County, Missouri, also had high rates of YPLL. In all geographies, rates of YPLL were highest for cancer. They were also generally high for heart disease and unintentional injury. Figures 1 through 8 depict the variation in mortality rates seen across the KCMA jurisdictions. Figure 1 (which corresponds to Table 5) depicts the all-cause age-adjusted mortality rate, with high rates 2

depicted by darker coloring. Ray and Wyandotte counties have the highest mortality rates. The lowest rates were observed in Johnson, Douglas, and Platte counties. Mortality rates due to cancer are summarized in Figure 2 and Table 6. The two highest cancer rates are observed in Wyandotte County and Kansas City. Douglas and Platte counties are the two lowest, after Johnson County, the referent county. 1 Ray County has a statistically significantly higher rate of cancer among women compared to Johnson County women, while there was no such difference for Ray County men. The reverse is true for Leavenworth County; men have a statistically higher cancer death rate than the referent county, while the women do not. Heart disease mortality rates were highest in Ray and Leavenworth counties (Figure 3, Table 7). These rates were significant for both men and women in comparison to Johnson County. Platte County had a significantly higher cancer death rate among men but not among women compared to the referent. Douglas County was the only jurisdiction to not have a significantly higher cancer mortality rate than Johnson County. Chronic lower respiratory disease mortality was highest in Clay and Ray counties (Figure 4, Table 8). Platte and Leavenworth counties had mortality rates significantly higher than the referent among men only; no difference was observed among women. Again, Douglas County was the only jurisdiction that did not have a significantly high mortality rate compared to Johnson County. The mortality rate for stroke was elevated for Cass County, Kansas City, Wyandotte County, and Kansas only compared to Johnson County (Figure 5, Table 9). The highest mortality rates were observed in Kansas City and Cass County. The lowest rates were observed in Leavenworth and Platte counties. Men in Wyandotte County and Kansas had statistically higher stroke mortality rates compared to the referent while women did not. Women in Cass County had a statistically higher stroke mortality rate compared to the referent while men did not. Unintentional injury deaths are depicted in Figure 6 and Table 10. All jurisdictions exhibited a statistically higher rate of death than the referent. In Leavenworth County, no significant elevation in rate was observed among women, while it was among men. Ray County has the highest unintentional injury mortality rate in the KCMA. While Alzheimer s disease was a leading cause of death across the KCMA, it was not a leading cause of death among men in Wyandotte County (Figure 7, Table 11). Alzheimer s was a leading cause of death for Wynadotte County women, but the mortality rate was significantly low compared to Johnson County women. Leavenworth County and the city of Independence exhibited the highest death rates due to Alzheimer s disease, while Douglas and Johnson counties and Kansas City had low rates. Diabetes was a leading cause of death for all of the jurisdictions (Figure 8, Table 12). Highest rates of diabetes mortality were observed in Leavenworth and Wyandotte counties while the lowest rates were 1 Calculations for statistical significance require selecting one of a group as the reference to which others are compared. Johnson County was initially selected as the referent county because it had the lowest overall mortality rate of counties in the immediate metro area. 3

observed in Johnson and Platte counties. Diabetes mortality rates were statistically higher than Johnson County among women in Clay and men in Eastern Jackson County while not true for their respective gender counterparts. The diabetes mortality rate among men in Ray, Leavenworth, and Wyandotte counties is greater than 30 deaths per 100,000 population. Discussion The Kansas City Data Collective has served multiple purposes. The first function of the group has been to bring area epidemiologists together every other month to discuss pressing data issues, network, and share the problems and needs arising in their unique communities. Secondly, it has allowed members the opportunity to identify individual strengths and weaknesses in current data collection processes. Thirdly, as an offspring of the second purpose, participants have collectively recognized the benefits that a regional needs assessment and survey, such as the Behavioral Risk Factor Surveillance System survey, would bring to the population. In addition, KCDC was able to identify possible differences in mortality data reporting between Kansas and Missouri. This consistency is vital for data analysis in the KCMA, which extends into both states. Technical issues that arose during the compilation of the data included 1) lack of racial and ethnic data on mortality in smaller jurisdictions and unreliability in race/ethnicity data overall, 2) use of different data suppression rules by reporting systems at the state level and need for data suppression rules at the local level when collecting primary and more local data, and 3) lack of public documentation on what ICD-10 codes were included in each mortality classification. Furthermore, there appears to be a need for training in data analysis for some epidemiology specialists. This training should be implemented following a workforce assessment of epidemiology skills and result in standard operating procedures that contain information on essential skills, such as how to calculate years of potential life lost, life expectancy, and population pyramids, and how to interpret these data. Conclusion Data collected in the KCMA suggest that there are substantial differences in the leading causes of mortality within the population, both by gender and across jurisdictions. There is a need for more data on variables associated with these disparities, including behavioral risk factors such as eating habits and exercise, environmental risk factors such as air quality and smoking rates, contributing causes of death, flu immunization rates per jurisdiction, maternal and child health indicators, etc. These can be used to identify potential areas for interventions and recommendations to area public health directors and decision makers. 4

Table 1. Five-year mortality rates for the top 10 leading causes of death for men and women in the Kansas City Metro Area, 2007-2011 Cause of death Cass Clay Eastern Jackson Independence Kansas Platte Ray Missouri Douglas Johnson Leavenworth Wyandotte Kansas City Cancer 182.0 187.8 173.1 187.6 195.9 157.2 193.1 185.5 145.8 150.9 180.2 223.1 173.1 Heart disease 174.0 153.6 175.5 184.0 171.4 141.1 221.6 207.3 125.8 120.5 194.7 176.5 167.1 Chronic lower respiratory disease 56.9 64.6 47.6 61.9 50.6 49.7 67.2 51.8 34.9 35.8 57.0 55.6 50.7 Stroke 51.0 40.4 38.5 40.8 48.0 34.7 36.7 45.9 38.3 38.4 31.5 47.9 43.2 Unintentional injury* 46.6 41.4 40.2 47.5 47.1 41.2 62.1 48.0 33.3 22.7 32.4 38.6 42.4 Alzheimer s disease 33.7 28.0 32.9 38.8 26.3 34.1 27.3 23.1 23.2 47.5 21.7 24.7 Diabetes 17.5 17.8 19.3 23.7 24.0 16.9 21.2 20.8 18.4 13.4 27.4 29.9 21.6 Nephritis, nephrotic syndrome, and 29.1 16.6 17.6 25.0 24.2 14.2 25.0 18.6 10.9 12.7 17.4 25.3 17.9 nephrosis Influenza and pneumonia 17.2 13.8 16.4 16.7 31.6 19.1 11.5 13.1 14.2 17.5 18.9 Suicide 15.6 14.2 14.8 20.4 13.1 12.7 25.3 13.9 11.7 13.4 Homicide 20.9 Atherosclerosis 44.5 Pneumonitis due to solids and liquids 11.7 32.1 Septicemia 14.5 18.9 All causes 807.6 761.9 772.5 858.8 845.8 663.4 926.3 825.1 631.2 635.4 789.0 929.5 769.6 * Motor vehicle accidents and "Other accidents and adverse effects" together constitute "Unintentional injury" Mortality rates are reported per 100,000 residents and are age-adjusted to the U.S. 2000 Standard Population. Table 2. Five-year mortality rates for the top 10 leading causes of death for women in the Kansas City Metro Area, 2007-2011 Cause of death Cass Clay Eastern Jackson Independence Kansas Platte Ray Missouri Douglas Johnson Leavenworth Wyandotte Kansas City Cancer 154.5 164.7 148.6 164.0 166.6 142.1 170.3 157.6 128.5 132.7 146.2 187.0 145.1 Heart disease 140.0 122.7 142.6 146.8 137.3 110.5 195.4 168.4 96.5 96.1 153.0 150.4 133.2 Chronic lower respiratory disease 53.5 64.2 45.8 58.3 47.8 41.1 56.9 46.5 33.0 35.2 45.6 49.2 43.9 Stroke 52.2 41.5 36.1 40.0 48.0 31.0 35.1 45.2 32.6 39.3 31.1 46.6 42.5 Unintentional injury* 40.5 28.3 25.2 31.5 30.6 32.0 44.3 32.7 21.3 16.7 20.4 26.2 29.0 Alzheimer s disease 38.0 30.8 37.2 45.4 29.3 34.8 24.4@ 29.7 25.9 25.4 53.1 23.2 26.7 Diabetes 14.7 17.7 14.5 22.0 20.2 12.2 17.6 14.4 11.5 24.0 27.3 19.1 Nephritis, nephrotic syndrome, and nephrosis 27.6 13.2 15.8 19.2 22.1 13.4 16.5@ 15.9 9.1 11.9 24.4 15.0 Influenza and pneumonia 14.6 11.3 13.4 17.6 10.1 8.9 42.6 16.6 10.6 11.7 11.8 16.3 Suicide Homicide Atherosclerosis 46.1 15.0 Pneumonitis due to solids and liquids 7.1 40.0 Septicemia 9.5 10.3 12.3 10.4 23.3 10.7 9.4 12.6 19.5 10.1 Essential hypertension 7.4 All causes 715.6 674.0 671.7 748.1 713.0 565.7 854.3 702.5 550.7 564.1 656.8 783.2 653.4 * Motor vehicle accidents and "Other accidents and adverse effects" together constitute "Unintentional injury" @ signifies an unstable rate Mortality rates are reported per 100,000 residents and are age-adjusted to the U.S. 2000 Standard Population. 5

Table 3. Five-year mortality rates for the top 10 leading causes of death for men in the Kansas City Metro Area, 2007-2011 Cause of death Cass Clay Eastern Jackson Independence Kansas Platte Ray Missouri Douglas Johnson Leavenworth Wyandotte Kansas City Cancer 221.0 224.0 211.2 223.2 239.3 179.1 219.8 224.9 170.8 178.1 229.7 274.1 212.6 Heart disease 218.1 193.7 221.6 233.5 216.0 186.1 250.0 256.8 163.5 154.7 245.4 208.8 211.0 Chronic lower respiratory disease 62.9 67.0 51.3 67.6 56.2 62.7 80.1 60.4 38.6 37.2 77.6 65.7 61.4 Stroke 45.4 37.6 41.7 40.6 47.1 40.2 37.0 45.7 47.0 36.1 31.4 48.9 43.2 Unintentional injury* 52.6 56.4 57.1 65.8 66.1 50.7 84.8 64.6 45.9 28.8 41.2 51.6 56.8 Alzheimer s disease 26.6 22.5 24.7 26.9 20.5 34.4 12.4 22.8 17.9 18.8 38.4 20.9 Diabetes 20.6 17.6 25.4 25.4 29.0 23.4 32.2 24.7 23.6 16.2 31.4 32.9 24.9 Nephritis, nephrotic syndrome, and 30.9 21.4 19.6 32.2 27.3 31.7 22.5 14.2 18.3 25.5 27.1 22.5 nephrosis Influenza and pneumonia 20.7 16.9 21.1 15.3 14.2 23.1 12.9 16.1 17.6 22.2 22.9 Suicide 23.4 23.9 23.0 30.3 21.0 19.5 41.3 23.0 17.4 19.4 25.5 22.2 Homicide 35.3 28.0 Atherosclerosis 40.9 Pneumonitis due to solids and liquids 19.3 20.8@ Septicemia 16.5 11.8 18.4 Chronic liver disease/cirrhosis 10.7 9.2 All causes 921.9 873.4 905.9 997.1 1011.1 800.1 990.5 978.4 733.6 728.8 963.1 1112.2 916.7 * Motor vehicle accidents and "Other accidents and adverse effects" together constitute "Unintentional injury" @ signifies an unstable rate Mortality rates are reported per 100,000 residents and are age-adjusted to the U.S. 2000 Standard Population. Table 4. Years of potential life lost based on 75 year life expectancy per 100,000 population for the top 10 leading causes of death for men and women in the KC Metro Area, 2007-2011 Cause of death Cass Clay Eastern Independence Kansas Platte Ray Missouri Douglas Johnson Leavenworth Wyandotte Kansas Jackson C. City Cancer 1,675 1,515 1,528 2,103 1,714 1,475 2,140 1,767 1,107 1,249 1,345 2,124 1,348 Heart disease 1,069 885 874 1,497 1,242 790 1,668 1,347 558 561 1,053 1,085 836 Chronic lower respiratory disease 298 269 180 378 275 143 334 281 90 106 176 307 212 Stroke 196 153 163 207 236 125 161 206 93 125 66 270 144 Unintentional injury* 1,210 945 980 1,322 1,270 1,015 1,656 1,369 477 569 712 1,156 1,068 Alzheimer s disease 18 13 16 15 10 15 15 8 7 12 16 10 Diabetes 176 142 151 322 223 197 272 191 97 105 206 301 170 Nephritis, nephrotic syndrome, and 59 81 80 149 142 25 137 94 314 45 62 148 67 nephrosis Influenza and pneumonia 100 74 74 111 66 96 3 48 42 139 86 Suicide 553 442 481 686 448 396 764 445 369 434 Homicide 988 Atherosclerosis 43 Pneumonitis due to solids and liquids 9 71 Septicemia 41 135 All causes 7,180 6,303 6,478 9,573 9,239 5,719 9,102 8,172 4,522 4,690 5,853 10,175 7,164 * Motor vehicle accidents and "Other accidents and adverse effects" together constitute "Unintentional injury" 6

Figure 1. All-cause age-adjusted death rates per 100,000 population, 2007-2011 Table 5. All-cause age-adjusted death rates per 100,000 population, 2007-2011 Area Total Significance Men Significance Women Significance Cass County 807.6 S 921.9 S 715.6 S Clay County 761.9 S 873.4 S 674.0 S Eastern Jackson County 772.5 S 905.9 S 671.7 S Independence 858.8 S 997.1 S 748.1 S Kansas City 845.8 S 1011.1 S 713.0 S Platte County 663.4 N 800.1 S 565.7 N Ray County 926.3 S 990.5 S 854.3 S Missouri 825.1 S 978.4 S 702.5 S Douglas County 631.2 N 733.6 N 550.7 N Johnson County 635.4 Referent 728.8 Referent 564.1 Referent Leavenworth County 789.0 S 963.1 S 656.8 S Wyandotte County 929.5 S 1112.2 S 783.2 S Kansas 769.6 S 916.7 S 653.4 S S is a statistically significant difference compared to Johnson County Mortality rates are reported per 100,000 residents and are age-adjusted to the U.S. 2000 Standard Population. 7

Figure 2. Cancer age-adjusted death rates per 100,000 population, 2007-2011 Table 6. Cancer age-adjusted death rates per 100,000 population, 2007-2011 Area Total Significance Men Significance Women Significance Cass County 182.0 S 221.0 S 154.5 S Clay County 187.8 S 224.0 S 164.7 S Eastern Jackson County 173.1 S 211.2 S 148.6 S Independence 187.6 S 223.2 S 164.0 S Kansas City 195.9 S 239.3 S 166.6 S Platte County 157.2 N 179.1 N 142.1 N Ray County 193.1 S 219.8 N 170.3 S Missouri 185.5 S 224.9 S 157.6 S Douglas County 145.8 N 170.8 N 128.5 N Johnson County 150.9 Referent 178.1 Referent 132.7 Referent Leavenworth County 180.2 S 229.7 S 146.2 N Wyandotte County 223.1 S 274.1 S 187.0 S Kansas 173.1 S 212.6 S 145.1 S S is a statistically significant difference compared to Johnson County Mortality rates are reported per 100,000 residents and are age-adjusted to the U.S. 2000 Standard Population. 8

Figure 3. Heart disease age-adjusted death rates per 100,000 population, 2007-2011 Table 7. Heart disease age-adjusted death rates per 100,000 population, 2007-2011 Area Total Significance Men Significance Women Significance Cass County 174.0 S 218.1 S 140.0 S Clay County 153.6 S 193.7 S 122.7 S Eastern Jackson County 175.5 S 221.6 S 142.6 S Independence 184.0 S 233.5 S 146.8 S Kansas City 171.4 S 216.0 S 137.3 S Platte County 141.1 S 186.1 S 110.5 N Ray County 221.6 S 250.0 S 195.4 S Missouri 207.3 S 256.8 S 168.4 S Douglas County 125.8 N 163.5 N 96.5 N Johnson County 120.5 Referent 154.7 Referent 96.1 Referent Leavenworth County 194.7 S 245.4 S 153.0 S Wyandotte County 176.5 S 208.8 S 150.4 S Kansas 167.1 S 211.0 S 133.2 S S is a statistically significant difference compared to Johnson County Mortality rates are reported per 100,000 residents and are age-adjusted to the U.S. 2000 Standard Population. 9

Figure 4. Chronic lower respiratory disease age-adjusted death rates per 100,000 population, 2007-2011 Table 8. Chronic lower respiratory disease age-adjusted death rates per 100,000 population, 2007-2011 Area Total Significance Men Significance Women Significance Cass County 56.9 S 62.9 S 53.5 S Clay County 64.6 S 67.0 S 64.2 S Eastern Jackson County 47.6 S 51.3 S 45.8 S Independence 61.9 S 67.6 S 58.3 S Kansas City 50.6 S 56.2 S 47.8 S Platte County 49.7 S 62.7 S 41.1 N Ray County 67.2 S 80.1 S 56.9 S Missouri 51.8 S 60.4 S 46.5 S Douglas County 34.9 N 38.6 N 33.0 N Johnson County 35.8 Referent 37.2 Referent 35.2 Referent Leavenworth County 57.0 S 77.6 S 45.6 N Wyandotte County 55.6 S 65.7 S 49.2 S Kansas 50.7 S 61.4 S 43.9 S S is a statistically significant difference compared to Johnson County Mortality rates are reported per 100,000 residents and are age-adjusted to the U.S. 2000 Standard Population. 10

Figure 5. Stroke age-adjusted death rates per 100,000 population, 2007-2011 Table 9. Stroke age-adjusted death rates per 100,000 population, 2007-2011 Area Total Significance Men Significance Women Significance Cass County 51.0 S 45.4 N 52.2 S Clay County 40.4 N 37.6 N 41.5 N Eastern Jackson County 38.5 N 41.7 N 36.1 N Independence 40.8 N 40.6 N 40.0 N Kansas City 48.0 S 47.1 S 48.0 S Platte County 34.7 N 40.2 N 31.0 N Ray County 36.7 N 37.0 N 35.1 N Missouri 45.9 S 45.7 S 45.2 S Douglas County 38.3 N 47.0 N 32.6 N Johnson County 38.4 Referent 36.1 Referent 39.3 Referent Leavenworth County 31.5 N 31.4 N 31.1 N Wyandotte County 47.9 S 48.9 S 46.6 N Kansas 43.2 S 43.2 S 42.5 N S is statistically significant difference compared to Johnson County Mortality rates are reported per 100,000 residents and are age-adjusted to the U.S. 2000 Standard Population. 11

Figure 6. Unintentional injury* age-adjusted death rates per 100,000 population, 2007-2011 Table 10. Unintentional injury* age-adjusted death rates per 100,000 population, 2007-2011 Area Total Significance Men Significance Women Significance Cass County 46.6 S 52.6 S 40.5 S Clay County 41.4 S 56.4 S 28.3 S Eastern Jackson County 40.2 S 57.1 S 25.2 S Independence 47.5 S 65.8 S 31.5 S Kansas City 47.1 S 66.1 S 30.6 S Platte County 41.2 S 50.7 S 32.0 N Ray County 62.1 S 84.8 S 44.3 S Missouri 48.0 S 64.6 S 32.7 S Douglas County 33.3 N 45.9 S 21.3 N Johnson County 22.7 Referent 28.8 Referent 16.7 Referent Leavenworth County 32.4 S 41.2 S 20.4 N Wyandotte County 38.6 S 51.6 S 26.2 S Kansas 42.4 S 56.8 S 29.0 S S is a statistically significant difference compared to Johnson County * Motor vehicle accidents and "Other accidents and adverse effects" together constitute "Unintentional injury" Mortality rates are reported per 100,000 residents and are age-adjusted to the U.S. 2000 Standard Population. 12

Figure 7. Alzheimer s disease age-adjusted death rates per 100,000 population, 2007-2011 Table 11. Alzheimer s disease age-adjusted death rates per 100,000 population, 2007-2011 Area Total Significance Men Significance Women Significance Cass County 33.7 S 26.6 N 38.0 S Clay County 28.0 N 22.5 N 30.8 N Eastern Jackson County 32.9 S 24.7 N 37.2 S Independence 38.8 S 26.9 N 45.4 S Kansas City 26.3 N 20.5 N 29.3 N Platte County 34.1 S 34.4 S 34.8 N Ray County @ @ @ Missouri 27.3 S 22.8 N 29.7 S Douglas County 23.1 N 17.9 N 25.9 N Johnson County 23.2 Referent 18.8 Referent 25.4 Referent Leavenworth County 47.5 S 38.4 S 53.1 S Wyandotte County 21.7 N 23.2 N Kansas 24.7 N 20.9 N 26.7 N S is a statistically significant difference compared to Johnson County @ signifies an unstable rate Mortality rates are reported per 100,000 residents and are age-adjusted to the U.S. 2000 Standard Population. 13

Figure 8. Diabetes age-adjusted death rates per 100,000 population, 2007-2011 Table 12. Diabetes age-adjusted death rates per 100,000 population, 2007-2011 Area Total Significance Men Significance Women Significance Cass County 17.5 N 20.6 N 14.7 N Clay County 17.8 S 17.6 N 17.7 S Eastern Jackson County 19.3 S 25.4 S 14.5 N Independence 23.7 S 25.4 S 22.0 S Kansas City 24.0 S 29.0 S 20.2 S Platte County 16.9 N 23.4 N 12.2 N Ray County 21.2 N 32.2 S @ Missouri 20.8 S 24.7 S 17.6 S Douglas County 18.4 N 23.6 N 14.4 N Johnson County 13.4 Referent 16.2 Referent 11.5 Referent Leavenworth County 27.4 S 31.4 S 24.0 S Wyandotte County 29.9 S 32.9 S 27.3 S Kansas 21.6 S 24.9 S 19.1 S S is a statistically significant difference compared to Johnson County @ signifies an unstable rate Mortality rates are reported per 100,000 residents and are age-adjusted to the U.S. 2000 Standard Population. 14