Race/ethnicity misclassification of persons reported with AIDS. The AIDS Mortality Project Group and The Supplement to HIV/AIDS Surveillance Project Group

Vil C, Vavilala MS, Bulger EM, Arbabi S, Rowhani-Rahbar A, Moore M. Identifying Common Data Elements to Achieve Injury-related Health Equity Across the Lifespan: A Consensus-Driven Approach

Background

Limited availability and poor quality of data in medical records and trauma registries impede progress to achieve injury-related health equity across the lifespan.

Methods

We used a Nominal Group Technique (NGT) in-person workgroup and a national web-based Delphi process to identify common data elements (CDE) that should be collected.

Results

The 12 participants in the NGT workgroup and 23 participants in the national Delphi process identified 10 equity-related CDE and guiding lessons for research on collection of these data.

Conclusions

These high-priority CDE define a detailed, equity-oriented approach to guide research to achieve injury-related health equity across the lifespan.

Collecting, Using, and Reporting Race and Ethnicity Information: Implications for Research in Nutrition Education, Practice, and Policy to Promote Health Equity

This report will describe approaches for collecting, analyzing, and reporting race and ethnicity information in nutrition education and behavior research, practice, and policy to advance health equity. Race and ethnicity information is used to describe study participants and compare nutrition and health-related outcomes. Depending on the study design, race and ethnicity categories are often defined by the research question or other standardized approaches. Participant self-reported data are more acceptable than researcher adjudicated identification data, which can add bias and/or error. Valid methods to collect, use, and report race and ethnicity information are foundational to publication quality, findings of value, contribution to the knowledge base, and health equity.

Participatory Approaches to Addressing Missing COVID-19 Race and Ethnicity Data

Varying dimensions of social, environmental, and economic vulnerability can lead to drastically different health outcomes. The novel coronavirus (SARS-CoV-19) pandemic exposes how the intersection of these vulnerabilities with individual behavior, healthcare access, and pre-existing conditions can lead to disproportionate risks of morbidity and mortality from the virus-induced illness, COVID-19. The available data shows that those who are black, indigenous, and people of color (BIPOC) bear the brunt of this risk; however, missing data on race/ethnicity from federal, state, and local agencies impedes nuanced understanding of health disparities. In this commentary, we summarize the link between racism and COVID-19 disparities and the extent of missing data on race/ethnicity in critical COVID-19 reporting. In addition, we provide an overview of the current literature on missing demographic data in the US and hypothesize how racism contributes to nonresponse in health reporting broadly. Finally, we argue that health departments and healthcare systems must engage communities of color to co-develop race/ethnicity data collection processes as part of a comprehensive strategy for achieving health equity.

Factors that influence minority use of high-volume hospitals for colorectal cancer care

BACKGROUND

Previous studies suggest that minorities cluster in low-quality hospitals despite living close to better performing hospitals. This may contribute to persistent disparities in cancer outcomes.

OBJECTIVE

The purpose of this work was to examine how travel distance, insurance status, and neighborhood socioeconomic factors influenced minority underuse of high-volume hospitals for colorectal cancer.

DESIGN

The study was a retrospective, cross-sectional, population-based study.

SETTINGS

All hospitals in California from 1996 to 2006 were included.

PATIENTS

Patients with colorectal cancer diagnosed and treated in California between 1996 and 2006 were identified using California Cancer Registry data.

MAIN OUTCOME MEASURES

Multivariable logistic regression models predicting high-volume hospital use were adjusted for age, sex, race, stage, comorbidities, insurance status, and neighborhood socioeconomic factors.

RESULTS

A total of 79,231 patients treated in 417 hospitals were included in the study. High-volume hospitals were independently associated with an 8% decrease in the hazard of death compared with other settings. A lower proportion of minorities used high-volume hospitals despite a higher proportion living nearby. Although insurance status and socioeconomic factors were independently associated with high-volume hospital use, only socioeconomic factors attenuated differences in high-volume hospital use of black and Hispanic patients compared with white patients.

LIMITATIONS

The use of cross-sectional data and racial and ethnic misclassifications were limitations in this study.

CONCLUSIONS

Minority patients do not use high-volume hospitals despite improved outcomes and geographic access. Low socioeconomic status predicts low use of high-volume settings in select minority groups. Our results provide a roadmap for developing interventions to increase the use of and access to higher quality care and outcomes. Increasing minority use of high-volume hospitals may require community outreach programs and changes in physician referral practices.

A Comprehensive Approach to Risk Reduction for Asian and Pacific Islander American Women With HIV/AIDS

As HIV incidence rises globally, Asian and Pacific Islander communities are increasingly affected. While often overlooked, Asian and Pacific Islander American women have shown the greatest percentage increase in HIV diagnosis rates. The development of a multilevel and multistrategy approach to HIV/AIDS education, prevention, and treatment among Asian and Pacific Islander females requires health care providers to identify personal and cultural barriers to prevention and treatment and implement culturally sensitive and specific measures. The purpose of this article is to illuminate barriers to HIV-related prevention, treatment, and care among Asian and Pacific Islander American females and provide practical application-based suggestions for providers, which may enhance Asian and Pacific Islander female inclusion in comprehensive HIV prevention.

HIV testing behavior among Pacific Islanders in Southern California: exploring the importance of race/ethnicity, knowledge, and domestic violence

This article presents an analysis of a 2008 community needs assessment survey of a convenience sample of 179 Pacific Islander respondents in southern California; the needs assessment focused on HIV knowledge, HIV testing behavior, and experience with intimate partner/relationship violence. Multivariate logistic regression results indicated that race/ethnicity and reported experience with intimate partner/relationship violence were the most important variables in explaining the variation in reported HIV testing among Chamorro/Guamanian and Samoan respondents. However, when analyzed separately, self-reported experience with intimate partner/relationship violence was associated with reported HIV testing only for Chamorro respondents and not for Samoan respondents. As U.S. Pacific Islanders experience a high degree of HIV health disparities, additional research is needed to clarify the links among race/ethnicity, intimate partner/relationship violence, and HIV testing behavior.

Agreement between self-reported and administrative race and ethnicity data among Medicaid enrollees in Minnesota

OBJECTIVE

This paper measures agreement between survey and administrative measures of race/ethnicity for Medicaid enrollees. Level of agreement and the demographic and health-related characteristics associated with misclassification on the administrative measure are examined.

DATA SOURCES

Minnesota Medicaid enrollee files matched to self-report information from a telephone/mail survey of 4,902 enrollees conducted in 2003.

STUDY DESIGN

Measures of agreement between the two measures of race/ethnicity are computed. Using logistic regression, we also assess whether misclassification of race/ethnicity on administrative files is associated with demographic factors, health status, health care utilization, or ratings of quality of health care.

DATA EXTRACTION

Race/ethnicity fields from administrative Medicaid files were extracted and merged with self-report data.

PRINCIPAL FINDINGS

The administrative data correctly classified 94 percent of cases on race/ethnicity. Persons who self-identified as Hispanic and those whose home language was English had the greater odds (compared with persons who self-identified as white and those whose home language was not English) of being misclassified in administrative data. Persons classified as unknown/other on administrative data were more likely to self-identify as white.

CONCLUSIONS

In this case study in Minnesota, researchers can be reasonably confident that the racial designations on Medicaid administrative data comport with how enrollees self-identify. Moreover, misclassification is not associated with common measures of health status, utilization, and ratings of quality of care. Further replication is recommended given variation in how race information is collected and coded by Medicaid agencies in different states.

Racial misidentification of American Indians/Alaska Natives in the HIV/AIDS Reporting Systems of five states and one urban health jurisdiction, U.S., 1984-2002

OBJECTIVES

We examined racial misidentification of American Indians/Alaska Natives (AI/AN) reported to the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) Reporting Systems (HARS) of five U.S. states and one county.

METHODS

To identify AI/AN records with misidentified race, we linked HARS data from 1984 through 2002 to the Indian Health Service National Patient Information and Reporting System (NPIRS), excluding non-AI/AN dependents, using probabilistic matching with clerical review. We used chi-square tests to examine differences in proportions and logistic regression to examine the associations of racial misidentification with HARS site, degree of AI/AN ancestry, mode of exposure to HIV, and urban or rural location of residence at time of diagnosis.

RESULTS

A total of 1,523 AI/AN individuals was found in both NPIRS and HARS; race was misidentified in HARS for 459 (30%). The percentages of racially misidentified ranged from 3.7% (in Alaska) to 55% (in California). AI/AN people were misidentified as white (70%), Hispanic (16%), black (11%), and Asian/Pacific Islander (2%); for 0.9%, race was unspecified. Logistic regression results (data from all areas, all variables) indicated that urban residence at time of diagnosis, degree of AI/AN ancestry, and mode of exposure to HIV were significantly associated with racial misidentification of AI/AN people reported to HARS.

CONCLUSIONS

Our findings add to the evidence that racial misidentification of AI/AN in surveillance data can result in underestimation of AI/AN HIV/AIDS case counts. Racial misidentification must be addressed to ensure that HIV/ AIDS surveillance data can be used as the basis for equitable resource allocation decisions, and to inform and mobilize public health action.

Advancing HIV/AIDS prevention among American Indians through capacity building and the community readiness model

Although HIV/AIDS prevention has presented challenges over the past 25 years, prevention does work! To be most effective, however, prevention must be specific to the culture and the nature of the community. Building the capacity of a community for prevention efforts is not an easy process. If capacity is to be sustained, it must be practical and utilize the resources that already exist in the community. Attitudes vary across communities; resources vary, political climates are constantly varied and changing. Communities are fluid-always changing, adapting, growing. They are "ready" for different things at different times. Readiness is a key issue! This article presents a model that has experienced a high level of success in building community capacity for effective prevention/intervention for HIV/AIDS and offers case studies for review. The Community Readiness Model provides both quantitative and qualitative information in a user-friendly structure that guides a community through the process of understanding the importance of the measure of readiness. The model identifies readiness- appropriate strategies, provides readiness scores for evaluation, and most important, involves community stakeholders in the process. The article will demonstrate the importance of developing strategies consistent with readiness levels for more cost-effective and successful prevention efforts.

Quality of race, Hispanic ethnicity, and immigrant status in population-based cancer registry data: implications for health disparity studies

Population-based cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute are based on medical records and administrative information. Although SEER data have been used extensively in health disparities research, the quality of information concerning race, Hispanic ethnicity, and immigrant status has not been systematically evaluated. The quality of this information was determined by comparing SEER data with self-reported data among 13,538 cancer patients diagnosed between 1973-2001 in the SEER--National Longitudinal Mortality Study linked database. The overall agreement was excellent on race (kappa = 0.90, 95% CI = 0.88-0.91), moderate to substantial on Hispanic ethnicity (kappa = 0.61, 95% CI = 0.58-0.64), and low on immigrant status (kappa = 0.21. 95% CI = 0.10, 0.23). The effect of these disagreements was that SEER data tended to under-classify patient numbers when compared to self-identifications, except for the non-Hispanic group which was slightly over-classified. These disagreements translated into varying racial-, ethnic-, and immigrant status-specific cancer statistics, depending on whether self-reported or SEER data were used. In particular, the 5-year Kaplan-Meier survival and the median survival time from all causes for American Indians/Alaska Natives were substantially higher when based on self-classification (59% and 140 months, respectively) than when based on SEER classification (44% and 53 months, respectively), although the number of patients is small. These results can serve as a useful guide to researchers contemplating the use of population-based registry data to ascertain disparities in cancer burden. In particular, the study results caution against evaluating health disparities by using birthplace as a measure of immigrant status and race information for American Indians/Alaska Natives.

American Indian women, HIV/AIDS, and health disparity

Data are presented regarding the prevalence of HIV/AIDS among American Indian women. Health disparities found among American Indians are discussed and biological, economic, social, and behavioral risk factors associated with HIV are detailed. Recommendations are suggested to alleviate the spread of HIV among American Indian women and, in the process, to diminish a culture of treatment malpractice and a weakening of treatment ethics, racism, and genderism.

Misclassification of race/ethnicity in a population-based cancer registry (United States)

Cancer registry data on race/ethnicity are vital for understanding cancer patterns in population subgroups, as they inform public health policies for allocating resources and form the bases of etiologic hypotheses. However, accuracy of cancer registry data on race/ethnicity has not been systematically evaluated. By comparing race/ethnicity in the Greater Bay Area Cancer Registry to self-reported race/ethnicity for patients from 14 racial/ethnic groups, we determined the accuracy of this variable and the patient and hospital characteristics associated with disagreement. The extent of misclassification (measured by sensitivity and predictive value positive (PV+)) varied across racial/ethnic groups (total n=11,676). Sensitivities and PV+'s were high (exceeding 90%) for non-Hispanic Whites and Blacks, moderate for Hispanics and some Asian subgroups (70-90%), and very low for American Indians (<20%). Overall, registry and interview race/ethnicity disagreed for 11% of the sample. In a multivariate model, disagreement was associated with non-White race/ethnicity, younger age, being married, being foreign-born but preferring to speak English, and diagnosis in a large hospital. Improving data quality for race/ethnicity will be most effectively attempted at the reporting source. We advocate a concerted effort to systematize collection of these patient data across all facilities, which may be more feasible given electronic medical admissions forms.

Determinants of survival for Native American adults with HIV infection

Few if any Native American/Alaska Native (NA/AN) people have been included in highly active antiretroviral therapy (HAART) treatment trials or epidemiologic studies, leaving little data on which to be assured of the efficacy of HAART in this unique population. This study aims to evaluate the impact of HAART and review determinants of survival in a cohort of NA/AN persons receiving treatment for HIV in a real life clinical setting. A retrospective chart review of 235 HIV-infected Native Americans receiving services at an urban medical center operated by the Indian Health Service from January 1, 1981 through June 30, 2004 was conducted, providing 782.7 person-years of follow-up. The main outcome measures were time from study entry and from incident AIDS diagnosis to death. Death rates fell from 18.4 (13.3-25.4) per 100 person-years in the period prior to 1998 to 6.4 (4.6-8.8) per 100 person-years in the years 1998-2004, (RR 0.35, p < 0.0001). Factors associated with the greatest reduction in risk of death from time of study entry were current use of HAART, HR 0.13 (0.06-0.30, p < 0.001), and CD4 count >/=200 at entry, HR 0.16 (0.08-0.35, p < 0.001). Current use of HAART was the strongest predictor of survival from time of AIDS diagnosis, HR 0.11 (0.05-0.25, p < 0.001). The use of HAART therapy and CD4 count were primary predictors of survival. Earlier diagnosis and access to effective medical treatment will be key factors in reducing disparities in health brought about by HIV infection in Native American/Alaska Native communities.

Use of death certificates to study ethnic-specific mortality

OBJECTIVES

The Hispanic population in the United States represents more than 40 million individuals, with Mexican Americans (MA) as the largest subgroup. To assess the utility of death certificates and medical records as the source of race/ethnicity data for epidemiologic studies, we compared self-reported race/ ethnicity to race/ethnicity recorded on death certificates and medical records in a bi-ethnic, non-immigrant U.S. community with a significant MA population.

METHODS

This study utilized data collected from a subset of 1,856 participants of the Brain Attack Surveillance in Corpus Christi (BASIC) project. In-person interviews were conducted to determine self-reported race/ethnicity. Of those interviewed, 480 subsequently expired. Using self-reported race/ethnicity as the gold standard, we determined percent agreement, sensitivity, and specificity of the death certificate and medical record.

RESULTS

Of the 480 subjects, 259 self-reported their race/ethnicity as non-Hispanic white (NHW), 195 self-reported as MA, and 26 self-reported as non-Hispanic black. Median age was 78.5 years and 55.8% were female. Percent agreement between self-reported race/ethnicity and race/ethnicity recorded on the death certificate and medical record was 97.1% and 96.3% respectively. Five percent of MAs were misclassified as NHW on their death certificates and 3% on their medical records.

CONCLUSIONS

Results indicated that Hispanic designation recorded on death certificates and medical records in this community was largely consistent with that of self-report. This study suggests that vital statistics data in non-immigrant U.S. Hispanic communities can be used with confidence to investigate ethnic-specific aspects of disease and mortality. Similar studies in other multi-racial communities should be conducted to confirm and generalize these results.

The changing face of HIV/AIDS among Native populations

AIDS has steadily increased in recent years, becoming the ninth leading killer of Native people between the ages of 15 and 44. In 2003, the Centers for Disease Control and Prevention (CDC) reported that ethnic minorities account for more than 71% of all reported AIDS cases and that there are still increases in AIDS cases in the American Indian population. Despite the work that has been done related to HIV/AIDS, there remain some major challenges in the prevention of HIV/AIDS in Native communities. Yet, there are changes on the horizon and these changes bring hope to Native communities in the ongoing battle to decrease HIV and AIDS. This article details information about the biological, social, economic and behavioral cofactors related to the rise in HIV/AIDS in Native communities and follows with issues related to special populations and consideration of the unique needs of prevention in these subpopulations. The need for norming of HIV testing is discussed as is the need for Native-specific programs and interventions. Finally, changes in the recognition of the culturally specific needs of Native people are noted and new resources are presented.

Epidemiology of HIV/AIDS among Asians and Pacific Islanders in the United States

Although the percentage of overall AIDS diagnoses remains low among Asian and Pacific Islanders (APIs) in the United States compared with other racial/ethnic groups, research on API risk behaviors and health status suggest that the low number of AIDS cases may not provide a full picture of the epidemic and issues faced by this understudied and underserved population. Data from national HIV/AIDS surveillance systems and the Behavioral Risk Factor Surveillance System (BRFSS) were examined to delineate the magnitude and course of the HIV/AIDS epidemic among APIs in the United States. Same-sex sexual activity is the main HIV risk for API men, whereas heterosexual contact is for API women. APIs are significantly less likely to report being tested for HIV despite the fact that a similar proportion of APIs and other racial/ethnic groups reported having HIV risk in the past 12 months. Given the enormous diversity among APIs in the United States it is important to collect detailed demographic information to improve race/ethnicity and HIV risk classification, conduct better behavioral and disease monitoring for informing prevention planning, and addressing cultural, linguistic, economic and legal barriers to HIV prevention among APIs.

High incidence of HIV-associated mortality among black and Hispanic infants and women of childbearing age in the United States 1990-2001

This study examined HIV-associated mortality in infants and in women of childbearing age (15-44 years) in the United States from 1990-2001. HIV-associated deaths were identified from national vital records using multiple cause-of-death data. HIV-associated mortality was higher in black and Hispanic women than in white women (rate ratio(black) = 13.5, 95% CI = 13.2-13.8; rate ratio(Hispanic) = 2.4, 95% CI = 1.9-3.2). Racial/ethnic trends in infant mortality rates from HIV reflected trends observed in women (rate ratio(black) = 16.3, 95% CI = 13.5-19.7; rate ratio(Hispanic) = 3.4, 95% CI = 3.3-3.5). HIV-associated mortality decreased in infants and in women of childbearing age following the availability of highly active antiretroviral therapy, but the decrease was considerably less marked in black women than in women of other racial/ethnic groups. Our findings indicate the need for increased emphasis on prevention of HIV mortality in black and Hispanic women and infants. Reduction of HIV prevalence in young women may also prevent infant mortality from HIV by reducing mother-to-child transmission.

Epidemiologic profile of HIV and AIDS among American Indians/Alaska Natives in the USA through 2000

OBJECTIVES

To describe HIV and AIDS among American Indians/Alaska Natives (AI/ AN) in the USA through 2000.

DESIGN

An epidemiologic profile was constructed using HIV/AIDS surveillance, sexually transmitted disease (STD), and seroprevalence data.

RESULTS

Although AIDS among AI/AN represents < 1% of cumulative AIDS cases in the USA, in 2000 the AIDS incidence rate (cases per 100,000 population) for AI/AN (11.9) was higher than that for whites (7.3). AI/AN had high rates of chlamydia, gonorrhea, and syphilis from 1996 through 2000; among all females, AI/AN females had the second highest rates of chlamydia, gonorrhea, and syphilis reported during this time period. Of all AIDS cases among AI/AN, 70% were reported by 10 states.

CONCLUSIONS

These data demonstrate that the impact of STDs and the potential for an impact of HIV/AIDS among AI/AN are greater than indicated by the relatively small number of AIDS cases in this population. Additional mechanisms are needed to fill gaps in the available data. Coordination among the complex network of healthcare providers, tribes, and federal, state, and local health agencies is needed to improve delivery of information about HIV/AIDS to AI/AN and to ensure access to HIV prevention and treatment programs for AI/AN.

Inconsistencies between self-reported ethnicity and ethnicity recorded in a health maintenance organization

PURPOSE

Information on patient ethnicity in hospital admissions databases is often used in epidemiologic and health services research. However, the extent of consistency of these data with self-reported ethnicity is not well studied, particularly for specific Asian subgroups. We examined agreement between ethnicity in records of a sample of members of five Northern California Kaiser Permanente medical centers with self-reported ethnicity.

METHODS

Subjects were 3168 cases and 2413 controls aged 45 years and older from a study of fractures. Ethnicity recorded in the Kaiser admissions database (primarily inpatient) was compared with self-reported ethnicity from the study interviews.

RESULTS

Among study subjects with available Kaiser ethnicity, sensitivities and positive predictive values of the Kaiser classification were high among blacks (0.95 for both measures) and whites (0.98 and 0.94, respectively), slightly lower among Asians (0.88 and 0.95, respectively), and considerably lower among Hispanics (0.55 and 0.81, respectively) and American Indians (0.47 and 0.50, respectively). Among Asian subgroups, the proportion classified as Asian was high among Chinese (0.94) and Japanese (0.99) but lower among Filipinos (0.79) and other Asians (0.74). Among the 228 (4%) subjects who self-identified with multiple ethnicities, 13 of 18 white + Hispanic subjects were classified as being white, and of the 77 subjects identifying as part American Indian, only one was classified as being American Indian in the Kaiser database.

CONCLUSIONS

Given the importance of ethnicity information, medical facilities should be encouraged to adopt policies toward collecting high quality data.

Multiple-race mortality data for California, 2000-2001

OBJECTIVES

To examine mortality rates and quality of race reporting for multiple-race individuals in California using the new multiple-race data available on the death certificate.

METHODS

Death date were drawn from California vital statistics for 2000 and 2001. Denominator data were drawn from the 2000 census Modified Race Data Summary File. The authors calculated mortality rates and relative standard errors for multiple-race individuals as a whole and by county, and for the three largest reported multiple-race groups (African American and white, American Indian/Alaska Native and white, and Asian and white).

RESULTS

Decedents reported to be of more than one race were disproportionately young, Hispanic, male, and never-married. Age-adjusted mortality rates for multiple-race groups were approximately one-sixth as high as rates for single-race individuals. There was substantial variability in rates for multiple-race decedents according to county of residence.

CONCLUSIONS

Mortality rates for multiple-race people were implausibly low, and death certificates for multiple-race individuals were geographically clustered. Race reporting on death certificates will need to be improved before accurate death rates can be calculated for those of multiple races.

Surveillance systems monitoring HIV/AIDS and HIV risk behaviors among American Indians and Alaska Natives

Few published reports describe patterns of occurrence of HIV/AIDS among American Indian/Alaska Native (AI/AN) people nationally. Data from national surveillance systems were examined to describe the spread of HIV/AIDS and the prevalence of HIV-related risk behaviors among AI/AN people. These data indicate that HIV/AIDS is a growing problem among AI/AN people and that AI/AN youth and women are particularly vulnerable to the continued spread of HIV infection.

Methods for using Medicare data to compare procedure rates among Asians, blacks, Hispanics, Native Americans, and whites

OBJECTIVE

Small sample sizes in Asian, Hispanic, and Native American groups and misreporting of race/ethnicity across all groups (including blacks and whites) limit the usefulness of racial/ethnic comparisons based on Medicare data. The objective of this paper is to compare procedure rates for these groups using Medicare data, to assess how small sample size and misreporting affect the validity of comparisons, and to compare rates after correcting for misreporting.

DATA

We use 1997 physician claims data for a 5 percent sample of Medicare beneficiaries aged 65 and older to study cardiac procedures and tests.

STUDY DESIGN

We calculate age and sex-adjusted rates and confidence intervals by race/ethnicity. Confidence intervals are compared among the groups. Out-of-sample data on misreporting of race/ethnicity are used to assess potential bias due to misreporting, and to correct for the bias.

PRINCIPAL FINDINGS

Sample sizes are sufficient to find significant ethnic and racial differences for most procedures studied. Blacks' rates tend to be lower than whites. Asian and Hispanic rates also tend to be lower than whites', and about the same as blacks'. Sample sizes for Native Americans are very small (about .1 percent of the data); nonetheless, some significant differences from whites can still be identified. Biases in rates due to misreporting are small (less than 10 percent) for blacks, Hispanics, and whites. Biases in rates for Asians and Native Americans are greater, and exceed 20 percent for some procedures.

CONCLUSIONS

Sample sizes for Asians, blacks, and Hispanics are generally adequate to permit meaningful comparisons with whites. Implementing a correction for misreporting makes Medicare data useful for all ethnic groups. Misreporting race/ethnicity and small sample sizes do not materially limit the usefulness of Medicare data for comparing rates among racial and ethnic groups.

Motor vehicle and fall related deaths among older Americans 1990-98: sex, race, and ethnic disparities

OBJECTIVES

To examine differences in motor vehicle and fall related death rates among older adults by sex, race, and ethnicity.

METHODS

Annual mortality tapes for 1990-98 provided demographic data including race and ethnicity, date, and cause of death. Trend analyses were conducted using Poisson regression.

RESULTS

From 1990-98, overall motor vehicle related death rates remained stable while death rates from unintentional falls increased. Motor vehicle and fall related death rates were higher among men. Motor vehicle related death rates were higher among people of color while fall related death rates were higher among whites. Among whites, fall death rates increased significantly during the study period, with an annual relative increase of 3.6% for men and 3.2% for women.

CONCLUSIONS

The risk of death from motor vehicle and fall related injuries among older adults differed by sex, race and ethnicity, results obscured by simple age and sex specific death rates. This study found important patterns and disparities in these death rates by race and ethnicity useful for identifying high risk groups and guiding prevention strategies.

Trends in AIDS incidence and survival among racial/ethnic minority men who have sex with men, United States, 1990-1999

OBJECTIVES

We describe trends in AIDS incidence, survival, and deaths among racial/ethnic minority men who have sex with men (MSM).

METHODS

We examined AIDS surveillance data for men diagnosed with AIDS from 1990 through 1999, survival trends from 1993 through 1997, and trends in AIDS incidence and deaths from 1996 to 1999, when highly active antiretroviral therapy (HAART) was introduced.

RESULTS

The percentage of racial/ethnic minority MSM with AIDS increased from 33% of 26,930 men in 1990 to 54% of 17,162 men in 1999. From 1996 through 1998, declines in AIDS incidence were smallest among black MSM (25%, from 66.2 to 49.5 per 100,000) and Hispanic MSM (29%, from 39.3 to 27.8), compared with white MSM (41%, from 17.9 to 10.5). Declines in deaths of MSM with AIDS were also smallest among black MSM (53%, from 39.7 to 18.6 deaths per 100,000) and Hispanic MSM (61%, 21.6 to 8.4), compared with white MSM (63%, 12.3 to 4.5). Survival improved each year for all racial/ethnic groups but was poorest for black MSM in all years.

CONCLUSIONS

Since the introduction of HAART, a combination of factors that include relatively higher infection rates in more recent years and differences in survival following AIDS diagnosis contribute to observed differences in trends in AIDS incidence and deaths among racial/ethnic minority MSM. Increased development of culturally sensitive HIV prevention services, and improved access to testing and care early in the course of disease are needed to further reduce HIV-related morbidity in racial/ethnic minority MSM.

Causes of death among women with human immunodeficiency virus infection in the era of combination antiretroviral therapy

PURPOSE

To examine changes in the causes of death and mortality in women with human immunodeficiency virus (HIV) infection in the era of combination antiretroviral therapy.

METHODS

Among women with, or at risk of, HIV infection, who were enrolled in a national study from 1994 to 1995, we used an algorithm that classified cause of death as due to acquired immunodeficiency syndrome (AIDS) or non-AIDS causes based on data from death certificates and the CD4 count. Poisson regression models were used to estimate death rates and to determine the risk factors for AIDS and non-AIDS deaths.

RESULTS

Of 2059 HIV-infected women and 569 who were at risk of HIV infection, 468 (18%) had died by April 2000 (451 HIV-infected and 17 not infected). Causes of death were available for 428 participants (414 HIV-infected and 14 not infected). Among HIV-infected women, deaths were classified as AIDS (n = 294), non-AIDS (n = 91), or indeterminate (n = 29). The non-AIDS causes included liver failure (n = 19), drug overdose (n = 16), non-AIDS malignancies (n = 12), cardiac disease (n = 10), and murder, suicide, or accident (n = 10). All-cause mortality declined an average of 26% per year (P = 0.03) and AIDS-related mortality declined by 39% per year (P = 0.01), whereas non-AIDS-related mortality remained stable (10% average annual decrease, P = 0.73). Factors that were independently associated with non-AIDS-related mortality included depression, history of injection drug use with hepatitis C infection, cigarette smoking, and age.

CONCLUSION

A substantial minority (20%) of deaths among women with HIV was due to causes other than AIDS. Our data suggest that to decrease mortality further among HIV-infected women, attention must be paid to treatable conditions, such as hepatitis C, depression, and drug and tobacco use.

The completeness, validity, and timeliness of AIDS surveillance data

PURPOSE

To assess the completeness, validity, and timeliness of the AIDS surveillance system after the 1993 change in the surveillance case definition.

METHODS

To assess completeness of AIDS case reporting, three study sites conducted a comparison of their AIDS surveillance registries with an independent source of information. To evaluate validity, the same sites conducted record reviews on a sample of reported AIDS cases, we then compared agreement between the original report and the record review for sex, race, and mode of transmission. To evaluate timeliness, we calculated the median delay from time of diagnosis to case report, before and after the change in case definition, in each of the three study sites.

RESULTS

After expansion of the case definition, completeness of AIDS case reporting in hospitals (> or = 93%) and outpatient settings (> or = 90%) was high. Agreement between the information provided on the original case report and the medical record was > 98% for sex, > 83% for each race/ethnicity group; and > 67% for each risk group. The median reporting delay after the change was four months, but varied by site from three to six months.

CONCLUSIONS

The completeness, validity, and timeliness of the AIDS surveillance system remains high after the 1993 change in the surveillance case definition. These findings might be useful for programs implementing integrated HIV and AIDS surveillance systems.

Economic deprivation and AIDS incidence in Massachusetts

OBJECTIVES

This study quantified AIDS incidence in Massachusetts in relation to economic deprivation.

METHODS

Using 1990 census block-group data, 1990 census population counts, and AIDS surveillance registry data for the years 1988 through 1994, we generated yearly and cumulative AIDS incidence data for the state of Massachusetts stratified by sex and by neighborhood measures of economic position for the total, Black, Hispanic, and White populations.

RESULTS

Incidence of AIDS increased with economic deprivation, with the magnitude of these trends varying by both race/ethnicity and sex. The cumulative incidence of AIDS in the total population was nearly 7 times higher among persons in block-groups where 40% or more of the population was below the poverty line (362 per 100,000) than among persons in block-groups where less than 2% of the population was below poverty (53 per 100,000).

CONCLUSIONS

Observing patterns of disease burden in relation to neighborhood levels of economic well-being elucidates further the role of poverty as a population-level determinant of disease burden. Public health agencies and researchers can use readily available census data to describe neighborhood-level socioeconomic conditions. Such knowledge expands options for disease prevention and increases the visibility of economic inequality as an underlying cause of AIDS.

Trends in AIDS among Hispanics in the United States, 1991-1996

OBJECTIVES

This article describes recent trends in AIDS among US Hispanics.

METHODS

Incidence rates were calculated from AIDS surveillance data for persons diagnosed from 1991 through 1996. Increases in the number of cases among Hispanics were calculated by linear regression.

RESULTS

Of the 415,864 persons diagnosed with AIDS from 1991 through 1996, 19% were Hispanic. Among Hispanics with AIDS, 67% were born in the United States or Puerto Rico. The relative risk (RR) of AIDS for Hispanics compared with Whites was highest for women (RR = 7.0), followed by children (RR = 6.2) and men (RR = 2.8). Increases in the number of cases were higher among foreign-born Hispanics.

CONCLUSIONS

An understanding of which Hispanic subgroups are at greatest risk for HIV infection is important for prevention efforts.