10/14/2010

Review: Epidemiology AgeAdjustment (U.S.Practices)

ElenaYu,Ph.D. PH302:EpidemiologyofCommunicable andInfectiousDiseases
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Study of the distribution and determinants of disease frequency in human populations Distribution and patterns of disease and death are analyzed by characteristics of person, place, and time.
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Disease rates categorized by

Person: Who has the disease? male vs. females, young vs. old, black vs. white Place: Where is the disease more or less common? Different scales of geography: regions of earth, countries, states, counties, cities, neighborhoods Time: Is the disease rate changing over time? Different scales of time: decades to seasons to days
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Descriptive statistics: Where?

Routinely collected data
mortality and natality from vital records reportable diseases from surveillance programs other health-related events from national surveys

National Center of Health Statistics http://www.cdc.gov/nchs/ More available through other sites
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Descriptive statistics are useful for:

1. Providing clues about disease causation and prevention that are usually investigated further in formal studies 2. 2 Assessing the health status of a population (e.g. Healthy People 2010) 3. Allocating resources efficiently and targeting populations for education or preventive programs

If morbidity or mortality from a given disease changes over time, you can infer:
It may be real - Some causes of the disease must also be changing Or it could be "artifactual (spurious) For example, there are differences in disease definition, diagnosis, or reporting over time. Or there are changes in enumerating the population denominator of the rate.
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Crude Rates
A summary measure The numerator is the total number of cases or deaths in the population The denominator is the total number of individuals in that population at a specified time period
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Example: Afghanistan and the U.S

2005 Estimates
Afghanistan
# of Deaths, in thousands Midyear Population, in thousands Crude Mortality Rate (per 1,000)

DifferentAgeDistributions
Not a good idea to compare the crude death rates

United States
2,449 , 295,753

485 25,538

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When the age distribution is so different between the two populations

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DifferentYears,SameCountry
The U.S. population is aging!

Are disease rates going up only because of population aging?

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Problems Comparing Crude Rates

Groups differ with respect to underlying characteristics that affect overall rate of disease (especially age, sex, and race)
So you may be making a u a co pa so ay a g an unfair comparison

CategorySpecificDeathRates
Useful to compare age-specific death rates between the groups Choose rates specific to some particular sub-population:
age-specific: compare two groups age for age race-specific sex-specific Income-specific
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Even within the same country, comparison of data from different time periods is problematic because we dont know if the change is real or due to population aging

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CategorySpecificRates
Withcategoryspecificrates,wedonthavea summarymeasure. Readingouteachcategoryspecificrateis cumbersome. cumbersome
Thetableisverybusy

Howdowegetasummarymeasurethat wouldtakeintoaccountthedifferentage structureofpopulationsbeingcompared?

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CommunitiesDifferinAgeStructure
Acommunitymadeupofmorefamilieswith youngchildrenwillhaveahigherrateof bicycleinjuriesthanacommunitywithfewer youngchildren. young children Acommunitywithalargernumberofolder individualswillhavehigherratesofcancer thanonewithyoungerindividuals.
Thisisbecausecancerisanageassociateddisease
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ConfoundingbyAge
Eveniftheindividualsintwocommunities havethesameriskofdevelopingcancer,the onewithproportionallymoreolderpeople willshowahighercancerrate. will show a higher cancer rate Epidemiologistsrefertothisasconfounding.
Confoundinghappenswhenthemeasurementof theassociationbetweentheexposureandthe diseaseismixedupwiththeeffectsofsome extraneousfactor(aconfoundingvariable).
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AgeAdjustmentRemovesAge
Ageadjustmentisastatisticalwaytoremove confoundingcausedbyage. Tousetheexampleoncancer,ageadjustment removestheeffectofcancerincreasingdueto removes the effect of cancer increasing due to populationaging,sothatwecancomparetwo communities.
Thecomparisonthenallowsustoconcludeif cancerratesaretrulyhigherinonecommunity thaninanother.
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ChangesinMortalityRates Massachusetts:2000and2007
Rate Cause
Cancer Heart Disease Stroke Chronic Lower Respiratory Disease All Injuries Alzheimers Disease Nephritis Diabetes All Diabetes-related

2000
206.1 216.7 50.9 41.8 35.9 19.5 17.6 19.6 61.5

2007
179.0 * 166.0 * 35.0 * 31.5 42.5 20.9 17.9 16.5 52.9 * *

% Change
13% 23% 31% 25% 18% 7% 2% 16% 14%
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* *

Rates are per 100,000 population. Age-adjusted to the 2000 US standard population. * Statistically different than 2000 rate (p<0.05)

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AgeAdjustedRate:Meaning?
Age-adjustment was done by the direct method It is a summary rate that accounts for age difference between populations. Any differences between rates cannot be attributed to age.

AgeAdjustment:
AStatisticalProcedure
Commonlyusedincomparingmortalityrates acrosstimeforthewholecountryorforstate leveldataandusesastandardpopulationfor
Healthoutcomes Riskfactors Healthservicesdata

Alsousedinsmallareastudyorclinical sample,butaconventionalstandard populationislackinginthesetypeofstudies

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WhatisaStandardPopulation?
Itisapopulationagedistributionthatis agreeduponbyconventiontobethechoice forageadjustment W H O uses a world standard populationto W.H.O.usesa worldstandardpopulation to comparemorbidityratesbetweencountries UnitedStatesusesthe(real)year2000 populationagedistributionasthestandardfor computingmortalityandmorbidityrates
Source: http://www.naphsis.org/NAPHSIS/files/ccLibraryFiles/Filename/000000000957/Mortality_AgeAdj%20Final_Lois.pdf

= 1.0

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AWeightedAverage
Theageadjustedratecanbeconsideredan averageofeachoftheindividualagespecific rates,butratherthanbeingasimpleaverage, itisaweightedaveragewitheachage it is a weighted average with each age specificrate weightedbytheproportionof peopleinthesameagegroupinthestandard population. Theweightisthe%ofpopulationineachage group,expressedasdecimals.Must: =1.0
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DirectAgeAdjustment:How?
Toapplydirectageadjustmenttoasetof rates,theagespecificrateforeachagegroup inthestudypopulationismultipliedbythe appropriate weight (i e population size or appropriate weight(i.e.,populationsizeor proportion)ineachcorrespondingagegroup ofthestandardpopulation. Thesumoftheseproductsisthedirectlyage adjusted,oragestandardizedrate
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ExampleofAgeAdjustment
ComparingStateofNewMexico withSierraCountyinNewMexico

Crude Rate
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Age-Adjusted

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FootnotestotheTable

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Crude Rate

Age-Adjusted

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DeathRateforDiabetesMellitus
StateofNewMexico CrudeRateper100,000 32.754 Based on crude rate we Basedoncruderate,we wouldconcludethat deathrateforNew Mexicostateislower. Ageadjustedrate 33.54 SierraCountyinN.M. CrudeRateper100,000 53.73 Based on ageadjusted Basedonageadjusted deathrate,however, ourconclusionisthe reverse! AgeAdjustedRate 27.01
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Ageadjustment:DirectMethod
Stepbystepillustration

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AgeAdjustedDeathRateforDiabetesMellitus,StateofNewMexico,20032005 A Age Group Under 1 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 & older Total # of Deaths For Diabetes 0 0 2 2 19 61 160 297 443 546 369 1899 B C Expected Death Rate

AgeAdjustedDeathRateforDiabetesMellitus,StateofNewMexico,20032005 A Age Group Under 1 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 & older Total # of Deaths For Diabetes 0 0 2 2 19 61 160 297 443 546 369 1899 B C Expected Death Rate

New Mexico Diabetes Death U.S. 2000 Population Rate Per 100,000 Standard Population 84,952 325,508 828,663 893,809 718,484 718 484 810,632 833,948 602,768 381,451 235,030 82,660 5,797,905 0 0 0.24135264 0.22376145

New Mexico Diabetes Death U.S. 2000 Population Rate Per 100,000 Standard Population 84,952 325,508 828,663 893,809 718,484 718 484 810,632 833,948 602,768 381,451 235,030 82,660 5,797,905 0 0 0.24135264 0.22376145 2.64445694 2 64445694 7.52499285 19.1858485 49.2726887 116.135493 232.310769 446.406968 32.75321

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AgeAdjustedDeathRateforDiabetesMellitus,StateofNewMexico,20032005 A Age Group Under 1 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 & older Total # of Deaths For Diabetes 0 0 2 2 19 61 160 297 443 546 369 1899 B C Expected Death Rate

AgeAdjustedDeathRateforDiabetesMellitus,StateofNewMexico,20032005 A Age Group Under 1 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 & older Total # of Deaths For Diabetes 0 0 2 2 19 61 160 297 443 546 369 1899 B C Expected Death Rate 0 0 0.035132 0.031024

New Mexico Diabetes Death U.S. 2000 Population Rate per 100,000 Standard Population 84,952 325,508 828,663 893,809 718,484 718 484 810,632 833,948 602,768 381,451 235,030 82,660 5,797,905 0 0 0.24135264 0.22376145 2.64445694 2 64445694 7.52499285 19.1858485 49.2726887 116.135493 232.310769 446.406968 32.75321 0.013818 0.055317 0.145565 0.138646 0.135573 0 135573 0.162613 0.134834 0.087247 0.066037 0.044842 0.015508 1

New Mexico Diabetes Death U.S. 2000 Population Rate per 100,000 Standard Population 84,952 325,508 828,663 893,809 718,484 718 484 810,632 833,948 602,768 381,451 235,030 82,660 5,797,905 0 0 0.24135264 0.22376145 2.64445694 2 64445694 7.52499285 19.1858485 49.2726887 116.135493 232.310769 446.406968 32.75321 0.013818 0.055317 0.145565 0.138646 0.135573 0 135573 0.162613 0.134834 0.087247 0.066037 0.044842 0.015508 1

The population size in each age group is expressed as a proportion of the total population
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The death rate for each age group is weighted by the proportion represented by the age group

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AgeAdjustedDeathRateforDiabetesMellitus,StateofNewMexico,20032005 A Age Group Under 1 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 & older Total # of Deaths For Diabetes 0 0 2 2 19 61 160 297 443 546 369 1899 B C Expected Death Rate 0 0 0.035132 0.031024 0.358517 0 358517 1.223662 2.586905 4.298894 7.669240 10.417279 6.922879 33.543532

GoodPractices(1)
Whenreportingageadjustedrates,always reportthestandardpopulationused Comparisons can only be made between rates calculated using the same standard population Theageadjustedrateishypothetical
Usefulonlyforcomparingpopulations,eitherover time,bygeographicarea,bysexorby racial/ethnicgroup
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New Mexico Diabetes Death U.S. 2000 Population Rate per 100,000 Standard Population 84,952 325,508 828,663 893,809 718,484 718 484 810,632 833,948 602,768 381,451 235,030 82,660 5,797,905 0 0 0.24135264 0.22376145 2.64445694 2 64445694 7.52499285 19.1858485 49.2726887 116.135493 232.310769 446.406968 32.75321 0.013818 0.055317 0.145565 0.138646 0.135573 0 135573 0.162613 0.134834 0.087247 0.066037 0.044842 0.015508 1

The sum is the age-adjusted (expected) death rate for the whole population

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GoodPractices(2)
Althoughageadjustmentmaybeusedwith broadpopulationagegroups,suchasadults (e.g.,age18+),dependingontheoutcome beingstudied,itmaynotbenecessary(or being studied it may not be necessary (or meaningful)toageadjustdataforsmallerage groups. Ageadjustmentisnotappropriateifthereis acrossoverofspecificratesbetweenthetwo groupsundercomparison.
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GoodPractices(3)
Donot doageadjustmentifdeathrates amongyoungerpersonsareincreasingover time,butdeathratesamongolderpersonsare decreasingovertime. decreasing over time
Thetrendsarenotconsistent.So,youcannotuse onenumbertorepresentthepopulation. Asummarymeasure,suchasanageadjusted rate,wouldreferdistort(ormisrepresent)the reality.
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Agespecificcancerdeathratesamong females,1970to1995
1600 1400 1200 1000 800 600 400 200 0 <1
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1995 1970

1-4

5-14 15-25 25-34 35-44 45-54 55-64 65-74 75-84 85+

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Source: National Vital Statistics System, CDC, NCHS.

Femalecancerdeathrates,byage adjustmentstandard
215 195 175 155 135 115 95 75 1970
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Crude rate

2000 standard population

1940 standard population

1980

1985

1990

1995
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Source: National Vital Statistics System, CDC, NCHS.

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Diabetesprevalencebyrace/ethnicity(Obj. 53),1999
7 6 5 perce ent 4

Diabetesagespecificrates,1999
Hispanic
25 20 percent 15 10 5 0 <18
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not-Hispanic White

3 2 1 0

18-44

45-64

65-74

75+
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Source: National Health Interview Survey (NHIS), CDC, NCHS.

Source: National Health Interview Survey (NHIS), CDC, NCHS.

2000Censusagedistribution
Hispanic 50 40 not-Hispanic White

Diabetesprevalence (Obj.53),1999
9 8 7 6 percent 5 4 3 2 1 0
Overall American Indian/ Alaska Native Asian/ Pacific Islander Hispanic Not-Hispanic White Not-Hispanic African American

percent

30 20 10 0 <18 18-44 45-64 65-74 75+

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Crude
Source: National Health Interview Survey (NHIS), CDC, NCHS.

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Diabetesprevalence (Obj.53),1999
9 8 7 6 percent 5 4 3 2 1 0 Crude
Source: National Health Interview Survey (NHIS), CDC, NCHS.

Caution
NCHSinthepast(before2000)used
Overall American Indian/ Alaska Native Asian/ Pacific Islander Hispanic Not-Hispanic White Not-Hispanic African American

1940agedistributionasthestandardformortality Mostly1970and1980agedistributionasthe standardforsurveydata standard for survey data

Age-adjusted
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NCHSnowusesyear2000U.S.resident populationasthestandardpopulationforall The1940U.S.standardpopulationisyounger The2000U.S.standardpopulationisolder

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Crudeandageadjusteddeathratesbasedonyear1940and 2000standardpopulations:UnitedStates,19792000
1200 1000 800 600 400 200 0 1979
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2000 standard crude rate

1940 standard

1982

1985

1988

1991

1994

1997

2000
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NCHSPractices
Betweenthespreadsheetandthemanual methodofcalculatingageadjustment,NCHS usesthemanualmethod.
Healthy People 2010 rate calculations are HealthyPeople2010ratecalculationsare rounded/truncatedtoonedecimalplace. Weightsarerounded/truncatedtosixplaces.

Ageadjustmentin HealthyPeople2010 Mainpurposes:

Observetrendsinpopulationsovertime Monitordisparitybetweenpopulationsbothata pointintimeandovertime point in time and over time Several different age groupings are used to ageadjust data from different sources Some data sources use fewer age groupings to stabilize the rates of less common events and smaller subpopulations (e.g. age groups for chronic disease)
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Question:Youarefocusingondeathratesfor femalebreastcancer.Doyoustillusethe 2000standardpopulation(forbothsexes)?

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Healthy People 2010 age-adjusted measures and age adjustment groups

Data Source NVSS-M NHIS NHDS NHDS/NHIS CSFII NHIS NHIS NHIS NHIS NHANES NHANES NHANES NHANES NHIS NHIS NHIS NHDS NHIS NHDS NHIS NHIS Standard Distribution** #1 #3 #4 # 4 (revised)1 #5 # 6 (revised)1 # 8/9(revised) 1,2 #9 # 9 (revised) 1 # 10 (revised)3 # 11 # 11 (revised)3 # 12 # 15 # 16 # 17 # 18 # 19 # 21 # 22 # 22 (revised)1 Age Adjustment Groups <1, 1-4, 5-14, 15-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, 85+ <18, 18-44, 45-54, 55-64, 65-74, 75+ <18, 18-44, 45-64, 65-74, 75+ 0-44, 45-64, 65-74, 75+ 2-5, 6-11, 12-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, 80+ 2-44, 45-54, 55-64, 65-74, 75+ 18-44, 45-64, 65-74, 75+ 18-24, 25-34, 35-44, 45-64, 65+ 18-44, 45-64, 65+ 18-49, 50-59, 60-69, 70-79, 80+ 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, 80+ 20-49, 50-59, 60-69, 70-79, 20-49 50-59 60-69 70-79 80+ 20-39, 40-59, 60+ 40-49, 50-64, 65+ 45-49, 50-64, 65+ 50-64, 65+ 65-74, 75+ 0-4, 5-11, 12-17 5-17, 18-44, 45-64 18-24, 25-34, 35-44, 45-64 18-44, 45-64

Healthy People 2010 age-adjusted measures and age adjustment groups

Data Source NVSS-M NHIS NHDS CSFII NHIS NHANES NHANES NHIS NHIS NHIS NHDS NHIS NHDS NHIS Standard Distribution** #1 #3 #4 #5 #9 # 11 # 12 # 15 # 16 # 17 # 18 # 19 # 21 # 22 Age Adjustment Groups <1, 1-4, 5-14, 15-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, 85+ <18, 18-44, 45-54, 55-64, 65-74, 75+ <18, 18-44, 45-64, 65-74, 75+ 2-5, 6-11, 12-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, 80+ 18-24, 25-34, 35-44, 45-64, 65+ 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, 80+ 20-39, 40-59, 60+ 40-49, 50-64, 65+ 45-49, 50-64, 65+ 50-64, 65+ 65-74, 75+ 0-4, 5-11, 12-17 5-17, 18-44, 45-64 18-24, 25-34, 35-44, 45-64

** Healthy People Statistical Notes, no. 20. January 2001. Education group breakouts begin age groups at age 25.

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* For datalines where denominator is people with chronic conditions. ** Healthy People Statistical Notes, no. 20. January 2001. 1 <45 age groups aggregated (denominator is people with chronic conditions). 2 65+ age group diaggregated (workgroup's request). 3 <50 age groups aggregated (denominator is people with chronic conditions). Education group breakouts begin age groups at age 25.

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ConfidenceIntervals
Inordertodeterminethereliabilityandthe chancevariationofadeathrate(especially thosebasedonsmallnumbersofevents)as wellastodeterminesignificantchangesover well as to determine significant changes over time,orsignificantdifferenceswhen comparingrates,itishighlyrecommended thatastandarderrororconfidenceinterval (usually95%)becalculatedandshownforthe rates.
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AgeGroupings
Therearedetailedagegroupingsof theyear2000StandardPopulation

Exceptions
Datathatarenotageadjusted Infantmortality UsesLIVEBIRTHSasthedenominator Maternalmortality NationalHouseholdSurveyonDrugAbuse OccupationalInjuryandDeath
FatalityAnalysisandReportingSystem CensusofFatalOccupationalInjuries

IndirectAgeAdjustment
Usedwhenpopulationsizeissmallor agespecificeventsarefew

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IndirectStandardization
Themethodappliestheagespecificrates foundinthestandardpopulationtotheage distributionofthesmallerareaorsub p p population Expectednumber. p Thenumberofobserveddeaths(inthe populationofinterest)isdividedbythe numberofexpecteddeaths,multipliedby 100,toobtainastandardizedmortality(or morbidity)ratio,calledSMRforshort.
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SMRforSmall#ofEvents
Ifthetotalnumberofeventsis25orless, calculateSMR. SMRswithinthesamepopulationcanbe comparedwitheachother. compared with each other
Example:SMRsforProstatecancer,breastcancer,lungcancer,skin cancerwithinChineseAmericanpopulationcanbecomparedwitheach other. Weareusingtheagespecificdeathratesforprostatecancer,breast cancer,lungcancer,andskincancerinthemainstreampopulation (usuallywhitepopulationisused),andmultiplyingthembythe populationsizeofChineseAmericansineachagegroup.
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SMRisaRatio
SMR =

SMRisaRelativeIndex
Theratioobtainedfromdividingtheobserved bytheexpectednumberofdeathsisusually multipliedby100 SMR. As with any age adjusted rates indirectly age Aswithanyageadjustedrates,indirectlyage standardizedratesshouldbeviewedas relativeindexes. Theyarenot actualmeasuresofmortalityrisk, anddonot conveythemagnitudeofthe problem.
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O E

(Observednumberofdeaths)__ (Expectednumberofdeaths)

SMR > 1 means that there were excess deaths compared to what was expected. SMR = 1 means that the observed # deaths = Expected # of deaths. So, the statistical test of significance for the SMR is whether the ratio is Significantly different from 1.0. To gauge statistical significance of SMR, we must calculate the 95% confidence Interval. If the 95% C.I. excludes 1.0, it may be considered statistically significant. The 95% C.I. is equal to 1.96 times the standard error of the estimate.
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Caution
Twoindirectlystandardizedrates,fromtwo different(small)populations,cannotbe comparedwitheachother. For example: the SMR for Latinos cannot be Forexample:theSMRforLatinoscannotbe comparedtotheSMRforAsians.
SMRsfromdifferentpopulationscannotbe compared,becausetheyhavedifferentpopulation agestructure.
SMRforprostatecanceramongLatinoscannotbecomparedwithSMR forprostatecanceramongChineseAmericans.
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