Public-private Partnership to establishPublic-private Partnership to establish

a Public Health Surveillance System for AIANa Public Health Surveillance System for AIAN

Indian Health Status Collaborative started in 2003

1. Tribal Health BoardCalifornia Rural Indian Health Board (CRIHB)

2. Indian Health Service (IHS) Area OfficeCalifornia Area Office

3. State Department of Health ServicesCalifornia Center for Health Statistics

4. UniversityUniversity of California San Francisco

AI / AN in California: AI / AN in California: LargeLarge Census PopulationCensus Population

AI / AN:BridgedEstimate

All 472,692

NotHispanic

225,265

Hispanic 247,427

* US Census 2000, Bridged Estimate Report 2003

1. California Center for Health Statistics concerned about AIAN statisticsconcerned about AIAN statistics

• Low Population Density AI / AN– 1.6% of state population– 4.3% is largest portion of any county

population

• High Racial Misclassification of AI / AN– 30% to 70% depending on data type

Example: Example: California Mortality Rate for AI / ANCalifornia Mortality Rate for AI / AN

RACE (non-Hispanics)

Age-Adjusted RATE*

White 804.5

AI / AN 517.0

Black 1,079.7

Asian / Pac Isl. 506.2

* Year 2000 Rate per 100,000 people, Adjusted with Year 2000 Standard Million Population

AI / AN in Indian Health Service: AI / AN in Indian Health Service:

User PopulationUser Population

* Indian Health Service

Calif 2000 2001 2002 2003 2004 2005

Users 65,299 66,617 67,266 69,238 71,696 75,195

Tribal Health Programs

(THP)

Service Areas in

37 of 58 counties

Tribally owned and operated,

Mainly IHS Funded

2. Tribal Health Board in California 2. Tribal Health Board in California concerned about no AIAN data concerned about no AIAN data

• Inform IHS funding allocation process– Uses mortality rates by cause (5)– Perception that CA AIAN are healthier

• Inform Disparities reduction efforts– Perception that CA AIAN had no disparities

• Advocate for fair treatment– Evaluate health impact of disparities in funding

of California THP

The Collaborative Links The Collaborative Links IHS Data to State Data IHS Data to State Data

• Use IHS Active User Population data to identify AIAN– Validated Social Security Number (to link)– Other Demographic fields to improve linkage

• Link to state health data bases– Deterministic linkage (SSN only)– Probabilistic linkage

• Obtain comparable data for Whites

IHS data identifies AIAN which is then IHS data identifies AIAN which is then linked to state data baseslinked to state data bases

AIAN Active Users

to Death Certificates

to Hospital Discharges

to Medicaid

to Birth Certificates

to Cancer Registry (SEER)

to AIDS Registry

Racial Misclassification in State DataRacial Misclassification in State Data

California Percent of Records

Death Certificates 26%

Hospital Discharges 61%

Medicaid Not Determined

Birth Certificates 23%

Cancer Registry (SEER) In Progress

AIDS Cases Not Determined

Effect of Racial Misclassification on Effect of Racial Misclassification on the the DisparityDisparity in Death Rates in Death Rates

AI / ANnon-

Hispanics*

 White non-

Hispanics

Rate Ratio[95% C.I.]

State data 517 805 0.64

IHS-State

Linked data1035 858

1.21[1.13,1.29]

Hospitalization Disparity Rate Ratios Hospitalization Disparity Rate Ratios by Cause for by Cause for THP Service AreasTHP Service Areas

• Diabetes

• Cardiovascular Disease

• Asthma

• Tobacco

• Alcohol & Drug

• Cancer

• Preventable

Disparities in Hospitalization Rate Ratios by THP Service Area

0.00

0.50

1.00

1.50

2.00

2.50

H V N D L A Q K U E J B O W I P F R C G T M S X

Major Factors in SuccessMajor Factors in Success

• Needs of all three groups are served• Long-term commitment (took 5 years)

– No turnover in major players

• Consistent commitment– Everyone showed up every time to deal with IRB

issues

• Follow-through– Findings used in testimony, reports and journal

articles produced change in perception and funds

Thanks to Collaborative Members:Thanks to Collaborative Members:

California Rural Indian Health Board (CRIHB)

California Area Office of the Indian Health services (IHS)

California state Center for Health Statistics (CHS)

University of California San Francisco (UCSF), Institute for Health Policy Studies

• James Crouch• Margo Kerrigan• James Sutocky• Carol Korenbrot• Chi Kao• Sara EhlersUC Berkeley:• Karen Garcia*• Sarah Johnson • Matthew Pearn • Sharon Lee