AM:ERICAN JOURNAL OF
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April 1977 Volume 67, Number 4
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Established 191 1
The Underutilization of Vital Statistics EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) Geroge M. Owen, MD (1979) Doris Roberts, PhD, MPH (1977) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1977)
STAFF William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor Janice Coleman Administrative Assistant CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Law Jean Conelley Book Section
AJPH April, 1977, Vol. 67, No. 4
Vital statistics have long been considered one of the basic public health activities. However, vital statistics were never intended to yield a data base that would answer all epidemiologic and administrative questions that might arise. As new public health needs presented themselves, vital statistics appear, therefore, to have been given a low priority in many health departments and largely ignored as a source of information to answer current questions. * Perhaps investigators have been turned off by the negative criticisms of specific aspects of the data produced by the system without giving adequate thought to their positive attributes. * Perhaps the production over generations of many repetitive, routine tabulations (to maintain trend data) have left the impression that vital statistics had nothing further to offer. * Perhaps investigators and planners are unfamiliar with details of the process and with what is available or, more important, what could be made available. * Perhaps those responsible for the vital statistics program have been too complacent, satisfied with repeating the same output year after year rather than aggressively selling new and different products in addition. The paper by Speizer, Trey, and Parker in this issue of the Journal' is an excellent illustration of what can be done with appropriate investigative imagination. The question was whether the observed increase in mortality from cirrhosis of the liver was real or an artifact. The increase was confirmed as real, a finding of considerable public health import. Unquestionably, labor was required to tease out the answer, but reckon the labor and expense that would be involved in a field epidemiologic study to answer the question, assuming a properly designed study could be mounted! Many other possibilities exist for greater utilization of vital statistics. Planning authorities need data on distribution, availability, and utilization of facilities and manpower, and the extent to which populations are served. Vital statistics cannot be expected to answer all these needs. But data from this system may shed light at minimum cost on related questions. For example, a study done in Santa Clara County, California, by Drosness and Lubin has shown that geographic distribution of maternity patients (a factor determinable by residence information on birth records) closely resembles that for all inpatients when the data are obtained much more laboriously from the hospital charts.2 The relationship observed in Santa Clara County may not hold elsewhere, but surely this is a lead worth following up. Moreover, similar review of residence areas on death records for deaths occurring in hospitals may also shed light on utilization and mobility for medical care. Perhaps such death data would be an effective estimator for those hospitals without a maternity service in lieu of a sample of hospital charts. Hospital utilization data for a total community may provide insight, too, on the extent to which such populations are served, regardless of the location of the facility. Sometimes it is assumed that people in a given area are underserved because they do not fully utilize a local facility when, in actuality, they are served by a more distant one, for one reason or another. It is not known whether births or deaths best reflect such situations or, indeed, whether either actually does so. Both should be examined in a number of localities in the manner described by Drosness and Lubin and their predecessors. 325
EDITORIALS
Vital statistics offices usually routinely identify the place (e.g. hospital) where each vital event occurs as well as the geographic area where the patient resides. If they do not, they could. It should be relatively easy, therefore, to crosstabulate births and deaths by hospital and residence area. From such tabulations estimates of sources of patients for individual hospitals could be established, as well as population mobility for hospital care. Vital statisticians especially (and others concerned with these problems, too) must be prepared to grasp opportunities to validate such suggested uses of vital statistics. The Drosness-Lubin study represents one such opportunity. An example of another opportunity is a monograph published not long ago by Blue Cross-Blue Shield of Greater New York on population movement for ambulatory medical care in hospitals3 derived from its one-day census of patients using such facilities. It is hoped that this organization will do a like analysis of the latest one-day census of inpatients. Despite their limitations, such studies provide insight on questions of geographic origin of both inpatients and outpatients of specific hospitals. In the reverse direction, one can examine the extent to which persons resident in specific areas utilize such facilities, thus approaching the question of lack of service or failure to utilize existing services. Comparison of such data with distributions obtained from birth and death records would serve to validate the vital statistics figures from an existing source (whenever it becomes available) rather than await an ad hoc investigation such as that of Drosness and Lubin. A proxy for analysis of hospital charts would be extremely valuable, especially one such as vital statistics from which annual tabulations can be readily available at little effort and expense. One of the difficulties encountered by Speizer et al. was the identification of specific death records pertinent to their study and the coding of all conditions mentioned in the medical certifications of such records, whether underlying cases, sequelae, or unrelated conditions. The National Center for Health Statistics has in recent years been coding multiple causes of death in such manner. To accomplish this end, the Center has designed a system called ACME (automated classification of medical entities).4 The system requires coding of all conditions mentioned on the medical certification and their location thereon, so that the underlying cause of death may be selected by computer for single cause tabulations. However, the information regarding other conditions also exists on the magnetic tape so that studies such as those
of Speizer and colleagues as well as others envisioned by them would be facilitated. While it takes personnel longer to code all conditions mentioned on a death certificate, the coders do not have to be as highly trained as the nosologist who must determine mentally the underlying cause from the certification completed by the physician, applying the same rules that the ACME program supplies within the computer. Hence, the expense of coding may not be increased, because lower paid staff can do the job. (The cost of training nosologists and then paying them commensurately with their expertise is an additional problem.) A number of states are presently using the ACME system in processing their own mortality data; more are expected to do so when the system is revised with the introduction of the Ninth Revision of the International Statistical Classification in 1979. As a result, multiple cause data will become more readily available locally for study. Thought should be given now to how such data can be most effectively used. One of the directions in PL 93-641 is that Health Systems Agencies should utilize, insofar as possible, existing sources of data. Vital statistics are certainly one such source when used with discrimination and wisdom. The support being provided through the National Center's Cooperative Health Statistics System program should help in further improvement of the data and its greater utilization. But neither legislative direction nor financing can substitute for effective innovative imagination.
CARL L. ERHARDT REFERENCES 1. Speizer, F. E., Trey, C., and Parker, P. The Uses of Multiple Causes of Death Data to Clarify Changing Patterns of Cirrhosis Mortality in Massachusetts. Am. J. Public Health 67:333-336, 1977. 2. Drosness, D. L. and Lubin, J. W. Planning Can be Based on Patient Travel. The Modern Hospital 106:92, 1966. 3. Blue Cross-Blue Shield of Greater New York. Small Area Utilization and Inter-Area Mobility for Ambulatory Care. ACS Report No. 5, Feb., 1976. 4. Templeton, M. C. and Evans, M. C. Automated Classification of Medical Entities (ACME) for Selection of Causes of Death. Presentation at the 98th Annual Meeting of the American Public Health Association, Statistics Section, Houston, TX, October 29, 1970. (Processed)
Address reprint requests to Dr. Carl L. Erhardt, Research Associate, Public Health Research Institute of New York City, Inc., 125 Worth Street, Room 609, New York, NY 10013.
History and Health Care Since the turn of the century a marked characteristic of the organized medical profession in the United States has been a generally negative attitude to innovation in the organization, financing, and delivery of health care. Change in326
volving these aspects has not been welcomed by the national, state, or local bodies speaking in the name of the profession, and has often been met with outright rejection or at best with grudging acceptance. An example is voluntary AJPH April, 1977, Vol. 67, No. 4
X *
April 1977 Volume 67, Number 4
q
_si
s
Established 191 1
The Underutilization of Vital Statistics EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1977) Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) Geroge M. Owen, MD (1979) Doris Roberts, PhD, MPH (1977) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1977)
STAFF William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor Janice Coleman Administrative Assistant CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Law Jean Conelley Book Section
AJPH April, 1977, Vol. 67, No. 4
Vital statistics have long been considered one of the basic public health activities. However, vital statistics were never intended to yield a data base that would answer all epidemiologic and administrative questions that might arise. As new public health needs presented themselves, vital statistics appear, therefore, to have been given a low priority in many health departments and largely ignored as a source of information to answer current questions. * Perhaps investigators have been turned off by the negative criticisms of specific aspects of the data produced by the system without giving adequate thought to their positive attributes. * Perhaps the production over generations of many repetitive, routine tabulations (to maintain trend data) have left the impression that vital statistics had nothing further to offer. * Perhaps investigators and planners are unfamiliar with details of the process and with what is available or, more important, what could be made available. * Perhaps those responsible for the vital statistics program have been too complacent, satisfied with repeating the same output year after year rather than aggressively selling new and different products in addition. The paper by Speizer, Trey, and Parker in this issue of the Journal' is an excellent illustration of what can be done with appropriate investigative imagination. The question was whether the observed increase in mortality from cirrhosis of the liver was real or an artifact. The increase was confirmed as real, a finding of considerable public health import. Unquestionably, labor was required to tease out the answer, but reckon the labor and expense that would be involved in a field epidemiologic study to answer the question, assuming a properly designed study could be mounted! Many other possibilities exist for greater utilization of vital statistics. Planning authorities need data on distribution, availability, and utilization of facilities and manpower, and the extent to which populations are served. Vital statistics cannot be expected to answer all these needs. But data from this system may shed light at minimum cost on related questions. For example, a study done in Santa Clara County, California, by Drosness and Lubin has shown that geographic distribution of maternity patients (a factor determinable by residence information on birth records) closely resembles that for all inpatients when the data are obtained much more laboriously from the hospital charts.2 The relationship observed in Santa Clara County may not hold elsewhere, but surely this is a lead worth following up. Moreover, similar review of residence areas on death records for deaths occurring in hospitals may also shed light on utilization and mobility for medical care. Perhaps such death data would be an effective estimator for those hospitals without a maternity service in lieu of a sample of hospital charts. Hospital utilization data for a total community may provide insight, too, on the extent to which such populations are served, regardless of the location of the facility. Sometimes it is assumed that people in a given area are underserved because they do not fully utilize a local facility when, in actuality, they are served by a more distant one, for one reason or another. It is not known whether births or deaths best reflect such situations or, indeed, whether either actually does so. Both should be examined in a number of localities in the manner described by Drosness and Lubin and their predecessors. 325
EDITORIALS
Vital statistics offices usually routinely identify the place (e.g. hospital) where each vital event occurs as well as the geographic area where the patient resides. If they do not, they could. It should be relatively easy, therefore, to crosstabulate births and deaths by hospital and residence area. From such tabulations estimates of sources of patients for individual hospitals could be established, as well as population mobility for hospital care. Vital statisticians especially (and others concerned with these problems, too) must be prepared to grasp opportunities to validate such suggested uses of vital statistics. The Drosness-Lubin study represents one such opportunity. An example of another opportunity is a monograph published not long ago by Blue Cross-Blue Shield of Greater New York on population movement for ambulatory medical care in hospitals3 derived from its one-day census of patients using such facilities. It is hoped that this organization will do a like analysis of the latest one-day census of inpatients. Despite their limitations, such studies provide insight on questions of geographic origin of both inpatients and outpatients of specific hospitals. In the reverse direction, one can examine the extent to which persons resident in specific areas utilize such facilities, thus approaching the question of lack of service or failure to utilize existing services. Comparison of such data with distributions obtained from birth and death records would serve to validate the vital statistics figures from an existing source (whenever it becomes available) rather than await an ad hoc investigation such as that of Drosness and Lubin. A proxy for analysis of hospital charts would be extremely valuable, especially one such as vital statistics from which annual tabulations can be readily available at little effort and expense. One of the difficulties encountered by Speizer et al. was the identification of specific death records pertinent to their study and the coding of all conditions mentioned in the medical certifications of such records, whether underlying cases, sequelae, or unrelated conditions. The National Center for Health Statistics has in recent years been coding multiple causes of death in such manner. To accomplish this end, the Center has designed a system called ACME (automated classification of medical entities).4 The system requires coding of all conditions mentioned on the medical certification and their location thereon, so that the underlying cause of death may be selected by computer for single cause tabulations. However, the information regarding other conditions also exists on the magnetic tape so that studies such as those
of Speizer and colleagues as well as others envisioned by them would be facilitated. While it takes personnel longer to code all conditions mentioned on a death certificate, the coders do not have to be as highly trained as the nosologist who must determine mentally the underlying cause from the certification completed by the physician, applying the same rules that the ACME program supplies within the computer. Hence, the expense of coding may not be increased, because lower paid staff can do the job. (The cost of training nosologists and then paying them commensurately with their expertise is an additional problem.) A number of states are presently using the ACME system in processing their own mortality data; more are expected to do so when the system is revised with the introduction of the Ninth Revision of the International Statistical Classification in 1979. As a result, multiple cause data will become more readily available locally for study. Thought should be given now to how such data can be most effectively used. One of the directions in PL 93-641 is that Health Systems Agencies should utilize, insofar as possible, existing sources of data. Vital statistics are certainly one such source when used with discrimination and wisdom. The support being provided through the National Center's Cooperative Health Statistics System program should help in further improvement of the data and its greater utilization. But neither legislative direction nor financing can substitute for effective innovative imagination.
CARL L. ERHARDT REFERENCES 1. Speizer, F. E., Trey, C., and Parker, P. The Uses of Multiple Causes of Death Data to Clarify Changing Patterns of Cirrhosis Mortality in Massachusetts. Am. J. Public Health 67:333-336, 1977. 2. Drosness, D. L. and Lubin, J. W. Planning Can be Based on Patient Travel. The Modern Hospital 106:92, 1966. 3. Blue Cross-Blue Shield of Greater New York. Small Area Utilization and Inter-Area Mobility for Ambulatory Care. ACS Report No. 5, Feb., 1976. 4. Templeton, M. C. and Evans, M. C. Automated Classification of Medical Entities (ACME) for Selection of Causes of Death. Presentation at the 98th Annual Meeting of the American Public Health Association, Statistics Section, Houston, TX, October 29, 1970. (Processed)
Address reprint requests to Dr. Carl L. Erhardt, Research Associate, Public Health Research Institute of New York City, Inc., 125 Worth Street, Room 609, New York, NY 10013.
History and Health Care Since the turn of the century a marked characteristic of the organized medical profession in the United States has been a generally negative attitude to innovation in the organization, financing, and delivery of health care. Change in326
volving these aspects has not been welcomed by the national, state, or local bodies speaking in the name of the profession, and has often been met with outright rejection or at best with grudging acceptance. An example is voluntary AJPH April, 1977, Vol. 67, No. 4
