# Presentation: 124167

## 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

## 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

## Outline of today’s 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

## Using Vitals Data for General Community Surveillance...

## Deaths from Selected Causes Massachusetts: 1842-2002

## Community Health Assessment Using Premature Mortality Rates (PMR): an application of vital statistics for ranking community’s overall health

## 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

## 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

## 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

## Slide 10

## Highest PMR:Holyoke

**Highest PMR:Holyoke**

**Lowest PMR: Amherst**

## Highest PMR: Somerville

**Highest PMR: Somerville**

**Lowest PMR: Weston**

## 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**	BROCKTON	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 < 0.05) 

- _Highest_ Premature Mortality Rates for
- Selected Communities*, MA 1999-2002

## Lowest Premature Mortality Rates for 

- _Lowest_ Premature Mortality Rates for
- Selected Communities*, MA 1999-2002

## Median Household Income and PMR by EOHHS Regions, MA 1999-2002

- _State Median Household Income: $66,365_

## Less than High School Education and PMR by EOHHS Regions,  MA 1999-2002

- _Less than High School Education for MA: 9.4%_

## Families Living < 100% Poverty and PMR by EOHHS Regions,  MA 1999-2002

- _% Families Living < 100 Poverty for MA: 6.7%_

## 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.)

## Providing Rapid Online Access to Vital Statistics Data for Community Needs Assessment: MassCHIP ( the Massachusetts Community Health Information Profile)

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

- Center for Health Information & Statistics
- Massachusetts Department of Public Health

## 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 user’s computer
- Currently transitioning to fully web-based system

## Who Uses MassCHIP?

- Bangladesh
- Canada
- Egypt
- Jamaica
- Nigeria

- Pakistan
- Philippines
- Sweden
- Tunisia

- Out-of-Country

- Out-of-Massachusetts

- 39 States-850 users - out of about 8,000 total

## 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

## 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

## 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)

## 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

## 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

## Special Projects Extending the Use of Vital Statistics Data...

## Monitoring Health Disparities: Tracking Ethnicity Variation in Perinatal Outcomes

## 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?

## Minority Perinatal Health Studies:  Populations 

_**Asian**_

_**Hispanic**_

_**Black**_

**Notes:**
On this slide are listed the ethnic group categories for which we provided data in each of the 3 reports.
The Asian report contains data on [LIST GROUPS]:.
The Hispanic report contains data on [LIST GROUPS]:
The most recently released report, Births to Black Mothers in Massachusetts, contains data on [LIST GROUPS].

## 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

**Notes:**
These next slides provide an illustration of the breadth of information provided in these reports.

This slide shows the percentage of preterm births for the major race and Hispanic ethnicity groups, from the annual 2000 births surveillance report.  The data shows what we already know -- that Black non-Hispanic infants are born preterm at a higher rate than all other race groups.

## 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

**Notes:**
Now, from our Births to Black Mothers report, which covers the period 1997-2000, we have information on ethnic subgroups of mothers who identified their race as Black on the birth certificate.   We now see that the percentages of preterm births vary among black infants by ethnic subgroup, with 6 out of the 8 groups having percentages lower than the 12.7% average for all Black non-Hispanics (red bar).

## 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.

**Notes:**
According to our 2000 births surveillance report, 72% of mothers who identified their race as Asian and Pacific Islander received adequate prenatal care (represented by red bar).

## 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.

**Notes:**
In the report, Asian Births in Massachusetts, we presented data on adequacy of prenatal care for 10 separate Asian ethnicity groups.  These data show great disparity by ethnic group, with fewer than 50% of Cambodian and Laotian mothers receiving adequate prenatal care, compared with 80% of Korean and Japanese mothers.

## Spanish Language Preference among Hispanic Mothers by Ethnicity, MA:  1997-2000

- Source: MA Department of Public Health, CHISRE

**Notes:**
Again, with information from the report, Hispanic Births in Massachusetts, we can see that the percentage of mothers preferring Spanish varied greatly by ethnic group.  Fewer than 30% of Cubans and Puerto Ricans in Massachusetts indicated that they preferred Spanish, compared with over 60% of Colombians, Dominicans, Central Americans and Salvadorans. 

## Percent of Mothers Breastfeeding by Race/Ethnicity, Massachusetts

**Notes:**
The percent of Asian mothers who reported breastfeeding or an intention to breastfeed upon discharge from the hospital also varied substantially by mother’s ethnicity.

Over 90% of Asian Indian, Japanese, and Pakistani mothers and over 80% of  Korean, Filipino and Thai mothers reported breastfeeding.  

In contrast, breastfeeding rates were low for Cambodians, Laotians, and Vietnamese.  Under half of these mothers were breastfeeding or intended to breastfeed their infants.

## Percent of Asian Mothers Breastfeeding, by Ethnicity, Massachusetts

**Notes:**
The percent of Asian mothers who reported breastfeeding or an intention to breastfeed upon discharge from the hospital also varied substantially by mother’s ethnicity.

Over 90% of Asian Indian, Japanese, and Pakistani mothers and over 80% of  Korean, Filipino and Thai mothers reported breastfeeding.  

In contrast, breastfeeding rates were low for Cambodians, Laotians, and Vietnamese.  Under half of these mothers were breastfeeding or intended to breastfeed their infants.

## Percent of Mothers Breastfeeding, by Hispanic Ethnicity, Massachusetts

## Percentage of Black Mothers Breastfeeding by Ethnicity, Massachusetts

**Notes:**
The percent of Black mothers who reported breastfeeding or an intention to breastfeed upon discharge from the hospital was over 80% for 6 out of 8 ethnicity groups:  Nigerians, Other Africans, Barbadians, Other West Indian/Caribbean Islanders, Jamaicans, and Haitians.

The two exceptions were Cape Verdeans and African Americans.  Around 70% of CapeVerdeans and 59% of African Americans indicated they would breastfeed.

## Percent of Asian Mothers Breastfeeding, by Ethnicity, Massachusetts

## 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____________)

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

## 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

## 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

## Objectives of CDC Project

- To link information from CDC’s 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

## 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

## 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

## 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).
-  N=3704 total infants;
-          2703 deliveries

## Data Linkage Strategy

- STAGE 1:
- link ART record to birth record using mothers date of birth and infant’s 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

## Final Match Rate by Clinic Size

## 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).

## 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%**

## 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

## 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

## 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

## 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

## 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...

## 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

## 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!