dhhs office of civil rights title vi training conference philadelphia, pa august 13, 2002 using data...

DHHS Office of Civil RightsTitle VI Training Conference

Philadelphia, PAAugust 13, 2002

Using Data to Identify Disparities: Issues, Limitations, Cautions

Richard J. Klein, MPHNational Center for Health Statistics

Centers for Disease Control and Prevention

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

Encounter-based sample surveys

Self-reported race/ethnicity Subject to sampling error

Administrative records Proxy-reported race/ethnicity (observation?) Subject to sampling error

Complete counts Proxy race/ethnicity

Complete counts "Self"-reported race/ethnicity

Complete counts/sample surveys "Self"-reported race/ethnicity

Data sources (cont.)

Vital records – deaths

Vital records – births/infant deaths (linked)

Census data

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

0

20

40

60

80

100

*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.

Comparison of diabetes prevalence*:United States, by specified race, 1999

Black/African American,not-Hispanic

American Indian/Alaska Native**

Hispanic***

White, not-HispanicAsian/Pacific Islander**

Rate

per

10

0,0

00

popula

tion

0

20

40

60

80

100

*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.

Crude rateAge-adjusted rate

Comparison of diabetes prevalence*:United States, by specified race, 1999



Hispanic***


Rate

per

10

0,0

00

popula

tion

*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, TennesseeSource: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.

15 Leading causes of death, 1999

Total Black/African

American

… All causes 881.9 932.6 1199.61 Diseases of heart 267.8 279.8 343.62 Malignant neoplasms 202.7 208.2 256.03 Cerebrovascular diseases 61.8 66.4 97.14 Chronic lower respiratory disease 45.8 48.1 33.25 Accidents (unintentional injuries) 35.9 43.7 49.46 Diabetes mellitus 25.2 25.1 51.87 Influenza and pneumonia 23.6 23.8 26.98 Alzheimer's disease 16.5 17.2 12.79 Nephritis, nephrotic syndrome and nephrosis 13.1 14.1 32.8

10 Septicemia 11.3 11.9 23.911 Intentional self-harm (suicide) 10.7 12.1 5.212 Chronic liver disease and cirrhosis 9.7 10.1 10.013 Hypertension and hypertensive renal disease 6.3 7.1 19.514 Assault (homicide) 6.2 7.7 18.015 Aortic aneurysm and dissection 5.8 5.8 4.7

US rank*

Cause of death**

Age-adjusted death rate***

Region IVUnited States

0

50

100

150

200

*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, TennesseeSource: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.


Diabetes death* rates: United States andRegion IV, by specified race, 1999



Hispanic***


Age-a

dju

sted r

ate

per

10

0,0

00

standard

popula

tion

2010 target (US)

0

50

100

150

200

Diabetes death* rates: United States andRegion IV States, by race, 1999

Black/African AmericanTotal population

United S

tate

s

Region

IV

Kentu

cky

Mississ

ippi

North

Car

olina

South

Car

olina

Tennes

see

Alabam

a

Florid

a

Georg

ia

*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.

Age-a

dju

sted r

ate

per

10

0,0

00

standard

popula

tion

2010 target (US)

Cause of death classification

0

20

40

60

80

100

120

140

*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, TennesseeSource: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.


Cerebrovascular disease (stroke)* death rates:United States and Region IV, by specified race, 1999



Hispanic***


Age-a

dju

sted r

ate

per

10

0,0

00

standard

popula

tion

2010 target (US)

0

20

40

60

80

100

120

140

Cerebrovascular disease (stroke)* death rates:United States and Region IV States, by race, 1999


United S

tate

s

Region

IV

Kentu

cky

Mississ

ippi

North

Car

olina

South

Car

olina

Tennes

see

Alabam

a

Florid

a

Georg

ia

*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.

Age-a

dju

sted r

ate

per

10

0,0

00

standard

popula

tion

2010 target (US)

*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, TennesseeSource: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.

0

10

20

30

40

50

Age-a

dju

sted r

ate

per

10

0,0

00

standard

popula

tion


Human immunodeficiency virus (HIV)* death rates:United States and Region IV, by specified race, 1999


Hispanic***White, not-Hispanic

2010 target (US)

0

10

20

30

40

50

Human immunodeficiency virus (HIV)* death rates:United States and Region IV States, by race, 1999


United S

tate

s

Region

IV

Kentu

cky

Mississ

ippi

North

Car

olina

South

Car

olina

Tennes

see

Alabam

a

Florid

a

Georg

ia

*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.

Age-a

dju

sted r

ate

per

10

0,0

00

standard

popula

tion

2010 target (US)

Data reliability

0

20

40

60

80

100Region IVUnited States

Percent of people under 65 years with health insurancecoverage: United States and Region IV, by specified race,

2000


American Indian/Alaska Native*

Hispanic**

White, not-HispanicAsian/Pacific Islander*

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, TennesseeSource: National Health Interview Survey (NHIS), Centers for Disease Control and Prevention, NCHS.

Age-a

dju

sted p

erc

ent

2010 target (US)

0

20

40

60

80

100

Percent of people under 65 years with health insurancecoverage: United States and Region IV States, by race,

2000


United S

tate

s

Region

IV

Kentu

cky

Mississ

ippi

North

Car

olina

South

Car

olina

Tennes

see

Alabam

a

Florid

a

Georg

ia

Age-a

dju

sted p

erc

ent

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.

2010 target (US)

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 havebeen suppressed.Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, TennesseeSource: National Health Interview Survey (NHIS), Centers for Disease Control and Prevention, NCHS.

0

20

40

60

80

100

Ag

e-a

dju

sted

perc

en

t


Black/African American, not-Hispanic

Hispanic*White, not-Hispanic

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

2010 target (US)

0

20

40

60

80

100

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


United S

tate

s

Region

IV

Kentu

cky

Mississ

ippi

North

Car

olina

South

Car

olina

Tennes

see

Alabam

a

Florid

a

Georg

ia

Age-a

dju

sted p

erc

ent

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.

2010 target (US)

Race/ethnicity classification

Census Birth certificate- self-reported by mother

Death certificate Underestimation of deaths and death rates Hospital reporting method sometimes unclear

Race/Ethnicity classification

Self-reported- considered most reliable

Report by observation or proxy- may reflect misclassification

0

20

40

60

80Region IVUnited States



Hispanic**


Percent distribution of the population by specified race/ethnicity: United States and Region IV, 2000

*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, TennesseeSource: Census 2000 Summary File 1, US Bureau of the Census.

Perc

en

t

0

20

40

60

80

100

*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.


Percent of mothers who began prenatal care in the first trimester of pregnancy: United States and Region IV,

by specified race, 2000



Hispanic**


Perc

ent

2010 target (US)

0

25

50

75

100

125

150

175

*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, TennesseeSource: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS.


Chronic lower respiratory disease* death rates for people 45 years and older: United States and Region IV,

by specified race, 1999



Hispanic***


Age-a

dju

sted r

ate

per

10

0,0

00

standard

popula

tion

2010 target (US)

Revision of OMB standardsfor race/ethnicity

anymention!

0

20

40

60

80

100

Percent of children 19 to 35 months who arefully immunized*: United States and Region IV,

By specified race, 2000


Hispanic**White, not-HispanicAsian, not-Hispanic

Perc

ent

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.

2010 target (US)

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.

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.

0

5

10

15

20

25

30

35

Ag

e-a

dju

sted

perc

en

t

BRFSS NHANES**NHIS

Obesity* in adults 20 years and older:United States, 1999

For more information:

National Center for Health Statistics

www.cdc.gov/nchs

DATA2010wonder.cdc.gov/data2010

Healthy People 2010www.health.gov/healthypeople

dhhs office of civil rights title vi training conference philadelphia, pa august 13, 2002 using data...

Documents

prevention slide

persons of hispanic

tennessee slide

age adjustment slide

census data slide

sampling error slide

standard population

ageadjusted rates