Kentucky Has One Of The Highest Excess Death Rates In US Amid Pandemic

Jul 30, 2021

Credit Ryan Van Velzer

Deaths from the pandemic are more than twice as high in Kentucky as the state reports in its COVID-19 death toll, according to estimates from the University of Washington.

Officially, Kentucky has reported around 7,300 COVID-19 deaths, but the latest data from UW’s Institute for Health Metrics and Evaluation estimates more than 17,000 Kentuckians have died as a result of of the pandemic.

This metric, known as “excess mortality,” uses death certificate data to get a more complete picture of the impact of the pandemic.

The magnitude of excess deaths is due, in part, to socioeconomic factors. In Kentucky, that includes a large percentage of the population with chronic health conditions like obesity and diabetes, less access to health care and lower levels of education, Mokdad said.

Kentucky also has higher than typical rates of death from diabetesheart disease and cancer, according to the U.S Centers for Disease Control and Prevention. More than 15% of all Kentuckians have multiple chronic conditions, second only to West Virginia as the highest rates in the country, according to a United Health Foundation report from 2020.  

Like any other natural disaster, people with chronic conditions are more vulnerable than healthy people during a pandemic, Mokdad said. 

“So when you have an event that comes — heat wave, earthquake or whatever — the people who are frail, about to die in six months, they are more likely to die from that shock to the system,” Mokdad said. “So when it comes to COVID-19 it’s exactly the same.”

To improve Kentucky’s high rate of excess mortality, Mokdad said the state should focus on public health policy on reducing preventable risk factors such as smoking, obesity and diabetes. 

But all of that doesn’t even account for the biggest reason for excess mortality: misidentified COVID-19 deaths.

‘Garbage Coding’ and Elected Coroners

Kentucky had among the highest rates of misclassified deaths in the country even before the pandemic. As many as 34% of all deaths in the state were misclassified in Kentucky in 2017, according to data from the University of Washington. 

UW researchers consider a death misclassified if the cause of death is not the actual reason the person died.

Listing heart failure as the cause of death, for example. 

“There’s no cause of death for heart failure, I mean we all die, our heart fails,” Mokdad said.  

Mokdad and researchers at U of W call this “garbage coding,” because it doesn’t actually explain the specific reasons a person died. 

The top five most common misclassifications on Kentucky death certificates were dementia, undetermined poisoning, heart failure, stroke and sepsis, according to 2017 death certificate data from U of W.   

Mokdad said these misclassifications continued amid the pandemic, even as public health departments ramped up the amount of data they were sharing with the public.  

The data produced in the pandemic was unlike any other moment in American history. States all across the country produced graphics, charts and reams of spreadsheets quantifying and qualifying the toll of the pandemic. 

But at the same time, when the coronavirus began to spread, there were no federal standards defining a COVID-19 case, test or death. So every state paved their own way. Not to mention, Kentucky’s testing capacity was extremely limited for the first months of the pandemic, and the first tests made by the CDC turned out to have faulty components. 

In the absence of a positive COVID test, health professionals misclassified deaths based on their underlying chronic conditions, Mokdad said.

“Many people died, COVID-19 caused that death, but because they had diabetes is was recorded as diabetes,” Mokdad said. 

One reason for the high number of misclassified deaths in the state is likely because of elected state coroners, Mokdad said. The job of coroner is enshrined in the state’s constitution as an elected position, but the only requirements are that a person be a resident of Kentucky and be at least 24 years old. 

“You’re driving blind if you don’t know what are the causes of death,” Mokdad said. “And yes, people should be professionals certified to [be coroners], not elected.”

Additional reporting was by Tom Scheck of APM Reports, the investigative unit of American Public Media. This story was produced as part of APM Reports’ public media accountability initiative, which supports investigative reporting at local media outlets around the country. Support also came from the Corporation for Public Broadcasting.

Researchers made their estimates by comparing week-to-week excess death rates to what would have been expected in a given place for a typical, non-pandemic year. They identified three main factors contributing to a higher number of deaths in the pandemic: excess COVID-19 deaths directly related to infections, increases in deaths related to delayed medical care and increases in deaths from suicide and drug overdoses.

Drug overdose deaths, for example, increased nearly 30% across the U.S. in 2020. In Kentucky, they were even higher, increasing nearly 54% over the year prior and accounting for an estimated 2,100 deaths, according to the CDC

Adding all of the impacts together, Kentucky has among the highest number of excess deaths of any state in the country, said Dr. Ali Mokdad, University of Washington epidemiologist and former official with the U.S. Centers for Disease Control and Prevention. 

“Excess mortality is in every state and in every country so you are not unique, but the scale of it is much higher in Kentucky,” Mokdad said. 

That’s even accounting for the fact that researchers weighed increases in excess mortality against reductions from a decreased number of things like car accidents, reduced transmission of other diseases, and fewer deaths from chronic conditions because of all the vulnerable people who instead died of COVID-19. 

Looking at the official COVID-19 death toll from the CDC, Kentucky performed better than many peer states. It was on par with the national average of COVID deaths per 100,000 residents.

In fact, Kentucky’s mortality rate of 163 per 100,000 residents was exactly the same as the median number of COVID deaths for U.S. states and territories as of July 25, according to an analysis of CDC data

But looking at pandemic deaths through the lens of excess mortality, Kentucky ranked among the six worst states in the country, with 17,417 excess deaths as of July 15. That’s according to UW’s data tracker. Others included Oklahoma, Arkansas, Mississippi, Arizona and Alabama.