Appendix: Indicator Measurement Definitions

Demographic group

Students in grades 9–12.

Numerator

Students in grades 9–12 who report consumption of at least one drink of alcohol in the past 30 days.

Denominator

Students in grades 9–12 who reported having a specific number of drinks of alcohol, including zero, in the past 30 days (excluding those who did not answer).

Measures of frequency

Biennial (odd years) prevalence with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Past 30 days.

Background

In 2011, 39% of high school students reported drinking alcohol on at least 1 day in the past 30 days (1). The prevalence of current drinking is similar for boys and girls but increases by grade. In 2011, among U.S. high school students, 80% had consumed alcohol by the 12th grade, even though the sale of alcohol to persons aged ≥21 years has been illegal in all states since 1988 (2). Current drinking by youths is correlated with current drinking by adults in states (3).

Significance

On average, alcohol is a factor in the deaths of approximately 4,300 youths in the United States per year, shortening their lives by an average of 60 years (4). Underage drinking cost the United States $24 billion in 2006 (5). Studies have determined that delaying the age when drinking is initiated until age 21 years or later substantially reduces the risk for experiencing alcohol-related problems (6). Underage drinking is also strongly associated with injuries, violence, fetal alcohol spectrum disorders, and risk for other acute and chronic health effects (7,8).

Limitations of indicator

The indicator does not convey the frequency of drinking or the specific amount of alcohol consumed. This indicator is available every other year.

Data resources

Youth Risk Behavior Surveillance System (YRBSS).

Limitations of data resources

As with all data from self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youths who are attending school and therefore might not be representative of all persons in this age group (1). Results are not available from every state because some states do not participate in YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data and are therefore not included in the results.

Related indicators or recommendations

Healthy People 2020 objective SA–13.1: Reduce the proportion of adolescents reporting use of alcohol or any illicit drugs in the past 30 days.

Related chronic disease indicator topics

School health.

Demographic group

Women aged 18–44 years who have had a live birth.

Numerator

Respondents who reported that they drank any alcoholic beverages during the 3 months before becoming pregnant with their most recent live-born infant, including those having less than one drink in an average week.

Denominator

Respondents who reported the number of drinks they had in an average week, including none, during the 3 months before becoming pregnant with their most recent live-born infant, as well as those who reported that they did not have any alcoholic drinks in the past 2 years (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Crude prevalence with 95% confidence intervals weighted using the Pregnancy Risk Assessment Monitoring System method (to compensate for unequal probabilities of selection and adjust for nonresponse and telephone noncoverage) and by demographic characteristics when feasible.

Time period of case definition

Three months before the pregnancy resulting in the most recent live birth.

Background

Preconception drinking patterns are highly predictive of alcohol use during pregnancy, which has been associated with adverse birth and infant outcomes, including fetal alcohol spectrum disorders (1,2). Therefore, medical guidelines advise against any alcohol use throughout pregnancy and around the time of conception because the effects of alcohol consumption on the fetus might occur before a woman is aware she is pregnant (3,4). According to 2004 PRAMS data collected from 26 reporting areas, the mean prevalence of alcohol use during the 3 months before the most recent pregnancy was 50.1% (5).

Significance

The U.S. Surgeon General has determined that no amount of alcohol consumption during pregnancy is known to be safe (3). The clinical workgroup of the Select Panel on Preconception Care recommends all women of childbearing aged be screened for alcohol use and provided with information regarding potential adverse health outcomes including the negative effects of alcohol consumption during pregnancy (6). In addition, women who exhibit signs of alcohol dependence or misuse should be directed to support programs that would assist them to achieve long-term cessation of alcohol use and be advised to delay any future pregnancies until they are able to abstain from alcohol use (6).

Limitations of indicator

The indicator does not convey the frequency of drinking or the number of drinks per day or per occasion. Other age group definitions are recognized for reproductive age; however, these measurements will consistently use the age range of 18–44 years.

Data resources

Pregnancy Risk Assessment Monitoring System (PRAMS).

Limitations of data resources

PRAMS data are collected only from women who delivered a live-born infant, not all women of reproductive age, and from 40 states and one city, not the entire United States. PRAMS data are self-reported and might be subject to recall bias and underreporting or overreporting of behaviors based on social desirability. Although most self-report surveys such as PRAMS might be subject to systematic error resulting from noncoverage (e.g., lower landline telephone coverage because of transition to cellular telephone–only households or undeliverable addresses), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement bias (e.g., recall bias), PRAMS attempts to contact potential respondents by mail and landline or cellular telephone to increase response rates. Women who experienced a fetal death or had an abortion are excluded. PRAMS estimates only cover the population of residents in each state who also deliver in that state; therefore, residents who delivered in a different state are not included in their resident state.

Related indicators or recommendations

Healthy People 2020 objective MICH-11: Increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant women.

Related chronic disease indicator topics

Reproductive health.

Demographic group

Students in grades 9–12.

Numerator

Students in grades 9–12 who report having five or more drinks of alcohol within a couple of hours on ≥1 day in the past 30 days.

Denominator

Students in grades 9–12 who report having a specific number, including zero, of drinks of alcohol within a couple of hours on ≥1 day in the past 30 days (excluding those who did not answer).

Measures of frequency

Biennial (odd years) prevalence with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Past 30 days.

Background

In 2011, 22% of high school students in the United States reported binge drinking in the past 30 days (1). Binge drinking accounts for 90% of the alcohol consumed by youths (2); approximately two out of three high school students who report drinking also report binge drinking (3), usually on multiple occasions. In 2011, the prevalence of binge drinking among boys was 24% and 20% among girls (1). The prevalence of binge drinking was higher among white (24%) and Hispanic (24%) students than black students (12%), and prevalence increased with grade (1). Binge drinking by youths is correlated with binge drinking by adults in states (4).

Significance

Alcohol is a factor in the deaths of approximately 4,300 youths in the United States per year, shortening their lives by an average of 60 years (5). Underage drinking cost the United States $24 billion in 2006 (6). Binge drinking is a risk factor for many health and social problems, including motor-vehicle crashes, violence, suicide, hypertension, acute myocardial infarction, sexually transmitted diseases, unintended pregnancy, fetal alcohol spectrum disorders, and sudden infant death syndrome (7,8).

Limitations of indicator

The indicator does not convey the frequency of binge drinking or the specific amount of alcohol consumed. The definition of binge drinking used in the data source (Youth Risk Behavior Surveillance System) is not gender specific. This indicator is available every other year.

Data resources

Youth Risk Behavior Surveillance System (YRBSS).

Limitations of data resources

As with all self-reported sample surveys, YRBSS data might be subject to systematic error resulting from noncoverage (e.g., no participation by certain schools), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). YRBSS data only apply to youths who are attending school and therefore might not be representative of all persons in this age group (1). Results are not available from every state because some states do not participate in YRBSS. Moreover, some states that do participate do not achieve a high enough overall response rate to receive weighted data and are therefore not included in the results.

Related indicators or recommendations

• Healthy People 2020 objective SA–14.1: Reduce the proportion of students engaging in binge drinking during the past 2 weeks—high school seniors.

• Healthy People 2020 objective SA–14.4: Reduce the proportion of persons engaging in binge drinking during the past month—persons aged 12–17 years.

• CDC Prevention Status Report: Excessive alcohol use (9).

Related chronic disease indicator topics

School health.

Demographic group

Adults aged ≥18 years.

Numerator

Adults aged ≥18 years who report having five or more drinks (men) or four or more drinks (women) on an occasion in the past 30 days.

Denominator

Adults aged ≥18 years who report having a specific number, including zero, of drinks on an occasion in the past 30 days (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 9 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Past 30 days.

Background

In 2010, a total of 17.1% of adults reported binge drinking on an occasion in the past 30 days (2). Binge drinking prevalence is higher among men, persons aged 18–34 years, whites, and those with household incomes ≥$75,000 (2).

Significance

Excessive alcohol use accounted for an estimated average of 88,000 deaths and 2.5 million years of potential life lost (YPLL) in the United States each year during 2006–2010 (3), and an estimated $223.5 billion in economic costs in 2006 (4). Binge drinking accounted for more than half of those deaths, two thirds of the YPLL (5), and three fourths of the economic costs (4). Binge drinking also is a risk factor for many health and social problems, including motor-vehicle crashes, violence, suicide, hypertension, acute myocardial infarction, sexually transmitted diseases, unintended pregnancy, fetal alcohol spectrum disorders, and sudden infant death syndrome (6,7). In the United States, binge drinking accounts for more than half of the alcohol consumed by adults (8). However, most binge drinkers are not alcohol dependent (9,10).

Limitations of indicator

The indicator does not convey the frequency of binge drinking or the specific amount of alcohol consumed.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate. A recent study using BRFSS data found that self-reports identify only 22%–32% of presumed alcohol consumption in states, based on alcohol sales (11).

Related indicators or recommendations

• Healthy People 2020 objective SA-14.3: Reduce the proportion of persons engaging in binge drinking in the past 30 days—adults aged ≥18 years.

• CDC Prevention Status Report: Excessive alcohol use (12).

Related chronic disease indicator topics

None.

Demographic group

Women aged 18–44 years.

Numerator

Women aged 18–44 years who report having four or more drinks on an occasion in the past 30 days.

Denominator

Women aged 18–44 years who report a specific number, including zero, of drinks on an occasion in the past 30 days (excluding those who refused to answer, had a missing answer, or who answered "don't know/not sure").

Measures of frequency

Prevalence with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Past 30 days.

Background

In 2010, an estimated 14.0% of women aged 18–44 years reported binge drinking on an occasion in the past 30 days (1).

Significance

Approximately 23,000 deaths among females each year in the United States are attributed to excessive alcohol use (2). Excessive alcohol use, including binge drinking, is strongly associated with injuries, violence, chronic liver disease, and risk for other acute and chronic health effects (3). Binge drinking can lead to unintended pregnancies, and females who are not expecting to get pregnant might not find out that they are until later in their pregnancy (4). If women binge drink while pregnant, they risk exposing their developing fetus to high levels of alcohol, increasing the chances the fetus will be harmed by the mother's alcohol use (5). Alcohol use by pregnant women causes fetal alcohol spectrum disorders (FASDs) (6,7). FASDs, which are estimated to affect at least 1% of all births in the United States, result in physical and growth problems, neurodevelopmental deficits, and lifelong disability (8).

Limitations of indicator

The indicator does not convey the frequency of binge drinking or the specific amount of alcohol consumed. Other age group definitions are recognized for reproductive age; however, these measurements will consistently use the age range of 18–44 years.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate. A recent study using BRFSS data found that self-reports identify only 22%–32% of presumed alcohol consumption in states, based on alcohol sales (9).

Related indicators or recommendations

• Healthy People 2020 objective SA-14.3: Reduce the proportion of persons engaging in binge drinking in the past 30 days—adults aged ≥18 years.

• Healthy People 2020 objective MICH-11: Increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant women.

Related chronic disease indicator topics

Reproductive health.

Demographic group

Adults aged ≥18 years.

Numerator

Number of binge drinking episodes (five or more drinks for men or four or more drinks for women on an occasion) in the past 30 days.

Denominator

Adults aged ≥18 years who report having five or more drinks (men) or four or more drinks (women) on an occasion in the past 30 days.

Measures of frequency

Annual binge drinking frequency: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 9 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Past 30 days.

Background

Excessive alcohol use accounted for an estimated average of 88,000 deaths and 2.5 million years of potential life lost (YPLL) in the United States each year during 2006–2010 (2) and an estimated $223.5 billion in economic costs in 2006 (3). Binge drinking accounted for more than half of those deaths, two thirds of the YPLL (4), and three fourths of the economic costs (3). In 2010, 85% of all alcohol-impaired driving episodes were reported by persons who also reported binge drinking (5). Approximately 90% of excessive drinkers report binge drinking, and most persons who report binge drinking do so frequently (6). In 2010, among binge drinkers, the frequency of binge drinking was 4.4 episodes per month (7). Binge drinking frequency was highest among binge drinkers aged ≥65 years (5.5 episodes per month) and those with household incomes <$25,000 (5.0 episodes per month) (7).

Significance

Binge drinking also is a risk factor for many health and social problems, including motor-vehicle crashes, violence, suicide, hypertension, acute myocardial infarction, sexually transmitted diseases, unintended pregnancy, fetal alcohol spectrum disorders, and sudden infant death syndrome (8,9). In the United States, binge drinking accounts for more than half of the alcohol consumed by adults (10). However, most binge drinkers are not alcohol dependent (11,12). The risk for alcohol-attributable harms (e.g., injuries) increases with the number of binge drinking episodes (13). Assessing the frequency of binge drinking might be particularly useful for planning and evaluating strategies recommended by the Guide to Community Preventive Services for preventing excessive alcohol use (14).

Limitations of indicator

Unless age, sex, education, and race/ethnicity estimates are generated for this indicator, subpopulations at high risk for binge drinking are not identified.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate. A recent study using BRFSS data found that self-reports identify only 22%–32% of presumed alcohol consumption in states, based on alcohol sales (15).

Related indicators or recommendations

Healthy People 2020 objective SA-14.3: Reduce the proportion of persons engaging in binge drinking in the past 30 days — adults aged ≥18 years.

Related chronic disease indicator topics

None.

Demographic group

Adults aged ≥18 years.

Numerator

Largest number of drinks consumed on an occasion in the past 30 days among adult binge drinkers aged ≥18 years.

Denominator

Adults aged ≥18 years who report having five or more drinks (men) or four or more drinks (women) on an occasion in the past 30 days.

Measures of frequency

Annual binge drinking intensity: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 9 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Past 30 days.

Background

Excessive alcohol use accounted for an estimated average of 88,000 deaths and 2.5 million years of potential life lost (YPLL) in the United States each year during 2006–2010 (2) and an estimated $223.5 billion in economic costs in 2006 (3). Binge drinking accounted for more than half of those deaths, two thirds of the YPLL (4), and three fourths of the economic costs (3). In 2010, 85% of all alcohol-impaired driving episodes were reported by persons who also reported binge drinking (5). In 2010, among binge drinkers, the binge drinking intensity was 7.9 drinks on occasion in the past 30 days (6). Binge drinking intensity was highest among persons aged 18–24 years (9.3 drinks on occasion) and those with household incomes <$25,000 (8.5 drinks on occasion) (6).

Significance

Binge drinking also is a risk factor for many health and social problems, including motor-vehicle crashes, violence, suicide, hypertension, acute myocardial infarction, sexually transmitted diseases, unintended pregnancy, fetal alcohol spectrum disorders, and sudden infant death syndrome (7,8). In the United States, binge drinking accounts for more than half of the alcohol consumed by adults. However, most binge drinkers are not alcohol dependent (9,10). The risk for alcohol-attributable harm (e.g., injuries) increases with the intensity of binge drinking (11). Assessing the intensity of binge drinking might be particularly useful for planning and evaluating strategies recommended by the Guide to Community Preventive Services for preventing excessive alcohol use (12).

Limitations of indicator

Unless age, sex, education, and race/ethnicity estimates are generated for this indicator, subpopulations at high risk are not identified.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate. A recent study using BRFSS data found that self-reports identify only 22%–32% of presumed alcohol consumption in states, based on alcohol sales (13).

Related indicators or recommendations

• Healthy People 2020 objective SA-14.3: Reduce the proportion of persons engaging in binge drinking in the past 30 days—adults aged ≥18 years.

• CDC Prevention Status Report: Excessive alcohol use (14).

Related chronic disease indicator topics

None.

Demographic group

Adults aged ≥18 years.

Numerator

Adults aged ≥18 years who report weekly alcohol consumption of 15 or more drinks (men) or eight or more drinks (women).

Denominator

Adults aged ≥18 years who report a specific number, including zero, for the number of weekly drinks (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 9 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Past 30 days.

Background

In 2010, 5.4% of adult men reported heavy drinking and 4.5% of adult women reported heavy drinking (2). Heavy drinkers are more likely to binge drink than moderate drinkers (3).

Significance

Excessive alcohol use accounted for an estimated average of 88,000 deaths and 2.5 million years of potential life lost (YPLL) in the United States each year during 2006–2010 (4) and an estimated $223.5 billion in economic costs in 2006 (5). Excessive alcohol use, including heavy drinking, is strongly associated with injuries, violence, chronic liver disease, and risk for other acute and chronic health effects (6).

Limitations of indicator

The indicator does not convey the exact amount of alcohol consumed per day. Therefore, a weekly consumption of seven alcoholic drinks for a woman or 14 alcoholic drinks for a man could be consumed over 2-day weekend on one or two occasions rather than up to one drink for a woman and up to 2 drinks for a man each day.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate. A recent study using BRFSS data found that self-reports identify only 22%–32% of presumed alcohol consumption in states, based on alcohol sales (7).

Related indicators or recommendations

Healthy People 2020 objective SA–15: Reduce the proportion of adults who drank excessively in the previous 30 days.

Related chronic disease indicator topics

Oral health.

Demographic group

Women aged 18–44 years.

Numerator

Women aged 18–44 years who reported having eight or more drinks per week on the days they drank alcohol in the past 30 days.

Denominator

Women aged 18–44 years who reported the number of drinks, including zero, on the days they drank alcohol as well as those who reported having had no drinks in the past 30 days (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Crude annual prevalence with 95% confidence intervals weighted using the Behavioral Risk Factor Surveillance System method (to compensate for unequal probabilities of selection and adjust for nonresponse and telephone noncoverage) and by demographic characteristics when feasible.

Time period of case definition

Past 30 days.

Background

Heavy alcohol use before pregnancy is predictive of continued use during pregnancy (1). CDC analysis of 2002 Behavioral Risk Factor Surveillance System data for women aged 18–44 years indicated that the prevalence of frequent drinking (seven or more drinks in a week or binge drinking) was 13.2% for all women of childbearing age overall (including pregnant women) and 13.1% for women who might become pregnant (2).

Significance

Alcohol consumption during pregnancy is associated with spontaneous abortions, birth defects, and developmental disorders, many of which occur early in gestation before the woman is aware that she is pregnant (2). Alcohol use during pregnancy is associated with fetal alcohol spectrum disorders, which might be characterized by specific physical features, impaired growth and abnormal development or functioning of the central nervous system (3). Even though a dose-response relationship has been observed between prenatal alcohol consumption and effects on the fetus, no amount of alcohol consumption during pregnancy is known to be safe (4). Therefore, medical guidelines, including the recommendations of the U.S. Surgeon General, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists, advise against any alcohol use around the time of conception and throughout pregnancy. Furthermore, the clinical workgroup of the Select Panel on Preconception Care recommends that all women of childbearing age be screened for alcohol use and provided with information regarding potential adverse health outcomes including the negative effects of alcohol consumption during pregnancy. In addition, women who exhibit signs of alcohol dependence or misuse should be directed to support programs that will assist them to achieve long-term cessation of alcohol use and be advised to delay any future pregnancies until they are able to abstain from alcohol use.

Limitations of indicator

The indicator does not convey the exact amount of alcohol consumed per day. Therefore, a weekly consumption of seven alcoholic drinks for a woman can be consumed over 2-day weekend on one or two occasions rather than up to one drink for a woman each day. Other age group definitions are recognized for reproductive age; however, these measurements will consistently use the age range of 18–44 years.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

Healthy People 2020 objective MICH-11: Increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant women.

Related chronic disease indicator topics

Reproductive health; oral health.

Demographic group

Entire U.S. population.

Numerator

Deaths with International Classification of Diseases, 10th Revision codes K70 or K73–K74 as the underlying cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Annual number of deaths. Annual mortality rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 1 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2010, a total of 31,903 persons died from chronic liver disease (2). The age-adjusted rate of death among males (12.7 per 100,000 population) was greater than the rate among females (6.1 per 100,000 population) (2).

Significance

Excessive alcohol use accounted for an estimated average of 88,000 deaths and 2.5 million years of potential life lost (YPLL) in the United States each year during 2006–2010 (3) and an estimated $223.5 billion in economic costs in 2006 (4). Sustained alcohol consumption is the leading cause of liver cirrhosis, the 12th leading cause of death (5). The risk for chronic liver disease and cirrhosis is directly to heavy and long-term consumption of alcohol (5).

Limitations of indicator

Because alcohol-related disease can have a long latency, changes in behavior or clinical practice affecting population mortality might not be apparent for years. Not all chronic liver disease deaths are alcohol-attributable. However, in 2009, almost 70% of cirrhosis deaths in the United States were alcohol-attributable (5), and the proportion of cirrhosis deaths coded as 100% alcohol-attributable has increased dramatically during 1970–2009 among United States adults aged 25–64 years (5).

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death and other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective SA–11: Reduce cirrhosis deaths.

Related chronic disease indicator topics

None.

Demographic group

Resident persons aged ≥14 years.

Numerator

Gallons of pure alcohol consumed during a calendar year.

Denominator

Mid-year resident population aged ≥14 years for the same calendar year.

Measures of frequency

Annual alcohol consumption per capita.

Time period of case definition

Calendar year.

Background

The past 75 years of per capita consumption data show that alcohol consumption increased sharply at the end of Prohibition to a transient peak in 1945, followed by a decrease and plateau through the early 1960s (1). This was followed by a steady 20-year increase in per capita consumption that lasted through the early 1980s, after which consumption dropped again through 1995 (1). Since 1995, per capita consumption has once again been increasing, albeit more slowly than in the 1960s and 1970s (1). During 1995–2012, per capita alcohol consumption increased 8% (from to 2.15 to 2.33 gallons), driven by a 24% increase in per capita spirits consumption (from 0.63 to 0.78 gallons) and a 45% increase in wine consumption (from 0.29 to 0.42 gallons) (1). In contrast, beer consumption has been decreasing steadily since the early 1980s and decreased 8% (from 1.23 to 1.13 gallons) during 1995–2012 (1).

Significance

Strong scientific evidence supports the usefulness of per capita alcohol consumption as a proxy measure of excessive alcohol use (2). The independent, nonfederal Community Preventive Services Task Force reviewed this measure in 2009, subsequently endorsed this measure, and decided to use it as a recommendation outcome for subsequent reviews of alcohol control policies (3). This indicator provides a more complete accounting of alcohol consumption in states than self-reported consumption indicators (2). A recent study using Behavioral Risk Factor Surveillance System data found that self-reports identify only 22%–32% of the presumed alcohol consumption in states based on this indicator (4). This indicator also supports state-level surveillance of alcohol consumption by beverage type. This indicator could serve as a very broad environmental and system change indicator of changes in factors that influence excessive consumption, such as price, retail availability, and regulatory environment.

Limitations of indicator

This indicator does not support local analyses of alcohol consumption (e.g., by county or city) or the analysis of alcohol consumption among specific demographic groups (e.g., age, sex, race/ethnicity).

Data resources

Alcohol Epidemiologic Data System (AEDS).

Limitations of data resources

Many factors may result in inaccuracies in estimates of per capita alcohol consumption (1). These include the use of fixed ethanol conversion coefficients (ECC, the proportion of pure alcohol for each beverage type), despite evidence that ECCs may change over time by beverage type (1). The assumption is that changes in the average net ethanol content across all beverages have probably been minimal and not large enough to alter recent trends in overall per capita consumption. Other factors include the possibility that estimates in some states might be inflated by cross-border sales to buyers from neighboring states (e.g., in New Hampshire) or tourists' consumption of alcohol (e.g., in Washington DC) (1). Other factors include variations in state reporting practices for sales of alcoholic beverages, time delay between state taxation records and actual consumption, exclusion of alcohol contained in medications and foods, unrecorded legal home production, and illicit production, importation, and sales (1).

Related indicators or recommendations

Healthy People 2020 objective SA–16: Reduce average annual alcohol consumption.

CDC Prevention Status Report: excessive alcohol use (5).

Related chronic disease indicator topics

None.

Demographic group

All resident persons.

Numerator

State taxes levied per gallon at the wholesale or retail level, by beverage type (reported separately for) 1) beer, 2) wine, or 3) distilled spirits.

Denominator

None.

Measures of frequency

Annual excise tax amount, by beverage type.

Time period of case definition

Annual as of January 1.

Background

The Community Preventive Services Task Force recommends increasing the unit price of alcohol by raising taxes based on strong evidence of effectiveness for reducing excessive alcohol consumption and related harms (1). Public health effects are expected to be proportional to the size of the tax increase (2). Alcohol consumption is particularly sensitive to the price of alcoholic beverages. (2) Across alcohol beverage types (i.e., beer, wine, and distilled spirits), the median price elasticity (a measure of the relationship between price and consumption) ranges from -0.50 for beer to -0.79 for spirits, and the overall price elasticity for ethanol is -0.77 (2). Thus, a 10% increase in the price of alcoholic beverages likely would reduce overall consumption by <7% (2). Recent analyses also note a substantial gap between the societal and governmental cost of excessive alcohol consumption (approximately $1.90 and $0.80 per drink, respectively) and the total federal and state taxes on alcoholic beverages (approximately $0.12 per drink) (3). Alcohol excise taxes are implemented at the state and federal level and are beverage specific (i.e., differ for beer, wine, and distilled spirits) (2). These taxes usually are based on the volume of alcohol sold and not on the sales price; therefore, their contribution to the total price of alcohol can erode over time because of inflation (2).

Significance

This indicator provides information about the level of state alcohol excise taxes. At the state and federal levels, inflation-adjusted alcohol taxes have decreased considerably since the 1950s (2). Concordant with this decrease in the real value of these taxes, the inflation-adjusted price of alcohol has decreased, reflecting the fact that changes in taxes are efficiently passed on through changes in prices (2). This indicator supports state-level surveillance of an important component of the price of alcohol (i.e., beverage-specific alcohol excise taxes), which has been strongly associated with changes in alcohol consumption (2).

Limitations of indicator

Additional taxes other than excise taxes that can affect the price of alcoholic beverages (e.g., sales taxes, which are levied as a percentage of the beverage's retail price) are not reported.

Data resources

Alcohol Policy Information System (APIS).

Limitations of data resources

Beverage-specific state tax levels are based on the taxes assessed on an index beverage within a particular beverage category (e.g., beer with 5% alcohol by volume) (4). APIS reports taxes for the most commonly sold container size and therefore does not include data on the taxes levied on alcoholic beverages sold in other container sizes. Tax amounts are not reported for states and beverage types for which the index beverage is available in state-run retail stores or through state-run wholesalers. In these cases, the state sets a price for each alcohol product that is some combination of cost, mark-up, and taxes, and determining the dollar value assigned to each of these components is not possible. Some states have separate tax rates for other types of alcoholic beverages (e.g., sparkling wine) that are not included in APIS. However, these beverages generally constitute a small segment of the alcohol retail market.

Related indicators or recommendations

CDC Prevention Status Report: Excessive alcohol use (5).

Related chronic disease indicator topics

None.

Demographic group

All resident persons.

Numerator

State has at least one of the following: 1) commercial host liability with no major limitations; 2) commercial host liability with major limitations; or 3) no commercial host liability. (Major limitations include having commercial host liability for minors or intoxicated adults but not both, increased evidentiary requirements for finding liability, limitations on damage awards, or restrictions on who may be sued.)

Denominator

None.

Measures of frequency

State commercial host liability status.

Time period of case definition

Annual as of January 1.

Background

The Community Preventive Services Task Force has concluded on the basis of strong evidence that dram shop liability is effective in preventing and reducing alcohol-related harms (1). Dram shop liability (also known as commercial host liability) holds alcohol retailers liable for alcohol-attributable harms (e.g., injuries or deaths resulting from alcohol-related motor vehicle crashes) caused by a patron who was either intoxicated or aged <21 years (the minimum legal drinking age, a minor) at the time of service (2). This liability can be established in states either by case law or statute. Some states only have commercial host liability for service to minors (3). Some states also restrict commercial host liability by increasing evidence requirements, capping the amount of compensation allowed in suits, or restricting who may be sued. However, the existence of commercial host liability in a state is thought to improve compliance with laws prohibiting alcohol service to intoxicated patrons or minors (2).

Significance

This indicator provides information on the existence of commercial host liability and whether this liability has major restrictions in those states where it exists. In states with major restrictions on this liability, the impact of this intervention on excessive alcohol use and related harms is likely to be reduced (2,3).

Limitations of indicator

The legal research required to support this indicator is time-consuming and requires expertise in the area of alcohol control policies and legal analysis.

Data resources

Mosher, JF, Cohen, EN, Jernigan, DH. Commercial host (dram shop) liability: current status and trends. Am J Prev Med 2013;45:347–53.

Limitations of data resources

This indicator is updated annually only for dram shop liability for sales to underage youths; no time frame exists for updating dram shop liability status for sales to adults. Specialized legal consultation is required to interpret laws and regulations.

Related Indicators or Recommendations

CDC Prevention Status Report: Excessive alcohol use (4).

Related chronic disease indicator topics

None.

Demographic group

All resident persons.

Numerator

State has at least one of the following: 1) exclusive local alcohol retail licensing, 2) joint local and state alcohol retail licensing, 3) exclusive state alcohol retail licensing but with local zoning authority, 4) mixed alcohol retail licensing policies, 5) nearly exclusive state alcohol retail licensing, or 6) exclusive state alcohol retail licensing.

Denominator

None.

Measures of frequency

Status of state's local authority to regulate alcohol outlet density.

Time period of case definition

Annual as of January 1.

Background

The Community Preventive Services Task Force has found sufficient evidence to recommend limiting alcohol outlet density through the use of regulatory authority (e.g., licensing and zoning) as a means of reducing or controlling excessive alcohol consumption and related harms (1). However, states vary in the extent to which they allow local governments to regulate the licensing of retail alcohol outlets and hence alcohol outlet density, ranging from the delegation of licensing authority to local governments to complete state control over alcohol licensing (2,3).

Significance

This indicator provides information on the degree of local control over the regulation of alcohol outlet density. In general, states that allow for greater local control over the regulation of alcohol outlet density (i.e., those that do not preempt local control over alcohol licensing) provide local governments with more opportunities to regulate alcohol outlet density and thereby reduce excessive alcohol consumption and related harms (2).

Limitations of indicator

The legal research required to support this indicator is time-consuming and requires expertise in the area of liquor control law.

Data resources

Mosher JF, Treffers R. State preemption, local control, and the regulation of alcohol retail outlet density. Am J Prev Med 2013; 44:399–405.

Limitations of data resources

No specified timeframe exists for updating this indicator. Specialized legal consultation is required to interpret laws and regulations.

Related indicators or recommendations

CDC Prevention Status Report: Excessive alcohol use (4).

Related chronic disease indicator topics

None.

Demographic group

Resident adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report having physician-diagnosed arthritis.

Denominator

Respondents aged ≥18 years who answered "yes" or "no" to the following question: "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?" (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence (during 2011–2015) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Lifetime.

Background

An estimated 52.5 million adults have physician-diagnosed arthritis, and 22.7 million report arthritis-attributable activity limitations (1). As the population ages, arthritis is expected to affect an estimated 67 million adults in the United States by 2030 (2). In 2003, arthritis cost an estimated $128 billion in direct medical and indirect costs (3).

Significance

Monitoring the prevalence and public health effects of arthritis are important for estimating the state-specific need for interventions that reduce symptoms, improve physical function, and improve the quality of life for persons with arthritis. These interventions include self-management education programs that have been shown to reduce pain and improve psychological health and health behaviors and physical activity programs that have been shown to improve physical function, mental health, and quality of life.

Limitations of indicator

Physician-diagnosed arthritis is self-reported in the Behavioral Risk Factor Surveillance System and was not confirmed by a health-care provider or objective monitoring; however, such self-reports have been shown to be acceptable for surveillance purposes (4) (despite minor changes made in 2011 to the case-finding question to include arthritis on the chronic conditions core).

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

In addition, CDC typically provides this estimate in standard arthritis BRFSS tables produced for each state for odd-numbered years. Unadjusted data are usually presented in these tables to provide actual estimates to help in state-level program planning.

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage, nonresponse, or measurement bias. To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

• Healthy People 2020 objective AOCBC-1: Reduce the mean level of joint pain among adults with doctor-diagnosed arthritis.

• Healthy People 2020 objective AOCBC-2: Reduce the proportion of adults with doctor-diagnosed arthritis who experience a limitation in activity because of arthritis or joint symptoms.

• Healthy People 2020 objective AOCBC-4: Reduce the proportion of adults with doctor-diagnosed arthritis who have difficulty in performing two or more personal care activities, thereby preserving independence.

• Healthy People 2020 objective AOCBC-5: Reduce the proportion of adults with doctor-diagnosed arthritis who report serious psychological distress.

• Healthy People 2020 objective AOCBC-6: Reduce the impact of doctor-diagnosed arthritis on employment in the working-age population.

• Healthy People 2020 objective AOCBC-7: Increase the proportion of adults with doctor-diagnosed arthritis who receive health-care provider counseling.

• Healthy People 2020 objective AOCBC-8: Increase the proportion of adults with doctor-diagnosed arthritis who have had effective, evidence-based arthritis education as an integral part of the management of their condition.

Related chronic disease indicator topics

None.

Demographic group

Resident adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report physician-diagnosed arthritis and who are obese (body mass index ≥30.0 kg/m²), calculated from self-reported weight and height.

Denominator

Respondents aged ≥18 years who are obese (body mass index ≥30.0 kg/m² calculated from self-reported weight and height) (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Current.

Background

An estimated 52.5 million adults have physician-diagnosed arthritis, and 22.7 million report arthritis-attributable activity limitations (1). In 2003, arthritis resulted in an estimated $128 billion in direct medical and indirect costs (2). Obesity is common among persons with arthritis and is a modifiable risk factor associated with arthritis-related disease progression, activity limitation, disability, reduced quality-of-life, total joint replacement, and poor clinical outcomes after joint replacement (3). The prevalence of obesity among adults with arthritis is an average of 54% higher than among adults without arthritis (3).

Significance

Monitoring the prevalence of arthritis among adults who are obese is important because obesity can worsen arthritis-related joint pain. Reaching and maintaining a normal weight can lower the risk for developing osteoarthritis, the most common type of arthritis (representing approximately two thirds of arthritis cases) and can improve symptoms and function in persons who already have the condition (3).

Limitations of indicator

Physician-diagnosed arthritis is self-reported in the Behavioral Risk Factor Surveillance System and was not confirmed by a health-care provider or objective monitoring; however, such self-reports have been shown to be acceptable for surveillance purposes (4) (despite minor changes made in 2011 to the case-finding question to include arthritis on the chronic conditions core). Height and weight are self-reported. Respondents tend to overestimate their height and underestimate their weight (3), likely leading to underestimation of body mass index and of the prevalence of obesity.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

In addition, CDC typically provides this estimate in standard arthritis BRFSS tables produced for each state for odd-numbered years. Unadjusted data are usually presented in these tables to provide actual estimates to help in state-level program planning.

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage, nonresponse, or measurement bias. To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

Healthy People 2020 objective AOCBC-7a: Increase the proportion of adults with physician-diagnosed arthritis who receive health-care provider counseling [...] for weight reduction among overweight and obese persons.

Related chronic disease indicator topics

Nutrition, physical activity, and weight status.

Demographic group

Resident adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report ever having physician-diagnosed diabetes other than diabetes during pregnancy and who report physician-diagnosed arthritis.

Denominator

Respondents aged ≥18 years who report ever having physician-diagnosed diabetes other than diabetes during pregnancy (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Current.

Background

An estimated 52.5 million adults have physician-diagnosed arthritis, and 22.7 million report arthritis-attributable activity limitations (1). During 2005 and 2007, the prevalence of arthritis among adults aged ≥18 years with diabetes was 52%, compared with 27% for all adults aged ≥18 years (2). The prevalence of physical inactivity is higher among adults with both diabetes and arthritis than those with either condition alone; physical activity is a recommended self-management strategy for both diabetes and arthritis (2).

Significance

Monitoring the prevalence of arthritis among adults with diabetes is important because more than half of the adults with diabetes also have arthritis (2). Diabetes and arthritis occur more frequently in older adults, women, and those who are obese (2). Arthritis might be an unaddressed barrier for adults with diabetes seeking to manage their condition through physical activity. Persons with arthritis report that increased joint pain is the number one barrier to participating in physical activities (3). Physical activity helps control blood glucose for persons with diabetes and can reduce pain, improve function, and delay disability among adults with arthritis (2). This indicator can be used to estimate the number of persons with diabetes who might need special interventions to help them become more physically active and manage their disease (e.g., through the Chronic Disease Self-Management Program or EnhanceFitness).

Limitations of indicator

Physician-diagnosed arthritis is self-reported in the Behavioral Risk Factor Surveillance System and was not confirmed by a health-care provider or objective monitoring; however, such self-reports have been shown to be acceptable for surveillance purposes (4) (despite minor changes made in 2011 to the case-finding question to include arthritis on the chronic conditions core). Diabetes also is self-reported.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

In addition, CDC typically provides this estimate in standard arthritis BRFSS tables produced for each state for odd-numbered years. Unadjusted data are usually presented in these tables to provide actual estimates to help in state-level program planning.

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage, nonresponse, or measurement bias. To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

None.

Related chronic disease indicator topics

Diabetes.

Demographic group

Resident adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report ever being told by a doctor, nurse, or other health professional that they had heart disease (myocardial infarction or coronary heart disease) and who report having physician-diagnosed arthritis.

Denominator

Respondents aged ≥18 years who report ever being told by a doctor, nurse, or other health professional that they had heart disease (myocardial infarction or coronary heart disease) (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Current.

Background

An estimated 52.5 million adults have physician-diagnosed arthritis, and 22.7 million report arthritis-attributable activity limitations (1). During 2005 and 2007, the prevalence of arthritis among adults aged ≥18 years with heart disease was 57%, compared with 27% for all adults aged ≥18 years (2). The prevalence of physical inactivity is higher among adults with both heart disease and arthritis than those with either condition alone (2); physical activity is a recommended self-management strategy for both heart disease and arthritis (2).

Significance

Monitoring the prevalence of arthritis among adults with heart disease is important because approximately half of the adults with heart disease also have arthritis. Heart disease and arthritis occur more frequently in older adults and those who are obese (2). Arthritis might be an unaddressed barrier for adults with heart disease seeking to manage their condition through physical activity. Persons with arthritis report that increased joint pain is the most common barrier to participating in physical activities (3). Physical activity helps control blood pressure and helps persons reach and maintain a healthy weight for persons with heart disease and can reduce pain, improve function, and delay disability among adults with arthritis (4). This indicator can be used to estimate the number of persons with heart disease who might need special interventions to help them become more physically active and manage their disease (e.g., through the Chronic Disease Self-Management Program or EnhanceFitness).

Limitations of indicator

Physician-diagnosed arthritis is self-reported in the Behavioral Risk Factor Surveillance System and was not confirmed by a health-care provider or objective monitoring; however, such self-reports have been shown to be valid for surveillance purposes (5) (despite minor changes made in 2011 to the case-finding question to include arthritis on the chronic conditions core). Physician-diagnosed heart disease also was self-reported.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).
In addition, CDC typically provides this estimate in standard arthritis BRFSS tables produced for each state for odd-numbered years. Unadjusted data are usually presented in these tables to provide actual estimates to help in state-level program planning.

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage, nonresponse, or measurement bias. To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

None.

Related chronic disease indicator topics

Cardiovascular disease.

Demographic group

Resident adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report having physician-diagnosed arthritis and an activity limitation because of arthritis or joint symptoms.

Denominator

Respondents aged ≥18 years (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Biannual prevalence with 95% confidence intervals (odd-numbered years) and by demographic characteristics when feasible.

Time period of case definition

Current.

Background

An estimated 52.5 million adults have physician-diagnosed arthritis, and 22.7 million report arthritis-attributable activity limitations (1). By 2030, 25 million (9.3% of the adult population) are projected to report arthritis-attributable activity limitations (2). In 2003, arthritis cost an estimated $128 billion in direct medical and indirect costs (3).

Significance

Monitoring the prevalence of arthritis-attributable activity limitation among the general population of adults is important for estimating the state-specific impact of arthritis, the need for interventions to reduce the disabling effects of arthritis, and how well existing interventions are working. These interventions include self-management education programs that have been shown to reduce pain and improve psychological health and health behaviors, and physical activity programs that have been shown to improve physical function, mental health, and quality of life (4).

Limitations of indicator

Physician-diagnosed arthritis is self-reported in the Behavioral Risk Factor Surveillance System and was not confirmed by a health-care provider or objective monitoring; however, such self-reports have been shown to be acceptable for surveillance purposes (5) (despite minor changes made in 2011 to the case-finding question to include arthritis on the chronic conditions core). Activity limitation also is self-reported.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS), Arthritis Burden Module (odd-numbered years only).

In addition, CDC typically provides this estimate in standard arthritis years. Unadjusted data are usually presented in these tables to provide actual estimates to help in state-level program planning.

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage, nonresponse, or measurement bias. To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

Healthy People 2020 objective AOCBC-2: Reduce the proportion of adults with doctor-diagnosed arthritis who experience a limitation in activity because of arthritis or joint symptoms.

Related chronic disease indicator topics

Disability.

Demographic group

Resident adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report physician-diagnosed arthritis and no leisure-time physical activity. Includes respondents reporting no activity when asked six questions about frequency and duration of participation in nonoccupational activities of moderate and vigorous intensity (i.e., lifestyle activities). All other respondents were classified as active.

Denominator

Respondents aged ≥18 years who report physician-diagnosed arthritis (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Current.

Background

An estimated 52.5 million adults have physician-diagnosed arthritis, and 22.7 million report arthritis-attributable activity limitations (1). By 2030, 25 million (9.3% of the adult population) are projected to report arthritis-attributable activity limitations (2). Staying physically active and maintaining a healthy weight through diet and exercise are recommended for persons with arthritis to reduce and delay disability (3). In 2003, arthritis cost an estimated $128 billion in direct medical and indirect costs (4).

Significance

Monitoring the prevalence of inactivity among persons with arthritis is important because increasing physical activity has significant benefits for persons with arthritis, including reductions in pain and improvements in physical function, mental health, and quality of life (5).

Limitations of indicator

Physician-diagnosed arthritis is self-reported in the Behavioral Risk Factor Surveillance System and was not confirmed by a health-care provider or objective monitoring; however, such self-reports have been shown to be acceptable for surveillance purposes (6) (despite minor changes made in 2011 to the case-finding question to include arthritis on the chronic conditions core). Physical activity also is self-reported. Unadjusted data are presented in this report to provide actual estimates to help in state-level program planning.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).
In addition, CDC typically provides this estimate in standard arthritis BRFSS tables produced for each state for odd-numbered years. Unadjusted data are usually presented in these tables to provide actual estimates to help in state-level program planning.

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage, nonresponse, or measurement bias. To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

Healthy People 2020 objective AOCBC-7.2: Increase the proportion of adults with doctor-diagnosed arthritis who receive health-care provider counseling[...]for physical activity or exercise.

Related chronic disease indicator topics

Nutrition, physical activity, and weight status.

Demographic group

Resident adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report physician-diagnosed arthritis and who report that their health is fair or poor.

Denominator

Respondents aged ≥18 years who report physician-diagnosed arthritis (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Current.

Background

An estimated 52.5 million adults have physician-diagnosed arthritis, and 22.7 million report arthritis-attributable activity limitations (1). Based on combined 2003, 2005, and 2007 BRFSS data, of persons aged ≥18 years with arthritis, 27% reported fair/poor health, compared with 12% without arthritis (2).

Significance

Monitoring health-related quality of life among adults with arthritis is important because persons with arthritis report worse health related quality of life than adults without arthritis (2). Self-management education can help improve physical function and quality of life among adults with arthritis (3) As self-management education becomes more widespread in states, this measure can help track improvements in quality of life of persons with arthritis.

Limitations of indicator

Physician-diagnosed arthritis is self-reported in BRFSS and was not confirmed by a health-care provider or objective monitoring; however, such self-reports have been shown to be acceptable for surveillance purposes (4) (despite minor changes made in 2011 to the case-finding question to include arthritis on the chronic conditions core). General health status also is self-reported.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

In addition, CDC typically provides this estimate in standard arthritis BRFSS tables produced for each state for odd-numbered years. Unadjusted data are usually presented in these tables to provide actual estimates to help in state-level program planning.

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage, nonresponse, or measurement bias. To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

None.

Related chronic disease indicator topics

None.

Demographic group

Resident adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report physician-diagnosed arthritis and who report ever taking a course or class on managing their arthritis or joint symptoms.

Denominator

Respondents aged ≥18 years who report physician-diagnosed arthritis (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Biannual prevalence with 95% confidence intervals (for odd-numbered years) and by demographic characteristics when feasible.

Time period of case definition

Lifetime.

Background

An estimated 52.5 million adults have physician-diagnosed arthritis, and 22.7 million report arthritis-attributable activity limitations (1). CDC recommends evidence-based programs that are proven to improve the quality of life of persons with arthritis, including self-management education classes or courses. Based on Healthy People 2010 data, only 11% of adults with arthritis have taken such recommended classes (2).

Significance

Self-management education programs can reduce pain and health-care costs and are an important arthritis intervention (3). The Arthritis Foundation's Self-Help Program teaches persons how to manage arthritis and decrease its effects. This 6-week course reduces arthritis pain by 20% (3). More widespread use of this course and similar programs (e.g., the Chronic Disease Self-Management Program, which addresses arthritis along with other chronic diseases) could improve function and quality of life for persons with arthritis. This measure will indicate the proportion of adults with arthritis who have ever taken a course or class to manage their symptoms.

Limitations of indicator

Physician-diagnosed arthritis is self-reported in the Behavioral Risk Factor Surveillance System and was not confirmed by a health-care provider or objective monitoring; however, such self-reports have been shown to be valid for surveillance purposes (4) (despite minor changes made in 2011 to the case-finding question to include arthritis on the chronic conditions core). Participation in self-management programs is also self-reported. Unadjusted data are presented in this report to provide actual estimates for state-level program planning. Because this question comes from a Behavioral Risk Factor Surveillance System optional module, data are missing for some states.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS), Arthritis Management optional module (odd-numbered years only).

In addition, CDC typically provides this estimate in standard arthritis BRFSS tables produced for each state for odd-numbered years. Unadjusted data are usually presented in these tables to provide actual estimates to help in state-level program planning.

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage, nonresponse, or measurement bias. To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

Healthy People 2020 objective AOCBC-8: Increase the proportion of adults with physician-diagnosed arthritis who have had effective, evidence-based arthritis education as an integral part of the management of their condition.

Related chronic disease indicator topics

None.

Demographic group

Civilian noninstitutionalized population.

Numerator

Weighted number of respondents who answer "yes" both to both of the following questions: "Have you ever been told by a doctor, nurse, or other health professional that you have asthma?" and "Do you still have asthma?"

Denominator

Weighted number of respondents to Behavioral Risk Factor Surveillance System (BRFSS) or National Survey of Children's Health (NSCH), excluding "don't know" and refused responses to the question "Do you still have asthma?".

Measures of frequency

Annual number of state residents with current asthma and annual current asthma prevalence percentage with 95% confidence intervals and by demographic characteristics when feasible.

Annual number of adults (aged ≥18 years) with current asthma and percentage of adults with current asthma with 95% confidence intervals and by demographic characteristics when feasible.

Annual number of children (aged 0–17 years) with current asthma and percentage of children with current asthma with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year of survey.

Background

Estimates of asthma prevalence indicate the number and percentage of the population with asthma at a given point in time. National estimates indicate that both adult and child current asthma prevalence estimates have been increasing from 20.3 million persons in 2001 to 25.7 million persons in 2010, of which 7.0 million were children (1). Adult current asthma prevalence, available for states from BRFSS since 2001, varies by state and region as well as by many demographic characteristics (2). Current asthma prevalence among children is available for a subset of states from BRFSS annually since 2005 (2). Current asthma prevalence among children is available for all states from the National Survey of Children's Health for 2003, 2007, and 2011 (3).

Significance

Asthma prevalence describes the size of a state's population with asthma as well as the overall asthma prevalence relative to other chronic conditions. The greater the prevalence of asthma, the greater the likelihood of adverse outcomes from asthma including emergency department visits, hospitalizations, and death (1). Compared with persons without asthma, persons with asthma have more days of activity limitation and missed school and missed work and are more likely to report comorbid depression (4–8).

Limitations of indicator

Although all states have collected adult BRFSS data annually since 2001, not all states collect child data using the child asthma module of the BRFSS. States that do not collect child asthma data from BRFSS cannot produce the total indicator for all years; they can only produce the adult indicator. However, child asthma prevalence data for all states is available every 4 years using the National Survey of Children's Health (2003, 2007, and 2011). (Because NSCH is being redesigned, its mode and future periodicity is unknown at this time.) For these years a total indicator can be produced for all states by combining the adult prevalence from BRFSS with the child prevalence from NSCH. This survey-based indicator requires a doctor diagnosis of asthma, which may not include all persons with asthma. The child information is provided by an adult proxy respondent.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS) for adults (all states) and for children (some states).

National Survey of Children's Health for those states not collecting child data with BRFSS.

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

None.

Related chronic disease indicator topics

None.

Demographic group

Women aged 18–44 years.

Numerator

Female respondents aged 18–44 years who reported that they had ever been told by a doctor, nurse, or other health professional that they had asthma and reported that they still have asthma.

Denominator

Female respondents aged 18–44 years who reported that they had or had not ever been told by a doctor, nurse, or other health professional that they had asthma (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual number of women (aged 18–44 years) with current asthma with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year of survey.

Background

Asthma affects at least 8.2% of pregnant women and 9.4% of women of reproductive age in the United States (1). For approximately 30% of women with asthma, the severity of the disease worsens during pregnancy (2).

Significance

Although outcomes of pregnancy in which the woman's asthma is mild or well-controlled are usually good, severe and poorly controlled asthma during pregnancy might be associated with an increased likelihood of premature delivery, cesarean delivery, preeclampsia, growth restriction, other perinatal complications, and maternal morbidity and mortality (3). Furthermore, subsequent pregnancies tend to follow a course similar as the first pregnancy with respect to status of asthma severity (4). The clinical workgroup of the Select Panel on Preconception Care recommends that women of reproductive age with asthma be counseled about the importance of achieving asthma control before pregnancy and the potential for their asthma control to decline during pregnancy (2). The panel also recommends that those women with poor control of their asthma should be encouraged to use effective birth control until they achieve symptom relief (2). Finally, preventive therapy with inhaled corticosteroids is highly recommended for women with chronic asthma who are planning to become pregnant or who could become pregnant as use of these medications before pregnancy has been shown to reduce the rate of asthma-related health-care use during pregnancy (4).

Limitations of indicator

This survey-based indicator requires a doctor diagnosis of asthma, which might not include all persons with asthma.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

None.

Related chronic disease indicator topics

Reproductive health.

Demographic group

All resident persons.

Numerator

1) Emergency department (ED) visits with a principal diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 493, 2) (if not already included) hospitalizations with the ED as the source of admission and an admission diagnosis of ICD-9-CM code 493, and 3) (if not already included) 24-hour observation beds where the source of the admission was the ED with a principal admission diagnosis of ICD-9-CM code 493 among residents during a calendar year. When possible, include ED visits, 24-hour observations, and hospitalizations for residents who have an ED visit, 24-hour observation, or hospitalization in another state.

Denominator

Midyear resident population for the same calendar year, obtained from the U.S. Census Bureau.

Measures of frequency

Annual number of ED visits. Annual ED visit rate per 10,000: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 1 [1]) and by demographic characteristics when feasible.

Time period of case definition

Use the ED discharge date used if available for the calendar year. For ED cases found in the hospitalization data that did not have an ED discharge date, use the hospital admission date as the ED discharge date.

Background

Each year, approximately 3.2 million ED visits related to asthma occur in the United States (2). As of 2010, an estimated 25.7 million U.S. residents had asthma, which is a 27% increase over 10 years (3). The cost of ED care is substantially higher than the cost of outpatient and pharmaceutical services (4).

Significance

Scientific and clinical consensus is that the majority of acute asthma events, particularly ED visits, can be prevented if asthma is properly managed according to established medical guidelines (5). Effective management includes control of exposure to factors that trigger exacerbations, adequate pharmacological management, continual monitoring of the disease, and patient education in asthma care (5).

Limitations of indicator

This indicator might overestimate the impact of asthma exacerbations because persons sometime use the ED inappropriately (i.e., for primary care). This indicator is calculated using the entire resident population, which includes persons who do not have asthma. A more appropriate measure is a rate that is calculated using the population that has asthma (i.e., based on those at risk). (See also the following indicator: At-Risk Emergency Department Visit Rate for Asthma.) A subset of patients who appear in the numerator of ED indicators (those who were hospitalized with the ED as source of admission) also appear in the numerator for both hospitalization indicators. Because resources were used by the patients at each site (ED and inpatient), counting the events in both indicators is important as an indicator of asthma hospital visit rates.

Data resources

State ED visit, observation unit, and hospitalization discharge data (numerator) from Agency for Healthcare Research and Quality and population estimates from the U.S. Census Bureau (denominator).

Limitations of data resources

Not all states have access to administrative billing ED data. The diagnosis information contained in this data source might not match perfectly with information on the medical records, which is considered the gold standard. State ED data sets might not include all facilities or populations. They might exclude Veterans Administration hospitals, Indian Health Service facilities, or institutionalized (prison) populations. For most states, this measure only includes state residents who visited the ED in their own state.

Related indicators or recommendations

Healthy People 2020 objective RD-3: Reduce hospital emergency department visits for asthma. (RD-3.1 is specific for children aged <5 years; RD-3.2 is specific for children and adults aged 5–64 years; RD-3.3 is specific for adults aged ≥65 years.)

Related chronic disease indicator topics

None.

Demographic group

Residents with asthma.

Numerator

1) Emergency department (ED) visits with a principal diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 493, 2) (if not already included) hospitalizations with the ED as the source of admission and an admission diagnosis of ICD-9-CM code 493, and 3) (if not already included) 24-hour observation beds where the source of the admission was the ED with a principal admission diagnosis of ICD-9-CM code 493 among residents during a calendar year. When possible, include ED visits, 24-hour observations, and hospitalizations for residents who have an ED visit, 24-hour observation, or hospitalization in another state.

Denominator

Estimate of the number of state residents with current asthma for the same calendar year. For adults the estimate is obtained from the Behavioral Risk Factor Surveillance System (BRFSS) and, for children, from the BRFSS child asthma module, if implemented. If not implemented, the child estimate can be obtained from the National Survey of Children's Health (NSCH).

Measures of frequency

Annual number of state residents with current asthma, annual number of asthma ED visits, and annual at-risk asthma ED visit rate by demographic characteristics when feasible.

• Children (aged 0–17 years) if BRFSS data are available.

• Annual number of ED visits for children aged 0–17 years.
• Annual number of state residents aged 0–17 years with current asthma.
• Annual risk-based child asthma ED rate per 10,000 population, crude and age-adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 19 [1]).

• Children (aged 0–17 years) if BRFSS data are not available.

• Number of ED visits for children aged 0–17 years for 2003, 2007, and 2011 (and every 4 years thereafter).
• Number of state residents aged 0–17 years with current asthma for 2003, 2007, and 2011 (and every 4 years thereafter).
• Risk-based child asthma ED visit rate per 10,000, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 19 [1]) for 2003, 2007, and 2011 (and every 4 years thereafter).

• Adults (aged ≥18 years).

• Annual number of ED visits for adults aged ≥18 years.
• Annual number of state residents aged ≥18 years with current asthma: Annual risk-based adult asthma ED visit rate per 10,000, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 9 [1]).

• Total (all ages).

• Annual number of ED visits for states and years with child prevalence and adult prevalence.
• Annual number of state residents with current asthma for states and years with child prevalence and adult prevalence.
• Annual risk-based asthma ED visit rate per 10,000, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 3 [1]) for states and years with child prevalence and adult prevalence).

Time period of case definition

Use the ED discharge date if available for the calendar year. For ED cases found in the hospitalization data that did not have an ED discharge date, use the hospital admission date as the ED discharge date.

Background

In 2009, 2.1 million ED visits were related to asthma in the United States (2). As of 2010, an estimated 25.7 million U.S. residents had asthma (2), which is a 27% increase over 10 years. The at-risk–based asthma ED rate controls for the increase in the number of state residents with asthma that has occurred over time or differences in the underlying asthma prevalence across states. The population-based rates can increase simply because more persons have asthma each year or are in specific geographic areas. The at-risk–based rate reflects the use of EDs for asthma care per person with asthma and is therefore independent of the number of persons with asthma.

The cost of ED care is substantially higher than the cost of outpatient and pharmaceutical services. An at-risk–based asthma ED rate better reflects the prevalence and asthma independent of the increase or differences in the number of persons with asthma. As more persons with asthma achieve higher levels of asthma control, the at-risk rate should decrease while the population-based rate might increase because more persons have asthma.

Significance

Scientific and clinical consensus is that the majority of acute asthma events, particularly ED visits, can be prevented if asthma is properly managed according to established medical guidelines. Effective management includes control of exposure to factors that trigger exacerbations, adequate pharmacological management, continual monitoring of the disease, and patient education in asthma care (3).

Limitations of indicator

As with the population-based rate, recognizing that myriad environmental factors affect asthma control is crucial, including the use of the ED (as opposed to physicians' offices) as the location to medically manage asthma. Diagnoses listed in ED data might be inaccurate. Practice patterns and payment mechanisms can affect decisions by health-care providers to see patients in the ED.

Because universal state ED data are not available, aggregations of state data to produce nationwide estimates are incomplete. Because repeat ED visits by the same person in a single calendar year are included in the numerator, the ED rate is a visit-level rate, not a person-level rate. A limited number of states have personal identifiers in the ED data and are able to deduplicate ED visit data. (As used here, the term deduplicated means that persons with multiple admissions during the calendar year are counted only once. However, deduplication of multiple billing records for the same ED visit is assumed.) However, assessing the full impact on the medical care system is important. Accordingly, the ED rate includes multiple visits by the same person and the rate calculated is a visit-level rate, not a person-level rate. However, multiple billing records for the same ED visit should only be counted as a single event. A subset of patients who appear in the numerator of ED indicators (those who were hospitalized with the ED as source of admission) also are included in the numerator for both hospitalization indicators. Because resources were used by the patients at each site (ED and inpatient), counting the events in both indicators as an indicator of asthma impact on the hospital system is important.

Data resources

State ED visit, observation unit, and state hospital discharge data (numerator) from the Agency for Healthcare Research and Quality and estimates of the number of state residents with current asthma from the Behavioral Risk Factor Surveillance System (BRFSS, adults and children) or the National Survey of Children's Health (NSCH) (children) if the Behavior Risk Factor Surveillance System child asthma module was not conducted (denominator).

Limitations of data resources

If the BRFSS child module was not implemented, annual child prevalence estimates are only available for 2003, 2007, and 2011 from NSCH, which is conducted every 4 years. (Because NSCH is being redesigned, its mode and future periodicity is unknown at this time.) For ED cases found in the hospitalization data, cases with an ED discharge date or a hospital admit date in the calendar year of interest might require use of the hospital discharge data file from the next calendar year. Some admissions at the end of the calendar year are discharged the following calendar year and are found in the hospital discharge file for the next year.

ED data are not available for all states. State ED data sets may not include all facilities or populations. They might exclude Veterans Administration hospitals, Indian Health Service facilities, or institutionalized (prison) populations. For most states, this measure only includes state residents who visited the ED in their own state.

Related indicators or recommendations

None.

Related chronic disease indicator topics

None.

Demographic group

All resident persons.

Numerator

Inpatient hospitalizations with a principal discharge diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification code 493 among residents during a calendar year. When possible, include hospitalizations for residents who are hospitalized in another state.

Denominator

Midyear resident population for the same calendar year, obtained from the US Census Bureau.

Measures of frequency

Annual number of hospitalizations. Annual hospitalization rate per 10,000: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 1 [1]) and by demographic characteristics when feasible.

Time period of case definition

Calendar year based on the hospital discharge date.

Background

Each year, approximately 480,000 hospitalizations related to asthma occur in the United States (2). As of 2010, an estimated 25.7 million U.S. residents have asthma, which is a 27% increase over 10 years (3). Although inpatient hospitalization for asthma is less frequently used than outpatient and pharmaceutical services, its cost is substantially higher.

Significance

Hospitalizations for asthma could be reduced if asthma were managed according to established guidelines. Effective management includes control of exposure to factors that trigger exacerbations, adequate pharmacological management, continual monitoring of the disease, and patient education in asthma care (4).

Limitations of indicator

Although reducing hospitalizations for asthma is theoretically a function of better care and self-management knowledge, the economy and the health-care system also greatly affect this measure. Practice patterns and payment mechanisms can affect decisions by health-care providers to hospitalize patients. The use of a population-based measure can be misleading because the measure is affected by changes in prevalence over space or time. Because one person can have multiple hospitalizations for asthma in a single calendar year, this indicator describes rate of events, not rate of persons hospitalized.

Data resources

State hospital discharge data (numerator) from the Agency for Healthcare Research and Quality and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

The diagnosis information contained in this data source might not match perfectly with information on the medical records, which is considered the gold standard. Hospital discharge data might not be available for all states. State hospitalization data sets might not include all facilities or populations. They might exclude Veterans Administration hospitals, Indian Health Service facilities, or institutionalized (prison) populations. For most states, this measure only includes state residents who were hospitalized in their own state. Hospital inpatient data files are usually organized by discharge date. Some inpatient stays may have been initiated in the previous calendar year since some admissions at the end of one calendar year are discharged the following calendar year. Consequently, rates based on discharge date may differ from other indicators based on admission date.

Related indicators or recommendations

Healthy People 2020 objective RD-2: Reduce hospitalizations for asthma. (RD-2.1 is specific for children aged <5 years; RD-2.2 is specific for children and adults aged 5–64 years; RD-2.3 is specific for adults aged ≥65 years.)

Related chronic disease indicator topics

None.

Demographic group

Residents with asthma.

Numerator

In-patient hospitalizations with a principal discharge diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification code 493 among state residents during a calendar year. When possible, include hospitalizations for state residents who have been hospitalized in another state.

Denominator

Estimate of the number of state residents with current asthma for the same calendar year. For adults the estimate is obtained from the Behavioral Risk Factor Surveillance System (BRFSS) and, for children, from the BRFSS child asthma module, if implemented. If not implemented, the child estimate can be obtained from the National Survey of Children's Health (NSCH).

Measures of frequency

Annual number of state residents with current asthma, annual number of asthma inpatient hospitalizations, and annual at-risk asthma hospital discharge rate by demographic characteristics when feasible.

• Children (aged 0–17 years) if BRFSS data are available.
  • Annual number of hospital discharges for children aged 0–17 years.
  • Annual number of state residents aged 0–17 years with current asthma.
  • Annual risk-based child asthma hospital discharge rate per 10,000 population, crude and age-adjusted (standardized by the direct method to the year 2000 standard U.S. population distribution [1]).
• Children (aged 0–17 years) if BRFSS data are not available.
  • Number of hospital discharges for children aged 0–17 years for 2003, 2007, and 2011 (and every 4 years thereafter).
  • Number of state residents aged 0–17 years with current asthma for 2003, 2007, and 2011 (and every 4 years thereafter).
  • Risk-based child asthma hospital discharge rate per 10,000 population, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population distribution [1]) for 2003, 2007, and 2011 (and every 4 years thereafter).
• Adults (aged ≥18 years)
  • Annual number of hospital discharges for adults aged ≥18 years.
  • Annual number of state residents aged ≥18 years with current asthma.
  • Annual risk-based adult asthma hospital discharge rate per 10,000 population, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population distribution [1]).
• Total (all ages)
  • Annual number of hospital discharges for states and years with child prevalence and adult prevalence.
  • Annual number of state residents with current asthma for states and years with child prevalence and adult prevalence.
  • Annual risk-based asthma hospital discharge rate per 10,000 population, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population distribution [1]) for states and years with child prevalence and adult prevalence.

Time period of case definition

Calendar year based on the hospital discharge date.

Background

Each year, approximately 500,000 inpatient hospital stays for asthma occur in the United States (2). As of 2010, an estimated 25.7 million U.S. residents had asthma (2), which is a 27% increase over 10 years. The at-risk–based asthma hospital discharge rate controls for the increase in the number of state residents with asthma that has occurred over time or differences in the underlying asthma prevalence across states. The population-based rates can increase simply because more persons have asthma each year or are in specific geographic areas. The at-risk–based rate reflects hospitalizations for asthma per person with asthma and is therefore independent of the number of persons with asthma. The cost of inpatient stays is substantially higher than the cost of outpatient and pharmaceutical services (3). An at-risk–based asthma hospital discharge rate better reflects the prevalence and asthma independent of the increase or differences in the number of persons with asthma. As more persons with asthma achieve higher levels of asthma control, the at-risk rate should decrease while the population-based rate might increase because more persons have asthma.

Significance

Scientific and clinical consensus is that the majority of acute asthma events, including inpatient stays, can be prevented if asthma is properly managed according to established medical guidelines. Effective management includes control of exposure to factors that trigger exacerbations, adequate pharmacological management, continual monitoring of the disease, and patient education in asthma care (4).

Limitations of indicator

As with the population based rate, recognizing that myriad environmental factors affect asthma control is crucial, including hospitalizations (as opposed to physicians' offices) as the location to medically manage asthma. Diagnoses listed in hospital data might be inaccurate. Practice patterns and payment mechanisms can affect decisions by health-care providers to admit patients to the hospital. Because universal state hospital discharge data are not available, aggregations of state data to produce nationwide estimates are incomplete or differ from those resulting from the national surveys. Because repeat stays by the same person in a single calendar year are included in the numerator, the at-risk–based hospital discharge rate is an in-patient stay-level rate, not a person-level rate. A limited number of states have personal identifiers in the hospital discharge data and are able to deduplicate inpatient data. (The term deduplicated means that persons with multiple admissions during the calendar year are counted only once. However, deduplication of multiple billing records for the same hospital admission is assumed.) However, assessing the full impact on the medical care system is important. Accordingly, the hospital discharge rate includes multiple stays by the same person and the rate calculated is a stay-level rate, not a person-level rate. However, multiple billing records for the same hospital admission should only be counted as a single admission.

Data resources

State hospital discharge data (numerator) and estimates of the number of state residents with current asthma from the Behavioral Risk Factor Surveillance System (BRFSS) (adults and children) or the National Survey of Children's Health (NSCH) (children) if the BRFSS child asthma module was not conducted (denominator).

Limitations of data resources

If the BRFSS child module was not implemented, annual child prevalence estimates are only available for 2003, 2007, and 2011 from NSCH. (Because NSCH is being redesigned, its mode and future periodicity is unknown at this time.) Hospital inpatient data files are usually organized by discharge date. Some inpatient stays might have been initiated in the previous calendar year because some admissions at the end of one calendar year are discharged the following calendar year. Consequently, rates based on discharge date might differ from other indicators based on admission date. Hospital discharge data might not be available for all states. State hospital discharge data sets might not include all facilities or populations. They might exclude Veterans Administration hospitals, Indian Health Service facilities, or institutionalized (prison) populations. For most states, this measure only includes state residents who were hospitalized in their own state.

Related indicators or recommendations

None.

Related chronic disease indicator topics

None.

Demographic group

All resident persons.

Numerator

Deaths with International Classification of Diseases, 10th Revision code J45–J46 as the underlying cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year obtained from the U.S. Census Bureau.

Measures of frequency

Annual number of deaths. Annual mortality rate per million: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 1 [1]) and by demographic characteristics when feasible.

Time period of case definition

Calendar year. States with <20 deaths in a calendar year should calculate 3- to 5-year moving averages to increase reliability.

Background

The number of deaths with asthma as the underlying cause decreased from 4,483 in 2000 (2) to 3,816 in 2004 (2) and then to 3,388 in 2009 (3). A very slight increase to 3,404 occurred in 2010 (4). The population-based asthma mortality rate decreased from 16.1 in per million population in 2000 (2) to 10.6 in 2010, whereas the risk-based asthma mortality rate decreased from 2.1 per 10,000 persons with asthma in 2001 to 1.3 in 2010 (4).

Significance

The majority of the problems associated with asthma are preventable if asthma is managed according to established guidelines. Effective management includes control of exposure to factors that trigger exacerbations, adequate pharmacological management, continual monitoring of the disease, and patient education in asthma care. With proper management, deaths from asthma are theoretically preventable (5).

Limitations of indicator

The reliability of death certificate data for asthma has been questioned, particularly for older age groups. Asthma might be overreported or underreported for adults because of misreporting the cause of death, particularly in persons with confounding medical conditions. In one study, inconsistencies in death certificate completion resulted in asthma automatically overriding the underlying cause chosen, leading to an overestimation of asthma deaths among persons aged ≥55 years (6,7). In contrast, a larger and well-designed study concluded that 1) asthma death coding had very high specificity (99%) and low sensitivity (42%), 2) asthma as a cause of death was underreported rather than overreported in preference to chronic obstructive pulmonary disease (58% false negative, 1% false positive), 3) and age had no effect (8). This study casts some doubt on the assumption that coding of asthma deaths in older persons is unreliable in the United States. However, no studies representative of the entire U.S. vital statistics system have been published.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death and other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective RD-1: Reduce asthma deaths. (RD-1.1 is specific for children and adults aged <35 years; RD-1.2 is specific for adults aged 35–64 years; RD-1.3 is specific for adults aged ≥65 years.)

Related chronic disease indicator topics

None.

Demographic group

Residents with asthma.

Numerator

Deaths with International Classification of Diseases, 10th Revision code J45-J46 as the underlying cause of death among residents during a calendar year.

Denominator

Estimate of the number of state residents with current asthma for the same calendar year, obtained from the Behavioral Risk Factor Surveillance System (for adults), and for children from the BRFSS child module, if implemented, or from the National Survey of Children's Health (NSCH) if the BRFSS child module was not implemented.

Measures of frequency

Annual number of residents with current asthma, annual number of asthma deaths, and annual at-risk asthma death rate by demographic characteristics when feasible. States with < 20 deaths in a calendar year should calculate 3- to 5-year moving averages to increase reliability.

• Children (aged 0–17 years) from BRFSS if available.
  • Annual number of deaths for children aged 0–17 years.
  • Annual number of state residents aged 0–17 years with current asthma.
  • Annual risk-based child asthma mortality rate per million, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 19 [1]).
• Children (aged 0–17 years) from NSCH if BRFSS data are not available.
  • Number of deaths for children aged 0–17 years for 2003, 2007, and 2011 (and every four years thereafter).
  • Number of state residents aged 0–17 years with current asthma for 2003, 2007, and 2011 (and every four years thereafter).
  • Risk-based child asthma mortality rate per million, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 19 [1]) for 2003, 2007, and 2011 (and every four years thereafter).
• Adults (≥18 years).
  • Annual number of deaths for adults aged ≥18 years.
  • Annual number of state residents aged ≥18 years with current asthma.
  • Annual risk-based adult asthma mortality rate per million, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 9[1]).
• Total (all ages).
  • Annual number of deaths.
  • Annual number of state residents with current asthma (for states and years with child prevalence and adult prevalence).
  • Annual risk-based asthma mortality rate per million, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 3 [1]).

Time period of case definition

Calendar year. States with <20 deaths in a calendar year should calculate 3- to 5-year moving averages to increase reliability.

Background

The number of deaths with asthma as the underlying cause decreased from 4,483 in 2000 (2) to 3,816 in 2004 (2) and then to 3,388 in 2009 (3). A very slight increase to 3,404 occurred in 2010 (4). The population-based asthma mortality rate decreased from 16.1 in 2000 (2) to 10.6 per million population in 2010 (4), while the risk-based asthma mortality rate decreased from 2.1 in 2001 (2) to 1.3 per 100,000 persons with asthma in 2010 (Carol Johnson, CDC, National Asthma Control Program, personal communication, August 28, 2014). As of 2010, an estimated 25.7 million U.S. residents had asthma (3), which is a 27% increase over 10 years. The at-risk–based asthma mortality rate controls for the increase in the number of state residents with asthma that has occurred over time and differences in the underlying asthma prevalence across states. Population-based asthma mortality rates could increase simply because more persons have asthma each year or are in specific geographic areas who are at risk for death from asthma. The at-risk–based rate reflects deaths among persons with asthma and is therefore independent of the number of persons with asthma.

Significance

The majority of the problems associated with asthma are preventable if asthma is managed according to established guidelines. Effective management includes control of exposure to factors that trigger exacerbations, adequate pharmacological management, continual monitoring of the disease, and patient education in asthma care (5). With proper management, deaths from asthma are theoretically preventable.

Limitations of indicator

The reliability of death certificate data for asthma has been questioned, particularly for older age groups. The cause of death in persons with confounding medical conditions might be misreported (6–8). Some studies have reported inconsistencies in death certificate completion that resulted in asthma automatically overriding the underlying cause chosen, leading to an overestimate of asthma deaths. In contrast, a larger and well-designed study concluded that asthma death coding had very high specificity (99%) and low sensitivity (42%), that asthma as a cause of death was underreported rather than overreported in preference to chronic obstructive pulmonary disease (58% false negative, 1% false positive), and that age had no effect. This study casts some doubt on the assumption that coding of asthma deaths in older persons is unreliable in the United States. However, no studies representative of the entire U.S. vital statistics system have been published.

Data resources

Death certificate data from vital statistics agencies (numerator) and estimates of the state population with current asthma from BRFSS and NSCH (denominator).

Limitations of data resources

Causes of death and other variables listed on the death certificate might be inaccurate.

If the BRFSS child module was not implemented, annual child prevalence estimates are only be available for 2003, 2007, and 2011 from NSCH. Because NSCH is being redesigned, its mode and future periodicity is unknown.

Related indicators or recommendations

Healthy People 2020 objective RD-1: Reduce asthma deaths. (RD-1.1 is specific for children and adults aged <35 years; RD-1.2 is specific for adults aged 35–64 years; RD-1.3 is specific for adults aged ≥65 years.)

Related chronic disease indicator topics

None.

Demographic group

Noninstitutionalized resident adults aged 18–64 years.

Numerator

Respondents aged 18–64 years who report having ever been told that they have asthma and who still have asthma and who report having received an influenza vaccination in the past 12 months.

Denominator

Respondents aged 18–64 years who report having ever been told that they have asthma and who still have asthma, and who report having received influenza vaccination in the past 12 months or not having received influenza vaccination in the past 12 months (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence: crude, age stratified, and age adjusted (to the 2000 U.S. standard population using the direct method [1]) with 95% confidence intervals and by demographic characteristics when feasible. Because of the relatively small numbers of Behavioral Risk Factor Surveillance System respondents at the state-level who have a history of asthma, 2- or 3-year averages might be needed to provide stable state-level estimates. U.S. estimates might be based on single years of data.

Time period of case definition

Current (still has asthma).

Past 12 months (vaccinated).

Background

Asthma has a significant public health impact. In the United States, approximately 18.5 million adults have asthma (2). During the 2010–2011 influenza season, 48.4% of adults aged 18–64 years at high risk for influenza received influenza vaccine (3).

Significance

Asthma appears to be related to influenza infection. Children and adults with asthma are at higher risk for influenza-related adverse health outcomes, including pneumonia, hospitalization for acute respiratory disease, and death. Because 5%–10% of the U.S. population has asthma, the potential public health impact of influenza infection on this vulnerable subgroup is enormous (4).

Limitations of indicator

Respondents might not distinguish between influenza and pneumococcal (Streptococcus pneumoniae) vaccinations. Estimates are not specific to one influenza season; influenza vaccinations reported in the past 12 months could have been received for one or more of up to three previous influenza seasons. (Additional information on influenza vaccination coverage surveillance is available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6204a1.htm?s_cid=ss6204a1_w. Additional information on influenza vaccination coverage estimates by season is available at http://www.cdc.gov/flu/fluvaxview.)

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

• Healthy People 2020 objective IID-12: Increase the percentage of children and adults who are vaccinated annually against seasonal influenza (IID-12.6 is specific for noninstitutionalized high-risk adults aged 18–64 years.) The Healthy People 2020 influenza vaccination objectives have been consolidated since the original publication of Healthy People 2020 but will continue to be monitored as part of Healthy People 2020 data reporting. (Additional information is available at http://www.cdc.gov/vaccines/acip/meetings/downloads/slides-oct-2013/03-Influenza-Singleton.pdf and from the Healthy People 2020 website at http://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives.)
• Promoting Preventive Services for Adults Aged 50–64 Years, Community and Clinical Partnerships: Percentage of adults who reported influenza vaccination within the past year.

Related chronic disease indicator topics

Immunization.

Demographic group

Noninstitutionalized resident adults aged ≥65 years.

Numerator

Respondents aged ≥65 years who report having ever been told that they have asthma and who still have asthma and who report having received influenza vaccination in the past 12 months.

Denominator

Respondents aged ≥65 years who report having ever been told that they have asthma and who still have asthma and who report having received influenza vaccination in the past 12 months or not having received influenza vaccination in the past 12 months (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence: crude, age stratified and age adjusted (to the 2000 U.S. standard population using the direct method [1]) with 95% confidence intervals and by demographic characteristics when feasible. Because of the relatively small numbers of BRFSS respondents at the state level who have a history of asthma, 2- or 3-year averages might be needed to provide stable state-level estimates. U.S. estimates might be based on single years of data.

Time period of case definition

Current (asthma).

Past 12 months (vaccinated).

Background

Asthma has a significant public health impact. In the United States, approximately 18.5 million adults have asthma (2). During the 2010–2011 influenza season, 68.6% of adults aged >65 years received influenza vaccine (3).

Significance

Asthma appears to be related to influenza infection. Children and adults with asthma are at higher risk for influenza-related adverse health outcomes, including pneumonia, hospitalization for acute respiratory disease, and death. Because 5%–10% of the U.S. population has asthma, the potential public health impact of influenza infection on this vulnerable subgroup is enormous (4).

Limitations of indicator

Respondents might not distinguish between influenza and pneumococcal (Streptococcus pneumoniae) vaccinations. Estimates are not specific to one influenza season; influenza vaccinations reported in the past 12 months could have been received for one or more of up to three previous influenza seasons. (Additional information on influenza vaccination coverage surveillance is available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6204a1.htm?s_cid=ss6204a1_w. Additional information on influenza vaccination coverage estimates by season is available at http://www.cdc.gov/flu/fluvaxview.)

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

• Healthy People 2020 objective IID-12: Increase the percentage of children and adults who are vaccinated annually against seasonal influenza (IID-12.7 is specific for noninstitutionalized adults aged ≥65 years at high risk for influenza complications.) The Healthy People 2020 influenza vaccination objectives have been consolidated since the original publication of Healthy People 2020 but will continue to be monitored as part of Healthy People 2020 data reporting. (Additional information is available at http://www.cdc.gov/vaccines/acip/meetings/downloads/slides-oct-2013/03-Influenza-Singleton.pdf and from the Healthy People 2020 website at http://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives.)
• Healthy People 2020 objective OA-2: Increase the proportion of older adults who are up to date on a core set of clinical preventive services.

Related chronic disease indicator topics

Immunization; older adults.

Demographic group

Noninstitutionalized resident adults aged 18–64 years.

Numerator

Respondents aged 18–64 years who report having ever been told that they have asthma and who still have asthma and who report ever having received a pneumococcal vaccination.

Denominator

Respondents aged 18–64 years who report having ever been told that they have asthma and who still have asthma and who report ever having or not ever having a pneumococcal vaccination (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence: crude, age-stratified and age-adjusted (to the 2000 U.S. standard population using the direct method [1]) with 95% confidence intervals and by demographic characteristics when feasible. Because of the relatively small numbers of BRFSS respondents at the state level who have a history of asthma, 2- or 3-year averages might be needed to provide stable state-level estimates. U.S. estimates might be based on single years of data.

Time period of case definition

Current (still has asthma).

Lifetime (ever vaccinated).

Background

Asthma has a significant public health impact. In the United States, approximately 18.5 million adults have asthma (2). In 2012, only 20.0% of high-risk persons aged 19–64 years reported ever receiving a pneumococcal vaccination (3).

Significance

In 2011, an estimated 8.2% of adults aged ≥18 years reported current asthma (4) . A case-control study conducted in Tennessee, which identified cases through active, population-based, and laboratory-based surveillance and verified history of asthma from the Tennessee Medicaid database, showed that among adults aged 18–49 years, invasive pneumococcal disease (IPD) was more common among persons with asthma than persons without asthma (adjusted odds ratio = 2.4; 95% confidence interval = 1.8–3.3) (5). Among persons with high-risk asthma, the risk for IPD was nearly twice that for persons with low-risk asthma (5). In contrast, in a study conducted among a cohort of older veterans (average age: 53 years), persons with asthma did not have higher rates of hospitalization for pneumococcal pneumonia compared with persons in a group without asthma or chronic obstructive pulmonary disease (COPD) who were matched to the asthma patients by age, sex, and region (6). However, in the same study, hospitalization rates for pneumococcal pneumonia among persons with COPD were higher than among persons in the control group (6). Because distinguishing between COPD and asthma becomes more difficult with advancing age, misclassification of persons in this study is a possibility (7). The Advisory Committee on Immunization Practices recommends that persons aged 19–64 years who have asthma should receive a single dose of pneumococcal vaccine (7).

Limitations of indicator

Although self-reported pneumococcal vaccination has been validated (8), the reliability and validity of this measure is unknown.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

• Healthy People 2020 objective IID-13: Increase the percentage of adults who are vaccinated against pneumococcal disease. IID-13.2 is specific to noninstitutionalized adults aged 18–64 years at high risk for influenza complications.
• Promoting Preventive Services for Adults Aged 50–64 Years, Community and Clinical Partnerships.
• Percentage of adults who reported current smoking, diabetes, asthma, or cardiovascular disease who have ever had a pneumococcal vaccination.

Related chronic disease indicator topics

Immunization.

Demographic group

Noninstitutionalized resident adults aged ≥65 years.

Numerator

Respondents aged ≥65 years who report having ever been told that they have asthma and who still have asthma and who report ever having received a pneumococcal vaccination.

Denominator

Respondents aged ≥65 years who report having ever been told that they have asthma and who still have asthma and who report ever having or not ever having a pneumococcal vaccination (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence: crude, age stratified, and age adjusted (to the 2000 U.S. standard population using the direct method [1]) with 95% confidence intervals and by demographic characteristics when feasible. Because of the relatively small numbers of BRFSS respondents at the state level who have a history of asthma, 2- or 3-year averages might be needed to provide stable state-level estimates. U.S. estimates might be based on single years of data.

Time period of case definition

Current (still has asthma).

Lifetime (ever vaccinated).

Background

Asthma has a significant public health impact. In the United States, approximately 18.5 million adults have asthma (2). In 2012 in the United States, pneumococcal vaccination coverage among adults aged ≥65 years was 59.9% overall (3).

Significance

In 2011, an estimated 8.2% of adults aged ≥18 years reported current asthma (4). A case-control study conducted in Tennessee, which identified cases through active, population-based and laboratory-based surveillance and verified history of asthma from the Tennessee Medicaid database, showed that among adults aged 18–49 years, invasive pneumococcal disease (IPD) was more common among persons with asthma than persons without asthma (adjusted odds ratio = 2.4; 95% confidence interval = 1.8–3.3). Among persons with high-risk asthma, the risk for IPD was nearly twice that for persons with low-risk asthma (5). In contrast, in a study conducted among a cohort of older veterans (average age: 53 years), persons with asthma did not have higher rates of hospitalization for pneumococcal pneumonia compared with persons in a group without asthma or chronic obstructive pulmonary disease (COPD) who were matched to the asthma patients by age, sex, and region (6). However, in the same study, hospitalization rates for pneumococcal pneumonia among persons with COPD were higher compared with persons in the control group (6). Because distinguishing between COPD and asthma becomes more difficult with advancing age, misclassification of persons in this study is a possibility (7).

Limitations of indicator

Although self-reported pneumococcal vaccination has been validated (8), the reliability and validity of this measure is unknown.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

• Healthy People 2020 objective IID-13: Increase the percentage of adults who are vaccinated against pneumococcal disease. IID-13.1 is specific to noninstitutionalized adults aged ≥65 years.
• Healthy People 2020 objective OA-2: Increase the proportion of older adults who are up to date on a core set of clinical preventive services.

Related chronic disease indicator topics

Immunization; older adults.

Demographic group

Resident women aged 50–74 years.

Numerator

Female respondents aged 50–74 years who report having had a mammogram within the previous 2 years.

Denominator

Female respondents aged 50–74 years who report ever having or never having had a mammogram (excluding unknowns and refusals).

Measures of frequency

Prevalence, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Past 2 years.

Background

In 2010, 20% of women aged 50–74 years had not had a mammogram with the past 2 years (2). Breast cancer is the most common cancer among women. In 2010, female breast cancer caused approximately 41,000 deaths (3). Approximately 207,000 new cases of invasive female breast cancer are diagnosed annually (3).

Significance

Strong evidence shows that mammography screening can reduce breast cancer deaths by 17% among women aged 50–69 years (4). The USPSTF recommends biennial screening for women aged 50–74 years (5). Evidence supporting mammography among women aged 40–49 years is lower but with higher false positives that result in less net benefit (5).

Limitations of indicator

Recommendations for mammography screening are not always consistent among national groups.

Data resources

Behavioral Risk Factor Surveillance Survey (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

Healthy People 2020 objective C-17: Increase the proportion of women who receive breast cancer screening based on the most recent guidelines.

Related chronic disease indicator topics

Older adults.

Demographic group

Resident women aged 21–65 years who have not had a hysterectomy.

Numerator

Female respondents aged 21–65 years who do not report having had a hysterectomy and who report having had a Papanicolaou (Pap) test within the past 3 years.

Denominator

Female respondents aged 21–65 years who do not report having had a hysterectomy and who report ever having or never having had a Pap test (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Prevalence, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Past 3 years.

Background

In 2010, 87% of women aged 21–65 years had a Pap test within the past 3 years (2). In 2010, cancer of the cervix caused approximately 4,000 deaths, and approximately 11,800 new cases are diagnosed annually (3). Black women have a higher incidence of and mortality from cervical cancer than do white women (3).

Significance

Approximately 40%–60% of cervical cancer deaths can be prevented by increased use of the Pap test (especially among women never screened) and effective, timely treatment (4). The dramatic decrease in cervical cancer incidence and mortality during the past 50 years is mainly the result of the widespread use of the Pap test (2).

Limitations of indicator

Recommendations for screening frequency vary by risk factor, and a 3-year interval might not be appropriate for some women.

Data resources

Behavioral Risk Factor Surveillance Survey (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

National recommendations also include use of human papillomavirus (HPV) testing along with Pap testing for cervical cancer screening. BRFSS does not contain questions about HPV status or testing.

Related indicators or recommendations

Healthy People 2020 objective C-15: Increase the proportion of women who receive a cervical cancer screening based on the most recent guidelines.

Related chronic disease indicator topics

None.

Demographic group

Women aged 21–44 years who have not had a hysterectomy.

Numerator

Female respondents aged 21–44 years who do not report having had a hysterectomy and who reported that they had a Papanicolaou (Pap) test within the previous 3 years.

Denominator

Female respondents aged 21–44 years who do not report having had a hysterectomy and who reported ever having or never having had a Pap test (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Crude prevalence with 95% confidence intervals weighted using the Behavioral Risk Factor Surveillance System method (to compensate for unequal probabilities of selection and adjust for nonresponse and telephone noncoverage) and by demographic characteristics when feasible.

Time period of case definition

Past 3 years.

Background

In 2010, 87% of women aged 21–65 years had a Pap test within the previous 3 years (1). In 2010, cancer of the cervix caused approximately 4,000 deaths, and approximately 11,800 new cases are diagnosed annually (2).

Significance

Approximately 40%–60% of cervical cancer deaths can be prevented by increased use of the Pap test and effective, timely treatment (3). The dramatic decrease in cervical cancer incidence and deaths during the past 50 years is primarily the result of the widespread use of the Pap test (1).

The CDC's Select Panel on Preconception Care recommends that clinicians screen for preconception risk factors and provide treatment or other interventions as necessary. The office visit during which a Pap test is most often performed, sometimes referred to as the annual examination, is a prime opportunity for clinicians to conduct this screening. In addition, women could be screened routinely for abnormalities of the cervix associated with human papillomavirus (HPV) and that recommended subgroups receive the HPV vaccine. Use of the vaccine, in conjunction with regular pap screening to detect HPV abnormalities early on, can reduce or eliminate the need for procedures that could decrease cervical competency during pregnancy (4).

Limitations of indicator

Pap tests are recommended beginning at age 21 years (5). The prevalence of Pap testing might be limited by any changes in age distribution over time, because younger women have had less opportunity to be in the age group recommended for the test. The reliability of the BRFSS item assessing having ever had a Pap test is high. Regarding the validity of recall periods for this item, sensitivity is high but specificity is low to moderate, with recollection being better with shorter periods of time (6).

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

National recommendations also include use of HPV testing along with Pap testing for cervical cancer screening. BRFSS does not currently contain questions about HPV status or testing.

Related indicators or recommendations

Healthy People 2020 objective C-15: Increase the proportion of women who receive a cervical cancer screening based on the most recent guidelines.

Related chronic disease indicator topics

Reproductive health.

Demographic group

Resident adults aged 50–75 years.

Numerator

Respondents aged 50–75 years who report having had 1) a fecal occult blood test (FOBT) within the past year, 2) a sigmoidoscopy within the past 5 years and an FOBT within the past 3 years, or 3) a colonoscopy within the past 10 years.

Denominator

Respondents aged 50–75 years who report ever having or never having an FOBT, sigmoidoscopy, or colonoscopy (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Prevalence, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Past year for FOBT alone, both past 5 years for sigmoidoscopy and past 3 years for FOBT, past 10 years for colonoscopy.

Background

In 2010, 35% of adults aged 50–75 years had not received a recommended colorectal cancer screening test within the appropriate time interval (2). Among adults aged 50–75 years, 60% reported having had colonoscopy within 10 years as their most recent colorectal cancer screening test (2). In 2010, colorectal cancer caused approximately 52,000 deaths (3). Approximately 131,600 cases are diagnosed annually (3).

Significance

Colorectal cancer screening can both prevent the occurrence of cancer by detecting and removing precancerous lesions, and detect colorectal cancer early when treatment is more effective (4). Colorectal cancer screening has been shown to significantly reduce deaths from the disease (4).

Limitations of indicator

National colorectal cancer screening guidelines vary regarding the choice of screening test, the appropriate screening interval, and the age at which screening should occur.

Data resources

Behavioral Risk Factor Surveillance Survey (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

Healthy People 2020 objective C-16: Increase the proportion of adults who receive a colorectal cancer screening based on the most recent guidelines.

Related chronic disease indicator topics

Older adults.

Demographic group

All resident persons.

Numerator

Incident cases of cancer with an International Classification of Diseases for Oncology, Second Edition, or International Classification of Diseases for Oncology, Third Edition (for cases diagnosed after January 1, 2001) code C00–C80 and a behavior code of 3 (malignant, primary site), C67.0–C67.9 (bladder cancer) and a behavior code of 2 or 3 (in situ or malignant, primary site) among residents during a calendar year. (Certain histologic types are excluded.)

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Average annual number of incident cases. Average annual incidence rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

Approximately 1.5 million new cases of cancer are diagnosed annually (2). Cancer is the second leading cause of death in the United States (3). Approximately one in two males and one in three females will receive a diagnosis of cancer over their lifetime (3).

Significance

Information on cancer at all sites combined provides a measure of, and means of tracking, the substantial impact of cancer. Morbidity and mortality from cancers of the lung, colon, female breast, cervix, oral cavity and pharynx, and multiple other cancers can be reduced through known interventions.

Limitations of indicator

Cancer is not a single disease but rather numerous diseases with different causes, risks, and potential interventions. Interpretation of trends or patterns in cancer incidence can be made only by examination of specific types of cancers. Because certain cancers have a long latency period, years might pass before changes in behavior or clinical practice patterns affect the incidence of new cancer cases. In addition, certain cancers are not amenable to primary prevention or screening.

Data resources

Cancer incidence data from statewide central cancer registries (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Data from certain statewide central cancer registries might not meet standards for data completeness and quality. Therefore, nationwide estimates calculated from aggregated state data might not include data from each state. However, state registry data should accurately represent state cancer incidence in the majority of states, particularly where completeness and quality of registry data are high.

Related indicators or recommendations

None.

Related chronic disease indicator topics

None.

Demographic group

All resident persons.

Numerator

Incident cases of cancer with an International Classification of Diseases, 10th Revision codes C00-C97 as the underlying cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Average annual number of deaths. Average annual death rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

Approximately 1.5 million new cases of cancer are diagnosed annually (2). Cancer is the second leading cause of death in the United States (3). Approximately one in two males and one in three females will receive a diagnosis of cancer over their lifetime (3).

Significance

Information on cancer at all sites combined provides a measure of, and means of tracking, the substantial impact of cancer. Morbidity and mortality from cancers of the lung, colon, female breast, cervix, oral cavity and pharynx, and multiple other cancers can be reduced through known interventions.

Limitations of indicator

Cancer is not a single disease but rather numerous diseases with different causes, risks, and potential interventions. Interpretation of trends or patterns in cancer mortality can be made only by examination of specific types of cancers. Because certain cancers have a long latency period, years might pass before changes in behavior or clinical practice patterns affect cancer mortality. In addition, certain cancers are not amenable to primary prevention or screening.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death or other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective C-1: Reduce the overall cancer death rate.

Related chronic disease indicator topics

None.

Demographic group

All female residents.

Numerator

Incident cases of cancer with an International Classification of Diseases for Oncology, Second Edition, or International Classification of Diseases for Oncology, Third Edition (for cases diagnosed after January 1, 2001) code C50 and a behavior code of 3 (malignant, primary site, excluding histologic types M9590–M9989) among female residents during a calendar year.

Denominator

Midyear female resident population for the same calendar year.

Measures of frequency

Average annual number of incident cases. Average annual incidence rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

In 2010, approximately 207,000 women received a breast cancer diagnosis, and approximately 41,000 died from the disease (2). Except for nonmelanoma skin cancer, breast cancer is the most common cancer among women (2).

Significance

Screening for breast cancer with mammography can reduce deaths from breast cancer (3). Although scientific controversy remains regarding the benefits versus risks of screening, particularly among women aged 40–49 years, mammography is recommended for women aged 50–74 years (4).

Limitations of indicator

Breast cancer has a long latency period, and years might pass before changes in behavior or clinical practice patterns affect the incidence of breast cancer.

Data resources

Cancer incidence data from statewide central cancer registries (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Data from some statewide central cancer registries might not meet standards for data completeness and quality. Therefore, nationwide estimates calculated from aggregated state data might not include data from each state. However, state registry data should accurately represent state cancer incidence in the majority of states, particularly where completeness and quality of registry data are high.

Related indicators or recommendations

Healthy People 2020 objective C-11: Reduce late-stage breast cancer.

Related chronic disease indicator topics

None.

Demographic group

All female residents.

Numerator

Deaths with International Classification of Diseases, 10th Revision code C50 as the underlying cause of death among female residents during a calendar year.

Denominator

Midyear resident female population for the same calendar year.

Measures of frequency

Average annual number of deaths. Average annual death rate, crude and age-adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

In 2010, approximately 207,000 women received a diagnosis of breast cancer and approximately 41,000 died from the disease (2). Except for nonmelanoma skin cancer, breast cancer is the most common cancer among women (2).

Significance

Screening for breast cancer with mammography can reduce deaths from breast cancer (3).Although scientific controversy remains regarding the benefits versus risks of screening, particularly among women aged 40–49 years, mammography is recommended for women aged 50–74 years (4).

Limitations of indicator

Because breast cancer can have a long latency period, years might pass before changes in behavior or clinical practice patterns affect population mortality.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death or other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective C-3: Reduce the female breast cancer death rate.

Related chronic disease indicator topics

None.

Demographic group

All female residents.

Numerator

Incident cases of cancer with an International Classification of Diseases for Oncology, Second Edition, or International Classification of Diseases for Oncology, Third Edition (for cases diagnosed after January 1, 2001) code C53 and a behavior code of 3 (malignant, primary site, excluding histologic types M9590–M9989) among female residents during a calendar year.

Denominator

Midyear female resident population for the same calendar year.

Measures of frequency

Average annual number of incident cases. Average annual incidence rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

In 2010, approximately 11,800 women received a diagnosis of cervical cancer, and 4,000 died from the disease (2). Black and Hispanic women have higher incidence rates of cervical cancer compared to white women (2).

Significance

The dramatic decrease in cervical cancer incidence and mortality during the past 45 years is mainly the result of the widespread use of the Papanicolaou test (3). Cervical cancer rates were markedly higher among most women living in lower socioeconomic status areas than among those in higher socioeconomic status areas (3).

Limitations of indicator

Cervical cancer has a long latency period, and years might pass before changes in behavior or clinical practice patterns affect the incidence of cervical cancer.

Data resources

Cancer incidence data from statewide central cancer registries (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Data from some statewide central cancer registries might not meet standards for data completeness and quality. Therefore, nationwide estimates calculated from aggregated state data might not include data from each state. However, state registry data should accurately represent state cancer incidence in the majority of states, particularly where completeness and quality of registry data are high.

Related indicators or recommendations

Healthy People 2020 objective C-10: Reduce invasive uterine cervical cancer.

Related chronic disease indicator topics

Reproductive health; tobacco.

Demographic group

All female residents.

Numerator

Deaths with International Classification of Diseases, 10th Revision code C53 as the underlying cause of death among female residents during a calendar year.

Denominator

Midyear resident female population for the same calendar year.

Measures of frequency

Average annual number of deaths. Average annual death rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

In 2010, approximately 11,800 women received a diagnosis of cervical cancer, and 4,000 died from the disease (2). Black and Hispanic women have higher incidence rates of cervical cancer than white women (2).

Significance

The dramatic decrease in cervical cancer incidence and mortality during the past 45 years is mainly the result of the widespread use of the Papanicolaou test (3). Cervical cancer rates were markedly higher among most women living in low socioeconomic status areas than among those in high socioeconomic status areas (3).

Limitations of indicator

Because cervical cancer can have a long latency period, years might pass before changes in behavior or clinical practice patterns affect population mortality.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death or other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective C-4: Reduce the death rate from cancer of the uterine cervix.

Related chronic disease indicator topics

Reproductive health; tobacco.

Demographic group

All resident persons.

Numerator

Incident cases of cancer with an International Classification of Diseases for Oncology, Second Edition, or International Classification of Diseases for Oncology, Third Edition (for cases diagnosed after January 1, 2001) code C18–C20, C26.0 and a behavior code of 3 (malignant, primary site, excluding histologic types M9590–M9989) among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Average annual number of incident cases. Average annual incidence rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

Colorectal cancer is the second leading cause of cancer death among cancers that affect both men and women (2). In 2010, approximately 131,600 persons received a diagnosis of colorectal cancer, and 52,000 persons died from the disease (2). The incidence of colorectal cancer rises sharply after age 50 years (2).

Significance

Screening for colorectal cancer with a fecal occult blood test, flexible sigmoidoscopy, or colonoscopy can prevent colorectal cancer by detecting and removing precancerous polyps and can detect cancer early when treatment is more likely to be effective (3).

Limitations of indicator

Colorectal cancer has a long latency period, and years might pass before changes in behavior or clinical practice patterns affect the incidence of colorectal cancer.

Data resources

Cancer incidence data from statewide central cancer registries (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Data from some statewide central cancer registries might not meet standards for data completeness and quality. Therefore, nationwide estimates calculated from aggregated state data might not include data from each state. However, state registry data should accurately represent state cancer incidence in the majority of states, particularly where completeness and quality of registry data are high.

Related indicators or recommendations

Healthy People 2020 objective C-9: Reduce invasive colorectal cancer.

Related chronic disease indicator topics

None.

Demographic group

All resident persons.

Numerator

Deaths with International Classification of Diseases, 10th Revision codes C18–C20 as the underlying cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Average annual number of deaths. Average annual death rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

Colorectal cancer is the second leading cause of cancer death among cancers that affect both men and women (2). In 2010, approximately 131,600 persons received a diagnosis of colorectal cancer, and 52,000 persons died from the disease (2). The incidence of colorectal cancer rises sharply after age 50 years (2).

Significance

Screening for colorectal cancer with a fecal occult blood test, flexible sigmoidoscopy, or colonoscopy can prevent colorectal cancer by detecting and removing precancerous polyps and can detect cancer early when treatment is more likely to be effective (3).

Limitations of indicator

Because colorectal cancer can have a long latency period, years might pass before changes in behavior or clinical practice patterns affect population mortality.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death or other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective C-5: Reduce the colorectal cancer death rate.

Related chronic disease indicator topics

None.

Demographic group

All resident persons.

Numerator

Incident cases of cancer with an International Classification of Diseases for Oncology, Second Edition, or International Classification of Diseases for Oncology, Third Edition (for cases diagnosed after January 1, 2001) code C34 and a behavior code of 3 (malignant, primary site, excluding histologic types M9590–M9989) among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Average annual number of incident cases. Average annual incidence rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

More persons die from lung cancer than from any other cancer (2). In 2008, approximately 201,100 persons received a diagnosis of lung cancer, and 158,200 died from the disease (2). During the past 10 years, lung cancer incidence and mortality have decreased among men and women but at a faster rate among men (3).

Significance

Cigarette smoking accounts for 80%–90% of lung cancer cases (4). Lung cancer is also associated with secondhand tobacco smoke and certain environmental exposures, such as radon (4).

Limitations of indicator

Lung cancer has a long latency period, and years might pass before changes in behavior or clinical practice patterns affect the incidence of lung cancer.

Data resources

Cancer incidence data from statewide central cancer registries (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Data from some statewide central cancer registries might not meet standards for data completeness and quality. Therefore, nationwide estimates calculated from aggregated state data might not include data from each state. However, state registry data should accurately represent state cancer incidence in the majority of states, particularly where completeness and quality of registry data are high.

Related indicators or recommendations

None.

Related chronic disease indicator topics

Tobacco.

Demographic group

All resident persons.

Numerator

Deaths with International Classification of Diseases, 10th Revision code C34 as the underlying cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Average annual number of deaths. Average annual death rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

More persons die from lung cancer than from any other cancer (2). In 2010, approximately 201,100 persons received a diagnosis of lung cancer, and 158,200 died from the disease (2). During the past 10 years, lung cancer incidence and mortality have continued to decrease among men and women but at a faster rate among men (3).

Significance

Cigarette smoking accounts for 80%–90% of lung cancer cases (4). Lung cancer also is associated with secondhand tobacco smoke and certain environmental exposures, such as radon (4).

Limitations of indicator

Because lung cancer can have a long latency period, years might pass before changes in behavior or clinical practice patterns affect population mortality.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death or other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective C-2: Reduce the lung cancer death rate.

Related chronic disease indicator topics

Tobacco.

Demographic group

All resident persons.

Numerator

Incident cases of cancer with an International Classification of Diseases for Oncology, Second Edition, or International Classification of Diseases for Oncology, Third Edition (for cases diagnosed after January 1, 2001) code C44 and a behavior code of 3 (malignant, primary site) and histologic types 8720–8790 among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Average annual number of incident cases. Average annual incidence rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

In 2010, approximately 61,100 persons received a diagnosis of melanoma, and approximately 9,200 died from the disease (2). The incidence of melanoma has continued to increase among both men and women over the past decade (3).

Significance

Exposure to ultraviolet light causes 65%–90% of melanomas (4). Risk factors for melanoma include a lighter natural skin color, a history of sunburns early in life, and a history of indoor tanning device use (5,6). In 2010, using sunscreen (37%) and staying in the shade (35%) were the most common protective behaviors reported among women aged 18–29 years, compared with wearing long clothing to the ankles (33%), staying in the shade (26%), and using sunscreen (16%) among men of the same age (7). According to the 2010 National Health Interview Survey, 19% of women aged 18–29 years reported using an indoor tanning device at least once during the past 12 months (8).

Limitations of indicator

Melanoma has a long latency period, and years might pass before changes in behavior or clinical practice patterns affect the incidence of melanoma.

Data resources

Cancer incidence data from statewide central cancer registries (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Melanoma is frequently diagnosed outside of the hospital and therefore might be underreported by a central cancer registry. Data from some statewide central cancer registries might not meet standards for data completeness and quality. Therefore, nationwide estimates calculated from aggregated state data might not include data from each state. However, state registry data should accurately represent state cancer incidence in the majority of states, particularly where completeness and quality of registry data are high.

Related indicators or recommendations

None.

Related chronic disease indicator topics

None.

Demographic group

All resident persons.

Numerator

Deaths with International Classification of Diseases, 10th Revision code C43 as the underlying cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Average annual number of deaths. Average annual death rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

In 2010, 61,100 persons received a diagnosis of melanoma, and approximately 9,200 died from the disease (2). Approximately 76% of all skin cancer–associated deaths are caused by melanoma (2). The incidence of melanoma has continued to increase among both men and women over the past decade (3).

Significance

Exposure to ultraviolet light causes about 65%–90% of melanomas (4). Risk factors for melanoma include a lighter natural skin color, a history of sunburns early in life, and a history of indoor tanning use (5,6). In 2010, using sunscreen (37 %) and staying in the shade (35%) were the most common protective behaviors reported among women aged 18–29 years, compared with wearing long clothing to the ankles (33%), staying in the shade (26%) and using sunscreen (16%) among men of the same age (7). According to the 2010 National Health Interview Survey, 19% of women aged 18–29 years reported using an indoor tanning device at least once during the past 12 months (8).

Limitations of indicator

Because melanoma can have a long latency period, years might pass before changes in behavior or clinical practice patterns affect population mortality.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death or other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective C-8: Reduce the melanoma cancer death rate.

Related chronic disease indicator topics

None.

Demographic group

All resident persons.

Numerator

Incident cases of cancer with an International Classification of Diseases for Oncology, Second Edition, or International Classification of Diseases for Oncology, Third Edition (for cases diagnosed after January 1, 2001) code C00.0–C14.8 and a behavior code of 3 (malignant, primary site, excluding histologic types M9590–M9989) among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Average annual number of incident cases. Average annual incidence rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

In 2010, approximately 36,300 persons received a diagnosis of cancer of the oral cavity or pharynx, and approximately 8,500 persons died from the disease (2). The incidence of and mortality from cancer of the oral cavity and pharynx is more than twice as high among man as among women (2).

Significance

Cancer of the oral cavity and pharynx is associated with use of tobacco products, excessive alcohol use, and human papillomavirus (HPV) infection (3,4). Together, alcohol and tobacco use account for approximately 75% of oral and pharyngeal cancers in the United States (3,4). A significant percentage (63%) of cancers primarily involving the base of the tongue and tonsils (i.e., oropharynx) have been linked to HPV infection (5).

Limitations of indicator

Cancer of the oral cavity and pharynx has a long latency period, and years might pass before changes in behavior or clinical practice patterns affect incidence.

Data resources

Cancer incidence data from statewide central cancer registries (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Data from some statewide central cancer registries might not meet standards for data completeness and quality. Therefore, nationwide estimates calculated from aggregated state data might not include data from each state. However, state registry data should accurately represent state cancer incidence in the majority of states, particularly where completeness and quality of registry data are high.

Related indicators or recommendations

None.

Related chronic disease indicator topics

Oral health; tobacco; alcohol.

Demographic group

All resident persons.

Numerator

Deaths with International Classification of Diseases, 10th Revision codes C00–C14 as the underlying cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Average annual number of deaths. Average annual death rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

In 2010, approximately 36,300 persons received a diagnosis of cancer of the oral cavity or pharynx, and approximately 8,500 persons died from the disease (2). The incidence of and mortality from cancer of the oral cavity and pharynx is more than twice as high among men as among women (2).

Significance

Cancer of the oral cavity and pharynx is associated with use of tobacco products, excessive alcohol use, and human papillomavirus (HPV) infection (3,4). Together, alcohol and tobacco use account for approximately 75% of oral and pharyngeal cancers in the United States (3,4). A significant percentage (63%) of cancers primarily involving the base of the tongue and tonsils (i.e., oropharynx) have been linked to HPV infection (5).

Limitations of indicator

Because cancer of the oral cavity and pharynx can have a long latency period, years might pass before changes in behavior or clinical practice patterns affect population mortality.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death or other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective C-6: Reduce oropharyngeal cancer death rate.

Related chronic disease indicator topics

Oral health; tobacco; alcohol.

Demographic group

All male residents.

Numerator

Incident cases of cancer with an International Classification of Diseases for Oncology, Second Edition, or International Classification of Diseases for Oncology, Third Edition (for cases diagnosed after January 1, 2001) code C61.9 and a behavior code of 3 (malignant, primary site, excluding histologic types M9590–M9989) among male residents during a calendar year.

Denominator

Midyear resident male population for the same calendar year.

Measures of frequency

Average annual number of incident cases. Average annual incidence rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

In 2010, approximately 196,000 men received a diagnosis of prostate cancer, and approximately 28,600 men died from the disease (2). Prostate cancer is the most common cancer among men (2). Black males have higher rates of prostate cancer incidence and mortality than white males (2).

Significance

Although screening for prostate cancer is not recommended by the United States Preventive Services Task Force, screening for prostate cancer has increased the number of new cases and the percentage of new cases diagnosed at an early stage (3).

Limitations of indicator

The impact of screening for prostate cancer on prostate cancer mortality is unknown. Current methods do not allow for differentiation between cases of prostate cancer that might result in death from indolent cases that are unlikely to result in death.

Data resources

Cancer incidence data from statewide central cancer registries (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Data from some statewide central cancer registries might not meet standards for data completeness and quality. Therefore, nationwide estimates calculated from aggregated state data might not include data from each state. However, state registry data should accurately represent state cancer incidence in the majority of states, particularly where completeness and quality of registry data are high.

Related indicators or recommendations

None.

Related chronic disease indicator topics

None.

Demographic group

All male residents.

Numerator

Deaths with International Classification of Diseases, 10th Revision code C61 as the underlying cause of death among male residents during a calendar year.

Denominator

Midyear resident male population for the same calendar year.

Measures of frequency

Average annual number of deaths. Average annual death rate, crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1] based on single years of age from the U.S. census P25–1130 series estimates, which are combined to form 5-year age groups) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Five years.

Background

In 2010, approximately 196,000 men received a diagnosis of prostate cancer, and approximately 28,600 men died from the disease (2). Prostate cancer is the most common cancer among men (2). Black males have higher rates of prostate cancer incidence and mortality than white males (2).

Significance

Although substantial evidence exists that prostate-specific antigen (PSA) can detect early-stage prostate cancer (3), evidence is inconclusive regarding the ability of early detection to improve health outcomes, including mortality.

Limitations of indicator

Because prostate cancer can have a long latency period, years might pass before changes in behavior or clinical practice patterns affect population mortality.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Bureau of the Census or suitable alternative (denominator).

Limitations of data resources

Causes of death or other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective C-7: Reduce the prostate cancer death rate.

Related chronic disease indicator topics

None.

Demographic group

All resident persons.

Numerator

Deaths with International Classification of Diseases, 10th Revision codes I00–I99 as the underlying cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Annual number of deaths. Annual mortality rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 1 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

Cardiovascular disease (CVD) is the leading cause of death in the United States, with nearly 800,000 persons dying in the United States each year from CVDs, or one out of every three deaths (2). About 150,000 persons in the United States who died from CVD in 2009 were aged <65 years (2).

Significance

Modifiable risk factors for CVD include behaviors (e.g., tobacco use, physical inactivity, and improper nutrition), health status (e.g., hypertension, hyperlipidemia, overweight, or diabetes), and policies (e.g., smoking policies in restaurants and work sites) (3). Substantial differences in CVD death rates exist by race, age, sex, place of residence, and other demographic factors (4).

Limitations of indicator

CVD is not a single disease but rather is multiple diseases with different causes, risks, and potential interventions. Interpretation of trends or patterns in deaths from CVD can be made only by examination of specific types of CVD. Because certain types of cardiovascular disease have a long latency period, years might pass before changes in behavior or clinical practice affect CVD mortality. Certain types of CVD (e.g., valvular and congenital heart disease) are not amenable to primary prevention or screening.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death and other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

• Healthy People 2020 objective HDS-2: Reduce coronary heart disease deaths.
• Healthy People 2020 objective HDS-3: Reduce stroke deaths.

Related chronic disease indicator topics

Diabetes; nutrition, physical activity, and weight status; tobacco.

Demographic group

All resident persons.

Numerator

Deaths with International Classification of Diseases, 10th Revision codes I00–I09, I11, I13, I20–I51 as the underlying cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Annual number of deaths. Annual mortality rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 1 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

Nearly 600,000 persons in the United States died from heart disease (one out of every four deaths) in 2009 (2). In 2009, the age-adjusted rate among males (202.9 per 100,000 population) is greater than the age-adjusted rate among females (187.89 per 100,000 population) (2).

Significance

Modifiable risk factors for heart disease include behaviors (e.g., tobacco use, physical inactivity, and improper nutrition), health status (e.g., hypertension, hyperlipidemia, overweight, or diabetes), and policies (e.g., smoking policies in restaurants and work sites) (3). Substantial differences in heart disease death rates and preventive measures exist by race, age, sex, place of residence, and other demographic factors (4).

Limitations of indicator

Heart disease is not a single disease but rather is multiple diseases with different causes, risks, and potential interventions. Interpretation of trends or patterns in deaths from heart disease can be made only by examination of specific types of heart disease. Because certain types of heart disease have a long latency period, years might pass before changes in behavior or clinical practice affect heart disease mortality. Certain types of heart disease (e.g., valvular and congenital heart disease) are not amenable to primary prevention or screening.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death and other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective HDS-2: Reduce coronary heart disease deaths.

Related chronic disease indicator topics

Diabetes; nutrition, physical activity, and weight status; tobacco.

Demographic group

All resident persons.

Numerator

Deaths with International Classification of Diseases, 10th Revision (ICD-10) codes I20–I25 as the underlying cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Annual number of deaths. Annual mortality rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 1 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2009, coronary heart disease (CHD) is the largest category of heart disease, resulting in approximately 385,000 deaths annually (2). In 2009, age-adjusted rate among males (138.7 per 100,000 population) is greater than the age-adjusted rate among females (113.3 per 100,000 population) (2).

Significance

Modifiable risk factors for CHD include behaviors (e.g., tobacco use, physical inactivity, and improper nutrition), health status (e.g., hypertension, hyperlipidemia, overweight, or diabetes), and policies (e.g., smoking policies in restaurants and work sites) (3). Substantial differences in CHD death rates and preventive measures exist by race, age, sex, place of residence, and other demographic factors (4).

Limitations of indicator

Historically, epidemiologists have used different groups of ICD-10 rubrics to monitor CHD mortality. This has created differences in published mortality measures. Because CHD might have a long preclinical phase, years might pass before changes in behavior or clinical practice affect population mortality.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death and other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective HDS-2: Reduce CHD deaths.

Related chronic disease indicator topics

Diabetes; nutrition, physical activity, and weight status; tobacco.

Demographic group

All resident persons.

Numerator

Deaths with International Classification of Diseases, 10th Revision code I50 as the underlying or contributing (any mentioned) cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Annual number of deaths. Annual mortality rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 1 [1]) with 95% confidence interval; and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

Heart failure is the primary cause of approximately 55,000 of the 600,000 heart disease deaths in 2009 and heart failure was mentioned as a contributing cause in approximately 270,000 deaths (1 in 9) in 2009 (2). Congestive heart failure (CHF) is the leading principal diagnosis for Medicare hospital claims (3).

Significance

Approximately 75% of persons with CHF have antecedent hypertension (4). During 1979–1996, hospitalization for CHF increased by 130% (5). Substantial differences in CHF death rates and preventive measures exist by race, age, sex, place of residence, and other demographic factors.

Limitations of indicator

Because congestive heart failure is a chronic disease and can have a long preclinical phase, years might pass before changes in behavior or clinical practice affect population mortality.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death and other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

None.

Related chronic disease indicator topics

Diabetes; nutrition, physical activity, and weight status; tobacco.

Demographic group

All resident persons.

Numerator

Deaths with International Classification of Diseases, 10th Revision codes I60–I69 as the underlying cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Annual number of deaths. Annual mortality rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 1 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2009, stroke accounted almost 130,000 of the 800,000 deaths among persons in the United States who died of cerebrovascular disease, or one out of every 19 deaths from all causes (2). Historically, the southeastern United States has experienced high stroke death rates (2).

Significance

Modifiable risk factors for stroke include behaviors (e.g., tobacco use, physical inactivity, and improper nutrition) and health status (e.g., untreated hypertension, hyperlipidemia, overweight, or diabetes) (3). Approximately 26% of stroke deaths in the United States are attributable to high blood pressure and 12% to smoking (3). Substantial differences in risk and preventive factors exist by race, age, sex, place of residence, and other demographic factors.

Limitations of indicator

Although the two major types of stroke (hemorrhagic, which accounts for approximately 10% of strokes [4] and ischemic, which accounts for approximately 65% of strokes [4]) share certain risk factors, their treatment varies. Consequently, accurate interpretation of trends or patterns in total mortality from cerebrovascular disease is difficult. Because cerebrovascular disease has a long latency period, years might pass before changes in behavior or clinical practice patterns affect cerebrovascular disease mortality.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death and other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective HDS-3: Reduce stroke deaths.

Related chronic disease indicator topics

Diabetes; nutrition, physical activity, and weight status; tobacco.

Demographic group

Medicare-eligible resident adults aged ≥65 years.

Numerator

Hospitalizations with principal diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification code 428 among Medicare-eligible resident adults aged ≥65 years.

Denominator

Residents aged ≥65 years who were eligible for Medicare Part A benefits on July 1 of the calendar year, excluding members of health maintenance organizations.

Measures of frequency

Annual number of hospitalizations. Annual hospitalization rates: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 18 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

Heart failure has become a major public health concern in the United States, especially among older adults. Data from the National Institutes of Health Heart, Lung, and Blood Institute Framingham Heart Study indicate that heart failure incidence is about 10 per 1,000 population at age >65 years (2). Heart failure is the leading principal diagnosis for Medicare hospital claims (3). In 2007, the rate was 188.3 per 10,000 population (3).

Significance

Approximately 75% of persons with heart failure have antecedent hypertension (4). During 1979–1996, hospitalizations for heart failure increased by 130% (2).

Limitations of indicator

Because heart failure is a chronic disease that can have a long preclinical phase, years might pass before changes in behavior or clinical practice affect population morbidity and mortality.

Data resources

Centers for Medicare and Medicaid Services (CMS) Part A claims data (numerator) and CMS estimates of the population of persons eligible for Medicare (denominator).

Limitations of data resources

Diagnoses listed on Medicare claims data might be inaccurate. Practice patterns and payment mechanisms could affect decisions by health-care providers to hospitalize patients. Indicator is limited to Medicare-eligible population. Multiple admissions for an individual patient can inaccurately increase the number of persons with heart failure. The Medicare claims dataset cannot provide incident (new) hospitalizations for heart failure.

Related indicators or recommendations

Healthy People 2020 objective HDS-24: Reduce hospitalizations of older adults with heart failure as the principal diagnosis. (24.1 is specific for adults aged 65–74 years; 24.2 is specific for adults aged 75–84 years; 24.3 is specific for adults aged ≥85 years.)

Related chronic disease indicator topics

Diabetes; nutrition, physical activity, and weight status; older adults; tobacco.

Demographic group

All resident persons.

Numerator

Hospitalizations with principal diagnosis International Classification of Diseases, Ninth Revision, Clinical Modification codes 430–434 and 436–438 among residents during a calendar year. When possible, include discharges for residents who are hospitalized in another state.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Annual number of hospitalizations. Annual hospitalization rates: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 1 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2009, stroke accounted almost 130,000 of the 800,000 deaths among persons in the United States who died of cerebrovascular disease, or one out of every 19 deaths from all causes (2). Approximately 800,000 persons have a stroke each year in the United States. A total of 610,000 of these strokes are first, or new, strokes, and 185,000, or nearly one out of four, are recurrent strokes (3).

Significance

Modifiable risk factors for stroke include behaviors (e.g., tobacco use, physical inactivity, and improper nutrition) and health status (e.g., untreated hypertension, hyperlipidemia, overweight, or diabetes) (3). Approximately 26% of stroke deaths in the United States are attributable to high blood pressure, and 12% are attributable to smoking (3). Substantial differences in stroke death rates and preventive measures exist by race, age, sex, place of residence, and other demographic factors. Historically, the southeastern United States has had high stroke death rates.

Limitations of indicator

Although the two major types of stroke (hemorrhagic, which accounts for approximately 10% of strokes [4] and ischemic, which accounts for approximately 65% of strokes [4]) share certain risk factors, their treatment varies. Because cerebrovascular disease has a long latency period, years might pass before changes in behavior or clinical practice patterns affect cerebrovascular disease morbidity and mortality.

Data resources

State hospital discharge data (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Diagnoses listed on hospital discharge data might be inaccurate. Practice patterns and payment mechanisms could affect decisions by health-care providers to hospitalize patients. Residents of one state might be hospitalized in another state and not be reflected in the first state's hospital data set. Multiple admissions for an individual patient can inaccurately increase the number of persons with stroke. Because state hospital discharge data are not universally available, aggregation of state data to produce nationwide estimates are incomplete. State discharge records cannot identify incident (new) hospitalizations for stroke.

Related indicators or recommendations

• Healthy People 2020 objective HDS-3: Reduce stroke deaths.
• Healthy People 2020 objective HDS-17 (Developmental): Increase the proportion of adults aged 20 years and older who are aware of the symptoms of and how to respond to a stroke.
• Healthy People 2020 objective HDS-23 (Developmental): Increase the proportion of adult stroke survivors who are referred to a stroke rehabilitation program at discharge.

Related chronic disease indicator topics

Diabetes; nutrition, physical activity, and weight status; tobacco.

Demographic group

All resident persons.

Numerator

Hospitalizations with principal diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification code 410 among residents during a calendar year. When possible, include hospitalizations for residents who are hospitalized in another state.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Annual number of hospitalizations. Annual hospitalization rates: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 1 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

National Hospital Discharge survey showed that age-adjusted hospitalization rate for myocardial infarction increased during 1979–1987, stabilized during 1987–1996, and then decreased during 1996–2005 (2). Although the trends were similar between men and women, men had the hospitalization rate almost twice as those of women (2). Myocardial infarction hospitalization rates increased with age (2).

Significance

Modifiable risk factors for coronary heart disease include behaviors (e.g., tobacco use, physical inactivity, and improper nutrition), health status (e.g., hypertension, hyperlipidemia, overweight, or diabetes), and policies (e.g., smoking policies in restaurants and work sites) (3). Rapid identification and treatment of heart attack reduces heart muscle damage, improves heart muscle function, and lowers the heart attack death rate (4). Substantial differences in coronary heart disease death rates and preventive measures exist by race, age, sex, place of residence, and other demographic factors.

Limitations of indicator

Substantial numbers of persons with acute myocardial infarction die before reaching a hospital (5). Because heart disease is a chronic disease that can have a long preclinical phase, years might pass before changes in behavior or clinical practice affect population morbidity and mortality. A substantial number of misdiagnoses, particularly among women, have been reported (5).

Data resources

State hospital discharge data (numerator) and population estimates from the U.S. Bureau of the Census or suitable alternative (denominator).

Limitations of data resources

Diagnoses listed on hospital discharge data might be inaccurate. Practice patterns and payment mechanisms can affect decisions by health-care providers to hospitalize patients. Residents of one state might be hospitalized in another state and not be reflected in the first state's hospital data set. Multiple admissions for an individual patient can inaccurately increase the number of persons with acute myocardial infarctions. Because state hospital discharge data are not universally available, aggregation of state data to produce nationwide estimates are incomplete. State hospital discharge data does not allow identification of incident (new) hospitalizations for acute myocardial infarction.

Related indicators or recommendations

• Healthy People 2020 objective HDS-16: Increase the proportion of adults aged 20 years and older who are aware of the symptoms of and how to respond to a heart attack.
• Healthy People 2020 objective HDS-18: (Developmental) Increase the proportion of out-of-hospital cardiac arrests in which appropriate bystander and emergency medical services are administered.
• Healthy People 2020 objective HDS-19.1: Increase the proportion of eligible patients with heart attacks who receive fibrinolytic therapy within 30 minutes of hospital arrival.
• Healthy People 2020 objective HDS-19.2: Increase the proportion of eligible patients with heart attacks who receive percutaneous intervention within 90 minutes of hospital arrival.
• Healthy People 2020 objective HDS-22: (Developmental) Increase the proportion of adult heart attack survivors who are referred to a cardiac rehabilitation program at discharge.
• Million Hearts: brings together communities, health systems, nonprofit organizations, federal agencies, and private-sector partners from across the country to fight heart disease and stroke (available at http://millionhearts.hhs.gov/index.html).

Related chronic disease indicator topics

Diabetes; nutrition, physical activity, and weight status; tobacco.

Demographic group

Resident adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report having their cholesterol checked within the previous 5 years.

Denominator

Respondents aged ≥18 years who report having their cholesterol checked within the past 5 years (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Biennial (odd years) prevalence: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 9 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Previous 5 years.

Background

25% of adults aged ≥18 years still have not had their cholesterol checked within the past 5 years (2). Among those who had ever been screened for high blood cholesterol, the percentage who reported ever being told by a health-care provider their blood cholesterol was high was 35.0% in 2009 (2).

Significance

Elevated levels of serum cholesterol can lead to development of atherosclerosis (3). Approximately 30%–40% of coronary heart disease and 10%–20% of strokes in the United States are attributable to elevated serum cholesterol (3). Elevated cholesterol has been associated with physical inactivity, high fat intake, smoking cigarettes, diabetes, and obesity (3). Lifestyle changes and medications can reduce cholesterol and prevent heart disease among persons with elevated serum cholesterol (3).

Limitations of indicator

Validity and reliability of this indicator can be low because patients might not be aware of the specific tests conducted on their blood samples collected in clinical settings.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., lower telephone coverage among populations of low socioeconomic status), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

Healthy People 2020 objective HDS-6: Increase the proportion of adults who have had their blood cholesterol checked within the preceding 5 years.

Related chronic disease indicator topics

Diabetes; nutrition, physical activity, and weight status; tobacco.

Demographic group

Resident adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report having been told by a doctor, nurse, or other health professional that they had high cholesterol.

Denominator

Respondents aged ≥18 years who report having their cholesterol checked within the past 5 years (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Biennial (odd years) prevalence: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 9 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Past 5 years.

Background

Among those who had ever been screened for high blood cholesterol, the percentage who reported ever being told by a health-care provider their blood cholesterol was high was 35.0% in 2009 (2). Only 33.5% (one out of three) adults with high cholesterol have the condition under control, and approximately half of adults with high cholesterol get treatment (3).

Significance

Elevated levels of serum cholesterol can lead to development of atherosclerosis (4). Approximately 30%–40% of coronary heart disease and 10%–20% of strokes in the United States are attributable to elevated serum cholesterol (4). Elevated cholesterol has been associated with physical inactivity, high fat intake, smoking cigarettes, diabetes, and obesity (4). Lifestyle changes and medications can reduce cholesterol and prevent heart disease among persons with elevated serum cholesterol (4).

Limitations of indicator

Validity and reliability of this indicator can be low because patients might not be aware of the specific tests conducted on their blood samples collected in clinical settings, or the patients cannot afford to visit a physician for a cholesterol check.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

• Healthy People 2020 objective HDS-6: Increase the proportion of adults who have had their blood cholesterol checked within the preceding 5 years.
• Healthy People 2020 objective HDS-7: Reduce the proportion of adults with high total blood cholesterol levels.

Related chronic disease indicator topics

Diabetes; nutrition, physical activity, and weight status; tobacco.

Demographic group

Resident adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report ever having been told by a doctor, nurse, or other health professional that they have high blood pressure. Women who were told high blood pressure only during pregnancy and those who were told they had borderline hypertension were not included.

Denominator

Respondents aged ≥18 years (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Biennial (odd years) prevalence: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 9 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Past year.

Background

In the United States, one out of three adults had hypertension (2003–2010 National Health and Nutrition Examination Survey) (2). Behavioral Risk Factor Surveillance System 2009 data showed that the overall age-adjusted prevalence of self-reported high blood pressure in the United States was 28.3% (3).

Significance

Approximately 348,000 American deaths in 2009 included high blood pressure as a primary or contributing cause (4). Approximately 20%–30% of coronary heart disease and 20%–50% of strokes in the United States are attributable to uncontrolled hypertension (4). Blood pressure–related cardiovascular complications can occur before the onset of established hypertension (4). Lifestyle risk factors for hypertension include high sodium intake, excessive caloric intake, physical inactivity, excessive alcohol consumption, and deficient potassium intake. Lifestyle changes and medications can be used to reduce blood pressure (4).

Limitations of indicator

Indicator does not measure the proportion of adults who currently have diagnosed high blood pressure and might result in an underestimate of the prevalence of high blood pressure. Indicator is based on having been told that one has high blood pressure and is subject to recall and actually having been told. In addition, reports are not validated against actual blood pressure measurements or medical records.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., lower telephone coverage among populations of low socioeconomic status), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

• Healthy People 2020 objective HDS-4: Increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high.
• Healthy People 2020 objective HDS-5.1: Reduce the proportion of adults with hypertension.

Related chronic disease indicator topics

Alcohol; diabetes; nutrition, physical activity, and weight status; tobacco.

Demographic group

Women aged 18–44 years.

Numerator

Female respondents aged 18–44 years who reported ever being told by a doctor, nurse, or other health professional that they have high blood pressure. Women with high blood pressure during pregnancy are included in the numerator, whereas women with borderline high blood pressure or prehypertension are not.

Denominator

Female respondents aged 18–44 years who reported that they had or had never been told by a doctor, nurse, or other health professional that they have high blood pressure (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Biennial (odd years) crude annual prevalence with 95% confidence intervals weighted using the Behavioral Risk Factor Surveillance System Method (to compensate for unequal probabilities of selection and adjust for nonresponse and telephone noncoverage), and by demographic characteristics when feasible.

Time period of case definition

Lifetime.

Background

In 2002, national data estimate that 3% of women of reproductive age had hypertension (1). As the number of pregnancies among women aged ≥35 years increases, this proportion is likely to grow.

Significance

Pregnancies among women with chronic hypertension can lead to preeclampsia or eclampsia, damage to the central nervous system, and kidney damage (2,3). Potential life-threatening conditions related to chronic hypertension during pregnancy include preterm delivery, intrauterine growth retardation, placental abruption, and fetal demise (4). The clinical workgroup of the Select Panel on Preconception Care recommends that all women of reproductive age with chronic hypertension be counseled before pregnancy about medication management and about the maternal and infant risks associated with hypertension during pregnancy (5).

Limitations of indicator

Estimates are based on self-reported high blood pressure, which has not been confirmed by a physician. Studies have reported high reliability for this BRFSS item (6). However, based on studies comparing self-reports with clinical data, validity is deemed to be moderate as self-reported high blood pressure status may result in an underestimate of true hypertension prevalence (7). However, this underestimation is consistent with other research (6). Other age group definitions are recognized for reproductive age; however, these measurements will consistently use the age range of 18–44 years.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

Healthy People 2020 objective HDS-5.1: Reduce the proportion of adults with hypertension.

Related chronic disease indicator topics

Reproductive health.

Demographic group

Resident adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report taking medicine for high blood pressure.

Denominator

Respondents aged ≥18 years who report having been told by a doctor, nurse, or other health professional of having high blood pressure other than during pregnancy (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Biennial (odd years) prevalence: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 9 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Previous year.

Background

CDC showed that approximately half (47%) of persons with high blood pressure have their condition under control (2). Improving the control rate to reduce the risk for heart attack and stroke is very important (3). Studies showed that 46,000 deaths might be averted each year if 70% of patients with high blood pressure were treated according to goals established in current clinical guidelines (3). Reducing average population systolic blood pressure by only 12–13 mmHg could reduce stroke by 37%, coronary heart disease by 21%, cardiovascular disease deaths by 25%, and deaths from all causes by 13% (3).

Significance

Approximately 20%–30% of coronary heart disease and 20%–50% of strokes in the United States are attributable to uncontrolled hypertension (3). Blood pressure–related cardiovascular complications can occur before the onset of established hypertension. Lifestyle risk factors for hypertension include high sodium intake, excessive caloric intake, physical inactivity, excessive alcohol consumption, and deficient potassium intake (3). Lifestyle changes and medications can be used to reduce blood pressure (3).

Limitations of indicator

Indicator does not measure the proportion of adults with diagnosed hypertension who have their blood pressure successfully controlled. In addition, the indicator does not include persons with hypertension who have their blood pressure successfully controlled through lifestyle changes and without medication. Indicator only measures those aware of being told they have high blood pressure and not those who have been told they have hypertension.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., lower telephone coverage among populations of low socioeconomic status), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

Healthy People 2020 objective HDS-11: Increase the proportion of adults with hypertension who are taking prescribed medications to lower their blood pressure.

Related chronic disease indicator topics

Alcohol; diabetes; nutrition, physical activity, and weight status; tobacco.

Demographic group

Women aged 18–44 years who have had a live birth.

Numerator

Respondents who reported having high blood pressure or hypertension before they became pregnant with their most recent live-born infant.

Denominator

Women who did or did not report having high blood pressure before they became pregnant with their most recent live-born infant (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Crude prevalence with 95% confidence intervals weighted using the Pregnancy Risk Assessment Monitoring System method (to compensate for unequal probabilities of selection and adjust for nonresponse and telephone noncoverage); and by demographic characteristics when feasible.

Time period of case definition

Before the pregnancy resulting in the most recent live birth.

Background

In 2002, national data estimate that 3% of women of reproductive age had hypertension (1). As the number of pregnancies among women aged 35 years and older increases, this proportion is likely to grow.

Significance

Pregnancies among women with chronic hypertension can lead to preeclampsia or eclampsia, damage to the central nervous system, and kidney damage (2,3). Potential life threatening conditions related to chronic hypertension during pregnancy include preterm delivery, intrauterine growth retardation, placental abruption, and fetal demise (4). The clinical workgroup of the Select Panel on Preconception Care recommends that all women of reproductive age with chronic hypertension be counseled before pregnancy about medication management and about the maternal and infant risks associated with hypertension during pregnancy (5). Based on studies making comparisons with clinical data, self- reports of hypertension status may underestimate hypertension prevalence (6).

Limitations of indicator

Estimates are based on self-reported high blood pressure, which has not been confirmed by a physician. Based on studies comparing self-reports with clinical data, validity is deemed to be moderate as self-reported high blood pressure status may result in an underestimate of true hypertension prevalence (6). However, this underestimation is consistent with other research (6). Other age group definitions are recognized for reproductive age; however, these measurements will consistently use the age range of 18–44 years.

Data resources

Pregnancy Risk Assessment Monitoring System (PRAMS).

Limitations of data resources

PRAMS data are only collected from women who delivered a live-born infant, not all women of reproductive age, and from 40 states and one city, not the entire United States. PRAMS data are self-reported and might be subject to recall bias and underreporting or overreporting of behaviors based on social desirability. Although most self-report surveys such as PRAMS might be subject to systematic error resulting from noncoverage (e.g., lower landline telephone coverage because of transition to cellular telephone–only households or undeliverable addresses), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement bias (e.g., recall bias), PRAMS attempts to contact potential respondents by mail and landline or cellular telephone to increase response rates. Women who experienced a fetal death or had an abortion are excluded. PRAMS estimates only cover the population of residents in each state who also deliver in that state; therefore, residents who delivered in a different state are not included in their resident state.

Related indicators or recommendations

Healthy People 2020 objective HDS-5.1: Reduce the proportion of adults with hypertension.

Related chronic disease indicator topics

Reproductive health.

Demographic group

Resident adults aged 18–64 years.

Numerator

Respondents aged 18–64 years ever told by a doctor or health professional that they have had a heart attack or stroke or have angina or other coronary heart disease who report having received an influenza vaccination in the past 12 months.

Denominator

Respondents age 18–64 years ever told by a doctor or health professional that they have had a heart attack or stroke or have angina or other coronary heart disease who report having or not having an influenza vaccination in the past 12 months (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence: crude, age stratified, and age adjusted (to the 2000 U.S. standard population using the direct method [1]) with 95% confidence intervals and by demographic characteristics when feasible. Because of the relatively small numbers of BRFSS respondents at the state level who have a history of coronary heart disease or stroke, 2- or 3-year averages might be needed to provide stable state-level estimates. U.S. estimates might be based on single years of data.

Time period of case definition

Past 12 months (influenza vaccination).

Lifetime (history of heart attack, stroke, angina, or other coronary heart disease).

Background

In 2005, only 34% of adults with coronary heart disease reported receiving an influenza vaccination in the past 12 months (2).

Significance

Annual vaccination against seasonal influenza prevents cardiovascular morbidity and all-cause mortality in persons with cardiovascular conditions (3). The American Heart Association and American College of Cardiology recommend influenza vaccination with inactivated vaccine as part of comprehensive secondary prevention in persons with coronary and other atherosclerotic vascular disease (2). The American Heart Association estimates that 16.3 million persons in the U.S. have a history of coronary heart disease and 7.0 million have a history of stroke (4). Influenza vaccination coverage levels in this population are well below national goals (2). Persons with cardiovascular disease (excluding isolated hypertension) are considered by the Advisory Committee on Immunization Practices to be at high risk for severe complications from influenza (5,6).

Limitations of indicator

Respondents might not distinguish between influenza and pneumococcal (Streptococcus pneumoniae) vaccinations. Estimates are not specific to one influenza season; influenza vaccinations reported in the past 12 months could have been received for one or more of up to three previous influenza seasons. (Additional information on influenza vaccination coverage is available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6204a1.htm?s_cid=ss6204a1_w. Additional information on influenza vaccination coverage estimates by season is available at http://www.cdc.gov/flu/fluvaxview.)

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

• Healthy People 2020 objective IID-12.6: Increase the percentage of noninstitutionalized high-risk adults aged 18–64 years who are vaccinated annually against seasonal influenza. The Healthy People 2020 influenza vaccination objectives have been consolidated since the original publication of Healthy People 2020 but will continue to be monitored as part of Healthy People 2020 data reporting. (Additional information is available at http://www.cdc.gov/vaccines/acip/meetings/downloads/slides-oct-2013/03-Influenza-Singleton.pdf and from the Healthy People 2020 website at http://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives.)
• Healthy People 2020 objective HDS-2: Reduce coronary heart disease deaths.
• Healthy People 2020 objective HDS-3: Reduce stroke deaths.
• Promoting Preventive Services for Adults Aged 50–64 Years, Community and Clinical Partnerships: Percentage of adults who reported influenza vaccination within the past year.
• Percentage of adults who reported current smoking, diabetes, asthma or cardiovascular disease who have ever had a pneumococcal vaccination.

Related chronic disease indicator topics

Immunization.

Demographic group

Resident adults aged ≥65 years.

Numerator

Respondents aged ≥65 years ever told by a doctor or health professional that they have had a heart attack or stroke or have angina or other coronary heart disease who report having received an influenza vaccination in the past 12 months.

Denominator

Respondents aged ≥65 years ever told by a doctor or health professional that they have had a heart attack or stroke or have angina or other coronary heart disease who report having or not having an influenza vaccination in the past 12 months (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence: crude, age stratified, and age adjusted (to the 2000 U.S. standard population using the direct method) (1), with 95% confidence intervals and by demographic characteristics when feasible. Because of the relatively small numbers of BRFSS respondents at the state level who have a history of coronary heart disease or stroke, 2- or 3-year averages might be needed to provide stable state-level estimates. U.S. estimates might be based on single years of data.

Time period of case definition

Past 12 months (influenza vaccination).

Lifetime (history of heart attack, stroke, angina or other coronary heart disease).

Background

In 2005, only 34% of adults with coronary heart disease reported receiving an influenza vaccination in the past 12 months (2).

Significance

Annual vaccination against seasonal influenza prevents cardiovascular morbidity and all-cause mortality in persons with cardiovascular conditions (3). The American Heart Association and American College of Cardiology recommend influenza vaccination with inactivated vaccine as part of comprehensive secondary prevention in persons with coronary and other atherosclerotic vascular disease (2). The American Heart Association estimates that 16.3 million persons in the United States have a history of coronary heart disease, and 7.0 million have a history of stroke (4). Influenza vaccination coverage levels in this population are well below national goals (2). Persons with cardiovascular disease (excluding isolated hypertension) are considered by the Advisory Committee on Immunization Practices to be at high risk for severe complications from influenza (5,6).

Limitations of indicator

Respondents might not distinguish between influenza and pneumococcal (Streptococcus pneumoniae) vaccinations. Estimates are not specific to one influenza season; influenza vaccinations reported in the past 12 months could have been received for one or more of up to three previous influenza seasons. (Additional information on influenza vaccination coverage surveillance is available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6204a1.htm?s_cid=ss6204a1_w. Additional information on influenza vaccination coverage estimates by season is available at http://www.cdc.gov/flu/fluvaxview.)

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

• Healthy People 2020 objective IID-12.7: Increase the percentage of noninstitutionalized adults aged ≥65 years who are vaccinated annually against seasonal influenza. The Healthy People 2020 influenza vaccination objectives have been consolidated since the original publication of Healthy People 2020 but will continue to be monitored as part of Healthy People 2020 data reporting. Additional information is available at http://www.cdc.gov/vaccines/acip/meetings/downloads/slides-oct-2013/03-Influenza-Singleton.pdf and from the Healthy People 2020 website at http://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives.)
• Healthy People 2020 objective HDS-2: Reduce coronary heart disease deaths.
• Healthy People 2020 objective HDS-3: Reduce stroke deaths.
• Healthy People 2020 objective OA-2: Increase the proportion of older adults who are up to date on a core set of clinical preventive services.

Related chronic disease indicator topics

Immunization; older adults.

Demographic group

Resident adults aged 18–64 years.

Numerator

Respondents aged 18–64 years ever told by a doctor or health professional that they have had a heart attack or have angina or other coronary heart disease who report ever having received a pneumococcal vaccination.

Denominator

Respondents aged 18–64 years ever told by a doctor or health professional that they have had a heart attack or have angina or other coronary heart disease who report ever having or not ever having a pneumococcal vaccination (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence: crude, age stratified, and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1]) with 95% confidence intervals and by demographic characteristics when feasible. Because of the relatively small numbers of BRFSS respondents at the state level who have a history of coronary heart disease, 2- or 3-year averages might be needed to provide stable state-level estimates. U.S. estimates might be based on single years of data.

Time period of case definition

Lifetime (ever vaccinated).

Lifetime (history of heart attack, angina or other coronary heart disease).

Background

In 2012, only 20.0% of adults aged 19–64 years at high risk for pneumococcal disease and its complications reported ever receiving a pneumococcal vaccination (2).

Significance

Invasive pneumococcal infection is a major cause of illness and death in the United States, with an estimated 43,500 cases and 5,000 deaths among persons of all ages in 2009 (3). Persons with chronic heart disease (excluding hypertension) are considered by the Advisory Committee on Immunization Practices to be a group at high risk for pneumococcal disease and its complications who should receive pneumococcal vaccination (4). The American Heart Association estimates that 16.3 million persons in the U.S. have a history of coronary heart disease (5). Pneumococcal vaccination rates among adults at high risk for pneumococcal disease and its complications are well below national goals (2).

Limitations of indicator

Respondents might not distinguish between influenza and pneumococcal (Streptococcus pneumoniae) vaccinations.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

• Healthy People 2020 objective IID-13.2: Increase the percentage of noninstitutionalized high-risk adults aged 18–64 years who are vaccinated against pneumococcal disease.
• Healthy People 2020 objective HDS-2: Reduce coronary heart disease deaths.
• Healthy People 2020 objective HDS-3: Reduce stroke deaths.
• Promoting Preventive Services for Adults Aged 50–64 Years, Community and Clinical Partnerships: Percentage of adults who reported influenza vaccination within the past year.
• Percentage of adults who reported current smoking, diabetes, asthma or cardiovascular disease who have ever had a pneumococcal vaccination.

Related chronic disease indicator topics

Immunization.

Demographic group

Resident adults aged ≥65 years.

Numerator

Respondents aged ≥65 years ever told by a doctor or health professional that they have had a heart attack or have angina or other coronary heart disease who report ever having received a pneumococcal vaccination.

Denominator

Respondents aged ≥65 years ever told by a doctor or health professional that they have had a heart attack or have angina or other coronary heart disease who report ever having or not ever having a pneumococcal vaccination (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence: crude, age stratified, and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1]) with 95% confidence intervals and by demographic characteristics when feasible. Because of the relatively small numbers of BRFSS respondents at the state level who have a history of coronary heart disease, 2- or 3-year averages might be needed to provide stable state-level estimates. U.S. estimates might be based on single years of data.

Time period of case definition

Lifetime (ever vaccinated).

Lifetime (history of heart attack, angina or other coronary heart disease).

Background

In 2012, only 59.9% of persons aged >65 years reported ever receiving a pneumococcal vaccination (2).

Significance

Invasive pneumococcal infection is a major cause of illness and death in the United States, with an estimated 43,500 cases and 5,000 deaths among persons of all ages in 2009 (3). Persons with chronic heart disease (excluding hypertension) are considered by the Advisory Committee on Immunization Practices to be a group at high risk for pneumococcal disease and its complications who should receive pneumococcal vaccination (4). The American Heart Association estimates that 16.3 million persons in the U.S. have a history of coronary heart disease (5). Pneumococcal vaccination rates among adults at high risk for pneumococcal disease and its complications are well below national goals (2).

Limitations of indicator

Respondents might not distinguish between influenza and pneumococcal (Streptococcus pneumoniae) vaccinations.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

• Healthy People 2020 objective IID-13.1: Increase the percentage of noninstitutionalized adults aged ≥65 years who are vaccinated against pneumococcal disease.
• Healthy People 2020 objective HDS-2: Reduce coronary heart disease deaths.
• Healthy People 2020 objective HDS-3: Reduce stroke deaths.
• Healthy People 2020 objective OA-2: Increase the proportion of older adults who are up to date on a core set of clinical preventive services.

Related chronic disease indicator topics

Immunization; older adults.

Demographic group

All resident persons.

Numerator

Deaths with International Classifications of Diseases, Tenth Revision code N03-N05, N13.0-N13.3, N17-N19, N25-N26, N28.0, and N28.8 as the underlying or contributing cause of death among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Annual number of deaths. Annual mortality rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 1 [1]) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2011, approximately 113,000 new cases of end-stage renal disease (ESRD), or kidney failure, were reported in the United States (2). Diabetes and hypertension are the leading causes of ESRD in the United States, accounting for 44% and 28%, respectively, of the new cases of ESRD in 2011 (2).

Significance

The complications of diabetes and hypertension, including ESRD, can be prevented through improved patient education and self-management and provision of adequate and timely medical care, including blood glucose and blood pressure control (3).

Limitations of indicator

The denominator is the general population and not specific to the population at risk for developing ESRD.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death and other variables listed on the death certificate might be inaccurate. The number of contributing causes of death listed on the death certificate might vary by person completing the death certificate and geographic region.

Related indicators or recommendations

Healthy People 2020 objective CKD-14: Reduce deaths in persons with ESRD.

Related chronic disease indicator topics

Diabetes; cardiovascular disease.

Demographic group

All resident persons.

Numerator

Initial claims for either renal dialysis or renal transplant among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Annual number of incident cases. Annual incidence: crude and adjusted (standardized by the method used by the US Renal Data System) [1]) and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2011, approximately 113,000 new cases of end-stage renal disease (ESRD), or kidney failure, were reported in the United States (2). Diabetes and hypertension are the leading causes of ESRD in the United States, accounting for 44% and 28%, respectively, of the new cases of ESRD in 2011 (2).

Significance

The complications of diabetes and hypertension, including ESRD, can be prevented through improved patient education and self-management and provision of adequate and timely medical care, including blood glucose and blood pressure control (3).

Limitations of indicator

The denominator is the general population and not specific to the population at risk for developing ESRD.

Data resources

ESRD incidence data (numerator) from the U.S. Renal Data System and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Because data are available only for patients whose ESRD therapy is reported to the Centers for Medicare and Medicaid Services (CMS), patients who die of ESRD before receiving treatment or whose therapy is not reported to CMS are not included in the database (1).

Related indicators or recommendations

Healthy People 2020 objective CKD-8: Reduce the rate of new cases of ESRD.

Related chronic disease indicator topics

Diabetes; cardiovascular disease.

Demographic group

All resident persons.

Numerator

Initial claims for either renal dialysis or renal transplant with diabetes listed as the primary cause of disease among residents during a calendar year.

Denominator

Midyear resident population for the same calendar year.

Measures of frequency

Annual number of incident cases. Annual incidence: crude and adjusted (standardized by the method used by the U.S. Renal Data System [1]) and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2011, approximately 113,000 new cases of end-stage renal disease (ESRD), or kidney failure, were reported in the United States (2). Diabetes and hypertension are the leading causes of ESRD in the United States, accounting for 44% and 28%, respectively, of the new cases of ESRD in 2011 (2).

Significance

The complications of diabetes and hypertension, including ESRD, can be prevented through improved patient education and self-management, and provision of adequate and timely medical care, including blood glucose and blood pressure control (3).

Limitations of indicator

The ESRD primary diagnosis, taken from the Medical Evidence Report provided by the ESRD networks, is based on the physician's assessment of the patient and might be affected if the patient has multiple comorbidities. In 2005–2008, three out of four persons with diabetes also had hypertension (3).

Data resources

ESRD incidence data (numerator) from the U.S. Renal Data System and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Because data are available only for patients whose ESRD therapy is reported to the Centers for Medicare and Medicaid Services (CMS), patients who die of ESRD before receiving treatment or whose therapy is not reported to CMS are not included in the database (1).

Related indicators or recommendations

Healthy People 2020 objective CKD-9: Reduce kidney failure due to diabetes.

Related chronic disease indicator topics

Diabetes; cardiovascular disease.

Demographic group

All adults aged ≥18 years.

Numerator

Respondents aged ≥18 years who report ever having been told by a doctor or other health professional that they have kidney disease.

Denominator

Respondents aged ≥18 years who report or do not report ever having been told by a doctor or other health professional that they have kidney disease (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 9) (1) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2011, kidney disease was the ninth leading cause of death in the United States (2). Although approximately 600,000 persons have end-stage renal disease (3), approximately 20 million U.S. adults aged ≥20 years are estimated to have chronic kidney disease (CKD) (4), and most of them are unaware of their condition (5).

Significance

If left untreated, CKD can lead to kidney failure, requiring dialysis or transplantation for survival (4) However, persons with CKD are more likely to die from cardiovascular disease than develop end-stage renal disease (4). Controlling blood glucose, blood pressure, and cholesterol can prevent or delay these conditions and improve health outcomes (4). For the first time, Healthy People 2020 included objectives addressing the earlier stages of kidney disease (6).

Limitations of indicator

Reducing the proportion of the U.S. population with CKD is likely to be difficult because of the growing prevalence of major risk factors such as diabetes, hypertension, and aging of the population (7). Many years may pass before declining trends are observed.

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

The estimated prevalence of CKD in the U.S. population is likely to be an underestimate because BRFSS is a telephone survey that excludes the institutionalized population, in whom the prevalence is likely to be higher (8), and because prevalence is based on self-report. Most persons with CKD are unaware of their condition (5). In addition, one data point is available. The following question was asked for the first time in the 2011 BRFSS core questionnaire: "Has a doctor, nurse, or other health professional EVER told you have kidney disease? Do NOT include kidney stones, bladder infection or incontinence." (9).

Related indicators or recommendations

Healthy People 2020 objective CKD-1: Reduce the proportion of the U.S. population with chronic kidney disease.

Related chronic disease indicator topics

Diabetes; cardiovascular disease.

Demographic group

Resident adults aged ≥45 years.

Numerator

Deaths with International Classification of Diseases, 10th Revision code J40–J44 as underlying cause death among residents aged ≥45 years.

Denominator

Midyear resident population aged ≥45 years.

Measures of frequency

Annual number of deaths. Annual mortality rate: crude and age adjusted per 100,000 population (standardized by the direct method to the year 2000 standard U.S. population [1]) with 95% confidence intervals and by demographic characteristics when feasible (age groups: 45–54, 55–64, 65–74, 75–84, and ≥85 years).

Time period of case definition

Calendar year.

Background

In 2010, a total of 133,575 deaths (63.1 per 100,000 population) occurred with chronic obstructive pulmonary disease (COPD) as the underlying cause of death for U.S. adults aged >25 years (2). During 1999–2010, COPD deaths decreased for U.S. men (p = 0.001) but not for women (p = 0.127) (2). More than 99% of deaths from COPD occur among adults aged ≥45 years (2).

Significance

Elimination of tobacco use or exposure might be the most effective way to reduce COPD because approximately 80% of COPD deaths are attributable to smoking (3). Other risk factors for COPD include occupational exposure, ambient air pollution, and long-term severe asthma (4). Public education and awareness of COPD symptoms and earlier diagnosis and treatment might slow additional lung damage, improve COPD symptoms, and reduce COPD-related disability and deaths (5).

Limitations of indicator

Because COPD is a chronic disease, years might pass before changes in behavior or clinical practice affect population mortality. Other comorbid conditions such as cardiovascular disease may displace COPD as the underlying cause of death that is reported on the death certificate (6,7).

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death and other variables listed on the death certificate might be inaccurate.

Related indicators or recommendations

Healthy People 2020 objective RD-10: Reduce deaths from COPD among adults.

Related chronic disease indicator topics

Asthma; tobacco; older adults.

Demographic group

Resident adults aged ≥45 years

Numerator

Deaths with International Classification of Diseases, 10th Revision Code J40–J44 as either underlying or contributing cause of death among residents aged ≥45 years

Denominator

Midyear resident population aged ≥45 years

Measures of frequency

Annual number of deaths. Annual mortality rate: crude and age adjusted per 100,000 population (standardized by the direct method to the year 2000 standard U.S. population [1]) with 95% confidence intervals and by demographic characteristics when feasible (age groups: 45–54, 55–64, 65–74, 75–84, and ≥85 years).

Time period of case definition

Calendar year.

Background

More than 99% of deaths from chronic obstructive pulmonary disease (COPD) occur among adults aged ≥45 years (2). COPD became the third leading cause of death in 2008 (3). However, other comorbid conditions such as cardiovascular disease might displace COPD as the underlying cause of death that is reported on the death certificate (4,5).

Significance

Deaths from COPD might be underestimated; therefore, a much more serious public health impact might be masked. Public education and awareness of COPD symptoms and earlier diagnosis and treatment can slow further lung damage, improve COPD symptoms, and reduce COPD-related disability and deaths (6).

Limitations of indicator

Because COPD is a chronic disease, years might pass before changes in behavior or clinical practice affect population mortality.

Data resources

Death certificate data from vital statistics agencies (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Causes of death and other variables listed on the death certificate might be inaccurate. The number of contributing causes of death listed on the death certificate might vary by person completing the death certificate and geographic region.

Related indicators or recommendations

Healthy People 2020 objective RD-10: Reduce deaths from COPD among adults.

Related chronic disease indicator topics

Older adults.

Demographic group

1. Resident adults aged ≥18 years.

2. Resident adults aged ≥45 years.

Numerator

Respondents aged ≥18 years (or ≥45 years) who report ever having physician-diagnosed chronic obstructive pulmonary disease (COPD), emphysema, or chronic bronchitis.

Denominator

Respondents aged ≥18 years (or ≥45 years) who report or do not report ever having physician-diagnosed COPD, emphysema, or chronic bronchitis (excluding refusals).

Measures of frequency

Annual prevalence (percentage), crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1]) with 95% confidence intervals and by demographic characteristics when feasible (age groups: 1] 18–24, 25–34, 35–44, 45–54, 55–64, 65–74, 75–84, and ≥85 years and 2] 45–54, 55–64, 65–74, 75–84,and ≥85 years).

Time period of case definition

Lifetime (ever diagnosed) with COPD, which includes emphysema and chronic bronchitis.

Background

In 2011, 6.3% (15 million) of adults aged ≥18 years reported that they had COPD (2). Another estimated 15 million adults have impaired pulmonary function and COPD symptoms but are unaware of having COPD because the disease has not been diagnosed by their physician with the use of spirometry (3). Approximately 80%–90% of identified COPD cases occur among persons aged ≥45 years (2,4).

Significance

Elimination of tobacco use or exposure might be the most effective way to reduce COPD because almost 80% of COPD deaths are attributable to smoking (5). Other risk factors for COPD include occupational exposure, ambient air pollution, and long-term severe asthma (6). Public education and awareness of COPD symptoms and earlier diagnosis with spirometry and treatment might slow additional lung damage, improve COPD symptoms, and reduce COPD-related disability and deaths (7).

Limitations of indicator

The indicator is based on being diagnosed by a physician and respondent recall of the diagnosis and might underestimate the true prevalence.

Data resources

Prevalence data from Behavioral Risk Factor Surveillance System (BRFSS) (numerator) and population estimates from the U.S. Census Bureau (denominator).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

Healthy People 2020 objective RD-13: (Developmental) Increase the proportion of adults with abnormal lung function whose underlying obstructive disease has been diagnosed.

Related chronic disease indicator topics

Asthma; tobacco; older adults.

Demographic group

1. Resident adults aged ≥18 years.

2. Resident adults aged ≥45 years.

Numerator

Respondents aged ≥18 years (or ≥45 years) who report being current smokers and ever having physician-diagnosed chronic obstructive pulmonary disease (COPD), emphysema, or chronic bronchitis.

Denominator

Respondents aged ≥18 years (or ≥45 years) who report ever having physician-diagnosed COPD, emphysema, or chronic bronchitis.

Measures of frequency

Annual prevalence (percentage): crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1]) with 95% confidence intervals and by demographic characteristics when feasible. (age groups: 1] 18–24, 25–34, 35–44, 45–54, 55–64, 65–74, 75–84, and ≥85 years and 2] 45–54, 55–64, 65–74, 75–84, and ≥85 years).

Time period of case definition

Lifetime (ever diagnosed) with COPD, which includes emphysema and chronic bronchitis.

Background

In 2011, 6.3% (15 million) of adults aged ≥18 years reported that they had COPD; 75% of these adults had a history of smoking and 39% continued to smoke despite awareness of having COPD (2). Approximately 80%–90% of identified COPD cases occur among persons aged ≥45 years (2,3). Approximately 80% of COPD deaths are attributable to tobacco use (4).

Significance

Elimination of tobacco use or exposure might be the most effective way to improve COPD symptoms among persons with COPD and the most effective way to prevent most COPD cases (5,6).

Limitations of indicator

Because COPD is a chronic disease, years might pass before changes in behavior or clinical practice affect population prevalence.

Data resources

Prevalence data from Behavioral Risk Factor Surveillance System (BRFSS) and population estimates from the U.S. Census Bureau (denominator).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

None.

Related chronic disease indicator topics

Older adults; tobacco.

Demographic group

1. Resident adults aged ≥18 years.

2. Resident adults aged ≥45 years.

Numerator

Respondents aged ≥18 years (or ≥45 years) who report any health-related activity limitation (≥1 day in past 30 days) and ever having physician-diagnosed chronic obstructive pulmonary disease (COPD), emphysema, or chronic bronchitis.

Denominator

Respondents aged ≥18 years (or ≥45 years) who report ever having physician-diagnosed COPD, emphysema, or chronic bronchitis.

Measures of frequency

Annual prevalence (percentage): crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1]) with 95% confidence intervals and by demographic characteristics when feasible (age groups: 1] 18–24, 25–34, 35–44, 45–54, 55–64, 65–74, 75–84, and ≥85 years and 2] 45–54, 55–64, 65–74, 75–84, and ≥85 years).

Time period of case definition

Lifetime (ever diagnosed) with COPD, which includes emphysema and chronic bronchitis.

Background

In 2011, 6.3% (15 million) of adults aged ≥18 years reported that they had COPD; 80% were aged ≥45 years (2). COPD is an important cause of activity limitation and disability. In the 2007–2009 North Carolina BRFSS, 5.7% of adults aged ≥18 years reported COPD; adults with COPD were more likely to report moderate to severe disability (37.0% versus 9.1%) than adults without COPD (3).

Significance

Public education and awareness of COPD symptoms and earlier diagnosis with spirometry and treatment might slow additional lung damage, improve COPD symptoms, and reduce COPD-related disability and deaths (4).

Limitations of indicator

Because COPD is a chronic disease, years might pass before changes in behavior or clinical practice affect population prevalence.

Data resources

Prevalence data from Behavioral Risk Factor Surveillance System (BRFSS) (numerator) and population estimates from the U.S. Census Bureau (denominator).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.

Related indicators or recommendations

Healthy People 2020 objective RD-9: Reduce activity limitations among adults with chronic obstructive pulmonary disease (COPD).

Related chronic disease indicator topics

Disability; older adults.

Demographic group

Resident adults aged ≥45 years.

Numerator

Hospitalizations with first-listed diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification codes 490, 491, 492, 466, and 496 or International Classification of Diseases, Tenth Revision, Clinical Modification codes J40–44 among residents aged ≥45 years. When possible, include hospitalizations for residents who are hospitalized in another state.

Denominator

Midyear resident population aged ≥45 years.

Measures of frequency

Annual number of hospitalizations. Annual hospitalization rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1], age categories: 45–54, 55–64, 65–74, 75–84, and ≥85 years) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2010, a total of 699,000 (34.4 per 10,000 U.S. civilian population) hospitalizations with a first-listed diagnosis of chronic obstructive pulmonary disease (COPD) occurred among adults aged ≥25 years; 97.5% occurred among those aged ≥45 years (2). Hospitalizations for a first-listed diagnosis of COPD decreased during 1999–2010 (p = 0.018) (2).

Significance

Decreasing the frequency and severity of acute exacerbations of COPD might affect the rate of hospital and emergency visits.

Limitations of indicator

Because COPD is a chronic disease, years might pass before changes in behavior or clinical practice affect populations who had COPD with serious complications. Multiple admissions for an individual patient can inaccurately increase the number of persons with COPD. State discharge records cannot identify incident (new) hospitalizations for COPD. Patients with COPD are often hospitalized with pneumonia, cardiovascular diseases, or both, which might be the first-listed diagnosis.

Data resources

State hospital discharge data (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Diagnoses listed on hospital discharge data might be inaccurate. Practice patterns and payment mechanisms could affect decisions by health-care providers to hospitalize patients. Residents of one state might be hospitalized in another state and not be reflected in the first state's hospital data set. Multiple admissions for an individual patient can inaccurately increase the number of persons with COPD. Because state hospital discharge data are not universally available, aggregation of state data to produce nationwide estimates are incomplete. State discharge records cannot identify incident (new) hospitalizations.

Related indicators or recommendations

Healthy People 2020 objective RD-11: Reduce hospitalizations for COPD.

Related chronic disease indicator topics

Older adults.

Demographic group

Resident adults aged ≥45 years.

Numerator

Hospitalizations with any diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification codes 490, 491, 492, 466, and 496 or International Classification of Diseases, Tenth Revision, Clinical Modification codes J40–44 among residents aged ≥45 years. When possible, include hospitalizations for residents who are hospitalized in another state.

Denominator

Midyear resident population aged ≥45 years.

Measures of frequency

Annual number of hospitalizations. Annual hospitalization rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1], age categories: 45–54, 55–64, 65–74, 75–84, and ≥85 years) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2010, a total of 699,000 (34.4 per 10,000 U.S. civilian population) hospitalizations occurred with a first-listed diagnosis of chronic obstructive pulmonary disease (COPD) among adults aged >25 years; 97.5% occurred among adults aged ≥45 years (2). Hospitalizations for a first-listed diagnosis of COPD declined during 1999–2010 (p = 0.018) (2). Patients with COPD might be often hospitalized with pneumonia, cardiovascular diseases, or both, which might be the first-listed diagnosis.

Significance

Decreasing the frequency and severity of acute exacerbations of COPD might affect the rate of hospital and emergency visits.

Limitations of indicator

Because COPD is a chronic disease, years might pass before changes in behavior or clinical practice affect populations who had COPD with serious complications. Multiple admissions for an individual patient can inaccurately increase the number of persons with COPD. State discharge records cannot identify incident (new) hospitalizations for COPD.

Data resources

State hospital discharge data (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Diagnoses listed on hospital discharge data might be inaccurate. Practice patterns and payment mechanisms can affect decisions by health-care providers to hospitalize patients. Residents of one state might be hospitalized in another state and not be reflected in the first state's hospital data set. Multiple admissions for an individual patient can inaccurately increase the number of persons with COPD. Because state hospital discharge data are not universally available, aggregation of state data to produce nationwide estimates will be incomplete.

Related indicators or recommendations

Healthy People 2020 objective RD-11: Reduce hospitalizations for COPD.

Related chronic disease indicator topics

Older adults.

Demographic group

Medicare-eligible resident adults aged ≥65 years.

Numerator

Hospitalizations with first-listed diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification codes 490, 491, 492, 466, and 496 or International Classification of Diseases, Tenth Revision, Clinical Modification codes J40–44 among Medicare-eligible resident adults aged ≥65 years.

Denominator

Residents aged ≥65 years who were eligible for Medicare Part A benefits on July 1 of the calendar year.

Measures of frequency

Annual number of hospitalizations. Annual hospitalization rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population (1), age categories: 65–74, 75–84, and ≥85 years) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2010, a total of 312,654 (11.1 per 1000 Medicare enrollees) hospitalizations occurred for a first-listed diagnosis of chronic obstructive pulmonary disease (COPD) among Medicare enrollees aged ≥65 years (2). Hospitalizations decreased during 1999–2010 for men (p = 0.022) but not for women (p = 0.138) (2).

Significance

Decreasing the frequency and severity of acute exacerbations of COPD might affect the rate of hospital and emergency visits.

Limitations of indicator

Because COPD is a chronic disease, years might pass before changes in behavior or clinical practice affect population prevalence. Multiple admissions for an individual patient can inaccurately increase the number of persons with COPD. Medicare claims records cannot identify incident (new) hospitalizations for COPD. Patients with COPD are often hospitalized with pneumonia, cardiovascular diseases, or both, which might be the first-listed diagnosis.

Data resources

Centers for Medicare and Medicaid Services (CMS) Part A claims data (numerator) and CMS estimates of the population of persons eligible for Medicare (denominator).

Limitations of data resources

Diagnoses listed on Medicare hospital claims might be inaccurate. Practice patterns and payment mechanisms can affect decisions by health-care providers to hospitalize patients and to report COPD as the first-listed diagnosis. Multiple admissions for an individual patient can inaccurately increase the number of persons with COPD.

Related indicators or recommendations

Healthy People 2020 objective RD-11: Reduce hospitalizations for COPD.

. indicator topics

Older adults.

Demographic group

Medicare-eligible resident adults aged ≥65 years.

Numerator

Hospitalizations with any diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification codes 490, 491, 492, 466, and 496 or International Classification of Diseases, Tenth Revision, Clinical Modification codes J40–44 among Medicare-eligible resident adults aged ≥65 years.

Denominator

Residents aged ≥65 years who were eligible for Medicare Part A benefits on July 1 of the calendar year.

Measures of frequency

Annual number of hospitalizations. Annual hospitalization rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1], age categories: 65–74, 75–84, and ≥85 years) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2010, 312,654 (11.1 per 1000 Medicare enrollees) hospitalizations occurred for a first-listed diagnosis of chronic obstructive pulmonary disease (COPD) among Medicare enrollees aged ≥65 years (2). Hospitalizations decreased during 1999–2010 for men (p = 0.022) but not for women (p = 0.138) (2). Patients with COPD are often hospitalized with pneumonia, cardiovascular diseases, or both, which might be the first-listed diagnosis.

Significance

Decreasing the frequency and severity of acute exacerbations of COPD might affect the rate of hospital and emergency visits.

Limitations of indicator

Because COPD is a chronic disease, years might pass before changes in behavior or clinical practice affect populations who had COPD with serious complications. Multiple admissions for an individual patient can inaccurately increase the number of persons with COPD. Medicare claims records cannot identify incident (new) hospitalizations for COPD.

Data resources

Centers for Medicare and Medicaid Services (CMS) Part A claims data (numerator) and CMS estimates of the population of persons eligible for Medicare (denominator).

Limitations of data resources

Diagnoses listed on Medicare hospital claims might be inaccurate. Practice patterns and payment mechanisms can affect decisions by health-care providers to hospitalize patients and to identify COPD as the first-listed diagnosis. Multiple admissions for an individual patient can inaccurately increase the number of persons with COPD.

Related indicators or recommendations

Healthy People 2020 objective RD-11: Reduce hospitalizations for chronic obstructive pulmonary disease (COPD).

Related chronic disease indicator topics

Older adults.

Demographic group

Resident adults aged ≥45 years.

Numerator

Number of emergency department (ED) visits with a first-listed diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification codes 490, 491, 492, 466, and 496 or International Classification of Diseases, Tenth Revision, Clinical Modification codes J40–44 among residents aged ≥45 years.

Denominator

Midyear resident population aged ≥45 years.

Measures of frequency

Annual number of ED visits. Annual ED visit rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population [1], age categories: 45–54, 55–64, 65–74, 75–84, and ≥85 years) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2010, a total of 1,468,000 (72.0 per 10,000 U.S. civilian population) ED visits occurred with a first-listed diagnosis of chronic obstructive pulmonary disease (COPD) among adults aged ≥25 years; 73.6% of these visits occurred among persons aged ≥45 years (2). ED visits have not changed during 1999–2010 (2).

Significance

Public education and awareness of COPD symptoms and earlier diagnosis and treatment can slow additional lung damage, improve COPD symptoms, and reduce COPD-related disability and deaths (3). Decreasing the frequency and severity of acute exacerbations of COPD will affect the rate of hospitalizations and ED visits and possibly number of deaths.

Limitations of indicator

Because COPD is a chronic disease, years might pass before changes in behavior or clinical practice affect populations who had COPD with serious complications.

Data resources

State ED databases (visits that do not result in an admission) from the Healthcare Cost and Utilization Project (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Diagnoses listed on ED visit data might be inaccurate. Practice patterns and payment mechanisms can affect decisions by health-care providers to identify COPD as the first-listed diagnosis. Residents of one state might be hospitalized in another state and not be reflected in the first state's hospital data set. Multiple admissions for an individual patient can inaccurately increase the number of persons with COPD. Data might not be available for all states.

Related indicators or recommendations

Healthy People 2020 objective RD-12: Reduce hospital emergency department visits for COPD.

Related chronic disease indicator topics

Older adults.

Demographic group

Resident adults aged ≥45 years.

Numerator

Number of emergency department (ED) visits with any diagnosis of International Classification of Diseases, Ninth Revision, Clinical Modification codes 490, 491, 492, 466, and 496 or International Classification of Diseases, Tenth Revision, Clinical Modification codes J40–44 among residents aged ≥45 years.

Denominator

Midyear resident population aged ≥45 years.

Measures of frequency

Annual number of ED visits. Annual ED visit rate: crude and age adjusted (standardized by the direct method to the year 2000 standard U.S. population (1), age categories: 45–54, 55–64, 65–74, 75–84, ≥85) with 95% confidence intervals and by demographic characteristics when feasible.

Time period of case definition

Calendar year.

Background

In 2010, a total of 1,468,000 (72.0 per 10,000 U.S. civilian population) ED visits occurred with a first-listed diagnosis of chronic obstructive pulmonary disease (COPD) among adults aged ≥25 years; 73.6% of these visits occurred among persons aged ≥45 years (2). ED visits have not changed during 1999–2010 (2).

Significance

Public education and awareness of COPD symptoms and earlier diagnosis and treatment can slow additional lung damage, improve COPD symptoms, and reduce COPD-related disability and deaths (3). Decreasing the frequency and severity of acute exacerbations of COPD will affect the rate of hospitalizations and ED visits and possibly number of deaths.

Limitations of indicator

Because COPD is a chronic disease, years might pass before changes in behavior or clinical practice affect populations who had COPD with serious complications.

Data resources

State ED databases (visits that do not result in an admission) from the Healthcare Cost and Utilization Project (numerator) and population estimates from the U.S. Census Bureau or suitable alternative (denominator).

Limitations of data resources

Diagnoses listed on ED visit data might be inaccurate. Practice patterns and payment mechanisms can affect decisions by health-care providers to identify COPD as the first-listed diagnosis. Residents of one state might be hospitalized in another state and not be reflected in the first state's hospital data set. Multiple admissions for an individual patient can inaccurately increase the number of persons with COPD. Data might not be available for all states.

Related indicators or recommendations

Healthy People 2020 objective RD-12: Reduce hospital emergency department visits for COPD.

Related chronic disease indicator topics

Older adults.

Demographic group

Noninstitutionalized resident adults aged ≥45 years.

Numerator

Respondents aged ≥45 years who report having ever been told that they have chronic obstructive pulmonary disease (COPD), emphysema, or chronic bronchitis and who report having received influenza vaccination in the past 12 months.

Denominator

Respondents aged ≥45 years having ever been told that they have COPD, emphysema, or chronic bronchitis and who report having received influenza vaccination in the past 12 months or not having received influenza vaccination in the past 12 months (excluding those who refused to answer, had a missing answer, or answered "don't know/not sure").

Measures of frequency

Annual prevalence: crude, age stratified, and age adjusted (to the 2000 U.S. standard population using the direct method [1]) with 95% confidence intervals and by demographic characteristics when feasible. Because of the relatively small numbers of BRFSS respondents at the state level who have a history of COPD, 2- or 3-year averages might be needed to provide stable state-level estimates. U.S. estimates might be based on single years of data.

Time period of case definition

Lifetime COPD, which includes emphysema and chronic bronchitis.

Past 12 months (vaccinated).

Background

In 2011, 6.3% (15 million) of adults aged ≥18 years reported that they had COPD; 80% were aged ≥45 years (2). During the 2010–2011 influenza season, 48.4% of adults aged 18–64 years at high risk for complications from influenza and 68.6% of adults aged ≥65 years received influenza vaccine (3).

Significance

In patients with underlying lung diseases such as COPD, influenza viruses cause respiratory tract infections that are associated with exacerbations and excess morbidity and mortality (4).

Limitations of indicator

Respondents might not distinguish between influenza and pneumococcal (Streptococcus pneumoniae) vaccinations. Estimates are not specific to one influenza season; influenza vaccinations reported in the past 12 months could have been received for one or more of up to three previous influenza seasons. (Additional information on influenza vaccination coverage surveillance is available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6204a1.htm?s_cid=ss6204a1_w. Additional information on influenza vaccination coverage estimates by season is available at http://www.cdc.gov/flu/fluvaxview.)

Data resources

Behavioral Risk Factor Surveillance System (BRFSS).

Limitations of data resources

As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias). To address some of these potential concerns, BRFSS began including cellular telephone–only users in the 2011 data collection. Because of changes in sampling and weighting methods, 2011 is a new baseline for BRFSS, and comparisons with previous years' data are inappropriate.