dhhs office of civil rights title vi training conference philadelphia, pa august 13, 2002
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Using Data to Identify Disparities: Issues, Limitations, Cautions. DHHS Office of Civil Rights Title VI Training Conference Philadelphia, PA August 13, 2002. Richard J. Klein, MPH National Center for Health Statistics Centers for Disease Control and Prevention. D.C. - PowerPoint PPT PresentationTRANSCRIPT
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
Black/African American,not-Hispanic
American Indian/Alaska Native**
Hispanic***
White, not-HispanicAsian/Pacific Islander**
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.
Region IVUnited States
Diabetes death* rates: United States andRegion IV, by specified race, 1999
Black/African American,not-Hispanic
American Indian/Alaska Native**
Hispanic***
White, not-HispanicAsian/Pacific Islander**
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.
Region IVUnited States
Cerebrovascular disease (stroke)* death rates:United States and Region IV, by specified race, 1999
Black/African American,not-Hispanic
American Indian/Alaska Native**
Hispanic***
White, not-HispanicAsian/Pacific Islander**
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
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
*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
Region IVUnited States
Human immunodeficiency virus (HIV)* death rates:United States and Region IV, by specified race, 1999
Black/African American,not-Hispanic
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
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
*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
Black/African American,not-Hispanic
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
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
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
Region IVUnited States
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
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
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
Black/African American,not-Hispanic
American Indian/Alaska Native*
Hispanic**
White, not-HispanicAsian/Pacific Islander*
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.
Region IVUnited States
Percent of mothers who began prenatal care in the first trimester of pregnancy: United States and Region IV,
by specified race, 2000
Black/African American,not-Hispanic
American Indian/Alaska Native*
Hispanic**
White, not-HispanicAsian/Pacific Islander*
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.
Region IVUnited States
Chronic lower respiratory disease* death rates for people 45 years and older: United States and Region IV,
by specified race, 1999
Black/African American,not-Hispanic
American Indian/Alaska Native**
Hispanic***
White, not-HispanicAsian/Pacific Islander**
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
Black/African American,not-Hispanic
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