4/14/091 Community Health Assessment Part I: Measuring Health NMDOH Community Health Assessment...

4/14/09 1

Community Health Assessment Part I: Measuring Health

Community Health Assessment Part I: Measuring Health

NMDOH Community Health Assessment Program (CHAP)

New Mexico Department of Health4/14/09 2

OverviewOverview

Community Health Assessment– What is it?– Measurement basics– Common public health measures


Public Health AssessmentPublic Health Assessment

The core functions of government in public health:– 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.

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.


Assessment Function of Public Health

Assessment Function of Public Health

Assessment is the regular and systematic

collection,

assembly,

analysis, and

dissemination

of information about the health of a community.

Institute of Medicine (1988) The Future of Public Health, National Academies Press.


AssessmentAssessment“An understanding of the determinants of health and of the nature and extent of community need is a fundamental prerequisite to sound decision-making about health. Accurate information serves the interests both of justice and the efficient use of available resources. Assessment is therefore a core governmental obligation in public health.” (emphasis mine)

Institute of Medicine (1988) The Future of Public Health, National Academies Press.


HealthHealth

World Health Organization definition of health:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

WHO Definition of Health, downloaded from http://www.who.int/about/definition /en/print.html on 7/6/09.

http://www.who.int/about/definition/en/print.html



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Fundamental Considerations in Measuring Community

Health Status

Fundamental Considerations in Measuring Community

Health Status


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)




Clinical prevention, early detection– Certain conditions are interesting primarily

because they may be prevented or detected early, before complications arise (e.g., vaccine-preventable diseases, dental caries, breast cancer)

Mooney, A. and Rives, N.W. (1978). Measures of community health status for health planning. Hospital Research and Educational Trust, (Summer), pp 129-145.


Types of PreventionTypes 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)


Morbidity versus MortalityMorbidity 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.


Incidence Versus PrevalenceIncidence 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)


Measurement BasicsMeasurement Basics

Example: Age Distribution of This Class.1. On a blank sheet of paper, write your age. (If you

don’t want to divulge your age, you can write a different age.)

2. Arrange yourselves in the back and sides of the classroom, from youngest to oldest.

3. Where there is more than one person of the same age, stand in front of one another.

4. Where there are gaps, with no person of a certain age, leave a space for that age.


Age Distribution HistogramAge Distribution Histogram

Age Distribution of Community Health Assessment Class (This is a special type of bar chart, called a HISTOGRAM)

0

1

2

3

4

5

24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68

Age

Nu

mb

er o

f P

erso

ns Mean: 48.8Median: 41.5

Mode: 37


Age Distribution HistogramAge Distribution Histogram

Age Distribution of Community Health Assessment Class (This is a special type of bar chart, called a HISTOGRAM)

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24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68

Age

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er o

f P

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Distribution “Curve”Distribution “Curve”Age Distribution of Community Health Assessment Class

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24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68

Age

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Age Distribution of Community Health Assessment Class

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24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68

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Distribution “Curve”Distribution “Curve”


The “Normal” DistributionThe “Normal” Distribution


Measurement and “True Scores”


Why do we look at data?

– Sometimes we just use the number at face value.

“If one obstetrician can serve 100 pregnant women and the births of their babies in a given year, and our community has had 883 births, on average, in the last 5 years, then we will need to ensure availability of 9 O.B.s for the women of this community.”




– More often, we use the data to tell us something about RISK.

– Which of these communities has the higher diabetes death risk?

Community

2004-2006 Diabetes Deaths

2004-2006 Population

Size

2004-2006 Diabetes

Death Rate (Age-adjusted)

A 96 234,932 59.8

B 62 213,156 31.9




– Which of these communities has the higher diabetes death risk?

Community

2004-2006 Diabetes Deaths

2004-2006 Population

Size

2004-2006 Diabetes

Death Rate (Age-adjusted)

A 96 234,932 59.8

C 96 430,479 22.3


Measurement and True Scores


What has this got to do with measurement and true risk?– Each of the three communities in the previous

examples has an underlying risk for diabetes death.

– The 3 communities have different RISK levels because of a variety of factors, including lifestyle (diet and exercise), medical care (diagnosis and disease management), and other factors.




What has this got to do with measurement and true risk?– The OBSERVED number of diabetes deaths,

and the diabetes death rates are a MEASURE of the diabetes death RISK.

– The TRUE RISK is the actual risk level. It can not be measured directly. We use death data to estimate, or INFER the diabetes death risk.




What has this got to do with measurement and true risk?– While the actual risk changes slowly, in

response to changes in the contributing factors, the measure (observed diabetes deaths) can very considerably from year to year, especially in a small population.


Trend Lines for Two Communities


Diabetes Deaths per 100,000 Population by Year

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10

20

30

40

50

60

70

1999 2000 2001 2002 2003 2004 2005 2006

Year

Dea

ths

per

100

,000

Community X

Community Y


Calculating Some StatisticsCalculating Some Statistics

Counts– Incidence is the number of new cases (e.g., of

disease) in a given period of time. – Prevalence is the number of existing cases

(e.g., of a disease or risk factor) in a given period of time.


CountCount

1. Get a count of the prevalence of green M&Ms in your sample. (Count the green M&Ms.)



Rate– A rate is a fraction, in which the numerator is

the number of people (or M&Ms) among whom an event occurred during a certain period of time, and the denominator is the total number of people (or M&Ms) in the population at risk for the same period of time. Rates are typically multiplied by some factor of ten so that the result is a whole number.


RateRate

1. Count the green M&Ms.

2. Count the total number of M&Ms.

3. Divide the number of green M&Ms by the total number of M&Ms.

# Green M&Ms

Total # M&Ms in the package

Formula

8

25= 0.32

Example



Percentage– A percentage is a rate in which the quotient

is multiplied by 100.

1. Using your green M&M prevalence rate, multiply it by 100 to get the percentage of green M&Ms in your sample.


Confidence IntervalConfidence 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.





0

20

40

60

80

100

120

140

1999 2000 2001 2002 2003 2004 2005 2006

Year

Dea

ths

per

100

,000

Community X

Community Y

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Community Health Assessment Part 2:

Documenting Health Status


Documenting Health Status


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Assembling Data to Communicate for Community

Health Status

Assembling Data to Communicate for Community

Health Status


Population-BasedPopulation-Based

Population-based: Covers the entire population.– Population-based:

• Residents of New Mexico• Children in Mora County

– Why are these NOT Population-based?• Clinic patients• WIC recipients


Mortality Risk Inferred from Mortality Data

Mortality Risk Inferred from Mortality Data

Life expectancy

Death Rates

Years of Potential Life Lost– YPLL stands for "Years of Potential Life Lost," and is

a measure of premature mortality. It is calculated as the difference, across all persons in a population, between the actual age at death and age 65. It can also be calculated as the sum of the remaining years of life expectancy for all decedents in a population.


Morbidity Risk Inferred from Mortality Data

Morbidity Risk Inferred from Mortality Data

Cause-specific deaths– Diabetes-related deaths– Alcohol-related motor vehicle crash deaths– Heart disease deaths– Chronic liver disease and cirrhosis– Suicide deaths– Chronic obstructive pulmonary disease

(emphysema)


Calculating a Death RateCalculating a Death Rate



A rate has four components:– A specified time period.– The numerator, the number of people in whom an

event occurred during a given period of time, and– The denominator, the total number of people in the

population at risk for the same period of time. This is also referred to as the "person-years at risk."

– A constant. The result of the fraction is usually multiplied by some factor of 10 (such as 100,000), so that the rate may be expressed as a whole number.


The Numerator: Causes of Death


National Center for Health Statistics, 50 Leading Causes of Death– In order to provide a consistent ranking

standard the NCHS (National Center for Health Statistics, part of the CDC) prepared a list of 113 selected causes of death. The NCHS 50 leading causes of death are taken from the list of 113. For more information about the NCHS rankings, see Cause of Death Ranking on the NCHS website.


International Classification of Disease, Version 10 (ICD-10)International Classification of Disease, Version 10 (ICD-10)



The calculation for the death rate for Heart Disease in Region 1 looks like this:

1. Do the division:

2. Multiply by the ‘constant’:


Age-Specific RatesAge-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.


Age- and Sex- Specific RatesAge- and Sex- Specific Rates


Age-Adjusted RatesAge-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.


Morbidity Risk Inferred from Infectious Disease Data

Morbidity Risk Inferred from Infectious Disease Data

State law determines which diseases are reportable.

Examples include:– Sexually transmitted (Chlamydia, HIV)– Vector borne (West Nile, Hanta Virus)– Food borne (E. coli, Salmonella)– Other (Influenza, meningitis)


Morbidity Risk and Access to Care Inferred from Birth DataMorbidity Risk and Access to Care Inferred from Birth Data

Infant birth weight (high or low)

Teen births

Births to single mothers

Alcohol use during pregnancy

Late or no prenatal care

High-risk infants born at tertiary care facilities


Morbidity Risk Inferred from Health Surveys

Morbidity Risk Inferred from Health Surveys

Behavioral Risk Factor Surveillance System (BRFSS)– Smoking– Physical Activity, overweight

Pregnancy Risk Assessment and Monitoring System (PRAMS)– Intendedness of pregnancy– Health care coverage for prenatal care

Youth Risk and Resiliency Survey (YRRS)– Drug use, smoking– Suicidal thoughts


Morbidity Risk Inferred from Utilization and Treatment Data

Morbidity Risk Inferred from Utilization and Treatment Data Inpatient Hospital Discharges

– Diabetes– Influenza, pneumonia

Emergency Department Encounters– Injury and substance abuse– Mental health encounters

RPMS/IHS– Chronic conditions– Preventive clinical care


Disease RegistriesDisease Registries

Cancer Registry

Traumatic Brain Injury/ Spinal Cord Injury (TBI/SCI)

Chronic diseases (diabetes, asthma, hypertension)

Child blood lead


Other AgenciesOther Agencies

Public Education Department– HS dropout rates– free and reduced lunch (measure of poverty)

Children Youth and Families– Child abuse and neglect– Children in foster care

Department of Workforce Solutions– unemployment


Census BureauCensus Bureau

Age, Sex, Race composition of the population

Geographic distribution of the population

POPULATION DENOMINATORS


Getting IBIS to Calculate Your Rates

Getting IBIS to Calculate Your Rates

New Mexico’s Indicator-Based Information System for Public Health (NM-IBIS).

http://ibis.health.state.nm.ushttp://ibis.health.state.nm.us


Why “Indicator-Based?”Why “Indicator-Based?”

GAO found that comprehensive key indicator systems had positive effects in four areas:

– Enhanced collaboration to address public issues,

– Provided tools to encourage progress,

– Informed decision making and improved research,

– Increased public knowledge about key issues

Government Accountability Office (GAO). Informing Our Nation. Improving how to understand the USA’s position and Progress. November 2004. Accessed 1/5/2007 online at http://www.gao.gov/new.items/d051.pdf.

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Prioritizing Needs and Planning Interventions


Prioritizing Needs and Planning Interventions


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Thank You!Thank You!

Lois M. Haggard, PhD

Community Health Assessment Program

New Mexico Department of Health

505-827-5274

[email protected]

4/14/091 Community Health Assessment Part I: Measuring Health NMDOH Community Health Assessment...

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