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2. NM-IBIS: New Mexico’s Indicator-Based Information System for Public Health February 2014

3. Outline  Overview of NM-IBIS –What is it for? –Website organization Resources Indicator Reports Explore Datasets  Keys to Understanding the Data –Datasets –Measures (count, rate, aarate) –Variability and data stability 2/14/2014 New Mexico Department of Health3

4. Public Health  The role of government in public health:1 –To develop policy that supports the health of populations, e.g., –Notifiable diseases required by law –Environmental regulation (clean air, water, soil) –Traffic safety (seat belts, DUI) –Labeling food packaging for nutrients, fat and calories –Smoking in public places 2/14/2014 New Mexico Department of Health4 1.Institute of Medicine; Committee for the Study of the Future of Public Health; Division of Health Care Services (1988) The Future of Public Health. Washington, D.C.: National Academies Press. *The Institute of Medicine is a national health advisory institute chartered by the National Academy of Sciences.

5. Public Health  The role of government in public health: 1 1.To develop policy that supports the health of populations. 2.To assure access to health care and the quality of that care, e.g., –Practitioner licensing –Nursing facility inspection –Public health clinics, immunization –Medicaid program 2/14/2014 New Mexico Department of Health5 1.Institute of Medicine; Committee for the Study of the Future of Public Health; Division of Health Care Services (1988) The Future of Public Health. Washington, D.C.: National Academies Press. *The Institute of Medicine is a national health advisory institute chartered by the National Academy of Sciences.

6. Public Health  The role of government in public health:1 –To develop policy that supports the health of populations, –To assure access to health care and the quality of that care, and –To assess the health status of the population. 2/14/2014 New Mexico Department of Health6 1.Institute of Medicine; Committee for the Study of the Future of Public Health; Division of Health Care Services (1988) The Future of Public Health. Washington, D.C.: National Academies Press. *The Institute of Medicine is a national health advisory institute chartered by the National Academy of Sciences.

7. Public Health Assessment Assessment is the –regular and systematic –collection, –assembly, –analysis, and –dissemination of information about the health of a community. 2/14/2014 New Mexico Department of Health7 Institute of Medicine (1988) The Future of Public Health, National Academies Press.

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9. Getting to NM-IBIS  New Mexico’s Indicator-Based Information System for Public Health (NM-IBIS). 2/14/2014 New Mexico Department of Health9 http://ibis.health.state.nm.us

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21. 2/14/2014 New Mexico Department of Health 21 How Are We Doing? New Mexico Versus U.S. What Is Being Done? Other Program Information * Definition * Numerator * Denominator Data Interpretation Issues * Why Is This Important? * HealthyPeople Objectives Other Objectives Evidence-based Practices

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28. Review:  NM-IBIS facilitates public health assessment in New Mexico.  There are five top tabs on every NM-IBIS web page, Home, Indicator Reports, Explore Datasets, Resources, and Search.  The NM-IBIS Resources and Help pages are indexed under the “Glossary and Index” page.  NM-IBIS Indicator Reports are Web-based reports that provide a graph and contextual information for 100+ public health topics in New Mexico.  You can view NM-IBIS indicator reports by each specific indicator, or by groups of indicators for each county. New Mexico Department of Health 2/14/201428

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34. The Streetlight Effect Late at night, a police officer finds a man crawling around on his hands and knees under a streetlight. The man tells the officer he’s looking for his keys. When the officer asks if he’s sure this is where he dropped the keys, the man replies that he thinks he more likely dropped them across the street. “Then why are you looking over here?” the befuddled officer asks. “Because the light’s better here,” explains the man. 2/14/2014 New Mexico Department of Health 34

35. Measuring Community Health  Health Conditions: Medical, social, and economic –Not all “Health-related Conditions” are medical (e.g., poverty, education, environment)  Population at Risk –Include demographic measures to help identify at-risk populations within the community. (e.g., age, sex, language) 2/14/2014 New Mexico Department of Health 35

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39. Types of Prevention  Primary Prevention –Reducing the incidence of a condition (e.g., vaccine)  Secondary Prevention –Reducing the complications of an illness (e.g., treating high blood pressure)  Tertiary Prevention –Reducing levels of residual disability or other long- term effects, given that an illness has already occurred (e.g., managing diabetes) 2/14/2014 New Mexico Department of Health 39

40. Morbidity versus Mortality –Morbidity is another term for illness. Morbidities are not deaths, and occur among the population of living persons. Examples of morbidities include Alzheimer's disease, diabetes, and traumatic brain injury. –Mortality is another term for death. A mortality rate is the number of deaths due to a disease divided by the number of persons in the population. A mortality rate is typically multiplied by a factor of ten (e.g, 100,000) so that the rate may be expressed as a whole number. 2/14/2014 New Mexico Department of Health 40

41. Incidence Versus Prevalence –Incidence is the number of new cases (of disease) in a given period of time. (e.g., cancer incidence is the number of new cases of cancer during the time period) –Prevalence is the number of existing cases (e.g., of a disease or risk factor) in a given period of time. (e.g., prevalence of high blood pressure, prevalence of obesity) 2/14/2014 New Mexico Department of Health 41

42. Confidence Interval  A confidence interval is a range around a measurement that conveys how precise the measurement is. –the possible range around the estimate –how stable the estimate is A stable estimate is one that would be close to the same value if the measurement were repeated. An unstable estimate is one that would vary from one measurement to another. 2/14/2014 New Mexico Department of Health 42

43. Trend Lines for Two Communities 2/14/2014 New Mexico Department of Health 43

44. Trend Lines for Two Communities 2/14/2014 New Mexico Department of Health 44

45. Trend Lines for Two Communities 2/14/2014 New Mexico Department of Health 45

46. Calculating a Death Rate 2/14/2014 New Mexico Department of Health 46

47. The Numerator: Causes of Death 2/14/2014 New Mexico Department of Health 47

48. The Numerator: Causes of Death 2/14/2014 New Mexico Department of Health 48

49. The Numerator: Causes of Death 2/14/2014 New Mexico Department of Health 49

50. International Classification of Disease, Version 10 (ICD-10) 2/14/2014 New Mexico Department of Health 50

51. The Numerator: Causes of Death 2/14/2014 New Mexico Department of Health 51

52. Age-Specific Rates  Calculation of an age-specific rate is the same as for a crude rate. The only difference is that the count in both the numerator and the denominator is limited to a specific age group.  Other examples of “–specific” rates include ‘age- and sex-specific’ rates, ‘cause-specific’ death rates, ‘county- specific’ rates, etc. 2/14/2014 New Mexico Department of Health 52

53. Age- and Sex- Specific Rates 2/14/2014 New Mexico Department of Health 53

54. Age-Adjusted Rates  An age-adjusted rate is a measure that controls for the effects of age differences on health event rates. When comparing across geographic areas, years, or race/ethnic groups, some method of age-adjusting is typically used to control for the influence that different population age distributions might have on health event rates. 2/14/2014 New Mexico Department of Health 54

55. Birth Certificate Data  Where do the data come from? –As you may have guessed by the name, the birth certificate data come from birth certificates. –When a woman is in the hospital to give birth, she completes a worksheet that provides the demographic information for the birth certificate. –The institution (or mid-wife) completes a facility worksheet that provides information on characteristics of the infant and the birth. –A “birth clerk” in the hospital enters the information from the worksheets into an electronic birth registration system that transmits the information to the DOH Bureau of Vital Records and Statistics. –Staff in the Bureau of Vital Records and Statistics create an annual statistical file for use in health assessment and other research projects. New Mexico Department of Health 2/14/201455

56. Birth Certificate Data  How may the data be used? –Aggregate data are available in NM-IBIS indicator reports and the interactive query system. –Legal statutes protect the confidentiality of the data. –Data are made available to the public both through NM-IBIS and annual reports. New Mexico Department of Health 2/14/201456

57. Birth Certificate Data  Population-based? –Birth (and death) data from state vital records systems are some of the cleanest and most comprehensive datasets currently available. They are used for legal certification of birth (including citizenship), and are put through extensive checks for completeness and validity. –A national agreement for state interchange of vital records is in place to capture vital events that happen to New Mexico residents while visiting other states. –Most analysis of vital records in New Mexico filter the dataset to New Mexico residents, only. New Mexico Department of Health 2/14/201457

58. Birth Certificate Data  Data classification issues? –Mother’s race/ethnicity, self-reported on the birth questionnaire, is used as a proxy for infant’s race/ethnicity. –Gestational age is not always known, even by the mother or her obstetrician. Currently the OB’s estimate of gestational age is used when the mother’s last menstrual period date is unknown. –Month of initiation of prenatal care is not always known. –New Mexico “Small Area” is classified by geocoding the latitude and longitude of the mother’s address as recorded on the birth certificate. Some addresses (especially P.O. boxes) may not represent the mother’s actual residential location. However, the vital records data system obtains both physical and mailing addresses, so once again, these are some of the best, most valid data available to us. New Mexico Department of Health 2/14/201458

59. Death Certificate Data  Where do the data come from? –As the name implies, these data come from death certificates. –After a person dies, a staff member at the funeral home interviews the decedent’s next of kin and completes a death certificate questionnaire. This questionnaire is the source of the demographic information on the death certificate. –The cause of death certification must come from a medical doctor. A majority of cause of death certifications are filed by a relatively small number of physicians in New Mexico, those serving in hospitals, the medical investigator’s office, and physicians serving nursing homes and assisted living facilities. –One-third of New Mexico deaths, including all violent and unattended deaths, are certified by the Office of the Medical Investigator. This can be a time-consuming process, depending on the circumstances of death (autopsy, toxicology, etc.). –After the cause of death has been certified, the information is entered into New Mexico’s electronic death reporting system. –Staff in the Bureau of Vital Records and Statistics create a statistical file for use in health assessment and other research projects. New Mexico Department of Health 2/14/201459

60. Death Certificate Data  How may the data be used? –Aggregate data are available in NM-IBIS indicator reports and the interactive query system. –Legal statutes protect the confidentiality of the data. –Data are made available to the public both through NM-IBIS and annual reports. New Mexico Department of Health 2/14/201460

61. Death Certificate Data  Population-based? –Death (and birth) data from state vital records systems are some of the cleanest and most comprehensive datasets currently available. They are used for legal certification of death, and are put through extensive checks for completeness and validity. One of the funders of state death certificate data systems is the Social Security Administration. –A national agreement for state interchange of vital records is in place to capture vital events that happen to New Mexico residents while visiting other states. –Most analysis of vital records in New Mexico filter the dataset to New Mexico residents, only. New Mexico Department of Health 2/14/201461

62. Death Certificate Data  Data classification issues? –Underlying cause of death is coded (currently using the ICD-10 set of codes) from the attending physician’s “literal” or text entries on the death certificate. The physician records the underlying cause of death, as well as any contributing causes. An electronic system called Super-MICAR at the National Center for Health Statistics “reads” the text literals and automatically encodes cause-of-death data into numeric ICD-10 codes. Specialists called “nosologists” handle cases that Super-MICAR is not able to code cleanly. –Historically, there has been misclassification of decedents of non-White races into the “White” category. For whatever reason, New Mexico has not had the same extent of race misclassification as other states. New Mexico Department of Health 2/14/201462

63. Death Certificate Data  Data classification issues? (continued) –New Mexico “Small Area” is classified by geocoding the latitude and longitude of the decedent’s address as recorded on the death certificate. Some addresses (especially P.O. boxes) may not represent the decedent’s actual residential location. However, the vital records data system obtains both physical and mailing addresses, so once again, these are some of the best, most valid data available to us. New Mexico Department of Health 2/14/201463

64. Hospital Inpatient Discharge Data (HIDD)  Where do the data come from? –The HIDD are called, “administrative data,” because they originate from an administrative data system intended for a purpose other than public health surveillance. They originate from hospital billing records. –In order to bill a patient’s insurance company, Medicaid or Medicare, the hospital must include diagnosis and procedure codes. These billing records provide the public health community with valuable information about population morbidity. New Mexico Department of Health 2/14/201464

65. Hospital Inpatient Discharge Data (HIDD)  How may the data be used? –Aggregate data are available in NM-IBIS indicator reports and the interactive query system. –The individual, identified HIDD records are considered “protected health information” according to federal law (the Health Information Privacy and Accountability Act, or HIPAA). As such, they are of limited availability. –Data are made available to the public through NM-IBIS and annual reports. New Mexico Department of Health 2/14/201465

66. Hospital Inpatient Discharge Data  Population-based? –Unlike the Vital Records system, there is no national program for interstate exchange of hospital records. NMDOH works with hospitals in Texas, Colorado and Arizona to collect hospital records for New Mexico residents, but these efforts are still relatively new. HIDD data for New Mexico residents to visit out-of state hospitals are generally not included in our dataset, yet. –New Mexicans who visit IHS and VA inpatient facilities are not included in our HIDD dataset, yet. NMDOH is also working this angle. –“Inpatient” is defined as an overnight stay, so by definition, same-day discharges are not included. –An Emergency Department (ED) data system is in the works. New Mexico Department of Health 2/14/201466

67. Hospital Inpatient Discharge Data  Data classification issues? –Hospitals are still using the ICD-9 version of diagnosis codes, which are not always directly comparable to the ICD-10 codes used for death data. –Data fields necessary for billing are of better quality than data fields not required for accurate billing. External cause, place and circumstances of injuries have been a quality improvement focus for about 20 years and are generally very good, now. Race/ethnicity is a current focus, we’re getting there. There is a concern that hospitals’ diagnoses and procedures may be biased toward codes that generate more income. We don’t know how extensive this might be, but it is some consolation that it has probably been consistent over time. New Mexico Department of Health 2/14/201467

68. Hospital Inpatient Discharge Data  Data classification issues? (continued) –Small area. Hospital billing records collect mailing address, so the data records are often missing a street address. We are currently looking at the ability to code hospital data into small areas with enough certainty to be useful. New Mexico Department of Health 2/14/201468

69. Behavioral Risk Factors Surveillance System (BRFSS)  Where do the data come from? –The BRFSS survey is conducted using scientific telephone survey methods. Data are collected from a calling facility in the New Mexico Department of Health, using a random sample of all possible telephone numbers. –As with all surveys, some error results from nonresponse (e.g., refusal to participate in the survey or to answer specific questions) and measurement (e.g., social desirability or recall bias). Error was minimized by use of strict calling protocols (up to 15 calls were made to reach each household), good questionnaire design, standardization of interviewer behavior, interviewer training, and frequent, on-site interviewer monitoring and supervision. New Mexico Department of Health 2/14/201469

70. Behavioral Risk Factors Surveillance System (BRFSS)  How may the data be used? –Aggregate data are available in NM-IBIS indicator reports and the interactive query system. –The BRFSS data are not considered protected health information, and there are no legal statutes governing their distribution. However, the NMDOH has an ethical obligation to the survey respondents to protect the confidentiality of the data. –Data are made available to the public through NM- IBIS and annual reports. New Mexico Department of Health 2/14/201470

71. Behavioral Risk Factors Surveillance System (BRFSS)  Population-based? –The BRFSS survey represents adults age 18 and over. –Adults living in group quarters such as college dormitories, nursing homes, military barracks, and prisons are excluded. Prior to 2011, adults living in households without a landline telephone were excluded. –Prior to analysis, data are weighted to represent the population distribution of adults by sex, age group, and area of residence. –Beginning in 2011, the data weighting method changed from a method called "post-stratification" to a method called "Raking." The two time periods (2010 and before versus 2011 and later) cannot be combined or compared. New Mexico Department of Health 2/14/201471

72. Behavioral Risk Factors Surveillance System (BRFSS)  Data classification issues? –The data collection and weighting methods were not intended for county-level analysis. We think it’s probably okay to analyze the data at the county level, but the consumer must realize that if the data were re-weighted at the county level, the results would probably change slightly. –Respondents are not asked for their addresses, so the data cannot be analyzed by New Mexico Small Area. –All data items are self-report. There have been numerous studies over the years to examine the validity of the BRFSS data, and the data validity holds up quite well. New Mexico Department of Health 2/14/201472

73. Youth Risk and Resiliency Survey (YRRS)  Where do the data come from? –YRRS data come from paper-and-pencil survey questionnaires administered in New Mexico high schools and middle-schools across the state every two years (odd- numbered years). New Mexico Department of Health 2/14/201473

74. Youth Risk and Resiliency Survey (YRRS)  How may the data be used? –Aggregate data are available in NM-IBIS indicator reports and the interactive query system. –The YRRS data are not considered protected health information, and there are no legal statutes governing their distribution. However, the NMDOH has an ethical obligation to the survey respondents to protect the confidentiality of the data. –Data are made available to the public through NM-IBIS and bi- annual reports. New Mexico Department of Health 2/14/201474

75. Youth Risk and Resiliency Survey (YRRS)  Population-based? –A statewide sample provides New Mexico data to be included in a nationwide sample. New Mexico supplements the statewide sample with individual county and race/ethnicity oversamples. –Prior to analysis, the data are weighted to represent New Mexico (statewide or county-level, depending on the sample being used). –Occasionally, a school district refuses to participate in the YRRS survey. Data limitations will typically be noted. New Mexico Department of Health 2/14/201475

76. Youth Risk and Resiliency Survey (YRRS)  Data classification issues? –Respondents are not asked for their addresses, so the data cannot be analyzed by New Mexico Small Area. –All data items are self-report. Studies suggest the data validity is generally good. New Mexico Department of Health 2/14/201476

77. Pregnancy Risk Assessment and Monitoring Survey (PRAMS)  Where do the data come from? –These data derive from mail (paper-and- pencil) and telephone surveys with women who recently gave birth. The survey sample comes from the birth certificate dataset. New Mexico Department of Health 2/14/201477

78. Pregnancy Risk Assessment and Monitoring Survey (PRAMS)  How may the data be used? –Aggregate data are available in NM-IBIS indicator reports and the interactive query system. –The PRAMS data are not considered protected health information, and there are no legal statutes governing their distribution. However, the NMDOH has an ethical obligation to the survey respondents to protect the confidentiality of the data. –Data are made available to the public through NM-IBIS and annual reports. New Mexico Department of Health 2/14/201478

79. Pregnancy Risk Assessment and Monitoring Survey (PRAMS)  Population-based? –Yes. A representative sample is drawn from all live births in the state. –Prior to analysis, data are weighted to represent the pregnancy and delivery experiences of all women giving birth in New Mexico. New Mexico Department of Health 2/14/201479

80. Pregnancy Risk Assessment and Monitoring Survey (PRAMS)  Data classification issues? –All data items are self-report. We believe the validity is generally good. –The sample is not as large as the other surveys, so county-level and analysis is not available. –Race/ethnicity information is collected, but the sample size does not allow for analysis of smaller race/ethnic groups. New Mexico Department of Health 2/14/201480

81. Notifiable Disease Reporting  Where do the data come from? –The list of notifiable conditions is in state statute, available online,here: http://nmhealth.org/erd/healthdata/documents/Notifiab leDiseasesConditions022912final.pdf http://nmhealth.org/erd/healthdata/documents/Notifiab leDiseasesConditions022912final.pdf –Physicians and labs throughout the state report conditions to the New Mexico Department of Health. –Most reports are obtained from laboratories who have processed a positive test result for a notifiable condition. New Mexico Department of Health 2/14/201481

82. Notifiable Disease Reporting  How may the data be used? –Aggregate data are available in NM-IBIS indicator reports and the interactive query system. –The individual data records are considered “protected health information” according to federal law (the Health Information Privacy and Accountability Act, or HIPAA). As such, they are of limited availability. –Data are made available to the public through NM- IBIS and annual reports. New Mexico Department of Health 2/14/201482

83. Notifiable Disease Reporting  Population-based? –Representativeness of the data varies based on: Disease severity (polio more likely than giardia). Case severity (bad case of giardia more likely than a mild case) Lab testing Other factors New Mexico Department of Health 2/14/201483

84. Notifiable Disease Reporting  Data classification issues? –Race/ethnicity information is often unavailable. –Data are not geocoded, and are not available by small area. New Mexico Department of Health 2/14/201484

85. New Mexico’s Indicator Based Information System (NMIBIS) New Mexico Community Data Collaborative New Mexico’s Environmental Public Health Tracking CDC WONDER United States Census American FactFinder County Health Rankings Community Health Commons Share New Mexico NM Kids Count Data Center New Mexico Department of Health 2/14/201485 Publically Available Data

86. THANK YOU!! Sam Swift, MPH Community Health Assessment Program Epidemiology and Response Division New Mexico Department of Health (505) 827-5274 lois.haggard@state.nm.us New Mexico Department of Health 2/14/201486