The Role of Vital Statistics in Community Health Assessment: Examples from Massachusetts

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The Role of Vital Statistics in Community Health
Assessment Examples from Massachusetts

• AI-NAPHSIS Conference
• September 2004
• Bruce Cohen, Ph.D, co-director
• Center for Health Information Statistics
• Massachusetts Department of Public Health

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Context

• Massachusetts has the oldest ongoing Vital
  Statistics program in the US
• Structure in MDPH allows for interplay of
  research and legal registration functions for
  RVRS and we continue to push the applications of
  Vitals data
• Trends in Massachusetts--online data base
  development, aging of birth cohort, relatively
  open access to mortality data, historically
  expanded items on birth birth certificate, new
  developments in Vitals--yield broad community uses

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Outline of todays presentation...

• Vitals for general community surveillance
• geographic variation in premature mortality rates
  as an example of using vitals to develop a robust
  indicator of community health
• MassCHIP getting Vitals data out to the
  community for planning and program development
• Special projects pushing the frontier
• ethnicity variation in perinatal indicators
  maximizing the use of birth certificate data to
  track disparities
• emerging research agenda around fertility
  assistance research using birth certificate data

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Using Vitals Data for General Community
Surveillance...
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Deaths from Selected Causes Massachusetts
1842-2002
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Community Health Assessment Using Premature
Mortality Rates (PMR) an application of vital
statistics for ranking communitys overall health
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PMR Background

• More than 6 out 10 deaths in Massachusetts occur
  to people age 75 and older
• Although quality of life for our older citizens
  is important, we wanted to develop a measure that
  focused on the health of younger persons
• Why? The rationale is that the vast majority of
  deaths to persons age 75 and older are due to
  chronic conditions associated with aging whereas
  
• It may be possible to identify many issues that
  are more amenable to systematic public health
  approaches to health promotion and disease
  prevention by focusing on a younger population
• THE PMR is considered an excellent single measure
• Sometimes used as an indicator of health care need

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PMR Definition, Properties and Features

• The number of deaths to persons age 0-74 divided
  by the population age 0-74 (per 100,000)
• Age adjusted to the 2000 US standard population,
  age 0-74
• Data used to calculate the PMR are readily
  available (mortality and age of population)
• Easily understandable and intuitive
• Moves away from considering single causes or
  single risk factors to a broader community
  perspective

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PMR Properties and Features, continued

• PMR may be related to socioeconomic status and
  its correlates environmental conditions,
  housing, education, stress, higher rates of
  smoking, substance abuse, violence, obesity, and
  lack of access to care
• Other possible reasons for high PMR specific
  subpopulations of younger persons at risk such as
• HIV/AIDS in Provincetown
• increased motor vehicle deaths in rural areas
• heart attack deaths in persons 45-64 in suburbia

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Lowest PMR Amherst
Highest PMRHolyoke
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Highest PMR Somerville
Lowest PMR Weston
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Highest Premature Mortality Rates for Selected
Communities, MA 1999-2002
Community of deaths
PMR/100,000 (age-adjusted)
SPRINGFIELD 2,509 490.9 LOWELL 1,601 474.6
WORCESTER 2,793 473.1 LYNN 1,465 471.1 B
ROCKTON 1,515 460.7 FALL RIVER 1,567 453.0
NEW BEDFORD 1,605 449.4 BOSTON 8,007 436.0
LAWRENCE 890 422.6 ATTLEBORO
636 418.2 CHICOPEE 952 416.5 MALDEN
865 410.9 REVERE 782 410.3 TAUNTON
829 408.5 SOMERVILLE 935 400.9
Massachusetts 346.1 Selected among the 30
largest communities. ( statistically
significant, p lt 0.05)
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Lowest Premature Mortality Rates for Selected
Communities, MA 1999-2002
Community of deaths
PMR/100,000 (age-adjusted)
BROOKLINE 433 213.6 NEWTON 732 218.2
ARLINGTON 502 277.1 BARNSTABLE 685 303.8
FRAMINGHAM 786 313.3 CAMBRIDGE 957 323.7
PEABODY 726 332.5 WALTHAM 731 339.3 METHUE
N 569 341.0 MEDFORD 783 344.8
Massachusetts 346.1 Selected among the 30
largest communities. ( statistically
significant, p lt 0.05)
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Median Household Income and PMR by EOHHS Regions,
MA 1999-2002
State Median Household Income 66,365
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Less than High School Education and PMR by EOHHS
Regions, MA 1999-2002
Less than High School Education for MA 9.4
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Families Living lt 100 Poverty and PMR by EOHHS
Regions, MA 1999-2002
Families Living lt 100 Poverty for MA 6.7
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PMR Limitations

• PMR does not identify specific reasons why some
  areas may be high or low
• Summary measures may sometimes obscure important
  subgroup differences
• Mortality might not be a good measure of
  important public health issues (e.g. arthritis,
  poor housing, etc.)

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Providing Rapid Online Access to Vital Statistics
Data for Community Needs Assessment MassCHIP (
the Massachusetts Community Health Information
Profile)
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The Role of Vital Statistics in Community Health
Assessment examples from Massachusetts

• Center for Health Information Statistics
• Massachusetts Department of Public Health

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MassCHIP(Massachusetts Community Health
Information Profile)

• Free, on-line interactive data dissemination
  system - 28 major data sets
• 2 types of reports - pre-defined and user-defined
• basic unit of geography is city/town
• provides counts, basic statistics, charts and
  maps
• vital statistics data are core data sets - birth
  and death data appear in 27 of 37 pre-defined
  (Instant Topic) reports
• Current application is client-server - must be
  downloaded onto users computer
• Currently transitioning to fully web-based system

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Who Uses MassCHIP?
Out-of-Country

• Bangladesh
• Canada
• Egypt
• Jamaica
• Nigeria

• Pakistan
• Philippines
• Sweden
• Tunisia

Out-of-Massachusetts
39 States-850 users - out of about 8,000 total
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Massachusetts MassCHIP Users

• Providers (Hospitals, Neighborhood Health
  Centers)
• Press
• Small Community non-profit Organizations
• Universities
• DPH Staff
• Private for-profit Organizations
• Other State Agencies
• Individuals

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What Questions does MassCHIP Answer - Instant
Topic Reports

• Available through website - no need to download
  client
• Convenient summary - accessible with 3-4 clicks
  of a mouse
• 7 reports focused on vital events (perinatal,
  perinatal trends, minority births/perinatal data,
  minority mortality data, mortality ranking,
  mortality trends, MCH 2010 Objectives)
• Reports contain latest available year or years of
  data

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What Questions does MassCHIP Answer - User
Queries?

• Shows trends over time (e.g., infant mortality by
  race/Hispanic ethnicity)
• Birthweight - specific mortality rates by
  race/ethnicity (with 95 confidence intervals -
  uses linked birth-death file)
• Allows users to examine association of maternal
  behaviors and birth outcomes (e.g., maternal
  smoking and low birthweight by maternal age)
• Allows comparisons of mortality rates by cause
  (e.g., breast and lung cancer mortality among
  women)

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Utilization of Vitals Data in MassCHIP

• Nearly half of all user-defined queries use Vital
  Statistics data (of about 30,000 queries
  annually)
• Two-thirds of all Instant Topic use references
  Vital Statistics (of about 30,000 accesses
  annually)
• Birth file the most frequently accessed
  mortality fourth most frequently accessed

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DPH Uses of Vitals Data in MassCHIP

• Data requirements for the MCH Block Grant and
  Annual Report
• Tracking progress of MCH HP2010 objectives
• Surveillance of targeted initiatives (e.g., teen
  birth prevention, smoking cessation,
  cardivascular disease, cancer, asthma) and
  monitoring of health outcome disparities
• Identifying community issues

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Special Projects Extending the Use of Vital
Statistics Data...
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Monitoring Health Disparities Tracking Ethnicity
Variation in Perinatal Outcomes
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Why Focus on Ethnicity?

• Data indicate that there is more variation within
  broad race groups than between them
• More useful for targeting and program development
• Reflects meaningful issues related to public
  health practice
• Categories less determined by socio-politics and
  more consistent over time more meaningful? less
  ambiguous?

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Minority Perinatal Health Studies Populations
Asian
Hispanic
Black
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Percentage of Preterm Births by Race/ Hispanic
Ethnicity, MA 2000
Source MA Department of Public Health, Center
for Health Statistics, Research and Evaluation
Preterm gestational age less than 37 weeks
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Percentage of Preterm Births among Black
Infants by Ethnicity,MA 1997-2000
Source MA Department of Public Health, Center
for Health Statistics, Research and Evaluation
Preterm gestational age less than 37 weeks
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Adequate Prenatal Care by Race and Hispanic
Ethnicity, MA 2000
Source MA Department of Public Health, Center
for Health Statistics, Research and Evaluation
Adequate prenatal care is a measure of the
timing and number of prenatal care visits. Based
on Kessner Index.
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Adequate Prenatal Care among Asian Mothers by
Ethnicity,MA 1996-1997
Source MA Department of Public Health, Center
for Health Statistics, Research and Evaluation
Adequate prenatal care is a measure of the
timing and number of prenatal care visits. Based
on Kessner Index.
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Spanish Language Preference among Hispanic
Mothers by Ethnicity, MA 1997-2000
Source MA Department of Public Health, CHISRE
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Percent of Mothers Breastfeeding by
Race/Ethnicity, Massachusetts
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Percent of Asian Mothers Breastfeeding, by
Ethnicity, Massachusetts
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Percent of Mothers Breastfeeding, by Hispanic
Ethnicity, Massachusetts
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Percentage of Black Mothers Breastfeeding by
Ethnicity, Massachusetts
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Percent of Asian Mothers Breastfeeding, by
Ethnicity, Massachusetts
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Expanded MDPH option for the Collection of Race
and Ethnicity Data

• Closed-ended detailed race-ethnicity data
  collection added ethnicity question
• 2. What is your ethnicity? (please select one or
  more)
• ? African ? European, other
• African American ? Filipino
• American ? Latin American Indian
• Asian Indian ? Haitian
• Brazilian ? Japanese
• Cambodian ? Korean
• Cape Verdean ? Laotian
• Caribbean Islander (specify) ? Middle Eastern
• Chinese ? Portuguese
• Eastern European ? Vietnamese
• Russian ? Other (specify____________)

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Developing a New Role for Birth Certificate Data
Crafting an Emerging Research Agenda Around
Fertility Assistance...
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Background

• Massachusetts has the third highest number of
  Assisted Reproductive Techonology procedures
  (ART) performed in US and highest rate (MMWR,
  4/30/04)
• Massachusetts has the highest multiple birth rate
  in US
• On the MA certificate of live birth, there are
  check boxes for use of ART and fertility drugs
  (FD)
• Massachusetts provides full access to
  confidential data for perinatal research purposes

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Two projects underway

• Joint research project with the CDC Division of
  Reproductive Health to link birth certificate
  data with all Massachusetts fertility clinic data
  to create a population-based cohort to examine
  risks and outcomes of ART use
• Joint research project with NICHD and UMass
  Amherst to examine the quality of birth
  certificate data on FD/ART

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Objectives of CDC Project

• To link information from CDCs assisted
  reproductive technology (SART) surveillance data
  files with Massachusetts state birth records
• To create the first US comprehensive,
  population-based dataset of ART mother-infant
  pairs which will include data on
• detailed circumstances surrounding conception
  (SART data)
• delivery and maternal and infant outcomes (birth
  certificate data

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Advantages of linked data file

• Linked dataset would allow for evaluation of ART
  mother-infant pairs in context of a US
  population
• ability to analyze various maternal and infant
  outcomes, including infant mortality
• proper controls for confounding factors and a
• comparison group of non-ART births from MA
  birth cohort
• detailed data on specific ART procedures linked
  to outcomes
• potential for further file linkage and trend
  analyses and longer term follow-up

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Timeline

• Receive permission for project after CDC and MDPH
  review July 2001
• Develop, test and implement computer linkage
  algorithms summer 2001- spring 2002
• Contact clinics for information to increase
  linkage rate and validate algorithm fall
  2001-summer 2002
• Create and finalize linked file for 1997-1998
  births winter, 2002
• Develop detailed analytic plans winter
  2002-fall, 2003
• Began analysis Winter 2004
• Completing linkage of 1999-2000 data Summer 2004

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Methods Study Population

• Data from live births reported to ART Registry
  were linked to the study population if
• ART treatment was in a MA or RI clinic (11
  clinics total)
• Infant(s) born in 1997 or 1998
• Maternal residency at time of ART listed as MA or
  unknown (because a large proportion , 45, were
  missing residency data).
• N3704 total infants
• 2703 deliveries

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Data Linkage Strategy

• STAGE 1
• link ART record to birth record using mothers
  date of birth and infants date of birth
• further evaluate records that link using other
  variables in common to the data sets --
  plurality, parity and birth weight
• STAGE 2
• further linkage by maternal name name data for
  a portion of records obtained through follow-up
  with ART clinics

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Final Match Rate by Clinic Size
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Possible Reasons for Non-Match

• 1) Patient received treatment in MA but actually
  lived in another state. This is likely to have
  been the case with patients who reported state of
  residency as unknown.
• 2) Patient was MA resident at the time of ART
  treatment but moved before delivery i.e.
  migration.
• 3) Misclassification/data entry error of state of
  residency by clinics default entry of MA.
• 4) Residency may have been recorded as MA for
  some couples who worked in MA and received MA
  benefits but lived in a surrounding state.
• 5) For some records, name data were not available
  from clinics, and therefore linkage status could
  not be verified or remained unknown (I.e. true
  matches that could not be reconciled).

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Sensitivity Analyses of Linkage Rate

• Final match rate 2413/2703 89.3
• If we assume
• Residency unknown 87.75 MA residents 12.25
  non-residents among unknown residency status and
  migration rate between ART and birth was 2.5
• Projected true match rate is changed to
  2441/2491 98

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Future Plans

• Data analysis of specific topics using linked
  data file.
• Expand project to include more recent years
• Explore linkages with other data sources such as
  hospital discharge data base

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Objectives of Joint NICHD Project

• To evaluate the quality of the FD/ART data
  provided on the hospital work sheet
• To review hospital procedures for ascertainment,
  completion, and submission of FD/ART variables to
  the RVRS
• To evaluate 1) if these variables provide a
  useful frame work to pursue FD/ART research 2)
  if not, recommend how to collect this information
  to improve quality of the data

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NICHD Project--Study 1, Methods

• identify cohort of births for whom use of ART/FD
  was indicated on birth certificate
• identify cohort of births where FD/ART use
  likely, but not reported (higher order multiple
  births and first births to older women)
• develop survey instrument to collect information
  on fertility treatment and perform survey

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NICHD Project--Study 1 Timeline and Issues

• Currently in final stages of MDPH approval of
  project
• Survey instrument developed CATI programmed
• Designing sample
• Field work scheduled Summer 2004-Winter
• Analysis early 2005
• Data collected from providers on hospital work
  sheet vs. from parents in survey

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NICHD Project--Study 2

• Review process of the completion of hospital work
  sheet prenatal care procedures check boxes for FD
  and ART
• document process of completion
• contact sample of hospitals and interview
  appropriate staff about issues--where are the
  data found in record? Who records? etc...

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Summary Birth Certificate Fertility Related
Research

• Massachusetts is currently involved in two
  projects using birth certificate data for
  research and evaluation of FD/ART
• This is an important and rapidly expanding use of
  birth data
• If we can accurately identify FD/ART use from bc,
  then many avenues of cross-sectional and
  longitudinal research can be implemented that
  will enable us to better understand the outcomes
  of fertility treatment assisted births

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Overall Conclusions

• Vital statistics are a robust source of
  information--they are available everywhere and
  there is more consensus on definitions than for
  most data sources
• Given the number of events, vitals can be used
  for broad, general,- trend surveillance as well
  as for local level community-focused planning
• Be creative expand the use of Vitals!