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National Information Center on Health Services Research and Health Care Technology (NICHSR)

Community Health Status Indicators (CHSI) Transcript

Event Started: 1/27/2010

Welcome to the second of the four-part Health Indicators webinar series brought to you by the National Information Center on Health Services Research and Health Care Technology (NICHSR) and the National Library of Medicine.

We are delighted to introduce Nancy Allee, our presenter today, who will provide an in-depth discussion of the Community Health Status Indicators project and website. Nancy is the Deputy Director, Health Sciences Libraries, University of Michigan, holds both M.L.S. and M.P.H. degrees, has extensive experience and expertise in public health training and education, and has participated in numerous outreach projects for public health professionals, including using Web 2.0 technologies to engage the public health workforce and the communities they serve.

Welcome Everyone. I am Nancy Allee and I will be talking with you today about the Community Health Status Indicators. This webinar is part 2 of a 4 part series on health indicators sponsored by the National Library of Medicine. The first webinar which Cheryl Wold presented on January 20th provided an excellent overview of health indicators. If you are interested in knowing more about health indicators, I would encourage you to listen to and watch this webinar which is available from the NLM website.

After today, there will be 2 more webinars relevant to health indicators and the dates and times are noted as well as the web address for registering. At the completion of the series, all of the webinars will be archived and available from the NLM web site.

For today's presentation, we are going to focus on the Community Health Status Indicators (CHSI). Our goal is to learn everything we need to know about effectively navigating CHSI in order to access, search, map and generate reports on local data. We will be covering 3 areas. The first part is the kinds of indicator data in CHSI. The second part is the CHSI website and features of it. Then, we will end with part 3, which will be a sample search in CHSI using a specific state and county and the kinds of information available about it.

As we are exploring CHSI, one question to be thinking about is - how can this data best be used? Particularly, how can librarians engage with the public health workforce and local communities in using CHSI for quality improvement. This question will help frame today's discussion and will lead us to the topic of the next webinar.

Before we begin, just a few comments about my background and interest in this area. I have degrees in both library science and public health. I have taught or co-taught several CE courses for the Medical Library Association including ones on community health status indicators, evidence-based public health, and public health 2.0. I have also worked many years with NLM and the Partners in Information Access group to provide training resources for the public health community.

The Community Health Status Indicators support the mission and goals of public health so let's start by defining what public health is. You can see that the focus is at the population and community level and that the focus spans from epidemiology and the prevention of infectious disease, to environmental health and protection from hazards, to health education and health promotion, to health administration and quality assurance. CHSI has information that helps address all these aspects of public health.

Another part of defining public health is understanding what are considered the Essential Public Health Services. As we learn more about CHSI today, we will see that data from the Community Health Status Indicators speak to most, if not all of these Essential Public Health Services: monitoring health status, informing and educating people about health issues and supporting research for new solutions to health problems.

The 10 Essential Public Health Services provide a working definition of public health as well as a guiding framework for the responsibilities of public health systems. The Public Health Functions Steering Committee, with representatives from the US Public Health Service and other major public health organizations, developed the framework for the Essential Services in 1994.

Now that we have defined public health, let's focus on CHSI. What is CHSI? What are the Community Health Status Indicators? CHSI is a collection of nationally available health indicators for counties -- helping to present a total picture of local health. It is a resource for monitoring and analyzing community health status and its determinants at the county level. The goal of CHSI is to give local public health agencies another tool for improving their community's health by identifying data resources and facilitating the setting of priorities. CHSI is a valuable resource that supports the mission and goals of public health, the 10 Essential Public Health Services, Healthy People 2010 initiatives, and evidence-based policy and research.

To produce a resource such as CHSI, much collaboration is involved. There are a number of partner organizations that contributed to the development of CHSI. These include both the federal and private partners who are identified here.

This list is not comprehensive but in thinking about uses of and users of CHSI, these are some of the areas that come to mind. CHSI can be used to develop public policy, public health programs and interventions, public health partnerships, and the data can support research, grant funding efforts, and a variety of publications. Users of CHSI come from the public health, library, and academic communities as well as government and nonprofit organizations. And because CHSI is freely and publicly available on the web, it is a resource that can be used by anyone with an interest in local public health data.

To help in addressing all of the areas of public health that we talked about earlier, numerous data sources are required. CHSI includes data from a number of government organizations which are listed here. The years of coverage for CHSI data are 1994-2006. The intent of the CHSI workgroup is to update CHSI data annually.

Evidence-based public health can be defined as the development, implementation, and evaluation of effective programs and policies in public health through the application of principles of scientific reasoning, including systematic uses of data and information systems and appropriate use of behavioral science theory and program planning models.

One way that CHSI supports evidence-based decision-making is by providing data for comparing counties to their peer counties and other US counties. We will see later on that the symbols that are used in CHSI - an apple, indicating favorable health status, and a magnifying glass, indicating unfavorable or needs more attention status, are very visually clear and help in quickly identifying health status for the community for specific indicators.

I like this definition of indicators because it emphasizes the reason statistics are important - to be able to make comparisons. And, it emphasizes that indicators are not just static information - not just information for information's sake, but they are designed in a purposeful way, to facilitate information being translated into action for the benefit of improvements and innovations in the community.

Health indicators can include measurements of illness or disease - such as birth and death measures like infant mortality and the national leading causes of death, as well as individual behaviors related to health, such as smoking, diet and nutrition and exercise. Indicators can change over time. Information provided by health indicators can be used to improve physical and mental health of individuals as well as their quality of life and risk for illness. The environmental health of a community can also be improved using health indicator data.

When we are talking about the health of a community, community is being defined in the Community Health Status Indicators at the local level of counties. County can be defined simply as the sections into which a state is divided or it can be defined in the following way: the government of the county is located at the county seat, a city or town where court sessions are held and duties are performed by county officers. The county board comprised of public health officials who are elected or appointed to serve on it, is the body that manages the government of the county. Counties have state granted authority to make provisions for the public health, safety and welfare of its residents through the enactment and enforcement of ordinances and regulations. The CHSI reports tell the story about the health status of the individual counties. There are data for 3,141 individual counties within the United States, which are included in CHSI.

And, as importantly, CHSI includes listings of peer counties for the individual counties. Peer counties are counties which are similar in population size and other selected characteristics, such as poverty level, age distribution, and density. This information allows the individual county to compare its health status to other counties in the US, which are similar to it.

There is a popular saying in public health, that all public health is local and for that reason, the fact that CHSI provides county-level data is important in helping to serve the broader mission and goals of public health. There are some interesting myths about health indicators from the Good Indicators Guide. They help to point out that no data is completely perfect and this is true for the data from CHSI as well. As we search CHSI, you will see there are many areas where a number for a health status indicator cannot be provided because there is insufficient information available.

This slide points out that health indicators are not the complete story for a community, but if used effectively, they can be very important in linking public health initiatives to quality improvement for the community. You will note that this linking of indicators to health improvement efforts is an ongoing theme. This slide details the type of health indicators featured in CHSI. It is important to understand how the different health indicators are defined in order to understand and interpret the search results, and the reports for your particular county of interest. So, we will spend some time going through these indicators one by one. There are 10.

Demographics include data for population size, poverty level, population by age, and population by race or ethnicity. These data are obtained from the Current Population Survey conducted by the US Bureau of the Census. Summary Measures of Health are broad measures of health that include average life expectancy, the risk of dying, or rates of death, and self related health status and average unhealthy days, which are health related quality of life measures. Average Life Expectancy represents the average number of years that a baby born in a particular year is expected to live if current age specific mortality trends continue. This data was calculated by representatives from the Harvard School of Public Health. Rates of Death data are from the National Vital Statistics System of the National Center for Health Statistics. Self Rated Health Status represents the percentage of adults aged 18 years and older who report fair or poor overall health. This data is from the Behavioral Risk Factor Surveillance System, a survey conducted jointly by states and the Centers for Disease Control and Prevention.

The Average Number of Unhealthy Days represents reports of either mental or physical unhealthy days by adults aged 18 years and older in the past 30 days. This data is from the Behavioral Risk Factor Surveillance System.

Data on the National Leading Causes of Death comes from the National Center for Health Statistics. For each cause of death, ICD coding - meaning the International Classification of Diseases coding - is used. ICD 9 coding applies to data before 1999 and ICD 10 coding applies from 1999 onward. This category includes complications of pregnancy and birth, such as low birth weight, short gestation, and respiratory and other conditions at time of birth - also, birth defects, injuries, homicide, cancer, suicide, heart disease, and HIV/AIDS.

Measures of Birth and Death are from the National Vital Statistics System from the National Center for Health Statistics. Each of these measures are provided as a rate or percent. Birth measures are percents, infant mortality measures are deaths per 1000 births, and death measures are age-adjusted death rates per 100,000 population. Birth Measures include: low birth weight, very low birth weight, premature births, births to women under 18, births to women over 40, and births to unmarried women. Death Measures include: infant mortality, neonatal mortality, and infant mortality by race or ethnicity. Other Death Measures include breast cancer, colon cancer, coronary heart disease, homicide, motor vehicle injuries, stroke and suicide among others

Relative Health Importance is designed to provide a quick and easy method for assessing one's county health relative to others. Data is presented that highlights favorable and unfavorable health status between peer counties and the nation at large. Data points to indicators for which further attention may be warranted.

Vunerable Populations are estimates of individuals in designated categories who tend to have poorer health status and more medical needs than the general population. Categories include: having no high school diploma, unemployed individuals, severe work disability, major depression, and recent drug use. Data sources for this indicator are the U.S. Census, the Bureau of Labor Statistics, the Behavioral Risk Factors Surveillance System and the Substance Abuse and Mental Health Services Administration.

Environmental Health Measures are important for assuring the conditions under which a population can be healthy. They include clean air, water, land and waste disposal. An example of an environmental health measure is the importance of good water quality and the safe growing , handling, and storing of food to help prevent infectious diseases. Data on infectious diseases in CHSI are from the CDC's National Notifiable Diseases Surveillance System.

Other Environmental Health Measures include toxic chemicals with data from EPA's Toxic Release Inventory and Air Quality Standards, also from the EPA. EPA has set standards for six pollutants: carbon monoxide, nitrogen dioxide, ozone, lead, particulate matter and sulfur dioxide.

Preventive Services Use focuses on one of the core definitions and purposes of public health, which is prevention of disease. Data are from the Behavioral Risk Factor Surveillance System and include: pap tests, mammograms, sigmoidoscopy and colonoscopy, pneumonia vaccination, and flu vaccination.

Risk Factors for Premature Death include risk factors for the nation's leading killers of heart disease and cancer as well as personal behaviors and lifestyles choices. Other risk factors are: lack of exercise, eating very few fruits and vegetables, obesity, high blood pressure, smoking, and diabetes. Data are from the Behavioral Risk Factor Surveillance System.

Access to Care looks at the health care resources available in a county and where there may be gaps in coverage such as uninsured individuals and the number of individuals enrolled in Medicare. Other measures include the number of primary care physicians, dentists, community health centers, and whether the county is designated as a health professional shortage area. Data on uninsured individuals are from the U.S. Census and Medicare enrollment data are from the Centers for Medicare and Medicaid Services. Data on community health services are from the Health Resources and Services Administration.

One of the unique features of CHSI is the comparison of a county with its peer counties which are similar in population composition and other selected demographics. The comparison of peer counties is thought to help explain some of the factors that make a difference in a community's health. There are a total of 88 strata in CHSI. These strata or peer groups were developed with input from an advisory committee composed of federal, state and local public health professionals and academic members collaborating on the development of CHSI. To define this strata, five factors were used: frontier status, population size, poverty quartiles, median age categories, and population density. Determining the strategy for defining peer counties is an iterative process and future versions of CHSI may use different methods and criteria than those that are currently used. In some cases, the number of events for an indicator may be too small to report for a county for a single year for privacy and confidentiality reasons. In these instances, data is aggregated over several years.

Now that we have covered some of the fundamental aspects of the data contained in CHSI, let's take a tour of the website and take a look at some of CHSI search features. CHSI is easily accessed on the web from the website of the Department of Health and Human Services at the web address provided: //

On the Community Health Status Indicators website, you will notice from the left navigation that you can search by state and county for information and also by the tabs in the top center of the webpage. We will go through each of the tabs one by one so that you are familiar with the type of information provided. The home page gives an overview of CHSI and emphasizes that the intended audience is not only public health professionals, but also members of the general public who are interested in the health status of their community. This page also highlights the importance of understanding behavioral factors, such as tobacco use, lack of physical activity and exercise, and substance abuse behaviors that can negatively contribute to poor health status. And, the home page encourages users of the site to think of the CHSI report as a starting point for community needs assessment and public health program planning.

When working with data, it is important to understand the source for the data, the time period covered, the methodology for how the data is calculated, as well as definitions of terms and other relevant information. The "About the Data" webpage provides detailed information on the data sources and methodology by topic. The same information is compiled and available in a printable form from the link to "Data Sources, Definitions and Notes" which is a document that can be accessed from this page. The complete CHSI dataset can also be downloaded for research and analysis purposes. The download file includes: a Microsoft Excel spreadsheet containing several worksheets, including one for the data elements in each of the indicator domains in CHSI: one that defines each data element and indicates where it's description is found in the Data Sources Definitions and Notes document; and one that defines the meaning of specific values, such as, missing or suppressed data. Another note about CHSI data - from within each CHSI report for a county, you can click on the Data Details link which provides more information about specific data sources and the time period covered by the data. Here you see annotations for population and poverty level data.

The CHSI project was initially launched in 2000, then archived in 2004 when the health indicator data become outdated. The project was relaunched in 2006 with a new group of federal and private partners who are listed under the Partners tab on the website. The webpage on "How to Use Your County's Report" offers many helpful suggestions for using health indicator information for the benefit of the local community - from ideas on celebrating success, to developing community partners, to integrating the CHSI report into health planning and assessment activities. This page also focuses on the theme of peer counties and recommends comparing a county with its peer county group to try to uncover reasons for health indicator rate differences. In areas where county rates are higher than others, information can be shared about model programs that are making a difference. Communities are encouraged to learn from each other in applying creative and innovative solutions for improving health.

We identified each of the federal and private partners earlier. Here is the Partners section on the actual website. While CHSI is federally designed and supported, there is a broad-based advisory board that helps with the initiative. From the Partners webpage, you can easily link to the Partner websites and find more detailed information about each of the individual partners.

The Resources page provides links to the websites of seven of the CHSI partner organizations. Here are the links to ASTHO, CDC and HRSA. These links are helpful in being able to access additional information complementary to CHSI such as planning guides, fact sheets and evaluation tools and also in some cases to be able to access more up-to-date data resources for the data provided in CHSI. These are the additional CHSI partners: NACCHO, NLM, the Public Health Foundation, and the National Association of Local Boards of Health with links to their organization's websites. You will notice there is an exit disclaimer to let you know when you are at leaving the CHSI site and entering a non-federal website.

One of the resource links featured in a CHSI is that of the National Library of Medicine (NLM). The NLM resources page identifies a set of web-based resources which have been carefully selected as being complementary to CHSI. The categories of resources are: general resources, consumer resources, public health resources, and training and evaluation resources. Resource links include, the National Network of Libraries of Medicine, PubMed and the PubMed Tutorial, MedlinePlus, Tox Town and TOXMAP, Partners in Information Access for the Public Health Workforce, as well as a link to "Measuring the Difference", a resource for planning and evaluating health information programs from the Outreach Evaluation Resource Center, among many other useful links.

CHSI offers several unique features related to maps and reports. The mapping feature allows you to generate maps by indicator group, specific health indicator, and county of interest simply by clicking on the mapping link and making a few selections.You can also generate full reports with health status indicator data for a specific county, again, simply by selecting state and county of interest and clicking on the printable report link. We will cover both mapping and generating reports in more detail when we do our sample search coming up next.

Now that we have explored the features of the CHSI website, we will demonstrate a sample search. Searching CHSI is as easy as searching Google. As we have just seen, it is a very user-friendly interface. To begin, you just need to select your state of interest and for us today, that is Michigan. Then, select your county of interest and for us today, that is Wayne County. Then, all you need to do is click on the Display Data button.

Remember that we said that CHSI tells the story and gives a picture of the health status of a community and that community is defined in terms of counties in the US. We are going to focus on one specific county during the remainder of this webinar and explore all of the data that is available from CHSI in order to learn the story there is to tell about that community. Then, when you have the chance to use CHSI after the webinar for the county or counties that are of primary interest to you, you will be familiar with how to access and search the data and how to interpret it. From the Wayne County website, we find that Wayne County is located in southeastern Michigan encompassing approximately 623 square miles. It is made up of 34 cities including the city of Detroit, nine townships and 41 public school districts. Its population of approximately 2,000,000 makes it the most populous county in the state of Michigan, and the 13th most populous county in the US. From the demographic information available, we can see that the population of Wayne County is approaching 2 million. There are approximately 17% of the individuals living below the poverty level. The majority of the county's inhabitants, that is, approximately 60%, are in the 19-64 age range with about 29% under the age of 19 and about two percent who are seniors over 85. In terms of race and ethnicity, approximately 54% of the individuals are white and 42% are black. The smallest percentage in this category is American Indian at less than 1%. Summary Measures provide graphs on average life expectancy, causes of death, self rated health status, and average number of unhealthy days in the past month. Here, we can see that the average life expectancy for Wayne County inhabitants is 73.4 years, which is below the median age of 76.5 for all US counties and is also below the age range for peer counties. For all causes of death, for deaths per 100,000 population, Wayne County is well above the median for US counties and the range among peer counties. It is not included in the graphs above but from CHSI you would also find that Wayne County is above the US and peer counties for the average number of unhealthy days in the past month. The median number of days for all US counties is 6 and for Wayne County, it is 7.1.

From this chart you can see Leading Causes of Death in Wayne County, broken down by cause of death, age and race/ethnicity. The percentages are higher for complications of identity and birth under the age of 1 - for Hispanics at 62% and for Blacks at 62% and for Whites at 54%. Also, for Homicide ages 15-24, the percentage is highest for Blacks at 53%, followed by Hispanics at 45%. Note that NRF stands for no report available because there were fewer than 20 deaths in the race/ethnicity and age group or less than 10% of the deaths were in that particular cause of death category.

The category of Measures of Birth and Death includes data on low birth weight, premature births, and infant mortality as well, but we are going to look at death measures. Note that an Apple symbol indicates a favorable health status in comparison to peer county median values and a Magnifying Glass symbol indicates there is an unfavorable health status in a comparison and therefore, closer attention to these causes of death are needed. You can see that for all of the death measures, the health status for Wayne County has the magnifying glass symbol indicating that the county rates are high in comparison to peer counties, US counties, and the Healthy People 2010 targets. For example, the county rate of death for coronary heart disease is 265.8, which is at the highest range for peer counties, above the US rate of 172 and above the Healthy People 2010 target of 162.

Relative Health Importance compares Wayne County to peer and US counties and you can see that there are many categories for which there is an unfavorable health status. Many having to do with infant mortality but also cancer, heart disease, homicide and stroke. It is not noted on the chart but if you look at the CHSI data, the only category of favorable health status for Wayne County as compared to peer and US counties is Births to Women over 40.

Vulnerable Populations within a county and in the US may face unique health risks as well as barriers and challenges to healthcare. These individuals may need specific strategies and programs for outreach and health management. Here, you see the estimates of prevalence for individuals who have no high school degree, are unemployed, have major depression, or are recent drug users.

In the area of Environmental Health, we see some good news. There are only Apple symbols, indicating favorable health status in comparison to peer counties and you can see that the answer is yes for the 6 categories of meeting national air quality standards. We talked earlier about the focus of prevention and public health. Here, you can see that the higher percentages of preventive services use in Wayne County are for women at about 85% for pap tests, and 80% for mammograms. Approximately 57% of adult 65 and older get the pneumonia vaccine and about 59% of adults 65 and over, get the flu vaccine. The lowest percentage is for sigmoidoscopy or colonoscopy at about 48% for those who are 50 and over.

In another category of Preventive Services Use for infectious disease cases, you see that there are 4 categories of favorable status comparing Wayne County to peer counties. These are denoted by the columns with an Apple and three categories with unfavorable status, these are denoted by a column with a Magnifying Glass. For syphilis at the bottom of the chart, the number of reported cases is over 1000, compared to expected cases. Also for Hepatitis A and Hepatitis B, the number of reported cases exceeds the number of expected cases and you can see that the number is significantly higher for Hepatitis B. This information is important for many reasons, not the least of which is that these diseases respond to public health control efforts.

In this graph, one category that particularly stands out in terms of Risk Factors for Premature Death in Wayne County is Nutrition and the Eating of Few Fruits and Vegetables as indicated by the green bar. The percentage of adults at risk for High Blood Pressure is about 30% as indicated by the yellow bar. And also, at about 30% for Obesity as indicated by the red bar. This information can be helpful to public health practitioners in terms of planning for targeted programs and decision-making for allocation of program funding.You will also notice that a characteristic of these indicators is that many represent lifestyle or behavioral choices. For the various risk factors for premature death, you may have no or very little control, some control, or a lot of control over the aspects of health that they represent. In the case of exercise, nutrition, and smoking, for instance, health status can be very much influenced by lifestyle and behavioral choices. Health status information provided by the Community Health Status Indicators can be empowering to individuals in terms of their health behavior choices.

Access to Care is defined in terms of use of services as well as by medical care coverage and service availability. Here, you see numbers of uninsured individuals and Medicare beneficiaries in Wayne County. You will note that information on Medicaid beneficiaries is not available in CHSI but may be obtained at the state level. You will also note that Wayne County is not identified as being in a Health Professional Shortage Area. But, if your county of interest does happen to be in a designated Health Professional Shortage Area, it may be helpful to indicate this in funding proposals.

We have now gone through all of the health indicators for Wayne County. As mentioned earlier, one of the key features of CHSI is that you can get all of this informationn as one comprehensive report for your county of interest and you can print the report as a PDF which will include numbers, tables and charts, similar to the ones we examined for Wayne County, Michigan.

Another goal of CHSI is to provide data in visually engaging ways and the mapping feature helps serve this purpose. If we were interested in visual data for the area of Major Depression, for example, we can do a search by the indicator group of Vulnerable Populations and the indicator category of Have Major Depression and have that mapped for the state of Michigan and Wayne County. What we then will see is how Wayne County compares to the rest of the state of Michigan county by county. You can see that Wayne County, bordered in green, is in the highest percentile category for Major Depression.

We have mentioned peer counties several times and CHSI will identify for you the peer counties across the US that are comparable to Wayne County, Michigan. So, you will see that this includes: LA County in California, Miami-Dade County in Florida, Cook County in Illinois, which includes Chicago, and Bexar County in Texas which includes San Antonio. If we wanted to map how the indicator category of major depression compares with Wayne County, Michigan, and Cook County, Illinois, we would find that for both counties, Major Depression is in the highest percentile. We then might want to explore how the public health practice community in the other county develops programs to address this indicator of health status or to share information about our own successful programs that might be helpful to colleagues interested in this area.

This map shows Community Migrant Health Centers in Michigan. This indicator reports the presence of health centers for low-income and uninsured individuals and families. These centers typically receive some of their funding through grants from HRSA. You'll note that red indicate counties where the standard is not met for the number of health centers. Green indicates that the standard is met and for our county of interest, Wayne County, it is in green, so the standard is met for this indicator category.

We have now covered everything we have set out to at the beginning: how to access, search, map and generate reports in CHSI. If you are interested in more information on CHSI, you might want to look at these articles from the July 2008 issue of the journal, Preventing Chronic Disease. There are articles giving an overview of the development of CHSI, discussing peer groupings and other aspects of CHSI data. The articles can be accessed online at the web addresses provided.

Also, these resources are particularly helpful for understanding aspects of the data used and reported in CHSI. The "Data Sources, Definitions and Notes" for CHSI, from the CHSI working group is particularly helpful for understanding the data elements in CHSI.

As just a reminder, there are two upcoming webinars in NLM four-part series that may be of interest. The next one is scheduled for February 3. The date for the final webinar will be announced later on. It will cover new indicator projects, including State of the USA and MATCH.

For the February 3 webinar on "Practical Approaches for Using Health Indicators", we will be exploring the topic of the role that librarians can have in engaging with the public health community and in being part of quality improvement efforts. If you have ideas and stories to tell about your successful experiences and projects working with public health, I would appreciate hearing from you and I would like to try to highlight these stories in the next webinar. Just send me your name and contact information and a brief description of the project you would like to share information about. Thanks everyone for your participation. Here is my contact information if you have any questions about today's webinar on Community Health Status Indicators.