Ann Rev. Public Health 1980. 1:1-36
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`Copyright © 1980 by Annual Reviews Inc. All rights reserved
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`HEALTH AND DISEASE
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`IN THE UNITED STATESl
`L. A. Fingerhut, R. W. Wilson, and J. J. Feldman
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`.12500
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`National Center for Health Statistics, Hyattsville, Maryland 20782
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`INTRODUCTION
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`The characterization of the overall health status of a population or of an
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`individual is not a simple task. Many factors must be considered. Factors
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`relating to mortality, such as life expectancy, mortality rates, both total and
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`cause specific, infant mortality, and maternal mortality, are frequently used
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`to assess the health of the people in an area. These measures are relatively
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`easy to obtain and are available for small geographic areas and often for
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`subgroups of the population. In addition, these measures are frequently
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`available for other countries and, although there are definitional differences,
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`international comparisons can be helpful. Finally, the impact of medical
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`intervention on these measures is generally very direct, i.e. mortality rates
`objec­
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`should go down and life expectancy should increase-both desirable
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`tives-with necessary and appropriate medical treatment.
`a have been used to characterize Many other measures of health status
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`population. The most common are measures of illness, i.e. the prevalence
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`and incidence of specific diseases and the impact of these diseases as mea­
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`of this type was sured by disability (8). In the past much of the information
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`based on research conducted in hospitals at medical schools. However,
`because
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`only about 10% of the population in any year is hospitalized and
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`ofthis group only 10% is in teaching hospitals, much ofthe health informa­
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`tion from examinations was based on only 1 % of the population. In 1960
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`the National Center for Health Statistics (NCHS) initiated a major effort to
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`improve the representativeness of health data by forming the National
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`Health Examination Survey (now called Health and Nutrition Examination
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`in this chapter
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`IMuch of the information pJ:esented has been taken from Health, United
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`includes selected States, 1979 (1) or earlier volumes. This chapter tables from Health, United
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`from NCHS. States, 1979. Reprints are available
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`0163-7525/80/0510-0001$01.00
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`LOWER DRUG PRICES FOR CONSUMERS, LLC
`Exhibit 1026-1
`IPR2016-00379
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`

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`2 FINGERHUT, WILSON & FELDMAN
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`Survey, or HANES), in which a national probability sample of persons was
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`given an extensive clinical examination with highly standardized proce­
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`dures in portable clinics that were moved around the country to the various
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`sampling sites. Information has been collected about selected conditions,
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`both known and previously undiagnosed, as well as about a variety of
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`physical, physiological, biochemical, and psychological measures (2a). Data
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`from these surveys have added greatly to the knowledge of our nation's
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`health. Only a limited amount of health data, however, can be collected at
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`anyone time, thus necessitating the utilization of other sources of health
`information.
`Health data can also be obtained by simply asking people about their
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`health, either as a part of an examination surveyor as a part of separate
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`health surveys. Interview surveys can provide information about what kinds
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`of illnesses people think they have or are willing to report and the presence
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`of various symptoms, as well as the ability of people to perform the routine
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`activities of daily living, the impact of health on their ability to perform
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`these activities, and the use of medical services. These and related questions
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`have been asked for more than 20 years in the National Health Interview
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`Survey conducted by NCHS.
`Many of these "nonmortality" health indicators are difficult to interpret,
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`especially when changes are observed over time. For example, does an
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`increase in the prevalence rate of a disease mean that people are less healthy,
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`or does it indicate that doctors are changing a diagnostic procedure? Does
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`an increase in the number of days lost from work as a result of illness mean
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`that employees are getting sicker, or does it mean that employers are
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`providing more liberal sick leave benefits? Does an increase in the number
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`of persons who are unable to work because of a disability indicate a less
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`healthy population, or does it reflect more liberal disability retirement
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`benefits, or possibly a change in the work ethic? Does an increase in the
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`number of people with long-term limitation of activities from chronic dis­
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`eases indicate a deterioration in health status, or does it reflect improve­
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`ments in health care that permit a person to survive a heart attack or a
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`stroke, although with some permanent disability? An increase in a health
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`status measure, therefore, does not necessarily mean that the true health
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`status is deteriorating (2b).
`Mental and emotional health are now considered to be an aspect of
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`overall health status. This type of measure is usually even more difficult
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`to interpret than the physical illness and disability data. In recent years
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`there has been an increased interest in the development of health status
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`indexes that combine a number of indicators into a single measure of health.
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`Although there are many conceptual problems in the development of health
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`status indexes, there is a frequently expressed desire for a single health
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`LOWER DRUG PRICES FOR CONSUMERS, LLC
`Exhibit 1026-2
`IPR2016-00379
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`

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`HEALTH, UNITED STATES 3
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`index, similar to the Gross National Product or the Consumer Price Index,
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`that will tell us if the health of the country is improving or deteriorating.
`A
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`number of indexes have been proposed and some have been used to assess
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`the health status of selected populations (3). However, most of the proposed
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`indexes are not composed of indicators that are currently available from
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`national data bases and therefore the collection of new data is required
`before they can be applied.
`One of the best single indicators of general health status is self-assessment
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`to be perceive their own status
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`of health. The vast majority of the population
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`excellent or good when asked the question: Compared with other persons
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`your age, would you say that your health is excellent, good, fair, or poor?
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`Just under half (48%) of the population perceive themselves as in excellent
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`health. Only about 12% report their health to be fair or poor (Table 1).
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`Even though respondents are asked to use other persons their own age as
`a reference
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`with age. group, respondents perceive their health as declining
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`Whereas only about 8% of young adults see themselves as in fair or poor
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`to age, United measures according and expenditure Table 1 Health status, utilization,
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`1 9 7 7a
`States,
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`Measure
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`Under 1 7 1 7-44 45-64 65 years
`All ages years years years and over
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`1 1.2 14.2 24.4 36.5
`3 .4
`8 . 1 2 3 . 1 43.0
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`3 .6
`1 2.3
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`0.2 1 . 2 6.2 1 7.2
`4.2 8 .5
`2 2.0
`29.9
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`Office visits to physicians per
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`99.7 41.0 1 04.7 1 24.6 165.9
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`2.7 2.0 2.5 3 . 3
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`4.1
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`Disability days per person per year 1 7 .8
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`Percentage limited in activity 1 3.5
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`Percentage unable to carryon
`major activity
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`Percentage feeling fair or poor
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`Discharges from short-stay
`b 1 69.2 7 3 . 3 159.7 1 98.4 3 74.4
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`hospitals per 1,000 population
`Days of care from short-stay
`b 1 ,2 36.7 308.2 849.2 1 ,688.3 4,156.3
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`hospitals per 1,000 population
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`Surgical operations
`per 1,000
`populationb
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`personb
`Percentage of office visits at which
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`patient's principal problem
`judged not serio usb
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`�er capita personal health care
`expendituresc
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`5 1.0 63.0 5 8.8 4 1 .8
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`3 1 .9
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`$646.00 $ 2 5 3 .00
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`$661.00 $ 1,745.00
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`a Source: National Center for Health Statistics and Health Care Financing Administra-
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`noninstitution-tion. Data are based on household interviews of a sample of the civilian
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`alized population, on medical records, and on compilations frum government sources.
`bThe rates for the under 17 age group are for under 15 age group and rates for 17-44
`age group are for 15-44 age group.
`C The age groups are under 19, 19-64, and 6S years and over.
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`LOWER DRUG PRICES FOR CONSUMERS, LLC
`Exhibit 1026-3
`IPR2016-00379
`
`

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`4 FINGERHUT, WILSON & FELDMAN
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`health, 30% of those 65 or over feel they are in fair or poor health. On the
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`other hand, an equal proportion of the elderly view themselves as being in
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`excellent health. Only minor differences exist between males and females in
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`self-perception of health.
`Striking differences are found in self-perceived health status between
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`persons living in families with low income and those with high family
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`incomes, even when the data are adjusted to account for the different age
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`structure of low and high income families. Almost one quarter of persons
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`in low income families (under $5,000) report that they are in fair or poor
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`health, compared with only 5% of those living in high income families (over
`$25,000) (Table 11). Blacks are twice as likely
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`to perceive themselves in fair
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`or poor health as are whites. Some racial differences remain even within
`income categories.
`In an effort to present a more detailed, although not necessarily compre­
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`hensive, picture of the nation's health, this chapter presents data on (a)
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`mortality, including information on life expectancy, infant mortality, and
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`selected causes of death, (b) morbidity, including information on selected
`(d) selected
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`diseases, (c) disability, data related to prevention of
`chronic
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`financing. illness, and (e) health care costs and
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`DEMOGRAPHIC DISTRIBUTION OF THE
`POPULATION
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`8% of the country's
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`The size and distribution of the population of the United States have and
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`will continue to have important implications for health status and the use
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`of health resources. Assuming a constant level of health, the more people
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`there are, the more health services will be necessary. However, as the shape
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`so too does the overall health status of the nation.
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`of the popUlation changes,
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`An aging population, for example, will place greater demands on the health
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`care system by virture of its poorer health relative to the younger popula­
`tion.
`The population of the United States is aging. A quarter of a century ago,
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`152 million people were 65 years of age and over; now
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`close to 11% or 23 million are aged 65 and over. This latter age group is
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`the most rapidly growing population group. Based on various population
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`projections, with each projection assuming different rates of mortality de­
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`cline, an estimated
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`or 32 million people, will
`be 65 years of age and over in the year 2000. Within that age group, the
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`population over age 75 will grow most rapidly. By 2000, an estimated 14
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`million people will be at least 75 years of age, 62% more than in 1977 (4).
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`How will these changes affect health status and health care utilization in
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`the United States? Older people consume more health care than do younger
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`11 to 13% of the population,
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`LOWER DRUG PRICES FOR CONSUMERS, LLC
`Exhibit 1026-4
`IPR2016-00379
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`

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`HEALTH, UNITED STATES 5
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`people. They have more chronic illnesses, more disabilities and physical
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`impairments. About 30% of the personal health care dollar, and close to
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`half of the public portion, is spent on people 65 years of age or over. The
`per capita personal
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`health care expenditure for people aged 65 years and
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`over is almost seven times that of people under 19 years of age (Table 1).
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`Projected changes in the size and age distribution of the population alone
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`will have an impact on health status, on utilization, and consequently on
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`expenditures (5). For example, it is estimated that by the year 2000, 24%
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`of all hospital days will be used by people aged 75 years and over, a third
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`more than in 1977, and 24% of all disability days will be reported by those
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`of at least 65 years of age, an eighth more than in 1977.
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`In addition to the age distribution of the population, the geographic
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`variation in the residential patterns of the elderly will necessitate selective
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`placement of medical care services. Most elderly people do not change
`For in­
`residences.
`However, those who do move, do so very selectively.
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`stance, whereas only 5% of all migrants are age 65 and older, about a fifth
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`of Florida's migrants are within this age group. Elderly migrants are likely
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`to seek destinations that have well developed social and medical services
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`and mild climates. In states such as California, Florida, Arizona, and Texas,
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`recreational and health service centers for the elderly are being promoted
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`(6). Further, the rapid growth of "retirement counties"2 is accounted for
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`primarily by migration. Between 1970 and 1975, growth rates of these
`counties doubled.
`An increasingly older popUlation will also place greater demands on
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`alternative care facilities. For instance, with death rates being much higher
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`for men than for women at older ages, widowed women with chronic or
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`disabling illness may need care they cannot provide for themselves. The
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`need for nursing homes, home health services, adult day care, etc will
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`therefore be heightened.
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`MORTALITY
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`The crude death rate in the United States continues its downward trend that
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`has been observed since the early 1930s when national mortality data were
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`first collected.3 At that time the rate was 10.7 deaths per 1,000 population.
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`to mid-l96Os, the rate declined every After a slight rise in the mid-1950s
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`year from 1968 (when the rate was 9.7) to 1977 except for 1971-1972 and
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`1975-1976. In 1977, there were 8.8 deaths per 1,000 population.
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`2Counties characterized by high in-migration of persons 60 years of age and over-360 of
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`them were identified by Calvin Beale in 1970 (7a).
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`3In 1933, the death registration area included all states and the District of Columbia.
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`LOWER DRUG PRICES FOR CONSUMERS, LLC
`Exhibit 1026-5
`IPR2016-00379
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`

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`6 FINGERHUT, WILSON & FELDMAN
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`rates for adults in each 5-year age group from 25 to 64 years
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`Trends in mortality rates differ among age groups. Mortality for infants
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`and age-specific deaths rates for children under 15 years of age decreased
`at a rate of about 2% per year from 1950 to 1970. By 1977, the pace of the
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`decline increased to about 3% annually overall and to 5% annually for
`infants under 1 year of age.
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`Among adolescents and young adults 15 to 19 and 20 to 24 years of age,
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`death rates decreased nearly 2% per year from 1950 to 1960 and then
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`increased at about the same rate during the next 10 years. In the current
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`decade, mortality again decreased, at an overall rate of 1.2 to 1.5% per
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`annum. However, from 1976 to 1977 the death rate for teenagers 15 to 1 9
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`years of age increased by 5%. This increase is attributable primarily to
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`increases in death from external causes-particularly suicide, which in­
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`creased 20%, and motor vehicle accidents, which increased 4%.
`Mortality
`1950 to 1970, but the pace of age decreased by less than 1 % per year from
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`accelerated to about 2 to 3% per year during the 1970s.
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`Similarly, changes in mortality for the elderly were very small from 1950
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`to 1970, but the rate of decline increased to an average of about 2 % annually
`from 1970 to 1977.
`Knowledge of changes in specific rates-Leo rates specific for any number
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`of population characteristics, such as sex, race, and age-is needed to
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`understand the factors affecting mortality. Geographic differences in age­
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`or race-specific mortality rates may reflect inadequate health care services
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`and facilities, or such differences may direct attention to possible environ­
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`mental problems associated with specific localities.
`however, is due largely to the changing age
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`structure of the population. For an analysis of trends over time, it is advan­
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`tageous to look at the age-adjusted death rate, a summary statistic useful
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`for making annual comparisons. This rate shows what the level of mortality
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`would be if no changes occurred in the age composition of the population
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`from year to year. From the beginning of this century, the age-adjusted
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`death rate decreased by 53%, from 17.8 deaths per 1,000 popUlation in 1 900
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`to 8.4 deaths per 1,000 population in 1950, and then by another 27% to 6. 1
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`from 1 950 in mortality deaths per 1,000 population the decrease in 1977. If
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`it would be about only by the crude rate, however, to 1 977 were measured
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`9%, a figure that does not reflect the magnitude of the true decline in death
`rates.
`Age-adjusted mortality decreases were much greater for females than for
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`males, both white and black, from 1950 to 1 970. During those 20 years,
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`white female mortality decreased at 1.2% per year, whereas white male
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`mortality declined by less than 0.5% per year. Among blacks, the difference
`was even greater-1.5% per year vs less than 0.5% per year for females and
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`The change in the death rate,
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`LOWER DRUG PRICES FOR CONSUMERS, LLC
`Exhibit 1026-6
`IPR2016-00379
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`

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`HEALTH, UNITED STATES 7
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`males respectively. These differences are largely a result of decreases in
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`mortality from heart disease and from cancer of the digestive system and
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`peritoneum, and genital organs, all of which have been greater for females
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`than for males. More recently, decreases in mortality rates have accelerated
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`for both males and females. From 1970 to 1977, white mortality rates
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`decreased at an average annual rate of 2.3% per year among females and
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`at 1.9% per year among males. Black female mortality decreased at 2.9%
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`per year and black male mortality decreased at 2.2% per year.
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`The relative difference between the age-adjusted mortality rates for males
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`and females has been increasing over time. In 1950, the death rate for males
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`was 1.5 times the female rate; by 1977, the ratio increased to 1.8. This
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`increase in the sex ratio in mortality is evident for both whites and blacks.
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`Among whites, the ratio increased from 1.5 in 1950 to 1.8 in 1977; for
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`blacks, it increased from 1.2 to 1. 7 during the same 27 years.
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`Infant Mortality
`in the last 12 years.
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`Infant mortality has shown marked improvements
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`From 1965 to 1977, the infant mortality rate decreased by 43% to 14.1
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`infant deaths per 1,000 live births. For both white and black infants, de­
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`clines of 5% per year have been observed. During the preceding decade,
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`from 1955 to 1965, the annual rate of decline was much slower, less than
`1% per year.
`Despite
`overall decreases, black infant mortality is still considerably
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`In 1977, the rate for black infants was
`higher than white infant mortality.
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`23.6 compared with 12.3 for white infants. Furthermore, there is no evi­
`dence that the rates are converging.
`A number of factors may have influenced the reductions in infant and
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`perinatal mortality: (a) more women receiving prenatal care early in preg­
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`nancy, (b) a decreasing proportion of higher order, thus higher risk births,
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`(c) advances in medical science, particularly in neonatology, (d) increasing
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`availability of the most modem care through regional perinatal centers,
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`(e) improvements in contraceptive utilization, allowing women to time and
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`space their pregnancies more effectively, thereby reducing the proportion
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`of high risk births, (f) increasing legal abortion rates, (g) the availability
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`of programs to improve the nutrition of pregnant women and infants, (h)
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`general improvements in socioeconomic conditions.
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`Geographic variation in infant mortality rates within the United States
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`is substantial. During the periods from 1965 to 1967 and from 1975 to 1977,
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`the New England and Pacific Divisions had the lowest infant mortality
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`rates, and the East South Central Division had the highest infant mortality
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`rate. During the latter period, Maine had the lowest infant mortality rate,
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`11.2, and the District of Columbia had the highest, 27.2. On the whole,
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`LOWER DRUG PRICES FOR CONSUMERS, LLC
`Exhibit 1026-7
`IPR2016-00379
`
`

`
`8 FINGERHUT, WILSON & FELDMAN
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`variations were as high from 1975 to 1977 as they were from
`geographic
`1 965 to 1967.
`During the period from 1975 to 1977, infant mortality among whites
`ranged from a low of 12.2 in New England to a high of 14.1 in the East
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`and West South Central States. Among blacks the rates ranged from 20.6
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`in the Pacific Division to 26.5 in the East North Central Division (Table
`2).
`is higher than the rate in The infant mortality rate in the United States
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`The 1977 data show Sweden, En­
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`certain other industrialized countries.
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`gland and Wales, the Netherlands, and the German Democratic Republic
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`(East Germany), among others, as having lower infant mortality rates than
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`the United States. The average annual decrease in infant mortality from
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`to that 1 972 through the 1975-1977 period for the United States is similar
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`countries. observed for other industrialized
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`Life Expectancy
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`reached a record 73.2 years
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`Life expectancy at birth in the United States
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`were in 1977. During the first half of the century, gains in life expectancy
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`dramatic, a fact which was attributa
`ble to decreases
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`in infectious and para­
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`sitic diseases. From 1950 to 1970,2.7 years were added to the expectation
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`of life. The pace of improvement has accelerated during the present decade,
`
`with 2.3 years being added since 1970. Major gains in life expectancy were
`
`
`
`
`noted especially for nonwhites whose life expectancy at birth improved by
`
`United States, division: to race and geographic Table 2 Infant mortality rates, according
`
`
`
`
`
`1 970-1972, and 1975-1977a
`average annual 1965-1967,
`
`1975-1977
`1970-19 7 2
`1965-1967
`Geographic
`division Totalb White Black Totalb White Black Totalb White Black
`
`Infant deaths per 1 ,000 live births
`
`United States 2 3 .6 20.6 3 9 .8 1 9 . 2 1 7 . 1 30.9 1 5 . 1 1 3. 3 25. 1
`New England 21.2 20.4 36.7 16.8 1 6 . 2 30.0 1 2. 8 1 2.2 2 3 .6
`Middle Atlantic 2 2 .6 1 9 . 7 3 9 . 5 1 8.6 1 6 . 3 3 0 . 8 1 5 . 3 1 3.2 25. 1
`East North Central 22.7 20.5 38.7 19.2 1 7 . 1 3 1.7 1 5 . 2 1 3.3 26.5
`West North Central 2 1 .3 1 9 .9 40. 1 1 8 . 1 1 7.2 30.7 1 4.0 1 3 . 1 25.5
`South Atlantic 26.9 2 1 .2 40.6 2 1 .0 1 7 .3 3 1.0 1 6.9 1 3 .6 25.2
`East South Central 29.1 22.8 44.7 22.3 1 8. 3 3 3 .5 1 7. 3 1 4 . 1 26. 1
`West South Central 25.4 2 1 .6 39.4 20.9 18.8 29.9 16.2 1 4 . 1 25. 1
`Mountain
`2 3 .3 2 1.9 34.2 18.2 1 7 .5 26.3 13.7 1 3.2 2 1 . 1
`Pacific
`20.9 20.0 32.7 1 6.8 1 6.2 26.4 1 2.8 1 2.4 20.6
`
`aSource: National Center for Health Statistics:
`Computed by the Division of Analysis
`
`from data compiled by the Division of Vital Statistics. Data are based on the national
`system.
`vital registration
`blncludes all other races not shown separately
`.
`
`
`
`LOWER DRUG PRICES FOR CONSUMERS, LLC
`Exhibit 1026-8
`IPR2016-00379
`
`

`
`HEALTH, UNITED STATES 9
`
`4.5 years from 1950 to 1970, compared with 2.6 years for whites. Since
`
`
`
`
`
`
`
`1970, an additional 3.5 years were added for nonwhite people, compared
`
`
`with 2.1 years for whites. Most of the improvement has been among
`
`
`
`females. There is still a sizable difference-5 years-in life expectancy at
`birth between whites and nonwhites.
`
`Recent gains in life expectancy for those 65 years of age have been similar
`
`
`
`for whites and nonwhites. On the average, people reaching 65 years of age
`
`in 1977 can expect to live an additional 16.3 years, or 1.1 years more than
`
`someone reaching age 65 in 1970.
`Expectation of life at birth is influenced heavily by mortality rates for
`
`
`
`
`
`
`infancy and childhood. It is not surprising, therefore, that life expectancy
`
`
`
`in the United States does not compare favorably with certain other industri­
`
`
`
`alized countries. However, the recent annual improvements in number of
`
`
`
`years gained are better in the United States than in most countries, for both
`males and females.
`
`Leading Causes of Death
`
`Heart disease, cancer, stroke, and accidents have been the leading causes
`
`
`
`
`
`
`of death since around 1950 (Table 3). In 1900, infectious diseases-particu­
`
`
`
`larly pneumonia and tuberculosis-were the leading causes of death, ac­
`
`
`
`counting for a fifth of all deaths in the United States. The precipitous decline
`
`
`
`in the death rates from these causes has been evident throughout the devel­
`
`
`
`oped world. Social improvements such as sanitation, nutrition, housing,
`
`
`
`
`
`education, and medical care have all contributed to the decline. More
`
`recently, however, decreases in death rates from some of the major chronic
`
`
`
`
`diseases-mainly the cardiovascular diseases including heart and cere­
`
`
`brovascular diseases-have been evident.
`
`
`
`Heart disease continues to be the leading cause of death in the United
`
`
`
`
`States and, as such, it is the predominant influence on total mortality. The
`
`age-adjusted death rate decreased by 18% in the 20 years from 1950 to
`
`
`
`1970, an average of 1 % per year; it declined by nearly the same amount in
`
`the first 7 years of this decade at an average decline of 2.6% per year.
`
`
`
`During those 27 years, the age-specific rates declined by more than 40% for
`each 5-year age group from 25 to 49 years of age, and by more than 30%
`
`
`
`for each succeeding age group from 50 to 74 years of age. For those in the
`
`
`5-year age groups from 75 to 85 years of age and over, the decline was more
`than 20%.
`Decreases in age-adjusted heart disease mortality rates have been much
`
`
`
`
`
`
`greater for females than for males, especially between 1950 and 1970.
`
`
`
`Among white and black females heart disease mortality dropped 25% and
`
`
`
`
`28%, respectively during this period, compared with decreases of 9% and
`
`10% among white and black males, respectively. During the current
`
`
`
`LOWER DRUG PRICES FOR CONSUMERS, LLC
`Exhibit 1026-9
`IPR2016-00379
`
`

`
`
`
`10 FINGERHUT, WILSON & FELDMAN
`
`Table 3 Age-adjusted
`
`
`
`selected years 1950-1977b
`
`leading causes of death in 1950: United States,
`
`death ratesa and average annual percentage change, according to
`
`Cause of death
`
`Diseases
`Cerebro-
`of the Malignant vascular
`Tubercu-
`All causes heart neoplasms disease AccidentsC losis
`
`Deaths per 100,000 resident population
`
`Year
`
`1950
`1955
`1960
`1965
`1970
`1975
`1976
`1977
`
`- 0.7
`
`88.8
`307.6 1 25 .4
`57.5
`8 4 1 .5
`54.4
`125.8 8 3 .0
`764.6 2 8 7 .5
`79.7
`760.9 286.2 1 25 . 8
`49 .9
`739.0 273.9 1 27.0
`72.7 53.3
`714.3 253.6 129.9 66.3
`53.7
`6 3 8 . 3 220.5 130.9 54.5 44.8
`216.7 1 32.3 51.4
`43.2
`627.5
`612.3 2 10.4 133.0 48.2
`43.8
`
`
`
`Average annual percentage change
`
`0.2 - 2.2
`
`21.7
`8 .4
`5.4
`3.6
`2.2
`1.2
`1.1
`1.0
`
`-10.8
`
`- 17.3
`-7.8
`
`-8.5
`
`-9.4
`-10.7
`-0.9
`
`1950-77 -1.2 -1.4
`1 950-55 -1.9 - 1 .3
`1955-60 -0.1 -0.1
`-0.9
`1960-65 -0.6
`-1.5
`1965-70
`-2.6
`1970-77 -2.2
`-2.3
`1975-77 -2.1
`
`-1.3
`0.1
`-0.8
`0.0
`0.2 -1.8
`-1.8
`0.5
`0.3
`-4.5
`-6.0
`0.8
`
`-1.0
`-1.1
`-1.7
`1.3
`0.1
`-2.9
`-0.5
`
`aNote: Age-adjusted
`
`rates computed by the direct method to the age distribution of
`the total U.S. population
`as enumerated in 1940, using 11 age intervals.
`
`bSource: Division of Vital Statistics, National Center for Health Statistics:
`Selected
`
`data. Data are based on the national vital registration system.
`C Includes motor vehicle and all other.
`
`decade, the rates of decline in heart disease mortality for both races and
`
`
`
`
`
`both sexes have become more nearly equal-IS and 19% for white and
`
`black females and 15 and 14% for white and black males. As a result, the
`
`
`
`relative differences in the death rates for heart disease between males and
`
`females have been increasing over time. In 1950, heart disease mortality
`for
`
`white males was 1.7 times that for white females, and by 1977, the ratio
`
`
`
`
`
`widened to 2.1. Similarly, the ratios for the black population increased from
`1.2 in 1950 to 1.6 in 1977.
`Racial differences in heart disease mortality for males are very large,
`
`
`
`age to 40 years of
`
`especially at the younger ages. In each 5-year age group from 25 years of
`
`age, heart disease mortality in 1977 for black males was
`more than twice as high as that for white males. Between
`
`
`of age the relative difference decreased. and for those 65 years of age and
`
`over mortality was lower for black males than for white males. Racial
`
`40 and 64 years
`
`
`
`LOWER DRUG PRICES FOR CONSUMERS, LLC
`Exhibit 1026-10
`IPR2016-00379
`
`

`
`HEALTH, UNITED STATES 11
`
`in heart disease mortality
`
`
`differences
`were greater among females than
`
`males, especially at the younger ages.
`
`
`
`Ischemic heart disease mortality includes about 90% of all heart disease
`
`
`
`
`mortality, and as such, the trends are similar. Age-adjusted death rates
`
`
`decreased about 3% per year during the past decade. For each 5-year age
`
`
`
`group between 25 and 69 years of age, declines of at least 25% during
`
`the period from 1968 to 1977 have been noted. Since 1968, the ratio of
`
`
`
`white male to white female mortality (2.2: I) has remained virtually un­
`changed.
`Some of the explanations suggested for the downturn in heart disease
`
`
`
`
`
`
`mortality are: (0) decreased smoking in general and in smoking of high tar
`
`and nicotine cigarettes in particular among adult males, (b) improved
`
`
`
`
`
`
`
`management of hypertension, (c) decreased dietary intake of saturated fats,
`
`
`
`
`
`(d) more widespread physical activity, (e) improved medical emergency
`
`
`
`
`
`
`services, (I) more widespread use and increased efficacy of coronary care
`
`
`
`
`which evidence for determining units. Unfortunately there is no definitive
`
`
`
`
`
`of these explanations or which combination thereof can account for the
`
`decline (7b).
`The second major component of cardiovascular diseases is cerebrovascu­
`
`
`
`
`
`
`
`lar disease or stroke, the third leading cause of death in the United States
`
`
`
`
`about rates decreased in 1977. Cerebrovascular age-adjusted mortality
`
`25%, to 66 deaths per 100,000 population from 1950 to 1970. By 1977, the
`
`
`
`Reduc­rate had decreased an additional 27% to 48 per 100,000 population.
`
`
`tions have been observed for males and females, whites and nonwhites, in
`
`nearly every age group. In recent years, cerebrovascular death rates have
`
`
`
`
`continued to decrease at a greater pace than have heart disease death rates,
`
`4.5% vs 2.6% annually since 1970. This downturn in stroke mortality
`
`
`
`
`probably reflects both a decrease in the incidence of stroke and in the fatality
`
`
`
`
`
`rate among stroke victims. Improved management of hypertension has been
`
`
`
`offered as an explanation of the declining incidence (7c, 7d).
`
`
`
`
`neoplasms or cancers are the second leading cause of death in
`Malignant
`
`
`the United States. In 1977, the age-adjusted mortality rate was 133 deaths
`
`
`per 100,000 population, 6% higher than in 1950. This overall rise masks
`
`
`
`
`
`significant differences in cancer mortality, not only for individual sites, but
`
`
`
`also for males and females, white and black people, and the elderly and the
`
`young. For example, from 1950 to 1970 the age-adjusted cancer mortality
`
`
`annual rate of 0.8% for whites and rate increased for males at an average
`
`
`
`2.3% for blacks; it decreased very slightly for females, 0.5% for whites and
`
`
`
`0.3% for blacks. During the 1970s the situation changed somewhat for
`
`
`females, showing annual increases of 0.1 % and 0.7% for whites and blacks
`
`
`
`
`respectively. The rate of increase decreased slightly for males with increases
`
`of 0.5% and 1.6% for whites and blacks, respectively.
`
`LOWER DRUG PRICES FOR CONSUMERS, LLC
`Exhibit 1026-11
`IPR2016-00379
`
`

`
`12 FINGERHUT, WILSON & FELDMAN
`
`Cancer mortality has been increasing for some sites, namely the respira­
`
`
`
`
`
`
`
`
`tory system, breast, colon, pancreas, and bladder, and has been decreasing
`
`
`
`
`for others, i.e. the stomach, rectum, cervix, and uterus.
`
`
`
`Of interest has been the 33% decrease in cancer mortality since 1950 for
`
`
`
`the population under 45 years of age. In addition, the rate for persons from
`
`
`45 to 49 years of age has decreased by 5% since 1974. The decreases have
`
`come about, in part, through reduced
`
`
`incidence of breast cancer in young
`
`
`women and lung cancer in young men, and throu