Appendix B
National and Community Health Data Sets
NATIONAL DATA SETS
The most readily available health-outcomes data for the United States are mortality data, which are derived from death certificates and population health surveys and contain self-reported health and functional status. The national surveys most often used are the Behavioral Risk Factors Surveillance System (BRFSS) and the National Health Interview Survey (NHIS), which provide data annually, and the National Health and Nutrition Examination Survey (NHANES), which provides data every 2 years (CDC, 2008, 2009a, 2009b).
The Behavioral Risk Factors Surveillance System
BRFSS is a cross-sectional telephone-based survey that collects information on changes in health conditions and risk factors (Mokdad, 2009). State health departments conduct BRFSS with support and design from the Centers for Disease Control and Prevention (CDC). Most states use BRFSS as their primary source of chronic-disease data for evaluating health behaviors in the population. BRFSS is the world’s largest telephone survey and has 413,000 adult participants each year (Balluz, 2010); it is offered in English and Spanish (CDC, 2008). The goals of BRFSS are to assess public health status, define public health priorities, evaluate programs, stimulate research, and monitor trends (Balluz, 2010). BRFSS provides state-level estimates and estimates for selected metropolitan statistical areas that have 500 or more respondents. It collects demographic variables on race, sex, age, income categories, education level, and number of children in the household
(Mokdad, 2009). The BRFSS questionnaire is organized by core and optional modules and includes individual-level risk factors associated with causes of premature death (Mokdad, 2009). More detailed information on chronic conditions—including diabetes, cardiovascular health, high blood pressure, and adult asthma—are included in optional modules (Balluz, 2010).
The National Health Information Survey
NHIS, supported by the CDC’s National Center for Health Statistics (NCHS), is a large-scale cross-sectional household interview survey. The survey includes information on population disease prevalence, extent of disability, and use of health care services and is offered in English, Spanish, and other languages. NHIS describes disease prevalence from self-reports of diagnoses received from clinicians (Burrows et al., 2007). The expected NHIS sample includes about 35,000–40,000 households with 75,000–100,000 persons of all ages. To provide state or local estimates of health outcomes and determinants of health, a few states and local areas, such as Wisconsin and New York City, conduct their own surveys based on the NHIS (and NHANES) method (CDC, 2009a; Parrish, 2010).
The National Health and Nutrition Examination Survey
NHANES is a “program of studies designed to assess the health and nutritional status of adults and children in the United States.” It combines interviews with physical examinations and is conducted by NCHS (CDC, 2009a). A nationally representative sample of about 5,000 people are interviewed each year. NHANES includes demographic, socioeconomic, dietary, and health-related questions offered in English and Spanish. The examination component consists of medical, dental, and physiologic measurements, including laboratory tests. The data from the survey are used to determine the prevalence of major diseases and risk factors for diseases (CDC, 2009a).
Limitations of the Behavioral Risk Factors Surveillance System, the National Health Information Survey, and the National Health and Nutrition Examination Survey
BRFSS, NHIS, and NHANES all have limitations and challenges. BRFSS has a declining and low response rate (for example, 18 percent in California and a national median of 34 percent—a lower response rate than NHIS and NHANES) and inadequate time available for questions, responses are self-reported, data are available only at the state level (and some large jurisdictions), and the survey contains no biometric measurements. BRFSS includes
few or no measures of newer constructs of community health, such as social cohesion, resilience, and literacy.
Data in national data sets can sometimes be stratified for a state, or state data may be available from a state’s own efforts (for example, a state-based Health and Nutrition Examination Survey), but local leaders who seek statistics for their county, city, or census tract face challenges in obtaining geocodable data. The obstacles are sometimes methodologic—as when sample sizes or survey techniques are problematic in sparsely populated rural communities—but often the difficulty is that source agencies have done little either to collect the data or, when the data are available, to make the information readily available to the typical decision-maker.
Procedures used by researchers to extract geocodable microdata from agency data warehouses or to file paperwork for agency approvals to integrate such data often pose a formidable barrier for busy policy-makers or staff of public health agencies. Making such data accessible to those important users requires efforts at a high level to develop a front end that enables users to obtain available statistics easily and to cross government agency silos (such as planning, zoning, transportation, and education) to gather and report relevant local data from multiple sources in a useful way.
NHIS does provide health status information on a representative sample of Americans, but it does not provide state or local estimates. BRFSS provides state estimates, but it does not provide local data, and it provides minimal data on children. To complement what they obtain from BRFSS, 16 states provide funding to enhance their BRFSS samples with substate sampling strata to generate their own representative local data sets, and others add their own modules on other topics of interest to them. Eleven states have established separate comprehensive surveys independent of BRFSS, such as the California Health Interview Survey (CHIS), to meet their needs for local and state data not being served by BRFSS (UCLA Center for Health Policy Research, 2008), and 10 states conduct independent surveys to assess the health of children (UCLA Center for Healthier Children, 2010).
Several states conduct city or county surveys on the basis of BRFSS and have been able to use the data to monitor trends and risks (CDC, 2009b), but overall the data are not adequate for use at the local level (and cannot measure inequalities in health that occur at the community level and among population subgroups), because samples are too small for calculating reliable estimates (Parrish, 2010). NHIS and NHANES provide only national and some large regional estimates because of their sampling schemes and relatively small samples. Because a premium is placed on statistical rigor and because securing financing for the surveys and supplements is complex, these sources do not adapt rapidly to and maximize opportunities afforded by available communication technologies. In addition, data are not available
as rapidly as needed, and some content reflects the needs of funders rather than the overall needs of public health.
COMMUNITY DATA SETS
One early effort in population health measurement and reporting is America’s Health Rankings (AHR), which was begun in 1990 and provides a scorecard of health determinants and health-outcome measures and an overall ranking for each state (America’s Health Rankings, 2009). In 2009, a county analogue to AHR, the County Health Rankings, was released; it ranks counties in each state on specific health measures (County Health Rankings, 2010a). The Community Health Status Indicators (CHSI) activity was initiated in 2000 and relaunched in 2006 by a collaborative group of federal, state, and local public health representation and nonprofit and academic partners (County Health Rankings, 2009).1 CHSI provides detailed health (and related) measures by county and allows users to compare peer counties (for example, counties with similar sociodemographic characteristics).
The interest in and proliferation of health indicators is linked to a national concern about health-related costs and health-system effectiveness and to a federal initiative on key national indicators (for example, related to population, economy, environment, health, education, and commerce) that began early in the 21st century. In 2003, the General Accounting Office (GAO), now the Government Accountability Office, held a forum on key national indicators in collaboration with the National Academies (GAO, 2003). In 2003 and 2004, GAO prepared several reports on the key indicators initiative; in 2004, the Organisation for Economic Co-operation and Development reported on this subject in its World Forum on Key Indicators (GAO, 2004). The Academies continue to serve as the secretariat for the effort, supporting several activities that include a recent Institute of Medicine committee convened to identify 20 health indicators in three domains (health outcomes, health-related behaviors, and medical care delivery systems) to track progress in health and health care (IOM, 2009). These will be incorporated into the State of the USA (SUSA) project, which is likely to be the repository for the Key National Indicators required by the Affordable Care Act in subjects including health and managed by the
National Academies (more information is available on the SUSA website2; see Public Law 111-148).
Tables B-1 (national indicator sets) and B-2 (community indicator sets) present samples of the numerous indicator sets in existence. Those represented in the table were chosen because they are the best known and are representative sets regarding the types of indications used currently in the United States. To view more exhaustive reviews of the existing data sets, see Public Health Institute (2010) and Wold (2008).
REFERENCES
Alameda County Public Health Department. 2008. Life and Death from Unnatural Causes: Health and Social Inequity in Alameda County. Oakland, CA: Alameda County Public Health Department.
America’s Health Rankings. 2009. A Call to Action for Individuals and Their Communities. Minnetonka, MN: United Health Foundation.
America’s Health Rankings. 2010. Definitions of Components: Core Measures and Supplemental Measures. http://www.americashealthrankings.org/2009/component.aspx (June 4, 2010).
Balluz, L. 2010. (January 21, 2010). Behavioral Risk Factor Surveillance System (BRFSS). Presentation to the IOM Committee on Public Health Strategies to Improve Health. Washington, DC: IOM.
Burrows, N. R., S. Parekh, Y. Li, L. S. Geiss, and CDC. 2007. Prevalence of self-reported cardiovascular disease among persons aged >35 years with diabetes—United States, 1997–2005. Morbidity and Mortality Weekly Report 56(43):1129-1132.
CDC (Centers for Disease Control and Prevention). 2008. Behavioral Risk Factor Surveillance System: About the BRFSS. http://www.cdc.gov/brfss/about.htm (January 1, 2010).
CDC. 2009a. About the National Health Interview Survey. http://www.cdc.gov/nchs/nhis/about_nhis.htm (January 6, 2010).
CDC. 2009b. Overview: BRFSS 2008. http://www.cdc.gov/brfss/technical_infodata/surveydata/2008/overview_08.rtf (January 6, 2010).
Community Health Status Indicators. 2009. Community Health Status Indicators Project Fact Sheet. Washington, DC: HHS.
Community Health Status Indicators Project Working Group. 2009. Data Sources, Definitions, and Notes for CHSI 2009. Washington, DC.: Department of Health and Human Services.
County Health Rankings. 2009. About the Community Health Status Indicators Project. http://www.countyhealthrankings.org/latest-news/how-washington-county-residents-stay-healthy (January 6, 2010).
County Health Rankings. 2010a. Data Collection Process. http://www.countyhealthrankings.org/about-project/data-collection-process (February 17, 2010).
County Health Rankings. 2010b. How Healthy Is Your County? New County Health Rankings Give First County-by-county Snapshot of Health in Each State. http://www.countyhealthrankings.org/latest-news/healthday-county-county-report-sizes-americans-health (February 17, 2010).
GAO (Government Accountability Office). 2003. Forum on Key National Indicators. Washington, DC: GAO.
GAO. 2004. Informing Our Nation: Improving How to Understand and Assess the USA’s Position and Progress. Washington, DC: GAO.
HHS (Department of Health and Human Services). 2009a. Healthy People 2020 Framework. http://www.healthypeople.gov/hp2020/objectives/framework.aspx (April 28, 2010).
HHS. 2009b. Healthy People 2020 Public Meetings—2009 Draft Objectives. Washington, DC: Department of Health and Human Services.
IOM (Institute of Medicine). 2009. State of the USA Health Indicators: Letter Report. Washington, DC: The National Academies Press.
Mokdad, A. H. 2009. The Behavioral Risk Factors Surveillance System: Past, present, and future. Annual Review of Public Health 30:43-54.
Parrish, R. G. 2010. Measuring population health outcomes. Preventing Chronic Disease Public Health Research, Practice and Policy 7(4). http://www.cdc.gov/pcd/issues/2010/jul/10_0005.htm. (July 4, 2010).
Public Health Institute. 2010. Data Sets, Data Platforms, Data Utility: Resource Compendium. Oakland, CA: Public Health Institute.
Saskatoon Regional Health Authority. 2007. 2006-2007 Annual Report to the Minister of Health and the Minister of Healthy Living Services. Saskatoon, Canada: Saskatoon Regional Health Authority.
Seattle and King County Public Health. 2010. King County Community Health Indicators. http://www.kingcounty.gov/healthservices/health/data/chi.aspx (January 6, 2010).
Summers, C., L. Cohen, A. Havusha, F. Sliger, and T. Farley. 2009. Take Care New York 2012: A Policy for a Healthier New York City. New York: New York City Department of Health and Mental Hygiene.
SUSA (State of the USA). 2010a. Mission. http://www.stateoftheusa.org/about/mission (June 11, 2010).
SUSA. 2010b. The State of the USA. http://www.stateoftheusa.org (September 1, 2010).
Trust for America’s Health. 2010. State Data. http://healthyamericans.org/states (October 15, 2010).
UCLA (University of California, Los Angeles) Center for Health Policy Research. 2008. About CHIS. http://www.askchis.com/about.html (September 1, 2010).
UCLA Center for Healthier Children. 2010. Framework for System Transformation. http://healthychild.ucla.edu/Transformation.asp (June 16, 2010).
Wold, C. 2008. Health Indicators: A Review of Reports Currently in Use. Conducted for The State of the USA. Wold and Associates.
TABLE B-1 National Indicator Sets
|
America’s Health Rankings (AHR) |
County Health Rankings (CHR) |
Community Health Status Indicators (CHSI) |
Total number of indicators |
39 |
26 |
200 |
Purpose |
The purpose of AHR is to have a comparable and comprehensive national and state measure of health and health outcomes. |
The purpose of CHR is to illustrate how factors in the environment affect health outcomes, such as a person’s health and longevity. CHR is a “call to action” for state and local health departments and community leaders outside the public health sector to improve community health. |
The purpose of CHSI is to provide health providers and community members with local community health indicators and encourage action in improving the community’s health. |
Primary data sources |
Public, federal sectora |
Public, federal sector,b local-area data |
|
Population-health outcome measures |
Mortality
Morbidity Quality of life
Poor birth outcomes
|
Mortality
Morbidity Health-related quality of life
Birth outcomes
|
Mortality
Health-related quality of life
|
Healthy People 2020 (HP2020) |
State of the USA (SUSA) |
Trust for America’s Health (TFAH) |
38 (objectives) |
20 |
32 |
The purpose of HP2020 is to provide the nation with science-based, 10-year objectives for promoting health and preventing disease and in doing so to increase the population’s quality of life and eliminate health disparities. |
The purpose of SUSA is to assist people in tracking progress in health and health care in the United States by using high-quality statistical data and to compare the United States with other countries. |
The purpose of TFAH’s state data is to rank states on various public health issues and health outcomes to prevent communicable and chronic diseases and to hold officials accountable for their performance on public health issues and activities. |
Public, federal sector |
Public, federal sector, nonprofit sector, internationalc |
Public, federal sector, nonprofit sectord |
Morbidity
Health-related quality of life
|
Mortality
Health-related quality of life
|
Mortality
|
|
America’s Health Rankings (AHR) |
County Health Rankings (CHR) |
Community Health Status Indicators (CHSI) |
Domain (or equivalent)
|
Mortality
Morbidity
Chronic disease
Environmental, community
Economic
|
Education
Employment
Income
Family and social support
Community safety
Physical environment
Built Environment
|
Chronic diseases, health problems
Environmental health |
Healthy People 2020 (HP2020) |
State of the USA (SUSA) |
Trust for America’s Health (TFAH) |
Chronic disease, health problems
Environmental, community
|
|
Alzheimer’s disease Chronic diseases, health problems
Communicable, infectious diseases
Sexually transmitted diseases
Community
|
|
America’s Health Rankings (AHR) |
County Health Rankings (CHR) |
Community Health Status Indicators (CHSI) |
Behavior domain (or equivalent) |
|
Health behavior Tobacco Use
Diet and exercise
Alcohol use
Unsafe sex
|
|
Health care domain: access, use, services, other |
|
Access to care
Quality care
|
Preventive-service use |
Healthy People 2020 (HP2020) |
State of the USA (SUSA) |
Trust for America’s Health (TFAH) |
|
|
|
|
Access to Care
|
TABLE B-2 Community Health Data Sets
|
Alameda County |
Total number of indicators |
60 |
Purpose |
The purpose of the Alameda County Public Health Department’s report is to provide a detailed description of inequities in the economic, social, physical, and service environments affecting health and leading to death from “unnatural causes.” Data and policy analysis can be used by residents to identify and advocate for policies that can reduce social and health inequalities, evaluate progress, and propose polices that affect inequities. |
Primary data sources |
Public sector, governmenta |
Population health outcome measures |
|
Seattle–King County |
City of Saskatoon |
New York City |
67 |
31 |
33 (10 core) |
The purpose of King County Community Indicators is to provide a broad array of comprehensive, population-based data to community-based organizations, community health centers, public agencies, policy-makers, and the general public. |
The purpose of Saskatoon’s community analysis is to describe the extent of health disparity, determine the causes of the health disparity, explain that most health disparity is preventable, and suggest that evidence-based policy options with sufficient public support should proceed into action. |
The purpose of NYC Policy for a healthier New York is to improve the health of New Yorkers; having policy-makers, residents, communities, businesses, organizations by developing policies, laws, regulations that will improve environmental, economic, social conditions affecting health; emphasizing preventive health care, improving quality of care, expanding access to care; health promotion to inform, educate, engage residents to improve their health, health of their communities. |
Public sectorb |
Public sectorc |
Public sector |
Mortality
Health outcomes, overall health
|
Mortality
|
|
Alameda County |
Domain (or equivalent)
|
Chronic diseases, health problems
Environmental, community
Transportation
Housing
Air quality
|
Behavior domain |
Physical activity
|
Seattle–King County |
City of Saskatoon |
New York City |
Communicable disease
Chronic diseases
Physical, environmental
|
Unemployment rate Income level Education level House prices Oral health Chronic diseases, health problems
Environmental, community |
Chronic diseases, health problems
Environmental, community |
|
|
|
Alameda County |
Health care access, use, services, other |
|
Other domains |
School performance, condition
Criminal justice
|
a Data sources include California Health Interview Survey 2003, 2005; FBI: Uniform Crime Report; Alameda County Sheriff’s Office; California Department of Finance; Alameda County Probation Department; Census Bureau 2000; California Center for Public Health Advocacy; California Department of Alcohol Beverage and Control; Environmental Protection Agency; California Department of Education; California Office of Statewide Health Planning and Development; California Highway Patrol, National Transit Database; Communities for a Better Environment; Labor Market Information System; State of cities Data System; |
Seattle–King County |
City of Saskatoon |
New York City |
|
|
|
Nativityww Overall health
Maternal, child health
Reproductive health
Injury, violence
|
Children 10–15 years old
|
|
DataQuick: Foreclosures; National Association of Homebuilders, Federal Financial Institutions Examination; Department of Housing and Urban Development; American Community Survey; Department of Commerce, Bureau of Economic Analysis; Census 2000 Equal Employment Opportunity Data. b Data sources include Births, deaths, abortions, hospitalizations: Washington State Department of Health, Center for Health Statistics; BRFSS, Department of Health and |