Measuring Healthy Measuring Healthy People 2010 People 2010 Objectives: Objectives: Methodologic and Methodologic and Definitional IssuesDefinitional Issues

Kathleen M. Turczyn, Michael Molla, Manon Kathleen M. Turczyn, Michael Molla, Manon Boudreault, Erin Reidy, Insun Kim, Leda Boudreault, Erin Reidy, Insun Kim, Leda Gbetibouo, Suzanne ProctorGbetibouo, Suzanne Proctor

National Center for Health StatisticsNational Center for Health Statistics

Data Users ConferenceData Users Conference

July 13, 2004July 13, 2004

Examples of Examples of Methodologic and Methodologic and Definitional IssuesDefinitional Issues

Coding Coding classifications classifications (ICD-9 to ICD-10)(ICD-9 to ICD-10)

Revisions to OMB Revisions to OMB standards for standards for race and ethnicity race and ethnicity classificationclassification

Changes in age-Changes in age-adjustment adjustment groupsgroups

Data source Data source changes changes including including question question wordingwording

Preliminary Preliminary analysis made analysis made finalfinal

New scientific New scientific findingsfindings

Four ExamplesFour Examples

Objective 5-12: Glycosolated Objective 5-12: Glycosolated hemoglobin measureshemoglobin measures

Objective 27-10: Exposure to Objective 27-10: Exposure to environmental tobacco smokeenvironmental tobacco smoke

Objective 24-4: Activity Objective 24-4: Activity limitations among persons with limitations among persons with asthma asthma

Goal 1: Increase quality and Goal 1: Increase quality and years of healthy lifeyears of healthy life

Objective 5-12Objective 5-12

Increase the proportion of Increase the proportion of adults with diabetes who adults with diabetes who have a glycosylated have a glycosylated hemoglobin measurement at hemoglobin measurement at least once a year.least once a year.

Measurement Measurement issuesissues Original baseline from 1998 BRFSS; Original baseline from 1998 BRFSS;

questions changed in 2000questions changed in 2000

Substantial increase in people with Substantial increase in people with diabetes getting A1C tests (testing diabetes getting A1C tests (testing recommendations changed)recommendations changed)

To include or exclude “Never heard To include or exclude “Never heard of A1C test” in the denominator in of A1C test” in the denominator in 20002000

Ever been told by a doctor that Ever been told by a doctor that you have diabetes (for females, you have diabetes (for females, exclude if told only when exclude if told only when pregnant)pregnant)

Denominator for 1998 Denominator for 1998 and 2000and 2000

Have you ever heard of Have you ever heard of glycosylated hemoglobin or glycosylated hemoglobin or hemoglobin A1C? [Yes]hemoglobin A1C? [Yes]

About how many times in the last About how many times in the last year have you seen a doctor, … for year have you seen a doctor, … for your diabetes? [One or more times]your diabetes? [One or more times]

About how many times in the last About how many times in the last year has a doctor, … checked you year has a doctor, … checked you for glycosylated hemoglobin or for glycosylated hemoglobin or hemoglobin A1C?hemoglobin A1C?

1998 Numerator 1998 Numerator QuestionsQuestions

About how many times in the past 12 About how many times in the past 12 months have you seen a doctor, … for months have you seen a doctor, … for your diabetes one or more times in the your diabetes one or more times in the last yearlast year

A test for hemoglobin A1C measures the A test for hemoglobin A1C measures the average level of blood sugar over the past average level of blood sugar over the past three months. About how many times in three months. About how many times in the past 12 months has a doctor, … the past 12 months has a doctor, … checked you for hemoglobin A1C? checked you for hemoglobin A1C?

•Answer categories include “Never heard Answer categories include “Never heard of A1C.”of A1C.”

2000 Numerator 2000 Numerator QuestionsQuestions

Why changes in Why changes in question wording?question wording? 1998 questions were confusing to 1998 questions were confusing to

respondents -- too many termsrespondents -- too many terms

Public health educators wanted Public health educators wanted people with diabetes to know people with diabetes to know specifically about the A1C lab testspecifically about the A1C lab test

Funding issue: The change Funding issue: The change shortened the questionnaire from shortened the questionnaire from 3 to 2 questions3 to 2 questions

Evolution of the Evolution of the EstimatesEstimates

Year Standard of care testing

Number of annual

Hemoglobin A1C tests

Incl “Never heard of A1C” in

denominator

Estimate

1998 Type I only 1+ 1 24%

2000 All Types 1+ 88%

2000 All Types 1+ 85%

2000 All Types2+ (new

guidelines) 63%

2000 All Types2+ (new

guidelines)

59% age-

adjusted

1Respondents who had “Never heard of A1C” were not asked about tests.

Final Final ResolutionResolution Change the measure of the objective from Change the measure of the objective from

“one or more” to “two or more…”“one or more” to “two or more…”

Change the baseline year from 1998 to Change the baseline year from 1998 to 20002000

New baseline is 59% using age-adjustment New baseline is 59% using age-adjustment groups for chronic conditions more groups for chronic conditions more prevalent among older age categoriesprevalent among older age categories

Target will be changed to reflect new dataTarget will be changed to reflect new data

Objective 24-4Objective 24-4

Reduce activity Reduce activity limitations among limitations among persons with asthmapersons with asthma

Intent of ObjectiveIntent of Objective

Earlier NHIS questionnaires Earlier NHIS questionnaires were not set up to capture were not set up to capture the actual intent of the actual intent of objective: to reduce activity objective: to reduce activity limitation limitation due to asthmadue to asthma among persons with asthmaamong persons with asthma

1997 NHIS 1997 NHIS Questionnaire Questionnaire ChangesChanges Asthma questions changedAsthma questions changed

Questions about “limitation of Questions about “limitation of activity” changedactivity” changed

Objective 24-4 was no longer Objective 24-4 was no longer measurable with former measurable with former questionsquestions

Changes in Asthma Changes in Asthma QuestionsQuestions

Pre-1997: Pre-1997:

• During the past 12 months, did anyone in the During the past 12 months, did anyone in the family {names} have asthma?family {names} have asthma?

1997+:1997+:

• Have you/{child’s name} EVER been told by a Have you/{child’s name} EVER been told by a doctor or other health professional that doctor or other health professional that you/{child’s name} had asthma?you/{child’s name} had asthma?

• Do you/Does {child’s name} still have asthma?Do you/Does {child’s name} still have asthma?

• Have you/Has {child’s name} had an asthma Have you/Has {child’s name} had an asthma episode or asthma attack within the last year?episode or asthma attack within the last year?

Changes in Activity Changes in Activity Limitation QuestionsLimitation Questions

Pre-1997:Pre-1997: Questions on Questions on limitation of activity due to limitation of activity due to “impairment or health problem”“impairment or health problem”

1997+:1997+: Questions on functional Questions on functional limitations due to “physical, limitations due to “physical, mental, or emotional problems” mental, or emotional problems” and receipt of services (children)and receipt of services (children)

Original 1994-96 Original 1994-96 BaselineBaseline Numerator: Persons who report Numerator: Persons who report

having asthma and activity having asthma and activity limitation in past yearlimitation in past year

Denominator: Persons who Denominator: Persons who report having asthma in past report having asthma in past yearyear

Baseline: 20%Baseline: 20%

New 1997 BaselineNew 1997 Baseline

Numerator: Persons who report Numerator: Persons who report having an asthma episode or attack having an asthma episode or attack in the past year who are limited in in the past year who are limited in activity due to a respiratory activity due to a respiratory problemproblem

Denominator: Persons who report Denominator: Persons who report having ever been told they had having ever been told they had asthma (changed from “past year”)asthma (changed from “past year”)

Baseline: 10%Baseline: 10%

Objective 27-10Objective 27-10

Reduce the proportion of Reduce the proportion of nonsmokers exposed to nonsmokers exposed to environmental tobacco environmental tobacco smoke.smoke.

Original MeasureOriginal Measure

Numerator: Number of Numerator: Number of nonsmokers aged 4 years and over nonsmokers aged 4 years and over who had a serum cotinine level who had a serum cotinine level above 0.10 ng/mLabove 0.10 ng/mL

Denominator: Number of Denominator: Number of nonsmokers aged 4 years and overnonsmokers aged 4 years and over

Definitional issues: What is a Definitional issues: What is a nonsmoker? Why was a serum nonsmoker? Why was a serum cotinine level of 0.10 ng/mL chosen cotinine level of 0.10 ng/mL chosen as the cut-off?as the cut-off?

Definition of Nonsmoker Definition of Nonsmoker in Original Measurein Original Measure Ages 4-7 considered nonsmokersAges 4-7 considered nonsmokers A response of “none” to these questions A response of “none” to these questions

for ages 8 and over:for ages 8 and over:• How many cigarettes have you smoked in How many cigarettes have you smoked in

the past 5 days?the past 5 days?

• How many pipes and how many cigars have How many pipes and how many cigars have you smoked in the past 5 days?you smoked in the past 5 days?

• How many containers of chewing tobacco or How many containers of chewing tobacco or snuff have you used in the past 5 days?snuff have you used in the past 5 days?

• How many pieces of nicotine gum have you How many pieces of nicotine gum have you chewed in the past 5 days?chewed in the past 5 days?

DefinitionsDefinitions

Serum cotinine level of 11 ng/mL or Serum cotinine level of 11 ng/mL or higher is found in active smokers higher is found in active smokers

Nonsmokers have a serum cotinine Nonsmokers have a serum cotinine level under 11 ng/mLlevel under 11 ng/mL

•Lowest detectable level of serum Lowest detectable level of serum cotinine is 0.05 ng/mLcotinine is 0.05 ng/mL

0.1 ng/mL = median value of all 0.1 ng/mL = median value of all cotinine values in nonsmokers from cotinine values in nonsmokers from the NHANESthe NHANES

Current Measure Current Measure (Provisional)(Provisional) Numerator: Number of nonsmokers Numerator: Number of nonsmokers

aged 4 years and over who had a aged 4 years and over who had a serum cotinine level of at least .05 serum cotinine level of at least .05 but less than 11 ng/mL. but less than 11 ng/mL.

Denominator: Number of nonsmokers Denominator: Number of nonsmokers aged 4 years and over who had a aged 4 years and over who had a serum cotinine level of less than 11 serum cotinine level of less than 11 ng/mL.ng/mL.

Exposure to ETS: Nonsmokers* Exposure to ETS: Nonsmokers* with Detectable Cotinine Levels**with Detectable Cotinine Levels**

0

20

40

60

80

100

2010 Target

1988-94 Baseline Percent with detectable serum cotinine 1999-2000

Mexican American Total White Black

Source: National Health and Nutrition Examination Survey (NHANES), NCHS, CDC.

I = 95% confidence interval* Nonsmokers are ages 4 and over, defined by serum cotinine levels < 11 ng/mL. ** Detectable serum cotinine levels: > .05 ng/mL < 11 ng/mL. Notes: Data are age adjusted to the 2000 standard population. Black and White exclude persons of Hispanic origin. Persons of Mexican origin may be any race. Persons reported one race or more than one race and identified one race as best representing their race. Data for other Hispanics, American Indians or Alaska Natives, and Asians or Pacific Islanders are unreliable.Source: National Health and Nutrition Examination Survey (NHANES), NCHS, CDC. Obj. 27-10

Original and Modified Original and Modified Baselines Baselines

Original 1988-94 baseline: 65%Original 1988-94 baseline: 65% Current provisional 1988-94 Current provisional 1988-94

baseline: 88%baseline: 88%

•Will incorporate responses to the 4 Will incorporate responses to the 4 nicotine-exposure questions in final nicotine-exposure questions in final estimateestimate

Healthy People 2010Healthy People 2010Goal 1Goal 1

Increase quality and years Increase quality and years of healthy lifeof healthy life

Measurement IssuesMeasurement Issues

Choice of summary measuresChoice of summary measures

Combining different data setsCombining different data sets

Age coverage in health Age coverage in health measuresmeasures

Race/ethnicity data Race/ethnicity data availability/ reliabilityavailability/ reliability

Choice of Summary Choice of Summary Measure for HP2010Measure for HP2010

Sullivan’s model of Healthy Life Sullivan’s model of Healthy Life Expectancy (HLE)Expectancy (HLE)

HLE uses a life-table approach HLE uses a life-table approach with cross-sectional health datawith cross-sectional health data

Many types of health measures Many types of health measures possiblepossible

Selected Types of Health Selected Types of Health Measures for HP2010Measures for HP2010 Years of life…Years of life…

•In good or better health In good or better health •Without functional disabilityWithout functional disability•Without chronic conditionsWithout chronic conditions•With good health behaviorsWith good health behaviors•Without serious mental illnessWithout serious mental illness

HLE varies by type of measure usedHLE varies by type of measure used

Using Mortality and Using Mortality and Health Survey DataHealth Survey Data

Mortality data from NVSSMortality data from NVSS Morbidity/health data from Morbidity/health data from

surveyssurveys•National Health Interview National Health Interview

Survey (NHIS)Survey (NHIS)

•Other more specialized Other more specialized surveyssurveys

Adjustment issuesAdjustment issues

Issues with Combining Issues with Combining Data SetsData Sets

Calculating the variability of Calculating the variability of estimates from different surveys estimates from different surveys with different sampling schemeswith different sampling schemes

Not all data sets have transitioned Not all data sets have transitioned to the new OMB race/ethnicity to the new OMB race/ethnicity standardsstandards

•Currently, must use older NHIS Currently, must use older NHIS race/ethnicity groupsrace/ethnicity groups

•YRBSS uses 1 race/ethnicity questionYRBSS uses 1 race/ethnicity question

Different Data Sources Different Data Sources Cover Different AgesCover Different Ages Mortality data are for all agesMortality data are for all ages

Morbidity/health data cover different Morbidity/health data cover different age groups for different measuresage groups for different measures

• Self-assessed health status – all agesSelf-assessed health status – all ages

• Without functional disability – all agesWithout functional disability – all ages

• Without chronic diseases – all ages Without chronic diseases – all ages

• With good health behaviors – ages 18+ ?With good health behaviors – ages 18+ ?

• Without serious mental illness – ages 18+; Without serious mental illness – ages 18+; maybe grades 9-12?maybe grades 9-12?

Race/Ethnic Data Race/Ethnic Data ChallengesChallenges Statistical reliability of smaller Statistical reliability of smaller

population groupspopulation groups Estimates for 5-year age groups Estimates for 5-year age groups

may not be possiblemay not be possible

•May combine yearsMay combine years

Cannot show full race/ethnic Cannot show full race/ethnic templatetemplate

•Non-Hispanic Black and Non-Hispanic Non-Hispanic Black and Non-Hispanic White onlyWhite only

SummarySummary

Variety of Goal 1 data issuesVariety of Goal 1 data issues

Measures still being developedMeasures still being developed

Estimates will be presented for:Estimates will be presented for:

•Total populationTotal population

•FemalesFemales

•MalesMales

•Black, Non-HispanicBlack, Non-Hispanic

•White, Non-HispanicWhite, Non-Hispanic

Take-Away PointsTake-Away Points

Tracking Healthy People Tracking Healthy People 2010 objectives is a fluid 2010 objectives is a fluid processprocess

Methodological and Methodological and definitional issues are on-definitional issues are on-going and can be complexgoing and can be complex

Many issues will be decided Many issues will be decided during the Midcourse Reviewduring the Midcourse Review

Measuring Healthy Measuring Healthy People 2010 People 2010 Objectives: Objectives: Methodologic and Methodologic and Definitional IssuesDefinitional Issues

Kathleen M. Turczyn, Kathleen M. Turczyn, MPHMPHkturczyn@cdc.govkturczyn@cdc.gov

DHHS Healthy People 2010 DHHS Healthy People 2010 Homepage:Homepage:www.health.gov/healthypeoplewww.health.gov/healthypeople

NCHS Healthy People 2010 NCHS Healthy People 2010 Homepage: Homepage: www.cdc.gov/nchs/hphome.htmwww.cdc.gov/nchs/hphome.htm

DATA2010 Homepage:DATA2010 Homepage:wonder.cdc.gov/data2010wonder.cdc.gov/data2010