Infant mortality.
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Confidence Intervals↗
Biomedical subjects
J C Kleinman
Publications and source records attributed to J C Kleinman.
Health service areas for the United States.
The objectives of this report are to document methods used to identify health service areas for the United States and to describe and evaluate these areas. A health service area is defined as one or more counties that are relatively self-contained with respect to the provision of routine hospital care. Service areas that include more than one county are characterized by travel between the counties for routine hospital care.
Catchment Area, Health↗
International and interstate comparisons of homicide among young males.
The homicide rate for males 15 through 24 years of age in the United States was compared with the rates in 21 other developed countries. The US homicide rate, 21.9 per 100,000, was more than four times higher than the next highest rate in Scotland (5.0). Most countries had rates that were between 1 and 3 per 100,000. The lowest rates were in Japan and Austria, each with rates below 0.6 per 100,000 males 15 through 24 years of age. Three quarters of the homicides in the United States resulted from the use of firearms contrasted with less than a quarter of all homicides in the comparison countries. The US homicide rate for black males 15 through 24 years of age (85.6) was more than seven times the rate for white males (11.2). In 1987 there were only four states that had homicide rates among white males that were as low as the rates among males in the comparison countries. The lowest state rate among young black males was still seven times the highest rate abroad. There are about 4000 homicides per year among young males in the United States. If the US homicide rate could be reduced to that in the country with the next highest rate, more than 3000 lives would be saved.
Adolescent↗
Poisson regression as an alternative to person-time logistic model.
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Epidemiologic Methods↗
The slowdown in the infant mortality decline.
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Black or African American↗
Smoking before, during, and after pregnancy.
We report the first national data on smoking before, during, and after pregnancy. Estimates are based on the 1986 Linked Telephone Survey that reinterviewed 1,550 White women 20-44 years of age who were respondents to the 1985 National Health Interview Survey. An estimated 39 percent of White women who had smoked before pregnancy quit smoking while pregnant (27 percent when they found out they were pregnant and 12 percent later during pregnancy). Women with less than 12 years of education were five times as likely to smoke and one-fourth as likely to quit as those with 16 or more years of education. Women who smoked more than one pack of cigarettes per day before pregnancy were one-fifth as likely to quit as those smoking less. Of the women who quit, 70 percent resumed smoking within one year of delivery. Of those who relapsed, 67 percent resumed smoking within three months of delivery and 93 percent within six months. There is little evidence of educational differentials in relapse rates. The fact that relapse remains high suggests that while health of the fetus is a strong influence on women's smoking habits, women may be less aware of the effect of passive smoke on the infant.
Adult↗
Infant mortality among racial/ethnic minority groups, 1983-1984.
Infant mortality varies considerably among racial/ethnic groups in the United States. For groups other than whites and blacks, previously published rates based on the vital statistics system have been underestimated because of inconsistencies in the classification of race and Hispanic status on birth and death certificates. For this report, infant mortality rates (IMRs) are based on the 1983 and 1984 linked birth and infant-death files, and mother's race and Hispanic origin are reported in accordance with information shown on the birth certificates. Overall, Asians have somewhat lower infant mortality rates than whites, but the rates vary from 6.0/1,000 among Japanese mothers to 9.0/1,000 among "other Asian" mothers. Hispanic mothers show even wider variation: from 7.8/1,000 among Cubans to 12.9/1,000 among Puerto Ricans. Blacks have an IMR twice as high as that for whites, and the rate for American Indians is nearly 60% above the rate for whites. Mexicans are the third largest minority group in the United States, accounting for one-quarter million births per year. Despite a high rate of poverty and low use of prenatal care, Mexicans have approximately the same IMR (9.0/1,000) as non-Hispanic whites. Further study of this group could assist in the development of prevention strategies.
Ethnicity↗
Plan and operation of the NHANES I Epidemiologic Followup Study, 1986.
This report describes the plan and operation for the 1986 data collection wave of the Epidemiologic Followup to the First National Health and Nutrition Examination Survey (NHANES I). Tracing and data collection were conducted on 3,980 persons 55-74 years of age at NHANES I who were not known to be deceased in the 1982-84 data collection wave of the NHANES I Epidemiologic Followup Study.
Aged↗
Postneonatal mortality in the United States: an international perspective.
The international standing of the United States in postneonatal mortality has deteriorated from third in 1950 to sixteenth in 1986. The high rate among United States blacks is not the reason for the poor United States standing: ten other countries had lower rates than that for United States whites. Recent trends show a slowdown in the decline in postneonatal mortality between 1970 to 1981 and 1981 to 1986 in Canada, England and Wales, Netherlands, and the United States. Norway actually experienced increases during the latter period. Only France showed an acceleration in its decline during the 1980s. Canada has maintained the most rapid rate of decline between 1950 and 1986. Although all countries examined here reported Sudden Infant Death Syndrome as the leading cause of postneonatal deaths, there was twofold variation among the countries in the Sudden Infant Death Syndrome rate. Similarly, congenital anomalies, the second leading cause of death, showed a 50% range in mortality rates. Infections accounted for less than 10% of all postneonatal deaths. A reasonable approach to assessing the magnitude of preventable mortality in the postneonatal period is to use mortality from all causes except congenital anomalies among normal birth weight infants. United States whites had a lower "preventable" postneonatal mortality rate than Denmark, England and Wales, and Scotland, but a higher rate than Sweden. United States blacks, on the other hand, had by far the highest rates. Disaggregating the United States rates further into three broad maternal risk groups, there was a doubling of rates with increasing level of maternal risk. About half the postneonatal deaths among normal birth weight infants could be prevented if the entire population experienced the rates of the lowest maternal risk group.
Black People↗
Empirical comparisons of proportional hazards and logistic regression models.
We compare parameter estimates from the proportional hazards model, the cumulative logistic model and a new modified logistic model (referred to as the person-time logistic model), with the use of simulated data sets and with the following quantities varied: disease incidence, risk factor strength, length of follow-up, the proportion censored, non-proportional hazards, and sample size. Parameter estimates from the person-time logistic regression model closely approximated those from the Cox model when the survival time distribution was close to exponential, but could differ substantially in other situations. We found parameter estimates from the cumulative logistic model similar to those from the Cox and person-time logistic models when the disease was rare, the risk factor moderate, and censoring rates similar across the covariates. We also compare the models with analysis of a real data set that involves the relationship of age, race, sex, blood pressure, and smoking to subsequent mortality. In this example, the length of follow-up among survivors varied from 5 to 14 years and the Cox and person-time logistic approaches gave nearly identical results. The cumulative logistic results had somewhat larger p-values but were substantively similar for all but one coefficient (the age-race interaction). The latter difference reflects differential censoring rates by age, race and sex.
Adolescent↗
Validity of mortality analysis based on retrospective smoking information.
We assess the validity of mortality analysis based on retrospective reporting of smoking habits by subjects and proxies after a time lag of approximately ten years. The analysis is based on 2855 subject respondents and 615 proxy respondents to the NHANES I Epidemiologic Followup Survey (NHEFS), a national followup study of persons examined in the National Health and Nutrition Examination Survey (NHANES I). Persons 45-77 years of age at baseline were selected for analysis. Using three categories of smoking at baseline (current, former, never), the retrospective classification (NHEFS) matched the NHANES I classification for 89 per cent of the subject respondents and 83 per cent of the proxy respondents. Agreement levels were higher for women (92 per cent of subjects and 89 per cent of proxies) than for men (85 and 80 per cent). We used Cox regression models to assess the use of retrospective smoking information in an analysis of the relationship between selected risk factors and mortality for persons 45-64 years of age. There were few substantive differences in results with use of NHEFS smoking data versus NHANES I smoking data. In particular, the effects of age, systolic blood pressure, education, and race on mortality were not sensitive to the source of the smoking data (NHANES I or NHEFS) or the form of the smoking variable (two-, three-, or six-level categorization). The effects of body mass index on mortality were sensitive to the form of the smoking variable but results based on NHANES I and NHEFS were quite similar. These results suggest that smoking information obtained from proxy respondents is adequate for analyses of the risk of total mortality associated with smoking and other risk factors. Further assessment is needed to determine the adequacy of such data for analyses of mortality from specific causes that are sensitive to amount smoked or duration of smoking.
Aged↗
NHANES III for older persons: nutrition content and methodological considerations.
The National Health and Nutrition Examination Surveys (NHANES) are important in the assessment of nutritional status of the population of the United States. The utility of these surveys for assessment of the nutritional status of older Americans has been limited because prior NHANES have not included persons aged greater than or equal to 75 y. This paper reviews the role of the NHANES for nutritional epidemiology, highlighting the unique opportunity NHANES III offers to expand the nutrition database for older persons. Data are presented on consequences of nonresponse in analytic work and mechanisms that have been devised to approach the potential problem of nonresponse within NHANES III.
Aged↗
National trends in educational differentials in mortality.
The authors examined national changes in socioeconomic differentials in mortality for middle-aged and older white men and women in the United States with the use of 1960 data from the Matched Records Study and 1971-1984 data from the first National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study (NHEFS). In 1960, there was little difference in mortality by educational level among middle-aged and older men. Since 1960, death rates among men declined more rapidly for the more educated than the less educated, which resulted in substantial educational differentials in mortality in 1971-1984. In contrast, among women, death rates declined at about the same rate regardless of educational attainment, so that a strong inverse relation between education and mortality in 1960 remained about the same magnitude during 1971-1984. Trends in educational differentials for heart disease mortality are responsible for much of the change for all causes of death. Relative risk estimates based on the NHEFS indicate that after taking into account selected baseline risk factors the least educated are still at substantially elevated risk of death from heart disease, ranging from a relative risk of 1.38 for men aged 65-74 years at baseline to 2.27 for men aged 45-64 years. Reasons for the observed educational differentials and their changes over time are not easily explained and are likely to be multifactorial.
Aged↗
Perspectives on statistical significance testing.
The question of whether statistical significance testing should be used for the analysis of public health and epidemiologic data has received considerable attention in recent years. In this paper we have described some of the arguments for and against the use of hypothesis testing for the analysis of biomedical data. In addition, we have reviewed the literature from related fields, in particular sociology and psychology, in which similar discussions have taken place within the last 30 years. Many of the significance testing criticisms in these scientific fields have been raised in the more recent discussions taking place in the biomedical field. We present an example that emphasizes the use of both confidence interval estimation and significance testing. The example is particularly pertinent because it represents a more complex problem than has generally been discussed by critics of significance testing. Much of the discussion on this topic has focused on simple data analysis, such as the analysis of a 2 x 2 table or problems involving simple linear regression. Most epidemiologic data are far more complicated and warrant the use of both confidence interval estimation and significance testing for statistical analysis. Both of these techniques have no doubt been misused in the analysis of data. These misuses may have arisen from a lack of understanding of the role of statistical methods in data analysis and the choice of such methods for data analysis. If used prudently and judiciously, significance testing can help reduce the number of variables involved in a statistical analysis, thereby resulting in shorter confidence intervals for the models presented. Both significance testing and confidence interval estimation can serve and have served very useful functions for the analysis of public health and biomedical data.
Data Interpretation, Statistical↗
Antihypertensive drug therapy and survival by treatment status in a national survey.
The National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study, an investigation of a cohort originally examined during the period 1971-1975, provided an opportunity to assess the frequency of antihypertensive drug therapy in the United States during the period 1982-1984. For most age-sex-race subgroups, the frequency of medication use during 1982-1984 was higher than that observed during 1976-1980 based on the NHANES II. In the interval 1982-1984, diuretic agents were the most frequent medications prescribed (47% of drugs prescribed), and beta-blockers were second (17%). At the time of the initial survey in 1971-1975, participants had their blood pressures measured and a history of diagnosis and treatment of hypertension ascertained. Follow-up for vital status was 93% complete by 1984 (average length of follow-up, 9 years). In white men and women aged 50 years and older, the relative risk of death increased steadily, from those with elevated blood pressure (systolic blood pressure greater than or equal to 160 mm Hg or diastolic blood pressure greater than or equal to 95 mm Hg) but no history of hypertension to those treated for hypertension but whose blood pressure was still elevated. Regardless of history or treatment, those with an elevated blood pressure had about a 25-30% excess risk of death. Evidence from these national studies shows a high frequency of antihypertensive drug therapy in 1982-1984 and suggests the importance of adequate blood pressure control for optimal survival.
Adrenergic beta-Antagonists↗
National trends in the use of preventive health care by women.
This study investigates national changes between 1973-74 and 1985 in women's use of three preventive health services based on data from the National Health Interview Survey. Smoothed proportions of women with recent preventive care were estimated using weighted least squares for subgroups categorized by age (20-39, 40-59, 60-79), race (White, Black), income (poor, nonpoor), and year of interview. Older women and Black women experienced the largest increases in recent use of clinical breast examinations and Pap tests. Between 1973 and 1985 changes in recent breast examination ranged from zero for White women ages 20-39 years to a 23 percentage point increase (95% CI = 17,30) for Black women ages 60-79 years. A similar pattern was found for Pap testing. Changes between 1974 and 1985 in recent blood pressure testing ranged from zero for women ages 20-39 years to an 8 percentage point increase (95% CI = 6, 10) for women ages 60-79 years. Despite the increases among older women, in 1985 recent use of breast exams and Pap tests remained lower among older women. Further, the poor remained less likely than the nonpoor to have recent preventive care (except blood pressure testing among older women). Most women without recent cancer screening tests had a recent physician contact, highlighting the need for greater emphasis on cancer prevention by health care providers.
Age Factors↗
Longitudinal study of physical ability in the oldest-old.
Based on 1984 data from the Longitudinal Study on Aging, one-third of White persons aged 80 or older living in the community (N = 1,791) were defined as having no difficulty in walking 1/4 of a mile, in lifting 10 pounds, in climbing 10 steps without resting, or in stooping, crouching or kneeling. Physical ability was associated with lower risk of death over two years mean follow-up; Relative odds (RO) = .4 (95 percent confidence interval = .4, .6) and in survivors, lower utilization of hospitals RO = .4 (CI = .3, .7), physicians RO = .6 (CI = .5, .8) and nursing homes RO = .3 (CI = .2, .5) compared with those having difficulty on any of the four functional measures included in the definition of physical ability. Fifty percent of the women and 42 percent of the men physically able at the time of the baseline survey in 1984 remained physically able at follow-up. Continued physical ability in this group was associated with never having had cardiovascular disease RO = 2.1, (CI = 1.2, 3.7), never having had arthritic complaints RO = 1.9 (CI = 1.2, 2.7), a body mass index less than the 75th percentile RO = 1.8 (CI = 1.2, 2.9), younger age (for each decade of age, RO = 2.0 (CI = 1.1, 3.6), and higher level of education (greater than 13 years versus 0-6 years) RO = 2.4 (CI = 1.2, 4.7). These correlates include factors amenable to preventive measures and highlight the need to consider the heterogeneity of the oldest-old in formulating programs aimed at prevention and postponement of disability.
Activities of Daily Living↗
Mortality among children and youth.
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Accidents, Traffic↗