Catalog of

University

Presentations

2000-2001

From the CENTERS FOR DISEASE CONTROL AND PREVENTION

National Center for Health Statistics

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention 

National Center for Health Statistics

Hyattsville, Maryland

September 2000

DHHS Publication No. (PHS) 2000-1302
National Center for Health Statistics

Edward J. Sondik, Ph.D., Director

Jack R. Anderson, Deputy Director

Jack R. Anderson, Acting Associate Director for

International Statistics

Jennifer H. Madans, Ph.D., Associate Director for Science

Lester R. Curtin, Ph.D., Acting Associate Director for

Research and Methodology

Jennifer H. Madans, Ph.D., Acting Associate Director for

Analysis, Epidemiology, and Health Promotion

P. Douglas Williams, Acting Associate Director for Data

Standards, Program Development, and Extramural Programs

Edward L. Hunter, Associate Director for Planning, Budget,

and Legislation

Jennifer H. Madans, Ph.D., Acting Associate Director for

Vital and Health Statistics Systems

Douglas L. Zinn, Acting Associate Director for

Management

Charles J. Rothwell, Associate Director for Information

Technology and Services

NCHS University Visitation Program Committee

Kenneth W. Harris, Chairman

CONTENTS

A. Programs of the National Center for Health Statistics

A-1. The National Center for Health Statistics—Plans for Its Future ................................. 1

A-2. Data Resources of the National Center for Health Statistics ................................... 1

A-3. The Statistical Research and Survey Methods Program of the National Center for Health Statistics . . . 1

A-4. Integrated Survey Redesign ............................................................. 1

A-5. The National Nutrition Monitoring and Related Research Program .............................. 1

A-6. The Research Data Center (RDC) ........................................................ 1

A-7. Developments in Cartography and GIS at the National Center for Health Statistics ................ 2

A-8. Minority Health Statistics Grants Programs ................................................. 2

A-9. The Nation’s Prevention Agenda: Tracking Healthy People 2010 ............................... 2

A-10. Evaluating a Government Web Site in the Cognitive Laboratory ................................ 2

A-11. Coordination for Improved Health Statistics—The National Committee on Vital and Health Statistics

and Other Mechanisms ................................................................. 2

A-12. Confidentiality and Data Access Policies at the National Center for Health Statistics ............... 2

A-13. Maternal and Child Health Research Efforts at the National Center for Health Statistics .............. 3

A-14. The National Health and Nutrition Examination Survey: 1999 and Beyond......................... 3

B. Data Systems of the National Center for Health Statistics

B-1. Overview of the Data Systems of the National Center for Health Statistics ....................... 4

B-2. The Second Longitudinal Study of Aging .................................................. 4

B-3. Development and Operation of the National Health Provider Inventory .......................... 4

B-4. Development and Operation of the National Nursing Home Survey ............................. 4

B-5. The National Health Care Survey ......................................................... 4

B-6. The National Death Index ............................................................... 4

B-7. The National Survey of Family Growth (NSFG): An Evolving Tool for the Study of U.S. Fertility and

Reproductive Health ................................................................... 5

B-8. Use of Data From the National Center for Health Statistics Regarding Renal Diseases ............... 5

B-9. Underlying and Multiple Causes of Death .................................................. 5

B-10. Environmental Data From the National Health and Nutrition Examination Survey ................. 5

B-11. The National Survey of Ambulatory Surgery ................................................. 5

B-12. Development and Operation of the National Home and Hospice Care Survey ...................... 5

B-13. Operations of the National Health and Nutrition Examination Survey (NHANES) .................. 5

B-14. The NHANES I Epidemiologic Followup Study: 20 Years After NHANES I ..................... 5

B-15. The National Mortality Followback Survey Program ......................................... 6

B-16. Overview of the Ambulatory Medical Care Surveys ........................................... 6

B-17. Third National Health and Nutrition Examination Survey ..................................... 6

B-18. Reporting Findings from Health Examination Surveys: Challenges and Solutions .................. 6

B-19. Racial and Ethnic Differences in Health: Evidence From NHANES.............................. 6

B-20. The National Health Interview Survey: An Overview ......................................... 6

B-21. The National Immunization Survey........................................................ 7

B-22. Statistical Methods for Analysis of the NHANES I Epidemiologic Followup Study (NHEFS): Effects

of the Complex Survey Design .......................................................... 7

B-23. Health Examination Surveys—What Can They Contribute to Assessing the Nation’s Health? ........ 7

v
B-24. The Third National Health and Nutrition Examination Survey—Contributions to Nutrition

Monitoring ........................................................................... 7

B-25. Injury Data From the Ambulatory Medical Care Surveys ....................................... 7

C. Methodology

C-1. Quality of Rare Item Coding ............................................................ 8

C-2. Quality Control Procedures for Medical Coding ............................................. 8

C-3. Quality of Data Collection in the National Hospital Discharge Survey ........................... 8

C-4. Applying Cognitive Interviewing to Questionnaire Design ..................................... 8

C-5. Issues in Standardizing NCHS Mortality Data ............................................... 8

C-6. Use and Interpretation of Diagnostic Statistics From Selected NCHS Data Systems ................ 8

C-7. Introduction to Sampling for Health Professionals ........................................... 9

C-8. Stratifying Primary Sampling Units ....................................................... 9

C-9. Expanding Surveillance Opportunities With Geographic Information Systems (GIS) ................ 9

C-10. Pitfalls to Avoid When Designing Survey Questionnaires ..................................... 9

C-11. The Randomized Response Technique for Collecting Data .................................... 9

C-12. Question, Questionnaire, and Survey Design in the NHIS ...................................... 9

C-13. Evaluating the Usability of the Internet for Disseminating Health Statistics ........................ 9

C-14. Sample Design, Weighting, and Estimation for the National Health Interview Survey (NHIS) . . . . . . . 10

C-15. Problems in International Comparison of Health Services Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

C-16. The International Classification of Diseases (ICD) and Its Uses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

C-17. Assessing Customer Satisfaction in a Federal Statistical Agency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

C-18. Impact of Written Informed Consent in a National Interview Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

C-19. Integrated Survey Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

C-20. Construction and Use of U.S. Life Tables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

C-21. Use of the Balanced Replication Technique to Estimate Variances From Complex Surveys . . . . . . . . . 11

C-22. Collection of Sensitive Data in the 1995 National Survey of Family Growth . . . . . . . . . . . . . . . . . . . . . . 11

C-23. Using Focus Group Methodology in Questionnaire Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

C-24. Combining a Technical Review of Questionnaires With Identification of Cognitive Issues . . . . . . . . . . 11

C-25. Analyzing Complex Survey Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

C-26. The Use of Survey Data Analysis (SUDAAN) for Complex Survey Data . . . . . . . . . . . . . . . . . . . . . . . . 12

C-27. Evolution of the Cognitive Aspects of Survey Methodology (CASM) Interdiscipline . . . . . . . . . . . . . . . . 12

C-28. Compensation Methods for Missing Data in National Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

C-29. Methodological Research Sponsored by the Minority Health Statistics Grants Program . . . . . . . . . . . . . 12

C-30. The Use of Remuneration (Monetary Incentives) in Health Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

C-31. Doing the National Health Interview Survey: Questionnaire Design, Fieldwork Procedures, Quality

Control, and Data Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

D. Analysis and Epidemiology

D-1. Decreasing Hospital Use in the 1990’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

D-2. Examining Change in a Cohort of Elderly Americans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

D-3. Trends in Hepatitis B Virus Using Data From NHANES II and NHANES III . . . . . . . . . . . . . . . . . . . . . 14

D-4. Multiple Births: Trends and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

vi

Contents ........................................................................................................................
D-5. Twins and Other Multiple Births: Time Trends and Perinatal Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . 14

D-6. Issues in Women’s Health: Menopause, Hysterectomy, and Hormone Replacement Therapy . . . . . . . . . 14

D-7. Years of Healthy Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

D-8. Do Older Adults in the United States Have Access to Health Care? Data From the National Health

Interview Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

D-9. Changes in Hospital Care for Childbirth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

D-10. Analytic and Epidemiologic Research Sponsored by the Minority Health Statistics Grants Program . . . 15

D-11. America’s Children: Key National Indicators of Well-Being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

D-12. Mental Health Data in the National Health Interview Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

D-13. The Epidemiology of Selected Infectious Diseases in the U.S. Population . . . . . . . . . . . . . . . . . . . . . . . . 15

D-14. Food Security in the United States: An Overview of Federal Activities . . . . . . . . . . . . . . . . . . . . . . . . . . 16

D-15. Analyzing Drug Data From the Ambulatory Medical Care Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

D-16. Review of Federal Standards for Collecting Data on Race and Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . 16

D-17. Trends in Hepatitis Virus A Using Data From NHANES II and NHANES III . . . . . . . . . . . . . . . . . . . . . 16

D-18. Data From the NHIS on Selected Year 2000 Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

D-19. Births to Unmarried Mothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

D-20. Trends in Pregnancies and Pregnancy Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

D-21. Infertility and the Use of Medical Care for Infertility: 1965-95 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

D-22. International Comparison by Indication of Cesarean Section Delivery in the 1980’s . . . . . . . . . . . . . . . . 17

D-23. Trends and Variations in Births to Hispanic Mothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

D-24. Analyzing Emergency Department Data From the NHAMCS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

D-25. Epidemiologic Issues in the Study of Infant Mortality and Low Birthweight . . . . . . . . . . . . . . . . . . . . . . 18

D-26. Health, United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

D-27. Collection of Race and Ethnicity Data in National Health Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

D-28. Diabetes Incidence and Mortality in a Nationally Representative Cohort . . . . . . . . . . . . . . . . . . . . . . . . . 18

D-29. Do Children in the United States Have Access to Health Care? Data From the National Health

Interview Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

D-30. General Considerations When Conducting Trend Analysis With Data From the National Center for

Health Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

D-31. The Availability and Use of Data From the National Center for Health Statistics Regarding Diabetes . . 19

D-32. Health Service Areas for the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

D-33. Trends in Herpes Simplex II Using Data From NHANES II and NHANES III . . . . . . . . . . . . . . . . . . . . 19

D-34. The Serioepidemiology of Hepatitis C Virus in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

D-35. Tetanus Immunity in the United States, NHANES III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

D-36. Statistical Methods for Analysis of the NHANES I Epidemiologic Followup Study (NHEFS). . . . . . . . . 20

D-37. Research Opportunities: Current Health Topics From the National Health Interview Survey . . . . . . . . . 20

D-38. Injury Data From the National Center for Health Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

D-39. Nursing Home Utilization Profiles for an Admissions Cohort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

D-40. Infant Mortality in the United States: An Introductory Explanation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

D-41. Trends in Delayed Childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

D-42. Teen Sexual Activity and Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

D-43. NHANES Anthropometric Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

vii

......................................................................................................................... Contents
D-44. Disability in America: Data From the National Health Interview Survey. . . . . . . . . . . . . . . . . . . . . . . . . . 21

D-45. Childlessness in America . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

D-46. Women’s Health Overview: National Data Available From the National Center for Health Statistics to

Address Health Issues of Adult Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

D-47. Firearms in American Households . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

D-48. Reaching the Media With the Results of Your Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

D-49. Overweight Prevalence—Evidence From NHANES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

D-50. Analytical and Epidemiologic Applications of NCHS Mortality Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

D-51. Data on AIDS Available From the National Center for Health Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . 22

D-52. Health Data for Minority Populations Available From the National Center for Health Statistics . . . . . . . 22

D-53. Trends in AIDS Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

D-54. Issues in the Process of Revising the National Center for Health Statistics Growth Charts . . . . . . . . . . . 22

D-55. Do Working-Age Adults in the United States Have Access to Health Care? Data From the National

Health Interview Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

D-56. Adolescent Health Indicators: Findings From the Adolescent Health Chartbook . . . . . . . . . . . . . . . . . . . . 23

E. Data Processing

E-1. Mortality Medical Indexing, Classification, and Retrieval System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

E-2. Automation of Methods for Tracing Subjects and Proxy Respondents in Longitudinal Cohorts . . . . . . . 24

E-3. Survey Statistics Automation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

E-4. Statistical Export and Tabulation System (SETS) Data Retrieval Software . . . . . . . . . . . . . . . . . . . . . . . . 24

E-5. Introduction to the Statistical Export and Tabulation System (SETS) Designer Kit Workshop . . . . . . . . 24

F. Other

F-1. A Career in Statistics With the National Center for Health Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

F-2. Minorities in Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

F-3. Geography Careers in Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

F-4. Funding Opportunities Under the Minority Health Statistics Grants Program . . . . . . . . . . . . . . . . . . . . . . 25

F-5. Understanding and Applying Statistical Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

viii

Contents ........................................................................................................................
CATALOG OF UNIVERSITY PRESENTATIONS

A. Programs of the National Center for Health Statistics

A-1. The National Center for Health Statistics—

Plans for Its Future

A description is given of the current programs

and organization of the National Center for

Health Statistics (NCHS), and its plans for

responding to new health needs and legislative

initiatives are discussed.

A-2. Data Resources of the National Center for

Health Statistics

This presentation is an overview of the

programs of NCHS, of the data it produces, and

of its methods of acquiring those data

resources. Publications, data tapes, CD-ROM’s,

diskettes, and other forms of data release are

described, as well as guides to NCHS data and

methods of identifying available data on

specific topics.

A-3. The Statistical Research and Survey

Methods Program of the National Center for

Health Statistics

This presentation is a description of a basic

long-range research program for the

improvement of existing measurement methods

and for the innovation of more efficient

methods for producing and analyzing health

and vital statistics. Some of the specific

research projects of this program are discussed.

A-4. Integrated Survey Redesign

During the past decade, NCHS embarked on a

program of integrating the sample designs of

about a dozen independently designed national

population and establishment surveys. The

National Health Interview Survey (NHIS), the

largest of the NCHS population sample surveys,

serves as the fulcrum for the integrated survey

design. The NHIS microdata set is the sampling

frame for NCHS population surveys and the

NHIS primary sampling units serve as the

primary sampling units for the NCHS

establishment surveys. The achievements of the

integrated design program over the past decade

and the research being planned for redesigning

NHIS after the 1990 Census are described in

this presentation.

A-5. The National Nutrition Monitoring and

Related Research Program

This presentation reviews the goals and extent

of the National Nutrition Monitoring and

Related Research Program (NNMRRP) in light

of current interest topics such as hunger, food

labeling, diet, and health. National surveys and

data systems that contribute to the monitoring

and the surveillance of nutritional status are

discussed in an integrated fashion to

demonstrate how the components of the

NNMRRP supplement and complement each

other. Programs such as the National Health

and Nutrition Examination Survey, the National

Health Interview Survey, the continuing Survey

of Food Intakes by Individuals, the Behavioral

Risk Factor Surveillance System, and the

National Nutrient Data Bank are examined in

relation to implementation activities for the

Ten-Year Comprehensive Plan for the National

Nutrition Monitoring and Related Research

Program.

A-6. The Research Data Center (RDC)

The National Center for Health Statistics

(NCHS) has developed a Research Data Center

(RDC) that allows researchers and data users to

access internal data files from its numerous

surveys that have not been available to the

research community until now. The internal

files contain lower levels of geography such as

State, county, census tract, block-group, or

blocks, depending on the survey.

Examples of data systems that are available

through the RDC include the National Health

Interview Survey, the National Health and

Nutrition Examination Survey, the National

Hospital Discharge Survey, the National Survey

of Family Growth (NSFG) (the NSFG

contextual data files consist of the survey data

and about 1,300 contextual variables and is

available only through the RDC), and others.

1
Researchers may use the files to merge other

contextual data from the Census Bureau, the

Area Resource File, or other data collected or

provided by the researcher (air pollution data;

State, county, or local laws or ordinances;

reimbursement policies; medical facilities; etc.)

to perform contextual analyses while

maintaining respondent confidentiality.

Because of the confidentiality constraints,

NCHS has not been able to release survey data

with lower levels of geography to its data users,

which has limited the amount and types of

research projects that could be undertaken with

its data systems. The development of the RDC

begins an exciting new era for NCHS and its

data users.

This presentation describes how researchers can

gain access to the RDC.

A-7. Developments in Cartography and GIS at

the National Center for Health Statistics

Mapping of health events at the national level

has evolved from labor-intensive procedures to

an automated process. Now with Geographic

Information Systems (GIS) and digital mapping

technology, personal computer applications

have become the basis for cartographic output

at NCHS. A wide range of statistical mapping

techniques and innovative cartographic designs

are presented.

A-8. Minority Health Statistics Grants Programs

The Disadvantaged Minority Health

Improvement Act of 1990 (P.L. 101–527)

authorized the NCHS to establish an extramural

grants program to improve minority statistics.

Grants are authorized for the support of special

studies or surveys to fill in gaps where national

surveys cannot provide sufficient data, analysis

of existing data, and research to improve

methods for obtaining information on racial and

ethnic subpopulations. This presentation

provides an overview of the grants program and

future plans for expanding its research agenda.

A-9. The Nation’s Prevention Agenda: Tracking

Healthy People 2010

The Healthy People 2000 objectives for the

Nation encompass a broad spectrum of public

health issues, a few of which are nutrition,

alcohol and drug use, violence, unintentional

injuries, oral health, cancer, HIV infection, and

surveillance and data systems. The next

generation of health promotion/disease

prevention objectives (Healthy People 2010) are

being developed. This presentation discusses

some of the issues and challenges for

identifying and developing data sources to track

the objectives, including data for special

population subgroups and subnational

geographic areas. Issues regarding measurement

and data quality are also discussed.

A-10. Evaluating a Government Website in the

Cognitive Laboratory

The National Center for Health Statistics

(NCHS), Office of Research and Methodology,

has conducted studies of the usability of the

NCHS Web site. This presentation describes

experiments that have been done recently to

learn more about how users navigate and

interpret Web sites.

A-11. Coordination for Improved Health

Statistics—The National Committee on Vital

and Health Statistics and Other Mechanisms

This presentation covers the history and

accomplishments of the National Committee on

Vital and Health Statistics. In addition, other

mechanisms that are promoting comparability

and quality of data are reviewed. The

development and promulgation of minimum

data sets, standard classifications, and other

products are discussed.

A-12. Confidentiality and Data Access Policies at

the National Center for Health Statistics

Review of need for statistical, legal, and ethical

factors in the development of confidentiality in

data collection programs at NCHS. Description

of how confidentiality affects field practices,

data processing procedures, analytical

programs, publication policies, and data release

arrangements. Overall effect on quality and

amount of detail of data available is evaluated.

Impact of recent and proposed legislation and

changes in institutional relationships is

discussed.

2

Programs of the National Center for Health Statistics ......................................................
A-13. Maternal and Child Health Research Efforts

at the National Center for Health Statistics

NCHS offers a number of data systems which

can be used to address, directly or indirectly,

issues in maternal and child health. Among the

resources available are the national birth files,

State-specific birth files, the linked birth and

infant death files, the National Maternal and

Infant Health Survey (NMIHS), and the

Longitudinal Followup to the NMIHS, studies

on child immunization, the National Survey of

Family Growth, and the Health Interview

Survey. This presentation will provide examples

of research conducted at NCHS from each of

these data systems, and touch on subjects such

as prenatal care use, national trends in adverse

birth outcomes, pediatric health care utilization,

racial and ethnic differentials in birth outcomes,

and childhood chronic conditions.

A-14. The National Health and Nutrition

Examination Survey: 1999 and Beyond

The content of the latest National Health and

Nutrition Examination Survey, which began

field operations in March 1999, will be

reviewed in terms of public health issues

addressed and methodologies. Discussion of

current design of the study, field operations,

and planned data releases as well as future

planned innovations for the NHANES program

will also be presented, including plans for the

merger with the USDA Continuing Survey of

Food Intake of Individuals (CSFII).

3

..................................................... Programs of the National Center for Health Statistics
B. Data Systems of the National Center for Health Statistics

B-1. Overview of the Data Systems of the

National Center for Health Statistics

This presentation is a summary of the various

data- collection mechanisms used by NCHS to

gather statistics on the health of the Nation.

The types of statistics produced by each are

described.

B-2. The Second Longitudinal Study of Aging

The Second Longitudinal Study of Aging

(LSOA II) provides a wealth of health-related

statistics on the U.S. elderly population. It is a

second-generation, multiwave survey of a

nationally representative sample of 9,447

civilian, noninstitutionalized persons 70 years

of age and over. As a second-generation study,

one of the major objectives of the LSOA II is

to replicate portions of the first Longitudinal

Study of Aging (LSOA), conducted with 7,527

persons 70 years of age and over in 1984,

1986, 1988, and 1990, particularly those

portions pertaining to functional status and the

causes and consequences of transitions in

functioning. A second objective of the LSOA II

is to provide a mechanism for monitoring the

impact of proposed changes in Medicare and

Medicaid and the accelerating shift toward

managed care on the health status of the elderly

and their patterns of health care utilization.

Like the LSOA, the LSOA II is scheduled to

consist of four waves of interviews: 1994/1995,

1997, 1999, and 2001. The first two have been

completed. The purposes, procedures, and data

elements are described in this presentation.

B-3. Development and Operation of the National

Health Provider Inventory

The purpose and methodology used to develop

the National Health Provider Inventory are

reviewed. The presentation also includes a

discussion of the development and content of

the data collection instruments, data collection

procedures, data processing procedures, and

dissemination of the data.

B-4. Development and Operation of the National

Nursing Home Survey

The purpose and methodology used to develop

the National Nursing Home Survey are

discussed. Also included is a description of data

collected to provide estimates of the Nation’s

nursing homes according to their characteristics,

costs, residents, and staff. The development and

content of the data collection instruments,

procedures, processing, and dissemination of

the data are also discussed.

B-5. The National Health Care Survey

NCHS conducts a family of health records

surveys, collectively called the National Health

Care Survey, in which information is collected

on patient and provider characteristics and the

services they provide. The surveys—the

National Hospital Discharge Survey, the

National Survey of Ambulatory Surgery, the

National Ambulatory Medical Care Survey, the

National Hospital Ambulatory Medical Care

Survey, the National Nursing Home Survey,

and the National Home and Hospice Care

Survey—are described in terms of scope, data

set, design, data collection methods, processing

procedures, and data dissemination. Specific

examples of how the survey data have been and

can be used for monitoring, evaluating, and

planning the use of health care are also

discussed. Plans for future survey and research

activities are also presented.

B-6. The National Death Index

The National Death Index (NDI) is a

computerized central file of death record

information. It is compiled from magnetic tapes

submitted to NCHS by the State vital statistics

offices. These tapes contain a standard set of

identifying information for each decedent,

beginning with deaths occurring in 1979.

Investigators conducting prospective and

retrospective studies can use the NDI to

determine whether persons in their studies have

died. If so, they can be provided with the

names of the States in which those deaths

occurred, the dates of death, and the

corresponding death certificate numbers. The

NDI user can then arrange with the appropriate

State offices to obtain copies of death

certificates or specific statistical information,

such as cause of death. This presentation

describes how the NDI operates, how the

matching criteria are used to link user records

with death records, how to interpret the results

of an NDI file search, the effectiveness of the

4
matching process, and how to apply for use of

the service.

B-7. The National Survey of Family Growth

(NSFG): An Evolving Tool for the Study of

U.S. Fertility and Reproductive Health

This presentation covers a brief review of the

survey over four decades, with emphasis on

innovations in Cycle 5 (fielded in 1995). In

addition to showcasing the content and analytic

potential of Cycle 5, particularly the new event

history data, possible future developments of

the survey are explored.

B-8. Use of Data From the National Center for

Health Statistics Regarding Renal Diseases

This presentation is an overview of the sources

and uses of data regarding renal conditions. It

includes a discussion of information available

on renal-related mortality, hospitalization, and

other health care use. Use of NCHS data to

make prevalence estimates for selected renal

conditions is also covered. The presentation

will provide some advice on the use of

International Classification of Diseases (ICD)

codes to identify renal conditions and the

appropriate interpretation of NCHS data

relevant to this topic.

B-9. Underlying and Multiple Causes of Death

This presentation is an overview of NCHS

mortality data, including the role of NCHS, the

World Health Organization, and the States in

collecting and classifying mortality data. The

distinction between underlying and multiple

cause-of-death data is emphasized. Advantages

and limitations of underlying and multiple

cause-of-death data are discussed. Applications

of multiple cause-of-death data (entity and

record axis), analytical potential, uses, and

quality of cause-of-death data are explored.

B-10. Environmental Data From the National

Health and Nutrition Examination Survey

Starting with the first National Health and

Nutrition Examination Survey (NHANES I), the

NHANES program has periodically collected

environmental exposure data on the civilian

population of the United States. This

presentation reviews environmental exposure

data sets from NHANES that are available for

analyses and gives examples of how the data

can be used.

B-11. The National Survey of Ambulatory Surgery

The National Survey of Ambulatory Surgery

was implemented in 1994 and data first became

available in 1996. This presentation covers

background, basic design components, data

processing, variables collected in the survey,

and data dissemination activities.

B-12. Development and Operation of the National

Home and Hospice Care Survey

The purpose and methodology used to develop

the National Home and Hospice Care Survey

are discussed. Also included is a description of

data collected to provide estimates of the

Nation’s home health agencies and hospices.

These data are described according to

characteristics of the agencies, resident

characteristics, costs, and staff. The

development and content of the data collection

instruments, procedures, processing, and

dissemination of the data are also discussed.

B-13. Operations of the National Health and

Nutrition Examination Survey (NHANES)

The practical field operations of the NHANES

study will be reviewed with a focus on current

methods employed to assure successful

implementation of a large national examination

study.

B-14. The NHANES I Epidemiologic Followup

Study: 20 Years After NHANES I

This presentation describes the NHANES I

Epidemiologic Followup Study. The cohort

comprises the 14,407 persons 25–74 years of

age who were examined in the first National

Health and Nutrition Examination Study

(NHANES I). The Followup investigated how

factors measured at baseline relate to health

conditions that have developed since that time.

Three waves of Followup have been completed,

1982–84, 1986, and 1987. Study design, tracing

success, and completeness of data collection are

5

............................................... Data Systems of the National Center for Health Statistics
reviewed. The mortality experience of the

cohort and selected epidemiologic findings are

also presented.

B-15. The National Mortality Followback Survey

Program

Designed to supplement data routinely collected

from death certificates, this presentation gives

an overview of the development of the

program, with an emphasis on the two most

recent surveys conducted in 1986 and 1993.

Included is a discussion of the sample design,

development and content of the data collection

instruments, data collection and quality control

procedures, data processing procedures, and the

dissemination of the data. Also presented is a

discussion of future directions for the program.

B-16. Overview of the Ambulatory Medical Care

Surveys

The National Ambulatory Medical Care Survey

(NAMCS) and the National Hospital

Ambulatory Medical Care Survey (NHAMCS)

are conducted annually to provide

comprehensive data on the patient, provider,

and visit characteristics of visits to physician

offices and hospital emergency and outpatient

departments. Using the sampling weights allows

researchers to estimate national statistics on

diagnoses made, therapies used, medications

prescribed, and differences found in provider

caseloads and practices. Data may be used for

epidemiological studies as well. This

presentation provides an overview of the

NAMCS and NHAMCS, the availability of the

data, and significant findings.

B-17. Third National Health and Nutrition

Examination Survey

The Third National Health and Nutrition

Examination Survey (NHANES III) content is

described in terms of public health issues

addressed and methodologies. Discussion of the

sample design and population coverage,

including response rates, is presented for issues

that should be considered as the data are

analyzed. The current status and availability of

microdata tapes, as well as NCHS plans for

data analysis, are presented.

B-18. Reporting Findings from Health

Examination Surveys: Challenges and

Solutions

The methods employed by NHANES in

reporting results back to study participants of

extensive and often sensitive clinical results

will be reviewed. Discussion will address

specific unique protocols developed for

NHANES, including a system for reporting

sexually transmitted diseases (STDs) results by

telephone, using passwords, and the procedures

for determining how abnormal results are

reported and assessing the severity of abnormal

results.

B-19. Racial and Ethnic Differences in Health:

Evidence From NHANES

The data from the National Health and

Nutrition Examination Surveys have been used

extensively to assess the patterns of differences

in health among the large racial and ethnic

groups in the U.S. and the causes for these

differences. A review of the important findings

based on NHANES examination and biologic

specimen data, including infectious diseases,

diabetes, obesity, and other common conditions,

will be presented.

B-20. The National Health Interview Survey: An

Overview

For nearly 50 years, the National Health

Interview Survey (NHIS) has been monitoring

the Nation’s health by means of face-to-face

interviews with large cross-sectional sample

surveys of the population. This presentation

gives an overview of the NHIS: its origins and

history, its design and content, its analysis and

dissemination, and its uses for making and

evaluating public health policy. Emphasis is

given to recent changes in the NHIS that have

improved its accuracy, timeliness, accessibility,

and policy relevance, such as computer-assisted

personal interviews, State and local area data,

and release of microdata on the World Wide

Web.

6

Data Systems of the National Center for Health Statistics ................................................
B-21. The National Immunization Survey

The National Immunization Survey (NIS)

collects information on the immunization

coverage of children 19 months to 35 months

of age across the United States. Data are used

to monitor immunization coverage in the

preschool population in 78 nonoverlapping

geographic areas. The survey is a collaborative

effort between NCHS and the Centers for

Disease Control and Prevention’s National

Immunization Program. This presentation can

include recent findings, background on the

survey design, methodological issues, and

questionnaire content.

B-22. Statistical Methods for Analysis of the

NHANES I Epidemiologic Followup Study

(NHEFS): Effects of the Complex Survey

Design

This presentation addresses the effect of survey

design in analyzing the NHEFS. The effect of

the survey design on parameter estimates from

Cox proportional hazards models and their

standard errors are discussed. Survey design

effects are measured under four analysis

options: 1) ignore the complex survey design,

2) incorporate only the stratification and

clustering, 3) incorporate only the sample

weights, and 4) incorporate stratification,

clustering, and sample weights. Additional

approaches considered are trimming the sample

weights to reduce their variability, stratifying the

analysis on variables used in the sample design,

and including variables used in the design as

covariates in the model.

B-23. Health Examination Surveys—What Can

They Contribute to Assessing the Nation’s

Health?

The purpose and methodologies used in the

National Health and Nutrition Examination

Surveys are described in detail. Uses of the

data are emphasized with respect to national

health and nutritional issues. How uses affect

future study design is discussed in terms of

sampling and content.

B-24. The Third National Health and Nutrition

Examination Survey—Contributions to

Nutrition Monitoring

The Third National Health and Nutrition

Examination Survey (NHANES III) sampled

over 40,000 Americans in 89 locations across

the United States in two 3-year phases that

began in 1988 and ended in 1994. NHANES III

features many components, including 24-hour

dietary recalls, food frequencies, interviews,

biochemical assessments, physical

examinations, and physiological testing that

contribute to monitoring the dietary, nutritional,

and health status of the U.S. population. This

presentation describes the methodologies used

to assess nutritional status in NHANES III,

examines the uses of nutrition monitoring data,

and illuminates the survey’s role in the

National Nutrition Monitoring and Related

Research Program.

B-25. Injury Data From the Ambulatory Medical

Care Surveys

The National Ambulatory Medical Care Survey

(NAMCS) and the National Hospital

Ambulatory Medical Care Survey (NHAMCS)

are conducted annually to provide

comprehensive data on the patient, provider,

and visit characteristics of visits to physician

offices and hospital emergency and outpatient

departments. The surveys include items on

external cause of injury, place of injury,

whether the injury was related to work, and the

intentionality of the injury. The surveys provide

one of the best national resources for data on

nonfatal injuries and the burden on the health

care industry. This presentation provides an

overview of the major findings of studies

looking at ambulatory injury visits and

methodological and analytical considerations

when using the survey data.

7

............................................... Data Systems of the National Center for Health Statistics
C. Methodology

C-1. Quality of Rare Item Coding

Generally, quality control systems are designed

to ensure that the processes measured are under

statistical control and to provide for courses of

action when the process is no longer in control.

As most quality control systems are based on

sample verification, the quality measure usually

refers to the overall process rather than to

specific components. For example, a coding

operation may be performed within the

established quality standard even though

specific categories of codes, especially those

that rarely or infrequently occur, have very high

error rates. Often it is not clear whether these

items with high error rates are inherently more

difficult to code or whether their high error

rates result more from the limited coding

experience associated with their lower

frequencies of occurrence. This presentation

includes a discussion of some of the procedures

tested at the National Center for Health

Statistics (NCHS) to identify and correct errors

associated with the coding of rare but critical

items in selected NCHS data systems.

C-2. Quality Control Procedures for Medical

Coding

This presentation is a description of recent

modifications made in the quality control

procedures for medical coding of data from

three of the Center’s data systems. The

modifications substantially reduced the original

resource requirements needed to operate the

quality control procedures while maintaining

the ability to provide unbiased estimates of

coding quality.

C-3. Quality of Data Collection in the National

Hospital Discharge Survey

Data have been collected by means of the

National Hospital Discharge Survey (NHDS) on

a continuing basis since its inception in 1964.

These data are based primarily on information

abstracted from a sample of patient medical

records. The quality of this data collection

operation is measured by independently

reabstracting a subset of the originally

sampled records. In recent years, the types of

source documents used to complete the

NHDS abstract form have become more

varied. Thus it has become more difficult to

measure the quality (in terms of accuracy and

completeness) of the information. This

presentation contains findings of a special

study designed to evaluate the effects of

expanded source use on the quality of

abstracted NHDS data.

C-4. Applying Cognitive Interviewing to

Questionnaire Design

Cognitive interviewing methods are

increasingly used to design, test, and evaluate

survey questionnaires. These methods rely on

theories of cognitive psychology and intensive

interviewing protocols to identify problems

with survey questions and improve researchers’

understanding of what responses mean. This

presentation is an overview of the principles

and methods of cognitive interviewing,

including examples of some interviewing

results. Additional topics can include how

laboratory methods complement other forms of

questionnaire evaluation and recent

investigations to enhance cognitive interviewing

methodology. The length and scope of the

presentation is flexible and can be adjusted to

the background of the audience.

C-5. Issues in Standardizing NCHS Mortality

Data

This presentation discusses the need for

eliminating, and methods designed to eliminate,

the confounding effects of population

composition on comparisons of death rates

between groups or over time. The focus will be

primarily on age standardization or

‘‘age-adjustment,’’ although issues in

standardizing for other compositional factors

will also be discussed. The presentation will

cover both the direct and indirect methods of

standardization. In addition, issues related to

changing the standard weights used in the

direct method will be discussed.

C-6. Use and Interpretation of Diagnostic

Statistics From Selected NCHS Data Systems

NCHS reports that present data from two or

more data systems may show substantially

different magnitudes for what is nominally the

same health condition or health care service for

a condition. This is true even when the same

classification of diagnoses has been used in

8
tabulating the data. This presentation describes

the factors that affect the use and interpretation

of diagnostic data, that is, information on the

occurrence of diseases, causes of death, health

conditions, and physiological characteristics that

are collected in selected NCHS data systems.

C-7. Introduction to Sampling for Health

Professionals

This presentation is an introduction to survey

sampling for health professionals who need a

basic understanding of sample surveys. The

objectives of the seminar are to present a

conceptual framework for survey sampling,

introduce common terminology, present the

steps involved in survey sampling, explain

common sampling strategies, and present

criteria for good sample design. The length and

technical sophistication of the seminar are

flexible.

C-8. Stratifying Primary Sampling Units

A common survey design problem is the

stratification of primary sampling units (PSU’s)

before sample selection. Historically,

stratification has been accomplished either

judgmentally or through the use of

custom-written computer software. This

problem can be addressed through standard

cluster analysis techniques. The use of the

Statistical Analysis System (SAS) procedure,

PROC CLUSTER, is demonstrated in the

context of an example from the Hispanic

Health and Nutrition Examination Survey

(HHANES).

C-9. Expanding Surveillance Opportunities With

Geographic Information Systems (GIS)

Digital cartography may well become one of

the more important technologies in health

surveillance in the 1990’s. GIS provide a

mechanism for integrating ‘‘n’’ map layers of

geographic-referenced observations through

highly sophisticated surface generation

techniques and a variety of map algebras.

Coefficients of association can in turn be used

to generate and model complex spatial

relationships that have otherwise been

impossible or difficult to detect.

C-10. Pitfalls to Avoid When Designing Survey

Questionnaires

This lecture provides an overview of general

principles of questionnaire design as well as

interesting problems detected when testing

questionnaires in the cognitive research

laboratory.

C-11. The Randomized Response Technique for

Collecting Data

The randomized response technique can be

used to produce estimates of sensitive behavior.

This presentation is a discussion of the

technique in general, a specific application in

the National Survey of Family Growth to

produce estimates of women having abortions,

problems experienced, and results.

C-12. Question, Questionnaire, and Survey Design

in the NHIS

The NHIS is an annual survey in two main

parts: a core that stays essentially the same

from year to year, and one or more topical

modules that add new questions or topics for a

given year. This presentation will cover the

concepts underlying the design of a new topical

module including objectives to be reached;

concepts to be included; question design

(including cognitive testing in a questionnaire

design laboratory); survey design, including

questionnaire flow and data output; computer

specifications; local and field pretests; and the

kind of data and publications that result.

C-13. Evaluating the Usability of the Internet for

Disseminating Health Statistics

The development of the Internet has fostered

studies of the potential for collecting and

disseminating public health statistics via this

rapidly evolving medium to a wider audience.

This presentation explores some of the issues

involved in these studies and describes the

outcome of usability tests of the NCHS Web

site done in the NCHS Questionnaire Design

Research Laboratory. Participants may be asked

to complete a brief survey on the Web site as

preparation for attending the seminar.

9

.................................................................................................................. Methodology
C-14. Sample Design, Weighting, and Estimation

for the National Health Interview Survey

(NHIS)

The National Health Interview Survey (NHIS)

is a multipurpose health survey, and it is the

principal source of information on the health of

the civilian, noninstitutionalized household

population of the United States. The NHIS data

are obtained through personal interviews with

household members conducted each week

throughout the year. These interviews produce a

probability sample of households. NHIS data

are obtained through a complex sample design

involving stratification, clustering, and

multistage sampling, and the weights are

subject to several adjustments. Variance

estimation methodology involves numerous

simplifying assumptions about the design and

weighting. This presentation focuses on

sampling design and its impact on weighting

calculations and variance estimation procedures.

Formation of sampling weights and detailed

procedures for taking the sampling design into

account for variance estimation are also

discussed.

C-15. Problems in International Comparison of

Health Services Data

International data on the supply, organization,

and use of health services are discussed.

Common differences from the United States in

definitions of basic measures, such as hospital

discharge, specialist, and physician visit are

described. The importance of the differences

and approaches to adjusting data to improve

comparability are examined.

C-16. The International Classification of Diseases

(ICD) and Its Uses

The ICD is used worldwide as the classification

standard for diagnostic and cause-of-death

statistics. It is increasingly being used as the

basis for reimbursements to health care

providers in a number of health care delivery

systems in the United States and several other

countries. The wide range of uses to which this

classification is being put, as well as its

periodic revision, present issues of data quality,

appropriate analytic techniques, and

interpretation.

C-17. Assessing Customer Satisfaction in a Federal

Statistical Agency

Executive Order 12862, issued in September

1993, requires all Federal agencies to survey

their customers to determine the kind and

quality of services wanted and the level of

satisfaction with existing services. This

presentation describes how the National Center

for Health Statistics (NCHS) is responding to a

Presidential directive to assess customer

satisfaction. Innovative discussion group

methodology was used to obtain input from

data users representing a variety of sectors in

eight small discussion groups at the 1994

NCHS Data Users Conference. Similar

procedures will be used to assess customer

satisfaction at the 1995 Public Health

Conference on Records and Statistics. This

presentation describes the methods used; some

results of the sessions; and how Federal

agencies can unobtrusively incorporate

customer satisfaction evaluations into current

programs, improve outreach aimed at current

and potential customers, and identify gaps in

current and future products or services needed

by private and public sectors.

C-18. Impact of Written Informed Consent in a

National Interview Survey

Recently, the NCHS Human Subjects Review

Board requested procedures be implemented for

obtaining written consent from respondents

taking part in the National Health Interview

Survey (NHIS), an ongoing face-to-face

national household survey that interviews

45,000 or more respondents annually. The

signature indicates the respondent has been

informed of the nature of the survey and has

consented to be interviewed. Before procedures

were implemented nationwide, a pilot study

was conducted to evaluate the impact of the

signed consent procedures on maintaining

confidentiality, field efficiency and effectiveness,

and data quality. Presenter(s) will summarize

and discuss data obtained from semistructured

10

Methodology ..................................................................................................................
interview notes for 1,100 assigned cases,

semistructured personal interviews conducted

with each of the 30 field staff, field

observations of initial interviews and followup

refusal conversions, and group telephone

debriefings.

C-19. Integrated Survey Design

Integrated survey design refers to designs for

families of linked surveys in which one (or

more) of the surveys in the family serves as the

sample frame(s) for the others. The Center’s

national household and establishment surveys

were originally designed as independent

surveys. This presentation is a discussion of the

progress being made in the Center’s program

for integrating the designs of the Center’s

household and establishment surveys with the

National Health Interview Survey serving as the

sampling frame for the other surveys.

C-20. Construction and Use of U.S. Life Tables

This presentation focuses on methodological

issues in the construction and use of U.S. life

tables. Both theoretical issues and practical

methods are discussed. Life table methods can

be used to show much more than life

expectancy. Also discussed are specialized uses

of life tables, including survival analysis,

multiple decrement life tables, and

cause-elimination life tables.

C-21. Use of the Balanced Replication Technique to

Estimate Variances From Complex Surveys

The Balanced Repeated Replication (BRR) for

variance estimation is one of the most

important advances in sample survey

technology in recent years. This presentation

includes a discussion of the important steps in

the development of this technique and current

uses of the method. The efficiency of the BRR

estimation is compared with that of other

commonly used estimates.

C-22. Collection of Sensitive Data in the 1995

National Survey of Family Growth

In the 1995 National Survey of Family Growth

(NSFG), two primary strategies were used to

improve the reporting of sensitive events

among women of reproductive age: 1) a $20

cash incentive was given to all respondents;

and 2) a small part of the interview was

conducted with a self-administered technique

called audio computer-assisted self-interviewing

(Audio CASI). Experience with the 1993 NSFG

Pretest as well as several other surveys

demonstrated that these approaches can elicit

more reports of sensitive data such as abortion,

HIV-risking behaviors, number of sexual

partners, and forced sexual intercourse. This

presentation will review past evidence as well

as results of using these innovative strategies in

the 1995 NSFG.

C-23. Using Focus Group Methodology in

Questionnaire Design

In the past 5 years, using focus group

methodology to design health questionnaires

has gained widespread interest among survey

researchers. Focus groups are qualitative in

nature and provide researchers with valuable

insights and a better understanding of people’s

way of thinking. They afford the researcher a

rare opportunity to obtain potential respondents’

perceptions, expectations, experiences, and

ideas about a research issue before developing

or finalizing a questionnaire. This presentation

provides a basic understanding of how focus

groups are conducted (for example, identifying

and recruiting participants, developing the

moderator’s guide, audio- and videotaping

results for analysis, and evaluating results),

potential uses to minimize response errors in

questionnaires (for example, clearly describing

the purpose of the study, item wording and

order, and identifying optimal item response

formats), and implementing results to construct

a quality questionnaire.

C-24. Combining a Technical Review of

Questionnaires With Identification of

Cognitive Issues

The Questionnaire Design Research Laboratory

develops and tests questionnaires in a

laboratory setting using the concepts and

techniques of cognitive science. In addition to

conducting cognitive interviews, which focus

on the internal processes by which individuals

11

.................................................................................................................. Methodology
respond to survey questions, critical

‘‘armchair’’ reviews of instruments are

performed. These reviews combine the

traditional questionnaire design process with

identification of cognitive issues. This

presentation describes the kinds of cognitive

factors that can be identified in a critical review

without the benefit of actual cognitive

interviews. These include judgments required to

answer questions, recall problems, complexity

of tasks imposed on respondents, vagueness,

and terminology problems.

C-25. Analyzing Complex Survey Data

This presentation focuses on the statistical

methods and software for the analysis of

complex survey data. In particular, variance

estimation, categorical data analysis, and

logistic regression analysis are addressed. The

emphasis in this presentation is on statistical

methodology and how to adjust test statistics to

account for survey design features. Examples to

illustrate the methods are taken from NCHS

population-based surveys such as the NHIS,

NHANES, and NMES.

C-26. The Use of Survey Data Analysis (SUDAAN)

for Complex Survey Data

The software package SUDAAN can be used to

produce variance estimates, including the use of

poststratification, and to analyze complex

sample survey data. The most recent version of

SUDAAN includes modules for continuous and

discrete data, quantile estimation, ratio

estimates, categorical data analysis, regression

analysis, logistic regression analysis, and

survival analysis. This presentation focuses on

the content and syntax of the software.

Examples from NCHS population-based

surveys are used to illustrate the software.

C-27. Evolution of the Cognitive Aspects of Survey

Methodology (CASM) Interdiscipline

The cognitive model of the question/response

process in surveys has stimulated research in

questionnaire design both in academic settings

and government laboratories since 1983. This

presentation describes: 1) how the

interdiscipline emerged, 2) its initial driving

goals, and 3) future directions. A significant

component of the presentation will be the

videotaped vignettes from oral histories of

some influential participants in the

interdiscipline. This presentation will also focus

on the research agenda for future CASM

research.

C-28. Compensation Methods for Missing Data in

National Surveys

This presentation includes a description of the

procedure used to compensate for missing data

due to unit and item nonresponse. It also

discusses procedures to produce analysis

weights for the data from Phase 1 of the Third

National Health and Nutrition Examination

Survey (NHANES III), 1988–91. Topics include

a summary of the compensation methods for

missing data, sample design for NHANES III,

procedures used to identify weighting classes to

adjust the basic sampling weights for unit

nonresponse, the use of health variables in

addition to sociodemographic variables,

household size, and geographic location to

protect against bias in survey estimates, ratio

adjustments, and linearization methods for

variance estimation.

C-29. Methodological Research Sponsored by the

Minority Health Statistics Grants Program

This presentation will provide highlights from

NCHS extramurally funded projects focusing

on the development of new and innovative

methodological approaches to surveying

hard-to-reach populations.

C-30. The Use of Remuneration (Monetary

Incentives) in Health Surveys

Although most sample surveys conducted by

the Federal Government are based on unpaid

voluntary participation, monetary or gift

incentives for participation may be justified for

certain types of household- and

establishment-based surveys in order to increase

participation rates, encourage accurate

recordkeeping, and to minimize data collection

costs. In addition, in order to maximize

response rates, remuneration may be justified

for health surveys that involve a physical

12

Methodology ..................................................................................................................
examination and the drawing of a blood

sample. This presentation highlights some

major institutional- and population-based

surveys that successfully use or have used

remuneration to increase survey response and

data quality. The surveys reviewed include

special features such as long interviews, the

maintenance of records such as health diaries or

event histories, sensitive questions, and

nonstandard survey data collection locations or

procedures.

C-31. Doing the National Health Interview Survey:

Questionnaire Design, Fieldwork Procedures,

Quality Control, and Data Processing

Like any large, high-quality national survey, the

annual National Health Interview Survey

(NHIS) doesn’t just happen. Doing the NHIS

takes detailed planning of scores of tasks

undertaken by hundreds of people. This

behind-the-scenes presentation traces the survey

process from the first recognition of a health

data need to the final analyzable data that meet

that need. Case studies illustrate the problems

that surveys must solve, such as converting

from paper questionnaires to computers,

compensating for declining public cooperation,

and complying with new safeguards on

confidentiality. This presentation will be

especially interesting to those who are studying

survey methods or using survey data.

13

.................................................................................................................. Methodology
D. Analysis and Epidemiology

D-1. Decreasing Hospital Use in the 1990’s

According to data from the National Hospital

Discharge Survey, people spent almost 40

million fewer days in short-stay hospitals in

1997 than they did in 1990. The rate of hospital

days decreased by 27 percent, due primarily to

a 20 percent decline in the average length of

stay. The discharge rate declined by only 8

percent. Trends are examined for age and sex

groups, geographic regions, diagnostic

categories, and types of surgeries.

D-2. Examining Change in a Cohort of Elderly

Americans

Providing for an increasing number of older

people is one of the great challenges facing the

public health establishment today. Knowing

how a cohort changes with age is critical for

developing good policy. This presentation

provides data on the aging of one cohort from

the Longitudinal Study of Aging and suggests

other research that could be based on these

data.

D-3. Trends in Hepatitis B Virus Using Data

From NHANES II and NHANES III

This presentation describes data from the

second and third National Health and Nutrition

Examination Surveys to look at trends in the

seroprevalence of HBV infection in the United

States. Due to the extensive data collected in

NHANES, serologic markers can be correlated

with a variety of demographic characteristics

and health variables.

D-4. Multiple Births: Trends and Outcomes

During 1980 to 1996, the number of twin births

rose 56 percent (from 68,338 to 106,689) and

the twin birth rate by 37 percent (18.9 to 25.9

per 1,000 live births). The number and rate of

triplet and other higher order births has climbed

even more dramatically; the number from 1,104

to 5,939 and the higher order multiple birth rate

from 37.0 to 152.6 per 100,000. The rapid rise

in multiples has been attributed to an increase

in delayed childbearing and in the use of

fertility-enhancing therapies. However, both

mother and child are at high risk of poor

outcome in a multiple gestation; multiple births

are more likely than singletons to be born too

early and too small and to die within the first

year of life. Trends, outcomes, and the reasons

behind the amazing climb in multiple births

will be discussed and interpreted.

D-5. Twins and Other Multiple Births: Time

Trends and Perinatal Outcomes

Perinatal and infant outcomes among twins and

other multiple births have been studied in

several NCHS data systems. For example, the

U.S. National Natality (live birth) Files have

been used: 1) to investigate the increase in the

rate of twin, triplet, quadruplet, and quintuplet

births over the last two decades; and 2) to

generate intrauterine growth standards (centiles

of birthweight-for-gestation) for twins. The U.S.

Linked Birth/Infant Death Data Sets have been

used: 1) to compare birthweight-specific infant

mortality in singletons, twins, and triplets; 2) to

study time trends in infant mortality in twins

and triplets; 3) to study the relationship of

maternal risk factors to twin infant mortality;

and 4) to investigate the effect of birthweight

discordance on twin infant mortality. The more

important findings from these NCHS studies of

multiple births will be presented and discussed.

D-6. Issues in Women’s Health: Menopause,

Hysterectomy, and Hormone Replacement

Therapy

This presentation uses the 20-year followup in

the NHANES I Epidemiologic Followup Study

to address health events regarding menopausal

issues, specifically use of postmenopausal

estrogen and progestin therapy and

hysterectomy. It will cover how the questions

related to these topics have been asked over

each of the followup waves and what

methodological issues are raised by changes in

the questions. Estimates of hormones ever used,

lengths of use, and age at last use will be

presented as well as socioeconomic correlates

of these endpoints. Similarly, use of

hysterectomy according to various

socioeconomic factors will be covered. The

data will also be used to look at the potential

bias introduced into studies of disease

associations with use of hormone therapy due

to differences between users and nonusers.

D-7. Years of Healthy Life

The first goal of Healthy People 2000 is to

increase the span of healthy life for Americans.

14
To monitor this goal and the related objectives

on an annual basis, the National Center for

Health Statistics developed a specialized

measure that combines data from the National

Health Interview Survey and vital statistics. The

measure is also being adapted for use at the

State level, combining data from the Behavioral

Risk Factor Surveillance System and vital

statistics. This presentation includes a

description of the methodology, trend data, and

a discussion of methodological issues

associated with monitoring the objective.

D-8. Do Older Adults in the United States Have

Access to Health Care? Data From the

National Health Interview Survey

In 1993, over 3.3 million older adults, 65 years

of age and over, had at least one unmet health

care need. Older adults who do not supplement

Medicare with private coverage are twice as

likely to have unmet medical needs, including

routine immunizations. In this presentation, data

from the National Health Interview Survey

(NHIS) Access to Care and Year 2000

Supplements are used to show the problems

U.S. elderly persons have in obtaining health

care. The NHIS uses a nationally representative

sample of the civilian noninstitutionalized

population of the United States. This

presentation will examine regular source of

care, unmet medical needs, and clinical and

preventive services in relation to selected

demographic variables and insurance coverage.

These issues will be presented with the most

current NHIS data available.

D-9. Changes in Hospital Care for Childbirth

Changes in the care provided to women

hospitalized for childbirth during the 1980’s

and 1990’s are examined using data from the

National Hospital Discharge Survey. Rates of

cesarean deliveries increased until the late

1980’s, declined for a few years, and then

leveled off. Other obstetrical procedures, such

as artificial rupture of membranes, medical

induction of labor, and vacuum extraction

greatly increased in the 1980’s and 1990’s.

However, two common procedures, forceps

delivery and episiotomy, decreased substantially

during this period. The average length of a

hospital stay for childbirth decreased until

1995, but then increased, mainly because of

fewer stays of one day or less.

D-10. Analytic and Epidemiologic Research

Sponsored by the Minority Health Statistics

Grants Program

This presentation provides lessons learned by

Minority Health Statistics Grants Program

grantees in designing analytic studies of racial

and ethnic populations.

D-11. America’s Children: Key National Indicators

of Well-Being

In order to foster coordination of the data

collection and reporting on children, the

National Center for Health Statistics

participates with other Federal agencies in the

Federal Forum on Child and Family Statistics.

The annual publication America’s Children: Key

National Indicators of Well-being, one of the

main products of the Forum, utilizes data from

several Federal agencies to provide a summary

of national indicators of child well-being and

monitors them over time. An overview of the

report will be presented, and issues related to

selecting national child well-being indicators

will be discussed.

D-12. Mental Health Data in the National Health

Interview Survey

Data on mental health and the use of mental

health services by children and adults are

collected in the National Health Interview

Survey (NHIS). Questions about mental health

are often considered to be sensitive for a

household interview. This presentation will

review recent national data on mental health

collected in the NHIS as well as discuss issues

involved in collecting sensitive data in a

national household survey. Future survey plans

for mental health topics will also be presented.

D-13. The Epidemiology of Selected Infectious

Diseases in the U.S. Population

The prevalence of serologic markers of the

hepatitis viruses (A, B, C, and D) are presented

from the National Health and Nutrition

Examination Surveys (NHANES). Data are also

15

............................................................................................. Analysis and Epidemiology
available on the seroepidemiology of

toxoplasmosis, rubella, varicella, and HIV. Due

to the extensive data collected in the NHANES,

serologic markers can be correlated with a

variety of demographic characteristics and

health variables.

D-14. Food Security in the United States: An

Overview of Federal Activities

With the passage of the Personal Responsibility

and Work Opportunity Act of 1996 (P.L.

104–193), the Federal guarantee of providing

welfare benefits to all eligible mothers and

children is eliminated and States are allowed to

create their own programs. Created by a

Federal nutrition monitoring body, the Welfare

Reform, Nutrition, and Data Needs Working

Group, brings together staff who work for the

Federal and State governments, advocacy

groups, and other nongovernment organizations

that are charged with determining whether or

not we are able to monitor the effects of

welfare reform on nutrition and health.

Members from the group have worked to

develop a tool to measure food security in U.S.

households (now being included in several

Federal surveys) and have also provided

technical assistance on the development of a

Healthy People 2010 objective on food security

and the planning of various conferences on the

topic. Various individuals from the group also

worked on a U.S. action plan to reduce food

insecurity. The presentation provides an

overview of these and other activities related to

welfare reform and nutrition monitoring.

D-15. Analyzing Drug Data From the Ambulatory

Medical Care Surveys

The National Ambulatory Medical Care Survey

(NAMCS) and the National Hospital

Ambulatory Medical Care Survey (NHAMCS)

are conducted annually to provide

comprehensive data on the patient, provider,

and visit characteristics of visits to physician

offices and hospital emergency and outpatient

departments. Data on medications provided or

prescribed at ambulatory visits are collected.

The National Center for Health Statistics

maintains a comprehensive drug database on

medications mentioned in the NAMCS and

NHAMCS, including therapeutic class, generic

and ingredient substances, and prescription

status. This presentation provides

methodological considerations when using

NAMCS and NHAMCS data for analyzing the

use of medication therapy in ambulatory

medical care.

D-16. Review of Federal Standards for Collecting

Data on Race and Ethnicity

The Office of Management and Budget (OMB)

Statistical Policy Directive 15, ‘‘Race and

Ethnic Standards for Federal Statistics and

Administrative Reporting,’’ which sets forth the

racial and ethnic categories to be used in the

collection and presentation of data by all

Federal agencies, is currently under review.

This presentation discusses the issues

underlying the concerns about the adequacy of

the current standards, the suggestions for

changes, the research conducted to evaluate the

feasibility and impact of implementing the

suggestions, and the implications of the findings

for NCHS data systems.

D-17. Trends in Hepatitis A Virus Using Data

From NHANES II and NHANES III

This presentation describes data from the

second and third National Health and Nutrition

Examination Surveys to look at trends in the

seroprevalence of HAV infection in the United

States. Due to the extensive data collected in

NHANES, serologic markers can be correlated

with a variety of demographic characteristics

and health variables.

D-18. Data From the NHIS on Selected Year 2000

Objectives

The NHIS includes questions each year to help

track the National Health Objectives for the

Year 2000. Recent topics have included cancer

risk factors, tobacco use, environmental health,

occupational safety and health, heart disease

and stroke, clinical and preventive services,

mental health, oral health, family health,

firearm safety, nutrition, and physical activity

and fitness. This presentation explains how

questions to measure progress toward the

16

Analysis and Epidemiology .............................................................................................
objectives were developed, tested, and

implemented, and also presents selected

analyses of the data.

D-19. Births to Unmarried Mothers

The risk and hazard of nonmarital childbearing

have increased in recent years as American

women are becoming sexually active at earlier

ages and marrying later. One of every three

births in America is to an unmarried mother. In

1992, there were 1.2 million births to

unmarried women, almost double the number in

1980. The rate of nonmarital childbearing has

increased rapidly since 1980, with the recent

increase most pronounced for white women

aged 20 and older. Still, rates of nonmarital

childbearing are highest among black women

and the overwhelming majority of all teenage

mothers—70 percent—are not married.

Unmarried mothers tend to have poorer birth

outcomes than married mothers because they

are disproportionately young, poorly educated,

and more likely to be poor. These patterns and

variations based on data from birth certificates

are described and discussed.

D-20. Trends in Pregnancies and Pregnancy Rates

During the period from 1980 to 1992, about

11 percent of women in the childbearing ages

of 15–44 years were pregnant in any year. The

1992 total of 6.5 million pregnancies included

4.1 million births, 1.5 million abortions, and

900,000 miscarriages and stillbirths. About five

of eight pregnancies in the United States end in

live birth, two of eight end in abortion, and one

of eight end in miscarriage or stillbirth. The

abortion rate declined by 12 percent from 1980

to 1992, partly due to the decline in the number

of women 18–29 years, the ages when abortion

rates are highest. Trends in pregnancies and

pregnancy rates by age and outcome are

discussed. In addition, differences in pregnancy

rates, rates by outcome, and lifetime

pregnancies among Hispanic and non-Hispanic

white and black women are described and

interpreted in this presentation.

D-21. Infertility and the Use of Medical Care for

Infertility: 1965–95

The National Survey of Family Growth is the

primary source of data on infertility and the use

of medical care for infertility in the United

States. The NSFG publishes two measures of

fertility problems: infertility is defined solely

for married women and captures problems in

conceiving a baby, and impaired fecundity is

defined for all women and includes problems in

conceiving or delivering a baby. Trends over

the past three decades in these two measures of

fertility problems are described within the

context of sociodemographic changes in the

population—specifically, the aging of the large

Baby Boom cohorts and the greater prevalence

of delayed childbearing. Findings are also

presented on the use of medical services for

infertility. These data have been collected in the

three most recent NSFG cycles (1982, 1988,

and 1995), with an increasing level of detail

and clinical/policy usefulness.

D-22. International Comparison by Indication of

Cesarean Section Delivery in the 1980’s

The cesarean section rate in the United States

remains among the highest in the world despite

a leveling-off in the late 1980’s. This

presentation compares the level and trends in

the use of cesarean delivery by indication in the

United States, Norway, Scotland, and Sweden

during the 1980’s. A comparison based on

medical indication for cesarean section is used

to identify factors underlying national

differences in obstetrical delivery practice and

to identify pathways to decrease cesarean

section rates, particularly in the United States.

D-23. Trends and Variations in Births to Hispanic

Mothers

The birth certificates of every State and the

District of Columbia include items on the

Hispanic or ethnic origin of parents. These

items were added to the birth certificates in

1978. Birth and fertility rates for Mexican,

Puerto Rican, Cuban, and other Hispanic

17

............................................................................................ Analysis and Epidemiology
women are shown for the years 1978–92 and

are compared with rates for white and black

non-Hispanic women. Using data from the birth

certificates, maternal and infant health

characteristics, and medical and lifestyle risk

factors are compared for babies born to

Hispanic and to non-Hispanic mothers.

D-24. Analyzing Emergency Department Data

From the NHAMCS

The National Hospital Ambulatory Medical

Care Survey (NHAMCS) is conducted annually

to provide comprehensive data on the patient,

provider, and visit characteristics of visits to

hospital emergency and outpatient departments.

The emergency department data set is

especially useful for examining data on medical

and trauma emergencies such as heart attacks,

drug overdoses, chest pains, abdominal pains,

and injuries from falls or motor vehicle crashes.

Diagnosis, treatment, and outcome patterns for

various conditions can be described or modeled.

This presentation provides an overview of

methodological considerations for analyzing

NHAMCS emergency department data.

D-25. Epidemiologic Issues in the Study of Infant

Mortality and Low Birthweight

This presentation covers a wide range of

research on issues related to infant mortality

and low birthweight. Particular emphasis is

given to trends in infant mortality at the

national, State, and local levels; the use of

linked birth and death records to assess

maternal factors related to pregnancy outcome;

the effects of smoking on pregnancy outcome;

and analysis of differentials in pregnancy

outcome by race and ethnicity.

D-26. Health, United States

This presentation is a discussion of highlights

from Health, United States, the annual report

on the health of the Nation compiled by NCHS

and submitted by the Secretary of Health and

Human Services to the President and Congress.

Health, United States presents national trends in

public health statistics organized around four

major subject areas: health status and

determinants, utilization of health resources,

health care resources, and health care

expenditures.

D-27. Collection of Race and Ethnicity Data in

National Health Surveys

In 1997, the Office of Management and Budget

revised its standards for the collection of race

and ethnicity data throughout the Federal

statistical system, also known as OMB

Directive 15. The central feature of this revised

standard is that it allows respondents to the

Census and Federal surveys to indicate more

than one race for the first time. This promises

to have a tremendous impact on the way race

and ethnicity data are collected and analyzed in

the future. This presentation provides a general

background for the changes to the OMB

Directive 15, and highlights the issues

associated with collecting race and ethnicity

data from vital statistics records, administrative

records, and face-to-face and telephone surveys.

Selected data from NCHS data systems are

used to illustrate the challenges in tabulating

and analyzing data on multiracial population

groups.

D-28. Diabetes Incidence and Mortality in a

Nationally Representative Cohort

Data from the NHANES I Epidemiologic

Followup Study are used to study the risk

factors for diabetes incidence with particular

emphasis on the role of obesity and

socioeconomic status. In addition, the mortality

experience of diabetics and nondiabetics is

compared. Emphasis is placed on the

contribution of diabetes to mortality by cause

of death, as well as differentials by sex and

other baseline characteristics.

D-29. Do Children in the United States Have

Access to Health Care? Data From the

National Health Interview Survey

In 1993, over 4 million (6 percent) U.S.

children from infants to 17 years lacked a

regular source of health care, and over 7.3

million children had at least one unmet need or

had delayed medical care because of worry

about the cost of care. In this presentation, the

18

Analysis and Epidemiology ............................................................................................
most recent data from the National Health

Interview Survey (NHIS) are used to show the

problems children have in obtaining health care,

as indicated by source of care, health care

coverage, delays in care, and inability to obtain

care.

D-30 General Considerations When Conducting

Trend Analysis With Data From the National

Center for Health Statistics

Many NCHS data systems have the potential to

examine trends in the prevalence of risk factors,

diseases, and health outcomes such as doctor

visits or mortality. However, care must be taken

when using NCHS data for this purpose. For

example, data systems will change over time;

rubrics to classify diseases or health-related

events may change; or the survey sample

design may vary. All of these factors can

influence observed trends in the outcomes of

interest. This presentation highlights key

epidemiologic issues to consider when trends

analysis is being conducted.

D-31. The Availability and Use of Data From the

National Center for Health Statistics

Regarding Diabetes

This presentation discusses the current and

future availability of data pertaining to diabetes

at NCHS. Sources of the data include

interviews, physical examinations, health care

utilization surveys, and birth and death

certificates. The strengths and limitations of

these data are described. The presentation also

highlights some examples of analyses that used

these data. The examples demonstrate how the

data can be used for cross-sectional,

longitudinal, and trend studies.

D-32. Health Service Areas for the United States

This presentation describes methods used to

identify health service areas for the United

States. A health service area is defined as one

or more counties that are relatively

self-contained with respect to the provision of

routine hospital care. Hierarchical cluster

analysis was used to group counties into service

areas based on travel between counties by

Medicare beneficiaries for routine hospital care.

Four alternative solutions were generated. The

preferred solution comprises 802 service areas,

some of which cross State boundaries and split

metropolitan statistical areas.

D-33. Trends in Herpes Simplex II Using Data

From NHANES II and NHANES III

This presentation describes data from the

second and third National Health and Nutrition

Examination Surveys to look at trends in the

seroprevalence of HSV II infection in the

United States. Due to the extensive data

collected in NHANES, serologic markers can

be correlated with a variety of demographic

characteristics and health variables including

sexual behavior data.

D-34. The Serioepidemiology of Hepatitis C Virus

in the United States

This presentation describes data from the third

National Health and Nutrition Examination

Survey that provide an estimate of the

seroprevalence of hepatitis C virus (HCV) in a

representative sample of the U.S. population.

These data are the first estimates of HCV

infection in the U.S. for this recently identified

virus. Due to the extensive data collected in

NHANES, serologic markers can be correlated

with a variety of demographic characteristics

and health variables including sexual behavior

data.

D-35 Tetanus Immunity in the United States,

NHANES III

This presentation provides an estimate of

tetanus immunity levels in the United States

using data from NHANES III. Despite the

availability of effective vaccines against tetanus

since the 1940’s, NHANES III confirmed the

existence of substantial gaps in tetanus

immunity, particularly among the elderly who

were either never vaccinated or had lost

protective tetanus antibody due to waning

immunity. Risk factors for lack of immunity are

described using the extensive demographic and

health data collected in NHANES.

19

............................................................................................. Analysis and Epidemiology
D-36. Statistical Methods for Analysis of the

NHANES I Epidemiologic Followup Study

(NHEFS)

This presentation addresses a number of

statistical issues encountered in the analyses of

the NHEFS including: 1) the effect of the

survey design on parameter estimates from Cox

proportional hazards models; 2) the choice of

the time-scale for the Cox models; and 3)

modeling approaches when there are age

interactions. The effect of the strata, primary

sampling units (PSU’s), and sample weights on

parameter estimates from Cox models and their

standard errors is discussed. Additional

approaches to incorporating the survey design

that are discussed include: 1) truncating the

sample weights; 2) stratifying the analysis on

variables used in the sample design; and 3)

including variables used in the sample design in

the model. The effect of using age as the

time-scale in Cox models, rather than length of

followup, is illustrated with data examples. In

studies of chronic disease morbidity and

mortality, the effect of risk factors may change

with age. In the NHEFS, age interactions are

complicated by the oversampling of certain age

groups. A number of modeling approaches for

handling age interactions are discussed.

D-37. Research Opportunities: Current Health

Topics From the National Health Interview

Survey

This presentation provides a description of data

available from special supplements of the NHIS

and examples of research issues that can be

addressed with the data. The presentation can

be a general overview of data available from

the NHIS or can focus on specific topics of

interest. Recent topics have included cancer risk

factors, health promotion and disease

prevention, health of the elderly, dental care,

child health, occupational illness and injury,

alcohol consumption, and medical device

implants.

D-38. Injury Data From the National Center for

Health Statistics

Injury is recognized as one of the major public

health problems currently facing the United

States. NCHS collects morbidity and mortality

data related to injury. This presentation

discusses the different data collection

mechanisms and the variables used to measure

injury.

D-39. Nursing Home Utilization Profiles for an

Admissions Cohort

Data from the 1985 National Nursing Home

Survey are used to describe and characterize

utilization patterns for a cohort of first

admissions to nursing homes. Methodological

and conceptual issues involved in the analysis

and interpretation of these data are discussed.

D-40. Infant Mortality in the United States: An

Introductory Explanation

Data from a variety of NCHS data sources will

be used to provide an overview of U.S. infant

mortality. The presentation will explore the

contribution of birthweight distribution and

birthweight-specific mortality to a population’s

overall infant mortality rate. The influence of

parental factors on low-birthweight and

birthweight-specific mortality will be explored.

All of those factors will be used to examine the

marked racial and ethnic infant mortality

differences that persist in the United States.

D-41. Trends in Delayed Childbearing

American women have been postponing

marriage and childbearing to an unprecedented

extent since the early 1970’s. Because of sharp

declines in birth rates for women in their

twenties, relatively large proportions of women

are still childless at age 30. Numbers and rates

of first births for women in their thirties have

doubled, tripled, and quadrupled since 1970.

Trends in first birth rates by age of mother are

presented for 1970–92. The unique

sociodemographic composition of women who

postpone motherhood is described. Also

discussed are differentials by age of mother in

various medical and lifestyle risk factors and

infant health measures.

D-42. Teen Sexual Activity and Pregnancy

There are approximately 1 million pregnancies

among teens each year in the United States, a

20

Analysis and Epidemiology.............................................................................................
rate that surpasses that of every other

industrialized democracy. The National Survey

of Family Growth is a principal source of

estimates of the antecedents to teen pregnancy:

teen sexual activity and contraceptive use

among females. The NSFG interviewed women

aged 15–44 in 1973, 1976, 1982, 1988, and

1995, so it allows examination of trends in

levels of sexual activity among teens for more

than two decades. In addition to tracking the

incidence, the NSFG allows examination of

other aspects of sexual activity, including

whether or not first sex was voluntary; age and

other characteristics of the first voluntary and

selected other male sexual partners; number of

sexual partners within specified time frames;

current sexual activity and frequency;

contraceptive use at first and last intercourse;

formal instruction on sex education topics; and

wantedness of pregnancies. A rich array of

background characteristics is available, enabling

detailed analyses of the processes by which

teens become sexually active and the

circumstances and consequences of sexual

activity.

D-43. NHANES Anthropometric Measurements

This presentation will focus on the selection

and utility of various categories of

anthropometric measurements in health

examination surveys. The rationale for body

measures as indicators of nutritional and overall

health status along with analytic uses of these

data will be covered. A discussion of practical

considerations for obtaining standardized

anthropometric measures in the survey

environment will include techniques used to

obtain measures and approaches for quality

assurance and quality control.

D-44. Disability in America: Data From the

National Health Interview Survey

Using data from the special 1994–97 National

Health Interview Survey on Disability and data

from the redesigned NHIS of 1997 and later,

trends and differentials in the prevalence of

disability are described and analyzed.

Depending on the interests of the audience,

attention may be focussed on special

populations, such as women or minorities, or

on special types of disability, such as sensory

or mobility. Methodological issues affecting

disability estimates, such as sample coverage,

operational definitions, classification systems,

and field procedures, are also covered.

D-45. Childlessness in America

The postponement of childbearing among

younger women in the recent past has resulted

in the current pattern of larger proportions

childless at older ages. Among women reaching

the end of the chilbearing period, those aged

40–44, the percent childless rose from 9 in

1975 to 16 in 1993. The NSFG allows

examination of the phenomenon of

childlessness in a particularly meaningful way.

Since it includes information on women’s and

their partners’ biological impediments to

childbearing, and information on expectations

for future births, it is possible to distinguish

those who have or expect no children even

though they are biologically capable of

reproducing: the ‘‘voluntarily childless.’’ The

NSFG also includes measures of the subjective

desire for children, allowing one to go beyond

biological characteristics and further refine the

classification of women as ‘‘voluntarily

childless.’’ These measures have been available

in most of the five cycles of the NSFG,

allowing trend analysis over a substantial

period of time.

D-46. Women’s Health Overview: National Data

Available From the National Center for

Health Statistics to Address Health Issues of

Adult Women

This presentation provides an overview of the

NCHS data systems and how they can be used

to address questions of health and health care

utilization among women. Each data system is

described in terms of how the information is

collected, what information is obtained, and

recent improvements in the data collection.

Examples of investigations of the health of

women using each of the data systems are

provided, such as use of hormone replacement

therapy, the associations with disease outcomes,

21

............................................................................................ Analysis and Epidemiology
breast cancer mortality, prevalence and health

services use, and osteoporosis.

D-47. Firearms in American Households

After a recent survey of data on mortality and

injury involving firearms, public health

objectives for safe storage of firearms in the

home are reviewed. Home storage of firearms is

described using data from the National Health

Interview Survey, and the social and

demographic factors associated with safe

storage practices are examined. Attention is also

given to methodological issues in survey

measurement of firearm ownership and storage.

D-48. Reaching the Media With the Results of

Your Research

Most Americans and even most policymakers

receive their health news through the

media—television, newspapers, and magazines.

However, researchers and scientists are often

more adept at communicating their findings

through the scientific literature than in working

with a reporter to announce or explain their

results. This presentation provides an overview

of the media and its requirements. It covers

how to find the media, how to promote a story,

how to work better with the press, how to

ensure better coverage, and how to prepare for

media interviews.

D-49. Overweight Prevalence—Evidence From

NHANES

The goal of this presentation is to create an

awareness of a significant nutrition-related

problem of clinical and public health

importance using data on overweight and

obesity from the NHANES. Descriptive

statistics will be provided on the current

prevalence of overweight in American youths

and adults, and trends in overweight over time

will be examined based on nationally

representative data from the NCHS Health

Examination Surveys.

D-50. Analytical and Epidemiologic Applications of

NCHS Mortality Data

Mortality data from NCHS constitute one of the

most widely used indicators of health because

they are universally available down to the

small-area level, uniformly processed, and

generally of good quality. This presentation is

an overview of cause-of-death classification in

NCHS mortality data, collection and processing

of the data, and data use. The distinction is

made between underlying and multiple

cause-of-death data. Problems of comparability

among revisions of the International

Classification of Diseases are discussed briefly.

D-51. Data on AIDS Available From the National

Center for Health Statistics

In this presentation, the available data on AIDS

are described. A discussion of the problems

related to the collection and interpretation of

the data is included.

D-52. Health Data for Minority Populations

Available From the National Center for

Health Statistics

In this presentation, NCHS data systems

providing health data for minorities are

described. A discussion of issues related to the

collection, tabulation, and limitations of these

data is included.

D-53. Trends in AIDS Testing

Since 1987, the National Health Interview

Survey has tracked testing for HIV infection in

large cross-sectional samples of U.S. adults.

The data show that changes in public

knowledge and attitudes about the AIDS

epidemic were followed by changes in the

frequency and manner of testing. In addition to

reviewing those data, this presentation

addresses issues of using health survey data to

formulate and evaluate public health policy.

D-54. Issues in the Process of Revising the National

Center for Health Statistics Growth Charts

The NCHS growth charts currently used

nationally and adapted for use internationally

were developed in the mid-1970’s. Since then,

statistical and substantive concerns have been

identified with regard to the creation of the

original charts. This presentation describes

these concerns and discusses steps being

undertaken in a multiphasic process to revise

22

Analysis and Epidemiology ............................................................................................
the NCHS growth charts with data from the

1988–94 NHANES III.

D-55. Do Working-Age Adults in the United States

Have Access to Health Care? Data From the

National Health Interview Survey

In 1993, 33 million (20.9 percent) adults aged

18–64 in the United States had unmet medical

needs. In this presentation, data from the

National Health Interview Survey (NHIS)

Access to Care Supplements are used to show

the problems working-age adults have in the

United States obtaining health care. The NHIS

uses a nationally representative sample of the

civilian noninstitutionalized population of the

United States. This presentation will examine

selected access indicators by selected

demographic variables with the most current

NHIS data available. Access indicators

considered include regular source of medical

care, insurance coverage, and health care issues

such as delaying medical care due to cost and

the inability to obtain prescription medicines,

dental care, and eyeglasses.

D-56 Adolescent Health Indicators: Findings From

the Adolescent Health Chartbook

Adolescence is a period of accelerated growth

and change, bridging the complex transition

from childhood to adulthood. Young people

experience profound biological, emotional,

intellectual, and social changes, and the patterns

of behavior they adopt may have long-term

consequences for their health and quality of

life. Measurements of health status, access to

care, reproductive health, risk behaviors, and

population demographic variables during the

transition from childhood to adulthood are

presented. Many of the health status measures

are shown by single year of age or by two- or

three-year age intervals to highlight the changes

that occur in health as adolescents move

through this important developmental period.

Disparities in race, ethnicity, and

socioeconomic status and gender differences are

also presented.

23

............................................................................................ Analysis and Epidemiology
E. Data Processing

E-1. Mortality Medical Indexing, Classification,

and Retrieval System

Mortality Medical Indexing, Classification, and

Retrieval (MICAR) is an automated medical

coding system designed to accept medical terms

as input principally in natural language text via

a key-entry operator. It also has the capability

of assigning the conventional International

Classification of Diseases (ICD) codes to these

medical terms and can store and retain for

retrieval the natural language text and the ICD

codes.

E-2. Automation of Methods for Tracing Subjects

and Proxy Respondents in Longitudinal

Cohorts

As the number of longitudinal studies fielded

by NCHS grows, the burden of tracing the

cohort members, their proxy respondents, and

other contacts becomes increasingly unwieldy.

To manage the workload and maintain

consistency among the tracing efforts for a

variety of surveys, an automated system has

been implemented. This presentation includes a

discussion of a variety of techniques for

obtaining and maintaining address, telephone,

and vital status information on survey subjects.

The difficulties and advantages of automating

the tracing process are introduced. Specific

topics include confidentiality issues, techniques

for determining the information most likely to

be accurate, comparisons of results from

different tracing methods, and processing

considerations such as database storage and the

user interface. Some examples from the NCHS

automated system are presented.

E-3. Survey Statistics Automation

NCHS is developing a completely automated

system from source data collection to final

report dissemination. Data collection, editing,

processing, analysis, report preparation,

publishing, and dissemination will be

accomplished through a system of portable and

fixed microcomputers networked with a large

mainframe computer. The system will also

allow survey instrument design and processing

by microcomputer.

E-4. Statistical Export and Tabulation System

(SETS) Data Retrieval Software

SETS is a unique collection of programs that

enable the personal computer user to easily

access data formerly available only on a

mainframe computer. This software was

developed by the National Center for Health

Statistics for distribution of survey data on

CD-ROM. The SETS software can be used on

virtually any data set. The data applications

produced with this kit may be distributed

without licensing fees. This presentation

includes a discussion on the benefits of using

the SETS software for data retrieval and a

demonstration of the capabilities of the SETS

software, which includes browsing data and

documentation, generating tables and queries,

creating data subsets, and exporting data from

SETS to EPI Info, SAS, SPSS, and BMDP.

E-5. Introduction to the Statistical Export and

Tabulation System (SETS) Designer Kit

Workshop

This introductory workshop teaches how to use

SETS software to incorporate documentation

and data as one set for distribution on diskette

or CD-ROM. The workshop is designed to give

students hands-on experience using SETS. Each

student must have an IBM-PC compatible

microcomputer 80286 or greater, at least 640K

memory, MS-DOS 3.31 or higher, and at least

20 MB of free space on the hard drive. The

students will use the SETS Designer Kit to

design the format to display their

documentation and data, develop files that

contain documentation and data as well as

codes and values, analyze and revise errors in

compilation and indexing of the set, and

produce a set and pack it to diskettes.

24
F. Other

F-1. A Career in Statistics With the National

Center for Health Statistics

In this presentation, a description is given of

the types of statistical problems that a

statistician at the National Center for Health

Statistics (NCHS) is often asked to solve. Most

of the problems deal with the subject areas of

sampling and survey design. The discussion

includes methodological topics that vary from

speaker to speaker, and it may relate to surveys

of institutionalized or noninstitutionalized

individuals, minority populations, or health care

establishments. Examples of topics include

optimum recall periods, use of the Yellow

Pages to supplement sampling frames,

correcting for undercoverage bias in a

random-digit-dialed survey, and designing a

Hispanic health and nutrition survey. The

presentation is intended primarily for students

in statistics who are contemplating different

career choices, including that of survey

designer.

F-2. Minorities in Statistics

Minorities, particularly black people, Hispanics,

and American Indians, are underrepresented in

the field of statistics. Special efforts are being

made at NCHS and other Federal agencies to

inform minorities of the advantages and

excellent opportunities relating to statistical

careers. In this presentation, topics of particular

interest to minorities are discussed, including

the study and analysis of racial and ethnic

statistics in such areas as labor, income, and

health characteristics.

F-3. Geography Careers in Public Health

Geographers can make important career

contributions to the Centers for Disease Control

and Prevention and the field of public health.

With the increasing demand for spatial analysis

at all levels of government and a growing

emphasis on multidisciplinary approaches to

problem solving, geographers need to take a

more active role in this dynamic area. In this

presentation, a variety of issues are delineated

to better prepare geographers for occupational

access to public health. Curriculum

strengthening, minority job opportunities,

employment strategies, and the uses of spatial

statistical tools in public health applications are

discussed.

F-4. Funding Opportunities Under the Minority

Health Statistics Grants Program

This presentation describes funding

opportunities available to extramural

researchers under the grants program. An

overview of the selection of the appropriate

financial assistance mechanism, preparation of

the funding announcement, and pre- and

post-award phases of sponsored research will

be discussed.

F-5. Understanding and Applying Statistical

Ethics

The American Statistical Association (ASA) has

adopted a revised and comprehensive set of

‘‘Ethical Guidelines for Statistical Practice,’’

November 1999. There are also United Nations

guidelines for official statistics systems. The

idea of statistical ethics is fairly new, having

been popularized by W. Edwards Deming in the

1960’s and 70’s. Successive ethics documents,

including the 1985 Declaration on Professional

Ethics of the International Statistical Institute,

have become more complex as public interest

in, and government oversight of, research ethics

have grown. Current statistical ethics derives

from diverse sources including ethical

philosophy, the concept of professional ethics

(as applied to doctors, lawyers, engineers, and

others), previous writings on statistical ethics,

and evolving ethical issues in society and in

research. There continue to be open issues

under consideration for future revisions of the

guidelines by the ASA’s Committee on

Professional Ethics. The presenter led the

development of the current ASA Ethical

Guidelines, advised the International Statistical

Institute on formation of its own Committee on

Professional Ethics, and has taught the first

ASA continuing education course in statistical

ethics. Emphasis in the presentation is on using

an understanding of statistical ethics to solve

practical problems in actual statistical work

environments.

25
DEPARTMENT OF

HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

6525 Belcrest Road

Hyattsville, Maryland 20782-2003

OFFICIAL BUSINESS

PENALTY FOR PRIVATE USE, $300

DHHS Publication No. (PHS) 2000-1302

0-0603 (9/00)

STANDARD MAIL (A)

POSTAGE & FEES PAID

CDC/NCHS

PERMIT NO. G-284