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Update Healthy New Jersey 2000
Second Update and Review

Appendix II
Healthy New Jersey 2000 - Second Update And Review
Technical Notes

Major Data Sources

Data from birth and death certificates provide the measurement of achievement for a number of the objectives encompassed by Healthy New Jersey 2000. Birth certificates are usually completed by hospital personnel, while death certificates are prepared by hospital personnel, physicians, medical examiners, and funeral directors. New Jersey law requires that certificates of all births and deaths which occur in the state must be filed with the Local Registrar within a specified time period of occurrence. The certificates are then submitted to the office of the State Registrar, where they are recorded and filed permanently.

For public health planning and policy determination, the most useful population to study is usually the resident population of an area. For the objectives comprising Healthy New Jersey 2000 which use birth and death data to measure progress, the data presented are for New Jersey residents. The National Center for Health Statistics sponsors a program of resident certificate exchange among the registration areas in the country, which fosters transfer of information on events occurring to out-of-state residents to the state of residence. This is particularly important to New Jersey, as a number of births to female residents of this state and deaths of New Jersey residents occur in New York and Pennsylvania.

Morbidity data (data on communicable diseases) contained in this report also relate to New Jersey residents. Reports of communicable diseases diagnosed in other states in New Jersey residents are transmitted to the New Jersey Department of Health and are included in the data contained in this report.

Data related to health behaviors in this report are from the survey results of the New Jersey Behavioral Risk Factor Surveillance System (BRFSS). The New Jersey BRFSS is part of the national Behavioral Risk Factor Surveillance System, a telephone survey of adults aged 18 and over. This survey is designed to monitor modifiable risk factors for chronic diseases and other leading causes of morbidity and death. This survey is a cooperative effort between the national Centers for Disease Control and Prevention (CDC) and all states, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands. The New Jersey Department of Health has been participating in the survey since 1991, collecting approximately 125 interviews per month through 1995 and nearly twice that number in 1996 through 1998.

Racial And Ethnic Classification

Racial designations used in this report are white, black, and minority, which includes all racial groups other than white (including black). The reporting of ethnicity is limited to Hispanic and non-Hispanic categories. These classifications are based on self-reports, or in the case of death records, on reports from respondents, usually a family member, or from persons responsible for preparing the death certificates. The race and ethnicity of an infant are not reported on the birth certificate and are classified for statistical purposes as the race and ethnicity of the mother.

A racial group (white, black, or a detailed list of twelve other races and an unknown race category) and an ethnicity (Hispanic or non-Hispanic) are reported for each individual for whom a vital record is filed. Thus persons who are identified as Hispanic also have been included in any analysis of data by race. For example, individuals may be designated as white Hispanic, black Hispanic, minority Hispanic, white non- Hispanic, black non-Hispanic, or minority non-Hispanic. Therefore, for objectives related to race (white, black, or minority), Hispanics and non-Hispanics may be included in each racial group. For objectives related to Hispanic ethnicity, persons identified as Hispanic include whites, blacks, and other races.

Development of Health Objectives for High Risk Groups

Where the relevant data were available, health objectives were developed for high-risk groups of the population, in addition to an objective for the total population. In general, these high-risk groups were defined by race, ethnicity or age. In addition, there were a few gender-specific areas, such as breast and cervical cancer, for which sex-specific objectives were set.

In general, data are available for births, deaths, and survey results from the Behavioral Risk Surveillance System for each of the major demographic subgroups. However, at the time that Healthy New Jersey 2000 was developed, population estimates provided by the U.S. Bureau of the Census only provided distribution by age, sex, and race (white and all races other than white). Estimates of the black population and of persons of Hispanic origin were not available. Thus, for objectives which required population estimates as denominators for rates, it was not possible to set objectives specifically for blacks or Hispanics. This was the case for objectives which used the death files for measurement. As a result, data for all races other than white were used as a "minority" category and when this group had higher death rates (qualifying as a high- risk group), separate minority sub-objectives were set. Because there were no population estimates available for the Hispanic population, it was not possible to determine whether there was a need for separate sub-objectives related to targeted causes of death for this population.

Most of the objectives related to birth outcomes use the total number of births as the denominator, therefore where the black or Hispanic population was at high-risk, special sub-objectives were set for these population groups. Recent population estimates provided by the Census Bureau include distribution of race in four categories: white, black, American Indian and Asian/Pacific Islander. Additionally, estimates of the Hispanic population by age, race, and sex categories are now provided.

Definitions

Active Case of Tuberculosis -- also referred to as a new verified case of tuberculosis. These cases are characterized by (1) any bacteriological confirmation of the presence of Mycobacterium tuberculosis or (2) in the absence of bacteriological confirmation, for a diagnosis of active pulmonary tuberculosis the patient must present a positive purified protein derivative (PPD), or must exhibit a positive chest x-ray, or in the case of children, must be epidemiologically linked to another active case of tuberculosis. In the case of extrapulmonary tuberculosis, the patient must show signs of clinical improvement while taking tuberculosis medication (K. Shilkret, personal communication, 1992).

Birth Weight -- the first weight of the fetus or newborn obtained after delivery. Birth weight is recorded in grams.

Cause of Death Classification -- a system of specification of the diseases and/or injuries which led to death and the sequential order of their occurrence. The version of the system currently in use is the International Classification of Diseases, Ninth Revision (1977), sponsored by the World Health Organization.

Infant Death -- death within the first year of life.

Life Expectancy -- the expected number of years to be lived, on average, by persons born in the year analyzed.

Live Birth -- the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy, which, after such separation, breathes or shows any evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.

Low Birth Weight -- birth weight of less than 2,500 grams or approximately 5 pounds, 8 ounces. Prior to 1989, New Jersey defined low birth weight as 2,500 grams or less.

Maternal Death -- a death in which the certifying physician has designated a maternal condition as the underlying cause of death. In the Ninth Revision of the International Classification of Diseases, (1977), the World Health Organization defined a maternal death as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes".

Minority -- all races other than white.

Motor Vehicle-Related Fatalities -- Motor vehicle-related fatalities is a broad term encompassing a number of different types of motorized vehicles and a variety of circumstances covering an encounter of an individual with a motorized vehicle. A motor vehicle is defined in Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, Volume 1 as "any mechanically or electrically powered device, not operated on rails, upon which any person or property may be transported or drawn upon a highway. Any object such as a trailer, coaster, sled, or wagon being towed by a motor vehicle is considered a part of the motor vehicle". The Manual includes automobile, bus, construction, industrial or farm machinery, fire engine, motorcycle, moped, motorized scooter, trolley bus not operating on rails, truck, and van in its definition of motor vehicle. Persons killed or injured by a motor vehicle can be drivers, passengers, bicyclists, or pedestrians.

Stages of Syphilis (Larsen and Kraus, 1990):

Primary Syphilis -- begins within approximately 30 hours after infection; a primary chancre usually forms within two through six weeks of infection. Both treponemal and nontreponemal antibodies appear one through four weeks after the lesion has formed. Even without treatment, the lesion usually resolves within two months.

Secondary Syphilis -- occurs within six weeks of healing of the primary lesion. Disseminated lesions appear that are attributable to systemic infection. Virtually every organ and tissue of the body are affected. Whether treated or untreated, the lesions of secondary syphilis usually resolve within 2 through 10 weeks.

Trimester of Pregnancy -- the first trimester includes the first 12 weeks of pregnancy, the second trimester encompasses the thirteenth through twenty-fourth weeks and the third trimester is the period after the twenty-fourth week through delivery.

Underlying Cause of Death -- the disease or injury which initiated the train of events leading directly to death or the circumstances of the unintentional injury or violence which produced the fatal injury. All cause- of-death data in this report relate to the underlying cause of death coded from the death certificate, except falls and fall-related injuries which come from the multiple cause of death file.

Very Low Birth Weight -- birth weight of less than 1,500 grams or approximately 3 pounds, 5 ounces.

Rates and Ratios

The presentation of vital statistics in the form of rates and ratios facilitates comparisons between political subdivisions with populations of different sizes or between subgroups of a population. Crude rates are calculated by dividing the number of events of a type that occur to the residents of an area, e.g., births, deaths, by the resident population of an area or subgroup. The events are limited to those that occur within a specific time period, usually a year, and the population is, in general, the mid-year estimate of the resident population of the area, although census counts as of April 1 may be used in decennial census years. Crude rates are expressed in terms of occurrences within a standard, rounded population, usually 1,000 or 100,000.

While the denominators for rates consist of the population at risk of the events included in the numerator (e.g., births, deaths), ratios are designed to indicate the relationship between two counts in which the denominator population is not at risk of the events included in the numerator. An example of a ratio contained in this report is the maternal mortality ratio in which the number of deaths due to maternal causes forms the numerator and the number of live births provides the denominator.

In order to compare natality and mortality experience among various ages and races or between the sexes, rates may be computed for subgroups of the population. These are referred to as age-, race-, or sex-specific rates and are calculated by dividing the relevant events within a subgroup by the population in the subgroup. Death rates from specific causes may also be calculated, with the numerator consisting of the deaths from the particular cause in an area and the denominator comprised of the population at risk of the disease or condition.

The definition of rates and ratios used in this report follows. It should be noted that alternative forms exist for some of these statistics. Some other states and the federal government may employ different formulae for the computation of selected rates.

Age-Adjusted Death Rate -- Direct Method-the elimination of the effect of age on the crude death rates for purposes of comparison with other rates by applying actual age-specific rates to a standard population. The resulting death rate in the standard population is age-adjusted and can be compared to other death rates age-adjusted to the same standard population.

Age-Specific Birth Rate -- the number of resident live births to females in a specific age group per 1,000 females in the age group.

Cause-Specific Death Rate -- the number of resident deaths from a specific cause per 100,000 population.

Crude Death Rate -- the number of resident deaths per 100,000 population.

General Fertility Rate -- the number of resident live births per 1,000 females aged 15 through 44 years.

Infant Death Rate -- the number of resident deaths under one year of age per 1,000 population.

Infant Mortality Rate -- the ratio of the number of deaths to children less than one year of age in a given year per 1,000 births in the same year.

Maternal Mortality Ratio -- the number of resident deaths from complications of pregnancy, childbirth, and the puerperium per 100,000 resident live births.

Total Fertility Rate -- age-specific birth rates of women in five-year age groups multiplied by five and summed to form a total for all ages. This rate yields the number of children a cohort of 1,000 women would bear if they experienced the existing age-specific birth rates throughout their childbearing years.

Caution should be exercised in the interpretation of rates and ratios based on small numbers.

Statistical Methodology

Age-Adjusted Rates -- The numbers of births and deaths in an area are directly related to the demographic characteristics of the area's population. In comparing rates over time or among geographic areas, it is helpful to eliminate the effects of the differences in the populations' demographic characteristics on the comparison. This can be accomplished through adjustments of the rates for the particular characteristics of interest. Since age is the variable that has the greatest effect on the magnitude of rates (Shryock, Siegel and Associates, 1976), the most common type of adjustment of rates is for age.

There are at least two methods of calculating an age-adjusted death rate: the Direct Method and the Indirect Method. Several different standard populations are currently in use by various agencies and groups. In this report, the age-adjusted rates follow the standard set by the National Center for Health Statistics and Healthy People 2000 in using the Direct Method and the 1940 standard population. Direct adjustment of vital statistics rates involves application of existing rates (age-, race-, or sex-specific) to a standard population to arrive at the theoretical number of events that would occur in the standard population, at the rates prevailing in the actual population. These events are then divided by the total number of persons in the standard population to arrive at an adjusted rate. Adjusted rates are index numbers and cannot be compared to crude or other actual rates. The use of adjusted rates is limited to comparison with other adjusted rates, based on the same standard population. The standard population used in this report is the United States 1940 standard million, derived from the counts of the 1940 decennial census.

Years of Potential Life Lost (YPLL) -- Crude and age-adjusted death rates have traditionally been used to examine the relative importance of the various causes of death acting upon a population. Since most deaths occur in the older age groups, these measures are heavily weighted toward the mortality experience of the elderly. An important public health priority, in general, and one of the overarching goals of Healthy New Jersey 2000 is the prevention of premature death, i.e., deaths that occur earlier than the average life expectancy or prior to some selected age, such as 65. A measure used to reflect the trends in premature mortality is years of potential life lost (YPLL). YPLL represents the summation of all of the years of life not lived to a defined upper limit. For this report, the YPLL age limit is set at 65. Deaths at younger ages receive a greater weight in computing YPLL than do deaths at older ages, e.g., one death at age 20 adds 45 years to YPLL, while a death at age 64 adds only one year to YPLL. Thus the death of one 20 year old is equivalent to the deaths of 45 persons aged 64 in the computation of years of potential life lost. The YPLL rate is the total YPLL in years, divided by the appropriate population under the age of 65.

Abbreviations and Acronyms

3TC -- an AIDS drug

ACS -- Ambulatory Care Sensitive (Condition)

ADDP -- AIDS Drug Distribution Program

AIDS -- Acquired Immune Deficiency Syndrome

ASSIST -- American Stop Smoking Intervention Study

ATSDR -- Agency for Toxic Substances and Disease Registry

CABG -- Coronary Artery Bypass Graft

CVD -- Cardiovascular Disease

ddl -- an AIDS drug

DOT -- Directly Observed Therapy (for tuberculosis)

DUI -- Driving Under the Influence

ESRD -- End-Stage Renal Disease

FACE -- Fatality Assessment and Control Evaluation (Project)

Hib -- Haemophilus Influenzae type b

HIV -- Human Immunodeficiency Virus

HMO -- Health Maintenance Organization

MDRTB -- Multiple Drug Resistant Tuberculosis

N/A -- Not Available

NICU -- Neonatal Intensive Care Unit

NJDOH -- New Jersey Department of Health

NPL -- National Priorities List

PAMR -- Pregnancy-Associated Mortality Review

PRO -- Peer Review Organization

PSA -- Prostate-Specific Antigen (Test)

SIC -- Standard Industrial Classifications

STD -- Sexually Transmitted Disease

TANF -- Temporary Aid to Needy Families

TASE -- Tobacco Age of Sale Enforcement (Program)

TB -- Tuberculosis

TBI/SCI -- Traumatic Brain Injury/Spinal Cord Injury

UMDNJ -- University of Medicine and Dentistry of New Jersey

WIC -- Women, Infants, and Children (Program)

YPLL -- Years of Potential Life Lost

ZDV/AZT -- Zidovudine, formerly Azidothymidine (an AIDS drug)

ICD-9 Codes for Mortality Objectives

HIV infection 042-044

 
Colorectal cancer 153.0-154.3, 154.8, 159.0

 
Lung cancer 162.2-162.9

 
Breast cancer 174

 
Cervical cancer 180

 
Coronary heart disease 402, 410-414, 429.2

 
Cerebrovascular disease 430-438

 
Cirrhosis 571

 
Motor vehicle injury E810-E825

 
Falls and fall-related injuries E880-E888

 
Suicide E950-E959

 
Homicide E960-E969

 
Drug-related deaths 292,304,305.2-305.9, E850-E858,E950.0-E950.5, E962.0, E980.0-E980.5
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