1. Measuring Healthy People 2010 Objectives: Methodologic and Definitional Issues Kathleen M. Turczyn, Michael Molla, Manon Boudreault, Erin Reidy, Insun Kim, Leda Gbetibouo, Suzanne Proctor National Center for Health Statistics Data Users Conference July 13, 2004

2. Examples of Methodologic and Definitional Issues Coding classifications (ICD- 9 to ICD-10) Coding classifications (ICD- 9 to ICD-10) Revisions to OMB standards for race and ethnicity classification Revisions to OMB standards for race and ethnicity classification Changes in age- adjustment groups Changes in age- adjustment groups Data source changes including question wording Data source changes including question wording Preliminary analysis made final Preliminary analysis made final New scientific findings New scientific findings

3. Four Examples Objective 5-12: Glycosolated hemoglobin measures Objective 5-12: Glycosolated hemoglobin measures Objective 27-10: Exposure to environmental tobacco smoke Objective 27-10: Exposure to environmental tobacco smoke Objective 24-4: Activity limitations among persons with asthma Objective 24-4: Activity limitations among persons with asthma Goal 1: Increase quality and years of healthy life Goal 1: Increase quality and years of healthy life

4. Objective 5-12 Increase the proportion of adults with diabetes who have a glycosylated hemoglobin measurement at least once a year. Increase the proportion of adults with diabetes who have a glycosylated hemoglobin measurement at least once a year.

5. Measurement issues Original baseline from 1998 BRFSS; questions changed in 2000 Original baseline from 1998 BRFSS; questions changed in 2000 Substantial increase in people with diabetes getting A1C tests (testing recommendations changed) Substantial increase in people with diabetes getting A1C tests (testing recommendations changed) To include or exclude “Never heard of A1C test” in the denominator in 2000 To include or exclude “Never heard of A1C test” in the denominator in 2000

6. Ever been told by a doctor that you have diabetes (for females, exclude if told only when pregnant) Ever been told by a doctor that you have diabetes (for females, exclude if told only when pregnant) Denominator for 1998 and 2000

7. Have you ever heard of glycosylated hemoglobin or hemoglobin A1C? [Yes] Have you ever heard of glycosylated hemoglobin or hemoglobin A1C? [Yes] About how many times in the last year have you seen a doctor, … for your diabetes? [One or more times] About how many times in the last year have you seen a doctor, … for your diabetes? [One or more times] About how many times in the last year has a doctor, … checked you for glycosylated hemoglobin or hemoglobin A1C? About how many times in the last year has a doctor, … checked you for glycosylated hemoglobin or hemoglobin A1C? 1998 Numerator Questions

8. About how many times in the past 12 months have you seen a doctor, … for your diabetes one or more times in the last year About how many times in the past 12 months have you seen a doctor, … for your diabetes one or more times in the last year A test for hemoglobin A1C measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, … checked you for hemoglobin A1C? A test for hemoglobin A1C measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, … checked you for hemoglobin A1C? Answer categories include “Never heard of A1C.” Answer categories include “Never heard of A1C.” 2000 Numerator Questions

9. Why changes in question wording? 1998 questions were confusing to respondents -- too many terms 1998 questions were confusing to respondents -- too many terms Public health educators wanted people with diabetes to know specifically about the A1C lab test Public health educators wanted people with diabetes to know specifically about the A1C lab test Funding issue: The change shortened the questionnaire from 3 to 2 questions Funding issue: The change shortened the questionnaire from 3 to 2 questions

10. Evolution of the Estimates YearStandard of care testing Number of annual Hemoglobin A1C tests Incl “Never heard of A1C” in denominator Estimate 1998Type I only1+ 1 24% 2000All Types1+88% 2000All Types1+85% 2000All Types 2+ (new guidelines)63% 2000All Types 2+ (new guidelines) 59% age- adjusted 1 Respondents who had “Never heard of A1C” were not asked about tests.

11. Final Resolution Change the measure of the objective from “one or more” to “two or more…” Change the measure of the objective from “one or more” to “two or more…” Change the baseline year from 1998 to 2000 Change the baseline year from 1998 to 2000 New baseline is 59% using age-adjustment groups for chronic conditions more prevalent among older age categories New baseline is 59% using age-adjustment groups for chronic conditions more prevalent among older age categories Target will be changed to reflect new data Target will be changed to reflect new data

12. Objective 24-4 Reduce activity limitations among persons with asthma Reduce activity limitations among persons with asthma

13. Intent of Objective Earlier NHIS questionnaires were not set up to capture the actual intent of objective: to reduce activity limitation due to asthma among persons with asthma Earlier NHIS questionnaires were not set up to capture the actual intent of objective: to reduce activity limitation due to asthma among persons with asthma

14. 1997 NHIS Questionnaire Changes Asthma questions changed Asthma questions changed Questions about “limitation of activity” changed Questions about “limitation of activity” changed Objective 24-4 was no longer measurable with former questions Objective 24-4 was no longer measurable with former questions

15. Changes in Asthma Questions Pre-1997: Pre-1997: During the past 12 months, did anyone in the family {names} have asthma? During the past 12 months, did anyone in the family {names} have asthma? 1997+: 1997+: Have you/{child’s name} EVER been told by a doctor or other health professional that you/{child’s name} had asthma? Have you/{child’s name} EVER been told by a doctor or other health professional that 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 episode or asthma attack within the last year? Have you/Has {child’s name} had an asthma episode or asthma attack within the last year?

16. Changes in Activity Limitation Questions Pre-1997: Questions on limitation of activity due to “impairment or health problem” Pre-1997: Questions on limitation of activity due to “impairment or health problem” 1997+: Questions on functional limitations due to “physical, mental, or emotional problems” and receipt of services (children) 1997+: Questions on functional limitations due to “physical, mental, or emotional problems” and receipt of services (children)

17. Original 1994-96 Baseline Numerator: Persons who report having asthma and activity limitation in past year Numerator: Persons who report having asthma and activity limitation in past year Denominator: Persons who report having asthma in past year Denominator: Persons who report having asthma in past year Baseline: 20% Baseline: 20%

18. New 1997 Baseline Numerator: Persons who report having an asthma episode or attack in the past year who are limited in activity due to a respiratory problem Numerator: Persons who report having an asthma episode or attack in the past year who are limited in activity due to a respiratory problem Denominator: Persons who report having ever been told they had asthma (changed from “past year”) Denominator: Persons who report having ever been told they had asthma (changed from “past year”) Baseline: 10% Baseline: 10%

19. Objective 27-10 Reduce the proportion of nonsmokers exposed to environmental tobacco smoke. Reduce the proportion of nonsmokers exposed to environmental tobacco smoke.

20. Original Measure Numerator: Number of nonsmokers aged 4 years and over who had a serum cotinine level above 0.10 ng/mL Numerator: Number of nonsmokers aged 4 years and over who had a serum cotinine level above 0.10 ng/mL Denominator: Number of nonsmokers aged 4 years and over Denominator: Number of nonsmokers aged 4 years and over Definitional issues: What is a nonsmoker? Why was a serum cotinine level of 0.10 ng/mL chosen as the cut- off? Definitional issues: What is a nonsmoker? Why was a serum cotinine level of 0.10 ng/mL chosen as the cut- off?

21. Definition of Nonsmoker in Original Measure Ages 4-7 considered nonsmokers Ages 4-7 considered nonsmokers A response of “none” to these questions for ages 8 and over: A response of “none” to these questions for ages 8 and over: How many cigarettes have you smoked in the past 5 days? How many cigarettes have you smoked in the past 5 days? How many pipes and how many cigars have you smoked in the past 5 days? How many pipes and how many cigars have you smoked in the past 5 days? How many containers of chewing tobacco or snuff have you used in the past 5 days? How many containers of chewing tobacco or snuff have you used in the past 5 days? How many pieces of nicotine gum have you chewed in the past 5 days? How many pieces of nicotine gum have you chewed in the past 5 days?

22. Definitions Serum cotinine level of 11 ng/mL or higher is found in active smokers Serum cotinine level of 11 ng/mL or higher is found in active smokers Nonsmokers have a serum cotinine level under 11 ng/mL Nonsmokers have a serum cotinine level under 11 ng/mL Lowest detectable level of serum cotinine is 0.05 ng/mL Lowest detectable level of serum cotinine is 0.05 ng/mL 0.1 ng/mL = median value of all cotinine values in nonsmokers from the NHANES 0.1 ng/mL = median value of all cotinine values in nonsmokers from the NHANES

23. Current Measure (Provisional) Numerator: Number of nonsmokers aged 4 years and over who had a serum cotinine level of at least.05 but less than 11 ng/mL. Numerator: Number of nonsmokers aged 4 years and over who had a serum cotinine level of at least.05 but less than 11 ng/mL. Denominator: Number of nonsmokers aged 4 years and over who had a serum cotinine level of less than 11 ng/mL. Denominator: Number of nonsmokers aged 4 years and over who had a serum cotinine level of less than 11 ng/mL.

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

25. Original and Modified Baselines Original 1988-94 baseline: 65% Original 1988-94 baseline: 65% Current provisional 1988-94 baseline: 88% Current provisional 1988-94 baseline: 88% Will incorporate responses to the 4 nicotine-exposure questions in final estimate Will incorporate responses to the 4 nicotine-exposure questions in final estimate

26. Healthy People 2010 Goal 1 Increase quality and years of healthy life Increase quality and years of healthy life

27. Measurement Issues Choice of summary measures Choice of summary measures Combining different data sets Combining different data sets Age coverage in health measures Age coverage in health measures Race/ethnicity data availability/ reliability Race/ethnicity data availability/ reliability

28. Choice of Summary Measure for HP2010 Sullivan’s model of Healthy Life Expectancy (HLE) Sullivan’s model of Healthy Life Expectancy (HLE) HLE uses a life-table approach with cross-sectional health data HLE uses a life-table approach with cross-sectional health data Many types of health measures possible Many types of health measures possible

29. Selected Types of Health Measures for HP2010 Years of life… Years of life… In good or better health In good or better health Without functional disability Without functional disability Without chronic conditions Without chronic conditions With good health behaviors With good health behaviors Without serious mental illness Without serious mental illness HLE varies by type of measure used HLE varies by type of measure used

30. Using Mortality and Health Survey Data Mortality data from NVSS Mortality data from NVSS Morbidity/health data from surveys Morbidity/health data from surveys National Health Interview Survey (NHIS) National Health Interview Survey (NHIS) Other more specialized surveys Other more specialized surveys Adjustment issues Adjustment issues

31. Issues with Combining Data Sets Calculating the variability of estimates from different surveys with different sampling schemes Calculating the variability of estimates from different surveys with different sampling schemes Not all data sets have transitioned to the new OMB race/ethnicity standards Not all data sets have transitioned to the new OMB race/ethnicity standards Currently, must use older NHIS race/ethnicity groups Currently, must use older NHIS race/ethnicity groups YRBSS uses 1 race/ethnicity question YRBSS uses 1 race/ethnicity question

32. Different Data Sources Cover Different Ages Mortality data are for all ages Mortality data are for all ages Morbidity/health data cover different age groups for different measures Morbidity/health data cover different age groups for different measures Self-assessed health status – all ages Self-assessed health status – all ages Without functional disability – all ages Without 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+; maybe grades 9-12? Without serious mental illness – ages 18+; maybe grades 9-12?

33. Race/Ethnic Data Challenges Statistical reliability of smaller population groups Statistical reliability of smaller population groups Estimates for 5-year age groups may not be possible Estimates for 5-year age groups may not be possible May combine years May combine years Cannot show full race/ethnic template Cannot show full race/ethnic template Non-Hispanic Black and Non-Hispanic White only Non-Hispanic Black and Non-Hispanic White only

34. Summary Variety of Goal 1 data issues Variety of Goal 1 data issues Measures still being developed Measures still being developed Estimates will be presented for: Estimates will be presented for: Total population Total population Females Females Males Males Black, Non-Hispanic Black, Non-Hispanic White, Non-Hispanic White, Non-Hispanic

35. Take-Away Points Tracking Healthy People 2010 objectives is a fluid process Tracking Healthy People 2010 objectives is a fluid process Methodological and definitional issues are on-going and can be complex Methodological and definitional issues are on-going and can be complex Many issues will be decided during the Midcourse Review Many issues will be decided during the Midcourse Review

36. Measuring Healthy People 2010 Objectives: Methodologic and Definitional Issues Kathleen M. Turczyn, MPH kturczyn@cdc.gov DHHS Healthy People 2010 Homepage: www.health.gov/healthypeople NCHS Healthy People 2010 Homepage: www.cdc.gov/nchs/hphome.htm www.cdc.gov/nchs/hphome.htm DATA2010 Homepage: wonder.cdc.gov/data2010