Transcript Using Data to Identify Disparities: Issues, Limitations, Cautions Richard J. Klein, MPH

Using Data to Identify Disparities:
Issues, Limitations, Cautions
Richard J. Klein, MPH
National Center for Health Statistics
Centers for Disease Control and Prevention
DHHS Office of Civil Rights
Title VI Training Conference
Philadelphia, PA
August 13, 2002
Public Health Service Region IV
D.C.
Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
Data sources

Population-based sample surveys
 Self-reported race/ethnicity
 Subject to sampling error

Encounter-based sample surveys
 Administrative records
 Proxy-reported race/ethnicity (observation?)
 Subject to sampling error
Data sources (cont.)

Vital records – deaths
 Complete counts
 Proxy race/ethnicity

Vital records – births/infant deaths (linked)
 Complete counts
 "Self"-reported race/ethnicity

Census data
 Complete counts/sample surveys
 "Self"-reported race/ethnicity
Modes of data collection

Personal interview

Examination

Administrative / Vital records

Telephone

Mail / Internet / Other
Data issues

Age adjustment

Cause of death classification

Data reliability

Race/ethnicity misclassification

Revision of OMB standards for race/ethnicity

Telephone coverage
Age adjustment
Comparison of diabetes prevalence*:
United States, by specified race, 1999
Rate per 100,000 population
100
80
60
40
20
0
American Indian/
Black/African American,
Alaska Native**
not-Hispanic
Asian/Pacific Islander**
White, not-Hispanic
*Diabetes that has been diagnosed by a physician.
**Includes persons of Hispanic and non-Hispanic origin.
***Persons of Hispanic origin may be any race.
Age-adjusted rates are adjusted to the year 2000 standard population.
Source: National Health Interview Survey (NHIS), Centers for Disease Control and Prevention, NCHS.
Hispanic***
Comparison of diabetes prevalence*:
United States, by specified race, 1999
Rate per 100,000 population
100
Age-adjusted rate
Crude rate
80
60
40
20
0
American Indian/
Black/African American,
Alaska Native**
not-Hispanic
Asian/Pacific Islander**
White, not-Hispanic
*Diabetes that has been diagnosed by a physician.
**Includes persons of Hispanic and non-Hispanic origin.
***Persons of Hispanic origin may be any race.
Age-adjusted rates are adjusted to the year 2000 standard population.
Source: National Health Interview Survey (NHIS), Centers for Disease Control and Prevention, NCHS.
Hispanic***
15 Leading causes of death, 1999
US
Cause of death**
rank*
…
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
All causes
Diseases of heart
Malignant neoplasms
Cerebrovascular diseases
Chronic lower respiratory disease
Accidents (unintentional injuries)
Diabetes mellitus
Influenza and pneumonia
Alzheimer's disease
Nephritis, nephrotic syndrome and nephrosis
Septicemia
Intentional self-harm (suicide)
Chronic liver disease and cirrhosis
Hypertension and hypertensive renal disease
Assault (homicide)
Aortic aneurysm and dissection
United
States
881.9
267.8
202.7
61.8
45.8
35.9
25.2
23.6
16.5
13.1
11.3
10.7
9.7
6.3
6.2
5.8
Region IV
Black/African
Total
American
Age-adjusted death rate***
932.6
1199.6
279.8
343.6
208.2
256.0
66.4
97.1
48.1
33.2
43.7
49.4
25.1
51.8
23.8
26.9
17.2
12.7
14.1
32.8
11.9
23.9
12.1
5.2
10.1
10.0
7.1
19.5
7.7
18.0
5.8
4.7
*Rank based on number of deaths.
**Cause-of-death definitions may differ for those used in Healthy People 2010 and the Leading Health Indicators.
***Age-adjusted rates per 100,000 standard population based on year 2000 standard.
Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
Source: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.
Diabetes death* rates: United States and
Region IV, by specified race, 1999
Age-adjusted rate per 100,000
standard population
200
United States
Region IV
2010
target (US)
150
100
50
0
American Indian/
Black/African American,
Alaska Native**
not-Hispanic
Asian/Pacific Islander**
White, not-Hispanic
*Diabetes deaths are classified by ICD-10 codes: E10-E14 and may be the underlying or contributing cause of death.
**Includes persons of Hispanic and non-Hispanic origin.
***Persons of Hispanic origin may be any race.
Rates are age-adjusted to the year 2000 standard population.
Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
Source: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.
Hispanic***
Age-adjusted rate per 100,000
standard population
Diabetes death* rates: United States and
Region IV States, by race, 1999
200
Total population
Black/African American
150
100
50
0
*Diabetes deaths are classified by ICD-10 codes: E10-E14 and may be the underlying or contributing cause of death.
Rates are age-adjusted to the year 2000 standard population.
Source: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.
2010
target (US)
Cause of death classification
Cerebrovascular disease (stroke)* death rates:
United States and Region IV, by specified race, 1999
Age-adjusted rate per 100,000
standard population
140
United States
Region IV
2010
target (US)
120
100
80
60
40
20
0
American Indian/
Alaska Native**
Black/African American,
not-Hispanic
Asian/Pacific Islander**
White, not-Hispanic
*Stroke deaths are classified by ICD-10 codes: I60-I69.
**Includes persons of Hispanic and non-Hispanic origin.
***Persons of Hispanic origin may be any race.
Rates are age-adjusted to the year 2000 standard population.
Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
Source: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.
Hispanic***
Cerebrovascular disease (stroke)* death rates:
United States and Region IV States, by race, 1999
Age-adjusted rate per 100,000
standard population
140
Total population
Black/African American
120
100
80
60
40
20
0
*Stroke deaths are classified by ICD-10 codes: I60-I69.
Rates are age-adjusted to the year 2000 standard population.
Source: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.
2010
target (US)
Age-adjusted rate per 100,000
standard population
Human immunodeficiency virus (HIV)* death rates:
United States and Region IV, by specified race, 1999
50
United States
Region IV
2010
target (US)
40
30
20
10
0
Black/African American,
not-Hispanic
White, not-Hispanic
Hispanic***
*HIV deaths are classified by ICD-10 codes: I11, I20-I25.
Rates are age-adjusted to the year 2000 standard population.
American Indian/Alaska Native and Asian/Pacific Islander death rates from HIV are unreliable in Region IV. Information on these populations have been
suppressed.
Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
Source: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.
Human immunodeficiency virus (HIV)* death rates:
United States and Region IV States, by race, 1999
Age-adjusted rate per 100,000
standard population
50
Total population
Black/African American
40
30
20
10
0
*HIV deaths are classified by ICD-10 codes: I11, I20-I25.
Rates are age-adjusted to the year 2000 standard population.
Source: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.
2010
target (US)
Data reliability
Percent of people under 65 years with health insurance
coverage: United States and Region IV, by specified race,
2000
United States
Age-adjusted percent
100
Region IV
2010 target (US)
80
60
40
20
0
American Indian/
Black/African American,
Alaska Native*
not-Hispanic
Asian/Pacific Islander*
White, not-Hispanic
I = 95% confidence interval.
*Includes persons of Hispanic and non-Hispanic origin.
**Persons of Hispanic origin may be any race.
Percents are age-adjusted to the year 2000 standard population.
Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
Source: National Health Interview Survey (NHIS), Centers for Disease Control and Prevention, NCHS.
Hispanic**
Percent of people under 65 years with health insurance
coverage: United States and Region IV States, by race,
2000
Total population
Age-adjusted percent
100
Black/African American
2010 target (US)
80
60
40
20
0
I = 95% confidence interval.
Percents are age-adjusted to the year 2000 standard population.
Source: National/Regional - National Health Interview Survey (NHIS), Centers for Disease Control and Prevention, NCHS;
State – Behavioral Risk Factor Surveillance System (BRFSS), Centers for Disease Control and Prevention, NCCDPHP.
Percent of women 40 and older who have received a
mammogram within the past 2 years: United States and
Region IV, by specified race, 2000
United States
Region IV
Age-adjusted percent
100
2010
target (US)
80
60
40
20
0
Black/African American,
not-Hispanic
White, not-Hispanic
Hispanic*
I = 95% confidence interval.
*Persons of Hispanic origin may be any race.
Percents are age-adjusted to the year 2000 standard population.
American Indian/Alaska Native and Asian/Pacific Islander mammogram rates are unreliable for Region IV. Information for these populations have
been suppressed.
Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
Source: National Health Interview Survey (NHIS), Centers for Disease Control and Prevention, NCHS.
Percent of women 40 and older who have received a
mammogram within the past 2 years: United States and
Region IV States, by race, 2000
Total population
Age-adjusted percent
100
Black/African American
2010
target (US)
80
60
40
20
0
I = 95% confidence interval.
Percents are age-adjusted to the year 2000 standard population.
Source: National/Regional - National Health Interview Survey (NHIS), Centers for Disease Control and Prevention, NCHS;
State – Behavioral Risk Factor Surveillance System (BRFSS), Centers for Disease Control and Prevention, NCCDPHP.
Race/ethnicity classification
Race/Ethnicity classification

Self-reported- considered most reliable
 Census
 Birth certificate- self-reported by mother

Report by observation or proxy- may reflect
misclassification
Death certificate
 Underestimation of deaths and death rates
 Hospital reporting method sometimes unclear

Percent distribution of the population by specified
race/ethnicity: United States and Region IV, 2000
80
United States
Region IV
Percent
60
40
20
0
American Indian/
Black/African American,
Alaska Native*
not-Hispanic
Asian/Pacific Islander*
White, not-Hispanic
*Includes persons of Hispanic and non-Hispanic origin.
**Persons of Hispanic origin may be any race.
Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
Source: Census 2000 Summary File 1, US Bureau of the Census.
Hispanic**
Percent of mothers who began prenatal care in the first
trimester of pregnancy: United States and Region IV,
by specified race, 2000
100
United States
Region IV
2010 target (US)
Percent
80
60
40
20
0
American Indian/
Black/African American,
Alaska Native*
not-Hispanic
Asian/Pacific Islander*
White, not-Hispanic
*Includes persons of Hispanic and non-Hispanic origin.
**Persons of Hispanic origin may be any race.
Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee.
Source: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.
Hispanic**
Age-adjusted rate per 100,000
standard population
Chronic lower respiratory disease* death rates for
people 45 years and older: United States and Region IV,
by specified race, 1999
175
United States
Region IV
150
125
100
75
2010 target (US)
50
25
0
American Indian/
Black/African American,
Alaska Native**
not-Hispanic
Asian/Pacific Islander**
White, not-Hispanic
*Chronic lower respiratory disease deaths are classified by ICD-10 codes: J40-J47.
**Includes persons of Hispanic and non-Hispanic origin.
***Persons of Hispanic origin may be any race.
Rates are age-adjusted to the year 2000 standard population.
Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
Source: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.
Hispanic***
Revision of OMB standards
for race/ethnicity
any
mention!
Percent of children 19 to 35 months who are
fully immunized*: United States and Region IV,
By specified race, 2000
100
2010 target (US)
Percent
80
60
40
20
0
Asian, not-Hispanic Black/African American,
not-Hispanic
White, not-Hispanic
Hispanic**
I = 95% confidence interval.
*Four or more doses of DTP, three or more doses of poliovirus, one or more doses of MCV, three or more doses of Hib, and three or more doses of HepB.
**Persons of Hispanic origin may be any race.
American Indian/Alaska Native immunization rates are unreliable for Region IV. Information on this population has been suppressed.
Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee.
Source: National Immunization Survey (NIS), Centers for Disease Control and Prevention, NIP and NCHS.
Telephone coverage
Limitations of telephone surveys

Surveys only capture persons with telephones

Possible biased response due to cell phones

Accuracy of responses

Low response rate due to answering machines,
Caller ID, etc.
Obesity* in adults 20 years and older:
United States, 1999
Age-adjusted percent
35
30
25
20
15
10
5
0
BRFSS
NHIS
NHANES**
I = 95% confidence interval.
*Obesity is defined as BMI > 30
**NHANES data are for adults 20 –74 years and for years 1999-2000 combined.
Percents are age-adjusted to the year 2000 standard population.
Source: Behavioral Risk Factor Surveillance System (BRFSS), Centers for Disease Control and Prevention, NCCDPHP;
National Health Interview Survey (NHIS), Centers for Disease Control and Prevention, NCHS;
National Health and Nutrition Examination Survey (NHANES), Centers for Disease Control and Prevention, NCHS.
For more information:
National Center for Health Statistics
www.cdc.gov/nchs
DATA2010
wonder.cdc.gov/data2010
Healthy People 2010
www.health.gov/healthypeople