DHHS Office of Civil Rights Title VI Training Conference Philadelphia, PA August 13, 2002 Using Data to Identify Disparities: Issues, Limitations, Cautions Richard J. Klein, MPH National Center for Health Statistics Centers for Disease Control and Prevention

Public Health Service Region IV 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

*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 100,000 population

*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 rate Age-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 100,000 population

*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. 15 Leading causes of death, 1999

*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. Region IV United States Diabetes 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-adjusted rate per 100,000 standard population 2010 target (US)

Diabetes death* rates: United States and Region IV States, by race, 1999 Black/African AmericanTotal population United States Region IV Kentucky Mississippi North Carolina South Carolina Tennessee Alabama Florida Georgia *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-adjusted rate per 100,000 standard population 2010 target (US)

Cause of death classification

*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. 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-adjusted rate per 100,000 standard population 2010 target (US)

Cerebrovascular disease (stroke)* death rates: United States and Region IV States, by race, 1999 Black/African AmericanTotal population United States Region IV Kentucky Mississippi North Carolina South Carolina Tennessee Alabama Florida Georgia *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-adjusted rate per 100,000 standard population 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, Tennessee Source: National Vital Statistics System (NVSS), Centers for Disease Control and Prevention, NCHS. Age-adjusted rate per 100,000 standard population 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)

Human immunodeficiency virus (HIV)* death rates: United States and Region IV States, by race, 1999 Black/African AmericanTotal population United States Region IV Kentucky Mississippi North Carolina South Carolina Tennessee Alabama Florida Georgia *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-adjusted rate per 100,000 standard population 2010 target (US)

Data reliability

Region IVUnited States Percent of people under 65 years with health insurance coverage: 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, Tennessee Source: National Health Interview Survey (NHIS), Centers for Disease Control and Prevention, NCHS. Age-adjusted percent 2010 target (US)

Percent of people under 65 years with health insurance coverage: United States and Region IV States, by race, 2000 Black/African AmericanTotal population United States Region IV Kentucky Mississippi North Carolina South Carolina Tennessee Alabama Florida Georgia Age-adjusted percent 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 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 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. Age-adjusted percent Region IV United 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, target (US)

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 States Region IV Kentucky Mississippi North Carolina South Carolina Tennessee Alabama Florida Georgia Age-adjusted percent 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 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

Region 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, Tennessee Source: Census 2000 Summary File 1, US Bureau of the Census. Percent

*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* Percent 2010 target (US)

*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. 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-adjusted rate per 100,000 standard population 2010 target (US)

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 Black/African American, not-Hispanic Hispanic**White, not-HispanicAsian, not-Hispanic Percent 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 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 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. Age-adjusted percent BRFSSNHANES**NHIS Obesity* in adults 20 years and older: United States, 1999

For more information: National Center for Health Statistics DATA2010 wonder.cdc.gov/data2010 Healthy People